Isolated Arthroscopic Rotator Interval Closure for Shoulder Instability

Abstract

We present our technique for isolated arthroscopic rotator interval closure in the treatment of mild symptomatic glenohumeral instability in the absence of a labral tear. A careful history, physical examination, and imaging help to identify a select subset of atraumatic instability patients who may benefit from this procedure, and diagnostic arthroscopy can provide further evidence. By use of a posterior viewing portal with anterior and anterolateral working portals, the anterior capsuloligamentous complex is mobilized, and the rotator interval is closed with carefully placed sutures to advance the capsule superiorly and provide tension through decreased capsular volume.T he rotator interval (RI), first described by Neer 1 in 1970, is composed of capsular tissue spanning the interval between the superior aspect of the subscapularis and the anterior border of the supraspinatus. The coracohumeral ligament and superior glenohumeral ligament (SGHL) are 2 consistent capsular structures that reinforce the RI. The base of the RI is the coracoid process, and the apex is the transverse humeral ligament at the biceps intertubercular sulcus. 2,3 The RI appears to (1) resist inferior translation of the humeral head in the adducted shoulder, (2) resist posterior translation of the humeral head in the flexed or abducted and externally rotated shoulder, and (3) provide a limit to external rotation. [4][5][6][7][8] Laxity of the RI capsule can result in symptomatic glenohumeral instability, 9 whereas contracture of the RI is often encountered in arthroscopy for adhesive capsulitis. 10 Two studies have described RI closure as an isolated procedure for a mild form of glenohumeral instability. 8,9 Field et al. 9 performed isolated open closure of RI defects in 15 patients with recurrent shoulder instability symptoms, and all patients achieved good or excellent results with the American Shoulder and Elbow Surgeons evaluation scale and the Rowe rating scale. They concluded that approximation or imbrication of the RI may confer adequate stability in a select group of patients and obviate the need for a standard stabilization procedure.In this study we outline our technique for isolated RI closure in the appropriately selected patient with mild glenohumeral instability and recurrent symptoms. Diagnosis and Surgical TechniqueIn our experience careful examination combined with imaging studies can help to identify the appropriate surgical candidate (Table 1). Appropriate patients will have mild inferior laxity on examination with a 1þ (up to 1 cm of inferior translation) or 2þ (1 to 2 cm of translation) sulcus sign. With the patient supine and the shoulder in neutral rotation in the scapular plane, the patient may show mild anterior translation, but this should be insufficient to cause the humeral head to subluxate over the glenoid rim. Plain radiographs should not show evidence of Hill-Sachs or bony Bankart lesions, and magnetic resonance imaging should show no evidence of labral or capsular tears.In the operating room, inters...

Anatomical structure of the coracohumeral ligament and its effect on shoulder joint stability

“…Since Neer [16] first proposed to describe the portion of the rotator cuff between supraspinatus tendon and subscapularis tendon with the term "rotator interval" in 1970, many scholars have conducted a series of dissected anatomical and biomechanical studies on the RI and its composition [12,21,25]. In 1980, Neer and Foster [17] verified the effects of the RI on anterior shoulder stability.…”

Controversies In The Surgical Management Of Shoulder Instability: Associated Soft Tissue Procedures

“…Other authors recommend to repair rotator interval after arthroscopic shoulder instability surgery because this area has been weakened by the placement of two cannulas and can be origin to recurrent instability [ 36 , 37 ]. Also, isolated rotator interval closure has been advocated in patients with mild inferior laxity with positive sulcus test but no radiographic or magnetic resonance imaging evidence of labral or capsular tears [ 38 ]. Several techniques have been described to close the rotator interval.…”

“…After the sutures have been passed through, the surgeon has to tie them by a blind knot through one of the cannulas plicating the rotator interval. 35 Regardless the chosen technique, it is crucial to externally rotate the shoulder in some degrees to avoid overtightening of the closure leading postoperative loss of external rotation [ 35 , 38 ]. According to Randelli et al results in a homogenous series of patients [ 39 ], the average loss of external rotation after Bankart repair with rotator interval closure associated was 12.14 degrees along the side of the arm and 7.21 degrees at 90º of flexion what represents 17´8% and 8% of the arc of motion,getting 85.7% of good to excellent results in Rowe Score.…”

The Rotator Interval of the Shoulder

“…Thus, while surgical plication of the RI has been advocated in cases of RI injury as well as in specific cases of shoulder instability, 35 , 60 , 66 , 68 the true indications for these procedures remain controversial. One concern with performing RI plication, particularly in cases in which the procedure is unnecessary, is the potential for postoperative loss of external rotation.…”

“… 54 , 57 , 71 , 78 Historically, RI plication was performed via open surgical approaches; however, all-arthroscopic techniques for RI plication have more recently been described. 10 , 12 , 16 , 32 , 35 , 44 , 66 , 69 Of note, open and arthroscopic RI closure are different surgical procedures and plicate different tissues, each in a different biomechanical vector. Thus, when evaluating the literature on RI closure, the specific technique used must be considered.…”