Arthroscopic Posterior Capsulorrhaphy for Osteoarthritis of the Shoulder Associated

with Posterior Instability: Two to Ten year results

ABSTRACT

INTRODUCTION: Two seemingly overlooked papers in the orthopaedic literature

provided the stimulus for this investigation. In 1981, Rowe and Zarins (2) presented a

series of patients with an unusual presentation of shoulder pain, which they treated with

capsulorrhaphy, achieving 94% good or excellent results. The patients had been seen

by various clinicians with failure to diagnose or sometimes various alternative

psychologic or neurologic diagnoses.

In 1983, Robert Samilson (3) described the importance of posterior instability and the

common appearance of posterior changes, such as posterior slope of the glenoid,

posterior Bankart tears and posterior erosion as a common accompaniment of

osteoarthritis.(1,4,5,6,7,8,9) He emphasized that delay in diagnosis of posterior

instability might be responsible for those changes.

As we began to see similar conditions in my practice, we began to think that there might

be a connection between these two findings; that perhaps persons with posterior

instability might go undiagnosed for years and not recognized until changes of

osteoarthritis began to occur as a result of shear forces on cartilage. (10,11) Although

much has been reported in orthopaedic studies about the effects of compressive forces

on articular cartilage, very little appears relating to shear forces as a cause of injury.

We postulate that once the mechanical effects of shoulder instability begin, shear

effects cause pathologic changes such as labral fragmentation and

chondromalacia. The subsequent inflammatory response may later accelerate the

process by virtue of the metabolic changes which act in concert with the mechanical

process to accelerate the changes of osteoarthritis. (1)

We postulated then, that treating the posterior instability in shoulders with early

osteoarthritis that have posterior instability might delay the progression or even halt the

progression of the disease. This paper is an attempt to examine that hypothesis. It is

not meant to state that all causes of shoulder osteoarthritis are caused by instability but

that there may be a group of patients who fit that category

METHODS

There were 25 patients in the group with a range of age of 44 to 74 years of age. The

median age at the time of surgery was 59. Eighty percent (20) were men, 20% (5)

were women. 56% had their dominant shoulder involved. 11.5% (3) had injury due to

work related incidence. All patients presented with painful various stages of

osteoarthritis or advanced chondromalacia of the shoulder and on clinical exam showed

evidence of posterior instability. Fig. 1

1

(Fig.1)

No patient in this study had been operated previously with a Putti-Platt procedure. One

had a previous Bankart procedure done by the author, another had a Magnuson –Stack

procedure done by another surgeon 20 years previously. Two had previous anterior

dislocations treated non-surgically, one had an AC separation many years previously.

Another had an open reduction internal fixation of a humerus fracture four years prior to

surgery. No patient had any hardware impingement as confirmed by pre-op x-rays and

arthroscopic exam at the time of index surgery.

Each shoulder was treated with bilateral examination under anesthesia, arthroscopic

exam, debridement, removal of any loose bodies, chondroplasty and posterior

capsulorrhaphy. SLAP tears or partial thickness rotator cuff tears, when present, were

included, but any patient with anterior Bankart tears or full thickness rotator cuff tear

repairs were eliminated from the study.(12) On average, the 25 patients scored 7.5 on

the pre-op simple shoulder test and rated their pre-op pain about five on a scale of 0-10

on the visual analog scale

Many patients at the time of the study could have been considered candidates for

resurfacing or replacement arthroplasty. All patients in this series had some

osteoarthritis on the glenoid of the treated shoulder with at least Grade III and some

2

degree of Grade IV posterior chondromalacia with functional range of motion and

reasonably normal contours of the glenoid and humerus. (Reasonable contours is

defined as no flattening of the humeral head or large glenohumeral joint osteophyte

formation.) The humerus was usually involved with one grade less of chondromalacia

than the glenoid. During the earlier stages the wear pattern on the humerus tended to

be on the central or slightly anterior portion of its articulating surface. Some patients

had developed some posterior erosion or posterior slope of the glenoid. All patients had

X-ray or MR evidence of glenohumeral joint arthritis and evidence of primarily posterior

instability on pre-op and intraoperative exams.

Surgery began with an examination under anesthesia of both shoulders to assess range

of motion and to confirm the diagnosis of posterior instability. Arthroscopic treatment

included a subacromial exam and a thorough glenohumeral examination through

posterior and anterior portals, removal of any loose bodies, debridement, abrasion

chondroplasty using a full radius synovial resector to freshen bony surfaces to bleeding

bone, and to trim loose articular cartilage to stable margins. A capsulorrhaphy was then

done using a combination of monopolar radiofrequency treating selected areas with a

striping technique, then with suture augmentation using absorbable or non-absorbable

suture in selected areas to complete the shoulder stabilization. (12,13,14) Post

treatment exam under anesthesia showed improvement of the instability with negative

sulcus and drawer signs. No pain pumps were used in the study but each patient was

given a single intra-articular injection of bupivacaine 0.5% before leaving the operating

suite. The patient was placed in a well padded, abduction pillow sling (Don-Joy, Breg).

before leaving the operating room.

The post-operative management was divided into two phases, a six week recovery

period involving healing and range of motion, followed by a six week rehabilitation

period involving strengthening and return to use, after which patients were allowed

unrestricted activities, including sports. A strict post-operative regimen was developed

and used based on the author’s experience and that of Wilk and Andrews (15), with

sling wear for six weeks, pendulum exercises beginning the day after surgery, range of

3

motion exercises beginning at the second through the sixth week and progressive

resistive exercises beginning at the sixth week with discontinuation of the sling. In most

cases physical therapy was augmented by a home exercise program. Controlled range

of motion during the healing phase was considered important to nourish the joint and

avoid stiffness. The goal was to reach functional, if not normal range of motion by the

end of the sixth week during the period when the capsule would be most stretchable.

(15,16)

RESULTS

Of the 25 patients, three were dropped from the analog pain and function scales test,

because they did not complete preoperative analog pain and function scales; however,

the same three were calculated in the Simple Shoulder Test as they had completed that

pre-op evaluation. All patients in this study had a pre-op and a post-op Simple Shoulder

Test performed at final follow up.

Statistical Analysis

SPSS (Statistical Package for the Social Sciences computer program) was used to

conduct the analysis. The paired-sample t-test was used to analyze the mean

differences for the analog pain and function scales as well as the Simple Shoulder Test.

(Fig. 2, Fig. 3)

Patient Satisfaction Form

4

Simple Shoulder Test (SST)There was significant improvement in the SST score (p < 0.001). The patients

performed on average of 7.5 of the twelve functions on the SST before surgery and a

mean of 10.3 of the functions at the time of the last follow-up, with a mean difference of

2.8. Our sample size is small, but a side by side observation of the preoperative and

postoperative shoulder functions shows a noteworthy increase with all the functions

evaluated in the SST. The top four increases sleep comfortably (46.1%), wash opposite

shoulder (42.3%), lift 8 pounds to shoulder level (34.6%), and shoulder comfortable with

arm rested at side (30.8%). The four smallest increases in shoulder functionality are

place a coin on a shelf at shoulder level (7.7%), lift a pint of liquid to shoulder (7.7%),

carry 20 pounds at your side (11.5%), and work full-time at your regular job (11.5%).

(Fig.4)

VAS For Pain and FunctionThere was a significant decrease in pain of the shoulder at long-term follow-up.. The

mean initial pain scale was 5.22 ± 2.02 (range 1 to 7) and the mean follow up pain scale

was 2.87 ± 2.22 (range 0 to 8). The mean difference of the pain scale was 2.35 (p

< .001, 95% CI). There was also a significant increase in functionality of the shoulder at

5

the time of the follow-up visit . The mean initial function scale was 4.35 ± 1.99 (range 2

to 8) and the mean follow up function scale was 8.57 ± 0.992 (range 5 to 10). The mean

difference of the function scale was 4.27 (p < .001, 95% CI). Overall this indicates that

the procedure was a success with these patients.

(Table 1)

Only four patients were unable to return to their previous level of work. One of these

had been a work injury. Of 25 patients, one reported that he was not satisfied with the

results of the procedure and would not have it again if the choice were given to him.

This patient has not come to a shoulder replacement or any further surgery. For

uncertain reasons he did not have an abrasion chondroplasty as part of his surgery. In

spite of that, he has managed to lead a very active life-style showing a significant

improvement in the post-op Simple Shoulder Test scores. Of the remaining 24, many

were enthusiastic and grateful about having had the procedure on their shoulder.

Twenty-two patients returned to “full activity including sports at the 80% or better level.

In some cases this included tennis, soft ball, basket ball. One had returned to national

level tournament amateur golf. One patient later came to having a shoulder

replacement. There were no infections, axillary nerve injuries, stiff shoulders, capsular

injuries or chondrolysis.

DISCUSSIONUp to now the only surgical treatments available for osteoarthritis of the shoulder have

been capsular release (17) and fascial (18) or replacement arthroplasty (19) when

conservative means such as physical therapy with oral anti-inflammatories or injections

have failed. Complications of replacement arthroplasty in a young patient, a major

surgery, often requiring later revisions has not been a satisfactory choice. Our

approach to treatment of the problem offers two advantages. First it does not burn any

6

bridges for future treatment. Secondly, management can be totally arthroscopic. Even a

few years spent avoiding replacement arthroplasty can be a definite advantage. So far

as we know, no other such approach treating arthritic shoulders has been described.

While arthroscopic fascial arthroplasty has been described as a possible treatment for

this condition, the results have not been durable or consistent, and the procedure is

difficult for even the experienced surgeon to perform. Ours is a simple approach to this

perplexing problem.

There is a learning curve of how much and where tightening should be achieved, but

the use of thermal energy thus allows some forgiveness of this problem, because it

allows stretching without tearing the tightened capsule.. It could be done using an open

procedure (28) or an arthroscopic suture capsulorrhaphy, the latter being the preference

of those two choices because open capsulorrhaphy can often over-tighten the capsule.

Over-tightening (29) is a complication which could doom the success of the procedure.

The posterior capsule, however, is generally more forgiving than the anterior capsule.

To this author’s knowledge reports of arthritis resulting from over-tightening have been

due to anterior tightening (e.g. Putti-Platt). A shoulder already on the pathway to

replacement has little to lose in the face of potential gain.

A paradox existed with the Simple Shoulder Test with other parts of the post op

evaluation in which three patients appeared to have a lesser score on their Simple

Shoulder Test post op than pre-op but had improved function or less pain on the visual

analog scale and expressed satisfaction with having had the procedure. Part of this

paradox can be explained by question number 12 and the fact that many office workers

have little physical demand on their shoulders are able to work whereas a laborer’s

work can be significantly affected by shoulder osteoarthritis. We suggest that question

12 on the simple shoulder test be changed to “ Able to perform maintenance and repair

tasks around the home”. Since many work positions are non-physical, “return to work”

may not be a reliable indication of physical capacity, but almost everyone does routine

household chores. The patients which did show a discrepancy in the simple shoulder

test did notice subjective improvement in their overall function. One of these was

7

enthusiastic about the surgery, saying that it made a “huge difference from his pre-

operative condition” All except the one mentioned above would have the surgery again

if given the choice. We developed the “Patient Satisfaction Questionnaire” to help

correct this SST discrepancy (Fig.3)

We feel there were no failures in this series of patients with the methods described. The

one patient who did come to a shoulder replacement gained seven years of relief before

requiring a hemi-arthroplasty. That patient was grossly overweight and had become

wheelchair bound, thereby relying heavily on her upper extremities for mobility, placing

added stress on an already impaired shoulder.

This study has some weaknesses. The patient number is limited. The study is not

blinded, being presented by a single author and surgeon. The procedure is not

compared with other methods of treatment. The analysis of the results is accomplished

with a visual analogue scale as to pain and function, a questionnaire evaluating post-op

activity level, quality of life and patient satisfaction and the Simple Shoulder Test. For

purposes of simplicity and convenience in a community office practice other more

complex shoulder scales were not used. In a pre-operative trial many of our patients

refused to answer the mental health parts of SF36 questionnaire making its use

impossible. The Simple Shoulder Test and Visual Analogue Scale have been shown to

be satisfactory indicators of success in other clinical studies. Patient satisfaction is

considered a good indicator of success or failure. (30)

CONCLUSION

This study demonstrates that at least in some cases posterior instability may be a

cause, not necessarily a result of osteoarthritis. This condition of posterior instability in

its early stages may require a high index of suspicion on the part of the evaluating

surgeon. We present a simple approach to treatment for many patients who may find

simple relief of a very difficult and disabling problem while still in the productive years of

their life.

8

REFERENCES

1. Iannoti, Joseph, Williams, Jr., Disorders of the Shoulder, Diagnosis and Management, Second Edition, Vol. I, 2007, Edited by Lippicott, William and Wilkins, Chapter 18, David N. Collins, pp 570-573.

2. Rowe CR and Zarins B. “Recurrent Transient Subluxation Of The Shoulder”. J Bone Joint Surg 1981; 63A(6): 863-872.

3. Samilson RL, Priet V: “Dislocation Arthropathy of the Shoulder”. J Bone Joint Surg AM. 1983; 65: 456-460

4. Edelson JG: “Patterns Of Degenerative Change In The Glenohumeral Joint”, J Bone Joint Surg Br, Mar 1995; 77-B: 288 - 292.

5. Habermeyer, P., Magosch, P., Luz, V., Lichtenberg, S. : “Three Dimensional Glenoid Deformity In Patients With Osteoarthritis: A Radiographic Analysis.” JBJS, Vol. 88, #6, June 2006, pp 1301-1307.

6. Mullali, A.B., Beddow, FH, Lamb, GHR: “CT Measurement of Glenoid Erosion in Arthritis.” J.B.J.S., Vol. 6B, 1994, pp 384-388.

7. Nightingale EJ, Walsh WR: “Radiofrequency Energy Effects on the Mechanical Properties of Tendon and Capsule – Arthroscopy.” The Journal of Arthroscopic and Related Surgery December 2005 (Vol. 21, Issue 12, Pages 1479-1485)

8. Spencer, Edwin E, Jr., Valdevit, Antonio, Kambic, Ellen, Brems, John J., Iannoti, Joseph P.: “The Effect of Humeral Component Anteversion on Shoulder Stability with Glenoid Component Retroversion”, JBJS, Vol 87-A, April 2005 pp 808-814

9. Buckwalter, JA, Menkin, HJ,: “Articular Cartilage”, JBJS, Vol 79-A, #4, April 1997, pp 600-632.

10.Buckwalter, JA: “Shear Effect Forces on Articular Cartilages”, Personal Communication.

11.Rockwood, C, Jr., Matsen, F III, Wirth, M A., Lippitt, S B: The Shoulder, Third Editions, Vol One, 2004, Elsevier, pp 308-309

12.Rockwood, C, Jr., Matsen, F III, Wirth, M A., Lippitt, S B: The Shoulder, Third Editions, Vol One, 2004, Elsevier, pp 304-305

13.Aneja A, Karas SG, Weinhold PS, Afshari HM, and Dahners LE: “Suture Plication, Thermal Shrinkage, and Sclerosing Agents: Effects on Rat Patellar Tendon Length and Biomechanical Strength.” Am. J. Sports Med., Nov 2005; 33: 1729 - 1734.

14.Abrams, Jeffrey: “Advanced Reconstruction of the Shoulder, First Edition”, 2007, AAOS, Chapter II, Arthroscopic Posterior Shoulder Repair, pp 11-19.

15.Wilk, Kevin E., Reinhold, Michael, Dugass, Jeffry, Andrews, James R.: “Rehabilitation Following Thermal Assisted Capsular Shrinkage Of The

9

Glenohumeral Joint: Current Concepts.” Journal of Orthopaedics and Sports Physical Therapy, Vol 32, #6, June 2002, pp 268-287.

16.Lu, Yan, Hayashi, Kei, Edwards, Ryland B. III, Fanton, Gary S., Thabit, George III, Markel, Mark D. : “The Affect of Monopolar Radiofrequency Treatment Pattern on Joint Capsular Healing.” Am Journal Sports Medicine, Vol 28, #5, 2000 pp 711-719

17.Richards D, Burkhart S: “Arthroscopic Debridement and Capsular Release for Glenohumeral Osteoarthritis, Arthroscopy”, The Journal of Arthroscopic and Related Surgery, Vol 23, No. 9 (Sept), 2007: pp 1019-1022

18.Cameron, B D., Iannoti, J: “Alternatives to Total Shoulder Arthroplasty in the Young Patient.” Tech Shoulder and Elbow Surgery, Vol 5, #3, September 2004: pp 135-145.

19.McCarty III LP, Cole BJ: “Non-arthroplasty Treatment of Glenohumeral Cartilage Lesions, Arthroscopy.” The Journal of Arthroscopic and Related Surgery, September 2005 (Vol. 21, Issue 9, Pages 1131-1142)

20.Brillhart, A.T. “Complications of Thermal Energy”. Operative Techniques in Sports Medicine, July 1998, Vol 6, #3, Saunders and Co., pp 182.

21.Fanton, G.S. “Arthroscopic Electrothermal Surgery of the Shoulder”. Operative Techniques in Sports Medicine, July 1998, Vol 6, #3, Saunders and Co. pp 139-146,

22.Foster, T.E., Elman, M. “Arthroscopic Delivery Systems for Thermally Induced Shoulder Capsulorrhaphy”. Operative Techniques in Sports Medicine, July 1998, Vol 6, #3, Saunders and Co., pp 126-130.

23.Levy O, Wilson M, Williams H, Bruguera J. A., Dodenhoff R, Sforza G, and Copeland S: “Thermal capsular shrinkage for shoulder instability: Mid-Term Longitudinal Outcome Study.” J Bone Joint Surg Br, Jul 2001; 83-B: 640 - 645.

24.Thabit, G III, Therapeutic Heat: “A Historical Perspective.” Op Tech Sports Med 1998; 6: 118-119.

25.Wong KL, Getz CL, Yeh GL, Ramsey M, Iannoti JP, Williams Jr GR: “Treatment of Glenohumeral Subluxation Using Electrothermal Capsulorrhaphy Arthroscopy.” The Journal of Arthroscopic and Related Surgery August 2005 (Vol. 21, Issue 8, Pages 985-991)

26.Hayashi, K DVM, PhD, Markel, M DVM, PhD: “Thermal Modification of Joint Capsule and Ligamentous Tissues.” Operative Techniques in Sports Medicine, Vol 6, No. 3, July, 1998.

27.Lu, Y MD, Markel, M DVM, PhD, Kalscheur, V, HS, Ciullo, J, BS and Ciullo, J. MD: “Histologic Evaluation of Thermal Capsulorrhaphy of Human Shoulder Joint Capsule with Monopolar Radiofrequency Energy During Short to Long Term Follow-up, Arthroscopy.” The Journal of Arthroscopic and Related Surgery, Vol 254, No. 2, February, 2008, pp 203-209.

10

28.Fuchs, Bruno, Jost, Bernhard, Gerber, Christian: “Posterior-Inferior Capsular Shift for the Treatment of Recurrent, Voluntary Posterior Subluxation of the Shoulder.” JBJS, Vol 82-A, #1, Jan 2000, pp 16-25

29.Wang Vincent M, Sugalski Matthew T, Levine William N, Pawluk Robert J, Mow Van C, and Bigliani Louis U: “Comparison of Glenohumeral Mechanics Following a Capsular Shift and Anterior Tightening.” J. Bone Joint Surg. Am., Jun 2005; 87: 1312 - 1322.

30.Harvie P, Pollard T. C. B., Chennagiri R. J., and Carr A. J.: “The Use Of Outcome Scores In Surgery Of The Shoulder.” J Bone Joint Surg Br, Feb 2005; 87-B: pp 151-154.

11

List Of Figures

Number

Fig. 1 – AGE DISTRIBUTION – The patients’ median age at the time of surgery was 53 ± 7 years (range 37 to 71). Twenty-one were men, five were women.

Fig. 2 -- PATIENT SATISFACTION FORM

Fig. 3 -- SIMPLE SHOULDER TEST FORM

Fig. 4 – SHOULDER FUNCTIONS TEST –Fig. 4 - There was significant improvement in the SST score after surgery. Most notable increases in activities were: Sleep comfortably, wash opposite shoulder, lift eight pounds to shoulder level and shoulder comfortable with arm rested at side. Three most common activities that patients could do before surgery were place a coin on a shelf at shoulder level, lift a pint to shoulder and carry 20 pounds at your side, therefore they show the least change post-operatively.

Table 1 -- VAS PAIN AND FUNCTION – Table 1 - There was a significant decrease in pain of the shoulder at the follow-up visit. There was also a significant increase in functionality of the shoulder at the time of the follow-up visit. Overall it appears that the procedure was a success with these patients.

12