Acute traumatic posterior shoulder instability is

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1 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 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. Acute traumatic posterior shoulder instability is a rare injury that may go undetected. 1-6 In addition to damaging the labrum and/or the ligamentous structures, significant bone lesions can also result from these dislocations. Defects involving the anterior humeral head (reverse Hill-Sachs lesions) have been recognized for some time in association with posterior shoulder dislocations. 5 These lesions may cause significant clinical symptoms and may increase the risk of recurrent instability. 1,2 Numerous surgical techniques for addressing these defects based on the involvement of the articular surface have been described. 3-5,7-9 Small to medium lesions have been treated in the past by filling the defect with either the subscapularis tendon or the lesser tuberosity (with its attached subscapularis tendon) to keep it from engaging the posterior glenoid rim when the arm is adducted and internally rotated. 5,6,9,10 In essence, such a technique is a reverse remplissage technique. We describe a new technique in which the middle glenohumeral ligament (MGHL) is used, in place of the subscapularisorlessertuberosity,tofill a reverse Hill- Sachs lesion that has resulted from recurrent traumatic posterior shoulder instability (Video 1). From The San Antonio Orthopaedic Group (R.E.D., S.S.B.), and the Department of Orthopaedic Surgery, University of Texas Health Science Center at San Antonio (S.S.B.), San Antonio, Texas, U.S.A. The authors report that they have no conflicts of interest in the authorship and publication of this article. Received July 18, 2012; accepted January 15, Address correspondence to Stephen S. Burkhart, M.D., 150 E Sonterra Blvd, Ste 300, San Antonio, TX 78259, U.S.A. ssburkhart@msn.com Ó 2013 by the Arthroscopy Association of North America /12478/$ 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 joint is carefully examined with a combination of both 30 and 70 arthroscopes. The 30 arthroscope is placed in the anterosuperolateral portal, and any posterior capsulolabral injury is identified (Fig 1). 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. 11 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). Next, a posterolateral working portal is created. The angle of approach from this portal is ideal for bone bed preparation and anchor placement 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 footprint for healing of the repaired capsulolabral tissue (Fig 2). Double-loaded suture anchors (BioComposite SutureTak) are placed along the posterior glenoid rim down to the 6-o clock position, if necessary. Sutures are passed through the torn soft-tissue structures in preparation for later repair; however, no knots are tied at this point (Fig 3). 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

2 e156 R. E. DUEY AND S. S. BURKHART Fig 1. Left shoulder, anterosuperolateral viewing portal, showing damage to posterior capsule (PC) and labrum (L). (H, humeral head.) 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 debrided down to a bleeding base with arthroscopic ring curettes (Arthrex) (Fig 4). A 3-mm double-loaded suture anchor (BioComposite SutureTak) is inserted into the superior aspect of the defect. One limb from each suture is passed through the superolateral aspect of the adjacent MGHL (Fig 5). For larger bone defects, additional suture anchors may be necessary. At this point, the sutures previously passed through the posterior capsulolabral structures are tied from inferior to superior with 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.) a double-diameter knot pusher (Surgeon s Sixth Finger; Arthrex) to repair the posterior Bankart lesion (Fig 6). These sutures are tied after the anchor has been placed in the reverse Hill-Sachs lesion. If this sequence of anchor placement and knot tying is not followed, the posteriorly directed forces generated by anchor placement into the bone defect may disrupt the posterior soft-tissue repair. Once the posterior capsulolabral tissues have been repaired, the sutures through the MGHL are tied, insetting the MGHL into the reverse Hill-Sachs defect (Fig 7). 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 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.)

3 REVERSE HILL-SACHS LESION e157 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.) 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 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.) 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 posterior capsulolabral complex can result from posterior shoulder instability, and arthroscopic treatment of these lesions has yielded good results 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 patient s symptoms. 2,3 McLaughlin 5 was the first to describe osteochondral defects involving the anterior aspect of the humeral head in patients who had had a posterior shoulder dislocation. A recent magnetic resonance imaging study showed

4 e158 R. E. DUEY AND S. S. BURKHART that after a first-time acute posterior dislocation, 86% of patients had a reverse Hill-Sachs lesion. 15 Another study looking at the epidemiology and outcomes after acute, traumatic posterior dislocations of the shoulder showed that 42% of patients had a large (volume of defect >1.5 cm 3 ) reverse Hill-Sachs lesion and the presence of such a defect carried with it a significantly increased risk of recurrence. 2 As a result, the question arises as to how best to treat these injuries. Traditionally, it was believed that lesions involving less than 20% of the articular surface did well, for the most part, with nonoperative treatment. 16 However, reverse Hill-Sachs lesions tend to involve more of the articular surface compared with their posterior counterparts. 1 Therefore some authors hold that lesions involving as little as 10% of the articular surface may be clinically significant and require direct intervention. 1 McLaughlin 5 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, 9 who performed a transfer of the lesser tuberosity along with the subscapularis insertion into the reverse Hill-Sachs lesion. Hawkins et al. 6 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. Of the 5 who did not have a satisfactory result, 2 had a humeral head defect involving more than 45% of the articular surface and the other 3 underwent surgery more than 1 year after their initial injury. For the 4 patients in whom the subscapularis transfer was successful, the humeral head defect involved between 20% and 45% of the articular surface, and surgery was performed within 6 months of the injury. Four additional patients in this same study underwent transfer of the lesser tuberosity into the anterior humeral head lesion, and all of them did well clinically. Consequently, 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 within 6 months of injury. However, some authors believe that these procedures are best reserved for those patients with defects involving less than approximately one-third of the articular surface. 4,7 These operations can produce undesirable effects, chief of which are a decrease in internal rotation strength and the added difficulty in performing prosthetic procedures in the future, should they be deemed necessary. 7 Krackhardt et al. 10 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. This essentially converts the reverse Hill-Sachs lesion into an extra-articular defect in the same way that remplissage converts a Hill-Sachs lesion into an extraarticular defect, thereby decreasing the likelihood of it engaging the glenoid and causing symptoms. This procedure does provide a less invasive approach when one is dealing with these lesions; however, it can lead to an internal rotation deficit. Furthermore, it alters the direction of force transmission for the subscapularis and decreases its working length. Given the critical role the subscapularis plays in normal glenohumeral kinematics, another viable alternative may be desirable. The novel technique that we describe does not alter the anatomy or the function of the subscapularis. Adherence to important pearls will facilitate the procedure (Table 1). It is similar to the procedure described by Krackhardt et al. 10 in that it fills the defect with adjacent soft tissue so that the reverse Hill-Sachs lesion becomes an extraarticular defect, thereby decreasing the likelihood of the lesion causing clinical symptoms. 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, in contradistinction to the technique of Krackhardt et al., in which the subscapularis is arthroscopically set into the lesion, where internal rotation is affected by the tethering of the subscapularis and decreased excursion of the muscle-tendon unit. 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. We know of no other report in the literature describing the treatment of reverse Hill-Sachs lesions in this manner. Certain anatomic variants of the ligament may not be amenable to this type of procedure. However, we believe that filling the reverse Hill-Sachs bone defect with Table 1. Pearls and Indication 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 glenoid bone loss

5 REVERSE HILL-SACHS LESION e159 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 (Table 1). References 1. Provencher MT, Frank RM, LeClere LE, et al. The Hill- Sachs lesion: Diagnosis, classification, and management. J Am Acad Orthop Surg 2012;20: Robinson CM, Seah M, Akhtar MA. The epidemiology, risk of recurrence, and functional outcome after an acute traumatic posterior dislocation of the shoulder. J Bone Joint Surg Am 2011;93: Kowalsky MS, Levine WN. Traumatic posterior glenohumeral dislocation: Classification, pathoanatomy, diagnosis, and treatment. Orthop Clin North Am 2008;39: , viii. 4. Robinson CM, Aderinto J. Posterior shoulder dislocations and fracture-dislocations. J Bone Joint Surg Am 2005;87: McLaughlin H. Posterior dislocation of the shoulder. J Bone Joint Surg Am 1952;24: Hawkins RJ, Neer CS II, Pianta RM, Mendoza FX. Locked posterior dislocation of the shoulder. J Bone Joint Surg Am 1987;69: Diklic ID, Ganic ZD, Blagojevic ZD, Nho SJ, Romeo AA. Treatment of locked chronic posterior dislocation of the shoulder by reconstruction of the defect in the humeral head with an allograft. J Bone Joint Surg Br 2010;92: Gerber C, Lambert SM. Allograft reconstruction of segmental defects of the humeral head for the treatment of chronic locked posterior dislocation of the shoulder. J Bone Joint Surg Am 1996;78: Hughes M, Neer CS II. Glenohumeral joint replacement and postoperative rehabilitation. Phys Ther 1975;55: Krackhardt T, Schewe B, Albrecht D, Weise K. Arthroscopic fixation of the subscapularis tendon in the reverse Hill-Sachs lesion for traumatic unidirectional posterior dislocation of the shoulder. Arthroscopy 2006;22:227.e1-227.e Burkhart SS, DeBeer JF, Tehrany AM, Parten PM. Quantifying glenoid bone loss arthroscopically in shoulder instability. Arthroscopy 2002;18: Bradley JP, Baker CL III, Kline AJ, Armfield DR, Chhabra A. Arthroscopic capsulolabral reconstruction for posterior instability of the shoulder: A prospective study of 100 shoulders. Am J Sports Med 2006;34: Provencher MT, Bell SJ, Menzel KA, Mologne TS. Arthroscopic treatment of posterior shoulder instability: Results in 33 patients. Am J Sports Med 2005;33: Savoie FH III, Holt MS, Field LD, Ramsey JR. Arthroscopic management of posterior instability: Evolution of technique and results. Arthroscopy 2008;24: Saupe N, White LM, Bleakney R, et al. Acute traumatic posterior shoulder dislocation: MR findings. Radiology 2008;248: Finkelstein JA, Waddell JP, O Driscoll SW, Vincent G. Acute posterior fracture dislocations of the shoulder treated with the Neer modification of the McLaughlin procedure. J Orthop Trauma 1995;9: