Favorable Outcomes After Arthroscopic Posterior Bankart Repair for Traumatic Posterior Shoulder Instability in Collision Athletes

Background: Humeral and glenoid bone loss is commonly seen in patients with posterior shoulder dislocation, like anterior dislocation. However, which reverse Hill-Sachs lesion should be treated has not yet been clarified. Purpose: To (1) determine the contact area of the glenoid on the humeral head with the arm in various degrees of flexion while keeping maximum internal rotation and horizontal flexion and (2) clarify the surgical indication of a reverse Hill-Sachs lesion. Study Design: Descriptive laboratory study. Method: The authors examined 20 shoulders of 10 healthy volunteers. The magnetic resonance imaging scans were taken in 3 arm positions (0°, 45°, and 90° of flexion) while keeping maximum internal rotation and horizontal flexion. All the scans were reconstructed using 3-dimensional visualization analysis software. The 3-dimensional surface bone models of the proximal humerus and glenoid were reconstructed. The contact area between the humeral head and the glenoid was measured. Results: With an increase in flexion, the glenoid contact area shifted, creating a zone of contact (reverse glenoid track). The distances from the medial margin of the footprint of the rotator cuff tendon to the medial margin of the glenoid were 16.7 ± 3.2 mm (0° of flexion), 18.0 ± 3.7 mm (45° of flexion), and 19.0 ± 3.2 mm (90° of flexion), which were equivalent to 80% ± 15%, 87% ± 14%, and 92% ± 14% of the glenoid width, respectively. The distances from the medial margin of the articular cartilage edge were 11.9 ± 2.2 mm, 10.1 ± 1.4 mm, and 12.1 ± 1.9 mm, which were equivalent to 59% ± 12%, 50% ± 8%, and 59% ± 10% of the glenoid width, respectively. Conclusion: With an increase in flexion, the glenoid contact area shifted, creating a zone of contact (reverse glenoid track). The width of the reverse glenoid track was 50% to 59% of the glenoid width. A reverse Hill-Sachs lesion has a risk of engagement if it extends medially over the medial margin of the reverse glenoid track. Such reverse Hill-Sachs lesion is needed to treated.

Shoulder instability events can often result in humeral head and glenoid bone defects. Lesion size, patient age, bone quality, and cause of instability affect management. Surgical options are numerous, depending on severity and complexity. In addressing posterior humeral head lesions, remplissage and humeral head allograft have been reliably described, but the approach to addressing these often significant lesions has been variably illustrated. As recently described by Yazdi et al in a systematic review in 2022, osteochondral allografts for Hill-Sachs or reverse Hill-Sachs lesions showed good patient-reported outcomes. This is in agreement with other studies in the literature, including another systematic review by Saltzman et al in 2015 that reported good outcomes after humeral head allografts for humeral head defects, as well as another study by Gerber et al that reported similar promising outcomes. Humeral head allograft should be considered in the setting of instability refractory to nonoperative measures in younger patients with large Hill-Sachs and reverse Hill-Sachs lesions, particularly in those that are engaging with the glenoid through range of motion and are over 30% of the depth of the humeral head. Following an examination under anesthesia and diagnostic arthroscopy, a deltopectoral incision was made from the coracoid to the deltoid insertion. The subscapularis tendon and anterior capsule were both carefully released from their humeral insertion and tagged. Following external rotation of ~180°, the Hill-Sachs defect was visualized, debrided, and molded with bone wax. After an osteochondral humeral head allograft was sized and sculpted on the back table, it was positioned and fixated with provisional Kirscher wires followed by 4-0 cannulated, headless compression screws. Finally, an open Bankart repair was completed, followed by a capsular closure and subscapularis repair. Humeral head allografts have demonstrated short-term improvements in motion and patient-reported outcome measures and can be used for posterior Hill-Sachs lesions, fully accessible through an anterior approach when anterior instability procedures are also warranted. Management of large Hill-Sachs and reverse Hill-Sachs lesions with a humeral head allograft using an anterior open approach is a viable option for patients with refractory instability. The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

Hill-Sachs lesions and reverse Hill-Sachs lesions (HSLs) are common in patients with shoulder instability, and addressing these lesions effectively is crucial for patient outcomes. Our study investigates a novel technique using talus osteochondral allografts (TOA) for the treatment of these lesions. The TOA offers several advantages, including congruency to the humeral head, dense bone structure, and a reduced risk of contamination compared with other allografts. We present 3 patients with large engaging Hill-Sachs lesions or reverse HSLs, who were treated using a TOA, highlighting its feasibility and positive clinical outcomes.

Reverse Hill–Sachs lesions pose a complex challenge in the acute management of posterior shoulder dislocations, often resulting in joint incongruity and compromised function. This article describes a surgical technique for the anatomical reduction and fixation of humeral head impaction injuries, aiming to restore the native sphericity of the articular surface and optimize joint stability. The proposed technique enables the precise realignment of the humeral cartilage and subchondral bone, thereby minimizing residual deformity and preserving the biomechanical integrity of the glenohumeral joint. When indicated, this approach offers a valuable alternative to traditional reconstructive procedures, potentially improving functional outcomes by preventing chronic instability and degenerative changes. The rationale, surgical steps, and key technical considerations are outlined, highlighting the advantages of early intervention in mitigating long-term sequelae.Supplementary InformationThe online version contains supplementary material available at 10.1007/s00590-025-04499-8.

Posterior Stabilization and Reverse Hill-Sachs Remplissage Using Linked Knotless Anchors

Objectives: Posterior shoulder instability is an uncommon injury, accounting for 2-12% of shoulder instability patients. Magnetic resonance imaging (MRI) is often utilized to non-invasively evaluate the joint for labral, cartilage, and bony injury. MR arthrography (MRA) may improve the evaluation of these intra-articular structures, but requires additional cost, time, and an invasive procedure. Moreover, its benefits for patients with posterior shoulder instability are unclear. Accurate imaging is critical in patients undergoing surgery because certain findings may influence the surgical approach. Thus, the purpose of this study is to compare the accuracy of MRA and non-enhanced MRI in detecting labral, chondral, and osseous lesions in patients with posterior shoulder instability. Methods: There were 291 patients with unilateral posterior shoulder instability who had preoperative MRA or MRI between 2006 and 2021 in the MOON database. Images were reviewed by a fellowship-trained musculoskeletal radiologist with 10+ years of experience and an orthopaedic surgeon. Evaluators were blinded to age, gender, medical history, MR report, and arthroscopic findings, but were aware of the patient's history of posterior shoulder instability. Examinations were evaluated for presence, location, morphology, and length of glenoid labral tears. Tear length and localization were noted using a standard clock face. The presence and size of humeral/glenoid osseous and cartilage lesions was also noted.Intraoperative findings from arthroscopic evaluation were documented by the surgeon using a standard response questionnaire. Diagnostic performance of standard MRA and MRI were evaluated using sensitivity and specificity with arthroscopic evaluation as the gold-standard. Chi-squared or Fisher’s exact tests were used to compare the sensitivities and specificities of MRA and MRI. Significance was defined as P < 0.05. Results: 200 patients (69%) had MRA, while 91 patients had non-contrast MRIs of the shoulder. On imaging evaluation, 273 (94%) patients had labral tears with a mean tear size of 156º. 39 (13%) patients had humeral cartilage lesions, whereas 40 (14%) patients had glenoid cartilage lesions. 34 (12%) patients had glenoid bone loss greater than 5%. The mean glenoid bone loss was 12% (range, 5% - 26%). A reverse Hill-Sachs lesion was present in 35 (12%) patients. 16 (6%) patients had bipolar bone loss. The sensitivity for detection of labral tears was high for both MRA (0.95) and standard MRI (0.98) (Tables 1 and 2), though the specificity was low for both modalities (0.25 and 0.40, respectively). There was no difference in the sensitivities or specificities of the two imaging modalities in the detection of labral tears. MRA had a lower sensitivity than MRI in the detection of glenoid cartilage lesions (0.31 vs 0.88, p < 0.001), but no difference was observed for specificity. There was no difference in the sensitivities and specificities of MRA and MRI for humeral cartilage lesions (p = 0.354).MRA had a higher sensitivity than MRI in assessing glenoid bone loss (0.78 vs 0.50, p < 0.001), though there was no difference in specificity. There was no difference between imaging modalities in the evaluation of humeral bone loss (p = 1.000). Conclusions: In this multicenter study, MRA was the most commonly utilized preoperative advanced imaging study for patients with posterior shoulder instability. MRA had a higher sensitivity in detecting glenoid bone loss but lower sensitivity in detecting glenoid cartilage lesions compared to standard non-contrast MRI. There was no difference in diagnostic performance between MRA and MRI in the diagnosis of labral tears and humeral chondral and osseous lesions. MRA may provide an advantage over standard MRI in the evaluation of glenoid bone loss, which can influence the treatment plan for patients undergoing surgical management of posterior shoulder instability.

Posterior shoulder instability is an increasingly recognized phenomenon and comprises approximately 5% of all shoulder instability cases. Posterior shoulder instability presents a complex clinical challenge, particularly when associated with bone loss. Bone loss may be present in up to 25% of patients with posterior shoulder instability. Understanding its etiology, diagnosis, and treatment options is crucial for optimal patient outcomes. Young athletic individuals, especially football linemen and throwing athletes, are commonly affected, with symptoms ranging from insidious onset pain to noticeable changes in athletic performance. History, physical examination, and imaging, including radiographs and advanced three-dimensional imaging, play pivotal roles in diagnosis, with specific tests like the Jerk, Kim, and load and shift tests aiding in provocation. Posterior glenoid bone loss (pGBL), whether dysplastic, attritional, or acute, significantly impacts management decisions. When pGBL exceeds critical thresholds, soft tissue repair alone may be insufficient, necessitating glenoid reconstruction with bone block procedures. Both iliac crest autograft and distal tibial allograft (DTA) offer viable options, with considerations including donor site morbidity and graft integration. Surgical techniques for reverse Hill-Sachs lesions vary from subscapularis transfers to arthroscopic balloon osteoplasty, each aiming to restore native anatomy and prevent engagement. Bipolar bone loss, involving both glenoid and humeral head defects, presents additional challenges and may require combined soft tissue and bony procedures. Quantifying bone loss and understanding its implications are essential for surgical planning. While various techniques show promise, further research is needed to elucidate their long-term outcomes and refine treatment algorithms for posterior shoulder instability with bone loss.

Batter's shoulder is characterized by posterior shoulder instability in the lead (front) shoulder of a batting athlete. This most commonly occurs as a discrete event, particularly a swing and miss at an outside pitch, which leads to an episode of shoulder subluxation. A thorough history and physical examination is key to diagnosis, with patients feeling pain and instability of the lead shoulder when attempting the baseball swing or during pushing-type activities, as well as positive posterior labral signs in tests such as the Kim, jerk, and modified dynamic labral shear tests. Magnetic resonance imaging can confirm the diagnosis of posterior labral tear and may show concomitant pathologies such as a reverse Hill-Sachs lesion. Nonsurgical treatment is directed at rotator cuff and scapular strengthening; however, arthroscopic posterior labral repair is often required for definitive stabilization. Overall, this is a relatively rare diagnosis, but outcomes of surgical repair are favorable with high satisfaction and rates of return to competition.

Shoulder dislocation is undoubtedly one of the most common injuries in traumatology. Posterior dislocation of the shoulder is regarded as comparatively rare compared to anterior dislocation, whilst it is strikingly extraordinary for this type of injury to be accompanied by a concomitant fracture. Accurate diagnosis and appropriate treatment can be considerably demanding, while being vitally important in this exceedingly rare condition. These injuries are broadly considered to be under-reported in the existing literature, especially among high-demand athletes. We present a rare case of a high-demand athlete sustaining a traumatic locked posterior shoulder dislocation with an accompanying fracture treated in our Institution. A detailed clinical examination and plain radiography revealed the peculiar condition, and a CT scan was subsequently performed for more thorough evaluation of the injury. The patient underwent surgery on the day following admission for repair of the extensive shoulder damage, and a deltopectoral approach was utilized. Reduction of the metaphyseal fracture and the dislocation was accomplished with gentle manipulations, and stabilization was obtained with an anatomic plate. A modified McLaughlin procedure was carried out to address the reverse Hill-Sachs lesion. The postoperative period was uneventful, followed by a painstaking physical rehabilitation program, and the patient returned successfully to his sporting activities 6 months postoperatively. By presenting this thought-provoking case, we stress the challenging nature of these immensely infrequent injuries while also highlighting the requirement for more sensitive factor-specific studies regarding their optimal treatment.

BackgroundIn patients with traumatic posterior shoulder instability, little is known about the precise location and size of the reverse Hill-Sachs lesion. MethodsForty-nine shoulders of 47 patients with traumatic posterior instability were included in this study based on the following inclusion criteria: 1) a primary or recurrent traumatic posterior shoulder dislocation, and 2) the initial event was caused by trauma. Patients were excluded if they had: 1) no history of trauma, 2) prior shoulder surgery, 3) no CT examination, or 4) seizure cases. Three-dimensional images of the humerus reconstructed from CT images were reviewed using an image analysis software. The location and size of the reverse Hill-Sachs lesion were measured and described on a clock face on the humeral head. ResultsThe reverse Hill-Sachs lesion was observed in 25 of 49 shoulders (51%). The reverse Hill-Sachs lesions were located between 1:37 and 2:48. The depth of the reverse Hill-Sachs lesion (mean ± SD) was 5.8 ± 2.2 mm. The extent of the reverse Hill-Sachs lesion was 35° ± 12°. The average orientation of the reverse Hill-Sachs lesion, represented by an angle measured from the 12 o'clock position, was 64° ± 12° and pointing towards 2:09 on a clock face. Length and width of reverse Hill-Sachs lesions were 9.7 ± 4.7 mm, 11.1 ± 3.6 mm, respectively. ConclusionThe reverse Hill-Sachs lesion was a semicircular compression fracture located on the anteromedial aspect of the humeral head. Compared with shoulders with anterior shoulder instability, the humeral defect was smaller and located more inferiorly in shoulders with posterior instability.

(1) Background: The aim of this study is to describe all of the possible surgical procedures that intend to treat the McLaughlin lesion (or Reverse Hill-Sachs) in posterior shoulder dislocation. (2) Methods: Google Scholar, Pubmed, and Embase were used as databases in our research. Studies reporting the results of posterior shoulder dislocations surgically treated with procedures addressing the humeral lesion were evaluated. The studies reporting results after fracture-dislocation and multidirectional instability were excluded. (3) Results: A total of 16 studies were included in our review for a total of 207 shoulders with a mean age of 41.7 years that were evaluated at a mean of 62.1 months. The Modified McLaughlin procedure and the Graft procedures were the most commonly performed. No statistically significant difference was found between the two at the evaluation of the clinical score. (4) Conclusions: Our review highlights the importance of a correct diagnosis and an accurate surgical treatment choice based on the surgeon's experience and on the patients' characteristics.

Arthroscopic Subdeltoid Humeroplasty in the Beach-Chair Position for Reverse Hill-Sachs Lesions

Posterior shoulder dislocation with a reverse Hill-Sachs lesion is a rare and complex injury, requiring specialized treatment due to the difficulty in diagnosis, reduction, and addressing both sides of the pathology to reduce the potential for recurrent dislocation. To evaluate the clinical and functional outcomes of closed reduction and arthroscopic McLaughlin procedure with posterior labral repair in patients with neglected locked posterior shoulder dislocation for less than 12 weeks. A prospective study was conducted at university hospitals, managing 15 patients with neglected locked posterior shoulder dislocation for less than 12 weeks and concomitant engaging reverse Hill-Sachs lesions of less than 40% of the humeral articular surface. They were treated with closed reduction and arthroscopic McLaughlin procedure with posterior labral repair. Patients' assessments included shoulder range of motion, pain levels using the visual analog scale (VAS) score, and functional outcome using the Oxford instability score and the University of California Los Angeles Shoulder Scale (UCLA) with at least 2years of postoperative follow-up. All 15 patients reported no recurrent dislocation and restored shoulder motion at the final follow-up. External rotation significantly improved from 0° to a mean of 65° in adduction, at 90° of abduction, the respective measurement was 85° (p<0.01). Active forward flexion increased from 35° to 145° (p<0.01). UCLA and Oxford instability scores Showed marked improvement (p<0.01). Closed reduction and arthroscopic McLaughlin procedure with posterior labral repair is a safe and effective way for managing patients with locked neglected posterior shoulder dislocations that have been neglected for less than 12 weeks with engaging reverse Hill-Sachs lesion defect, less than 40% of the humeral head.

Various surgical treatments have been described for the treatment of reverse Hill-Sachs lesions (rHSls) sized between 20% and 50% in the case of posterior shoulder dislocation. The aim of this systematic review is to report the clinical and radiological outcomes of subscapularis or lesser tuberosity transfer (McLaughlin and modified procedures) compared to bone or osteochondral autograft or allograft. A systematic review was performed on five medical databases up to December 2022. The inclusion criteria were clinical studies of all levels of evidence describing clinical or radiological outcomes of either procedure. The assessment of the quality of evidence was performed with the Modified Coleman Score. A total of 14 studies (five prospective and nine retrospective) were included. A total of 153 patients (155 shoulders, 78.4% male) with a mean age of 37.2 (22-79) years were reviewed at an average follow-up of 53.1 (7.1-294) months. No relevant difference was found for the clinical scores, range of motion, complicationsand redislocation rate between the two treatments. Radiological osteoarthritis (OA) was reported in 11% (10/87) in the McLaughlin group and in 21% (16/73) in the humeral reconstruction group. McLaughlin and anatomic humeral reconstruction lead to similar satisfactory clinical results and a low redislocation rate in the treatment of rHSls. Anatomic humeral reconstruction seems associated with an increased risk of OA progression. Level IV.

All-Arthroscopic Management of Locked Posterior Shoulder Dislocation: Reduction Under Direct Visualization and Treatment of Intra-articular Pathologies

The posterior shoulder dislocation is very uncommon scenario with incidence ranging from 3% - 5% of all different types shoulder dislocations and Locked posterior fracture dislocation of shoulder can be missed due to improper radiological investigations though patient have pain and difficulty in range of movements. The modified McLaughlin procedure in which both the tendon of Subscapularis along with Lesser tuberosity bone chunk were displaced and transferred into the Reverse Hill-Sachs lesion for stabilization.The procedure is aimed to achieve a stable Gleno-humeral joint as well as early and full functional recovery in cases of an acute posterior locked fracture-dislocation of the shoulder. Here, we discuss a posterior locked fracture dislocation which has been missed initially at a peripheral institute even though patient have pain and restricted range of movements. The patient was investigated thoroughly. The surgical note and physiotherapy protocol have been discussed in detail in the case report where the patient returned to pre-injury status in 3 months post-surgery.

Posterior glenohumeral instability is an increasingly common and challenging orthopaedic problem. While an arthroscopic soft tissue stabilization procedure (i.e., reverse Bankart repair) is effective in treating most cases of posterior instability, this procedure may be inadequate in shoulders with critical posterior glenoid bone loss (GBL), or in cases of an engaging reverse Hill-Sachs lesion. Thus, the purpose of the present manuscript was to report contemporary surgical approaches, techniques, and outcomes for the open treatment of glenoid or humeral head bone loss in posterior instability to help guide clinical decision making. Open osteoarticular augmentation procedures have emerged as a popular option to treat posterior bone loss, with bony auto- and allografts utilized from a variety of donor sites including iliac crest, scapular spine, acromion, distal clavicle, and distal tibia. The combination of glenoid retroversion and bone loss can be addressed with a posterior glenoid opening wedge osteotomy. Bipolar bone loss may be treated with a combination of the aforementioned techniques, in addition to a reverse remplissage, a modified McLaughlin procedure, or various arthroplasty-related options. Although short and mid-term outcomes are dependable, studies reporting long-term outcomes are sparse. Moreover, there is no current consensus regarding the most effective treatment of posterior shoulder instability in the setting of bone loss, and open surgical techniques continue to evolve. Further research is necessary to determine long-term effectiveness of these surgical options.

Posterior shoulder instability (PSI) accounts for 2% to 10% of all shoulder instability, with recurrent posterior subluxation being the most common type. One of the most important risk factors is the presence of an anterior humeral notch (so-called reverse Hill-Sachs lesion), and the most common lesion in PSI is a posterior labral lesion. When conservative treatment fails, surgery is recommended to provide long-term stability, manage pain, and enable a return to previous activity levels. Most posterior labral tears are treated by an arthroscopic posterior Bankart procedure. Visualization of the posterior aspect of the glenohumeral joint is technically challenging in this procedure. The instrumental portal is also a matter of concern because there is no rotator interval posteriorly for cannula placement. The purpose of this article is to propose a technique using a secondary posterolateral Wilmington instrumental portal to perform easy and reproducible placement of the posterior suture anchor at a 45° angle to the glenoid rim. We recommend implementing this technique in patients with painful PSI or with a type B2 lesion according to the Moroder classification.

BackgroundIn cases with injuries to the shoulder region, the combination of acromioclavicular joint dislocation, reverse Hill–Sachs lesion, and proximal humeral fracture is a very rare condition.Case presentationThis study described a 38-year-old male Persian patient with simultaneous acromioclavicular joint dislocation, proximal humeral fracture, and reverse Hill–Sachs lesion due to motor vehicle crash injury who underwent arthroscopic acromioclavicular joint fixation using tight rope technique. In the 7-month follow-up period following the surgical fixation, range of motion was approximately normal. Reduction and hardware were intact, no dislocation or apprehension to dislocation was observed. Patient only had minor shoulder pain at the end of range of motion and a dull pain on the site of incision over the clavicle in deep touch. Our findings showed acceptable arthroscopic outcomes in the management of such complex case.ConclusionOur experience on this case showed acceptable outcomes of the arthroscopic treatment of the acromioclavicular joint dislocation in the management of such a complex case with associated injuries to the shoulder region.