1. Clinical Evaluation History Physical Exam
Patients often report high energy initial traumatic dislocation event
Arm typically in abduction & external rotation
Most patients have recurrent instability with subluxation and/or dislocations
Often low energy mechanisms in mid-range of motion
Pain may be primary symptom
may be unaware of actual subluxation
Mechanical symptoms may be present
Catching
Crepitation
Assess seizure history in patients with previous posterior dislocation
Important to note whether patient has previous surgical intervention
Possible failed previous soft tissue repair
obtain surgical reports if possible
Inquire about collagen disorder or general ligamentous laxity
Physical Exam
Inspect symptomatic shoulder while comparing to contralateral shoulder
Deformity
Muscular atrophy
Surgical scars
Neurovascular exam
Special attention to axillary nerve function
Rotator cuff strength
Evaluate range of motion
Active & passive
Assess rotator cuff strength
Special tests: asses for direction and degree of instability
Apprehension
Stressed in abduction and external rotation
bone loss may lead to apprehension at lower degrees
30-70° of abduction and less than 90° of external rotation
Hyperabduction Test
Load & Shift
Sulcus sign (inferior instability)
Posterior Jerk Test (posterior instability)
Anterior translation of humeral head over glenoid rim
Clinical exam often not indicative of bone loss but simply consistent with instability

2. Radiographic Evaulation
X-ray
Begin with standard AP, scapular Y, & axillary views
Axillary most valuable: assess for humeral head impaction and glenoid loss
Stryker Notch view
evaluation of Hill-Sachs lesion
West- Point Axillary:
evaluation of anteroinferior glenoid rim
Only 57% of osseous lesion detected on plain radiographs
MRI
Often first advanced modality used to evaluate unstable shoulder
Provides detailed evaluation of soft tissue structures
Labrum, rotator cuff, and capsuloligamentous structures
Arthrography provides additional detail and may elicit bone loss
Figure 4. En Face Glenoid View CT 3D reconstruction with humeral head subracted allowing for visualization ofglenoid defect. Reprinted with permission from JAAOS. Streubel et al. Anterior Glenohumeral Instability: A pathology based treatment strategy. JAAOS, May (5): CT
Allows for precise evaluation in osseous structure in multiple planes
Glenoid bone loss leads to “inverted pear” appearance
Provides more accurate assessment of size of Hill-Sachs lesions
3D reconstruction is the most reliable and accurate modality to asses glenoid bone loss
Humeral head subtraction allows en face view of glenoid
Gold Standard remains arthroscopy
75% sensitivity of detecting Hill-Sachs lesions on CT
Calculation of Bone Loss
Humerus
Depth or width measurements
Percentage of humeral head
Hill-Sachs Angle
Glenoid
Multiple methods have been proposed to quantify glenoid bone loss
Most calculations are based on either linear method or surface area
“Best Fit Circle” drawn on the inferior 2/3 of the pear-shaped glenoid face
Linear methods use ratios and geometric equations to approximate loss
Surface area methods use best fit circles and digital quantification to quantify loss
Figure 5. Glenoid Bone Defects En face view of glenoid demonstrating 15% and 30% bone loss.. Reprinted with permission from JAAOS. Piasecki et al. Glenoid Bone Deficiency in Recurrent Anterior Shoulder Instability: Diagnosis and Management. JAAOS, :
Figure 6. Calculation of Humeral Bone Loss. A) Depth/Width. B) Percentage of humeral head (X/Y x 100) C) measurement of Hill-Sachs Angle. Reprinted with permission from the Cleveland Clinic Cleveland Clinic Center for Medical Art and Photography.

3. Glenoid Procedures: Arthroscopic Bankart Repair
Indications
Arthroscopic anterior stabilization has become the procedure of choice for most surgeons, despite the fact that open Bankart repair remains the gold standard procedure
Advantages:
- avoids subscapularis violation
- ability to repair additional intra-articular lesions
- improved cosmetics
- decreased postoperative pain
Not all patients with anterior instability are surgical candidates
Indications for surgery:
- episodes of recurrent instability refractory
conservative management (bracing, PT, and
rest)
- young patients with first time dislocation
that engage in contact or high demand
sports
Indications for open repair:
- glenoid bone deficiency of greater than
25%-30%
- deficiency of capsulolabral complex
- associated lesion such as HAGL
Figure 7. Bankart Repair Arthroscopic image of a Bankart repair with suture anchors
Surgical Technique
GOAL: restore the labrum and attached capsule and ligaments to the anatomical position, while reducing any capsular redundancy
Critical step :adequately mobilize the labrum and capsule with a rasp or periosteal elevator
Posterior portal, second portal inferior to the biceps tendon, and third portal above the superior border of the subscapularis tendon
The direction of the third portal is crucial: must be inferior enough to reach the 5:30 position on the glenoid and lateral enough to place anchors on the face of the glenoid
A minimum of 3 anchors should be used for the repair; fewer than 3 has been shown to be a risk factor for recurrent instability
Complications
Arthroscopic Bankart repair is a well tolerated procedure with few complications
Recurrent instability is one of the most commonly encountered complications
Arthrosis of the glenohumeral joint is a long term complication of the procedure, with up to 71% of the patients developing arthrosis in 13 years according to a Kavaja et al
In a study of 91 patients with arthroscopic Bankart repair, Boileau et al reported 14 patients (15.3%) with recurrent instability
- subluxation in 8 patients
- dislocation in 6 patients
Risk of postoperative recurrence was significantly related to the presence of a osseous defect
Outcomes
Arthroscopic Bankart repair is an effective surgical technique. Open repair does not offer a significantly better 2-year result in terms of stability and can negatively affect the recovery of full range of motion of the shoulder

4. Glenoid Procedures: Coracoid Transfer
Indications
A significant bony defect (of humeral or glenoid origin) in the setting of anterior shoulder instability can compromise the effectiveness of arthroscopic Bankart repair
The Latarjet and Bristow procedures address recurrent anterior shoulder instability in the context of a significant bony defect
Bristow
Transferring the terminal “half-inch” of the coracoid process (onto which the conjoint tendon attaches) to the scapular neck just medial to the anteroinferior edge of the glenoid rim
The bone cut is made immediately distal to the insertion of the pectoralis minor
Suture fixation to the subscapular tissue
Latarjet
The Latarjet procedure involves transfer of a larger piece of the coracoid
The pectoralis minor is detached from the coracoid, and the bony cut is made just distal to the coracoclavicular (CC) ligament insertions
Bone screw fixation to the glenoid neck
Surgical Technique
Skin incision form the coracoid tip extending directly inferior
Release of the pectoralis minor tendon and exposure of the “knee” of the coracoid process
Cutting of the coracoid at the level of the “knee”
The CA ligament is transected and the CH ligament is released from the coracoid
Two 3.2-ram holes are drilled in the coracoid process perpendicular to its long axis
The subscapularis muscle is divided in line with its fibers
Perform 1-cm vertical capsulotomy with a scalpel at the glenohumeral joint
An anterior to posterior hole in the scapula at approximately the 5 o'clock position is created
Figure 8. Laterjet Procedure Axial and sagittal depiction demonstrating anterior/extracapsular tranfer of coracoid. Reprinted with permission from JAAOS. Piasecki et al. Glenoid Bone Deficiency in Recurrent Anterior Shoulder Instability: Diagnosis and Management. JAAOS, :
Complications
- graft nonunion, fibrous union, or migration
10.1%
- graft osteolysis in 1.6%
- infection in 1.5%
- graft or glenoid fractures in 1.1%
A review study of 1658 cases of coracoid process transfers revealed the following complications:
- recurrent instability in 6% of the cases
- hardware complications in 6.5%
- graft nonunion, fibrous union, or migration in 10%
Outcomes
Coracoid transfers for shoulder instability can reliably improve shoulder stability with acceptable recurrence rates
Challenging procedures associated with a broad range and significant incidence of complications
These procedures are best indicated in the setting of glenoid or humeral bony deficiency

5. Glenoid Procedures: Graft Reconstruction
Indications
Anterior shoulder instability associated with severe glenoid bone loss is rare
Burkhart et al. observed that substantial bony loss of the anterior glenoid is associated with a very high recurrence rate after arthroscopic repair of instability
Anatomical restoration of glenoid depth and width is essential to restore stability to the shoulder
Piasecki et al. recommended bone grafting to be considered for defects measuring 15–25% of the total surface area, with these procedures being imperative for glenoid bone loss greater than 25%
Figure 9. Intra-articular Grafft Reconstruction Axial and sagittal depiction demonstrating instracapsular graft placement. Reprinted with permission from JAAOS. Piasecki et al. Glenoid Bone Deficiency in Recurrent Anterior Shoulder Instability: Diagnosis and Management. JAAOS, :
Surgical Technique
Anterior deltopectoral incision
The capsule is released from the humeral neck and split down to the glenoid
Periosteal elevator is used to strip the
periosteal sleeve from the anterior scapular neck
A tri-cortical autogenous wedge-shaped iliac crest bone graft approximately 3 cm in length by 2 cm in width is commonly used
Iliac crest, distal tibia, or femoral head allografts could be used
The graft is contoured to match the desired dimensions and to approximate a normal joint surface
The graft is temporarily fixed in place using terminally threaded K-wires
Three cannulated screws with a single No.2 polyethylene suture around the shaft for holding the graft in place
The sutures can be used to repair the capsule-periosteal sleeve
Figure 10. Intra-articular Graft Reconstruction Operative photograph of iliac crest autograft to glenoid. Reprinted with permission from JAAOS. Provencher et al. The Hill Sachs Lesion: Diagnosis, Classification, and Management. JAAOS, :
Complications
Recurrent instability
Arthrosis
Outcomes
Beran et al. reporedt recurrent instability rate from 0 to 4.9%
systematic review revealed >90% return to sports
mean Rowe score of 90.5 (excellent) and Constant scores of 94 and 94.4
there is no clear delineation of outcomes between allograft and iliac crest bone graft
All of these methods appear effective in restoring and maintaining stability

6. Humerus Procedures: Remplissage
Indications
The remplissage procedure has substantial effects on shoulder stability and motion
The Hill-Sachs defect is an impression fracture of the posterosuperior humeral head that is present in >80% of cases of recurrent glenohumeral instability
Purchase et al. described a technique of arthroscopic posterior capsulodesis and infraspinatus tenodesis into the Hill-Sachs defect to prevent engagement
Procedure aims to convert a bony intra-articular defect into an extra-articular defect by insetting the infraspinatus into the Hill-Sachs lesion
It is commonly used with an arthroscopic Bankart repair procedure for the treatment of anterior shoulder instability
Rowe et al. recognized that a severe Hill-Sachs lesion might be a factor in recurrent dislocation after a Bankart repair
Surgical Technique
The surface of the engaging Hill-Sachs lesion
freshened
Place the Bankart repair anchors
Clear the subacromial bursa
Place one or two suture anchors into the
Hill-Sachs defect
Tie of the Bankart repair sutures
Tie the “remplissage” sutures
Figure 11. Hill-Sachs remplissage. An anchor is used to fixate the posterior capsule and infraspinatus into the humeral head defect. Anterior bankart repair also demonstrated. Reprinted with permission from JBJS. Boileau et al. Anatomical and functional results after arthroscopic Hill-Sachs remplissage. JBJS (7):
Complications
Wolf et al. followed 45 patient for a minimum of 2 years who were treated with arthroscopic Bankart repair and “remplissage” and reported 2 patients with recurrent instability due to trauma
One patient with postoperative stiffness
Two patients had secondary arthroscopic procedures for painful posterior labral tear and retained fixation device
Five patients had persistent apprehension when placing their arms in certain positions and had mild limitation and minimum discomfort
Outcomes
Remplissage and Bankart repair procedures are an effective combination for approaching a difficult subgroup of instability patients with a significant potential for failure with a standard arthroscopic Bankart repair only
Wolf et al reported mean Rowe and Constant scores of 92 after a follow-up of minimum 2 years
No significant loss of external rotation or any plane of motion before or after the remplissage
None of the patients reported posterior shoulder pain

7. Humerus Procedures: Graft Reconstruction
Indications
Lesions encompassing at least 20% to 40% of the humeral head have to be addressed surgically
Lesions that lie within the glenoid track and engage during functional range of motion should be considered for surgery
Patients who have failed previous instability repairs are surgical candidates
Hill-Sachs lesions of more than 30% of the humeral head
Surgical Technique
Exposure of the Hill-Sachs lesion
Chevron-type osteotomy to reshape the defect
Cut a corresponding piece from the humeral head allograft, that is 2-3mm bigger than the defect
Place the allograft and precisely reshape it to match the humeral head contour
Provisional fixation is achieved with K-wires
K-wires are replaced with 3.5-mm cortical or 4.0-mm cancellous screws
The screw heads are countersunk to be below the level of the articular surface
Figure 12. Allograft Reconstruction of Humeral Head Defect Operative photographs demonstrating Hill Sachs lesion (A), preparation of graft site (B), matching of allograft (C/D), and fixation of graft (E). Reprinted with permission from JAAOS. Provencher et al. The Hill Sachs Lesion: Diagnosis, Classification, and Management. JAAOS, :
Complications
Miniaci et al. revealed in a series of 18 patients with large humeral head defects the following complications;
- partial graft collapse in 2 patients
- signs of osteoarthritis in 3 patients
- mild subluxation in 1 patient
- hardware complications in 2 patients, who complained of pain with extreme external rotation
Outcomes
Miniaci and Gish have reported on 18 cases with the use of osteoarticular allograft for reconstruction of humeral head defects
All patients had failed instability repairs and had humeral head defects greater than 25% of the articular surface
- Constant score was 78.5 for all patients
- >89% of patients returned to work
- no patients had recurrent instability
Dipaola et al. reported the following results in a study of 4 patients with humeral head defects:
- average postoperative ASES score of 85.3
- average postoperative UCLA score of 28.4
- all patients demonstrated full strength
- subscapularis testing was intact for all
patients

8. Humerus Procedures: Resurfacing/Arthroplasty
Indications
Humeral head hemiarthroplasty or total shoulder arthroplasty is indicated in patients with large Hill-Sachs lesions that involve greater than 40% to 50% of the articular surface
Arthroplasty should be avoided in young patients and is best suited for older patients with preexisting glenohumeral osteoarthritis and osteopenic bone
Due to the limited lifespan of these implants, evaluation of patient suitability for any of the aforementioned procedures is necessary prior to committing to humeral head resurfacing or hemiarthroplasty
According to Uribe et al., patients with advanced-stage osteonecrosis measuring less than 40 mm in diameter on radiographs or MRI were indicated for resurfacing
Partial humeral head resurfacing is indicated in younger patients (<50y) with focal chondral defects of the humeral head, such as:
- Hill-Sachs
- avascular necrosis
- traumatic or iatrogenic osteochondral lesions
- osteoarthritis
Partial resurfacing may be contraindicated in patients with osteoporosis or deficient bone stock
Surgical Technique
Deltopectoral approach
Elevation of the subscapularis from the lesser tuberosity subperiosteally
Proximal humeral osteotomy should be made at the anatomic neck
Placement of the stemmed humeral implant should reproduce the anatomically correct position of the humeral head
Humeral component can be implanted with press-fit, fully cemented or proximally cemented technique
Resurfacing:
- select size-specific drill
guide to assess defect
coverage
- insert guide pin
- insert taper post
- permanent prosthesis
is placed flush with
the articular cartilage
Figure 13. Humeral Head Resurfacing. Reprinted with permission; Moros et. al. Partial Humeral Head Resurfacing and Latarjet Coracoid Transfer for Treatment of  Recurrent Anterior Glenohumeral Instability. Orthopedics, ISSN: , 2009 Aug; Vol. 32 (8)
Complications
Hemiarthroplasty:
- progressive glenoid erosion
- painful arthrosis
Total shoulder arthroplasty:
- glenoid component loosening
- infection
Resurfacing:
- inadequate fixation of the implant
- mismatch between the implant and defect
geometry that requires reaming and
resurfacing of unaffected humeral cartilage
- inaccurate alignment of the prosthesis
with the adjacent articular surface
Outcomes
Pritchett and Clark reported outcomes of HA and TSA in 7 patients with chronic dislocations and significant Hill-Sachs lesions
Good results were reported to 5/7 with no recurrent dislocations
Follow-up was limited to 2 years post op
Scalise et al. reported on 62 patients at 6 institutions undergoing partial humeral resurfacing and a mean follow-up of 8 months
ASES and Constant scores significaly improved
There are limited studies available in the literature regarding the use of partial articular resurfacing for instability

9. Treatment Algorithm for Treatment of Shoulder Instability due to Glenoid and/or Humeral Bone Loss
Combined bone loss
(incidence in recurrent anterior instability 79%-84%)
Determine relative contribution of each lesion
Address most problematic lesion first
Consider reconstruction of both glenoid and humeral head lesions
Humeral bone loss Glenoid bone loss
(incidence in recurrent instability 70%-100%) (incidence in recurrent instability 40%)
non-engaging lesions <20%
engaging lesions >20%
lesions <25%
lesions >25%
PT with strengthening of the dynamic stabilizers of the shoulder
Disimpaction (<3 weeks old)
- defects of >20% and <40%
Remplissage
- >20% humeral loss and
<25% glenoid loss
Graft reconstruction
- >30% humeral loss
Partial head resurfacing
- >40% humeral loss
- active
- good bone stock
HA or TSA
- not active
- poor bone stock
- previous failed reconstruction
PT with strengthening of the dynamic stabilizers of the shoulder
Bristow procedure
Latarjet procedure (larger defects)
Hybbinette-Eden procedure (iliac crest autograft)
Fresh-frozen osteochondral allograft