Says Wayne Burkhead, M.D.: “Why consider arthroplasty for large Hill-Sachs lesions? I don’t do surface replacements that often, but when I do, I do them for Hill-Sachs lesions.” Au contraire, argues Anthony Romeo, M.D.: “The Hill-Sachs lesion is a lesion that occurs with instability and to jump right to some sort of surface replacement seems to be overaggressive even in individuals that have a large Hill-Sachs lesion.” Despite Buz’s bad cold, this was a spirited strong debate. We hope you enjoy it as much as we did.
This week’s Orthopaedic Crossfire® debate was part of the 16th Annual CCJR – Spring meeting, which took place in Las Vegas this past May. This week’s topic is “A Hill-Sachs Lesion: It Is Best Treated With a Surface Replacement.” For the proposition is Wayne Z. Burkhead, Jr., M.D., of the W.B. Carrell Memorial Clinic in Dallas, Texas. Anthony A. Romeo, M.D. of Rush University Medical Center is in opposition. Moderating is Thomas P. Sculco, M.D., from the Hospital for Special Surgery.
Dr. Burkhead: My first disclosure…I’ve never lost a debate here at CCJR. My second disclosure is I have a pretty bad cold right now. I’m feeling a little bit weak and I’m not sure the vitamin C and Zithromax will help me beat this guy that I’m talking against because he is quite a smart guy.
So I changed the title a little bit, a large 40%-45% Hill-Sachs lesion is best treated with a surface replacement and I’m affirming that. Hill-Sachs lesions, as we know, come in all shapes and sizes. They come in regular Hill-Sachs lesions, reverse Hill-Sachs lesions, they can be of various depths and this whole new concept of glenoid track is an important method of understanding the importance of the Hill-Sachs lesion in regard to recurrent instability.
Why would you consider arthroplasty as an initial option, or in this patient, in the face of previously failed surgery? Glenohumeral arthritis, for example, may already be present in this individual and that has recurrent instabilities. In further instability surgery, with its obligate decrease in range of motion, it’s therefore increasing the joint reaction force posteriorly. That can do little more than make the arthritis worse in an effort to control the stability of the shoulder.
So therefore I think presenting a spherical surface to the glenoid—much like you do with avascular necrosis—can prolong the need for a polyethylene glenoid component which we know in the shoulder is problematic. We also know that the sooner you pull the trigger and do a shoulder replacement on a patient, the better. The more operations patients have prior to index arthroplasty, the worse those patients do, as is pretty well established in the literature.
So what are the options? These are the order of frequency that I use these devices in my practice.
One is a hemi-capper; we call it the “Junior Mint” replacement. That just replaces the defect alone. The other is a conventional hemiarthroplasty. The final is a surface replacement of the humeral head.
Each option may require some form of anterior stabilization procedure, possibly including a bone block, so you need to be well versed with all the different types of surgery.
When I use humeral head replacement, a conventional stemmed hemiarthroplasty, I do that when I need to change the version of the humerus. Why? Because version of the humerus…in a lot of studies, especially Swiss in old osteotomy days…shows the patients who have anteverted humeri are more likely to dislocate. So if you have an opportunity on the CT scan…I always get some cuts through the elbow…to really see what that patient’s own native humeral version is. And if they are not retroverted to 35 or 45 degrees then I put them in that amount when I do a hemiarthroplasty.
So why consider arthroplasty for large Hill-Sachs lesions? I’m undoubtedly the second most interesting man in the world. I gave these most expensive cortisone shots two years ago in Saudi Arabia. If everyone on Earth downloads one of my songs from iTunes, I will be worth $144 billion. I don’t do surface replacements like the most interesting man who does the Dos Equis commercials, does. I don’t do surface replacements that often, but when I do, I do them for Hill-Sachs lesions.
Dr. Romeo: Buz always has a very interesting perspective on things and great experience with managing these patients so he gives you a lot of really important clinical pearls to pay attention to. The Hill-Sachs lesion is a lesion that occurs with instability very frequently and to jump right to some sort of surface replacement seems to be overaggressive even in individuals that have a large Hill-Sachs lesion. So we try to start with something that’s more biologic, more anatomic in terms of trying to resolve the problem before we go over to a metal implant. How do these things occur? The mechanism of injury is abduction external rotation with a lot of force. The shoulder goes out the front and there’s a big dent in the back of the humeral head. We’ve written a nice paper on this, it’s a good review article in the Journal of the American Academy of Orthopaedic Surgeons, which goes over the diagnosis classification and management of these lesions (2012).
We understand the Hill-Sachs lesion was described by two radiologists quite some time ago in 1940 and the key feature is that the lesion is in the back of the humeral head and away from the bare area. Again, it is related to the dislocation. It could be in different parts of the humerus depending on whether the humerus went directly anteriorly or more inferiorly. It happens very commonly and in 95% of recurrent dislocations you’re going to see some bone loss in the back of humeral head.
From your exam under anesthesia you will see where you can engage that Hill-Sachs, or catch on the front of the shoulder, and you understand that soft tissue operations to resolve all of these are not likely to solve every problem related to the bone. And that’s really where we get into the discussion of how to manage this.
Really, when you look at which ones need to be treated, other than the glenoid side, it’s less than 10% and the vast majority of surgeon practices focus on the glenoid side, but occasionally the humeral side. The glenoid side is really critical and if you fail on the glenoid side you definitely are not going to be successful on the humeral side.
So remember that these lesions from 15-25% on the glenoid side require some consideration of bone and anything over 25% needs to be resolved with a bone operation. You can’t fix these bony lesions with a soft tissue repair. No matter how tight you make the shoulder, you will not solve this problem. And if you make them so tight that you solve this problem, you’ve created a separate problem. We thought about the humeral bone loss in a very similar way and when it’s a small lesion, as it happens in many of our patients, we just manage the glenoid side. They do very well. We’ve learned that we can arthroscopically assist our surgical repairs with a Remplissage and anything about 25% or more we have to consider surgical management.
How do we decide if it’s 25%? We use advanced imaging. CT scan is very helpful, better than MRI. We use the concept of the glenoid track, which is a relatively new idea, but the idea is that if the pothole on the humeral side gets larger than the width of the remaining glenoid, the glenoid is going to fall into that pothole and you’re going to have problems with this lesion.
Now in larger defects, we do have to engage the articular surface…and Buz showed you a technique using metal…but there are ways you can do that without metal. You can use allograft and plugs, or some soft tissue or partial resurfacing, but this is what we do.
Through an anterior approach, we can take a fresh osteochondral graft…we like this because it’s bone and cartilage that we’re transplanting into the shoulder. We can fill that graft so that it has a nice articular surface and won’t engage. We could also do this arthroscopically…in other words we can manage our anterior glenoid instability with an arthroscopic anterior stabilization and then through a posterior approach in the lateral position we can see the defect and fill it in with a matched allograft. I think this works particularly well for those lesions from 25% to 40%. Fills in very nicely. The articular surface has now been recreated. They’re not going to engage in a Hill-Sachs lesion.
The best study to date to look at this from a biomechanical view in the lab is the one by George Athwal and the group up in Western Ontario. They looked at Remplissage versus osteochondral allograft versus partial resurfacing. I’m telling you I would prefer a biological solution because many of these patients who come to us are actually under the age of 40. They’ve had a singular event and I can’t see putting metal in them at this time.
Moderator Sculco: Wayne, I’d like to start with you. Maybe you can elaborate a little bit. Who are the ideal candidates for the surface replacement because anterior instability with the shoulder where the defects occur is usually a young person’s kind of problem although it can also occur in the older patients? Tell us a little bit more about your indications, your age distribution for who you are using this in.
Dr. Burkhead: You have to take age into consideration, size of defect, as Tony elaborated, and this whole concept of glenoid tracks. This is a rare operation in my practice. I don’t want anyone leaving here thinking that this is something I do routinely for small Hill-Sachs lesions. I treat them just exactly like Tony does. When you get into these 45%, 50% humeral head lesions, patients who have had previous surgery, their humeral surface oftentimes have significant chondromalacia. The seizure patients are the ones who have the worst because every time their shoulder goes out, the forces that are placed across the articular surface are just huge. Oftentimes those patients are arthritic even if they’re index procedure…that being said, I don’t always do that unless their defect would be 45%. It’s a real unusual operation. If you compare the costs it’s probably a lot cheaper to put a piece of metal in there than an osteochondral allograft.
Moderator Sculco: Anthony, let me turn to you now. You heard Wayne’s argument for the use of this in large defects. What’s your feeling? You showed use of allografts and dealing more on the glenoid side. Do you do surface replacements of the humeral head?
Dr. Romeo: Very rarely do I do surface replacements of the humeral head. In this diagnosis, if I’m going on to do an arthroplasty, typically it’s going to be along the lines of replacing the entire humeral head — not trying to put a circular graft into an orange slice type wedge to try and see if I can fill that in correctly. So I’d rather just take off the entire head and put in a proper sized head in the proper position. If I am going to go on to do an arthroplasty (and those arthroplasties are typically in patients who are just a little bit older or have really a joint that is under distress and both the glenoid and humeral side are showing signs of arthritis and it’s a very large lesion) then in that situation an osteochondral allograft may, in fact, not be enough for the treatment of the patients. But that’s an extremely rare situation.
Moderator Sculco: So why then, in that situation, would you do a surface replacement of the humeral head and not go to a total shoulder replacement? Maybe you could educate us about that. Your patient that has some arthritis.
Dr. Romeo: It’s more along the line of Buz’s talk. The idea of a surface replacement is a nice idea but we’ve learned that some of our surface replacements don’t match the normal anatomy of the humerus very well. For people that have done this operation they’ll find it sometimes very hard for the surgeon to identify exactly where that center point of the articular arc is and, therefore it can be challenging to get the surface replacement in the right spot. So when they’re done, the replacement is sitting a little high or a little bit in varus. If you just take off the head at the anatomic neck and replace the head with a normal head that’s in the systems and available now…an anatomic system… then I think many surgeons are more consistent with the quality of the results when they’re done.
Moderator Sculco: You would agree with that Wayne?
Dr. Burkhead: I would. I don’t do very many…like I said in my slide…I don’t do very many surface replacements, but when I do I usually use them for this particular indication or for AVN [avascular necrosis] and it’s critically important that you understand the geometry and I use a device that is more anatomically normal for patients.
Moderator Sculco: I think the takeaway message here is that surface replacement is an option probably very infrequently needed. Other options are available as Anthony has outlined. But certainly a serious problem in the older patient with developing arthritis, replacement, particularly in that patient population, is probably indicated. I want to thank both of our speakers.
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