Accuracy of Suture Passage During Arthroscopic Remplissage-What Anatomic Landmarks Can Improve It?: A Cadaveric Study

Abstract

Background: Recent data suggest that inaccurate suture passage during remplissage may contribute to a loss of external rotation, with the potential to cause posterior shoulder pain because of the proximity to the musculotendinous junction.

Purpose: To evaluate the accuracy of suture passage during remplissage and identify surface landmarks to improve accuracy.

Study design: Descriptive laboratory study.

Methods: Arthroscopic remplissage was performed on 6 cadaveric shoulder specimens. Two single-loaded suture anchors were used for each remplissage. After suture passage, position was recorded in reference to the posterolateral acromion (PLA), with entry perpendicular to the humeral surface. After these measurements, the location of posterior cuff penetration was identified by careful surgical dissection.

Results: Twenty-four sutures were passed in 6 specimens: 6 sutures (25.0%) were correctly passed through the infraspinatus tendon, 12 (50%) were through the infraspinatus muscle or musculotendinous junction (MTJ), and 6 (25%) were through the teres minor. Suture passage through the infraspinatus were on average 25 ± 5.4 mm inferior to the PLA, while sutures passing through the teres minor were on average 35.8 ± 5.7 mm inferior to the PLA. There was an odds ratio of 25 (95% CI, 2.1-298.3; P < .001) that the suture would be through the infraspinatus if the passes were less than 3 cm inferior to the PLA. Sutures passing through muscle and the MTJ were significantly more medial than those passing through tendon, measuring on average 8.1 ± 5.1 mm lateral to the PLA compared with 14.5 ± 5.5 mm (P < .02). If suture passes were greater than 1 cm lateral to the PLA, it was significantly more likely to be in tendon (P = .013).

Conclusion: We found remplissage suture passage was inaccurate, with only 25% of sutures penetrating the infraspinatus tendon. Passing sutures 1 cm lateral and within 3 cm inferior of the PLA improves the odds of successful infraspinatus tenodesis. We recommend this "safe zone" to improve the odds of infraspinatus tenodesis during remplissage. These results may help improve remplissage techniques and prevent previously reported complications, including external rotation loss and pain from myodesis.

Keywords: Hill-Sachs; anchors; remplissage; suture passage.

Figure 1.

Appropriate anchor placement into a “theoretically” large Hill-Sachs lesion (L), as defined by Omi et al. The dotted trajectory (S) defines the line for placement into the valley of a large Hill-Sachs lesion. Reprinted with permission from Omi et al. C, center of the humeral head; F, bare spot.

Figure 2.

A posterior dissection with separation of all 4 suture limbs. The exiting posterior structure was recorded for each limb.

Figure 3.

The suggested safe zone is demonstrated. Staying 1 cm lateral and within 3 cm inferior of the posterolateral acromion significantly improves passage through the infraspinatus tendon.