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    Shoulder Instability with Glenoid Bone Loss and a Large Hill-Sachs Defect

    A 36-year-old firefighter presents with right shoulder pain and instability after a traumatic dislocation sustained while responding to a fire 7 months prior. Imaging demonstrates an anterior labral tear, a chronic bony Bankart with 15% glenoid bone loss, and a large Hill-Sachs defect. What is the next step in treating this patient?

    Authors

    James P. Doran, MD, and Fotios P. Tjoumakaris, MD

    Introduction

    Primary traumatic anterior shoulder dislocation is a common problem, affecting up to 24 in 100,000 persons per year, and it can be complicated by recurrent shoulder instability in up to 60% of cases, depending on patient factors. [1-5] The incidence of shoulder instability increases in males, contact athletes, military personnel, and patients with ligamentous laxity, and it predominantly affects individuals in their second or third decade of life. Unfortunately, there is a significantly higher risk of recurrence with younger age at initial dislocation. [6,7]

    A thorough history, physical examination, and imaging work-up are critical for determining the treatment plan most likely to achieve a successful outcome and avoid recurrent shoulder instability. The history and physical should include:

    • Patient age, occupation, sports participation, and hand dominance
    • Dislocation location and direction
    • Concomitant injuries
    • Primary versus recurrent dislocation
    • Mechanism and energy of the trauma
    • Presence of generalized hyperlaxity
    • History of contralateral shoulder dislocations or other joint dislocations
    • Treatment history
    • Was the shoulder reduced spontaneously?
    • Was the shoulder self-reduced by the patient?
    • Was the shoulder reduced in the emergency department under local anesthesia or conscious sedation?

    Radiographs, magnetic resonance imaging (MRI), and computed tomography (CT) scan can improve the identification of glenohumeral injuries and provide details regarding both soft tissue and osseous structures.

    A thorough understanding of the anatomy and pathology of the glenohumeral joint is also necessary to appropriately treat shoulder instability and its sequelae. The mechanism of anterior shoulder dislocations commonly involves shoulder positioning in abduction, external rotation, and extension. Anterior dislocation of the humeral head from the glenoid fossa can result in a wide spectrum of glenohumeral pathology, including injuries to the labrum, glenoid, humeral head, capsuloligamentous structures, and articular cartilage.

    • A Bankart lesion occurs with detachment of the antero-inferior glenohumeral ligament-labrum complex from the glenoid, [8,9] becoming a bony Bankart lesion if anterior glenoid fracture occurs concomitantly with the labral detachment.
    • A Hill-Sachs defect refers to an impaction fracture of the posterosuperior aspect of the lateral humeral head that occurs when the humeral head dislocates anteriorly and impinges on the anterior/inferior glenoid rim. [8]

    In patients with a first-time dislocation, the rate of Bankart lesions and Hill-Sachs defects identified at the time of arthroscopy can be as high as 97% and 90%, respectively. [10] Recurrent instability rates of primary traumatic shoulder dislocations vary based on age at first dislocation. [7] In a cohort of patients ages 15 to 35, recurrent instability rates were 55.7% by 2 years and 66.8% by 5 years. The rate increased to 87% in younger patients ages 15 to 20. [6]

    Recent literature has highlighted the importance of adequately addressing osseous defects. [11-14] Unacceptably high failure rates can occur when glenoid bone loss exceeds 13.5% in patients treated with anatomic, soft tissue-only stabilization techniques, such as Bankart repair or Remplissage. Anterior inferior glenoid bone loss results in a glenoid that resembles an inverted pear. [11]

    The Latarjet procedure, first described by French surgeon Dr. Michel Latarjet in 1954, can restore glenoid bone loss and reduce the risk of recurrence. [15] Although surgeons have modified the original procedure over the years, the core concept remains the same: Performing an osteotomy and transfer of the coracoid process to the defect on the anterior-inferior glenoid rim will address bone loss in patients with anterior instability.

    This is a non-anatomic technique, performed through either an open or an arthroscopic approach. The “triple blocking effect” of the procedure involves: [8]

    • Increasing the glenoid diameter and articular contact area with the coracoid process bone block
    • Creating a sling effect as the conjoined tendon acts to reinforce the inferior subscapularis and antero-inferior capsule
    • Repairing the anterior capsule with the sleeve of coracoacromial ligament from the lateral edge of the coracoid bone block

    Multiple studies have established the effectiveness of the Latarjet procedure in addressing anterior shoulder instability, [16-18] as evidenced by the increase in the number of open Latarjet procedures that have been performed over the last 10 years. [19]

    Case Presentation

    A 36-year-old, right-hand-dominant, male firefighter presents for a second opinion and surgical evaluation of a right shoulder injury. He has a history of traumatic shoulder dislocation that occurred on the job approximately 7 months prior. He had fallen down a flight of stairs while attempting to exit a burning building. He was transported to the emergency department, where radiographs showed an anterior shoulder dislocation. The shoulder was urgently reduced under anesthesia and placed in a sling. The patient then underwent extensive physical therapy.

    On presentation for the second opinion, he reports continued pain and apprehension and a recent history of recurrent subluxation events. He says he has significant limitations in his activities and difficulty performing his duties as a firefighter. He denies any numbness, tingling, or weakness in the injured extremity, and he also denies any shoulder issues or dislocations prior to the injury 7 months ago.

    The patient is interested in discussing surgical options to relieve his continued shoulder symptoms. He denies any pertinent medical or surgical history. He is currently taking 800 mg of ibuprofen 3 times a day as needed for right shoulder pain. He has no known drug allergies.

    Physical Examination

    • Height: 5 feet, 11 inches; weight: 243 pounds; BMI: 33.89 kg/m2
    • No significant skin changes, soft tissue swelling, muscular atrophy, or ecchymosis on inspection
    • Full active and passive range of motion (ROM) of the shoulder
    • 5/5 strength in rotator cuff testing for internal and external rotation and forward elevation
    • Slight tenderness over the anterior capsule to deep palpation
    • No tenderness on palpation of the greater tuberosity, bicipital groove, acromioclavicular joint, or posterior capsule
    • Positive apprehension sign, with a positive relocation test
    • Positive Mayo/dynamic labral shear test
    • Negative sulcus sign
    • Negative Neer and Hawkin’s impingement signs
    • Mildly positive Obrien’s test
    • Negative Yergason’s and Speed’s tests
    • Neurovascularly intact distally

    Imaging

    Figure 1. Radiographs of the right shoulder, obtained 1 day after the initial injury and reduction, show the anatomically reduced glenohumeral joint with an osseous fragment at the anterior inferior glenoid, representing a bony Bankart lesion, as well as an impaction fracture of the posterolateral superior aspect of the humeral head, representing a large Hill-Sachs defect.

    Figures 2a-b. MRI of the right shoulder without contrast, obtained 2 weeks after the initial injury and reduction, demonstrates sequelae of an anterior glenohumeral dislocation with osseous Bankart/anterior glenoid rim fracture, tear of the overlying anteroinferior labrum, and defect of the anterior inferior glenoid cartilage.

    Figures 2c-e. MRI of the right shoulder without contrast, obtained 2 weeks after the initial injury and reduction, demonstrates reciprocal severely depressed and edematous Hill-Sachs impaction fracture of the humeral head. There is no evidence of rotator cuff tendon or biceps tendon tears, and the humeral head cartilage and acromioclavicular joint are intact.

    Figures 3a-c. CT scan of the right shoulder without contrast, obtained 3 months after the initial injury and reduction, demonstrates 1.4cm x 0.44cm osseous Bankart lesion displaced 0.6 cm medial to the glenoid margin.

    Figures 3d-e. CT scan of the right shoulder without contrast, obtained 3 months after the initial injury and reduction, demonstrates a broad and deep Hill-Sachs defect with an engaging appearance measuring 1.6 cm x 2.8 cm, with a depth of 1.0 cm.

    Diagnosis

    • Chronic instability of the right shoulder, with glenoid bone loss and Hill-Sachs defect

    Treatment

    With the diagnosis made, we had a lengthy discussion with the patient regarding treatment options. We told him he could continue non-operative treatment with physical therapy or he could undergo surgical treatment. He was unlikely to benefit significantly from further non-operative treatment, however, given that he had failed to improve with 6 months of non-operative treatment.

    We then discussed various open versus arthroscopic stabilization procedures. Arthroscopic soft tissue procedures, such as Bankart repair with or without Remplissage, however, might not fully address his bony pathology, resulting in continued instability. We predicted the Hill-Sachs defect would be off-track by:

    • Calculating the glenoid track on his CT scan using the best-fit circle technique for intact glenoid diameter (D), multiplying by 83%, and then subtracting the diameter of the anterior glenoid defect (d), as described by Di Giacomo et al. [20] For this patient, glenoid track = D x 83%-d, or 27.57 mm x 0.83 – 4.37 mm = 18.51 mm (Figure 4).
    • Calculating the Hill-Sachs interval (HIS) on the axial MRI by measuring the width of the Hill-Sachs defect (HS) plus the width of the intact bony bridge (BB) from the lateral edge of the Hill-Sachs lesion to the medial insertion of the rotator cuff, as described and validated by Gyftopoulos et al. [21] For this patient, HSI = HS + BB, or 14.98 mm + 4.95 mm = 19.93 mm (Figure 4).

    Figure 4. Using the CT scan (left) and MRI (right) images to calculate the glenoid track and Hill-Sachs interval, respectively.

    Because the Hill-Sachs interval is larger than the glenoid track (19.93 mm vs 18.51 mm), this lesion is “off-track” and will likely engage on the anterior bony Bankart defect, leading to shoulder instability. In consideration of the patient’s combined anterior glenoid bone loss (15.9%) and off-track Hill-Sachs defect, we focused our discussion on bony augmentation procedures, such as open coracoid transfer and distal tibia allograft surgeries, which we believed would most likely optimize his outcome and reduce the risk of recurrent instability.

    After further discussion, the patient agreed to undergo an open coracoid bone block transfer (Latarjet) procedure. We discussed the nature of the surgery and the associated risks, including injury to the axillary, musculocutaneous, and suprascapular nerves, potential wound complications and infection, graft osteolysis, glenohumeral arthritis, failed or broken hardware, need for hardware removal, postoperative arthrofibrosis, subscapularis injury or dysfunction, and recurrent instability, as well as the postoperative recovery and rehabilitation protocol. The patient communicated his understanding of the discussion, and the decision was made to proceed with surgery.

    Surgical Procedure

    • The patient was given preoperative antibiotics and placed in the modified beach chair position, with all bony prominences well padded. He received an interscalene nerve block, as well as general anesthesia.
    • The right shoulder was then prepped and draped in the usual sterile fashion. Care was taken to ensure the scapula of the involved side was free, as pins would be placed anterior to posterior at the level of the glenoid and retrieved transcutaneously during the procedure.
    • An anterior shoulder incision was made, approximately 8 cm in length and extending from the tip of the coracoid distally toward the axillary fold. Dissection was carried down to the deltopectoral interval. The cephalic vein was identified and mobilized laterally with the deltoid. The interval was developed and Kolbel retractors were placed, exposing the coracoid process as well as the coracoacromial ligament. Note: It is essential to identify and protect the axillary nerve throughout the procedure.
    • The coracoacromial ligament was then sharply excised off the undersurface of the acromion, maintaining its insertion onto the coracoid to assist in anterior capsular closure at a later point in the case.
    • The pectoralis minor tendon was released from the medial aspect of the coracoid process. Care was taken to protect the musculocutaneous nerve as it traverses from the lateral cord of the brachial plexus medially and enters the coracobrachialis approximately 3 cm to 8 cm from the inferior tip of the coracoid. Variations in anatomy are common, and this distance can be shorter in some cases.
    • The coracoid drill guide was then positioned on the coracoid process, with the alpha hole positioned distally 1 cm above the tip of the coracoid and between the medial one third and lateral two thirds of the coracoid.
    • With the guide in the appropriate position, a 1.5-mm coracoid Kirschner wire (K-wire) was drilled bicortically, from anterior to posterior, just through the posterior cortex of the coracoid in the alpha hole. Next, the second 1.5-mm K-wire was drilled through the beta hole in similar fashion. The drill guide was removed to ensure that the K-wires were parallel and well positioned in the coracoid.
    • Next, a cannulated coracoid step drill was used to drill the alpha hole over the K-wire. The drill and wire were then removed, and the “top hat” cortical fixation screw was placed into the alpha drill hole. This drilling sequence and “top hat” application was repeated with the beta hole (Figure 5).

    Figure 5. Intraoperative photo showing that the “top hat” cortical fixation screws were placed into the alpha and beta drill holes.

    • Prior to performing the coracoid osteotomy, the coracoclavicular ligaments were identified and their insertion site on the coracoid was preserved. A 90° saw blade was used to perform the coracoid osteotomy from medial to lateral, protecting the medial and deep neurovascular structures. An osteotome was used to finish the osteotomy.
    • With the coracoid osteotomy performed, careful exploration of the musculocutaneous nerve distally was done. It is important to identify the nerve and ensure that it will not be under tension on transfer of the coracoid bone block to the glenoid. In this patient, the nerve was identified entering the coracobrachialis approximately 4 cm from the tip of the coracoid.
    • Next, the undersurface of the osteotomized coracoid was prepared. The soft tissues were debrided and a burr was used to carefully decorticate the bone. The coracoid was carefully placed into the incision without tension on the conjoined tendon/musculocutaneous nerve while the dissection to the glenoid was performed.
    • Anterior dissection was continued to identify the subscapularis tendon and muscle. A blunt Hohmann retractor was placed inferiorly to protect the axillary nerve. A horizontal split in the subscapularis muscle was performed at approximately one half of the upper and lower borders of the muscle at the level of the joint.
    • The capsule was identified within the subscapularis split. The level of the glenohumeral joint line was palpated and a scalpel was used to incise the capsule longitudinally to access the joint. A Fukuda retractor was placed in the joint to retract the humeral head laterally.
    • The medial leaflet of the capsule was then partially excised with a long-handle scalpel. A Richardson retractor was then placed medially on the glenoid neck to facilitate exposure of the anterior inferior glenoid. (A Bankart glenoid retractor can also be used to expose the glenoid.)
    • The anterior labral tear and medially displaced, healed bony Bankart were visualized. No loose bodies were evident after the joint was irrigated.
    • The deep scalpel was used to excise the anterior labrum off the glenoid. The burr was then used to prepare the anterior inferior glenoid to a healthy bleeding bone bed and to remove the bony Bankart lesion, as its malposition was blocking the reduction of the coracoid transfer.
    • The glenoid was now completely exposed and prepared for the coracoid transfer (Figure 6).

    Figure 6. Intraoperative photo showing glenoid exposure in preparation for the coracoid transfer.

    • The coracoid double-barrel positioning device was then attached to the 2 threaded “top hat” cortical fixation devices on the anterior surface of the coracoid, with the cannula handle oriented upward. The cannula was used to transfer the coracoid bone block flush against the anterior inferior glenoid defect. The coracoid should be oriented with its longitudinal axis superior-inferiorly at the 3 o’clock to 5 o’clock position on the glenoid, with the lateral edge of the bone block aligned even to the level of the glenoid articular surface.
    • Once this position was confirmed, the coracoid bone block was provisionally pinned on the glenoid anterior to posteriorly with 2 K-wires, using the cannula guide holes. The pins should be oriented parallel to the glenoid articular surface. Care should be taken to assess both the axillary and musculocutaneous nerves to ensure that they are neither impinged nor under tension.
    • The K-wires were advanced posteriorly through the skin of the posterior shoulder and clamped at the skin with a hemostat to protect them from removal with the drill. A 3.2-mm drill was used to drill the alpha hole over the K-wire in the double-barrel cannula. The drill calibration was used to determine the screw length through the bone block and glenoid.
    • A 34-mm x 3.5-mm cannulated screw was then selected and advanced over the alpha K-wire. The process was repeated for the beta screw. A 34-mm long screw was also placed. Final tightening of the coracoid bone block was performed, and the K-wires were removed posteriorly through the skin.
    • Stability of the shoulder through ROM was then assessed. The axillary and musculocutaneous nerves were also reassessed to ensure they were not impinged or tensioned through shoulder ROM.
    • Fluoroscopy was used to confirm the anatomic position of the bone block and screw orientation and position (Figure 7).

    Figure 7. Fluoroscopic image confirming the anatomic position of the bone block.

    • The joint was copiously irrigated with saline. A #2 braided suture was then used to repair the lateral leaflet of the capsule to the coracoacromial ligament at the lateral border of the coracoid bone block. The subscapularis split was also re-approximated with #2 braided suture.
    • The wound was thoroughly irrigated and closed in a layered fashion. A sterile dressing was applied, and the patient was placed in a shoulder immobilizer.

    Figure 8. Radiographs of the right shoulder, obtained at the 2week postoperative followup appointment, demonstrate an anatomically reduced glenohumeral joint with coracoid bone block well-positioned on the anterior inferior glenoid and fixed with 2 screws.

    Postoperative FollowUp

    The goal of the first 6 weeks postoperatively is to allow for bony healing of the coracoid transfer. Below is the postoperative protocol the authors have found effective. Patients should understand it will be 6 to 9 months before they can perform at their optimal level. Some may progress faster, others may be slower, but this is a general guideline.

    Weeks 0-6

    • Patient performs home exercises: pendulums, elbow/wrist/hand ROM, grip strengthening
    • Patient remains in a shoulder immobilizer at all times, day and night, except for pendulum exercises

    Weeks 6-12

    • Discontinue shoulder immobilizer
    • Progress to full active and passive ROM as tolerated
    • Begin rotator cuff and deltoid isometrics

    Months 4-6

    • Progress to full active and passive ROM without discomfort
    • Rotator cuff strengthening and scapular stabilization rehabilitation program
    • Sport-specific return-to-play program/throwing program, depending on the sport
    • Return to sport/work at 6 months if the patient has full, painless ROM; scapular stabilization; and symmetric strength

    Surgical Pearls

    • Proper positioning and draping are important for this procedure. The K-wires need to be retrieved posteriorly from the shoulder, so a wider preparation is required than for typical beach chair positioning cases.
    • Careful dissection and retractor placement throughout the case will allow for safe and adequate exposure to the glenoid and mobilization of the coracoid bone block.
    • Understanding and respecting the anatomy of the axillary and musculocutaneous nerves is essential throughout all stages of the procedure, including ROM testing after securing the coracoid.
    • Careful planning of the osteotomy site and screw holes within the coracoid is important for avoiding the complication of graft fracture.

    Discussion

    Successful outcomes in the treatment of shoulder instability are multifactorial. Not only is it essential to understand the pathology of each individual’s injury, but it is also vital to understand the patient’s goals of treatment, including short-term and long-term quality-of-life goals. A patient’s occupation or an athlete’s sport – especially for contact and throwing athletes – position, level of participation, length and timepoint of the season when the injury occurred, and return-to-play timeline can all weigh heavily into selecting the most appropriate surgical technique with the patient.

    In this case, the patient sustained a first-time, traumatic anterior dislocation with large bony Bankart and Hill-Sachs lesions 7 months prior to his presentation at our office. Despite initial non-operative treatment, including 6 months of physical therapy, he continued to have pain and apprehension. He did not have any subsequent complete dislocations, but he continued to have subluxation events and perceived instability.

    The patient’s goal was to return to his job as a firefighter. He had a bipolar lesion with approximately 15.9% glenoid bone loss and a large, off-track Hill-Sachs lesion. We elected to pursue the Latarjet procedure after a detailed discussion with the patient about his goals, the extent of his bipolar injuries, and a review of the risks and benefits of soft tissue repair procedures versus bony augmentation procedures. We discussed the high risk of recurrence with an arthroscopic Bankart repair with or without Remplissage. We mutually agreed that a Latajet would afford him the best chance at returning to work and activities with a single surgery.

    With respect to non-operative versus operative treatment, Kirkley et al [22] randomized 31 patients with first-time shoulder dislocations to either sling immobilization for 3 weeks or arthroscopic Bankart repair. The 15 non-operative, sling-immobilized patients had a 60% recurrence rate, while the 16 patients in the arthroscopic stabilization group had only a 19% recurrence rate. Patients in the arthroscopic stabilization group also reported a statistically significant improvement in their Western Ontario Shoulder Instability Index (WOSI) scores. [22]

    Dickens et al [23] studied the effect of subcritical bone loss in college football players with recurrent dislocations after arthroscopic Bankart repair. Players with more than 20% glenoid bone loss, engaging Hill-Sachs lesions, and off-track lesions were excluded from the study. Of the 50 players included, 3 had recurrent instability postoperatively; all 3 had glenoid bone loss greater than 13.5%. No subsequent dislocations were seen in players with less than 13.5% glenoid bone loss. [23]

    A study by Yang et al [12] included 189 patients with recurrent anterior shoulder instability, off-track Hill-Sachs lesions, and less than 25% glenoid bone loss who were treated with either arthroscopic Bankart and Remplissage (98 patients) or modified Latarjet (91 patients). The complication rate was a higher for the Latarjet group than for the arthroscopic Bankart and Remplissage group: 12.1% vs 1%, respectively. No difference was seen in the WOSI scores. In subgroup analysis of patients with more than 15% glenoid bone loss, modified Latarjet had a lower recurrence rate (6.06% vs 28.6%) and lower revision rates (3.03% vs 21.4%). In subgroup analysis of contact and collision sport athletes, Latarjet resulted in improved WOSI scores and lower recurrence rates: 30% for arthroscopic Bankart repair and Remplissage versus 0% for Latarjet. [12]

    An et al [14] performed a systematic review of Level II and III, predominantly retrospective studies comparing Latarjet and Bankart repair in recurrent traumatic anterior instability of the shoulder, including primary and revision procedures. They showed that the Latarjet procedure conferred a significantly lower risk of recurrent dislocation than Bankart repair, 11.6% vs 21.1%, respectively. There was no clinically significant increase in complications requiring reoperation with Latarjet, 5.0% vs 3.1%. [14]

    A 2015 systematic review of 23 articles by Randelli et al [17] showed comparable clinical results for open and arthroscopic Latarjet. However, the direct costs associated with arthroscopic Latarjet were double those of open Latarjet procedures. [17]

    Hurley et al [24] performed a systematic review of open Latarjet procedures for anterior shoulder instability with at least 10-year follow-up. They reported excellent functional outcomes from the 13 studies of 822 patients (82% male, average age 27.4 years) at mean follow-up of 16.6 years. The overall return to sport rate was 84.9%, with 76.3% returning to the previous level of play. The recurrent instability rate was 8.5%, and the revision rate due to recurrence was 1.6%. Nearly 40% of patients (38.2%) had arthritic changes and 35.7% had residual shoulder pain, but only 4.8% reported daily pain. Overall, the rate of good or excellent outcomes was 86.1%. [24]

    Shoulder dislocations and recurrent instability can be difficult injuries to manage. Careful analysis of each patient’s case is important for optimizing the outcome. In patients with significant glenoid bone loss and large Hill-Sachs lesions from traumatic anterior shoulder dislocations, open Latarjet procedures can be effective in restoring joint stability and function.

    Author Information

    James P. Doran, MD, is an orthopaedic sports medicine fellow at The Rothman Institute, Philadelphia, Pennsylvania. Fotios P. Tjoumakaris, MD, is an orthopaedic sports surgeon and the sports medicine fellowship program director at The Rothman Institute, Philadelphia, Pennsylvania. He is a Professor of Orthopaedic Surgery at the Sidney Kimmel College of Medicine, Thomas Jefferson University, Philadelphia, Pennsylvania.

    Sports Medicine Section Editor, Rothman Institute Grand Rounds

    Brandon J. Erickson, MD

    Disclosures: The authors have no disclosures relevant to this article.

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