Remplissage for Engaging Hill-Sachs Lesions

Indication. Anterior shoulder instability with an off-track (engaging) Hill-Sachs lesion confirmed on dynamic arthroscopic assessment, with glenoid bone loss less than 15–20 percent on 3D CT, that has failed non-operative management or recurred after a Bankart repair performed without significant glenoid bone loss. It is the arthroscopic soft-tissue answer to a humeral-sided bone defect when the glenoid is intact enough for soft-tissue work. Absolute indications - Anterior instability with an off-track (engaging) Hill-Sachs lesion on dynamic arthroscopic assessment.

• Glenoid bone loss less than 15–20 percent confirmed on 3D CT.
• Recurrent dislocations or subluxations despite appropriate non-operative management, or after a failed Bankart repair without significant glenoid bone loss.
• Patient preference for an arthroscopic soft-tissue procedure over open bony augmentation when glenoid bone loss is minimal. Relative indications - On-track Hill-Sachs lesion that becomes engaging after a Bankart repair (a rare intra-operative finding).
• Contact or collision athlete with minimal glenoid bone loss who wishes to avoid Latarjet hardware.
• Revision surgery after failed soft-tissue stabilisation where glenoid bone loss remains below threshold. Contraindications. Absolute: glenoid bone loss greater than 15–20 percent (Latarjet or other bony augmentation required); bipolar bone loss with an off-track lesion; glenoid bone loss of any magnitude with an inverted-pear glenoid morphology; active infection or uncontrolled medical comorbidity. Relative: an overhead throwing athlete in whom even 5–10 degrees of external rotation loss would be career-limiting; significant glenoid dysplasia or version abnormality requiring bony correction; patient inability to comply with the rehabilitation protocol. The one decision that matters. Remplissage addresses the humeral defect; it does nothing for the glenoid. So the whole operation turns on the bone-loss balance between the two sides of the joint:

Consent specifically for recurrence (5–10 percent), loss of external rotation (5–10 degrees), posterior shoulder pain, anchor pull-out, axillary nerve injury, stiffness, and the possibility of conversion to an open Latarjet if unexpected glenoid bone loss is encountered intra-operatively. Setup. Beach-chair position, head secured neutral, operative arm in a pneumatic arm holder (Spider or similar) so it can be moved freely through the full arc for the dynamic engagement test. General anaesthesia with an interscalene block for post-operative analgesia; hypotensive anaesthesia (systolic 90–100 mmHg) improves visualisation.

The goal: confirm an off-track engaging lesion dynamically, restore the anterior labral bumper with a Bankart repair, then fill the Hill-Sachs defect by tenodesing the infraspinatus and posterior capsule into it so the lesion is converted from an intra-articular engaging defect to an extra-articular non-engaging one. The exposure is entirely arthroscopic — the portals and the dynamic engagement test are the whole game, and they are laid out as the first steps below.

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Rehabilitation | Phase | Timing | Immobilisation | Motion & therapy | |-------|--------|----------------|------------------| | 1 — Protection | 0–6 weeks | Sling with abduction pillow (removed only for hygiene and pendulum exercises) | Passive forward flexion/abduction to 90 degrees; external rotation limited to neutral; no active external rotation, no forced passive external rotation, no cross-body adduction, no lifting | | 2 — Motion recovery | 6–12 weeks | Sling discontinued at 6 weeks if healing confirmed | Full passive and active-assisted forward flexion/abduction by week 10; external rotation to 30–45 degrees by week 12; light rotator-cuff and periscapular theraband from week 8–10 | | 3 — Strengthening & function | 12–24 weeks | None | Progressive resistance for rotator cuff, deltoid and scapular stabilisers; closed-chain and proprioceptive work; sport-specific drills from week 16 | | Return to sport | ~6 months | None | Full pain-free range of motion, greater than 90 percent strength symmetry, sport-specific testing passed; contact sport typically cleared at 6 months | Long-term considerations. Document the external rotation deficit at 6 months — most patients adapt; a persistent symptomatic deficit greater than 15 degrees may warrant tenodesis release (rare). Return to overhead sport is individualised; many non-elite athletes return successfully, but elite throwers may need a modified technique. Radiographs at 6 months and 1 year assess anchor position and joint health.

Complications

Glenoid track concept (Di Giacomo, Itoi). The glenoid track is the zone of contact between the glenoid articular surface and the humeral head during abduction-external rotation. Its width equals 0.83 times the glenoid diameter minus the width of any glenoid bone loss. As glenoid bone loss increases, the medial margin of the track moves medially and the safe zone of humeral head contact shrinks. A Hill-Sachs lesion is on-track (non-engaging) when its medial margin lies lateral to or at the medial margin of the glenoid track, and off-track (engaging) when its medial margin lies medial to the track margin. Multiple validation studies confirm that off-track lesions have significantly higher recurrence after isolated Bankart repair than on-track lesions.

Hill-Sachs lesion. An impression fracture of the postero-superolateral humeral head caused by impaction against the anterior glenoid rim during anterior dislocation. The typical location is the 0–2 o'clock position on the humeral head (right shoulder, viewed from above). Engagement occurs when the lesion contacts the anterior glenoid rim during abduction-external rotation. Size is classed by the proportion of the humeral head diameter it occupies:

Infraspinatus and posterior capsule. The infraspinatus tendon inserts on the greater tuberosity immediately posterior and lateral to the Hill-Sachs lesion in most cases, and the posterior capsule lies deep to it — both are incorporated into the tenodesis. Tenodesing the infraspinatus into the defect fills it and shifts the posterior capsule medially, rendering the lesion extra-articular. The posterior humeral circumflex artery and axillary nerve lie inferior and medial to the typical remplissage portal sites and are at risk with inferior anchor placement. Glenoid bone loss considerations. Glenoid bone loss is quantified on 3D CT using the best-fit circle method or the Pico method. The critical threshold is greater than 15–20 percent of glenoid width, which significantly narrows the glenoid track and increases recurrence risk after soft-tissue stabilisation. An inverted-pear glenoid morphology indicates substantial bone loss and is a contraindication to isolated remplissage. Remplissage outcomes. Arthroscopic remplissage combined with Bankart repair achieves recurrence rates of 5–10 percent in appropriately selected patients with engaging Hill-Sachs lesions and glenoid bone loss less than 15 percent. Systematic reviews report a mean loss of external rotation of 5–10 degrees, usually well tolerated. Patient-reported outcomes (WOSI, Rowe, ASES) improve significantly and are comparable to Latarjet in low-glenoid-bone-loss cohorts. Because remplissage does not restore glenoid bone stock, failure rates rise sharply when glenoid bone loss exceeds 15–20 percent.