Rockwood Adults CH34

1102

SECTION TWO • Upper Extremity

Authors’ Preferred Treatment for Anterior Glenohumeral Instability (Algorithms 34-1 and 34-2)

Anterior shoulder instability (primary)

Age < 14 (open physis)

Age > 30

Age 14 to 30

Low demand nonathlete

High demand contact athlete

Physical therapy conservative management

MR arthrogram é ABER view

Recurrent dislocation

Surgery

Arthroscopic or open Bankart repair

Concern for glenoid bone loss Grashey (true AP) radiograph (loss of sclerotic line)

Glenoid bone loss (CT with 3D reconstruction)

> 30%

< 13.5% to 17.3%

17.4% to 30%

Nonengaging Hill–Sachs (on track)

Engaging Hill–Sachs (off track)

Glenoid bone grafting (autograft or allograft)

Arthroscopic or open Bankart repair + remplissage

Arthroscopic or open Bankart repair

Latarjet

Algorithm 34-1.  Authors’ preferred treatment for primary anterior shoulder instability.

For patients with anterior shoulder instability, the decision between conservative or surgical management is dependent on age, number of subluxations/dislocations, amount of glenoid bone loss, type of sports (contact vs. noncontact), and the patient’s own expectations. Primary dislocation in patients under the age of 14 years is managed with physical therapy and rotator cuff and deltoid strengthening exercises. In patients aged 14 to 30 years who are active and play a high-demand or contact sports, MRA is recommended after the primary subluxation or dislocation event. If a Bankart lesion is detected on MRA, surgery is recommended to stabi- lize the shoulder and prevent recurrent instability that would result in damage to the intra-articular structures. If there is no Bankart lesion on the MRA, a trial of physical therapy

and strengthening program is recommended. For patients in this age group who are of low demand and not athletes, the authors recommend a trial of conservative management with physical therapy. Furthermore, for primary instability in low-demand patients over the age of 30 years, physical therapy is also the treatment of choice. Surgery should be indicated for any patients who have recurrence of instability after a trial of physical therapy. A CT scan with 3D reconstruction is critical to assess for anterior glenoid bone loss, the size of the Hill–Sachs lesion, and whether the shoulder is “on” or “off” track. A review of recent literature suggests that the “subcritical” to “criti- cal” bone loss is between 13.5% and 17.3% glenoid bone loss. 209,211 The decision to use 13.5% or 17.3% as the cutoff