Management of off-track Hill-Sachs lesions in anterior glenohumeral instability

Abstract

Bone loss has been identified as a risk factor for recurrent shoulder dislocations or failure after soft tissue repair. Although the range for "critical" bone loss is yet to be determined, glenoid and humeral bone defects should not be regarded as independent problems, but the interaction between them during shoulder motion should be evaluated as suggested by the glenoid track concept. The glenoid track concept is now widely accepted and considered essential for making decisions about surgery. Soft-tissue procedures usually work well in patients with on-track Hill-Sachs lesions but in off-track lesions do not. In this situation additional procedures should be performed.Different surgical options have been described to address off-track Hill-Sachs lesions, most commonly remplissage, Latarjet or free bone block procedures. Coracoid graft and free bone grafts convert the off-track Hill-Sachs lesion into on-track by lengthening the glenoid-track, whereas remplissage fill-in the humeral lesion so that it does not engage. In the setting of a Hill-Sachs lesion with little or no glenoid bone loss, remplissage has demonstrated satisfactory outcomes with a low complications and recurrence rate. Favorable results have been reported with glenoid bone grafting when managing isolated Hill-Sachs or bipolar lesions. Studies analyzing Latarjet and Eden-Hybinette procedures show that both procedures are safe and effective in the management of anterior glenohumeral instability. Attention should be paid to those patients with large bone defects not amenable to be restored with an isolated Latarjet that may be better addressed with an Eden-Hybinnete or adding a remplissage to the Latarjet procedure.

Keywords: Eden-Hybinette; Hill-Sachs; Iliac crest bone graft; Instability; Latarjet; Off-track; Remplissage; Shoulder.

Fig. 1

The remplissage procedure. Sutures passed through the infraspinatus and the posterior shoulder capsule are tightened filling the humerus defect

Fig. 2

Intraoperative imaging of a Latarjet procedure with the coracoid graft accurate positioned

Fig. 3

Postoperative CT-scan of a patient with a large and medial Hill-Sachs lesion that was not fully restored with the Latarjet procedure

Fig. 4

Postoperative CT-scan of a patient with an off-track Hill-Sachs lesions who underwent an arthroscopic Eden-Hybinette procedure. Courtesy of Dr Miguel García Navlet, Hospital Asepeyo Coslada (Madrid)