Off-track Hill-Sachs lesions do not increase postoperative recurrent instability after arthroscopic Bankart repair with selective Remplissage procedure

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.

Validating the Glenoid Track Concept Using Dynamic Arthroscopic Assessment

Background

Failure after isolated Bankart repair has led surgeons to consider when to address the Hill-Sachs lesion, which is thought to be a contributor to recurrent instability. One approach utilizes the glenoid track concept to determine whether a Hill-Sachs lesion is classified as "off-track," suggesting that the addition of a remplissage procedure may aid stability. However, the accuracy and reliability of using this approach require validation using an appropriate reference.

Purpose

To determine the accuracy and reliability of using the glenoid track concept against dynamic arthroscopic assessment of Hill-Sachs lesion engagement.

Study Design

Cohort study (diagnosis); Level of evidence, 3.

Methods

A total of 49 patients undergoing arthroscopic Bankart repair surgery for recurrent traumatic anterior shoulder instability were enrolled in this diagnostic validation study. Shoulders were classified as on-track or off-track using 3-dimensional computed tomography (3DCT) and static arthroscopic measurements. These classifications were compared with dynamic arthroscopic assessment (engagement of the Hill-Sachs lesion on the anterior glenoid rim in the 'athletic position') to determine their accuracy and reliability.

Results

The 3DCT-based measurements to determine glenoid track status had a higher positive predictive value (66% vs 42%), higher specificity (47% vs 42%), and higher accuracy (65% vs 59%) compared with static arthroscopic measurements. Static arthroscopic measurements to determine glenoid track status had a higher negative predictive value (96% vs 64%) and higher sensitivity (96% vs 81%) compared with 3DCT-based measurements. Interrater reliability (Krippendorff α) was 'fair' for determining the glenoid track status using 3DCT (0.368; 95% CI, 0.217-0.519) and 'moderate' for static arthroscopic measurements (0.523; 95% CI, 0.364-0.666). Intrarater reliability (intraclass correlation coefficient [ICC] 3,k) was 'moderate' for 3DCT measurements (0.660; 95% CI, 0.444-0.798) and 'good' for static arthroscopic measurements (0.769; 95% CI, 0.629-0.862).

Conclusion

Determining glenoid track status using either 3DCT or static arthroscopic measurements yielded moderate accuracy and reliability. Surgeons using the glenoid track concept to aid surgical decision-making in traumatic recurrent anterior shoulder instability should utilize 3DCT or static arthroscopic measurements with caution.

Arthroscopic double-row bridge fixation provided satisfactory shoulder functional restoration with high union rate for acute anterior glenoid fracture

PURPOSE

To introduce a novel surgical technique for arthroscopic reduction and double-row bridge fixation using trans-subscapularis tendon portal for anterior glenoid fracture and to evaluate the clinical and radiological outcomes.

METHODS

A total of 22 patients who underwent arthroscopic reduction and double-row bridge fixation for an acute anterior glenoid fracture were retrospectively evaluated. Arthroscopic surgery was performed using four portals including a trans-subscapularis tendon portal. All patients underwent 3D-CT preoperatively and one day and one year postoperatively to evaluate the fracture fragment size, reduction status, and presence of fracture union. To evaluate the degree of fragment displacement, articular step-off and medial fracture gap were measured using 3D-CT. Clinical outcomes were assessed based on the ASES and Constant scores. Postoperative glenohumeral joint arthritis was evaluated using plain radiographs with the Samilson and Prieto classification.

RESULTS

The average preoperative fracture fragment size was 25.9 ± 5.6%. Articular step-off (preoperative: 6.0 ± 3.3 mm, postoperative one day: 1.1 ± 1.6 mm, P < 0.001) and medial fracture gap (preoperative: 5.2 ± 2.6 mm, postoperative one day: 1.9 ± 2.3 mm, P < 0.001) were improved after surgery. On the postoperative one year 3D-CT, 20 patients achieved complete fracture union, and two patients showed partial union. Postoperative glenohumeral joint arthritis was observed in four patients. At the last visit, the ASES score was 91.8 ± 7.0 and the Constant score was 91.6 ± 7.0.

CONCLUSION

Arthroscopic reduction and double-row bridge fixation using a trans-subscapularis tendon portal for acute anterior glenoid fracture achieved satisfactory clinical outcomes and anatomical reduction as demonstrated by a low degree of articular step-off and medial fracture gap.

LEVEL OF EVIDENCE

Level IV.

First-time traumatic anterior shoulder dislocation: current concepts

The management of first-time traumatic anterior shoulder dislocations has been a topic of extensive study yet remains controversial. Development of a treatment plan requires an understanding of patient-specific considerations, including demographics, functional demands, and extent of pathology. Each of these can influence rates of recurrence and return to activity. The purpose of this review is to provide a framework for decision-making following a first-time anterior shoulder dislocation, with particular focus on the high-risk young and athletic population. A summary of surgical treatment options and their outcomes is outlined, along with future biomechanical and clinical perspectives.

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.

Off-track Hill-Sachs lesions predispose to recurrence after nonoperative management of first-time anterior shoulder dislocations

PURPOSE

The purpose of this study was to evaluate whether the presence of an off-track Hill-Sachs lesion has an impact on the recurrence rate after nonoperative management of first-time anterior shoulder dislocations.

METHODS

A retrospective cohort study was planned with a follow-up via questionnaire after a minimum of 24 months. Fifty four patients were included in the study (mean age: 29.5 years; 16 female, 38 male). All of these patients opted for primary nonoperative management after first-time traumatic anterior shoulder dislocation, in some cases even against the clinician's advice. The glenoid track and the Hill-Sachs interval were evaluated in the MRI scans. The clinical outcome was evaluated via a shoulder-specific questionnaire, ASES-Score and Constant Score. Further, patients were asked to report on recurrent dislocation (yes/no), time to recurrent dislocation, pain, feeling of instability and satisfaction with nonoperative management.

RESULTS

In 7 (13%) patients, an off-track Hill-Sachs lesion was present, while in 36 (67%) the lesion was on-track and 11 (20%) did not have a structural Hill-Sachs lesion at all. In total, 31 (57%) patients suffered recurrent dislocations. In the off-track group, all shoulders dislocated again (100%), while 21 (58%) in the on-track group and 3 (27%) in the no structural Hill--Sachs lesion group had a recurrent dislocation, p = 0.008. The mean age in the group with a recurrence was 23.7 ± 10.1 years, while those patients without recurrent dislocation were 37.4 ± 13.1 years old, p < 0.01. The risk for recurrence in patients under 30 years of age was higher than in those older than 30 years (OR = 12.66, p < 0.001). There were no significant differences between patients with on- and off-track lesions regarding patients' sex, height, weight and time to reduction and glenoid diameter. Off-track patients were younger than on-track patients (24.9 ± 7.3 years vs. 29.6 ± 13.6 years). However, this difference was not statistically significant.

CONCLUSION

The presence of an off-track Hill-Sachs lesion leads to significantly higher recurrence rates compared to on-track or no structural Hill--Sachs lesions in patients with nonoperative management and should be considered when choosing the right treatment option. Therefore, surgical intervention should be considered in patients with off-track Hill-Sachs lesions.

LEVEL OF EVIDENCE

IV.

Editorial Commentary: Recurrence After Arthroscopic Bankart Repair: What the Instability Severity Index Score Will and Will Not Predict

The recurrence of shoulder instability is a challenging complication after anterior open or arthroscopic stabilization in patients with glenohumeral instability. Use of the arthroscopic Bankart procedure has increased over the last decade, because of its less invasiveness and low complication rates compared with the Latarjet procedure. However, arthroscopic repair has the possibility of a greater recurrent instability rate. The Instability Shoulder Index Score (ISIS) has been developed to predict the success of isolated arthroscopic Bankart repair for the management of recurrent anterior shoulder instability. The risk factors associated with the recurrence of instability are age, level and type of sports participation, shoulder hyperlaxity, and humeral and glenoid bony lesions. The ISIS is a validated tool to predict the recurrence of dislocation after arthroscopic surgery in patients with shoulder instability. The arthroscopic Bankart procedure can be performed in patients with ISIS ≤3 with a low risk of recurrence of glenohumeral instability. The Latarjet procedure should be recommended in patients with ISIS >6. The management of patients with ISIS between 4 and 6 is still controversial and ranges from arthroscopic Bankart procedure with the addition of remplissage to the Latarjet procedure. Because advanced imaging techniques, such as computed tomography scans, allow us to assess appropriately the glenoid and humeral bone defect, their use is recommended in addition to ISIS.

High Variability of the Definition of Recurrent Glenohumeral Instability: An Analysis of the Current Literature by a Systematic Review

Purpose

To determine the definitions for recurrence used in the literature, assess the consensus in using these definitions, and determine the impact of these definitions on recurrence rates.

Methods

A literature search was performed in PubMed and EMBASE including studies from 2000 to 2020 reporting on recurrence rates after anterior arthroscopic shoulder instability surgery. Dislocation, apprehension, subluxation and recurrence rates were compared.

Results

Ninety-one studies were included. In 68% of the eligible studies, recurrence rates are not well defined. Thirty (33%) studies did not report on dislocations, 45 (49%) did not report on subluxations, and 58 (64%) did not report on apprehension. Seventeen different definitions for recurrence of instability, 4 definitions of dislocations, and 8 definitions of subluxation were used.

Conclusion

Recurrence rates are poorly specified and likely underreported in the literature, hampering comparison with results of other studies. This highlights the need for a consensus on definition of recurrence across shoulder instability studies. We recommend not using the definition recurrence of instability anymore. We endorse defining dislocations as a radiographically confirmed dislocation or a dislocation that is manually reduced, subluxations as the feeling of a dislocation that can be (spontaneously) reduced without the need for a radiographically confirmed dislocation, and a positive apprehension sign as fear of imminent dislocation when placing the arm in abduction and external rotation during physical examination. Reporting on the events resulting in a dislocation or subluxation aids in making an estimation of the severity of instability.

Level of Evidence

Level IV, systematic review.

Editorial Commentary: Preoperative 3-Dimensional Imaging for Shoulder Instability Is Vital for Determination of Off-Track Lesions and May Indicate Bankart Repair Plus Remplissage

The on- and off-track concept is gaining momentum for surgeons who treat patients with anterior shoulder instability. Preoperative imaging is critical for improving our outcomes. Determination of an off-track lesion prior to surgery using 3-dimensional computed tomography allows for improvement in outcomes by indicating remplissage. Intraoperative determination with the patient under anesthesia is not as good or as accurate. However, although Bankart repair plus remplissage shows good outcomes, bony procedures such as Latarjet, distal tibia allograft, and iliac crest or other bone graft procedures are preferred for large defects. Still, perhaps it is time to truly look at posterior adjuncts to anterior instability such as remplissage in patients who have off-track lesions, even with notable bipolar bone loss.

Does an "Off-Track" Hill-Sachs Lesion That Is Misclassified as "Non-Engaging" Affect Outcomes From Bankart Repair Alone Compared With Bankart Repair Combined With Remplissage?

PURPOSE

To determine how intraoperative assessment (engagement test) may affect recurrent dislocation rate and to compare the clinical outcomes, recurrence rates, and presence of on-/off-track conditions between cases that received arthroscopic Bankart repair alone (nonengaged Hill-Sachs lesion) and Bankart repair with remplissage (engaged Hill-Sachs lesion).

METHODS

We retrospectively reviewed 213 patients who underwent arthroscopic Bankart repair alone (186 patients with nonengaging lesions, group A) or with remplissage (27 patients with engaging lesion, group B) for recurrent anterior shoulder instability with <25% glenoid bone defect. The presence of an engaging Hill-Sachs lesion was determined during arthroscopic evaluation. On-track or off-track lesions were assessed retrospectively from preoperative 3-dimensional (3D) computed tomography (CT).

RESULTS

Mean glenoid bone defect was 13.7% in group A and 20.7% in group B (P < .001). Off-track lesions were identified in 8.1% (15/186) and 100% (27/27) in group B. At the final follow-up (minimum 2 years; mean follow-up periods after surgery of 50.1 months in group A and 47.7 months in group B), there were no significant differences in shoulder functional scores and recurrence rates between groups, despite improvement after surgery. In the off-track lesion (group A-1: nonengaging but off-track lesion), recurrence instability occurred in 9 patients (60%, 9/15). Also, comparing group A-1 and group B, we noted significant differences in shoulder functional scores and recurrence rates (P < .001).

CONCLUSION

Of 186 patients, 8.1% with nonengaging Hill-Sachs lesions during direct arthroscopic examination under anesthesia actually demonstrated off-track lesions on preoperative 3D CT scans retrospectively, with 60% experiencing recurrent instability. Intraoperative manual assessment for Hill-Sachs engagement was inferior to 3D CT scan in establishing the presence of off-track defects.

LEVEL OF EVIDENCE

III, retrospective comparative study.

When to Abandon the Arthroscopic Bankart Repair: A Systematic Review

CONTEXT

Bone loss is a major factor in determining surgical choice in patients with anterior glenohumeral instability. Although bone loss has been described, there is no consensus on glenoid, humeral head, and bipolar bone loss limits for which arthroscopic-only management with Bankart repair can be performed.

OBJECTIVE

To provide guidelines for selecting a more complex repair or reconstruction (in lieu of arthroscopic-only Bankart repair) in the setting of glenohumeral instability based on available literature.

DATA SOURCES

An electronic search of the literature for the period from 2000 to 2019 was performed using PubMed (MEDLINE).

STUDY SELECTION

Studies were included if they quantified bone loss (humeral head or glenoid) in the setting of anterior instability treated with arthroscopic Bankart repair.

STUDY DESIGN

Systematic review.

LEVEL OF EVIDENCE

Level 4.

DATA EXTRACTION

Study design, level of evidence, patient demographics, follow-up, recurrence rates, and measures of bone loss (glenoid, humeral head, bipolar).

RESULTS

A total of 14 studies met the inclusion criteria. Of these, 10 measured glenoid bone loss, 5 measured humeral head bone loss, and 2 measured "tracking" without explicit measurement of humeral head bone loss. Measurement techniques for glenoid and humeral head bone loss varied widely. Recommendations for maximum glenoid bone loss for arthroscopic repair were largely <15% of glenoid width in recent studies. Recommendations regarding humeral head loss were more variable (many authors providing only qualitative descriptions) with increasing attention on glenohumeral tracking.

CONCLUSION

It is essential that a standardized method of glenoid and humeral head bone loss measurements be performed preoperatively to assess which patients will have successful stabilization after arthroscopic Bankart repair. Glenoid bone loss should be <15%, and humeral head lesions should be "on track" if an arthroscopic-only Bankart is planned. If there is greater bone loss, adjunct or open procedures should be performed.

Effects of Glenoid and Humeral Bone Defects on Recurrent Anterior Instability of the Shoulder

For proper treatment of recurrent anterior instability of the shoulder with a bone defect, the defect size should be assessed preoperatively with three-dimensional computed tomography or magnetic resonance imaging. In general, the risk of postoperative recurrence of instability is estimated on the basis of preoperative imaging of bipolar bone defects: more than 20%–25% glenoid bone loss and off-track Hill-Sachs lesions have been considered risk factors for recurrence. In patients with a glenoid bone defect more than 20%–25%, a bone graft procedure, such as the Latarjet procedure, is preferred regardless of the glenoid track concept, because compared with arthroscopic stabilization procedure, it provides greater postoperative stability. For patients with a borderline glenoid bone defect (around 20%), surgeons should discuss surgical options with the patients, considering their demand and physical activity level. In addition, the surgeon should take care to prevent postoperative instability and long-term complications. Arthroscopic soft-tissue reconstruction including labral repair and capsular plication combined with the additional remplissage procedure is an anatomical procedure and could be considered as one of the primary treatment methods for patients with glenoid bone defects around 20%. Therefore, treatment strategies for recurrent anterior shoulder instability combined with bone defects should be determined more flexibly on the basis of the patient's individual condition.

Editorial Commentary: Open or Arthroscopic Surgery? Practice Makes Perfect…We Do Best What We Do Most Often

The reported outcomes of Bankart procedures performed after 2000 are significantly better than those reported prior to that date. The cause of this improvement can be found in adherence to the specific steps outlined in the Arthroscopy Association of North America Proficiency-Based Training program, improvements in instrumentation and implants and more appropriate patient selection. What is defined as an arthroscopic Bankart has also expanded. Patient-selection criteria have also changed dramatically over the past 2 decades, reflecting a better understanding of anterior shoulder instability and altering the choice of patients who should receive arthroscopic Bankart procedures. The arthroscopic Bankart with dual suture anchor remplissage is arguably the current arthroscopic gold standard for anterior shoulder "off-track" instability.