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Treatment of combined bone defects of the humeral head and glenoid: Combined arthroscopic and open technique


OVERVIEW

Chapter synopsis

Traumatic anterior dislocation of the glenohumeral joint is frequently associated with osseous injury, including glenoid bone loss and impaction fractures of the posterosuperior humeral head (Hill-Sachs lesion). Recognition of osseous defects is critical to preserve the balance of static and dynamic forces that maintain shoulder stability. Failure to recognize and adequately treat bone loss can lead to recurrent instability and poor clinical outcomes. This chapter focuses on a combined arthroscopic and open technique to address bipolar bone loss of the glenoid and humeral head to reduce the risk of recurrent instability and improve postoperative outcomes.

Important points

  • Multiple factors can contribute to glenohumeral instability; thus, it is important to perform a thorough history and comprehensive evaluation.

  • Computed tomography should be the primary diagnostic tool for assessing bony injury, including glenoid asymmetry, bony erosion, and humeral head impaction fractures.

  • The glenoid track illustrates the dynamic relationship between humeral head and glenoid bone loss and should be evaluated preoperatively by the treating surgeon. “Off-track” lesions decrease the articular arc of the joint and predispose to recurrent instability.

  • Anterior glenohumeral instability with substantial bipolar bone loss (>15 to 20% glenoid bone loss and engaging, off-track Hill-Sachs lesion) should be treated with combined procedures to address both the glenoid and humeral head.

Clinical/surgical pearls

Pearls

  • Preoperative three-dimensional computed tomography (CT) should be obtained to aid in surgical planning

  • Humeral head and glenoid bone defects should be thoroughly assessed through both anterior and posterior arthroscopic portals

  • Hill-Sachs remplissage preparation should be performed without tying knots to avoid both disruption to the repair and impaired exposure during the subsequent open Latarjet

  • Position the transferred coracoid process so that it sits flush with the anteroinferior glenoid rim before drilling

Clinical/surgical pitfalls

Pitfalls

  • Completing the remplissage in a shoulder position of excessive internal or external rotation

  • Lateralization of the transferred coracoid graft

  • Using screws of inappropriate length (too short or long) for fixation of the coracoid process

  • Combined arthroscopic remplissage plus open Latarjet to treat anterior glenohumeral instability should be avoided in patients with uncontrolled epilepsy, voluntary instability, subscapularis tear, or multidirectional instability with generalized ligamentous laxity

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