Chapter 3 Instability

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CHAPTER 3 | Instability

as it is brought through a range of abduction. This allows assessment of the position of engagement of the Hill-Sachs lesion (Fig. 3-43). We then use a calibrated probe to take all the necessary measurements to determine significant bone loss. If there is no significant glenoid bone loss and if the Hill-Sachs lesion is calculated to be off-track, we proceed with an arthroscopic Bankart repair and remplissage. The Bankart lesion is addressed first, with anchor place- ment and suture passage, but the knots are not tied until after the remplissage anchors have been placed. The reason for this sequence is that the anteriorly directed forces associ- ated with placing suture anchors in the back of the humerus can disrupt the suture fixation of the labrum if the Bankart knots are tied before placing the Hill-Sachs anchors. For the remplissage, the bone bed in the Hill-Sachs lesion is prepared by means of ring curettes placed through a posterior working portal while viewing from the antero- superolateral portal (Fig. 3-44). Next, the subacromial space is prepared. Bursa and fibro- fatty tissue are removed by alternating between posterior and lateral portals for viewing and working. Care is taken to clear out the posterior gutter so that the entire infraspi- natus tendon can be visualized.

Bankart repair. We have confirmed the validity of this para- digm for arthroscopic remplissage in a recent biomechanical study. 8 Furthermore, a recent clinical study confirmed that off- track shoulders were at much higher risk of recurrent instabil- ity with isolated arthroscopic Bankart repairs. 6 RemplissageTechniques Remplissage of a Hill-Sachs lesion consists of insetting the infraspinatus tendon into the Hill-Sachs defect, thereby making the defect extra-articular and preventing engage- ment with the anterior glenoid rim (Fig. 3-41). Technique of Arthroscopic Remplissage This procedure, like all of our arthroscopic shoulder pro- cedures, is done with the patient in the lateral decubitus position. We begin with three standard portals: posterior, anterior, and anterosuperolateral. Viewing from an anterosuperolateral portal, the glenoid is visualized and evaluated for bone loss (Fig. 3-42). If there is >25% loss of the inferior glenoid diameter, the pro- cedure is converted to an open Latarjet reconstruction. The arm is removed from its balanced suspension and is rotated

FIGURE 3-41  Schematic of remplissage for a Hill-Sachs lesion. A: Axial schematic of a Hill- Sachs lesion. B: Anchors are placed into the Hill-Sachs defect. C: Sutures are passed through the infraspinatus tendon and tied to inset the tendon into the defect. Inset of the infraspinatus into the defect converts the Hill-Sachs lesion to an extra-articular defect. D: Sagittal oblique view demonstrates the mattress stitches between the two anchors that have been tied using a double- pulley technique. G, glenoid; H, humeral head; IS, infraspinatus tendon.