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.

Technique Video

Video 1

Double pulley combined remplissage and a Bankart repair. Patient is in the beach chair position with the abducted left shoulder and arm positioned using a Trimano limb positioner. Diagnostic arthroscopy showing a very large Hill-Sachs defect. From the view of the posterior portal, the Hill-Sachs defect is located, and a shaver is used to debride soft tissue for remplissage preparation. Percutaneous access is placed superolateral and posterolateral to the posterior portal for broad anchor placements of the 5.5-mm BioComposite corkscrews in the large Hill-Sachs defect using pilot hole tapping. Each anchor is loaded with a repair suture placed through separate capsular puncture holes through the same posterior portal. Switching to anterior portals, the surgeon uses a shaver to debride soft tissue for Bankart repair preparation. An Arthrex suture passer is used to pass large bites of 0-PDS around the Bankart and anterior capsular tissue. A no. 2 FiberWire is then tied to the passed end of the suture and shuttled around to luggage tag a stitch around the damaged labrum. A drill is used to create a pilot hole for the 2.9-mm BioComposite Arthrex PushLock anchor, into which the FiberWire is loaded. This process is repeated three times, taking large bites of the capsule and Bankart labrum to complete the Bankart repair. To complete the remplissage, the repair sutures from anchor 1 and the FiberWire sutures from anchor 2, located inferior and superior to the infraspinatus tendon, respectively, are retrieved and tied together in a parallel fashion. The repair sutures pulled through anchor 2 are then pulled to tighten them into the double pulley, reducing the infraspinatus into the Hill-Sachs defect. Several half hitches with a knot pusher are used to secure the reduction. Finally, an arthroscopic view of the reduction of the infraspinatus into the Hill-Sachs defect is shown.