Multidirectional instability of the shoulder: surgical techniques and clinical outcome

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Abstract

Multidirectional instability of the shoulder has a complex pathoanatomy. It is characterized by a redundant glenohumeral capsule and increased joint volume.
Subtle clinical presentation, unclear trauma history and multifactorial etiology poseses a great challenge for orthopedic surgeons in terms of diagnosis.
Generally accepted therapeutic approach is conservative and the majority of patients achieve good results with rehabilitation.
In patients who are symptomatic despite appropriate rehabilitation, surgical intervention may be considered.
Good results have been obtained with open inferior capsular surgery, which has historically been performed in these patients.
In recent years, advanced arthroscopic techniques have taken place in this field, and similar results compared to open surgery have been obtained with the less-invasive arthroscopic capsular plication procedure.

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Most cited references 63

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Inferior capsular shift for involuntary inferior and multidirectional instability of the shoulder. A preliminary report.

D. Foster, Charles Neer (1980)

In thirty-six patients (forty shoulders) with involuntary inferior and multidirectional subluxation and dislocation, there had been failure of standard operations or uncertainty regarding diagnosis or treatment. Clinical evaluation of these patients stressed meticulous psychiatric appraisal, conservative treatment, and repeated examination of the shoulder. All patients were treated by an inferior capsular shift, a procedure in which a flap of the capsule reinforced by overlying tendon is shifted to reduce capsular and ligamentous redundancy on all three sides. This technique offers the advantage of correcting multidirectional instability through one incision without damage to the articular surface. One shoulder began subluxating again within seven months after operation, but there have been no other unsatisfactory results to date. Seventeen shoulders were followed for more than two years.

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Classification of glenohumeral joint instability.

Christian Gerber, Richard Nyffeler (2002)

Shoulder instabilities have been classified according to the etiology, the direction of instability, or on combinations thereof. The current authors describe a classification system, which distinguishes between static instabilities, dynamic instabilities, and voluntary dislocation. Static instabilities are defined by the absence of classic symptoms of instability and are associated with rotator cuff or degenerative joint disease. The diagnosis is radiologic, not clinical. Dynamic instabilities are initiated by a trauma and may be associated with capsulolabral lesions, defined glenoid rim lesions, or with hyperlaxity. They may be unidirectional or multidirectional. Voluntary dislocation is classified separately because dislocations do not occur inadvertently but under voluntary control of the patient.

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Mechanisms of glenohumeral joint stability.

S Lippitt, F Matsen (1993)

The biomechanics of glenohumeral stability involve several static and dynamic mechanisms to achieve the intricate balance between shoulder mobility and stability. In conjunction with recent in vitro studies, two important stabilizing mechanisms, concavity compression and scapulohumeral balance, were described. Concavity compression refers to the stability obtained by compressing the humeral head into the concave glenoid fossa. Increasing the magnitude of the compressive load, as provided by dynamic muscle contraction, and the depth of the glenoid concavity, which varies from the asymmetric geometry, enhance concavity compression stabilization. The related scapulohumeral balance refers to the dynamic positioning of the glenohumeral joint so that the joint reaction force is balanced within the glenoid fossa. The greater the arc provided by the glenoid, the larger the range of joint force angles acting through the humeral head that may be stabilized. The presence of an intact glenoid labrum is important to both mechanisms. Concavity compression and scapulohumeral balance may be of particular importance to glenohumeral joint stability in the midrange of motion where the capsuloligamentous constraints are lax. Clinical correlation of these mechanisms contributes to the understanding of glenohumeral instability.