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  • summary
  • Epidemiology
  • Etiology
    • Pathophysiology
      • mechanism of injury
        • anteriorly directed force on the arm when the shoulder is abducted and externally rotated
      • pathoanatomy
        • "on-track" versus "off-track" concept of Hill-Sachs lesion (instability as a bipolar concept)
          • Hill-Sachs defect is "off-track" and will "engage" on the glenoid if the size of the Hill-Sachs defect > glenoid articular track (HSI > GT)
            • Some find it helpful to conceptualize on-track and off-track lesions in the setting of a tire and a pothole. Imagine the glenoid (and glenoid track) as a tire, and the Hill-Sachs interval as a pothole. An off-track lesion is analogous to the tire falling into a pothole. This can occur in the setting of either marked glenoid bone loss or a very large Hill-Sachs.
          • conversely, the Hill-Sachs defect is "on track" and will NOT "engage" if the size of the Hill-Sachs defect < glenoid articular track (HSI < GT)
          • Glenoid Track (GT) = 0.83D-d (D = diameter of inferior glenoid, d = width of anterior glenoid bone loss)
          • Hill-Sachs Interval (HSI) = HS+BB (HS = width of the Hill-Sachs, BB = width of bony bridge)
          • may have implications regarding surgical management
            • goal is to convert on off-track lesion into an on-track lesion
    • Associated injuries
      • orthopaedic
        • labrum & cartilage Injuries
            • is an avulsion of the anterior labrum and anterior band of the IGHL from the anterior inferior glenoid.
            • is present in 80-90% of patients with TUBS
          • humeral avulsion of the glenohumeral ligament (HAGL)
            • occurs in patients slightly older than those with Bankart lesions
              • also found in female collegiate athletes
            • associated with a higher recurrence rate if not recognized and repaired
            • an indication for possible open surgical repair
          • glenoid labral articular defect (GLAD)
            • is a sheared off portion of articular cartilage along with the labrum
            • presence is a risk factor for failure following arthroscopic stabilization procedures
          • anterior labral periosteal sleeve avulsion (ALPSA)
            • can cause torn labrum to heal medially along the medial glenoid neck
            • associated with higher failure rates following arthroscopic repair
            • common finding in patients with recurrent instability managed nonoperatively
              • 97% of patients with recurrent instability have either a Bankart or ALPSA lesion
        • fractures & bone Defects
          • bony bankart lesion
            • is a fracture of the anterior inferior glenoid
            • present in up to 49% of patients with recurrent dislocations
            • higher risk of failure of arthroscopic treatment if not addressed
            • defect >20-25% is considered "critical bone loss" and is biomechanically highly unstable
              • stability cannot be restored with soft tissue stabilization alone (unacceptable >2/3 failure rate)
              • requires bony procedure to restore bone loss (Latarjet-Bristow, other sources of autograft or allograft)
              • recent studies suggest critical bone loss may be as low as 13.5%
              • each dislocation event causes, on average, 6.8% bone loss
              • glenoid takes on an inverted-pear appearance as bone loss increases
                • 89% failure rate following arthroscopic repair in patients with this glenoid morphology
          • Hill-Sachs defect
            • is a chondral impaction injury in the posterosuperior humeral head secondary to contact with the glenoid rim.
            • is present in 80%-100% of traumatic dislocations and 25% of traumatic subluxations
            • is not clinically significant unless it engages the glenoid
          • greater tuberosity fracture
            • is associated with anterior dislocation in patients > 50 years of age
            • increases risk of recurrence
          • lesser tuberosity fracture
            • is associated with posterior dislocations
        • nerve injuries
          • axillary nerve injury
            • is most often a transient neurapraxia of the axillary nerve
            • present in up to 5% of patients <ul style="font-family: Arial, Helvetica, sans-serif; font-size: medium;"> </ul>
        • rotator cuff tears
          • 30% of TUBS patients > 40 years of age
      • medical
        • global hyperlaxity (i.e. Ehlers-Danlos Syndrome, collagen disorders)
          • often associated with atraumatic instability
          • global hyperlaxity confers an odds ratio (OR) of 2.68 for the development of anterior shoulder instability
          • individuals with global hyperlaxity have a 3x higher rate of recurrent instability
        • patients with global hyperlaxity are less likely to develop capsulolabral lesions
  • Anatomy
  • Classification
  • Presentation
  • Imaging
  • Treatment
  • Techniques
  • Complications
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