Acute traumatic posterior glenohumeral dislocations are

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1 1 COPYRIGHT Ó 2014 BY THE JOURNAL OF BONE AND JOINT URGERY, INCORPORATED Posterior houler Instability with a Reverse Hill-achs Defect: Repair with Use of Combine Arthroscopic Labral Repair an Fracture Disimpaction ACaseReport imon A. Euler, MD, Ulrich J.A. piegl, MD, an Peter J. Millett, MD, Mc Investigation performe at the teaman Philippon Research Institute, Vail, Colorao Acute traumatic posterior glenohumeral islocations are rare; they are typically cause by high-velocity trauma, epileptic seizures, or electrocution 1,2. Anterior impression fractures of the humeral hea (reverse Hill-achs efect) occur in over 80% of iniviuals following a posterior islocation of the shouler 3. The size of reverse Hill-achs efects varies an has been reporte to be as large as 55% of the cartilage surface 4. Defects affecting less than 10% of the articular surface can be treate conservatively with close reuction, an immobilization may prouce excellent stability with a low risk for reislocation 1. However, traitional sling immobilization in internal rotation puts the shouler at risk to reislocate. Therefore, surgical treatment is recommene in efects that affect between 10% an 20% of the articular surface; they can be treate either with an arthroscopic approach, open remplissage, bone-grafting, or prosthetic replacement 5. Compare with traitional posterior Hill-achs efects that occur with anterior islocations, the extent of osseous an cartilaginous estruction of the anterior humeral hea is usually more extensive in reverse Hill-achs efects 6. Therefore, to stabilize the glenohumeral joint an avoi potential progressive cartilage estruction, which may lea to early osteoarthritis, reverse Hill-achs efects affecting more than 20% of the articular surface are nearly always treate surgically 7. everal techniques have been escribe, incluing subscapularis transfer with or without the lesser tuberosity into the humeral hea efect, isimpaction an bone-grafting, allograft reconstruction of the humeral articular surface, an arthroplasty 8. If the joint becomes unstable, repair of the posterior capsulolabral structures can be performe to restore stability, as escribe for treatment of symptomatic posterior subluxation 9,10. Large efects of greater than 40% of the articular surface typically require initial arthroplasty because of the increase risk of osteoarthritis, humeral hea necrosis, an mechanical symptoms or instability We present a clinical case of a reverse Hill-achs efect that involve more than 30% of the articular surface. It was successfully treate with combine arthroscopic posterior labral repair; capsulorrhaphy; open isimpaction of the fracture, which was augmente with mineralize subchonral cancellous allograft bone; an internal screw fixation of a humeral hea impaction fracture. The patient was informe that ata concerning the case woul be submitte for publication, an he provie consent. Case Report Athirty-eight-year-ol highly active man sustaine a irect fall on the right shouler while snowboaring. The patient sustaine a posterior islocation of the shouler in combination with a reverse Hill-achs efect. The shouler was reuce in the emergency epartment but it reislocate spontaneously. After another reuction, raiographs (Figs. 1-A, 1-B, an 1-C) an compute tomography (CT) (Fig. 1-D) emonstrate the large reverse Hill-achs efect. This efect involve approximately 33% of the articular surface of the proximal part of the humerus (Fig. 1-D). Because there was instability, the arm was place in external rotation to maintain reuction. urgical fixation was recommene an was performe the following ay. urgical Proceure After aequate regional an general anesthesia, the patient was place in the beach-chair position. The examination uner Disclosure: None of the authors receive payment or services, either irectly or inirectly (i.e., via his or her institution), from a thir party in support of an aspect of this work. One or more of the authors, or his or her institution, has ha a financial relationship, in the thirty-six months prior to submission of this work, with an entity in the biomeical arena that coul be perceive to influence or have the potential to influence what is written in this work. No author has ha any other relationships, or has engage in any other activities, that coul be perceive to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitte by authors are always provie with the online version of the article. JBJ Case Connect 2014;4:e86

2 JBJ CAE C ONNECTOR POTERIOR HOULDER I NTABILITY WITH A R EVERE H ILL-ACH D EFECT Fig. 1 Figs. 1-A through 1-D Raiographs an CT imaging. Fig. 1-A, 1-B, an 1-C Raiographs of the posterior islocation.

$anesthesia showe an excessive posterior translation with crepitation. The humeral hea coul be easily islocate posteriorly an locke on the impression fracture of the reverse Hill-achs efect.$

2 2 JBJ CAE C ONNECTOR POTERIOR HOULDER I NTABILITY WITH A R EVERE H ILL-ACH D EFECT Fig. 1 Figs. 1-A through 1-D Raiographs an CT imaging. Fig. 1-A, 1-B, an 1-C Raiographs of the posterior islocation. Fig. 1-D CT (axial view) of the shouler. Borers of the articular surface were set by the re horizontal line; 33% of the articular surface was involve. anesthesia showe an excessive posterior translation with crepitation. The humeral hea coul be easily islocate posteriorly an locke on the impression fracture of the reverse Hill-achs efect. The shouler was manually reuce. The iagnostic arthroscopic evaluation emonstrate some chonral ebris an hemarthrosis; a posterior labral tear an posterior capsular injury also were evient. No other intra-articular pathologies were present. We performe an extensive glenohumeral ebriement with evacuation of the hemarthrosis, a chonroplasty, removal of multiple loose boies, a partial labrectomy, an a synovectomy. The posterior labrum was then repaire. Three 2.4-mm anchors (BioComposite uturetak; Arthrex, Naples, Floria) were place in the posteroinferior glenoi rim, an a crescent suture shuttle (uturelasso; Arthrex) was use to pass the sutures aroun the labrum an the capsule. utures were tie with use of a sliing, locking Weston knot, an they were backe up with alternating half-stitches. Upon completion, the posterior capsulolabral complex appeare very stable. The osteochonral impression efect in the anterior humeral hea was again visualize (Fig. 2). A ynamic arthroscopic examination was performe an showe that even after surgical stabilization of the posterior capsulolabral complex, the fracture continue to engage on the posterior glenoi rim when the arm was rotate internally by more than 40. Therefore, the reverse Hill-achs efect fracture was aresse. A eltopectoral approach was performe, an the rotator interval was opene. Approximately 1 cm of the upper subscapularis was reflecte inferiorly to allow visualization of the Fig. 2 Arthroscopic view of the efect. The blue arrows inicate the efect s borer. RC = rotator cuff, D = efect on the humeral hea, CF = chonral fragment, an C = cartilaginous surface.

3 JBJ CAE C ONNECTOR POTERIOR HOULDER I NTABILITY WITH A R EVERE H ILL-ACH D EFECT Fig. 3 Figs. 3-A through Fig. 3-D Illustrations of the surgical proceure. Fig. 3-A Access through the major tuberosity with an 8-mm ACL reamer.

3-C an 3-D Final setting with the surface reuce; the efect was fille, an the supportive screws were in place. efect. The efect appeare to be approximately 1 cm eep an was easily palpable.

3 3 JBJ CAE C ONNECTOR POTERIOR HOULDER I NTABILITY WITH A R EVERE H ILL-ACH D EFECT Fig. 3 Figs. 3-A through Fig. 3-D Illustrations of the surgical proceure. Fig. 3-A Access through the major tuberosity with an 8-mm ACL reamer. Fig. 3-B Retrograe reuction of the cartilaginous surface as well as efect filling with osseous chips. Figs. 3-C an 3-D Final setting with the surface reuce; the efect was fille, an the supportive screws were in place. efect. The efect appeare to be approximately 1 cm eep an was easily palpable. The arm was internally rotate, an a 8-mm cortical viewing portal was create. With use of an 8-mm anterior cruciate ligament (ACL) reamer, a tunnel was mae laterally in the greater tuberosity towar the efect (Fig. 3-A). The fracture was isimpacte an reuce anatomically with curve bone tamps. Reuction was controlle uner irect vision through the rotator interval an with finger palpation by rotating the arm externally. The comminute articular segments were also place back into anatomic position. Next, 15 cc of mineralize cancellous allograft bone chips (Alloource, Centennial, Colorao) were impacte into the bone tunnel to buttress the subchonral fracture (Fig. 3-B). The articular cartilage surface was reuce anatomically an was controlle manually by finger palpation through the rotator interval. Aitionally, to support the subchonral bone Fig. 4 Intraoperative fluoroscopic views after repair. Two screws can be visualize, leaing laterally to meially, supporting the isimpacte region of the anterior aspect of the articular surface.

$The fracture site was well reuce with screws in situ. There were no signs of osteoarthritis or humeral hea necrosis. uner the efect, two 4.$

4 4 JBJ CAE C ONNECTOR POTERIOR HOULDER I NTABILITY WITH A R EVERE H ILL-ACH D EFECT Fig. 5 Postoperative anteroposterior (left) an axial (right) raiographs at forty-three months. The fracture site was well reuce with screws in situ. There were no signs of osteoarthritis or humeral hea necrosis. uner the efect, two 4.0-mm fully threae screws were inserte extra-articularly from the anterolateral irection (Figs. 3-C an 3-D). crew heas were countersunk laterally an thus i not interfere with rotation. Anteroposterior an axillary fluoroscopic views confirme an anatomic reuction an correct placement of the screws anterolaterally to meially, irectly supporting the reverse Hill-achs efect (Fig. 4). The lesion was now visualize as flush, an the chonral surface emonstrate restoration to its normal convexity. The patient ha an uneventful postoperative course an was ischarge the next ay. The shouler was secure in an immobilizing sling for four weeks. Rehabilitation was initiate on postoperative ay 1 with penulums an passive range of motion, limiting external rotation to 30 to protect the repaire upper subscapularis an to restrict internal rotation to the boy. Active motion an active-assiste motion were initiate after four weeks. Posterior loaing to the shouler an overhea activities were avoie for six weeks. The patient was allowe to return to full sports activities after sixteen weeks. Outcome At the time of the final follow-up at forty-three months, the patient was pain-free an ha returne to full activities. He ha unrestricte range of motion (flexion of 170, external rotation of 60, an abuction of 120 ; with the arm in abuction to 90 : externalrotationof90 an internal rotation of 75 ), which was no ifferent from the uninjure contralateral sie. Multiplanar raiographs showe maintenance of the reuction an no signs of osteoarthritis or humeral hea necrosis (Fig. 5). The patient ha recovere fully from the injury, ha no signs of instability, an ha returne to full activity without limitation. Discussion Our patient ha an acute traumatic posterior glenohumeral islocation with a reverse Hill-achs efect that affecte more than 33% of the cartilage surface. The patient was treate with combine arthroscopic posterior labral repair, capsulorrhaphy, an fracture isimpaction of the reverse Hill-achs efect, leaing to an excellent outcome. For efects that affect between 20% an 40% of the cartilage surface, a variety of ifferent treatment options have been propose. Banerjee et al. reporte excellent results after two years of follow-up in two patients who ha sustaine reverse Hill-achs efects of less than 35% of the articular surface; there was no evience of osteonecrosis, collapse, or progression of osteoarthritis 14. The efects were fille retrograe with allogenic bone-graft putty, an two screws were use to support the subchonral zone. However, concerns have been raise about the use of an open approach through the subscapularis tenon, especially with lesions that encompass over 30% of the cartilage surface 14. Bock et al. also reporte goo results for the antegrae reconstruction of reverse Hill-achs efects after a mean followup of sixty-two an one-half months 15. In six cases where 30% to 45% of the articular surface ha been affecte, they use both autografts an allografts. However, the compacte cartilaginous area was elevate an completely remove from the shouler in orer to graft the impacte area. Then, the surface was secure back to the humeral hea with anchors, leaving the sutures on the surface of the cartilaginous joint. Martetschläger et al. escribe a moifie arthroscopic McLaughlin proceure 7. With use of suture anchors, the subscapularis was attache into the reverse Hill-achs efect. However, this nonanatomic repair may bear the risk of limite internal rotation an might complicate future arthroplasty 16.It may not be ieal for more centrally locate reverse Hill-achs efects or for larger efects because avancing the subscapularis in such settings coul certainly affect glenohumeral joint kinematics. Moroer et al. escribe an all-arthroscopic repair for a reverse Hill-achs efect that involve over 40% of the humeral hea surface in which they use bone-chip allografting with cannulate screws 17. However, because of humeral hea

5 5 JBJ CAE C ONNECTOR POTERIOR HOULDER I NTABILITY WITH A R EVERE H ILL-ACH D EFECT necrosis an partial osseous absorption, the patient require an arthroplasty six months after the initial surgery. Although the proceure ha been technically feasible, the lesion size seeme to limit the biological healing response. In a recent stuy, Jacquot et al. escribe a new technique of balloon treatment for reverse Hill-achs efects 18. With fluoroscopic guiance, they percutaneously reuce four reverse Hill-achs efects in three patients with use of balloon ilatation an cement fixation. The efect sizes were not reporte. After twelve months of follow-up, the results were moerate, with a mean Constant score 19 of 73 points. Nonetheless, information regaring meium-term to long-term results is still not well unerstoo or available for this technique. To prevent the humeral hea from islocating posteriorly in cases of instability, posterior labral repair an capsulorrhaphy are recommene in orer to avoi recurrent (sub)luxation accompanie by potential progressive cartilage wear an osteoarthritis 20,21. Our patient receive an arthroscopic posterior labral repair an capsulorrhaphy prior to open reuction an internal fixation of the anterior humeral hea efect, leaing to a stable joint with full range of motion. To support the subchonral bone, two screws were inserte. This screw technique, which has been escribe by other authors, has been use routinely in other periarticular fractures, incluing tibial plateau fractures 14,17. In conclusion, this case report emonstrates the repair of an acute, impacte, an comminute reverse Hill-achs efect that involve more than 33% of the articular surface with combine arthroscopic labral repair an fracture isimpaction of the reverse Hill-achs efect with an excellent outcome at almost four years postoperatively. n NOTE: The authors thank Angelica Weell, BA, for her work on the illustrations. imon A. Euler, MD Department of Trauma urgery an ports Traumatology, Meical University Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria Ulrich J.A. piegl, MD Department of Trauma an Reconstructive urgery, University of Leipzig, Liebigstrasse 20, Leipzig, Germany Peter J. Millett, MD, Mc teaman Philippon Research Institute, 181 West Meaow Drive, uite 1000, Vail, CO aress: rmillett@thesteamanclinic.com References 1. Cicak N. Posterior islocation of the shouler. J Bone Joint urg Br Apr;86 (3): Robinson CM, Aerinto J. Posterior shouler islocations an fracture-islocations. J Bone Joint urg Am Mar;87(3): aupe N, White LM, Bleakney R, chweitzer ME, Recht MP, Jost B, Zanetti M. Acute traumatic posterior shouler islocation: MR finings. Raiology Jul;248(1): Epub 2008 May Gerber C, Lambert M. Allograft reconstruction of segmental efects of the humeral hea for the treatment of chronic locke posterior islocation of the shouler. J Bone Joint urg Am Mar;78(3): Paul J, Buchmann, Beitzel K, olovyova O, Imhoff AB. Posterior shouler islocation: systematic review an treatment algorithm [Review]. Arthroscopy Nov;27(11): Epub 2011 ep Provencher MT, Frank RM, Leclere LE, Metzger PD, Ryu JJ, Bernharson A, Romeo AA. The Hill-achs lesion: iagnosis, classification, an management. J Am Aca Orthop urg Apr;20(4): Martetschläger F, Paalecki JR, Millett PJ. Moifie arthroscopic McLaughlin proceure for treatment of posterior instability of the shouler with an associate reverse Hill-achs lesion. Knee urg ports Traumatol Arthrosc Jul;21 (7): Epub 2012 Oct Ponce BA, Warner JP. Management of posterior glenohumeral instability with large humeral hea efects. Tech houler Elbow urg. 2004;5: Braley JP, Baker CL 3r, Kline AJ, Armfiel DR, Chhabra A. Arthroscopic capsulolabral reconstruction for posterior instability of the shouler: a prospective stuy of 100 shoulers. Am J ports Me Jul;34(7): Epub 2006 Mar avoie FH 3r, Holt M, Fiel LD, Ramsey JR. Arthroscopic management of posterior instability: evolution of technique an results. Arthroscopy Apr;24 (4): Engel T, Hepp P, Osterhoff G, Josten C. Arthroscopic reuction an subchonral support of reverse Hill-achs lesions with a bioabsorbable interference screw. Arch Orthop Trauma urg Aug;129(8): Epub 2009 Feb Gavriiliis I, Magosch P, Lichtenberg, Habermeyer P, Kircher J. Chronic locke posterior shouler islocation with severe hea involvement. Int Orthop Feb;34(1): Epub 2009 Mar Hawkins RJ, Neer C 2n, Pianta RM, Menoza FX. Locke posterior islocation of the shouler. J Bone Joint urg Am Jan;69(1): Banerjee, ingh VK, Das AK, Patel VR. Anatomical reconstruction of reverse hill-sachs lesions using the unerpinning technique. Orthopeics May;35(5): e Bock P, Kluger R, Hintermann B. Anatomical reconstruction for Reverse Hill-achs lesions after posterior locke shouler islocation fracture: a case series of six patients. Arch Orthop Trauma urg ep;127(7): Epub 2007 May Verma NN, ellars RA, Romeo AA. Arthroscopic reuction an repair of a locke posterior shouler islocation. Arthroscopy Nov;22(11):1252.e1-5. Epub 2006 ep Moroer P, Resch H, Tauber M. Faile arthroscopic repair of a large reverse Hill- achs lesion using bone allograft an cannulate screws: a case report. Arthroscopy Jan;28(1): Epub 2011 Nov Jacquot F, Costil V, Werther JR, Atchabahian A, autet A, Feron JM, Doursounian L. Balloon treatment of posterior shouler islocation with reverse Hill-achs injury: escription of a new technique. Int Orthop Jul;37(7): Epub 2013 Apr Constant CR, Murley AH. A clinical metho of functional assessment of the shouler. Clin Orthop Relat Res Jan;(214): Millett PJ, Clavert P, Hatch GF 3r, Warner JJ. Recurrent posterior shouler instability [Review]. J Am Aca Orthop urg Aug;14(8): Millett PJ, Clavert P, Warner JJ. Arthroscopic management of anterior, posterior, an multiirectional shouler instability: pearls an pitfalls. Arthroscopy Dec;19(uppl 1):86-93.

Acute traumatic posterior shoulder instability is

Arthroscopic Treatment of a Reverse Hill-Sachs Lesion Richard E. Duey, M.D., and Stephen S. Burkhart, M.D. Abstract: Acute traumatic posterior shoulder instability is a rare injury. Such injuries can result