This article presents the case of a 52-year-old man with a chronic anterior shoulder dislocation accompanied by a massive Hill-Sachs lesion. The dislocation occurred 6 weeks prior to presentation as the result of a seizure. At the time of the initial injury, the patient was treated in the emergency department and told that his shoulder was reduced. Despite this, he continued to experience pain and inability to move his shoulder. Repeat radiographs and magnetic resonance imaging (MRI) revealed an anterior shoulder dislocation with a massive Hill-Sachs lesion that was locked onto the anterior glenoid. Attempts at a gentle closed reduction in the operating room failed, necessitating an open reduction that involved an extensive capsular release and a Bankart repair. The Hill-Sachs lesion was managed with a humeral head-plasty performed with an 8-mm anterior cruciate ligament guide (Smith & Nephew, Andover, Massachusetts) placed adjacent to the lesser tuberosity. The Hill-Sachs lesion was tamped out to restore the contour of the humeral head and back filled with allograft. Postoperative MRI of the shoulder revealed successful restoration of the contour of the humeral head, although avascular necrosis was present. At 6-month follow-up, the patient reported no instability or pain and had resumed his activities of daily living without difficulty. He regained forward flexion of 165°, abduction of 160°, internal rotation of 75°, and external rotation of 70°. This article presents the successful management of a large, engaging Hill-Sachs lesion using a novel bone-tamping technique that provides an alternative to coracoid transfer procedures and osteochondral allografting.
Anterior shoulder dislocations are a common problem faced by the orthopedic surgeon. Chronic, neglected dislocations are less common and present the clinician with a more challenging clinical scenario. These chronic dislocations are often associated with capsular contracture, which makes a closed reduction impossible. Also, concomitant bony defects of the glenoid or humeral head may be present. Treatment of these bony defects is often necessary in order to restore stability to the joint. This article describes the treatment of a chronic anterior shoulder dislocation with a massive Hill-Sachs lesion that was successfully managed by open reduction, Bankart repair, and humeral head plasty.
A 52-year-old, right-hand-dominant man presented 6 weeks after a shoulder injury that was the result of a fall during a seizure. At the time of injury he was treated in the emergency department and told that his shoulder was reduced. He postponed his follow-up care until 5 weeks after injury, when he saw an outside orthopedic surgeon who subsequently referred him to me.
At presentation, he reported diffuse shoulder pain with an inability to move his shoulder in any direction. He reported no neurological symptoms. His pain was exacerbated by attempts at shoulder motion. On physical examination, the contour of his shoulder was flattened compared to his contralateral side. His arm was in a sling with the shoulder in 25° of external rotation, 5° of flexion, and 0° of abduction. He had diffuse tenderness about the shoulder. He was passively and actively capable of 2° to 3° of motion in each direction before encountering a mechanical block. Further examination was limited by the position of the arm and pain experienced by the patient. Neurological examination revealed intact radial, median, and ulnar nerve motor strength and sensation. Axillary nerve sensation was also intact, and palpable distal pulses were present.
Radiographs revealed an anteriorly dislocated glenohumeral joint. Magnetic resonance imaging (MRI) confirmed the chronic dislocation and revealed a large Hill-Sachs lesion with the glenoid wedged into the humeral head (Figure 1). The decision was made to proceed with attempted closed reduction, followed, if successful, by arthroscopic labral repair and possible humeral head plasty. If closed reduction was unsuccessful, an open reduction was to be performed, followed by open labral repair and humeral head plasty.
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Figure 1: Preoperative MRI revealing anterior dislocation with large Hill-Sachs lesion. Figure 2: A tamp was placed through the lesser tuberosity and used to tamp out the defect and restore the contour of the humeral head: subscapularis tendon tagged and reflected (A); Hill-Sachs lesion being tamped (B); infraspinatus tendon (C).
Gentle closed reduction was unsuccessful; subsequently, an open reduction was performed. A deltopectoral incision was made and the subscapularis detached from the lesser tuberosity. The humeral head was reduced but remained anteriorly translated. Capsular releases were performed, and this allowed the humeral head to rest in an anatomic position. A massive Hill-Sachs lesion was noted, although the majority of the articular surface remained intact. The tip of an anterior cruciate ligament (ACL) guide (Smith & Nephew, Andover, Massachusetts) was placed in the center of the Hill-Sachs lesion. The starting point of the ACL guide was placed at the lesser tuberosity, taking care to avoid the articular surface and the anterolateral ascending branch of the anterior circumflex artery. An 8-mm acorn reamer was used to ream from the lesser tuberosity to the center of the Hill-Sachs defect, taking care not to penetrate the cortical bone. A combination of tamps was used to restore the contour of the posterior humeral head under direct visualization (Figure 2). The inferior aspect of the defect could not be visualized as easily, and palpation was used to assess whether the humeral head contour had been adequately restored. The articular cartilage in the area of the Hill-Sachs defect had been denuded by the injury. The void that was created was filled with allograft cancellous bone chips. An anterior labral repair was performed with four 3-mm Bio-SutureTak anchors (Arthrex, Naples, Florida).
Figure 3: Postoperative MRI revealing reduced glenohumeral joint and restored contour of the humeral head. Note the focus of avascular necrosis near the articular surface.
Postoperatively, the patient was placed in a shoulder immobilizer for 4 weeks. After 4 weeks, a standard Bankart repair protocol was followed.
At 6 months postoperatively, the patient was pain free, reported no further instability, and returned to his activities of daily living without difficulty. Physical examination revealed a stable shoulder with a negative apprehension test and a normal load-and-shift maneuver. Active and passive motion were equal, with forward flexion of 165°, abduction of 160°, internal rotation of 75°, and external rotation of 70°. Magnetic resonance imaging revealed a located glenohumeral joint with reduction of the large Hill-Sachs lesion (Figure 3). Postoperative edema in the head remained, and an area of avascular necrosis appeared to be present, although it remained clinically asymptomatic.
Large Hill-Sachs defects remain a challenging problem that, if not adequately addressed, can lead to continued instability.1,2 Attempts at surgical treatment have traditionally involved soft tissue and bony transfers to return stability to the joint. More recently, anatomic solutions have been advocated involving allograft transfers to restore the contour of the humeral head.3 Humeral head plasty has also been described previously, but clinical data regarding this technique is limited.4,5 This article describes the successful use of humeral head plasty and documents the efficacy of this technique at restoring head contour with a postoperative MRI. Large, long-term studies are needed to determine whether it is as successful as alternative procedures. Also, through further refinement of the technique and arthroscopic instrumentation, it may be possible to perform this procedure arthroscopically. Such a technique is currently being refined by the author in a cadaver model.
- Burkhart SS, De Beer JF. Traumatic glenohumeral bone defects and their relationship to failure of arthroscopic Bankart repairs: significance of the inverted-pear glenoid and the humeral engaging Hill-Sachs lesion. Arthroscopy. 2000; 16(7):677-694.
- Boileau P, Villalba M, Héry JY, Balg F, Ahrens P, Neyton L. Risk factors for recurrence of shoulder instability after arthroscopic Bankart repair. J Bone Joint Surg Am. 2006; 88(8):1755-1763.
- Kropf EJ, Sekiya JK. Osteoarticular allograft transplantation for large humeral head defects in glenohumeral instability. Arthroscopy. 2007; 23(3):322.
- Re P, Gallo RA, Richmond JC. Transhumeral head plasty for large Hill-Sachs lesions. Arthroscopy. 2006; 22(7):798.
- Kazel MD, Sekiya JK, Greene JA, Bruker CT. Percutaneous correction (humeroplasty) of humeral head defects (Hill-Sachs) associated with anterior shoulder instability: a cadaveric study. Arthroscopy. 2005; 21(12):1473-1478.
Dr Mehta is from Fox Valley Orthopaedic Institute, Geneva, Illinois.
Dr Mehta has no relevant financial relationships to disclose.
Correspondence should be addressed to: Vishal Mehta, MD, Fox Valley Orthopaedic Institute, 2525 Kaneville Rd, Geneva, IL 60134.