Dr. Andrew Sheean:
Welcome to the Arthroscopy Journal Podcast. The views expressed in this podcast do not necessarily reflect the views of the Arthroscopy Association or the Arthroscopy Journal.
Welcome everybody. I'm Dr. Andrew Sheean from the San Antonio Military Medical Center. This evening, I'm excited to be talking to Dr. Rob Hartzler from TSAOG Orthopaedics here in San Antonio. Dr. Hartzler's paper entitled “Remplissage Using Interconnected Knotless Anchors: Superior Biomechanical Properties to a Knotted Technique?” was published in the November, 2018 edition of Arthroscopy Journal. Rob, welcome to the podcast and thanks for joining me.
Dr. Rob Hartzler:
Andy, thanks for having me on. This was a fun little study to carry out and one that I think is practical. And I appreciate your reading the title of the article in the form of a question. Skillfully done.
Dr. Andrew Sheean:
I didn't know if I should have said question mark or not at the end, so I'm glad you noticed that. So I think for topics like this, and we have a lot of listeners that maybe focus primarily on hip surgery and knee surgery. And so they may not be familiar necessarily with remplissage. So just real quickly, why don't you give us an overview of what the remplissage technique is and why it was first proposed?
Dr. Rob Hartzler:
Well, remplissage was a technique that was originally described by Dr. Eugene Wolf, and it is a French term which means “filling.” I don't speak French, but that's what I'm told. And so it's a way to treat the humeral head defect, which often occurs with instability, and the filling that occurs in this with the rotator cuff and capsule by placing suture anchors into the defect and then tying them. There's a bunch of different remplissage techniques, but the basic idea is what I've just said, to treat the lesion in that fashion.
Dr. Andrew Sheean:
Why don't you tell me and the listeners what the impetus behind this paper was, how you all set it up and what you think the key findings were from the effort?
Dr. Rob Hartzler:
Well, this study was done basically to validate a new type of anchor, and we thought that it would be good to test this in a common clinical scenario that we use it. In this study we chose to look at remplissage, which we typically perform with two suture anchors. And prior to this knotless type of anchor coming out, we would tie one suture from each anchor to the other suture two times so that... And Dr. Burkhart came up with that technique, which he called the medial... Well, a double-pulley technique often that was used in rotator cuff surgery. And so we would call it a medial double-pulley, but basically to use the eyelid of each anchor as a pulley. And when you tie the two suture tails together, then you can create a double mattress type of fixation between two suture anchors. So we would use that in rotator cuff surgery and remplissage, and we thought that testing the construct with the new suture anchors, which are knotless and tensionable anchors would be a good clinical application for the experiment.
So that was the background. And I should say that these are proprietary anchors that were designed by Arthrex, and Arthrex did both fund the study and provide the lab space for us to carry out the experiments. And at the time of the initiation of the study and the experiments and the writing, Dr. Burkhart and I were both working as consultants for Arthrex. So, those disclosures I think should be made upfront, and they're made clear in the article. So we initiated this study after these anchors had come out. And one of Dr. Burkhart's principles was to, with each iteration and step advance in arthroscopic shoulder surgery that he made, to really test and validate that what was coming on as something new at least was equivalent to what had been done before.
And so these knotless anchors are quite handy because as the name implies, one doesn't have to tie knots to achieve secure fixation. And so there are some advantages for reproducibility and for saving time in the operating room with these and we just wanted to make sure that the mechanism was sound and that the construct using interconnectivity between two anchors with the knotless mechanism was equivalent to a knotted construct.
Dr. Andrew Sheean:
Well, that was a great synopsis of the impetus behind the study. So why don't you tell us what you found?
Dr. Rob Hartzler:
So in this study, we tested seven matched pairs of cadaver shoulders, each one getting either a knotted or a knotless remplissage construct, and the knotless construct was equivalent or better to the traditional knotted type of repair. And in fact, the knotless construct was better in load to clinical failure and yield load in the single pole to failure type of testing. Both constructs performed very well and didn't have clinical failure during cyclic loading. So, one thing that was very interesting in looking at the mode of failure was that they were different between the two groups, and in the knotted group, the typical mode of failure was either suture breakage or suture loosening, whereas in the knotless group, they failed either by the tendon tearing or by the anchors pulling out.
And so, it really gave us some confidence that the knotless mechanism of the anchor was sound. And it makes sense because in this particular knotless design, the mechanism of the security is that the suture is threaded back into itself inside of the anchor body, which is called a suture splice mechanism, and it has a self-reinforcing nature so that the more that it's pulled against, the tighter that fixation becomes. And so it makes sense that that construct would be better. It also makes sense in that each anchor to suture pair in the knotless group is independent of one another, whereas in a double-pulley type of fixation, if either one suture or one knot fails, the entire construct fails.
So it does seem like this type of anchor and this type of fixation is an advance. It does seems to have more reliability just by leasing it out and time-saving and seems to be stronger as well. So each type of technology like this certainly has disadvantages and new things are more expensive and have their own quirks and ways that it can be vexing in the operating room, but at least in terms of the biomechanics in this experiment, this knotless interconnected type of fixation performed very, very well.
Dr. Andrew Sheean:
So why don't you give us a synopsis on how you do remplissage today? Where do you put your anchors? How you pass your sutures, things like that.
Dr. Rob Hartzler:
In general, our technique, which Dr. Burkhart described and which we used in this paper, was to place the anchors at the rim of the defects so that the rotator cuff completely excluded it from being able to engage and fill the entire defect. And we also pass the sutures through both the cuff and the capsule and tie them in the, or secure them in the subacromial space. So there are a few different techniques described for remplissage, but that was Dr. Burkhart's preferred way and that's typically the way that I still do it now.
Dr. Andrew Sheean:
Real quick, tell us what the sequence of events is. Do you put your anchors in the defect first and then go address your Bankart repair and then go back and tie them or secure them down, or do you the opposite, or how do you do it?
Dr. Rob Hartzler:
So you will get swelling back there fairly quickly. And so I do like to get those anchors in and pass through the cuff fairly quickly. But what I like to do is prepare the Bankart repair, prepare the bone and the labrum, and at least place the most inferior anchor and pass sutures for that without securing them prior to putting in the remplissage anchors.
Dr. Andrew Sheean:
Have you seen any of these gone bad?
Dr. Rob Hartzler:
I've treated two patients in my practice who were referred, who had complications of prior instability surgery, which seem to be complications of remplissage. One was a rotator cuff tear at the musculotendinous junction, and one had basically had the deltoid remplissaged in with the reconstruction. And both of those patients were treated and did fine, but those seemed to be technical error. The downsides of remplissaging seems to cause more pain. I think that's been established in a couple of studies. Arciero and colleagues published a paper that was on Bankart remplissage versus Latarjet, and those patients seemed to have more pain and a higher recurrent instability rate than Latarjet, although less overall complications. So, that's another factor to consider. And then we already talked about some loss of external rotation.
Dr. Andrew Sheean:
The first of those two cases that you mentioned, the musculotendinous junction tear. So that would presumably had been, the technical error then would have been not passing the stitches through the tendon, correct?
Dr. Rob Hartzler:
Yeah, and that's why I like to repass them. You'll see some techniques reported as just placing the anchors through a posterior approach, standard posterior arthroscopy portal, and then tying them. But I think that that places the sutures then either at the musculotendinous junction or in muscle, whereas if you use a posterior portal, which gives you the best angle for the anchor placement, and then repass the sutures using a percutaneous approach, as I described earlier, then that tends to place the sutures as lateral as you can, hopefully through real tendon, but also hopefully with enough tissue that it'll actually inset the tissue into the Hill–Sachs in effect. So it's complicated. There's a lot of competing interests there when you're doing all that work.
Dr. Andrew Sheean:
So let's take a step back from the technical aspects of instability surgery and talk more philosophically for a minute. So, and I asked Brett Owens when he was a guest in the podcast several months ago this question, so I'll pose it to you. What are you doing for the, let's say a senior in high school collision athlete with 15% bone loss? Dr. Arciero published a paper several years ago in the American Journal of Sports Medicine that would suggest that remplissage is inferior to Latarjet in terms of recurrence. Is there a role for remplissage in your hands with respect to that patient?
Dr. Rob Hartzler:
I think my bias is to hedge towards soft tissue reconstruction, unless they have severe glenoid bone loss, which would be, for me, the primary driver to do a Latarjet. The complication rate is lower, as you said. Often these are younger patients, and so I think it just preserves... I mean, remplissage is somewhat of a non-anatomic reconstruction, but I think sort of preserves more of their normal anatomy. And in my experience, proposing Latarjet to younger patients and their families and trainers and things like that is a harder sell. So I think that at least from what we've been able to determine... From other studies in literature and from what we've been able to determine by following up Dr. Burkhart's patients since he was using the on-track or off-track paradigm, Bankart remplissage has been quite successful in preventing recurrent instability, even in this situation where there's that subcritical amount of glenoid bone loss.
And one of our fellows last year completed a project that we initiated a few years ago on that. And so we'll be submitting that pretty soon. But, yeah, I think Bankart remplissage is going to be a really nice option for this situation that you've described and knowing perhaps that there will be a little bit of a higher recurrence rate in really high risk patients versus a bony reconstruction, but there are a number of advantages, as I stated, for doing a soft tissue reconstruction for them.
Dr. Andrew Sheean:
Well, Rob, this has been a great conversation. You're a busy guy. You're all over the place. You're a social media maven. You just launched the Arthroscopy Journal YouTube page. So I really appreciate you taking time out of your busy schedule to get into the weeds and talk technique and philosophy about remplissage this evening.
Dr. Rob Hartzler:
Well, thanks Andy. I think shoulder instability is really a fun topic because there's lots of room for refining our techniques and indications and postoperative care. And these can be challenging patients, but a really fun topic. So thanks for having me on and resurrecting an old study. We, I think, did a lot of work on it, and I think it is a valuable addition to the literature. So, if the listeners haven't checked out that study, I'd encourage them to get into the weeds of it.
Dr. Andrew Sheean:
Well, that's going to do it for this edition of the Arthroscopy Journal Podcast. Dr. Hartzler's paper entitled “Remplissage Using Interconnected Knotless Anchors: Superior Biomechanical Properties to a Knotted Technique?”was published in November of 2018 in the Arthroscopy Journal. It could currently be accessed at www.arthroscopyjournal.org. Thanks for joining us and have a nice evening.