Laser Capsulorrhaphy for MDI

Abstract & Commentary

Synopsis: Laser capsulorrhaphy may be effective for patients with acquired multidirectional instability (MDI) secondary to repetitive microtrauma but is less predictable in other patient subgroups.

Source: Joseph TA, et al. Laser capsulorrhaphy for multidirectional instability of the shoulder. Am J Sports Med. 2003; 31:26-35.

The use of thermal energy has gained popularity within the orthopedic community due to its minimally invasive approach and ease of use. Early anecdotal results of laser capsulorrhaphy for treating shoulder instability appear promising; however, these studies have included mixed patient populations, inconsistencies in defining MDI, and various combinations of surgical procedures for treatment. The present study evaluates patient satisfaction and functional outcomes after Ho:YAG laser capsulorrhaphy treatment of MDI in 3 specific patient subgroups.

Joseph and associates define MDI as global shoulder laxity on physical examination with symptoms inferiorly and in at least 1 other direction. Twenty-five shoulders in 21 patients met the inclusion criteria for this study—patients with MDI who had no prior surgical procedure to address instability and no concomitant surgical procedures to address other shoulder pathology. All patients had failed a course of at least 3 months of physical therapy. Patients were classified etiologically: Type I—congenital/inherited with generalized ligamentous laxity and no history of trauma; Type II—acquired with history of repetitive microtrauma; and Type III—post-traumatic with identifiable traumatic event precipitating onset of symptoms. Postoperative questionnaires assessing patient satisfaction and level of pain, the Simple Shoulder Test (SST), and physical examination were used to evaluate outcomes.

Type I patients (n = 10) tended to present at a younger age and became symptomatic with activities of daily living. Type II (n = 6) patients commonly had less severe instability. Pain represented a more significant and consistent symptom in Type III patients (n = 9). At a mean follow-up of 32 months (range, 24-48 months) 10 of 25 shoulders (40%) experienced recurrent postoperative instability, with 8 of these patients remaining stable for at least 1 year after the procedure. Patients with generalized ligamentous laxity had a 60% recurrence (9 of 15) compared to 10% of those (1 of 10) without generalized ligamentous laxity (P < .05). Recurrence rates based on etiology were 60% for Type I, 17% for Type II, and 33% for Type III (P = 0.20). Mean SST and pain scores at most recent follow-up were 84% and 3.3 (10-point scale), respectively. Shoulder strength was near or equal to that of the opposite extremity in all patients at most recent follow-up, and no patient lost more than 10 degrees of forward elevation, external rotation, or 3 spinal levels of internal rotation. Patient satisfaction with the procedure showed a significant decline from follow-up at 1 year (80%) to the most recent follow-up (44%) (P = .008), respectively. Reasons for dissatisfaction included recurrent instability, persistent pain, and inability to participate in desired activities due to shoulder discomfort. Five of 6 shoulders (83%) with Type II MDI reported subjective improvement after the procedure, while only 4 of 10 (40%) with Type I and 2 of 9 (22%) with Type III noted improvement (P = 0.06).

Comment by Brian J. Cole, MD, MBA, and Stephen J. Lee, BA

With the advancement in surgical techniques and equipment, the use of arthroscopic stabilization has rapidly increased. However, outcome studies must demonstrate similar or better results compared to an open inferior capsular shift, the standard surgical treatment, to justify their use. The findings of this study suggest laser capsulorrhaphy may be an effective treatment or patients with Type II MDI and those without generalized ligamentous laxity. However, the sharp rise in recurrence rates and decline in satisfaction 1 year after the procedure indicate that these outcomes may only be of short-term benefit. Long-term clinical outcome studies are needed to assess the clinical efficacy of this technology and its potential use in the treatment of shoulder instability.

Dr. Cole is Assistant Professor, Orthopaedic Surgery, Rush Presbyterian Medical Center, Midwest Orthopaedics, Chicago, IL.
Stephen J. Lee, BA, Northwestern University Feinberg School of Medicine, Chicago, Ill.