What is Shoulder Capsular Repair?
Shoulder capsular repair is a surgical procedure to treat shoulder instability that does not improve with more conservative or non-surgical methods.
The shoulder joint, also referred to as the glenohumeral joint, is a ball and socket joint, formed by the bone of the upper arm (humerus), which articulates with the shoulder blade (scapula) in a cavity called the glenoid fossa. A group of 3 ligaments called the glenohumeral ligaments form a capsule around the shoulder joint and connect the head of the upper arm bone to the glenoid cavity of the shoulder blade. The capsule forms a water-tight sac around the joint. Glenohumeral ligaments play a very important role in providing stability to the otherwise unstable shoulder joint by preventing dislocation.
Shoulder instability is a chronic condition that causes frequent dislocation of the shoulder joint as a result of damage to the shoulder capsule. A dislocation occurs when the end of the humerus (the ball portion) partially or completely dislocates from the glenoid (the socket portion) of the shoulder. A partial dislocation is referred to as a subluxation whereas a complete separation is referred to as a dislocation.
Shoulder capsular repair involves repairing the damaged or loose shoulder capsule to perform its stabilizing function using either a traditional open shoulder surgery approach with one large incision over the shoulder joint or a minimally invasive arthroscopic approach with a few small key-hole incisions around the shoulder joint.
Indications for Shoulder Capsular Repair
Shoulder capsular repair surgery is indicated as a treatment option for shoulder instability as a result of damage to the shoulder capsule due to conditions, such as:
- Injury or trauma to the shoulder
- Falling on an outstretched hand
- Repetitive overhead sports such as baseball, swimming, volleyball or weightlifting
- Loose shoulder ligaments or an enlarged capsule
The common symptoms of shoulder instability include pain with certain movements of the shoulder, popping or grinding sound that may be heard or felt, swelling and bruising of the shoulder seen immediately following subluxation or dislocation. Visible deformity and loss of function of the shoulder can occur after subluxation as well as sensation changes such as numbness. Partial paralysis can occur below the dislocation because of pressure on nerves and blood vessels.
Preparation for Shoulder Capsular Repair
Preparation for shoulder capsular repair may involve the following steps:
- A review of your medical history and a physical examination to check for any medical issues that need to be addressed prior to surgery.
- Diagnostic tests such as blood work and imaging to help detect any abnormalities that could compromise the safety of the procedure.
- Disclosing information about any allergies to medications, anesthesia, or latex.
- You should inform your doctor of any medications or supplements you are taking or any conditions you have such as heart or lung disease.
- You may be asked to stop taking medications, such as blood thinners and anti-inflammatories or other supplements for a week or two.
- You should refrain from alcohol and tobacco at least a few days prior to surgery and several weeks after, as it can hinder the healing process.
- You should not consume any solids or liquids at least 8 hours prior to surgery.
- You should arrange for someone to drive you home after surgery.
- A signed informed consent form will be obtained from you after the pros and cons of the surgery have been explained.
Procedure for Shoulder Capsular Repair
Shoulder capsular repair can be performed with two surgical approaches:
- Standard open surgery through a capsular shift in which an incision is made over the anterior (front) of the shoulder.
- Arthroscopic surgery where small incisions on the shoulder joint are made followed by insertion of an arthroscope into the joint.
Open Capsular Shift
In general, standard open capsular shift surgery for repairing the damaged or loose shoulder capsule involves the following steps:
- The procedure is performed under general and/or regional anesthesia with you lying either in a beach chair or lateral decubitus position.
- The skin around your shoulder is sterilized with an antiseptic solution, and an incision is made over the anterior of the shoulder joint.
- The overlying shoulder muscle (subscapularis) in front of the shoulder is detached to allow your surgeon to see inside the joint.
- The defective shoulder capsule is detected and split.
- The bottom portion of the shoulder capsule is pulled up, and then the top is pulled down to reduce the volume of the shoulder joint. This tightens the shoulder capsule including other ligaments that stabilize the shoulder. By tightening the ligaments, they are then able to perform their stabilizing function.
- A final shoulder assessment is performed to confirm satisfactory repair, and the skin incision is closed and bandaged.
Capsular Plication
A capsular plication is an arthroscopic surgery, which is less invasive than an open procedure. Healing is generally faster with minimal pain than with an open approach.
In general, arthroscopic shoulder capsular plication surgery involves the following steps:
- The procedure is performed under general and/or regional anesthesia with you lying either in a beach chair or lateral decubitus position.
- Your surgeon makes a few small incisions (arthroscopic portals), about half-inch in length, over your shoulder joint.
- An arthroscope - a slender tubular device attached with a light and a small video camera at the end - is inserted through one of the incisions into your shoulder joint.
- The arthroscope transmits the image of the inside of your shoulder joint onto a television monitor for your surgeon to evaluate the defects.
- Your surgeon then passes miniature surgical instruments through the other incisions and "grabs" the segment of the shoulder capsule and stitches it upon itself to tighten the capsular tissue.
- A final shoulder assessment is performed to confirm satisfactory repair, the instruments are withdrawn, and the skin incisions are closed and bandaged.
Postoperative Care and Recovery
In general, postoperative care and recovery after shoulder capsular repair will involve the following steps:
- You will be transferred to the recovery area where your nurse will closely observe you for any allergic/anesthetic reactions and monitor your vital signs as you recover.
- Following the surgery, your arm will be placed in a shoulder sling for 2 to 4 weeks to rest the shoulder and promote healing.
- You may experience pain, swelling, and discomfort in the shoulder area. Pain and anti-inflammatory medications are provided as needed to address these.
- Antibiotics are also prescribed to address the risk of surgery-related infection.
- You may also apply ice packs on the shoulder area to help reduce swelling and pain.
- Instructions on incision site care and bathing will be provided to keep the wound clean and dry.
- Refrain from strenuous activities and lifting heavy weights for at least a couple of months. A gradual increase in activities is recommended.
- An individualized physical therapy protocol is designed to help strengthen your shoulder muscles and optimize shoulder function.
- You will be able to resume your normal daily activities in 3 to 4 weeks, but with certain activity restrictions. Return to sports may take 6 months or longer.
- Refrain from driving until you are fully fit and receive your doctor's consent.
- A periodic follow-up appointment will be scheduled to monitor your progress.
Risks and Complications
Shoulder capsular repair is a relatively safe procedure; however, as with any surgery, some risks and complications may occur, such as the following:
- Infection
- Bleeding
- Postoperative pain
- Damage to surrounding structures
- Stiffness or restricted motion
- Thromboembolism or blood clots
- Anesthetic/allergic reactions
- Recurrence of instability
