Long-term outcome of arthroscopic remplissage in addition to the classic Bankart repair for the management of recurrent anterior shoulder instability with engaging Hill-Sachs lesions

Rehabilitation Protocol Variability Following Arthroscopic Bankart Repair and Remplissage for Management of Anterior Shoulder Instability: A Systematic Review

Background

Augmentation of an arthroscopic Bankart repair with the remplissage (ABR) procedure has shown to confer a decrease in recurrence rates, yet, at the expense of potentially compromising shoulder motion.

Purpose/Hypothesis

The purpose was to examine clinical studies that described a post-operative rehabilitation protocol after an arthroscopic Bankart repair and remplissage procedure. It was hypothesized that a review of the literature would find variability among the studies and that, among comparative studies, there would be a limited distinction from protocols for isolated Bankart repairs.

Study design

Systematic Review.

Materials and Methods

A search was conducted using three databases (PubMed, EMBASE, and CINAHL) according to the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) guidelines. The following terms were combined while utilizing Boolean operators: (Bankart lesion OR labral tear) AND (remplissage). Studies evaluating patients after arthroscopic stabilization for unidirectional anterior glenohumeral instability with the addition of the remplissage procedure and at least 1 year follow-up were included for analysis.

Results

A total of 41 studies (14 Level IV, 24 Level III, 2 Level II, and 1 Level I) were included with a total of 1,307 patients who underwent ABR. All patients had <30% glenoid bone loss and a range of 10-50% humeral head size Hill-Sachs lesion. Type and position of immobilization were the most reported outcomes (41/41) followed by time of immobilization (40/41). Moreover, 23/41 studies described their initial post-operative shoulder range of motion restrictions, while 17/41 specified any shoulder motion allowed during this restrictive phase. Time to return to sport was also described in 37/41 of the retrieved studies. Finally, only two of the 27 comparative studies tailored their rehabilitation protocol according to the specific procedure performed, underscoring the lack of an individualized approach (i.e. same rehabilitation protocol for different procedures).

Conclusion

The results of the present systematic review expose the variability among rehabilitation protocols following ABR. This variability prompts consideration of the underlying factors influencing these disparities and underscores the need for future research to elucidate optimal rehabilitation. Based on the results of this systematic review and the senior authors´ clinical experience, a rehabilitation approach similar to an isolated Bankart repair appears warranted, with additional precautions being utilized regarding internal rotation range of motion and external rotation strengthening.

Level of Evidence

Level 3.

Arthroscopic subscapularis augmentation of the classic Bankart repair leads to satisfactory clinical and functional mid-term outcomes in patients with recurrent anterior shoulder instability and less than a subcritical glenoid bone loss

PURPOSE

The long-term failure rate of the arthroscopic Bankart repair may reach unacceptable values, raising the need to augment this classic procedure. Arthroscopic subscapularis augmentation is the tenodesis of the upper part of the subscapularis tendon to the anterior glenoid rim. The aim of the study was to evaluate the mid-term clinical and functional outcomes of patients operated with arthroscopic subscapularis augmentation of the classic Bankart repair due to recurrent anterior shoulder instability.

METHODS

This is a retrospective single-centre case series study with prospectively collected data. All patients suffered from recurrent anterior shoulder instability and had glenoid bone loss less than 13.5% of the inferior glenoid diameter (subcritical glenoid bone loss). Patients with greater anterior glenoid bone defect, engaging Hill-Sachs lesions, multidirectional instability or subscapularis insufficiency were excluded. Postoperatively, all patients were evaluated for recurrence and apprehension. The patient's shoulder range of motion and functional scores were recorded.

RESULTS

The final study cohort included 34 patients with a mean age of 29.3 ± 10.2 years. The mean follow-up period was 42.4 ± 10.7 months (range, 24-62 months). Two out of 34 patients (5.8%) experienced a re-dislocation postoperatively, while one additional patient had a subjective feeling of apprehension. External rotation at the last follow-up was lower compared to preoperative values or the healthy side, but only one patient had restrictions in his sporting activities. The functional scores were significantly increased compared to the preoperative values. Twenty-two out of 26 patients (84.6%) returned to the same level of sporting activities, and 30/34 patients (88.2%) were highly satisfied with the results.

CONCLUSION

Arthroscopic subscapularis augmentation of the classic Bankart repair reduces the dislocation recurrence rate and leads to satisfactory clinical and functional mid-term outcomes in patients with recurrent anterior shoulder instability and less than a subcritical glenoid bone loss.

LEVEL OF EVIDENCE

Level IV.

Arthroscopic Bankart Repair With Remplissage in Anterior Shoulder Instability Results in Fewer Redislocations Than Bankart Repair Alone at Medium-term Follow-up of a Randomized Controlled Trial

BACKGROUND

A multicenter, double-blinded randomized controlled trial comparing isolated Bankart repair (NO REMP) to Bankart repair with remplissage (REMP) reported benefits of remplissage in reducing recurrent instability at 2 years postoperative. The ongoing benefits beyond this time point are yet to be explored.

PURPOSE

To (1) compare medium-term (3 to 9 years) outcomes of these previously randomized patients undergoing isolated Bankart repair (NO REMP) or Bankart repair with remplissage (REMP) to manage recurrent anterior glenohumeral instability; (2) examine the failure rate, overall recurrent instability, and reoperation rate.

STUDY DESIGN

Randomized controlled trial; Level of evidence, 1.

METHODS

Recruitment and randomization for the original randomized trial occurred between 2011 and 2017. Patients ≥14 years diagnosed with recurrent traumatic anterior shoulder instability with an engaging Hill-Sachs defect of any size were included. Those with a glenoid defect >15% were excluded. In 2020, participants were contacted by telephone and asked standardized questions regarding ensuing instances of subluxation, dislocation, or reoperation on their study shoulder. "Failure" was defined as a redislocation, and "overall recurrent instability" was described as a redislocation or ≥2 subluxations. Descriptive statistics, relative risk, and Kaplan-Meier survival curve analyses were performed.

RESULTS

A total of 108 participants were randomized, of whom 50 in the NO REMP group and 52 in the REMP group were included in the analyses in the original study. The mean number of months from surgery to the final follow-up was 49.3 and 53.8 months for the NO REMP and REMP groups, respectively. Failure rates were 22% (11/50) in the NO REMP group versus 8% (4/52) in the REMP group. Rates of overall recurrent instability were 30% (15/50) in the NO REMP group versus 10% (5/52) in the REMP group. Survival curves were significantly different, favoring REMP in both scenarios.

CONCLUSION

For the treatment of traumatic recurrent anterior shoulder instability with a Hill-Sachs lesion and subcritical glenoid bone loss (<15%), a significantly lower rate of overall postoperative recurrent instability was observed with arthroscopic Bankart repair and remplissage than with isolated Bankart repair at a medium-term follow-up (mean of 4 years). Patients who did not receive a remplissage experienced a failure (redislocated) earlier and had a higher rate of revision/reoperation than those who received a concomitant remplissage.

REGISTRATION

NCT01324531 (ClinicalTrials.gov identifier).

Understanding the Remplissage: History, Biomechanics, Outcomes, and Current Indications

PURPOSE OF REVIEW

Arthroscopic remplissage has continued to gain popularity as an adjunct to Bankart repair for patients with anterior shoulder instability. Although the original remplissage technique was described over 15 years ago, our understanding of when and how to use this procedure continues to evolve. This article provides a review of how remplissage affects shoulder biomechanics, compares clinical outcomes between remplissage and other procedures for shoulder instability, and discusses current indications for remplissage.

RECENT FINDINGS

Current research focuses on the use of remplissage across a wide range of glenoid bone loss. Remplissage appears effective at preventing recurrent instability in patients with glenoid bone loss up to 15% of the glenoid width. However, once glenoid bone exceeds 15%, outcomes tend to favor bony reconstruction procedures such as Latarjet. Results of biomechanical studies examining shoulder range of motion (ROM) after remplissage are mixed, though clinical studies tend to report no significant limitations in ROM when remplissage is added to a Bankart repair. Adding a remplissage to conventional Bankart repair may improve clinical outcomes and lower rates of recurrent instability without significantly altering shoulder ROM. However, surgeons should recognize its limitations in treating patients with large amounts of glenoid bone loss and should be prepared to discuss alternative procedures on a case-by-case basis. Absolute indications and contraindications for remplissage are not well defined currently and require further scientific research.

Arthroscopic remplissage: history, indications, and clinical outcomes

Several surgical procedures have been proposed to address anterior glenohumeral instability, which is one of the most common complaints in the general population. The remplissage, first described in early 2000s, is a procedure performed simultaneously with the arthroscopic Bankart repair to correct large, engaging Hill-Sachs lesions (HSLs). This procedure stabilizes the joint by tenodesing the infraspinatus tendon into the HSL to fill and disengage the defect. This procedure gained popularity because it has relatively low risk and is able to improve shoulder stability while being less invasive than other bone-blocking procedures. The remplissage has become a valuable add-on technique that can substantially improve outcomes in unstable patients undergoing arthroscopic Bankart repair. Nevertheless, several studies in the literature have raised concerns regarding its efficacy in critically unstable patients and the potential range of motion limitations that can arise postoperatively. Additional comparative studies and trials should be conducted to appropriately establish the role of remplissage in treating anterior instability, especially in patients with critical bone loss.

Dynamic Anterior Stabilization with Hill-Sachs Remplissage Can be Employed in Skeletally Immature Patients-Operative Technique

BACKGROUND

Numerous studies indicate that glenoid bony augmentation raises the risk of complications during and after surgery. On the other hand, repairing the labrum alone in cases with subcritical glenoid bone loss results in recurrent instability and persistent apprehension. As a result, recent advancements in shoulder instability surgery prioritize fully restoring the anterior shoulder restraint.

OPERATIVE TECHNIQUE

A novel method for treating recurrent anterior shoulder instability with subcritical glenoid bone loss and off-track Hill-Sachs lesion in skeletally immature patients is suggested: the use of dynamic anterior stabilization technique incorporating the long head of the biceps tendon onto the anterior glenoid rim via trans-subscapular transfer, in conjunction with Hill-Sachs remplissage. A practical, step-by-step surgical technique for a complete reconstruction of the anterior capsule-labral-ligamentous complex is provided. This involves utilizing a soft-tissue dynamic anterior sling, achieved through the trans-subscapularis transfer of the long head of the biceps tendon at the glenoid level. The procedure concludes with a Hill-Sachs remplissage to further prevent off-track events and alleviate apprehension.

CONCLUSION

Dynamic anterior stabilization is a suitable approach for addressing recurring anterior shoulder instability in skeletally immature patients who have subcritical glenoid bone loss and bipolar bone lesions.

Arthroscopic Bankart with remplissage results in lower rates of recurrent instability with similar range of motion compared to isolated arthroscopic Bankart for anterior glenohumeral instability: A systematic review and meta-analysis

PURPOSE

The addition of the remplissage procedure to an arthroscopic Bankart procedure has been shown to improve clinical outcomes, yet at the expense of potentially decreasing shoulder range of motion. The purpose of this study was to assess recurrent instability, range of motion, functional outcomes and rates of return to sport outcomes in patients undergoing an isolated arthroscopic Bankart repair compared to those undergoing arthroscopic Bankart repair in addition to the remplissage procedure.

METHODS

According to the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) guidelines, a search was conducted using three databases (MEDLINE/OVID, EMBASE and PubMed). Retrieved studies were screened based on predefined inclusion and exclusion criteria for comparative studies. Data were extracted and meta-analysis performed using a random-effects model.

RESULTS

A total of 16 studies (13 level III studies, 2 level II studies and 1 level I) were included with a total of 507 and 704 patients in the Bankart plus remplissage and isolated Bankart repair groups, respectively. No studies reported glenoid bone loss of >20% with the least percentage of glenoid bone loss reported among studies being <1%. There was a significantly increased rate of recurrent dislocations (odds ratio [OR] = 4.22, 95% confidence interval [CI]: 2.380-7.48, p < 0.00001) and revision procedures (OR = 3.36, 95% CI: 1.52-7.41, p = 0.003) in the isolated Bankart repair group compared to the Bankart plus remplissage group. Additionally, there were no significant differences between groups in terms of external rotation at side (n.s.), in abduction (n.s.) or at forward flexion (n.s.) at final follow-up. Furthermore, return to preinjury level of sport favoured the Bankart plus remplissage group (OR = 0.54, 95% CI: 0.35-0.85, p = 0.007).

CONCLUSION

Patients undergoing arthroscopic Bankart plus remplissage for anterior shoulder instability have lower rates of recurrent instability, higher rates of return to sport, and no significant difference in range of motion at final follow-up when compared to an isolated arthroscopic Bankart repair. Further large, prospective studies are needed to further determine which patients and degree of bone loss would benefit most from augmentation with the remplissage procedure.

LEVEL OF EVIDENCE

Level III.

Remplissage reduced sense of apprehension and increased the rate of return to sports at preinjury level of elite overhead athletes with on-track anterior shoulder instability

PURPOSE

The purpose of this study was to compare the results of arthroscopic isolated Bankart repair (B) with Bankart repair plus Remplissage (B + R) procedure in contact overhead athletes with on-track anterior shoulder instability.

METHODS

A total of 64 athletes playing basketball, volleyball and handball in elite professional level who underwent arthroscopic isolated Bankart repair (34 patients) or Bankart repair plus Remplissage procedure (30 patients) with the diagnosis of recurrent anterior shoulder instability between 2017 and 2020, were retrospectively reviewed. Radiologically all patients had on-track Hill-Sachs defects and minimal or subcritical glenoid bone loss (< 13.5%). Patients were evaluated using pre- and postoperative pVAS, SANE, ASES, ROWE, WOSI scores and postoperative active ROM assessment. Patients were also asked for the frequency of any subjective apprehension and satisfaction with the surgery in four grades.

RESULTS

The mean ages of the groups B and B + R were 26.8 and 26 years (SD = 3.22), respectively; the mean follow-up times were 37.8 and 36.2 months (SD = 11.19). Compared with the preoperative status, there was a statistically significant improvement of all 5 postoperative outcome scores in both groups (P < 0.001). However, significant difference between the improvement of the groups were only found for the SANE (B: 22.3 ± 4.1, B + R: 26.3 ± 4.3; P = 0.0004), ASES (B: 26.1 ± 2.6, B + R: 30.2 ± 3.6; P < 0.001) and ROWE (B: 42 ± 3.7, B + R: 47.7 ± 2.8; P < 0.001) scores in favor of the group B + R. The loss of internal and external rotation of the adducted arm in group B + R was found to be approximately 5 degrees compared to the group B (P < 0.001). More than 80% of group B + R showed no apprehension in sports activities and almost completely returned to pre-injury athletic level, depicting statistically significant improvement compared to group B athletes (P = 0.002 and 0.036, respectively). 3 patients developed re-dislocation after isolated Bankart repair, whereas no re-dislocation occurred in the B + R group.

CONCLUSION

Adding Remplissage procedure to the Bankart repair provided an advantage in terms of both return to sport at preinjury level and the frequency of apprehension sensation during sports activity.

LEVEL OF EVIDENCE

III.

Arthroscopic Remplissage Combined With Bankart Repair Results in a Higher Rate of Return to Sport in Athletes Compared With Bankart Repair Alone or the Latarjet Procedure: A Systematic Review and Meta-analysis

BACKGROUND

Traumatic anterior shoulder instability affects athletes at a higher rate compared with the general population. In recent years, indications for arthroscopic remplissage, an adjunct procedure classically used to reduce the recurrence of anterior shoulder instability in patients with off-track Hill-Sachs lesions, have expanded.

PURPOSE

To investigate return-to-sport (RTS) rates, functional outcomes, and adverse events in athletes who underwent arthroscopic Bankart repair with remplissage compared with surgical alternatives such as Bankart repair alone or the Latarjet procedure.

STUDY DESIGN

Systematic review and meta-analysis; Level of evidence, 4.

METHODS

A literature review of the Embase, PubMed (MEDLINE), and Web of Science databases was conducted for articles published before May 22, 2022. For the systematic review, 16 of 457 studies that reported RTS rates at any time point after remplissage were deemed eligible for inclusion in quantitative analysis and 17 of 457 studies in qualitative analysis. For the meta-analysis, 8 of 457 studies reported RTS rates after remplissage compared with surgical alternatives including Bankart repair alone or the Latarjet procedure and were deemed eligible for inclusion.

RESULTS

In total, 538 athletes underwent remplissage and were included in the study. RTS at any level was achieved by 86% (395/457) of patients, and the odds of RTS at any level were significantly higher after remplissage compared with surgical alternatives (odds ratio [OR], 2.71 [95% CI, 1.14-6.43]; P = .02). The odds of RTS at a previous or higher level were also significantly higher after remplissage compared with surgical alternatives (OR, 2.07 [95% CI, 1.29-3.31]; P = .002). The mean Rowe score increased significantly from 43.9 ± 7.77 preoperatively (n = 173) to 92.2 ± 4.02 after remplissage (n = 397) (P < .001), but there was no significant difference in Rowe scores between remplissage and surgical alternatives (P = .54). After remplissage, the recurrence rate was 5.0% for athletes (n = 220) and 7.3% for all patients (n = 634), with a mean time to recurrence of 24.0 ± 12.5 months. Reoperations occurred in 3.6% of athletes (n = 110) and 4.1% of all patients (n = 445). Recurrence and reoperations were significantly less likely after remplissage compared with surgical alternatives (OR, 0.18 [95% CI, 0.08-0.39]; P < .001 and OR, 0.17 [95% CI, 0.06-0.50]; P = .001, respectively).

CONCLUSION

Arthroscopic Bankart repair with remplissage augmentation significantly improved RTS rates among athletes, both at any level and at previous levels of play. Additionally, remplissage appeared to significantly decrease recurrence and reoperation rates compared with surgical alternatives such as Bankart repair alone or the Latarjet procedure.

Return to Preinjury-Level Sports After Arthroscopic Latarjet for Recurrent Anterior Shoulder Instability in Professional Athletes

Background

The Latarjet procedure is recommended to treat recurrent anterior shoulder instability with glenoid bone loss. Longer return-to-sport (RTS) times have been reported after the open Latarjet when compared with the arthroscopic Latarjet.

Purpose

To assess the clinical outcomes and RTS in athletes who underwent an arthroscopic Latarjet.

Study Design

Case series; Level of evidence, 4.

Methods

This study included 46 professional athletes with recurrent anterior shoulder instability who underwent an arthroscopic Latarjet between 2010 and 2016. Patients were divided by type of sport: noncollision and nonoverhead (n = 22), collision and martial arts (n = 13), and overhead (n = 11). Sport activity was evaluated with the Kerlan-Jobe Orthopaedic Clinic (KJOC) score, Subjective Patient Outcome for Return to Sports score, and RTS time. Clinical results were evaluated by Constant-Murley score, Walch-Duplay score, and range of external and internal rotation. Complication rates, recurrence of shoulder instability, and number of revision procedures were recorded. Correlation tests were used to assess the relationship between measured parameters.

Results

The mean ± SD patient age was 27.1 ± 7.3 years, and the mean follow-up was 50.7 ± 18 months. Overall, 44 patients (95.7%) returned to their previously practiced sports, and 40 (87%) returned to their preinjury levels. The RTS time was 5 ± 1.4 months, with no significant difference among sport types. KJOC and Subjective Patient Outcome for Return to Sports scores were 95.2 ± 5.6 and 9.5 ± 1, respectively. Significant pre- to postoperative improvement was seen on the Constant-Murley score (from 54.3 ± 9.4 to 87.9 ± 8.2; P = .001) and Walch-Duplay score (from 53.7 ± 7.3 to 88.1 ± 10.7; P = .001). Mean postoperative external and internal rotation was 72.8° ± 18.6° and 81.3° ± 11.3°. Procedure-related complications occurred in 10 patients (21.7%); recurrence of shoulder instability was observed in 4 (8.7%); and 4 (8.7%) underwent revision surgery. A worse Walch-Duplay score was significantly associated with longer RTS time (r = -0.39; P = .019) and lower KJOC score (r = 0.29; P = .03).

Conclusion

There was a 95.7% RTS rate after the arthroscopic Latarjet procedure, although the procedure was not free from complications.

Rehabilitation after Shoulder Instability Surgery

Shoulder instability can occur in any direction and presents across a broad spectrum including traumatic dislocations, repetitive microinstability events or subluxations, and global joint laxity. The development of pain, functional decline, and articular pathologic condition is a multifaceted process that is influenced by the underlying bony morphology, biology of the surrounding soft tissue structures, dynamic coordination of the periscapular musculature, and patient factors such as age, activity level, and associated injuries. This article will focus on the younger, active patient with instability due to deficiencies in the capsulolabral complex and dynamic stabilizers.

Knotless Arthroscopic Glenoid Labral Stabilization for a 270° Tear With Concurrent Remplissage in the Lateral Decubitus Position

Labral tears resulting in 270° near-circumferential pathology predispose patients to recurrent instability and are technically challenging to repair. Furthermore, when such lesions are associated with Hill-Sachs lesions, recurrent instability risk is significantly increased and can result in substantially lower clinical outcomes. When determining a surgical treatment algorithm for shoulder stabilization, it is important to consider both humeral- and glenoid-sided pathology because subtle defects can have significant influence on recurrence and patient reported outcomes. In this Technical Note and accompanying video, we discuss our surgical technique for knotless arthroscopic stabilization for a 270° labral tear with concurrent remplissage in the setting of recurrent shoulder instability.

Remplissage in addition to arthroscopic Bankart repair for shoulder instability with on-track Hill-Sachs lesions reduces residual apprehension without external rotation limitation

PURPOSE

To evaluate the role of remplissage as an adjunct to Bankart repair in patients with recurrent anterior shoulder dislocation combined with on-track Hill-Sachs lesion.

METHODS

Arthroscopic Bankart repair with remplissage data (December 2018-2020) were collected (BR group). Inclusion criteria were (1) recurrent anterior shoulder dislocation, (2) on-track Hill-Sachs lesion, (3) minimal/subcritical glenoid bone loss (<17%), and (4) postoperative follow-up >1 year. Exclusion criteria were (1) revision surgery, (2) first dislocation with acute glenoid rim fracture, and (3) combined with other surgery. The control group was identified in Bankart repair-only cohort (B group). All patients were evaluated preoperatively, and at 3 weeks, 6 weeks, 3 months, 6 months, and then annually postoperatively. Visual analogue scale for pain, Self-Assessment Numerical Evaluation, American Shoulder and Elbow Surgeons Shoulder score, ROWE, and Western Ontario Shoulder Instability were evaluated at preoperative and final follow-up. Residual apprehension experience and external rotation deficit were evaluated. Patients, who were followed-up for more than 1 year, were asked how often they experienced any subjective apprehension in 4 grades (1: always, 2: frequently, 3: occasionally, 4: never). Patients who had a history of recurrent dislocation or revision surgery were investigated.

RESULTS

In total, 53 patients (B, 28; BR, 25) were included. At final follow-up, both groups showed improvement in 5 clinical scores postsurgery (P < .001). The BR group showed greater ROWE scores than the B group (B: 75.2 ± 13.6, BR: 84.4 ± 10.8; P = .009). Residual apprehension patient ratio (B: 71.4% [20/28], BR: 32% [8/25]; P = .004) and the mean subjective apprehension grade (B: 3.1 ± 0.6, BR: 3.6 ± 0.6; P = .005) showed statistically significant difference, whereas no patients in either group experienced external rotation deficit (B: 14.8 ± 12.9°, BR: 18.0 ± 15.2°, P = .420). Only 1 patient in the B group had not responded to surgery, with dislocation recurrence (P = .340).

CONCLUSIONS

Remplissage with arthroscopic Bankart repair in on-track Hill-Sachs lesion has a role in reducing residual apprehension without external rotation limitation.

LEVEL OF EVIDENCE

Level III, retrospective comparative therapeutic trial.

Long-term results of arthroscopic Bankart repair with Hill-Sachs remplissage

Background

Arthroscopic Bankart repair with Hill-Sachs remplissage (BHSR) is suggested for the treatment of anterior shoulder instability in the presence of an engaging humeral lesion. The objective of this study is to report the long-term clinical and radiological results of this procedure.

Methods

This is a single-center retrospective study including 51 patients who underwent surgery by BHSR for anterior shoulder instability with engaging Hill-Sachs lesion and who were reviewed after a minimum follow-up of 5 years. The mean age was 26 years (16-49; ±8.4) and 70% of the patients practiced sports. The average for Instability Severity Index score was 3.3 points (3-7; ±1.7). At the last follow-up, active range of motion, Subjective Shoulder Value, Walch-Duplay and Rowe scores, and the incidence of osteoarthritis according to the Samilson classification were assessed.

Results

At a mean follow-up of 87 months (60.0-124; ±17), 83% of the patients had resumed their sports activities. The mean Rowe, Walch-Duplay, and Subjective Shoulder Value scores were respectively 88 points (51-100; ±12), 82 points (50-100; ±16.4), and 89% (50-100; ±8). There was a recurrence of dislocation or subluxation for 8 patients (15.6%). In univariate analysis, patients who were unstable at follow-up had a deeper Hill-Sachs lesion (25% vs. 18% of the humeral head radius, P = .04) and were younger (19 vs. 27 years, P = .04). Radiographically, 17% of the patients showed signs of osteoarthritis (14% grade 1).

Conclusion

Considering that at a follow-up of more than 5 years, the failure rate was more than 15% of the BHSR, this procedure should be recommended with caution in case of deep Hill-Sachs lesions in young patients. The incidence of osteoarthritis after this procedure was acceptable, with few severe forms.

Surgical delay for traumatic recurrent shoulder dislocations leads to inferior functional outcomes

BACKGROUND

The effect of time interval between injury and surgery on outcomes of Bankart repair surgery has not been published previously. The purpose of this study was to assess the effect of surgical delay on functional outcomes after arthroscopic Bankart repair.

METHOD

One hundred and five athletes who underwent arthroscopic Bankart repair ± remplissage were enrolled in the study. Patients were divided into 2 groups depending upon the injury to surgery time- < 12 months (n = 19), and ≥12 months (n = 86). Depending upon the number of episodes of dislocation, patients were further categorized into 2 groups- <10 episodes (n = 66) and ≥10 episodes (n = 39). All patients were assessed post-operatively for functional outcomes (Modified Rowe's score, Constant Murley score) and return to sports at a minimum of 2 years of follow-up.

RESULTS

The mean injury to surgery time was 31.7 ± 23.1 months. The average number of episodes of dislocation before surgery were 10 (range 3-50). 49/105 (46.7%) patients returned to sports after a mean post-operative duration of 10.9 months. Athletes operated after a surgical delay of ≥12 months had inferior functional outcomes (Modified Rowe's score-89.5 ± 8.9 vs.77.4 ± 21.4; p = 0.02), lower rate of return to sports (14/19 vs. 35/86; p = 0.02) and higher mean time to return to sports (8.7 ± 1.9 vs. 11.5 ± 2.6; p < 0.05). Similarly, athletes who had ≥10 dislocations before surgery had inferior functional outcomes (Modified Rowe's score-84.5 ± 15.2 vs.72.9 ± 25.6; p = 0.004), lower rate of return to sports (37/66 vs. 12/39; p = 0.02) and higher mean time to return to sports (10.3 ± 2.4 vs. 12.6 ± 2.5; p < 0.05).

CONCLUSION

A delay in surgery (≥12 months) or dislocation episodes of ≥10 are associated with inferior functional outcomes, lower rate of return to sports and higher surgical failure rate.

LEVEL OF EVIDENCE

Level III; Prospective cohort study.

Long-term outcomes of arthroscopic Bankart repair and Hill-Sachs remplissage for bipolar bone defects

PURPOSE

To evaluate long-term results after arthroscopic Bankart repair and Hill-Sachs remplissage (BHSR) in bipolar bone defects with less than 20% of glenoid bone loss (GBL) and to analyse risk factors for recurrent dislocation.

METHODS

From 2009-2012, 43 patients with recurrent anterior shoulder instability were treated with BHSR. Inclusion criteria were GBL < 20% and minimum of 4-yearfollow-up. There were 35 males and 8 females with a mean age of 29 years (range 16-53). The mean ISIS score was 3.6 (range 2-6). Patients were evaluated for recurrence, range of motion and functional outcomes (Walch-Duplay and Rowe score). Post-operative MRI was performed at least 6 months after surgery to evaluate infraspinatus capsulotenodesis healing. Glenoid track was assessed retrospectively from pre-operative computed tomography. Mean follow-up was 7.3 years (range 4-11).

RESULTS

At the last follow-up, good to excellent outcomes were reported in 86% of patients. Average post-operative Walch-Duplay was 87.9 (range 75-100) and ROWE 93.7 (range 70-100). Infraspinatus capsulotenodesis healing was achieved in 86%. The rate of recurrence and revision surgery was 9.3% and 13.9%, respectively. Recurrence was associated with higher ISIS score (p = 0.0191) and lower age at surgery (p = 0.0227). Four (9.3%) Hill-Sachs lesions were considered off-track. The presence of off-track Hill-Sachs was associated with higher risk of recurrence (p < 0.00001).

CONCLUSION

Arthroscopic BHSR improves shoulder instability in the setting of bipolar bone defects with less than 20% of GBL. Patient-related factors and pre-operative glenoid track should be taken into consideration to reduce the risk of recurrence.

Long-term outcomes of open modified inferior capsular shift for traumatic anterior shoulder instability: over 20 years of follow-up

BACKGROUND

This study aimed to assess the long-term outcomes of the open modified inferior capsular shift procedure across more than 20 years in patients with traumatic anterior shoulder instability.

METHODS

Participants in this study comprised 84 patients (86 shoulders; 67 men, 17 women). Mean follow-up was 28.0 years. We compared the recurrent instability rate after surgery, apprehension, revision rate, satisfaction, return to preinjury sporting activity, and patient background characteristics between recurrent and nonrecurrent groups. Twenty-seven patients who were examined directly were evaluated for differences in range of motion and muscle strength between affected and nonaffected sides. Clinical outcome scores used for this study were the Western Ontario Shoulder Instability Index and the Rowe score.

RESULTS

Nine shoulders (10.5%) showed recurrent instability, as dislocation in 3 shoulders and subluxation in 6 shoulders, but no revisions were required. All patients with recurrent instability were males with new trauma. Three shoulders developed recurrent instability ≤5 years after surgery, and the remaining 6 shoulders showed recurrent instability >5 years after surgery. No significant differences in any patient characteristic were identified between the recurrent and nonrecurrent groups. Significant differences between affected and nonaffected sides were seen in the mean active range of motion or muscle strength for external rotation in the anatomic position or in 90° of abduction. Western Ontario Shoulder Instability Index and Rowe score were significantly worse in the recurrent group than in the nonrecurrent group. Patients reported that 84 shoulders (97.7%) were "much better." Most athletes (88.4%) had returned to sports activity at a level >70%.

CONCLUSION

We investigated long-term outcomes of the open modified inferior capsular shift procedure for traumatic anterior shoulder instability. Our data suggest that recurrent instability might result from new trauma even if a long time has passed since the open modified inferior capsular shift procedure, so follow-up should be continued as long as possible after surgery. As in other reports, satisfaction was high and clinical scores were good. We thus believe this surgical method offers good results even after more than 20 years.

Mid-term results of arthroscopic Bankart repair and remplissage for recurrent anterior shoulder instability in patients with a history of seizures

Background

Seizure predisposes patients to shoulder dislocation. However, there is no consensus regarding the best management approach for recurrent shoulder dislocation in patients who have a history of seizures. In this study, we report the outcome of arthroscopic Bankart repair augmented by Remplissage for the recurrent anterior shoulder dislocation in a series of patients with a history of seizures.

Methods

In this retrospective study, 27 patients with 29 recurrent anterior shoulder dislocations who were treated with the arthroscopic Bankart repair were included. All cases had deep Hill-Sachs lesions according to Hardy classification that was managed with a Remplissage technique. Patients with a glenoid defect of more than 20% in the CT scan were excluded. Twenty-two patients had an epileptic seizure, while the remaining five patients had convulsions due to other causes. The mean age of the patients was 28.3 ± 6.2 years. The mean follow-up of the patients was 3.1 ± 1.2 years. Outcome measures included the shoulder range of motion that was compared with the non-injured side in the unilateral subjects and the shoulder function that was evaluated by the Rowe score and the Walch-Duplay score.

Results

The mean forward flexion, abduction, external rotation, and internal rotation were not significantly different between injured and non-injured shoulder (p = 0.34, p = 0.41, p = 0.11, p = 0.23). The mean Rowe score was 49.1 ± 7.8 before the surgery and 92.1 ± 6.4 at the last visit (p < 0.001). According to the Walch-Duplay score, the shoulders were categorized as excellent, good, and fair in 17 (58.7%), 11 (37.9%), and 1 (3.4%) shoulder, respectively. The overall rate of instability recurrence was 17.2% (n = 5).

Conclusion

In patients with a history of seizures, arthroscopic Bankart repair augmented by Remplissage could be regarded as a safe and efficient method for the treatment of recurrent anterior shoulder dislocation with glenoid defect < 20%.

With the exception of the Hill-Sachs interval, CT and MRI show no significant differences in the diagnostic value of the HSL measurement regardless of the measurement technique

PURPOSE

The aim of the current study was to compare the diagnostic precision and reliability of different methods in measuring Hill-Sachs lesions (HSLs) using MRI and CT.

METHODS

A total of 80 consecutive patients with a history of anterior shoulder instability were retrospectively included. The preoperative CT and MRI scans of the affected shoulders were analysed. To investigate the ability of the Franceschi grading, Calandra classification, Richards, Hall, and Rowe grading scale, Flatow percentage and "glenoid track" assessment according to Di Giacomo et al. to quantify the extent of humeral bone loss, the results of each measurement method obtained with MRI were compared with those achieved with CT. In addition, the intra- and inter-rater reliabilities of each measurement method using CT and MRI were calculated and compared.

RESULTS

A significant difference was found between CT and MRI in the determination of the Hill-Sachs interval (HSI) (p = 0.016), but not between the results of any of the other measurement techniques. With the exceptions of the Franceschi grade and Calandra classification, all measurement methods showed good or excellent intra- and inter-rater reliabilities for both MRI and CT.

CONCLUSIONS

While the determination of the HSI with MRI was more accurate, all other analysed techniques for measuring the amount of humeral bone loss showed similar diagnostic precision. With regard to the intra- and inter-rater reliabilities, all measurement techniques analysed, with the exception of the Franceschi and Calandra classifications, provided good to very good reliabilities with both CT and MRI.

LEVEL OF EVIDENCE

III.

Arthroscopic Bankart repair with and without arthroscopic infraspinatus remplissage in anterior shoulder instability with a Hill-Sachs defect: a randomized controlled trial

BACKGROUND

The purpose of this study was to compare patient-reported and clinic outcomes between arthroscopic Bankart repair with (REMP) and without (NO REMP) arthroscopic infraspinatus remplissage in patients with recurrent anterior shoulder instability with a Hill-Sachs lesion and minimal glenoid bone loss.

METHODS

Patients 14 years or older with a recurrent anterior shoulder instability with the presence of an engaging Hill-Sachs defect (of any size) confirmed on computed tomography or magnetic resonance imaging were eligible to participate. Consented patients were randomized intraoperatively to NO REMP or REMP. Study visits were conducted preoperatively and 3, 6, 12, and 24 months postoperatively. The primary outcome was the Western Ontario Shoulder Instability score. Secondary outcomes included incidence of postoperative recurrent shoulder instability, Simple Shoulder Test, American Shoulder and Elbow Surgeons score, range of motion, complications, and revision surgery. To compare groups, a mixed-effects linear model was used for continuous variables and a χ² or Fisher's exact test for categorical data. A Kaplan-Meier survival analysis assessed survival distribution between groups.

RESULTS

One hundred and eight patients were randomized to Bankart repair with (n = 54) or without (n = 54) remplissage. The mean follow-up was 26.5 months (21-53 months) and 24.3 months (23-64 months) for the REMP and NO REMP groups, respectively. Rates of postoperative recurrent instability were higher (P = .027) in the NO REMP group with 9 of 50 (18%) vs. 2 of 52 (4%) postoperative dislocations in the REMP group. There were no significant differences in patient-reported outcomes between groups at any time point. Survival curve distributions were also significantly different favoring REMP (χ² = 5.255, P = .022). There was a significant difference in rate of revision surgery between groups with 6 in the NO REMP and none in the REMP groups (P = .029). Post hoc, patients were noted to have a higher risk for re-dislocation if their Hill-Sachs lesion was ≥20 mm in width or ≥15% of humeral head diameter. One intraoperative complication was reported in the REMP group.

CONCLUSIONS

There is significantly greater risk of postoperative recurrent instability in patients who did not have a remplissage performed in conjunction with an arthroscopic Bankart repair for the treatment of traumatic recurrent anterior shoulder instability with Hill-Sachs lesions of any size and minimal glenoid bone loss (<15%) at 2 years postoperatively. Otherwise, there are no differences in patient-reported outcomes, complications, or shoulder function at 2 years postoperatively. In addition, the remplissage procedure has significantly lower rates of re-dislocation in high-risk patients with Hill-Sachs lesions ≥20 mm and/or ≥15% in size.

Patient Outcomes and Fear of Returning to Sports After Arthroscopic Bankart Repair With Remplissage

Background:

Although Bankart repair with remplissage is commonly performed to treat anterior shoulder instability, there is limited information on specific outcomes or patients’ fears regarding return to sports (RTS).

Purpose:

To study recurrence rates, pain, shoulder function, active range of motion (ROM), RTS rate, and patients’ fears and expectations for RTS after arthroscopic Bankart repair with remplissage for anterior shoulder instability. We compared these outcomes with those after Bankart repair alone.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

A retrospective cohort study was carried out between 2007 and 2017 among patients who underwent arthroscopic Bankart repair with remplissage (group BR) and Bankart repair alone (group B). At the final follow-up, outcomes including recurrence, pain, shoulder function, active ROM, RTS rate, and fear toward RTS were assessed. The specific outcomes for RTS were evaluated based on 3 levels: return to normal life, RTS at any level (RTSA), and RTS at previous level (RTSP).

Results:

A total of 70 patients were included (29 in group BR and 41 in group B) with a mean 67.2 months of follow-up. Group BR demonstrated a significantly lower recurrence rate than did group B (0 vs 22.0%, respectively; P = .007) as well as higher postoperative Rowe score (92.8 ± 7.1 vs 83.3 ± 16.2, respectively; P = .005). There were no differences between the groups in postoperative visual analog scale for pain score, American Shoulder and Elbow Surgeons score, Oxford Shoulder Instability Score, or active ROM. The rates of RTSA (100% vs 84.2%; P = .03) and RTSP (77.8% vs 50.0%; P = .02) were higher in group BR than in group B, respectively, and significantly fewer patients in group BR reported fear of RTS (40.7% vs 63.2%; P = .04).

Conclusion:

In this study, recurrence rate, pain, shoulder function, active ROM, and RTS rate were satisfactory after arthroscopic Bankart repair with remplissage. Patients who underwent this procedure reported less fear toward RTS and higher rates of RTSA and RTSP than did those who undergo Bankart repair alone.

Comparison between all-suture and biocomposite anchors in the arthroscopic treatment of traumatic anterior shoulder instability: A retrospective cohort study

Purpose

Suture anchors have revolutionized arthroscopic surgery, enabling direct soft tissue-to-bone repair. There are many types of anchors still used in arthroscopic shoulder operations. We sought to compare the clinical outcome of all-suture and biocomposite anchors when used in arthroscopic Bankart repair for patients suffering from anterior shoulder instability.

Methods

A single-center retrospective cohort study of 30 patients (mean age: 26.6 years, SD: 8.8 years, male/female ratio: 5/1, mean follow up: 28 months, SD: 23.8, range: 12-92) with anterior shoulder instability was conducted. Patients were divided into 2 groups based upon the type of suture anchors used for the Bankart repair: group A (14 patients) used only all-suture anchors and group B (16 patients) used only biocomposite anchors. Outcomes reported were postoperative dislocations, positive shoulder apprehension test, self-reported sense of shoulder instability, return to activities of daily living, return to sports, patient satisfaction and complications. Patient reported outcome measures (PROMs) used were the Rowe Score for Instability, Constant Shoulder Score, Walch Duplay Score, The American Shoulder and Elbow Surgeons (ASES) Shoulder Score, Oxford Shoulder Instability Score and external rotation at 90° of arm abduction, external rotation at 0° of arm abduction, forward flexion, abduction, adduction and internal rotation.

Results

Rates of postoperative shoulder dislocation demonstrated no significant difference between the 2 groups (p > .05). Four postoperative dislocations happened, two in each group (14.3% and 12.5% for all suture only and biocomposite only groups, respectively), with three of them being traumatic. In addition, no significant differences were observed amongst groups regarding shoulder apprehension test (group A: 85.7% vs. group B: 93.8%), sense of shoulder instability (7.1% vs. 6.3%), return to activities of daily living (group A: 85.7% vs. group B: 93.8%), return to sports (group A: 85.7% vs. group B: 87.5%), patient satisfaction (moderate level: group A 21.4% vs. group B 12.5%), and PROMs.

Conclusion

The short-term failure rate and clinical/functional outcomes of arthroscopic Bankart repair using all-suture anchors is similar to the use of biocompatible anchors.

Level of evidence

Level III, retrospective cohort study.

Excellent Clinical and Radiological Midterm Outcomes for the Management of Recurrent Anterior Shoulder Instability by All-Arthroscopic Modified Eden-Hybinette Procedure Using Iliac Crest Autograft and Double-Pair Button Fixation System: 3-Year Clinical Case Series With No Loss to Follow-Up

PURPOSE

To evaluate the clinical, functional, and radiological midterm outcomes of the all-arthroscopic modified Eden-Hybinette procedure in patients with recurrent anterior shoulder instability.

METHODS

A retrospective, single-center case series with prospectively collected data was conducted. The inclusion criterion was traumatic recurrent anterior shoulder instability with significant glenoid bone loss; patients with atraumatic or multidirectional instability were excluded. An all-arthroscopic modified Eden-Hybinette procedure using iliac crest autograft and double-pair button fixation was carried out. All patients were postoperatively assessed for recurrence and apprehension. Shoulder range of motion values and functional scores, including American Shoulder and Elbow Surgeons Score, Oxford instability, Rowe instability, and Walch-Dupplay, were recorded. Graft positions, healing, and absorption were evaluated with computed tomography. Comparisons of values were performed with paired t tests for normally distributed differences and with nonparametric Wilcoxon's signed rank test otherwise.

RESULTS

The final study cohort included 28 patients, mean age 36 ± 10 years, and mean follow-up period 43 ± 6 months (range 36 to 53). Median glenoid bone loss was 12.4% (range 8% to 33%). No recurrence occurred, no subjective shoulder instability was reported, and no major complications were documented through the last follow-up. Postoperative shoulder range of motion had no significant differences compared with the healthy side. All final postoperative functional scores significantly increased to show excellent results compared with preoperative values. All grafts were positioned and healed optimally, and none was completely reabsorbed.

CONCLUSIONS

The all-arthroscopic modified Eden-Hybinette procedure is safe, leading to excellent clinical and radiological midterm outcomes in patients with recurrent anterior shoulder instability. This technique restores glenoid bone defects and preserves the normal shoulder anatomy.

LEVEL OF EVIDENCE

IV, therapeutic, retrospective case series.

What Are the Effects of Remplissage on 6-Month Strength and Range of Motion After Arthroscopic Bankart Repair? A Multicenter Cohort Study

BACKGROUND

Patients who have undergone shoulder instability surgery are often allowed to return to sports, work, and high-level activity based largely on a time-based criterion of 6 months postoperatively. However, some believe that advancing activity after surgery should be dependent on the return of strength and range of motion (ROM).

HYPOTHESIS

There will be a significant loss of strength or ROM at 6 months after arthroscopic Bankart repair with remplissage compared with Bankart repair alone.

STUDY DESIGN

Cohort study; Level of evidence, 2.

METHODS

A total of 38 patients in a prospective multicenter study underwent arthroscopic Bankart repair with remplissage (33 males, 5 females; mean age, 27.0 ± 10.2 years; 82% with ≥2 dislocation events in the past year). Strength and ROM were assessed preoperatively and at 6 months after surgery. Results were compared with 104 matched patients who had undergone Bankart repair without remplissage, although all had radiographic evidence of a Hill-Sachs defect.

RESULTS

At 6 months, there were no patients in the remplissage group with anterior apprehension on physical examination. However, 26% had a ≥20° external rotation (ER) deficit with the elbow at the side, 42% had a ≥20° ER deficit with the elbow at 90° of abduction, and 5% had persistent weakness. Compared with matched patients who underwent only arthroscopic Bankart repair, the remplissage group had greater humeral bone loss and had a greater likelihood of a ≥20° ER deficit with the elbow at 90° of abduction (P = .004). Risk factors for a ≥20° ER deficit with the elbow at 90° of abduction were preoperative stiffness in the same plane (P = .02), while risk factors for a ≥20° ER deficit with the elbow at the side were increased number of inferior quadrant glenoid anchors (P = .003), increased patient age (P = .02), and preoperative side-to-side deficits in ER (P = .04). The only risk factor for postoperative ER weakness was preoperative ER weakness (P = .04), with no association with remplissage (P = .26).

CONCLUSION

Arthroscopic Bankart repair with remplissage did not result in significant strength deficits but increased the risk of ER stiffness in abduction compared with Bankart repair without remplissage at short-term follow-up.

A retrospective cohort analysis of arthroscopic Bankart repair with or without remplissage in patients with off-track Hill-Sachs lesion evaluated for functional outcomes, recurrent instability, and range of motion

BACKGROUND

Lone Bankart repair is associated with high rates of recurrence, especially in off-track Hill-Sachs (HS) lesion. The objective of the study was to assess the impact of remplissage in off-track HS lesion influencing the rate of redislocation and range of motion (ROM) of the shoulder.

MATERIAL AND METHOD

We retrospectively reviewed 136 patients for arthroscopic Bankart repair without remplissage (group 1, n = 77) or with remplissage (group 2, n =59) for recurrent anterior dislocation of the shoulder with glenoid bone loss of <25%. Further subgroups of on- and off-track HS lesion were based on computed tomographic assessment. At a minimum follow-up of 2 years; patients were evaluated for functional scores (Rowe, Constant-Murley, Western Ontario Shoulder Instability Index), redislocations, and ROM.

RESULTS

At a mean follow-up of 54 and 44 months in group 1 and 2, respectively, there was no difference in postoperative functional scores. There were significantly more dislocations in patients with Bankart repair with off-track lesion than in patients with Bankart repair with on-track lesion (P = .02). There were significantly fewer redislocations in patients with off-track lesion who underwent Bankart repair and remplissage than in those who did not undergo remplissage (P = .0007). Compared with group 1 patients, those in group 2 revealed a statistically significant loss of ROM.

CONCLUSIONS

Although a nonremplissaged off-track HS lesion remains an important risk factor for recurrent instability, remplissage also results in significant loss of shoulder ROM compared with those who do not undergo remplissage.

Clinical and functional outcomes of the remplissage technique to repair anterior shoulder dislocation: average 7 years of follow-up

PURPOSE

The purpose of this work is to report mid- to long-term clinical results, recurrence rates and instability following surgery to repair anterior dislocation of the shoulder by the remplissage technique.

METHODS

This was a retrospective case series at a single center with patients with anterior shoulder instability that received surgery using the remplissage technique. Rowe questionnaire, instability complaints, recurrence episodes and return to sport were analyzed.

RESULTS

Of all patients screened, 21 (92.3%) were enrolled and only 2 patients were lost to follow-up. The mean age of the patients at the time of surgery was 27.8y.o., and the mean number of dislocations before surgery was 3.2 episodes. The follow-up average was 83.8 months (range 28-126). No case of postoperative infection was observed. Two patients (9.5%) had recurrent shoulder instability and required reintervention after 18 and 48 months. The average final Rowe score was 92.9 (range 75-100). All patients that played sports before surgery returned to the sport, and 73.7% of them returned to the same activity level.

CONCLUSION

The remplissage technique applied to repair anterior shoulder dislocation with humeral bone loss presents good results regarding clinical scores, shoulder stability and acceptable rates of return to sports, even in a mid- to long-term follow-up.

LEVEL OF EVIDENCE

IV.

[Research progress of surgical treatment for anterior shoulder dislocation and combined injuries]

Objective

To summarize the research progress of surgical treatment for anterior shoulder dislocation and combined injuries.

Methods

The related literature was reviewed, and the surgical treatment options for the anterior shoulder dislocation and its combined injuries were summarized.

Results

Anterior shoulder dislocation can combine with anteroinferior capsular ligament complex injury (Bankart injury), bony Bankart defect, and Hill-Sachs lesion. For Bankart and bony Bankart injuries, arthroscopic repair or coracoid osteotomy combined with bony graft reconstruction can be performed. For Hill-Sachs lesion, conservative treatment, soft tissue repair, or bony reconstruction should be selected based on the extent of the bone defect. For bipolar injury, the Bankart repair, Remplissage, or arthroplasty should be selected based on the extent of the glenoid defect.

Conclusion

With the development of arthroscopy and the improvement of the surgical concept, there is a complete set of surgical options for various injuries of the anterior shoulder dislocation. When choosing a surgical procedure, the patient's specific injury and age, exercise level, and other relating factors should be comprehensively assessed in order to achieve the best results.