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Editorial Commentary: Recurrent Anterior Shoulder Instability With Glenoid Bone Loss Requires Restoring the Bone

      Abstract

      The success of treating anterior glenohumeral instability relies on multiple factors, including glenoid bone loss. Subcritical bone loss (<13.5%) has proven again and again to be a critical consideration when treating this problem. This proves more challenging in a population that participates in contact sports. The importance of restoring native anatomy, including the glenoid bone, is critical in ensuring a successful outcome. This is especially true in the setting of a bony Bankart lesion, where merely repairing the soft tissues and ignoring the bony fragment leads to unfavorable results.
      All you need is bone—at least on the glenoid. The treatment of anterior glenohumeral instability is continually evolving. In my own experience, the treatment algorithm for recurrent instability has changed frequently. The literature focuses on and constantly updates risk factors for recurrent instability and varying operative techniques to address the responsible pathology.
      • Yang J.S.
      • Mehran N.
      • Mazzocca A.D.
      • Pearl M.L.
      • Chen V.W.
      • Arciero R.A.
      Remplissage versus modified latarjet for off-track Hill-Sachs lesions with subcritical glenoid bone loss.
      • Atala N.A.
      • Bongiovanni S.
      • Rossi L.A.
      • et al.
      Arthroscopic acute bony Bankart repair in lateral decubitus.
      • Levy B.J.
      • Grimm N.L.
      • Arciero R.A.
      When to abandon the arthroscopic Bankart repair: A systematic review.
      • Cole B.J.
      • Warner J.J.
      Arthroscopic versus open Bankart repair for traumatic anterior shoulder instability.
      • DeFroda S.F.
      • Perry A.K.
      • Bodendorfer B.M.
      • Verma N.N.
      Evolving concepts in the management of shoulder instability.
      Nakagawa, Hirose, Uchida, Yokoi, Ohori, Sahara, and Mae report in “A Glenoid Defect of 13.5% or Larger Is Not Always Critical in Male Competitive Rugby and American Football Players Undergoing Arthroscopic Bony Bankart Repair: Contribution of a Resultant Large Bone Fragment.”
      • Nakagawa S.
      • Hirose T.
      • Uchida R.
      • et al.
      A glenoid defect of 13.5% or larger is not always critical in male competitive rugby and American football players undergoing arthroscopic bony Bankart repair: Contribution of resultant large bone fragment.
      The authors found that, in the setting of a large bony Bankart lesion, reduction and repair of the bony fragment led to improved outcomes. They found that the subcritical bone loss cut-off of 13.5% was less important than the healing of the bony fragment. The authors should be commended for reporting on shoulder stabilization in a challenging demographic.
      Although the authors posit that bone loss may be of less importance in this group, the results reflect the opposite. They found that reduction and healing of a large bony fragment led to significantly lower failure rates and restoration of the native glenoid anatomy. This finding is intuitive, especially in the setting of bone loss. The authors note that they did not anatomically reduce the small fragments when present and, instead, performed a more standard Bankart repair. Not surprisingly, they found that the isolated Bankart group (control with no bone loss) had a similar failure rate to the small, unreduced bony fragment group (33% vs 39%).
      It is my experience that a similar practice of managing instability is widespread. Many, like the authors, recognize the need for a bony block to the anterior translation of the humeral head. This is accomplished by reduction of the bony fragment or, when not present, the addition of a bone block (Latarjet, distal clavicle, etc.). We should pay more attention to reducing any and all anterior structures to their native anatomy, including small bone fragments, to maximize postoperative stability and ensure lesions are on-track. In this challenging group, I think that more must be done, as supported by the authors’ findings.

      Supplementary Data

      References

        • Yang J.S.
        • Mehran N.
        • Mazzocca A.D.
        • Pearl M.L.
        • Chen V.W.
        • Arciero R.A.
        Remplissage versus modified latarjet for off-track Hill-Sachs lesions with subcritical glenoid bone loss.
        Am J Sports Med. 2018; 46: 1885-1891
        • Atala N.A.
        • Bongiovanni S.
        • Rossi L.A.
        • et al.
        Arthroscopic acute bony Bankart repair in lateral decubitus.
        Arthrosc Tech. 2020; 9: e1907-e1915
        • Levy B.J.
        • Grimm N.L.
        • Arciero R.A.
        When to abandon the arthroscopic Bankart repair: A systematic review.
        Sports Health. 2020; 12: 425-430
        • Cole B.J.
        • Warner J.J.
        Arthroscopic versus open Bankart repair for traumatic anterior shoulder instability.
        Clin Sports Med. 2000; 19: 19-48
        • DeFroda S.F.
        • Perry A.K.
        • Bodendorfer B.M.
        • Verma N.N.
        Evolving concepts in the management of shoulder instability.
        Indian J Orthop. 2021; 55: 285-298
        • Nakagawa S.
        • Hirose T.
        • Uchida R.
        • et al.
        A glenoid defect of 13.5% or larger is not always critical in male competitive rugby and American football players undergoing arthroscopic bony Bankart repair: Contribution of resultant large bone fragment.
        Arthroscopy. 2021; 38: 673-681