Remplissage may augment arthroscopic labral repairs for anterior shoulder instability
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Anterior shoulder instability is a common shoulder pathology, occurring in 1% to 2% of the general population. This instability is caused by injuries to the labrum or capsuloligamentous structures, which normally stabilize the joint.
Anterior shoulder instability is most often caused by traumatic injury, which is why its incidence is highest among young contact athletes who undergo repetitive high-impact collisions.
Source: Ryan C. Rauck, MD; Erryk Katayama, BA; Akshar V. Patel, BS
Surgical management of anterior shoulder instability is indicated for patients with recurrent instability. The Bankart repair involves repairing the torn anterior labrum and capsule to the glenoid using anchors. In cases of glenoid bone loss or higher-demand contact athletes, the recurrence rates after arthroscopic anterior labral repair can be unacceptable. Alternatives include bone restoration procedures, such as Latarjet or distal tibia allograft, if there is glenoid bone loss. However, in cases without significant glenoid bone loss but Hill-Sachs lesions that engage the glenoid, or nearly engage the glenoid, arthroscopic remplissage can be used as an adjunct to anterior labral repair. Recurrent instability after arthroscopic labral repair alone has been shown to increase as the Hill-Sachs interval approaches the size of the glenoid track.
The remplissage procedure is an effective augment for addressing instability due to a Hill-Sachs lesion, an impaction fracture of the posterosuperior humeral head that occurs secondary to anterior shoulder dislocation. During a remplissage procedure, the infraspinatus tendon and posterior capsule are used to “fill” the Hill-Sachs defect, thereby turning it into an extra-articular lesion and preventing engagement with the anterior glenoid. Remplissage is safe and effective, with numerous benefits. The procedure is completed arthroscopically and can be completed in conjunction with a simultaneous labral repair.
Preoperative history
The patient is a 23-year-old man who presented to our clinic with right shoulder instability. Past medical history was significant for a prior shoulder dislocation 4 years ago. The patient experienced a recurrent dislocation 1 month prior to his presentation, which was reduced in the ED. In the ED, imaging showed an anterior dislocation followed by a concentric glenohumeral joint after reduction. His goals were to have a stable shoulder for rock climbing and working as a surgical nurse.
The patient had several subsequent subluxations. His physical exam demonstrated intact motor and neuro function of the affected shoulder. The exam was positive for apprehension. MRI was obtained and demonstrated an anterior labral tear and a Hill-Sachs lesion.
He was indicated for surgery given the recurrent instability with an anterior labral tear and a Hill-Sachs lesion. The surgical plan was arthroscopic anterior labral repair with capsulorrhaphy and remplissage.
Surgical technique
The patient was placed in the beach chair position. Examination under anesthesia demonstrated grade 3 anterior instability, no posterior instability and negative sulcus sign. Diagnostic arthroscopy was performed and demonstrated an anterior labral tear. He had a large Hill-Sachs defect with a Hill-Sachs interval of 17 mm (Figure 2). His glenoid track measured 24 mm, indicating a distance to dislocation of 7 mm. This was consistent with “near track” lesions and, therefore, remplissage was performed.
First, the anterior labrum was mobilized. While viewing from anterolateral, a shaver and rasp were used to gently decorticate the Hill-Sachs defect. A spinal needle was used to establish the appropriate trajectory for placement of the remplissage anchors. Next, a 7-mm cannula was introduced through the deltoid and down to the infraspinatus without going through it. Large sweeping motions were used to clear the subacromial space. The sharp drill guide was then placed through the cannula, and the infraspinatus tendon and capsule were pierced at the inferior medial aspect of the Hill-Sachs lesion. The anchor was then drilled for and placed (Figure 3). This was a 2.6-mm all-suture anchor with a #5 suture and a knotless mechanism. The drill guide was then removed, and the 7-mm cannula was placed against the infraspinatus at the superomedial aspect of the Hill-Sachs lesion. A second pass through the infraspinatus tendon and capsule was performed with the drill guide. The second 2.6-mm all-suture knotless anchor was drilled for and placed (Figure 3). An adequate bridge of soft tissue was ensured to allow for proper filling of the Hill-Sachs lesion. These sutures were maintained in the cannula with the cannula maintained in the subacromial space for completion of the remplissage at the end of the case.
To repair the anterior labrum and capsule, four 1.8-mm all-suture anchors with a #2 suture and knotless mechanism were used (Figure 4). After repairing the labrum in the front, the remplissage was continued with the #5 repair suture from the inferior anchor placed through the shuttling suture of the superior anchor. This was then shuttled through the anchor and tensioned. This step was repeated with the #5 repair suture from the superior anchor through the shuttling suture of the inferior anchor. These sutures underwent final tensioning while being viewed from within the glenohumeral joint. This provided excellent compression and fill of the Hill-Sachs defect with the infraspinatus tendon and capsule (Figure 5).
Postoperative rehabilitation
Postoperatively, the patient was maintained in a sling for 6 weeks. Physical therapy began 2 weeks postoperatively. This progressed from passive to active assisted and then active motion.
One difference with the remplissage protocol is avoiding external rotation strengthening, internal rotation or grade 3 or 4 posterior joint mobilizations until 12 weeks postoperatively. The patient could return to contact sports 6 months after surgery.
- References:
- Li RT, et al. J Bone Joint Surg Am. 2021;doi:10.2106/JBJS.20.00917.
- Lin A, et al. J Shoulder Elbow Surg. 2023;doi:10.1016/j.jse.2023.02.011.
- For more information:
- Erryk Katayama, BA; Akshar V. Patel, BS; and Ryan C. Rauck, MD, are of the department of orthopedic surgery at The Ohio State University Wexner Medical Center. Rauck’s email: ryan.rauck@gmail.com.
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