ASSESSMENT AND SIGNIFICANCE OF STATE OF THE CAPSULE IN SURGICAL TREATMENT OF CHRONIC INSTABILITY OF THE SHOULDER JOINT

ASSESSMENT AND SIGNIFICANCE OF STATE OF THE CAPSULE IN SURGICAL TREATMENT OF CHRONIC INSTABILITY OF THE SHOULDER JOINT

Parshikov M.V., Uzhakhov I.M., Yarygin N.V., Guryev V.V., Teterskiy A.A., Perevedentseva A.M., Gneteckiy S.F., Govorov M.V.

Yevdokimov Moscow State University of Medicine and Dentistry, Semashko Road Clinical Hospital at Lyublino station of Russian Railways, Moscow, Russia

The shoulder dislocations consist 50-60 % of similar injuries to big joints. Their incidence is the highest among such injuries, with 90-97 % of anterior dislocations [1-4]. An injury-related shoulder dislocation causes the disorder in functioning of structures providing the stability of the shoulder joint. It can be the trigger for development of habitual dislocation of the shoulder [3, 5-7].
Shoulder plasty for such pathology is the standard surgery in various prevention and treatment facilities in our country and in the world [8-12]. But is it efficient in each case, and do surgeons receive appropriate results? The literature analysis gave “no” answer [11-13]. So, Hovelius, B. Sandström, M. Saebö analyzed the treatment results in more than 100 patients after 15 years from the moment of Bristow-Latarjet shoulder plasty. All patients showed various signs of arthropathy [14]. The Russian scientists Dlyasin N.G. and Norkin I.A. identified that 9.2 % of patients (among 54 patients who received such surgery) had the decrease in movement range by 20-30˚ as compared to the healthy shoulder joint [15]. A study by Bailie D.S. and Ellenbecker T.S. presented 23 cases of postsurgical chondrolysis, which was caused by laceration of scapular articular lip after use of the biodegradable screw in 14 cases [15]. At the same time, G.W. Misamore and W.A. Facibene treat the posterior instability of the shoulder joint with use of restoration of articular lip in combination with suturing of the appropriate part of the capsule. They have good results, particularly, in sportspeople: 13 persons received surgery; 14 persons resumed previous physical activity with restoration of sports results [16]. However, we did not find any studies of the shoulder joint capsule in the anterior part.
Objective – to estimate and define the dependence of condition of the capsule in surgical treatment of chronic instability of the shoulder joint. 

PATIENTS AND METHODS

We analyzed the treatment results of 37 patients in conditions of the clinical bases of the department of traumatology, orthopedics and disaster medicine of Yevdokimov Moscow State University of Medicine and Dentistry. During 2010-2016, 43 patients (age of 17-66) with chronic instability of the shoulder joint were treated in the traumatology and orthopedic center of Semashko Railway Clinical Hospital, and in the traumatology unit of Moscow City Clinical Hospital No.59 (the facility does not exist now). Among them, 37 patients were examined later. There were 40 men and 3 women.
The patients had the previous history of at least 3 dislocations. The period of the disease varied from one and a half of a month to 4 years and 8 months. Desault's bandage was used for immobilization after primary dislocation in 26 patients. 11 patients received the triangular bandage. Probably, one of the causes of primary dislocation of the shoulder was insufficient rigidity of immobilization.
The local status ofpatients was estimated with the following tests (the table 1).

Table 1. Clinical tests in diagnosis of shoulder joint instability

Positive

Negative

Reliability percentage

Anxiety symptom (Weinstein’s)

34

3

91.9 %

Relocation test

36

1

97.3 %

Drawer test

29

8

78.4 %

Load and shift test

29

8

78.4 %

Khitrov’s symptom

32

5

86.5 %

Karelin-Ivlev’s symptom (scissors symptom)

26

11

70.3 %

Sulcus symptom

29

8

78.4 %

The apprehensivenesstest (Weinstein’s symptom) was positive in 34 cases, whereas the patients did not have the feeling of anxiety. These patients had more than 20 times of reluxation of the shoulder joint. They considered the shoulder joint as the event, which did not cause significant discomfort or did not worse the life quality. Let’s note that they reduced the dislocation independently. This test was one of the most reliable and simple for identification of anterior instability. The relocation test was more specific for determination of anterior instability. It was positive for 36 patients. Therefore, this test was the most reliable that we used. The load and shift test did not show any results in 8 patients with developed muscles. The drawer test also did not show any results. These tests were positive in other 29 cases. Karelin_Ivlev’s symptom was positive in 26 patients and negative in 11. Khitrov’s symptom was positive in 32 patients. The sulcus test was positive in 29 patients. However, it was negative or weakly positive in patients with prominent muscle mass. Therefore, due to insufficient reliability, we made a decision to exclude Karelin-Ivlev’s symptom from the examination. Owing to high reliability, we conducted and will conduct the relocation test for all patients. Also the obligatory estimation of the tone of trapezius, deltoid and supraspinous muscles was carried out [6].
The statistical analysis of the data was conducted with the standard techniques with Microsoft Excel 13 and SТАТISТIСА 6.0. With the diagnostic test for susceptibility to diseases, we estimated the sensitivity and specificity of the above-mentioned tests. It allowed estimating the predictive value of positive and negative results for each test. The tables 2-3 present the results of the statistical examination. The following formulae were used:

Sensitivity = a / (a + b) x 100

Specificity = c / (d + c) x 100

Predictive value of positive result (+) = Sensitivity / (Sensitivity + d) x 100

Predictive value of negative result (-) = c / (b + c) x 100,

with a = true-positive; b = false-negative; c = true-negative; d = false-positive; PV (+) – predictive value of positive result, probability of disease in positive (abnormal) result; PV (-) – predictive value of negative result, probability of disease in negative (normal) result.

Table 2. Clinical tests in diagnosis of dislocation of long head of biceps

Positive

Negative

Reliability percentage

Anxiety symptom (Weinstein’s)

8

29

21.6 %

Relocation test

6

31

16.2 %

Drawer test

1

36

2.7 %

Load and shift test

2

35

5.4 %

Khitrov’s symptom

0

37

0 %

Karelin-Ivlev’s symptom (scissors symptom)

1

36

2.7 %

Sulcus symptom

4

33

14.5 %

Table 3. Statistical characteristics of clinical tests

Positive

Negative

Reliability percentage

Specificity, %

Predictive value of positive result, %

Predictive value of negative result, %

Anxiety symptom (Weinstein’s)

34

3

91.9 %

78.4 %

80.9 %

90.6 %

Relocation test

36

1

97.3 %

83.8 %

85.7 %

96.9 %

Drawer test

29

8

78.4 %

97.3 %

96.7 %

81.8 %

Load and shift test

29

8

78.4 %

94.6 %

93.6 %

81.4 %

Khitrov’s symptom

32

5

86.5 %

100 %

100 %

88.1 %

Karelin-Ivlev’s symptom (scissors symptom)

26

11

70.3 %

97.3 %

96.3 %

76.6 %

Sulcus symptom

29

8

78.4 %

89.2 %

87.9 %

80.5 %

The examination showed the hypertrophy of trapezius muscle, and deltoid and supraspinous muscular hypotrophy in all patients. Besides the clinical examination, two-plain X-ray examination, CT and MRI were used. 23 patients received Sverdlov’s shoulder plasty, 5 patients – Boychev’s plasty, 2 – lavsan plasty for humeral-coronoid and humeral-acromial ligaments, 6 – arthroscopic suture for articular lip with anchor fixation, 3 – arthroscopic suture for articular lip with anchors in combination with strengthening of the joint capsule according to the offered technique (Fig. 2), 4 – single strengthening of the capsule according to the offered technique (Fig. 1).

Figure 1. Isolated strengthening of the joint capsule



Figure 2. Bankart surgery combined with the capsule strengthening according to the offered technique


The strengthening of the capsule was realized as described below (the RF patent No.2392896). The surgery was initiated with exposure to the intertubercular region and with opening of the tendon sheath of caput longum. Then the joint capsule was dissected to the upper border of cavitas glenoidalis scapulae with exposure of the tendon to its place of fixing to tuberculum supraglenoidale, without dissection of the latter. The tendon was separated into two parts. The capsule was sutured under the tendon. At the next stage, the patient’s hand was abducted as far as possible. The first part of the separated tendon was shifted downwards and was fixed to the capsule with the suture, making the dublicator. Preserving the position of abduction, the shoulder was rotated outwards. The second part was placed along the anterior-internal surface immediately onto the capsule and was fixed in such position.
For estimation of the treatment results, the patients received the consultation and clinical examination. The postsurgical follow-up varied from one and a half month to 4 years and 8 months. For estimation of functional condition of the shoulder joint, we used the tests for identification of instability type, and special questionnaires. Pain, function, stability and range of movements were estimated with Rowe score. Pre- and postsurgical quality of life was estimated with WOSI (Western Ontario Shoulder Instability Index). Among 43 operated patients, 37 persons visited the control follow-up. Among 37 examined patients, 6 (16 %) ones showed the limitation of movement volume (the table 4) due to insufficient training of movements in the postsurgical period or due to absence of rehabilitation measures in view of physiotherapeutic procedures or remedial gymnastics. The muscular mass restored to the full degree in 31 (84 %) patients. 6 (16 %) patients showed the residual signs of hypotrophy: 3 patients – as result of recurrence of habitual dislocation, with decreasing load to the injured upper extremity, 3 – with limited load to the joint, although the events of recurrent dislocation were absent. The recurrent dislocation of the shoulder joint was identified in 3 (8 %) patients.
The analysis of the causes of failure showed the inconsistency of the anterior capsule with its thinning and increasing volume.

Table 4. Estimation of volume of movements in the retrospective group of patients

Volume of movements

Number of patients

Full volume of movements

31

Insignificant restriction of movements

3

Moderate restriction of movements

3


As known, computer tomography (CT) and magnetic resonance imaging (MRI) are used in many clinics along with standard examination. However according to a study by Goncharov E.N., CT does not have any diagnostic advantages in terms of identification of bone pathologies as compared to X-ray imaging. But it allows objective estimating the condition of bones in presence of limited motions or pain syndrome in some positions of the upper extremity [6]. As for MRI, it rarely gives the conclusion on the shoulder joint capsule. Such characteristics as thinning, thickening, edema or scarry are often missed. Moreover, some regions of the Russian Federation do not include enough medical facilities with MRI, and private centers can be absent at all.
Ultrasonic examination can estimate the shoulder joint capsule. It is the most available technique for medical care the in polyclinic. The advantages are low costs, absence of necessary preparation of the patient, a possibility for estimation of condition of the joint and the capsule during movement, and a possibility of realization by traumatologists-orthopedists after special courses. So, N.A. Eskin in his publication Ultrasonic Diagnosis in Traumatology and Orthopedics, describes the possibilities of the technique as replacement for magnetic resonance imaging in some clinical situations, adding some precise details to the clinical and morphological picture of the disease. Ultrasonic diagnosis allows visualizing the joint capsule with estimation of various regions, which pass into periarticular muscles and ligaments [17].
It stimulated us to add the ultrasonic examination to the presurgical complex of examination. For the moment of December 2018, the ultrasonic examination was conducted for 22 patients. Voluson E-6 was used. The time of primary dislocation was from 6 days to 11 months. The number of dislocations – 1-60. The X-ray examination showed some indirect signs of Bankart lesion in 14 patients, including 5 cases of its bone variant. 3 cases were associated with Hill-Sachs lesion. MRI showed Bankart lesion in 17 patients. CT showed Bankart lesion in 5 persons, and Hill-Sachs lesion in 3. Moreover, it is necessary to note that the above-mentioned examinations did not show the thinning of the joint capsule.
Ultrasonic examination was conducted in sitting position with patient’s hand fixed in the ulnar joint or straight. Obese patients or patients with developed muscles received the examination in supine position with maximal free movements in the joint. A pillow (sometimes a roller) was put between scapulas. The hands were abducted aside, with slight external rotation. However the advantage of this position is visualization of anterior parts of articular lip. Also in presence of Bankart lesion, with a necessity for functional studies, the first stage included the placement of the transducer in the standard plane. Then, without changing the transducer’s position, with preservation of standard plane of scanning and shoulder rotation, the dynamic study was conducted. It allowed estimating the articular lip. Moreover, despite of possible limitation in mobility of the shoulder joint, it can be examined while moving the transducer. This advantage was important for us considering the fact that external rotation and abduction of the unstable shoulder caused the threat of reluxation. The examination of the shoulder joint was conducted in four views: anterior, lateral, posterior and coronary, including 8 standard positions. For each view, the joint is examined in two almost perpendicular planes: in frontal, lateral and posterior planes – in longitudinal and transverse plane sections; in coronary view – in longitudinal plane section [17].
The detailed analysis of the data showed the thinning of the shoulder capsule in its anterior part on the side of chronic instability in 12 patients. The thickness of the capsule on the side of habitual dislocation was 0.26-0.44 mm, whereas on the side of the healthy joint it was 0.59-0.92 mm. Other 10 patients did not show any signs of the capsule thinning during ultrasonic examination.
Besides the estimation of the shoulder capsule, we examined the state of musculus biceps brachii. The examination was conducted in two views: anterior transverse and anterior longitudinal. Among 22 examined patients, 4 patients showed some degenerative changes with pain during physical load (weight lifting more than 5 kg), palpatory tenderness in caput longum. Other 4 patients showed the signs of tendinitis of caput longum tendon after ultrasonic examination. As result, the joint capsule was not strengthened during surgical examination. However, the anterior part of articular lip is difficult for visualization and is often absent due anatomic development.
The present study was approved by the interuniversity ethical committee (the protocol No.05-18, 24 May 2018).  

A clinical case

A patient R., male, age of 30, addressed to the clinic. He complained of chronic posttraumatic instability of the shoulder joint. He identified the first signs of the dislocation 8 years ago during playing volleyball in 2009. The dislocation was reduced within 6 hours. Plaster immobilization was performed. The dislocation was confirmed by X-ray examination. In 2009-2017, the patient noted some events of joint reluxation. He could reduce it by himself. MRI did not find any articular lip injuries or changes in the humerus head. However, the ultrasonic examination showed the 0.26 mm capsule thinning (Fig. 3). The shoulder function was 65 points according to ROWE. WOSI was 1,160 points. During surgery, an injury to articular lip (Bankart type) was identified. The volume of surgical intervention included the fixation of scapular articular lip with anchor fixators, and strengthening the shoulder joint capsule. The surgery was conducted with the arthroscopy technique. The blood loss was minimal. The surgery lasted for 1 hour and 45 minutes. Then the shoulder joint was immobilized with the orthosis for 4 weeks. The patient was examined after 8 weeks and 6 months. There were not any recurrent events of dislocation. The range of movements was full. There were not any limitations in physical load. ROWE was 95, WOSI – 185 after surgery.

 Figure 3. Ultrasonic examination of the shoulder joint (the joint capsule)

DISCUSSION AND RESULTS

The results of the complex study allowed optimizing the character and the volume of a surgical intervention, combining the various types of shoulder joint plasty in our practice, particularly, using the strengthening of the shoulder joint capsule in anterior and anterior-inferior part as addition to anchor fixation of an injured part of scapular labrum according to the offered technique. The surgical interventions with the shoulder joint capsule strengthening were conducted for 12 patients. 7 patients received the single surgery. The positive short term and long term results testify the appropriateness of additional strengthening of the capsule for its thinning during surgical treatment of patients with chronic instability of the shoulder joint. The data analysis shows the necessity for targeted estimation of the shoulder joint capsule by means of ultrasonic or MRI examinations which allow objective estimation of changes in all structures of the joint and selecting the optimal volume and pattern of a surgical intervention. However, our experience shows that MRI presents some difficulties for estimation of the state of the shoulder joint capsule. The subsequent study of changes in the capsule after dislocation, and monitoring at various time intervals will allow clearing the mechanisms of formation of chronic instability. 

CONCLUSION

Considering the above-mentioned characteristics of ultrasonic examination, we think that such examination should be included into presurgical investigation of patients with habitual dislocation of the shoulder, especially in regions with low availability of more complex and expensive techniques. Moreover, another direction is improvement in professional skills of ultrasonic diagnosis physicians with aim of more precise determination of indications for surgical interventions and for making a decision on necessary volume of surgical treatment. Expensive materials, and low availability of equipment and specialists in shoulder arthroscopy in some regions of RF dictate the necessity that orthopedic surgeons have to learn with opened plasty of the shoulder joint according to the offered technique. 

Information on financing and conflict of interests

The study was conducted without sponsorship. The authors declare the absence of any clear or potential conflicts of interests relating to publication of this article.

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