Remplissage Procedure

The operation. Remplissage is an arthroscopic posterior capsulodesis and infraspinatus tenodesis into the Hill-Sachs defect, done with an anterior Bankart repair in the same procedure. It converts an engaging, intra-articular Hill-Sachs lesion into a non-engaging, extra-articular one, and so deals with the humeral side of bipolar bone loss arthroscopically, without open bone grafting.

Why it matters. Off-track, engaging Hill-Sachs lesions are a major cause of recurrent instability after isolated Bankart repair. Until the glenoid track concept arrived, surgeons struggled to decide when a Hill-Sachs lesion was clinically significant. Remplissage, one of the most significant advances in arthroscopic shoulder instability surgery of the past two decades, dramatically reduces recurrence in these shoulders.

How common the lesion is. A Hill-Sachs lesion is present in 40-90% of anterior shoulder dislocations. After a first-time dislocation it is visible on a plain AP in 40-70% and on CT in up to 90%; with recurrent instability the prevalence approaches 100%, and the lesions are larger and more engaging.

Bipolar bone loss. A Hill-Sachs lesion combined with a glenoid defect is present in up to 50% of revision cases.

How the lesion forms. When the shoulder dislocates anteriorly, the posterosuperior humeral head impacts the anterior glenoid rim and sustains a compression fracture, the Hill-Sachs lesion. The position of the arm at the moment of impact, typically abduction and external rotation, determines the orientation of the defect.

Engagement. A lesion is engaging when, in abduction and external rotation, the defect aligns with the anterior glenoid rim so that the rim falls within it. The rim then forms a bony barrier to concentric reduction and predisposes to recurrent dislocation. A small, non-engaging lesion is typically irrelevant; a large, engaging one drives recurrence despite labral repair. The glenoid track, described under Classification, quantifies this risk geometrically.

How remplissage works. The posterior capsule and infraspinatus are tenodesed into the defect and fill it, so the articular surface of the head bypasses the anterior rim instead of engaging it. The tethered infraspinatus also acts as a biological bumper, a posterior soft-tissue buttress resisting anterior translation. And the humeral head shifts medially: its effective radius in the remplissage zone decreases, which widens the functional glenoid track. The Bankart repair restores the anterior bumper; the remplissage prevents humeral engagement.

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The glenoid track. Itoi's on-track/off-track classification (2012) replaced the older percentage-based Hill-Sachs size classifications because it accounts for the interaction between humeral and glenoid bone loss rather than measuring the Hill-Sachs in isolation.

Two widths. The glenoid track is 0.84 multiplied by (glenoid width minus anterior rim bone loss). Normally it is 84 percent of glenoid width, approximately 23-25 mm for a 28-30 mm glenoid, and anterior glenoid bone loss narrows it. The Hill-Sachs interval is the Hill-Sachs width plus the bony bridge posterior to it.

On-track or off-track. When the glenoid track is greater than the Hill-Sachs interval the lesion is on-track and non-engaging. When the interval is greater than the track the lesion is off-track and engaging, and it is treated by remplissage with a Bankart repair, or by a Latarjet if the glenoid loss is large.

The older size grades. The percentage-based grading describes how much of the humeral head the defect occupies:

History. Establish the pattern of instability and what the patient needs the shoulder to do. Record the number of dislocations, their mechanism and direction, whether each was reduced by the patient or in hospital, and the arm position at the time, typically abduction and external rotation. Ask which positions apprehension makes the patient avoid, such as overhead throwing or reaching back.

Prior surgery and demands. A failed Bankart repair alone suggests significant bone loss. Note the sport and functional demands: overhead athletes, manual workers and contact athletes.

Examination. Test for instability and record a baseline.

• Apprehension test: anterior apprehension in abduction and external rotation
• Relocation test: a posterior force on the humeral head relieves the apprehension
• Sulcus sign: inferior laxity, associated with multidirectional instability
• Range of motion: document external and internal rotation before surgery, as the baseline for postoperative comparison
• Rotator cuff: infraspinatus strength, because remplissage affects this muscle

Radiographs. Plain films are the first line and the initial screen, but they underestimate bone loss by 20-50 percent compared with CT. Look for the Hill-Sachs lesion, the glenoid morphology, a bony Bankart fragment and, after a posterior dislocation, a reverse Hill-Sachs.

• True AP (Grashey) and Stryker notch: the Hill-Sachs lesion
• Axillary lateral: glenoid morphology; this view is essential
• Scapular lateral
• West Point axillary: anterior glenoid rim detail, good for anterior glenoid fractures and for assessing an acute bony Bankart

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CT with 3D reconstruction. CT is the gold standard for quantifying bone loss and the mandatory investigation for recurrent instability and before deciding on remplissage. The whole decision rests on the glenoid track, and the measurements of glenoid and humeral bone loss it needs are unreliable on plain radiographs alone. Scan both shoulders in thin (1 mm) slices with 3D surface reconstructions in en face and rotated views; comparing the two sides on the same scan accounts for individual variation in glenoid size.

Taking the measurements.

1. Glenoid bone loss. On the en face 3D reconstruction, fit a best-fit circle to the inferior glenoid and measure the width of the missing anterior rim; the defect can also be measured on sagittal CT. Bone loss (percent) is the defect width divided by the glenoid diameter, multiplied by 100. A normal inferior glenoid AP diameter is approximately 28-30 mm.
2. Hill-Sachs. Measure its width, depth and orientation, and from them the Hill-Sachs interval.
3. Glenoid track. Calculate it from the glenoid width and rim loss and compare it with the Hill-Sachs interval. An interval greater than the track is off-track, the threshold for remplissage.

MRI arthrogram. Complementary to CT. It shows the labral tear pattern, capsular laxity and the integrity of the rotator cuff, and earns its place when planning combined procedures or when SLAP, posterior labral or rotator cuff pathology is a concern. It is good for soft tissue and inferior for bone: MRI underestimates bone loss, so do not use it alone to decide on remplissage.

The decision. Two measurements drive the choice: whether the Hill-Sachs is on or off the glenoid track, and how much anterior glenoid is missing. An on-track lesion needs a Bankart repair alone. An off-track lesion with glenoid loss under 20-25 percent needs a Bankart repair plus remplissage. Above that threshold large glenoid bone loss dominates the instability, and it needs a bony procedure (Latarjet, Eden-Hybinette or distal tibial allograft), because remplissage alone cannot compensate for the glenoid deficiency.

The grey zone. Between 10 and 25 percent glenoid loss the thresholds shade into each other. At 10-20 percent remplissage is suitable but borderline: it may be sufficient, though Latarjet is more robust once the loss is over 15-20 percent. At 20-25 percent remplissage is only marginally suitable and may be insufficient, and Latarjet may be safer as the loss approaches 25 percent.

On-track lesions. When the glenoid track is greater than or equal to the Hill-Sachs interval, the lesion is non-engaging and an arthroscopic anterior Bankart repair with suture anchors is the whole operation. Restoring the anterior labral bumper prevents the head from translating far enough anteriorly for the Hill-Sachs to contact the glenoid rim, so no humeral-side procedure is needed.

Off-track lesions. When the track is less than the interval and glenoid bone loss is under 20-25 percent, add a posterior capsulodesis and infraspinatus tenodesis into the Hill-Sachs defect to the arthroscopic Bankart repair. Contraindications:

• Isolated remplissage without Bankart repair (insufficient stability)
• Glenoid bone loss greater than 25 percent (Latarjet preferred)
• Active infection
• Severe shoulder arthritis

Setup. Lateral decubitus is preferred for remplissage because it gives superior posterior access; beach chair is also described. Apply lateral traction with 10 degrees of abduction and 20 degrees of forward flexion. Four portals are used: posterior viewing, anterior working, anterosuperior (Wilmington) for the Bankart anchors, and a posterolateral accessory portal for remplissage anchor placement.

Diagnostic arthroscopy. Inspect the labral tear pattern (Bankart, ALPSA, Perthes), the capsular laxity and the size of the Hill-Sachs. Confirm off-track engagement dynamically, bringing the arm into abduction and external rotation to engage the Hill-Sachs against the anterior glenoid under vision, and estimate its dimensions with a probe to correlate with the CT.

The Bankart repair. Debride the labral edge to bleeding bone on the glenoid neck. Place 3-4 suture anchors along the anterior glenoid rim from inferior up to the 4-5 o'clock position, pass the sutures through the labrum with suture shuttles, and shift the labrum medially to restore the bumper effect. Add side-to-side capsular plication stitches if there is capsular laxity, then check that the repair restores anterior stability before moving to the posterior aspect.

The remplissage.

1. Prepare the defect. Switch to the posterior or posterolateral portal to view the Hill-Sachs. Remove fibrous tissue and sclerotic bone from its floor with a curette or shaver down to bleeding cancellous bone, across the whole surface that will receive the capsular tethers.
2. Insert the anchors. Place 2-3 double-loaded suture anchors (bioabsorbable or metallic, 4.5-5.5 mm) in the floor of the defect at the posteromedial humeral head, spaced along its long axis. They must be intra-defect only: do not penetrate the articular surface outside the Hill-Sachs.
3. Pass the sutures. Through the posterolateral portal, use a suture hook or penetrating grasper to retrieve the sutures and pass them through the posterior capsule (including the posterior labrum if present) in a mattress or simple configuration, then through the infraspinatus footprint. The infraspinatus is tenodesed, not detached and repaired: the tendon stays attached at its insertion and is pulled into the defect with the capsule.
4. Tie and check. Secure all knots, pulling capsule and infraspinatus into the defect. Viewed from the anterior portal, the defect should be filled with capsule and tendon, confirming extra-articularisation, and with the shoulder in abduction and external rotation the Hill-Sachs should no longer engage the anterior glenoid rim. Finally, make sure the Bankart repair is intact and the remplissage tissue well seated.

Rehabilitation. A sling is worn for 4-6 weeks, with a small abduction pillow optional, and motion is restored in stages.

• Weeks 0-3: passive forward flexion and internal rotation only; no external rotation beyond neutral, which protects both the Bankart and the remplissage
• Weeks 3-6: active assisted forward flexion and internal rotation; begin gentle passive external rotation to 30 degrees
• Weeks 6-12: progressive active range of motion; restore external rotation gradually, with no forced external rotation beyond a comfortable limit
• Weeks 12-24: strengthening, proprioceptive training and a gradual return to sport
• Contact sport: a minimum of 6-9 months, once full strength and functional stability are confirmed

After an isolated Bankart repair the sling is also worn for 4-6 weeks, with no passive external rotation beyond neutral for 3 weeks. Active assisted motion starts at week 3, avoiding external rotation beyond 30 degrees for 6 weeks; strengthening starts at 6-8 weeks, and return to contact sport is at 6-9 months.

What predicts a good result. The best prognosis belongs to an off-track Hill-Sachs with minimal glenoid bone loss (under 10 percent), a first or second dislocation, compliant rehabilitation and avoidance of contact sport during recovery. The prognosis is poorer with multiple recurrences, hyperlaxity, an early return to contact sport, inadequate remplissage coverage, and glenoid bone loss over 15-20 percent treated with remplissage alone. An external rotation loss over 20 degrees may be functionally limiting for overhead athletes.