Diagnosis and Management of Humeral Head Bone Loss in Shoulder Instability

Abstract

Humeral head bone defects (Hill-Sachs lesions) are caused by anterior shoulder dislocation with impaction of the posterosuperior humeral head onto the anterior glenoid rim. Frequently, these bony lesions are associated with glenohumeral instability, and large lesions may contribute to recurrent instability after failure of a soft tissue repair. To improve outcomes and minimize the risk of persistent instability, a thorough understanding of the biomechanics of humeral bone loss is required. Detection and quantification of clinically relevant humeral head bone loss are performed through an accurate history, physical examination, and interpretation of imaging studies. The diagnosis and treatment options for reverse Hill-Sachs lesions are discussed, and the various treatment options for Hill-Sachs lesions are reviewed, including operative techniques to limit engagement of the deformity by soft tissue transfer, rotational osteotomy, bone grafting, or osteochondral transplantation.

Remplissage Versus Latarjet for Engaging Hill-Sachs Defects Without Substantial Glenoid Bone Loss: A Biomechanical Comparison

“…Generally, defects measuring less than 20% of humeral head width are adequately stabilized with an isolated soft tissue Bankart repair [7,19]. However, for defects measuring 20% to 40%, there are minimal comparative data on existing treatment options to support one over another [1,19,22]. The various procedures can be separated into two classes: anatomic procedures, which attempt to restore normal proximal humeral anatomy, and nonanatomic procedures, which attempt to limit engagement of the Hill-Sachs defect [1,19,21,22,27].…”

“…However, for defects measuring 20% to 40%, there are minimal comparative data on existing treatment options to support one over another [1,19,22]. The various procedures can be separated into two classes: anatomic procedures, which attempt to restore normal proximal humeral anatomy, and nonanatomic procedures, which attempt to limit engagement of the Hill-Sachs defect [1,19,21,22,27]. Of the nonanatomic procedures, proponents of remplissage favor this procedure because it can be done arthroscopically, heals predictably with minimal reported limitations on ROM, and is associated with success rates of up to 98% [2,22].…”

“…The various procedures can be separated into two classes: anatomic procedures, which attempt to restore normal proximal humeral anatomy, and nonanatomic procedures, which attempt to limit engagement of the Hill-Sachs defect [1,19,21,22,27]. Of the nonanatomic procedures, proponents of remplissage favor this procedure because it can be done arthroscopically, heals predictably with minimal reported limitations on ROM, and is associated with success rates of up to 98% [2,22]. On the other hand, proponents of the Latarjet procedure favor it because of the conferred triple effect, including restoration of the glenoid arc, providing a sling effect via the transferred conjoint tendon and subscapularis tensioning, and repairing the joint capsule with augmentation via the coracoacromial ligament, citing a success rate of up to 95% [5].…”

“…Transfer of the coracoid process to the anteroinferior glenoid rim extends the glenoid arc length, providing not only additional bony support but also a restrictive soft tissue sling effect that helps resist anterior translation of the humeral head [5,9,22]. By increasing the glenoid arc length, and subsequently the distance to the reconstructed anterior glenoid rim, greater external rotation and anterior translation are required before a defect can engage, reducing the frequency of glenohumeral dislocation [5].…”

Current concepts in the management of recurrent anterior gleno-humeral joint instability with bone loss

“…A trial of immobilization followed by physiotherapy focusing on dynamic shoulder stabilizers is warranted. In most individuals this will be a suitable management strategy, especially in the elderly and low demand patients [76] (Figure 1). …”