shoulder rotator cuff chronic shoulder dislocation hill sack lesion journal club orthopaedics

1. Journal Club on LPDS
Dr. Shubhanshu

2. Introduction
• Posterior instability 10% of all shoulder
dislocation
• Trauma(59%), Seizure(40%), Electric shock(1%)
• A/W Reverse Hill-Sacks lesion
• Pain posterior part of shoulder & weakness
rather than instability
• Diagnostic Trap as it can be missed, (frozen
shoulder)
• Flattening at anterior aspect of shoulder, fixed
internal rotation with adduction deformity

3. Investigation
• Radiographs- AP/Lateral
• CT with 3-D reconstruction
• MRI shoulder

4. RHSL related
• Early onset Osteoarthritis
• Chronic posterior shoulder instability

5. Treatment
• Operative management for lesion affects >10 articular
surface
• 25-40% reconstruction, >40% prosthesis
• RHSL
– Subscapularis tendon to humeral defect -McLaughlin
procedure
– Lesser tuberosity transfer with subscapularis tenodesis
fixed with Double row suture anchor(Modified McLaughlin
procedure)
– Lesser tuberosity transfer(Hawkins modification
– Disimpaction with bone grafting
– Allograft reconstruction
– Shoulder Arthroplasty

6. Surgical Steps
• Diagnostic Arthroscopy
• Delto-pectoral Approach
• Breach chair position
• RHSL identified on External Rotation, Head
Engagement with posterior glenoid rim seen
20 degree of Internal rotation.
• Biceps Tenotomy

7. Surgical Steps
• Aim to decrease alpha angle by transfering lesser
tuberosity and subscapularis tenodesis
• Debride injured cartilage
• Rectangular osteotomy around lesser tuberosity
by oscillating saw from bicipital groove parallel to
RHSL
• Place anchor into RHSL 8-10mm from medial
border of osteotomy
• Double pulley suture anchor technique through
subscapularis tendon

8. Rehabilitation
• Sling/Brace with an abduction(30) ER(10)
pillow to protect posterior repair.
• No pendulum excercises untill 4 weeks
• At 6 week, wean from sling and active ROM
• 12 weeks, strenthening excersices
• 16 weeks, more strenthening excercises
• 6 month, all activites

9. Outcomes
• 2 year after follow up: asymptomatic shoulder
• American Shoulder Elbow Surgeon – 91
• Western Ontario shoulder Instability Index –
8.6%
• Oxford Shoulder score- 43
• Simple Shoulder Test - -11

10. Outcomes

11. Take Home Message
• LPDS can be missed
• Arthroscopic and open surgery both had good
outcome.
• This procedure for joint preservation in
extensive humeral head defects.
• Alternative to shoulder arthroplasty.