Arthroscopic Knotless Modified McLaughlin Procedure for Reverse Hill-Sachs Lesions

Abstract

Posterior shoulder dislocations often are associated with an impression fracture involving the anterior humeral head known as a reverse Hill-Sachs lesion. These injuries can result in significant bone defects that require surgical management to prevent them from engaging the posterior glenoid. We present a modified arthroscopic, knotless McLaughlin procedure (tenodesis of the subscapularis tendon into the bone defect) for the treatment of small-to medium-sized, engaging Hill-Sachs lesions. The knotless fashion aims to eliminate potential problems associated with knot tying, such as knot migration, knot impingement, and chondral abrasion.

Fig 1

Left shoulder: Arthroscopic visualization of the posterior capsulolabral defect seen through anterosuperior portal. Yellow arrow demonstrates area of capsulolabral separation from the posterior glenoid. (G, glenoid; L, labrum.)

Fig 2

Left shoulder: Arthroscopic visualization of the anterior, humeral reverse Hill–Sachs lesion seen through anterosuperior portal. Yellow arrow points to the reverse Hill–Sachs lesion of the anterior humeral head. (G, glenoid; HH, humeral head; rHS, reverse Hill–Sachs lesion.)

Fig 3

Left shoulder: Arthroscopic visualization through the posterior portal showing debridement and preparation of the reverse HilleSachs defect with an oscillating shaver to create a denuded surface for healing. (rHS, reverse Hill–Sachs lesion; SSC, subscapularis tendon.)

Fig 4

Left shoulder: Arthroscopic visualization through the posterior portal showing debridement of the rotator interval and subacoracoid space, with particular attention to clearing the space anterior to the subscapularis tendon to facilitate future suture retrieval. (HH, humeral head; SSC, subscapularis tendon.)

Fig 5

Left shoulder: Arthroscopic visualization through the posterior portal showing the spinal needle inserted percutaneously, passing through the space created anterior to the subscapularis, and then into the subscapularis tendon medial to its attachment point on the lesser tuberosity and in-line with the area of the reverse Hill–Sachs lesion (yellow arrow). (HH, humeral head; SSC, subscapularis tendon.)

Fig 6

Left shoulder: Arthroscopic visualization through the posterior portal showing the polydioxanone suture passed through the spinal needle and retrieved through the anteroinferior portal, where the 6-mm cannula had been placed. (SSC, subscapularis tendon.)

Fig 7

Left shoulder: Arthroscopic visualization through the posterior portal showing the 2 suture limbs retrieved through the anteroinferior portal (yellow arrow) using a FiberTape retriever through the 6-mm cannula to ensure no tissue bridge. (SSC, subscapularis tendon.)

Fig 8

Left shoulder: Arthroscopic visualization through the posterior portal showing the punch used to create a hole to receive the SwiveLock anchor, centered in the reverse Hill–Sachs bony lesion. (rHS, reverse Hill–Sachs lesion; SSC, subscapularis tendon.)

Fig 9

Left shoulder: Arthroscopic visualization through the posterior portal showing the SwiveLock placed into the hole, sutures tensioned to pull the subscapularis tendon into the prepared bony defect. (rHS, reverse Hill–Sachs lesion; SSC, subscapularis tendon.)

Fig 10

Left shoulder: Arthroscopic visualization through the posterior portal showing of the final fixation. The sutures are cut flush and a dynamic arthroscopic examination can be performed to confirm that the reverse Hill–Sachs lesion no longer engages the posterior glenoid rim. (SSC, subscapularis tendon.)