By Dev K. Mishra, M.D.
President, Sideline Sports Doc
Clinical Assistant Professor of Orthopedic Surgery, Stanford University
• Surgery for an unstable shoulder in a young athlete is commonly recommended if a shoulder repeatedly dislocates
• Results from standard arthroscopic repairs are highly variable, with repeat dislocation rates ranging from 10% to 50%
• A soft tissue procedure added to the repair called a “remplissage” may lead to substantially better results
Chances are you’ve heard of a young athlete with an unstable shoulder. And chances are that you’ve never heard of a surgical procedure called a “remplissage”. This unusual French name indicates a surgical procedure in which soft tissue is tacked down to the back of the shoulder inside the joint. It’s becoming increasingly popular as part of shoulder stabilization surgery for the young athlete, and is well worth a discussion with the surgeon.
A shoulder dislocation typically occurs from trauma or an injury, often a fall onto an outstretched arm. The force levers the ball portion of the shoulder (the humeral head) completely out of the socket. The joint often has to be put back in place in an emergency room.
The problem with shoulder dislocations in young athletes is that once the first one happens, the chances of it coming out again are very high. In some scientific studies there is a 90% (or higher) chance of the shoulder coming out again. We will typically treat a first time dislocation without surgery, but if the shoulder repeatedly comes out of the socket then surgery is preferred.
Shoulder stabilization surgery is usually done with arthroscopic technique. Small incisions are made, a camera is used to see the inside the joint, and the injured tissues in the front of the shoulder are repaired. This is a variation of a procedure that’s been around for many decades, called a “Bankart repair”.
The Bankart repair works well in adults but the results in adolescents are not quite as good. Depending on the published series, 10% to 50% of these repairs in adolescent athletes will fail. So how do we do better?
Over the years surgeons have gained a better understanding of the role the bone plays in shoulder joint stability. When a shoulder dislocates, it can produce a bony dent in the back of the humerus called a “Hill-Sachs lesion”. The deeper the dent, the higher chance of another dislocation.
A remplissage is a technique to address the bony dent. Remplissage, a French word for “filling” involves filling the dent with soft tissue in the back of the shoulder joint. The photo at right is from a recently published scientific study of the remplissage procedure for dislocating shoulders in young athletes. The photo shows the Bankart repair in the front and the remplissage in the back.
The study authors, from the Rady Children’s Hospital and UC San Diego reported a substantial improvement in outcomes when the remplissage was used compared to a group when it was not used. This is a small group of patients and needs to be repeated in larger studies but the results are compelling. They found a 13% repeat dislocation rate in the remplissage group and almost 45% repeat dislocation rate in the standard group. Function was also better in the remplissage group.
A shoulder dislocation in a young athlete has a high chance of recurrence without surgery, and a lower chance of recurrence with surgery. If you or your child is considering shoulder stabilization surgery you’ll want to discuss these issues carefully with the surgeon.