Arch Orthop Trauma Surg (2002) 122 : 447–450
DOI 10.1007/s00402-002-0416-5
O R I G I N A L A RT I C L E
E. van Tankeren · M. C. de Waal Malefijt ·
C. J. M. van Loon
Open capsular shift for multi directional shoulder instability
Received: 10 September 2001 / Published online: 20 June 2002
© Springer-Verlag 2002
Abstract We evaluated the outcome of open antero-infe-
rior capsular shift in 17 patients with multidirectional in-
stability of the shoulder who failed to respond to conserv-
ative treatment. Six shoulders presented with secondary
impingement syndrome and 11 with involuntary instabil-
ity. The mean duration of follow-up was 39 months (range
7–89 months). Based on the Rowe and Constant scores
and the 12-item questionnaire of Dawson, the results were
rated excellent in 14 patients, fair in 2 and poor in 1. All
but 2 patients were satisfied with the results, although 6 pa-
tients experienced some residual pain, and 4 suffered mi-
nor instability. There were no neurovascular complications,
infections or symptomatic posterior instability. Open an-
tero-inferior capsular shift yields promising short-term to
medium-term results in multidirectional, involuntary in-
stability of the shoulder.
Keywords Shoulder · Multidirectional instability ·
Impingement (secondary) · Capsular shift
Introduction
Multidirectional instability of the shoulder (MDI) [5] can
be symptomatic with or without an adequate trauma to the
shoulder. The presentation may be recurrent instability (dis-
location or subluxation) or pain during overhead activities
(secondary impingement syndrome). Operative treatment,
such as the open antero-inferior capsular shift procedure
(OACS), may be considered if conservative management
is unsuccessful. Other surgical procedures include arthro-
scopic capsular shift or arthroscopic capsular shrinkage
[9, 10].
E. van Tankeren · M.C. de Waal Malefijt (✉) · C.J.M. van Loon
University Medical Centre St. Radboud, Dept. of Orthopaedics,
PO Box 9101, 6500 HB Nijmegen, The Netherlands
e-mail: M.deWaalMalefijt@orthp.azn.nl,
Tel.: +31-24-3614148, Fax: +31-24-3540230
The purpose of this study was to review the results of
the OACS procedure in patients with involuntary MDI of
the shoulder.
Patients and methods
In the period from January 1990 to June 1999, 20 patients with
MDI of the shoulder were treated with OACS. Only patients with
involuntary instability who had not undergone previous surgery
were included. Three patients were lost to follow-up. There were
7 men and 10 women with a mean age of 25 (range 19–40) years
at the time of surgery. Six patients presented with a painful shoul-
der due to secondary impingement, and 11 patients presented with
instability; 4 subluxations, 7 dislocations. Ten of the affected shoul-
ders involved the dominant extremity. In 5 patients there had been
an adequate trauma to the shoulder, resulting in a dislocation in
4 patients. None of the patients had a connective tissue disorder.
An extensive training program was initiated in all cases, focused
on strengthening the rotator cuff and deltoid muscles, under super-
vision of a physiotherapist and lasting at least 3 months. All the re-
viewed cases failed this conservative treatment, and therefore ex-
amination under general anaesthesia and arthroscopy of the gleno-
humeral joints was performed. All patients had MDI of the shoulder,
and 9 of the 17 patients had an additional labral lesion on arthros-
copy. Follow-up evaluation was performed in all patients after a
mean period of 39 months (range 7–89 months), using the Rowe
and Constant scales and the 12-item questionnaire from Dawson
[3, 4, 6]. The Dawson questionnaire score indicates the severity of
impairment during activities of daily living. A score of 12 indi-
cates no difficulties at all, and a score of 60 indicates severe diffi-
culties. The patients were asked for their subjective opinion about
the outcome after surgery: satisfied or unsatisfied.
Surgical technique
All patients were operated on in the ‘beachchair’ position by one
surgeon through an anterior approach via the deltopectoral groove,
lateral to the cephalic vein.
The subscapular muscle was dissected from the capsule. The
capsule was opened just superior to the medial glenohumeral liga-
ment, along the lateral attachment to the humeral head and down to
the 6 o’clock position. The shift was performed in the craniolateral
direction without plication. In case of a labral lesion, the labrum
was reattached to the glenoid with the use of Mitek-suture anchors
(Mitek products, division of Ethicon, Westwood, Mass., USA). The
capsule was closed with the glenohumeral joint in 15 deg of exter-
nal rotation, and the rotator cuff interval was approximated. The
448
shoulder was immobilized in a sling for 6 weeks. The rehabilita-
tion program was started the first day after surgery with supported
active elevation to 90 deg without external rotation. External rota-
tion was allowed to 10 deg after 3 weeks and to a maximum, pain-
free external rotation position after 6 weeks. Muscle strengthening
exercises were started 6 weeks postoperatively.
Results
Pain. Eleven patients were totally free of shoulder pain at
follow-up. Of the 6 patients who reported pain postopera-
tively, 3 did not improve, 2 patients did improve, and 1 pa-
tient was worse compared with the preoperative status. In
the group with secondary subacromial impingement (6 pa-
tients), 3 patients were free of pain, 2 patients improved,
and 1 patient did not improve. In the group with instabil-
ity (11 patients), 8 patients are free of pain, 2 patients did
not improve, and 1 patient was worse (Table 1).
Instability. At the time of follow-up, 2 patients (18%) had
suffered a recurrent dislocation of the shoulder, and 2 pa-
tients (18%) experienced subluxation. Of the 2 patients
with a recurrent dislocation, 1 experienced dislocations
during sports after a new trauma to the shoulder, and the
other had had 2 recurrent episodes during pregnancy. The
latter case was only temporary instability and disappeared
after the delivery. Of the 2 patients with recurrent sublux-
ations, one did not notice any difference compared with
the preoperative situation; the other experienced fewer
subluxations, which started after a fall down the stairs
3.5 months after surgery.
Motion. There was an average loss of 18.5 (range 5–55)
deg of external rotation in 10 patients, and an average im-
provement of 12 (range 5–20) deg in 3 patients at follow-
up. In 4 patients there was no difference in external rota-
tion. In 5 patients a painful arc was present before the op-
eration, which was absent at follow-up. Twelve patients
had full motion equal to that of the opposite side for active
flexion: 180 deg. Four patients had a loss of flexion of be-
tween 10 and 90 deg (mean 45 deg). Thirteen patients had
full motion equal to that of the opposite side for abduc-
tion: 180 deg. Four patients had a loss of abduction of be-
tween 10 and 90 deg (mean 31 deg).
Strength. The mean difference in abduction strength be-
tween the operated shoulder and the opposite side was
1.4 kg (range 0–6 kg).
Overall score. The mean Rowe score improved from 57
(range 36–82) points preoperatively to 87 (range 39–100)
points at follow-up. The mean Constant score at follow-
up was 77 (range 60–87) points for the patients who were
operated on for secondary subacromial impingement and
83 (range 47–100) points for the patients who were oper-
ated on for instability. The mean Dawson questionnaire
score at follow-up was 26 (range 14–40) in the overall pa-
tient group, 32 (range 27–43) in the impingement group
and 25 (range 14–40) in the instability group.
Subjective result. All but 2 patients said they were satis-
fied with the operation (88%). One patient who was dis-
satisfied was unable to play sports because of recurrent
dislocations; the other didn’t notice any difference in the
shoulder condition and complained about pain and sublux-
ations. Both patients were in the instability group.
Complications. There were no infections, neurovascular
complications or symptomatic posterior instability.
Discussion
MDI of the shoulder affects mostly younger patients be-
tween 19 and 40 years of age. Pre-existent asymptomatic
MDI may become symptomatic after an adequate trauma
to the shoulder, resulting in a labral lesion and subsequent
increased instability. Of the 17 patients we investigated, 5
had suffered an adequate trauma preoperatively, 6 had an
inadequate trauma, and 6 had no preoperative trauma. Al-
though excellent results may be obtained with conserva-
tive treatment, one in every 6 patients will not respond to
such treatment [2, 7]. For the non-responders, several op-
erative techniques have been described [5, 9, 10, 11]. In
short-term follow-up studies of arthroscopic capsular shift,
the recurrence rate ranged from 0% to 45% [1, 10]. Arthro-
scopic capsular shift is a technically demanding procedure
with a long learning curve, while with the open procedure
under direct vision, the extent of the shift can be easily de-
termined. In most reports of open capsular shift for MDI,
the recurrence rate for instability ranged from 0% to 39%
[1, 8, 11, 12], which is comparable to the 36% in our study.
In studies of open capsular shift for secondary im-
pingement syndrome, the results were good, with recur-
rent impingement ranging from 13% to 36% [8]. In our
study two patients (33%) in the impingement group still
experienced some residual pain at follow-up.
In studies of arthroscopic capsular shrinkage [9] for
MDI, the results were good, with recurrent instability
ranging from 3% to 7%. However, little is known about
the long-term effects of the shrinkage, the effect of the
thermal damage to the proprioceptive nerve endings within
the capsule, and the time for them to fully reform and
function normally. If the applied temperature exceeds a
critical limit, destruction of the entire capsular matrix may
occur, with devastating results [9].
No complications (infection, nerve injury or haematoma)
occurred in our study. In other studies dystrophy, thoracic
outlet syndrome, degenerative arthritis, haematoma, axil-
lary neuropraxis and thrombophlebitis of the cephalic vein
were described [5, 8, 12]. The OACS may lead to over-
tightening of the anterior capsule with subsequent symp-
tomatic posterior instability or degenerative arthritis [5].
None of our patients demonstrated this phenomenon, prob-
ably because the capsule was closed in 15 deg of external
rotation. Most patients regained a sufficient range of ex-
ternal motion during their rehabilitation. In our study 15
of 17 patients (88%) thought the operation was success-
ful.
Table 1 Patient data and results

Patient no.
Gender
Age (years)
Operation typea
Operation time (minutes)
Rowe score, preoperatively
Preoperative stabilityb
Preoperative painc
Preoperative traumad
Flexion preoperatively (deg)
Abduction preoperatively (deg)
External rotation preoperatively (deg)
Painful arc preoperatively
Follow-up (months)
Rowe score, follow-up
Postoperative stabilitye
Constant score, postoperatively
Pain, follow-upf
Flexion, follow-up (deg)
Abduction, follow-up (deg)
External rotation, follow-up (deg)
Painful arc, follow-up
Subluxation at passive abduction, follow-up
Dawson questionnaire score, follow-up
Satisfied

1 M 33 1 65 53 3 1 2 160 160 70 + 61 100 3 87 4 180 180 80 – – 25 Yes

2 F 22 1 85 45 1 2 1 180 180 80 – 62 95 3 84 4 180 180 75 – – 34 Yes
3 M 21 2 110 71 2 4 3 180 180 90 – 89 92 1 91 4 180 180 70 – + 25 No
4 F 29 1 85 82 3 3 3 180 180 80 + 53 97 3 76 3 180 180 70 – – 27 Yes
5 F 23 1 70 54 3 1 3 180 180 80 + 16 90 3 79 4 180 180 70 – – 27 Yes
6 M 24 1 80 51 1 3 1 170 160 70 – 11 98 3 100 4 180 180 70 – – 21 Yes
7 M 28 2 105 70 1 4 2 180 180 80 – 40 100 3 97 4 180 180 80 – – 14 Yes
8 M 40 2 120 52 1 4 2 90 95 80 – 38 100 3 89 4 140 170 65 – – 15 Yes
9 M 19 2 85 42 1 3 1 180 180 80 – 19 92 3 91 3 180 180 80 – – 20 Yes
10 F 24 2 80 67 1 3 1 180 180 80 – 35 100 3 83 4 180 180 80 – – 15 Yes
11 F 25 2 90 65 3 1 2 180 180 80 + 9 95 3 76 3 180 180 70 – – 37 Yes
12 F 22 2 85 56 1 4 3 180 180 70 – 79 60 1 47 2 90 90 55 – – 40 Yes
13 F 23 1 80 43 3 1 1 150 160 85 + 11 64 3 60 3 140 180 70 – – 43 Yes
14 F 25 1 85 36 2 1 3 150 170 70 – 45 39 2 62 1 170 160 75 – + 38 No
15 F 23 2 85 62 2 3 2 180 180 80 – 72 85 2 81 4 180 175 70 – – 20 Yes
16 M 29 2 85 63 3 1 2 170 100 70 + 14 95 3 81 4 180 180 90 – – 32 Yes
17 F 21 1 90 50 2 1 3 180 180 70 – 7 91 3 80 4 180 180 30 – – 31 Yes
aOperation type: 1 capsular shift, 2 capsular shift + labral repair dPreoperative trauma: 1 adequate, 2 inadequate, 3 none
bPreoperative stability: 1 dislocation, 2 subluxation, 3 impingement ePostoperative stability: 1 dislocation, 2 subluxation, 3 impingement
cPreoperative pain: 1 severe, 2 moderate, 3 mild, 4 none fPain, follow-up: 1 severe, 2 moderate, 3 mild, 4 none
449
450
Our study indicates that OACS is a valuable treatment
for involuntary MDI with acceptable short-term to medium-
term results. Avoiding overtightening of the anterior cap-
sule prevents symptomatic posterior instability.
References
1. Bigliani LU (1998) Glenohumeral instability repairs: complica-
tions and failures. In: Bigliani LU (ed) The unstable shoulder.
Internal publication, Monograph series, American Academy of
Orthopaedic Surgeons
2. Burkhead WZ, Rockwood CA Jr (1992) Treatment of instabil-
ity of the shoulder with an exercise program. J Bone Joint Surg
Am 74: 890–896
3. Constant CR, Murley AHG (1987) A clinical method of func-
tional assessment of the shoulder. Clin Orthop 214: 160–164
4. Dawson J, Fitzpatrick R, Carr A (1999) The assessment of
shoulder instability. J Bone Joint Surg Br 81: 420–426
5. Neer CS, Foster CR (1980) Inferior capsular shift for involun-
tary inferior and multidirectional instability of the shoulder.
J Bone Joint Surg Am 62: 897–908
6. Rowe CR (1988) Evaluation of the shoulder. In: Rowe CR (ed)
The shoulder. Churchill Livingstone, New York, pp 631–637
7. Rowe CR (1988) Dislocations of the shoulder. In: Rowe CR
(ed) The shoulder. Churchill Livingstone, New York, pp 165–
287
8. Rowe CR, Patel D, Southmayd WW (1978) The Bankart pro-
cedure. J Bone Joint Surg Am 60: 5–15
9. Savoie FH 3rd, Field LD (2000) Thermal versus suture treat-
ment of symptomatic capsular laxity. Clin Sports Med 19: 63–
75
10. Treacy SH, Savoie FH III, Field LD (1999) Arthroscopic treat-
ment of multidirectional instability. J Shoulder Elbow Surg 8:
345–349
11. Yamaguchi K, Flatow EL (1995) Management of multidirec-
tional instability. Clin Sports Med 14: 885–902
12. Zabinski SJ, Callaway GH, Cohen S, Warren RF (1999) Revi-
sion shoulder stabilization 2- to 10-year results. J Shoulder El-
bow Surg 8: 58–65