Anterior Shoulder Instability: To Remplissage or Not to Remplissage

Anterior shoulder instability, with either a bony Bankart lesion or Hill-Sachs defect, increases the risk of failure after arthroscopic labral repair (ALR)-specifically, bipolar lesions that are "off-track" or have an increased propensity for recurrent dislocation. Nonoperative management with the strengthening of the cuff and periscapular region and bracing can be attempted, but surgical intervention is recommended for patients with recurrent dislocation, Hill-Sachs lesion, and glenoid bone loss or high-risk athletes. Remplissage, which is an arthroscopic technique in which the infraspinatus tendon is attached to the Hill-Sachs defect, has been used more frequently in the past few years, given the recent literature showing high rates of recurrent instability after ALR.

Ideal remplissage techniques have been debated with some surgeons using anchors with knot fixation and access through the subacromial space at the level of the teres minor, which creates technical difficulty and adds to surgical time. The utilization of 2 single-loaded, knotless, all-suture anchors accessed through the posterior portal and infraspinatus tendon allows for easier visualization, capsulotenodesis, and anatomic approximation of the humeral head to the rotator cuff without the need to access the subacromial space, which makes surgery faster and easier.

The remplissage technique is an augmentation to ALR. It is performed with 2 single-loaded all-suture anchors using a posterior portal through the infraspinatus tendon into the Hill-Sachs lesion.

ALR with remplissage provides adequate anterior shoulder stability for patients with "off-track" lesions using a small percutaneous incision through the infraspinatus tendon and placement of 2 knotless all-suture anchors.

Prior studies have demonstrated that adding remplissage to ALR leads to fewer recurrent dislocations postoperatively, especially in contact athletes. Recent literature demonstrates this benefit in patients with both on-track and off-track lesions. A multicenter review found that remplissage in addition to ALR protects against subsequent dislocation and improved patient outcomes.

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