Dynamic Anterior Stabilization with Hill-Sachs Remplissage Can be Employed in Skeletally Immature Patients-Operative Technique

Abstract

Background: Numerous studies indicate that glenoid bony augmentation raises the risk of complications during and after surgery. On the other hand, repairing the labrum alone in cases with subcritical glenoid bone loss results in recurrent instability and persistent apprehension. As a result, recent advancements in shoulder instability surgery prioritize fully restoring the anterior shoulder restraint.

Operative technique: A novel method for treating recurrent anterior shoulder instability with subcritical glenoid bone loss and off-track Hill-Sachs lesion in skeletally immature patients is suggested: the use of dynamic anterior stabilization technique incorporating the long head of the biceps tendon onto the anterior glenoid rim via trans-subscapular transfer, in conjunction with Hill-Sachs remplissage. A practical, step-by-step surgical technique for a complete reconstruction of the anterior capsule-labral-ligamentous complex is provided. This involves utilizing a soft-tissue dynamic anterior sling, achieved through the trans-subscapularis transfer of the long head of the biceps tendon at the glenoid level. The procedure concludes with a Hill-Sachs remplissage to further prevent off-track events and alleviate apprehension.

Conclusion: Dynamic anterior stabilization is a suitable approach for addressing recurring anterior shoulder instability in skeletally immature patients who have subcritical glenoid bone loss and bipolar bone lesions.

Keywords: Anterior shoulder instability; Bankart repair; Complications in shoulder instability procedures; Dynamic anterior stabilization; Glenoid bone loss; Remplissage.

FIGURE 1

(A) Sagittal oblique proton density (PD)—weighted sequence depicting the amount of anterior glenoid bone loss of 3.02 / 0.42 × 100% = 13% of bone loss. (B) T2—weighted axial sequence depicting a 1.38 cm Hill‐Sachs interval.

FIGURE 2

Step‐by‐step approach to performing dynamic anterior stabilization and Hill‐Sachs remplissage. (A) 360° arthroscopic evaluation identifies anterior disruption of the capsule‐labral complex extending to the inferior pole of the glenoid; (B) disruption of the capsule‐labrum complex can be seen at the inferior glenoid pole; (C) the anterior disruption of the inferior glenoid ligament can be identified; (D) a large Hill‐Sachs lesion can be seen and is debrided using a shaving device; (E) an all‐suture anchor is placed in the now debrided Hill‐Sachs defect in a transtendinous fashion; (F) a bird‐beak suture passer is used to pass each suture limb through the infraspinatus tendon; (G) final configuration of the Hill‐Sachs remplissage can be seen—parachute technique; (H) the repairability of the capsule‐labral complex is assessed using a grasper type instrument; (I) after assessing the repairability of the capsule‐labral complex an all‐suture anchor is placed at the 5 o'clock position and the labrum is repaired using classical Bankart repair technique; (J) before addressing the biceps tendon, the rotator interval is identified and opened but without disrupting the superior glen‐humeral ligament and anterior expansion of the rotator cable; (K) after opening the rotator interval the next step is to address the biceps tendon by releasing the transvers ligament and the rest of the biceps pulley until reaching the superior border of the pectoralis major muscle; (L) after completely releasing the biceps from its groove, a PDS suture (polyester poly p‐dioxanone) is percutaneously passed through the biceps tendon near its proximal end; (M) the PDS suture is used to shuttle a cut limb from the remplissage (economic option) and is used to create a 360° lasso loop around the biceps tendon; (N) the suture limbs of the 360° lasso loop wrapped around the biceps tendon are passed over the intact superior glen‐humeral ligament and anterior extension of the rotator cable and through the subscapularis tendon; (O) arthroscopic view from D portal, watching in front of the subscapularis: a switching stick is used to penetrate the subscapularis muscle through the posterior portal and a canulated obturator is used through the E portal to performs the subscapularis split; (P) once the canulated obturator has performed the subscapularis split, a shuttling wire is passed through it and grasped with a grasper through the posterior portal; (Q) after the shuttle wire is brought to the posterior portal its anterior end together with the 360° lasso‐loop wrapped around the biceps tendon are brought outside through the E portal, tied together and then the shuttling wire is used to pull the suture limbs through the posterior portal. While pulling the suture limbs, the biceps tendon is pushed synchronously with the grasper through the subscapularis so that the biceps tendon can penetrate the subscapularis muscle; (R) once passed through the subscapularis muscle, a tenodesis of the biceps tendon is performed as described; (S) after the biceps tenodesis, the first lasso‐loop around the capsule‐labral complex is tied; (T) the repairability of the superior labrum‐capsule complex is assessed; (U) the superior labrum‐capsule complex is deemed repairable and an all‐suture anchor is used together with a lasso‐loop using a bird‐beak suture passer; and (V) the final view shows a complete reconstruction of the anterior buttress composed of complete restoration of the labrum‐capsule complex together with the biceps tendon that serves as anterior sling and hammock.

FIGURE 3

Technique illustration: the long head of the biceps tendon is tenotomies from the superior glenoid rim and transferred at the anterior glenoid at the 3 o'clock position through a subscapularis split.