Honoki Keigo, McRae Sheila, Woodmass Jarret, Lapner Peter, MacDonald Peter
Pan Am Clinic, Winnipeg, MB, Canada.
Department of Surgery, Section of Orthopaedic Surgery, University of Manitoba, Winnipeg, MB, Canada; Department of Research, Pan Am Clinic Foundation, Winnipeg, MB, Canada.
J Shoulder Elbow Surg. 2025 Jul 29. doi: 10.1016/j.jse.2025.06.010.
Arthroscopic remplissage with arthroscopic Bankart repair (ABR) may be considered for those with Hill-Sachs (HSL) and Bankart lesions. This treatment has a reported postoperative instability rate between 3.2% and 13.0%. Remplissage has demonstrated improved outcomes in patients with medially extended HSL, but the relevance of inferior craniocaudal Hill-Sachs extension (IC-HSE) in postoperative recurrent instability and the benefits of remplissage have not been thoroughly examined. The main purpose of this study was to compare ABR with and without remplissage with respect to postoperative recurrent instability and clinical outcomes in patients with and without IC-HSE.
Data for the present study were collected as part of a previous randomized clinical trial comparing ABR (NO REMP) vs. ABR with remplissage (REMP) in the treatment of anterior shoulder instability with HSL. The original trial was double-blinded at 2 centers involving 6 surgeons. Patients were more than 13 years old with recurrent traumatic anterior shoulder instability with an engaging HSL of any size with an available preoperative magnetic resonance imaging (MRI) or computed tomographic (CT) scan. The extent of the IC-HSE was determined by measuring the lower-edge angle (LEA) in the sagittal-oblique plane. Patients were categorized as having an LEA of greater than or less than 90°. The primary outcome was recurrence of instability defined as at least 1 episode of redislocation after surgery or a minimum of 2 subluxations occurring at least 12 weeks postoperatively. Odds ratios were generated for postoperative recurrent instability based on an LEA less than or greater than 90°, in patients who underwent a Bankart repair with or without remplissage.
One hundred two patients (50 NO REMP, 52 REMP) were included in the original trial, of which 95 patients (47 NO REMP, 48 REMP) had preoperative MRI (n = 94) or CT (n = 1) available. In those patients with LEA less than 90°, the odds of recurrent instability in NO REMP (n = 3/17; 17.6%) were 1.21 (95% confidence interval [CI] 0.211, 6.985; P = .828) compared with REMP (n = 3/20; 15.0%). In those with LEA greater than 90°, the odds of recurrent instability in NO REMP (n = 11/30; 36.7%) were 7.53 (95% CI 1.492, 37.978; P = .015) compared with REMP (n = 2/28; 7.1%).
In cases with inferior extension of the HSL, where LEA was greater than 90°, remplissage significantly reduced the rate of recurrent instability compared with isolated ABR, whereas the remplissage did not significantly affect the rate of recurrent instability if the LEA was less than 90°.
对于存在希尔-萨克斯损伤（HSL）和Bankart损伤的患者，可考虑采用关节镜下Bankart修复术（ABR）联合关节镜下充填术。据报道，这种治疗方法术后的不稳定率在3.2%至13.0%之间。充填术已证明在伴有内侧扩展型HSL的患者中能改善预后，但HSL下向头尾侧延伸（IC-HSE）在术后复发性不稳定中的相关性以及充填术的益处尚未得到充分研究。本研究的主要目的是比较有或无IC-HSE的患者在接受有或无充填术的ABR治疗后，术后复发性不稳定情况和临床结局。
本研究的数据收集自一项先前的随机临床试验，该试验比较了ABR（无充填，NO REMP）与ABR联合充填术（REMP）治疗伴有HSL的前肩不稳。原试验在2个中心由6名外科医生进行双盲操作。患者年龄超过13岁，有复发性创伤性前肩不稳，伴有任何大小的嵌顿性HSL，且有术前磁共振成像（MRI）或计算机断层扫描（CT）。通过在矢状斜平面测量下边缘角（LEA）来确定IC-HSE的范围。患者被分为LEA大于或小于90°。主要结局是不稳定复发，定义为术后至少有1次再脱位发作或术后至少12周至少发生2次半脱位。根据LEA小于或大于90°，在接受有或无充填术的Bankart修复患者中，生成术后复发性不稳定的比值比。
原试验纳入了102例患者（50例NO REMP，52例REMP），其中95例患者（47例NO REMP，48例REMP）有术前MRI（n = 94）或CT（n = 1）。在LEA小于90°的患者中，NO REMP组（n = 3/17；17.6%）复发性不稳定的比值为1.21（95%置信区间[CI]为0.211，6.985；P = 0.828），而REMP组（n = 3/20；15.0%）。在LEA大于90°的患者中，NO REMP组（n = 11/30；36.7%）复发性不稳定的比值为7.53（95%CI为1.492，37.978；P = 0.015），而REMP组（n = 2/28；7.1%）。
在HSL下向延伸且LEA大于90°的病例中，与单纯ABR相比，充填术显著降低了复发性不稳定的发生率；而如果LEA小于90°，充填术对复发性不稳定的发生率没有显著影响。
