Remplissage Procedure

Original Editor - Shreya Pavaskar

Top Contributors - Shreya Pavaskar  

Description[edit | edit source]

Remplissage (a French term meaning “to fill in”) involves a posterior capsulodesis and infraspinatus tenodesis performed arthroscopically in patients with anterior shoulder instability and engaging Hill-Sachs lesions.

Hill sachs lesion.jpg

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. It is a non-anatomic technique that renders the defect extra-articular to prevent instability, using an arthroscopic posterior capsulodesis and infraspinatus tenodesis into the Hill-Sachs defect, performed in conjunction with a Bankart repair.
The filling of the abraded Hill-Sachs lesion effectively obliterates it and converts the lesion into an extra-articular one. Therefore it prevents engagement.

In particular, the concern that the remplissage would limit rotation did not materialize. There was no significant loss of motion in any plane after the procedure. [1]

Indication [2][edit | edit source]

Hill-Sachs defect >25 % in width, glenoid bone loss, <20 %, a more horizontal orientation/Hill-Sachs angle or engagement demonstrated during dynamic arthroscopic evaluation and a Hill-Sachs defect ending medial to the glenoid tract

Procedure[edit | edit source]

There are various adaptations of this procedure. Here is one video about it -

[3]

Advantages [4][edit | edit source]

Easier control of ROM without possible damage to previously reconstructed anterior-inferior capsulolabral structures
Better visualization and easier reconstruction of the anterior-inferior capsulolabral structures because the humeral head moves more posteriorly
Inserting the sutures from lateral to medial attaching the rotator cable, as well suturing in the horizontal plane, allows stronger fixation and avoids damage to the blood supply of the posterior capsule and infraspinatus tendon.

Disadvantages [4][edit | edit source]

Blind suturing during the remplissage procedure sometimes requires the surgeon to check the subacromial space.
In cases with a concomitant supraspinatus rupture, orientation and determination of the rotator cable structure can be difficult.

Physiotherapy Management[edit | edit source]

The healing timeframes associated with rotator cuff repair must be considered in order to optimize the healing of the tendon into the defect. As such, active and passive tension across this repair should be avoided for the first 6 weeks following surgery, and resistance to the posterior cuff avoided for 12 weeks. Based on these timeframes the following modifications to the anterior shoulder reconstruction rehab model follow remplissage:

Phase I (Weeks 0-6)[edit | edit source]

Sling immobilization at all times except for showering

Therapeutic Exercise - Elbow/Wrist/Hand Range of Motion

Grip Strengthening

Phase II (Weeks 7-12)[edit | edit source]

Discontinue sling immobilization

Range of Motion – Slowly Increase Forward Flexion, Internal/External Rotation as tolerated

Therapeutic Exercise - Continue with Elbow/Wrist/Hand Range of Motion and Grip Strengthening

Begin Prone Extensions and Scapular Stabilizing Exercises (trapezius/rhomboids/levator scapula)

Gentle joint mobilization

Modalities per PT discretion

Phase III (Months 3-6)[edit | edit source]

Range of Motion – Progress to full AROM without discomfort

Therapeutic Exercise – Advance theraband exercises to light weights (1-5 lbs) - 8-12 repetitions/2-3 sets for Rotator Cuff, Deltoid and Scapular Stabilizers

Continue and progress with Phase II exercises

Begin UE ergometer

Modalities per PT discretion

Phase IV (Months 6+)[edit | edit source]

Range of Motion – Full without discomfort

Therapeutic Exercise – Advance exercises in Phase III (strengthening 3x per week)

Sport/Work specific rehabilitation

Return to throwing at 4.5 months

Return to sports at 8 months if approved

References[edit | edit source]

  1. Morsy MG. Arthroscopic remplissage: Is it still an option?. EFORT Open Reviews. 2017 Dec 8;2(12):478-83.
  2. Purchase RJ, Wolf EM, Hobgood ER, Pollock ME, Smalley CC. Hill-Sachs “remplissage”: an arthroscopic solution for the engaging Hill-Sachs lesion. Arthroscopy: The Journal of Arthroscopic & Related Surgery. 2008 Jun 1;24(6):723-6.
  3. Doctive LAB - orthopaedic trauma cases. Arthroscopic Bankart repair & remplissage. Available from: http://www.youtube.com/watch?v=ApmX-BBY4jk[last accessed 2/10/2022]
  4. 4.0 4.1 Rahu M, Kartus JT, Põldoja E, Kolts I, Kask K. Hill-Sachs remplissage procedure based on posterosuperior capsulomuscular anatomy. Arthroscopy techniques. 2019 Jun 1;8(6):e623-7.