Poster 171: Does the addition of remplissage to arthroscopic labral repair result in decreased patients’ perception of their shoulder function and clinical outcome?

Abstract

Objectives:

Recurrent anterior shoulder instability after arthroscopic labral repair surgery particularly in young athletes is a concerning problem occurring in approximately 9 - 18 % of patients with subcritical bone loss. The addition of an arthroscopic remplissage procedure has been shown to decrease recurrence rates. Moreover, the recent literature suggests that the recurrence rates of arthroscopic labral repair with remplissage approach that of the open Latarjet procedure. This has led some to suggest that remplissage supplementation should be considered for all labral repairs when a Hill Sachs lesion is present. However, critics are concerned that the remplissage procedure is associated with increased pain, decreased function, and loss of range of motion due to the non-anatomic attachment of the infraspinatus, potentially over-constraining the glenohumeral joint. The purpose of our study was to determine if patients perceive a difference in their clinical results based upon patient reported outcome measures (PROMs) between those undergoing isolated labral repair surgery (IL) and those undergoing labral surgery with remplissage (LR).

Methods:

Patients who underwent arthroscopic anterior labral repairs were selected from the Surgical Outcomes System (SOS) registry between January 2011 and July 2020. Further eligibility requirements included anterior instability, primary repair (excluding revisions), presence of a Hill Sachs lesion, and verification of whether remplissage was performed or not. The patients were stratified into two groups: isolated labral repairs (IL) and labral repairs with remplissage (LR). This analysis assessed PROMs using the American Shoulder and Elbow Surgeons (ASES) Index, Pain Visual Analog Scale (VAS), the Single Assessment Numeric Evaluation (SANE) scores, as well as the Veterans RAND 12-item health survey (VR- 12) at pre-treatment, and 3 months, 6 months, 1 year, and 2 years postoperatively. VAS had additional data points at 2 and 6 weeks. Statistical Analysis was performed using two-tailed student t-tests and chi-square tests for non-parametric data. A post hoc power analysis was performed. This study was approved by the Salus IRB.

Results:

722 patients met the inclusion criteria for the study: isolated labral repairs (IL) without remplissage (n=416) and labral repairs with remplissage (LR) (n=306). The ASES 2-year post hoc power analysis for a type II error was 4.7%. There was no statistical difference in the demographics between the groups other than the LR having a greater number of preoperative dislocations than the IL group, (p<0.0001) (Table 1). Both IL and LR showed statistically significant improvement from pre-treatment ASES (means, 68.62 ± 19.22 and 70.79 ± 19.22, respectively) to 2 years post-operative ASES (means, 91.61 ± 11.66 and 91.14 ± 13.75, respectively, (p <.05). The preoperative PROM measures were statistically similar (p>.05) except for the VR-12. The mean VR12 preoperative scores were 42.93 ± 8.96 and 44.60 ± 8.36 (p=0.0251) for the IL and LR, respectively. There was no statistical difference between the groups at all postoperative time points in the VAS, VR-12, ASES, and SANE scores (p>0.05) except for the ASES score at 3 months (p=.0098) and the SANE score at 2 years (p=.0064). At 3 months, the ASES IL score was 80.28 ± 14.72 and the LR score was 76.73 ± 15.83 (p=0.0098); this did not reach MCID of 8.5 points. The 2-year SANE scores for IL and LR were 84.85 ± 17.67 and 77.48 ± 25.65 (p=0.0064), respectively; this similarly did not reach MCID of 14.5 points. Additionally, in the early postoperative period, 2 and 6 weeks, there was no difference in VAS scores between the groups (p<.05) (Figures 1, 2, 3).

Conclusions:

Both labral repairs and labral repairs with remplissage resulted in excellent clinical outcomes based on PROMs. Remplissage supplementation was not clinically inferior to labral repair alone, using PROMs and applying MCID, for VAS, ASES, VR-12, and SANE scores at any time points up to 2-years post-operatively.

Clinical Significance:

The addition of arthroscopic remplissage to decrease recurrent instability does not result in lower patients’ perceived clinical outcomes. Therefore, remplissage supplementation should be given strong consideration in patients undergoing labral repairs with Hill Sachs lesions to potentially reduce recurrences.

Level of Evidence:

Therapeutic, Retrospective analysis of prospectively collected PROMs, Level III.