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.

Cyst formation and bony ingrowth inside coil-type open-architecture anchors used for arthroscopic remplissage: a volumetric computed tomographic study of 50 anchors.

BACKGROUND: The use of anchors in the proximal humerus during arthroscopic surgery can cause localized bone loss due to osteolysis and cyst formation. The purpose of this study was to use computed tomography (CT) to evaluate the incidence of implant-related bone loss and cyst formation after implantation of polyetheretherketone (PEEK) coil-type open-architecture anchors during remplissage for the management of Hill-Sachs defects (HSDs) in patients with shoulder instability. METHODS: This was a single-cohort, observational study with a minimum of 12 months of follow-up. Subjects undergoing arthroscopic instability surgery with HSD requiring remplissage were included. The volume of the bone defects and the degree of bony ingrowth into the anchor were measured on CT images. RESULTS: Thirty-one participants (28 males, 3 females; mean age 29.4 years, standard deviation [SD] 10.6) in whom 50 anchors (4.5-mm Healicoil PEEK double-loaded anchors) were used were evaluated with a CT performed at a mean of 14.1 (SD 3.74) months after surgery. Full bony ingrowth inside the anchor was found in 15 anchors (30%, range 17.8%-44.5%); clear ossification with a thin lucent rim was found in 10 anchors (20%, range 10.0%-33.7%); discontinuous ossification was found in 8 anchors (16%, range 7.2%-29.1%); and no ossification was observed inside 17 anchors (34%, range 21.2%-48.7%). Regarding bone defect size, no bone defect was identified in 15 anchors (30%, 95% CI 17.9%-44.6%), a partial bone defect was found in 17 anchors (34%, 95% CI 21.2%-48.7%), hole enlargement was found in 17 anchors (34%, 95% CI 21.2%-48.7%), and 1 anchor caused a cyst larger than twice the size of the hole made for anchor insertion (2%, 95% CI 0.1%-8.6%). At the 1-year evaluation, none of the participants presented recurrence or residual apprehension. CONCLUSION: The use of PEEK coil-type open-architecture anchors for remplissage during instability surgery caused large cystic lesions in less than 10% of anchors. There was full bony ingrowth in one-third of anchors, and partial cancellous bone ingrowth occurred in another third of anchors.

Chronic locked posterior gleno-humeral dislocation: technical note on fibular grafting for restoration of humeral head sphericity.

BACKGROUND: Reconstruction of reverse Hill-Sachs defect using osteo-chondral allograft has the advantages of spherical re-contouring and provision of smooth biological articular surface of the reconstructed humeral head. However, worldwide availability and risk of disease transmission of osteo-chondral allograft remain points of increasing concerns. As an alternative to lacking osteo-chondral allograft, the current technical note describes a reconstructive technique of reverse Hill-Sachs defect using autologous fibular grafting. METHODS: Following open reduction of the dislocated humeral head, reverse Hill-Sachs defect was reconstructed using 3-4 autologous fibular pieces (each is of 10 mm in length) fixed in flush with the articular cartilage using 4-mm cancellous screws. Defect reconstruction was then followed by modified McLaughlin's transfer and posterior capsulorrhaphy. RESULTS: Spherical contour of the humeral head and gleno-humeral range of motion were restored. Intra-operative dynamic testing of the reconstruct revealed no residual posterior gleno-humeral instability. CONCLUSION: Currently reported technique might offer advantages of graft availability, technical simplicity, familiarity and reproducibility, safety (i.e. no disease transmission) and bone preservation facilitating future revision management (if needed). Nevertheless, long-term outcomes of this technique should be investigated via further cohort clinical studies.

[Arthroscopic Bankart repair combined with Reimplissage for the treatment of recurrent anterior dislocation of shoulder in adults with Hill-Sachs defect].

OBJECTIVE: To investigate the method and clinical effects of the treatment of recurrent anterior dislocation of shoulder with Hill-Sachs injury by arthroscopic Bankart repair and Remplissage. METHODS: From March 2016 to March 2019, 106 patients with recurrent anterior dislocation of shoulder with glenoid bone defect less than 20% underwent arthroscopic Bankart repair, including 76 males and 30 females, aged from 18 to 45 (27.3±8.6) years, 59 cases of left shoulder and 47 cases of right shoulder. Range of motion (ROM), American Shoulder and Elbow Surgeons(ASES) score, Constant-Murley score and Rowe score were used to evaluate shoulder functionand stability before and after operation. RESULTS: All patients were followed up, and the duration ranged from 21 to 60 months, with a mean of (41.5± 8.5) months. One patient developed infection after operation, and the infection was controlled after arthroscopic debridement again. The remaining patients did not have clinical complications such as infection, intra articular hematocele and redislocation. Shoulder flexion and lifting increased from (158.33±15.72) ° preoperatively to (169.43±10.04) ° at the latest follow up, and internal rotation changed from T7 (T4 to T10) preoperatively to T8 (T5 to T10) at the latest follow up;the average lateral external rotation and abduction 90 ° external rotation decreased from (58.46±15.51) ° preoperatively and (99.37±14.09) ° to (53.18±14.90) ° and (92.52±13.10) ° at the latest follow up, respectively. The ASES score, Constant -Murley score and Rowe score were significantly improved. CONCLUSION: The clinical effect of rehabilitation of Bankart repair combined with Remplissageunder arthroscopy in the treatment of recurrent dislocation of shoulder joint in adults with Hill-Sachs defect is satisfactory. Although the external rotation function is weaker than that before operation, it can effectively reconstruct the shoulder function and avoid the occurrence ofdislocation after operation.

Arthroscopic Bankart repair combined with Reimplissage for the treatment of recurrent anterior dislocation of shoulder in adults with Hill-Sachs defect / 中国骨伤

OBJECTIVE@#To investigate the method and clinical effects of the treatment of recurrent anterior dislocation of shoulder with Hill-Sachs injury by arthroscopic Bankart repair and Remplissage.@*METHODS@#From March 2016 to March 2019, 106 patients with recurrent anterior dislocation of shoulder with glenoid bone defect less than 20% underwent arthroscopic Bankart repair, including 76 males and 30 females, aged from 18 to 45 (27.3±8.6) years, 59 cases of left shoulder and 47 cases of right shoulder. Range of motion (ROM), American Shoulder and Elbow Surgeons(ASES) score, Constant-Murley score and Rowe score were used to evaluate shoulder functionand stability before and after operation.@*RESULTS@#All patients were followed up, and the duration ranged from 21 to 60 months, with a mean of (41.5± 8.5) months. One patient developed infection after operation, and the infection was controlled after arthroscopic debridement again. The remaining patients did not have clinical complications such as infection, intra articular hematocele and redislocation. Shoulder flexion and lifting increased from (158.33±15.72) ° preoperatively to (169.43±10.04) ° at the latest follow up, and internal rotation changed from T7 (T4 to T10) preoperatively to T8 (T5 to T10) at the latest follow up;the average lateral external rotation and abduction 90 ° external rotation decreased from (58.46±15.51) ° preoperatively and (99.37±14.09) ° to (53.18±14.90) ° and (92.52±13.10) ° at the latest follow up, respectively. The ASES score, Constant -Murley score and Rowe score were significantly improved.@*CONCLUSION@#The clinical effect of rehabilitation of Bankart repair combined with Remplissageunder arthroscopy in the treatment of recurrent dislocation of shoulder joint in adults with Hill-Sachs defect is satisfactory. Although the external rotation function is weaker than that before operation, it can effectively reconstruct the shoulder function and avoid the occurrence ofdislocation after operation.

Management of Recurrent Anterior Shoulder Instability With Bipolar Bone Loss: A Systematic Review to Assess Critical Bone Loss Amounts.

BACKGROUND: There is increasing evidence to suggest that the amount of glenoid bone loss to indicate bone block procedures may be lower than previously thought, particularly in the presence of a Hill-Sachs defect. PURPOSE: To better establish treatment recommendations for anterior shoulder instability among patients with bipolar bone lesions. STUDY DESIGN: Systematic review and meta-analysis; Level of evidence, 4. METHODS: A systematic review of the literature was performed with PubMed, EMBASE, Cochrane Library, and Scopus databases according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines. Studies evaluating outcomes of operative management in anterior shoulder instability that also reported glenoid bone loss in the presence of Hill-Sachs defects were included. Recurrence rates, glenoid bone loss, and humeral bone loss were pooled and analyzed with forest plots stratified by surgical procedure. Methods of quantification were analyzed for each article qualitatively. RESULTS: Thirteen articles were included in the final analysis, with a total of 778 patients. The mean ± SD age was 24.9 ± 8.6 years. The mean follow-up was 30.1 months (range, 11-240 months). Only 13 of 408 (3.2%) reviewed bipolar bone loss articles quantified humeral and/or glenoid bone loss. Latarjet procedures had the greatest glenoid bone loss (21.7%; 95% CI, 14.8%-28.6%), followed by Bankart repairs (13.1%; 95% CI, 9.0%-17.2%), and remplissage (11.7%; 95% CI, 5.5%-18.0%). Humeral bone loss was primarily reported as percentage bone loss (22.2%; 95% CI, 13.1%-31.3% in Bankart repairs and 31.7%; 95% CI, 21.6%-41.1% in Latarjet) or as volumetric defects (439.1 mm3; 95% CI, 336.3-541.9 mm3 in Bankart repairs and 366.0 mm3; 95% CI, 258.4-475.4 mm3 in remplissage). Recurrence rates were as follows: Bankart repairs, 19.5% (95% CI, 14.5%-25.8%); remplissage, 4.4% (95% CI, 1.3%-14.0%); and Latarjet, 8.7% (95% CI, 5.0%-14.7%). Bankart repairs were associated with significantly greater recurrence of instability in included articles (P = .013). CONCLUSION: There exists a need for universal and consistent preoperative measurement of humeral-sided bone loss. The presence of concomitant Hill-Sachs defects with glenoid pathology should warrant more aggressive operative management through use of bone block procedures. Previously established values of critical glenoid bone loss are not equally relevant in the presence of bipolar bone loss.

[Recurrent instability and instability arthropathy]. / Rezidivinstabilität und Instabilitätsarthropathie.

Capsulolabral reconstruction (Bankart repair) is recommended as the first line treatment in young and functionally demanding active patients with anteroinferior shoulder instability, due to the high tendency to recurrent dislocation. This has become established both for arthroscopic and open primary shoulder stabilization with good clinical outcome; nevertheless, recurrence of dislocation is reported in up to 25% of patients. Risk factors for failed surgery are patient (e.g. young age, male gender and contact sports) and surgery (e.g. primarily underestimated glenoid bone loss, Hill-Sachs lesion, non-treatment of bipolar defects or malpositioned anchors) related. In the management of recurrent instability, it is necessary to carry out a thorough clinical investigation in addition to extended diagnostics with X­ray and computed tomography. A second Bankart repair is only indicated in patients with low demands and without any glenoid bone loss. In the majority of patients, bony augmentation of the glenoid is necessary and realized by coracoid or iliac crest bone block transfer. The Latarjet procedure is biomechanically advantageous due to the additional sling effect of the conjoined tendons and both techniques show good clinical outcomes and a low recurrence rate. Furthermore, engaging Hill-Sachs lesions also require additional treatment. Remplissage of the infraspinatus muscle, iliac crest bone block transfer and partial joint replacement are viable options. A final consensus for treatment of Hill-Sachs lesions has yet to be defined. Dislocation arthropathy is an underestimated complication as a result of frequent recurrent dislocations. After development of dislocation arthropathy, patients reported a painful restriction of range of motion rather than instability. Arthroscopic arthrolysis and comprehensive arthroscopic management (CAM procedure) are possible joint-preserving treatment options.

Arthroscopic remplissage: Is it still an option?

Posterolateral humeral head defects can be large and engage on the anterior glenoid, and they usually contribute to anterior shoulder instability in 40% to 90% of cases.The purpose of this study is to evaluate the results of the largest series of patients who underwent arthroscopic remplissage with Bankart repair for recurrent anterior shoulder instability due to associated Bankart lesions, with large and engaging (> 25% involvement) humeral Hill-Sachs defects (HSDs).A total of 51 patients underwent arthroscopic Bankart repair with remplissage technique for the treatment of recurrent anterior glenohumeral instability with large and medial HSDs. Pre-operative imaging in all patients identified a Bankart lesion with an associated HSD that involved > 25% of the humeral head. The Rowe score was used to assess the patients clinically.A total of 46 patients were male. The mean age of the patients was 28.7 years (18 to 43). The mean follow-up period was 31 months (20 to 39). At the final follow-up, three patients reported recurrence of instability (two dislocations and one subluxation). The mean Rowe score improved to 95.4 points (function, 45.5 of 50; stability, 26.4 of 30; motion, 8 of 10; pain, 8 of 10).The arthroscopic remplissage technique with Bankart repair gave satisfactory results and is still considered to be an effective, safe and reliable procedure for treatment of glenohumeral instability in cases with large and medial HSDs. Cite this article: EFORT Open Rev 2017;2:478-483. DOI: 10.1302/2058-5241.2.160070.

Influence of defect size and localization on the engagement of reverse Hill-Sachs lesions.

BACKGROUND: Reverse Hill-Sachs (RHS) lesions can cause recurrent posterior shoulder instability because of engagement with the posterior glenoid rim; however, the effect of defect size and localization have yet to be determined. HYPOTHESIS: Both size and localization are critical for the engagement of an RHS defect with the posterior glenoid rim. STUDY DESIGN: Controlled laboratory study. METHODS: Ten RHS defects with predefined extent and localization were created through an anterolateral rotator cuff sparing approach in 10 fresh-frozen cadaveric shoulder specimens using a custom-made saw guide. Computed tomography scans of all specimens were completed, and standardized measurements were performed to determine the size (alpha angle) and localization (beta angle) of the defect as well as a combination of both parameters (gamma angle). Internal rotation motions were imposed on the shoulder joint in different arm positions and with varying amount of posterior translation by means of a robot-assisted shoulder simulator. The association between engagement of the defects and the defined parameters (alpha, beta, and gamma angles) was analyzed. RESULTS: In 0° of abduction, a cutoff value between engaging and nonengaging defects of 37.5° for the alpha angle (100% sensitivity; 75% specificity; area under the curve [AUC], 0.875; P = .055) and 36.5° for the beta angle (100% sensitivity; 25% specificity; AUC, 0.708; P = .286) was determined. The gamma angle showed the highest discriminatory power (AUC, 0.938; P = .025) with a cutoff value of 85.5° rendering 100% sensitivity and 75% specificity in the prediction of engagement. An increase in the applied posterior translation force decreased the degrees of internal rotation necessary before engagement occurred. No engagement occurred during internal rotation with the arm in 60° of abduction or 60° of flexion. CONCLUSION: The size and localization of RHS defects are both critical factors for engagement. The combination of both parameters in terms of the gamma angle measurement might be a helpful tool to identify defects prone to engagement. CLINICAL RELEVANCE: Not only the size but also the localization is decisive for engagement of RHS defects. The standardized measurement of the gamma angle combines both factors and might be a helpful tool to identify defects prone to engagement warranting surgical treatment.