Arthroscopic Rotator Cuff Remplissage Technique to Limit Soft Tissue Interposition

Abstract

Anterior shoulder instability is commonly associated with Hill‐Sachs lesions and subcritical glenoid bone loss. In patients with an off‐track pattern, arthroscopic Bankart repair augmented with the Remplissage procedure has been shown to reduce recurrent instability. However, conventional Remplissage techniques often require blind suture retrieval in the subacromial space, which may be time‐consuming and increase the risk of soft tissue interposition. This technical note presents a simplified arthroscopic Remplissage technique that enables direct visualization and retrieval of all suture limbs through a single posterior portal and a guided lateral accessory portal. By maintaining precise cannula positioning and direct visualization of suture management throughout the procedure, this technique minimizes soft tissue interposition, preserves deltoid integrity, and streamlines the operative workflow, thereby reducing overall operative time.

Shoulder instability is a common diagnosis of shoulder injury after sports activities, with anterior shoulder instability making up most of the cases. ¹ Both Hill‐Sachs lesion and glenoid bone loss often develop after such injuries. ² Arthroscopic procedures including arthroscopic Bankart repair (ABR) remain the mainstay of surgical intervention for lesions with <25% glenoid bone loss. ³ However, residual instability may be a concern for patients with hyperlaxity or participation in contact sports, military service, or other physically demanding occupations. In recent studies, augmentation of ABR with the Remplissage procedure produced a lower risk of recurrent instability, ⁴ superior postoperative function, ⁵ , ⁶ providing a safe and effective option for addressing recurrent anterior instability.

Purchase et al. described the arthroscopic Remplissage technique, and since then, several techniques with various advantages had been proposed. ⁷ Suture collection within the subacromial space is often a time‐consuming step because of the lack of direct arthroscopic visualization and is associated with an increased risk of soft tissue interposition. Inadequate suture control may lead to unintended capture of surrounding structures, such as the deltoid muscle, during knot tying.

In this article and short Video 1, we show a straightforward and reproducible method to minimize soft tissue interposition and reduce suture retrieval time by enabling direct arthroscopic visualization and collection of all suture limbs through a single posterior portal.

VIDEO 1.

Download video file ^{(73.1MB, mp4)}

Arthroscopic rotator cuff Remplissage technique to limit soft tissue interposition. The patient is placed in left lateral decubitus position with the injured right shoulder in 45° abduction. Anterior, anterosuperior, and posterior portals are established. With the arm in external rotation, diagnostic arthroscopy is performed through anterosuperior portal, followed by thorough debridement of the lesions with a ring curette and arthroscopic shaver through the posterior portal. A double‐loaded Y‐Knot all‐suture anchor is placed in the center of the Hill‐Sachs lesion through the posterior portal. The posterior portal is retreated to between deltoid and rotator cuff, and tissue‐penetrating grasper is carefully advanced through the joint capsule through the posterior portal to ensure penetration on the tendinous part of the infraspinatus, while maintaining a single controlled deltoid penetration. All suture limbs are pulled out from the posterior portal and can be visualized with arthroscopy through the posterior portal. A spinal needle is used to create a lateral accessory portal reaching the suture limbs, through which all sutures are collected by a suture retriever. Viewing from the anterosuperior portal, the posterior portal is advanced into the joint capsule and is preserved for use in Bankart repair. With the arm in neutral position, the Bankart lesion is repaired with 4 single‐loaded Y‐Knot all‐suture anchors. The sutures for Remplissage procedure are tied with surgical knots through the lateral accessory portal under arthroscopy from the posterior portal after completion of arthroscopic Bankart repair. Video content can be viewed at https://doi.org/10.1002/atn2.70268.

SURGICAL TECHNIQUE

Preoperative Evaluations

The mechanism and presentation of injury should be documented when suspecting an anterior shoulder dislocation or instability. If the patient presents in an emergency setting, radiograph of shoulder including the anteroposterior view and Y‐view may reveal a dislocated humeral head and, sometimes, an extensive Bankart or Hill‐Sachs lesion. Computed tomography or magnetic resonance imaging should be performed to evaluate the lesion ⁸ (Figure 1). The on‐/off‐track concept can be implemented to aid surgical decision‐making. ³ , ⁹ Physical examination including apprehension test, load‐and‐shift test, and evaluation for hyperlaxity should be performed, preferably under general anesthesia. Sulcus sign or jerk test can be performed when there's suspicion of multidirectional instability.

FIGURE 1.

The patient is placed in left lateral decubitus position with the injured right shoulder in 45° abduction. MRI provides clear visualization of soft tissue which can be useful when evaluating Bankart and Hill‐Sachs lesion. (A) The Hill‐Sachs lesion is evaluated in transverse view at the slice that shows the widest Hill‐Sachs lesion. In this case, the width of the Hill‐Sachs lesion is 20.5 mm, and the bone bridge, which is the distance between the lateral margin of the Hill‐Sachs lesion and the insertion of the infraspinatus tendon, is 16.7 mm. (B) The Bankart lesion is evaluated in sagittal view at the slice closest to the articular surface of the glenoid. A best‐fit circle for the posterior and inferior margin of the glenoid was used to determine the diameter of glenoid (D), which is 32.3 mm in this case. The glenoid defect (d), which is the distance between the circle and the anterior margin of the remaining glenoid, is 7.3 mm. The lesion is an off‐track lesion with less than 25% glenoid bone loss. (MRI, magnetic resonance imaging.)

Patient Preparation

The patient is placed in the lateral decubitus position under general anesthesia. The injured shoulder is put in 45° abduction and is thoroughly disinfected with Hibiscrub and Betadine alcohol. The patient is then draped with only the injured shoulder exposed. An anterior portal, an anterosuperior portal, and a posterior portal are created for the procedure.

Diagnostic Arthroscopy

Diagnostic arthroscopy is performed through the anterosuperior portal with external rotation of the arm to validate preoperative findings and lesions and to locate both the Hill‐Sachs lesion and the Bankart lesion. Viewing from the anterosuperior portal, thorough debridement and shaving of the lesions are performed with a ring curette and arthroscopic shaver through the posterior portal to provide a clear surgical view and stimulate tissue healing.

Suture Anchor Placement and Suture Coverage on Rotator Cuff

Viewing from the anterosuperior portal while the arm remains in external rotation, the outlet of the posterior portal cannula is advanced into the joint capsule. A double‐loaded 1.8‐mm all‐suture anchor (Y‐Knot Flex, ConMed, Largo, FL) is placed, tapped, and deployed at the center of the Hill‐Sachs lesion through the posterior portal.

The posterior portal cannula is then retracted and repositioned so that its outlet is located between the deltoid muscle and the rotator cuff. A tissue‐penetrating grasper is used to penetrate the rotator cuff and retrieve the sutures through the posterior portal.

Because the cannula outlet consistently remains within the interval between the deltoid and the rotator cuff, all instruments travel through a single, controlled deltoid incision. This configuration allows a high degree of instrument maneuverability while simultaneously preserving the structural integrity of the deltoid muscle. Subsequently, all sutures are passed through the rotator cuff over a desired area to adequately fill the Hill‐Sachs lesion (Figure 2).

FIGURE 2.

The patient is placed in left lateral decubitus position with the injured right shoulder in 45° abduction. Suture coverage of the infraspinatus tendon. (A) Viewing from the anterosuperior portal and the outlet of posterior portal cannula between the deltoid muscle and the joint capsule. A tissue‐penetrating grasper (yellow arrow) is used to retrieve and to cover a desirable area of the infraspinatus tendon through the posterior portal. Under direct arthroscopic visualization, the sutures are made sure to only cover the tendinous part of the infraspinatus to minimize external rotation deficit. (B,C) Surgical instruments can be manipulated with a high degree of freedom (shown with red arrows) through the posterior portal. Because the cannula outlet is deep to the deltoid muscle, the instruments always travel through a single and secure incision of the deltoid muscle, preserving its structural integrity.

Suture Retrieval Through Accessory Portal

After all 4 suture limbs are retrieved through the posterior portal, direct arthroscopic visualization of the sutures is achieved by placing the arthroscope in the posterior portal. This approach significantly reduces the time required for suture retrieval compared with blind collection techniques. The posterior portal cannula is then slightly retracted to facilitate subsequent suture management.

A spinal needle is inserted percutaneously through the lateral aspect of the shoulder under direct arthroscopic visualization from the posterior portal to locate the sutures. A small skin incision is made at the needle entry point, and a lateral accessory portal is established (Figure 3). All 4 suture limbs are then retrieved simultaneously through this accessory portal using a suture retriever in a single maneuver, effectively minimizing soft tissue interposition (Figure 4). With the sutures securely collected, the posterior portal is preserved for subsequent Bankart repair (Figure 5).

FIGURE 3.

The patient is placed in left lateral decubitus position with the injured right shoulder in 45° abduction. Creation of lateral accessory portal. (A) A spinal needle (yellow arrow) is used as a guide to create a lateral accessory portal. (B) With the arthroscope in the posterior portal, the spinal needle can be seen reaching the sutures.

FIGURE 4.

The patient is placed in left lateral decubitus position with the injured right shoulder in 45° abduction. Suture collection through lateral accessory portal. (A) With the arthroscope in the posterior portal (red arrow) and the sutures (white arrow) still in the posterior portal, a suture retriever (yellow arrow) is used to retrieve the sutures through the previously made lateral accessory portal. (B) The suture retriever (yellow arrow) can be seen reaching the sutures under arthroscopy from the posterior portal. All sutures can be visualized through the posterior portal where they are pulled out by a tissue‐penetrating grasper, greatly reducing operation time compared with finding the sutures blindly. (C) The sutures are pulled out of the lateral accessory portal (white arrows), and they are left secured but not tied to avoid collapse of the posterior capsule before completion of Bankart repair. The sutures are pulled with a single maneuver under arthroscopy, minimizing soft tissue interposition in the process.

FIGURE 5.

The patient is placed in left lateral decubitus position with the injured right shoulder in 45° abduction. Preservation of posterior portal. (A) Because the sutures are moved to the lateral accessory portal and are secured, the posterior portal (yellow arrow) can then be advanced into the joint capsule again, preserved for use during Bankart repair. The posterior portal can be clearly visualized with the arthroscope through the anterosuperior portal. (B) The posterior portal is free to use during Bankart repair.

ABR and Completion of Procedure

After securing the sutures, the posterior portal cannula is advanced into the joint capsule again, and the arm is put into neutral position. In this case, the injured labrum is approximated and secured back to the glenoid with 4 single‐loaded 1.3‐mm suture anchors (Y‐Knot Flex All, ConMed). After completing ABR, the sutures of the Remplissage procedure are tied securely with surgical knots through the lateral accessory portal previously created (Figure 6). The posterior portal is still free for arthroscope insertion to assess the knots when tying them down.

FIGURE 6.

The patient is placed in left lateral decubitus position with the injured right shoulder in 45° abduction. Suture tying after completion of Bankart repair. (A) The sutures for Remplissage are exiting out of the lateral accessory portal (yellow arrow), and they are tied with surgical knots completing the operation. (B) Knot tying can be visualized through the posterior portal, which was preserved for Bankart repair in previous steps.

Rehabilitation Protocol

Sling immobilization is initiated immediately after surgery, and active exercises of the elbow, wrist, and hand are encouraged to preserve neuromuscular function of the adjacent joints. The sling is discontinued at 6 weeks postoperatively, followed by gradual restoration of shoulder range of motion with progressive flexion as well as internal and external rotation. Strengthening exercises are initiated after 3 months, with the goal of achieving full active range of motion. Return to sport is considered after 8 months postoperatively, provided that functional testing shows satisfactory results.

DISCUSSION

The technique presented in this study optimizes the Remplissage procedure by utilizing an accessory portal and controlling cannula depth, thereby effectively preventing soft tissue interposition and minimizing operative time. Surgical intervention should be considered when treating recurrent anterior shoulder instability, because conservative treatment may result in a high risk of recurrent instability, pain, and development of radiologically evident and symptomatic osteoarthritis. ¹⁰ Yamamoto et al. first described the concept of glenoid track when evaluating glenoid bone loss. ¹¹ The concept was further investigated by Di Giacomo et al., ³ who described the concept of “on‐track/off‐track lesion,” in which Remplissage procedure was recommended for off‐track lesions with glenoid bone loss less than 25%. Hatta Taku et al. provided further evidence supporting the use of this concept in surgical decision‐making. ⁹ It is of international consensus that Remplissage procedure is indicated for an off‐track lesion on preoperative imaging. ¹² A previous study published by Woodmass et al. also revealed that Remplissage procedure provided significantly lower postoperative instability and redislocation rate compared with isolated ABR. ¹³ Recently, Tansey et al. reported significant improvement in Rowe score without significant range of motion deficit with the Remplissage procedure in a systematic review. ¹⁴ Ahmed et al. reported significantly greater return‐to‐sport rate at any playing level and lower revision rate with the Remplissage procedure compared with isolated ABR. ⁶ The addition of the Remplissage procedure is not only safe and effective for management of off‐track lesions but also provides superior functional outcomes.

The modern arthroscopic Remplissage technique was described by Purchase et al. ⁷ Several techniques had been proposed since then. McQuivey et al. proposed a technique using knotless, all‐suture anchors. ¹⁵ The anchors were placed on the terminal ends of the Hill‐Sachs lesion, and the repair sutures were passed through each other creating a suture bridge to secure the posterior capsule and infraspinatus tendon onto the humeral head. The use of knotless suture anchors eliminated the bulk of tied knots when securing traditional suture anchors. Similar anchor positioning was also shown by Zhang et al. and Ashy et al.; the former combined a double‐pulley Remplissage technique with autologous iliac bone grafting for augmentation of glenoid bone loss, ¹⁶ and the latter collected the sutures with digital exploration through a posterior incision in their technique, which simplified the procedure at the cost of a larger surgical wound. ¹⁷ Edge et al. implemented the use of a percutaneous needle through the posterolateral portal. ¹⁸ The needle provided a guide when positioning the desired point of penetration of the inferior anchor on the infraspinatus tendon before irreversibly committing to the placement of the inferior anchor. Pushpasekaran et al. also used a spinal needle as a portal, ¹⁹ the needle penetrates the infraspinatus percutaneously and serves as a cannula for suture collection using polypropylene sutures, and the technique is repeated 4 times to achieve suture coverage for the infraspinatus, which also leaves 4 additional penetrations to surrounding soft tissues.

In the technique we propose, the anchor is positioned at the center of the Hill‐Sachs lesion. ²⁰ Tissue‐penetrating grasper is carefully advanced through the posterior capsule under direct arthroscopic visualization to ensure that the sutures passed through the tendinous portion of the infraspinatus rather than its muscular belly. This strategy minimizes postoperative external rotation deficit while providing adequate tenodesis coverage using a single‐suture anchor. In our previous experience, the tissue‐penetrating grasper was introduced through an additional incision rather than the posterior portal, resulting in unorganized sutures within the subacromial bursa. This configuration made suture retrieval more cumbersome and prolonged operative time. In contrast, with the technique described herein, all sutures are readily visualized through the posterior portal and can be retrieved under direct arthroscopic guidance through a spinal needle‐guided lateral accessory portal, significantly reducing suture management time. Furthermore, controlled mobilization of the posterior portal cannula at varying depths provides protection to the surrounding soft tissues and minimizes soft tissue interposition while maintaining sufficient freedom for instrument manipulation at each step.

This simplified arthroscopic Remplissage technique comes with several pearls. Controlled positioning of the posterior cannula at different depths allows safe passage of instruments between the deltoid and rotator cuff, whereas spinal needle‐guided creation of a lateral accessory portal enables direct visualization and efficient retrieval of all suture limbs. This approach reduces incisions on the deltoid, preserves the posterior portal for subsequent Bankart repair, and minimizes soft tissue interposition, thereby improving suture organization and operative efficiency. Potential pitfalls include incorrect cannula positioning and placing the posterior portal too medially, which may lead to unintended suture passage through the muscular portion of the infraspinatus (Table 1). Although an additional small incision is required for the accessory portal and suture passage in the subacromial bursa may increase technical complexity, these limitations are generally outweighed by the improved suture management, minimized soft tissue interposition, and reduced operative time achieved with this technique (Table 2). Overall, this technique facilitates efficient suture organization, shortens operative time, and reduces the risk of excessive soft tissue interposition.

TABLE 1.

Pearls and Pitfalls of Simplified Arthroscopic Remplissage

Pearls	Pitfalls
Cannula positioned at different depths for specific steps	Incorrect positioning of the cannula depth
Accessory portal securing sutures for Remplissage procedure	Placing the posterior portal too medially can result in penetration of sutures through the muscular part of the infraspinatus
Manipulation of tissue‐penetrating grasper between deltoid and rotator cuff Use of spinal needle to create the accessory portal for retrieving the sutures

TABLE 2.

Advantages and Disadvantages of Simplified Arthroscopic Remplissage

Advantages	Disadvantages
Tissue‐penetrating grasper can be manipulated through an ensured single incision of deltoid muscle	Though small in size, additional incision is required for securing the sutures
With the sutures secured in the accessory portal, the posterior portal is preserved for further use in Bankart repair	Complexity of suture passage between deltoid and rotator cuff
Minimized soft tissue interposition by retrieving the sutures under arthroscopy
Shortened operation time with confidence when manipulating instruments with minimal soft tissue interposition

DISCLOSURES

The authors (C‐L.T., K‐H.C., E‐R.C., H‐H.M.) declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Tao Chun‐Lin, Chen Kun‐Hui, Chiang En‐Rung, Ma Hsuan‐Hsiao. Arthrosc Tech. 2026; 15:e70268. 10.1002/atn2.70268