Table 1 Pearls and pitfalls of the currently reported technique

Pearls

Dissection of disturbed anatomy can be facilitated by reference point of coracoid process

Extensive adhesions and fibrosis can be overcome by a combination of blunt (gauze sponge) and sharp (knife blade/scissor/diathermy cauterization) dissection

Tenotomy of LHB should be delayed until identification of the lesser tuberosity and SSC

Release of SSC should include a bony fleck to ease future re-attachment and improve healing

Medial refection of released SSC can be maximized by rotator interval release

Debridement of intra-articular adhesion is essential to identify the plane between reverse Hill-Sachs defect and the posterior glenoid; this plane is gently and gradually opened by a sharp osteotome and mallet to avoid unnecessary bone loss till completely freeing the humeral head from the posterior glenoid

Reduction of dislocated head can be further eased by additional release of upper pectoralis major and/or posterior GH capsulotomy

Local biology for fibular graft incorporation into the defect should be enhanced by debridement, curettage and microfracture

Assessment of Hill-Sachs defect in terms of size, geometry and engagement over posterior glenoid rim is crucial for appropriate intra-operative sizing and orientation of placement of fibular graft pieces

For restoration of articular congruity, fibular graft pieces should be placed tightly backed to each other at the posterior margin of the defect and in flush and in parallel orientation with articular surface of the humeral head

Provisional articular (outward) surfaces of these pieces (during placement at the recipient defect) should be lateral surface of the native fibula as it is the smoothest fibular surface

Pitfalls

Fibular graft fixation screws should be countersunk into the pieces to protect glenoid chondral surface during ROM and of appropriate length to avoid intra-articular penetration

Osteotomy of lesser tuberosity should be delayed until fibular grafting of the defect and assessment of size and geometry of the residual defect

Following reconstruction, GH joint should be placed in extreme provocative position for posterior dislocation to ensure that there is no longer residual reverse Hill-Sachs defect which might engage the posterior glenoid

Following reconstruction, GH joint is tested in different positions to exclude engagement of free ends of fibular graft pieces over the anterior glenoid (otherwise, glenoid chondral damage might be a possibility) and to ascertain smooth surface joint motion of the reconstructed head over the glenoid

Posterior GH capsulorrhaphy is essential to help centralize humeral head over the glenoid