Recurrent Shoulder Instability: Current Concepts for ... Shoulder Instability: Current Concepts for Evaluation and Management of Glenoid Bone Loss By CDR Matthew T. Provencher, MD,

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2010;92:133-151. doi:10.2106/JBJS.J.00906 J Bone Joint Surg Am.Christopher B. Dewing, LT Lance LeClere and Anthony A. Romeo CDR Matthew T. Provencher, Sanjeev Bhatia, Neil S. Ghodadra, Robert C. Grumet, Bernard R. Bach, Jr., LCDR

Management of Glenoid Bone LossRecurrent Shoulder Instability: Current Concepts for Evaluation and

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Recurrent Shoulder Instability: Current Conceptsfor Evaluation and Management of

Glenoid Bone LossBy CDR Matthew T. Provencher, MD, MC, USN, Sanjeev Bhatia, MD, Neil S. Ghodadra, MD,

Robert C. Grumet, MD, Bernard R. Bach Jr., MD, LCDR Christopher B. Dewing, MD, MC, USN,LT Lance LeClere, MD, MC, USN, and Anthony A. Romeo, MD

Introduction

Recurrent instability of the glenohumeral joint is usuallyassociated with a Bankart tear—a soft-tissue injury of the

glenoid labrum attachment. However, patients with recurrentshoulder instability often present with osseous injury to theglenoid and humeral head as well. Understanding and appro-priately addressing irregularities in the osseous architectureof the glenohumeral joint are critical to the overall success ofsurgical repair for the treatment of glenohumeral instability1.The integrity of the osseous architecture of the glenoid hasrecently been highlighted as one of the most important factorsrelated to the success of surgical repair2,3. After the initialtraumatic shoulder dislocation, an associated glenoid rimfracture or attritional bone injury may compromise the staticrestraints of the glenohumeral joint, making further instabilitymore likely. With recurrent instability, there can be furtherattritional glenoid bone loss.

Glenoid bone deficiency with recurrent shoulder insta-bility is an increasingly recognized cause of failed shoulderstabilization surgery. It is critical to evaluate all patients withrecurrent shoulder instability for the presence of osseous in-juries to the glenoid. Specific findings in the history and thephysical examination provide important clues to the presenceof glenoid bone loss, and a careful preoperative evaluation todiagnose and quantify anterior glenoid deficiency is crucial forthe success of surgical treatment.

Appropriate preoperative imaging is essential for detec-tion and quantification of osseous abnormalities in patientswith recurrent shoulder instability. The apical oblique viewdescribed by Garth et al.4, the West Point view5, and the Didieeview6 are recognized as being the most sensitive radiographs fordetecting osseous abnormalities of the glenoid. Magnetic res-onance imaging and magnetic resonance arthrography may be

used, but they are primarily employed to assess the sur-rounding soft tissues. If any osseous lesion is discovered onradiographs, or with magnetic resonance imaging, a computedtomography scan can provide valuable information about theextent of the bone loss. Furthermore, a three-dimensional-reconstruction computed tomography scan allows digitalsubtraction of the humeral head from images of the glenohu-meral complex, providing an en face sagittal oblique view of theglenoid. Precise measurements of the percentage of glenoidbone loss can be calculated by modeling the inferior aspect ofthe intact glenoid as a true circle7,8.

It is preferable to accurately assess glenoid bone loss priorto surgical intervention, as this permits informed consent andshared clinical decision-making with the patient regarding op-timal treatment strategies. Once a precise estimation of bone lossis made, decisions regarding the surgical approach to be used,particularly those related to the risk of the recurrence of shoulderinstability, can be discussed with the patient. Although the exacttreatment for each percentage of glenoid bone loss has yet to befully defined, the published literature supports the idea that, inpatients with less than 15% to 20% glenoid bone loss (usuallyless than 5 to 7 mm of bone), recurrent instability can be suc-cessfully treated with soft-tissue stabilization alone. However,when bone loss is 25% to 30% of the glenoid sphere (more than6 to 8 mm of bone loss), open repair or bone augmentationprocedures should be considered. Osseous reconstruction tech-niques include the Bristow procedure9, the Latarjet procedure10,use of iliac crest bone graft11,12, and allografting with use of thefemoral head13 or the distal part of the tibia14.

The principles of surgical management are guided by theextent of osseous deficiency, consideration of combined glenoidand humeral bone defects, the surgeon’s personal experiencewith specific reconstructive techniques, and patient-specific

Disclosure: The authors did not receive any outside funding or grants in support of their research for or preparation of this work. One or more of theauthors, or a member of his or her immediate family, received, in any one year, payments or other benefits in excess of $10,000 or a commitment oragreement to provide such benefits from commercial entities (Smith & Nephew, dj Orthopedics, Ossur, Arthrex, AthletiCo, MioMed, Scheck & Siress, andConMed Linvatec).

Disclaimer: The views expressed in this article are those of the authors and do not necessarily reflect the official policy or position of the Department ofthe Navy, the Department of Defense, or the United States Government.

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COPYRIGHT � 2010 BY THE JOURNAL OF BONE AND JOINT SURGERY, INCORPORATED

J Bone Joint Surg Am. 2010;92 Suppl 2:133-51 d doi:10.2106/JBJS.J.00906

factors such as work and athletic demands. Techniques for soft-tissue stabilization, the type and orientation of the glenoid bonegraft, and treatment of concomitant pathologic conditions are allvariables that should be carefully considered to optimize thelikelihood of a well-functioning shoulder joint after surgicalrepair.

Source of FundingNo external funds were used for this study.

Diagnosis of Glenoid Bone LossPatient History

Athorough orthopaedic history should be recorded for allpatients with recurrent glenohumeral instability, as some

key clues from the shoulder instability history may signal thefinding of glenoid bone loss. The diagnosis of glenoid bone lossshould be suspected when the patient had a high-energy injury,

especially if the arm was abducted ‡70� and extended ‡30� atthe time of the initial dislocation, or presents with shoulderinstability that occurs within the range of 20� to 60� of ab-duction (Table I). Patients with glenoid bone loss often notethat it has become progressively easier to subluxate the gleno-humeral joint and often have a long history of either shoulderinstability symptoms or coping with this injury. Although theemphasis is likely on instability when the patient is seen, caremust be taken to thoroughly consider other shoulder disorders,such as rotator cuff tears, particularly in patients over the ageof forty who have instability, a concomitant superior labralanterior-posterior (SLAP) tear, and cartilage injury.

Physical ExaminationA thorough physical examination to compare the affectedshoulder with the contralateral shoulder will confirm the diag-nosis of instability, but it will also identify other shoulder dis-

TABLE I Key Clues from the History and Physical Examination That May Herald the Finding of Glenoid Bone Loss

History Physical Examination

High-energy mechanism of injury Deformity is present

Arm was abducted (‡70�) and extended (‡30�)at time of initial dislocation

Shoulder apprehension test is positive in midranges of abduction (30�-90�) andlesser amounts of external rotation

Patient reports that most instability occurs inmidrange of motion (20�-60� of abduction)

Anterior translation of humeral head over glenoid rim is reproducible

Patient notes progressive ease of instability

Prolonged history of instability

Fig. 1

For a West Point axillary view, the beam is directed at the axilla at a 25� angle medially and a 25�angle cephalad, centered inferior and medial to the acromioclavicular joint.

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TH E J O U R N A L O F B O N E & JO I N T SU R G E RY d J B J S . O R G

VO LU M E 92-A d S U P P L E M E N T 2 d 2010RE C U R R E N T SH O U L D E R IN S TA B I L I T Y: CU R R E N T CO N C E P T S F O R

EVA LUAT I O N A N D MA N AG E M E N T O F GL E N O I D B O N E LO S S

orders. Visual inspection of the shoulder should focus onidentifying deformity, rotator cuff atrophy, or scapular dyskinesia.The initial physical examination should always include a carefulneurovascular evaluation of the entire upper extremity, testing ofactive and passive shoulder motion, and assessment of rotator cuffstrength. The magnitude and direction of shoulder instability aredocumented. Special maneuvers such as the Jobe relocation test15,sulcus sign16, Gagey hyperabduction sign17, and apprehensionsign18 are often useful. To complete the examination specific forglenoid bone loss, the shoulder apprehension test is performed invarious degrees of shoulder abduction and external rotation. Al-

though a patient with glenoid bone loss will typically have apositive apprehension test in 90� of shoulder abduction and 90� ofexternal rotation, patients with apprehension findings in 30� to90� of shoulder abduction and in a lesser amount of externalrotation may have glenoid bone loss, as the humeral head iseasily subluxated over the glenoid. In addition, the examinershould evaluate anterior translation of the humeral head overthe glenoid rim (Table I), which, when strongly positive, maybe an additional indication that glenoid bone loss is likelypresent and should be investigated further with advancedimaging studies.

Fig. 2

A: A sagittal image from a magnetic resonance arthrogram demonstrates anterior glenoid bone loss

with no identifiable fracture fragment (arrow). (Reprinted, with permission, from: Piasecki DP, Verma

NN, Romeo AA, Levine WN, Bach BR Jr, Provencher MT. Glenoid bone deficiency in recurrent anterior

shoulder instability: diagnosis and management. J Am Acad Orthop Surg. 2009;17:482-93.) B:

Magnetic resonance arthrogram depicting 20% to 25% glenoid bone loss.

Fig. 3

Glenoid bone loss seen on a three-dimensional computed tomography reconstruction. Bone loss can be either acute (A) or chronic (B).

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ImagingIn addition to basic radiographic views of the shoulder, specializedglenoid views in which the radiographic beam is angled oblique tothe glenoid face are frequently useful for enhanced visualization oflesions of the osseous glenoid rim. The most useful radiographicviews include the West Point view, Didiee view, and apical oblique(Garth) view. The West Point view, a variation of the axillary lateralradiograph, is a tangential view of the anteroinferior aspect of theglenoid and is the best view for radiographic detection of osseousBankart lesions5 (Fig. 1). However, patient positioning for thisradiographic view may be difficult after acute trauma, and theapical oblique radiograph may be utilized instead4.

Although proper radiographic technique is importantto provide information about the presence of a glenoid boneinjury, radiographs alone often fail to detect, or to allow ac-curate quantification of, glenoid bone loss. Two-dimensionalcomputed tomography and magnetic resonance imaging arehelpful in detecting glenoid bone loss and newly formedglenoid rim fragments2. However, because of the glenoid’snatural three-dimensional structure and variations in glenoidversion among individual patients, these methods may beinadequate for quantifying glenoid bone loss. In standardtwo-dimensional computed tomography, the degree of glen-oid version affects the gantry angle needed to gain an accuraterepresentation of the glenoid. The beam must be exactlyperpendicular to the long axis of the glenoid while the glenoidis in a fixed position. A sagittal oblique magnetic resonanceimage, especially when an arthrogram is also made, may bevery helpful if the magnetic resonance imaging magnet is

strong enough to provide reasonable resolution to differen-tiate glenoid bone from soft-tissue injury. Magnetic resonancearthrography allows clearer delineation of the glenoid fossaand en face measurements of glenoid bone loss on the sagittaloblique images (Fig. 2). However, like an axial computedtomography scan, axial magnetic resonance imaging ormagnetic resonance arthrography may still underestimatethe amount of glenoid bone loss because images are only two-dimensional: scans with a larger interslice distance, or greatergap spacing between cuts, may not provide accurate mea-surements for bone loss quantification.

A three-dimensional computed tomography scan is con-sidered the gold standard for glenoid imaging because it allowsdigital subtraction of the humeral head from images of theglenohumeral complex19 (Fig. 3). The net effect is a precise enface sagittal oblique view of the glenoid surface and vault, whichallows free body analysis of the scapula. In order to obtain the enface sagittal oblique view, the humeral head has to be digitallysubtracted after the three-dimensional reconstructions are per-formed by the computed tomography software.

A three-dimensional computed tomography scan pro-vides the most information about the extent and magnitude ofglenoid bone loss as well as information about the type ofglenoid bone injury or loss—i.e., whether it is due to an acutefracture, partial attritional loss, or complete attritional loss(Table II). Three-dimensional computed tomography also candemonstrate that glenoid bone loss occurs clinically along a lineparallel to the long axis of the glenoid from 12 o’clock to 6o’clock20.

Fig. 4

A: A best-fit circle is drawn on the inferior two-thirds of the glenoid fossa to aid with quantification of the percent bone loss. B: Measurement of

glenoid bone loss according to surface area22. On an en face view of the glenoid, the surface areas of both a best-fit circle on the inferior two-

thirds of the glenoid and the osseous defect are digitally measured. The percent bone loss is quantified according to the indicated equation.

(Drawing by Sanjeev Bhatia, MD.)

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Quantification of Glenoid Bone LossRadiography

It is often difficult to visualize osseous glenoid lesions with use ofradiographs. Although specialized views such as the West Point

axillary, apical oblique, and Didiee radiographs enhance the de-tection of osseous Bankart lesions, they are too imprecise for

quantification of the percentage of glenoid bone loss. Despite thisdrawback, Bigliani et al. reported a radiographic classification ofBankart lesions consisting of three basic types21. Type I is a dis-placed avulsion fracture with an attached capsule; Type II, amedially displaced fragment malunited to the glenoid rim; andType III, an erosion of the glenoid rim. Type-III lesions are further

Fig. 5

Fig. 6

Fig. 5 Measurement of glenoid bone loss based on ratios23. An en face view of the glenoid is visualized on a computed tomography scan. With use of the

intersection of the longitudinal axis and the widest anteroposterior diameter of the glenoid, the bare spot is approximated on the glenoid fossa. A best-fit

circle centered at the bare-spot approximation is then drawn about the inferior two-thirds of the glenoid (red). The distance from the bare spot to the anterior

edge (d) is measured and compared with the radius of the best-fit circle (R). The ratio of d/R is inserted into the indicated equation23 for estimation of the

percent bone loss. For ease of calculation, a function graph using common values from this equation is frequently utilized. (Drawing by Sanjeev Bhatia, MD.)

Fig. 6 Importance of Bankart fragment length. If the length (x) is greater than half of the widest anteroposterior (AP) diameter (R), the dislocation resistance is

£70% of that of an intact glenohumeral joint24. (Drawing by Sanjeev Bhatia, MD.)

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classified according to whether bone loss is less (Type IIIA) orgreater (Type IIIB) than 25%. If glenoid bone loss is detected onany radiographic view, a three-dimensional computed tomogra-phy scan should help to better define the amount of the loss.

Computed TomographyIn a cadaveric study of forty scapulae, Huysmans et al. dem-onstrated that the inferior aspect of the glenoid has the shapeof a true circle7, so this geometric comparison can be usedwhen quantifying glenoid osseous lesions. Glenoid bone losscan easily be quantified on a three-dimensional computedtomography scan by modeling the inferior portion of theglenoid contour as a true circle on an en face view7,22. Thedimensions and position of this circle are determined bydrawing a best-fit circle about the inferior two-thirds of theglenoid, with the center of this circle roughly at the glenoid‘‘bare spot’’ (a thinning in the cartilaginous covering andincreased subchondral density that overlies the tubercle ofAssaki)7 (Fig. 4, A). The amount of glenoid bone loss is cal-culated with one of two techniques. The most precise methodis a digital surface area calculation that determines theamount of glenoid bone loss or injury on the basis of theamount of glenoid surface area that is involved. The percentageof glenoid bone loss is determined by dividing the surface areaof the osseous defect by the surface area of the true circle (Fig. 4,B). A simpler technique to determine glenoid bone loss is alinear measurement in millimeters of the bone missing fromthe circle8.

In 2008, Barchilon et al.23 described a method forquantification of glenoid bone loss using an en face sagittaloblique three-dimensional computed tomography view. The

Fig. 7

Estimation of bone loss based on glenoid rim distances26. An en face view of the glenoid is visualized on a computed tomography scan. With use of the

intersection of the longitudinal axis and the widest anteroposterior diameter of the glenoid, the bare spot is approximated on the glenoid fossa. A best-fit circle

centered at the bare-spot approximation is then drawn about the inferior two-thirds of the glenoid (red). The distances from the bare spot to the anterior rim (A)

and posterior rim (B) are subsequently measured. The percent bone loss is calculated according to the indicated equation. (Drawing by Sanjeev Bhatia, MD.)

TABLE II Indications for Obtaining a Computed Tomography

Scan* of Patients with Shoulder Instability†

History of multiple dislocations

History of bilateral shoulder dislocation, especially dislocation onnondominant side

History of failed stabilization procedure

Dislocation after trivial trauma (initial episode) or little provocation

Radiographs or magnetic resonance imaging demonstratingglenoid bone loss

Instability in midranges of motion

*A three-dimensional computed tomography scan is best forquantification of bone loss. †Adapted from: Provencher MT,Metzger P, Peace W, Barlow B, Leonardelli D, Solomon DJ. Clinicalgrading of Hill-Sachs injuries: association with glenoid bone lossand clinical application of the ‘‘glenoid track’’ concept: when isthere humeral head engagement? Read at the 2009 ClosedMeeting of the American Shoulder and Elbow Surgeons; 2009 Oct24-27; New York, NY. Paper no. 26.)

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authors approximated the bare area on the glenoid fossa usingthe intersection of the longitudinal axis and the widest an-teroposterior diameter of the glenoid. A best-fit circle cen-tered at the bare-spot approximation was then drawn, and itsradius (R) was noted. The distance from the bare spot to theanterior edge (d) was measured, and the ratio of d/R wasentered into a geometric equation for quantification of thepercentage of glenoid bone loss (Fig. 5). The length of theosseous lesion has also been described as an important markerof glenohumeral stability. If the length (x) is greater than halfof the widest anteroposterior diameter (R), the resistance torecurrent shoulder dislocation is £70% of that of an intactglenohumeral joint24 (Fig. 6).

Perhaps the simplest method for computed tomographymeasurement of glenoid bone loss relies on the same tech-niques used during diagnostic arthroscopy. After approxi-mation of the bare spot with use of the intersection of thelongitudinal axis and the widest width on an en face view ofthe glenoid, the distance from the bare spot to the anterioredge (A) and from the bare spot to the posterior rim (B) aremeasured25 (Fig. 7). Percent bone loss is calculated as: ([B 2

A]/2B) · 100%26. A summary of the various methods forquantifying glenoid bone loss is provided in Table III.

ArthroscopyMethods for arthroscopic quantification of glenoid boneloss are based on the fact that the inferior two-thirds of theglenoid cavity is circularly shaped7,27. As shown by Burkhartet al., the glenoid bare spot is consistently equidistant fromthe anterior, posterior, and inferior glenoid margins and canbe regarded as a practical center point for the inferior part ofthe glenoid circle27. With use of the glenoid bare spot as ageometrical reference point, the percentage of glenoid boneloss can be calculated during arthroscopy by measuring theanterior and posterior distances to the glenoid rim25,27 (Fig. 8,A and B).

To effectively utilize the glenoid-bare-spot method forintra-articular quantification, one must understand the opti-mum circumstances for its use. As we showed previously20, theglenoid-bare-spot method is most accurate for quantifyingBankart lesions that occur parallel to the long axis of the glenoid.In these situations, arthroscopic measurement from either the2 o’clock or the 3 o’clock posterior portal is sufficient for truemeasurement of bone loss. If the glenoid rim defect occurs at a45� angle relative to the long axis of the glenoid, the glenoid-bare-spot method substantially overestimates the amount ofbone loss20. However, glenoid bone loss does not typically occur

TABLE III Computed Tomography Methods* for Quantification of Glenoid Bone Loss8,22-24,26,47

Quantification Method Description

Surface area method22� Three-dimensional computed tomography image of glenoid with humeral head

subtraction is obtained

� Best-fit circle is drawn on inferior 2/3 of pear-shaped glenoid

� Osseous deficiency is measured directly on circle with use of digital means

Superimposed circle method8� Best-fit circle centered at bare-spot approximation is drawn on injured glenoid

and contralateral, uninjured glenoid

� Glenoid circle on normal shoulder is superimposed on injured-shoulder circle

� Preinjury size and amount of bone loss are calculated

Pico method47� Best-fit circle is drawn on inferior portion of contralateral, uninjured glenoid with use of

MPR (multiplanar reconstruction) software, and its surface area (A) is digitally calculated

� Circle is superimposed onto injured glenoid, and surface area of defect (D) is calculated

� Percent bone loss = D/A · 100%

AP distance from bare area method26� Bare area is approximated on computed tomography with use of intersecting lines

� Distances are measured from bare area to anterior edge of osseous lesion (A) and frombare area to posterior aspect of glenoid rim (B)

� Percent bone loss = ([B 2 A]/2B) · 100%

Bankart length measurement24� Best-fit circle with radius (R) drawn on inferior 2/3 of glenoid

� Length of osseous lesion (x) is measured

� If x > R, dislocation resistance is £70% of that of an intact joint

Ratio method23� Best-fit circle with radius (R) is drawn on inferior 2/3 of injured glenoid

� Distance is measured from center of circle to anterior edge of osseous lesion (d)

� Percentage bone loss found with use of ratio d/R and specialized graph expressing percentbone loss as function of (d) and (R)

*A three-dimensional computed tomography scan with digital subtraction of the humeral head is best for accurate quantification.

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at a 45� angle. Rather, it occurs along a line parallel to the longaxis of the glenoid, and the measurement from the posterior rimto the anterior rim of the glenoid provides reasonable and ac-curate depiction of glenoid bone loss (Fig. 9).

Other authors have described additional problems withthe glenoid-bare-spot method that pertain to its reliance on theglenoid bare spot. Kralinger et al. used computed tomographyverification to show that the glenoid bare spot is approximately

Fig. 8

The glenoid-bare-spot method25,27 for estimation of the osseous defect size. A: With use of the bare spot as a

reference point, the distance from the glenoid bare spot to the posterior glenoid rim (BC) is measured. B: After the

probe is advanced, the distance from the bare spot to the anterior rim (AB) is measured. The percent bone loss is

calculated according to the indicated equation25,27. (Drawings by Sanjeev Bhatia, MD.)

Fig. 9

En face drawing of the glenoid fossa, demonstrating the clinical appearance of glenoid bone

loss, which usually occurs along a line nearly parallel to the long axis of the glenoid (0�). This

is in contrast to many 45� osteotomy cadaveric models originally used to simulate bone

loss20.

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1.4 mm anterior to the true center point, a finding that impliesthat the glenoid-bare-spot technique overestimates bone loss28.Huysmans et al., despite pioneering the notion that the inferior

aspect of the glenoid can be compared with a true circle,demonstrated that the glenoid bare spot is not identifiable in allshoulders7. In order to circumvent problems associated with

Fig. 10

The secant method29 for quantification of bone loss. A: A secant is a straight line that intersects the circumferenceof a circle twice

and extends beyond the radius. When two secants share an end point outside of a circle, the products of their lengths and external

segments are equal. The formula FN = (DE · ME/NE) 2 NE can be derived from this relationship. B: To estimate glenoid bone loss,

the lengths of segments DE, ME, and NE are determined as shown. Next, the theoretical value of FN (FNcalc) is calculated with use

of the formula FNcalc = (DE · ME/NE) 2 NE. The actual value of FN (FNmeas) is then measured intra-articularly with use of a

calibrated probe. The percent bone loss is estimated as ([FNcalc 2 FNmeas]/FNcalc) · 100%. (Drawings by Sanjeev Bhatia, MD.)

Fig. 11

Losses of <15% of the width of the glenoid (<3 to 4 mm from the anterior rim) are probably unimportant in most patients. Defects of 15% to

30% (between 4 and 9 mm of bone remaining anterior to the bare spot) are relevant in some patients. Finally, losses of >30% (<4 mm of

bone left anterior to the bare spot) are likely to be important in most patients. A: A summary of critical bone defects. B: A typical glenoid seen

in most patients with >30% bone loss. The posterior slope of the defect results in a narrower inferior glenoid width, leading to the so-called

inverted-pear glenoid (when viewed superiorly through the anterosuperior portal). (Reprinted, with permission, from: Piasecki DP, Verma NN,

Romeo AA, Levine WN, Bach BR Jr, Provencher MT. Glenoid bone deficiency in recurrent anterior shoulder instability: diagnosis and

management. J Am Acad Orthop Surg. 2009;17:482-93.)

141




the glenoid-bare-spot method, Detterline et al. developed anew technique for glenoid bone loss quantification that relieson the secant chord theory29. Simply put, a secant is a straightline that intersects the circumference of a circle twice and ex-tends beyond the radius. With use of simple geometry ofchords and secants, the percentage of glenoid bone loss can becalculated with a simple formula (Fig. 10, A and B).

Amount of Glenoid Bone LossThe anterior-to-posterior dimension of the glenoid at the levelof the bare spot is between 23 and 30 mm, and in most patientsit ranges from 24 to 26 mm7. Thus, a 25% glenoid bone injury

or loss comprises about 6 to 8 mm of the glenoid. This un-derscores the finding that only a relatively small amount ofbone loss is required for clinical relevance. As an additionaldiagnostic and treatment aid, one can consider the glenoid in5% increments, with each 5% increment comprising about 1.5to 2.0 mm of bone (Fig. 11).

Glenoid Bone Loss Treatment Algorithm

The degree of glenoid bone injury or loss, patient expecta-tions, and the anticipated postoperative activity level are the

three most important factors to consider when selecting treat-ment for patients with recurrent shoulder instability. Otherfactors to consider are listed in Table IV. Nonsurgical treatmentmay be appropriate for patients with <20% glenoid bone losswho have low activity demands, are sedentary, or are older aswell as for those with a high surgical risk or a history of voluntaryglenohumeral dislocation. If nonoperative management fails orif the patient is a highly active individual with glenoid osseousdeficiency, surgery is generally indicated. In patients with aprevious failure of a surgical repair that was done to addressshoulder instability who currently have recurrent instability, itis imperative to rule out glenoid bone loss as a contributingfactor prior to considering further surgical treatment.

As shown in Figure 12, the decision-making regardingsurgical treatment of a patient with recurrent shoulder instabilityand glenoid bone loss may be aided by the following recom-mendation. In patients with 0% to 20% (and even up to 25%)

TABLE IV Important Prognostic Factors to Consider During the

Preoperative Work-up for Patients with Recurrent

Shoulder Instability

Age

Activity level

Capsular integrity

Voluntary component

Failure to identify cause

Failure to recognize pathologic lesion(s)

Poor tissue quality

Humeral or glenoid osseous loss

Fig. 12

Treatment algorithm for surgical management of glenoid bone loss in patients with recurrent shoulder instability. CT = computed tomography;

ICBG = iliac crest bone graft. (Reproduced, with modification, from: Piasecki DP, Verma NN, Romeo AA, Levine WN, Bach BR Jr, Provencher MT.

Glenoid bone deficiency in recurrent anterior shoulder instability: diagnosis and management. J Am Acad Orthop Surg. 2009;17:482-93. Reprinted

with permission.)

142




glenoid bone loss, it may be possible to treat the instability suc-cessfully with arthroscopic repair31. Multiple anchors may be used,and a posterior repair may help to balance the repair. Althoughthese patients have only minor bone loss, incorporation ofthe Bankart fragment has been shown to potentially improvethe outcome31,32. However, some authors have advocated boneaugmentation procedures even in those with little or no glenoidbone loss and have reported excellent clinical outcomes32.

Patients with between 15% and 25% glenoid bone lossmay still be treated with arthroscopic techniques, but thesetechniques should be used more cautiously, as instability-related failure has been associated with this amount of glenoidbone loss. In these patients, sound osseous fragment fixation isimperative and open capsulolabral repair is still considered thegold standard for surgical treatment33. If the osseous Bankartfragment has either partially or fully resorbed, which is oftenthe case with attritional bone loss seen in association withchronic instability, bone augmentation techniques may be

needed. In addition, patients’ expectations and desires shouldbe thoroughly addressed when treatment is being discussedfor any amount of glenoid bone loss, as the risk of recurrentinstability after open repair or glenoid bone augmentationprocedures is clearly decreased compared with that after ar-throscopic repair, especially with an increased percentage ofglenoid bone loss2,25,34.

In patients with greater than 20% to 25% bone loss, openbone augmentation procedures such as the Latarjet, iliac crestbone-grafting, or allograft technique should be considered pri-marily to reconstitute the glenoid osseous arc. Transfer of thecoracoid has been used for more than fifty years, with excellentresults in terms of shoulder stability and function35,36. However,there are concerns about postoperative arthrosis and limitationsin shoulder motion after the nonanatomic coracoid reconstruc-tion. Other bone graft options, including the use of autogenousiliac crest graft and various frozen and fresh osteochondral al-lografts, have also been described. Ultimately, the patient’s wishes

Fig. 13

Arthroscopic repair of an osseous Bankart lesion. A: Anterior labral bone fragment attached to the glenoid labrum. B: A combination

of an arthroscopic bone-cutting shaver (<3.5 mm in diameter so that it can easily fit between the bone fragments) as well as a small

arthroscopic burr or arthroscopic rasp is very helpful to adequately prepare the glenoid prior to fixation. C: Sutures being passed

through the fragment-labral interface. D: The final repair construct. (Reprinted, with permission, from: Piasecki DP, Verma NN,

Romeo AA, Levine WN, Bach BR Jr, Provencher MT. Glenoid bone deficiency in recurrent anterior shoulder instability: diagnosis and

management. J Am Acad Orthop Surg. 2009;17:482-93.)

143




and the surgeon’s preference and comfort level should be con-sidered when choosing the best bone augmentation procedure.

Surgical Options for the Treatment of Glenoid Bone LossArthroscopic Repair

If the osseous defect is less than 20% to 25%, the Bankartfragment may be reliably repaired with use of an arthroscopic

technique30 (Fig. 13). Several techniques utilizing suture anchorsand a variety of suture configuration constructs to repair theosseous injury have been described. Arthroscopic methods maybe used for an acute glenoid fracture as well as in patients whohave attritional or partial attritional glenoid bone loss. The maingoal is to incorporate any remaining bone fragment into therepair and to restore the tension in the capsulolabral soft-tissuestructures37. Bankart lesion fixation is accomplished with sutureanchors introduced through a posterolateral, transsubscapularis,or midglenoid portal. The posterolateral portal allows ease ofaccess to the inferiormost aspect of the glenoid, especially if thepatient is in the lateral decubitus position.

Preparation of the native glenoid and osseous surfaces isimperative for a successful repair. A combination of an ar-throscopic bone-cutting shaver (<3.5 mm in diameter so that itcan easily fit between the bone fragments) as well as a smallarthroscopic burr or arthroscopic rasp is very helpful to ade-quately prepare the glenoid osseous surface prior to fixation(Fig. 13, B). Adequate preparation of the anterior aspect of theglenoid neck is signified by visualization of the posterior sub-scapularis fibers through the capsule, which has been elevatedsubperiosteally off the glenoid.

Arthroscopic repair techniques continue to evolve, andspecial instruments such as sharp penetrators, sharp suturehooks, or other curved suture devices or punches may be uti-lized in order to punch through the mid-aspect of the glenoidbone fracture or bone injury. If the glenoid bone loss is partiallyattritional in nature or chronic, the glenoid bone fragment isusually relatively soft, and standard arthroscopic repair deviceswill usually penetrate the bone. A variety of anchors and sutureconfigurations—both standard and knotless—may be utilizedfor effective surgical repair in this scenario (Fig. 13, C and D).

Postoperatively, patients wear a shoulder abduction slingfor four to six weeks to allow the osseous injury and capsularrepair to heal. Passive shoulder flexion and abduction in thescapular plane as well as gentle passive pendulum exercises andisometric strengthening of the scapular musculature are al-lowed during this time. At six weeks after the surgery, patientsuse more progressive shoulder motion, coupled with a com-prehensive strengthening program. By four to five months,patients may return to competitive sports and most activities,although those who engaged in contact sports and those whoseshoulder is routinely in a provocative instability position ofabduction and external rotation might wait for six months untilthey fully return to activities.

Open StabilizationAs described by Pagnani, open stabilization is a simple andeffective means for improving glenohumeral joint stability38.

Through a standard deltopectoral approach, the subscapu-laris tendon is transected approximately 1 cm medial to itsinsertion on the lesser tuberosity. The interval between thesubscapularis tendon and the underlying anterior aspect ofthe capsule is developed. It is helpful to isolate the under-lying capsule more medially and to bluntly dissect toward thelesser tuberosity prior to completing the subscapularistenotomy.

The capsule is divided transversely, allowing placementof a humeral head retractor. If a labral lesion is encountered,the detached labrum is elevated from the glenoid neck withangled liberator devices. The glenoid neck is abraded with arasp or mechanized burr to healthy bleeding bone, and anchorsare placed into the glenoid at the anterior glenoid cartilagemargin.

The anchor sutures are utilized to imbricate the inferioraspect of the divided capsule into the Bankart repair. Capsu-lorrhaphy is performed by one of two methods. If there is<5 mm of overlap between the inferior and superior aspects ofthe divided capsule, the edges are imbricated by suturing thesuperior aspect of the capsule over the inferior aspect of thecapsule with the same sutures. If the overlap exceeds 5 mm,then a vertical capsular incision is made at the articular marginof the humeral neck to facilitate a larger capsular shift. The

Fig. 14

Drawing depicting the anterior view of a shoulder during open

shoulder stabilization. Vertical and horizontal capsular incisions

that create separate superior and inferior capsular flaps can be

made. (Reprinted from: Altchek DW, Warren RF, Skyhar MJ, Ortiz

G. T-plasty modification of the Bankart procedure for multidi-

rectional instability of the anterior and inferior types. J Bone Joint

Surg Am. 1991;73:105-12.)

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T-capsular incision (Fig. 14) allows the inferior aspect of thecapsule to be shifted superolaterally, while the superior aspectof the capsule can be closed inferomedially (Fig. 15). Thecapsular repair and shift are done with the glenohumeral jointin 45� of abduction and external rotation.

The subscapularis is repaired with nonabsorbable suture,and the deltopectoral interval is loosely reapproximated.

Latarjet ProcedureIn the Latarjet procedure, a locally harvested coracoid autograftis positioned to become an extra-articular platform that acts asan extension of the articular arc of the glenoid. Three processeswork together to improve anterior shoulder stability. First, theosseous block serves to extend the glenoid rim and enhancesthe ‘‘safe arc’’ available for translation prior to dislocation.Second, the conjoined tendon functions as a sling to resistanterior humeral translation when the arm is abducted andexternally rotated. Finally, the transferred coracoid and con-joined tendon over the lower subscapularis tendon create atenodesis effect that reinforces a deficient anteroinferior aspectof the capsule34. There are numerous methods with which toperform a Latarjet osseous reconstruction of the glenoid—ranging from utilizing the coracoid as a free intra-articular graftto employing the triple-blocking effect of the graft and soft-tissue sling39. Suture anchors may be utilized on the anterior-most aspect of the native glenoid at the coracoid-glenoidinterface in order to repair the native capsule that has been

previously dissected off the glenoid neck. Typically, two3.5-mm metal screws are utilized to fix the coracoid in positionas flush as possible with the native glenoid. The native capsuleis then repaired to the native glenoid via suture anchors orbone tunnels so that the coracoid is extra-articular, or thecapsule is repaired to the anterior aspect of the coracoid so thatthe coracoid is intra-articular. Some authors have advocatedlimited capsule and labral repair, believing that the majority ofthe stability is provided by restoration of the glenoid arc40.

Although the Latarjet procedure has been advocatedfor many years and has undergone several variations, therehave been very few studies that have addressed optimal graftplacement and orientation. In a recent biomechanical study,Ghodadra et al. evaluated variations in contact pressure andarea in a glenoid bone-loss model with varied placement andorientation of iliac crest autograft and Latarjet graft41. Thoseauthors demonstrated optimal normalization of glenohu-meral contact pressures with flush placement of the iliaccrest autograft and the Latarjet graft oriented with the in-ferior aspect of the coracoid congruent with the face of theglenoid. In addition, Ghodadra et al. determined that graftsplaced 2 mm medial to the glenoid face led to increased edgeloading and grafts placed 2 mm lateral to the glenoid faceresulted in an increased shift of contact pressure to theposterosuperior quadrant of the glenoid. These authors alsofound that the coracoid placed with the inferior surface asthe glenoid face in an anterior 30% glenoid defect provided a

Fig. 15

Drawing showing T-plasty repair. A: Superior shift of the inferior capsular flap and suture to the glenoid

margin. B: The superior flap is advanced inferiorly to make a double-layer closure. (Reprinted from: Altchek

DW, Warren RF, Skyhar MJ, Ortiz G. T-plasty modification of the Bankart procedure for multidirectional

instability of the anterior and inferior types. J Bone Joint Surg Am. 1991;73:105-12.)

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mean of 9.6 ± 0.1 mm of glenoid diameter reconstructionwhereas coracoid placement with the lateral surface as theglenoid face led to a mean addition of 7.3 ± 0.2 mm to theglenoid diameter.

Long-term studies of the Latarjet procedure have con-firmed its efficacy and lasting benefits. In a retrospective reviewof fifty-eight shoulders treated with a Latarjet procedure andfollowed for an average of 14.3 years, Allain et al. noted an‘‘excellent’’ result in 88% of the shoulders and no recurrent dis-locations42. At the time of final follow-up, thirty-four of the fifty-

eight shoulders had glenohumeral arthritis, with the majority(twenty-five) having grade-1 changes. Hovelius et al., in a pro-spective study of 118 shoulders treated with a Bristow-Latarjetrepair and followed for an average of 15.2 years, noted an overallsatisfaction rate of 98% of the patients43. However, in a follow-upstudy of the radiographs in this population, the authors foundmoderate-to-severe dislocation arthropathy in 14% of the pa-tients44. In perhaps the longest follow-up study on patients treatedoperatively for anterior shoulder instability (mean duration offollow-up, 26.4 years), Schroder et al. found a nearly 70% rate of

Fig. 16

Use of iliac crest bone graft to augment an anterior glenoid osseous deficiency. A: Preoperative three-dimensional

computed tomography scan demonstrating an attritional osseous defect in the anterior glenoid rim. B: Intraoperative image

of an iliac crest bone allograft being fixed to the anterior aspect of the glenoid. C: Postoperative axial computed tomography

scan. D: Postoperative three-dimensional computed tomography scan.

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good-to-excellent results in forty-nine patients who had un-dergone a modified Bristow procedure36. Fifteen percent ofthe shoulders, however, eventually had recurrent instability,with a mean time to the recurrent dislocation of seven years.

After a Latarjet procedure, patients are treated with arehabilitation program similar to that used after an arthro-scopic repair, although the surgical technique employed for thesubscapularis dominates the postoperative protocol. If thesubscapularis was taken down either partially or completely,patients should have internal rotation strengthening and pas-sive external rotation protected for at least six weeks. If asubscapularis split was utilized for the Latarjet procedure,patients may be more aggressive in their internal rotationstrengthening with less protection of external rotation. How-ever, the subscapularis split is part of the ‘‘sling’’ component ofthe Latarjet procedure as the conjoined tendon is draped overthe subscapularis tendon.

Iliac Crest Bone-GraftingIliac crest bone graft has also been employed to augment anteriorglenoid defects and in some instances may result in a betterarticular arc match than the coracoid transfer; this is due to theanatomic orientation of the iliac crest graft, which allows theinner table of the iliac crest to become congruent with the glenoidsurface. The inner table of the iliac wing is concave and fits thenative glenoid curvature well41. The iliac crest bone graft has beendescribed as both an intra-articular and an extra-articular con-struct11,12. The iliac crest bone graft is especially helpful in patientswith extensive glenoid bone deficiency as the iliac crest providesan adequate supply of bone to reconstruct large defects (Fig. 16).

Future Directions for the Treatment of Glenoid Bone LossAllografts for Glenoid Bone Loss

In order to avoid the potential morbidity of an autograftcoracoid and conjoined tendon transfer, various allografts

Fig. 17

A: The lateral aspect of the distal part of the tibia is an excellent fit for the glenoid, providing a nearly anatomic match of the

radius of curvature, glenoid and tibial cartilage thickness, and dense corticocancellous weight-bearing bone14. B: Acute

osseous glenoid deficiency as seen on a three-dimensional computed tomography scan. C: A three-dimensional computed

tomography scan of the glenoid obtained shortly after bone augmentation with use of distal tibial allograft. D: The final distal

tibial allograft as seen on a postoperative axial computed tomography scan. Note the good incorporation of the allograft into

host bone. E: Final postoperative three-dimensional computed tomography scan.

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have been identified for use in the treatment of glenoid bonedeficiency. Fresh osteochondral glenoid, frozen humeral head,frozen femoral head13, and fresh distal tibial osteochondralgrafts have been described14. Although the most logical re-construction is to replace the missing glenoid bone with sim-ilar glenoid bone, these glenoid allograft specimens have beendifficult to obtain because of issues with graft contamination,donor consent, and availability14. The lateral aspect of the distaltibial allograft is an excellent fit for the glenoid, providing anearly anatomic match of the radius of curvature, glenoid andtibial cartilage thickness, and dense corticocancellous weight-bearing bone14 (Fig. 17). In addition, because this allograft isprocessed fresh and is available without freezing, the normalsubchondral osseous architecture is preserved.

Use of a distal tibial allograft for reconstruction of theglenoid surface arc has many potential advantages. In addition

to potentially recreating the glenoid articular surface, the distaltibial bone stock is composed of dense corticocancellous bone.The size of the distal tibial allograft can be customized for anindividual patient, and the grafts are readily available from al-lograft distributors.

Distal Tibial Allograft TechniqueA distal tibial glenoid allograft is applied14 through a delto-pectoral approach with the subscapularis split longitudinally.The capsule is exposed and is dissected subperiosteally asmedial as possible; it is then tagged with a number-2 nonab-sorbable suture. The glenohumeral joint is then exposed, andthe amount of glenoid bone loss is assessed.

The glenoid is prepared to receive the allograft. It is im-portant to attempt to maintain any remaining labral tissue, asthis will be repaired after osseous augmentation. Occasionally,

Fig. 18

Distal tibial allograft technique for reconstruction of osseous defects in the glenoid. A: Allograft preparation takes place on

the back table and begins with measurement of the appropriate width. B: The allograft is cut with adequate depth, with

enough subchondral bone to allow for placement of 3.5-mm screws to secure the graft to the glenoid. C: Prior to fixation of the

allograft onto the glenoid, two 1.6-mm Kirschner wires are placed at a 45� angle to the articular surface of the graft. D: The

allograft is provisionally fixed with its articular surface congruent with the native glenoid.

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as a result of chronic instability, there is attrition of the labraltissue and it cannot be repaired. A high-speed burr is then usedto create a uniform glenoid graft bed by making a recipient sitethat is perpendicular to the articular surface of the glenoid.

Allograft preparation takes place on the back table andbegins with measurement of the appropriate width (Fig. 18, A).The lateral aspect of the distal part of the tibia is the ideal portionof the plafond for use, and usually between 8 and 11 mm at thearticular surface is required. A 0.5-mm sagittal saw is employedto make the cuts while an assistant secures the graft with pointedreduction clamps or towel clips. The corners of the graft can berounded with the sagittal saw to closely mimic the morphologyof the native glenoid. The allograft is cut with adequate depth,with sufficient subchondral bone to allow placement of 3.5-mmscrews to secure the graft to the glenoid (Fig. 18, B).

Prior to fixation of the allograft onto the glenoid, two1.6-mm Kirschner wires are placed at a 45� angle to the artic-ular surface of the graft (Fig. 18, C) for provisional fixation ofthe allograft to the glenoid. It is important to plan where the3.5-mm screws will be placed for final fixation of the graft andto avoid placing the Kirschner wires in these locations. Thegraft is provisionally fixed with the articular surface of the al-lograft congruent with the native glenoid (Fig. 18, D). Afterprovisional fixation, the graft is secured to the native glenoidwith a lag technique and use of a 3.5-mm fully threaded corticalscrew. Typically, these screws measure 34 to 38 mm in length.Washers can be added for additional fixation and dissipation ofsurface-area forces at the screw-graft interface.

The labrum and capsule are repaired. Prior to final screwtightening, the suture used to repair the labral and capsulartissue is passed under the screw head or washer for securefixation. After final screw tightening and capsular repair, thewound is closed in the typical fashion. An abduction sling isapplied, and the patient gradually returns to active motion overfour to six weeks. This is followed by a strengthening program.

Arthroscopic Glenoid Bone-GraftingPerforming the Latarjet procedure with use of an all-arthroscopictechnique allows the orthopaedic surgeon to improve glenohu-meral joint stability while using a minimally invasive approach.First described by Lafosse et al., the arthroscopic Latarjet pro-cedure consists of five stages: exposure, coracoid preparation,coracoid drilling and osteotomy, coracoid transfer, and finallyfixation of bone graft45. Because an arthroscope is used, theprocedure allows excellent visualization of the coracoid graft’sposition, thereby decreasing the risk of anterior bone-blockoverhang. In theory, this should reduce the risk of rapid-onsetosteoarthrosis, a common complication associated with openLatarjet procedures45. However, an arthroscopic Latarjet or cor-acoid transfer technique is a difficult operation with a steeplearning curve, even for skilled arthroscopists. In a prospectivereview of 100 consecutive shoulders that had undergone an all-arthroscopic Latarjet procedure, Lafosse and Boyle noted ex-cellent scores in 91% of those followed at twenty-six months46.The mean time until the patients returned to work was twomonths, and the mean time until they returned to sports was ten

weeks. Computed tomography imaging demonstrated that 80%of the patients had a coracoid graft that was placed flush, 8% hada graft that was too medial, and 12% had a graft that had lateraloverhang. It is notable that 69% of the patients had no arthrosisat the time of final follow-up.

Concomitant Pathologic Conditions

To avoid problems with recurrent instability after shoulderstabilization, patients should be thoroughly evaluated for

concomitant shoulder disorders prior to any surgical man-agement. Magnetic resonance imaging or magnetic resonancearthrography is often useful in identifying associated injuriessuch as glenoid labrum articular disruptions (GLAD lesions),

TABLE V Common Pathologic Findings Associated with Anterior

Shoulder Instability Repair*

Pathologic Condition Pearls: How to Treat

Rotator cuff tear Recognize partial tears and look forcommon tear patterns:

Crescent

U-shaped

L-shaped

Note: intact cuff confers stability

Acromioclavicularjoint pain

Consider a distal clavicle excision vs.preoperative acromioclavicular jointinjection

Extensive labral tear Visualize entire glenoid labrum

SLAP lesion Tackle at time of surgery

Search for concomitant biceps lesion

ALPSA lesion Search for tear of anterior band ofinferior glenohumeral ligament

Remember labrum and scapularperiosteal sleeve are detachedmedially and inferiorly on glenoid neck

HAGL lesion Visualize from posterior portal with30� arthroscope in axillary pouch inexternal and internal rotation

Repair in both inferior-to-superior andmedial-to-lateral directions

Bankart lesion Dissect labrum medially until musclefibers of subscapularis are visible

<15% bone loss / labral andcapsular repair

15%-25% bone loss / incorporateosseous fragment into repair

>25% bone loss / glenoid bonereconstruction

Hill-Sachs lesion If engaging, consider remplissage orbone augmentation

*A thorough preoperative work-up should aim to identify con-comitant shoulder injuries.

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anterior labral periosteal sleeve avulsions (ALPSA lesions), andhumeral avulsions of the glenohumeral ligaments (HAGL le-sions). Tips for addressing concomitant pathologic conditionsare listed in Table V.

Overall, there are multiple well-supported approachesfor the operative management of shoulder instability. Optimal

treatment should be guided by the extent of glenoid bone lossand anticipated patient activity levels. Tips for avoidance ofcommon surgical complications are listed in Table VI.

Conclusions

The diagnosis and management of glenoid bone loss inpatients with recurrent shoulder instability continue to

evolve. The finding of glenoid bone loss should be suspectedin a patient with a prolonged history of instability, multipledislocations, a progressive ease of dislocation, and symp-toms of humeral head engagement. Multiple radiographicstudies for evaluation of glenoid bone loss are available;however, the three-dimensional reformatted computed to-mography scan provides the most accurate assessment ofbone deficiency or combined glenoid and humeral headdefects. Multiple procedures, ranging from arthroscopic toopen repair to open bone-grafting techniques, have beensuccessfully employed in the management of glenoid bonedefects. n

CDR Matthew T. Provencher, MD, MC, USNLT Lance LeClere, MD, MC, USNLCDR Christopher B. Dewing, MD, MC, USNDepartment of Orthopaedic Surgery,Naval Medical Center San Diego,34800 Bob Wilson Drive,Suite 112, San Diego, CA 92134.E-mail address for M.T. Provencher: [email protected]

Sanjeev Bhatia, MDNeil S. Ghodadra, MDBernard R. Bach Jr., MDAnthony A. Romeo, MDDivision of Sports Medicine,Department of Orthopaedic Surgery,Rush University Medical Center,1611 West Harrison Street,Chicago, IL 60612.E-mail address for S. Bhatia: [email protected] address for N.S. Ghodadra: [email protected]

Robert C. Grumet, MDOrthopaedic Specialty Institute,280 South Main Street,Suite 200, Orange,CA 92868

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TABLE VI Surgical Complications Associated with

Instability Repair

Surgical Complication Pearls: How to Avoid

Misdiagnosis Do a full shoulder examinationwith patient under anesthesia

Place patient in lateral decubitusposition for optimal visualizationand access to glenoid labrum

Nerve damage Axillary nerve / situated 1-1.5 cmbelow inferior aspect ofglenohumeral capsule

Musculocutaneous nerve / sit-uated 5-8 cm inferior to coracoid

Careful placement of humeralhead to avoid excessiveflexion-extension

Avoid excessive humeraldistraction

Inadequate capsulorrhaphytension

Examine shoulder range ofmotion after repair

Inadequate restorationof glenoid concavity

Incorporate osseous Bankartfragment into repair

If >25% bone loss, considerbone augmentation with Latarjetvs. iliac crest graft

Avoid excessive anterior-inferiorcapsular tightening in overheadathletes

Chondrolysis Avoid thermal capsulorrhaphyand intra-articular pain pumps

Hardware failure Do not use bioabsorbable tacks

Place anchors below articularmargin with firm purchase insubchondral bone

Place 3 anchors below 3:00position

Use >3 anchors with 1st anchorat 5:30 position and 45� toarticular surface

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