Coordinated interaction between static, dynamic, and

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1 REVIEW ARTICLE Matthew J. Bollier, MD* and Robert Arciero, MDw Abstract: Glenoid and humeral head bone deficiency is a common reason for recurrent anterior shoulder instability and failure of capsulolabral reconstruction. There is a strong association between the severity of the bone defects and the number and ease of recurrent instability. Clinical evaluation, advanced imaging, examination under anesthesia, and diagnostic arthroscopy are important in decision making. Glenoid bone loss greater than 20%, an engaging Hill-Sachs lesion, or Instability Severity Index Score greater than 6 are indications for an open bony procedure to restore the glenoid articular arc. Hill-Sachs lesions greater than 30% should be directly addressed with either an arthroscopic remplissage technique or open bone grafting procedure. Key Words: glenoid, humeral head, instability, shoulder, bone loss, Latarjet, Bankart, Hill-Sachs (Sports Med Arthrosc Rev 2010;18: ) Coordinated interaction between static, dynamic, and bony structures is necessary to keep the humeral head centered on the glenoid. 1,2 Instability may result from disruption of static stabilizers (labrum, capsule, and glenohumeral ligaments), dynamic stabilizers (rotator cuff musculature), or the normal articular anatomy. After an initial traumatic dislocation, the most common pathology involves anteroinferior capsulolabral avulsion with or without associated glenohumeral ligament attenuation. 3,4 Several factors have been found to affect recurrence rates including age of the patient, contact sports, hyperlaxity, and significant bone loss. 5,6 Humeral head impression defects or anteroinferior glenoid bone loss play a large role in recurrent instability by altering the glenohumeral joint contact area, congruency, and function of the static restraints Although glenoid defects are present in only 22% of patients with acute dislocations, they are found 73% of the time in recurrent dislocations. 11,12 In the senior author s practice, 8% of all shoulder instability requiring surgical stabilization will require specific attention to bone loss of the glenoid or humeral head. The management of bone deficiency in shoulder instability has been a challenge to surgeons for many years. Nonanatomic procedures have been shown to prevent recurrent instability but are associated with stiffness and arthritis. 13 Over the last 10 years, a considerable amount of research has been devoted in understanding the role of bone deficiency in recurrent shoulder instability. Our purpose is to review the optimal management of patients with bone loss and shoulder instability. TYPES OF BONE DEFECTS Glenoid bone loss has been found in 49% to 86% of patients with recurrent instability. 1,14 16 Humeral head impression defects have been found in 70% of shoulders sustaining a first-time dislocation and 93% to 100% of shoulders with recurrent instability A direct correlation has been established between the severity of bone defects and the number of recurrent instability events. 8,16,20 In the presence of an engaging Hill-Sachs lesion, bone deficiency can be present on both the glenoid and humeral head. These lesions significantly reduce functional range of motion by increasing the ease of dislocation in lower degrees of abduction and external rotation. Glenoid Bone Loss Attritional glenoid bone loss from recurrent instability and fragment resorption leads to an inverted-pear glenoid (glenoid is wider superiorly than inferiorly) (Fig. 1). 10,21,22 Anteroinferior glenoid bone deficiency decreases the normal glenoid articular arc and concavity-compression restraint leading to decreased resistance to anterior humeral head dislocation. With a significant amount of bone deficiency, the humeral head is able to dislocate anteriorly with only minimal amounts of translation. There has been much debate on how to quantify anterior bone loss and how much bone loss is needed for a significant defect. Burkhart and DeBeer 10 found a 4% recurrence rate after arthroscopic Bankart repair without the presence of significant bone defects (greater than 25% loss of inferior glenoid diameter or engaging Hill-Sachs lesion) and a 67% recurrent instability rate in athletes with significant bone defects (greater than 25% loss of inferior glenoid diameter or engaging Hill-Sachs lesion). Gerber and Nyffeler 23 reported a greater than 30% loss of resistance to anterior From the *Department of Orthopaedic Surgery, University of Iowa, Iowa City, IA; and wdepartment of Orthopaedic Surgery, University of Connecticut, Connecticut, CT. Reprints: Matthew Bollier MD, Department of Orthopaedics and Rehabilitation, University of Iowa Hospitals and Clinics, 200 Hawkins Drive, JPP, Iowa City, IA ( mattbollier@yahoo.com). Copyright r 2010 by Lippincott Williams & Wilkins FIGURE 1. Inverted pear glenoid. Arthroscopy picture with the scope in the anterior superior portal looking inferiorly. There is obvious anteroinferior glenoid bone loss and a labral tear Sports Med Arthrosc Rev Volume 18, Number 3, September 2010

2 Sports Med Arthrosc Rev Volume 18, Number 3, September 2010 shoulder dislocation when the length of the anteroinferior rim defect was more than half of the maximal anteroposterior (AP) inferior glenoid diameter (Fig. 2). Itoi and colleagues 7 performed sequential osteotomies in cadaver shoulders of the anteroinferior glenoid and found that stability to anterior translation was significantly less with a bony defect greater than 21% of the diameter of the glenoid. 7 It is clear that increasing glenoid bone defect size correlates with decreased stability of the glenohumeral joint. 23,24 Although there is no agreement on the exact amount of bone loss needed for a significant lesion, most experts suggest between 20% and 30%. Humeral Head Impression Fracture (Hill-Sachs Lesion) Hill-Sachs lesions involve an impression defect in the posterolateral humeral head when the soft humeral head contacts the hard glenoid rim during an anterior shoulder dislocation (Fig. 3A). Lesions less than 20% of the humeral head curvature are typically are not significant causes of instability. 2,11 Hill-Sachs lesions greater than 40% are considered large and directly correlate with the presence of recurrent instability. 2,16 Hill-Sachs defects between 20% and 40% may be significant, but depend on the location, orientation, and engagement of the lesion with the anteroinferior glenoid. An engaging Hill-Sachs lesion typically falls into the glenoid rim defect as the shoulder is externally rotated and always leads to recurrent shoulder instability (Fig. 3B). 9,22 In addition, isolated soft tissue stabilization in the presence of an engaging Hill-Sachs lesion has a high rate of failure. 10 DIAGNOSIS History and Physical Examination Initial evaluation of the patient with recurrent anterior instability should include a complete history of the onset, FIGURE 3. A, Hill-Sachs lesion on radiograph. Hill-Sachs lesion is seen on an anteroposterior shoulder x-ray. B, Engaging Hill-Sachs lesion. Arthroscopic picture viewing from the posterior portal. The humeral head is engaging the glenoid defect and dislocating anterior. FIGURE 2. Anteroinferior glenoid bone defect size and resistance to dislocation. This graph shows the relation between size of an anteroinferior bony glenoid rim. Defect (x) and dislocation resistance of the humeral head. If the glenoid rim lesion measures more than half of the maximal anteroposterior diameter of the glenoid fossa (w), the dislocation resistance is 30% less than the intact joint. Adapted with permission from Clin Orthop Relat Res. 2002;400:65 76 (Figure 6). chronology, and frequency of dislocations. Other pertinent information includes the position of the arm at the time of dislocation and nonoperative or operative treatments to date. The ease and frequency of instability episodes increases the likelihood of significant bone defects. 8,19,25 Anterior shoulder dislocation that occurs with activities of daily living, sleep, or at lower arm abduction angles is associated with large glenoid or humeral head lesions. In addition, significant bone defects are suspected in patients who have failed in arthroscopic capsulolabral reconstruction and in patients who report many dislocation events in a short period of time. Patients with an engaging Hill-Sachs lesion may complain of pain, crepitus, or catching as the humeral head falls into the glenoid defect when the arm is abducted and externally rotated. Physical examination begins with an inspection of the shoulder contour, muscle symmetry, and active and passive range of motion. Assessment of laxity with translation tests and instability with apprehension tests is essential. The load and shift test will identify the direction of instability and r 2010 Lippincott Williams & Wilkins 141

3 Bollier and Arciero Sports Med Arthrosc Rev Volume 18, Number 3, September 2010 must be performed in the plane of the scapula with the scapula stabilized (Fig. 4). A load is applied so that the humeral head is compressed into the center of the glenoid. The humeral head is then shifted in an anterior and posterior direction. Decreased resistance will be felt with a defect in the anterior glenoid rim and any grinding or crepitus may indicate a bone defect. Translation can be graded by assessing movement of the humeral head over the glenoid rim: 1+ to the rim, 2+ over the rim, and 3+ locked. The apprehension and relocation test will reproduce the patients symptoms with the arm abducted and externally rotated. Patients who present with apprehension and guarding at lower degrees of abduction are more likely to have significant bone deficiencies. 25 Bone Loss Assessment Bone deficiency of the glenoid and the humeral head can be assessed with plain radiographs, computed tomography (CT) scan, and at the time of arthroscopy. Although magnetic resonance imaging is valuable in assessing the location and degree of soft tissue injury, it often underestimates the degree of bone loss. Routine radiographs consist of an AP, trans-scapular lateral, and axillary view and may confirm the direction of dislocation, associated bone defects, or fracture. A modified axillary radiograph, the West Point view, specifically examines glenoid bone loss (Fig. 5). Itoi and colleagues 26 have reported that the West Point view demonstrates a high correlation with CT in estimating glenoid bone loss. The patient is positioned prone with the head turned to the contralateral side and the x-ray beam is angled 25 degrees from the midline and directed through the axilla. CT scan is the imaging modality of choice to evaluate bone deficiencies. Indications for obtaining a CT include significant apprehension in lower levels of abduction, instability with minimal provocation, multiple instability events, revision surgery, and any bone loss detected on plain radiographs. Many authors now advocate the use of 3-dimensional CT with digital subtraction of the humeral head (Fig. 6). 1,19,27 The anteroinferior bone defect can be quantified as a percentage of the inferior glenoid surface area. A circle outlining the inferior two-thirds of the glenoid is drawn and the amount of bone missing from the circle is calculated as a percentage of the total surface area of the circle. 1,28 In addition, the length of the anteroinferior FIGURE 5. West point axillary x-ray. West point axillary radiograph showing a glenoid rim fracture. glenoid defect can be calculated on the sagittal cuts and if this lesion is greater than the normal AP radius of the inferior glenoid, a 30% loss of resistance to anterior dislocation can be expected with concern for soft tissue reconstruction failure (Fig. 2). 23 Hill-Sachs lesions can be FIGURE 4. Load and shift test. The load and shift test is performed with an axial load to the arm and anterior and posterior humeral head translation. FIGURE 6. CT scan of glenoid bone deficiency. Three-dimensional CT scan showing anteroinferior glenoid bone deficiency. CT indicates computed tomography r 2010 Lippincott Williams & Wilkins

4 Sports Med Arthrosc Rev Volume 18, Number 3, September 2010 quantified on either the coronal or axial cuts by dividing the defect arc with the humeral head arc to obtain a percentage of bone loss. 24 Significant glenohumeral bone loss can be identified at arthroscopy by looking for the inverted-pear glenoid (greater than 25% loss of the inferior glenoid diameter) or an engaging Hill-Sachs lesion. 10 The glenoid bone defect can be assessed arthroscopically with the camera in the anterior superior portal. The distances from the posterior glenoid to the bare area and from the bare area to the anterior rim are measured. In the normal glenoid, the anterior and posterior rims are equidistant from the central bare area. Anteroinferior glenoid bone loss can be determined by dividing the distance from the bare area to the anterior rim by the 2 the distance from the bare area to the posterior rim. 1,21 During diagnostic arthroscopy, the arm can be taken out of traction and put through a range of motion. If the humeral head falls into the anterior-inferior glenoid defect with the arm in an abducted, externally rotated position, an engaging Hill-Sachs lesion is present (Fig. 3B). TREATMENT Surgical Decision Making Arthroscopic soft tissue repair alone is appropriate in the presence of a nonengaging Hill-Sachs lesion (continuous contact of the articular surfaces as the humeral head passes across the anterior glenoid) and glenoid bone loss less than 20% (Fig. 7). 10,16,26,29,30 In an attempt to preoperatively predict success or failure with arthroscopic soft tissue repair, Balg and Boileau 31 recently reported the Instability Severity Index Score. It is based on a preoperative questionnaire, clinical examination, and review of radiographs. Patients are given 2 points if they are below 20 years of age, participate in a competitive sport, have a Hill-Sachs lesion visible on an AP radiograph in external rotation, or have loss of glenoid contour on an AP radiograph. They are given 1 point if they participate in a contact or overhead sport or have shoulder hyperlaxity. Patients with a score greater than 6 points had a recurrence rate of 70% with soft tissue repair alone. 31 In patients with a score greater than 6 points, an open procedure to address the bony defect is recommended. In the presence of significant glenoid bone deficiency, the anterior soft tissue structures may not be able to resist the displacing force. Burkhart and DeBeer 10 reported a 67% recurrence rate after soft tissue stabilization in athletes with significant bone defects. They noted an 89% failure rate in contact athletes with bone defects and soft tissue repair. Other authors reported good outcomes with arthroscopic stabilization for recurrent instability in the presence of glenoid bone defects. 32,33 Mologne and colleagues 33 reported a 14% failure rate of arthroscopic stabilization in 21 patients with greater than 20% anteroinferior bone loss. Each of their failures had attritional bone loss without a specific detached fragment. The success of arthroscopic stabilization in the presence of bone loss is higher when the bony fragment can be incorporated into the repair. 1,28 Pagnani 32 had a 2% overall recurrence rate after open capsular repair in the presence of bony deficiency. However, only 4% of patients had severe (>20%) bone defects. Clinical evaluation and Standard shoulder radiographs Instability during sleep or with increasing ease Multiple recurrences Apprehension at low abduction angles Radiographic evidence of bone deficiency or Hill-Sachs No evidence of bony deficiency on clinical exam or imaging Arthroscopic Evaluation CT scan Glenoid bone loss >20% Engaging Hill-Sachs Glenoid bone loss < 20% Non-engaging Hill-Sachs Good tissue quality Hill-Sachs > 40% Significant arthritic changes Glenoid bone loss > 20% Glenoid bone loss < 20% Hill-Sachs lesion > 30% Engaging Hill- Sachs Deficient tissues HAGL lesion Arthroscopic soft tissue capsulolabral repair Hemiarthroplasty +/- glenoid resurfacing Open Latarjet or glenoid bone grafting procedure to extend articular arc Arthroscopic soft tissue capsulolabral repair Remplissage procedure or open humeral head bone grafting Open soft tissue capsulolabral repair FIGURE 7. Algorithm for managing humeral head and glenoid bone loss. CT indicates computed tomography; HAGL, humeral avulsion of glenohumeral ligament. r 2010 Lippincott Williams & Wilkins 143

5 Bollier and Arciero Sports Med Arthrosc Rev Volume 18, Number 3, September 2010 FIGURE 9. Anteroinferior glenoid is exposed and prepared. FIGURE 8. A, Coracoid is osteotomized anterior to coracoclavicular ligaments. B, An angled saw blade achieves the proper angle of approach. Adapted with permission from Arthroscopy. 2007;23: Indications for an open bony procedure to extend the glenohumeral articular arc include anteroinferior bone loss greater than 20%, an engaging Hill-Sachs lesion, or Instability Severity Index Score greater than 6 (Fig. 7). 10,16,29,31 Transfer of the coracoid tip and conjoined tendon (Bristow procedure) has been used historically as a bone block to resist anterior glenohumeral translation. Successful long-term results can be achieved in preventing recurrent anterior instability, but concerns exist regarding the development of arthropathy and loss of external rotation. 1,19,34 36 Current recommendations include the Latarjet procedure or iliac crest bone graft. 9,10,37 The Latarjet procedure involves osteotomizing the coracoid process at its base, rotating the graft 90 degrees, passing it through a split in the subscapularis, and securing it flush to the anterior glenoid with screws. This increases the arc of motion by extending the glenoid margin, restores bony architecture, and provides tension to the lower subscapularis. Iliac crest autograft and allograft and distal tibia allograft have also been described to address glenoid bone deficiency Similar to the Latarjet procedure, these techniques extend the glenoid arc to increase the amount of translation or excursion needed for dislocation. These grafts may be better for larger glenoid lesions, but lower union rates may be a concern. Outcomes after bony stabilization procedures have been encouraging. Burkhart and colleagues 9 reviewed outcomes on 102 patients treated with the modified Latarjet procedure for glenoid bone loss greater than 25%. Four percent of patients sustained a recurrent dislocation, 5% had instability complaints, and there was an average of 5 degree loss of external rotation with the arm adducted. Auffarth and colleagues 37 reported no recurrences and 1 traumatic graft failure with iliac crest bone graft transfer to the glenoid rim. Allain and colleagues 41 reported on 56 patients followed for an average of 14 years after the Latarjet procedure. 41 They had no recurrent dislocations and 12% of patients complained of recurrent instability. Although the Latarjet procedure has been effective in preventing recurrent instability, it is a nonanatomic reconstruction and there is in an increased risk of osteoarthritis at long-term follow-up. When an engaging Hill-Sachs lesion is discovered, there is often associated anteroinferior glenoid bone deficiency. It is important to provide bony stability so that the arc of motion between the humerus and glenoid is sufficient in the patient s desired range of motion. Treatment of the humeral head defect depends on the amount of glenoid bone loss (Fig. 7). Most commonly, a large humeral head defect is present in association with a significant glenoid defect. In this case, an open bony procedure can be performed to address the glenoid bone loss and increase the glenoid articular arc to prevent an otherwise engaging Hill-Sachs lesion from translating anteriorly. In this case, the humeral head defect does not usually need to be addressed directly. In the rare case of a humeral head defect with minimal attritional glenoid bone loss, treatment depends on the size of the humeral head defect. In the presence of a small Hill-Sachs lesion (<30%), the humeral head defect can be left alone. A moderate Hill-Sachs lesion (30% to 40%) may require either the remplissage technique, r 2010 Lippincott Williams & Wilkins

6 Sports Med Arthrosc Rev Volume 18, Number 3, September 2010 FIGURE 10. Coracoid is orientated on the glenoid and fixed with 2 cannulated screws. A and B, Coracoid graft fixed to glenoid with two cannulated screws. C, Coracoid graft is extra-articular with suture anchors placed on edge of glenoid. Adapted with permission from Arthroscopy. 2007;23: autograft, or allograft bone grafting, or focal prosthetic resurfacing, depending on the ease of engagement in abduction, external rotation, and the severity of the instability. 13,19,42 45 Hemi-arthroplasty is recommended for large Hill-Sachs lesions (>40%). Approach to Significant Glenoid Bone Loss We routinely order CT scans with 2 and 3-dimensional reconstructions if there is any concern for bone deficiency on history, physical examination, or routine radiographic series. The anteroinferior glenoid on the sagittal images is closely examined and if the length of the cliff is greater than the normal inferior glenoid radius, we assume that bone deficiency is contributing to the instability events. If significant bone loss is present, the patient will be scheduled for a Latarjet procedure with diagnostic arthroscopy in the beach chair position. The beach chair position provides the opportunity to easily convert to open surgery. The examination under anesthesia and diagnostic arthroscopy FIGURE 11. Latarjet fixation: 2 cannulated screws are used to secure the coracoid bone graft to the glenoid defect. The remnant of coracoacromial ligament attached the coracoid is used to attach the anterior capsule. provide valuable information in confirming the chosen procedure. If the patient has 3+ anterior laxity with load and shift test (locks out anteriorly), has greater than 20% anteroinferior glenoid bone loss when viewing from the anterior superior arthroscopy portal, demonstrates a dynamic engaging Hill-Sachs lesion, and has bone loss identified on preoperative imaging studies, a open Latarjet procedure will be performed. A standard deltopectoral approach is used and the coracoid is exposed. The pectoralis minor tendon is detached and the superior aspect of the coracoids is cleared of soft tissue. The coracohumeral ligament is detached leaving a 1 cm stump attached to the coracoid. An osteotomy is performed with a 90 degree oscillating saw just anterior to the coracoclavicular ligaments at the base of the coracoid (Figs. 8A, B). The conjoined tendon remains attached to the coracoid and is released so that adequate excursion exists. The subscapularis is split horizontally at the junction between the superior two-thirds and the inferior one-third. The upper subscapularis is detached and a capsulotomy is performed to gain access to the anteroinferior glenoid. Soft tissue is then removed from the glenoid and a bleeding surface is prepared (Fig. 9). Suture anchors are placed on the anteroinferior glenoid. The coracoid is orientated to fit on the anteroinferior glenoid flush with the glenoid and secured with 2 cannulated screws (Figs. 10, 11). Sutures are passed through the anterior capsule for repair to the glenoid allowing the coracoid graft to sit extra-articularly. The conjoined tendon passes superior to the intact lower one-third of the subscapularis. The upper subscapularis is re-attached with the conjoined tendon exiting between the split in the subscapularis split. Postoperatively, patients remain in a shoulder immobilizer for 4 weeks. Pendulum exercises are allowed after the first week but no formal shoulder range of motion program is started until week 4. Elbow and wrist range of motion is encouraged. After 6 weeks, physical therapy is started, the sling is removed, and patients are allowed to use the arm for activities of daily living. Shoulder strengthening is delayed until 3 months. We do not feel that patients lose range of motion after a Latarjet reconstruction and extraarticular placement of the coracoid graft does not seem to alter postoperative range of motion. r 2010 Lippincott Williams & Wilkins 145

7 Bollier and Arciero Sports Med Arthrosc Rev Volume 18, Number 3, September 2010 FIGURE 12. A, Remplissage: passing suture through posterior capsule and infraspinatus tendon for remplissage technique. A (a and b), Sutures are passed from the Hill-Sachs defect through the posterior capsule and infraspinatus. Adapted with permission from Arthroscopy. 2008;24: (Figure 2). B, Completed remplissage repair with posterior capsule and infraspinatus secured to Hill- Sachs lesion. B (a and b), Posterior capsule and infraspinatus are secured into the Hill-Sachs defect after knot tying. Adapted with permission from Arthroscopy. 2008;24: (Figure 3). Approach to Significant Humeral Head Defect The Hill-Sachs lesion is evaluated on both the coronal and axial CT images. If the defect is greater than 30% of the humeral head arc, we perform either an arthroscopic remplissage technique or open allograft bone grafting in addition to an anterior soft tissue Bankart repair or Latarjet procedure. If the patient has 3+ anterior laxity with load and shift test (locks out anteriorly) and has a large Hill-Sachs lesion confirmed with arthroscopy, it is important to directly address the humeral head. The remplissage technique has been recently popularized by Purchase and colleagues 43 and involves securing the infraspinatus tendon and posterior capsule to the abraded bony surface of the Hill-Sachs lesion with suture anchors. This prevents the Hill-Sachs lesion from engaging the glenoid with shoulder abduction and external rotation. This technique is performed arthroscopically with the scope in the anterosuperior portal. An accessory posterior portal is created that allows anchor placement directly into the Hill- Sachs lesion. The surface of the Hill-Sachs lesion is gently abraded with a burr. The cannula is then withdrawn into the subdeltoid space superficial to the infraspinatus tendon. Two anchors are placed and a penetrating grasper is used to pass suture in a mattress fashion through the posterior capsule and infraspinatus tendon (Fig. 12A). Arthroscopic knots are then tied extra-articularly in the subacromial space compressing the infraspinatus tendon and posterior capsule into the Hill-Sachs lesion (Fig. 12B). Humeral head bone grafting can be performed through a deltopectoral or posterior approach. 42,45 With either approach, the humeral head defect is fully exposed and debrided. When using a deltopectoral approach, r 2010 Lippincott Williams & Wilkins

8 Sports Med Arthrosc Rev Volume 18, Number 3, September 2010 FIGURE 13. A, Large humeral head defect fixed with screws. B, Humeral head allograft radiograph with countersunk screws. significant capsular releases are required so that the humeral head can be dislocated. A humeral head allograft is cut and shaped to fit the Hill-Sachs lesion and secured with counter-sunk screws (Figs. 13A, B). There has been recent interest in prosthetic resurfacing of focal humeral head defects as an alternative to autograft or allograft. Although use of these implants has been limited to case reports, this may be a good option in certain patients. 46 CONCLUSIONS Multiple dislocation events occurring with increasing ease and at lower abduction angles should alert the physician to the possibility of bony defects contributing to shoulder instability. CT scans can provide objective preoperative analysis of the location and degree of bone deficiency and the examination under anesthesia and diagnostic arthroscopy play large roles in treatment decisions. Glenoid bone loss greater than 20%, an engaging Hill- Sachs lesion, or Instability Severity Index Score greater than 6 are indications for an open bony procedure to restore the glenoid articular arc. Hill-Sachs lesions greater than 30% should be directly addressed with either an arthroscopic remplissage technique or open bone grafting procedure. REFERENCES 1. Piasecki DP, Verma NN, Romeo AA, et al. Glenoid bone deficiency in recurrent anterior shoulder instability: diagnosis and management. J Am Acad Orthop Surg. 2009;17: Chen AL, Hunt SA, Hawkins RJ, et al. Management of bone loss associated with recurrent anterior glenohumeral instability. Am J Sports Med. 2005;33: Rowe CR, Patel D, Southmayd WW. The Bankart procedure: a long-term end-result study. J Bone Joint Surg Am. 1978; 60: Urayama M, Itoi E, Sashi R, et al. Capsular elongation in shoulders with recurrent anterior dislocation. Quantitative assessment with magnetic resonance arthrography. Am J Sports Med. 2003;31: Wang RY, Arciero RA. Treating the athlete with anterior shoulder instability. Clin Sports Med. 2008;27: Robinson CM, Howes J, Murdoch H, et al. Functional outcome and risk of recurrent instability after primary traumatic anterior shoulder dislocation in young patients. J Bone Joint Surg Am. 2006;88: Itoi E, Lee SB, Berglund LJ, et al. The effect of a glenoid defect on anteroinferior stability of the shoulder after Bankart repair: a cadaveric study. J Bone Joint Surg Am. 2000;82: Lynch JR, Clinton JM, Dewing CB, et al. Treatment of osseous defects associated with anterior shoulder instability. J Shoulder Elbow Surg. 2009;18: Burkhart SS, De Beer JF, Barth JR, et al. Results of modified Latarjet reconstruction in patients with anteroinferior instability and significant bone loss. Arthroscopy. 2007;23: Burkhart SS, De Beer JF. 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. Arthroscopy. 2000;16: Taylor DC, Arciero RA. Pathologic changes associated with shoulder dislocations. Arthroscopic and physical examination findings in first-time, traumatic anterior dislocations. Am J Sports Med. 1997;25: Calandra JJ, Baker CL, Uribe J. The incidence of Hill-Sachs lesions in initial anterior shoulder dislocations. Arthroscopy. 1989;5: Ochoa E Jr, Burkhart SS. Glenohumeral bone defects in the treatment of anterior shoulder instability. Instr Course Lect. 2009;58: Sugaya H, Moriishi J, Dohi M, et al. Glenoid rim morphology in recurrent anterior glenohumeral instability. J Bone Joint Surg Am. 2003;85-A: Griffith JF, Antonio GE, Yung PS, et al. Prevalence, pattern, and spectrum of glenoid bone loss in anterior shoulder dislocation: CT analysis of 218 patients. AJR Am J Roentgenol. 2008;190: Boileau P, Villalba M, Hery JY, et al. Risk factors for recurrence of shoulder instability after arthroscopic Bankart repair. J Bone Joint Surg Am. 2006;88: Yiannakopoulos CK, Mataragas E, Antonogiannakis E. A comparison of the spectrum of intra-articular lesions in acute and chronic anterior shoulder instability. Arthroscopy. 2007; 23: Antonio GE, Griffith JF, Yu AB, et al. First-time shoulder dislocation: High prevalence of labral injury and age-related differences revealed by MR arthrography. J Magn Reson Imaging. 2007;26: Bushnell BD, Creighton RA, Herring MM. Bony instability of the shoulder. Arthroscopy. 2008;24: Hintermann B, GÃchter A. Arthroscopic findings after shoulder dislocation. Am J Sports Med. 1995;23: Lo IK, Parten PM, Burkhart SS. The inverted pear glenoid: an indicator of significant glenoid bone loss. Arthroscopy. 2004; 20: Burkhart SS, Danaceau SM. Articular arc length mismatch as a cause of failed Bankart repair. Arthroscopy. 2000;16: r 2010 Lippincott Williams & Wilkins 147

9 Bollier and Arciero Sports Med Arthrosc Rev Volume 18, Number 3, September Gerber CMD, Nyffeler RWMD. Classification of glenohumeral joint instability. Clin Orthop Relat Res. 2002;400: Montgomery WH Jr, Wahl M, Hettrich C, et al. Anteroinferior bone-grafting can restore stability in osseous glenoid defects. J Bone Joint Surg Am 2005;87: Bushnell BD, Creighton RA, Herring MM. The bony apprehension test for instability of the shoulder: a prospective pilot analysis. Arthroscopy. 2008;24: Itoi E, Lee SB, Amrami KK, et al. Quantitative assessment of classic anteroinferior bony Bankart lesions by radiography and computed tomography. Am J Sports Med. 2003;31: Chuang TY, Adams CR, Burkhart SS. Use of preoperative three-dimensional computed tomography to quantify glenoid bone loss in shoulder instability. Arthroscopy. 2008;24: Sugaya H, Moriishi J, Kanisawa I, et al. Arthroscopic osseous Bankart repair for chronic recurrent traumatic anterior glenohumeral instability. J Bone Joint Surg Am. 2005;87: Yamamoto N, Itoi E, Abe H, et al. Effect of an anterior glenoid defect on anterior shoulder stability: a cadaveric study. Am J Sports Med. 2009;37: Abrams JS. Role of arthroscopy in treating anterior instability of the athlete s shoulder. Sports Med Arthrosc. 2007;15: Balg F, Boileau P. The instability severity index score. A simple pre-operative score to select patients for arthroscopic or open shoulder stabilisation. J Bone Joint Surg Br. 2007;89: Pagnani MJ. Open capsular repair without bone block for recurrent anterior shoulder instability in patients with and without bony defects of the glenoid and/or humeral head. Am J Sports Med. 2008;36: Mologne TS, Provencher MT, Menzel KA, et al. Arthroscopic stabilization in patients with an inverted pear glenoid: results in patients with bone loss of the anterior glenoid. Am J Sports Med. 2007;35: Schroder DT, Provencher MT, Mologne TS, et al. The modified Bristow procedure for anterior shoulder instability. Am J Sports Med. 2006;34: Hovelius L, Sandstrom B, Sundgren K, et al. One hundred eighteen Bristow-Latarjet repairs for recurrent anterior dislocation of the shoulder prospectively followed for fifteen years: study I clinical results. J Shoulder Elbow Surg. 2004;13: Hovelius L, Sandstrom B, Saebo M. One hundred eighteen Bristow-Latarjet repairs for recurrent anterior dislocation of the shoulder prospectively followed for fifteen years: study IIthe evolution of dislocation arthropathy. J Shoulder Elbow Surg. 2006;15: Auffarth A, Schauer J, Matis N, et al. The J-bone graft for anatomical glenoid reconstruction in recurrent posttraumatic anterior shoulder dislocation. Am J Sports Med. 2008;36: Kropf EJ, Sekiya JK. Osteoarticular allograft transplantation for large humeral head defects in glenohumeral instability. Arthroscopy. 2007;23:322 e1 325 el. 39. Provencher MT, Ghodadra N, LeClere L, et al. Anatomic osteochondral glenoid reconstruction for recurrent glenohumeral instability with glenoid deficiency using a distal tibia allograft. Arthroscopy. 2009;25: Warner JJ, Gill TJ, O Hollerhan JD, et al. Anatomical glenoid reconstruction for recurrent anterior glenohumeral instability with glenoid deficiency using an autogenous tricortical iliac crest bone graft. Am J Sports Med. 2006;34: Allain J, Goutallier D, Glorion C. Long-term results of the Latarjet procedure for the treatment of anterior instability of the shoulder. J Bone Joint Surg Am. 1998;80: Miniaci A, Berlet G, Hand C, et al. Segmental humeral head allografts for recurrent anterior instability of the shoulder with large Hill-Sachs defects: a two to 8 year follow up. J Bone Joint Surg Br. 2008;90 (suppl I): Purchase RJ, Wolf EM, Hobgood ER, et al. Hill-Sachs remplissage : an arthroscopic solution for the engaging Hill-Sachs lesion. Arthroscopy. 2008;24: Toro FMD, Melean PMD, Moraga CMD, et al. Remplissage: infraspinatus tenodesis and posterior capsulodesis for the treatment of hill sachs lesions: an all intraarticular technique. Tech Shoulder Elbow Surg. 2008;9: Bushnell BDMD, Creighton RAMD, Herring MMMD. Hybrid treatment of engaging Hill-Sachs lesions: arthroscopic capsulolabral repair and limited posterior approach for bone grafting. Tech Shoulder Elbow Surg. 2007;8: Moros C, Ahmad CS. Partial humeral head resurfacing and Latarjet coracoid transfer for treatment of recurrent anterior glenohumeral instability. Orthopedics. 2009; r 2010 Lippincott Williams & Wilkins

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