Arthroscopic Double-Pulley Remplissage Technique for Engaging Hill-Sachs Lesions in Anterior Shoulder Instability Repairs

Intra-articular view of a right shoulder from anterosuperolateral viewing portal. (A) A 30° arthroscope shows the Hill-Sachs defect. (B) A 70° arthroscope provides an even better view of the entire Hill-Sachs defect.

An angled ring curette, through a posterior working portal, is used to prepare the Hill-Sachs bone bed to a bleeding base.

Two transtendon spinal needles are placed, one near the superior aspect of the Hill-Sachs lesion and the other near its inferior aspect. The spinal needles traverse the subacromial space and cross the infraspinatus tendon just lateral to the musculotendinous junction.

Subacromial view of a right shoulder from posterior viewing portal. The bursal tissue around the 2 spinal needles is liberally debrided to afford clear visualization of the sutures once the suture anchors are placed.

Intra-articular view (left shoulder) from anterosuperolateral viewing portal. (A) The transtendon cannula (Spear Guide; Arthrex) is inserted adjacent to the spinal needle. (B) Two anchors have been placed, one at the superior aspect of the Hill-Sachs lesion and one at its inferior aspect.

A double-pulley technique is used to create a double-mattress suture between the 2 anchors, firmly compressing the tendon bridge against the bone bed of the Hill-Sachs lesion.

(A) Subacromial and (B) intra-articular views of completed remplissage. This intra-articular view through an anterosuperolateral viewing portal shows how the remplissage has exteriorized the Hill-Sachs defect and excluded it from the joint.