Osteoarticular Allograft Transplantation for Large Humeral Head Defects in Glenohumeral Instability

During traumatic anterior shoulder dislocation, significant derangement of normal anatomy occurs. Open and arthroscopic techniques alike have emphasized anatomic reconstruction of anterior capsulolabral structures while often neglecting associated osteoarticular pathology. Recent studies have shown that failure rates after Bankart repair are dramatically higher in the presence of large glenohumeral bone defects, yet little has been written about how to best address these lesions. Historically, these patients will undergo multiple procedures culminating with nonanatomic solutions to constrain the humeral head (coracoid transfer or open capsular shift). Significant loss of motion yields unacceptable results in a high-demand athletic population. We present a new approach to athletic, highly functional patients with recurrent anterior instability and large humeral head defects (Hill-Sachs lesion). Anterior capsulolabral pathology is addressed arthroscopically, and the Hill-Sachs lesion is then addressed via a limited posterior approach to the humeral head. Osteoarticular allograft transplantation is performed by use of a single plug to fill the defect. As described, this procedure can be performed in a single operative setting or as a staged procedure for those patients who still have subjective subluxation as a result of continued engagement of a large humeral head defect after Bankart repair. Importantly, our posterior approach does not require takedown of the anterior capsulolabral repair to address the bone defect. We have performed this procedure in a 19-year-old enlisted US Navy seaman, with excellent short-term results. At 1-year of follow-up, he has returned to full active military duty without restriction.