Transhumeral Head Plasty and Massive Osteocartilaginous Allograft Transplantation for the Management of Large Hill-Sachs Lesions

Abstract

PURPOSE OF THE STUDY: The aim of this presentation is to inform the medical community about causal therapy (transhumeral head plasty or massive osteochondral allograft transplantation) for large Hill-Sachs lesions which frequently cause failure of anterior stabilisation following ventral shoulder dislocations. MATERIAL: Seven men with an average age of 26 years (19 to 33 years) undergoing surgery in 2006 and 2007 were evaluated. The minimum follow-up was 18 months (41 to 18 months). Impressions on more than 30 % of the articular surface, or those whose critical size was larger than one-eighth of the humeral diameter (on CT scan) were taken as indications for surgery. Four patients had had previous surgery for anterior instability and three had a primary procedure. Four men underwent acute surgery and three had elective operations.Trans- humeral head plasty was used in five and massive osteochondral allograft in two patients. METHODS: In the patients with large lesions in the anterior aspect of the shoulder joint, transhumeral head plasty involving repair of the ventral structures from the anterior approach was indicatedúúú in those with an isolated posterior bony defect, a massive osteochondral allograft was transplanted through the posterior approach. The Constant-Murley score was used to assess clinical status before (not in acute conditions) and after surgery. RESULTS: All patients reported improved clinical status. The average Constant-Murley score at final follow-up was 95.9 points (83-100 points). In the patients not having an acute procedure in whom pre-operative Constant-Murley scores were obtained, the average improvement was by 22.7 points (8 - 37 points). No general surgical complications were recorded. All patients reported subjective satisfaction and willingness to undergo surgery under the same conditions again. DISCUSSION: A Hill-Sachs lesion is a frequent injury to the humeral head resulting from anterior shoulder dislocation. To distinguish between major and minor defects in terms of clinical significance is essential for the choice of appropriate shoulder treatment. Up to now large lesions have mostly been managed by non-causal techniques affecting shoulder biomechanics. Transhumeral head plasty or transplantation of a massive osteochondral allograft, on the other hand, offers a causal treatment. However, these two methods have rarely been mentioned in the international literature, and usually only as case reports. CONCLUSIONS: Transhumeral head plasty and transplantation of a massive osteochondral allograft offer a causal therapy for the management of Hill-Sachs lesions that does not alter shoulder biomechanics. They are not associated with a higher percentage of post-operative complications. Neither technique is more demanding than non-causal procedures. Operations carried out as primary and not as "salvage" procedures restored the function of the shoulder joint to normal. After secondary surgery, occasional shoulder pain may persist as well as its restricted range of motion.