Anterior Shoulder Instability: Pre- and Postoperative Imaging

• Abstract
• Soft Tissue Stabilizer Anatomy and Function
• Preoperative Soft Tissue Injuries
• Glenoid-Sided LLC Injuries
• Humeral Avulsion of the Glenohumeral Ligament
• Postoperative Soft Tissue Repairs
• Labral Repair and Postoperative Labrum
• Postoperative Humeral Avulsion of the Glenohumeral Ligament
• Capsulorrhaphy
• Imaging Techniques for Soft Tissue Injuries
• Preoperative Bone
• Glenoid Bone Loss
• Hill-Sachs Lesion
• The Glenoid Track
• Postoperative Bone
• Glenoid Augmentation
• Remplissage
• Older Patients
• Conclusion
• References

Abstract

Treatment algorithms for anterior glenohumeral instability are evolving. Identification of soft tissue injuries remains important because stand-alone labrum and ligament repairs are a mainstay of primary intervention. Increasingly recognized is the importance of bone lesions, particularly the synergistic effects of bipolar bone loss in the glenoid track model. Accordingly, reporting and measurement of bone lesions is crucial to treatment planning, especially in patients with a failed Bankart repair. This review covers (1) anatomy related to anterior shoulder instability, (2) preoperative imaging assessment of soft tissue injuries, (3) postoperative imaging assessment of soft tissue injuries, (4) imaging techniques for soft tissue injuries, (5) preoperative imaging of bone injuries, and (6) postoperative imaging of bone injuries.

Traumatic anterior shoulder instability refers to a condition where the shoulder joint becomes unstable due to a traumatic event, typically with the arm in the abducted, externally rotated position. This scenario is frequently seen in contact sports, such as football, wrestling, and ice hockey. It should not be confused with multidirectional instability that results from supraphysiologic generalized laxity and presents with instability in multiple planes. Differentiating between these two distinct clinical entities is crucial because the treatment algorithm for each is substantially different.

Initial management of traumatic anterior shoulder instability is to reduce the shoulder joint. After reduction, radiographs should be obtained to ensure concentric reduction and to evaluate for fractures. Subsequent work-up with magnetic resonance imaging (MRI) can identify injuries to the labrum, capsule, ligaments, and bone. In the acute setting, hemarthrosis may act as a contrast agent, helping identify minimally displaced labral tears and capsular/ligamentous injuries. In the chronic setting, magnetic resonance arthrography (MRA) may be more sensitive for soft tissue injuries.[1] Computed tomography (CT) and MRI may both be used to identify and quantify glenoid bone loss and Hill-Sachs lesions.

The goal of treatment is to reduce the risk of subsequent dislocation and further joint damage. The patient's age, activity level, sporting interests, and imaging findings help determine the risk of subsequent dislocation and guide treatment recommendations.[2] The presence and size of glenoid bone lesions, including acute fractures and chronic bone loss, are the first imaging variables considered in a modern treatment algorithm because a critical amount of glenoid bone loss is a contraindication to a Bankart repair.[3]

The width and location of Hill-Sachs lesions is another crucial imaging variable. Its synergistic interaction with glenoid bone loss is increasingly recognized with the glenoid track model.[4] [5] Soft tissue injuries to the anterior labroligamentous complex (LLC) and inferior glenohumeral ligament (IGHL) complex are also relevant. Humeral avulsion of the glenohumeral ligament (HAGL) is a particularly essential soft tissue injury to identify preoperatively. It requires different patient positioning, surgical equipment, and implants. Combining patient characteristics with these imaging findings help determine the best treatment option.

Soft Tissue Stabilizer Anatomy and Function

The glenohumeral joint is the most mobile diarthrodial joint, and therefore adequate static and dynamic stabilization is most important for function. The glenoid fossa is relatively shallow and small, allowing for greater range of motion but providing less stability. The labrum and glenohumeral ligaments are key static stabilizers, together referred to as the labroligamentous complex (LLC). Dynamic support is provided by the rotator cuff, biceps, and deltoid muscles. The rotator cuff compresses the humeral head into the glenoid throughout the range of motion. The LLC contains mechanoreceptors that provide proprioceptive feedback to these muscles that is crucial to coordinate stabilizing activity.[6]

The labrum is a fibrocartilaginous ring that circumscribes the glenoid. The labrum functions to deepen the concavity of the glenoid and increase the contact surface area of the glenoid and humeral head. These features improve force distribution across the joint and resist translational forces, both directly by a concavity-compression, or “chock block” mechanism, and indirectly by vacuum seal, or a “suction cup effect.”[7] [8] Labral resection reduces resistance to translation by 20%.[8] The labrum also typically provides the scapular attachment for the middle and inferior glenohumeral ligaments.

The three major glenohumeral ligaments are described as superior, middle, and inferior. This last type is better referred to as the inferior glenohumeral ligament (IGHL) complex, composed of an anterior band (aIGHL), a posterior band, and the intervening axillary pouch. Each of these ligaments restricts external rotation and anteroinferior translation of the joint to different degrees, depending on the degree of arm abduction.[9] The superior glenohumeral ligament extends from the supraglenoid tubercle to the superior aspect of the lessor tuberosity and provides stability with the arm substantially adducted. The middle glenohumeral ligament extends from the anterosuperior glenoid neck and labrum to the lesser tuberosity and provides stability with the arm abducted up to 90 degrees. The middle glenohumeral ligament has multiple variants and may be absent.

The IGHL complex provides greatest stability with the arm abducted at 90 degrees. Moreover, the aIGHL is taut when the arm is in the abduction and external rotation (ABER) position, with the hand overhead. The aIGHL usually inserts directly into the labrum but may insert along the scapular neck, separate from the labrum.[10] The aIGHL most commonly attaches at the 4 o'clock position but may attach anywhere from 3 to 5 o'clock.[10] On the humeral side, the IGHL complex has a collar-like attachment to the anatomical neck of the humerus.

Preoperative Soft Tissue Injuries

The anteroinferior portion of the LLC, including the labrum and IGHL complex, is crucial for anterior shoulder stability. Hyperabduction and external rotation injury with or without joint dislocation may damage these structures. Injuries are categorized as glenoid-sided, midsubstance, or humeral-sided with numerous subtypes of lesions named as acronyms and eponyms ([Table 1]). The most essential information for the surgeon is whether a soft tissue lesion is glenoid-sided or HAGL because these require different surgical approaches.

Glenoid-Sided LLC Injuries

Most injuries occur on the glenoid side of the LLC ([Fig. 1]). It is important to understand the common injury patterns categorized in [Table 1], but fitting an LLC injury into a particular category is not crucial for preoperative treatment planning. A descriptive approach to LLC injuries is a common and acceptable method for reporting.

Perthes lesions are named after Dr. Georg Clemens Perthes, who first described the lesion in 1905. They are the mildest type of LLC avulsion injury and characterized by labral detachment with or without partial stripping of the adjacent scapular periosteum. Waldt et al found 17.9% of patients with acute instability and 4% of patients with chronic instability to have Perthes lesions at arthroscopy.[11] Perthes lesions can be difficult to visualize with MRI because the torn labrum may remain in the normal position. Detection is essential, however, because the stabilizing function is lost.[12] Imaging in the ABER position improves detection of the unstable labrum by putting the aIGHL under tension.[12] [13] Wischer et al[12] found that half of Perthes lesions were only visible in the ABER position on MRA. Similarly, Tian et al demonstrated that MRA in the ABER position revealed Perthes lesions in 66.7 to 74.4% of arthroscopically confirmed cases, compared with a detection rate of 35.9 to 40% with the arm in the neutral position.[13]

In an anterior labral periosteal sleeve avulsion (ALPSA) lesion, there is more extensive injury of the aIGHL than in a Perthes lesion, and there is medial displacement of the labrum into a sleeve of stripped scapular neck periosteum ([Fig. 2]). Over time, the labrum may become scarred along the scapular neck, making it possibly difficult to find on arthroscopy. Medially displaced labral tissue is an essential piece of information for the arthroscopist, who may potentially overlook this available tissue when performing the LLC repair. Waldt et al found 12.5% of patients with acute anterior instability and 31% of patients with chronic instability had ALPSA lesions at arthroscopy.[11] ALPSA lesions are better defined from Bankart lesions on MRA than MRI because the periosteum can easily be seen as intact.[14]

Several studies found that a routine adducted arm position during MRA is effective to diagnose ALPSA lesions and the ABER position imaging is less so.[13] [15] This finding is likely due to the ABER position reducing the stripped periosteum by tightening the anterior capsule. Conversely, by putting the arm into adduction internal rotation (ADIR) with the hand behind the back, Song et al found improved sensitivity for ALPSA lesions compared with routine and ABER positions.[15] During arthrography, the ADIR position generates greater distension of the anterior capsule by tightening the posterior capsule and loosening the anterior capsule. Finally, a variant attachment of the aIGHL may occur along the scapular neck, separate from the labrum. In these patients it is possible to injure the aIGHL without injuring the labrum, referred to as a glenoid avulsion of the glenohumeral ligament and reported in 3% of cases.[10]

An anteroinferior labral tear with associated cartilage lesion is referred to as a glenolabral articular disruption (GLAD) lesion. The precise definition and implication of a GLAD lesion has changed over time.[16] A GLAD lesion was originally defined as a superficial anteroinferior labral tear with an associated anteroinferior articular cartilage injury produced by shear forces during a forced adduction injury to the shoulder in an ABER position.[17] According to the original definition, the deep labral fibers remain intact, LLC remains stable, and there is no associated anterior instability.[11] [16] [17] However, many authors associate this lesion with instability and an avulsion mechanism of injury. The definition now may include a labral detachment with an associated unstable cartilage flap[16] that could be considered a variation of a Perthes lesion with intact periosteum.

Soft tissue Bankart lesions are the most common LLC injury and defined as avulsion of the aIGHL with associated detachment of the labrum and disruption of the periosteum. Waldt et al found that 86% of patients with acute anterior instability had Bankart lesions at surgery.[11] A chronic Bankart lesion may be difficult to distinguish from a chronic ALPSA lesion, but if the labrum is displaced lateral to the glenoid, the periosteum must have been torn, and the injury is a Bankart lesion.

Humeral Avulsion of the Glenohumeral Ligament

HAGL lesions refer to avulsion of part or all of the IGHL complex from the humeral neck. They are reported in up to 9% in patients with anterior instability[18]; however, assessment in the first week after dislocation may identify more HAGL lesions (21%) than after 3 weeks (7.1%).[14] Most of these injuries involve the anterior band, the most specific finding on MRA (100% specificity).[19] Most HAGL lesions are associated with additional injuries to the shoulder, such as labral tears and Hill-Sachs lesions.[20] Some HAGL lesions have a bony avulsion from the medial cortex of the humeral neck, referred to as a “bony HAGL,” or BHAGL. Cadaveric studies have established that large HAGL lesions result in increased shoulder range of motion, external rotation, and multidirectional translation, as well as shifting of the humeral head apex.[21] These biomechanical changes were significantly reduced following repair. Clinical studies have lent credence to these findings, establishing increased external rotation with abduction on physical exam in patients with HAGL lesions.[22] Up to 100% of patients with HAGL injuries experience repeat dislocation with nonoperative management.[20]

Coronal MR images best demonstrate avulsion of the IGHL from the humeral attachment, characterized by inferior ligament displacement and extravasation of joint fluid or arthrographic contrast through the capsular defect down the shaft of the humerus ([Fig. 3a, b]). When the IGHL falls inferiorly away from the attachment, the normal U-shaped appearance of the IGHL is transformed into a J shape.[23] Iatrogenic extravasation of arthrographic contrast is common on MRA and may be mistaken for a HAGL lesion. This benign extravasation typically occurs at the axillary pouch.

Features to distinguish an IGHL complex tear from benign iatrogenic extravasation at MRI include a torn anterior band, a thickened ligament (> 3 mm), reverse-tapered ligament caliber, and scarred appearance of the torn ligament margin.[19] That being said, isolated axillary pouch injuries have been described.[24] Associated injuries to the rotator cuff, humeral head, and labrum are common with HAGL lesions and may be distractors. The most common associated injury is a tear of the subscapularis tendon, reported in 68% of patients with HAGL lesions.[25] Arthroscopic or open surgical repair of HAGL lesions is associated with good clinical outcomes and lower recurrence rates, and failure to repair may result in recurrent anterior shoulder instability. One study reported that 100% of patients with HAGL injuries experience repeat dislocation with nonoperative management.[20] Preoperative identification of HAGL lesions on imaging is key because it may influence elements of the operative treatment plan, such as patient positioning, equipment, and implants.

Postoperative Soft Tissue Repairs

Labral Repair and Postoperative Labrum

Anterior labral repair (Bankart repair) is usually performed arthroscopically using anchors placed along the edge of the glenoid along the extent of the tear. Anchors are made of various materials that may or may not be absorbable. Some anchors are made entirely of suture. After the anchor is secured in bone, a suture coming out of the anchor is passed around the labrum and used to repair the labrum back to its anatomical location at the edge of the glenoid.

Postoperative imaging of the shoulder following instability repair can be complicated by technical and interpretive factors. Metallic suture anchors or small metallic shavings can result in paramagnetic artifact and limit evaluation of immediately adjacent structures. With these limitations in mind, MRI and MRA are still considered the optimal imaging studies for postoperative evaluation of the shoulder. In the immediate postoperative time frame, hyperemic granulation tissue forms in the labrum repair, resulting in increased signal on fluid-sensitive sequences that may be mistaken for a recurrent tear.[26] Comparison with prior imaging and the operative report, when available, is helpful for delineating findings of prior injury from recurrent injury or a surgical complication.

Following repair, the labrum should be firmly attached to the glenoid. The repaired labrum may demonstrate morphological abnormalities, such as thickening, irregularity, heterogeneous signal, and/or blunting or rounding of its margin. These findings are considered within normal postoperative limits ([Fig. 4]).[26] [27]

Findings indicative of a recurrent tear include complete detachment of the labrum from the glenoid or capsulolabral stripping, often seen with displacement of labral tissue from its expected position. A minimal amount of joint fluid or arthrographic contrast undercutting of the labrum may be seen with an intact labral repair that may represent trivial areas lacking robust labral attachment to the glenoid. However, contrast deeply or completely undermining the base of the labrum or extending into labral tissue indicates a recurrent tear ([Fig. 5]).[28] [29]

Development of paralabral cysts or signs of recurrent joint dislocation, such as a new or enlarging Hill-Sachs lesion, increase the likelihood that suspicious labral findings represent a recurrent labral tear. Recurrent instability is the most common complication following labral repair.[30] Although implant failure is rare, with an estimated occurrence as low as < 1% in both arthroscopic and open Bankart lesion repairs, it remains critical to evaluate for suture anchor loosening, backing out, or fracture.[31] Additional complications include nerve injury, infection, and postoperative arthritis.

Postoperative Humeral Avulsion of the Glenohumeral Ligament

HAGL injuries may be repaired using open, mini-open, and arthroscopic techniques. The open surgical approach repair results in more soft tissue disruption, possibly leading to postoperative fibrosis and pain. Additionally, the subscapularis tendon may be weakened during an open approach because it must be incised to gain access to the joint and then repaired. The mini-open approach attempts to reduce this postoperative weakness by limiting the entry incision to the lower third of the subscapularis tendon, thus preserving the superior half of its fibers. The arthroscopic approach allows for superior visualization of the glenohumeral joint and is associated with improved cosmetic outcomes and quicker postoperative recovery, but it is technically difficult, and initial placement of portals may lead to neurovascular injury.[32] [33]

Whether open or arthroscopic, the steps of HAGL repair are similar. First, the humeral neck at the site of the glenohumeral ligament injury is debrided. Suture anchors are then placed along the humeral neck with care taken to avoid injury to the adjacent articular cartilage. The injured glenohumeral ligament is identified and debrided. Sutures are passed through both the debrided ligament and humeral neck suture anchors and then tightened until they reach appropriate tension and tied.

Only sparse literature has addressed MRI or MRA criteria for evaluating the integrity of HAGL repair. Logically, the repaired glenohumeral ligament should remain attached to the humerus at its site of anatomical insertion ([Fig. 3c]). The capsuloligamentous complex may be intermediate in signal intensity and irregular, frayed, thickened, or nodular in appearance. HAGL repair tears result in disruption of the repaired glenohumeral ligament fibers at the site of repair and appear similar to the original injury with an abnormal J-shaped appearance of the inferior axillary pouch. Additionally, the repaired capsular/ligamentous tissue is not attached to the humerus at the suture anchor ([Fig. 6]).

Capsulorrhaphy

Capsulorrhaphy, defined as suture or surgical repair of the capsule, is a procedure performed in patients with shoulder instability to reduce capsular volume and laxity. It can be performed as a stand-alone procedure or concurrently with repair of underlying shoulder instability lesions. Many methods for capsulorrhaphy are described in the literature, including but not limited to open or arthroscopic capsular shift, nonanatomical repairs, such as Putti-Platt and Magnuson-Stack operations, and arthroscopic capsular tightening via staple or suture plication versus thermal capsulorrhaphy.[34] Many of these techniques have fallen out of favor due to long-term adverse effects, such as accelerated osteoarthritis following nonanatomical repair or chondrolysis after thermal capsulorrhaphy.[35]

In current practice, two primary forms of capsulorrhaphy are performed: capsular shift and capsule suture plication. These procedures may be indicated in patients with increased capsular laxity that could be the result of anterior instability but also a connective tissue disorder such as Ehlers-Danlos syndrome.

Both open and arthroscopic approaches for capsular shift have been described. Open capsular shift is performed by creating a T-shaped anterior capsular incision, shifting the inferior capsule superiorly and the superior capsule anteriorly, and then suturing the overlapping redundant capsular tissue together. The arthroscopic capsular shift is similar overall, although it is performed through arthroscopic portals with passage of sutures through iatrogenic perforations in the capsule. Capsular plication is performed arthroscopically and entails simple suture tightening of the redundant/lax capsule without redirection of capsular tissue. It may be performed entirely within the substance of the capsule or incorporated into a labral repair. Many surgeons incorporate some degree of capsular plication into almost all of their labral repairs to enlarge the stabilizing “bumper” that likely accounts for the enlarged appearance of many repairs ([Fig. 1c] and [Fig. 4]).

Postoperative imaging features of the shoulder capsule following capsulorrhaphy were well described by Rand et al.[36] In their study, numerous measurements of the shoulder capsule were made on MRA before and following arthroscopic capsular repair. Results showed a decreased mean anterior capsular distance, an increased mean posterior capsular distance, and an increased posterior to anterior capsular ratio. Other studies have confirmed an overall reduction in joint volume following capsulorrhaphy procedures, with variability in degree of quantitative volumetric reduction following capsular shift when compared with plication.[37] [38] Additional expected postoperative findings after capsular tightening include irregularity or nodularity of the capsule and IGHL, as well as capsular thickening ([Fig. 7]).[36] Findings indicative of repeat capsular injury are discontinuity of the capsule and extracapsular leakage of arthrographic contrast with MRA.

Imaging Techniques for Soft Tissue Injuries

Conventional MRI is highly effective to evaluate traumatic shoulder pain, including for detection of pathologies involving the labrum and glenohumeral ligaments.[39] Despite the effectiveness of MRI, MRA is considered the gold standard of imaging the shoulder in the setting of traumatic injury and instability, with very high sensitivity for soft tissue injury and good concordance with findings on subsequent arthroscopy.[39] [40]

Numerous studies comparing the accuracy and sensitivity between MRI and MRA in the preoperative setting have been performed, demonstrating that MRA has superior detection rates for labral and capsular injuries following shoulder trauma.[41] [42] [43] Despite the advantages of MRA, drawbacks do exist. For most institutions, including ours, intra-articular injection of a gadolinium-based contrast agent is performed under fluoroscopy, thus exposing the patient to ionizing radiation and other risks of skin puncture. Contrast injection introduces the possibility for an adverse reaction, such as a medication allergy. MRA is also higher in monetary and time costs to the patient.

A large meta-analysis by Liu et al in 2019 states that “MRA enhances the sensitivity of the detection of labral disorders, while it is only marginally superior to MRI in terms of specificity” and argues that MRI should be adequate to detect acute, severe, or unstable labral lesions.[1] The authors suggest reserving MRA for more chronic or subtle injuries. This recommendation may be strengthened by a retrospective review study by Cong et al in 2024,[41] reporting that the superiority of MRA for diagnosing labral pathology may increase with time. MRI became less accurate for labral tears with longer time periods between dislocation and imaging, with a significant drop-off in accuracy at the 2-week mark. Conversely, MRA did not suffer a temporal decline in diagnostic accuracy and remained highly effective beyond 2 weeks.

In the postoperative setting, MRA does remain highly accurate and advantageous versus MRI in evaluating repeat labral injury.[28] [44] [45] MRA can better differentiate T2 hyperintense granulation tissue from labral detachment, may separate labral detachment via hydrostatic pressure, and can highlight recurrent capsuloligamentous injury with extracapsular leakage. A recent white paper from the Society of Skeletal Radiology stated that provocative maneuvers, such as the ABER position, are not recommended in routine practice; however, selective application of the ABER position may be advantageous for assessment of anterior instability.[46] ABER position imaging is more helpful to identify Perthes lesions, and neutral or ADIR position imaging is more helpful to identify ALPSA lesions,[12] [13] [15] the latter of which is not commonly performed. CT arthrography is an excellent alternative in patients with MRI contraindications.[47]

Preoperative Bone

Bone lesions are relatively common in anterior instability with Hill-Sachs lesions seen in more than half of first-time dislocations and in almost all patients with recurrent anterior instability.[3] The anterior glenoid rim is reported to be deficient in 80% of recurrent instability cases.[48] Although many factors contribute to the treatment options for anterior shoulder instability, the presence and size of bone lesions is the first variable considered with numerous operative treatment algorithms that direct most patients to one of three surgical options: arthroscopic Bankart repair, arthroscopic Bankart repair with remplissage, or glenoid augmentation.[3] [49] A certain threshold of glenoid bone loss is a contraindication to a Bankart repair. Failure to recognize and/or appropriately treat a certain threshold of bone loss predisposes to failure of labral repair.[50] [51] Accordingly, cases of a failed primary Bankart repair should be scrutinized for bone lesions.

Glenoid Bone Loss

Glenoid bone loss may result from a displaced or resorbed anterior glenoid rim fracture fragment and/or attrition. MRI and CT are both highly accurate to measure glenoid bone loss; radiographs are not.[52] To be sure, there are multiple reported ways to measure bone loss ([Fig. 8]). Most simplistically, it can be accomplished by using a sagittal image of the glenoid fossa and making a best-fit circle to the bottom two thirds of the glenoid. On oblique sagittal images or a three-dimensional (3D) surface-shaded images, viewing the glenoid en face resembles an upright pear if there is no bone loss. This circle should be well approximated to the posterior and inferior margins of the glenoid. When anterior glenoid bone loss is present, the circle extends beyond the damaged anterior glenoid rim. The diameter of missing bone at the glenoid equator is divided by the diameter of the intact glenoid diameter (diameter of the best-fit circle diameter).

Although this measurement technique is widely performed, drawing a best-fit circle only estimates the geometry of the native glenoid. The contralateral shoulder, if normal, may be imaged to estimate the normal glenoid width, but it requires additional expense and ionizing radiation if CT is used instead of MRI. The intact glenoid width may also be estimated from measuring the glenoid height (mm) × (1/3) + 15 mm for males (13 mm for females).[53]

Glenoid bone loss can also be calculated in terms of surface area using the so-called Pico method that also requires a best-fit circle in the inferior two thirds of the glenoid. The area of missing bone is measured using a freehand tool and divided by the best-fit circle diameter. Intuitively, this technique more accurately measures bone loss when it is more profound anteroinferiorly than at the glenoid equator, but this free-tracing tool is not readily available on all imaging software.

A meta-analysis showed that the best-fit circle width and Pico methods are the most widely used and accurate.[52] One head-to-head study using best-fit circles from a contralateral normal shoulder CT found the Pico method more accurate than the glenoid width method.[54]

Comparing the accuracy of CT and MRI, both were shown to have similar high accuracy in diagnosing critical bone loss in a systematic literature review.[52] One study showed 3D CT had increased accuracy compared with 2D MRI and marginally increased accuracy versus 2D CT in a head-to-head comparison.[55] However, 3D MRI was subsequently reported to produce no statistically significant difference in glenoid bone loss measurement compared with 3D CT[56] and arthroscopy.[57] Of note, 2D MRI is most useful for glenoid bone loss when the oblique sagittal image sequence is appropriately aligned with the glenoid fossa. With CT, image slices are virtually always thin enough to allow for reconstruction of satisfactory oblique sagittal images if the imaging plane was not initially prescribed appropriately.

Appropriate management of acute anterior rim glenoid fractures depends on the size and displacement of the glenoid fragment as well as patient demographics and physical demands.[58] The width and displacement of these fractures should be reported. In general, small and medium size fractures are treated with nonoperative management or arthroscopic reduction and internal fixation with suture anchors or percutaneous screws; larger displaced fragments may be treated with open reduction and internal fixation.[58]

Hill-Sachs Lesion

The Hill-Sachs lesion is an impaction fracture deformity of the posterosuperior humeral head. Although radiography can demonstrate the presence of a Hill-Sachs lesion, measurements are better accomplished with CT, MRI, or MRA with the two latter modalities sparing ionizing radiation and simultaneously characterizing LLC injuries.[59] [60] There are multiple reported measurements for a Hill-Sachs lesion, but its width and location is used to determine whether the lesion engages the anterior glenoid rim, using the increasingly accepted glenoid track model. The width of the Hill-Sachs lesion is measured on a axial MR or CT image, drawing a horizontal line from the lateral to the medial margins. The Hill-Sachs interval (HSI) is the width of the Hill-Sachs lesion plus any intact bone bridge (if present) between the lesion and the rotator cuff insertion ([Fig. 9]). The HSI essentially upgrades the size of Hill-Sachs lesions that are medialized, causing them to engage with the anterior glenoid rim earlier in the ABER position.

Establishing the so-called correct way to precisely measure the HSI on imaging is elusive. Arthroscopically, the Hill-Sachs lesion and bone bridge width are often measured separately and added.[5] On a single axial MR or CT image, these two measurements can also be performed separately and added,[60] but some choose to measure with a single line from the medial margin of the Hill-Sachs lesion to the rotator cuff insertion.[61] Based on trigonometry, the latter produces a slightly shorter measurement that will be trivial unless the bone bridge is large. Additionally, some measure the HSI on 3D surface-shaded CT reconstructions that allows measurement of the HSI perpendicular to the vertical axis of the Hill-Sachs lesion rotator cuff footprint.[4] This measurement technique mirrors the single-line technique. Regarding imaging modality selection for HSI measurements, MRI has been validated to predict Hill-Sachs engagement.[60] However, MRI was shown to overestimate the HSI when measured on conventional axial images compared with CT with oblique axial reconstructions performed perpendicular to the Hill-Sachs lesion.[4]

The Glenoid Track

It has long been known that critical glenoid bone loss (∼ 20%) requires bone graft augmentation and not a stand-alone soft tissue Bankart repair.[3] Increasingly recognized is the synergistic relationship between glenoid bone loss and the Hill-Sachs lesion in bipolar bone loss. When a Hill-Sachs lesion is sufficiently large, even mild or subcritical glenoid bone loss may result in a lesion that engages with the anterior glenoid rim during a normal range of motion. This so-called engaging Hill-Sachs lesion may be predicted by using the glenoid track model to predict whether a Hill-Sachs lesion is engaging (off-track) or nonengaging (on-track).[5]

The glenoid track (GT) is calculated by multiplying the intact glenoid diameter by 0.83 and then subtracting the width of bone loss ([Table 2]). If the HSI is smaller than the GT, the Hill-Sachs lesion is on-track and predicted to be nonengaging. If the HSI is larger than the GT, the Hill-Sachs lesion is off-track and predicted to be engaging. The 3D surface-shaded images allow for easier depiction of bone lesions with complex morphologies and are preferred by some surgeons, who may draw the medial margin of the GT on a posterior 3D surface-shaded image of the shoulder to see whether the GT overlaps with the Hill-Sachs lesion, thus qualifying as an off-track lesion.[5]

Postoperative Bone

Glenoid Augmentation

Anterior glenoid augmentation may be indicated when a substantial amount of glenoid bone loss (∼ 20%) is present or in the setting of recurrent instability following a failed stabilization procedure.[3] Numerous autograft and allograft augmentation options are available.

The Latarjet procedure widens the glenoid by transferring a portion of the coracoid process to the anterior glenoid.[62] Stabilization of the glenohumeral joint is provided both from the bone grafting and from the so-called sling effect created by the conjoint tendons attached to the transferred coracoid passing through a horizontal split created in the subscapularis.[63] Indications for the Latarjet procedure include recurrent anterior glenohumeral instability with glenoid bone loss > 15 to 20%,[64] but it may also be considered in high-risk contact athletes even in the absence of significant bone loss.[62] There is strong consensus regarding relative contraindications to performing a Latarjet procedure: multidirectional joint instability, operating on patients who perform voluntary joint dislocations, uncontrolled seizure disorders, and glenoid bone loss exceeding the width that a coracoid graft may be able to supplement.[64]

The Latarjet procedure may be performed arthroscopically or open. Following harvest and preparation of the coracoid process, a subscapularis split and capsulotomy are performed to expose the glenoid. Once the coracoid has been transferred, the subscapularis split and capsulotomy are both repaired before skin closure.[62] Postoperatively, the coracoid graft, positioned superior to inferior along the glenoid and fixed with two screws directed from anterior to posterior, should lie flush with or slightly medial to the articular surface.[62] [65] Coracoid grafts placed too laterally may increase the degree of postoperative glenohumeral degenerative changes, whereas over-medialization of the graft may fail to augment the glenoid successfully and may also lead to graft resorption.[62] In addition to graft malposition and development of secondary glenohumeral osteoarthritis, complications of the Latarjet procedure may include bleeding, infection, neurovascular injury (axillary and/or musculocutaneous nerves), nonunion, and hardware failure ([Fig. 10]).[62] [64]

Alternatively, glenoid augmentation with free bone allograft or autograft, initially introduced as a treatment for patients with failed prior Latarjet, has gained popularity as a primary intervention for anterior shoulder instability with glenoid bone loss.[66] The iliac crest is a common autograft choice, and although there are many options for free bone allografts, the distal tibia is frequently selected. Distal tibial allograft is favored for its comparable radius of curvature to the glenoid contour, dense subchondral bone, and associated cartilage.[64] [66] The primary indications for glenoid bone grafting are glenoid bone loss > 20%, a failed prior Latarjet procedure, and epilepsy.[64] Additionally, bone grafting may be indicated over the Latarjet procedure when there is more profound bone loss (i.e., > 25%) because the coracoid transfer typically supplements only 10 to 12 mm of bone[64] [66]; tibial allografts may be cut larger.

Similar to the Latarjet procedure, distal tibial allografting may be performed arthroscopically or open. The glenohumeral joint is accessed by a lesser tuberosity or subscapularis split and capsulotomy. Before graft transfer, the glenoid is debrided back to a healthy bleeding bone surface and contoured into a flat surface to maximize contact with the graft. The graft is secured using screws or suture button fixation.[66] Postoperatively, the bone graft should lie flush with the glenoid rim ([Fig. 11]).[66] [67] Potential complications following glenoid bone grafting are bleeding, infection, hardware failure, resorption of the graft, traction injury to the musculocutaneous nerve, and upper subscapular nerve injury if the capsulotomy is extended too medially.[64] [66] [67] Lesser tuberosity osteotomy, if performed, can develop nonunion and migration with Latarjet or allografting ([Fig. 12]).

The Latarjet and free glenoid bone grafting have been described as “competing” techniques that both offer solutions to anterior shoulder instability associated with glenoid bone loss.[68] Glenoid bone grafting may be preferred in cases of substantial glenoid bone loss. However, the Latarjet provides stabilization both through osseous reconstruction and the sling effect that supplements inferior glenohumeral ligamentous laxity.[62] [65] Free bone block procedures rose to initial popularity not only as an option for a patient with failed Latarjet, but also in part due to concerns about the Latarjet procedure's complications and nonanatomical nature. In particular, decreased internal rotation and fatty atrophy of the subscapularis on CT were described after Latarjet and believed to be sequelae of the subscapularis split.[69]

Taken together, multiple studies comparing the Latarjet procedure with various types of free bone grafting have demonstrated comparable patient outcomes. A randomized controlled trial comparing the Latarjet procedure with iliac crest bone graft transfer found no difference in clinical and radiologic outcomes, including no difference in patient satisfaction or pain, except for worse internal rotation capacity in patients who had undergone the Latarjet procedure and donor site sensory disturbances in bone autograft patients.[68] Patients enrolled in this trial underwent CT imaging at 6, 12, and 24 months after surgery, and although the bone autograft patients demonstrated significantly more augmentation effect initially, this effect diminished over time with bony remodeling. Likewise, a matched cohort study comparing the Latarjet procedure with the distal tibia allografting did not identify a difference in patient outcomes or complication rates.[67]

In the setting of overall comparable patient outcomes, both operations are reasonable treatment options for anterior shoulder instability with glenoid bone loss, and there is expert consensus that surgeon preference can guide the ultimate choice of operation.[64] Regardless of the glenoid augmentation technique, the procedure is followed routinely with radiographs to ensure stable graft position and evaluate for evidence of fixation loosening. Radiographs are unlikely to depict graft healing that would be better assessed with CT.

Remplissage

The remplissage procedure is a surgical option for patients with a large Hill-Sachs lesion. It entails a capsulotenodesis of the posterior capsule and infraspinatus tendon to fill in the Hill-Sachs lesion ([Fig. 13]).[70] As a result, the defect becomes extra-articular and unable to engage the anterior glenoid rim. Remplissage is often performed at the time of Bankart repair.[64] [70] The primary relative indications include a Hill-Sachs lesion resulting in significant humeral bone loss (20–40%), which is either off-track on preoperative imaging or found to be engaging during arthroscopy.[64] [65] Remplissage may be considered in isolation for patients who underwent prior glenoid augmentation but also had a Hill-Sachs lesion that was not addressed.[64]

Relative contraindications include small Hill-Sachs lesions or those that are on-track on imaging or nonengaging during arthroscopy, preoperative stiffness, and infraspinatus compromise.[64] Notably, severe glenoid bone loss has also been described as a relative contraindication to remplissage. Data suggest poorer outcomes in arthroscopic Bankart repair with remplissage patients with > 10% glenoid bone loss, compared with those with similar bone loss who underwent Latarjet.[71] However, a retrospective study comparing remplissage and Latarjet across a larger range of preoperative bone loss did not identify a difference in complication or recurrence rates.[72]

Following remplissage, postoperative imaging should demonstrate a suture anchor in the Hill-Sachs lesion along the posterior humerus, with the posterior capsule and infraspinatus tendon well opposed to the bone ([Fig. 14]).[70] [73] Occasionally, additional anchors are used.[73] On postoperative MRI, the Hill-Sachs defect is typically filled 75 to 100% with a combination of granulation tissue and fibrous tissue that will have heterogeneous signal intensity on MRI.[65] A transition to predominantly fibrous tissue occurs ∼ 9 months after surgery.[73] Dehiscence may be detected on MRI by lack of closely opposed capsule and tendon tissue to the suture anchor ([Fig. 15]).[65] The robustness of remplissage filling of the Hill-Sachs lesion has been evaluated with MRA, but the degree of filling did not correlate with patient clinical outcomes.[74] Complications unrelated to remplissage dehiscence and recurrent instability are rare; loss of external rotation is the most frequently described.[64]

Hill-Sachs lesions involving > 40% of the articular surface are treated with arthroplasty in patients with lower functional demand. Hill-Sachs osteochondral allografting ([Fig. 16]) can be performed in young active patients.[75] A meta-analysis of the scant literature on humeral osteochondral allografting does show overall improved shoulder function, although there was a fairly high incidence of allograft resorption and arthritic changes; some cases of allograft osteonecrosis were also observed.[75]

Older Patients

Most of the literature on anterior instability treatment is on young patients (< 30 years of age). This population uses their shoulders most vigorously and has a higher incidence of recurrent instability when left untreated. Even though the older population has a lower rate of recurrent instability, evaluation with MRI after dislocation shows a higher incidence of rotator cuff tears after anterior dislocation, particularly with patients > 60 years of age, such as supraspinatus, infraspinatus, and subscapularis tendons.[76] Because repair of large rotator cuff tears is time dependent, prompt identification may be significant. Older patient populations also have a higher incidence of greater tuberosity fractures and axillary nerve injury after anterior dislocation.[76]

Conclusion

The synergistic effect of bipolar bone lesions is increasingly recognized as the GT model is promulgated among surgeons. The size and location of bone lesions in anterior shoulder instability is crucial. They are the first considered imaging findings when selecting an operative treatment strategy. After glenoid bone augmentation, CT is the study of choice for evaluating graft healing; graft migration and implant loosening can be assessed with both CT and radiographs. For soft tissue instability lesions, preoperative recognition of HAGL lesions is crucial for surgical planning. MRI is useful for diagnosis of labral tears in the acute setting, but MRA is advantageous with chronic cases and in the postoperative setting. MRA with ABER positioning is advantageous for nondisplaced labral tears.

Conflict of Interest

None declared.

• References

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Publication History

Article published online:
11 February 2025

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• References

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