Remplissage Procedure

• Present in 40-90 percent of anterior shoulder dislocations
• First-time dislocation: Hill-Sachs visible on plain AP in 40-70 percent, on CT in up to 90 percent
• Recurrent instability: larger and more engaging lesions, approaching 100 percent prevalence
• Bipolar bone loss (combined Hill-Sachs and glenoid defect) present in up to 50 percent of revision cases

• Small non-engaging Hill-Sachs: typically irrelevant, Bankart repair alone sufficient
• Large engaging Hill-Sachs: drives recurrence risk despite labral repair
• Critical-size lesions: the defect engages the anterior glenoid rim in abduction/external rotation, creating a bony block to reduction
• Remplissage: addresses the humeral side of bipolar bone loss arthroscopically

Normal glenoid track: 84 percent of glenoid width (approximately 23-25 mm for a 28-30 mm glenoid)

Anterior glenoid bone loss narrows the track: Each millimetre of anterior rim loss reduces the glenoid track by the same amount

Hill-Sachs interval: measured as Hill-Sachs width plus the bony bridge posterior to it

Off-track: Hill-Sachs interval greater than glenoid track width

Extra-articularisation: Capsule and infraspinatus fill the defect, so the articular surface bypasses the anterior rim

Humeral head shifts medially: The effective radius of the humeral head in the remplissage zone decreases, widening the functional glenoid track

Infraspinatus tenodesis effect: The tethered infraspinatus creates a posterior soft tissue buttress resisting anterior translation

Combined with Bankart: Bankart restores the anterior bumper; remplissage prevents humeral engagement

• Dislocation events: Number, mechanism, direction, reduction method (self vs hospital)
• Instability pattern: position of arm at dislocation (typically abduction + external rotation)
• Apprehension: Does the patient avoid specific arm positions (e.g. overhead throwing, reaching back)
• Prior surgery: Bankart repair alone that failed suggests significant bone loss
• Sport and functional demands: Overhead athletes, manual workers, contact athletes

• Apprehension test: Anterior apprehension in abduction/external rotation
• Relocation test: Posterior force on humeral head relieves apprehension
• Sulcus sign: Inferior laxity (associated with multidirectional instability)
• Range of motion: Document external rotation and internal rotation preoperatively (baseline for postoperative comparison)
• Rotator cuff: Infraspinatus strength (remplissage affects this muscle)

• Anterior shoulder instability affects 1-2 percent of the general population
• Hill-Sachs lesions are present in 40-90 percent of first-time dislocations (higher with imaging sensitivity)
• Engaging Hill-Sachs requiring remplissage is estimated in 10-20 percent of operative instability cases
• Bipolar bone loss (combined Hill-Sachs and glenoid defect) is a significant predictor of recurrence after isolated Bankart repair

• High-resource centres: Routine 3D CT for bone loss quantification; arthroscopic remplissage as standard for off-track lesions with small glenoid loss
• Limited-resource settings: CT may not be available; clinical judgement and plain radiographs used; decision to use remplissage may be intraoperative based on arthroscopic engagement testing
• Global trend: Arthroscopic remplissage has largely replaced open humeral plasty or partial humeral head resurfacing for engaging Hill-Sachs

No head-to-head randomised trial exists. Latarjet provides a bony block and may have lower recurrence in the setting of significant glenoid loss, but carries higher complication rates (nerve injury, graft problems, subscapularis dysfunction). Remplissage is arthroscopic, lower morbidity, but trades stiffness for stability. Surgeon preference and patient demands often dictate the choice.

Theoretical concern exists that the tenodesed infraspinatus rubbing against the posterior glenoid may accelerate degenerative change. Mid-term series (up to 10 years) have not shown significant arthritis progression, but truly long-term data (over 15-20 years) are not yet available.

Remplissage is almost always combined with Bankart repair. Performing isolated remplissage without restoring the anterior labral bumper is generally considered insufficient for anterior instability. However, rare case reports describe isolated remplissage in revision settings where the anterior labrum is scarred but competent. This is not standard practice.

The external rotation loss (8-14 degrees mean) is functionally significant for throwers and overhead sport athletes. Some authors recommend avoiding remplissage in competitive overhead athletes and favouring Latarjet or humeral osteoplasty instead. Other authors report acceptable return to overhead sport after remplissage with targeted rehabilitation. This remains a clinical judgement call.