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Editorial Commentary: We Need to Customize Surgical Treatment When Treating Patients With Recurrent Anterior Shoulder Instability

      Abstract

      Surgical repair of shoulder instability is challenging, and multiple procedures have been proposed. In an attempt to reduce risk of recurrence following surgical reconstruction, some surgeons have added steps to prior arthroscopic procedures, and other surgeons have selected a bone reinforcement procedure. These additional augmented repair techniques have reduced the risk of postoperative recurrence, but introduced additional risk of complications related to hardware, fixation, and possible need for additional surgery. Surgeons should become familiar with multiple surgical procedures to treat patients with recurrent shoulder instability, and select the appropriate procedure that addresses the demands of the athlete's shoulder and minimize the risk of complication.
      Recurrent shoulder instability continues to be a challenge, and surgical stabilization does not completely remove the risk of recurrence. New procedures or augmentations of prior techniques continue to be introduced to reduce the number of recurrences and the potential for surgery-related complications, and return the majority to full activity and playing sports. There is a current split in philosophy on choosing an anatomic arthroscopic or open soft tissue repair versus using a coracoid transfer procedure to lessen the likelihood of recurrent subluxation or dislocation, avoiding missed athletic seasons. This controversy becomes more relevant when surgical complication in this age group can be devastating. The fact that there are multiple surgical options to address glenohumeral instability would suggest that the approach should be customized to the patient, anatomic deficits, and activity demands.
      The most common scenario is an anterior dislocation with the creation of a Bankart soft tissue detachment, possible glenoid rim avulsion, and a Hill-Sachs lesion. The most common technique to address these individuals is an arthroscopic Bankart repair with a well-demonstrated success rate and a low surgical complication rate.
      • Owens B.D.
      • DeBerardino T.M.
      • Nelson B.J.
      • et al.
      Long-term follow-up of acute arthroscopic Bankart repair for initial anterior shoulder dislocations in young athletes.
      • Ozturk B.Y.
      • Maak T.G.
      • Fabricant P.
      • et al.
      Return to sports after arthroscopic anterior stabilization in patients aged younger than 25 years.
      Missed athletic seasons can be frustrating if there is recurrent subluxation. To reduce this risk, additional soft tissue tensioning and fixation has been added to increase the percentage of success and resilience of the procedure. The success of arthroscopic Bankart has been questioned in high-risk populations with chronic bone loss, soft tissue adaptations following recurrence, and collision sports. The risk of recurrence has been alarmingly high in some studies and does not guarantee an uninterrupted return to sport.
      • Burkhart S.S.
      • DeBeer J.F.
      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.
      • Boileau P.
      • Villalba M.
      • Héry J.Y.
      • Balg F.
      • Ahrens P.
      • Neyton L.
      Risk factors for recurrence of shoulder instability after arthroscopic Bankart repair.
      The Latarjet or Bristow procedure with the transfer of coracoid has gained popularity with additional bone grafting to the injured glenoid rim, combined with a soft tissue sling effect restricting movement of the subscapularis and adherent anterior-inferior capsule. The procedure has traditionally been performed in an open setting, but several arthroscopic experts have been using arthroscopic techniques to perform this procedure.
      • Lafosse L.
      • Lejeune E.
      • Bouchard A.
      • Kakuda C.
      • Gobezie R.
      • Kochhar T.
      The arthroscopic Latarjet procedure for the treatment of anterior shoulder instability.
      The number and type of complications have raised concern as to whether this type of procedure should be used routinely or should be reserved for a select subset of injured shoulders. The dilemma is worsened by the fact that surgical experience reduces the risk of complication, and if this procedure is infrequently performed, how do surgeons gain this experience? Complications including neurologic injury and hardware-related arthritic changes can be profound and create significant barriers to allow increased stabilization rate to make this an automatic answer to patients with shoulder dislocations.
      • Shah A.A.
      • Butler R.B.
      • Romanowski J.
      • Goel D.
      • Karadagli D.
      • Warner J.J.
      Short-term complications of the Latarjet procedure.
      The patient with a failed surgical procedure due to recurrence adds to this complex decision. Open soft tissue repairs, bone grafting procedures, and arthroscopic remplissage have all been added to reduce the risk of recurrence from primary and revision surgeries. Failures have been identified from a combination of articular bone defects, soft tissue damage, inherent laxity, and patients' activity demands. Preoperative identification of the deficient shoulder is the best way to lead to a successful choice of surgical stabilization procedures.
      • DiGiacomo G.
      • Itoi E.
      • Burkhart S.S.
      Evolving concept of bipolar bone loss and the Hill-Sachs lesion: From “engaging/nonengaging” lesion to “on-track/off-track” lesion.
      Intraoperative assessment adds to identifying potential articular injuries that can place the surgical procedure at risk for failure.
      • Arrigoni P.
      • Huberty D.
      • Brady P.C.
      • Weber I.C.
      • Burkhart S.S.
      The value of arthroscopy before an open modified Latarjet reconstruction.
      Douoguih, Goodwin, Churchill, Paulus, and Maxwell in the article “Conjoined Tendon Transfer for Traumatic Anterior Glenohumeral Instability in Patients With Large Bony Defects and Anterior Capsulolabral Deficiency”
      • Douoguih W.A.
      • Goodwin D.
      • Churchill R.
      • Paulus M.
      • Maxwell A.
      Conjoined tendon transfer for traumatic anterior glenohumeral instability in patients with large bony defects and anterior capsulolabral deficiency.
      have modified the bone block transfer by creating a surgical procedure that transfers the conjoined tendon without the bone, allowing for suture anchor fixation. This procedure can be performed as an open procedure or arthroscopically performed. The hurdle that the authors avoided is the misplacement of the coracoid, precipitating degenerative arthritis and avoiding metallic hardware to secure the transfer. In their hands, they were satisfied with the recurrence risk and felt that it was superior to an anatomic repair. They did not select overhead throwing and collision athletes, both of which are a challenge when treating this problem. Risks to neurologic structures were not addressed in this publication, nor were potential difficulties with revision surgery. They have provided a technique that will address a soft tissue dilemma when a purely arthroscopic Bankart may seem insufficient to treat this athlete. The question of treating patients with a large bony deficit remains, and also whether a soft tissue procedure can compensate for glenoid rim deficiency, Hill-Sachs humeral head engaging defect, and damaged, stretched soft tissue restraints. If the rate of surgical failure is influenced by bone loss, then this technique does not increase the width of the articulation.
      • Shaha J.S.
      • Cook J.B.
      • Song D.J.
      • et al.
      Redefining “critical” bone loss in shoulder instability: Functional outcomes worsen with “subcritical” bone loss.

      Authors' Preferred Indications and Techniques

      Currently, my advice for surgeons is to be able to perform a number of surgical procedures to correct glenohumeral instability. The most common scenario is a capsule labral avulsion or a bony Bankart which can be predictably repaired with an arthroscopic or open soft tissue repair.
      • Pagnani M.J.
      Open capsular repair without bone block for recurrent anterior shoulder instability in patients with and without bony defects of the glenoid and/or humeral head.
      Augmentation of the procedure may include posterior plication, remplissage, and additional anterior subscapularis/anterior capsule fixation. The open capsular crisscrossing repair may add to the anterior restraint. Bone grafting the glenoid is an important addition when pre- and intraoperative measurements demonstrate a deficiency.
      • Warner J.J.
      • Gill T.J.
      • O'Hollerhan J.D.
      • Pathare N.
      • Millett P.J.
      Anatomical glenoid reconstruction for recurrent anterior glenohumeral instability with glenoid deficiency using an autogenous tricortical iliac crest bone graft.
      Personally, I have added autograft clavicle to widen the deficient glenoid with good early success. Through a small incision, an 8-mm to 1-cm piece of distal clavicle is harvested. After soft tissue debridement, a drill hole is placed to allow suture passage. The graft will be oriented to allow the articular cartilage of the distal clavicle to align with the cartilage of the glenoid. The sutures can be shuttled through the graft from a double-loaded suture anchor placed in the defect of the glenoid. The clavicle graft can be trimmed to fit into the defect to match in size and shape. The labrum adds to the fixation as the anchors above and below the defect secure the augmentation. In my hands, the Latarjet is reserved for the more compromised shoulder that shares bone loss with soft tissue deficiencies. Addressing the anterior capsule is an important part of this procedure to help with the proprioception and stability.
      • Jerosch J.
      • Castro W.H.
      • Halm H.
      • Drescher H.
      Does the glenohumeral joint capsule have proprioceptive capability?.
      There is no one procedure that fits all of the patients with anterior instability. Individualize your approach based on patients' bone changes, soft tissue quality, activity requirements, and surgical experience to be able to customize your procedure. This is the best current philosophy to maximize success and reduce surgical complications.

      Supplementary Data

      References

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        • Cook J.B.
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        Redefining “critical” bone loss in shoulder instability: Functional outcomes worsen with “subcritical” bone loss.
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        Open capsular repair without bone block for recurrent anterior shoulder instability in patients with and without bony defects of the glenoid and/or humeral head.
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        • Halm H.
        • Drescher H.
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