How to handle minor and major bone loss in the shoulder? Current concepts

Anterior shoulder instability is a significant problem in orthopaedic surgery. It carries a heavy burden on quality of life, especially in young, active patients. Surgical treatment is therefore often carried out in this population. Several strategies can effectively address this issue. Yet, the consensus is lacking on the parameters which favour one technique over another, especially when bone loss is present. This is because of the complex, dynamic interplay between bone loss on the humeral side (ie, Hill-Sachs lesion) and glenoid bone loss, which is a common occurrence and defined as ‘bipolar’. There is an ongoing debate over the percentage of glenoid bone loss warranting bone block procedures: 13.5–15% is an indicator for such procedures (ie, Latarjet), although this value is still considered controversial and not uniformly accepted. A multitude of other factors (ie, age, sex, level of activity and so on) come into play alongside bipolar bone loss and the weight of each factor has yet to be fully elucidated. Also, refining the algorithm for the right procedure in the right patients will reduce the number of side effects stemming from initial, suboptimal treatment choice. Knowing how to manage previous surgical treatment failure is also key for the treating orthopaedic surgeon, who must be able to address the root cause of failure and react accordingly and effectively. This paper analyses key factors in treatment choice, the current stance of the literature on varying degrees of bone loss and choices on surgical treatment failure, lack of evidence and need for future research.