Sporting Activity After Arthroscopic Bankart Repair for Chronic Glenohumeral Instability Johannes E. Plath, M.D., Matthias J. Feucht, M.D., Tim Saier, M.D., Philipp Minzlaff, M.D., Gernot Seppel, M.D., Sepp Braun, M.D., and Andreas B. Imhoff, M.D.
Purpose: The purpose of this study was to collect detailed data on postoperative sporting activity after arthroscopic Bankart repair for chronic shoulder instability. Methods: Of 113 patients who underwent arthroscopic Bankart repair between February 2008 and August 2010, 81 met the inclusion criteria and were surveyed by a specially designed postal sport-specific questionnaire. Of these 81 patients, 66 (82%) were available for evaluation. Results: All previously active patients performed some activity at follow-up. Of 9 patients (56%) who had been inactive, 5 took up new activities postoperatively. Forty-four patients (66%) stated that surgery had (strongly) improved their sporting proficiency. Seventeen patients (26%) reported no impact, and 5 patients (8%) reported a further deterioration compared with preoperatively. The improvement in sporting proficiency was negatively correlated with the preoperative risk level (r ¼ 0.42, P < .001), preoperative performance level (r ¼ 0.31, P ¼ .012), and preoperative Tegner scale (r ¼ 0.36, P ¼ .003), as well as hours of sporting activity per week (r ¼ 0.25, P ¼ .042), whereas age showed a positive correlation (r ¼ 0.28, P ¼ .023). There was no change in duration, frequency, number of disciplines, Tegner activity scale, risk category, or performance level. Conclusions: Arthroscopic Bankart repair provides a high rate of return to activity among patients treated for chronic shoulder instability. A number of previously inactive patients returned to activity postoperatively. However, one-third of patients reported no benefit from surgery in terms of sporting activity. The improvement in sporting proficiency was highly dependent on the demands on the shoulder in sports, as well as the age of the patient. Overall, there was no significant increase in duration, frequency, number of disciplines, Tegner activity scale, or performance level between preoperative and follow-up evaluation and no increased return to high-risk activities. Level of Evidence: Level IV, therapeutic case series.
T
raumatic anteroinferior shoulder dislocation is a common injury in athletes.1 Patients with glenohumeral instability are mostly young and active with high demands on shoulder function. The redislocation rate after nonoperative treatment is high, particularly among young athletes, ranging up to
From the Department of Orthopaedic Sports Medicine, Klinikum rechts der Isar, Technische Universität München (J.E.P., M.J.F., G.S., S.B., A.B.I.), Munich; Department of Trauma Surgery, Klinikum Augsburg (J.E.P.), Augsburg; Department of Orthopedic Surgery and Traumatology, Freiburg University Hospital (M.J.F.), Freiburg; Department of Trauma and Orthopaedic Surgery, Berufsgenossenschaftliche Unfallklinik Murnau (T.S.), Murnau; and Department of Sporttraumatology, Knee- and Shoulder-Surgery, Berufsgenossenschaftliche Unfallklinik Frankfurt am Main (P.M.), Frankfurt am Main, Germany. The authors report the following potential conflict of interest or source of funding: A.B.I. receives support from Arthrex and Arthrosurface. Received August 10, 2014; accepted April 10, 2015. Address correspondence to Johannes E. Plath, M.D., Department of Orthopaedic Sports Medicine, Klinikum rechts der Isar, Technische Universität München, Ismaninger Strasse 22, 81675 Muenchen, Germany. E-mail: [email protected] Ó 2015 by the Arthroscopy Association of North America 0749-8063/14686/$36.00 http://dx.doi.org/10.1016/j.arthro.2015.04.087
1996
92%.2-6 Therefore early surgical shoulder stabilization is indicated for the young athlete involved in shoulderdemanding activities.2-4,7 However, this patient group represents a minority.8,9 Many patients have a longlasting history of chronic shoulder instability with failed nonoperative treatment and multiple events of dislocation and subluxation before surgery is performed. These chronic instability patients may adapt their level and type of activity, but most of them remain active and engage in sports despite chronic shoulder instability.10 Surgeons recommend shoulder stabilization to avoid further injury to the shoulder joint and promise shoulder stability, improved shoulder function, and a successful return to sports.9,11-13 Several studies have reported on the return to sporting activity after arthroscopic Bankart repair compared with the pre-trauma activity level.7,11,13-19 However, because the primary dislocation dates back many years, this comparison fails to meet the specific situation of patients with chronic shoulder instability. These patients want to be counseled about what they may expect from surgery compared with their current situation.
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 31, No 10 (October), 2015: pp 1996-2003
RETURN TO SPORTS AFTER BANKART REPAIR
Detailed knowledge about the expected level of postoperative sporting activity is important in terms of preoperative patient information and will help surgeons inform their patients in detail before surgery. Realistic patient expectations regarding the surgical procedure may help to avoid subjective failure. In addition, even though most studies report comparable functional outcomes with arthroscopic Bankart repair and with open repair, the return to sporting activity is still a matter of discussion and some authors recommend open repair for collision athletes.11,14,15,18,20-23 Therefore the purpose of this study was to collect detailed data on postoperative sporting activity after arthroscopic Bankart repair for chronic shoulder instability. We hypothesized that patients with chronic recurrent instability will increase their sporting activity after surgical stabilization and may even return to highrisk sports.
Methods Patient Selection We retrospectively evaluated all patients who underwent arthroscopic Bankart repair for traumatic anteroinferior shoulder instability during the period from February 2008 to August 2010 in our department. The inclusion criteria for this study were isolated chronic glenohumeral anteroinferior instability and a minimum follow-up period of 24 months. Chronic shoulder instability was defined as recurrent shoulder dislocations and a minimum time interval from initial dislocation to surgery of 12 months. The exclusion criteria were multidirectional instability, glenoid bone loss greater 20%, engaging HillSachs lesions, advanced osteoarthritis (Samilson and Prieto24 grade 3), glenoid dysplasia, and full-thickness or high-grade partial-thickness (>50% thickness) rotator cuff tears. The study protocol was approved by the local ethics committee, and all patients provided written informed consent to participate in this investigation. Arthroscopic Procedure and Sport-Specific Rehabilitation The patient was placed in the beach-chair position. Diagnostic arthroscopy was performed through a standard posterior portal. For Bankart repair, a deep anteroinferior portal (5:30 clock-face position) through the lower third of the subscapularis muscle was used in all patients.10,25 The number of anchors (BioFastak; Arthrex, Naples, FL) used varied among patients, depending on the pathologic findings. Yet, we favored a repair using 3 anchors placed at the 5:30, 4:30, and 3-o’clock position (for right shoulders). In case of a reparable SLAP lesion (type II or type IV), suture anchor repair (BioFastak) was performed
1997
Table 1. Risk Categories for Traumatic Shoulder Instability Based on Study of Owens et al.1 and Recommendations of American Academy of Pediatrics Committee on Sports Medicine29 High risk Medium risk
Low risk
Sports Handball, rock climbing, windsurfing, surfing, wrestling, judo, ice hockey, football, rugby Volleyball, basketball, soccer, tennis, squash, badminton, swimming, weightlifting, mountain biking, canoeing, boxing Cycling, running, rowing
through a transtendinous lateral portal. Small buckethandle tears or frayed labra were resected. Postoperatively, a sling was used for comfort, and progressive active and assisted range-of-motion exercise was initiated on the following day, limiting external rotation to 30 and limiting abduction, as well as flexion, to 45 . At 4 weeks postoperatively, abduction and flexion were allowed to 90 and external rotation was limited to 0 . Free active range of motion was allowed after 6 weeks postoperatively. Patients were permitted to return to sport-specific training after 3 months and to overhead and high-contact activities after 6 months postoperatively. In case of a concomitant SLAP repair, active biceps training was prohibited for the first 6 weeks. Data Collection Patients were retrospectively evaluated at a minimum of 24 months after arthroscopic Bankart repair using a postal sport-specific questionnaire, which has been used by several authors before.26-28 Patients were asked to compare their current activity level with their preoperative activity level. Data collection and evaluation were performed by an orthopaedic surgeon (J.E.P.) who was not involved in the surgical treatment. The questionnaire assessed the sports frequency (defined as sessions per week), sports duration (defined as hours per week), number of sports disciplines, and performance level (recreational, competitive, highly competitive, or professional). In addition, the patient’s preoperative and postoperative participation in 32 different sports and recreational activities was evaluated. In case of a reduction of sporting activity or termination of disciplines, patients were asked to indicate their reasons (shoulder related, noneshoulder related, or concern of recurrence). Sports and recreational activities were furthermore allocated into risk categories for traumatic shoulder instability (high, medium, and low risk) based on the study of Owens et al.1 and recommendations of the American Academy of Pediatrics Committee on Sports Medicine29 adjusted to meet the distribution of sporting activities in central Europe (Table 1). The questionnaire also inquired about the subjective overall improvement
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in sporting and recreational proficiency (severely impaired, impaired, unchanged, improved, or strongly improved) due to the surgical procedure, as well as the ability to participate in contact and overhead sports. The QuickDASH (short version of Disabilities of the Arm, Shoulder and Hand questionnaire) score (scaled from 0 to 100, where 0 represents no disability and 100 represents the most disability) was used to measure the patient’s upper limb functional disability, and the Tegner activity scale was recorded to determine the activity level.30,31 Statistics Statistical analysis was performed using SPSS software, version 20.0 (IBM, Armonk, NY). All data were tested for normal distribution using the KolmogorovSmirnov test. For normally distributed data, paired and unpaired t tests were used for intragroup and intergroup comparisons. The Wilcoxon signed rank and Mann-Whitney U tests (paired/unpaired) were used for nonenormally distributed data. Dichotomous data were computed by the c2 test. To compare the participation in sporting activities before and after surgery, the McNemar test was used. Correlations were calculated using the Spearman correlation coefficient. The level of significance was set at P < .05.
Results Demographics From February 2008 to August 2010, a total of 113 patients underwent arthroscopic Bankart repair for traumatic anteroinferior shoulder instability in our department. Of these 113 patients, 81 fulfilled the inclusion criteria of the study. A total of 66 questionnaires were available for evaluation (follow-up rate, 82%). Details of patient enrollment are shown in Figure 1. The mean postoperative follow-up period was 43 9 months (range, 25 to 56 months). Of the 66 patients, 6 (9%) sustained a recurrent shoulder dislocation. Two patients underwent arthroscopic revision Bankart repair. There were no neurovascular complications, postoperative infections, or cases of postoperative shoulder stiffness that needed surgical intervention within our patient population. The detailed patient characteristics are provided in Table 2. Sports and Recreational Activities All patients who were active before the operation (57 patients) returned to at least 1 sporting or recreational activity after surgery. Of 9 patients who had been inactive before surgery, 5 (56%) took up new activities postoperatively. Forty-four patients (66%) stated that arthroscopic Bankart repair had strongly (33%) or somewhat (33%)
Fig 1. Flowchart of patient enrollment.
improved their sporting and recreational proficiency compared with preoperatively. Seventeen patients (26%) reported no impact, and 5 patients (8%) stated that their sports performance ability decreased after surgery, with the findings showing some impairment in 4 patients (6%) and severe impairment in 1 case. The lower the preoperative risk (r ¼ 0.42, P < .001) and performance level (r ¼ 0.31, P ¼ .012), Tegner scale (r ¼ 0.36, P ¼ .003), and hours of sporting activity per week (r ¼ 0.25, P ¼ .042), the higher the subjective overall improvement in sporting and recreational proficiency due to the surgical procedure. Patients who indicated no improvement or a decline in sporting ability did not show a higher rate of recurrence (9%) or a higher amount of disability (QuickDASH score) compared with patients who benefited from surgery (P ¼ .401). Age at the time of surgery was positively correlated with improvement in sporting proficiency (r ¼ 0.28, P ¼ .023), whereas the number of sports disciplines (r ¼ 0.25, P ¼ .046) and risk level (r ¼ 0.26, P ¼ .036) at follow-up and the Tegner activity levels before surgery (r ¼ 0.34, P ¼ .005), as well as at follow-up (r ¼ 0.34, P ¼ .005), showed a negative correlation. Overall, there was no significant difference between preoperative and postoperative values regarding the number of disciplines, frequency and duration of sports participation, Tegner activity scale, risk category, or performance level (Table 3).
1999
RETURN TO SPORTS AFTER BANKART REPAIR Table 2. Patient Demographic Data Demographic Characteristic Patients, n Sex, male/female, n (%) Shoulder, right/left, n (%) Dominant side affected, n (%) Follow-up, mo QuickDASH score at follow-up Age at surgery, yr Preoperative dislocations, n (%) 10 Duration of instability, mo Anchors used, n SLAP repair, n (%) Recurrence, n (%)
Data 66 46/20 (70) 33/33 (50) 37/29 (56) 43 9 (25-56) 6.9 9.9 (0-55) 29.3 10.4 (14-62) 28 13 25 87 84 3 11 6
(42) (20) (38) (12-360) (1-5) (17) (9)
NOTE. Data are presented as mean standard deviation (range) or median (range) unless otherwise indicated. QuickDASH, short version of Disabilities of the Arm, Shoulder and Hand questionnaire.
When patients were asked the reasons that they quit disciplines or reduced the extent of sporting activity during the follow-up period, 19% indicated shoulderrelated causes (persisting instability, pain, and dysfunction) and 22% stated that they were asymptomatic yet were concerned about sustaining a further injury to the shoulder. Most patients (59%) indicated that noneshoulder-related reasons accounted for the activity change, such as career, family, and other personal interests. Cycling, fitness training, and mountain hiking, all low-risk activities for shoulder dislocation, gained significantly in participation postoperatively (P ¼ .016, P < .001, and P ¼ .008, respectively), whereas martial arts, a high-risk activity for shoulder dislocation, was the only activity that dropped significantly in participation (P ¼ .031). Seventy-nine percent of the patients stated that they felt comfortable participating in overhead activities, and 82% reported that they were able to participate in contact sports. The distribution patterns for different sports and recreational activities before and after arthroscopic stabilization are shown in Figure 2. Subgroup Analysis: Recurrence and SLAP Repair Patients who sustained a recurrent shoulder dislocation after arthroscopic Bankart repair showed a significantly higher amount of disability based on QuickDASH score results compared with patients who did not (P ¼ .010). Patients with redislocations were significantly younger (P ¼ .003) and reported more frequently that they felt uncomfortable engaging in overhead activities (P ¼ .004), whereas no difference concerning contact sports could be detected (P ¼ .313). With the number of patients available, there were no significant intergroup differences at follow-up
regarding the number of disciplines, Tegner scale, risk level, sports frequency and duration, number of anchors used during surgery, or duration of chronic shoulder instability (Table 4). Patients who underwent a concomitant SLAP repair during shoulder stabilization did not differ significantly in terms of all of the aforementioned criteria from patients who did not undergo this additional procedure (Table 4).
Discussion All patients who were active before surgery performed some sporting activity at follow-up, and more than half of the patients who were inactive before surgery took up new activities postoperatively. Sixty-six percent of our patients stated that surgery improved or strongly improved their sporting or recreational proficiency compared with preoperatively. On the other hand, 26% reported no improvement and 8% even reported a further deterioration. The improvement in sporting proficiency was highly dependent on the age of the patient, as well as individual demands regarding risk level, performance level, Tegner scale, and duration of activity. Contrary to our hypothesis, there was no increase in sporting activity between preoperative and follow-up evaluation concerning sports duration and frequency, number of sports disciplines, or Tegner activity scale and no increased return to high-risk activities. The large number of patients who did not report a significant improvement through surgery seems surprising at first. However, one should take into consideration that this is a chronic population with a mean duration of shoulder instability of 88 months. A certain amount of functional impairment of the affected shoulder with a subjective feeling of instability during activity may persist despite a successful structural repair. Accordingly, patients who did Table 3. Extent of Sports and Recreational Activities Before and After Arthroscopic Stabilization Preoperative No. of disciplines 4 3 (0-14) Sports frequency, wk 2.6 1.6 (0-7) Sports duration h/wk 5.1 4.6 (0-21) No sports, n (%) 9 (14) Performance level, n (%) Recreational 35 (53.0) Competitive 14 (21.2) Highly competitive 6 (9.1) Professional 2 (3.0) Risk category, n (%) Low 5 (33) Medium 30 (46) High 22 (8) Tegner scale score 6.5 (1-10)
Follow-up P Value 5 3 (0-14) .206 2.6 1.4 (0-7) .700 4.9 3.8 (0-21) .878 4 (6) .432 45 12 4 1
(68.2) (18.2) (6.1) (1.5)
5 36 21 6
(7.6) (54.5) (31.8) (3-10)
.178
.358
NOTE. Data are presented as mean standard deviation (range) or median (range) unless otherwise indicated.
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Fig 2. Distribution patterns of sports and recreational activities before and after arthroscopic stabilization. Asterisks indicate a significant difference (P < .05).
not indicate a benefit through surgery showed neither a greater disability score nor a higher recurrence rate. The subjective improvement in sporting activity was rather affected by young age and an increased demand on shoulder function. This finding is consistent with other reports in the literature on shoulder instability.18,32 Pavlik et al.32 published a report as early as 1996 dealing exclusively with the return to sports after open transosseous Bankart repair and reported that the return to sports was highly dependent on the preoperative risk level of the athletes. Similarly, Kim et al.18 found the return to preinjury sporting activity to be best in patients without regular sporting activity and worst in collegiate or professional athletes. A recent study by Stein et al.33 showed that the return to sports was dependent on the type of resumed shoulder sport. They subdivided their study population of 46 patients into non-collision/non-overhead athletes, collision
athletes, overhead athletes, and martial arts participants. All groups were prospectively analyzed using shoulderdependent yet non-validated sport-specific scores. Functionally demanding activities, such as overhead sports and martial arts, showed significant limitations of the reattained proficiency level. This finding is consistent with reports by Ide et al.22 and Cho et al.15 Both study groups found a limited return to collision and overhead sports compared with non-collision/non-overhead activity after arthroscopic shoulder stabilization. Before performing surgery, surgeons should thoroughly inform this young and high-demand group of patients in detail about the expected postoperative sporting ability. Unrealistically high patient expectations may lead to subjective failure despite a successful operation from the surgeon’s point of view. Concerning the type of sports performed in our study, most patients were able to return to their previous
2001
RETURN TO SPORTS AFTER BANKART REPAIR Table 4. Subgroup Analysis: Recurrence and SLAP Repair Recurrent Dislocation Patients, n Age at surgery, yr No. of anchors used QuickDASH score at FU No. of disciplines at FU Sports frequency at FU, wk Sports duration at FU, h/wk Tegner scale score at FU Risk category at FU, n (%) Low risk Moderate risk High risk No sport Overhead activity at FU, yes/no, n (%) Contact sports at FU, yes/no, n (%) Performance level, n (%) Recreational Competitive Highly competitive Professional No sport
Yes 6 19.5 5.5 3 23.8 20.3 32 2.8 2.3 5.6 6.3 5 0 5 0 1 2/4
SLAP Repair
(15-30) (2-4) (0-55) (0-6) (0-6) (0-15) (3-9)
No 60 30.3 10.3 3 5.3 6.4 53 2.6 1.4 4.8 3.6 6
(14-62) (1-5) (0-34) (0-14) (0-7) (0-21) (3-10)
(0.0) (83) (0) (17) (33/67)
5 31 21 3 50/10
(8) (52) (35) (5) (83/17)
4/2 (67/33)
P Value
50/10 (83/17)
.003* .853 .010* .376 .974 .578 .451 .182
Yes 11 25.0 5.0 (17-37) 3 (2-4) 7.6 6.7 (0-23) 5 4 (0-14) 2.7 1.6 (0-5) 5.0 3.2 (0-10) 6 (3-10)
.004*
0 4 6 1 8/3
.313
9/2 (82/18)
No 55 30.1 11.0 3 6.8 10.5 53 2.6 1.5 4.8 4.0 6
(14-62) (1-5) (0-55) (0-14) (0-7) (0-21) (3-10)
5 32 15 3 44/11
(9) (58) (27) (6) (80/20)
(0) (36) (55) (9) (73/27)
P Value
45/10 (82/18)
.974 3 1 1 0 1
(50) (17) (17) (0) (17)
42 11 3 1 3
(70) (18) (5) (2) (5)
.188 .753 .261 .488 .552 .463 .993 .125
.590 >.99 .958
7 2 1 0 1
(64) (18) (9) (0) (9)
38 10 3 1 3
(69) (18) (5) (2) (5)
NOTE. Data are presented as mean standard deviation (range) or median (range) unless otherwise indicated. FU, follow-up; QuickDASH, short version of Disabilities of the Arm, Shoulder and Hand questionnaire. *Statistically significant.
activity. In accordance with the results of Stein et al.,33 martial arts, a high-risk activity for shoulder dislocation, was the only activity that dropped significantly in participation. Patients extending their activities to new sports most frequently chose activities with a low risk for shoulder dislocation. Thus cycling, mountain hiking, and fitness training gained significantly in participation postoperatively. The hypothesized postoperative shift toward activities with a higher risk level could not be confirmed by the data from our study. Furthermore, there was no overall increase in sporting activity between preoperative and follow-up evaluation regarding duration, frequency, number of sports disciplines, or Tegner activity scale. On the one hand, this finding may be explained by the fact that only 66% of patients indicated an improvement in sporting proficiency, as stated previously. However, when patients were asked about the reasons that may have led to a reduced level of activities, only 1 of 5 patients indicated shoulderrelated causes such as persisting instability or pain. Most patients indicated noneshoulder-related reasons for the reduction or stated that the shoulder felt stable and they were satisfied yet concerned about sustaining a further injury to the shoulder. In the young patient population with shoulder instability, many patients undergo changes in their personal living circumstances because of career and family that may affect their sporting and recreational
activity. This must be taken into account when interpreting the data. This fact was reported by other authors previously.32 Retrospectively, the exact impact of this subjective finding on our data is difficult to assess, but the level of postoperative sporting activity may be understated. Within the literature, several authors have reported increased rates of redislocation associated with a high number of preoperative dislocations, young patient age, and participation in contact and overhead activities.10,11,13,15,34 Ide et al.,22 however, found a comparable recurrence rate between contact and noncontact athletes. Although the risk factors for redislocation were not the primary objective of this study and considering the limited number of patients with a recurrence, we found that patients who sustained a redislocation were significantly younger whereas there was no difference regarding the duration of instability or the risk level of sporting activities. Limitations There are several limitations to this study that need to be considered. First, data in this retrospective study were collected through a questionnaire. The patients did not undergo a physical examination or stability testing. Furthermore, because patients were asked about participation in sporting activities that dated back several years, the possibility of recall bias exists. Second,
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15 patients (18.5%) were lost to follow-up or refused to participate, raising the possibility of selection bias. Third, chronic shoulder instability in this study was defined as recurrent dislocations with more than 12 months between primary dislocation and surgery because the actual term “chronic” has not generally been defined in the orthopaedic literature. A recent systematic review suggested 6 months as the cutoff point between acute and chronic shoulder instability35; however, because this suggestion was based on clinical reports only and not on histologic or pathophysiological studies of tissue damage, we chose a longer time interval to give us a more homogeneous patient population. Fourth, the group sizes in the subgroup analysis were small and possibly underpowered. Finally, the group of patients in this study was an active yet not high-demand patient population with chronic shoulder instability. In our experience the selected study group represents the majority of patients with shoulder instability. The results may not apply to a high-demand athletic patient population. However, we have presented detailed information on the impact of arthroscopic Bankart repair on the sporting and recreational behavior of 66 patients with chronic shoulder instability.
5.
6.
7.
8.
9.
10.
Conclusions Arthroscopic Bankart repair provides a high rate of return to activity among patients treated for chronic shoulder instability. A number of previously inactive patients returned to activity postoperatively. However, one-third of patients reported no benefit from surgery in terms of sporting activity. The improvement in sporting proficiency was highly dependent on the demands on the shoulder in sports, as well as the age of the patient. Overall, there was no significant increase in duration, frequency, number of disciplines, Tegner activity scale, or performance level between preoperative and follow-up evaluation and no increased return to high-risk activities.
11.
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15.
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compartment knee osteoarthritis. Am J Sports Med 2009;37:312-318. Schumann K, Flury MP, Schwyzer H-K, Simmen BR, Drerup S, Goldhahn J. Sports activity after anatomical total shoulder arthroplasty. Am J Sports Med 2010;38: 2097-2105. American Academy of Pediatrics Committee on Sports Medicine. Recommendations for participation in competitive sports. Pediatrics 1988;81:737-739. Tegner Y, Lysholm J. Rating systems in the evaluation of knee ligament injuries. Clin Orthop Relat Res 1985:43-49. Kennedy CA, Beaton DE, Solway S, McConnell S, Bombardier C. Disabilities of the Arm, Shoulder and Hand (DASH). The DASH and QuickDASH Outcome Measure User’s Manual. Ed 3. Toronto, ON: Institute for Work & Health, 2011. Pavlik A, Csépai D, Hidas P, Bánóczy A. Sports ability after Bankart procedure in professional athletes. Knee Surg Sports Traumatol Arthrosc 1996;4:116-120. Stein T, Linke RD, Buckup J, et al. Shoulder sport-specific impairments after arthroscopic Bankart repair: A prospective longitudinal assessment. Am J Sports Med 2011;39: 2404-2414. Torchia ME, Caspari RB, Asselmeier MA, Beach WR, Gayari M. Arthroscopic transglenoid multiple suture repair: 2 to 8 year results in 150 shoulders. Arthroscopy 1997;13:609-619. Flint JH, Wade AM, Giuliani J, Rue J-P. Defining the terms acute and chronic in orthopaedic sports injuries: A systematic review. Am J Sports Med 2014;42:235-241.
Purpose: The purpose of this study was to collect detailed data on postoperative sporting activity after arthroscopic Bankart repair for chronic shoulder instability. Methods: Of 113 patients who underwent arthroscopic Bankart repair between February 2008 and August 2010, 81 met the inclusion criteria and were surveyed by a specially designed postal sport-specific questionnaire. Of these 81 patients, 66 (82%) were available for evaluation. Results: All previously active patients performed some activity at follow-up. Of 9 patients (56%) who had been inactive, 5 took up new activities postoperatively. Forty-four patients (66%) stated that surgery had (strongly) improved their sporting proficiency. Seventeen patients (26%) reported no impact, and 5 patients (8%) reported a further deterioration compared with preoperatively. The improvement in sporting proficiency was negatively correlated with the preoperative risk level (r ¼ 0.42, P < .001), preoperative performance level (r ¼ 0.31, P ¼ .012), and preoperative Tegner scale (r ¼ 0.36, P ¼ .003), as well as hours of sporting activity per week (r ¼ 0.25, P ¼ .042), whereas age showed a positive correlation (r ¼ 0.28, P ¼ .023). There was no change in duration, frequency, number of disciplines, Tegner activity scale, risk category, or performance level. Conclusions: Arthroscopic Bankart repair provides a high rate of return to activity among patients treated for chronic shoulder instability. A number of previously inactive patients returned to activity postoperatively. However, one-third of patients reported no benefit from surgery in terms of sporting activity. The improvement in sporting proficiency was highly dependent on the demands on the shoulder in sports, as well as the age of the patient. Overall, there was no significant increase in duration, frequency, number of disciplines, Tegner activity scale, or performance level between preoperative and follow-up evaluation and no increased return to high-risk activities. Level of Evidence: Level IV, therapeutic case series.
T
raumatic anteroinferior shoulder dislocation is a common injury in athletes.1 Patients with glenohumeral instability are mostly young and active with high demands on shoulder function. The redislocation rate after nonoperative treatment is high, particularly among young athletes, ranging up to
From the Department of Orthopaedic Sports Medicine, Klinikum rechts der Isar, Technische Universität München (J.E.P., M.J.F., G.S., S.B., A.B.I.), Munich; Department of Trauma Surgery, Klinikum Augsburg (J.E.P.), Augsburg; Department of Orthopedic Surgery and Traumatology, Freiburg University Hospital (M.J.F.), Freiburg; Department of Trauma and Orthopaedic Surgery, Berufsgenossenschaftliche Unfallklinik Murnau (T.S.), Murnau; and Department of Sporttraumatology, Knee- and Shoulder-Surgery, Berufsgenossenschaftliche Unfallklinik Frankfurt am Main (P.M.), Frankfurt am Main, Germany. The authors report the following potential conflict of interest or source of funding: A.B.I. receives support from Arthrex and Arthrosurface. Received August 10, 2014; accepted April 10, 2015. Address correspondence to Johannes E. Plath, M.D., Department of Orthopaedic Sports Medicine, Klinikum rechts der Isar, Technische Universität München, Ismaninger Strasse 22, 81675 Muenchen, Germany. E-mail: [email protected] Ó 2015 by the Arthroscopy Association of North America 0749-8063/14686/$36.00 http://dx.doi.org/10.1016/j.arthro.2015.04.087
1996
92%.2-6 Therefore early surgical shoulder stabilization is indicated for the young athlete involved in shoulderdemanding activities.2-4,7 However, this patient group represents a minority.8,9 Many patients have a longlasting history of chronic shoulder instability with failed nonoperative treatment and multiple events of dislocation and subluxation before surgery is performed. These chronic instability patients may adapt their level and type of activity, but most of them remain active and engage in sports despite chronic shoulder instability.10 Surgeons recommend shoulder stabilization to avoid further injury to the shoulder joint and promise shoulder stability, improved shoulder function, and a successful return to sports.9,11-13 Several studies have reported on the return to sporting activity after arthroscopic Bankart repair compared with the pre-trauma activity level.7,11,13-19 However, because the primary dislocation dates back many years, this comparison fails to meet the specific situation of patients with chronic shoulder instability. These patients want to be counseled about what they may expect from surgery compared with their current situation.
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 31, No 10 (October), 2015: pp 1996-2003
RETURN TO SPORTS AFTER BANKART REPAIR
Detailed knowledge about the expected level of postoperative sporting activity is important in terms of preoperative patient information and will help surgeons inform their patients in detail before surgery. Realistic patient expectations regarding the surgical procedure may help to avoid subjective failure. In addition, even though most studies report comparable functional outcomes with arthroscopic Bankart repair and with open repair, the return to sporting activity is still a matter of discussion and some authors recommend open repair for collision athletes.11,14,15,18,20-23 Therefore the purpose of this study was to collect detailed data on postoperative sporting activity after arthroscopic Bankart repair for chronic shoulder instability. We hypothesized that patients with chronic recurrent instability will increase their sporting activity after surgical stabilization and may even return to highrisk sports.
Methods Patient Selection We retrospectively evaluated all patients who underwent arthroscopic Bankart repair for traumatic anteroinferior shoulder instability during the period from February 2008 to August 2010 in our department. The inclusion criteria for this study were isolated chronic glenohumeral anteroinferior instability and a minimum follow-up period of 24 months. Chronic shoulder instability was defined as recurrent shoulder dislocations and a minimum time interval from initial dislocation to surgery of 12 months. The exclusion criteria were multidirectional instability, glenoid bone loss greater 20%, engaging HillSachs lesions, advanced osteoarthritis (Samilson and Prieto24 grade 3), glenoid dysplasia, and full-thickness or high-grade partial-thickness (>50% thickness) rotator cuff tears. The study protocol was approved by the local ethics committee, and all patients provided written informed consent to participate in this investigation. Arthroscopic Procedure and Sport-Specific Rehabilitation The patient was placed in the beach-chair position. Diagnostic arthroscopy was performed through a standard posterior portal. For Bankart repair, a deep anteroinferior portal (5:30 clock-face position) through the lower third of the subscapularis muscle was used in all patients.10,25 The number of anchors (BioFastak; Arthrex, Naples, FL) used varied among patients, depending on the pathologic findings. Yet, we favored a repair using 3 anchors placed at the 5:30, 4:30, and 3-o’clock position (for right shoulders). In case of a reparable SLAP lesion (type II or type IV), suture anchor repair (BioFastak) was performed
1997
Table 1. Risk Categories for Traumatic Shoulder Instability Based on Study of Owens et al.1 and Recommendations of American Academy of Pediatrics Committee on Sports Medicine29 High risk Medium risk
Low risk
Sports Handball, rock climbing, windsurfing, surfing, wrestling, judo, ice hockey, football, rugby Volleyball, basketball, soccer, tennis, squash, badminton, swimming, weightlifting, mountain biking, canoeing, boxing Cycling, running, rowing
through a transtendinous lateral portal. Small buckethandle tears or frayed labra were resected. Postoperatively, a sling was used for comfort, and progressive active and assisted range-of-motion exercise was initiated on the following day, limiting external rotation to 30 and limiting abduction, as well as flexion, to 45 . At 4 weeks postoperatively, abduction and flexion were allowed to 90 and external rotation was limited to 0 . Free active range of motion was allowed after 6 weeks postoperatively. Patients were permitted to return to sport-specific training after 3 months and to overhead and high-contact activities after 6 months postoperatively. In case of a concomitant SLAP repair, active biceps training was prohibited for the first 6 weeks. Data Collection Patients were retrospectively evaluated at a minimum of 24 months after arthroscopic Bankart repair using a postal sport-specific questionnaire, which has been used by several authors before.26-28 Patients were asked to compare their current activity level with their preoperative activity level. Data collection and evaluation were performed by an orthopaedic surgeon (J.E.P.) who was not involved in the surgical treatment. The questionnaire assessed the sports frequency (defined as sessions per week), sports duration (defined as hours per week), number of sports disciplines, and performance level (recreational, competitive, highly competitive, or professional). In addition, the patient’s preoperative and postoperative participation in 32 different sports and recreational activities was evaluated. In case of a reduction of sporting activity or termination of disciplines, patients were asked to indicate their reasons (shoulder related, noneshoulder related, or concern of recurrence). Sports and recreational activities were furthermore allocated into risk categories for traumatic shoulder instability (high, medium, and low risk) based on the study of Owens et al.1 and recommendations of the American Academy of Pediatrics Committee on Sports Medicine29 adjusted to meet the distribution of sporting activities in central Europe (Table 1). The questionnaire also inquired about the subjective overall improvement
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in sporting and recreational proficiency (severely impaired, impaired, unchanged, improved, or strongly improved) due to the surgical procedure, as well as the ability to participate in contact and overhead sports. The QuickDASH (short version of Disabilities of the Arm, Shoulder and Hand questionnaire) score (scaled from 0 to 100, where 0 represents no disability and 100 represents the most disability) was used to measure the patient’s upper limb functional disability, and the Tegner activity scale was recorded to determine the activity level.30,31 Statistics Statistical analysis was performed using SPSS software, version 20.0 (IBM, Armonk, NY). All data were tested for normal distribution using the KolmogorovSmirnov test. For normally distributed data, paired and unpaired t tests were used for intragroup and intergroup comparisons. The Wilcoxon signed rank and Mann-Whitney U tests (paired/unpaired) were used for nonenormally distributed data. Dichotomous data were computed by the c2 test. To compare the participation in sporting activities before and after surgery, the McNemar test was used. Correlations were calculated using the Spearman correlation coefficient. The level of significance was set at P < .05.
Results Demographics From February 2008 to August 2010, a total of 113 patients underwent arthroscopic Bankart repair for traumatic anteroinferior shoulder instability in our department. Of these 113 patients, 81 fulfilled the inclusion criteria of the study. A total of 66 questionnaires were available for evaluation (follow-up rate, 82%). Details of patient enrollment are shown in Figure 1. The mean postoperative follow-up period was 43 9 months (range, 25 to 56 months). Of the 66 patients, 6 (9%) sustained a recurrent shoulder dislocation. Two patients underwent arthroscopic revision Bankart repair. There were no neurovascular complications, postoperative infections, or cases of postoperative shoulder stiffness that needed surgical intervention within our patient population. The detailed patient characteristics are provided in Table 2. Sports and Recreational Activities All patients who were active before the operation (57 patients) returned to at least 1 sporting or recreational activity after surgery. Of 9 patients who had been inactive before surgery, 5 (56%) took up new activities postoperatively. Forty-four patients (66%) stated that arthroscopic Bankart repair had strongly (33%) or somewhat (33%)
Fig 1. Flowchart of patient enrollment.
improved their sporting and recreational proficiency compared with preoperatively. Seventeen patients (26%) reported no impact, and 5 patients (8%) stated that their sports performance ability decreased after surgery, with the findings showing some impairment in 4 patients (6%) and severe impairment in 1 case. The lower the preoperative risk (r ¼ 0.42, P < .001) and performance level (r ¼ 0.31, P ¼ .012), Tegner scale (r ¼ 0.36, P ¼ .003), and hours of sporting activity per week (r ¼ 0.25, P ¼ .042), the higher the subjective overall improvement in sporting and recreational proficiency due to the surgical procedure. Patients who indicated no improvement or a decline in sporting ability did not show a higher rate of recurrence (9%) or a higher amount of disability (QuickDASH score) compared with patients who benefited from surgery (P ¼ .401). Age at the time of surgery was positively correlated with improvement in sporting proficiency (r ¼ 0.28, P ¼ .023), whereas the number of sports disciplines (r ¼ 0.25, P ¼ .046) and risk level (r ¼ 0.26, P ¼ .036) at follow-up and the Tegner activity levels before surgery (r ¼ 0.34, P ¼ .005), as well as at follow-up (r ¼ 0.34, P ¼ .005), showed a negative correlation. Overall, there was no significant difference between preoperative and postoperative values regarding the number of disciplines, frequency and duration of sports participation, Tegner activity scale, risk category, or performance level (Table 3).
1999
RETURN TO SPORTS AFTER BANKART REPAIR Table 2. Patient Demographic Data Demographic Characteristic Patients, n Sex, male/female, n (%) Shoulder, right/left, n (%) Dominant side affected, n (%) Follow-up, mo QuickDASH score at follow-up Age at surgery, yr Preoperative dislocations, n (%) 10 Duration of instability, mo Anchors used, n SLAP repair, n (%) Recurrence, n (%)
Data 66 46/20 (70) 33/33 (50) 37/29 (56) 43 9 (25-56) 6.9 9.9 (0-55) 29.3 10.4 (14-62) 28 13 25 87 84 3 11 6
(42) (20) (38) (12-360) (1-5) (17) (9)
NOTE. Data are presented as mean standard deviation (range) or median (range) unless otherwise indicated. QuickDASH, short version of Disabilities of the Arm, Shoulder and Hand questionnaire.
When patients were asked the reasons that they quit disciplines or reduced the extent of sporting activity during the follow-up period, 19% indicated shoulderrelated causes (persisting instability, pain, and dysfunction) and 22% stated that they were asymptomatic yet were concerned about sustaining a further injury to the shoulder. Most patients (59%) indicated that noneshoulder-related reasons accounted for the activity change, such as career, family, and other personal interests. Cycling, fitness training, and mountain hiking, all low-risk activities for shoulder dislocation, gained significantly in participation postoperatively (P ¼ .016, P < .001, and P ¼ .008, respectively), whereas martial arts, a high-risk activity for shoulder dislocation, was the only activity that dropped significantly in participation (P ¼ .031). Seventy-nine percent of the patients stated that they felt comfortable participating in overhead activities, and 82% reported that they were able to participate in contact sports. The distribution patterns for different sports and recreational activities before and after arthroscopic stabilization are shown in Figure 2. Subgroup Analysis: Recurrence and SLAP Repair Patients who sustained a recurrent shoulder dislocation after arthroscopic Bankart repair showed a significantly higher amount of disability based on QuickDASH score results compared with patients who did not (P ¼ .010). Patients with redislocations were significantly younger (P ¼ .003) and reported more frequently that they felt uncomfortable engaging in overhead activities (P ¼ .004), whereas no difference concerning contact sports could be detected (P ¼ .313). With the number of patients available, there were no significant intergroup differences at follow-up
regarding the number of disciplines, Tegner scale, risk level, sports frequency and duration, number of anchors used during surgery, or duration of chronic shoulder instability (Table 4). Patients who underwent a concomitant SLAP repair during shoulder stabilization did not differ significantly in terms of all of the aforementioned criteria from patients who did not undergo this additional procedure (Table 4).
Discussion All patients who were active before surgery performed some sporting activity at follow-up, and more than half of the patients who were inactive before surgery took up new activities postoperatively. Sixty-six percent of our patients stated that surgery improved or strongly improved their sporting or recreational proficiency compared with preoperatively. On the other hand, 26% reported no improvement and 8% even reported a further deterioration. The improvement in sporting proficiency was highly dependent on the age of the patient, as well as individual demands regarding risk level, performance level, Tegner scale, and duration of activity. Contrary to our hypothesis, there was no increase in sporting activity between preoperative and follow-up evaluation concerning sports duration and frequency, number of sports disciplines, or Tegner activity scale and no increased return to high-risk activities. The large number of patients who did not report a significant improvement through surgery seems surprising at first. However, one should take into consideration that this is a chronic population with a mean duration of shoulder instability of 88 months. A certain amount of functional impairment of the affected shoulder with a subjective feeling of instability during activity may persist despite a successful structural repair. Accordingly, patients who did Table 3. Extent of Sports and Recreational Activities Before and After Arthroscopic Stabilization Preoperative No. of disciplines 4 3 (0-14) Sports frequency, wk 2.6 1.6 (0-7) Sports duration h/wk 5.1 4.6 (0-21) No sports, n (%) 9 (14) Performance level, n (%) Recreational 35 (53.0) Competitive 14 (21.2) Highly competitive 6 (9.1) Professional 2 (3.0) Risk category, n (%) Low 5 (33) Medium 30 (46) High 22 (8) Tegner scale score 6.5 (1-10)
Follow-up P Value 5 3 (0-14) .206 2.6 1.4 (0-7) .700 4.9 3.8 (0-21) .878 4 (6) .432 45 12 4 1
(68.2) (18.2) (6.1) (1.5)
5 36 21 6
(7.6) (54.5) (31.8) (3-10)
.178
.358
NOTE. Data are presented as mean standard deviation (range) or median (range) unless otherwise indicated.
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Fig 2. Distribution patterns of sports and recreational activities before and after arthroscopic stabilization. Asterisks indicate a significant difference (P < .05).
not indicate a benefit through surgery showed neither a greater disability score nor a higher recurrence rate. The subjective improvement in sporting activity was rather affected by young age and an increased demand on shoulder function. This finding is consistent with other reports in the literature on shoulder instability.18,32 Pavlik et al.32 published a report as early as 1996 dealing exclusively with the return to sports after open transosseous Bankart repair and reported that the return to sports was highly dependent on the preoperative risk level of the athletes. Similarly, Kim et al.18 found the return to preinjury sporting activity to be best in patients without regular sporting activity and worst in collegiate or professional athletes. A recent study by Stein et al.33 showed that the return to sports was dependent on the type of resumed shoulder sport. They subdivided their study population of 46 patients into non-collision/non-overhead athletes, collision
athletes, overhead athletes, and martial arts participants. All groups were prospectively analyzed using shoulderdependent yet non-validated sport-specific scores. Functionally demanding activities, such as overhead sports and martial arts, showed significant limitations of the reattained proficiency level. This finding is consistent with reports by Ide et al.22 and Cho et al.15 Both study groups found a limited return to collision and overhead sports compared with non-collision/non-overhead activity after arthroscopic shoulder stabilization. Before performing surgery, surgeons should thoroughly inform this young and high-demand group of patients in detail about the expected postoperative sporting ability. Unrealistically high patient expectations may lead to subjective failure despite a successful operation from the surgeon’s point of view. Concerning the type of sports performed in our study, most patients were able to return to their previous
2001
RETURN TO SPORTS AFTER BANKART REPAIR Table 4. Subgroup Analysis: Recurrence and SLAP Repair Recurrent Dislocation Patients, n Age at surgery, yr No. of anchors used QuickDASH score at FU No. of disciplines at FU Sports frequency at FU, wk Sports duration at FU, h/wk Tegner scale score at FU Risk category at FU, n (%) Low risk Moderate risk High risk No sport Overhead activity at FU, yes/no, n (%) Contact sports at FU, yes/no, n (%) Performance level, n (%) Recreational Competitive Highly competitive Professional No sport
Yes 6 19.5 5.5 3 23.8 20.3 32 2.8 2.3 5.6 6.3 5 0 5 0 1 2/4
SLAP Repair
(15-30) (2-4) (0-55) (0-6) (0-6) (0-15) (3-9)
No 60 30.3 10.3 3 5.3 6.4 53 2.6 1.4 4.8 3.6 6
(14-62) (1-5) (0-34) (0-14) (0-7) (0-21) (3-10)
(0.0) (83) (0) (17) (33/67)
5 31 21 3 50/10
(8) (52) (35) (5) (83/17)
4/2 (67/33)
P Value
50/10 (83/17)
.003* .853 .010* .376 .974 .578 .451 .182
Yes 11 25.0 5.0 (17-37) 3 (2-4) 7.6 6.7 (0-23) 5 4 (0-14) 2.7 1.6 (0-5) 5.0 3.2 (0-10) 6 (3-10)
.004*
0 4 6 1 8/3
.313
9/2 (82/18)
No 55 30.1 11.0 3 6.8 10.5 53 2.6 1.5 4.8 4.0 6
(14-62) (1-5) (0-55) (0-14) (0-7) (0-21) (3-10)
5 32 15 3 44/11
(9) (58) (27) (6) (80/20)
(0) (36) (55) (9) (73/27)
P Value
45/10 (82/18)
.974 3 1 1 0 1
(50) (17) (17) (0) (17)
42 11 3 1 3
(70) (18) (5) (2) (5)
.188 .753 .261 .488 .552 .463 .993 .125
.590 >.99 .958
7 2 1 0 1
(64) (18) (9) (0) (9)
38 10 3 1 3
(69) (18) (5) (2) (5)
NOTE. Data are presented as mean standard deviation (range) or median (range) unless otherwise indicated. FU, follow-up; QuickDASH, short version of Disabilities of the Arm, Shoulder and Hand questionnaire. *Statistically significant.
activity. In accordance with the results of Stein et al.,33 martial arts, a high-risk activity for shoulder dislocation, was the only activity that dropped significantly in participation. Patients extending their activities to new sports most frequently chose activities with a low risk for shoulder dislocation. Thus cycling, mountain hiking, and fitness training gained significantly in participation postoperatively. The hypothesized postoperative shift toward activities with a higher risk level could not be confirmed by the data from our study. Furthermore, there was no overall increase in sporting activity between preoperative and follow-up evaluation regarding duration, frequency, number of sports disciplines, or Tegner activity scale. On the one hand, this finding may be explained by the fact that only 66% of patients indicated an improvement in sporting proficiency, as stated previously. However, when patients were asked about the reasons that may have led to a reduced level of activities, only 1 of 5 patients indicated shoulderrelated causes such as persisting instability or pain. Most patients indicated noneshoulder-related reasons for the reduction or stated that the shoulder felt stable and they were satisfied yet concerned about sustaining a further injury to the shoulder. In the young patient population with shoulder instability, many patients undergo changes in their personal living circumstances because of career and family that may affect their sporting and recreational
activity. This must be taken into account when interpreting the data. This fact was reported by other authors previously.32 Retrospectively, the exact impact of this subjective finding on our data is difficult to assess, but the level of postoperative sporting activity may be understated. Within the literature, several authors have reported increased rates of redislocation associated with a high number of preoperative dislocations, young patient age, and participation in contact and overhead activities.10,11,13,15,34 Ide et al.,22 however, found a comparable recurrence rate between contact and noncontact athletes. Although the risk factors for redislocation were not the primary objective of this study and considering the limited number of patients with a recurrence, we found that patients who sustained a redislocation were significantly younger whereas there was no difference regarding the duration of instability or the risk level of sporting activities. Limitations There are several limitations to this study that need to be considered. First, data in this retrospective study were collected through a questionnaire. The patients did not undergo a physical examination or stability testing. Furthermore, because patients were asked about participation in sporting activities that dated back several years, the possibility of recall bias exists. Second,
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15 patients (18.5%) were lost to follow-up or refused to participate, raising the possibility of selection bias. Third, chronic shoulder instability in this study was defined as recurrent dislocations with more than 12 months between primary dislocation and surgery because the actual term “chronic” has not generally been defined in the orthopaedic literature. A recent systematic review suggested 6 months as the cutoff point between acute and chronic shoulder instability35; however, because this suggestion was based on clinical reports only and not on histologic or pathophysiological studies of tissue damage, we chose a longer time interval to give us a more homogeneous patient population. Fourth, the group sizes in the subgroup analysis were small and possibly underpowered. Finally, the group of patients in this study was an active yet not high-demand patient population with chronic shoulder instability. In our experience the selected study group represents the majority of patients with shoulder instability. The results may not apply to a high-demand athletic patient population. However, we have presented detailed information on the impact of arthroscopic Bankart repair on the sporting and recreational behavior of 66 patients with chronic shoulder instability.
5.
6.
7.
8.
9.
10.
Conclusions Arthroscopic Bankart repair provides a high rate of return to activity among patients treated for chronic shoulder instability. A number of previously inactive patients returned to activity postoperatively. However, one-third of patients reported no benefit from surgery in terms of sporting activity. The improvement in sporting proficiency was highly dependent on the demands on the shoulder in sports, as well as the age of the patient. Overall, there was no significant increase in duration, frequency, number of disciplines, Tegner activity scale, or performance level between preoperative and follow-up evaluation and no increased return to high-risk activities.
11.
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15.
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