Humeral Head Reconstruction With Osteochondral Allograft Transplantation

Mid-term outcomes of microfracture for the treatment of focal, full-thickness cartilage defects isolated to the humeral head

BACKGROUND

While microfracture has been shown to be an effective treatment for chondral lesions in the knee, evidence to support its use for chondral defects in the shoulder is limited to short-term outcomes studies. The purpose of this study is to determine if microfracture provides pain relief and improved shoulder function in patients with isolated focal chondral defects of the humeral head at a minimum 5-year follow-up.

METHODS

Patients who underwent microfracture procedure for isolated focal chondral defects of the humeral head with a minimum follow-up of 5 years between 02/2006 and 08/2016 were included. At minimum 5-year follow-up, pre- and postoperative patient-reported outcome (PRO) measures were collected, including the American Shoulder and Elbow Surgeons (ASES), Single Assessment Numeric Evaluation (SANE), Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH), Short Form-12 (SF-12) Physical Component Summary (PCS), Visual Analog Scale (VAS) for pain, and patient satisfaction level (1 = unsatisfied, 10 = very satisfied). Demographic, injury, and surgical data were retrospectively reviewed. Surgical failure was defined as revision surgery for humeral chondral defects or conversion to arthroplasty. Kaplan-Meier analysis was performed to determine survivorship at 5 years.

RESULTS

A total of 17 patients met inclusion/exclusion criteria. There were 15 men and 2 women with an average age of 51 years (range 36-69) and an average follow-up of 9.4 years (range 5.0-15.8). The median ASES score improved from 62 (range: 22-88) preoperatively to 90 (range: 50-100) postoperatively (P = .011). Median satisfaction was 8 out of 10 (range: 2-10). There was no correlation between patient age or defect size and PROs. Postoperatively, patients reported significant improvements in recreational and sporting activity as well as the ability to sleep on the affected shoulder (P ≤ .05). Three patients failed and required revision surgery. The Kaplan-Meier analysis determined an overall survivorship rate of 80% at 5 years.

CONCLUSION

The presented study illustrates significant improvements for PROs, improved ability to perform recreational and sporting activities, and a survival rate of 80% at a mean of 9.4 years after microfracture for focal chondral humeral head defects.

Osteochondral Allograft Transplantation in the Shoulder: A Systematic Review of Indications and Outcomes

OBJECTIVE

To collate current literature pertaining to the published reports of indications for, and outcomes of, osteochondral allograft (OCA) transplantations in the shoulder so as to guide surgeons in the management of various etiologies of osteochondral lesions in this joint.

DESIGN

A systematic review of the current literature was performed in February 2022 in the PubMed, Cochrane, and EMBASE databases using specific search terms and predetermined inclusion/exclusion criteria.

RESULTS

One-hundred-twenty-three articles were initially identified, 30 full-text articles were assessed for eligibility, and 17 articles met inclusion criteria. Data were collected for study characteristics, etiology, lesion size/location, intervention/type of graft used, follow-up, and outcomes. In total, 83 shoulders were included (n = 83) in the review with an average follow-up of 45.7 months. Nine specific indications for OCA transplantation in the shoulder included: reverse Hill-Sachs lesions (33), Hill-Sachs lesions (22), pain pump chondrolysis (10), recurrent shoulder instability (7), osteoarthritis/degenerative changes (5), radiofrequency chondrolysis (2), prominent suture anchors (2), glenoid lesion (1), and osteochondritis dissecans (1). Seventeen patients had concomitant surgeries and two patients were lost to follow-up. Of the total 83 shoulders, 68 had favorable outcomes and 13 had unfavorable outcomes as determined by graft incorporation, pain scores, functionality/ROM, patient-reported satisfaction, and/or requirement for revision/arthroplasty. Of the 13 with unfavorable outcomes, a disproportionate number had concomitant surgeries and/or were performed for pain pump chondrolysis (6).

CONCLUSIONS

The use of OCAs appears to be a viable option for a variety of difficult-to-treat shoulder pathologies, particularly those characterized by isolated osteochondral injuries.

Gunshot-Induced Humeral Head Osteochondral Defect Treated with an Osteochondral Allograft: A Case Report

CASE

A 25-year-old right-hand dominant male police officer presented to the emergency department with a gunshot wound to his left shoulder. Magnetic resonance imaging demonstrated an osteochondral defect overlying the humeral head along the mid to lower aspect of the glenohumeral joint. A staged operation with shoulder arthroscopy followed by an osteochondral allograft (OCA) of the humeral head was performed. During his 6-month postoperative visit, he had returned to full work duty with no restrictions and reported that his pain was well controlled.

CONCLUSION

Humeral head OCA transplantation may be an effective treatment option for traumatic osteochondral lesions of the glenohumeral joint.

Treatment of osteochondral injuries of the humeral head using fresh osteochondral allograft transplantation

Background

Large osteochondral lesions of the humeral head can result from locked posterior dislocations, avascular necrosis, and osteochondritis dissecans. Fresh osteochondral allograft (OCA) transplantation is a treatment option for young patients with focal osteochondral defects of the humeral head. The purpose of this case series was to assess graft survivorship, subjective patient-reported outcomes, and satisfaction among 7 patients who underwent OCA transplantation of the humeral head.

Methods

We identified 7 patients who underwent humeral head OCA transplantation between 2008 and 2017. A custom questionnaire including the American Shoulder and Elbow Surgeons score, Quick Disabilities of the Arm, Shoulder, and Hand score (QuickDash), Likert satisfaction, and reoperations was mailed to each patient. Clinical failure was defined as further surgery that involved removal of the allograft.

Results

Median follow-up duration was 10 years (range, 4.6 to 13.5 years) with a median age of 21.6 years (range, 18.5 to 43.5 years). Most patients (86%) reported improved function and reduced pain. At the final follow-up, 71% of patients reported ongoing problems with their shoulder including pain, stiffness, clicking/grinding, limited range of motion, and instability. Return to recreational activities was high at 86% but 43% expressed limitations with activity due to their shoulder. Overall satisfaction was high at 71% with mean American Shoulder and Elbow Surgeons and QuickDASH scores at 62.4 and 29.2, respectively. Reoperation after OCA occurred in 1 patient (14%).

Conclusion

Among this case series of 7 patients who underwent OCA transplantation of the humeral head, patient satisfaction was high at 10-year follow-up and most returned to recreational activity although most also had persistent shoulder symptoms.

Low Recurrence of Instability and Satisfying Patient-Reported Outcomes Following Various Surgical Treatments of Reverse Hill-Sachs Lesions in the Setting of Posterior Instability: A Systematic Review

PURPOSE

To systematically review the literature and report the outcomes of various surgical treatments for reverse Hill-Sachs lesions (RHSL) in the setting of posterior shoulder instability.

METHODS

Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed. All studies assessing outcomes of surgical treatment of RHSL from inception to January 2023 were identified in PubMed, Embase, and Cochrane Library. Inclusion criteria consisted of studies reporting outcomes, minimum mean 1-year follow-up, and minimum Level IV evidence. Outcomes were assessed using Forest plots with random effects models using R software.

RESULTS

A total of 29 studies consisting of 291 patients were included with a mean age of 42 years (range 16-88 years), 87% male gender, and mean follow-up of 4.5 years. The mean size of impacted or affected cartilage was 35%, and time from injury to surgery was mean 15 weeks. Nearly all studies were Level IV evidence, and quality of studies was low. Random effect models were performed, and data are presented as range. A low incidence of instability was noted for all surgical techniques with good patient-reported outcome measures. Most studies reported outcomes of the modified McLaughlin procedure (13 studies, 126 patients) with overall Constant-Murley Score of 65 to 92. Trends were seen towards better Constant-Murley Score and external rotation with a shorter delay between injury, and when arthroscopic and joint preserving treatments were performed.

CONCLUSIONS

This systematic review showed low rates of instability recurrence, reproducible range of motion, and favorable patient-reported outcome measures were reported following all treatments for RHSLs with posterior instability. There was a significant association between better outcomes and a shorter delay between injury and surgery. The level of evidence is limited, given the small and retrospective studies which can be explained by the rarity of these injuries. LEVEL OF EVIDENCE: Level IV; systematic review of Level III and IV studies.

Treatment of Shoulder Cartilage Defects in Athletes

Articular cartilage defects in the glenohumeral joint may be found in laborers, the elderly, and young athletes, among others. Various factors can contribute to cartilage damage, including prior surgery, trauma, avascular necrosis, inflammatory arthritis, joint instability, and osteoarthritis. There is a wide variety of treatment options, from conservative treatment, injections, and surgical options, including arthroscopic debridement, microfracture, osteochondral autograft transfer, osteochondral graft transplantation, autologous chondrocyte implantation, and the newly emerging techniques such as biologic augmentation. There is a challenge to determine the optimal treatment options, especially for young athletes, due to limited outcomes in the literature. However, there are many options which are viable to address osteochondral defects of the glenohumeral joint.

Bulk osteochondral allograft for massive Hill-Sachs defect combined with Latarjet procedure for bipolar bone loss in anterior instability

A proportion of patients with anterior glenohumeral instability present with bipolar bone loss comprising large Hill-Sachs lesions and substantial glenoid defect. These are surgically difficult cases to treat. We describe a novel surgical procedure of bulk size-matched osteochondral allograft reconstruction for massive Hill-Sachs lesions combined with the Latarjet procedure for these challenging cases.

Long-term outcomes after osteochondral allograft transplantation to the humeral head

BACKGROUND

Long-term outcomes of osteochondral allograft (OCA) transplantation to the humeral head have been sparsely reported in the literature.

PURPOSE

To evaluate outcomes and survivorship of OCA transplantation to the humeral head in patients with osteochondral defects at a minimum of 10 years of follow-up.

METHODS

A registry of patients who underwent humeral head OCA transplantation between 2004 and 2012 was reviewed. Patients completed pre and postoperative surveys including the American Shoulder and Elbow Surgeons score, Simple Shoulder Test, Short Form 12 (SF-12), and the visual analog scale. Failure was defined by conversion to shoulder arthroplasty.

RESULTS

Fifteen of 21 (71%) patients with a minimum of ten year of follow-up (mean: 14.2 ± 2.40) were identified. Mean patient age was 26.1 ± 8.8 years at the time of transplantation and eight (53%) patients were male. Surgery was performed on the dominant shoulder in 11 of the 15 (73%) cases. The use of local anesthetic delivered via an intra-articular pain pump was the most often reported underlying etiology of chondral injury (n = 9; 60%). Eight (53%) patients were treated with an allograft plug, while seven (47%) patients were treated with a mushroom cap allograft. At final follow-up, mean American Shoulder and Elbow Surgeons (49.9 to 81.1; P = .048) and Simple Shoulder Test (43.1 to 83.3; P = .010) significantly improved compared to baseline. Changes in mean SF-12 physical (41.4 to 48.1; P = .354), SF-12 mental (57.5 to 51.8; P = .354), and visual analog scale (4.0 to 2.8; P = .618) did not reach statistical significance. Eight (53%) patients required conversion to shoulder arthroplasty at an average of 4.8 ± 4.7 years (range: 0.6-13.2). Kaplan-Meier graft survival probabilities were 60% at 10 years and 41% at 15 years.

CONCLUSION

OCA transplantation to the humeral head can result in acceptable long-term function for patients with osteochondral defects. While patient-reported outcomes metrics were generally improved compared to baseline, OCA graft survival probabilities diminished with time. The findings from this study can be used to counsel future patients with significant glenohumeral cartilage injuries and set expectations about the potential for further surgery.

All-Arthroscopic Treatment of Off-Track Hill-Sachs Lesions Using Fresh Osteochondral Allograft Plugs: "Rocks in a Stream"

Osteochondral allograft transplantation is a well-described technique for the treatment of large, engaging Hill-Sachs lesions. Traditionally, osteochondral allografts are size-matched to the defect, which can be expensive and time-consuming, and the majority of described techniques require an open approach. This Technical Note describes an all-arthroscopic approach to Hill-Sachs osteochondral allograft transplantation using premade osteochondral allograft plugs, eliminating the need for size-matching and graft harvest. This approach works not by anatomically filling the defect, but rather by bridging the defect to prevent it from engaging the glenoid.

Utility of Talus Osteochondral Allograft Augmentation for Varying Hill-Sachs Lesion Sizes: A Cadaveric Study

Background

Humeral head reconstruction with fresh osteochondral allografts (OCA) serves as a potential treatment option for anatomic reconstruction. More specifically, talus OCA is a promising graft source because of its high congruency with a dense cartilaginous surface.

Purpose

To analyze the surface geometry of the talus OCA plug augmentation for the management of shoulder instability with varying sizes of Hill-Sachs lesions (HSLs).

Study Design

Controlled laboratory study.

Methods

Seven fresh-frozen cadaveric shoulders were tested in this study. The humeral heads were analyzed using actual patients' computed tomography scans. Surface laser scan analysis was performed on 7 testing states: (1) native state; (2) small HSL; (3) talus OCA augmentation for small HSL; (4) medium HSL; (5) talus OCA augmentation for medium HSL; (6) large HSL; and (7) talus OCA augmentation for large HSL. OCA plugs were harvested from the talus allograft and placed in the most medial and superior aspect of each HSL lesion. Surface congruency was calculated as the mean absolute error and the root mean squared error in the distance. A 1-way repeated-measures analysis of variance was performed to evaluate the effects of the difference in the HSL size and associated talus OCA plugs on surface congruency and the HSL surface area.

Results

The surface area analysis of the humeral head with the large (1469 ± 75 mm2), medium (1391 ± 81 mm2), and small (1230 ± 54 mm2) HSLs exhibited significantly higher surface areas than the native state (1007 ± 88 mm2; P < .001 for all sizes). The native state exhibited significantly lower surface areas as compared with after talus OCA augmentation for large HSLs (1235 ± 63 mm2; P < .001) but not for small or medium HSLs. Talus OCA augmentation yielded improved surface areas and congruency after treatment in small, medium, and large HSLs (P < .001).

Conclusion

Talus OCA plug augmentation restored surface area and congruency across all tested HSLs, and the surface area was best improved with the most common HSLs-small and medium.

Clinical Relevance

Talus OCA plugs may provide a viable option for restoring congruity of the shoulder in patients with recurrent anterior glenohumeral instability and an HSL.

Avascular necrosis of the proximal humerus: a novel indication for the use of osteochondral allograft transplantation in the shoulder: Case report

Osteochondral allograft (OCA) transplantation is an increasingly available biologic treatment option for a range of intraarticular aetiologies. To our knowledge, no prior publication has documented the use of this technology to treat a lesion of the proximal humerus secondary to avascular necrosis (AVN). We describe our experience treating a 42-year-old female executive with idiopathic AVN of the proximal humerus with a fresh osteochondral allograft. Computed tomography (CT) at 3 months post-op showed full bony incorporation and a restored native joint contour. Over the initial 7 months post-operatively, she reported continued improvements in pain and function as measured by quick Disabilities of the Arm, Shoulder, and Hand (DASH) scores. She was discharged from physical therapy after 6 months, reporting no rest pain, full active and passive range of motion, and unrestricted occupational and recreational activity.

Humeral Head Reconstruction With Osteochondral Allograft: Bone Plug Optimization for Hill-Sachs Lesions Using CT-Based Computer Modeling Analysis

Background

Engaging Hill-Sachs lesions (HSLs) pose a significant risk for failure of surgical repair of recurrent anterior shoulder instability. Reconstruction with fresh osteochondral allograft (OCA) has been proposed as a treatment for large HSLs.

Purpose

To determine the optimal characteristics of talus OCA bone plugs in a computer-simulated HSL model.

Study Design

Descriptive laboratory study; Level of evidence, 6.

Methods

Included were 132 patients with recurrent anterior instability with visible HSLs; patients who had multidirectional instability or previous shoulder surgery were excluded. Three-dimensional computed tomography models were constructed, and a custom computer optimization algorithm was generated to maximize bone plug surface area at the most superior apex (superiorization) and minimize its position relative to the most medial margin of the HSL defect (medialization). The optimal number, diameter, medialization, and superiorization of the bone plug(s) were reported. Percentages of restored glenoid track width and conversion from off- to on-track HSLs after bone plug optimization were calculated.

Results

A total of 86 patients were included in the final analysis. Off-track lesions made up 19.7% of HSLs and, of these, the mean bone plug size was 9.9 ± 1.4 mm, with 2.2 mm ± 1.7 mm of medialization and 3.3 mm ± 2.9 mm of superiorization. The optimization identified 21% of HSLs requiring 1 bone plug, 65% requiring 2 plugs, and 14% requiring 3 plugs, with a mean overall coverage of 60%. The mean width of the restored HSLs was 68%, and all off-track HSLs (n = 17) were restored to on-track. A Jenks natural-breaks analysis calculated 3 ideal bone plug diameters of 8 mm (small), 10.4 mm (medium), and 12 mm (large) in order to convert this group of HSLs to on-track.

Conclusion

Using a custom computer algorithm, we have demonstrated the optimal talus OCA bone plug diameters for reconstructing HSLs to successfully restore the HSL track and, on average, 60% of the HSL surface area and 68% of the HSL width.

Clinical Relevance

Reconstructing HSLs with talus OCA is a promising treatment option with excellent fit and restoration of HSLs. This study will help guide surgeons to optimize OCA bone plugs from the humeral head, femoral head, and talus for varying sizes of HSLs.

The "BioHumi" Humeral Head Osteochondral Allograft Transplantation for Reverse Hill-Sachs Lesion of the Shoulder

Osteochondral defects of the shoulder due to posterior instability are less frequent than those caused by anterior instability. Although uncommon, locked posterior dislocations can create sizable osteochondral lesions of the anterior humeral head known as reverse Hill-Sachs lesions. Treatment of these defects to restore the congruent contour of the glenohumeral joint is essential to reduce recurrence of instability and prevent long-term sequelae of arthritis. Historically, nonanatomic options, such as transposition of the subscapularis tendon or lesser tuberosity into the defect and humeral rotational osteotomy, have been endorsed to treat reverse Hill-Sachs lesions. More contemporary techniques have focused on restoring not only the bony architecture but also the chondral surface using fresh osteochondral allografts. The evolution of this approach has been challenging because of the large impacted wedge-shaped defect typically encountered with a locked posterior dislocation. Many surgeons employ techniques using multiple circular grafts or customizing a nonanatomic graft to fill these defects. Given the unstable nature of these grafts, metallic screws are often placed through the chondral surface for fixation. The evolution of the "BioHumi" technique has made treatment of large reverse Hill-Sachs lesions technically simpler and more reproducible using innovative instrumentation to transplant an elliptical osteochondral allograft.

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.

Surgical management of osteoarthritis in the shoulder and elbow

Interesting recent trends are apparent in the setting of shoulder and elbow pathology. There is an increase in utilization of shoulder arthroplasty for osteoarthritis and post traumatic arthritis. At the same time, there remain limited options for osteoarthritis of the elbow particularly in the young and or active patient. This manuscript details surgical options for osteoarthritis at the elbow and shoulder.

Humeral Head Resurfacing for Isolated Primary Humeral Osteoarthritis With a Large Chondral Defect

Primary, isolated humeral head arthritis or focal chondral defects are uncommon and difficult to diagnose preoperatively. While these lesions have traditionally been treated with total shoulder arthroplasty, shoulder hemiarthroplasty is a viable option for patients with isolated humeral head disease and minimal degenerative changes in the glenoid. This approach can be performed in a minimally invasive fashion, which preserves bone stock and native biomechanics, and can be beneficial if conversion to total shoulder arthroplasty is required in the future and avoids risk of glenoid loosening or failure in younger and more active individuals. In this Technical Note and accompanying video, we describe our technique of humeral head resurfacing in a patient with isolated primary humeral osteoarthritis with a large focal chondral defect in the humeral head.

Chronic locked posterior gleno-humeral dislocation: technical note on fibular grafting for restoration of humeral head sphericity

Background

Reconstruction of reverse Hill-Sachs defect using osteo-chondral allograft has the advantages of spherical re-contouring and provision of smooth biological articular surface of the reconstructed humeral head. However, worldwide availability and risk of disease transmission of osteo-chondral allograft remain points of increasing concerns. As an alternative to lacking osteo-chondral allograft, the current technical note describes a reconstructive technique of reverse Hill-Sachs defect using autologous fibular grafting.

Methods

Following open reduction of the dislocated humeral head, reverse Hill-Sachs defect was reconstructed using 3–4 autologous fibular pieces (each is of 10 mm in length) fixed in flush with the articular cartilage using 4-mm cancellous screws. Defect reconstruction was then followed by modified McLaughlin’s transfer and posterior capsulorrhaphy.

Results

Spherical contour of the humeral head and gleno-humeral range of motion were restored. Intra-operative dynamic testing of the reconstruct revealed no residual posterior gleno-humeral instability.

Conclusion

Currently reported technique might offer advantages of graft availability, technical simplicity, familiarity and reproducibility, safety (i.e. no disease transmission) and bone preservation facilitating future revision management (if needed). Nevertheless, long-term outcomes of this technique should be investigated via further cohort clinical studies.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13018-021-02835-2.

Joint Preserving Treatment of Chronic Locked Posterior Shoulder Dislocation by Means of Combined Humeral Allograft Reconstruction and Posterior Glenoid Autograft Augmentation

Chronic locked posterior shoulder dislocations are challenging to treat and often warrant total shoulder arthroplasty. While joint preserving treatment is preferable in young patients, surgical techniques to treat this pathology have rarely been described in the literature. This technical note presents the treatment of a 30-year-old male patient with a chronic locked posterior shoulder dislocation by means of combined humeral allograft reconstruction and posterior glenoid autograft augmentation. Restoration of the spheric humeral head surface was obtained using a fresh-frozen femoral allograft fixed with two reabsorbable screws. Due to the intraoperatively persistent posterior instability after humeral reconstruction, the posterior glenoid was augmented with a tricortical iliac crest autograft, which was fixed with two metal screws. This treatment strategy resulted in a full range of motion and a centered stable shoulder joint at one-year follow-up. Therefore, the procedure of segmental reconstruction of the humeral head with a fresh-frozen allograft combined with a posterior glenoid augmentation with an iliac crest bone autograft is a joint-preserving treatment alternative to shoulder arthroplasty in young patients when humeral head reconstruction alone does not suffice.

The "BioHumi" Humeral Head Elliptical Osteochondral Allograft Transplantation

Cartilage defects of the humeral head in young, active patients provide a challenge to treating surgeons. The causes of humeral head osteochondral lesions are variable, but these lesions most commonly result from trauma and recurrent glenohumeral instability. Palliative and reparative techniques such as arthroscopic debridement and microfracture have traditionally been used as surgical treatment but have high failure rates. Similarly to surgical trends in the knee, cartilage restoration in the shoulder is becoming more prevalent in younger patients. Osteochondral allograft transplantation (OAT) has been used as a joint-preserving surgical option to restore hyaline cartilage in multiple joints for decades. Although OAT is more commonly used to re-establish the subchondral bony architecture in the treatment of recurrent shoulder instability, the procedure may also be indicated in young, active patients with focal humeral head chondral defects. OAT has been shown in early studies to provide improvement in functional outcome scores and good long-term graft survival with relatively low rates of complications. This report describes our straightforward, reproducible technique for the treatment of large, oblong chondral defects of the humeral head using OAT.

Pedicled-lesser tuberosity osteotomy for glenohumeral joint exposure: a technical note and case report highlighting its use in allograft reconstruction of a large engaging reverse Hill-Sachs lesion after posterior shoulder dislocation

Exposure of the humeral articular surface through an anterior approach to the shoulder for grafting humeral bone defects requires partial or complete detachment of the subscapularis tendon and traditionally is achieved through a subscapularis tenotomy, peel tuberosity osteotomy, or lesser tuberosity osteotomy. This case report presents a technique of performing a pedicled-lesser tuberosity osteotomy to allow adequate access for allograft reconstruction of a large reverse Hill-Sachs lesion after a traumatic posterior dislocation, to restore humeral head sphericity and prevent recurrent glenohumeral joint instability. The inferior subscapularis insertion is left intact leaving a periosteal sleeve and preserving the blood supply to the lesser tuberosity and humeral head, with the aim of improving healing of the osteotomy and preventing graft-related complications, such as resorption. Successful union of the pedicled-lesser tuberosity osteotomy and allograft was seen on a 6-month follow-upcomputed tomography scan, with adequate restoration of subscapularis function.

Harvest, Transport, and Storage of Fresh Humeral Head Osteochondral Allograft: Step-by-Step Protocol

Articular cartilage defects are not common in the glenohumeral joint and are mostly found in patients after shoulder trauma, in patients with recurrent instability, or in patients who underwent previous surgical treatment. Articular cartilage defects lead to pain and loss of motion, consequently causing shoulder function impairment and reducing quality of life. In young patients, the use of osteochondral allografts for the treatment of humeral head defects may avoid well-known complications of shoulder arthroplasty. The goal of this Technical Note is to describe a step-by-step protocol for the harvesting, transport, and preservation of fresh humeral head osteochondral tissue for use in allograft transplantation.

Utility of Allograft Talus as a Source for Grafting of Concurrent Humeral and Glenoid Defects Associated With Anterior Glenohumeral Instability: An Anthropometric Analysis

PURPOSE

To compare morphologic data of the talus using magnetic resonance images with previously reported values of the humeral head and the glenoid as a potential graft source for both the humeral head as well as glenoid reconstruction in the setting of concomitant glenoid and humeral head defects.

METHODS

All magnetic resonance images of the ankle were reviewed for assessment of the morphology and variation of the talus among individuals. Patients with post-traumatic, osteoarthritic, or surgical changes to the distal tibia about the mid- or hind- foot, or patients with incomplete medical records were excluded. Radiographic parameters that were measured included the maximum vertical height (MVH), the height to the talar neck, the radius of curvature (ROC) of the talar dome, ROC of the subtalar joint, and the maximum medial-to-lateral width of the talar dome. Demographic data also were collected on each individual. Statistical analysis was performed via a linear regression model with backwards elimination to determine which demographic data correlated most strongly with talar anthropometric values.

RESULTS

A total of 82 study patients met inclusion criteria (59 male, 23 female; mean age 40.91 ± 14.69 years). Sex was found have a positive correlation of the following talar dimensions: MVH (P = .039), talar dome ROC (P < .001), and subtalar joint ROC (p = 0.001). Height was the most positive correlation for medial-to-lateral width (P < .001), height to the talar neck (P = .004), and also correlate for MVH (P = .004). Body mass index was found to have multicollinearity and was therefore not used as a variable.

CONCLUSIONS

Allograft talus appears to be a viable graft, as demonstrated in this anthropometric study for both reconstruction of the glenoid and humeral head when cases of bipolar glenohumeral bone loss are present.

CLINICAL RELEVANCE

This study aims to further evaluate potential allograft donor sites for bipolar lesions.

Assessment of Safe Cartilage Harvesting Quantity in the Shoulder: A Cadaveric Study

Purpose

To evaluate the volume and yield of morselized cartilage that can be harvested from the shoulder for immediate reimplantation and repair.

Methods

A standard arthroscopic approach was used to harvest non–load-bearing cartilage from 5 cadaveric shoulder specimens. Cartilage was separated from the humerus, grasped, added to the cartilage particulator, and morselized to form a cartilage paste. The volume of reclaimed cartilage was measured and compared with average humeral and glenoid defects.

Results

The total yield of cartilage paste following tissue processing that was obtained from the 5 glenohumeral joints ranged from 1.0 mL to 2.4 mL with a mean volume of 1.9 ± 0.5 mL, yielding a theoretical 18.6 cm² ± 5.2 cm² of coverage with a 1-mm monolayer. Previously reported mean glenoid defect size ranges from 1.12 cm² to 2.73 cm², while the mean humeral defect size ranges from 4.22 cm² to 6.00 cm².

Conclusions

This study validated that through a single-stage surgical and processing technique it is possible to obtain a sufficient volume for re-implantable autologous morselized cartilage graft to address most glenohumeral articular cartilage defects.

Clinical Relevance

Chondrocyte grafts have been shown to be effective in cartilage repair. A single-site, single-staged procedure that uses a patient’s autologous shoulder cartilage from the same joint has the potential to reduce morbidity associated with multiple surgical sites, multistaged procedures, or nonautologous tissue in shoulder surgery.

A Modified Reverse Remplissage Procedure for Management of a Locked Posterior Shoulder Dislocation

Posterior shoulder dislocation is rare and often represents a diagnostic and therapeutic challenge. An impaction fracture of the anteroinferior aspect of the humeral head (called a reverse Hill-Sachs (RHS) fracture) is always present in case of chronic locked posterior dislocation. Surgical management is required and decided on the delay between the trauma and the diagnosis and the importance of the RHS (in percentage). The authors present a chronic locked posterior shoulder dislocation in a 32-year-old active male with a reverse Hill-Sachs lesion of more than 40%. An open reduction was required, and stabilization was achieved with a modified remplissage technique with detachment of the upper quarter of the subscapularis tendon. Three years after the surgery, the patient recovered an excellent functional level with a stable shoulder.

Humeral Head Osteochondral Allograft Reconstruction with Arthroscopic Anterior Shoulder Stabilization at a Long-Term Follow-Up: A Case Report

CASE

The authors report a case of recurrent anterior shoulder instability in a 19-year-old man. Intraoperative arthroscopic examination identified Bankart and engaging Hill-Sachs lesions. The patient was treated with humeral head osteochondral allograft reconstruction and concomitant arthroscopic anterior stabilization. At the 14-year follow-up, there was no recurrent instability.

CONCLUSION

Humeral head osteochondral allograft reconstruction combined with an arthroscopic anterior stabilization procedure can be successful for recurrent shoulder instability and engaging Hill-Sachs lesion.

Osteochondral allograft transplantation for large Hill-Sachs lesions: a retrospective case series with a minimum 2-year follow-up

PURPOSE

To investigate the clinical outcomes after osteochondral allograft transplantation for large Hill-Sachs lesions.

METHODS

Patients who underwent osteochondral allograft transplantation for large Hill-Sachs lesions were identified. Clinical assessment consisted of active range of motion (ROM), American Shoulder and Elbow Surgeons score (ASES), Constant-Murley score, Rowe score, and patient satisfaction rate. Radiographic assessment was performed with CT scan.

RESULTS

Nineteen patients met the inclusion criteria. The mean age was 21.7 years. The mean preoperative size of the Hill-Sachs lesion was 35.70 ± 3.02%. The mean follow-up was 27.8 months. All grafts achieved union at an average of 3.47 months after surgery. At the final follow-up, graft resorption was observed in 43.1% of patients. The average size of residual humeral head articular arc loss was 12.31 ± 2.79%. Significant improvements (P < .001) were observed for the active ROM, ASES score, Constant-Murley score, and Rowe score. The overall satisfaction rate was 94.7%. No significant difference was found between the resorption group and the nonresorption group in postoperative clinical outcomes.

CONCLUSION

Osteochondral allograft transplantation is a useful treatment option for patients with large Hill-Sachs lesions. Although the incidence of graft resorption may be relatively high, the clinical outcomes at a minimum 2-year follow-up are favorable.

LEVEL OF EVIDENCE

Level IV, case series.

[Research progress of surgical treatment for anterior shoulder dislocation and combined injuries]

Objective

To summarize the research progress of surgical treatment for anterior shoulder dislocation and combined injuries.

Methods

The related literature was reviewed, and the surgical treatment options for the anterior shoulder dislocation and its combined injuries were summarized.

Results

Anterior shoulder dislocation can combine with anteroinferior capsular ligament complex injury (Bankart injury), bony Bankart defect, and Hill-Sachs lesion. For Bankart and bony Bankart injuries, arthroscopic repair or coracoid osteotomy combined with bony graft reconstruction can be performed. For Hill-Sachs lesion, conservative treatment, soft tissue repair, or bony reconstruction should be selected based on the extent of the bone defect. For bipolar injury, the Bankart repair, Remplissage, or arthroplasty should be selected based on the extent of the glenoid defect.

Conclusion

With the development of arthroscopy and the improvement of the surgical concept, there is a complete set of surgical options for various injuries of the anterior shoulder dislocation. When choosing a surgical procedure, the patient's specific injury and age, exercise level, and other relating factors should be comprehensively assessed in order to achieve the best results.

Arthroscopic Knotless Remplissage for the Treatment of Hill-Sachs Lesions Using the PASTA Bridge Configuration

Recurrent glenohumeral dislocations can produce Hill-Sachs lesions-bony defects on the humeral head resulting from the humerus hitting the glenoid during dislocations. Some of these lesions can engage on the glenoid during motion, producing instability and potentially affecting the success of a labral repair. The remplissage was developed to address these Hill-Sachs lesions and improve stability. French for "filling," the goal of the remplissage is to fill the Hill-Sachs lesion with the infraspinatus tendon, preventing the margins of the lesion from engaging with the glenoid. Analogous to restoring the rotator cuff footprint during repair, a primary goal of the remplissage is to have the infraspinatus cover the Hill-Sachs lesion. The partial articular supraspinatus tendon avulsion (PASTA) bridge was originally developed for partial-thickness rotator cuff repair in situ, but additional uses have been found in other settings. The PASTA bridge uses a medial row horizontal mattress with a lateral anchor to create a linked construct to effectively distribute force and provide adequate coverage of the lesion. Knotless anchor technology used in this procedure prevents the need for arthroscopic knot tying and potentially damaging knot stacks. This Technical Note describes a remplissage technique using the PASTA bridge configuration to address Hill-Sachs lesions associated with recurrent glenohumeral instability.

Shoulder Instability: Anterior, Posterior, Multidirectional, Arthroscopic Versus Open, Bone Block Procedures

This article presents a retrospective comprehensive review of the history of anterior, posterior, and multidirectional shoulder instability and also reviews key concepts such as open versus arthroscopic repair and glenoid and humeral head bone loss and associated treatments. The future of shoulder instability will continue to evolve as research and clinical experience will determine the direction of the future.

Nonarthroplasty Options for the Athlete or Active Individual with Shoulder Osteoarthritis

The management of glenohumeral osteoarthritis is difficult in young, active individuals. After nonoperative management fails, arthroscopic debridement with concomitant procedures (eg, loose body removal, capsular release, labral debridement, synovectomy, osteophyte resection, bursectomy, subacromial decompression, microfracture, and biceps tenotomy or tenodesis) to address potential pain generators may be an option in small, contained, unipolar lesions.

Allograft Use in Shoulder Surgery: Instability and Rotator Cuff

Shoulder instability and rotator cuff pathology can provide a challenging problem, especially in the revision setting. Allograft use in primary or revision surgical intervention for shoulder instability and rotator cuff tear may be a valuable resource. This paper reviews allograft tissue use in shoulder surgery for instability and rotator cuff tear.

Tsmu solution improves rabbit osteochondral allograft preservation and transplantation outcome

To compare the effects of Tsmu solution with vitrification on chondrocyte viability and examine histological and biomechanical properties of osteochondral allografts (OCAs) after storage, OCAs from femoral condyles of New Zealand rabbits were harvested, stored for 35 days in Tsmu solution or by in vitro vitrification, and subjected to in vivo and in vitro assays. Stored OCAs were transplanted into knee femoral condyle cartilage defects in recipient rabbits. Chondrocyte viability and histological changes of cartilage grafts were assessed in vitro. Gross assessment, chondrocyte viability, histological assessment, OCA biomechanics, and immunological markers were evaluated in vivo 6 months after transplantation. Fresh OCAs served as in vitro and in vivo controls. Chondrocyte viability and scores for cartilage surface and histological quantitative assessment were superior for Tsmu solution compared with vitrification, but inferior compared with fresh OCAs in vitro and in vivo. With the exception of interleukin 6 content, biomechanical features of samples stored in Tsmu solution were superior to vitrification, and inferior to fresh OCAs in vivo. Thus, Tsmu solution provided suitable storage that improved chondrocyte viability, intact OCA cartilage matrix architecture, and transplantation outcomes.

Orthopedic Surgical Options for Joint Cartilage Repair and Restoration

The limited natural capacity for articular cartilage to regenerate has led to a continuously broadening array of surgical interventions. Used once patients' symptoms are not relieved by nonoperative management, these share the goals of joint preservation and restoration. Techniques include bone marrow stimulation, whole-tissue transplantation, and cell-based strategies, each with its own variations. Many of these interventions are performed arthroscopically or with extended-portal techniques. Indications, operative techniques, unique benefits, and limitations are presented.

Three-dimensional computed tomography measurement accuracy of varying Hill-Sachs lesion size

BACKGROUND

The glenoid track concept has been proposed to correlate shoulder stability with bone loss. Accurate assessment of Hill-Sachs lesion size preoperatively may affect surgical planning and postoperative outcomes; however, no measurement method has been universally accepted. This study aimed to assess the accuracy and reliability of measuring Hill-Sachs lesion sizes using 3-dimensional (3D) computed tomography (CT).

METHODS

Nine polyurethane humerus bone substitutes were used to create Hill-Sachs lesions of varying sizes with a combination of lesion depth (shallow, intermediate, and deep) and width (small, medium, and large). Specimens were scanned with a clinical CT scanner for size measurements and a micro-CT scanner for measurement of true lesion size. Six evaluators repeated measurements twice in a 2-week interval. Scans were measured by use of 3D CT reconstructions for length, width, and Hill-Sachs interval and with use of 2D CT for depth. The interclass correlation coefficient evaluated interobserver and intraobserver variability and percentage error, and Student t-tests assessed measurement accuracy.

RESULTS

Interclass correlation coefficient reliability demonstrated strong agreement for all variables measured (0.856-0.975). Percentage error between measured length and measured depth and the true measurement significantly varied with respect to both lesion depth (P = .003 and P = .005, respectively) and lesion size (P = .049 and P = .004, respectively).

DISCUSSION AND CONCLUSIONS

The 3D CT imaging is effective and reproducible in determining lesion size. Determination of Hill-Sachs interval width is also reliable when it is applied to the glenoid track concept. Measured values on 3D and 2-dimensional imaging using a conventional CT scanner may slightly underestimate true measurements.

Management of Complex Anterior Shoulder Instability: a Case-Based Approach

PURPOSE OF THE REVIEW

The goal of this review is to provide a guide on surgical decision-making options for complex anterior shoulder instability using a case-based approach.

RECENT FINDINGS

Arthroscopic Bankart repair is well documented for having successful outcomes in patients with isolated labral tear involvement with minimal bone loss. Latarjet is a generally accepted procedure in patients with 20-30% glenoid bone loss. When bone loss exceeds that which cannot be managed through Latarjet, a range of options exist and are highly dependent upon the extent of osseous deficiency on both the glenoid and humeral sides, surgeon experience, and patient-specific factors. The use of reverse total shoulder arthroplasty for the management of chronic locked shoulder dislocations has been described as a successful management option. Treatment options for complex anterior shoulder instability range widely based on patients' presenting exam, surgical history, amount of glenoid bone loss, size of Hill-Sachs lesion, and surgeon preference. When selecting the appropriate surgical intervention, the treating surgeon must consider the patient history, physical exam, and preoperative imaging along with patient expectations.

Management of Humeral Defects in Anterior Shoulder Instability

BACKGROUND

A Hill Sachs lesion is a posterior-superior bony defect of the humeral head caused by a compression of the hard glenoid rim against the soft cancellous bone in the context of an anterior instability episode. The presence of these humeral defects increases with the number of dislocations and larger lesions are associated with a greater chance of development of recurrent instability and recurrence after surgery. Also its location and pattern, in particular the so-called engaging Hill-Sachs, are associated with poor prognosis.

METHODS

There is a lack of consensus in terms of classification and management algorithm, although lesions greater than 25% of the humeral head had been suggested to need more than a simple Bankart repair to avoid recurrence. The concept of glenoid track has turned the attention to location and shape and not only size of the humeral defect. Moreover, the glenoid bone loss is crucial when choosing a treatment option as it contributes to decrease the glenoid track as well. A thorough revision of treatment options has been performed.

RESULTS

Numerous treatment options have been proposed including remplissage, glenoid or humeral head augmentation, bone desimpaction, humeral rotational osteotomy and arthroplasty.

CONCLUSION

Humeral defects treatment should be individualized. Determination of size and location of the defect and its relation with glenoid track is mandatory to achieve satisfactory results.

Fresh Osteochondral Allograft Transplantation for Focal Chondral Defect of the Humerus Associated With Anchor Arthropathy and Failed SLAP Repair

Isolated, full-thickness articular cartilage lesions of the glenohumeral joint can cause pain, mechanical symptoms, and impaired function. Reports on operative management of these injuries with arthroscopic techniques, such as marrow stimulation, have shown improvement in patient symptoms. In cases where the subchondral bone is involved, osteochondral allograft (OCA) transplantation has shown positive results for contained, focal cartilage defects. The technique for OCA transplantation to treat Hill-Sachs lesions has been reported in detail, and there are multiple case series reporting on the outcomes of OCA used for this purpose. This Technical Note shows the application of OCA to treat a case of anchor arthropathy where a glenoid anchor placed during arthroscopic stabilization causes iatrogenic damage to the humeral head. This type of injury can result in cartilage lesions in uncommon locations, such as on the posterior humeral head. In this description, the technical pearls and pitfalls of managing difficult-to-access posterior humeral head lesions are presented along with the senior authors' general technique for OCA to treat focal lesions of the humeral head cartilage.

Joint Preservation Techniques in Orthopaedic Surgery

CONTEXT

With increasing life expectancy, there is growing demand for preservation of native articular cartilage to delay joint arthroplasties, especially in younger, active patients. Damage to the hyaline cartilage of a joint has a limited intrinsic capacity to heal. This can lead to accelerated degeneration of the joint and early-onset osteoarthritis. Treatment in the past was limited, however, and surgical treatment options continue to evolve that may allow restoration of the natural biology of the articular cartilage. This article reviews the most current literature with regard to indications, techniques, and outcomes of these restorative procedures.

EVIDENCE ACQUISITION

MEDLINE and PubMed searches relevant to the topic were performed for articles published between 1995 and 2016. Older articles were used for historical reference. This paper places emphasis on evidence published within the past 5 years.

STUDY DESIGN

Clinical review.

LEVEL OF EVIDENCE

Level 4.

RESULTS

Autologous chondrocyte implantation and osteochondral allografts (OCAs) for the treatment of articular cartilage injury allow restoration of hyaline cartilage to the joint surface, which is advantageous over options such as microfracture, which heal with less favorable fibrocartilage. Studies show that these techniques are useful for larger chondral defects where there is no alternative. Additionally, meniscal transplantation can be a valuable isolated or adjunctive procedure to prolong the health of the articular surface.

CONCLUSION

Newer techniques such as autologous chondrocyte implantation and OCAs may safely produce encouraging outcomes in joint preservation.

Allografts: Osteochondral, Shell, and Paste

There is an increasing need for articular cartilage restoration procedures. Hyaline cartilage lacks intrinsic healing capacity. Persistent osteochondral defects can lead to early and rapid degenerative changes. Microfracture and autologous chondrocyte implantation provide reasonable outcomes for smaller defects without bone loss. However, these techniques have limited effectiveness for lesions greater than 4 cm² or with significant bony involvement. Ostochondral allografts provide an option for these lesions. This article reviews osteochondral allografts for articular defects. Emerging options provide different approaches to difficult cartilage defects. We discuss current screening, procurement, and storage methods, surgical techniques, outcomes, and bacterial/viral transmission.

Prevention and management of post-instability glenohumeral arthropathy

Post-instability arthropathy may commonly develop in high-risk patients with a history of recurrent glenohumeral instability, both with and without surgical stabilization. Classically related to anterior shoulder instability, the incidence and rates of arthritic progression may vary widely. Radiographic arthritic changes may be present in up to two-thirds of patients after primary Bankart repair and 30% after Latarjet procedure, with increasing rates associated with recurrent dislocation history, prominent implant position, non-anatomic reconstruction, and/or lateralized bone graft placement. However, the presence radiographic arthrosis does not predict poor patient-reported function. After exhausting conservative measures, both joint-preserving and arthroplasty surgical options may be considered depending on a combination of patient-specific and anatomic factors. Arthroscopic procedures are optimally indicated for individuals with focal disease and may yield superior symptomatic relief when combined with treatment of combined shoulder pathology. For more advanced secondary arthropathy, total shoulder arthroplasty remains the most reliable option, although the clinical outcomes, wear characteristics, and implant survivorship remains a concern among active, young patients.

Equine Dental Pulp Connective Tissue Particles Reduced Lameness in Horses in a Controlled Clinical Trial

OBJECTIVE

To assess if injection of allogeneic dental pulp tissue particles would improve lameness in horses with naturally occurring osteoarthritis (OA) or soft tissue (ST) injury.

DESIGN

Prospective, randomized, blinded, and controlled clinical trial and client survey assessment.

ANIMALS

Forty lame client-owned horses.

PROCEDURES

Sterile dental pulp, recovered from otherwise healthy foals that perish during dystocia, was processed under good manufacturing processing to produce mechanically manipulated, unexpanded pulp tissue particles containing viable cells surrounded in extracellular matrix. Forty lame client-owned horses with confirmed OA (n = 20), or ST injury (desmitis or tendonitis) received a 2 mL intra-articular (n = 20 OA) or intra-lesional (n = 20) injection of control transport vehicle (n = 20) or 10 × 106 dental pulp tissue particles (n = 20). Acclimatized horses had baseline measurements performed and were then injected on day 0. Horses were treadmill exercised for 2 weeks, evaluated by clinical parameters, lameness score, edema (score and circumference), pain on flexion (OA) or pressure (ST), and clients' scores for pain and discomfort before and through 45 days after pulp injection. Twenty horses were available for >2.5-year follow-up.

RESULTS

Pulp-treated horses showed decrease in lameness compared to baseline (P < 0.009) or placebo controls (P < 0.013) for at least 2 weeks. Client assessments of comfort were improved between before and 45 days after pulp injection (P < 0.001). Clinical improvement with ST injury was significantly greater than OA (P < 0.001). At >2.5-year follow-up, at least 10 horses were in work.

CONCLUSION AND CLINICAL RELEVANCE

Dental pulp tissue particles can be considered as a treatment option for equine lameness due to OA, desmitis, or tendonitis.

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.