Remplissage Procedure: Difference between revisions
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Remplissage (a French term meaning “to fill in”) involves a posterior capsulodesis and infraspinatus tenodesis performed arthroscopically in patients with anterior shoulder instability and engaging Hill-Sachs lesions. | Remplissage (a French term meaning “to fill in”) involves a posterior capsulodesis and infraspinatus tenodesis performed arthroscopically in patients with anterior shoulder instability and engaging Hill-Sachs lesions. | ||
[[File:Hill sachs lesion.jpg|thumb|300x300px]] | [[File:Hill sachs lesion.jpg|thumb|300x300px]] | ||
The Hill-Sachs remplissage technique is similar to an arthroscopic repair of a partial-thickness, articular surface rotator cuff tear. It consists of fixation of the infraspinatus tendon and posterior capsule to the abraded surface of the Hill-Sachs lesion. It is a non-anatomic technique that renders the defect extra-articular to prevent instability, using an arthroscopic posterior capsulodesis and infraspinatus tenodesis into the Hill-Sachs defect, performed in conjunction with a Bankart repair.<br>The filling of the abraded Hill-Sachs lesion effectively obliterates it and converts the lesion into an extra-articular one. Therefore it prevents engagement. | The [[Hill Sachs Lesion|Hill-Sachs]] remplissage technique is similar to an arthroscopic repair of a partial-thickness, articular surface rotator cuff tear. It consists of fixation of the infraspinatus tendon and posterior capsule to the abraded surface of the Hill-Sachs lesion. It is a non-anatomic technique that renders the defect extra-articular to prevent instability, using an arthroscopic posterior capsulodesis and infraspinatus tenodesis into the [[Hill Sachs Lesion|Hill-Sachs]] defect, performed in conjunction with a [[Bankart lesion|Bankart]] repair.<br>The filling of the abraded Hill-Sachs lesion effectively obliterates it and converts the lesion into an extra-articular one. Therefore it prevents engagement. | ||
In particular, the concern that the remplissage would limit rotation did not materialize. There was no significant loss of motion in any plane after the procedure. <ref>Morsy MG. Arthroscopic remplissage: Is it still an option?. EFORT Open Reviews. 2017 Dec 8;2(12):478-83.</ref> | In particular, the concern that the remplissage would limit rotation did not materialize. There was no significant loss of motion in any plane after the procedure. <ref>Morsy MG. Arthroscopic remplissage: Is it still an option?. EFORT Open Reviews. 2017 Dec 8;2(12):478-83.</ref> | ||
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== Indication <ref>Purchase RJ, Wolf EM, Hobgood ER, Pollock ME, Smalley CC. Hill-Sachs “remplissage”: an arthroscopic solution for the engaging Hill-Sachs lesion. Arthroscopy: The Journal of Arthroscopic & Related Surgery. 2008 Jun 1;24(6):723-6.</ref> == | == Indication <ref>Purchase RJ, Wolf EM, Hobgood ER, Pollock ME, Smalley CC. Hill-Sachs “remplissage”: an arthroscopic solution for the engaging Hill-Sachs lesion. Arthroscopy: The Journal of Arthroscopic & Related Surgery. 2008 Jun 1;24(6):723-6.</ref> == | ||
Hill-Sachs defect >25 % in width, glenoid bone loss, <20 %, a more horizontal orientation/Hill-Sachs angle or engagement demonstrated during dynamic arthroscopic evaluation and a Hill-Sachs defect ending medial to the glenoid tract | Hill-Sachs defect >25 % in width, [[Glenoid Labrum|glenoid]] bone loss, <20 %, a more horizontal orientation/Hill-Sachs angle or engagement demonstrated during dynamic arthroscopic evaluation and a Hill-Sachs defect ending medial to the glenoid tract | ||
== Procedure == | == Procedure == | ||
There are various adaptations of this procedure. Here is one video about it - | There are various adaptations of this procedure. Here is one video about it - | ||
{{#ev:youtube|ApmX-BBY4jk|300}}<ref>Doctive LAB - orthopaedic trauma cases. Arthroscopic Bankart repair & remplissage. Available from: http://www.youtube.com/watch?v=ApmX-BBY4jk[last accessed 2/10/2022]</ref> | {{#ev:youtube|ApmX-BBY4jk|300}}<ref>Doctive LAB - orthopaedic trauma cases. Arthroscopic Bankart repair & remplissage. Available from: http://www.youtube.com/watch?v=ApmX-BBY4jk[last accessed 2/10/2022]</ref> | ||
== Advantages <ref name=":0">Rahu M, Kartus JT, Põldoja E, Kolts I, Kask K. Hill-Sachs remplissage procedure based on posterosuperior capsulomuscular anatomy. Arthroscopy techniques. 2019 Jun 1;8(6):e623-7.</ref> == | == Advantages <ref name=":0">Rahu M, Kartus JT, Põldoja E, Kolts I, Kask K. Hill-Sachs remplissage procedure based on posterosuperior capsulomuscular anatomy. Arthroscopy techniques. 2019 Jun 1;8(6):e623-7.</ref> == | ||
{| class="wikitable" | {| class="wikitable" | ||
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|Blind suturing during the remplissage procedure sometimes requires the surgeon to check the subacromial space. | |Blind suturing during the remplissage procedure sometimes requires the surgeon to check the subacromial space. | ||
|- | |- | ||
|In cases with a concomitant supraspinatus rupture, orientation and determination of the rotator cable structure can be difficult. | |In cases with a concomitant [[supraspinatus]] rupture, orientation and determination of the rotator cable structure can be difficult. | ||
|} | |} | ||
== Physiotherapy Management == | |||
The healing timeframes associated with rotator cuff repair must be considered in order to optimize the healing of the tendon into the defect. As such, active and passive tension across this repair should be avoided for the first 6 weeks following surgery, and resistance to the posterior cuff avoided for 12 weeks. Based on these timeframes the following modifications to the anterior shoulder reconstruction rehab model follow remplissage: | |||
=== Phase I (Weeks 0-6) === | |||
Sling immobilization at all times except for showering | |||
Therapeutic Exercise - Elbow/Wrist/Hand Range of Motion | |||
[[Grip Strength|Grip]] Strengthening | |||
=== Phase II (Weeks 7-12) === | |||
Discontinue sling immobilization | |||
Range of Motion – Slowly Increase Forward Flexion, Internal/External Rotation as tolerated | |||
Therapeutic Exercise - Continue with [[Elbow]]/[[Wrist and Hand|Wrist]]/Hand Range of Motion and Grip Strengthening | |||
Begin Prone Extensions and Scapular Stabilizing Exercises ([[trapezius]]/[[rhomboids]]/[[Levator Scapulae|levator scapula]]) | |||
Gentle joint mobilization | |||
Modalities per PT discretion | |||
=== Phase III (Months 3-6) === | |||
Range of Motion – Progress to full AROM without discomfort | |||
Therapeutic Exercise – Advance theraband exercises to light weights (1-5 lbs) - 8-12 repetitions/2-3 sets for Rotator Cuff, [[Deltoid]] and Scapular Stabilizers | |||
Continue and progress with Phase II exercises | |||
Begin UE ergometer | |||
Modalities per PT discretion | |||
=== Phase IV (Months 6+) === | |||
Range of Motion – Full without discomfort | |||
Therapeutic Exercise – Advance exercises in Phase III (strengthening 3x per week) | |||
Sport/Work specific rehabilitation | |||
Return to throwing at 4.5 months | |||
Return to sports at 8 months if approved | |||
== References == | == References == | ||
<references /> | <references /> | ||
Revision as of 16:15, 2 October 2022
Original Editor - User Name
Top Contributors - Shreya Pavaskar and Nupur Smit Shah
Description[edit | edit source]
Remplissage (a French term meaning “to fill in”) involves a posterior capsulodesis and infraspinatus tenodesis performed arthroscopically in patients with anterior shoulder instability and engaging Hill-Sachs lesions.
The Hill-Sachs remplissage technique is similar to an arthroscopic repair of a partial-thickness, articular surface rotator cuff tear. It consists of fixation of the infraspinatus tendon and posterior capsule to the abraded surface of the Hill-Sachs lesion. It is a non-anatomic technique that renders the defect extra-articular to prevent instability, using an arthroscopic posterior capsulodesis and infraspinatus tenodesis into the Hill-Sachs defect, performed in conjunction with a Bankart repair.
The filling of the abraded Hill-Sachs lesion effectively obliterates it and converts the lesion into an extra-articular one. Therefore it prevents engagement.
In particular, the concern that the remplissage would limit rotation did not materialize. There was no significant loss of motion in any plane after the procedure. [1]
Indication [2][edit | edit source]
Hill-Sachs defect >25 % in width, glenoid bone loss, <20 %, a more horizontal orientation/Hill-Sachs angle or engagement demonstrated during dynamic arthroscopic evaluation and a Hill-Sachs defect ending medial to the glenoid tract
Procedure[edit | edit source]
There are various adaptations of this procedure. Here is one video about it -
Advantages [4][edit | edit source]
| Easier control of ROM without possible damage to previously reconstructed anterior-inferior capsulolabral structures |
| Better visualization and easier reconstruction of the anterior-inferior capsulolabral structures because the humeral head moves more posteriorly |
| Inserting the sutures from lateral to medial attaching the rotator cable, as well suturing in the horizontal plane, allows stronger fixation and avoids damage to the blood supply of the posterior capsule and infraspinatus tendon. |
Disadvantages [4][edit | edit source]
| Blind suturing during the remplissage procedure sometimes requires the surgeon to check the subacromial space. |
| In cases with a concomitant supraspinatus rupture, orientation and determination of the rotator cable structure can be difficult. |
Physiotherapy Management[edit | edit source]
The healing timeframes associated with rotator cuff repair must be considered in order to optimize the healing of the tendon into the defect. As such, active and passive tension across this repair should be avoided for the first 6 weeks following surgery, and resistance to the posterior cuff avoided for 12 weeks. Based on these timeframes the following modifications to the anterior shoulder reconstruction rehab model follow remplissage:
Phase I (Weeks 0-6)[edit | edit source]
Sling immobilization at all times except for showering
Therapeutic Exercise - Elbow/Wrist/Hand Range of Motion
Grip Strengthening
Phase II (Weeks 7-12)[edit | edit source]
Discontinue sling immobilization
Range of Motion – Slowly Increase Forward Flexion, Internal/External Rotation as tolerated
Therapeutic Exercise - Continue with Elbow/Wrist/Hand Range of Motion and Grip Strengthening
Begin Prone Extensions and Scapular Stabilizing Exercises (trapezius/rhomboids/levator scapula)
Gentle joint mobilization
Modalities per PT discretion
Phase III (Months 3-6)[edit | edit source]
Range of Motion – Progress to full AROM without discomfort
Therapeutic Exercise – Advance theraband exercises to light weights (1-5 lbs) - 8-12 repetitions/2-3 sets for Rotator Cuff, Deltoid and Scapular Stabilizers
Continue and progress with Phase II exercises
Begin UE ergometer
Modalities per PT discretion
Phase IV (Months 6+)[edit | edit source]
Range of Motion – Full without discomfort
Therapeutic Exercise – Advance exercises in Phase III (strengthening 3x per week)
Sport/Work specific rehabilitation
Return to throwing at 4.5 months
Return to sports at 8 months if approved
References[edit | edit source]
- ↑ Morsy MG. Arthroscopic remplissage: Is it still an option?. EFORT Open Reviews. 2017 Dec 8;2(12):478-83.
- ↑ Purchase RJ, Wolf EM, Hobgood ER, Pollock ME, Smalley CC. Hill-Sachs “remplissage”: an arthroscopic solution for the engaging Hill-Sachs lesion. Arthroscopy: The Journal of Arthroscopic & Related Surgery. 2008 Jun 1;24(6):723-6.
- ↑ Doctive LAB - orthopaedic trauma cases. Arthroscopic Bankart repair & remplissage. Available from: http://www.youtube.com/watch?v=ApmX-BBY4jk[last accessed 2/10/2022]
- ↑ 4.0 4.1 Rahu M, Kartus JT, Põldoja E, Kolts I, Kask K. Hill-Sachs remplissage procedure based on posterosuperior capsulomuscular anatomy. Arthroscopy techniques. 2019 Jun 1;8(6):e623-7.
