Humeral Head Defects Research Articles

Osteoarticular Allograft Reconstruction of a Large Glenoid and Humeral Head Defect in Recurrent Shoulder Instability

In a select group of patients, recurrent shoulder instability is accompanied by sizable glenoid or humeral osteochondral lesions. Occasionally, these lesions may be large enough to warrant surgical reconstruction, as previous reports have shown that these defects can contribute to surgical failure if not addressed. The following article outlines a novel technique that was used to address a combined humeral and glenoid osteoarticular defect using allograft tissue. Both defects were large enough to warrant surgical reconstruction, with the potential benefit of a near-anatomic postoperative glenohumeral range of motion.

Osteoarticular Allograft Transplantation for Large Humeral Head Defects in Glenohumeral Instability

During traumatic anterior shoulder dislocation, significant derangement of normal anatomy occurs. Open and arthroscopic techniques alike have emphasized anatomic reconstruction of anterior capsulolabral structures while often neglecting associated osteoarticular pathology. Recent studies have shown that failure rates after Bankart repair are dramatically higher in the presence of large glenohumeral bone defects, yet little has been written about how to best address these lesions. Historically, these patients will undergo multiple procedures culminating with nonanatomic solutions to constrain the humeral head (coracoid transfer or open capsular shift). Significant loss of motion yields unacceptable results in a high-demand athletic population. We present a new approach to athletic, highly functional patients with recurrent anterior instability and large humeral head defects (Hill-Sachs lesion). Anterior capsulolabral pathology is addressed arthroscopically, and the Hill-Sachs lesion is then addressed via a limited posterior approach to the humeral head. Osteoarticular allograft transplantation is performed by use of a single plug to fill the defect. As described, this procedure can be performed in a single operative setting or as a staged procedure for those patients who still have subjective subluxation as a result of continued engagement of a large humeral head defect after Bankart repair. Importantly, our posterior approach does not require takedown of the anterior capsulolabral repair to address the bone defect. We have performed this procedure in a 19-year-old enlisted US Navy seaman, with excellent short-term results. At 1-year of follow-up, he has returned to full active military duty without restriction.

The success of closed reduction in acute locked posterior fracture-dislocations of the shoulder

We retrospectively reviewed the results of closed treatment in 7 patients with acute locked posterior fracture-dislocations of the shoulder. Shoulders were reduced with patients under general anesthesia and were splinted in neutral rotation for 6 weeks. Follow-up averaged 46 months (range, 24-88 months). All shoulders were reduced within 14 days. Humeral head defects ranged from 18% to 32% of the articular surface, and all patients had documented posterior instability under anesthesia after relocation. Of the 7 patients, 6 had a stable shoulder. The mean American Shoulder and Elbow Surgeons shoulder index was 93.5 (range, 83-100). The mean findings with regard to motion were active forward elevation to 169 degrees , external rotation to 73 degrees , and internal rotation to T11. All patients without preexisting shoulder pathology were treated successfully. Closed management of acute posterior fracture-dislocations can be highly successful, even in the face of instability under anesthesia and a 30% humeral head defect.

Arthroscopic Reduction and Repair of a Locked Posterior Shoulder Dislocation

Locked posterior shoulder dislocations are an uncommon but difficult problem for the orthopaedic clinician. Furthermore, they are often missed on initial presentation, resulting in significant delays in treatment. Traditional treatment has involved formal open reduction, most commonly from an anterior approach, followed by transfer of the lesser tuberosity or subscapularis tendon into the anterior humeral head defect. We present the case of a patient with locked posterior shoulder dislocation, who was treated with arthroscopically assisted reduction followed by arthroscopic posterior stabilization. Use of this technique allows the surgeon to reduce the dislocation without performing an open arthrotomy, thereby decreasing the patient’s overall morbidity. Furthermore, an arthroscopic technique used for stabilization allows visualization of the entire glenohumeral joint and enables the surgeon to directly address posterior disease, rather than compensating for the defect with an anteriorly based transfer.

Transhumeral Head Plasty for Large Hill-Sachs Lesions

Large, engaging Hill-Sachs lesions can cause recurrent glenohumeral instability following Bankart repair of torn anterior capsulolabral structures. We offer a novel technique for correcting the posterolateral humeral head defect without significantly altering normal anatomic structures. The glenohumeral joint is exposed via a deltopectoral approach. After the defect geometry is appreciated by direct palpation and visualization, the tip of an anterior cruciate ligament tibial guide is centered in the defect. The drill sleeve is approximated to the anterior lesser tuberosity starting hole, and a graduated guidewire is advanced to the posterior subchondral surface. After confirmation of satisfactory positioning, an 8-mm cannulated acorn drill is drilled to within 1 cm of the posterior surface. Bone tamps are used to elevate the depressed area using the tunnel created within the head. Allograft cancellous bone chips are impacted into the defect to elevate and support the subchondral surface. After successful impaction grafting and restoration of the head surface, anterior capsulolabral reconstruction is undertaken using either the Bankart or Latarjet technique. A standard Bankart rehabilitation program is followed postoperatively. We confirmed the clinical efficacy of our technique in 4 patients who experienced no instability or other complications at an average of 1-year follow-up.

Quantitative Evaluation of Humeral Head Defects by Comparison with the Opposite Side

Quantitative Evaluation of Humeral Head Defects by Comparison with the Opposite Side

Percutaneous Correction (Humeroplasty) of Humeral Head Defects (Hill-Sachs) Associated With Anterior Shoulder Instability: A Cadaveric Study

The goal of our study was to determine whether a bone tamp could be used to correct a Hill-Sachs lesion by a unique technique that we developed termed "humeroplasty." In vitro cadaveric study. We created reproducible Hill-Sachs lesions in 14 cadaveric humerii, which we then reduced with a curved bone tamp using our proposed technique. Paired t tests, with the significance set at P < .05, were then used to compare the prereduction and postreduction depths, widths, lengths, and volumes of the lesions. The average prereduction defect measurements were 8.9 mm deep, 16.3 mm wide, 24.1 mm long, and 1,755 mm3 in volume. The average postreduction defect measurements were 1.6 mm deep, 6.2 mm wide, 10.4 mm long, and 50.3 mm3 in volume. A statistically significant improvement (P < .001) was seen in all parameters. Our technique was able to consistently and significantly restore all measured parameters of the Hill-Sachs lesions using a curved bone tamp. This reduction to a "small" defect may reduce the higher rate of recurrence normally found with the surgical treatment of shoulder instability when "large" Hill-Sachs lesions are present. Humeroplasty potentially might reduce the higher rate of recurrence observed when the surgical treatment of shoulder instability involves the presence of large Hill-Sachs lesions.

Operative Stabilization of Posterior Shoulder Instability

Background Symptomatic, traumatic posterior shoulder instability is often the result of a posteriorly directed blow to an adducted, internally rotated, and forward-flexed upper extremity. Operative repair has been shown to provide favorable results. Current arthroscopic techniques with suture anchors and the ability to plicate the capsule using a nonabsorbable suture may provide favorable outcomes with reduced morbidity. Purpose To evaluate the results of operative shoulder stabilization in patients with traumatic posterior shoulder instability. Study Design Case series; Level of evidence, 4. Methods A consecutive series of patients who underwent arthroscopic or open posterior stabilization for traumatic posterior shoulder instability were evaluated using subjective assessments, physical examinations, the Single Assessment Numeric Evaluation, Rowe score, Simple Shoulder Test, and the Western Ontario Shoulder Instability Index. Results Between May 1996 and February 2002, 31 shoulders (30 patients) underwent posterior stabilization (19 arthroscopically, 12 open). There were 29 men and 1 woman (mean age, 23 years). Preoperatively, all patients had a distinct traumatic cause for the instability. On physical examination, all patients had posterior apprehension and increased (2+, 3+) posterior load-shift testing. Preoperative radiographs and/or magnetic resonance imaging revealed posterior rim calcification or reverse Bankart lesions in 29 cases (94%). At arthroscopy, posterior labral injuries, reverse Bankart lesions, or humeral head defects were identified. Follow-up averaged 40 months, and the mean duration between injury and surgery was 21 months. The mean Single Assessment Numeric Evaluation, Rowe score, Simple Shoulder Test, and Western Ontario Shoulder Instability Index scores, respectively, for the entire group were 89, 87, 11, and 346; for the open group, they were 81, 80, 10.5, and 594; for the arthroscopic group, they were 92, 92, 11.4, and 190. The Western Ontario Shoulder Instability Index (P <. 03) and Rowe score (P <. 04) outcomes scores for the arthroscopic group were statistically better than those of the open group. Twenty-nine of 31 shoulders were rated as excellent or good. Conclusion In the case of traumatic posterior shoulder subluxation, posterior lesions of the labrum (“reverse Bankart”), articular edge, and capsule are observed. Surgical treatment addressing these lesions led to satisfactory results for both the open and arthroscopic treated groups. In this study, an arthroscopic technique utilizing suture anchor repair with capsular placation provided the most favorable outcomes.

Simultane bilaterale vordere und hintere Schulterluxation nach epileptischem Anfall—eine seltene Verletzungskombination

We report about a 29 year old male patient who had a simultaneous bilateral ventral and dorsal shoulder dislocation. The dislocation happened during a first incident of an epileptic convulsion, previously not diagnosed. On the right shoulder following a closed reduction manoeuvre a dislocation fracture was seen. It needed operative open reduction and fixation with angular stable plate osteosynthesis. The locked dorsal shoulder dislocation on the left was operated dorsally secondary via a dorsal approach. In a first step the reduction was carried out and in the same intervention the humeral head defect was lifted and supported in a closed technique under radiographic control.6 months postoperatively the patient was free of pain in both shoulder joints. The range of motion was unimpeded on the left and only with slight deficits in abduction and anteversion on the right. The diagnostics and the treatment strategy for this rare injury combination are described critically in this paper.

Management of Posterior Glenohumeral Instability With Large Humeral Head Defects

Traumatic posterior instability may occasionally cause a large osteochondral lesion when the anterior humeral head is compressed against the posterior glenoid rim. This is termed a reverse Hill–Sachs lesion. Such osteochondral defects may be very large in the case of chronic locked dislocations. Even in acute posterior disclocations, closed reduction may be difficult when the humeral head is locked posteriorly over the glenoid. In such cases closed or open reduction under general anesthesia with muscle relaxation may be necessary. In cases where the anterior humeral head defect is large, reconstruction may be necessary to maintain stability. Management must be tailored to the individual patient and depends on several factors, which include the size of the defect, the duration of the dislocation, the quality of the bone, the status of the articular cartilage, and the patient’s overall health. Treatment options include skillful neglect, subscapularis-lesser tuberosity transfer into the humeral head defect, disimpaction and bone grafting, allograft reconstruction of the humeral articular surface, and arthroplasty.

Percutaneous humeroplasty of posterolateral humeral head defects (Hill-Sachs) associated with anterior shoulder dislocation: a cadaveric study (SS-63)

The significance of the Hill-Sachs lesion in relation to recurrent anterior dislocations of the shoulder has been well described. While numerous procedures have been devised for the treatment of recurrent anterior shoulder dislocations associated with these defects, none are directly aimed at correcting the lesion itself. A percutaneous bone tamp has been used successfully in treating central tibial articular depressions seen in plateau fractures. We propose that the percutaneous bone tamp can be used to correct or decrease the size of large Hill-Sachs defects which we will term “humeroplasty.” The purpose of our study was to evaluate whether percutaneous humeroplasty can be used to achieve correction of a large Hill-Sachs defect. Our hypothesis is that percutaneous humeroplasty can reduce large Hill-Sachs lesions to normal. Fourteen cadaveric humeri were used for our study. The average age was 49.9 years. There were 13 males, 1 female. A reproducible, “significant” Hill-Sachs defect that was morphologically similar to in vivo lesions was created, as defined by previous studies. Defect arc depth, arc width and the length were then measured and will be used to calculate the volumetric loss from the Hill-Sachs lesion as well as volume restoration following humeroplasty. The defect was then reduced visually and under fluoroscopic guidance using our percutaneous humeroplasty technique. This technique involves a 10-mm diameter cortical window created in the mid-greater tuberosity just lateral to the bicipital groove, through which the curved bone tamp is directed to the defect and correction is obtained. The residual defect following humeroplasty was then measured and recorded. Paired t tests were used to compare the pre- to post-humeroplasty parameters including arc depth, width, length, and volume as well as comparing post-humeroplasty measurements to no defect. Significance is set at P = .05. The average arc depth, width, length, and volume of the Hill-Sachs defect measured 8.9 mm, 16.3 mm, 24.1 mm, and 1755.6 mm3, respectively. Following percutaneous humeroplasty, these defects were reduced to 1.6 mm, 6.2 mm, 10.4 mm, and 50.3 mm3, respectively. All reductions were statistically significant (P < .001). When the reduced defect arc depth, width, length, and volume were compared with no defect (0 mm or 0 mm3), there was a statistically significant difference in all parameters (P < .001). We were able to reproducibly create large Hill-Sachs deformities in vitro. While we were not able to prove our hypothesis that percutaneous humeroplasty can reduce large Hill-Sachs lesions to normal, we were able to significantly reduce these to “small” defects, as described in previous clinical studies. This reduction of the Hill-Sachs lesion to a “small” defect may prevent the increased risk of recurrence normally seen following the surgical treatment of anterior shoulder instability with large Hill-Sachs defects. Additional cadaveric research followed by clinical studies is needed to further investigate percutaneous humeroplasty as a viable technique for the treatment of anterior shoulder instability with large Hill-Sachs lesions.

Acromial impression fracture of the greater tuberosity with rotator cuff avulsion due to hyperabduction injury of the shoulder

A heavy-set, muscular, 23-year-old, right hand–dominant male office worker who participates in basketball, weight lifting, and some throwing sports had a hyperabduction injury (without evidence of glenohumeral dislocation) of the right shoulder after falling down a cliff. As depicted in Figure 1, the fall was a sheer 15-foot free fall onto the hyperabducted arm, as he had placed his forearm over his head for protection. After this, there was a further 40-foot sloped descent whereupon the patient reports that he “tumbled like a rag doll through trees and rocks.” Upon landing the final time, his arm was out to the side (in abduction), feeling locked, with normal motor function in the hand. He also had multiple ligamentous injuries to the left knee. The radiographs depicted in Figure 2 demonstrate the lateral defect in the greater tuberosity. Subsequent ultrasound examination of the shoulder (not shown) suggested rotator cuff avulsion. Axial computed tomography (CT) (Figure 3, A) demonstrated the extensive lateral impression fracture of the superolateral greater tuberosity and anatomic neck, which left an extensive cavitary bony deficit. In Figure 3, B, the reconstructed sagittal CT section better demonstrates the bony defect and its extent, as well as defining the fragments of subacromial bone, which were presumed to represent avulsion of the supraspinatus tendon from the greater tuberosity. After the patient’s knee was reconstructed, operative treatment involved positioning the patient supine and semiupright in the beach-chair position. A longitudinal lateral incision was made from the acromion down the deltoid, followed by a deltoid split to explore the damage. After finding the crater of the humeral head defect, which appeared to key together with the acromion, the rotator cuff was explored and the deltoid dissected subperiosteally from the acromion for proper exposure. We did not enter the rotator interval anteriorly. The substance of the rotator cuff tendons appeared to be entirely intact, and they mobilized remarkably well, considering that the operation was at 18 days after injury. The rotator cuff could not be classified as a tear,2,3 as the substance of it was in full continuity. However, we did keep in mind the principle of regaining tension of the tendon, which has been noted in rotator cuff tears to be more Dr Kaspar holds research grants from McMaster University and from the Physicians’ Services Incorporated (PSI) Foundation of Ontario, neither of which had any bearing on this report. From McMaster University. Reprint requests: Scott Mandel, MD, FRCSC, 414 Victoria Ave N, Suite M8, Hamilton, Ontario, Canada, L8L 5G8. J Shoulder Elbow Surg 2004;13:112-14 Copyright © 2004 by Journal of Shoulder and Elbow Surgery Board of Trustees. 1058-2746/2004/$35.00 0 doi:10.1016/S0009-9236(03)00177-0 Figure 1 Diagrammatic representation of the mechanism of injury. The patient’s body weight landed onto his right upper extremity, which he had used to protect his head, hence yielding a hyperabducted right shoulder. After this 15-foot free fall, he continued tumbling for a further 40 feet.

Die Schultergelenksarthrodese nach posttraumatischer Humeruskopfresektion und Plexus-brachialis-Schaden - ein Fallbericht

The literature study shows many valid indications for shoulder arthrodesis, but with regard to the technical feasibility there exists no uniform concept. In situations with humeral head defects after failured arthroplastic procedure, after infection, or tumor, especially in combination with nerval deficits, a possibility to reach anodynia with a rest of function of the shoulder is the arthrodesis. With the common techniques, the arthrodesis is difficult because of the long distance of osseous defect. We report on 2 patients with complicated dislocated humeral head fractures with traumatic brachial plexus palsy. After reconstruction by internal fixation, they suffered from a humeral head necrosis. The arthroplastic procedure was followed by relapsed multiple luxations of the joint, the explantation of the humeral head prosthesis resulted in persistant pain and functional disability of the shoulder. Therefore we decided to perform a glenohumeral arthrodesis in both cases. We present here a procedure of arthrodesis between glenoid and humeral shaft as a modification of the AO-technique. We present the operative procedure and the results of this method.

Use of allograft for large Hill–Sachs lesion associated with anterior glenohumeral dislocation: A case report

Though Hill–Sachs lesion is a common injury associated with anterior glenohumeral dislocation, there have been only few articles describing specific treatments for the humeral head defects. This paper described the case of an alternative treatment for large defect of the posterior-superior aspect of the humeral head using allograft. The patient was a 69-year-old male and the diagnosis was a chronic anterior dislocation of the right glenohumeral joint with a large impaction fracture of the posterior-superior aspect of the humeral head. The size of this defect was 4 cm by 2.5 cm in diameter with a 2 cm depth. To reduce the impaction fracture of the humeral head, a preserved frozen allograft of the femoral head was selected and configured to fit the defect. The graft was then impacted firmly down into the defect, and appeared to offer excellent stability even without adjuvant internal fixation. Two years after surgery, the patient was doing quite well with no complaints. Radiographs showed humeral head with incorporation of the graft and no evidence of collapse.

Gleno-humeral instabilities.

The purpose of this review is to highlight the most efficient imaging exploratory techniques depicting shoulder instability, to describe its various forms and to point out the findings which can simulate instability. In anterior recurrent dislocation, surgery is indicated and the procedure essentially depends on the importance of glenoid rim lesions. In this case, a standard X-ray evaluation is usually sufficient. The CT arthrography or MRI techniques give more specific details as to the severity of the lesions, particularly soft tissues alterations; however, these data do not alter standard therapeutic protocol. In fixed posterior dislocations, CT scan represents the most pertinent technique to evaluate the size of the humeral head defect and to determine the therapeutic follow-up. In subtle forms of instability, diagnosis or instability direction are not clearly assessed clinically and standard X-ray evaluation is usually unremarkable. In this case, further exploration, such as CT arthrography, MR imaging or MR arthrography, are recommended to confirm the diagnosis of instability and to evaluate its direction. The technique of choice is undoubtedly MR arthrography. Atraumatic voluntary painless subluxations associated with hyperlaxity of the shoulder do not require any specific exploratory method because the findings are generally limited to a capacious axillary pouch.

Posterior fracture-dislocation of the shoulder: Treatment with acute osteochondral grafting

Posterior fracture-dislocations of the shoulder are rare, accounting for approximately 1% to 4% of all shoulder injuries. 9, 2o Treatment recommendations for this injury have been based on the type of associated fracture, the size of the articular defect, and the chronicity of the injury. 1, 6-8, 17-19 To our knowledge the use of osteochondral autografting of the humeral head defect associated with an acute posterior fracture-dislocation has not been previously reported. We report a case of bilateral posterior fracture-dislocations of the shoulder, one of which was suitable for treatment in this manner.

Arthroscopic shoulder stabilization using transglenoid sutures. A four-year minimum followup.

Thirty-seven of 41 consecutive patients with recurrent anterior instability of the shoulder were retrospectively observed for a mean of 5.6 years (range, 4 to 10) after an arthroscopic stabilization procedure had been performed. The operative technique involved the use of transglenoid sutures to repair the capsule and labrum. According to the criteria established by Rowe, 27 patients (74%) had good or excellent results, and 3 patients (7%) were graded as fair. Seven patients (19%) developed recurrent instability after the procedure and had failed results. Failure rates were equal in patients with a history of recurrent dislocation and those with recurrent subluxation. Absence of a Bankart lesion at operation was associated with postoperative instability (P = 0.03). The presence or size of humeral head defects did not influence the result. Eight of 12 athletes who engaged in sports requiring repetitive overhead shoulder motion returned to full activity, and none of the 12 developed instability after operation. Four of the 13 patients who participated in contact sports or recreational skiing developed postoperative instability (P = 0.21). All failures occurred within 2 years of the procedure.

Recurrent Posterior Glenohumeral Dislocation Associated With Increased Retro version of the Glenoid

Recurrent traumatic posterior glenohumeral dislocation is rare and probably represents < 5% of all recurrent shoulder instability cases. Operative management of this problem is considered when symptomatic recurrent instability occurs despite an adequate physician-directed rehabilitation program. Before surgery, it is essential to recognize all directions of instability and any anatomic factors that may predispose the shoulder to recurrent instability, such as humeral head or glenoid defects, abnormal glenoid version or other anthropomorphic abnormalities, rotator cuff tears, neurologic injuries, or generalized ligamentous laxity. The authors report on a patient who had 2 previous failed attempts at posterior capsulorrhaphy for recurrent posterior shoulder dislocation after an atraumatic injury. The patient demonstrated a previously unrecognized unilateral increase in glenoid fossa retroversion and was successfully treated with a posterior opening wedge osteotomy of the scapular neck.

Stellenwert der Magnetresonanztomographie in der Diagnostik von Schultergelenkerkrankungen

In a prospective study 43 patients with shoulder pain were examined by sonography and MRI. The findings were controlled by plain radiography, arthrography, and CT arthrography. Joint effusions and humeral head defects were equally identified by MR and sonography. In the diagnosis of labrum lesions, rotator cuff lesions, subacromial spurs, and synovial inflammatory disease sonography was not as accurate as MR. A special MR scoring system improved the diagnosis of an impingement syndrome.

Luxatio Erecta Humeri

Luxatio erecta humeri is a rare type of glenohumeral dislocation. The pathomechanics of this injury involve either direct axial loading on a fully abducted extremity or leverage of the humeral head across the acromion by a hyperabduction force. The clinical presentation of this type of shoulder dislocation is unique, with the affected extremity held rigidly above the head in abduction. Reduction is accomplished by a form of traction-countertraction under intravenous sedation and analgesia. A variety of neurologic and vascular injuries may be associated with luxatio erecta humeri, involving the brachial plexus and axillary artery, respectively. Concomitant fracture of the acromion, clavicle, coracoid, greater tuberosity, and humeral head may also be seen. A computed tomography scan of the case reviewed here revealed a large humeral head defect oriented perpendicular to the classic Hill-Sachs lesion. Luxatio erecta humeri is associated with significant late morbidity, including recurrent dislocation, instability, and adhesive capsulitis.