Glenohumeral instability frequently requires surgical intervention to prevent recurrence. Various techniques are utilized depending on the direction of instability and the presence of soft tissue and/or bony lesions. New implants and techniques have made arthroscopic surgery more common.
14 Shoulder Stabilization Procedures
I. Anterior instability
Accounts for the majority of glenohumeral dislocations
Indications for surgical treatment:
First-time dislocation, under 25 years old.
Soft tissue (▶ Fig. 14.1 )
Hill-Sachs lesion (▶ Fig. 14.1 )
Humeral avulsion of the inferior glenohumeral ligament (HAGL) (▶ Fig. 14.2 ).
Procedures for soft tissue lesions:
Bankart repair +/− capsular shift:
Primary treatment of anteroinferior instability with Bankart lesion
Commonly performed with suture anchors
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.
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.
Contraindicated in >25% glenoid bone loss (▶ Fig. 14.3 ).
Procedures for glenoid bone loss:
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.
Used in cases of bone loss or revision but can also be used as primary treatment in cases of anteroinferior instability without bone loss
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.
Better long-term outcomes than Bankart repair:
i. Fewer recurrence
ii. Higher patient satisfaction.
Higher early complication rate:
i. Recurrence or arthrosis due to malpositioning
ii. Graft fracture or osteolysis
iii. Neurovascular injury
Primarily performed as an open procedure but more recently performed arthroscopically in a few centers.
Iliac crest bone block placed anteroinferiorly on glenoid (▶ Fig. 14.5 ):
i. Alternatives include iliac crest or distal tibia allograft.
Used in cases of glenoid bone loss or failed Latarjet
Open procedure with some reports of being performed arthroscopically
Higher rates of arthrosis and recurrence than Latarjet with added donor site morbidity.
Procedures for humeral (Hill-Sachs) lesions:
Posterior capsule and rotator cuff fixed into defect to prevent engaging on glenoid
Commonly done concurrently with Bankart repair
Performed arthroscopically and by open procedure but may be easier with arthroscopic approach
May lead to loss of motion.
Humeral head allograft or bone grafting:
For lesions involving >40% of the humeral head
High complication and reoperation rate:
i. Graft necrosis or resorption
Traditionally an open procedure but has been performed arthroscopically recently.
Rotational (Weber) osteotomy:
Rotates Hill-Sachs lesion to prevent engagement
High reoperation rate:
i. Hardware removal
iv. Excessive rotation.
For large lesions
Removes lesion and replaces with implant to prevent engagement
Has outcomes and complications associated with arthroplasty procedures:
i. Less desirable in younger patients.
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.
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.