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Primary arthroscopic Bankart repair with remplissage shows low failure rate
American Shoulder and Elbow Scores improved significantly with these procedures.
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Patients with shoulder instability and bone loss that underwent Bankart repair with arthroscopic infraspinatus tenodesis with posterior capsulodesis showed improved outcome scores, but they had higher failure rates for revisions, according to an investigator.
“Arthroscopic remplissage for shoulder instability with moderate bone loss appears to be an effective adjunct to Bankart reconstruction and primary surgery and it was associated with a significantly higher failure rate in revision surgery in our experience,” Michael P. McCabe, MD, of Walter Reed National Military Medical Center, in Bethesda, Md., USA, said.
The researchers completed the study when McCabe was a sports medicine fellow at Tulane University in New Orleans and the Mississippi Sports Medicine & Orthopaedic Center in Jackson, Miss., USA.
Remplissage as a remedy
Images: McCabe MP
“[The study] is relevant for patients with instability who have a moderate amount of bone loss and that is a particularly problematic patient population because of the relatively high failure rates that have been shown over the years compared to patients without bone loss,” McCabe said. “The moderate grade bone loss is a compounding factor or a factor that makes surgery results less favorable in previous studies. So remplissage was initially suggested as a technique to help address that issue with bone loss.”
McCabe noted in his presentation at the Arthroscopy Association of North America Annual Meeting that he and colleagues found relatively few published studies that discussed failure rates in patients with shoulder instability and moderate bone loss who underwent arthroscopic infraspinatus tenodesis with posterior capsulodesis, which is known as remplissage.
The studies they found showed failure rates of 0% to 15%, he said.
Primary and revision surgeries
The retrospective study that McCabe and colleagues conducted included 31 patients with an average age of 25 years and 41 months follow-up, average, who were divided into a group of 20 primary surgeries done with remplissage and 11 revision instability surgeries with remplissage. Patients with small non-engaging Hill-Sachs lesions underwent standard arthroscopic treatment for shoulder instability and patients with engaging Hill-Sachs lesions underwent Bankart reconstruction with arthroscopic remplissage.
For the surgery, patients were placed in the lateral decubitus position. Surgeons placed the anterior inferior anchor first and then performed the remplissage, when indicated, “as it allowed adequate access to and visualization of the posterior humeral head as the capsular volume was still increased.” They then completed the anterior reconstruction, McCabe explained.
Higher revision failure rate
The researchers reported four failures among the 31 patients for an overall 13% failure rate. The 11 patients with revisions had a 36% overall failure rate and there was a 0% failure rate for the 20 primary surgeries. For the entire group, preoperative American Shoulder and Elbow Scores (ASES) improved from 50 points to 90 points postoperatively. The revision remplissage patients showed improved ASES scores, but that trend was not significant, according to McCabe.
This was a multi-surgeon study which introduces some variability in the techniques used and the size of the cohort was small, McCabe said, discussing the study’s weaknesses.
In the future, he and his colleagues plan to follow this cohort long-term to determine if the patients maintain an acceptable failure rate, better quantify the amount of bone loss per patient and to understand who is the best candidate for this technique in primary and revision situations.
“You want to address all pathology at the time of the first surgery if you are faced with bone loss at that time,” McCabe said. – by Renee Blisard Buddle
- Reference:
- McCabe MP. Paper #SS-02. Presented at: Arthroscopy Association of North America Annual Meeting; May 17-19, 2012; Orlando, Fla., USA.
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For more information:
- Michael P. McCabe, MD, can be reached at Walter Reed National Military Medical Center, 8901 Wisconsin Ave., Bethesda, MD 20889 USA; email: michael.p.mccabe.mil@health.mil.
Disclosure: McCabe has no relevant financial disclosures.
Perspective
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Dinshaw Pardiwala, MS(Orth) DNB(Orth) FCPS
Anterior glenohumeral instability with significant bone loss poses a treatment challenge to shoulder surgeons. Although there seems to be a consensus that glenoid bone loss exceeding 25% is best treated with bone augmentation procedures, such as the Latarjet and Eden-Hybbinette procedures, especially in contact athletes, the optimal treatment for large humeral head defects is more controversial. Termed engaging Hill-Sachs lesions, these humeral head defects are large enough to cause locking against the anterior glenoid rim when the arm is at 90° of abduction and more than 30° of external rotation. There is increasing evidence that simultaneous arthroscopic Bankart repair and infraspinatus tenodesis (remplissage) provides lower recurrence rates than does Bankart repair alone for instability associated with humeral head defects.
This study advocates arthroscopic remplissage with anterior capsulolabral repair for anterior glenohumeral instability with moderate glenoid bone loss. Although soft tissue procedures are successful in providing stability in the context of bone loss in low-demand shoulders, I would caution the use of a soft-tissue reconstructive procedure on the humeral side as a means to address bone loss that is on the glenoid side.
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