Posterior Glenohumeral Capsular Reconstruction With Modified McLaughlin for Chronic Locked Posterior Dislocation

Abstract

Posterior instability is relatively rare when compared with anterior instability but can comprise up to 40% of operatively treated instability cases. Posterior dislocations are much rarer and are classically due to trauma, seizure, or electric shock. Due to a lack of an obvious deformity and an internally rotated and adducted arm position, posterior shoulder dislocations often are missed on initial presentation. In the management of posterior dislocations, considerations need to be made in regard to bony and soft-tissue pathology. In the setting of soft-tissue deficiency, previous options included nonoperative management primarily consisting of bracing and activity modification as well as arthroplasty options that do not rely on the capsulolabral complex for stability. In this paper, we present a technique for treating a chronic posterior shoulder dislocation with an associated large reverse Hill-Sachs deformity. In this setting, a revision labral repair and capsulodesis is generally not possible due to insufficient capsulolabral tissues. Here, we present the technique for an arthroscopic posterior capsule reconstruction using an acellular dermal allograft as well as a McLaughlin procedure for the treatment of a reverse Hill-Sachs lesion.

Fig 1

Picture of a patient placed in the lateral decubitus position, left shoulder, with the use of a bean bag positioner and SPIDER limb positioner. The bony landmarks of the borders of the acromion, clavicle, acromioclavicular joint, and scapular spine are marked as well as the posterior portal 1 cm inferior to the posterolateral corner. (A, acromion; C, clavicle; P, portal site marked in blue.)

Fig 2

Posterior glenoid (G) debridement with the use of a Freer Elevator (F) (Sklar Instruments, West Chester, PA), patient in lateral decubitus position, left shoulder, viewing from the anterosuperior portal. (H, humerus.)

Fig 3

Glenoid (G) measurement using a calibrated probe (P) from the posterior portal viewing from the anterosuperior portal. (H, humerus.)

Fig 4

Road map diagram of the Allopatch configuration. (A, anterior side; L, lateral [humeral] side; M, medial [glenoid] side; P, posterior side.)

Fig 5

Percutaneous placement of the inferior humeral anchor (A) into the humerus (H) posteriorly, patient in lateral decubitus position, left shoulder, viewing from the posterior portal.

Fig 6

Passing of the shuttling suture from the posterior cannula (left) to the anterior cannula (right) in the left shoulder, patient in lateral decubitus position, viewing from the anterosuperior portal. Arrow indicates the direction of suture shuttling. (G, glenoid; Gr, grasper; H, humerus; SM, suture manipulator.)

Fig 7

Placement of the suture anchor (A) into the inferior glenoid (IG) from the anterior cannula while viewing from the anterosuperior portal.

Fig 8

Introduction of the graft (G) into the glenohumeral joint by use of a grasper (Gr), and shuttling sutures, viewing from the anterosuperior portal, left shoulder, patient in lateral decubitus position. (C, posterior cannula; H, humerus.)

Fig 9

Tying of the superior humeral anchor knot (arrow), for initial fixation of the graft to the humerus once it has been brought intra-articularly, viewing from the anterosuperior portal, left shoulder, patient in lateral decubitus position. (KP, Knot Pusher.)

Fig 10

SPECTRUM suture passer (blue arrow) penetrating the inferior glenoid anchor site on the allograft (red arrow). SPECTRUM is passed through the posterior cannula while viewing from the anterosuperior portal. (G, glenoid; H, humerus.)

Fig 11

Reduction and fixation of the graft to the inferior glenoid (G) using a sliding knot (SMC knot). Tying from the anterior cannula while viewing from the anterosuperior portal, left shoulder, patient in the lateral decubitus position. (Gr, graft; H, humerus; KP, Knot Pusher.)

Fig 12

Posterior capsular reconstruction completed with graft (Gr) anchored to the glenoid (G) and the humerus (H), viewing from the anterosuperior portal, left shoulder, patient in the lateral decubitus position.

Fig 13

Humeral anchor (A) being inserted into the center of the reverse Hill–Sachs defect (H) while viewing from the anterosuperior portal, left shoulder, patient in the lateral decubitus position. (AC, anterior capsule.)

Fig 14

BirdBeak suture passer (blue arrow) penetrating the subscapularis (SS) to retrieve suture limb of humeral anchor (red arrow), viewing from the anterosuperior portal, left shoulder, patient in the lateral decubitus position. (H, humerus.)

Fig 15

Subscapularis (SS) being reduced into the reverse Hill–Sachs defect (H) on the humerus, viewing from the anterosuperior portal, left shoulder, patient in the lateral decubitus position.