Standing the Test of Time. . . Neer Inferior Capsular Shift for Multidirectional Instability of the Shoulder
abstract & commentary
Synopsis: The Neer inferior capsular shift for multidirectional instability stands the test of time and sufficiently stabilizes the shoulder in these complex patients with global shoulder instability.
Source: Pollock RG, et al. Operative results of the inferior capsular shift procedure for multidirectional instability of the shoulder. J Bone Joint Surg Am 2000;82:919-928.
Multidirectional instability (mdi) in the shoulder is instability in more than one direction. Neer described the inferior capsular shift procedure for the treatment of shoulder MDI in a classic article in 1980, which reported good results at short-term follow-up. The purpose of this article is to provide the reader long-term follow up on the Neer Approach to shoulder MDI.
A retrospective review of Neer’s approach for shoulder MDI between 1982 and 1992 identified 52 shoulders in 49 patients. Only three patients were lost to follow-up, leaving 49 shoulders to study. The average postoperative follow-up was 61 months. The patients were included in the study if they gave a history and exam consistent with MDI (+ sulcus sign, + anterior apprehension, + posterior stress test) and did not respond to appropriate shoulder and scapular strengthening exercises. Patients were excluded if they exhibited willful or voluntary instability. Twenty-eight male and 18 female patients were an average age of 23 when they underwent a surgical repair. A traumatic event precipitated the shoulder instability in 51%, no traumatic event precipitated the instability in 31%, and recurrent micro trauma was noted in 18%. An anterior approach was used in 69%, and a posterior approach was used in 31%. The direction of the surgical approach for the capsular shift was determined by the physical exam in the operating room. All patients underwent an inferior capsular shift procedure as described by Neer and Foster. The surgical procedures are well outlined in this article.
The intraoperative findings identified a redundant capsule in all patients, a detachment of the anteroinferior labrum in 10 shoulders, a posterior labral tear in one shoulder and fracture of the glenoid rim in two shoulders. Shoulder stability was obtained in 96% of the shoulders at the time of final follow-up. Two shoulders needed additional repair for recurrent instability. Sixty-seven percent were pain free and 96% had full range of motion. Eighty-six percent of athletes returned to their sporting events but only 69% achieved the same premorbid condition within their sport.
Of the 34 patients undergoing an anterior approach, 91% had good or excellent results, 94% remained stable, and 91% had full motion. Of the 15 shoulders undergoing a posterior approach, 100% had a good or excellent result and remained stable, and 93% had full range of motion.
Comment by James R. Slauterbeck, MD
This is a great long-term follow-up study of Neer’s approach to MDI. Several points are worth mentioning in this article.
First, the decision on whether to perform the capsular shift by an anterior or posterior approach is based upon the predominant direction of instability on exam and by history. The intraoperative exam is the best time to determine the surgical approach and gives the best identification of the true instability pattern. Therefore, the capsular shift should be performed by a posterior approach when significant posterior laxity is identified and by an anterior approach if significant anterior laxity is identified on the preoperative exam.
Second, one must examine the glenoid attachment of the capsule and labrum because untreated avulsions from the glenoid will not give a stable base on which to shift the capsule to the humerus. This study demonstrates that repair of the labrum and capsule to the glenoid in addition to the capsular shift to the humerus will give a good outcome.
Third, this study supports the concept that many of our patients have significant laxity in the shoulder and function well until a traumatic event moves them from functional laxity to pathological instability. More than 50% of the patients with MDI presented with this type of traumatic history.
In my opinion, this is an excellent long-term follow-up paper describing a single approach to shoulder MDI. The results are convincing. The shoulder scoring system used in this manuscript could be improved upon by using one of the more accepted measurement scoring systems. Further study of patients evaluated prospectively and measured by a standardized and tested scoring system would be an excellent follow-up to this article.