Combined Double-Pulley Remplissage and Bankart Repair

Abstract

The use of arthroscopic Bankart repair to treat anterior shoulder instability has become increasingly widespread. However, high rates of recurrent instability within the presence of glenohumeral bony defects, specifically Hill-Sachs lesions, have well documented a key concern regarding the arthroscopic Bankart repair process. Our technique describes the pairing of a remplissage to fill the Hill-Sachs lesion with the Bankart repair, preventing loss in shoulder stiffness and stability. This technique involves a double-pulley-combined remplissage and Bankart repair to maintain a low-failure, minimally invasive procedure.

Fig 1

Patient is positioned in the beach chair position with the left shoulder and arm positioned with a Trimano limb positioner. Diagnostic arthroscopy of the left shoulder shows a large Hill-Sachs defect on the humeral head, as seen through the posterior portal. A 4-0 shaver is used to debride soft tissue for remplissage preparation.

Fig 2

Patient is positioned in the beach chair position with the left shoulder and arm positioned with a Trimano limb positioner. Intraoperative photograph of the percutaneous access placements via needle localization. Viewing from the anterior portal, pilot holes are created for the 5.5 mm BioComposite corkscrews within the Hill-Sachs defect perpendicular to the lesion.

Fig 3

Patient is positioned in the beach chair position with the left shoulder and arm positioned with a Trimano limb positioner. Intraoperative arthroscopic imaging of the BioComposite 5.5-mm suture anchors sitting in a broadly placed inferior/superior configuration within the Hill-Sachs lesion, as seen through the anterior portal. Each anchor is loaded with a repair suture in preparation for the remplissage, during which sutures from both anchors will be tied together and tensioned to reduce the infraspinatus into the lesion following the Bankart repair.

Fig 4

Patient is positioned in the beach chair position with the left shoulder and arm positioned with a Trimano limb positioner. Intraoperative arthroscopic imaging of the left anteroinferior glenoid labrum and humeral head during the Bankart repair. (A) ReelPass from Arthrex is used to pass 0-PDS around the injured labrum. (B) The 0-PDS is retrieved through the anterior portal and tied to a no. 2 FiberWire. The 0-PDS is then used to shuttle the FiberWire around the damaged labrum to establish a stitch.

Fig 5

Patient is positioned in the beach chair position with the left shoulder and arm positioned with a Trimano limb positioner. Intraoperative arthroscopic imaging of the left anteroinferior glenoid labrum during the Bankart repair. (A) A PushLock drill and drill guide is used to establish a pilot hole to the adjacent glenoid. (B) The FiberWire suture is subsequently loaded into the 2.9-mm BioComposite PushLock from Arthrex and then implanted with a mallet. The stitching and anchoring process is repeated three times.

Fig 6

Patient is positioned in the beach chair position with the left shoulder and arm positioned with a Trimano limb positioner. Intraoperative photograph of the left shoulder from a bird’s eye view during the remplissage. (A) One suture from each BioComposite corkscrew sitting inferior and superior to the infraspinatus tendon are tied together in a parallel fashion, which is then tensioned down into the double pulley over the infraspinatus tendon by pulling on the other pair. (B) A knot pusher and several half hitches are used to secure the reduction of the infraspinatus into the Hill-Sachs lesion.

Fig 7

Patient is positioned in the beach chair position with the left shoulder and arm positioned with a Trimano limb positioner. Intraoperative arthroscopic imaging of the posterolateral humeral head, as seen through the anterior portal, confirms the reduction of the infraspinatus into the Hill-Sachs defect, indicating the completion of the remplissage.