Failed arthroscopic repair of a large reverse Hill-Sachs lesion using bone allograft and cannulated screws: a case report

Restoration of Articular Geometry Using Current Graft Options for Large Glenoid Bone Defects in Anterior Shoulder Instability

PURPOSE

The purpose of this cadaveric study was to compare standard and modified coracoid transfer procedures, bicortical and tricortical iliac crest autografts, and tibial plafond and glenoid allografts with respect to glenoid surface curvature restoration.

METHODS

Computed tomography scans of 8 cadaveric shoulders were acquired in 9 conditions: (1) intact, (2) 25% width defect, (3) classic Latarjet, (4) modified congruent-arc Latarjet, (5) tricortical iliac crest inner table, (6) outer table, (7) bicortical iliac crest, (8) distal tibia, and (9) glenoid allograft. Outcome measures included articular surface area, width, depth, axial and coronal radius of curvature, and subchondral articular step-off, analyzed in bone and soft-tissue window.

RESULTS

Reconstruction of the articular surface area was optimal with the glenoid allograft (99.4%), classic Latarjet (97.4%), and iliac crest bicortical graft (93.2%). Depth was best restored by the congruent-arc Latarjet (101.0%), tibial (98.9%), and glenoid (95.3%) allografts. Axial curvature was closely matched by the glenoid allograft (97.5%), classic Latarjet (108.7%), and iliac bicortical graft (91.2%). Coronal curvature was most accurately restored by the glenoid allograft (102.6%), the tibial allograft (115.0%), and the classic Latarjet (55.9%). The articular step-off was smallest using the glenoid allograft.

CONCLUSIONS

Overall, glenoid allografts most accurately restored articular geometry. Alternative grafts provided restoration of some parameters but not others. Classic Latarjet performed well in axial and coronal curvature on average but exhibited large variability. Tibial allograft produced the poorest results in axial curvature, despite excellent coronal curvature reconstruction. The congruent-arc Latarjet did not restore the axial curvature accurately and overcorrected coronal curvature. Graft geometry must be weighed against availability, morbidity, and the role of additional stabilizers.

CLINICAL RELEVANCE

Accurate graft morphology may help prevent postoperative osteoarthritis. Grafts differ significantly regarding geometric parameters. The findings of this study will help surgeons select the most appropriate graft for glenoid reconstruction.

Neglected posterior dislocation of the shoulder: A systematic literature review

Posterior dislocation of the shoulder (PSD) is a rare injury; the diagnosis is often missed on initial examination. We present a systematic review of the current literature and discuss the key of the diagnosis of PSD. We searched the MEDLINE, PubMed, EMBASE, MD Consult, and the Cochrane Controlled Trial Register databases for the articles according to our eligibility criteria. Finally, 53 articles were included in our systematic review. There were 242 shoulders in 205 patients. In total, in the initial assessment with anteroposterior radiographs in 166 cases, only 19 (11.4%) cases confirmed the right diagnosis. When anteroposterior combined with axillary or Y view radiographs or computed tomography were present as the initial assessments in 36 cases, the diagnoses were made correctly and timely (100%). When axillary or Y view radiographs or computed tomography were taken subsequently, the diagnosis was confirmed in all 205 patients.

Dry arthroscopy of the shoulder

A technique to perform glenohumeral arthroscopy without using arthroscopic fluid for visualization or instrumentation is presented. The patient is placed in the beach-chair position. No traction is applied. Portal placement is performed as usual. Water flow is used only sporadically to wash the joint cavity, and then it is immediately aspirated with a synoviotome suction pump. The entire exploration and instrumentation occur within a pressure-free dry joint. We have applied this technique in more than 50 patients, and in none of these cases was there a need to switch from the dry to the wet technique. By use of this surgical technique, intra-articular shoulder pathology treatment can be performed in a more accurate biomechanical and physiological scenario. It avoids many visualization and instrumentation inconveniences, as well as the risk of some major complications. Joint distension with fluid becomes unnecessary, making it possible to use medium-sized incisions to perform and simplify complex procedures.

Arthroscopic anatomic humeral head reconstruction with osteochondral allograft transplantation for large hill-sachs lesions

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.

Long-term follow-up of allograft reconstruction of segmental defects of the humeral head associated with posterior dislocation of the shoulder

The purpose of this study is to report the long-term follow-up result of allograft reconstruction of segmental defect of the humeral head associated with posterior dislocation of the shoulder. Six men underwent operative management of defects of the humeral head involving 40% of the articular surface, following posterior dislocation of the humeral head. The period of time between dislocation and surgery ranged from 7 to 8 weeks. The defect in the head was filled with an allogeneic segment of humeral head contoured to restore the spherical shape. All the patients returned to their occupation 4 months later. All the cases were evaluated clinically and by radiographs and computed tomography (CT) scan at a mean of 122 (96-144) months after the operative procedure. Three men had no complaints of pain, instability, clicking or catching, whereas three had pain, clicking, catching and stiffness. The three patients with good clinical result showed also good radiographic result. The computed tomography (CT) confirmed incorporation of the allograft and no osteoarthrosis. Another patient had a good clinical and radiographic result until the eighth postoperative year. At 8-year follow-up examination, this patient developed shoulder osteoarthrosis and he had pain and stiffness. He needed an arthroplasty 10 years after the operation. The other two patients developed collapse of the graft and osteoarthrosis that were yet evident at 4-year follow-up. These patients required a shoulder arthroplasty 8 years after the procedure. We conclude that the treatment of segmental defects of the humeral head associated with posterior dislocations of the shoulder by allograft reconstruction has a good long-term follow-up result in 50% of the patients.

Reliability of a new standardized measurement technique for reverse Hill-Sachs lesions in posterior shoulder dislocations

PURPOSE

The purpose of this study was to determine whether standardized measurements are more reliable than mere estimation in determining the extent of the defect in reverse Hill-Sachs lesions.

METHODS

Twelve patients with 13 reverse Hill-Sachs lesions and available computed tomographic scans were included in this study. Based on the computed tomographic scans, estimation and measurement of the defect size in reverse Hill-Sachs lesions using a novel standardized method were carried out twice by 6 observers (3 experts and 3 residents), with an interval of 3 months between observations. To assess and compare the reliability of the estimation of the defect size and the measurement of the defect size, intraclass correlation coefficients were computed.

RESULTS

Estimation of the defect size showed a low interobserver reliability of 0.61 (95% confidence interval [CI], 0.38 to 0.83) and 0.47 (95% CI, 0.24 to 0.74) and a moderate intraobserver reliability of 0.71 (95% CI, 0.51 to 0.89). The estimations of the different observers showed statistically significant differences (P < .001). The standardized measurements reached high interobserver reliability (at least ≥0.81) and excellent intraobserver reliability (at least ≥0.88). Residents provided less reliable estimations compared with experts; however, they obtained similarly high reliability when applying the standardized measurements.

CONCLUSIONS

The mere estimation of the size of reverse Hill-Sachs lesions showed poor reliability, raising the concern for potential overestimation or underestimation in clinical practice. Standardized measurements, which showed good reliability, should be used whenever analyzing the size of a reverse Hill-Sachs defect.

LEVEL OF EVIDENCE

Level IV, diagnostic case series.