Multidirectional Shoulder Instability With Bone Loss and Prior Failed Latarjet Procedure: Treatment With Fresh Distal Tibial Allograft and Modified T-Plasty Open Capsular Shift

Abstract

Recurrent multidirectional shoulder instability (MDI) is a challenging clinical problem, particularly in the setting of connective tissue diseases, and there is a distinct lack of literature discussing strategies for operative management of this unique patient group. These patients frequently present with significant glenoid bone loss, patulous and abnormal capsulolabral structures, and a history of multiple failed arthroscopic or open instability procedures. Although the precise treatment algorithm requires tailoring to the individual patient, we have shown successful outcomes in correcting recurrent MDI in the setting of underlying connective tissue disorders by means of a modified T-plasty capsular shift and rotator interval closure in conjunction with distal tibial allograft bony augmentation. The purpose of this Technical Note was to describe a technique that combines a fresh distal tibial allograft for glenoid bony augmentation with a modified T-plasty capsular shift and rotator interval closure for the management of recurrent shoulder MDI in patients presenting with Ehlers-Danlos syndrome or other connective tissue disorders after failed Latarjet stabilization.

Comprehensive Review of Multidirectional Instability of the Shoulder

“…A recent technique article described using a distal tibia allograft in combination with open T-plasty capsular shift and rotator interval closure for recurrent MDI in patients with Ehlers-Danlos syndrome after a failed Latarjet. 40 However, neither of these articles assessed outcomes, complications, or recurrence rates to validate these techniques in any capacity. 39,40…”

Open Stabilization Procedures of the Shoulder in the Athlete: Indications, Techniques, and Outcomes

“…39 Many techniques have since been proposed. 10,15,39,[79][80][81][82][83][84] Miller et al compared efficacy of three anterior techniques, humeral-based (group A), glenoidbased (group B), and a central vertical capsular shift (group C) by monitoring capsular volume change in 24 fresh-frozen human cadaver shoulders. 79 While all three significantly reduced capsular volume (A = 48.9%, B = 36.8%, and C = 40.3%), authors recommended use of the humeral-based capsular shift, as it led to the largest volume reduction that was significantly higher than the glenoid-based group.…”

Surgical Management of Shoulder and Knee Instability in Patients with Ehlers-Danlos Syndrome: Joint Hypermobility Syndrome

“… 10) In addition, significantly increased capsular redundancy has been observed during the intraoperative evaluation of the shoulder joint in patients with hEDS/JHS compared to patients with shoulder instability without underlying connective tissue disease. 14 15) Therefore, shoulder stabilization procedures that have been proven to be effective in patients without hEDS/JHS might not yield equally successful outcomes in patients with connective tissue disorder. For this reason, bony augmentation procedures that increase the articular surface of the shoulder and rely less on the stabilization properties of the soft tissues might be preferred in patients with hEDS/JHS.…”