Posterior Humeral Head Allograft and Open Bankart Repair Through an Anterior Approach.

Abstract

Background: Shoulder instability events can often result in humeral head and glenoid bone defects. Lesion size, patient age, bone quality, and cause of instability affect management. Surgical options are numerous, depending on severity and complexity. In addressing posterior humeral head lesions, remplissage and humeral head allograft have been reliably described, but the approach to addressing these often significant lesions has been variably illustrated. As recently described by Yazdi et al in a systematic review in 2022, osteochondral allografts for Hill-Sachs or reverse Hill-Sachs lesions showed good patient-reported outcomes. This is in agreement with other studies in the literature, including another systematic review by Saltzman et al in 2015 that reported good outcomes after humeral head allografts for humeral head defects, as well as another study by Gerber et al that reported similar promising outcomes.

Indications: Humeral head allograft should be considered in the setting of instability refractory to nonoperative measures in younger patients with large Hill-Sachs and reverse Hill-Sachs lesions, particularly in those that are engaging with the glenoid through range of motion and are over 30% of the depth of the humeral head.

Technique description: Following an examination under anesthesia and diagnostic arthroscopy, a deltopectoral incision was made from the coracoid to the deltoid insertion. The subscapularis tendon and anterior capsule were both carefully released from their humeral insertion and tagged. Following external rotation of ~180°, the Hill-Sachs defect was visualized, debrided, and molded with bone wax. After an osteochondral humeral head allograft was sized and sculpted on the back table, it was positioned and fixated with provisional Kirscher wires followed by 4-0 cannulated, headless compression screws. Finally, an open Bankart repair was completed, followed by a capsular closure and subscapularis repair.

Results: Humeral head allografts have demonstrated short-term improvements in motion and patient-reported outcome measures and can be used for posterior Hill-Sachs lesions, fully accessible through an anterior approach when anterior instability procedures are also warranted.

Discussion/conclusion: Management of large Hill-Sachs and reverse Hill-Sachs lesions with a humeral head allograft using an anterior open approach is a viable option for patients with refractory instability.

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