AANA Middle East Arthroscopy Master Course (International)-Bone Loss in Shoulder Instability

Bone Loss in Shoulder Instability

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This document discusses the evaluation and treatment of bone loss related to shoulder instability, focusing on the humeral Hill-Sachs lesion and glenoid bone loss. It highlights when standard soft tissue repair may be insufficient, particularly with larger bone defects. The key clinical challenge is distinguishing between engaging and non-engaging Hill-Sachs lesions, with involvement of 15-25% or more of the humeral head articular surface considered significant.<br /><br />Glenoid bone loss typically presents anterior-inferiorly, creating an "inverted pear" deformity. Defects on both the humeral and glenoid sides are additive in their destabilizing effect. The concept of the “Glenoid Track” is emphasized, whereby if the medial margin of the Hill-Sachs lesion extends more medially than this track (approximately 84% of the glenoid width), then soft tissue repair alone is likely to fail.<br /><br />Treatment options for glenoid bone loss include bone grafting procedures such as the Latarjet or iliac crest grafts, which increase the glenoid track. For humeral head defects, options range from fresh osteochondral allografts and resurfacing to metal implants. The document focuses in detail on Hill-Sachs “Remplissage,” an arthroscopic technique adapted from Connolly’s open procedure, which involves posterior capsulodesis and infraspinatus tenodesis to fill the Hill-Sachs lesion and prevent engagement. <br /><br />Remplissage is especially indicated for lower-demand patients with 15-25% Hill-Sachs lesions who do not require full external rotation and prefer less invasive surgery compared to bone grafting. The step-by-step technique involves four arthroscopic portals, lesion debridement, anchor insertion, suture management, and completion of anterior capsular repair.<br /><br />The choice of treatment is guided by patient demand: high-demand younger athletes with significant bone loss often require bony reconstruction like Latarjet or osteoarticular allografts, while low-demand older or non-contact patients may benefit from remplissage or resurfacing. Revision surgery strategies are also discussed.<br /><br />In summary, careful evaluation of bone loss magnitude and patient activity level dictate whether soft tissue repair, remplissage, bone grafting, or resurfacing best addresses shoulder instability with glenohumeral bone loss.

Keywords

shoulder instability

Hill-Sachs lesion

glenoid bone loss

engaging lesion

Glenoid Track

Latarjet procedure

bone grafting

Remplissage technique

arthroscopic surgery

shoulder instability treatment