Fresh Osteochondral Allograft to the Humeral Head for Treatment of an Engaging Reverse Hill-Sachs Lesion

Posterior dislocation of the shoulder is rare, occurring in approximately 2% to 4% of all shoulder dislocations. Through a mechanism similar to that first characterized by Hill and Sachs, these dislocations have the potential to result in impaction fractures of the anterior aspect of the humeral head. These so-called reverse Hill-Sachs or McLaughlin lesions are estimated to occur in 86% of acute traumatic posterior shoulder dislocations and are often clinically significant, giving rise to persistent shoulder instability in approximately 35% of cases. An array of treatment options are described in the literature, dependent on factors including but not limited to the location, size, and scale of the defect; mechanism of recurrence; chronicity of the dislocation; and, importantly, the patient’s age, prior activity, and postoperative goals. Osteochondral autograft has been reported rarely, save for a few patients with bilateral fracture-dislocations of the humeral head wherein the contralateral shoulder provides the graft source during treatment with concurrent hemiarthroplasty. Discussion of osteochondral allograft has focused largely on the treatment of chronic, locked posterior fracture-dislocations. These authors express concern regarding the potential for degenerative changes associated with chronic instability, suggesting a biomechanical environment distinctly different from lesions treated in the period shortly after initial presentation. In a systematic review of osteochondral allograft for humeral head reconstruction, Saltzman et al identified 2 instances of fresh humeral head osteochondral allograft in humeral head reconstruction. In both instances, the allograft was fixed to adjacent tissue using nonabsorbable compression screws. Several case series involving osteochondral allograft for the treatment of similar Hill-Sachs lesions have been reported using a variety of fixation methods. We report the use of fresh osteochondral allograft to the humeral head using a press-fit dowel technique in the context of the spectrum of historical options.