Arthroscopic Remplissage for Moderate-Size Hill-Sachs Lesion

Abstract

Humeral bone loss has been shown to be a risk factor for failure after arthroscopic treatment of instability. We present the arthroscopic remplissage technique originally described by Koo and Burkhart et al. with a modification in the percutaneous anchor placement and suture tying that is reproducible and effective. We percutaneously place 2 suture anchors, which require no additional suture passing across the tissue, to create a double pulley technique, filling the defect with posterior capsule and rotator cuff. Therefore, the Hill-Sachs defect becomes extra-articular, eliminating the potential engagement of the anterior glenoid and contribution to recurrence of instability. This technique is applicable broadly for most Hill-Sachs lesions that need addressing. By not having to pass or shuttle any suture through tissue after anchor placement and by eliminating the necessity to go subacromially to retrieve or tie suture, the technique saves time and improves reproducibility. The compression of tissue into the Hill Sachs surface area also is improved by double-reinforced suturing through the double-pulley technique. The combination of these advantages creates a sound and efficient technique for remplissage.

Fig 1

Left shoulder visualization of Hill-Sachs posterior humeral defect through anterior superior portal. (HH, humeral head; HS, Hill-Sachs.)

Fig 2

First percutaneous anchor through capsule and infraspinatus into posterior-inferior aspect of humeral defect. (HS, Hill-Sachs; IS, infraspinatus.)

Fig 3

Second percutaneous anchor placed through same incision in skin and deltoid, but piercing cuff tendon 15-20 mm anterior-superior to first anchor. (HS, Hill-Sachs; IS, infraspinatus.)

Fig 4

The 4 suture strands exit the percutaneous portal. One strand from each suture anchor is tied together over a switching stick, and the 2 remaining free ends (one from each anchor) are pulled, thereby using the anchor eyelets as pulleys and sliding the knot down onto the bursal side of the infraspinatus for the double pulley technique.

Fig 5

Complete fill of posterior humeral defect with rotator cuff tendon through double pulley remplissage technique. (HH, humeral head.)

Fig 6

Anterior inferior Bankart repair completed before the final tying of remplissage sutures to maximize visualization during Bankart repair and prevent stress on remplissage. (G, glenoid; HH, humeral head.)