Systematic Review

Open Capsular Shift and Arthroscopic Capsular Plication for

Treatment of Multidirectional Instability

Mark E. Jacobson, M.D., Michael Riggenbach, M.D., Adam N. Wooldridge, B.A., B.S., and
Julie Y. Bishop, M.D.

Purpose: To compare the results of open inferior capsular shift with arthroscopic capsular plication
for multidirectional instability in patients without a Bankart lesion. We hypothesized that there is no
difference with regard to the specific clinical outcomes evaluated, including recurrent instability,
range of motion, return to sport, and complications. Methods: We conducted a comprehensive
literature search. Databases searched included PubMed from 1966 to 2010, the Cochrane Database
of Systematic Reviews and Controlled Trials, CINAHL (Cumulative Index to Nursing and Allied
Health Literature) from 1982 to 2010, and SPORTDiscus from 1975 to 2010. Limits included English
language, human subjects, and title. Results: We found 7 articles with a total of 197 patients (219
shoulders) that met our inclusion criteria. The data did not clearly show open treatment to be superior
to arthroscopic treatment. No study reported a consistent loss of greater than 40° of external rotation.
No technique showed significantly less external rotation loss over the other. Whereas there was a
slight trend toward increased return to sport for patients treated arthroscopically, no clear conclusion
can be drawn given the variability of reporting in the reviewed studies. Analysis of complications
shows that both procedures are reliably safe with minimal complications. Conclusions: When one is
evaluating patients with traumatic or atraumatic onset of shoulder instability in 2 directions and no
structural lesions, arthroscopic capsular plication yields comparable results to open capsular shift
with regard to recurrent instability, return to sport, loss of external rotation, and overall complica-
tions. Level of Evidence: Level IV, systematic review of Level IV studies.

I n 1980, Neer and Foster1 coined the term “mul-

tidirectional instability” (MDI) and proposed
specific surgical treatment to patients in whom con-
inferior capsule that they believed to be the respon-
sible pathology. Although open inferior capsular
shift remains the standard in surgical treatment of
servative management has failed. In this classic MDI, multiple alternative procedures have been de-
article they report preliminary results of the inferior veloped. In 1993, Duncan and Savoie2 first reported
capsular shift as a means to address the patulous preliminary results of arthroscopic capsular plica-
tion.
In all patients presenting with MDI, a regimented
From the Division of Shoulder Surgery, Department of Ortho- course of physical therapy directed at strengthening
paedics, The Ohio State University, Columbus, Ohio, U.S.A.
The authors report that they have no conflicts of interest in the
of scapular stabilizers, the rotator cuff, and the
authorship and publication of this article. deltoid is warranted.1,3,4 Burkhead and Rockwood4
Received September 30, 2011; accepted December 6, 2011. reported good or excellent results in 88% of patients
Address correspondence to Julie Y. Bishop, M.D., Department of
Orthopaedics, The Ohio State University Medical Center, 2050 with atraumatic instability treated with an exercise
Kenny Rd, Ste 3300, Columbus, OH 43221, U.S.A. E-mail: julie program; however, more recent results have been
[email protected] less encouraging, at 30% to 61%.3,5 If these recent
© 2012 by the Arthroscopy Association of North America
0749-8063/11627/$36.00 reports more adequately represent our current pa-
doi:10.1016/j.arthro.2011.12.006 tient population and its expectations, it is reason-

1010 Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 28, No 7 (July), 2012: pp 1010-1017
 MULTIDIRECTIONAL INSTABILITY 1011

able to expect that surgical management of MDI articles, articles reporting results of patients with Ban-
will increase. kart lesions, and articles including patients in whom
The definition of MDI has been somewhat conflict- dislocation occurred voluntarily.
ing over the years, making interpretation of surgical After thorough review of each article, the following
outcomes articles somewhat difficult. Several ar- data were extracted: patient demographics, definition
throscopic outcomes articles6-11 and a recent review of of MDI, surgical technique, failure rate, change in
treatment options12 have not differentiated patients range of motion from preoperatively to postopera-
with and without focal structural pathology, such as tively, return to sport, and complications. Patient de-
the Bankart lesion. mographics included gender, age, and arm dominance.
The purpose of this study is to review the literature Surgical technique was classified as open or ar-
systematically and compare the results of open infe- throscopic, with an anterior or posterior approach,
rior capsular shift with arthroscopic capsular plication with a medial- or lateral-based capsular shift. Treat-
for MDI in patients without a Bankart lesion; thus ment failure was determined in those patients who did
surgical intervention was purely aimed at capsular not achieve satisfactory results as defined by the Neer
plication. We hypothesize that there is no difference criteria: no recurrence of dislocation or subluxation,
with regard to the specific clinical outcomes evalu- no significant pain, full activities, normal strength, and
ated, including recurrent instability, range of motion, within 10° of full elevation and 40° of rotation com-
return to sport, and complications. pared with the contralateral shoulder.1 Range of mo-
tion was determined as the mean postoperative change
METHODS in external rotation with the arm in 90° of abduction.
In October 2010, a comprehensive literature search
was conducted. Databases searched included PubMed
from 1966 to 2010, the Cochrane Database of Sys- RESULTS
tematic Reviews and Controlled Trials, CINAHL (Cu-
mulative Index to Nursing and Allied Health Litera- Search Results
ture) from 1982 to 2010, and SPORTDiscus from
1975 to 2010. Limits to this search included English The number of hits for each search term for a given
language, human subjects, and title. Each database database is shown in Table 1. After reviewing the
was searched for the terms “multidirectional instabil- abstracts of all search results, we identified 33 articles
ity,” “inferior instability,” “capsular shift,” “capsular with relevance to this review. After application of our
plication,” and “capsulorrhaphy.” Abstracts from each inclusion and exclusion criteria, 7 articles remained
search “hit” relevant to this systematic review were (Fig 1). Two of these studies included patient popu-
identified, and these articles were reviewed in their lations with and without Bankart lesions; however, the
entirety by a senior attending fellowship trained in results of these groups could be interpreted indepen-
shoulder surgery and assisted by a resident. Inclusion dently and therefore met our inclusion criteria.30,31 In
criteria consisted of the following: MDI defined as these 2 articles we were able to cleanly dissect the
instability in at least 2 directions, results with a min- failure data for patients who did not have Bankart
imum of 2-year follow up, and surgical treatment lesions and thus had purely capsular-based surgery.
consisting of either open inferior capsular shift or We did not include articles in which we could not
arthroscopic capsular plication. We excluded review clearly differentiate this population.

TABLE 1. Literature Search Results

PubMed Medline Cochrane CINAHL SPORTDiscus

MDI 103 (21) 95 (20) 0 42 (11) 46 (12)

Capsular plication 18 (0) 14 (0) 1 (0) 7 (0) 6 (1)
Capsular shift 69 (18) 69 (19) 2 (0) 27 (8) 29 (10)
Inferior instability 46 (11) 44 (15) 2 (0) 16 (7) 16 (8)
Capsulorrhaphy 109 (2) 108 (2) 5 (0) 32 (0) 32 (1)

NOTE. The number of articles for each search term relevant to this review is shown in parentheses.
1012 M. E. JACOBSON ET AL.

MDI was defined as instability in at least 2 direc-

tions in all studies. Four studies specified that inferior
instability must be present with instability in at least 1
other direction.30-33 Two studies only specified that 2
directions of instability be present.34,35 One study
specified that all cases must be atraumatic with infe-
rior instability and positive anterior apprehension.36
Two studies reported patients with prior shoulder
surgeries. The cohort of Baker et al.30 included 3
patients with a prior thermal capsulorrhaphy and 1
patient with a prior open anterior capsulorrhaphy. The
cohort of Treacy et al.31 included 1 patient with a prior
distal clavicle excision and 2 patients with prior open
acromioplasty.
There was an even distribution of male and female
patients in the included studies (106 and 111, respec-
tively); however, a significantly greater proportion of
female patients were treated with open surgery, and
more male patients were treated with arthroscopic
surgery. Of the studies reporting hand dominance,
both arthroscopic and open procedures were more
commonly performed on the dominant extremity. Pa-
tient characteristics are summarized in Table 2.

Procedure
Four of seven studies used open capsular shift pro-
cedures.32,34-36 Bak et al.34 and Choi and Ogilvie-
FIGURE 1. Article exclusion flowchart. Exclusion criteria in- Harris35 preferred the method described by Neer. An-
cluded review articles,13-16 less than 2 years’ follow-up,1-3,17-24 terior or posterior capsular shift was performed
inclusion of Bankart or bony lesions,6-11 wrong procedures,25-27 depending on the predominant direction of instability
and inclusion of voluntary dislocators.28,29
as determined by the history and examination of the
patient in the office and under anesthesia. Whereas
Characteristics of Included Studies Bak et al. performed all anterior inferior shift proce-
dures (N ⫽ 26), Choi and Ogilvie-Harris included 37
No study with a level of evidence higher than Level anterior and 16 posterior procedures. A standard del-
IV was identified, and all studies consisted of case topectoral approach was used in the anterior approach.
series, 5 of which were retrospective. There were 197 Whereas Bak et al. preserved the insertion of the
patients included in all studies, of whom 22 underwent subscapularis tendon, Choi and Ogilvie-Harris split it
bilateral procedures. Of the shoulders, 137 were obliquely. The subscapularis was dissected from the
treated with open capsular shift whereas 92 were capsule, and a T capsulotomy was performed with the
treated arthroscopically. All patients were included in short arm of the T based laterally and longitudinally.
analysis of patient demographics, range of motion, With the arm in 45° of abduction and neutral rotation,
complication, and return to sport. A total of 37 pa- the inferior flap was rotated anteriorly and superiorly
tients from 2 studies30,31 in the arthroscopic group and sutured in a position such that the inferior pouch
were excluded from the failure analysis because of the was obliterated. With the arm in adduction, the supe-
presence of a Bankart lesion. The mean age was 25.6 rior flap was rotated anteriorly and inferiorly. When
years in the open treatment group and 23.2 years in the the posterior shift was used, the infraspinatus was split
arthroscopic group. Whereas all patients were fol- obliquely and the capsular shift was performed in an
lowed up for a minimum of 2 years, mean follow-up identical manner as the anterior shift. Although the
of the open treatment group was longer (57 months v subscapularis tendon was not shortened in the anterior
44 months). approach, the infraspinatus was shortened in the pos-
 MULTIDIRECTIONAL INSTABILITY 1013

TABLE 2. Patient Characteristics of Individual Studies

Age Gender Follow-Up Shoulder Dominance
Shoulders Patients (Mean) (Mean)
Procedure Study (N) (N) (yr) Male Female (mo) Dominant Nondominant

Open capsular shift Bak et al.34 26 25 23 18 17 NR 14 12

Choi and Ogilvie- 53 47 NR 18 29 42 NR NR
Harris35
Marquardt et al.36 38 35 25.4 9 26 89 NR NR
Steinbeck and 20 20 26 3 17 38 18 2
Jerosch32
Arthroscopic capsular Baker et al.30 43 (23 with 40 (20 with 19.1 24 16 33.5 23 20
plication Bankart) Bankart)
Treacy et al.31 25 (14 with 11 (14 with 26.4 21 5 60 14 11
Bankart) Bankart)
Wichman and 24 24 26.6 13 11 NR NR NR
Snyder33

Abbreviation: NR, not reported.

terior approach because of the relative thinness of the labrum. A similar technique was used for posterior
posterior capsule. Marquardt et al.36 (N ⫽ 38) and predominant instability shoulders starting at the 6:30
Steinbeck and Jerosch32 (N ⫽ 20) modified the ante- clock position. Suture anchors were used where the
rior inferior shift in that the short arm of the T was labrum was deficient (but not torn or detached). For
medially based. The inferior flap shift was performed open and arthroscopic procedures, closure of the ro-
first with the arm in 20° of abduction and 20° of tator interval was variable and not clearly docu-
external rotation. The inferior capsular flap was se- mented.
cured to the decorticated rim of the glenoid by use of
2 suture anchors. Recurrent Instability
There was slight variation in technique for perform-
The procedure-specific recurrent instability results
ing arthroscopic capsular plication. Wichman and
are summarized in Table 3. A lower rate of recurrent
Snyder33 (N ⫽ 24) used an anterior inferior capsular
instability in the studies using an open technique as
pinch stitch that was then passed through the labrum
compared with an arthroscopic technique was repor-
to create a 1-cm capsular fold in a horizontal mattress
ted: 11.7% (16 of 137) versus 20% (11 of 55). This
fashion. Additional sutures were placed anterior, pos-
difference was not statistically significant. Failure in
terior, or inferior as deemed necessary by the history,
patients treated by open means was equally associated
examination, and arthroscopic findings. They did note
with spontaneous (5 patients) and traumatic (5 pa-
that after plication, the humeral head sat concentri-
tients) recurrent instability.32,34,36 A history of prior
cally within the glenoid as opposed to the anterior
surgery was associated with half of the cases of re-
inferior position seen on diagnostic arthroscopy.
current instability after arthroscopic repair.30,31 The
Treacy et al.31 preferred a capsular plication using a
cohort of arthroscopically treated patients reported by
transglenoid approach. Three O polydioxanone su-
Wichman and Snyder33 had the highest failure rate
tures were placed into the inferior glenohumeral lig-
(21%). Patient involvement with Workers’ Compen-
ament at the anterior band, at the posterior band, and
sation claims or litigation accounted for 4 of 5 of their
centrally 1 cm from the glenoid rim. After abrasion of
reported failures.
the inferior glenoid rim, these sutures were then
passed through the glenoid neck in an anterior-to- Return to Sport
posterior direction with a Beath pin. As multiple
sutures in the capsule were tightened and sutured There was a trend toward increased return to pre-
posteriorly, the capsule tightened and advanced operative level of sports participation for patients
superiorly. Baker et al.30 used 4 nonabsorbable cap- treated arthroscopically versus those treated with open
sular-labral plication stitches starting at the 5:30 clock capsular shift (86% v 80%) (Table 4). No study re-
positioning in the capsule 1 cm off the glenoid and ported the preoperative level of play or specific sport
advancing this to the 4:30 clock position of the for all patients; thus no clear conclusions can be drawn
1014 M. E. JACOBSON ET AL.

TABLE 3. Study- and Procedure-Specific Failures and Suspected Cause

Overall Procedure
Procedure Author Failure Rate Association With Failures Failure Rate

Open capsular shift Bak et al.34 19% (5/26) 3 traumatic, 2 spontaneous 11.7% (16/137)
Choi and Ogilvie-Harris35 9% (5/53) Mechanism not reported
Marquardt et al.36 11% (4/38) 2 traumatic, 1 who had prior
surgery, 1 spontaneous
Steinbeck and Jerosch32 10% (2/20) 2 spontaneous
Arthroscopic capsular Baker et al.30 20% (4/20) 1 traumatic, 1 spontaneous, 2 with 20% (11/55)
plication history of thermal capsulorrhaphy
Treacy et al.31 18% (2/11) 1 spontaneous, 1 prior surgery
Wichman and Snyder33 21% (5/24) Mechanism not reported (3 involved
in BWC claims, 1 involved in
litigation for MVA)

Abbreviations: BWC, Bureau of Workers’ Compensation; MVA, motor vehicle accident.

from these data. In addition, patients with Bankart ies, making interpretation of this outcome difficult.
lesions in the cohorts of Baker et al.30 and Treacy et Postoperative external rotation with the arm in abduc-
al.31 could not be excluded from these results. tion is shown in Table 5. In no study was a failure of
Both Choi and Ogilvie-Harris35 and Bak et al.34 either open or arthroscopic repair attributed to limited
specifically focused on open capsular shift in athletes. range of motion according to the Neer criteria. With
Choi and Ogilvie-Harris noted that of the 6 patients respect to the open capsular shift procedure, Choi and
who underwent bilateral procedures in their cohort, Ogilvie-Harris35 did note a greater loss of external
only 1 returned to sport. The authors concluded that rotation after anterior capsular shift as opposed to a
the outcome for patients with bilateral instability is posterior shift (71° v 82°). Wichman and Snyder33
poor. The overall rate of return to sport in the patient reported mean postoperative external rotation of
population of Bak et al. was 84%; however, this was 80.4°; however, no preoperative data were reported. In
reduced (76%) in overhead athletes. In the cohort addition, they noted that the largest loss of external
reported by Marquardt et al.,36 the 72% rate of return rotation was found in patients involved in Workers’
to sport decreased to 50% (3 of 6) when only “elite” Compensation claims or litigation.
athletes were included.
The rate of return to sport after arthroscopic capsu-
lar plication in the cohorts of Baker et al.30 and Treacy Complications
et al.31 was 86%. Of these athletes, swimmers were Complications from MDI repair (outside of recur-
least likely to return to the level of prior participa- rent instability) were infrequent in the included stud-
tion.30 ies. Choi and Ogilvie-Harris35 had 2 superficial wound
Loss of External Rotation infections and 1 musculocutaneous nerve injury that
resolved with observation. Marquardt et al.36 had 1
Reporting of preoperative and postoperative range superficial wound infection in a patient who was lost
of motion was highly variable among included stud- to follow-up. Treacy et al.31 reported 2 patients in

TABLE 4. Study- and Procedure-Specific Return to Preoperative Level of Sport

Study-Specific Return to Overall Return to Preoperative
Procedure Author Preoperative Level of Sport Level of Sport

Open capsular shift Bak et al.34 84% (21/25) 80% (101/127)

Choi and Ogilvie-Harris35 81% (44/53)
Marquardt et al.36 72% (21/29)
Steinbeck and Jerosch32 75% (15/20)
Arthroscopic capsular plication Baker et al.30 86% (31/36) 86% (37/43)
Treacy et al.31 86% (6/7)
Wichman and Snyder33 Not reported
 MULTIDIRECTIONAL INSTABILITY 1015

TABLE 5. Range of Motion After Open Capsular Shift and Arthroscopic Plication
Procedure Author Range of Motion Reported

Open capsular shift Bak et al.34 Mean, 90°

Choi and Ogilvie-Harris35 Anterior shift: mean, 71°
Posterior shift: mean, 82°
Marquardt et al.36 3.4° mean loss of ER, no patient lost ⬎10°
Steinbeck and Jerosch32 Rowe score improvement from 17 to 19 for ROM
Arthroscopic capsular plication Baker et al.30 91% satisfactory ROM, 9% limited ROM
Treacy et al.31 No loss of ER
Wichman and Snyder33 Mean, 80.4°; loss of ⬎10° in 2/24

NOTE. Mean range of motion and loss of motion represent external rotation with the arm in 90° of abduction.
Abbreviations: ER, external rotation; ROM, range of motion.

whom persistent pain developed over the posterior definition of MDI as the traumatic or atraumatic onset
suture knot, requiring removal. of involuntary symptomatic shoulder instability in
more than 1 direction without a structural lesion such
as a Bankart lesion.
DISCUSSION The procedures pertinent to this review were de-
signed to address the patulous capsule present in pa-
MDI presents a complex problem to manage for the tients with MDI rather than the labrum. Whereas both
treating surgeon. Previously reported success rates of labral pathology and ligamentous laxity may be seen
nonoperative management have recently been chal- in concert in a patient with MDI, we elected to elim-
lenged as patient expectations increase.5,37 Frequently, inate patients with labral pathology in an effort to
patients present with long-term disability and have not reduce confounding factors. Our goal was to evaluate
uncommonly undergone a prior surgical procedure on the surgical outcomes of procedures aimed at elimi-
the symptomatic shoulder. Prior surgical dissection nating shoulder instability that were purely capsular
and capsular manipulation such as thermal capsu- based. To our knowledge, this is the first comparison
lorrhaphy may compromise the soft tissues and of procedures to address MDI as a distinct entity from
complicate a revision stabilization procedure.38,39 labral pathology.
Patients are typically young and involved in sport- A patulous inferior capsule and laxity of the inferior
ing activities, which increase the demand on any glenohumeral ligaments are agreed on in the literature
planned procedure. as the responsible pathologies in MDI.1,2,11,44 Since
Further complicating matters is the inconsistent def- Neer and Foster1 proposed the open capsular shift,
inition of MDI, which has led to difficulty interpreting multiple procedures have been developed to both
the available literature. McFarland et al.40 showed that tighten the inferior capsule and reduce total joint vol-
variability in the definition of MDI led to a statistically ume. In an in vitro study comparing volume reduction
significant difference in the number of patients as- of the glenohumeral joint using 2 techniques, Cohen et
signed this diagnosis. Thomas and Matsen41 classified al.45 found that arthroscopic capsular plication using
the etiology of recurrent shoulder instability as trau- three 1-cm capsulolabral plication sutures resulted in a
matic in origin, resulting in unidirectional instability, volume reduction of 22% whereas open capsular shift
or atraumatic in origin, resulting in MDI. Neer and as described by Neer and Foster reduced joint volume
Foster1 and other authors42 have cautioned against a by nearly 50%. Ponce et al.46 noted that the addition of
strictly atraumatic definition of MDI because this may five 1-cm capsular plication stitches was shown to
lead to misdiagnosis and failure to address the offend- reduce capsular volume by 49% with a suture-only
ing pathology. More recently, a classification system technique and by 52% with suture anchors. Flanigan
incorporating frequency, etiology, direction, and se- et al.47 found that volume reduction increased from
verity (FEDS) was introduced.43 Interestingly, the au- 16% to 34% when the arthroscopic capsulolabral pli-
thors purposefully avoided the concept of MDI, opting cation was increased from 5 to 10 mm. Miller et
instead to rely on the history and physical examination al.48 compared volume reduction of the glenohu-
to determine a single primary direction of instability. meral joint using 3 different open capsular shift
For the purposes of this review, we chose an inclusive techniques: the humeral- or lateral-based shift as
1016 M. E. JACOBSON ET AL.

described by Neer and Foster, the glenoid- or me- CONCLUSIONS

dial-based shift as used by Marquardt et al.36 and
Steinbeck and Jerosch,32 and a centrally based shift. When one is evaluating patients with traumatic or
atraumatic onset of shoulder instability in 2 directions
The humeral-based shift reduced glenohumeral
and no structural lesions, arthroscopic capsular plica-
joint volume by a statistically significant amount
tion yields comparable results to open capsular shift
greater than the glenoid-based shift (49% v 37%).48
with regard to recurrent instability, return to sport, loss
Although these studies suggest that open capsular of external rotation, and overall complications.
shift and the sequential capsular plication stitches
can achieve a 50% joint volume reduction, the
clinical significance of this is unknown.
This review shows that arthroscopic capsular plica- REFERENCES
tion is a reasonable alternative to open capsular shift
1. Neer CS II, Foster CR. Inferior capsular shift for involuntary
to reliably decrease the incidence of recurrent insta- inferior and multidirectional instability of the shoulder. A
bility in patients with MDI. Whereas the gold standard preliminary report. J Bone Joint Surg Am 1980;62:897-908.
2. Duncan R, Savoie FH III. Arthroscopic inferior capsular shift
for this pathology has classically been thought to be an for multidirectional instability of the shoulder: A preliminary
open capsular shift, this review does not clearly show report. Arthroscopy 1993;9:24-27.
open treatment to be superior to arthroscopic treat- 3. Kiss J, Damrel D, Mackie A, Neumann L, Wallace WA.
Non-operative treatment of multidirectional shoulder instabil-
ment. Loss of range of motion is a concern in any ity. Int Orthop 2001;24:354-357.
capsular tightening procedure; however, no study re- 4. Burkhead WZ Jr, Rockwood CA Jr. Treatment of instability of
ported a consistent loss of greater than 40° of external the shoulder with an exercise program. J Bone Joint Surg Am
1992;74:890-896.
rotation (which was defined as a failure according to 5. Misamore GW, Sallay PI, Didelot W. A longitudinal study of
the early Neer criteria). Neither technique was shown patients with multidirectional instability of the shoulder with
seven- to ten-year follow-up. J Shoulder Elbow Surg 2005;14:
to be superior with respect to postoperative range of 466-470.
motion. Although there was a slight trend toward 6. Alpert JM, Verma N, Wysocki R, Yanke AB, Romeo AA.
increased return to sport for patients treated ar- Arthroscopic treatment of multidirectional shoulder instability
with minimum 270 degrees labral repair: Minimum 2-year
throscopically, no clear conclusion can be drawn follow-up. Arthroscopy 2008;24:704-711.
given the variability of reporting in the reviewed stud- 7. Altchek DW, Warren RF, Skyhar MJ, Ortiz G. T-plasty mod-
ification of the Bankart procedure for multidirectional insta-
ies. Analysis of complications shows that both proce- bility of the anterior and inferior types. J Bone Joint Surg Am
dures are reliably safe with minimal complications. 1991;73:105-112.
Although this report does show a similar efficacy 8. Cooper RA, Brems JJ. The inferior capsular-shift procedure
for multidirectional instability of the shoulder. J Bone Joint
with regard to the reported outcomes, the potential Surg Am 1992;74:1516-1521.
benefits of an all-arthroscopic approach that have not 9. Gartsman GM, Roddey TS, Hammerman SM. Arthroscopic
been addressed should not be ignored. These include treatment of multidirectional glenohumeral instability: 2- to
5-year follow-up. Arthroscopy 2001;17:236-243.
avoidance of subscapular or infraspinatus takedown 10. McIntyre LF, Caspari RB, Savoie FH III. The arthroscopic
and the associated complications, limited scarring, and treatment of multidirectional shoulder instability: Two-year
results of a multiple suture technique. Arthroscopy 1997;13:
ability to address associated pathology, which may be 418-425.
inaccessible with an open approach.49 11. Pollock RG, Owens JM, Flatow EL, Bigliani LU. Operative
There are several limitations to this systematic re- results of the inferior capsular shift procedure for multidirec-
tional instability of the shoulder. J Bone Joint Surg Am 2000;
view. First, there is a large discrepancy between the 82:919-928.
number of patients treated arthroscopically (n ⫽ 55) 12. Caprise PA Jr, Sekiya JK. Open and arthroscopic treatment of
multidirectional instability of the shoulder. Arthroscopy 2006;
and those treated with an open procedure (n ⫽ 137). 22:1126-1131.
This is not surprising, given that open capsular shift 13. Sperling JW, Cordasco FA. Inferior capsular shift for bidirec-
was introduced more than 10 years before ar- tional and multidirectional instability. Sports Med Arthrosc
2000;8:265-271.
throscopic treatment methods. In addition, there was 14. Setter KJ, Voloshin I, Bigliani LU. The anterior inferior cap-
variability in the method used to report loss of external sular shift. Am J Orthop (Belle Mead NJ) 2004;33:223-228.
rotation, which makes drawing conclusions between 15. Pagnani MJ, Warren RF. Multidirectional instability: Medial
T-plasty and selective capsular repairs. Sports Med Arthrosc
the 2 groups difficult. Finally, there was inconsistent 1993;1:249-258.
reporting of patients having undergone prior proce- 16. Yamaguchi K, Flatow EL. Management of multidirectional
instability. Clin Sports Med 1995;14:885-902.
dures, which could directly influence recurrent insta- 17. Bigliani LU, Kurzweil PR, Schwartzbach CC, Wolfe IN, Fla-
bility. tow EL. Inferior capsular shift procedure for anterior-inferior
 MULTIDIRECTIONAL INSTABILITY 1017

shoulder instability in athletes. Am J Sports Med 1994;22: 34. Bak K, Spring BJ, Henderson JP. Inferior capsular shift pro-
578-584. cedure in athletes with multidirectional instability based on
18. Kim SH, Kim HK, Sun JI, Park JS, Oh I. Arthroscopic cap- isolated capsular and ligamentous redundancy. Am J Sports
sulolabroplasty for posteroinferior multidirectional instability Med 2000;28:466-471.
of the shoulder. Am J Sports Med 2004;32:594-607. 35. Choi CH, Ogilvie-Harris DJ. Inferior capsular shift operation
19. Lebar RD, Alexander AH. Multidirectional shoulder instabil- for multidirectional instability of the shoulder in players of
ity. Clinical results of inferior capsular shift in an active-duty contact sports. Br J Sports Med 2002;36:290-294.
population. Am J Sports Med 1992;20:193-198. 36. Marquardt B, Pötzl W, Witt KA, Steinbeck J. A modified
20. Lupo R, Giorgi L, Rapisarda S, Viola E, Pavesi FC. Neer capsular shift for atraumatic anterior-inferior shoulder insta-
capsular shift surgery in the treatment of recurrent antero-
bility. Am J Sports Med 2005;33:1011-1015.
inferior shoulder dislocations. Chir Organi Mov 1999;84:153-
160. 37. Kiss RM, Illyes A, Kiss J. Physiotherapy vs. capsular shift and
21. Nixon RT Jr, Lindenfeld TN. Early rehabilitation after a mod- physiotherapy in multidirectional shoulder joint instability. J
ified inferior capsular shift procedure for multidirectional in- Electromyogr Kinesiol 2010;20:489-501.
stability of the shoulder. Orthopedics 1998;21:441-445. 38. D’Alessandro DF, Bradley JP, Fleischli JE, Connor PM. Pro-
22. van Tankeren E, de Waal Malefijt MC, van Loon CJ. Open spective evaluation of electrothermal arthroscopic capsulor-
capsular shift for multi directional shoulder instability. Arch rhaphy for shoulder instability: Indications, technique and
Orthop Trauma Surg 2002;122:447-450. preliminary results. Paper presented at the 15th Annual Meet-
23. Voigt C, Schulz AP, Lill H. Arthroscopic treatment of multi- ing of the American Shoulder and Elbow Surgeons, New
directional glenohumeral instability in young overhead ath- York, March 15, 1998.
letes. Open Orthop J 2009;3:107-114. 39. Nottage WM. Laser-assisted shoulder surgery. Arthroscopy
24. Massoud SN, Levy O, Copeland SA. Inferior capsular shift for 1997;13:635-638.
multidirectional instability following failed laser-assisted cap- 40. McFarland EG, Kim TK, Park HB, Neira CA, Gutierrez MI.
sular shrinkage. J Shoulder Elbow Surg 2002;11:305-308. The effect of variation in definition on the diagnosis of mul-
25. Favorito PJ, Langenderfer MA, Colosimo AJ, Heidt RS Jr, tidirectional instability of the shoulder. J Bone Joint Surg Am
Carlonas RL. Arthroscopic laser-assisted capsular shift in the 2003;85:2138-2144.
treatment of patients with multidirectional shoulder instability. 41. Thomas SC, Matsen FA III. An approach to the repair of
Am J Sports Med 2002;30:322-328. avulsion of the glenohumeral ligaments in the management of
26. Wirth MA, Groh GI, Rockwood CA Jr. Capsulorrhaphy
traumatic anterior glenohumeral instability. J Bone Joint Surg
through an anterior approach for the treatment of atraumatic
posterior glenohumeral instability with multidirectional laxity Am 1989;71:506-513.
of the shoulder. J Bone Joint Surg Am 1998;80:1570-1578. 42. Bell JE. Arthroscopic management of multidirectional insta-
27. Yeargan SA III, Briggs KK, Horan MP, Black AK, Hawkins bility. Orthop Clin North Am 2010;41:357-365.
RJ. Determinants of patient satisfaction following surgery for 43. Kuhn JE, Helmer TT, Dunn WR, Throckmorton VT. Devel-
multidirectional instability. Orthopedics 2008;31:647. opment and reliability testing of the frequency, etiology, di-
28. Hamada K, Fukuda H, Nakajima T, Yamada N. The inferior rection, and severity (FEDS) system for classifying glenohu-
capsular shift operation for instability of the shoulder. Long- meral instability. J Shoulder Elbow Surg 2011;20:548-556.
term results in 34 shoulders. J Bone Joint Surg Br 1999;81: 44. Schenk TJ, Brems JJ. Multidirectional instability of the shoul-
218-225. der: Pathophysiology, diagnosis, and management. J Am Acad
29. Krishnan SG, Hawkins RJ, Horan MP, Dean M, Kim YK. A Orthop Surg 1998;6:65-72.
soft tissue attempt to stabilize the multiply operated glenohu- 45. Cohen SB, Wiley W, Goradia VK, Pearson S, Miller MD.
meral joint with multidirectional instability. Clin Orthop Relat Anterior capsulorrhaphy: An in vitro comparison of volume
Res 2004:256-261. reduction—Arthroscopic plication versus open capsular shift.
30. Baker CL III, Mascarenhas R, Kline AJ, Chhabra A, Pombo Arthroscopy 2005;21:659-664.
MW, Bradley JP. Arthroscopic treatment of multidirectional 46. Ponce BA, Rosenzweig SD, Thompson KJ, Tokish J. Sequen-
shoulder instability in athletes: A retrospective analysis of 2- tial volume reduction with capsular plications: Relationship
to 5-year clinical outcomes. Am J Sports Med 2009;37:1712- between cumulative size of plications and volumetric reduc-
1720.
tion for multidirectional instability of the shoulder. Am J
31. Treacy SH, Savoie FH III, Field LD. Arthroscopic treatment of
multidirectional instability. J Shoulder Elbow Surg 1999;8: Sports Med 2011;39:526-531.
345-350. 47. Flanigan DC, Forsythe T, Orwin J, Kaplan L. Volume analysis
32. Steinbeck J, Jerosch J. Surgery for atraumatic anterior-inferior of arthroscopic capsular shift. Arthroscopy 2006;22:528-533.
shoulder instability. A modified capsular shift evaluated in 20 48. Miller MD, Larsen KM, Luke T, Leis HT, Plancher KD.
patients followed for 3 years. Acta Orthop Scand 1997;68:447- Anterior capsular shift volume reduction: An in vitro compar-
450. ison of 3 techniques. J Shoulder Elbow Surg 2003;12:350-354.
33. Wichman MT, Snyder SJ. Arthroscopic capsular plication for 49. Tjoumakaris FP, Bradley JP. The rationale for an arthroscopic
multidirectional instability of the shoulder. Oper Tech Sport approach to shoulder stabilization. Arthroscopy 2011;27:1422-
Med 1997;5:238-243. 1433.