Remplissage Procedure: Understanding Shoulder Instability, Surgical Technique, and Recovery

What is a Remplissage Procedure?

The remplissage procedure is a surgical technique primarily used to treat recurrent anterior shoulder instability, specifically addressing a significant bony defect on the humeral head known as a Hill-Sachs lesion, by filling the lesion with soft tissue to prevent re-dislocation.

Understanding Shoulder Instability

The shoulder joint, a ball-and-socket articulation, is the most mobile joint in the human body. This extensive range of motion, however, comes at the cost of inherent stability. The "ball" (humeral head) sits in a shallow "socket" (glenoid fossa), stabilized by a complex interplay of the joint capsule, ligaments, and surrounding musculature (rotator cuff).

Shoulder instability occurs when these stabilizing structures are compromised, allowing the humeral head to abnormally translate within the glenoid, leading to subluxation (partial dislocation) or full dislocation. Recurrent instability, often following an initial traumatic dislocation, can significantly impact an individual's quality of life and athletic performance.

A common consequence of an anterior shoulder dislocation is the formation of specific bony or soft tissue lesions:

• Bankart Lesion: A tear of the anterior-inferior labrum (the fibrous rim of the glenoid) and often the associated capsule and ligaments.
• Hill-Sachs Lesion: A compression fracture or indentation on the postero-superior aspect of the humeral head. This occurs when the humeral head impacts the anterior rim of the glenoid during an anterior dislocation.

When a Hill-Sachs lesion is significant and "engaging," it can catch on the anterior glenoid rim during specific movements (like abduction and external rotation), acting as a "fulcrum" that levers the humeral head out of the socket, leading to recurrent dislocations.

What is the Remplissage Procedure?

"Remplissage" is a French term meaning "to fill." In orthopedic surgery, the remplissage procedure is an arthroscopic technique designed to address an engaging Hill-Sachs lesion. The core concept is to surgically fill the bony defect on the humeral head with soft tissue, effectively eliminating its ability to engage with the glenoid rim during shoulder movement.

This procedure typically involves:

• Anchoring the posterior capsule and the infraspinatus tendon (one of the rotator cuff muscles) directly into the Hill-Sachs lesion.
• Creating a tenodesis, where the tendon and capsule are secured within the bony defect, thereby "filling" it.

By filling the lesion, the procedure prevents the humeral head from locking out or catching on the glenoid, significantly reducing the risk of future dislocations. It is important to note that remplissage is almost always performed in conjunction with an anterior stabilization procedure, such as a Bankart repair, to address the primary anterior capsulolabral pathology.

When is Remplissage Indicated?

The remplissage procedure is primarily indicated for patients experiencing recurrent anterior shoulder instability who also have a significant and engaging Hill-Sachs lesion. Specific criteria for considering remplissage include:

• Recurrent Anterior Dislocation or Subluxation: Patients who have experienced multiple episodes of the shoulder coming out of joint.
• Engaging Hill-Sachs Lesion: This is the critical factor. The lesion must be large enough or positioned in such a way that it consistently engages with the anterior glenoid rim during provocative movements (e.g., abduction and external rotation), contributing to instability. Imaging studies (MRI, CT scans) are crucial for assessing the size and location of the lesion.
• Concomitant Anterior Labral Pathology: Remplissage is often combined with a Bankart repair or other anterior capsulolabral reconstruction to address the primary soft tissue damage on the glenoid side.
• Absence of Significant Glenoid Bone Loss: If there is substantial bone loss from the glenoid rim, other procedures like the Latarjet procedure might be more appropriate, as remplissage primarily addresses the humeral head defect.
• Patient Activity Level: While effective, the procedure can sometimes lead to a slight loss of external rotation. This is a consideration for high-level overhead athletes, though for many, the benefit of stability outweighs this potential limitation.

The Surgical Procedure

The remplissage procedure is typically performed arthroscopically (minimally invasive) under general anesthesia.

1. Patient Positioning: The patient is usually positioned in a beach chair or lateral decubitus position.
2. Diagnostic Arthroscopy: The surgeon first performs a thorough arthroscopic examination of the entire shoulder joint to confirm the diagnosis, assess the extent of the Hill-Sachs lesion, and identify any other associated injuries (e.g., Bankart lesion, rotator cuff tears).
3. Lesion Preparation: The Hill-Sachs lesion on the posterior aspect of the humeral head is identified. The cartilage within the lesion is debrided (cleaned) to expose healthy bone, promoting healing and integration of the soft tissue.
4. Anchor Placement: One or more suture anchors (small, biocompatible devices with sutures attached) are carefully inserted into the prepared bony bed of the Hill-Sachs lesion.
5. Suture Passage: The sutures from these anchors are then passed through the posterior joint capsule and the infraspinatus tendon.
6. "Filling" the Lesion: The sutures are tied, pulling the posterior capsule and infraspinatus tendon into the Hill-Sachs defect. This effectively fills the bony void, creating a tenodesis and preventing the lesion from engaging with the glenoid rim.
7. Concomitant Procedures: As mentioned, an anterior stabilization procedure (e.g., Bankart repair) is often performed at the same time to repair the damaged labrum and capsule on the anterior aspect of the glenoid.
8. Closure: The arthroscopic portals are closed, and a sterile dressing is applied.

Benefits and Risks

Like any surgical intervention, the remplissage procedure carries both potential benefits and risks.

Benefits:

• Increased Shoulder Stability: Significantly reduces the risk of recurrent anterior shoulder dislocations, particularly in cases with an engaging Hill-Sachs lesion.
• Addresses a Key Instability Factor: Directly neutralizes the "engaging" mechanism of the Hill-Sachs lesion.
• Minimally Invasive: Performed arthroscopically, resulting in smaller incisions, less pain, and generally quicker initial recovery compared to open surgery.
• Good Success Rates: When appropriately indicated and performed, studies show high rates of preventing re-dislocation.

Risks:

• Loss of External Rotation: This is the most common and significant potential complication. By tightening the posterior capsule and infraspinatus tendon into the lesion, a slight to moderate restriction in external rotation range of motion can occur. This is a crucial consideration for athletes involved in overhead throwing sports.
• Stiffness: General shoulder stiffness can occur, as with any shoulder surgery.
• Surgical Complications: Standard risks associated with any surgery, including infection, nerve or blood vessel damage, bleeding, and adverse reaction to anesthesia.
• Persistent Instability or Pain: While rare, some patients may still experience residual instability or pain.
• Hardware-Related Issues: Though uncommon, issues with suture anchors can occur.

Recovery and Rehabilitation

Post-operative recovery and rehabilitation are critical for the success of the remplissage procedure and typically follow a structured, phased approach under the guidance of a surgeon and physical therapist.

1. Immobilization (Weeks 0-4/6):

   • The arm is typically immobilized in a sling to protect the surgical repair.
   • Emphasis on pain management and protecting the surgical site.
   • Passive range of motion (PROM) may be initiated, often with strict limitations on external rotation to prevent undue stress on the repair.
   • Elbow, wrist, and hand exercises are encouraged to maintain circulation and prevent stiffness.

2. Early Motion and Gentle Strengthening (Weeks 6-12):

   • Gradual discontinuation of the sling, as advised by the surgeon.
   • Active-assisted range of motion (AAROM) and then active range of motion (AROM) exercises are introduced, still carefully monitoring external rotation.
   • Gentle isometric exercises for the rotator cuff and scapular stabilizers may begin.
   • Focus on restoring normal movement patterns without stressing the repair.

3. Progressive Strengthening and Functional Training (Weeks 12-24):

   • Progressive resistance exercises are introduced for all shoulder muscles, including the rotator cuff, deltoid, and scapular stabilizers.
   • Focus shifts to regaining strength, endurance, and proprioception.
   • Introduction of functional movements relevant to daily activities.

4. Return to Activity/Sport (Months 6-12+):

   • Sport-specific drills and advanced strengthening are incorporated.
   • Gradual return to high-impact or overhead activities, contingent on achieving specific strength, range of motion, and stability benchmarks.
   • Full recovery and return to competitive sports can take 6 to 12 months or longer.

Adherence to the rehabilitation protocol is paramount to optimize outcomes, minimize stiffness, and maximize shoulder function and stability.

Conclusion

The remplissage procedure is an important and effective surgical option for individuals suffering from recurrent anterior shoulder instability with an engaging Hill-Sachs lesion. By arthroscopically "filling" this bony defect, the procedure significantly reduces the risk of re-dislocation. While it carries potential risks, notably a possible limitation in external rotation, its benefits in restoring shoulder stability are substantial for appropriately selected patients. A thorough evaluation by an orthopedic surgeon specializing in shoulder conditions is essential to determine if the remplissage procedure, often in conjunction with other stabilization techniques, is the most suitable treatment approach.