Remplissage
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The document describes a study evaluating the "Remplissage" arthroscopic technique for treating traumatic shoulder instability accompanied by glenoid bone loss and Hill-Sachs defects. The study involved 28 patients who underwent the Remplissage procedure. Post-operatively, patients showed excellent functional outcomes with no reoccurrences of dislocation, nearly full return to work and sports, and significant improvements in shoulder scoring systems. The conclusion is that Remplissage offers excellent short-term results for addressing shoulder instability with humeral bone loss, despite some loss of external rotation.
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- 1. E. Mataragas, C. Vassos, N. Tzanakakis, G. Mouzopoulos, C.K. Yiannakopoulos, Emm. Antonogiannakis 2nd Orthopaedic Dpt. – Shoulder and Arthroscopy Unit, IASO GENERAL Hospital OUR EXPERIENCE WITH “REMPLISSAGE” IN CASES WITH HUMERAL BONE LOSS HILL-SACHS DEFECTS
- 2. BACKGROUND Hill Sachs Lesion Impression fracture of the posterolateral humeral head; Present in 90% of anterior dislocations and 25% of anterior subluxations. (Calandra JJ, Arthroscopy 1989;5:254) Can also be reverse.
- 3. GRADING Less than 20% of head (minor) Between 20-45% of head (moderate) Greater than 45% of head (severe)
- 4. GRADING Burkhart SS, De Beer JF : Arthroscopy 2003;19 : 732–739 Engaging Non Engaging
- 5. GRADING Arthroscopic Grade I: defect in the articular surface down to subchondral bone Grade II: includes the subchondral bone Grade III: large subchondral defect Calandra et. Al, 1989
- 6. GUIDELINES Most Hill-Sachs lesions are small and don’t require treatment. Each lesion should be evaluated during surgery. Require treatment: - Lesions found to be engaging in a normal ROM. - Lesions representing >30% of the articular surface.
- 7. TREATMENT OPTIONS Humeral rotation osteotomy (Weber BG, JBJS 1984;66A:1443) Hemiarthroplasty / TSA for patients >50y/o (Flatow E, JSES 1993;2:2) Humeral head allograft (Gerber C, JBJS 1996;78A:376) Remplissage (Wolf EM, Arthrosopy 2004;20(suppl1) :e14)
- 8. PURPOSE To evaluate the Remplissage arthroscopic technique as described by Eugene Wolf used in patients with traumatic shoulder instability that present glenoid bone loss and Hill Sachs defects.
- 9. STUDY DESIGN Retrospective, continuous, monocentric Series of 28 patients Epidemiology 23M, 5F -Mean age of patients: 31 1st episode: 20 dislocations: 24 -Revision surgery: 4 -Joint hypermobility: 14 Sport Participation Athletes: 18 8 Overhead 0 Contact 10 Overhead & Contact No sports: 10
- 10. STUDY DATA Follow up ranged from 5-28 months (Mean=18). Post op rehabilitation was supervised by a doctor dedicated to shoulder problems. Recurrence and functional outcome were evaluated pre-op and post-op with the Rowe Zarins Score.
- 11. ARTHROSCOPIC SURGERY One Surgeon (A.E.) performed all the procedures. The arthroscopic procedure performed was the Remplissage technique as described by Eugene Wolf in conjuction with a typical soft tissue repair.
- 12. OPERATIVE FINDINGS Osseous Lesions: Hill Sachs 28 Large or medium Glenoid loss 11 “Inverted pear” glenoid shape 4 “Bony” Bankart Lesion 6 Osteoarthritis 0
- 13. OPERATIVE FINDINGS Soft Tissue Lesions: Bankart Lesions 22 22/28 (78,6%) SLAP 11 11/28 (39%) Supraspinatus Tear 1 1/28 (3,6%) Capsular Distention 3 3/28 (10,7%)
- 14. “REMPLISSAGE” TECHNIQUE The Hill-Sachs lesion is freshened with a bur.
- 15. “REMPLISSAGE” TECHNIQUE A cannula is inserted in the posterior portal through the deltoid and an anchor is placed in the inferior aspect of the humeral lesion.
- 16. “REMPLISSAGE” TECHNIQUE A penetrating grasper is passed through the tendon and posterior capsule, 1 cm inferior to the initial portal entry site to pull 1 suture limb.
- 17. “REMPLISSAGE” TECHNIQUE The inferior suture is tied first with the knots remaining extra-articular, pulling the infraspinatus and capsule into the lesion.
- 18. SUBJECTIVE RESULTS Patient Satisfaction 28 Very Satisfied/Satisfied 100% Return to Work 100% Return to Sports 10 on the same level 55,5% 8 on lower level 45,5%
- 19. FUNCTIONAL RESULTS Pre-Op Post-Op p Rowe Zarins 23 97 < .0001
- 20. RESULTS ON STABILITY No reccurent Dislocations so far
- 21. RESULTS ON PAIN 9 shoulders remained painful 1 effort (7 months post-op), 8 barometric 2 had previous procedures All 9 patients described the pain as minimal. No patients presented O.A.
- 22. R.O.M. 10 patients showed decrease in external rotation (arm at the side) 0ο -15ο
- 23. CONCLUSION The “Remplissage” technique in patients with humeral bone loss seems to offer so far excellent post op results despite the slight decrease in the external rotation of the shoulder.