What is the Remplissage Procedure?
The remplissage procedure (French for “to fill in”) is a surgical technique used to treat shoulder instability caused by a Hill-Sachs lesion. A Hill-Sachs lesion is a compression fracture or dent in the posterior-lateral aspect of the humeral head (the ball of the shoulder joint) that occurs when it repeatedly contacts the glenoid (socket) during anterior shoulder dislocations.
The procedure involves “filling in” the Hill-Sachs defect by suturing the infraspinatus tendon and the posterior joint capsule into the defect. This prevents the humeral head from engaging with the glenoid edge during shoulder movements, thereby reducing instability and dislocation risk.
Why is the Remplissage Procedure Performed?
The remplissage procedure is typically used in conjunction with an arthroscopic Bankart repair when there is:
- Engaging Hill-Sachs Lesion: When the humeral head defect is large enough to engage with the edge of the glenoid, causing instability.
- Recurrent Shoulder Instability: Particularly in active individuals or athletes involved in overhead or contact sports.
- Failed Previous Stabilization Surgery: If prior shoulder stabilization procedures were unsuccessful.
- Combined Bony and Soft-Tissue Damage: The remplissage addresses the humeral head defect, while a Bankart repair addresses the glenoid labrum.
How Does Remplissage Work?
The procedure converts the Hill-Sachs lesion into a “non-engaging” defect. By filling in the dent with soft tissue, the humeral head is less likely to lock into the edge of the glenoid during shoulder movement, reducing the chance of dislocation.
Procedure Overview
The remplissage procedure is performed arthroscopically and is often done alongside a Bankart repair.
- Preparation: The patient is placed under general anesthesia, and an arthroscope is inserted into the shoulder joint.
- Assessment: The surgeon evaluates the extent of the Hill-Sachs lesion and other injuries.
- Suture Placement: Sutures are passed through the infraspinatus tendon and the posterior capsule using anchors placed in the Hill-Sachs defect.
- Tissue Fixation: The sutures are tied, pulling the infraspinatus tendon and capsule into the lesion to “fill” the defect.
- Bankart Repair: If necessary, the surgeon also repairs the torn labrum to address anterior instability.
Benefits of the Remplissage Procedure
- Reduces Risk of Recurrent Dislocations: Particularly in patients with engaging Hill-Sachs lesions.
- Minimally Invasive: Performed arthroscopically with minimal tissue damage.
- Improves Shoulder Stability: By addressing both the humeral and glenoid components of instability.
- Enhances Long-Term Outcomes: Effective for athletes and active individuals.
Recovery and Rehabilitation
Post-Surgery Recovery:
- Immobilization: The shoulder is immobilized in a sling for 4-6 weeks to protect the repair.
- Pain Management: Includes medications and cold therapy.
Rehabilitation Phases:
- Phase 1 (0-6 weeks):
- Passive range-of-motion exercises.
- No active shoulder use to allow healing.
- Phase 2 (6-12 weeks):
- Gradual introduction of active range-of-motion exercises.
- Begin light strengthening exercises.
- Phase 3 (3-6 months):
- Progressive strengthening and functional training.
- Return to sports or overhead activities typically after 6 months.
Risks and Complications
While the remplissage procedure is generally safe, potential risks include:
- Stiffness: Due to additional soft tissue being fixed into the humeral head.
- Reduced Range of Motion: Some loss of external rotation may occur.
- Recurrent Instability: Rare but possible if the Hill-Sachs defect or labrum repair fails.
- Overtightening: Can result in joint stiffness or limited mobility.
Who is a Candidate for Remplissage?
The procedure is suitable for patients with:
- An engaging Hill-Sachs lesion.
- Combined bony defects of the humeral head and glenoid.
- Recurrent shoulder instability despite prior stabilization surgery.
- Active individuals or athletes requiring a stable shoulder for overhead or contact sports.
Outcomes and Success Rates
The remplissage procedure has a high success rate, with studies showing 85-95% stability restoration in patients with Hill-Sachs lesions. However, some trade-offs in shoulder mobility, particularly external rotation, are reported, especially in athletes involved in throwing sports.
Remplissage vs. Other Procedures
| Feature | Remplissage | Latarjet Procedure | Bankart Repair |
|---|---|---|---|
| Indication | Hill-Sachs lesion | Glenoid bone loss | Soft-tissue labral tears |
| Focus | Humeral head stabilization | Glenoid stabilization | Soft-tissue repair |
| Recovery Time | 4-6 months | 4-6 months | 4-6 months |
| Preferred in Athletes | Effective for most athletes | Better for contact sports | Suitable for most athletes |
Conclusion
The remplissage procedure is a highly effective surgical option for addressing shoulder instability associated with Hill-Sachs lesions. By combining it with a Bankart repair, surgeons can achieve comprehensive stabilization, restoring function and reducing the risk of recurrent dislocations.