Arthroscopic All-Inside Remplissage Technique With Knotless Tape Bridge for Hill-Sachs Lesions

Approach to Treating Patients after First-time Anterior Shoulder Instability: What Does the Evidence Say?

PURPOSE OF REVIEW

Management of first-time anterior shoulder instability (ASI) is an extensively studied yet controversial topic. Successful treatment requires incorporation of a wide range of factors including patient demographics, varying presenting pathology, functional demands, and sport specific considerations. The purpose of this review is to provide an up-to-date summary of the current literature and trends regarding management of first time ASI events.

RECENT FINDINGS

For non-operative treatment of first-time ASI events, shorter times for immobilization and consideration of positioning in external rotation may be more beneficial. Operative intervention may be favored for patients at high risk of recurrence (young, male, collision sports, and/or overhead athlete). Historically, open soft tissue stabilization was a primary treatment option for ASI. More recently, there has been an increased emphasis on arthroscopic Bankart repair (ABR) especially in the United States. The remplissage has become a useful adjunct to ABR to manage cases with Hill-Sachs lesions or sub-critical bone loss. Latarjet (coracoid transfer) remains a well-studied and common option for cases of critical glenoid bone loss. When directly compared both ABR with Remplissage and Latarjet improve outcomes and reduce the risk of recurrence in athletes with first-time ASI. Currently, there is no uniform approach to managing first-time ASI events. Therefore, an individualized approach is required with consideration of the individuals demographic, presence of bone loss, functional demands, and sport specific considerations. In young, male, collision athletes early surgical intervention may be beneficial to prevent recurrence. When faced with minimal (< 13.5%) or subcritical bone loss (13.5% to 20%), ABR with Remplissage may reduce rates of instability compared to ABR alone.

Management of bone loss in anterior shoulder instability

Bone defects are frequently observed in anterior shoulder instability. Over the last decade, knowledge of the association of bone loss with increased failure rates of soft-tissue repair has shifted the surgical management of chronic shoulder instability. On the glenoid side, there is no controversy about the critical glenoid bone loss being 20%. However, poor outcomes have been described even with a subcritical glenoid bone defect as low as 13.5%. On the humeral side, the Hill-Sachs lesion should be evaluated concomitantly with the glenoid defect as the two sides of the same bipolar lesion which interact in the instability process, as described by the glenoid track concept. We advocate adding remplissage to every Bankart repair in patients with a Hill-Sachs lesion, regardless of the glenoid bone loss. When critical or subcritical glenoid bone loss occurs in active patients (> 15%) or bipolar off-track lesions, we should consider anterior glenoid bone reconstructions. The techniques have evolved significantly over the last two decades, moving from open procedures to arthroscopic, and from screw fixation to metal-free fixation. The new arthroscopic techniques of glenoid bone reconstruction procedures allow precise positioning of the graft, identification, and treatment of concomitant injuries with low morbidity and faster recovery. Given the problems associated with bone resorption and metal hardware protrusion, the new metal-free techniques for Latarjet or free bone block procedures seem a good solution to avoid these complications, although no long-term data are yet available.

All-Arthroscopic Treatment of Combined Off-Track Hill-Sachs Lesions Using Interference Screw and Shoulder Glenoid Bone Defects Using Bone Grafting With Soft Fixation

Bony changes such as glenoid bone defects and Hill-Sachs lesions are responsible for recurrent anterior shoulder dislocations. With the development of arthroscopic techniques as well as arthroscopic surgical instruments, arthroscopic repair of bony structures has become an important surgical procedure for the treatment of recurrent shoulder dislocation. In this Technical Note, we used screws to fill Hill-Sachs lesions and autologous iliac bone grafts combined with soft tissue to repair the glenoid bone defects. In the surgical procedures within the shoulder, all operations are done arthroscopically, are minimally invasive, and achieve the goal of repairing composite shoulder injuries.