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 2, 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 procedures 3
• The axillary nerve runs as close as 3 mm from the inferior shoulder capsule 3
• Repeat surgery in this region carries substantial risk of recurrent nerve injury, particularly given the scarring and altered anatomy from prior procedures 3
• The far medial portal used in anatomic glenoid reconstruction places the axillary nerve at a mean distance of 46.28 mm, but individual variation exists 4

Conservative Management Priority

Aggressive conservative management should be exhausted before considering any additional surgery:

• 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 surgical intervention per standard orthopedic practice 6
• Multidirectional instability (which may be contributing given the capsulolabral insufficiency) often responds to physical therapy, with surgery considered only after 3 months of failed conservative treatment 7

Specific Surgical Contraindications

The following factors argue strongly against additional surgery at this time:

• Early arthrosis with ongoing instability creates a scenario where neither stabilization nor arthroplasty has strong evidence support 1
• Loose bodies and synovitis suggest ongoing mechanical irritation that may worsen with implant placement 1
• Subacromial impingement complicates the picture and may worsen with certain reconstructive procedures, particularly RSA 1
• Biceps tendinopathy adds another pain generator; while biceps tenotomy/tenodesis could be considered with arthroplasty, there is insufficient evidence to recommend for or against this approach 1

Clinical Decision Algorithm

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

1. Quantify glenoid bone loss with 3D CT reconstruction to determine if bone block procedure is feasible or if bone stock is too deficient 2

2. Assess rotator cuff integrity definitively with MRI to determine if TSA is absolutely contraindicated or if RSA is the only arthroplasty option 1

3. Document functional limitations and pain severity to justify surgical risk in the context of prior failed surgery 1

4. Evaluate axillary nerve function thoroughly given prior neurolysis and risk of repeat injury 3

5. Consider surgeon volume: Surgeons performing fewer than 2 shoulder arthroplasties per year have increased complication rates and length of stay 1

Critical Pitfalls to Avoid

• Do not proceed with TSA if rotator cuff function is questionable, as this is a consensus contraindication 1
• Do not underestimate the impact of prior failed surgery on outcomes; revision procedures have substantially higher complication rates 1
• Do not ignore glenoid bone stock assessment; inadequate bone stock dooms both stabilization and arthroplasty procedures 2
• Do not rush to surgery without exhausting conservative measures, particularly given the complexity and prior surgical failure 6, 5

Without knowing the specific intervention being considered, the general recommendation is that this patient requires comprehensive imaging reassessment (3D CT for bone stock, MRI for rotator cuff), exhaustive conservative management, and consultation with a high-volume shoulder surgeon before any additional surgical intervention can be deemed medically indicated.