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. 2024 Sep 4;12(9):23259671241261741.
doi: 10.1177/23259671241261741. eCollection 2024 Sep.

Comparing Access to Engaging Hill-Sachs Lesions Between the Modified Posterior Deltoid Split Approach and Standard Deltopectoral Approach for Bone Grafting

Elizabeth C Bond  1 , Anna R Bryniarski  2 , Imoh Udoh  2 , Jocelyn R Wittstein  1 , Brian C Lau  1 , Dean C Taylor  1 , Jonathan F Dickens  1
Affiliations

Comparing Access to Engaging Hill-Sachs Lesions Between the Modified Posterior Deltoid Split Approach and Standard Deltopectoral Approach for Bone Grafting

Elizabeth C Bond et al. Orthop J Sports Med. .

Abstract

Background: Hill-Sachs lesions are common after shoulder instability, and treatment options vary but include remplissage or implantation of structural bone graft. Large Hill-Sachs lesions not addressed by remplissage are challenging to manage and may frequently require an open surgical approach for bone filling treatment options. The optimal approach to maximize visualization of the humeral head during these procedures remains unclear.

Purpose/hypothesis: The purpose of this study was to compare the area of the humeral head accessed using a modified posterior deltoid split approach versus a standard deltopectoral approach without surgical dislocation, with particular attention to access of engaging Hill-Sachs lesions for the purpose of bone grafting in the setting of anterior shoulder instability. It was hypothesized that both approaches would provide equal access to a simulated Hill-Sachs lesion.

Study design: Controlled laboratory study.

Methods: Four human cadaveric shoulders were mounted in the beach-chair position. The modified posterior deltoid split approach and nonextensile deltopectoral approaches were performed. A typical Hill-Sachs lesion was simulated on the humeri. The percentage of the total surface area of the humeral head that was accessed, including access to the simulated Hill-Sachs lesion, was mapped using 3-dimensional digitizing software.

Results: The deltopectoral approach provided 45% ± 15.2% access (range, 24% to 58%) to the humeral head versus 22.2% ± 6.1% (range, 17% to 30%) for the modified posterior deltoid split approach (P = .057). The modified posterior deltoid split approach enabled 100% access of the simulated Hill-Sachs lesion compared with 0% for the nonextensile deltopectoral approach. The angle of access to the articular surface was direct and perpendicular with the modified posterior deltoid split approach.

Conclusion: The overall surface area of the humeral head accessed via the modified posterior deltoid split approach was less compared with the deltopectoral approach; however, the entire area of a typical Hill-Sachs lesion was able to be accessed from the modified posterior deltoid split approach, whereas this area was not well visualized from the standard deltopectoral approach.

Clinical relevance: The modified posterior deltoid split approach provided sufficient access to the humeral head for the purposes of grafting an engaging Hill-Sachs lesion in the setting of anterior shoulder instability.

Keywords: Hill-Sachs lesion; bone grafting; shoulder; shoulder instability; surgical approach.

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Conflict of interest statement

One or more of the authors has declared the following potential conflict of interest or source of funding: laboratory facilities and equipment were provided by TriCoast Surgical, an Arthrex distributor. E.C.B. has received grant support from Arthrex, education payments from TriCoast Surgical, and hospitality payments from Lima. J.R.W. has received consulting fees from Geistlich Pharma and Vericel; education payments from Southtech Orthopedics and Tricoast Surgical; nonconsulting fees from Vericel, Arthrex, and Southtech Orthopedics; and hospitality payments from Aesculap Biologics. B.C.L. has received grant support from DJO and Zimmer Biomet, education payments from Arthrex and Smith+Nephew, and hospitality payments from Wright Medical, Stryker, and Crossroads Extremity Systems. D.C.T. has received consulting fees and royalties from DePuy Synthes. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto. Ethical approval for this study was waived by Duke Health.

Figures

Figure 1.
Figure 1.
(A) Skin incision and landmarks for the modified posterior deltoid split approach. (B) Exposure of the posterior aspect of teres minor and infraspinatus before developing the interval. (C) Close-up view of the interval between teres minor and infraspinatus; the quadrangular space would be seen with the wound inferomedially. (D) Visualization of the posterior humeral head articular surface after capsulotomy with the arm in neutral rotation; this can be further increased with rotation of the humerus.
Figure 2.
Figure 2.
(A) Skin incisions and surface anatomy for the deltopectoral approach. (B) Exposure obtained through the deltopectoral approach. (C) Superior angle showing the area to be accessed for a typical Hill-Sachs lesion.
Figure 3.
Figure 3.
(A) Posterior view of the humeral head showing the articular area accessed through the modified posterior deltoid split approach (blue pins) with a small amount of overlap of the area accessed with the deltopectoral approach (green pins); (B) Simulated Hill-Sachs lesion (white with pink pins) secured in place, showing 100% access in this specimen with the modified posterior deltoid split approach.
Figure 4.
Figure 4.
Renderings of the area accessible from each approach overlaid on 3-dimensional computed tomography reconstruction of the proximal humerus. (A) Area of the humeral head accessed through the standard deltopectoral approach. (B) Area accessed through the modified posterior deltoid split approach.
Figure 5.
Figure 5.
A point-to-point probe was used to collect data that were translated into digitized images and analyzed using Rhinoceros 3-dimensional modeling software. In this example, 54% (1755 mm3) of the humeral head was able to be accessed from the deltopectoral approach versus 30% (975 mm3) from the modified posterior deltoid split approach. (A) Rendering of the surface area of the humeral head visualized from the deltopectoral approach (light blue) and the modified posterior deltoid split approach (turquoise blue) over the entire humeral articular surface (dark blue). (B) Rendering of the surface area visualized from the modified posterior deltoid split approach. (C) Rendering of the surface area visualized from the deltopectoral approach.
Figure 6.
Figure 6.
Superior view of a specimen showing the angle of access and instrumentation from the (A and B) deltopectoral approach versus the (C) modified posterior deltoid split approach.
See this image and copyright information in PMC

References

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