Thank you very much, it's always an honor to be here, Conflicts. So remplissage is a French word which means to fill, it was coined by Gene Wolf to describe this infraspinatus transfer into the Hill-Saxon defect. As with everything orthopedic, it originally described way in the past by Connolly in 1972 called it a reverse McLaughlin because McLaughlin described the subscap transfer. So our indications are an engaging Hill-Saxon defect. So what does that mean? Maybe glenoid bone loss less than 20%, probably an indication, combined loan loss that allows the Hill-Saxon to engage, the only way you get a Hill-Saxon lesion is for the engagement to occur, or maybe your exam shows apprehension at lower levels of abduction, external rotation without significant bone loss. So clinically it's a bit difficult to say, oh, these are an absolute indication. So as everyone, Steve Burkhart really made just an incredible change in how we think about this with his paper with Joe DeBeer and found that when you have a giant Hill-Saxon as you see here, that's going to give you, and some glenoid bone loss, you're going to have an increased risk of failure. So Ian Lowe looked at this, E.G. Toy described on track, off track. So then the question is how do you manage the humerus and can you do a remplissage and we'll go through when and how and why. There's some additional advantages to doing that because instability always has poster lateral problems on the PIGHL and you tighten that when you do this. You could bone graft it as Tony talked about. You can ignore it because we now currently think that Laterge works on everyone, even though Bristow didn't do that, we now think we do it better, which is probably not true. Or you can do partial replacements or bone grafts. You got to tailor it as Tony just showed you. You can't put a round peg in an oblong hole. So how do you decide? Radiographs may be helpful, CT scan, 3D where you can see the Hill-Sax defect here and sort of measure it or maybe wait for arthroscopy to decide. And then the other question is there a critical bone loss and the whole concept of on track, off track I think is a bit more math than I like to do and I was actually pretty good at math, but if you think of it this way, it's pretty simple. If the glenoid loss and the humeral loss are bigger than the line you have across here, you probably need to do something with bone and not with soft tissue. If it's smaller, then rhomplosage comes into play. So what is it? It's a transfer of the infraspinatus tendon and the posterior capsule into the defect to make it extra articular as you see here. It had an added advantage that it tightens the PIGHL, which is always injured when the shoulder dislocates. So how do you do it? First, prepare the humerus. This is not enough just to look at it and put an anchor in. Scrape it, microfracture it, create a healing bed. This is a compression fracture and unless you're doing it acutely, it's not vascular. It's already down and so you want to make sure that that works. Put an anchor in pretty much in the center. Some people move it to the top, to the bottom. I usually put it as most medial as I can and put it in the center of the defect. Let's see if we can move that forward. So then you have your anchor in. Shuttle your sutures out the front, which makes it easy and then you're going to draw a line, if you look at the one to the right, from the defect straight across to the capsule and try to fill this in. All you're trying to do is move that and tighten the back of this and you can see as you tighten it, it pulls the head back. You can see we've already done our inferior repair to put that back together. Once you finish this and finish your repair, you should have a perfectly balanced shoulder as you see here. There's our Bankart repair. You can see we've actually tightened the back and then here's the posterior capsule and we have it tucked into the lower part of the heel sacs, which in this one was all we wanted. So why do it? Well, it decreases your recurrence rate. That's the name of the game, right? We want them to not dislocate again and in mild to moderate bone loss patients, this is an indicated procedure. It does not seem to result in motion loss and the question you would ask yourself is why not? Because that posterior capsule and heel sacs are stretched out. If you look at this patient with an anterior instability, what you don't see is capsule here posteriorly. That's been torn, stretched out and you're looking at infraspinatus muscle. So in this case, you need to do something in the back, even if you do a Latergé in the front to balance the shoulder. So you can do autoanalografts, Tony talked about that. And so what are the results? Well, we did a paper on this. Mike McCabe was one of the first ones in moderate bone loss after Gene and we showed no recurrence in primary surgeries. Only in our revision cases that had failed prior surgery did we have recurrences and no reoperations. Gene Wolfe said it increased his success rate by about 10% and then John Kelly, our chairman, has shown that he has 97% stability when he has a remplissage. He did find that throwers did badly if you do this and you should never touch the infraspinatus in a thrower. So it's not an indicated procedure in a throwing athlete. So in conclusion, remplissage is an effective adjunct to reconstruction for shoulder instability and working in the back of the shoulder both fills the defect and tightens that damaged posterior capsule, posterior infraglinal ligament and rebalances the shoulder to a more anatomically normal state. Thank you.

remplissage

French word

surgical technique

Hill-Sachs defect

shoulder joint