What is Arthroscopic Remplissage?
Arthroscopic remplissage is a surgical technique performed in combination with arthroscopic Bankart or arthroscopic anterior shoulder stabilization surgery in order to correct an extensive engaging Hill-Sachs defect or lesion in the shoulder. This lesion engages the shoulder socket or anterior glenoid, resulting in insufficient space for overhead movement, which limits shoulder range of motion. The Remplissage technique has been found to be successful in decreasing the instances of recurrent anterior shoulder instability when utilized in conjunction with arthroscopic Bankart repair.
The principal advantage of the Remplissage technique is the ability to manage the Hill-Sachs lesion without affecting the anterior glenoid rim. It is perfect for individuals who experience shoulder instability because of large Hill-Sachs lesions. These individuals frequently have a higher degree of failure than individuals with small lesions. The Remplissage technique has a lesser recurrence rate than procedures involving only arthroscopic Bankart repair.
Anatomy of the Shoulder
The shoulder is a ball and socket joint, formed by the bone of the upper arm (humerus), which articulates with the shoulder blade in a cavity called the glenoid fossa. The joint relies a great deal on surrounding soft-tissue structures such as tendons, ligaments, and muscles (rotator cuff muscles) to maintain smooth motion and stability. The glenoid cavity is surrounded by a raised ridge of cartilage called the labrum that deepens the cavity and a ligamentous structure called the shoulder capsule that centers the humerus in the cavity. The biceps muscle, certain back muscles, as well as a group of muscles, called the rotator cuff all work together to stabilize the shoulder.
Indications for Arthroscopic Remplissage
The main indication for arthroscopic remplissage technique is anterior shoulder instability connected with a large engaging Hill Sachs defect and minimal to no glenoid bone loss and adequate capsular tissue.
- Anterior shoulder instability: Also known as anterior glenohumeral instability is a shoulder condition in which damage to the soft tissues or bone causes the head of the humerus (upper arm bone) to dislocate or sublux from the glenoid fossa, compromising the function of the shoulder.
- Hill-Sachs lesions: Damage to the back and outer portion of the humeral head can result in a defect called a Hill-Sachs lesion. A Hill-Sachs lesion usually occurs when the humeral head dislocates towards the front of the joint.
- Bankart tear or injury: A specific type of labral tear that occurs when the shoulder dislocates is called a Bankart tear. This is a tear to a part of the labrum called the inferior glenohumeral ligament and is common in the young who sustain a dislocation of the shoulder.
Preparation for Arthroscopic Remplissage
Preoperative preparation for anterior shoulder stabilization surgery may involve the following steps:
- A thorough examination is performed by your doctor to check for any medical issues that need to be addressed prior to surgery.
- Depending on your medical history, social history, and age, you may need to undergo tests such as bloodwork and imaging to screen for any abnormalities that could compromise the safety of the procedure.
- You will be asked if you have allergies to medications, anesthesia, or latex.
- You should inform your doctor of any medications, vitamins, or supplements that you are taking.
- You may need to refrain from supplements or medications such as blood thinners or anti-inflammatories for a week or two prior to surgery.
- You should refrain from alcohol or tobacco at least a few days prior to surgery.
- You should not consume solids or liquids at least 8 hours prior to surgery.
- A written consent will be obtained from you after the surgical procedure has been explained in detail.
Procedure for Arthroscopic Remplissage
Arthroscopic remplissage technique is usually performed after dealing with the Bankart tear or lesion. During an arthroscopic Bankart repair, your surgeon makes a few small incisions (portals), about half-inch in length, over your shoulder joint. An arthroscope, a slender tubular device attached with a light and a small video camera at the end is inserted through one of the incisions into your shoulder joint. The video camera transmits the image of the inside of your shoulder joint onto a television monitor for your surgeon to view. Your surgeon then uses small surgical instruments through the other tiny incisions to trim the edges of your glenoid cavity. Suture anchors are then inserted to reattach the detached labrum to the glenoid.
Arthroscopic remplissage technique does not need any additional surgical incisions. During the procedure, an arthroscope is inserted into the anterior portal to view the Hill-Sachs lesion that is located on the posterior portion of the humerus. A surgical bur (cutting instrument) is inserted through the posterior to remove the lesion. Then, a large suture anchor (fixation devices for fixing ligaments and tendons to bone) is placed into the Hill-Sachs lesion through the posterior portal. Sutures are then introduced into the infraspinatus tendon and posterior capsule before they are tied with a parachute technique. Remplissage is a French word meaning "To Fill the Defect." Therefore, in this technique, an extra pair of anchors are introduced into the Hill-Sachs lesion and the infraspinatus rotator cuff tendon is repaired into the defect to fill the defect. Finally, the tiny keyhole incisions are closed and covered with a bandage.
Postoperative Care Instructions and Recovery
In general, postoperative care instructions and recovery after arthroscopic remplissage involves the following steps:
- You will be transferred to the recovery area to be monitored until you are awake from the effects of anesthesia.
- Your nurse will monitor your blood oxygen level and other vital signs as you recover.
- You may notice some pain, swelling, and discomfort in the shoulder area. Pain and anti-inflammatory medications are provided as needed.
- You may also apply ice packs on the shoulder to help reduce swelling and pain.
- Antibiotics are prescribed for the risk of infection associated with surgery.
- Your arm may be secured with assistive devices such as a sling for the first few weeks to facilitate healing.
- You are advised to walk as frequently as possible to prevent the risk of blood clots.
- Keep your surgical site clean and dry. Instructions on surgical site care and bathing will be provided.
- Refrain from smoking as it can negatively affect the healing process.
- Eating a healthy diet rich in vitamin D is strongly advised to promote healing and a faster recovery.
- Refrain from strenuous activities and lifting heavy weights for a defined period. A gradual increase in activities over a period of time is recommended.
- An individualized physical therapy protocol is designed to help strengthen your shoulder muscles and optimize shoulder function.
- You will be able to resume your normal activities in a month or two with certain activity restrictions; however, return to sports may take about 6 months or longer.
- Refrain from driving until you are fully fit and receive your doctor’s consent.
- A periodic follow-up appointment will be scheduled to monitor your progress.
Risks and Complications
Arthroscopic remplissage is a relatively safe procedure; however, as with any surgery, some risks and complications may occur, such as the following:
- Postoperative pain
- Damage to surrounding structures
- Stiffness or restricted motion
- Thromboembolism or blood clots
- Anesthetic/allergic reactions
- Recurrence of instability