Arthroscopic Treatment of Osseous Instability of the Shoulder

Abstract

Background: Bony deficiency of the anteroinferior glenoid rim as a result of a dislocation can lead to recurrent glenohumeral instability. These lesions, traditionally treated by open techniques, are increasingly being treated arthroscopically as our understanding of the pathophysiology and anatomy of the glenohumeral joint becomes clearer. Different techniques for arthroscopic management have been described and continue to evolve. While the success of the repair is surgeon dependent, the recent advances in arthroscopic shoulder surgery have contributed to the growing acceptance of arthroscopic reconstruction of glenoid bone defects to restore stability.

Questions/purposes: The purpose of this study was to describe arthroscopic surgical management options for patients with glenohumeral osseous lesions and instability.

Methods: A comprehensive search of PubMed, Cochrane, and Medline was conducted to identify eligible studies. The reference lists of identified articles were then screened. Both technique articles and long-term outcome studies evaluating arthroscopic management of glenohumeral lesions were included.

Results: Studies included for final analysis ranged from Level II to V evidence. Technique articles include suture anchor fixation of associated glenoid rim fractures, arthroscopic reduction and percutaneous fixation of greater tuberosity fractures, arthroscopic filling ("remplissage") of the humeral Hill-Sachs lesion, and an all-arthroscopic Latarjet procedure. The overall redislocation rate varied but was consistently <10% with a low complication rate.

Conclusion: Management of glenohumeral instability can be challenging but more recent advances in arthroscopic techniques have provided improved means of treating this diagnosis. This manuscript provides a comprehensive review of the arthroscopic treatment of osseous instability of the shoulder. It provides an in depth look at the various treatment options and describes techniques for each.

Keywords: Hill-Sachs lesion; arthroscopy; bony Bankart lesion; glenoid fracture; shoulder instability.

Fig. 1

a Three-dimensional CT scan demonstrating a bony Bankart lesion involving approximately 25% of the anteroinferior glenoid. b Three-dimensional CT scan showing an accompanying depressed greater tuberosity fracture. c A left shoulder viewing from a posterior portal in beach chair position. A significant bony Bankart lesion with attached capsulolabral tissue (asterisk). Black arrow demonstrating the anterior glenoid rim. HH humeral head, G glenoid. d Medial row anchor placement through a lateral rotator interval portal utilizing a curved drill and anchor system. e Reduction and fixation of the bony fragment with a suture bridge construct to a knotless anchor on the glenoid face, with placement standard anchor placement inferior to the fracture fragment. f Final anatomic reduction with suture bridge fixation around the fragment and standard knot-tied anchors superior and inferior. g, h The concomitant greater tuberosity (GT) fracture fixed percutaneously with a 3.5-mm cannulated screw.

Fig. 2

(*All images reprinted from Journal Shoulder Elbow Surg, Vol 19/2, LaFosse L, Boyle, S., Arthroscopic Latarjet Procedure, 2-12, 2010, with permission from Elsevier.) a Subscapularis split with a switching stick elevating the muscle. b View from the anterolateral portal demonstrating the coracoid tip with a spinal needle inserted anteriorly to define the anterior tip. Two Kirschner wires are placed into the coracoid (asterisk) through a guide in a superior to inferior direction. These will be used to drill and tap the coracoid. c Coracoid osteotomy performed through the base subsequent to using a burr on the lateral, superior, and inferior edges of the coracoid. Viewing from the anterolateral portal. d Coracoid being reduced onto the coracoid positioning cannula using chia wires placed through the previously made holes. e, f View from anterolateral portal demonstrating coracoid reduction (e) with screws and final fixation on glenoid rim (f). Asterisk coracoid tip, HH humeral head, G glenoid.

Fig. 3

a, b MRI and CT scans demonstrating a large Hill-Sachs lesion with associated soft tissue Bankart lesion. c A right shoulder in beach chair position viewed from a posterior portal. A large engaging Hill-Sachs lesion. d The Hill-Sachs lesion after bur preparation and placement of two suture anchors (Arthrex double-loaded suturetac 2.9 mm biocomposite anchors). e View from the anterior superior rotator interval portal of the suture anchors. Sutures were shuttled through the infraspinatus with a bird beak penetrator. f View again from the anterior superior portal demonstrating fill of the Hill-Sachs defect after tying of the suture anchors. The infraspinatus is to the left and humerus is to the right.

Fig. 4

a Injury x-ray showing a shoulder fracture-dislocation with a displaced greater tuberosity fragment. b A left shoulder in beach chair position, viewing the glenohumeral joint from a posterior portal, demonstrating the displaced greater tuberosity (GT) fragment. Asterisk designates the fracture bed. c The same fragment after reduction and fixation. d Postoperative x-rays demonstrating fixation of the fracture fragment with cannulated screws.

Fig. 5

a Pre-operative x-ray demonstrating a displaced greater tuberosity fracture after a recent dislocation event. b A right shoulder in beach chair position, viewing the glenohumeral joint from a posterior portal, demonstrating the displaced greater tuberosity (GT) fragment. (Arrow pointing to GT avulsion with attached rotator cuff. Asterisk at fracture bed.) c The subacromial space viewed from the lateral portal demonstrating suture bridge repair of the fracture fragment. d Postoperative x-ray demonstrating reduction of the greater tuberosity fracture.