Volume 25, Issue 1 , Pages 110-111, January 2009
Authors' Reply
Article Outline
We welcome Dr. Provencher's comments on our article. He essentially poses four excellent questions, and although we believe that they were addressed adequately in the article and on numerous occasions by the senior author, we will attempt to explain more fully in order that he might understand.
The question of arthroscopic diagnosis is simply to look carefully at the normal ligamentous contour and fiber arrangement before placing an anterior portal. Similarly, that anterior portal should be placed in the soft spot of the interval, which would allow palpation of the structures so that the area of injury can also be felt. Careful inspection for areas of scarring and disruption of the normal fiber alignment is indicative of damage (Fig 1). Repair plicates both the coracohumeral and superior glenohumeral ligaments (Fig 2; arm in 90° of external rotation).
Figure 1.
Posterior view of a stretched and scarred rotator interval of a right shoulder with posterior instability in 90° of external rotation in the lateral decubitus position. Note the stranding and spacing of the remnants of the superior glenohumeral ligament. The arrows mark the tears and the areas of scar tissue.
Figure 2.
The same patient as seen in Fig 1 after placement of 2 oblique rotator interval plication stitches that restored both the superior glenohumeral ligament and coracohumeral ligament to normal tension. The patient is in the lateral decubitus position with the arm in 90° of external rotation. The arrows mark the reconstructed superior glenohumeral ligament and the plicated rotator interval.
The second question regards range of motion. All of our surgeries are performed in the lateral decubitus position with the arm in 90° of external rotation. Therefore, external rotation loss is not a problem in our patient population. All patients had normal external rotation, and we regret that we did not include that information in the manuscript. The loss of external rotation is not usually a factor in posterior instability, but we appreciate Dr. Provencher's concern.
The third question is in regard to our rotator interval closure technique. Our 2 sutures are placed obliquely between the superspinatus and the subscapularis mimic plicating the coracohumeral ligament and super glenohumeral ligament, a technique established by Harryman et al.1 Dr. Provencher's work on the rotator interval is well recognized and is superbly done; however, he has never tested this configuration, only the middle glenohumeral ligament–superior glenohumeral ligament closure which is, in our opinion, not a rotator interval closure but a capsular shift, and therefore his comments regarding our supposed lack of familiarity with Dr. Harryman's technique are, I think, somewhat ill-advised.
We also recognize that Dr. Provencher does not believe the work of Warner et al.,2 O'Brien et al.,3 Warren et al.,4 Bigiliani et al.,5 Neer and Foster,6 Rowe et al.,7 and Itoi et al.8 regarding rotator interval closure and the circle concept of the shoulder; however, clinically, this certainly is applicable, and the basic scientific studies previously cited provide enough information to warrant that true dislocation of the shoulder does require damage in more than 1 area of the shoulder. It has been our experience, in more than 30,000 shoulder surgeries, that the area of additional damage regarding the instability patterns is relatively consistent and does need to be addressed.
Lastly, in our series of patients, the failures occurred in the patients in whom we failed to close the rotator interval. While fully recognizing that excellent surgeons will obtain excellent results, when we created a subset of our failure group from our success group, the one consistency in the failure group was the failure to address either the rotator interval, the anterior-superior labrum, or the additional pathology that we noted in the anterior-superior quadrant of the shoulder. We firmly believe that every patient should be given the opportunity to fully heal, and that in the lateral decubitus position, a rotator interval closure supplements our posterior reconstruction. This provides an increased measure of success in most cases. While an increase of 4% may not seem significant in a series with low numbers, 4% of 30,000 surgeries represents a large number of patients that otherwise might have failed.
Again, we appreciate Dr. Provencher's comments, and look forward to visiting with him more in the future.
References
- . The role of the rotator interval capsule in passive motion and stability of the shoulder. J Bone Joint Surg Am. 1992;74:53–66
- . Static capsuloligamentous restraints to superior inferior translation of the glenohumeral joint. Am J Sports Med. 1992;20:675–685
- . Capsular restraints to anterior-posterior motion of the abducted shoulder: A biomechanical study. J Shoulder Elbow Surg. 1995;4:298–308
- . Static factors affecting posterior shoulder instability. Orthop Trans. 1984;8:89
- . Tensile properties of the inferior glenohumeral ligament. J Orthop Res. 1992;10:187–197
- . Inferior capsular shift for involuntary inferior and multidirectional instability of the shoulder (A preliminary report). J Bone Joint Surg Am. 1980;62:897–908
- . The Bankart procedure: A long-term end-result study. J Bone Joint Surg Am. 1978;60:1–16
- . Biomechanical investigation of the glenohumeral joint. J Shoulder Elbow Surg. 1996;5:407–424
PII: S0749-8063(08)00813-X
doi:10.1016/j.arthro.2008.10.013
© 2009 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.
Refers to article:
- The Use of Rotator Interval Closure in the Arthroscopic Treatment of Posterior Shoulder Instability
Volume 25, Issue 1 , Pages 110-111, January 2009