Arthroscopic Anterior Labral Repair with Concurrent Remplissage

Abstract

Background:

Shoulder instability is a complex problem, particularly in the setting of concomitant subcritical bone loss, which may increase patients’ risk of recurrent dislocation. Although bony augmentation may be successful for patients with critical bone loss, those with subcritical bone loss may benefit from arthroscopic labral repair and remplissage.

Indications:

Indications for arthroscopic stabilization and remplissage include (1) off-track or engaging Hill-Sachs lesions with subcritical bone loss, which often measure between 20% to 40% in volume; (2) failed previous arthroscopic repair without bone loss; and (3) collision or contact athletes with smaller, on-track Hill-Sachs lesions that are at higher risk for recurrence.

Technique Description:

The patient is placed in the lateral decubitus position, with the arm in a pneumatic arm holder to assist with traction. Examination under anesthesia is performed. The Hill-Sachs lesion on the posterolateral humeral head is visualized, and the bony bed is prepared for healing. Traction is removed during the remplissage suture passage and final tightening. Two knotless anchors are placed through the infraspinatus and into the defect through the same cannula. The repair stitches from each anchor are shuttled through the opposing anchor's shuttling stitch, which creates a double mattress, staple-like configuration. The remplissage is not tightened until the end of the case to limit closing down the shoulder volume. The labral repair is performed then in standard fashion, utilizing knotless anchors and advancing capsulolabral tissue. The capsulolabral repair is retensioned with each new anchor. Once the labral repair is complete, traction is relieved, and the remplissage is finally tightened.

Results:

Outcomes after labral repair with concomitant remplissage are similar to labral repair alone, but with lower rates of dislocation. Current data demonstrate a similar range of motion, including external rotation, with additive remplissage.

Discussion/Conclusion:

Arthroscopic anterior labral repair with remplissage is a useful technique for patients at high risk for dislocation, whether due to anatomic or patient-specific factors. Current postoperative outcomes are similar to labral repair alone, with lower rates of dislocation without loss of motion.

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 following is a video presentation describing a surgical technique for shoulder arthroscopic labral repair with concurrent remplissage in the management of a patient with a large anteroinferior labral tear and a Hill-Sachs lesion in the setting of recurrent anterior shoulder dislocations.

In this video, we will provide a brief overview of the surgical management of labral tears, present a case, discuss surgical pearls, describe our postoperative management, and review postoperative outcomes.

Background and Indications

A Hill-Sachs lesion is a compression fracture of the posterosuperolateral aspect of the humeral head that occurs from impaction along the glenoid rim in an estimated 40% to 90% of anterior shoulder instability events.^2,3,7 The concept of the glenoid track describes the interface of bone on the glenoid and humeral head as on track or off track.^3,6,8 Lesions that are deemed to be off track are those in which the size of the Hill-Sachs lesion exceeds that of the remaining track, which is commonly defined as 83% of the glenoid diameter. Off-track lesions are associated with a high risk of engaging the glenoid rim and recurrent dislocation.^5,7 Arthroscopic labral repair with remplissage, which means to fill, has traditionally been indicated for off-track lesions; however, recent indications have expanded to include on-track lesions with subcritical bone loss with good results. ⁴

Indications for arthroscopic stabilization and remplissage include (1) off-track or engaging Hill-Sachs lesions with subcritical bone loss, which often measure between 20% to 40% in volume; (2) failed previous arthroscopic repair without bone loss; and (3) collision or contact athletes with smaller, on-track Hill-Sachs lesions that are at higher risk for recurrence.

Arthroscopic labral repair with concurrent remplissage is being performed with increasing frequency as indications expand and the incidence of shoulder instability rises. Therefore, the authors aim to present a case to highlight several technical pearls for performing the procedure.

In this case, a 22-year-old right-hand-dominant, otherwise healthy male collegiate hockey player presents to our clinic after sustaining a left shoulder dislocation 1 year prior when he was checked during a face-off. Since that time, he reports 5 to 6 episodes of recurrent shoulder dislocation in hockey and physical therapy, twice necessitating reduction in the emergency department.

Physical examination of the left shoulder was notable for a normal range of motion, equivalent to the contralateral side—including active forward flexion to 170°, abduction to 170°, external rotation to 60°, and internal rotation to the mid thoracic level. The patient had 5/5 rotator cuff strength testing, but positive apprehension testing, relieved by relocation maneuver. ¹ The patient had a normal neurovascular examination.

A standard 3-view series of shoulder radiographs was obtained and notable for a moderately sized osseous Hill-Sachs lesion at the edge of the humeral articular surface. A magnetic resonance imaging of the left shoulder demonstrated intact rotator cuff tendons without signs of muscular atrophy, in addition to the previously mentioned Hill-Sachs lesion and a tear of the anterior labrum from 3- to 6-o'clock. A 3-dimensional computed tomography scan was obtained to further characterize the Hill-Sachs lesion, which showed a 2 cm transverse × 2 cm craniocaudal × 0.3 cm in depth. There were no other signs of glenoid or humeral fracture.

Given the patient's clinical history, examination, and imaging findings, the patient was indicated for an arthroscopic Bankart repair with remplissage.

Technique Description

In the operating room, we position the patient in the lateral position. An examination under anesthesia is performed, demonstrating anterior shoulder instability, with the ability to sublux the humeral head to the glenoid rim. A distractor is applied to the operative limb. The following portals are marked along with the native anatomy of the scapular spine, acromion, distal clavicle, and coracoid: a posterior viewing portal, an anterosuperior viewing portal, a standard anterior portal, an accessory posterior portal for remplissage, and 5- and 7-o’clock portals.

From the initial posterior viewing portal, standard lateral position diagnostic arthroscopy is performed. This demonstrates an anteroinferior labral tear from 3- to 6-o’clock. The anterior portal is created with spinal needle localization just superior to the subscapularis tendon upper border, with an entry point closer to the humeral head and a trajectory aimed down toward the glenoid face. The anterior portal is dilated, and an 8.25-mm cannula is placed.

The anterosuperior portal is created at an entry point just distal to the anterolateral border of the acromion. The spinal needle should enter superior to the biceps tendon, again aiming toward the glenoid. A switching stick is used to switch to this anterosuperior portal, which serves as the viewing portal.

An arthroscopic shaver is placed through the posterior portal and utilized to debride frayed labral tissue.

We then turn attention to the remplissage. Anchor and suture passage is performed for the remplissage before the labral repair, and final tightening of the remplissage is then performed after the labral repair. The arm is relaxed during this portion of the procedure. A spinal needle is localized to penetrate through the posterior capsule and infraspinatus into the humeral head Hill-Sachs defect. A curette is used to debride soft tissue, followed by a shaver to prepare the bony bead for healing.

A cannula is placed through the soft tissues up to the superficial aspect of the infraspinatus tendon. The cannula helps guide the drill guide for the anchor, which will pierce the infraspinatus and enter the humeral head defect inferiorly. The drill is used, and the anchor is placed with standard technique. The sutures remain within the cannula and the cannula remains in the same plane and moves to a new, superior location. A second anchor is placed superiorly to the first by about 1 cm in a similar fashion. The sutures from each anchor are identified and should be through the same cannula. The repair stitch from 1 anchor is passed through the loop shuttling stitch of the opposite anchor and shuttled in. This step is repeated for the other anchor. Once the sutures are shuttled in, slack is removed, and the remplissage is not finally tightened until the end of the case. Ultimately, this configuration will create a double mattress, staple-like, knotless configuration.

Arm distraction is reapplied, and attention is turned to the labral repair. An angled elevator is utilized to elevate the anterior labrum and capsule. A shaver and rasp are used to create a bony bed for healing. A grasper evaluates the ability to retension the capsulolabral complex. The 5-o’clock portal is localized with a spinal needle, angled toward the glenoid face for anticipated percutaneous anchor placement. The knotless all-suture anchor is placed through a standard technique. A curved suture passing device is passed through the labrum and capsule, and a No. 0 polydioxanone (PDS) suture is shuttled into the joint. The PDS and repair stitch are removed through the posterior portal, and the PDS is used to shuttle the repair stitch around the labrum. Then, the looped end of the shuttling suture and the repair stitch are taken out of the anterior portal, and the repair stitch is shuttled through the shuttling suture. The labrum is reduced with a grasper while the repair stitch is tensioned to secure the knotless configuration.

This process is repeated for additional anchors as necessary. Each time a new anchor repair stitch is ready to be tightened, the labrum and capsule are reduced before tightening. The prior more inferior anchors can again be retensioned at each step. Here we show the process again for a third and ultimately fourth anchor, coming more superiorly each time.

Attention is turned back to the remplissage. The arm jack and distraction are relaxed, and the repair stitches are final tightened, securing the double mattress knotless configuration by pulling tension in an alternating fashion. A closed-end arthroscopic cutter is used to cut the knots on the superficial side of the infraspinatus and capsule.

Key pearls for the surgical technique are listed here. We recommend passing the anchors and shuttling the sutures for the remplissage at the beginning of the case, while the view of the Hill-Sachs defect is facilitated by the humeral head subluxing anteriorly. However, these sutures should be tightened only at the end of the case after the labral repair is complete. Before tensioning the repair stitch from each anchor, the capsulolabral complex should be reduced. The knotless mechanism may be retensioned at each anchor throughout the case. The remplissage should be final tightened with minimal distraction and displacement of the operative limb with the arm in a neutral rotation position.

Results

Postoperatively, patients are placed in a sling with a focus on passive range of motion from days 10 to 14. Additionally, during the first 4 weeks, emphasis is placed on deltoid and rotator cuff isometrics. The sling is discontinued at 4 weeks postoperatively. During weeks 4 to 8, patients progress from active assist to active range of motion, with goals of forward flexion to 140° and external rotation to 40°. Additionally, patients focus on periscapular strengthening during this time. During weeks 8 to 12, patients aim to achieve full range of motion with progression in external rotation and strengthening below the horizontal plane. From postoperative month 3 onward, focus is turned to advanced eccentric strengthening and progressive resistive exercises, which begin below the 90° horizontal plane and eventually progress to overhead.

A 2023 systematic review and meta-analysis comparing arthroscopic Bankart repair with concurrent remplissage to Bankart repair alone and Latarjet alone found that Bankart repair with remplissage had a statistically superior rate of return to play as well as a reduced rate of instability recurrence and reoperations despite equivalent functional scores. ⁴ Another recent study investigating Bankart to Bankart with remplissage for patients with on-track Hill-Sachs lesions and subcritical glenoid bone loss found superior functional outcomes, reduced residual apprehension, and equivalent shoulder external rotation, and risk of dislocation in the Bankart with remplissage group, highlighting the potential for expansion of surgical indications for this effective combination procedure. ⁹

Conclusion

Bankart repair with concurrent remplissage is a procedure gaining popularity that may be performed efficiently and reproducibly through the approach highlighted in this technique video.