Remplissage, which is used in combination with arthroscopic Bankart repair, addresses anterior instability associated with bone loss. Biomechanical studies indicate that insetting the posterior capsule and infraspinatus tendon into a Hill-Sachs defect improves joint stability. With recent innovations in knotless products and techniques, the addition of remplissage is more reproducible and efficient. A knotless technique—with two tensionable, knotless anchors and interconnected repair sutures—creates a reliably strong repair that minimizes the risk of knot impingement and migration.

Shoulder

Procedure

The Knotless FiberTak soft anchors provide tensionable, knotless soft-tissue fixation with either a small 1.8 mm or 2.6 mm soft anchor body. The repair sutures from both Knotless FiberTak soft anchors are interconnected to create a mattress stitch fixation of the posterior capsule and infraspinatus tendon into the Hill-Sachs defect.

The Knotless FiberTak® soft anchor has a tensionable, self-locking mechanism that helps create an adjustable, knotless soft-tissue repair. Two anchors may be interconnected to create an adjustable, knotless, bridging construct.

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Knotless FiberTak® Soft Anchor: Interconnected Remplissage Technique

Patrick J. Denard, MD (Medford, OR), performs a live surgery using Knotless FiberTak® soft anchors for instability.

Live Surgery: Instability Repair With Remplissage Using Knotless FiberTak® Soft Anchors

I'm Patrick Denard from Medford, Oregon. I'm going to demonstrate a bank card of Remplissage. Our defect is completely prepped. My next step is to place an accessory posterior cannula. I like to use a spinal needle first. This cannula is typically directly lateral to my posterior inferior cannula. Usually it's going to be 2 to 3cm. And I want to get an angle of approach that's going to aim toward the middle of the Hill-Sachs defect. So this is pretty good here because I'm right in the center of the defect. Next I'll take a switching stick and I'll go down to just above the posterior capsule to confirm that I'm at the right location. So we can see the switching stick. We are clearly just above the posterior tissue. I'll insert another seven millimeter threaded cannula. So the goal of the cannula is to go below the deltoid and just above the posterior soft tissue. And at this point I take the cannula and move it in a circular motion to clear out all the posterior soft tissue, which is the Bursa. And I can clearly see that I'm just above the posterior capsule and rotator cuff. Once we've established this space, it's really important that your assistant holds the cannula so it does not back out. I'm first going to insert my inferior anchor. You want to insert the inferior anchor first. Because once you insert the inferior anchor, it becomes difficult to see the superior anchor. So I use a 1.8mm knotless FiberTak anchor. I'll insert with a sharp guide to penetrate through the posterior tissue. I'll typically try to be right in line with the Hill-Sachs defect. I can just see the tip of the insertion guide here. That's going to provide a good angle of approach because I don't want to over or under tension the posterior capsule. Once I establish that location, sometimes I will move inferior so that I'm directed Where I have the most space just below the head. I'll remove the trocar of the guide, and I'll be just up against the cartilage of the humeral head. If I have a really large defect, sometimes I won't go all the way over to the medial edge of the defect. I typically find that A18 anchor works very well in this location. Now, prior to removing the guide, it's important to push the cannula back down to confirm that you have it just above the posterior capsule. And I'll remove the guide. Next I'm going to place my superior anchor. Now I will insert the guide first without the trocar in place. So both anchors are going to go through this same cannula. Once I get down to just above the tissue which I can see here, now I'll insert the trocar into place. And I think that's important so that I just do not catch the other sutures on my way down. So here we can see the spike just reaching the soft tissue. Once I go through, barely, I'll direct away so as to not damage the cartilage and just use a subtle twisting motion. Again, you can see my anchor placement is in line with the posterior capsule, so I'll tag both sets of sutures. I'll typically tag one shorter so that I can distinguish which anchor is which. So again we can see both sets of sutures are coming out the posterior cannula. And I'll set these to the side. At this point I'll move on to do my bankart repair. So I need to prep the labrum first. Typically I'll place anywhere from 3 to 4 anchors from inferior to superior. You can use a variety of suture configurations. With these anchors, you can use simple configurations or mattress configurations. I often use a hybrid approach where I will place a mattress suture configuration inferiorly. A simple configuration in the middle and then mattress again up top. So here is our completed bankart repair. You see, we nicely brought the labrum and the capsule up against the glenoid. The humeral head is already well centered. We have nice tension of the inferior glenohumeral ligaments. And now we're going to go complete our Remplissage. And I think this illustrates nicely how difficult it can be to do the Remplissage at the end. Because you can see already our space here is half that of which it was before. We're actually fortunate we can see in this case, because sometimes you get so much soft tissue swelling you can't see at all. So again, it's important to make that decision at the very beginning. So now we have both sets of suture limbs at our posterior cannula. The inferior anchor is here. The superior anchor is the one that I'm tagged by doubling up my assist. And I will take our repair sutures and pass these to each other. And then we will each convert so that the inferior repair limb will be going into the superior anchor, and the superior repair limb will be going into the inferior anchor. In order to create a double mattress knotless configuration. Okay, now both sets of sutures are converted and will simultaneously go back and forth to bring that soft tissue down to the Hill-Sachs defect. Okay, now our Hill-Sachs defect is extra articular and the capsule is right up against that bone bed. So there will be our final tightening. So here's our completed bankart and Remplissage. You see that this technique for the Remplissage in particular, let us complete this Remplissage in a very efficient manner, adding perhaps only five minutes to the case. The key steps being placement of the anchors first, followed by your bankart repair, and then going back and tensioning the Remplissage.

Patrick J. Denard, MD (Medford, OR), discusses his experience performing combined Bankart repair with remplissage for instability with bipolar bone loss using Knotless FiberTak® soft anchors.

Tensionable Knotless Bankart and Remplissage Using Knotless FiberTak® Soft Anchors

Hi, I'm Patrick Denard from Medford, Oregon. And I'm going to share with you a case of Remplissage using Knotless FiberTak anchors. So in recent years, we've really grown our understanding of bipolar bone loss and particularly of the glenoid track. And as we've understood this concept, we've adapted our technique to incorporate Remplissage into many of our soft tissue label repairs. A recent systematic review out of Russia looked at this in 2019. Out of JSM 778 patients, and what they demonstrated is that the recurrence rate was actually much higher with an isolated bankart repair compared to latter or even the lowest recurrence rate was with a Remplissage, where it was 4.4%, so nearly half of that with latter J. So we've had a lot of success with Remplissage, and we've used this technique for several years, but our technique has changed over time. Originally we would do a knotted technique where we placed two suture anchors in the Hill-Sachs defect posteriorly, but then had to go into the subacromial space and tie knots. That took increased time compared to what we do now. Currently, we use a knotless technique where we use two knotless 1.8 or 2.6 millimeter FiberTak anchors. And I'll show you a technique subsequently where we can do this percutaneously without having to go into the subacromial space. This leads to increased time savings, and it's backed up biomechanically with studies that show increased pullout compared to techniques where we tie knots. So here's a case example of a young man right hand dominant. He's had a left shoulder dislocation after sliding into second base. And this is his third dislocation after the first one occurred two years previous. He's otherwise healthy, but based on his age and activity level, he's at high risk for recurrence on his exam. He has normal motion, he has good strength, but he has instability on exam, as evidenced by his positive apprehension maneuver and positive relocation maneuver. Here are his radiographs. You see an AP radiograph. Here we can look at the glenoid and see that he has minimal bone loss. If we look at the axillary view you see that he has a large Hill-Sachs lesion Posteriorly. We're going to gain a better appreciation of this with this MRI. Again, we scroll up and down this axial MRI and we can see his Hill-Sachs lesion. So we're going to proceed with an arthroscopic repair. And I'm going to show you how we use these knotless FiberTak anchors to accomplish that. So here's this diagnostic arthroscopy. We have a left shoulder viewing from a posterior viewing portal. You can see his bankart tear anteriorly. And as we pull posteriorly we can see his large Hill-Sachs lesion. I'm going to move to an ASL portal and I'm first going to calculate his glenoid width. I estimate that his glenoid width is about 12mm posteriorly. So our projected width overall should be about 24mm. And on my estimation here he has about three millimeters of bone loss anteriorly. I'm now going to take that and calculate his Hill-Sachs interval. And we can see here we're estimating it. It's difficult to estimate in some cases. But we're going to estimate this at about 15 18mm. So we have a borderline lesion. But based on his age and activity level, I think this is going to be best to do a Remplissage in this case because he's at high risk of recurrence. So I placed a Gemini cannula posteriorly. I like this cannula posteriorly, because I can usually pull the soft tissue posteriorly and really create a space. I'm first going to curette the defect. I want to create a good base for healing. Next I'm going to insert my Remplissage anchors. So the first thing I'm going to do is use a spinal needle to locate where I want to place my anchors. From here I'm then going to insert a threaded cannula, and I'll swirl this cannula around to create some space in the subacromial area beneath the deltoid. But I'm not going to go all the way through the soft tissue with that cannula. Now through that cannula, I can penetrate through the capsule and the tendon percutaneously with my knotless FiberTak anchor. We want to first place our anchor inferiorly. Then through that same cannula I'm going to place my second anchor more superiorly. In doing this my sutures from both anchors are through that same cannula. We'll drill our superior anchor. Place our FiberTak anchor. This is going to set us up for our subsequent Remplissage. I'll then go to my bankart repair and I'll skip through the steps here. But you can see we have a lesion which we've prepped. I'm going to use Knotless FiberTaks to perform my repair. Here I'm going to place three anchors. These are one eight knotless FiberTak anchors. We really like these anchors because we can get nice tension of the labrum. And especially with using those knotless anchors, we can get as low as we need to get to reestablish the labral bumper. I'm going to pull the repair stitch posteriorly after I've shuttled through, and then bring the repair stitch down into the knotless mechanism, and if desired, after I place my subsequent anchors, I can go back and retention. Here you can see that labrum pulled up nicely to the glenoid rim. I'll tension a little bit more as I hold against the anchor and then cut the tail. So here's our completed bankart repair. And now I need to simply complete my Remplissage. Since I have those sutures coming out my percutaneous cannula posteriorly, I can simply link those two anchors through that cannula to create my double mattress Knotless stitch without having to go into the subacromial space. There you see that posterior capsule nicely inset into the humerus. So here he is at two years post-op. He has excellent range of motion. He has full external rotation despite the Remplissage full forward elevation and good internal rotation behind the back. Now here he is at the collegiate level, participating in boxing. You can see that Remplissage is holding up quite well on that left side. And he's been back to full activities. So I hope you enjoyed this technique. I think if you give it a try, you'll really find you'll have good success in your patients with increased efficiency for you in the operating room. Thank you.

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Remplissage for Anterior Instability Scientific Update

This animation provides an overview of the features and benefits of the Knotless 1.8 FiberTak® soft anchor for the treatment of shoulder instability.

Knotless 1.8 FiberTak® Soft Anchor for Shoulder Instability Repair

Knotless FiberTak Soft Anchor Technique - Remplissage

Child (D)

The Knotless Corkscrew anchor enables tensionable, knotless soft-tissue fixation using a 3.9 mm partially threaded hard anchor body. The repair sutures from each anchor are interconnected to create a strong mattress stitch fixation of the posterior capsule and infraspinatus tendon into the Hill-Sachs defect.

Paul C. Brady, MD, (Knoxville, TN) demonstrates the versatility of tensionable, knotless anchor technology for a Bankart and remplissage repair using Knotless SutureTak® and Knotless Corkscrew® anchors.

Bankart and Remplissage Repair

Hi, my name is Doctor Paul Brady. I'm from Knoxville, Tennessee, and today I want to demonstrate a bank cart Remplissage combination utilizing the latest and knotless technology, including the three Knotless SutureTak for my Bankart repair and the three nine Knotless Corkscrew for my Remplissage repair. Now I'll I'll hold position while my assistant taps seats it, and then go ahead and drill all the way to the hub for our three Knotless SutureTak. And again, I'm holding the position. I'm not moving my hand. My assistant puts in the anchor, taps it down flush, and all you have to do is remove the tab and then twist and pull the inserter. And there you have it. And now we'll have to pass the repair suture. So you see here we have a have a repair suture. We have a repair suture. And which is blue and white? And we have a FiberLink, which is blue. Okay. So we'll take a good inferior bite of our tissue. Give it a just rotate the hand. Looks like a good bite. And then we'll load in some monofilament. And then when we load in the monofilament I'll reach in through my antero-superolateral portal. And I'll grab both my repair suture and the monofilament. And I'll pull that out my antero-superolateral portal. So here we just load a, make a loop on our monofilament and place our repair suture in the loop. Tighten that up, and then we'll be able to load this or shuttle this through the tissue. Our repair suture is not a sliding suture. So you can go ahead and get it nice and tight. And the last step is to load the repair suture into the looped end of the splice. So I'm going to go ahead and take them out another portal so I know I have the right one. So I'll go ahead and load the repair suture into the looped end of the FiberLink. And then I'll pull on the other end of the FiberLink. And this is going to load my suture here. My suture is coming down right here. Now once it gets to that point where you get a little tension, you want to give it several tugs. So I'm going to give it a little tug and that loads it into the splice. I'll go ahead and finish my tensioning. And I'm going to I'm going to tension it just with a few tugs. And then I'm going to finish my tensioning with a new instrument called the tensioner cutter device. This is nice because it's got a tip which allows you to seat the device right on top of the anchor that you just placed. And if you see there's the tensioner cutter is beveled. You want the hole where the suture is coming out toward the glenoid. Okay. So we're going to pull tension there. I'm going to insert the that side onto the glenoid right onto the anchor. And once it's onto the anchor I'm going to hold the T handle pull tension. Pull tension on my suture. But I'm not going to push the plunger until I'm ready to cut the suture. So let's go ahead and tension it holding the suture. That feels good. And then at the final step, we'll pull the plunger and pull our suture out. Now let's turn to our Remplissage. I'm going to do most of this procedure while visualizing through the Antero-superolateral portal. So there we see our bankart repair. Now let's turn to our Remplissage. Now, the safest way to insert the anchors on this Hill-Sachs defect is through the posterior portal. We're going to utilize three nine Knotless Corkscrew anchors for our Remplissage. So we're going to go ahead and put this right here. That's I'm going to look at the humeral head. That looks like a like a very safe. I'm not going to penetrate the humeral head with that anchor. You know, you can either drill or tap this. If it's really hard bone, you probably want to drill it. We're going to go ahead and try a tap first and see if the tap is adequate. Looks like the tap is going to be perfect for this cadaver situation. Right to the line. I'm going to hold my inserter there and then we'll take the anchor. It's a 3.9 knotless Corkscrew peak anchor. We'll seat that. That's perfect. And again we just pull the tab and then twist the inserter while we're pulling. And we'll give that a little tensioning. And that's nice. That anchors in there. So so let's insert the second anchor also through our posterior portal. Now this one I think is going to we're going to get a better approach to this if we give it some external rotation. Perfect. Okay. So? So I'll seat this. I'll use my hand to lever that exactly where I want it. I think that's a safe spot right there. Just insert the anchor anchor right over top of the right through the inserter. And then we'll give that a few tugs just to make sure that's that's in there. And both those anchors are, are nicely seated through our posterior portal. Next we want to go ahead and and place our sutures. I'm going to use a spinal needle to get the appropriate angle here. So I want one coming essentially just inferior to that posterior cannula which on the outside view you can see is is a pretty good angle there. Okay. So I like that angle. Let's make a small nick in the skin. I'm going to use a spinal needle where I've already placed a sheath from a FiberStick over top of the spinal needle, and that sheath is going to act as a protector for my sutures when I load those sutures through here. So. So I know my trajectory. I'm going to go through that small hole with my suture retriever. I'm going to grab all the sutures from my inferior anchor, along with the loop of the nitinol, and I'm going to pass those out my posterior portal. I took the spinal needle out. I'm going to load those sutures through the sheath of the FiberStick, the FiberStick sheath. We're going to hold that FiberStick sheath in place. I'm going to pull those sutures in. You can see that red catheter protecting all those sutures. This is important because when I go into the subacromial space, I'm going to be able to utilize my shaver into the subacromial space without having to worry about capturing those sutures. So we're going to place a hemostat right on those sutures. That's going to keep that red cannula, red catheter in place and protect those sutures. So now we're in the subacromial space. I need to make a lateral portal for my working portal in the subacromial space. We'll place a passport cannula in that lateral portal. So we'll go ahead. And now that we've got remember we have those red catheters that are protecting our sutures. So essentially I'll just take the shaver and I'll keep working my way toward my camera. And there we see one of them right there. Now we have our two catheters here. So to complete our Remplissage, we're going to load the repair suture from one of these anchors into the splice of the second and vice versa. So I'll go ahead and get my suture retriever. Let's go ahead and get the inferior repair suture. So let's take the catheter off the inferior sutures. We'll get just the repair suture. And then now let's take the catheter off the superior. And I'm going to get just the, the looped end. So I'm going to push I'm going to actually push everything away from me. Get some slack. And then if you'll pull on the looped in real gently, there's the looped in right there. So so we'll pull out those two from our posterior portal, and we'll go ahead and load the repair suture into the looped end of the FiberLink, and then we'll pull tension on the other end of the FiberLink that's going to load the inferior repair suture into the superior anchor. Now I'm going to tension it right till it's touching the tissue, but not I don't want it. I don't want it compressing the tissue. Okay, so let's go just a tad further. There you go. Now I want to I want to note which one of these I just took because I don't want to take that one again. So hold that one for me. Now we'll grab the other repair suture, which I believe is this one. Give that one a tug that we did. Yep. So that's I've got the right one and then I'll take the looped end of the other FiberLink. There we go. So we got the looped end and we got the repair the second repair suture. We'll pull that out our posterior portal, load our splice and then load that back into the splice. Again we'll tension it until the till. The suture is just touching the tissue. But I don't want to. I want to equally tension these, and I don't want to do the final tensioning until. Until we've got an intra-articular view. So there. We're there. We're barely on the tissue, but we're not compressing the tissue. Now we're going to go into the subacromial space. This is my favorite part to watch this come down here. So there we see our our Hill-Sachs defect. Now I'm going to take these repair sutures one in each hand. And I'm going to alternatively tension them. Number one, number two, number one, number two. So let's go ahead and do that. And you can see how that seats the the cuff the infraspinatus down into the Hill-Sachs defect nicely. Let's externally rotate this now makes this a non engaging lesion. And this has been very successful with these patients with significant bankart even some bone loss.

J. Lee Pace, MD (Farmington, CT), reviews a case in which he used remplissage and Bankart procedures to treat recurrent glenohumeral instability in a young athlete. Dr. Pace discusses using 3.9 mm Knotless Corkscrew® and 3.0 mm Knotless SutureTak® anchors to achieve an anatomically tensioned glenohumeral labral repair and remplissage to address a Hill-Sachs lesion.

Arthroscopic Bankart and Remplissage Repairs in a Young Patient Using Tensionable Knotless Anchors

My name is Lee pace from Farmington, Connecticut. I'm here today to share a case of a combined Remplissage and arthroscopic Bankart repair using current Knotless tensioning technology. This is a 21 year old right hand dominant male with recurrent right shoulder instability. He sustained about 10 to 15 dislocations. He's a recreational basketball player and at this point he's interested in surgery. On exam, he has obviously a positive apprehension test, relocation test, etc.. Normal cuff and deltoid strength, normal range of motion. You can see on his imaging that he has a moderate Hill-Sachs lesion on the striker notch in the West Point views. His imaging shows the obvious labral tear, about 10% bone loss on the glenoid and a moderate Hill-Sachs lesion. Our clinical decision making revolved around these different surgical options arthroscopic bankart repair and isolation versus an open bankart repair, arthroscopic bankart repair plus Remplissage, as well as a latter J. After some discussion, we decided on a arthroscopic bankart repair and then intra op examination to determine if a Remplissage would be needed. In addition to that, however, before surgery and after his last clinic visit with me, he sustained another shoulder dislocation that required a reduction in the emergency room. So now the question is, is what is his shoulder going to look like when we get into the operating room? When we did our diagnostic arthroscopy, we found actually a rather large, engaging Hill-Sachs lesion. This really confirmed our decision to perform the Remplissage in addition to the arthroscopic bankart repair. And we proceeded with this using the interconnected knotless technique. So first we threw a standard posterior portal. We drilled and placed two knotless 3.9mm Corkscrew anchors as seen here. And then after that, we established a subacromial portal using a spinal needle to localize the portal placement. And this is usually going to be a little bit lateral to a standard posterior arthroscopic portal. From there, we use a penetrating device like this to bring the sutures through the tendon of the infraspinatus. At this point, we leave these sitting in the cannula and then proceed to our arthroscopic bankart repair. We use the percutaneous kit to get low 530 to 6:00 anchor placement, and we used a series of knotless three millimeter biocomposite suture techs for this arthroscopic bankart repair. You can see here as we proceed through the aggressive appropriate bumper using Knotless tensioner technology. So there's no not BB-Tak. This is a very low profile set of implants for the shoulder joint. After that, we then turn our attention to the Remplissage in this interconnected suture passage technique. So repair anchor number one. The stitch from that gets loaded up through repair anchor number two and vice versa, to create a broad surface area to compress the infraspinatus in a knotless technique against the Hill-Sachs lesion. And you can see here in this video, as we tighten those sutures up, how the infraspinatus becomes compressed up against the Hill-Sachs lesion and obliterates that space on that engaging Hill-Sachs lesion. So our post-op protocol for this patient was a sling for three weeks daily pendulum exercises. After about six weeks, we institute full range of motion and progressive strengthening. And we anticipate a return to basketball in about 4 to 6 months. So in conclusion, with current Knotless TensionLoc technology, we were able to deliver aggressive and appropriate surgical treatment for this patient in a minimally invasive fashion. Thank you.

Paul C. Brady, MD, (Knoxville, TN) discusses the arthroscopic Bankart repair and knotless remplissage by presenting a case study of glenohumeral instability with &lt;25% glenoid bone loss and an off‐track Hill‐Sachs lesion. In this case, Dr. Brady performs an arthroscopic knotless Bankart repair and discusses the benefits of using an interconnected Knotless SutureBridge™ technique for insetting the infraspinatus into the Hill‐Sachs lesion. He also shares valuable surgical pearls and the evolution of his technique for managing Hill‐Sachs lesions.

Arthroscopic Bankart Repair With Knotless Remplissage

Hi, my name is Doctor Paul Brady and today I would like to discuss arthroscopic Bankart repair with Knotless Remplissage. And any current discussion of instability must at least acknowledge the concept of the glenoid track, first described by Yamamoto and Itoi in 2007. But while the steps of determining the glenoid track can seem onerous, doctors Giacomo and Burkhart do an eloquent job at summarizing the process. In an article recently published in the Arthroscopy Journal. And Doctor Burkhart tells me that it's simple arithmetic. But despite being Burkhart fellow number seven, his cognitive equal, I am definitely not. And Doctor Burkhart approaches these things with one mind, and my mind frequently finds the glenoid track calculations a little more daunting. So I'm very thankful that the authors included beautiful pictures in the article, because even I can look at the one on the left and say, that's really bad, and the one on the right that's not so bad. But and they also did a great job at simplifying the treatment paradigm into essentially three categories. If you have glenoid bone loss of greater than 25%, that patient gets a letter J. If you have glenoid bone loss, less than 25%. And an on track lesion, that's a bankart repair in isolation, less than 25% bone loss with an off track lesion is a bankart with a Remplissage. So what's the history of the Remplissage? Well, it's a French word and it means to fill in. And the procedure was first described by Doctor Eugene Wolf approximately 14 years ago. Subsequently, there has been a plethora of literature on the Remplissage, and overall it's been very positive for the Remplissage. When you add the Remplissage to a bankart repair, typically you've seen improved outcomes, decrease recurrent instability rates, minimal loss of range of motion, and a And a decreased complication rate when comparing it to the latter procedure. So let's look at a case. Here's a 17 year old football player. He's had multiple subluxations and dislocations, finished his junior year of high school. And then we took him to the O.R.. So I'm viewing from the anterior superior lateral portal here, preparing the labrum, and then through a 5:00 portal. I'll use this rigid inserter to lever the humeral head out of the way. I'll place the anchor, and then I'll pass the repair suture from the anchor. Utilizing, in this case, a real pass SutureLasso, which says monofilament inside a reel that you just reel out. And then I'll pass the repair suture and take the looped end of the shuttle suture and use that to load my repair suture back into the locking splice of the anchor, pull the desired tension, and and then work your way up the glenoid with these anchors until our bankart is finished. Now, this patient had an off track lesion. So I'm going to do a Remplissage. And at the time of this procedure I did a trans tendon anchor insertion Remplissage. Here you can see I use a percutaneous insertion kit again in that rigid inserter. This time, however, I'm going to leave the rigid inserter in place. I'm going to place the anchor, but I'm not going to remove the rigid inserter. I'll just use the second one, and that will allow it to protect those sutures when I go into the subacromial space. So here I'm in the subacromial space, clearing it out. I'll then link these two anchors to one another, repair suture from one into the eyelet, or the splice of the other, and vice versa. I'll go back Intra-articular pull alternating tension and that inserts that infraspinatus into your Hill-Sachs defect nicely. This player went on to to a stellar senior year. He got a scholarship, a college scholarship, and I just saw him last week. He finished his freshman year and he played every game and did very well. So Knotless options. Arthrex has clearly pioneered the field of knotless technology, but the question becomes why not less? And I often hear the voice of Chris Adams in my head, and he's talking about the ABCs of shoulder surgery. Specifically, knotless technology allows for anatomic labral repair. The biomechanics and biology are also very favorable in that these constructs are very strong. They eliminate the possibility of knot migration as well as knot abrasion. And we've already seen this graph. But the bridging construct with the knotless suture is almost twice as strong as your traditional double pulley construct. Knot strength can also be a problem. This study looks at knot strength variability both between various shoulder specialists as well as within each surgeons tied knots, and there's significant variability. It's also clear that knots can migrate. This is a revision case of mine in which the knot is clearly migrated onto the glenoid articular surface. I promise you, I did not put that knot there when I did the first case. Doctor al-Atrash has shared this video of a volleyball player with player with significant, not abrasion, which caused an articular side of rotator cuff tear and persistent shoulder pain after a previous slap repair by another surgeon. And I particularly like this biologic benefit of of the cannulation of these anchors. If you watch these videos, you'll see the blood and the marrow elements erupting from the middle of the anchor site on the right. As I punch the anchor in, you can see the other anchor sites, the other three anchor sites the blood and the marrow coming up through those anchor sites. And I really like that potential. But most importantly is clinical results. I've put in over a thousand of these anchors since 2015, and I've done two revision surgery cases on these patients, but it's not in the Arthrex DNA to rest on any good single good thing. And the latest and greatest, as Tom showed, is A39 knotless Corkscrew anchor. This anchor uses the same internal locking splice mechanism, but it has twice the pull out strength because it's a threaded Anchor. So along with the technology, my my technique is also evolved. And now I put these anchors in from the posterior portal right at that articular margin of my Hill-Sachs defect. But now I'm going to pass these sutures utilizing a 14 gauge angiocath, and it's 3.25in long. You place the Angiocath through the infraspinatus exactly where you want it to go, and then you take the nitinol wire from the from the SutureLasso, and you use that nitinol wire to shuttle the repair suture and your shuttle sutures into that angiocath. I'll then leave the angiocath in place. I'll do a second anchor, a second angio catheter, and this time you'll see my assistant. He's pushing the nitinol wire, the looped end of the nitinol wire down through the angiocath. I'll grab it, and I'll use that to shuttle all those sutures into the angiocath. And then I place a hemostat on that angiocath so that it doesn't move when I'm debriding in the subacromial space, I really like to go in the subacromial space. Identify both of those angio casts. I'll switch to the lateral portal, and now I'm going to do my linking technique, where I take the repair suture from the inferior anchor, and I load it into the splice of the superior anchor by taking the looped end of the shuttle suture. I'll create that first link, and then I'll take my repair suture from my superior anchor, and I'll load it into the locking splice of my inferior anchor. And then I'll just I'll tension it so that those sutures are just barely touching the tissue. But I don't want to fully tension until I'm looking through the ASL portal. And then I can see that that Infraspinatus sets into the Hill-Sachs and makes that an extra articular non-engaging Hill-Sachs. I'll then take those limbs, bring them laterally. I'll compress them laterally into a SwiveLock to get nice double row compression of the tissue down against the Hill-Sachs defect. Effect. So I've done over 75 of the Bangkok Remplissage cases, and thus far I've had no recurrent dislocations, at least none that I know of. And I've found that this has caused me to really push the indications of that 25% glenoid bone loss. For example, here's an anesthesiologist buddy of mine who had significant bipolar bone loss, and he's now two years out from this bankart Remplissage. And since he's an anesthesiologist and work seldom gets in the way, he's able to do this pretty much every weekend. So this is this is this is very important to him to be able to do this. Likewise, the Arthrex SOS global data has been very, very positive in regards to the Remplissage procedure with improved outcome scores. So I'll conclude with a few pearls. First, if you're using the 300 Knotless SutureTak, I typically use the 2.6mm drill. However, if I feel like it's an older patient or softer bone, I'll drop down to a 2.4mm millimeter drill. Second, I always use the Gemini cannulas. I use them anteriorly and posteriorly. They are fantastic. They don't come out. I also use the percutaneous insertion kit frequently to get those good angles on the inferior portion of the glenoid. Third, a quick method to grab the looped end is push. Push both of those sutures away from you, and then have your assistant just gently tug on the looped end of the shuttle suture, and that will pull it right back into your grasper, and you can grab it quickly without having to struggle. But most importantly, as last week, the tensioner cutter was released, this allows you to place the tip of that device directly on the top of the anchor. Hold the t-handle portion and you can. Honestly, you can cut your fingers. You can pull so hard. I mean, you can pull as much tension as you could possibly want. When you're ready, you just press the plunger, and that cuts your suture flush and allows for a really nice secure repair. Thank you very much.

Remplissage

Knotless FiberTak Soft Anchor Technique - Remplissage

Knotless Corkscrew® Anchor Technique - Remplissage