Management of off-track Hill-Sachs lesions in anterior glenohumeral instability

Bone loss has been identified as a risk factor for recurrent shoulder dislocations or failure after soft tissue repair. Although the range for “critical” bone loss is yet to be determined, glenoid and humeral bone defects should not be regarded as independent problems, but the interaction between them during shoulder motion should be evaluated as suggested by the glenoid track concept. The glenoid track concept is now widely accepted and considered essential for making decisions about surgery. Soft-tissue procedures usually work well in patients with on-track Hill-Sachs lesions but in off-track lesions do not. In this situation additional procedures should be performed. Different surgical options have been described to address off-track Hill-Sachs lesions, most commonly remplissage, Latarjet or free bone block procedures. Coracoid graft and free bone grafts convert the off-track Hill-Sachs lesion into on-track by lengthening the glenoid-track, whereas remplissage fill-in the humeral lesion so that it does not engage. In the setting of a Hill-Sachs lesion with little or no glenoid bone loss, remplissage has demonstrated satisfactory outcomes with a low complications and recurrence rate. Favorable results have been reported with glenoid bone grafting when managing isolated Hill-Sachs or bipolar lesions. Studies analyzing Latarjet and Eden-Hybinette procedures show that both procedures are safe and effective in the management of anterior glenohumeral instability. Attention should be paid to those patients with large bone defects not amenable to be restored with an isolated Latarjet that may be better addressed with an Eden-Hybinnete or adding a remplissage to the Latarjet procedure.