MDI Arthroscopic Capsular Plication

Shoulder capsule anatomy

synonyms: multi-directional instaiblity of the shoulder

MDI Arthroscopic Plication CPT

MDI Arthroscopic Plication Indications

  • Failed non-operative management of MDI

MDI Arthroscopic Plication Contraindications

  • Emotional/psychological problems
  • Congenital glenoid aplasia
  • Hypoplasia
  • Non-compliance with therapy
  • Workman’s comp
  • Axillary/suprascapular nerve injury

MDI Arthroscopic Plication Alternatives

  • Open anterior-inferior Capsular shift (Pollock RG, JBJS 2000:82:919).
  • Thermal capsular shrinkage: risks chondrolysis (Levine WN, JBJS 2005;87A:616), capsular thinning / recurrent instability (Park HB, AJSM 2005;33:1321).

MDI Arthroscopic Plication Planning / Special Considerations

  • Essential components=rotator interval closure & reduction of joint volume
  • Goal: FE=160, IR=T-8, ER=30 degrees
  • Closure of the rotator interval has not been definitively shown to enhance stability or improve outcomes for patients with MDI.

MDI Open Technique

  • Sign operative site.
  • Pre-operative antibiotics, +/- regional block.
  • EUA
  • Beach chair, eye patches, bony prominences well padded, arm prepped and draped
  • standard axillary incision from coracoid to axilla, in the anterior axillary fold
  • inject 1% lido with epi along incision
  • cephalic vein, deltopectoral interval
  • cephalic vein preserved and taken laterally with deltoid(repair cephalic vein lacs with 8-0 nylon)
  • can release proximal 1-2cm of pectoralis insertion for improved inferior exposure. 
  • Richardson retractors to reflect deltoid laterally, pec medially
  • incised clavipectoral fascia just lateral to conjoined tendon.
  • axillary nerve palpated by sliding finger along anterior border of subscapularis.  Should be at @ 6o’clock position.
  • retract conjoined tendon to expose subscapulairs
  • anterior humeral circumflex vessels preserved(on inferior third of subscapularis tendon)
  • small Darrach retractor placed in rotator interval
  • proximal 2/3 of subscapularis incised 1.5-2cm from lesser tuberosity insertion
  • subscapularis tendon reflected off anterior capsule
  • horizontal incision in line with tendon fibers separating proximal 2/3 form distal 1/3.  Distal 1/3 preserved.
  • #2 Ethibond placed in subscap tendon
  • inferior subscap reflected form capsule with periosteal elevator
  • Scoffield retractor placed in interval protecting axillary nerve
  • capsule exposed from 12o’clock to 6o’clock position
  • anterior capsule incised midway between glenoid and humeral attachments from rotator interval to 6 o’clock position
  • horizontal mattress sutures placed in medial capsule, sutures exit extra-articular
  • retract medial capsule to exposed glenoid rim; evaluate for Bankart lesion decorticate anterior glenoid with bur
  • 2-3 suture anchors placed from 2-6o’clock for right shoulder, 10-6o’clock for left shoulder
  • Rowe or Fukuda retractor pushing HH posteriorly may aid exposure.
  • any rotator interval defect repair/closed
  • medial capsule shifted laterally and superior beginning with most inferior suture.
  • inferior sutures tied at abducted 90, ER 50
  • middle suture tied at abducted 45 ER 40
  • superior sutures tied at arm at side ER 30
  • check ROM
  • irritation
  • repair subscapularis using previously placed stay sutures, repair horizontal defect with #2 ethibond
  • check ROM
  • irrigate
  • palpate Axillary nerve
  • SQ closed with 2-0 inverted interrupted Vicryl
  • skin closed with 3-0 running SQ stich
  • mastisol, steri-strips-zerofrom-4x4-ABD-foam tape-shoulder immobilizer

MDI Arthroscopic Plication Complications

  • Neurologic injury; 8.2% incidence after anterior reconstruction for recurrent GH instability. 78% recover completely. (Ho E, JSES 1999;8:266-270). Axillary nerve, Brachial plexus
  • Loss of ER, with eventual GH DJD.
  • Recurrent MDI
  • Pain
  • Hardware failure / Anchor pull-out
  • Infections
  • Stiffness
  • CRPS
  • Fluid Extravasation:
  • Chondrolysis: though to be related to heat from electo cautery or radiofrequency probes used during capsular release or capsular shrinkage.
  • Hematoma
  • Chondral Injury / arthritis
  • Instrument failure
  • Weakness

MDI Arthroscopic Plication Follow-up care

  • Post-op: shoulder immobilizer, remove dressing at 72 hrs, replace dressing, may shower if dry, replace dressing after each shower.
  • 7-10 Days: Pendelum exercises, passive FE with overhead pulley, gentle passive ER with a stick 4-6 times daily.  Limit of ER is determined at surgery.  Elbow wrist hand ROM. Sling contiuously for 2-3 weeks, with activity thereafter.
  • 6 Weeks: Advance to stregthening. Full active ROM.
  • 3 Months: Sport specific training.
  • 6 Months: Return to sport/heavy labor at 5-8months depending on regaining 90% of strength.
  • 1Yr: Mid-range stability is mainly dependent on muscular balance and coordination. Lifelong rehab program is required.
  • Shoulder Outcome measures

MDI Arthroscopic Plication Outcomes

  • Arthorscopic Capsular Plication: 97% good/excellent results (Kim SH, AJSM 2004;32:594).
  • Nonsurgically treated young, athletic patients: 49% significant pain, 46% continued instability, 37% go on to have surgical treatment. By the modified Rowe grading scale 14% excellent results, 33% good, 53% poor results. (Misamore GW, JSES 2005;14:466).

MDI Arthroscopic Plication Review References


  • Burkhart SS, A Cowboy's Guide to Advanced Shoulder Arthroscopy, 2006
  • Rockwood and Green's Fractures in Adults 6th ed, 2006
  • OKU - Shoulder and Elbow 2nd ed, 2002°
  • Tjoumakaris FP, Bradley JP. The rationale for an arthroscopic approach to shoulder stabilization. Arthroscopy. 2011 Oct;27(10):1422-33. Epub 2011 Aug 26. 
  • Gaskill TR, Taylor DC, Millett PJ. Management of multidirectional instability of the shoulder. J Am Acad Orthop Surg. 2011 Dec;19(12):758-67. Review. PubMed PMID: 22134208.