The dual subscapularis procedure: a modified Hawkins’ technique for neglected posterior fracture/dislocation of the shoulder

  • Mohamed S. Arafa
  • Ahmed AbdelbadieEmail author
Original Article • SHOULDER - FRACTURES



Posterior fracture/dislocation of the shoulder is a rare injury that is frequently missed on initial assessment. It is frequently associated with reverse Hill–Sachs impression fracture. Several orthopaedics procedures have been described on the literature for reconstructable reverse Hill–Sachs lesion. The McLaughlin’s procedure and its modifications, anatomic bone grafting procedures, rotational osteotomies, and the remplissage technique were reported by many authors. We advocated a new “dual subscapularis procedure” that consists of the Hawkins lesser tuberosity transfer with addition of filling the remainder of the defect with a part of subscapularis tendon.

Materials and methods

In the period between January 2013 to December 2017, 12 patients (13 shoulders) suffering from a delayed managed posterior fracture dislocation were managed. Our inclusion criteria were adult patients less than 60 years presented with reverse Hill–Sachs impression defects from 20 to 50% with or without fractures. For all patients, the dual subscapularis procedure was done. UCLA score was used for postoperative functional assessment.


After a minimum follow-up of 6 months, the results of UCLA score were excellent/good in eight patients and fair/poor in five patients. All patients were found stable after open reduction ± internal fixation with no reported complications. There was a significant correlation of the UCLA score and non-abuse or lower doses of tramadol and the shorter interval between trauma and procedure. Twelve patients were satisfied after the operation.


Reconstructing the reverse Hill–Sachs defect with the dual subscapularis technique provides adequate stability, pain relief, and function in patients with locked chronic posterior shoulder fracture/dislocation. The used technique has the merit of versatility with different fracture patterns, improved fixation of the tendon and increasing the tendon’s footprint that ensures extra-articular location of the defect.

Level of evidence



Reverse Hill–Sachs Posterior shoulder dislocation Dual subscapularis procedure McLaughlin’s technique Hawkins’ technique Tramadol 


Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interests.

Ethical approval

The study was approved by our local ethical committee and was in accordance with the ethical standards of the institutional and national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.

Informed consent

All patients signed an informed consent after clear explanation of the surgical procedure.


  1. 1.
    Robinson CM, Aderinto J (2005) Posterior shoulder dislocations and fracture-dislocations. J Bone Joint Surg Am 87:639–650CrossRefGoogle Scholar
  2. 2.
    Gosens T, Poels PJ, Rondhuis JJ (2000) Posterior dislocation fractures of the shoulder in seizure disorders—two case reports and a review of literature. Seizure-Eur J Epilepsy 9(6):446–448CrossRefGoogle Scholar
  3. 3.
    Kokkalis ZT, Mavrogenis AF, Ballas EG, Papagelopoulos PJ, Zoubos AB (2012) Bilateral neglected posterior fracture–dislocation of the shoulders. Orthopedics 35(10):e1537–e1541CrossRefGoogle Scholar
  4. 4.
    Bock P, Kluger R, Hintermann B (2007) Anatomical reconstruction for reverse Hill–Sachs lesions after posterior locked shoulder dislocation fracture: a case series of six patients. Arch Orthop Trauma Surg 127(7):543–548CrossRefGoogle Scholar
  5. 5.
    Robinson CM, Akhtar A, Mitchell M, Beavis C (2007) Complex posterior fracture-dislocation of the shoulder. Epidemiology, injury patterns, and results of operative treatment. J Bone Joint Surg Am 89(7):1454–1466Google Scholar
  6. 6.
    Cicak N (2004) Posterior dislocation of the shoulder. J Bone Joint Surg Br 86(3):324–332CrossRefGoogle Scholar
  7. 7.
    Wilson JC, McKeever FM (1949) Traumatic posterior (retroglenoid) dislocation of the humerus. JBJS 31(1):160–180CrossRefGoogle Scholar
  8. 8.
    WHO Expert Committee on Drug Dependence (2014) 36th meeting Agenda item 6.1Google Scholar
  9. 9.
    Fawzi MM (2010) Some medicolegal aspects concerning tramadol abuse: the new Middle East youth plague 2010. An Egyptian overview. Egypt J Forensic Sci 1(2):99–102CrossRefGoogle Scholar
  10. 10.
    Neer CS (1970) Displaced proximal humerus fractures. Part I: classification and evaluation. J Bone Joint Surg Am 52-A:1077–1089CrossRefGoogle Scholar
  11. 11.
    McLaughlin HL (1952) Posterior dislocation of the shoulder. J Bone Joint Surg Am 24(3):584–590CrossRefGoogle Scholar
  12. 12.
    Hawkins RJ, Neer CS 2nd, Pianta RM, Mendoza FX (1987) Locked posterior dislocation of the shoulder. J Bone Joint Surg Am 69(1):9–18CrossRefGoogle Scholar
  13. 13.
    Kokkalis ZT, Mavrogenis AF, Ballas EG, Papanastasiou J, Papagelopoulos PJ (2013) Modified McLaughlin technique for neglected locked posterior dislocation of the shoulder. Orthopedics 36(7):e912–e916CrossRefGoogle Scholar
  14. 14.
    Charalambous CP, Gullett TK, Ravenscroft MJ (2009) A modification of the McLaughlin procedure for persistent posterior shoulder instability. Arch Orthop Trauma Surg 129(6):753–755CrossRefGoogle Scholar
  15. 15.
    Martetschläger F, Padalecki JR, Millett PJ (2013) Modified arthroscopic McLaughlin procedure for treatment of posterior instability of the shoulder with an associated reverse Hill–Sachs lesion. Knee Surg Sports Traumatol Arthrosc 21(7):1642–1646CrossRefGoogle Scholar
  16. 16.
    Amstutz HC, Sew AH, Clarke IC (1981) UCLA anatomic total shoulder arthroplasty. Clin Orthop Relat Res 155:7–20Google Scholar
  17. 17.
    Nutton RW, Mcbirnie JM, Phillips C (1997) Treatment of chronic rotator-cuff impingement by arthroscopic subacromial decompression. J Bone Joint Surg Br 79(1):73–76CrossRefGoogle Scholar
  18. 18.
    Jacquot F, Costil V, Werther JR, Atchabahian A, Sautet A, Feron JM, Doursounian L (2013) Balloon treatment of posterior shoulder dislocation with reverse Hill–Sachs injury: description of a new technique. Int Orthop 37(7):1291–1295CrossRefGoogle Scholar
  19. 19.
    Zafra M, Uceda P, Ruiz-Bonilla C (2019) Subtraction osteotomy of the humeral head in posterior shoulder dislocation: a case report. Eur J Orthop Surg Traumatol. Google Scholar
  20. 20.
    Shams A, El-Sayed M, Gamal O, ElSawy M, Azzam W (2016) Modified technique for reconstructing reverse Hill–Sachs lesion in locked chronic posterior shoulder dislocation. Eur J Orthop Surg Traumatol 26(8):843–849CrossRefGoogle Scholar
  21. 21.
    Kokkalis ZT, Iliopoulos ID, Antoniou G, Antoniadou T, Mavrogenis AF, Panagiotopoulos E (2017) Posterior shoulder fracture–dislocation: an update with treatment algorithm. Eur J Orthop Surg Traumatol 27(3):285–294CrossRefGoogle Scholar
  22. 22.
    Jariwala A, Haines S, McLeod G (2008) “Locked” posterior dislocation of the shoulder with communition of the lesser tuberosity: a stabilisation technique. Eur J Orthop Surg Traumatol 18(5):377–379CrossRefGoogle Scholar
  23. 23.
    Gerber C, Lambert SM (1996) Allograft reconstruction of segmental defects of the humeral head for the treatment of chronic locked posterior dislocation of the shoulder. JBJS 78(3):376–382CrossRefGoogle Scholar
  24. 24.
    Diklic ID, Ganic ZD, Blagojevic ZD, Nho SJ, Romeo AA (2010) Treatment of locked chronic posterior dislocation of the shoulder by reconstruction of the defect in the humeral head with an allograft. J Bone Joint Surg Br 92(1):71–76CrossRefGoogle Scholar
  25. 25.
    Dubousset J (1967) Posterior dislocations of the shoulder. Revue de chirurgie orthopedique et reparatrice de l’appareil moteur 53(1):65–85Google Scholar
  26. 26.
    Chaudhuri GK, Sengupta A, Saha AK (1974) Rotation osteotomy of the shaft of the humerus for recurrent dislocation of the shoulder: anterior and posterior. Acta Orthop Scand 45(1–4):193–198CrossRefGoogle Scholar
  27. 27.
    Keppler P, Holz U, Thielemann FW, Meinig R (1994) Locked posterior dislocation of the shoulder: treatment using rotational osteotomy of the humerus. J Orthop Trauma 8(4):286–292CrossRefGoogle Scholar
  28. 28.
    Magu NK, Gogna P, Singh A, Rohilla R (2016) Check-rein technique for management of neglected locked posterior shoulder dislocations: evaluation of mid-term outcome of a novel technique. Malays Orthop J 10(3):3CrossRefGoogle Scholar
  29. 29.
    Lavender CD, Hanzlik SR, Pearson SE, Caldwell PE III (2016) Arthroscopic reverse remplissage for posterior instability. Arthrosc Tech 5(1):e43–e47CrossRefGoogle Scholar
  30. 30.
    Krackhardt T, Schewe B, Albrecht D, Weise K (2006) Arthroscopic fixation of the subscapularis tendon in the reverse Hill–Sachs lesion for traumatic unidirectional posterior dislocation of the shoulder. Arthrosc: J Arthrosc Relat Surg 22(2):227-e1CrossRefGoogle Scholar
  31. 31.
    Ionescu N, Mayer J, Guignand D, Cuny C (2010) Locked posterior shoulder dislocation treated by arthroscopic tenodesis of the subscapularis in the reversed Hill–Sachs lesion. Eur J Orthop Surg Traumatol 20(1):47CrossRefGoogle Scholar
  32. 32.
    Aparicio G, Calvo E, Bonilla L, Espejo L, Box R (2000) Neglected traumatic posterior dislocations of the shoulder: controversies on indications for treatment and new CT scan findings. J Orthop Sci 5(1):37–42CrossRefGoogle Scholar
  33. 33.
    Checchia SL, Santos PD, Miyazaki AN (1998) Surgical treatment of acute and chronic posterior fracture-dislocation of the shoulder. J Shoulder Elbow Surg 7(1):53–65CrossRefGoogle Scholar
  34. 34.
    Lu Y, Jiang C, Zhu Y, Wang M, Bowles RJ, Mauffrey C (2014) Delayed ORIF of proximal humerus fractures at a minimum of 3 weeks from injury: a functional outcome study. Eur J Orthop Surg Traumatol 24(5):715–721CrossRefGoogle Scholar

Copyright information

© Springer-Verlag France SAS, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Department of Orthopaedic SurgeryFayoum UniversityKiman Fares District, FayoumEgypt
  2. 2.Department of Orthopaedic Surgery and TraumaSuez Canal University HospitalsIsmailiaEgypt

Personalised recommendations