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Arthroscopic Treatment of a Reverse Hill-Sachs Lesion

Richard E. Duey, M.D., and Stephen S. Burkhart, M.D.

Abstract: Acute traumatic posterior shoulder instability is a rare injury. Such injuries can result in signicant bone defects
of the anterior humeral head that require surgical intervention. In the past, small to medium defects have been treated by
a soft-tissue or bone transfer into the lesion. We present an arthroscopic technique for addressing these lesions in which
the middle glenohumeral ligament is sutured into the defect, thereby making it an extra-articular defect and preventing it
from engaging the posterior glenoid.

A cute traumatic posterior shoulder instability is

a rare injury that may go undetected.1-6 In
addition to damaging the labrum and/or the liga-
Surgical Technique
The patient is placed in the lateral decubitus position
with the affected shoulder in 20 to 30 of abduction and
mentous structures, signicant bone lesions can also 20 of forward exion by use of 5 to 10 lb of balanced
result from these dislocations. Defects involving the suspension. A posterior portal is created initially for
anterior humeral head (reverse Hill-Sachs lesions) visualization. An anterior portal is then made, followed by
have been recognized for some time in association an anterosuperolateral portal. The anterior portal is used
with posterior shoulder dislocations.5 These lesions as a working portal. The anterosuperolateral cannula
may cause signicant clinical symptoms and may provides continuous inow and also functions both as
increase the risk of recurrent instability.1,2 Numerous a working portal and as a primary viewing portal. The
surgical techniques for addressing these defects based joint is carefully examined with a combination of both 30
on the involvement of the articular surface have been and 70 arthroscopes. The 30 arthroscope is placed in the
described.3-5,7-9 Small to medium lesions have been anterosuperolateral portal, and any posterior capsulola-
treated in the past by lling the defect with either the bral injury is identied (Fig 1). The glenoid is carefully
subscapularis tendon or the lesser tuberosity (with its examined and measured by means of a calibrated probe
attached subscapularis tendon) to keep it from en- placed in the posterior cannula to determine whether any
gaging the posterior glenoid rim when the arm is signicant glenoid bone loss has occurred.11 In the
adducted and internally rotated.5,6,9,10 In essence, absence of signicant posterior bone loss, arthroscopic
such a technique is a reverse remplissage technique. repair of the posterior capsulolabral structures is per-
We describe a new technique in which the middle formed with suture anchors (BioComposite SutureTak;
glenohumeral ligament (MGHL) is used, in place of the Arthrex, Naples, FL). Next, a posterolateral working
subscapularis or lesser tuberosity, to ll a reverse Hill- portal is created. The angle of approach from this portal is
Sachs lesion that has resulted from recurrent traumatic ideal for bone bed preparation and anchor placement
posterior shoulder instability (Video 1). along the posterior glenoid rim. The damaged posterior
capsulolabral structures are mobilized with arthroscopic
elevators. A 2- to 3-mm strip of bare bleeding bone is
prepared along the posterior glenoid rim by use of
arthroscopic ring curettes to provide a broad biologic
From The San Antonio Orthopaedic Group (R.E.D., S.S.B.), and the
footprint for healing of the repaired capsulolabral tissue
Department of Orthopaedic Surgery, University of Texas Health Science Center
at San Antonio (S.S.B.), San Antonio, Texas, U.S.A. (Fig 2). Double-loaded suture anchors (BioComposite
The authors report that they have no conicts of interest in the authorship SutureTak) are placed along the posterior glenoid rim
and publication of this article. down to the 6-oclock position, if necessary. Sutures are
Received July 18, 2012; accepted January 15, 2013. passed through the torn soft-tissue structures in prepa-
Address correspondence to Stephen S. Burkhart, M.D., 150 E Sonterra
ration for later repair; however, no knots are tied at this
Blvd, Ste 300, San Antonio, TX 78259, U.S.A. E-mail:
2013 by the Arthroscopy Association of North America point (Fig 3).
2212-6287/12478/$36.00 Attention is then given to the reverse Hill-Sachs defect involving the anterior humeral head. The degree of

Arthroscopy Techniques, Vol 2, No 2 (May), 2013: pp e155-e159 e155


Fig 1. Left shoulder, anterosuperolateral viewing portal,

Fig 3. Left shoulder, anterosuperolateral viewing portal,
showing damage to posterior capsule (PC) and labrum (L).
showing a suture hook for passing sutures for later repair of
(H, humeral head.)
posterior capsulolabral tissues (PC). (H, humeral head;
L, labrum.)
articular involvement is noted, and the shoulder can be
internally rotated to assess whether the lesion engages
the posterior glenoid. The bone bed of the lesion is a double-diameter knot pusher (Surgeons Sixth Finger;
debrided down to a bleeding base with arthroscopic ring Arthrex) to repair the posterior Bankart lesion (Fig 6).
curettes (Arthrex) (Fig 4). A 3-mm double-loaded suture These sutures are tied after the anchor has been placed in
anchor (BioComposite SutureTak) is inserted into the the reverse Hill-Sachs lesion. If this sequence of anchor
superior aspect of the defect. One limb from each suture placement and knot tying is not followed, the posteriorly
is passed through the superolateral aspect of the adjacent directed forces generated by anchor placement into the
MGHL (Fig 5). For larger bone defects, additional suture bone defect may disrupt the posterior soft-tissue repair.
anchors may be necessary. At this point, the sutures Once the posterior capsulolabral tissues have been
previously passed through the posterior capsulolabral repaired, the sutures through the MGHL are tied, inset-
structures are tied from inferior to superior with ting the MGHL into the reverse Hill-Sachs defect (Fig 7).

Fig 2. Left shoulder, anterosuperolateral viewing portal, Fig 4. Left shoulder, anterosuperolateral viewing portal,
showing prepared bone bed (B) for later repair of posterior showing preparation of reverse Hill-Sachs defect (D) with an
capsulolabral tissues. (H, humeral head; L, labrum; PC, arthroscopic ring curette. (H, humeral head; M, middle gle-
posterior capsule.) nohumeral ligament; S, subscapularis tendon.)

Fig 5. Left shoulder, anterosuperolateral viewing portal,

showing a suture anchor that has been placed in the superior
aspect of the bone lesion. The sutures are passed with an
antegrade suture passer through the middle glenohumeral liga-
ment (M). (D, reverse Hill-Sachs defect; S, subscapularis tendon.)

Patients are kept in a sling for 6 weeks postoperatively,

and active elbow motion is allowed. At 6 weeks, a self-
directed program of progressive stretching and strength-
ening exercises is initiated. Three months postoperatively,
the patient may begin more advanced strengthening
exercises in the gym. Return to full activities is delayed for
6 to 9 months depending on the quality of the tissues and
the repair.

Posterior instability of the glenohumeral joint is an
uncommon injury comprising approximately 3% of all Fig 7. Left shoulder, anterosuperolateral viewing portal. (A)
Sutures have been passed through the middle glenohumeral
ligament (M), which is pulled into the defect (D). (B) Middle
glenohumeral ligament (M) after it has been sutured into the
reverse Hill-Sachs defect. (S, subscapularis tendon; H,
humeral head.)

shoulder dislocations, with a reported prevalence of

1.1 per 100,000 per year.1,2,4,5 Many of these injuries
are missed at the time of initial presentation and can go
undiagnosed for a long period.3,6 Damage to the poste-
rior capsulolabral complex can result from posterior
shoulder instability, and arthroscopic treatment of these
lesions has yielded good results.12-14 However, if there
is a concomitant injury to the bony anatomy involving
the glenoid and/or the humeral head, soft-tissue repair
alone may be inadequate to completely address the
patients symptoms.2,3
McLaughlin5 was the rst to describe osteochondral
Fig 6. Left shoulder, anterosuperolateral viewing portal, defects involving the anterior aspect of the humeral head
showing repair of posterior capsulolabral tissues (PC) to glenoid in patients who had had a posterior shoulder dislocation.
(posterior Bankart repair). (G, glenoid; H, humeral head.) A recent magnetic resonance imaging study showed

that after a rst-time acute posterior dislocation, 86% of involves the subscapularis and is a modication of the
patients had a reverse Hill-Sachs lesion.15 Another study McLaughlin procedure. It maintains the attachment of
looking at the epidemiology and outcomes after acute, the subscapularis tendon to the lesser tuberosity while
traumatic posterior dislocations of the shoulder showed insetting it into the bony defect with 2 suture anchors.
that 42% of patients had a large (volume of defect This essentially converts the reverse Hill-Sachs lesion
>1.5 cm3) reverse Hill-Sachs lesion and the presence of into an extra-articular defect in the same way that
such a defect carried with it a signicantly increased risk remplissage converts a Hill-Sachs lesion into an extra-
of recurrence.2 As a result, the question arises as to how articular defect, thereby decreasing the likelihood of it
best to treat these injuries. engaging the glenoid and causing symptoms. This
Traditionally, it was believed that lesions involving procedure does provide a less invasive approach when
less than 20% of the articular surface did well, for the one is dealing with these lesions; however, it can lead to
most part, with nonoperative treatment.16 However, an internal rotation decit. Furthermore, it alters the
reverse Hill-Sachs lesions tend to involve more of the direction of force transmission for the subscapularis and
articular surface compared with their posterior coun- decreases its working length. Given the critical role the
terparts.1 Therefore some authors hold that lesions subscapularis plays in normal glenohumeral kine-
involving as little as 10% of the articular surface may be matics, another viable alternative may be desirable.
clinically signicant and require direct intervention.1 The novel technique that we describe does not alter the
McLaughlin5 reported satisfactory results in a small anatomy or the function of the subscapularis. Adherence
series of patients that he treated by transferring the to important pearls will facilitate the procedure (Table 1).
subscapularis tendon insertion into the anterior It is similar to the procedure described by Krackhardt
humeral head defect. This technique was later modied et al.10 in that it lls the defect with adjacent soft tissue so
by Hughes and Neer,9 who performed a transfer of the that the reverse Hill-Sachs lesion becomes an extra-
lesser tuberosity along with the subscapularis insertion articular defect, thereby decreasing the likelihood of the
into the reverse Hill-Sachs lesion. Hawkins et al.6 lesion causing clinical symptoms. There may be a slight
reported on a group of individuals with a history of loss of internal rotation with this technique. However,
a locked posterior dislocation of the glenohumeral joint the degree of limitation depends primarily on the size of
who were treated with 1 of the 2 previously mentioned the lesion and the amount of the articular surface that is
procedures. Nine were treated with the McLaughlin affected, in contradistinction to the technique of Krack-
procedure, and 4 of these patients had a successful hardt et al., in which the subscapularis is arthroscopically
clinical outcome. In 5 of them, however, treatment set into the lesion, where internal rotation is affected by
failed. Of the 5 who did not have a satisfactory result, 2 the tethering of the subscapularis and decreased excur-
had a humeral head defect involving more than 45% of sion of the muscle-tendon unit. It is our opinion that the
the articular surface and the other 3 underwent surgery procedure of Krackhardt et al. could lead to a signicant
more than 1 year after their initial injury. For the loss of internal rotation, as well as internal rotation
4 patients in whom the subscapularis transfer was strength, due to subscapularis dysfunction that may
successful, the humeral head defect involved between result from altering its force vector. Therefore, when
20% and 45% of the articular surface, and surgery was a clinically signicant reverse Hill-Sachs lesion involving
performed within 6 months of the injury. Four addi- less than one-third of the humeral articular surface is
tional patients in this same study underwent transfer of present, we recommend addressing it by arthroscopically
the lesser tuberosity into the anterior humeral head suturing the MGHL into the defect. We know of no other
lesion, and all of them did well clinically. Consequently, report in the literature describing the treatment of
the authors recommended that a transfer of the sub- reverse Hill-Sachs lesions in this manner.
scapularis insertion, or the lesser tuberosity, to address Certain anatomic variants of the ligament may not be
a reverse Hill-Sachs lesion should only be performed in amenable to this type of procedure. However, we believe
patients with defects involving less than 45% of the that lling the reverse Hill-Sachs bone defect with
articular surface and in whom surgery is performed
within 6 months of injury. However, some authors Table 1. Pearls and Indication
believe that these procedures are best reserved for those Pearls
patients with defects involving less than approximately Place all anchors (glenoid and humeral) before tying knots to
one-third of the articular surface.4,7 These operations avoid knot disruption with subsequent anchor insertion.
can produce undesirable effects, chief of which are Use a ring curette to prepare the bone bed on the glenoid and
humeral footprint surfaces.
a decrease in internal rotation strength and the added If the MGHL is decient, inset a portion of the subscapularis into
difculty in performing prosthetic procedures in the the reverse Hill-Sachs lesion.
future, should they be deemed necessary.7 Indication
Krackhardt et al.10 described an arthroscopic tech- Reverse Hill-Sachs lesion with normal size and consistency of
nique for addressing reverse Hill-Sachs lesions. It too MGHL, with no signicant glenoid bone loss

MGHL rather than subscapularis tendon has the distinct 8. Gerber C, Lambert SM. Allograft reconstruction of
advantage of not altering the muscle-tendon length or segmental defects of the humeral head for the treatment
vector direction of the subscapularis, thereby maintain- of chronic locked posterior dislocation of the shoulder.
ing a more anatomic and physiologic construct while J Bone Joint Surg Am 1996;78:376-382.
9. Hughes M, Neer CS II. Glenohumeral joint replacement
addressing the anatomic distortion (the reverse Hill-
and postoperative rehabilitation. Phys Ther 1975;55:850-
Sachs lesion). We believe that suturing of the MGHL into
the reverse Hill-Sachs lesion is preferable to altering the 10. Krackhardt T, Schewe B, Albrecht D, Weise K. Arthros-
anatomy and function of the subscapularis (Table 1). copic xation of the subscapularis tendon in the reverse
Hill-Sachs lesion for traumatic unidirectional posterior
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