Navigating Shoulder Instability: Open vs. Arthroscopic surgery – A guide for Orthopedic Professionals
WAIKOLOA, Hawaii — At Orthopedics Today Hawaii, Julie Y. Bishop, MD, illuminated the critical decision-making process between open and arthroscopic surgery for shoulder instability. Her insights,drawn from extensive experience,offer a nuanced approach to treatment based on the degree of bone loss and patient-specific factors.
Understanding the Core Principles of Surgical Approach
Dr. Bishop frames her decision-making around the extent of bone loss, a key determinant in selecting the appropriate surgical technique. “I break it down into categories of bone loss,” she explained. “And when I look at patients that have less than 10% bone loss, the majority of my patients are getting an arthroscopic procedure. And then I think the Hill-Sachs and the athlete contact sport activity level realy is the dependent factor for remplissage or not.”
The Role of Bone Loss Percentage
The percentage of bone loss dictates the initial pathway. Arthroscopic procedures are favored for patients with minimal bone loss (under 10%). However, this is not a rigid rule, and other factors come into play.The presence of a hill-Sachs lesion—a compression fracture on the back of the humeral head—and the patient’s participation in contact sports substantially influence the decision regarding whether to proceed with a remplissage procedure (glenoid augmentation).
Extraordinary Cases for Open Bankart Repair with Minimal Bone Loss
While generally favoring arthroscopic approaches for minimal bone loss, Dr.Bishop acknowledges specific scenarios where an open Bankart repair is considered. “It’s very rare, but I think the young, female, ligamentously lax athlete with instability and no bone loss at all — I think they are high risk for recurrence. So, those are the patients that I may consider an open Bankart,” she stated. This highlights the importance of recognizing inherent ligamentous laxity as a risk factor for treatment failure, even in the absence of structural bone loss.
Navigating the ‘Gray Area’: 10-15% Bone Loss
Patients presenting with 10% to 15% bone loss fall into a more complex decision-making zone. The definition of “critical bone loss” varies, influenced by factors such as the patient’s age and activity level. This intermediate range demands a tailored assessment.
Impact of Athletic Activity on Treatment Choice
for contact athletes in this 10-15% bone loss range, dr. Bishop typically favors the Latarjet procedure—a surgical technique involving the transfer of a piece of the coracoid process to the glenoid to enhance stability. However, older patients or those involved in lower-impact recreational activities may be suitable candidates for an arthroscopic Bankart repair, often augmented with a remplissage. “When I’m between 10% and 15% if I have a contact athlete, I’m almost always going with a Latarjet (procedure). But if I’m between 10% and 15% and I have an older patient with instability or just a lower level recreational athlete, I am much more apt to do an arthroscopic Bankart and remplissage,” she explained.
Bone Loss Exceeding 15%: A Clear Path to Latarjet for Athletes
When bone loss surpasses 15%, Dr. Bishop consistently recommends the Latarjet procedure for all contact athletes. This decision is driven by the need for robust stabilization in individuals subjected to high forces. For patients with over 25% glenoid bone loss, nonetheless of activity level, she advocates for an intra-articular graft to restore cartilage and further address the structural deficit.
Understanding the procedures
To provide context, let’s briefly define the procedures mentioned:
- arthroscopic Bankart Repair: A minimally invasive procedure utilizing an arthroscope (a small camera) to repair the torn labrum and ligaments, stabilizing the shoulder joint.
- Remplissage: An arthroscopic technique where bone marrow and soft tissue are used to fill the glenoid defect, adding bone stock and improving stability.
- Latarjet Procedure: An open surgical procedure involving the transfer of the coracoid process (a bony prominence) to the glenoid rim, increasing bone coverage and resisting dislocation.
- Intra-articular graft: Utilizing cartilage or other tissue to repair important cartilage loss within the shoulder joint
The Broader Context of Shoulder Instability
The shoulder joint, renowned for its extensive range of motion, is inherently susceptible to instability and dislocation. Physiopedia explains that the “spheroid shape of the glenohumeral joint…renders it prone to dislocation and other injuries.” Understanding the anatomical factors contributing to instability is crucial for selecting the appropriate surgical approach.
Future Directions and Personalized Treatment
Dr. Bishop’s insights exemplify a growing trend toward personalized treatment plans in orthopedic surgery. Careful assessment of individual patient characteristics, including age, activity level, ligamentous laxity, and the extent of bone loss, is paramount to achieving optimal outcomes. As research continues, we can anticipate even more refined techniques and criteria informing surgical decisions for shoulder instability.
Sources/Disclosures
Source:
Healio Interviews
Disclosures: Bishop reports no relevant financial disclosures.
