The Eden - Hybbinette salvage procedure

History of the surgery (from UW Orthopaedic Surgery and Sports Medicine)

The Eden-Hybbinette procedure was performed independently by Eden (Eden, 1918) in 1918 and by Hybbinette (Hybbinette, 1932) in 1932. Eden first used tibial grafts, but both authors finally recommended the use of iliac grafts. This procedure is supposed to extend the anterior glenoid. It has been used by Palmer and Widen, (Palmer and Widen, 1948) Lavik, (Lavik, 1961) and Hovelius (Hovelius, Akermark and Albrektsson, 1983) in treating shoulder subluxation and dislocation. Lavik modified the procedure by inserting the graft into the substance of the anterior glenoid rim. Lange (Lange, 1944) inserted the bone graft into an osteotomy on the anterior glenoid. Hehne and Hubner (Hehne and Hubner, 1980) reported a comparison of the Eden-Hybbinette--Lange and the Putti-Platt procedures in 170 patients; their results seemed to favor the latter. Paavolainen and coworkers (Paavolainen et al, 1984) reported on 41 cases of Eden-Hybbinette procedures; 3 had recurrent instability, and external rotation was diminished an average of 10 per cent. They found the results similar to their series of Putti-Platt operations. Ten per cent in each group developed degenerative joint disease!

Niskanen and coworkers (Niskanen et al, 1991) reported a series of 52 shoulders with a mean follow-up of 6 years that had been treated with a modification of the Eden-Hybbinette procedure. The operation involved the creation of a trough through the capsule and into the anteroinferior aspects of the scapula neck. A tricortical iliac crest bone graft was then wedged into the trough without fixation. A 21% recurrence rate was attributed to one spontaneous dislocation and 10 traumatic redislocations. Postoperative arthrosis was noted in nine shoulders and early degenerative changes in an additional 18 shoulders.

The following case illustrates the challenges and difficulties in treating a patient who is young and active and unfortunately has a failed prior reconstruction for anterior traumatic instability associated with a seizure. Initially, he was diagnosed with an anterior dislocation, fracture of the greater tuberosity, and soft tissue Bankart lesion. The first operation performed elsewhere was an open Bankart repair with repair of the rotator cuff and resection of the CA ligament. When referred to us he had a chronic locked anterior shoulder dislocation, a large size Hill Sachs lesion and chronic rotator cuff deficiency. Although, arthrodesis or reverse total shoulder replacement are the alternatives, due to his young age, an attempt was made to reduce the dislocated humerus and prevent further dislocations. The was clinically anterior superior escape, during surgery it was found that the subscapularis was ruptured,  and the CA ligament was resected during the previous operation. The rotator cuff repair that was performed primarily had failed. An Eden Hybbinette procedure was chosen because the alternative Latarjet would have provided an insufficient -small bone - restraint to anterior directed forces and tendency for anterior dislocation.

Postoperative images after the Eden Hybbinette are shown below:

Osteoporosis and collapse of the head after ORIF of the proximal humerus fracture

The following case illustrates the problem of the osteoporosis in the treatment of the proximal humerus fractures. In addition, it highlights the need to avoid approximation of the articular surface with the proximal locking screws if a locking plate is used for the treatment of this fracture. In this case due to the young age and smoking status of the patient which would have compromised the healing of the tuberosities a hemiarthroplasty was not chosen.

3 months 

4 months post op the hardware was removed to avoid penetration of the humeral head articular surface with the screws.

Short stems in anatomic total shoulder arthroplasty.

Short stems in anatomic shoulder replacement provide the advantage of avoiding the insertion of the stem at the curved area of the proximal humerus thus avoiding reaming of the cortices . This provides the theoretical advantage of protection of the cortical bone from from stress risers. In addition, the mismatch between the diaphyseal and metaphyseal area of the humerus is eliminated as the fixation is achieved in the metaphyseal area. It remains to be seen whether "distal fixation" is not necessary - at the tip of the stem, as this type of implant has no distal fixation. We use this stem in patients with good bone stock and no severe osteopenia with the idea that if future removal of the stem is required then revision surgery will be easier. In addition, the periprosthetic fracture below the stem should be less of a problem with this implant.

Szerlip BW, Morris BJ, Laughlin MS, Kilian CM, Edwards TB. Clinical and
radiographic outcomes after total shoulder arthroplasty with an anatomic
press-fit short stem. J Shoulder Elbow Surg. 2018 Jan;27(1):10-16. 

Non operative treatment of the fracture of the surgical neck of the proximal humerus

Non operative treatment of proximal humerus surgical neck fractures can and should be offered for patients who are reliable and are willing to follow up with serial x-rays. The following fracture was healed in 7 months cradio-graphically. "Clinically", it was healed at 6 weeks. The range of motion was active FE to 160 degrees without pain.

Another case below is presented with serial radiographs and progressive healing.

Operative management of the fractures of the surgical neck of the humerus

This type of fracture requires operative approach if the patient is active. Proper reduction in order to achieve good results in terms of function and pain are the goals of surgery. It is not uncommon for patients to complain of severe pain after this injury. In the osteoporotic patient population this injury can be the result of low energy trauma, in the young and healthy individual it is usually the result of high energy trauma.  

The decision for surgery should also include the functional demands of the patients, the presence of comorbidities, and the ability to undergo operative treatment.

Indications for hemiarthroplasty do not apply for this fracture

Due to severe osteoporosis the fixation was lost, the fracture went into varus but eventually healed in the varus position. This patient had severe loss of bone from chronic use of oral corticosteroids