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. 2014 Jan 3;472(8):2363–2371. doi: 10.1007/s11999-013-3436-2

Remplissage Versus Latarjet for Engaging Hill-Sachs Defects Without Substantial Glenoid Bone Loss: A Biomechanical Comparison

Ryan M Degen 1, Joshua W Giles 1, James A Johnson 1, George S Athwal 1,✉
PMCID: PMC4079856  PMID: 24385035

Abstract

Background

Recurrent shoulder instability is commonly associated with Hill-Sachs defects. These defects may engage the glenoid rim, contributing to glenohumeral dislocation. Two treatment options to manage engaging Hill-Sachs defects are the remplissage procedure, which fills the defect with soft tissue, and the Latarjet procedure, which increases glenoid arc length. Little evidence exists to support one over the other.

Questions/purposes

We performed a biomechanical comparison of the remplissage procedure to the traditional Latarjet coracoid transfer for management of engaging Hill-Sachs defects in terms of joint stiffness (resistance to anterior translation), ROM, and frequency of dislocation.

Methods

Eight cadaveric specimens were tested on a shoulder instability simulator. Testing was performed with a 25% Hill-Sachs defect with an intact glenoid and after remplissage and Latarjet procedures. Joint stiffness, internal-external rotation ROM, and frequency of dislocation were assessed. Additionally, horizontal extension ROM was measured in composite glenohumeral abduction.

Results

After remplissage, stiffness increased in adduction with neutral rotation (12.7 ± 3.7 N/mm) relative to the Hill-Sachs defect state (8.7 ± 3.3 N/mm; p = 0.016). The Latarjet procedure did not affect joint stiffness (p = 1.0). Internal-external rotation ROM was reduced in abduction after the Latarjet procedure (49° ± 14°) compared with the Hill-Sachs defect state (69° ± 17°) (p = 0.009). Horizontal extension was reduced after remplissage (16° ± 12°) relative to the Hill-Sachs defect state (34° ± 8°) (p = 0.038). With the numbers available, there was no difference between the procedures in terms of the frequency of dislocation after reconstruction: 84% of specimens (27 of 32 testing scenarios) stabilized after remplissage, while 94% of specimens (30 of 32 testing scenarios) stabilized after the Latarjet procedure.

Conclusions

Both procedures proved effective in reducing the frequency of dislocation in a 25% Hill-Sachs defect model, while neither procedure consistently altered joint stiffness.

Clinical Relevance

In the treatment of shoulder instability with a humeral head bone defect and an intact glenoid rim, this study supports the use of both the remplissage and Latarjet procedures. Clinical studies and larger cadaveric studies powered to detect differences in instability rates are needed to evaluate these procedures in terms of their comparative efficacy at preventing dislocation, as any differences between them seem likely to be small.

Introduction

In addition to capsuloligamentous disruptions, traumatic shoulder dislocations frequently result in osseous defects of the anteroinferior glenoid rim (bony Bankart lesions) or impaction fractures of the posterosuperior humeral head (Hill-Sachs defects). Hill-Sachs defects differ in size and orientation, producing variable effects on subsequent shoulder instability. Some research suggests that, when a lesion represents more than 20% of the diameter of the humeral head, the arc of motion available before the lesion engages the anterior glenoid rim in abduction and external rotation is reduced, facilitating an anterior dislocation [12, 19]. However, the best treatment option for a defect of this size is controversial. It has been demonstrated that isolated soft tissue Bankart repair with a Hill-Sachs defect of large proportion leads to higher instability recurrence rates [3, 4]. Treating the associated Hill-Sachs defect, however, can dramatically reduce recurrence rates from as high as 67% down to 2% to 5% [3, 5]. Procedures described to address this humeral head defect include allograft humeral head reconstruction, rotational proximal humeral osteotomies, osteochondral transplant, or even humeral head replacement [1]. Two additional procedures, the remplissage procedure and Latarjet coracoid transfer, are aimed at limiting defect engagement and subsequent dislocation.

The remplissage procedure, initially described by Purchase et al. [20] in 2008, involves an arthroscopic posterior capsulodesis and infraspinatus tenodesis into the Hill-Sachs defect. This converts the intraarticular defect into an extraarticular defect and prevents engagement through a soft tissue bumper effect. With a reported success rate of 93% in one study, this represents a viable treatment option [20].

Similarly, the Latarjet coracoid transfer, more commonly used in the reconstruction of glenoid-sided bone loss, has been proposed as a treatment for engaging Hill-Sachs defects [6, 8]. Transfer of the coracoid process to the anteroinferior glenoid rim extends the glenoid arc length, providing not only additional bony support but also a restrictive soft tissue sling effect that helps resist anterior translation of the humeral head [5, 9, 22]. By increasing the glenoid arc length, and subsequently the distance to the reconstructed anterior glenoid rim, greater external rotation and anterior translation are required before a defect can engage, reducing the frequency of glenohumeral dislocation [5].

Little evidence exists to support one procedure over the other. We therefore performed a biomechanical comparison of the remplissage procedure to the traditional Latarjet coracoid transfer for management of engaging Hill-Sachs defects with an intact glenoid rim. Glenohumeral joint stiffness, or the resistance to anterior translation of the humeral head during force application, and ROM in various arm configurations and planes of motion were the primary outcomes measured. A secondary outcome measure included joint stability (frequency of dislocation). We hypothesized that shoulders treated with a Latarjet coracoid transfer would have greater stability and preserved ROM relative to shoulders treated with the remplissage procedure.

Materials and Methods

Specimen Preparation

Eight fresh-frozen cadaveric shoulder specimens were used for this study (age: 74 ± 11 years). An a priori power analysis was performed and eight specimens were determined to be sufficient to achieve a minimum power of 80% in detecting clinically relevant differences of 10° for ROM and 30% for joint stiffness, with an alpha of 0.05. Sample size calculations were performed for each outcome variable separately due to the varying SDs associated with each. Before specimen preparation, CT scans were obtained and reviewed to ensure specimen quality was satisfactory for testing. Any evidence of trauma, rotator cuff tears, arthritic changes of the glenohumeral joint, or cystic changes in the humeral head were used as exclusion criteria. Each specimen was allowed to thaw for 24 hours before preparation. Some superficial soft tissues were removed; however, the origin and insertions of the deltoid muscle, rotator cuff muscles, both heads of the biceps, and the glenohumeral capsule were preserved. Number 2 Ethibond® sutures (Ethicon Inc, Somerville, NJ, USA) were placed into the tendons of the three heads of the deltoid, supraspinatus, infraspinatus, teres minor, subscapularis, the conjoint group, and the long head of the biceps to allow the application of physiologic loads via the shoulder instability simulator [10, 11, 13, 14, 23, 25].

The proximal portion of a steel intramedullary rod fitted with a six-degrees-of-freedom load cell (Mini45; ATI Industrial Automation, Apex, NC, USA) was cemented into the humeral canal such that a transverse reference axis on the rod was aligned with the anatomic epicondylar axis as described by Wellmann et al. [25]. It was then possible to connect the specimen to the shoulder simulator during testing via the distal end of the rod (Fig. 1).

Fig. 1.

Fig. 1

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A rendering of the in vitro shoulder simulator is shown, including a mounted specimen with soft tissues removed for clarity. The overlaid arrows indicate the loading vectors for each of the muscle groups: FDELTS = three deltoid heads; FSUP = supraspinatus; FINF = infraspinatus and teres minor; FSSC = subscapularis; FLHB = long head of the biceps; FSHB = conjoint tendon of the short head of the biceps. The simulator is capable of physiologically orienting the scapula and glenohumeral joint in four degrees of freedom and is shown with a potted scapula specimen (with soft tissues omitted for clarity) (A), a humerus (with soft tissues omitted for clarity) (B), a computer-controlled scapular elevation mechanism that achieves repeatable positioning (C), a glenohumeral abduction guide arc and slider (D), a glenohumeral plane of elevation adjustment plate (E), a low-friction deltoid and rotator cuff guide system that routes cables to pneumatic actuators (F), six-degrees-of-freedom tracking markers (G), a cemented humeral rod with an interposed six-degrees-of-freedom load cell (H), and pneumatic actuators used to separately load the rotator cuff, deltoid, and biceps tendons (I).

Shoulder Simulator

Each specimen was mounted to the shoulder simulator by cementing the inferior portion of the scapula into the scapular pot in 10° of forward inclination. To cement the scapula, soft tissues on the inferior portion of the scapula were removed. The humeral intramedullary rod was then connected to the simulator via a spherical bearing, which allowed the specimen to be positioned throughout its ROM while permitting unaffected glenohumeral kinematics. It was then possible to test the specimen in repeatable glenohumeral and scapulothoracic orientations through adjustment of the custom stability testing apparatus. The nine sutured tendons were passed through alignment guides to ensure physiologic force vectors and connected to computer-controlled pneumatic actuators (Airpot Co, Norwalk, CT, USA). The conjoint tendon was loaded with 10 N and the supraspinatus, subscapularis, and the combination of the infraspinatus and teres minor were all loaded with 7.5 N each [10, 11, 13, 14, 23, 25]. The anterior, lateral, and posterior heads of the deltoid muscle were each loaded with 5 N [11, 18, 23, 25]. Applied loads were determined from previous studies with similar testing protocols, as well as from literature examining the effect of muscular loading on joint compression [7, 9, 10, 17, 24, 25].

Optical markers (Optotrak Certus®; Northern Digital, Waterloo, ON, Canada) were mounted on the scapula and humerus to continuously monitor glenohumeral kinematics including joint translations and rotations during the testing protocol. Additionally, a clinically relevant coordinate system was created using a series of points digitized on the humerus and scapula relative to these bone-affixed optical markers in accordance with International Society of Biomechanics recommendations [26]. The axes of these coordinate systems coincide with standard definitions of shoulder motion and thus carry clinical meaning.

Surgical Protocol

This protocol was designed to test the effects of the remplissage and Latarjet procedures on shoulder stability and motion in the setting of a moderate (25%) Hill-Sachs defect. A lesser tuberosity osteotomy was performed to allow repetitive access to the joint, initially for creation of the engaging Hill-Sachs defect but also for access for performing the remplissage and Latarjet procedures. The lesser tuberosity osteotomy has been shown to preserve shoulder stability and ROM [11]. Testing was conducted on the intact shoulder after creation and repair of the lesser tuberosity osteotomy and again after creation of a soft tissue Bankart lesion, which involved releasing the anteroinferior portion of the labrum from the glenoid rim and releasing the inferior glenohumeral joint capsule. Additionally, specimens were tested after creation of a 25% Hill-Sachs defect and after treatment with the remplissage and Latarjet procedures. With the Latarjet procedure involving an osteotomy of the coracoid and release of attached soft tissue stabilizers, we believed that the remplissage would not be accurately represented if performed after this. As a result, in each specimen, the remplissage procedure was conducted first, after which the sutures were released and the Latarjet procedure was subsequently performed. The total duration of our testing protocol for each specimen, including both the remplissage and Latarjet procedures, was well below the upper limit established by King et al. [15], where the effect of low-load mechanical testing was observed over an extended period of testing. As a result, we did not believe that performing the Latarjet second would jeopardize our results.

The Hill-Sachs defect was created in accordance with the work of Sekiya et al. [21] and Yamamoto et al. [28]. The specimens were positioned in 90° of combined abduction (30° of scapular abduction and 60° of glenohumeral abduction) and 60° of external rotation. The anteroinferior glenoid margin was then observed and a mark parallel to this was placed on the humeral head to simulate the orientation of the Hill-Sachs defect. The width of the head was then measured perpendicular to this line using a digital caliper and a 25% defect was created in this orientation at the posterosuperior aspect of the humeral head with a microsagittal saw. The depth of the lesion extended to the articular margin of the humeral head, with the osteotomy in line with the anatomic neck (Fig. 2).

Fig. 2.

Fig. 2

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A 25% Hill-Sachs defect is shown.

The remplissage procedure was performed by placing two single-loaded suture anchors (Super Revo®; ConMed Linvatec, Largo, FL, USA) into the valley of the Hill-Sachs defect (Fig. 3). The accompanying sutures were then passed through the posterior capsule and infraspinatus tendon using a straight needle. The horizontal mattress sutures were then tied, insetting these soft tissue structures into the Hill-Sachs defect.

Fig. 3.

Fig. 3

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A remplissage procedure with placement of suture anchors in the valley of the Hill-Sachs defect is shown.

The Latarjet procedure was performed in the classic manner using two screws for fixation [16]. The coracoid body was exposed and osteotomized at its angle while leaving the conjoint tendon attachment intact. A horizontal split in the subscapularis was then made at the junction of the middle and inferior thirds. The coracoid and attached conjoint tendon were passed through this split. The coracoid was then fixed to the anteroinferior glenoid rim using two 3.75-mm cannulated cortical screws (Arthrex, Inc, Naples, FL, USA) of sufficient length to achieve bicortical fixation (Fig. 4).

Fig. 4.

Fig. 4

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A Latarjet reconstruction with the coracoid fixed to the anteroinferior glenoid with two cortical screws is shown.

Experimental Protocol and Outcome Variables

Rotational ROM was assessed by internally and externally rotating the arm in both abduction and adduction. The rotational force utilized for this measurement was applied via the constrained intramedullary humeral rod, where the boundaries of maximal rotation were determined when a predefined torque of 0.8 Nm was measured with our six-degrees-of-freedom load cell. The 0.8-Nm torque criterion was obtained as an average of several trials by the senior author (GSA) manually rotating a pilot test specimen to the extremes of motion and stopping when encountering resistance consistent with clinical examination.

Glenohumeral joint stability was assessed with the application of an 80-N quasistatic force to the posterior aspect of the humeral head in the anteroinferior direction, consistent with the force applied during a clinical anterior drawer test [14, 20]. This load was applied through a uniaxial load cell (Model 34 Precision Miniature; Honeywell, Golden Valley, MN, USA). Tracking allowed for calculation of joint stiffness (N/mm) based on the amount of anterior humeral head translation measured with the applied force. The force was applied until real-time data from our load cell demonstrated a resistive force of 80 N provided by the shoulder stabilizers or until a dislocation occurred, at which point loading was stopped to avoid permanent deformation or damage to our specimen that would have precluded further testing. Both engagement and shoulder dislocation were determined by two observers (JWG, RMD) and corroborated with the optical tracking data that showed an abrupt medialization of the humeral head relative to the glenoid. Joint stiffness was assessed with the humerus adducted and abducted in both neutral and 60° of external rotation. Horizontal extension ROM was also assessed with the arm in a position of 90° of combined abduction and 60° of external rotation (Fig. 5).

Fig. 5.

Fig. 5

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A flow diagram demonstrates the testing protocol followed for each specimen in each condition (intact, Hill-Sachs defect, remplissage, and Latarjet coracoid transfer). ER = external rotation; IR = internal rotation; N = neutral.

Statistical Analysis

Joint stiffness and glenohumeral ROM were monitored as our primary outcome measures with a 30% increase in stiffness and a 10° decrease in ROM set as our clinically significant differences, as utilized in our power calculation. One-way ANOVA tests and pairwise comparisons were conducted for these variables. Secondarily, we also monitored the frequency of glenohumeral dislocations, although we were not statistically powered to detect a difference for this parameter. We used the SPSS® 21.0 software package (SPSS Inc, Chicago, IL, USA) for all statistical analyses. Significance was set at p values of less than 0.05.

Results

Joint Stiffness

With the arm in abduction and external rotation (ie, the position of apprehension), both the remplissage and the Latarjet procedures were able to restore joint stiffness values to near intact levels, with no differences in stiffness between them (p = 1.0, 0.224; Fig. 6A). The defect state was found to be less stiff (more unstable) than the intact state (p = 0.029). With the arm in abduction and neutral rotation, no differences in joint stiffness were noted between remplissage (mean ± SD: 5.5 ± 3.2 N/mm) and the Latarjet procedure (5.7 ± 3.3 N/mm) (p = 0.907) (Fig. 6B).

Fig. 6A–D.

Fig. 6A–D

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Graphs show joint stiffness in (A) abduction and external rotation, (B) abduction and neutral rotation, (C) adduction and neutral rotation, and (D) adduction and external rotation among the four specimen states (intact, Hill-Sachs defect, remplissage, and Latarjet coracoid transfer). (A) Joint stiffness in abduction and external rotation is lower (more unstable) in the Hill-Sachs defect state than in the intact state (p = 0.029). Both remplissage and Latarjet restore stiffness to intact levels, with no differences between groups (p > 0.08). (B) No significant differences are noted between the remplissage and Latarjet groups in joint stiffness in abduction and neutral rotation (p = 0.907). (C) Remplissage has significantly greater joint stiffness in adduction and neutral rotation compared to the Latarjet procedure (p = 0.003). Neither procedure is significantly different from intact (p = 1.0). (D) No significant differences are noted between the remplissage and Latarjet groups in joint stiffness in adduction and external rotation (p = 0.137). Values are shown as means with SDs (error bars). HSD = Hill-Sachs defect.

With the arm in adduction and neutral rotation, the remplissage procedure resulted in more joint stiffness (13 ± 3.7 N/mm) than the Latarjet procedure (7.0 ± 2.3 N/mm) (p = 0.003), with neither procedure differing from the intact specimen (8.7 ± 3.3 N/mm) (p = 1.0) (Fig. 6C). With the arm in adduction and external rotation, no differences were noted in joint stiffness (p = 0.137) (Fig. 6D).

ROM

Testing horizontal extension, in the position of anterior apprehension with the arm in abduction and external rotation, the remplissage procedure reduced this ROM (16° ± 12°) relative to the Latarjet procedure (34° ± 8°) (p = 0.043), while the Latarjet procedure did not affect this motion relative to the Hills-Sachs defect state (34° ± 8°) (p = 1.0). Once again, neither procedure affected extension ROM compared to the intact specimen (30° ± 11°) (p > 0.19) (Fig. 7).

Fig. 7.

Fig. 7

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A graph shows horizontal extension ROM with the arm in abduction and external rotation (60°) among the four specimen states (intact, Hill-Sachs defect, remplissage, and Latarjet coracoid transfer). Remplissage significantly reduces this motion (16.1° ± 12.1°) relative to the Latarjet procedure (34.4° ± 7.8°) (p = 0.043). The Latarjet procedure does not affect this motion relative to the Hill-Sachs defect state (34.3° ± 7.6°) (p = 1.0). Neither procedure significantly affects this motion compared to the intact specimen (29.7° ± 10.5°) (p > 0.19). Values are shown as means with SDs (error bars). HSD = Hill-Sachs defect.

With the arm in an adducted position, no effect on internal-external rotation ROM was noted (p > 0.24) (Fig. 8A). With the humerus abducted, the Latarjet procedure reduced the overall internal-external rotation ROM (49° ± 14°) relative to the Hill-Sachs defect state (69° ± 17°) (p = 0.009), while the remplissage procedure did not limit this motion (69° ± 12°) (p = 1.0). Neither procedure altered the ROM compared to the intact specimen (62° ± 18°) (p > 0.13) (Fig. 8B).

Fig. 8A–B.

Fig. 8A–B

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Graphs show internal-external rotation ROM in (A) adduction and (B) abduction among the four specimen states (intact, Hill-Sachs defect, remplissage, and Latarjet coracoid transfer). (A) No significant effect in internal-external rotation ROM in adduction is noted (p > 0.24). (B) The Latarjet procedure limits internal-external rotation ROM in abduction relative to the Hill-Sachs defect state (p = 0.009), while remplissage does not (p = 1.0). Neither procedure significantly alters this motion compared to the intact specimen (p > 0.13). Values are shown as means with SDs (error bars). IR/ER = internal-external rotation; HSD = Hill-Sachs defect.

Frequency of Dislocation

With the numbers available, no difference was noted between the treatment groups in terms of the frequency of dislocation, where the remplissage had an overall stabilization rate of 84% (27 of 32 testing scenarios) and the Latarjet procedure had an overall stabilization rate of 94% (30 of 32 testing scenarios), although we were not powered to detect a difference for this outcome measure. With the arm in adduction, the remplissage and Latarjet procedures also experienced no dislocations. With testing in abduction after the remplissage procedure, two and three dislocations occurred with the arm in neutral and external rotation, respectively. None of the intact specimens dislocated. After creation of the Hill-Sachs defect, no specimens dislocated in the adducted group, while seven specimens dislocated in both abduction neutral rotation and abduction external rotation (Table 1).

Table 1.

Frequency of dislocation after application of anteroinferiorly directed 80-N force

Position Number of specimens
Hill-Sachs defect Latarjet procedure Remplissage procedure
Abduction and neutral rotation 7 1 2
Abduction and external rotation 7 1 3
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Discussion

The treatment of engaging Hill-Sachs defects with an intact glenoid rim remains controversial. While studies have shown the role these defects play in perpetuating instability [3, 4], a consensus on critical defect values and the best treatment options are lacking [12, 19]. Generally, defects measuring less than 20% of humeral head width are adequately stabilized with an isolated soft tissue Bankart repair [7, 19]. However, for defects measuring 20% to 40%, there are minimal comparative data on existing treatment options to support one over another [1, 19, 22]. The various procedures can be separated into two classes: anatomic procedures, which attempt to restore normal proximal humeral anatomy, and nonanatomic procedures, which attempt to limit engagement of the Hill-Sachs defect [1, 19, 21, 22, 27]. Of the nonanatomic procedures, proponents of remplissage favor this procedure because it can be done arthroscopically, heals predictably with minimal reported limitations on ROM, and is associated with success rates of up to 98% [2, 22]. On the other hand, proponents of the Latarjet procedure favor it because of the conferred triple effect, including restoration of the glenoid arc, providing a sling effect via the transferred conjoint tendon and subscapularis tensioning, and repairing the joint capsule with augmentation via the coracoacromial ligament, citing a success rate of up to 95% [5]. Additionally, the Latarjet can now be done arthroscopically. No comparative studies exist, so we attempted to provide biomechanical data on these two nonanatomic procedures to support their use in the setting of recurrent instability with a Hill-Sachs defect. Specifically, we monitored their effect on joint stability (frequency of dislocation and stiffness) and ROM (internal-external rotation and horizontal extension).

Limitations of this study include the use of elderly specimens and the applicability of these results to the younger population more apt to experience shoulder instability. Additionally, we are limited by the fact that our results represent Time 0 biomechanics, with no ability to account for patients’ healing responses beyond this cadaver model. Additionally, the remplissage procedure is typically performed arthroscopically, but given our testing setup, this was not possible. However, when performing this procedure with the joint open, we made every effort to pass the sutures in a manner technically similar to the arthroscopic method. Given this, differences in suture placement through the posterior capsule and rotator cuff may still have occurred. As stated earlier, we were limited in our ability to conduct these two stabilization procedures in a randomized fashion. As a result, the remplissage was performed and followed in succession by the Latarjet coracoid transfer for each specimen. However, we did not consider this a major limitation as the stiffness after Latarjet coracoid transfer was not adversely affected by the duration or order of testing, and the frequency of dislocation was actually lower after the Latarjet procedure relative to remplissage, despite being performed later in our testing protocol. Finally, we were underpowered to compare the two procedures in terms of frequency of dislocation; both achieved this end with a relatively high degree of success, but clinical studies and larger cadaveric studies powered to detect differences in instability rates are needed to make more robust comparisons on this important end point.

Joint stiffness in adduction and neutral rotation was increased after the remplissage procedure, while in adduction and external rotation no differences were identified after either procedure. Stiffness in abduction and neutral rotation was not affected after either procedure, while in the abducted externally rotated position the remplissage procedure increased stiffness relative to the Hill-Sachs defect state. Neither procedure altered stiffness in comparison to the intact specimen group. This likely means that the introduced stiffness in the few select conditions noted above is insignificant, although further clinical study may be required to further validate our selection of a 10° change in ROM for our power analysis.

Neither procedure influenced the internal-external ROM in the adducted position. However, Elkinson et al. [7] noted in their biomechanical study of the remplissage procedure that internal-external rotation was found to be reduced with the humerus adducted. Similar to their results in abduction, our testing produced no effect, likely due to a decrease in rotator cuff tension in the abducted position [7]. Conversely, after the Latarjet procedure, there was no effect on internal-external rotation ROM in adduction, while in abduction a 29% decrease in this ROM relative to the Hill-Sachs defect state was noted. This likely relates to the tensioning effect of the conjoint tendon on the inferior capsule and lower subscapularis fibers with increasing external rotation [9]. Horizontal extension was reduced by 53% after remplissage relative to the Hill-Sachs defect state. This is attributable to the fact that the inset posterior capsule and infraspinatus tendon form a bumper that impinges on the posterior glenoid rim, limiting extension but also preventing defect engagement [7]. This was detected as gapping of the glenohumeral joint in our tracking data, which confirmed the end point of extension caused by this soft tissue impingement. The Latarjet coracoid transfer, however, did not affect horizontal extension in abduction. As slight restrictions in ROM after the Latarjet procedure for rotational ROM and after remplissage in horizontal extension, individualized patient scenarios may arise where preservation of either rotation or horizontal extension may be desirable.

Finally, we noted that neither group experienced a dislocation in the adducted position. After remplissage, two and three dislocations were noted in the abducted neutrally rotated and abducted externally rotated positions, respectively, while only one dislocation was seen in both of those conditions after the Latarjet procedure. Both procedures effectively stabilized the shoulder with an engaging Hill-Sachs defect, with no difference in the frequency of dislocations between the procedures with the numbers we had available for study. Similar clinical results have been identified by Boileau et al. [2] who noted only a 2% recurrence rate after remplissage. Unfortunately, no literature exists in terms of clinical results of the Latarjet coracoid transfer for isolated humeral head defects.

In summary, we evaluated the biomechanical effects of the remplissage and Latarjet procedures in the treatment of a moderately sized engaging Hill-Sachs defect with an intact glenoid rim. Both the remplissage and Latarjet procedures improved joint stability, reducing the overall frequency of dislocation, while having minimal effect on global shoulder ROM. Further clinical studies are required to determine the functional significance of the slight restrictions in ROM after the remplissage procedure in horizontal extension and after the Latarjet procedure for rotational ROM, as well as to evaluate the procedures in terms of their comparative efficacies in preventing recurrent dislocation, although our biomechanical results suggest that any differences between them in this parameter are likely to be small.

Footnotes

The institution of the authors has received funding from the Academic Medical Organization of Southwestern Ontario (London, Ontario, Canada) and the National Science and Engineering Research Council (Ottawa, Ontario, Canada).

All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research editors and board members are on file with the publication and can be viewed on request.

Each author certifies that his or her institution approved the human protocol for this investigation and that all investigations were conducted in conformity with ethical principles of research.

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