Modified MacLaughlin procedure in the treatment of neglected posterior dislocation of the shoulder

Low Recurrence of Instability and Satisfying Patient-Reported Outcomes Following Various Surgical Treatments of Reverse Hill-Sachs Lesions in the Setting of Posterior Instability: A Systematic Review

PURPOSE

To systematically review the literature and report the outcomes of various surgical treatments for reverse Hill-Sachs lesions (RHSL) in the setting of posterior shoulder instability.

METHODS

Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed. All studies assessing outcomes of surgical treatment of RHSL from inception to January 2023 were identified in PubMed, Embase, and Cochrane Library. Inclusion criteria consisted of studies reporting outcomes, minimum mean 1-year follow-up, and minimum Level IV evidence. Outcomes were assessed using Forest plots with random effects models using R software.

RESULTS

A total of 29 studies consisting of 291 patients were included with a mean age of 42 years (range 16-88 years), 87% male gender, and mean follow-up of 4.5 years. The mean size of impacted or affected cartilage was 35%, and time from injury to surgery was mean 15 weeks. Nearly all studies were Level IV evidence, and quality of studies was low. Random effect models were performed, and data are presented as range. A low incidence of instability was noted for all surgical techniques with good patient-reported outcome measures. Most studies reported outcomes of the modified McLaughlin procedure (13 studies, 126 patients) with overall Constant-Murley Score of 65 to 92. Trends were seen towards better Constant-Murley Score and external rotation with a shorter delay between injury, and when arthroscopic and joint preserving treatments were performed.

CONCLUSIONS

This systematic review showed low rates of instability recurrence, reproducible range of motion, and favorable patient-reported outcome measures were reported following all treatments for RHSLs with posterior instability. There was a significant association between better outcomes and a shorter delay between injury and surgery. The level of evidence is limited, given the small and retrospective studies which can be explained by the rarity of these injuries. LEVEL OF EVIDENCE: Level IV; systematic review of Level III and IV studies.

Clinical and radiographic outcomes of the modified McLaughlin procedure for locked posterior dislocation of the shoulder: a systematic review

Background

Multiple treatment options for locked posterior dislocation of the shoulder (LPDS) have been described, including the modified McLaughlin procedure. The purpose of this review, therefore, was to perform a systematic review of the literature to synthesize the available data reporting on the clinical and radiographic outcomes of patients undergoing the modified McLaughlin procedure for the treatment of LPDS.

Methods

A systematic review of the PubMed Central, MEDLINE, Embase, Scopus, Web of Science, and Cochrane Library databases from inception through January 2023 was performed. Outcomes studies reporting on clinical and radiographic outcomes in patients undergoing the modified McLaughlin procedure for LPDS were included. Postoperative complications and episodes of recurrent instability were noted.

Results

A total of 1322 studies were initially identified, of which 9 were deemed eligible for inclusion in our review. Among included studies, a total of 97 shoulders (96 patients) with a mean age of 37.7 years (range, 26-51) were identified. The most common mechanisms of injury included trauma, seizure, and electrocution. Reverse Hill-Sachs lesions ranged in size from 20% to 50% of the humeral head articular surface. At final follow-up, the weighted mean University of California at Los Angeles shoulder score, Constant-Murley Score, American Shoulder and Elbow Surgeons shoulder score, and visual analog scale for pain score were 29 (range, 27-31), 75 (range, 65-92), 92 (range, 83-98), and 1.9 (range, 1-2.4), respectively. Postoperative Constant-Murley Score and University of California at Los Angeles scores were highest in the one study reporting exclusively on treatment during the acute period. Weighted mean postoperative forward flexion, abduction, external rotation, and internal rotation were 154° (range, 102-176), 144° (range, 118-171), 64° (range, 44-84), and 47° (range, 42-56), respectively. Osteointegration of the lesser tuberosity was noted in all patients at the final follow-up. Postoperative complications occurred in one patient (1.0% of cohort); a screw migration successfully treated with operative removal. Recurrent instability was noted in two epileptic patients (2.1% of cohort).

Conclusion

The literature surrounding the use of the modified McLaughlin procedure for LPDS remains sparse. This review demonstrates that this procedure is associated with favorable clinical and radiographic outcomes with overall low rates of complication and recurrent instability, especially when the time from injury to surgery is minimized. These findings illustrate that in patients presenting with LPDS and a reverse Hill-Sachs lesion between 20% and 50% of the humeral head articular surface, the modified McLaughlin procedure is a safe and effective treatment option.

McLaughlin technique and humeral grafting provide similar results for treatment of reverse Hill-Sachs lesions: A systematic review

Purpose

Various surgical treatments have been described for the treatment of reverse Hill-Sachs lesions (rHSls) sized between 20% and 50% in the case of posterior shoulder dislocation. The aim of this systematic review is to report the clinical and radiological outcomes of subscapularis or lesser tuberosity transfer (McLaughlin and modified procedures) compared to bone or osteochondral autograft or allograft.

Methods

A systematic review was performed on five medical databases up to December 2022. The inclusion criteria were clinical studies of all levels of evidence describing clinical or radiological outcomes of either procedure. The assessment of the quality of evidence was performed with the Modified Coleman Score.

Results

A total of 14 studies (five prospective and nine retrospective) were included. A total of 153 patients (155 shoulders, 78.4% male) with a mean age of 37.2 (22-79) years were reviewed at an average follow-up of 53.1 (7.1-294) months. No relevant difference was found for the clinical scores, range of motion, complications and redislocation rate between the two treatments. Radiological osteoarthritis (OA) was reported in 11% (10/87) in the McLaughlin group and in 21% (16/73) in the humeral reconstruction group.

Conclusions

McLaughlin and anatomic humeral reconstruction lead to similar satisfactory clinical results and a low redislocation rate in the treatment of rHSls. Anatomic humeral reconstruction seems associated with an increased risk of OA progression.

Level of Evidence

Level IV.

Irreducible Posterior Shoulder Dislocation With Concomitant Fracture of Both the Greater and Lesser Tuberosity: An Extremely Rare Shoulder Injury

Posterior shoulder dislocation is a relatively rare injury representing only 5% of all shoulder dislocations. It is usually the result of a high-energy trauma or an epileptic seizure. Diagnosis is challenging with half of these injuries missed in the emergency room (ER). Often the dislocation is accompanied by a lesser tuberosity fracture as a result of the impact between the posterior glenoid and the proximal humerus. Additionally, fractures of the greater tuberosity or even the metaphysis are extremely rare, and their treatment remains challenging. We present a rare case of posterior locked shoulder dislocation with a concomitant lesser and greater tuberosity fracture in a young patient. A 29-year-old male was brought to the ER following a motor vehicle accident. The patient reported significant pain and inability to move his left shoulder. The arm was locked in an internal rotation and was neurovascularly intact. Simple radiographs revealed a locked posterior dislocation with fractures of both the lesser and greater tuberosity. The CT scan confirmed the fracture pattern and excluded metaphyseal fracture. Surgical treatment was decided. Under general anesthesia and a classic thoracodeltoid approach, both tuberosities were recognized and the dislocation was gently reduced. Fixation of the tuberosities with an anatomic plate and Ethibond No. 5 sutures was performed. He was discharged the next day with a 30-degree abduction sling cast. He was instructed to perform passive shoulder and scapula exercises once a day. After one month, the sling was removed and active elevation and rotation exercises were started. Plane X-rays were performed at one, six, and twelve months. The reduction remained stable and the patient recovered full range of motion with a slight loss of external rotation (10 degrees) compared to the contralateral limb. He returned to his previous activities without any complications. Posterior shoulder dislocations with additional fractures of the tuberosities are rare and severe injuries requiring open surgery as the humeral head may remain locked prohibiting closed reduction. Even after the reduction, the stable fixation of the tuberosities is crucial for shoulder stability and postoperative clinical and functional results.

A novel modified McLaughlin surgery for treating locked chronic posterior shoulder dislocation

BACKGROUND

Posterior shoulder dislocation is an uncommon orthopaedics injury and is frequently missed or misdiagnosed, accounting for 2%-4% of all shoulder dislocations, and is associated with the reverse Hill-Sachs lesion. Once posterior shoulder dislocation develops into a chronic disease, it will bring a lot of trouble to the treatment, especially in repairing the humeral defects. Surgical strategies are also developing and innovating to deal with this injury, including transfer of subscapularis tendon or lesser tubercle, humeral rotational osteotomy, autogenous bone graft or allograft. Shoulder replacement seems to be the ultimate and only option when the injury becomes irreparable, although some studies have shown unsatisfactory follow-up results. Considering no gold-standard treatment for locked posterior shoulder dislocation, we described a novel modified McLaughlin procedure for locked chronic posterior shoulder dislocation and evaluated the functional outcomes.

METHODS

This study included five locked chronic posterior shoulder dislocation patients with an associated reverse Hill-Sachs lesion, in which the compression surface covered 30-40% of the humeral head. The mean period from injury to receiving surgery was 11.6 weeks (6-24 weeks). All five patients underwent the modified McLaughlin procedure, mainly divided into three steps, including open reduction, transfer of the partial lesser tuberosity and artificial bone to repair the reverse Hill-Sachs defects. The kernel technique was to fix the transferred tuberosity with two lag screws and strengthen it with two Ethibond sutures. The Constant-Murley score (CMS), the range of shoulder motion and the complications were recorded to assess and compare the functional situation of the shoulder postoperatively and postoperatively.

RESULTS

After an average of 19.8 months (12-30) of follow-up, the mean CMS improved to 85.8 ± 4.9 (79-91) compared with 46.0 ± 4.5 (40-52) preoperatively, which showed a significant difference (p = 0.001). In the final follow-up, all five patients showed no symptoms of shoulder instability, and there was no pain or limited activity in daily life, thus all patients were satisfied with the results.

CONCLUSION

Repairing the reverse Hill-Sachs lesion by transferring the partial lesser tuberosity combined with artificial bone fixed by lag screws and sutures can ensure shoulder stability and provide pain relief and good function in patients with locked chronic posterior shoulder dislocation associated with the humeral head defect.

Irreducible Posterior Fracture Dislocation of the Shoulder: A Case Report

Posterior shoulder fracture-dislocation is a rare traumatic entity. Early diagnosis results in the adequate treatment of these lesions and prevents serious complications, such as avascular necrosis. Several therapeutic options have been proposed depending on the size of the humeral defect, duration of the dislocation, age of the patient, associated comorbidities, and functional requirements. For this kind of injury, early open anatomical reduction and stable internal fixation remain the optimum treatment option. Arthroplasty is often the last resort for active young patients, particularly in cases of avascular necrosis, humeral head complex fracture, or undiagnosed posterior shoulder dislocation. Here, we report a case of a complex posterior shoulder fracture-dislocation in a young man, which was treated surgically with open reduction and locked plate osteosynthesis using a deltopectoral approach.

Management of Locked Posterior Shoulder Dislocation with Reverse Hill-Sachs Lesions via Anatomical Reconstructions

Objective

To evaluate the outcomes of locked posterior shoulder dislocation with reverse Hill–Sachs lesions in patients treated with anatomical reconstructions.

Methods

Patients who were treated at our institution between January 2016 and June 2020 were retrospectively reviewed. The demographics of the patients including gender, age, occupation, and dominant arm were recorded. Eleven cases from 10 patients qualified in this study. Nine males and one female were included. The mean age of the patients was 44.8 years (range, 33–54 years). Mechanism of injury, duration between injuries and definitive diagnosis, misdiagnosis, size of humeral head impaction, treatment maneuver, and details of operation performed were reviewed. Plain radiographs and computed tomography (CT) scan were taken to determine the size of defects preoperatively and fracture healing during follow‐up. During surgery, the deltopectoral approach was employed. Anatomical reconstruction procedure including reduction, disimpaction, bone grafting, and fixation were sequentially performed. Either cancellous autograft from iliac crest or allograft were used and the fractures were anatomically reduced and stabilized by screws or plates. Visual Analog Scale (VAS) and Constant–Murley score were recorded to determine the functional outcomes preoperatively, at 3 months and 6 months postoperatively, and at the last follow‐up. The range of motion in forward flexion was recorded at 6 months follow‐up postoperatively.

Results

Causes of injuries included epileptic seizure in four cases, fall in three cases, and road traffic accident in three cases. Misdiagnoses occurred in five out of 10 patients. The mean time between injury and definitive treatment among those misdiagnosed was 112 days. The mean size of the impacted reverse Hill–Sachs lesions was 33.95% (range, 19.1%–42.6%). All patients received surgical management with anatomical reconstruction approach, including open reduction, disimpaction, bone grafting, and internal fixation. The mean amount of bleeding during operation was 450 mL. The mean follow‐up period was 22.6 months. Fracture healing was observed by 8 weeks in all cases postoperatively and evidence of bone grafting could not be further detected on CT scan at 6 month during follow‐up. VAS was significantly lower at the last follow‐up (0.68 ± 0.21) in comparison to preoperative scores (4.96 ± 0.97) (P < 0.05). Constant–Murley was improved significantly at the last follow‐up (91.7 ± 8.3) in comparison to that preoperatively (40.6 ± 10.3) (P < 0.05). The mean range of motion in forward flexion was 38.25° ± 9.36° preoperatively and significantly improved to 162.48° ± 12.68° at 6‐month follow‐up (P < 0.05).

Conclusion

The anatomical reconstruction procedure by open reduction and bone augmentation for the treatment of locked posterior shoulder dislocation with reverse Hill–Sachs lesion was promising in both fracture healing and functional outcomes.

Arthroscopic reduction and subscapularis remplissage (ARR) of chronic posterior locked shoulder dislocation leads to optimized outcomes and low rate of complications

PURPOSE

Unrecognized posterior shoulder dislocation with a concomitant humeral head fracture affects joint function and no consensus exists regarding treatment. The present study analyses clinical and radiographic outcomes of a novel arthroscopic technique for reducing chronic locked posterior shoulder dislocation associated with subscapularis remplissage.

METHODS

The study comprises a retrospective analysis of consecutive chronic posterior locked shoulders (CPLS) with minimum 2-years follow-up of patients who had undergone McLaughlin technique arthroscopic modification for the treatment of CPLS with a reverse Hill-Sachs lesion. Active range of motion (ROM), Western Ontario (WOSI) and Constant Score (CS), were evaluated pre- and postoperatively. Plain radiographs and magnetic resonance imaging (MRI) scans were collected pre- and post-operatively, recording bone defect, osteoarthritis, cuff integrity/fatty infiltration, and the grade of filling of the reverse Hill-Sachs.

RESULTS

Twelve male patients with a mean follow-up of 37.3 months ± 10.5 (range, 24-58) were included. Mean WOSI and CS scores improved from 41 to 92 and 28 to 94 points, respectively. ROM measurements all had significantly increased at final follow-up, with no significant differences in arm rotation. No defects were left unfilled at final MRI examination.

CONCLUSION

The results of this uncontrolled study with a limited number of patients confirm that arthroscopic reduction and subscapularis remplissage is a highly effective and satisfactory treatment method resulting in no shoulder rotation deficits.

LEVEL OF EVIDENCE

Level IV.

Posterior shoulder fracture-dislocation: A systematic review of the literature and current aspects of management

PURPOSE

Posterior fracture-dislocation of shoulder is an infrequent traumatic event; however, most orthopaedic surgeons may face the challenge of treating it. The aim of this study is to review and summarise systematically the current principles of the management of this complex injury, and create a treatment algorithm.

METHODS

Both PubMed and Scopus Databases were systematically searched for the terms "posterior shoulder fracture-dislocation" or "posterior glenohumeral fracture-dislocation" or "posterior glenoid fracture-dislocation" for articles written in English and published in the last decade.

RESULTS

A total of 900 articles were identified, of which 13 were retained for analysis. A total of 153 patients (161 shoulders) were identified. These patients were treated either with open reduction and internal fixation, modified McLaughlin procedure, allograft/autograft humeral head reconstruction or shoulder arthroplasty. The mean age was 40.15 years. The mean postoperative Constant score in cases treated by open reduction and internal fixation was 86.45, whereas by bone graft was 84.18. Further, the mean postoperative Constant score was between 79.6 and 67.1 in those that were managed by modified McLaughlin and arthroplasty procedure, respectively.

CONCLUSION

The management of posterior shoulder fracture-dislocation may be challenging, and the best surgical option depends on many variables such as the chronicity of the injury, the presence of a fracture at the level of the surgical neck or tuberosities and the extend of the Hill-Sachs lesion if any. A treatment algorithm is proposed, based on the current literature in an effort to create a consensus for these injuries. For the acute shoulder fracture-dislocations, an open reduction should be performed. For the chronic fracture/dislocations in the elderly low-demand patients, conservative treatment should be performed. For the rest of the patients, depending on the severity of the Hill-Sachs lesion different surgical options are available such as the McLaughlin technique, the use of an allograft, osteotomy or arthroplasty.

Imaging of shoulder instability

The shoulder enjoys the widest range of motion of all the joints in the human body, therefore requires a delicate balance between stability and motility. The glenohumeral joint is inclined to fall into two main instability categories: macro and micro. Macroinstability can be traumatic or atraumatic, with anterior or posterior dislocation of the humeral head. Microinstability falls within the broader section of acquired instability in overstressed shoulder caused by repeated joint stress. Anterior traumatic instability is the most frequent entity and a relatively common injury in young and athletic population. While shoulder instability is a clinical diagnosis, imaging impacts the patient management by detailing the extent of injury, such as capsulo-labral-ligamentous tears, fracture, and/or dislocation, describing the predisposing anatomic conditions and guide the therapetic choice. The aim of this comprehensive review is to cover the imaging findings of shoulder instability by different imaging techniques.

Shoulder-Preserving Surgery in Case of Defect of more than half of the Joint Surface: A Case Report

Introduction

This report highlights chronic locked posterior shoulder dislocation, which is of special interest because the patient who had a reverse Hill-Sachs and Hill-Sachs lesion, with >50% joint surface defects was treated with a shoulder-preserving surgery.

Case Report

A 42-year-old man presented to our clinic with complaints of pain and limited movement in his left shoulder. The patient's complaints began after he experienced a fall 7 months ago. The patient was believed to have experienced posterior shoulder dislocation, and the clinical diagnosis was confirmed by radiological imaging. Computed tomography revealed a reverse Hill-Sachs lesion on the humeral head and on approximately 25% of the joint surface. During the McLaughlin procedure, because the osteoporotic humerus showed a collapse of approximately 30% on the posterior articular surface, an iatrogenic Hill-Sachs lesion was added to the reverse Hill-Sachs lesion at the beginning of the humeral head. The subscapularis tendon was transferred to the anterior defective area of the humeral head with three anchor sutures. Fixation was performed with a Kirschner wire, while the joint was in the reduction position. At the 62-month follow-up, constant shoulder score was calculated as 84. The patient was pleased with his results and was able to continue his routine activities.

Conclusion

Arthroplasty is the recommended treatment for patients manifesting >50% defect on the humeral head joint surface. However, when these defects are evaluated, factors such as their localization, size, depth, and orientations with respect to the glenoid should be considered. Only after this multifaceted evaluation, appropriate surgical interventions can be planned.

Treatment options for locked posterior shoulder dislocations and clinical outcomes

Posterior dislocations are rare and diagnostically difficult injuries. Diagnosis is often delayed and this leads to a locked posteriorly dislocated humeral head.

Treatment options include conservative methods and surgical anatomic reconstruction options as well as non-anatomic surgical procedures such as subscapularis tendon transfer, hemiarthroplasty and total shoulder arthroplasty.

Decision-making for treatment as well as prognosis depend on the extent of the articular defect size of the humeral head, duration of the dislocation and patient-specific conditions such as age and activity levels.

Cite this article: EFORT Open Rev 2019;4:194-200. DOI: 10.1302/2058-5241.4.180043

Locked posterior dislocation of the shoulder: A systematic review

Locked posterior dislocation of the shoulder is very rare. Seizures and trauma are the most common causes of this injury.There is no current benchmark treatment strategy for these rare cases.This study has shown that reconstruction of the shoulder joint in an anatomical way in acute and chronic cases up to 16 weeks provides good results.The purpose of this study is to evaluate the results of different treatment procedures with outcomes and to compare the results of the same procedures in acute and chronic cases. Cite this article: EFORT Open Rev 2017;3:15-23. DOI: 10.1302/2058-5241.3.160089.

Open management of neglected inferior dislocation of the shoulder with proximal humeral fracture in an adolescent

Neglected dislocation of the shoulder is a rare condition with some cases of anterior and posterior dislocation being reported. We report a case with a fracture dislocation of the proximal humerus with the dislocated head lying inferior to the glenoid. We also report on the surgical management of a case with this extremely rare condition which required shortening of the distal fragment to reduce tissue tension.