Editorial Commentary: Use Remplissage as a "Fill In" for Latarjet in Patients With Shoulder Instability and Hill Sachs Lesions

Editorial Commentary: Use Remplissage as a “Fill In” for Latarjet in Patients With Shoulder Instability and Hill Sachs Lesions John D. Kelly IV, M.D. Abstract: Remplissage minimizes recurrence and confers minimal motion loss when applied to glenoid defects up to 20% and humeral loss up to 40% in patients with shoulder instability. However, variability in the reporting of volume of both glenoid and humeral head bone loss deters the formulation of distinct thresholds for indications and contraindication for remplissage. However, there appears to be little downside in the performance of this “biologic” solution to Hill-Sachs lesions. See related article on page 2894 T he article in this issue, “Recurrence Rate of Instability After Remplissage for Treatment of Traumatic Anterior Shoulder Instability: A Systematic Review in Treatment of Subcritical Glenoid Bone Loss,” by Liu, Gowd, Garcia, Cvetanovich, Cabarcas, and Verma1 from Rush adds to the mounting evidence that remplissage is here to stay. Although no randomized controlled trials were used, this systematic review included 22 studies deemed to have low bias and superior quality according to criterion 1 of the MINORS (Methodological Index for Nonrandomized Studies) and ROBINS (Risk of Bias in Nonrandomized Studies) instruments. In addition, rigorous PRISMA (Preferred Reporting Items for Systematic Reviews and Metaanalyses) guidelines were used in selecting studies for review. The investigated sample included 694 patients with a mean age of 28.3 years and mean follow-up of 32.5 months. The authors conclude that remplissage minimizes recurrence and confers minimal motion loss when applied to glenoid defects up to 20% and humeral loss up to 40%. The described techniques for the performance of remplissage varied, as did the number of anchors, with Penn Perelman School of Medicine The author reports that he has no conflicts of interest in the authorship and publication of this article. Full ICMJE author disclosure forms are available for this article online, as supplementary material. Ó 2018 by the Arthroscopy Association of North America 0749-8063/18852/$36.00 https://doi.org/10.1016/j.arthro.2018.07.018 2908 most studies using no more than 2 anchors. Of note, no difference was seen in range of motion in remplissage as compared with isolated Bankart, which has been confirmed in a cadaveric study as well.2 The lack of uniformity in the studies in reporting the volume of both glenoid and humeral head bone loss deters the formulation of distinct thresholds for indications and contraindications for remplissage. However, there appears to be little downside in the performance of this biologic solution to Hill-Sachs lesions.3 We and others4,5 have reported on appreciable healing of this infraspinatus tenodesis with a good measure of fibrous-like tissue noted on magnetic resonance imaging. We posit that remplissage is a de facto stem cell transplant with some pluripotential capacity for tendon tissue to transform from granulation and fibrous tissue into fibrocartilaginous tissue in time.4 It is important to note that the preponderance of the examined studies were conducted before the depiction by Garcia et al.6 of the safe zone 5 (Video 1) for suture retrieval to ensure a tendinous rather than an infraspinatus muscle suture purchase. Garcia et al.6 elegantly demonstrated that an inferolateral portal is essential in piercing the infraspinatus tendon, which has much more tensile strength than muscle tissue. Further, a more laterally based tenodesis will theoretically restrict motion less (Fig 1). In addition, an increasing body of knowledge has emerged on improved fixation methods. The paltry 1 to 2 single loaded anchors used in most of the reviewed studies would be expected to perform less well than Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 34, No 10 (October), 2018: pp 2908-2909 EDITORIAL COMMENTARY 4. 5. 6. 7. Fig 1. Filled Hill-Sachs lesion. View from anterior superior portal with right shoulder in the lateral decubitus position showing the infraspinatus tendon secured into the defect. contemporary double-pulley, knotless, and multistrand anchor constructs.7-9 Given the morbidity of Latarjet10 and open Bankart11,12 procedures, surgeons are well advised to adopt remplissage into their surgical armamentarium. In light of the work of Kitayama et al.13 showing bone hypertrophy after bony Bankart repair, I have begun adding local bone procured from the Hill-Sachs lesion to my capsulolabral reapproximation in addition to remplissage. Thankfully, we are beginning to recognize that there are indeed kinder and gentler means of addressing bone instability. It is time to shake hands with remplissage and recognize that it favorably alters glenoid track mechanics,14 confers appreciable stability in the face of even modest glenoid defects,15 offers minimal complications,16 and affords durable success.17 In a head-tohead comparison with Latarjet, remplissage matched recurrence rates while offering an overwhelmingly more favorable complication rate as compared with the coracoid transfer cohort.18 The debate is over. The arthroscope wins. 8. 9. 10. 11. 12. 13. 14. 15. References 1. Liu JN, Gowd AK, Garcia GH, Cvetanovich GL, Cabarcas BC, Verma NN. Recurrence rate of instability after remplissage for treatment of traumatic anterior shoulder instability: A systematic review in treatment of subcritical glenoid bone loss. Arthroscopy 2018;34:2894-2907. 2. Nourissat G, Kilinc AS, Werther JR, Doursounian L. A prospective, comparative, radiological, and clinical study of the influence of the “remplissage” procedure on shoulder range of motion after stabilization by arthroscopic Bankart repair. Am J Sports Med 2011;39:2147-2152. 3. Degen RM, Giles JW, Johnson JA, Athwal GS. Remplissage versus Latarjet for engaging Hill-Sachs defects 16. 17. 18. 2909 without substantial glenoid bone loss: a biomechanical comparison. Clin Orthop Rel Res 2014;472:2363-2371. Park MJ, Garcia G, Malhotra A, Major N, Tjoumakaris FP, Kelly JD IV. The evaluation of arthroscopic remplissage by high-resolution magnetic resonance imaging. Am J Sports Med 2012;40:2331-2336. Boileau P, O’Shea K, Vargas P, Pinedo M, Old J, Zumstein M. Anatomical and functional results after arthroscopic Hill-Sachs remplissage. J Bone Joint Surg Am 2012;94:618-626. Garcia GH, Degen RM, Liu JN, Kahlenberg CA, Dines JS. Accuracy of suture passage during arthroscopic remplissagedWhat anatomic landmarks can improve it? A cadaveric study. Orthop J Sports Med 2016;4: 2325967116663497. Koo SS, Burkhart SS, Ochoa E. Arthroscopic doublepulley remplissage technique for engaging Hill-Sachs lesions in anterior shoulder instability repairs. Arthroscopy 2009;25:1343-1348. Ratner DA, Rogers JP, Tokish JM. Use of a knotless suture anchor to perform double-pulley capsulotenodesis of infraspinatus. Arthrosc Tech 2018;7:e485-e490. Tan BHM, Kumar VP. The arthroscopic Hill-Sachs remplissage: A technique using a PASTA repair kit. Arthrosc Tech 2016;5:e573-e578. Griesser MJ, Harris JD, McCoy BW, et al. Complications and re-operations after Bristow-Latarjet shoulder stabilization: A systematic review. J Shoulder Elbow Surg 2013;22:286-292. Green MR, Christensen KP. Arthroscopic versus open Bankart procedures: A comparison of early morbidity and complications. Arthroscopy 1993;9:371-374. Sachs RA, Williams B, Stone ML, Paxton L, Kuney M. Open Bankart repair: Correlation of results with postoperative subscapularis function. Am J Sports Med 2005;33: 1458-1462. Kitayama S, Sugaya H, Takahashi N, et al. Clinical outcome and glenoid morphology after arthroscopic repair of chronic osseous Bankart lesions: A five to eightyear follow-up study. J Bone Joint Surg Am 2015;97: 1833-1843. Hartzler RU, Bui CN, Jeong WK, et al. Remplissage of an off-track Hill-Sachs lesion is necessary to restore biomechanical glenohumeral joint stability in a bipolar bone loss model. Arthroscopy 2016;32:2466-2476. McCabe MP, Weinberg D, Field LD, O’Brien MJ, Hobgood ER, Savoie FH III. Primary versus revision arthroscopic reconstruction with remplissage for shoulder instability with moderate bone loss. Arthroscopy 2014;30: 444-450. Buza JA III, Iyengar JJ, Anakwenze OA, Ahmad CS, Levine WN. Arthroscopic Hill-Sachs remplissage: A systematic review. J Bone Joint Surg Am 2014;96:549-555. Wolf EM, Arianjam A. Hill-Sachs remplissage, an arthroscopic solution for the engaging Hill-Sachs lesion: 2-to 10-year follow-up and incidence of recurrence. J Shoulder Elbow Surg 2014;23:814-820. Cho NS, Yoo JH, Rhee YG. Management of an engaging Hill-Sachs lesion: Arthroscopic filling with Bankart repair versus Latarjet procedure. Knee Surg Sports Traumatol Arthrosc 2016;24:3793-3800.