What is the most appropriate treatment approach for a patient with right shoulder instability and multiple associated conditions, who has undergone previous surgeries including arthroscopic glenoid reconstruction and axillary nerve neurolysis?

Treatment Approach for Complex Shoulder Instability with Prior Failed Reconstruction

The question lacks specificity about which "medication/surgery" is being considered, making it impossible to provide a definitive recommendation on medical indication; however, given this patient's complex presentation with failed prior glenoid reconstruction, early arthrosis, partial rotator cuff involvement, and multiple pathologies, further surgical intervention carries substantial risk and limited evidence-based support.

Critical Context for Decision-Making

This patient presents with a particularly challenging clinical scenario:

• Prior failed arthroscopic glenoid reconstruction with persistent instability 1
• Early glenohumeral arthrosis with chondromalacia 1
• Partial-thickness rotator cuff fraying (not full-thickness tear) 1
• Glenoid insufficiency despite prior reconstruction 2
• Previous axillary nerve neurolysis indicating nerve injury history 3

Evidence-Based Treatment Considerations

Arthroplasty Options and Limitations

Total shoulder arthroplasty (TSA) is generally contraindicated in this clinical scenario based on multiple factors:

• TSA should not be performed in patients with irreparable rotator cuff tears (consensus recommendation, Level V evidence) 1. While this patient has only partial-thickness fraying, the distinction becomes critical—if the rotator cuff is functionally compromised or at risk of progression, TSA outcomes deteriorate significantly 1.

• Revision rates after failed prior surgery are substantially elevated, with complication rates for shoulder arthroplasty reaching 39.8% and revision rates up to 11% in primary cases 1. This patient's prior failed reconstruction increases these risks considerably.

• Young patients with instability and early arthrosis present a management dilemma. The 2010 AAOS guidelines express concern about performing shoulder arthroplasty in patients aged <50 years due to increased prosthetic loosening and decreased survivorship 1.

Reverse Shoulder Arthroplasty Considerations

Reverse shoulder arthroplasty (RSA) may be the only arthroplasty option if surgery is pursued, given:

• RSA was designed for rotator cuff deficiency and has been used as a salvage procedure for failed arthroplasties 1
• The construct compensates for instability by moving the center of rotation medially and distally, allowing the deltoid to serve as the primary stabilizer 1
• However, RSA complications include scapular notching, dislocation (particularly relevant given this patient's instability history), periprosthetic fractures, and glenoid baseplate failure 1

Revision Instability Surgery

Revision arthroscopic or open stabilization procedures face significant challenges:

• Glenoid bone loss is a critical determinant of surgical approach. If glenoid bone loss exceeds 20-25%, bone block transfer procedures (Latarjet or anatomic glenoid reconstruction) are recommended over soft-tissue repair 2

• The patient has already undergone glenoid reconstruction, suggesting significant bone loss was present initially. Failure of this reconstruction indicates either inadequate bone restoration, technical failure, or biological factors preventing healing 4

• Capsulolabral insufficiency after prior surgery makes repeat soft-tissue stabilization procedures unlikely to succeed without addressing bone deficiency 2

Axillary Nerve Considerations

The prior axillary nerve neurolysis is a critical red flag:

• Nerve injuries occur in 1-8% of instability surgeries and 1-4% of arthroplasty cases 3
• The axillary nerve runs within 3 mm of the inferior shoulder capsule, placing it at risk during any revision procedure 3
• Further surgery carries substantial risk of re-injury or worsening nerve function, which would significantly impact deltoid function and overall shoulder mechanics 3

Conservative Management Priority

Aggressive conservative management should be exhausted before any surgical intervention:

• Physical therapy focusing on rotator cuff strengthening, periscapular muscle stabilization, and proprioceptive training is the foundation of instability management 5
• Conservative treatment must be attempted and failed before elective orthopedic procedures 6
• A minimum 3-6 month trial of structured rehabilitation is recommended before considering revision surgery 7

Clinical Decision Algorithm

If considering any surgical intervention, the following must be evaluated:

1. Quantify glenoid bone loss with 3D CT reconstruction 2

   • If >25% bone loss: bone block procedure may be considered
   • If 13.5-25%: adjunct procedures to stabilization required
   • If <13.5%: soft-tissue repair potentially viable (though prior failure suggests otherwise)

2. Assess rotator cuff integrity with MRI or MR arthrography 1

   • If progression to full-thickness tear: TSA contraindicated 1
   • If partial-thickness but functionally intact: proceed with caution

3. Evaluate axillary nerve function with electrodiagnostic testing 3

   • If compromised function: surgical risk substantially elevated
   • Document baseline function before any intervention

4. Assess arthrosis severity radiographically 1

   • Early arthrosis may progress with further instability or surgery
   • Consider patient age and activity demands

Common Pitfalls to Avoid

• Do not proceed with TSA if rotator cuff function is questionable, as this leads to poor outcomes and high revision rates 1
• Do not underestimate the significance of prior surgical failure—revision procedures have substantially worse outcomes than primary procedures 1
• Do not ignore the axillary nerve history—further injury could be catastrophic for shoulder function 3
• Do not rush to surgery without adequate conservative management trial, as physical therapy can improve stability even in complex cases 5

Evidence Quality Assessment

The available evidence is predominantly Level IV-V (expert opinion and case series) for this specific clinical scenario 1. The 2010 AAOS guidelines on glenohumeral osteoarthritis provide the highest-quality systematic review, but acknowledge significant limitations in the evidence base 1. No high-quality randomized trials exist for revision instability surgery in the setting of early arthrosis and prior failed reconstruction.