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solated electrothermal capsulorrhaphy in overhand athletes

erome G. Enad, MD, Neal S. ElAttrache, MD, James E. Tibone, MD, and Lewis A. Yocum, MD,os Angeles, CA

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he purpose of this study was to determine the efficacyf arthroscopic electrothermal capsulorrhaphy for the

reatment of instability in overhand athletes. Electro-hermal capsulorrhaphy without labral repair was usedo treat 20 symptomatic overhand athletes (15 base-all, 3 softball, and 2 volleyball). Nineteen patientsere evaluated at a mean of 23 months. Overallowe results were 10 excellent, 4 good, 2 fair, and 3oor, with a mean score of 82. The overall meanmerican Shoulder and Elbow Surgeons score was5.7 (mean pain score, 42.2; mean score for activi-

ies of daily living, 43.5). Two failures (ten percent)equired open shoulder stabilization. Ten athletes re-urned to their prior level of sport, three returned to aower level, and six were unable to return to theirport. These preliminary results indicate that treatmentf the overhand athlete with isolated electrothermalapsulorrhaphy is favorable but does not reproducehe success of open surgery. Overall recurrence andailure rates were high. Instability in overhand athletesay require something other than isolated electrother-al capsulorrhaphy to address laxity. (J Shoulder El-ow Surg 2004;13:133-7.)

lenohumeral laxity is common in the overhandthlete. The forceful overhand action places extremeemands on the shoulder. Chronic stress from repeti-

ive overhand throwing, serving, or swimming activi-ies may lead to attenuation of the anterior staticestraints. Over time, this may allow mild anteriorlenohumeral translation.11 Initially, increased activ-

ty of the dynamic stabilizers compensates for mildnstability. With continued overhand use, however,atigue of these muscles can lead to further anteriorubluxation of the humeral head with resultant micro-rauma and abrasion to the rotator cuff and la-rum.12,28 The most common symptom is pain at the

rom Kerlan-Jobe Orthopaedic Clinic.eprint requests: Jerome G. Enad, MD, LCDR, MC, USN, Bone andJoint/Sports Medicine Institute, Naval Medical Center, 27 Effin-gham St, Portsmouth, VA 23708 (E-mail: jgenad@mar.med.navy.mil).opyright © 2004 by Journal of Shoulder and Elbow SurgeryBoard of Trustees.

058-2746/2004/$35.00 � 0oi:10.1016/j.jse.2003.11.005

osterior glenohumeral joint line in the horizontallybducted and externally rotated (ie, cocking) posi-

ion.9,28

If a conservative rehabilitative program fails toeturn the athlete to competition in 3 to 6 months,urgery may be an option. The capsular laxity can beeduced by open anterior reconstruction. Labral de-achments (eg, Bankart or superior labral anterior-osterior [SLAP]) are uncommon findings.21 Openurgery has had good success in returning properlyelected patients to competition.1-3,8,19 Current stud-es on arthroscopic capsular shift to treat shouldernstability have included few overhand athletes.17,27

The past several years have seen an increase inreating shoulder instability with arthroscopic electro-hermal capsulorrhaphy (ETC).4-6,14,15,18,25,26 How-ver, the few reports involving overhand athletes havelso included concomitant labral repairs.5,13,25 Theurpose of this study is to review the results of an

solated ETC performed for the treatment of glenohu-eral instability in the overhand athlete without

abral detachment with a minimum follow-up of 16onths.

ATERIALS AND METHODS

From October 1997 and December 1999, a total of 23verhand athletes who exhibited symptoms of pain or insta-ility during sport were treated with ETC. Indications forperative intervention were shoulder pain, instability, oroth while in the position of horizontal abduction andxternal rotation during throwing or serving. Symptomsere unresponsive to activity modifications, antiinflamma-

ory medications, and a minimum of 3 months of a compre-ensive rehabilitative program emphasizing strengtheningf the dynamic stabilizers of the shoulder.8 Plain radio-raphs showed no signs of arthrosis or outlet impingement

hat may have contributed to the pain. Typically, such aatient would undergo an open anterior capsulolabral re-onstruction.8,19,24 ETC was attempted in a small sample ofatients presenting to a single group practice in order tovoid an open procedure. This decision was based solelyn surgeon preference. Excluded from the study were pa-

ients with prior shoulder surgery, concomitant bony proce-ures, or complete Bankart tear or labral detachment re-uiring stabilization and repair. These exclusionary criteriaermitted review of the results of an isolated ETC procedurenly and left a sample of 20 patients.

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134 Enad et al J Shoulder Elbow SurgMarch/April 2004

perative techniqueAll patients underwent the diagnostic arthroscopy and

TC procedure under general anesthesia in the lateralecubitus position. The shoulder was placed in 30° to 45°f abduction and 15° to 30° of forward flexion with 5 to 15

b of traction on the affected arm. Diagnostic arthroscopy ofhe glenohumeral joint was performed through a standardosterior portal and an anterior portal made at the rotator

nterval.7 Laxity of the glenohumeral ligaments, most com-only the anteroinferior band, and a positive drive-through

ign were noted in each patient. Partial tears or fraying ofhe labrum, biceps anchor, or rotator cuff was debridedith a motorized shaver.Thermal capsulorrhaphy was performed with a monopo-

ar Oratec thermal probe (Oratec, Inc, Menlo Park, CA),ith power set at 40 W and temperature at 65°C to 67°C.he probe was introduced through the anterior portal andsed to shrink the glenohumeral ligaments thermally, begin-ing along the inferior aspect of the inferior glenohumeraligament, passing medially to laterally, and advancinguperiorly to include shrinkage of the middle glenohumeraligament.4 Because symptoms were attributed predomi-antly to anterior instability, the rotator interval and poste-ior capsule were not treated. Capsular shrinkage waserformed by use of a striping pattern (mean, 3-5 stripes)ith areas of normal untreated tissue between each stripe;ainting or a grid pattern of thermally treated tissue was notone. There was visible darkening and contraction of theapsule with the shrinkage. The drive-through sign wasliminated in each case, and subluxation of the humeralead was decreased. The affected arm was then placednto a sling with the shoulder in slight abduction and internalotation.

A padded sling was maintained for 4 weeks after theperation.4 During the period of immobilization, only ac-

ive range-of-motion exercises of the wrist and elbow wereermitted. Gentle Codman exercises of the shoulder werellowed. After the period of immobilization, range of mo-

ion of the shoulder was allowed to 20° of external rotation,0° of forward flexion and abduction, and 10° of extensionntil 6 to 8 weeks postoperatively. After 6 to 8 weeks,ggressive range-of-motion and strengthening exercisesere initiated. Passive stretching was limited to 10° to 20°

ess than that in the opposite shoulder in forward flexion,bduction, and external rotation. The patient was allowed

o achieve the final end range of motion actively over timeith activity to minimize the risk of stretching the repair.verhand throwing and serving were not allowed until ainimum of 12 weeks postoperatively. Maximal effort andelocity were allowed when full motion and strength wereegained.

Patients were evaluated at follow-up with a physicalxamination and functional questionnaire based on theodified American Shoulder and Elbow Society assess-ent.22 Postoperative function was also evaluated andraded by use of the system of Rowe et al.23 Failures wereefined as recurrent symptoms requiring further surgery for

nstability or a fair or poor result based on the criteria ofowe et al.

All data were acquired on a Microsoft Excel spreadsheetMicrosoft, Redmond, WA). Mean values and SD are pre-ented for ranges of motion. Mean values and ranges are

resented for all other continuous data. The small sampleize precluded meaningful statistical analysis between de-criptive parameters.10

ESULTS

Of 20 patients, 19 (95%) were available for eval-ation at a mean of 23 months (range, 16-39onths). The preoperative demographic data are

ummarized in Table I. The mean age at treatmentas 21.8 years (range, 15-36 years). There were 15ale and 4 female subjects. The dominant extremityas involved in all cases (11 right and 8 left). Threeatients could recall a distinctive throwing episodehen symptoms began, whereas sixteen were asso-iated with repetitive microtrauma during overhandctivities. Each patient participated in an overhandport at a competitive level, including baseball (15),oftball (3), and volleyball (1). Preoperative symptomsere pain alone in 14 patients (74%), pain and

nstability in 4 (21%), and instability alone in 1 (5%).o patient had a history of frank dislocation requiring

eduction by a clinician. Symptoms had been presentor a mean of 9.6 months (range, 3-46 months).

On physical examination, 9 patients had a positiventerior apprehension test. Fifteen had relief of either

heir apprehension or pain with the relocation test.ach patient demonstrated translational laxity of thenvolved shoulder of at least one grade higher thanhe uninvolved shoulder in one or more directions.1hysical examination demonstrated predominantlynterior instability in 14 patients and anteroinferior

nstability in 5.Examination with patients under anesthesia con-

rmed the preoperative diagnosis in each case. Nonef the shoulders demonstrated more than grade 1 or

able I Preoperative demographic data

o. of patients 19ge (y) [mean (range)] 21.8 (15-36)exMale 15Female 4

ymptom duration (mo) [mean (range)] 9.6 (3-46)redominant instability patternAnterior 14Anteroinferior 5verhand sportBaseball

High school 3College 2Professional 10

SoftballRecreational 1High school 1College 1

VolleyballHigh school 1

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J Shoulder Elbow Surg Enad et al 135Volume 13, Number 2

instability compared with the contralateral side.1ssociated findings at arthroscopy are summarized inable II. Two patients had chondromalacia of theumeral head articular surface. Fraying of the labrumt the biceps anchor indicative of a SLAP tear, type 1,as noted in 11 patients. Fraying or partial-thickness

earing of the rotator cuff crescent overlying the pos-erior-superior labrum in the abducted–externally ro-ated position, corresponding to the lesion of internalmpingement, was noted in 8 patients.

On follow-up physical examination, forward flex-on averaged 175° � 9.3° compared with 180° onhe contralateral side. External rotation with the armt the side averaged 61° � 8.8° versus 65° on theontralateral side. External rotation with the arm ele-ated averaged 96° � 16.4° versus 95° on theontralateral. Internal rotation averaged as follows:humb reaching eighth thoracic vertebral level �1.7evels (vs T8 on the contralateral side).

The mean postoperative American Shoulder andlbow Surgeons score was 85.7 (range, 39.2-100),ith a mean pain score of 42.2 (range, 15-50) and aean activities of daily living score of 43.5 (range,6.7-50). There were no significant differences seen

n American Shoulder and Elbow Surgeons scoresith regard to age, duration of symptoms, trauma,resence of apprehension or relocation signs, diag-osis, or sport.

The mean postoperative Rowe score was 82range, 40-100), yielding 10 excellent, 4 good, 2air, and 3 poor overall results. Seventy-four percentf the patients had a good or excellent result (Table

II). There were no significant differences seen inowe scores with regard to age, duration of symp-oms, trauma, presence of apprehension or relocationigns, diagnosis, or sport.

able II Intraoperative arthroscopic findings

ankart* 0ill-Sachs 0umeral head chondromalacia 2

nternal impingement 8ull-thickness rotator cuff tear 0uperior labral fraying 11

The presence of a Bankart tear (i.e., anterior-inferior labral detach-ent) was an exclusionary criterion.

able III Overall results based on Rowe et al23 scores

Rating ScoresNo. of

patients

xcellent 90-100 10ood 89-75 4

air 74-51 2oor �50 3

At latest follow-up, 10 patients had returned toheir prior level of sport, 3 returned to a lower level,nd 6 were unable to return to their sport (Table IV).ive patients were unable to return to sport because ofecurrence of their preoperative symptoms of pain,nd one patient could not return because of recur-ence of instability symptoms. All volleyball and soft-all players returned to their same level of sport. Onlyof 3 high school baseball players and 4 of 10

rofessional baseball players returned to their priorevel. Of the 10 professional baseball players, 4 werenable to return to any level of their sport. Neither ofhe 2 college baseball players returned to any level ofheir sport.

No operative complications, nerve deficits, oround infections occurred in any patient. At latest

ollow-up, 1 patient lacked more than 10° of externalotation and another patient lacked more than 10° oforward flexion when compared to their unoperatedides. Two patients required a second open anteriorrocedure to address recurrent symptoms of instabil-

ty.Of the 3 poor results, 2 required an open surgical

tabilization for recurrence. One patient was a highchool baseball player who returned to competition2 months postoperatively but had the same painfulymptoms recur. He underwent an open capsular shift4 months after the index procedure and was able toarticipate in junior college baseball the followingear. Another patient was a professional baseballlayer who exhibited similar symptoms of pain whene resumed throwing 6 months postoperatively. Henderwent an anterior capsulolabral reconstruction 8onths after the index procedure and returned torofessional baseball the following year. The thirdatient was a professional baseball player who hadecurrent symptoms of pain when he resumed throw-ng 6 months postoperatively. He chose to have nourther treatment and, 2 years after surgery, was stillnable to participate in baseball because of contin-ed symptoms in his shoulder.

able IV Level of return to sport after electrothermal capsulorrhaphyn 19 patients

SportSamelevel

Lowerlevel

Did notreturn

aseballHigh school 2 1 —College — — 2Professional 4 2 4

oftballRecreational 1 — —High school 1 — —College 1 — —

olleyballHigh school 1 — —

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ISCUSSION

In 1991 Jobe et al8 described the use of anteriorapsulolabral reconstruction to treat shoulder instabil-ty in overhand athletes. By using their original openurgical technique or a modification thereof, theseuthors reported that over 92% of patients returned toompetition.8,19,24 Using a humeral-based inferiorapsular shift procedure, Bigliani et al3 reported on aubset of 31 overhand athletes treated for instability.ll 31 patients returned to their sport, and 22 (71%)

eturned to the same level.There have been few reports on the treatment of

verhand athletes with ETC. In a retrospective,atched controlled study, Savoie and Field25 com-ared the results of arthroscopic capsular shift, laser-ssisted capsulorrhaphy, and ETC for the treatment ofultidirectional instability (MDI) and noted recurrence

ates of 10%, 3%, and 6.7%, respectively. In thattudy 80% of athletes in each group returned to theirrevious level of sport. In another matched controlledtudy, Levitz et al13 noted that when ETC was addedo the arthroscopic treatment of microinstability inaseball players, 93% of patients returned to compet-

tive play versus 80% who had arthroscopy withoutTC. Of note, subjects who had concomitant labralepairs (including SLAP and Bankart tears) were in-luded in these reports.

The current study describes the short-term results ofn isolated ETC for the treatment of symptomatichoulder instability in overhand athletes. Only 13 of9 patients (68%) returned to their previous sport,nd only 10 returned to their previous level. There arefew possible causes for the high failure rate. First, it

s possible that some of the patients with bidirectionalnstability may have had true MDI, and therefore,hese shoulders would have also required closure ofhe rotator interval to address the instability.15,25

anton5 has noted that patients with MDI treated withTC have less consistent results than those with unidi-ectional anterior instability. A second possible factoray have been unrecognized—unstable SLAP tears

n some of the labra that were debrided. Morgan etl20 noted that the relocation maneuver was highlyensitive for unstable posterior SLAP lesions in symp-omatic overhead athletes with subtle instability. Theombination of labral repair and ETC seems to im-rove the overall results in overhand ath-

etes.5,13,18,25 A third possible contribution to surgi-al failure might involve the undefined effects on theollagen ultrastructure after thermal treatment.16 Fi-ally, postoperative rehabilitation may have contrib-ted to the mixed results. In a follow-up report, Fan-on5 noted that postoperative immobilization may beeeded for at least 4 weeks to treat capsular laxity,hereas our patients discontinued the use of slingsfter 4 weeks. Furthermore, our patients were al-

owed to participate in overhand activities at 12eeks postoperatively, whereas other authors haveaited longer before initiating overhand exercis-s.5,13

A number of weaknesses exist in this study. Dataere collected retrospectively and did not allow for aomparison group. The strict inclusion criteria (eg, norior shoulder surgeries, no labral detachment) re-ulted in a more specific but small sample size, whichimited the benefit of meaningful statistical analysiscross parameters without introducing a type II er-or.10 Moreover, our data suggest that the etiology ofnstability in the overhand athlete is multifactorial andariable. No attempt was made to compare our sam-le with a cohort of open reconstruction or arthro-copic suture capsulorrhaphy. Lastly, the follow-uperiod was short, and continued evaluation of theseatients will determine whether the results deterioratever time.

In summary, an isolated ETC procedure was safelyerformed in 19 overhand patients with symptomaticlenohumeral instability. At 16-month minimum fol-

ow-up, the preliminary results are favorable but doot reproduce the success of open surgery. With 2eoperations, 5 fair or poor results, and 6 patientsnable to return to their sport, failure rates for thisnique population are unacceptably high. This studyuggests that overhand athletes may require treatmentther than an isolated ETC procedure (eg, labralepair, rotator interval closure) to address the instabil-ty. Therefore, current indications for ETC should beetter defined, and further long-term results areeeded before its isolated use can be recommendedn the overhand athlete.

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