Arthroscopic remplissage surgery for the hill sach defect
This will be the procedure of choice in those who dislocate the shoulder recurrently as a result of anterior structures damage and also fracture in the back of the humeral head. If there is fracture in the back of the upper arm bone, then it is called as Hill sach lesion. This lesion pivots around the glenoid margin while doing outward rotation movement of the shoulder. Hence dislocation occurs recurrently.
Elective patients may be suitable for an arthroscopic surgery even in the presence of Hillsach defect. In such patients after doing anterior stabilisation surgery as mentioned above, the remplissage procedure helps in preventing further dislocations.
Nature of the procedure
The principle of remplissage surgery is to fill the gap of the hillsach lesion with the rotator cuff muscle. Hence it will act as a physical restraint when the provocative manoeuvres for dislocation are undertaken.
Steps of the Surgery
The procedure is performed as an arthroscopic procedure. Tiny stab incisions of less than 1cm are made around the shoulder joint. Initial anterior shoulder stabilisation is done. Then the camera is focussed on the hill sach lesion. The hill sach lesion can be easily made out as a dent in the back of the head of the arm bone (Posterolateral aspect). The dent is freshened with the help of mini tubular 4.2mm shavers and bone edges are burred with a special burr. Usually over the hill sach lesion one could visualise the infraspinatus muscle (a part of rotator cuff muscle). With a miniature drill two small holes are made in the dent. Absorbable screws with fibre wire are fixed in these holes. The fibrewires attached to these holes are retrieved through the infraspinatus muscle and the knot is applied to fix the infraspinatus muscle to the hill sach lesion.
Immediately after the procedure, a sling will be given to rest the arm. The movements that can put tension on the repaired structures are prevented for a duration of 4 – 6 weeks. Further to that the movements are encouraged. A systematic physiotherapy programme will be initiated to get the full function back.
The arthroscopic procedure is pretty safe. The pain is minimal as the procedure is done through tiny stab incisions. Infection, chondral damage, nerve damage is possible complications but the reported incidences are rare.