Study: Arthroscopic remplissage successfully fills glenohumeral head defects

Patients who underwent the procedure did not report deficits in external rotation.

Issue: May 2012

SAN FRANCISCO — Researchers found that 75% to 100% of large Hill Sachs defects in patients with recurrent glenohumeral instability were filled after arthroscopic remplissage at a minimum of 8 months follow-up based on the high-resolution 3T MRI findings, according to a study presented at the American Orthopaedic Society for Sports Medicine 2012 Specialty Day.

“We showed that the humeral head defect was successfully filled with infraspinatus tendon and posterior capsule at the minimum of 8 months,” study presenter Min Jung Park, MD, MMSc, of the University of Pennsylvania Hospital, said. “All of our patients had 75% to 100% of humeral head defects filled after the remplissage procedure, and there was no external rotation deficit that patients complained about. For carefully selected patients, arthroscopic remplissage along with bankart repair can help the patients avoid potentially more invasive procedures.”

Park said the recurrence rate of glenohumeral instability is higher in patients with bony defects. There are a few clinical reports demonstrating good clinical outcome after arthroscopic remplissage — which Park described as tenodesis of posterior capsule, along with infraspinatus into the humeral head defect — for patients with large Hill-Sachs lesions that primarily contribute to shoulder instability, but there is no data evaluating postoperative outcome using high resolution MRI studies correlating with clinical findings. Therefore, Park and colleagues devised a prospective study to investigate what happens in the humeral head defect following the arthroscopic remplissage procedure and determine whether this affects clinical outcomes.

Prospective study

The researchers enrolled 11 patients with an average age of 25 years who underwent arthroscopic remplissage for glenohumeral bony defects. The patients had an average humeral head defect size of 311.2 cm³.

“We picked the minimum follow-up of 8 months because by then all of the patients are done with the physical therapy and went back to their previous level of play or whatever other sports they were playing,” Park said.

Abduction/external rotation view of shoulder scanned high resolution 3T MRI showing mixed fibrous and granulation signal filling most of the humeral head defect (white arrow).

Image: Park MJ

The investigators reasoned one anchor may be enough as long as engagement could be prevented. They used an average of 1.4 anchors during the remplissage, using a range of one to three anchors. Each patient underwent high resolution MRI in abduction, external rotation and neutral positions. Two musculoskeletal radiologists reviewed the images. Measurement criteria included signal intensity of tissue within the prior defect, signal intensity of the residual infraspinatus, degree of atrophy, presence of marrow edema and the number of anchors in the defect. The researchers used Western Ontario Shoulder Instability (WOSI) questionnaires to obtain functional scores and recorded range of motion with a goniometer.

Results

The researchers found that 75% to 100% of the humeral head defect were filled in with either granulation or fibrous tissue. Two of the patients had primarily granulation tissue, and three had fibrous tissue filling the defect, while the remaining patients had mixture of granulation and fibrous tissue, according to the abstract. The patients had an average WOSI score of 71. The mean loss of external rotation was 5.8°.

The study showed MRI evidence of tendon incorporation into the Hill-Sachs defect after the arthroscopic remplissage procedure and good clinical outcome following the procedure. – by Renee Blisard

Reference:

Park MJ, Garcia GH, Malhotra A, et al. The evaluation of arthroscopic remplissage by high resolution MRI: Are we getting our fill? Paper #3. Presented at the American Orthopaedic Society for Sports Medicine 2012 Specialty Day. Feb. 11. San Francisco.

For more information:

Min Jung Park, MD, MMSc, can be reached at email: parkmj82@gmail.com.
Disclosure: Park and his co-authors have no relevant financial disclosures.