Managing severe bipolar bone loss in athletes: A comprehensive approach with open Latarjet and arthroscopic remplissage

Background

Severe bipolar bone loss (BBL) represents one of the toughest challenges when managing the instability of glenohumeral joints among athletes and more specifically the ones involved in overhead sports. It refers to the significant loss of the humeral head and the glenoid bone, with an increased risk of failure. The present study aimed to evaluate the functional outcomes of a combined open Latarjet and arthroscopic remplissage in such high-risk individuals.

Methods

A retrospective evaluation was carried out among athletes with antero-inferior loss of glenoid bone of more than 15 % and large off-track Hill-Sachs defect who underwent the Latarjet technique with iliac crest bone graft (ICBG) harvest used in combination with arthroscopic remplissage between 2021 and 2023. The University of California, Los Angeles (UCLA) score, constant-Murley score (CMS), and the range of motion (ROM; measured as forward flexion, external rotation, and abduction) were evaluated pre-operative and post-operative at the timepoint of 3-month, 6-month, and 1-year. Pre-operative magnetic resonance imaging scans (MRI) and computed tomography scans (CT) were obtained among the patients with severe glenohumeral BBL, and the glenoid track was calculated to identify on-track and off-track Hill-Sachs lesions. Post-operative MRI with filled Hill-Sachs defect post remplissage procedure and 3D CT scan was also done at 6-month to evaluate the union of the ICBG to the native glenoid bone.

Results

Overall, 11 patients underwent for the combined procedure for severe BBL. The UCLA score (31.18 ± 3.74), and the CMS (93.64 ± 8.38) at the time-point of 1-year post-operatively showed remarkable improvement in comparison with the preoperative scores (P < 0.0001); and the ROM including abduction, external rotation, and forward flexion were restored to near normality. All patients showed bony union at 6-month as confirmed by post-operative CT scan. No complications such as redislocation or subluxation were observed over 1-year. There were no neurological complications or complications related to graft (graft migration or graft breakage or resorption) as well. All the athletes returned to sports activities at an average duration of 6.8-month post-operatively, with 73 % returning to sports at the level of pre-injury.

Conclusion

The combined procedure of ICBG Latarjet and arthroscopic remplissage for the treatment of severe BBL in athletes achieved satisfactory outcomes over 1-year, with all athletes returning to sports activities.

Higher Return to Sport and Lower Revision Rates when Performing Arthroscopic Bankart Repair with Remplissage for Anterior Shoulder Instability with a Hill-Sachs Lesion: A Meta-Analysis

BACKGROUND

Recurrent anterior shoulder instability remains the most common complication from a prior shoulder dislocation, especially among young and active individuals who engage in athletic activities. This instability can lead to repeated subluxation or dislocations of the humeral head from the glenoid fossa. The purpose of this study is to compare postoperative recurrence rates, instability-related revision and return to sport (RTS) rates between isolated arthroscopic Bankart repair (ABR) and ABR with remplissage (ABR+R) for anterior shoulder instability with subcritical glenoid bone loss (GBL) and a Hill-Sachs lesion (HSL).

METHODS

PubMed, Embase, and Web of Science were searched on June 2022. Studies sought were those comparing postoperative outcomes of ABR+R versus isolated ABR for subcritical GBL and an HSL. Study quality was evaluated using the revised Cochrane tool. Redislocations, instability-related revisions, and return to sport rates were extracted and pooled estimates were calculated using the random-effect model.

RESULTS

Twelve studies were included with a mean follow-up of 48.2 months for isolated ABR and 43.2 months for ABR+R. The meta-analytic comparison demonstrated that ABR+R resulted in statistically significant improvement in Rowe and American Shoulder and Elbow Surgeons scores by 6.5 and 2.2 points, respectively, however, the improvements in patient-reported outcomes were not clinically meaningful. ABR+R resulted in reduced external rotation at the side by 1˚ which was not clinically meaningful, and there was no significant difference in terms of forward elevation. ABR+R resulted in a statistically significant reduction of overall postoperative recurrences (odd ratio (OR): 9.36), postoperative dislocations (OR: 6.28) instability-related revision (OR: 3.46), and RTS to any level (OR: 2.85).

CONCLUSION

The addition of remplissage to ABR for recurrent anterior shoulder instability with subcritical GBL and HSL results in significantly lower postoperative instability recurrence, lower instability-related revisions, and higher RTS to any level.

Mechanisms of shoulder trauma: Current concepts

Acute traumatic injuries to the glenohumeral articulation are common. The types of injuries depend on age, muscle strength, bone density, and biomechanics of the traumatic event. Understanding the different mechanisms of trauma and how they affect the functional anatomical structures of the shoulder joint is crucial for the treatment of these lesions. Therefore, when clinicians have knowledge of these mechanisms they can accurately diagnose and treat shoulder pathology and predict distinct injury patterns. Here, we have described the fundamentals of the mechanisms of injury of the glenohumeral dislocation, dislocation with fracture of the humeral head, and the proximal humerus fracture. We have focused on common injury mechanisms and the correlation with radiological diagnostics. Radiological and laboratory findings of distinct types of injury were also discussed.

Current Concepts in the Measurement of Glenohumeral Bone Loss

PURPOSE

The extent of glenohumeral bone loss seen in anterior shoulder dislocations plays a major role in guiding surgical management of these patients. The need for accurate and reliable preoperative assessment of bone loss on imaging studies is therefore of paramount importance to orthopedic surgeons. This article will focus on the tools that are available to clinicians for quantifying glenoid bone loss with a focus on emerging trends and research in order to describe current practices.

RECENT FINDINGS

Recent evidence supports the use of 3D CT as the most optimal method for quantifying bone loss on the glenoid and humerus. New trends in the use of 3D and ZTE MRI represent exciting alternatives to CT imaging, although they are not widely used and require further investigation. Contemporary thinking surrounding the glenoid track concept and the symbiotic relationship between glenoid and humeral bone loss on shoulder stability has transformed our understanding of these lesions and has inspired a new focus of study for radiologists and orthopedist alike. Although a number of different advanced imaging modalities are utilized to detect and quantify glenohumeral bone loss in practice, the current literature supports 3D CT imaging to provide the most reliable and accurate assessments. The emergence of the glenoid track concept for glenoid and humeral head bone loss has inspired a new area of study for researchers that presents exciting opportunities for the development of a deeper understanding of glenohumeral instability in the future. Ultimately, however, the heterogeneity of literature, which speaks to the diverse practices that exist across the world, limits any firm conclusions from being drawn.

Bone loss in shoulder instability: putting it all together

Glenohumeral bone loss is frequently observed in cases of recurrent anterior and posterior shoulder instability and represents a risk factor for failure of nonoperative treatment. Patients with suspected glenoid or humeral bone loss in the setting of recurrent instability should be evaluated with a thorough history and physical examination, as well as advanced imaging including computed tomography (CT) and/or magnetic resonance imaging (MRI). In cases of both anterior and posterior instability, the magnitude and location of bone loss should be determined, as well as the relationship between the glenoid track (GT) and any humeral defects. While the degree and pattern of osseous deficiency help guide treatment, patient-specific risk factors for recurrent instability must also be considered when determining patient management. Treatment options for subcritical anterior bone loss include labral repair and capsular plication, while more severe deficiency should prompt consideration of bony augmentation including coracoid transfer or free bone block procedures. Concomitant humeral lesions are treated according to the degree of engagement with the glenoid rim and may be addressed with soft tissue remplissage or bony augmentation procedures. While critical and subcritical thresholds of glenoid bone loss guide the management of anterior instability, such thresholds are less defined in the setting of posterior instability. Furthermore, current treatment algorithms are limited by a lack of long-term comparative studies. Future high-quality studies as well as possible modifications in indications and surgical technique are required to elucidate the optimal treatment of anterior, posterior, and bipolar glenohumeral bone loss in the setting of recurrent shoulder instability.

Management of off-track Hill-Sachs lesions in anterior glenohumeral instability

Bone loss has been identified as a risk factor for recurrent shoulder dislocations or failure after soft tissue repair. Although the range for "critical" bone loss is yet to be determined, glenoid and humeral bone defects should not be regarded as independent problems, but the interaction between them during shoulder motion should be evaluated as suggested by the glenoid track concept. The glenoid track concept is now widely accepted and considered essential for making decisions about surgery. Soft-tissue procedures usually work well in patients with on-track Hill-Sachs lesions but in off-track lesions do not. In this situation additional procedures should be performed.Different surgical options have been described to address off-track Hill-Sachs lesions, most commonly remplissage, Latarjet or free bone block procedures. Coracoid graft and free bone grafts convert the off-track Hill-Sachs lesion into on-track by lengthening the glenoid-track, whereas remplissage fill-in the humeral lesion so that it does not engage. In the setting of a Hill-Sachs lesion with little or no glenoid bone loss, remplissage has demonstrated satisfactory outcomes with a low complications and recurrence rate. Favorable results have been reported with glenoid bone grafting when managing isolated Hill-Sachs or bipolar lesions. Studies analyzing Latarjet and Eden-Hybinette procedures show that both procedures are safe and effective in the management of anterior glenohumeral instability. Attention should be paid to those patients with large bone defects not amenable to be restored with an isolated Latarjet that may be better addressed with an Eden-Hybinnete or adding a remplissage to the Latarjet procedure.

Arthroscopic Bankart Repair for Adolescent Anterior Shoulder Instability: Clinical and Imaging Predictors of Revision Surgery and Recurrent Subjective Instability

BACKGROUND

Multiple clinical and radiologic risk factors for recurrent instability after arthroscopic Bankart repair have been described. Humeral bone loss has gained more recent attention, particularly with respect to "off-track" lesions and increased rates of recurrent instability and revision surgery.

PURPOSE

To evaluate clinical and radiologic predictors of failure after arthroscopic Bankart repair in adolescents.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

A single-institution retrospective study was performed in patients <19 years of age treated with arthroscopic Bankart repair from 2011 to 2017. Magnetic resonance imaging measurements of glenoid and humeral bone loss, the glenoid track, and the presence of off-track Hill-Sachs (HS) lesions were assessed. All patients had a minimum follow-up of 24 months and completed patient-reported outcome scores. Failure was defined as revision surgery or postoperative subjective instability.

RESULTS

A total of 59 patients (46 male, 13 female) with a median age of 16 years (range, 12-18 years) were included. Ten patients (17%) had revision surgery and 8 patients (14%) had subjective instability without revision surgery. No clinical or radiologic factors were significantly different between the failure cohort and the nonfailure cohort. Four patients (7%) measured off-track, and 2 of these patients experienced failure. A total of 38 patients (64%) were identified to have an HS defect. Subgroup analysis of these patients identified a greater HS interval (HSI) in patients who underwent revision surgery as compared with those patients who did not have revision surgery. Among patients with GT ratio ≥15 mm, there was a 50% rate of revision surgery. The Pediatric/Adolescent Shoulder Survey (PASS) and Single Assessment Numeric Evaluation (SANE) scores at the final follow-up were not significantly different among patients with or without revision surgery. However, those with subjective instability who had not undergone revision surgery had significantly lower PASS and SANE scores as compared with the remainder of the cohort.

CONCLUSION

Of the adolescents in this cohort, 31% either had revision surgery (17%) or reported subjective feelings of instability (14%) after arthroscopic Bankart repair. Off-track instability was identified in 7% of the cohort but was not predictive of failure. Among the subgroup of patients with an HS defect, those who underwent revision surgery had a significantly larger HSI.

Allograft reconstruction for humeral head defects in the setting of shoulder instability: a systematic review

Background

Glenohumeral joint instability and dislocation are common orthopedic pathologies that can produce osseous humeral head defects such as Hill-Sachs (HS) or Reverse Hill-Sachs (RHS) lesions. Numerous reconstruction techniques have been reported in the literature, including remplissage, disimpaction, and allograft reconstruction. No group has previously assessed the outcomes of allograft reconstruction for RHS lesions, nor compared the outcomes of allograft reconstruction for HS and RHS lesions. In this study, we aim to provide a comprehensive assessment of osteochondral allograft reconstruction for the distinct pathologies of RHS lesions and HS lesions by comparing postreconstruction patient-reported outcomes, complications, and radiographic assessments for each lesion.

Methods

Using Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines, a systematic review was performed to identify and include studies that reported patient outcomes after the use of osteochondral allografts in the reconstruction of HS or RHS lesions of the humeral head. A comprehensive search of the Google Scholar, PubMed, and Embase databases was conducted with the key terms "allograft," "Hill-Sachs," and "reverse Hill-Sachs."

Results

Eight studies, with a total of 84 patients, were included for review. Of the 84 allograft-treated patients, there were 44 patients with HS lesions and 40 patients with RHS lesions. The average patient age was 27.3 years for HS lesions and 43.0 years for RHS lesions. Postoperative range of motion and average Constant-Murley score (87.9 for HS and 80.1 for RHS) appeared to be greater for those with HS lesions. In addition, 20.5% of HS patients experienced postoperative complications, whereas 42.5% of RHS patients had postoperative complications (P = .03). HS and RHS patients experienced similar proportions of graft resorption or collapse rate (22.7% for HS and 12.5% for RHS; P = .2).

Conclusion

Patient-reported outcomes indicate that osteochondral allograft reconstruction for large RHS and HS lesions is an acceptable intervention. RHS patients had lower rates of graft resorption and collapse but worse postoperative range of motion and functional outcomes, although these differences were not statistically significant. HS patients experienced significantly fewer complications than those with RHS lesions.

Belt and suspender technique for bipolar bone loss in shoulder instability

Bipolar glenohumeral bone loss is a challenging condition to address in patients with recurrent anterior shoulder instability. In this category of patients, most isolated soft-tissue procedures such as remplissage or infraspinatus capsulotenodesis are associated with high risk of failure and instability recurrence. Even bony procedures such as Latarjet may fail to provide absolute stability, and instability may eventually recur. For a better understanding of the cause of failure in this particular type of patient, we may refer to the glenoid track concept which has been described as a useful tool for surgical planning. In fact, Latarjet procedure alone may leave a place for engagement of the Hill-Sachs defect on the anterior glenoid resulting in an off-track situation and secondary glenohumeral instability. In this technical note, we present the combination of arthroscopic remplissage and an open Latarjet procedure to treat patients with bipolar glenohumeral bone loss with good results at 31-month follow-up. Our aim is to propose these techniques as a possible rescue procedure for highly unstable shoulders combining engaged Hill-Sachs lesion and glenoid bone loss of more than 25%. We believe this technique would be a good option for patients who present other risk factors of recurrence such as past medical history of epilepsy, laxity, and psychiatric illnesses.

Remplissage for Anterior Shoulder Instability: History, Indications, and Outcomes

Remplissage is a nonanatomic capsulotenodesis of the infraspinatus tendon used to fill engaging or "off-track" Hill-Sachs lesions in patients at high risk of recurrent instability with isolated Bankart repair. Indications for remplissage are expanding, as the importance of subcritical bone loss and the glenoid track on patient outcomes and recurrence rates continues to be investigated. Remplissage is also suggested in patients at high risk of recurrent instability following isolated anterior labral repair, such as collision and contact athletes with Hill-Sachs lesions that have not reached the threshold of "off track." Multiple arthroscopic remplissage techniques exist including, more recently, knotless techniques.

Athletes with primary glenohumeral instability demonstrate lower rates of bone loss than those with recurrent instability and failed prior stabilization

BACKGROUND

The purpose of this study was to compare the preoperative magnetic resonance arthrography findings in patients who underwent glenohumeral stabilization with a history of primary instability, recurrent instability, or failed stabilization.

METHODS

All patients who presented with glenohumeral instability and underwent stabilization performed by a single surgeon in our institution between 2008 and 2020 were considered for inclusion in this study. The magnetic resonance arthrography findings of all patients were recorded. Imaging findings were compared between patients with primary instability, those with recurrent instability, and those with failed prior stabilization. P < .05 was considered statistically significant.

RESULTS

Overall, 871 patients were included, of whom 814 (93.5%) were male patients; the mean age was 23.1 years (range, 13-57 years). There were 200 patients with primary instability, 571 with recurrent instability, and 100 who required revision stabilization surgery, with no significant differences in demographic characteristics between the groups. A significantly higher amount of glenoid bone loss was noted in patients with recurrent instability (43.4%) and failed prior stabilization (56%) than in those with primary instability (26.5%) (P < .0001). Additionally, a significantly higher number of Hill-Sachs lesions were observed in patients with recurrent instability (70.1%) and failed prior stabilization (89%) than in those with primary instability (67.5%) (P < .0001). We found no significant differences between the groups regarding articular cartilage damage, glenolabral articular disruption, anterior labral periosteal sleeve avulsion, humeral avulsion of the glenohumeral ligaments, or superior labral anterior-posterior tears (P > .05).

CONCLUSION

Patients presenting for stabilization with recurrent instability or following a failed stabilization procedure have higher rates of glenohumeral bone loss than those with primary instability. Therefore, stabilization of primary instability, particularly in high-functioning athletes with a view to preventing recurrence, may reduce the overall progression of glenohumeral bone loss and potential subsequent inferior clinical outcomes.

Long-term outcomes of arthroscopic Bankart repair and Hill-Sachs remplissage for bipolar bone defects

PURPOSE

To evaluate long-term results after arthroscopic Bankart repair and Hill-Sachs remplissage (BHSR) in bipolar bone defects with less than 20% of glenoid bone loss (GBL) and to analyse risk factors for recurrent dislocation.

METHODS

From 2009-2012, 43 patients with recurrent anterior shoulder instability were treated with BHSR. Inclusion criteria were GBL < 20% and minimum of 4-yearfollow-up. There were 35 males and 8 females with a mean age of 29 years (range 16-53). The mean ISIS score was 3.6 (range 2-6). Patients were evaluated for recurrence, range of motion and functional outcomes (Walch-Duplay and Rowe score). Post-operative MRI was performed at least 6 months after surgery to evaluate infraspinatus capsulotenodesis healing. Glenoid track was assessed retrospectively from pre-operative computed tomography. Mean follow-up was 7.3 years (range 4-11).

RESULTS

At the last follow-up, good to excellent outcomes were reported in 86% of patients. Average post-operative Walch-Duplay was 87.9 (range 75-100) and ROWE 93.7 (range 70-100). Infraspinatus capsulotenodesis healing was achieved in 86%. The rate of recurrence and revision surgery was 9.3% and 13.9%, respectively. Recurrence was associated with higher ISIS score (p = 0.0191) and lower age at surgery (p = 0.0227). Four (9.3%) Hill-Sachs lesions were considered off-track. The presence of off-track Hill-Sachs was associated with higher risk of recurrence (p < 0.00001).

CONCLUSION

Arthroscopic BHSR improves shoulder instability in the setting of bipolar bone defects with less than 20% of GBL. Patient-related factors and pre-operative glenoid track should be taken into consideration to reduce the risk of recurrence.

Improving detection of Hill-Sachs fractures on radiographs

OBJECTIVE

To investigate factors which affect radiographic diagnosis of Hill-Sachs fractures, and find criteria which improve detection.

MATERIALS AND METHODS

Retrospective search was made for the term "Hill Sachs" within MRI reports in our local PACS system, and cases with post-reduction radiographs were included in the study. Prospective diagnoses and subspecialty MSK training of the interpreting radiologist of record were recorded. Images were then retrospectively reviewed by two observers and statistical analysis was performed.

RESULTS

Our retrospective study included 181 cases, of which 35% had prospective radiographic diagnosis of Hill-Sachs fracture. Retrospective review found that 73% of the radiograph series had at least 1 sign of a Hill-Sachs fracture. The internal rotation view showed a Hill-Sachs lesion in 59% of cases, but did not detect it in 14% of cases, where the lesion was instead visible on axillary, external rotation, and/or scapular Y view. Odds ratio of prospective Hill-Sachs detection on radiographs was 2.68 for musculoskeletal fellowship-trained radiologists versus non-musculoskeletal-trained radiologists.

CONCLUSION

Hill-Sachs fractures are often not recognized on post-reduction radiographs. Diagnosis of Hill-Sachs lesion can be significantly increased if radiologists are aware that the internal rotation view may fail to show the injury, and if all 4 views of a shoulder series are scrutinized.

Do Techniques for Hill-Sachs Remplissage Matter in Terms of Functional and Radiological Outcomes?

Background:

Different techniques are used for the remplissage procedure, including the double-pulley and mattress suture techniques. Both techniques have shown good results; however, it is unclear if one technique is superior.

Hypothesis:

The remplissage procedure using the double-pulley technique with 2 anchors would have superior functional and radiological outcomes compared with the mattress suture technique with a single anchor.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

This study included patients with anterior shoulder instability who were treated using arthroscopic Bankart repair combined with remplissage between 2012 and 2017. A structured questionnaire was used to gather information on the following metrics: Instability Severity Index Score, hyperlaxity, Sugaya index, presence of a Hill-Sachs defect, number of dislocations before surgery, sports participation, radiological measurement of the Hill-Sachs lesion, postoperative range of motion in both shoulders, Rowe score, Walch-Duplay score, American Shoulder and Elbow Surgeons score, and Filling Index Score of Remplissage grade according to magnetic resonance imaging scans at the last follow-up.

Results:

There were 41 patients included with a mean age of 30 ± 7 years who underwent the Hill-Sachs remplissage procedure using the double-pulley technique with 2 anchors (n = 21; group DA) or the mattress suture technique with a single anchor (n = 20; group SA). At the final follow-up, there were no significant differences between the groups regarding the Instability Severity Index Score (P = .134), the Sugaya index (P = .538), sports participation (P = .41), the radiological measurement of the Hill-Sachs lesion (P = .803), or the Rowe score (P = .182). However, there were significant differences between the groups in the Walch-Duplay score (P = .012), American Shoulder and Elbow Surgeons score (P = .005), and Filling Index Score of Remplissage grade (P = .015), favoring group DA, as well as differences in external rotation in a neutral position (external rotation loss: 9° ± 3° [group SA] vs 12° ± 3° [group DA]; P = .003) and at 90° of abduction (external rotation loss: 8° ± 3° [group SA] vs 11° ± 3° [group DA]; P = .006), favoring group SA.

Conclusion:

In the remplissage procedure, the double-pulley technique provided better filling of the lesion and improvement in functional scores, but external rotation was limited compared with the mattress suture technique.

Interobserver agreement for detecting Hill-Sachs lesions on magnetic resonance imaging

BACKGROUND

Our aim is to determine the interobserver reliability for surgeons to detect Hill-Sachs lesions on magnetic resonance imaging (MRI), the certainty of judgement, and the effects of surgeon characteristics on agreement.

METHODS

Twenty-nine patients with Hill-Sachs lesions or other lesions with a similar appearance on MRIs were presented to 20 surgeons without any patient characteristics. The surgeons answered questions on the presence of Hill-Sachs lesions and the certainty of diagnosis. Interobserver agreement was assessed using the Fleiss' kappa (κ) and percentage of agreement. Agreement between surgeons was compared using a technique similar to the pairwise t-test for means, based on large-sample linear approximation of Fleiss' kappa, with Bonferroni correction.

RESULTS

The agreement between surgeons in detecting Hill-Sachs lesions on MRI was fair (69% agreement; κ, 0.304; p<0.001). In 84% of the cases, surgeons were certain or highly certain about the presence of a Hill-Sachs lesion.

CONCLUSIONS

Although surgeons reported high levels of certainty for their ability to detect Hill-Sachs lesions, there was only a fair amount of agreement between surgeons in detecting Hill-Sachs lesions on MRI. This indicates that clear criteria for defining Hill-Sachs lesions are lacking, which hampers accurate diagnosis and can compromise treatment.

Evolving Concepts in the Management of Shoulder Instability

BACKGROUND

Shoulder instability exists on a spectrum ranging from subtle subluxation and pain to dislocation and can be the result of a traumatic event or repetitive microtrauma. Shoulder instability can result in significant disability and often requires surgical intervention, especially amongst younger, active patient populations. The optimal treatment of shoulder instability depends on the degree of instability and concomitant pathology involving the labrum, capsule, and bony anatomy of the glenoid and humeral head. Even with surgical intervention, recurrent instability remains a relatively common and difficult problem to address.

PURPOSE

With a focus on anterior instability, the purpose of this review article is to discuss the current assessment and treatment of shoulder instability, and highlight current and future treatment modalities, as well as to identify current trends and deficiencies in our current management. We also provide an algorithm for the surgical treatment of anterior shoulder instability.

METHODS

Literature databases were extensively searched for recent articles related to the mechanism, diagnosis, and treatment of shoulder instability to comprise a comprehensive review.

CONCLUSION

Although there are multiple treatment modalities available for shoulder instability, such as nonoperative management, open and arthroscopic Bankart repair, Latarjet procedures, and remplissage, orthopaedic surgeons continue to learn about the most appropriate method of management as increasing long-term outcomes become available.

Are there racial differences between patients undergoing surgery for shoulder instability? Data from the Multicenter Orthopaedic Outcomes Network (MOON) Shoulder Instability Group

BACKGROUND

The purpose of this study was to identify differences related to race in preoperative and intraoperative findings of patients undergoing operative treatment for shoulder instability.

METHODS

Data from the Multicenter Orthopaedic Outcomes Network (MOON) Shoulder Instability cohort were used. Of 1010 patients, 995 provided race and ethnicity information and were included in the analyses. Demographic characteristics, injury history, radiographic and intraoperative findings, and preoperative patient-reported instability, pain, and function were compared (1) between white and minority patients and (2) in a subgroup analysis between white patients and the 3 largest minority groups. The Distressed Communities Index (DCI) score was recorded for each patient's home ZIP code. Multiple logistic regressions were performed to determine whether models consisting of race/ethnicity, insurance carrier, and/or DCI score were predictive of bone and cartilage loss at the time of surgery.

RESULTS

Compared with white patients, a greater percentage of US minority patients had ≥2 dislocations (68.0% vs. 57.1%, P = .01), which corresponded with more frequent articular cartilage lesions (62.2% vs. 51.0%, P = .007) and increased frequencies of glenoid bone loss > 10% (16.2% vs. 8.7%, P = .03) and Hill-Sachs lesions (68.6% vs. 56.0%, P = .004). Specifically, when compared with white patients, African American and Asian patients showed significantly increased frequencies of glenoid bone loss > 10% (19.7% of African American patients, 18.4% of Asian patients, and 8.9% of white patients; P = .01) and Hill-Sachs lesions (65.6%, 71.7%, and 52.4%, respectively; P = .02). Race was an independent predictor of articular cartilage lesions (P = .04) and the presence of Hill-Sachs lesions (P = .01). A higher DCI score (P = .03) and race (P = .04) were both predictive of having glenoid bone loss > 10%.

CONCLUSION

We found that minority race was associated with increased number of preoperative dislocations and increased frequency of articular cartilage and Hill-Sachs lesions at the time of surgery, and both minority race and an increased DCI score were associated with glenoid bone loss > 10%. Further research is needed to understand the underlying reason for these differences and to optimize care for all patients with shoulder instability.

Coracoacromial morphology: a contributor to recurrent traumatic anterior glenohumeral instability?

BACKGROUND

Although scapular morphology contributes to glenohumeral osteoarthritis and rotator cuff disease, its role in traumatic glenohumeral instability remains unknown. We hypothesized that coracoacromial and glenoid morphology would differ between healthy subjects and patients with recurrent traumatic anterior shoulder instability.

METHODS

Computed tomography scans of 31 cadaveric control scapulae and 54 scapulae of patients with recurrent traumatic anterior shoulder instability and Hill-Sachs lesions were 3-dimensionally reconstructed. Statistical shape modeling identified the modes of variation between the scapulae of both groups. Corresponding measurements quantified these modes in relation to the glenoid center (linear offset measures), defined by the best-fit circle of the inferior glenoid, or the glenoid center plane (angles), which bisects the glenoid longitudinally. Distances were normalized for glenoid size.

RESULTS

Compared with controls, the unstable coracoids were shorter (P = .004), with a more superior and medial offset of the tip (mean difference [MD], 7 and 3 mm, respectively; P < .001) and an origin closer to the 12-o'clock position (MD, 6°; P < .001). The unstable scapular spines originated closer to the 9-o'clock position (MD, 4°; P = .012), and the unstable acromions were more vertically oriented (MD, 6°; P < .001). The unstable glenoids had an increased height-width index (MD, 0.04; P = .021), had a flatter anterior-posterior radius of curvature (MD, 77 mm; P < .001), and were more anteriorly tilted (MD, 5°; P = .005).

CONCLUSIONS

Coracoacromial and glenoid anatomy differs between individuals with and without recurrent traumatic anterior shoulder instability. This pathologic anatomy is not addressed by current soft-tissue stabilization procedures and may contribute to instability recurrence.

[Treatment of anterior shoulder instability with remplissage for Hill-Sachs injuries and Bankart injury compared to pure Bankart injuries]

BACKGROUND

Anterior shoulder dislocation occurs in more than 90% of the time, the main cause is traumatic, describing two main lesions in this pathology: Bankarts and Hill-Sachss injury, the recurrence rate is not similar in open repair and with a possible advantage of arthroscopic surgery with less loss of movement range, lower risk of subscapular muscle damage, faster return to daily activities and increased patient satisfaction.

OBJECTIVE

Assessing functionality, mobility and stability of the shoulder in patients treated: arthroscopic Bankart repair versus arthroscopic Bankart repair + remplissage.

METHODS

Clinical records of patients with shoulder instability were reviewed Hill-Sachs and Bankart lesions were doumented; 21 post-surgical patients and were physically examined to evaluate the range of motion, Rowe functional scales and Western Ontario Shoulder Instability Index were used. 13 months of follow up as an average.

RESULTS

There was no recurrence of dislocation with either technique, greater satisfaction was observed in the remplissage group; however, the limitation of the motion arc is greater.

CONCLUSION

Both groups reduce instability, control pain and mostly satisfy patients in the 13-month follow-up.

Arthroscopic Bankart Repairs With and Without Remplissage in Recurrent Adolescent Anterior Shoulder Instability With Hill-Sachs Deformity

Background:

Recurrent shoulder dislocation after surgical intervention in adolescents with anterior instability is now understood to occur with a relatively high frequency. The remplissage procedure is successfully used in the adult population to mitigate the ability of a Hill-Sachs lesion to engage the anterior glenoid and can be used during an arthroscopic Bankart repair for anterior shoulder instability.

Purpose:

To compare the clinical outcomes in adolescent patients who underwent a Bankart repair with or without remplissage for treatment of recurrent anterior shoulder instability and associated Hill-Sachs defects.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

A retrospective review was conducted on adolescents who underwent a remplissage procedure for recurrent anterior shoulder instability from 2009 to 2017 at a single institution. Controls were identified in a cohort of patients who underwent a Bankart repair only and were matched based on age, sex, and size of Hill-Sachs lesion. All patients were then contacted to determine instability recurrence as well as to complete the shortened version of the Disabilities of the Arm, Shoulder and Hand (QuickDASH) and the Pediatric Adolescent Shoulder Score (PASS) outcome surveys.

Results:

Twenty-one adolescents underwent a remplissage procedure, and 20 matched controls underwent only a Bankart procedure. A significantly higher rate of recurrence was noted in the Bankart-only patients (8/17) compared with remplissage patients (2/15) (P = .04). No statistical difference was found in patient-reported outcome scores between treatment groups or in range of motion measurements (P > .05). In a subset of patients in the remplissage group with pre- and postoperative surveys available, mean ± SD scores for PASS (77 ± 11) and QuickDASH (19 ± 12) improved when compared with preoperative scores (PASS, 54 ± 16; QuickDASH, 35 ± 28), but only the PASS score was statistically improved (PASS, P = .003; QuickDASH, P = .23).

Conclusion:

The addition of the remplissage procedure to a Bankart repair is a reasonable surgical option to treat a Hill-Sachs deformity in adolescents with anterior shoulder instability. The success of this additional procedure may be due to filling the Hill-Sachs defect, or perhaps it augments stability through a mechanism of posterior capsulorrhaphy. Either way, this young athletic population appears to have a lower rate of recurrence and improved patient-reported outcomes with a remplissage procedure to address the Hill-Sachs deformity.

The Incidence of Glenohumeral Bone and Cartilage Lesions at the Time of Anterior Shoulder Stabilization Surgery: A Comparison of Patients Undergoing Primary and Revision Surgery

BACKGROUND

Intra-articular glenohumeral joint changes frequently occur after shoulder instability events.

PURPOSE

(1) To compare demographic characteristics, baseline patient-reported outcomes, and intraoperative findings for patients undergoing primary or revision shoulder stabilization surgery and (2) to determine the incidence of glenohumeral bone and cartilage lesions in this population while identifying factors independently associated with these lesions.

STUDY DESIGN

Cross-sectional study; Level of evidence, 3.

METHODS

The Multicenter Orthopaedic Outcomes Network (MOON) Shoulder Group shoulder instability database was used to identify all prospectively enrolled patients undergoing shoulder stabilization surgery for anterior instability between October 2012 and September 2016. Any patient who underwent surgery for posterior or multidirectional shoulder instability or concomitant rotator cuff repair surgery was excluded. Patient demographic characteristics, preoperative patient-reported outcomes, and intraoperative findings, including glenohumeral bone and cartilage lesions, were compared for patients undergoing primary and revision shoulder stabilization surgery. Additionally, patients with and without glenohumeral bone and cartilage lesions were compared and independent associations determined using multivariate analysis.

RESULTS

There were 545 patients available for analysis (461/545 [84.6%] primary; 84/545 [15.4%] revision). Patients undergoing revision surgery were older ( P = .001), were more frequently smokers ( P = .022), had a greater number of instability events before surgery ( P = .047), more frequently required reduction assistance ( P < .001), and had lower Short Form-36 (SF-36) Mental Component Summary ( P = .020) and Western Ontario Shoulder Instability Index (WOSI) ( P = .026) scores preoperatively. Additionally, patients undergoing revision surgery had a higher frequency of bone and cartilage lesions than those undergoing primary surgery (47.6% vs 18.4%, respectively; P < .001). Male sex, revision surgery, black race, increasing body mass index, increasing patient age, and lower preoperative SF-36 Physical Component Summary score were independently associated with the presence of glenohumeral bone and cartilage lesions at the time of shoulder stabilization surgery. Revision surgery was strongly associated with the presence of glenohumeral bone and cartilage lesions (odds ratio [OR], 4.381 [95% CI, 2.591-7.406]) and glenoid bone loss greater than 10% (OR, 9.643 [95% CI, 5.128-18.134]) or 20% (OR, 13.076 [95% CI, 5.113-33.438]) of the glenoid width.

CONCLUSION

Glenohumeral bone and cartilage lesions are common at the time of shoulder stabilization surgery, occurring more frequently in patients undergoing revision surgery as compared with primary surgery. On the basis of these findings, future prospective studies should aim to compare the clinical outcomes in these 2 groups.

Arthroscopic Bankart Repair for the Management of Anterior Shoulder Instability: Indications and Outcomes

PURPOSE OF REVIEW

Arthroscopic Bankart repair is commonly utilized for shoulder stabilization in patients with anterior shoulder instability with minimum glenoid bone loss. The purpose of this review is to provide the indications, surgical technique, complications, and recent outcomes in arthroscopic Bankart repair for shoulder instability.

RECENT FINDINGS

Improvements in arthroscopic techniques have led to better patient outcomes, as well as an improved understanding of the pathoanatomy of instability. More recent studies have shown that one of the potential failures of primary arthroscopic repair may be due to unaddressed bone loss. This underscores the importance of evaluating glenoid bone loss and proper patient selection for this procedure to ensure successful outcome. When indicated, arthroscopic stabilization is the treatment of choice for many surgeons due to its lower morbidity and low overall complication rate. Future work must focus on longer-term outcomes in patients undergoing arthroscopic Bankart repair, as well as the clinical outcomes of new fixation techniques, augmentation techniques, and the effect of glenoid bone loss in outcome.

Eponymous terms in anterior shoulder stabilization surgery

Shoulder dislocation and its treatment are probably as old as time. Surgical treatment has gained acceptance recently, especially in recurrent cases. Within roughly the last 100years, numerous treatment strategies have been developed and questions elucidated regarding the entity of shoulder instability. Shoulder instability holds many eponymous terms. By means of literature and historical research, we present the biographical background of some common eponymous terms and the original publication on which those terms are based. We describe the Perthes lesion, Bankart lesion and repair, Hill-Sachs lesion, Bristow-Latarjet procedure and Eden-Hybbinette procedure. Shoulder instability has been recognized and treated for many centuries. Before the invention of X-rays and the ability to intervene surgically, empirical reduction and time were the only feasible treatment options. Understanding of the pathophysiology of this problem and its corresponding treatment has kept increasing since the 19th century. The originators involved still have their name attached to the different signs and procedures.

LEVEL OF EVIDENCE

IV.

Radiographic Evaluation of Patients with Anterior Shoulder Instability

PURPOSE OF REVIEW

Injuries to the labrum, joint capsule (in particular the inferior glenohumeral ligament), cartilage, and glenoid periosteum are associated with anterior shoulder instability. The goal of this review is to provide common radiographic images and findings in patients with anterior shoulder instability. Furthermore, we will demonstrate the best methods for measuring anterior glenoid bone loss.

RECENT FINDINGS

Magnetic resonance (MR) imaging is highly relied upon for evaluating anterior shoulder instability and can diagnose soft tissue injuries with high sensitivity. While 3D computed tomography (CT) scan has been considered the optimal tool for evaluating osseous defects, certain MR imaging sequences have been shown to have similar diagnostic accuracy. Repair of Bankart lesions is critical to stabilizing the shoulder, and in the recent years, there has been an increasing focus on imaging to accurately characterize and measure glenoid bone loss to properly indicate patients for either arthroscopic repair or anterior bony reconstruction. Furthermore, Hill-Sachs lesions are commonly seen with shoulder instability, and importance must be placed on measuring the size and depth of these lesions along with possible engagement, as these factors will dictate management. The labral-ligamentous complex and rotator cuff are primary stabilizers of the shoulder. With anterior shoulder instability, the labrum is frequently injured. MRI with an arthrogram or provocative maneuvers is the gold standard for diagnosis. Various imaging modalities and methods can be performed to identify and measure Bankart and Hill-Sachs lesions, which can then be used for surgical planning and treating shoulder instability.

Imaging of the Unstable Shoulder

Background:

Unstable shoulder can occur in different clinical scenarios with a broad spectrum of symptoms and presentations: first-time (or recurrent) traumatic acute shoulder anterior dislocation or chronic anterior instability after repeated dislocations.

Imaging in unstable shoulder is fundamental for choosing the right treatment preventing recurrence.

The goal of imaging depends on clinical scenario and patient characteristics.

Method:

Careful selection and evaluation of the imaging procedures is therefore essential to identify, characterize and quantify the lesions. Proper imaging in unstable shoulder cases is critical to the choice of treatment to prevent recurrence, and to plan surgical intervention.

Results:

In acute setting, radiographs have to roughly detect and characterize the bone defects present. At about 7 days, it is recommended to perform a MR to demonstrate lesions to labrum and/or ligaments and bone defects: in acute setting, the MRA is not necessary, because of effusion and hemarthrosis that behave as the contrast medium.

In recurrence, it is fundamental not only to detect lesions but characterize them for planning the treatment. The first study to do is the MRI (with a magnetic field of at least 1.5 Tesla), and if possible MRA, above all in younger patients. Then, on the basis of the pathologic findings as bipolar lesion or severity of bone defects, CT can be performed. PICO method on 2D or 3D CT is helpful if you need to study a glenoid bone loss, with the “en face view” of glenoid, while a 3D CT reconstruction with the humeral head “en face view” is the gold standard to assess an Hill-Sachs lesion.

Conclusion:

The clinical diagnoses of anterior shoulder instability can be different and acknowledgement of imaging findings is essential to guide the treatment choice.

Imaging features are quite different in chronic than in acute scenario. This requires appropriate indications of many different imaging techniques.

Biomechanical comparison of acute Hill-Sachs reduction with remplissage to treat complex anterior instability

BACKGROUND

Acute Hill-Sachs reduction represents a potential alternative method to remplissage for the treatment of an engaging Hill-Sachs lesion. This study biomechanically compared the stabilizing effects of an acute Hill-Sachs reduction technique and remplissage.

METHODS

Six cadaveric shoulders were tested. For the acute Hill-Sachs lesion, a unique model was used to create a 30% defect, compressing the subchondral bone while preserving the articular surface. Five scenarios were tested: intact specimen, bipolar lesion, Bankart repair, remplissage with Bankart repair, and Hill-Sachs reduction technique with Bankart repair. The Hill-Sachs lesion was reduced through a lateral cortical window with a bone tamp, and the subchondral void was filled with bone cement.

RESULTS

At 90° of abduction and external rotation (ER), total translation was 11.6 ± 0.9 mm for the bipolar lesion. This was significantly reduced after remplissage (5.9 ± 1.1 mm; P < .001) and after Hill-Sachs reduction (4.7 ± 0.4 mm; P < .001). Compared with an isolated Bankart repair, the average ER loss after remplissage was 4° ± 4° (P = .65), and the average ER loss after Hill-Sachs reduction was 1° ± 3° (P = .99). Similar joint stability was conferred after both procedures, with minimal change in range of motion.

CONCLUSIONS

Remplissage may still be the best way to address chronic Hill-Sachs lesions; however, the reduction technique is a more anatomic alternative and may be a potential option for treating an acutely engaging Hill-Sachs lesion.

Results of arthroscopic Bankart repair with Hill-Sachs remplissage for anterior shoulder instability

PURPOSE

The aim of this study was to evaluate mid-term outcomes of Bankart repair with Hill-Sachs remplissage (BHSR) and to highlight prognostic factors of failure.

METHODS

Thirty-four patients operated on for anterior shoulder instability with BHSR were enrolled in a prospective non-randomised study. Clinical and radiographic evaluation was performed at 1.5, three, six months and yearly thereafter. Outcome measures included Rowe and Walch-Duplay score.

RESULTS

At mean follow-up of 35 months (24-63), the Rowe and Walch-Duplay scores reached respectively 92.7 and 88.2 points. The mean deficit in external rotation was 6° in ER1 and 1° in ER2 (p = 0.4, p = 0.9 respectively). Five patients (14.7%) had a recurrence of instability and three others had a persistent anterior apprehension. In the failure group, the Hill-Sachs lesion was deeper (26% vs 19% of the humeral diameter; p = 0.04) and range of motion at 1.5 months postoperatively was greater. Age at surgery, pre-operative instability severity index score (ISIS), hyperlaxity, type and level of sport, amount of glenoid bone loss had no correlation with failure rate.

CONCLUSIONS

The rate of failure at mid-term follow-up of BHSR was higher than commonly reported. The premature recovery of range of motion seems to be a clinical sign of failure at follow-up. Moreover, in case of deep Hill-Sachs lesion (>20%) an alternative procedure should be considered.

LEVEL OF EVIDENCE

Level IV.

Hill-Sachs lesion classification under arthroscopic findings

BACKGROUND

The Hill-Sachs lesion (HSL) plays a role in recurrent glenohumeral joint instability. Currently, there are no studies based on the form characteristics of HSL. The purposes of this study were to report the HSL form characteristics and to determine whether they are correlated with number of prior subluxations and dislocations.

METHODS

The study enrolled 134 consecutive patients diagnosed with anterior shoulder instability during an arthroscopic procedure. We classified the arthroscopic findings into 4 types, as follows: type 1, cyst type; type 2, gutter type; type 3, island type; and type 4, wide type. Subsequently, we investigated the correlation between each type and the number of shoulder subluxations and dislocations reported. The following data were analyzed: subluxation and dislocation history, arthroscopic findings, and maximum lesion size.

RESULTS

Of the patients evaluated, 18, 32, 30, and 54 were classified as types 1 to 4, respectively. The mean numbers of shoulder dislocations were 3.3, 7.3, 6.0, and 12.0 for types 1 to 4, respectively. The wide type was correlated with more subluxations and dislocations than the other types (P = .001, .046, and .007, respectively). There were significant differences in mean width among all types (P < .0001). HSL width was correlated with lesion type and angle.

CONCLUSION

We classified HSL into 4 types on the basis of visual inspection and found a correlation between lesion type and lesion size. However, HSL width was correlated with lesion type and angle; that is, the number of dislocations and subluxations does not affect HSL width.

3D-MR vs. 3D-CT of the shoulder in patients with glenohumeral instability

OBJECTIVE

To determine whether 3D-MR osseous reformats of the shoulder are equivalent to 3D-CT osseous reformats in patients with glenohumeral instability.

MATERIALS AND METHODS

Patients with glenohumeral instability, who were to be imaged with both CT and MRI, were prospectively selected. CT and MR were performed within 24 h of one another on 12 shoulders. Each MR study included an axial 3D isotropic VIBE sequence. The image data from the isotropic VIBE sequence were post-processed using subtraction and 3D software. CT data were post-processed using 3D software. The following measurements were obtained for both 3D-CT and 3D-MR post-processed images: height and width of the humeral head and glenoid, Hill-Sachs size and percent humeral head loss (if present), size of glenoid bone loss and percent glenoid bone loss (if present). Paired t-tests and two one-sided tests for equivalence were used to assess the differences between imaging modalities and equivalence.

RESULTS

The measurement differences from the 3D-CT and 3D-MR post-processed images were not statistically significant. The measurement differences for humeral height, glenoid height and glenoid width were borderline statistically significant; however, using any adjustment for multiple comparisons, this failed to be significant. Using an equivalence margin of 1 mm for measurements and 1.5% for percent bone loss, the 3D-MR and 3D-CT post-processed images were equivalent.

CONCLUSION

Three-dimensional-MR osseous models of the shoulder using a 3D isotropic VIBE sequence were equivalent to 3D-CT osseous models, and the differences between modalities were not statistically significant.

Accuracy of Suture Passage During Arthroscopic Remplissage-What Anatomic Landmarks Can Improve It?: A Cadaveric Study

Background:

Recent data suggest that inaccurate suture passage during remplissage may contribute to a loss of external rotation, with the potential to cause posterior shoulder pain because of the proximity to the musculotendinous junction.

Purpose:

To evaluate the accuracy of suture passage during remplissage and identify surface landmarks to improve accuracy.

Study Design:

Descriptive laboratory study.

Methods:

Arthroscopic remplissage was performed on 6 cadaveric shoulder specimens. Two single-loaded suture anchors were used for each remplissage. After suture passage, position was recorded in reference to the posterolateral acromion (PLA), with entry perpendicular to the humeral surface. After these measurements, the location of posterior cuff penetration was identified by careful surgical dissection.

Results:

Twenty-four sutures were passed in 6 specimens: 6 sutures (25.0%) were correctly passed through the infraspinatus tendon, 12 (50%) were through the infraspinatus muscle or musculotendinous junction (MTJ), and 6 (25%) were through the teres minor. Suture passage through the infraspinatus were on average 25 ± 5.4 mm inferior to the PLA, while sutures passing through the teres minor were on average 35.8 ± 5.7 mm inferior to the PLA. There was an odds ratio of 25 (95% CI, 2.1-298.3; P < .001) that the suture would be through the infraspinatus if the passes were less than 3 cm inferior to the PLA. Sutures passing through muscle and the MTJ were significantly more medial than those passing through tendon, measuring on average 8.1 ± 5.1 mm lateral to the PLA compared with 14.5 ± 5.5 mm (P < .02). If suture passes were greater than 1 cm lateral to the PLA, it was significantly more likely to be in tendon (P = .013).

Conclusion:

We found remplissage suture passage was inaccurate, with only 25% of sutures penetrating the infraspinatus tendon. Passing sutures 1 cm lateral and within 3 cm inferior of the PLA improves the odds of successful infraspinatus tenodesis. We recommend this “safe zone” to improve the odds of infraspinatus tenodesis during remplissage. These results may help improve remplissage techniques and prevent previously reported complications, including external rotation loss and pain from myodesis.

Outcomes of the Remplissage Procedure and Its Effects on Return to Sports: Average 5-Year Follow-up

BACKGROUND

Short-term outcomes for patients with large, engaging Hill-Sachs lesions who underwent remplissage have demonstrated good results. However, limited data are available for longer term outcomes.

PURPOSE

To evaluate the long-term outcomes of remplissage and determine the long-term rate of return to specific sports postoperatively.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

This was a retrospective review of patients treated with the remplissage procedure from 2007 to 2013. All underwent preoperative magnetic resonance imaging demonstrating large Hill-Sachs lesions by the Rowe criteria and glenoid bone loss <20%. All Hill-Sachs lesions were "off track" by an arthroscopic examination and preoperative imaging. At final follow-up, patients underwent a range of motion evaluation and were administered a detailed outcome survey, which included Western Ontario Shoulder Instability Index (WOSI) and American Shoulder and Elbow Surgeons (ASES) scores as well as questions regarding sports, employment, physical activities, and dislocation events.

RESULTS

A total of 50 patients (51 shoulders) were included in the study. The average patient age at surgery was 29.8 years (range, 15.0-72.4 years), and the average follow-up time was 60.7 months (range, 25.5-97.6 months); 20.0% of patients underwent previous surgery on their shoulder. The average postoperative WOSI score was 79.5%, and the average ASES score was 89.3. Six shoulders had dislocation events (11.8%) postoperatively: 3 were traumatic, and 3 were atraumatic. Increased preoperative dislocations led to a greater risk of a postoperative dislocation (P < .001). There was also a trend toward higher postoperative dislocation rates in patients who underwent revision (P = .062). The average loss of external rotation was 5.26° (P = .13). The rate of return to ≥1 sports was 95.5% of patients at an average of 7.0 months postoperatively; 81.0% returned to their previous intensity and level of sport. Of patients who played a throwing sport, 65.5% (n = 19) stated that they had problems throwing, and 58.6% (n = 17) felt that they could not normally wind up throwing a ball. Direct rates of return to overhead sports were volleyball, 100%; basketball, 69%; baseball, 50%; and football, 50%.

CONCLUSION

The redislocation rate after remplissage was 11.8% at an average of 5 years, with 95.5% of patients returning to full sports at an average of 7 months. For throwing sports, 65.5% of patients complained of decreased range of motion during throwing. The results should be considered preoperatively in candidates for remplissage who are engaged in throwing sports.

Outcomes of arthroscopic Hill-Sachs remplissage and anterior Bankart repair: a retrospective controlled study including ultrasound evaluation of posterior capsulotenodesis and infraspinatus strength assessment

BACKGROUND

Hill-Sachs lesions are compression fractures that result from shoulder dislocation. They involve "engaging" the humeral head on the anterior glenoid rim when the arm is abducted and externally rotated. The defect grows as the number of dislocations increases.

HYPOTHESIS

Arthroscopic remplissage and anterior Bankart repair do not significantly affect infraspinatus strength while ensuring healing of the capsulotenodesis.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Sixty-one patients with traumatic anterior shoulder instability treated by arthroscopic Bankart repair and Hill-Sachs remplissage at least 24 months previously were compared with a control group of 40 healthy participants. Preoperative imaging included magnetic resonance imaging for Bankart lesion identification and computed tomography to quantify the humeral head defect. Active range of motion and clinical scores (Walch-Duplay, Constant-Murley, and Rowe) were assessed. External rotation (ER) and internal rotation (IR) were measured with arm at the side (ER1 and IR1) and abducted at 90° (ER2 and IR2). Infraspinatus strength was assessed with the scapula free (infraspinatus strength test [IST]) and retracted (infraspinatus scapula retraction test [ISRT]). Infraspinatus tenodesis and posterior capsulodesis healing were evaluated by ultrasound (US).

RESULTS

The follow-up median was 39.5 months (range, 24-56 months). One patient experienced a recurrence of instability at 34 months. In the remplissage patients, ER1 was significantly lower in the affected compared with the unaffected shoulder (P < .001). Mean IST and ISRT strength values did not show differences between sides. The mean Constant-Murley score rose from 62.9 ± 7.1 to 90 ± 5.2 (P < .0001). The Walch-Duplay and Rowe scores were excellent in 23 (78.6%), good in 6 (17.8%), and poor in 1 patient (both scores). The remplissage group had significantly lower ER1 (P < .001), ER2 (P < .001), and IR2 (P < .01) values compared with the control group. Differences in IST and ISRT between the groups were not significant. Capsulotenodesis healing and filling of the Hill-Sachs defect were confirmed by dynamic US in all subjects.

CONCLUSION

Arthroscopic remplissage is a reliable approach to Hill-Sachs lesions. The ER and IR restriction does not significantly affect quality of life. Infraspinatus strength recovery is satisfactory even compared with healthy subjects. Ultrasound examination allows accurate evaluation of capsulotenodesis healing.

Management of bone loss in glenohumeral instability

This review discusses the evaluation and management of bone loss in glenohumeral instability. The glenohumeral joint may experience a dislocation or subluxation associated with traumatic injury or through repetitive atraumatic events. Nearly 62% of cases with recurrent dislocation have both Hill-Sachs and bony Bankart defects. Treatment of unstable bone defects may require soft-tissue repair, bone grafting, or both, depending on the size and nature of the defects. The most common treatment is isolated soft-tissue repair, leaving the bone defects untreated, although emerging evidence supports directly addressing these bony defects.

Shoulder instability in older patients

Glenohumeral instability has a bimodal age distribution, with most affected patients younger than 40 years, but with a second peak in older patients. Glenohumeral dislocations in older patients often present with complex injury patterns, including rotator cuff tears, fractures, and neurovascular injuries. Glenohumeral instability in patients older than 40 years requires a different approach to treatment. An algorithmic approach aids the surgeon in the stepwise decision-making process necessary to treat this injury pattern.

Early clinical results of arthroscopic remplissage in patients with anterior shoulder instability with engaging hill-sachs lesion in iran

BACKGROUND

To assess the outcome of the remplissage arthroscopic surgical method in patients with anterior shoulder dislocation associated with Hill-Sachs lesion.

METHODS

Ten patients with anterior shoulder dislocations and Hill-Sachs lesions were entered into this study and were operated on by the remplissage arthroscopic surgical method. They were followed up 22 months after surgery in order to evaluate the outcome of the treatment, including recurrence of dislocation and motion limitation.

RESULTS

During the internal follow up period, no case of recurrence was found. Motion limitation during the follow up period was not significant (internal rotation limitation=5°±1°, and external rotation limitation=4°±1°).

CONCLUSIONS

Our findings suggest that the remplissage arthroscopic surgical method is an acceptable, safe and reliable treatment for anterior shoulder dislocation with engaging Hill-Sachs lesion.

Biomechanics of complex shoulder instability

Identification and treatment of the osseous lesions associated with complex shoulder instability remains challenging. Further biomechanical testing is required to delineate critical defect values and determine which treatments provide improved glenohumeral joint stability for the various defect sizes, while minimizing the associated complications.

Assessment of bone defects in anterior shoulder instability

Glenohumeral bone defects are a common finding in shoulder instability and they are strongly correlated with recurrence of dislocation and failure following arthroscopic Bankart repair. Most authors agree that open surgery should be considered in the presence of certain conditions: glenoid bone loss > 25%, a lesion involving > 30% of the humeral head, an engaging Hill-Sachs lesion, bipolar bone lesions even without engagement. A careful imaging evaluation must therefore be performed in order to identify, quantify and characterize the bone defects. Even though magnetic resonance has important additional value in the assessment of the glenoid labrum and rotator cuff, computed tomography scan is the examination of choice for studying bone defects. Several methods have been proposed to quantify the extent of the glenoid bone defect; the most accurate ones utilize two-dimensional computed tomography images with multiplanar reconstructions (PICO method) or more sophisticated three-dimensional reconstruction software. Conversely, the literature lacks studies that accurately quantify humeral bone defects and, above all, that demonstrate definitively the clinical and prognostic significance of the lesion location and size.