Nip and Tuck for MDI
Abstract & Commentary
Synopsis: Laser shrinkage plus tightening of the rotator interval resulted in 96% success for shoulder multidirectional instability.
Source: Lyons TR, et al. Laser-assisted capsulorrhaphy for multidirectional instability of the shoulder. Arthroscopy. 2001; 17(1):25-30.
Lyons and colleagues report on their experience with the use of the Holmium:Yag laser to assist with capsular shrinkage for multidirectional shoulder instability. Inclusion criteria were patients with at least 2 planes of instability and no evidence of Bankart tear or labral detachment. Interestingly, only 3 patients had generalized ligamentous laxity. It seems that the rest of these were a combination of traumatic and atraumatic capsular stretch type patients with primarily inferior instability. All patients had failed at least a 3-month nonoperative treatment program.
Twenty-six consecutive patients were followed over an average of 27 months and a minimum of 2 years. Follow-up was available for all patients. Twelve patients were competitive athletes and 6 sustained documented dislocations, while the remaining patients had subluxation episodes. Surgery included laser shrinkage of the entire capsule. In patients whom the rotator interval did not shrink with the laser, suture plication was performed. This was done on all but 3 patients.
Twenty-six of 27 shoulders remained stable and asymptomatic at a minimum of 2 years. A total of 86% of the 12 athletes returned to their previous level of sports. Only 1 patient suffered dislocations postoperatively who had Ehlers-Danlos syndrome.
Comment by David R. Diduch, MS, MD
This paper raises more questions than it answers. The results certainly are excellent. It is hard to argue with 96% clinical success with a consecutive series of patients and 100% follow-up. The real question is why did they do so well. Recent papers presented at the Academy are suggesting only about a 50% success rate with thermal shrinkage alone if done in the absence of some capsular shift or Bankart reattachment. Is the difference the laser compared to the radiofrequency probes? Instead, I would suggest that the difference is in the suture plication of the rotator interval. What we really need are controlled prospective studies that compare the laser to the radiofrequency probe, and shrinkage with or without plication of the rotator interval.
The rotator interval is an area that can be difficult to assess arthroscopically and difficult to treat. This article does provide helpful figures for passing a suture around the interval and tightening it arthroscopically. Patients who have a large sulcus sign that does not reduce with external rotation with the arm at the side should be suspected of having a rotator interval lesion. Given that the primary component of instability for these patients was inferior, it may be that the rotator interval plication was the difference. Interestingly, William Bennett, MD, offers another article in the same issue of Arthroscopy describing how to arthroscopically visualize the anatomy of the rotator interval and detect a tear.1
While these researchers are to be congratulated on their excellent results and sound methodology for this study, I believe we still need prospective studies with control groups to better understand what intervention or combinations thereof are necessary for success. Perhaps their database is sufficient to review all of those patients with and without rotator interval plication over a period of years to see if that is what made a difference.
Reference
1. Bennett WF. Visualization of the anatomy of the rotator interval and bicipital sheath. Arthroscopy. 2001;17(1):107-111.
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