The best way to treat the unstable shoulder with a bony defect hasn’t been determined yet, but presentations at the 26th Annual Meeting of the Arthroscopy Association of North America (AANA) are providing clues about what works.
The arthroscopic treatment of anterior shoulder instability has improved, and surgeons are seeing higher rates of clinical success. But among patients who have bony defects of the glenoid and humeral head (Hill-Sachs lesions), there
have been high rates of recurrent instability.
A promising technique presented by John D. Kelly IV, MD, and Shade Ogungro, MD, involves filling the humeral head defect with a synthetic bone substitute. In a series of 25 patients (12 of whom had at least 6 months follow-up), only one patient experienced a subsequent episode of instability, resulting from a traumatic episode during a football game.
“The approach is not extraordinarily difficult and is associated with minimal morbidity,” reported Dr. Kelly. All surgeries were performed on an outpatient basis, with the patient in the lateral decubitus position. Two portals are routinely used: a high anterior superior viewing portal and an accessory inferior medial portal, widened with a hemostat, to provide access to the humeral head defect.
The chief indication for the procedure is the presence of the “inverted pear” glenoid in conjunction with an “engaging” Hill-Sachs lesion. In this series, Dr. Kelly prepared the humeral head with mosaicplasty-type instruments and inserted one to three bone plugs. Patients followed a standard postoperative treatment protocol—including use of an abduction sling for 4 weeks, followed by physical therapy.
“We attempted to ensure that the donor plugs were ‘flush’ to the adjacent articular surface,” reported Dr. Kelly, “and—especially with larger defects—we made no attempt to fill the entire defect, focusing instead on the more proximal portions that abutted the glenoid articular surface.” He also noted that as he gained experience with the technique, he began to do more substantive “fills.”
None of the 12 patients reported on in this study had any complications (infections, axillary nerve injury, or loose body formation). The recurrence rate of 8 percent compares favorably with historic controls for patients with large bony defects. Although this is just a very short-term report and lacks a second-look arthroscopic evaluation, Dr. Kelly believes “this technique offers promise as at least a partial solution to a most difficult clinical problem.”
Arthroscopic Hill-Sachs remplissage
In Hill-Sachs “remplissage” (from the French for “filling”), the surgeon performs an arthroscopic posterior capsulodesis and infraspinatus tenodesis to fill the Hill-Sachs lesion, in addition to an arthroscopic anterior Bankart repair. According to the report presented by the team of Eugene M. Wolf, MD; Michael E. Pollack, MD; and Chad C. Smalley, MD, this additional procedure “provides an effective arthroscopic approach in those cases of anterior shoulder instability that present with the combination of glenoid bone loss and a Hill-Sachs lesion.”
Their study involved 27 patients who met those criteria, including eight in whom prior stabilization surgery had failed. Of the 24 patients available with a minimum 2-year follow-up, 22 were very satisfied; of these, 15 reported excellent results and 7 had good results. Two patients were rated with poor results. The eight patients in whom prior surgery had failed were without recurrence at follow-up. There were two recent dislocations, one due to a motorcycle accident and the other resulting from a wrestling match.
“The Hill-Sachs remplissage is similar to an arthroscopic repair of a partial thickness, articular surface rotator cuff tear,” reported Dr. Wolf. “We have used different types of anchors, but the principle remains the same: the fixation of the conjoined infraspinatus tendon and posterior capsule to the abraded surface of the Hill-Sachs lesion.”
The technique involves three portals: a posterior inferior portal, located laterally over the Hill-Sachs lesion; an interior inferior portal, which serves as the primary anterior working portal for the repair of any anterior labral lesions; and an anterior superior viewing portal at the anterior margin of the acromion.
After freshening the surfaces of both the engaging Hill-Sachs lesion and the entire posterior capsule, the surgeon uses a smaller anchor cannula and obturator to pass through the infraspinatus and posterior capsule into the joint. Once the first anchor is in place, a penetrating grasper is used to pull one of the sutures from the joint at a point 1 cm from the anchor cannula’s entry point. A second anchor and suture are placed at the superior aspect of the Hill-Sachs lesion. Tying the sutures in the subdeltoid space draws the infraspinatus and posterior capsule to the abraded bony surfaces, thus filling the lesion.
“Filling the lesion effectively obliterates the Hill-Sachs lesion and converts it into an extra-articular lesion, thereby preventing engagement,” reported the authors. “There were no significant complications, and the concern that the remplissage would limit rotation did not materialize.”
Generally, an immobilizer is used for six weeks after surgery, but patients are allowed out for “controlled” activities, such as eating, showering, and computer use, provided the arm is not abducted and does not go beyond neutral rotation. Active and resistive range-of-motion exercises begin at 6 weeks, but “at risk” work activities and contact sports are prohibited for at least 6 months.
During subsequent arthroscopic procedures in two patients, surgeons were able to take a second look at the remplissage results. In both patients, the capsule and tendons had healed into the Hill-Sachs lesion. “Remplissage is an effective approach to a difficult subgroup of instability patients with a significant potential for failure of a standard arthroscopic Bankart,” concluded the authors.