Location of the Suture Anchor in Hill-Sachs Lesion Could Influence Glenohumeral Cartilage Quality and Limit Range of Motion After Arthroscopic Bankart Repair and Remplissage

No Difference in External Rotation Loss After Isolated Bankart Repair, Remplissage, or Latarjet: A Systematic Review and Meta-analysis

BACKGROUND

Despite the effectiveness of remplissage in reducing instability recurrence, debate remains about the loss of external rotation (ER) after this procedure.

PURPOSE

To compare the loss of ER after primary isolated arthroscopic Bankart repair alone (BR), Bankart with remplissage (REMP), and Latarjet (LAT) procedures.

STUDY DESIGN

Meta-analysis; Level of evidence, 3.

METHODS

A literature search of 4 databases was conducted to identify comparative studies reporting ER after BR, REMP, or LAT. ER loss with the arm at side was collected, along with postoperative Rowe score, return to previous sport level, instability recurrence, reintervention, and noninstability complications. Dichotomous variables were assessed using odds ratios with 95% CIs, and continuous variables were analyzed using mean differences (MDs) with 95% CIs. A random-effects meta-analysis was used for continuous outcomes and dichotomous outcomes.

RESULTS

In total, 27 studies were included, consisting of 2100 patients: 824 in BR, 378 in REMP, and 898 in LAT groups. The mean ER loss was 6.8°± 11° after BR, 9.3°± 12.6° after REMP, and 0.8°± 20.4° after LAT. Comparing REMP and BR, the MD was 5.9° (P = .13); between REMP and LAT, the MD was 9.6° (P = .17). For Rowe scores, the MD was 3.46 (P = .49) between REMP and BR and 0.24 (P = .9) between REMP and LAT. Odds ratios for return to previous sport level were 1.08 (P = .84) for REMP versus BR and 1.62 (P = .09) for REMP versus LAT. Regarding instability recurrence, the odds ratio was 6.67 (P = .04) for REMP versus BR and 1.43 (P = .48) for REMP versus LAT. The odds ratio for reoperation for BR was 7.69 (P = .05) compared with REMP, and the odds ratio for complications for LAT was 6.25 (P = .02) compared with REMP.

CONCLUSION

Remplissage reduces instability recurrence compared with isolated Bankart repair without any statistically significant difference in postoperative ER deficit. Remplissage may reduce the risk of reoperation compared with Latarjet with no difference in postoperative ER deficit or recurrence.

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.

Biomechanical Analysis Reveals Shoulder Instability With Bipolar Bone Loss Is Best Treated With Dynamic Anterior Stabilization for On-Track Lesions and With Remplissage for Off-Track Lesions

PURPOSE

To compare the biomechanical effects of augmenting Bankart repair (BR) with either remplissage or dynamic anterior stabilization (DAS) in the treatment of anterior shoulder instability with on-track or off-track bipolar bone loss.

METHODS

Eight fresh-frozen cadaveric shoulders were tested at 60° of glenohumeral abduction in the intact, injury, and repair conditions. Injury conditions included 15% glenoid bone loss with an on-track or off-track Hill-Sachs lesion as previously recommended. Repair conditions included isolated BR, BR with remplissage, and BR with DAS (long head of biceps transfer). The glenohumeral stability was assessed by measuring the anterior translation under 0, 10, 20, 30, 40, 50 N load and maximum load without causing instability at mid-range (60°) and end-range (90°) external rotation (ER). Maximum range of motion (ROM) was measured by applying a 2.2-N·m torque in passive ER and internal rotation.

RESULTS

Isolated BR failed to restore native glenohumeral stability in both on-track and off-track bipolar bone loss models. Both remplissage and DAS significantly decreased the anterior instability in the bipolar bone loss models, showing better restoration than the isolated BR. In the on-track lesions, DAS successfully restored native glenohumeral stability and mobility, whereas remplissage significantly decreased anterior translation without load (-2.12 ± 1.07 mm at 90° ER, P = .003; -1.98 ± 1.23 mm at 60° ER, P = .015). In the off-track lesions, remplissage restored native glenohumeral stability but led to significant ROM limitation (-8.6° ± 2.3° for internal rotation, P < .001; -13.9° ± 6.2° for ER, P = .003), whereas DAS failed to restore native stability at 90° ER regarding the increased anterior translation under 50 N (4.10 ± 1.53 mm, P < .001) and decreased maximum load (-13.8 ± 9.2 N, P = .021).

CONCLUSIONS

At time-zero, both remplissage and DAS significantly reduced residual anterior instability compared with isolated BR in the bipolar bone loss models and restored the native glenohumeral stability under most translational loads. However, remplissage could decrease the anterior translation without load for on-track lesions and may restrict ROM for off-track lesions, whereas DAS failed to restore native stability under high translational loads for off-track lesions.

CLINICAL RELEVANCE

DAS could be recommended to treat on-track bipolar bone loss with less biomechanical adverse effects, whereas remplissage might be the preferred procedure to address off-track bipolar bone loss for better stability.

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.

Lower Range of Recurrent Instability Rates Following Bankart Repair and Remplissage Compared to Isolated Bankart Repair in Patients With "Nonengaging/On-Track" Hill-Sachs Lesions and <20% Glenoid Bone Loss

PURPOSE

To compare recurrent instability and return-to-sport rates along with external rotation differences between on-track (nonengaging) Hill-Sachs lesion patients undergoing either an isolated Bankart repair (IBR) or a Bankart repair augmented with a remplissage procedure (B+R).

METHODS

A search was conducted using 3 databases (PubMed, EMBASE, CINAHL) in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Only clinical comparative (level of evidence I-III) studies were considered for inclusion. Quality assessment was performed using the Methodological Index for Non-Randomized Studies criteria.

RESULTS

Six level of evidence III studies, totaling 537 patients (202 B+R and 335 IBR) were included for analysis. All patients had <20% glenoid bone loss and a nonengaging, on-track Hill-Sachs lesion. At a median final follow-up of 34.7 months, recurrent dislocation rates ranged from 0% to 7.7% and 3.5% to 30% in the B+R and IBR groups, respectively. Moreover, subjective instability and revision surgery rates presented lower ranges in the B+R upon comparison with the IBR cohort (0%-32% vs 5%-71.4% and 0%-5% vs 0%-35%, respectively). Furthermore, return to preinjury level of sports ranged from 64% to 100% in the remplissage-augmented group and 50% to 90% in the IBR cohort. Postoperative external rotation at side varied from 50° to 63° in the B+R and 55° to 63° in the IBR arm. Additional subgroup analysis revealed recurrent dislocation rates in athletes and patients with near-track Hill-Sachs lesions undergoing remplissage augmentation to be 0% to 5% and 2% to 47% while ranging from 8.8% to 30% and 9% to 66% for IBR patients, respectively.

CONCLUSIONS

Upon qualitative analysis, ranges of recurrent instability measures, including recurrent dislocation rates, are higher in patients undergoing IBR in comparison to B+R. Activity level influences outcomes as athletes were found to have a higher range of recurrent dislocation rates in the IBR group. The addition of remplissage showed a higher range of return-to-sport rates with comparable postoperative external rotation between groups.

LEVEL OF EVIDENCE

Level III, systematic review of Level III studies.

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.

Glenoid Track Width Is Smaller Under Dynamic Conditions: An In Vivo Dual-Fluoroscopy Imaging Study

BACKGROUND

The glenoid track concept has been widely used to assess the risk of instability due to bipolar bone loss. The glenoid track width was commonly used as 83% of the glenoid width to determine if a lesion was on-track or off-track. However, the value was obtained under static conditions, and it may not be able to reflect the actual mechanism of traumatic dislocation during motion.

PURPOSE

To compare the glenoid track width under dynamic and static conditions using a dual-fluoroscopic imaging system.

STUDY DESIGN

Controlled laboratory study.

METHODS

In total, 40 shoulders of 20 healthy volunteers were examined for both dynamic and static tests within a dual-fluoroscopic imaging system at 5 different arm positions: 30°, 60°, 90°, 120°, and 150° of abduction, keeping the shoulder at 90° of external rotation. The participants performed a fast horizontal arm backswing for dynamic tests while keeping their arm in maximum horizontal extension for static tests. Computed tomography scans were used to create 3-dimensional models of the humerus and scapula for 2-dimensional to 3-dimensional image registration. Magnetic resonance imaging scans were obtained to delineate the medial margin of the rotator cuff insertion. The glenoid track width was measured as the distance from the anterior rim of the glenoid to the medial margin of the rotator cuff insertion and compared between static and dynamic conditions.

RESULTS

The mean glenoid track widths at 30°, 60°, 90°, 120°, and 150° of abduction were significantly smaller under dynamic conditions (88%, 81%, 72%, 69%, and 68% of the glenoid width) than those under static conditions (101%, 92%, 84%, 78%, and 77% of the glenoid width) (all P < .001). The glenoid track width significantly decreased with the increasing abduction angles in the range of 30° to 120° under static conditions (all P < .003) and 30° to 90° under dynamic conditions (all P < .001).

CONCLUSION

A smaller dynamic-based value should be considered for the glenoid track width when distinguishing on-track/off-track lesions. Clinical evidence is needed to establish the superiority of the dynamic-based value over the static-based value as an indicator for augmentation procedures.

CLINICAL RELEVANCE

Some off-track lesions might be misclassified as on-track lesions when the original commonly used static-based value of 83% is used as the glenoid track width.

Editorial Commentary: For Shoulder Hill-Sachs Lesion Remplissage, Medial Anchor Position Must Be Optimized to Achieve Stability Yet Minimize External Rotation Loss

An off-track Hill-Sachs lesion (HSL) is a significant risk factor for recurrent shoulder instability after arthroscopic Bankart repair. Bankart repair combined with remplissage can better restore shoulder stability versus isolated Bankart repair when treating a combined Bankart lesion and off-track HSL. However, remplissage may be nonanatomic and associated with limitation of shoulder external rotation (ER), especially when the arm is in a 90° shoulder abduction position. Excessive medial placement of remplissage anchors is associated with postoperative ER loss and increased glenohumeral cartilage degeneration. The use of 2 medial anchors results in lower articular forces. Thus, in patients with shoulder instability, we recommend using 2 remplissage anchors in those with a Bankart lesion plus an off-track HSL. The anchors should be placed medially to achieve stability-but not so medial as to result in postoperative stiffness and significant ER loss.

Bankart Repair With Transferred Long Head of the Biceps Provides Better Biomechanical Effect Than Conjoined Tendon Transfer in Anterior Shoulder Instability With 20% Glenoid Defect

PURPOSE

To examine the biomechanical differences between labral repair with transferred conjoined tendon and transferred long head of the biceps tendon (LHBT) for anterior shoulder instability with 20% bone loss.

METHODS

Twelve cadaveric shoulders were tested in sequent 5 conditions: intact, 20% glenoid defect, Bankart repair, Bankart repair with transferred conjoined tendon (dynamic conjoined tendon sling, DCS), and with transferred LHBT (dynamic LHBT sling, DLS) at 60° of glenohumeral abduction and 60° of external rotation. The physiological glenohumeral joint load was created by forces applied to the rotator cuff, conjoined tendon, and LHBT. The glenohumeral compression force and range of motion were recorded before anteroinferior force application. The anterior, inferior, and total translations were measured with 20, 30, 40, and 50 N of anteroinferior force, respectively.

RESULTS

Anteroinferior glenoid defect led to significant increase of humerus translation and decrease of glenohumeral compression force. DLS provided better resistance effect in both anterior-posterior and superior-inferior directions than DCS under high loading condition (40 N, P =.03; 50 N, P <.01). Both DCS and DLS procedures could further restore glenohumeral compression force with Bankart repair (Bankart repair: 32.1 ± 4.0 N; DCS: 36.7 ± 3.2 N, P < .01; DLS: 35.8 ± 3.6 N, P =.03). No range of motion restrictions were observed relative to the normal shoulder.

CONCLUSIONS

Both the DLS and DCS techniques could reduce the anterior-inferior translation and partially restore the glenohumeral stability in anterior shoulder instability with 20% anteroinferior glenoid defect compared with Bankart repair. Under greater loading conditions, DLS provides better stability than DCS.

CLINICAL RELEVANCE

Shoulder stability can be restored by DLS and DCS with low load. With greater shoulder stability requirements, DLS might be a better option than DCS for anterior shoulder instability with 20% bone loss.

Remplissage for Anterior Shoulder Instability: History, Indications, and Outcomes

Remplissage is a nonanatomic capsulotenodesis of the infraspinatus tendon used to fill engaging or "off-track" Hill-Sachs lesions in patients at high risk of recurrent instability with isolated Bankart repair. Indications for remplissage are expanding, as the importance of subcritical bone loss and the glenoid track on patient outcomes and recurrence rates continues to be investigated. Remplissage is also suggested in patients at high risk of recurrent instability following isolated anterior labral repair, such as collision and contact athletes with Hill-Sachs lesions that have not reached the threshold of "off track." Multiple arthroscopic remplissage techniques exist including, more recently, knotless techniques.

Anterior Shoulder Instability Part II-Latarjet, Remplissage, and Glenoid Bone-Grafting-An International Consensus Statement

PURPOSE

The purpose of this study was to establish consensus statements via a modified Delphi process on the Latarjet procedure, remplissage, and glenoid-bone grafting for anterior shoulder instability.

METHODS

A consensus process on the treatment utilizing a modified Delphi technique was conducted, with 65 shoulder surgeons from 14 countries across 5 continents participating. Experts were assigned to one of 9 working groups defined by specific subtopics of interest within anterior shoulder instability.

RESULTS

The technical approaches identified in the statements on the Latarjet procedure and glenoid bone-graft were that a subscapularis split approach should be utilized, and that it is unclear whether a capsular repair is routinely required. Furthermore, despite similar indications, glenoid bone-grafting may be preferred over the Latarjet in patients with bone-loss greater than can be treated with a coracoid graft, and in cases of surgeon preference, failed prior Latarjet or glenoid bone-grafting procedure, and epilepsy. In contrast, the primary indications for a remplissage procedure was either an off-track or engaging Hill-Sachs lesion without severe glenoid bone loss. Additionally, in contrast to the bone-block procedure, complications following remplissage are rare, and loss of shoulder external rotation can be minimized by performing the tenodesis via the safe-zone and not over medializing the fixation.

CONCLUSION

Overall, 89% of statements reached unanimous or strong consensus. The statements that reached unanimous consensus were the prognostic factors that are important to consider in those undergoing a glenoid bone-grafting procedure including age, activity level, Hill-Sachs Lesion, extent of glenoid bone-loss, hyperlaxity, prior surgeries, and arthritic changes. Furthermore, there was unanimous agreement that it is unclear whether a capsular repair is routinely required with a glenoid bone graft, but it may be beneficial in some cases. There was no unanimous agreement on any aspect related to the Latarjet procedure or Remplissage.

LEVEL OF EVIDENCE

Level V, expert opinion.

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.

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.