Ultrasound‐Assisted Arthroscopic Remplissage

Abstract

Recurrent anterior shoulder dislocation, especially in cases with an engaging Hill–Sachs lesion, can lead to high recurrence rates following Bankart repair alone. Remplissage, an adjunct technique involving the infraspinatus and teres minor, enhances stability by converting the intra‐articular Hill–Sachs lesion into an extra‐articular defect. However, it is technically demanding and requires precise anatomical identification. We describe an ultrasound‐assisted arthroscopic remplissage technique that enhances procedural accuracy and safety. In this method, ultrasound is used intraoperatively to identify the infraspinatus, teres minor, and the Hill–Sachs lesion. Percutaneous needle placement and anchor insertion are guided under real‐time ultrasound visualization. This approach facilitates accurate fixation using the double‐pulley technique, ensuring optimal tissue compression and stability. Ultrasound complements conventional arthroscopy by enabling soft tissue visualization, guiding safe portal placement, and improving anchor orientation, especially for less‐experienced surgeons. This technique offers a safer and more effective alternative in treating recurrent shoulder instability with engaging Hill–Sachs lesions.

Recurrent anterior shoulder dislocation often occurs owing to trauma or sports activities, leading to functional impairment and decreased quality of life if not treated appropriately. Arthroscopic Bankart repair is widely performed as the first‐choice surgical procedure; however, cases with extensive bone loss reportedly have a high recurrence rate. In cases of Hill–Sachs lesions, Bankart repair alone may not sufficiently reduce the redislocation risk caused by bone defects. ¹

The remplissage procedure has gained attention as it can control anterior instability owing to suturing and securing the infraspinatus, teres minor, and joint capsule to the Hill–Sachs lesion on the humeral head. ² Remplissage is performed together with Bankart repair, providing extra‐articular reinforcement to enhance stability and reduce the recurrence rate. ³

Although remplissage is performed arthroscopically, it is often perceived as technically demanding, and the decision to perform it as an additional procedure depends on the surgeon's experience. Remplissage requires time to learn and is considered challenging, particularly for less‐experienced surgeons. Ensuring an adequate surgical field and improving suturing techniques are essential; thus, new assistive technologies are expected to be beneficial.

Recently, the use of ultrasound to assist arthroscopic procedures has advanced, significantly improving the visualization of soft tissues. ⁴ , ⁵ Ultrasound‐assisted technology is useful for real‐time confirmation of soft tissue positioning and reducing the risk of intraoperative damage to critical structures. In remplissage procedures, accurately identifying the infraspinatus and teres minor during surgery enhances the precision of suturing and fixation.

Ultrasound‐assisted arthroscopy complements conventional arthroscopic surgery, enabling safer and more precise procedures. This technique describes a method of ultrasound‐assisted arthroscopic remplissage.

SURGICAL TECHNIQUE

Ultrasonographic Findings

Prior to initiating the surgery, ultrasound scanning is performed. Beneath the deltoid, the rotator cuff comprises the supraspinatus, infraspinatus, subscapularis, and teres minor muscles, which are attached to the humerus. The infraspinatus inserts primarily into the middle facet of the greater tuberosity, whereas the teres minor inserts mainly into the inferior facet (Figure 1a). Palpating the scapular spine and the posterior angle of the acromion and placing the probe parallel to the scapular spine and slightly inferior to the posterior angle of the acromion allows visualization of a short‐axis view of the glenohumeral joint.

FIGURE 1.

Ultrasound findings in the left shoulder with the patient in the beach‐chair position. No arthroscopic viewing portal was used for these ultrasonographic images. (a) The greater tuberosity is divided into superior facet, MF, and IF sections. (b) Longitudinal sonograms of the ISP and TM at their insertions on the humeral head show that the ISP has a long, wedge‐shaped insertion. (c) Longitudinal sonograms of the ISP and TM at their insertions on the humeral head show that the TM has a quadrangular‐shaped insertion. (Δ, labrum; Delt, deltoid; IF, inferior facet; ISP, infraspinatus; MF, middle facet; SF, superior facet; TM, teres minor.)

From the superficial to deep layers, the deltoid and infraspinatus that are inserted into the middle facet are visible (Figure 1b). Deep to the infraspinatus, the humeral head and glenoid cavity appear as linear hyperechoic structures. The glenoid cavity has a convex structure. The triangular hyperechoic labrum is visible between the humeral head and glenoid cavity. Moving the transducer inferiorly reveals that the minor teres is inserted into the inferior facet (Figure 1c). Hill–Sachs lesions are identifiable as irregularities and bony depressions on the humeral head (Figure 2). This study describes a method of ultrasound‐assisted arthroscopic remplissage (Video 1).

FIGURE 2.

Ultrasonographic findings of a Hill–Sachs lesion in the left shoulder with the patient in the beach‐chairposition. No arthroscopic viewing portal was used for this ultrasonographic image. Characteristic findings include irregularities and a bony depression (*) of the humeral head. (Δ, labrum; Delt, deltoid; ISP, infraspinatus.)

VIDEO 1.

Download video file ^{(37.3MB, mp4)}

Ultrasound‐assisted arthroscopic remplissage in the left shoulder with the patient in the beach‐chair position, using the posterior and posterolateral portal as the viewing portal. This video shows the use of intraoperative ultrasonography to identify the infraspinatus, teres minor, and Hill–Sachs lesion, and to guide percutaneous needle placement and anchor insertion. The double‐pulley technique is then used to compress the posterior capsule, infraspinatus, and teres minor into the Hill–Sachs lesion. Narration was provided by VIDWEB, a video production company ( https://vidweb.co.jp//). Video content can be viewed at https://doi.org/10.1002/atn2.70181.

Operative Technique

Initially, the anterior labrum‐inferior glenohumeral ligament complex is released from the glenoid cavity until the 06:00 position. An anchor is inserted into the glenoid cavity, and the suture is placed through the complex without tying the knot. Next, Hill–Sachs remplissage is performed, followed by Bankart repair.

After debriding the subdeltoid bursa, the superficial layers of the infraspinatus and teres minor are exposed under arthroscopy. The Hill–Sachs lesion is confirmed arthroscopically, and the transducer is placed posteriorly to identify the Hill–Sachs lesion on ultrasonography. Ultrasound‐assisted arthroscopic surgery is performed up to the step of confirming the Hill–Sachs lesion and creating the portal, with viewing consistently from the posterior portal. The lesion is visualized in long‐axis mode, ensuring the tip of the scope is in view (Figure 2). While visualizing the infraspinatus and teres minor, a needle is inserted percutaneously into the Hill–Sachs lesion under ultrasound guidance using the crosswise technique (Figure 3). One needle is inserted through the previously created posterolateral portal, whereas the other is introduced slightly superiorly to the posterolateral portal, creating an additional portal.

FIGURE 3.

Ultrasound‐guided needle insertion into the Hill–Sachs lesion in the left shoulder with the patient in the beach‐chair position. Arthroscopic visualization was performed through the posterior viewing portal. While visualizing the infraspinatus and teres minor, a needle is inserted percutaneously into the Hill–Sachs lesion using the crosswise technique under ultrasound guidance. (*, bony depression.)

With both needles in place, a scalpel is inserted along the fiber orientation of the rotator cuff, and a slotted cannula is guided to the Hill–Sachs lesion (Figure 4). Two anchors are inserted beneath the infraspinatus and teres minor through a slotted cannula. Anchor positions are confirmed in a previously debrided bursal area. Each suture is retrieved through separate portals, and the double‐pulley technique is used to secure the joint capsule, infraspinatus, and teres minor to the Hill–Sachs lesion (Figure 5). As the sutures are finally tied, each suture is slid to allow for compression from above while securing the joint capsule and rotator cuff and filling the Hill–Sachs lesion.

FIGURE 4.

Anchor insertion into the Hill–Sachs lesion in the left shoulder with the patient in the beach‐chair position. Arthroscopic visualization was performed through the posterior viewing portal. After inserting 2 needles, an incision is made along the needles. Then, a slotted cannula is inserted into the incision path, and the anchor is placed into the Hill–Sachs lesion.

FIGURE 5.

Arthroscopic remplissage technique in the left shoulder with the patient in the beach‐chair position. (a) Viewed through the posterolateral portal, after anchor insertion, 2 sutures are confirmed to emerge from the subacromial bursa side. (b) Viewed through the posterolateral portal, the sutures from each anchor are passed through separate portals. (c) Viewed through the posterolateral portal, sutures from different anchors are paired and tied together. (d) Viewed through the posterolateral portal, the remaining sutures are tied to allow sliding compression and secure fixation from above. Final confirmation that the joint capsule and rotator cuff fill the Hill–Sachs lesion is obtained through the posterior portal.

DISCUSSION

Bankart repair is the standard treatment for recurrent anterior shoulder dislocations. In cases of significant bone loss or for collision athletes, the Latarjet procedure has a lower redislocation rate. ⁶ Consequently, arthroscopic remplissage is primarily performed by experienced shoulder surgeons. Surgeons less accustomed to arthroscopic remplissage often find it challenging to accurately and efficiently insert the needle into the Hill–Sachs lesion.

Ultrasound‐assisted surgery has recently gained popularity. ⁴ , ⁵ , ⁷ Unlike fluoroscopy, ultrasonography allows soft tissue visualization. For example, ultrasound‐guided portal creation enables the safe identification of nerves. Additionally, ultrasound provides a clear image of bone surfaces, allowing simultaneous visualization of the Hill–Sachs lesion and the infraspinatus and teres minor, facilitating accurate needle insertion. Ultrasound guidance also simplifies the determination of the appropriate anchor placement direction. Performing intra‐articular procedures arthroscopically while monitoring extra‐articular structures in real‐time using ultrasound is crucial to ensure safe and accurate surgery. Pearls and Pitfalls of the technique are presented in Table 1.

TABLE 1.

Pearls and Pitfalls of the Ultrasound‐Assisted Arthroscopic Remplissage

Pearls
• Precise portal creation
• Visual tracking of instruments

Pitfalls
• Learning curve associated with ultrasonography
• Synchronization of the camera and needle with the transducer
• Needle insertion using the crosswise technique is difficult

DISCLOSURES

The authors (K.M., Y.K., H.C., R.N., H.A., S.T., Y.I.) declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.