Review Question - QID 5736

This patient has recurrent anterior glenohumeral instability with >20% glenoid bone loss and therefore would benefit most from an open coracoid transfer (Latarjet procedure).

Recurrent anterior shoulder instability occurs in 33-67% of patients who sustain an initial traumatic dislocation. Specific risk factors include age < 25 years, male gender, anterior glenoid (Bankart) and/or posterior humeral (Hill-Sachs) osseous defect(s) and participation in contact sports. Surgical management of recurrent instability depends on the presence or absence of glenohumeral bone loss. Patients with < 20% glenoid bone loss can be managed with arthroscopic Bankart repair. An engaging Hill-Sachs lesion, meaning the humeral head defect engages the glenoid rim in abduction (ABD) and external rotation (ER) [see Illustration B], in the setting of minimal glenoid bone loss can be managed with remplissage. Patients with > 20% glenoid bone loss require greater stabilization, mostly commonly in the form of an open coracoid transfer (Latarjet procedure).

Burkhart et al. (2000) found arthroscopic Bankart repairs equivalent to open Bankart repairs if no substantial bone defects were present. However, patients with an “inverted pear” glenoid secondary to significant anteroinferior bone loss or an engaging Hill-Sachs lesion of the humerus had a 67% recurrence rate overall and an 89% recurrence rate if they were contact athletes. Therefore, contact athletes with structural bone deficits require open surgery and often necessitate reconstruction with bone-block procedures.

Itoi et al. determined that an osseous defect with a width of >/= 21% of the glenoid length was associated with anteroinferior instability in ABD and internal rotation (IR), as well as loss of external rotation following Bankart repair. The authors concluded that while Bankart repair in the setting of a substantial bone loss conferred adequate stability in ABD and ER, it did so at the cost of overtightening the anterior structures which limited ER and did not affect stability in IR when the anterior capsuloligamentous structures are lax.

Burkhart et al. (2007) concluded that in the setting of significant glenohumeral bone deficiency, an open Latarjet procedure had only a 4.9% recurrence rate as compared to a 67% recurrence rate following arthroscopic Bankart repair. The Latarjet procedure works to extend the bony glenoid concavity, provide a dynamic sling from the conjoint tendon, preserve the lower third of the subscapularis and repair the capsule.

Figures A and B are the axial CT scan and 3D reconstruction en face view of the glenoid demonstrating significant anteroinferior glenoid bone loss of approximately 40%. Illustration A is an algorithm for the management of anterior shoulder instability based on pertinent risk factors and glenohumeral bone loss. Illustration B compares non-engaging and engaging Hill Sachs lesions. Size and depth of the Hill-Sachs lesion as well as glenoid bone deficiency both contribute to risk of engagement. Illustration C depicts a simplistic version of the Latarjet procedure.

Incorrect Responses:
Answers 1 and 2: Open capsular shift and remplissage alone will not address the significant glenoid bone loss contributing to his recurrent instability.
Answers 3 and 4: Arthroscopic Bankart repair in the presence of substantial glenohumeral bone deficits has been shown to have an unacceptably high recurrence rate.