Arthroscopic Allograft Bone Block Procedure with Remplissage for Bipolar Lesions

Abstract

Anterior shoulder instability with bone loss is a challenging condition. The two most performed procedures, Bankart repair & Latarjet, are not without issues. We describe a technique where arthroscopic free bone grafting was performed in conjunction with remplissage. We feel that this combined arthroscopic procedure offers advantages that include reduced risk of conventional Latarjet complications, including neurological deficits and metal hardware complications while preserving subscapularis and coracoid. Furthermore, these advantages may not come at the cost of compromised outcomes, particularly recurrence rate, as the remplissage may compensate for the possible lack of "sling effect" with free bone graft reconstruction.

Keywords: Bipolar lesions; Bone block; Hill Sachs lesions; Instability; Remplissage.

Figure 1

Arthroscopic view of scope in the posterior portal showing the anterior labral tear and the HS lesion

Figure 2

Preoperative 3D reconstruction CT scans showing the glenoid bone loss & HS lesion

Figure 3

Arthroscopic view of scope in the anterosuperior portal showing the labral lesion, quality of the soft tissue, and the anterior glenoid morphology

Figure 4

Arthroscopic view of scope in the anterosuperior portal: anterior glenoid preparation

Figure 5

Arthroscopic view from anterosuperior portal: Introduction of the needle from the posterior portal aiming towards the center of the glenoid bone defect

Figure 6

Arthroscopic view from anterosuperior portal: Introduction of switching stick aiming towards the center of the glenoid bone defect

Figure 7

Arthroscopic view from anterosuperior portal: Introduction of guide and hook

Figure 8

Arthroscopic view from anterosuperior portal: Positioning of the hook

Figure 9

Arthroscopic view from anterosuperior portal: passage & positioning of cannulated sleeves

Figure 10

Schematic diagram showing the bone block guide and sleeves in place

Figure 11

Arthroscopic view from anterosuperior portal: 2.3 all suture anchors in the HS lesion

Figure 12

Arthroscopic view from posterior portal: 1.4 all suture anchors for the labral repair to be performed later

Figure 13

Arthroscopic view from anterosuperior portal: Retrieval of suture limbs

Figure 14

Schematic diagram showing the prepared bone block just before insertion with remplissage & glenoid anchors in situ

Figure 15

Schematic diagram demonstrating the passage of bone block through the metal cannula

Figure 16

Arthroscopic view from posterior portal: the passage of bone block graft

Figure 17

Arthroscopic view from anterosuperior portal: tensioning & securing the bone graft using posterior endo-buttons, tensioning device & Nice knot

Figure 18

Arthroscopic view from posterior portal: completion of labral repair over bone graft block

Figure 19

Arthroscopic view from anterosuperior portal: completion of remplissage

Figure 20

Final arthroscopic view from the anterosuperior portal with labral repair covering the bone block

Figure 21

Diagram showing bone block secured with labrum repaired over it & remplissage of HS lesion

Figure 22

Postoperative X-ray images (Axillary and Y views)