Hello, everyone, and thank you for tuning in. I understand these virtual lectures can be a drag at times. I'm Nick Traslini. I'm an assistant professor of orthopedic surgery at Wake Forest. I'm also the associate fellowship director there for sports medicine, and I'm here to talk about surgical management of multidirectional instability. My disclosures are available online. I'd like to acknowledge Dr. Waterman. Many of these cases and slides are his, and I appreciate his contribution to this talk. Some of this was presented as well at the Shoulder 360 course last year. Before we talk about multidirectional instability, I wanted to give the caveat that laxity and instability are not necessarily the same. Multidirectional laxity may be hyperlaxity, such as what is seen with Ehlers-Danlos and Marfan's amongst others. There may be unidirectional instability, even though there is multidirectional laxity, but there may also be multidirectional instability with laxity and apprehension in more than one plane. And many of these concepts have been promoted by Dr. Savoie and others. When we evaluate the stability of the shoulder, especially in these multidirectional cases, we always want to consider the Baten criteria, many of these patients having greater than five. The load and shift test is important for testing the anterior and posterior bands of the inferior glenohumeral ligament. We always want to check for apprehension in all planes. The sulcus test can give you some clues about the integrity of the rotator interval and laxity of the coracohumeral ligament and the middle glenohumeral ligament. And then the gage test, certainly we'll look at the IGHL, the hyperabduction test. That's something that's commonly performed in the seated position, as you see there in the middle aspect of the slide. And I'd encourage you to add that to your repertoire in these cases. Posterior stability can be tested with the push-pull test, the jerk test, and the Kim test, which similarly attempt to subluxate the shoulder posteriorly with adduction and internal rotation forces. Shoulder dyskinesis is an important component of multidirectional instability and shoulder instability in general. The scapula will move abnormally in an attempt to keep the shoulder located, and that can sometimes be appreciated on exam. Traumatic multidirectional instability is something that certainly can be seen in addition to the hyperlaxity multidirectional instability that is commonly discussed. In traumatic multidirectional instability, you always want to look for combined pathoanatomy. Labral repairs commonly can involve the slap lesion, anteriorly inferior labrum, the posterior labrum, and can often be either 270 degrees or 360 degrees around the labrum itself. So certainly with multidirectional instability on exam after a traumatic event, be prepared for quite a large labral repair. Associated traumatic injuries that can be seen with these can be avulsions of the IGHL off the humerus, reverse Hill-Sachs lesions or Hill-Sachs lesions, labral cysts, glenoid rim fractures, fractures of the tuberosities, capsular laxity, and articular disruption. In the atraumatic cases, it can always be challenging to determine what is normal. Posterior glenoid hypoplasia or dysplasia can be noted in many patients with laxity of the shoulder. Common retroversion in throwers is something that's been seen commonly, and there may be a hyperplastic posterior labrum as a result. Radiographic findings that can be seen in these multidirectional instability cases include an enlarged axillary pouch, patchless capsule, or a thin capsule, an enlarged rotator interval, and the quote, infinity pool labrum, where it just falls off the edge. Main goal here is to talk about the surgical management of multidirectional instability, and we'll discuss a few aspects of that now. Arthroscopic techniques have become the mainstay of management of multidirectional instability as we've become more sophisticated arthroscopically. The indications for this are traumatic instability, provocative instability that can be reproduced on exam, labral tears that extend from anterior to posterior, chronic injuries, and atraumatic instability. Caution should be exercised with throwing shoulders, atraumatic or insidious onset, acuity of symptoms less than 12 weeks, retroverted glenoids, and uncorrected scapular mechanics. Even more cautions should be considered in glenoid bone loss, dysplasia, global retroversion, arthritis, and patients who habitually dislocate. The techniques that we use arthroscopically are modern extrapolation of what was initially described by Neer with the open capsular shift, and the open capsular shift can still be considered the gold standard in many scenarios for multidirectional instability. Here are some images that were found from this book chapter at top right. These demonstrate that there are many steps to the open capsular shift, but it's something that's very reproducible, and for those of us who perform shoulder arthroplasty, the approach will look familiar. It begins with a tenotomy of the subscapularis tendon, the capsule is released, the humeral head is exposed, the capsule is freed from the subscapularis, it is then divided in a T fashion with the lateral based extension of the T already performed at the initial step and that medial to lateral based extension of the T as seen in the right side of the screen there performed at this step once it's teased out from the subscapularis. The inferior leaflet of the capsule can then be advanced superiorly as shown in that 39.14 picture there on the right side of the screen. That tensions the AIGHL, decreases the axillary pouch volume, and tightens the capsule. A pants over vest is then performed with the superior leaflet, and finally the subscapularis tenotomy is repaired anatomically. There's certainly debate whether the more modern arthroscopic capsular plication is better, worse, or different than the open capsular shift as described. What we found in systematic reviews and comparative studies is that return to play, range of motion changes and complications may be similar between groups. There's always the question of subscapularis morbidity, do we lose strength, is there atrophy, what is the cost of that subscapularis takedown? Moving on to the arthroscopic capsular labral plication, the goals of that surgery are to restore a labral bumper, re-tension the glenohumeral ligaments, and reduce capsular volume. One thing to keep in mind is that studies have shown that anchor-based capsular plication is a key aspect, and restoring the anchor-based fixation to the glenoid is important rather than capsular imbrication in and of itself. We tend to perform this in the lateral decubitus position using a dual suspension construct. Additionally, in the armpit, a bump can be placed to help improve lateral translation to give a better view in working space. Infrared portals are a key in order to achieve appropriate trajectories for fixation in different parts of the glenoid, and we liberally use the 7 o'clock posterior inferior portal as well as the 5 o'clock trans-subscapularis portal to achieve appropriate fixation in capsular plication. The steps for the pan-capsular plication start with capsular abrasion to induce a healing response. The first anchor is placed at 6 o'clock. Once we have petechial bleeding of the capsule, ensure good glenoid purchase with that anchor. And the remaining steps will feel similar to a labral repair, albeit with greater bites of capsule, and at times a pinch-and-tuck technique to achieve two different bites, one with capsule and one with labrum, if the suture-passing device is not large enough to get the appropriate amount of tissue in a single pass. We've gone to using re-tensionable knotless anchors to allow for sequential tensioning, and the use of a grasper can help to achieve a labral bumper when the final tensioning is performed. The way this is done is by grabbing the labral tissue and rolling it up over the face as the assistant tensions the anchor. In performing the capsular plication, as discussed, volumetric capsular reduction is an important part. It is challenging to understand how much is enough. The study by Dr. Tokish used 10-millimeter capsular bites each hour, excuse me, one hour lower on the clock face to advance the capsule and reduce the inferior axillary pouch. They found a 47 percent volume reduction with one centimeter of capsular bite, leading to a 10 percent volume reduction in each anchor. Their goal was to achieve a 50 percent reduction overall, and they achieved that once they got past four anchors. Particularly in cases of a sulcus sign, one additional thing that can be performed is a rotator interval closure, which does improve anterior stability as well as improve stability against traction. However, it can reduce external rotation range of motion. Additionally, closing the posterior portal is something that is often discussed in these cases to prevent additional posterior capsular laxity from developing. Final examination under anesthesia should demonstrate a well-centered humeral head, which is more challenging to distract with the same amount of traction force. Clinical outcomes from arthroscopic pain capsular shift or capsular placation have really been quite good. This nine-year follow-up series from Dr. Millett was 49 shoulders in 44 patients, only a 5 percent revision, which is quite good for labral surgery in the shoulder. Twenty-nine percent did have some subjective feelings of instability, and that did correlate with worse patient-reported outcomes. But overall, there was high patient satisfaction, improvements of PROs, and really they didn't find any difference between the traumatic and atraumatic cases. In refractory cases or revision scenarios where there's severely lax capsule, there are reconstructive options, whether that be anterior capsular augmentation with dermal allograft or Achilles allograft, or use of the biceps tendon or a tubular graft to reconstruct the anterior aspect of the joint. Postoperative rehabilitation protocol I won't get into in detail in the interest of time, but it's available here and on our website. In conclusion, multidirectional instability requires both laxity and apprehension in more than one plane. Additionally, which I didn't get into as much here, is that non-operative treatment is still the mainstay for initial management, with failure of dedicated PT and scapular correction for at least 6 to 12 weeks, and I'll tell you in practice, typically we're trying more than one course of PT for the atraumatic cases. Anchor-based arthroscopic pancapsular application is comparable to the traditional open capsular shift, with recurrence rates being quite low at long-term follow-up. Surgical success has been found with a minimum of 4 to 5 anchors, balanced retentioning of the IGHL complex, and very selective allograft augmentation for severe hyperlaxity or revision cases. Thank you for your attention. Hope you enjoy the course.

surgical management

multidirectional instability

shoulder stability

capsular shift

rehabilitation protocol

orthopedic surgery

labral plication