AANA25 Shoulder Access Pass-GENERAL SESSION: Shoulder Instability, Catch It Before Critical Bone Loss (Main Stage)

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Video Summary

The session on shoulder instability, moderated by Dr. John Tokasch, focused on the critical issue of bone loss and its impact on surgical outcomes for anterior shoulder instability. Historical context revealed early recognition of bone loss in the shoulder but delayed consensus on its critical threshold until recent decades. Critical bone loss, originally defined around 20-25% glenoid defect, leads to high failure rates in arthroscopic Bankart repairs, especially in contact athletes.<br /><br />Recent research introduced "subcritical" bone loss (~13.5%), which correlates with poor patient outcomes even without dislocation recurrence, emphasizing the need to consider more nuanced parameters beyond recurrence rates. The concept of “on-track” and “off-track” lesions, especially incorporating the humeral side Hill-Sachs lesion, further refined surgical decision-making. Off-track lesions show very high failure rates with Bankart repair alone, necessitating alternative strategies.<br /><br />Presentations highlighted the protective role of remplissage — a capsulotenodesis procedure addressing the Hill-Sachs lesion — significantly reducing recurrence for critical humeral bone loss when combined with Bankart repairs. Randomized trials comparing arthroscopic anatomic glenoid reconstruction (AAGR) to Bankart repair showed AAGR to have similar safety but lower recurrence and better graft integration. Experts agreed remplissage is effective with minimal complications and should be added routinely with Bankart repair in appropriate cases, though large lesions may require bony augmentation such as Latarjet or distal tibial allograft.<br /><br />Panel discussions emphasized tailoring surgery based on bone loss extent, patient factors, and lesion tracking; remplissage addresses humeral defects arthroscopically with low morbidity, while large bipolar bone loss calls for bone grafting. Complex cases with recurrent instability after prior surgery often require combined bone procedures and remplissage. Overall, a progressive algorithm respects bone loss thresholds to optimize stability and function, balancing arthroscopic approaches and bony reconstructions as needed.

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Keywords

shoulder instability

bone loss

anterior shoulder instability

Bankart repair

critical bone loss

subcritical bone loss

on-track lesions

off-track lesions

Hill-Sachs lesion

remplissage

arthroscopic anatomic glenoid reconstruction