Mid-Term outcomes following fresh-frozen humeral head osteochondral allograft reconstruction for reverse Hill Sachs lesion: a case series

Osteochondral Allograft Transplantation in the Shoulder: A Systematic Review of Indications and Outcomes

OBJECTIVE

To collate current literature pertaining to the published reports of indications for, and outcomes of, osteochondral allograft (OCA) transplantations in the shoulder so as to guide surgeons in the management of various etiologies of osteochondral lesions in this joint.

DESIGN

A systematic review of the current literature was performed in February 2022 in the PubMed, Cochrane, and EMBASE databases using specific search terms and predetermined inclusion/exclusion criteria.

RESULTS

One-hundred-twenty-three articles were initially identified, 30 full-text articles were assessed for eligibility, and 17 articles met inclusion criteria. Data were collected for study characteristics, etiology, lesion size/location, intervention/type of graft used, follow-up, and outcomes. In total, 83 shoulders were included (n = 83) in the review with an average follow-up of 45.7 months. Nine specific indications for OCA transplantation in the shoulder included: reverse Hill-Sachs lesions (33), Hill-Sachs lesions (22), pain pump chondrolysis (10), recurrent shoulder instability (7), osteoarthritis/degenerative changes (5), radiofrequency chondrolysis (2), prominent suture anchors (2), glenoid lesion (1), and osteochondritis dissecans (1). Seventeen patients had concomitant surgeries and two patients were lost to follow-up. Of the total 83 shoulders, 68 had favorable outcomes and 13 had unfavorable outcomes as determined by graft incorporation, pain scores, functionality/ROM, patient-reported satisfaction, and/or requirement for revision/arthroplasty. Of the 13 with unfavorable outcomes, a disproportionate number had concomitant surgeries and/or were performed for pain pump chondrolysis (6).

CONCLUSIONS

The use of OCAs appears to be a viable option for a variety of difficult-to-treat shoulder pathologies, particularly those characterized by isolated osteochondral injuries.

Osteochondral allografts for the treatment of shoulder instability

Aims

To systematically review the predominant complication rates and changes to patient-reported outcome measures (PROMs) following osteochondral allograft (OCA) transplantation for shoulder instability.

Methods

This systematic review, following PRISMA guidelines and registered in PROSPERO, involved a comprehensive literature search using PubMed, Embase, Web of Science, and Scopus. Key search terms included "allograft", "shoulder", "humerus", and "glenoid". The review encompassed 37 studies with 456 patients, focusing on primary outcomes like failure rates and secondary outcomes such as PROMs and functional test results.

Results

A meta-analysis of primary outcomes across 17 studies revealed a dislocation rate of 5.1% and an increase in reoperation rates from 9.3% to 13.7% post-publication bias adjustment. There was also a noted rise in conversion to total shoulder arthroplasty and incidence of osteoarthritis/osteonecrosis over longer follow-up periods. Patient-reported outcomes and functional tests generally showed improvement, albeit with notable variability across studies. A concerning observation was the consistent presence of allograft resorption, with rates ranging from 33% to 80%. Comparative studies highlighted similar efficacy between distal tibial allografts and Latarjet procedures in most respects, with some differences in specific tests.

Conclusion

OCA transplantation presents a promising treatment option for shoulder instability, effectively addressing both glenoid and humeral head defects with favourable patient-reported outcomes. These findings advocate for the inclusion of OCA transplantation in treatment protocols for shoulder instability, while also emphasizing the need for further high-quality, long-term research to better understand the procedure's efficacy profile.

Treatment of osteochondral injuries of the humeral head using fresh osteochondral allograft transplantation

Background

Large osteochondral lesions of the humeral head can result from locked posterior dislocations, avascular necrosis, and osteochondritis dissecans. Fresh osteochondral allograft (OCA) transplantation is a treatment option for young patients with focal osteochondral defects of the humeral head. The purpose of this case series was to assess graft survivorship, subjective patient-reported outcomes, and satisfaction among 7 patients who underwent OCA transplantation of the humeral head.

Methods

We identified 7 patients who underwent humeral head OCA transplantation between 2008 and 2017. A custom questionnaire including the American Shoulder and Elbow Surgeons score, Quick Disabilities of the Arm, Shoulder, and Hand score (QuickDash), Likert satisfaction, and reoperations was mailed to each patient. Clinical failure was defined as further surgery that involved removal of the allograft.

Results

Median follow-up duration was 10 years (range, 4.6 to 13.5 years) with a median age of 21.6 years (range, 18.5 to 43.5 years). Most patients (86%) reported improved function and reduced pain. At the final follow-up, 71% of patients reported ongoing problems with their shoulder including pain, stiffness, clicking/grinding, limited range of motion, and instability. Return to recreational activities was high at 86% but 43% expressed limitations with activity due to their shoulder. Overall satisfaction was high at 71% with mean American Shoulder and Elbow Surgeons and QuickDASH scores at 62.4 and 29.2, respectively. Reoperation after OCA occurred in 1 patient (14%).

Conclusion

Among this case series of 7 patients who underwent OCA transplantation of the humeral head, patient satisfaction was high at 10-year follow-up and most returned to recreational activity although most also had persistent shoulder symptoms.

Low Recurrence of Instability and Satisfying Patient-Reported Outcomes Following Various Surgical Treatments of Reverse Hill-Sachs Lesions in the Setting of Posterior Instability: A Systematic Review

PURPOSE

To systematically review the literature and report the outcomes of various surgical treatments for reverse Hill-Sachs lesions (RHSL) in the setting of posterior shoulder instability.

METHODS

Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed. All studies assessing outcomes of surgical treatment of RHSL from inception to January 2023 were identified in PubMed, Embase, and Cochrane Library. Inclusion criteria consisted of studies reporting outcomes, minimum mean 1-year follow-up, and minimum Level IV evidence. Outcomes were assessed using Forest plots with random effects models using R software.

RESULTS

A total of 29 studies consisting of 291 patients were included with a mean age of 42 years (range 16-88 years), 87% male gender, and mean follow-up of 4.5 years. The mean size of impacted or affected cartilage was 35%, and time from injury to surgery was mean 15 weeks. Nearly all studies were Level IV evidence, and quality of studies was low. Random effect models were performed, and data are presented as range. A low incidence of instability was noted for all surgical techniques with good patient-reported outcome measures. Most studies reported outcomes of the modified McLaughlin procedure (13 studies, 126 patients) with overall Constant-Murley Score of 65 to 92. Trends were seen towards better Constant-Murley Score and external rotation with a shorter delay between injury, and when arthroscopic and joint preserving treatments were performed.

CONCLUSIONS

This systematic review showed low rates of instability recurrence, reproducible range of motion, and favorable patient-reported outcome measures were reported following all treatments for RHSLs with posterior instability. There was a significant association between better outcomes and a shorter delay between injury and surgery. The level of evidence is limited, given the small and retrospective studies which can be explained by the rarity of these injuries. LEVEL OF EVIDENCE: Level IV; systematic review of Level III and IV studies.

From Diagnosis to Decision-Making: A Systematic Review of the Management of Reverse Hill-Sachs Lesions after Posterior Shoulder Dislocations

(1) Background: The aim of this study is to describe all of the possible surgical procedures that intend to treat the McLaughlin lesion (or Reverse Hill-Sachs) in posterior shoulder dislocation. (2) Methods: Google Scholar, Pubmed, and Embase were used as databases in our research. Studies reporting the results of posterior shoulder dislocations surgically treated with procedures addressing the humeral lesion were evaluated. The studies reporting results after fracture-dislocation and multidirectional instability were excluded. (3) Results: A total of 16 studies were included in our review for a total of 207 shoulders with a mean age of 41.7 years that were evaluated at a mean of 62.1 months. The Modified McLaughlin procedure and the Graft procedures were the most commonly performed. No statistically significant difference was found between the two at the evaluation of the clinical score. (4) Conclusions: Our review highlights the importance of a correct diagnosis and an accurate surgical treatment choice based on the surgeon's experience and on the patients' characteristics.

Management of Bone Loss in Posterior Glenohumeral Shoulder Instability: Current Concepts

» Posterior glenohumeral instability is relatively uncommon compared with anterior instability, but is becoming an increasingly recognized and surgically managed shoulder pathology.» Soft-tissue stabilization alone may not be sufficient in patients who present with substantial bone loss to the posterior glenoid and/or the anterior humeral head.» For posterior glenoid defects, posterior glenoid osteoarticular augmentation can be used, and posterior glenoid opening wedge osteotomy can be considered in cases of posterior instability with pathologic retroversion.» For humeral head lesions, several surgical treatment options are available including subscapularis transposition into the humeral head defect, autograft or allograft reconstruction, humeral rotation osteotomy, and shoulder arthroplasty.

McLaughlin technique and humeral grafting provide similar results for treatment of reverse Hill-Sachs lesions: A systematic review

Purpose

Various surgical treatments have been described for the treatment of reverse Hill-Sachs lesions (rHSls) sized between 20% and 50% in the case of posterior shoulder dislocation. The aim of this systematic review is to report the clinical and radiological outcomes of subscapularis or lesser tuberosity transfer (McLaughlin and modified procedures) compared to bone or osteochondral autograft or allograft.

Methods

A systematic review was performed on five medical databases up to December 2022. The inclusion criteria were clinical studies of all levels of evidence describing clinical or radiological outcomes of either procedure. The assessment of the quality of evidence was performed with the Modified Coleman Score.

Results

A total of 14 studies (five prospective and nine retrospective) were included. A total of 153 patients (155 shoulders, 78.4% male) with a mean age of 37.2 (22-79) years were reviewed at an average follow-up of 53.1 (7.1-294) months. No relevant difference was found for the clinical scores, range of motion, complications and redislocation rate between the two treatments. Radiological osteoarthritis (OA) was reported in 11% (10/87) in the McLaughlin group and in 21% (16/73) in the humeral reconstruction group.

Conclusions

McLaughlin and anatomic humeral reconstruction lead to similar satisfactory clinical results and a low redislocation rate in the treatment of rHSls. Anatomic humeral reconstruction seems associated with an increased risk of OA progression.

Level of Evidence

Level IV.

Avascular necrosis of the proximal humerus: a novel indication for the use of osteochondral allograft transplantation in the shoulder: Case report

Osteochondral allograft (OCA) transplantation is an increasingly available biologic treatment option for a range of intraarticular aetiologies. To our knowledge, no prior publication has documented the use of this technology to treat a lesion of the proximal humerus secondary to avascular necrosis (AVN). We describe our experience treating a 42-year-old female executive with idiopathic AVN of the proximal humerus with a fresh osteochondral allograft. Computed tomography (CT) at 3 months post-op showed full bony incorporation and a restored native joint contour. Over the initial 7 months post-operatively, she reported continued improvements in pain and function as measured by quick Disabilities of the Arm, Shoulder, and Hand (DASH) scores. She was discharged from physical therapy after 6 months, reporting no rest pain, full active and passive range of motion, and unrestricted occupational and recreational activity.

Segmental Humeral Head Reconstruction in Patients with Chronic Locked Posterior Shoulder Dislocation

Background and Objectives: The goal of this study was to evaluate the functional outcomes of patient treatment using an allograft after chronic locked posterior shoulder dislocation associated with a bony defect of the upper edge of the humerus that involves 25-50% of the articular surfaces. Materials and Methods: A total of 20 patients were included in this study. Electrocution was the cause of injury in eight patients; in ten patients, the cause was direct trauma; and in two patients, the cause of injury was a fall due to hypoglycemic coma. A standard deltoid pectoral approach was used and a fresh-frozen osteochondral allograft of the femoral condyle was applied. In evaluating the results, Constant's scoring scale was used. Results: The average value of Constant's point scale for the operated shoulder is 84.14 points. This result is good according to the average value of Constant's point scale. Conclusions: Patients with locked chronic posterior dislocation in combination with a bony defect of the humeral head that covers 25-50% of the articular surface, in our opinion, should be treated using bone allografts rather than non-anatomical reconstruction methods.

Characteristics and Clinical Outcomes After Osteochondral Allograft Transplantation for Treating Articular Cartilage Defects: Systematic Review and Single-Arm Meta-analysis of Studies From 2001 to 2020

Background

Osteochondral allograft transplantation (OCA) treats symptomatic focal cartilage defects with satisfactory clinical results.

Purpose

To comprehensively analyze the characteristics and clinical outcomes of OCA for treating articular cartilage defects.

Study Design

Systematic review; Level of evidence, 4.

Methods

We searched Embase, PubMed, Cochrane Database, and Web of Science for studies published between January 1, 2001, and December 31, 2020, on OCA for treating articular cartilage defects. Publication information, patient data, osteochondral allograft storage details, and clinical outcomes were extracted to conduct a comprehensive summative analysis.

Results

In total, 105 studies involving 5952 patients were included. The annual reported number of patients treated with OCA increased from 69 in 2001 to 1065 in 2020, peaking at 1504 cases in 2018. Most studies (90.1%) were performed in the United States. The mean age at surgery was 34.2 years, and 60.8% of patients were male and had a mean body mass index of 26.7 kg/m2. The mean lesion area was 5.05 cm2, the mean follow-up duration was 54.39 months, the mean graft size was 6.85 cm2, and the number of grafts per patient was 54.7. The failure rate after OCA was 18.8%, and 83.1% of patients reported satisfactory results. Allograft survival rates at 2, 5, 10, 15, 20, and 25 years were 94%, 87.9%, 80%, 73%, 55%, and 59.4%, respectively. OCA was mainly performed on the knee (88.9%). The most common diagnosis in the knee was osteochondritis dissecans (37.9%), and the most common defect location was the medial femoral condyle (52%). The most common concomitant procedures were high tibial osteotomy (28.4%) and meniscal allograft transplantation (24.7%). After OCA failure, 54.7% of patients underwent revision with primary total knee arthroplasty.

Conclusion

The annual reported number of patients who underwent OCA showed a significant upward trend, especially from 2016 to 2020. Patients receiving OCA were predominantly young male adults with a high body mass index. OCA was more established for knee cartilage than an injury at other sites, and its best indication was osteochondritis dissecans. This analysis demonstrated satisfactory long-term postoperative outcomes.

The "BioHumi" Humeral Head Osteochondral Allograft Transplantation for Reverse Hill-Sachs Lesion of the Shoulder

Osteochondral defects of the shoulder due to posterior instability are less frequent than those caused by anterior instability. Although uncommon, locked posterior dislocations can create sizable osteochondral lesions of the anterior humeral head known as reverse Hill-Sachs lesions. Treatment of these defects to restore the congruent contour of the glenohumeral joint is essential to reduce recurrence of instability and prevent long-term sequelae of arthritis. Historically, nonanatomic options, such as transposition of the subscapularis tendon or lesser tuberosity into the defect and humeral rotational osteotomy, have been endorsed to treat reverse Hill-Sachs lesions. More contemporary techniques have focused on restoring not only the bony architecture but also the chondral surface using fresh osteochondral allografts. The evolution of this approach has been challenging because of the large impacted wedge-shaped defect typically encountered with a locked posterior dislocation. Many surgeons employ techniques using multiple circular grafts or customizing a nonanatomic graft to fill these defects. Given the unstable nature of these grafts, metallic screws are often placed through the chondral surface for fixation. The evolution of the "BioHumi" technique has made treatment of large reverse Hill-Sachs lesions technically simpler and more reproducible using innovative instrumentation to transplant an elliptical osteochondral allograft.