Introduction

In athletes with RASI, selecting the appropriate surgery is always controversial. Patient’s age, type of sport and bipolar bone defect (BBD) are the main risk factors [1]. In our setting, probably the most common clinical presentation of a patient with RASI is a limited-contact athlete, < 30 years old, with or without subcritical glenoid bone defect (SGBL) and on-track Hill Sachs lesion (HSL). According to the surgeon's preference, this patient can be treated with an arthroscopic Bankart repair plus remplissage (ABR + R), open Bankart repair plus inferior capsular shift (OBICS) or the Latarjet procedure (LA) in some European countries [2, 3]. However, some current algorithms still recommend an isolated arthroscopic Bankart repair (IABR) [4, 5]. The Bankart lesion, a detachment of the anteroinferior glenoid labrum that typically extends from the 2 o’clock position to the 6 o’clock position, is considered the "essential" lesion in patients with RASI [6]. Clinical studies have described a wide variety of Bankart lesion variants as well as combined labral lesions [7]. One of these is the Bankart lesion combined with a type II SLAP lesion (Superior, Labral, Anterior to Posterior) referred to as type V SLAP lesion by Maffet et al. [8]. In athletes with RASI, the incidence of type V SLAP lesions can range from 20 to 57% [9]. Studies report that type II SLAP lesions may cause increased glenohumeral translation, which may be augmented if it is associated with a Bankart lesion [10, 11]. Several studies have reported that the repair of type V SLAP lesions is associated with promising results including low recurrence rate, good function and early return to sport [12, 13]. However, other studies have also found some complications, probably related to the large repair of the injured labral segment. These include loss of ROM, slow postoperative ROM recovery and slow return to sports [14, 15]. As a treatment alternative, open or arthroscopic Bankart repair without SLAP lesion repair may offer a minor labral repair with probably similar results [16, 17]. To our knowledge, only one prospective study has evaluated the clinical effect of an extended labral repair in patients with type V SLAP lesions [16]. The aim of this study was to compare the functional outcomes, recurrence rate, ROM and return to sport between ABR versus (vs.) ABR/S in limited-contact athletes with type V SLAP lesions in the RASI scenario. Our hypothesis was that there is no difference between the two treatments.

Methods

Study design and patient selection

Over the last 8 years we conducted a prospective study in which 108 athletes with RASI agreed to participate. Only 90 completed the study with a minimum follow-up of 2 years. Informed consent was obtained from all patients. This study was approved by the ethics committee of our hospital. RASI was defined as the presence of two or more episodes of dislocation and/or subluxation. Hyperlaxity was defined as external rotation (ER) > 85° and/or Gagey hyperabduction test > 100°. According to the American Academy of Pediatrics Committee on Sports Medicine (AAPCSM), sports such as basketball, volleyball, artistic gymnastics, hockey, bodybuilding, martial arts and skateboarding were considered limited-contact sports. Limited-contact athletes with RASI ≥ 16 years and ≤ 30 years with a diagnosis of type V SLAP lesion were included in this study. Variants of Bankart lesion (ALPSA, Perthes, or GLAD) as well as athletes with SGBL ≤ 10% and on-track HSL were included. Athletes with hyperlaxity were also included. We excluded bony Bankart lesion, triple labral lesion, collision athletes, 1st episode of anterior instability, athletes with previous surgeries, degenerative joint changes, rotator cuff rupture, pain as the main symptom, multidirectional instability or voluntary instability. Two study groups of 45 patients each were formed. Group 1 was treated with ABR while group 2 with ABR/S. Surgical treatment was performed by two surgeons with more than 15 years of experience in shoulder surgery. It was decided that surgeon “A” would perform all surgeries in group 1 while surgeon “B” would conduct all surgeries in group 2 (Fig. 1).

Fig. 1
figure 1

Methodological diagram, limited contact sports, group conformation and inclusion and exclusion criteria

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Surgical technique

All operations were performed under general anaesthesia. Patients were placed in the lateral decubitus position with the arm in 60° abduction. Bankart repair was initially performed through three portals; a standard posterior visualization portal and two working portals, anterosuperior and anteroinferior. Arthroscopic labral examination was performed to look for a type V SLAP lesion. The labral margin of the glenoid rim was mobilized with a curette from the 2 o'clock to the 7 o'clock position. The bony margin was decorticated with an arthroscopic rasp to create a bleeding bone bed. The first anchor was placed in the 5 o'clock position through the anteroinferior portal at 1–2 mm from the articular cartilage of the glenoid rim. We used single suture non-absorbable polymer (Peek) anchors in all cases. Through the anteroinferior portal and using a spectrum set loaded with 1–0 polydioxadone monofilament suture, the joint capsule was penetrated 1 cm from the glenoid rim under the anteroinferior labrum. The anchor suture was used to attach the labrum to the glenoid rim by a sliding knot. Additional anchors were placed in the 4 o'clock and 3 o'clock positions. In some cases, an additional anchor was placed in the posteroinferior location through a portal in the 7 o'clock position. In group 2, an additional Wilmington portal was created to facilitate SLAP repair. In all cases, 2 anchors were used, one of them was placed in the 11 o'clock position and the other in the 1 o'clock position.

Rehabilitation protocol

The rehabilitation process was similar in both groups. A sling with the shoulder in internal rotation was used as a means of protection for 6 weeks. Active flexion and extension of the elbow as well as progressive ER up to 25° were allowed. From 6 weeks onwards, exercises were started to improve ER and shoulder elevation. Muscle strengthening exercises of the rotator cuff and scapular muscles were performed after 8 weeks. Depending on the patient, return to sport was allowed after 6 months.

Clinical and functional assessment

The WOSI score and the ASES scale were used to measure primary functional outcomes. It is important to stress that the WOSI score was converted to a value from 0 to 100, with a higher score representing a better quality of life. All patients were evaluated pre and postoperatively and then between groups. The recurrence rate was assessed between the two groups. Using a manual goniometer, pre and postoperative ROM were measured for each group, as well as between them. Return to pre-injury sports activities was also evaluated. Like Jeon et al., we classified the levels of postoperative sports activities into 4 grades [18]. All evaluations were conducted at six months, one year and at least two years’ follow-up. Postoperative examinations were performed by the same surgeons.

Image assessment

All athletes underwent frontal X-rays in external rotation (ER), internal rotation (IR) and axial view as well as magnetic resonance imaging (MRI). Three-dimensional CT scan with image subtraction was only performed in those patients who presented BBD. The "best circle" method and the glenoid track (GT) concept were used to assess whether the patient had SGBL ≤ 10% as well as to define the type of HSL. Finally, arthroscopic visualisation confirmed the diagnosis of type V SLAP lesion.

Statistical analysis

Data were analysed with SPSS for Windows 7, version 18.0. A power analysis was performed based on a probable recurrence rate of 25%. The chi-square test or Fisher's exact test were used for categorical variables, and the independent t-test was used for continuous variables. The Bonferroni correction was applied for multiple comparisons. The Mann–Whitney U-test was used to investigate differences in the level of return to sport. Categorical data were presented as numbers or percentages, and continuous data as mean and standard deviation. A p-value < 0.05 was considered statistically significant.

Results

Demographic data, functional outcomes, ROM and return to previous sports activities

There were no significant differences between the demographic characteristics of the two groups (Table 1). The mean WOSI and ASES scores of each group reported significant differences between the pre- and postoperative period of each group. However, there were no significant differences in the WOSI and ASES scores between the two groups at the end of follow-up (Table 2). No significant differences were found between the pre- and postoperative ROM of each group. There were also no differences between the two groups at the end of follow-up (Table 2). Most patients returned to sport after 6 months. There was no difference in the level of return to sport activities between the two groups (Table 2).

Table 1 Baseline demographic characteristics of included patients
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Table 2 Functional outcomes, ROM and Return to sporting level at final follow up evaluation. (Media—Standard deviation)
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Recurrence of instability

At the end of follow-up, 4 patients (8.8%) in group 1 and 5 patients (11.1%) in group 2 had recurrence of instability. These results were not significant (p = 0.62). Three basketball players in group 1 had recurrence in the form of dislocation and one martial arts patient had a subluxation. All were high-energy episodes in abduction and ER. All athletes were hyperlaxed, < 25 years old, with SGBL and HSL. Five athletes in group 2 had episodes of dislocation secondary to new traumatic events. Two were involved in martial arts, two in artistic gymnastics and one in basketball. Four of them were < 25 years old and all of them had hyperlaxity, SGBL and HSL (Table 3).

Table 3 Recurrent instability at final follow-up
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Discussion

This study has shown that limited-contact athletes with type V SLAP lesion can be treated with either an ABR or ABR/S without compromising shoulder function and stability. In an athlete with RASI, the selection of the best surgical procedure is closely related to risk factors [19]. According to the surgeon's preference, ABR + R, OBICS or LA are currently the best alternatives to reduce the rate of recurrence [3, 4]. However, some current algorithms still promote IABR in limited-contact athletes with SGBL ≤ 10% and on-track HSL [4, 5, 19] In a comparative study, Petrera et al. treated collision and contact athletes without glenoid bone defect with IABR [20] In turn, Yamamoto et al. conducted a retrospective study comparing contact vs. non-contact athletes in < 25 years treated with IABR. The authors do not mention how many patients had SGBL [21]. In our study, all patients were limited-contact athletes, with or without SGBL, on-track HSL and all of them were treated with IABR. Our study found no differences between the functional outcomes of the two groups. In a retrospective study conducted by Aydin et al. including patients with type V SLAP lesion comparing ABR vs ABR/S, the authors found no difference between the groups when assessing Constant and Rowe scores [14]. In a similar study, Lee et al. compared ABR vs ABR/S with no differences in the ASES, Rowe and Constant scores reported [17]. In surgical practice, when faced with an arthroscopic diagnosis of a type V SLAP lesion, most colleagues will probably tend to repair both lesions. However, the evidence is unclear regarding the likely consequences of an extended labral repair. Biomechanical studies have reported a further increase in anteroinferior glenohumeral instability with the combination of a Bankart or variant lesion with a SLAP lesion [22, 23]. Recent clinical studies comparing ABR vs ABR/S report no difference between the two treatments in terms of recurrence rate [16, 23] In a prospective cohort study, Hantes et al. compared ABR vs ABR/S, reporting a single episode of recurrence for each group. The authors include athletes with different levels of competition and they do not include athletes with glenoid bone defect. Due to the time of publication, the concept of GT as a predictor of failure is not mentioned and not all athletes included had a type V SLAP lesion [16]. In a retrospective study, Aydin et al. compared 19 patients treated with ABR/S (group 1) vs. 38 treated with ABR (group 2). One patient in group 1 and two in group 2 had recurrence in the form of dislocation with no differences reported between the groups. The authors do not include patients with SGBL and do not describe the type of sport practised [14]. In a retrospective study of 58 patients divided into two groups, group C 30 ABR and group NC 28 ABR/S, Lee et al. reported no differences in recurrence rate. The authors did not include SGBL and did not mention the type of sport involved [17]. In our study, 4 (8.8%) athletes in group 1 and 5 in group 2 (11.1%) had recurrence of instability. However, there were no differences between the two groups with most of them being < 25 years old, limited-contact athletes; some were hyperlaxed and many had SGBL with on-track HSL. Studies report decreased ROM with combined repair of a Bankart lesion plus SLAP lesion [24, 25]. The cause of the stiffness could be multifactorial or perhaps associated with the location of the anchors [26]. In a cadaveric study, Itoigawa et al. compared the open Bankart repair with the open Bankart plus SLAP lesion repair. Although the authors reported no differences in terms of glenohumeral stability, patients who underwent the Bankart repair alone reported greater range of motion [26]. In a comparative clinical study between ABR vs ABR/S, Lee et al. found no difference in ROM [17]. Other studies performing the same comparison also reported no difference in ROM [14, 16, 17]. In our study, similar results were reported in ROM between preoperative and postoperative values of each group as well as between them. Probably due to a greater difficulty in ROM recovery, some studies report a slow return to the same sport level in athletes who had a combined labral repair [25, 27, 28]. This situation is particularly noticiable in overhead athletes [26]. Cho et al. reported a substantial reduction in ROM in the first weeks postoperatively in 15 patients with type V SLAP lesion managed with ABR/S, who achieved normal ROM at the end of follow-up. The authors did not evaluate return to sport [25]. Hantes et al. reported that 89% of patients in Group A and 76% in Group B returned to the same sporting level [22]. Lee et al. also reported that 90% of the patients in Group C and 85.7% in Group NC resumed their sporting activities [16]. In our study, more than 90% of the patients in both groups returned to sporting activities. Our study has limitations. First of all, it is not a randomised study. Second, 18 patients declined mainly due to cultural reasons. Third, the follow-up of our patients is too short. A longer follow-up could possibly alter the current results regarding recurrence of stability.

Conclusions

Limited-contact athletes with RASI who have a type V SLAP lesion as their primary diagnosis can be treated using either ABR or ABR/S with equal efficacy. Both treatment alternatives preserve athlete's function, stability, ROM and return to sport.