High Variability in Functional Outcomes and Recurrences Between Contact Sports After Arthroscopic Bankart Repair: A Comparative Study of 351 Patients With a Minimum 3-Year Follow-Up

Methodology and development of a machine learning probability calculator: Data heterogeneity limits ability to predict recurrence after arthroscopic Bankart repair

PURPOSE

The aim of this study was to develop and train a machine learning (ML) algorithm to create a clinical decision support tool (i.e., ML-driven probability calculator) to be used in clinical practice to estimate recurrence rates following an arthroscopic Bankart repair (ABR).

METHODS

Data from 14 previously published studies were collected. Inclusion criteria were (1) patients treated with ABR without remplissage for traumatic anterior shoulder instability and (2) a minimum of 2 years follow-up. Risk factors associated with recurrence were identified using bivariate logistic regression analysis. Subsequently, four ML algorithms were developed and internally validated. The predictive performance was assessed using discrimination, calibration and the Brier score.

RESULTS

In total, 5591 patients underwent ABR with a recurrence rate of 15.4% (n = 862). Age <35 years, participation in contact and collision sports, bony Bankart lesions and full-thickness rotator cuff tears increased the risk of recurrence (all p < 0.05). A single shoulder dislocation (compared to multiple dislocations) lowered the risk of recurrence (p < 0.05). Due to the unavailability of certain variables in some patients, a portion of the patient data had to be excluded before pooling the data set to create the algorithm. A total of 797 patients were included providing information on risk factors associated with recurrence. The discrimination (area under the receiver operating curve) ranged between 0.54 and 0.57 for prediction of recurrence.

CONCLUSION

ML was not able to predict the recurrence following ABR with the current available predictors. Despite a global coordinated effort, the heterogeneity of clinical data limited the predictive capabilities of the algorithm, emphasizing the need for standardized data collection methods in future studies.

LEVEL OF EVIDENCE

Level IV, retrospective cohort study.

Similar outcomes in collision athletes with subcritical glenoid bone loss and on-Track Hill Sachs lesion versus off-track Hill Sachs lesion managed with open Bankart repair plus inferior capsular shift

INTRODUCTION

Open Bankart repair plus inferior capsular shift has not yet been tested under the concept of glenoid track as a predictor of failure. The aim of this study was to compare the subjective and objective outcomes in collision athletes with subcritical glenoid bone loss and on-track Hill Sachs lesions versus those with off-track Hill Sachs lesions, all treated with open Bankart repair.

METHODS

Two study groups were created: 50 patients had on-track Hill Sachs lesions, while 38 had off-track lesions. The subcritical glenoid bone loss was ≤ 10%. A minimum follow-up period of 3 years was established. Preoperative and postoperative evaluation of each group and between them was performed. The Western Ontario Shoulder Instability Index score and the American Shoulder and Elbow Surgeons scale were used to assess subjective outcomes. Recurrence rate, range of motion and return to sport were evaluated as objective outcomes.

RESULTS

Significant differences were reported in the WOSI and ASES scores between preoperative and postoperative values in each group. There were no significant differences between the two groups (p-value = 0.36 and 0.71). Three dislocations (6%) in the on-track group and 3 (7.8%) in the off-track group were recorded, showing no differences between the two groups (p-value = 0.83). There were no differences in ROM between pre- and post-operatively in each group or when comparing the two groups.

CONCLUSIONS

We found no differences between the outcomes of the two groups. According to the surgeon's preference, we recommend performing open Bankart repair plus inferior capsular shift as a treatment alternative in collision athletes with SGBL ≤ 10% independently of the type of Hill Sachs lesion.

Arthroscopic Labral Reconstruction With a Modified Inferior Capsular Shift Allows Return to Sport and Excellent Outcomes in Contact and Noncontact Athletes With Anterior Shoulder Instability at Minimum 5-Year Follow-Up

PURPOSE

To compare return to sport, functional outcomes, recurrence of instability, and osteoarthritis (OA) between collision/contact and limited/noncontact athletes following arthroscopic labral reconstruction with a modified inferior capsular shift for anterior shoulder instability.

METHODS

Athletes underwent an arthroscopic labral reconstruction with a modified inferior capsular shift by the senior author between 1999 and 2018. Inclusion criteria were labral stripping from 12 (just beyond the biceps anchor) to 6 o'clock, less than 20% glenoid bone loss, active sports participation, and no previous surgery. Athletes were divided into collision/contact and limited/noncontact groups. Outcome measures, physical examination, and radiographic evaluation were collected at a minimum 5-year follow-up. Reoperations or any subjective laxity were considered failures. Radiographs were analyzed for OA using the Samilson-Prieto Radiological Classification.

RESULTS

Ninety-two patients underwent arthroscopic labral reconstruction with a modified inferior capsular shift. Sixty-four met the inclusion criteria. Thirty-eight (age = 26.0 ± 8.0 years) participated in at least 1 collision/contact sport, and 26 (age = 38.0 ± 9.0 years) participated in limited/noncontact sports. Two (5%) collision/contact and 3 (12%) limited/noncontact athletes had traumatic reinjury requiring revision surgery. Of the remaining athletes (59/64), minimum 5-year follow-up was obtained on 54 (92%), with a mean follow-up of 12 ± 4 years (range 5-23 years). All athletes returned to their original sport at the same level. There was no significant difference between collision/contact and limited/noncontact athletes in timing of return to sports (5.2 ± 1.9 and 6.0 ± 3.1 months, respectively; P = .389). There were no significant differences between groups on any outcomes scores.

CONCLUSIONS

Arthroscopic labral reconstruction with a modified inferior capsular shift addressed anterior instability with return to sport for both collision/contact and limited/noncontact athletes with excellent functional and clinical outcomes, full shoulder range of motion, and a low prevalence of advanced OA at minimum 5-year follow-up. This modified technique resulted in a low failure rate in both limited/noncontact and collision/contact athletes.

LEVEL OF EVIDENCE

Level III, retrospective case control study.

Return to play following operative management of anterior shoulder instability in overhead athletes-A systematic review

Background

The purpose of this study was to systematically review the rate and timing of return to play in overhead athletes following operative management of anterior shoulder instability.

Methods

A systematic literature search based on PRISMA guidelines, utilizing the EMBASE, MEDLINE, and The Cochrane Library Databases. Eligible for inclusion were clinical studies reporting on return to play among overhead athletes following arthroscopic Bankart repair, open Latarjet procedure or Remplissage procedure.

Results

There are 23 studies included with 961 patients. Among those undergoing arthroscopic Bankart repair, the rate of return to play was 86.2%, with 70.6% returning to the same level of play and the mean time to return to play was 7.1 months. Among those undergoing an open Latarjet procedure, the rate of return to play was 80.9%, with 77.7% returning to the same level of play and the mean time to return to play was 5.1 months. Among those undergoing a Remplissage procedure, the rate of return to play was 70.6%, with 70.0% returning to the same level of play or mean time to return to play.

Discussion

Overall, there were high rates of return to play following operative management of anterior shoulder instability in overhead athletes.

Results After Arthroscopic Bankart Repair in Contact Athletes Should Not Be Reported Globally Because of the High Variability in Recurrences Among the Different Contact or Collision Sports: A Systematic Review

PURPOSE

To describe and compare the recurrence rates in contact or collision (CC) sports after arthroscopic Bankart repair (ABR) and to compare the recurrence rates in CC versus non-collision athletes after ABR.

METHODS

We followed a prespecified protocol registered with PROSPERO (registration No. CRD42022299853). In January 2022, a literature search was performed using the electronic databases MEDLINE, Embase, and CENTRAL (Cochrane Central Register of Controlled Trials), as well as clinical trials records. Clinical studies (Level I-IV evidence) that evaluated recurrence after ABR in CC athletes with a minimum follow-up period of 2 years postoperatively were included. We assessed the quality of the studies using the Risk of Bias in Non-randomized Studies of Interventions (ROBINS-I) tool, and we described the range of effects using synthesis without meta-analysis and described the certainty of the evidence using GRADE (Grading of Recommendations, Assessment, Development, and Evaluations).

RESULTS

We identified 35 studies, which included 2,591 athletes. The studies had heterogeneous definitions of recurrence and classifications of sports. The recurrence rates after ABR varied significantly among studies between 3% and 51% (I2 = 84.9%, 35 studies and 2,591 participants). The range was at the higher end for participants younger than 20 years (range, 11%-51%; I2 = 81.7%) compared with older participants (range, 3%-30%; I2 = 54.7%). The recurrence rates also varied by recurrence definition (I2 = 83.3%) and within and across categories of CC sports (I2 = 83.8%). CC athletes had higher recurrence rates than did non-collision athletes (7%-29% vs 0%-14%; I2 = 29.2%; 12 studies with 612 participants). Overall, the risk of bias of all the included studies was determined to be moderate. The certainty of the evidence was low owing to study design (Level III-IV evidence), study limitations, and inconsistency.

CONCLUSIONS

There was high variability in the recurrence rates reported after ABR according to the different types of CC sports, ranging from 3% to 51%. Moreover, variations in recurrence among CC sports were observed, with ice hockey players being in the upper range but field hockey players being in the lower range. Finally, CC athletes showed higher recurrence rates when compared with non-collision athletes.

LEVEL OF EVIDENCE

Level IV, systematic review of Level II, III, and IV studies.

Psychological Factors That Affect Return to Sport After Surgical Intervention for Shoulder Instability: A Systematic Review

Background

Recent advances have begun to identify the nonphysical factors facilitating successful return to sport (RTS) after shoulder instability surgery, yet little is currently known regarding psychological factors and RTS.

Purpose/Hypothesis

The purposes of this study were to (1) identify psychological factors associated with RTS, (2) evaluate the prognostic utility of various psychological factors, and (3) evaluate the available metrics used to assess psychological RTS readiness. It was hypothesized that psychological factors would be identified as critical elements influencing a patient's RTS.

Study Design

Systematic review; Level of evidence, 4.

Methods

Clinical studies reporting on the psychological determinants of RTS for patients who had surgery for shoulder instability between 1996 and 2022 were identified from MEDLINE, Embase, and Cochrane databases. Demographic, clinical, and psychometric properties were extracted for pooled weighted analysis.

Results

Of the 969 studies screened, 24 (2.5%) met inclusion criteria. Overall, 2135 patients were included (mean age, 26.0 years; range, 17.4-35.5 years; 84.7% male). The mean time to RTS was 6.8 months (range, 3.7-11.9 months). There was a 76.3% rate of any RTS; of the 1212 patients who reported level of play at return, 305 (25.2%) were unable to perform at their prior level. Psychological reasons were cited by 85% (n = 360) of patients who did not RTS. Fear of reinjury was the most common reason (n = 154; 42.8%); other psychological factors included lack of confidence (n = 46; 12.8%), anxiety (n = 45; 12.5%), depression (n = 44; 12.2%), psychosocial factors (n = 48; 13.3%), and lack of motivation (n = 23; 6.4%). The Shoulder Instability Return to Sport after Injury, Western Ontario Shoulder Instability Index, Quick Inventory of Depressive Symptoms Self Report, Degree of Shoulder Involvement in Sports, Tampa Scale of Kinesiophobia-11, and Veterans Rand 12-Item Health Survey were reported measures for assessing psychology and RTS.

Conclusion

Fear of reinjury was found to be the most commonly reported impediment to RTS. The psychological characteristics identified through this review may be incorporated into future RTS protocols seeking to address resilience and nonphysical factors associated with RTS.

Return to sports after arthroscopic Bankart repair in teenage athletes: a retrospective cohort study

BACKGROUND

Anterior shoulder instability is frequent among young athletes. Surgical treatment for this injury aims to facilitate an early return to sports (RTS). However, the rate of recurrent instability after surgery is reportedly high among young patients, and it is unclear whether surgery ensures satisfactory RTS. The purpose of this study was to verify the clinical outcomes and RTS after arthroscopic Bankart repair in competitive teenage athletes without critical bone loss in the glenoid.

METHODS

We retrospectively reviewed competitive teenage athletes who underwent arthroscopic Bankart repair. Patients with large bony defects in the glenoid, larger than 20% of the healthy side, were excluded. Clinical outcomes, recurrent instability, the final level of RTS, and the time needed for RTS were analyzed.

RESULTS

In total, 50 patients with a mean follow-up period of 44.5 ± 19.6 (range, 24-85 months) months were included. The mean age at surgery was 16.8 ± 1.7 (range, 13-19 years) years. Two patients (4.0%) experienced recurrent instability. All patients returned to sports, 96% of patients participated competitively, and 76% achieved a complete return to the pre-injury level without any complaints. The time for RTS was 6.6 ± 2.7 months (range, 3-18 months), to competitions was 9.3 ± 4.0 (range, 6-24 months) months, and to complete return was 10.6 ± 4.3 (range, 8-24 months) months. The complete return rates varied by sports type, with 82% in contact athletes, 59% in dominant-hand overhead athletes, and 100% in other athletes (P = 0.026). Other preoperative factors or concomitant lesion such as bony Bankart, superior labrum tear, or humeral avulsion of glenohumeral ligament lesion did not affect the complete RTS.

CONCLUSION

Arthroscopic Bankart repair is an effective surgical procedure for anterior shoulder instability, even among competitive teenage athletes. Sports type was the only factor associated with complete RTS after surgery.

Outcomes of Open Bankart Repair Plus Inferior Capsular Shift Compared with Latarjet Procedure in Contact Athletes with Recurrent Anterior Shoulder Instability

Background

Open Bankart repair plus inferior capsular shift (OBICS) and Latarjet procedure (LA) are considered appropriate treatment alternatives for high-performance athletes. The purpose of this study was to evaluate the functional outcomes and recurrence rate of each surgery. Our hypothesis: there were no differences between the two treatments.

Methods

A prospective cohort study was conducted with n=90 contact athletes divided into two groups of 45 patients. One group was treated with OBICS, and the other one with LA. The mean follow-up period was 25 (24-32) months for the OBICS group and 26 (24-31) months for the LA group. Primary functional outcomes of each group were assessed at baseline, six months, one year, and two years after surgery. The functional outcomes were also compared between the groups. The evaluation tools used were the Western Ontario Shoulder Instability score (WOSI) and the American Shoulder and Elbow Surgeons scale (ASES). In addition, recurrent instability and range of motion (ROM) were also evaluated.

Results

In each group, significant changes were found in the WOSI score and ASES scale from pre-op to postop. However, there were no significant differences between the functional outcomes of the groups at the final follow-up (P-values 0.73 and 0.19). Three dislocations and one subluxation (8.8%) were reported in the OBICS group, and three subluxations were reported in the LA group (6.6%), revealing no significant differences between the groups (P=0.37). Moreover, there were no significant differences between preoperative and postoperative ROM in each group or in terms of external rotation (ER) and ER in 90º abduction between the groups.

Conclusion

No differences were found between OBICS and LA surgery. Both procedures can be indicated according to the surgeon's preference to reduce recurrence rates in contact athletes with recurrent anterior shoulder instability.

Failure and Complication Rates in Common Sports and Arthroscopic Procedures: Reality Check

Expectations following sports medicine and arthroscopic procedures have been elevated because of captivating modern-day media coverage of high-profile athletic injuries, surgery, and rapid return to sports. Unfortunately, this general perception may be misleading, and orthopedic sports medicine physicians must be aware of the harsh reality of the trials and tribulations associated with the subspecialty. The purpose of this review article is to provide an updated brief overview of the complications and failure rates associated with common arthroscopic procedures including rotator cuff repair, biceps tenodesis, Bankart procedure, Latarjet procedure, anterior cruciate ligament reconstruction, anterior cruciate ligament repair, meniscal repair, tibial tubercle osteotomy, and medial patellofemoral ligament reconstruction. Highlighting the complications is the first step toward early recognition, enhancing preventative measures, and successful management.

Clinical outcomes of Gaelic Athletic Association athletes after surgical stabilization in the setting of anterior shoulder instability

Background

Gaelic Athletic Association (GAA) games are collision sports played at an amateur level, which represent the most popular sports played on the island of Ireland. Each year, many GAA players in Ireland require surgical stabilization with either arthroscopic Bankart repair (ABR) or open Latarjet (OL) procedures in the setting of anterior shoulder instability. The purpose of this study was to evaluate the clinical outcomes, recurrence, and return to play (RTP) in athletes who play GAA games having undergone surgical stabilization with either ABR or OL procedures in the setting of anterior shoulder instability.

Methods

A retrospective review of all patients with anterior shoulder instability whom had stabilization with either ABR or OL under a single surgeon between 2012 and 2018 was performed. Patients who were athletes partaking in GAA sports were followed up by chart review and telephone survey to assess their clinical outcomes including satisfaction, pain as measured on the visual analog scale score, the Subjective Shoulder Value, recurrence, complications, and revision surgeries. In addition, RTP rates, time to RTP, level of RTP, and Shoulder Instability–Return to Sport after Injury scores were evaluated.

Results

A total of 200 GAA athletes (194 males) with a mean age of 23.9 ± 6.1 years with mean follow-up of 50.4 ± 24 months were included in this study. A total of 98.1% patients were satisfied with their procedure at the latest follow-up, with an overall recurrence rate of 5%. A total of 6.5% of athletes required revision surgery, of whom 4% required revision stabilization (all of whom had recurrence). The overall rate of RTP was 88% at mean 6.0 ± 1.7 months postoperatively, with 75% of athletes returning at the same or higher levels than their preinjury level. There were no significant differences for all outcome measures analyzed between patients who had ABR or OL procedures.

Conclusion

GAA athletes with anterior shoulder instability treated with either ABR or OL procedures report excellent clinical outcomes at medium-term follow-up, with high satisfaction rates, excellent functional outcomes, and high rates of RTP. Furthermore, this cohort demonstrates low rates of recurrence after stabilization with few requiring revision surgery.