“I have a simple philosophy: Fill what’s empty. Empty what’s full. Scratch where it itches.”

Alice Roosevelt Longworth

Remplissage

James Wilson

ST8 Trainee T&OUpper Limb Fellow

Wrightington Hospital

• Remplissage -

• filling

• filling in

• filling out

• padding

• charging

Definition

• Humeral head defects commonly associated with dislocation

• Hill-Sachs lesion = impression fracture postero superior (>80%)

• Large defect reduces rotational arc length

• Engagement leads to recurrent dislocation

Background

Hill HA Sachs MD . The grooved defect of the humeral head. A frequently unrecognized complication of dislocations of the shoulder joint. Radiology. 1940;35:690-700.

• Published by Purchase et.al as a Technical Note in Arthroscopy

• Posterior portal for initial assessment

• Antero-Superior portal then used for viewing

• Hill-Sachs and capsule freshened

• Bankart repair prepared

Description

7

• September 2014 - Systematic review in Arthroscopy

• Looked at studies reporting outcomes for:

• Remplissage

• Weber osteotomy

• Allograft reconstruction

• Arthroplasty

What is the evidence

• Remplissage 29.5 months

• Weber osteotomy 108 months

• Allograft reconstruction 61.3 months

• Arthroplasty 51.4 months

Follow up

• Remplissage 0.9% 2/212

• Weber osteotomy 29% 53/184

• Allograft reconstruction 74% 17/23

• Arthroplasty 19% 20/104

Complications

Outcomes

Constant Rowe score for instability ASES

Remplissage 94.6 (3) 89.4 (9) 89.1 (5)

Weber Osteotomy 79 (1)

Allograft 76.2 (3)

Arthroplasty 58.2 (4) 71.4 (1) 65.8 (2)

• Dislocation or subluxation

• Remplissage 6.3% 21/333

• Weber osteotomy 5.6%

• Allograft reconstruction 0%

• Arthroplasty 14%

Recurrence of instability

• Remplissage did not significantly affect ROM

• Studies comparing Bankart to Bankart plus remplissage - no significant difference.

Range of motion

• Franceschi • Comparative study

• Historical controls

• Different surgeons

• However, groups well matched for age and pathology • Average D/R index 30%

• Good scores, no recurrence and good ROM in the R&B group

More detail

• Cohort study designed to compare ROM for the two groups

• Dissimilar groups: • ISIS 5 or 6 vs ISIS < 5

• Outcomes similar

• ROM no difference

• One recurrence per group

Nourissat et al

• Stephen Burkhart

• If D/R index >15% (about 4mm) high rate of recurrent instability

• Minimal glenoid bone loss (<25%)

• Where arthroscopic stabilisation planned but increased stability wanted

• Not for inverted pear glenoids

• Do the Bankart first

Other opinions

Follow up