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Humeral head defects (Hill-Sachs lesions) are common sequelae of glenohumeral instability and potentiate recurrence. Engaging Hill-Sachs lesions clearly increase risk of recurrent instability when not addressed surgically. Arthroscopic remplissage, in conjunction with Bankart repair, has proven to be a safe and effective means to treat anterior gelnohumeral instability. Remplissage, when executed properly, favorably alters the “glenoid track” and thus lessens the risk of glenohumeral engagement in abduction external rotation. Remplissage is a biologic tissue transfer that confers much less morbidity than glenoid bone grafting procedures (Latarjet), while demonstrating comparable efficacy.

The accurate identification and quantification of both glenoid bone loss and the presence of a Hill-Sachs lesion is essential in the setting of anterior shoulder instability as it directly dictates patient outcomes. The ability to diagnose and address these potential osseous defects of the glenohumeral joint based on patient history, physical exam, and the findings of various imaging modalities in a clinical setting is fundamental to the overall success of a surgeon's treatment algorithm. Multiple methods exist to quantify bone loss based on diagnostic imaging or arthroscopy, and the surgeon should be mindful of the respective pearls and pitfalls of each imaging modality and their ability to accurately diagnose shoulder bone loss. Pertinent findings in a patient's history such as age, level of activity, enlistment status, and events of recurrent anterior glenohumeral instability can help one not only predict the presence of bone loss, but the location and size of the defect as well. Furthermore, symptoms and signs of chronic instability along with accurate quantification of glenoid bone loss are essential in the algorithm of selecting the correct surgical procedure to provide optimal stabilization and maximize clinical outcomes.

Arthroscopic shoulder stabilization is the most commonly used technique to treat shoulder instability; however, recurrence rates have been shown to be high in our literature. Optimizing treating of glenohumeral instability is crucial to improve patient outcomes. This chapter will provide a basic review of the key steps in the evaluation and management of patients with shoulder instability with minimal bone loss.

Glenoid and humeral bone loss is an increasingly recognized cause of recurrent instability and failure of soft tissue stabilization in both anterior and posterior glenohumeral instability. Given that participation in contact and collision sports is associated with a greater risk of recurrent glenohumeral instability, a thorough understanding of the pathoanatomy, clinical evaluation, and treatment of this condition is paramount. This review provides an overview of the pathoanatomy and clinical evaluation of shoulder instability with bone loss as well as bony augmentation procedures for treatment of the condition.

Intra-articular pathology that occurs from glenohumeral instability events, including labral tears, glenoid bone loss, and Hill-Sachs lesions, may contribute to increased risk of recurrent instability and persistent pain and disability following initial treatment. Careful analysis of radiographic and advanced imaging studies can assist in the recognition of clinically significant pathology. This article provides guidance on the appropriate use of diagnostic imaging for the evaluation of glenohumeral instability and describes radiographic and advanced imaging findings that can affect treatment outcomes in the contact athlete.

The glenohumeral joint is a highly congruous articulation that is dependent on the osseous integrity of both the glenoid rim and the humeral head. Disruptions in the bony architecture of either surface occur in up to 100% of shoulders in the setting of recurrent anterior shoulder instability. Unrecognized, as well as underappreciated, glenoid bone loss in the setting of glenohumeral instability is especially problematic. As bone loss approaches 20% or more of the glenoid surface area, surgical strategies tend to incorporate a bony reconstruction, with either an autograft or an allograft. Similarly, bone defects of greater than 25%-30% of the humeral head tend to warrant surgical treatment; although often in this setting, reconstruction of the glenoid restores smooth articulation with the humeral head, despite the defect, and no further treatment is required. Although short-term outcomes following allograft reconstruction of the glenohumeral joint are encouraging, given the relatively few medium- and long-term reports available, it is difficult to draw conclusions as to how these procedures fare over time. Cases of recurrent instability despite appropriate allograft reconstruction exist, and surgical options are typically salvage-type procedures, limited to revision allograft reconstruction or arthroplasty. This review focuses on the indications for allograft reconstruction of the glenohumeral joint, definition of and workup of patients experiencing recurrent instability following allograft augmentation, and treatment options for these difficult patients. A treatment algorithm summarizing the authors׳ recommended management of these patients has also been provided.

When compared with anterior glenohumeral instability, posterior glenohumeral instability is a relatively rare condition, and it can pose a diagnostic and therapeutic challenge for the orthopaedic surgeon. Although many patients only have damage to the posterior capsulolabral structures, some have bone defects associated with posterior instability, including defects of the posterior glenoid rim, glenoid retroversion, and an anterosuperior impaction fracture of the humeral head known as the reverse Hill-Sachs lesion. When nonoperative treatments fail, surgical management aims to identify and address both soft tissue and bony factors involved in posterior instability so as to minimize the chances of recurrent instability after surgery. Operative treatment options vary for these different bone defects associated with posterior instability, and there are relatively little data to guide surgical indications and treatment decisions. In this article, we discuss our approach to the treatment of bone defects in posterior instability with emphasis on which techniques are used in different circumstances as well as technical pearls and pitfalls.

Most cases of instability of the shoulder do not involve a significant osseous lesion. Bony lesions of the glenoid and humeral head, however, can be a major cause of recurrent anterior glenohumeral instability. Unrecognized bony glenoid defects and Hill-Sachs lesions can lead to failure after arthroscopic soft tissue stabilization procedures for anterior instability. However bony defects can usually be identified and effectively treated, if an appropriate protocol and workup is followed. Current indications for the treatment of anterior glenohumeral instability with a bony augmentation procedure include anteroinferior glenoid bone loss of greater than 20%-30%, an engaging Hill-Sachs lesion, or an Instability Severity Index Score greater than 6. A variety of procedures have been described for treating bony instability, including both arthroscopic and open techniques. Here we discuss the evaluation, workup, and treatment of anterior shoulder instability related to bone deficiency of the glenohumeral joint.

Recurrent glenohumeral instability can be a debilitating condition that affects an athlete’s ability to compete at the highest levels of competition and, in our military population, meet the demands of active military service. Significant advances in the understanding of the natural history of this condition have led to new operative interventions and rehabilitative protocols that aim to return the athlete to their previous level of activity. There has been increased interest in the arthroscopic stabilization of shoulder instability, which is evolving from first-time dislocators to recurrent instability in noncontact and contact athletes as well. A thorough understanding of the pathoanatomy involved in shoulder instability allows us to address all injured structures responsible for recurrent instability including the Bankart tear (reverse Bankart for posterior instability) and loss of capsuloligamentous tension. As our arthroscopic techniques continue to improve, our clinical results will approach that of traditional open techniques with perhaps less perioperative morbidity and loss of motion. We have presented one such arthroscopic technique of a multipleated plication through a single anterior and posterior portal that has served us well in the management of recurrent shoulder instability. At present, the only contra-indication to an arthroscopic procedure is significant bony defects of the humeral head or glenoid, which requires a more extensive intervention.

Treatment of glenohumeral instability and capsulolabral pathology continues to evolve as arthroscopic techniques improve. A growing body of biomechanical and clinical research provides an enhanced perspective on results obtained with both arthroscopic and open treatment of these conditions. Labral repair and capsulolabral reconstruction can effectively be treated with suture anchors by both arthroscopic and open methods. Suture anchors are low-profile fixation devices that can minimize articular surface compromise and afford an anatomic reconstruction of the labrum and glenohumeral ligament complex. Although the use of suture anchors has become increasingly common to obtain stable fixation and healing at the bone-tendon interface in rotator cuff repair, critical distinctions exist between this function and their implementation in labral repair and capsulolabral reconstruction. This article examines the technical aspects of labral repair and capsulolabral reconstruction with metallic and bioabsorbable suture anchors. The emphasis is on implant options, technical advantages, potential limitations, and relevant biomechanical considerations to better achieve an optimal outcome.

Glenohumeral instability is relatively commonly observed in the female athlete. Studies have shown an increased incidence of both asymptomatic and pathological laxity among women. Female athletes participating in sports involving repetitive use of the upper extremity may be at particular risk for developing symptoms. Shoulder instability is classified according to etiology, onset, degree, and direction. Accurate diagnosis is important to determine proper management. Female athletes presenting with symptoms of shoulder instability should be initially treated with a comprehensive rehabilitation program emphasizing strengthening of the rotator cuff and dynamic scapular stabilizing muscles. After failure of nonoperative management, satisfactory results can be obtained using either open or arthroscopic surgical techniques.

Anterior glenohumeral instability is a common disorder often associated with traumatic detachment of theanteroinferior capsulolabral complex (Bankart lesion). Surgical treatment is often required to prevent recurrent instability. Open Bankart reconstruction has proven to be a reliable procedure with low recurrence rates. The open surgical approach allows treatment of all patterns of anterior instability and does not require the presence of a discrete Bankart lesion. Successful reconstruction requires reattachment of the capsulolabral complex as well as reduction of capsular redundancy if present. Excessive tightening of the capsule should be avoided. The techniques for open repair have been well established and should be easily reproducible by most surgeons.

Shoulder instability in the skeletally immature athlete is an uncommon but challenging clinical problem. Theclassification of shoulder instability in the pediatric athlete is similar to that in the adult athlete, but may also include the voluntary and habitual dislocator. The natural history of such instability depends on the classification of instability type. Traumatic anterior dislocation has an exceedingly high recurrence, and posterior dislocation is less well known. A natural history of voluntary instability is also uncertain. As in the adult athlete, clinical evaluation is made by history and physical exam. An understanding of the bony development of the glenohumeral joint is crucial in interpreting radiographs of the skeletally immature athlete with glenohumeral instability. The treatment of glenohumeral instability will depend on the classification of the instability type. Surgical treatment, when indicated, should emphasize an anatomic approach aimed at correcting the underlying glenohumeral pathology. This article is intended to provide an overview of the approach to diagnosis and treatment of glenohumeral instability in the pediatric athlete.

The Holmium:YAG (Ho:YAG) laser is the arthroscopic laser of choice. The arthroscopic surgeon can ablate, coagulate, or shrink periarticular soft tissues by manipulating Ho:YAG laser power settings. The ability to ablate soft tissue in a hemostatic fashion greatly facilitates the treatment of labral tear, synovitis, subacromial arch decompression, and distal clavicle arthritis. The nonablative application of Ho:YAG laser energy has been used successfully to treat glenohumeral instability. The laser-assisted capsular shift (LACS) procedure, in conjunction with standard labral repair techniques, successfully treats unidirectional and multidirectional shoulder instability Neuromuscular rehabilitation is accelerated. Excellent clinical results may be achieved with appropriate surgical technique and postoperative rehabilitation.

Multidirectional glenohumeral instability secondary to ligamentous laxity, capsular redundancy, and excessive joint volume occurs frequently. Traditional treatment programs have included conservative care, physical therapy, open surgical stabilization, and arthroscopic techniques. The laser-assisted capsular shift procedure uses low-dose, subablative laser energy to cause shrinkage of the shoulder capsule. The shrinkage of the shoulder capsule results in a decrease in glenohumeral volume improving glenohumeral stability. The Holmium:YAG laser appears to be a useful instrument for the arthroscopic treatment of glenohumeral instability. Holmium:YAG laser energy can be used to thermally modify capsular tissue to cause a reduction in its length without detrimental effects to the viscoelastic properties of the tissue. Early clinical reports have been promising and further follow-up is required to assess the long-term outcome of this procedure.

Magnetic resonance imaging (MRI) has emerged as a powerful tool for the noninvasive evaluation of the musculoskeletal system. The use of MRI for the evaluation of disorders of the shoulder, however, remains more controversial than its use for the study of the knee. MRI has been shown by numerous investigators to be an accurate technique for confirming the presence of rotator cuff tears, determining their size, determining the presence of atrophy of the cuff muscles, and detecting the presence of different causes of cuff impingement. The use of MRI for the evaluation of glenohumeral instability is more problematic. In the presence of a large amount of joint fluid, MRI is reasonably accurate for the depiction of anatomic abnormalities associated with instability. In the absence of effusion, MRI is relatively inaccurate. For these cases MR arthrography is probably necessary to confirm the diagnosis.

The clinical impact of magnetic resonance imaging (MRI) of the shoulder is dependent upon the clinical diagnosisand clinical indications for surgical management. MRI of the shoulder is very useful in defining the anatomic pathology associated with shoulder pain and disability. The clinical impact of MRI is improved when it is obtained under well defined criteria which should be based upon clinical treatment algorithms. Shoulder MRI is best used to define the anatomic pathology associated with rotator cuff tears and traumatic glenohumeral instability.