Introduction: Anterior shoulder instability often occurs in combination with a Hill-Sachs defect on the humeral head that may contribute to recurrent instability if not managed at the time of surgery. This video describes a method for performing arthroscopic remplissage for the management of an engaging Hill-Sachs lesion in patients with glenohumeral instability. The technique is efficient; can be performed with minimal technical difficulty; and can be used to augment other stabilization procedures, such as labral repair. Indications include an engaging Hill-Sachs defect in patients with little or no glenoid bone loss. In appropriately selected patients, arthroscopic remplissage is associated with decreased rates of recurrent instability.

Background: Patients with a bone defect of the humeral head, such as a Hill-Sachs lesion, after anterior dislocation of the glenohumeral joint have an increased risk for recurrent instability and failed soft-tissue stabilization surgery. Various procedures have been described for the augmentation of anterior labral repair in patients with a Hill-Sachs lesion that engages the glenoid, including open capsular shift, coracoid transfer to the anterior glenoid, humeral head plasty, osteochondral allograft transplantation, and remplissage. Remplissage involves advancement of the posterior capsule with or without the infraspinatus into the humeral head defect. Multiple studies have reported relatively low recurrence rates (<5%) in patients treated via labral repair and remplissage for the management of anterior instability and an engaging Hill-Sachs lesion. This video details an arthroscopic technique for capsular remplissage that is performed in combination with anterior labral repair in patients with a Bankart labral injury and an engaging Hill-Sachs lesion. This technique involves the use of the capsule alone to fill the defect so the infraspinatus is not unnecessarily tensioned. The infraspinatus can be incorporated into this repair if the treating surgeon feels it is indicated. If precise surgical steps are followed, this procedure can be performed in a quick and efficient manner. We hope this video provides surgeons with a treatment option that, in properly selected patients, decreases the likelihood of recurrent glenohumeral instability.

Technique: All patients are examined preoperatively in the clinical setting and under anesthesia. The uninjured shoulder also is examined for comparative purposes. For surgery, patients are placed in the beach-chair position (our preference) or the lateral decubitus position. Complete diagnostic arthroscopy is performed, and the anterior labrum and glenoid are inspected. Viewing from a standard posterior portal, the humeral head is evaluated for bony defects. If an osseous defect is identified, then the shoulder is taken through full functional range of motion to determine if the defect engages the anterior glenoid. This typically occurs in abduction and external rotation. After this is confirmed, the decision is made to perform capsular remplissage. Before remplissage, a standard anterior portal is created, and the anterior labrum is prepared (débrided, elevated off the glenoid, etc.) as necessary but is not yet fixed. Surgeons should perform remplissage before anterior labral repair so the humeral head is better positioned for remplissage. Viewing from the posterior portal, the humeral head is subluxed anteriorly and internally rotated to bring the Hill-Sachs lesion into optimal view. Via needle localization, a posterolateral accessory portal is created to attain perpendicular access to the lesion. This portal typically is created just distal to the inferolateral edge of the posterior acromion. After this posterolateral portal is created, a switching stick is placed in the posterior portal, and the camera is inserted into the anterolateral portal. Although the posterior portal is not used during remplissage, the switching stick is left in place to maintain patency. This is helpful because the posterior portal may be difficult to access after the capsule is pulled into the defect. Viewing from the anterolateral portal, the humeral head is subluxed anteriorly to allow for ample posterior working space. The anterior soft tissues should not yet be repaired; doing so would decrease the working space. A 7-mm screw-in cannula is then inserted into the posterolateral portal centered over the lesion. This typically is placed anterior to the infraspinatus (between the muscular portion of the infraspinatus and the posterior capsule). The cannula is initially introduced into the capsule during defect preparation. The lesion is then prepared with the use of shavers and a curet back to a gently bleeding bony surface. Defect preparation should focus on débridement of soft tissue, and minimal bone should be removed. After the bed is prepared, a small punch is used to identify the site for anchor placement in the center of the lesion. Fixation typically involves the use of a single 4.5-mm double-loaded suture anchor. If unusually soft bone or exceedingly large defects are encountered, then use of an additional anchor may be considered. The bone of the posterior humeral head typically is hard and requires tapping before anchor placement. The anchor is placed perpendicular to the lesion. The cannula is retracted from the capsule, but the lumen remains deep to the deltoid and the rotator cuff. A sharp tissue penetrator is used to pass sutures. The bird peak is passed through the capsule and over the posterior superior aspect of the lesion approximately 1 cm from the portal, and the first suture is pulled through the capsule and out of the cannula. The second suture is then passed through the capsule and over the anterior superior aspect of the defect in a similar fashion. An assistant maintains tension on these sutures to prevent entanglement. The other two suture strands are then passed through the capsule at the posteroinferior and anteroinferior margins of the lesion in the same manner. The inferior sutures are then tied down as an assistant maintains tension on the superior sutures. From the anterior portal, reduction of the capsule to the defect bed is confirmed as the sutures are tied. The superior sutures are then tied down. The knots typically are tied in a blind fashion. After remplissage is complete, attention is turned back to the anterior labrum, which is repaired as necessary. The patient's arm is placed in a 30° external rotation sling for 4 weeks postoperatively followed by a standard sling for 2 additional weeks. During postoperative weeks zero through four, rehabilitation focuses on elbow, wrist, and hand range of motion and scapular isometrics; shoulder motion is discouraged. From postoperative weeks four through six, rehabilitation focuses on shoulder forward elevation in the scapular plane to 90° and gentle deltoid isometrics. After 6 weeks postoperatively, strengthening and range of motion exercises are gradually increased, with the goal of full range of motion obtained by 12 weeks postoperatively. A gradual return to sports activity and other activities is pursued after 12 to 14 weeks postoperatively.

Discussion: The current indication for remplissage in patients with anterior glenohumeral instability is a Hill-Sachs lesion that engages the anterior rim of the glenoid. Minimal glenoid bone loss (ideally <10%) should be present. The presence of a Hill-Sachs can be observed on preoperative imaging studies (axillary radiograph or advanced imaging studies), and engagement can be assessed via physical examination and intraoperative observation. If a patient's humeral head locks out during the anterior load and shift test (anterior translational force applied to the humeral head with the arm abducted in the scapular plane), then an engaging lesion should be suspected.