Chapter 3 Instability

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CHAPTER 3 | Instability

FIGURE 3-48  The double-pulley technique for remplissage in a right shoulder. A: Lateral subacromial viewing portal. Sutures from two anchors placed in a Hill-Sachs lesion are visualized in the subacromial space passing through the infraspinatus. B: A single blue suture limb from each anchor is retrieved and extracorporeally tied over an instrument. C: The suture limbs are cut, and the knot is delivered back into the subacromial space by pulling on the opposite blue suture limbs. D: The first knot ( black arrow ) now rests on the infraspinatus. The remaining suture limbs may be retrieved and tied as static knots to complete the double pulley. RC, rotator cuff.

configuration. Then, we again look intra-articularly to be sure that the tendon has inset all the way into the Hill- Sachs lesion (Fig. 3-49). Postoperatively, we keep the patient in a sling for 6 weeks and then begin a stretching program. We do not start strengthening until 12 weeks post-op. The ratio- nale for the delayed strengthening is that for rehabili- tation considerations, we view remplissage in the same way as an infraspinatus tendon repair, and for rotator cuff repairs, we do not allow strengthening until 12 weeks post-op. We have not observed clinically sig- nificant loss of internal or external rotation after rem- plissage. However, we have not done remplissage in an overhead athlete, and we suspect it would affect the amount of combined abduction–external rotation that could be achieved in the late cocking phase of throwing.

One suture limb of a given color from each anchor is retrieved through the working cannula. Then, outside the patient’s body, these two suture limbs are tied to each other over the top of a rigid instrument by means of a six-throw surgeon’s knot. Next, the two corresponding “free” limbs are tensioned and pulled, using the suture anchors’ eyelets like pulleys, to pull the knot into the subacromial space and onto the top of the infraspinatus tendon (Fig. 3-48). Then, the two “free” limbs are tied together with a static six-throw surgeon’s knot using the Surgeon’s Sixth Finger Knot Pusher (Arthrex, Inc., Naples, FL). It should be noted that this second knot must be a static knot; a sliding knot cannot be tied here because the other two suture limbs of this pair have already been fixed with a knot that will prevent sliding. Finally, the two other suture pairs are tied with the double-pulley technique in the same way as the first two suture pairs, creating another double-mattress