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Arthrosc Tech
Arthrosc Tech
Arthroscopy Techniques
2212-6287
Elsevier

S2212-6287(24)00154-3
10.1016/j.eats.2024.103045
103045
Technical Note
Shoulder
All-Arthroscopic Treatment of Combined Off-Track Hill-Sachs Lesions Using Interference Screw and Shoulder Glenoid Bone Defects Using Bone Grafting With Soft Fixation
Wu Yu-Mei B.S. a
Xiao Yi-Fan B.S. a
Meng Jia-Hao B.S. a
Xiong Yi-Lin M.D. a
Tang Hang B.S. a
Gao Shu-Guang M.D. gaoshuguang0341@csu.edu.cn
abcd∗
a Department of Orthopaedics, Xiangya Hospital, Central South University, Changsha, Hunan, China
b Hunan Key Laboratory of Joint Degeneration and Injury, Changsha, Hunan, China
c Hunan Engineering Research Center of Osteoarthritis, Changsha, Hunan, China
d National Clinical Research Center of Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, Hunan, China
∗ Address correspondence to Shu-Guang Gao, M.D., Department of Orthopaedics, Xiangya Hospital, Central South University, No. 87 Xiangya Road, Changsha, Hunan, China 410008. gaoshuguang0341@csu.edu.cn
28 5 2024
9 2024
28 5 2024
13 9 10304512 1 2024
3 4 2024
© 2024 The Authors
2024
https://creativecommons.org/licenses/by-nc-nd/4.0/ This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Bony changes such as glenoid bone defects and Hill-Sachs lesions are responsible for recurrent anterior shoulder dislocations. With the development of arthroscopic techniques as well as arthroscopic surgical instruments, arthroscopic repair of bony structures has become an important surgical procedure for the treatment of recurrent shoulder dislocation. In this Technical Note, we used screws to fill Hill-Sachs lesions and autologous iliac bone grafts combined with soft tissue to repair the glenoid bone defects. In the surgical procedures within the shoulder, all operations are done arthroscopically, are minimally invasive, and achieve the goal of repairing composite shoulder injuries.

Technique Video
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pmcDefects of the glenoid bone can easily cause recurrent dislocations of the shoulder, and 78% of patients with recurrent shoulder dislocations have glenoid bone loss.1 An increasing number of preoperative shoulder dislocations are most strongly associated with glenoid bone loss, Hill-Sachs lesions, and combined lesions.2 Surgical options for shoulder dislocation can be done arthroscopically or openly. Arthroscopic techniques such as Bankart repair are less damaging and have a quicker recovery, whereas open surgical options such as rostral bone transfer surgery or Latarjet and iliac bone grafting can also be done for severe injuries.3,4

Coracoid transfer or the Latarjet procedure is usually recommended for patients with greater than 20% bone loss.5 Autologous iliac bone grafting to fill glenoid labral defects is effective in preventing redislocation of the shoulder joint and can also be used in patients who could not be repaired by other surgical modalities.6, 7, 8

Hill-Sachs lesions are strongly associated with shoulder dislocations, and it is more likely that the shoulder will dislocate again if only the Bankart injury is repaired alone.1,9 The modalities used to deal with Hill-Sachs lesions are remplissage, bone graft, knotless tape bridge, and so on.10, 11, 12 In this Technical Note, we used interference screws to fill Hill-Sachs lesions and autologous iliac bone grafts combined with soft tissue to repair the glenoid bone defects and Bankart injury (Video 1, Table 1).Table 1 Tips and Main Surgical Procedure

Surgical Step	Tips and Pearls	Pitfalls	
Hill-Sachs lesions	Clean the surface of the posterior and joint capsule and the surface of the Hill-Sachs lesion.
Insert a 2-mm K-wire for positioning.
Enlarge the bone tunnel with an 8-mm drill and implant an interference screw.
Implant the second screw adjacent to the first screw in the same manner.	Controlling the depth of the drill is crucial, as drilling too deep or too shallow can potentially lead to redislocation or pain.
There is a definite learning curve for novice surgeons to learn this technique, and high-volume shoulder surgeons are much more comfortable with it.	
Graft preparation and fixation	Take the ilium from the affected side hip to create a bone block.
Extract the ilium from the affected hip to form a bone block.
Drill a central hole in the bone block and secure it to the ULTRABUTTON (Smith & Nephew) with reinforced sutures.
Drill a hole in the glenoid, secure the bone block onto it using sutures, and posteriorly fix with an ULTRABUTTON.	Soft tissues need to be isolated or cleaned thoroughly to facilitate the entry of the bone block.
If the bone block is inadequately secured, there is a risk of loosening or rotational displacement, leading to surgical failure.	
Bankart repair	Clear the scar tissue and thoroughly release the inferior capsulolabral complex.
Two anchors are placed at 3-o’clock and 5-o’clock positions in the direction of the glenoid.
Pass the sutures on the screw through the soft tissue covering the bone block and tie a knot.	The glenoid labrum should be adequately relieved prior to placement of the anchor nail or reset will be difficult.
Incomplete coverage of bone block.	

Patient Evaluation and Indications for Surgery

For patients with recurrent shoulder dislocations, computed tomography is the most effective test for evaluating bone defects, measuring the size of glenoid defects.5 In circumstances with significant glenoid bone loss, typically over 20%, a bone graft is recommended.4 Magnetic resonance imaging scans are more likely to detect soft tissue injuries like rotator cuff tears and Hill-Sachs lesions (Fig 1).Fig 1 On the patient’s left shoulder magnetic resonance image, a Hill-Sachs lesion (red arrow) as well as glenoid injury and defect (red circle) are seen.

Surgical Technique

Anesthesia and Patient Positioning

Patients are anesthetized with a combination of an interscalene nerve catheter and general anesthesia. Then, the patient is placed on the healthy side in the lateral position. The position employed is a posterior tilt of the body of approximately 30°. The shoulder is in 30° of abduction and 15° of forward flexion. A force of 10 kg is exerted to the distal end of the affected limb to pull the shoulder joint to gain room for surgical maneuvering.

Hill-Sachs Lesions Using Interference Screw

The posterior approach is established 2 cm medial and 2 cm inferior to the posterior border of the left acromion, and an 8.25-mm diameter corkscrew cannula (Smith & Nephew) is placed. An anterosuperior approach is established at the midpoint between the rostral eminence and the anterior angle of the acromion with a 7.0-mm diameter corkscrew cannula (Smith & Nephew) inserted, and then an anteroinferior approach is established 2 cm below the rostral eminence, with an 8.25-mm diameter corkscrew cannula (Smith & Nephew) inserted.

The joint cavity is explored from the anterosuperior approach, and a bone defect of approximately 4 cm in length is seen on the posterior-lateral aspect of the humeral head (Fig 2A). The synovium is cleaned using a shaver. A 2.0-mm K-wire is driven approximately 15 mm from the edge of the bone defect to serve as a guide, followed by an 8-mm-diameter drill to establish a 20-mm-deep bone channel (Fig 2B), and a screw (BIOSURE HA Screw, 8 × 30 mm; Smith & Nephew) is screwed into the channel. Another 2-mm K-wire is inserted about 12 mm from the edge of the first screw (Fig 2C), the corkscrew cannula of the posterior approach is removed, and another screw (BIOSURE HA Screw, 9 × 30 mm; Smith & Nephew) is implanted in the same way (Fig 2D). Then, the corkscrew cannula is inserted back into the posterior approach.Fig 2 (A) From the anterosuperior approach, a Hill-Sachs lesion of about 4 cm in length can be seen. (B) A 2.0-mm K-wire is driven approximately 15 mm from the edge of the bone defect to serve as a guide, followed by an 8-mm-diameter drill to establish a 20-mm-deep bone channel. (C) The 8-mm screw is implanted into the bone channel, leaving approximately 10 mm on the surface according to preoperative measurements. Another 2-mm K-wire is inserted about 12 mm from the edge of the first screw to be used as a locator for the second screw. (D) After enlarging the bone channel with a 9-mm-diameter drill, a 9-mm screw is implanted, leaving a surface length of approximately 10 mm. (The patient is positioned in the right lateral decubitus position, with observation conducted via the anterior superior approach to the left shoulder, while all maneuvers are performed through a posterior approach to the left shoulder.)

Graft Preparation

The skin is incised along the anterior iliac crest for approximately 5 cm. Any muscle and periosteum are removed from the graft. The bone block is taken out using an osteotome, polished, and shaped to create a rectangular bone block of approximately 20 × 15 × 12 mm in size. The hole is created with a 2.0-mm K-wire approximately 7 mm from the edge of the bone block, and the 4 holes in the center of the ULTRABUTTON (Smith & Nephew) are threaded through 2 high-strength sutures through the holes of the bone block. The skin incision at the anterior iliac crest can be sutured closed.

Graft Fixation

Adequate loosening of the anterior aspect of the glenoid is performed, and an arthroscopic burr is used to debride and decorticate the glenoid to create a flat surface. From the posterior approach, the posterior drill guide is placed between the humeral head and glenoid and tightened against the glenoid, and a 1-mm K-wire is punched through the lowermost locator hole as a guide (Fig 3). Next, a 4.5-mm drill is driven to widen the bony channel, and a 1-mm K-wire is removed. A 0-polydioxanone suture (0-PDS) is passed through the 4.5-mm drill and pulled out of the anteroinferior approach, the drill and the corkscrew cannula are removed, and the approach is expanded to 15 mm. Fingers can be used to separate the soft tissue around the bone block while pulling it in, and after seeing that the block fits the glenoid, an ULTRABUTTON (Smith & Nephew) is threaded in the glenoid from the posterior side to knot the sutures on the block to secure it. The bone block needs to fit snugly against the glenoid (Fig 4). The corkscrew cannula for the anteroinferior approach is then repositioned, and sutures may be utilized to secure the corkscrew cannula.Fig 3 We introduce a simple bone channel locator, the posterior drill guide. The posterior drill guide is placed between the humeral head and the glenoid from the posterior approach and pressed against the glenoid, and then a 1-mm-diameter K-wire (red arrow) is punched through the lowermost hole of the posterior drill guide as a guide pin. At this point, the guide pin is 7 mm from the surface of the glenoid. (The healthy side lateral position.)

Fig 4 (A-D) After placing the posterior drill guide from the posterior approach, a 1-mm K-wire is driven in as a guide, and then a 4.5-mm drill is used to enlarge the bone channel. The 0-polydioxanone suture is threaded into the 4.5-mm drill and then grasped out from the anterior-inferior approach using wire-grasping forceps, and finally the bone block is pulled close to tighten the glenoid labrum and secured using the ULTRABUTTON (Smith & Nephew). (The patient is positioned in the right lateral decubitus position, with observation conducted via the anterior superior approach to the left shoulder, positioning achieved using the posterior approach to the left shoulder, and passing through the bone block accomplished using the anterior inferior approach to the left shoulder.)

Bankart Repair

Two anchors (OSTEORAPTOP 2.9 suture anchor; Smith & Nephew) are implanted in the direction of the glenoid at 3-o’clock and 5-o’clock, the soft tissues are sutured using a suture hook with a 0-PDS thread through the soft tissues, and the capsule is sutured using a 0-PDS thread assisted by a suture on the anchors. The capsule should cover the bone mass as much as possible to achieve refixation. Before knotting the suture in the 5-o’clock position, it can be tied around the bone block and then knotted, which can prevent rotational displacement of the bone block (Fig 5). The shoulder should be moved to check that there will be no further dislocation, the joint cavity needs to be cleaned out, and the surgical incision should be sutured closed.Fig 5 Two anchors are implanted at 3-o’clock and 5-o’clock in the glenoid. The sutures on the anchors are tied with the capsule covering as much of the bone block as possible. The sutures in the 5-o’clock direction could be wrapped around the bone block to prevent rotational displacement of the bone block. (The patient is positioned in the right lateral decubitus position, with observation conducted via the anterior superior approach to the left shoulder, and all maneuvers performed from the anteroinferior approach to the left shoulder.)

Rehabilitation

The protocol of postoperative care and local immobilization should be personalized, usually requiring immobilization for 6 weeks. While the patient performs daily activities under control, the braking device can be temporarily removed but must not exceed 1 to 2 days. When removing the braking device, caution is needed to make sure not to extend or rotate the arms beyond the midline of the body. Starting from 6 weeks, active and resistance movements are allowed, while physical activity or sports can be carried only out after 6 months.

Discussion

For recurrent shoulder dislocation, numerous surgical options are available. For patients with glenoid defects exceeding 20%, bone grafting is typically employed as a treatment method.13 Avramidis et al.14 used an all-arthroscopic modified Eden-Hybinette procedure in patients with recurrent anterior shoulder instability and demonstrated excellent radiologic and clinical midterm outcomes. The fixation of the graft is a critical step for the success of the surgery. Li et al.15 demonstrated that both button fixation and screw fixation techniques can result in better clinical outcomes. In the article by Zhao et al.,16 patient outcomes were satisfactory following the all-arthroscopic modified Eden-Hybinette procedure using an autologous iliac crest grafting technique through a 1-tunnel fixation system with a double Endobutton. Autologous iliac bone grafts can also fail, such as multidirectional instability, subscapularis insufficiency, and voluntary dislocation attributed to schizoaffective disorder.8 Therefore, it is important to control the patient’s underlying disease in the perioperative period and to manage other injuries to the shoulder at the same time.

For Hill-Sachs lesions, most cases involve the use of remplissage, whereas bone grafting is employed when there is significant bone loss. Engel et al.17 achieved favorable outcomes using a bioabsorbable interference screw. In our Technical Note, interference screws were utilized to fill Hill-Sachs lesions, and autogenous iliac bone block grafting combined with screw fixation of soft tissue was used to repair bone defects in the glenoid and Bankart injury (Fig 6). A combination of methods was used to repair recurrent shoulder dislocations with complex injuries, effectively placing the shoulder for redislocation. On the other hand, our technique needs to be validated by long follow-up, and the cumbersome surgical steps and long surgical time are also areas for improvement (Table 2).Fig 6 The patient’s postoperative computed tomography and 3-dimensional reconstruction images of the left shoulder show that the glenoid (A, C) and the humeral head (B, D) are well filled (red circle).

Table 2 Advantages and Disadvantages

Advantages	Disadvantages	
Comprehensive repair of factors contributing to dislocation	High technical requirements for surgical operation	
Less invasive surgery
More secure fixation of bone fragments
Improved shoulder joint mobility	The surgical procedure is intricate and time-consuming	
Preoperative planning and the use of tools make the surgery more precise	The surgical cost is expensive	

Disclosures

The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: This work was supported by the 10.13039/501100001809 National Natural Science Foundation of China (No. 81672225, 81601941); the National Clinical Research Center for Geriatric Disorders, 10.13039/501100011790 Xiangya Hospital, Central South University (2021KFJJ06); and Hunan Provincial Natural Foundation of China (2021JJ30040). All authors (Y-M.W., Y-F.X., J-H.M., Y-L.X., H.T., S-G.G.) declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Supplementary Data

ICMJE author disclosure forms

Video 1

On the patient’s left shoulder magnetic resonance image, the Hill-Sachs lesion as well as glenoid injury and defect are seen. After anesthesia, the patient is placed in the lateral decubitus position on the healthy side. The posterior approach, anterosuperior approach, and anteroinferior approach are established in sequence, and the corkscrew cannula is inserted. From the anterosuperior approach into the joint cavity, Hill-Sachs lesions can be observed. First, the synovium and the defect surface are cleaned thoroughly. Then, a K-wire is used for positioning and 2 screws are implanted. The ilium is taken from the affected side hip joint to create a bone block. Holes are created, and 4 holes in the center of the ULTRABUTTON (Smith & Nephew) are threaded with 2 high-strength sutures through the bone block. Utilizing the posterior drill guide for precision from the posterior approach, a 1-mm K-wire and a 4.5-mm drill are sequentially inserted. The 0-polydioxanone suture (0-PDS) is then passed through the drill, pulling the bone graft toward the glenoid from the anteroinferior approach. Soft tissue around the bone block can be gently separated with fingers. Once the fit is confirmed, an ULTRABUTTON is threaded from the posterior side in the glenoid to secure the sutures on the block. Two anchors are placed at the 3-o’clock and 5-o’clock positions in the direction of the glenoid. Soft tissues are sutured using a suture hook with a 0-PDS thread, followed by capsule suturing with a 0-PDS thread assisted by anchors. To prevent rotational displacement of the bone block, the suture at 5-o’clock can be looped around the block before knotting. Shoulder movement is checked to ensure stability, and the joint is cleaned before closing the incision.

Y-M.W. and Y-F.X. contributed equally to this work.
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