Review Question - QID 5588

This patient has recurrent shoulder instability with a small bony defect of the anterior glenoid and no previous surgery. The most appropriate definitive management in this patient would be arthroscopic bony Bankart repair.

Older (>20 years old), recreational athletes with minor glenoid bone loss (<20% of the glenoid surface area) may be treated with soft tissue stabilization procedures using suture anchors. Goals of this procedure include tightening and repairing the torn ligament and labrum to the glenoid. Younger, contact sports athletes with large glenoid defect (>20%) may require bony augmentation type of procedures.

Lynch et al. review the clinical presentation, assessment and treatment algorithm for surgical management of bone loss associated with anterior shoulder instability. While defects larger than 25% of glenoid width should be managed with bony augmentation, they recommend soft-tissue stabilization in smaller defects.

Balg et al. analyzed 131 patients following Bankart procedure and identified following risk factors for failure: age <=20, competitive participation in contact sports, shoulder hyperlaxity, Hill-Sachs on AP radiograph, glenoid bone loss of contour on AP radiograph.

Using human cadaveric shoulders with various anterior glenoid defects sizes, The MOON Shoulder Group compared radiography, MRI and CT to determine the most reliable imaging modality for predicting bone loss. Three-dimensional CT, followed by regular CT were the most reliable and reproducible imaging modalities for predicting glenoid bone loss.

Figure A shows an en face sagittal 3D reconstruction of a glenoid with 10% surface area loss.

Incorrect Answers:
Answer 1: While closed reduction and immobilization are appropriate initial management, after failing conservative management, definitive management for recurrent shoulder dislocation is surgical.
Answer 3: Remplissage procedure is indicated in setting of large Hill-Sachs lesions.
Answers 4 & 5: Glenoid augmentation procedures using coracoid transfer (Bristow-Latarjet) and tricortical iliac crest graft would be indicated in setting of larger glenoid bone loss.