Massive Hill-Sachs lesion (>25% volume of the humeral head) Management - rotational osteotomy - hemiarthroplasty - infraspinatus transfer - osteo-articular allograft - arthroscopic remplissage
J Shoulder Elbow Surg. 2007 Sep-Oct;16(5):649-56
Distance from the medial margin of the rotator cuff footprint to the medial margin of the Hill-Sachs lesion was measured.
Incision: 1 cm proximal to th e coracoid process and extended 8 cm distally toward the anterior axillary fold
Coracoid exposure with attached conjoined tendon & CA & CC ligaments Harvesting Coracoid graft from its base using angled saw blade Harvested graft with attached conjoined tendon
The figure of eight configuration allows for a better torsional orientation of the plate on the dorsal coracoid graft surface. This allows the plate to distribute its load evenly throughout the bone, avoiding any stress risers that may occur when only screws are used. This is the arthrex medial wedged profile plate with a thick medial border to provide medial tilt of graft during compression. There are 4 spikes which help in stabilisation of plate over graft. Its figure of 8 configuration gives torsional stability with even load distribution during compression. This shows excellent exposure of glenoid neck which was due to our incision being medial to coracoid, so no vigourous retraction ws required and this decreases the chances of neuro vascular injuries. The Mini-Plate medial wedge profile, under compression will allow the coracoid bone graft to be tilted medially. This is aimed at improving the bone match between the coracoid bone graft and the glenoid neck bone surface. Four spikes on the plate are designed to aid in the stabilization of the plate and the graft during surgical fixation (during the drilling of screw holes) and to …
Strengthening exercises ?
Mean interval between bankart and latarjet surgery- 18 months (range 12- 29 months)
Failure was associated with a traumatic episode in 8 patients, and a bone block complication( engaging Hill sach’s lesion in 7 patients and glenoid loss>25% in 9 patients) in 16 patients.
up mean forward elevation was 164.8 degree + 2.0 degree (range, 154 degree to 170 degree; loss of 3.1 degree) and external rotation with the arm at the side is 45.6 degree + 3.0 degree (range, 35 degree to 70 degree; loss of 6.4 degree).
The MEAN ASES was 52(pain, 29.6; function, 22.4) preoperatively which improved to 92.5 postoperatively (pain, 47.3; function, 45.3) p value < .05 The mean WOSI score was 34.76% (mean physical symptom score, 37%; mean sports and recreation score, 25%; mean lifestyle score, 50%; mean emotions score, 20%) preoperatively which improved to 76.84% postoperatively (mean physical symptom score, 79.10%; mean sports and recreation score, 68%; mean lifestyle score, 76%; mean emotions score, 60.50%). p value < .05.
H /O Arthroscopic Bankart repair 2 Years back No. of dislocation after surgery : 1 First Episode Before Sugery was :5 yrs back Last Episode Before surgery was : 3 months back
Results of Mini-Open Latarjet Procedure in Failed in Arthroscopic Bankart Repair-Dr. Rahul Kumar
Results Of Mini-Open Latarjet
Procedure In Failed Arthroscopic
– A Retrospective analysis
Dr Rahul Kumar
Sports Injury centre, Safdarjung Hospital
The authors have no financial conflicts to
Anterior shoulder instability is most common type of
Arthroscopic bankart repair has become the
procedure of choice of primary recurrent anterior
However, failures of stabilization can and do occur.
Recurrent instability after Bankart
repair is a difficult problem for both
the patient and treating physician.
• Open procedure: 10%
• Arthroscopic procedure:
CAUSES OF FAILURES
GLENOID BONE LOSS
- no bone loss 4% recurrence
- inverted pear 61% recurrence
(>25% Glenoid Bone loss)
Burkhart SS, De Beer JF. Traumatic Glenohumeral bone defects and their relationship to
failure of arthroscopic Bankart repairs: significance of the inverted-pear glenoid and the
humeralengaging Hill-Sachs lesion. Arthroscopy 2000;16:677-694.)
Humeral head bone defects
Engaging Hill sach’s lesion
Yamamoto at al. JSES 2007
mapped track of glenoid on
humeral head through
simulated motion started in
max ER Varied Abduction
from 0 degree to 60 degree.
Humeral head defect -
outside the glenoid
track - high risk for
Humeral head defect
– inside the track –
Non engaging ( IN-NE)
Developed and reported in 1954 using
Standard delto-pectoral approach
Transfers a large segment of the coracoid (2.5
to 3 cm in length) as bone graft to the anterior
inferior glenoid rim.
Latarjet M. Traitement de la luxation récidivante de l’épaule. Treatment of
recurrent dislocation of the shoulder. Lyon Chirurgical. 1954; 49:994–997.
Mini open Latarjet
Limited delto-pectoral approach
Skin incision: 1 cm above the tip
of the coracoid extending 4-5 cm
toward the axillary fold.
Slightly medial to coracoid, so
that anterior inferior glenoid
neck is exposed easily.
Materials and Methods
Study design: Retrospective study
Sample size : 24
Study period: June 2010 – May 2012
Inclusion criteria: Patients who had undergone arthroscopic
Bankart repair for recurrent anterior shoulder instability who
presented with persistent instability after surgery with positive
Exclusion Criteria: Primary latarjet procedures were excluded
from the study.
Clinical and radiological
• Size of Hill sach’s
• Glenoid Bone Loss
3D CT was
Post op Rehabilitation
Shoulder immobiliser upto 2 weeks
Shoulder pendulum exercises are started from
Passive abduction & forward elevation upto 900
and External rotation upto 300 is initiated from
3rd week after suture removal.
Minimum Follow up: 2 years
• AP view
• scapular Y view
• American shoulder and elbow score(ASES)
• Western Ontario shoulder instability score(WOSI).
Range of motion
• Loss of mean forward elevation
• Loss of external rotation
•Student’s T-test with statistical
significance set at p value < .05
All patients were Male.
Mean age of patients was 31.8 years (range: 21-37
The right shoulder was involved in 13 cases (54.17 %),
and the dominant arm was affected in 11 patients
Average glenoid bone loss was 21% as assessed by
three dimensional computed tomography (range ; 15-
CAUSE OF FAILURE
GLENOID BONE LOSS
HUMERAL HEAD DEFECT
RANGE OF MOTION
Loss of 3.1 degree
Loss of 6.4 degree
Shoulder pain was found in 6 patients (32%) (4
with mild pain and 2 with moderate pain)
One patient had hardware complication in terms of
screw backing out from the plate. The implant was
removed after 15 months of surgery.
One patient had superficial wound infection which
responded to irrigation and oral antibiotics.
POST OP ROM
• Flexion: 164.8
degree + 2.0
degree + 3.0
Burkhart and De
Allain et al
Burkhart S, De Beer J, Barth J, et al. Results of modified Latarjet reconstruction in patients with
anteroinferior instability and significant bone loss. . Arthroscopy.2007; 23(10):1033–1041. doi:
Allain J, Goutallier D, Glorion C. Long-term results of the latarjet procedure for the treatment of
anterior instability of the shoulder. Journal of Bone and Joint Surgery A. 1998; 80(6):841–852.
Redislocation & Subluxation
Our study Hill et al Allain et al Hovelius et al
26 mths 58 mths 14.3 yrs 15 yrs
Arthroscopic vs open Latarjet
There is superior stabilization effect of the
open Latarjet technique in the ABD
position(Abduction with neutral rotation)
- anterior capsular repair
In the ABER position, no difference
Johanna Schulze-Borges, Dr.Eng: Arthroscopy: Vol 29, No 4 (April), 2013: pp 630-637
Biomechanical Comparison of Open and Arthroscopic Latarjet Procedures:
Small sample size
Short follow up – effect of bone graft
on gleno-humeral degenerative
arthritis could not be assessed.
The mini-open Latarjet procedure provides satisfactory
outcome and stabilization in this extremely challenging
category of patients who present with dramatic bone
loss and failed soft tissue reconstruction.
We recommend this procedure for young active
patients with recurrent anterior inferior shoulder
instability even after Arthroscopic Bankart repair.