Arthroscopic remplissage for management of engaging and deep hill-sachs lesions

Arthroscopic Hill-Sachs remplissage (AHSR) is indicated for patients who are at high risk for recurrence or failure after isolated arthroscopic anterior soft tissue repair, and in whom large humeral head defects are contributing significantly to the instability complex.

Indications: Anterior shoulder instability with associated large Hill-Sachs defects as visualized on preoperative plain radiographs, computed tomography (CT) scanning, or magnetic resonance imaging (MRI), or identified as engaging the glenoid surface during diagnostic arthroscopy at the time of instability surgery.

Contraindications: Isolated glenoid bone loss without a Hill-Sachs defect, unaddressed glenoid bone loss greater than 10%, or forms of shoulder instability other than isolated traumatic anterior instability.

Surgical technique: AHSR is not indicated as an isolated procedure and is typically performed in combination with an anterior capsulolabral repair or bone-block augmentation of the anterior glenoid as indicated.

Adequate preoperative workup is important to fully assess the size and location of osseous deficiency on both the humeral and glenoid sides of the shoulder joint. Hill-Sachs lesions can be classified as “on-track” versus “off-track” to aid in the understanding of whether the humeral defect will engage on the glenoid rim during shoulder motion.

An accessory posterolateral portal is established through which the base of the lesion is debrided and suture anchors are inserted.

The anterior repair must be prepared before proceeding to the posterior procedure, as the working space within the joint is significantly reduced after remplissage.

Once the humeral sutures have been placed, it is not necessary to reposition the arthroscope in the posterior subdeltoid space before knot tying. More important is the ability to visualize the quality of reduction of the posterior capsulotenodesis into the defect from within the joint as the sutures are being tied.

After preparation of the anterior capsulolabral tissues, the humeral head is translated anteriorly and perched on the glenoid rim. The Hill-Sachs defect is prepared and anchors are inserted into its base via an 8-mm cannula placed through the posterolateral accessory portal. Extreme care should be taken to ensure an optimal trajectory of suture anchor insertion. If a poor line is taken, there is a risk of anchor penetration of the anterior humeral head cartilaginous surface.

Neither of the two suture limbs exiting via the posterolateral portal should be used as the posts during arthroscopic knot tying, as the resultant knot will end up within the joint and the quality of remplissage will be reduced.

Video 14.1: Arthroscopic Bankart repair and Hill-Sachs remplissage