The Procedure
Remplissage surgery is a procedure where a dent or groove in the humeral head that develops after dislocation, called a Hill-Sachs lesion, is filled. The Hill-Sachs lesion is filled with the infraspinatus tendon and posterior capsule, which prevents the humeral head from dislocating. The surgery is done primarily to treat anterior shoulder instability by stopping the humeral head from getting caught on the glenoid, in particular during abduction and external rotation (when the shoulder is being lifted out to the side and rotated outwards, respectively).
The surgery is typically performed arthroscopically, and can be done as an independent procedure or in conjunction with other surgeries, such as a Bankart repair.
Complications
General risks of surgery include:
- Bruising & haematoma: this will vary for each patient. Bruising is a normal side effect of surgery and usually resolves in a short time.
- Infection: infection is a rare but possible risk and is usually treated with antibiotics.
- DVT and PE: deep vein thrombosis and pulmonary embolism are blood clots that form in either the lower limbs or lungs. If left untreated, DVT and PE can have serious effects, however if treated promptly, the risks are significantly lowered. More information can be found here.
- Anaesthetic risks: general anaesthetic (GA) carries a number of risks, which will be discussed in detail with your anaesthetist prior to surgery. Fortunately, Australia is one of the safest places to undergo a GA. In Australia, the risk of mortality from GA is around 1 in 100,000. For context, the risk of death in a car accident in Queensland is around 1 in 10,000 per year.
- Wound issues: some superficial issues can develop in surgical wounds postoperatively, however most will require a small intervention to resolve the problem.
Specific risks of Remplissage include:
- Reduced external range of motion:this may affect abduction movements, including throwing and overhead movement
- Posterior shoulder pain
- Re-dislocation
- Stiffness
- Frozen shoulder: frozen shoulder can occur after any surgery around the shoulder joint. It resolves with time.You will still get a good result from the surgery once the frozen shoulder hasresolved, however it can make the rehab prolonged and miserable if the frozen shoulder is severe.
Pre Op
Whilst you wait for your surgery date, there are a few things to do:
- Speak to your health fund to confirm if the hospital fee for your surgery is covered on your policy
- Speak to your anaesthetist to confirm their fees
- Register your details with the hospital
- Read through, complete and return your paperwork to my office
- Plan your transport to and from the hospital. You won’t be able to drive yourself home after the surgery, so make sure you have a travel plan in place
- If required, arrange any recommended pre op physio appointments
- If required, get any pre op pathology tests (e.g., blood tests)
- Use benzoyl peroxide 5% wash on your shoulder for 5 applications: twice a day for two days, and then again on the morning of the surgery. This will help reduce your risk of infection from Cutibacterium acnes.
- Pack a bag for your hospital stay including regular medications in the original packaging, a loose button-up shirt to wear after surgery, nightwear, personal items including toiletries. If you have sleep apnoea, you must bring your CPAP machine.
- If you are on any blood thinners, ring my office and confirm when to stop taking them before the operation.
- If you are on any diabetic tablet medications, ring your anaesthetist and confirm whether you need to stop taking them before the operation.
- Confirm your admission details with my office one to two business days prior to surgery.
Though this can seem overwhelming, you will be provided with detailed instructions on what needs to be done so your surgery journey can be as smooth as possible.
Day of Surgery
Your admission details will be confirmed one to two business days prior to surgery. You will need to make note of your admission time and your fasting time. Your admission time may be as early as 6am. If you aren’t local to Brisbane, it is usually recommended that you stay the night before in case your admission is early.
When you arrive at the hospital, you will go through the admissions process and then be taken through to the surgical waiting area. Your anaesthetist will have a short consultation with you before you go into theatre and under general anaesthetic. I will say hi to you before the surgery in the anaesthetic bay of the operating theatre and mark your operation site with you.
Your hospital stay will usually be one night. You will be discharged usually around 10am. I will see you before your discharge. I will provide you with a folder containing a detailed postoperative pack including a letter telling you what I found at surgery and exactly what I did in your operation along with information about your rehabilitation and postoperative care. Remember to have someone available to take you home from the hospital.
Post Op Recovery & Healing
After Remplissage surgery, recovery involves plenty of rest and immobilisation of shoulder to allow adequate healing of the repair. For 6 weeks, a sling needs to be worn fulltime to immobilise the shoulder, during which time, no driving, working or physical activities are allowed. Gentle, passive range of motions exercises of the hand, wrist and elbow may be done, but the shoulder movement is limited.
Full recovery can take up to 6 to 12 months, depending on individual factors, with a gradual progression towards normal activities.
Rehabilitation
Rehabilitation exercises typically begin at six weeks postoperatively, once the sling is no longer needed. Initial physiotherapy exercises focus on passive and active range of motion, followed by strengthening exercises and proprioception.
Physiotherapy Guidelines
Day 1 Physiotherapy Guidelines
The hospital physio will demonstrate how to fit your sling and how to eat, shower & dress whilst in your sling. Please make sure you go through these things with the physio so that you get them really clear in your mind before you leave hospital.
Goals:
- Protect soft tissue healing by limiting active motion of posterior cuff or passive stretching
- Assist in the reduction of pain and management of inflammation
- Minimise the development of GH (glenohumeral) joint stiffness
- Passive pendulum
- Strict Passive External rotation
Day One:
- Education and Reassurance: healing time frames, precautions as per remplissage procedure (no posterior cuff activation, no cross body motion, no internal rotation, no WB (weight bearing), remain in sling other than showering and doing gentle exercises)
- Sling: for 6 weeks (check surgical notes), don/doff independently and correct fit, possible need for ER (external rotation) brace or gun slinger position. Demonstrate activities of daily living (showering, dressing etc)
- Day 1 exercise program:
- Cervical spine, Elbow, Wrist and Hand AROM(active range of motion)
- Gentle scapular neutral exercises/general posture advice
- Shoulder
- passive only pendulum – aim for minimum 70°drop, ideally in scapula plane
- strict passive external rotation to 20° (unless stated otherwise)
- patient may refer to Extend Rehab or Dr Cutbush’s website for exercise videos
- Pain management: positioning, appropriate sling fitting, cryotherapy initially (x20 min every 2-3 hours for first 5 days post-operatively), then heat may be useful
- Oedema control for the upper limb: ice, effleurage
- ADL (activities of daily living)advice: use of hand for light function within sling
Considerations:
- Refer to surgical notes for greater understanding of soft tissue procedure.
Follow up:
- With local physiotherapist week 2 to check. Week 6 with me and Extend Rehabilitation Physiotherapist when patient’s rehabilitation will be progressed.
Results After Surgery
Remplissage surgery is generally successful at improving instability, allowing a high rate of patients to return to normal physical activities. Some patients may experience limitations in the range of motion, particularly with external rotation, however individual factors will influence this outcome.