394
LETTERS TO THE EDITOR
instability: Systematic review and quantitative synthesis of the literature.” The article that has been published in Arthroscopy is a well-executed systematic review about the repair options for Hill-Sachs defects. The title of the article indicates that this is a review that describes the possible treatment options for shoulder instability due to humeral bone defects. Although the authors give an extensive overview of local humeral treatment options, we feel that the role of an established procedure in the management of shoulder instability due to Hill-Sachs lesions is overlooked. In the introduction of their review, Longo et al. mention that Hill-Sachs defects are found in 65% to 71% of patients after an initial glenohumeral dislocation. The possible persisting instability, however, is not solely due to these lesions. Bony lesions of the glenoid are also seen in 41% of patients after an initial dislocation and in up to even 81% of patients with recurrent dislocations.2 Recurrent shoulder dislocations are the result of an interplay between these often bipolar lesions.3 This is explained by the glenoid track concept.2 Shortening of the glenoid track can be caused by anteroinferior glenoid bone loss. Even in the absence of significant glenoid bone loss, the Hill-Sachs lesion can be changed from an off-track lesion to an on-track lesion by performing a bone block augmentation procedure of the anterior glenoid rim.4 In other words, a Latarjet procedure or another proposed open or arthroscopic bone block procedure may well serve as a treatment option for shoulder instability due to HillSachs lesions.5 The advantage of a bone block procedure is that many shoulder surgeons have extensive experience with this type of surgery in contrast to procedures for filling the defect of the humeral head. Bony augmentation procedures have been performed for many years and are supported by numerous reports in the literature reporting favorable results6 compared with the described procedures in the article by Longo et al.1 With this letter, we would like to bring to their attention that bone block procedures should be considered in the treatment of Hill-Sachs defects and therefore deserve to have been addressed and analyzed in their review. Dirk P. ter Meulen, M.D. Alexander A. Weening, M.D. Derek F.P. van Deurzen, M.D. Michel P.J. van den Bekerom, M.D. Amsterdam, The Netherlands Note: The authors report the following potential conflict of interest or source of funding: D.F.P.v.D. receives support from Smith & Nephew. Enabling grant for research in rotator cuff surgery. Tornier. Financial support for research.
Ó 2015 by the Arthroscopy Association of North America http://dx.doi.org/10.1016/j.arthro.2015.01.001
References 1. Longo UG, Loppini M, Rizzello G, et al. Remplissage, humeral osteochondral grafts, Weber osteotomy, and shoulder arthroplasty for the management of humeral bone defects in shoulder instability: Systematic review and quantitative synthesis of the literature. Arthroscopy 2014;30: 1650-1666. 2. Griffith JF, Antonio GE, Yung PS, et al. Prevalence, pattern, and spectrum of glenoid bone loss in anterior shoulder dislocation: CT analysis of 218 patients. AJR Am J Roentgenol 2008;190:1247-1254. 3. Burkhart SS, De Beer JF. Traumatic glenohumeral bone defects and their relationship to failure of arthroscopic Bankart repairs: Significance of the inverted-pear glenoid and the humeral engaging Hill-Sachs lesion. Arthroscopy 2000;16:677-694. 4. Di Giacomo G, De Vita A, Costantini A, de Gasperis N, Scarso P. Management of humeral head deficiencies and glenoid track. Curr Rev Musculoskelet Med 2014;7:6-11. 5. Degen RM, Giles JW, Johnson JA, Athwal GS. Remplissage versus Latarjet for engaging Hill-Sachs defects without substantial glenoid bone loss: A biomechanical comparison. Clin Orthop Relat Res 2014;472:2363-2371. 6. Mizuno N, Denard PJ, Raiss P, Melis B, Walch G. Longterm results of the Latarjet procedure for anterior instability of the shoulder. J Shoulder Elbow Surg 2014;23: 1691-1699.
Authors’ Reply
We appreciate the concerns raised by Dr. ter Meulen et al. in their letter on our article.1 They pointed out that bone block procedures should be considered in the treatment of Hill-Sachs defects and therefore deserve to have been addressed and analyzed in our review. We respectfully point out that this review is part of a series of systematic reviews on shoulder instability performed by our research group, including the following: 1. A systematic review in which we analyzed clinical outcome, rate of recurrence, complications, and rate of postoperative osteoarthritis in patients with anterior shoulder instability managed with Latarjet, Bristow, or Eden-Hybinette procedures2 2. A systematic review on remplissage, humeral osteochondral grafts, Weber osteotomy, and shoulder arthroplasty for the management of humeral bone defects in shoulder instability1 3. A systematic review analyzing outcomes of surgical procedures for glenoid and/or humeral bony defects, performed singularly or in combination, in patients with posterior glenohumeral instability3
395
LETTERS TO THE EDITOR
4. A systematic review on the management of primary acute anterior shoulder dislocation4 5. A systematic review aimed to analyze outcomes of surgical procedures for glenoid and/or humeral bony defects, performed singularly or in combination, in patients with traumatic anterior glenohumeral instability with the secondary aim to establish, in clinical settings, what percentage of glenoid or humeral bone loss needs to be treated with a bony procedure to avoid recurrence of dislocation5 It is obvious that all these issues cannot be covered in one single article because the literature is too extensive. Therefore, while we do appreciate the concerns of ter Meulen et al., we ask that they and others take all 5 review articles as a whole to have a complete approach to the difficult management of a patient with bony lesions in the setting of shoulder instability. Of course, as stated by ter Meulen et al., “The advantage of a bone block procedure is that many shoulder surgeons have extensive experience with this type of surgery in contrast to procedures for filling the defect of the humeral head.” However, the aim of shoulder surgery should be restoration of the anatomy. The future of anatomic reconstruction in a patient with bony lesions in the setting of shoulder instability will be to address both bony glenoid and Hill-Sachs lesions (as well as soft-tissue lesions) with minimally invasive techniques. The available techniques for the management of Hill-Sachs defects are still unsatisfactory. Umile Giuseppe Longo, M.D., M.Sc., Ph.D. Giacomo Rizzello, M.D. Mattia Loppini, M.D.
Mauro Ciuffreda, M.D. Alessandra Berton, M.D. Nicola Maffulli, M.D., M.Sc., Ph.D. Vincenzo Denaro, M.D. Rome, Italy Ó 2015 by the Arthroscopy Association of North America http://dx.doi.org/10.1016/j.arthro.2015.01.002
References 1. Longo UG, Loppini M, Rizzello G, et al. Remplissage, humeral osteochondral grafts, Weber osteotomy, and shoulder arthroplasty for the management of humeral bone defects in shoulder instability: Systematic review and quantitative synthesis of the literature. Arthroscopy 2014;30: 1650-1666. 2. Longo UG, Loppini M, Rizzello G, Ciuffreda M, Maffulli N, Denaro V. Latarjet, Bristow, and Eden-Hybinette procedures for anterior shoulder dislocation: Systematic review and quantitative synthesis of the literature. Arthroscopy 2014;30:1184-1211. 3. Longo UG, Rizzello G, Locher J, et al. Bone loss in patients with posterior gleno-humeral instability: A systematic review. Knee Surg Sports Traumatol Arthrosc in press, available online 24 July, 2014. doi:10.1007/s00167-014-3161-8. 4. Longo UG, Loppini M, Rizzello G, Ciuffreda M, Maffulli N, Denaro V. Management of primary acute anterior shoulder dislocation: Systematic review and quantitative synthesis of the literature. Arthroscopy 2014;30:506-522. 5. Longo UG, Loppini M, Rizzello G, Romeo G, Huijsmans PE, Denaro V. Glenoid and humeral head bone loss in traumatic anterior glenohumeral instability: A systematic review. Knee Surg Sports Traumatol Arthrosc 2014;22:392-414.
LETTERS TO THE EDITOR
instability: Systematic review and quantitative synthesis of the literature.” The article that has been published in Arthroscopy is a well-executed systematic review about the repair options for Hill-Sachs defects. The title of the article indicates that this is a review that describes the possible treatment options for shoulder instability due to humeral bone defects. Although the authors give an extensive overview of local humeral treatment options, we feel that the role of an established procedure in the management of shoulder instability due to Hill-Sachs lesions is overlooked. In the introduction of their review, Longo et al. mention that Hill-Sachs defects are found in 65% to 71% of patients after an initial glenohumeral dislocation. The possible persisting instability, however, is not solely due to these lesions. Bony lesions of the glenoid are also seen in 41% of patients after an initial dislocation and in up to even 81% of patients with recurrent dislocations.2 Recurrent shoulder dislocations are the result of an interplay between these often bipolar lesions.3 This is explained by the glenoid track concept.2 Shortening of the glenoid track can be caused by anteroinferior glenoid bone loss. Even in the absence of significant glenoid bone loss, the Hill-Sachs lesion can be changed from an off-track lesion to an on-track lesion by performing a bone block augmentation procedure of the anterior glenoid rim.4 In other words, a Latarjet procedure or another proposed open or arthroscopic bone block procedure may well serve as a treatment option for shoulder instability due to HillSachs lesions.5 The advantage of a bone block procedure is that many shoulder surgeons have extensive experience with this type of surgery in contrast to procedures for filling the defect of the humeral head. Bony augmentation procedures have been performed for many years and are supported by numerous reports in the literature reporting favorable results6 compared with the described procedures in the article by Longo et al.1 With this letter, we would like to bring to their attention that bone block procedures should be considered in the treatment of Hill-Sachs defects and therefore deserve to have been addressed and analyzed in their review. Dirk P. ter Meulen, M.D. Alexander A. Weening, M.D. Derek F.P. van Deurzen, M.D. Michel P.J. van den Bekerom, M.D. Amsterdam, The Netherlands Note: The authors report the following potential conflict of interest or source of funding: D.F.P.v.D. receives support from Smith & Nephew. Enabling grant for research in rotator cuff surgery. Tornier. Financial support for research.
Ó 2015 by the Arthroscopy Association of North America http://dx.doi.org/10.1016/j.arthro.2015.01.001
References 1. Longo UG, Loppini M, Rizzello G, et al. Remplissage, humeral osteochondral grafts, Weber osteotomy, and shoulder arthroplasty for the management of humeral bone defects in shoulder instability: Systematic review and quantitative synthesis of the literature. Arthroscopy 2014;30: 1650-1666. 2. Griffith JF, Antonio GE, Yung PS, et al. Prevalence, pattern, and spectrum of glenoid bone loss in anterior shoulder dislocation: CT analysis of 218 patients. AJR Am J Roentgenol 2008;190:1247-1254. 3. Burkhart SS, De Beer JF. Traumatic glenohumeral bone defects and their relationship to failure of arthroscopic Bankart repairs: Significance of the inverted-pear glenoid and the humeral engaging Hill-Sachs lesion. Arthroscopy 2000;16:677-694. 4. Di Giacomo G, De Vita A, Costantini A, de Gasperis N, Scarso P. Management of humeral head deficiencies and glenoid track. Curr Rev Musculoskelet Med 2014;7:6-11. 5. Degen RM, Giles JW, Johnson JA, Athwal GS. Remplissage versus Latarjet for engaging Hill-Sachs defects without substantial glenoid bone loss: A biomechanical comparison. Clin Orthop Relat Res 2014;472:2363-2371. 6. Mizuno N, Denard PJ, Raiss P, Melis B, Walch G. Longterm results of the Latarjet procedure for anterior instability of the shoulder. J Shoulder Elbow Surg 2014;23: 1691-1699.
Authors’ Reply
We appreciate the concerns raised by Dr. ter Meulen et al. in their letter on our article.1 They pointed out that bone block procedures should be considered in the treatment of Hill-Sachs defects and therefore deserve to have been addressed and analyzed in our review. We respectfully point out that this review is part of a series of systematic reviews on shoulder instability performed by our research group, including the following: 1. A systematic review in which we analyzed clinical outcome, rate of recurrence, complications, and rate of postoperative osteoarthritis in patients with anterior shoulder instability managed with Latarjet, Bristow, or Eden-Hybinette procedures2 2. A systematic review on remplissage, humeral osteochondral grafts, Weber osteotomy, and shoulder arthroplasty for the management of humeral bone defects in shoulder instability1 3. A systematic review analyzing outcomes of surgical procedures for glenoid and/or humeral bony defects, performed singularly or in combination, in patients with posterior glenohumeral instability3
395
LETTERS TO THE EDITOR
4. A systematic review on the management of primary acute anterior shoulder dislocation4 5. A systematic review aimed to analyze outcomes of surgical procedures for glenoid and/or humeral bony defects, performed singularly or in combination, in patients with traumatic anterior glenohumeral instability with the secondary aim to establish, in clinical settings, what percentage of glenoid or humeral bone loss needs to be treated with a bony procedure to avoid recurrence of dislocation5 It is obvious that all these issues cannot be covered in one single article because the literature is too extensive. Therefore, while we do appreciate the concerns of ter Meulen et al., we ask that they and others take all 5 review articles as a whole to have a complete approach to the difficult management of a patient with bony lesions in the setting of shoulder instability. Of course, as stated by ter Meulen et al., “The advantage of a bone block procedure is that many shoulder surgeons have extensive experience with this type of surgery in contrast to procedures for filling the defect of the humeral head.” However, the aim of shoulder surgery should be restoration of the anatomy. The future of anatomic reconstruction in a patient with bony lesions in the setting of shoulder instability will be to address both bony glenoid and Hill-Sachs lesions (as well as soft-tissue lesions) with minimally invasive techniques. The available techniques for the management of Hill-Sachs defects are still unsatisfactory. Umile Giuseppe Longo, M.D., M.Sc., Ph.D. Giacomo Rizzello, M.D. Mattia Loppini, M.D.
Mauro Ciuffreda, M.D. Alessandra Berton, M.D. Nicola Maffulli, M.D., M.Sc., Ph.D. Vincenzo Denaro, M.D. Rome, Italy Ó 2015 by the Arthroscopy Association of North America http://dx.doi.org/10.1016/j.arthro.2015.01.002
References 1. Longo UG, Loppini M, Rizzello G, et al. Remplissage, humeral osteochondral grafts, Weber osteotomy, and shoulder arthroplasty for the management of humeral bone defects in shoulder instability: Systematic review and quantitative synthesis of the literature. Arthroscopy 2014;30: 1650-1666. 2. Longo UG, Loppini M, Rizzello G, Ciuffreda M, Maffulli N, Denaro V. Latarjet, Bristow, and Eden-Hybinette procedures for anterior shoulder dislocation: Systematic review and quantitative synthesis of the literature. Arthroscopy 2014;30:1184-1211. 3. Longo UG, Rizzello G, Locher J, et al. Bone loss in patients with posterior gleno-humeral instability: A systematic review. Knee Surg Sports Traumatol Arthrosc in press, available online 24 July, 2014. doi:10.1007/s00167-014-3161-8. 4. Longo UG, Loppini M, Rizzello G, Ciuffreda M, Maffulli N, Denaro V. Management of primary acute anterior shoulder dislocation: Systematic review and quantitative synthesis of the literature. Arthroscopy 2014;30:506-522. 5. Longo UG, Loppini M, Rizzello G, Romeo G, Huijsmans PE, Denaro V. Glenoid and humeral head bone loss in traumatic anterior glenohumeral instability: A systematic review. Knee Surg Sports Traumatol Arthrosc 2014;22:392-414.
