AANA Lab Course 1002 -3rd Annual Fellows/Chief Residents-Humeral-Based Management of Recurrent Instability-Timothy S. Leroux, M.D.

Humeral-Based Management of Recurrent Instability-Timothy S. Leroux, M.D.

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This presentation by Dr. Timothy Leroux discusses humeral-based management of recurrent shoulder instability, focusing on the role of Hill-Sachs defects. These defects, which involve compression fractures of the humeral head, are commonly present in recurrent instability cases and significantly contribute to the problem—100% of engaging Hill-Sachs lesions were associated with recurrent instability. Historically, such defects were classified by size (e.g., involvement of 20%, 20–40%, or 40% of the humeral articular surface), but this method has limitations due to detection challenges, with CT and MRI offering more reliable imaging than x-rays.<br /><br />A critical concept highlighted is the "glenoid track," which assesses the risk of engagement (defect catching on the glenoid rim during shoulder movement). Defects are classified as "on-track" (low risk of engagement) or "off-track" (high risk). This classification can be determined preoperatively or intraoperatively using CT or MRI and helps guide treatment decisions.<br /><br />One common surgical option for managing Hill-Sachs defects is arthroscopic remplissage ("to fill"), which involves filling the defect with soft tissue to prevent engagement. Techniques include posterior portal insertion of anchors into the defect, tying sutures under visualization, and a reported recurrence rate of only 5% at a two-year follow-up, with low complications and no significant motion loss.<br /><br />Large humeral defects (around 40%) present additional challenges. Moreover, humeral bone loss rarely occurs alone; concurrent glenoid bone loss affects the glenoid track and increases the complexity of management. Significant glenoid bone loss (>13.5%) alters the stability mechanics, and studies suggest no difference in outcomes when addressing bipolar bone loss compared to isolated defects.<br /><br />Overall, the management strategy emphasizes understanding the interplay between humeral and glenoid defects, utilizing imaging to assess risk, and applying surgical techniques like remplissage or other procedures tailored to defect size and engagement risk.

Keywords

humeral-based management

recurrent shoulder instability

Hill-Sachs defects

compression fractures

glenoid track

on-track lesions

off-track lesions

arthroscopic remplissage

glenoid bone loss

bipolar bone loss