Outcomes of arthroscopic "Remplissage": capsulotenodesis of the engaging large Hill-Sachs lesion
© Haviv et al; licensee BioMed Central Ltd. 2011
Received: 20 November 2010
Accepted: 15 June 2011
Published: 15 June 2011
A Hill-Sachs lesion of the humeral head after a shoulder dislocation is clinically insignificant in most cases. However, a sizable defect will engage with the anterior rim of the glenoid and cause instability even after anterior glenoid reconstruction. The purpose of this study was to evaluate the outcome of arthroscopic capsulotenodesis of the posterior capsule and infraspinatus tendon ("remplissage") to seal a large engaging Hill-Sachs lesion in an unstable shoulder.
This was a prospective follow-up study of patients who underwent arthroscopic surgery for recurrent shoulder instability with a large engaging Hill-Sachs lesion from 2007 to 2009. The clinical results were measured preoperatively and postoperatively with the Simple Shoulder test (SST) and the Rowe score for instability.
Eleven patients met the inclusion criteria of this study. The mean follow-up time was 30 months (range 24 to 35 months). At the last follow-up, significant improvement was observed in both scores with no recurrent dislocations. The mean SST improved from 6.6 to 11 (p < 0.001). The mean Rowe Score improved from 10.6 to 85 points (p < 0.001). On average patients regained more than 80% of shoulder external rotation.
Arthroscopic remplissage for shoulder instability is an effective soft tissue technique to seal a large engaging Hill-Sachs lesion with respect to recurrence rate, range of motion and shoulder function.
Posterior-lateral compression fracture of the humeral head (a Hill-Sachs lesion) is a common finding associated with anterior shoulder instability [1–3]. Most Hill-Sachs lesions are clinically insignificant and do not require surgical treatment. However, Palmer and Widen  realized that a sizable defect will engage with the anterior rim of the glenoid and cause instability even after anterior glenoid reconstruction. The term engaging Hill-Sachs lesion was used by Burkhart and De Beer  to describe the leverage of the humeral head from the glenoid rim in the presence of a large bony defect. They concluded that arthroscopic stabilization in the presence of such bony deficiencies is likely to fail and requires open surgery. Thus, despite an adequate Bankart repair, consideration must be given toward treating the associated posterolateral defect within the humeral head if it is of sufficient size. Several different reconstructive solutions have been proposed for dealing with large Hill-Sachs lesions. These solutions vary from soft tissue transfers  to bony reconstructions such as humeral osteotomy , structural osteochondral allografts  and transhumeral impaction grafting . Others advocate hemi arthroplasty  as a definitive treatment. Recently, Purchase et al  presented a technique of capsulotenodesis of the posterior capsule and infraspinatus tendon to fill the Hill-Sachs lesion tendon (also known as the French term "remplissage"). The purpose of our study was to evaluate the outcome of arthroscopic remplissage in an unstable shoulder with a large engaging Hill-Sachs lesion. Our hypothesis was that arthroscopic remplissage is an effective adjunct to shoulder stabilization in the presence of engaging Hill-Sachs lesions in terms of function and patient satisfaction.
Materials and methods
Overall, 65 all arthroscopic shoulder stabilizations were performed in our institution from 2007 to 2009. Up to date, 25 patients were identified in whom arthroscopic shoulder stabilization included a capsulotenodesis to fill the humeral head lesion in addition to capsulolabral repair around the glenoid rim. This procedure was done in patients without a significant glenoid bone loss. This study included patients with a minimum follow-up of 2 years (11 of the 25 patients). The diagnosis of recurrent, anterior shoulder instability was made on the basis of a history of recurrent anteroinferior dislocation or subluxation with physical signs of anteroinferior instability. All patients underwent preoperative radiographic and MRI evaluations. The decision to address the lesion was made during arthroscopy if the posterolateral humeral defect engaged the anterior rim of the glenoid in abduction and external rotation of less than 90°, as described Koo et al . Data was retrieved from the surgical reports and follow-up files.
All patients provided formal informed consent for participation in this study.
Mean Age (range)
Mean Follow-Up Time in Months (range)
Pattern of Instability (Unidirectional, MDI)
Sports Participation (Professional, Recreational)
Post operatively the shoulder was protected in a sling for 4 weeks while performing movements of elbow, wrist and fingers. At week 3 the patient started isometric exercises and at week 4 shoulder external rotation motion. After week 4 the patient was encouraged to perform elevation above 90° and was reviewed by the surgeon and physiotherapist at 6 weeks after the surgery. During weeks 6 to 12 the patient gradually increased elevation and rotation strengthening exercises. Return to sport was allowed after 6 months when at least 90% of shoulder strength and range of motion had been regained.
Results were expressed with descriptive methods (mean, range). The paired Student's t test was used for comparison between scores before and after surgery. P value of less than 0.05 was considered statistically significant.
Common surgical findings
Full ROM, AI translation +3
Anterior tear, 5 patients had minimal glenoid bone loss (<25% of glenoid width)
Number of Anchors in Anterior Glenoid Rim
3 to 4
Simple Shoulder Test (SST) and Rowe results
Total, mean (range)
Our findings suggest that performing the remplissage technique in conjunction with Bankart repair on unstable shoulders with large engaging Hill-Sachs lesion provides good short term functional results with no recurrent dislocations.
The presence of a large Hill-Sachs lesion can engage with the anterior glenoid rim with the arm in abduction and external rotation levering the humeral head anteriorly. This mechanism has been regarded as a significant cause of recurrent shoulder dislocations and of arthroscopic reconstruction failure . The treatment of osseous defects as part of shoulder stabilization surgery was recently reviewed by Bushnell et al  and Lynch et al . Specifically, humeral head defects can be addressed in several ways. The defect can be redirected using the Weber rotational osteotomy  to increase the retroversion of the proximal humerus. However, although the published results were good  most patients had an internal rotation deficit and there is a considerable risk of malunion or nonunion. Other options are to seal the defect with structural allograft  or transhumeral impaction bone grafting . The former requires an extensive open approach with risks of graft or hardware failure while the later is less invasive and more anatomical but might not be suitable for large defects or osteopenic patients. Recently, Chapovsky and Kelly described an all-arthroscopic technique to fill the defect with an osteoarticular allograft . A Prosthetic resurfacing arthroplasty has also been used to treat focal deficits of the humeral head [19, 20] but since shoulder instability is mostly encountered in the younger population with a higher likelihood of prosthetic failure it is a less favorable solution. From 2007 the senior author has started to use the remplissage technique for instability cases involving a large posterior engaging Hill-Sachs lesion. The decision to perform a remplissage was made during arthroscopy. The all arthroscopic technique was previously described by Wolf and colleagues for treatment of combined glenoid loss and a Hill-Sachs lesion  and also by Krackhardt et al  for a reverse Hill-Sachs lesion. The principle is a fixation of the conjoined infraspinatus tendon and posterior capsule to the abraded surface of the humeral head defect. At the 26th Annual Meeting of the Arthroscopy Association of North America, Wolf et al reported on an unpublished study of 24 patients with a minimum of 2-year follow-up. Twenty two were very satisfied; of these, 15 reported excellent results and 7 had good results. Two patients were rated with poor results. The eight patients in whom prior surgery had failed were without recurrence at follow-up. There were two recurrent dislocations, one due to a motorcycle accident and the other resulting from a wrestling match. They concluded that "Filling the lesion effectively obliterates the Hill-Sachs lesion and converts it into an extra-articular lesion, thereby preventing engagement. There were no significant complications, and the concern that the remplissage would limit rotation did not materialize". The patients in our study were mostly a community-based young population but also included two professional athletes (Australian Football players). In our current study the results showed a significant improvement at the last follow-up (mean 30 months) with no recurrent dislocations. We used the Simple Shoulder Test which was previously found reliable, valid and responsive  to document functional improvement. Overall, the average number of positive responses on the 12-question Simple Shoulder Test were 6.6 before the operation and 11 at the last follow-up (p < 0.001). We used the Rowe score  to assess postoperative stability. The Rowe score for instability improved from 10.6 preoperatively to 85 at the last follow-up (p < 0.001) and was considered good to excellent in 78% of the patients postoperatively.
We share the opinion of Koo et al.  on this procedure's advantages. It is a minimally invasive approach to convert an intra-articular lesion into an extra-articular lesion, without the morbidity associated with open procedures and no additional graft material, thereby making the procedure quick and easy to perform.
Even though there is a concern that the tenodesed cuff and capsular tissue can act as a mechanical block to external rotation of the shoulder  it was found to be minor in our patients and did not interfere with daily activities.
The strength of this study is in its uniform surgical indication, operative technique, postoperative care and follow-up methodology. Nevertheless it has several limitations. First, all procedures were performed by the same surgeon which might not reflect other people's results. Another drawback is the small number of patients (most participate in recreational sports only) and the relative short follow-up time. This is because the technique was introduced only recently and significant Hill-Sachs lesions are relatively rare. Thus in order to support our results there is a need for long term controlled studies preferably with a larger cohort of patients.
Arthroscopic remplissage for shoulder instability offers an effective soft tissue technique to seal a large engaging Hill-Sachs lesion with respect to recurrence rate, range of motion and shoulder function.
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