Pembimbing : dr.Maksum Pandelima,Sp.

OT

Oleh : Rifrindra Adeniar Rahmi
( 08700094 )
Arthroscopic Treatment of a
Reverse Hill-Sachs Lesion

ABSTRACT
Acute traumatic posterior shoulder instability is a rare injury.
Such injuries can result in significant 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.
We describe a new technique in which the middle
glenohumeral ligament (MGHL) is used, in place of
the subscapularis.

Middle Glenohumeral Ligament
SURGICAL TECHNIQUE
The patient is placed in the lateral decubitus position
with the affected shoulder in 20 to 30 of abduction and
20 of forward flexion by use of 5 to 10 lb of balanced
suspension. A posterior portal is created initially for
visualization. An anterior portal is then made, followed
by an anterosuperolateral portal. The anterior portal is
used as a working portal.
The anterosuperolateral cannula provides continuous
inflow and also functions both as a working portal and as
a primary viewing portal.

The glenoid is carefully examined and measured by
means of a calibrated probe placed in the posterior
cannula to determine whether any significant glenoid
bone loss has occurred.

Fig 1 : Left shoulder,
anterosuperolateral
viewing portal, showing
damage to posterior
capsule (PC) and
labrum (L).
(H, humeral head.)

In the absence of significant posterior bone loss,
arthroscopic repair of the posterior capsulolabral
structures is performed with suture anchors
(BioComposite SutureTak; Arthrex, Naples, FL).

Fig 2. Left shoulder,
anterosuperolateral
viewing portal, showing
prepared bone bed (B) for
later repair of posterior
capsulolabral tissues. (H,
humeral head; L, labrum;
PC, posterior capsule.

Fig 3. Left shoulder,
anterosuperolateral
viewing portal, showing a
suture hook for passing
sutures for later repair of
posterior capsulolabral
tissues (PC). (H, humeral
head; L, labrum.)

the degree of articular involvement is noted, and
the shoulder can be internally rotated to assess
whether the lesion engages the posterior glenoid.

Fig 4. Left shoulder,
anterosuperolateral viewing
portal, showing preparation
of reverse Hill-Sachs defect
(D) with an arthroscopic ring
curette. (H, humeral head;
M, middle glenohumeral
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 ligament (M). (D,
reverse Hill-Sachs defect; S,
subscapularis tendon.)

for larger bone defects, additional suture anchors
may be necessary.
Fig 6. Left shoulder,
anterosuperolateral
viewing portal, showing
repair of posterior
capsulolabral tissues (PC)
to glenoid (posterior
Bankart repair). (G,
glenoid; H, humeral
head.)

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.)

Patients are kept in a sling for 6 weeks postoperatively,
and active elbow motion is allowed. At 6 weeks, a
selfdirected program of progressive stretching and
strengthening 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.
DISCUSSION
Posterior instability of the glenohumeral joint is an uncommon
injury comprising approximately 3% of all shoulder dislocations,
with a reported prevalence of 1.1 per 100,000 per year.
McLaughlin reported satisfactory results in a small series of
patients that he treated by transferring the subscapularis
tendon insertion into the anterior humeral head defect. This
technique was later modified by Hughes and Neer,
who performed a transfer of the lesser tuberosity along with the
subscapularis insertion into the reverse Hill-Sachs lesion.
Hawkins et al. reported on a group of individuals with a history
of a locked posterior dislocation of the glenohumeral joint who
were treated with 1 of the 2 previously mentioned procedures.
Nine were treated with the McLaughlin procedure, and 4 of
these patients had a successful clinical outcome. In 5 of them,
however, treatment failed.

The authors recommended that a transfer of the subscapularis
insertion, or the lesser tuberosity, to address a reverse Hill-Sachs lesion
should only be performed in patients with defects involving less than
45% of the articular surface and in whom surgery is performed with in 6
months of injury.
These operations can produce undesirable effects, chief
of which are a decrease in internal rotation strength
Krackhardt et al. described an arthroscopic technique
for addressing reverse Hill-Sachs lesions. It too involves
the subscapularis and is a modification of the
McLaughlin procedure. It maintains the attachment of
the subscapularis tendon to the lesser tuberosity while
insetting it into the bony defect with 2 suture anchors

Table 1:
Pearls :
Place all anchors (glenoid and humeral) before tying knots to avoid knot
disruption with subsequent anchor insertion. Use a ring curette to prepare the
bone bed on the glenoid and
humeral footprint surfaces. If the MGHL is deficient, inset a portion of the
subscapularis into the reverse Hill-Sachs lesion.
Indication :
Reverse Hill-Sachs lesion with normal size and consistency of MGHL, with no
significant lenoid bone loss
There may be a slight loss of internal rotation with this
technique. However, the degree of limitation depends
primarily on the size of the lesion and the amount of the
articular surface that is affected
It is our opinion that the procedure of Krackhardt et al.
could lead to a significant loss of internal rotation, as well as
internal rotation strength, due to subscapularis dysfunction
that may result from altering its force vector. Therefore,
when a clinically significant reverse Hill-Sachs lesion
involving less than one-third of the humeral articular surface
is present, we recommend addressing it by arthroscopically
suturing the MGHL into the defect.


However, we believe that filling the reverse Hill-
Sachs bone defect with MGHL rather than
subscapularis tendon has the distinct advantage of
not altering the muscle-tendon length or vector
direction of the subscapularis,
thereby maintaining a more anatomic and physiologic
construct while addressing the anatomic distortion
(the reverse Hill- Sachs lesion). We believe that
suturing of the MGHL into the reverse Hill-Sachs
lesion is preferable to altering the anatomy and
function of the subscapularis