CASE REPORT

Irreparable Capsule Tears in Initial Surgery
for Glenohumeral Instability:
Report of Two Cases Treated with Iliotibial Band AutograftKiyohisa Ogawa,1 Toyohisa Naniwa2 and Noriko Okuyama2Sports Clinic, School of Medicine, Keio University, Tokyo, Japan
Department of Orthopedic Surgery, School of Medicine, Keio University, Tokyo, Japan
12(Received for publication on January 13, 2009)(Revised for publication on March 4, 2009)(Accepted for publication on March 19, 2009)

Abstract
Anterior shoulder instability due to massive capsular tearing can usually be repaired by suturing the torn ends together with a satisfactory result. The purposes of this report are to demonstrate the presence of capsular deficiency irreparable by primary sutures even in an initial surgical intervention and to ponder the cause of primary irreparability. We documented the surgical reconstructive technique using the iliotibial band and the subsequent postoperative resultsin two cases. To our knowledge, there have been no such cases with primarily irreparable capsular tear. (Keio J Med 58 (3) : 185－189, September 2009)

Keywords: shoulder, instability, irreparable capsular tear, reconstruction, iliotibial band
Introduction

Case Report
Case 1

Occurring in a first-time traumatic anterior shoulder
dislocation is detachment of the ligamento-labro-periosteal complex from the glenoid edge, or the so-called
Bankart lesion. Both clinical and experimental demonstrations have shown that the joint capsule including theinferior glenohumeral ligament (IGHL) is injured independently or concurrently with the Bankart lesion.1-6
Tearing may occur at any site, be it laterally, in the midsubstance, or medially. Anterior instability due to capsular tearing can usually be repaired by suturing the tornends together with a satisfactory result.3, 7-11
We describe two cases experienced during open Bankart
procedure, in whom primary capsular repair was infeasible due to capsular deficiency including the IGHL despite an initial surgery to address anterior instability. We
also present the presumed cause of primary irreparability
and the surgical reconstructive technique we employed.
Informed consent was obtained from the patients for thiscase report.

A 30-year-old right-handed male visited our clinic witha complaint of left shoulder instability. He had sufferedleft shoulder subluxation due to a fall during snowboarding 4 years earlier, and had subsequently experienced atotal of 12 episodes of subluxation. On examination, decrease of elevation and external rotation was 35º as compared to his normal right shoulder, and the anterior apprehension test was intensively positive. Radiograms revealed a typical postero-lateral notch and mild osteoarthritis on the humeral head. Computed tomography (CT)using air contrast disclosed the bony defect of the anteroinferior glenoid and air-leakage into the subacromialbursa. Arthrography showed contrast medium leakage
from the supraspinatus tendon and a triangular bulge in
the antero-inferior joint cavity (Fig. 1a).
At operation, there was a small slit of the subscapularis
communicating with the joint cavity. When the subscap-Reprint requests to: Kiyohisa Ogawa, MD, Sports Clinic, Department of Medicine, Keio University, 35 Shinanomachi, Shinjuku-ku, Tokyo 160-8582, Japan,
Tel:+81-3-3352-9478, Fax: +81-3-3352-9467 E-mail: ogawa51@jcom.home.ne.jp
185Ogawa K, et al: Irreparable Capsule Tear of the Shoulder

186abcFig. 1 A 30-year-old male with complete rupture of the supraspinatus tendon.
(a): Arthrogram revealing a contrast medium leakage from the supraspinatus tendon into the subacromial bursa and a triangular bulge
in the antero-inferior joint cavity, the latter of which we had not preoperatively understood its meaning (white arrow).
(b): Schema showing the operative findings. The capsular tear ran longitudinally at its insertion onto the humeral neck down to thelowermost neck and then extended obliquely to midway of the capsule along the fiber bundles of the IGHL. The torn capsule wasreflected anteromedially.
(c): A 45°craniocaudal radiogram at the time of follow-up detecting mild osteoarthritis and a spur formation on the medial humeral
surgical neck (black arrow). The spur formation on the neck is inferred to represent a form of spontaneous healing consequent on
detachment of a part of the IGHL along with that of the adjoining periosteum.

ularis tendon was cut longitudinally and reflected medially, the humeral head was immediately exposed underneath. The capsular tear ran longitudinally at the insertion onto the humeral anatomical neck down to its lowermost end and then extended obliquely along the IGHL
fiber bundles. The torn capsule was reflected anteromedially with the attached deep muscle layer of the subscapularis (Fig. 1b) and no Bankart lesion was exhibited.
The torn capsule was fragile and contracted, and was impossible to suture it onto the original site even with theshoulder in neutral rotation. With the shoulder held in
90º abduction and external rotation in the scapular plane,
the humeral head was pushed backward and controlled
manually against its anterior protrusion. In this position,
the torn part along the IGHL fiber bundles ran transversely over the inferior one-third of the head and wassutured side to side. An irregularly tetragonal capsular
defect thence remained between the capsular stump andthe anatomical neck. While maintaining the apprehension position, the region encompassing the capsular defect was covered with the patient’s iliotibial band (ITB)in such a way that its main fiber bundles were aligned
horizontally. The ITB was then sutured onto both the labrum and the torn end of the capsule medially, onto theIGHL inferiorly, and onto the deep dissected stump of
the subscapularis tendon laterally. With the arm at theside and at 60º of external rotation, the ITB was further
sutured to the coracohumeral ligament. After an anterior
acromioplasty, the completely torn supraspinatus tendon

was sutured to the original site. Finally resutured was thesubscapularis tendon.
A follow-up at 11 years post-operatively revealed radiographic evidence of a spur formation on the medial
humeral neck and mild osteoarthritis (Fig. 1c). The
Rowe’s score was 95 points with 15º restriction in external rotation as compared to the normal joint.1 2 The patient had no apprehension toward any further dislocationin occupation (home electronic appliance repair), or recreational sports (e.g., skiing, snowboarding, tennis).
Case 2A 36-year-old right-handed male was examined with acomplaint of right shoulder instability. He first suffereddislocation due to forced extension of the joint 10 years
earlier when he took a hard fall during skiing. He incurred only a total of 3 episodes of dislocation thereafter
but had serious apprehension concerning possible furtherdislocation. On examination, range of motion was restricted 30º in elevation and 50º in external rotation ascompared to his left shoulder and the anterior apprehension test was strongly positive. Radiograms demonstrated a small postero-lateral notch on the humeral head.
Pneumoarthro-CTs revealed detachment of the anterior
labrum, an anteroinferior glenoid defect, and a sharply
demarcated contrast medium outflow into the subscapularis.
At operation, when the upper half of the subscapularisKeio J Med 2009; 58 (3): 185－ 189Fig. 2 Photogram showing an autologous ITB graft filling thecapsular defect (black arrows). It was sutured medially onto theglenoid margin in line with Rowe’s modification of the Bankart
procedure, onto the IGHL inferiorly, and laterally onto the deep
dissected stump of the subscapularis tendon.

was cut and reflected medially, the capsule was noted tobe torn at its junction with the labrum down to the 4o’clock position, with the tear thence running obliquely
in an inferolateral direction along the IGHL fiber bundles
and reaching the lowermost end of the humeral neck.
The labrum at the 1-to-5-o’clock position was detachedand medially transposed. Suturing of the capsular tornend onto the original site was infeasible with the shoulder in neutral rotation. With the same technique andshoulder position employed in Case 1, the capsular defect was filled with an autologous ITB graft. Medially,
the grafted ITB was sutured onto the glenoid margin(Fig. 2).
At 3 years post-operatively, there was no disturbanceto his daily living activities. The range of shoulder motion was restricted 20º in elevation and 20º in externalrotation, and the Rowe’s score was 90 points.12
Discussion
The IGHL itself functions as the primary check against
the forward translation of the humeral head in the apprehension position.1 3, 1 4 This ligament has its insertions
medially on the labrum and the anterior aspect of thescapular neck and laterally on the humeral anatomicalneck,1, 6 while the main collagen fiber bundles are oriented in a radial fashion so as to bind these insertions.1 5
Mechanical experiments have shown that disruption of
the IGHL can occur at any site along its course, includ-187Fig. 3 Scheme showing the course of capsular tears in the present
two cases with the shoulder in the apprehension position (boldline or dotted lines). In this shoulder position, the caudal part of
the IGHL tear proceeding along the orientation of its main fiber
bundle runs in a horizontal direction and lies just anterior to thehumeral head. The entire shape of the tear, therefore, is basically
L-shaped irrespective of the site of the IGHL rupture. Therefore,
the resultant capsular defects due to contraction of the torncapsule are irregularly tetragonal (fine line or dotted lines).

ing, most medially, detachment of the ligamento-labroperiosteal complex from the glenoid margin corresponding to the Bankart lesion, then the junction of the ligament with the labrum, midsubstance, and the insertion
on the humeral anatomical neck.5, 6 In the clinical setting,the Bankart lesion is known to occur in most cases of
initial traumatic anterior dislocation while in some cases
the IGHL is torn at the junction of the ligament with thelabrum, midsubstance, and at the insertion on the humeral neck; hence consistent with the results of experiments.1, 4 Tearing of the IGHL constitutes one of themain causes of recurrent anterior dislocation, as is thecase with the Bankart lesion, and it arises at any site
along its course just as in initial traumatic dislocation.3, 7-11 In the present series, the site of tearing was theinsertion on the humeral neck (Case 1), or the junction ofthe ligament with the labrum (Case 2). It is impossible toprove completely the existence of capsular tear from thepreoperative clinical findings and imaging including
MRI.
In our cases of IGHL tear including the two cases described herein, the caudal part of the tear runs obliquelyalong the orientation of the main fiber bundle of theIGHL, irrespective of the tear site.8 In the apprehension
position, this course of tearing along the IGHL main fiber-bundle runs in a horizontal direction and lies just anterior to the humeral head. With the arm in this position,
the entire shape of the tear is therefore basically
L-shaped irrespective of the site of the IGHL rupture(Fig. 3). The maximum principal nonrecoverable strain
direction does not coincide with the principal fiber bun-188

dle direction of the IGHL in studies in which a three-dimensional loading was applied via the humeral headwith the whole IGHL shape maintained intact.1 6 Therefore, it might not be unusual that tears occur in the direction consistent with the principal fiber bundle direction.
The L-shaped tears enable a substantially enormous
transposition of the torn capsular flap including theIGHL.
The deep layer of subscapularis has its insertion on theanterior capsule.1 7 Even in the case with the capsulartear, the torn end is not largely transposed insofar as integrity of the deep layer of the subscapularis inserted on
the capsule and the remainder of this muscle is maintained. However, if separation occurs between the deeplayer and the remainder of the subscapularis muscle, thetorn part of the capsule is largely transposed due to traction exerted by the deep layer of the subscapularis. Traction by this deep layer of subscapularis inserted on thetorn capsular flap was evident in Case 1 of the present
study. If the deep layer of the subscapularis separates
from the capsule, it makes the torn capsular part free.
This phenomenon was seen in Case 2. The capsular flap
substantially transposed, which is no longer extended inassociation with shoulder joint movement, graduallycontracts.
If the torn and contracted capsule is sutured to theoriginal site, it causes a marked restriction on externalrotation which may constitute a factor contributing to thedevelopment of osteoarthritis following surgery for anterior shoulder instability.18 Therefore, the shortened IGHL
must be complemented to restore its physiologicallength. The length to be made up should be determinedin the apprehension position at which the greatest strain
is imposed on the IGHL and the graft is sutured with thearm in this position. As the principal collagen fiber bundles of the IGHL run in a practically horizontal directionin this position, the major fiber bundles of the graft
should also be oriented in a horizontal direction accordingly. Because the torn capsular flap is fragile, the graft
is sutured on the glenoid margin or labrum medially andon the humeral anatomical neck or the deep layer of thesubscapularis tendon laterally so as to cover the defectand flap. Inferiorly, it is sutured side to side onto the upper margin of the intact IGHL. When the superior portion of the graft is sutured to the residual upper capsulewith the arm in apprehension position, external rotation
with the arm at the side is restricted. It should thus be sutured to the coracohumeral ligament with the arm at theside and in the externally rotated position. Iliotibial bandreconstruction was reported by Iannotti et al. in patientswith capsular and subscapularis deficiency after two or
more failed surgeries.19 In the cases they documented, agraft was folded twice into three layers because of thesubscapularis as the anterior dynamic stabilizer also being injured. Use of a single layer of graft is considered tobe sufficient in terms of strength for initial surgery as in

Ogawa K, et al: Irreparable Capsule Tear of the Shoulder

the present series. In a review of the literature, we could
find no case with primarily irreparable capsular tear andtherefore no reconstructive technique for it.
References
1. Nicola T: Acute anterior dislocation of the shoulder. J Bone Joint
Surg Am 1949; 31-A: 153－159
2. Bigliani LU, Polloch RG, Soslowsky LJ, Flatow EL, Pawluk RJ,
Mow VC: Tensile properties of the inferior glenohumeral ligament. J Orthop Res 1992; 10: 187－197
3. Wolf EM, Cheng JC, Dickson K: Humeral avulsion of glenohumeral ligaments as a cause of anterior shoulder dislocation. Arthroscopy 1995; 11: 600－607
4. Taylor DC, Arciero RA: Pathologic changes associated withshoulder dislocations: Arthroscopic and physical examination
findings in first-time, traumatic anterior dislocations. Am J SportsMed 1997; 25: 306－311
5. McMahon PJ, Tibone JE, Cawley PW, Hamilton C, Fechter JD,Elattrache NS, Lee TQ: The anterior band of the inferior glenohumeral ligament: Biomechanical properties from tensile testing inthe position of apprehension. J Shoulder Elbow Surg 1998; 7: 467－471
6. McMahon PJ, Dettling J, Sandusky MD, Tibone JE, Lee TQ: Theanterior band of the inferior glenohumeral ligament: Assessmentof its permanent deformation and the anatomy of its glenoid attachment. J Bone Joint Surg Br 1999; 81-B: 406－413
7. Bach BR, Warren RF, Fronek J: Disruption of the lateral capsuleof the shoulder. J Bone Joint Surg Br 1988; 70-B: 274－276
8. Ogawa K, Yoshida A: Extensive shoulder capsule tearing as amain cause of recurrent anterior shoulder dislocation. J ShoulderElbow Surg 1997; 6: 1－5
9. Bokor DJ, Conboy VB, Olson C: Anterior instability of the glenohumeral joint with humeral avulsion of the glenohumeral ligament: A review of 41 cases. J Bone Joint Surg Br 1999; 81-B: 93－96
10. Mizuno N, Yoneda M, Hayashida K, Nakagawa S, Mae T, Izawa
K: Recurrent anterior shoulder dislocation caused by a midsubstance complete capsular tear. J Bone Joint Surg Am 2005; 87-A:2717－2723
11. Rhee YG, Ha JH, Park KJ: Clinical outcome of anterior shoulder
instability with capsular midsubstance tear: A comparison of isolated midsubstance tear and midsubstance tear with Bankart lesion. J Shoulder Elbow Surg 2006; 15: 586－590
12. Rowe CR, Patel D, Southmayd WW: The Bankart procedure: A
long-term end-result study. J Bone Joint Surg Am 1978; 60-A: 1－16
13. Turkel SJ, Panio MW, Marshall JL, Girgis FG: Stabilizing mechanisms preventing anterior dislocation of the glenohumeral joint. J
Bone Joint Surg Am 1981; 63-A: 1208－1217
14. O’Brien SJ, Neves MC, Arnoczky SP, Rozbruck SR, Dicarlo EF,Warren RF, Schwartz R, Wickiewicz TL: The anatomy and histology of the inferior glenohumeral ligament complex of the shoulder. Am J Sports Med 1990; 18: 449－456
15. Gohlke F, Essigkrug B, Schmitz F: The pattern of the collagen fiber bundles of the capsule of the glenohumeral joint. J ShoulderElbow Surg 1992; 3: 111－128
16. Malicky DM, Kuhn JE, Frisancho JC, Lindholm SR, Raz JA, Soslowsky LJ: Nonrecoverable strain fields of the anteroinferior glenohumeral capsule under subluxation. J Shoulder Elbow Surg
2002; 11: 529－540
17. Clark J, Sidles JA, Matsen FA: The relationship of the glenohumeral joint capsule to the rotator cuff. Clin Orthop Relat Res
1990; 254: 29－34
18. Rosenberg BN, Richmond JC, Levine WN: Long-term followup

Keio J Med 2009; 58 (3): 185－ 189of Bankart reconstruction. Incidence of late degenerative glenohumeral arthrosis. Am J Sports Med 1995; 23: 538－544
19. Iannotti JP, Antoniou J, Williams GR, Ramsey ML: Iliotibial band

189
reconstruction for treatment of glenohumeral instability associatedwith irreparable capsular deficiency. J Shoulder Elbow Surg 2002;
11: 618－623