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CURRENT CONCEPTS

Recurrent Anterior Shoulder The role of glenoid bone loss in relation to the success or

Instability with Glenoid Bone Loss failure of anterior stabilization procedures was initially noted in
1961 when Rowe identified increased failures in his patients

and Subscapularis Insufficiency: with greater than 30% glenoid bone loss. This concept
was revisited in the setting of arthroscopic Bankart repair
Successful Surgical Treatment
through the work of Burkhart and DeBeer who coined the
term “inverted Pear” glenoid to describe the appearance of
with Distal Tibia Allograft and Split critical glenoid bone loss, which has been further lowered in

Pectoralis Major Tendon Transfer
biomechanical study to the “critical” threshold of 19–20%.

In addition to bony deficiency and failure of the repaired
capsulolabral complex, subscapularis deficiency has been Jonathan T. Bravman, MD

identified as a complicating issue in the management of failed Assistant Professor
open stabilization procedures. This is specifically dependent CU Sports Medicine

upon the manner in which access to the anterior shoulder Division of Sports Medicine and
is obtained (ie: subscapularis split vs. partial takedown Shoulder Surgery
Department of Orthopaedics
vs. tenotomy). Though there have been several reports of
subscapularis rupture in association with acute instability, University of Colorado

it was Nevaiser that pointed out that subscapularis rupture
should be considered in all cases of recurrent instability as well Charles T. Crellin BS,
as in older patients following traumatic anterior dislocation.
Armando F. Vidal MD

This report demonstrates a case of complex, recurrent Introduction:

anterior shoulder instability following two failed attempts at Anterior shoulder instability is a common problem, particularly
open capsullorhaphy with resultant critical glenoid bone loss amongst the young, active sporting population. The resultant
capsulolabral injury, coined a Bankart tear, can often be
and subscapularis insufficiency. A novel surgical approach
utilizing a fresh osteochondral distal tibia allograft for glenoid accompanied by bone loss on either the humeral side (Hill-
Sachs lesion) or on the glenoid side, such as in the case
reconstruction and a split pectoralis major tendon transfer to
address subscapularis insufficiency is presented.
acutely with a bony Bankart or chronically with attritional wear
of the anterior glenoid due to repetitive subluxation.

Case Report:
A 38 year old healthy female presented for evaluation of

recurrent left anterior shoulder instability and pain. She was an
active-duty soldier and initially sustained a traumatic anterior

shoulder dislocation 18 years prior to presentation in a fall
down several stairs. This was treated at the time with an

open Bankart repair and capsullorhaphy. She reports that the
shoulder became recurrently unstable within a year, prompting
a return to the OR for a revision open anterior shoulder

stabilization, 20 months following the first procedure.

She states the shoulder “never felt stable” and she had
progressively increasing instability with multiple subluxation
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and frank dislocation events requiring reduction. She presented
to our Shoulder Service with complaints of constant 7/10 pain

as well as 3–4 instability episodes per week with a subjective
shoulder value of 30%.

Exam demonstrated a healed deltopectoral incision without

atrophy with forward flexion to 160°abduction to 100°, external
rotation in adduction to 95° (vs 45° on the right), and internal

rotation to L2. She had 5/5 strength of the supraspinatus
and infraspinatus with an asymmetric, weak belly press and
lift-off with lag. She had positive anterior apprehension with

relocation as well as a 3+ anterior load shift.

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30 ISAKOS NEWSLETTER 2013: Volume II