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mtomaino 04-01-2012 03:53 PM

What can be done for persistent shoulder instability?
For most cases of recurrent shoulder instability, and in the setting of unsuccessful arthroscopic or open repair of torn capsule and ligaments, this problem may mean some degree of glenoid bone loss. In this setting, the humeral head is inherently unstable in the socket---this has been likened to trying to keep a golf ball on top of a tee that is missing half its surface. The Laterjet procedure has been a very successful salvage in these cases--please see this link for more information:

Why might a Laterjet procedure be unsuccessful? Well---the problems could include a failure to execute it properly (too small a coracoid transfer, for example), a persistent humeral head defect (which might need to be addressed), an insufficient subscapularis sling (due to too inferior a split in the subscap muscle), attrition of the subscap, axillary nerve injury, coracoid nonunion-----and the list goes on.

Certainly a close analysis of all previous operations (via op notes), recent CT scans, preferably with 3-Dimensional reconstruction, and possibly an MRI will be needed to discern what the root cause of failure is, and whether other treatment options might exist.

Obviously a thorough physical exam and perusal of plain xray is the place to start.

What then? Is fusion the only option?

One new option that is a potential alternative, though not proven by any "evidence-base" yet is a so-called "Anatomic Glenoid Reconstruction" with osteoarticular glenoid allograft.
Simply put, a cadaver graft is shaped to restore the normal glenoid anatomy. Although most Laterjet procedures are successful--in the absence of a complication--it is certainly possible that the anatomic and kinematic reconstruction is not sufficient to provide long-term stability.

Before concluding that no other option exists other than shoulder fusion, it may be worthwhile having a shoulder specialist evaluate the studies I mentioned above to see if Anatomic Glenoid Reconstruction with Glenoid Allograft is an option.

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