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Why do patients with anterior shoulder instability not return to sport after surgery? A systematic review of 63 studies comprising 3545 patients

  • Theodore P. van Iersel
    Correspondence
    Corresponding author: Theodore P. van Iersel MD, Jan Tooropstraat 164, 1061AE, Amsterdam, The Netherlands Phone: +31614564784
    Affiliations
    Shoulder and elbow unit, Department of Orthopedic Surgery, OLVG, Amsterdam, The Netherlands

    Amsterdam Shoulder and Elbow Centre of Expertise (ASECE), Amsterdam, The Netherlands

    Faculty of Behavioral and Movement Sciences, Department of Human Movement Sciences, Vrije Universiteit Amsterdam, Amsterdam Movement Sciences, Amsterdam, the Netherlands
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  • Sanne H. van Spanning
    Affiliations
    Shoulder and elbow unit, Department of Orthopedic Surgery, OLVG, Amsterdam, The Netherlands

    Amsterdam Shoulder and Elbow Centre of Expertise (ASECE), Amsterdam, The Netherlands

    Faculty of Behavioral and Movement Sciences, Department of Human Movement Sciences, Vrije Universiteit Amsterdam, Amsterdam Movement Sciences, Amsterdam, the Netherlands
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  • Lukas P.E. Verweij
    Affiliations
    Amsterdam Shoulder and Elbow Centre of Expertise (ASECE), Amsterdam, The Netherlands

    Amsterdam UMC, Department of Orthopedic Surgery, University of Amsterdam, Amsterdam Movement Sciences, Location AMC, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands

    Academic Center for Evidence-Based Sports Medicine (ACES), Amsterdam, The Netherlands

    Amsterdam Collaboration on Health and Safety in Sports (ACHSS), AMC/VUmc IOC Research Center, Amsterdam, Netherlands
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  • Simone Priester-Vink
    Affiliations
    Department of Research and Epidemiology, OLVG, Amsterdam, The Netherlands
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  • Derek F.P. van Deurzen
    Affiliations
    Shoulder and elbow unit, Department of Orthopedic Surgery, OLVG, Amsterdam, The Netherlands

    Amsterdam Shoulder and Elbow Centre of Expertise (ASECE), Amsterdam, The Netherlands
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  • Michel P.J. van den Bekerom
    Affiliations
    Shoulder and elbow unit, Department of Orthopedic Surgery, OLVG, Amsterdam, The Netherlands

    Amsterdam Shoulder and Elbow Centre of Expertise (ASECE), Amsterdam, The Netherlands

    Faculty of Behavioral and Movement Sciences, Department of Human Movement Sciences, Vrije Universiteit Amsterdam, Amsterdam Movement Sciences, Amsterdam, the Netherlands
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Open AccessPublished:January 19, 2023DOI:https://doi.org/10.1016/j.jseint.2023.01.001

      Abstract

      Purpose

      To review athletes’ reasons not to return to sport (RTS) after surgical treatment of anterior shoulder instability, comparing capsulolabral repair and bony reconstruction procedures. The hypothesis is that the mostly named reason for patients unable to RTS is not due to physical inability of the shoulder.

      Methods

      A systematic review was performed using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analysis) guidelines. PubMed, Embase/Ovid, Cochrane Database of Systematic Reviews/Wiley, Cochrane Central Register of Controlled Trials/Wiley, SPORTDiscus/Ebsco and Web of Science/Clarivate Analytics were searched in collaboration with an information specialist up to August 11th 2022. Observational and interventional studies reporting reasons for no RTS following surgical treatment of anterior shoulder instability were included. Quality assessment of studies was conducted using the Methodological Index for Non-Randomized Studies (MINORS) criteria and Risk of Bias (RoB) assessment. Forest plots were generated to show an overview of the proportion shoulder function independent reasons for each study.

      Results

      Sixty-three studies were included reporting on 3545 athletes, of which 2588 (73%) underwent capsulolabral repair versus 957 (27%) who underwent surgical treatment with bony reconstruction procedures. A total of 650 athletes (18%) was unable to RTS. The reason not to RTS was most frequently shoulder function independent (70%) compared to shoulder function dependent (30%) following both capsulolabral repair and bony reconstruction procedures. Most cited reasons for no RTS after capsulolabral repair were fear of re-injury (17%), personal reasons or change of priorities (11%) and retirement/discharge of military service or sports team (10%). Of these reasons, 106 (22%) were not specified other than being shoulder function dependent or shoulder function independent. Most cited reasons for no RTS after bony reconstruction procedures were fear of re-injury (12%), shoulder pain (10%) and retirement/discharge of military service or sports team (9%). Of these reasons, 74 (44%) were not specified other than being shoulder function dependent or shoulder function independent. Forest plots showed a variation from 0-100% shoulder independent reasons for both capsulolabral repair and bony reconstruction procedures.

      Conclusion

      The majority of athletes who did not RTS following surgical treatment for anterior shoulder instability did so due to shoulder function independent reasons, such as fear of re-injury. However, there was a high variety between studies and many reasons were unspecified, warranting unified definitions for reasons of patients that do not RTS.

      Keywords

      Abbreviation:

      RTS (Return to sport), PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analysis), MINORS (Methodological index for non-randomized studies), SD (Standard Deviation), y (years), mo (months)
      Shoulder instability is highly frequent among contact/collision and overhead athletes
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      . It can result in time-loss (e.g. missed games) and high socio-economical and hospital costs
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      . Furthermore, shoulder dislocations are the most occurring dislocations of the human body, for which surgical treatment is often indicated. It is widely used after failed non-operative treatment
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      . Even though RTS rates are high in current literature, up to 19% of patients undergoing surgical treatment of anterior shoulder instability are unable to RTS
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      Return to Play After the Latarjet Procedure for Anterior Shoulder Instability: A Systematic Review.
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      A recent study of Rossi et al. showed that 74% of these patients failed to RTS because of reasons independent of the shoulder, such as fear for re-injury, kinesiophobia and concerns about a new rehabilitation process
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      . In addition, another study shows shoulder independent reasons such as self-motivation, social support and shift in priorities as consideration not to RTS
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      . Moreover, patients’ ability to RTS following surgical treatment of anterior shoulder instability is a multifactorial process. Recent insights show a relation between fear for shoulder movements (kinesiophobia) and return to pre-injury level of sport after shoulder stabilizing surgery, suggesting a prominent reason not to RTS could be psychologically motivated and not solely shoulder function dependant
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      Numerous studies have evaluated and summarized quantitative variables regarding this subject
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      • Ali Z.
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      • et al.
      Return to Play After the Latarjet Procedure for Anterior Shoulder Instability: A Systematic Review.
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      • Memon M.
      • Kay J.
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      Return to sport following arthroscopic Bankart repair: a systematic review.
      . However, there is a lack of literature summarizing reasons for athletes who do not RTS following shoulder stabilizing surgery. Knowledge of these reasons may be helpful for both physicians and patients in the shared decision-making process and can possibly increase RTS rates following surgery. Therefore, the purpose of this study is to critically review patients’ reasons not to RTS after surgical treatment of anterior shoulder instability, comparing capsulolabral repair and bony reconstruction procedures. The hypothesis is that the mostly named reason for patients unable to RTS is not due to physical inability of the shoulder.

      Materials and methods

      A review protocol was developed based on the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement (www.prisma-statement.org) and was submitted to Prospero under review number CRD42022301102.

      Literature Search

      Relevant studies were identified by searching PubMed, Embase/Ovid, Cochrane Database of Systematic Reviews/Wiley, Cochrane Central Register of Controlled Trials/Wiley, SPORTDiscus/Ebsco and Web of Science/Clarivate Analytics from inception up to October 19th 2021 and updated on August 11th 2022 (by TPI and SPV, information specialist). The following terms, including synonyms and closely related words, were used as index terms or free-text words: ‘shoulder, ‘instability’, ‘surgery’ and ‘return to sports’. Full search strategies for all databases are available as Supplementary Information (Supplement 1). A language filter for English, German and Dutch language was applied, when available in the database. Duplicate articles were excluded by the information specialist (SPV) using EndNote X8 (2018; Analytics Clarivate, Philadelphia, PA, USA).
      First, one reviewer (T.P.I.) extracted the references of the database search into the research software program (Rayyan QRCI, Cambridge, MA, USA)
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      Rayyan—a web and mobile app for systematic reviews.
      . Then, two experienced reviewers (T.P.I. and S.H.S) screened the studies based on abstract and title. Third, studies were screened based on full-text and included if they met the inclusion criteria. Any disagreement was resolved by discussion and consensus. If the authors were unable to reach a consensus, a final judgement was given by a third author L.P.E.V.

      Inclusion and Exclusion Criteria

      Observational and interventional studies reporting reasons for patients not returning to sport after surgical treatment of shoulder instability were included. Articles were excluded 1) if they only stated reasons for return to a different level of sports, 2) if no reason for no RTS was mentioned or 3) if the reasons were not assigned to a type of surgical treatment in case the article contained several types of surgery. Moreover, studies including patients with other types of ipsilateral shoulder surgery, animal studies, cadaveric studies and abstract-only publications were excluded. When studies used the same cohort of patients, the study with largest sample size was included.

      Data Extraction

      After quality appraisal, study data were extracted using a pre-determined format. Baseline characteristics included study design, sample size, gender, data regarding surgical procedure(s), mean age at surgery and mean age at follow-up. The primary outcome was reasons for patients not to RTS after surgical treatment of shoulder instability. No RTS was defined as failure to return to pre-injury type of sport after surgery. Data were divided in either capsulolabral repair or bony reconstruction procedures. Capsulolabral repair was defined as any repair of the capsulolabral complex, both open and arthroscopic, which could be combined with a remplissage. Bony reconstruction procedures were defined as any reconstruction procedure using bony tissue (e.g. Latarjet or allograft) to restore the stability of the shoulder. Besides these reasons, data was extracted regarding RTS, type of sports and sports level. Data was extracted to Excel (Microsoft Excel 2016; Microsoft Corporation, Redmond, WA, USA).

      Quality Appraisal and Proportions

      The quality of non-randomized studies was assessed using the Methodological index for non-randomized studies (MINORS) criteria
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      . Assessment was performed by two authors T.P.I. and S.H.S. Any disagreement was resolved by discussion and consensus. If the authors were unable to reach a consensus, a final judgement was given by a third author (L.P.E.V). Quality assessment for randomized studies was assessed using the revised tool to assess risk of bias in randomized trials (RoB 2) developed by Cochrane
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      RoB 2: a revised tool for assessing risk of bias in randomised trials.
      . Proportions and 95% confidence intervals were calculated for each study and forest plots were generated using Excel to visualize the data.

      Results

      Screening and Study Characteristics

      After removal of duplicates, 5320 studies were screened based on abstract and title (Figure 1). Three-hundred-eighty-one studies underwent full-text screening, given that the abstract and title of 4939 studies did not match the inclusion criteria of this study. Of these 381 studies, 333 did not meet the inclusion criteria in the end, leaving 63 studies for inclusion, comprising 3545 patients
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      • et al.
      Modified Latarjet Without Capsulolabral Repair in Rugby Players With Recurrent Anterior Glenohumeral Instability and Significant Glenoid Bone Loss.
      • Ranalletta M.
      • Rossi L.A.
      • Sirio A.
      • Diaz Dilernia F.
      • Bertona A.
      • Maignon G.D.
      • et al.
      Return to Sports and Recurrences After Arthroscopic Anterior Shoulder Stabilization in Martial Arts Athletes.
      • Roberts S.N.
      • Taylor D.E.
      • Brown J.N.
      • Hayes M.G.
      • Saies A.
      Open and arthroscopic techniques for the treatment of traumatic anterior shoulder instability in Australian rules football players.
      • Rossi L.A.
      • Tanoira I.
      • Brandariz R.
      • Pasqualini I.
      • Ranalletta M.
      Reasons Why Athletes Do Not Return to Sports After Arthroscopic Bankart Repair: A Comparative Study of 208 Athletes With Minimum 2-Year Follow-up.
      • Rossi L.A.
      • Tanoira I.
      • Gorodischer T.
      • Pasqualini I.
      • Muscolo D.L.
      • Ranalletta M.
      Are the Classic and the Congruent Arc Latarjet Procedures Equally Effective for the Treatment of Recurrent Shoulder Instability in Athletes?.
      • Saper M.G.
      • Courson J.
      • Milchteim C.
      • Plummer H.
      • Andrews J.R.
      • Ostrander 3rd, R.V.
      Successful Outcomes and Return to Sport After Arthroscopic Bankart Repair in National Collegiate Athletic Association and National Football League Football Players.
      • Saper M.G.
      • Milchteim C.
      • Zondervan R.L.
      • Andrews J.R.
      • Ostrander R.V.
      Outcomes After Arthroscopic Bankart Repair in Adolescent Athletes Participating in Collision and Contact Sports.
      ,
      • Tjong V.K.
      • Devitt B.M.
      • Murnaghan M.L.
      • Ogilvie-Harris D.J.
      • Theodoropoulos J.S.
      A Qualitative Investigation of Return to Sport After Arthroscopic Bankart Repair: Beyond Stability.
      ,
      • Uchiyama Y.
      • Hamada K.
      • Miyazaki S.
      • Handa A.
      • Fukuda H.
      Neer modified inferior capsular shift procedure for recurrent anterior instability of the shoulder in judokas.
      ,
      • Venkatachalam S.
      • Storey P.
      • Macinnes S.J.
      • Ali A.
      • Potter D.
      The Sheffield bone block procedure: a new operation for the treatment of glenoid bone loss in patients with anterior traumatic shoulder instability.
      ,
      • Yamamoto N.
      • Kijima H.
      • Nagamoto H.
      • Kurokawa D.
      • Takahashi H.
      • Sano H.
      • et al.
      Outcome of Bankart repair in contact versus non-contact athletes.
      • Yee A.J.
      • Devane P.A.
      • Horne G.
      Surgical repair for recurrent anterior instability of the shoulder.
      • Yee A.J.M.
      • Devane P.A.
      • Horne G.
      SURGICAL REPAIR FOR RECURRENT ANTERIOR INSTABILITY OF THE SHOULDER.
      • Yoneda M.
      • Hayashida K.
      • Wakitani S.
      • Nakagawa S.
      • Fukushima S.
      Bankart procedure augmented by coracoid transfer for contact athletes with traumatic anterior shoulder instability.
      . A flow chart diagram listing the reasons for exclusion is displayed in Figure 1. Forty-nine retrospective studies and ten prospective studies, of which one randomized controlled trial, were included.
      Sixty-three studies listed reasons for no RTS after surgical treatment of shoulder instability, including a total of 3545 athletes
      • Alentorn-Geli E.
      • Álvarez-Díaz P.
      • Doblas J.
      • Steinbacher G.
      • Seijas R.
      • Ares O.
      • et al.
      Return to sports after arthroscopic capsulolabral repair using knotless suture anchors for anterior shoulder instability in soccer players: minimum 5-year follow-up study.
      • Arianjam A.
      • Bell S.N.
      • Coghlan J.
      • Old J.
      • Sloan R.
      Outcomes for intra-substance free coracoid graft in patients with antero-inferior instability and glenoid bone loss in a population of high-risk athletes at a minimum follow-up of 2 years.
      • Bacilla P.
      • Field L.D.
      • Savoie 3rd, F.H.
      Arthroscopic Bankart repair in a high demand patient population.
      ,
      • Belangero P.S.
      • Lara P.H.S.
      • Figueiredo E.A.
      • Andreoli C.V.
      • de Castro Pochini A.
      • Ejnisman B.
      • et al.
      Bristow versus Latarjet in high-demand athletes with anterior shoulder instability: a prospective randomized comparison.
      ,
      • Blonna D.
      • Bellato E.
      • Caranzano F.
      • Assom M.
      • Rossi R.
      • Castoldi F.
      Arthroscopic Bankart Repair Versus Open Bristow-Latarjet for Shoulder Instability: A Matched-Pair Multicenter Study Focused on Return to Sport.
      • Bohu Y.
      • Klouche S.
      • Gerometta A.
      • Herman S.
      • Lefevre N.
      Outpatient Latarjet surgery for gleno-humeral instability: Prospective comparative assessment of feasibility and safety.
      • Brandariz R.N.
      • Gorodischer T.D.
      • Pasqualini I.
      • Rossi L.A.
      • Tanoira I.
      • Ranalletta M.
      The Latarjet Procedure Without Remplissage Is Effective to Restore Stability in Athletes With Glenoid Bone Defects Greater Than 25% and Off-Track Hill-Sachs Lesions.
      ,
      • Castricini R.
      • Castioni D.
      • De Benedetto M.
      • Cimino M.
      • Massarini A.
      • Galasso O.
      • et al.
      Arthroscopic Latarjet for Primary Shoulder Instability With Off-Track Lesions or Revision Surgery Yields Satisfactory Clinical Results and Reliable Return to Sport and Work at Minimum 3-Year Follow-Up: A Single Surgeon's Experience on 95 Cases.
      • Cordasco F.A.
      • Lin B.
      • Heller M.
      • Asaro L.A.
      • Ling D.
      • Calcei J.G.
      Arthroscopic shoulder stabilization in the young athlete: return to sport and revision stabilization rates.
      • Cruz C.A.
      • Sy J.
      • Miles R.
      • Bottoni C.R.
      • Min K.S.
      Surgical treatment of anterior shoulder instability with glenoid bone loss with the Latarjet procedure in active-duty military service members.
      • Davey M.S.
      • Hurley E.T.
      • Gaafar M.
      • Mullett H.
      • Pauzenberger L.
      Arthroscopic Bankart Repair for Primary Versus Recurrent Anterior Instability in Athletes Results in Excellent Clinical Outcomes, High Rates of Return to Play, and Low Recurrence Rates.
      • De Carli A.
      • Vadalà A.
      • Proietti L.
      • Ponzo A.
      • Desideri D.
      • Ferretti A.
      Latarjet procedure versus open capsuloplasty in traumatic anterior shoulder dislocation: long-term clinical and functional results.
      • Dekker T.J.
      • Goldenberg B.
      • Lacheta L.
      • M P.H.
      • Millett P.J.
      Anterior Shoulder Instability in the Professional Athlete: Return to Competition, Time to Return, and Career Length.
      • Dickens J.F.
      • Rue J.P.
      • Cameron K.L.
      • Tokish J.M.
      • Peck K.Y.
      • Allred C.D.
      • et al.
      Successful Return to Sport After Arthroscopic Shoulder Stabilization Versus Nonoperative Management in Contact Athletes With Anterior Shoulder Instability: A Prospective Multicenter Study.
      ,
      • Domos P.
      • Ascione F.
      • Wallace A.L.
      Arthroscopic Bankart repair with remplissage for non-engaging Hill-Sachs lesion in professional collision athletes.
      ,
      • Ee G.W.
      • Mohamed S.
      • Tan A.H.
      Long term results of arthroscopic Bankart repair for traumatic anterior shoulder instability.
      • Fabre T.
      • Abi-Chahla M.L.
      • Billaud A.
      • Geneste M.
      • Durandeau A.
      Long-term results with Bankart procedure: a 26-year follow-up study of 50 cases.
      • Fremerey R.
      • Bosch U.
      • Lobenhoffer P.
      • Wippermann B.
      Joint position awareness and sports activity after capsulolabral reconstruction in the overhead athlete.
      ,
      • Gartsman G.M.
      • Roddey T.S.
      • Hammerman S.M.
      Arthroscopic treatment of anterior-inferior glenohumeral instability. Two to five-year follow-up.
      • Gerometta A.
      • Rosso C.
      • Klouche S.
      • Hardy P.
      Arthroscopic Bankart shoulder stabilization in athletes: return to sports and functional outcomes.
      • Goldberg B.J.
      • Nirschl R.P.
      • McConnell J.P.
      • Pettrone F.A.
      Arthroscopic transglenoid suture capsulolabral repairs: preliminary results.
      • Harada Y.
      • Iwahori Y.
      • Kajita Y.
      • Takahashi R.
      • Yokoya S.
      • Sumimoto Y.
      • et al.
      Return to sports after arthroscopic bankart repair on the dominant shoulder in overhead athletes.
      • Hayashida K.
      • Yoneda M.
      • Mizuno N.
      • Fukushima S.
      • Nakagawa S.
      Arthroscopic Bankart repair with knotless suture anchor for traumatic anterior shoulder instability: results of short-term follow-up.
      • Hurley E.T.
      • Davey M.S.
      • Mojica E.S.
      • Montgomery C.
      • Gaafar M.
      • Jazrawi L.M.
      • et al.
      Analysis of patients unable to return to play following arthroscopic Bankart repair.
      • Hurley E.T.
      • Davey M.S.
      • Montgomery C.
      • Moore D.M.
      • Mojica E.S.
      • Gaafar M.
      • et al.
      Analysis of Athletes Who Did Not Return to Play After Open Latarjet.
      ,
      • Ide J.
      • Maeda S.
      • Takagi K.
      Arthroscopic Bankart repair using suture anchors in athletes: patient selection and postoperative sports activity.
      • Iizawa N.
      • Yoneda M.
      • Yamada S.
      • Mizuno N.
      • Goto K.
      • Iwashita S.
      • et al.
      Benefits of bone graft augmentation to arthroscopic Bankart repair for recurrent anterior shoulder instability with glenoid bone loss.
      • Jobe F.W.
      • Giangarra C.E.
      • Kvitne R.S.
      • Glousman R.E.
      Anterior capsulolabral reconstruction of the shoulder in athletes in overhand sports.
      • John M.
      • Nebelung W.
      • Röpke M.
      • Ender S.A.
      • Urbach D.
      Arthroscopic labrum reconstruction with capsular shift in anterior shoulder instability: improved midterm results by using a standardized suprabicipital camera position.
      • Jones K.J.
      • Kahlenberg C.A.
      • Dodson C.C.
      • Nam D.
      • Williams R.J.
      • Altchek D.W.
      Arthroscopic capsular plication for microtraumatic anterior shoulder instability in overhead athletes.
      ,
      • Kjeldsen S.R.
      • Tordrup P.J.
      • Hvidt E.P.
      Return to sport after a Bankart operation of the shoulder using the Mitek anchor system.
      ,
      • Levine W.N.
      • Arroyo J.S.
      • Pollock R.G.
      • Flatow E.L.
      • LU Bigliani
      Open revision stabilization surgery for recurrent anterior glenohumeral instability.
      • Levy D.M.
      • Gvozdyev B.V.
      • Schulz B.M.
      • Boselli K.J.
      • Ahmad C.S.
      Arthroscopic anterior shoulder stabilization with percutaneous assistance and posteroinferior capsular plication.
      • Levy O.
      • Matthews T.
      • Even T.
      The "purse-string" technique: an arthroscopic technique for stabilization of anteroinferior instability of the shoulder with early and medium-term results.
      • Lima E.B.S.
      • Osés G.L.
      • de Godoy G.P.
      • Lara P.H.S.
      • Ribeiro L.M.
      • de Figueiredo E.A.
      • et al.
      Evaluation of Latarjet procedure in female athletes: a 3-year follow-up prospective cohort study.
      ,
      • Lunn J.V.
      • Castellano-Rosa J.
      • Walch G.
      Recurrent anterior dislocation after the Latarjet procedure: outcome after revision using a modified Eden-Hybinette operation.
      • Marcacci M.
      • Zaffagnini S.
      • Petitto A.
      • Neri M.P.
      • Iacono F.
      • Visani A.
      Arthroscopic management of recurrent anterior dislocation of the shoulder: analysis of technical modifications on the Caspari procedure.
      • Marquardt B.
      • Pötzl W.
      • Witt K.A.
      • Steinbeck J.
      A modified capsular shift for atraumatic anterior-inferior shoulder instability.
      • Massoud S.N.
      • Levy O.
      • Copeland S.A.
      The vertical-apical suture Bankart lesion repair for anteroinferior glenohumeral instability.
      • McLeod A.
      • Delaney R.
      Outcomes of the arthroscopic Bankart procedure in Irish collision sport athletes.
      ,
      • Milchteim C.
      • Tucker S.A.
      • Nye D.D.
      • Lamour R.J.
      • Liu W.
      • Andrews J.R.
      • et al.
      Outcomes of Bankart Repairs Using Modern Arthroscopic Technique in an Athletic Population.
      • Mishra A.
      • Sharma P.
      • Chaudhary D.
      Analysis of the functional results of arthroscopic Bankart repair in posttraumatic recurrent anterior dislocations of shoulder.
      • Neviaser R.J.
      • Benke M.T.
      • Neviaser A.S.
      Mid-term to long-term outcome of the open Bankart repair for recurrent traumatic anterior dislocation of the shoulder.
      • Neyton L.
      • Young A.
      • Dawidziak B.
      • Visona E.
      • Hager J.P.
      • Fournier Y.
      • et al.
      Surgical treatment of anterior instability in rugby union players: clinical and radiographic results of the Latarjet-Patte procedure with minimum 5-year follow-up.
      • Ortmaier R.
      • Fink C.
      • Schobersberger W.
      • Kindermann H.
      • Mattiassich G.
      • Hochreiter J.
      • et al.
      Return to sports after glenoid reconstruction using an implant-free iliac crest bone graft.
      ,
      • Owens B.D.
      • DeBerardino T.M.
      • Nelson B.J.
      • Thurman J.
      • Cameron K.L.
      • Taylor D.C.
      • et al.
      Long-term follow-up of acute arthroscopic Bankart repair for initial anterior shoulder dislocations in young athletes.
      • Pagnani M.J.
      • Dome D.C.
      Surgical treatment of traumatic anterior shoulder instability in american football players.
      • Pagnani M.J.
      • Warren R.F.
      • Altchek D.W.
      • Wickiewicz T.L.
      • Anderson A.F.
      Arthroscopic shoulder stabilization using transglenoid sutures. A four-year minimum followup.
      • Park I.
      • Park C.J.
      • Lee J.H.
      • Hyun H.S.
      • Park J.Y.
      • Shin S.J.
      Clinical Outcomes and Recurrence Rates After Arthroscopic Stabilization Procedures in Young Patients With a Glenoid Bone Erosion: A Comparative Study Between Glenoid Erosion More and Less Than 20.
      ,
      • Plath J.E.
      • Feucht M.J.
      • Bangoj R.
      • Martetschläger F.
      • Wörtler K.
      • Seppel G.
      • et al.
      Arthroscopic Suture Anchor Fixation of Bony Bankart Lesions: Clinical Outcome, Magnetic Resonance Imaging Results, and Return to Sports.
      • Privitera D.M.
      • Bisson L.J.
      • Marzo J.M.
      Minimum 10-year follow-up of arthroscopic intra-articular Bankart repair using bioabsorbable tacks.
      • Ranalletta M.
      • Rossi L.A.
      • Bertona A.
      • Tanoira I.
      • Hidalgo I.A.
      • Maignon G.D.
      • et al.
      Modified Latarjet Without Capsulolabral Repair in Rugby Players With Recurrent Anterior Glenohumeral Instability and Significant Glenoid Bone Loss.
      • Ranalletta M.
      • Rossi L.A.
      • Sirio A.
      • Diaz Dilernia F.
      • Bertona A.
      • Maignon G.D.
      • et al.
      Return to Sports and Recurrences After Arthroscopic Anterior Shoulder Stabilization in Martial Arts Athletes.
      • Roberts S.N.
      • Taylor D.E.
      • Brown J.N.
      • Hayes M.G.
      • Saies A.
      Open and arthroscopic techniques for the treatment of traumatic anterior shoulder instability in Australian rules football players.
      • Rossi L.A.
      • Tanoira I.
      • Brandariz R.
      • Pasqualini I.
      • Ranalletta M.
      Reasons Why Athletes Do Not Return to Sports After Arthroscopic Bankart Repair: A Comparative Study of 208 Athletes With Minimum 2-Year Follow-up.
      • Rossi L.A.
      • Tanoira I.
      • Gorodischer T.
      • Pasqualini I.
      • Muscolo D.L.
      • Ranalletta M.
      Are the Classic and the Congruent Arc Latarjet Procedures Equally Effective for the Treatment of Recurrent Shoulder Instability in Athletes?.
      • Saper M.G.
      • Courson J.
      • Milchteim C.
      • Plummer H.
      • Andrews J.R.
      • Ostrander 3rd, R.V.
      Successful Outcomes and Return to Sport After Arthroscopic Bankart Repair in National Collegiate Athletic Association and National Football League Football Players.
      • Saper M.G.
      • Milchteim C.
      • Zondervan R.L.
      • Andrews J.R.
      • Ostrander R.V.
      Outcomes After Arthroscopic Bankart Repair in Adolescent Athletes Participating in Collision and Contact Sports.
      ,
      • Tjong V.K.
      • Devitt B.M.
      • Murnaghan M.L.
      • Ogilvie-Harris D.J.
      • Theodoropoulos J.S.
      A Qualitative Investigation of Return to Sport After Arthroscopic Bankart Repair: Beyond Stability.
      ,
      • Uchiyama Y.
      • Hamada K.
      • Miyazaki S.
      • Handa A.
      • Fukuda H.
      Neer modified inferior capsular shift procedure for recurrent anterior instability of the shoulder in judokas.
      ,
      • Venkatachalam S.
      • Storey P.
      • Macinnes S.J.
      • Ali A.
      • Potter D.
      The Sheffield bone block procedure: a new operation for the treatment of glenoid bone loss in patients with anterior traumatic shoulder instability.
      ,
      • Yamamoto N.
      • Kijima H.
      • Nagamoto H.
      • Kurokawa D.
      • Takahashi H.
      • Sano H.
      • et al.
      Outcome of Bankart repair in contact versus non-contact athletes.
      • Yee A.J.
      • Devane P.A.
      • Horne G.
      Surgical repair for recurrent anterior instability of the shoulder.
      • Yee A.J.M.
      • Devane P.A.
      • Horne G.
      SURGICAL REPAIR FOR RECURRENT ANTERIOR INSTABILITY OF THE SHOULDER.
      • Yoneda M.
      • Hayashida K.
      • Wakitani S.
      • Nakagawa S.
      • Fukushima S.
      Bankart procedure augmented by coracoid transfer for contact athletes with traumatic anterior shoulder instability.
      . Study characteristics are displayed in Supplement 2. Articles were published between 1991 and 2022, with sample sizes ranging from 16 to 208. The mean age for patients at time of surgery ranged from 18 to 41.2 years and the mean follow-up ranged from 17 to 88.8 months.

      Quality Assessment

      The MINORS score ranged from 6 to 21 in studies listing reasons for patients not returning to sport after surgical treatment of shoulder instability (Supplement 2). The RoB 2 score of the randomized study by Belangero, listing reasons for patients not returning to sport after surgical treatment of shoulder instability revealed a low risk of bias (Supplement 2)
      • Belangero P.S.
      • Lara P.H.S.
      • Figueiredo E.A.
      • Andreoli C.V.
      • de Castro Pochini A.
      • Ejnisman B.
      • et al.
      Bristow versus Latarjet in high-demand athletes with anterior shoulder instability: a prospective randomized comparison.
      .

      Reasons for patients not to return to sport following capsulolabral repair

      Of the 3545 athletes who were involved in sport prior to surgical treatment, 2588 (73%) athletes underwent capsulolabral repair, of which 482 (18%) did not RTS. When comparing different reasons for no RTS following capsulolabral repair, athletes cited shoulder function independent reasons more often than shoulder function dependent reasons (72% vs 28%). Mostly cited shoulder function dependent reasons for no RTS were apprehension (9%), recurrent shoulder instability (8%) and persisting shoulder pain (3%) (Figure 2). Thirty-three athletes (7%) cited shoulder related reasons which were not further specified. Mostly cited shoulder function independent reasons were fear of re-injury (17%), personal reasons or change of priorities (12%) and retirement/discharge from military service or sports team (10%) (Figure 3). Seventy-three athletes (15%) cited shoulder unrelated reasons which were not further specified. Reasons for no RTS following capsulolabral repair are listed in Figure 2 and 3. The forest plot demonstrating shoulder function independent reasons not to RTS following capsulolabral repair showed proportions ranging from 0-100% (Figure 4).
      Figure thumbnail gr2
      Figure 2Shoulder function dependent reasons for no return to sports after capsulolabral repair
      Figure thumbnail gr3
      Figure 3Shoulder function independent reasons for no return to sports after capsulolabral repair
      Figure thumbnail gr4
      Figure 4Forest plot demonstrating studies’ proportions of shoulder function independent reasons for no return to sport following capsulolabral repair

      Reasons for patients not to return to sport following bony reconstruction procedures

      A total of 957 (27%) out of 3545 included athletes underwent surgical treatment with bony reconstruction procedures, of which 168 did not RTS (18%). Similar to capsulolabral repair, shoulder function independent reasons were cited more often compared to shoulder function dependent reasons following bony reconstruction procedures (65% vs 35%). Mostly cited shoulder function dependent reasons for not returning to sport were shoulder pain (10%), apprehension (8%) and recurrent shoulder instability (2%). Twenty-three athletes (13%) cited shoulder related reasons which were not further specified. Mostly cited shoulder function independent reasons were fear of re-injury (13%), retirement/discharge from military service or sports team (10%) and graduation (4%). Fifty-one patients cited shoulder unrelated reasons which were not further specified (30%). Reasons for no RTS following bony reconstruction procedures are listed in Figure 5 and 6. The forest plot demonstrating shoulder function independent reasons not to RTS following bony reconstruction procedures showed proportions ranging from 0-100% (Figure 7).
      Figure thumbnail gr5
      Figure 5Shoulder function dependent reasons for no return to sports following bony reconstruction procedures
      Figure thumbnail gr6
      Figure 6Shoulder function independent reasons for no return to sports following bony reconstruction procedures
      Figure thumbnail gr7
      Figure 7Forest plot demonstrating studies’ proportions of shoulder function independent reasons for no return to sport following bony reconstruction procedures

      Discussion

      The purpose of this study was to critically and systematically review athletes’ reasons not to RTS after surgical treatment of anterior shoulder instability, in order to improve pre- and postoperative patient counselling. The most important finding of this study is that majority of athletes who did not RTS following surgical treatment of shoulder instability did so due to shoulder function independent reasons, like fear of re-injury. The cause of this remains unclear. It might be associated with pathophysiological alterations such as functional cerebral changes fear or the unpredictability of an unstable shoulder
      • Livett M.F.
      • Williams D.
      • Potter H.
      • Cairns M.
      Functional cortical changes associated with shoulder instability – a systematic review.
      ,
      • Shitara H.
      • Shimoyama D.
      • Sasaki T.
      • Hamano N.
      • Ichinose T.
      • Yamamoto A.
      • et al.
      The Neural Correlates of Shoulder Apprehension: A Functional MRI Study.
      . To elucidate this relationship, further (prospective) research is needed. Second, this study compared the reasons for patients who did not RTS following capsulolabral repair and bony reconstruction procedures. This study found a high failure rate to RTS for both treatments, which can be explained by the exclusion of studies with a 100% RTS rate. In addition, there were slight differences in the distribution of reasons not to RTS between the two types of surgical treatment, with shoulder function independent reasons seemingly being listed more often in patients undergoing capsulolabral repair.

      Return to sport

      This systematic review showed that there are multiple reasons for athletes not to return to (their pre-in jury type of) sport, ranging from shoulder related reasons (e.g. recurrent shoulder instability and fear-of re-injury) to shoulder unrelated reasons (e.g. knee injury, motivation, and personal reasons). The maximal medical improvement following shoulder stabilization surgery may take up to 12 months, which could be explained by the underexposed psychological components of the issue
      • Patel B.H.
      • Lu Y.
      • Agarwalla A.
      • Puzzitiello R.N.
      • Nwachukwu B.U.
      • Cvetanovich G.L.
      • et al.
      Maximal Medical Improvement Following Shoulder Stabilization Surgery May Require up to 1 Year: A Systematic Review.
      . This can differ depending on the athletes’ motivational and type of medical and emotional support during the process. Despite the fact that the reported RTS rates after surgery seem high, returning to pre-injury level of sports may be challenging. Two studies show that respectively 50% and 68% of the high-level athletes were able to RTS after surgical stabilization of the glenohumeral joint
      • LU Bigliani
      • Kurzweil P.R.
      • Schwartzbach C.C.
      • Wolfe I.N.
      • Flatow E.L.
      Inferior Capsular Shift Procedure for Anterior-inferior Shoulder Instability in Athletes.
      ,
      • Kvitne R.S.
      • Jobe F.W.
      • Jobe C.M.
      Shoulder instability in the overhand or throwing athlete.
      . Additionally, the study of Bak et al shows that after 4.5 years of follow-up, only 48% of their population was still participating in sports following surgical stabilization of the glenohumeral joint
      • Bak K.
      • Spring B.J.
      • Henderson J.P.
      Inferior capsular shift procedure in athletes with multidirectional instability based on isolated capsular and ligamentous redundancy.
      .

      Psychological impact of physical trauma

      In this study, 20% of the athletes who did not RTS after surgical treatment of shoulder instability cited fear of re-injury, lack of confidence or insecurity as reason to cease their sport activity. Psychological components have been reported to play a key role in considering the RTS of athletes
      • Kordasiewicz B.
      • Małachowski K.
      • Kicinski M.
      • Chaberek S.
      • Boszczyk A.
      • Marczak D.
      • et al.
      Intraoperative graft-related complications are a risk factor for recurrence in arthroscopic Latarjet stabilisation.
      ,
      • Rossi L.A.
      • Tanoira I.
      • Brandariz R.
      • Pasqualini I.
      • Ranalletta M.
      Reasons Why Athletes Do Not Return to Sports After Arthroscopic Bankart Repair: A Comparative Study of 208 Athletes With Minimum 2-Year Follow-up.
      ,
      • Tjong V.K.
      • Devitt B.M.
      • Murnaghan M.L.
      • Ogilvie-Harris D.J.
      • Theodoropoulos J.S.
      A Qualitative Investigation of Return to Sport After Arthroscopic Bankart Repair: Beyond Stability.
      . Kordasiewicz et al found that 46% of the patients were anxious to RTS after undergoing the Latarjet procedure, which is regarded as the type of shoulder stabilizing procedure yielding the lowest prevalence of recurrent instability
      • Abdul-Rassoul H.
      • Galvin J.W.
      • Curry E.J.
      • Simon J.
      • Li X.
      Return to Sport After Surgical Treatment for Anterior Shoulder Instability: A Systematic Review.
      . In addition, a qualitative study containing 25 semi-structured interviews with shoulder instability patients also revealed that reasons which were not a physical shoulder problem (e.g. fear of re-injury, social support, and self-motivation) greatly influenced the patients’ decision to RTS
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      A Qualitative Investigation of Return to Sport After Arthroscopic Bankart Repair: Beyond Stability.
      . Although recent studies already showed that kinesiophobia is correlated to the RTS after shoulder stabilization surgery, there is no (p)rehabilitation consensus protocol currently available which includes this psychosocial component
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      . Future studies are needed to reach consensus about the content of such a (p)rehabilitation protocol, explicitly including the psychological component of the physical problem of shoulder instability.

      Return to sport as outcome measure

      Patients often have high expectations of surgical treatment of shoulder instability
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      Patient understanding, expectations, outcomes, and satisfaction regarding surgical management of shoulder instability.
      . One of those key expectations is RTS. However, to date, there is no consensus on the definition of RTS in current literature, which may result in heterogeneity, potentially causing bias among studies investigating RTS
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      . Most studies define RTS as the return to any level of sport postoperatively. However, others strictly define it as the return to pre-injury level of sport, which was defined as successful RTS in this study. Moreover, there is also no consensus on what the RTS includes. Some studies refer to return to competitive play or competing a game, while other studies also include return to practice. Furthermore, it is not well defined for what period of time an athlete should return for it to be defined as RTS and whether or not physical complaints are allowed to be present during this return. Broad consensus is needed to clearly define these dimensions to reduce potential bias.
      Moreover, this study showed that the majority of athletes who did not RTS following surgical treatment of shoulder instability did so due to shoulder function independent reasons, including reasons like fear of re-injury and apprehension. Almost all included studies did not report on readiness to RTS, which could explain the high amount of shoulder function independent reasons. If an athlete is not ready to RTS, it might not be fair to assess the surgical treatment with RTS as an outcome.

      Limitations

      This systematic review has several limitations. First, most (53/63) included studies had a retrospective design, which may introduce bias into the design of a study, such as recall bias
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      Arthroscopic Latarjet for Primary Shoulder Instability With Off-Track Lesions or Revision Surgery Yields Satisfactory Clinical Results and Reliable Return to Sport and Work at Minimum 3-Year Follow-Up: A Single Surgeon's Experience on 95 Cases.
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      ,
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      ,
      • Yamamoto N.
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      • et al.
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      • Devane P.A.
      • Horne G.
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      • Yee A.J.M.
      • Devane P.A.
      • Horne G.
      SURGICAL REPAIR FOR RECURRENT ANTERIOR INSTABILITY OF THE SHOULDER.
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      Bankart procedure augmented by coracoid transfer for contact athletes with traumatic anterior shoulder instability.
      . Moreover, retrospective studies are susceptible to methodological flaws such as selection bias and possible loss of data
      • Tofthagen C.
      Threats to validity in retrospective studies.
      . Second, many studies reported whether reasons for not returning to sports after surgery were shoulder related or not shoulder related, but reasons were not always specified. This precluded a detailed statement of the nature of the reasons and if they were largely physically or psychologically motivated, potentially explaining the wide spectrum of proportions in the forest plots. In addition, RTS rate in general is a relevant and important patient-centered outcome measure to assess the treatment chain. However, it may not be an optimal outcome to evaluate the effect of surgery itself. Both physical and psychological rehabilitation remain of vital importance. Third, this study included studies ranging from 1991 to 2022, with nine out of 63 studies being published before 2000. The main focus was to include as many reasons of patients not returning to sport, not specifically focusing on one group, for instance professional athletes. This could potentially lead to high heterogeneity an could create bias. However, subgroup analysis was performed comparing studies only including competitive and professional athletes, and results were comparable to those of the entire included population in this systematic review.
      Further research should focus on the integration of these two aspects within the treatment protocol. Recently Kim et al published a comparable study investigating reasons for failure to sports after arthroscopic Bankart repair in 17 studies containing 813 athletes
      • Kim M.
      • Haratian A.
      • Fathi A.
      • Kim D.R.
      • Patel N.
      • Bolia I.K.
      • et al.
      Can We Identify Why Athletes Fail to Return to Sports After Arthroscopic Bankart Repair: A Systematic Review and Meta-analysis.
      . In contrast to that study, this study managed to summarize data of 63 studies containing reasons of 3545 athletes ceasing sports activity following both capsulolabral repair and bony reconstruction procedures, making it the largest sample size currently available regarding this subject.

      Conclusion

      The majority of athletes who did not RTS following surgical treatment for anterior shoulder instability did so due to shoulder function independent reasons, such as fear of re-injury. However, there was a high variety between studies and many reasons were unspecified, warranting unified definitions for reasons of patients that do not RTS.

      Appendix A. Supplementary data

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