Remplissage (Hill-Sachs Lesion Treatment)

Why this approach — at MOS

We use the glenoid track concept to determine who needs remplissage. The glenoid track is the zone on the humeral head that articulates with the glenoid through functional range of motion. If the Hill-Sachs lesion falls within the glenoid track ("on-track"), it will engage the glenoid and should be treated. If it falls outside the track ("off-track"), Bankart repair alone is sufficient. This assessment uses measurements from CT or MRI — the size of the Hill-Sachs relative to the humeral head width, and the glenoid width accounting for any bone loss.

Bethesda-area patients with shoulder instability who have Hill-Sachs lesions are evaluated with both MRI and CT when needed to precisely characterize the defect and plan the appropriate combination of procedures. We are transparent about one known trade-off of remplissage: the procedure can limit external rotation by 5–10 degrees in some patients. For most patients this is not clinically significant, but for competitive overhead throwers and pitchers, this loss matters. We discuss this trade-off explicitly with every throwing athlete before surgery.

Who is a candidate?

Indications

• Hill-Sachs lesion deemed "off-track" using the glenoid track concept — the defect will engage the anterior glenoid during functional range of motion
• Shoulder instability with large Hill-Sachs lesion where soft-tissue Bankart repair is otherwise appropriate (glenoid bone loss less than 20–25%)
• Recurrent instability with an engaging Hill-Sachs defect on examination under anesthesia or imaging

Contraindications

• Glenoid bone loss exceeding 20–25% (Latarjet procedure preferred over Bankart + remplissage)
• Very small non-engaging Hill-Sachs lesions (remplissage not necessary)
• Patients for whom the anticipated external rotation loss would be unacceptable (overhead pitchers may be counseled about this trade-off)

Conservative Treatment First

Remplissage addresses a structural mechanical problem — a defect that physically engages the glenoid. Physical therapy can strengthen the dynamic stabilizers around the shoulder, but it cannot fill or reshape a bone defect. If a Hill-Sachs lesion is determined to be engaging, the non-operative pathway has a very high failure rate, and the decision to operate is primarily driven by the instability indication (Bankart lesion) rather than the Hill-Sachs finding specifically. Non-operative management may be appropriate for very small non-engaging defects in lower-demand patients, combined with a structured therapy program as for any Bankart lesion.

The procedure

What Is Remplissage?

Remplissage is an arthroscopic procedure that fills a Hill-Sachs defect — a dent in the back of the humeral head caused by shoulder dislocation — with the posterior capsule and infraspinatus tendon. This prevents the defect from catching on the front of the glenoid and causing re-dislocation. It is almost always performed with a Bankart repair.

The word "remplissage" is French for "filling." When the humeral head dislocates anteriorly, it forcefully impacts against the hard front rim of the glenoid, creating a compression fracture on the back of the ball. This dent is called a Hill-Sachs lesion. In most patients with small defects, this lesion does not cause problems after a Bankart repair. But in some patients — particularly those with larger defects — the dent lines up with the front of the glenoid when the arm is in the provocative position (abduction and external rotation, the throwing position), and the dent literally catches on the glenoid rim. This "engagement" is a mechanical cause of recurrent dislocation that a Bankart repair alone cannot prevent.

Remplissage solves this problem by arthroscopically placing suture anchors inside the Hill-Sachs defect and using the attached sutures to secure the posterior capsule and infraspinatus tendon into the defect. This fills the void with soft tissue, converting it from an intra-articular defect that can catch on the glenoid to an extra-articular soft-tissue mass that cannot. The procedure effectively eliminates the Hill-Sachs lesion as a source of instability without requiring bone grafting to the humeral side.

Remplissage is performed through the same arthroscopic portals as the Bankart repair and adds only 15–20 minutes of operative time. For appropriately selected patients — those with "off-track" Hill-Sachs lesions — combining the two procedures significantly reduces recurrence risk compared to Bankart repair alone.

What Happens During Remplissage?

Remplissage is performed as part of the same operative session as Bankart repair and takes place entirely arthroscopically. After the anterior Bankart repair is completed, the arthroscope is repositioned to view the posterior-superior humeral head and the Hill-Sachs defect directly. One or two suture anchors (typically 3 mm knotless anchors) are inserted through a posterior portal directly into the base of the Hill-Sachs defect. The sutures from these anchors are then passed through the posterior capsule and a bite of the infraspinatus tendon using a suture passer. When the sutures are tensioned and tied (or locked, for knotless anchors), the posterior capsule and infraspinatus are pulled snugly into the defect, obliterating the void.

The shoulder is then tested through a range of motion to confirm that the Hill-Sachs defect no longer engages the glenoid rim. Portals are closed and the arm is placed in a sling.

Recovery timeline

Frequently Asked Questions