Balloon osteoplasty--a new technique for minimally invasive reduction and stabilisation of Hill-Sachs lesions of the humeral head: a cadaver study

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

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.

Managing Bony Defects of the Shoulder Joint that Occur in Association with Dislocation

Background

Defects to the articular surface of the humeral head have been known to be associated with shoulder dislocation since the 19^th century. It wasn't until 1934 that the first description of the ubiquitous compression fracture of the posterolateral humeral head that occurs with traumatic anterior instability appeared. From 1940, this defect became referred to as a Hill-Sachs lesion after the investigators who reported the condition. The significance of, and therefore treatment of, these and other such bony defects around the shoulder joint has been hotly debated.

Methods

We reviewed the available current literature to determine and report on the most up to date concepts and treatment techniques being used to manage bony defects of the shoulder.

Results

Numerous surgical options have been proposed to manage bony defects of the shoulder, including a variety of defect-filling procedures, with good outcomes. However, the small numbers and diversity of case mix makes for difficult comparisons.

Conclusion

We are currently developing a greater appreciation of how both the humeral and glenoid defects interact and therefore should be assessed and addressed simultaneously in order to improve patient outcomes. More research and collaboration is needed to determine the optimal method of assessing and managing these patients.

Anatomic Humeral Head Reconstruction With Fresh Osteochondral Talus Allograft for Recurrent Glenohumeral Instability With Reverse Hill-Sachs Lesion

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.

Arthroscopic Reduction and Balloon Humeroplasty in the Treatment of Acute Hill-Sachs Lesions

Shoulder instability is often associated with an impaction fracture of the humeral head, commonly referred to as a "Hill-Sachs lesion." This lesion is present in both anterior and posterior instability. Forty percent to 90% of anterior shoulder dislocations have associated Hill-Sachs lesions, whereas 29% to 86% of posterior shoulder dislocations have reverse Hill-Sachs lesions. Both of these lesions can contribute to recurrent instability of the shoulder and require surgery to be treated. Currently, the most common procedures to address Hill-Sachs lesions are the remplissage procedure (transfer of the infraspinatus into the posterior humeral head defect), capsular shift, disimpaction technique, humeral head resurfacing, bone block transfer, or shoulder arthroplasty. Reverse Hill-Sachs lesions are managed with similar procedures, such as the remplissage-equivalent technique described by McLaughlin, which involves transfer of the subscapularis tendon to fill the humeral head defect. The procedure has the advantage of "exteriorizing" the humeral head defect, but in the case of large lesions, it can result in significant loss of the articulating articular surface. The purpose of this article is to describe an arthroscopically assisted disimpaction technique with supplemental grafting using a balloon osteoplasty technique for a reverse Hill-Sachs lesion with bone cement to support and maintain the reduction.

Balloon-guided inflation osteoplasty in the treatment of Hill-Sachs lesions of the humeral head: case report of a new technique

Background

The use of the extra-vertebral balloon osteoplasty is increasing and in the meanwhile it has become a safe surgical technique in the treatment of tibial head, distal radius and calcaneus fractures. In addition, we already could show in a biomechanical setup that the balloon osteoplasty might be a safe tool for reduction in the treatment of Hill-Sachs lesions, but clinical application has not been performed so far.

Case presentation

We report the case of a 53 year- old male patient who was referred to our Trauma department (level I trauma center) after the first manifestation of a posterior shoulder dislocation due to an epileptic seizure, originated in a- up to this date unknown -glioblastoma. After closed reduction of the dislocated shoulder the X-ray showed a subcapital fracture of the proximal humerus with a large reversed Hill-Sachs lesion. We performed an open surgery via a deltoideopectoral approach and balloon osteoplasty was used to reduce the impression fracture (Hill-Sachs lesion) before fixing the fracture with a locking plate. In the post-operative CT scan we could show an anatomical reduction of the Hill-Sachs lesion. At the follow-up examination one year after surgery the patient reached full range of motion and stated no re-dislocation of the shoulder nor instability or pain.

Conclusion

The reduction of an impressed humeral head fracture by use of balloon osteoplasty is a safe technique. This technique could be a new option in the treatment of Hill-Sachs lesions and might be an alternative to well known standard procedures like the remplissage or tendon transfers without affecting rotation.

The biomechanical effect of shoulder remplissage combined with Bankart repair for the treatment of engaging Hill-Sachs lesions

PURPOSE

The purpose of this study was to determine the biomechanical effects of the remplissage repair combined with Bankart repair for engaging Hill-Sachs lesions on range of motion (ROM), translation, and glenohumeral kinematics.

METHODS

Six cadaveric shoulders were tested using a custom shoulder testing system. ROM, kinematics, and anterior-posterior (AP) and superior-inferior glenohumeral translations were quantified at 0° and 60° glenohumeral abduction. Six conditions were tested: intact, Bankart lesion, Bankart with 40 % Hill-Sachs lesion, Bankart repair, Bankart repair with remplissage, and remplissage repair alone.

RESULTS

Humeral external rotation (ER) and total range of motion increased significantly after the creation of the Bankart lesion at both 0° and 60° abduction. The Bankart repair restored ER to intact values at 0° and 60° abduction, and the addition of the remplissage repair did not significantly alter range of motion from the Bankart repair alone. AP translation increased following the creation of the Bankart and Hill-Sachs lesions and was restored with the Bankart repair; the remplissage did not alter translation from the Bankart repair alone. At maximum ER at 60° abduction, the apex of the humeral head shifted posteriorly and inferiorly with remplissage repair.

CONCLUSIONS

The addition of the remplissage procedure combined with Bankart repair for treatment of large Hill-Sachs lesions had no statistically significant effect on ROM or translation, but altered the kinematics of the glenohumeral joint. Thus, by addressing the humeral bone defect following an anterior shoulder dislocation, the remplissage technique with concurrent Bankart repair may be a relatively minimally invasive option for converting engaging Hill-Sachs lesions to non-engaging and promoting shoulder stability, though further biomechanical and clinical studies are warranted.

Management of humeral and glenoid bone loss in recurrent glenohumeral instability

Recurrent shoulder instability and resultant glenoid and humeral head bone loss are not infrequently encountered in the population today, specifically in young, athletic patients. This review on the management of bone loss in recurrent glenohumeral instability discusses the relevant shoulder anatomy that provides stability to the shoulder joint, relevant history and physical examination findings pertinent to recurrent shoulder instability, and the proper radiological imaging choices in its workup. Operative treatments that can be used to treat both glenoid and humeral head bone loss are outlined. These include coracoid transfer procedures and allograft/autograft reconstruction at the glenoid, as well as humeral head disimpaction/humeroplasty, remplissage, humeral osseous allograft reconstruction, rotational osteotomy, partial humeral head arthroplasty, and hemiarthroplasty on the humeral side. Clinical outcomes studies reporting general results of these techniques are highlighted.

Balloon treatment of posterior shoulder dislocation with reverse Hill-Sachs injury: description of a new technique

PURPOSE

Posterior shoulder dislocations are rare, and are usually the result of seizures. Anterior defects of the humeral head known as "reverse Hill-Sachs lesions" may increase the risk of recurrent dislocation and are difficult to treat. We developed a percutaneous technique for reduction of the dislocation or reduction of the anterior impaction fracture, using percutaneous balloon dilatation and cement fixation.

METHODS

From 2009 to 2012, three patients aged 33, 72 and 75 years were admitted to our institution with a posterior shoulder dislocation showing an anterior "reverse Hill-Sachs" impaction fracture. One case was bilateral (four fractures). Patients were operated upon in the sitting position; the humeral head was stabilised by external fixator pins during balloon inflation. Reduction or filling of the defect was obtained in all cases. All patients were followed up and two patients (three fractures) were examined after one year by an independent observer. The clinical results were assessed using the Constant score and the RAND-36 physical components score. A computed tomography (CT) scan was obtained in all patients before and after the operation and at the latest follow-up.

RESULTS

At three months postoperatively, all patients had resumed work or daily life activities with no limitation. The mean Constant score was 71 and RAND-36 score was 85.5. After one year, the mean Constant score was 73 and the RAND-36 score was 86.4 for the two patients who had sufficient follow-up. On the postoperative radiograph and CT scan, sphericity of the humeral head was restored, and the reverse Hill-Sachs impaction was filled or reduced in all cases. There was no recurrent dislocation.

CONCLUSION

Based on this small series, we believe that this technique should be added to our current armamentarium for posterior shoulder dislocations showing a deep impaction fracture of the humeral head that are at risk for recurrent dislocation.