To Remplissage or Not to Remplissage Part 1: Prognostic Factors Influencing Recurrent Shoulder Instability in High-Risk Individuals with On-Track Shoulders Undergoing Primary Arthroscopic Anterior Stabilization
Stephanie Boden, Ehab Nazzal, Matthew Como, Romano Sebastiani, Jonathan Hughes, Mark Rodosky, Adam Popchak, Volker Musahl, Bryson Lesniak, Dharmesh Vyas, Albert Lin, Shaquille Charles- Orthopedics and Sports Medicine
Objectives:
Recent studies have shown that a subset of on-track Hill-Sachs lesions (HSL), defined as near-track lesions, may have a high risk of failure after primary arthroscopic Bankart repair (ABR) alone. The aim of this study was to evaluate rates of recurrent shoulder instability among patients with on-track HSL who underwent primary ABR with and without remplissage in the setting of numerous risk factors highlighted in recent literature. We hypothesized that primary ABR with remplissage (ABR+R) would lower postoperative rates of recurrent shoulder instability, particularly for “high-risk” patients defined as “near-track” lesions, hyperlaxity, younger age, contact athletes, and >1 preoperative instability episodes.
Methods:
Prospectively collected data was retrospectively reviewed for consecutive patients aged 14-40 years who underwent either ABR or ABR+R between 2013 and 2021 for anterior glenohumeral instability. Glenoid bone loss, Hills-Sachs Interval (HSI), glenoid track (GT), and distance-to-dislocation (DTD) values (DTD = GT-HSI) were determined via preoperative magnetic resonance imaging. Additionally, “near-track” lesions are a subset of on-track lesions with a DTD from 0 – 10mm. Capsuloligamentous laxity (i.e., hyperlaxity) was defined as external rotation greater than 85 degrees and/or grade 2+ posterior and inferior load-and-shift on examination under anesthesia. Recurrent shoulder instability was defined as recurrent dislocation and/or subjective subluxation postoperatively. Patients were excluded if the indexed surgery was a revision procedure, < 2-year follow-up, or glenoid bone loss (GBL) >20%. Univariate and multivariate Cox regression analysis was used to determine predictors of recurrent shoulder instability and reoperation.
Results:
One-hundred-and-fifty-five patients were included for analysis (ABR: 116 | ABR+R: 39) with an average age of 21.6 ± 6.2 years and an average follow-up of 5.1 ± 2.0 years (range: 2.0 – 8.7 yrs). Overall, 30 patients (19%) experienced recurrent shoulder instability postoperatively (4.3 per 100 person-years), and 20 (13%) underwent secondary surgery (2.9 per 100 person-years) for revision stabilization. Among the 116 patients who underwent primary ABR only, 27 (23.3%) experienced recurrent shoulder instability, compared with only three of the 39 ABR+R patients (7.7%). Risk factors assessed included: age, gender, sport, number of preoperative instability episodes, shoulder laxity, GBL, and DTD. Multivariate analysis demonstrated that younger age (p=0.003), increased shoulder laxity (p=0.010), 2+ episodes of preoperative instability episodes (p=0.009), and a lower DTD (p=0.046) were independent risk factors for recurrent shoulder instability postoperatively. However, contact athlete status was not identified as a significant predictor of recurrent shoulder instability. According to multivariate results, patients who underwent primary ABR only were roughly 9-times more likely to experience recurrent shoulder instability (HR: 8.7, p=0.002) and 7-times more likely to undergo reoperation (HR:6.8, p=0.019) than those who underwent primary ABR+R. When considering patients with three or more risk factors (i.e., “near-track” lesions, hyperlaxity, age < 25, or 2+ preoperative instability episodes), 9 of 12 ABR patients (75%) and 2 of 16 ABR+R (13%) experienced recurrent shoulder instability (p = 0.001), Table 1. Survival rates for ABR only versus ABR+R for patients with three or more risk factors are plotted in Figure 1 using Kaplan-Meier survival plots.
Conclusions:
Arthroscopic primary Bankart repair with remplissage may be an effective approach for decreasing the likelihood of recurrent shoulder instability and the need for secondary surgery among patients with on-track HSL. This surgical approach is especially beneficial for patients with lower DTD, increased shoulder laxity, younger age, or 2+ preoperative instability episodes in a dose-dependent manner. Those with higher risks of recurrence may benefit significantly more with the addition of a remplissage than those with fewer risk factors.