Forceful posterior glenohumeral dislocations such as those resulting from seizures or electrocution may sustain a large reverse Hill-Sachs defect resulting in persistent instability in internal rotation or a locked posterior dislocation. These patients may benefit from having the lesser tuberosity along with the subscapularis advanced into the bony defect on the anterior humeral head (modified McLaughlin procedure). The original description by McLaughlin involved transferring the subscapularis tendon into the defect, and was later modified and popularized by Neer who recommended transferring the lesser tuberosity with the subscapularis.
Finkelstein et al reported good functional results using this procedure acutely in 7 patients who were unstable in internal rotation and had an anteromedial impaction fracture occupying 25-40% of the articular surface.
Hawkins et al descibe various treaments for locked posterior dislocations. All 4 of their patients with a lesser tuberosity transfer did well and they suggest using it when closed reduction fails for smaller defects and for moderate defects with head involvement of 20-45%.
A CT scan showing a posterior dislocation with large reverse Hill-Sachs lesion in shown in Illustration A. The post-op CT scan after open reduction and lesser tuberosity transfer into the defect is seen in Illustration B.
None of the other patients meet the accepted indications for this stability procedure.
1. & 2. May benefit from other procedures such as a shoulder arthroplasty.
4. May benefit from subscapularis repair or pectoralis tendon transfer to restore function.
5. A Hill-Sachs defect is on the posterior superior aspect of the humeral head and may benefit from bone grafting or remplissage, but not a lesser tuberosity transfer.
Finkelstein JA, Waddell JP, O'Driscoll SW, Vincent G. Acute posterior fracture dislocations of the shoulder treated with the Neer modification of the McLaughlin procedure. J Orthop Trauma. 1995 Jun;9(3):190-3. 7623169.
PMID:7623169 (Link to Abstract)
Hawkins RJ, Neer CS 2nd, Pianta RM, Mendoza FX. Locked posterior dislocation of the shoulder. J Bone Joint Surg Am. 1987 Jan;69(1):9-18.
PMID:3805075 (Link to Abstract)