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In This Article

  • Summary
  • Abstract
  • Introduction
  • Protocol
  • Results
  • Discussion
  • Disclosures
  • Acknowledgements
  • Materials
  • References
  • Reprints and Permissions

Summary

Here, we describe a modified technique for arthroscopy-assisted Remplissage and open Eden-Hybinette procedure for patients with failed Latarjet and off-tract Hill-Sachs lesions.

Abstract

This case report describes a 49-year-old former semi-professional judo player with recurrent right shoulder instability following his first dislocation in 2006. He underwent two unsuccessful arthroscopic Bankart repairs due to improper anchor positioning. In March 2020, an open Latarjet procedure was performed to address his ongoing instability, but he suffered another dislocation in January 2023 after a fall. Physical examination revealed a full range of motion, normal rotator cuff strength, and a positive apprehension test. X-rays showed a broken coracoid bone block, screw displacement, and a significant Hill-Sachs lesion. CT confirmed resorption of the previous coracoid graft and an off-track Hill-Sachs lesion. The patient underwent revision surgery, combining an arthroscopic-assisted Remplissage with an Eden-Hybinette procedure. One year postoperatively, the patient reported improved outcomes. Managing recurrent shoulder instability after failed surgeries is challenging. While the Latarjet procedure has a 10% recurrence rate, revision options such as distal tibial allograft and Eden-Hybinette procedures offer promising results. This case emphasizes the importance of combined surgical approaches and individualized treatment plans, particularly for patients with significant humeral bone loss, to enhance stability and reduce recurrent instability.

Introduction

Recurrent shoulder instability is a demanding condition, especially in patients with previous surgical interventions1,2,3. Soft tissue procedures such as Bankart repair, capsulorrhaphy, Remplissage, and bony procedures such as Eden-Hybinette4, Trillat5, Bristow6, and Latarjet procedure7,8,9,10 were developed. However, there are still reports for failed Latarjet procedure necessitating alternative revision surgical strategies11,12. This case study describes a patient with a failed Latarjet procedure managed with an arthroscopy-assisted Remplissage and open Eden-Hybinette procedure. The objective is to explore the details of surgical technique, rationale, and outcomes of this combined approach.

CASE PRESENTATION
A 49-year-old male, a previous semi-professional Judo player with an ISI score13 10 of 5, presented with recurrent right shoulder instability following his first-time dislocation in 2006 after a fall on the stairs. He underwent two failed arthroscopic Bankart repairs in 2006 and 2007 with an imperfect anchor position. Due to the unsolved condition, he underwent an open Latarjet procedure in March 2020. Figure 1 demonstrated the preoperative and postoperative X-ray following Latarjet procedure. In January 2023, the patient experienced another fall from multiple stairs, resulting in a dislocation of the right shoulder again.

Diagnosis, assessment, and plan
He returned to our outpatient clinic for follow-up. During the physical examination, he demonstrated a full shoulder range of motion (ROM), a normal strength of the rotator cuff, and no signs of scapular dyskinesis or hyperlaxity; all neurovascular exams were within normal limits. The apprehension test was positive, and the sulcus sign was grade 1. X-rays revealed a breakage of the coracoid bone block and screw displacement around the axillary pouch, and a huge Hill-Sachs lesion (HSL) (Figure 2A,B). The computer tomography (CT) imaging confirmed their resorption of the previous coracoid grafts and an off-track HSL as the size of the HSL was 44.5 units which is larger than the glenoid tract of 43.4 units (Figure 2C,D). Due to the repeated positive apprehension, the patient underwent revision surgery, which included an arthroscopy-assisted Remplissage procedure14 to address the HSL and open Eden-Hybinette procedure4 with autologous iliac crest grafting, secured with two cannulated screws. Loose screws from previous surgeries were removed.

Protocol

This study was approved by the Ethics Committee of our institution and informed consent was obtained from the patient.

  1. Put the patient in a beach chair position with an arm holder under general anesthesia and interscalene nerve block.
  2. Create posterior, posterolateral, anterior, and anterolateral portals with a No. 11 blade (Figure 3A).
  3. Perform a thorough arthroscopic exam with a 4-mm, 30-degree-angled arthroscope to define the location of the Hill-Sachs lesion from the anterior portal.
  4. Clean the subacromial bursae with a 5.5 mm shaver blades. Shuttle the arthroscope through the anterolateral portal to evaluate the size of the Hill-Sachs lesion intraarticularly (Figure 3B).
  5. Debride the exposed proximal humerus bone bed (Figure 3C).
  6. Insert an all-suture Y-Knot RC anchor at the deepest part of the Hill-Sachs lesion (Figure 3D).
  7. Make three mattress sutures by piercing the musculotendinous junction of the infraspinatus tendon with the birdbeak suture passer (Figure 3E).
    NOTE: Do not tie the knots until the completion of the open Eden-Hybinette procedure (Figure 3F).
  8. For the open Eden-Hybinette procedure, perform the deltopectoral approach along the previous wound.
    1. Define the subscapularis through the deltopectoral interval and split the lower third of the musculotendinous junction of the subscapularis.
    2. Vertically cut the capsule and expose the anterior glenoid.
    3. Remove previous loose screws (Figure 4A).
    4. Use a burr to create a flat bleeding surface on the anterior glenoid for graft placement.
    5. Harvest a 3 cm x 1 cm x 1.5 cm tricortical iliac crest autograft (Figure 4B,C) from a 5 cm incision
    6. Secure the tricortical iliac crest autograft with two 4.5 mm cannulated screws (Figure 4D).
    7. Confirm the graft is flush to the glenohumeral joint line under arthroscopy (Figure 4G).
  9. After the open procedure, tie the Remplissage knots.
  10. Introduce the arthroscope into the glenohumeral joint to confirm the filling of the Hill-Sachs lesion (Figure 3H).
  11. Make sure the tricortical iliac crest bone graft is flush with the anterior glenoid (Figure 3H).

2. Rehabilitation

  1. Immobilize the operated arm with a sling for the first 2-3 weeks.
  2. Instruct the patient to gradually resume activities as long as they do not trigger pain.
  3. Educate the patient on a home-based, self-rehabilitation exercises since the first postoperative day, followed by the protocol designed by a sports physician15.
  4. Allow return to sports and strengthening exercises by an experienced physiotherapist 3 months after surgery.

Results

One year postoperatively, the patient's reported outcomes showed significant improvements. The Oxford Shoulder Instability Score improved from 26 to 54, the QuickDASH score decreased from 63.6 to 11.4, and the WOSI score dropped from 78.4 to 15.1. One-year postoperative X-rays showed full incorporation of the bone graft without evidence of osteolysis (Figure 5A). A computer tomography scan was performed 12 months postoperatively to evaluate the bone union between the graft and host bone ...

Discussion

Decision-making following a failed Latarjet procedure
Numerous studies have confirmed the efficacy of the Latarjet procedure in treating recurrent anterior shoulder instability16. Despite the generally high success rates, there remains a possibility of recurrent instability following the procedure17,18,19. Previous research has reported recurrence and reoperation rates around 10%

Disclosures

The authors have no conflicts of interest to declare.

Acknowledgements

The authors gratefully thank the Taiwan Minister of Science and Technology and Linkou Chang Gung Memorial Hospital for the financial support of this study (Grant: MOST 111-2628-B-182A-016, NSTC112-2628-B-182A-002, CMRPG5K0092, CMRPG3M2032, CMRPG5K021, SMRPG3N0011)

Materials

NameCompanyCatalog NumberComments
4 mm, 30°-angled arthroscope Stryker Endoscopy, Michigan, USAFor arthroscopic visualization
4.5 mm cannulated screws Synthes, SwitzerlandFor graft fixation
5.5 mm shaver blades, DyonicsSmith & Nephew, Andover, MAFor arthroscopic debridement
Y-Knot RC all-suture anchor ConMed Linvatec, Largo, FLTriple-loaded all suture anchors. Increase the repair area of Remplissage procedure

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