Posterior Inferior Capsular Shift for Posterior Subluxation of the Shoulder
ABSTRACT & COMMENTARY
Synopsis: This is a retrospective chart review studying a surgical treatment for a difficult shoulder problem. The posterior-inferior capsular shift stabilized the instability in most of these shoulders.
Source: Fuchs B, et al. Posterior-inferior capsular shift for the treatment of recurrent, voluntar, posterior subluxation of the shoulder. J Bone Joint Surg Am 2000;82:16-25.
This is a retrospective chart review analyzing the success of a posterior capsular shift procedure to stabilize posterior shoulder instability. The inclusion criteria included painful posterior instability affecting the activities of daily living, involuntary as well as voluntary posterior subluxation, and failure to respond to nonoperative management for three months. The exclusion criteria included a locked posterior dislocation requiring a reduction and patients with involuntary posterior subluxation demonstrated by apprehension without the ability to reproduce the posterior subluxation.
The chart review studied 26 shoulders in 24 consecutive patients who were an average age of 24 at the time of surgery. Psychiatric evaluation was obtained in two patients revealing no emotional disturbances. The operative technique was clearly described and involved a posterior approach with a repair of the posterior labral detachment (7 shoulders) and posterior-inferior capsular shift. Four shoulders also had glenoid osteotomies (3) or bone blocks (1) to improve excessive retroversion. The rehabilitation involved an initial period of immobilization followed by an exercise program. Five shoulders had six reoperations. Clinical, radiographic, and outcome data were recorded.
At an average follow-up of seven years, the patients estimated the surgically repaired shoulder to function at 86% of the other shoulder. The subjective result was good or excellent in 24 of 26 shoulders. All but one shoulder had excellent range of motion. Instability recurred in 23% and usually recurred in patients with previous surgery or with excess retroversion. Radiographs in six patients showed mild degenerative changes.
Comment by James R. Slauterbeck, MD
The management of posterior shoulder instability is a challenging problem. When a patient demonstrates voluntary posterior shoulder instability, one may be concerned about the patient’s psychological problems complicating the postoperative care. This article illustrates this, as 19 of the 26 shoulders were referred to Fuchs and colleagues for care because of concern for psychiatric problems. However, after evaluation by Fuchs et al, only two patients needed an official psychiatric work-up and no emotional disturbances were noted. This suggests that a subset of the voluntary instability group may not have the significant psychological problems previously thought.
Multiple surgical procedures have been proposed for the treatment of posterior instability and most have a high recurrence rate. The surgical technique used by Fuchs et al was nicely described and addresses both the labral injury and the capsular laxity. This repair in these patients resulted in an overall subjective shoulder rating of 86% compared to their normal shoulder and a low recurrence rate if this was the index posterior procedure.
I was surprised at the number of patients with an actual posterior labral injury since most of the patients did not report trauma as the initial event causing the instability. A possible cause for some of the poor results in the literature may be due to not addressing the posterior labral injury during surgical treatment.
Overall this is a good paper, which supports the idea of maximizing nonoperative treatment in voluntary subluxation of the shoulder. However, in cases where operative intervention is necessary, an anatomic approach to the shoulder repair addressing the pathology will give good results. The ability for patients to voluntarily sublux the shoulder was not associated with overt psychological tendencies and did not appear to affect the postoperative results. Patients with prior posterior shoulder surgery should be of more concern since these shoulders had a greater recurrence rate for instability.
All patients with posterior shoulder pain and posterior instability with activities of daily living in addition to voluntary shoulder subluxation require:
a. a complete psychiatric work-up before surgery.
b. an open, rather than arthroscopic, approach to regain stability of the shoulder.
c. a combined anterior and posterior surgical approach to address all the instability in the shoulder.
d. a thorough nonoperative trial because most will improve without surgery.
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