Open Inferior Capsular Shift

The shoulder joint is one of the most mobile joints in the human body, allowing for a wide range of movements necessary for daily activities and athletic performance. However, this mobility comes at the cost of stability, making the shoulder susceptible to dislocations and chronic instability. One surgical technique designed to address recurrent shoulder instability is the open inferior capsular shift. This procedure targets the inferior capsule of the shoulder, which often becomes lax or stretched after repeated dislocations, contributing to instability. Understanding the indications, surgical technique, postoperative care, and potential complications of an open inferior capsular shift is essential for both patients and healthcare providers.

Indications for Open Inferior Capsular Shift

The open inferior capsular shift is primarily indicated for patients experiencing multidirectional shoulder instability, particularly when conservative treatments have failed. Patients may present with recurrent subluxations or dislocations that affect their ability to perform daily activities or participate in sports. The procedure is often considered in younger, active individuals or athletes who require robust shoulder stability. It is also indicated when imaging or intraoperative findings reveal capsular redundancy, which contributes to joint instability.

Multidirectional Instability

Multidirectional instability (MDI) of the shoulder involves excessive movement in multiple directions, typically inferiorly, anteriorly, and posteriorly. Patients with MDI often have a history of generalized ligamentous laxity or previous traumatic events. The open inferior capsular shift effectively reduces the capsular volume and tightens the inferior glenohumeral ligament, restoring stability while preserving a functional range of motion.

Failed Conservative Management

Conservative management for shoulder instability usually includes physical therapy, strengthening of the rotator cuff and scapular stabilizers, and activity modification. When these measures fail to provide adequate stability or when recurrent dislocations persist despite rehabilitation, surgical intervention with an open inferior capsular shift may be recommended. Proper patient selection is crucial to achieve optimal outcomes.

Surgical Technique

The open inferior capsular shift is performed under general anesthesia, often with the patient in a beach-chair or lateral decubitus position. The procedure involves a precise incision and meticulous dissection to access the inferior capsule of the shoulder joint. The goal is to reduce capsular redundancy and reinforce the inferior glenohumeral ligament, thereby improving shoulder stability.

Incision and Exposure

The surgeon makes a deltopectoral or anterolateral incision to expose the shoulder capsule. Care is taken to preserve the surrounding neurovascular structures. The subscapularis tendon is often mobilized to allow adequate access to the inferior capsule. Proper exposure is essential for identifying the capsular tissue that requires shifting and plication.

Capsular Shift and Plication

Once the inferior capsule is exposed, the surgeon performs a shift by overlapping the redundant capsular tissue and securing it with non-absorbable sutures. This technique effectively reduces capsular volume and tightens the joint, preventing excessive inferior and multidirectional translation. The shift can be tailored to address the patient’s specific pattern of instability, with attention to preserving as much range of motion as possible.

Closure and Postoperative Management

After the capsular shift, the subscapularis tendon and deltopectoral fascia are carefully repaired. The skin is closed in layers, and a sterile dressing is applied. Postoperative care includes immobilization in a shoulder sling or abduction pillow for a prescribed period to protect the repair. Early passive range-of-motion exercises are initiated under the guidance of a physical therapist, gradually progressing to active-assisted and active strengthening exercises over several weeks.

Rehabilitation Protocol

Rehabilitation is a critical component of successful outcomes following an open inferior capsular shift. The protocol aims to protect the surgical repair while restoring functional range of motion and strengthening the surrounding musculature to prevent recurrent instability.

Phase 1 Immobilization and Protection

• Shoulder is immobilized in a sling for 4-6 weeks.
• Pain and swelling are managed with ice and analgesics.
• No active shoulder movements to protect the capsular repair.

Phase 2 Passive and Active-Assisted Motion

• Begin gentle passive range-of-motion exercises as tolerated.
• Progress to active-assisted exercises focusing on flexion, abduction, and external rotation.
• Avoid movements that place stress on the inferior capsule.

Phase 3 Strengthening and Functional Training

• Gradual introduction of rotator cuff and scapular stabilizer strengthening.
• Functional exercises and sport-specific drills initiated around 12 weeks postoperatively.
• Continued focus on maintaining stability while restoring full range of motion.

Potential Complications

As with any surgical procedure, the open inferior capsular shift carries potential risks. Complications may include stiffness, recurrent instability, infection, neurovascular injury, or failure of the repair. Careful surgical technique, patient selection, and adherence to postoperative rehabilitation protocols can minimize these risks. Early recognition and management of complications are essential for achieving optimal outcomes.

Recurrent Instability

Despite the procedure, some patients may experience recurrent instability, particularly if there is generalized ligamentous laxity or non-compliance with rehabilitation. Revision surgery may be necessary in rare cases.

Stiffness and Loss of Motion

Over-tightening of the capsule or prolonged immobilization can lead to reduced shoulder mobility. Structured physical therapy helps restore motion while maintaining stability.

Neurovascular Complications

Care must be taken to avoid injury to the axillary nerve, musculocutaneous nerve, and surrounding vessels during dissection. Prompt recognition and management of nerve injury are critical for functional recovery.

Outcomes and Prognosis

Overall, the open inferior capsular shift has shown excellent results in restoring shoulder stability, particularly in patients with multidirectional instability. Most patients experience reduced episodes of subluxation or dislocation, improved shoulder function, and enhanced quality of life. Long-term follow-up indicates a high rate of patient satisfaction and return to pre-injury activity levels, provided that rehabilitation protocols are followed diligently.

Factors Affecting Success

• Patient age and activity level.
• Severity and pattern of instability.
• Quality of surgical repair and technique.
• Compliance with postoperative rehabilitation.

The open inferior capsular shift is a well-established surgical procedure for addressing multidirectional shoulder instability, particularly in patients who have failed conservative management. By reducing capsular redundancy and reinforcing the inferior glenohumeral ligament, the procedure restores stability while preserving functional range of motion. Success depends on careful patient selection, meticulous surgical technique, and structured rehabilitation. Awareness of potential complications and adherence to postoperative protocols are essential to achieving optimal outcomes. For patients struggling with recurrent shoulder instability, the open inferior capsular shift offers a reliable solution that can significantly improve quality of life and restore confidence in shoulder function.