Chapter 3 Instability


CHAPTER 3 | Instability

One of the problems with the “double-pulley” tech- nique of remplissage is that it can be very time consum- ing. We have been able to simplify our technique by using self-cinching knotless suture anchors (Knotless SutureTak; Arthrex, Inc., Naples, FL) with interlocking splices. Biomechanical testing has shown this construct to be even stronger than the double-mattress construct created by the double-pulley remplissage. Furthermore, we often perform the interlocking cinching part of the procedure in “blind” fashion, without directly visualizing the sutures in the sub- acromial space. In this way, we avoid a time-consuming subacromial bursectomy, which further shortens and sim- plifies the technique. Knotless Interlocking Remplissage The Knotless SutureTak (Arthrex, Inc., Naples, FL) has been used since 2012 for arthroscopic labral repairs. It has a unique mechanism in which the end of a coreless suture is passed through soft tissue (e.g., labrum) and then shuttled back through a segment of its coreless sheath to create a one-way knotless splice that will not slip (Fig. 3-50). FIGURE 3-49  A: Right shoulder, anterosuperolateral portal demonstrating a Hill-Sachs lesion. B: Following a remplissage, the infraspinatus fills the defect so that the lesion is now extra-articular. C: Posterior subacromial viewing portal in the same shoulder after remplissage showing the mattress sutures tied with a double-pulley technique. G, glenoid; H, humeral head; IS, infraspinatus tendon; RC, rotator cuff.

By interlocking the splices of the two knotless anchors used in remplissage, we can simplify the technique and strengthen the construct. The interlocking creates a knot- less double-mattress construct between the two anchors. The cinching of the splices can be done with direct visual- ization in the subacromial space, but achieving satisfactory visualization in the posterolateral part of the subacromial space can be very time consuming. Therefore, we devel- oped a “blind” technique of cinching down the remplis- sage that is quick and easy to perform, yet very strong and reliable. The steps are as follows: Two working cannulas are used, a straight posterior can- nula that goes intra-articularly and a posterolateral can- nula that goes into the subacromial space (Fig. 3-51A). An anterosuperolateral viewing portal is used. The surgeon should visualize intra-articularly while the subacromial portal is placed. A spinal needle identifies the proper angle of approach, which is ~45° to the plane of the Hill-Sachs lesion. This angle assures that the tendon rather than the muscle is inset into the defect.

Video 3-7

Video 3-6

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