Current concepts in the management of recurrent anterior gleno-humeral joint instability with bone loss

Abstract

The management of recurrent anterior gleno-humeral joint instability is challenging in the presence of bone loss. It is often seen in young athletic patients and dislocations related to epileptic seizures and may involve glenoid bone deficiency, humeral bone deficiency or combined bipolar lesions. It is critical to accurately identify and assess the amount and position of bone loss in order to select the most appropriate treatment and reduce the risk of recurrent instability after surgery. The current literature suggests that coracoid and iliac crest bone block transfers are reliable for treating glenoid defects. The treatment of humeral defects is more controversial, however, although good early results have been reported after arthroscopic Remplissage for small defects. Larger humeral defects may require complex reconstruction or partial resurfacing. There is currently very limited evidence to support treatment strategies when dealing with bipolar lesions. The aim of this review is to summarise the current evidence regarding the best imaging modalities and treatment strategies in managing this complex problem relating particularly to contact athletes and dislocations related to epileptic seizures.

Keywords: Bone loss; Hill-Sachs lesion; Latarjet; Remplissage; Shoulder dislocation.

Figure 1

Management of glenoid and humeral bone loss in shoulder instability. ISIS: Instability severity index score; ORIF: Open reduction and internal fixation; pt: Patient.

Figure 2

45-year-old gentleman with previous open latarjet procedure for left shoulder instability. Subsequent non-union of graft and failure of metalwork is seen on the axillary (A) and antero-posterior (B) radiographs.

Figure 3

Failed latarjet procedure in Figure 1 treated with an Eden Hybinette procedure using an autologous iliac crest bone graft. The graft position and fixation with 2 screws is shown on the antero-posterior radiograph.

Figure 4

Antero-posterior radiograph (A) and computed tomography scan (B) of a 25-year-old epileptic with massive bipolar bone loss. He was found to have > 25% glenoid bone loss and > 40% humeral bone loss pre-operatively.

Figure 5

Antero-posterior (A) and scapular Y (B) views of an epileptic patient with massive bipolar bone loss treated with a humeral HemiCap and Latarjet procedure.

Figure 6

42-year-old manual worker with anterior shoulder instability with < 25% glenoid bone loss and an engaging Hill-Sachs lesion. He was managed successfully with an arthroscopic Remplissage and Bankart repair. Pre-operative antero-posterior radiographs (A) and computed tomography (B) images are demonstrated.

Figure 7

Antero-posterior (A) and axillary view (B) radiographs six months following shoulder fusion after failure of a combined HemiCap and Latarjet procedure in an epileptic patient with massive bipolar bone loss.