AANA24 Shoulder All-Access Pass-CONCURRENT SCIENTIFIC SESSION 2E: Shoulder Instability

Video Transcription

Video Summary

The session opened with a comprehensive discussion on glenoid bone loss in shoulder instability, emphasizing the importance of accurate measurement—ideally using the best fit circle method—since visual estimation often underdetects significant bone loss. Imaging techniques like MRI and CT are both useful, with CT currently holding greater value despite advancements in MRI sequences. Clinically, as little as 10-15% glenoid bone loss impacts stability, especially when considered alongside humeral bone loss in the bipolar "glenoid track" concept.<br /><br />The biphasic nature of shoulder instability was highlighted by Drew Lansdowne, who discussed Hill-Sachs lesions on the humeral head. These lesions are common in dislocation and affect stability proportionally to size and location. Combining Bankart repair with remplissage has demonstrated improved outcomes and reduced recurrence, supporting remplissage as a routine adjunct, especially for off-track or near-track lesions.<br /><br />A debate on surgical positioning followed, contrasting beach chair versus lateral decubitus positions. Both showed similar recurrence rates, with surgeon preference influenced by technical considerations and access to inferior glenoid regions. Knot-tying techniques in arthroscopic repairs were also debated; knotted repairs may offer better capsular shift and tension control but increase knot burden, while knotless anchors reduce complications and operative time, showing promising clinical outcomes.<br /><br />Management of failed instability surgeries was reviewed through surveys from Brazil and Spain, indicating a preference for bone block procedures like open Latarjet in failures, particularly with bone loss. Various graft options—iliac crest autograft, distal tibial allograft, distal clavicle autograft, and scapular spine autograft—were assessed, each with pros and cons including donor site morbidity and graft resorption.<br /><br />The central case debate on a young athlete with failed arthroscopic Bankart and 14% glenoid bone loss contrasted revision arthroscopic Bankart with remplissage, open Bankart repair with capsular shift, distal tibial allograft reconstruction, and Latarjet procedure. Evidence favored Latarjet for revision in contact athletes with bone loss due to low recurrence and durability, despite technical challenges and potential complications.<br /><br />Advancements in arthroscopic bone block fixation were discussed, with screw fixation currently standard, offering superior mechanical stability compared to suture buttons and cerclage, although all techniques showed varied outcomes.<br /><br />Emerging innovations included the use of xenografts (equine bone blocks) combined with subscapularis augmentation, showing promising graft incorporation without resorption over mid-term follow-up and theoretical advantages in restoring both bone and soft tissue integrity.<br /><br />In summary, the management of shoulder instability with glenoid and humeral bone loss increasingly relies on precise imaging and measurement, understanding bipolar lesions, and individualized surgical approaches balancing defect size, patient factors, and surgical expertise. Traditional open procedures, particularly Latarjet, remain gold standard for revision cases with bone loss, while arthroscopic techniques, knotless anchors, and novel graft options show evolving promise for improved outcomes.

Asset Caption

Introduction by Moderators: Matthew J. Salzler, M.D., FAANA, Ian K.Y. Lo, M.D., F.R.C.S.C.

Keywords

glenoid bone loss

shoulder instability

best fit circle method

MRI imaging

CT imaging

glenoid track concept

Hill-Sachs lesions

Bankart repair

remplissage technique

beach chair position

lateral decubitus position

knot-tying techniques

open Latarjet procedure

iliac crest autograft

xenograft equine bone block