Excellent Clinical Outcomes and Rates of Return to Play After Arthroscopic Rotator Cuff Repair for Traumatic Tears in Athletes Aged 30 Years or Less

Open AccessPublished:March 22, 2021DOI:https://doi.org/10.1016/j.asmr.2021.01.003

      Purpose

      To evaluate clinical outcomes and rate of return to play (RTP) among athletes aged 30 years or younger who have undergone an arthroscopic rotator cuff repair (ARCR) after trauma.

      Methods

      We performed a retrospective review of patients who underwent an ARCR with a minimum of 12 months’ follow-up between 2012 and 2019. Patients were followed up to assess the American Shoulder and Elbow Surgeons score, Subjective Shoulder Value, visual analog scale score, and satisfaction level. Whether patients were able to RTP was reported, in addition to the timing of return and the level to which they returned.

      Results

      Our study included 20 athletes (20 shoulders), with a mean follow-up period of 31.8 months. All patients were satisfied with their surgical procedure, and all would opt to undergo surgery again. Overall, 85% returned to sport and 50.0% returned to the same level or a higher level. The overall mean American Shoulder and Elbow Surgeons score was 92.4; mean Subjective Shoulder Value, 87.0; and mean visual analog scale score, 0.7. At final follow-up, only 1 patient (5.0%) had undergone a revision procedure. Of the 15 patients who played collision sports, 93.3% returned to sport but only 60.0% returned to the same level or a higher level.

      Conclusions

      After ARCR, athletes aged 30 years or younger show excellent functional outcomes with high rates of patient satisfaction and RTP after the procedure.

      Level of Evidence

      Level IV, therapeutic case series.
      Rotator cuff tears (RCTs) are a common pathology occurring mostly in older patients, with the prevalence approaching 65% in those aged 80 years or older in the general population.
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      Patient preference before and after arthroscopic rotator cuff repair: Which is more important, pain relief or strength return?.
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      A survey of expert opinion regarding rotator cuff repair.
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      Do articular-sided partial-thickness rotator cuff tears after a first-time traumatic anterior shoulder dislocation in young athletes influence the outcome of surgical stabilization?.
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      The purpose of this study was to evaluate clinical outcomes and rate of RTP among athletes aged 30 years or younger who have undergone an ARCR after trauma. Our hypothesis was that young athletes undergoing ARCR would show satisfactory clinical outcomes and levels of RTP at final follow-up.

      Methods

       Inclusion Criteria

      We carried out a retrospective review of all patients who underwent ARCR performed by a single surgeon (H.M.) between July 2012 and March 2019. The inclusion criteria for this study included athletes presenting acutely after trauma while playing organized sports, age 30 years or younger, ARCR performed within 3 months of injury, and a minimum of 12 months’ follow-up. The exclusion criteria included previous ipsilateral shoulder surgery and concomitant repair of other pathology after diagnostic arthroscopy.

       Surgical Technique and Rehabilitation Protocol

      Rotator cuff repairs were performed as necessary with 1 or more suture anchors in a single- or double-row configuration. In case of a double-row repair, a configuration with medial knots and knotless lateral anchors was used. Because all patients included in this series were young and active, a double-row repair with medial knots and knotless lateral anchors was performed in all cases. A mixture of knotted medial-row anchors with No. 2 high-strength sutures (TwinFix [Smith & Nephew, Andover, MA] and Y-Knot [ConMed, Utica, NY]) and knotless lateral-row anchors (SwiveLock [Arthrex, Naples, FL] and Healicoil [Smith & Nephew]) was used. Depending on the extent of the tear, 1 or 2 medial-row anchors and 1 or 2 lateral anchors were used in this series. In patients with concomitant subscapularis tears, an additional suture anchor was used.
      The rehabilitation protocol was the same for all patients. Postoperatively, the shoulder was placed in a sling for 3 weeks, but passive exercises and non-resisted activities of daily living, without excessive elevation or external rotation of the shoulder, were allowed. Patients started active physiotherapy in the fourth postoperative week, which continually increased in intensity over the next 9 weeks. A controlled return to contact in training was allowed after 12 weeks if comfortable, whereas a return to full contact and competition usually followed within the next 3 months.

       Clinical Outcomes

      An evaluation of postoperative patient-reported outcomes was performed after a telephone survey including the American Shoulder and Elbow Surgeons (ASES) score, Subjective Shoulder Value (SSV), visual analog score (VAS) score, rate of RTP, level of RTP, patient satisfaction, willingness to undergo the same procedure again, postoperative complications, and further operations on the ipsilateral shoulder. Collision sports were defined as rugby, Gaelic athletic games, hockey, and football in the National Football League. Additionally, RTP was defined as a return to organized sports involving competition in league format and was self-reported by the athletes at final follow-up.

       Statistical Analysis

      Statistical analysis was carried out using IBM SPSS Statistics for Windows software (version 22.0 [2013 release]; IBM, Armonk, NY).

      Results

       Patient Demographic Characteristics

      Overall, 996 patients underwent ARCR. After analysis, 20 patients (16 male and 4 female patients), including 20 shoulders, met the inclusion criteria. The patients comprised 2 professional athletes (10.0%), 16 competitive athletes (80.0%) and 2 recreational athletes (10.0%); there were 15 collision athletes (75.0%). Overall, the mean age of included patients was 25.5 ± 3.5 years (range, 18-29 years), with a mean follow-up period of 31.8 ± 14.7 months (range, 15-56 months). All included athletes underwent ARCR for supraspinatus tears, with 2 patients undergoing concomitant subscapularis tear repair. A summary of patient demographic characteristics is presented in Table 1.
      Table 1Patient Characteristics
      Outcomen%MeanRange
      Shoulders20
      Patients20
      Male patients1680
      Age, yr25.518-29
      Follow-up, mo31.815-56
      Collision athlete1575
      Overhead sport athlete420
      Professional athlete210
      Competitive athlete1680
      Recreational athlete210

       Patient-Reported Outcomes

      At final follow-up, the mean ASES score was 92.4 ± 5.4 (range, 83.3-100); mean SSV, 87.0 ± 10.2 (range, 70-100); and mean VAS score, 0.7 ± 1.0 (range, 0.0-3.0). Overall, 100% of patients were satisfied at final follow-up, and all included patients reported that they would opt to undergo ARCR surgery again. A summary of patient-reported outcomes is presented in Table 2.
      Table 2Patient-Reported Outcomes
      Outcomen%MeanRange
      Total20100
      Satisfied20100
      Patient would undergo surgery again20100
      ASES score92.483.3-100
      SSV87.070-100
      VAS score0.70-3
      Revision surgery15.0
      ASES, American Shoulder and Elbow Surgeons; SSV, Subjective Shoulder Value; VAS, visual analog scale.

       Return to Play

      At final follow-up, the overall rate of RTP was 85.0%, with a mean duration of 5.8 ± 2.8 months required after ARCR to RTP. Overall, 50.0% of athletes returned to the same level or a higher level of sport and 30.0% returned to a lower level of sport. After ARCR, 1 patient (5.0%) opted to change sport. For the professional and competitive athletes, the overall rate of RTP was 88.9%. Among the 3 patients who did not RTP (15.0%), they reported this was because of the shoulder injury in 10% of cases and because of other factors in 5.0%. A summary of RTP is presented in Table 3.
      Table 3Return to Play
      Outcomen%Mean
      RTP1785
      Time to RTP, mo5.8
      RTP at SL or HL1050
      RTP at LL630
      RTP at LL owing to shoulder-related factor420
      RTP at LL owing to other factor210
      Changed sport15
      No RTP315
      No RTP owing to shoulder-related factor210
      No RTP owing to other factor15
      HL, higher level; LL, lower level; RTP, return to play; SL, same level.

       Complications

      Overall, no intraoperative complications (0%) were reported for any of the ARCR procedures. Only 1 subsequent procedure (5.0%) was reported after ARCR: a single arthroscopic stabilization in a collision athlete.

       Collision Athletes

      Overall, 15 collision athletes (13 male and 2 female patients) who underwent ARCR were included in this study, with a mean age of 25.1 ± 3.3 years (range, 18-29 years) and mean follow-up period of 31.1 ± 12.9 months (range, 15-56 months). At final follow-up, the mean ASES score was 94.4 ± 4.6 (range, 86.7-100); mean SSV, 87.0 ± 10.2 (range, 75-100); and mean VAS score at rest, 0.5 ± 0.9 (range, 0-2). The overall rate of RTP was 93.3%, with a mean duration of 5.9 ± 3.0 months required after ARCR to RTP. Overall, 60.0% of collision athletes returned to the same level or a higher level of sport and 33.3% returned to a lower level of sport (20% because of shoulder issues). No intraoperative complications (0%) were reported, and only 1 subsequent procedure (5.0%) was reported after ARCR: a single arthroscopic stabilization in a collision athlete. All patients reported being satisfied with the ARCR procedure at final follow-up. A summary of findings specific to collision athletes is presented in Table 4.
      Table 4Findings Specific to Collision Athletes
      Outcomen%MeanRange
      Shoulders15
      Male patients1386.7
      Professional213.3
      Competitive1386.7
      Age, yr25.118-29
      Follow-up, mo31.115-56
      ASES score94.486.7-100
      SSV87.075-100
      VAS score0.50-2
      RTP1493.3
      Time to RTS, mo5.93-12
      RTP at SL or HL960.0
      RTP at LL533.3
      RTP at LL owing to shoulder-related factor320.0
      No RTP16.7
      No RTP owing to other factor16.7
      ASES, American Shoulder and Elbow Surgeons; HL, higher level; LL, lower level; RTP, return to play; SL, same level; SSV, Subjective Shoulder Value; VAS, visual analog scale.

      Discussion

      The most important finding from this study was that patients aged 30 years or younger undergoing ARCR reported excellent clinical outcomes and satisfactory levels of return to sport at short-term follow-up. Both collision and non-collision athletes were satisfied with their pain levels and functional outcomes after ARCR while reporting high rates of RTP. Thus, ARCR is a reasonable option in athletes who have traumatic RCTs and are hoping to RTP; however, counseling is required because many young athletes are unable to RTP at their preinjury level after ARCR.
      Shoulder injuries are more common among athletes when compared with the general population; however, the incidence of RCTs has been shown to increase proportionally with increasing age.
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      Our study reported on a variety of athletes, with three-quarters of included athletes being involved in collision sports and one-fifth, in overhead-throwing sports. Multiple studies have described the challenge for the overhead athlete in achieving RTP after ARCR, with a wide range of rates of RTP from less than 20% to nearly 90% reported for these athletes.
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      However, despite collision athletes having high frequencies of shoulder pathologies including not only glenohumeral instability but also traumatic RCTs, RTP in the young collision athlete after ARCR remains a lesser-discussed topic.
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      reported in their series of collision athletes that approximately 90% managed to RTP at 5 months after ARCR, despite nearly half of the players showing findings of anterior shoulder instability. Similarly, Goldberg et al.
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      found that nearly 85% of the professional collision athletes in their series were able to RTP after ARCR, at a mean time of 9 months postoperatively. Our study had similar findings, given that over 90% of the collision athletes in our cohort managed to RTP, but in contrast, this occurred at a mean of just under 6 months after ARCR. However, over one-third did not RTP at their preinjury level of sport.
      The literature reports a wide range of revision rates after ARCR, with between 0% and 55% of cases reported to require revision after ARCR.
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      Although most of such studies in the literature report revision rates for older, nonathletic patients, discrepancies still exist for revision rates after ARCR in the young athletic patient. In their systematic review, Klouche et al.
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      Return to sport after rotator cuff tear repair: A systematic review and meta-analysis.
      reported a revision rate of less than 8% in athletes. Similarly, Azzam et al.
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      found that nearly 8% of the young athletes in their study required a revision. In contrast, Rossi et al.
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      Return to sports after in situ arthroscopic repair of partial rotator cuff tears.
      found that no revisions were required in their 72-patient series; however, there were 5 cases of adhesive capsulitis at a mean of 54 months’ follow-up. A systematic review by Millett et al.
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      • et al.
      Predictors of outcomes after arthroscopic transosseous equivalent rotator cuff repair in 155 cases: A propensity score weighted analysis of knotted and knotless self-reinforcing repair techniques at a minimum of 2 years.
      found that fewer than 2% of patients required revision surgery after ARCR; however, analysis was limited by heterogeneity. Although our study had a 5% revision rate at a mean of nearly 3 years’ follow-up, excellent rates of patient-reported satisfaction were found, given that 100% of the patients included in this study were satisfied with their ARCR.

       Limitations

      Our study has several limitations. Because this is a retrospective study, it possesses the limitations inherent to all retrospective reviews. Although rotator cuff injuries are still uncommon in our patient population, our small sample size limits analysis. Furthermore, the lack of preoperative patient-reported outcome measures limits further assessment in the validation of the postoperative results of this study because we could not correlate outcome scores.

      Conclusions

      After ARCR, athletes aged 30 years or younger show excellent functional outcomes with high rates of patient satisfaction and RTP after the procedure.

      Supplementary Data

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