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The treatment of recurrent glenohumeral instability, especially with a concomitant bony lesion, remains challenging. This is especially true in the case of posterior instability given its less common incidence. Moreover, the presence of an engaging reverse Hill-Sachs lesion in combination with posterior instability will result in the need for a more aggressive treatment option. In comparison with a Hill-Sachs lesion, a reverse Hill-Sachs lesion features greater chondral deficiency that must be addressed during treatment. We propose the talus allograft as a potential allograft for treatment of an engaging reverse Hill-Sachs lesion. The superior articular surface of the talus may be used to reconstruct the articular surface of the humeral head. In this technical note, we describe our preferred primary technique for treatment of an engaging reverse Hill-Sachs lesion with recurrent glenohumeral instability through use of a fresh osteochondral talus allograft, as well as discuss the advantages and disadvantages of this allograft option.
Technique Video
See video under supplementary data.
Glenohumeral instability management can be complicated by recurrent instability. Posterior glenohumeral instability with a large, concomitant reverse Hill-Sachs lesion has limited surgical treatment options.
Soft-tissue filling of the defect has been used to address the reverse Hill-Sachs cartilaginous deficiency and bony defect. The McLaughlin procedure involves an open transfer of a lesser tuberosity that has undergone osteotomy, with the subscapularis tendon and anterior capsule attachments filling the defect bed.
have been used for patients with large, engaging, reverse Hill-Sachs lesions encompassing more than 40% of the humeral head. Alternatively, percutaneous balloon humeroplasty is currently undergoing biomechanical cadaveric and early clinical attempts.
Reconstruction with fresh osteochondral allograft is a promising operative technique to address reverse Hill-Sachs lesions in the case of failed McLaughlin and remplissage procedures
or during primary surgical repair of large, engaging reverse Hill-Sachs lesions. A fresh humeral osteochondral allograft has been used for anatomic reconstruction of a reverse Hill-Sachs lesion and has the additional benefit of addressing the associated chondral deficiency.
Concerns over the availability of fresh humeral head allograft donor sources and the potential risk of graft harvest contamination from the donor warranted the search for alternative allograft sites. Given that the humeral head is located closely to the central portion of the body, this heightens the risk of graft harvest contamination from the donor because of greater potential for exposure to pathogens. On the other hand, the talus is found much farther from major organs; therefore, this decreases risk of graft harvest contamination from the donor in comparison with the humeral head. Fresh talar allograft, with its highly congruent radius of curvature and robust weight-bearing dense bone and thick cartilage, is a potential source for anatomic allograft reconstruction. We present our surgical technique for anatomic humeral head reconstruction with a fresh osteochondral talar allograft to treat recurrent glenohumeral instability with a reverse Hill-Sachs lesion. This is a primary procedure for treatment of large reverse Hill-Sachs lesions with recurrent glenohumeral instability.
Diagnosis of Posterior Shoulder Instability
A focused physical examination of the shoulder is performed preoperatively. First, the severity of instability and laxity of the glenohumeral joint is assessed versus the contralateral, uninjured side. Then, apprehension and laxity testing should be completed with specific attention to apprehension during the mid range of abduction. Apprehension during this mid range of abduction is suggestive of a bony lesion, especially when combined with other mechanical symptoms such as clicking, catching, and crepitus. A reverse Hill-Sachs lesion with minimal to no glenoid bone loss may be clinically silent.
A comprehensive radiographic evaluation is conducted preoperatively to accurately evaluate the presence, volume, and orientation of the reverse Hill-Sachs lesion. Although radiographs may be used to identify the presence of a reverse Hill-Sachs lesion, additional imaging such as computed tomography (CT) scans and magnetic resonance imaging provides better 3-dimensional evaluation and quantification of the compression fracture. Through advanced imaging, one can discern the size, orientation, and location of the lesion.
In particular, CT scans allow for accurate estimation of the width, length, depth, and volume of the lesion. CT also allows for the quantification of glenoid bone loss; in cases of bipolar lesions, the glenoid track concept may be used to determine if and when the reverse Hill-Sachs lesion will engage with the glenoid rim. Ultimately, this potential for interaction dictates the risk of engagement and recurrence of instability.
After the induction of general anesthesia, an examination under anesthesia is performed to document range of motion, as well as positions of instability, and to examine the point of engagement of the reverse Hill-Sachs lesion. The patient is then placed in the lateral decubitus position through use of a standard 10-lb balanced suspension in the Arthrex Shoulder Suspension System (S3; Arthrex, Naples, FL). All bony prominences are well padded to prevent decubitus ulcers. After completion of the examination under anesthesia and positioning, the shoulder is prepared and draped in a sterile fashion.
Diagnostic Arthroscopy and Arthroscopic Bankart Repair
A diagnostic arthroscopic evaluation of the shoulder is performed through use of a standard posterior portal made 2 cm distally and in line with the posterior tip of the acromion. A standard anterosuperior portal is made outside-in under direct visualization in the region of the coracoid. For labral repair, the first anterior portal is made in the superior aspect of the rotator interval, followed by the creation of a second midanterior glenoid portal established distally or under the previously established anterior portal under direct visualization. Then, the arthroscope is moved to the midanterior portal to complete the diagnostic procedure. Concomitant intra-articular pathology, such as a posterior labral tear, synovitis, rotator cuff tear, or biceps tenosynovitis, can be addressed arthroscopically. These surgical techniques are not the subject of this technical report.
Exposure of Glenohumeral Joint
After a thorough arthroscopic evaluation, the patient is repositioned in the beach-chair position, with re-preparation and draping in a standard fashion. A deltopectoral incision is made beginning at the coracoid process and extending 7 cm distally (Fig 1). The subcutaneous tissue is incised, and the deltopectoral fascial layer is identified and incised. Establishment of the deltopectoral interval is facilitated by identification of the cephalic vein, which typically lies within this interval. The vein is identified and retracted medially after dissection and cauterization of perforating branches. The deltoid is retracted laterally. Hemostasis is maintained throughout the approach by electrocautery. After retraction of the deltoid and cephalic vein, the interval between the deltoid and conjoined tendon is bluntly developed after the clavipectoral fascia is incised. The superior one-third to one-half of the subscapularis is identified and then taken down through a 1.5-cm incision. The subscapularis is reflected off the bone through use of a peel technique and then tagged with a high-strength No. 2 suture for later repair. Finally, a T-shaped capsulotomy is performed to expose the humeral head and to visualize and evaluate the defect.
Fig 1(A) With the patient in the beach-chair position, a standard deltopectoral approach is undertaken on the affected left shoulder with the initial incision (red arrow) extending from the coracoid process to the distal aspect of the pectoralis major and anterior deltoid insertion on the humerus for a total of 7 cm in length. (B) In a left shoulder with the patient in the beach-chair position, the upper one-third to one-half of the subscapularis tendon insertion on the lesser tuberosity is peeled from the bone. Care is taken to avoid the 3 sister vessels at the inferior aspect of the insertion site. A tagging stitch (red arrow) is helpful to aid in retraction and eventual identification for partial subscapularis repair at the end of the procedure.
Evaluation of the Hill-Sachs lesion is facilitated by placement of the shoulder in abduction and external rotation. Once fully assessed, the lesion is outlined and an oscillating saw with a 1.3-cm-wide blade is used for further bony excision to form a regular “orange slice”–shaped defect that will be shape-fit with the talus allograft (Fig 2). Further smoothing of the prepared defect bed can be completed with a rasp. With the use of a ruler, the prepared defect size is measured, including width, length, and depth, to aid in the preparation of the talus allograft. In our case example, the width, length, and depth of the lesion measured 17 mm, 38 mm, and 12 mm, respectively.
Fig 2(A) In a left shoulder with the patient in the beach-chair position, after full exposure of the glenohumeral joint, the humeral head is finally reached. The extent of the Hill-Sachs lesion can now be seen with subsequent evaluation. The red arrows indicate the large defect before careful formation of the orange slice shape necessary for bony reconstruction. (B) In a left shoulder with the patient in the beach-chair position, the prepared defect size is measured with a ruler, including width, length, and depth, to aid in the preparation of the talus allograft. The green arrows indicate the prepared defect after use of an oscillating saw.
The talar dome from a donor source (JRF Ortho, Centennial, CO) is prepared to the appropriate size to fill the reverse Hill-Sachs defect based on the previous measurements (width, length, depth) (Fig 3). The size and shape of the graft are outlined with a surgical pen. The finalized outline should measure 1 to 2 mm larger across all dimensions than the lesion itself to account for the kerf of the saw blade. This will allow for better customization of the graft to fit the defect. All cuts are made across the outline through the use of an oscillating saw while the assistant and surgeon hold the graft firmly in place. Towel clamps may further facilitate stabilization of the graft. It is key that the allograft is kept cool with copious irrigation to avoid thermal necrosis of the cartilage and underlying subchondral bone. For optimal fitting of the allograft into the humeral head, the orange slice configuration must be kept in mind during shaping of the allograft.
Fig 3(A) The size and shape of the graft are outlined with a surgical pen and ruler (red arrows) on the surface of the talar dome based on the width, length, and depth measurements of the prepared defect. The finalized outline should measure 1 to 2 mm larger than the actual prepared defect across all dimensions. (B) The assistant and surgeon hold the graft firmly in place while all cuts are made along the outline (red arrows), with further facilitation possible through the use of towel clamps. (C) All cuts are made along the outline through use of an oscillating saw (red arrow). It is key that the allograft is kept cool with copious saline solution irrigation to avoid thermal necrosis of the cartilage and underlying subchondral bone.
Once the cuts are finalized, three 2.4-mm Kirschner wires are added onto the graft (Fig 4). Then, pulse lavage of the allograft is performed to remove all marrow elements before graft fixation. We find that approximately 5 minutes of lavage is necessary to adequately remove these elements. After pulse lavage, the allograft is soaked in a combination of autologous conditioned plasma and platelet-rich plasma for application through use of a Double Syringe System (Greyledge Technologies, Vail, CO). Before this, 60 mL of peripheral blood is collected from the patient and undergoes centrifugation for approximately 10 minutes to heterogeneously divide the blood.
Fig 4(A) In a left shoulder with the patient in the beach-chair position, once the cuts are made, three 2.4-mm K-wires are drilled onto the graft to be used to transport the graft. The allograft is then positioned into the prepared defect by the K-wires. The K-wires (green arrows) are advanced to reach the humeral cortex. Once this is completed, the leveling between the allograft and native humeral head is verified to ensure optimal positioning. (B) In a left shoulder with the patient in the beach-chair position, a cannulated drill is used over the K-wires and 3 separate 3.0-mm Acutrak headless compression titanium screws (green arrow) are placed in unicortical fashion to definitively fix the graft into the defect. Care should be taken to verify that the screws are countersunk into the subcortical bone to avoid violation of the cartilage surface. (C) Reconstruction of the Hill-Sachs lesion with a fresh osteochondral talus allograft (red arrows) in the affected left shoulder is shown while the patient is in the beach-chair position. Once all the screws have been placed and definitive fixation has been reached, examination by internal and external rotation of the shoulder is performed to ensure optimal positioning of the graft as well as proper leveling between the graft and native humeral head. This is also necessary to avoid any damage to the glenoid bone.
The graft is then positioned into the defect, and the previously placed K-wires are advanced from the allograft into the proximal humerus. A cannulated drill is used over the K-wires, and 3 separate 3.0-mm Acutrak headless compression titanium screws (Acumed, Hillsboro, OR) are placed in a unicortical fashion to definitively fix the graft into the defect. Care should be taken to verify that the screws are countersunk into the subcortical bone to avoid violation of the cartilage surface. Once fixation is complete, leveling between the graft and native humeral head is verified to ensure complete anatomic restoration throughout shoulder range of motion. The goal of reconstruction is to reconstruct a smooth articular surface and fill the reverse Hill-Sachs defect.
Closure of Glenohumeral Joint and Repair of Subscapularis Tendon
The partially detached subscapularis tendon is identified by the tagging stitch, and the subscapularis is repaired through use of a double-row technique with three 4.75-mm PEEK (polyether ether ketone) SwiveLock anchors (Arthrex) and FiberTape (Arthrex) in conjunction with a side-to-side repair. The surgical wound is then closed in layered fashion with No. 0 Vicryl (Ethicon) for closure of the deltopectoral fascia, No. 3-0 Vicryl for closure of the subcutaneous layer, and No. 3-0 Monocryl (Ethicon) for closure of the subcuticular layer. Lastly, Dermabond (Ethicon) and Steri-Strips (3M) are applied, followed by application of a sterile dressing. The surgical technique is reviewed in Video 1.
Postoperative Rehabilitation
The patient is initially placed in an UltraSling (DJO Global) in neutral rotation for the first 5 weeks after surgical treatment. Internal rotation of the shoulder is strictly not allowed for the first 6 weeks, whereas passive flexion to 120° and abduction to 90° are permitted. Once the UltraSling is removed, the patient is limited to maximum internal rotation of a neutral position with passive flexion to 160° and passive abduction to 160°. Horizontal abduction and open-can exercises, as well as deltoid isometric exercises at less than 30° of abduction and TheraBand (Hygenic) exercises with the elbow at the patient's side, are begun. From postoperative week 6 through week 12, the patient is expected to have restoration of full range of motion in all planes and internal rotation in 90° of abduction is permitted. Furthermore, additional strengthening exercises including plyometric exercises, sport-specific motion exercises through use of a pulley and manual resistance, and proprioceptive training are implemented during this period. During weeks 12 through 16, strength deficits are eliminated and flexibility is maintained, and a return to full contact in exercise is allowed if abduction and external rotation strength are symmetric with the nonoperative side. After postoperative week 16, isokinetic testing is emphasized. At postoperative week 24, the patient is allowed to return to full, unrestricted activity. Table 1 lists pearls and pitfalls of the described technique, and Table 2 lists advantages and disadvantages.
Table 1Pearls and Pitfalls of Talus Allograft Procedure for Anatomic Humeral Head Reconstruction
Pearls
Preoperative planning should be performed with advanced radiographic imaging (e.g., CT scan with 3D reconstruction).
Partial subscapularis takedown during the approach without disruption of the 3 sister vessels may improve postoperative rehabilitation.
Copious saline solution irrigation during bone cutting or shaping should be used to avoid necrosis of the fresh cartilage graft.
Intraoperative range-of-motion measurements should be taken after augmentation to ensure smooth and full range of motion.
Early, monitored and formal physical therapy should be performed to enhance postoperative outcomes.
Pitfalls
Inaccurate measurement of the defect preoperatively may result in inadequate allograft size.
Complete takedown of the subscapularis may slow down rehabilitation.
Inadequate irrigation during bone cuts may theoretically result in cartilage thermal necrosis and early graft failure.
Failure to perform thorough evaluation of the joint (occasionally requiring arthroscopy) may result in missing associated pathology (e.g., labral tearing).
Delayed rehabilitation may lead to decreased postoperative range of motion and a stiff shoulder joint.
Countersinking of compression screws must be verified to ensure protection of the glenoid joint surface during range of motion.
Bony defects—both glenoid bone loss and Hill-Sachs lesions—can result in refractory glenohumeral instability that is not readily amenable to surgical treatment.
introduced the concept of the glenoid track, which is defined as the contact zone between the glenoid and humeral head. Through this concept, the lesion is defined as either engaging or non-engaging. An engaging Hill-Sachs lesion is also considered “off-track” if it is located outside of the contact zone between the glenoid and humeral head, resulting in engagement with the glenoid rim. Non-engaging lesions are considered “on-track” if they fall within the contact zone between the glenoid and humeral head, which results in no engagement with the glenoid rim.
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.
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.
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.
Although the remplissage procedure is a viable treatment option, the resulting loss of external rotation has been noted as a concern, especially in throwing athletes.
One hundred eighteen Bristow-Latarjet repairs for recurrent anterior dislocation of the shoulder prospectively followed for fifteen years: Study II—The evolution of dislocation arthropathy.
Although reconstruction through use of a humeral head allograft has been described as effective for treatment of Hill-Sachs lesions, the graft has limited accessibility and requires more precise size matching.
The talus allograft has recently been proposed as a potential allograft for Hill-Sachs and reverse Hill-Sachs lesion reconstruction.
The superior articular surface of the talus is used to reconstruct the articular surface of the humeral head because of the similar congruency between the radii of curvature seen with the talar dome and with the humeral head.
The cartilaginous surface of the talus allograft provides for better articular contact with the glenoid bone. The dense quality of the subchondral bone allows for more stable fixation of the graft to the humeral head. The more consistent size matching is advantageous, allowing for wider application to more patients.
Talus allograft reconstruction of a reverse Hill-Sachs defect is associated with some disadvantages. There is limited availability of allografts in some regions of the world. The theoretical risk of nonunion between the humeral head and talus allograft is an additional concern; therefore, platelet-rich plasma is used to enhance biological factors to potentially promote bony union.
In summary, our technical note describes a viable and safe method for bony reconstruction of the humeral head to address an engaging reverse Hill-Sachs lesion that resulted in recurrent glenohumeral instability. Future long-term studies are needed to assess the clinical efficacy of this technique.
First, examination under anesthesia is performed to document range of motion, as well as severity of instability, and to examine the point of engagement of the reverse Hill-Sachs lesion. The patient is then placed in the lateral decubitus position, all bony prominences are well padded, and the shoulder is prepared and draped in a sterile fashion. A diagnostic arthroscopic evaluation of the shoulder is performed before exposure. After arthroscopic evaluation, the patient is repositioned in the beach-chair position. A deltopectoral incision is made beginning at the coracoid process and extending 7 cm distally. The subcutaneous tissue is incised, and then the deltopectoral fascial layer is identified and incised as well. The deltoid is retracted laterally, and the interval between the deltoid and conjoined tendon is bluntly dissected. The superior one-third to one-half of the subscapularis is identified and then partially taken down through a 1.5-cm incision and tagged with a high-strength No. 2 suture for later repair. A T-shaped capsulotomy is performed to expose the humeral head and evaluate the defect. The Hill-Sachs lesion is outlined, and an oscillating saw with a 1.3-cm-wide blade is used for further bony excision to carefully shape the orange slice defect that will be used as a reference for measurements to form the talus allograft. With the use of a ruler, the prepared defect size is measured, including width, length, and depth, to aid in the preparation of the talus allograft. The size and shape of the graft are outlined with a surgical pen on the surface of the talar dome. The finalized outline should measure 1 to 2 mm larger across all dimensions than the lesion itself to account for the kerf of the saw blade. All cuts are made across the outline through the use of an oscillating saw while the assistant and surgeon hold the graft firmly in place. It should be noted that the allograft must be kept cool with copious saline solution irrigation to avoid thermal necrosis of the cartilage and underlying subchondral bone. Moreover, for optimal fitting of the allograft into the humeral head, the orange slice shape must be kept in mind while cuts are being completed. Once the cuts are finalized, three 2.4-mm K-wires are added onto the graft. After this, pulse lavage is performed to remove all marrow elements before graft fixation. Then, the allograft is bathed in a combination of autologous conditioned plasma and platelet-rich plasma. The graft is positioned into the defect, and the previously placed K-wires are advanced from the allograft into the proximal humerus. A cannulated drill is then used over the K-wires, and 3 separate 3.0-mm Acutrak headless compression titanium screws are placed in a unicortical fashion for definitive fixation. Once fixation is complete, leveling between the graft and native humeral head is verified to ensure complete anatomic restoration. The partially detached subscapularis tendon is identified by the previously placed tagging stitch; then, the subscapularis is repaired through use of three 4.75-mm PEEK (polyether ether ketone) SwiveLock anchors and FiberTape in conjunction with a side-to-side repair. After this, the surgical wound is closed in a layered fashion, and DermaBond, Steri-Strips, and a sterile dressing are applied.
References
Shah N.
Tung G.A.
Imaging signs of posterior glenohumeral instability.
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.
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.
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.
One hundred eighteen Bristow-Latarjet repairs for recurrent anterior dislocation of the shoulder prospectively followed for fifteen years: Study II—The evolution of dislocation arthropathy.
The authors report the following potential conflicts of interest or sources of funding: M.T.P. receives support from Arthrex, JRF Ortho. Consultant. Patent numbers (issued) 9226743, 20150164498, 20150150594, 20110040339. Arthrex, SLACK. Publishing royalties.
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