Glenoid rim morphology in recurrent anterior glenohumeral instability

BACKGROUND: Knowledge regarding the morphology of the glenoid rim is important when patients with recurrent anterior glenohumeral instability are assessed. Ordinary imaging techniques are not always sensitive enough to demonstrate the morphology of the glenoid rim accurately. We developed a method of three-dimensionally reconstructed computed tomography with elimination of the humeral head to evaluate glenoid morphology. The purpose of the present study was to quantify glenoid osseous defects and to define their characteristics in patients with recurrent anterior instability. METHODS: The morphology of the glenoid rim in 100 consecutive shoulders with recurrent unilateral anterior glenohumeral instability was evaluated on three-dimensionally reconstructed computed tomography images with the humeral head eliminated. The configuration of the glenoid rim was evaluated on both en face and oblique views. Concurrently, we also investigated seventy-five normal glenoids, including both glenoids in ten normal volunteers. Shoulders without an osseous fragment at the anteroinferior portion of the glenoid were compared with the contralateral shoulder in the same patient to determine if the glenoid morphology was normal. In shoulders with an osseous fragment, the fragment was evaluated quantitatively and its size was classified as large (>20% of the glenoid fossa), medium (5% to 20%), or small (<5%). Finally, all 100 shoulders were evaluated arthroscopically to confirm the presence of the lesion at the glenoid rim that had been identified with three-dimensionally reconstructed computed tomography. RESULTS: Investigation of the normal glenoids revealed no side-to-side differences. Investigation of the affected glenoids revealed an abnormal configuration in ninety shoulders. Fifty glenoids had an osseous fragment. One fragment was large (26.9% of the glenoid fossa), twenty-seven fragments were medium (10.6% of the glenoid fossa, on the average), and twenty-two were small (2.9% of the glenoid fossa, on the average). In the forty shoulders without an osseous fragment, the anteroinferior portion of the glenoid appeared straight on the en face view and it appeared obtuse or slightly rounded, compared with the normally sharp contour of the normal glenoid rim, on the oblique view, suggesting erosion or a mild compression fracture at this site. Arthroscopic investigation revealed a Bankart lesion in ninety-seven of the 100 shoulders and an osseous fragment in forty-five of the fifty shoulders in which an osseous Bankart lesion had been identified with the three-dimensionally reconstructed computed tomography. In the shoulders with distinctly abnormal morphology on three-dimensionally reconstructed computed tomography, the arthroscopic appearance of the anteroinferior portion of the glenoid rim was compatible with the appearance demonstrated by the three-dimensionally reconstructed computed tomography. CONCLUSIONS: We introduced a method to evaluate the morphology of the glenoid rim and to quantify the osseous defect in a simple and practical manner with three-dimensionally reconstructed computed tomography with elimination of the humeral head. Fifty percent of the shoulders with recurrent anterior glenohumeral instability had an osseous Bankart lesion; 40% did not have an osseous fragment but demonstrated loss of the normal circular configuration on the en face view and an obtuse contour on the oblique view, suggesting erosion or compression of the glenoid rim.     

The Hill-Sachs lesion: diagnosis, classification, and management

The Hill-Sachs lesion is an osseous defect of the humeral head that is typically associated with anterior shoulder instability. The incidence of these lesions in the setting of glenohumeral instability is relatively high and approaches 100% in persons with recurrent anterior shoulder instability. Reverse Hill-Sachs lesion has been described in patients with posterior shoulder instability. Glenoid bone loss is typically associated with the Hill-Sachs lesion in patients with recurrent anterior shoulder instability. The lesion is a bipolar injury, and identification of concomitant glenoid bone loss is essential to optimize clinical outcome. Other pathology (eg, Bankart tear, labral or capsular injuries) must be identified, as well. Treatment is dictated by subjective and objective findings of shoulder instability and radiographic findings. Nonsurgical management, including focused rehabilitation, is acceptable in cases of small bony defects and nonengaging lesions in which the glenohumeral joint remains stable during desired activities. Surgical options include arthroscopic and open techniques.     

Arthroscopic findings in the subluxating shoulder

The arthroscopic findings in 19 shoulders (18 patients) with subluxation are described. The clinical diagnosis of subluxation of the shoulder is primarily based on clinical history with inconsistent physical findings and radiographic studies. Arthroscopic findings in these patients were consistent. Increased translation of the humeral head in the anteroposterior plane was noted secondary to attenuation of the anteroinferior glenohumeral ligament. Incompetence of this ligamentous structure obviated its function as an anterior buttress and allowed the humeral head to translate anteriorly on the glenoid. Fraying, tearing, or detachment of the anteroinferior glenoid labrum and articular defects in the posterolateral humeral head were also consistent findings, thought to be secondary to repeated injury as the humeral head translates forward and backward in the glenoid fossa. In several cases the classic "click" that occurs with subluxation of the shoulder could be reproduced under arthroscopic visualization and corresponded to the defect in the posterolateral humeral head riding over the torn labrum and/or anterior glenoid rim. Shoulder arthroscopy is an accurate method for confirming the clinical impression of subluxation of the shoulder, especially in subtle glenohumeral instability, and should be helpful in selecting specific surgical reconstruction procedures.     

Radiographic evaluation of the Hill-Sachs lesion in patients with recurrent anterior shoulder instability

The Hill-Sachs lesion is an important bony sign of previous anterior shoulder dislocation and instability. Using orthographic projection, we evaluated the Hill-Sachs lesion in 30 shoulders in 27 patients with recurrent anterior shoulder instability. This produced a clear and undistorted view of the posterolateral notch. For orthographic imaging, the patient was placed supine with the arm in 135 degrees of flexion and 15 degrees of internal rotation. The x-ray beam was angled vertically through the humeral head. The width and depth of the posterolateral notches were measured on the orthographic radiographs. The average posterolateral notch depths were 3.9 +/- 0.9 mm in the dislocation group and 2.1 +/- 1.0 mm in the subluxation group. A shallow Hill-Sachs lesion was indicative of a greater degree of anterior instability of the shoulder.     

Articular arc length mismatch as a cause of failed Bankart repair

Summary: The purpose of this article is to recognize an often overlooked cause of failed anterior stabilization procedures of the shoulder. Hill-Sachs lesions are common occurrences after anterior dislocation. But despite the frequency of occurrence, they are commonly not addressed in the treatment of recurrent anterior dislocation. The Hill-Sachs lesion produces a shortened rotational arc length of the humeral head on the glenoid; any engagement of the defect with the glenoid produces a sensation in the patient of subluxation/dislocation. However, instead of subluxation/dislocation, the sensation may be caused by mismatch between the articular arc length of the humeral head and the glenoid. The literature concerning the Hill-Sachs lesion and its association with recurrent dislocation has been reviewed. There is no recognition in the literature of this articular arc length mismatch as a cause of failed anterior stabilization procedures. We present a case in which a Hill-Sachs lesion was the cause of a perceived recurrent subluxation/dislocation of the shoulder.Arthroscopy: The Journal of Arthroscopic and Related surgery, Vol 16, No 7 (October), 2000: pp 740–744     

Long-term results of total shoulder arthroplasty following bone-grafting of the glenoid.

BACKGROUND: The marked loss of glenoid bone volume or alteration of glenoid version can affect glenoid component fixation in patients undergoing total shoulder arthroplasty. The purpose of this study was to evaluate the long-term results associated with the use of bone-grafting for restoration of glenoid volume and version at the time of total shoulder arthroplasty. METHODS: Twenty-one shoulders received an internally fixed, corticocancellous bone graft for the restoration of peripheral glenoid bone stock at the time of total shoulder arthroplasty between 1980 and 1989. Grafting was indicated when glenoid bone stock was insufficient to maintain adequate version or fixation of the prosthesis. Seventeen shoulders were available for follow-up; the average duration of follow-up for the thirteen shoulders that did not have prosthetic failure within the first two years was seventy months. Total shoulder arthroplasty was performed because of osteoarthritis in five shoulders, chronic anterior fracture-dislocation in five, capsulorrhaphy arthropathy in three, inflammatory arthritis in two, recurrent dislocation in one, and failure of a previous arthroplasty in one. All patients had some form of anterior or posterior instability preoperatively. There were five anterior and twelve posterior glenoid defects. Bone from the resected humeral head was used for grafting in fifteen shoulders, and bicortical iliac-crest bone was used in two. RESULTS: The average glenoid version after grafting was 4 degrees of retroversion, with an average correction of 33 degrees. The graft failed to maintain the original correction in three shoulders due to nonunion, dissolution, or shift. Five total shoulder replacements failed, necessitating glenoid revision at two to ninety-one months postoperatively. The failures were associated with recurrent massive cuff tears (one shoulder), persistent instability (two shoulders), improper component placement (one shoulder), and loss of graft fixation (one shoulder). There were no humeral component failures. According to the criteria of Neer et al., the functional result was rated as excellent in three shoulders, satisfactory in six, and unsatisfactory in eight. CONCLUSIONS: Despite the finding that eight shoulders had an unsatisfactory functional result at the time of longterm follow-up, corticocancellous grafting of the glenoid successfully restored glenoid version and volume in fourteen of the seventeen shoulders in the present study. Patients with glenoid deficiency often have associated glenohumeral instability, which may affect the results of total shoulder arthroplasty. Bone-grafting of the glenoid is a technically demanding procedure that can restore bone stock in patients with structural defects.     

Focal cortical bone loss at the inferior aspect of the glenoid: A new radiographic sign of anterior shoulder instability

This report describes the detection of localized cortical bone loss at the inferior glenoid with the use of anteroposterior radiographs of the shoulder. This bone loss was noticed in two of 100 patients who had recurrent anterior instability of traumatic origin. Double-contrast arthrography and the operative findings disclosed that this lesion coincided anatomically with the scapular insertion of the detached anterior capsule. A survey of 544 radiographs from patients who had various other shoulder disorders did not detect any similar bony changes. Thus this pattern of bone loss, although small and uncommon, appears to be a new radiographic sign of damage to the anterior capsular mechanism.     

Anatomical glenoid reconstruction via a J-bone graft for recurrent posttraumatic anterior shoulder dislocation

Objective

To reconstruct the anatomical glenoid shape in cases of osseous glenoid rim defects after recurrent posttraumatic anterior shoulder dislocation to restore stability without severely compromising the range of motion.

Indications

Osseous glenoid defects after recurrent posttraumatic anterior shoulder dislocation. Suitable for primary stabilization as well as for revision surgery in cases previously operated on.

Contraindications

Recurrent anterior shoulder dislocations without glenoid rim defects. Hyperlax shoulders with multidirectional instability. Patients over 60?years of age due to compromised bone quality. Teenage patients due to incomplete apophyseal fusion at the iliac crest.

Surgical technique

The subscapularis tendon and capsule are split. The humeral head is retracted laterally, and the glenoid defect is prepared and abraded with a rasp. A bicortical iliac crest bone block including crest and outer cortex is harvested and molded in a J-shaped manner. To incorporate the graft, a crevice on the glenoid rim is produced using a chisel. The keel is fitted into the preformed crevice with a spiked impactor. The graft??s surface is contoured using a high-speed burr.

Results

A total of 47?shoulders were followed-up after an average of 90?months (range 25?C152?months). The mean Rowe scores were 94.3 for the affected shoulder and 96.8 for the uninjured shoulder. The Constant scores reached 93.5 and 95?points, respectively. Loss of external rotation was 4.4°. In addition, 24?shoulders were followed-up by computed tomography (CT). There were no recurrences, with the exception of one traumatic graft fracture. Of 19?patients with arthropathy at follow-up, 11?already had arthropathy prior to the procedure.     

Pathomorphologie der Schulterinstabilität

In cases of a traumatic anterior first-time dislocation of the shoulder, pathomorphological changes may initially occur at three different sites: at the capsule itself, at its origin or at its insertion. The typical injury is an avulsion of the labrum and the capsule from the glenoid and is called a Bankart lesion. There is a tendency to underestimate the amount of plastic deformation of the capsule and alternative injuries, such as avulsion of the capsule from the humeral head (HAGL lesion). Bony deformities at the humeral head or at the glenoid are of utmost importance for the prognosis of shoulder instability. In the dislocated position the anterior glenoid rim may notch the posterior surface of the humeral head (Hill-Sachs lesion). Bony defects of the glenoid may be caused by a fracture or due to chronic wear (fracture or erosion type). If bony defects exceed a certain size, isolated reconstruction of soft tissues does not guarantee stability of the shoulder.     

The roentgenographic evaluation of anterior shoulder instability

Retrospective evaluations of roentgenograms of 83 patients with unilateral shoulder instability were surveyed to evaluate the usefulness of various radiographic projections and to correlate the information with the osseous pathology associated with prior glenohumeral dislocation. The Hill-Sachs and the osseous Bankart defects were considered pathognomonic radiographic signs of glenohumeral joint instability. Based on history, physical examination, and examination under general anesthesia, patients were divided into three categories--(1) dislocation group, (2) subluxation group, and (3) combination group. Roentgen projections evaluated included the anteroposterior view with the humerus in internal and external rotation, axillary view, West Point view, Stryker notch, and Didiee view. The Hill-Sachs defect on the posterolateral aspect of the humeral head was best demonstrated on the combination of an internal rotation and a Stryker notch view. The osseous Bankart defect on the anteroinferior glenoid rim was best documented on the Didiee and West Point views. The external rotation and axillary view did not add significantly to the preoperative radiographic findings. In a patient with an unstable shoulder, a radiographic series that includes an internal rotation, a Stryker notch view, and either a West Point or a Didiee view would maximize the diagnostic yield per radiographic cost, time, and exposure.     

New quantitative measurement of the Hill–Sachs lesion: a prognostic factor for clinical results of arthroscopic glenohumeral stabilization

Purpose

A detailed morphometry of the Hill–Sachs lesion and quantification of its volume was studied in 71 patients with traumatic anterior shoulder instability with radiographs and computerized arthrotomography.

Methods

The accuracy of the conventional radiographs and Bernageau view to visualize the humeral and the glenoid lesion was also assessed. This study also analysed the depth of the Hill–Sachs lesion (D) and the humeral head radius (R) from conventional radiograph and its location from the computerized arthrotomography. All the findings were analysed and correlated with the outcome of the arthroscopic stabilization procedure.

Results

Sensitivity for demonstrating the Hill–Sachs lesion for the 45° internal rotation anteroposterior radiograph was 84%, whereas sensitivity for demonstrating the glenoid lesion for the comparative Bernageau view was 68%. The mean D/R ratio, the lateralization angle and the volume of the Hill–Sachs lesion were 16.2%, 188° and 1,019?mm3, respectively. The mean Hill–Sachs lesion volume represented 2.28% of the total humeral head volume. The D/R ratio, the lateralization angle and the volume of the Hill–Sachs lesion were significantly high in the recurrent dislocation group, whereas the D/R ratio and the lesion volume were also significantly high in the group that did not perform well following the stabilization procedure. The recurrence rate in this study was 16.6%, majority being from the recurrent dislocation group.

Conclusion

This study confirms the interest as risk factor for a simple and reproducible radiographic quantitative measure of the Hill–Sachs lesion: D/R.

Level of evidence

II.     

Humeral avulsion of glenohumeral ligaments as a cause of anterior shoulder instability

The avulsion of the glenohumeral ligament labral complex at the glenoid (Bankart lesion), as well as ligamentous laxity are well known causes of anterior shoulder instability. A lesser known entity, the humeral avulsion of glenohumeral ligaments (HAGL), was studied to determine its incidence and its role in anterior glenohumeral instability. Sixty-four shoulders with the diagnosis of anterior instability were prospectively evaluated by arthroscopy for intraarticular pathology, including Bankart, capsular laxity, and HAGL lesions. Six shoulders were found to have HAGL lesions (9.3%), 11 shoulders with generalized capsular laxity (17.2%), and 47 shoulders with Bankart lesions (73.5%). In patients with documented anterior instability without a demonstratable “primary” Bankart lesion, a HAGL lesion should be ruled out. This lesion is readily recognized arthroscopically, and an appropriate repair of this lesion can restore anterior stability to the patient. The pathological anatomy of the HAGL lesion and our treatment of this lesion is discussed.     

Arthroskopische J-Span-Implantation bei knöchernem Glenoiddefekt

Background

Glenoid defect is a significant risk factor for recurrent shoulder instability and influences the surgical outcome. In case of a relevant bony Bankart lesion, sole soft-tissue stabilization (Bankart repair) is not recommended due to a high risk of recurrence. As a consequence, various open surgical techniques have been successfully applied for shoulder stabilization with concomitant anterior glenoid defect. However, only a few short-term studies report the outcome of bony glenoid augmentation via arthroscopic techniques. In the following study, 1-year results of clinical and radiographic outcome of all-arthroscopic J-bone grafting are presented.

Material and methods

Ten consecutively admitted patients (9 men, 1 women, mean age 29.1 years) with traumatic recurrent ventral shoulder instability with bony glenoid defect were prospectively evaluated before, 3 and 12 months after all-arthroscopic anatomic glenoid restoration surgery using a J-shaped iliac crest bone graft. Data of interest were a clinical examination, the Constant Score (CS), the Rowe Score (RS), and the Subjective Shoulder Value (SSV). In addition to standard radiographs, a computed tomography was performed at each point in time to evaluate glenoid defect, glenoid cavity, and graft remodeling.

Results

The mean CS (69.40?±?10.03 preoperatively) and the RS (57.70?±?16.47 preoperatively) improved significantly to 94.20?±?4.98 and 96.35?±?3.79, respectively. In all, 7 patients reported to be very satisfied, while 3 were fairly satisfied (SSV). The average glenoid bone defect (18.66?%?±?4.40 preoperatively) was reduced immediately after the operation to 4.55?%?±?3.40. Due to anatomical glenoid remodeling, the bony defect increased to 10.26?%?±?3.47 after 1 year. No complications were reported and no recurrent instability occurred during the entire follow-up period.

Conclusion

The study showed for the first time that all-arthroscopic anatomic glenoid reconstructive surgery using the J-bone graft provides good clinical and radiological results 12 months after surgery.

     

Iliac crest allograft glenoid reconstruction for recurrent anterior shoulder instability in athletes: Surgical technique and results

Performing a labral repair alone in patients with recurrent anterior instability and a large glenoid defect has led to poor outcomes. We present a technique involving the use of the iliac crest allograft inserted into the glenoid defect in athletes with recurrent anterior shoulder instability and large bony defects of the glenoid (>25% of glenoid diameter). All athletes with recurrent anterior shoulder instability and a large glenoid defect that underwent open anterior shoulder stabilization and glenoid reconstruction with the iliac crest allograft were followed over a 4-year period. Preoperatively, a detailed history and physical exam were obtained along with standard radiographs and magnetic resonance imaging of the affected shoulder. All patients also completed the Simple Shoulder Test (SST) and American Shoulder and Elbow Surgeons (ASES) evaluation forms preoperatively. A computed tomography scan was obtained postoperatively to assess osseous union of the graft and the patient again went through a physical exam in addition to completing the SST, ASES, and Western Ontario Shoulder Instability Index (WOSI) forms. 10 patients (9 males, 1 female) were followed for an average of 16 months (4–36 months) and had a mean age of 24.4 years. All patients exhibited a negative apprehension/relocation test and full shoulder strength at final follow-up. Eight of 10 patients had achieved osseous union at 6 months (80.0%). ASES scores improved from 64.3 to 97.8, and SST scores improved from 66.7 to 100. Average postoperative WOSI scores were 93.8%. The use of the iliac crest allograft provides a safe and clinically useful alternative compared to previously described procedures for recurrent shoulder instability in the face of glenoid deficiency.     

Glenohumeral osteometry by computed tomography in normal and unstable shoulders

Past radiologic and anthropometric studies report a high incidence of glenoid anteversion and increased humeral retrotorsion in patients with recurrent anterior dislocation (RAD) of the shoulder. However, recent radiologic studies do not demonstrate significant developmental variations between normal and unstable shoulders. To investigate these conditions, the authors used computed tomography (CT), which offered the advantage of permitting a transverse view at different levels of the glenohumeral joint. CT also avoided the typical distortion inherent in plain radiographs performed in the axial projection. No significant developmental differences in glenohumeral index, glenoid anteroposterior orientation, and humeral retrotorsion were found between 50 normal subjects and 40 patients with RAD. Only erosions and fractures of the glenoid may affect orientation and anteroposterior diameter of the glenoid. Mainly, traumatic lesions rather than developmental abnormalities seem to affect these parameters in RAD patients.     

Arthroscopic osseous Bankart repair for chronic recurrent traumatic anterior glenohumeral instability

BACKGROUND: A chronic osseous Bankart lesion has traditionally been treated with soft-tissue repair and/or open bone-grafting for a large glenoid defect. We developed an arthroscopic method of osseous reconstruction of the glenoid without bone-grafting. The purpose of this study was to evaluate the postoperative outcomes of our technique for chronic recurrent traumatic anterior glenohumeral instability. METHODS: A consecutive series of forty-two shoulders in forty-one patients with chronic recurrent traumatic glenohumeral instability underwent an arthroscopic osseous Bankart repair. All shoulders were evaluated preoperatively with three-dimensionally reconstructed computed tomography, which confirmed an osseous fragment at the anteroinferior portion of the glenoid. The average bone loss in the glenoid was 24.8% (range, 11.4% to 38.6%), and the average fragment size was 9.2% (range, 2.1% to 20.9%) of the glenoid fossa. In all shoulders, a displaced osseous fragment, firmly attached to the labroligamentous complex, was separated from the glenoid neck before reduction and fixation in the optimal position with use of suture anchors. All patients were assessed with use of the scoring systems of Rowe et al. and the University of California at Los Angeles preoperatively and at the final evaluation. RESULTS: The mean duration of follow-up was thirty-four months. At that time, thirty-nine of the forty-two shoulders were rated as having a good or excellent result. The mean Rowe score improved from 33.6 points preoperatively to 94.3 points postoperatively (p < 0.01). The mean score on the University of California at Los Angeles system improved from 20.5 points preoperatively to 33.6 points at the final evaluation (p < 0.01). The average passive external rotation was 75 degrees with the arm at the side and 93 degrees with the arm at 90 degrees of abduction. Two patients had a reinjury. Eventually, thirty-five of thirty-seven patients who were active participants in sports returned to the sport they had played before the injury. CONCLUSIONS: Arthroscopic osseous Bankart repair with use of suture anchors yields a successful outcome even in shoulders with a chronic large glenoid defect.     

Die arthroskopische Bankart-Operation mit Hilfe von resorbierbaren Nahtankern

OBJECTIVE: Arthroscopic refixation of the labrum-ligament complex at the glenoid. INDICATIONS: Posttraumatic anterior or anterior-inferior shoulder instability with Bankart or ALPSA lesion (anterior labral periosteal sleeve avulsion). CONTRAINDICATIONS: Atraumatic shoulder instability. Instabilities due to blunted or frayed degeneration of the labrum-ligament complex. HAGL lesion (humeral avulsion of the glenohumeral ligaments) with humeral detachment of the glenohumeral ligaments. Larger bony glenoid defects. SURGICAL TECHNIQUE: Mobilization of the labrum-ligament complex from the neck of the glenoid, superior tightening and refixation at the glenoid rim with the aid of absorbable suture anchors. POSTOPERATIVE MANAGEMENT: Immobilization of the affected arm for 4 weeks in an immobilization bandage with abduction pillows. Daily pendulum exercises. Active flexion up to 70 degrees and abduction up to 40 degrees, all in neutral or internal rotation. Avoidance of external rotation for a total of 6 weeks. RESULTS: From January 1999 to December 2001, 58 patients with a Bankart or ALPSA lesion were treated with arthroscopic shoulder stabilization using absorbable suture anchors and slowly absorbable braided sutures. 56 patients underwent a follow-up clinical examination after, on average, 31 months (24-48 months). None of these patients had suffered more than five shoulder dislocations before the operation (average 2.8). Of the intraoperative lesions, a plain Bankart lesion was present in twelve patients (21.4%), 44 patients had an ALPSA lesion (78.6%), of which one in two were combined with an SLAP 2 or SLAP 3 lesion (superior labrum from anterior to posterior). In the evaluation using the Rowe Score, there was an excellent result for 40 patients (71.4%), and a good result for twelve (21.4%). Four patients suffered a repeat dislocation and were therefore classified as poor results (7.2%).     

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

Purpose: Our goal was to analyze the results of 194 consecutive arthroscopic Bankart repairs (performed by 2 surgeons with an identical suture anchor technique) in order to identify specific factors related to recurrence of instability. Type of Study: Case series. Materials and Methods: We analyzed 194 consecutive arthroscopic Bankart repairs by suture anchor technique performed for traumatic anterior-inferior instability. The average follow-up was 27 months (range, 14 to 79 months). There were 101 contact athletes (96 South African rugby players and 5 American football players). We identified significant bone defects on either the humerus or the glenoid as (1) “inverted-pear” glenoid, in which the normally pear-shaped glenoid had lost enough anterior-inferior bone to assume the shape of an inverted pear; or (2) “engaging” Hill-Sachs lesion of the humerus, in which the orientation of the Hill-Sachs lesion was such that it engaged the anterior glenoid with the shoulder in abduction and external rotation. Results: There were 21 recurrent dislocations and subluxations (14 dislocations, 7 subluxations). Of those 21 shoulders with recurrent instability, 14 had significant bone defects (3 engaging Hill-Sachs and 11 inverted-pear Bankart lesions). For the group of patients without significant bone defects (173 shoulders), there were 7 recurrences (4% recurrence rate). For the group with significant bone defects (21 patients), there were 14 recurrences (67% recurrence rate). For contact athletes without significant bone defects, there was a 6.5% recurrence rate, whereas for contact athletes with significant bone defects, there was an 89% recurrence rate. Conclusions: (1) Arthroscopic Bankart repairs give results equal to open Bankart repairs if there are no significant structural bone deficits (engaging Hill-Sachs or inverted-pear Bankart lesions). (2) Patients with significant bone deficits as defined in this study are not candidates for arthroscopic Bankart repair. (3) Contact athletes without structural bone deficits may be treated by arthroscopic Bankart repair. However, contact athletes with bone deficiency require open surgery aimed at their specific anatomic deficiencies. (4) For patients with significant glenoid bone loss, the surgeon should consider reconstruction by means of the Latarjet procedure, using a large coracoid bone graft.Arthroscopy: The Journal of Arthroscopic and Related surgery, Vol 16, No 7 (October), 2000: pp 677–694     

Glenoid Avulsion of the Glenohumeral Ligaments as a Cause of Recurrent Anterior Shoulder Instability

Although the Bankart lesion is accepted as the primary pathology responsible for recurrent shoulder instability, recognition of other soft-tissue lesions has improved the surgical treatment for this common problem. Whereas humeral avulsion of the glenohumeral ligaments has been acknowledged as a cause of anterior shoulder instability, we have not found any reported cases of glenoid avulsion of the glenohumeral ligaments. We describe 3 cases of recurrent anterior shoulder instability due to glenoid avulsion of the glenohumeral ligaments. The avulsed ligaments were repaired to the labrum and glenoid, restoring the glenohumeral ligament–labral complex.