title: Multidirectional Instability of the Shoulder: A Systematic Review.
abstract: OBJECTIVE
  To analyze outcomes of surgical and conservative treatment options for multidirectional instability (MDI).
  
  
  METHODS
  A systematic review of the literature according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines was performed. A comprehensive search of the PubMed, MEDLINE, CINAHL, Cochrane, EMBASE, and Google Scholar databases using various combinations of the keywords "shoulder," "multidirectional instability," "dislocation," "inferior instability," "capsulorrhaphy," "capsular plication," "capsular shift," "glenoid," "humeral head," "surgery," and "glenohumeral," over the years 1966 to 2014 was performed.
  
  
  RESULTS
  Twenty-four articles describing patients with open capsular shift, arthroscopic treatment, and conservative or combined management in the setting of atraumatic MDI of the shoulder were included. A total of 861 shoulders in 790 patients was included. The median age was 24.3 years, ranging from 9 to 56 years. The dominant side was involved in 269 (58%) of 468 shoulders, whereas the nondominant side was involved in 199 (42%) shoulders. Patients were assessed at a median follow-up period of 4.2 years (ranging from 9 months to 16 years). Fifty-two of 253 (21%) patients undergoing physiotherapy required surgical intervention for MDI management, whereas the overall occurrence of redislocation was seen in 61 of 608 (10%) shoulders undergoing surgical procedures. The redislocation event occurred in 17 of 226 (7.5%) shoulders with open capsular shift management, in 21 of 268 (7.8%) shoulders with arthroscopic plication management, in 12 of 49 (24.5%) shoulders undergoing arthroscopic thermal shrinkage, and in 11 of 55 (22%) shoulders undergoing arthroscopic laser-assisted capsulorrhaphy.
  
  
  CONCLUSIONS
  Arthroscopic capsular plication and open capsular shift are the best surgical procedures for treatment of MDI after failure of rehabilitative management. Arthroscopic capsular plication shows results comparable to open capsular shift.
  
  
  METHODS
  Level IV, systematic review of Level I to IV studies.
authors.affiliation: Department of Orthopaedic and Trauma Surgery, Campus Bio-Medico University, Rome, Italy. Electronic address: g.longo@unicampus.it.
authors.forename: Umile Giuseppe
authors.initials: UG
authors.lastname: Longo
authors.affiliation: Department of Orthopaedic and Trauma Surgery, Campus Bio-Medico University, Rome, Italy.
authors.forename: Giacomo
authors.initials: G
authors.lastname: Rizzello
authors.affiliation: Department of Orthopaedic and Trauma Surgery, Campus Bio-Medico University, Rome, Italy.
authors.forename: Mattia
authors.initials: M
authors.lastname: Loppini
authors.affiliation: Department of Orthopaedic and Trauma Surgery, Campus Bio-Medico University, Rome, Italy.
authors.forename: Joel
authors.initials: J
authors.lastname: Locher
authors.affiliation: Department of Orthopaedic Sports Medicine, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany.
authors.forename: Stefan
authors.initials: S
authors.lastname: Buchmann
authors.affiliation: Centre for Sports and Exercise Medicine, Barts and The London School of Medicine and Dentistry, London, England; Department of Musculoskeletal Disorders, University of Salerno School of Medicine and Surgery, Salerno, Italy.
authors.forename: Nicola
authors.initials: N
authors.lastname: Maffulli
authors.affiliation: Department of Orthopaedic and Trauma Surgery, Campus Bio-Medico University, Rome, Italy.
authors.forename: Vincenzo
authors.initials: V
authors.lastname: Denaro
mesh_terms: D001182:Arthroscopy; D006801:Humans; D017746:Joint Capsule / Q000601:surgery*; D007593:Joint Instability / Q000601:surgery* / Q000628:therapy; D012783:Shoulder Dislocation / Q000601:surgery* / Q000628:therapy; D012785:Shoulder Joint / Q000601:surgery*