Anterior Shoulder Instability: To Remplissage or Not to Remplissage

Abstract

Background:

Anterior shoulder instability, with either a bony Bankart lesion or Hill-Sachs defect, increases the risk of failure after arthroscopic labral repair (ALR)—specifically, bipolar lesions that are “off-track” or have an increased propensity for recurrent dislocation. Nonoperative management with the strengthening of the cuff and periscapular region and bracing can be attempted, but surgical intervention is recommended for patients with recurrent dislocation, Hill-Sachs lesion, and glenoid bone loss or high-risk athletes. Remplissage, which is an arthroscopic technique in which the infraspinatus tendon is attached to the Hill-Sachs defect, has been used more frequently in the past few years, given the recent literature showing high rates of recurrent instability after ALR.

Indications:

Ideal remplissage techniques have been debated with some surgeons using anchors with knot fixation and access through the subacromial space at the level of the teres minor, which creates technical difficulty and adds to surgical time. The utilization of 2 single-loaded, knotless, all-suture anchors accessed through the posterior portal and infraspinatus tendon allows for easier visualization, capsulotenodesis, and anatomic approximation of the humeral head to the rotator cuff without the need to access the subacromial space, which makes surgery faster and easier.

Technique Description:

The remplissage technique is an augmentation to ALR. It is performed with 2 single-loaded all-suture anchors using a posterior portal through the infraspinatus tendon into the Hill-Sachs lesion.

Results:

ALR with remplissage provides adequate anterior shoulder stability for patients with “off-track” lesions using a small percutaneous incision through the infraspinatus tendon and placement of 2 knotless all-suture anchors.

Discussion/Conclusion:

Prior studies have demonstrated that adding remplissage to ALR leads to fewer recurrent dislocations postoperatively, especially in contact athletes. Recent literature demonstrates this benefit in patients with both on-track and off-track lesions. A multicenter review found that remplissage in addition to ALR protects against subsequent dislocation and improved patient outcomes.

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

The authors’ disclosures are presented at the beginning of the article.

Background

Off-track Hill-Sachs lesions or on-track lesions in high-risk patients are prone to recurrent instability after isolated Bankart repair. ⁴ In large lesions on the humeral head in high-risk patients, the recommended intervention is to manage the instability through primary labral repair augmented with a remplissage procedure, which involves filling the defect with rotator cuff tendon tissue to restore stability.^1,3,8

Ideal remplissage techniques have been debated, with some surgeons using anchors with knot fixation and access through the subacromial space at the teres minor level, creating technical difficulty and adding to the surgical time.^5-7 The utilization of 2 single-loaded, knotless, all-suture anchors accessed through the posterior portal and infraspinatus tendon allows for easier visualization, capsulotenodesis, and anatomic approximation of the humeral head to the rotator cuff without the need to access the subacromial space, which makes surgery faster and easier.

Indications

The remplissage procedure is commonly indicated for young male patients who participate in contact athletics and have a history of shoulder dislocation or instability. It is suitable for patients with Hill-Sachs defects involving less than 25% glenoid bone loss, where intraoperative assessment reveals dynamic engagement of the anterior glenoid rim or preoperative imaging shows off-track lesions on the Hill-Sachs interval-to-glenoid track (HSI-GT) view. More recently, Lin et al ² demonstrated a benefit of remplissage for both off-track and on-track lesions in high-risk patients who are younger and participate in contact sports with a distance to dislocation of less than 10 mm.

In our current case, an 18-year-old right-hand dominant male defensive lineman presented with recurrent right shoulder instability and pain. He sustained an initial contact injury during a football game, leading to a shoulder dislocation that was reduced on the sideline, allowing him to return to play. However, he experienced 2 more dislocations with spontaneous reductions, followed by a third dislocation that could not be reduced onsite. Notably, the patient has plans to play college football, further underscoring the importance of addressing his shoulder condition to support his athletic goals.

For the preoperative planning, first, the presence of a labral tear with a Hill-Sachs lesion is confirmed on the radiograph and magnetic resonance imaging (MRI). Measurement of the Hill-Sachs lesion and glenoid track should be performed to confirm if the lesion is on-track or off-track, as seen on the slide here. The Hill-Sachs interval (HSI) is calculated as the distance between the medial edge of the Hill-Sachs lesion to the insertion of the articular fibers of the rotator cuff. The HSI here is 26.6, which is greater than the GT of approximately 25, indicating that the current lesion is classified as off-track.

Given his age, sex, contact sport participation, high risk of redislocation, and further damage to the shoulder, including bone, labral, ligament, and cartilage damage, surgical intervention was recommended to include right shoulder arthroscopic labral repair and remplissage.

Technique Description

The patient is placed in the beach-chair or lateral decubitus position per the surgeon's preference. For the purposes of this video, the patient is placed in the lateral decubitus position.

During the surgical procedure, with a view from the anterosuperior portal, a probe is used to estimate the size of the Hill-Sachs lesion intraoperatively. The shaver is introduced through the standard posterior portal, and debridement of the Hill-Sachs lesion is performed to prepare the area for anchor placement. An arthroscopic rasp is utilized here to stimulate bleeding. A spinal needle is used to confirm the direction for the insertion of the anchor through the infraspinatus tendon and into the humeral head. Subsequently, the anchor guide and trochar are placed through the infraspinatus tendon. After adequate placement of the guide onto the desired location on the Hill-Sachs defect, a drill is used, followed by deployment of the distal anchor, a 1.8-mm single-loaded, knotless, all-suture anchor. We prefer using 2 anchors for the remplissage procedure and starting with the distal anchor to have better visualization. The same steps are repeated for the insertion of the proximal anchor. The arthroscope should be used to visualize the humeral head at this time, ensuring no penetration from the drill has occurred. A gentle traction is applied to seat the suture in the bone.

After both anchors are placed, the shuttling sutures of both anchors are cycled to ensure a smooth passage of the repair sutures (the blue sutures in this video) through the anchors. The sutures from each anchor will exit at a different point through the infraspinatus/capsular tissue, but all sutures will exit from the same posterolateral cannula. To complete the repair, the surgeon then loads the repair suture from the distal anchor through the loop of the shuttle suture (the white suture in this video) from the proximal anchor and vice versa. The surgeon then pulls the tail of the shuttle suture of each anchor to complete the double mattress knotless stitch. This will seat the infraspinatus tendon onto the humeral head defect, filling the Hill-Sachs lesion. Following remplissage, labral repair is performed. This technique of the remplissage procedure ensures the approximation of the infraspinatus tendon to the humeral head at the site of the Hill-Sachs lesion.

The most common complication is loss of range of motion, specifically a decrease in external rotation. It is hypothesized that a potential loss in external rotation could occur as a result of the tenodesis of the infraspinatus tendon and posterior capsule into the Hill-Sachs defect, which may act as a mechanical block to external rotation. Redislocation or recurrent shoulder instability can occur, although remplissage can help reduce this risk compared to isolated Bankart repair.

Results

Following the procedure, the standard postoperative protocol for labral repair is followed to include immobilization in a sling for 6 weeks. Physical therapy beginning at 2 weeks postoperatively is initiated with a focus on maximizing range of motion and avoiding anterior capsular stress, followed by strength exercises increased at 3 months postoperatively. Return to sport is allowed once there is full painless range of motion, symmetric strength, stable shoulder, and psychological readiness.

Discussion/Conclusion

A recent randomized control trial, followed up on a previous study comparing isolated Bankart repair to Bankart repair with remplissage for recurrent anterior shoulder instability with a Hill-Sachs defect. ⁹ This study found that at the 4-year follow-up time point, the remplissage group had a significantly lower rate of failure, at 8%, as measured by redislocation, versus 22% in the group of patients who underwent isolated Bankart repair. The remplissage group also had a lower overall recurrent instability at 10%, defined as either redislocation or 2 or more subsequent subluxations, versus 30% in the isolated Bankart repair group. Overall, those who did not receive remplissage experienced treatment failure earlier and underwent more revisions or reoperations compared to those who received concomitant remplissage.

These are our references.