Management of Shoulder Instability in Patients with Underlying Hyperlaxity

Rupp, Marco-Christopher; Rutledge, Joan C; Quinn, Patrick M.; Millett, Peter J.

doi:10.1007/s12178-023-09822-6

Cited by 6 publications

(1 citation statement)

References 134 publications

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“…The dynamic, 3-dimensional nature of anterior shoulder instability remains poorly understood. Significant gaps in understanding of bone morphology and soft tissue contributions exist and include, but are not limited to, bipolar instability in the medial-lateral axis (the DTD spectrum), 2 capsulolabral hyperlaxity, 4,34 Hill-Sachs size and capsulolabral laxity in relation to multiple dislocations, 9 Hill-Sachs angle and its relation to arm position at time of dislocation, 8,10 labral volume, 42 glenoid version, 27 glenoid concavity, 31,41,44 and motion-dependent dynamic stability from such contributions as labral concavity compression 28 and muscle imbalance. 32 Studies that have attempted to portray the Hill-Sachs lesion in all 3 dimensions have only successfully shown that larger and more medially positioned Hill-Sachs lesions pose greater risk of recurrent instability.…”

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confidence: 99%

Defining Critical Humeral Bone Loss: Inferior Craniocaudal Hill-Sachs Extension as Predictor of Recurrent Instability After Primary Arthroscopic Bankart Repair

Cong,

Charles,

Reddy

et al. 2024

Am J Sports Med

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Background: The glenoid track concept for shoulder instability primarily describes the medial-lateral relationship between a Hill-Sachs lesion and the glenoid. However, the Hill-Sachs position in the craniocaudal dimension has not been thoroughly studied. Hypothesis: Hill-Sachs lesions with greater inferior extension are associated with increased risk of recurrent instability after primary arthroscopic Bankart repair. Study Design: Case-control study; Level of evidence, 3. Methods: The authors performed a retrospective analysis of patients with on-track Hill-Sachs lesions who underwent primary arthroscopic Bankart repair (without remplissage) between 2007 and 2019 and had a minimum 2-year follow-up. Recurrent instability was defined as recurrent dislocation or subluxation after the index procedure. The craniocaudal position of the Hill-Sachs lesion was measured against the midhumeral axis on sagittal magnetic resonance imaging (MRI) using either a Hill-Sachs bisecting line through the humeral head center (sagittal midpoint angle [SMA], a measure of Hill-Sachs craniocaudal position) or a line tangent to the inferior Hill-Sachs edge (lower-edge angle [LEA], a measure of Hill-Sachs caudal extension). Univariate and multivariate regression were used to determine the predictive value of both SMA and LEA for recurrent instability. Results: In total, 176 patients were included with a mean age of 20.6 years, mean follow-up of 5.9 years, and contact sport participation of 69.3%. Of these patients, 42 (23.9%) experienced recurrent instability (30 dislocations, 12 subluxations) at a mean time of 1.7 years after surgery. Recurrent instability was found to be significantly associated with LEA >90° (ie, Hill-Sachs lesions extending below the humeral head equator), with an OR of 3.29 ( P = .022). SMA predicted recurrent instability to a lesser degree (OR, 2.22; P = .052). Post hoc evaluation demonstrated that LEA >90° predicted recurrent dislocations (subset of recurrent instability) with an OR of 4.80 ( P = .003). LEA and SMA were found to be collinear with Hill-Sachs interval and distance to dislocation, suggesting that greater LEA and SMA proportionally reflect lesion severity in both the craniocaudal and medial-lateral dimensions. Conclusion: Inferior extension of an otherwise on-track Hill-Sachs lesion is a highly predictive risk factor for recurrent instability after primary arthroscopic Bankart repair. Evaluation of Hill-Sachs extension below the humeral equator (inferior equatorial extension) on sagittal MRI is a clinically facile screening tool for higher-risk lesions with subcritical glenoid bone loss. This threshold for critical humeral bone loss may inform surgical stratification for procedures such as remplissage or other approaches for at-risk on-track lesions.

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