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 Table of Contents  
Year : 2021  |  Volume : 11  |  Issue : 4  |  Page : 22-26

Midterm clinical results of bankart repair, bankart remplissage, and latarjet procedures for treating recurrent anterior shoulder dislocation

1 Department of Orthopedics, Faculty of Medicine, Hamadan University of Medical Sciences, Hamadan, Iran
2 Department of Physical Education and Sport Science, Islamic Azad University, Borujerd Branch, Borujerd, Iran
3 Department of Physical Education and Sports Sciences, Islamic Azad University, Borujerd Branch, Borujerd, Iran

Date of Submission18-Feb-2021
Date of Decision15-Mar-2021
Date of Acceptance30-Apr-2021
Date of Web Publication16-Oct-2021

Correspondence Address:
Hossein Saremi
No. 11, Shokufeh St, Milad Ave, Ostadan Blv, Hamadan
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/aihb.aihb_22_21

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Introduction: This study compared the midterm outcomes of pain, apprehension and range of motion in the shoulder after three arthroscopic procedures including Bankart repair, Bankart repair plus remplissage, and Latarjet surgeries, in patients with recurrent anterior shoulder dislocation. Materials and Methods: We evaluated 128 patients who had undergone anterior shoulder instability surgery at least 4 years ago in our centre based on pain, apprehension and range of motion of both shoulders. Pain was assessed with visual analogue scale, apprehension by physical examination and range of motion with goniometer. We divided them into three groups based on their treatment: (1) Bankart repair, (2) Bankart remplissage and (3) Laterjet procedure. Results: There were 34 patients with Bankart repair, 68 with Bankart remplissage and 26 with Latarjet procedure. The mean of follow-up time was 6.2 years. There was only one re-dislocation. Apprehension was positive in two patients of Bankart repair, eight patients of Bankart remplissage and none of Latarjet procedure groups. The movement limitation average of the external rotation was 9.12° in Bankart repair, 7° in Bankart rempilssage and 18.53° in Latarjet procedure groups. The means of visual analogue scales were 0.29, 0.76, and 0.38 in Bankart repair, Bankart remplissage and Latarjet procedure groups. Conclusion: All operations had had satisfactory results. Remplissage does not induce more restriction on the range of motion. However, in case of more bone loss in the humeral head, apprehension seems to be more positive in those who do remplissage. Latarjet procedure seems to be very effective but causes more range of motion restrictions.

Keywords: Apprehension test, Bankart repair, Latarjet procedure, recurrent shoulder dislocation, remplissage, shoulder range of motion

How to cite this article:
Saremi H, Saneii A, Goodarzi B. Midterm clinical results of bankart repair, bankart remplissage, and latarjet procedures for treating recurrent anterior shoulder dislocation. Adv Hum Biol 2021;11:22-6

How to cite this URL:
Saremi H, Saneii A, Goodarzi B. Midterm clinical results of bankart repair, bankart remplissage, and latarjet procedures for treating recurrent anterior shoulder dislocation. Adv Hum Biol [serial online] 2021 [cited 2022 Aug 15];11:22-6. Available from: https://www.aihbonline.com/text.asp?2021/11/4/22/328391

  Introduction Top

The shoulder joint has the largest range of motion of all joints with little inherent bony stability. It is a frequently dislocated joint in the body (up to 47/100,000 people each year).[1] Throughout the wide range of shoulder activities, the humeral head (ball of the shoulder joint) remains precisely centred in the glenoid (the joint socket).[2] Shoulder instability encompasses a wide spectrum from subluxation to frank dislocation with a high prevalence, affecting mainly the young, active population with a significant impact on the quality of life.[3]

In the early 20th century, Perthes and Bankart described an avulsion of anterior inferior labrum from the glenoid rim. Afterwards, several open and arthroscopic techniques were described to address the anterior shoulder instability.[4] The Bankart repair focuses on the anatomical re-attachment of the labrum to the glenoid rim. It has been described initially using an open technique and more recently with arthroscopic techniques as well.[5] Although Bankart lesion can be repaired to provide stability, it is more complicated when there is bone loss in the glenoid or humeral head.

When there is a significant glenoid bone loss, transfer of the coracoid process to the anterior glenoid (Latarjet procedure) extends the bony articular arc of the glenoid.[5] Latarjet procedure can improve the anterior stability.[6] Adding the conjoint tendon may provide dynamic stability as well. This procedure addresses the issue of glenoid bone loss that has recently been identified as a key factor in recurrent instability; however, due to its significant complications, especially in case of technical problems, it is not chosen as the initial treatment for recurrent anterior shoulder dislocation without significant glenoid bone loss.[7]

The remplissage technique, which was initially described by Wolff, is an arthroscopic method to fill the Hill-Sachs lesion using infraspinatus tenodesis and posterior capsulodesis. This technique was designed to prevent recurrent instability by making the Hill-Sachs lesion extra-articular, consequently eliminating Hill-Sachs' engagement with the anterior glenoid rim.[8]

Arthroscopic remplissage done in conjunction with arthroscopic Bankart repair is a safe and effective procedure for patients with engaging Hill-Sachs lesions and subcritical glenoid bone loss. Although both of the included clinical and biomechanical studies suggest minimal changes in glenohumeral range of motion after the remplissage procedure, making strong conclusions are limited by the heterogeneity of reports about range of motion results and lack of comparative studies.[9]

In this study, we aimed to compare the midterm clinical results of three procedures, including Bankart repair, Bankart repair plus remplissage and Latarjet surgery, in patients with recurrent anterior shoulder dislocations.

  Methods Top

We did this quasi-experimental study at our centre on patients who had undergone different types of surgery for treating recurrent anterior shoulder dislocation (Bankart repair, Bankart repair plus remplissage and Latarjet surgeries). They had undergone surgery from June 2011 to June 2016.

The inclusion criterion was having done this treatment at least 4 years before our study. Patients who could not attend the final examination or had any problem in their normal shoulder were excluded from the study. All patients signed an informed consent before being examined in the study.

The indication for doing Bankart remplissage was having an engaging Hill-Sachs test during arthroscopy. The indication for doing Latarjet procedure was more than 25% anterior glenoid loss in the pre-surgery 3D computed tomography scan or measurement during arthroscopy [Figure 1]. One of the authors evaluated all patients under the supervision of a specialist unaware of the patients' previous surgery type.
Figure 1: Arthroscopic measurement of the anterior glenoid defect.

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Range of motion of the operated shoulder was measured using a stainless-steel goniometer (JAMAR Co., USA) in terms of the external rotation in the neutral arm position and in 90° abduction of the arm compared to the normal shoulder. The apprehension test was evaluated in sitting and supine positions.[10],[11],[12] We used the visual analogue scale for measuring pain. This scale can help in easier grading of pain to be used in different specialties including orthopaedic surgery.[13],[14],[15] Data were analysed by Kolmogorov–Smirnov test and paired t-test using the Statistical Package for the Social Sciences (SPSS) software version 21 and IBM SPSS version21(IBM,Armonk,NY,USA).

  Results Top

There were 128 patients, of whom 34 patients had underwent arthroscopic Bankart repair, 26 patients open Latarjet and 68 patients Bankart repair plus remplissage procedures [Table 1]. Their mean of age was 27 years old (16–54-year-old). Mean of follow-up time was 6.2 years (4–9 years). There was only one re-dislocation which had happened 5 years after the operation in the Bankart remplissage group.
Table 1: The number of participants (original)

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Apprehension test was positive for two patients (5.8%) in the Bankart repair, eight patients (11.7%) in the Bankart remplissage and none in the Latarjet surgery groups [Table 2]. Average of movement limitation was 9.12° in the Bankart repair, 7° in the Bankart remplissage and 18.5° in the Latarjet groups for external rotation in the side arm. This average for the external rotation in 90° of abduction was 8.76° in the Bankart repair, 10.44° in the Bankart remplissage and 16.61° in the Latarjet surgery groups [Table 3].
Table 2: Positive apprehension test on physical examination (original)

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Table 3: Range of motion restriction in the studied patients (original)

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The mean of visual analogue scale score for shoulder pain had decreased significantly in all of the three surgeries, post- versus pre-operations (P < 0.001). At the final follow-up, there was no significant difference between pain in the three groups (P > 0.05). The means of visual analogue scales were 0.29, 0.76, and 0.38 in the Bankart repair, Bankart remplissage and Latarjet procedure groups [Table 4].
Table 4: Results of pain (mean of visual analog scale score) in the three surgery types (original)

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The mean, t-test, and P value types show that there was a significant difference between pain before and after the surgery in all of the three surgeries (P > 0.001). There was no significant difference in post-operative pain between the three groups.

  Discussion Top

This study compared the outcomes of the three surgeries i.e., arthroscopic Bankart repair, Bankart repair plus remplissage and open Latarjet surgeries, for treating recurrent anterior shoulder dislocation with a mean of 6.2-year follow-up. Recurrent anterior shoulder instability is a costly and debilitating problem that is a challenge for orthopaedic surgeons. Recurrent dislocations lead to structural damage to the shoulder joint[11] as well as functional disability and reduced work capacity.[12]

The pathology associated with traumatic anterior shoulder instability has been well described in the literature.[17],[18],[19],[20],[21],[22],[23],[24],[25] The clinical studies have indicated that capsulolabral separation from the glenoid (Bankart lesion) is the most common pathology.

Arthroscopic Bankart repair is a well-known treatment of anterior shoulder instability with satisfactory results.[26],[27],[28],[29],[30] In a systematic review of studies with 10-year follow-up, Alison et al. reported 16% re-dislocation and 26% positive apprehension test results after doing Bankart repair for recurrent instability. However, recurrent instability rates after arthroscopic Bankart repair vary from 9.4% to 35.3%.[31] Thomas et al. studied 56 patients who had undergone Bankart repair. After a mean of 11.9 years after the surgery, the mean of external rotation loss was 12° (0°–30°).[32] In our study, we had no re-dislocation in the Bankart repair group. The reason might be that we did a midterm follow-up. Thus, 5.8% positive apprehension might lead to re-dislocation in a longer follow-up time.

Loss of external rotation in our Bankart repair group is consistent with the results mentioned in the literature. Engaging Hill-Sachs lesion refers to the glenoid rim involvement when the shoulder is physiologically abducted and externally rotated. Engaging Hill-Sachs lesions lead to recurrent instability and a high rate of failure when treated only with arthroscopic Bankart repair.[33]

Wolf et al. presented an arthroscopic technique to treat traumatic shoulder instability in patients with a large Hill-Sachs lesion. The procedure, known as remplissage, consists of an arthroscopic capsulotenodesis of the posterior capsule and infraspinatus tendon to fill the Hill-Sachs lesion.[34]

In a systematic review, John et al. evaluated six studies including 167 patients to investigate the outcome of remplissage procedure.[35] In the studies with motion measurements, shoulder motion was not affected postoperatively (P > 0.05); mean of external rotation changed from 57.2 to 54.6. Nine of 167 studied shoulders had experienced an episode of recurrent glenohumeral instability (overall recurrence rate = 5.4%). In our study, re-dislocation was 1.5% in the Bankart remplissage group. However, as apprehension was positive in 11.7% of the patients, we expect to have more re-dislocations in future.

Although most studies indicate no increase of range of motion restriction after Bankart repair plus remplissage procedure,[35] some studies have claimed a decreased range of motion after it. Deutsch et al. reported a case, in which a patient treated with the arthroscopic remplissage lost his shoulder external rotation 2 years later.[36] In our study, Banker remplissage did not increase the external rotation restriction in neutral arm position or in abduction. The high apprehension rate in our Bankart remplissage group makes us think more about doing Latarjet procedure on patients with <25% glenoid loss who have engaging Hill-Sachs instead of doing Bankart remplissage. Still, more studies are required to determine the amount of glenoid bone loss accompanying engaging Hill-Sachs suitable for doing Latarjet surgery.

Laterjet procedure is about transferring the coracoid process and its attached conjoined tendon to the anterior glenoid. It is an effective method for tackling recurrent instability in patients with recurrent anterior instability and high degrees of glenoid bone loss.[37] In a systematic review of ten studies on Latarjet procedure, the rate of recurrent anterior shoulder instability ranged from 0% to 8%. Five of the studies had reported post-operative complications.

Burkhart et al.[38] reported five complications in 102 patients, including hematoma in two (one of which was drained), asymptomatic loose screws in two and asymptomatic fibrous non-union in one patient (no revision required). Lafosse et al.[39] reported two post-operative hematomas, one intraoperative graft fracture, one transient musculocutaneous nerve palsy that fully recovered, four cases of non-union and three shoulders with osteolysis around screws. Schmid et al.[40] reported complications in six of their 49 patients (12%): four had delayed wound healing, one had a post-operative frozen shoulder and one had malunion of the coracoid to the glenoid rim. Finally, Shah et al.[41] reported complications in 12 of their 48 patients (25% complication rate): infection in three (6%), recurrent instability in four (8%) and neurologic injury in five patients (10%). Hurley et al.[42] found 8.5% post-operative recurrence rate after Latarjet procedure in studies with more than 10-year follow-up.

Stiffness and loss of external rotation are an important complication of Latarjet procedure. Some studies have reported a significant loss of external rotation after this procedure.[42],[43],[44],[45] However, in a multicentred study of 390 cases, Metais et al. found only about 5° of stiffness without any significant differences between the methods.[46]

In our study, there was no re-dislocation or apprehension in the Latarjet group. However, there was a mean of 18.54° range of motion restriction in the side arm's external rotation and 16.61° restriction of external rotation in abduction. As the main cause of loss of external rotation after this procedure is subscapularis tenotomy,[47] we think that this amount of range of motion restriction is related to our technique of subscapularis tenotomy. We cut the superior part of the tendon 1 cm medial to insertion instead of a transverse cut. Although it leads to more range of motion restriction while leading to more stability, we had no re-dislocation or apprehension in our patients.

We evaluated shoulder pain after all the three procedures with visual analogue scale. There was no significant difference between them. This means that probably Bankart remplissage and Latarjet procedures do not induce more pain.

  Conclusion Top

Bankart Repair, Bankart repair plus remplissage and Latarjet procedures have satisfactory midterm results considering shoulder stability, range of motion and pain. Remplissage does not seem to induce any external rotation restriction on patients with engaging Hill-Sachs and those undergoing Bankart repair. However, it seems that the apprehension rate is high when there is accompanying glenoid bone loss even <25%. We recommend more studies with long-term follow-up to evaluate these findings.

Latarjet procedure is effective in restoring stability. Range of motion restriction may be significant in using a superior part tenotomy of the subscapularis tendon instead of a transverse tenotomy. Comparative studies are necessary to investigate this finding. There is no significant difference in pain outcomes regarding doing daily activities between the three procedures. A study with long-term follow-up and more cases is recommended to compare the results of these procedures.


The authors thank Muhammed Hussein Mousavinasab for editing this text.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

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  [Figure 1]

  [Table 1], [Table 2], [Table 3], [Table 4]

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