Humeral head bone defects: remplissage, allograft, and arthroplasty

Bulk osteochondral allograft for massive Hill-Sachs defect combined with Latarjet procedure for bipolar bone loss in anterior instability

A proportion of patients with anterior glenohumeral instability present with bipolar bone loss comprising large Hill-Sachs lesions and substantial glenoid defect. These are surgically difficult cases to treat. We describe a novel surgical procedure of bulk size-matched osteochondral allograft reconstruction for massive Hill-Sachs lesions combined with the Latarjet procedure for these challenging cases.

The size of the Hill Sachs defect increases during reduction of a first time shoulder dislocation in older adults: a pilot study in 20 cases

PURPOSE

To evaluate if the size of Humeral Hill-Sachs Defects (HSDs) increases during reduction in the emergency department (ED) in subjects that have a first-time anterior shoulder dislocation.

METHODS

Subjects more than 18 years old presenting to the ED a first-time anterior shoulder dislocation were included. A computed tomography was performed prior to any reduction attempt (Pre-CT). The shoulder was reduced in the emergency room with intraarticular lidocaine; if two attempts failed, the shoulder was reduced under anaesthesia. A second CT was performed after reduction of the shoulder (Post-CT). CT were evaluated using the Osirix software. A 3-dimensional reconstruction of the humeral head was performed and the maximum width of the humeral defect, maximum depth of the humeral defect and total volume of the humeral defect were measured. The relative increase in size was calculated.

RESULTS

Twenty subjects were included in the study. All subjects presented HSDs in the Pre-CT that had a width of a median of 9.9(interquartile range:2.9)mm, a depth of 7.0(3.0]mm and a volume of 355(333)mm2. The HSD in the Post-CT had a width of 10.9(3.0)mm (an increase of 7.23[8.5]%, significant differences, p = 0.0001) a depth of 7.2(2.7)mm (an increase of 9.93[20.7]%, significant differences, p < 0.0001) and a volume of 469(271) mm2 (an increase of 27.5[26.9]%, significant differences, p < 0.0001). There were size increases larger than 25% in 15/20 (75%) of subjects.

CONCLUSION

Standard reduction manoeuvres performed in a first-time anterior shoulder dislocation increase the size of the HSD. This increase in size is larger than 25% in four out of five cases.

LEVEL OF EVIDENCE

IV, prospective cases series study.

Poor evidence is used to support commercial payers' coverage policies for shoulder arthroplasty

BACKGROUND

The incidence of shoulder arthroplasty has continued to increase over the past decade. In response, commercial payers have implemented strategies to control the medical requirement of these surgeries in attempt to contain the growing costs. For example, most payers require a prolonged trial of conservative management prior to shoulder arthroplasty for patients who may otherwise be surgical candidates. However, little is known regarding the evidence used to support these indications. The purpose of this study was to analyze the references used by commercial payers to substantiate their coverage policies for shoulder arthroplasty.

METHODS

Ten of the leading commercial payers for total shoulder arthroplasty were identified. Publicly available coverage policies were searched on the internet or requested directly from the payer via email or telephone. Cited references were reviewed independently by two authors for type of document, level of evidence, and mention of the efficacy of conservative management.

RESULTS

A total of 5 coverage policies were obtained with 118 references. The most common reference type was primary journal article (n = 70; 59.3%) followed by review or expert opinion articles (n = 35; 29.7%). Most references were of level IV evidence (n = 60; 52.2%), with only 6 (5.2%) of level I or II evidence. Only 4 (3.5%) references mentioned the efficacy of conservative management in patients who may be candidates for shoulder arthroplasty.

CONCLUSION

The majority of references used to substantiate the coverage policies for shoulder arthroplasty among major commercial payers within the United States are of low scientific evidence and fail to demonstrate the success of required nonoperative intervention strategies. Our study underscores the need for high-quality, comparative trials that evaluate the outcomes of conservative management vs. shoulder arthroplasty in end-stage glenohumeral osteoarthritis patients in order to determine the most cost-effective treatment algorithm.

Segmental Humeral Head Reconstruction in Patients with Chronic Locked Posterior Shoulder Dislocation

Background and Objectives: The goal of this study was to evaluate the functional outcomes of patient treatment using an allograft after chronic locked posterior shoulder dislocation associated with a bony defect of the upper edge of the humerus that involves 25-50% of the articular surfaces. Materials and Methods: A total of 20 patients were included in this study. Electrocution was the cause of injury in eight patients; in ten patients, the cause was direct trauma; and in two patients, the cause of injury was a fall due to hypoglycemic coma. A standard deltoid pectoral approach was used and a fresh-frozen osteochondral allograft of the femoral condyle was applied. In evaluating the results, Constant's scoring scale was used. Results: The average value of Constant's point scale for the operated shoulder is 84.14 points. This result is good according to the average value of Constant's point scale. Conclusions: Patients with locked chronic posterior dislocation in combination with a bony defect of the humeral head that covers 25-50% of the articular surface, in our opinion, should be treated using bone allografts rather than non-anatomical reconstruction methods.

Taping Adjunct to Strengthening and Proprioception in a Hill-Sachs Lesion Patient: A Case Report

A Hill-Sachs lesion is a bony defect in the head of the humerus due to recurrent dislocation, which results in friction between the humeral head and the glenoid fossa. This recurrent incident of dislocation that occurs in the anterior direction eventually leads to a Bankart lesion (a defect in the glenoid rim). A 21-year-old male, a recreational football player, reported recurrent shoulder dislocation, complaining of pain and difficulty doing certain activities. He had hypermobility of the shoulder joint during joint play assessment. Proprioception is the sense of the position and movement of one's own body. Exercises that improve proprioception can help improve shoulder stability and reduce the risk of shoulder injuries. Proprioception has shown significant positive results in shoulder dislocations. A physiotherapy protocol was designed that included strengthening of shoulder and scapular musculatures, proprioceptive exercises, and plyometric exercises for developing agility. All these exercises were given with taping for the shoulder joint. Taping helps stabilize the shoulder and normalizes muscle function. With the help of physiotherapy, patients can avoid invasive procedures for restoring stability in non-traumatic recurrent shoulder dislocations.

Anterior Shoulder Instability and Open Procedures: History, Indications, and Clinical Outcomes

The shoulder, being the most mobile joint in the human body, is often susceptible to dislocations and subluxations more so than other joints. As such, shoulder instability constitutes a common complaint among patients worldwide, especially those who are young, participate in contact sports, and have increased innate flexibility in their joints. Management options in the setting of instability vary between conservative and surgical options that aim to mitigate symptoms and allow return of function. Surgical options can be arthroscopic and open, with a general shift among surgeons towards utilizing arthroscopic surgery in the past several decades. Nevertheless, open procedures still play a role in managing shoulder instability patients, especially those with significant bone loss, recurrent instability, coexisting shoulder pathologies, and high risk of failure with arthroscopic surgery. In these clinical settings, open procedures, like the Latarjet procedure, open Bankart repair, glenoid bone augmentation using iliac crest autograft or distal tibial allograft, and salvage options like glenohumeral arthrodesis and arthroplasty may show good clinical outcomes and low recurrence rates. Each of these open procedures possesses its own set of advantages and disadvantages and entails a specific set of indications based on published literature. It is important to cater treatment options to the individual patient in order to optimize outcomes and reduce the risk of complications. Future research on open shoulder stabilization procedures should focus on the long-term outcomes of recently utilized procedures, investigate different graft options for procedures involving bone augmentation, and conduct additional comparative analyses in order to establish concrete surgical management guidelines.

Fixation devices for anterior shoulder instability

PURPOSE

Over the past 40 years, advances in the development of anchors and sutures have contributed to the improvement in surgical outcomes for treatment of shoulder instability. Important choices in surgery when treating instability include the use of knotless versus knotted suture anchors, and bony versus soft tissue reconstruction techniques.

METHODS

A literature review was conducted to evaluate the history of instability of the shoulder and the results of specific fixation techniques including bony and soft tissue reconstructions as well as knotted and knotless suture anchors.

RESULTS

As knotless suture anchors have continued to grow in popularity since their development in 2001, many studies have compared this newer technique to that of the standard knotted suture anchors. In general, these studies have demonstrated no difference in patient-reported outcome measures between the two options. Additionally, the choice of bony versus soft tissue reconstructions is patient specific as it depends on the specific pathology or combination of injuries.

CONCLUSION

In each surgery performed for shoulder instability, it is vitally important that we try to restore normal anatomy. The normal anatomy is best established by knotted mattress sutures. However, loop laxity and tear through by the sutures in the capsule can eliminate this restoration, increasing risk of failure. Knotless anchors may allow better soft tissue fixation of the labrum and capsule to the glenoid, but without complete restoration of normal anatomy.

Predictors of Bone Loss in Anterior Glenohumeral Instability

BACKGROUND

Anterior shoulder instability can result in bone loss of both the anterior glenoid and the posterior humerus. Bone loss has been shown to lead to increased failure postoperatively and may necessitate more complex surgical procedures, resulting in worse clinical outcomes and posttraumatic arthritis.

HYPOTHESIS/PURPOSE

The purpose of this study was to investigate predictors of glenoid and humeral head bone loss in patients undergoing surgery for anterior shoulder instability. It was hypothesized that male sex, contact sport participation, traumatic dislocation, and higher number of instability events would be associated with greater bone loss.

STUDY DESIGN

Cross-sectional study; Level of evidence, 3.

METHODS

A total of 892 patients with anterior shoulder instability were prospectively enrolled in the Multicenter Orthopaedic Outcomes Network (MOON) Shoulder Instability cohort. The presence and amount of anterior glenoid bone loss and accompanying Hill-Sachs lesions were quantified. Descriptive information and injury history were used to construct proportional odds models for the presence of any bone defect, for defects >10% of the anterior glenoid or humeral head, and for combined bony defects.

RESULTS

Anterior glenoid bone loss and Hill-Sachs lesions were present in 185 (20.7%) and 470 (52.7%) patients, respectively. Having an increased number of dislocations was associated with bone loss in all models. Increasing age, male sex, and non-White race were associated with anterior glenoid bone defects and Hill-Sachs lesions. Contact sport participation was associated with anterior glenoid bone loss, and Shoulder Actitvity Scale with glenoid bone loss >10%. A positive apprehension test was associated with Hill-Sachs lesions. Combined lesions were present in 19.4% of patients, and for every additional shoulder dislocation, the odds of having a combined lesion was 95% higher.

CONCLUSION

An increasing number of preoperative shoulder dislocations is the factor most strongly associated with glenoid bone loss, Hill-Sachs lesions, and combined lesions. Early surgical stabilization before recurrence of instability may be the most effective method for preventing progression to clinically significant bone loss. Patients should be made aware of the expected course of shoulder instability, especially in athletes at high risk for recurrence and osseous defects, which may complicate care and worsen outcomes.

REGISTRATION

NCT02075775 (ClinicalTrials.gov identifier).

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.

Arthroscopic Remplissage Using Knotless, All-Suture Anchors

Glenohumeral bone loss is a significant risk factor for recurrent instability after shoulder dislocation. The Hill-Sachs lesion is an osseous defect of the posterior humeral head that is commonly recognized after anterior shoulder dislocation. Several procedures exist to address humeral-sided bone loss, including soft tissue filling procedures, osteoarticular allografts, bone plugs, rotation osteotomies, and humeral head replacements. However, among the most common of these procedures is the arthroscopic remplissage. This technique involves capsulotenodesis of the posterior shoulder capsule and infraspinatus tendon into a Hill-Sachs lesion. Previously described techniques use knotted suture anchors. In this report, we describe a modified technique for remplissage using knotless, all-suture anchors to perform capsulotenodesis of a Hill-Sachs lesion. Benefits of this technique include a single skin incision, improved bone preservation, and easier facilitation of revision surgery if required.

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.

Posterior shoulder dislocation with reverse Hill-Sachs lesion. A technical note and report of two cases

Posterior shoulder dislocation (PSD) with a reverse Hill-Sachs lesion is a rare injury with challenging management. This article is a technical note, describing the combination of both, modified McLaughlin procedure with posterior Bankart repair, for the surgical treatment of traumatic PSD associated with a substantial reverse Hill-Sachs lesion. Two patients with mid-term follow-up are presented. Approaching and repairing both sides of the joint, balance and congruency are restored, the humeral head is centralized in the glenoid and the patient starts early mobilization and rehabilitation safely.

Comparison of Interface Pressure, Contact Surface Area, and Percent Area of Coverage Between Two Suture Configurations for Hill-Sachs Remplissage

Purpose:

To compare maximum contact pressure, contact surface area, and the percent area of coverage of the bone-tendon interface in the remplissage procedure between two different suture configurations (independent mattress versus double-pulley).

Methods:

A sample size of seven specimens per group was defined by a 96% power analysis.

Hill-Sachs lesions were created in all fourteen ex vivo ovine shoulders, corresponding to a 30% defect of the axial diameter of the humeral head (significant lesion according to literature). The defects were repaired using the remplissage technique applying one of the two randomly chosen suture configurations: two independent mattress sutures or a double-pulley. The contact pressure and contact surface area, as well as percent defect coverage, were recorded using a film sensitive to these parameters. Independent nonparametric tests (Mann-Whitney) were used for the statistical analysis.

Results:

The double-pulley group exhibited an average pressure of 0.128 ± 0.018 mPa, the contact surface of 0.199 ± 0.044 cm2, and 41.97 ± 9.8% defect coverage. The independent mattress group showed an average pressure of 0.102 ± 0.01 mPa, the contact surface of 0.081 ± 0.041 cm2, and defect coverage of 15.6 ± 8.1%. All three parameters were statistically superior in the double-pulley group (p=0.038, p=0.008, and p=0.008, respectively)

Conclusion:

The remplissage technique using the double-pulley configuration, presented superior biomechanical characteristics, in terms of contact pressure, contact area, and percent coverage of the defect, compared to the simple independent mattress configuration.

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.

Clinical and functional outcomes of the remplissage technique to repair anterior shoulder dislocation: average 7 years of follow-up

PURPOSE

The purpose of this work is to report mid- to long-term clinical results, recurrence rates and instability following surgery to repair anterior dislocation of the shoulder by the remplissage technique.

METHODS

This was a retrospective case series at a single center with patients with anterior shoulder instability that received surgery using the remplissage technique. Rowe questionnaire, instability complaints, recurrence episodes and return to sport were analyzed.

RESULTS

Of all patients screened, 21 (92.3%) were enrolled and only 2 patients were lost to follow-up. The mean age of the patients at the time of surgery was 27.8y.o., and the mean number of dislocations before surgery was 3.2 episodes. The follow-up average was 83.8 months (range 28-126). No case of postoperative infection was observed. Two patients (9.5%) had recurrent shoulder instability and required reintervention after 18 and 48 months. The average final Rowe score was 92.9 (range 75-100). All patients that played sports before surgery returned to the sport, and 73.7% of them returned to the same activity level.

CONCLUSION

The remplissage technique applied to repair anterior shoulder dislocation with humeral bone loss presents good results regarding clinical scores, shoulder stability and acceptable rates of return to sports, even in a mid- to long-term follow-up.

LEVEL OF EVIDENCE

IV.

Osteoprotegerin (OPG) Promotes Recruitment of Endothelial Progenitor Cells (EPCs) via CXCR4 Signaling Pathway to Improve Bone Defect Repair

Background

The aim of this study was to investigate the effect of using osteoprotegerin (OPG) to treat bone defects mediated by endothelial progenitor cell (EPC) recruitment and migration through the CXCR4 signaling pathway.

Material/Methods

The EPCs extracted from human peripheral blood were cultured in vitro and the expression of CXCR4 and its downstream p-AKT was monitored by the Western blot analysis after OPG treatment. Using the scratch wound healing test and Transwell assay, we assessed the variables influencing the effect of OPG on EPCs after pre-treatment with CXCR4 blocker (AMD3100) and PI3K blocker (Ly294002). After 4 weeks, the bone defect repair condition was estimated via micro-CT and staining with HE and Masson trichrome. Then, immunofluorescence staining was performed to assess angiogenesis in bone defects, while the expression of EPC marker and vascular endothelial growth factor receptor 2 (VEGFR2) was detected by immunohistochemical staining.

Results

The EPCs treated with OPG had increased levels of CXCR4 and p-AKT. Moreover, the difference in EPC levels among groups in the scratch wound healing experiment and migration experiment indicated that the OPG treatment promoted cell migration and AMD3100 and LY294002 inhibited the function of OPG. In addition, OPG promoted angiogenesis and repair of bone defect in rats, and these effects were abolished by AMD3100 and LY294002 administration.

Conclusions

OPG enhanced the proliferation and migration of EPCs through the CXCR4 pathway and promoted angiogenesis and bone formation at bone defect sites.

Arthroscopic Double-Pulley Remplissage Using a 2-Portal Technique for Hill-Sachs Lesions in Recurrent Anterior Shoulder Instability

Hill-Sachs lesions of the humeral head are associated with recurrent anterior shoulder instability. Arthroscopic double-pulley remplissage has emerged as the leading alternative to the open Latarjet procedure to address recurrent shoulder instability with comparable recurrence rates and favorable complication rates. This Technical Note describes our adaptation of the double-pulley remplissage technique by using 2 portals, with the anterior portal used as the viewing portal and suture passage through the posterior portal. This technique eliminates the need for a lateral percutaneous portal, consequently minimizing operative time and postoperative morbidity. Furthermore, using the anterior portal as the viewing portal allows for direct visualization of the reduction of the infraspinatus into the Hill-Sachs defect. The drawback of this technique is that there is no view of the subacromial space during knot tying.

Arthroscopic Knotless Remplissage for the Treatment of Hill-Sachs Lesions Using the PASTA Bridge Configuration

Recurrent glenohumeral dislocations can produce Hill-Sachs lesions-bony defects on the humeral head resulting from the humerus hitting the glenoid during dislocations. Some of these lesions can engage on the glenoid during motion, producing instability and potentially affecting the success of a labral repair. The remplissage was developed to address these Hill-Sachs lesions and improve stability. French for "filling," the goal of the remplissage is to fill the Hill-Sachs lesion with the infraspinatus tendon, preventing the margins of the lesion from engaging with the glenoid. Analogous to restoring the rotator cuff footprint during repair, a primary goal of the remplissage is to have the infraspinatus cover the Hill-Sachs lesion. The partial articular supraspinatus tendon avulsion (PASTA) bridge was originally developed for partial-thickness rotator cuff repair in situ, but additional uses have been found in other settings. The PASTA bridge uses a medial row horizontal mattress with a lateral anchor to create a linked construct to effectively distribute force and provide adequate coverage of the lesion. Knotless anchor technology used in this procedure prevents the need for arthroscopic knot tying and potentially damaging knot stacks. This Technical Note describes a remplissage technique using the PASTA bridge configuration to address Hill-Sachs lesions associated with recurrent glenohumeral instability.

Shoulder Instability: Anterior, Posterior, Multidirectional, Arthroscopic Versus Open, Bone Block Procedures

This article presents a retrospective comprehensive review of the history of anterior, posterior, and multidirectional shoulder instability and also reviews key concepts such as open versus arthroscopic repair and glenoid and humeral head bone loss and associated treatments. The future of shoulder instability will continue to evolve as research and clinical experience will determine the direction of the future.

Isolated arthroscopic Bankart repair vs. Bankart repair with "remplissage" for anterior shoulder instability with engaging Hill-Sachs lesion: A meta-analysis

INTRODUCTION

Arthroscopic "remplissage" of a Hill-Sachs lesion (HSL) associated with a Bankart repair (BR) has been recently introduced as a surgical option to treat chronic anterior shoulder instability. The purpose of this study was to analyze the current literature comparing results of isolated BR versus BR+remplissage in the treatment of anterior shoulder instability with engaging HSL.

HYPOTHESIS

BR+remplissage are superior to isolated BR in the management of anterior shoulder instability with engaging HSL.

MATERIAL AND METHODS

Four electronic databases were searched for original, English-language studies comparing BR vs. BR+remplissage procedures. During the inclusion process we used international Preferred Reporting Items for Systematic review and Meta-Analysis (PRISMA) guidelines and the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) checklist. Our data were extracted from the text, tables and figures of the selected studies.

RESULTS

Three comparative studies were identified, which included 146 patients; 74 of them underwent isolated BR, and 72 BR+remplissage procedure. The isolated BR results in significantly higher risk of recurrence and redislocation. There was no significant difference in the rates of reoperation and time to return to sport between the two procedures. Rowe and UCLA scores were lower in the isolated BR group compared with the BR+remplissage group.

DISCUSSION

This meta-analysis demonstrates the superiority of BR+remplissage procedure vs. isolated BR in the management of anterior shoulder instability with engaging HSL and with up to 25% glenoid bone loss regarding redislocation rate, recurrent instability and functional scores. A comparison between postoperative range of motion and particularly external rotation was not able to be formally assessed in this study.

LEVEL OF EVIDENCE

III.

Chronic anterior shoulder instability with significant Hill-Sachs lesion: Arthroscopic Bankart with remplissage versus open Latarjet procedure

BACKGROUND

The objective of this study was to compare short-term shoulder stability after arthroscopic Bankart repair with remplissage versus the open Latarjet procedure in patients who had chronic anterior shoulder instability with a significant Hill-Sachs lesion.

HYPOTHESIS

The dislocation recurrence rate is higher after Bankart repair with remplissage than after open Latarjet.

PATIENTS AND METHODS

An observational non-randomised retrospective cohort study was conducted at two surgical centres in patients treated for chronic anterior shoulder instability with a significant Hill-Sachs defect between January 2009 and July 2014. The study compared 43 patients managed by arthroscopic Bankart repair and remplissage and 43 patients managed with open Latarjet. The two groups were matched on age at surgery and on follow-up duration. All patients were evaluated by independent observers based on a questionnaire including recurrences, range of motion, and functional outcomes (Shoulder Subjective Value [SSV], Walch-Duplay score, and Rowe score).

RESULTS

Mean follow-up was 47.3 months (range, 24-67 months). The recurrence rate at last follow-up was not significantly different between the two groups (9.3% versus 11.2%; P=0.67). The Bankart group had significantly greater loss of external rotation and a significantly higher proportion of patients with residual pain (21% versus 9%, P=0.023). The SSV, Walch-Duplay score, and Rowe score values were similar between groups.

DISCUSSION

In patients who had chronic anterior shoulder instability with a significant Hill-Sachs lesion, arthroscopic Bankart repair with remplissage and open Latarjet were reliable and safe procedures associated with low and similar recurrence rates. However, loss of external rotation and residual pain were significantly more common with the combined Bankart-remplissage procedure.

LEVEL OF EVIDENCE

III; comparative retrospective study.

Understanding the Hill-Sachs Lesion in Its Role in Patients with Recurrent Anterior Shoulder Instability

PURPOSE OF REVIEW

The purpose of this study is to provide an update to the orthopedic field in regard to treatment of the Hill-Sachs lesion and anterior shoulder instability. The review highlights the most current knowledge of epidemiology, clinical evaluation, and surgical methods used to treat Hill-Sachs lesions. It also details the relevant clinical and surgical findings that have been made throughout the literature in the past couple of years.

RECENT FINDINGS

The most recent literature covering the Hill-Sachs lesion has focused on the relatively new and unexplored topic of the importance of concomitant injuries while treating a humeral head defect. The glenoid track concept has been clinically validated as a method to predict engagement. 3D-CT has become the "gold standard" for Hill-Sachs imaging; however, it has been noted that 3D-MRI produces results that are not significantly different from CT. Also, it has been found that when the arm is in a position of abduction during the primary injury, there is a higher risk of engagement and subsequent dislocation. Recent studies have demonstrated successful results stemming from purely arthroscopic procedures in treating Hill-Sachs lesions. Anterior shoulder instability, specifically the Hill-Sachs lesion, is an area of orthopedic study that is highly active and constantly producing new studies in an attempt of gaining the best outcomes for patients. The past few years have yielded many excellent discoveries, but there is still much more work to be done in order to fully understand the role of the Hill-Sachs lesion in anterior shoulder instability.

Indication for Computed Tomography Scan in Shoulder Instability: Sensitivity and Specificity of Standard Radiographs to Predict Bone Defects After Traumatic Anterior Glenohumeral Instability

Background:

Quantifying glenohumeral bone loss is key in preoperative surgical planning for a successful Bankart repair.

Hypothesis:

Simple radiographs can accurately measure bone defects in cases of recurrent shoulder instability.

Study Design:

Cohort study (diagnosis); Level of evidence, 2.

Methods:

A true anteroposterior (AP) view, alone and in combination with an axillary view, was used to evaluate the diagnostic properties of radiographs compared with computed tomography (CT) scan, the current gold standard, to predict significant bone defects in 70 patients. Sensitivity, specificity, and positive and negative predictive values were evaluated and compared.

Results:

Detection of glenoid bone loss on plain film radiographs, with and without axillary view, had a sensitivity of 86% for both views and a specificity of 73% and 64% with and without the axillary view, respectively. For detection of humeral bone loss, the sensitivity was 8% and 17% and the specificity was 98% and 91% with and without the axillary view, respectively. Regular radiographs would have missed 1 instance of significant bone loss on the glenoid side and 20 on the humeral side. Interobserver reliabilities were moderate for glenoid detection (κ = 0.473-0.503) and poor for the humeral side (κ = 0.278-0.336).

Conclusion:

Regular radiographs showed suboptimal sensitivity, specificity, and reliability. Therefore, CT scan should be considered in the treatment algorithm for accurate quantification of bone loss to prevent high rates of recurrent instability.

Management of Humeral Defects in Anterior Shoulder Instability

BACKGROUND

A Hill Sachs lesion is a posterior-superior bony defect of the humeral head caused by a compression of the hard glenoid rim against the soft cancellous bone in the context of an anterior instability episode. The presence of these humeral defects increases with the number of dislocations and larger lesions are associated with a greater chance of development of recurrent instability and recurrence after surgery. Also its location and pattern, in particular the so-called engaging Hill-Sachs, are associated with poor prognosis.

METHODS

There is a lack of consensus in terms of classification and management algorithm, although lesions greater than 25% of the humeral head had been suggested to need more than a simple Bankart repair to avoid recurrence. The concept of glenoid track has turned the attention to location and shape and not only size of the humeral defect. Moreover, the glenoid bone loss is crucial when choosing a treatment option as it contributes to decrease the glenoid track as well. A thorough revision of treatment options has been performed.

RESULTS

Numerous treatment options have been proposed including remplissage, glenoid or humeral head augmentation, bone desimpaction, humeral rotational osteotomy and arthroplasty.

CONCLUSION

Humeral defects treatment should be individualized. Determination of size and location of the defect and its relation with glenoid track is mandatory to achieve satisfactory results.

Posterior shoulder dislocation with a reverse Hill-Sachs lesion treated with frozen femoral head bone allograft combined with osteochondral autograft transfer

Management of a posterior shoulder dislocation with an associated reverse Hill-Sachs lesion is challenging, both diagnostically and therapeutically. Diagnosis is frequently delayed or missed, whereas the resulting humeral head defect is often larger and more difficult to salvage than in anterior shoulder dislocations. This report presents the case of a 29-year-old male with a recurrent posterior shoulder dislocation associated with a large reverse Hill-Sachs defect, treated with bone augmentation of the lesion with a combination of fresh femoral head allograft and a locally harvested humeral head autograft transfer, with a successful outcome. Level of evidence V.

Arthroscopic Bone Grafting of the Humeral Head for Treatment of a Deep Hill-Sachs Lesion

Recurrent anterior shoulder dislocation often leads to the presence of a Hill-Sachs lesion. A large Hill-Sachs lesion compromises shoulder stability and should be addressed with bone augmentation when it is too deep. Here, we introduce a method of arthroscopic bone grafting of the humeral head for the treatment of a deep Hill-Sachs lesion in patients with anterior shoulder instability. Our indication for this procedure is a deep off-track Hill-Sachs lesion measuring at least 8 mm in depth and 10 mm in width. The main steps of this procedure include graft placement via special shoulder bone grafting instruments, graft suspension fixation using suture anchors, and bone fragment compression using the infraspinatus tendon. We routinely use this technique in combined treatment procedures for complicated anterior shoulder instability.

Interobserver and intraobserver variability of glenoid track measurements

BACKGROUND

A method of assessing combined glenoid and humeral bone loss in traumatic shoulder instability with an associated treatment protocol was recently published. The aim of this study was to investigate its reliability and reproducibility.

METHODS

Seventy-one patients with unilateral anteroinferior shoulder instability underwent computed tomography scans, from which 3-dimensional images were derived. En face views of both glenoid fossae and with 3 views of the humeral head were provided to 4 assessors to determine interobserver reliability. From these measurements, the shoulder was assigned a treatment classification. Two observers repeated their assessments 1 month later to determine intraobserver reliability. For each measurement, the mean coefficient of variability was calculated.

RESULTS

Assessment of glenoid bone loss showed good interobserver (4 observers agreeing in 90.1% of cases) and also good intraobserver agreement (94% and 96%). There was a poor level of interobserver reliability regarding the on-track or off-track classification (72%). Intraobserver reliability for this measurement was less variable (90% and 80%). There was a poor level of agreement between observers (65%) regarding treatment classification. The coefficient of variability for the Hill-Sachs lesion measured 19.2%, indicating a high level of variability for this measurement compared with <4% for all other measures.

CONCLUSION

Linear bone loss on the glenoid can be measured reliably and reproducibly; however, evaluation of Hill-Sachs lesions demonstrates a high level of variability, and poor interobserver reliability.

Management of an engaging Hill-Sachs lesion: arthroscopic remplissage with Bankart repair versus Latarjet procedure

PURPOSE

This study compared the clinical outcomes of arthroscopic remplissage with Bankart repair and Latarjet operation in patients with a large engaging Hill-Sachs lesion.

METHODS

Thirty-seven shoulders subjected to arthroscopic remplissage with a Bankart repair (group A) and 35 shoulders subjected to a Latarjet operation (group B), for a large engaging Hill-Sachs lesion without significant glenoid bone loss, were retrospectively evaluated. Each group was followed up for a mean more than 2-year period.

RESULTS

At the last follow-up, postoperative pain, shoulder mobility, muscle strength, Rowe score, and UCLA score revealed no significant difference between the two groups. The postoperative mean deficit in external rotation at the side (ERs) was 8° ± 23° in group A (P = 0.044). In group B, the mean deficits in ERs, external rotation at 90° of abduction, and internal rotation to the posterior were 10° ± 20°, 7° ± 16°, and 1.9° ± 4°, respectively (P = 0.004, 0.022, and 0.009, respectively). The recurrence rate was 5.4 % (two shoulders) in group A and 5.7 % (two shoulders) in group B (n.s.). The overall complication rate was significantly higher in group B (14.3 %) than in group A (0 %) (P = 0.017).

CONCLUSIONS

For recurrent anterior shoulder instability with a large engaging Hill-Sachs lesion, both arthroscopic remplissage with Bankart repair and the Latarjet procedure were safe and reliable techniques with a low recurrence rate. However, the Latarjet group had a significantly higher postoperative complication rate than the remplissage group.

LEVEL OF EVIDENCE

Case-control study, Level III.

Anterior shoulder instability with engaging Hill-Sachs defects: a comparison of arthroscopic Bankart repair with and without posterior capsulodesis

PURPOSE

The purpose of this study was to compare the clinical results of isolated arthroscopic Bankart repair and those of arthroscopic Bankart repair with posterior capsulodesis for anterior shoulder instability with engaging Hill-Sachs lesions.

METHODS

Thirty-five shoulders that underwent isolated arthroscopic Bankart repair (Bankart group) and 37 shoulders that underwent arthroscopic Bankart repair with posterior capsulodesis (remplissage group) for anterior shoulder instability with engaging Hill-Sachs lesions were evaluated retrospectively. The mean age at the time of the surgery was 26.1 ± 7.0 years in the Bankart group and 24.8 ± 9.0 years in the remplissage group.

RESULTS

At the final follow-up, the Rowe and UCLA scores significantly improved in both the Bankart and remplissage groups (P < 0.001, in both groups). The post-operative mean deficit in external rotation at the side was 3° ± 10° in the Bankart group and 8° ± 23° in the remplissage group (P = n.s. and P = 0.044, respectively). There was no decrease in muscle strength in either group. The recurrence rate was 25.7 % in the Bankart group and 5.4 % in the remplissage group (P = 0.022).

CONCLUSIONS

Arthroscopic Bankart repair with posterior capsulodesis demonstrated good clinical outcomes with a low recurrence rate in the treatment for anterior shoulder instability with an engaging Hill-Sachs lesion. Although a limitation in external rotation was observed, there was no significant limitation of any other motion and no decrease in muscle strength after the remplissage procedure. Posterior capsulodesis alone for remplissage should be considered as a surgical technique that can replace the conventional method.

LEVEL OF EVIDENCE

Case-control study, Level III.

A six months old neglected anterior shoulder dislocation managed by closed reduction and Latarjet procedure

A neglected shoulder dislocation is a rarer entity and only few cases are reported in the literature. An anterior dislocation of the shoulder is rarely missed as patients present with limb in abduction and external rotation, an attitude very familiar to orthopaedic surgeon. Occasionally such cases are missed when they present with fracture of proximal humerus or when they receive treatment from unqualified practitioners who commonly practise in rural areas. Owing to very few reports there is paucity of literature and no standard treatment protocol exists for neglected anterior dislocation of the shoulder, though most such chronic cases are managed by open reduction. This case report describes a six months old neglected anterior dislocation with a significant Hill Sachs lesion, which was managed by closed reduction and Latarjet procedure.

The Arthroscopic Hill-Sachs Remplissage: A Technique Using a PASTA Repair Kit

The arthroscopic remplissage procedure has gained popularity in recent years and is gaining acceptance as an excellent and safe procedure to perform in patients with large engaging Hill-Sachs lesions. The procedure was introduced as an arthroscopic procedure, but surgeons not familiar with the procedure often encounter many problems, which makes the procedure difficult and frustrating to perform. A technique for this procedure using a commercially available PASTA (partial articular supraspinatus tendon avulsion) repair kit is presented.

Arthroscopic treatment of glenoid bone loss

Recurrent anterior instability of the glenohumeral joint has long been an arduous problem to solve surgically, owing to its difficulty to the need to restore both osseous and dynamic constraints in the unstable shoulder. Biomechanical studies have indicated that glenoid bone loss shortens the safe arc through which the glenoid can resist axial forces; in these cases, a soft tissue repair alone may be insufficient to maintain stability. Clinical studies have confirmed that major bone loss is associated with an unfavourable outcome. The benefits of using arthroscopic procedures for surgical stabilization of the shoulder include smaller incisions and less soft tissue dissection, better access for repair and, potentially, the maximum respect for the undamaged anatomical structures. The biggest disadvantage of arthroscopic procedures until recently was the inability to successfully treat a significant bone defect. Over the last 10 years, several new arthroscopic techniques have been developed, providing new surgical options for successfully treating soft tissues and bony lesions in anterior-inferior glenohumeral instability. Level of evidence V.

History of shoulder instability surgery

PURPOSE

The surgical management of shoulder instability is an expanding and increasingly complex area of study within orthopaedics. This article describes the history and evolution of shoulder instability surgery, examining the development of its key principles, the currently accepted concepts and available surgical interventions.

METHODS

A comprehensive review of the available literature was performed using PubMed. The reference lists of reviewed articles were also scrutinised to ensure relevant information was included.

RESULTS

The various types of shoulder instability including anterior, posterior and multidirectional instability are discussed, focussing on the history of surgical management of these topics, the current concepts and the results of available surgical interventions.

CONCLUSIONS

The last century has seen important advancements in the understanding and treatment of shoulder instability. The transition from open to arthroscopic surgery has allowed the discovery of previously unrecognised pathologic entities and facilitated techniques to treat these. Nevertheless, open surgery still produces comparable results in the treatment of many instability-related conditions and is often required in complex or revision cases, particularly in the presence of bone loss. More high-quality research is required to better understand and characterise this spectrum of conditions so that successful evidence-based management algorithms can be developed.

LEVEL OF EVIDENCE

IV.

Bipolar bone defect in the shoulder anterior dislocation

In the anterior shoulder instability with glenoid bone loss among 25 % or more of the inferior glenoid diameter (inverted-pear glenoid), the consensus of recent authors is that glenoid bone grafting (Latarjet procedure) should be performed. The engaging Hill-Sachs lesion has been recognized as a risk factor for recurrent anterior shoulder instability. We have developed a method using radiographic and arthroscopic studies and the concept of the glenoid track to determine whether a Hill-Sachs lesion will engage the anterior glenoid rim, whether or not there is concomitant anterior glenoid bone loss. If the Hill-Sachs lesion engages, it is called an "off-track" Hill-Sachs lesion; if it does not engage, it is an "on-track" lesion. On the basis of our quantitative method, we have developed a treatment paradigm with specific surgical criteria for all patients with anterior shoulder instability (first dislocation or recurrent dislocation), both with and without bipolar bone loss.

Remplissage, humeral osteochondral grafts, weber osteotomy, and shoulder arthroplasty for the management of humeral bone defects in shoulder instability: systematic review and quantitative synthesis of the literature

PURPOSE

The aim of this study was to evaluate clinical outcomes, rate of recurrence, complications, and range of movement after remplissage, Weber osteotomy, humeral allograft reconstruction, shoulder arthroplasty, and hemiarthroplasty in patients with anterior or posterior shoulder instability associated with humeral bone loss.

METHODS

A systematic review of published studies on the management of dislocation of the shoulder with humeral bony procedures was performed. A comprehensive search of the PubMed, Medline, CINAHL (Cumulative Index to Nursing and Allied Health Literature), Cochrane, Embase, and Google Scholar databases was performed using various combinations of the keywords "shoulder," "dislocation," "treatment," "remplissage," "hemiarthroplasty," "arthroplasty," "allograft," "osteotomy," "bone," "loss," "clinical," "outcome," and "Hill Sachs" since inception of the databases to 2014. The following data were extracted: demographic characteristics, bone defects and other lesions, type of surgery, outcome measurement, range of motion, recurrence of instability, and complications.

RESULTS

Twenty-six studies were included, in which 769 shoulders were evaluated. The mean value of the Coleman Methodology Score was 69.2 points. Preoperatively, the most detected injuries were Hill-Sachs and Bankart lesions. Shoulder arthroplasty procedures had the highest rate of postoperative recurrence and the lowest scores for postoperative clinical outcomes. The combination of remplissage and Bankart procedures was associated with a lower rate of recurrence when compared with Bankart repair alone (odds ratio, 0.05; 95% confidence interval, 0.01 to 0.25; P = .0002). A high heterogeneity (I(2) = 85%) across the study results was found.

CONCLUSIONS

Arthroscopic remplissage is the safest technique for the management of patients with shoulder instability with humeral bone loss. Remplissage-Bankart procedures are associated with a lower rate of recurrence when compared with Bankart repair alone. Weber osteotomy, humeral allograft reconstruction, shoulder arthroplasty, and hemiarthroplasty are characterized by a high rate of recurrence, complications, and poor outcome scores.

LEVEL OF EVIDENCE

Level IV, systematic review of Level II, III, and IV studies.

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.

Remplissage versus latarjet for engaging Hill-Sachs defects without substantial glenoid bone loss: a biomechanical comparison

BACKGROUND

Recurrent shoulder instability is commonly associated with Hill-Sachs defects. These defects may engage the glenoid rim, contributing to glenohumeral dislocation. Two treatment options to manage engaging Hill-Sachs defects are the remplissage procedure, which fills the defect with soft tissue, and the Latarjet procedure, which increases glenoid arc length. Little evidence exists to support one over the other.

QUESTIONS/PURPOSES

We performed a biomechanical comparison of the remplissage procedure to the traditional Latarjet coracoid transfer for management of engaging Hill-Sachs defects in terms of joint stiffness (resistance to anterior translation), ROM, and frequency of dislocation.

METHODS

Eight cadaveric specimens were tested on a shoulder instability simulator. Testing was performed with a 25% Hill-Sachs defect with an intact glenoid and after remplissage and Latarjet procedures. Joint stiffness, internal-external rotation ROM, and frequency of dislocation were assessed. Additionally, horizontal extension ROM was measured in composite glenohumeral abduction.

RESULTS

After remplissage, stiffness increased in adduction with neutral rotation (12.7 ± 3.7 N/mm) relative to the Hill-Sachs defect state (8.7 ± 3.3 N/mm; p = 0.016). The Latarjet procedure did not affect joint stiffness (p = 1.0). Internal-external rotation ROM was reduced in abduction after the Latarjet procedure (49° ± 14°) compared with the Hill-Sachs defect state (69° ± 17°) (p = 0.009). Horizontal extension was reduced after remplissage (16° ± 12°) relative to the Hill-Sachs defect state (34° ± 8°) (p = 0.038). With the numbers available, there was no difference between the procedures in terms of the frequency of dislocation after reconstruction: 84% of specimens (27 of 32 testing scenarios) stabilized after remplissage, while 94% of specimens (30 of 32 testing scenarios) stabilized after the Latarjet procedure.

CONCLUSIONS

Both procedures proved effective in reducing the frequency of dislocation in a 25% Hill-Sachs defect model, while neither procedure consistently altered joint stiffness.

CLINICAL RELEVANCE

In the treatment of shoulder instability with a humeral head bone defect and an intact glenoid rim, this study supports the use of both the remplissage and Latarjet procedures. Clinical studies and larger cadaveric studies powered to detect differences in instability rates are needed to evaluate these procedures in terms of their comparative efficacy at preventing dislocation, as any differences between them seem likely to be small.

Management of humeral and glenoid bone loss in recurrent glenohumeral instability

Recurrent shoulder instability and resultant glenoid and humeral head bone loss are not infrequently encountered in the population today, specifically in young, athletic patients. This review on the management of bone loss in recurrent glenohumeral instability discusses the relevant shoulder anatomy that provides stability to the shoulder joint, relevant history and physical examination findings pertinent to recurrent shoulder instability, and the proper radiological imaging choices in its workup. Operative treatments that can be used to treat both glenoid and humeral head bone loss are outlined. These include coracoid transfer procedures and allograft/autograft reconstruction at the glenoid, as well as humeral head disimpaction/humeroplasty, remplissage, humeral osseous allograft reconstruction, rotational osteotomy, partial humeral head arthroplasty, and hemiarthroplasty on the humeral side. Clinical outcomes studies reporting general results of these techniques are highlighted.

Arthroscopic Hill-Sachs remplissage: a systematic review

BACKGROUND

Failure to address humeral osseous defects during arthroscopic stabilization surgery for glenohumeral instability leads to an increased rate of recurrence. Arthroscopic remplissage has been proposed as a treatment option for substantial Hill-Sachs lesions. The aim of this systematic review was to examine the outcomes of the remplissage procedure for the treatment of anterior glenohumeral instability of the shoulder with a humeral head defect.

METHODS

A systematic literature review was performed to evaluate the outcomes of arthroscopic Hill-Sachs remplissage. Studies that reported on patients who underwent arthroscopic infraspinatus tenodesis concomitant with a standard Bankart repair were included if they had relevant clinical outcomes and associated complications. The frequency-weighted mean was calculated for outcome measures that were similar across several studies.

RESULTS

Six studies fulfilled the inclusion criteria and were included in the review. The studies included 167 patients (mean age, 27.5 years) with a mean follow-up of 26.8 months (range, twelve to forty-three months). Patients had a frequency-weighted mean adjusted Rowe score of 36.1 preoperatively compared with 87.6 postoperatively (p < 0.001). In the studies with motion measurements, shoulder motion was not affected postoperatively (p > 0.05); mean forward elevation changed from 165.7° preoperatively to 170.3° postoperatively, and mean external rotation changed from 57.2° to 54.6°. Nine of 167 shoulders experienced an episode of recurrent glenohumeral instability (overall recurrence rate, 5.4%).

CONCLUSIONS

Postoperative clinical outcome scores were generally good to excellent following arthroscopic remplissage. No studies indicated a significant loss of shoulder motion following the procedure. The failure rate following Hill-Sachs remplissage compared favorably with previously published rates for patients without clinically important Hill-Sachs lesions who underwent arthroscopic Bankart repair alone. The overall complication rate across the studies was low, further supporting the use of this technique along with Bankart repair in the treatment of glenohumeral instability with a concurrent osseous defect of the humeral head.

Assessment of coincidence and defect sizes in Bankart and Hill-Sachs lesions after anterior shoulder dislocation: a radiological study

OBJECTIVE

Bankart and Hill-Sachs lesions are often associated with anterior shoulder dislocation. The MRI technique is sensitive in diagnosing both injuries. The aim of this study was to investigate Bankart and Hill-Sachs lesions with MRI to determine the correlation in occurrence and defect sizes of these lesions.

METHODS

Between 2006 and 2013, 446 patients were diagnosed with an anterior shoulder dislocation and 105 of these patients were eligible for inclusion in the study. All patients were examined using MRI. Bankart lesions were classified as cartilaginous or bony lesions. Hill-Sachs lesions were graded I-III using a modified Calandra classification.

RESULTS

The co-occurrence of injuries was high [odds ratio (OR) = 11.47; 95% confidence interval (CI) = 3.60-36.52; p < 0.001]. Patients older than 29 years more often presented with a bilateral injury (OR = 16.29; 95% CI = 2.71-97.73; p = 0.002). A correlation between a Bankart lesion and the grade of a Hill-Sachs lesion was found (ρ = 0.34; 95% CI = 0.16-0.49; p < 0.001). Bankart lesions co-occurred more often with large Hill-Sachs lesions (O  = 1.24; 95% CI = 1.02-1.52; p = 0.033).

CONCLUSION

If either lesion is diagnosed, the patient is 11 times more likely to have suffered the associated injury. The size of a Hill-Sachs lesion determines the co-occurrence of cartilaginous or bony Bankart lesions. Age plays a role in determining the type of Bankart lesion as well as the co-occurrence of Bankart and Hill-Sachs lesions.

ADVANCES IN KNOWLEDGE

This study is the first to demonstrate the use of high-quality MRI in a reasonably large sample of patients, a positive correlation of Bankart and Hill-Sachs lesions in anterior shoulder dislocations and an association between the defect sizes.

Anatomic shoulder arthroplasty as treatment for locked posterior dislocation of the shoulder

BACKGROUND

Chronic locked shoulder dislocations account for 2% to 5% of all shoulder dislocations. There is little information regarding the mid-term to long-term results of anatomic shoulder arthroplasty for treatment of this problem.

METHODS

Thirty-two shoulder arthroplasties were performed in thirty-two patients who had chronic locked posterior dislocation of the shoulder. Eighteen patients were treated with a hemiarthroplasty and fourteen, with a total shoulder arthroplasty. Inclusion criteria included moderate or severe pain and functional limitations. Structural indications included an impression fracture involving ≥45% of the humeral head, fibrosis of the articular cartilage, and/or severe osteopenia of the humeral head. When one-third or more of the glenoid was devoid of articular cartilage, a glenoid component was placed. All patients were followed for a minimum of two years (mean, 8.2 years) or until a reoperation.

RESULTS

The operations led to pain relief, with the median pain score decreasing from 4 (on a 5-point scale) preoperatively to 3 postoperatively (p < 0.01), and improvement in shoulder external rotation, from a preoperative median of -15° to a postoperative median of 50° (p < 0.001). Instability recurred in three patients in the early postoperative period. Nine patients underwent a reoperation for various reasons. According to a modified Neer rating system, there were four excellent, fifteen satisfactory, and thirteen unsatisfactory outcomes.

CONCLUSIONS

Although shoulder arthroplasty for locked posterior dislocation can provide pain relief, improved shoulder external rotation, and a low risk of recurrent instability, the overall rate of satisfaction is inferior to that following anatomic arthroplasty for treatment of glenohumeral osteoarthritis.

Humeral head reconstruction for Hill-Sachs defects: a biomechanical comparison of 2 fixation techniques for bone grafting

PURPOSE

The purpose of this biomechanical study was to compare anterograde with retrograde screw fixation for allograft reconstruction of Hill-Sachs defects.

METHODS

In 8 pairs of fresh-frozen humeral heads, a 40% Hill-Sachs defect was created. The resultant wedge-shaped osteochondral fragment was used as allograft. For each technique, two 3.75-mm screws were used for fixation. To test the strength of fixation, a custom tool was used that would apply load to the graft. By use of a materials testing machine, a staircase cyclic loading protocol was performed (500 cycles at 10, 20, 30, and 40 N) and then load to failure. Graft displacement was measured by an optical tracking system.

RESULTS

For the 2 techniques, graft displacement increased with increasing load and increasing number of cycles up to a mean of 0.9 ± 0.42 mm for anterograde fixation and 1.1 ± 0.79 mm for retrograde fixation. This increase was significant within each technique across all 4 loading levels (P < .05). However, there were no significant differences in graft displacement between the 2 techniques at any loading level or number of cycles (P = .16 to P = .96). In addition, the load to failure between the anterograde and retrograde techniques (98.5 N and 95.6 N, respectively) was not significantly different (P = .706).

CONCLUSIONS

The initial fixation and failure strength of anterograde and retrograde graft fixation techniques for substantial Hill-Sachs defects do not significantly differ in a biomechanical cadaveric model.

CLINICAL RELEVANCE

This biomechanical study supports that in an engaging Hill-Sachs defect, both anterograde and retrograde screw fixation techniques can be used for fixation of humeral head allografts.

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.

Combined arthroscopic Bankart repair and remplissage for recurrent shoulder instability

PURPOSE

The objective of our study was to summarize the available clinical evidence pertaining to the combined arthroscopic Bankart repair and remplissage procedure (BRR) for the management of recurrent anterior glenohumeral instability.

METHODS

We searched Medline (1946 to the third week of November, 2012), the Cochrane Central Register of Controlled Trials, Embase (1947 to the 50th week of 2012), and PubMed for studies that reported clinical outcome data at a minimum of 1 year after BRR. Two independent reviewers selected studies for inclusion, assessed methodological quality, and extracted relevant data. Clinical outcome data were pooled and summarized.

RESULTS

Seven clinical studies with a total of 220 patients met the inclusion criteria. Mean patient age was 29 years and mean follow-up was 26 months. Among all studies, the pooled rate of recurrent dislocation after BRR was 3.4%. Compared with preoperative range of motion (ROM) and ROM after Bankart repair (BR) for similar pathologic conditions, there were no clinically significant losses in glenohumeral motion after BRR. Moreover, BRR resulted in favorable functional outcome scores and high patient satisfaction. Four studies reported on postoperative imaging and found high rates of healing and tissue fill-in at the site of infraspinatus tenodesis.

CONCLUSIONS

After BRR, the rate of recurrent dislocation is low and there are no clinically significant losses in glenohumeral ROM. Moreover, functional outcome scores are good and there is a high rate of patient satisfaction. Going forward, there is a need for high-level clinical studies to support the findings of this systematic review and to develop an evidence-based approach to the management of patients with recurrent glenohumeral instability in the setting of a Hill-Sachs defect (HSD).