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Current Concepts

Bony Instability of the Shoulder

Brandon D. Bushnell, M.D., R. Alexander Creighton, M.D., and Marion M. Herring, M.D.

Abstract: Instability of the shoulder is a common problem treated by many orthopaedists. Instabilitycan result from baseline intrinsic ligamentous laxity or a traumatic event—often a dislocation thatinjures the stabilizing structures of the glenohumeral joint. Many cases involve soft-tissue injury onlyand can be treated successfully with repair of the labrum and ligamentous tissues. Both open andarthroscopic approaches have been well described, with recent studies of arthroscopic soft-tissuetechniques reporting results equal to those of the more traditional open techniques. Over the lastdecade, attention has focused on the concept of instability of the shoulder mediated by bonypathology such as a large bony Bankart lesion or an engaging Hill-Sachs lesion. Recent literature hasidentified unrecognized large bony lesions as a primary cause of failure of arthroscopic reconstructionfor instability, a major cause of recurrent instability, and a difficult diagnosis to make. Thus, althoughsuch bony lesions may be relatively rare compared with soft-tissue pathology, they constitute acritically important entity in the management of shoulder instability. Smaller bony lesions may beamenable to arthroscopic treatment, but larger lesions often require open surgery to prevent recurrentinstability. This article reviews recent developments in the diagnosis and treatment of bony insta-bility. Key Words: Instability—Shoulder—Glenoid—Bankart—Hill-Sachs—Insufficiency.

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he shoulder is, by design, one of the most mobile andeast constrained joints in the body.1 This lack ofnatomic constraint enables the shoulder to have aignificant range of motion in multiple planes, but itlso sets the stage for pathologic instability. The sta-ilizing forces of the shoulder can be divided intotatic constraints and dynamic constraints.2 Static con-traints include the glenoid labrum, the joint capsule,he coracohumeral arch, and the glenohumeral liga-

ents.2,3 Dynamic stabilizers include the rotator cuffith its “compression concavity” mechanism, the del-

From the Steadman-Hawkins Clinic (B.D.B.), Denver, Colorado,epartment of Orthopaedic Surgery, University of North Caro-

ina Hospitals (R.A.C.), Chapel Hill, North Carolina, and Ad-anced Orthopaedic Centers (M.M.H.), Richmond, Virginia,.S.A.The authors report no conflict of interest.Address correspondence and reprint requests to Brandon D.

ushnell, M.D., 8200 East Belleview Ave, Suite 615, Greenwoodillage, CO 80111, U.S.A. E-mail: [email protected]© 2008 by the Arthroscopy Association of North America

a0749-8063/08/2409-8137$34.00/0doi:10.1016/j.arthro.2008.05.015

Arthroscopy: The Journal of Arthroscopic and Related Surg

oid, the biceps, and other periscapular muscles.1,2,4

he specific contributors to the stability of the shoul-er at any given moment vary widely by the exactosition of the arm and constitute a complex interac-ion of forces that is beyond the scope of this article.n any case, however, the foundation of stability be-ins with the bony structure of the glenoid and theumerus, and compromise of this foundation can leado significant problems.

DIAGNOSIS

istory and Physical Examination

In a patient with bony instability, several features ofhe history and physical examination often set thempart from other cases of instability. The first keyeature of the history is the ease and frequency ofislocation of the shoulder. Patients may describeislocation events associated with various activities ofaily living or even during sleep and often with therm in a position of much lower degrees of abduction
nd external rotation than the well-described “position
1061ery, Vol 24, No 9 (September), 2008: pp 1061-1073

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1062 BONY INSTABILITY OF SHOULDER

f athletic function” at 90° of abduction and 90° ofxternal rotation.5,6 Multiple dislocation events areften reported, with some patients even describinghundreds” of episodes in a short period of time. Theecond key feature is a past traumatic event involvinghe shoulder, often higher energy and usually requir-ng medical treatment for reduction. The third keyeature is one of a prior surgical intervention. Bonynstability has been identified as the primary cause ofailed arthroscopic reconstruction,7,8 and thus ithould sit atop the differential in cases of symptomaticnstability after surgery. Obviously, not all patientsith bony instability will have had prior surgery, and

hus surgeons should keep bony instability in mind inrimary cases as well. Despite these “warning signs”n the history, bony instability may also be deceptivelyimilar to ligamentous instability, with complaints suchs a “dead arm,” decreased strength or athletic perfor-ance, or nonspecific pain dominating the history.The physical examination begins with inspection

or prior scars, atrophy, or deformity. Then, a com-arative analysis of range of motion, strength, andeurovascular status of both upper extremities is com-leted. Asymmetric active or passive motion couldndicate an imbalance of the anterior and posteriorapsule or prior shortening or imbrication of the sub-

TABLE 1. Description of Special Tests f

Test

nteriorapprehension test

The arm is placed into a position of 90°positive if the patient reports a feelingbe performed in a upright or supine p

elocation test After a positive apprehension test, a posthe glenoid fossa. The relocation testinstability.

nterior release(“surprise”) test

After a positive anterior relocation test,positive if the pain or apprehension re

nterior drawer test With the patient supine, the arm is placexaminer stabilizes the scapula, appliehumeral head over the glenoid rim wthat re-creates symptoms is considere

osterior drawertest

With the patient supine, the elbow is fleVarious degrees of abduction have bestabilizes the scapula, flexes the arm,pressure to the humeral head in an atthe glenoid rim that re-creates sympto

oad-and-shift test With the patient upright, the arm is placrotation. The examiner then grasps thanterior and posterior translational for

ony apprehensiontest

The arm is placed into a position of 45°“standard” apprehension test. The testsubluxation of the shoulder. This test

capularis from a previous procedure. Particular atten- r

ion should be paid to the status of the rotator cuff—specially the subscapularis—as well as the bicepsendon, both of which may be injured in an anteriorislocation event.Multiple testing maneuvers may then be used to

solate instability as the primary problem (Table 1).9-12

n particular, the bony apprehension test has beenescribed as a specific means of screening for osse-us-mediated instability.13,14 It involves testing forpprehension at the lower position of 45° of abductionnd 45° of external rotation, rather than the standardpprehension position of 90°/90° (Fig 1). With all ofhese tests, the patient’s sense of apprehension—ather than pain—should be used as a positive result toncrease the reliability of the examination.9,15

In every case involving surgery, the operative pro-edure should always include a physical examinationnder anesthesia.4 This is a comprehensive analysis ofhe shoulder in which the patient’s pain, volitional con-rol, and dynamic stabilizers are removed as variables inhe assessment of instability. The physician can performcomparative evaluation of motion, which provides fur-

her information about the amount of laxity, subscapu-aris contracture, and the presence of bony crepitation orclunks” that may indicate bony lesions. The position ofngagement, subluxation/locking, and relocation can be

gnosis of Shoulder Instability1,9,11-16,79-81

Description

uction, 90° of external rotation, and slight extension. The test ispending dislocation or subluxation of the shoulder. This test can.

directed force is applied to the humeral head to relocate it intotive if the posteriorly directed force relieves the pain or sense of

teriorly directed force is suddenly released. The release test is

a position of 60° to 80° of abduction and 0° of rotation. Theght axial load, controls the arm, and attempts to translate thenteriorly directed force. Subluxation beyond the glenoid rimitive test.120° and the arm is placed into 20° to 30° of forward flexion.

cribed in different modifications of this test. The examiner theninternally rotates the arm, and applies a posteriorly directed

o translate it over the posterior glenoid rim. Subluxation beyondconsidered a positive test.

a position of slight abduction and forward flexion and neutralmal humerus and applies a slight axial load, followed bygnificant translation can indicate possible instability.uction and 45° of external rotation—notably lower than the

itive if the patient reports a feeling of impending dislocation orperformed in an upright or supine position.

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ny discomfort for the patient. The examination undernesthesia also represents the final opportunity to maker change a diagnosis before beginning an actual surgicalrocedure.

adiographic Workup

Every patient should receive a radiographic “insta-ility series” consisting of a true anteroposteriorGrashey) view, internal and external rotation views, acapular Y view, an axillary lateral view, and an apicalblique (Garth) view.16,17 The West Point and Strykerotch views can also provide detail about bony defor-ity and may be obtained if desired.18 Sometimes,

lain radiography alone is sufficient to identify a bony

IGURE 1. Bony apprehension test. (A) The standard apprehen-ion test is performed with the arm at a position of 90° of abductionnd 90° of external rotation. (B) The bony apprehension test, whichcreens for instability mediated by a bony lesion, is performed withhe arm at a position of 45° of abduction and 45° of externalotation.13,14

esion and permit adequate planning of treatment. In c

any cases, however, plain radiographs will not leado an accurate diagnosis. A recent study identified thatlmost 60% of operative bony lesions were missed bylain radiographs alone.13

Cases with a negative instability series but a historynd physical examination concerning for possibleony instability should therefore undergo cross-sec-ional imaging with either computed tomography oragnetic resonance imaging (or both) to identify and

uantify bone loss.19,20 Unless a contraindication tooint injection exists, these modalities should be usedlong with arthrography to increase the sensitivity ofhe study.21-23 Cross-sectional imaging should includeoronal, axial, and oblique sagittal cuts to evaluatehe glenoid and the humerus appropriately. Evenf the plain radiographs are positive for a bony lesion,he surgeon may elect to order advanced imaging toetter characterize the size, location, and extent of theesion and to rule out additional pathology such asotator cuff tears, labral tears, biceps tendon injury,igamentous disruption, and other problems. Dynamicmaging (i.e., with the arm in a symptomatic position)ay be considered, but it has not been established as

uperior to standard positioning.A recent study described the use of the radiographic

lenoid index in determining the need for bone graft inhoulder instability. By use of 3-dimensional com-uted tomography scans of both shoulders, the glenoidndex is calculated as the maximum inferior diameterf the injured glenoid relative to the maximum inferioriameter of the uninjured glenoid. A glenoid index of.75 was found to be predictive of the need for a bonerafting procedure.24

rthroscopic Diagnosis

Although the diagnosis of bony instability shouldopefully be made before any surgical intervention, itas been well established as an entity that is quite easyo miss.7,8 In every case of shoulder arthroscopy foriagnostic purposes and for treatment of instability,he surgeon should thus specifically seek to rule out aony lesion as a possible cause of the problem. If openurgery is already planned, the surgeon should stillonsider a diagnostic arthroscopy before proceedingith open surgery,25 because certain areas of the

houlder (especially posteriorly) may be better visu-lized with arthroscopy than with certain open ap-roaches—and the arthroscopic findings may alter thehoice of open approach. The surgeon may also en-
ounter unexpected additional pathology (such as

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oose bodies, SLAP tears, cuff tendon injuries, andhondromalacia) requiring arthroscopic treatment.25,26

Posterior bone loss from the glenoid and a standardill-Sachs lesion of the humerus can be seen with the

rthroscope in the standard posterior viewing por-al.27,28 Anterior bone loss from the glenoid (bonyankart lesion) and a reverse Hill-Sachs lesion areetter seen by use of an anterior viewing portal throughhe rotator interval.16 The glenoid bare spot has beenescribed as a reference marker to assess the percentagef bone loss from the glenoid,29,30 and its use has beenalidated in several subsequent studies.28,31,32 If a Hill-achs lesion is identified, a dynamic examinationhould be performed in which the shoulder is broughthrough a full range of motion to screen for “engage-ent” of the defect with the rim of the glenoid and the

xact position of engagement noted.7

TYPES OF BONY LESIONS

Bony instability lesions can be generally groupedccording to the direction of bone loss (anterior orosterior) and the involved bone (glenoid or hu-erus). In several cases both bones may be in-

olved—usually on opposite sides (i.e., anterior gle-oid with posterior humerus and vice versa).

lenoid

Lesions of the anterior glenoid are the most com-on reason for bony instability of the shoulder.33 In

923 Bankart34 described an avulsion of the capsulo-abral complex of the anteroinferior glenoid rim.35

he lesion, which now bears his name, usually occurss a result of an anterior shoulder dislocation. Whenn osseous fragment is also involved in this avulsion,t is commonly called a bony Bankart lesion. Cases ofarge bony Bankart lesions have been referred to as annverted-pear glenoid because the affected glenoid inhe en face oblique plane is wider superiorly thannferiorly (Fig 2).7 Like a golf ball attempting to restn a broken tee, the resistance to excessive anteriorranslation of the humeral head is obviously compro-ised when a significant amount of bone is destabi-

ized or missing from the glenoid. Some controversyoes exist about just how much bone loss is requiredo deem a lesion “significant” (Table 2), but mostources fall between 20% and 30%. The balance sta-ility angle has also been described to help quantifyhis loss of stability secondary to bone loss.36

Because of differences in treatment options for each
ntity, a distinction should be made between attri- m
ional bone loss of the glenoid, a bony Bankart lesionr rim avulsion, and a frank glenoid fracture. Attri-ional bone loss may represent a prior bony Bankartesion with subsequent resorption of the bony frag-ent.8,37 Congenital glenoid dysplasia or hypoplasia

IGURE 2. Inverted-pear glenoid concept. In this oblique sagittalomputed tomography image, the superior portion of the glenoid isider than the inferior portion of the glenoid (A), giving it an

ppearance like an actual inverted pear (B).85

ay also be present in cases of bony instability and

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as been described as a loss of depth or an atrophicosterior and inferior wall—making it more likely aontributor in situations of posterior instability.1,38-40

Lesions of the posterior glenoid are less commonhan lesions of the anterior glenoid and are usuallyssociated with a history of a distinct traumatic eventith a posterior dislocation.27 Nevertheless, the samerinciples of bony stability apply in that the humeralead lacks bony resistance to posterior translation.he amount of osseous insufficiency needed for insta-ility has not been studied as much as that for thenterior glenoid, but some reports in the literatureave cited various guidelines for “significant” boneoss (Table 2). These lesions can prove more difficulto treat if not recognized before surgery, because theyften require a posterior approach for access.

umerus

A Hill-Sachs lesion is an impression fracture of theosterosuperolateral humeral head, named for Hill andachs,41 who described it in 1940. This entity canccur with any dislocation event wherein the soft bone

TABLE 2. Significant Sizes

Author Year Size Study Details

lenoid defectsBigliani et al.82 1998 25% ClinicalBurkhart and

De Beer7

2000 25%/6 mm Clinical

Itoi et al.83 2000 21% BiomechanicalBurkhart et al.30 2002 25% BiomechanicalGreis et al.84 2002 30% BiomechanicalPorcellini et al.57 2002 25% ClinicalLo et al.85 2004 25% Clinical/

biomechanicalTauber et al.8 2004 5 mm ClinicalChen et al.33 2005 20% ReviewSugaya et al.47 2005 25% ClinicalBahk et al.1 2007 20% ReviewBurkhart29 2007 25% ClinicalMologne et al.46 2007 20% ClinicalAuffarth et al.62 2008 25% Clinical

umeral head defectsGerber and

Lambert70

1996 40% Clinical

Miniaci and Gish6 2004 25% ClinicalChen et al.33 2005 20% ReviewMillett et al.86 2005 20%-30% ReviewBock et al.65 2007 30% ClinicalRaiss et al.78 2008 21% Clinical

NOTE. Selected articles and their recommendations about whatize defect constitutes one “significant” enough to indicate treat-ent with bony reconstruction surgery are listed.

f the humeral head impacts against the harder,ia

harper edge of the glenoid (Fig 3). Its incidence haseen estimated at 47% to 80% in anterior shoulderislocation cases and up to 100% in cases of recurrentnstability.33,42-44 A reverse Hill-Sachs lesion is anmpression fracture of the humeral head that occurs onhe anterior aspect of the bone, usually in cases ofosterior shoulder dislocation.27

IGURE 3. Etiology of Hill-Sachs lesions. (A) A Hill-Sachs lesions created when a dislocation event causes the soft bone of theosterosuperolateral humeral head to impinge against the hard edgef the anterior glenoid rim. A reverse Hill-Sachs lesion occurs viahe same mechanism but with a posterior dislocation event.Adapted with permission.7) (B) An axial computed tomography
mage shows both a reverse Hill-Sachs lesion of the humeral headnd significant posterior glenoid bone loss.

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Although a Hill-Sachs or reverse Hill-Sachs lesionay be present in many cases of instability, it is

ritical to determine whether the lesion is actuallyontributing to the instability. First, the size of theesion should be determined by both radiographic andrthroscopic measurements. As with glenoid boneoss, controversy exists about the range of “signifi-ance” of size (Table 2). Second is the concept ofngagement, described by Burkhart and De Beer7 as aesion “that presents the long axis of its defect parallelo the anterior glenoid with the shoulder in a func-ional position of abduction and external rotation, sohat the Hill-Sachs lesion engages the corner of thelenoid” (Fig 4). Identification of an “engaging” le-ion is a dynamic process that requires physical ex-mination and often diagnostic arthroscopy to fullyvaluate the contribution of the humeral lesion to thenstability of the shoulder.

TREATMENT OPTIONS

Nonoperative treatment of bony instability is notecommended. Bony lesions associated with instabil-ty represent a significant compromise of the founda-ional structure of the shoulder and generally will notmprove without surgical intervention. Maquieira etl.45 have reported successful nonoperative treatmentf large anterior glenoid fractures, but these cases didot involve symptomatic instability. Although somell-arthroscopic procedures addressing bony lesionsave been described,46-53 most situations of bony in-tability require full open reconstruction or “hybrid”echniques combining arthroscopic and open por-ions.16,50 Balg and Boileau54 have described an insta-ility severity index score to help the surgeon decideetween arthroscopic and open approaches by screen-ng for patients with a high probability for failure ofrthroscopic surgery (Table 3). The heart of any treat-ent plan centers on adequate recognition of the in-

olved bony lesions and stable reconstruction of theony architecture supporting the joint.

pproaches

The standard anterior deltopectoral interval can besed to address pathology in the anterior portion of thehoulder, such as bony Bankart lesions, glenoid frac-ures, and reverse Hill-Sachs lesions. This interval canlso be used to address a standard Hill-Sachs lesion,ut it requires extensive takedown of multiple struc-ures (including the subscapularis, biceps, rotator in-
erval, and sometimes even part of the deltoid), forces n
xcessive rotation of the humerus, and does not pro-ide the best visualization or access.16 In addition,ignificant fatty atrophy of the subscapularis has been

IGURE 4. Engaging Hill-Sachs lesion. A Hill-Sachs lesionA) “engages” the glenoid rim in a functional position of abductionnd external rotation (B), thereby contributing to the instability ofhe shoulder. (Adapted with permission.7)

oted in cases in which the subscapularis was taken

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own again for revision surgery.55 A posterior approachan therefore be used to address posterior pathology,ncluding Hill-Sachs lesions and posterior glenoid insuf-ciency or fracture. Various posterior approach tech-iques have been described, including minimally in-asive approaches that involve splitting the deltoidnd the infraspinatus muscles.16,56 Finally, a hybridpproach combining arthroscopy for 1 lesion and anpen approach for another, such as a soft-tissue Ban-art lesion in conjunction with an engaging Hill-Sachsesion, may also be used.16

lenoid

Fractures of the glenoid may be treated with openeduction and internal fixation if identified early and ifurgery is indicated for the fracture pattern (Table 4).cute bony Bankart lesions with a small fragment andlenoid loss not meeting the size parameters for “sig-ificant” may be addressed with arthroscopic or openepair, with recent arthroscopic series reporting resultsimilar to open techniques.57 Cases of delayed diag-osis, “significant” bone loss, and/or attritional loss ofone, however, usually require a bony reconstructionechnique from 1 of 2 major categories: coracoid

TABLE 3. Instability Severity Index Score

Prognostic Factor Points

ge at surgery�20 yrs 2�20 yrs 0

egree of sport participation (preoperative)Competitive 2Recreational or none 0

ype of sport (preoperative)Contact or forced overhead 1Other 0

houlder hyperlaxityAnterior or inferior hyperlaxity 1Normal laxity 0

ill-Sachs on anteroposterior radiographVisible in external rotation 2Not visible in external rotation 0

lenoid loss of contour on anteroposterior radiographLoss of contour 2No lesion 0

otal (points) 10

NOTE. A score of greater than 6 had at least a 70% risk ofecurrence after arthroscopic Bankart repair. The instability sever-ty index score is based on a preoperative questionnaire, clinicalxamination, and radiographs. (Reproduced with permission andopyright © of the British Editorial Society of Bone and Jointurgery.54)

ransfer and iliac crest grafting.

Several procedures have been described to provideony stability to the deficient glenoid via a localransfer of part of the coracoid process to the anteriorlenoid rim. The Bristow procedure involves transferf the tip of the coracoid to the glenoid and functionss a bone block to stabilize anterior translation (Fig 5).ultiple studies have reported successful results with

ts use in recurrent instability.58 The Latarjet proce-ure is similar to the Bristow procedure, but it in-olves a larger portion of the coracoid process andeeks to re-create more of the bony arc of the glenoidFig 6).59 Proponents of this procedure believe that theengthened glenoid arc and the additional slinglikeupport of the conjoined tendon help stabilize thehoulder even more effectively.59 In addition, minimalorbidity to the biceps is involved.60

Other authors advocate reconstruction of the ante-ior glenoid using iliac crest autograft—especiallyith very large lesions in which the coracoid pro-

ess may not provide adequate bone for completetability.36,61 Although multiple variations of thisechnique have been described, 2 essential themesxist: use as an extra-articular bone block to trans-ation and use as an intra-articular extension of thelenoid arc (Fig 7).36 Proponents of the latter methodelieve that it can provide better union rates andmproved rotation of the shoulder.62,63

Although the current gold standard for addressingony instability of the anterior glenoid is an openeconstructive procedure, some authors have reporteduccessful results with arthroscopic repair of bonyesions. Mologne et al.46 had only a 14% failure rate inseries of 21 patients with at least a 20% loss of bone

rom the anterior glenoid. All of the failures, however,

TABLE 4. Indications for Open Reduction–InternalFixation of Glenoid87-93

ignificantly displaced fractures of glenoid cavity (rim andfossa)

At least 10 mm of displacement of fragmentsAt least 5 mm of articular incongruity (step-off)At least 25% of anterior aspect of glenoid cavityAt least 33% of posterior aspect of glenoid cavity

ailure to maintain concentric radiographic reduction of humeralhead

ignificantly displaced fractures of glenoid neckAt least 10 mm of translational displacementAt least 40° of angular displacement (transverse or coronal

plane)oncomitant disruption of superior shoulder suspensory complex

in which one or more elements of scapula are significantly
displaced

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nvolved attritional bone loss with no identifiable bonyragment. In cases with an identifiable fragment, itas incorporated into the repair, resulting in signifi-

antly improved stability and outcome scores. Sugayat al.47 reported only a 5% failure rate in a series of 39atients with mean bone loss of 25%. In all cases aony lesion was identified and incorporated into theepair. These authors highlighted the importance ofearching for the bony fragment, which they oftenound hidden within the capsulolabral soft-tissue com-lex. Although these studies report some success withrthroscopic repair instead of open reconstruction, theommon theme to their success was adequate recog-ition of the bony lesion and incorporation of the bonyragment into the repair when possible.

IGURE 6. Latarjet procedure. The Latarjet procedure involves fixation ocrews (A) to re-create the pear shape of the glenoid (B). (C) The graft is

In addition to the success of these procedures fornown bony instability, several authors have also de-eloped arthroscopic versions of various existing re-onstructive procedures. Nourissat et al.53 performed auccessful cadaveric pilot study of a mini-open arthro-copically assisted Bristow-Latarjet procedure. Boi-eau et al.48 have reported good results at 19 months’ollow-up for an arthroscopic Bankart repair supple-ented by an arthroscopic Bristow transfer of the

onjoined tendon with a coracoid fragment for pa-ients with a stretched or deficient capsule. Lafosset al.51 subsequently described an arthroscopic versionf the Latarjet technique using a larger coracoid graftragment to re-create the glenoid arc. Mochizukit al.52 have reported on all-arthroscopic bone grafting

FIGURE 5. Bristow procedure.The Bristow procedure involvestransfer of the tip of the coracoidprocess along with the conjoinedtendon to the anteroinferior gle-noid rim (Adapted with permissionfrom The Journal of Bone andJoint Surgery, Inc.94)

f a longer arc of coracoid graft to the glenoid by use of 2 bicorticalplaced outside of the anterior capsule. (Adapted with permission.59)

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umeral Head

Several authors have described various forms ofone grafting for humeral head lesions, including iliacrest autograft,16,65 coracoid process autograft,66 localraft, fresh-frozen osteochondral allograft,67 cancel-ous allograft,65 humeral head allograft (Fig 8),6,16,68

nd femoral head allograft.69,70 Reverse Hill-Sachs

IGURE 7. Intra-articular (arc extension) iliac crest graft to gle-oid. (A) An appropriately sized and contoured iliac crest autograftan be fixed to the glenoid with screws as an intra-articular exten-ion of the glenoid arc beneath the capsule and subscapularisuscle. (Reprinted with permission of SAGE Publications, Inc.63)

B) A postoperative Garth view shows the completed reconstruc-ion.

esions may also be treated with a transfer of theSp

ubscapularis tendon or the lesser tuberosity into theefect.66,70

Rotational osteotomy represents another option forreatment of humeral head lesions. In this techniquehe humeral head is rotated such that the area ofathology no longer contributes biomechanically tohe instability.71,72 Variations of a humeroplasty tech-ique, in which the impression fracture of the humeralead is reduced by use of a bone tamp, may also besed. Kazel et al.73 described a percutaneous humero-lasty in a cadaveric study, and Re et al.74 described

IGURE 8. Humeral head allograft for Hill-Sachs lesion. Preop-rative (A) and postoperative (B) radiographs from a large Hill-
achs lesion treated with fixation of a humeral head allograft via aosterior approach and 2 screws.16

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n open humeroplasty in a small clinical series. Wolft al.75 have also described an arthroscopic “remplis-age” procedure for treatment of engaging Hill-Sachsesions, and Kelly and Ogunro76 have described ar-hroscopic “filling” of Hill-Sachs lesions.

Prosthetic resurfacing arthroplasty has alsoained popularity recently as a means of addressingarge Hill-Sachs lesions and other focal deficits ofhe humeral head (Fig 9). Scalise et al.77 haveescribed their limited experience with the Hemi-AP prosthesis (Arthrosurface, Franklin, MA) in

argeted replacement of limited areas of insuffi-iency. Raiss et al.78 have reported the use of theopeland Shoulder prosthesis (Biomet Europe,ordrecht, Netherlands) and the Epoca RH Cup

Argomedical, Cham, Switzerland) in reconstruct-ng significant humeral head bone defects.

ostoperative Rehabilitation

Rehabilitation after surgical intervention dependsn the particular surgery involved, demands and ex-ectations of the patient, medical comorbidities, otherroblems with the same shoulder (e.g., concomitantotator cuff tear requiring repair), injuries or problemslsewhere in the body, available resources, and prefer-nces of the treating surgeon. Ultimately, an individual-zed rehabilitation program should be specifically tai-ored for each patient, taking into consideration all ofhese factors.

omplications

As with any invasive procedure, the surgeon mustarn the patient about possible complications such asleeding, infection, anesthetic risks, and worsening of

GURE 9. HemiCAP prosthesis for Hill-Sachs lesion. (A) Pre-erative and (B, C) postoperative radiographs of a large Hill-chs lesion treated with placement of a HemiCAP implantrthrosurface).78

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edical comorbidities. Bony stabilization procedureslso have their own unique possible complications asell. Harvesting graft from the iliac crest can lead toonor-site problems such as lateral femoral cutaneouserve hypoesthesia, pain, or infection.8 Open proce-ures requiring takedown of the subscapularis tendonave had high rates of subscapularis insufficiency,specially in revision cases.55 Given the small, thinreas of bone involved in bony reconstruction of thelenoid or humerus, hardware-related problems maylso occur, such as screw pullout, partial graft resorp-ion, and excessive length with irritation of nearbytructures (Fig 10). Arthritis is also a significant prob-em, especially in cases with greater bone loss, anday appear late even in cases of successful surgical

reatment of instability.In conclusion, most cases of instability of the shoul-

er usually do not involve a significant osseous lesion.hen a contributory bony lesion is involved, how-

ver, it can be easily missed and result in failure ofttempted surgical repair—usually because the sur-eon has unknowingly addressed a bony problem withsoft-tissue solution. If the surgeon always considersony instability in the differential diagnosis and fol-ows an appropriate protocol for workup, however, the

IGURE 10. Hardware complications. In this case a large Hill-achs lesion was treated with an allograft fixed with 2 headlesscrews. At 9 months postoperatively, the radiograph showed aymptomatic prominent screw and some resorption of the graft.
he patient’s symptoms resolved after removal of the screws, andtability was still maintained because the graft was well fixed.
ymptomatic lesion can usually be effectively identi-ed. The best choice of treatment options, on the otherand, still remains unclear. Multiple authors haveeported successful outcomes in treating bony insta-ility using a variety of procedures, but the literatureas not yet provided definitive answers about whichrocedures may be better than others through directomparisons in randomized controlled trials. The rel-tive infrequency of bony instability makes such stud-es a challenging undertaking, and surgeons thus mustely on the existing literature for guidance. Open re-onstructive procedures currently represent the best-tudied options for treating bony instability, but ar-hroscopic versions of these techniques are quicklyaining popularity.

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