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Open reconstruction of the anterior glenohumeral capsulolabral structures with tendon allograft in chronic shoulder instability

Offene vordere Kapsel-Band-Rekonstruktion der Schulter mit einem Sehnenallograft bei chronischer Instabilität

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Abstract

Objective

The presented technique aims at reconstruction of the anterior capsulolabral structures of the glenohumeral joint in the case of recurrent severe instability after multiple surgical attempts to achieve stabilization.

Indications

The procedure is indicated for patients experiencing significant lifestyle-limiting recurrent shoulder instability with etiologic soft tissue deficiency.

Contraindications

Bony defects or abnormalities can not be addressed with the index technique.

Surgical technique

A standard deltopectoral approach with lateral incision of the subscapularis tendon is used for exposure to prepare the anterior glenoid rim. Suture anchors placed at the glenoid rim are used for fixation of a tibialis anterior tendon allograft, which is tightened and fixed to the bone on the humerus with intereference screws. This recreates the anterior labrum and the middle glenohumeral ligament and the anterior band of the inferior glenohumeral ligament. Intraosseuos repair of the subscapularis tendon and reinforcement of the capsular structures by sewing the capsule into the allograft complete the procedure.

Postoperative management

Postoperatively, the use of an arm sling is recommended for 6 weeks with limited physical exercises to avoid stretching the tightened and reconstructed soft tissue structures.

Results

The results of this salvage procedure in this highly challenging population have been satisfying. Twenty shoulders in 15 patients were operated (3 male, 12 female, average age 26 years) from July 2002 to April 2008. In 14 of the 20 (70%) shoulders, adequate stability was gained and no further surgery was required. The average ASES score increased by 37 points at a mean follow-up of 37 months (range 22–74 months). Mean satisfaction with surgical outcomes was 6.5 points (max. 10). In 5 patients, 6 shoulders were considered failures and required further surgical treatment after a mean of 9 months (range 3–24 months).

Zusammenfassung

Operationsziel

Wiederherstellung der ventralen Kapsel-Band-Strukturen des glenohumeralen Gelenks mit einem allogenen Sehnentransplantat bei Patienten mit schwerwiegender rezidivierender Instabilität nach mehrfach fehlgeschlagenen operativen Stabilisierungsversuchen.

Indikationen

Schulterinstabilität mit erheblicher Einschränkung der Lebensqualität und hohem Leidensdruck bei Insuffizienz des Weichteilgewebes.

Kontraindikationen

Schulterinstabilität durch knöcherne Defekte oder Anomalitäten, z. B. Anteversion des Glenoids.

Operationstechnik

Darstellung des vorderen Glenoidrands über einen deltoideopektoralen Standardzugang mit lateraler Inzision der Subscapularissehne. Einbringen von Fadenankern an der Glenoidkante zur Fixierung eines allogenen Transplantats der Tibialis-anterior-Sehne. Spannen des Transplantats und Fixation am Humerus mit Interferenzschrauben. Dadurch wird das vordere Labrum, das mittlere glenohumerale Ligament und das anteriore Band des inferioren glenohumeralen Ligamentes rekonstruiert. Die ventralen Strukturen werden durch Vernähen der Kapsel mit dem Allograft und durch transossäre Refixation der Subscapularissehne zusätzlich verstärkt.

Weiterbehandlung

Zur Nachbehandlung wird für 6 Wochen eine Armschlinge empfohlen. Mit Physiotherapie soll das Einsteifen des Gelenks verhindert, dabei ein Aufdehnen der operativ rekonstruierten und gestrafften Kapsel-Band-Strukturen jedoch vermieden werden.

Ergebnisse

Die Ergebnisse der vorgestellten Salvage-Operation bei komplizierter Ausgangssituation sind durchweg zufriedenstellend. Im Zeitraum von Juli 2002 bis April 2008 wurden 20 Schultern (15 Patienten, 3 männlich, 12 weiblich, Durchschnittsalter 26 Jahre) operiert. Bei 14 Schultern (70%) wurde eine adäquate Stabilität erreicht; sie mussten nicht nochmals operiert werden. Der ASES-Score stieg nach durchschnittlich 37 Monaten um 37 (22–74) Punkte. Die durchschnittliche Zufriedenheit mit dem Ergebnis wurde mit 6,5 von 10 Punkten bewertet. Bei 5 Patienten (6 Schultern) wurde die Behandlung nach 9 (3–24) Monaten als Fehlschlag angesehen, was eine weitere operative Therapie erforderte.

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Conflict of interest

The corresponding author states that one or more authors has declared a potential conflict of interest: Dr. Millett is a consultant to Arthrex and Arthrocare. He receives royalties from Arthrex and has stock options in Game Ready, Inc. and VuMedi. Dr. Braun’s position as a research scholar at the Steadman Philippon Research Institute (SPRI) was generously sponsored by Arthrex, Naples, FL. All authors received indirect financial support from the SPRI. Companies that have supported the SPRI are Arthrocare, Arthrex, Orthrorehab, Ossur, Siemens, and Smith & Nephew.

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Authors and Affiliations

  1. Abt. Sportorthopädie, Klinik für Orthopädie und Unfallchirurgie, Klinikum rechts der Isar, Technische Universität München, München, Deutschland

    S. Braun

  2. Steadman Philippon Research Institute, Vail, CO, USA

    M.P. Horan

  3. Steadman Clinic, 181 West Meadow Drive, Suite 1000, 81657, Vail, CO, USA

    P.J. Millett MD, MSc

Authors
  1. S. Braun
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  2. M.P. Horan
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  3. P.J. Millett MD, MSc
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Corresponding author

Correspondence to P.J. Millett MD, MSc.

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Braun, S., Horan, M. & Millett, P. Open reconstruction of the anterior glenohumeral capsulolabral structures with tendon allograft in chronic shoulder instability. Orthop Traumatol 23, 29–36 (2011). https://doi.org/10.1007/s00064-010-0011-9

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  • DOI: https://doi.org/10.1007/s00064-010-0011-9

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