Arthroscopic Bankart repair with and without arthroscopic infraspinatus remplissage in anterior shoulder instability with a Hill-Sachs defect: a randomized controlled trial.

BACKGROUND

The purpose of this study was to compare patient-reported and clinic outcomes between arthroscopic Bankart repair with (REMP) and without (NO REMP) arthroscopic infraspinatus remplissage in patients with recurrent anterior shoulder instability with a Hill-Sachs lesion and minimal glenoid bone loss.

METHODS

Patients 14 years or older with a recurrent anterior shoulder instability with the presence of an engaging Hill-Sachs defect (of any size) confirmed on computed tomography or magnetic resonance imaging were eligible to participate. Consented patients were randomized intraoperatively to NO REMP or REMP. Study visits were conducted preoperatively and 3, 6, 12, and 24 months postoperatively. The primary outcome was the Western Ontario Shoulder Instability score. Secondary outcomes included incidence of postoperative recurrent shoulder instability, Simple Shoulder Test, American Shoulder and Elbow Surgeons score, range of motion, complications, and revision surgery. To compare groups, a mixed-effects linear model was used for continuous variables and a χ or Fisher's exact test for categorical data. A Kaplan-Meier survival analysis assessed survival distribution between groups.

RESULTS

One hundred and eight patients were randomized to Bankart repair with (n = 54) or without (n = 54) remplissage. The mean follow-up was 26.5 months (21-53 months) and 24.3 months (23-64 months) for the REMP and NO REMP groups, respectively. Rates of postoperative recurrent instability were higher (P = .027) in the NO REMP group with 9 of 50 (18%) vs. 2 of 52 (4%) postoperative dislocations in the REMP group. There were no significant differences in patient-reported outcomes between groups at any time point. Survival curve distributions were also significantly different favoring REMP (χ = 5.255, P = .022). There was a significant difference in rate of revision surgery between groups with 6 in the NO REMP and none in the REMP groups (P = .029). Post hoc, patients were noted to have a higher risk for re-dislocation if their Hill-Sachs lesion was ≥20 mm in width or ≥15% of humeral head diameter. One intraoperative complication was reported in the REMP group.

CONCLUSIONS

There is significantly greater risk of postoperative recurrent instability in patients who did not have a remplissage performed in conjunction with an arthroscopic Bankart repair for the treatment of traumatic recurrent anterior shoulder instability with Hill-Sachs lesions of any size and minimal glenoid bone loss (<15%) at 2 years postoperatively. Otherwise, there are no differences in patient-reported outcomes, complications, or shoulder function at 2 years postoperatively. In addition, the remplissage procedure has significantly lower rates of re-dislocation in high-risk patients with Hill-Sachs lesions ≥20 mm and/or ≥15% in size.