This document discusses treatment options for bone defects in the glenoid and humeral head that can cause recurrent shoulder instability. It finds that humeral head (Hill-Sachs) defects occur in 65-93% of cases depending on the number of dislocations, while glenoid defects occur in 5-56% of cases. Treatment depends on the size and engagement of the defects. For large Hill-Sachs lesions, options include bone grafting, arthroplasty, or the remplissage procedure. For significant glenoid bone loss over 20-30%, options include soft tissue repair plus bone grafting or procedures like Bristow or Latarjet to add bone to the glenoid. The document advocates

1. Treatment of
Glenoid and Humeral Head
Bone Defects
in Shoulder Instability
Nikolaos Tzanakakis
Orthopedic Surgeon
2nd
Orthopedic Dept.
Center for Shoulder Arthroscopy
IASO General Hospital
Athens, Greece

2. Background
There is a well-recognized association between
osseous defects of the glenoid or humerus
and shoulder dislocation, which often leads to
recurrent instability.
Boileau P., J Bone Joint Surg Am. 2006 Aug;88(8):1755-63.
Lynch JR., J Shoulder Elbow Surg. 2009 Mar-Apr;18(2):317-28.
Burkhart SS., Instr Course Lect. 2009;58:323-36.
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3. Mechanism of Bone Defects
Hill-Sachs Glenoid bone
Loss
Normal Shoulder Bone contact
Dislocation
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4. Bone defects after anterior dislocation
(unpublished data, 125 patients)
Hill-Sachs &
Glen. Defect
Hill-Sachs &
No Glen. Defect
No Hill-Sachs &
No Glen. Defect
No Hill-Sachs &
Glen. Defect
23.6%
45.5%
30.1%
0.8%
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5. Bone Defects Frequency
 Hill-Sachs: 65-71% first dislocation
 Hill-Sachs: 93% recurrent dislocations
 Glenoid bone loss: 5-56% traumatic instability
 Possitive correlation between Number of
dislocations and depth/extend of the lesions
Lynch JR, J Shoulder Elbow Surg (2009) 18, 317-328
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6. Humeral Head
Bone Defect
(Hill-Sachs Lesion)
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7. Hill-Sachs Lesion
•Impression fracture of the
posterolateral humeral head
•Present up to 90% of anterior
dislocations and 25% of
anterior subluxations
(Calandra JJ, Arthroscopy1989;5:254)
•Reverse Hill-Sachs
(posterior dislocations)
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8. Hill-Sachs Arthroscopic Grading
 Grade I: defect in the articular surface
down to subchondral bone
 Grade II: includes the subchondral bone
 Grade III: large subchondral defect
Calandra et. Al, 1989
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9. Hill-Sachs Grading
 MINOR: Less than 20% of head
 MODERATE: 20-40% of head
 SEVERE: Greater than 40% of head
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10. Hill-Sachs Grading
Engaging
Non Engaging
Burkhart SS, De Beer JF : Arthroscopy 2003;19 : 732–739
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11. Hill-Sachs: Pre-Op evaluation
X-ray
CT
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12. Arthroscopic Evaluation
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13. Arthroscopic Evaluation
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14. Guidelines for Hill-Sachs Treatment
 Most Hill-Sachs lesions are small and don’t
require treatment
 Each lesion should be evaluated during surgery
 Treatment Required for:
- Lesions found to be engaging in a normal ROM
- Lesions representing >30%-40% of the
articular surface
Center for Shoulder
Arthroscopy
IASO GENERAL Hospital

15. Treatment Options for Hill-Sachs
 Humeral rotation osteotomy
(Weber BG, JBJS 1984;66A:1443)
 Hemiarthroplasty / TSA for patients >50y/o
(Flatow E, JSES 1993;12:1, 29)
 Humeral head grafting
(Gerber C, JBJS 1996;78A:376)
 Remplissage
(Wolf EM, Arthroscopy 2004;20(suppl1) :e14)
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16. Treatment Options for Hill-Sachs
 Humeral rotation osteotomy
(Weber BG, JBJS 1984;66A:1443)
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17. Humeral Head Grafting for Hill-Sachs
Bushnell BD, Creighton RA, Herring MM. Hybrid treatment
of engaging Hill-Sachs lesions: Arthroscopic capsulolabral
repair and limited posterior approach for bone-grafting. Tech
Shoulder Elbow Surg 2007;8:194-203.
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18. Trans-humeral head plasty
Re P, Gallo RA, Richmond JC. Transhumeral
head plasty for large Hill-Sachs lesions. Arthroscopy
2006;22:798.e1-798.e4
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19. Hemi-CAP
Raiss P, Aldinger PR, Kasten P, Rickert M, Loew M. Humeral
head resurfacing for fixed anterior glenohumeral dislocation.
Int Orthop 2007 Dec 19 [Epub ahead of print]
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20. “Remplissage” Technique
Eugene Wolf, 2004,Arthroscopy
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21. Arthroscopic Remplissage
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22. Glenoid
Bone Defects
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23. Background Knowledge
Considerable Glenoid defects
after shoulder dislocation
decrease the intrinsic
stability.
[Burkhart, De Beer, Itoi, Mologne]
In vitro, less forces need to
dislocate the shoulder.
[Burkhart SS. Arthroscopy, 2000]
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24. Types of Glenoid bone defects
Bony Bankart Attritional bone loss
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25. Glenoid Shape
a b
Normally:
a = b = 12mm
Huysmans PE, J Shoulder Elbow Surg 2006;15:759-763.www.shoulder.gr

26. Glenoid Bone Defect
Considerable
Glenoid Bone
Loss
a > b/2
“Inverted Pear”
a b
Loss of 8.6mm of anterior radius of glenoidLoss of 8.6mm of anterior radius of glenoid
at the level of the bare spot corresponds toat the level of the bare spot corresponds to
35% of the normal anteroposterior width35% of the normal anteroposterior width
Lo IK, Parten PM, Burkhart SS:
Arthroscopy 2004;20:169-174.www.shoulder.gr

27. Bare Spot
b a
% Bone Loss
Lo IK, Parten PM, Burkhart SS: The
inverted pear glenoid: An indicator of
significant glenoid bone loss.
Arthroscopy 2004;20:169-174.
a
ba
2
−
=
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28. Imaging Evaluation:
Pico Method (2D CT)
 Taverna et al. Pico Method 2D CT – measurement of glenoid
surface
 Critical Limit 25% loss of glenoid surface
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29. Imaging Evaluation:
Glenoid Index (3D CT)
 Glenoid Index in 3D CT scan of both shoulders
 Critical Limit Glenoid index 0.75
SS Burkhart Arthroscopy: Vol 24, No 4 (April), 2008: pp 376-382
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30. The Real Problem:
Large Glenoid bone defect
+ Large Hill-Sachs Lesion
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31. Treatment Options for Glenoid Defects
 Soft Tissue Repair
 Bone Grafting
 Bristow / Latarjet
 Open
 Arthroscopic
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32. Soft Tissue Repair
NOT A SIMPLE BANKART
REPAIR BUT:
 Labrum Mobilization
 ALPSA reduction
 Double loaded anchors
 Usually 3 anchors to
anterior rim
 Rotator Interval Closure
 Posterior Capsule
plication
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33. Autologous Grafting:
Eden-Hybbinette procedure
 Autologous Tricortical Iliac Crest Bone Graft
Warner JP Am. J. Sports Med. 2006; 34; 205
18%
recurrence
rate
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34. Bristow procedure
Young DC, Rockwood CA Jr. J Bone Joint Surg Am
1991;73:969-981.
Hovelius L,. J Shoulder Elbow Surg 2004;13:509-16.13.6%
recurrence
rate
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35. Latarjet procedure
Burkhart SS, De Beer JF, Barth JR, Cresswell T, Roberts C,
Richards DP. Arthroscopy 2007;23:1033-1041
3.4 - 14%
recurrence rate
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36. Bone Graft from Acromion
Mochizuki Y, Hachisuka H, Kashiwagi K, Oomae H, Yokoya
S, Ochi M. Arthroscopic autologous bone graft with arthroscopic
Bankart repair for a large bony defect lesion caused by
recurrent shoulder dislocation. Arthroscopy 2007;23:677.e1-
677.e4.
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37. Arthroscopic Bone Block
E.Taverna, et.al,Knee
Surg Sports Traumatol
Arthrosc (2008)
16:872–875
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38. Arthroscopic Latarjet
Lafosse L, Arthroscopy, Vol 23, No 11 (November), 2007: pp 1242.e1-1242.e5
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39. What is the critical
Glenoid Bone Defect?
Critical bone loss:
>20-30%
6.8 mm width of resection 21%
to total length of the glenoid -
substantial loss of stability
Cadaveric biomechanical study
Itoi,et.al. JBJS 2000
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40. Glenoid Bone Loss Algorithm
 <15% (0-3.5mm) Soft Tissue Repair
 15-(25)30% (5-6mm) Soft Tissue Repair +
Bony Bankart
Consider patient demands
 >(25)30% (6.5-8.6mm) Bone Grafting procedures
Piasecki et al. AAOS J17 (8): 482. (2009)
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41. Our Technique
 Typical Bankart Repair
 Labrum mobilization
(ALPSA repair)
 Double loaded anchors
 Tight knots
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42. Our Technique
 Remplissage
for large Hill-Sachs
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43. Our Technique
 Rotator Interval
Closure
 Posterior Capsule
Plication
Rehabilitation Protocol:
from early passive movements to
propioception and return to sports.
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44. Our Results
 Period: 1999-2004
 116 patients with anterior shoulder instability
 Arthroscopic Treatment
 At least 5 years follow-up (range 5-9.75 years)
 Hill-Sachs 78/116 67.2%
 Glenoid defect 36/116 31.0%
 Invetred pear 8/116 6.8%
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45. Our Results
 Recurrence rate: 7/116 6.03%
(2 MVA, 2 Sports, 1 Fall, 1 No Comply, 1 Minor Trauma)
6/7 re-operated arthroscopicaly – No recurrence yet
 Rowe-Zarins: Pre-Op 33 (15-80),Post-Op:95 (80-100)
 Satisfaction
 109/116 Very Satisfied 93.9%
 6/116 Satisfied 5.2%
 1/116 Did not answer 0.9%
 Return to work: 116/116 100%
 Return to sports: 45/116 38.8%
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46. Handball player: 23y, 1st
dislocation 21y,
total 3 Dislocations
Typical Bankart No Considerable Glen Defect
Hill-Sachs Typical Repair
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47. Typical Rehabilitation Program
…full return to sports 9 months later
…but 15 months after the operation….
Handball player: 23y, 1st
dislocation 21y,
Left shoulder, Total 3 Dislocations
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48. Handball player: 23y, 1st
dislocation 21y,
Left shoulder, Total 3 Dislocations
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49. Handball player: 25y,
15 months after first Bankart Repair
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50. HAGL repair
Handball player: 25y,
15 months after first Bankart Repair
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51. Conclusions
 Humeral Head bone loss (Hill-Sachs)
 Graft reconstruction
 Prosthetic replacement
 Remplissage
 Glenoid bone loss
 Soft Tissue Repair (more than a simple Bankart
repair)
 Bone Grafting (many methods)
 Bristow or Laterjet
 Open
 Arthroscopic
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52. Thank you for your attention
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