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. Author manuscript; available in PMC: 2019 Apr 29.
Published in final edited form as: J ISAKOS. 2018 Nov 10;4(1):33–40. doi: 10.1136/jisakos-2018-000224

High rate of return to sport in adolescent athletes following anterior shoulder stabilisation: a systematic review

Connor S Kasik 1, Michael R Rosen 1, Michael G Saper 2, Robert L Zondervan 3
PMCID: PMC6487304  NIHMSID: NIHMS1024505  PMID: 31044093

Abstract

Importance

Traumatic anterior shoulder instability remains common for the adolescent athletes.

Aim or objective

To perform a systematic review on the outcomes and return to sport (RTS) following Bankart repair in adolescent athletes.

Evidence review

A systematic review using the Preferred Reporting Items for Systematic Review and Meta-Analysis guidelines was conducted of studies reporting outcomes following open and/or arthroscopic Bankart repair using modern suture anchors following traumatic anterior shoulder dislocations in adolescent patients (ages 10–19 years). Quality assessment was evaluated with ROBINS-I and MINORS instruments. The outcomes analysed included RTS, timetable to unrestricted activity, recurrent instability and revision surgery.

Findings

This systematic review identified 11 studies comprising 461 adolescent athletes with a mean age of 15.7 years (range, 11–19 years) and an average follow-up of 48.8 months (range, 22–85.2 months). A total of 392 patients (400 shoulders) underwent arthroscopic Bankart repair, while the remaining 69 patients (69 shoulders) underwent an open procedure. The average MINORS score was 9.6 for non-comparative studies and 17 for comparative studies. ROBINS-I revealed six studies to have a moderate risk of bias, while the remaining five studies presented serious risk of bias. There was an overall 81.5% rate of RTS to preinjury levels of athletic competition at an average of 5.3 months following Bankart repair for traumatic anterior shoulder instability. The overall total mean incidence of recurrent instability was 18.5%, while the mean incidence of revision surgery was 12.1%. Contact athletes had a 31.1% and 13% rate of recurrence and revision surgery, respectively. In comparison, collision athletes were shown to have a 10.4% and 1.4% incidence of recurrent instability and revision surgery, respectively.

Conclusions and relevance

Adolescent athletes who undergo Bankart repair for traumatic anterior shoulder instability have an 81.5% rate of RTS to preinjury levels of play at an average of 5 months following surgery. The overall total mean incidence of recurrent instability in the adolescent population is 18.5%, while the mean incidence of revision surgery is 12.1%. The results of anterior shoulder stabilisation in contact athletes is much less predictable, with higher reported rates of recurrent instability and revision surgery.

Level of evidence

Level IV.

INTRODUCTION

Traumatic anterior shoulder dislocations represent more than 90% of shoulder dislocations and are commonly seen in adolescents participating in collision or contact sports.1–6 Initial non-operative treatment can lead to high rates of recurrent instability, with a recent systematic review reporting a 71% rate in the adolescent population.7 The high rate of recurrent dislocation following non-operative treatment has led to an increase of surgical stabilisation procedures performed for the young active patients following traumatic anterior shoulder instability. Surgical stabilisation of acute traumatic shoulder dislocations in adolescent athletes decreases the risk of recurrent shoulder instability when compared with non-operative therapy.1,2,7–9 Bankart repair is currently the treatment of choice with >90% of surgeons choosing the Bankart procedure as initial repair for recurrent instability.10

Although the historical rates of recurrent instability following open and arthroscopic anterior shoulder stabilisation have been previously reported in heterogeneous patient populations, less information is available in the adolescent population.11–19 With increasing student participation in high school athletics over the past decade, anterior shoulder instability continues to become more prevalent in athletes.20 Recurrent shoulder instability can affect functional activities and quality of life in addition to influencing athletic sporting participation.21–23 Continued participation in sporting activity can lead to significant morbidity such as recurrent instability and an increased risk of developing glenohumeral osteoarthritis, leading to physical activity modifications and decline in physical capacity.7,24–26 Both open and arthroscopic anterior shoulder stabilisation surgery have proven to be effective surgical interventions to prevent recurrence while allowing athletes to return to sport (RTS). However, there have been few studies comparing RTS and clinical outcomes following arthroscopic and open Bankart repairs strictly in the adolescent population. There is also a lack of standardisation of outcome reporting following surgical Bankart repair in this age group.27 Consequently, it is difficult to draw conclusions relative to the efficacy of the surgical treatment for traumatic anterior shoulder instability.

The ability to return to athletic competition also depends on the relative risk of injury that is present within each individual sport, with collision and contact athletes historically yielding less favourable outcomes in heterogeneous patient populations.2,4,14,18,19,28,29 Only a few studies have reported the rates of return to preinjury levels of athletic competition following surgical Bankart repair in the adolescent population.1,2,9,28,30–32 There is a further lack of information evaluating the risk of recurrence after open and arthroscopic shoulder stabilisation in the collision and contact adolescent athlete population.28 Additionally, the timetable and surgeon-specific functional criteria required prior to unrestricted return to athletic competition in this age group has been sparsely reported in the literature.33,34 This is important in order to provide general guidelines to aid in determining the appropriate timelines to allow an athlete to unrestricted activity.

The purpose of this study is to perform a systematic review and a meta-analysis on the outcomes and RTS following arthroscopic and open Bankart repair in adolescent athletes participating in collision and contact sports. We sought to review the current literature to (1) report the rates of RTS in the adolescent population, (2) evaluate the timetable and surgeon-specific parameters required prior to unrestricted RTS, (3) analyse the risk of postoperative recurrent instability, (4) compare the recurrence rate between collision and contact athletes, and (5) calculate the overall risk of revision surgery in the adolescent population. We hypothesised that RTS rates in adolescents undergoing anterior shoulder stabilisation surgery would be similar to the adult counterparts. Furthermore, we hypothesised that there would be higher rates of recurrent instability and revision surgery in collision and contact athletes.

METHODS

Literature search strategy

This study was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.35 A comprehensive literature search was conducted on 2 September 2017 of the electronic databases Medline, EMBASE, PubMed and EBSCO (CINAHL, SPORTDiscus) for clinical studies reporting outcomes following arthroscopic or open Bankart repair for anterior shoulder instability in an adolescent population. There was no time restriction. The search strategy combined the following terms: adolescent, young adult, Bankart lesion, joint instability, recurrent dislocation, recurrent shoulder dislocation, shoulder dislocation, subluxation and surgery. Two senior orthopaedic residents (CSK and MRR) independently screened abstracts for relevant articles. Full texts were reviewed when a decision regarding inclusion or exclusion could not be made from the abstract alone. The reference lists of the included studies and recent review articles were also reviewed to identify any additional relevant studies.

Selection criteria

Studies meeting the following inclusion criteria were included in the review: (1) clinical studies reporting outcomes after arthroscopic or open Bankart repair in adolescent patients (ages 10–19 years, consistent with WHO’s definition of adolescence),36 (2) studies involving patients with unidirectional anterior instability pattern following a traumatic shoulder dislocation, (3) recurrent anterior shoulder instability following an initial traumatic event, (4) no glenoid bone loss and (5) studies with minimum of 1 year’s follow-up. Exclusion criteria were as follows: (1) non–English-language studies; (2) abstract-only publications, review articles, technical notes, basic science, case reports and expert opinions; (3) studies containing previously published data; (4) studies with no age specified or populations with an age range that exceeded 19 years (eg, 14–23 years); (5) studies including patients with posterior and/or multidirectional instability; and (6) any concomitant bony procedures performed.

Data extraction

Two investigators (CSK and MRR) independently collected all relevant information from the included studies and recorded the extracted data in Microsoft Office 365—Excel (V.1710; Microsoft, Redmond, Washington, USA). Demographic information included title, author, year of publication, study design, level of evidence, sample size and type of operative procedure (arthroscopic vs open). The means and ranges were collected regarding number of patients, age and follow-up. In addition, all major outcome measures reported were extracted and recorded including rates of RTS, recurrent instability and revision surgery. Recurrent instability was defined as any dislocation or subluxation event that occurred following surgery. A dislocation was defined as any traumatic instability event requiring manual reduction, while subluxation was defined as a feeling of transient instability but not requiring reduction. If a patient had contralateral traumatic anterior shoulder dislocations that were treated with surgical Bankart repair, this was considered as two separate outcomes. Revision surgery was defined as any additional anterior shoulder stabilisation procedure performed after the index surgery. Any information regarding specific sporting categorisation and classification, timetable to unrestricted RTS following surgery and surgeon-specific objective criteria required prior to releasing an athlete to unrestricted activity was also recorded. As definitions for collision and contact athletes differ between included studies, the classification established by the Committee on Sports Medicine and Fitness of the American Academy of Paediatrics was used as referenced in table 1.37 Under this classification system, sports are categorised according to the amount of contact and relative risk of an acute injury. The specific indications of each author performing Bankart repair is listed in figure 2 under the inclusion and exclusion criteria of each listed study. Additionally, the indication for arthroscopic versus open repair was based on the presence or absence of repairable anteroinferior labrum at the time of arthroscopic examination.

Table 1.

Classification of sports participation

Classification of sports by contact*
Collision Contact Limited contact
Football Basketball Baseball
Rugby Soccer Softball
Lacrosse Wrestling Volleyball
Ice hockey Gymnastics Bicycling
Martial arts
Water polo
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*

According to the American Academy of Paediatrics Committee of Sports Medicine and Fitness.

Figure 2.

Figure 2

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Study characteristics and mean values for the group of cited studies.

Quality assessment

The methodological quality and risk of bias of the included studies were evaluated by two senior orthopaedic residents (CSK and MRR) using the Risk of Bias in Non-randomized Studies – of Intervention (ROBINS-I) and Methodological Index for Non-Randomized Studies (MINORS) instruments.38,39 The ROBINS-I tool provides a detailed framework for the assessment of risk of bias in non-randomised studies. Each domain is determined to exhibit low, moderate, serious or critical risk of bias. Low risk indicates that a study is ‘comparable to a well-performed randomised trial,’ moderate risk indicates the study is ‘sound for a non-randomised study,’ serious risk indicates the presence of ‘important problems’ while critical risk indicates the study is ‘too problematic to provide any useful evidence on the effects of intervention’. MINORS is a validated scoring instrument to appraise non-randomised studies. There is a total of 12 items, with each criterion given a score of 0, 1 or 2, with maximum scores of 16 and 24 for non-comparative and comparative studies, respectively. The level of evidence was determined based on the Oxford Centre for Evidence-Based Medicine’s Levels of Evidence Scale.40 Disagreements between the two reviewers were resolved by discussion.

Statistical analysis

Means and ranges were calculated for continuous variables (eg, age) extracted from the included studies. Categorical variables (eg, sport) were expressed as a number and percentage. If a study did not report on a specific statistic, then it was not included in that calculation. All episodes of postoperative re-dislocations and subluxations were summed to calculate the overall rate of recurrent instability for a study. All patients undergoing a revision procedure on the injured shoulder were added to calculate the total rate of revision surgery. If not provided by the authors, risks were calculated by using the number of occurrences of an event divided by the number of patients in the population. Review Manager V.5.3 used for the meta-analysis and generation of Forest plots.41 ORs with a 95% CI were used to summarise the effect of independent variables (ie, procedure type) on outcomes (ie, instability and reoperation). Heterogeneity of the included study data was assessed using a X2 test and the Higgins I2 value was used to estimate the percentage of total variation across studies due to heterogeneity rather than to chance. For studies that did not report comparisons between open and arthroscopic procedures, data were pooled and descriptive statistics were reported. Absolute risk was calculated using pooled data for recurrent instability and reoperation. Statistical significance was set at p value ≤0.05. All data were tabulated in Microsoft Office 365—Excel (V.1710) and analyses conducted using open-source.41

RESULTS

The literature search generated 1043 relevant abstracts. A total of 353 duplicates were removed. Thirty-nine remained after applying inclusion criteria. Cross-referencing resulted in 34 additional articles that were screened. Following full-text screening of the 73 articles, 11 articles met the inclusion criteria and were included for final analysis (figure 1).

Figure 1.

Figure 1

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ROBINS-I risk of bias assessment.

The details of the ROBINS-I risk of bias assessment for each study is reported in figure 1. Characteristics of the selected studies are presented in figure 2 along with the MINORS score used for quality appraisal. All studies were classified by their level of evidence according to the Oxford Centre for Evidence-based Medicine’s Level of Evidence.42 There were a total of six level IV studies, four level III studies and one level II study included in this review. Six studies were found to have an overall moderate risk of bias under the ROBINS-I instrument, while the remaining five studies had serious risk of bias. The average MINORS score for the non-comparative studies was 9.6 (range, 8–12), whereas the average score for the comparative studies was 17 (range, 14–19).

All included articles were published between 2000 and 2017. Of the studies, six were conducted in the USA and two in Italy. The remaining studies were conducted in the UK, Germany and Greece. A total of 461 patients (469 shoulders) were included with a mean age of 15.7 years (range, 11–19 years). There was a total of 391 men and 70 women included in the study. The average number of patients in each study was 57 (range, 4–99). The mean follow-up for the group was 48.8 months (range, 22–85.2 months). Of the 11 papers included, six studies used solely the arthroscopic Bankart repair, one study used solely the open Bankart repair and four studies employed a combination of the two procedures. A total of 392 patients (400 shoulders) underwent arthroscopic Bankart repair, while the remaining 69 patients (69 shoulders) underwent an open procedure. The overall summary of outcomes and RTS timetable for the study cohorts are reported in figure 3.

Figure 3.

Figure 3

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Summary of outcomes and return to sport timetable for the study cohort.

Return to sport

The overall RTS to any level of athletic play following surgical stabilisation of traumatic anterior shoulder instability in the adolescent population was 93%. There was an 81.5% overall rate of RTS to preinjury levels of athletic competition. Of the remaining athletes unable to return to preinjury levels, 11.5% were able to return to a lower level of competition, while the remaining 7% were unable to return to any athletic competition. There was an overall lower rate of RTS to preinjury levels following arthroscopic Bankart repair (79.8%) when compared with open Bankart repair (100%). The overall RTS was reported in a total of eight studies.1,2,9,28,30–32,43 All eight of these studies reported on the athlete’s ability to return to a preinjury level of competition, decreased level or the inability to return to athletics. Five of these studies listed specific sports classification under the categories of collision, contact, limited-contact or non-contact athletes.1,2,28,30,32 There was a total of seven studies listing a specific timetable from surgery for unrestricted RTS, with the average number of months reported being 5.3 months (range, 3–10 months).1,2,9,28,30–32 Six out of the 11 studies cited an absolute number of months after which an athlete was allowed to return to unrestricted activity.1,2,9,28,30,32 One study did not report an absolute number, but rather cited a range of time in which athletes were allowed to return.31 The most commonly reported timetable for return to unrestricted participation was 5 months following surgery. Surgeon-specific functional parameters required prior to release to unrestricted athletic competition was cited in three out of the seven studies reporting RTS data.2,28,30 The functional parameters in these studies included range of motion, shoulder muscle strength and endurance as dictated by normal preoperative levels or comparison with the contralateral shoulder.

Recurrent instability

All of the included studies included recurrence as an outcome measure. Despite this, there was a disparity among the studies regarding definition of recurrent shoulder instability. Six studies1,2,9,30,43,44 reported recurrence as including both dislocations and subluxations, while the remaining five studies28,31,32,34,45 included solely repeat episodes of shoulder dislocation that required manual reduction. The overall total mean incidence of recurrent instability in the adolescent population was 18.5%. The rates reported in the included studies ranged from 0% to 31.1%. Recurrence rates following arthroscopic Bankart repair ranged between 0% and 31.1%, while reported ranges of recurrence following open Bankart repair were between 0% and 14%. The recurrent rate following arthroscopic Bankart repair was 19.8%. This is in comparison with open repair, which results in an 8.7% rate of recurrence.

Revision surgery

The rate of revision surgery reported ranged between 0% and 18.2%. The reported rates of revision surgery following arthroscopic Bankart repair (range, 0% to 18.1%) were similar to open Bankart repair (range, 0% to 18.2%). The overall mean incidence of revision surgery was 12.1% following Bankart repair for traumatic anterior shoulder instability. Revision surgery was required in 12.8% and 7.7% of arthroscopic and open Bankart repairs, respectively.

Collision and contact athletes

Collision and contact athletes had the highest reported rates of recurrent instability among the five studies that included these data.1,2,28,30,32 Collision athletes had reported overall rates of recurrence ranging from 0% to 44.4%. Contact athletes had similar results ranging between 0% and 43.5%. Four of these studies were arthroscopic in nature, and recurrent instability rates seen after arthroscopic Bankart repair were similar between collision (range, 4.2% to 44.4%) and contact athletes (range, 0% to 43.5%).1,2,28,30 The one study involving open Bankart repair reported a 0% recurrence rate in both collision and contact athletes.32 However, contact athletes had the overall highest pooled risk for recurrence, with a mean recurrent instability rate of 31.1%. Arthroscopic repair resulted in a 35.9% risk of recurrence in contact athletes. This is in comparison with open repair, which reported a 0% recurrent instability rate in contact athletes. Collision athletes demonstrated an overall 10.4% mean incidence of recurrence. Arthroscopic repair resulted in a 13.8% risk of recurrence in collision athletes. This is in comparison with open repair, which reported a 0% recurrent instability rate in collision athletes.

There were a total of four studies that reported revision surgery events in collision and contact athletes.1,2,28,32 Three of these studies were arthroscopic in nature.1,2,28 The overall highest incidence of revision surgery occurred with contact athletes (13%). Collision athletes had a 1.4% rate of revision surgery. The reported ranges of revision surgery following arthroscopic Bankart repair was higher in contact athletes (range, 0% to 40%) as compared with collision athletes (range, 0% to 8.3%). The overall mean incidence of revision surgery following arthroscopic Bankart repair in collision athletes is 2%. This is in contrast to contact athletes, which have an average incidence of 18.8% following arthroscopic repair. The one study involving open Bankart repair reported a 0% rate of revision surgery in both collision and contact athletes.32 The lack of comparative studies between collision and contact athletes precluded a formal meta-analysis.

DISCUSSION

This systematic review summarises the current literature regarding outcomes and RTS in adolescent athletes following anterior shoulder stabilisation and confirms the hypothesis of the study that there are higher rates of recurrent instability and revision surgery in collision and contact athletes. However, due to the relatively small number of included studies meeting the inclusion criteria, it was not possible to reach any statistical significance and definitive conclusion regarding appropriate management of traumatic anterior shoulder instability in adolescent patients. Moreover, the heterogeneity of the included studies and, subsequently, low methodological quality seriously affect the level of evidence and strength of recommendation of the present study.

The principal findings of this study suggest that adolescents have a high rate of RTS following anterior shoulder stabilisation for traumatic instability. Overall, Bankart repair resulted in an 81.5% rate of RTS to preinjury levels of play at an average of 5 months following surgery. Both open and arthroscopic Bankart repairs are effective surgical options with similar overall reported rates of recurrent instability and revision surgery. However, the results are much less predictable in collision and contact athletes, with higher reported rates of both recurrence and revision surgery. There was also under-reporting of surgeon-specific rehabilitation timetables and functional parameters required prior to release to unrestricted sporting activity.

Our study revealed an 81.5% overall rate of RTS to preinjury levels of athletic competition after surgical stabilisation of traumatic anterior shoulder instability in the adolescent population. Of the remaining athletes unable to return to preinjury levels, 11.5% were able to return to a lower level of competition, while the remaining 7% were unable to return to any athletic competition. The overall RTS to any level of athletic play was 93%. There was an overall lower rate of RTS to preinjury levels following arthroscopic Bankart repair (79.8%) when compared with open Bankart repair (100%). However, this difference is due to the small sample size of studies reporting RTS data in open (n=21) and arthroscopic Bankart repair (n=240). This contrasts with a recent systematic review performed in a heterogeneous adult patient population (age 14–65) which noted a significant difference in rate of RTS to preinjury levels when comparing arthroscopic (74%) versus open (89%) Bankart repair.46 These data suggest that arthroscopic and open Bankart repair have favourable outcomes, which are similar to their adult counterparts. Further, failure of a patient to return to the same preinjury level of sport does not necessarily constitute a poor outcome. It has been shown that subjective and psychosocial factors can contribute to a patient’s decision to RTS. This includes fear of re-dislocation, psychological competing interests, social support and competing priorities.22,47,48 Some patients choose not to RTS for reasons unrelated to their function or symptoms, and thus RTS as an outcome may not be appropriate for all patients.22

Recurrent shoulder instability following arthroscopic Bankart repair has known risk factors including younger age, male sex, glenoid bone loss, presence of an engaging Hill-Sachs lesion, shoulder hyperlaxity, participation in collision or contact sports, forced-overhead athletes, increased time to initial surgery, number of preoperative dislocations and use of ≤3 suture anchors.2,17,18,21,49–58 Arthroscopic advances have led to a shift of increasing arthroscopic repair compared with open Bankart repair despite the higher recurrence rate in the adolescent athlete.1,9,12,59,60 The failure rate following arthroscopic Bankart repair in the adolescent population has been documented at 10.3%–37.5%.1,2,7,9,17,28,30,31,34,43–45 Recently, some have suggested that open Bankart repair is a more reliable operation for young athletes involved in contact sports as results have shown lower re-dislocation rates after open procedures (14%) versus arthroscopic repairs (25%).2,18,56,60–64 Randelli et al51 looked at the preoperative risks factors for recurrent instability after arthroscopic repair and recommended that open stabilisation be performed in young (<22 years of age), high-demand male athletes. The overall mean incidence of recurrent instability following Bankart repair in our study was 18.5%. Recurrent instability occurred in 19.8% of arthroscopic Bankart repairs, compared with 8.7% of open repairs. When comparing athletic subgroups, the highest incidence for recurrence occurred in contact athletes with a mean recurrent instability rate of 31.1%. This was followed by a recurrence rate of 10.4% in collision athletes. These results are similar to the higher recurrent instability risk that has been historically seen in heterogeneous athletic patient populations participating in collision and contact sports.11–16,18,19,56,62,65,66 However, the reasons for a lower recurrence rate seen in collision athletes compared with contact athletes are unclear. One difference may be due to the lack of a strict definition of instability among included studies. There was variation in defining an episode of recurrence among the included studies, with definitions falling along a spectrum of apprehension to subluxations to dislocations. The variability in defining an episode of recurrence among studies can affect the clinical outcome measurement data. Another potential explanation could be the overhead athlete. More sports requiring overhead motion are classified under the contact athlete category, which could possibly lead to increased recurrence rates.

Recurrent instability in young patients often necessitates revision anterior shoulder stabilisation surgery, the results of which are mostly unknown in the adolescent population. Because adolescents have an increased risk of recurrence, analysis of postoperative failure rates and risk factors of re-operation is important. Our systematic review yielded a 12.1% mean incidence of revision surgery following surgical Bankart repair for traumatic anterior shoulder instability in the adolescent population. The rate of revision surgery following arthroscopic Bankart repair was 12.8%, compared with a 7.7% rate following open Bankart repair. There are a variety of confounding factors that contribute to this revision surgery rate. Increased functional sporting requirements such as being overhead or collision/ contact athletes, re-entering high-risk physical activities too early and ambitions to participate in next-level collegiate athletics may contribute to the increased risk.1,45 The higher overall rate of recurrent instability (18.5%) compared with revision surgery (12.1%) indicates that some athletes were able to rehabilitate their shoulders following recurrent instability episodes. On the other hand, the lower rate could also indicate non-compliance with postoperative rehabilitation process, changing focus to another less demanding sport or shifting of prioritisation away from sports.1,22,45

The timing of unrestricted athletic competition following open or arthroscopic Bankart repair varies among treating surgeons. In addition, few studies have reported specific functional sport-specific RTS guidelines and parameters following Bankart surgery in athletes.67 Standardisation of criteria on which surgeons base their recommendations to release athletes to unrestricted RTS is important to optimise outcomes. Our systematic review yielded considerable variation in expected timelines to unrestricted RTS, with only seven of the included studies reporting specific timetable from surgery criterion. In studies that reported this outcome, the average timing from surgery to unrestricted RTS was 5.3 months (range, 3–10 months). These results are similar to a recent systematic review performed in the adult population, which reported 6 months as the most commonly cited timetable prior to release to full activity.67 Besides chronological timing, other functional parameters required prior to RTS were only specifically stated in three studies.2,28,30 The functional parameters listed in all these studies included range of motion, shoulder muscle strength and endurance as dictated by normal preoperative levels or comparison to the contralateral shoulder. This further emphasises the need for reporting postoperative protocols and sport-related indicators to make decision-making reproducible.67,68 There was also no reporting difference seen in time to full unrestricted RTS with regards to arthroscopic versus open Bankart repairs. Further studies need to be conducted regarding sport-specific postoperative rehabilitation regimens, RTS timetables and a functionally based checklist with resultant effect on long-term shoulder outcomes.67,68

Limitations

The authors acknowledge some limitations to the present systematic review. As with any systematic review, it is possible that relevant studies may have not been identified with our search criteria. This review looked solely at the studies published in the English language and, as such, may contribute to the level of publication bias. The literature review identified only 11 studies meeting our inclusion criteria, demonstrating the currently limited published evidence regarding outcomes of Bankart repair in the adolescent population. This systematic review included level of evidence III and IV studies, with only three comparative studies meeting our inclusion criteria. There was no Level 1 evidence available. The heterogeneity of these included studies leads to the potential for confounding factors and bias. There were also a very small number of studies reporting on open Bankart repair. Furthermore, surgeon-specific indications for performing an arthroscopic or open Bankart repair may have affected the results in the included studies. Another important limitation is the high risk of bias in the study domains. The lowest level of overall bias observed using the ROBINS-I risk of bias assessment was moderate in nature, with a total of six studies included under this category. The remaining five studies were found to have an overall serious risk of bias, indicating the presence of important problems especially in the confounding domain. Future studies should be prospective in nature and use a longitudinal prospective cohort design to determine predictors of outcome.

CONCLUSION

Adolescent athletes who undergo Bankart repair for traumatic anterior shoulder instability have an 81.5% rate of RTS to preinjury levels of play at an average of 5 months following surgery. The overall total mean incidence of recurrent instability in the adolescent population is 18.5%, while the mean incidence of revision surgery is 12.1%. The results of anterior shoulder stabilisation in contact athletes is much less predictable, with higher reported rates of recurrent instability and revision surgery.

What is already known.

  • The historical rates of recurrent instability following open and arthroscopic anterior shoulder stabilisation in a heterogeneous adult population are well known; however, there have been few studies comparing return to sport (RTS) and clinical outcomes following anterior shoulder stabilisation strictly in the adolescent population.

  • There is a further lack of information evaluating outcomes in the collision and contact adolescent athlete population, and the efficacy of various treatment options has still to be determined.

What are the new findings.

  • There is an 81.5% rate of RTS to preinjury levels of play following anterior shoulder stabilisation in the adolescent population at an average of 5 months following surgery.

  • Arthroscopic Bankart repair results in an 89.2% rate of RTS to any level of play, with 79.8% of patients able to return to preinjury levels of competition.

  • The mean incidence of recurrent instability following arthroscopic Bankart repair is 19.8%, while the overall risk of requiring a secondary revision anterior shoulder stabilisation is 12.8%.

  • Contact athletes have a 31.1% and 13% rate of recurrent instability and revision surgery, respectively.

  • Collision athletes have a 10.4% and 1.4% incidence of recurrent instability and revision surgery, respectively.

Acknowledgments

Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

Footnotes

Competing interests None declared.

Patient consent Not required.

Provenance and peer review Not commissioned; externally peer reviewed.

Data sharing statement The corresponding author will share unpublished data on request, subject to various conditions.

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