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Arthroscopic Posterior Glenohumeral Capsular Augmentation With Gracilis Tendon Allograft

Open AccessPublished:October 07, 2019DOI:https://doi.org/10.1016/j.eats.2019.06.020

      Abstract

      Recurrent shoulder instability complicated by capsular insufficiency due to underlying soft-tissue disorders or multiple prior failed surgical procedures poses a challenging surgical problem. Traditional capsulolabral soft-tissue reconstruction techniques are less effective in this setting, and bony procedures sacrifice normal anatomic relations. The described arthroscopic technique aims to prevent instability while maintaining range of motion through creation of a soft-tissue allograft “sling” augmenting the posterior glenohumeral capsule.

      Technique Video

      See video under supplementary data.

      Surgical techniques for addressing recurrent shoulder instability can be divided into 2 categories: anatomic and nonanatomic. Anatomic techniques include various anterior and posterior capsulolabral repair and capsulorrhaphy or capsular shift procedures.
      • Vavken P.
      • Tepolt F.A.
      • Kocher M.S.
      Open inferior capsular shift for multidirectional shoulder instability in adolescents with generalized ligamentous hyperlaxity or Ehlers-Danlos syndrome.
      Current literature shows that arthroscopic Bankart repair techniques have equivalent outcomes to open techniques.
      • Owens B.D.
      • Cameron K.L.
      • Peck K.Y.
      • et al.
      Arthroscopic versus open stabilization for anterior shoulder subluxations.
      Nonanatomic techniques include various coracoid process transfer procedures, such as the Bristow-Latarjet procedure.
      • Latarjet M.
      [Treatment of recurrent dislocation of the shoulder].
      • Joshi M.A.
      • Young A.A.
      • Balestro J.C.
      • Walch G.
      The Latarjet-Patte procedure for recurrent anterior shoulder instability in contact athletes.
      This is most commonly performed as an open procedure, but arthroscopic techniques have also been described with equivalent mid-term outcomes.
      • Marion B.
      • Klouche S.
      • Deranlot J.
      • Bauer T.
      • Nourissat G.
      • Hardy P.
      A prospective comparative study of arthroscopic versus mini-open Latarjet procedure with a minimum 2-year follow-up.
      • Zhu Y.
      • Jiang C.
      • Song G.
      Arthroscopic versus open Latarjet in the treatment of recurrent anterior shoulder dislocation with marked glenoid bone loss: A prospective comparative study.
      Long-term studies have suggested that the primary Latarjet procedure may have superior outcomes to arthroscopic Bankart repair.
      • Zimmermann S.M.
      • Scheyerer M.J.
      • Farshad M.
      • Catanzaro S.
      • Rahm S.
      • Gerber C.
      Long-term restoration of anterior shoulder stability: A retrospective analysis of arthroscopic Bankart repair versus open Latarjet procedure.
      Despite the advantages, nonanatomic bony augmentation procedures can be more invasive and make further revision surgery still more difficult because of alteration of normal anatomic structures and relations.
      • Braun S.
      • Millett P.J.
      Open anterior capsular reconstruction of the shoulder for chronic instability using a tibialis anterior allograft.
      In cases in which bony defects exist but coracoid transfer is not preferred or not possible, other techniques to address glenoid bone loss include iliac crest autograft reconstruction
      • Warner J.J.
      • Gill T.J.
      • O'Hollerhan J.D.
      • Pathare N.
      • Millett P.J.
      Anatomical glenoid reconstruction for recurrent anterior glenohumeral instability with glenoid deficiency using an autogenous tricortical iliac crest bone graft.
      or distal tibial allograft reconstruction.
      • Millett P.J.
      • Schoenahl J.Y.
      • Register B.
      • Gaskill T.R.
      • van Deurzen D.F.
      • Martetschlager F.
      Reconstruction of posterior glenoid deficiency using distal tibial osteoarticular allograft.
      • Provencher M.T.
      • Frank R.M.
      • Golijanin P.
      • et al.
      Distal tibia allograft glenoid reconstruction in recurrent anterior shoulder instability: Clinical and radiographic outcomes.
      Techniques to address humeral head bone loss, such as a Hills-Sachs lesion, include osteochondral allograft transplantation
      • Kropf E.J.
      • Sekiya J.K.
      Osteoarticular allograft transplantation for large humeral head defects in glenohumeral instability.
      • Diklic I.D.
      • Ganic Z.D.
      • Blagojevic Z.D.
      • Nho S.J.
      • Romeo A.A.
      Treatment of locked chronic posterior dislocation of the shoulder by reconstruction of the defect in the humeral head with an allograft.
      or remplissage procedures.
      • Buza III, J.A.
      • Iyengar J.J.
      • Anakwenze O.A.
      • Ahmad C.S.
      • Levine W.N.
      Arthroscopic Hill-Sachs remplissage: A systematic review.
      In cases in which the bony anatomy is normal, instability is attributable to a soft-tissue problem. Capsular insufficiency in these patients may be a result of multiple prior failed surgical procedures; underlying soft-tissue disorders, such as type III Ehlers-Danlos syndrome
      • Vavken P.
      • Tepolt F.A.
      • Kocher M.S.
      Open inferior capsular shift for multidirectional shoulder instability in adolescents with generalized ligamentous hyperlaxity or Ehlers-Danlos syndrome.
      ; and historically, thermal capsulorrhaphy with resultant tissue necrosis.
      • Massoud S.N.
      • Levy O.
      • de los Manteros O.E.
      • et al.
      Histologic evaluation of the glenohumeral joint capsule after radiofrequency capsular shrinkage for atraumatic instability.
      Often, underlying collagen disorders are undiagnosed. In difficult revision surgical stabilization attempts, results are compromised by this multitude of factors.
      • Dewing C.B.
      • Horan M.P.
      • Millett P.J.
      Two-year outcomes of open shoulder anterior capsular reconstruction for instability from severe capsular deficiency.
      In patients with generalized tissue laxity, it is logical that allograft reconstructions would be more durable than procedures relying on the patients' native tissue, which may be compromised by underlying collagen abnormalities or disorders.
      • Dewing C.B.
      • Horan M.P.
      • Millett P.J.
      Two-year outcomes of open shoulder anterior capsular reconstruction for instability from severe capsular deficiency.
      With this in mind, an arthroscopic technique using allograft augmentation was developed to treat multidirectional instability in patients with capsular insufficiency. The technique described here uses gracilis tendon allograft to reconstruct the posterior capsuloligamentous structures, creating a “sling” to prevent recurrent instability while maintaining range of motion (ROM). It is recommended in cases of recurrent multidirectional instability in which there is capsular insufficiency.

      Surgical Technique

      A demonstration of the reconstruction technique in a right shoulder is provided in Video 1. Table 1 describes the preoperative clinical evaluation and imaging in patients with recurrent multidirectional shoulder instability. The indications and contraindications of the procedure are presented in Table 2. The pearls and pitfalls of the procedure are summarized in Table 3.
      Table 1Evaluation of Recurrent Multidirectional Shoulder Instability
      Patient history
       Symptoms can include pain, instability, weakness, mechanical symptoms and/or crepitus, and paresthesia
       Atraumatic dislocation and/or subluxation with daily activities
       History of surgical procedures
       History of diagnosed or suspected soft-tissue disorder—genetic consultation or testing should be considered
      Physical examination
       Sulcus sign
       Apprehension or relocation test
       Posterior load-and-shift test
       Generalized hypermobility (i.e. Beighton criteria
      • Grahame R.
      • Bird H.A.
      • Child A.
      The revised (Brighton 1998) criteria for the diagnosis of benign joint hypermobility syndrome (BJHS).
      )
      Imaging studies
       Standard radiographic evaluation in multiple planes with AP, true AP (Grashey), axillary lateral, and scapular Y views
       Advanced imaging including MR or CT scan—bone loss or pathologic bony conditions such as glenoid hypoplasia or excessive glenoid anteversion or retroversion should be ruled out; 3-dimensional reconstructions with humeral head subtraction can aid in glenoid bone loss evaluation
      AP, anteroposterior; CT, computed tomography; MR, magnetic resonance.
      Table 2Indications and Contraindications of Arthroscopic Posterior Capsular Augmentation With Gracilis Tendon Allograft
      Indications
       Recurrent glenohumeral multidirectional instability with capsular insufficiency due to multiple prior surgical procedures or underlying soft-tissue disorder
       Failed nonsurgical management
      Contraindications
       Significant bone loss or deficiency (bony Bankart lesion, engaging Hill-Sachs lesion, glenoid hypoplasia)
       Voluntary recurrent dislocation
      Table 3Pearls and Pitfalls of Arthroscopic Posterior Capsular Augmentation With Gracilis Tendon Allograft
      Pearls
       Different colored sutures should be used in graft preparation for easier identification during the procedure.
       A graft length of approximately 65 mm is critical. Whipstitching may affect the functional length of the graft, so the graft should be trimmed to length after placement of whipstitches.
       Some counter tension should be held on the sutures of the trailing end of the graft as it is shuttled into the joint to avoid suture or graft entanglement.
       The graft should be drawn fully into the joint, and after placement of the inferior glenoid anchor, the graft should be pushed inferiorly to allow free space for placement of the superior glenoid anchor.
      Pitfalls
       Graft and suture entanglement can complicate suture management.

      Patient Positioning and Preparation

      The patient undergoes a single-shot interscalene block, and general anesthesia is induced. The patient is placed in the lateral decubitus position. The operative shoulder is examined with the patient under anesthesia: ROM and instability including glenohumeral translation and the sulcus sign are documented. The operative shoulder is placed in 10 lb of traction at approximately 50° of abduction and 20° of forward flexion, with neutral rotation.

      Diagnostic Arthroscopy

      Standard anterior and posterior arthroscopic portals are established. A diagnostic arthroscopy of the glenohumeral joint is performed with the arthroscope in the posterior portal. Optionally, a capsulorrhaphy plication stitch can be placed anteriorly through the capsule and glenoid labrum using a curved, cannulated suture passer (SutureLasso; Arthrex, Naples, FL) and free braided polyethylene-polyester suture (SutureTape; Arthrex). The suture is docked outside the cannula for tying later in the procedure. Switching sticks are used to move the arthroscope to the anterior portal. A cannula with deployable internal wings (Gemini cannula; Arthrex) is placed posteriorly to establish a working portal.

      Graft Preparation

      A gracilis tendon allograft is selected that is no more than 5 mm in diameter. The graft is trimmed to 65 mm in total length with whipstitches (FiberLoop; Arthrex) on both ends and a single suture in a luggage-tag configuration (FiberLink; Arthrex) at the midpoint to form the apex (Fig 1). Different suture coloration schemes should be selected for each suture to aid in identification during the procedure.
      Figure thumbnail gr1
      Fig 1The gracilis tendon allograft, no greater than 5 mm in diameter, is trimmed to 65 mm in total length with whipstitches (FiberLoop) on both ends and a single suture in a luggage-tag configuration (FiberLink) at the midpoint to form the apex. The end FiberLoops are anchored to the glenoid, and the apex FiberLink is anchored to the humeral head. Different suture coloration schemes should be selected for each suture to aid in identification during the procedure.

      Graft Shuttling and Anchor Placement

      As an accessory posterolateral portal, the portal of Wilmington is established with spinal needle localization and a small skin incision. A disposable percutaneous cannula kit for the 2.9-mm PushLock suture anchor (Arthrex) is placed through this accessory portal, a pilot hole is drilled into the posterior-inferior glenoid, and the first PushLock anchor is placed through the portal and into the joint but not yet impacted into place. A SutureLasso is placed into the posterior working portal cannula, and the nitinol loop is threaded through the anchor eyelet and retrieved (Fig 2). The FiberLoop suture at the end of the first limb of the graft is loaded into the nitinol loop and shuttled through the eyelet at the tip of the anchor. The suture is used to shuttle the graft into the joint through the Gemini cannula, pulling counter tension on the graft's other suture limbs to prevent tangling or bunching of the graft (Fig 3). With the graft pulled into the joint and at the tip of the PushLock, the anchor is placed into the pilot hole, ensuring that no soft tissue from the graft obstructs the pilot hole, and is secured with a mallet (Fig 4). The graft is then pushed fully into the joint to clear the Gemini cannula and pushed inferiorly to free up working space. Next, placement of a more proximal mid-glenoid posterior anchor is achieved in the same fashion as the first, anchoring the other end of the graft (Fig 5).
      Figure thumbnail gr2
      Fig 2Right shoulder with patient in lateral decubitus position and an anterior viewing portal. A 2.9-mm PushLock suture anchor is placed into the joint through a percutaneous cannula using an accessory posterolateral portal (i.e. portal of Wilmington). A left curved SutureLasso is brought into the joint through the Gemini cannula in the posterior portal and used to pass a nitinol wire loop through the PushLock eyelet. The nitinol wire is then retrieved through the posterior portal and used to shuttle the graft FiberLoop suture through the eyelet in preparation for anchoring at the glenoid.
      Figure thumbnail gr3
      Fig 3Right shoulder with patient in lateral decubitus position. The graft is shuttled into the joint through the Gemini cannula in the posterior portal. The camera is in the anterior portal, and a 2.9-mm PushLock suture anchor is held in the joint space through a posterolateral accessory portal with a percutaneous cannula.
      Figure thumbnail gr4
      Fig 4Right shoulder with patient in lateral decubitus position and anterior viewing portal. With the graft shuttled into the joint using suture through the eyelet of the 2.9-mm PushLock suture anchor, the graft is anchored into the pilot hole created at the posterior-inferior glenoid.
      Figure thumbnail gr5
      Fig 5Right shoulder with patient in lateral decubitus position and anterior viewing portal. The second end of the graft is anchored into the mid-posterior glenoid using a second 2.9-mm PushLock suture anchor.
      A pilot hole is then placed into the posterior humeral head directly opposite the 2 anchored limbs of the graft. The luggage-tag FiberLink suture at the apex of the graft is loaded into a 4.75-mm SwiveLock anchor (Arthrex) and secured into the hole (Fig 6), which gives an inverse V shape to the final graft configuration (Fig 7).
      Figure thumbnail gr6
      Fig 6Right shoulder with patient in lateral decubitus position and anterior viewing portal. The apex of the graft is anchored to the posterior humeral head at the articular margin using a 4.75-mm SwiveLock anchor and the FiberLink suture previously placed at the graft's apex.
      Figure thumbnail gr7
      Fig 7Right shoulder with patient in lateral decubitus position and anterior viewing portal. The final graft configuration is an inverse V, with either end anchored to the glenoid and the apex anchored to the humeral head. Anchor points are labeled with yellow text and arrows.
      Next, as desired, a posterior capsule suture plication can be performed. A SutureLasso is introduced through the posterior portal cannula, and suture plication using a free SutureTape suture is performed, securing the posterior-inferior capsule to the allograft augmentation with arthroscopic knots.
      The camera is again placed posteriorly, and the working portal is re-established anteriorly using switching sticks. Any previously placed anterior capsulorrhaphy plication stitches are tied arthroscopically reducing the anterior-inferior capsular pouch volume.

      Postoperative Care

      The operative shoulder should be immobilized in a sling with an abduction pillow for 6 weeks postoperatively at all times except during bathing and exercise activity. Under the guidance of a skilled therapist, the patient can proceed through early restricted and protected ROM exercises, first passive and then progressing to active-assisted ROM (phase 1). This includes external rotation at 90° of abduction as tolerated and forward flexion to 90° as tolerated but no internal rotation for 8 weeks. Submaximal shoulder isometrics and rhythmic stabilization drills are also incorporated. Over weeks 9 to 16 (phase 2), rehabilitation focuses on gradually re-establishing ROM, normalizing arthrokinematics, increasing strength, improving neuromuscular control, and enhancing proprioception and kinesthesia. By week 16, the patient should have achieved full, non-painful ROM; no pain or tenderness; and strength at 70% of the contralateral side. Then, the patient can enter phase 3, focused on dynamic strengthening. Return to unrestricted activity can be expected at approximately 24 to 28 weeks postoperatively.

      Discussion

      Many novel reconstruction techniques have been proposed to address the difficult problem of recurrent shoulder instability. Anterior reconstruction techniques have been described using graft from the iliotibial band,
      • Gallie W.E.
      • Le Mesurier A.B.
      Recurring dislocation of the shoulder.
      • Iannotti J.P.
      • Antoniou J.
      • Williams G.R.
      • Ramsey M.L.
      Iliotibial band reconstruction for treatment of glenohumeral instability associated with irreparable capsular deficiency.
      Achilles tendon,
      • Moeckel B.H.
      • Altchek D.W.
      • Warren R.F.
      • Wickiewicz T.L.
      • Dines D.M.
      Instability of the shoulder after arthroplasty.
      • Chaudhury S.
      • Gasinu S.
      • Rodeo S.A.
      Bilateral anterior and posterior glenohumeral stabilization using Achilles tendon allograft augmentation in a patient with Ehlers-Danlos syndrome.
      hamstring tendon,
      • Lazarus M.D.
      • Harryman D.T.
      Open repair for anterior instability.
      • Warner J.J.
      • Venegas A.A.
      • Lehtinen J.T.
      • Macy J.J.
      Management of capsular deficiency of the shoulder. A report of three cases.
      • Bouaicha S.
      • Moor B.K.
      Arthroscopic autograft reconstruction of the inferior glenohumeral ligament: Exploration of technical feasibility in cadaveric shoulder specimens.
      tibialis anterior tendon allograft,
      • Braun S.
      • Millett P.J.
      Open anterior capsular reconstruction of the shoulder for chronic instability using a tibialis anterior allograft.
      • Dewing C.B.
      • Horan M.P.
      • Millett P.J.
      Two-year outcomes of open shoulder anterior capsular reconstruction for instability from severe capsular deficiency.
      split subscapularis tendon flap,
      • Denard P.J.
      • Narbona P.
      • Ladermann A.
      • Burkhart S.S.
      Bankart augmentation for capsulolabral deficiency using a split subscapularis tendon flap.
      and more recently, acellular human dermal allograft capsular reconstruction.
      • Pogorzelski J.
      • Hussain Z.B.
      • Lebus G.F.
      • Fritz E.M.
      • Millett P.J.
      Anterior capsular reconstruction for irreparable subscapularis tears.
      • Whelan A.
      • Coady C.
      • Ho-Bun Wong I.
      Anterior glenohumeral capsular reconstruction using a human acellular dermal allograft.
      An alternative anterior augmentation approach describes using a folded porcine skin surgical mesh membrane to reconstruct the anterior glenoid labrum and create a voluminous anterior bumper.
      • Gervasi E.
      • Sebastiani E.
      • Spicuzza A.
      Multidirectional shoulder instability: Arthroscopic labral augmentation.
      Described posterior-based soft-tissue procedures are fewer but have included simultaneous anterior and posterior reconstruction with Achilles allograft.
      • Chaudhury S.
      • Gasinu S.
      • Rodeo S.A.
      Bilateral anterior and posterior glenohumeral stabilization using Achilles tendon allograft augmentation in a patient with Ehlers-Danlos syndrome.
      Recently, an arthroscopic dermal allograft reconstruction procedure was described,
      • Karpyshyn J.
      • Gordey E.E.
      • Coady C.M.
      • Wong I.H.
      Posterior glenohumeral capsular reconstruction using an acellular dermal allograft.
      which is similar in concept to currently used superior capsular reconstruction techniques.
      • Laskovski J.R.
      • Boyd J.A.
      • Peterson E.E.
      • Abrams J.S.
      Simplified technique for superior capsular reconstruction using an acellular dermal allograft.
      Compared with other allograft augmentation techniques described previously, the advantages of our technique include its relative simplicity, speed and ease of use, knotless fixation, and ability to combine the technique with other procedures including capsulorrhaphy and labral repair. Normal anatomic relations are preserved, making potential revision easier. Nonanatomic solutions such as the Latarjet procedure can be reserved as a future salvage option (Table 4).
      Table 4Advantages and Disadvantages of Arthroscopic Posterior Capsular Augmentation With Gracilis Tendon Allograft
      Advantages
       Standard arthroscopic setup and portals
       Familiar arthroscopic shuttling and anchor placement techniques
       Can be used in combination with concurrent arthroscopic procedures such as capsular plication
       Allograft tissue avoids need for graft harvest and avoids risk of autograft tissue failure owing to underlying collagen disorder
       Soft-tissue procedure avoids nonanatomic bony procedures and maintains anatomic range of motion
       Bony augmentation (i.e. Latarjet) can be reserved as salvage procedure
      Disadvantages
       Risk of surgical failure at anchor or graft-suture interface may result in intra-articular loose foreign body requiring revision arthroscopy for removal with or without revision stabilization procedure
       Inability to address significant bone loss with this procedure
      The ability to treat multidirectional instability with a posteriorly based procedure is supported in the literature. One recent study showed that posterior medial capsular plication reduced anterior shoulder instability without restricting motion in the setting of an engaging Hill-Sachs defect.
      • Werner B.C.
      • Chen X.
      • Camp C.L.
      • Kontaxis A.
      • Dines J.S.
      • Gulotta L.V.
      Medial posterior capsular plication reduces anterior shoulder instability similar to remplissage without restricting motion in the setting of an engaging Hill-Sachs defect.
      Initial results after use of the described technique have been promising, with patients experiencing restored stability without sacrificing ROM. Arthroscopic posterior capsular augmentation with gracilis tendon allograft can be a very useful and reproducible technique in patients with capsular insufficiency and/or collagen disorders, and it should be considered in cases of multidirectional instability without significant bone defects.

      Supplementary Data

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