Functional outcome of arthroscopic bankart repair with or without remplissage in recurrent anterior shoulder instability

Lalithmohan Chodavarapu; K K Kiran Kumar; Venkatesham Bitla; Chandrashekhar Patnala

doi:10.4103/jotr.jotr_89_22

ORIGINAL ARTICLE

Year : 2022 | Volume : 14 | Issue : 2 | Page : 144-148

Functional outcome of arthroscopic bankart repair with or without remplissage in recurrent anterior shoulder instability

Lalithmohan Chodavarapu, K K Kiran Kumar, Venkatesham Bitla, Chandrashekhar Patnala
Department of Orthopaedics, Nizam's Institute of Medical Sciences, Hyderabad, Telangana, India

Date of Submission	13-Sep-2022
Date of Acceptance	13-Nov-2022
Date of Web Publication	30-Dec-2022

Correspondence Address:
Dr. K K Kiran Kumar
Department of Orthopaedics, Nizam's Institute of Medical Sciences, Punjagutta, Hyderabad - 500 082, Telangana
India

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/jotr.jotr_89_22

Abstract

Background: Arthroscopic Bankart repair is now the standard procedure for shoulder stabilization in patients with recurrent anterior shoulder instability with Bankart lesion with minimum glenoid bone loss. Aims: The aim of this study is to evaluate the postoperative shoulder motion and functional outcome following arthroscopic repair of Bankart lesion with suture anchors with or without remplissage. Materials and Methods: This is a prospective study done between May 2019 and April 2021. A total of 20 patients with recurrent anterior shoulder instability were stabilized arthroscopically by the same surgical team over time. All patients met the inclusion criteria and were assessed with the American Shoulder and Elbow Surgeons (ASES) and Rowe scoring systems. The range of motion, postoperative function, recurrence rate, and return to preinjury activities were evaluated. Results: In our study, all 20 patients were followed up for a minimum period of 1 year. All patients had a good range of motion. The two shoulder scores (ASES and Rowe) significantly improved after surgery (P < 0.05). There was only one recurrence (5%). Patients were able to return to their previous activities or physically demanding jobs. Conclusions: Arthroscopic Bankart repair for traumatic anterior shoulder instability is a good procedure with less postoperative morbidity and excellent functional outcome. It allows return of patients to previous activities without any restriction.

Keywords: American Shoulder and Elbow Surgeons Score, Bankart repair, external rotation, recurrent instability, remplissage, Rowe score

How to cite this article:
Chodavarapu L, Kumar K K, Bitla V, Patnala C. Functional outcome of arthroscopic bankart repair with or without remplissage in recurrent anterior shoulder instability. J Orthop Traumatol Rehabil 2022;14:144-8

How to cite this URL:
Chodavarapu L, Kumar K K, Bitla V, Patnala C. Functional outcome of arthroscopic bankart repair with or without remplissage in recurrent anterior shoulder instability. J Orthop Traumatol Rehabil [serial online] 2022 [cited 2023 Apr 1];14:144-8. Available from: https://www.jotr.in/text.asp?2022/14/2/144/365830

Introduction

Recurrent traumatic anterior shoulder dislocations lead to bipolar injury on the glenoid and humeral side. Soft tissue or bony avulsion of capsuloligamentous complex from anteroinferior glenoid (Bankart lesion) and concomitant postsuperolateral osseous defect of the humeral head (Hill‒Sachs lesion) are common pathologic changes.^[1]

Repeated episodes of instability cause more damage to capsulolabral junction^[2] and lead to erosion of the glenoid rim.^[3] Risk factors for recurrent dislocations are young age, number of dislocations, participation in competitive sports, contact sport or overhead sport, and joint hyperlaxity.^[4]

Glenoid bone loss >25% is treated with a bone graft to the glenoid.^[5] In cases with <25% glenoid bone loss, Bankart repair is indicated. Open Bankart repair gives good results with low recurrence rates but more postoperative pain, scarring, and loss of external rotation were commonly reported complications.^[6],[7] Arthroscopic Bankart repair has less postoperative pain, decreased morbidity, and faster rehabilitation with no loss of motion. Initially, high recurrence rates were reported in the literature^[8],[9] but with advances in arthroscopic techniques, now rates are comparable to open procedure.^[10],[11]

An off-track Hill‒Sachs lesion can result in recurrence after arthroscopic Bankart repair.^[12] Remplissage is an arthroscopic procedure of filling Hill‒Sachs lesion with infraspinatus tendon and posterior capsule, converting it into extra-articular defect. Furthermore, it acts as check rein to the anterior translation of the humeral head.^[13] Remplissage when combined with arthroscopic Bankart repair in an off-track Hill‒Sachs lesion results in a significantly reduced rate of recurrence in comparison to lone Bankart repair.^[14]

The following study aims to report the functional outcome of arthroscopic Bankart repair with or without remplissage for recurrent anterior shoulder instability.

Materials and Methods

A prospective observational study of arthroscopic Bankart repair with or without remplissage for recurrent anterior shoulder instability of 20 patients was done at our institute from May 2019 to April 2021.

Inclusion and exclusion criteria

Patients with recurrent anterior glenohumeral instability, with glenoid bone loss <25% between 20 and 40 years of age with minimum follow-up of 1 year were included in this study. Exclusion criteria were patients with >25% glenoid bone loss, concomitant rotator cuff tears, multidirectional instability, and voluntary shoulder dislocation.

Preoperative evaluation

All patients were thoroughly evaluated by standard physical examination including range of motion. Magnetic resonance imaging was done in all to confirm the diagnosis and rule out other pathologies. The percentage of the glenoid bone loss was calculated on the “en face” view reconstructed by three-dimensional computed tomography using the method described by Sugaya.^[15] Shoulder function was evaluated by the American Shoulder and Elbow Surgeons (ASES) score and Rowe score.

Surgical technique

All the surgeries were performed by a single surgeon under general anesthesia in lateral decubitus position with the affected shoulder in 30° of abduction and 15° of forward flexion. Standard posterior, anterosuperior, and anteroinferior (mid glenoid) portals were created and cannulas were inserted in all portals. Diagnostic arthroscopy was performed in all patients to confirm the presence of a Bankart lesion and to assess the size and glenoid track of Hill-‒Sachs lesion if present. If an off-track Hill‒Sachs lesion was present, one 5 mm double-loaded suture anchor was placed adjacent to the articular cartilage for remplissage to be done later. The Bankart lesion was elevated off the glenoid neck using a periosteal elevator and bone was rasped for improved biology [Figure 1]. The Bankart lesion was completely freed anteriorly before proceeding with fixation. The first anchor was usually placed as inferior as possible (5:30–6 o'clock position) from the mid glenoid portal, on the glenoid articular surface 3 mm from the articular edge. A suture passer was used to shuttle suture strand of the suture anchor and knot was applied on the capsular side of the glenoid labrum to push the labrum up onto glenoid socket to create labral bump [Figure 2]. One or two more suture anchors were placed superior to the first anchor and a similar labral bump was created. Then, to complete the remplissage procedure, the arthroscope was switched from the posterior to the anterior superior portal, and sutures were tied in mattress configuration over the Hill‒Sachs lesion creating a posterior capsulotenodesis [Figure 3]. Finally, after switching back the arthroscope in the posterior portal, all repairs were checked (Bankart repair with or without remplissage).

Figure 1: Bankart lesion. Elevation of capsuloligamentous complex from glenoid with periosteal elevator

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Figure 2: Labral bump created after Bankart repair

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Figure 3: (a) Large Hill‒Sachs lesion. (b) A 5 mm suture anchor placed in the defect. (c) Completed Remplissage ‒ Infraspinatus filling the defect

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Postoperative rehabilitation and follow-up

The operated shoulder was immobilized in arm sling pouch for 3 weeks. Pendulum exercises and forward elevation of the shoulder to 90° were allowed from the 3^rd week to 6^th week. Full range of motion exercises were started after 6 weeks. Patients were followed up at 4, 8, and 12 weeks and then at 6 months and 1 year. Shoulder range of motion, ASES and Rowe scores were recorded. The variables were represented by frequencies. The analysis was performed using IBM SPSS Statistics version 20.0. P < 0.05 was considered statistically significant.

Results

A total of 20 patients underwent arthroscopic Bankart repair ± remplissage. Most of the patients (12 patients, 60%) were in the age group of 20–24 years [Table 1]. The mean age of distribution was 25.7 years with a range between 20 and 40 years. All patients were male.

Table 1: Age distribution

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About one-third of patients (7, 35%), were students. Five out of 20 (25%) patients were manual laborers by profession. Sports injuries were the most common cause of injury, seen in 10 patients (kabaddi – 30%, cricket ‒ 10%, others ‒ 10%), whereas motor vehicle accident was the cause in 3 (15%) patients.

The right side was more commonly injured (80%) than the left side. The most common symptom at presentation was shoulder pain with instability (65%) followed by instability (35%). The average duration of presentation to us after 1^st episode of dislocation was 55.7 months (range, 12–180 months). The average number of preoperative instability episodes was 13 (range, 4–30).

Five (25%) patients had bony Bankart lesions. The rest of the patients had bony erosion <25% of glenoid width. All patients had Hill‒Sachs lesions. Ten (50%) patients had large off-track lesions that required remplissage along with Bankart repair. In the majority of patients (14 patients, 70%), two suture anchors were used, whereas three suture anchors were used in 30% of patients.

A SLAP type 5 lesion was identified intraoperatively in one patient and was repaired with 1 additional suture anchor at 12 o'clock position after Bankart repair. No significant difference in the postoperative range of motion and functional scores was observed in this patient.

The average active forward flexion increased by 7.3°, from 170.7° ± 4.5° preoperatively to 178° ± 1° postoperatively. Average external rotation decreased by 6.7° and 6.4° with the arm at the side (ER1) and in 90° abduction (ER2), respectively. Average abduction also decreased by 6° postoperatively. Average internal rotation with the arm in 90° abduction was not reduced significantly [Table 2].

Table 2: Comparison of pre- and postoperative shoulder range of motion

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At the final follow-up, there was a statistically significant improvement in ASES and Rowe scores in comparison to the preoperative scores. The ASES score increased from a mean of 48.9 to 85.95. Rowe score also increased from a mean of 32.5 to 92 [Table 3].

Table 3: Comparison of pre- and postoperative functional scores

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Discussion

Arthroscopic Bankart repair with or without remplissage is currently the most used technique of surgical management in patients with Bankart lesion without significant bone loss. The risk for recurrent instability is low and the return of the patient to previous sport or work is high.^[16]

The understanding of the mechanism and resultant development of surgical techniques of anterior shoulder instability is progressing. Latarjet or other bone-grafting procedures should be done if glenoid bony loss is >25%.^[17] Arthroscopic Bankart repair is indicated in patients without significant glenoid bone loss but large Hill‒Sachs lesions can cause recurrence after isolated Bankart repair.^[18] Large “engaging” Hill‒Sachs lesion as described by Burkhart and De Beer^[19] or “off-track” lesion described by Di Giacomo et al.^[5] are treated with remplissage. It is a nonanatomical procedure but gives excellent results with low recurrence rate. Loss of terminal external rotation is a concern with remplissage but no significant effect on functional scores was observed in many studies.^[14]

The age of the patient remains one of the most important nonmodifiable risk factors for recurrent instability. In our study, most of the patients (12 patients, 60%) were in the age group of 20–24 years. Hovelius et al.^[20] found that the risk of redislocation varied inversely with age at the time of primary dislocation and over a third of patients under the age of 20 years required surgery eventually. All patients in our study were male as they are more involved in outdoor activities such as sports and road traffic accidents.

Percentage of glenoid bone erosion and size of Hill‒Sachs lesion increase with greater number of dislocations.^[3] We have also observed that patients with a greater number of instability episodes (>10) had large Hill‒Sachs lesions.

In the majority of patients (70%) only two suture anchors were used for Bankart repair. Shibata et al.^[21] found that redislocation occurred if large Hill‒Sachs lesion was present and less than four suture anchors were used. We had only one redislocation (5%) after repair as we had treated concomitant large Hill‒Sachs lesions with remplissage.

In our study, off-track large Hill‒Sachs lesions were found in 10 (50%) cases and were treated with remplissage using a double-loaded 5.0 mm suture anchor. The anchor was placed after diagnostic arthroscopy and sutures were retrieved from different areas of infraspinatus before proceeding with Bankart repair. Sutures were tied down after completion of repair.

A SLAP lesion was found in one patient and was repaired. This is an advantage of arthroscopic Bankart repair over open technique as concomitant lesions can be identified and managed immediately.

Wang et al. after a meta-analysis concluded that patients treated with arthroscopic Bankart repair had significant better shoulder range of motion than those treated by open repair.^[22] Many studies have reported decrease in external rotation, especially when remplissage is also done. Our patients had restriction of terminal abduction and external rotation while forward flexion increased with no restriction of internal rotation.

ASES shoulder score and the Rowe score are frequently used patient recorded outcomes scales following arthroscopy Bankart repair and show good improvement in many studies. Both scores showed significant improvement postoperatively in our study. Patients of age <25 years and those who participated in sports activities had better functional scores.

In our study, 15 (75%) patients were involved in occupations requiring overhead activities such as daily labor (25%), agriculturists (10%), and students (40%). All returned to their previous level of activities. The average rate of return to work is about 70.7% when data were pooled from six high-quality studies by DeFroda et al.^[16] Postoperatively students restricted themselves to sports activities not involving overhead shoulder movements while other returns to their previous jobs. Return to play is as high as 90% by Donohue et al.^[23]

While a large number of studies have looked at the recurrence of shoulder instability following arthroscopic Bankart repair, a large degree of variability exists ranging from 3.4 to 33.3% lifetime recurrence rate, with an average rate of 13.1%.^[24] In addition, the average amount of time before another instability event is less with arthroscopic than open Bankart repair (12.6 vs. 34.2 months, respectively).^[25] In our study, only 1 (5%) patient had redislocation which occurred after 3 years from repair during a throwing activity. He was treated with open Latarjet procedure.

Conclusions

We conclude that arthroscopic management for recurrent anterior shoulder instability has less morbidity, good functional outcome, low recurrence rate, and high rate of return of patients to their previous jobs. Future work must focus on long-term outcomes and the rate of glenohumeral arthritis in patients undergoing arthroscopic repair with suture anchors.

Limitations

Our sample size is small and it is a short-term study. There is a need for a long-term study with large sample size to validate the results of this study.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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