Combined All-arthroscopic Hill-Sachs Remplissage, Latarjet, and Bankart Repair in Patients With Bipolar Glenohumeral Bone Loss

Abstract

Patients presenting with recurrent shoulder instability and bipolar glenohumeral bone loss are at risk of failed standard soft-tissue repair techniques. Even isolated bony-stabilization procedures such as the Latarjet or remplissage technique may not provide sufficient stability in the face of combined bone loss. We use a combined all-arthroscopic remplissage, Latarjet, and Bankart repair for patients with significant combined glenohumeral bone loss and/or in the revision setting. This allows reconstruction of both the Hill-Sachs and glenoid bone defects and repair of the capsulolabral complex in a minimally invasive manner. Furthermore, the use of cortical-button fixation of the coracoid bone graft may reduce the risk of hardware-related complications while still achieving excellent bone union.

Anterior shoulder instability has classically been treated with open or arthroscopic soft-tissue Bankart repair, with failure rates between 3.4% and 35%.1, 2, 3, 4 Burkhart and De Beer⁵ highlighted the importance of glenohumeral bone defects when they identified a very high failure rate for soft-tissue repair in the presence of significant bone defects. What exactly constitutes a significant bone defect has been explored biomechanically.6, 7, 8 In the typical 3-o'clock location (in a right shoulder) of a glenoid lesion, Yamamoto et al.⁷ determined glenoid bone loss greater than 26% of the glenoid width was significant.⁹ The critical clinical threshold for glenoid bone loss has yet to be determined because some authors have found increased failure rates and lower functional outcomes after arthroscopic Bankart repair in patients with as low as 13.5% glenoid width loss.10, 11 Similar research has evaluated what constitutes a significant Hill-Sachs lesion; however, there is not yet a clear answer, with ranges of bone loss between 37.5% and 65% having been reported.8, 12

In the presence of significant glenoid bone loss, various bone-block methods have been used, most commonly the open Latarjet procedure.13, 14, 15 Recently, Boileau et al.¹⁶ have shown positive results of a guided, arthroscopic, cortical-button Latarjet technique. In the other setting of an isolated, large Hill-Sachs lesion, performance of a combined remplissage (infraspinatus capsulotenodesis) and anterior soft-tissue Bankart repair has yielded good results.17, 18 However, a patient may present with both significant glenoid and Hill-Sachs defects, which can have an additive effect on glenohumeral instability.¹⁹ The presence of an untreated Hill-Sachs defect in the setting of a Latarjet procedure has recently been found to be a risk factor for failure.20, 21 There is 1 previous case report describing an open Latarjet procedure combined with an arthroscopic remplissage with satisfactory results.²²

On the basis of clinical workup, our patients receive an instability severity index score to guide surgical management.²³ We further evaluate any glenohumeral bone loss with 2- and 3-dimensional computed tomography (Fig 1). If patients have an instability severity index score greater than 3 with both glenoid and humeral head bone loss, we have begun to perform a combined all-arthroscopic remplissage, Latarjet, and Bankart repair (Video 1). We also perform this technique in appropriate revision situations.

Fig 1.

(A) Preoperative sagittal computed tomography scan in a left shoulder showing significant glenoid bone loss (arrow). (B) Preoperative axial computed tomography scan showing a large Hill-Sachs bone defect (arrow). © 2017 Pascal Boileau. All Rights Reserved.

Surgical Technique

Positioning and Portal Location

General anesthesia and an interscalene block are used. The patient is positioned in the lazy beach-chair position (30°-40°), which may allow lower systemic blood pressure while maintaining cerebral perfusion (Fig 2A). Abduction of the arm is detrimental to the Latarjet procedure by bringing the axillary nerve into the operative field, and thus we recommend performing this procedure with the patient in the beach-chair position. The arm is placed in a mobile support (Spider Limb Positioner; Smith & Nephew, Andover, MA) without traction. A 70° arthroscope is used to enhance visualization of the anterior neck of the scapula and minimizes the need for extra portals because it has the capacity to view around acute angles. The procedure includes 6 steps: remplissage procedure; coracoid preparation, drilling, and osteotomy; glenoid preparation and anchor placement; subscapularis splitting and axillary nerve protection; coracoid transfer and fixation; and finally, Bankart repair.

Fig 2.

(A) Positioning of a left shoulder with the patient in the lazy beach-chair position (30°-40°) and a mobile arm support. (B) Anterior portals: The northwest portal (NW) is located at the anterolateral corner of the acromion. Relative to the coracoid, the north portal (N) is 1 fingerbreadth proximal and just medial; the south portal (S) is distal in the axillary fold; the west portal (W) is lateral to the conjoint tendon and midway between the northwest and south portals; and the east portal (E) (passing obliquely at 45° through the pectoralis major muscle) is 3 fingerbreadths medial to the conjoint tendon in line with the west portal. © 2017 Pascal Boileau. All Rights Reserved.

Through a standard posterior portal, a systematic inspection of the joint is performed. The first anterior (northwest) portal is used for intra-articular work; it is located on the skin at the anterolateral corner of the acromion. Four additional anterior portals (Fig 2B) will be created to complete the Latarjet procedure, on each side of the coracoid, as described by Boileau et al.¹⁶

Remplissage Procedure

We begin with the Hill-Sachs remplissage. The arm is flexed to 40° and its rotation optimized to present the Hill-Sachs defect. We use the arm positioner to translate the humeral head anteriorly and give excellent visualization of the Hill-Sachs lesion (Fig 3 A and B). The arthroscope can typically remain in the posterior portal because the 70° angle enhances appropriate visualization. Depending on patient anatomy, the arthroscope can be switched to the northwest portal to obtain another view of the defect. A spinal needle is centered over the Hill-Sachs lesion, and an accessory posterolateral portal is created 2 fingerbreadths lateral to the posterior viewing portal to allow orthogonal insertion of suture anchors (Fig 3A). A cannula is inserted intra-articularly, and a shaver is used to abrade the Hill-Sachs lesion. Two single-loaded anchors (SutureFix; Smith & Nephew) are inserted in the valley of the defect adjacent to the articular margin, 1 superior and 1 inferior (Fig 3B). The cannula is retracted into the subdeltoid space. A curved penetrating grasper is used to retrieve the inferior anchor suture (Fig 3C), followed by a straight penetrating grasper for the superior anchor suture. The humeral head is reduced, and the inferior sutures are tied in mattress fashion in the subdeltoid space, followed by the superior sutures, to complete the Hill-Sachs remplissage (Fig 3D).

Fig 3.

(A) The arm positioner is used to translate the humeral head anteriorly. (B) Arthroscopic view of left shoulder with arthroscope in posterior viewing portal: Anterior translation gives an excellent view of the Hill-Sachs defect from the posterior portal. Two anchors are inserted into the Hill-Sachs defect just lateral to the cartilage. (C) A penetrating tool is used to grasp 1 strand of the inferior suture anchor from the Hill-Sachs defect into the subdeltoid space. (D) As viewed through the posterior portal, the humeral head is reduced and the sutures are tied, filling the Hill-Sachs defect. © 2017 Pascal Boileau. All Rights Reserved.

Coracoid Preparation, Drilling, and Osteotomy

We maintain the arthroscope in the posterior viewing portal and transition smoothly to the Latarjet procedure without having to reposition the patient. By use of electrocautery through the northwest portal, the rotator interval is opened and the subscapularis is followed medially to the coracoid. During this time, the arm should be internally rotated to relax the subscapularis. The coracoid is dissected and the coracoacromial ligament released. The north portal is established just medial to the coracoid, and the pectoralis minor is released. The undersurface of the coracoid is flattened with a motorized rasp through the northwest portal (Fig 4A). The coracoid is drilled with a coracoid drill guide (Smith & Nephew), a polydioxanone suture is passed through the bone tunnel, and the coracoid peg button is shuttled in place (Fig 4B). Through the northwest portal, the coracoid undergoes osteotomy 1.5 to 2.0 cm from its tip (Fig 4C).

Fig 4.

(A) Motorized rasp through the northwest portal to flatten the inferior surface of the coracoid. (B) Coracoid drill guide inserted through the north portal used to reproducibly drill the coracoid 5 mm from the tip and medial and lateral aspects. (C) Coracoid osteotomy with an oscillating saw is performed through the northwest portal 15 to 20 mm from the tip of the coracoid. (D) Motorized rasp to flatten the anterior glenoid neck. (E) Insertion of a Bankart anchor at the 3-o'clock position (arrow). (F) Placement of the glenoid drill guide at the 5-o'clock position (in a right shoulder) along the glenoid face. © 2017 Pascal Boileau. All Rights Reserved.

Glenoid Preparation and Anchor Insertion

The labrum is released from the anterior glenoid neck, and a polydioxanone suture is placed through the labrum at the 5-o'clock position. The anterior glenoid neck is abraded to a flat surface using a motorized rasp and a suture anchor inserted at the 3-o'clock position to be used later for the Bankart repair (Fig 4 D and E).

Subscapularis Splitting and Axillary Nerve Protection

By use of switching sticks, the arthroscope is transferred to the northwest portal, the anterior glenoid neck preparation is confirmed, and a short half-pipe cannula is placed through the posterior portal. The glenoid drill guide (Smith & Nephew) is inserted over the cannula and placed flush with the glenoid face at the 5-o'clock position (Fig 4F). A switching stick retracts the labrum and subscapularis through the west portal, and the glenoid tunnel is drilled from posterior with a 2.8-mm K-wire (the outer sleeve is left in place to facilitate the cortical-button transfer later). The posterior subscapularis spreader replaces the glenoid drill guide and is pushed through the subscapularis muscle along the 5-o'clock position, at the inferior one-third junction of the subscapularis.

An anterior bursectomy is performed through the south portal to identify the “3 sisters” (anterior humeral circumflex vasculature), which are followed to the “2 brothers” (musculocutaneous and axillary nerves). The nerves are carefully protected with a nerve retractor, and the tip of the posterior spreader is slowly opened within the subscapularis muscle. The tendon is split from medial to lateral while the capsule is being preserved, and the anterior subscapularis spreader is inserted through the east portal with its tip medial to the posterior spreader (Smith & Nephew).

Coracoid Transfer and Fixation

By use of a suture retriever through the posterior sleeve, the cortical button and coracoid bone block are transferred through the subscapularis muscle and lie flush with the anterior glenoid neck. This fixation is made using 2 round, 6.5-mm, slightly convex titanium buttons, connecting with a loop of continuous suture, forming 4 parallel strands (Smith & Nephew). The glenoid cortical button is slid over the 4 white suture strands, a sliding-locking Nice knot is tied, and the button is advanced onto the posterior glenoid neck. A specific suture tensioner (Smith & Nephew) is used to increase bone compression to 100 N.

Bankart Repair

Using the previously placed glenoid anchor, we complete the labral repair, placing the bone block in an extra-articular position. Additional anchors can be inserted depending on the clinical situation and patient anatomy. The tensioning device is removed posteriorly, and 3 surgeon's knots are tied to complete the coracoid fixation.

Postoperative Management

Postoperative radiographs are taken to confirm the correct graft position, and follow-up computed tomography is performed to confirm Latarjet union (Fig 5). The patient is discharged from the hospital the same day or the day after surgery. The arm is strictly immobilized for 2 weeks in a neutral-rotation sling; this allows healing of the conjoint tendon in the muscular part of the subscapularis muscle and avoids postoperative loss of external rotation. Pendulum exercises start after 2 weeks (5 times a day, 5 minutes for each session). After 4 weeks, the sling is removed and formal rehabilitation with a physiotherapist is started. Swimming pool therapy is encouraged. No heavy lifting is allowed for the first 12 weeks. Return to all types of sports activities, including collision and contact-overhead sports, is allowed between 3 and 6 months postoperatively.

Fig 5.

(A) Postoperative sagittal computed tomography scan confirming subequatorial positioning and union of coracoid transfer. (B) Postoperative axial computed tomography scan confirming positioning of coracoid graft flush with articular surface. © 2017 Pascal Boileau. All Rights Reserved.

Discussion

In certain patients with bipolar glenohumeral bone loss and recurrent instability and/or failed previous stabilization procedures, both the glenoid- and humeral-sided bone lesions need to be addressed. A combined all-arthroscopic Hill-Sachs remplissage, Latarjet, and Bankart repair is an efficient method to address these patients (Table 1). There is no need to reposition the patient or make separate approaches, and the procedure progresses in a step-wise, streamlined manner. As shown previously, a guided approach allows safe and accurate placement of the coracoid bone graft and the ability to complete a Bankart repair placing the graft extra-articularly.¹⁶ Although overall the procedure is technically demanding, by identifying the anterior neurovascular bundle, the arthroscopic Latarjet procedure actually increases safety because of excellent direct visualization. Identification of the neurovascular bundle is facilitated by following the 3 sisters (anterior humeral circumflex vessels) to the 2 brothers (axillary and musculocutaneous nerves). Furthermore, the safety is maintained by controlling the arm position; abduction is contraindicated because it brings the axillary nerve into the surgical field (Table 2).

Table 1.

Advantages and Disadvantages of Combined Arthroscopic Remplissage, Latarjet, and Bankart Repair

Advantages

Ability to treat both glenoid- and humeral-sided bone lesions in a single arthroscopic procedure

No need to reposition patient

Ability to treat associated pathology (e.g., biceps or rotator cuff lesions)

Accurate bone graft positioning facilitated by arthroscopy

Safety of Latarjet procedure increased by excellent visualization of neurovascular structures

Disadvantages

Technically demanding (associated with learning curve)

Potential for loss of external rotation

Potential for prolonged surgical duration

Table 2.

Pearls for Successful Performance of Arthroscopic Remplissage, Latarjet, and Bankart Repair

Use of a 70° arthroscope allows a wide viewing angle.

A mobile arm holder can be used to anteriorly subluxate the humeral head while working posteriorly to perform Hill-Sachs remplissage (Fig 3A).

To limit loss of external rotation, during remplissage, the surgeon should take the infraspinatus and/or capsule more toward the humeral side than the glenoid side; a postoperative splint should be applied in neutral rotation to prevent the conjoint tendon from healing in the tendinous portion of the subscapularis.

The surgeon should internally rotate the arm when working in the subcoracoid recess to relax the subscapularis.

Abduction of the arm should be avoided because this can bring the axillary nerve into the field.

Yamamoto et al.²⁴ described the “glenoid track” theory in 2007 to help identify which Hill-Sachs lesions were significant, in that they were at high risk of “engaging” with the glenoid in a functional position of abduction and external rotation. This theory is currently being evaluated as a tool to integrate the relation between bipolar glenohumeral bone lesions and highlights the importance of combined lesions. In patients with even a 2-mm glenoid lesion and medium-sized Hill-Sachs defect, there is an additive and negative effect on stability.¹⁹ Mook et al.²⁰ evaluated the results of the open modified Latarjet procedure in bipolar bone lesions. In a case series of 38 patients, patients with “off-track” Hill-Sachs lesions were 4 times more likely to have failure of open Latarjet stabilization. Yang et al.²¹ compared patients undergoing a modified Latarjet procedure for an engaging Hill-Sachs lesion without or with significant glenoid bone loss (>25% glenoid surface area loss). Although there were similar recurrence rates between the 2 groups, patients with significant glenoid loss had worse Single Assessment Numeric Evaluation scores and rotator cuff strength postoperatively. In a cadaveric study, Patel et al.²⁵ evaluated the ability of the Latarjet procedure to stabilize the shoulder in the presence of a Hill-Sachs lesion. They noted that combined defects were stabilized by the Latarjet procedure with a Hill-Sachs lesion of up to 31% of the diameter; Hill-Sachs lesions greater than 31% were not sufficiently stabilized. A combined remplissage, Latarjet, and Bankart repair addresses both the glenoid- and humeral-sided bone defects, which should increase stability.

The combined all-arthroscopic remplissage, Latarjet, and Bankart procedure moves seamlessly from step to step, with no changes required for patient positioning between the remplissage and Latarjet procedures. It is a safe procedure because the neurovascular structures are directly identified and protected. Finally, for the Latarjet component, our drilling guide system allows parallel placement of a cortical button, as well as accurate positioning of the bone graft, and the button itself reduces hardware-related complications such as prominent screw heads and graft fracture. We believe the combined technique is an efficient solution for dealing with bipolar glenohumeral lesions while remaining minimally invasive (decreased bleeding, less postoperative pain, better cosmesis).

Supplementary Data

Video 1

Combined all-arthroscopic Hill-Sachs remplissage, Latarjet, and Bankart repair.