Does External Rotation Deficit After Arthroscopic Labral Repair with Remplissage Affect Clinically Meaningful Outcomes ?

BACKGROUND: Recent evidence suggests that postoperative external rotation (ER) loss following arthroscopic labral repair with remplissage is affected by patient-specific and Hill-Sachs lesion related factors. More medial lesions lead to more medialized tenodesis, causing greater ER restriction. However, the role of the lesion's craniocaudal position remains unclear. Also, while ER loss is quantitatively labeled as a "deficit," prevailing evidence indicates it may not result in impaired functional outcomes. However, this interpretation relies on traditional scores, and the impact of ER loss on clinically meaningful outcomes (the Minimal Clinically Important Difference [MCID], Substantial Clinical Benefit [SCB], and Patient Acceptable Symptom State [PASS]) remains underexplored. Therefore, this study aimed to evaluate the MCID, SCB, and PASS in patients who underwent labral repair with remplissage, examine how demographic and anatomical factors affect ER deficit, and analyze the relationship between ER deficit and clinically meaningful outcomes.

METHODS: This retrospective case series included patients who underwent arthroscopic labrum repair with remplissage for anterior shoulder instability between May 2021 and March 2024. The evaluation comprised the American Shoulder and Elbow Surgeons (ASES) score, Western Ontario Shoulder Instability Index (WOSI), Visual Analog Scale (VAS), and ER measurements. Hill-Sachs interval (HSI) and sagittal midpoint angle (SMA) were also assessed using imaging. The proportions of patients who achieved the thresholds for the MCID, SCB, and PASS were identified based on the ASES, WOSI, and VAS. Regression analyses were performed to evaluate factors associated with ER deficit and its relationship with achievement of MCID, SCB, and PASS.

RESULTS: This study included 45 patients (age 28.2 ± 8.3 years; follow-up 30.5 ± 5.2 months). The rates of patients achieving MCID, PASS, and SCB thresholds were as follows: ASES (82%, 78%, 73%), WOSI (93%, 80%, 71%), and VAS (91%, 80%,78%). Mean ER deficit compared with the contralateral shoulder was 15.3 ± 8.4° at side and 11.4 ± 5.9° in abduction. Increased HSI, decreased SMA, and non-dominant extremity involvement were associated with greater ERSide (p=0.042, p=0.042, p=0.042) and ERAbduction (p=0.028, p=0.031, p=0.028) deficits; however, ER deficits did not significantly affect clinically meaningful outcomes.

CONCLUSIONS: The cohort demonstrated significant improvements in PROM scores, and most patients achieved clinically meaningful outcome thresholds after arthroscopic labral repair with remplissage.Although medial and superior Hill-Sachs lesion localization and non-dominant extremity involvement were associated with greater ER loss, these deficits were not significantly associated with clinically meaningful outcomes at a minimum follow-up of two years.