Arthroscopic Latarjet

The location and size of the Hill-Sachs lesion determines whether the articular arc is reduced and whether this will engage on the glenoid. A dynamic arthroscopy with the shoulder in abduction and external rotation will demonstrate whether the lesion is engaging during an athletic overhead range of movement. A bone-block procedure will increase the arc of the anterior glenoid, thereby increasing the degree of external rotation that can be achieved before the lesion approaches the glenoid rim. An alternative to this would be the infraspinatus and posterior capsule remplissage (French for ‘‘to fill in’’) procedure, as described by Purchase et al.5 We consider that by enlarging the glenoid articular arc with a bone graft, there is no increased joint contact pressure during external rotation. A remplissage can lead to a decrease in the external rotation and give rise to increased contact forces on the articular cartilage during external rotation.

These two lesions usually occur in tandem with varying degrees of severity. Preoperative x-ray images and CT scans usually detect the lesions, but arthroscopic dynamic evaluation of stability is necessary to determine the likely clinical effects of this combination.

HAGL lesions can be diagnosed on preoperative CT, arthrograms or MRI; however, these injuries are often not discovered until the initial arthroscopic evaluation.

Numerous techniques are described for the arthroscopic repair of HAGL lesions, but most case series are small with only short follow-up periods. Our experience using an all-arthroscopic soft-tissue repair technique with anchors has been disappointing due to the postoperative stiffness experienced by some patients. Furthermore, the intrinsic structure of the glenohumeral ligaments is usually deranged in patients with multiple dislocations, although this may not be evident macroscopically. Simply repairing this damaged tissue to the glenoid does not restore stability to the shoulder. This has been likened to rehanging a baggy or incompetent hammock.

This initial procedure may fail acutely for any of the previously mentioned reasons; however, we also have found a second group of patients in whom the Bankart repairs appeared successful but who presented with recurrent instability 5 to 7 years postoperatively. In this subgroup, the joint was not sufficiently stabilized initially, but it does allow for functioning of a more sedentary lifestyle without overt symptoms of instability. This can partly explain the excellent results seen in series with a short follow-up. Although the initial operations were considered successful in these patients, the pathologic lesions were never truly corrected and the glenoid subsequently becomes increasingly eroded. These patients can be effectively managed with a bone-block ligamentoplasty.