Massoud SN, Levy O, Copeland SA
Journal of Shoulder and Elbow Surgery 2007 ;16 (1):43-48.
The management of this particular group of patients is extremely difficult and usually the patient responds to physiotherapy in 80% of cases. In those patients whose voluntary shoulder instability has responded to physiotherapy but are still left with symptomatic involuntary instability should be offered surgery. Patients who have psychological disorders should not be offered surgery.
The traditional surgery for these patients is an inferior capsular shift which is an open procedure and can result in intra and extra-articular scarring. It has a success of 50-60% in voluntary instability. The authors performed a non randomised, prospective study of an alternative form of arthroscopic surgery using radiofrequency probes to shrink the redundant shoulder capsule.
They studied 13 patients in whom voluntary instability had ceased but involuntary instability continued to be a problem with pain or disabling instability despite 12 months of physiotherapy. Patients were followed up for an average of 45 months. All patients had multidirectional instability except one who had antero-inferior instability. 4 patients had prior instability surgery.
All surgeries were performed by arthroscopic radiofrequency shrinkage of the capsule and ligaments in the lateral decubitus position. Patients were assessed using a Rowe score, Constant score and patient satisfaction with a simple grading system (much better, better, same or worse) up to one year post operatively.
The authors conclude that radiofrequency capsular shrinkage is not helpful when patients have had prior failed surgery for voluntary instability, as all four patients had a recurrence of their instability. In patients who have failed physiotherapy and have symptomatic involuntary instability the results following radiofrequency capsular shrinkage are poor but results are improved with repeated radiofrequency shrinkage.
The authors also recommend not using interscalene anaesthesia to avoid potential injury to the axillary nerve by monitoring of the nerve activity intraoperatively when the radiofrequency probe is in close proximity. The authors also point out their low numbers in this study and the short follow up period but within a short period of time we can see that capsular shrinkage does not appear to be helpful in achieving stability unless performed repeatedly. A randomised blind prospective study comparing capsular placation to capsular shrinkage was also suggested.
