Arthroscopic Treatment of Multidirectional Shoulder Instability

Chapter 4

Arthroscopic Treatment of Multidirectional Shoulder Instability

Steven B. Cohen and Jon K. Sekiya

DEFINITION

• Neer and colleagues14 described the concept of multidirectional instability of the shoulder in detail in 1980.

  • This established the difference between unidirectional instability and global laxity of the capsule inferiorly, posteriorly, and anteriorly.

• Subjective complaints of pain and global shoulder instability

• Subluxation or dislocation from traumatic, microtraumatic, or atraumatic injury

  ANATOMY

• Stability of the shoulder relies on dynamic and static restraints.

• Static restraints:

  • Inferior glenohumeral ligament

    • Anterior band resists anterior translation in 90 degrees of abduction and external rotation.

    • Posterior band resists posterior translation in forward flexion, adduction, and internal rotation.

  • Middle glenohumeral ligament

    • Resists anterior translation in 45 degrees of abduction

  • Superior glenohumeral ligament

    • Resists posterior and inferior translation with arm at side

  • Rotator interval and coracohumeral ligament

    • Resists posterior and inferior translation with arm at side

• Dynamic restraints

  • Rotator cuff muscles

  • Deltoid

  • Effects of concavity and compression

• Shoulder instability has been found to be a result of several pathologic processes:

  • Capsular laxity

  • Labral detachment and Bankart lesion

  • Rotator interval defects

    PATHOGENESIS

• Typically, there is not a history of a traumatic shoulder dislocation, but it may be the inciting event. Most commonly, the instability is due to microtrauma resulting in global capsular laxity.

• There may be a history of recurrent dislocations or repetitive subluxation events.

• Patients are typically young and active and present with the following:

  • Pain

  • Complaints of shoulder shifting

  • Difficulty with overhead activity

  • Inability to do sports

  • Instability while sleeping

  • Trouble with activities of daily living

  • Episodes of “dead arm” sensation

  • Failed prior attempts at physical therapy

NATURAL HISTORY

• Unable to change static restraints

• Stability can be achieved by restoring neuromuscular control through rehabilitation.

• Recurrent dislocations may lead to Hill-Sachs lesions, glenoid erosion, or chondral injury, which may predispose to early degenerative arthritis of the glenohumeral joint.

• Recurrent instability affecting daily activities despite formal physical therapy generally requires surgical treatment.

   

  PHYSICAL FINDINGS

• Infrequent atrophy

• Symmetric range of motion

  • Possible scapulothoracic winging

  • Loss of active motion may be related to pain.

  • Loss of passive motion may be from capsular contracture.

• Normal strength testing

  • Loss of strength can indicate rotator cuff pathology or nerve injury.

• Evaluation for ligamentous laxity

  • Frequently positive for generalized ligamentous laxity

  • Predisposed to shoulder instability

• Evaluation for impingement. Impingement may be a sign of rotator cuff tendinitis or internal impingement in throwers.

• Stability testing

  • Positive increased load and shift test for anterior and posterior translation

  • Positive sulcus sign (both in neutral and external rotation) for inferior translation

  • A sulcus sign graded as 3+ that remains 2+ in external rotation is pathognomonic for multidirectional instability.

• Specific tests

  • Apprehension test: Positive result indicates anterior instability.

  • Relocation test: Positive result indicates anterior instability.

  • O’Brien sign: Pain or click indicates a superior labrum anterior posterior (SLAP) tear; anterosuperior pain indicates acromioclavicular joint pathology.

  • Jerk test: Positive result indicates posteroinferior instability.

  • Kim test: Positive result indicates posteroinferior instability.

  • Circumduction test: Positive result indicates posterior instability.

  • Speed’s test: Positive result indicates biceps tendinitis or SLAP tear.

     

    IMAGING AND DIAGNOSTIC STUDIES

• Plain radiographs

  • Anteroposterior view

     

    30

     

     

     

     

    MRI Finding

    +/— Bankart tear

    +/— Labral tear

    +/— Superior labrum anterior posterior (SLAP) tear

    +/— Capsular laxity, enlarged axillary pouch

    +/— Hill-Sachs or reverse Hill-Sachs lesion

    +/— Bony Bankart or glenoid erosion

    Structure Anterior labrum Posterior labrum Superior labrum Inferior capsule Humeral head Glenoid

    MRI Findings

    Table 1

     

     

    • Axillary lateral or West Point axillary view

    • Outlet view

    • Stryker notch view

    • Evaluate for:

      • Hill-Sachs or reverse Hill-Sachs lesion

      • Glenoid pathology

      • Bony humeral avulsion of the glenohumeral ligaments

      • Magnetic resonance (MR) arthrogram (Table 1): Evaluate for:

        • Capsular laxity

        • Labral pathology

        • Biceps tendon pathology

        • Rotator cuff lesions (rare)

      • Computed tomography

        • Evaluate for proximal humeral and glenoid bony pathology.

          NONOPERATIVE TREATMENT

      • In many patients with atraumatic multidirectional instability, proper neuromuscular control of dynamic glenohumeral stability has been lost.

      • The goal is to restore shoulder function through training and exercise.

      • Patients with loose shoulders may not necessarily be unstable, as evidenced by examining the contralateral asymptomatic shoulder in patients with symptomatic multidirectional instability.

      • The mainstay of treatment is nonoperative, with attempts to achieve stability using scapular and glenohumeral strengthening exercises.

        SURGICAL TREATMENT

        Indications

      • Patients who have attempted a dedicated program of physical therapy, have functional problems, and remain unstable may then be candidates for surgical treatment.

      • Patients with a history of multidirectional instability who sustain fractures of the glenoid or humeral head with a dislocation generally require surgical treatment.

      • Patients with significant defects in the humeral head associated with multiple dislocations consistent with Hill-Sachs lesions may require earlier surgical treatment.

      • Glenoid erosion or lip fractures, if significant, can also necessitate surgical intervention if associated with recurrent instability.

        Contraindications

      • Patients with voluntary or habitual instability

         

• Patients who have not attempted a formal physiotherapy program should avoid initial surgical treatment.

• Any patient unable or unwilling to comply with the postoperative rehabilitation regimen

  Surgical Planning

• Patient education is critical in planning surgical treatment for the patient with an unstable shoulder.

• Patients should have failed a trial at nonoperative treatment and have persistent instability with functional deficits.

• The goal of surgical treatment is to reduce capsular volume and restore glenoid concavity with capsulolabral augmentation.

• Decreasing capsular volume may lead to decreased range of motion.

  • It is important to discuss this possibility with the patient because some more active athletic patients such as throwers, gymnasts, and volleyball players may not tolerate losses of motion to maintain participation in their sport.

• Additional risks should be discussed, including infection, recurrence of instability, pain, neurovascular injury, persistent functional limitations, and implant complications.

• The surgical planning continues with the evaluation under anesthesia and diagnostic arthroscopy.

  • This may alter the plan to include any combination of the following: capsular plication (anterior, posterior, or inferior), rotator interval closure, anteroposterior labral repair, SLAP repair, biceps tenodesis or tenotomy, and possible conversion to an open capsular shift.

• Arthroscopic techniques have evolved from capsular shift via transglenoid sutures, Bankart repair and shift with biodegradable tacks or suture anchors, thermal capsulorrhaphy, rotator interval repair, and capsular plication.

  • Standard portals are listed in Table 2.

• Our current method of treatment for patients with multidirectional shoulder instability who have failed to respond to nonoperative attempts is to perform an arthroscopic capsular shift by reducing capsular volume using capsular plication with a multipleated repair.18

   

  Accessory

  Superior 1 cm lateral and anterior to posterolateral border of acromion

  Inferoposterior 2 cm inferior to standard posterior portal Neviaser In the notch between posterior acromioclavicu-

  lar joint and spine of scapula

  2 cm inferior and medial to posterolateral border of acromion

  Lateral to coracoid (external) and just inferior to biceps tendon (internal) in the rotator interval

  Lateral to coracoid (external) and just superior to subscapularis tendon (internal)

  Anteroinferior

  Anterosuperior

  Location

  Portal

  Standard

  Posterior

  Arthroscopic Portals

  Table 2

   

   

  Anesthesia and Patient Positioning

  • The procedure can be performed under interscalene block or general endotracheal anesthesia with an interscalene block for postoperative pain control.

  • The patient is then placed in the lateral decubitus position with the affected shoulder positioned superior.

    • An inflatable beanbag holds the patient in position.

    • Foam cushions are placed to protect the peroneal nerve at the neck of the fibula on the down leg.

    • An axillary roll is placed.

    • The operating table is placed in a slight reverse-Trendelenburg position.

       

       

    • The full upper extremity is prepared to the level of the sternum anteriorly and the medial border of the scapula posteriorly.

      • The operative shoulder is placed in 10 pounds of traction and is positioned in 45 degrees of abduction and 20 degrees of forward flexion.

• Alternatively, the beach-chair position can be used. In our experience, however, this position gives limited exposure of the posterior inferior capsule.

  • The head of the bed is raised to about 70 degrees with the affected shoulder off the side of the bed with support medial to the scapula.

  • The head should be well supported and all bony prominences padded.

  • The entire arm, shoulder, and trapezial region are prepared into the surgical field.

     

    TECHNIQUES	ESTABLISHING LANDMARKS AND PORTALS
    	through an 18-gauge spinal needle to inflate the joint. sary using our multipleated technique. TECH FIG 1 • Arthroscopic portals.
    	DIAGNOSTIC ARTHROSCOPY
    	and Warren,13 is performed with the patient supine. ■ The labrum, capsule, biceps tendon, subscapularis, ro- applied in an attempt to translate the humeral head ■ This ensures that no associated lesions will be over the anterior or posterior glenoid. overlooked. ity has an inferior component. ■ Patulous inferior capsule rectional instability. ■ Articular partial-thickness rotator cuff tears

    • The bony landmarks, including the acromion, distal clav- ■ If a second portal is desired, it is created using a spinal icle, acromioclavicular joint, and coracoid process, are de- needle at the level just superior to the subscapularis marcated with a marking pen (TECH FIG 1). tendon lateral to the coracoid and at least 1 cm infe-

    • After prepping and draping the patient, the gleno- rior to the anterior portal. humeral joint is injected with 50 mL of sterile saline

    • A posterior portal can be established 1 cm proximal (high) and 1 cm lateral (humeral) to the standard posterior portal to allow access to the rim of the posterior glenoid for anchor placement if a posterior labral or capsular repair is necessary.

    • An anterior portal is then established in the rotator interval via an outside-in technique using a spinal needle.

      • Care should be taken using the switching stick to verify that the low anterior inferior 5 o’clock anchor can be placed through this portal.

      • If two anterior portals are desired, this portal should be placed “high” in the interval to make room for the second “low” portal.

    • Typically, an additional anteroinferior portal is unneces-

    • The examination under anesthesia is performed on a ■ Testing is completed on both the affected and unaf-firm surface with the scapula relatively fixed and the fected shoulders, and differences between the two humeral head free to rotate. are documented.

      • A “load and shift” maneuver, as described by Murrell ■ Diagnostic arthroscopy of the glenohumeral joint

      • The arm is held in 90 degrees of abduction and neu- tator interval, rotator cuff, and articular surfaces are tral rotation while an anterior or posterior force is visualized in systematic fashion.

      • A “sulcus sign” is performed with the arm adducted ■ Lesions typically seen in multidirectional instability and in neutral rotation to assess whether the instabil- include:

      • A 3+ sulcus sign that remains 2+ or greater in exter- ■ Labral tears (TECH FIG 2) or fraying and splitting nal rotation is considered pathognomonic for multidi- ■ Widening of the rotator interval

     

     

     

    TECHNIQUES

     

    • After viewing the glenohumeral joint from the posterior portal, the arthroscope is switched to the anterior portal to allow improved visualization of the posterior capsule and labrum.

    • A switching stick can then be used in replacing the posterior cannula with an 8.25-mm distally threaded or fully threaded clear cannula (Arthrex Inc., Naples, FL), thus allowing passage of an arthroscopic probe and other instruments through the clear cannula to explore the posterior labrum for evidence of tears.

TECH FIG 2 • Labral tear.

PREPARATION FOR REPAIR

• The arthroscope remains in the posterior portal and the anterior portals serve as the working portal for the anterior repair and vice versa for the posterior repair.

• The side (anterior or posterior) that is least unstable is fixed first. For example, if posterior instability is the most severe direction, the anterior and inferior sides are fixed first and the posterior capsule and labrum is addressed last.

A

• An arthroscopic rasp or chisel is used to mobilize any torn labrum from the glenoid rim (TECH FIG 3A).

• A motorized synovial shaver or meniscal rasp is used to abrade the capsule adjacent to a labral tear and to débride and decorticate the glenoid rim to achieve a bleeding surface for capsular plication (TECH FIG 3B).

   

  TECH FIG 3 • A. Rasping capsule to stimulate healing after capsular plication. B. Capsular and glenoid abrasion with a motorized shaver.

   

  MULTIPLEATED PLICATION

  • A 3.0-mm Bio-Suture Tak anchor loaded with no. 2 FiberWire (Arthrex, Naples, FL) is placed in the 5 o’clock position (right shoulder) for the anterior repair and the 7 o’clock position for the posterior repair and the sutures are brought out through the working portal (TECH FIG 4A,B).19

  • A soft tissue penetrator (Spectrum Suture Hook, Linvatec, Largo, FL) or crescent suture passer is passed through the labrum directly adjacent to the anchor and the inferior FiberWire on the anchor is pulled through the labrum (TECH FIG 4C).

  • The penetrator is then used to pierce the inferior capsule in the most anteroinferior (5 o’clock anchor) and lateral point or posteroinferior (7 o’clock anchor) and lateral point.

  • Once through the capsule, a no. 1 PDS suture (Ethicon, Johnson & Johnson, Somerville, NJ) is shuttled into the joint and the penetrator is removed (TECH FIG 4D).

  • A suture grasper is then used to grab both the passed PDS suture and the labral suture and pull them out of the same portal, or the working portal if two portals are used.

     

• The PDS suture is tied with a simple knot to the FiberWire and then used to shuttle the working suture through the inferior tuck of capsule (TECH FIG 4E).

• This simple process is repeated while moving superiorly up the capsule until adequate capsular tension is restored (TECH FIG 4F). This can be done multiple times until adequate capsular tension is achieved with each suture.

• The suture is checked to ensure it will still slide, and then a locking sliding knot backed with three half-hitches is tied. The remaining suture is then cut (TECH FIG 4G).

• This is begun posteriorly and inferiorly (7 o’clock anchor), working posterior with additional anchors as necessary (TECH FIG 4H), and then anterior and inferiorly (5 o’-clock anchor), working up anterior, again using additional anchors as necessary (TECH FIG 4I). This would be the case if anterior instability is the most severe direction. If posterior instability is predominant, then the plication would begin anteriorly and inferiorly and then finish posteriorly.

• The completed multipleated capsular plication reduces volume and improves stability (TECH FIG 4J).

   

   

  Biceps

  8

  9

  10

  5

  6

  7

  1

  4

  2

  3

  A

   

   

   

   

  TECHNIQUES

   

  B

  MGHL

   

  AIGHL

   

  C

  D

   

  E

  F G

   

  H

  I J

   

  TECH FIG 4 • A. Multipleated plication. B. Placing anchor on the rim of the glenoid. C. Passing suture through labrum using a suture passer. D. Passing Spectrum suture passer in the capsular tissue and placing no. 1 PDS suture.

  E. Passing PDS suture into joint through capsular tissue. F. Passing FiberWire suture through capsulolabral tissue after multipleat passage. G. Completed tied knot after first anchor and capsular plication. H. Residual labral tear remaining after first anchor placed and capsule plicated. I. Placing second anchor as necessary for the capsulolabral repair and plication. J. Completed plication with multiple anchors.

   

   

  ARTHROSCOPIC KNOT TYING with the knot used and skilled in its use. ■ Each half-hitch must be completely seated before the is threaded through a knot-pusher and the end is secured ■ Placing tension on the non-post suture and advancing with a hemostat. the knot-pusher “past point” will lock the Weston knot. is tightened. ■ This knot has been found to be biomechanically similar to an open square knot.4	TECHNIQUES
  ROTATOR INTERVAL CLOSURE orly and posteriorly to bring up the entire axillary ■ A no. 0 PDS suture is then fed into the joint and retrieved pouch.16 with a penetrator through the superior glenohumeral viewed with the arthroscope in the posterior portal. ■ The PDS suture is then withdrawn out the anterior can-
  POSTERIOR PORTAL CLOSURE with a penetrator through the inferior border of the capsular opening in the posterior portal (TECH FIG 5B).   A B C   TECH FIG 5 • A. Placing crescent suture passer through posterior capsular and passing PDS suture into the joint. B. Passing suture grasper through posterior capsule for closure of posterior portal. C. Completed closure of the posterior portal after capsular plication.

  • We prefer the sliding, locking Weston knot, but a num- ■ The knot should be secured posteriorly on the capsule, ber of arthroscopic knot-tying techniques work well. not on the rim of the glenoid, to prevent humeral head

  • What is most important is that the surgeon is familiar abrasion from the knot.

  • The posterior braided suture exiting through the capsule next half-hitch is thrown.

  • This suture serves as the post, which in effect will advance ■ A total of three alternating half-hitches are placed to the capsule and labrum to the glenoid rim when the knot secure the Weston knot.

  • In the setting of multidirectional instability, the rotator ■ It is then passed through the middle glenohumeral liga-interval may not require closure (defined by a 2+ or ment at the inferior border of the rotator interval. This greater sulcus sign that does not improve in external ro- makes up the inferior aspect of the rotator interval tation) if a multipleated repair is performed both anteri- closure.

  • However, if rotator interval closure is required, it is ligament.

  • A crescent suture passer is advanced from the anterior nula and exchanged for a no. 2 FiberWire. The knot is portal through the anterior capsule just above the supe- then tied blindly in the cannula on the outside of the an-rior border of the subscapularis tendon 1 cm lateral to terior capsule as the closure is visualized through the the glenoid. posterior portal.

  • A crescent suture passer is advanced from the posterior ■ The PDS suture is then withdrawn out the posterior can-portal through the posterior capsule just above the supe- nula and exchanged for a no. 2 FiberWire. The knot is rior border of the capsular opening of the posterior por- tied blindly in the cannula on the outside of the poste-tal (TECH FIG 5A). rior capsule as the closure is visualized through the ante-

  • A no. 0 PDS suture is then fed into the joint and retrieved rior portal (TECH FIG 5C).

   

   

  PEARLS AND PITFALLS

  Indications ■ Persistent pain and functional disability despite appropriate aggressive rehabilitation program Contraindications ■ Voluntary dislocators or failure to comply with postoperative rehabilitation program

  Multipleated ■ Multiple passage of same suture through capsule allows varied amount of volume reduction to address plication technique capsular laxity.

  Posterior portal closure ■ Posterior portal closure allows added capsular volume reduction and prevents potential posterior capsule tear from portal location.

  Axillary nerve injury ■ Aggressive passage of Spectrum suture hook in the inferior capsule places axillary nerve at risk.

  • Shallow capsular penetration prevents injury to axillary nerve.

    Recurrent instability ■ Inadequate capsular volume reduction may allow recurrent instability.

  • Multipleated technique allows greater capsular volume reduction and restoration of normal tension.

   

   

  POSTOPERATIVE CARE

  • The patient is discharged home on the day of surgery.

  • The sutures are removed 6 to 8 days later.

  • The arm is immobilized in an Ultrasling (DonJoy, Carlsbad, CA) for 6 weeks (30 degrees abduction in neutral rotation).

  • The sling is removed for bathing and for gentle pendulum and elbow, wrist, and hand range-of-motion exercises.

  • Isometric exercises are started at week 3, passive and active-assisted range-of-motion exercises at week 3.

  • Sling is discontinued at week 6.

  • Active range of motion is started at week 6.

  • Sport-specific exercises are started at 4 months.

  • Overhead sports are started at 6 months.

  • The patient can return to contact sports at 6 to 8 months.

     

    OUTCOMES

  • Table 3 summarizes outcomes of clinical studies.

  • Several studies have investigated the effect of surgical intervention on capsular volume.

  • Comparisons have been made between open capsular shifts using numerous techniques, arthroscopic thermal plications, and arthroscopic suture capsular plications by testing capsular volume in cadaveric specimens before and after procedures.

  • Table 4 summarizes the results and type of shift performed in these studies.

     

    Table 3	Summary of Clinical Studies of Arthroscopic Treatment of Multidirectional Shoulder Instability
    Study Duncan & Savoie, 19933 Pagnani et al, 199615 McIntyre et al, 199711 Treacy et al, 199922 Gartsman et al, 20008 Tauro, 200021 Fitzgerald et al, 20026 Favorito et al, 20025 Frostick et al, 20037 D’Alessandro et al, 20042	Procedure Performed Scope inferior capsular shift Scope stabilization using transglenoid sutures Scope capsular shift Scope capsular shift Scope labral repair + laser capsulorrhaphy Scope inferior capsular split and advancement Scope thermal capsulorrhaphy Scope laser-assisted capsular shift Scope laser capsular shrinkage Scope thermal capsulorrhaphy	Follow-up (mo) Average Range 12–36 55 48–120 34 60 33 26–63 24–60 36 24–40 28 26 24–33 38 24–60	Outcome 100% satisfactory 74% good or excellent 95% good or excellent 88% satisfactory 92% good or excellent 88% satisfactory 76% satisfactory 81.5% success 83% satisfactory 63% satisfactory

     

    Table 4	Summary of Results of In Vitro Capsular Volume Studies
    Study	Type of Capsular Shift	Amount of Volume Reduction
    Miller et al, 200312	Three open (medial, lateral, vertical)	Medial = 37%
    		Lateral = 50%
    Karas et al, 20049	Three arthroscopic (thermal, suture plication, combined)	Vertical = 40% Scope thermal = 33%
    		Scope plication = 19%
    Victoroff et al, 200423	Arthroscopic thermal	Scope combined = 41% Scope thermal = 37%
    Luke et al, 200410	Open inferior vs. arthroscopic thermal	Open inferior = 50%
    Cohen et al, 20051	Open lateral vs. arthroscopic plication	Scope thermal = 30% Open lateral = 50%
    Sekiya et al, 200717	Open inferior vs. arthroscopic multipleated plication	Scope plication = 23% Open inferior = 45%
    		Scope multipleated = 58%

     

    COMPLICATIONS

    • Loss of motion

    • Recurrence of instability

    • Neurovascular injury

    • Failure to address missed causes of instability

      • Large Hill-Sachs lesions that cause instability and are not addressed at surgery may lead to recurrence.20

REFERENCES

1. Cohen SB, Wiley W, Goradia VK, et al. Anterior capsulorrhaphy: an in vitro comparison of volume reduction—-arthroscopic plication versus open capsular shift. Arthroscopy 2005;21:659–664.

2. D’Alessandro DF, Bradley JP, Fleischli JE, et al. Prospective evaluation of thermal capsulorrhaphy for shoulder instability: indications and results, two- to five-year follow-up. Am J Sports Med 2004;32:21–33.

3. Duncan R, Savoie FH III. Arthroscopic inferior capsular shift for multidirectional instability of the shoulder: a preliminary report. Arthroscopy 1993;9:24–27.

4. Elkousy HA, Sekiya JK, Stabile KJ, et al. A biomechanical comparison of arthroscopic sliding and sliding-locking knots. Arthroscopy 2005;21:204–210.

5. Favorito PJ, Langenderfer MA, Colosimo AJ, et al. Arthroscopic laser-assisted capsular shift in the treatment of patients with multidirectional shoulder instability. Am J Sports Med 2002;30:322–328.

6. Fitzgerald BT, Watson BT, Lapoint JM. The use of thermal capsulorrhaphy in the treatment of multidirectional instability. J Shoulder Elbow Surg 2002;11:108–113.

7. Frostick SP, Sinopidis C, Al Maskari S, et al. Arthroscopic capsular shrinkage of the shoulder for the treatment of patients with multidirectional instability: minimum 2-year follow-up. Arthroscopy 2003;19:227–233.

8. Gartsman GM, Roddey TS, Hammerman SM. Arthroscopic treatment of anterior-inferior glenohumeral instability: two- to five-year follow-up. J Bone Joint Surg Am 2000;82A:991–1003.

9. Karas SG, Creighton RA, DeMorat GJ. Glenohumeral volume reduction in arthroscopic shoulder reconstruction: a cadaveric analysis of suture plication and thermal capsulorrhaphy. Arthroscopy 2004;20: 179–184.

10. Luke TA, Rovner AD, Karas SG, et al. Volumetric change in the shoulder capsule after open inferior capsular shift versus arthroscopic thermal capsular shrinkage: a cadaveric model. J Shoulder Elbow Surg 2004;13:146–149.

11. McIntyre LF, Caspari RB, Savoie FH III. The arthroscopic treatment of multidirectional shoulder instability: two-year results of a multiple suture technique. Arthroscopy 1997;13:418–425.

12. Miller MD, Larsen KM, Luke T, et al. Anterior capsular shift volume reduction: an in vitro comparison of 3 techniques. J Shoulder Elbow Surg 2003;12:350–354.

13. Murrell GA, Warren RF. The surgical treatment of posterior shoulder instability. Clin Sports Med 1995;14:903.

14. Neer CS II, Foster CR. Inferior capsular shift for involuntary inferior and multidirectional instability of the shoulder: a preliminary report. J Bone Joint Surg Am 1980;62:897–908.

15. Pagnani MJ, Warren RF, Altchek DW, et al. Arthroscopic shoulder stabilization using transglenoid sutures. A four-year minimum follow-up. Am J Sports Med 1996;24:459–467.

16. Sekiya JK, Ong BC, Bradley JP. Thermal capsulorrhaphy for shoulder instability. AAOS Instr Course Lect 2003;52:65–80.

17. Sekiya JK, Willobee JA, Miller MD, et al. Arthroscopic multi-pleated capsular plication compared with open inferior capsular shift for multidirectional instability. Arthroscopy 2007;23:1145–1151.

18. Sekiya JK, Zehms CT. Arthroscopic management of recurrent shoulder instability. Op Tech Sports Med 2006;13:189–195.

19. Sekiya JK. Arthroscopic labral repair and capsular shift of the glenohumeral joint: Technical pearls for a multiple pleated plication through a single working portal. Arthroscopy 2005;21:766.

20. Stehle J, Wickwire AC, Debski RE, et al. A technique to reduce Hill-Sachs lesions after acute anterior dislocation of the shoulder. Tech Shoulder Elbow Surg 2005;6:230–235.

21. Tauro JC. Arthroscopic inferior capsular split and advancement for anterior and inferior shoulder instability: technique and results at 2-to 5-year follow-up. Arthroscopy 2000;16:451–456.

22. Treacy SH, Savoie FH III, Field LD. Arthroscopic treatment of multidirectional instability. J Shoulder Elbow Surg 1999;8: 345–350.

23. Victoroff BN, Deutsch A, Protomastro P, et al. The effect of radiofre-quency thermal capsulorrhaphy on glenohumeral translation, rotation, and volume. J Shoulder Elbow Surg 2004;13:138–145.