Current Trends in Management of Glenoid Bone Loss in Anterior Shoulder Instability

Vikram K Kandhari, Bibhas DasGupta, Deepak N Bhatia

Volume 2 | Issue 1 | Jan – Apr 2017 | Page 20 – 28

Author: Vikram K Kandhari [1], Bibhas DasGupta [1], Deepak N Bhatia [1].

[1] Department of Orthopaedic Surgery, Seth GS Medical College, King Edward VII Memorial Hospital, Parel, Mumbai, Maharashtra,
[2] Sportsmed Mumbai, Parel, Mumbai, Maharashtra, India

Address of Correspondence

Dr. Deepak N Bhatia,
Department of Orthopaedic Surgery,  Seth GS Medical College, and King Edward VII Memorial Hospital,
Parel, Mumbai – 400 012, Maharashtra, India.


Significant bone defects of glenohumeral joint play an important role in the management of shoulder instability. Bony instability is an important cause of failed soft-tissue repair and recurrent episodes of shoulder dislocations. Bony instability can also be associated with labral (superior and posterior) tears, humeral avulsion of glenohumeral ligament lesions, or rotator cuff tears. Computed tomography (CT) scan with three-dimensional reconstruction is essential for quantification of glenohumeral bone loss. Magnetic resonance imaging (MRI) is reliable for quantification of bone loss, and in addition, demonstrates the soft tissue pathology. Surface area based methods of quantifying glenoid bone loss are more accurate than width based methods. Certain factors important in managing patients with anterior glenohumeral instability include patients’ age, level of sports participation, involvement with contact sports, time of presentation (acute or chronic), and type of bony defect (bony Bankart or attritional bone loss). Soft-tissue reconstruction procedures (labroplasty and remplissage) are usually used in managing patients with nonsignificant bone loss. Patients having significant bone defects of glenoid (>25%) and humerus (off-track/engaging Hill-Sachs lesions) are candidates for open bone grafting of glenohumeral bone defects. Coracoid transfer(Latarjet procedure), either mini-open or arthroscopic gives good functional results and decreases chances of recurrence. Associated lesions should be addressed concomitantly to improve the functional outcome in patients with bony instability of the shoulder. This review presents an evidence-based comprehensive diagnostic and treatment options for patients with bony glenoid deficiency in anterior shoulder instability.
Keywords: Shoulder instability, Hill-Sachs lesion,Labroplasty, Latarjet procedure,Remplissage, Glenoid bone loss, Bony Bankart.


1. Burkhart SS, De Beer JF. Traumatic glenohumeral bone defects and their relationship to failure of arthroscopic Bankart repairs: Significance of the inverted-pear glenoid and the humeral engaging Hill-Sachs lesion. Arthroscopy 2000;16(7):677-694.
2. Hovelius L. Incidence of shoulder dislocation in Sweden. ClinOrthopRelat Res 1982;166:127-131.
3. Taylor DC, Arciero RA. Pathologic changes associated with shoulder dislocations. Arthroscopic and physical examination findings in first-time, traumatic anterior dislocations. Am J Sports Med 1997;25(3):306-311.
4. Fujii Y, Yoneda M, Wakitani S, Hayashida K. Histologic analysis of bony Bankart lesions in recurrent anterior instability of the shoulder. J Shoulder Elbow Surg 2006;15(2):218-223.
5. Hill HA, Sachs MD. The grooved defect of the humeral head a frequently unrecognized complication of dislocations of the shoulder joint. Radiology1940;35(6):690-700.
6. Calandra JJ, Baker CL, Uribe J. The incidence of Hill-Sachs lesions in initial anterior shoulder dislocations. Arthroscopy 1989;5(4):254-257.
7. de Beer J, Bhatia DN. Shoulder injuries in rugby players. Int J Shoulder Surg 2009;3(1):1-3.
8. Arrigoni P, Huberty D, Brady PC, Weber IC, Burkhart SS. The value of arthroscopy before an open modified latarjet reconstruction. Arthroscopy 2008;24(5):514-519.
9. Bhatia DN, DasGupta B. Surgical treatment of significant glenoid bone defects and associated humeral avulsions of glenohumeral ligament (HAGL) lesions in anterior shoulder instability. Knee Surg Sports TraumatolArthrosc 2013;21(7):1603-1609.
10. Bushnell BD, Creighton RA, Herring MM. Bony instability of the shoulder. Arthroscopy 2008;24(9):1061-1073.
11. Bushnell BD, R. Creighton A, Herring MM. The Bony Apprehension Test for instability of the shoulder: A prospective pilot analysis. Arthroscopy: The Journal of Arthroscopic and Related Surgery 2008;24(9):974-982.
12. Edwards TB, Boulahia A, Walch G. Radiographic analysis of bone defects in chronic anterior shoulder instability. Arthroscopy 2003;19(7):732-739.
13. Rokous JR, Feagin JA, Abbott HG. Modified axillary roentgenogram. A useful adjunct in the diagnosis of recurrent instability of the shoulder. ClinOrthopRelat Res 1972;82:84-86.
14. Garth WP Jr, Slappey CE, Ochs CW. Roentgenographic demonstration of instability of the shoulder: The apical oblique projection. A technical note. J Bone Joint Surg Am 1984;66(9):1450-1453.
15. Pavlov H, Warren RF, Weiss CB Jr, Dines DM. The roentgenographic evaluation of anterior shoulder instability. ClinOrthopRelatRes 1985;194:153-158.
16. Gerber C, Nyffeler RW. Classification of glenohumeral joint instability. ClinOrthopRelat Res 2002;400:65-76.
17. Murachovsky J, Bueno RS, Nascimento LG, Almeida LH, Strose E, Castiglia MT, et al. Calculating anterior glenoid bone loss using the Bernageau profile view. Skeletal Radiol 2012;41(10):1231-1237.
18. Itoi E, Lee SB, Amrami KK, Wenger DE, An KN. Quantitative assessment of classic anteroinferior bony Bankart lesions by radiography and computed tomography. Am J Sports Med 2003;31(1):112-118.
19. Sugaya H. Techniques to evaluate glenoid bone loss. Curr Rev Musculoskelet Med 2014;7(1):1-5.
20. Ito H, Takayama A, Shirai Y. Radiographic evaluation of the Hill-Sachs lesion in patients with recurrent anterior shoulder instability. J Shoulder Elbow Surg 2000;9(6):495-497.
21. Bhatia DN, de Beer JF, du Toit DF. Coracoid process anatomy: Implications in radiographic imaging and surgery. ClinAnat 2007;20(7):774-784.
22. Bhatia DN, Dasgupta B, Rao N. Orthogonal radiographic technique for radiographic visualization of coracoid process fractures and pericoracoid fracture extensions. J Orthop Trauma 2013;27(5):e118-e121.
23. Goldberg RP, Vicks B. Oblique angled view for coracoid fractures. Skeletal Radiol 1983;9(3):195-197.
24. Griffith JF, Antonio GE, Tong CW, Ming CK. Anterior shoulder dislocation: Quantification of glenoid bone loss with CT. AJR Am J Roentgenol 2003;180(5):1423-1430.
25. Sekiya JK, Cutuk A. Humeral head defects – Biomechanics, measurements, and treatments. In: Provencher MT, Romeo AA, editors. Shoulder Instability: AComprehensive Approach. Philadelphia, PA:Elsevier, Saunders; 2012.p. 234-247.
26. Saito H, Itoi E, Minagawa H, Yamamoto N, Tuoheti Y, Seki N. Location of the Hill-Sachs lesion in shoulders with recurrent anterior dislocation. Arch Orthop Trauma Surg 2009;129(10):1327-1334.
27. Miniaci A, Gish M. Management of anterior glenohumeral instability associated with large Hill-Sachs defects. Tech Shoulder Elbow Surg2004;5(3):170-175.
28. Lee RK, Griffith JF, Tong MM, Sharma N, Yung P. Glenoid bone loss: Assessment with MR imaging. Radiology 2013;267(2):496-502.
29. Huijsmans PE, Haen PS, Kidd M, Dhert WJ, van der Hulst VP, Willems WJ. Quantification of a glenoid defect with three-dimensional computed tomography and magnetic resonance imaging: A cadaveric study. J Shoulder Elbow Surg 2007;16(6):803-809.
30. Bencardino JT, Gyftopoulos S, Palmer WD. Imaging in anterior glenohumeral instability. Radiology 2013;269(2):323-337.
31. Simão MN, Nogueira-Barbosa MH, Muglia VF, Barbieri CH. Anterior shoulder instability: Correlation between magnetic resonance arthrography, ultrasound arthrography and intraoperative findings. Ultrasound Med Biol 2012;38(4):551-560.
32. Bigliani LU, Newton PM, Steinmann SP, Connor PM, Mcllveen SJ. Glenoid rim lesions associated with recurrent anterior dislocation of the shoulder. Am J Sports Med 1998;26(1):41-45.
33. Itoi E, Lee SB, Berglund LJ, Berge LL, An KN. The effect of a glenoid defect on anteroinferior stability of the shoulder after Bankart repair: A cadaveric study. J Bone Joint Surg Am 2000;82(1):35-46.
34. Lo IK, Parten PM, Burkhart SS. The inverted pear glenoid: An indicator of significant glenoid bone loss. Arthroscopy 2004;20(2):169-174.
35. Greis PE, Scuderi MG, Mohr A, Bachus KN, Burks RT. Glenohumeral articular contact areas and pressures following labral and osseous injury to the anteroinferior quadrant of the glenoid. J Shoulder Elbow Surg 2002;11(5):442-451.
36. Flatow EL, Miniaci A, Evans PJ, Simonian PT, Warren RF. Instability of the shoulder: Complex problems and failed repairs: Part II. Failed repairs. Instr Course Lect 1998;47:113-125.
37. Yamamoto N, Itoi E, Abe H, Minagawa H, Seki N, Shimada Y, et al. Contact between the glenoid and the humeral head in abduction, external rotation, and horizontal extension: A new concept of glenoid track. J Shoulder Elbow Surg 2007;16(5):649-656.
38. Huysmans PE, Haen PS, Kidd M, Dhert WJ, Willems JW. The shape of the inferior part of the glenoid: A cadaveric study. J Shoulder Elbow Surg 2006;15(6):759-763.
39. Bhatia S, Saigal A, Frank RM, Bach BRJr, Cole BJ, Romeo AA, et al. Glenoid diameter is an inaccurate method for percent glenoid bone loss quantification: Analysis and techniques for improved accuracy. Arthroscopy 2015;31(4):608-614.
40. Baudi P, Campochiaro G, Rebuzzi M, Matino G, Catani F. Assessment of bone defects in anterior shoulder instability. Joints 2013;1(1):40-48.
41. Dumont GD, Russell RD, Browne MG, Robertson WJ. Area-based determination of bone loss using the glenoid arc angle. Arthroscopy 2012;28(7):1030-1035.
42. Burkhart SS, Debeer JF, Tehrany AM, Parten PM. Quantifying glenoid bone loss arthroscopically in shoulder instability. Arthroscopy 2002;18(5):488-491.
43. Detterline AJ, Provencher MT, Ghodadra N, Bach BR Jr, Romeo AA, Verma NN. A new arthroscopic technique to determine anterior-inferior glenoid bone loss: Validation of the secant chord theory in a cadaveric model. Arthroscopy 2009;25(11):1249-1256.
44. Bakshi NK, Patel I, Jacobson JA, Debski RE, Sekiya JK. Comparison of 3-dimensional computed tomography-based measurement of glenoid bone loss with arthroscopic defect size estimation in patients with anterior shoulder instability. Arthroscopy 2015;31(10):1880-1885.
45. Rowe CR, Zarins B, Ciullo JV. Recurrent anterior dislocation of the shoulder after surgical repair. Apparent causes of failure and treatment. J Bone Joint SurgAm 1984;66(2):159-168.
46. Montgomery WH Jr, Wahl M, Hettrich C, Itoi E, Lippitt SB, Matsen FA 3rd. Anteroinferior bone-grafting can restore stability in osseous glenoid defects. J Bone Joint Surg Am 2005;87(9):1972-1977.
47. Hardy P. Bony Lesions Influence on the Result of the Arthroscopic Treatment of Glenohumeral Instability. Symposium: Shoulder Instability-Limits of Arthroscopic Surgery: Bone Deficiency, Shrinkage, Acute Instability. Presented at the 5th International Society of Arthroscopy, Knee Surgery and Orthopaedic Sports Medicine Congress, March 10-14, 2003; Auckland, New Zealand.
48. Forsythe B, Frank RM, Ahmed M, Verma NN, Cole BJ, Romeo AA, et al. Identification and treatment of existing copathology in anterior shoulder instability repair. Arthroscopy 2015;31(1):154-166.
49. Balg F, Boileau P. The instability severity index score. A simple pre-operative score to select patients for arthroscopic or open shoulder stabilisation. J Bone Joint Surg Br 2007;89(11):1470-1477.
50. Di Giacomo G, Itoi E, Burkhart SS. Evolving concept of bipolar bone loss and the Hill-Sachs lesion: From “engaging/non-engaging” lesion to “on-track/off-track” lesion. Arthroscopy 2014;30(1):90-98.
51. Yamamoto N, Itoi E. Osseous defects seen in patients with anterior shoulder instability. ClinOrthopSurg 2015;7(4):425-429.
52. Bhatia DN, DeBeer JF. Management of anterior shoulder instability without bone loss: arthroscopic and mini-open techniques. Shoulder Elbow 2011;3:1-7.
53. Wolf EM, Arianjam A. Hill-Sachs remplissage, an arthroscopic solution for the engaging Hill-Sachs lesion: 2-to10-year follow-up and incidence of recurrence. J Shoulder Elbow Surg 2014;23(6):814-820.
54. Argintar E, Heckmann N, Wang L, Tibone JE, Lee TQ. The biomechanical effect of shoulder remplissage combined with Bankart repair for the treatment of engaging Hill-Sachs lesions. Knee Surg Sports TraumatolArthrosc 2016;24(2):585-592.
55. Haviv B, Mayo L, Biggs D. Outcomes of arthroscopic “remplissage”: Capsulotenodesis of the engaging large Hill-Sachs lesion. J OrthopSurg Res 2011;6:29.
56. Elkinson I, Giles JW, Faber KJ, Boons HW, Ferreira LM, Johnson JA, et al. The effect of the remplissage procedure on shoulder stability and range of motion: An in vitro biomechanical assessment. J Bone Joint Surg Am 2012;94(11):1003-1012.
57. Bhatia DN. The “double-barrel” knot: A new sliding knot for arthroscopic soft tissue fixation using single-pulley and double-pulley techniques. Tech Hand Up ExtremSurg 2013;17(3):128-133.
58. Bhatia DN. Double-barrel remplissage: An arthroscopic all-intra-articular technique using the double-barrel knot for anterior shoulder instability. Arthrosc Tech 2015;4(1):e65-e70.
59. HelfetAJ. Coracoid transplantation for recurring dislocation of the shoulder. J Bone Joint Surg Br 1958;40-B(2):198-202.
60. Schroder DT, Provencher MT, Mologne TS, Muldoon MP, Cox JS. The modified Bristow procedure for anterior shoulder instability: 26-year outcomes in Naval Academy midshipmen. Am J Sports Med 2006;34(5):778-786.
61. Boileau P, Bicknell RT, El Fegoun AB, Chuinard C. Arthroscopic Bristow procedure for anterior instability in shoulders with a stretched or deficient capsule: The “belt-and-suspenders” operative technique and preliminary results. Arthroscopy 2007;23(6):593-601.
62. Latarjet M. Treatment of recurrent dislocation of the shoulder. Lyon Chir 1954;49(8):994-997.
63. Allain J, Goutallier D, Glorion C. Long-term results of the Latarjet procedure for the treatment of anterior instability of the shoulder. J Bone Joint Surg Am 1998;80(6):841-852.
64. Mizuno N, Denard PJ, Raiss P, Melis B, Walch G. Long-term results of the Latarjet procedure for anterior instability of the shoulder. J Shoulder Elbow Surg 2014;23(11):1691-1699.
65. Patte D, Debeyre J. Luxations recidivantes de l’epaule. Encycl Med Chir (Ed. Elsevier, Paris), Techniques chirurgicales–orthopédie–traumatologie 1980;44-265.
66. de Beer JF, Roberts C. Glenoid bone defects- Open latarjet with congruent arc modification. OrthopClin North Am 2010;41(3):407-415.
67. Burkhart SS, De Beer JF, Barth JR, Cresswell T, Roberts C, Richards DP. Results of modified Latarjet reconstruction in patients with anteroinferior instability and significant bone loss. Arthroscopy 2007;23(10):1033-1041.
68. Noonan B, Hollister SJ, Sekiya JK, Bedi A. Comparison of reconstructive procedures for glenoid bone loss associated with recurrent anterior shoulder instability. J Shoulder Elbow Surg 2014;23(8):1113-1119.
69. Ghodadra N, Gupta A, Romeo AA, Bach BR Jr, Verma N, Shewman E, et al. Normalization of glenohumeral articular contact pressures after Latarjet or iliac crest bone-grafting. J Bone Joint Surg Am 2010;92(6):1478-1489.
70. Bhatia DN. Dual-window subscapularis-sparing approach: A new surgical technique for combined reconstruction of a glenoid bone defect or bankart lesion associated with a HAGL lesion in anterior shoulder instability. Tech Hand Up ExtremSurg 2012;16(1):30-36.
71. Lafosse L, Lejeune E, Bouchard A, Kakuda C, Gobezie R, Kochhar T. The arthroscopic Latarjet procedure for the treatment of anterior shoulder instability. Arthroscopy 2007;23(11):1242.e1-e5.
72. Bhatia DN. Arthroscopic Latarjet and Capsular Shift (ALCS) procedure: A new “freehand” technique for anterior shoulder instability associated with significant bone defects. Tech Hand Up ExtremSurg 2015;19(1):11-17.
73. Hindmarsh J, Lindberg A. Eden-hybbinette’soperation for recurrent dislocation of the humero-scapular joint. ActaOrthopScand 1967;38:459-478.
74. Niskanen RO, Lehtonen JY, Kaukonen JP. Alvik’sglenoplasty for humeroscapular dislocation 6-year follow-up of 52 shoulders. ActaOrthopScand 1991;62(3):279-283.
75. Auffarth A, Schauer J, Matis N, Kofler B, Hitzl W, Resch H. The J-bone graft for anatomical glenoid reconstruction in recurrent posttraumatic anterior shoulder dislocation. Am J Sports Med 2008;36(4):638-647.
76. Provencher MT, Bhatia S, Ghodadra NS, Grumet RC, Bach BR Jr, Dewing CB, et al. Recurrent shoulder instability: Current concepts for evaluation and management of glenoid bone loss. J Bone Joint Surg Am 2010;92Suppl 2:133-151.

How to Cite this article:. Kandhari VK, DasGupta B, Bhatia DN. Current Trends in Management of Glenoid Bone Loss in Anterior Shoulder Instability. Asian Journal of Arthroscopy Jan – April 2017;1(2):20-28.



(Abstract)      (Full Text HTML)      (Download PDF)

0 replies

Leave a Reply

Want to join the discussion?
Feel free to contribute!

Leave a Reply

Your email address will not be published. Required fields are marked *