The standard technique for open capsular shift has changed little since its original description in 1980.2 An incision is made in the axillary fold, and the cephalic vein is located and protected during retraction. The deltopectoral interval is used to access the subscapularis, which is incised and retracted medially. The capsule is divided in a T fashion to form inferior and superior flaps. The inferior flap is then mobilized from the inferior humeral neck. Superior advancement of the mobilized inferior flap serves to decrease the volume of the axillary pouch. Once the inferior flap is advanced, it is secured to the humeral neck with strong nonabsorbable sutures. The superior flap is then placed over the top of the inferior flap to reinforce the repair. The subscapularis is reattached anatomically (Fig. 20-3).
An alternative technique approaches the capsule by splitting the subscapularis tendon in line with its fibers. This approach is theorized to provide less surgical trauma to the subscapularis tendon, which may be favorable in throwing athletes undergoing open inferior capsular shift.20
Figure 20-3 Open capsular shift. A, The subscapularis is incised to expose the anterior capsule. B, A laterally based T-capsulotomy produces superior and inferior capsular flaps. C, After the inferior flap is released from the humeral neck, it is advanced superior to reduce the volume of the axillary pouch and tighten the inferior and middle glenohumeral ligaments. (From Hawkins RJ, Bell RH, Lippitt SB: Instability. In Hawkins RJ, Bell RH, Lippitt SB [eds]: Atlas of Shoulder Surgery. Philadelphia, Mosby, 1996, pp 65-67.)
Arthroscopic reconstruction for MDI typically involves pancap-sularplication of the glenohumeral capsule. Due to global laxity in the MDI shoulder, the posterior, anterior, inferior, and superior (rotator interval) structures must be addressed. We prefer the lateral position for all intra-articular reconstructions due to the enhanced field of vision that joint distraction provides.
A standard posterior arthroscopic portal is used to inspect the articular surfaces, labral rim, rotator interval and biceps, rotator cuff articular side, and the axillary pouch. Placing the arthro-scope into the anterior portal will also facilitate improved visualization of the posterior labrum, the posterior band of the inferior glenohumeral ligament, and the posterior capsule. In classic MDI, there are few anatomic lesions. The most commonly encountered finding is a voluminous axillary recess, the classically defined entity in MDI.
We prefer to address the voluminous pouch with a series of "pinch tucks" or capsular plications. A suture shuttle device is passed through a fold of capsular tissue that will be folded over itself toward the labrum. These 1- to 2-cm tissue advancements begin at the 6 o'clock position on the glenoid and proceed superoanteriorly and superoposteriorly until adequate ligamentous tensioning is achieved. For most moderate to severe cases of MDI, we also incorporate a previously described method of interval closure21 (Fig. 20-4).
Thermal treatment of collagenous structures was originally met with great enthusiasm. The concept is straightforward; the glenohumeral ligaments are heated with an arthroscopic laser or radiofrequency device. This thermal energy causes the ligaments to contract and become tighter, thus rendering the shoulder more stable. The technique is simple and minimally invasive and does not require tying intra-articular knots. Unfortunately, with longer follow-up, few authors have noted uniformly good results. Others believe that there may still be a limited role for thermal energy in addressing subtle instability in throwing ath-letes.22 However, a number of authors have recently reported on the relatively poor surgical results for MDI treated with thermal capsulorrhaphy.23-25
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