Introduction  

The techniques of stabilization progressed these last years and now seem to be able to make it possible to obtain results as good as the techniques with open sky. Without being unaware of the importance of the problems of loss of bone substance, the techniques of stabilization primarily concentrated on the rebuilding of the lesions and . Recently, and of , in a broad series of patients who had had a stabilization of their shoulder by anchoring of the , stressed the fundamental character of the osseous lesions in occurred of the failures. Thus, on 194 repairs by , they had met 21 failures is 10,8%. In this series, when there was no problem of osseous lesion, this failure rate fell to 4%. This rate is completely comparable with those met in stabilizations with open sky. While studying the causes of failure, the authors reported themselves that 67% of the patients forwarded an osseous lesion either to the level of or of the humeral head corresponding to a lesion of . Thus they were brought to speak about “engaging lesion of ” and alerted on the fact that these patients could not perhaps be discussed .

This problem of commitment of the lesion of was highlighted by and Hartmann in 1890. The authors showed well that these two lesions corresponded to a commitment of the lesion of the humeral head in a loss of bone substance of . It is naturally as we wondered how to be able to deal with optimum of way of the patients forwarding of the important losses of bone substance as well to the level of the humeral head as on the level of . brought back an important rate relatively     of iterative luxations when the lesions on the level of were important (12%). It recommended to carry out   systematically a   capsular during the repair of the pad. For this type of patients forwarding a loss of bone substance to the level of the (reversed pear ) must concern the intervention of .

Concerning the patients primarily forwarding a lesion of without lesion to the level of , recommends to limit external rotation by carrying out, with open sky, a capsular followed by six weeks of immobilization. The majority of the authors recommend to carry out a limitation of glenohumeral mobility via capsular which probably would avoid a commitment of the lesion of by limiting external rotation and abduction.

For certain authors finally, it is even necessary to carry out an osteotomy under-capital of rotation of the humerus, even a filling of the notch by an iliac crest or then to carry out, with open sky, a transfer of the tendon of and of the capsule in the lesion of .

Methods

From May 2002 in March 2005, 27 patients having forwarded a former traumatic luxation of the shoulder and consulting for an instability with lesions as well of as of the posterior party of the humeral head had a with and interposition of the tendon in the lesion of associated with (figure 2 and 3). In 8 cases, they were patients having forwarded a failure of stabilization (6 opened and 2 ). 23 of the 27 patients were available for the review with a two years minimum of follow-up. The Middle Age was 29 years (from 13 to 49). There were en and 5 women. 24 patients were available for the follow-up which was on average nths (from 24 to 57).

The clinical outcomes are reported by using a subjective score of the shoulder which makes it possible to evaluate the results according to the physical-activity that it is a simple physical-activity, of sport in leisures or of professional sport. The system of evaluation takes into account the pain, the force, stability, the function, the mobility and the overall state of the shoulder. The patients were contacted by telephone and, according to their answer it was carried out an evaluation going from 0 to 4 points. With a maximum of 24 points the results were judged like excellent between 21 and 24  ; goods between 17 and 20  ; means between 13 and 16; and bad when they were lower than 13.

All the patients had a radiography of the shoulder preoperative in internal rotation, external and neutral rotation as well as a profile of which made it possible to visualize the losses of bone substance.

MRI had been carried out finding the lesion of but making it possible to make the diagnosis of lesion of only in 9 cases. 15 patients had a which made it possible to precisely identify the lesion on the level of the .

The decision to carry out a filling of the notch was systematically per-operational after evaluation of the bony lesions under control by evaluating those by the antéro-higher channel. A loss of bone substance on the level of in its dial antéro-inferior associated with an engaging lesion of was identified among all patients having profited from this technique (figure 4).

Figure 1: Lesion of Hill engaging, and Hartmann 1890.

Figure 2: Former luxation with osseous and lesion of .

Figure 3: Filling of the lesion of and former repair.

Figure 4: Pear aspect reversed of and engaging lesion of Hill seen channel .

Figure 5: the initially posterior channel is right compared to the osseous lesion.

Operative procedures

The patients are installed in side with an arm which is put in traction at 30° abduction is 15° of former front elevation. Traction is of ilos. After surgical, it is carried out a posterior channel on the level of the external edge of the humeral head right compared to the lesion of (figure 5). This channel initially will allow at the same time the articular filling, but also a good articular visualization and finally will make it possible to work on the bony lesion of the humeral head. The second sees initially realized antéro-lower is carried out on the lower part of the interval of the rotators according to a technique of outside in inside. The entrance point is located just at the distal and side point of the at the higher edge of the . This channel initially will make it possible to deal with the lesion . Then an initially antéro-higher channel is carried out with the lower margin of the always according to a technique of outside in inside. This channel of input is done just in lower part of the tendon of the biceps.

The is changed place and re-enters in a nozzle located in the antéro-higher channel. It is at this time that it is possible to evaluate the extent and the localization of the lesion of , to confirm the good positioning of the posterior channel and to make it possible to evaluate exactly the osseous on the level of . If ever the initially posterior channel is just compared to the lesion of , it is then possible of set up a nozzle of 8,m which is descended on trocar through the deltoid but not through the or capsules it. Using a strawberry, the bone surface of the lesion of is revived by paying attention well not to withdraw a bone. In parallel, the former and posterior capsule is revived delicately.

The and the former capsule will be taken off gently and all the former party of will be cleaned; this act is carried out before the filling.

The processing of the lesion of is made in the same way that a repair of a lesion partial of the cap interesting the deep face. Even if various anchors were used during these three last years, the technique remains same the  : the fixing of the joint tendon of the and the posterior capsule on the revived face of the lesion of .

The initially posterior channel for the filling must be realized in an angle quite precise and centered on the loss of bone substance. If ever it is not exactly at the good place during the introduction of the trocar one, one will use a pointer to just carry it out opposite the lesion. The nozzle used is a nozzle of 8,m which once again must be last through the deltoid but must adhere to the tendon of the and the posterior capsule. This moment we will use a smaller nozzle allowing to reduce our anchors. This smaller nozzle passed through the tendon of and the posterior capsule.

The first anchor is put in the most distal party of the lesion of . The nozzle of the anchor is then withdrawn and a penetrant makes it possible to recover one of the joinings 1cm above the initial entrance point through the tendon and the capsule (figure 6). A second anchor is placed in the upper part of the lesion of and at this time the yarn is recovered same manner with the grip catch-yarn (figure 7). The first lower joining is then tight with a node remaining extra-articular in space under-deltoïdien. This tightening can be carried out under control while passing in subacromial space on the level of the posterior party of the purse. The joinings are carried out standard on the capsule and the tendon of the to cover the lesion with (figure 8).

or the osseous lesion of as well as the capsule can then be repaired on the former edge of . This repair can be done either by a simple channel initially or by using the two initially former channels.
The post-operative immobilization as well as rehabilitation are done according to the history of each patient. Generally we use an immobilization for one six weeks duration.

The patients have the right to withdraw their immobilization for the epic of the everyday life (fuel supply, hygiene, use of the computer) with J 1 or 2. They have the right to withdraw their immobilization as long as their arm is not forwarded to movements of abduction and that they do not carry out movements beyond neutral rotation. An active mobilization and against-resistance are carried out as from the sixth week. No sport at the risk or contact is authorized before the sixth month.

Figure 6: The first anchor is installation and a trap yarn passed remotely to recover one of the joinings.

Figure 7: The 2 joinings are with being tight.

Figure 8: The lesion of is filled by the capsule and it thorny.

Figure 9: At the time of a of control, in nths, the capsule and the tendons are healed in the osseous lesion.

Fig. 10a: Preoperative MRI showing the very major osseous lesion of Hill . In fig. 10b: MRI showing the healed aspect of filling.

Results

24 of the 27 patients were available for the follow-up with nths an average passing (from 24 to 57). 11 patients answered the questionnaire which was addressed to them by Internet or mail, ade an examination by telephone interview. 3 patients were lost sight of the fact. All the patients were evaluated by (subjective score)  ; there were 15 excellent results, 7 goods and 2 bad. 2 patients forwarded a posttraumatic luxation  : due to an accident of the public highway and the other with a local traumatism. 22 of the 24 patients were very satisfied. Among patients who had had a primary failure of stabilization, there were 5 satisfied, 3 goods and no case of repetition.

A patient had a post-operative stiffness which was discussed . 2 patients had a recovery  : one to 2nths for a postéro-side painful lesion of the pad, the other in nths for an ablation of hardware. These two surgical recoveries made it possible to carry out a control which showed the effectiveness of the filling with a tendon and a capsule which was healed in the lesion of (figure 9). 2 patients had a post-operative MRI and in all the cases it was highlighted a cicatrization of the tendon of the transfer in the lesion of (figure 10a and 10b).
Discussion

Many authors showed the importance of the lesion of in the former instability of the shoulder. In these particular cases, rate of recurrence is relatively variable but can go up up to 67% like showed it the study of and . In their series, there had been a former stabilization among patients forwarding a osseous but without taking account of the lesion of . These authors recommended to give up the processing of instability and to move towards a procedure of when there exists an important osseous on the level of the .

Historically the lesion of much less interested people than the lesion in the level of . The role of a wide lesion postéro-higher than the level of the humeral head in the repetition of former luxations of shoulder was seldom mentioned. This is probably related to the fact that in the conventional surgery with open sky, this lesion was seldom explored. However as of years 48, Micrometer caliper and showed that, in the presence of a large lesion of , there was a significant risk of repetition even in the event of repair of the . They already noted at the time the fact that to put the arm in abduction external rotation predisposed upon the engagement of this lesion on the former face of .

Thereafter, other authors discussing, with open sky, of instabilities of the shoulder, noted a going rate of recurrence from 6 to 10% among patients forwarding a large lesion of isolated without osseous lesion to the level from .

and collaborators recognized that a large lesion of could be a major mailman of repetition of a shoulder dislocation in the continuations of an intervention of . In their series of repetition of luxations after surgical stabilization of the shoulder, 3/4 their bad or poor results forwarded a severe lesion of . They classified this lesion as small when it made less than 20% of the surface of the humeral head, moderate between 20 and 50% and severe in the event of more than 50%.

and collaborators confirmed in their important series that the size of the lesion was correlated with rate of recurrence after pure former stabilization. They thus noted a rate of recurrence of 4,7% in the event of small lesion and 6% in the event of significant injury against an overall rate of repetition of 3,5% among patients not having a lesion of . They concluded thus that these lesions were to be dealt with specifically, in particular in the event of failure of former stabilization or when there was a weakness of the or capsule.

recently confirmed that it was necessary to pay great attention to these notches of in instabilities repeating after surgery. He thus saw an unacceptable rate of repetition among patients who had had a stabilization by . He joined the recommendations of the first times of Micrometer caliper and namely that a reduction in external rotation with open sky to prevent a commitment of the lesion of is necessary.

For other authors, it is advisable to carry out an osteotomy under-capital of rotation, a filling of by a bone grafting or then a transfer to open sky of the tendon of the as well as capsule. This last technique, described by , corresponds in fact to a technique reversed: brought back results satisfying among 15 patients discussed by this transfer in the lesion of the humeral head. It brought back its results in an overall series of 90 patients. It was confined to primarily use this technique for important on the level of the humeral head. For him, this technique does not limit external rotation, but limit the translation of the humeral head and thus, consequently, did not involve stiffness in external rotation nor even in the movements above the scapula.

Conclusion

The filling of the lesion of is a technique which makes it possible to directly deal with bone lesion of the humeral head. The filling of this revived lesion completely fills this osseous lesion which becomes extra-articular and thus prevents the phenomena of commitment. We did not note any complication. In particular in any case we did not note a significant limitation of rotation. The overall results were completely comparable with those of the patients having had simply a former stabilization by .

This technique appears effective to us to discuss the patients having great losses of bone substance of the humeral head, and for which the risk of failure of therapy by isolated is high.

Only 2 of our 24 patients (7%) forwarded a repetition of luxation but following severe traumatisms of the operated member. This is why we consider that these results are extremely encouraging compared to the other techniques suggested. 

 

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