Chapter 3 Instability

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CHAPTER 3 | Instability

FIGURE 3-31  3D CT scan. A: Posterior projection of the humerus shows a large Hill-Sachs lesion. B: En face view of the glenoid shows that there is ~20% loss of the inferior glenoid diameter.

We did not think that a meaningful arthroscopic exam- ination could be carried out with a locked subcora- coid dislocation, so we proceeded to perform an open reduction with open Latarjet reconstruction. Pearls, Pitfalls, and Decision-making: ■ With attempted closed reduction under C-arm, there was absolutely no motion of the humerus relative to the glenoid. It was obvious that closed reduction or arthroscopic-assisted closed reduction would not work. So we went straight to open reduction and Latarjet reconstruction through a deltopectoral inci- sion. Latarjet was deemed necessary because of the large amount of bipolar bone loss. ■ The subscapularis and anterior capsule were extremely tight, and the only way to reduce the shoulder was to take down the entire subscapularis and the anterior capsule from their humeral attachments. After fixation of the coracoid graft and reattachment of the capsule to the native glenoid, we repaired the lower half of the subscapularis to the humerus by passing it inferior to the coracoid graft. We repaired the upper half of the subscapularis to the humerus by passing it superior to the coracoid graft. Since we had detached the entire subscapularis in order to reduce the shoulder, we thought it was important to have an extremely secure

repair of the subscapularis to the humerus. Therefore, we repaired each half of the subscapularis to the humerus with a load-sharing rip-stop construct. ■ At 4 months post-op, the patient had full active and passive range of motion and excellent strength. His x-rays at 4 months post-op showed that the coracoid graft was beginning to show radiographic evidence of uniting to the anterior glenoid (Fig. 3-32). Remplissage The Off-track (Engaging) Hill-Sachs Lesion:When Is Remplissage Indicated? Most engaging Hill-Sachs lesions are associated with sig- nificant bone loss ( ≥ 25%) on the glenoid side. When that is the case, these off-track engaging Hill-Sachs lesions are adequately treated by Latarjet reconstruction and will no longer engage after such surgery. However, the surgeon sometimes encounters Hill-Sachs lesions that will engage the anterior glenoid rim even though there is not a significant glenoid bone loss (i.e., the glenoid bone loss is <25% of the inferior glenoid diam- eter). We call such lesions “off-track” Hill-Sachs lesions, 4 and we have found that they are best treated by a combined arthroscopic Bankart repair and arthroscopic remplissage (insetting of the capsule and rotator cuff tendon into the