I. Anterior instability

1. 
   

   Accounts for the majority of glenohumeral dislocations

   
   
2. 
   

   Indications for surgical treatment:

   
   
   
   
   1. 
      

      Recurrent instability

      
      
   2. 
      

      First-time dislocation, under 25 years old.

   
   
3. 
   

   Contraindications:

   
   
   
   
   1. 
      

      Voluntary dislocators.

   
   
4. 
   

   Associated lesions:

   
   
   
   
   1. 
      

      Bankart lesion:

      
      
      
      
      1. 
         

         Soft tissue (▶ Fig. 14.1 )

         
         
      2. 
         

         Bony.

      
      
   2. 
      

      Hill-Sachs lesion (▶ Fig. 14.1 )

      
      
   3. 
      

      Humeral avulsion of the inferior glenohumeral ligament (HAGL) (▶ Fig. 14.2 ).

   
   
5. 
   

   Procedures for soft tissue lesions:

   
   
   
   
   1. 
      

      Bankart repair +/− capsular shift:

      
      
      
      
      1. 
         

         Primary treatment of anteroinferior instability with Bankart lesion

         
         
      2. 
         

         Commonly performed with suture anchors

         

         

         
         
      3. 
         

         Can be done arthroscopically or by open procedure:

         
         
         
         
         • 
           

           i. Similar results with open and arthroscopic treatments but with improved range of motion (ROM) in arthroscopic group.

         
         
      4. 
         

         Risk factors for recurrence:

         
         
         
         
         • 
           

           i. <20 years of age at the time of surgery

           
           
         • 
           

           ii. Participation in contact sports

           
           
         • 
           

           iii. Ligamentous laxity

           
           
         • 
           

           iv. Glenoid bone loss

           
           
         • 
           

           v. Hill-Sachs lesion.

         
         
      5. 
         

         Contraindicated in >25% glenoid bone loss (▶ Fig. 14.3 ).

      
      
   2. 
      

      HAGL repair:

      
      
      
      
      1. 
         

         Missed HAGL lesion may lead to failure of Bankart repair

         
         
      2. 
         

         Can be repaired with open or arthroscopic technique

         
         
      3. 
         

         Suture anchors typically used to repair inferior glenohumeral ligament (IGHL) to its humeral attachment.

         

   
   
6. 
   

   Procedures for glenoid bone loss:

   
   
   
   
   1. 
      

      Bristow-Latarjet procedure:

      
      
      
      
      1. 
         

         Transfer of coracoid process to anteroinferior glenoid:

         
         
         
         
         • 
           

           i. Traditional fixation with lag screws (▶ Fig. 14.4 )

           
           
         • 
           

           ii. Recent literature reports use of suture buttons in some arthroscopic cases.

         
         
      2. 
         

         Used in cases of bone loss or revision but can also be used as primary treatment in cases of anteroinferior instability without bone loss

         
         
      3. 
         

         Achieves stability in three ways:

         
         
         
         
         • 
           

           i. Increase glenoid size and translation distance required for dislocation

           
           
         • 
           

           ii. Capsule is repaired to the coracoacromial (CA) ligament

           
           
         • 
           

           iii. Conjoint tendon provides dynamic sling effect.

         
         
      4. 
         

         Better long-term outcomes than Bankart repair:

         
         
         
         
         • 
           

           i. Fewer recurrence

           
           
         • 
           

           ii. Higher patient satisfaction.

         
         
      5. 
         

         Higher early complication rate:

         
         
         
         
         • 
           

           i. Recurrence or arthrosis due to malpositioning

           
           
         • 
           

           ii. Graft fracture or osteolysis

           
           
         • 
           

           iii. Neurovascular injury

           
           
         • 
           

           iv. Nonunion.

         
         
      6. 
         

         Primarily performed as an open procedure but more recently performed arthroscopically in a few centers.

         

      
      
   2. 
      

      Eden-Hybinette procedure:

      
      
      
      
      1. 
         

         Iliac crest bone block placed anteroinferiorly on glenoid (▶ Fig. 14.5 ):

         
         
         
         
         • 
           

           i. Alternatives include iliac crest or distal tibia allograft.

         
         
      2. 
         

         Used in cases of glenoid bone loss or failed Latarjet

         
         
      3. 
         

         Open procedure with some reports of being performed arthroscopically

         
         
      4. 
         

         Higher rates of arthrosis and recurrence than Latarjet with added donor site morbidity.

   
   
7. 
   

   Procedures for humeral (Hill-Sachs) lesions:

   
   
   
   
   1. 
      

      Remplissage:

      
      
      
      
      1. 
         

         Posterior capsule and rotator cuff fixed into defect to prevent engaging on glenoid

         
         
      2. 
         

         Commonly done concurrently with Bankart repair

         
         
      3. 
         

         Performed arthroscopically and by open procedure but may be easier with arthroscopic approach

         
         
      4. 
         

         May lead to loss of motion.

      
      
   2. 
      

      Humeral head allograft or bone grafting:

      
      
      
      
      1. 
         

         For lesions involving >40% of the humeral head

         
         
      2. 
         

         High complication and reoperation rate:

         
         
         
         
         • 
           

           i. Graft necrosis or resorption

           
           
         • 
           

           ii. Arthrosis.

         
         
      3. 
         

         Traditionally an open procedure but has been performed arthroscopically recently.

         

      
      
   3. 
      

      Rotational (Weber) osteotomy:

      
      
      
      
      1. 
         

         Rotates Hill-Sachs lesion to prevent engagement

         
         
      2. 
         

         High reoperation rate:

         
         
         
         
         • 
           

           i. Hardware removal

           
           
         • 
           

           ii. Nonunion

           
           
         • 
           

           iii. Recurrence

           
           
         • 
           

           iv. Excessive rotation.

      
      
   4. 
      

      Resurfacing/Arthroplasty:

      
      
      
      
      1. 
         

         For large lesions

         
         
      2. 
         

         Removes lesion and replaces with implant to prevent engagement

         
         
      3. 
         

         Has outcomes and complications associated with arthroplasty procedures:

         
         
         
         
         • 
           

           i. Less desirable in younger patients.

      
      
   5. 
      

      Other procedures:

      
      
      
      
      1. 
         

         Trillat procedure:

         
         
         
         
         • 
           

           i. Closing wedge osteotomy on undersurface of coracoid process, which is then fixed to glenoid neck with screw

           
           
         • 
           

           ii. Primarily open procedure that has been performed arthroscopically

           
           
         • 
           

           iii. Performed in patients with concern for graft fracture if Latarjet is performed or if there is concern for nonhealing of labral repair

           
           
         • 
           

           iv. Iatrogenic coracoid impingement may lead to loss of motion and arthrosis.

         
         
      2. 
         

         Putti-Platt procedure:

         
         
         
         
         • 
           

           i. Subscapularis divided with lateral portion fixed to glenoid and medial portion fixed to humerus in a pants over vest fashion

           
           
         • 
           

           ii. Results in loss of motion and variable recurrence rates.