Arthroscopic Reverse Remplissage for Posterior Instability

Abstract

Posterior shoulder dislocation is an unusual injury often associated with electrical shock or seizure. As with anterior instability, patients frequently present with an impaction injury to the anterior aspect of the humeral head known as a "reverse Hill-Sachs lesion." The treatment of this bony defect is controversial, and multiple surgical procedures to fill the defect in an effort to decrease recurrence have been described. Most of the reports have focused on an open approach using variations of lesser tuberosity and subscapularis transfers, bone allograft, and even arthroplasty to assist with persistent instability. We advocate an arthroscopic technique that involves a suture anchor-based distal tenodesis of the subscapularis tendon or a reverse remplissage procedure.

Fig 1

Sagittal and axial views of the shoulder show traditional portal placement for shoulder arthroscopy as well as the reverse Hill-Sachs lesion associated with posterior instability.

Fig 2

Arthroscopic view of the right shoulder in the lateral decubitus position from the posterior portal with a 70° arthroscope visualizing the subscapularis tendon and humeral head.

Fig 3

Arthroscopic view of the right shoulder in the lateral decubitus position from the posterior portal with a 70° arthroscope visualizing the reverse Hill-Sachs lesion.

Fig 4

Arthroscopic view of the right shoulder in the lateral decubitus position from the posterior portal with a 70° arthroscope visualizing the first anchor placement within the reverse Hill-Sachs lesion in preparation for a reverse remplissage procedure.

Fig 5

Arthroscopic view of the right shoulder in the lateral decubitus position from the posterior portal with a 70° arthroscope visualizing the second anchor placement within the reverse Hill-Sachs lesion in preparation for a reverse remplissage procedure.

Fig 6

Arthroscopic view of the right shoulder in the lateral decubitus position from the posterior portal with a 70° arthroscope visualizing suture retrieval in a retrograde fashion through the subscapularis tendon in preparation for a reverse remplissage procedure.

Fig 7

Arthroscopic view of the right shoulder in the lateral decubitus position from the posterior portal with a 70° arthroscope visualizing sutures passed through the subscapularis tendon in preparation for a reverse remplissage procedure.

Fig 8

Sagittal and axial views of the shoulder show placement of the double-loaded suture anchors into the reverse Hill-Sachs lesion with passage of the sutures through the subscapularis tendon.

Fig 9

Arthroscopic view of the right shoulder in the lateral decubitus position from the posterior portal with a 70° arthroscope visualizing sutures tied on the anterior aspect of the subscapularis tendon after completion of a reverse remplissage procedure.

Fig 10

Sagittal and axial views of the shoulder show completion of the reverse remplissage procedure with the sutures tied down to fill the reverse Hill-Sachs with the subscapularis tendon.