Thanks for the opportunity to talk about Remplisage procedure, technical tips that make it simple. These are my disclosures. Heel sac lesions were originally described in 1940 by Hill and Sacks. They described the lesion in 74% of recurrent shoulder dislocations as a compression fracture with soft cancellous humeral head impacting a dense anterior glenoid rim. In 1984, Rowe et al. reported on 76% of 32 failed instability surgeries possessing a heel sac lesion and suggested that it may play a role in surgical failure. Now, of course, we know that it does. Burkhart et al. in 2000 reported on 194 cases that had recurrent instability in 11% after an arthroscopic bank cart, but two-thirds of the recurrences had significant bone defects that were present. In 2015, a report of 153 shoulders evaluated with CT prior to an arthroscopic bank cart procedure demonstrated bipolar lesions in over half of the cases and no bony lesion and only a small percentage of those instability patients. Also comma, the number of dislocations correlated with the bony lesion prevalence and size. A separate study evaluating 90 patients with anterior instability that had undergone 3D CT scans demonstrated bone defects in 96% of the glenoids and 98% of the humeral heads, demonstrating the fact that recurrent shoulder anterior instability patients almost always have some degree of bone loss. But just what is the critical size of the heel sac lesion? Must it be engaging? Is there a minimum size? What about bipolar involvement? Must it be off-track to matter? Suffice it to say that identification and quantification of heel sac lesions is important. A careful history and physical examination along with high-quality radiographs and specialty x-ray views as well as a CT scan can be very helpful in helping us identify and make decisions regarding heel sac lesions. Methods for management of heel sac lesions include, of course, ignoring the lesion or performing non-anatomic procedures such as a Latergé or a Remplissage or anatomic procedures including osteoarticular allograft transplantation. Anatomic reconstruction of large heel sac lesions has been described. It helps to recreate the convexity and sphericity of the humeral head articular surface. Fresh frozen or radiated grafts can be used and it may be carried out with or without a glenoid bony procedure. Here a limited posterior approach with reaming of the defect and filling with allograft was reported. The benefits of which include a more limited posterior approach, no anterior dissection and this can be combined with an arthroscopic Bancart or as a staged procedure. Arthroscopic techniques have even been described and reported for reconstruction of these heel sac defects. In this example showing multiple fresh frozen plugs overlapped and impacted using an arthroscopic technique. With that in mind, the REMPLICISE procedure, initially described by Purchase et al. in 2008, is nothing more than advancement of the posterior capsule and infraspinatus into the defect created by the heel sacs lesion, with that soft tissue secured using suture anchor fixation. Also, the REMPLICISE is only carried out as a supplement to other arthroscopic procedures. This REMPLICISE procedure has, in fact, met with significant clinical success as a supplement in stabilization procedures. There's been concern expressed over the non-anatomic nature of the infraspinatus advancement, but there's been strong clinical evidence to support REMPLICISE. There have been multiple clinical studies that show low recurrence rates, non-to-minimal motion loss, and very low complication rates when REMPLICISE is utilized. In our own published experience, performing REMPLICISE on 20 primary stabilizations, all of which had engaging heel sacs lesions, we had no recurrences of instability at three and a half years post-operatively, and no motion loss in that group. In this study, reviewing 61 patients with 40-month follow-up, the patients only had 9% loss of external rotation, and there was no difference in infraspinatus strength when compared post-operatively. Also in their study, ultrasounds showed consistent feeling of the defect with soft tissue. Likewise, there have been multiple systematic reviews that support the use of REMPLICISE as well, all of these demonstrating low recurrence rates, non-to-minimal motion loss, and again, very low complication rates. This specific study from JBJS in 2014, a systematic review of REMPLICISE, they included six studies, 167 patients with overall good results, and no studies showed decreased shoulder motion post-operatively. There's near universal agreement in the literature that the indications for REMPLICISE is an quote-unquote engaging heel sacs lesion during dynamic arthroscopic assessment with no substantial glenoid bone loss. Clearly in this example, this would not be a good case to consider REMPLICISE, mainly because of the significant glenoid bone loss that's present in this particular patient. Also importantly, there have been a number of studies that are commonly quoted as it relates to the critical amount of glenoid bone loss for which arthroscopic stabilizations should probably not be performed. In this study from AGSM in 2017, they found that when there was less than 13.5% of glenoid bone loss, none of their patients developed recurrent instability. When there was greater than that amount of glenoid bone loss, all of their patients developed recurrent instability. However, interestingly, no REMPLICISE procedures were performed in any of their patients. Likewise, in another commonly quoted study of 169 anterior instability patients with glenoid bone loss, this study found that as long as there were less than 17.3% bone loss, the failure rate was acceptable. However, again, no REMPLICISE procedures were performed in these patients. In this study, in which a REMPLICISE was performed in some of the patients, they found that for those patients undergoing Bank Heart Repair alone, 57% of their patients failed when they had large engaging heel sex lesions, compared to 20% when REMPLICISE was added to the procedure. Likewise, in a different study comparing Bank Heart patients with Bank Heart plus REMPLICISE patients, they found that the recurrence rate decreased from 26% to 5% when a REMPLICISE procedure was added. In this cadaveric study, looking at eight specimens for which a glenoid bone loss model with an on-track or off-track heel sex lesion was created as well, demonstrated when the Bank Heart Repair was performed alone without a REMPLICISE, it did not prevent engagement in any of the shoulders that were used in this biomechanical study. However, when the REMPLICISE was added to these cadaver models, none of the shoulders that had previously engaged then engaged. What about comparing the outcomes of REMPLICISE procedure in complement with a Bank Heart to a LATERGYE procedure? In this study from 2016, comparing REMPLICISE patients with LATERGYE patients, all of which had large engaging heel sex lesions and relatively well-preserved glenoids, no differences in outcomes were noted. In fact, the recurrence instability rate was 5% for both groups and external rotation loss was the same for both groups. The only significant difference was that for the REMPLICISE group, there were no complications, but for the LATERGYE group, 14% complication rate. The REMPLICISE technique, as shown here, demonstrates a large heel sex lesion. We can also see that this large lesion engages over the anterior edge of the glenoid. After abrasion of the heel sex defect to stimulate healing of the posterior capsule to the exposed bony surface, in this case, two suture anchors can be placed at the new articular margin of the humeral head. Notice that the bone is very hard because of the impacted nature of it, and a drill and tap should be routinely used. We can see here that the bone is very hard because of the impacted nature of it, and a drill and tap should be routinely used. We can see here two anchors have been placed. Notice how much space there is in the area of the heel sex lesion to work. Now, the cannula is backed up posterior to the infraspinatus fascia, and a retrograde retriever can be advanced independently, and these suture limbs can then be retrieved. Sutures have been passed, but they're not yet tied, but this portion of the REMPLICISE procedure is performed before the Bancorp procedure for reasons we will show. Notice in this case, there's very little glenoid bone loss, making the indications for REMPLICISE procedure secure. After extensive mobilization of the labor ligamentous tissues, as seen here, we can translate those tissues to re-tension the labor ligamentous tissues at the time of Bancorp repair. Following Bancorp repair, as shown here, there's good re-tensioning of these anterior tissues. Notice, however, the significant reduction of space posteriorly in this patient who's not yet had his REMPLICISE sutures tied because of the obligate posterior humeral head translation that happens when Bancorp is carried out. This is why the REMPLICISE procedure should be done before the Bancorp procedure is done. In summary, REMPLICISE technique is valuable and effective as a supplement to arthroscopic Bancorp repair. It reduces recurrence rates, it consistently demonstrates a very low complication rate, and there are minimal range of motion loss reported in the literature. The indications, of course, are important for the supplemental use of REMPLICISE, including engaging hill-like lesions, especially when there's a relatively well-preserved glenoid. Thank you very much.

Remplissage procedure

heel sac lesions

shoulder dislocations

surgical management

arthroscopic procedures