Inferiorly positioned Hill-Sachs lesions may be associated with Bankart repair failure
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Key takeaways:
- Inferior sagittal position of Hill-Sachs lesions may be associated with increased risk of Bankart repair failure.
- Further research is necessary to determine if sagittal position can be used to stratify results of surgery.
WASHINGTON — Results presented here showed that an inferior sagittal position of a Hill-Sachs lesion may be associated with increased failure risk of primary arthroscopic Bankart repair.
In a retrospective cohort study, Ting Cong, MD, and colleagues evaluated data for 176 patients (mean age, 20.6 years; 69.3% contact sport participation) with on-track lesions who underwent primary Bankart repair between 2007 and 2019 to determine the association between the inferior sagittal position of a Hill-Sachs lesion and the risk of Bankart repair failure after a minimum of 2-year follow-up. Researchers defined Bankart repair failure as subluxation or dislocation.
To compare the association between sagittal position of a Hill-Sachs lesion and Bankart failure, researchers created four Hill-Sachs quadrants based on superior (angle 40°), mid-superior (angle between 40° and 60°), mid (angle between 61° and 90°) and inferior (angle 90°) physiologic arm positions. An angle of 90° served as the equator.
“We looked at sagittal MRI, and we looked at whether these lesions extended below the equator of the humerus,” Cong said in his presentation at the American Orthopaedic Society for Sports Medicine Annual Meeting.
Cong said that the mid and inferior quadrants represented nearly a 24% risk of Bankart repair failure. In addition, he noted that after multivariate analysis, inferior sagittal position was increasingly associated with recurrent dislocation.
“In summary, we think this is quite a simple screening method. Any Hill-Sachs lesions that extend below the equator [of the humerus], just pay attention to them when you scroll through an MRI,” Cong said. “This is extraordinarily clinically facile; it doesn’t waste your time in the clinic, and you don’t have to crunch any numbers. Eyeball it next time you scroll through the sagittals.”
He added, “We do need to validate this and see if it could potentially be a ‘stratifier’ for surgery.”
Perspective
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The authors of this intriguing paper have shown that, in addition to the well-known on-track/off-track concept for glenohumeral instability, which evaluates the medial-lateral width of the Hill-Sachs lesion in relationship to a Bankart defect, the superior-inferior sagittal position of the Hill-Sachs is relevant as well. When evaluating arthroscopic Bankart repairs in the on-track shoulder, they found inferiorly based Hill-Sachs lesions were associated with nearly double the risk of failure of the repair. This paper presents a new concept, that appears to be another important piece of the puzzle when evaluating reasons for recurrent instability after prior arthroscopic Bankart repair in the on-track shoulder. Given the high recurrence rate after primary arthroscopic Bankart repair, we clearly need more data points in our algorithms when evaluating risk factors for recurrent instability.
The authors presented a relatively straightforward way to calculate the superior-inferior position of the Hill-Sachs lesion, and their study highlights the increasing need for clinicians to scrutinize the Hill-Sachs lesion more closely. As surgeons continue to assess various treatment modalities to prevent recurrent instability, this new concept adds another dimension to the risk-stratification when identifying higher-risk patients. However, we are not done, and I encourage these authors and all surgeons to continue our mission to bring recurrent instability rates as low as we possibly can.
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Cong T, et al. Paper 5. Presented at: American Orthopaedic Society for Sports Medicine Annual Meeting; July 12-16, 2023; Washington, D.C.
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