Failure of Operative Treatment for Glenohumeral Instability: Etiology and Management

Allograft reconstruction of humeral head in patient with recurrent left shoulder instability due to large, engaging Hill-Sachs lesion. In this patient 4 surgical stabilizations, including coracoid transfer, failed. (A) Examination under anesthesia shows that the patient has a positive bony apprehension test, which is performed in 45° of abduction and 45° of external rotation. The patient's instability in the midrange of motion explains his history of multiple atraumatic dislocation events that occurred during activities of daily living and occasionally during sleep.

(B) Intraoperative fluoroscopy with an axillary view shows that the patient has disruption of stability provided through concavity compression, due to the large humeral head defect.

(C) Diagnostic arthroscopy confirms the presence of an engaging Hill-Sachs lesion. At this point in the operation, the senior surgeon (J.K.S.) elects to proceed with the planned allograft reconstruction of the humeral head.

(D) After completion of the open surgical exposure and measurement of the humeral head defect, an oscillating saw is used to harvest the size-matched humeral head allograft.

(E) The graft and the recipient site are also prepared with an oscillating saw and bur. Because of initial graft-defect mismatch, the section of allograft humeral head is revised such that it lies flush with the patient's native humeral head. It is critical that the final section of allograft does not lie proud.

(F) The allograft is provisionally secured with Kirschner wires and then definitely secured with headless compression screws.