Remplissage

When the shoulder dislocates, the ball of the joint (the humeral head) can be dented as it passes over the rim of the socket. That dent is called a Hill-Sachs lesion. If it is large, the dent can catch on the front rim of the socket when the arm is lifted and rotated outwards, and the shoulder can dislocate again.

A Remplissage fills in that dent. The name comes from the French for ‘filling’. The infraspinatus tendon and the posterior capsule are brought into the defect and fixed there, so the groove is no longer exposed and cannot engage on the glenoid.

The procedure

The infraspinatus tendon and the posterior capsule are used to fill the Hill-Sachs groove in the humeral head. The aim is to stop the humeral head catching on the glenoid, which happens mainly when the arm is abducted (lifted away from the body) and externally rotated.

A Remplissage is usually performed arthroscopically. It can be done on its own, or alongside another procedure such as a Bankart repair.

Risks and complications

General surgical risks

• Bruising and haematoma. The amount of bruising varies from person to person. It is a normal part of healing and usually settles quickly.
• Infection. Uncommon but possible, and usually treated with antibiotics.
• Deep vein thrombosis (DVT) and pulmonary embolism (PE). Blood clots in the leg or the lung. The risk of harm is significantly reduced when they are treated promptly.
• Anaesthetic risk. This is discussed in detail with your anaesthetist before surgery. The risk of death under a general anaesthetic in Australia is approximately 1 in 100,000.
• Wound problems. Superficial wound problems can occur. Most need only a small intervention.

Risks specific to this procedure

• Reduced external rotation. Because the tendon is fixed into the humeral head, outward rotation can be reduced. This may affect abduction, throwing and overhead movement.
• Posterior shoulder pain. Pain at the back of the shoulder.
• Re-dislocation
• Stiffness
• Frozen shoulder. This can follow any shoulder surgery and resolves with time. A good result is still expected, but if it is severe, rehabilitation can be long and difficult.

Before surgery

There are a number of things to organise while you are waiting for surgery. You will also be given detailed written instructions.

1. Confirm with your health fund whether the hospital fee is covered by your policy.
2. Confirm your anaesthetist’s fees.
3. Register your details with the hospital.
4. Complete the paperwork and return it to the office.
5. Plan your transport to and from hospital. You will not be able to drive yourself home.
6. Arrange any pre-operative physiotherapy that has been recommended.
7. Have any pre-operative pathology that is required, such as blood tests.
8. Benzoyl peroxide 5% wash. Use it five times in total: twice daily for two days, then once more on the morning of surgery. This reduces the risk of Cutibacterium acnes infection.
9. Hospital bag. Bring your regular medications in their original packaging, a loose button-up shirt, nightwear and toiletries. If you have sleep apnoea, bring your CPAP machine.
10. Blood thinners. Phone the office to confirm when to stop them.
11. Diabetic tablets. Phone your anaesthetist to confirm whether to stop them.
12. Confirm your admission details with the office one to two business days before surgery.

The day of surgery

• Your admission details are confirmed one to two business days before surgery. Make a note of your admission time, which may be as early as 6am, and your fasting time.
• If you live outside Brisbane, it is usually recommended that you stay in Brisbane the night before.
• After admissions you wait in the surgical waiting area. The anaesthetist consults with you before you go through to theatre.
• Dr Cutbush greets you in the anaesthetic bay and then marks the operation site with you.
• The usual stay is one night, with discharge around 10am. Dr Cutbush reviews you before you are discharged.
• You are given a post-operative folder containing a letter describing what was found and what was done, along with rehabilitation and aftercare information.
• Arrange for someone to take you home.

Recovery and healing

Rest and immobilisation are essential after a Remplissage, because the tendon has to heal into the bone of the humeral head.

• The sling is worn full time for six weeks. During this time you cannot drive, work or do physical activity.
• Gentle passive movement of the hand, wrist and elbow is allowed. Shoulder movement is limited.
• Full recovery takes six to twelve months, with a gradual return to normal activities. The timeframe depends on individual factors.

Rehabilitation

Formal rehabilitation usually starts at around six weeks, once the sling is no longer needed. The early focus is on passive and then active range of motion, with strengthening and proprioception work following on from that.

Day one

The hospital physiotherapist shows you how to fit the sling, and how to eat, shower and dress while wearing it. Make sure you understand these before you leave hospital.

Goals

• Protect soft tissue healing by limiting active work of the posterior cuff and limiting passive stretching.
• Reduce pain and inflammation.
• Minimise glenohumeral stiffness, using passive pendulum exercises and strict passive external rotation.

Education and precautions

• Healing timeframes and precautions are explained.
• Avoid activating the posterior cuff, cross-body movement, internal rotation and weight bearing.
• Stay in the sling except when showering and doing your gentle exercises.

Sling

• Worn for six weeks. Check your surgical notes.
• You should be able to put it on and take it off independently, and check the fit.
• An external rotation brace, or a ‘gunslinger’ position, may be needed.

Exercises

• Active range of motion for the neck, elbow, wrist and hand.
• Gentle scapular neutral exercises and postural advice.
• Passive pendulum exercises only, aiming for at least a 70 degree drop, ideally in the scapular plane.
• Strict passive external rotation to 20 degrees, unless you have been told otherwise.
• Exercise videos are available through Extend Rehab and on this website.
• Pain. Managed with positioning, correct sling fit, and cryotherapy for 20 minutes every two to three hours during the first five days. Heat may be useful after that.
• Swelling. Managed with ice and effleurage.
• Daily activities. Light hand use only, within the sling.

Follow-up

You see your local physiotherapist at week two. At week six, Dr Cutbush and an Extend Rehabilitation physiotherapist review your progress and decide how to progress your program.

Results after surgery

Published series report that a Remplissage improves instability in most patients, and many people return to normal physical activity. Individual results vary.

Some patients are left with a reduced range of motion, particularly external rotation. This is one of the trade-offs of the procedure and is worth discussing before surgery if you throw or work overhead.

Next steps

• Anterior shoulder instability
• Shoulder instability
• Shoulder anatomy
• Surgery FAQs
• Book a consultation

This page is general information about a surgical procedure and is not a recommendation that you have it. Whether surgery is appropriate for you can only be determined after assessment. All surgery carries risk; the risks relevant to you are discussed in consultation before any decision is made.