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      Bankart Repair With or Without Concomitant Remplissage Results in Similar Shoulder Motion and Postoperative Outcomes in the Treatment of Shoulder Instability

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          Abstract

          Purpose

          To compare the results of patients who underwent Bankart repair with or without concomitant remplissage for treatment of shoulder instability.

          Methods

          All patients who underwent shoulder stabilization for shoulder instability from 2014 to 2019 were evaluated. Patients who underwent remplissage were matched to those patients who received no remplissage based on sex, age, body mass index, and date of surgery. Glenoid bone loss and presence of an engaging Hill–Sachs lesion were quantified by 2 independent investigators. Postoperative complications, recurrent instability, revision, shoulder range of motion (ROM), return to sport (RTS), and patient-reported outcome measures (Oxford Shoulder Instability, Single Assessment Numeric Evaluation, and American Shoulder and Elbow Surgeons scores) were compared between groups.

          Results

          Overall, 31 patients who underwent remplissage were identified and matched to 31 patients who received no remplissage at a mean follow-up of 2.8 ± 1.8 years. Glenoid bone loss was similar between groups (11% vs 11%, P = .956); however, engaging Hill–Sachs lesions were more prevalent in the patients who underwent remplissage than the patients who received no remplissage (84% vs 3%, P < .001). There were no significant differences in rates of redislocation (remplissage: 12.9% vs no remplissage: 9.7%), subjective instability (45.2% vs 25.8%), reoperation (12.9% vs 0%), or revision (12.9% vs 0%) between groups (all P > .05). Also, there were no differences in RTS rates, shoulder range of motion, or patient-reported outcome measures (all P > .05).

          Conclusions

          If a patient is indicated for Bankart repair with concomitant remplissage, surgeons may expect shoulder motion and postoperative outcomes similar to those of patients without engaging Hill–Sachs lesions who undergo Bankart repair without concomitant remplissage.

          Level of Evidence

          Therapeutic case series, level IV.

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          Most cited references32

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          Risk factors for recurrence of shoulder instability after arthroscopic Bankart repair.

          The higher failure rates reported with arthroscopic stabilization of traumatic, recurrent anterior shoulder instability compared with open stabilization remain a concern. The purpose of this study was to evaluate the outcomes of arthroscopic Bankart repairs with the use of suture anchors and to identify risk factors related to postoperative recurrence of shoulder instability. Ninety-one consecutive patients underwent arthroscopic stabilization for recurrent anterior traumatic shoulder instability. The mean age (and standard deviation) at the time of surgery was 26.4 +/- 5.4 years. Seventy-one patients were male. Seventy-nine patients were involved in sports (forty, in high-risk sports). Capsulolabral reattachment and capsule retensioning was performed with use of absorbable suture anchors (mean, 4.3 anchors; range, two to seven anchors). All patients were prospectively followed, and, at the time of the last review, the patients were examined and assessed functionally by independent observers. At a mean follow-up of thirty-six months, fourteen patients (15.3%) experienced recurrent instability: six sustained a frank dislocation and eight reported a subluxation. The mean delay to recurrence was 17.6 months. The risk of postoperative recurrence was significantly related to the presence of a bone defect, either on the glenoid side (a glenoid compression-fracture; p = 0.01) or on the humeral side (a large Hill-Sachs lesion; p = 0.05). By contrast, a glenoid separation-fracture was not associated with postoperative recurrent dislocation or subluxation. Recurrence of instability was significantly higher in patients with inferior shoulder hyperlaxity (p = 0.03) and/or anterior shoulder hyperlaxity (p = 0.01). On multivariate analysis, the presence of glenoid bone loss and inferior hyperlaxity led to a 75% recurrence rate (p < 0.001). Lastly, the number of suture-anchors was critical: patients who had three anchors or fewer were at higher risk for recurrent instability (p = 0.03). In the treatment of traumatic recurrent anterior shoulder instability, patients with bone loss or with shoulder hyperlaxity are at risk for recurrent instability after arthroscopic Bankart repair. At least four anchor points should be used to obtain secure shoulder stabilization.
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            The Hill-Sachs lesion: diagnosis, classification, and management.

            The Hill-Sachs lesion is an osseous defect of the humeral head that is typically associated with anterior shoulder instability. The incidence of these lesions in the setting of glenohumeral instability is relatively high and approaches 100% in persons with recurrent anterior shoulder instability. Reverse Hill-Sachs lesion has been described in patients with posterior shoulder instability. Glenoid bone loss is typically associated with the Hill-Sachs lesion in patients with recurrent anterior shoulder instability. The lesion is a bipolar injury, and identification of concomitant glenoid bone loss is essential to optimize clinical outcome. Other pathology (eg, Bankart tear, labral or capsular injuries) must be identified, as well. Treatment is dictated by subjective and objective findings of shoulder instability and radiographic findings. Nonsurgical management, including focused rehabilitation, is acceptable in cases of small bony defects and nonengaging lesions in which the glenohumeral joint remains stable during desired activities. Surgical options include arthroscopic and open techniques.
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              Hill-sachs "remplissage": an arthroscopic solution for the engaging hill-sachs lesion.

              We present an arthroscopic technique used to treat traumatic shoulder instability in patients with glenoid bone loss and a large Hill-Sachs lesion. The procedure consists of an arthroscopic capsulotenodesis of the posterior capsule and infraspinatus tendon to fill the Hill-Sachs lesion. With the patient in the lateral decubitus position, a posterior portal is established at the lateral aspect of the convexity of the humeral head that is centered over the lesion. After anterior-inferior and anterior-superior portals have been established, the camera is placed in the anterior-superior portal. The Hill-Sachs lesion is freshened with a bur through the posterior portal. A cannula is inserted in the posterior portal through the deltoid but not through the infraspinatus or capsule, and an anchor is placed in the inferior aspect of the humeral lesion. A penetrating grasper is passed through the tendon and posterior capsule, 1 cm inferior to the initial portal entry site to pull 1 suture limb. A second anchor is placed superiorly, and 1 suture limb is similarly passed. The inferior suture is tied first with the knots remaining extra-articular, pulling the infraspinatus and capsule into the lesion. After completion, the Bankart lesion can then be repaired.
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                Author and article information

                Contributors
                Journal
                Arthrosc Sports Med Rehabil
                Arthrosc Sports Med Rehabil
                Arthroscopy, Sports Medicine, and Rehabilitation
                Elsevier
                2666-061X
                21 December 2022
                February 2023
                21 December 2022
                : 5
                : 1
                : e171-e178
                Affiliations
                [a ]Rothman Orthopaedic Institute, Philadelphia, Pennsylvania, U.S.A.
                [b ]Hackensack Meridian School of Medicine, Nutley, New Jersey, U.S.A.
                [c ]Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, U.S.A.
                [d ]Reconstructive Orthopedics, Medford, New Jersey, U.S.A.
                [e ]Rothman Orthopaedic Institute, New York, New York, U.S.A.
                Author notes
                []Address correspondence to Brandon J. Erickson, M.D., Rothman Orthopaedic Institute, 645 Madison Ave., 3rd and 4th floors, New York, NY 10022. Brandon.erickson@ 123456rothmanortho.com
                Article
                S2666-061X(22)00181-X
                10.1016/j.asmr.2022.11.009
                9971860
                36866319
                eb4ca971-0b2f-465a-addf-7f30bbe304a6
                © 2022 The Authors

                This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

                History
                : 25 May 2022
                : 8 November 2022
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