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Shoulder

Complex Shoulder Instability / Bone Transfer Procedure

Complex shoulder instability comprises a range of disorders including damage to soft tissues and bone resulting from shoulder dislocations. The glenoid socket is shallow and relies on the surrounding tissues for stability. Damage can occur to the labrum, the protective cuff of cartilage that lines the socket; and / or to stabilizing tissues the rotator cuff and ligaments. Arthroscopic surgery can repair the soft tissues.  However, when there are associated injuries such as fractures, bone loss, large lesions, recurrent instability, reinjury to a previous soft tissue repair or a failed repair, reconstruction surgery with bone transfer may be recommended.

What is complex shoulder instability?

Complex shoulder instability is defined as instability associated with not only damage to soft tissues but also bony defects around the shoulder. The bony defects may be minimal or substantial bone loss, fracture or significant damage to the ball or socket. In the presence of bone loss or significant risk factors for instability, the risk of recurrent instability is high if only soft tissue procedures are performed.

Bony lesions are common in shoulder instability. Addressing bone defects is a key to avoiding recurrence of instability after surgery. The solution is bone augmentation surgery.  It is designed to reconstruct the shoulder joint to restore shoulder stability. Bone block procedures are state-of-the-art treatment for complex shoulder instability. Bone transfers have been proven to be effective at augmenting the glenoid surface and achieving adequate shoulder stability with good outcomes and early return to athletics.

Innovations in techniques have permitted bone augmentation procedures to be performed arthroscopically to treat associated injuries. The advantages of these minimally invasive procedures are smaller incisions, less blood loss and manipulation of soft tissues, and faster recovery.

Common bony lesions

Common bony lesions are glenoid bone loss and a Hill – Sachs lesion.

  • Glenoid bone loss is a well-established cause of shoulder instability and long-term disability if not addressed.
  • A Hill – Sachs defect is an injury secondary to a shoulder dislocation that causes a compression fracture or a divot on the head of upper arm bone. The risk of instability from a Hill – Sachs lesion is not only from the lesion but also the health of the glenoid socket.
  • A Bony Bankart lesion is associated with instability due to injury to the labrum that also breaks off part of the glenoid bone (a glenoid rim fracture). It is often caused by a traumatic shoulder dislocation. Most of these fractures are small and can be treated non-operatively. However, a large bony Bankart is associated with recurrent instability. Surgery is the gold standard treatment for large lesions. Left untreated there will be pain and persistent instability which will cause arthritis and poor outcomes.

Treatment options for complex shoulder instability range widely based on the patient’s exam, surgical history, amount of glenoid bone loss, size of a Hill – Sachs lesion and the surgeon’s preference. Thus Dr. Petrigliano will consider the patient’s history, physical exam, and preoperative imaging with patient expectations when selecting the appropriate surgical procedure.

Who may benefit from a glenoid reconstruction with bone transfers?

  • Bone transfers are valuable for young athletes with high functional demands, who participate in contact sports and have other lesions including a large Hill – Sachs lesion.
  • Patients who have experienced a shoulder dislocation and have a large Hill – Sachs lesion that alters the rim of the socket and have damage to the head of the humerus (the ball).
  • Patients with a bony Bankart tear who are living with chronic joint instability and are predisposed to future dislocations.
  • Young athletes who had a successful primary stabilization procedure, but experience recurrent instability typically related to bone loss.

Shoulder reconstruction surgery is necessary to restore function and prevent recurrent dislocations.

What are the treatment options for complex shoulder instability?

Anterior shoulder instability is associated with injuries to the labrum and shoulder capsule and with bony defects of varying degrees. If the bone defect exceeds a clinical threshold, mere soft tissue repairs result in high rates of recurrent instability. This means the glenoid needs to be reconstructed with bone augmentation.

Anterior Glenoid Reconstruction

Surgery to treat complex anterior shoulder instability can be challenging. Dr. Frank Petrigliano is a renowned shoulder surgeon and the “go to” surgeon for complex anterior glenoid reconstruction.

The Latarjet Procedure

The Latarjet surgical reconstruction procedure is one of the most effective and well-known techniques to treat anterior shoulder instability. It involves repair of soft tissue damage and reconstructs the glenoid bone to stabilize the shoulder joint. Studies report that it has reliable success in reducing recurrent instability and minimizes the risk of osteoarthritis caused by shoulder dislocation.

Distal Tibial Allograft (DTA) for Complex Glenoid Reconstruction

DTA is utilized to treat recurrent anterior shoulder instability due to significant glenoid bone loss and to manage a failed Latarjet procedure. DTA is a highly effective revision surgery for patients who had a failed Latarjet procedure or for patients with massive bone loss.   It offers a clinically stable joint with excellent outcomes.

How is the appropriate surgical procedure determined?

Treatment options vary based on the patient’s exam, surgical history, amount of bone loss and preoperative imaging studies, including patient expectations, and pre-injury levels activity.

Dr. Petrigliano will review your symptoms and order imaging studies and a CT scan to identify and quantify bone damage. He will evaluate each patient with complex shoulder instability to determine the best surgical procedure to achieve the best functional outcome with decreased risk of failure.

Why choose Dr. Petrigliano?

Dr. Frank Petrigliano is an orthopaedic surgeon who was fellowship trained in sports medicine and shoulder surgery at the prestigious Hospital for Special Surgery where he provided care to athletes of all ages. He currently serves as the head team physician for the LA Kings hockey team and associate team physician for USC Athletics. Dr. Petrigliano is a renowned orthopaedic surgeon and researcher who employs state of the art treatments and procedures to get you back to your active life and back to sport. He always treats his patients with compassion and respect. Dr. Petrigliano is located in El Segundo California, and serves greater Los Angeles, Beverly Hills, the South Bay, and the Santa Clarita Valley. Contact Dr. Petrigliano to schedule a consultation today.

At a Glance

Dr. Frank Petrigliano

  • Associate Professor of Orthopaedic Surgery at USC
  • Chief of the Epstein Family Center for Sports Medicine
  • Team physician for the LA Kings and USC Athletics
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