All right, so I'm Kelly Kilcoyne from Walter Reed Military Medical Center in DC, and I'm tasked to talk to you about REM plasage, and hopefully I'll answer the when, why and the how. So I have no relevant disclosures this talk. So he'll sex, a lesion is a compression fracture of the poster superlateral humoral head that occurs in association with enter instability or dislocation you can see in the reconstructed CT here. Eugene wolf in 2004 described a technique to fill this defect, and that's what the term replication means and it's an arthroscopic posterior capsulitis and infraspinatus tinnitus into the defect. And it converts a bony intra articular defect into an extra articular defect with soft tissue coverage. There's a review study, JSC 2009, and it notes that the bony defects of the glenoid are reported in upwards of 50% 56% of cases of traumatic inter shoulder instability. He'll sex lesions can occur 65 to 71%, with the first time shoulder dislocation and 93% of shoulders with recurrent dislocations will have a hill sex lesion of some size. So a positive correlation between the number of recurrent dislocations, and the extent and depth of these bony injuries. So I mentioned, Dr. Wolf's initial study, and this is a outcome study published in 2014 that looked at those that initial cohort of patients so it was results of an arthroscopic replication patients with glenoid bone loss and a significant hill sex lesion as you can see there is, as I described what a rental size is. So of the 270 patients total in the cohort 59% had answer and instability with the hill sacks and glenoid deficiency, specifically less than 25% who underwent replication. So this graphic here, this kind of actual cut here shows here the hill sex defect in the back in an anchor placement, kind of in the valley there, and then multiple anchor placement about the anterior glenoid. So the schematic here just shows here that kind of the outline of the, of the hill sacks and then placement of an anchor, kind of on the articular edge superior inferior, and then the arthroscopic image here shows. Again, basically, past my suture passage in a mattress fashion from those anchors. Of the 45 patients from the initial 59 that were available for two to 10 year follow up they had to traumatic recurrent dislocations in this group, and they did note five with positive apprehension but they still had high outcome scores by report. They noted no specific range of motion numbers, but they know no significant loss of experimentation, or any plan of range of motion. And you can see the high row constant and mostly scores that they report. So, in 2009, Dr. Burkhardt and authors described just an alternate technique of how to do the, the rental size. Again, you saw two anchors with a horizontal mattress configuration. On the left hand side. This is a double pulley technique, and they use it to treat mild blended bone loss and a large hillside hell sex lesion. I think it's important to note they they did this in response to an unacceptably high failure rate 67% for arthroscopic repair alone for these patients who have instability with plenary humor bone loss defined as either an engaging hill sex lesion or an inverted paranoid. So this slide shows here suture anchor configuration is similar with this technique. The difference is you don't pass in a mattress fashion, you go then go subacromial and you do a double pulley technique here. And you can see that the rotator cuff and caps are kind of compressed down into the defect adjacent where you place your anchors, and their indication for ample size again moderate to large hill sex with a clinical loss less than 25% or borderline case where the defect, the glenoid bone loss was close to 25%, but the hills sex was a little bit smaller or moderate. So no matter how you do it. Dr. Athwell and his group did a biomechanical study that evaluated three different configurations for the rental size so in technique one they place the anchor in the valley of the defect and place the sutures essentially in line with the anchors and the defect through the capsule intended. In technique two they went off the humoral head rim, and again play sutures in line. And then in technique, three, again they place the anchor in the valley but then they place the sutures one centimeter medial within the capsule intended. And what they found was that all techniques enhanced shoulder stability and restricted range of motion increase stiffness. There were no difference between technique one and technique to however they found that medial suture placement which was taking three resulted in the greatest stiffness values and mean restriction range of motion so again suture passage and where's passing your sutures I think is important. I think this shows us amongst other studies to maybe avoid going to medial and risk restricting extra rotation. And this study by Dr. McCabe at all looked at primary versus revision reconstruction with replicas in patients with moderate bone loss so it was a retrospective review of 30 patients who underwent primary or vision bankarton replicas and what they found were no failures failure defined as apprehension and or re dislocation or subluxation no no failure in the primary group but in the revision group, those who are undergoing revision surgery obviously 9% re dislocation rate so one of 11, which was three of 11. So they concluded that aggressive capsule labor reconstruction with replicas and traumatic instability patients with moderate bone loss and an engaging humoral Hillside's lesion. They found acceptable outcomes for primary but not so much for revision. So I know we've certainly heard more about on track off track lesion and other talks. I mentioned it here, because I think there's two points to make one you need to get advanced imaging. In order to characterize the degree of clinical loss and the size of the whole sex lesion. It's really not that hard to calculate if it's going to be on or off track. The depth of the Hillside's lesion and the degree of a colonoid bone loss. And I think that's important because I think as you're approaching that case and entering the operating room you kind of need to know ahead of time, and be prepared to do a clinical size and it shouldn't just be an intraoperative determination and assessment, my opinion. So here's a case example of mine, a 23 year old activity marine he had had recurrent shoulder instability after, and he had to enter your shoulder dislocations, you can see the agile sagittal MRI depicting a, I would say you know, moderate size Hillside's lesion, here as well. I get CTs to further characterize bone loss he only had a mild degree of colonoid bone loss, but you can kind of see the the Hillside's lesion and depth here unfortunately is a little externally rotated there. So, once in the operating room I like to perform instability cases in the lateral position. So here's a preview from your entry superior portal. He's got a large Hillside's lesion, and I'm noting here kind of the degree of extension and how deep it is. And certainly you can see he's resting anterior here, and if I think one challenge of being lateral you have to kind of bring them out of traction and up into abduction, abduction external rotation to to test engagement maybe a little bit easier in the But you can see here in abduction external rotation he has positive engagement of that lesion. So at that point, I know based on again my pre operative calculation of on off track and then interrupt assessment of engagement that he's going to get a rumble So again, different techniques here, different ways to do it. This is how I like to do it. Kind of similar to what I presented previously so prepare the bony bed with a curette and a burr place to double loaded to nine anchors through the posterior cannula and again type of anchor size that that can certainly be variable you can use bigger rotator cuff anchors you can use all suture anchors. You can, you know, you can use newer techniques with not less configuration as well, or the double pulley like I mentioned, and I would encourage you to kind of see different ones up throughout the course if you can. So basically place your anchor through the cannula then you want to back that cannula out outside of the of the capsule and rotator cuff and then I like to just use a bird beak to place my mattress configuration here. Kind of, again, in line with your anchors don't go to medial, and then you're going to store those sutures to tie the end after the labor repair so in this case this is kind of the progression, and I went ahead, went up anteriorly. He had an out solution. So we free that up and mobilize that did our bank our repair, and then at the end of the case. Now, we've already passed our sutures then we go pull our cannula back into the posterior cannula back into subacromial space, and then you can tie your past I like to do that time blind and viewing the, the tinnitus effect from intraarticular but you can certainly go subacromial and view from there as well. So this is just a video, showing kind of those steps. So again you can use different anchors that's a bit bigger anger. Here's your mattress configuration tie here's your final construct, a nice fill of that defect. So in summary, he'll sex lesions are seen in first time dislocators commonly but they're almost always going to be there 93% of the time if you have a patient with a current dislocation, make sure you look for it. I would suggest that you know before you go, you need to measure the glenoid bone loss and he'll sex depth and determine if it's on or off track that we are prepared in the operating room you've also prepared the patient, and then intraoperatively assess if the whole sex engages and abduction external rotation. Again, it's better to do this in the primary as opposed to revision so if you see it in that primary go ahead and do it. And medial suture placement can restrict your external rotation. So thanks I hope you have a great course, encourage you to hopefully see maybe at different stations different techniques, feel free to reach out to me and my emails there. Thanks.

Kelly Kilcoyne

Walter Reed Military Medical Center

REM plasage

hill-sachs lesions

shoulder dislocation