How Should the Surgeon Treat Shoulder Instability with Bone Loss?
Dr. Josef Eichinger answers ICJR’s questions on the treatment options for patients who present with shoulder instability that is revealed to involve bipolar bone loss as well.
ICJR: How should the surgeon determine whether to treat bipolar bone loss in shoulder instability with a Latarjet procedure or Bankart repair plus remplissage?
Josef K. Eichinger, MD: The first step is to obtain adequate imaging to help with quantification of the glenoid and humeral bone loss:
- A 3-dimensional (3D) computed tomography (CT) scan is the most accurate method for quantifying bone loss (Figure 1). 
- Although not widely available, 3D magnetic resonance imaging (MRI) may also be a viable method of accurately determining bone loss. 
- Two-dimensional CT and MRI scans without 3D reconstructions can be misleading, depending on the orientation of the patient in the CT gantry, and can over- or underestimate bone loss. 
Figure 1. 3D CT scans demonstrating (A) glenoid bone loss (in red) and (B) humeral bone loss, Hill Saches lesion.
Patients with glenoid bone loss of more than 20% to 25% should be treated with a bony reconstructive procedure of the glenoid, and several surgical options are available. The most-popular and best-studied option is the Latarjet procedure; iliac crest bone graft (Eden-Hybinette) and distal tibial allograft are other options. It is not known whether remplissage is required for cases in which glenoid bone reconstruction is performed, but the prevailing opinion is that it is not needed.
The concept of subcritical glenoid bone loss (10% to 13%) and “off-track” bipolar lesions have recently been proposed as indications for treatment with Latarjet procedures in lieu of traditional Bankart repair. [4,5] Smaller percentages of bone loss, particularly those with off-track lesions in which the Hill-Sachs lesion size and orientation potentiate the severity of minimal glenoid bone loss, may be better treated with a bony reconstructive glenoid procedure than with a traditional Bankart repair. 
Remplissage combined with a Bankart repair is a strategy used for treatment of anterior-capsulolabral lesions with minimal to no glenoid bone loss and the presence of a large, engaging Hill-Sachs lesion. 
ICJR: What does the literature say about the effectiveness of these procedures – has one produced better outcomes than another?
Dr. Eichinger: The optimal method for surgically managing anterior shoulder instability with bipolar bone loss has not been fully elucidated, but the published literature can help guide decision making.
In a case-controlled series comparing Latarjet with Bankart-remplissage in the treatment of less than 10% bone loss, no differences were seen in recurrence or outcomes, but the Latarjet group experienced a higher rate of complications.  Worse clinical outcomes were seen with the addition of remplissage for a Bankart in patients with substantial bone loss (20% to 25%) than in patients with minimal glenoid bone loss. 
These studies suggest there is a limit to which a remplissage can add stability in patients with increasing glenoid bone loss. Any soft tissue Bankart procedure (including the addition of remplissage) should probably be avoided in patients with more than 20% to 25% bone loss. Conversely, the use of the Latarjet in patients with instability and minimal glenoid bone loss appears to be risk factor for resorption of the glenoid graft, as identified by DiGiacomo et al. 
Therefore, combining remplissage with an arthroscopic Bankart repair has been shown to be effective in treating patients with non-substantial (less than 20% to 25%) glenoid bone loss, with excellent results in several clinical studies. For patients with subcritical glenoid bone loss (10% to 20%), an isolated Bankart repair results in worse clinical outcomes, but the addition of remplissage appears to potentially decrease the risk of recurrence and improve outcomes.
Unfortunately, no published prospective, controlled studies evaluate Latarjet versus Bankart plus remplissage in patients with shoulder instability and bipolar bone loss, Furthermore, it is unknown if on-track or off-track lesions with subcritical bone loss are better treated with Latarjet or Bankart-remplissage.
The literature suggests the following:
- In general, less than 10% glenoid bone loss with a large Hill-Sachs lesion can be treated with a Bankart-remplissage.
- For subcritical bone loss and an on-track Hill-Sachs lesion, a Bankart-remplissage seems to be a reasonable option.
- For off-track lesions and subcritical glenoid bone loss, other patient factors such as age, type of sport, and ligamentous laxity should be considered risk factors for potential Bankart-remplissage failure.
- Patients with greater than 20-25% glenoid bone loss, regardless of the size of the Hill-Sachs lesions, are likely best treated with Latarjet.
About the Expert
Josef K. Eichinger, MD, is an associate professor in the Department of Orthopaedics at Medical University of South Carolina in Charleston.
Dr. Eichinger has no disclosures relevant to this article.
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- Gyftopoulos S, Beltran LS, Yemin A, et al. Use of 3D MR reconstructions in the evaluation of glenoid bone loss: a clinical study. Skeletal radiology. 2014;43(2):213-218.
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- Di Giacomo G, de Gasperis N, Costantini A, De Vita A, Beccaglia MA, Pouliart N. Does the presence of glenoid bone loss influence coracoid bone graft osteolysis after the Latarjet procedure? A computed tomography scan study in 2 groups of patients with and without glenoid bone loss. J Shoulder Elbow Surg. 2014;23(4):514-518.