Next we have Carolyn Hetrick talking to us about arthroscopic labral repair with remplissage indications in 2023. Thank you for letting me speak. Remplissage as you know is the French word for filling. It was originally described somewhat recently in 2008 by Purchase. Remplissage involves capsulotinodesis of the infraspinatus or the teres minor tendons in the posterior capsule into your Hill-Sachs lesion. It does this to prevent engagement into the glenoid rim through extra-articular conversion and restraint against humeral head anterior translation. It's not without potential consequences as there can be a lack of external rotation and early osteoarthritis. This is just a quick review mostly for the handout for anyone who wanted to take a look at the different definitions of your Hill-Sachs interval and your glenoid tract because these words are used a lot when determining if you want to go ahead and do a remplissage. Historically if you look at the early literature from this, people were doing this in less than 25% glenoid bone loss and engaging Hill-Sachs lesion. But now the indications seem to have evolved over time as in many of our procedures. And so we still do them in engaging Hill-Sachs lesions. But how much glenoid bone loss and are there any other risk factors for patients for a non-engaging lesion? And this is a paper that came out somewhat recently by Peter McDonald which really got me to increase my usage of remplissages. It was a randomized control trial looking at remplissage plus Bankart versus Bankart alone. And if you looked at the two-year follow-up to this, there was 18% repeat dislocation in Bankart alone versus 4% dislocation in remplissage and Bankart group. So a significant difference. Looking at patient factors, this was a great study by Domos looking at collision athletes. These were non-engaging lesions, so smaller Hill-Sachs lesions, 20 collision athletes. They were matched to patients with Bankart alone. And again the recurrence rate in Bankart alone was 30% versus 5% when you added the remplissage. So pretty convincing data. And this again was out of Dr. Lin and the Pitt group. We just saw some of this research. Same thing, significantly higher dislocation rate in Bankart alone versus Bankart and remplissage in contact athletes with a DTD of less than 10. So how much glenoid bone loss should we be looking at? This is a paper out of, I think this is Pascal Boileau's group, retrospective, 133 patients. They looked at Bankart and remplissage and less than 10% glenoid bone loss as well as more than 10%. And then again found significant differences in the rates of recurrent instability with an odd ratio of 35. And again it's not often in orthopedics that we see an odds ratio of 35. This is another paper that looked at greater than 15% bone loss. Didn't have a huge difference with LaDerge. So there are some other opinions out there. So my indications in 2023 are glenoid bone loss less than 10% to 15% with an engaging Hill-Sachs. But also if it's a non-engaging Hill-Sachs and a contact athlete, soft tissue laxity in young age. This is looking at the surgical technique. You can set it up in any way you normally do a scope, beach chair, lateral, standard portals. Do your standard diagnostic arthroscopy. It is important to get a good preparation of the Hill-Sachs lesion so that you get good biologic healing. I like to use a ring curette as well as a shaver to go ahead and clean the lesion down to a nice cancellous bone. For your anchor placement, you want to usually place the inferior anchor first. This will be followed by the superior anchor. This is just looking at the Hill-Sachs lesion showing that it is an engaging lesion. The lesion has been cleaned up. This is go ahead and we're inserting the first anchor. It's a double loaded anchor into the defect. Here was used with standard anchors, not knotless. We do have to go in and retrieve those into the subacromial space. Here again is just the bird beak going in, grabbing the other suture, pulling it through the capsule and the tendon. So next we're putting in the second anchor, same thing. Those sutures again will be using a bird beak, will be retrieved, pulled into the subacromial space. And again, they do have knotless constructs out where there's techniques online, I have not admittedly done them yet, where you can link the anchors and you don't have to then go into the subacromial space. This is going into the subacromial space, just going in there, tying down the sutures, securely standard using a knot pusher. And then going back and then looking at your repair. So there is your Rem-Plessage. You can see it nicely fills the Hill-Sacks lesion. You know, a note on anchor placement, a tip, is really the literature has been showing now you need to avoid excess medial placement of your anchors. You'll get increased loss of external rotation, potential degenerative changes with changes in your cartilage. And you need to be especially thoughtful in this with overhead throwing athletes. Because while the return to sport literature overall looks good, when you do subgroup analyses looking at overhead athletes, that number can be less. Thank you.

arthroscopic labral repair

remplissage indications

capsulotinodesis

Hill-Sachs lesions

dislocation rates