Does an “Off-Track” Hill-Sachs Lesion That Is Misclassified as “Non-Engaging” Affect Outcomes From Bankart Repair Alone Compared With Bankart Repair Combined With Remplissage?

Editorial Commentary: Preoperative 3-Dimensional Imaging for Shoulder Instability Is Vital for Determination of Off-Track Lesions and May Indicate Bankart Repair Plus Remplissage

“…3 However, this is where preoperative workup and imaging have been critical for improving our outcomes. The study by Lee et al 1 shows us the same. Because 3-dimensional (3D) computed tomography (CT) has been validated as a tool to determine on-and off-track lesions, 4 Lee et al went on to review whether or not these lesions were truly on track or off track, retrospectively, using 3D CT.…”

“…So, should we be performing remplissage with higher levels of bone loss and off-track lesions? Certainly, Lee et al 1 would agree that this would be the case. However, the jury is still out, and many authors would argue that bony procedures such as Latarjet, distal tibia allograft, and iliac crest graft or other bone graft procedures would be preferred for large defects.…”

“…The patients in the study by Lee et al 1 were monitored for almost 4 years on average, which is a robust follow-up time and speaks to the overall stability of the surgical constructs performed by the authors. Although longer-term follow-up would be desirable, the level of follow-up after 4 years certainly speaks to the durability of the repair in this challenging group of patients with bone loss as well as engaging lesions.…”

“…The utility of these findings shows that although intraoperative determination of an engaging or nonengaging lesion with the patient under anesthesia has historically been important, 5,6 intraoperative assessment for Hill-Sachs engagement is not as good as 3D imaging to predict on-and off-track lesions. A notable limitation of the study by Lee et al 1 is its retrospective nature; however, all measures were independently verified through the existing preoperative CT scans. The mere confirmation of an on-or off-track lesion has also been validated through examination under anesthesia.…”

“…Although range of motion (ROM) has also been a persistent concern with the remplissage procedure, Lee et al 1 showed overall minimal ROM differences. Although the differences in the ROM findings were statistically significant, we are not sure whether the differences were clinically meaningful, except external rotation with the arm at the side and abducted external rotation, which both showed a difference of approximately 8 .…”