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• W2560640476 abstract "The mobility of the glenohumeral joint in multiple anatomic planes is not without consequence as recurrent instability is common, particularly among young, active individuals. Throughout midranges of shoulder motion, stability is conferred primarily by the compression-cavity effect of the rotator cuff as muscular contractions maintain the humeral head centred in the glenoid cavity. At extremes of shoulder motion (flexion and abduction), derangements of capsule-ligamentous complex, glenoid and glenoid labrum drive a pathophysiological cascade that manifests clinically as recurrent anterior, unidirectional instability. In the setting of bone loss <25% of the inferior glenoid diameter, arthroscopic Bankart repair using proper technique yields reliable clinical results. Additionally, much is now known about the extent to which attritional glenoid bone loss, related commonly to repeated dislocation events, affects the predicted success of certain treatment approaches. The preponderance of existing literature supports performing a bone grafting procedure for cases in which the osseous defect comprises >25% of the glenoid width, with the Latarjet procedure being favoured among recent authors. A growing body of evidence has elucidated the consequence of humeral head defects (the Hill-Sachs lesion) as a predictor of recurrent instability. Thus, the concept of ‘bipolar bone loss’ has emerged as a critical concept in the surgical treatment of recurrent shoulder instability. Surgeons should adopt a treatment paradigm that focuses on the relationship between both osseous defects—glenoid and humeral head—and incorporates a surgical tactic to appropriately address each lesion. The mobility of the glenohumeral joint in multiple anatomic planes is not without consequence as recurrent instability is common, particularly among young, active individuals. Throughout midranges of shoulder motion, stability is conferred primarily by the compression-cavity effect of the rotator cuff as muscular contractions maintain the humeral head centred in the glenoid cavity. At extremes of shoulder motion (flexion and abduction), derangements of capsule-ligamentous complex, glenoid and glenoid labrum drive a pathophysiological cascade that manifests clinically as recurrent anterior, unidirectional instability. In the setting of bone loss <25% of the inferior glenoid diameter, arthroscopic Bankart repair using proper technique yields reliable clinical results. Additionally, much is now known about the extent to which attritional glenoid bone loss, related commonly to repeated dislocation events, affects the predicted success of certain treatment approaches. The preponderance of existing literature supports performing a bone grafting procedure for cases in which the osseous defect comprises >25% of the glenoid width, with the Latarjet procedure being favoured among recent authors. A growing body of evidence has elucidated the consequence of humeral head defects (the Hill-Sachs lesion) as a predictor of recurrent instability. Thus, the concept of ‘bipolar bone loss’ has emerged as a critical concept in the surgical treatment of recurrent shoulder instability. Surgeons should adopt a treatment paradigm that focuses on the relationship between both osseous defects—glenoid and humeral head—and incorporates a surgical tactic to appropriately address each lesion. Traumatic anterior glenohumeral dislocation is a common clinical entity, occurring at a rate of 0.08 dislocations per 1000 person-years.1Zacchilli MA Owens BD Epidemiology of shoulder dislocations presenting to emergency departments in the United States.J Bone Joint Surg Am. 2010; 92: 542-54910.2106/JBJS.I.00450Crossref PubMed Scopus (429) Google Scholar Young, active individuals are at particular risk for recurrent instability, which has been demonstrated in a number of series of collegiate athletes and military trainees.2Owens BD Agel J Mountcastle SB et al.Incidence of glenohumeral instability in collegiate athletics.Am J Sports Med. 2009; 37: 1750-175410.1177/0363546509334591Crossref PubMed Scopus (224) Google Scholar, 3Owens BD Dawson L Burks R et al.Incidence of shoulder dislocation in the United States military: demographic considerations from a high-risk population.J Bone Joint Surg Am. 2009; 91: 791-79610.2106/JBJS.H.00514Crossref PubMed Scopus (205) Google Scholar, 4Owens BD Duffey ML Nelson BJ et al.The incidence and characteristics of shoulder instability at the United States Military Academy.Am J Sports Med. 2007; 35: 1168-117310.1177/0363546506295179Crossref PubMed Scopus (312) Google Scholar, 5Dumont GD Golijanin P Provencher MT Shoulder instability in the military.Clin Sports Med. 2014; 33: 707-72010.1016/j.csm.2014.06.006Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar Owens et al queried the Defense Medical Epidemiology Database from 1998 through 2006 and reported an overall incidence of shoulder dislocation to be markedly higher (1.69 dislocations per 1000 person-years) than the general US population. In this series, significant risk factors for instability events included male gender, age <30 years and service in the US Army.3Owens BD Dawson L Burks R et al.Incidence of shoulder dislocation in the United States military: demographic considerations from a high-risk population.J Bone Joint Surg Am. 2009; 91: 791-79610.2106/JBJS.H.00514Crossref PubMed Scopus (205) Google Scholar Moreover, a prior history of shoulder instability is a significant risk factor for future instability events. Cameron et al6Cameron KL Mountcastle SB Nelson BJ et al.History of shoulder instability and subsequent injury during four years of follow-up: a survival analysis.J Bone Joint Surg Am. 2013; 95: 439-44510.2106/JBJS.L.00252Crossref PubMed Scopus (49) Google Scholar conducted a prospective cohort study of freshmen at the US Military Academy, reporting that a prior history of glenohumeral instability events was associated with a 5.6 times increased risk (p<0.001) of subsequent anterior instability event. The pathophysiological cascade of events related to anterior shoulder instability is well described.7Sugaya H Moriishi J Dohi M et al.Glenoid rim morphology in recurrent anterior glenohumeral instability.J Bone Joint Surg Am. 2003; 85-a: 878-884Crossref PubMed Scopus (553) Google Scholar Anterior dislocation of the humeral head involves avulsion of the inferior glenohumeral ligament (IGHL), resulting in various types of injuries to the capsuloligamentous complex of the shoulder. Pathology related to glenohumeral instability is further described in terms of (1) the tissue avulsed, (2) the location of the avulsion and (3) the nature, location and size of the associated osseous injuries. The Bankart lesion represents avulsion of the IGHL off of the glenoid. Conversely, avulsions off of the humerus are referred to as humeral avulsion of the glenohumeral ligament (HAGL). In addition to capsuloligamentous injuries, associated osseous defects are divided into glenoid and humeral lesions. Osseous defects about the glenoid are further distinguished based on the presence or absence of fragments. Sugaya et al7Sugaya H Moriishi J Dohi M et al.Glenoid rim morphology in recurrent anterior glenohumeral instability.J Bone Joint Surg Am. 2003; 85-a: 878-884Crossref PubMed Scopus (553) Google Scholar demonstrated that in a consecutive series of 100 shoulders with recurrent, anterior dislocation, Bankart lesions were observed arthroscopically in 97% of cases and bony Bankart lesions were observed in 50% of cases. In a more recent review of 80 patients with recurrent anterior instability, d'Elia et al8d'Elia G Di Giacomo A D'Alessandro P et al.Traumatic anterior glenohumeral instability: quantification of glenoid bone loss by spiral CT.Radiol Med. 2008; 113: 496-50310.1007/s11547-008-0274-5Crossref PubMed Scopus (28) Google Scholar reported 64 patients (80%) were found to have glenoid lesions visualised on CT scans. The type and amount of glenoid bone loss has a marked effect on treatment approach and expected clinical outcomes (table 1). For cases of attritional bone loss comprising <20–25% of the glenoid measured using the best fit circle method, multiple authors have shown that arthroscopic procedures are effective at treating glenohumeral instability with recurrence rates ranging from 4.2% to 19%.9Robinson CM Jenkins PJ White TO et al.Primary arthroscopic stabilization for a first-time anterior dislocation of the shoulder. A randomized, double-blind trial.J Bone Joint Surg Am. 2008; 90: 708-72110.2106/JBJS.G.00679Crossref PubMed Scopus (148) Google Scholar, 10Brophy RH Marx RG The treatment of traumatic anterior instability of the shoulder: nonoperative and surgical treatment.Arthroscopy. 2009; 25: 298-30410.1016/j.arthro.2008.12.007Abstract Full Text Full Text PDF PubMed Scopus (160) Google Scholar, 11Chahal J Marks PH Macdonald PB et al.Anatomic Bankart repair compared with nonoperative treatment and/or arthroscopic lavage for first-time traumatic shoulder dislocation.Arthroscopy. 2012; 28: 565-57510.1016/j.arthro.2011.11.012Abstract Full Text Full Text PDF PubMed Scopus (62) Google Scholar, 12Milchteim C Tucker SA Nye DD et al.Outcomes of Bankart repairs using modern arthroscopic technique in an athletic population.Arthroscopy. 2016; 32: 1263-127010.1016/j.arthro.2016.01.025Abstract Full Text Full Text PDF PubMed Scopus (40) Google Scholar, 13Milano G Grasso A Russo A et al.Analysis of risk factors for glenoid bone defect in anterior shoulder instability.Am J Sports Med. 2011; 39: 1870-187610.1177/0363546511411699Crossref PubMed Scopus (86) Google Scholar, 14Kim SH Ha KI Cho YB et al.Arthroscopic anterior stabilization of the shoulder: two to six-year follow-up.J Bone Joint Surg Am. 2003; 85-a: 1511-1518Crossref PubMed Scopus (261) Google Scholar, 15Flinkkila T Hyvonen P Ohtonen P et al.Arthroscopic Bankart repair: results and risk factors of recurrence of instability.Knee Surg Sports Traumatol Arthrosc. 2010; 18: 1752-175810.1007/s00167-010-1105-5Crossref PubMed Scopus (81) Google Scholar, 16Porcellini G Campi F Pegreffi F et al.Predisposing factors for recurrent shoulder dislocation after arthroscopic treatment.J Bone Joint Surg Am. 2009; 91: 2537-254210.2106/JBJS.H.01126Crossref PubMed Scopus (181) Google Scholar With glenoid bone loss >25% of the inferior glenoid width, arthroscopic procedures alone have been associated with rates of recurrent instability as high as 67%.17Ahmed I Ashton F Robinson CM Arthroscopic Bankart repair and capsular shift for recurrent anterior shoulder instability: functional outcomes and identification of risk factors for recurrence.J Bone Joint Surg Am. 2012; 94: 1308-131510.2106/JBJS.J.01983Crossref PubMed Scopus (131) Google Scholar 18Burkhart SS De Beer JF Traumatic glenohumeral bone defects and their relationship to failure of arthroscopic Bankart repairs: significance of the inverted-pear glenoid and the humeral engaging Hill-Sachs lesion.Arthroscopy. 2000; 16: 677-69410.1053/jars.2000.17715Abstract Full Text Full Text PDF PubMed Scopus (1333) Google Scholar Burkhart and DeBeer were the first to describe the ‘inverted pear’ en face appearance of a glenoid, which lacks anteroinferior bone. This morphology was shown to be a risk factor for failure of arthroscopic stabilisation procedures.18Burkhart SS De Beer JF Traumatic glenohumeral bone defects and their relationship to failure of arthroscopic Bankart repairs: significance of the inverted-pear glenoid and the humeral engaging Hill-Sachs lesion.Arthroscopy. 2000; 16: 677-69410.1053/jars.2000.17715Abstract Full Text Full Text PDF PubMed Scopus (1333) Google Scholar The concept of a critical glenoid defect has subsequently been corroborated by several biomechanical studies, which have convincingly demonstrated that glenoid defects larger than 25% were significantly less stable following Bankart repair.19Yamamoto N Muraki T Sperling JW et al.Stabilizing mechanism in bone-grafting of a large glenoid defect.J Bone Joint Surg Am. 2010; 92: 2059-206610.2106/JBJS.I.00261Crossref PubMed Scopus (176) Google Scholar, 20Yamamoto N Itoi E Abe H et al.Effect of an anterior glenoid defect on anterior shoulder stability: a cadaveric study.Am J Sports Med. 2009; 37: 949-95410.1177/0363546508330139Crossref PubMed Scopus (238) Google Scholar, 21Itoi E Lee SB Berglund LJ et al.The effect of a glenoid defect on anteroinferior stability of the shoulder after Bankart repair: a cadaveric study.J Bone Joint Surg Am. 2000; 82: 35-46Abstract Full Text Full Text PDF PubMed Scopus (215) Google Scholar, 22Yamamoto A Massimini DF DiStefano J et al.Glenohumeral contact pressure with simulated anterior Labral and osseous defects in cadaveric shoulders before and after soft tissue repair.Am J Sports Med. 2014; 42: 1947-195410.1177/0363546514531905Crossref PubMed Scopus (25) Google Scholar In this setting of larger glenoid defects, bone grafting procedures are indicated, and the Latarjet procedure has been shown to confer stability through the combined ‘triple effect’ of increasing the articular congruence of the glenoid and bolstering the stiffness of the surrounding soft tissues.Table 1Commonly used outcome measures to characterize instability-related shoulder debilityOutcome measureDescriptionSelf administered?Minimal clinically important differenceConstant ScoreTwo components: Physical examination assessment (65 points; ROM and power), subjective assessment (35 points; pain, ADL)Maximum: 100 pointsNo10.4American Shoulder and Elbow Surgeons (ASES) ScoreTwo components: Visual analog pain and functional ability (Pain calculated by subtracting visual scale from 10 and multiplying by 5. Both components have a maximum score of 50 points)Maximum: 100 pointsYes6.4Simple Shoulder TestTwelve question questionnaire comprised of 12 yes/no questions (yes=1, no=0)Maximum: 12 pointsYes2.33Western Ontario Shoulder Instability Index (WOSI)Twenty one questions using 100 mm VAS response, 6 domains: physical symptoms (10 questions), sports and recreation, and work (4 questions), lifestyle (4 questions), and emotions (3 questions)Maximum: 100%Yes220Rowe ScoreTwo components: Physical examination assessment (ROM), subjective assessment (stability, function)Maximum: 100 pointsNoNot reportedWalch-Duplay ScoreFour components: Physical examination assessment (ROM), subjective assessment (daily activities, pain, stability)Maximum: 100 pointsNoNot reported Open table in a new tab Glenoid bone defects frequently do not occur in isolation, and compression fractures of the humeral head (Hill-Sachs (HS) lesions) are commonly observed in patients with recurrent instability. Furthermore, the role of humeral-sided bone defects in glenohumeral instability continues to be elucidated in biomechanical and clinical studies, as several authors have described the reciprocal pathomechanic relationship between these ‘bipolar’ lesions.18Burkhart SS De Beer JF Traumatic glenohumeral bone defects and their relationship to failure of arthroscopic Bankart repairs: significance of the inverted-pear glenoid and the humeral engaging Hill-Sachs lesion.Arthroscopy. 2000; 16: 677-69410.1053/jars.2000.17715Abstract Full Text Full Text PDF PubMed Scopus (1333) Google Scholar 23Boileau P Villalba M Hery JY et al.Risk factors for recurrence of shoulder instability after arthroscopic Bankart repair.J Bone Joint Surg Am. 2006; 88: 1755-176310.2106/JBJS.E.00817Crossref PubMed Scopus (745) Google Scholar HS lesions that engage the glenoid destabilise the shoulder through increasing degrees of abduction and external rotation. Itoi and associates expanded on the concept of HS lesion engagement by first proposing the concept of the ‘glenoid track’, which precisely defines the zone of contact between the glenoid and humeral head.19Yamamoto N Muraki T Sperling JW et al.Stabilizing mechanism in bone-grafting of a large glenoid defect.J Bone Joint Surg Am. 2010; 92: 2059-206610.2106/JBJS.I.00261Crossref PubMed Scopus (176) Google Scholar 24Itoi E Yamamoto N Kurokawa D et al.Bone loss in anterior instability.Curr Rev Musculoskelet Med. 2013; 6: 88-9410.1007/s12178-012-9154-7Crossref PubMed Scopus (50) Google Scholar, 25Yamamoto N Itoi E Abe H et al.Contact between the glenoid and the humeral head in abduction, external rotation, and horizontal extension: a new concept of glenoid track.J Shoulder Elbow Surg. 2007; 16: 649-65610.1016/j.jse.2006.12.012Abstract Full Text Full Text PDF PubMed Scopus (440) Google Scholar, 26Saito H Itoi E Sugaya H et al.Location of the glenoid defect in shoulders with recurrent anterior dislocation.Am J Sports Med. 2005; 33: 889-89310.1177/0363546504271521Crossref PubMed Scopus (187) Google Scholar As the shoulder is abducted and externally rotated, the contact area on the glenoid shifts from the inferomedial to superolateral surface of the posterior humeral articular surface. Using this model, the size and orientation of HS lesions are coupled with measurements of glenoid bone defects to predict the pathomechanical significance of humeral-sided defects. The relationship between concomitant glenoid and humeral head osseous defects—'bipolar bone loss'—has significantly improved contemporary understandings of recurrent glenohumeral instability. Burkhart and De Beer pioneered this concept, and Boileau and Balg devised an 'instability severity index score (ISIS)' that incorporated the concept of bipolar bone loss into a grading scheme to help guide treatment. These authors identified several risk factors, including age younger than 20 years, participation in competitive or contact sports, shoulder hypermobility and identifiable bone defects of either the humeral head or glenoid on plain radiographs, as predictors for failure of arthroscopic repair.27Balg F Boileau P The instability severity index score. A simple pre-operative score to select patients for arthroscopic or open shoulder stabilisation.J Bone Joint Surg Br. 2007; 89: 1470-147710.1302/0301-620X.89B11.18962Crossref PubMed Scopus (616) Google Scholar Box 1 provides a synopsis of several important patient-specific factors important to consider when evaluating patients with recurrent glenohumeral instability. Since the proposal of the ISIS, several important biomechanical and clinical studies have been published to validate the concept of bipolar bone loss and its effect on recurrent glenohumeral instability. Box 1Key issues of patient selection•Number of previous shoulder dislocations;•Estimation of time spent dislocated;•History of previous stabilisation procedures;•Sport-specific considerations: participation in collision sports, throwing athlete;•Precise measurements of: glenoid bone loss, glenoid track, Hill-Sachs lesion, Hill-Sachs interval. •Number of previous shoulder dislocations;•Estimation of time spent dislocated;•History of previous stabilisation procedures;•Sport-specific considerations: participation in collision sports, throwing athlete;•Precise measurements of: glenoid bone loss, glenoid track, Hill-Sachs lesion, Hill-Sachs interval. The purpose of this review is to provide an update on the salient issues in the surgical management of glenohumeral instability with a special focus on bone loss and an emphasis on a treatment paradigm that addresses bipolar bone defects. We present our view of the most important papers published on this topic (box 2) and a comprehensive treatment approach that defines the limits of arthroscopic stabilisation techniques and clarifies indications for open procedures. Box 2Top ten papers in glenohumeral instability•Burkhart and De Beer;18Burkhart SS De Beer JF Traumatic glenohumeral bone defects and their relationship to failure of arthroscopic Bankart repairs: significance of the inverted-pear glenoid and the humeral engaging Hill-Sachs lesion.Arthroscopy. 2000; 16: 677-69410.1053/jars.2000.17715Abstract Full Text Full Text PDF PubMed Scopus (1333) Google Scholar•Di Giacomo et al;55Di Giacomo G Itoi E Burkhart SS Evolving concept of bipolar bone loss and The Hill-Sachs lesion: from ‘engaging/non-engaging’ lesion to ‘on-track/off-track’ lesion.Arthroscopy. 2014; 30: 90-9810.1016/j.arthro.2013.10.004Abstract Full Text Full Text PDF PubMed Scopus (384) Google Scholar•Yamamoto et al;25Yamamoto N Itoi E Abe H et al.Contact between the glenoid and the humeral head in abduction, external rotation, and horizontal extension: a new concept of glenoid track.J Shoulder Elbow Surg. 2007; 16: 649-65610.1016/j.jse.2006.12.012Abstract Full Text Full Text PDF PubMed Scopus (440) Google Scholar•Balg and Boileau;27Balg F Boileau P The instability severity index score. A simple pre-operative score to select patients for arthroscopic or open shoulder stabilisation.J Bone Joint Surg Br. 2007; 89: 1470-147710.1302/0301-620X.89B11.18962Crossref PubMed Scopus (616) Google Scholar•Purchase et al;69Purchase RJ Wolf EM Hobgood ER et al.Hill-Sachs 'remplissage’: an arthroscopic solution for the engaging Hill-Sachs lesion.Arthroscopy. 2008; 24: 723-72610.1016/j.arthro.2008.03.015Abstract Full Text Full Text PDF PubMed Scopus (277) Google Scholar•Burkhart et al;65Burkhart SS Debeer JF Tehrany AM et al.Quantifying glenoid bone loss arthroscopically in shoulder instability.Arthroscopy. 2002; 18: 488-49110.1053/jars.2002.32212Abstract Full Text Full Text PDF PubMed Scopus (320) Google Scholar•Itoi et al;21Itoi E Lee SB Berglund LJ et al.The effect of a glenoid defect on anteroinferior stability of the shoulder after Bankart repair: a cadaveric study.J Bone Joint Surg Am. 2000; 82: 35-46Abstract Full Text Full Text PDF PubMed Scopus (215) Google Scholar•Burkhart et al;77Burkhart SS De Beer JF Barth JR et al.Results of modified Latarjet reconstruction in patients with anteroinferior instability and significant bone loss.Arthroscopy. 2007; 23: 1033-104110.1016/j.arthro.2007.08.009Abstract Full Text Full Text PDF PubMed Scopus (432) Google Scholar•Ghodadra et al;82Ghodadra N Gupta A Romeo AA et al.Normalization of glenohumeral articular contact pressures after Latarjet or iliac crest bone-grafting.J Bone Joint Surg Am. 2010; 92: 1478-148910.2106/JBJS.I.00220Crossref PubMed Scopus (152) Google Scholar•Hartzler et al.72Hartzler RU Bui CN Jeong WK et al.Remplissage of an Off-track Hill-Sachs lesion is necessary to restore biomechanical glenohumeral joint stability in a bipolar bone loss model.10.1016/j.arthro.2016.04.03010.1016/j.arthro.2016.04.030Google Scholar •Burkhart and De Beer;18Burkhart SS De Beer JF Traumatic glenohumeral bone defects and their relationship to failure of arthroscopic Bankart repairs: significance of the inverted-pear glenoid and the humeral engaging Hill-Sachs lesion.Arthroscopy. 2000; 16: 677-69410.1053/jars.2000.17715Abstract Full Text Full Text PDF PubMed Scopus (1333) Google Scholar•Di Giacomo et al;55Di Giacomo G Itoi E Burkhart SS Evolving concept of bipolar bone loss and The Hill-Sachs lesion: from ‘engaging/non-engaging’ lesion to ‘on-track/off-track’ lesion.Arthroscopy. 2014; 30: 90-9810.1016/j.arthro.2013.10.004Abstract Full Text Full Text PDF PubMed Scopus (384) Google Scholar•Yamamoto et al;25Yamamoto N Itoi E Abe H et al.Contact between the glenoid and the humeral head in abduction, external rotation, and horizontal extension: a new concept of glenoid track.J Shoulder Elbow Surg. 2007; 16: 649-65610.1016/j.jse.2006.12.012Abstract Full Text Full Text PDF PubMed Scopus (440) Google Scholar•Balg and Boileau;27Balg F Boileau P The instability severity index score. A simple pre-operative score to select patients for arthroscopic or open shoulder stabilisation.J Bone Joint Surg Br. 2007; 89: 1470-147710.1302/0301-620X.89B11.18962Crossref PubMed Scopus (616) Google Scholar•Purchase et al;69Purchase RJ Wolf EM Hobgood ER et al.Hill-Sachs 'remplissage’: an arthroscopic solution for the engaging Hill-Sachs lesion.Arthroscopy. 2008; 24: 723-72610.1016/j.arthro.2008.03.015Abstract Full Text Full Text PDF PubMed Scopus (277) Google Scholar•Burkhart et al;65Burkhart SS Debeer JF Tehrany AM et al.Quantifying glenoid bone loss arthroscopically in shoulder instability.Arthroscopy. 2002; 18: 488-49110.1053/jars.2002.32212Abstract Full Text Full Text PDF PubMed Scopus (320) Google Scholar•Itoi et al;21Itoi E Lee SB Berglund LJ et al.The effect of a glenoid defect on anteroinferior stability of the shoulder after Bankart repair: a cadaveric study.J Bone Joint Surg Am. 2000; 82: 35-46Abstract Full Text Full Text PDF PubMed Scopus (215) Google Scholar•Burkhart et al;77Burkhart SS De Beer JF Barth JR et al.Results of modified Latarjet reconstruction in patients with anteroinferior instability and significant bone loss.Arthroscopy. 2007; 23: 1033-104110.1016/j.arthro.2007.08.009Abstract Full Text Full Text PDF PubMed Scopus (432) Google Scholar•Ghodadra et al;82Ghodadra N Gupta A Romeo AA et al.Normalization of glenohumeral articular contact pressures after Latarjet or iliac crest bone-grafting.J Bone Joint Surg Am. 2010; 92: 1478-148910.2106/JBJS.I.00220Crossref PubMed Scopus (152) Google Scholar•Hartzler et al.72Hartzler RU Bui CN Jeong WK et al.Remplissage of an Off-track Hill-Sachs lesion is necessary to restore biomechanical glenohumeral joint stability in a bipolar bone loss model.10.1016/j.arthro.2016.04.03010.1016/j.arthro.2016.04.030Google Scholar The success of arthroscopic treatment of glenohumeral instability has been well established in scenarios involving minimal glenoid bone loss. However, high-quality prospective clinical trials are generally lacking. In a large systematic review encompassing the results of 1781 patients with a mean follow-up of 11 years, Harris et al28Harris JD Gupta AK Mall NA et al.Long-term outcomes after Bankart shoulder stabilization.Arthroscopy. 2013; 29: 920-93310.1016/j.arthro.2012.11.010Abstract Full Text Full Text PDF PubMed Scopus (195) Google Scholar reported the overall recurrence rate of 8% and 11% for open and arthroscopic procedures, respectively, which was not a significant discrepancy between cohorts (p=0.06). It should be noted that these authors commented on the overall poor methodological quality of the 26 studies included in their review. While this review was unable to clearly identify the superiority of arthroscopic stabilisation techniques, several other recent reports have demonstrated excellent clinical outcomes among patient populations at high risk for recurrent instability. Andrews and associates reported on a series of 94 shoulders that underwent either primary or revision arthroscopic Bankart repairs using bioabsorbable anchors at a mean follow-up of 5 years (range: 3–8.3 years). Among these patients, 82.5% were able to return to preinjury levels of sport participation and 6% experienced recurrence. Interestingly, zero recurrences were observed among professional and collegiate athletes, whereas participation in either recreational or high school athletes was a significant risk factor for recurrent instability following arthroscopic Bankart repair.29Milchteim C Tucker SA Nye DD et al.Outcomes of Bankart repairs using modern arthroscopic technique in an athletic population.Arthroscopy. 2016; 32: 1263-127010.1016/j.arthro.2016.01.025Abstract Full Text Full Text PDF PubMed Scopus (44) Google Scholar Similarly, Waterman et al showed the success of arthroscopic Bankart repair among a cohort of 3854 Active Duty military members. Overall, 193 patients underwent revision stabilisation, and these authors observed a lower rate of recurrence in those patients treated with arthroscopic versus open stabilisation procedures (4.5% vs 7.7%, p=0.001).30Waterman BR Burns TC McCriskin B et al.Outcomes after bankart repair in a military population: predictors for surgical revision and long-term disability.Arthroscopy. 2014; 30: 172-17710.1016/j.arthro.2013.11.004Abstract Full Text Full Text PDF PubMed Scopus (47) Google Scholar Arthroscopic techniques for addressing instability in the setting of minimal glenoid bone loss continue to be refined. Several authors have described techniques for addressing displaced anterior glenoid rim fractures that are potentially repairable, commonly referred to as ‘bony Bankart’ lesions. These lesions are common, with the prevalence reported to be as high as 50% of shoulders with instability events7Sugaya H Moriishi J Dohi M et al.Glenoid rim morphology in recurrent anterior glenohumeral instability.J Bone Joint Surg Am. 2003; 85-a: 878-884Crossref PubMed Scopus (553) Google Scholar 31Mologne TS Provencher MT Menzel KA et al.Arthroscopic stabilization in patients with an inverted pear glenoid: results in patients with bone loss of the anterior glenoid.Am J Sports Med. 2007; 35: 1276-128310.1177/0363546507300262Crossref PubMed Scopus (196) Google Scholar (figure 1). Describing an all-arthroscopic technique for fixing large anterior glenoid rim fractures, Sugaya et al32Sugaya H Moriishi J Kanisawa I et al.Arthroscopic osseous Bankart repair for chronic recurrent traumatic anterior glenohumeral instability. Surgical technique.J Bone Joint Surg Am. 2006; 88: 159-169Crossref PubMed Google Scholar reported good-to-excellent clinical outcomes among a series of 42 patients with fracture fragments encompassing a mean 9.2% of the glenoid fossa. This technique involved the passage of sutures through and/or around the bony fragment and fixation with using one or two suture anchors. Millett et al have described a modified technique for addressing the bony Bankart lesion, which utilises two points of fixation so as to compress the fragment against the anterior glenoid. In this technique, a suture anchor is first placed medial to the fragment on the anterior aspect of the glenoid. Next, the sutures are passed through the tissues attached to the bony Bankart fragment, spanning the fragment and are then fed into a bioabsorable anchor, which is placed on the glenoid face at the chondral-fracture margin.3" @default.
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• W2560640476 title "Shoulder instability: State of the Art" @default.
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