Remplissage Surgical Procedure: Safe and Effective for Repeated Shoulder Dislocations

Athletes who suffer repeated anterior (forward) shoulder dislocations may have two problems going on in the joint: a Bankart lesion and a Hill-Sachs lesion. Unless both problems are recognized and treated, shoulder function may not improve. The authors of this article report on results using two different methods of treating this type of shoulder instability.

To better understand this report, let’s take a quick look at the shoulder and these two injuries. The shoulder joint is a ball-and-socket joint. The socket is fairly shallow. This puts the joint at risk for dislocation. To help deepen the socket, the shoulder joint has a rim of cartilage called a labrum. The labrum forms a cup for the end of the arm bone (humerus) to rest and move inside.

A Bankart lesion is an injury to the labrum caused by forward (anterior) shoulder dislocation. The force of the head of the humerus (upper arm bone) as it dislocates, tears the labrum and the ligaments attached to it. The shoulder joint is unstable when the labrum is torn. There isn’t anything to keep the head of the humerus from slipping forward out of the socket again. Surgery to repair the damage is usually needed.

A Hill-Sachs lesion is an injury that causes damage to the head of the humerus. It also occurs with shoulder dislocation and usually develops after the Bankart lesion occurs. When the shoulder dislocates, the smooth surface of the humerus hits against the bony edge of the socket (called the glenoid). The collision causes a dent in the bone of the humerus. This is also called an impaction fracture.

Treatment is designed to prevent any more dislocations and further damage (and later arthritis) to the surface of the humerus. Reducing pain and improving motion and function are additional goals of surgery. Surgical treatment for each of these problems is slightly different. The Bankart procedure is done to reattach the labrum to the bone. The layers of soft tissue around the labrum (ligaments, joint capsule, tendons) must also be stitched back together layer by layer.

In this study, the surgeons used a Remplissage procedure to repair the Hill-Sachs lesion. The word remplissage is French and means “to fill in” or “to fill up.” In the context of this surgery, a portion of the joint capsule and the infraspinatus tendon are moved (transposed) to fill in the hole or “defect” in the bone.

The design of this procedure is to stop the humeral head from banging against the edge of the socket when the arm is rotated and moved away from the body (movements called external rotation and abduction). When pain occurs during this arc of motion for someone who already has a Hill-Sachs lesion, it’s referred to as an engaging Hill-Sachs lesion.

The intention of this study was to compare results in two groups of athletes with both problems: an engaging Hill-Sachs and a Bankart shoulder lesion. One group of 25 athletes had just the Bankart repair. The second group of 25 athletes had a Bankart repair along with the Remplissage procedure. The results were measured by change in shoulder function and whether or not the shoulder dislocated again.

The authors report equal results between the two groups when just looking at improved symptoms (decreased pain, increased motion). But five of the 25 athletes in the Bankart-only group had another shoulder dislocation. That’s a 20 per cent recurrence rate and of course, very distressing to the athlete after having surgery.

In summary, this is the first study to take a look at results of two different surgical treatments for combined Bankart and Hill-Sachs shoulder injuries in athletes. Although the study was small (only 50 patients) and only two surgeons were involved, they say the use of a new approach (the Remplissage Repair) is safe and effective. None of the athletes who had the combined Bankart and Remplissage repairs had any further shoulder dislocations. The Bankart procedure alone for these kinds of shoulder instabilities may not be enough as evidenced by a 20 per cent re-dislocation rate.