Arthroscopic Transtendinous Double-Pulley Remplissage Technique in the Beach-Chair Position for Large Hill-Sachs Lesions

Arthroscopic Posterior Labral Repair in Active-Duty Military Patients: A Reliable Solution for an At-Risk Population, Regardless of Anchor Type

BACKGROUND

Active-duty servicemembers are a population at risk for the development of posterior shoulder instability. While short-term outcomes after arthroscopic posterior labral repair for posterior shoulder instability are promising, there is a paucity of longer term follow-up data for this procedure.

PURPOSES

The primary purpose was to report midterm outcomes after arthroscopic posterior labral repair in active-duty military patients for posterior shoulder instability without bone loss. The secondary purpose was to determine if outcomes varied between anchor types used.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Preoperative and postoperative outcomes, with a minimum 3-year follow-up, for a visual analog scale for pain, the Single Assessment Numeric Evaluation (SANE), the American Shoulder and Elbow Surgeons (ASES) score, and the Rowe score were collected and analyzed. A separate subgroup analysis was performed comparing the outcomes of patients who underwent repair with biocomposite anchors versus those who underwent repair with all-suture anchors.

RESULTS

A total of 73 patients with a mean follow-up of 82.55 ± 24.20 months met the inclusion criteria and were available for analysis. As a whole, the cohort demonstrated statistically and clinically significant improvements in outcome scores at final follow-up. Preoperative and postoperative range of motion did not vary significantly. While the difference in final outcome scores between the 2 anchor types did not reach statistical significance, a statistically significantly larger proportion of patients who underwent repair with all-suture anchors versus those who underwent repair with biocomposite anchors met the Patient Acceptable Symptom State for the SANE (97.14% vs 78.95%, respectively; P = .0180) and the ASES score (88.57% vs 68.42%, respectively; P = .0171). The proportion of patients who achieved the substantial clinical benefit or surpassed the minimal clinically important difference, however, did not vary by anchor type. Overall, 70 patients (95.89%) remained on active duty and were able to return to preinjury work and recreational activity levels. There were 3 patients (4.11%) who had recurrent posterior instability.

CONCLUSION

This population of active-duty servicemembers undergoing posterior labral repair for posterior labral instability without bone loss demonstrated a statistically and clinically significant improvement in midterm outcomes, a low recurrence rate, and a rate of return to active duty of 95.89%, regardless of the anchor type used.

Double-Pulley Remplissage in Active-Duty Military Population With Off-Track Anterior Shoulder Instability Results in Improved Outcomes and Low Recurrence at Minimum 4-Year Follow-Up

PURPOSE

To report mid-term outcomes of active-duty patients with anterior shoulder instability following our technique for double-pulley remplissage (DPR) with concomitant anterior labral repair.

METHODS

All consecutive patients from 1/2010 through 12/2016 that underwent DPR by the senior surgeon with complete outcome scores were identified. All patients had experienced a shoulder dislocation following a traumatic event, and had subsequent instability recalcitrant to conservative management. Patients were excluded if they were lost to follow-up (3) of if they underwent stabilization procedures other than DPR (148). Outcome measures were completed by patients within 1 week prior to surgery and at latest follow-up. Twenty-four patients met the inclusion criteria for the study, and all were active-duty military at the time of surgery.

RESULTS

20/24 (83.3%) patients met the patient acceptable symptomatic state (PASS), while 21/24 (87.5%) achieved substantial clinical benefit (SCB) and 22/24 (91.7%) exceeded the minimal clinically important difference (MCID) for their operative shoulder, as determined by the American Shoulder and Elbow Surgeons (ASES) Score. 21/24 (87.5%) patients met the PASS, while 19/24 (79.2%) achieved SCB and 20/24 (83.3%) exceeded the MCID for their operative shoulder, as determined by the single assessment numeric evaluation (SANE). In addition, 23/24 (95.8%) patients exceeded the MCID for their operative shoulder, as determined by the Rowe Instability score. Preoperative and postoperative range of motion did not vary significantly. All patients had decreased pain postoperatively (P < .0001); 22/24 (91.67%) of patients remained on active-duty status. Failure rate, defined as recurrent subluxation or dislocation, was 4.2%.

CONCLUSIONS

Mid-term outcomes in this population of active-duty patients undergoing DPR for shoulder instability without glenoid bone loss demonstrate a statistically and clinically significant improvement in patient-reported outcomes, a significant decrease of pain and an overall return to active-duty rate of 91.67%.

LEVEL OF EVIDENCE

IV, therapeutic case series.

Editorial Commentary: Double-Pulley Remplissage Using Transtendon Anchors: Keep It Simple

A large Hill-Sachs lesion that engages the glenoid rim and predisposes to recurrent anterior instability confers a substantial management challenge. Arthroscopic remplissage, either in isolation or combined with anterior labral repair, gives the arthroscopic surgeon a tool to stabilize the shoulder without reverting to more extensive open procedures or bone block reconstructions. In arthroscopic remplissage, the posterior capsule and infraspinatus are sutured into the humeral defect to limit such engagement between the HilleSachs lesion and the glenoid rim. The double-pulley technique using 2 transtendon anchors makes arthroscopic remplissage technically simpler, and potentially more reproducible, than earlier techniques. As we refine remplissage techniques, we need to further explore issues such as the optimal distance between the 2 anchors (and hence the resultant tendon bridge) as this distance-along with the pliability of the tendon-potentially determines how much compression against the bone can be achieved. Furthermore, as remplissage techniques are proven to be effective in restoring shoulder stability and conferring successful clinical function, there is even more need for high-quality comparative studies to define their role versus that of more extensive open stabilization procedures. Mechanistic studies are also needed to define the fill-effect versus the possible check-rein and neuromuscular control activation components of remplissage.

Arthroscopic Remplissage Using a Double-Pulley System for Hill-Sachs Lesions for Recurrent Shoulder Instability

Hills-Sachs lesions are bony lesions in the humeral head that occur as a result of an anterior shoulder dislocation. These lesions often happen in conjunction with tears of the labrum, and large, engaging lesions must be addressed in order to avoid recurrent instability. Moderate to large (≥3 mm deep) Hill-Sachs defects can be treated using arthroscopic remplissage to reduce the rotator cuff down into the lesion. We describe in this Technical Note and accompanying video an adaptation of the classic arthroscopic remplissage that uses a knotless double-pulley technique with 2 suture anchors, which increases the footprint of fixation, reduces the technical difficulty of the procedure, and minimizes the number of portals that need to be made.

The Tripod-Pulley Technique for Arthroscopic Remplissage in Engaging Hill-Sachs Lesions

Arthroscopic Bankart repair is now a well-established technique for the treatment of shoulder instability. However, failure rates are considerable when significant bony defects are not addressed. Hill-Sachs lesions, present in the vast majority of those with recurrent anterior instability, when of significant dimension and location, may account for some of these failures. The remplissage procedure involves capsulotenodesis of the posterior capsule and the infraspinatus tendon to fill the Hill-Sachs lesion. "Double-pulley" remplissage is a transtendinous technique that has been described elsewhere and that may simplify the procedure. We present a modification of this technique, the "tripod-pulley" technique, which we feel may potentiate healing of the Hills-Sachs lesions of the capsule and infraspinatus by increasing the surface contact area. At the same time, this technique minimizes the risk of potential damage to the infraspinatus as it uses 2.3-mm "all-suture" anchors.