Bankart Repair in Overhead Athletes – Remplissage or Not
By: William B. Stetson. M.D.
Member AANA Communications and Technology Committee
Co-Authored by: Akin Akinwumi. B.S., Pre-Med Intern
Over the past 10 years it has become apparent from many excellent research articles that first time anterior shoulder dislocators, especially athletes, do well with arthroscopic Bankart reconstruction1,2. Risk factors for recurrent glenohumeral instability after arthroscopic Bankart repair includes younger age, number of shoulder dislocations, types of sports participation3 and the presence or absence of a Hill Sachs lesion4.
Taking care of overhead athletes with anterior glenohumeral instability, we not only want to give them a stable shoulder, but we also want to get them to return to sports at their pre-injury level. Unfortunately, that has not been the case for our overhead athletes with Bankart repairs of the dominant arm. In 2019, Park and colleagues reported on the return to play after arthroscopic treatment for anterior shoulder instability in baseball players5. Of 20 baseball players who had an arthroscopic Bankart repair of their throwing shoulder, only 65% were able to return to play one or more official games and only 60% were able to return to play for greater than 10 games. The results were worse for pitchers as 0% were able to return to play for more than 10 games. Catchers and infielders did better as 75% of catchers and 82% of infielders were able to return to play after Bankart repairs of their throwing shoulder.
Interestingly, none of the baseball players had recurrent episodes of instability, but the pitchers who did not return complained of persistent pain with loss of velocity and loss of control. The other non-pitchers also had no episodes of recurrent instability but had persistent pain with loss of velocity and control that made them retire. Park et al.5 showed that muscle strength and range of motion among pitchers, catchers and infielders was reportedly the same in all groups. However, more likely the inability to return to pre-injury throwing level was due to some decrease in shoulder range of motion and the inability to achieve the necessary amount of shoulder external range of motion for throwing effectively. We have seen in our own analysis of the failure of SLAP repairs in overhead athletes was that even a loss of a few degrees of external rotation can be devastating for an overhead athlete6.
If recurrent instability is not the problem with these overhead athletes after arthroscopic Bankart repair but rather pain with loss of velocity and control, what are we doing at the time of surgery to cause this or is it just the natural history of the injury? What we do know is that restoring normal range of motion or at least reducing the loss of external rotation after arthroscopic Bankart repair is key for any overhead athlete’s dominant shoulder.
The next question or dilemma we face is the role of remplissage in these overhead athletes and is it really necessary? The remplissage procedure has shown good results with low recurrence rates and high outcome scores7-9(7–9) but many of the patients in these studies were not overhead athletes. There is concern that the remplissage procedure can limit external rotation in throwing overhead athletes and limit performance. Boileau et al.7 reported only about ⅔ or 68% of patients were able to return to their previous level of overhead sporting activities. Cho et al.10 also demonstrated that only 68.7% of patients returned to their previous level of activity after arthroscopic Bankart repair with remplissage.
Garcia, Kelly and colleagues11 reported a five-year follow-up in athletes with anterior instability treated with arthroscopic Bankart repair with remplissage. The good news is that over 80% were able to return to their previous level and intensity of sport. However, the bad news is those athletes who participated in overhead sports (softball, baseball and football), 65% stated they had issues throwing following surgery and 58.6% felt they did not have their normal wind up when throwing. In this subgroup of patients, recurrent instability was not the issue but rather pain and stiffness with loss of velocity while throwing. Only 51.7 % of these over-head athletes were able to return to their previous level of sporting activity.
Reviewing these studies and the literature, it is apparent we have not quite figured out the best way to get our overhead athletes back to their pre-injury lever after an anterior shoulder dislocation. Remplissage has shown to be effective in reducing recurrent anterior shoulder instability in most patients, but it may not be necessary in an overhead athlete such as baseball pitchers or volleyball players. These unique types of overhead throwing or hitting athletes historically do not tolerate a loss of external rotation as it can have a dramatic effect on shoulder mechanics. However, even without remplissage, the results after arthroscopic Bankart repairs are fair at best in these overhead athletes and we have more to learn about treating shoulder instability in these high-level overhead athletes.
References
- Alkhatib, N., Abdullah, A.S.A., AlNouri, M., Alzobi, O.Z.A., Alkaramany, E., Ishibashi, Y. Short-and Long-Term Outcomes in Bankart Repair vs. Conservative Treatment for first-Time Anterior Shoulder Dislocation: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Journal of Shoulder and Elbow Surgery. 2022;31(8):1751–62.
- Van Spanning, S.H., Verweij, L.P., Priester-Vink, S., van Deurzen, D.F., van den Bekerom, M.P. Operative Versus Nonoperative Treatment Following First-Time Anterior Shoulder Dislocation: A Systematic Review and Meta-Analysis. Journal of Bone and Joint Surgery Reviews. 2021;9(9):e20.
- Balg, F., Boileau, P. The Instability Severity Index Score: A Simple Pre-Operative Score to select Patients For Arthroscopic or Open Shoulder Stabilisation. Journal of Bone and Joint Surgery, British. 2007;89(11):1470–7.
- Kay, J., Heyworth, B.E., Bae, D.S., Kocher, M.S., Milewski, M.D., Kramer, D.E. Arthroscopic Bankart Repair for Anterior Glenohumeral Instability in 488 Adolescents Between 2000 and 2020: Risk Factors for Subsequent Recurrent Instability Requiring Revision Stabilization. American Journal of Sports Medicine. 2024;52(9):2331–9.
- Park, J.Y., Lee, J.H., Oh, K.S., Chung, S.W., Lim, J.J., Noh, Y.M. Return to Play After Arthroscopic Treatment for Shoulder Instability in Elite and Professional Baseball Players. Journal of Shoulder and Elbow Surgery. 2019;28(1):77–81.
- Stetson, W.B., Polinsky, S., Morgan, S.A., Strawbridge, J., Carcione, J. Arthroscopic Repair of Type II SLAP Lesions in Overhead Athletes. Arthroscopy Techniques. 2019;8(7):e781–92.
- Boileau, P., O’Shea K., Vargas, P., Pinedo, M., Old, J., Zumstein, M. Anatomical and functional Results After Arthroscopic Hill-Sachs Remplissage. Journal of Bone and Joint Surgery, American. 2012;94(7):618–26.
- Park, M.J., Tjoumakaris, F.P., Garcia, G., Patel, A., Kelly, J.D. Arthroscopic Remplissage With Bankart Repair for the Treatment of Glenohumeral Instability With Hill-Sachs Defects. Arthroscopy. 2011;27(9):1187–94.
- Zhu, Y.M., Lu, Y., Zhang, J., Shen, J.W., Jiang, C.Y. Arthroscopic Bankart Repair Combined With Remplissage Technique for the Treatment of Anterior Shoulder Instability With Engaging Hill-Sachs Lesion: A Report of 49 Cases With A Minimum 2-Year Follow-Up. American Journal of Sports Medicine. 2011;39(8):1640–8.
- Cho, N.S., Yoo, J.H., Rhee, Y.G. Management of an Engaging Hill–Sachs Lesion: Arthroscopic Remplissage With Bankart Repair Versus Latarjet Procedure. Knee Surgery, Sports Traumatology, Arthroscopy. 2016;24:3793–800.
- Garcia, G.H., Wu, H.H., Liu, J.N., Huffman, G.R., Kelly, J.D. Outcomes of the Remplissage Procedure and Its Effects on Return to Sports: Average 5-Year Follow-Up. American Journal of Sports Medicine. 2016;44(5):1124–30.