Sporting Activity After Arthroscopic Bankart Repair for Chronic Glenohumeral Instability Johannes E

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Sporting Activity After Arthroscopic Bankart Repair for Chronic Glenohumeral Instability Johannes E. Plath, M.D., Matthias J. Feucht, M.D., Tim Saier, M.D., Philipp Minzlaff, M.D., Gernot Seppel, M.D., Sepp Braun, M.D., and Andreas B. Imhoff, M.D.

Purpose: The purpose of this study was to collect detailed data on postoperative sporting activity after arthroscopic Bankart repair for chronic shoulder instability. Methods: Of 113 patients who underwent arthroscopic Bankart repair between February 2008 and August 2010, 81 met the inclusion criteria and were surveyed by a specially designed postal sport-specific questionnaire. Of these 81 patients, 66 (82%) were available for evaluation. Results: All previously active patients performed some activity at follow-up. Of 9 patients (56%) who had been inactive, 5 took up new activities postoperatively. Forty-four patients (66%) stated that surgery had (strongly) improved their sporting proficiency. Seventeen patients (26%) reported no impact, and 5 patients (8%) reported a further deterioration compared with preoperatively. The improvement in sporting proficiency was negatively correlated with the preoperative risk level (r ¼ 0.42, P < .001), preoperative performance level (r ¼ 0.31, P ¼ .012), and preoperative Tegner scale (r ¼ 0.36, P ¼ .003), as well as hours of sporting activity per week (r ¼ 0.25, P ¼ .042), whereas age showed a positive correlation (r ¼ 0.28, P ¼ .023). There was no change in duration, frequency, number of disciplines, Tegner activity scale, risk category, or performance level. Conclusions: Arthroscopic Bankart repair provides a high rate of return to activity among patients treated for chronic shoulder instability. A number of previously inactive patients returned to activity postoperatively. However, one-third of patients reported no benefit from surgery in terms of sporting activity. The improvement in sporting proficiency was highly dependent on the demands on the shoulder in sports, as well as the age of the patient. Overall, there was no significant increase in duration, frequency, number of disciplines, Tegner activity scale, or performance level between preoperative and follow-up evaluation and no increased return to high-risk activities. Level of Evidence: Level IV, therapeutic case series.

raumatic anteroinferior shoulder dislocation is a 92%.2-6 Therefore early surgical shoulder stabilization is Tcommon injury in athletes.1 Patients with gleno- indicated for the young athlete involved in shoulder- humeral instability are mostly young and active with demanding activities.2-4,7 However, this patient group high demands on shoulder function. represents a minority.8,9 Many patients have a long- The redislocation rate after nonoperative treatment is lasting history of chronic shoulder instability with failed high, particularly among young athletes, ranging up to nonoperative treatment and multiple events of dislocation and subluxation before surgery is performed. These From the Department of Orthopaedic Sports Medicine, Klinikum rechts der chronic instability patients may adapt their level and type Isar, Technische Universität München (J.E.P., M.J.F., G.S., S.B., A.B.I.), of activity, but most of them remain active and engage in Munich; Department of Trauma Surgery, Klinikum Augsburg (J.E.P.), sports despite chronic shoulder instability.10 Augsburg; Department of Orthopedic Surgery and Traumatology, Freiburg University Hospital (M.J.F.), Freiburg; Department of Trauma and Ortho- Surgeons recommend shoulder stabilization to paedic Surgery, Berufsgenossenschaftliche Unfallklinik Murnau (T.S.), avoid further injury to the shoulder joint and Murnau; and Department of Sporttraumatology, Knee- and Shoulder-Sur- promise shoulder stability, improved shoulder func- gery, Berufsgenossenschaftliche Unfallklinik Frankfurt am Main (P.M.), tion, and a successful return to sports.9,11-13 Several Frankfurt am Main, Germany. studies have reported on the return to sporting ac- The authors report the following potential conﬂict of interest or source of funding: A.B.I. receives support from Arthrex and Arthrosurface. tivity after arthroscopic Bankart repair compared 7,11,13-19 Received August 10, 2014; accepted April 10, 2015. with the pre-trauma activity level. However, Address correspondence to Johannes E. Plath, M.D., Department of Or- because the primary dislocation dates back many thopaedic Sports Medicine, Klinikum rechts der Isar, Technische Universität years, this comparison fails to meet the speciﬁcsit- München, Ismaninger Strasse 22, 81675 Muenchen, Germany. E-mail: uation of patients with chronic shoulder instability. [email protected] Ó 2015 by the Arthroscopy Association of North America These patients want to be counseled about what they 0749-8063/14686/$36.00 may expect from surgery compared with their cur- http://dx.doi.org/10.1016/j.arthro.2015.04.087 rent situation.

1996 Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 31, No 10 (October), 2015: pp 1996-2003 RETURN TO SPORTS AFTER BANKART REPAIR 1997

Detailed knowledge about the expected level of Table 1. Risk Categories for Traumatic Shoulder Instability postoperative sporting activity is important in terms of Based on Study of Owens et al.1 and Recommendations of preoperative patient information and will help surgeons American Academy of Pediatrics Committee on Sports 29 inform their patients in detail before surgery. Realistic Medicine patient expectations regarding the surgical procedure Sports may help to avoid subjective failure. In addition, even High risk Handball, rock climbing, windsurfing, surfing, though most studies report comparable functional wrestling, judo, ice hockey, football, rugby outcomes with arthroscopic Bankart repair and with Medium risk Volleyball, basketball, soccer, tennis, squash, open repair, the return to sporting activity is still a badminton, swimming, weightlifting, mountain biking, canoeing, boxing matter of discussion and some authors recommend Low risk Cycling, running, rowing open repair for collision athletes.11,14,15,18,20-23 Therefore the purpose of this study was to collect detailed data on postoperative sporting activity after arthroscopic Bankart repair for chronic shoulder insta- through a transtendinous lateral portal. Small bucket- bility. We hypothesized that patients with chronic handle tears or frayed labra were resected. recurrent instability will increase their sporting activity Postoperatively, a sling was used for comfort, and pro- after surgical stabilization and may even return to high- gressive active and assisted range-of-motion exercise was risk sports. initiated on the following day, limiting external rotation to 30 and limiting abduction, as well as flexion, to 45. Methods At 4 weeks postoperatively, abduction and flexion were allowed to 90 and external rotation was limited to 0. Patient Selection Free active range of motion was allowed after 6 weeks We retrospectively evaluated all patients who un- postoperatively. Patients were permitted to return to derwent arthroscopic Bankart repair for traumatic sport-specific training after 3 months and to overhead anteroinferior shoulder instability during the period and high-contact activities after 6 months post- from February 2008 to August 2010 in our department. operatively. In case of a concomitant SLAP repair, active The inclusion criteria for this study were isolated biceps training was prohibited for the first 6 weeks. chronic glenohumeral anteroinferior instability and a minimum follow-up period of 24 months. Chronic Data Collection shoulder instability was defined as recurrent shoulder Patients were retrospectively evaluated at a minimum dislocations and a minimum time interval from initial of 24 months after arthroscopic Bankart repair using a dislocation to surgery of 12 months. postal sport-specific questionnaire, which has been The exclusion criteria were multidirectional insta- used by several authors before.26-28 Patients were asked bility, glenoid bone loss greater 20%, engaging Hill- to compare their current activity level with their pre- Sachs lesions, advanced osteoarthritis (Samilson and operative activity level. Data collection and evaluation Prieto24 grade 3), glenoid dysplasia, and full-thickness were performed by an orthopaedic surgeon (J.E.P.) or high-grade partial-thickness (>50% thickness) ro- who was not involved in the surgical treatment. tator cuff tears. The study protocol was approved by the The questionnaire assessed the sports frequency local ethics committee, and all patients provided written (defined as sessions per week), sports duration (defined informed consent to participate in this investigation. as hours per week), number of sports disciplines, and performance level (recreational, competitive, highly Arthroscopic Procedure and Sport-Specific competitive, or professional). In addition, the patient’s Rehabilitation preoperative and postoperative participation in 32 The patient was placed in the beach-chair position. different sports and recreational activities was evalu- Diagnostic arthroscopy was performed through a stan- ated. In case of a reduction of sporting activity or dard posterior portal. termination of disciplines, patients were asked to indi- For Bankart repair, a deep anteroinferior portal (5:30 cate their reasons (shoulder related, noneshoulder clock-face position) through the lower third of the related, or concern of recurrence). subscapularis muscle was used in all patients.10,25 The Sports and recreational activities were furthermore number of anchors (BioFastak; Arthrex, Naples, FL) allocated into risk categories for traumatic shoulder used varied among patients, depending on the patho- instability (high, medium, and low risk) based on the logic findings. Yet, we favored a repair using 3 anchors study of Owens et al.1 and recommendations of the placed at the 5:30, 4:30, and 3-o’clock position (for American Academy of Pediatrics Committee on Sports right shoulders). Medicine29 adjusted to meet the distribution of sporting In case of a reparable SLAP lesion (type II or type IV), activities in central Europe (Table 1). The questionnaire suture anchor repair (BioFastak) was performed also inquired about the subjective overall improvement 1998 J. E. PLATH ET AL. in sporting and recreational proficiency (severely impaired, impaired, unchanged, improved, or strongly improved) due to the surgical procedure, as well as the ability to participate in contact and overhead sports. The QuickDASH (short version of Disabilities of the Arm, Shoulder and Hand questionnaire) score (scaled from 0 to 100, where 0 represents no disability and 100 represents the most disability) was used to measure the patient’s upper limb functional disability, and the Tegner activity scale was recorded to determine the activity level.30,31

Statistics Statistical analysis was performed using SPSS soft- ware, version 20.0 (IBM, Armonk, NY). All data were tested for normal distribution using the Kolmogorov- Smirnov test. For normally distributed data, paired and unpaired t tests were used for intragroup and intergroup comparisons. The Wilcoxon signed rank and Mann-Whitney U tests (paired/unpaired) were used for nonenormally distributed data. Dichotomous data were computed by the c2 test. To compare the participation in sporting activities before and after surgery, the McNemar test was used. Correlations were calculated using the Spearman correlation coefﬁcient. The level of Fig 1. Flowchart of patient enrollment. signiﬁcance was set at P < .05.

fi Results improved their sporting and recreational pro ciency compared with preoperatively. Seventeen patients Demographics (26%) reported no impact, and 5 patients (8%) stated From February 2008 to August 2010, a total of 113 that their sports performance ability decreased after patients underwent arthroscopic Bankart repair for surgery, with the findings showing some impairment in traumatic anteroinferior shoulder instability in our 4 patients (6%) and severe impairment in 1 case. department. Of these 113 patients, 81 fulfilled the in- The lower the preoperative risk (r ¼0.42, P < .001) clusion criteria of the study. A total of 66 questionnaires and performance level (r ¼0.31, P ¼ .012), Tegner were available for evaluation (follow-up rate, 82%). scale (r ¼0.36, P ¼ .003), and hours of sporting ac- Details of patient enrollment are shown in Figure 1. tivity per week (r ¼0.25, P ¼ .042), the higher the The mean postoperative follow-up period was 43 9 subjective overall improvement in sporting and recre- months (range, 25 to 56 months). Of the 66 patients, 6 ational proficiency due to the surgical procedure. Pa- (9%) sustained a recurrent shoulder dislocation. Two tients who indicated no improvement or a decline in patients underwent arthroscopic revision Bankart sporting ability did not show a higher rate of recurrence repair. (9%) or a higher amount of disability (QuickDASH There were no neurovascular complications, post- score) compared with patients who benefited from operative infections, or cases of postoperative shoulder surgery (P ¼ .401). stiffness that needed surgical intervention within our Age at the time of surgery was positively correlated patient population. The detailed patient characteristics with improvement in sporting proficiency (r ¼ 0.28, are provided in Table 2. P ¼ .023), whereas the number of sports disciplines (r ¼0.25, P ¼ .046) and risk level (r ¼0.26, P ¼ Sports and Recreational Activities .036) at follow-up and the Tegner activity levels before All patients who were active before the operation (57 surgery (r ¼0.34, P ¼ .005), as well as at follow-up patients) returned to at least 1 sporting or recreational (r ¼0.34, P ¼ .005), showed a negative correlation. activity after surgery. Of 9 patients who had been Overall, there was no significant difference between inactive before surgery, 5 (56%) took up new activities preoperative and postoperative values regarding the postoperatively. number of disciplines, frequency and duration of sports Forty-four patients (66%) stated that arthroscopic participation, Tegner activity scale, risk category, or Bankart repair had strongly (33%) or somewhat (33%) performance level (Table 3). RETURN TO SPORTS AFTER BANKART REPAIR 1999

Table 2. Patient Demographic Data regarding the number of disciplines, Tegner scale, risk level, sports frequency and duration, number of an- Demographic Characteristic Data chors used during surgery, or duration of chronic Patients, n 66 Sex, male/female, n (%) 46/20 (70) shoulder instability (Table 4). Patients who underwent Shoulder, right/left, n (%) 33/33 (50) a concomitant SLAP repair during shoulder stabilization Dominant side affected, n (%) 37/29 (56) did not differ significantly in terms of all of the afore- Follow-up, mo 43 9 (25-56) mentioned criteria from patients who did not undergo QuickDASH score at follow-up 6.9 9.9 (0-55) this additional procedure (Table 4). Age at surgery, yr 29.3 10.4 (14-62) Preoperative dislocations, n (%) <5 28 (42) Discussion 5-10 13 (20) All patients who were active before surgery per- >10 25 (38) formed some sporting activity at follow-up, and more Duration of instability, mo 87 84 (12-360) than half of the patients who were inactive before Anchors used, n 3 (1-5) SLAP repair, n (%) 11 (17) surgery took up new activities postoperatively. Sixty-six Recurrence, n (%) 6 (9) percent of our patients stated that surgery improved or NOTE. Data are presented as mean standard deviation (range) or strongly improved their sporting or recreational profi- median (range) unless otherwise indicated. ciency compared with preoperatively. On the other QuickDASH, short version of Disabilities of the Arm, Shoulder and hand, 26% reported no improvement and 8% even Hand questionnaire. reported a further deterioration. The improvement in sporting proficiency was highly dependent on the age of the patient, as well as individual demands regarding When patients were asked the reasons that they quit risk level, performance level, Tegner scale, and duration disciplines or reduced the extent of sporting activity of activity. during the follow-up period, 19% indicated shoulder- Contrary to our hypothesis, there was no increase in related causes (persisting instability, pain, and sporting activity between preoperative and follow-up dysfunction) and 22% stated that they were asymp- evaluation concerning sports duration and frequency, tomatic yet were concerned about sustaining a further number of sports disciplines, or Tegner activity scale and injury to the shoulder. Most patients (59%) indicated no increased return to high-risk activities. The large that noneshoulder-related reasons accounted for the number of patients who did not report a significant activity change, such as career, family, and other per- improvement through surgery seems surprising at first. sonal interests. However, one should take into consideration that this is a Cycling, fitness training, and mountain hiking, all chronic population with a mean duration of shoulder low-risk activities for shoulder dislocation, gained instability of 88 months. A certain amount of functional significantly in participation postoperatively (P ¼ .016, impairment of the affected shoulder with a subjective P < .001, and P ¼ .008, respectively), whereas martial feeling of instability during activity may persist despite a arts, a high-risk activity for shoulder dislocation, was successful structural repair. Accordingly, patients who did the only activity that dropped significantly in participation (P ¼ .031). Seventy-nine percent of the patients Table 3. Extent of Sports and Recreational Activities Before stated that they felt comfortable participating in over- and After Arthroscopic Stabilization head activities, and 82% reported that they were able to participate in contact sports. The distribution patterns Preoperative Follow-up P Value for different sports and recreational activities before and No. of disciplines 4 3 (0-14) 5 3 (0-14) .206 after arthroscopic stabilization are shown in Figure 2. Sports frequency, wk 2.6 1.6 (0-7) 2.6 1.4 (0-7) .700 Sports duration h/wk 5.1 4.6 (0-21) 4.9 3.8 (0-21) .878 No sports, n (%) 9 (14) 4 (6) Subgroup Analysis: Recurrence and SLAP Repair Performance .432 Patients who sustained a recurrent shoulder disloca- level, n (%) tion after arthroscopic Bankart repair showed a signif- Recreational 35 (53.0) 45 (68.2) icantly higher amount of disability based on Competitive 14 (21.2) 12 (18.2) QuickDASH score results compared with patients who Highly competitive 6 (9.1) 4 (6.1) ¼ Professional 2 (3.0) 1 (1.5) did not (P .010). Patients with redislocations were Risk category, n (%) .178 significantly younger (P ¼ .003) and reported more Low 5 (33) 5 (7.6) frequently that they felt uncomfortable engaging in Medium 30 (46) 36 (54.5) overhead activities (P ¼ .004), whereas no difference High 22 (8) 21 (31.8) Tegner scale score 6.5 (1-10) 6 (3-10) .358 concerning contact sports could be detected (P ¼ .313). With the number of patients available, there were no NOTE. Data are presented as mean standard deviation (range) or median (range) unless otherwise indicated. significant intergroup differences at follow-up 2000 J. E. PLATH ET AL.

Fig 2. Distribution patterns of sports and recreational activities before and after arthroscopic stabilization. Asterisks indicate a signiﬁcant difference (P < .05).

not indicate a benefit through surgery showed neither a athletes, overhead athletes, and martial arts participants. greater disability score nor a higher recurrence rate. All groups were prospectively analyzed using shoulder- The subjective improvement in sporting activity was dependent yet non-validated sport-specific scores. rather affected by young age and an increased demand Functionally demanding activities, such as overhead on shoulder function. This finding is consistent with sports and martial arts, showed significant limitations of other reports in the literature on shoulder insta- the reattained proficiency level. This finding is consistent bility.18,32 Pavlik et al.32 published a report as early as with reports by Ide et al.22 and Cho et al.15 Both study 1996 dealing exclusively with the return to sports after groups found a limited return to collision and overhead open transosseous Bankart repair and reported that the sports compared with non-collision/non-overhead ac- return to sports was highly dependent on the preop- tivity after arthroscopic shoulder stabilization. erative risk level of the athletes. Similarly, Kim et al.18 Before performing surgery, surgeons should thor- found the return to preinjury sporting activity to be oughly inform this young and high-demand group of best in patients without regular sporting activity and patients in detail about the expected postoperative worst in collegiate or professional athletes. sporting ability. Unrealistically high patient expecta- A recent study by Stein et al.33 showed that the return tions may lead to subjective failure despite a successful to sports was dependent on the type of resumed shoulder operation from the surgeon’s point of view. sport. They subdivided their study population of 46 pa- Concerning the type of sports performed in our study, tients into non-collision/non-overhead athletes, collision most patients were able to return to their previous RETURN TO SPORTS AFTER BANKART REPAIR 2001

Table 4. Subgroup Analysis: Recurrence and SLAP Repair

Recurrent Dislocation SLAP Repair Yes No P Value Yes No P Value Patients, n 6 60 11 55 Age at surgery, yr 19.5 5.5 (15-30) 30.3 10.3 (14-62) .003* 25.0 5.0 (17-37) 30.1 11.0 (14-62) .188 No. of anchors used 3 (2-4) 3 (1-5) .853 3 (2-4) 3 (1-5) .753 QuickDASH score at FU 23.8 20.3 (0-55) 5.3 6.4 (0-34) .010* 7.6 6.7 (0-23) 6.8 10.5 (0-55) .261 No. of disciplines at FU 3 2 (0-6) 5 3 (0-14) .376 5 4 (0-14) 5 3 (0-14) .488 Sports frequency at FU, wk 2.8 2.3 (0-6) 2.6 1.4 (0-7) .974 2.7 1.6 (0-5) 2.6 1.5 (0-7) .552 Sports duration at FU, h/wk 5.6 6.3 (0-15) 4.8 3.6 (0-21) .578 5.0 3.2 (0-10) 4.8 4.0 (0-21) .463 Tegner scale score at FU 5 (3-9) 6 (3-10) .451 6 (3-10) 6 (3-10) .993 Risk category at FU, n (%) .182 .125 Low risk 0 (0.0) 5 (8) 0 (0) 5 (9) Moderate risk 5 (83) 31 (52) 4 (36) 32 (58) High risk 0 (0) 21 (35) 6 (55) 15 (27) No sport 1 (17) 3 (5) 1 (9) 3 (6) Overhead activity at FU, 2/4 (33/67) 50/10 (83/17) .004* 8/3 (73/27) 44/11 (80/20) .590 yes/no, n (%) Contact sports at FU, 4/2 (67/33) 50/10 (83/17) .313 9/2 (82/18) 45/10 (82/18) >.99 yes/no, n (%) Performance level, n (%) .974 .958 Recreational 3 (50) 42 (70) 7 (64) 38 (69) Competitive 1 (17) 11 (18) 2 (18) 10 (18) Highly competitive 1 (17) 3 (5) 1 (9) 3 (5) Professional 0 (0) 1 (2) 0 (0) 1 (2) No sport 1 (17) 3 (5) 1 (9) 3 (5) NOTE. Data are presented as mean standard deviation (range) or median (range) unless otherwise indicated. FU, follow-up; QuickDASH, short version of Disabilities of the Arm, Shoulder and Hand questionnaire. *Statistically significant. activity. In accordance with the results of Stein et al.,33 activity. This must be taken into account when inter- martial arts, a high-risk activity for shoulder dislocation, preting the data. This fact was reported by other authors was the only activity that dropped significantly in previously.32 Retrospectively, the exact impact of this participation. Patients extending their activities to new subjective finding on our data is difficult to assess, but sports most frequently chose activities with a low risk the level of postoperative sporting activity may be for shoulder dislocation. Thus cycling, mountain hiking, understated. and fitness training gained significantly in participation Within the literature, several authors have reported postoperatively. The hypothesized postoperative shift increased rates of redislocation associated with a high toward activities with a higher risk level could not be number of preoperative dislocations, young patient age, confirmed by the data from our study. Furthermore, and participation in contact and overhead activ- there was no overall increase in sporting activity be- ities.10,11,13,15,34 Ide et al.,22 however, found a compa- tween preoperative and follow-up evaluation regarding rable recurrence rate between contact and noncontact duration, frequency, number of sports disciplines, or athletes. Although the risk factors for redislocation Tegner activity scale. On the one hand, this finding may were not the primary objective of this study and be explained by the fact that only 66% of patients considering the limited number of patients with a indicated an improvement in sporting proficiency, as recurrence, we found that patients who sustained a stated previously. However, when patients were asked redislocation were significantly younger whereas there about the reasons that may have led to a reduced level was no difference regarding the duration of instability of activities, only 1 of 5 patients indicated shoulder- or the risk level of sporting activities. related causes such as persisting instability or pain. Most patients indicated noneshoulder-related reasons Limitations for the reduction or stated that the shoulder felt stable There are several limitations to this study that need to and they were satisfied yet concerned about sustaining be considered. First, data in this retrospective study a further injury to the shoulder. were collected through a questionnaire. The patients In the young patient population with shoulder did not undergo a physical examination or stability instability, many patients undergo changes in their testing. Furthermore, because patients were asked personal living circumstances because of career and about participation in sporting activities that dated back family that may affect their sporting and recreational several years, the possibility of recall bias exists. Second, 2002 J. E. PLATH ET AL.

15 patients (18.5%) were lost to follow-up or refused to randomized study with 10-year follow-up. Arthroscopy participate, raising the possibility of selection bias. 2007;23:118-123. Third, chronic shoulder instability in this study was 5. Robinson CM, Howes J, Murdoch H, Will E, Graham C. defined as recurrent dislocations with more than 12 Functional outcome and risk of recurrent instability after months between primary dislocation and surgery primary traumatic anterior shoulder dislocation in young patients. J Bone Joint Surg Am 2006;88:2326-2336. because the actual term “chronic” has not generally fi 6. Robinson CM, Jenkins PJ, White TO, Ker A, Will E. Pri- been de ned in the orthopaedic literature. A recent mary arthroscopic stabilization for a first-time anterior systematic review suggested 6 months as the cutoff dislocation of the shoulder. A randomized, double-blind 35 point between acute and chronic shoulder instability ; trial. J Bone Joint Surg Am 2008;90:708-721. however, because this suggestion was based on clinical 7. Law BK-Y, Yung PS-H, Ho EP-Y, Chang JJH-T, Chan K-M. reports only and not on histologic or pathophysiological The surgical outcome of immediate arthroscopic Bankart studies of tissue damage, we chose a longer time in- repair for first time anterior shoulder dislocation in young terval to give us a more homogeneous patient popula- active patients. Knee Surg Sports Traumatol Arthrosc tion. Fourth, the group sizes in the subgroup analysis 2007;16:188-193. were small and possibly underpowered. Finally, the 8. Larrain MV, Montenegro HJ, Mauas DM, Collazo CC, group of patients in this study was an active yet not Pavón F. Arthroscopic management of traumatic anterior shoulder instability in collision athletes: Analysis of high-demand patient population with chronic shoulder 204 cases with a 4- to 9-year follow-up and results instability. In our experience the selected study group with the suture anchor technique. Arthroscopy 2006;22: represents the majority of patients with shoulder 1283-1289. instability. The results may not apply to a high-demand 9. Yiannakopoulos CK, Mataragas E, Antonogiannakis E. athletic patient population. However, we have pre- A comparison of the spectrum of intra-articular lesions in sented detailed information on the impact of arthro- acute and chronic anterior shoulder instability. Arthroscopy scopic Bankart repair on the sporting and recreational 2007;23:985-990. behavior of 66 patients with chronic shoulder 10. Imhoff AB, Ansah P, Tischer T, et al. Arthroscopic repair instability. of anterior-inferior glenohumeral instability using a portal at the 5:30-o’clock position: Analysis of the effects of age, fixation method, and concomitant shoulder injury on Conclusions surgical outcomes. Am J Sports Med 2010;38:1795-1803. Arthroscopic Bankart repair provides a high rate of 11. Mazzocca AD, Brown FM, Carreira DS, Haydeb J, return to activity among patients treated for chronic Romeo AA. Arthroscopic anterior shoulder stabilization of shoulder instability. A number of previously inactive collision and contact athletes. Am J Sports Med 2005;33: patients returned to activity postoperatively. However, 52-60. one-third of patients reported no benefit from surgery 12. Martetschläger F, Imhoff AB. Shoulder dislocation in athletes. Current therapy concepts. Orthopaede 2014;43: in terms of sporting activity. The improvement in fi 236-243 [in German]. sporting pro ciency was highly dependent on the de- 13. Franceschi F, Papalia R, Del Buono A, Vasta S, Maffulli N, mands on the shoulder in sports, as well as the age of Denaro V. Glenohumeral osteoarthritis after arthroscopic the patient. Overall, there was no significant increase in Bankart repair for anterior instability. 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RETURN TO SPORTS AFTER BANKART REPAIR 2003

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