Arthroscopic Bone Block Stabilization for Anterior Shoulder Instability with Subcritical Glenohumeral Bone Loss

The management options for anterior shoulder instability with minimal bone loss or with critical bone loss are well established. However, there is less clear evidence to guide management for patients with subcritical bone loss, the spectrum of pathology where soft tissue repair alone is prone to higher rates of failures. In this range of bone loss, likely around 13.5% to 20%, the goal of surgery is to restore function and stability while limiting morbidity. As with many procedures in the shoulder, this decision should be tailored to patient anatomy, functional goals, and risk factors. This article provides a review of our current understanding of subcritical bone loss and treatment strategies as well as innovations in management.

While surgeons have largely understood that restoration of anatomy is important to optimize outcomes after stabilization surgery, there is increasing evidence that reconstructing bony anatomy and addressing both osseous and soft tissue structures yields better results than either alone. Even in the setting of subcritical bone loss, there is likely a benefit to combined osseous augmentation with soft tissue management. Additionally, there is new evidence to support management of even on-track humeral lesions when the distance to dislocation is sufficiently small, particularly for athletes.

Surgeons must balance bony and soft tissue restoration to achieve optimal outcomes for anterior instability with subcritical bone loss. There are still significant limitations in the literature and several emerging techniques for management will require further study to prove their long-term efficacy. Beyond surgery, there should be a focus on a collaborative treatment strategy with the surgeon, patient, and therapists to achieve high-level function and minimize recurrence.