Arthroscopic Anatomic Humeral Head Reconstruction With Osteochondral Allograft Transplantation for Large Hill-Sachs Lesions Nimrod Snir, M.D., Theodore S. Wolfson, B.S.E., Mathew J. Hamula, B.S., Soterios Gyftopoulos, M.D., and Robert J. Meislin, M.D.
Abstract: Anatomic reconstruction of the humeral head with osteochondral allograft has been reported as a solution for large Hill-Sachs lesions with or without glenoid bone loss. However, to date, varying techniques have been used. This technical note describes an arthroscopic reconstruction technique using fresh-frozen, side- and size-matched osteochondral humeral head allograft. Allograft plugs are press fit into the defect without internal fixation and seated flush with the surrounding articular surface. This technique restores the native articular contour of the humeral head without compromising shoulder range of motion. Potential benefits of this all-arthroscopic approach include minimal trauma to the soft tissue and articular surface without the need for hardware or staged reoperation.
T
he Hill-Sachs lesion is a compression fracture of the posterosuperolateral humeral head that occurs after traumatic anterior subluxation or dislocation of the glenohumeral joint. Hill-Sachs lesions are commonly associated with high rates of recurrent shoulder instability.1 Though historically overlooked, it is now recognized that Hill-Sachs lesions require prompt identification and appropriate management to restore normal glenohumeral biomechanics and prevent recurrent instability.1,2 Nonsurgical management is usually reserved for cases with small osseous defects, for cases with non-engaging lesions, or in poor surgical candidates (e.g., lowdemand, high-risk patients).3 A variety of open and arthroscopic techniques have been described to treat Hill-Sachs lesions that are larger, engaging, or associated with recurrent instability.4-10 Nonanatomic procedures, including glenoid bone augmentation,5,11,12
From the Department of Orthopaedic Surgery, New York University Hospital for Joint Diseases (N.S., T.S.W., M.J.H., R.J.M.), New York, New York; and the Department of Radiology, New York University Langone Medical Center (S.G.), New York, New York, U.S.A. The authors report the following potential conflict of interest or source of funding in relation to this article: R. J. Meislin is a consultant with Depuy Mitek. Received February 11, 2013; accepted April 5, 2013. Address correspondence to Robert J. Meislin, M.D., NYU Langone Center for Musculoskeletal Care, 333 E 38th St, New York, NY 10016, U.S.A. E-mail: [email protected] Ó 2013 by the Arthroscopy Association of North America 2212-6287/13113/$36.00 http://dx.doi.org/10.1016/j.eats.2013.04.002
capsular shift,6 and rotational humeral osteotomy,4 traditionally focused on preventing the Hill-Sachs lesion from engaging with the anterior glenoid rim. Recently, tissue-filling techniques, such as infraspinatus transfer (remplissage), have been described with promising results.10,13 However, nonanatomic techniques may limit range of motion and function and have been associated with increased rates of osteoarthritis, nonunion, and hardware failure.14 Moreover, nonanatomic techniques fail to address the underlying humeral defect. Anatomic solutions, including humeral head augmentation, disimpaction, resurfacing, and arthroplasty, attempt to restore the spherical contour of the humeral head to permit smooth articulation with the glenoid. Bone augmentation of the humeral head has been reported to manage large defects with or without concomitant glenoid bone loss.8,9,15-17 This technical note describes an arthroscopic approach using osteochondral allograft transplantation without internal fixation to treat a large Hill-Sachs lesion in a patient with recurrent anterior instability.
Surgical Technique Osteochondral allograft transplantation is performed with the COR Cartilage Transplant System (DePuy Mitek, Raynham, MA) developed for femoral articular cartilage lesions and adapted for arthroscopic humeral head osteochondral allograft transplantation. The COR
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Fig 1. (A) Coronal-view computed tomography scan and (B) 3-dimensional reconstruction of posterosuperolateral aspect of humeral head depicting a 2.0 1.7 (anteroposterior) 1.0 cm (depth) Hill-Sachs impaction deformity covering approximately 23% of humeral head articular surface. There was minimal flattening along the anterior margin of the glenoid with evidence of approximately 5% glenoid bone loss (not shown).
system offers surgeons a choice of 4-, 6-, 8-, or 10-mm diameter sizes and variability for graft plug length. Ideally, fresh-frozen, side- and size-matched osteoarticular humeral head allograft is obtained from a certified tissue bank. The graft size can be estimated from preoperative imaging to gauge the size of the defect and assist the tissue bank in selecting an appropriate specimen. In this case computed tomography imaging (Fig 1A) with 3-dimensional reconstruction (Fig 1B) was obtained to evaluate glenoid and humeral bone loss before surgery, and ipsilateral humeral head donor tissue was chosen. Under general anesthesia, the patient is placed in the beach-chair position. The arthroscope is then introduced into the glenohumeral joint through a posterosuperior portal. The Hill-Sachs lesion is located at the posterosuperolateral aspect of the humeral head (Fig 2; Video 1, minute 1:05). Visualization of the defect is facilitated by a rotator cuff tear. In the absence of a cuff tear, cannulation over a guidewire is performed to extend the portal through the capsule overlying the defect. Once the defect is visualized, the operative arm is manipulated in abduction and external rotation to show engagement with the anterior glenoid rim. The surgeon then performs standard diagnostic arthroscopy, paying close attention to the anterior glenoid and labrum. For the remainder of the surgery, the posterosuperior portal is used as the primary working portal to allow access to the defect, and the arthroscope is alternated between the anterolateral and posterolateral portals. Once the lesion is adequately exposed, a tamp of fixed diameter is matched to the defect. Alternatively, intraoperative calipers can be used to accurately measure the dimensions of the defect. Once the donor tissue is thawed, the cylindrical allograft plug is harvested from the location corresponding to the site of the humeral head defect. Multiple plugs of varying sizes may be needed to fill the defect, in which case a mosaicplasty is performed. The
surgeon prepares the first allograft plug for delivery using the harvester-cutter assembly, inspecting for quality, length, and shape. A sagittal saw is used to trim the plug to the appropriate length. Although the length may range from 8 to 15 mm, we recommend a length of 10 to 12 mm to allow for at least 8 mm of overlap with the surrounding drill hole and up to 2 mm of protrusion from the adjacent articular surface, while still accounting for the depth of the defect. A drill is introduced through the posterosuperior portal, and the recipient site is drilled to the size corresponding to the first allograft plug. Care is taken to drill perpendicular to the articular surface until the appropriate depth is reached. The allograft plug is then introduced into the prepared socket and gently
Fig 2. Arthroscopic view of Hill-Sachs lesion through posterolateral portal. The plus sign denotes the bloody bed of the Hill-Sachs defect, and the asterisk denotes the adjacent native articular surface.
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Table 1. Step-by-Step Technique 1. Gather advanced imaging (e.g., magnetic resonance imaging or computed tomography with 3-dimensional reconstruction) to evaluate the Hill-Sachs lesion. 2. Obtain side- and size-matched fresh-frozen humeral head allograft. 3. Position the patient in the beach-chair or lateral decubitus position. 4. Advance the arthroscope through the posterosuperior portal to visualize the defect. 5. Measure the size of the defect with a fixed-diameter tamp or intraoperative calipers. 6. Harvest the allograft plug from the corresponding site on the humeral head graft tissue. 7. Drill the recipient site to the depth of the plug. 8. Press fit the allograft plug into the bone socket to seat flush with the adjacent surface. 9. Repeat steps 5-8 for remaining defect(s). 10. Address associated labral, glenoid, and rotator cuff pathology. 11. Irrigate, close the portal sites, dress the wound, and place the arm in a shoulder immobilizer.
Fig 3. Arthroscopic view of final reconstruction. Allograft plugs are press fit into the defect and seated within the prepared socket to achieve a “snowman” appearance. Two allograft plugs measuring 10 mm and 6 mm in diameter were transplanted.
impacted to seat the graft flush with the adjacent articular surface. A “proud” graft with slight protrusion from the native articular cartilage rim is acceptable, allowing for settling to occur along with physiological compression and impaction from the glenoid. Care is taken not to countersink or recess the plugs. The plugs are press fit into stable position, and no internal fixation is required. To maintain the integrity of the osteochondral bridge between holes and avoid disturbing the alignment, grafts should be implanted after each hole is drilled. In the current case, 2 allograft plugs, sized 10 mm and 6 mm in diameter, were transplanted. After implantation, a “snowman” presentation with 2 overlapping grafts is achieved (Fig 3; Video 1, minute 3:48). After reconstruction of the humeral head defect, attention is turned to concomitant shoulder pathology. The associated Bankart lesion is repaired, and glenoid bone loss may be addressed with staged reconstruction. For a concomitant rotator cuff tear, the tendon is then mobilized and repaired. Once repairs are complete, the joint is taken through a range of motion to show smooth articulation. After copious irrigation, the portal sites are closed in routine fashion. A sterile dressing is applied, and the arm is placed in a shoulder immobilizer. Key steps of this technique are outlined in Table 1, and key points and pearls are shown in Table 2. The immobilizer is worn for 3 to 4 weeks postoperatively. Passive range of motion can be initiated immediately. Active range of motion is begun at 4 weeks. Progressive resistive exercise may be started at 7 to 8 weeks. If rotator cuff repair is performed, passive range of motion is delayed until 10 days, active-assisted
range of motion is not started until 6 weeks, and progressive resistive exercise begins at 3 months. Stretching and strengthening exercises commence at 4 to 5 months. Functional training is started at 6 months. Return to sport or high-demand work is allowed when full range of motion and reasonable strength are achieved. Follow-up computed tomography imaging is obtained at 6 months to evaluate graft incorporation.
Discussion The Hill-Sachs lesion was traditionally overlooked in the treatment of glenohumeral instability. Only recently has reconstruction of the humeral head been performed to prevent symptomatic engagement of the lesion and restore functional motion.7-9,15-18 Anatomic reconstruction directly addresses the underlying defect without sacrificing range of motion. Disimpaction of the Table 2. Key Points/Pearls of Arthroscopic Osteochondral Allograft Reconstruction Technique Obtain advanced imaging (e.g., computed tomography with 3-dimensional reconstruction) before the procedure to gauge the magnitude of the Hill-Sachs lesion and appropriately size the allograft specimen. Advance the arthroscope through the posterosuperior portal and externally rotate and abduct the arm to visualize the Hill-Sachs defect engaging with the glenoid. Fresh-frozen, side- and size-matched osteoarticular humeral head allograft is preferred for transplantation. Harvest osteochondral allograft plugs, and then drill recipient sites one at a time to maintain the osteochondral bridge between holes and achieve optimal alignment with the articular surface. Seat the graft flush with the adjacent articular surface, and take care not to countersink or recess the plugs. After implantation, a “snowman” presentation with 2 overlapping grafts may be achieved. Concomitant pathology, including labral tear, glenoid bone loss, capsular redundancy, and rotator cuff tear, must be addressed to optimize outcomes.
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humeral head defect, also known as humeroplasty, offers a minimally invasive approach to restore the humeral head contour.7,18 However, healthy articular cartilage is required, and disimpaction is associated with avascular necrosis and increased risk of injury to the articular surface and axillary nerve.7 Resurfacing and arthroplasty are more invasive procedures generally reserved for recurrent, large Hill-Sachs lesions that have failed more conservative procedures.11 Humeral head augmentation with osteochondral plugs is an alternative method to fill the defect and restore the native anatomy of the humeral head. Various open techniques to reconstruct the Hill-Sachs lesion with osteochondral allograft transplantation have been described.8,9,15-17 In 2002 Yagishita and Thomas15 reported a case of a large Hill-Sachs lesion associated with anterior glenohumeral dislocation in which open allograft reconstruction without adjuvant internal fixation was performed. After 2 years of follow-up, the patient had full range of motion, reported no further instability or pain, and had radiographic evidence of graft incorporation without collapse or failure. In a larger cohort study, Miniaci and Gish8 described 18 patients with recurrent anterior instability and greater than 25% Hill-Sachs defects who underwent osteochondral transplantation with fresh-frozen, sizeand side-matched allografts secured with Kirschner wires. Several complications were reported, including partial graft collapse in 2 patients, early evidence of osteoarthritis in 3 patients, and mild subluxation in 1 patient. Hardware complications requiring reoperation and hardware retrieval occurred in 2 patients. Despite the high rate of early complications, after a mean follow-up of 50 months, there were no episodes of recurrent instability, the mean Constant score was 78.5, and 89% of patients returned to work. Although favorable results were ultimately achieved, this technique has several drawbacks. An extensive open deltopectoral approach is required, including subscapularis takedown and anterior capsulotomy to access the glenohumeral joint. The Hill-Sachs lesion is substantially enlarged to receive the wedge-shaped graft, and Kirschner wires are needed for internal fixation. Considerable trauma to the soft tissue and humeral head increases the risk of neurovascular injury and avascular necrosis. Furthermore, hardware complications may develop. Nathan and Parikh,17 using a modified Miniaci-Gish technique, advocate using screws directed into the allograft from the nonarticular humeral head surface to protect the articular surface from damage or hardware prominence. In 2007 Kropf and Sekiya9 described a combined arthroscopic capsulolabral repair and open osteoarticular allograft transplantation to reconstruct large, engaging Hill-Sachs defects while preserving shoulder function. A limited posterolateral approach preserves the anterior
repair while permitting direct access to the humeral head defect. If allograft tissue is not immediately available, the procedure can be staged. In the only report of a purely arthroscopic technique in the English-language literature, Chapovsky and Kelly16 describe the case of an active 16-year-old boy with a large Hill-Sachs lesion who underwent revision arthroscopic allograft mosaicplasty along with anterior capsular shift after failure of arthroscopic Bankart repair. Three small, fresh-frozen osteochondral allograft plugs were press fit into the defect. Good approximation of the articular surface was achieved without filling the entire defect or use of internal fixation. At 1-year follow-up, the patient had no recurrent instability and returned to playing basketball. Although this approach is less invasive, concerns have been raised over the articular coverage and biomechanical properties achieved with mosaicplasty. However, multiple studies in cadaveric models have shown that humeral head allograft transplantation restores joint biomechanics better than alternative reconstruction procedures, without compromising range of motion.19,20 The current technique describes an arthroscopic approach to osteochondral allograft reconstruction of a large Hill-Sachs lesion. The benefits of this technique include a minimally invasive approach without the risk of hardware complications. Close approximation of the allograft plugs allows restoration of the native articular surface and joint biomechanics while maintaining shoulder range of motion. However, graft reabsorption, graft failure, and cyst formation are potential complications. Although excellent reduction of the articular surface may be technically achievable, ultimately, the biologic healing response is critical to graft integration.21 Finally, allograft transplantation carries the added risk of disease transmission. Further clinical outcome studies are required to validate the theoretical benefits of arthroscopic osteochondral allograft reconstruction for Hill-Sachs lesions.
References 1. Burkhart SS, De Beer JF. Traumatic glenohumeral bone defects and their relationship to failure of arthroscopic Bankart repairs: Significance of the inverted-pear glenoid and the humeral engaging Hill-Sachs lesion. Arthroscopy 2000;16:677-694. 2. Boileau P, Villalba M, Hery JY, Balg F, Ahrens P, Neyton L. Risk factors for recurrence of shoulder instability after arthroscopic Bankart repair. J Bone Joint Surg Am 2006;88:1755-1763. 3. Provencher MT, Frank RM, Leclere LE, et al. The HillSachs lesion: Diagnosis, classification, and management. J Am Acad Orthop Surg 2012;20:242-252. 4. Weber 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;66:1443-1450.
OSTEOCHONDRAL ALLOGRAFT FOR HILL-SACHS LESION 5. Boileau P, Bicknell RT, El Fegoun AB, Chuinard C. Arthroscopic Bristow procedure for anterior instability in shoulders with a stretched or deficient capsule: The “beltand-suspenders” operative technique and preliminary results. Arthroscopy 2007;23:593-601. 6. Pagnani 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;36:1805-1812. 7. Kazel 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;21:1473-1478. 8. Miniaci A, Gish MW. Management of anterior glenohumeral instability associated with large Hill-Sachs defects. Tech Shoulder Elbow Surg 2004;5:170-175. 9. Kropf EJ, Sekiya JK. Osteoarticular allograft transplantation for large humeral head defects in glenohumeral instability. Arthroscopy 2007;23:322.e1-322.e5. 10. Purchase RJ, Wolf EM, Hobgood ER, Pollock ME, Smalley CC. Hill-Sachs “remplissage”: An arthroscopic solution for the engaging Hill-Sachs lesion. Arthroscopy 2008;24:723-726. 11. Provencher MT, Ghodadra N, LeClere L, Solomon DJ, Romeo AA. Anatomic osteochondral glenoid reconstruction for recurrent glenohumeral instability with glenoid deficiency using a distal tibia allograft. Arthroscopy 2009;25:446-452. 12. Ghodadra N, Gupta A, Romeo AA, et al. Normalization of glenohumeral articular contact pressures after Latarjet or iliac crest bone-grafting. J Bone Joint Surg Am 2010;92: 1478-1489.
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13. Boileau 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;94:618-626. 14. Young DC, Rockwood CA Jr. Complications of a failed Bristow procedure and their management. J Bone Joint Surg Am 1991;73:969-981. 15. Yagishita K, Thomas BJ. Use of allograft for large HillSachs lesion associated with anterior glenohumeral dislocation. A case report. Injury 2002;33:791-794. 16. Chapovsky F, Kelly JD IV. Osteochondral allograft transplantation for treatment of glenohumeral instability. Arthroscopy 2005;21:1007. 17. Nathan ST, Parikh SN. Osteoarticular allograft reconstruction for Hill-Sachs lesion in an adolescent. Orthopedics 2012;35:e744-e747. 18. Re P, Gallo RA, Richmond JC. Transhumeral head plasty for large Hill-Sachs lesions. Arthroscopy 2006;22:798.e1798.e4. 19. Sekiya JK, Wickwire AC, Stehle JH, Debski RE. Hill-Sachs defects and repair using osteoarticular allograft transplantation biomechanical analysis using a joint compression model. Am J Sports Med 2009;37:2459-2466. 20. Giles JW, Elkinson I, Ferreira LM, et al. Moderate to large engaging Hill-Sachs defects: An in vitro biomechanical comparison of the remplissage procedure, allograft humeral head reconstruction, and partial resurfacing arthroplasty. J Shoulder Elbow Surg 2012;21:1142-1151. 21. Moroder P, Resch H, Tauber M. Failed arthroscopic repair of a large reverse Hill-Sachs lesion using bone allograft and cannulated screws: A case report. Arthroscopy 2012;28:138-144.
Abstract: Anatomic reconstruction of the humeral head with osteochondral allograft has been reported as a solution for large Hill-Sachs lesions with or without glenoid bone loss. However, to date, varying techniques have been used. This technical note describes an arthroscopic reconstruction technique using fresh-frozen, side- and size-matched osteochondral humeral head allograft. Allograft plugs are press fit into the defect without internal fixation and seated flush with the surrounding articular surface. This technique restores the native articular contour of the humeral head without compromising shoulder range of motion. Potential benefits of this all-arthroscopic approach include minimal trauma to the soft tissue and articular surface without the need for hardware or staged reoperation.
T
he Hill-Sachs lesion is a compression fracture of the posterosuperolateral humeral head that occurs after traumatic anterior subluxation or dislocation of the glenohumeral joint. Hill-Sachs lesions are commonly associated with high rates of recurrent shoulder instability.1 Though historically overlooked, it is now recognized that Hill-Sachs lesions require prompt identification and appropriate management to restore normal glenohumeral biomechanics and prevent recurrent instability.1,2 Nonsurgical management is usually reserved for cases with small osseous defects, for cases with non-engaging lesions, or in poor surgical candidates (e.g., lowdemand, high-risk patients).3 A variety of open and arthroscopic techniques have been described to treat Hill-Sachs lesions that are larger, engaging, or associated with recurrent instability.4-10 Nonanatomic procedures, including glenoid bone augmentation,5,11,12
From the Department of Orthopaedic Surgery, New York University Hospital for Joint Diseases (N.S., T.S.W., M.J.H., R.J.M.), New York, New York; and the Department of Radiology, New York University Langone Medical Center (S.G.), New York, New York, U.S.A. The authors report the following potential conflict of interest or source of funding in relation to this article: R. J. Meislin is a consultant with Depuy Mitek. Received February 11, 2013; accepted April 5, 2013. Address correspondence to Robert J. Meislin, M.D., NYU Langone Center for Musculoskeletal Care, 333 E 38th St, New York, NY 10016, U.S.A. E-mail: [email protected] Ó 2013 by the Arthroscopy Association of North America 2212-6287/13113/$36.00 http://dx.doi.org/10.1016/j.eats.2013.04.002
capsular shift,6 and rotational humeral osteotomy,4 traditionally focused on preventing the Hill-Sachs lesion from engaging with the anterior glenoid rim. Recently, tissue-filling techniques, such as infraspinatus transfer (remplissage), have been described with promising results.10,13 However, nonanatomic techniques may limit range of motion and function and have been associated with increased rates of osteoarthritis, nonunion, and hardware failure.14 Moreover, nonanatomic techniques fail to address the underlying humeral defect. Anatomic solutions, including humeral head augmentation, disimpaction, resurfacing, and arthroplasty, attempt to restore the spherical contour of the humeral head to permit smooth articulation with the glenoid. Bone augmentation of the humeral head has been reported to manage large defects with or without concomitant glenoid bone loss.8,9,15-17 This technical note describes an arthroscopic approach using osteochondral allograft transplantation without internal fixation to treat a large Hill-Sachs lesion in a patient with recurrent anterior instability.
Surgical Technique Osteochondral allograft transplantation is performed with the COR Cartilage Transplant System (DePuy Mitek, Raynham, MA) developed for femoral articular cartilage lesions and adapted for arthroscopic humeral head osteochondral allograft transplantation. The COR
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Fig 1. (A) Coronal-view computed tomography scan and (B) 3-dimensional reconstruction of posterosuperolateral aspect of humeral head depicting a 2.0 1.7 (anteroposterior) 1.0 cm (depth) Hill-Sachs impaction deformity covering approximately 23% of humeral head articular surface. There was minimal flattening along the anterior margin of the glenoid with evidence of approximately 5% glenoid bone loss (not shown).
system offers surgeons a choice of 4-, 6-, 8-, or 10-mm diameter sizes and variability for graft plug length. Ideally, fresh-frozen, side- and size-matched osteoarticular humeral head allograft is obtained from a certified tissue bank. The graft size can be estimated from preoperative imaging to gauge the size of the defect and assist the tissue bank in selecting an appropriate specimen. In this case computed tomography imaging (Fig 1A) with 3-dimensional reconstruction (Fig 1B) was obtained to evaluate glenoid and humeral bone loss before surgery, and ipsilateral humeral head donor tissue was chosen. Under general anesthesia, the patient is placed in the beach-chair position. The arthroscope is then introduced into the glenohumeral joint through a posterosuperior portal. The Hill-Sachs lesion is located at the posterosuperolateral aspect of the humeral head (Fig 2; Video 1, minute 1:05). Visualization of the defect is facilitated by a rotator cuff tear. In the absence of a cuff tear, cannulation over a guidewire is performed to extend the portal through the capsule overlying the defect. Once the defect is visualized, the operative arm is manipulated in abduction and external rotation to show engagement with the anterior glenoid rim. The surgeon then performs standard diagnostic arthroscopy, paying close attention to the anterior glenoid and labrum. For the remainder of the surgery, the posterosuperior portal is used as the primary working portal to allow access to the defect, and the arthroscope is alternated between the anterolateral and posterolateral portals. Once the lesion is adequately exposed, a tamp of fixed diameter is matched to the defect. Alternatively, intraoperative calipers can be used to accurately measure the dimensions of the defect. Once the donor tissue is thawed, the cylindrical allograft plug is harvested from the location corresponding to the site of the humeral head defect. Multiple plugs of varying sizes may be needed to fill the defect, in which case a mosaicplasty is performed. The
surgeon prepares the first allograft plug for delivery using the harvester-cutter assembly, inspecting for quality, length, and shape. A sagittal saw is used to trim the plug to the appropriate length. Although the length may range from 8 to 15 mm, we recommend a length of 10 to 12 mm to allow for at least 8 mm of overlap with the surrounding drill hole and up to 2 mm of protrusion from the adjacent articular surface, while still accounting for the depth of the defect. A drill is introduced through the posterosuperior portal, and the recipient site is drilled to the size corresponding to the first allograft plug. Care is taken to drill perpendicular to the articular surface until the appropriate depth is reached. The allograft plug is then introduced into the prepared socket and gently
Fig 2. Arthroscopic view of Hill-Sachs lesion through posterolateral portal. The plus sign denotes the bloody bed of the Hill-Sachs defect, and the asterisk denotes the adjacent native articular surface.
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Table 1. Step-by-Step Technique 1. Gather advanced imaging (e.g., magnetic resonance imaging or computed tomography with 3-dimensional reconstruction) to evaluate the Hill-Sachs lesion. 2. Obtain side- and size-matched fresh-frozen humeral head allograft. 3. Position the patient in the beach-chair or lateral decubitus position. 4. Advance the arthroscope through the posterosuperior portal to visualize the defect. 5. Measure the size of the defect with a fixed-diameter tamp or intraoperative calipers. 6. Harvest the allograft plug from the corresponding site on the humeral head graft tissue. 7. Drill the recipient site to the depth of the plug. 8. Press fit the allograft plug into the bone socket to seat flush with the adjacent surface. 9. Repeat steps 5-8 for remaining defect(s). 10. Address associated labral, glenoid, and rotator cuff pathology. 11. Irrigate, close the portal sites, dress the wound, and place the arm in a shoulder immobilizer.
Fig 3. Arthroscopic view of final reconstruction. Allograft plugs are press fit into the defect and seated within the prepared socket to achieve a “snowman” appearance. Two allograft plugs measuring 10 mm and 6 mm in diameter were transplanted.
impacted to seat the graft flush with the adjacent articular surface. A “proud” graft with slight protrusion from the native articular cartilage rim is acceptable, allowing for settling to occur along with physiological compression and impaction from the glenoid. Care is taken not to countersink or recess the plugs. The plugs are press fit into stable position, and no internal fixation is required. To maintain the integrity of the osteochondral bridge between holes and avoid disturbing the alignment, grafts should be implanted after each hole is drilled. In the current case, 2 allograft plugs, sized 10 mm and 6 mm in diameter, were transplanted. After implantation, a “snowman” presentation with 2 overlapping grafts is achieved (Fig 3; Video 1, minute 3:48). After reconstruction of the humeral head defect, attention is turned to concomitant shoulder pathology. The associated Bankart lesion is repaired, and glenoid bone loss may be addressed with staged reconstruction. For a concomitant rotator cuff tear, the tendon is then mobilized and repaired. Once repairs are complete, the joint is taken through a range of motion to show smooth articulation. After copious irrigation, the portal sites are closed in routine fashion. A sterile dressing is applied, and the arm is placed in a shoulder immobilizer. Key steps of this technique are outlined in Table 1, and key points and pearls are shown in Table 2. The immobilizer is worn for 3 to 4 weeks postoperatively. Passive range of motion can be initiated immediately. Active range of motion is begun at 4 weeks. Progressive resistive exercise may be started at 7 to 8 weeks. If rotator cuff repair is performed, passive range of motion is delayed until 10 days, active-assisted
range of motion is not started until 6 weeks, and progressive resistive exercise begins at 3 months. Stretching and strengthening exercises commence at 4 to 5 months. Functional training is started at 6 months. Return to sport or high-demand work is allowed when full range of motion and reasonable strength are achieved. Follow-up computed tomography imaging is obtained at 6 months to evaluate graft incorporation.
Discussion The Hill-Sachs lesion was traditionally overlooked in the treatment of glenohumeral instability. Only recently has reconstruction of the humeral head been performed to prevent symptomatic engagement of the lesion and restore functional motion.7-9,15-18 Anatomic reconstruction directly addresses the underlying defect without sacrificing range of motion. Disimpaction of the Table 2. Key Points/Pearls of Arthroscopic Osteochondral Allograft Reconstruction Technique Obtain advanced imaging (e.g., computed tomography with 3-dimensional reconstruction) before the procedure to gauge the magnitude of the Hill-Sachs lesion and appropriately size the allograft specimen. Advance the arthroscope through the posterosuperior portal and externally rotate and abduct the arm to visualize the Hill-Sachs defect engaging with the glenoid. Fresh-frozen, side- and size-matched osteoarticular humeral head allograft is preferred for transplantation. Harvest osteochondral allograft plugs, and then drill recipient sites one at a time to maintain the osteochondral bridge between holes and achieve optimal alignment with the articular surface. Seat the graft flush with the adjacent articular surface, and take care not to countersink or recess the plugs. After implantation, a “snowman” presentation with 2 overlapping grafts may be achieved. Concomitant pathology, including labral tear, glenoid bone loss, capsular redundancy, and rotator cuff tear, must be addressed to optimize outcomes.
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humeral head defect, also known as humeroplasty, offers a minimally invasive approach to restore the humeral head contour.7,18 However, healthy articular cartilage is required, and disimpaction is associated with avascular necrosis and increased risk of injury to the articular surface and axillary nerve.7 Resurfacing and arthroplasty are more invasive procedures generally reserved for recurrent, large Hill-Sachs lesions that have failed more conservative procedures.11 Humeral head augmentation with osteochondral plugs is an alternative method to fill the defect and restore the native anatomy of the humeral head. Various open techniques to reconstruct the Hill-Sachs lesion with osteochondral allograft transplantation have been described.8,9,15-17 In 2002 Yagishita and Thomas15 reported a case of a large Hill-Sachs lesion associated with anterior glenohumeral dislocation in which open allograft reconstruction without adjuvant internal fixation was performed. After 2 years of follow-up, the patient had full range of motion, reported no further instability or pain, and had radiographic evidence of graft incorporation without collapse or failure. In a larger cohort study, Miniaci and Gish8 described 18 patients with recurrent anterior instability and greater than 25% Hill-Sachs defects who underwent osteochondral transplantation with fresh-frozen, sizeand side-matched allografts secured with Kirschner wires. Several complications were reported, including partial graft collapse in 2 patients, early evidence of osteoarthritis in 3 patients, and mild subluxation in 1 patient. Hardware complications requiring reoperation and hardware retrieval occurred in 2 patients. Despite the high rate of early complications, after a mean follow-up of 50 months, there were no episodes of recurrent instability, the mean Constant score was 78.5, and 89% of patients returned to work. Although favorable results were ultimately achieved, this technique has several drawbacks. An extensive open deltopectoral approach is required, including subscapularis takedown and anterior capsulotomy to access the glenohumeral joint. The Hill-Sachs lesion is substantially enlarged to receive the wedge-shaped graft, and Kirschner wires are needed for internal fixation. Considerable trauma to the soft tissue and humeral head increases the risk of neurovascular injury and avascular necrosis. Furthermore, hardware complications may develop. Nathan and Parikh,17 using a modified Miniaci-Gish technique, advocate using screws directed into the allograft from the nonarticular humeral head surface to protect the articular surface from damage or hardware prominence. In 2007 Kropf and Sekiya9 described a combined arthroscopic capsulolabral repair and open osteoarticular allograft transplantation to reconstruct large, engaging Hill-Sachs defects while preserving shoulder function. A limited posterolateral approach preserves the anterior
repair while permitting direct access to the humeral head defect. If allograft tissue is not immediately available, the procedure can be staged. In the only report of a purely arthroscopic technique in the English-language literature, Chapovsky and Kelly16 describe the case of an active 16-year-old boy with a large Hill-Sachs lesion who underwent revision arthroscopic allograft mosaicplasty along with anterior capsular shift after failure of arthroscopic Bankart repair. Three small, fresh-frozen osteochondral allograft plugs were press fit into the defect. Good approximation of the articular surface was achieved without filling the entire defect or use of internal fixation. At 1-year follow-up, the patient had no recurrent instability and returned to playing basketball. Although this approach is less invasive, concerns have been raised over the articular coverage and biomechanical properties achieved with mosaicplasty. However, multiple studies in cadaveric models have shown that humeral head allograft transplantation restores joint biomechanics better than alternative reconstruction procedures, without compromising range of motion.19,20 The current technique describes an arthroscopic approach to osteochondral allograft reconstruction of a large Hill-Sachs lesion. The benefits of this technique include a minimally invasive approach without the risk of hardware complications. Close approximation of the allograft plugs allows restoration of the native articular surface and joint biomechanics while maintaining shoulder range of motion. However, graft reabsorption, graft failure, and cyst formation are potential complications. Although excellent reduction of the articular surface may be technically achievable, ultimately, the biologic healing response is critical to graft integration.21 Finally, allograft transplantation carries the added risk of disease transmission. Further clinical outcome studies are required to validate the theoretical benefits of arthroscopic osteochondral allograft reconstruction for Hill-Sachs lesions.
References 1. Burkhart SS, De Beer JF. Traumatic glenohumeral bone defects and their relationship to failure of arthroscopic Bankart repairs: Significance of the inverted-pear glenoid and the humeral engaging Hill-Sachs lesion. Arthroscopy 2000;16:677-694. 2. Boileau P, Villalba M, Hery JY, Balg F, Ahrens P, Neyton L. Risk factors for recurrence of shoulder instability after arthroscopic Bankart repair. J Bone Joint Surg Am 2006;88:1755-1763. 3. Provencher MT, Frank RM, Leclere LE, et al. The HillSachs lesion: Diagnosis, classification, and management. J Am Acad Orthop Surg 2012;20:242-252. 4. Weber 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;66:1443-1450.
OSTEOCHONDRAL ALLOGRAFT FOR HILL-SACHS LESION 5. Boileau P, Bicknell RT, El Fegoun AB, Chuinard C. Arthroscopic Bristow procedure for anterior instability in shoulders with a stretched or deficient capsule: The “beltand-suspenders” operative technique and preliminary results. Arthroscopy 2007;23:593-601. 6. Pagnani 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;36:1805-1812. 7. Kazel 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;21:1473-1478. 8. Miniaci A, Gish MW. Management of anterior glenohumeral instability associated with large Hill-Sachs defects. Tech Shoulder Elbow Surg 2004;5:170-175. 9. Kropf EJ, Sekiya JK. Osteoarticular allograft transplantation for large humeral head defects in glenohumeral instability. Arthroscopy 2007;23:322.e1-322.e5. 10. Purchase RJ, Wolf EM, Hobgood ER, Pollock ME, Smalley CC. Hill-Sachs “remplissage”: An arthroscopic solution for the engaging Hill-Sachs lesion. Arthroscopy 2008;24:723-726. 11. Provencher MT, Ghodadra N, LeClere L, Solomon DJ, Romeo AA. Anatomic osteochondral glenoid reconstruction for recurrent glenohumeral instability with glenoid deficiency using a distal tibia allograft. Arthroscopy 2009;25:446-452. 12. Ghodadra N, Gupta A, Romeo AA, et al. Normalization of glenohumeral articular contact pressures after Latarjet or iliac crest bone-grafting. J Bone Joint Surg Am 2010;92: 1478-1489.
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13. Boileau 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;94:618-626. 14. Young DC, Rockwood CA Jr. Complications of a failed Bristow procedure and their management. J Bone Joint Surg Am 1991;73:969-981. 15. Yagishita K, Thomas BJ. Use of allograft for large HillSachs lesion associated with anterior glenohumeral dislocation. A case report. Injury 2002;33:791-794. 16. Chapovsky F, Kelly JD IV. Osteochondral allograft transplantation for treatment of glenohumeral instability. Arthroscopy 2005;21:1007. 17. Nathan ST, Parikh SN. Osteoarticular allograft reconstruction for Hill-Sachs lesion in an adolescent. Orthopedics 2012;35:e744-e747. 18. Re P, Gallo RA, Richmond JC. Transhumeral head plasty for large Hill-Sachs lesions. Arthroscopy 2006;22:798.e1798.e4. 19. Sekiya JK, Wickwire AC, Stehle JH, Debski RE. Hill-Sachs defects and repair using osteoarticular allograft transplantation biomechanical analysis using a joint compression model. Am J Sports Med 2009;37:2459-2466. 20. Giles JW, Elkinson I, Ferreira LM, et al. Moderate to large engaging Hill-Sachs defects: An in vitro biomechanical comparison of the remplissage procedure, allograft humeral head reconstruction, and partial resurfacing arthroplasty. J Shoulder Elbow Surg 2012;21:1142-1151. 21. Moroder P, Resch H, Tauber M. Failed arthroscopic repair of a large reverse Hill-Sachs lesion using bone allograft and cannulated screws: A case report. Arthroscopy 2012;28:138-144.
