Chronic anterior shoulder instability with bone loss: a practical approach.

The stability of the glenohumeral joint, known for its remarkable mobility, relies on several factors, including the congruency of the joint's bones and the integrity of capsulolabral structures, encompassing the labrum, the capsule, and the glenohumeral ligaments. In cases of anterior shoulder instability, bone lesions are a common occurrence, most frequently involving glenoid bone loss and Hill-Sachs lesions. When both glenoid and humeral bone lesions coexist, the isolated Bankart procedure has exhibited a significant rate of failure. In such instances, the Latarjet procedure, especially when bone loss is present, retains its position as the gold standard, thanks to its consistent success in both short- and long-term outcomes. Recent advancements in research have explored alternative strategies to address bone loss, including the Remplissage procedure for humeral bone deficits and the use of bone block grafts to manage glenoid bone lesions, with a focus on achieving more anatomical techniques. However, it's crucial to recognize that, beyond bone loss, a multitude of intrinsic and extrinsic factors come into play when determining the most suitable treatment. The patient's profile, including factors like constitutional laxity and activity level, must be carefully considered in the decision-making process. The Latarjet procedure maintains its esteemed status as a benchmark in the field, thanks to its consistent excellence in both short- and long-term results. This article seeks to provide insights into the roles and placement of various surgical techniques within the context of chronic anterior shoulder instability, taking into account the intricate interplay of factors that influence treatment decisions.

High Variability in Standardized Outcome Thresholds of Clinically Important Changes in Shoulder Instability Surgery: A Systematic Review.

PURPOSE: The purpose of this study was to examine reported MCID and PASS values for PROMs following shoulder instability surgery and assess variability in published values depending on the surgery performed. Secondarily, our aims were to describe the methods used to derive MCID and PASS values in the published literature, including anchor-based, distribution-based, or other approaches, and to assess the frequency of MCID and PASS usage in studies on shoulder instability surgery. METHODS: A systematic review of MCID and PASS values following Bankart, Latarjet, and Remplissage procedures was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA). The Embase, Pubmed, and Cochrane Central Register of Controlled Trials (CENTRAL) databases were queried from 1985 to 2023. Inclusion criteria included studies written in English, and studies reporting utilization MCID or PASS for patient reported outcome measures (PROMS) following Latarjet, Bankart, Remplissage approaches for shoulder instability surgery. Extracted data included study population characteristics, intervention characteristics, and outcomes of interest. Continuous data were described using median and range. Categorical variables, including PROMs reported and MCID/PASS methods, were described using percentages. As MCID is a patient-level metric and not a group-level metric, the authors validated that all included studies reported proportions (%) of subjects that met or exceeded the MCID. RESULTS: A total of 174 records were screened, and 8 studies were included in this review. MCID was the most widely utilized outcome threshold which was reported in all 8 studies, with only 2 studies reporting both the MCID and the PASS. The most widely studied PROMs were the American Shoulder and Elbow Surgeons (ASES) (range 5.65-9.6 for distribution MCID, 8.5 anchor MCID, 86 anchor PASS); Single Assessment Numeric Evaluation (SANE) (range 11.4-12.4 distribution MCID, 82.5-87.5 anchor PASS); visual analog scale (VAS) (range 1.1-1.7 distribution MCID, 1.5-2.5 PASS); Western Ontario Shoulder Instability Index (WOSI) (range 60.7-254.9 distribution MCID, 126.43 anchor MCID, 571-619.5 anchor PASS); and Rowe scores (range 5.6-8.4 distribution MCID, 9.7 anchor MCID). Notably, no studies reported on substantial clinical benefit (SCB) or maximal outcome improvement (MOI). CONCLUSION: Despite the wide array of available PROMs for assessing shoulder instability surgery outcomes, the availability of clinically significant outcome thresholds such as MCID and PASS remains relatively limited. While MCID has been the most frequently reported metric, there is considerable inter-study variability observed in their values. CLINICAL RELEVANCE: Knowing the outcome thresholds such as MCID and PASS of the PROMs frequently used to evaluate the results of glenohumeral stabilization surgery is fundamental, since they allow us to know what is a clinically significant improvement for the patient.

Humeral Head Preservation after Neglected Glenohumeral Dislocation by Latarjet and Infraspinatus Remplissage-A Case Report.

Background: Neglected anterior glenohumeral dislocations provide a challenging problem for physicians. For many patients with these injuries, reverse shoulder arthroplasty has been the treatment of choice, although the preservation of the patient's own humeral head might have significant advantages. Methods: We present a case of a 66-year-old male with a neglected anterior glenohumeral dislocation that he sustained 6 weeks prior when he was hit by a car as a pedestrian. Radiographic imaging revealed a large off-track Hill-Sachs deformity and a fracture of the greater tuberosity in addition to the persisting glenohumeral dislocation. We performed open reduction and to aid stability, an infraspinatus tendon remplissage and a Latarjet procedure were performed. Results: Apart from minor and self-limiting neuropraxia, recovery was without complications. At 24 month follow-up, the patient had no impairment in general activities, had no residual pain, and had a good active range of motion. Conclusions: The authors, therefore, believe that a combination of infraspinatus tendon remplissage and the Latarjet procedure seems a feasible alternative for reverse shoulder arthroplasty and can preserve the patient's own humeral head.

Arthroscopic Management of Anterior Shoulder Instability: A Study of Functional Outcome and Analysis.

Background The remarkable range of motion of the shoulder comes at the cost of increased instability, especially anterior instability. Arthroscopic Bankart repair with or without remplissage, which is a minimally invasive surgery, is the preferred treatment for recurrent anterior instability. This study investigated the effectiveness of Bankart repair, with or without remplissage, in restoring function, preventing redislocation, and improving patient satisfaction. Methods A prospective observational study examined 40 patients (19-50 years old) with recurrent anterior instability and MRI-confirmed Bankart or Bankart with Hill-Sachs lesions. Patients underwent arthroscopic Bankart repair with or without remplissage based on the inclusion criteria of this study. Preoperative assessments included demographics, history, physical examination, American Shoulder and Elbow Surgeons (ASES) score, Quick Disabilities of the Arm, Shoulder, and Hand (DASH) score, ROWE score, and plain MRI of the shoulder joint. Post-operative radiographs and rehabilitation were advised. Functional recovery was evaluated at three months and six months after surgery. Results All patients underwent Bankart repair. Among them, 22 with engaging Hill-Sachs lesions received an additional remplissage procedure. Both groups showed significant improvements in their functional scores (p<0.05) and returned to their prior activities. However, the additional remplissage group had a slightly reduced mean external rotation (86.59°) compared with the Bankart repair-only group (90°). Notably, the recurrence rate was very low, with only one patient (2.5%) experiencing instability. Conclusion  Our study emphasizes the importance of proper capsulolabral tissue elevation to achieve a sufficient labral bump during Bankart repair. This technique allowed us to efficiently use only two suture anchors in 35 cases (87.5%). Additionally, remplissage was performed on all identified engaging Hill-Sachs lesions. We found that proper anchor placement and suturing techniques were crucial for successful Bankart repair. The emphasis on the potential cost benefits of a two-anchor approach is a valuable contribution to the field.

Glenoid bone loss and Hill-Sachs width percentage score are useful to select optimal operation for the treatment of glenohumeral instability in overhead athletes: Arthroscopic Bankart repair with remplissage versus open Latarjet.

PURPOSE: Glenohumeral instability with combined bone lesion in contact and overhead athletes with subcritical bone loss is challenging to treat with high recurrent instability. Treatment options are arthroscopic Bankart repair with remplissage and Latarjet operations. However, there is no consensus on their effectiveness. This study aims to compare the clinical outcomes and return to sports after both operations and whether evaluating the glenoid bone loss and Hill-Sachs width to calculate the total bone loss can help determine the appropriate operation. METHODS: In this retrospective comparative analysis, 30 athletes who underwent index arthroscopic Bankart repair with remplissage (n = 16) or Latarjet procedure (n = 14) between 2017 and 2020 were included. Computed tomography (CT) and magnetic resonance imaging (MRI) were routinely performed. The quick Disabilities of the Arm, Shoulder and Hand (qDASH), American Shoulder and Elbow Surgeons (ASES), instability severity index (ISI) scores and range of motion (ROM) were recorded preoperatively and at a mean follow-up of 53 months (SD = 12). Follow-up included time-to-return sports, self-perceived sports performance level and complications/recurrent dislocations. RESULTS: Preoperative qDASH, ASES, ISI scores, ages and genders were similar. The Latarjet group had significantly larger glenoid bone loss, Hill-Sachs width and total bone loss (p < 0.01). Both groups had significant improvement in patient-reported outcomes (PROs) after the operations (p < 0.01). Athletes with a total bone loss <25% underwent arthroscopic Bankart repair with remplissage and total bone loss ≥25% underwent Latarjet procedure, and there were no differences between the groups in terms of postoperative PROs, ROM, time-to-return sports and performance. There were no re-dislocations. CONCLUSION: Arthroscopic Bankart repair with remplissage or Latarjet procedure can adequately address glenohumeral instability with combined bone lesions. Patients with total bone loss scores greater than or equal to 25 may particularly benefit from the Latarjet procedure, while the minimally invasive arthroscopic Bankart repair with remplissage can yield equally satisfying scores for total bone loss less than 25. LEVEL OF EVIDENCE: Level III.

Arthroscopic Bankart Repair with Remplissage Yields Similar Outcomes to Open Latarjet for Primary and Revision Stabilization in The Setting of Subcritical Glenoid Bone Loss.

BACKGROUND: Management of patients with recurrent anterior glenohumeral instability in the setting of subcritical glenoid bone loss (GBL), defined in this study as 20% GBL or less, remains controversial. This study aimed to compare arthroscopic Bankart with remplissage (ABR+R) to open Latarjet for subcritical GBL in primary or revision procedures. We hypothesized that ABR+R would yield higher rates of recurrent instability and reoperation compared to Latarjet in both primary and revision settings. METHODS: A retrospective study was conducted on patients undergoing either arthroscopic ABR+R or an open Latarjet procedure. Patients with connective tissue disorders, critical GBL (>20%), < 2 year follow-up, or insufficient data were excluded. Recurrent instability and revision were the primary outcomes of interest. Additional outcomes of interest included subjective shoulder value (SSV), strength and range of motion (ROM) RESULTS: 108 patients (70 ABR+R, 38 Latarjet) were included with an average follow-up of 4.3 ±2.1 years. In the primary and revision settings, similar rates of recurrent instability (Primary: p=0.60; Revision: p=0.28) and reoperation (Primary: p=0.06; Revision: p=1.00) were observed between Latarjet and ABR+R. Primary ABR+R exhibited better SSV, active ROM, and internal rotation strength compared to primary open Latarjet. However, no differences were observed in the revision setting. CONCLUSION: Similar rates of recurrent instability and reoperation in addition to comparable outcomes with no differences in ROM were found for ABR+R and Latarjet in patients with subcritical GBL in both the primary and revision settings. ABR+R can be a safe and effective procedure in appropriately selected patients with less than 20% GBL for both primary and revision stabilization.

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.

Remplissage May Decrease the Redislocation Rate After Arthroscopic Bankart Repair in Patients With an Engaging Hill-Sachs Defect: A Systematic Review and Meta-analysis of Studies With Minimal 2-Year Follow-up.

BACKGROUND: The redislocation rate after arthroscopic Bankart repair (BR) among patients with a Hill-Sachs lesion (HSL) may be reduced with the use of remplissage. PURPOSE: To investigate the outcomes of adding remplissage to an arthroscopic BR in patients with concomitant HSL. STUDY DESIGN: Meta-analysis; Level of evidence, 3. METHODS: PubMed and ScienceDirect databases were searched between February 2022 and April 2023 with the terms "remplissage" and "shoulder instability" according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. The inclusion criteria were formed using the population, intervention, control, and outcome method; the investigation included studies that compared BR with and without remplissage and had ≥24 months of follow-up. RESULTS: From 802 articles found during the initial search, 7 studies with a total of 837 patients-558 receiving isolated BR (BR group) and 279 receiving BR with remplissage (BR+REMP)-were included. The probability of recurrence of instability among patients with an engaging HSL was significantly diminished in the BR+REMP group compared with the BR group (odds ratio, 0.11; 95% CI, 0.05 to 0.24; P < .001). Regarding shoulder range of motion, the BR+REMP group achieved increased forward flexion (mean difference [MD], 1.97°; 95% CI, 1.49° to 2.46°; P < .001) and decreased external rotation in adduction (MD, -1.43°; 95% CI, -2.40° to -0.46°; P = .004) compared with the BR group. Regarding patient-reported outcome measures, the BR+REMP group had Rowe (MD, 2.53; 95% CI, -1.48 to 6.54; P = .21) and Western Ontario Shoulder Instability Index (WOSI) (MD, -61.60; 95% CI, -148.03 to 24.82; P = .162) scores that were comparable with those of the BR group. CONCLUSION: Remplissage resulted in a 9-fold decrease in the recurrence of instability after arthroscopic BR in patients with HSL. Remplissage not only led to an increase in forward flexion but also only slightly limited patients' external rotation in adduction. WOSI and Rowe scores after remplissage at the final 24-month follow-up were comparable with those obtained after isolated Bankart repair.

Higher return to sport and lower revision rates when performing arthroscopic Bankart repair with remplissage for anterior shoulder instability with a Hill-Sachs lesion: a meta-analysis.

BACKGROUND: Recurrent anterior shoulder instability remains the most common complication from a prior shoulder dislocation, especially among young and active individuals who engage in athletic activities. This instability can lead to repeated subluxation or dislocations of the humeral head from the glenoid fossa. The purpose of this study is to compare postoperative recurrence rates, instability-related revision and return to sport (RTS) rates between isolated arthroscopic Bankart repair (ABR) and ABR with remplissage (ABR + R) for anterior shoulder instability with subcritical glenoid bone loss (GBL) and a Hill-Sachs lesion (HSL). METHODS: PubMed, Embase, and Web of Science were searched on June 2022. Studies sought were those comparing postoperative outcomes of ABR + R versus isolated ABR for subcritical GBL and an HSL. Study quality was evaluated using the revised Cochrane tool. Redislocations, instability-related revisions, and RTS rates were extracted and pooled estimates were calculated using the random-effect model. RESULTS: Twelve studies were included with a mean follow-up of 48.2 months for isolated ABR and 43.2 months for ABR + R. The meta-analytic comparison demonstrated that ABR + R resulted in statistically significant improvement in Rowe and American Shoulder and Elbow Surgeons scores by 6.5 and 2.2 points, respectively; however, the improvements in patient-reported outcomes were not clinically meaningful. ABR + R resulted in reduced external rotation at the side by 1° which was not clinically meaningful and there was no significant difference in terms of forward elevation. ABR + R resulted in a statistically significant reduction of overall postoperative recurrences (odds ratio [OR]: 9.36), postoperative dislocations (OR: 6.28), instability-related revision (OR: 3.46), and RTS to any level (OR: 2.85). CONCLUSION: The addition of remplissage to ABR for recurrent anterior shoulder instability with subcritical GBL and HSL results in significantly lower postoperative instability recurrence, lower instability-related revisions, and higher RTS to any level.

Beyond guesswork: how accurate are surgeons at determining the degree of glenoid bone loss in instability surgery?

Background: Accurate measurement of glenoid bone loss (GBL) is critical to preoperative planning in cases of recurrent shoulder instability. The concept of critical bone loss has been established with a value of GBL >13.5% being associated with higher failure rate following arthroscopic Bankart Repair. Advanced imaging, such as magnetic resonance imaging (MRI) scans, can be used to quantify GBL prior to surgery using the best-fit circle technique. Surgeons have traditionally relied on visual inspection of the MRI scan preoperatively or on visual inspection of the glenoid at the time of arthroscopy to determine whether GBL is present. The purpose of this study is to determine if 3 fellowship-trained shoulder surgeons could adequately quantify GBL without using best-fit circle measurements on MRI. Methods: A retrospective review was performed which included 122 patients over an 8-year period that had an arthroscopic Bankart repair performed by 3 fellowship-trained surgeons. In all patients, preoperative MRI scans were retrospectively measured using best-fit circle technique to determine true GBL and compare that to the surgeons' preoperative and intraoperative estimation of GBL. Results: GBL was correctly identified in only 36% (18/50) of patients when the preoperative best-fit circle measurements were not made. Critical bone loss was missed in 9.8% (12/122) of patients in the study group. The estimated mean bone loss in that group by visual inspection was 11.3% compared to 16% true bone loss measured on MRI. Even in the 18 patients with some identified bone loss prior to surgery, critical bone loss was missed in 6 patients when using visual inspection of the MRI or intraoperative inspection alone. Conclusion: Simple visual inspection of glenoid images on MRI scan and visual inspection of the glenoid at the time of surgery are inaccurate in determining the true extent of GBL especially in cases of subtle bone deficiency. Preoperative planning is dependent on the exact degree of bone deficiency and measurement on the MRI scan using the best-fit circle technique is recommended in all cases of instability surgery.

Return to play following operative management of anterior shoulder instability in overhead athletes-A systematic review.

Background: The purpose of this study was to systematically review the rate and timing of return to play in overhead athletes following operative management of anterior shoulder instability. Methods: A systematic literature search based on PRISMA guidelines, utilizing the EMBASE, MEDLINE, and The Cochrane Library Databases. Eligible for inclusion were clinical studies reporting on return to play among overhead athletes following arthroscopic Bankart repair, open Latarjet procedure or Remplissage procedure. Results: There are 23 studies included with 961 patients. Among those undergoing arthroscopic Bankart repair, the rate of return to play was 86.2%, with 70.6% returning to the same level of play and the mean time to return to play was 7.1 months. Among those undergoing an open Latarjet procedure, the rate of return to play was 80.9%, with 77.7% returning to the same level of play and the mean time to return to play was 5.1 months. Among those undergoing a Remplissage procedure, the rate of return to play was 70.6%, with 70.0% returning to the same level of play or mean time to return to play. Discussion: Overall, there were high rates of return to play following operative management of anterior shoulder instability in overhead athletes.

Managing severe bipolar bone loss in athletes: A comprehensive approach with open Latarjet and arthroscopic remplissage.

Background: Severe bipolar bone loss (BBL) represents one of the toughest challenges when managing the instability of glenohumeral joints among athletes and more specifically the ones involved in overhead sports. It refers to the significant loss of the humeral head and the glenoid bone, with an increased risk of failure. The present study aimed to evaluate the functional outcomes of a combined open Latarjet and arthroscopic remplissage in such high-risk individuals. Methods: A retrospective evaluation was carried out among athletes with antero-inferior loss of glenoid bone of more than 15 % and large off-track Hill-Sachs defect who underwent the Latarjet technique with iliac crest bone graft (ICBG) harvest used in combination with arthroscopic remplissage between 2021 and 2023. The University of California, Los Angeles (UCLA) score, constant-Murley score (CMS), and the range of motion (ROM; measured as forward flexion, external rotation, and abduction) were evaluated pre-operative and post-operative at the timepoint of 3-month, 6-month, and 1-year. Pre-operative magnetic resonance imaging scans (MRI) and computed tomography scans (CT) were obtained among the patients with severe glenohumeral BBL, and the glenoid track was calculated to identify on-track and off-track Hill-Sachs lesions. Post-operative MRI with filled Hill-Sachs defect post remplissage procedure and 3D CT scan was also done at 6-month to evaluate the union of the ICBG to the native glenoid bone. Results: Overall, 11 patients underwent for the combined procedure for severe BBL. The UCLA score (31.18 ± 3.74), and the CMS (93.64 ± 8.38) at the time-point of 1-year post-operatively showed remarkable improvement in comparison with the preoperative scores (P < 0.0001); and the ROM including abduction, external rotation, and forward flexion were restored to near normality. All patients showed bony union at 6-month as confirmed by post-operative CT scan. No complications such as redislocation or subluxation were observed over 1-year. There were no neurological complications or complications related to graft (graft migration or graft breakage or resorption) as well. All the athletes returned to sports activities at an average duration of 6.8-month post-operatively, with 73 % returning to sports at the level of pre-injury. Conclusion: The combined procedure of ICBG Latarjet and arthroscopic remplissage for the treatment of severe BBL in athletes achieved satisfactory outcomes over 1-year, with all athletes returning to sports activities.

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.

Infraspinatus function impairment after arthroscopic Bankart repair with Hill Sachs remplissage. Isokinetic, functional, and radiographic analysis.

PURPOSE: Arthroscopic Bankart repair with Hill Sachs remplissage (BHSR) is an option for anterior shoulder instability with humeral defect. Our hypothesis was that infraspinatus capsulo-tenodesis is an effective solution, with good clinical results and no consequences on shoulder strength and ranges of motion. METHODS: We performed a retrospective case-control study involving 22 patients operated with arthroscopic BHSR. We compared isokinetic evaluation of both shoulders using a dynanometer in concentric, eccentric force and endurance. Ranges of motion were measured using a goniometer and compared to the contralateral unaffected side. Functional assessment included Constant, Rowe, Walch and Duplay and WOSI scores. Healing and fatty degeneration were analyzed with magnetic resonance imaging. RESULTS: At mean 37.2 months follow-up, 21 patients (95.4%) were satisfied or very satisfied with the intervention. Range of motion in external rotation of the affected side decreased by 10.8° in adduction and 6° at 90° of abduction (p<0.05). Deficit in external rotation strength of the affected side greater than 15% was found in all isokinetic tests (p<0.05). Walch and Duplay, Rowe, WOSI and adjusted Constant average scores were respectively 71.05±14.1 (40-90), 67.63±19.7 (15-100), 34.6%±19.9 (8.43-76.23) and 69.8±13.57 (36.7-101). Postoperative MRI showed good capsulo-tenodesis healing without infraspinatus muscle fatty degeneration. CONCLUSION: Arthroscopic BHSR provides satisfactory functional outcomes but significant infraspinatus functional impairments in both strength and ranges of motion in external rotation. LEVEL OF EVIDENCE: III; case-control study.

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.

Stabilizing Mechanisms in Patients Treated Using Hill-Sachs Remplissage With Bankart Repair in Abduction-External Rotation Position.

BACKGROUND: Hill-Sachs lesion (HSL) remplissage with Bankart repair (RMBR) provides a minimally invasive solution for treating HSLs and glenoid bone defects of <25%. The infraspinatus tendon is inserted into the HSL during the remplissage process, causing the infraspinatus to shift medially, leading to an unknown effect on glenohumeral alignment during the resting abduction-external rotation (ABER) and muscle-active states. PURPOSE/HYPOTHESIS: The purpose of this study was to evaluate the possible check-rein effect and muscle-active control in stabilizing the glenohumeral joint after RMBR in vivo. We hypothesized that the check-rein effect and active control would stabilize the glenohumeral joint in the ABER position in patients after RMBR. STUDY DESIGN: Controlled laboratory study. METHODS: We included 42 participants-22 patients in group A who met the inclusion criteria after RMBR and 20 healthy participants in group B without shoulder laxity. Three-dimensional magnetic resonance imaging was performed to analyze the alignment relationship of the glenohumeral joint with and without muscular activity. Ultrasonic shear wave elastography was used to evaluate the elastic properties of the anterior capsule covered with the anterior bands of the inferior glenohumeral ligament. RESULTS: Patients who underwent RMBR demonstrated more posterior (-1.81 ± 1.19 mm vs -0.76 ± 1.25 mm; P = .008) and inferior (-1.05 ± 0.62 mm vs -0.45 ± 0.48 mm; P = .001) shifts of the humeral head rotation center and less anterior capsular elasticity (70.07 ± 22.60 kPa vs 84.01 ± 14.08 kPa; P = .023) than healthy participants in the resting ABER state. More posterior (-3.17 ± 0.84 mm vs -1.81 ± 1.19 mm; P < .001) and less-inferior (-0.34 ± 0.56 mm vs -1.05 ± 0.62 mm; P < .001) shifts of the humeral head rotation center and less anterior capsular elasticity (36.57 ± 13.89 kPa vs 70.07 ± 22.60 kPa; P < .001) were observed in the operative shoulder during muscle-active ABER than in resting ABER states. CONCLUSION: The check-rein effect and muscle-active control act as stabilizing mechanisms in RMBR during the ABER position. CLINICAL RELEVANCE: Stabilizing mechanisms in RMBR during the ABER position include the check-rein effect and muscle-active control.

Curative effect analysis of arthroscopic Bankart repair combined with Remplissage for the treatment of recurrent anterior dislocation of shoulder in soldiers with Bipolar lesions / 中国内镜杂志

Objective To evaluate the clinical effects of the treatment of recurrent anterior dislocation of shoulder in soldiers with bipolar lesions by arthroscopic Bankart repair and Remplissage surgery.Methods From February 2019 to March 2022,15 patients with recurrent anterior dislocation of shoulder in our hospital were selected,all of whom were male;The age ranged from 18～33(23.07±4.39)years,Beighton score was(4.40±1.89).4 cases of left shoulder and 11 cases of right shoulder.Preoperative CT evaluation of Hill-Sachs injury was(16.93±2.17)%.The range of motion was recorded,and the function and stability of the shoulder was evaluated by the American Shoulder and Elbow Surgeons(ASES)score and Constant-Murley score.Results All patients were followed up for 10～28(18.47±6.46)months.No patient had clinical complications such as infections,neurovascular injuries and redislocation.Shoulder flexion and lifting increased from(152.41±14.28)° pre-operatively to(167.48±10.23)° at the latest follow-up,and internal rotation,preoperative spinous process levels were T5 1 cases,T6 2 cases,T7 6 cases,T8 3 cases,T9 2 cases,T10 1 cases,postoperative spinous process levels were T5 1 cases,T6 1 cases,T7 3 cases,T8 6 cases,T9 4 cases,the average lateral external rotation and abduction 90° external rotation decreased from(60.31±13.43)°and(97.41±13.17)° pre-operatively to(51.23±14.27)° and(89.47±14.15)° at the latest follow-up,respectively.The ASES score and Constant-Murley score were significantly improved.Conclusion The clinical effect of rehabilitation of Bankart repair combined with Remplissage under arthroscopy in the treatment of recurrent dislocation of shoulder in soldiers with Bipolar lesions is satisfactory.Although the external rotation angle of shoulder is slightly decreased after operation,it can significantly reduce the recurrence rate of shoulder dislocations and return to the training.

Bankart repair with remplissage vs. Latarjet procedure on recurrence, postoperative pain scores, external rotation, and Rowe score in patients with a Hill-Sachs lesion. A systematic review.

Background: Currently, recurrent anterior shoulder instability in patients with a Hill-Sachs lesion managed using the Bankart repair showed higher recurrent instability compared with the Latarjet technique. Addition of posterior capsulodesis with infraspinatus remplissage to the Bankart repair, known as Bankart with remplissage (BR), increases shoulder stability in patients with a Hill-Sachs lesion. BR can potentially match the low recurrence rates of the Latarjet procedure while being less invasive. This systematic review compares the Bankart repair with remplissage and Latarjet procedure on postoperative pain, external rotation range of motion, and recurrent instability in anterior shoulder instability patients with a Hill-Sachs lesion. Methods: A systematic search of the PubMed, Web of Science, and Cochrane Library databases was performed. Studies comparing BR and Latarjet on recurrent instability and/or visual analogue scale (VAS) pain score in anterior shoulder instability patients with a Hill-Sachs lesion were included. Expert opinion, conference presentations, editorials, abstracts, case reports, and nonclinical studies were excluded. Records were initially screened by title and abstract, during the second screening full text was consulted. Study quality was examined using the Methodological Index for Nonrandomized Studies criteria. Risk ratios were calculated for recurrent instability, and standardized mean difference (Cohen's d) were calculated for VAS pain, external rotation, and Rowe score. Results: Eight of the 146 studies were included in the analysis. The study population consisted of a total of 845 patients, of whom 450 patients underwent the Latarjet procedure and 395 patients underwent BR. Three studies included revision surgery patients; more revision surgery patients were allocated to the Latarjet group. Risk ratios for recurrent instability varied from 0.45 to 2.41. Effect size varied for VAS pain from -2.28 to 0.04, for external rotation from -1.44 to 1.12, and for Rowe score from -0.67 to 1.37. Limitations of the included studies were differences in baseline demographics and functional outcomes. Conclusion: Recurrent instability seems equal between BR and Latarjet in patients with a Hill-Sachs lesion depth <10 mm. Latarjet showed superior external rotation than BR. Future research should examine patient demographics optimal for minimizing recurrent instability using BR.

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.