Technical Note

Hill-Sachs “Remplissage”: An Arthroscopic Solution for the

Engaging Hill-Sachs Lesion

Robert J. Purchase, M.D., Eugene M. Wolf, M.D., E. Rhett Hobgood, M.D.,

Michael E. Pollock, M.D., and Chad C. Smalley, M.D.

Abstract: We present an arthroscopic technique used to treat traumatic shoulder instability in

patients with glenoid bone loss and a large Hill-Sachs lesion. The procedure consists of an
arthroscopic capsulotenodesis of the posterior capsule and infraspinatus tendon to fill the
Hill-Sachs lesion. With the patient in the lateral decubitus position, a posterior portal is
established at the lateral aspect of the convexity of the humeral head that is centered over the
lesion. After anterior-inferior and anterior-superior portals have been established, the camera is
placed in the anterior-superior portal. The Hill-Sachs lesion is freshened with a bur through the
posterior portal. A cannula is inserted in the posterior portal through the deltoid but not through
the infraspinatus or capsule, and an anchor is placed in the inferior aspect of the humeral lesion.
A penetrating grasper is passed through the tendon and posterior capsule, 1 cm inferior to the
initial portal entry site to pull 1 suture limb. A second anchor is placed superiorly, and 1 suture
limb is similarly passed. The inferior suture is tied first with the knots remaining extra-articular,
pulling the infraspinatus and capsule into the lesion. After completion, the Bankart lesion can
then be repaired. Key Words: Traumatic shoulder instability—Glenoid bone loss—Hill-Sachs
lesion—Posterior capsulodesis and infraspinatus tenodesis.

B roca and Hartmann recognized the problem of

engagement of the Hill-Sachs lesion on a defi-
cient glenoid in 1890, but Burkhart and De Beer1
highlighted the role of bony defects in the failure of
arthroscopic stabilization procedures. Recognition of
the role that glenohumeral bone deficiency plays in the
From the California Pacific Medical Center (R.J.P., E.M.W.),
San Francisco, California; Mississippi Sports Medicine and Or-
thopaedic Center (E.R.H.), Jackson, Mississippi; Hunterdon Or-
thopaedic Specialists (M.E.P.), Flemington, New Jersey; and Cen-
ter for Sports Medicine & Orthopaedics (C.C.S.), Chattanooga,
Tennessee, U.S.A.
The authors report no conflict of interest.
Address correspondence and reprints requests to Robert J. Pur-
chase, M.D., California Pacific Medical Center, 3000 California
St, San Francisco, CA 94115, U.S.A. E-mail: rpurchase@gmail.
com
© 2008 by the Arthroscopy Association of North America
0749-8063/08/2406-0858$34.00/0
doi:10.1016/j.arthro.2008.03.015
failure of arthroscopic shoulder stabilization proce-
dures continues today.2
The question of how best to treat unstable shoul-
ders with significant glenoid and humeral bone de-
fects remains. Some authors have advocated limit-
ing glenohumeral motion through some type of
open capsular shift that would prevent engagement
of the Hill-Sachs lesion by limiting external rotation
and abduction. Other open procedures have been
described such as an open transfer of the infraspi-
natus tendon and capsule into the Hill-Sachs le-
sion.3 More recently, several authors have described
more novel approaches to treat the engaging Hill-
Sachs lesion.4-8 We present a procedure that con-
sists of an arthroscopic posterior capsulodesis and
infraspinatus tenodesis to fill (remplissage, which
means “to fill” in French) the Hill-Sachs lesion in
addition to an arthroscopic Bankart repair.

Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 24, No 6 (June), 2008: pp 723-726 723
724 R. J. PURCHASE ET AL.
FIGURE 1. Left shoulder in lateral decubitus position showing
proper placement of posterior remplissage portal.
TECHNIQUE
The Hill-Sachs remplissage technique is similar to
an arthroscopic repair of a partial-thickness, articular-
surface rotator cuff tear. It consists of fixation of the
infraspinatus tendon and posterior capsule to the
abraded surface of the Hill-Sachs lesion.
The patient is placed in the lateral decubitus
position and leaned back approximately 30° with
the shoulder in 30° of abduction and 15° of forward
flexion. The arm is suspended with 15 lb of distal
traction.
The glenohumeral joint is entered through a posterior
portal that is placed at the lateral aspect of the convexity
of the humeral head so that it is centered directly over the
Hill-Sachs lesion (Fig 1). This remplissage posterior
portal will allow initial visualization and evaluation of
the joint as well as working access to the Hill-Sachs
lesion. After an anterior-inferior portal is made in the
rotator interval, which will be the primary working portal
for the anterior labral repair, an anterior-superior portal is
established at the anterior margin of the acromion. This
portal should enter immediately behind the biceps ten-
don. The arthroscope is switched from the posterior
portal to the anterior-superior portal, and a cannula is
placed into the posterior portal.
While viewing from the anterior-superior portal, the
surgeon assesses the Hill-Sachs lesion, glenoid bone
loss, and anterior labral lesion, as well as the location
of the posterior portal. Posterior portal placement is
appropriate if it is located directly over the Hill-Sachs
lesion and at an angle that will allow the placement of
2 anchors. If the posterior portal is not appropriate, its
location is optimized with the assistance of a spinal
needle at this time. The surface of the engaging Hill-
Sachs lesion is gently freshened with a bur in reverse
mode with care taken to remove the minimum amount
of surface bone. In addition, the surface of the entire
posterior and inferior capsule is freshened with a
whisker blade. In anticipation of a Bankart repair, the
anterior labrum and glenoid neck must be prepared
before one proceeds with the remplissage.
While maintaining the camera in the anterior-supe-
rior portal, the surgeon carefully withdraws the can-
nula in the posterior portal from the posterior capsule
and infraspinatus tendon but not through the deltoid.
Therefore the mouth of the cannula is in the subdeltoid
space. The anchor cannula with obturator is passed
through the infraspinatus tendon and posterior capsule
via the pre-existing portal, and the first anchor is
placed in the inferior aspect of the Hill-Sachs lesion.
A penetrating grasper is passed through the tendon
and posterior capsule, 1 cm inferior to the initial portal
entry site, to grasp and pull 1 suture limb (Fig 2A). A
second anchor is placed in the superior aspect of the
Hill-Sachs lesion, and a grasper penetrator is used in
the same fashion to pass 1 suture limb 1 cm superior
to the initial portal entry site (Fig 2B). The inferior
suture is tied first with the knots remaining extra-
articular in the subdeltoid space. The superior suture is
tied to complete the remplissage. The knots can be
visualized by opening the posterior wall of the sub-
acromial bursa. These mattress sutures draw the in-
fraspinatus and posterior capsule to the abraded bony
surfaces, thus filling the Hill-Sachs lesion (Fig 3A).
The Bankart repair can then be completed (Fig 3B).
Postoperative care and immobilization are individ-
ualized and based on the patient’s history and pathol-
ogy, but in general, we require the use of an immo-
bilizer for 6 weeks. Patients are allowed to remove the
immobilizer for “controlled” activities of daily living
such as eating, showering, and computer use within 1
or 2 days. They can remove it for these activities as
long as the arm is not abducted and does not externally
rotate beyond neutral. Active and resistive range of
motion is started at 6 weeks. No “at-risk” work activ-
ities or contact sports are allowed for 6 months.
DISCUSSION
Several authors have recognized the contribution of
glenoid deficiency to the recurrence of anterior insta-
bility.1,2 Typically, less attention has been focused on
the significance of the Hill-Sachs lesion. However, it
was recognized, in 1948, that a dislocation might recur
after repair of the capsule and labrum in the presence
 HILL-SACHS “REMPLISSAGE” 725

transfer of the infraspinatus tendon and capsule into

the defect. Connolly3 reported satisfactory results in
all but 1 of 15 patients treated with this transfer of the
infraspinatus tendon for large defects of the humeral
head. He postulated that this procedure afforded max-

FIGURE 2. (A) Penetrator grasper preparing to pass 1 suture

through posterior capsule and infraspinatus tendon. (B) Arthro-
scopic view of remplissage just before completion by tying sutures
in subdeltoid space.

of a sizable Hill-Sachs lesion.9 It was suggested that

abduction and external rotation of the arm would bring
the Hill-Sachs lesion to engage with the anterior rim
of the glenoid, thereby levering the humeral head out
anteriorly.
Burkhart and De Beer1 have recently refocused
attention on the role of the engaging Hill-Sachs lesion
in recurrent instability. In their series of 194 patients
with recurrent shoulder instability treated with suture
anchors, there were 21 failures (10.8%). However,
those patients who did not have significant bony de-
fects had a failure rate of 4%. It was noted that 14 of
21 recurrences (67%) had significant bone defects in
the form of anterior-inferior glenoid loss and/or large
Hill-Sachs lesions.
FIGURE 3. (A) Completed remplissage repair with posterior cap-
Several open techniques have been developed to sule and infraspinatus tendon well apposed to Hill-Sachs lesion.
address large Hill-Sachs lesions, including an open (B) Completed Bankart repair and remplissage.
726 R. J. PURCHASE ET AL.
imum stability by only affecting gliding of the hu-
meral head rather than rotation, thus minimizing the
limitation of external rotation in the overhead posi-
tion. This is essentially the reverse of the McLaughlin
procedure.
Interestingly, an arthroscopic technique has recently
been described by Krackhardt et al.5 to fix the sub-
scapularis into the anterior humeral head impression
fracture. This technique uses suture anchors in a man-
ner similar to the technique described for the remplis-
sage. Short-term results of 12 patients treated with the
arthroscopic McLaughlin procedure are pending.
There have been more recent attempts to develop
techniques to solve the problem of the engaging Hill-
Sachs lesion. Re et al.6 have described a “trans-
humeral head plasty” by use of a deltopectoral ap-
proach in which the depressed, compacted bone of the
Hills-Sachs lesion is tamped up from below. Another
technique, using a limited posterior approach, was
described to fill the humeral head defect with osteo-
articular allograft.7
As instruments and techniques are refined, the role
of arthroscopy has expanded. Chapovsky and Kelly4
described an all-arthroscopic technique to fill the le-
sion, also using osteoarticular allograft. In addition,
Lafosse et al.8 recently described a technique for an
arthroscopic Latarjet procedure for anterior shoulder
instability. They admit that their technique is complex
and requires experience but report that the early re-
sults of 44 cases are promising.
Remplissage is an arthroscopic technique that di-
rectly addresses the problem of the engaging Hill-
Sachs lesion. The filling of the abraded Hill-Sachs
lesion effectively obliterates it and converts the lesion
into an extra-articular one. Therefore it prevents en-
gagement. In an unpublished review, only 2 of 24
patients (7%) treated with remplissage have had re-
current instability. In both, this occurred after signif-
icant trauma. Furthermore, there were no significant
complications. In particular, the concern that the rem-
plissage would limit rotation did not materialize.
There was no significant loss of motion in any plane
after the procedure. Remplissage is an effective ar-
throscopic approach in a difficult subgroup of insta-
bility patients with a significant potential for failure
after a standard arthroscopic Bankart repair.
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