Review Question - QID 219887

Traumatic Anterior Shoulder Instability (TUBS) QID: 219887 (SBQ24SE.38)

QID 219887 (Type "219887" in App Search)

A 23-year-old man falls off a scaffold 15 feet high and sustains a right glenohumeral dislocation, which is promptly reduced in the emergency department. He is discharged, and subsequently sustains another dislocation which he self-reduces before following up in the orthopedic clinic. A selected CT cut is presented in Figure A. MRI of the right shoulder demonstrates an anterior labral tear. Which of the following treatment options is the best treatment option to prevent future dislocation?

Type & Select Correct Answer

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Physical therapy with an emphasis on scapular stabilization

27/478

Arthroscopic labral repair

13%

61/478

Arthroscopic labral repair and humeral remplissage

80%

384/478

Proximal humerus hemiarthroplasty

1/478

Thermal capsulorrhaphy

1/478

Select Answer to see Preferred Response

The patient presents with an anterior Bankart lesion and a medium to large Hill-Sachs lesion. The best treatment option to prevent future dislocation is an arthroscopic labral repair with humeral remplissage (Answer 3).

Anterior shoulder dislocation is a common injury that can lead to a posterosuperolateral humeral head compression fracture, also known as a Hill-Sachs lesion. This is caused by impaction on the anterior glenoid rim during dislocation. Additionally, this injury is most commonly sustained in conjunction with anterior labral tears (Bankart lesion) or bony injuries of the anterior glenoid (bony Bankart). The constellation of both Bankart and Hill-Sachs lesions (bipolar lesions) can result in diminished shoulder function and recurrent dislocation if left untreated. The main focus of surgical management of anterior shoulder instability revolves around addressing the glenoid lesion, but in the presence of a moderate to large-sized Hill-Sachs and small Bankart lesion, the humeral side defect must also be addressed. Options for addressing humeral-sided defects include open or arthroscopic remplissage (filling procedure), open capsular shift, allograft reconstruction, and hemiarthroplasty.

Valencia et al. review the management of humeral-sided defects in anterior shoulder instability. They also review the epidemiology, diagnosis, radiographic evaluation, and treatment of Hill-Sachs lesions and conclude that larger or engaging lesions require surgical management.

MacDonald et al. performed a randomized control trial of 108 patients with recurrent anterior shoulder instability and an engaging Hill-Sachs lesion. Patients were randomized to arthroscopic Bankart repair alone and arthroscopic Bankart repair combined with humeral head remplissage. At a mean follow-up of two years, they found that patients randomized to arthroscopic Bankart repair with humeral head remplissage had a decreased risk of recurrent dislocation and reoperation.

Figure A is an axial CT cut of the humeral head, demonstrating a moderate-sized Hill-Sachs lesion, with no bony glenoid involvement.

Incorrect Answers:
Answer 1: The patient has a moderate-sized Hill-Sachs lesion and recurrent instability and thus is indicated for operative management
Answer 2: Arthroscopic labral repair alone does not address the Hill-Sachs lesion and is associated with increased recurrent instability and revision rates
Answer 4: The patient does not have significant degenerative changes or a Hill-Sachs lesion >45% of the humeral articular surface, so arthroplasty is not indicated
Answer 5: Thermal capsulorrhaphy has a high failure rate and should be avoided in the modern treatment of shoulder instability