Castoldi_edit.qxp 28/9/07 03:19 Page 64
Orthopaedic Surgery Shoulder
Figure 1: Visualisation of the Impression Fracture of the
option aims to anatomically restore the humeral head shape, preserving
Humeral Head
the cartilage, the articular congruity and the lesser tuberosity
contribution of the concavity–compression effect. Nevertheless, in the
authors’ experience the limition of this approach is the instability of the
elevated cartilage and subchondral bone, which is prone to collapse,
thus negating all of its advantages.
Gerber et al. introduced the use of allograft to fill the defect, restoring the
sphericity of the head. He used this technique in nine shoulder dislocations
with a delay in treatment ranging from one to 12 months and with a
McLaughlin defect involving 40–55% of the humeral articular surface.
17
The author reported that this technique yielded similar results to the
modified McLaughlin procedure without altering the osseous architecture.
The use of allograft represents an alternative to hemiarthroplasty or total
joint arthroplasty in carefully selected larger defects in chronic cases (six to
12 months), but is a demanding surgical technique.
In rare cases when the impression defect is bilateral, an ostechondral
The split is obtained by opening the rotator interval without detaching the subscapularis tendon from the
lesser tuberosity. autograft can be taken from one shoulder during hemiarthroplasty and
used to fill the defect in the controlateral side, in a similar way to the
Figure 2: Correct Position of the Cortical Window
autograft reconstruction described by Gerber.
18
Considering the limits
and advantages of anatomical reconstruction, it was thought that
combining the Dobousset principles with the use of the subcondral
bone as an autograft would achieve a strong and safe support.
Surgical Technique
The patient is positioned supine semi-sitting on a beach chair with the
upper body approximately 60–70° from the horizontal plane, with the
shoulder operating table placed ‘cut-away’ to facilitate the procedure.
The whole arm is prepared and draped to allow for assisted free
movements (performed by an assistant). The advantage of this position
is that the surgeon can access the whole operative site from above and
overlook the fracture from 360°, ensuring better access and control of
the entire surgical field area.
First, an anterior deltopectoral standard approach is performed. The
subacromialis bursa is removed and the rotator cuff interval is opened
(see Figure 1). The visualisation of the fracture is obtained by
transposition of the subscapularis can limit the internal rotation and opening the rotator interval without detaching the subscapularis
complicate future prosthetic reconstruction.
12,13
tendon from the lesser tuberosity.
Rotational osteotomy of the proximal part of the humerus has also The next step is the creation of a little cortical window (of about
been described as a non-anatomical procedure.
15
After a transverse 10x10mm), 2cm distal from the greater tuberosity apex and 2cm
osteotomy of the surgical humeral neck, the shaft is rotated internally lateral to the long head of biceps sulcum (see Figure 2). To elevate the
and fixed with an angled blade plate. Only six of the 10 patients treated bone defect, specific tools were developed (see Figure 3): a hollow
with this technique achieved good results. Due to its complexity and trephine cutter to create a bone carrot, and a bone tapper that allows
intrinsic complications, this technique should be used in young people optimal running into the hollow trephine (10mm in diameter). The
only when it is the sole alternative to shoulder arthroplasty. reduction procedure is performed via the cortical window using the
bone tapper, moving from the cortical window to the impression
Anatomical Techniques fracture. Using the hollow trephine cutter in an oblique direction from
Alternative treatments to the above-described procedures are the cortical window to the impression fracture, a bone carrot is obtained.
anatomical restoration of the humeral head through the use of allograft, This bone tissue is used to perform the reduction of the head defect
osteochondral autograft or the elevation of the depressed cartilage and using the bone tapper (see Figure 2). The anatomical reduction
subchondral buttressing with autologous cancellous bone graft. through the open rotator cuff interval is evaluated step by step. Finally,
once the head surface is adequately reduced, it is secured definitively
Dobousset was the first to use the anatomical technique, re-establishing with a 9x30mm interference biabsorbable screw (see Figure 4) inserted
the humeral shape with an autogenous bone graft associated with the through the window perpendicularly in the same direction as the
reconstruction of the posterior glenohumeral capsule.
16
This surgical depression. The humeral head is tested in free movements by the
64 EUROPEAN MUSCULOSKELETAL REVIEW 2007
Page 1 |
Page 2 |
Page 3 |
Page 4 |
Page 5 |
Page 6 |
Page 7 |
Page 8 |
Page 9 |
Page 10 |
Page 11 |
Page 12 |
Page 13 |
Page 14 |
Page 15 |
Page 16 |
Page 17 |
Page 18 |
Page 19 |
Page 20 |
Page 21 |
Page 22 |
Page 23 |
Page 24 |
Page 25 |
Page 26 |
Page 27 |
Page 28 |
Page 29 |
Page 30 |
Page 31 |
Page 32 |
Page 33 |
Page 34 |
Page 35 |
Page 36 |
Page 37 |
Page 38 |
Page 39 |
Page 40 |
Page 41 |
Page 42 |
Page 43 |
Page 44 |
Page 45 |
Page 46 |
Page 47 |
Page 48 |
Page 49 |
Page 50 |
Page 51 |
Page 52 |
Page 53 |
Page 54 |
Page 55 |
Page 56 |
Page 57 |
Page 58 |
Page 59 |
Page 60 |
Page 61 |
Page 62 |
Page 63 |
Page 64 |
Page 65 |
Page 66 |
Page 67 |
Page 68 |
Page 69 |
Page 70 |
Page 71 |
Page 72 |
Page 73 |
Page 74 |
Page 75 |
Page 76 |
Page 77 |
Page 78 |
Page 79 |
Page 80 |
Page 81 |
Page 82 |
Page 83 |
Page 84 |
Page 85 |
Page 86 |
Page 87 |
Page 88 |
Page 89 |
Page 90 |
Page 91 |
Page 92 |
Page 93 |
Page 94 |
Page 95 |
Page 96 |
Page 97 |
Page 98 |
Page 99