Multidirectional Shoulder Instability With Circumferential Labral Tear and Bony Reverse Hill Sachs: Treatment with 270° Labral Repair and Fresh Talus Osteochondral Allograft to the Humeral Head

Abstract

Traumatic posterior dislocations of the shoulder can result in bony defects, labral tears, and cartilage injuries of the glenohumeral joint. Although traditional Hill-Sachs lesions from anterior dislocations are more commonly identified, reverse Hill-Sachs lesions caused by posterior dislocation often leads to recurrent engagement of the humeral head with the glenoid and significantly greater damage to the humeral chondral surface. In severe traumatic cases, concomitant damage of the capsulolabral soft tissues, such as circumferential labral lesions, can lead to chronic shoulder instability and residual glenoid bone loss. These lesions further add to the complexity of managing patients with posterior dislocations of the shoulder because of the challenges of achieving adequate anatomic reduction and tensioning of the capsulolabral junction, while also using a combination of arthroscopic and open-labral repair techniques. In the setting of reverse Hill-Sachs lesions treatment, it is important to address the bony and cartilage defect. The purpose of this Technical Note is to describe our preferred technique for arthroscopic repair of circumferential lesions of the glenoid labrum causing multidirectional instability with concomitant reverse Hill-Sachs Lesion treatment with fresh talus osteochondral allograft.

Fig 1

Arthroscopic view from the anterosuperior portal of the circumferential lesion of the glenoid labrum in a left shoulder in lateral decubitus position. The lesion can be seen extending from the 4 o’clock position (A) to the 6 o’clock (B) and 9 o’clock (C) positions, causing multidirectional instability. The labrum is prepped and mobilized using an elevator through the posterior portal, and a shaver is used to debride the loose frayed tissue to achieve a stable capsulolabral rim. HH, humeral head; G, glenoid; L, labrum.

Fig 2

Arthroscopic views from the anterosuperior portal of a large reverse Hill-Sachs lesion in a left shoulder in the lateral decubitus position. HH, humeral head; G, glenoid.

Fig 3

Arthroscopic views from the anterosuperior portal of the circumferential lesion of the glenoid labrum in a left shoulder in lateral decubitus position. The repair begins at the 7 o’clock position and proceeds sequentially to the 9 o’clock position to stabilize the posteroinferior aspect of the lesion first (A and B). The anteroinferior lesion is then addressed from the 7 o’clock to 4o’clock position (C). The number of anchors placed are dictated by the extent of the lesions, as anchors are placed 3 mm apart to achieve adequate fixation. HH, humeral head; G, glenoid; L, labrum.

Fig 4

Fresh talus allograft preparation. The fresh talus allograft is prepared on the back table and begins with measuring the dimensions of the defect with a ruler and marked with a surgical pen (A). The base of the fresh talus allograft is removed with an oscillating saw and the graft is cut matching the dimensions of the prepared humeral defect. A towel clamp can be used to stabilize the graft while cutting. Cutting the graft 1 to 2 mm larger than the resected lesion allows for a press fit match into the previously prepared lesion of the shoulder (B). K-wires are placed to aid with fixation and manipulation of the fresh talus allograft (C).

Fig 5

Fresh talus allograft fixation in a left shoulder. The defect is again measured to ensure proper sizing of the allograft (A). After graft preparation, the graft is gently tamped into the matched position on the humeral head, and the previously placed K-wires are advanced for temporary fixation of the allograft (B). Care is taken to ensure that the articular margin of the humeral head and fresh talus osteochondral allograft are matched as closely as possible (C). The K-wires are overdrilled and three 2.5 mm headless compression screws (Acutrak; Acumed, Hillsboro, OR) are placed providing stable fixation of the fresh talus allograft (D).

Fig 6

(A) Anteroposterior and (B) axial postoperative standard radiographs showing final fresh talus allograft fixation in a left shoulder. The radiographs show filling of the bony defect with the fresh talus allograft using three 2.5 mm headless compression screws (Acutrak; Acumed, Hillsboro, OR). CP, coracoid process; G, glenoid; LT, lesser tuberosity; A, acromion.