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Allograft reconstruction of segmental defects of the humeral head associated with posterior dislocations of the shoulder
Injury, Int. J. Care Injured (2008) 39, 319—322
www.elsevier.com/locate/injury
Allograft reconstruction of segmental defects of the humeral head associated with posterior dislocations of the shoulder Angel Antonio Martinez *, Angel Calvo, Javier Domingo, Jorge Cuenca, Antonio Herrera, Manuel Malillos Service of Orthopaedic and Trauma Surgery, Miguel Servet University Hospital, Zaragoza, Spain Accepted 7 November 2007
KEYWORDS Allograft; Humeral head; Fracture; Posterior dislocation
Summary Six men underwent operative management of defects of the humeral head involving at least 40% of the articular surface, following posterior dislocation of the humeral head. The cause of dislocation was a grand mal seizure in three and a fall in three cases. In five cases the dislocation was reduced under general anaesthesia, and in all the posterior dislocation recurred early. Time between dislocation and surgery ranged from 7 to 8 weeks. The defect in the head, revealed by CT, was filled with an allogeneic segment of humeral head contoured to restore the spherical shape. All the patients returned to their occupation 4 months later. The mean duration of follow-up was 62.6 (60—68) months. At discharge, four of the men had no complaints of pain, instability, clicking or catching; two had pain, clicking, catching and stiffness. Radiographs and CTrevealed no failures of fixation or of incorporation of the allograft. In four cases the contour and volume of the graft were maintained, but in the two with a bad clinical result, flattening and collapse of the graft and osteoarthrosis were observed. If the procedure fails, prosthetic reconstruction should be simple because the skeletal anatomy has not been distorted. # 2007 Elsevier Ltd. All rights reserved.
Introduction Posterior fracture-dislocations are rare, approximately 60% are missed initially4—6 and almost 50% * Corresponding author at: Service of Orthopaedic and Trauma Surgery, Miguel Servet University Hospital, C/Princesa, 11-13, 18C, Zaragoza 50005, Spain. Tel.: +34 976 214 881; fax: +34 976 765 652. E-mail address: [email protected] (A.A. Martinez).
are associated with fractures of the surgical neck of the humerus. Treatment has been based on the size of the articular defect. Transfer of the lesser tuberosity with its attached subscapularis tendon into the defect of the humeral head has been recommended for posterior impaction injuries involving as much as 30 or 40% of the humeral head,4 but this procedure alters the skeletal anatomy of the proximal part of the humerus and can limit internal rotation and complicate future prosthetic reconstruction.
0020–1383/$ — see front matter # 2007 Elsevier Ltd. All rights reserved. doi:10.1016/j.injury.2007.11.017
320
A.A. Martinez et al.
For defects involving more than 40% of the articular surface, the treatment of choice is hemiarthroplasty.2 Osteochondral allografting of humeral head defects that involve 40% of the articular surface has been successfully used in chronic locked posterior3,2 and anterior7 dislocations. To our knowledge the largest published series is that of Gerber and Lambert,3 who reported good results in three cases and a bad result in one case where avascular necrosis of the humeral head developed. Later, Gerber reported2 a series of nine people treated with the same method; the result was good in seven cases and bad in two. The purpose of this paper is to report the longterm results of reconstruction of the humeral head with allogeneic bone for six people who had a posterior dislocation of the shoulder with an anteromedial defect of the humeral head involving at least 40% of the articular surface. Figure 1 Intraoperative photograph showing filling of the defect with allograft.
Materials and methods Between 1998 and 2002, six men underwent operative management of defects of the humeral head that involved at least 40% of the articular surface, following posterior dislocation of the humeral head. None of the men had a previous history of shoulder disorder. The cause of the dislocation was a grand mal seizure in three cases and a fall in three cases. For five patients the dislocation was reduced under general anaesthesia. CTwas performed after reduction to evaluate the lesion in the humeral head. The arm was immobilised in a sling in neutral rotation for 4 weeks and, after this, rehabilitation was started. In all cases the posterior dislocation recurred early, during the 3 weeks following the start of rehabilitation. The sixth man presented 6 weeks after a fall onto the left shoulder, and radiographs revealed a posterior fracture-dislocation of the shoulder. CT showed that in all cases between 40 and 50% of the articular surface had been affected. The period of time between dislocation and surgery ranged from 7 to 8 weeks. Surgery was per-
formed using a deltopectoral approach. The defect of the head was filled with a frozen allogeneic segment of humeral head contoured to restore the spherical shape, and was fixed with three or four Herbert screws; one 4-mm cancellous screw was added in one case (Fig. 1). The anterior capsule and subscapularis were repaired in their anatomical positions. The arm was kept at the side, in neutral rotation, for 4 weeks. Passive and active ranges of motion were started from 4 to 6 weeks following surgery, respectively.
Results We had no early or late infections, non-unions at the graft-host junction or joint instability. All the men returned to their occupation 4 months after surgery. All the cases were evaluated at a mean of 62.6 (60— 68) months after the operative procedure, using the Constant and Murley score, and all were assessed clinically and also by plain radiography and CT. Four men had no complaints of pain, instability, clicking
Table 1 Range of motion and Constant score at final follow-up examinations Patient
Age (years)
Follow-up (months)
Forward elevation (8)
Lateral elevation
External rotation
Internal rotation
Constant score
1 2 3 4 5 6
34 36 29 33 28 30
60 62 64 68 62 60
160 170 140 160 80 80
160 160 140 140 80 75
90 90 80 90 50 55
90 90 80 80 50 55
100 100 90 96 40 45
Allograft reconstruction of segmental defects
321
Figure 2 (a) Preoperative CT showing the impaction fracture of the humeral head, (b) radiograph 5 years postoperatively showing incorporation of the graft and no evidence of osteonecrosis or collapse and (c) CT 5 years after reconstruction of the humeral head. There is good incorporation of the graft.
or catching, whereas two had pain, clicking, catching and stiffness. The range of motion and the Constant score at the last follow-up examinations are shown in Table 1. Radiographs showed no failures of fixation of the allograft. CT confirmed incorporation of the allograft in all cases (Figs. 2 and 3). In four cases, the contour and volume of the graft were maintained, but in two cases, flattening and collapse of the graft and osteoarthrosis were observed (Fig. 4). These two cases had poor clinical results.
Discussion Fresh osteochondral allografts have been used to restore joint surfaces in weight-bearing joints with good long-term results. The experience of Gerber and Lambert3 in chronic locked posterior dislocations of the shoulder has been satisfactory. They treated four people with chronic locked posterior dislocations of the glenohumeral head and defects of 40% of the articular surface, using an allogeneic segment of femoral head, i.e. a frozen femoral head in three cases and a fresh autoclaved femoral
head in one case. The result was satisfactory in three cases. However, in one case avascular necrosis of the humeral head developed, with collapse of the graft; this man had osteoarthrosis and osteopenia of the dislocated humeral head preoperatively. Gerber2 reported a series of nine patients treated with the same method, achieving a good result for seven and a poor result for two. He concluded that the procedure was indicated in large anteromedial defects in humeral heads without osteoporosis or degenerative joint disease. If the humeral head is already osteoporotic, it can became flattened through the compressive forces acting after relocation and it may collapse and redislocate, as happened in our two cases with poor outcome. In acute cases, the osteopenia or degenerative changes that may develop in chronic cases are not present. Allograft reconstruction preserves the normal anatomy and, even if the procedure fails, prosthetic reconstruction should be simple because the skeletal anatomy is not distorted as it is if transfer of the lesser tuberosity or rotational osteotomy have been performed. Allograft reconstruction is particularly indicated for young people with good bone
322
A.A. Martinez et al.
Figure 4 CT 5 years postoperatively showing flattening of the graft and osteoarthrosis.
Conflict of interest None.
References Figure 3 (a) Preoperative CT showing the impaction fracture of the humeral head and (b) CT 5 years later showing good incorporation of the graft.
quality of the residual head and an absence of relevant osteoarthrosis. We used frozen allografts because fresh allografts were not available. We also found that frozen allografts have the advantage that the antigenicity of frozen bone decreases greatly, so that matching of the major histocompatibility complex or immunosuppressive drugs are not required. The risk of microbiological contamination or transmission of unrecognised microorganisms exists but is low, because the tissues are exhaustively analysed using bone bank techniques.
2. Gerber G. Chronic, locked, anterior and posterior dislocations. In: Warner JP, Iannotti JP, Flatow EL, editors. Complex and revision problems in shoulder surgery. 2nd ed., Philadelphia: Lippincott Williams & Wilkins; 2005. p. 89—103. 3. Gerber G, Lambert SM. Allograft reconstruction of segmental defects of the humeral head for the treatment of chronic locked posterior dislocation of the shoulder. J Bone Joint Surg Am 1996;78:376—82. 4. Hawkins RJ, Neer CS, Pianta RM, Mendoza FX. Locked posterior dislocation of the shoulder. J Bone Joint Surg Am 1987;69:9— 18. 5. McLaughlin HL. Posterior dislocation of the shoulder. J Bone Joint Surg Am 1952;34:584—90. 6. Rowe CR, Zarins B. Chronic unreduced dislocation of the shoulder. J Bone Joint Surg Am 1982;64:494—505. 7. Yagishita K, Thomas B. Use of allograft for large Hill-Sachs lesion associated with anterio glenohumeral dislocation. A case report. Injury 2002;33:791—4.
www.elsevier.com/locate/injury
Allograft reconstruction of segmental defects of the humeral head associated with posterior dislocations of the shoulder Angel Antonio Martinez *, Angel Calvo, Javier Domingo, Jorge Cuenca, Antonio Herrera, Manuel Malillos Service of Orthopaedic and Trauma Surgery, Miguel Servet University Hospital, Zaragoza, Spain Accepted 7 November 2007
KEYWORDS Allograft; Humeral head; Fracture; Posterior dislocation
Summary Six men underwent operative management of defects of the humeral head involving at least 40% of the articular surface, following posterior dislocation of the humeral head. The cause of dislocation was a grand mal seizure in three and a fall in three cases. In five cases the dislocation was reduced under general anaesthesia, and in all the posterior dislocation recurred early. Time between dislocation and surgery ranged from 7 to 8 weeks. The defect in the head, revealed by CT, was filled with an allogeneic segment of humeral head contoured to restore the spherical shape. All the patients returned to their occupation 4 months later. The mean duration of follow-up was 62.6 (60—68) months. At discharge, four of the men had no complaints of pain, instability, clicking or catching; two had pain, clicking, catching and stiffness. Radiographs and CTrevealed no failures of fixation or of incorporation of the allograft. In four cases the contour and volume of the graft were maintained, but in the two with a bad clinical result, flattening and collapse of the graft and osteoarthrosis were observed. If the procedure fails, prosthetic reconstruction should be simple because the skeletal anatomy has not been distorted. # 2007 Elsevier Ltd. All rights reserved.
Introduction Posterior fracture-dislocations are rare, approximately 60% are missed initially4—6 and almost 50% * Corresponding author at: Service of Orthopaedic and Trauma Surgery, Miguel Servet University Hospital, C/Princesa, 11-13, 18C, Zaragoza 50005, Spain. Tel.: +34 976 214 881; fax: +34 976 765 652. E-mail address: [email protected] (A.A. Martinez).
are associated with fractures of the surgical neck of the humerus. Treatment has been based on the size of the articular defect. Transfer of the lesser tuberosity with its attached subscapularis tendon into the defect of the humeral head has been recommended for posterior impaction injuries involving as much as 30 or 40% of the humeral head,4 but this procedure alters the skeletal anatomy of the proximal part of the humerus and can limit internal rotation and complicate future prosthetic reconstruction.
0020–1383/$ — see front matter # 2007 Elsevier Ltd. All rights reserved. doi:10.1016/j.injury.2007.11.017
320
A.A. Martinez et al.
For defects involving more than 40% of the articular surface, the treatment of choice is hemiarthroplasty.2 Osteochondral allografting of humeral head defects that involve 40% of the articular surface has been successfully used in chronic locked posterior3,2 and anterior7 dislocations. To our knowledge the largest published series is that of Gerber and Lambert,3 who reported good results in three cases and a bad result in one case where avascular necrosis of the humeral head developed. Later, Gerber reported2 a series of nine people treated with the same method; the result was good in seven cases and bad in two. The purpose of this paper is to report the longterm results of reconstruction of the humeral head with allogeneic bone for six people who had a posterior dislocation of the shoulder with an anteromedial defect of the humeral head involving at least 40% of the articular surface. Figure 1 Intraoperative photograph showing filling of the defect with allograft.
Materials and methods Between 1998 and 2002, six men underwent operative management of defects of the humeral head that involved at least 40% of the articular surface, following posterior dislocation of the humeral head. None of the men had a previous history of shoulder disorder. The cause of the dislocation was a grand mal seizure in three cases and a fall in three cases. For five patients the dislocation was reduced under general anaesthesia. CTwas performed after reduction to evaluate the lesion in the humeral head. The arm was immobilised in a sling in neutral rotation for 4 weeks and, after this, rehabilitation was started. In all cases the posterior dislocation recurred early, during the 3 weeks following the start of rehabilitation. The sixth man presented 6 weeks after a fall onto the left shoulder, and radiographs revealed a posterior fracture-dislocation of the shoulder. CT showed that in all cases between 40 and 50% of the articular surface had been affected. The period of time between dislocation and surgery ranged from 7 to 8 weeks. Surgery was per-
formed using a deltopectoral approach. The defect of the head was filled with a frozen allogeneic segment of humeral head contoured to restore the spherical shape, and was fixed with three or four Herbert screws; one 4-mm cancellous screw was added in one case (Fig. 1). The anterior capsule and subscapularis were repaired in their anatomical positions. The arm was kept at the side, in neutral rotation, for 4 weeks. Passive and active ranges of motion were started from 4 to 6 weeks following surgery, respectively.
Results We had no early or late infections, non-unions at the graft-host junction or joint instability. All the men returned to their occupation 4 months after surgery. All the cases were evaluated at a mean of 62.6 (60— 68) months after the operative procedure, using the Constant and Murley score, and all were assessed clinically and also by plain radiography and CT. Four men had no complaints of pain, instability, clicking
Table 1 Range of motion and Constant score at final follow-up examinations Patient
Age (years)
Follow-up (months)
Forward elevation (8)
Lateral elevation
External rotation
Internal rotation
Constant score
1 2 3 4 5 6
34 36 29 33 28 30
60 62 64 68 62 60
160 170 140 160 80 80
160 160 140 140 80 75
90 90 80 90 50 55
90 90 80 80 50 55
100 100 90 96 40 45
Allograft reconstruction of segmental defects
321
Figure 2 (a) Preoperative CT showing the impaction fracture of the humeral head, (b) radiograph 5 years postoperatively showing incorporation of the graft and no evidence of osteonecrosis or collapse and (c) CT 5 years after reconstruction of the humeral head. There is good incorporation of the graft.
or catching, whereas two had pain, clicking, catching and stiffness. The range of motion and the Constant score at the last follow-up examinations are shown in Table 1. Radiographs showed no failures of fixation of the allograft. CT confirmed incorporation of the allograft in all cases (Figs. 2 and 3). In four cases, the contour and volume of the graft were maintained, but in two cases, flattening and collapse of the graft and osteoarthrosis were observed (Fig. 4). These two cases had poor clinical results.
Discussion Fresh osteochondral allografts have been used to restore joint surfaces in weight-bearing joints with good long-term results. The experience of Gerber and Lambert3 in chronic locked posterior dislocations of the shoulder has been satisfactory. They treated four people with chronic locked posterior dislocations of the glenohumeral head and defects of 40% of the articular surface, using an allogeneic segment of femoral head, i.e. a frozen femoral head in three cases and a fresh autoclaved femoral
head in one case. The result was satisfactory in three cases. However, in one case avascular necrosis of the humeral head developed, with collapse of the graft; this man had osteoarthrosis and osteopenia of the dislocated humeral head preoperatively. Gerber2 reported a series of nine patients treated with the same method, achieving a good result for seven and a poor result for two. He concluded that the procedure was indicated in large anteromedial defects in humeral heads without osteoporosis or degenerative joint disease. If the humeral head is already osteoporotic, it can became flattened through the compressive forces acting after relocation and it may collapse and redislocate, as happened in our two cases with poor outcome. In acute cases, the osteopenia or degenerative changes that may develop in chronic cases are not present. Allograft reconstruction preserves the normal anatomy and, even if the procedure fails, prosthetic reconstruction should be simple because the skeletal anatomy is not distorted as it is if transfer of the lesser tuberosity or rotational osteotomy have been performed. Allograft reconstruction is particularly indicated for young people with good bone
322
A.A. Martinez et al.
Figure 4 CT 5 years postoperatively showing flattening of the graft and osteoarthrosis.
Conflict of interest None.
References Figure 3 (a) Preoperative CT showing the impaction fracture of the humeral head and (b) CT 5 years later showing good incorporation of the graft.
quality of the residual head and an absence of relevant osteoarthrosis. We used frozen allografts because fresh allografts were not available. We also found that frozen allografts have the advantage that the antigenicity of frozen bone decreases greatly, so that matching of the major histocompatibility complex or immunosuppressive drugs are not required. The risk of microbiological contamination or transmission of unrecognised microorganisms exists but is low, because the tissues are exhaustively analysed using bone bank techniques.
2. Gerber G. Chronic, locked, anterior and posterior dislocations. In: Warner JP, Iannotti JP, Flatow EL, editors. Complex and revision problems in shoulder surgery. 2nd ed., Philadelphia: Lippincott Williams & Wilkins; 2005. p. 89—103. 3. Gerber G, Lambert SM. Allograft reconstruction of segmental defects of the humeral head for the treatment of chronic locked posterior dislocation of the shoulder. J Bone Joint Surg Am 1996;78:376—82. 4. Hawkins RJ, Neer CS, Pianta RM, Mendoza FX. Locked posterior dislocation of the shoulder. J Bone Joint Surg Am 1987;69:9— 18. 5. McLaughlin HL. Posterior dislocation of the shoulder. J Bone Joint Surg Am 1952;34:584—90. 6. Rowe CR, Zarins B. Chronic unreduced dislocation of the shoulder. J Bone Joint Surg Am 1982;64:494—505. 7. Yagishita K, Thomas B. Use of allograft for large Hill-Sachs lesion associated with anterio glenohumeral dislocation. A case report. Injury 2002;33:791—4.