Arthroscopy: The Journal of Arthroscopic and Related Surgery
Volume 25, Issue 11 , Pages 1343-1348, November 2009

Arthroscopic Double-Pulley Remplissage Technique for Engaging Hill-Sachs Lesions in Anterior Shoulder Instability Repairs

  • Samuel S. Koo, M.D., M.P.H.

      Affiliations

    • The San Antonio Orthopaedic Group, San Antonio, Texas, U.S.A.
    • ,
  • Stephen S. Burkhart, M.D.

      Affiliations

    • The San Antonio Orthopaedic Group, San Antonio, Texas, U.S.A.
    • Department of Orthopaedic Surgery, University of Texas Health Science Center at San Antonio, San Antonio, Texas, U.S.A.
    • Corresponding Author InformationAddress correspondence and reprint requests to Stephen S. Burkhart, M.D., 150 E Sonterra Blvd, Ste 300, San Antonio, TX 78258, U.S.A.
    • ,
  • Eloy Ochoa, M.D.

      Affiliations

    • The San Antonio Orthopaedic Group, San Antonio, Texas, U.S.A.

Received 7 April 2009; accepted 5 June 2009.

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Article Outline

Abstract 

We present a modified arthroscopic technique used to treat anterior shoulder instability associated with mild glenoid bone loss and a large Hill-Sachs lesion. The procedure aims to convert a bony intra-articular defect into an extra-articular defect by insetting the infraspinatus into the Hill-Sachs lesion. The arthroscopic procedure is performed with the patient in the lateral decubitus position, and the same portals used for anterior instability repair are used for this technique. The sequence of steps involves placing and passing the glenoid anchors and sutures and then waiting to tie the anterior sutures until after the humeral suture anchors have been placed. The subacromial bursa is cleared; then 2 transtendon suture anchors are placed in the Hill-Sachs lesion. Next, the previously placed Bankart repair sutures are tied, and finally, the remplissage sutures are tied in the subacromial space over the infraspinatus by use of the transtendon double-pulley technique. This technique uses the eyelets of the 2 suture anchors as pulleys and creates a double-mattress suture.

Key Words: Shoulder instability, Hill-Sachs lesion, Posterior capsulodesis, Infraspinatus tenodesis, Anterior shoulder instability, Glenoid bone defect

 

The senior author has previously reported an unacceptably high failure rate (67%) for arthroscopic suture anchor repair of anterior instability patients with glenohumeral bone deficiency, defined either as an engaging Hill-Sachs lesion, an inverted-pear glenoid, or both.1 Large glenoid-sided defects have been successfully addressed with the open Latarjet procedure. For large engaging Hill-Sachs lesions, numerous surgical options have been proposed, including a variety of defect-filling procedures; procedures to prevent engagement of the lesion, such as Latarjet reconstruction with coracoid autograft; capsular reconstruction; and osteoarticular allograft.1, 2, 3, 4 However, in patients who have an engaging Hill-Sachs lesion without significant glenoid bone loss, we now perform our modified version of the arthroscopic “remplissage,” first described by Wolf et al.5, 6 The purpose of this report is to describe our modification of the arthroscopic remplissage procedure, which differs in some vital ways from the procedure described by Wolf et al.

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Technique 

Our Hill-Sachs remplissage technique differs from the original description of Wolf et al.5, 6 in that we use a double-pulley suture technique with 2 anchors to inset the infraspinatus tendon into the entire Hill-Sachs defect with a broad footprint of fixation.

The patient is placed in the standard lateral decubitus position (Video 1, available at www.arthroscopyjournal.org). The arthroscopic repair is performed through the same portals used for anterior instability repair. These portals include a standard posterior portal, anterior portal (placed just superior to the lateral half of the subscapularis tendon), and anterosuperolateral portal. Two additional percutaneous accessory portals are placed superolateral to the posterior portal for transtendon suture anchor placement.7

We first proceed with the diagnostic glenohumeral arthroscopy through the standard posterior portal. Once we have confirmed the presence of Bankart and Hill-Sachs lesions, we move the arthroscope to the anterosuperolateral portal, where we can obtain a global view of the glenoid and the Hill-Sachs lesion (Fig 1). Dynamic arthroscopic examination from the anterosuperolateral portal can help identify clinically significant humeral-sided bone loss. When the Hill-Sachs deformity engages the glenoid rim in a position of athletic function (abduction and external rotation), it is deemed to be an “engaging Hill-Sachs lesion.” Such lesions may occur in patients with or without inverted-pear glenoid lesions. Our primary criterion for performing the remplissage is a moderate to large Hill-Sachs defect (defined as ≥3 mm deep) (Phillippe Hardy, M.D., personal remplissage communication, 2008) associated with bony glenoid loss of less than 25%. Any Hill-Sachs lesions associated with glenoid bone loss of greater than 25% are better addressed with an open Latarjet procedure. Furthermore, written can be an excellent alternative for borderline arthroscopic cases (i.e., close to 25% glenoid bone loss with a moderate-sized Hill-Sachs lesion) as a means of augmenting stability (Table 1).

  • View full-size image.
  • Figure 1. 

    Intra-articular view of a right shoulder from anterosuperolateral viewing portal. (A) A 30° arthroscope shows the Hill-Sachs defect. (B) A 70° arthroscope provides an even better view of the entire Hill-Sachs defect.

Table 1. Indications for Remplissage
Moderate to large Hill-Sachs defect (≥3 mm in depth) associated with bony glenoid loss of <25%
Borderline arthroscopic cases where bone defect is close to 25% but Hill-Sachs is small to moderate in size

The sequence of steps is important when performing this procedure (Table 2). We recommend placing glenoid suture anchors and passing sutures (without tying them) for the anterior-inferior labral repair and superior labral repair (if a concomitant SLAP lesion is present) first. We then proceed to prepare the Hill-Sachs bone bed for anchor placement. Tying the knots for the Bankart or SLAP repair before placing the anchors for the Hill-Sachs defect can result in disruption of the capsulolabral repair because of the sometimes forceful pushing and manipulation of the shoulder while inserting the suture anchors into the humerus. Therefore we strongly recommend the preparation of the Hill-Sachs bone bed and placement of the anchors in the Hill-Sachs lesion before tying the anterior-inferior labral repair sutures.

Table 2. Remplissage: Sequence of Steps

1.Place and pass glenoid sutures/anchors without tying them (both Bankart and SLAP).

2.Prepare Hill-Sachs bone bed.

3.Position 2 spinal needles to determine the angle of approach for the transtendon placement of the suture anchors.

4.Clear the subacromial space posteriorly and posterolaterally to visualize the musculotendinous portion of the infraspinatus.

5.While viewing intra-articularly, place the suture anchors adjacent to the spinal needles at the superior and inferior margins of the Hill-Sachs defect. (Do not tie.)

6.Tie the glenoid sutures. Start with the Bankart and then proceed to the SLAP.

7.Tie the remplissage sutures.

Our remplissage technique involves passing the sutures just lateral to the musculotendinous junction of the infraspinatus and using a transtendon double-pulley technique for fixation. This technique avoids strangulation of the muscle belly of the infraspinatus and broadens the footprint of the repair.8 Preparation of the humeral bone defect can be easily accomplished with the arthroscope in the anterosuperolateral portal. An angled ring curette is used through the posterior portal to prepare the bone bed for anchor placement (Fig 2). Once the bone bed has been cleared to a bleeding base, 2 spinal needles are used to determine the correct transtendon angle of approach for the suture anchors through the subacromial space (Fig 3). Then, we place the arthroscope in the subacromial space to clear the posterior, lateral, and posterolateral gutters of bursal tissue to visualize and tie the sutures over the infraspinatus (Fig 4). By leaving the spinal needles at the same angle of approach that the suture anchors will take, one ensures adequate subacromial bursal removal for adequate suture visualization, management, and knot tying without later risking damage to poorly visualized sutures. Once the subacromial space has been prepared, the arthroscope is again placed intra-articularly. Two double-loaded anchors are placed at the superior and inferior margins of the Hill-Sachs defect through percutaneous portals adjacent to the 2 previously placed spinal needles. A small-diameter transtendon cannula facilitates anchor placement (Fig 5). We have found the bone in this area to be quite dense in young persons, and therefore we typically use 3.5-mm push-in anchors (Bio-SutureTak; Arthrex, Naples, FL). If the bone is soft, we use 4.75-mm screw-in anchors (Bio-Corkscrew FT; Arthrex). The shoulder may be internally rotated if necessary to provide for a better angle of approach for anchor insertion. Once the Hill-Sachs anchors are placed, we complete the anterior-inferior capsulolabral repair and the SLAP repair by tying the sutures (Bankart sutures first and then SLAP sutures). We then return to the subacromial space to tie down the transtendon sutures using the double-pulley remplissage technique (Fig 6). This technique uses the eyelets of the 2 suture anchors as pulleys and creates a double-mattress suture.8 Final subacromial and intra-articular views verify the completed repair (Fig 7). Our endpoint is to obtain an anatomic labral repair with the humerus centered on the glenoid when viewing through an anterosuperolateral portal.

  • View full-size image.
  • Figure 3. 

    Two transtendon spinal needles are placed, one near the superior aspect of the Hill-Sachs lesion and the other near its inferior aspect. The spinal needles traverse the subacromial space and cross the infraspinatus tendon just lateral to the musculotendinous junction.

  • View full-size image.
  • Figure 4. 

    Subacromial view of a right shoulder from posterior viewing portal. The bursal tissue around the 2 spinal needles is liberally debrided to afford clear visualization of the sutures once the suture anchors are placed.

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  • Figure 5. 

    Intra-articular view (left shoulder) from anterosuperolateral viewing portal. (A) The transtendon cannula (Spear Guide; Arthrex) is inserted adjacent to the spinal needle. (B) Two anchors have been placed, one at the superior aspect of the Hill-Sachs lesion and one at its inferior aspect.

  • View full-size image.
  • Figure 6. 

    A double-pulley technique is used to create a double-mattress suture between the 2 anchors, firmly compressing the tendon bridge against the bone bed of the Hill-Sachs lesion.

  • View full-size image.
  • Figure 7. 

    (A) Subacromial and (B) intra-articular views of completed remplissage. This intra-articular view through an anterosuperolateral viewing portal shows how the remplissage has exteriorized the Hill-Sachs defect and excluded it from the joint.

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Discussion 

Defects of the humeral head articular surface have been known to be associated with shoulder dislocation since the 19th century,9 long before Hill and Sachs10 proposed that such lesions were caused by compression fractures. The significance of the Hill-Sachs lesion has been hotly debated. Bankart11 is famously quoted as stating that “nothing can be done about them.” Meanwhile, other investigators have dismissed the significance of Bankart's “essential lesion,” the anterior glenohumeral capsulolabral disruption, and instead claimed this title for the deformity of the humeral head.12 The senior author's previous work showed that glenohumeral bone deficiency, on both the glenoid and humeral sides, plays a significant role in the failure of arthroscopic shoulder stabilization procedures.1 In that study there were 21 failures (10.8%) in 194 patients with recurrent shoulder instability treated with suture anchors. Those without significant bone defects had a failure rate of 4% versus a 67% failure rate in those with bone defects.1

Historically, several different approaches to address humeral bone loss have been reported.13, 14, 15, 16, 17 Weber et al.17 described the use of rotational osteotomies with good results. This procedure can be technically demanding and is associated with other complications, such as nonunion and neurovascular damage. Gerber and Lambert15 were first credited with the use of bone grafting in patients with Hill-Sachs lesions. Since that report, other approaches, such as disimpaction bone grafting and structural allograft, have all been reported to decrease the articular arc mismatch caused by a large Hill-Sachs lesion.2, 3, 15, 18, 19 More recently, reports of allograft mosaicplasty and osteochondral allograft transport system, both arthroscopic and open, have been published.4, 20 However, allografts carry the potential risks of disease transmission and increased cost.20, 21, 22 As a last resort, shoulder arthroplasty has been recommended for failed instability repairs or excessive bone loss due to chronic locked dislocations.23, 24, 25

Wolf and Pollack6 were the first authors to use the phrase “remplissage” (French for “filling”) in their description of an arthroscopic approach to inset the infraspinatus muscle into a Hill-Sachs deformity. Before this, an open procedure designed to limit the engagement of the Hill-Sachs deformity by insetting the infraspinatus into the Hill-Sachs defect had been described.13 Our remplissage technique differs from that of Wolf and Pollack in that we tie our sutures over the infraspinatus tendon rather than the muscle, thereby obtaining a more physiologic and mechanically sound construct. Furthermore, our technique eliminates the possibility of muscle necrosis due to strangulation by sutures.

We believe that a modified version of the remplissage is an excellent solution for addressing the articular arc mismatch created by moderate- to large-sized Hill-Sachs lesions without significant glenoid bone loss. It is also an excellent alternative for borderline arthroscopic cases (i.e., close to 25% glenoid bone loss with a moderate-sized Hill-Sachs lesion) as a means of augmenting stability.

There are some significant advantages to this procedure. First, it is a minimally invasive approach to convert an intra-articular lesion into an extra-articular lesion, preventing engagement of the humeral defect on the glenoid rim. By performing the procedure in an all-arthroscopic manner, one avoids the morbidity associated with open procedures. In addition, the remplissage does not require additional graft material, thereby making the procedure quick and easy to perform. Despite the theoretic possibility of loss of internal rotation due to tethering of the infraspinatus,26 we have not observed this complication in over 20 cases. Postoperative range of motion and strength have been uniformly excellent with the exception of 1 patient in whom generalized postoperative stiffness developed that required arthroscopic capsular release (anterior, posterior, and inferior) and lysis of adhesions. We believe that our remplissage technique has significant advantages over previously described remplissage procedures, specifically by providing a large footprint of fixation, with direct visualization of knot tying over the infraspinatus tendon for precise and secure repair, and by firmly insetting the infraspinatus tendon (rather than capsule and muscle) into the Hill-Sachs defect.

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Supplementary data 

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Video 1. Arthroscopic Remplissage.

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References 

  1. Burkhart SS, De Beer JF. Traumatic glenohumeral bone defects and their relationship to failure of arthroscopic Bankart repairs: Significance of the inverted-pear glenoid and the humeral engaging Hill-Sachs lesion. Arthroscopy. 2000;16:677–694
  2. Flatow EL, Miniaci A, Evans PJ, Simonian PT, Warren RF. Instability of the shoulder: Complex problems and failed repairs: Part II (Failed repairs). Instr Course Lect. 1998;47:113–125
  3. Burkhart SS, Danaceau SM. Articular arc length mismatch as a cause of failed Bankart repair. Arthroscopy. 2000;16:740–744
  4. Miniaci A, Gish MW. Management of anterior glenohumeral instability associated with large Hill-Sachs defects. Tech Shoulder Elbow Surg. 2004;5:170–175
  5. Wolf EM, Pollack M, Smalley C. Hill-Sachs “remplissage”: An arthroscopic solution for the engaging Hill-Sachs lesion. Arthroscopy. 2007;23(Suppl, Abstr):e1–e2www.arthroscopyjournal.org
  6. Wolf EM, Pollack M. Hill-Sachs “remplissage”: An arthroscopic solution for the engaging Hill-Sachs lesion. Arthroscopy. 2004;20(Suppl 1, Abstr):e14–e15www.arthroscopyjournal.org
  7. Burkhart SS, Lo IKY, Brady PC. Burkhart's View of the Shoulder: The Cowboy's Guide to Advanced Shoulder Arthroscopy. Philadelphia: Lippincott Williams & Wilkins; 2006;
  8. Arrigoni P, Brady PC, Burkhart SS. The double-pulley technique for double-row rotator cuff repair. Arthroscopy. 2007;23:675.e1–675.e4www.arthroscopyjournal.org
  9. Saha AK. Recurrent dislocation of the shoulder: Physiopathology and operative corrections. Stuttgart: Georg Thieme Verlag; 1981;
  10. Hill HA, Sachs MD. The grooved defect of the humeral head. Radiology. 1940;35:690–700
  11. Bankart BA. Discussion on recurrent dislocation of the shoulder. J Bone Joint Surg Br. 1948;30:47
  12. Palmer I, Widen A. The bone block method for recurrent dislocation of the shoulder joint. J Bone Joint Surg Br. 1948;30:53–58
  13. Connolly JF. Humeral head defects associated with shoulder dislocation—Their diagnostic and surgical significance. Instr Course Lect. 1972;21:42–54
  14. Hawkins RH, Hawkins RJ. Failed anterior reconstruction for shoulder instability. J Bone Joint Surg Br. 1985;67:709–714
  15. Gerber C, Lambert SM. Allograft reconstruction of segmental defects of the humeral head for the treatment of chronic locked posterior dislocation of the shoulder. J Bone Joint Surg Am. 1996;78:376–382
  16. Krackhardt T, Schewe B, Albrecht D, Weise K. Arthroscopic fixation of the subscapularis tendon in the reverse Hill-Sachs lesion for traumatic unidirectional posterior dislocation of the shoulder. Arthroscopy. 2006;22:227.e1–227.e6www.arthroscopyjournal.org
  17. Weber BG, Simpson LA, Hardegger F. Rotational humeral osteotomy for recurrent anterior dislocation of the shoulder associated with a large Hill-Sachs lesion. J Bone Joint Surg Am. 1984;66:1443–1450
  18. Re P, Gallo RA, Richmond JC. Transhumeral head plasty for large Hill-Sachs lesions. Arthroscopy. 2006;22:798.e1–798.e4www.arthroscopyjournal.org
  19. Branes J. Tratamiento de las luxaciones recidivantes de la articulacion escapulo humeral. In: Presented at the IV Congress of Simposia Latino Americana Ortopedica y Traumatologia. Santiago, Chile. 1969;
  20. Chapovsky F, Kelly JD. Osteochondral allograft transplantation for treatment of glenohumeral instability. Arthroscopy. 2005;21:1007
  21. Kropf EJ, Sekiya JK. Osteoarticular allograft transplantation for large humeral head defects in glenohumeral instability. Arthroscopy. 2007;23:322.e1–322.e5www.arthroscopyjournal.org
  22. Kelly JD, Ogunro S. Arthroscopic “filling” of Hill Sachs lesions. Arthroscopy. 2007;23:e2;(Abstr) www.arthroscopyjournal.org
  23. Cheng SL, Mackay MB, Richards RR. Treatment of locked posterior fracture-dislocations of the shoulder by total shoulder arthroplasty. J Shoulder Elbow Surg. 1997;6:11–17
  24. Pritchett JW, Clark JM. Prosthetic replacement for chronic unreduced dislocations of the shoulder. Clin Orthop Relat Res. 1987;89–93
  25. Green A, Norris TR. Shoulder arthroplasty for advanced glenohumeral arthritis after anterior instability repair. J Shoulder Elbow Surg. 2001;10:539–545
  26. Deutsch AA, Kroll DG. Decreased range of motion following arthroscopic remplissage. Orthopedics. 2008;31:492

 The authors report no conflict of interest.

 

Note: To access the supplementary video accompanying this report, visit the November issue of Arthroscopy at www.arthroscopyjournal.org.

PII: S0749-8063(09)00523-4

doi:10.1016/j.arthro.2009.06.011

Arthroscopy: The Journal of Arthroscopic and Related Surgery
Volume 25, Issue 11 , Pages 1343-1348, November 2009

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