Dr. Kevin Yip

Dr Kevin Yip
Orthopaedic Surgeon
MBBS(UK), FRCS(EDIN), FAM(SING), FHKCOS(ORTHO)

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Capsular Plication

Capsular plication is used to tension abnormally lax or redundant tissue that is often found in patients with MDI or atraumatic anterior or posterior instability. For posterior instability and MDI, the joint is visualized through the anterior cannula while the posterior cannula is used for instrumentation. Using the motorized shaver on reverse without suction, the posterior capsule is abraded to promote healing.

The shift begins at the six o’clock position. Using an angled shuttling instrument, the capsule is grasped and the sharp tip of the instrument is passed through it and through the labrum. The shift begins about 1.5 cm lateral to the glenoid rim. When working on the posterior capsule, the angled shuttling instrument usually has a curve in the opposite direction of the side of shoulder being worked on (i.e., in a right shoulder posterior capsule, use a left-curved shuttling instrument).

This is the opposite scenario than what is encountered when working on the anterior capsule, where the instrument curve is the same as the side of the shoulder being worked on (i.e.,. right shoulder anterior capsule, right curved shuttling instrument). A monofilament suture or shuttle relay (Linvatec, Largo, FL) is then passed through the capsule and labrum. A sliding, locking knot is used to fold the capsule over itself and create a “bumper” of capsulolabral tissue.

The same steps are repeated at the seven, eight, and nine o’clock positions to complete the inferior and posterior capsular shifts. After the posterior capsular
capsulorraphy, the capsular shift is repeated at the five and four o’clock positions to tighten the anteroinferior capsule.

In MDI cases with global placement of anchors and plication, sometimes it can be helpful to place and tie the anterior five o’clock anchor first before moving to complete the posterior capsule plications. In this situation the rest of the anterior anchors are then placed after completion of the posterior capsule.

Placing the anterior five o’clock anchor prior to the posterior capsular plication can sometimes be helpful because this anterior-inferior position can be very hard to reach after a complete posterior capsule plication has been performed.

In the case of a posterior Bankart lesion, the lesion is released and mobilized as described for anterior instability. With the use of the motorized shaver, electrocautery, and small elevator, the capsulolabral tissue is released mobilized and the glenoid rim abraded. Here again, drill holes are made on the edge of the glenoid rim, or a few millimeters on the glenoid face.

The anchors are inserted through a posterior portal. In some cases it may be helpful to place an accessory posteroinferior portal (and slightly more lateral than a standard posterior portal) that provides a better angle and approach to the inferior capsule and glenoid rim. While viewing from the anterosuperior portal or from the standard anterior portal.

The same steps as described previously are repeated to tension the posterior capsule superiorly to nine o’clock position. Complete repair is assessed from both the anterior and the posterior portals.

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