Treatment of Glenoid and Humeral Head

Bone Defects in Shoulder Instability

Nikolaos TzanakakisOrthopedic Surgeon

2nd Orthopedic Dept.Center for Shoulder Arthroscopy

IASO General HospitalAthens, Greece

Background

There is a well-recognized association between osseous defects of the glenoid or humerus and shoulder dislocation, which often leads to recurrent instability.

Boileau P., J Bone Joint Surg Am. 2006 Aug;88(8):1755-63. Lynch JR., J Shoulder Elbow Surg. 2009 Mar-Apr;18(2):317-28.

Burkhart SS., Instr Course Lect. 2009;58:323-36.

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Mechanism of Bone Defects

Hill-Sachs Glenoid bone Loss

Normal Shoulder Bone contact

Dislocation

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Bone defects after anterior dislocation (unpublished data, 125 patients)

Hill-Sachs & Glen. Defect

Hill-Sachs & No Glen. Defect

No Hill-Sachs & No Glen. Defect

No Hill-Sachs & Glen. Defect

23.6%

45.5%

30.1%

0.8%

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Bone Defects Frequency Hill-Sachs: 65-71% first dislocation

Hill-Sachs: 93% recurrent dislocations

Glenoid bone loss: 5-56% traumatic instability

Possitive correlation between Number of dislocations and depth/extend of the lesions

Lynch JR, J Shoulder Elbow Surg (2009) 18, 317-328

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Humeral Head Bone Defect

(Hill-Sachs Lesion)

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Hill-Sachs Lesion

•Impression fracture of the posterolateral humeral head

•Present up to 90% of anterior dislocations and 25% of anterior subluxations

(Calandra JJ, Arthroscopy1989;5:254)

•Reverse Hill-Sachs (posterior dislocations)

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Hill-Sachs Arthroscopic Grading

Grade I: defect in the articular surface down to subchondral bone

Grade II: includes the subchondral bone

Grade III: large subchondral defect

Calandra et. Al, 1989

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Hill-Sachs Grading MINOR: Less than 20% of head

MODERATE: 20-40% of head

SEVERE: Greater than 40% of head

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Hill-Sachs Grading

Engaging

Non Engaging

Burkhart SS, De Beer JF : Arthroscopy 2003;19 : 732–739

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Hill-Sachs: Pre-Op evaluation

X-ray

CT

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Arthroscopic Evaluation

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Arthroscopic Evaluation

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Guidelines for Hill-Sachs Treatment Most Hill-Sachs lesions are small and don’t

require treatment

Each lesion should be evaluated during surgery

Treatment Required for:

- Lesions found to be engaging in a normal ROM

- Lesions representing >30%-40% of the articular surface

Center for Shoulder Arthroscopy

IASO GENERAL Hospital

Treatment Options for Hill-Sachs

Humeral rotation osteotomy (Weber BG, JBJS 1984;66A:1443)

Hemiarthroplasty / TSA for patients >50y/o (Flatow E, JSES 1993;12:1, 29)

Humeral head grafting(Gerber C, JBJS 1996;78A:376)

Remplissage (Wolf EM, Arthroscopy 2004;20(suppl1) :e14)

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Treatment Options for Hill-Sachs Humeral rotation osteotomy

(Weber BG, JBJS 1984;66A:1443)

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Humeral Head Grafting for Hill-Sachs

Bushnell BD, Creighton RA, Herring MM. Hybrid treatmentof engaging Hill-Sachs lesions: Arthroscopic capsulolabral

repair and limited posterior approach for bone-grafting. TechShoulder Elbow Surg 2007;8:194-203.

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Trans-humeral head plasty

Re P, Gallo RA, Richmond JC. Transhumeralhead plasty for large Hill-Sachs lesions. Arthroscopy

2006;22:798.e1-798.e4

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Hemi-CAP

Raiss P, Aldinger PR, Kasten P, Rickert M, Loew M. Humeralhead resurfacing for fixed anterior glenohumeral dislocation.

Int Orthop 2007 Dec 19 [Epub ahead of print]

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“Remplissage” Technique

Eugene Wolf, 2004,Arthroscopy

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Arthroscopic Remplissage

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Glenoid Bone Defects

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Background KnowledgeConsiderable Glenoid defects after shoulder dislocation decrease the intrinsic stability.

[Burkhart, De Beer, Itoi, Mologne]

In vitro, less forces need to dislocate the shoulder.

[Burkhart SS. Arthroscopy, 2000]

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Types of Glenoid bone defects

Bony Bankart Attritional bone loss

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Glenoid Shape

a b

Normally:

a = b = 12mm

Huysmans PE, J Shoulder Elbow Surg 2006;15:759-763.www.shoulder.gr

Glenoid Bone Defect

Considerable Glenoid Bone

Loss

a > b/2

“Inverted Pear”

a b

Loss of 8.6mm of anterior radius of glenoid Loss of 8.6mm of anterior radius of glenoid at the level of the bare spot corresponds to at the level of the bare spot corresponds to 35% of the normal anteroposterior width35% of the normal anteroposterior width

Lo IK, Parten PM, Burkhart SS:Arthroscopy 2004;20:169-174.www.shoulder.gr

Bare Spot

b a

% Bone Loss

Lo IK, Parten PM, Burkhart SS: Theinverted pear glenoid: An indicator of

significant glenoid bone loss.Arthroscopy 2004;20:169-174.

a

ba

2

−=

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Imaging Evaluation:Pico Method (2D CT) Taverna et al. Pico Method 2D CT – measurement of glenoid

surface

Critical Limit 25% loss of glenoid surface

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Imaging Evaluation:Glenoid Index (3D CT)

Glenoid Index in 3D CT scan of both shoulders

Critical Limit Glenoid index 0.75

SS Burkhart Arthroscopy: Vol 24, No 4 (April), 2008: pp 376-382

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The Real Problem:

Large Glenoid bone defect

+ Large Hill-Sachs Lesion

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Treatment Options for Glenoid Defects Soft Tissue Repair

Bone Grafting

Bristow / Latarjet Open Arthroscopic

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Soft Tissue Repair NOT A SIMPLE BANKART

REPAIR BUT:

Labrum Mobilization ALPSA reduction Double loaded anchors Usually 3 anchors to

anterior rim Rotator Interval Closure Posterior Capsule

plication

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Autologous Grafting:Eden-Hybbinette procedure

Autologous Tricortical Iliac Crest Bone Graft

Warner JP Am. J. Sports Med. 2006; 34; 20518% recurrence

ratewww.shoulder.gr

Bristow procedure

Young DC, Rockwood CA Jr. J Bone Joint Surg Am1991;73:969-981.

Hovelius L,. J Shoulder Elbow Surg 2004;13:509-16.13.6% recurrence

ratewww.shoulder.gr

Latarjet procedure

Burkhart SS, De Beer JF, Barth JR, Cresswell T, Roberts C,Richards DP. Arthroscopy 2007;23:1033-1041

3.4 - 14%

recurrence rate

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Bone Graft from Acromion

Mochizuki Y, Hachisuka H, Kashiwagi K, Oomae H, YokoyaS, Ochi M. Arthroscopic autologous bone graft with arthroscopic

Bankart repair for a large bony defect lesion caused byrecurrent shoulder dislocation. Arthroscopy 2007;23:677.e1-

677.e4.

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Arthroscopic Bone Block

E.Taverna, et.al,Knee Surg Sports Traumatol

Arthrosc (2008) 16:872–875

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Arthroscopic Latarjet

Lafosse L, Arthroscopy, Vol 23, No 11 (November), 2007: pp 1242.e1-1242.e5

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What is the critical Glenoid Bone Defect?

Critical bone loss:>20-30%

6.8 mm width of resection 21% to total length of the glenoid - substantial loss of stability

Cadaveric biomechanical study

Itoi,et.al. JBJS 2000

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Glenoid Bone Loss Algorithm <15% (0-3.5mm) Soft Tissue Repair

15-(25)30% (5-6mm) Soft Tissue Repair + Bony BankartConsider patient demands

>(25)30% (6.5-8.6mm) Bone Grafting procedures

Piasecki et al. AAOS J17 (8): 482. (2009)

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Our Technique

Typical Bankart Repair Labrum mobilization

(ALPSA repair) Double loaded anchors Tight knots

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Our Technique

Remplissage for large Hill-Sachs

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Our Technique

Rotator Interval Closure

Posterior Capsule Plication

Rehabilitation Protocol:

from early passive movements to

propioception and return to sports.

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Our Results Period: 1999-2004

116 patients with anterior shoulder instability

Arthroscopic Treatment

At least 5 years follow-up (range 5-9.75 years)

Hill-Sachs 78/116 67.2% Glenoid defect 36/116 31.0% Invetred pear 8/116 6.8%

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Our Results Recurrence rate: 7/116 6.03%

(2 MVA, 2 Sports, 1 Fall, 1 No Comply, 1 Minor Trauma)6/7 re-operated arthroscopicaly – No recurrence yet

Rowe-Zarins: Pre-Op 33 (15-80),Post-Op:95 (80-100)

Satisfaction 109/116 Very Satisfied 93.9% 6/116 Satisfied 5.2% 1/116 Did not answer 0.9%

Return to work: 116/116 100% Return to sports: 45/116 38.8%

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Handball player: 23y, 1st dislocation 21y, total 3 Dislocations

Typical Bankart No Considerable Glen Defect

Hill-Sachs Typical Repair

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Typical Rehabilitation Program

…full return to sports 9 months later

…but 15 months after the operation….

Handball player: 23y, 1st dislocation 21y, Left shoulder, Total 3 Dislocations

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Handball player: 23y, 1st dislocation 21y, Left shoulder, Total 3 Dislocations

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Handball player: 25y, 15 months after first Bankart Repair

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HAGL repair

Handball player: 25y, 15 months after first Bankart Repair

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Conclusions Humeral Head bone loss (Hill-Sachs)

Graft reconstruction Prosthetic replacement Remplissage

Glenoid bone loss Soft Tissue Repair (more than a simple Bankart

repair) Bone Grafting (many methods) Bristow or Laterjet

Open Arthroscopic

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Thank you for your attention

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