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Figure A
2%
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Figure B
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Figure C
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Figure D
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Figure E
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The presence of a preoperative defect in the glenoid has been shown to portend failure when arthroscopic labral repair alone is performed for recurrent instability in high level athletes. Fractures and bony defects of the glenoid are not uncommonly seen with shoulder dislocations. A bony Bankart lesion is a fracture of the anterior inferior glenoid. While there is no consensus on the most accurate technique for measuring glenoid bone loss, defects of 15-25% are considered biomechanically unstable, and thus many surgeons advocate for bony procedures to restore bone loss in these cases. However, note that some surgeons may consider bony procedures in higher level athletes with recurrent instability from bone loss below this threshold while lower demand patients may tolerate a higher threshold. Bony procedures include the Latarjet procedure or osseous augmentation with autograft or allograft. There is a high risk of failure when an arthroscopic soft tissue procedure is performed in isolation for high level athletes with recurrent shoulder instability. . Di Giacomo et al. described the evolving concept of bipolar bone loss and the Hill-Sachs lesion. They described a radiographic arthroscopic method that uses the concept of the glenoid track to determine whether a Hill-Sachs lesion will engage the anterior glenoid rim, in the presence or absence of concomitant anterior glenoid bone loss. They reported that if the Hill-Sachs lesion engages, it is called an "off-track" Hill-Sachs lesion; if it does not engage, it is an "on-track" lesion. They concluded that conversion of an off-track Hill-Sachs lesion to an on-track Hill-Sachs lesion is essential in stabilizing the shoulder with anterior instability. They recommend the use of their proposed treatment paradigm with specific surgical criteria for all patients with anterior instability, both with and without bipolar bone loss. Nakagawa et al. performed a study to investigate risk factors related to the postoperative recurrence of instability after arthroscopic Bankart repair in athletes. They reported that risk factors for postoperative recurrence of instability included playing rugby, age between 10 and 19 years at surgery, preoperative glenoid defect, small bone fragment of bony Bankart lesion, and capsular tear. They concluded that younger age at operation and preoperative glenoid defect with small or no bone fragment significantly influenced recurrent instability among competitive athletes. Figure A demonstrates a small posterior labral tear with a spinoglenoid cyst. Figure B demonstrates a normal shoulder MRI. Figure C demonstrates a posterior labral tear. Figure D demonstrates anterior glenoid fracture and bone loss. Figure E demonstrates an anterior labral tear. Incorrect Answers: Answers 1: Arthroscopic labral repair with a cyst decompression would likely be successful in addressing the posterior labral tear with the spinoglenoid cyst. Answer 3 & 5: Arthroscopic labral repair would likely be successful in anterior and posterior labral tears without bony defects. Answer 2: Figure B demonstrates a normal shoulder MRI.
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