Biceps‐Augmented Reverse Remplissage for Filling of Reverse Hill‐Sachs Defects

Abstract

Reverse Hill‐Sachs lesions pose a complex challenge in the management of posterior shoulder dislocations. These lesions complicate surgical management as a result of their association with recurrent instability and further joint destruction. We describe an arthroscopic reverse remplissage technique that utilizes both the long head of the biceps tendon and the subscapularis to address reverse Hill‐Sachs defects. This combined approach provides comprehensive defect filling and enhanced stability while avoiding the morbidity associated with extensive subscapularis tenodesis.

Arthroscopic reverse remplissage is a modern modification of the classic remplissage technique originally described by Purchase et al. ¹ for anterior instability. Developed by Krackhardt et al., ² it addresses reverse Hill‐Sachs lesions (RHSL) in cases with posterior shoulder dislocations. It compromises filling the anteromedial defect with the subscapularis tendon to convert the lesion to an extra‐articular defect, prevent posterior engagement, and restore stability. ³ , ⁴

The procedure can be performed arthroscopically or via a mini‐open approach. It is mainly indicated for engaging RHSLs involving 20% to 40% of the humeral head. When the defects are large, incorporating a large portion of the subscapularis tendon may complicate loss of external rotation, stiffness, or subscapularis weakness. In the presenting technique, both the subscapularis and biceps tendons are used to fill the defect to decrease the volume of subscapularis tenodesis. ³ , ⁴

Long head of the biceps tendon represents a biologically sound and economical solution for most shoulder problems, i.e., dynamic anterior stabilization, cuff augmentation, anterior cable reconstruction, superior capsular reconstruction, soft tissue Latarjet procedure, and others. However, it has never been described for cases with posterior shoulder instability. ⁵ , ⁶

We describe a technique where the tendon itself used for augmenting reverse remplissage for RHSLs. When the instability challenges the anatomy, the biceps always returns as savior rewriting a new chapter in posterior shoulder instability.

SURGICAL TECHNIQUE

The procedure is illustrated in Video 1. Peals and pitfalls are discussed in Table 1, and the advantages and disadvantages of the technique are discussed in Table 2. The procedure is done under general anesthesia with an interscalene block in the modified beach chair position. Diagnostic shoulder arthroscopy was done first to diagnose any concomitant shoulder pathologies. The anterior RHSL defect is examined and debrided using a 4.5‐mm motorized shaver (Stryker Shaver System, Kalamazoo, MI). The posterior labrum is examined and repaired if needed (Figure 1).

VIDEO 1.

Download video file ^{(78.6MB, mp4)}

A diagnostic shoulder arthroscopy is done first to diagnose any concomitant shoulder pathologies. The anterior reverse Hill‐Sachs lesion defect is examined and debrided using a 4.5‐mm motorized shaver to bleeding subchondral bone. An arthroscopic cannula is inserted through the anterior portal using a transillumination technique. The first double‐loaded titanium anchor is then inserted through the cannula at the medial part of the defect. The sutures of the medial anchor are then shuttled through the subscapularis tendon using the penetrating suture. The second double‐loaded titanium anchor is then inserted into the lateral part of the defect with adequate trajectory to avoid the 2 anchors’ convergence. A straight penetrating suture forceps is used to make the first bite inside the biceps tendon. The forceps should shuttle 1 suture only. A lasso loop is then made around the anterior part of the biceps tendon for better tissue holding and to avoid suture cutout during repair. A second biceps tendon bite is made using a penetrating suture forceps far enough from the first bite to avoid biceps tendon splitting. When pulling on the post limb of the 2 sutures, the lasso loop will drive the biceps tendon into the defect (Bicepssage effect). The biceps tendon is then tenotomized from its insertion into superior. The sutures of the 2 anchors are then tied with the limb in neutral rotation. Video content can be viewed at https://doi.org/10.1002/atn2.70095.

TABLE 1.

Advantages and Disadvantages of the BARR Technique

Advantages	Disadvantages
Biologically sound	Difficult suture manipulation
Economically effective	Healthy biceps tendon is mandatory for this technique
Decrease the volume of subscapularis tenodesis	Not applicable in cases with defects >40% of the head
Less limitation of external rotation
If there is a concomitant SLAP tear, biceps tenodesis is a good option to treat this lesion
Can be easily performed arthroscopically

BARR, biceps‐augmented reverse remplissage.

TABLE 2.

Pearls and Pitfalls of the BARR Technique

Pearls	Pitfalls
Biceps tendon should be intact to hold the sutures of the second anchor	Bone bridge between 2 anchors may be violated if the distance between 2 anchors is very small
Limb rotation is important to allow best trajectory for the anchor insertion and to avoid articular cartilage scuffing	It is important to allow adequate space between the 2 biceps bites to avoid tendon damage in this technique
Lasso loops around biceps tendon allow better tissue holding and avoid tendon slippage during tenodesis	Elbow extension is important during Bicepssage to avoid postoperative biceps pain

BARR, biceps‐augmented reverse remplissage.

FIGURE 1.

Arthroscopic view of the left shoulder looking from the posterior portal showing the frayed posterior labral tear.

An arthroscopic cannula (Stryker, Kalamazoo, MI) is inserted through the anterior portal using a transillumination technique. The defect is debrided to bleeding subchondral bone, removing all soft tissue inside the RHSL for better tendon‐to‐bone healing after the repair (Figure 2).

FIGURE 2.

Arthroscopic view of the left shoulder looking from the posterior portal with cannula inserted through the anterior portal. An RHSL is seen anteriorly. (MGHL, middle glenohumeral ligament; RHSL, reverse Hill‐Sachs lesion; RI, rotator interval; SubSc, subscapularis tendon.)

The first double‐loaded titanium anchor (V‐LoX 5.5 mm, Parcus Medical, Sarasota, FL, USA) is then inserted through the anterior cannula at the medial part of the defect. Limb rotation is important to allow the best trajectory for the anchor insertion and to avoid articular cartilage scuffing (Figure 3).

FIGURE 3.

Arthroscopic view of the left shoulder looking from the posterior portal showing insertion of the first titanium anchor at the medial part of the RHSL. (MGHL, middle glenohumeral ligament; RHSL, reverse Hill‐Sachs lesion; RI, rotator interval; SubSc, subscapularis tendon.)

The sutures of the medial anchor are then shuttled through the subscapularis tendon using the penetrating suture forceps (Mitek, Inc, Norwood, MA, USA). It is important to distribute the sutures over a reasonable subscapularis area to allow adequate defect filling without limiting external rotation. Grasping too much of the tendon may limit the external rotation, causing postoperative stiffness (Figures 4 and 5).

FIGURE 4.

Arthroscopic view of the left shoulder looking from the posterior portal showing shuttling of first anchor sutures through the subscapularis muscle. (MGHL, middle glenohumeral ligament; RHSL, reverse Hill‐Sachs lesion; SubSc, subscapularis tendon.)

FIGURE 5.

Arthroscopic view of the left shoulder looking from the posterior portal showing shuttling of the first anchor sutures through the subscapularis muscle using suture penetrating forceps. (MGHL, middle glenohumeral ligament; RHSL, reverse Hill‐Sachs lesion; SubSc, subscapularis tendon.)

The second double‐loaded titanium anchor (V‐LoX 5.5 mm, Parcus Medical, Sarasota, FL, USA) is then inserted into the lateral part of the defect with adequate trajectory to avoid the 2 anchors’ convergence. It is important to be just below the cartilage for better coverage of the lateral part of the defect with biceps tendon as it emerges from its groove inside the joint (Figure 6).

FIGURE 6.

Arthroscopic view of the left shoulder looking from the posterior portal showing insertion of the second anchor at more lateral part of the RHSL. (MGHL, middle glenohumeral ligament; RHSL, reverse Hill‐Sachs lesion; SubSc, subscapularis tendon.)

A straight penetrating suture forceps (Mitek, Norwood, MA, USA) is used to make the first bite inside the biceps tendon. The forceps should shuttle 1 suture only (the blue one in Figure 7). It is important to allow adequate space between the 2 biceps bites to avoid tendon damage in this technique (Figure 7). A lasso loop is then made around the anterior part of the biceps tendon for better tissue holding and to avoid suture cut out during repair (Figures 8 and 9).

FIGURE 7.

Arthroscopic view of the left shoulder looking from the posterior portal showing first suture of the second lateral anchor retrieval through the biceps tendon. (SubSc, subscapularis tendon.)

FIGURE 8.

Arthroscopic view of the left shoulder looking from the posterior portal showing lasso loop formation at the anterior part of the biceps tendon. (SubSc, subscapularis tendon.)

FIGURE 9.

Arthroscopic view of the left shoulder looking from the posterior portal showing the anterior lasso loop formation around the biceps tendon. (SubSc, subscapularis tendon.)

A second biceps tendon bite is made using a penetrating suture forceps far enough from the first bite to avoid biceps tendon splitting. The forceps should shuttle the opposite strand color (Tiger braided suture in Figure 10), making another lasso loop. The suture is then looped around the whole biceps tendon, capturing the posterior and anterior parts of the tendon (Figure 11).

FIGURE 10.

Arthroscopic view of the left shoulder looking from the posterior portal showing the penetrating forceps forming the second lasso loop around the biceps at more cranial position using the other colored suture of the second anchor. (SubSc, subscapularis tendon.)

FIGURE 11.

Arthroscopic view of the left shoulder looking from the posterior portal showing the second suture capturing the posterior part of the biceps tendon. (SubSc, subscapularis tendon.)

When pulling on the post limb of the 2 sutures, the lasso loop will drive the biceps tendon into the defect (Bicepssage effect) as shown in Figure 12. The other strand of the first suture is used again to make another lasso loop around the biceps, tendon not through it, for further capturing the tendon and seating it inside the defect and to avoid suture slippage from the tenotomized biceps tendon (Figures 13 and 14).

FIGURE 12.

Arthroscopic view of the left shoulder looking from the posterior portal showing the reduction of the biceps tendon into the defect when pulling on 2 lasso sutures filling the defect (Bicepssage effect).

FIGURE 13.

Arthroscopic view of the left shoulder looking from the posterior portal showing the second lasso loop around the biceps tendon using the third suture.

FIGURE 14.

Arthroscopic view of the left shoulder looking from the posterior portal showing the second lasso loop around the biceps tendon using the third suture.

The biceps tendon is then tenotomized from its insertion into the superior labrum using a straight punch forceps (Mitek, Norwood, MA, USA). The sutures of the 2 anchors are then tied with the limb in neutral rotation to avoid postoperative stiffness and with the elbow in full extension to keep adequate tension of biceps tenodesis and avoid postoperative midarm and elbow pains (Figure 15). The scope is then shifted to the anterior portal to assess adequate defect filling using dual tendon remplissage (subscapularis and biceps) (Figure 16).

FIGURE 15.

Arthroscopic view of the left shoulder looking from the posterior portal showing the biceps tendon filling the defect after it was tenotomized from the superior labrum and suturing the strands of 2 anchors.

FIGURE 16.

Arthroscopic view of the left shoulder looking from the anterior portal showing biceps and subscapularis tendons together filling the RHSL defect after suturing the strands of 2 anchors. (RHSL, reverse Hill‐Sachs lesion.)

DISCUSSION

Posterior shoulder dislocations constitute a relatively rare subset of shoulder dislocations, accounting for only 2% to 4% of cases, yet they pose significant diagnostic and therapeutic challenges due to their often subtle clinical presentation and frequent association with the RHSL. The size of the defect, which may range from minor cortical depressions to large articular surface losses, critically influences management decisions. If left untreated, these lesions can result in recurrent instability, chronic pain, restricted motion, and early degenerative joint disease. ⁴

Treatment strategies for RHSLs are guided by lesion severity, chronicity, and patient factors. Options span from conservative management in small defects to surgical interventions such as the McLaughlin procedure ⁷ (subscapularis transfer), arthroscopic techniques (cartilage elevation, capsulolabral repair, and plication), and bone grafting for larger defects. The modified McLaughlin procedure is the most commonly employed among all those surgical techniques. ³ , ⁴

Modified McLaughlin procedures have been described using multiple variations. Hawkins et al. ⁸ reported transferring the lesser tuberosity with subscapularis, Banerjee et al. ⁹ reported transferring the upper two‐thirds of the lesser tuberosity, Romano et al., ¹⁰ Duey and Burkhart, ¹¹ and Lavander et al. ¹² described an arthroscopic reverse remplissage of the subscapularis only, whereas Ralph et al. ¹³ reported arthroscopic reverse remplissage using the middle glenohumeral ligament instead of subscapularis.

Among the available biological options, the long head of the biceps tendon has emerged as a practical autograft choice for shoulder reconstruction, offering a readily available, cost‐free tissue source without additional implants or donor site morbidity. Building upon the momentum of biceps‐driven strategies in shoulder reconstruction, we describe a technique utilizing the biceps tendon to augment reverse remplissage for RHSLs in the setting of posterior shoulder instability. Employing the biceps tendon not merely acts as a defect filling structure but also as a dynamic ally to resist posterior instability.

DISCLOSURES

The authors (M.G.M., A.R.N.A., H.M.G.) declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.