Abstract
Background
Anterior shoulder instability frequently occurs in young, physically active individuals and may be treated with surgical stabilization. Previous studies have shown that males more often require surgical management for anterior shoulder instability and may have a higher frequency of recurrent instability episodes after surgical management, but females have been found to have increased incidence of apprehension after surgical stabilization. The purpose of this study is to review the literature and assess anterior shoulder surgical stabilization postoperative outcomes between males and females to identify and describe sex-based differences.
Methods
A systematic search of electronic databases was conducted to identify level I-IV clinical studies on anterior shoulder instability published between 1960 and August 2020. We included studies that evaluated sex-specific outcomes in patients who underwent anterior shoulder instability procedures. A meta-analysis of the data was performed to analyze sex-specific outcomes.
Results
Thirty studies (2.1%) met inclusion criteria, representing 9829 patients. Of the studies that reported the number of male and female patients, 74% were male and 26% were female. Twenty-six studies used Bankart repair alone, two used open Latarjet procedure alone, and two had a Bankart repair group and Latarjet procedure group. Instability recurrence, return to sport, and apprehension were included in the meta-analysis. Our meta-analysis demonstrated a significantly higher rate of instability recurrence for males than for females who underwent arthroscopic Bankart repair (risk ratio [RR] = 1.25; 95% confidence interval [CI] = 1.03, 1.52; P = .0239). We did not identify a significant difference between males and females in rates of apprehension (RR = 0.68; 95% CI = 0.37, 1.27; P = .2300) or return to sport (RR = 0.98; 95% CI = 0.81, 1.18; I2 = 0%; P = .8110) for arthroscopic Bankart repair or open Latarjet procedure.
Conclusion
For patients who underwent arthroscopic Bankart repair for anterior shoulder stabilization, recurrent rates of instability were significantly higher for males than for females. When open Bankart and Latarjet procedures were included, there was no difference. No difference was seen between males and females after arthroscopic Bankart repair or open Latarjet procedures with regard to return to sport or apprehension.
Keywords: Anterior shoulder instability, Sex, Gender, Bankart repair, Latarjet procedure, Outcomes
Shoulder instability is a common problem in young, physically active individuals. Instability can be related to the shoulder’s wide range of motion (ROM), requiring muscle strength and coordination for stability.3 More than 95% of shoulder dislocations occur anteriorly, and recurrent anterior instability after the first dislocation has been estimated in up to 92% of cases with 7 years of follow-up.6,15 Recurrent shoulder instability after conservative management can be treated surgically, most often with arthroscopic or open Bankart repair. However, in cases with significant glenoid bone loss, procedures such as the modified Bristow-Latarjet coracoid transfer, or bone block autograft or allograft augmentation, can be used.6 When it comes to sex-specific outcomes after these shoulder stabilization procedures, previous studies have shown that males more often undergo surgical management than females.5,10 However, male sex may also be a contributing factor for recurrence of instability after surgical management.2 In contrast, Kaipel et al evaluated sex-related differences after arthroscopic shoulder stabilization and found females to have a lower Constant-Murley score and increased incidence of a positive apprehension test.20
The underlying impact of sex on outcomes of anterior shoulder instability has been postulated to be due to differences between males and females in muscle forces on the shoulder, which are critical for maintaining proper articulation.20 The differences are believed to be the result of females having lower muscle mass than males, and therefore lacking balanced muscle forces required to maintain stability of the shoulder. Another possible cause for differences in outcomes between males and females could be the increased prevalence of hyperlaxity in females. However, other studies have shown that external factors, such as contact sports, may predispose males to instability as they may put themselves in positions that increase their risk of sustaining a shoulder dislocation compared with females.
Owing to this reported discrepancy in incidence and outcomes of shoulder instability between males and females, the purpose of this study was to review the current literature and to analyze sex-based differences in outcomes after anterior shoulder surgical stabilization.
Materials and methods
Search strategy and study selection
The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were used to complete this systematic review and meta-analysis, and approval from the institutional review board was not required.27 An electronic database search was conducted using PubMed, Embase, PubMed Central, Ovid, and Cochrane Library. Search terms included “shoulder instability”, “Bankart repair”, “labral repair”, “Remplissage technique”, “Remplissage procedure”, “Latarjet technique”, “Latarjet procedure”, “Bristow technique”, “Bristow procedure”, “Bristow-Latarjet technique”, “Bristow-Latarjet procedure”, “Capsular shift”, “distal tibia allograft”, “distal clavicle autograft”, “iliac crest allograft”, “iliac crest autograft”, “male”, “female”, “gender”, and “sex”. Further references were obtained from identified review articles. Clinical studies with a level of evidence I-IV and a publication date between 1960 and August 21, 2020, were considered for inclusion.
Eligibility criteria
Studies that evaluated patients who underwent anterior shoulder instability operative repair, assessed sex-specific outcomes, and had a mean follow-up of at least one year were included. Only human clinical studies reported in the English language were considered for review. Case reports, review articles, and studies including concomitant biceps tenotomy or tenodesis or rotator cuff repair were excluded. Animal, cadaver, and laboratory-based studies were also excluded.
Data extraction and quality appraisal
Data related to sex-specific differences in outcomes were extracted from each study. The following data points were extracted from at least one study: failure/instability recurrence rate (which included rates of redislocation, subluxation, and/or requiring revision surgery, depending on the study), return-to-sport (RTS) rate, apprehension, sulcus sign, ROM, strength, maximum voluntary contraction, and validated outcome scores. In addition to evaluating instability recurrence and RTS rates, we also reviewed the definitions for instability recurrence and RTS and compared them across studies.
Validated outcome scores included in this study were the Rowe score; Western Instruments score; Disabilities of the Arm, Shoulder, and Hand (DASH) score; Subjective Shoulder Value (SSV); Subjective Assessment of Shoulder Function (SASF); American Shoulder and Elbow Surgeons (ASES) evaluation form; and Constant-Murley score. The Rowe score is a rating system based on stability, motion, and function and is scored out of 100 points.21 The Western Ontario Shoulder Instability Index (WOSI) evaluates symptoms and different domains of function—sports, recreation, work, lifestyle, and emotional well-being. The WOSI score can be presented in a raw form—0 to 2,100, with 2100 being the worst score—or converted to a percentage—0 to 100%, with 100% being the best possible score.21 The DASH assessment is a 30-item questionnaire that evaluates symptoms and functional status.21 The SSV is a subjective patient assessment scored as a percentage out of 100%.16 The SASF score is determined by asking the patient “How does your shoulder function in daily living and different physical activities?” and is also rated out of 100%.19 The ASES consists of a physician assessment (unscored) and patient evaluation and is scored out of 100 possible points.21 The Constant-Murley assessment includes 65 points for physical examination and 35 points for subjective patient evaluation.21 The quality of each study was assessed using the Tools to Assess Risk of Bias in Cohort Studies, Case Control Studies, and Randomized Controlled Trials by the CLARITY Group at the McMaster University.4 This tool is used as a guide to assess studies for bias due to the selection of cohorts, assessment of prognostic and outcome variables, and length of follow-up.
Statistical analysis
The random-effects model was used to determine pooled estimates of sex-based differences for failure/instability rates and RTS rates. Meta-analysis of the previously mentioned validated outcomes scores was not performed because of heterogeneity of reported study outcomes. An odds ratio and 95% confidence interval (CI) were calculated for each outcome evaluated. Heterogeneity was examined using the I2 statistic.17 P < .05 was considered significant. R (version 4.0.2) was used for all statistical analyses.
Results
A total of 1412 studies were identified in the initial database search, of which 30 (2.1%) met inclusion criteria (Fig. 1). The characteristics of these studies are included in Table I. Of the 30 studies, 24 studies analyzed arthroscopic Bankart repair alone,1,2,6, 7, 8,11,14,15,20,22, 23, 24, 25,28,30, 31, 32,36, 37, 38, 39, 40, 41, 42 two studies compared arthroscopic Bankart and open Bankart repair,3,12 one study compared arthroscopic Bankart and open Latarjet procedure,43 one study compared open Bankart repair and open Latarjet,19 and two studies analyzed only the open Latarjet procedure.9,33
Figure 1.
Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram.
Table I.
Study characteristics.
| First author | Year published | Study design | Level of evidence | Sex |
Age∗, y | Procedure | Length of follow-up∗, mo | |
|---|---|---|---|---|---|---|---|---|
| Male | Female | |||||||
| Aboalata1 | 2017 | Case series | IV | 107 | 107 | 24.8 | Arthroscopic Bankart repair | — |
| Ahmed2 | 2012 | Prospective cohort | Prognostic I | 265 | 37 | 26.5 | Arthroscopic Bankart repair | 68.5 |
| Chan6 | 2019 | Retrospective case-control | IV | 119 | 12 | 26.8 | Arthroscopic Bankart repair | 24 |
| Cordasco7 | 2020 | Case series | IV | 48 | 19 | 17.5 | Arthroscopic Bankart repair | 42.72 |
| de Almeida Filho8 | 2012 | Case series | IV | 42 | 7 | 30 | Arthroscopic Bankart repair | 42.7 |
| Flinkkilä11 | 2010 | Case series | IV | 132 | 50 | 28 | Arthroscopic Bankart repair | 51 |
| Gartsman14 | 2000 | Case series | IV | 44 | 9 | 32 | Arthroscopic Bankart repair | 33 |
| Gigis15 | 2014 | Prospective cohort study | II | 24 | 14 | — | Arthroscopic Bankart repair | 204 |
| Kaipel20 | 2010 | Case series | IV | 24 | 12 | 30.8 | Arthroscopic Bankart repair | 58.65 |
| Locher22 | 2016 | Case series | IV | — | — | — | Arthroscopic Bankart repair | 22.4 |
| Loppini23 | 2019 | Retrospective case-control | III | 572 | 98 | 27 | Arthroscopic Bankart repair | 100.8 |
| Mahure24 | 2018 | Case series | IV | 4013 | 1706 | 24.9 | Arthroscopic Bankart repair | — |
| Martel25 | 2016 | Case series | IV | 43 | 4 | — | Arthroscopic Bankart repair | 33 |
| Nakagawa28 | 2017 | Retrospective cohort | III | 214 | 43 | — | Arthroscopic Bankart repair | 55 |
| Nakagawa29 | 2017 | Retrospective case-control | III | 110 | 13 | 18.3 | Arthroscopic Bankart repair | — |
| Ozturk31 | 2013 | Case series | IV | 42 | 11 | 19.5 | Arthroscopic Bankart repair | 27 |
| Panzram32 | 2020 | Case series | IV | 76 | 24 | 37 | Arthroscopic Bankart repair | 99.6 |
| Robinson36 | 2008 | Randomized controlled trial | Therapeutic I | 82 | 6 | — | Arthroscopic Bankart repair | — |
| Sommaire37 | 2012 | Retrospective cohort | III | 54 | 23 | 27.48 | Arthroscopic Bankart repair | 44.4 |
| Szyluk38 | 2015 | Case series | IV | 74 | 18 | 25.6 | Arthroscopic Bankart repair | 98.4 |
| Thal39 | 2007 | Case series | IV | 57 | 15 | 26.7 | Arthroscopic Bankart repair | — |
| Vermeulen40 | 2019 | Case series | IV | 112 | 35 | 30 | Arthroscopic Bankart repair | 75.6 |
| Yamamoto41 | 2019 | Retrospective cohort | III | 30 | 13 | 26 | Arthroscopic Bankart repair | 32 |
| Yian42 | 2020 | Retrospective cohort | III | 281 | 56 | — | Arthroscopic Bankart repair | 74.4 |
| Augustsson3 | 2012 | Prospective cohort | III | 24 | 7 | — | Arthroscopic Bankart repair | 84 |
| Open Bankart repair | ||||||||
| Flint12 | 2018 | Case series | IV | 56 | 3 | 19 | Arthoscopic Bankart repair | — |
| Open Bankart repair | ||||||||
| Zimmerman43 | 2016 | Retrospective cohort | Therapeutic III | 184 | 87 | 28.2 | Arthroscopic Bankart repair | — |
| 82 | 11 | 30.8 | Open Latarjet procedure | |||||
| Hovelius19 | 2011 | Retrospective case-control | III | 68 | 20 | 21.8 | Open Bankart repair | — |
| 82 | 15 | 22.7 | Open Latarjet procedure | |||||
| Domos9 | 2020 | Case series | IV | 26 | 19 | 15.7 | Open Latarjet procedure | 79.2 |
| Privitera33 | 2018 | Case series | IV | 64 | 9 | 25.8 | Open Latarjet procedure | 52 |
Patient demographics
The 30 studies represent 9829 patients; 74% male and 26% female among the studies that reported number of male and female patients. One study did not stratify the total number of patients according to sex but stratified the recurrence rate by sex.22 The mean age was not provided for every study but ranged from 15.7 ± 1 years to 37 ± 1 years among the 23 studies (8,777 patients) that reported mean age.1,2,6, 7, 8,11,20,23,24,30, 31, 32,37, 38, 39, 40, 41
Quality bias assessment
A quality bias analysis was completed using the Tools to Assess Risk of Bias in Cohort Studies, Case Control Studies, and Randomized Controlled Trials by the CLARITY Group at the McMaster University, and the results of these analyses are displayed in Table II. Of the studies included in this review, the levels of evidence were two level I studies, one level II study, nine level III studies, and eighteen level IV studies. Given that many of these studies were case series, there was a high level of bias associated with matching exposed and unexposed participants, as is indicated in Table II. However, the remainder of the bias analysis table indicates low levels of bias for the other categories of bias.
Table II.
Tools to assess risk of bias cohort studies.
| Study | Year | 1. Was selection of exposed and nonexposed cohorts drawn from the same population? | 2. Can we be confident in the assessment of exposure? | 3. Can we be confident that the outcome of interest was not present at the start of study? | 4. Did the study match exposed and unexposed for all variables that are associated with the outcome of interest or did the statistical analysis adjust for these prognostic variables? | 5. Can we be confident in the assessment of the presence or absence of prognostic factors? | 6. Can we be confident in the assessment of outcome? | 7. Was the follow-up of cohorts adequate? | 8. Were co-interventions similar between groups? |
|---|---|---|---|---|---|---|---|---|---|
| Aboalata et al1 | 2016 | N/A | Definitely yes | Definitely yes | Definitely no | Probably yes | Probably yes | Definitely yes | Probably yes |
| Ahmed et al2 | 2012 | N/A | Definitely yes | Definitely yes | Definitely no | Definitely yes | Probably yes | Definitely yes | Probably yes |
| Augustsson et al3 | 2012 | N/A | Definitely yes | Definitely yes | Definitely no | Probably yes | Probably yes | Definitely yes | Probably no |
| Cordasco et al7 | 2020 | N/A | Definitely yes | Definitely yes | Definitely no | Probably yes | Probably yes | Probably yes | Probably yes |
| de Almeida Filho et al8 | 2012 | N/A | Definitely yes | Definitely yes | Definitely no | Probably yes | Probably yes | Probably yes | Probably yes |
| Domos et al9 | 2020 | N/A | Definitely yes | Definitely yes | Definitely no | Definitely yes | Definitely yes | Probably yes | Definitely yes |
| Flinkkilä et al11 | 2010 | N/A | Definitely yes | Definitely yes | Definitely no | Definitely yes | Probably no | Probably yes | Probably no |
| Flint et al12 | 2018 | N/A | Definitely yes | Definitely yes | Definitely no | Definitely yes | Definitely yes | Probably yes | Definitely no |
| Gartsman et al14 | 2000 | N/A | Definitely yes | Definitely yes | Definitely no | Definitely yes | Probably yes | Probably yes | Definitely no |
| Gigis et al15 | 2014 | Probably yes | Definitely yes | Definitely yes | Probably no | Definitely yes | Probably yes | Probably yes | Probably yes |
| Kaipel et al20 | 2010 | N/A | Definitely yes | Definitely yes | Definitely no | Probably no | Probably yes | Probably yes | Definitely yes |
| Locher et al22 | 2016 | N/A | Definitely yes | Definitely yes | Definitely no | Definitely yes | Definitely yes | Probably no | Probably no |
| Mahure et al24 | 2018 | N/A | Definitely yes | Definitely yes | Definitely no | Definitely yes | Probably yes | Probably yes | Definitely yes |
| Martel et al25 | 2016 | N/A | Definitely yes | Definitely yes | Definitely no | Definitely yes | Probably yes | Probably no | Probably no |
| Nakagawa et al28 | 2017 | Probably yes | Definitely yes | Definitely yes | Probably yes | Probably yes | Probably no | Probably yes | Probably no |
| Ozturk et al31 | 2013 | N/A | Definitely yes | Definitely yes | Definitely no | Definitely yes | Definitely yes | Probably yes | Probably no |
| Panzram et al32 | 2020 | N/A | Definitely yes | Definitely yes | Definitely no | Probably yes | Probably yes | Definitely yes | Probably yes |
| Privitera et al33 | 2018 | N/A | Definitely yes | Definitely yes | Definitely no | Probably yes | Probably no | Probably yes | Probably yes |
| Sommaire et al37 | 2012 | N/A | Definitely yes | Definitely yes | Definitely no | Probably no | Probably yes | Probably yes | Definitely yes |
| Szyluk et al38 | 2015 | N/A | Definitely yes | Definitely yes | Definitely no | Definitely yes | Definitely yes | Definitely yes | Definitely yes |
| Open Bankart & Open Latarjet | N/A | Definitely yes | Definitely yes | Definitely no | Probably yes | Definitely yes | Probably yes | Defininitely yes | |
| Vermeulen et al40 | 2019 | N/A | Definitely yes | Definitely yes | Definitely no | Definitely yes | Probably yes | Definitely yes | Probably yes |
| Yamamoto et al41 | 2019 | Open Latarjet procedure | Definitely yes | Definitely yes | Definitely no | Probably yes | Definitely yes | Probably yes | Probably yes |
| Yian et al42 | 2020 | N/A | Definitely yes | Definitely yes | Definitely no | Definitely yes | Probably yes | Definitely yes | Probably yes |
| Zimmerman et al43 | 2016 | N/A | Definitely yes | Definitely yes | Definitely no | Probably no | Probably yes | Definitely yes | Probably yes |
| Case-control studies | ||||||
|---|---|---|---|---|---|---|
| Study | Year | 1. Can we be confident in the assessment of exposure? | 2. Can we be confident that cases had developed the outcome of interest and controls had not? | 3. Were the cases (those who were exposed and developed the outcome of interest) properly selected? | 4. Were the controls (those who were exposed and did not develop the outcome of interest) properly selected? | 5. Were cases and controls matched according to important prognostic variables or was statistical adjustment carried out for those variables? |
| Chan et al.6 | 2019 | Definitely yes | Definitely yes | Definitely yes | Definitely yes | Definitely no |
| Hovelius et al.19 | 2011 | Definitely yes | Probably yes | Probably yes | Probably yes | Definitely no |
| Loppini et al.23 | 2019 | Definitely yes | Definitely yes | Definitely yes | Definitely yes | Definitely no |
| Nakagawa et al.29 | 2017 | Definitely yes | Definitely yes | Definitely yes | Definitely yes | Definitely no |
| Randomized controlled trials | |||||||
|---|---|---|---|---|---|---|---|
| Study | Year | 1. Was the allocation sequence adequately generated? | 2. Was the allocation adequately concealed? | 3. Blinding: Was knowledge of the allocated interventions adequately prevented? | 4. Was loss to follow-up (missing outcome data) infrequent? | 5. Are reports of the study free of selective outcome reporting? | 6. Was the study apparently free of other problems that could put it at risk of bias? |
| Robinson et al.36 | 2008 | Definitely yes | Definitely yes | Definitely yes | Definitely yes | Definitely yes | Probably yes |
Functional outcomes
Instability recurrence, RTS, and apprehension were included in the meta-analysis. The definition of instability recurrence for each study is provided in Table III. Three studies defined instability recurrence as redislocation,1,8,15 11 studies defined it as redislocation or subluxation,2,6,11,12,30,31,36, 37, 38, 39, 40 two studies defined it as needing revision surgery for instability,7,24 five studies defined it as “recurrent instability” (with no additional clarification),23,25,28,32,42 one study defined it as redislocation or revision surgery,43 and one study defined it as revisions, recurrences, and/or subluxations.18
Table III.
Instability recurrence rate and definition of instability recurrence for arthroscopic Bankart repair, open Bankart repair, and open Latarjet procedure.
| Author | Procedure | Instability recurrence rate, n (%) |
Definition of failure/instability recurrence | ||
|---|---|---|---|---|---|
| Male | Female | ||||
| Arthroscopic Bankart | Aboalata et al1 | Arthroscopic Bankart repair | 22/107 (21) | 4/107 (11) | Redislocation |
| Ahmed et al2 | Arthroscopic Bankart repair | 37/265 (14) | 3/37 (8) | Redislocation or subluxation | |
| Chan et al6 | Arthroscopic Bankart repair | 28/119 (24) | 6/12 (50) | Redislocation or subluxation | |
| Cordasco et al7 | Arthroscopic Bankart repair | 4/48 (8) | 0/19 (0) | Revision surgery for instability | |
| de Almeida Filho et al8 | Arthroscopic Bankart repair | 8/42 (19) | 0/7 (0) | Redislocation | |
| Flinkkilä et al11 | Arthroscopic Bankart repair | 27/132 (20) | 6/50 (12) | Redislocation or subluxation | |
| Gigis et al15 | Arthroscopic Bankart repair | 3/24 (13) | 2/14 (14) | Redislocation | |
| Loppini et al23 | Arthroscopic Bankart repair | 100/572 (17) | 14/98 (14) | Recurrent instability | |
| Mahure et al24 | Arthroscopic Bankart repair | 340/4013 (9) | 121/1706 (7) | Revision surgery for instability | |
| Martel et al25 | Arthroscopic Bankart repair | 8/43 (19) | 1/4 (25) | Recurrent instability | |
| Nakagawa et al29 | Arthroscopic Bankart repair | 37/214 (17) | 5/43 (12) | Recurrent instability | |
| Nakagawa et al30 | Arthroscopic Bankart repair | 21/110 (19) | 2/13 (15) | Redislocation or subluxation | |
| Ozturk et al31 | Arthroscopic Bankart repair | 4/42 (10) | 1/11 (9) | Redislocation or subluxation | |
| Panzram et al32 | Arthroscopic Bankart repair | 16/76 (21) | 6/24 (25) | Recurrent instability | |
| Robinson et al36 | Arthroscopic Bankart repair | 19/82 (23) | 0/6 (0) | Redislocation or subluxation | |
| Sommaire et al37 | Arthroscopic Bankart repair | 9/54 (17) | 3/23 (13) | Redislocation or subluxation | |
| Szyluk et al38 | Arthroscopic Bankart repair | 6/74 (8) | 3/18 (17) | Redislocation or subluxation | |
| Thal et al39 | Arthroscopic Bankart repair | 5/57 (9) | 0/15 (0) | Redislocation or subluxation | |
| Vermeulen et al40 | Arthroscopic Bankart repair | 28/112 (25) | 5/35 (14) | Redislocation or subluxation | |
| Yian et al42 | Arthroscopic Bankart repair | 90/281 (32) | 12/56 (21) | Recurrent instability | |
| Zimmerman et al43 | Arthroscopic Bankart repair | 68/184 (37) | 25/87 (29) | Redislocation or revision surgery | |
| Arthroscopic and open Bankart | Flint et al12 | Arthoscopic Bankart repair | 17/57 (30) | 3/3 (100) | Redislocation or subluxation |
| Open Bankart repair | |||||
| Open Bankart and open Latarjet | Hovelius et al18 | Open Bankart repair | 32/150 (21) | 6/35 (17) | Revisions, recurrences, and/or subluxations |
| Open Latarjet procedure | |||||
Twenty-three studies were included in the instability recurrence analysis for all procedural categories (arthroscopic Bankart repair, open Bankart repair, and open Latarjet procedures), representing 6858 males and 2423 females (Fig. 2)1,2,6, 7, 8,11,12,15,18,23, 24, 25,28,29,31,32,35,37, 38, 39, 40,42,43 No significant difference was found in instability recurrence rate between males and females (risk ratio [RR] = 1.16; 95% CI = 0.85, 1.58; P = .3490). There was a significantly high level of heterogeneity among the studies (I2 = 71%).
Figure 2.
Instability recurrence for males and females for arthroscopic Bankart repair, open Bankart repair, and open Latarjet procedure.
A subgroup analysis of studies using only arthroscopic Bankart repair was performed and included 21 studies representing 6858 males and 2423 females (Fig. 3).1,2,6, 7, 8,11,15,23, 24, 25,28,29,31,32,35,37, 38, 39, 40,42,43 Males had a significantly higher rate of recurrence than females (RR = 1.25; 95% CI = 1.03, 1.52; P = .0239). Heterogeneity between studies was low and not significant (I2 = 18%).
Figure 3.
Instability recurrence analysis for males and females for arthroscopic Bankart repair.
We were unable to perform a separate analysis of instability recurrence for open Bankart repair and open Latarjet procedural groups due to insufficient data. Two studies12,18 using open Bankart repair and one study18 using open Latarjet procedure reported instability recurrence rates, but did not report separate instability recurrence rates for males and females. The overall recurrence rate (for males and females combined) was reported by each study; 8% and 30% in the two open Bankart repair studies12,18 and 11% in the open Latarjet procedure study.18
Three studies were included for the RTS analysis, representing 130 males and 34 females (Table IV, Fig. 4). Gigis et al did not state how RTS was determined for their study.15 Privitera et al defined RTS as returning to original sport at preinjury level or decreased level of competition.33 Ozturk et al reported RTS as return to preinjury level of sports activity or return to less competitive activities.31 The number of individuals who participated in contact and noncontact or limited-contact sports is also listed in Table IV. The classification of contact and noncontact or limited-contact sports comes from The American Academy of Pediatrics.34 No significant difference in RTS rate was found between males and females (RR = 0.98; 95% CI = 0.81, 1.18; I2 = 0%; P = .8110).
Table IV.
Return to sport according to sex, contact level, participation level, and definition of RTS.
| Author | Procedure | Athlete type, n (%) |
Participation level | Definition of RTS | RTS, n (%) |
|||
|---|---|---|---|---|---|---|---|---|
| Contact | Non-contact/Limited contact | Male | Female | |||||
| Gigis et al15 | Arthroscopic Bankart repair | 9 (33) | 18 (67) | Competitive level | -- | 17/24 (71) | 8/14 (57) | |
| Ozturk et al31 | Arthroscopic Bankart repair | 22 (42) | 31 (58) |
|
Return to preinjury level of sports activity or return to less competitive activities | 36/42 (86) | 10/11 (89) | |
| Privitera et al33 | Open Latarjet procedure | 64 (88) | 9 (12) |
|
Return to original sport at preinjury level or decreased level of competition | 40/64 (63) | 6/9 (67) | |
RTS, return to sport.
Figure 4.
Return-to-sport (RTS) analysis for males and females.
Postoperative rates of apprehension for males and females were reported in three studies and represented 74 males and 45 females (Fig. 5).9,15,20 Analysis of reported apprehension revealed no significant difference in the rate of apprehension between males and females (RR = 0.68; 95% CI = 0.37, 1.27; P = .2300). Significant heterogeneity was found between the studies (I2 = 79%).
Figure 5.
Apprehension analysis for males and females.
Outcome scores and physical examination findings were not included in the statistical meta-analysis because of significant heterogeneity in the results reported in each study, but outcomes scores are included in Table V. Table V contains male and female outcome scores for the shoulder functional assessment tools: Rowe, WOSI, DASH, SSV, SASF, ASES, and Constant-Murley. Only one study reported sex-stratified physical examination findings (maximum voluntary contraction, strength, and ROM), and as such, we have not included the data in this analysis.3
Table V.
Postoperative functional assessment scores.
| First author | Procedure | Rowe |
WOSI (%) |
WOSI (Raw) |
ASES |
Constant-Murley |
|||||
|---|---|---|---|---|---|---|---|---|---|---|---|
| Male | Female | Male | Female | Male | Female | Male | Female | Male | Female | ||
| Gartsman et al14 | Arthroscopic Bankart repair | 92 | 91 | — | — | — | — | — | — | — | — |
| Kaipel et al20 | Arthroscopic Bankart repair | — | — | — | — | — | — | — | — | 88 ± 2 | 79 ± 6 |
| Thal et al39 | Arthroscopic Bankart repair | 92.8 | 95.7 | — | — | — | — | 96 | 96 | — | — |
| Yamamoto et al41 | Arthroscopic Bankart repair | — | — | 70.9 ± 18.5 | 81 ± 20.4 | — | — | — | — | — | — |
| Augustsson et al3 | Arthroscopic Bankart repair | — | — | — | — | 231 ± 403.5 | 191 ± 103.25 | — | — | 89 ± 18.5 | 80 ± 3.75 |
| Augustsson et al3 | Open Bankart repair | ||||||||||
All averages are means.
WOSI, Western Ontario Shoulder Instability Index; DASH, Disabilities of the Arm, Shoulder, and Hand; SSV, Subjective Shoulder Value; SASF, Subjective Assessment of Shoulder Function; ASES, American Shoulder and Elbow Surgeons.
Discussion
In this systematic review and meta-analysis of anterior shoulder surgical stabilization postoperative outcomes between males and females, we analyzed instability recurrence, RTS, and apprehension. We found males to have a higher rate of instability recurrence than females after arthroscopic Bankart repair, which is consistent with what was previously reported in the literature.2 Arthroscopic Bankart repair was the only procedural category that could be analyzed individually for instability recurrence in the meta-analysis because of the limited availability of studies and sex-specific data for open Bankart repair and open Latarjet procedure. An analysis of instability recurrence for all procedural categories grouped together was able to be performed, and there was no significant difference between males and females when including the open Bankart repair and open Latarjet procedure. We did not find a significant difference between males and females in terms of apprehension or RTS rates for arthroscopic Bankart repair and open Latarjet procedure studies. One possible explanation for the lack of significant difference when all procedural categories were grouped together is the inclusion of the open Latarjet procedure, which has been found to have better outcomes for contact athletes.26 Although none of the studies of contact vs. noncontact athletes reported the percentage of males and females within each category (contact vs. noncontact), if more males were included in the contact sports category, it would follow that they would have better outcomes when undergoing the open Latarjet procedure.
Instability recurrence was defined differently across the 23 studies that reported this outcome, making interstudy analysis less reliable and generalizable. Three studies defined instability recurrence as redislocation,1,8,15 11 studies defined it as redislocation or subluxation,2,6,11,12,30,31,36, 37, 38, 39, 40 two studies defined it as needing revision surgery for instability,7,24 five studies defined it as “recurrent instability”,23,25,28,32,42 one study defined it as redislocation or revision surgery,43 and one study defined it as revisions, recurrences, and/or subluxations.18 These varying definitions of recurrent instability create a wide umbrella under which we include various types of failure after surgery and make it difficult to determine the true success and failure rates of procedures. These definitions of recurrence also do not address failure of the procedure in terms beyond instability—such as return to activity—which raises questions about the value of the definition of recurrence or failure. In order to better assess failure/instability recurrence in future studies, a standard definition for failure/instability recurrence should be established and used when assessing patients during the follow-up period. It would also add to the strength of these studies to subcategorize surgical procedures based on intraoperative variations to ensure equivalent procedures are being compared.
The RTS and apprehension analyses only included three studies, representing a small sample of patients. The limited number of studies and participants increases the risk for bias. In addition, the definition of RTS was only reported in two of these studies, and the definition varied between the two.31,33 Privitera et al33 considered RTS as patients returning to their original sport, while Ozturk et al31 considered RTS as returning to any sports activity. These studies also did not clearly differentiate levels of activity (contact vs. noncontact) for males and females, making it difficult to compare males and females in terms of RTS. An additional consideration with the apprehension analysis is the lack of explicit definition for apprehension as well as the variability in apprehension determination based on the examiner. All these factors combined elucidate a need for more accurate and consistent reporting of RTS and apprehension for the sake of future studies.
This review contributes to the literature in several ways. Our analysis suggests that males have higher rates of recurrent instability after arthroscopic Bankart repair, but it is unknown whether open Bankart repair has better outcomes for males because there are currently not enough studies available for sex-specific analysis of this procedure. This calls attention to the need for more studies of open Bankart repair that take patient sex into consideration when assessing outcomes; however, open Bankart repair has recently been shown to have less favorable outcomes overall than arthroscopic Bankart repair and may fall out of favor as a result.13 Our study also highlights the need for consistent definitions of failure/recurrence and RTS. The studies included in our analysis defined these two outcomes in a variety of ways, making it difficult to compare these outcomes across studies. Our proposed definition of failure is more nuanced than the current definition. Rather than defining failure as an overarching category, we propose classifying every patient during the follow-up period in terms of laxity and apprehension assessed on physical examination, along with patient report of the number of episodes of redislocation and subluxation (reported separately). If all studies reported each of these outcomes separately, we could analyze them across studies to better identify which procedures produce better outcomes. In addition, for studies with patients who participated in sports before surgery, we propose categorizing every athlete as participating in either a contact or noncontact sport before surgery and documenting if or when the patient RTS, and whether they returned to contact or noncontact sports. Using our proposed definitions for failure/recurrence and RTS would allow for more reliable and generalizable analyses of these outcomes after shoulder stabilization procedures. The greatest limitation to this study was the inclusion of mostly level IV studies (18 out of 30 studies), which increased the risk of inherent bias. In addition, females represented approximately 24% of the patients in the analysis, which incorporated bias and decreased the generalizability of the studies. This trend is present in many sports medicine–related studies but becomes more noticeable and problematic in sex-specific studies that would benefit from more equal ratios of males and females. Finally, this study was limited by the lack of sex-stratified outcomes within studies and resultant inability to compare these data between studies. Furthermore, outcomes within these studies were heterogeneous. Seven different functional assessment tools were used, and many studies did not use the same tools, resulting in data that could not be analyzed between studies.
Conclusion
For patients who underwent arthroscopic Bankart repair for anterior shoulder stabilization, recurrent rates of instability were significantly higher for males than for females. When open Bankart and Latarjet procedures were included, there was no difference. No difference was seen between males and females after arthroscopic Bankart repair or open Latarjet procedures with regard to RTS or apprehension.
Disclaimers
Funding: No funding was disclosed by the authors.
Conflicts of interest: Dr. Wolf reports receiving personal fees from Medtronic outside the submitted work. Dr. Vopat reports receiving personal fees from DePuy and research support from Stryker, both outside the submitted work. The other authors, their immediate families, and any research foundation with which they are affiliated have not received any financial payments or other benefits from any commercial entity related to the subject of this article.
Footnotes
Institutional review board approval was not required for this systematic review.
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