Surgical treatment of "multidirectional" shoulder instability.

This patient is in his 20s and presented to the office with multidirectional shoulder instability. He reported more 100 dislocations that they started since high school and were not painful at the beginning and without hx of trauma. He has generalized laxity and reports no recent trauma. At the time of evaluation he did not have a sulcus sign but had a positive Jerk's and negative apprehension test. The patient reported that the pain is a new problem and his past recent dislocations were painless. Currently, the dislocations are associated with severe pain and no neurologic deficits.

His shoulder would dislocate easily posteriorly and inferiorly as you can see on the XRs below that were taken in the office. 

His MRI demonstrated a posterior labrum tear and unfortunately was not ordered with intra-articular contrast by his PCP and thus information about laxity of the inferior capsule was not available.

Due to the significant pain and the failure of his 4 months of PT to provide relief we elected to proceed with arthroscopic reverse Bankart repair and possible arthroscopic capsular shift. On exam in the operating room and under anesthesia he had a +3 posterior load and shift test. Postoperative images after his repair as shown below. 

Symptomatic posterior inferior instability is an indication of multidirectional instability and those cases have either recurrent or persistent labral pathology or patulous capsules with occult multi-directional instability primarily manifesting in the posterior direction. 

There have been cases of a painful multidirectional instability that have no associated shoulder pathology other than patulous capsules. Although some authors report on performing a 180-270 deg repair it seems more appropriate to address the lesion/ first without extensive use of anchors and by repaing only the detached labrum. We will follow him closely hoping that this procedure will solve this difficult problem.