Editorial Commentary: Double-Pulley Remplissage Using Transtendon Anchors: Keep It Simple.

A large Hill-Sachs lesion that engages the glenoid rim and predisposes to recurrent anterior instability confers a substantial management challenge. Arthroscopic remplissage, either in isolation or combined with anterior labral repair, gives the arthroscopic surgeon a tool to stabilize the shoulder without reverting to more extensive open procedures or bone block reconstructions. In arthroscopic remplissage, the posterior capsule and infraspinatus are sutured into the humeral defect to limit such engagement between the HilleSachs lesion and the glenoid rim. The double-pulley technique using 2 transtendon anchors makes arthroscopic remplissage technically simpler, and potentially more reproducible, than earlier techniques. As we refine remplissage techniques, we need to further explore issues such as the optimal distance between the 2 anchors (and hence the resultant tendon bridge) as this distance-along with the pliability of the tendon-potentially determines how much compression against the bone can be achieved. Furthermore, as remplissage techniques are proven to be effective in restoring shoulder stability and conferring successful clinical function, there is even more need for high-quality comparative studies to define their role versus that of more extensive open stabilization procedures. Mechanistic studies are also needed to define the fill-effect versus the possible check-rein and neuromuscular control activation components of remplissage.