Return to sports, functional outcomes, and recurrences after arthroscopic Bankart repair in soccer players

Abstract

Background

There is a shortage of relevant reports about the results obtained after shoulder stabilization in soccer players. Therefore, this retrospective study aims to report return to sports, functional outcomes, and recurrences after arthroscopic Bankart repair in soccer players.

Methods

A total of 156 soccer players were treated for anterior shoulder instability at a single institution between 2008 and 2017. The Rowe score and Athletic Shoulder Outcome Scoring System were used to assess functional outcomes. Return to sport and recurrence rates were also evaluated.

Results

The Rowe and Athletic Shoulder Outcome Scoring System scores showed statistical improvement after surgery (P < .001). Overall, 148 soccer players (94.8%) returned to sports, and 122 (78.2%) returned to the same level. The mean time to return to sport was 4.8 months. The recurrence rate was 5.2%.

Discussion

Soccer players who underwent an arthroscopic isolated Bankart repair for anterior glenohumeral instability have shown remarkable outcomes, with most of the patients returning to sports, and at the same level they had before surgery with a low rate of recurrence.

Introduction

Glenohumeral instability is a frequent condition among athletes specifically engaged in contact sports. Soccer is one of the most popular sports worldwide. ¹ According to FIFA there are over 260 million active players, therefore, shoulder-related injuries are remarkable. ¹

Soccer is considered a contact sport where lower-extremity injuries are far more frequent than upper limb injuries. Consequently, more data are available evidencing lower-extremity traumatic events. Although it is reported that only 3% of all soccer-related injuries involve the upper limbs, there is an evident increase in the incidence of these events over the years.^2–4 This increase is thought to be related to changes in soccer performance (high-speed) and physical demanding skills (pressing and marking) for soccer players, thus turning this sport nowadays into a harsher contact sport, where traumatic injuries ensue more frequently.^2–4

The majority of upper limb injuries related to soccer are shoulder injuries. Twenty-eight percent are considered severe since they prevent soccer players from competing for 28 days or more. ² Regarding the type of lesion, 90% are traumatic and only 10% arise due to overuse. ⁵ Moreover, it has been reported that the two most common upper limb pathologies associated with soccer are acromioclavicular joint sprain (13%) and shoulder dislocation (12%). ⁵

Considering the position of the player regarding shoulder traumatic events, goalkeepers are more often known by specialized literature to get injured rather than outfield players. This association results from the fact that goalkeepers are constantly demanding a higher shoulder activity either to grab the ball or receive direct impacts on the ground. ⁶

The best surgical treatment for glenohumeral instability in soccer players is controversial. Surgical stabilization for Bankart lesions can be achieved both by arthroscopic and open means. Although both techniques have been proven to be highly effective from an evidence-based perspective and considered gold-standard procedures, the permanent ongoing evolution of arthroscopic Bankart repair (ABR) techniques has encouraged specialists to perform ABR more frequently. ⁷

Although ABR demonstrated to be highly effective in treating athletes with glenohumeral instability, the outcomes regarding contact sports remain debatable.^8–10 Different authors reported that a considerable number of athletes could not return to their previous level of competition after ABR procedure. ⁹ Moreover, the recurrence rate in contact sport athletes varied from 3 to 23%. ¹¹ However, the majority of the studies have analyzed contact sports as a global group and not considering the specific demands of each sport. Even though in the most commonly used classifications, soccer is considered a contact sport, the risk of suffering a shoulder injury is lower than in a more demanding shoulder sport, such as rugby.^10,12

The aim of this study was to report return to sports, functional outcomes, and recurrences after isolated ABR in soccer players. Since shoulder trauma in soccer is rare, our study hypothesizes that if we only analyzed soccer players as a specific sport, the outcomes after an ABR would be more encouraging.

Materials and methods

Participants and data collection

Our sample consisted of 156 soccer players who underwent arthroscopic isolated Bankart repair between 2008 and 2017. The ethics committee of our institution approved this study (IRB: 00010193).

Inclusion criteria were soccer players who had anterior shoulder instability, who participated at a competitive level (regular sport with competitions and practices >2 times/week) ¹² and underwent an isolated ABR.

Exclusion criteria were follow-up <2 years, significant bone loss >20%, engaging Hill–Sachs lesion, associated full-thickness rotator cuff tear, multidirectional instability and humeral avulsion of the glenohumeral ligament lesion, posterior labral tears, associated superior labral from anterior to posterior lesions, or previous surgery on the same shoulder.

Preoperative and postoperative evaluations consisted of a patient-based questionnaire and a physical examination performed by a shoulder fellowship-trained physician.

Patients were asked if they could practice their previous sport and if they could perform it at the same level as before their injury. The Rowe score was used as a global outcome measure. ¹³ Shoulder dependent sports ability was measured by the Athletic Shoulder Outcome Scoring System (ASOSS). ¹² All recurrences and surgery-related complications and reoperations were documented. We defined recurrence as the presence of a dislocation, subluxation, or apprehension during the follow-up physical examination that limited daily activities or sports.

Surgical treatment

The patient was placed in the lateral decubitus position. The arm was abducted 60deg –70deg with forearm traction of 10–15 kg. We used a standard posterior portal with two anterior portals, and flow of irrigation was maintained by an arthroscopic pump (40–60 mm Hg). Looking from the posterior portal, we evaluated the relation of the Hill–Sachs lesion with the anterior glenoid, reproducing the dislocated shoulder position. Moreover, a final evaluation of the glenoid bone defect was performed intraoperatively.

The labral edge was debrided after complete liberation and release of the capsulolabral ligament beyond the 6-o'clock position. Then, the anterior and inferior glenoid rim and neck were lightly abraded with a shaver. Typically, three anchors with No. 2 nonabsorbable sutures were placed on the cartilage edge of the glenoid surface. The first one was placed in the inferior area of the anterior glenoid rim below the 5-o'clock position. Additional anchors were placed in a similar manner at both the 3- and 4-o'clock positions. Capsular plication was performed, starting 1 h inferior to the anchor placement and lateral depending on capsular laxity, between 5 and 15 mm, to create superior tensioning of the inferior glenohumeral ligament and eliminating inferior capsular redundancy. Once the sutures were placed in the correct position, they were secured with sliding knots.

Postoperative rehabilitation

The arm was supported with a sling for four weeks. All patients followed a standard postoperative rehabilitation protocol supervised by one of the authors (XXX). After one week, supervised gentle physical therapy consisting of passive pendulum and gradual passive range of motion exercises was begun. Active-assisted range of motion exercises were started two weeks after surgery. When the patient could perform active forward elevation above the shoulder level, usually at 4–6 weeks after surgery, shoulder-strengthening exercises were started. Rehabilitation continued for three months. Return to sports was allowed when the patient was pain free, full shoulder range of motion had been achieved, and shoulder strength was the same as before the injury.

Data analysis

Data were statistically analyzed with SPSS software (version 25). Preoperative and postoperative outcome scores were compared with the paired t test for dependent samples. Continuous variables were expressed as means and ranges or standard deviations (SDs). Frequencies and percentages were calculated for categorical variables. As a measure of magnitude 95% confidence interval was used. The level for statistical significance was set to an alpha level of p-value < .05.

Results

All of them underwent isolated ABR. Of these, 153 were males and 3 were females. The mean follow-up was 57.1 months (SD = 20.1); the mean age was 20.8 years (SD = 4.2) and 93 patients (59.6%) were ≤21 years old. A total of 148 (94.8%) soccer players were able to return to sports and 122 (78.2%) returned to the same level. The mean time to return to sport was 4.8 (SD = 1.1) monthsRegarding functional outcomes, both the Rowe and the ASOSS scores improved significantly. The former, from a mean of 44.2 (SD = 12.4) preoperatively to 93.3 (SD = 11.6) postoperatively (P < 0.001), whereas the latter, from a mean of 53.5 (SD = 4) preoperatively to 93.4 (SD = 4.3) postoperatively (P < 0.001) (Table 1). The final rate of recurrences was 5.2% and the complication rate was 1.9%. The recurrence rate in patients <21-year-olds was 7.5% and in >21-year-olds was 1.6% (P = 0.097).

Discussion

The main findings of this study were that most soccer players with anterior shoulder instability treated with an isolated ABR returned to sports at the same level and with a low rate of recurrences.

In a recent meta-analysis Ialenti et al. ¹⁴ evaluated return to sports in 545 patients who underwent ABR. Seventy-one percent returned to their desired sport at the same level of play. Another recent systematic review evaluating return to sport following ABR reported a pooled rate of return to any level of sports of 81%, while 66% returned to pre-injury levels. ¹⁵ Results regarding return to sports in competitive contact athletes after Bankart repair range from 51 to 100%.^8,9

However, generally, these results are reported in a mixed form, including a wide variety of risky sports for the shoulder, making it impossible to know the specific return to sport rates for each sport.^8,9 Therefore, there is an important limitation when it comes to informing the patient precisely about the results to be expected after an ABR. In our study, the percentage of return to sport was 94.8, and 78.2% returned at the same level. These results are more favorable than those reported by other authors for other types of contact sports. We believe that this could be due to the lower demands imposed on the shoulder in soccer, compared to other high-risk sports such as rugby, martial arts, or American football. Previous authors also found high rates of return to sports in soccer players after ABR. Alentorn-Geli et al. ¹⁶ evaluated 57 competitive soccer players after an ABR. Forty-nine (86%) were able to resume their sport, while 36 (73%) of them were able to return to the same pre-injury level.

Table 1.

Summary of functional outcomes and return to sport. ^a

Variable	Preoperative	Postoperative	P-value
Rowe score	44.2 ± 12.4	93.3 ± 11.6	<0.001
ASOSS	53.5 ± 4	93.4 ± 4.3	<0.001
Return to sport, n (%)	–	94.8%	–
Return to same level (%)	–	78.2%	–
Time to return to sports (months)	–	4.8	–

ASOSS: Athletic Shoulder Outcome Scoring System.

^aValues are expressed as mean ± SD unless otherwise indicated.

Concerning time to return to sports, Ialenti et al. ¹⁴ have reported that contact athletes returned to sports at a mean of 6.1 months after an ABR. Soccer players in our series returned to play at a mean time of 4.8 (SD 1.1) months. These results are comparable to previous authors. Alentorn-Geli et al. ¹⁶ documented a median of four months of return to pre-injury level in soccer players and Hart and Funk ¹⁷ demonstrated that professional soccer players can return to sports within three months. Finally, Gibson et al. ¹⁸ analyzed 34 professional footballers who returned to sports in a range of 9–14 weeks. This decrease in time to return to play was due to the fact that they underwent an accelerated rehabilitation regimen. These slightly different results found by Ialenti et al. ¹⁴ can be explained because this meta-analysis evaluated return to sports in general and did not consider the different types of sports. Moreover, as soccer is not a high shoulder demanding sport, return to soccer may be even quicker than other contact sports.

Regarding functional outcomes, most of our soccer players showed remarkable improvements with a final Rowe score of 93.3 and a final ASOSS score of 93.4. Similarly, favorable outcomes have been described in other series evaluating soccer players. Alentorn-Geli et al. ¹⁶ reported a final mean Rowe score of 80 and Ranalletta et al. ¹⁹ reported a Rowe and ASOSS scores of 92.5 and 91.9, respectively.

Several studies reported high rates of recurrence after ABR in contact sports ranging from 8 to 35% after ABR.^20–22 Unfortunately, most authors analyzed all the contact sports together, including sports where the participation of the shoulder is extremely different. Alentorn-Geli et al. ¹⁶ have reported a low recurrence rate of 10.5% in their soccer players. In our series, the recurrence rate was 5.2%. Similarly to Alentorn-Geli et al., ¹⁶ we found a low rate of recurrence. Even though there is still a slight difference with the recurrence rate found by Alentorn-Geli et al., ¹⁶ this could be due to two main reasons. First, in our series, most of our athletes were not professionals; therefore, the intensity and frequency of impacts directly over the shoulder are not as high as in professional soccer players. Second, our patients were operated using an ABR (knot-tying) technique compared to a knotless technique used by Alentorn-Geli et al. ¹⁶ Cho et al. ²³ compared these two techniques in athletes, indicating that the knot-tying suture anchors technique has fewer recurrence rates than the knotless group. Furthermore, last but not least, like Alentorn-Geli et al. ¹⁶ we have not analyzed player's field positions, since it is known that goalkeepers are more predisposed to have higher shoulder recurrence episodes rather than other field positions. ⁶ Finally, regarding soccer per se, we think that this finding of low recurrence rates compared to other contact sports could be specifically because of the lower physical demands imposed on the shoulder.

Young active athletes have a higher risk of recurrence. ²² A recent systematic review analyzed adolescent athletes following anterior shoulder stabilization. ²⁴ The overall total mean incidence of recurrence instability was 18.5 and 31.1% in contact sports. Regarding soccer, Alentorn-Geli et al. ¹⁶ evaluated competitive soccer players after arthroscopic capsulolabral repair and found a recurrence rate of 15.2% in patients <20 years old and 7.1% in patients >20 years old. Moreover, Gibson et al. ¹⁸ reported 9% of recurrence rate, from which all of the players who suffered a recurrence of instability were aged less than 20 years. Likewise, in our study, soccer players <20 years old had a recurrence rate of 7.5% compared to 1.6% in athletes >20 years old (P 0.097).

This study presents some limitations. First, it was a retrospective case series. Second, we did not analyze the relation between soccer player's field position and functional outcomes. Third, we did not differentiate between 11-a-side football players and 5-a-side players. Although the sport is the same, it is possible that there were differences between the distinct soccer subtypes. Finally, we had no control group to compare our results with another surgical technique.

In conclusion, soccer players who underwent an arthroscopic isolated Bankart repair for anterior glenohumeral instability have shown remarkable outcomes, with most of the patients returning to sports, and at the same level they had before surgery with a low rate of recurrence.