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-
mentous structures, signicant 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 signicant 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 lling the defect with either the
subscapularis tendon or the lesser tuberosity (with its
attached subscapularis tendon) to keep it from en-
gaging 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
subscapularis or lesser tuberosity, to ll 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 conicts of interest in the authorship
and publication of this article.
Received July 18, 2012; accepted January 15, 2013.
Address correspondence to Stephen S. Burkhart, M.D., 150 E Sonterra
Blvd, Ste 300, San Antonio, TX 78259, U.S.A. E-mail: ssburkhart@msn.com
2013 by the Arthroscopy Association of North America
2212-6287/12478/$36.00
http://dx.doi.org/10.1016/j.eats.2013.01.007
Arthroscopy Techniques, Vol 2, No 2 (May), 2013: pp e155-e159
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 exion 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 inow 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 capsulola-
bral injury is identied (Fig 1). The glenoid is carefully
examined and measured by means of a calibrated probe
placed in the posterior cannula to determine whether any
signicant glenoid bone loss has occurred.11 In the
absence of signicant posterior bone loss, arthroscopic
repair of the posterior capsulolabral structures is per-
formed 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-oclock position, if necessary. Sutures are
passed through the torn soft-tissue structures in prepa-
ration 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
e155
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 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.)
a double-diameter knot pusher (Surgeons 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, inset-
ting the MGHL into the reverse Hill-Sachs defect (Fig 7).
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 gle-
nohumeral ligament; S, subscapularis tendon.)
 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 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.

Discussion
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

Fig 6. Left shoulder, anterosuperolateral viewing portal,
showing repair of posterior capsulolabral tissues (PC) to glenoid
(posterior Bankart repair). (G, glenoid; H, humeral head.)
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
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
e158 R. E. DUEY AND S. S. BURKHART
that after a rst-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 cm3) reverse Hill-Sachs lesion and the presence of
such a defect carried with it a signicantly 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 coun-
terparts.1 Therefore some authors hold that lesions
involving as little as 10% of the articular surface may be
clinically signicant and require direct intervention.1
McLaughlin5 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 modied
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 addi-
tional 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 sub-
scapularis 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
difculty in performing prosthetic procedures in the
future, should they be deemed necessary.7
Krackhardt et al.10 described an arthroscopic tech-
nique for addressing reverse Hill-Sachs lesions. It too
involves the subscapularis and is a modication 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 extra-
articular 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 decit. 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 kine-
matics, 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 lls the defect with adjacent soft tissue so
that the reverse Hill-Sachs lesion becomes an extra-
articular 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 Krack-
hardt 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 excur-
sion of the muscle-tendon unit. It is our opinion that the
procedure of Krackhardt et al. could lead to a signicant
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 signicant 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 lling 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 decient, 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 signicant glenoid bone loss
 REVERSE HILL-SACHS LESION
MGHL rather than subscapularis tendon has the distinct
advantage of not altering the muscle-tendon length or
vector direction of the subscapularis, thereby maintain-
ing 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).
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