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Open Capsular Shift and Arthroscopic Capsular Plication for Treatment of Multidirectional Instability
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 complications. Level of Evidence: Level IV, systematic review of Level IV studies.
I
n 1980, Neer and Foster1 coined the term “multidirectional instability” (MDI) and proposed specific surgical treatment to patients in whom conservative management has failed. In this classic article they report preliminary results of the inferior capsular shift as a means to address the patulous
From the Division of Shoulder Surgery, Department of Orthopaedics, The Ohio State University, Columbus, Ohio, U.S.A. The authors report that they have no conflicts of interest in the authorship and publication of this article. Received September 30, 2011; accepted December 6, 2011. Address correspondence to Julie Y. Bishop, M.D., Department of Orthopaedics, The Ohio State University Medical Center, 2050 Kenny Rd, Ste 3300, Columbus, OH 43221, U.S.A. E-mail: julie [email protected] © 2012 by the Arthroscopy Association of North America 0749-8063/11627/$36.00 doi:10.1016/j.arthro.2011.12.006
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inferior capsule that they believed to be the responsible pathology. Although open inferior capsular shift remains the standard in surgical treatment of MDI, multiple alternative procedures have been developed. In 1993, Duncan and Savoie2 first reported preliminary results of arthroscopic capsular plication. In all patients presenting with MDI, a regimented course of physical therapy directed at strengthening of scapular stabilizers, the rotator cuff, and the deltoid is warranted.1,3,4 Burkhead and Rockwood4 reported good or excellent results in 88% of patients with atraumatic instability treated with an exercise program; however, more recent results have been less encouraging, at 30% to 61%.3,5 If these recent reports more adequately represent our current patient population and its expectations, it is reason-
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 28, No 7 (July), 2012: pp 1010-1017
MULTIDIRECTIONAL INSTABILITY able to expect that surgical management of MDI will increase. The definition of MDI has been somewhat conflicting over the years, making interpretation of surgical outcomes articles somewhat difficult. Several arthroscopic outcomes articles6-11 and a recent review of treatment options12 have not differentiated patients with and without focal structural pathology, such as the Bankart lesion. The purpose of this study is to review the literature systematically and compare the results of open inferior capsular shift with arthroscopic capsular plication for MDI in patients without a Bankart lesion; thus surgical intervention was purely aimed at capsular plication. We hypothesize 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 In October 2010, a comprehensive literature search was conducted. 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 to this search included English language, human subjects, and title. Each database was searched for the terms “multidirectional instability,” “inferior instability,” “capsular shift,” “capsular plication,” and “capsulorrhaphy.” Abstracts from each search “hit” relevant to this systematic review were identified, and these articles were reviewed in their entirety by a senior attending fellowship trained in shoulder surgery and assisted by a resident. Inclusion criteria consisted of the following: MDI defined as instability in at least 2 directions, results with a minimum of 2-year follow up, and surgical treatment consisting of either open inferior capsular shift or arthroscopic capsular plication. We excluded review
TABLE 1.
MDI Capsular plication Capsular shift Inferior instability Capsulorrhaphy
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articles, articles reporting results of patients with Bankart lesions, and articles including patients in whom dislocation occurred voluntarily. After thorough review of each article, the following data were extracted: patient demographics, definition of MDI, surgical technique, failure rate, change in range of motion from preoperatively to postoperatively, return to sport, and complications. Patient demographics included gender, age, and arm dominance. Surgical technique was classified as open or arthroscopic, with an anterior or posterior approach, with a medial- or lateral-based capsular shift. Treatment failure was determined in those patients who did not achieve satisfactory results as defined by the Neer criteria: no recurrence of dislocation or subluxation, no significant pain, full activities, normal strength, and within 10° of full elevation and 40° of rotation compared with the contralateral shoulder.1 Range of motion was determined as the mean postoperative change in external rotation with the arm in 90° of abduction.
RESULTS Search Results The number of hits for each search term for a given database is shown in Table 1. After reviewing the abstracts of all search results, we identified 33 articles with relevance to this review. After application of our inclusion and exclusion criteria, 7 articles remained (Fig 1). Two of these studies included patient populations with and without Bankart lesions; however, the results of these groups could be interpreted independently and therefore met our inclusion criteria.30,31 In these 2 articles we were able to cleanly dissect the failure data for patients who did not have Bankart lesions and thus had purely capsular-based surgery. We did not include articles in which we could not clearly differentiate this population.
Literature Search Results
PubMed
Medline
Cochrane
103 (21) 18 (0) 69 (18) 46 (11) 109 (2)
95 (20) 14 (0) 69 (19) 44 (15) 108 (2)
0 1 (0) 2 (0) 2 (0) 5 (0)
CINAHL 42 (11) 7 (0) 27 (8) 16 (7) 32 (0)
NOTE. The number of articles for each search term relevant to this review is shown in parentheses.
SPORTDiscus 46 (12) 6 (1) 29 (10) 16 (8) 32 (1)
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M. E. JACOBSON ET AL. MDI was defined as instability in at least 2 directions 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 inferior 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, respectively); 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. Patient characteristics are summarized in Table 2. Procedure
FIGURE 1. Article exclusion flowchart. Exclusion criteria included review articles,13-16 less than 2 years’ follow-up,1-3,17-24 inclusion of Bankart or bony lesions,6-11 wrong procedures,25-27 and inclusion of voluntary dislocators.28,29
Characteristics of Included Studies No study with a level of evidence higher than Level IV was identified, and all studies consisted of case series, 5 of which were retrospective. There were 197 patients included in all studies, of whom 22 underwent bilateral procedures. Of the shoulders, 137 were treated with open capsular shift whereas 92 were treated arthroscopically. All patients were included in analysis of patient demographics, range of motion, complication, and return to sport. A total of 37 patients from 2 studies30,31 in the arthroscopic group were excluded from the failure analysis because of the presence of a Bankart lesion. The mean age was 25.6 years in the open treatment group and 23.2 years in the arthroscopic group. Whereas all patients were followed up for a minimum of 2 years, mean follow-up of the open treatment group was longer (57 months v 44 months).
Four of seven studies used open capsular shift procedures.32,34-36 Bak et al.34 and Choi and OgilvieHarris35 preferred the method described by Neer. Anterior or posterior capsular shift was performed depending on the predominant direction of instability as determined by the history and examination of the patient in the office and under anesthesia. Whereas Bak et al. performed all anterior inferior shift procedures (N ⫽ 26), Choi and Ogilvie-Harris included 37 anterior and 16 posterior procedures. A standard deltopectoral approach was used in the anterior approach. Whereas Bak et al. preserved the insertion of the subscapularis tendon, Choi and Ogilvie-Harris split it obliquely. The subscapularis was dissected from the capsule, and a T capsulotomy was performed with the short arm of the T based laterally and longitudinally. With the arm in 45° of abduction and neutral rotation, the inferior flap was rotated anteriorly and superiorly and sutured in a position such that the inferior pouch was obliterated. With the arm in adduction, the superior flap was rotated anteriorly and inferiorly. When the posterior shift was used, the infraspinatus was split obliquely and the capsular shift was performed in an identical manner as the anterior shift. Although the subscapularis tendon was not shortened in the anterior approach, the infraspinatus was shortened in the pos-
MULTIDIRECTIONAL INSTABILITY TABLE 2.
Procedure
Study
Open capsular shift
Bak et al.34 Choi and OgilvieHarris35 Marquardt et al.36 Steinbeck and Jerosch32 Arthroscopic capsular Baker et al.30 plication Treacy et al.31 Wichman and Snyder33
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Patient Characteristics of Individual Studies Gender Shoulder Dominance Age Follow-Up (Mean) (Mean) (yr) Male Female (mo) Dominant Nondominant
Shoulders (N)
Patients (N)
26 53
25 47
23 NR
18 18
17 29
NR 42
14 NR
12 NR
38 20
35 20
25.4 26
9 3
26 17
89 38
NR 18
NR 2
19.1
24
16
33.5
23
20
26.4
21
5
60
14
11
26.6
13
11
NR
NR
NR
43 (23 with 40 (20 with Bankart) Bankart) 25 (14 with 11 (14 with Bankart) Bankart) 24 24
Abbreviation: NR, not reported.
terior approach because of the relative thinness of the posterior capsule. Marquardt et al.36 (N ⫽ 38) and Steinbeck and Jerosch32 (N ⫽ 20) modified the anterior inferior shift in that the short arm of the T was medially based. The inferior flap shift was performed first with the arm in 20° of abduction and 20° of external rotation. The inferior capsular flap was secured to the decorticated rim of the glenoid by use of 2 suture anchors. There was slight variation in technique for performing arthroscopic capsular plication. Wichman and Snyder33 (N ⫽ 24) used an anterior inferior capsular pinch stitch that was then passed through the labrum to create a 1-cm capsular fold in a horizontal mattress fashion. Additional sutures were placed anterior, posterior, or inferior as deemed necessary by the history, examination, and arthroscopic findings. They did note that after plication, the humeral head sat concentrically within the glenoid as opposed to the anterior inferior position seen on diagnostic arthroscopy. Treacy et al.31 preferred a capsular plication using a transglenoid approach. Three O polydioxanone sutures were placed into the inferior glenohumeral ligament at the anterior band, at the posterior band, and centrally 1 cm from the glenoid rim. After abrasion of the inferior glenoid rim, these sutures were then passed through the glenoid neck in an anterior-toposterior direction with a Beath pin. As multiple sutures in the capsule were tightened and sutured posteriorly, the capsule tightened and advanced superiorly. Baker et al.30 used 4 nonabsorbable capsular-labral plication stitches starting at the 5:30 clock positioning in the capsule 1 cm off the glenoid and advancing this to the 4:30 clock position of the
labrum. A similar technique was used for posterior predominant instability shoulders starting at the 6:30 clock position. Suture anchors were used where the labrum was deficient (but not torn or detached). For open and arthroscopic procedures, closure of the rotator interval was variable and not clearly documented. Recurrent Instability The procedure-specific recurrent instability results are summarized in Table 3. A lower rate of recurrent instability in the studies using an open technique as compared with an arthroscopic technique was reported: 11.7% (16 of 137) versus 20% (11 of 55). This difference was not statistically significant. Failure in patients treated by open means was equally associated with spontaneous (5 patients) and traumatic (5 patients) recurrent instability.32,34,36 A history of prior surgery was associated with half of the cases of recurrent instability after arthroscopic repair.30,31 The cohort of arthroscopically treated patients reported by Wichman and Snyder33 had the highest failure rate (21%). Patient involvement with Workers’ Compensation claims or litigation accounted for 4 of 5 of their reported failures. Return to Sport There was a trend toward increased return to preoperative level of sports participation for patients treated arthroscopically versus those treated with open capsular shift (86% v 80%) (Table 4). No study reported the preoperative level of play or specific sport for all patients; thus no clear conclusions can be drawn
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M. E. JACOBSON ET AL. TABLE 3. Procedure
Open capsular shift
Arthroscopic capsular plication
Study- and Procedure-Specific Failures and Suspected Cause
Author
Failure Rate
Association With Failures
Bak et al.34 Choi and Ogilvie-Harris35 Marquardt et al.36
19% (5/26) 9% (5/53) 11% (4/38)
Steinbeck and Jerosch32 Baker et al.30
10% (2/20) 20% (4/20)
Treacy et al.31 Wichman and Snyder33
18% (2/11) 21% (5/24)
3 traumatic, 2 spontaneous Mechanism not reported 2 traumatic, 1 who had prior surgery, 1 spontaneous 2 spontaneous 1 traumatic, 1 spontaneous, 2 with history of thermal capsulorrhaphy 1 spontaneous, 1 prior surgery Mechanism not reported (3 involved in BWC claims, 1 involved in litigation for MVA)
Overall Procedure Failure Rate 11.7% (16/137)
20% (11/55)
Abbreviations: BWC, Bureau of Workers’ Compensation; MVA, motor vehicle accident.
from these data. In addition, patients with Bankart lesions in the cohorts of Baker et al.30 and Treacy et al.31 could not be excluded from these results. Both Choi and Ogilvie-Harris35 and Bak et al.34 specifically focused on open capsular shift in athletes. Choi and Ogilvie-Harris noted that of the 6 patients who underwent bilateral procedures in their cohort, only 1 returned to sport. The authors concluded that the outcome for patients with bilateral instability is poor. The overall rate of return to sport in the patient population of Bak et al. was 84%; however, this was reduced (76%) in overhead athletes. In the cohort reported by Marquardt et al.,36 the 72% rate of return to sport decreased to 50% (3 of 6) when only “elite” athletes were included. The rate of return to sport after arthroscopic capsular plication in the cohorts of Baker et al.30 and Treacy et al.31 was 86%. Of these athletes, swimmers were least likely to return to the level of prior participation.30 Loss of External Rotation Reporting of preoperative and postoperative range of motion was highly variable among included studTABLE 4. Procedure Open capsular shift
Arthroscopic capsular plication
ies, making interpretation of this outcome difficult. Postoperative external rotation with the arm in abduction is shown in Table 5. In no study was a failure of either open or arthroscopic repair attributed to limited range of motion according to the Neer criteria. With respect to the open capsular shift procedure, Choi and Ogilvie-Harris35 did note a greater loss of external rotation after anterior capsular shift as opposed to a posterior shift (71° v 82°). Wichman and Snyder33 reported mean postoperative external rotation of 80.4°; however, no preoperative data were reported. In addition, they noted that the largest loss of external rotation was found in patients involved in Workers’ Compensation claims or litigation. Complications Complications from MDI repair (outside of recurrent instability) were infrequent in the included studies. Choi and Ogilvie-Harris35 had 2 superficial wound infections and 1 musculocutaneous nerve injury that resolved with observation. Marquardt et al.36 had 1 superficial wound infection in a patient who was lost to follow-up. Treacy et al.31 reported 2 patients in
Study- and Procedure-Specific Return to Preoperative Level of Sport Author
Study-Specific Return to Preoperative Level of Sport
Overall Return to Preoperative Level of Sport
Bak et al.34 Choi and Ogilvie-Harris35 Marquardt et al.36 Steinbeck and Jerosch32 Baker et al.30 Treacy et al.31 Wichman and Snyder33
84% (21/25) 81% (44/53) 72% (21/29) 75% (15/20) 86% (31/36) 86% (6/7) Not reported
80% (101/127)
86% (37/43)
MULTIDIRECTIONAL INSTABILITY TABLE 5.
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Range of Motion After Open Capsular Shift and Arthroscopic Plication
Procedure Open capsular shift
Arthroscopic capsular plication
Author
Range of Motion Reported
Bak et al.34 Choi and Ogilvie-Harris35
Mean, 90° Anterior shift: mean, 71° Posterior shift: mean, 82° 3.4° mean loss of ER, no patient lost ⬎10° Rowe score improvement from 17 to 19 for ROM 91% satisfactory ROM, 9% limited ROM No loss of ER Mean, 80.4°; loss of ⬎10° in 2/24
Marquardt et al.36 Steinbeck and Jerosch32 Baker et al.30 Treacy et al.31 Wichman and Snyder33
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 suture knot, requiring removal.
DISCUSSION MDI presents a complex problem to manage for the treating surgeon. Previously reported success rates of nonoperative management have recently been challenged as patient expectations increase.5,37 Frequently, patients present with long-term disability and have not uncommonly undergone a prior surgical procedure on the symptomatic shoulder. Prior surgical dissection and capsular manipulation such as thermal capsulorrhaphy may compromise the soft tissues and complicate a revision stabilization procedure.38,39 Patients are typically young and involved in sporting activities, which increase the demand on any planned procedure. Further complicating matters is the inconsistent definition of MDI, which has led to difficulty interpreting the available literature. McFarland et al.40 showed that variability in the definition of MDI led to a statistically significant difference in the number of patients assigned this diagnosis. Thomas and Matsen41 classified the etiology of recurrent shoulder instability as traumatic in origin, resulting in unidirectional instability, or atraumatic in origin, resulting in MDI. Neer and Foster1 and other authors42 have cautioned against a strictly atraumatic definition of MDI because this may lead to misdiagnosis and failure to address the offending pathology. More recently, a classification system incorporating frequency, etiology, direction, and severity (FEDS) was introduced.43 Interestingly, the authors purposefully avoided the concept of MDI, opting instead to rely on the history and physical examination to determine a single primary direction of instability. For the purposes of this review, we chose an inclusive
definition of MDI as the traumatic or atraumatic onset of involuntary symptomatic shoulder instability in more than 1 direction without a structural lesion such as a Bankart lesion. The procedures pertinent to this review were designed to address the patulous capsule present in patients with MDI rather than the labrum. Whereas both labral pathology and ligamentous laxity may be seen in concert in a patient with MDI, we elected to eliminate patients with labral pathology in an effort to reduce confounding factors. Our goal was to evaluate the surgical outcomes of procedures aimed at eliminating shoulder instability that were purely capsular based. To our knowledge, this is the first comparison of procedures to address MDI as a distinct entity from labral pathology. A patulous inferior capsule and laxity of the inferior glenohumeral ligaments are agreed on in the literature as the responsible pathologies in MDI.1,2,11,44 Since Neer and Foster1 proposed the open capsular shift, multiple procedures have been developed to both tighten the inferior capsule and reduce total joint volume. In an in vitro study comparing volume reduction of the glenohumeral joint using 2 techniques, Cohen et al.45 found that arthroscopic capsular plication using three 1-cm capsulolabral plication sutures resulted in a volume reduction of 22% whereas open capsular shift as described by Neer and Foster reduced joint volume by nearly 50%. Ponce et al.46 noted that the addition of five 1-cm capsular plication stitches was shown to reduce capsular volume by 49% with a suture-only technique and by 52% with suture anchors. Flanigan et al.47 found that volume reduction increased from 16% to 34% when the arthroscopic capsulolabral plication was increased from 5 to 10 mm. Miller et al.48 compared volume reduction of the glenohumeral joint using 3 different open capsular shift techniques: the humeral- or lateral-based shift as
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M. E. JACOBSON ET AL.
described by Neer and Foster, the glenoid- or medial-based shift as used by Marquardt et al.36 and Steinbeck and Jerosch,32 and a centrally based shift. The humeral-based shift reduced glenohumeral joint volume by a statistically significant amount greater than the glenoid-based shift (49% v 37%).48 Although these studies suggest that open capsular 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 plication is a reasonable alternative to open capsular shift to reliably decrease the incidence of recurrent instability in patients with MDI. Whereas the gold standard for this pathology has classically been thought to be an open capsular shift, this review does not clearly show open treatment to be superior to arthroscopic treatment. Loss of range of motion is a concern in any capsular tightening procedure; however, no study reported a consistent loss of greater than 40° of external rotation (which was defined as a failure according to the early Neer criteria). Neither technique was shown to be superior with respect to postoperative range of motion. Although 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. Although this report does show a similar efficacy with regard to the reported outcomes, the potential benefits of an all-arthroscopic approach that have not been addressed should not be ignored. These include avoidance of subscapular or infraspinatus takedown and the associated complications, limited scarring, and ability to address associated pathology, which may be inaccessible with an open approach.49 There are several limitations to this systematic review. First, there is a large discrepancy between the number of patients treated arthroscopically (n ⫽ 55) and those treated with an open procedure (n ⫽ 137). This is not surprising, given that open capsular shift was introduced more than 10 years before arthroscopic treatment methods. In addition, there was variability in the method used to report loss of external rotation, which makes drawing conclusions between the 2 groups difficult. Finally, there was inconsistent reporting of patients having undergone prior procedures, which could directly influence recurrent instability.
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 complications.
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shoulder instability in athletes. Am J Sports Med 1994;22: 578-584. Kim SH, Kim HK, Sun JI, Park JS, Oh I. Arthroscopic capsulolabroplasty for posteroinferior multidirectional instability of the shoulder. Am J Sports Med 2004;32:594-607. Lebar RD, Alexander AH. Multidirectional shoulder instability. Clinical results of inferior capsular shift in an active-duty population. Am J Sports Med 1992;20:193-198. Lupo R, Giorgi L, Rapisarda S, Viola E, Pavesi FC. Neer capsular shift surgery in the treatment of recurrent anteroinferior shoulder dislocations. Chir Organi Mov 1999;84:153160. Nixon RT Jr, Lindenfeld TN. Early rehabilitation after a modified inferior capsular shift procedure for multidirectional instability of the shoulder. Orthopedics 1998;21:441-445. van Tankeren E, de Waal Malefijt MC, van Loon CJ. Open capsular shift for multi directional shoulder instability. Arch Orthop Trauma Surg 2002;122:447-450. Voigt C, Schulz AP, Lill H. Arthroscopic treatment of multidirectional glenohumeral instability in young overhead athletes. Open Orthop J 2009;3:107-114. Massoud SN, Levy O, Copeland SA. Inferior capsular shift for multidirectional instability following failed laser-assisted capsular shrinkage. J Shoulder Elbow Surg 2002;11:305-308. Favorito PJ, Langenderfer MA, Colosimo AJ, Heidt RS Jr, Carlonas RL. Arthroscopic laser-assisted capsular shift in the treatment of patients with multidirectional shoulder instability. Am J Sports Med 2002;30:322-328. Wirth MA, Groh GI, Rockwood CA Jr. Capsulorrhaphy through an anterior approach for the treatment of atraumatic posterior glenohumeral instability with multidirectional laxity of the shoulder. J Bone Joint Surg Am 1998;80:1570-1578. Yeargan SA III, Briggs KK, Horan MP, Black AK, Hawkins RJ. Determinants of patient satisfaction following surgery for multidirectional instability. Orthopedics 2008;31:647. Hamada K, Fukuda H, Nakajima T, Yamada N. The inferior capsular shift operation for instability of the shoulder. Longterm results in 34 shoulders. J Bone Joint Surg Br 1999;81: 218-225. Krishnan SG, Hawkins RJ, Horan MP, Dean M, Kim YK. A soft tissue attempt to stabilize the multiply operated glenohumeral joint with multidirectional instability. Clin Orthop Relat Res 2004:256-261. Baker CL III, Mascarenhas R, Kline AJ, Chhabra A, Pombo MW, Bradley JP. Arthroscopic treatment of multidirectional shoulder instability in athletes: A retrospective analysis of 2to 5-year clinical outcomes. Am J Sports Med 2009;37:17121720. Treacy SH, Savoie FH III, Field LD. Arthroscopic treatment of multidirectional instability. J Shoulder Elbow Surg 1999;8: 345-350. Steinbeck J, Jerosch J. Surgery for atraumatic anterior-inferior shoulder instability. A modified capsular shift evaluated in 20 patients followed for 3 years. Acta Orthop Scand 1997;68:447450. Wichman MT, Snyder SJ. Arthroscopic capsular plication for multidirectional instability of the shoulder. Oper Tech Sport Med 1997;5:238-243.
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34. Bak K, Spring BJ, Henderson JP. Inferior capsular shift procedure in athletes with multidirectional instability based on isolated capsular and ligamentous redundancy. Am J Sports Med 2000;28:466-471. 35. Choi CH, Ogilvie-Harris DJ. Inferior capsular shift operation for multidirectional instability of the shoulder in players of contact sports. Br J Sports Med 2002;36:290-294. 36. Marquardt B, Pötzl W, Witt KA, Steinbeck J. A modified capsular shift for atraumatic anterior-inferior shoulder instability. Am J Sports Med 2005;33:1011-1015. 37. Kiss RM, Illyes A, Kiss J. Physiotherapy vs. capsular shift and physiotherapy in multidirectional shoulder joint instability. J Electromyogr Kinesiol 2010;20:489-501. 38. D’Alessandro DF, Bradley JP, Fleischli JE, Connor PM. Prospective evaluation of electrothermal arthroscopic capsulorrhaphy for shoulder instability: Indications, technique and preliminary results. Paper presented at the 15th Annual Meeting of the American Shoulder and Elbow Surgeons, New York, March 15, 1998. 39. Nottage WM. Laser-assisted shoulder surgery. Arthroscopy 1997;13:635-638. 40. McFarland EG, Kim TK, Park HB, Neira CA, Gutierrez MI. The effect of variation in definition on the diagnosis of multidirectional instability of the shoulder. J Bone Joint Surg Am 2003;85:2138-2144. 41. Thomas SC, Matsen FA III. An approach to the repair of avulsion of the glenohumeral ligaments in the management of traumatic anterior glenohumeral instability. J Bone Joint Surg Am 1989;71:506-513. 42. Bell JE. Arthroscopic management of multidirectional instability. Orthop Clin North Am 2010;41:357-365. 43. Kuhn JE, Helmer TT, Dunn WR, Throckmorton VT. Development and reliability testing of the frequency, etiology, direction, and severity (FEDS) system for classifying glenohumeral instability. J Shoulder Elbow Surg 2011;20:548-556. 44. Schenk TJ, Brems JJ. Multidirectional instability of the shoulder: Pathophysiology, diagnosis, and management. J Am Acad Orthop Surg 1998;6:65-72. 45. Cohen SB, Wiley W, Goradia VK, Pearson S, Miller MD. Anterior capsulorrhaphy: An in vitro comparison of volume reduction—Arthroscopic plication versus open capsular shift. Arthroscopy 2005;21:659-664. 46. Ponce BA, Rosenzweig SD, Thompson KJ, Tokish J. Sequential volume reduction with capsular plications: Relationship between cumulative size of plications and volumetric reduction for multidirectional instability of the shoulder. Am J Sports Med 2011;39:526-531. 47. Flanigan DC, Forsythe T, Orwin J, Kaplan L. Volume analysis of arthroscopic capsular shift. Arthroscopy 2006;22:528-533. 48. Miller MD, Larsen KM, Luke T, Leis HT, Plancher KD. Anterior capsular shift volume reduction: An in vitro comparison of 3 techniques. J Shoulder Elbow Surg 2003;12:350-354. 49. Tjoumakaris FP, Bradley JP. The rationale for an arthroscopic approach to shoulder stabilization. Arthroscopy 2011;27:14221433.
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 complications. Level of Evidence: Level IV, systematic review of Level IV studies.
I
n 1980, Neer and Foster1 coined the term “multidirectional instability” (MDI) and proposed specific surgical treatment to patients in whom conservative management has failed. In this classic article they report preliminary results of the inferior capsular shift as a means to address the patulous
From the Division of Shoulder Surgery, Department of Orthopaedics, The Ohio State University, Columbus, Ohio, U.S.A. The authors report that they have no conflicts of interest in the authorship and publication of this article. Received September 30, 2011; accepted December 6, 2011. Address correspondence to Julie Y. Bishop, M.D., Department of Orthopaedics, The Ohio State University Medical Center, 2050 Kenny Rd, Ste 3300, Columbus, OH 43221, U.S.A. E-mail: julie [email protected] © 2012 by the Arthroscopy Association of North America 0749-8063/11627/$36.00 doi:10.1016/j.arthro.2011.12.006
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inferior capsule that they believed to be the responsible pathology. Although open inferior capsular shift remains the standard in surgical treatment of MDI, multiple alternative procedures have been developed. In 1993, Duncan and Savoie2 first reported preliminary results of arthroscopic capsular plication. In all patients presenting with MDI, a regimented course of physical therapy directed at strengthening of scapular stabilizers, the rotator cuff, and the deltoid is warranted.1,3,4 Burkhead and Rockwood4 reported good or excellent results in 88% of patients with atraumatic instability treated with an exercise program; however, more recent results have been less encouraging, at 30% to 61%.3,5 If these recent reports more adequately represent our current patient population and its expectations, it is reason-
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 28, No 7 (July), 2012: pp 1010-1017
MULTIDIRECTIONAL INSTABILITY able to expect that surgical management of MDI will increase. The definition of MDI has been somewhat conflicting over the years, making interpretation of surgical outcomes articles somewhat difficult. Several arthroscopic outcomes articles6-11 and a recent review of treatment options12 have not differentiated patients with and without focal structural pathology, such as the Bankart lesion. The purpose of this study is to review the literature systematically and compare the results of open inferior capsular shift with arthroscopic capsular plication for MDI in patients without a Bankart lesion; thus surgical intervention was purely aimed at capsular plication. We hypothesize 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 In October 2010, a comprehensive literature search was conducted. 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 to this search included English language, human subjects, and title. Each database was searched for the terms “multidirectional instability,” “inferior instability,” “capsular shift,” “capsular plication,” and “capsulorrhaphy.” Abstracts from each search “hit” relevant to this systematic review were identified, and these articles were reviewed in their entirety by a senior attending fellowship trained in shoulder surgery and assisted by a resident. Inclusion criteria consisted of the following: MDI defined as instability in at least 2 directions, results with a minimum of 2-year follow up, and surgical treatment consisting of either open inferior capsular shift or arthroscopic capsular plication. We excluded review
TABLE 1.
MDI Capsular plication Capsular shift Inferior instability Capsulorrhaphy
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articles, articles reporting results of patients with Bankart lesions, and articles including patients in whom dislocation occurred voluntarily. After thorough review of each article, the following data were extracted: patient demographics, definition of MDI, surgical technique, failure rate, change in range of motion from preoperatively to postoperatively, return to sport, and complications. Patient demographics included gender, age, and arm dominance. Surgical technique was classified as open or arthroscopic, with an anterior or posterior approach, with a medial- or lateral-based capsular shift. Treatment failure was determined in those patients who did not achieve satisfactory results as defined by the Neer criteria: no recurrence of dislocation or subluxation, no significant pain, full activities, normal strength, and within 10° of full elevation and 40° of rotation compared with the contralateral shoulder.1 Range of motion was determined as the mean postoperative change in external rotation with the arm in 90° of abduction.
RESULTS Search Results The number of hits for each search term for a given database is shown in Table 1. After reviewing the abstracts of all search results, we identified 33 articles with relevance to this review. After application of our inclusion and exclusion criteria, 7 articles remained (Fig 1). Two of these studies included patient populations with and without Bankart lesions; however, the results of these groups could be interpreted independently and therefore met our inclusion criteria.30,31 In these 2 articles we were able to cleanly dissect the failure data for patients who did not have Bankart lesions and thus had purely capsular-based surgery. We did not include articles in which we could not clearly differentiate this population.
Literature Search Results
PubMed
Medline
Cochrane
103 (21) 18 (0) 69 (18) 46 (11) 109 (2)
95 (20) 14 (0) 69 (19) 44 (15) 108 (2)
0 1 (0) 2 (0) 2 (0) 5 (0)
CINAHL 42 (11) 7 (0) 27 (8) 16 (7) 32 (0)
NOTE. The number of articles for each search term relevant to this review is shown in parentheses.
SPORTDiscus 46 (12) 6 (1) 29 (10) 16 (8) 32 (1)
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M. E. JACOBSON ET AL. MDI was defined as instability in at least 2 directions 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 inferior 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, respectively); 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. Patient characteristics are summarized in Table 2. Procedure
FIGURE 1. Article exclusion flowchart. Exclusion criteria included review articles,13-16 less than 2 years’ follow-up,1-3,17-24 inclusion of Bankart or bony lesions,6-11 wrong procedures,25-27 and inclusion of voluntary dislocators.28,29
Characteristics of Included Studies No study with a level of evidence higher than Level IV was identified, and all studies consisted of case series, 5 of which were retrospective. There were 197 patients included in all studies, of whom 22 underwent bilateral procedures. Of the shoulders, 137 were treated with open capsular shift whereas 92 were treated arthroscopically. All patients were included in analysis of patient demographics, range of motion, complication, and return to sport. A total of 37 patients from 2 studies30,31 in the arthroscopic group were excluded from the failure analysis because of the presence of a Bankart lesion. The mean age was 25.6 years in the open treatment group and 23.2 years in the arthroscopic group. Whereas all patients were followed up for a minimum of 2 years, mean follow-up of the open treatment group was longer (57 months v 44 months).
Four of seven studies used open capsular shift procedures.32,34-36 Bak et al.34 and Choi and OgilvieHarris35 preferred the method described by Neer. Anterior or posterior capsular shift was performed depending on the predominant direction of instability as determined by the history and examination of the patient in the office and under anesthesia. Whereas Bak et al. performed all anterior inferior shift procedures (N ⫽ 26), Choi and Ogilvie-Harris included 37 anterior and 16 posterior procedures. A standard deltopectoral approach was used in the anterior approach. Whereas Bak et al. preserved the insertion of the subscapularis tendon, Choi and Ogilvie-Harris split it obliquely. The subscapularis was dissected from the capsule, and a T capsulotomy was performed with the short arm of the T based laterally and longitudinally. With the arm in 45° of abduction and neutral rotation, the inferior flap was rotated anteriorly and superiorly and sutured in a position such that the inferior pouch was obliterated. With the arm in adduction, the superior flap was rotated anteriorly and inferiorly. When the posterior shift was used, the infraspinatus was split obliquely and the capsular shift was performed in an identical manner as the anterior shift. Although the subscapularis tendon was not shortened in the anterior approach, the infraspinatus was shortened in the pos-
MULTIDIRECTIONAL INSTABILITY TABLE 2.
Procedure
Study
Open capsular shift
Bak et al.34 Choi and OgilvieHarris35 Marquardt et al.36 Steinbeck and Jerosch32 Arthroscopic capsular Baker et al.30 plication Treacy et al.31 Wichman and Snyder33
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Patient Characteristics of Individual Studies Gender Shoulder Dominance Age Follow-Up (Mean) (Mean) (yr) Male Female (mo) Dominant Nondominant
Shoulders (N)
Patients (N)
26 53
25 47
23 NR
18 18
17 29
NR 42
14 NR
12 NR
38 20
35 20
25.4 26
9 3
26 17
89 38
NR 18
NR 2
19.1
24
16
33.5
23
20
26.4
21
5
60
14
11
26.6
13
11
NR
NR
NR
43 (23 with 40 (20 with Bankart) Bankart) 25 (14 with 11 (14 with Bankart) Bankart) 24 24
Abbreviation: NR, not reported.
terior approach because of the relative thinness of the posterior capsule. Marquardt et al.36 (N ⫽ 38) and Steinbeck and Jerosch32 (N ⫽ 20) modified the anterior inferior shift in that the short arm of the T was medially based. The inferior flap shift was performed first with the arm in 20° of abduction and 20° of external rotation. The inferior capsular flap was secured to the decorticated rim of the glenoid by use of 2 suture anchors. There was slight variation in technique for performing arthroscopic capsular plication. Wichman and Snyder33 (N ⫽ 24) used an anterior inferior capsular pinch stitch that was then passed through the labrum to create a 1-cm capsular fold in a horizontal mattress fashion. Additional sutures were placed anterior, posterior, or inferior as deemed necessary by the history, examination, and arthroscopic findings. They did note that after plication, the humeral head sat concentrically within the glenoid as opposed to the anterior inferior position seen on diagnostic arthroscopy. Treacy et al.31 preferred a capsular plication using a transglenoid approach. Three O polydioxanone sutures were placed into the inferior glenohumeral ligament at the anterior band, at the posterior band, and centrally 1 cm from the glenoid rim. After abrasion of the inferior glenoid rim, these sutures were then passed through the glenoid neck in an anterior-toposterior direction with a Beath pin. As multiple sutures in the capsule were tightened and sutured posteriorly, the capsule tightened and advanced superiorly. Baker et al.30 used 4 nonabsorbable capsular-labral plication stitches starting at the 5:30 clock positioning in the capsule 1 cm off the glenoid and advancing this to the 4:30 clock position of the
labrum. A similar technique was used for posterior predominant instability shoulders starting at the 6:30 clock position. Suture anchors were used where the labrum was deficient (but not torn or detached). For open and arthroscopic procedures, closure of the rotator interval was variable and not clearly documented. Recurrent Instability The procedure-specific recurrent instability results are summarized in Table 3. A lower rate of recurrent instability in the studies using an open technique as compared with an arthroscopic technique was reported: 11.7% (16 of 137) versus 20% (11 of 55). This difference was not statistically significant. Failure in patients treated by open means was equally associated with spontaneous (5 patients) and traumatic (5 patients) recurrent instability.32,34,36 A history of prior surgery was associated with half of the cases of recurrent instability after arthroscopic repair.30,31 The cohort of arthroscopically treated patients reported by Wichman and Snyder33 had the highest failure rate (21%). Patient involvement with Workers’ Compensation claims or litigation accounted for 4 of 5 of their reported failures. Return to Sport There was a trend toward increased return to preoperative level of sports participation for patients treated arthroscopically versus those treated with open capsular shift (86% v 80%) (Table 4). No study reported the preoperative level of play or specific sport for all patients; thus no clear conclusions can be drawn
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M. E. JACOBSON ET AL. TABLE 3. Procedure
Open capsular shift
Arthroscopic capsular plication
Study- and Procedure-Specific Failures and Suspected Cause
Author
Failure Rate
Association With Failures
Bak et al.34 Choi and Ogilvie-Harris35 Marquardt et al.36
19% (5/26) 9% (5/53) 11% (4/38)
Steinbeck and Jerosch32 Baker et al.30
10% (2/20) 20% (4/20)
Treacy et al.31 Wichman and Snyder33
18% (2/11) 21% (5/24)
3 traumatic, 2 spontaneous Mechanism not reported 2 traumatic, 1 who had prior surgery, 1 spontaneous 2 spontaneous 1 traumatic, 1 spontaneous, 2 with history of thermal capsulorrhaphy 1 spontaneous, 1 prior surgery Mechanism not reported (3 involved in BWC claims, 1 involved in litigation for MVA)
Overall Procedure Failure Rate 11.7% (16/137)
20% (11/55)
Abbreviations: BWC, Bureau of Workers’ Compensation; MVA, motor vehicle accident.
from these data. In addition, patients with Bankart lesions in the cohorts of Baker et al.30 and Treacy et al.31 could not be excluded from these results. Both Choi and Ogilvie-Harris35 and Bak et al.34 specifically focused on open capsular shift in athletes. Choi and Ogilvie-Harris noted that of the 6 patients who underwent bilateral procedures in their cohort, only 1 returned to sport. The authors concluded that the outcome for patients with bilateral instability is poor. The overall rate of return to sport in the patient population of Bak et al. was 84%; however, this was reduced (76%) in overhead athletes. In the cohort reported by Marquardt et al.,36 the 72% rate of return to sport decreased to 50% (3 of 6) when only “elite” athletes were included. The rate of return to sport after arthroscopic capsular plication in the cohorts of Baker et al.30 and Treacy et al.31 was 86%. Of these athletes, swimmers were least likely to return to the level of prior participation.30 Loss of External Rotation Reporting of preoperative and postoperative range of motion was highly variable among included studTABLE 4. Procedure Open capsular shift
Arthroscopic capsular plication
ies, making interpretation of this outcome difficult. Postoperative external rotation with the arm in abduction is shown in Table 5. In no study was a failure of either open or arthroscopic repair attributed to limited range of motion according to the Neer criteria. With respect to the open capsular shift procedure, Choi and Ogilvie-Harris35 did note a greater loss of external rotation after anterior capsular shift as opposed to a posterior shift (71° v 82°). Wichman and Snyder33 reported mean postoperative external rotation of 80.4°; however, no preoperative data were reported. In addition, they noted that the largest loss of external rotation was found in patients involved in Workers’ Compensation claims or litigation. Complications Complications from MDI repair (outside of recurrent instability) were infrequent in the included studies. Choi and Ogilvie-Harris35 had 2 superficial wound infections and 1 musculocutaneous nerve injury that resolved with observation. Marquardt et al.36 had 1 superficial wound infection in a patient who was lost to follow-up. Treacy et al.31 reported 2 patients in
Study- and Procedure-Specific Return to Preoperative Level of Sport Author
Study-Specific Return to Preoperative Level of Sport
Overall Return to Preoperative Level of Sport
Bak et al.34 Choi and Ogilvie-Harris35 Marquardt et al.36 Steinbeck and Jerosch32 Baker et al.30 Treacy et al.31 Wichman and Snyder33
84% (21/25) 81% (44/53) 72% (21/29) 75% (15/20) 86% (31/36) 86% (6/7) Not reported
80% (101/127)
86% (37/43)
MULTIDIRECTIONAL INSTABILITY TABLE 5.
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Range of Motion After Open Capsular Shift and Arthroscopic Plication
Procedure Open capsular shift
Arthroscopic capsular plication
Author
Range of Motion Reported
Bak et al.34 Choi and Ogilvie-Harris35
Mean, 90° Anterior shift: mean, 71° Posterior shift: mean, 82° 3.4° mean loss of ER, no patient lost ⬎10° Rowe score improvement from 17 to 19 for ROM 91% satisfactory ROM, 9% limited ROM No loss of ER Mean, 80.4°; loss of ⬎10° in 2/24
Marquardt et al.36 Steinbeck and Jerosch32 Baker et al.30 Treacy et al.31 Wichman and Snyder33
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 suture knot, requiring removal.
DISCUSSION MDI presents a complex problem to manage for the treating surgeon. Previously reported success rates of nonoperative management have recently been challenged as patient expectations increase.5,37 Frequently, patients present with long-term disability and have not uncommonly undergone a prior surgical procedure on the symptomatic shoulder. Prior surgical dissection and capsular manipulation such as thermal capsulorrhaphy may compromise the soft tissues and complicate a revision stabilization procedure.38,39 Patients are typically young and involved in sporting activities, which increase the demand on any planned procedure. Further complicating matters is the inconsistent definition of MDI, which has led to difficulty interpreting the available literature. McFarland et al.40 showed that variability in the definition of MDI led to a statistically significant difference in the number of patients assigned this diagnosis. Thomas and Matsen41 classified the etiology of recurrent shoulder instability as traumatic in origin, resulting in unidirectional instability, or atraumatic in origin, resulting in MDI. Neer and Foster1 and other authors42 have cautioned against a strictly atraumatic definition of MDI because this may lead to misdiagnosis and failure to address the offending pathology. More recently, a classification system incorporating frequency, etiology, direction, and severity (FEDS) was introduced.43 Interestingly, the authors purposefully avoided the concept of MDI, opting instead to rely on the history and physical examination to determine a single primary direction of instability. For the purposes of this review, we chose an inclusive
definition of MDI as the traumatic or atraumatic onset of involuntary symptomatic shoulder instability in more than 1 direction without a structural lesion such as a Bankart lesion. The procedures pertinent to this review were designed to address the patulous capsule present in patients with MDI rather than the labrum. Whereas both labral pathology and ligamentous laxity may be seen in concert in a patient with MDI, we elected to eliminate patients with labral pathology in an effort to reduce confounding factors. Our goal was to evaluate the surgical outcomes of procedures aimed at eliminating shoulder instability that were purely capsular based. To our knowledge, this is the first comparison of procedures to address MDI as a distinct entity from labral pathology. A patulous inferior capsule and laxity of the inferior glenohumeral ligaments are agreed on in the literature as the responsible pathologies in MDI.1,2,11,44 Since Neer and Foster1 proposed the open capsular shift, multiple procedures have been developed to both tighten the inferior capsule and reduce total joint volume. In an in vitro study comparing volume reduction of the glenohumeral joint using 2 techniques, Cohen et al.45 found that arthroscopic capsular plication using three 1-cm capsulolabral plication sutures resulted in a volume reduction of 22% whereas open capsular shift as described by Neer and Foster reduced joint volume by nearly 50%. Ponce et al.46 noted that the addition of five 1-cm capsular plication stitches was shown to reduce capsular volume by 49% with a suture-only technique and by 52% with suture anchors. Flanigan et al.47 found that volume reduction increased from 16% to 34% when the arthroscopic capsulolabral plication was increased from 5 to 10 mm. Miller et al.48 compared volume reduction of the glenohumeral joint using 3 different open capsular shift techniques: the humeral- or lateral-based shift as
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described by Neer and Foster, the glenoid- or medial-based shift as used by Marquardt et al.36 and Steinbeck and Jerosch,32 and a centrally based shift. The humeral-based shift reduced glenohumeral joint volume by a statistically significant amount greater than the glenoid-based shift (49% v 37%).48 Although these studies suggest that open capsular 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 plication is a reasonable alternative to open capsular shift to reliably decrease the incidence of recurrent instability in patients with MDI. Whereas the gold standard for this pathology has classically been thought to be an open capsular shift, this review does not clearly show open treatment to be superior to arthroscopic treatment. Loss of range of motion is a concern in any capsular tightening procedure; however, no study reported a consistent loss of greater than 40° of external rotation (which was defined as a failure according to the early Neer criteria). Neither technique was shown to be superior with respect to postoperative range of motion. Although 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. Although this report does show a similar efficacy with regard to the reported outcomes, the potential benefits of an all-arthroscopic approach that have not been addressed should not be ignored. These include avoidance of subscapular or infraspinatus takedown and the associated complications, limited scarring, and ability to address associated pathology, which may be inaccessible with an open approach.49 There are several limitations to this systematic review. First, there is a large discrepancy between the number of patients treated arthroscopically (n ⫽ 55) and those treated with an open procedure (n ⫽ 137). This is not surprising, given that open capsular shift was introduced more than 10 years before arthroscopic treatment methods. In addition, there was variability in the method used to report loss of external rotation, which makes drawing conclusions between the 2 groups difficult. Finally, there was inconsistent reporting of patients having undergone prior procedures, which could directly influence recurrent instability.
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 complications.
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