The diagnosis and treatment of patients with unstable shoulders present unique challenges. In the setting of recurrent anterior and anterior-inferior glenohumeral instability, treatment options vary. In acute, traumatic episodes of instability, especially in young individuals, labral detachment usually occurs<sup>6 Bankart A.S.B. The pathology and treatment of recurrent dislocation of the shoulder Br J Surg 1938 ;  26 : 23-29  [cross-ref]

Haga clic aquí para ir a la sección de Referencias, 30 Perthes G. Uber operationen bei habitueller achulterluxation Dtsch Ztschr Chir 1906 ;  85 : 199-222  [cross-ref]

Haga clic aquí para ir a la sección de Referencias</sup> and can be associated with abnormal capsular laxity. In this case, the diagnosis is usually more apparent than in the case of repetitive microtrauma or atraumatic instability, in which abnormal capsular laxity is the primary problem. When a surgical approach is chosen, however, the operative technique must allow for complete flexibility to address all aspects of the surgical pathology, especially when intraoperative decisions deviate from the preoperative plan.

Traditional procedures that were recommended to address anterior patterns of glenohumeral instability were considered successful if the operation eliminated additional instability. A new, broader definition of “success” after instability surgery takes into account the specific functional demands of individuals, especially athletes whose sports require overhead motion. A successful surgical procedure for glenohumeral instability restores stability and ensures painless and functional range of motion based on a patient's requirements. The benefits of an anatomic reconstruction that directly addresses the soft-tissue pathology in anterior glenohumeral instability are being increasingly recognized.^{*References 1, 9, 18, 20, 25, 26, 32, 35, 49 and 52.} The selective capsular shift is an open procedure that offers the versatility necessary to address the pathology that may be encountered.<sup>40References 1, 9, 18, 20, 25, 26, 32, 35, 49 and 52.

Haga clic aquí para ir a la sección de Referencias, 49References 1, 9, 18, 20, 25, 26, 32, 35, 49 and 52.

Haga clic aquí para ir a la sección de Referencias</sup> This technique is useful to treat soft-tissue or bony abnormalities of the capsular attachment on the glenoid and capsular injury in its midsubstance or at the humeral attachment. The selective capsular shift is a modification of the capsular shift procedure described by Neer et al<sup>25References 1, 9, 18, 20, 25, 26, 32, 35, 49 and 52.

Haga clic aquí para ir a la sección de Referencias, 26References 1, 9, 18, 20, 25, 26, 32, 35, 49 and 52.

Haga clic aquí para ir a la sección de Referencias</sup> and Bigliani et al<sup>9References 1, 9, 18, 20, 25, 26, 32, 35, 49 and 52.

Haga clic aquí para ir a la sección de Referencias</sup> but offers potential advantages when the operation has progressed to the stage of capsular repair by limiting the extent of the capsular shift to restore normal capsular anatomy. This is achieved with the selective tensioning of the inferior and superior capsule by varying arm position during the capsular repair. In this manner, stability is restored while the potentially harmful effects of loss of external rotation can be avoided. This is especially important in athletes who use overhead motions.

Experimental studies have demonstrated the characteristics and importance of the inferior glenohumeral ligament as the primary static stabilizer against anterior-inferior translation of the humeral head when the arm is abducted and externally rotated and the ligament is placed under significant tension.<sup>8 Bigliani L.U., Pollock R.G., Soslowsky L.J. , y al. Tensile properties of the inferior glenohumeral ligament J Orthop Res 1992 ;  10 : 189-197

Haga clic aquí para ir a la sección de Referencias, 24 Mow V.C., Bigliani L.U., Flatow E.L. , y al. Mechanical properties of the inferior glenohumeral ligament and the glenohumeral articular cartilage The Shoulder: A Balance of Mobility and Stability Park Ridge, IL: AAOS Press (1993).  29-67

Haga clic aquí para ir a la sección de Referencias, 36 Ticker J.B., Flatow E.L., Pawluk R.J. , y al. The inferior glenohumeral ligament: A correlative biomechanical, biochemical, and histological investigation Orthop Trans 1994 ;  17 : 721-722

Haga clic aquí para ir a la sección de Referencias, 38 Ticker J.B., Bigliani L.U., Soslowsky L.J. , y al. The inferior glenohumeral ligament: Geometry and strain-rate dependent properties J Shoulder Elbow Surg 1996 ;  5 : 269-279  [cross-ref]

Haga clic aquí para ir a la sección de Referencias, 43 Turkel S.J., Panio M.W., Marshall J.L. , y al. Stabilizing mechanisms preventing anterior dislocation of the glenohumeral joint J Bone Joint Surg Am 1981 ;  63 : 1208-1217

Haga clic aquí para ir a la sección de Referencias, 46 Warner J.J.P., Caborn D.N.M., Berger R. , y al. Dynamic capsuloligamentous anatomy of the glenohumeral joint J Shoulder Elbow Surg 1993 ;  2 : 115-133  [cross-ref]

Haga clic aquí para ir a la sección de Referencias</sup> Conversely, the superior and middle glenohumeral ligaments function to restrict anterior-inferior translation when the arm is adducted and externally rotated and are in maximal tension in this arm position.<sup>46 Warner J.J.P., Caborn D.N.M., Berger R. , y al. Dynamic capsuloligamentous anatomy of the glenohumeral joint J Shoulder Elbow Surg 1993 ;  2 : 115-133  [cross-ref]

Haga clic aquí para ir a la sección de Referencias</sup> With this in mind, repair of the inferior capsular flap and the superior capsular flap are performed separately, with the arm in positions closer to the end ranges of motion to achieve static stability but avoid overtightening of the capsule. The capsule tensioned in this manner during the selective capsular shift helps to preserve normal glenohumeral rotation and prevent loss of external rotation.

The capsular shift is performed laterally because the release of the capsular attachment on the humerus is believed to allow for a more precise repair. This is suggested by the “funnel” shape of the capsule and its attachments, which is more narrow at the glenoid and wider near the humerus.<sup>38 Ticker J.B., Bigliani L.U., Soslowsky L.J. , y al. The inferior glenohumeral ligament: Geometry and strain-rate dependent properties J Shoulder Elbow Surg 1996 ;  5 : 269-279  [cross-ref]

Haga clic aquí para ir a la sección de Referencias</sup> Also, although the capsular attachment to the glenoid labrum does not typically vary in “normal” shoulders, the capsular attachment on the humeral neck can be variable.<sup>29 O'Brien S.J., Neves M., Rozbruch R. , y al. The anatomy and histology of the inferior glenohumeral ligament complex of the shoulder Am J Sports Med 1990 ;  18 : 449-456  [cross-ref]

Haga clic aquí para ir a la sección de Referencias, 38 Ticker J.B., Bigliani L.U., Soslowsky L.J. , y al. The inferior glenohumeral ligament: Geometry and strain-rate dependent properties J Shoulder Elbow Surg 1996 ;  5 : 269-279  [cross-ref]

Haga clic aquí para ir a la sección de Referencias</sup> These variations include the V-shaped and collarlike humeral attachments of the inferior glenohumeral ligament as described by O'Brien et al.<sup>29 O'Brien S.J., Neves M., Rozbruch R. , y al. The anatomy and histology of the inferior glenohumeral ligament complex of the shoulder Am J Sports Med 1990 ;  18 : 449-456  [cross-ref]

Haga clic aquí para ir a la sección de Referencias</sup> Cooper and Brems<sup>12 Cooper R.A., Brems J.J. The inferior capsular shift procedure for multidirectional instability of the shoulder J Bone Joint Surg Am 1992 ;  74 : 1516-1521

Haga clic aquí para ir a la sección de Referencias</sup> suggested that a lateral capsular surgical approach, together with increasing external rotation of the arm, allows for exposure more posteriorly and greater advancement of the posterior portion of the capsule to enhance posterior stability in patients with multidirectional instability. Furthermore, instability as a result of a humeral capsular disruption can be addressed during the lateral approach without additional surgical dissection because this can be corrected during the capsular repair.<sup>4 Bach B.R., Warren R.F., Fronek J. Disruption of the lateral capsule of the shoulder: A cause of recurrent dislocation J Bone Joint Surg Br 1988 ;  70 : 274-276

Haga clic aquí para ir a la sección de Referencias, 22 McLaughlin H.L. Recurrent anterior dislocation of the shoulder: I. Morbid anatomy Am J Surg 1960 ;  99 : 628-632  [cross-ref]

Haga clic aquí para ir a la sección de Referencias, 51 Warner J.J.P., Beim G.M. Combined Bankart and HAGL lesion associated with anterior shoulder instability Arthroscopy 1997 ;  13 : 749-752  [cross-ref]

Haga clic aquí para ir a la sección de Referencias, 54 Wolf E.M., Cheng J.C., Dickson K. Humeral avulsion of glenohumeral ligaments as a cause of anterior shoulder instability Arthroscopy 1995 ;  11 : 600-607  [cross-ref]

Haga clic aquí para ir a la sección de Referencias</sup>

In patients with recurrent anterior-inferior instability who have failed nonoperative treatment, the surgical approach must be individualized based on several factors, including age, activity level, arm dominance, specific sports participation, pattern of instability, tissue quality, cosmesis, and patient expectations. Arthroscopic procedures are becoming more refined and reproducible. Reports suggest improving success rates, depending on the indications, surgical pathology, operative techniques, and devices used, but the results are not uniform.^{*References 2, 5, 7, 13, 19, 23, 33, 41, 44, 50 and 53.} The surgical dissection of the open approach is avoided with an arthroscopic approach, which results in less scarring, but capsular tensioning is more precise in an open procedure, particularly with the selective shift technique. Open and arthroscopic procedures require specific, but separate, skills when repairing a labral detachment and when shifting the capsule. Operative time is also related to the skill level of the surgeon. One other aspect of the open procedure is the closure of the rotator interval. Open treatment for isolated rotator interval lesions has been described, <sup>14References 2, 5, 7, 13, 19, 23, 33, 41, 44, 50 and 53.

Haga clic aquí para ir a la sección de Referencias, 27References 2, 5, 7, 13, 19, 23, 33, 41, 44, 50 and 53.

Haga clic aquí para ir a la sección de Referencias</sup> and techniques to repair this arthroscopically have been reported.<sup>16References 2, 5, 7, 13, 19, 23, 33, 41, 44, 50 and 53.

Haga clic aquí para ir a la sección de Referencias, 42References 2, 5, 7, 13, 19, 23, 33, 41, 44, 50 and 53.

Haga clic aquí para ir a la sección de Referencias</sup> Addressing the rotator interval is not always discussed in the descriptions of arthroscopic techniques for anterior and anterior-inferior glenohumeral instability.<sup>13References 2, 5, 7, 13, 19, 23, 33, 41, 44, 50 and 53.

Haga clic aquí para ir a la sección de Referencias, 23References 2, 5, 7, 13, 19, 23, 33, 41, 44, 50 and 53.

Haga clic aquí para ir a la sección de Referencias, 33References 2, 5, 7, 13, 19, 23, 33, 41, 44, 50 and 53.

Haga clic aquí para ir a la sección de Referencias, 34References 2, 5, 7, 13, 19, 23, 33, 41, 44, 50 and 53.

Haga clic aquí para ir a la sección de Referencias, 41References 2, 5, 7, 13, 19, 23, 33, 41, 44, 50 and 53.

Haga clic aquí para ir a la sección de Referencias, 44References 2, 5, 7, 13, 19, 23, 33, 41, 44, 50 and 53.

Haga clic aquí para ir a la sección de Referencias, 53References 2, 5, 7, 13, 19, 23, 33, 41, 44, 50 and 53.

Haga clic aquí para ir a la sección de Referencias</sup> Typically, in an open capsular shift, the superior edge of the capsule is sutured to the tissue at the anterior edge of the supraspinatus to close the interval.<sup>9References 2, 5, 7, 13, 19, 23, 33, 41, 44, 50 and 53.

Haga clic aquí para ir a la sección de Referencias, 25References 2, 5, 7, 13, 19, 23, 33, 41, 44, 50 and 53.

Haga clic aquí para ir a la sección de Referencias, 26References 2, 5, 7, 13, 19, 23, 33, 41, 44, 50 and 53.

Haga clic aquí para ir a la sección de Referencias, 49References 2, 5, 7, 13, 19, 23, 33, 41, 44, 50 and 53.

Haga clic aquí para ir a la sección de Referencias</sup> Consideration must be given to this aspect of the instability pattern and addressed during any procedure, open or arthroscopic, to correct this abnormality, when present.