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Arthroscopic Remplissage for Engaging Hill-Sachs Lesions in Patients With Anterior Shoulder Instability

February 19, 2016

Contributors: Christopher L. Camp, MD; Diane Lynn Dahm, MD; Patrick Reardon, BS; Aaron J Krych, MD

INTRODUCTION: Anterior shoulder instability is often accompanied by a Hill-Sachs defect on the humeral head that can contribute to recurrent instability if not addressed at the time of surgery. This technique describes a method of performing arthroscopic remplissage used to treat engaging Hill-Sachs lesions in patients with glenohumeral instability. It has the benefits of being an efficient procedure that can be performed with minimal technical difficultly and can be used to augment other stabilization procedures such as labral repair. Indications include the presence of an engaging Hill-Sachs defect in patients will little or no glenoid bone loss. In appropriately selected patients, arthroscopic remplissage has demonstrated reduced rates of recurrent instability.

BACKGROUND: Patients with bone defects of the humeral head, such as Hill-Sachs lesions, following anterior dislocation of the glenohumeral joint are at increased risk of recurrent instability and failure of soft tissue stabilization surgery. (1, 2) To address this problem, a number of procedures have been described that augment anterior labral repair in patients with Hill-Sachs lesions that engage the glenoid. A few examples include the open capsular shift, coracoid transfer to the anterior glenoid, humeral head plasty, osteochondral allograft transplantation, and remplissage.(3) Remplissage involves advancement of the posterior capsule with or without the infraspinatus into the humeral head defect, and multiple studies have demonstrated relatively low recurrence rates (< 5%) for patients treated with labral repair and remplissage for anterior instability with engaging Hill-Sachs lesions.(4, 5) This report details an arthroscopic technique for capsular remplissage to be used concomitantly with anterior labral repair for patients with Bankart labral injuries and engaging Hill-Sachs lesions. This technique utilizes capsule alone to fill the defect so that the infraspinatus is not unnecessarily tensioned. If the treating surgeon feels it indicated, the infraspinatus can be incorporated into this repair. When precise surgical steps are followed, this procedure can be performed in a quick and efficient manner (Video 1). We present this technique to provide surgeons with a treatment option that, in properly selected patients, can reduce the likelihood of recurrent glenohumeral instability.(1, 2, 5)

TECHNIQUE: All patients are examined preoperatively in the clinical setting and under anesthesia. The uninjured shoulder is also examined for comparative purposes. For surgery, patients are positioned in either the beach chair (our preference) or lateral decubitus position. A complete diagnostic arthroscopy is performed and the anterior labrum and glenoid are inspected. Viewing from a standard posterior portal, the humeral head is inspected for bony defects. If an osseus defect is identified (Figure 1A), the shoulder is taken through a full functional range of motion to determine if the defect engages the anterior glenoid. When present, this typically occurs in abduction and external rotation. Once this is confirmed, the decision is made to perform a capsular remplissage. Prior to the remplissage procedure, a standard anterior portal is created and the anterior labrum is prepared (debrided, elevated off glenoid, etc.) as needed, but it is not yet fixed. It is important to perform the remplissage prior to anterior labral repair so that the humeral head can be better positioned for the remplissage. While viewing from the posterior portal, the humeral head is subluxed anteriorly and internally rotated to bring the Hill-Sachs lesion into optimal view. Using needle localization, a posterolateral accessory portal is created with perpendicular access to the lesion. This portal is typically just distal to the inferolateral edge of the posterior acromion. Once this posterolateral portal is created, a switching stick is placed in the posterior portal and the camera is inserted into the anterolateral portal (Fig. 1B). Although the posterior portal is not utilized during remplissage, the switching stick is left in place to maintain patency. This is helpful because the posterior portal can become difficult to access after the capsule has been pulled into the defect. While viewing from the anterolateral portal, the humeral head is subluxed anteriorly, to allow ample posterior working space. It is critical that the anterior soft tissues have not been repaired yet, as this would close down the space. A 7 mm screw in cannula is then inserted into the posterolateral portal centered over the lesion. This is typically placed anterior to the infraspinatus (between the muscular portion of the infraspinatus and the posterior capsule). The canula is introduced into the capsule initially during defect preparation. The lesion is then prepared using shavers and a curette back to a gently bleeding bony surface. Defect preparation focuses on debridement of soft tissue, and minimal bone should be removed (Fig 1C). Once the bed is prepared, a small punch is used to identify the site for anchor placement in the center of the lesion. Fixation typically utilizes only a single 4.5 mm double-loaded suture anchor. When unusually soft bone or exceedingly large defects are encountered, an additional anchor could be considered. The bone of the posterior humeral head in these patients is typically hard and requires tapping prior to anchor placement. The anchor is placed perpendicular to the lesion (Figure 2A). The canula is retracted from the capsule, but the lumen remains deep to the deltoid and rotator cuff. A sharp tissue penetrator is used to pass sutures. The bird peak is passed through the capsule over the posterior superior aspect of the lesion approximately one centimeter from the portal, and the first suture is pulled through capsule and out of the canula (Figure 2B). The second suture is then passed through the capsule over the anterior superior aspect of the defect in a similar fashion. An assistant maintains tension on these sutures to prevent entanglement. The other two suture strands are then passed through the capsule at the posterior inferior and anterior inferior margins of the lesion in the same manner. The inferior sutures are then tied down while an assistant maintains tension on the superior sutures. From the anterior portal, reduction of the capsule to the defect bed is confirmed as the sutures are tied. The superior sutures are then tied down (Figure 2C). The knots are typically tied in a blind fashion. Once the remplissage is completed, attention is turned back to the anterior labrum which is repaired as needed. Postoperatively, the patient is placed in a 30 degree external rotation sling for 4 weeks postoperatively followed by a standard sling for two additional weeks. During weeks 0-4, rehabilitation focuses on elbow, wrist, and hand range of motion (ROM); scapular isometrics; and shoulder motion is discouraged. Weeks 4-6 introduce shoulder forward elevation in the scapular plane to 90 degrees and gentle deltoid isometrics. After week 6, strengthening and ROM exercises are gradually increased with the goal of obtaining full ROM by week 12. After 12-14 weeks, a gradual return to sport and other activities is pursued.

DISCUSSION: The current indication for remplissage in patients with anterior glenohumeral instability is the presence of a Hill-Sachs lesion that engages the anterior rim of the glenoid.(5, 6) Minimal (ideally <10%) glenoid bone loss should be present. Presence of a Hill-Sachs can be determined on preoperative imaging (axillary x-ray or advanced imaging), and engagement can be assessed by physical examination and intraoperative observation. If the patient's humeral head locks out during the anterior load and shift test (anterior translational force applied to the humeral head with the arm abducted in the scapular plane), one should suspect an engaging lesion. During arthroscopic examination of the shoulder, remplissage should be considered if the Hill-Sachs lesion engages the anterior glenoid at any point within a functional range of motion. If an engaging Hill-Sachs lesion is suspected preoperatively, the possible necessity of remplissage should be discussed in detail with the patient prior to surgery. This technique of arthroscopic remplissage can be completed in an efficient manner without significant technical difficulty. It is performed completely arthroscopically and permits stabilization of humeral head defects with less morbidity than other open alternatives such as allograft transplantation, bone transfers, and open capsular shifts. In appropriately selected instability patients (those with engaging Hill-Sachs lesions and adequate glenoid bone stock), this procedure has demonstrated reduced rates of recurrent instability.(2, 5) In addition, postoperative MRI has demonstrated good healing of the capsulotenodesis into the humeral head defect, with a minimal external rotation deficit of 8 degrees.(7) Biomechanical comparison of remplissage to Latarjet transfer demonstrated similar reductions in instability and maintenance of motion for the two procedures in patients with < 25% glenoid bone loss.(8) The capsule only remplissage has the added benefit of minimizing undue stress on the rotator cuff, but this technique can be adapted to incorporate the infraspinatus if the surgeon feels it is indicated. Ultimately, when appropriate steps are followed (Table 1), this technique provides orthopaedic surgeons with an additional option for treating patients with complex anterior shoulder instability.



Figure 1

When intra-articular viewing of the right shoulder in the beach chair position from the posterior portal, revealing the the large Hill-Sachs (HS) lesion on the humeral head (HH) is seen as it engages the glenoid (G) with the arm abducted and externally rotated, A. While viewing from the anterolateral portal, the posterolateral accessory portal is created directly over the HS defect. A View of a switching stick is placed in the posterior portal to maintain patency in the standard posterior portal and a shaver in the accessory posterolateral portal as seen from the anterolateral portal, B. The Debridement of Hill-Sachs (HS) lesion is then debrided with a shaver or curette to prepare the base for healing, C.

Figure 2

Viewing from the anterolateral portal, the Ssuture anchor is placed in the center of the Hill-Sachs defect, A. The sutures are then Superior suture being retrieved through the capsule, B. After the sutures are tied down, the capsule fills Final view of the Hill-Sachs (HS) defect on the humeral head (HH) filled with capsule after sutures are tied, C.

Video 1

The key steps and technical principles for arthroscopic remplissage of an engaging Hill-Sachs lesion in a patient with anterior shoulder instability are highlighted in this video. highlighting key steps and technical principles. While viewing the right shoulder from the posterior portal with the patient in the beach chair position, the Hill-Sachs lesion is noted to engage the glenoid when the arm abducted and externally rotated. The remplissage procedure is performed through an accessory posterolateral portal while the camera is viewing from an anteriolateral portal.


Table 1

Table 2

Results for "Shoulder: Biceps/Labrum"

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