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.
Why was this article selected as a classic
orthopaedic reference?
This article was the first to describe the heretofore unrecognized
condition of multidirectional instability of the shoulder. In 1980,
all orthopaedic surgeons were aware of persons who had atraumatic
instability and did very poorly after surgery, but not until the
publication of this article was a specific diagnostic category of
multidirectional instability defined.
How has the information in the article withstood
the "test of time"?
The article made the important distinction between capsular laxity
and the Bankart lesion, which is not always present in these individuals.
Furthermore, it offered a method of treatment that has, indeed,
withstood the test of time, as the inferior capsular shift procedure
often provides sufficient stability to minimize or eliminate shoulder instability
in these patients.
How has our thinking changed with regard to
this subject since the publication of this landmark work?
Our understanding of this condition is still evolving and still
is not much clearer than that provided by Neer’s and Foster’s description.
The categorization of recurrent shoulder instability into two major
types—unidirectional and multidirectional— is almost
universal throughout the world.
R.R.R.
Many classic, landmark articles have been published in The
Journal in the past. Monthly, we will be publishing summaries of selected
articles, along with a contemporary commentary by a knowledgeable
member of the editorial board identifying the article’s
significance in orthopaedics and its continuing relevance to our
practices. Please let us know of a classic journal article that
you believe should be summarized and commented upon in the future.
J.D.H.