Recurrent anterior shoulder dislocation caused by a midsubstance complete capsular tear

BACKGROUND: A midsubstance complete capsular tear is one of the well-known causes of anterior glenohumeral instability. However, its prevalence and clinical picture have not been well elucidated. The purpose of this study was to examine the prevalence of isolated complete capsular tears and to assess the clinical features as well as the results of surgical treatment of recurrent anterior glenohumeral instability caused by such tears. METHODS: Three hundred and three shoulders underwent surgery to treat recurrent anterior glenohumeral instability at our institution during a five-year period. Twelve (4.0%) of these shoulders had an isolated complete capsular tear as the main pathological condition. Those twelve patients (nine male and three female) were the subjects of the present study. The average age at the time of the operation was twenty-five years. Patient age; the cause of the initial dislocation; the position of the arm at the initial dislocation; and the findings of the preoperative physical examination, of computed tomographic arthrography, and at surgery were assessed. Eleven patients underwent arthroscopic capsular repair, and one was treated with an open capsular repair. RESULTS: The twelve patients either did not have a Hill-Sachs lesion or had a chondral indentation-type of Hill-Sachs lesion. When assessed with arthrography, the Hill-Sachs lesions were small compared with those in shoulders with an isolated Bankart lesion and, interestingly, they were quite similar in size to those seen with humeral avulsion of the inferior glenohumeral ligament. The average Rowe score for the twelve patients improved from 30.4 points preoperatively to 90.4 points at an average of thirty-one months postoperatively. CONCLUSIONS: The prevalence of isolated complete capsular tears causing recurrent glenohumeral instability was 4.0% (twelve of 303). These tears were associated with either a small or no Hill-Sachs lesion. We believe that a complete capsular tear should be recognized as one of the essential lesions causing recurrent anterior shoulder dislocation. Arthroscopic examination and repair can provide effective treatment.     

Anterior Shoulder Instability Management: Indications,Techniques, and Outcomes

Anterior shoulder instability is common in young athletes. Male individuals younger than 20 years who are involved in contact sports are at particular risk of injury and recurrence. Essential imaging includes radiography and magnetic resonance imaging in all patients, with 3-dimensional computed tomography being helpful to evaluate glenoid bone loss and Hill-Sachs lesions. Evaluation of the glenoid track is essential to help determine appropriate treatment because off-track scenarios in which the Hill-Sachs width is greater than the glenoid width impart a risk of failure with isolated arthroscopic treatment. Associated injuries also must be evaluated, including bone loss, Hill-Sachs lesions, humeral avulsion of the glenohumeral ligament (HAGL), glenolabral articular disruption (GLAD), anterior labroligamentous periosteal sleeve avulsion (ALPSA), rotator cuff injury, other fractures, and axillary nerve injury. Optimal treatment continues to be debated. Conservative management with physical therapy for rotator cuff and periscapular strengthening can be attempted, with the addition of bracing if continued play is desired until the season’s conclusion. Surgical intervention is considered in patients with recurrent dislocations, glenoid bone loss, or large Hill-Sachs lesions or in young athletes involved in contact or high-risk sports. Treatment options include arthroscopic capsulolabral repair with at least 4 anchors if good tissue quality and no bone loss exist. Remplissage has been recommended by some surgeons if a large Hill-Sachs exists. Open repair is suggested in patients with a high number of recurrent dislocations without bone loss or in those who participate in high-risk sports. Coracoid transfer or the Latarjet procedure is suggested in patients with bone loss greater than 20%. Bone grafting for glenoid bone loss using autograft or allograft, such as distal tibial allograft, is recommended in patients with a failed Latarjet procedure or those with significant bone loss. Hill-Sachs lesion grafting may also be beneficial in those with large lesions that engage.     

Effect of bone loss in anterior shoulder instability

Anterior shoulder instability with bone loss can be a difficult problem to treat. It usually involves a component of either glenoid deficiency or a Hill-Sachs lesion. Recent data shows that soft tissue procedures alone are typically not adequate to provide stability to the shoulder. As such, numerous surgical procedures have been described to directly address these bony deficits. For glenoid defects, coracoid transfer and iliac crest bone block procedures are popular and effective. For humeral head defects, both remplissage and osteochondral allografts have decreased the rates of recurrent instability. Our review provides an overview of current literature addressing these treatment options and others for addressing bone loss complicating anterior glenohumeral instability.     

Double Hill-Sachs lesion: a report of two cases

Hill-Sachs lesions are common after anterior dislocation of the shoulder. We present two cases of uncommon double Hill-Sachs lesions composed of a typical Hill-Sachs lesion and an atypical extra compression fracture with a rim of normal cartilage in between. Both patients had two anterior shoulder dislocations before surgery. These case reports show that recurrent posttraumatic anterior glenohumeral dislocations can result in increased damage to the humeral cartilage.     

Management of Complex and Revision Anterior Shoulder Instability

Treatment of recurrent anterior shoulder instability has gained significant interest in recent years and involves evaluation of both glenoid and humeral sided bone loss. Decision making is more complex in patients with significant humeral or glenoid bone defects or in those who underwent previous instability surgery. Appropriate assessment of the glenoid track is necessary as “off track” lesions typically require treatments beyond arthroscopic labral repair alone. In those with significant humeral or glenoid sided bone loss, the authors recommend three-dimensional computed tomography in addition to magnetic resonance imaging for accurate evaluation. The Glenoid Track Instability Management Score is a useful guide to help direct treatment by using the glenoid track as well as other known risk factors for recurrence. In circumstances with significant glenoid bone loss, typically over 20%, a coracoid transfer such as the Latarjet is recommended. In patients that previously failed a coracoid transfer, the authors recommend a distal tibia allograft; however, distal clavicle and iliac crest autograft have also been reported to have high success rates. In those with large Hill-Sachs lesions, remplissage or bone grafting are recommended. An estimation of the postoperative glenoid track after glenoid bone augmentation is required for appropriate Hill-Sachs lesion treatment. The authors typically recommend against revision instability surgical treatment with arthroscopic repair alone.     

Capsular Tear in Line With the Inferior Glenohumeral Ligament: A Cause of Anterior Glenohumeral Instability in 2 Patients

Anterior glenohumeral instability typically involves lesions associated with the inferior glenohumeral ligament complex. Multiple lesions have been described in this setting, including Bankart, humeral avulsion of the inferior glenohumeral ligament complex, and mid-substance capsular tears. These lesions are indicative of the high-force traumatic nature of anterior shoulder dislocation. Two cases of recurrent anterior shoulder instability are presented with a capsular tear perpendicular to the usual orientation and not consistent to the amount of force involved in a dislocation. Arthroscopy revealed a capsular defect from the glenoid to the humeral head in the anterior inferior glenohumeral ligamentous complex in both. This lesion is an unusual circumstance, providing another pathology to include in the differential diagnosis of anterior glenohumeral instability.     

Combined arthroscopic-open procedure for the recurrent shoulder dislocation in a 74-year-old man with an irreparable massive rotator cuff tear and a large Hill-Sachs lesion

Large, engaging Hill-Sachs lesions can be one of causes for recurrent glenohumeral instability after initial anterior shoulder dislocation or Bankart repair for the torn anteroinferior labrum. However, there have been relatively few articles describing specific treatments for the humeral head defects. This article described a case of an alternative treatment for large Hill-Sachs lesion using the corticocancellous iliac autograft. The authors present a case of recurrent anterior shoulder dislocation, with a large humeral head defects, and an irreparable massive rotator cuff tear in a 74-year-old man. The size of this Hill-Sachs lesion was 2.7 × 2 cm with a depth of 1.2 cm. After arthroscopic anterior capsulolabral repair, a 3 × 2 cm semicircular graft was harvested from the inner table of anterior iliac crest, trimmed, and transplanted to the humeral defect by cancellous screw fixation. At his 2-year follow-up, the patient remained free of dislocation and apprehension. We recommend this technique as an alternative method for symptomatic patients with engaging Hill-Sachs lesion.     

Hill-Sachs reconstruction and repair using a synthetic scaffold

Dislocation of the shoulder joint is an unfortunate consequence of trauma to the shoulder girdle. It can occur in varying age groups with a complication of an impaction injury to the posterior aspect of the humeral head, termed a Hill-Sachs lesion. This can pose further problems leading to instability of the glenohumeral joint and recurrent dislocations. Varying surgical techniques have been developed to address this issue especially in young, active individuals. We describe another technique that can be used to treat Hill-Sachs lesions in patients with recurrent dislocations of the shoulder.     

Editorial Commentary: For Shoulder Hill-Sachs Lesion Remplissage,Medial Anchor Position Must Be Optimized to Achieve Stability Yet Minimize External Rotation Loss

An off-track Hill-Sachs lesion (HSL) is a significant risk factor for recurrent shoulder instability after arthroscopic Bankart repair. Bankart repair combined with remplissage can better restore shoulder stability versus isolated Bankart repair when treating a combined Bankart lesion and off-track HSL. However, remplissage may be nonanatomic and associated with limitation of shoulder external rotation (ER), especially when the arm is in a 90° shoulder abduction position. Excessive medial placement of remplissage anchors is associated with postoperative ER loss and increased glenohumeral cartilage degeneration. The use of 2 medial anchors results in lower articular forces. Thus, in patients with shoulder instability, we recommend using 2 remplissage anchors in those with a Bankart lesion plus an off-track HSL. The anchors should be placed medially to achieve stability—but not so medial as to result in postoperative stiffness and significant ER loss.     

The relationship between Hill-Sachs lesion and recurrent anterior shoulder dislocation

The relationship between the number of shoulder dislocations and the depth and percent of head involvement of the Hill-Sachs lesions was investigated in this study. Thirty patients with recurrent anterior dislocation of the shoulder were divided into three groups according to the numbers of dislocations they had presented: Group 1: 1 to 5 dislocations ; Group 2: 6 to 20; Group 3: over 20. The mean percentage of head involvement was 11.9% in the first group, 25.4% in the second group and 26% in the third group of patients with Hill-Sachs lesions. The average depth of the Hill-Sachs lesions was 4.14 mm in the first group, 5.13 mm in the second group and 4.38 mm in the third group. Based on these findings, it appears that there is a correlation between the number of dislocations and the extent and depth of the Hill-Sachs lesions. Surgical treatment should therefore be performed as early as possible in patients with recurrent anterior dislocation of the shoulder, in order to prevent progression of the Hill-Sachs lesion which can become by itself a cause of instability.     

Evolving Concept of Bipolar Bone Loss and the Hill-Sachs Lesion: From “Engaging/Non-Engaging” Lesion to “On-Track/Off-Track” Lesion

For anterior instability with glenoid bone loss comprising 25% or more of the inferior glenoid diameter (inverted-pear glenoid), the consensus of recent authors is that glenoid bone grafting should be performed. Although the engaging Hill-Sachs lesion has been recognized as a risk factor for recurrent anterior instability, there has been no generally accepted method for quantifying the Hill-Sachs lesion and then integrating that quantification into treatment recommendations, taking into account the geometric interplay of various sizes and various orientations of bipolar (humeral-sided plus glenoid-sided) bone loss. We have developed a method (both radiographic and arthroscopic) that uses the concept of the glenoid track to determine whether a Hill-Sachs lesion will engage the anterior glenoid rim, whether or not there is concomitant anterior glenoid bone loss. If the Hill-Sachs lesion engages, it is called an “off-track” Hill-Sachs lesion; if it does not engage, it is an “on-track” lesion. On the basis of our quantitative method, we have developed a treatment paradigm with specific surgical criteria for all patients with anterior instability, both with and without bipolar bone loss.     

Editorial Commentary: Management of First-Time Anterior Shoulder Instability Requires Risk Stratification and Surgery for Many,But Not All

The management of a patient with a first-time anterior shoulder dislocation has been the subject of longstanding debate among shoulder surgeons. A number of prognostic factors for recurrent instability have been proposed, including younger age, male sex, contact sports, and glenoid bone loss. Predictive tools and scores have been developed to assist in risk stratifying this patient population; however, no universally agreed upon, clinically validated algorithm exists. More recently, there has been emerging evidence favoring early surgical stabilization, as it has been shown to result in better overall outcomes compared with patients undergoing surgery following episodes of recurrent instability. With each subsequent dislocation or subluxation event, there is increased glenoid bone loss (and development of inverted-pear glenoid), a greater prevalence of engaging (i.e., off-track) Hill-Sachs lesions, more extensive labral tears, a greater risk of rotator cuff involvement (in the older patient), and increased plastic and/or permanent deformation, elongation, and compromise of the antero-inferior glenohumeral joint capsule and associated inferior glenohumeral ligament complex. Moreover, there is now sufficient evidence to suggest that recurrence comes at a cost, as it is a major risk factor for poor outcomes following arthroscopic stabilization. However, one risk is overtreatment, potentially exposing those individuals who would not have had another instability event due to an unnecessary procedure. We should continue to use the available evidence within the literature to help risk-stratify patients and develop an individualized treatment plan through a shared decision-making process with the patient.     

Traumatic Shoulder Dislocation With Combined Bankart Lesion and Humeral Avulsion of the Glenohumeral Ligament in a Professional Basketball Player: Three-Year Follow-up of Surgical Stabilization

Traumatic anterior shoulder instability has been well documented to have associated lesions such as a Bankart tear, humeral avulsion of the glenohumeral ligament (HAGL), Hill-Sachs lesion, fracture, and nerve injury. To our knowledge, the combined Bankart and HAGL injury in a single acute anterior shoulder dislocation has not yet been reported. We describe a traumatic first-time anterior-inferior shoulder dislocation in a professional basketball player with a combined Bankart and HAGL lesion. The patient underwent arthroscopic Bankart repair followed by open repair of the HAGL lesion with an open capsular shift reconstruction. At 3 years' follow-up, the patient had returned to an elite level of play, with an excellent outcome.     

Radiographic evaluation of the Hill-Sachs lesion in patients with recurrent anterior shoulder instability

The Hill-Sachs lesion is an important bony sign of previous anterior shoulder dislocation and instability. Using orthographic projection, we evaluated the Hill-Sachs lesion in 30 shoulders in 27 patients with recurrent anterior shoulder instability. This produced a clear and undistorted view of the posterolateral notch. For orthographic imaging, the patient was placed supine with the arm in 135 degrees of flexion and 15 degrees of internal rotation. The x-ray beam was angled vertically through the humeral head. The width and depth of the posterolateral notches were measured on the orthographic radiographs. The average posterolateral notch depths were 3.9 +/- 0.9 mm in the dislocation group and 2.1 +/- 1.0 mm in the subluxation group. A shallow Hill-Sachs lesion was indicative of a greater degree of anterior instability of the shoulder.     

Glenoid Avulsion of the Glenohumeral Ligaments as a Cause of Recurrent Anterior Shoulder Instability

Although the Bankart lesion is accepted as the primary pathology responsible for recurrent shoulder instability, recognition of other soft-tissue lesions has improved the surgical treatment for this common problem. Whereas humeral avulsion of the glenohumeral ligaments has been acknowledged as a cause of anterior shoulder instability, we have not found any reported cases of glenoid avulsion of the glenohumeral ligaments. We describe 3 cases of recurrent anterior shoulder instability due to glenoid avulsion of the glenohumeral ligaments. The avulsed ligaments were repaired to the labrum and glenoid, restoring the glenohumeral ligament–labral complex.     

Anterior shoulder instability with humeral avulsion of the glenohumeral ligament lesion

Humeral avulsion of the glenohumeral ligament (HAGL) is a rare lesion. The purpose of this study was to analyze the clinical manifestations of HAGL lesions in patients who underwent operative treatment for anterior shoulder instability. Six patients with HAGL lesions were studied. Four patients had an HAGL lesion associated with a Bankart lesion, and two had an isolated HAGL lesion. The range of motion at final follow-up showed a loss of 1 degree in forward flexion and of 15 degrees in external rotation. During an operation to treat anterior shoulder instability, a thorough examination for not only Bankart lesions but also other associated lesions, including an HAGL lesion, should be considered to lower the risk of redislocation. In repairing an HAGL lesion, the surgeon should keep in mind the possibility of a postoperative loss of external rotation and follow an active rehabilitation protocol to obtain successful results.     

Editorial Commentary: Remplissage Is Not Needed When Performing the Latarjet Procedure in the Setting of Off-Track Hill-Sachs Lesions: One of the Classics Continues to Get Better With Age (and Some Help From New Data)

The glenoid track paradigm has played a pivotal role in the development of a contemporary approach to shoulder stabilization surgery. A number of studies have validated the importance of bipolar bone loss in the pathogenesis of recurrent anterior shoulder instability and defined the limitations of soft tissue–based, arthroscopic surgical approaches. The glenoid track paradigm has also helped to clarify the indications for coracoid transfer procedures, although some question persists as to the necessity of addressing an “off-track” Hill-Sachs lesion with remplissage concurrently with the Latarjet procedure for large glenoid bone defects. The best available evidence would suggest that the Latarjet procedure can be expected to yield favorable clinical outcomes even in the setting of an off-track Hill-Sachs lesion, thereby obviating the necessity of concomitant remplissage for cases involving advanced degrees of bipolar bone loss.     

Risk factors for recurrence of shoulder instability after arthroscopic Bankart repair

BACKGROUND: The higher failure rates reported with arthroscopic stabilization of traumatic, recurrent anterior shoulder instability compared with open stabilization remain a concern. The purpose of this study was to evaluate the outcomes of arthroscopic Bankart repairs with the use of suture anchors and to identify risk factors related to postoperative recurrence of shoulder instability. METHODS: Ninety-one consecutive patients underwent arthroscopic stabilization for recurrent anterior traumatic shoulder instability. The mean age (and standard deviation) at the time of surgery was 26.4 +/- 5.4 years. Seventy-one patients were male. Seventy-nine patients were involved in sports (forty, in high-risk sports). Capsulolabral reattachment and capsule retensioning was performed with use of absorbable suture anchors (mean, 4.3 anchors; range, two to seven anchors). All patients were prospectively followed, and, at the time of the last review, the patients were examined and assessed functionally by independent observers. RESULTS: At a mean follow-up of thirty-six months, fourteen patients (15.3%) experienced recurrent instability: six sustained a frank dislocation and eight reported a subluxation. The mean delay to recurrence was 17.6 months. The risk of postoperative recurrence was significantly related to the presence of a bone defect, either on the glenoid side (a glenoid compression-fracture; p = 0.01) or on the humeral side (a large Hill-Sachs lesion; p = 0.05). By contrast, a glenoid separation-fracture was not associated with postoperative recurrent dislocation or subluxation. Recurrence of instability was significantly higher in patients with inferior shoulder hyperlaxity (p = 0.03) and/or anterior shoulder hyperlaxity (p = 0.01). On multivariate analysis, the presence of glenoid bone loss and inferior hyperlaxity led to a 75% recurrence rate (p < 0.001). Lastly, the number of suture-anchors was critical: patients who had three anchors or fewer were at higher risk for recurrent instability (p = 0.03). CONCLUSIONS: In the treatment of traumatic recurrent anterior shoulder instability, patients with bone loss or with shoulder hyperlaxity are at risk for recurrent instability after arthroscopic Bankart repair. At least four anchor points should be used to obtain secure shoulder stabilization.     

Is CT scan a predictor of instability in recurrent dislocation shoulder?

Purpose: Glenoid bone defect and the defect on the posterior-superior surface of the humerus “HillSachs lesion” are the commonly seen bony lesions in patients with recurrent dislocation shoulder. Computed tomography (CT) scan is considered as the best option in assessing the bony defects in the recurrent dislocation shoulder. The aim of this study was to assess the clinical and radiological corelation in the patients with recurrent dislocation shoulder. Methods: Forty-four patients of recurrent dislocation shoulder who were evaluated between January 2015 and December 2017 at a tertiary care center, clinically and radiologically using CT scan and meeting the inclusion criteria, were included. The correlation between the clinical history of the number of dislocations and the bone loss using CT scan was evaluated. Two sided statistical tests were performed at a significance level of a = 0.05. The analysis was conducted using IBM SPSS STATISTICS (version 22.0). Results: All the patients were male with mean age of 25.95 (SD ± 4.2) years were evaluated. Twenty-four patients sustained injury in sporting activities while 20 patients sustained injury in training. There were an average of 4.68 (SD ± 3.1, range 2-15, median 3) episodes of dislocation. Forty-one patients had the glenoid bone loss while 40 had the Hill-Sachs lesions. The mean glenoid width defect was 10.80% (range 0-27%) while the mean Hill-Sachs defect was 14.27 mm (range 0-26.6 mm). The mean area of bone loss of the glenoid surface was 10.81% (range 0-22.4%). The lesions were on track in 34 patients and off track in 10 patients. Conclusions: CT scan of the shoulder joint is an effective method for assessing the amount of bone loss. The number of dislocations are correlated significantly with off-track lesions and the amount of bone loss on the glenoid and Hill-Sachs lesion. The glenoid width bone loss of more than 9.80% or Hill-Sachs defect of more than 14.80 mm are the critical defects after which the frequency of dislocations increases.