Arthroscopic Anterior Labral Repair and Remplissage in a Young,Active Athlete

Abstract

Background:

Arthroscopic remplissage is an effective adjunct for anterior shoulder stabilization in patients with large engaging Hill-Sachs lesions (HSLs) and without significant glenoid bone loss or on-track HSLs with high risk of recurrence.

Indications:

The arthroscopic remplissage shown was performed in a patient with a high-risk profile for recurrence (age <25, near track) following a first-time traumatic anterior dislocation event. In this specific case, the remplissage was used to fill a near-track HSL, a significant risk factor for recurrence.

Technique Description:

Following diagnostic shoulder arthroscopy, the anterior labral repair is started with placement of the most inferior anchor and passage of the suture around the labrum and capsule. This anchor is not tightened to allow visualization and access to the posterior humeral head. Posterior labral work is then performed if there is a posterior labral tear extension. Next, for the remplissage, 2 double loaded suture anchors are placed spanning the HSL and passed through the capsule/infraspinatus without tightening. The prior placed anterior inferior anchor is then tightened. The remaining anterior labrum is then completed with capsulorraphy using additional 3 knotless suture anchors. Finally, the remplissage is completed using a double pulley method to pull the posterior capsule into fill the HSL.

Results:

Based on literature and the author's experience, addition of a remplissage for arthroscopic anterior stabilization in patients with anterior glenohumeral instability and either off-track HSL, or on-track HSL with high risk of recurrence can significantly reduce rates of recurrent instability when compared to arthroscopic Bankart repair alone.

Discussion/Conclusion:

Arthroscopic remplissage is an effective adjunct for arthroscopic anterior instability in patients with off-track HSLs or on-track HSLs with high risk of recurrence that is efficient with low surgical complication risk when performed with proper technique.

Patient Consent Disclosure Statement:

The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

Graphical Abstract

This is a visual representation of the abstract.

Video transcript

In this video, we present the surgical technique for arthroscopic Bankart repair with remplissage for a patient with anterior shoulder instability.

All relevant disclosures are listed below.

Background

Hill-Sachs lesions (HSLs) are defined as posterosuperior humeral head defects and are a hallmark finding after anterior shoulder instability events. HSLs are commonly classified by the glenoid track (GT) concept, where the HSL is characterized as “on-track,”“off-track,” or “near-track” in relation to the physiologic arc of motion between the humeral head and glenoid.^2,5,6 For off-track lesions without critical glenoid bone loss, arthroscopic labral repair with remplissage is a common treatment strategy. However, recent studies have further suggested this intervention for on-track lesions with small distances to dislocation (generally defined as <10 mm in the literature), known as “near-track” lesions, or for high-risk patients such as contact athletes. ³ The addition of remplissage converts the HSL into an extra-articular lesion and restores an uninterrupted GT.

Indications

Indications and contraindications are listed below. In our practice, engaging HSLs with subcritical glenoid bone loss, as well as on-track HSLs with high risk of recurrence are indications for the addition of remplissage. Risk factors for recurrence include contact athletes, near track lesions, hyperlaxity, more than 1 preoperative dislocation, and age < 25. ³ Contraindications include critical glenoid bone loss (defined as >20%-25%), and any HSL defect greater than 30% of the humeral head.

For this case, we will discuss a 19-year-old right-hand-dominant competitive pole vaulter who sustained a first-time traumatic dislocation of his left shoulder when diving during kickball. His shoulder self-reduced at the time of injury.

On examination, the patient was not in pain at rest, and had relatively preserved range of motion and strength in all planes. With provocative testing, he had a positive O’Briens, positive anterior apprehension sign, and guarding to posterior load shift and circumduction.

Preoperative orthogonal shoulder imaging was obtained demonstrating a reduced shoulder. The radiographs demonstrate an HSL and a small amount of anterior glenoid bone loss, circled in red and yellow, respectively.

Axial and sagittal cuts of the magnetic resonance imaging (MRI) confirmed the presence of the HSL in addition to an anteroinferior labral tear and minor anterior glenoid bone loss.

Preoperative planning starts with the evaluation of the MRI. In addition to identifying the classic Bankart lesion, it is important to identify and quantify humeral and glenoid sided bone loss. In the case of HSLs, we establish whether the lesion is on or off track and also the distance to dislocation (DTD).

For this specific patient, these calculations are shown. First, looking at a representative sagittal cut, we applied the circle of best fit and found the diameters of this circle and the anterior glenoid bone loss, giving a GT of 20.24 mm.

On axial imaging, the HSL interval was measured. Using this measurement and the GT measured on the slide before, we calculated a DTD of 9.44 mm, making this a near-track lesion. Notably, the patient was also found to have posterior labral involvement, but we will focus on the anterior capsulolabral repair with remplissage for the purpose of this video.

Technique Description

We will now shift our focus to the surgical technique.

The patient is positioned in the lateral decubitus position with the left shoulder toward the ceiling and held under 15 pounds of longitudinal traction. All bony prominences were well padded.

Then, the patient's bony landmarks were marked. Anteriorly, the coracoid process was marked out, then the clavicle, acromioclavicular joint, and the acromion were marked. The planned portal sites include the anterior, accessory high anterosuperior lateral (ASL), and posterior portals are also labeled.

The posterior portal is established first and is done by palpating the posterolateral edge of the acromion. We prefer a superior and lateral entry point, about 1 cm distal to the posterolateral edge. This allows an appropriate trajectory for a single working portal for posterior labral repair work if needed and also allows access to the Hill-Sachs defect. The anterior portal is planned by marking approximately halfway between the acromioclavicular joint and lateral aspect of the coracoid process.

Following diagnostic arthroscopy, the 30° arthroscope camera is placed in the posterior viewing portal to visualize the anterior labral tear. Then the anterior portal is established under spinal needle visualization with a trajectory to drill a low 5:30 anchor. A shaver is used to debride any frayed labral tissue. An arthroscopic elevator is used to mobilize the scarred anterior labrum and capsule until the subscapularis muscle is visualized, and a shaver is used to debride frayed labrum and also induce bleeding bone on the medial glenoid.

Starting inferiorly just off the glenoid face at the 5:30 position, a curved drill and guide is used to place a knotless FiberTak anchor (FiberTak, Arthrex) to start the knotless repair. A curved guide offers a better trajectory and viewing from posterior portal allows for optimal viewing for placement of the most inferior anterior anchor prior to the remplissage anchors occupying the posterior portal. A curved suture passer is used to perform a capsular shift with the torn labrum, then the nitinol wire is deployed to shuttle the repair suture. It is important to retrieve the nitinol wire and repair suture as close as possible to the medial glenoid for efficient suture management and to prevent tangle. Using the proprietary mechanism, the repair suture is shuttled through the knotless mechanism. It is important to note that a FiberTak (FiberTak, Arthrex) is used to allow the suture to maintain some slack as to allow maximal space for visualization for the remplissage anchors. Finally, the accessory high ASL portal is established in the rotator interval posterior to the long head of the biceps, under visualization from the posterior portal. This accessory portal is used as a visualization portal throughout the case as the trajectory facilitates excellent access to both the posterior and anterior glenoid, in addition to the inferior glenoid for the Bankart repair, and provides excellent visualization for the remplissage procedure. Attention is now turned to the remplissage anchors as tightening and completing the anterior labral repair prior to the remplissage will reduce the humeral head posteriorly and diminish joint mobility and visualization and make placement of the remplissage anchors more difficult.

As stated previously, this patient's injury did include a posterior labral tear, which was repaired prior to remplissage anchor placement and in a similar fashion to the anterior labrum. We will skip the specifics because it is outside the scope of this video, but for clarity, in the video we have included a still image of the completed repair here.

The HSL is now visualized. A rasp and shaver are used to prepare the HSL. Note that the purpose of this preparation is to clear any excess soft tissue and fibrocartilage and to decorticate the surface to maximize healing.

Then, a sharp trochar is used to push through the posterior capsule just inferior to the site where the cannula was originally inserted, and the first inferior anchor is placed. Anchor pullout, a potential pitfall, is unlikely given the increased bone density from the compressive mechanism that formed the HSL. In the rare event it occurs, the anchor can easily be upsized. The goal will be to incorporate the posterior inferior capsule into the remplissage. Active visualization throughout cannula movement avoids tethering other soft tissue structures.

This is repeated on the superior aspect of the original portal to incorporate the capsule into the superior aspect of the HSL. The different color sutures allow easy identification of superior and inferior anchors. This method allows an all intra-articular technique for remplissage without having to retrieve or manipulate the sutures in the subacromial space. Note that the anchors should remain perpendicular to the surface of the HSL during placement to prevent skiving.

This cartoon illustration of the remplissage procedure demonstrates incorporation of the posterior capsule into the HSL, while avoiding the infraspinatus tendon. As shown in this diagram, since both anchors are inserted within the cannula, which is immediately superficial to the capsule but deep to the infraspinatus, all sutures trace back through the posterior cannula only diverging at the posterior capsule superiorly and inferiorly. Thus, when a double pulley method is employed only the posterior capsule is captured when the sutures are tied down.

With the superior and inferior anchors established for the remplissage, we turn our attention back to complete the anterior labral repair. This is done with the camera in the accessory high anterosuperior portal and through the regular working anterior portal. The initial suture passed previously from the low anchor is now cut. Apart from the initial anteroinferior labral repair seen, the technique outlined above is repeated 2 to 3 more times along the torn edge of the anterior labrum until the anterior labral repair and capsulorraphy are complete. In this video, knotless PushLock anchors (PushLock, Arthrex) with suture tapes were passed at the 5, 4, and 3 O'clock positions. Unlike anchor 1, which used a FiberTak anchor (FiberTak, Arthrex), anchors at these positions are the appropriate trajectory for PushLock anchors (PushLock, Arthrex). In addition, we can see that the humeral head tracks more centrally now through the glenoid with the repair complete.

Finally, attention is turned back toward the HSL to complete the remplissage. With the superior and inferior anchors placed, a double pulley method is employed. One suture from each anchor is tied together outside of the cannula with 6 alternating half-hitches. The remaining suture limbs from each are shuttled back and forth to pull down the posterior capsule to fill the HSL using a double pulley technique. An external view of this technique is shown. A knot pusher is then used to tie the remaining 2 suture limbs with 6 alternating arthroscopic half-hitches from outside-in to lock the repair. Note that this remplissage technique uses the posterior capsule to fill in the HSL and avoids incorporation of the infraspinatus tendon, as described previously in the literature. This is the senior surgeon's preference, to minimize theoretical risk of decreased range of motion due to constraint of the tendon during normal shoulder range of motion. Complications such as decreased external rotation and overtightening are still possible. This unique technique is an expert opinion (level V) and an area of interest we continue to research.

Postoperatively, the arm is immobilized in a sling for 4 to 6 weeks with no formal PT or pendulum swings, although elbow range of motion is initiated at the first postoperative visit to prevent stiffness. Starting at 4 to 6 weeks, shoulder pendulums are initiated, as well as a home-based exercise apparatus and passive range of motion exercises. External rotation is limited to 30° for the first 6 to 8 weeks, then active range of motion is initiated at 8 to 10 weeks, followed by strengthening exercises at 12 weeks.

Patients are generally allowed to return to sport in 5 to 6 months, but final determination is based on a objective criteria-based return-to-sport testing protocols that are used by our physical therapists and during the postoperative visit.

Discussion

The literature has demonstrated positive outcomes following the use of remplissage with arthroscopic labral repair. MacDonald et al ⁴ performed a 2021 prospective study with 2-year follow-up, and found a 4% recurrent dislocation rate following anterior labral repair with remplissage, compared to 18% with labral repair. A retrospective study by Domos et al ¹ found similar results, where anterior shoulder instability patients who underwent labral repair without remplissage had a 30% recurrent dislocation rate, compared to a 5% rate for those who underwent remplissage. A study performed at our institution looking at contact athletes and near-track lesions found a 3.2% failure rate for anterior labral repair with remplissage for high-risk patients, compared to a 21% failure rate after isolated anterior labral repair. ³ These studies demonstrate the utility of the remplissage, and show that it is an important adjunct procedure to prevent failure and improve patient outcomes, especially in the young, high-risk athletes.

These are our references.

Thank you for your attention.