Posterior shoulder dislocation with associated reverse Hill-Sachs lesion: Treatment options and functional outcome after a 5-year follow up

Abstract

Background
The current study describes several surgical techniques for the treatment of the reverse Hill - Sachs lesion after posterior shoulder dislocation; we also aimed to present long term results followed for a minimum of five years.

Methods
This study is a prospective case series of 17 patients who were treated in our clinic between 2008 and 2011. Patients with a defect size smaller than 25% of the articular surface were treated conservatively. An endoprosthesis of the glenohumeral joint was implanted in patients with a defect size bigger than 40%. All remaining patients were treated by a variety of operative techniques, depending on the quality of the bone and size of the defect.

Results
Twelve of seventeen patients had a defect size of the humeral articular surface between 25% and 40% with a mean age of 39 years. Depending on the defect size these patients were treated with retrograde chondral elevation, antegrade cylindrical graft or a graft of the iliac bone crest with an open approach. All the procedures showed fair results, e.g. the open approach with a graft of the iliac bone crest (2010: Dash 3.89, Constant 90.33, Rowe 86.67; 2015: Dash 2.22, Constant 92.00, Rowe 93.33).

Conclusion
The open approach is not a disadvantage for the functional outcome. The treatment algorithm should involve the superficial size of the defect as well as the depth of the defect and the time interval between the dislocation and the surgical treatment.

Trial registration
223/2012BO2, 02 August 2010.

Full text

R E S E A R C H A R T I C L E Open Access
Posterior shoulder dislocation with
associated reverse Hill-Sachs lesion:
treatment options and functional
outcome after a 5-year follow up
Markus Guehring
1
, Simon Lambert
2
, Ulrich Stoeckle
1
and Patrick Ziegler
1*
Abstract
Background: The current study describes several surgical techniques for the treatment of the reverse Hill - Sachs
lesion after posterior shoulder dislocation; we also aimed to present long term results followed for a minimum of
five years.
Methods: This study is a prospective case series of 17 patients who were treated in our clinic between 2008 and 2011.
Patients with a defect size smaller than 25% of the articular surface were treated conservatively. An endoprosthesis of
the glenohumeral joint was implanted in patients with a defect size bigger than 40%. All remaining patients were
treated by a variety of operative techniques, depending on the quality of the bone and size of the defect.
Results: Twelve of seventeen patients had a defect size of the humeral articular surface between 25% and
40% with a mean age of 39 years. Depending on the defect size these patients were treated with retrograde
chondral elevation, antegrade cylindrical graft or a graft of the iliac bone crest with an open approach. All the procedures
showed fair results, e.g. the open approach with a graft of the iliac bone crest (2010: Dash 3.89, Constant 90.33, Rowe 86.
67; 2015: Dash 2.22, Constant 92.00, Rowe 93.33).
Conclusion: The open approach is not a disadvantage for the functional outcome. The treatment algorithm should
involve the superficial size of the defect as well as the depth of the defect and the time interval between the dislocation
and the surgical treatment.
Trial registration: 223/2012BO2, 02 August 2010.
Keywords: Posterior shoulder dislocation, Defect size, Osteosynthesis, Outcome
Background
Posterior shoulder dislocation is a rare injury, compris-
ing 2% to 5% of all shoulder dislocations [1, 2] and up to
10% in patients with shoulder instability (mostly polar
type II and III according to the Stanmore instability clas-
sification). The spectrum of posterior dislocation ranges
from acute traumatic dislocation to chronic irreducible
dislocations, and in combination with a proximal
humeral fracture [3]. An extreme muscle contraction
(seizures or electric shock), a direct or indirect trauma
that occurs with flexion, adduction and internal rotation
of the affected arm, is pathognomonic for the posterior
shoulder dislocation [4–6].
Cooper first described the typical clinical signs of the
posterior shoulder dislocation: dorsal protrusion of the
humeral head in accordance with a flattened front shoul-
der and prominent coracoid, significantly limited or even
repealed external rotation, or fixed internal rotation and
restricted abduction under 90 degrees [7]. However, in
contrast to the anterior shoulder dislocation, there may
be very little obvious deformity of the shoulder girdle.
Accordingly, the posterior shoulder dislocation is not de-
tected in the primary examination in 60% to 79% of the
* Correspondence: patrick.ziegler333@googlemail.com
1
Department for Traumatology and Reconstructive Surgery, BG Trauma
Center Tübingen, University of Tübingen, Schnarrenbergstr 95, 72076
Tuebingen, Germany
Full list of author information is available at the end of the article
© The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Guehring et al. BMC Musculoskeletal Disorders (2017) 18:442
DOI 10.1186/s12891-017-1808-6
Content courtesy of Springer Nature, terms of use apply. Rights reserved.

cases [1, 2, 8]. Periods of over 10 years between disloca-
tion and diagnosis are described in the literature [4].
A radiological examination in two views is obligatory
(anteroposterior (a-p) and axial; Fig. 1). If pain precludes
an axial x-ray because of limited abduction, a ‘scapular-
Y’view is recommended, even if there is marked pain. In
the a.-p. view the posterior dislocation classically appears
as a ‘light-bulb’but this is not diagnostic and dislocation
is thus sometimes difficult to detect [9]. Moreover, a
careful clinical examination (lack of external rotation in
a patient with a history of a shoulder injury) is
mandatory. Computed tomography (CT) is essential for
evaluating the injury and for preoperative planning
regarding bone defects in the humeral head (Fig. 2). A
magnetic resonance imaging scan (MRI), with contrast,
is useful to diagnose lesions of the labrum and rotator
cuff [1, 2, 4], particularly of the incarcerated tendon of
the long head of biceps in irreducible dislocations [4].
Compared to anterior shoulder dislocations with defects
in the anterior labrum and capsule (that is, soft tissue
lesions), posterior dislocation typically causes bone le-
sions (the anterior humeral head impression fracture,,
otherwise known as the “reverse Hill-Sachs lesion”,
McLaughlin lesion, or “l’encoche de Malgaigne”) [5].
Other injuries such as lesions of the posterior labrum, or
fractures the posterior glenoid rim are described
[10–12]. Treatment depends on the size of the bone
defect, the duration of the dislocated condition, and
the functional demand of the patient [13].
Conservative treatment is possible with a stable situ-
ation after closed reduction and no significant bone defect.
Subsequently, the affected shoulder should be immobi-
lized in internal rotation or neutral position over a short
period of time [6, 14]. Depending on the size, the reverse
Hill-Sachs lesion is a risk factor for re-dislocation and
therefore a surgical treatment is normally recommended
[15]. For the treatment of the bone defect in the region of
Fig. 1 Axial and ap view of posterior shoulder dislocation
Fig. 2 CT scan after posterior shoulder dislocation
Fig. 3 Diagnostic arthroscopy after posterior shoulder dislocation to
detect cartilage defects
Guehring et al. BMC Musculoskeletal Disorders (2017) 18:442 Page 2 of 7
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the humeral head, a variety of surgical procedures are
described in the literature: filling the defect by tendon
transposition of the subscapularis muscle [5], medial
transposition of the lesser tuberosity [16] or allograft [17];
rotational osteotomy [18]; and hemi- or total arthroplasty
[19, 20] are options.
The choice of the surgical technique depends on the
size of the bone defect. With a stable shoulder joint and
a defect of less than 25% of the articular surface, conser-
vative treatment normally shows a satisfactory outcome.
Reconstruction of the anatomical joint surface is recom-
mended for defects between 25% and 40% of the articu-
lar surface. Lesions with greater defects than 40% of the
articular surface should be treated with shoulder
prosthesis [16, 19]. The literature of posterior disloca-
tions of the shoulder largely comprises case reports
or small series, while studies with a significant num-
ber of patients are rare. The aims of the present
study are: to evaluate the anatomical reconstruction
of the articular surface in a homogeneous patient
population; and to evaluate the long-term functional
outcomes in the cohort.
Methods
Between January 2008 and December 2011, 17 patients
were treated with a posterior shoulder dislocation. The
diagnosis was confirmed by using two orthogonal x-rays
of the shoulder joint (anteroposterior (AP) and axial
views). Closed reduction of the dislocation was attempted
immediately under analgesia and sedation. A CT scan, to
evaluate the size of the reverse Hill-Sachs lesion, was
undertaken if closed reduction was not possible using the
method of Cicak et al [21]. Five patients were excluded
from this study. Four patients with defects of less than
25% of the articular surface in whom the joint was stable
after open reduction were treated conservatively. One pa-
tient with a defect greater than 40% of the articular surface
had a total shoulder arthroplasty. The remaining twelve
patients had a reverse Hill-Sachs compression fracture in-
volving 25–40% of the articular surface of the humeral
head following a traumatic posterior shoulder dislocation.
All patients were male with a mean age of 39 years
(range 17–55). The postoperative results were evaluated
after a mean of one and five years following intervention
using the Constant score [22], the Rowe score [23] and
the DASH (disability of the arm, shoulder and hand)
score [24]. The subjective perception of pain was evalu-
ated by a VAS (visual analogue scale). No patient had
multidirectional instability, prior shoulder surgery, or a
neuromuscular disorder.
Diagnostic arthroscopy of the affected shoulder was
attempted in all cases. The depth of the bone defect
and the cartilage of the humeral articular surface
were noted, together with associated injuries of the
labrum and the rotator cuff. If no deep lesions of the
Fig. 4 Arthroscopic retrograde elevation with target device from cruciate ligament surgery
Fig. 5 Open approach for the treatment with an iliac bone crest graft
Guehring et al. BMC Musculoskeletal Disorders (2017) 18:442 Page 3 of 7
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cartilage surface were detected during the diagnostic arth-
roscopy (ICRS classification grade 0–2, Fig. 3) and the time
between the shoulder dislocation and the operative treat-
ment was less than 14 days, we elected to restore the joint
surface by retrograde elevation with arthroscopic assistance
using a target device from the knee ligament surgery (Fig. 4).
Larger cartilage lesions (ICRS classification grade 3 + 4)
were treated during open debridement [25] using a delto-
pectoral approach in all cases (Fig. 5). If the interval be-
tween the accident and operative treatment was less than
14 days the joint surface was reconstructed with antegrade
cortico-cancellous cylindrical grafts. If the interval was
more than 14 days the defect was reconstructed using an
autologous iliac crest fixed by small fragment screws (Fig. 6).
The therapeutic algorithm is shown in Fig. 7.
Statistical analysis
Statistical analysis was performed in SPSS (version 22.0,
SPSS Inc., Chicago, US). The t-test was used to calculate
differences between the one and five year evaluations of
pain and function. Differences in outcome between the
surgical techniques were calculated using the Kruskal-
Wallis variance method.
Results
The cause of the posterior shoulder dislocation was a
high energy trauma in 75% (8 cases). The average length
of in-hospital stay was 7.6 (4-24) days (Table 1).
In five cases with an ICRS score of 0–2 (42%),
arthroscopically-assisted elevation of the articular sur-
face was performed. Four patients had ICRS grade 3 or
higher cartilage lesions, and were treated by antegrade
cortico-cancellous cylindrical grafts. Three patients had
polytrauma and had definitive treatment of the shoulder
more than 14 days after injury using iliac crest cortico-
cancellous graft. There were no postoperative infections,
bleeding or nerve injuries, and no complication after
harvesting the iliac bone graft. There were no re-
dislocations over the period of review.
Fig. 6 Before and after reconstruction with an autologous graft of the iliac crest with small fragment screws
Guehring et al. BMC Musculoskeletal Disorders (2017) 18:442 Page 4 of 7
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A complete minimum follow up of five years was
achieved in all patients. There was an improvement in out-
comes at five years compared with the one year results:
5.28 points in the DASH score, 7.58 points in the Constant
score, 8 points in the ROWE score and 0.86 points on the
VAS on average (Table 2). Patients who were treated with a
corticocancellous graft of the iliac crest had the best results
after one and five years within the small group of patients
(year one: Dash 3.89, Constant 90.33, Rowe 86.67; year five:
Dash 2.22, Constant 92.00, Rowe 93.33). This could be
demonstrated in all evaluated scores as well as in the VAS
(year one, 0.67; year five, 0.5) (Tables 3 and 4).
Discussion
Optimal treatment of the reverse Hill-Sachs lesion after
posterior shoulder dislocation remains controversial.
Due to the rare entity of this injury pattern, high num-
bers of cases in clinical trials are difficult to generate
[17, 26]. The cause of traumatic, non-epileptic posterior
dislocation is usually a direct force applied to the
adducted and extended arm in internal rotation [3] while
the mechanism in epilepsy is considered to be a high
muscular force generating internal rotation in an
adducted arm [27, 28]. Posterior dislocation of the hu-
meral head may cause a posterior-directed shearing of
the labrum or the bony glenoid rim [29, 30] but is pri-
marily characterized by the osteochondral impression
fracture of the ventromedial articular surface of the
humeral head, the so-called reverse Hill-Sachs lesion
[5, 31]. Concomitant neurovascular injuries or lesions
of the rotator cuff occur much rarely after posterior
dislocation [30, 32]. We observed two lesions of the
labrum requiring operative treatment in addition to
the reverse Hill-Sachs lesion in this study. These were
detected during the diagnostic arthroscopy and ac-
cordingly fixed by suture anchors. We did not detect
any rotator cuff injuries.
The treatment of posterior instability with a reverse
Hill-Sachs lesion considers the arc of stability relative to
the arc of rotation of the humeral head with respect to
the glenoid surface. The treatment therefore largely de-
pends on the size of the humeral head defect [33]. The
surgical strategies are either: the optimization of the sur-
face arc of rotation by restoration of the sphericity of the
humeral head (and thereby optimizing the arc of stabil-
ity), or the restriction of motion of the humeral head
relative to the glenoid so that the arc of stability be-
comes equivalent to the more limited arc of rotation.
Various techniques have been described to reconstruct
Fig. 7 Treatment algorithm for posterior shoulder dislocations depending on defect size and timer interval between the trauma and surgery
Table 1 Epidemiological data of the patients included in the study
Criteria Specification Total
Total number of
patients
Reverse Hill-Sachs lesion[n] 12
Age total [y (range)] 39 (17–55)
Gender male [n] 12 100%
female [n] 0 0%
Treatment Arthroscopic reduction and
retrograde elevation [n]
5 42%
Open reduction antegrade
cylindric graft [n]
4 33%
Iliac bone crest 3 25%
Cause of injury High energy trauma [n] 9 75%
Low energy trauma [n] 2 17%
Eplilepsy [n] 1 8%
Table 2 Functional outcome and the VAS after one and five
years showed better results in the five year follow up in all
evaluated scores
Score 2010 2015
DASH 10.49 ± 2.57 5.21 ± 1.37
Constant 81.92 ± 3.10 89.50 ± 2.72
ROWE 72.92 ± 5.56 87.92 ± 3.61
VAS 1.67 ± 0.36 0.81 ± 0.19
Guehring et al. BMC Musculoskeletal Disorders (2017) 18:442 Page 5 of 7
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the joint surface defect by osteochondral allograft [34].
Miniaci and Gish performed osteochondral transplant-
ation using fresh-frozen, size-matched allograft in 18 pa-
tients with a defect greater than 25% with an average
follow-up of 50 months. The allografts were fixed with
Kirschner wires [35]. Outcomes were reasonable with an
average Constant score of 78.5 points. Several complica-
tions such as osteoarthritis, secondary sintering, sublux-
ation and wire migration were noted. In another series,
Diklic et al. recorded an average Constant score of 86.8
points with a follow-up period of 54 months after re-
construction using femoral allograft and fixation with
cannulated screws [36]. Gerber and Lambert showed
an average Constant score of 82 points in a group of
4 patients after reconstruction of the articular surface
by femoral allograft [17]. Krackhart et al. recom-
mended fixing the subscapularis tendon with suture
anchors into the defect [37]. This leads to restriction
of internal rotation [38].
Only patients with a defect size between 25 and 40%
of the joint surface after posterior shoulder dislocation
were included in our study. The patients were reviewed
at a mean of one year and five years after surgery. Irre-
spective of the operative technique used in the present
study, we observed a fair outcome with a mean Constant
score of 81.92 and 89.50 points respectively. Over time,
all of the scores showed an improvement, with low pain
scores, related to exercise, at both time points. The best
outcome for patients at both time-points was observed
after using an autologous iliac crest cortico-cancellous
bone graft. This could result from a lower secondary sin-
tering rate of cortico-cancellous bone graft compared to
retrograde elevation of the articular surface or antegrade
cylindrical osteochondral grafting. These findings have
to be interpreted carefully due to the small number of
cases of this study.
The limiting factor of this study remains the small
number of cases. Nevertheless, we believe the treatment
algorithm shown in Fig. 7 is very useful, since it includes
the extent of cartilage damage and the interval between
the injury and surgical treatment, in addition to the size
of the humeral defect.
Conclusion
This study shows the results and techniques of recon-
structive treatment options for reverse Hill-Sachs lesion
after posterior shoulder dislocation. The best results
were demonstrated in the reconstruction of the joint
surface by autologous iliac crest grafts. The open ap-
proach does not appear to be a disadvantage for the
functional outcome despite the invasiveness. In our
opinion, the treatment algorithm of the reverse Hill
- Sachs lesion should involve the superficial size of
the defect, as well as the depth of the defect and the
time interval between the dislocation and the surgi-
cal treatment.
Abbreviations
CT: Computed tomography; DASH: Disability of the arm, shoulder and hand;
ICRS: International Cartilage Repair Society; MRI: Magnetic resonance imaging;
SD: Standard Deviation; VAS: Visual analogue scale
Acknowledgements
Not applicable
Funding
There is no funding source.
Availability of data and materials
The datasets used and analyzed during the current study are available from
the corresponding author on reasonable request.
Authors’contributions
MG has initiated the study, has made the data collection and interpretation.
PZ has made the statistics, written the manuscript and has analyzed most of
the data. SL and US have helped with analyzing the data and supervised the
development of the study. All authors read and approved the final manuscript.
Ethics approval and consent to participate
Informed written consent was obtained from all individual participants included
in the study. The study was conducted according to the Helsinki Declaration
(Ethical Principles for Medical Research Involving Human Subjects) and
was approved by the University of Tuebingen ethics committee.
Consent for publication
Not Applicable
Competing interests
The authors declare that they have no competing interests.
Publisher’sNote
Springer Nature remains neutral with regard to jurisdictional claims in
published maps and institutional affiliations.
Author details
1
Department for Traumatology and Reconstructive Surgery, BG Trauma
Center Tübingen, University of Tübingen, Schnarrenbergstr 95, 72076
Table 3 Functional outcome and the VAS showed the best results
for patients treated with an iliac bone crest graft in 2015
Score 2015 Retrograde
elevation (n=5)
Antegrade cylindric
graft (n=4)
Iliac bone crest
(n=3)
p
DASH 7.33 ± 2.64 4.79 ± 2.02 2.22 ± 1.21 .39
Constant 89.80 ± 4.66 87.25 ± 5.59 92.00 ± 4.61 .84
ROWE 85.00 ± 7.25 87.50 ± 6.29 93.33 ± 3.33 .89
VAS 0.94 ± 0.30 0.88 ± 0.43 0.50 ± 0.29 .67
Table 4 Functional outcome and the VAS showed the best results
for patients treated with an iliac bone crest graft in 2010
Score 2010 Retrograde
elevation (n=5)
Antegrade cylindric
graft (n=4)
Iliac bone crest
(n=3)
p
DASH 12.17 ± 4.21 13.33 ± 5.28 3.89 ± 0.56 .18
Constant 79.00 ± 3.70 79.25 ± 7.33 90.33 ± 2.33 .31
ROWE 76.00 ± 8.57 58.75 ± 8.00 86.67 ± 8.33 .11
VAS 1.80 ± 0.37 2.25 ± 0.85 0.67 ± 0.33 .21
Guehring et al. BMC Musculoskeletal Disorders (2017) 18:442 Page 6 of 7
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Tuebingen, Germany.
2
Shoulder and Elbow Service, Royal National
Orthopaedic Hospital, Stanmore HA7 4LP, UK.
Received: 2 July 2017 Accepted: 6 November 2017
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