0:01

Let's talk about the dynamic examination

0:03

of the shoulder with a Hill-Sachs lesion.

0:07

I don't have a, I don't have a glenoid bone loss lesion here

0:10

yet, but let's look at prior to and after Bankart repair.

0:16

So here we are in the abduction external rotation position,

0:21

the midrange position, and the forward position.

0:25

The capsule is not attached, it's lax, it's a little bit

0:30

wavy, and as we go forward, the Hill-Sachs lesion engages

0:36

with the anterior glenoid, and produces a scenario

0:40

where there is high risk of repetitive dislocation.

0:44

So now we fix it.

0:46

We reattach the capsule to the

0:49

glenoid, and everything is just fine.

0:53

We're in the abduction external rotation

0:55

position where the capsule is taut.

0:58

Now we're in the midrange position.

1:01

We see a little bit more of our Hill-Sachs.

1:03

It's a pretty broad Hill-Sachs, but we still have a

1:06

reasonable repair, keeping everything in check.

1:12

And now, as we move forward, the Hill-Sachs engages the

1:17

anterior aspect of the glenoid, despite attachment and

1:23

still produces a higher risk of recurrent dislocation

1:29

despite the fact that this has been repaired.

1:34

So, there are again two techniques for assessing

1:37

whether your Bankart is going to be successful or not.

1:40

One is this dynamic technique where you bring the arm

1:43

back and forward and this one has some limitations.

1:50

Namely, that the arm You might not be

1:53

able to dislocate the shoulder in the OR.

1:55

R.

1:56

But in certain positions, due to this scenario, the

1:59

arm will still come out, despite the Bankart repair.

2:03

So what's the other option?

2:05

The other option is to measure the glenoid track.

2:09

And if the glenoid track measurements dictate that you

2:13

are off track and that you are at risk for engagement,

2:17

perhaps it's wiser not to just do a Bankart repair

2:24

With capsular reattachment, but to add another

2:28

procedure, like a Latarjet or a Latarjet Bristow.

2:32

And if that is unsuccessful, or if that is predicted

2:39

not to be successful by itself, you can add a third

2:43

stabilization procedure, which is humeral head remplissage.

2:48

In which you take the infraspinatus and sew it into the

2:51

humeral head defect, along with some capsular tissue.

2:55

Now, when would you consider proactively doing these

3:00

procedures without mechanically measuring the degree

3:04

of stability on physical examination or in the OR?

3:09

So, for on track, Hilsack's loss, or Hilsack's lesions, and

3:15

glenoid bone loss, bipolar lesions, if it's less than 25%,

3:19

in other words, the glenoid bone loss less than 25%, area.

3:26

And I would use the Knopfsinger technique for this.

3:29

Then a soft tissue repair is usually sufficient.

3:32

For on track Hillsex lesions and glenoid bone loss

3:36

that's greater than 25%, then the loss needs to be fixed.

3:43

So in other words, if you've lost more than 25

3:45

percent of the area on the Knopfsinger technique, You

3:49

should consider a capsular repair and a lit tar jay.

3:53

What's a lit tar jay?

3:54

You take the coracoid with, with its associated

3:59

muscular structures, which actually do contribute

4:02

to stabilization, and some capsule, and you

4:05

move it over to the anterior inferior glenoid.

4:08

Very similar to the old Bristow procedure,

4:11

where you took the tip of the coracoid, you

4:14

plunged it through the subscapularis, and you

4:16

hammered it into the anterior inferior glenoid.

4:21

So we're going to use predictive measurements before we

4:24

even do the procedure to decide what the procedure might be.

4:28

Now for off track Hill Sachs lesions and for glenoid

4:32

bone loss of less than 25% You may want to add a

4:39

humeral remplissage, where you take the infraspinatus

4:43

encapsule and sew it into the humeral head.

4:47

Now if the patient is a throwing athlete, who requires

4:50

full range of motion and external rotation, or a

4:54

collision athlete, with a very high risk of recurrence,

4:58

then a l'etarger procedure is probably essential in

5:03

those individuals since it can convert an off track

5:07

lesion to an on track lesion and it provides stability.

5:12

Now, what if you have an off track Hill Sax lesion

5:17

and greater than 25 percent area glenoid loss?

5:22

Then probably you have to go all in.

5:25

Capsular Repair, Liturgy, and Humoral Head Remplissage.

5:32

So why don't we stop right there and look at

5:35

some cases, if you have some time, following

5:38

these series of conceptual vignettes.