Hill-Sachs “Remplissage”: an arthroscopic solution for the engaging Hill-Sachs lesion (SS-32)

The purpose of this paper is to present a new arthroscopic approach to a subset of instability patients that present with a combination of bony lesions. These lesions of the glenoid (bony Bankart, fractures, erosion), and humerus (Hill-Sachs) have long been established as significant contributing pathology in recurrent shoulder instability. Several authors have recognized the presence of anterior glenoid rim deficiencies in shoulder instability, as well as their role in producing failures of shoulder stabilization procedures. Although less attention has been focused on the significance of the Hill-Sachs lesion, its role in producing recurrent dislocations has been recognized since the article by Broca and Hartman in 1894. Recurrent dislocators with the combination of glenoid loss and Hill-Sachs lesion (engaging Hill-Sachs lesion) have been a difficult group to treat and have proved to be recalcitrant to most open and the best of arthroscopic surgical approaches. This has been the subject of recent publications, the conclusion of which was that in the presence of the combination of a glenoid defect and Hill-Sachs lesion, the Latarjet procedure is recommended. Our arthroscopic technique, Arthroscopic Hill-Sachs Remplissage (Fr.: to fill in, or to fill up), shows promise as the first arthroscopic technique to attempt to specifically address the engaging Hill-Sachs lesion. This arthroscopic transfer of the posterior capsule and infraspinatus tendon into the Hill-Sachs lesion effectively converts the lesion into an extra-articular one and prevents engagement of the lesion on the glenoid rim. It is analogous to an arthroscopic repair of a partial-thickness rotator cuff repair. Over a one-year period, fourteen of forty-two patients with recurrent shoulder instability were felt to have the combination of these lesions and underwent this procedure. Thus far, all fourteen patients treated in this manner have maintained stable shoulders without any unusual loss of motion in any plane. A second look arthroscopy in one patient eight months post op, showed the tenodesed tissue intact. The offending fixation device was removed. It is no longer being used and had been replaced with a suture anchor technique. We believe it is an anatomic, lesion specific and minimally invasive approach to a significant subset of recurrent dislocators who would otherwise have to undergo a more invasive open procedure. Although initially successful, further studies are necessary to refine our indications and address the efficacy of this arthroscopic approach.