Remplissage for Engaging Hill-Sachs Lesions

Surgical Indications

Absolute Indications

• Anterior shoulder 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 failed Bankart repair without significant glenoid bone loss
• Patient preference for 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 Bankart repair (rare intraoperative 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 off-track lesion (combined glenoid and humeral defects require bony glenoid restoration)
• Glenoid bone loss of any magnitude with an inverted-pear glenoid morphology
• Active infection or uncontrolled medical comorbidity precluding surgery

Relative:

• Overhead throwing athlete in whom even 5-10 degrees of external rotation loss would be career-limiting (consider alternative procedures)
• Significant glenoid dysplasia or version abnormality requiring bony correction
• Patient inability to comply with post-operative rehabilitation protocol

Evidence for Glenoid Track Concept and Remplissage

Glenoid Track and On-Track / Off-Track Lesions

• The glenoid track concept, introduced by Di Giacomo, Itoi and colleagues, defines the zone of contact between the glenoid and humeral head during abduction-external rotation
• An off-track Hill-Sachs lesion engages the anterior glenoid rim because its medial margin lies medial to the glenoid track margin
• The formula for glenoid track width is 0.83 times the glenoid diameter minus the width of glenoid bone loss
• Multiple validation studies have confirmed that off-track lesions have significantly higher recurrence rates after isolated Bankart repair compared with on-track lesions

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 mean loss of external rotation of 5-10 degrees, which is usually well tolerated
• Patient-reported outcomes (WOSI, Rowe, ASES) improve significantly and are comparable to Latarjet in low-glenoid-bone-loss cohorts
• Remplissage does not restore glenoid bone stock; failure rates rise sharply when glenoid bone loss exceeds 15-20 percent

Key Evidence

Glenohumeral Joint Anatomy Relevant to Remplissage

Hill-Sachs Lesion

• A Hill-Sachs lesion is an impression fracture of the postero-superolateral humeral head caused by impaction against the anterior glenoid rim during anterior dislocation
• Typical location: 0-2 o'clock position on the humeral head when viewed from above (right shoulder)
• Size classification: small (less than 20 percent humeral head diameter), medium (20-40 percent), large (greater than 40 percent)
• Engagement occurs when the lesion comes into contact with the anterior glenoid rim during abduction-external rotation

Glenoid Track Concept

• The glenoid track is the zone of contact between the glenoid articular surface and the humeral head during abduction-external rotation
• Width of the glenoid track equals 0.83 times the glenoid diameter minus the width of any glenoid bone loss (Di Giacomo formula)
• The medial margin of the glenoid track moves medially as glenoid bone loss increases
• A Hill-Sachs lesion is on-track when its medial margin lies lateral to or at the medial margin of the glenoid track (non-engaging)
• A Hill-Sachs lesion is off-track when its medial margin lies medial to the glenoid track margin (engaging)

Infraspinatus and Posterior Capsule

• The infraspinatus tendon inserts on the greater tuberosity immediately posterior and lateral to the Hill-Sachs lesion in most cases
• The posterior capsule lies deep to the infraspinatus and can be incorporated into the tenodesis
• Tenodesis of the infraspinatus into the Hill-Sachs defect fills the defect 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

Anterior Labrum and Capsule (Bankart Component)

• The anterior inferior labrum (IGHL complex) is the primary static restraint to anterior translation in abduction-external rotation
• A Bankart lesion is an avulsion of the anterior inferior labrum from the glenoid rim, often with capsular stripping
• Remplissage is performed in conjunction with arthroscopic Bankart repair; the Bankart repair restores the anterior labral bumper and glenoid concavity while remplissage addresses the humeral defect

Glenoid Bone Loss Considerations

• Glenoid bone loss is quantified on 3D CT using the best-fit circle method or Pico method
• Critical threshold: greater than 15-20 percent of glenoid width significantly narrows the glenoid track and increases recurrence risk after soft-tissue stabilisation
• Inverted-pear glenoid morphology indicates substantial bone loss and is a contraindication to isolated remplissage

Positioning and Preparation

Patient position: Beach-chair position with the head secured in a neutral position. The operative arm is placed in a pneumatic arm holder (Spider or similar) allowing free positioning in all planes. The shoulder is prepared and draped to allow full access to the posterior and anterior aspects.

Anaesthesia: General anaesthesia with interscalene block for post-operative analgesia. Hypotensive anaesthesia (systolic blood pressure 90-100 mmHg) improves visualisation during arthroscopy.

Portals: Standard posterior viewing portal (2 cm inferior and 2 cm medial to the posterolateral acromion corner), anterosuperior working portal (just anterior to the biceps tendon in the rotator interval), and anteroinferior portal (immediately superior to the subscapularis tendon). An accessory posterolateral portal may be required for anchor placement in the Hill-Sachs defect.

Equipment: 30-degree and 70-degree arthroscopes, 5.0 mm cannulas, double-loaded 3.0 mm or 4.5 mm suture anchors (bioabsorbable or PEEK), knotless or knotted fixation devices, arthroscopic suture passers and graspers, radiofrequency ablation device, 4.5 mm shaver and burr.

Consent discussion: Specific risks include 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 open Latarjet if unexpected glenoid bone loss is encountered.

Arthroscopic Remplissage + Bankart Repair — Step-by-Step

Step 1: Diagnostic Arthroscopy and Dynamic Engagement Test

Perform a complete diagnostic arthroscopy through the posterior portal. Document the size and location of the Hill-Sachs lesion, the presence and extent of glenoid bone loss, the status of the anterior labrum, and any associated pathology (biceps, rotator cuff, cartilage).

Perform the dynamic engagement test: position the arm in 90 degrees of abduction and progressive external rotation while viewing from the posterior portal. Observe whether the Hill-Sachs lesion engages the anterior glenoid rim. If the lesion engages, it is off-track and remplissage is indicated.

Step 2: Glenoid Preparation and Bankart Repair (Anterior Phase)

Switch the viewing portal to the anterosuperior portal to visualise the anterior glenoid rim. Debride the anterior labrum and glenoid neck with a shaver and radiofrequency device. Place two or three double-loaded suture anchors on the glenoid face at the 3, 4 and 5 o'clock positions (right shoulder) or equivalent. Pass the sutures through the labrum and capsule using a suture passer. Tie the knots to complete the Bankart repair, restoring the anterior labral bumper and capsular tension.

Step 3: Hill-Sachs Lesion Preparation (Posterior Phase)

Return the viewing portal to the posterior portal. Identify the Hill-Sachs lesion. Use a shaver or burr to debride any fibrous tissue or loose cartilage from the base of the defect until bleeding cancellous bone is exposed. This promotes healing of the tenodesed infraspinatus into the defect.

Place two or three double-loaded suture anchors into the base of the Hill-Sachs defect. The anchors are typically placed in a medial-to-lateral or superior-to-inferior configuration depending on defect geometry. Ensure the anchors are seated securely with good purchase in the humeral head.

Step 4: Suture Passage Through Capsule and Infraspinatus

Using an arthroscopic suture passer or penetrating device, pass one limb of each anchor suture through the posterior capsule and infraspinatus tendon approximately 1 cm lateral to the defect margin. The goal is to capture a substantial tissue bridge that will tenodese the infraspinatus into the defect when the sutures are tied.

Pass the sutures in a mattress or simple configuration depending on tissue quality and defect size. Ensure the sutures exit the skin through the same portal or a separate percutaneous stab to allow knot tying.

Step 5: Knot Tying and Defect Filling Confirmation

Tie the sutures using a sliding knot followed by multiple half-hitches or a knotless fixation device. As the sutures are tensioned, the infraspinatus tendon is drawn into the Hill-Sachs defect, filling it and rendering the lesion extra-articular. The posterior capsule is shifted medially, further reinforcing the repair.

Reassess the dynamic engagement test after remplissage. The previously engaging lesion should no longer contact the anterior glenoid rim during abduction-external rotation.

Step 6: Final Assessment and Closure

Confirm haemostasis. Close the portals with absorbable sutures. Apply a sterile dressing and place the arm in a sling with abduction pillow.

Post-operative Protocol

Phase 1: Protection (Weeks 0-6)

• Sling immobilisation: Sling with abduction pillow for 4-6 weeks. Remove only for hygiene and gentle pendulum exercises
• Range of motion: Passive forward flexion and abduction to 90 degrees, external rotation limited to neutral (0 degrees) for the first 4 weeks to protect the infraspinatus tenodesis
• Active motion: None until week 4; then gentle active-assisted motion within protected range
• Isometrics: Begin submaximal rotator cuff isometrics at week 4 in neutral position
• Precautions: No active external rotation, no forced passive external rotation beyond neutral, no cross-body adduction, no lifting

Phase 2: Motion Recovery (Weeks 6-12)

• Sling discontinuation: At 6 weeks if healing confirmed clinically
• Range of motion goals: Full passive and active-assisted forward flexion and abduction by week 10; external rotation to 30-45 degrees by week 12
• Active motion: Progress to active range of motion in all planes except forced external rotation
• Strengthening: Begin light rotator cuff and periscapular strengthening with theraband at week 8-10
• Precautions: Avoid aggressive stretching into external rotation; monitor for posterior pain

Phase 3: Strengthening and Function (Weeks 12-24)

• Strength progression: Progressive resistance exercises for rotator cuff, deltoid, and scapular stabilisers
• Functional training: Closed-chain exercises, proprioceptive training, sport-specific drills from week 16
• Return to sport criteria: Full pain-free range of motion, symmetric strength (greater than 90 percent of contralateral), successful completion of sport-specific testing
• Contact sport clearance: Typically 6 months post-operatively after clearance by surgeon and physiotherapist

Long-term Considerations

• External rotation deficit: Document at 6 months; most patients adapt. Persistent symptomatic deficit greater than 15 degrees may warrant consideration of tenodesis release (rare)
• Return to overhead sport: Individualised; many non-elite athletes return successfully. Elite throwers may require modified technique or alternative procedures
• Surveillance: Clinical review at 6 weeks, 3 months, 6 months, and 1 year. Radiographs at 6 months and 1 year to assess anchor position and joint health