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Talar Allograft Preparation for Treatment of Reverse Hill-Sachs Defect in Recurrent Posterior Shoulder Instability

      Abstract

      Reverse Hill-Sachs lesions (rHSLs) after chronic posterior shoulder instability are important to recognize and treat appropriately. Treatment options for posterior instability with rHSL in the current literature are primarily based on percentage of humeral bone loss. In cases of moderate (25% to 50%) anterolateral humeral head bone loss, fresh osteochondral allografts are preferred. Recent literature has indicated that the talus serves as a robust grafting alternative site for the humeral head, as the talar dome shows high congruency and offers variable sizes. The purpose of this Technical Note is, therefore, to describe our technique for talus allograft preparation for the treatment of a large rHSL that highlights precise cutting anatomy, sizing options, and use of orthobiologics to ensure excellent talus union to the native humeral head surface.

      Technique Video

      (mp4, (82.01 MB)

      A comprehensive preoperative evaluation is conducted to accurately evaluate the presence, volume, and orientation of the rHSL. The shoulder is placed in an abducted, externally rotated position to ensure proper evaluation of the rHSL. Once appropriately visible, the lesion is outlined, and an oscillating saw with a 1.3-cm-wide blade is used for further bony excision of the lesion to form a pie-shaped defect. Once preparation of the proximal humerus defect is complete, lesion length, depth, and width are measured. Talar dome from a donor source (JRF Ortho, Centennial, CO) is obtained on the back table. The talar dome should be matched with the humeral defect. First, the cartilage margin at the medial and lateral aspect of the allograft is marked. An additional line is drawn from medial to lateral along the anterior aspect of the allograft, which will mark the desired graft length. While the assistant and surgeon hold the allograft firmly in place with a Kocher clamp, a sagittal saw is used to remove the preoperatively templated portion of the medial talar dome as the initial medial sagittal cut. A second cut is made along the lateral talar dome as the initial lateral sagittal cut. After the initial medial and lateral sagittal cuts are completed, the talus allograft is rotated and the longitudinal cut is made in line to the axis of the talus to remove the excess portion of the predefined graft. Attention is turned back to the exposed medial portion of the talar dome, and the preoperatively templated maximum depth is then marked. A parallel guide with a finger projection is angled toward the anterior portion of the allograft. A 2.4-mm Kirschner wire (K-wire) is inserted into the graft. Next, the graft is inserted into the humeral defect and marked with a marker pen, ensuring that an area of error for fitting the graft of the defect is included. A cannulated drill is used over the K-wires, and three 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 confirm that the screws are not violating the articular surface.

      Technique Video

      See video under supplementary data.

      Introduction

      Stability of the glenohumeral joint is dependent on the articulation of the scapular glenoid and humeral head. In the case of an instability event, the humeral head is forced out of the glenoid in an anterior- or posterior-inferior direction. Traumatic episodes such as this can cause compression of the postero- or anterolateral region of the humeral head, known as a Hill-Sachs lesion (HSL) or reverse HSL (rHSL), respectively. While incidence of HSLs have been reported as a high as 100% in patients with recurrent anterior shoulder dislocations,
      • Provencher M.T.
      • Frank R.M.
      • Leclere L.E.
      • et al.
      The Hill-Sachs lesion: Diagnosis, classification, and management.
      rHSLs are detected in roughly 39% of dislocations posteriorly.
      • Moroder P.
      • Plachel F.
      • Tauber M.
      • et al.
      Risk of engagement of bipolar bone defects in posterior shoulder instability.
      At present, algorithms for posterior instability intervention reflect many of the same principles as anterior instability: consideration of the arc of rotation of the humeral head with respect to the glenoid surface. Therefore, surgical strategies include either optimizing the surface arc of rotation (and, therefore, total arc of stability) by restoration of the humeral head (e.g., osteochondral graft), or restriction of the arc of rotation by constraining the motion of the humeral head relative to the glenoid (e.g., reverse-remplissage).
      • Guehring M.
      • Lambert S.
      • Stoeckle U.
      • Ziegler P.
      Posterior shoulder dislocation with associated reverse Hill-Sachs lesion: treatment options and functional outcome after a 5-year follow up.
      Treatment options for posterior instability with rHSL in the current literature are primarily based on the percentage of humeral bone loss: posterior capsulolabral repairs or plications for <25% bone loss, and iliac crest structural bone grafting or distal tibial allografting, reverse remplissage, balloon humeroplasty,
      • Sandmann G.H.
      • Ahrens P.
      • Schaeffeler C.
      • et al.
      Balloon osteoplasty—A new technique for minimally invasive reduction and stabilisation of hill-sachs lesions of the humeral head: a cadaver study.
      hemiarthroplasty,
      • Barlow J.D.
      • Abboud J.
      Surgical options for the young patient with glenohumeral arthritis.
      or a talar osteochondral allograft wedge
      • Provencher M.T.
      • Sanchez G.
      • Schantz K.
      • et al.
      Anatomic humeral head reconstruction with fresh osteochondral talus allograft for recurrent glenohumeral instability with reverse Hill-Sachs lesion.
      for patients with 25% to 50% humeral head bone loss. Resurfacing and replacement options should be reserved for the older patients who are less active or have severe arthritis in which >50% of the humeral head articular surface is affected.
      • Provencher M.T.
      • Frank R.M.
      • Leclere L.E.
      • et al.
      The Hill-Sachs lesion: Diagnosis, classification, and management.
      In cases of moderate (25% to 50%) anterolateral humeral head bone loss, fresh osteochondral allografts are preferred. Recent literature has illustrated that osteo- and osseocartilaginous intervention both maximizes anatomic restoration of the humeral head, while minimizing disruption of healthy native bone. Allografting for humeral head defects have also reported lower resorption rates than other intervention options.
      • Provencher M.T.
      • LeClere L.E.
      • Ghodadra N.
      • Solomon D.J.
      Postsurgical glenohumeral anchor arthropathy treated with a fresh distal tibia allograft to the glenoid and a fresh allograft to the humeral head.
      ,
      • Saltzman B.M.
      • Riboh J.C.
      • Cole B.J.
      • Yanke A.B.
      Humeral head reconstruction with osteochondral allograft transplantation.
      While use of fresh humeral head allografts has shown success in repairing humeral head lesions, concerns over donor availability and risk of graft harvest contamination have justified the search for alternative allograft sites.
      • Nathan S.T.
      • Parikh S.N.
      Osteoarticular allograft reconstruction for hill-sachs lesion in an adolescent.
      Recent literature has indicated that the talus serves as a robust grafting alternative site for the humeral head, as the talar dome shows high congruency and offers a maximum size of 30 × 10 mm for a single graft.
      • Provencher M.T.
      • Sanchez G.
      • Schantz K.
      • et al.
      Anatomic humeral head reconstruction with fresh osteochondral talus allograft for recurrent glenohumeral instability with reverse Hill-Sachs lesion.
      ,
      • Chan C.M.
      • LeVasseur M.R.
      • Lerner A.L.
      • Maloney M.D.
      • Voloshin I.
      Computer modeling analysis of the talar dome as a graft for the humeral head.
      • Griswold B.G.
      • Paré D.W.
      • Herzwurm Z.P.
      • et al.
      Utility of allograft talus as a source for grafting of concurrent humeral and glenoid defects associated with anterior glenohumeral instability: An anthropometric analysis.
      • Mitchell J.J.
      • Vap A.R.
      • Sanchez G.
      • et al.
      Concomitant reverse Hill-Sachs lesion and posterior humeral avulsion of the glenohumeral ligament: Treatment with fresh talus osteochondral allograft and arthroscopic posterior humeral avulsion of the glenohumeral ligament and labrum repair.
      Moreover, anthropometric properties of talus are similar to the native humeral head and the radius of curvature (ROC) of the glenoid.
      • Griswold B.G.
      • Paré D.W.
      • Herzwurm Z.P.
      • et al.
      Utility of allograft talus as a source for grafting of concurrent humeral and glenoid defects associated with anterior glenohumeral instability: An anthropometric analysis.
      Although techniques using talus allograft for humeral head reconstruction have been described in the previous literature, it is essential to provide an outlined preparatory allograft procedure that optimizes bone union. The purpose of this Technical Note is, therefore, to describe our technique for talus allograft preparation for the treatment of a large rHSL that highlights precise cutting anatomy, sizing options, and use of orthobiologics to ensure excellent talus union to the native humeral head surface.

      Surgical Technique

      A detailed video with demonstration of the surgical technique described in the following may be reviewed (Video 1). The pearls and pitfalls associated with the talus allograft preparation technique are listed in Table 1. Advantages, risks, and limitations of this surgical preparation are also listed in Table 2.
      Table 1Pearls and Pitfalls of Talus Allograft Preparation for Anatomic Head Reconstruction
      PearlsPitfalls
      Preoperative planning with advanced imaging (CT-scan with 3D reconstruction) is crucialInaccurate measurement of the defect preoperatively may result in inadequate allograft size.
      It is essential that the allograft is kept cool and is copiously irrigated to avoid risk of thermal necrosis of the cartilage and the underlying subchondral bone.High learning curve
      All cut outline should be 2–5 mm larger than the desired graft length to compensate for an error of measurement and the kerf of the saw blade.Potential of saw blade injury
      The orange slice configuration must be kept in mind during shaping of the allograft for an optimal fitting.
      A biologic treatment such as autologous conditioned plasma and platelet-rich-plasma is encouraged
      Table 2Advantages, Risks and Limitations of Talus Allograft Preparation for Anatomic Head Reconstruction
      AdvantagesRisks and Limitations
      The fresh talus allograft is identical to the radius of curvature of the humeral headImproper graft sizing and positioning that fails to restore the anatomic glenohumeral arc of motion
      Restoration of humeral head sphericity and its arc of rotation against the glenoid surfaceRisk of nonunion
      Offers a dense, weight-bearing cartilaginous surface to create a more profound articular contact with the glenoid, and stable fixationAvailability of talus allograft
      Precise cutting anatomy, sizing options, and orthobiologics ensure excellent talus union to the native humeral head surfaceLearning curve

      Lesion Sizing

      A comprehensive preoperative evaluation is conducted to accurately evaluate the presence, volume, and orientation of the rHSL. While radiographs may be used to identify the rHSL, supplemental imaging, including computed tomography (CT) scans and magnetic resonance imaging should also be used to provide better 3-dimensional evaluation and quantification of the compression fracture.
      • Provencher M.T.
      • Sanchez G.
      • Schantz K.
      • et al.
      Anatomic humeral head reconstruction with fresh osteochondral talus allograft for recurrent glenohumeral instability with reverse Hill-Sachs lesion.
      The shoulder is placed in an abducted, externally rotated position to ensure proper evaluation of the rHSL. Once appropriately visible, the lesion is outlined and an oscillating saw with a 1.3-cm-wide blade is used for further bony excision of the lesion to form a pie-shaped defect. This will produce a lesion that is shape-fit with the subsequently prepared talus allograft. Once preparation of the proximal humerus defect is complete, lesion length, depth, and width are measured.

      Graft Preparation: Width and Length Sizing

      Talar dome from a donor source (JRF Ortho, Centennial, CO) is obtained on the back table. The talar dome should be matched with the humeral defect. First, the cartilage margin at the medial and lateral aspect of the allograft is marked. This will match the preoperatively templated width of the proximal humerus defect (Fig 1). An additional line is drawn from medial to lateral along the anterior aspect of the allograft, which will mark the desired graft length. While the assistant and surgeon hold the allograft firmly in place with a Kocher clamp, a sagittal saw is used to remove the preoperatively templated portion of the medial talar dome as the initial medial sagittal cut (Fig 2). With the allograft kept in the same position, a second cut is made along the lateral talar dome as the initial lateral sagittal cut. The excess lateral portion of the talar dome is removed (Fig 3). During this time, it is essential that the allograft is kept cool and is copiously irrigated to avoid risk of thermal necrosis of the cartilage and the underlying subchondral bone. The final cut outline should be 2–5 mm larger than the desired graft length to compensate for the kerf of the saw blade and potential erroneous measurement and allow for better overall customization of the graft to the defect. After the initial medial and lateral sagittal cuts are completed, the talus allograft is rotated. The longitudinal cut is made in line to the axis of the talus to remove the excess portion of the predefined graft (Fig 4).
      Figure thumbnail gr1
      Fig 1The talus allograft (right) on the preparation table. The cartilage margin is marked at the medial and lateral aspect of the talus allograft (medial talar dome), matching the preoperative template width of the proximal humerus defect (graft width and length sizing).
      Figure thumbnail gr2
      Fig 2The talus allograft (right) on the preparation table. Using Kocher clamps to firmly hold the allograft in place, an initial medial sagittal cut is made on the medial talar dome (Initial medial sagittal cut).
      Figure thumbnail gr3
      Fig 3The talus allograft (right) on the preparation table. With the allograft in the same position, a second cut is made along the lateral aspect of the medial talar dome (initial lateral sagittal cut).
      Figure thumbnail gr4
      Fig 4The talus allograft (right) rotated 90° on the preparation table. After the initial medial and lateral cuts are made, the allograft is rotated and a longitudinal cut is made in line to the axis of the talus to remove the excess portion of the predefined graft.

      Graft Preparation: The Cut Graft Contour and Depth Sizing

      Attention is turned back to the exposed medial portion of the talar dome. The cut graft contour should be rechecked with the humeral defect (Fig 5). The preoperatively templated maximum depth is then marked. The final cut will form an “orange wedge,” which is similar to the shape of the previously prepared humeral defect. The anatomical landmarks for the final cut are as follows: the junction of the articular surface of the talar dome and the talar neck for the anterior anatomical landmark; and the posterior margin of the talar articular cartilage for the posterior anatomical landmark (Fig 6).
      Figure thumbnail gr5
      Fig 5The talus allograft (right) on the preparation table. The cut graft contour is rechecked with the humeral defect and the preoperatively templated maximum depth is marked.
      Figure thumbnail gr6
      Fig 6The talus allograft (right) on the preparation table. The anatomic landmarks for the final cut (depth) are the junction of the articular surface of the talar dome and the talar neck for the anterior anatomic landmark (seen above) and the posterior margin of the talar articular cartilage for the posterior anatomical landmark.

      Graft Drilling and Final Adjustments for Implantation

      A parallel guide with a finger projection is angled toward the anterior portion of the allograft. A 2.4-mm Kirschner wire (K-wire) is inserted into the graft. Next, the graft is inserted into the humeral defect and marked with a marker pen, ensuring that an area of error for fitting the graft of the defect is included. The graft is then brought back to the table and finally adjusted for implantation. For optimal fitting of the allograft into the humeral head, the orange wedge configuration must be kept in mind during allograft shaping. The humeral head defect can be prepared using a rasp to ensure perfect graft fit. The allograft fit should be tight enough to stand in place without manual impaction (Fig 7).
      Figure thumbnail gr7
      Fig 7The operative photograph of the left shoulder. The graft is inserted into the humeral defect and marked to show an area of error. The graft is adjusted, and a rasp is used to ensure perfect graft fit. The allograft should be tight enough to stand in place without manual impaction. H, humeral head; Ta, talus allograft.

      Irrigation and Insertion

      A pulse lavage can be used on the allograft for at least 10 minutes to remove remnant bone marrow and mitigate the risk for cross-reactivity and inflammatory responses following transplantation. The graft is then soaked in a combination of autologous conditioned plasma and platelet-rich-plasma using a double syringe system (Greyledge Technologies, Vail, CO) (Fig 8). Prior to graft insertion, 2 or 3 2.4 -mm K-wires are drilled through the center portion of the graft, aiming directly toward the center of the humeral head. Once the graft is positioned appropriately, the K-wires are advanced to provisionally fix the graft into the proximal humerus. A cannulated drill is used over the K-wires, and three 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 confirm that the screws are not violating the articular surface.
      Figure thumbnail gr8
      Fig 8The talus allograft (right) on the preparation table. The allograft is pulse lavaged for 10 minutes to remove remnant bone marrow and then soaked in platelet-rich plasma.

      Discussion

      This Technical Note outlines our technique for talus allograft preparation for treatment of a large rHSL. Advantages of this preparatory technique include precise cutting anatomy, sizing pearls, and use of orthobiologics to ensure excellent talus union to the native humeral head surface.
      Notable treatment options for rHSLs include humeral head reconstruction, tissue filling (reverse-remplissage type procedure), disimpaction, and prosthesis replacement. To establish an appropriate treatment algorithm for humeral head bone loss in the setting of posterior glenohumeral instability; however, appropriate lesion sizing is imperative. In their multicenter case series of 102 posterior instability patients, Moroder et al.
      • Moroder P.
      • Tauber M.
      • Scheibel M.
      • et al.
      Defect characteristics of reverse Hill-Sachs lesions.
      distinguished posterior shoulder instability into three severity subgroups: dislocation, locked dislocation, and chronic locked dislocation. The authors determined that rHSL size, depth, and medialization significantly increased with chronicity. These findings were supplemented by Gheuring et al.
      • Guehring M.
      • Lambert S.
      • Stoeckle U.
      • Ziegler P.
      Posterior shoulder dislocation with associated reverse Hill-Sachs lesion: treatment options and functional outcome after a 5-year follow up.
      in their retrospective case series of 17 patients that underwent management for rHSLs, in which the authors found that defect sizes <25% of the humeral articular cartilage could be treated conservatively if stable, while patients with 25-40% and >40% defects were successfully managed with bony augmentation and arthroplasty procedures, respectively. Such findings emphasize the importance of rHSL parameters, including superficial size, depth, and medialization, which should be considered to guide treatment decision making and optimize outcomes in the setting of posterior glenohumeral instability.
      Osteochondral allograft transplantation remains the treatment of choice for reconstruction the humeral head.
      • Saltzman B.M.
      • Riboh J.C.
      • Cole B.J.
      • Yanke A.B.
      Humeral head reconstruction with osteochondral allograft transplantation.
      ,
      • Zhuo H.
      • Xu Y.
      • Zhu F.
      • Pan L.
      • Li J.
      Osteochondral allograft transplantation for large hill-sachs lesions: A retrospective case series with a minimum 2-year follow-up.
      ,
      • Riff A.J.
      • Yanke A.B.
      • Shin J.J.
      • Romeo A.A.
      • Cole B.J.
      Midterm results of osteochondral allograft transplantation to the humeral head.
      To date, there exist a wide variety of allograft options, including fresh or fresh-frozen femoral head, humeral head, allograft plug or the talus allograft.
      • Provencher M.T.
      • Sanchez G.
      • Schantz K.
      • et al.
      Anatomic humeral head reconstruction with fresh osteochondral talus allograft for recurrent glenohumeral instability with reverse Hill-Sachs lesion.
      ,
      • Saltzman B.M.
      • Riboh J.C.
      • Cole B.J.
      • Yanke A.B.
      Humeral head reconstruction with osteochondral allograft transplantation.
      ,
      • Griswold B.G.
      • Paré D.W.
      • Herzwurm Z.P.
      • et al.
      Utility of allograft talus as a source for grafting of concurrent humeral and glenoid defects associated with anterior glenohumeral instability: An anthropometric analysis.
      ,
      • Mitchell J.J.
      • Vap A.R.
      • Sanchez G.
      • et al.
      Concomitant reverse Hill-Sachs lesion and posterior humeral avulsion of the glenohumeral ligament: Treatment with fresh talus osteochondral allograft and arthroscopic posterior humeral avulsion of the glenohumeral ligament and labrum repair.
      ,
      • Zhuo H.
      • Xu Y.
      • Zhu F.
      • Pan L.
      • Li J.
      Osteochondral allograft transplantation for large hill-sachs lesions: A retrospective case series with a minimum 2-year follow-up.
      ,
      • Riff A.J.
      • Yanke A.B.
      • Shin J.J.
      • Romeo A.A.
      • Cole B.J.
      Midterm results of osteochondral allograft transplantation to the humeral head.
      In their retrospective case series, Zhu et al. demonstrated a high union rate and significantly improved subjective and functional outcomes at a mid-term follow-up period (mean 27.8 months) following reconstruction of large HSLs using a fresh-frozen humeral head allograft.
      • Zhuo H.
      • Xu Y.
      • Zhu F.
      • Pan L.
      • Li J.
      Osteochondral allograft transplantation for large hill-sachs lesions: A retrospective case series with a minimum 2-year follow-up.
      However, the authors also reported a high graft resorption rate (43.1%).
      • Zhuo H.
      • Xu Y.
      • Zhu F.
      • Pan L.
      • Li J.
      Osteochondral allograft transplantation for large hill-sachs lesions: A retrospective case series with a minimum 2-year follow-up.
      Saltzman et al.
      • Saltzman B.M.
      • Riboh J.C.
      • Cole B.J.
      • Yanke A.B.
      Humeral head reconstruction with osteochondral allograft transplantation.
      found similar complications in their systematic review, including 35 patients who underwent humeral head reconstruction with osteochondral allograft, of which 36.2% experienced graft resorption, and glenohumeral arthritic changes in 35.7% of patients.
      The fresh talus allograft has recently been proposed as an excellent alternative graft choice for reconstruction the humeral head.
      • Griswold B.G.
      • Paré D.W.
      • Herzwurm Z.P.
      • et al.
      Utility of allograft talus as a source for grafting of concurrent humeral and glenoid defects associated with anterior glenohumeral instability: An anthropometric analysis.
      The talus allograft offers several advantages. First, the anthropometric measurements of the talus are almost identical to the radius of curvature (ROC) of the humeral head, optimizing restoration of the humeral head sphericity and its arc of rotation with respect to the glenoid surface.
      • Chan C.M.
      • LeVasseur M.R.
      • Lerner A.L.
      • Maloney M.D.
      • Voloshin I.
      Computer modeling analysis of the talar dome as a graft for the humeral head.
      ,
      • Griswold B.G.
      • Paré D.W.
      • Herzwurm Z.P.
      • et al.
      Utility of allograft talus as a source for grafting of concurrent humeral and glenoid defects associated with anterior glenohumeral instability: An anthropometric analysis.
      Additionally, the dense, weight-bearing cartilaginous surface of the talus creates a more profound articular contact with the glenoid and allows for more stability.
      • Provencher M.T.
      • Sanchez G.
      • Schantz K.
      • et al.
      Anatomic humeral head reconstruction with fresh osteochondral talus allograft for recurrent glenohumeral instability with reverse Hill-Sachs lesion.
      The dense, weight-bearing talus allows for a stable graft fixation.
      • Provencher M.T.
      • Sanchez G.
      • Schantz K.
      • et al.
      Anatomic humeral head reconstruction with fresh osteochondral talus allograft for recurrent glenohumeral instability with reverse Hill-Sachs lesion.
      These morphological advantages have recently been described by Griswold et al.
      • Griswold B.G.
      • Paré D.W.
      • Herzwurm Z.P.
      • et al.
      Utility of allograft talus as a source for grafting of concurrent humeral and glenoid defects associated with anterior glenohumeral instability: An anthropometric analysis.
      in their retrospective review of 82 patient’s tali using magnetic resonance images (MRIs). The authors reported that the talus head ROC was extremely compatible to humeral heads, specifically in males (mean: +2.86 mm; males: +1.36 mm), and maximum vertical height of the talus was 23.54 ± 2.87 mm, ensuring ample thickness to provide a suitable humeral head graft. Such findings reinforce the characteristics that make the talus a viable allograft candidate for humeral head reconstruction in the setting of a large rHSL.
      However, the use of the talus allograft comes with notable disadvantages inherent to all grafting procedures; such pitfalls can include improper graft sizing that fails to restore the anatomic glenohumeral arc of motion, or risk of nonunion between the native humeral head and talus allograft. Steps to ensure accurate sizing, positioning, and subsequent union of the talus allograft must, therefore, be taken to reduce these risks. This Technical Note outlines our technique and notable pearls for talus allograft preparation for the treatment of a large rHSL that highlights precise cutting anatomy, sizing options, and use of orthobiologics to ensure excellent talus union to the native humeral head surface.

      Supplementary Data

      References

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