Management of Failed Latarjet and Off-tract Hill-Sachs Lesion: Arthroscopy-assisted Remplissage and Open Eden-Hybinette Procedure

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.

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.

Recurrent shoulder instability is a demanding condition, especially in patients with previous surgical interventions^1,2,3. Soft tissue procedures such as Bankart repair, capsulorrhaphy, Remplissage, and bony procedures such as Eden-Hybinette⁴, Trillat⁵, Bristow⁶, and Latarjet procedure^7,8,9,10 were developed. However, there are still reports for failed Latarjet procedure necessitating alternative revision surgical strategies^11,12. 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.

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.

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 (Figure 5B).

Figure 1: X-rays of the patient before and after the Latarjet procedure. (A) Anteroposterior view X-ray before, (B) axillary view X-ray before, (C) anteroposterior view X-ray after, and (D) axillary view X-ray after the procedure. (A,B) The previous anchor position was too high before the procedure. (C,D) After the open Latarjet procedure, the two cannulated screws were used to fix the coracoid autograft. Please click here to view a larger version of this figure.

Figure 2: X-rays and computer tomography imaging following the failed Latarjet procedure. (A) Anteroposterior X-ray. The two compression screws were dislodged at the axillary pouch (arrowhead). A huge Hill-Sachs lesion (arrow) was observed both in the AP and axillary view with anterior subluxation of the humerus. (B) Axillary X-ray of the patient following the dislocation of the Latarjet procedure. (C) The resorption of the previous coracoid graft and (D) an off-track bipolar lesion were observed in the CT scan. Please click here to view a larger version of this figure.

Figure 3: The arthroscopy-assisted Remplissage procedure. (A) Posterior, posterolateral, anterior, and anterolateral portals are made. (B) The arthroscope was shuttled through the anterolateral portal to evaluate the size of the Hill-Sachs lesion intraarticularly. (C) Debridement of the exposed proximal humerus bone bed. (D) An all-suture Y-Knot RC anchor (arrowhead) was inserted at the deepest part of the Hill-Sachs lesion. (E) Three mattress sutures were made by piercing the the musculotendinous junction of the infraspinatus tendon with the birdbeak suture passer. (F) The knots were not tied until the completion of the open Eden-Hybinette procedure. (G) The confirmation of the Remplissage procedure filling of the Hill-Sachs lesion. (H) Flush of the iliac crest bone graft onto the anterior glenoid. Abbreviations: P = posterior; PL = posterolateral; HS = Hill-Sachs; ISP = infraspinatus; GL = glenoid; BG = bone graft. Please click here to view a larger version of this figure.

Figure 4: The open Eden-Hybinette procedure. (A) Remove previous loose screws. (B,C) A 3 cm x 1 cm x 1.5 cm iliac crest autograft was harvested. (D) Secure the iliac autograft with two 4.5 mm cannulated screws. Please click here to view a larger version of this figure.

Figure 5: Postoperative X-ray and computed tomography at one-year follow-up showed a reduced joint line and full incorporation of the bone graft. (A) Anteroposterior X-ray. (B) Axial view of the computed tomography demonstrated the full incorporation of the tricortical iliac crest bone graft. Please click here to view a larger version of this figure.

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 procedure^17,18,19. Previous research has reported recurrence and reoperation rates around 10%^20,21,22.

Failure in Latarjet procedure is characterized by the recurrence of shoulder dislocation or subluxation, nonunion, malposition, or resorption of the coracoid bone block^19,23,24. Additionally, issues such as symptomatic hardware, a painful or unstable shoulder, and the onset or worsening of glenohumeral osteoarthritis may also occur^22,25,26. These complications often necessitate revision surgery. Several studies have also highlighted that athletes under 20 years old,²⁷ participating in contact sports, and having a concomitant HSL can increase the likelihood of recurrence following open stabilization and other bony augmentation procedures^28,29,30.

Previous literature has proposed several graft options, including the iliac crest (Eden-Hybinette procedure)³¹, distal clavicle³², distal tibia allograft³³, and scapular spine³⁴. The tricortical iliac crest autograft is a viable graft option for revision glenoid reconstruction after a failed Latarjet procedure³⁵. The anterior superior iliac spine (ASIS) autograft offers substantial bone stock and abundant cancellous bone, promoting successful union. Its dense cortical structure further supports its suitability for revisional glenoid bone augmentation^30,36.

A recent meta-analysis¹⁸ reviewing treatment options for recurrent instability after a failed Latarjet procedure concluded that the Eden-Hybinette procedure is the most popular and safest option. This procedure has demonstrated good to excellent clinical outcomes and satisfaction rates, ranging from 67% to 89%¹⁸. The Eden-Hybinette procedure is preferred by most orthopedic surgeons, especially when failure is attributed to complications with the coracoid graft. The study also found that revision procedures, such as the Eden-Hybinette, had similar rates of major postoperative complications to those of initial Latarjet procedures, with both being relatively low. The meta-analysis¹⁸ reported a recurrence rate of instability at 8.6%^37,38 following these revision procedures. Therefore, according to our analysis, the Eden-Hybinette procedure is considered the most rational choice for addressing a failed Latarjet procedure.

Rationale for combining the free bone block procedure with Remplissage
Since Itoi et al.³⁹ introduced the concept of on-track and off-track lesions, numerous researchers have focused on this topic, developing various solutions⁴⁰. One such approach is the Remplissage procedure^41,42, which is used to address bony defects in the humerus.

A systematic review⁴¹ of the Remplissage procedure concluded that, from a biomechanical perspective, the arthroscopic Remplissage procedure consistently prevents engagement of the HSL^43,44,45. However, while the potential impact of the Remplissage procedure on the shoulder's range of motion is a concern, there are still debates from studies to substantiate this concern^46,47. While the free bone block (FBB) procedure is effective at reducing the recurrence of glenohumeral instability, a subset of patients with significant humeral bone loss remains at risk for recurrent instability, even when the length of the glenoid track is increased.

Calvo et al.⁴⁸ reported that 11.8% of patients with bipolar bone loss had remaining off-track lesions at a 2-year follow-up after undergoing an arthroscopic Latarjet procedure. Patients with a persistent off-track lesion were found to be at a higher risk of experiencing recurrent subluxations⁴⁹. This highlights that patients with HSL may require additional procedures to address their humeral bone loss despite having undergone an FBB procedure. Abboud et al. also reported that patients treated with a combined open Latarjet and arthroscopic Remplissage in their group had good to excellent patient-reported outcomes, without recurrent dislocations⁵⁰. Lin et al. developed the PIT Risk Score, which considers significant prognostic factors for recurrent shoulder instability following primary arthroscopic Bankart repair and evaluates the role of Remplissage augmentation for on-track shoulders based on a patient's risk profile. They found that when the Bankart repair was augmented with Remplissage, it decreased 10 points of PIT Risk Score, making patients with extreme risk to a moderate risk. Thus, it is reasonable to combine a FBB procedure with Remplissage in patients undergoing revision for off-track shoulder instability.

The importance of sling effect in revision surgeries
Tricortical Iliac crest graft reconstruction is less advantageous than coracoid transfer biomechanically due to the absence of the 'sling effect. However, tricortical iliac crest grafts have been reported to effectively restore stability in high-risk populations and as a revision technique following failed Latarjet procedures³⁵. Studies have shown that the outcomes of grafts mentioned above are comparable to those of the Latarjet procedure, raising questions about the necessity of the 'sling effect' when addressing bone loss^31,51.

According to Callegari et al.⁵², incorporating Remplissage with an FBB procedure minimized translation, bringing it closer to the intact condition, and increased the force required for dislocation compared to using only a FBB or the Latarjet procedure in a bipolar bone loss model with an off-track HSL. In a similar vein, Hartzler et al.⁵² highlighted the importance of the Remplissage procedure for off-track lesions, particularly in the context of the engagement patterns of HSLs with a 15% glenoid defect. A systematic review⁵³ found no differences in recurrent instability, progression of osteoarthritis, complication rates, or return to sport between the Latarjet and FBB groups. In the current study, adding a Remplissage to an FBB procedure led to comparable resistance to translation and the highest force required to dislocate the glenohumeral joint. Although Remplissage has not traditionally been augmented with a FBB procedure, its addition may increase the stiffness of the construct and the requirement of a higher force to cause further dislocation, which may help reduce the rate of recurrent instability, especially in cases where a previous Latarjet procedure has failed.

To our knowledge, previous literature discussing failed Latarjet procedures lacks consensus¹⁸, likely due to the low failure rate and the absence of an agreed-upon revision method. We present this case report to demonstrate that the FBB procedure combined with arthroscopic Remplissage is feasible and results in favorable clinical outcomes.

Recurrent shoulder instability post Latarjet procedure presents a significant challenge. The combination of the arthroscopy-assisted Remplissage and open Eden-Hybinette procedure offers a viable alternative for patients with significant bone loss and failed previous surgeries. This case underscores the importance of tailored surgical strategies to optimize outcomes in complex shoulder instability cases.

The authors have no conflicts of interest to declare.

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)