University of Pennsylvania, Department of Orthopedic Surgery, Philadelphia, PA 19104, USA.
Am J Sports Med. 2012 Oct;40(10):2331-6. doi: 10.1177/0363546512456974. Epub 2012 Aug 20.
Arthroscopic remplissage is a novel procedure recently advocated for the treatment of large Hill-Sachs lesions with recurrent anterior glenohumeral instability. We have shown previously that infraspinatus tenodesis and Bankart repair reduce the risk of recurrent instability in high-risk patients. The ability to perform this procedure arthroscopically and without the need for bone grafting or an open approach makes this an appealing alternative to more traditional techniques.
To evaluate and characterize the postoperative appearance of the remplissage procedure on high-resolution magnetic resonance imaging (MRI) and to correlate these findings to clinical outcome (Western Ontario Shoulder Instability [WOSI] score, range of motion).
Case series; Level of evidence, 4.
In patients who had undergone arthroscopic remplissage for recurrent glenohumeral instability with large Hill-Sachs defects, images were acquired with a 3-T protocol (and reviewed by 2 musculoskeletal radiologists) with the shoulder in the abduction-external rotation (ABER) and neutral positions at the time of the latest clinical examination. Measured parameters included signal intensity of tissue within the prior defect, signal intensity of the residual infraspinatus, degree of fatty infiltrate and muscle atrophy as a percentage of fat signal versus muscle signal (Goutallier grade), presence of marrow edema, and number of anchors in the defect. Functional scores were obtained with the WOSI questionnaire, and comprehensive range of motion data were recorded with a goniometer.
In 11 patients with an average clinical follow-up of 18.0 months (range, 8.8-27.2 months), the average size of the Hill-Sachs deformity was 334.3 mm(3) (range, 93.6-825.1 mm(3)). The percentage of the deformity filled in with tendon was 75% to 100%, and the degree of atrophy was 0% to 25% for all patients studied. No defects were left unfilled. Two patients had granulation tissue filling the lesion, and 3 patients had fibrous tissue, while the rest of the patients had the MRI appearance of both granulation and fibrous tissue. Four of 9 patients had tendinopathy or partial tears of the residual infraspinatus tendon insertion, and 1 patient demonstrated residual bone marrow edema. The average number of anchors used was 1.4 (range, 1-3). The average WOSI score was 74.3% (range, 41.6%-99.2%), with an average external rotation loss of 5.8° (range, 0°-22°). One patient had recurrence of instability.
Our data suggest that there is evidence of tendon incorporation and fill into the Hill-Sachs defect following arthroscopic remplissage at 8 months and beyond. Although MRI findings did not correlate with the clinical findings, patients were satisfied with the procedure and demonstrated minimal loss of external rotation (average, 5.8°) at early follow-up.
关节镜下填充术是一种最近被提倡用于治疗复发性前肩盂肱关节不稳定伴大 Hill-Sachs 损伤的新方法。我们之前已经证明，冈下肌肌腱固定术和 Bankart 修复术降低了高危患者复发性不稳定的风险。能够通过关节镜进行此手术，而无需植骨或开放入路，这使其成为更传统技术的一种有吸引力的替代方法。
评估和描述填充术在高分辨率磁共振成像（MRI）上的术后表现，并将这些发现与临床结果（Western Ontario 肩不稳定[WOSI]评分、活动范围）相关联。
病例系列；证据水平，4 级。
在接受关节镜下填充术治疗复发性肩盂肱关节不稳定伴大 Hill-Sachs 缺损的患者中，在最近的临床检查时，使用 3-T 协议（由 2 名肌肉骨骼放射科医生进行回顾）采集肩关节外展外旋（ABER）和中立位的图像。测量的参数包括先前缺损内组织的信号强度、残余冈下肌的信号强度、脂肪浸润程度和肌肉萎缩程度（以脂肪信号与肌肉信号的百分比表示，Goutallier 分级）、骨髓水肿的存在以及缺损内的锚钉数量。使用 WOSI 问卷获得功能评分，并使用量角器记录全面的活动范围数据。
在平均临床随访 18.0 个月（范围，8.8-27.2 个月）的 11 例患者中，Hill-Sachs 畸形的平均大小为 334.3mm3（范围，93.6-825.1mm3）。所有研究患者的缺损填充肌腱百分比为 75%至 100%，所有患者的萎缩程度为 0%至 25%。没有未填充的缺损。2 例患者有肉芽组织填充病变，3 例患者有纤维组织，而其余患者则有肉芽组织和纤维组织的 MRI 表现。9 例患者中有 4 例存在残余冈下肌肌腱插入处的肌腱病或部分撕裂，1 例存在残余骨髓水肿。使用的锚钉平均数量为 1.4 个（范围，1-3 个）。平均 WOSI 评分为 74.3%（范围，41.6%-99.2%），平均外旋丢失 5.8°（范围，0°-22°）。1 例患者出现不稳定复发。
我们的数据表明，在关节镜下填充术 8 个月及以后，有证据表明肌腱会合并并填充到 Hill-Sachs 缺损中。尽管 MRI 结果与临床结果没有相关性，但患者对该手术满意，在早期随访中仅表现出轻微的外旋丢失（平均 5.8°）。
