Arthroscopic Knotless Remplissage for the Treatment of Hill-Sachs Lesions Using the PASTA Bridge Configuration

Abstract

Recurrent glenohumeral dislocations can produce Hill-Sachs lesions-bony defects on the humeral head resulting from the humerus hitting the glenoid during dislocations. Some of these lesions can engage on the glenoid during motion, producing instability and potentially affecting the success of a labral repair. The remplissage was developed to address these Hill-Sachs lesions and improve stability. French for "filling," the goal of the remplissage is to fill the Hill-Sachs lesion with the infraspinatus tendon, preventing the margins of the lesion from engaging with the glenoid. Analogous to restoring the rotator cuff footprint during repair, a primary goal of the remplissage is to have the infraspinatus cover the Hill-Sachs lesion. The partial articular supraspinatus tendon avulsion (PASTA) bridge was originally developed for partial-thickness rotator cuff repair in situ, but additional uses have been found in other settings. The PASTA bridge uses a medial row horizontal mattress with a lateral anchor to create a linked construct to effectively distribute force and provide adequate coverage of the lesion. Knotless anchor technology used in this procedure prevents the need for arthroscopic knot tying and potentially damaging knot stacks. This Technical Note describes a remplissage technique using the PASTA bridge configuration to address Hill-Sachs lesions associated with recurrent glenohumeral instability.

Fig 1

With the patient in the beach chair position and an intra-articular view through the anterior portal, the exposed Hill-Sachs lesion (solid yellow arrow) of the right shoulder can be seen.

Fig 2

With the patient in the beach chair position and an intra-articular view through the anterior portal, the 17-gauge spinal needle (dashed red arrow) can be seen puncturing through the infraspinatus (asterisk) of the right arm. The spinal needle allows the surgeon to identify the correct position for anchor placement in the Hill-Sachs lesion (solid yellow arrow).

Fig 3

With the patient in the beach chair position and an intra-articular view through the anterior portal, the nitinol wire (solid yellow arrow) can be seen replacing the inner trocar of the spinal needle in the right arm.

Fig 4

With the patient in the beach chair position and an intra-articular view of the right shoulder through the anterior portal, the portal dilator (solid yellow arrow) that replaced the nitinol wire can be seen.

Fig 5

With the patient in the beach chair position and an intra-articular view of the right shoulder through the anterior portal, the half-pipe spear (solid yellow arrow) can be seen.

Fig 6

With the patient in the beach chair position and an intra-articular view of the right shoulder through the anterior portal, the punch (dashed red arrow) used to create the sockets for anchor placement can be seen. The punch is guided into position by the half-pipe spear (solid yellow arrow).

Fig 7

With the patient in the beach chair position and an intra-articular view of the right shoulder through the anterior portal, the Knotless Corkscrew anchor (dashed red arrow) can be seen being fixed into position. The anchor is guided into position by the half-pipe spear (solid yellow arrow).

Fig 8

With the patient in the beach chair position while the subacromial space of the right shoulder is viewed through the posterior portal, the sutures from the inferior (solid yellow arrow) and superior (dashed red arrow) anchors can be seen. These sutures will create the horizontal mattress and also be used to attach the lateral anchor.

Fig 9

With the patient in the beach chair position while the subacromial space of the right shoulder is viewed through the posterior portal, a grasper is used to pull a FiberLink looped suture (solid yellow arrow) extra-articularly. The TigerWire suture (dashed red arrow) will be pulled extra-articularly from the opposing anchor and used to shuttle the sutures to create one half of the horizontal mattress. (Note: The marked TigerWire suture in the figure is identified for simplicity purposes and is not the TigerWire suture that is used to pass the FiberLink suture marked in the figure.)

Fig 10

With the patient in the beach chair position while the subacromial space of the right shoulder is viewed through the posterior portal, the mattress construct (solid yellow arrow) can be seen after the TigerWire repair sutures (dashed red arrows) has been shuttled through with the FiberLink passing suture.

Fig 11

With the patient in the beach chair position while the subacromial space of the right shoulder is viewed, the infraspinatus (solid yellow arrow) can be seen abutted against the humeral head (dashed red arrow). After the horizontal mattress is created, the infraspinatus is set into the Hill-Sachs lesion. The margin of the Hill-Sachs lesion can be seen (solid black arrowhead).

Fig 12

With the patient in the beach chair position while the subacromial space of the right shoulder is viewed through the posterior portal, a grasper (dashed red arrow) gathers the remaining TigerWire repair sutures (solid yellow arrows).

Fig 13

With the patient in the beach chair position while the subacromial space of the right shoulder is viewed through the posterior portal, the BioComposite Vented SwiveLock anchor (solid yellow arrow) can be seen being fixed into position. The TigerWire repair sutures (solid black arrowheads) are attached to the anchor for the PASTA Bridge configuration.

Fig 14

With the patient in the beach chair position while the subacromial space of the right shoulder is viewed, the completed remplissage with the PASTA Bridge configuration can be seen. The low-profile sutures and absence of knot stacks should be noted.