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Arthroscopic Reverse Remplissage for Posterior Instability
Arthroscopic Reverse Remplissage for Posterior Instability Chad D. Lavender, M.D., Shane R. Hanzlik, M.D., Sara E. Pearson, Ph.D., and Paul E. Caldwell III, M.D.
Abstract: Posterior shoulder dislocation is an unusual injury often associated with electrical shock or seizure. As with anterior instability, patients frequently present with an impaction injury to the anterior aspect of the humeral head known as a “reverse Hill-Sachs lesion.” The treatment of this bony defect is controversial, and multiple surgical procedures to fill the defect in an effort to decrease recurrence have been described. Most of the reports have focused on an open approach using variations of lesser tuberosity and subscapularis transfers, bone allograft, and even arthroplasty to assist with persistent instability. We advocate an arthroscopic technique that involves a suture anchorebased distal tenodesis of the subscapularis tendon or a reverse remplissage procedure.
P
osterior dislocation of the shoulder is a relatively uncommon occurrence, with a reported incidence of only 5% of shoulder dislocations.1 Posterior dislocation is often associated with a delay in diagnosis, which frequently complicates subsequent treatment. Management of this condition is more complex when associated with a reverse Hill-Sachs lesion, although rare. The reverse Hill-Sachs lesion is a depression in the anterior humeral head that could predispose the shoulder to chronic instability during internal rotation.1 Treatment of posterior instabilitydsimilar to anterior instabilitydoften requires addressing the humeral bony defect. Recommendations for operative management of the anterior Hill-Sachs lesion range from traditional open procedures to newer arthroscopic techniques. Open treatment for this lesion includes transfer of the lesser tuberosity into the defect, as well as the use of
From Orthopaedic Research of Virginia (C.D.L., S.R.H., S.E.P., P.E.C.); and Tuckahoe Orthopaedics (P.E.C.), Richmond, Virginia, U.S.A. The authors report the following potential conflict of interest or source of funding: C.D.L., S.R.H., S.E.P., and P.E.C. receive support from Arthrex, Bon Secours, DJO, DePuy Mitek, and Smith & Nephew. Received June 15, 2015; accepted September 22, 2015. Address correspondence to Paul E. Caldwell, III, M.D., Tuckahoe Orthopaedics, 1501 Maple Ave, Ste 200, Richmond, VA 23226, U.S.A. E-mail: [email protected] Ó 2016 by the Arthroscopy Association of North America 2212-6287/15546/$36.00 http://dx.doi.org/10.1016/j.eats.2015.09.005
allografts in larger lesions.2,3 Other authors have advocated arthroplasty in the setting of chronic and expansive defects of the humeral head.4 With the evolution in arthroscopy, more recent techniques have focused on addressing the pathology using a minimally invasive approach. Our preferred technique for addressing the anterior Hill-Sachs lesion associated with posterior instability involves filling the defect with subscapularis tendon arthroscopically or by a reverse remplissage procedure.
Surgical Technique Our technique (Video 1) uses the traditional lateral decubitus position. A standard posterior portal is created, and a diagnostic arthroscopy is performed. By use of an outside-in technique, an 18-gauge spinal needle is used to establish an anteroinferior portal just superior to the subscapularis tendon and an anterosuperior portal just inferior to the biceps tendon (Fig 1). Special attention is directed toward confirming an adequate working distance between the 2 portals. We recommend using a 70 arthroscope (Arthrex, Naples, FL) through the posterior portal to adequately visualize the reverse Hill-Sachs lesion and subscapularis tendon (Fig 2). The posterior portal is the primary viewing portal throughout the procedure to allow for maximal space to work anteriorly. An assistant with knowledge of the “posterior lever push”5 is also recommended for optimal visualization of the reverse Hill-Sachs lesion (Fig 3). The lesion is first
Arthroscopy Techniques, Vol 5, No 1 (February), 2016: pp e43-e47
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C. D. LAVENDER ET AL.
Fig 1. Sagittal and axial views of the shoulder show traditional portal placement for shoulder arthroscopy as well as the reverse Hill-Sachs lesion associated with posterior instability.
debrided of all soft tissue with an oscillating 4.5-mm full-radius shaver (Smith & Nephew, Andover, MA) to evaluate its size and location. A 4.5-mm Helicut burr (Smith & Nephew) or curette is used to lightly decorticate the lesion in preparation for repair. We place two 5.5-mm BioComposite double-loaded anchors (Arthrex) within the defect (Figs 4 and 5). A tap is uniformly used for insertion because the bone is typically dense as a result of the impaction injury. The anterosuperior portal is used for suture management. The sutures are then retrieved through the subscapularis tendon in a retrograde fashion (Fig 6) from inferior to superior in a mattress configuration by use of a 60 suture passer (DePuy Mitek, Raynham, MA). The sutures are retrieved in pairs from interior to superior through the anteroinferior portal (Figs 7 and 8)
Fig 2. Arthroscopic view of the right shoulder in the lateral decubitus position from the posterior portal with a 70 arthroscope visualizing the subscapularis tendon and humeral head.
and tied using a sliding-locking arthroscopic knot backed up with 3 reverse half-hitches. All sutures are retrieved before tying, and knot tying is carried out from inferior to superior for adequate visualization of filling of the defect (Figs 9 and 10). Once knot tying is completed, the portals are closed in the standard fashion, and the shoulder is immobilized in an external-rotation UltraSling IV (DonJoy, Vista, CA) for 6 weeks before formal physical therapy is started. The patient is instructed on elbow range of motion, scapular positioning, and bathing.
Discussion Given the high prevalence of traumatic anterior instability of the shoulder, treatment recommendations
Fig 3. Arthroscopic view of the right shoulder in the lateral decubitus position from the posterior portal with a 70 arthroscope visualizing the reverse Hill-Sachs lesion.
ARTHROSCOPIC REVERSE REMPLISSAGE
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Fig 4. Arthroscopic view of the right shoulder in the lateral decubitus position from the posterior portal with a 70 arthroscope visualizing the first anchor placement within the reverse Hill-Sachs lesion in preparation for a reverse remplissage procedure.
Fig 6. Arthroscopic view of the right shoulder in the lateral decubitus position from the posterior portal with a 70 arthroscope visualizing suture retrieval in a retrograde fashion through the subscapularis tendon in preparation for a reverse remplissage procedure.
Fig 5. Arthroscopic view of the right shoulder in the lateral decubitus position from the posterior portal with a 70 arthroscope visualizing the second anchor placement within the reverse Hill-Sachs lesion in preparation for a reverse remplissage procedure.
Fig 7. Arthroscopic view of the right shoulder in the lateral decubitus position from the posterior portal with a 70 arthroscope visualizing sutures passed through the subscapularis tendon in preparation for a reverse remplissage procedure.
Fig 8. Sagittal and axial views of the shoulder show placement of the double-loaded suture anchors into the reverse Hill-Sachs lesion with passage of the sutures through the subscapularis tendon.
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C. D. LAVENDER ET AL. Table 1. Advantages of Arthroscopic Reverse Remplissage for Posterior Instability Standard arthroscopic shoulder setup and portals Familiar arthroscopic passing and shuttling techniques Ability to address common posterior pathology arthroscopically Alleviation of need for special equipment or grafts Potential reduction in recurrence of instability
Fig 9. Arthroscopic view of the right shoulder in the lateral decubitus position from the posterior portal with a 70 arthroscope visualizing sutures tied on the anterior aspect of the subscapularis tendon after completion of a reverse remplissage procedure.
regarding posterior instability are frequently less familiar. As documented with anterior instability, bone loss in posterior instability must be recognized and addressed in an effort to reduce recurrence. Applying similar concepts used for the treatment of anterior instability,6 our technique for arthroscopic reverse remplissage for the treatment of posterior shoulder dislocation with a reverse Hill-Sachs lesion offers certain advantages over traditional methods (Table 1). The reverse remplissage procedure uses customary arthroscopic techniques without special equipment to fill the humeral head defect with the subscapularis
tendon. One of the principal advantages of this procedure is the ability to perform it arthroscopically as opposed to traditional open procedures. The ability to address both the posterior and anterior pathology associated with posterior instability is substantially meaningful to the arthroscopic shoulder surgeon. Although clinical studies to substantiate the reduction in recurrence rate are lacking, the presented technique offers potential benefits to decrease posterior instability. Although the literature regarding this topic is limited, Krackhardt et al.7 originally reported arthroscopic mobilization of the subscapularis and subsequent fixation into the reverse Hill-Sachs lesion for treatment of posterior instability in 2006. Duey and Burkhart8 later described an arthroscopic technique that involves filling the reverse Hill-Sachs lesion with the middle glenohumeral ligament. Martetschläger et al.9 reported a modified arthroscopic McLaughlin procedure in which the bony defect is filled with the subscapularis tendon. We present our video technique along with 6-month follow-up in an effort to substantiate these previous methods of treatment for the reverse Hill-Sachs lesion
Fig 10. Sagittal and axial views of the shoulder show completion of the reverse remplissage procedure with the sutures tied down to fill the reverse Hill-Sachs with the subscapularis tendon.
ARTHROSCOPIC REVERSE REMPLISSAGE
associated with acute and chronic posterior instability of the shoulder.
References 1. Blaisier RB, Burkus JK. Management of posterior fracturedislocations of the shoulder. Clin Orthop Relat Res 1988;232: 197-204. 2. Diklic ID, Ganic ZD, Blagojevic ZD, Nho SJ, Romeo AA. Treatment of locked chronic posterior dislocation of the shoulder by reconstruction of the defect in the humeral head with an allograft. J Bone Joint Surg Br 2010;92:7176. 3. Gerber C, Lambert SM. Allograft reconstruction of segmental defects of the humeral head for the treatment of chronic locked posterior dislocation of the shoulder. J Bone Joint Surg Am 1996;78:376-382. 4. Hughes M, Neer CS II. Glenohumeral joint replacement and postoperative rehabilitation. Phys Ther 1975;55:850-858.
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5. Adams CR, Schoolfield JD, Burkhart SS. The results of arthroscopic subscapularis tendon repairs. Arthroscopy 2008;24:1381-1389. 6. Purchase RJ, Wolf EM, Hobgood ER, Pollock ME, Smalley CC. Hill-Sachs “remplissage”: An arthroscopic solution for the engaging Hill-Sachs lesion. Arthroscopy 2008;24:723-726. 7. Krackhardt T, Schewe B, Albrecht D, Weise K. Arthroscopic fixation of the subscapularis tendon in the reverse Hill-Sachs lesion for traumatic unidirectional posterior dislocation of the shoulder. Arthroscopy 2006;22:227.e1227.e6. 8. Duey RE, Burkhart SS. Arthroscopic treatment of a reverse Hill-Sachs lesion. Arthrosc Tech 2013;2:e155e159. 9. Martetschläger F, Padalecki JR, Millett PJ. Modified arthroscopic McLaughlin procedure for treatment of posterior instability of the shoulder with an associated reverse Hill-Sachs lesion. Knee Surg Sports Traumatol Arthrosc 2013;21:1642-1646.
Abstract: Posterior shoulder dislocation is an unusual injury often associated with electrical shock or seizure. As with anterior instability, patients frequently present with an impaction injury to the anterior aspect of the humeral head known as a “reverse Hill-Sachs lesion.” The treatment of this bony defect is controversial, and multiple surgical procedures to fill the defect in an effort to decrease recurrence have been described. Most of the reports have focused on an open approach using variations of lesser tuberosity and subscapularis transfers, bone allograft, and even arthroplasty to assist with persistent instability. We advocate an arthroscopic technique that involves a suture anchorebased distal tenodesis of the subscapularis tendon or a reverse remplissage procedure.
P
osterior dislocation of the shoulder is a relatively uncommon occurrence, with a reported incidence of only 5% of shoulder dislocations.1 Posterior dislocation is often associated with a delay in diagnosis, which frequently complicates subsequent treatment. Management of this condition is more complex when associated with a reverse Hill-Sachs lesion, although rare. The reverse Hill-Sachs lesion is a depression in the anterior humeral head that could predispose the shoulder to chronic instability during internal rotation.1 Treatment of posterior instabilitydsimilar to anterior instabilitydoften requires addressing the humeral bony defect. Recommendations for operative management of the anterior Hill-Sachs lesion range from traditional open procedures to newer arthroscopic techniques. Open treatment for this lesion includes transfer of the lesser tuberosity into the defect, as well as the use of
From Orthopaedic Research of Virginia (C.D.L., S.R.H., S.E.P., P.E.C.); and Tuckahoe Orthopaedics (P.E.C.), Richmond, Virginia, U.S.A. The authors report the following potential conflict of interest or source of funding: C.D.L., S.R.H., S.E.P., and P.E.C. receive support from Arthrex, Bon Secours, DJO, DePuy Mitek, and Smith & Nephew. Received June 15, 2015; accepted September 22, 2015. Address correspondence to Paul E. Caldwell, III, M.D., Tuckahoe Orthopaedics, 1501 Maple Ave, Ste 200, Richmond, VA 23226, U.S.A. E-mail: [email protected] Ó 2016 by the Arthroscopy Association of North America 2212-6287/15546/$36.00 http://dx.doi.org/10.1016/j.eats.2015.09.005
allografts in larger lesions.2,3 Other authors have advocated arthroplasty in the setting of chronic and expansive defects of the humeral head.4 With the evolution in arthroscopy, more recent techniques have focused on addressing the pathology using a minimally invasive approach. Our preferred technique for addressing the anterior Hill-Sachs lesion associated with posterior instability involves filling the defect with subscapularis tendon arthroscopically or by a reverse remplissage procedure.
Surgical Technique Our technique (Video 1) uses the traditional lateral decubitus position. A standard posterior portal is created, and a diagnostic arthroscopy is performed. By use of an outside-in technique, an 18-gauge spinal needle is used to establish an anteroinferior portal just superior to the subscapularis tendon and an anterosuperior portal just inferior to the biceps tendon (Fig 1). Special attention is directed toward confirming an adequate working distance between the 2 portals. We recommend using a 70 arthroscope (Arthrex, Naples, FL) through the posterior portal to adequately visualize the reverse Hill-Sachs lesion and subscapularis tendon (Fig 2). The posterior portal is the primary viewing portal throughout the procedure to allow for maximal space to work anteriorly. An assistant with knowledge of the “posterior lever push”5 is also recommended for optimal visualization of the reverse Hill-Sachs lesion (Fig 3). The lesion is first
Arthroscopy Techniques, Vol 5, No 1 (February), 2016: pp e43-e47
e43
e44
C. D. LAVENDER ET AL.
Fig 1. Sagittal and axial views of the shoulder show traditional portal placement for shoulder arthroscopy as well as the reverse Hill-Sachs lesion associated with posterior instability.
debrided of all soft tissue with an oscillating 4.5-mm full-radius shaver (Smith & Nephew, Andover, MA) to evaluate its size and location. A 4.5-mm Helicut burr (Smith & Nephew) or curette is used to lightly decorticate the lesion in preparation for repair. We place two 5.5-mm BioComposite double-loaded anchors (Arthrex) within the defect (Figs 4 and 5). A tap is uniformly used for insertion because the bone is typically dense as a result of the impaction injury. The anterosuperior portal is used for suture management. The sutures are then retrieved through the subscapularis tendon in a retrograde fashion (Fig 6) from inferior to superior in a mattress configuration by use of a 60 suture passer (DePuy Mitek, Raynham, MA). The sutures are retrieved in pairs from interior to superior through the anteroinferior portal (Figs 7 and 8)
Fig 2. Arthroscopic view of the right shoulder in the lateral decubitus position from the posterior portal with a 70 arthroscope visualizing the subscapularis tendon and humeral head.
and tied using a sliding-locking arthroscopic knot backed up with 3 reverse half-hitches. All sutures are retrieved before tying, and knot tying is carried out from inferior to superior for adequate visualization of filling of the defect (Figs 9 and 10). Once knot tying is completed, the portals are closed in the standard fashion, and the shoulder is immobilized in an external-rotation UltraSling IV (DonJoy, Vista, CA) for 6 weeks before formal physical therapy is started. The patient is instructed on elbow range of motion, scapular positioning, and bathing.
Discussion Given the high prevalence of traumatic anterior instability of the shoulder, treatment recommendations
Fig 3. Arthroscopic view of the right shoulder in the lateral decubitus position from the posterior portal with a 70 arthroscope visualizing the reverse Hill-Sachs lesion.
ARTHROSCOPIC REVERSE REMPLISSAGE
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Fig 4. Arthroscopic view of the right shoulder in the lateral decubitus position from the posterior portal with a 70 arthroscope visualizing the first anchor placement within the reverse Hill-Sachs lesion in preparation for a reverse remplissage procedure.
Fig 6. Arthroscopic view of the right shoulder in the lateral decubitus position from the posterior portal with a 70 arthroscope visualizing suture retrieval in a retrograde fashion through the subscapularis tendon in preparation for a reverse remplissage procedure.
Fig 5. Arthroscopic view of the right shoulder in the lateral decubitus position from the posterior portal with a 70 arthroscope visualizing the second anchor placement within the reverse Hill-Sachs lesion in preparation for a reverse remplissage procedure.
Fig 7. Arthroscopic view of the right shoulder in the lateral decubitus position from the posterior portal with a 70 arthroscope visualizing sutures passed through the subscapularis tendon in preparation for a reverse remplissage procedure.
Fig 8. Sagittal and axial views of the shoulder show placement of the double-loaded suture anchors into the reverse Hill-Sachs lesion with passage of the sutures through the subscapularis tendon.
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C. D. LAVENDER ET AL. Table 1. Advantages of Arthroscopic Reverse Remplissage for Posterior Instability Standard arthroscopic shoulder setup and portals Familiar arthroscopic passing and shuttling techniques Ability to address common posterior pathology arthroscopically Alleviation of need for special equipment or grafts Potential reduction in recurrence of instability
Fig 9. Arthroscopic view of the right shoulder in the lateral decubitus position from the posterior portal with a 70 arthroscope visualizing sutures tied on the anterior aspect of the subscapularis tendon after completion of a reverse remplissage procedure.
regarding posterior instability are frequently less familiar. As documented with anterior instability, bone loss in posterior instability must be recognized and addressed in an effort to reduce recurrence. Applying similar concepts used for the treatment of anterior instability,6 our technique for arthroscopic reverse remplissage for the treatment of posterior shoulder dislocation with a reverse Hill-Sachs lesion offers certain advantages over traditional methods (Table 1). The reverse remplissage procedure uses customary arthroscopic techniques without special equipment to fill the humeral head defect with the subscapularis
tendon. One of the principal advantages of this procedure is the ability to perform it arthroscopically as opposed to traditional open procedures. The ability to address both the posterior and anterior pathology associated with posterior instability is substantially meaningful to the arthroscopic shoulder surgeon. Although clinical studies to substantiate the reduction in recurrence rate are lacking, the presented technique offers potential benefits to decrease posterior instability. Although the literature regarding this topic is limited, Krackhardt et al.7 originally reported arthroscopic mobilization of the subscapularis and subsequent fixation into the reverse Hill-Sachs lesion for treatment of posterior instability in 2006. Duey and Burkhart8 later described an arthroscopic technique that involves filling the reverse Hill-Sachs lesion with the middle glenohumeral ligament. Martetschläger et al.9 reported a modified arthroscopic McLaughlin procedure in which the bony defect is filled with the subscapularis tendon. We present our video technique along with 6-month follow-up in an effort to substantiate these previous methods of treatment for the reverse Hill-Sachs lesion
Fig 10. Sagittal and axial views of the shoulder show completion of the reverse remplissage procedure with the sutures tied down to fill the reverse Hill-Sachs with the subscapularis tendon.
ARTHROSCOPIC REVERSE REMPLISSAGE
associated with acute and chronic posterior instability of the shoulder.
References 1. Blaisier RB, Burkus JK. Management of posterior fracturedislocations of the shoulder. Clin Orthop Relat Res 1988;232: 197-204. 2. Diklic ID, Ganic ZD, Blagojevic ZD, Nho SJ, Romeo AA. Treatment of locked chronic posterior dislocation of the shoulder by reconstruction of the defect in the humeral head with an allograft. J Bone Joint Surg Br 2010;92:7176. 3. Gerber C, Lambert SM. Allograft reconstruction of segmental defects of the humeral head for the treatment of chronic locked posterior dislocation of the shoulder. J Bone Joint Surg Am 1996;78:376-382. 4. Hughes M, Neer CS II. Glenohumeral joint replacement and postoperative rehabilitation. Phys Ther 1975;55:850-858.
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5. Adams CR, Schoolfield JD, Burkhart SS. The results of arthroscopic subscapularis tendon repairs. Arthroscopy 2008;24:1381-1389. 6. Purchase RJ, Wolf EM, Hobgood ER, Pollock ME, Smalley CC. Hill-Sachs “remplissage”: An arthroscopic solution for the engaging Hill-Sachs lesion. Arthroscopy 2008;24:723-726. 7. Krackhardt T, Schewe B, Albrecht D, Weise K. Arthroscopic fixation of the subscapularis tendon in the reverse Hill-Sachs lesion for traumatic unidirectional posterior dislocation of the shoulder. Arthroscopy 2006;22:227.e1227.e6. 8. Duey RE, Burkhart SS. Arthroscopic treatment of a reverse Hill-Sachs lesion. Arthrosc Tech 2013;2:e155e159. 9. Martetschläger F, Padalecki JR, Millett PJ. Modified arthroscopic McLaughlin procedure for treatment of posterior instability of the shoulder with an associated reverse Hill-Sachs lesion. Knee Surg Sports Traumatol Arthrosc 2013;21:1642-1646.