Management of Glenohumeral Instability with Humeral Bone Lossi

 

 

DEFINITION

The glenohumeral joint is one of the most commonly dislocated joints in the body.

With anterior dislocations, bony defects of the anterior glenoid and posterosuperior aspect of the humeral head occur with relative frequency.

Osseous injuries directly impact recurrent instability by altering joint contact area, congruency, and function of the static restraints.3,14,15,25,28

One of the first descriptions of the lesions found on the humeral head was by Flower13 in 1861, with many subsequent investigators reporting on these bony defects.26

In 1940, two radiologists, Hill and Sachs,17 reported that these defects were actually compression fractures produced when the posterolateral humeral head impinged against the anterior rim of the glenoid.

The true incidence of Hill-Sachs lesions is unknown; however, they are associated with approximately 40% to 90% of initial anterior glenohumeral dislocations.7,36,38,41,45

The incidence in recurrent instability can vary up to 70% to 100%, with arthroscopy often identifying lesions not appreciated on imaging.17,38

The management of Hill-Sachs lesions depends mainly on the size of the lesion and whether it is engaging.4

A majority of lesions are small and clinically insignificant.

Often, lesions that are clinically relevant may be indirectly managed with procedures aimed to address primary instability at the glenoid (ie, Bankart repair, glenoid reconstruction, etc.).

 

ANATOMY

 

With an anterior shoulder dislocation, the humeral head externally rotates relative to the glenoid while translating anteriorly.

 

The static glenohumeral restraints (ie, capsule, ligaments, labrum) are stretched or torn with further anterior translation, and dislocation, of the humeral head.

 

The posterosuperolateral aspect of the humeral head then impacts on the anterior aspect of the glenoid rim and creates a Hill-Sachs lesion (FIG 1A-C).

 

PATHOGENESIS

 

The most common mechanism responsible for a traumatic anterior shoulder dislocation occurs when an indirect force is applied to an abducted and externally rotated arm.

 

Palmer and Widen along with Burkhart and De Beer described an “engaging” Hill-Sachs lesion as one that encounters the anterior glenoid rim with the arm in the “active” position of abduction (90 degrees) and external rotation (0 to 135 degrees).4,6,30

 

These humeral head defects are parallel to the surface of the anterior glenoid when the arm is abducted and externally rotated.1

 

This has been termed an articular arc deficit as there is disruption of the arc of the glenohumeral articulation when the Hill-Sachs lesion rotates over the anterior glenoid rim.4

 

Lesions that are not parallel to the glenoid rim in the “active” or “athletic” position do not engage and are

termed nonengaging lesions.4,6 The Hill-Sachs defect passes diagonally across the anterior glenoid with external rotation; therefore, there is continual contact of the articulating surfaces and no engagement of the Hill-Sachs lesion by the anterior glenoid.27

 

Hence, when a patient has symptomatic anterior instability associated with an engaging Hill-Sachs lesion with an articular arc deficit, treatment must be directed at both repairing the Bankart lesion, if present, and preventing the Hill-Sachs lesion from engaging the anterior glenoid.

 

On an axial view with 0 degrees representing direct anterior, the typical Hill-Sachs lesion lies between 170 and 260 degrees with a midpoint at 209 degrees (FIG 2A,B).35

 

Cho et al9 looked at three-dimensional (3-D) computed tomography (CT) scans of 107 shoulders undergoing surgery for recurrent anterior instability to preoperatively predict engagement of a Hill-Sachs lesion.

 

 

The mean width was 52% (range, 27% to 66%) and depth was 14% (range, 8% to 20%) of the humeral head diameter on axial images.

 

Hill-Sachs lesions typically are accompanied with other pathology including soft tissue and/or bony Bankart lesions and anterior glenohumeral ligament disruption. Optimal surgical management requires addressing these lesions with or without management of the Hill-Sachs lesion.

 

Multiple options exist to address Hill-Sachs defects in anterior glenohumeral instability, including humeroplasty, remplissage, allograft reconstruction (osteochondral plugs vs. size-matched bulk allograft), partial resurfacing, and total resurfacing/arthroplasty.

 

The authors’ preferred technique is an anatomic allograft reconstruction of the humeral head using a side- and sizematched humeral head osteoarticular allograft that eliminates the structural pathology while maintaining the range of motion of the glenohumeral joint.

 

 

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FIG 1 • Posterior views of an anterior glenohumeral dislocation (A), an “engaging” Hill-Sachs lesion after relocation of the glenohumeral joint (B), and a humeral head with a large Hill-Sachs lesion (C).

 

NATURAL HISTORY

 

Hovelius et al19 prospectively followed 229 shoulder dislocations for 25 years. All patients were treated nonoperatively initially and prognostic factors, recurrence, and surgical intervention were monitored.

 

 

At 10 years, 99 of 185 (53.5%) shoulders that were evaluated with radiographs had evidence of a Hill-Sachs lesion.

 

 

Of these 99 shoulders, 60 redislocated at least once and 51 redislocated at least twice during the 10-year follow-up.18

 

This compares with 38 (44%) of the 86 shoulders that did not have such a lesion documented (P < 0.04).

 

However, at 25 years, they concluded a small humeral impression fracture at the time of initial dislocation did not influence the recurrence rate.

 

Rowe et al36 analyzed the long-term results of Bankart repairs for recurrent instability and found an overall recurrence rate of 3.4% (5/145); the recurrence rates were 4.7% and 6% for patients with moderately severe and severe Hill-Sachs lesions, respectively.

 

Although Rowe et al used 3, 5, and greater than 10 mm depths to differentiate their size of Hill-Sachs lesions, various methods of determining size and/or volume of the humeral head defect have been proposed without

consensus; these include Hill-Sachs quotient, articular arc circumference, and Hill-Sachs angle.6,8,9,20,23,26,37,39

PATIENT HISTORY AND PHYSICAL FINDINGS

 

All patients are initially evaluated with a complete history and physical examination.

 

 

Specifics of the history include questioning about the mechanism of instability and timing of initial symptoms and about the details of presenting symptoms, including pain, frequency, instability, and level of function.

 

Arm position and amount of force required for instability may be an evolving process.

 

 

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FIG 2 • A. Typical location of Hill-Sachs lesion. B. Anatomic groove. (Adapted from Richards RD, Sartoris DJ, Pathria MN, et al. Hill-Sachs lesion and normal humeral groove: MR imaging features allowing their differentiation. Radiology 1994;190:665-668.)

 

 

 

Pertinent medical history including collagen disorders or epilepsy should be noted. All previous surgical procedures performed on the shoulder should be noted.

 

Many patients will give a history of recurrent dislocations or multiple surgical attempts to correct the instability.

 

Physical examination should focus on inspection for previous scars, gross asymmetry, a thorough comparison of active and passive range of motion, strength testing, particularly, evaluation of the integrity and strength of the rotator cuff, and axillary nerve function.

 

The clinician should perform a detailed examination for glenohumeral laxity in the anterior, posterior, and inferior directions.

 

Examination for apprehension should be performed in multiple positions (ie, sitting, standing, supine) as patients with large Hill-Sachs lesions usually exhibit apprehension that often occurs with the arm in significantly less than 90 degrees abduction and 90 degrees external rotation.26,27

 

Anterior apprehension test: Positive apprehension can be associated with anterior labral injuries.

 

 

 

 

FIG 3 • A. Axillary radiograph of shoulder demonstrating a large Hill-Sachs lesion. B. Axial MRI image demonstrating large engaging Hill-Sachs lesion.

 

 

Bony apprehension test: Apprehension with fewer degrees of abduction may indicate a significant and symptomatic bony contribution to the instability.

 

IMAGING AND OTHER DIAGNOSTIC STUDIES

 

Preoperative imaging includes a comprehensive radiographic evaluation with anteroposterior (AP), true AP, axillary, and Stryker notch views of the involved shoulder (FIG 3A).

 

All patients require a preoperative axial imaging study (CT > magnetic resonance imaging [MRI]) to more fully define the bony architecture of the glenoid and humeral head (FIG 3B).

 

 

A 3-D reconstruction can be a useful tool to more clearly define the size and location of the defect and to estimate the amount of the articular surface involved.

 

Although the volume and depth of the lesion certainly affect the stability of the shoulder, even more important may be the size of the defect in the articular arc.

 

In imaging, the plane of the Hill-Sachs defect is oblique to the plane of the axial image; therefore, the size of these

 

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defects, and even occurrence is often underestimated with standard axial imaging.38

 

DIFFERENTIAL DIAGNOSIS

 

Anterior shoulder dislocation with or without the following:

 

 

Bankart lesion

 

 

“Bony Bankart” or an anterior glenoid lesion Hill-Sachs lesion

 

Combination of the aforementioned

 

 

Posterior shoulder dislocation with or without associated soft tissue and bony lesions Inferior shoulder dislocation with or without associated soft tissue and bony lesions

NONOPERATIVE MANAGEMENT

 

Small osseous lesions and nonengaging Hill-Sachs lesions can be managed nonoperatively. Often, combined humeral head and glenoid injuries may be treated with addressing the primary defect alone (ie, Bankart, humeral avulsion of the glenohumeral ligament [HAGL], or glenoid bone loss).

 

A monitored rehabilitation program focusing on strengthening the dynamic stabilizers (deltoid, rotator cuff, and periscapular muscles) of the shoulder should be started after an initial brief period of immobilization.

 

SURGICAL MANAGEMENT

Surgical Indications

 

Absolute33

 

 

Displaced humeral head fracture with humeral fracturedislocation and associated Hill-Sachs injury.

 

 

Lesion greater than 30% to 40% of the humeral head with chronic dislocation or recurrent anterior instability Relative33

 

Engaging lesion greater than 20% to 25% of the humeral head

 

Lesion greater than 10% to 25% of the humeral head that does not remain well centered in the glenoid fossa after arthroscopic instability repair.

 

Surgical Options

 

Rotational proximal humeral osteotomies internally rotate the proximal humerus, increasing humeral retroversion and minimizing the potential for the defect to engage the anterior glenoid on external rotation.42

 

This technique is essentially of historic interest given the risk of complications and more successful alternatives.4,5,34,36,42

 

Open anterior procedures, such as an East-West plication, shift the glenoid track medially and superiorly to limit external rotation, preventing the humeral head defect from engaging.4,6

 

These soft tissue-only techniques may not be adequate in the setting of a large humeral head defect; furthermore, concerns with restricted motion in young patients may prevent return to function and cause late arthrosis.

 

Humeroplasty or disimpaction may be possible in the acute (<3 weeks) setting.21,40

 

Remplissage: transfer of the infraspinatus into the defect to render the lesion essentially extra-articular10,44

 

Humeral head augmentation using either osteochondral bone plugs or size-matched bulk allograft transfers can be used reestablish the articular arc.

 

Humeral head augmentation with a prosthetic cap matched to defect size.29

 

In severe or failed reconstructive cases, prosthetic replacement using a hemiarthroplasty or total shoulder arthroplasty may become necessary.32

ANATOMIC ALLOGRAFT RECONSTRUCTION

 

The indications for anatomic allograft reconstruction of the humeral head are as follows:

 

A large engaging Hill-Sachs lesion is identified before undergoing initial surgical treatment. Clinical experience suggests that lesions involving more than 25% to 30% of the articular surface may be

significant.27

 

Ongoing symptomatic anterior glenohumeral instability or painful clicking, catching, or popping in patients with a large engaging Hill-Sachs lesion who have failed to respond to previous soft tissue stabilization procedures

 

Patients at high risk of redislocation (eg, epilepsy with recurrent anterior instability and large Hill-Sachs defects, or contact athletes with combined bony defects to the glenoid and humeral head) can consider this procedure as a primary treatment option.

 

Contact athletes can be considered in this group as time lost from an activity can be a significant issue. Thus, treatment focused on all bony and soft tissue lesions might lessen the likelihood that they would sustain a failed procedure and the associated delay in returning to full competition.

 

Contraindications to this procedure include routine medical comorbidities precluding an elective surgical procedure with general anesthetic, existing infection, or presence of a nonengaging or functionally nonengaging Hill-Sachs lesion.

 

Preoperative Planning

 

A fresh frozen cryopreserved osteoarticular humeral head allograft is obtained from a reputable, certified tissue bank.

 

 

It is important to obtain a side- and size-matched graft as this allows for an optimal recreation of the radius of curvature of the humeral head.

 

The details regarding treatment, preservation, and storage differ depending on the type of sample and the preference of the surgeon.

 

The graft serves mainly a structural function, and cartilage viability is unpredictable.

 

Fresh frozen grafts are preferred but can be difficult to obtain. The secondary, and less preferred, option are irradiated grafts.

 

In our series of 20 cases, the two cases using irradiated grafts had partial collapse of the graft, which required reoperation and screw removal. Fortunately, this did not lead to recurrent instability.

 

Proper allograft sizing of the humeral head requires the patient’s imaging to be sent to the chosen bone bank for measurement.

 

 

Plain radiographs are acceptable as long as calibration is performed with accepted magnification markers.

 

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Acceptable markers include some form of recognizable currency, such as a United States quarter or dime, or a standard magnification marker obtained from your tissue bank.

 

CT or MRI imaging of the proximal humerus allows for direct sizing as magnification is accounted for in the scan.

 

The match from the tissue bank should have a side and size match within ±2 mm. Clinically, we have found that this tolerance yields acceptable results for this procedure.

 

Availability of a matched humeral allograft can be unpredictable.

 

 

For time-sensitive cases, a nonmatched humeral graft or femoral head allograft can be used.

 

Of note, femoral heads often have evidence of osteoarthritis including loss of articular cartilage and should be avoided if possible.

 

If nonmatched humeral grafts or femoral head grafts are used, careful trimming and resection may be needed to match the curvature of the native humeral head.

 

It is important to understand and disclose the details of allograft use as it may have direct implications to your patient.

 

Positioning

 

The patient is positioned in a modified beach-chair position, inclined about 45 degrees, with the upper extremity draped free.

 

Approach

 

An extended deltopectoral approach is used.

 

The lateral border of the conjoined tendon is identified and gently retracted medially to expose the underlying subscapularis tendon.

 

 

TECHNIQUES

• Release of the Subscapularis Muscle and Capsulotomy

  The entire tendon is transected vertically about 0.5 cm medial to its insertion onto the lesser tuberosity.

  Tag sutures of no. 2 Control Release Ethibond Excel (#DC494, Ethicon, Somerville, NJ) are placed in the lateral aspect of the subscapularis tendon as it is released from the lesser tuberosity.

  The interval between the subscapularis and the anterior capsule is then carefully developed using sharp dissection, continuing medially to the neck of the glenoid.

  The inferior capsule is then further isolated using careful blunt dissection.

  A laterally based capsulotomy is made with the vertical limb in line with the subscapularis incision and continuing superiorly.

  The anteroinferior capsule is then released off the surgical neck of the humerus with intra-articular dissection using a periosteal elevator.

• Anterior Labral Inspection and Bankart Reconstruction

  A standard humeral head retractor is placed into the glenohumeral joint, allowing inspection of the glenoid and anteroinferior capsulolabral structures for any pathology.

  If a Bankart lesion is found, it is repaired in the usual fashion using either bony drill holes or suture anchors. The sutures can be left untied until completion of the allograft reconstruction.

• Exposure of the Hill-Sachs Lesion

   

  The humeral head retractor is withdrawn and the humerus is brought into maximal external rotation to expose the Hill-Sachs lesion.

   

  Unroof the synovial expansion of the supraspinatus to allow the humerus to be more fully externally rotated, allowing better visualization and access to the Hill-Sachs lesion.

   

  A flat narrow retractor (eg, Darrach) is then placed over the reflected undersurface of the subscapularis tendon and behind the neck of the humerus on the posterior rotator cuff in order to lever out the humeral head (TECH FIG 1).

   

   

   

  TECH FIG 1 • Intraoperative exposure of large Hill-Sachs lesion to be reconstructed.

   

   

   

• Humeral Head Osteotomy

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  With the Hill-Sachs lesion adequately exposed, a microsagittal saw is used to smooth and reshape the defect into a chevrontype configuration.

   

  The piece of matching allograft humeral head to be inserted should resemble a “deep-dish slice of pie” (TECH FIG 2A,B).

   

   

   

  TECH FIG 2 • A. Diagram of the humeral head after osteotomies. B. Reshaping of Hill-Sachs lesion to prepare to receive allograft. C. Schematic representation of required measurements of the defect and graft. Base (X), height (Y), length (Z), and rough outside partial circumference (C) of the defect are then measured to the nearest millimeter.

   

   

  The base and side of the defect can then be further smoothed using a hand rasp to achieve precise, flat surfaces.

   

  The base (X), height (Y), length (Z), and rough outside partial circumference (C) of the defect are then measured to the nearest millimeter (TECH FIG 2C).

• Osteotomy of the Humeral Head Allograft

   

  A corresponding piece is cut from the matched humeral head allograft that is 2 to 3 mm larger in all dimensions than the measured defect.

   

  The allograft segment is then provisionally placed into the Hill-Sachs defect and resized in all three planes.

   

  Excess graft is then carefully trimmed with the microsagittal saw and is reshaped in the other two planes as well.

   

  Fine-tuning of graft size is then continued in one plane at a time until a perfect size match is achieved in all planes, including base (X), height (Y), length (Z), and outside partial circumference (C).

• Fixation of the Humeral Head Allograft

   

  The allograft segment is placed into the defect and aligned so as to achieve a congruent articular surface.

   

  It is provisionally secured in place with two or three smooth 0.045-inch Kirschner wires (TECH FIG 3A,B).

   

  The wires are then sequentially replaced with 3.5-mm fully threaded cortical or 4.0-mm cancellous screws placed in a lag fashion (TECH FIG 3C,D).

   

  Ensure that the screw heads are countersunk so that they are below the level of the articular surface.

   

  The joint is irrigated and taken through a range of motion to ensure that the reconstructed humeral head provides a smooth congruent articulating surface.

   

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  TECH FIG 3 • A. Anatomic allograft reconstruction of Hill-Sachs defect with humeral allograft provisionally held in place with two Kirschner wires. B. Diagram of allograft reconstruction of Hill-Sachs defect with humeral allograft held in place with a Kirschner wire and an AO screw. C. AP radiograph of shoulder demonstrating anatomic allograft reconstruction of Hill-Sachs defect fixed with two countersunk cortical screws. (Dashed line represents the area filled by the allograft.) D. Axillary view of shoulder demonstrating anatomic allograft reconstruction of Hill-Sachs defect fixed with two countersunk cortical screws.

• Labral Repair and Subscapularis Reapproximation

 

The capsulotomy is closed with absorbable suture after tying any previously placed sutures used to repair the capsulolabral pathology, if present.

 

The subscapularis tendon is then reapproximated to its stump anatomically, without shortening, using suture anchors or a soft tissue repair with nonabsorbable suture.

 

Allow the conjoined tendon, deltoid, and pectoralis major muscles to return to their normal anatomic

positions.

A routine subcutaneous and skin closure is then performed. Sterile dressing is applied.

The arm is placed into a shoulder immobilizer.

 

 

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POSTOPERATIVE CARE

After surgery, patients are given a sling for comfort and allowed full passive range of motion immediately as tolerated.

Because of the subscapularis detachment, we protect against active and resisted internal rotation for 6 weeks. After the initial 6-week period, patients are allowed terminal stretching and strengthening exercises.

The shoulders are imaged with repeat radiographs at 6 weeks and 6 months and with CT scans at 6 months to assess for consolidation and incorporation of the graft.

 

OUTCOMES

Between 1995 and 2001, we performed and reviewed this procedure in 18 patients who had failed previous attempts at surgical stabilization with an average follow-up of 50 months (range 24 to 96 months).26,27

Fifteen patients had a history of traumatic anterior glenohumeral instability related to sports, and three

 

PEARLS AND PITFALLS

Anterior labral

injury

• The surgeon should ensure this injury pattern is identified early after

exposure of the joint. Anchors or sutures are placed in the anterior glenoid for later labral repair after reconstruction of the Hill-Sachs lesion.

Exposure of the

posterior superior humeral head

• This area of the humeral head can be accessed through external rotation and

forward flexion of the upper extremity. Appropriately placed retractors assist in this exposure.

Allograft sizing

• The surgeon should ensure the allograft obtained is larger in dimension by 2-

3 mm than the actual defect. This allows for in situ sizing.

Screw

placement

• It is easier to initially place two 0.045-inch Kirschner wires for fixation and

  then replace them with two 3.5-mm stainless steel AO screws lagged into position.

• Screw heads are countersunk beneath the surface of the allograft articular surface to prevent hardware penetration.

 

patients had instability related to seizures or other trauma.

 

All had posterolateral humeral head defects (Hill-Sachs lesions) that represented greater than about 25% to 30% of the humeral head.

 

One patient had both anterior and posterior humeral head defects from bidirectional shoulder instability sustained as a result of a seizure disorder.

 

No patients had true multidirectional instability.

 

 

Patients in the formal review were assessed preoperatively and postoperatively with the following: Radiographic evaluation (plain films and axial imaging [CT, MRI, or both])

 

Validated clinical evaluation measures (Constant-Murley shoulder score, Western Ontario Shoulder

Instability Index [WOSII], and SF-36)

 

 

Findings at the time of surgery included the following: Nine patients with recurrent Bankart lesions

 

Nine patients with capsular redundancy only

 

No patients with subscapularis tears

 

One patient with posterior glenoid erosion

 

Three patients with anterior glenoid deficiency (<20%), which was not reconstructed

 

There were no episodes of recurrent instability. Sixteen of 18 (89%) patients returned to work.

 

The average Constant score postoperatively was 78.5. The WOSII, which is a validated quality-of-life scale specific to shoulder instability using a visual analog scale response format, decreased significantly, indicating improvement.

 

Overall, this represents the first reported series of anatomic allograft reconstruction of Hill-Sachs defects for recurrent traumatic anterior instability after failed repairs.

 

Diklic et al11 treated 13 patients with fresh frozen femoral head allograft reconstructions for Hill-Sachs lesions between 25% and 50% of the humeral head.

 

 

At an average of 54 months postoperatively, the mean Constant score for the cohort was 86.8. Twelve patients had stable shoulders, and one patient had evidence of osteonecrosis.

 

COMPLICATIONS

Complications that occurred in our series of humeral osteoarticular allograft reconstruction of Hill-Sachs lesions included radiographic follow-up evidence of partial graft collapse in 2 of 18 patients, early

evidence of osteoarthritis in 3 patients (marginal osteophytes), and 1 mild subluxation (posterior).26,27 Screw penetrance developed in two patients who complained of pain with extreme external rotation.

The screws were removed at about 2 years postoperatively in both patients, thereby relieving their symptoms.

One must weigh the risks of continued shoulder dysfunction versus the risk associated with the use of fresh osteoarticular allografts. A metallic partial resurfacing arthroplasty is an option that allows for

reestablishment of the humeral articular surface without the use of allograft.16

 

ARTHROSCOPIC REMPLISSAGE

 

Remplissage (French) for “to fill”

 

Surgical technique involves converting an intra-articular humeral head defect into an extra-articular defect with soft tissue coverage to prevent engagement with the anterior glenoid rim (FIG 4).

 

Originally described by Connolly10 as an open procedure by filling the Hill-Sachs lesion via transfer of the infraspinatus tendon with a portion of greater tuberosity

 

An all-arthroscopic technique was first described by Wolff et al43 which involved a posterior capsulodesis and infraspinatus tenodesis with transfer into the humeral head defect in conjunction with standard anteroinferior glenoid repair.

 

 

Reserved for large Hill-Sachs lesions defects with associated glenoid loss of less than 25%. Larger defects would require a conversion to open Latarjet.

 

 

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FIG 4 • Schematic representation of the arthroscopic remplissage. The infraspinatus tendon is tenodesed to the Hill-Sachs defect, and an anterior capsulolabral repair is performed. (Adapted from Purchase RJ, Wolf EM, Hobgood ER, et al. Hill-Sachs “remplissage”: an arthroscopic solution for the engaging Hill-Sachs lesion. Arthroscopy 2008;24[6]:723-726.)

 

 

Suture anchors were placed into the valley of the defect with suture limbs passed directly posteriorly.

 

 

This was modified by Koo et al22 by using a double-pulley technique in which two anchors were used to insert the infraspinatus tendon into the humeral head defect.

 

 

This allowed for the sutures to be tied over the tendon rather than through the tendon or on the muscle belly allowing a more anatomic and tissue-preserving construct that is biomechanically stronger.12

Surgical Technique

 

 

 

Anesthesia: general endotracheal anesthesia with interscalene block Positioning (based on surgeon preference): beach chair versus lateral decubitus Portals

 

Posterior: slightly lateral to humeral head over the lesion to best visualize the defect

 

 

Anterosuperior portal: off the anterior margin of acromion, superior and just posterior to biceps tendon Accessory posterolateral (“Remplissage portal”): two fingerbreadths lateral to posterior portal

 

Preparation of anterior labrum and glenoid to allow mobilization of labrum/inferior glenohumeral ligament for eventual soft tissue repair

 

Humeral head defect should then be débrided with either a shaver or burr. Microfracture can be completed to stimulate a bleeding surface.

 

Two spinal needles are passed through the subacromial space to assess transtendon angle of suture anchors.

 

The arthroscope should be transferred to the subacromial space for débridement. The posterior, lateral, and posterolateral gutters should be adequately débrided to ensure visualization for suture tying over the infraspinatus tendon.

 

Suture passage begins with moving the arthroscope to the anterosuperior portal. Suture anchors should be placed at the superior and inferior margin of lesion via the posterior portal. One limb from each suture should be passed through the posterior capsule and infraspinatus tendon.

 

With the humeral head reduced and arm in the neutral rotation, a capsulodesis is created with two mattress stitches tied on the bursal surface of the rotator cuff.

 

Finally, standard anteroinferior soft tissue repair is performed.

 

Postoperative Care

 

Postoperative rehabilitation protocol is similar to that of a Bankart repair.

 

 

 

Sling immobilization in neutral rotation for 4 weeks Pendulums can begin the day after surgery.

 

Formal physical therapy begins at 4 weeks with return to athletic activities around 3 to 6 months.

Outcomes

 

Early studies reported a 7% (2/24) incidence of recurrent instability with no loss of motion in any plane at 2-year follow-up.34

 

Zhu and colleagues46 evaluated 49 consecutive patients with a minimum of 2-year follow-up.

 

On average, patients had an increase of 8 degrees of forward elevation with a loss of only 1.9 degrees of external rotation.

 

An 8.2% (4/49) failure rate with 1 redislocation, 2 subluxations, and 1 patient with positive apprehension test

 

An MRI investigation of 11 patients at an average follow-up of 18 months found evidence of tendon incorporation into the humeral head defect as early as 8 months.31

 

The infraspinatus tendon filled 75% to 100% of the lesions and the degree of atrophy was found to be 0% to 25%.

 

Boileu et al2 studied 47 patients with a mean 2-year followup who underwent arthroscopic remplissage.

 

Ninety-eight percent had a stable shoulder at last followup with all patients who underwent imaging (42 patients) showing evidence of healing of the posterior capsule and infraspinatus tendon into the defect.

 

There was a deficit of external rotation (8 degrees ±7) and abduction (9 degrees ±7).

 

This was not functionally limiting; of the 41 patients who played athletics prior to surgery, 37 (90%) returned to sport with 28 (68%) returning to the same level of sport, including overhead sports.

 

A systematic review evaluated seven studies (levels II, III, IV) of combined arthroscopic remplissage with Bankart repair with an average 26-month follow-up and a pooled rate of recurrent dislocation of 3.4%.24

 

No clinically significant loss of range of motion.

 

Four studies reviewed postoperative imaging and found high rates of healing and tissue filling at the infraspinatus tenodesis.

 

 

 

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