Review Question - QID 219975

The patient has sustained numerous anterior shoulder dislocations and now has traumatic anterior shoulder instability with significant anterior glenoid bone loss. The recommended procedure to prevent recurrent instability in the setting of significant bone loss is a bony augmentation procedure such as a Latarjet (Answer 3).

Traumatic Anterior Shoulder Instability, also referred to as TUBS (Traumatic Unilateral dislocations with a Bankart lesion requiring Surgery), results from traumatic shoulder injuries that generally occur as a result of an anterior force sustained to the shoulder while the arm is in an abducted and externally rotated position. The diagnosis is made clinically with the presence of positive anterior instability provocative tests and confirmed with MRI studies that may reveal labral and/or bony injuries of the glenoid and proximal humerus (Hill-Sachs lesion). Though critical bone loss was traditionally described as that which exceeds 20-25% of the diameter of the glenoid, recent studies suggest critical bone loss may be as low as 13.5%. In some instances, "sub-critical" bone loss may be successfully treated with arthroscopic Bankart repair in addition to a remplissage when a concurrent "off-track" Hill-Sachs lesion is present; however, the gold standard treatment for recurrent instability with significant bone loss is still the Latarjet, or coracoid transfer, procedure.

Provencher et al. reviewed the diagnosis and management of traumatic anterior shoulder instability. The authors note that glenoid bone loss (GBL) and type of bone loss (on-track/off-track) are important factors when recommending treatment strategies. They conclude that good results can be expected after Bankart repair in on-track Hill-Sachs lesions (HSLs) with GBL < 13.5%, but that Bankart repair without adjunct procedures is not recommended in off-track HSLs, regardless of the size of GBL, and that bone block transfer is recommended when GBL > 20% to 25% or when the HSL is off-track.

Yang et al. reviewed the use of remplissage versus modified Latarjet for off-track Hill-Sachs lesions with subcritical glenoid bone loss. The authors looked at 189 patients with recurrent anterior shoulder instability, off-track Hill-Sachs lesion, and less than 25% glenoid bone loss, and found that both arthroscopic Bankart repair with remplissage and modified Latarjet can achieve satisfactory results with the initial surgical intervention in the general population, but that a higher complication rate was observed in the Latarjet group. Despite this, they concluded that Latarjet appears to be a better choice in patients with revision instability surgery, collision and contact athletes, and those with >10% glenoid bone loss.

Figures A-C are coronal, axial, and 3D reconstruction CT scan views showing an anteroinferior glenoid defect exceeding 20% and evidence of a humeral head Hill-Sachs lesion.

Incorrect Answers:
Answer 1: The patient has significant glenoid bone loss and an off-track Hill-Sachs lesion, so an isolated Bankart repair without remplissage would not provide adequate treatment to prevent recurrence.
Answer 2: Though arthroscopic Bankart repair with remplissage has been shown in some studies to be nearly as effective as Latarjet in instances of "sub-critical" bone loss, remplissage with isolated capsular plication without labral repair is not indicated in this patient.
Answer 4: Though an open Bankart may be an appropriate choice in a patient without critical bone loss, the addition of a remplissage would be prudent in this patient with an "off-track" Hill-Sachs to prevent recurrence.
Answer 5: A latissimus dorsi transfer is not indicated in this high-level athlete with a competent subscapularis.