22.1 Introduction

The contribution of osseous lesions to recurrent anterior glenohumeral instability has been well described by Burkhart and De Beer. ¹ Focusing on the humeral head, the “glenoid track” concept, proposed by Yamamoto et al, improved our understanding of potentially significant Hill–Sachs defects that may contribute to further episodes of instability. ² Continual study of critical defect sizes with retrospective clinical studies and biomechanical cadaveric studies has altered treatment guidelines in recent years. ³ With an increasingly large, “off-track” Hill–Sachs defect and limited glenoid bone loss, isolated arthroscopic Bankart repair is often insufficient in stabilizing the shoulder. Consequently, augmentative procedures, such as Remplissage, are required to stabilize the joint and reduce failure rates of isolated soft-tissue stabilizations. This chapter will review the technical pearls associated with performing a Remplissage procedure for an engaging Hill–Sachs defect, in conjunction with a Bankart repair.

22.2 Goals of Procedure

As initially described by Purchase et al, the technical goal of the procedure is to prevent further engagement between the Hill–Sachs defect and the anterior glenoid rim, preventing recurrent instability episodes. ⁴ This is accomplished by performing a posterior capsulodesis and infraspinatus tenodesis into the Hill–Sachs defect to “fill” the defect ( Fig. 22.1a, b). As a result, the defect is converted from an intra-articular defect to an extra-articular one, which then limits engagement.

22.3 Advantages

An advantage of this procedure is that it can be performed arthroscopically. The technical ease and limited associated surgical morbidity allows the procedure to be easily performed in conjunction with an arthroscopic Bankart repair. Additionally, while it represents a “nonanatomic” stabilization technique, it is significantly less invasive and expensive when compared to osteochondral allograft reconstruction, Latarjet coracoid transfer, or partial humeral head resurfacing.

22.4 Indications

Currently, indications for performing a remplissage procedure continue to evolve. However, absolute indications include anterior glenohumeral instability with an engaging Hill–Sachs defect. Historically, a defect size of 15 to 30% of the humeral head width was also considered an indication. However, recent work by Di Giacomo et al ⁵ has resulted in a new terminology that may more appropriately quantify defect width, or the so-called Hill–Sachs interval width, in relation to the glenoid width.

22.5 Contraindications

Remplissage has few absolute contraindications, although it should not be performed in those with isolated glenoid bone loss or habitual dislocators.

A relative contraindication is the presence of significant bipolar bony lesions, specifically where the glenoid defect is greater than 20 to 25% of the glenoid width. In this scenario, a combined Bankart repair and remplissage is often insufficient in preventing subsequent dislocations. Rather, the glenoid defect must be addressed with either a coracoid process transfer or structural bone grafting.

Similarly, a Hill–Sachs defect size of greater than 30% of the humeral head width is also considered a relative contraindication. In this scenario, the defect is best managed with allograft reconstruction, rotational osteotomies, partial resurfacing arthroplasty, or hemiarthroplasty.