Comparing Access to Engaging Hill-Sachs Lesions Between the Modified Posterior Deltoid Split Approach and Standard Deltopectoral Approach for Bone Grafting

Abstract

Background: Hill-Sachs lesions are common after shoulder instability, and treatment options vary but include remplissage or implantation of structural bone graft. Large Hill-Sachs lesions not addressed by remplissage are challenging to manage and may frequently require an open surgical approach for bone filling treatment options. The optimal approach to maximize visualization of the humeral head during these procedures remains unclear. Purpose/Hypothesis: The purpose of this study was to compare the area of the humeral head accessed using a modified posterior deltoid split approach versus a standard deltopectoral approach without surgical dislocation, with particular attention to access of engaging Hill-Sachs lesions for the purpose of bone grafting in the setting of anterior shoulder instability. It was hypothesized that both approaches would provide equal access to a simulated Hill-Sachs lesion. Study Design: Controlled laboratory study. Methods: Four human cadaveric shoulders were mounted in the beach-chair position. The modified posterior deltoid split approach and nonextensile deltopectoral approaches were performed. A typical Hill-Sachs lesion was simulated on the humeri. The percentage of the total surface area of the humeral head that was accessed, including access to the simulated Hill-Sachs lesion, was mapped using 3-dimensional digitizing software. Results: The deltopectoral approach provided 45% ± 15.2% access (range, 24% to 58%) to the humeral head versus 22.2% ± 6.1% (range, 17% to 30%) for the modified posterior deltoid split approach ( P = .057). The modified posterior deltoid split approach enabled 100% access of the simulated Hill-Sachs lesion compared with 0% for the nonextensile deltopectoral approach. The angle of access to the articular surface was direct and perpendicular with the modified posterior deltoid split approach. Conclusion: The overall surface area of the humeral head accessed via the modified posterior deltoid split approach was less compared with the deltopectoral approach; however, the entire area of a typical Hill-Sachs lesion was able to be accessed from the modified posterior deltoid split approach, whereas this area was not well visualized from the standard deltopectoral approach. Clinical Relevance: The modified posterior deltoid split approach provided sufficient access to the humeral head for the purposes of grafting an engaging Hill-Sachs lesion in the setting of anterior shoulder instability.