C HA P T E R 5
Arthroscopic Rotator Interval
Capsule Closure
There is growing interest in the role of the rotator
interval capsule in shoulder instability. The rotator interval
capsule is a triangular area of anterior capsule between
the superior border of the subscapularis inferiorly, the
anterior margin of the supraspinatus superiorly, the
coracoid process medially, and the intertubercular groove
laterally (Fig. 5-1). The superior glenohumeral ligament
and coracohumeral ligament are structural components of
this capsule. Cole et al6 demonstrated that most of the
remaining interval capsule is thin and poorly organized
tissue.
Harryman et al9 demonstrated the importance of the
rotator interval capsule in glenohumeral motion and sta-
bility. Their study concluded that the role of the interval
capsule is to decrease inferior translation in the adducted
shoulder and to limit posterior translation in the flexed
shoulder. Van der Reis and Wolf18 demonstrated in a
cadaver model that glenohumeral translation and motion
could be decreased with arthroscopic rotator interval
imbrication.
Imbrication of the rotator interval capsule has
become a standard part of open instability procedures
since it was first advocated by Neer in 1980.15 Recent
advances in arthroscopic surgery have allowed surgeons to
duplicate the open techniques with respect to labral repair
and capsular shift. Numerous authors have also described
arthroscopic techniques of rotator interval capsular imbri-
cation that are used as part of anterior, posterior, or mul-
tidirectional instability procedures.2,4,5,8,12,14,17 We describe
a simple technique of rotator interval capsular imbrication
with use of nonabsorbable suture.
ch005-X3447.indd 45
Bradley J. Nelson, MD
Robert A. Arciero, MD
Preoperative Considerations
History
A focused history is essential in the diagnosis and manage-
ment of shoulder instability.
The presence or absence of trauma, the mechanism of
injury, and the position of the arm when symptoms occur
offer important clues to the direction and extent of the
shoulder instability. A history of the arm “dropping out the
bottom” is particularly concerning for a lax interval capsule.
Physical Examination
Examination of the cervical spine, areas of tenderness, and
range-of-motion and motor strength testing are performed
to rule out other sources of shoulder disease. The anterior
and posterior apprehension-relocation tests as well as the
load and shift test are important in determining the pres-
ence and direction of glenohumeral instability. A sulcus
sign greater than 2 cm that persists with external rotation
of the adducted arm is a crucial indicator of an incompe-
tent rotator interval capsule (Fig. 5-2). The presence of
ligamentous laxity may influence the decision to imbricate
the rotator interval capsule.
Imaging
Plain radiographs including a true anteroposterior view of
the glenohumeral joint and a West Point axillary view are
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 Surgical Techniques for Shoulder Instability

Coracoid part of an arthroscopic capsular plication. Patients with a

RI capsule component of inferior instability demonstrated by a sig-
Supraspinatus m. nificant sulcus sign are proper candidates for an interval
capsule imbrication. In addition, most patients with pos-
terior shoulder instability require an interval capsule
imbrication as basic science research demonstrates the
importance of the interval capsule in resisting posterior
Biceps translation.
tendon
Contraindications include patients who are not
candidates for an arthroscopic stabilization. Patients
with significant bone loss or true voluntary instability
SGHL secondary to a psychological disorder are not candidates
for rotator interval imbrication. We do not routinely
MGHL close the rotator interval capsule in patients undergoing
stabilization for primary, unidirectional, traumatic
instability.

IGHL
Surgical Planning
Arthroscopic shoulder stabilization and rotator interval
Subscapularis m. capsule closure require a significant amount of specialized
equipment. Large disposable cannulas, devices to shuttle
Figure 5-1 Diagram of rotator interval (RI) capsule. IGHL, inferior
glenohumeral ligament; MGHL, middle glenohumeral ligament; SGHL, suture, suture anchors, and specialized hand-held instru-
superior glenohumeral ligament. ments are required to perform the procedure.

Surgical Technique
Anesthesia and Positioning

Arthroscopic rotator interval capsule closure can be safely

performed under general or interscalene regional anesthe-
sia. The patient is positioned in either the lateral decubitus
or beach chair position on the basis of the surgeon’s prefer-
ence. A shoulder-specific positioner and arm holder is
helpful (Fig. 5-3).

Surgical Landmarks, Incisions,

Figure 5-2 Clinical examination demonstrating significant sulcus sign.
obtained for all patients to assess glenoid and humeral
head bone loss. Magnetic resonance imaging, with or
without the intra-articular administration of gadolinium,
is performed to assess for labral disease.
Indications and Contraindications
Rotator interval capsule closure is indicated in conjunc-
tion with an arthroscopic stabilization procedure such
as a labral repair (anterior, posterior, or superior) or as
and Portals
Portal location is usually determined by the concomitant
procedures performed before the rotator interval capsule
closure. Most frequently, a 30-degree arthroscope is used
through a standard posterior portal, and dual cannulas are
placed anteriorly (Fig. 5-4). One cannula is placed through
an anterior superior portal entering the joint just below
the biceps tendon. A second cannula is placed through the
anterior inferior portal entering the joint just above the
subscapularis tendon (Fig. 5-5). These portals allow repair
of most anterior labral lesions and anterior capsular plica-
tion. Additional accessory portals are often required for
superior or posterior labral repairs.

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 Arthroscopic Rotator Interval Capsule Closure

Examination Under Anesthesia and

Diagnostic Arthroscopy
An examination under anesthesia is performed to assess
range of motion and shoulder stability. The load and shift
test is performed to determine anterior and posterior
instability. The sulcus test is performed with the arm at
neutral rotation and in external rotation to assess inferior
instability.
A careful diagnostic arthroscopy is performed to
evaluate for evidence of instability, including labral tears,
biceps fraying, superior subscapularis fraying, and chon- 5
dral scuffing. The rotator interval capsule is evaluated
arthroscopically, although there is no consensus on what
constitutes a lax interval capsule. Fitzpatrick et al7 suggest
that the interval is widened if it is seen extending superior
to the biceps tendon.

Figure 5-3 The patient in beach chair position with specialized table and
arm holder.
Specific Steps (Box 5-1)

1. Concomitant Stabilization Procedures

The initial step in arthroscopic stabilization after cannula
placement is repair of any associated labral disease. The
anterior or posterior capsule is then plicated as indicated.
The details of these procedures are discussed elsewhere in
this text.

2. Piercing the Middle Glenohumeral Ligament

A No. 2 nonabsorbable suture is loaded into a straight
tissue penetrator (Fig. 5-6). The penetrator is placed
through the anterior inferior portal cannula (Fig. 5-7) and
pierces the middle glenohumeral ligament just above the
subscapularis (Fig. 5-8). A suture grasper is placed in the
anterior superior portal cannula, and the end of the
Figure 5-4 Portal sites marked with the patient in the sitting position. AIP,
nonabsorbable suture is transported out the cannula
anterior inferior portal; ASP, anterior superior portal.
(Fig. 5-9).

3. Piercing the Superior Glenohumeral Ligament

The anterior superior portal cannula is carefully backed
out of the glenohumeral joint so it is positioned just
outside the capsule. An angled tissue penetrator is placed
through this cannula (Fig. 5-10), and the superior gleno-
humeral ligament is pierced (Fig. 5-11). The limb of the

Box 5-1 Surgical Steps

1. Concomitant stabilization procedures

2. Piercing the middle glenohumeral ligament

3. Piercing the superior glenohumeral ligament

4. Knot tying

5. Closure
Figure 5-5 Dual anterior cannulas in the right shoulder.

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 Surgical Techniques for Shoulder Instability

Figure 5-6 No. 2 nonabsorbable suture placed in a tissue penetrator.

Figure 5-9 Suture grasped from the anterior superior cannula.

Figure 5-7 Tissue penetrator in the anterior inferior cannula. Figure 5-10 Tissue penetrator in the anterior superior cannula.

Figure 5-11 Tissue penetrator piercing the superior glenohumeral ligament.

Figure 5-8 Tissue penetrator piercing the middle glenohumeral ligament.

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Figure 5-12 Grasping of the suture limb anterior to the middle glenohumeral
ligament.
Figure 5-13 Both cannulas repositioned outside of the glenohumeral joint
capsule.
suture that is still within the anterior inferior portal
cannula is grasped anterior to the middle glenohumeral
ligament (Fig. 5-12). This limb of suture is transported out
the anterior superior portal.
4. Knot Tying
The anterior inferior portal cannula is removed. Both
limbs of the suture are exiting the anterior superior portal
cannula, which still traverses the subcutaneous tissue and
deltoid muscle but sits just outside the capsule (Fig. 5-13).
The shoulder is positioned in 45 degrees of abduction and
45 degrees of external rotation to prevent loss of external
rotation, and tension is applied to the sutures (Fig. 5-14).
The middle and superior glenohumeral ligaments will be
brought together as the rotator interval capsule is imbri-
ch005-X3447.indd 49
Arthroscopic Rotator Interval Capsule Closure
Figure 5-14 Suture tied outside of capsule.
cated. A sliding-locking arthroscopic knot is tied and
advanced until the knot can be felt contacting the capsule.
This knot is not visible from within the joint. Two or three
half-hitch throws can be placed. An end-cutting suture
cutter is slid down the suture and the knot is cut. This is
performed with tactile feedback as the knot is extracapsu-
lar and not visible. Shoulder range of motion is checked to
ensure that there has not been an excessive loss of external
rotation.
5. Closure
The portals are closed in a standard fashion. Local anes-
thetic can be instilled into the joint or a pain pump can be
placed, depending on the surgeon’s preference. The patient
is placed into a shoulder immobilizer in internal rotation
and slight abduction if an anterior stabilization procedure
was performed. An external rotation sling is used if the
posterior labrum was repaired.
Postoperative Considerations
Follow-up
Most patients are sent home the day of surgery. Sutures
are removed at 7 to 10 days.
Rehabilitation
The postoperative rehabilitation is determined by the
primary stabilization procedure performed. In general, a
sling is worn for 4 weeks with the arm in internal rotation
after an anterior stabilization or in neutral rotation after a
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 Surgical Techniques for Shoulder Instability
Table 5-1 Results of Rotator Interval Capsule Closure
Author Type of Instability
Ide et al11 (2004) Anterior
Gartsman et al8 (1999) Anterior
Noojin et al16 (2000) Anterior
Kim et al13 (2002) Anterior (revisions)
Bottoni et al3 (2005) Posterior
Abrams1 (2003) Posterior
Hewitt et al10 (2003) Multidirectional
posterior stabilization procedure. Gentle passive range-of-
motion exercises are started on the first day after surgery.
Progressive rotator cuff and periscapular muscle strength-
ening exercises are started at 4 weeks. Full return to
sports is allowed at 4 to 6 months, depending on the
patient’s progress.
PEARLS AND PITFALLS
● Loss of motion can occur if the interval capsule is closed
indiscriminately. Patients should demonstrate a sulcus sign with the
arm in external rotation.
● The arm should be positioned in at least 45 degrees of external
rotation and 45 degrees of abduction to prevent excessive tightening.
Results
It is difficult to determine the results of rotator interval
capsule closure presented in the literature as the procedure
is usually performed secondary to an anterior or posterior
References
1. Abrams JS. Arthroscopic repair of posterior instability and reverse
humeral glenohumeral ligament avulsion lesions. Orthop Clin North
Am 2003;34:475-483.
2. Almazan A, Ruiz M, Cruz F, et al. Simple arthroscopic technique for
rotator interval closure. Arthroscopy 2006;22:230.
3. Bottoni CR, Franks BR, Moore JH, et al. Operative stabilization of
posterior shoulder instability. Am J Sports Med 2005;33:996-1002.
4. Calvo A, Martinez AA, Domingo J, et al. Rotator interval closure
after arthroscopic capsulolabral repair: a technical variation. Arthros-
copy 2005;21:765.
5. Cole BJ, Mazzocca AD, Meneghini RM. Indirect arthroscopic rotator
interval repair. Arthroscopy 2003;19:E28-31.
6. Cole BJ, Rodeo SA, O’Brien SJ, et al. The anatomy and histology
of the rotator interval capsule of the shoulder. Clin Orthop
2001;390:129-137.
7. Fitzpatrick MJ, Powell SE, Tibone JE, et al. The anatomy, pathology,
and definitive treatment of rotator interval lesions: current concepts.
Arthroscopy 2003;19:70-79.
50
ch005-X3447.indd 50
Outcome
50 of 55 (91%) good–excellent
49 of 53 (92%) good–excellent
642 of 662 (97%) good–excellent
19 of 23 (83%) good–excellent
29 of 31 (94%) good–excellent
42 of 49 (88%) good–excellent
29 of 30 (90%) good–excellent
Complications
Infection, neurovascular injury, and anesthetic complica-
tions are rare serious complications of arthroscopic shoul-
der stabilization. Recurrent instability and loss of motion
are more common complications.
● A sliding knot must be used as the knot is tied on the outside of the
capsule.
● An end-cutting suture cutter is required because the suture is cut
blindly.
● The superior glenohumeral ligament must be pierced anterior to the
biceps tendon or the biceps tendon will be entrapped within the
capsular closure.
labral repair. Results of studies in which rotator
interval closure was specifically described are presented in
Table 5-1.
8. Gartsman GM, Taverna E, Hammerman SM. Arthroscopic rotator
interval repair in glenohumeral instability: description of an opera-
tive technique. Arthroscopy 1999;15:330-332.
9. Harryman DT, Sidles JA, Harris SL. et al. The role of the rotator
interval capsule in passive motion and stability of the shoulder. J
Bone Joint Surg Am 1992;74:53-66.
10. Hewitt M, Getelman MH, Snyder SJ. Arthroscopic management
of multidirectional instability: pancapsular plication. Orthop Clin
North Am 2003;34:549-557.
11. Ide J, Maeda S, Takagi K. Arthroscopic Bankart repair using suture
anchors in athletes: patient selection and postoperative sports activ-
ity. Am J Sports Med 2004;32:1899-1905.
12. Karas SG. Arthroscopic rotator interval repair and anterior portal
closure: an alternative technique. Arthroscopy 2002;18:436-439.
13. Kim SH, Ha KI, Kim YA. Arthroscopic revision Bankart repair: a
prospective outcome study. Arthroscopy 2002;18:469-482.
14. Lewicky YM, Lewicky RT. Simplified arthroscopic rotator interval
capsule closure: an alternative technique. Arthroscopy 2005;21:1276.
10/17/2007 1:58:38 PM

15. Neer CS, Foster CR. Inferior capsular shift for involuntary inferior
and multidirectional instability of the shoulder. A preliminary report.
J Bone Joint Surg Am 1980;62:897-908.
16. Noojin FK, Savoie FH, Field LD. Arthroscopic Bankart repair using
long-term absorbable anchors and sutures. Orthop Today 2000;
4:18-19.
ch005-X3447.indd 51
Arthroscopic Rotator Interval Capsule Closure
17. Treacy SH, Field LD, Savoie FH. Rotator interval capsule closure:
an arthroscopic technique. Arthroscopy 1997;13:103-106.
18. Van der Reis W, Wolf EM. Arthroscopic rotator cuff interval capsu-
lar closure. Orthopedics 2001;24:657-661.
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