Posterior Approach to Humeral Head for Allograft Reconstruction of Hill-Sachs Lesions

Anterior glenohumeral instability is common in athletes and is often associated with an impaction fracture of the posterolateral humeral head, known as a Hill-Sachs lesion. As humeral bone loss increases, these lesions become more likely to engage anteriorly and require surgical intervention. With greater degrees of anterior glenoid bone loss, smaller Hill-Sachs lesions can be more clinically relevant, which can necessitate treatment of the posterior humerus in addition to addressing the anterior glenoid.

Traditional anterior open approaches to Hill-Sachs lesions require detaching the subscapularis and dislocating the shoulder for access, which compromises anterior shoulder stabilizers and is limited by arthroscopy.

This open posterior approach to the humeral head was previously described with a modified deltoid split. Beginning 1.5 cm medial and inferior to the posterolateral acromion, a 5-cm incision is made in line with the posterior deltoid fibers. Electrocautery is used to maintain hemostasis, and the deltoid fascia is split, carefully avoiding the axillary nerve and posterior humeral circumflex artery. Exposure of the infraspinatus and teres minor fascia is obtained with retractors. The fascia is split in line with the interval between the infraspinatus and teres minor, and the tissue plane between the posterior rotator cuff and posterior capsule is bluntly developed. Exposure of the capsule is obtained with placement of another retractor between the 2 muscles. The Hill-Sachs lesion is palpated, and a vertical capsulotomy overlying the defect is performed to visualize the lesion in preparation for humeral head allograft reconstruction.

An open posterior approach to the humerus allows for complete visualization of the Hill-Sachs lesion, facilitating allograft reconstruction while preserving the subscapularis anteriorly and without the need for surgical dislocation of the shoulder.

A previous study has demonstrated that the described approach exposes 100% of the Hill-Sachs lesion, with the benefits of subscapularis preservation, elimination of the need for shoulder dislocation or extreme external rotation, and a perpendicular approach for instrumenting the defect. The humeral head blood supply is also preserved, with no interaction anteriorly with the anterior humeral circumflex artery, and the posterior humeral circumflex artery is kept out of the dissection field.

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