The Open Orthopaedics Journal




ISSN: 1874-3250 ― Volume 15, 2021
REVIEW ARTICLE

Management of Humeral Defects in Anterior Shoulder Instability



Maria Valencia Mora1, *, Miguel Ángel Ruiz-Ibán2, Jorge Diaz Heredia2, Raquel Ruiz Diaz2, Ricardo Cuéllar3
1 Hospital Fundación Jiménez Diáz, Madrid, Spain
2 Hospital Universitario Ramón y Cajal; Madrid, Spain
3 Hospital Universitario San Sebastían, San Sebastían, Spain

Abstract

Background:

A Hill Sachs lesion is a posterior-superior bony defect of the humeral head caused by a compression of the hard glenoid rim against the soft cancellous bone in the context of an anterior instability episode. The presence of these humeral defects increases with the number of dislocations and larger lesions are associated with a greater chance of development of recurrent instability and recurrence after surgery. Also its location and pattern, in particular the so-called engaging Hill-Sachs, are associated with poor prognosis.

Methods:

There is a lack of consensus in terms of classification and management algorithm, although lesions greater than 25% of the humeral head had been suggested to need more than a simple Bankart repair to avoid recurrence. The concept of glenoid track has turned the attention to location and shape and not only size of the humeral defect. Moreover, the glenoid bone loss is crucial when choosing a treatment option as it contributes to decrease the glenoid track as well. A thorough revision of treatment options has been performed.

Results:

Numerous treatment options have been proposed including remplissage, glenoid or humeral head augmentation, bone desimpaction, humeral rotational osteotomy and arthroplasty.

Conclusion:

Humeral defects treatment should be individualized. Determination of size and location of the defect and its relation with glenoid track is mandatory to achieve satisfactory results.

Keywords: Shoulder, Instability, Humeral defect, Remplissage, Autograft, Osteotomy.


Article Information


Identifiers and Pagination:

Year: 2017
Volume: 11
Issue: Suppl-6, M18
First Page: 1011
Last Page: 1022
Publisher Id: TOORTHJ-11-1011
DOI: 10.2174/1874325001711011011

Article History:

Received Date: 07/05/2016
Revision Received Date: 27/10/2016
Acceptance Date: 28/10/2016
Electronic publication date: 31/08/2017
Collection year: 2017

© 2017 Mora et al.

open-access license: This is an open access article distributed under the terms of the Creative Commons Attribution 4.0 International Public License (CC-BY 4.0), a copy of which is available at: https://creativecommons.org/licenses/by/4.0/legalcode. This license permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.


* Address correspondence to this author at the Hospital Fundación Jiménez Diáz, Madrid, Spain; Tel: 915504800; E-mail: maria.valencia.mora@gmail.com





1. INTRODUCTION

Malgaigne first described a bony defect of the posterolateral humeral head in 1855 [1Malgaigne JF. Traité des fractures et des luxations. Paris: JB Balliêre 1855.]. Later on, in 1940, Hill and Sachs wrote a review article on humeral bony defects after traumatic glenohumeral dislocations, what has given their names to the well-known lesion [2The grooved defect of the humeral head: A frequently unrecognized complication of dislocations of the shoulder joint. Radiology 1940; (35): 690-700.]. It was described as a “line of condensation on the shoulder radiograph when performed in internal rotation” and explained as a compression fracture of the posterior-superior aspect of the humeral head due to an impact against the glenoid rim. Since then, a thorough study of shoulder instability pathophysiology and a better understanding of biomechanics have demonstrated the relevance of this lesion when choosing a treatment option. A correct identification of this injury leads to a well-established decision-making process depending on its size and location and has shown to have a predictive value in recurrence rate.

1.1. Epidemiology

The real incidence of Hill Sachs lesion remains unknown. Hill and Sachs reported in their review an incidence of 20% to 100% [2The grooved defect of the humeral head: A frequently unrecognized complication of dislocations of the shoulder joint. Radiology 1940; (35): 690-700.]. Nowadays, the incidence ranges from 32% to 88% of all anterior shoulder instability events and has been associated to high rates of recurrent instability, where it is present in 77% to 100% of the cases [3Calandra JJ, Baker CL, Uribe J. The incidence of Hill-Sachs lesions in initial anterior shoulder dislocations. Arthroscopy 1989; 5(4): 254-7.
[http://dx.doi.org/10.1016/0749-8063(89)90138-2] [PMID: 2590322]
-6Yiannakopoulos CK, Mataragas E, Antonogiannakis E. A comparison of the spectrum of intra-articular lesions in acute and chronic anterior shoulder instability. Arthroscopy 2007; 23(9): 985-90.
[http://dx.doi.org/10.1016/j.arthro.2007.05.009] [PMID: 17868838]
]. It is also well known that dislocations rather than subluxations cause larger Hill-Sachs lesions, as well as repetitive events [7Kim DS, Yoon YS, Yi CH. Prevalence comparison of accompanying lesions between primary and recurrent anterior dislocation in the shoulder. Am J Sports Med 2010; 38(10): 2071-6.
[http://dx.doi.org/10.1177/0363546510371607] [PMID: 20709942]
, 8Ozaki R, Nakagawa S, Mizuno N, Mae T, Yoneda M. Hill-sachs lesions in shoulders with traumatic anterior instability: evaluation using computed tomography with 3-dimensional reconstruction. Am J Sports Med 2014; 42(11): 2597-605.
[http://dx.doi.org/10.1177/0363546514549543] [PMID: 25231817]
]. When defining the incidence by direct visualization in arthroscopy, the presence of the “bare area” should be taken into account in order to avoid over-diagnosing. It is the area that lies between the insertion of the posterior capsule and the edge of the articular surface, located along the anatomical neck of the humerus and should not be mistaken for a Hill Sachs lesion. Saito et al. reported that the most inferior portion of the Hill-Sachs lesion could overlap the bare area when it extended more than 19mm from the top of the humeral head [9Saito H, Itoi E, Minagawa H, Yamamoto N, Tuoheti Y, Seki N. Location of the Hill-Sachs lesion in shoulders with recurrent anterior dislocation. Arch Orthop Trauma Surg 2009; 129(10): 1327-34.
[http://dx.doi.org/10.1007/s00402-009-0854-4] [PMID: 19301017]
].

1.2. Pathophysiology

Anterior shoulder dislocation typically occurs with the arm in external rotation and abduction. As the humeral head is forced anteriorly, the capsulolabral structures of the shoulder are stretched and often torn [10Speer KP. Anatomy and pathomechanics of shoulder instability. Clin Sports Med 1995; 14(4): 751-60.
[PMID: 8581997]
]. Then, the head subsequently translates farther anteriorly and inferiorly. In this stage, the postero-superior-lateral aspect of the humeral head impacts against the anterior glenoid rim resulting in a compression fracture [2The grooved defect of the humeral head: A frequently unrecognized complication of dislocations of the shoulder joint. Radiology 1940; (35): 690-700.]. As mentioned before, in order to allow the humeral head to dislocate, an anterior detachment of the capsulolabral tissues is mandatory, what is called a Bankart lesion [11Protzman RR. Anterior instability of the shoulder. J Bone Joint Surg Am 1980; 62(6): 909-18.
[http://dx.doi.org/10.2106/00004623-198062060-00005] [PMID: 7430178]
]. In other cases, however, equivalent lesions can be present, as for example, glenoid bony injury (Bony Bankart) or periosteal lesions (anterior labro-ligamentous periosteal sleeve avulsion lesion, ALPSA) [4Hintermann B, Gächter A. Arthroscopic findings after shoulder dislocation. Am J Sports Med 1995; 23(5): 545-51.
[http://dx.doi.org/10.1177/036354659502300505] [PMID: 8526268]
, 7Kim DS, Yoon YS, Yi CH. Prevalence comparison of accompanying lesions between primary and recurrent anterior dislocation in the shoulder. Am J Sports Med 2010; 38(10): 2071-6.
[http://dx.doi.org/10.1177/0363546510371607] [PMID: 20709942]
], that can also contribute to recurrent instability patterns. When any of these happen, in each episode, the soft tissues attenuate progressively, allowing more contact between the soft humeral cancellous bone and the hard glenoid rim cortical bone (Fig. 1). Both mechanisms result in a greater bony defect and a weaker anterior soft tissue restraint, and eventually a higher risk of re-dislocation [12Provencher MT, Frank RM, Leclere LE, et al. The Hill-Sachs lesion: diagnosis, classification, and management. J Am Acad Orthop Surg 2012; 20(4): 242-52.
[http://dx.doi.org/10.5435/JAAOS-20-04-242] [PMID: 22474094]
].

Fig. (1)
(A)Development of the Hill-Sachs defect: As the humeral heads displaces anteriorly during dislocation (B), the anterior glenoid rim will impact with the soft humeral bone, causing the lesion.


In 2000, Burkhart and De Beer [13Burkhart 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(7): 677-94.
[http://dx.doi.org/10.1053/jars.2000.17715] [PMID: 11027751]
] demonstrated that it is not only size that matters, but also location and shape. Sixty years after the first description of a Hill Sachs lesion, a new concept emerged, called the “engaging Hill Sachs”. It was defined arthroscopically as a humeral head defect that is oriented parallel to the anterior rim and thus engages with it when the shoulder is positioned in the dislocation position. The prevalence of this engaging Hill-Sachs lesion was reported to be 1.5% by Burkhart and De Beer [13Burkhart 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(7): 677-94.
[http://dx.doi.org/10.1053/jars.2000.17715] [PMID: 11027751]
], 27% by Pagnani [14Pagnani MJ. Open capsular repair without bone block for recurrent anterior shoulder instability in patients with and without bony defects of the glenoid and/or humeral head. Am J Sports Med 2008; 36(9): 1805-12.
[http://dx.doi.org/10.1177/0363546508316284] [PMID: 18448579]
], and 34% by Cho et al. [15Cho SH, Cho NS, Rhee YG. Preoperative analysis of the Hill-Sachs lesion in anterior shoulder instability: How to predict engagement of the lesion. Am J Sports Med 2011; 39(11): 2389-95.
[http://dx.doi.org/10.1177/0363546511398644] [PMID: 21398576]
]. A few years later, in 2007, Yamamoto et al. introduced the second key concept in order to understand recurrent dislocations, the “glenoid track” [16Yamamoto N, Itoi E, Abe H, et al. Contact between the glenoid and the humeral head in abduction, external rotation, and horizontal extension: a new concept of glenoid track. J Shoulder Elbow Surg 2007; 16(5): 649-56.
[http://dx.doi.org/10.1016/j.jse.2006.12.012] [PMID: 17644006]
]. It was described as the contact zone between the glenoid and the humeral head when the arm is elevated in maximum external rotation and maximum horizontal extension and can be expressed in quantitative or qualitative terms. If the Hill-Sachs lesion extends more medially over the medial margin of the glenoid track, there is a risk of engagement and dislocation (Fig. 2). According to the measurement of Yamamoto et al. using cadaveric shoulders, the medial margin of the glenoid track was located at a distance equivalent to 84% of the width of the glenoid. Omori et al. also confirmed this measurement with MRI [17Omori Y, Yamamoto N, Koishi H, et al. Measurement of the glenoid track in vivo as investigated by 3-dimensional motion analysis using open MRI. Am J Sports Med 2014; 42(6): 1290-5.
[http://dx.doi.org/10.1177/0363546514527406] [PMID: 24681398]
]. These authors also demonstrated that the glenoid track was smaller as the degree of abduction increased, reaching a minimum of 81% of the width of the glenoid when the arm was abducted 150º. In summary, as recently demonstrated by Kurokawa et al. [18Kurokawa D, Yamamoto N, Nagamoto H, et al. The prevalence of a large Hill-Sachs lesion that needs to be treated. J Shoulder Elbow Surg 2013; 22(9): 1285-9.
[http://dx.doi.org/10.1016/j.jse.2012.12.033] [PMID: 23466174]
] in a CT study, two different types of engaging Hill Sachs can be identified. The first engaging Hill Sachs injury would be a large and wide bone defect and the second type, a narrow but medially located lesion. These authors described an overall incidence of 7% of engaging Hill-Sachs lesions. Interestingly, in all of the cases, a large glenoid bony defect was present. It could be said that when an osseous glenoid lesion increases in size, the glenoid track decreases accordingly, raising the probability of engaging.

Fig. (2)
Arthroscopic view of an large engaging Hill- Sachs lesion (A) viewed form the posterior portal in a left shoulder. When the humerus is rotated externally the defect slides over the glenoid, “engaging” and causing the dislocation (B).


1.3. Imaging

In order to evaluate anterior glenohumeral instability, the following three radiological projections should be obtained: an antero-posterior view of the shoulder in internal and external rotation and an axillary view. As mentioned before, the Hill Sachs defect occurs in the posterolateral aspect of the humeral head and can be better demonstrated by a combination of the internal rotation AP view and the Stryker notch view. On the other hand, Didiee and West Point views allow are especially useful when looking for bony Bankart defects [19Pavlov H, Warren RF, Weiss CB Jr, Dines DM. The roentgenographic evaluation of anterior shoulder instability. Clin Orthop Relat Res 1985; (194): 153-8.
[PMID: 3978907]
].

Although MRI continues to be the most used imaging technique (as it is routinely performed in this context to evaluate soft tissue damage), computerized tomography (CT) is widely considered the gold standard for evaluating bone loss Fig. (3). Three-dimensional CT reconstructions allow for a precise evaluation of the size (width and depth on axial and coronal images), orientation (Hill-Sachs angle) and location (bicipital and vertical angles) [15Cho SH, Cho NS, Rhee YG. Preoperative analysis of the Hill-Sachs lesion in anterior shoulder instability: How to predict engagement of the lesion. Am J Sports Med 2011; 39(11): 2389-95.
[http://dx.doi.org/10.1177/0363546511398644] [PMID: 21398576]
]; however, it is not useful for detecting purely cartilaginous lesions [8Ozaki R, Nakagawa S, Mizuno N, Mae T, Yoneda M. Hill-sachs lesions in shoulders with traumatic anterior instability: evaluation using computed tomography with 3-dimensional reconstruction. Am J Sports Med 2014; 42(11): 2597-605.
[http://dx.doi.org/10.1177/0363546514549543] [PMID: 25231817]
].

Fig. (3)
Computed tomography of the shoulder of a patient with shoulder instability showing a small Hill-Sachs lesion.


Magnetic resonance (MR) imaging and MR arthrography are the optimal techniques to define soft tissue lesions of the capsule-labral anterior complex. Some authors advocate the use of T1-weighted sequences with fat suppression in axial, oblique sagittal and coronal directions, as well as the ABER (Abduction-External rotation) series [20Van der Woude HJ, Vanhoenacker FM. MR arthrography in glenohumeral instability. JBR-BTR 2007; 90(5): 377-83.
[PMID: 18085192]
]. This type of images that are obtained in the prone position for shoulder dislocation, are typically useful in order to detect articular supraspinatus tears and a better identification of the anterior portion of the glenoid labrum and the anterior band of the inferior glenohumeral band [21Aydıngöz U, Maraş Özdemir Z, Ergen FB. Demystifying ABER (ABduction and External Rotation) sequence in shoulder MR arthrography. Diagn Interv Radiol 2014; 20(6): 507-10.
[http://dx.doi.org/10.5152/dir.2014.14117] [PMID: 25205022]
].

1.4. Classification and Clinical Relevance

Several classification systems have been proposed, however, none of them has been yet accepted as a useful management tool. For example, Rowe et al. [22Rowe CR, Zarins B, Ciullo JV. Recurrent anterior dislocation of the shoulder after surgical repair. Apparent causes of failure and treatment. J Bone Joint Surg Am 1984; 66(2): 159-68.
[http://dx.doi.org/10.2106/00004623-198466020-00001] [PMID: 6693441]
] classified the lesion depending on the size as measured in the axillary projection. The Hill Sachs lesion was defined as mild (2cm long x 0.3 cm deep), moderate (2-4 cm long x 0.3-1 cm deep) and severe (>4 cm x > 1cm deep). Calandra et al. [3Calandra JJ, Baker CL, Uribe J. The incidence of Hill-Sachs lesions in initial anterior shoulder dislocations. Arthroscopy 1989; 5(4): 254-7.
[http://dx.doi.org/10.1016/0749-8063(89)90138-2] [PMID: 2590322]
] and Franceschi et al. [23Franceschi F, Longo UG, Ruzzini L, Rizzello G, Maffulli N, Denaro V. Arthroscopic salvage of failed arthroscopic Bankart repair: A prospective study with a minimum follow-up of 4 years. Am J Sports Med 2008; 36(7): 1330-6.
[http://dx.doi.org/10.1177/0363546508314403] [PMID: 18375787]
] based their classification in severity of the injury on direct visualization, whether or not it affected subchondral bone. More recent studies have focused on the volume of humeral head involved or the percentage of the surface of the articular part of the humeral head, either on direct visualization during arthroscopy or measured in MRI or CT images.

Given the lack of consensus when classifying Hill Sachs lesions together with the fact that soft tissue damage, demographic features and quality of repair can influence the clinical result of the surgery, the question is now whether or not the injury is of clinical relevance. This idea was first proposed by Flatow and Warner [24Flatow EL, Warner JI. Instability of the shoulder: complex problems and failed repairs: Part I. Relevant biomechanics, multidirectional instability, and severe glenoid loss. Instr Course Lect 1998; 47: 97-112.
[PMID: 9571407]
] and was complemented by Di Giacomo et al. recognizing the importance of bipolar bony lesions when applying the glenoid track concept [25Di Giacomo G, Itoi E, Burkhart SS. Evolving concept of bipolar bone loss and the Hill-Sachs lesion: from “engaging/non-engaging” lesion to “on-track/off-track” lesion. Arthroscopy 2014; 30(1): 90-8.
[http://dx.doi.org/10.1016/j.arthro.2013.10.004] [PMID: 24384275]
].

The average size of the Hill Sachs lesion is 22 mm in width and 5 mm in depth [9Saito H, Itoi E, Minagawa H, Yamamoto N, Tuoheti Y, Seki N. Location of the Hill-Sachs lesion in shoulders with recurrent anterior dislocation. Arch Orthop Trauma Surg 2009; 129(10): 1327-34.
[http://dx.doi.org/10.1007/s00402-009-0854-4] [PMID: 19301017]
]. Saito et al. also studied the location on axial CT images, using a clock face (12 o’clock = anterior, 3 o’clock = medial, 6 o’clock = posterior, 9 o’clock = lateral) and described the top of the lesion located more posteriorly (6:46 hours) and the bottom more laterally (average 8:56) [9Saito H, Itoi E, Minagawa H, Yamamoto N, Tuoheti Y, Seki N. Location of the Hill-Sachs lesion in shoulders with recurrent anterior dislocation. Arch Orthop Trauma Surg 2009; 129(10): 1327-34.
[http://dx.doi.org/10.1007/s00402-009-0854-4] [PMID: 19301017]
]. The critical size of the Hill Sachs lesion that can cause instability is a medium or large defect, greater than 20% of the humeral head articular surface, with a depth greater than 16% of the humeral head diameter, a volume greater than 250mm3 or 1000mm3 or those that affect more than 5/8 of the humeral head radius [26Kaar SG, Fening SD, Jones MH, Colbrunn RW, Miniaci A. Effect of humeral head defect size on glenohumeral stability: A cadaveric study of simulated Hill-Sachs defects. Am J Sports Med 2010; 38(3): 594-9.
[http://dx.doi.org/10.1177/0363546509350295] [PMID: 20194958]
]. On the other hand, Sekiya et al. in a cadaveric study, demonstrated that although a defect of 25% of the humeral head causes an increase in anterior translation and bony contact force, it was not enough in isolation to cause recurrent anterior instability [27Sekiya JK, Jolly J, Debski RE. The effect of a Hill-Sachs defect on glenohumeral translations, in situ capsular forces, and bony contact forces. Am J Sports Med 2012; 40(2): 388-94.
[http://dx.doi.org/10.1177/0363546511425018] [PMID: 22053324]
].

1.5. Management

A correct assessment and treatment of the bony lesions associated to soft tissue damage in anterior shoulder instability is crucial. The recurrence rate after arthroscopic labral repair in the absence of glenoid or humeral head loss is only 4% [28Petrera M, Patella V, Patella S, Theodoropoulos J. A meta-analysis of open versus arthroscopic Bankart repair using suture anchors. Knee Surg Sports Traumatol Arthrosc 2010; 18(12): 1742-7.
[http://dx.doi.org/10.1007/s00167-010-1093-5] [PMID: 20237768]
] but it rises to 67% when substantial glenoid or humeral bone loss is present [13Burkhart 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(7): 677-94.
[http://dx.doi.org/10.1053/jars.2000.17715] [PMID: 11027751]
]. It has also been reported that the presence of a Hill-Sachs that could be noticed in a simple Rx with the shoulder in external rotation multiplied the recurrence rate by three (from 10% to 31%) [13Burkhart 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(7): 677-94.
[http://dx.doi.org/10.1053/jars.2000.17715] [PMID: 11027751]
].

Traditionally, the different treatment options considered when dealing with a large Hill-Sachs defect were focused in addressing the humeral defect itself (by filling it with bone or tendon or tendon or putting it away with an osteotomy); However, the concept of glenoid track changed the focus to an association of both humeral and glenoid defects. Some authors have advocated that a procedure more focused in the glenoid side that increases the glenoid track, such as a coracoid transfer to the anterior glenoid would be able to reduce the risk of an engaging Hill-Sachs [29Cho NS, Yoo JH, Rhee YG. Management of an engaging hill-sachs lesion: Arthroscopic remplissage with bankart repair versus latarjet procedure. Knee Surg Sports Traumatol Arthrosc 2015.
[PMID: 26044354]
]. Nevertheless, the most accepted absolute indications for an specific surgical management of Hill Sachs lesions are: Displaced humeral head fracture-dislocation and an associated Hill Sachs injury or lesions that affect more than 30%-40% of the humeral head with chronic dislocation or recurrent anterior instability. Relative indications would include: lesions of 20% to 35% of the humeral head with glenoid engagement on examination, lesions of more than 20% of the articular surface and signs of humeral head engagement on examination and lesions of 10% to 25% of the humeral head in the cases when the humeral head does not remain well centered in the glenoid fossa after arthroscopic instability repair [12Provencher MT, Frank RM, Leclere LE, et al. The Hill-Sachs lesion: diagnosis, classification, and management. J Am Acad Orthop Surg 2012; 20(4): 242-52.
[http://dx.doi.org/10.5435/JAAOS-20-04-242] [PMID: 22474094]
].

1.6. Conservative Management

A non-surgical approach might be considered in the cases of small osseous defects and non-engaging Hill-Sachs lesions. An appropriate treatment of Bankart lesion and other relevant pathology should be carefully addressed. In these cases, the standard rehabilitation protocol is performed afterwards, with an especial focus in deltoid muscle, rotator cuff muscles and scapular stabilizers strengthening [12Provencher MT, Frank RM, Leclere LE, et al. The Hill-Sachs lesion: diagnosis, classification, and management. J Am Acad Orthop Surg 2012; 20(4): 242-52.
[http://dx.doi.org/10.5435/JAAOS-20-04-242] [PMID: 22474094]
].

1.7. Remplissage

This technique consists in transforming an intra-articular humeral defect in an extra-articular lesion, thus reducing the risk of engaging (Fig. 4). Remplissage is the French word for “fill-in” and it is used in this context as the technique consists in a posterior capsulodesis and infraspinatus tenodesis into the bony defect area. It was first described by Purchase et al. [30Purchase RJ, Wolf EM, Hobgood ER, Pollock ME, Smalley CC. Hill-sachs “remplissage”: An arthroscopic solution for the engaging hill-sachs lesion. Arthroscopy 2008; 24(6): 723-6.
[http://dx.doi.org/10.1016/j.arthro.2008.03.015] [PMID: 18514117]
] in 2008 and posteriorly modified by Koo et al. [31Koo SS, Burkhart SS, Ochoa E. Arthroscopic double-pulley remplissage technique for engaging Hill-Sachs lesions in anterior shoulder instability repairs. Arthroscopy 2009; 25(11): 1343-8.
[http://dx.doi.org/10.1016/j.arthro.2009.06.011] [PMID: 19896057]
] in 2009 and is indicated in moderate to great humeral head bony defects without glenoid bone loss or combined with a non significant glenoid bone loss.

The arthroscopic technique starts with a posterior vision in order to identify the Hill Sachs lesion, once the standard general evaluation of the joint has been performed [30Purchase RJ, Wolf EM, Hobgood ER, Pollock ME, Smalley CC. Hill-sachs “remplissage”: An arthroscopic solution for the engaging hill-sachs lesion. Arthroscopy 2008; 24(6): 723-6.
[http://dx.doi.org/10.1016/j.arthro.2008.03.015] [PMID: 18514117]
]. An accessory portal is made just lateral to the posterior portal aiming the area of the lesion.

After carefully debriding the Hill Sachs zone an implant with two strands is introduced in the cancellous bone, and the two strands are passed independently through the infraspinatus muscle. It can also be performed with two or more implants to create a greater footprint. More recently, the use of all-suture implants has also been advocated. Care should be taken not to place the anchors too medial as it can result in restricted motion [32Elkinson I, Giles JW, Boons HW, et al. The shoulder remplissage procedure for Hill-Sachs defects: Does technique matter? J Shoulder Elbow Surg 2013; 22(6): 835-41.
[http://dx.doi.org/10.1016/j.jse.2012.08.015] [PMID: 23107147]
]. Knots are usually tied in the subacromial space after the anterior capsulolabral repair.

Fig. (4)
The Remplissage procedure: the lesion is identified from the anterosuperior portal (A). After debridement of the surface (B), two implants are placed along the defect (C) and the corresponding sutures passed percutaneously through the posterior capsule and infraspinatus tendon (D) allowing for an effective capsulotenodesis.


The postoperative management is not different from a simple anterior capsulolabral repair and will consist in 3 weeks of sling followed by passive and active exercises limiting external rotation to 0º until the sixth week. Several authors have demonstrated healing of the capsulotenodesis by means of imaging techniques [33Boileau P, O’Shea K, Vargas P, Pinedo M, Old J, Zumstein M. Anatomical and functional results after arthroscopic Hill-Sachs remplissage. J Bone Joint Surg Am 2012; 94(7): 618-26.
[http://dx.doi.org/10.2106/JBJS.K.00101] [PMID: 22488618]
, 34Zhu YM, Lu Y, Zhang J, Shen JW, Jiang CY. Arthroscopic Bankart repair combined with remplissage technique for the treatment of anterior shoulder instability with engaging Hill-Sachs lesion: a report of 49 cases with a minimum 2-year follow-up. Am J Sports Med 2011; 39(8): 1640-7.
[http://dx.doi.org/10.1177/0363546511400018] [PMID: 21505080]
].

Remplissage is an effective procedure and has demonstrated that reduces the rate of re-dislocation from >25% to approximately 5% when a Hill Sachs of 25% of the humeral head is present [29Cho NS, Yoo JH, Rhee YG. Management of an engaging hill-sachs lesion: Arthroscopic remplissage with bankart repair versus latarjet procedure. Knee Surg Sports Traumatol Arthrosc 2015.
[PMID: 26044354]
, 34Zhu YM, Lu Y, Zhang J, Shen JW, Jiang CY. Arthroscopic Bankart repair combined with remplissage technique for the treatment of anterior shoulder instability with engaging Hill-Sachs lesion: a report of 49 cases with a minimum 2-year follow-up. Am J Sports Med 2011; 39(8): 1640-7.
[http://dx.doi.org/10.1177/0363546511400018] [PMID: 21505080]
-36Longo 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(12): 1650-66.
[http://dx.doi.org/10.1016/j.arthro.2014.06.010] [PMID: 25194166]
]. Wolf et al. reported excellent results in their series of 45 patients with medium size humeral defects even in the presence of small glenoid defects. The mean follow up was 4 years and the reported re-dislocation rate of only 4.5% with a minimal rate of complications [37Wolf EM, Arianjam A. Hill-Sachs remplissage, an arthroscopic solution for the engaging Hill-Sachs lesion: 2- to 10-year follow-up and incidence of recurrence. J Shoulder Elbow Surg 2014; 23(6): 814-20.
[http://dx.doi.org/10.1016/j.jse.2013.09.009] [PMID: 24295834]
]. Park et al. in a longer follow up series found a recurrence rate of 15% after 5 years [38Park MJ, Tjoumakaris FP, Garcia G, Patel A, Kelly JD IV. Arthroscopic remplissage with Bankart repair for the treatment of glenohumeral instability with Hill-Sachs defects. Arthroscopy 2011; 27(9): 1187-94.
[http://dx.doi.org/10.1016/j.arthro.2011.05.010] [PMID: 21820842]
]. However, most of these studies lack of a control group. Ruiz Ibán et al. in a paired cohort study compared a group of similar patients with large Hill-Sachs defects that underwent simple Bankart repair with a group of patients in which both procedures were performed. They also reported a decrease in dislocation rate of 17% without finding any differences in range of motion or functional outcome [39Ruiz Ibán MA. Técnica de remplissage para defectos humerales grandes. Un estudio a medio plazo de cohortes emparejadas. Revista Española De Cirugía Artroscópica 2015; 21(2): 85-9.].

With regards to clinical outcome, Boileau et al. in their series reported a rate to return to sports of 90%, achieving the same level in 68% of the cases, including overhead activities. The rate of stable shoulders after 2 years of follow up was 98% [33Boileau P, O’Shea K, Vargas P, Pinedo M, Old J, Zumstein M. Anatomical and functional results after arthroscopic Hill-Sachs remplissage. J Bone Joint Surg Am 2012; 94(7): 618-26.
[http://dx.doi.org/10.2106/JBJS.K.00101] [PMID: 22488618]
]. Park et al. found lower WOSI scores at final follow up in the cases when a concomitant lesion (ALPSA; Kim lesion) was present and subsequently addressed during surgery [38Park MJ, Tjoumakaris FP, Garcia G, Patel A, Kelly JD IV. Arthroscopic remplissage with Bankart repair for the treatment of glenohumeral instability with Hill-Sachs defects. Arthroscopy 2011; 27(9): 1187-94.
[http://dx.doi.org/10.1016/j.arthro.2011.05.010] [PMID: 21820842]
].

The complication rate of this procedure is very low (0.9%). Persistent tenosynovitis of the long head of biceps and ipsilateral ulnar nerve palsy have been described [36Longo 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(12): 1650-66.
[http://dx.doi.org/10.1016/j.arthro.2014.06.010] [PMID: 25194166]
]. Despite the safety of this technique, it has been related to stiffness of the joint and limited range of motion due to its non-anatomic nature. Boileau et al. reported a loss of external rotation of approximately 10º in their series [33Boileau P, O’Shea K, Vargas P, Pinedo M, Old J, Zumstein M. Anatomical and functional results after arthroscopic Hill-Sachs remplissage. J Bone Joint Surg Am 2012; 94(7): 618-26.
[http://dx.doi.org/10.2106/JBJS.K.00101] [PMID: 22488618]
]. However, when comparing final range of movement after undergoing simple Bankart repair and Bankart repair with an associated remplissage technique, a similar loss of external rotation can be expected in both groups [39Ruiz Ibán MA. Técnica de remplissage para defectos humerales grandes. Un estudio a medio plazo de cohortes emparejadas. Revista Española De Cirugía Artroscópica 2015; 21(2): 85-9.]. This finding could suggest that the loss of external rotation might not be attributed only to this technique. Moreover, Merolla et al. have reported that infraspinatus muscle strength is recovered satisfactory when comparing to healthy subjects [40Merolla G, Paladini P, Di Napoli G, Campi F, Porcellini G. Outcomes of arthroscopic Hill-Sachs remplissage and anterior Bankart repair: a retrospective controlled study including ultrasound evaluation of posterior capsulotenodesis and infraspinatus strength assessment. Am J Sports Med 2015; 43(2): 407-14.
[http://dx.doi.org/10.1177/0363546514559706] [PMID: 25504843]
].

2. GLENOID BONE AUGMENTATION

Glenoid bone augmentation is a well-documented technique for addressing recurrent instability in the presence of an anterior glenoid defect [13Burkhart 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(7): 677-94.
[http://dx.doi.org/10.1053/jars.2000.17715] [PMID: 11027751]
, 41Burkhart SS, De Beer JF, Barth JR, et al. Results of modified Latarjet reconstruction in patients with anteroinferior instability and significant bone loss. Arthroscopy 2007; 23(10): 1033-41.
[http://dx.doi.org/10.1016/j.arthro.2007.08.009] [PMID: 17916467]
]. The most common procedures include coracoid transfer and iliac bone grafting. However, as previously mentioned some authors also advocate the use of these procedures in the presence of a Hill Sachs lesion in order to increase the glenoid track and reduce the risk of engagement (Fig. 5) [29Cho NS, Yoo JH, Rhee YG. Management of an engaging hill-sachs lesion: Arthroscopic remplissage with bankart repair versus latarjet procedure. Knee Surg Sports Traumatol Arthrosc 2015.
[PMID: 26044354]
, 42Degen 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(8): 2363-71.
[http://dx.doi.org/10.1007/s11999-013-3436-2] [PMID: 24385035]
, 43Lynch JR, Clinton JM, Dewing CB, Warme WJ, Matsen FA III. Treatment of osseous defects associated with anterior shoulder instability. J Shoulder Elbow Surg 2009; 18(2): 317-28.
[http://dx.doi.org/10.1016/j.jse.2008.10.013] [PMID: 19218054]
].

Fig. (5)
Biomechanical rationale for anterior glenoid bone augmentation: in a patient with a significant humeral bony defect (A) supplementation of the anterior glenoid rim will avoid engaging of the Hill-Sachs lesion (B).


3. HUMERAL HEAD BONE AUGMENTATION

The aim of this technique is to restore the anatomy of the humeral head by filling the defect created by the impaction of the glenoid [44Gerber C, Lambert SM. Allograft reconstruction of segmental defects of the humeral head for the treatment of chronic locked posterior dislocation of the shoulder. J Bone Joint Surg Am 1996; 78(3): 376-82.
[http://dx.doi.org/10.2106/00004623-199603000-00008] [PMID: 8613444]
]. This would eventually avoid engaging of the lesion. The main indications are a humeral defect of more than 40% of the humeral head in the absence of glenoid bone loss or a failed Bankart repair in the presence of a humeral defect greater than 25% [36Longo 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(12): 1650-66.
[http://dx.doi.org/10.1016/j.arthro.2014.06.010] [PMID: 25194166]
, 45Diklic ID, Ganic ZD, Blagojevic ZD, Nho SJ, Romeo AA. Treatment of locked chronic posterior dislocation of the shoulder by reconstruction of the defect in the humeral head with an allograft. J Bone Joint Surg Br 2010; 92(1): 71-6.
[http://dx.doi.org/10.1302/0301-620X.92B1.22142] [PMID: 20044682]
]. Bone plugs are custom-made for each defect using an autograft, an allograft Fig. (6) or a synthetic material [45Diklic ID, Ganic ZD, Blagojevic ZD, Nho SJ, Romeo AA. Treatment of locked chronic posterior dislocation of the shoulder by reconstruction of the defect in the humeral head with an allograft. J Bone Joint Surg Br 2010; 92(1): 71-6.
[http://dx.doi.org/10.1302/0301-620X.92B1.22142] [PMID: 20044682]
-48Saltzman BM, Riboh JC, Cole BJ, Yanke AB. Humeral head reconstruction with osteochondral allograft transplantation. Arthroscopy 2015; 31(9): 1827-34.
[http://dx.doi.org/10.1016/j.arthro.2015.03.021] [PMID: 25979686]
]. In exceptional occasions a fresh humeral osteoarticular graft can be used to replace the entire humeral head. The potential advantages of this procedure are the anatomical nature of the reconstruction, the restoration of range of movement and the avoidance of a replacement in extreme cases. The downsides are the necessity of an open approach, the risks of osteonecrosis of the humeral, graft resorption, nonunion or hardware complications [46Gerber C, Catanzaro S, Jundt-Ecker M, Farshad M. Long-term outcome of segmental reconstruction of the humeral head for the treatment of locked posterior dislocation of the shoulder. J Shoulder Elbow Surg 2014; 23(11): 1682-90.
[http://dx.doi.org/10.1016/j.jse.2014.03.017] [PMID: 24930838]
]. Only case series and case reports have been published [49Kazel MD, Sekiya JK, Greene JA, Bruker CT. Percutaneous correction (humeroplasty) of humeral head defects (Hill-Sachs) associated with anterior shoulder instability: a cadaveric study. Arthroscopy 2005; 21(12): 1473-8.
[http://dx.doi.org/10.1016/j.arthro.2005.09.004] [PMID: 16376238]
]. The complication rate is as high as 20% to 30% with a reoperation rate of more than 25% of the patients.

Fig. (6)
Humeral head augmentation: An osteochondral allograft is placed in the humeral defect and fixed with 2 headless compression screws (A,B). The CT scan shows adequate integration of the defect and restoration of the concavity (C).


4. DESIMPACTION

Desimpaction of the humeral head is relative new techniques that consist in elevating the compressed bone and support it with bone graft in an attempt to restore native anatomy [50Re P, Gallo RA, Richmond JC. Transhumeral head plasty for large Hill-Sachs lesions. Arthroscopy 2006; 22(7): 798.e1-4.
[http://dx.doi.org/10.1016/j.arthro.2005.12.038] [PMID: 16848061]
-52Weber BG, Simpson LA, Hardegger F. Rotational humeral osteotomy for recurrent anterior dislocation of the shoulder associated with a large Hill-Sachs lesion. J Bone Joint Surg Am 1984; 66(9): 1443-50.
[http://dx.doi.org/10.2106/00004623-198466090-00019] [PMID: 6501339]
]. The main indication would be an acute lesion of less than 3 weeks of evolution and less than 40% of involvement of the articular surface [12Provencher MT, Frank RM, Leclere LE, et al. The Hill-Sachs lesion: diagnosis, classification, and management. J Am Acad Orthop Surg 2012; 20(4): 242-52.
[http://dx.doi.org/10.5435/JAAOS-20-04-242] [PMID: 22474094]
]. It can be performed using a cortical window in the mid greater tuberosity just lateral to the bicipital groove and introducing a curved bone tamps in a retrograde fashion until reaching the defect. The correction should be performed and evaluated under fluoroscopic guidance [50Re P, Gallo RA, Richmond JC. Transhumeral head plasty for large Hill-Sachs lesions. Arthroscopy 2006; 22(7): 798.e1-4.
[http://dx.doi.org/10.1016/j.arthro.2005.12.038] [PMID: 16848061]
]. Alternatively, Re et al. described a percutaneous technique helped by an anterior cruciate ligament tibial guide [51Stachowicz RZ, Romanowski JR, Wissman R, Kenter K. Percutaneous balloon humeroplasty for Hill-Sachs lesions: a novel technique. J Shoulder Elbow Surg 2013; 22(9): e7-e13.
[http://dx.doi.org/10.1016/j.jse.2012.12.035] [PMID: 23473608]
]. More recently, the use of an inflatable balloon has also been described [52Weber BG, Simpson LA, Hardegger F. Rotational humeral osteotomy for recurrent anterior dislocation of the shoulder associated with a large Hill-Sachs lesion. J Bone Joint Surg Am 1984; 66(9): 1443-50.
[http://dx.doi.org/10.2106/00004623-198466090-00019] [PMID: 6501339]
]. However, only cadaveric studies have been reported and consequently more clinical studies should be performed before recommending these techniques.

5. HUMERAL OSTEOTOMY

Humeral osteotomy was first described by Weber and consists in a rotational osteotomy of the proximal humeral shaft in order to improve retroversion of the proximal humerus [53Armitage MS, Faber KJ, Drosdowech DS, Litchfield RB, Athwal GS. Humeral head bone defects: Remplissage, allograft, and arthroplasty. Orthop Clin North Am 2010; 41(3): 417-25.
[http://dx.doi.org/10.1016/j.ocl.2010.03.004] [PMID: 20497816]
]. It involves a subcapital humeral osteotomy with a medial rotation of the humeral head and imbrication of the subscapularis and anterior capsule [54Brooks-Hill AL, Forster BB, van Wyngaarden C, Hawkins R, Regan WD. Weber osteotomy for large Hill-Sachs Defects: clinical and CT assessments. Clin Orthop Relat Res 2013; 471(8): 2548-55.
[http://dx.doi.org/10.1007/s11999-013-3024-5] [PMID: 23653098]
]. The main retroversion aimed is 20º to 35º and the use of a guide intraoperatively is recommended to confirm the amount of derotation before plating, as it is a technically highly demanding procedure [55Kronberg M, Broström LA. Rotation osteotomy of the proximal humerus to stabilise the shoulder. Five years’ experience. J Bone Joint Surg Br 1995; 77(6): 924-7.
[PMID: 7593108]
, 56Grondin P, Leith J. Case series: Combined large Hill-Sachs and bony Bankart lesions treated by Latarjet and partial humeral head resurfacing: a report of 2 cases. Can J Surg 2009; 52(3): 249-54.
[PMID: 19503672]
]. Kronberg et al. studied the influence of diminished humeral retroversion in recurrence rate after Bankart repair [56Grondin P, Leith J. Case series: Combined large Hill-Sachs and bony Bankart lesions treated by Latarjet and partial humeral head resurfacing: a report of 2 cases. Can J Surg 2009; 52(3): 249-54.
[PMID: 19503672]
].

The reported recurrence rate is of 5% to 10%, however, the overall rate of complications and reoperation is high [55Kronberg M, Broström LA. Rotation osteotomy of the proximal humerus to stabilise the shoulder. Five years’ experience. J Bone Joint Surg Br 1995; 77(6): 924-7.
[PMID: 7593108]
]. Complications would include pain (complex regional syndrome), hematoma, infection, delayed malunion, rotation deficit and necessity of hardware removal [36Longo 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(12): 1650-66.
[http://dx.doi.org/10.1016/j.arthro.2014.06.010] [PMID: 25194166]
, 53Armitage MS, Faber KJ, Drosdowech DS, Litchfield RB, Athwal GS. Humeral head bone defects: Remplissage, allograft, and arthroplasty. Orthop Clin North Am 2010; 41(3): 417-25.
[http://dx.doi.org/10.1016/j.ocl.2010.03.004] [PMID: 20497816]
, 56Grondin P, Leith J. Case series: Combined large Hill-Sachs and bony Bankart lesions treated by Latarjet and partial humeral head resurfacing: a report of 2 cases. Can J Surg 2009; 52(3): 249-54.
[PMID: 19503672]
]. Weber et al. [53Armitage MS, Faber KJ, Drosdowech DS, Litchfield RB, Athwal GS. Humeral head bone defects: Remplissage, allograft, and arthroplasty. Orthop Clin North Am 2010; 41(3): 417-25.
[http://dx.doi.org/10.1016/j.ocl.2010.03.004] [PMID: 20497816]
] reported the greatest series of rotational osteotomies, consisting of 180 cases. The recurrence rate that they found was 6.8% without detecting a significant loss of external or internal rotation. Excluding hardware removal, only 9 patients required re-operation for a major complication. However, more recent series have been unable to reproduce their results. Brooks-Hill et al. in their series of 25 patients reported that the mean ASES score was 78 points, but 10 of them were unable to wash their backs with the affected arm. Moreover, nine of the 25 patients required a re-intervention [55Kronberg M, Broström LA. Rotation osteotomy of the proximal humerus to stabilise the shoulder. Five years’ experience. J Bone Joint Surg Br 1995; 77(6): 924-7.
[PMID: 7593108]
].

6. RESURFACING AND HEMIARTHROPLASTY

Humeral arthroplasty could be indicated in patients with humeral defects greater than 45% of the humeral head. In elderly patients, the existence of osteoporotic bone leads to greater bony defects. Moreover, it is frequent to find a rotator cuff disease and degenerative changes what can be an indication for a hemiarthroplasty, total arthroplasty or even reverse arthroplasty.

In the clinical scenario of a young patient with a massive Hill Sachs and early degenerative changes, there are not satisfactory options. More conservative options would include partial and complete resurfacing [54Brooks-Hill AL, Forster BB, van Wyngaarden C, Hawkins R, Regan WD. Weber osteotomy for large Hill-Sachs Defects: clinical and CT assessments. Clin Orthop Relat Res 2013; 471(8): 2548-55.
[http://dx.doi.org/10.1007/s11999-013-3024-5] [PMID: 23653098]
]. When comparing partial resurfacing with graft implantation, it is not clear whether it is easier to match the defect with the implant or with the bone plug, as the geometry might be difficult to reproduce [57Moros C, Ahmad CS. Partial humeral head resurfacing and Latarjet coracoid transfer for treatment of recurrent anterior glenohumeral instability. Orthopedics 2009; 32(8): orthosupersite.com/view.asp?rID=41928.
[http://dx.doi.org/10.3928/01477447-20090624-21] [PMID: 19708626]
, 58]. With regards to complete resurfacing and arthroplasty, it might be indicated in the setting of chronic dislocations with Hill Sachs defects greater than 40% [36Longo 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(12): 1650-66.
[http://dx.doi.org/10.1016/j.arthro.2014.06.010] [PMID: 25194166]
, 54Brooks-Hill AL, Forster BB, van Wyngaarden C, Hawkins R, Regan WD. Weber osteotomy for large Hill-Sachs Defects: clinical and CT assessments. Clin Orthop Relat Res 2013; 471(8): 2548-55.
[http://dx.doi.org/10.1007/s11999-013-3024-5] [PMID: 23653098]
].

CONCLUSION

In the context of anterior shoulder instability, humeral defects (Hill-Sachs lesions) have a clear impact in the recurrence rate of the dislocated shoulder and in the success of its surgical management.

It is essential to assess the humeral defects appropriately; this can be done with simple radiographic evaluation or MRI, but CT with 3D reconstruction is considered the best diagnostic procedure. During evaluation, attention should be paid not only to the width, length and depth of the defect but also to its position and orientation, trying to define if the defect can easily converge with the anterior rim of the glenoid during abduction and external rotation (an engaging Hill-Sachs). This can happen even with smaller defects when an associated glenoid defect is present, thus the glenoid track has to be carefully assessed.

Larger lesions and engaging lesions should be addressed specifically during surgery. Many alternatives have been proposed such as allo or autograft reconstruction, desimpaction of the compressed bone, humeral osteotomies and even arthroplasty but there are only significant reports of efficacy with the remplissage technique. This procedure, a posterior capsule-tenodesis of the infraspinatus over the defect has shown to lower the recurrence rate of patients with larger defects to levels similar to patients without relevant defects and has a low complication rate.

LIST OF ABBREVIATIONS

ABER  = Abduction-external rotation
ALPSA  = Anterior labro-ligamentous periosteal sleeve avulsion lesion
ASES  = American Shoulder and Elbow Score
CT  = Computerized tomography
WOSI  = Western-Ontario Shoulder Instability Score

CONSENT FOR PUBLICATION

Not applicable.

CONFLICT OF INTEREST

The authors declare no conflict of interest, financial or otherwise.

ACKNOWLEDGEMENTS

Declared none.

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