A Remplissage procedure is a surgical technique addressing shoulder instability. The term “Remplissage,” derived from French, means “to fill,” precisely reflecting the procedure’s objective. This intervention focuses on filling a bony indentation located on the humeral head, which is the ball-shaped upper part of the arm bone that fits into the shoulder socket. By strategically filling this defect, the procedure aims to stabilize the shoulder joint, thereby reducing the risk of recurring dislocations and improving overall joint function.
Addressing Shoulder Instability
Shoulder instability commonly arises when the humeral head repeatedly displaces from the glenoid, the shallow socket of the shoulder blade. This can lead to recurrent shoulder dislocations. A frequent consequence of these dislocations is the formation of a Bankart lesion, which is a tear of the labrum, the connective tissue rim around the glenoid. The Bankart lesion itself contributes to instability by removing the natural bumper effect of the labrum.
Beyond labral tears, a more complex issue often accompanies recurrent shoulder dislocations: the Hill-Sachs defect. This defect is an indentation or compression fracture on the posterolateral aspect of the humeral head. It occurs when the humeral head forcibly impacts the anterior rim of the glenoid during a dislocation event. The presence of a Hill-Sachs defect significantly increases the likelihood of future dislocations.
When the arm is moved into certain positions, an “engaging” Hill-Sachs defect can catch on the anterior glenoid rim. This engagement prevents the humeral head from smoothly gliding within the socket, making the shoulder highly susceptible to another dislocation. In such cases, a Bankart repair alone may not be sufficient to restore stability. The Remplissage procedure directly addresses this bony defect, aiming to convert the intra-articular lesion into an extra-articular one, thereby preventing its engagement.
The Surgical Process
The Remplissage procedure is typically performed arthroscopically, a minimally invasive surgical approach. This involves making small incisions around the shoulder to insert a camera (arthroscope) and specialized instruments into the joint.
The surgeon first identifies and evaluates the Hill-Sachs defect on the humeral head. Once identified, the defect’s surface is prepared by gently debriding it to create a bleeding base that promotes healing and tissue adherence.
The Remplissage procedure involves tenodesis, attaching the infraspinatus tendon and a portion of the posterior capsule into the prepared Hill-Sachs defect. This is achieved by placing suture anchors directly into the bony defect of the humeral head. These anchors are inserted into the Hill-Sachs defect. Sutures from these anchors are then passed through the infraspinatus tendon and adjacent posterior shoulder capsule. The sutures are subsequently tied, effectively pulling the tendon and capsule into the indentation.
This “fills” the defect and creates a posterior harness, preventing the humeral head from engaging the glenoid rim during shoulder movement. The procedure converts the Hill-Sachs lesion from an intra-articular (within the joint) to an extra-articular (outside the joint) defect, thereby eliminating its ability to cause recurrent instability. This filling effect also acts as a check-rein, limiting excessive anterior translation of the humeral head. The Remplissage procedure is frequently performed in conjunction with a Bankart repair, addressing both the labral tear and the bony defect.
Recovery and Rehabilitation
Recovery following a Remplissage procedure requires a structured and phased rehabilitation program. Immediately after surgery, patients typically experience some pain, swelling, and discomfort, which is managed with prescribed medication and regular application of ice packs. The surgical site is protected, and the shoulder is usually immobilized in a sling for four to six weeks to allow tissues to heal properly. During this initial protective phase, the primary goals are to minimize pain and swelling, protect the surgical repair, and educate the patient on post-operative restrictions.
Physical therapy commences with passive range of motion exercises, where a therapist gently moves the patient’s arm within controlled limits without the patient actively engaging their muscles. This helps prevent stiffness while protecting the healing infraspinatus tenodesis. As healing progresses, active-assisted exercises are gradually introduced, followed by active range of motion exercises to further improve mobility. Around three months post-surgery, strengthening exercises begin, progressing from light resistance to more challenging movements to restore muscle strength and endurance around the shoulder joint.
Throughout the rehabilitation process, careful attention is paid to specific movement precautions. For instance, active external rotation strengthening is typically avoided for approximately 12 weeks to protect the infraspinatus tenodesis. Similarly, internal rotation or cross-body stretching may be restricted for an extended period to prevent undue tension on the posterior capsule and infraspinatus.
Adherence to the physical therapy regimen guides the gradual return to full shoulder function and activities. Return to sports and more demanding physical activities is typically phased and occurs around six months after surgery, depending on individual progress and the surgeon’s clearance. While the procedure aims to preserve motion, some patients may experience a slight reduction in external rotation, which is often a trade-off for improved stability.