Open Capsulorrhaphy With Capsular Shift and Open Coracohumeral Ligament Reconstruction for Chronic Recurrent Multidirectional Shoulder Instability

Abstract

Background:

This case features the surgical reconstruction of the coracohumeral ligament (CHL) in conjunction with open capsulorrhaphy and capsular shift for the management of chronic, recurrent, multidirectional shoulder instability (MDI). While there is a paucity of existing literature examining the clinical outcomes of this technique, biomechanical studies have implied its potential to restore stability. This procedure may be of particular benefit to patients who have failed previous conservative management and/or attempts at surgical stabilization, as well as those with severe joint hyperlaxity or connective tissue disorders.

Indications:

This patient failed extensive physical therapy, as well as previous arthroscopic labral repair and capsulorrhaphy of the shoulder, necessitating further intervention to achieve the desired level of activity and function.

Technique Description:

After positioning the patient in a modified beach-chair position, a deltopectoral approach is utilized. Next, a subscapularis split is performed, followed by a T-capsulotomy. A capsular shift is performed. Then, the semitendinosus allograft is docked into the lateral and posterior aspect of the coracoid. After placing the arm into neutral forward flexion with 40° of external rotation and 30° of abduction, the graft is secured onto the humerus.

Results:

Cadaveric biomechanical studies have demonstrated an increased resistance to translation after imbrication of the CHL. However, no clinical outcome studies have been reported to date using the technique described in this video. In our patient, stabilization of the shoulder joint was achieved. Reduction of the sulcus sign and decreased degree/frequency of subjective symptoms of instability were reported in the early postoperative period. This patient reported no pain, had negative apprehension and relocation tests, and a near-full range of motion at 7 months postoperatively, although external rotation was moderately decreased.

Discussion/Conclusion:

In the setting of recurrent MDI refractory to conservative or previous surgical interventions, reconstruction of the CHL may be considered as an adjunct to other operative stabilization procedures. Further research is needed to determine clinical outcomes.

Patient Consent Disclosure Statement:

The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

Graphical Abstract

This is a visual representation of the abstract.

Video Transcript

This is a presentation describing open capsulorrhaphy with capsular shift and coracohumeral ligament (CHL) reconstruction for chronic, recurrent, multidirectional shoulder instability (MDI).

Background

This patient is a 22-year-old female who presented to the orthopedic sports medicine clinic for a multiyear history of bilateral shoulder pain and instability without a clear mechanism of injury, more symptomatic on the left side. She has a status after arthroscopic labral repair and capsulorrhaphy of her left shoulder 2 years before presentation, as well as on the right side 3 years before presentation. Extensive physical therapy with a focus on periscapular strengthening and scapular posture control was trialed and failed.

On examination, no deformity or atrophy of the shoulder was present. However, bilateral scapular dyskinesis with pseudo-winging was noted, as well as profound instability with anterior subluxation with self-reduction throughout range of motion bilaterally. Apprehension and relocation tests, Kim and Jerk tests, sulcus signs, and anterior-posterior load-and-shift tests were positive bilaterally. The patient had full strength, no point tenderness, and no signs of impingement or rotator cuff injury.

Radiographs obtained preoperatively in our patient show previous anchor tracts in the glenoid. The joint appears concentrically reduced. Her computed tomography once again demonstrates previous anchor tracts in the glenoid. There is no significant bone loss. The joint seems concentrically reduced. Her magnetic resonance imaging reveals postsurgical changes. There is a possible recurrent tearing of the labrum. The rotator cuff is intact.

Indications

The clinical and radiographic findings of this case are consistent with recurrent MDI with scapular dyskinesis. Given her failed previous surgical stabilization attempt and continued symptoms, open capsulorrhaphy with capsular shift and CHL reconstruction was recommended as treatment.

The CHL is a small, strong band of connective tissue that originates medially from the dorsolateral aspect of the coracoid process of the scapula and attaches laterally to the greater and lesser tubercles of the humerus.^2,9 It plays a role in reinforcing the glenohumeral articular capsule, helping in particular to resist superior and inferior translation of the humeral head.^2,9 Reconstruction of the CHL is rarely performed, and has been reserved as a last resort option for addressing MDI. ¹ It is performed concomitantly with other stabilization procedures, such as a capsular shift for recurrent multidirectional instability and laxity, refractory to either conservative or previous surgical management. Contraindications to this procedure include voluntary dislocation.^1,5 Clinically, a positive sulcus sign in a position of external rotation may be seen in the setting of glenohumeral laxity.^1,8 While nonoperative management and physical therapy are considered first-line treatment, surgical management is often recommended when these strategies fail to address symptoms. Important populations to consider as being potentially high-risk for persistent and recurrent MDI include those with connective tissue disorders, such as Ehlers-Danlos Syndrome, or congenital or acquired structural anomalies of the shoulder joint. ¹

A 2016 study performed by Vavken et al ⁷ examined outcomes of isolated capsular shift in 15 patients with shoulder instability secondary to Ehlers-Danlos Syndrome. While this procedure alone improved pain/stability in the vast majority of patients, 36% were unable to return to sports participation, and over half experienced recurrence of instability. Studies such as this one highlight the need for adjunct procedures such as CHL reconstruction, specifically in high-risk populations, to achieve adequate stabilization and the desired level of function.

After a thorough discussion with the patient regarding risks and benefits of continued conservative rehabilitation attempts versus surgical intervention, she opted to pursue open capsulorrhaphy with capsular shift and CHL reconstruction. This procedure was performed in an outpatient surgical center under general anesthesia with a regional serratus anterior plane block. Tranexamic acid and cefazolin (Ancef) were administered preoperatively to reduce the risk of bleeding and infection, respectively. Materials for the surgery are listed.

Technique Description

The patient was placed in the modified beach-chair position. Before prepping and draping, an examination under anesthesia was performed. This patient demonstrated joint hypermobility of her upper extremity, a 2+ load and shift anterior and posterior, and a 2+ sulcus sign, consistent with multidirectional instability.

A standard deltopectoral approach is utilized. A combination of Bovie and blunt dissection is carried out down through the deltopectoral interval, and the cephalic vein is taken laterally. The overlying bursa is removed to aid the exposure.

On the back table, one end of a semitendinosus allograft is whipstitched with No. 2 FiberWire (Arthrex) and then soaked in a vancomycin solution.

The lateral and posterior aspect of the coracoid is exposed subperiosteally. ⁶ After drilling for the anchor tract, we recommend sounding the tunnel to ensure that cortical bone remains throughout the circumference of the tunnel and at the posterior aspect. A short 2.9-mm push-lock anchor is then inserted with the graft flush against the cortex. The whipstitched limbs of suture are used to oversew and secure the graft in place.

After wrapping the graft in wet gauze, attention is turned back to the exposure. A subscapularis split is performed at the midpoint of the subscapularis using electrocautery. The interval between the subscapularis and the joint capsule is developed using a sponge. Next, a T-shaped lateral-based capsulotomy is performed with the vertical limb lateral and the horizontal limb extending medially. The superior and inferior limbs are identified and tagged with 0 Vicryl, and the capsular shift is performed with No. 2 FiberWire. The inferior leaflet is first brought superiorly and sewn to the lateral aspect of the capsule. The superior limb is then carried inferiorly over the inferior limb and secured. ⁴ Last, the horizontal limb of the capsule is closed with several interrupted sutures. The subscapularis split is closed with several figure-of-8 stitches of 0-Vicryl.

Next, the CHL graft is passed under the coracoacromial ligament. The superior and lateral aspect of the subscapularis is identified, and the anatomic insertion of the CHL is noted. A 4.75-mm peek swivel lock anchor loaded with fiber tape is inserted at this location. The arm should be placed in neutral forward flexion with 40° of external rotation and 30° of abduction. Both limbs of fiber tape are then passed through the semitendinosus allograft and tied to secure in place with appropriate tension. Excess limbs of suture and graft are trimmed.

The arm can then be taken through range of motion and assessed for stability and graft tensioning. The subcutaneous tissue and skin are closed in a standard fashion.

The primary complication of concern in this procedure is fracture of the coracoid or blowout through the tunnel sidewall. Loss of fixation and failure of the procedure to restore stability are possible. The risk of injury to nearby neurovascular structures can be mitigated through careful dissection. The keys to the success of this technique are the precise placement of the CHL graft tunnel and patient positioning for final fixation. ¹ As previously mentioned, it may be valuable to sound the tunnel before anchoring the graft to ensure that cortical bone surrounds all sides. Placing the arm in neutral forward flexion with 40° of external rotation and 30° of abduction when securing the graft to the humerus will help achieve appropriate tension. Take care during this step to avoid inadvertently incorporating the proximal biceps tendon into the graft fixation.

This patient was placed in a sling with an abductor pillow for 6 weeks. External rotation was restricted to zero for the first 4 weeks, then to 30° until 6 weeks postoperatively. At 12 weeks, strengthening exercises were initiated and advanced as tolerated.

Discussion/Conclusion

To date, no studies have examined the clinical postoperative outcomes of CHL reconstruction, first described by Provencher in 2019. ¹ However, several related biomechanical studies have described similar procedures and demonstrated their potential to restore joint stability. A 1992 study by Harryman et al ³ found that imbrication of the CHL increased resistance to inferior and posterior translation in cadaveric shoulders.

A similar study by Provencher in 2007 compared open versus arthroscopic plication of the rotator interval in cadaveric shoulders, finding that both sulcus stability and anterior stability improved significantly in the open group. ⁵ Of note, a significant loss of external rotation was noted in both groups, and posterior stability was not improved. ⁵ While these studies are valuable to understanding the biomechanical foundations of CHL reconstruction and the ligament's role in stabilization of the shoulder, there is a need for further biomechanical research pertaining to the specific technique described in this presentation. Furthermore, clinical outcome data are necessary to appreciate the impact on range of motion, strength, stability, satisfaction, and overall function on a mid- and long-term postoperative basis.

At 7 months postoperatively, our patient reported no pain, restored preoperative range of motion, except for a 20° decrease in external rotation, and a subjective and objective improvement in stability. She underwent the same procedure on her contralateral shoulder 3 months postoperatively.