Remplissage
Indications
Engaging Hill Sachs
Engaging Hill Sachs
Usually 50-60 years old
1° uncommon
2° most common
- AVN
- trauma
- cuff arthropathy (Neer)
- instability
Cuff & biceps intact as rule
- rare to have OA and rotator cuff pathology
Anterior
Anterolateral
Posterior
Indications
- shoulder stabilization
- arthroplasty
- fracture fixation
Approach
Position
- beach chair
- upper body elevated 30- 40o / reduces venous pressure and bleeding
Wind-up
- cocking
- ER up to 180o in pitcher
Acceleration
- large scapular muscles
- acceleration - 7000o/sec
- rotatory acceleration similar to car tyre at 130 kph
Control and deceleration
- fragile cuff & glenohumeral ligament complex
Fewer complications than TSR
Simpler procedure
Posterior Portal
- make slightly inferior and lateral compare to normal
- inspect joint
Compare both shoulders
- ROM
- anterior and posterior draw
- load and shift
- sulcus sign
1. Patient factors
A. Recurrent Trauma
- contact athletes higher risk
B. MDI / Ligamentous Laxity / Voluntary dislocaters
C. Poor rehabilitation
- poor motivation
- too rapid
- patients rarely get stiff, better to go very slow
2. Surgeon Factors
A. Unrecognised bony defect
Humeral Avulsion of Glenohumeral Ligament
Bokor et al JBJS Br 1999
- 514 cases surgical treatment traumatic instability
- incidence 7.5%
- 25% associated SSC tear
- likelihood of HAGL if no Bankart or MDI 27%
Concept
Plication subscapularis & capsule
Problems
Loss ER
Secondary OA if ER < 0°
Contraindication
MDI
- will force head out posteriorly
Technique
Divide SSC 2.5cm from insertion
- may divide capsule in same plane