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Abstract

Background:

Posterior glenoid labral injuries are more common in football players than in the general population. Arthroscopic repair with all-suture anchors has proven to be an effective technique to address other abnormalities, allowing for low-profile constructs that minimize damage to surrounding tissue. Few studies have examined the outcomes of posterior labral repair with all-suture anchors in football players.

Hypothesis:

It was hypothesized that after labral repair with all-suture anchors, functional outcomes would improve, revision rates would be low, return-to-sport rates would be high, and clinical outcomes would be comparable with those seen after arthroscopic repair performed with traditional solid anchors among football players.

Study Design:

Case series; Level of evidence, 4.

Methods:

The authors identified patients in the institution’s ongoing data repository who were football players when they underwent arthroscopic posterior glenoid labral repair using all-suture anchors. The authors collected baseline (preoperative) and follow-up demographic, clinical, surgical, and functional outcome data, with a minimum follow-up time of 2 years. Patient-reported outcome measures included the American Shoulder and Elbow Surgeons (ASES) score and the Western Ontario Shoulder Instability Index (WOSI).

Results:

The authors identified 52 male football athletes (mean age at surgery, 18.5 years) with both baseline and follow-up data (mean follow-up time, 3.8 years), with all competing at either the high school (n = 41 [79%]) or collegiate (n = 11 [21%]) level. Mean outcome scores improved significantly from baseline to follow-up for both the ASES score (baseline: 63.2; follow-up: 97.1) and the WOSI (baseline: 48.1; follow-up: 94.0). Overall, 37 of 52 (71%) returned to football at their preinjury level after surgery. However, only 38 of 52 athletes attempted to return to sport. Among athletes who attempted to return to sport, 97% (37/38) were able to return. There were no significant differences in follow-up ASES or WOSI scores between high school and collegiate athletes, between blocking and nonblocking positions, or between isolated posterior labral repair and combined labral repair.

Conclusion:

The results demonstrated excellent outcomes, including large and significant improvements in ASES and WOSI scores, in football players. While 29% did not return to football, 97% of those who attempted to return to play did so at their preinjury level. This study shows encouraging results for the use of all-suture anchors for posterior labral repair in this population of athletes.

Keywords

glenoid labrum arthroscopic labral repair shoulder instability all-suture anchor soft anchor

Although traditionally underdiagnosed because of its vague symptoms of pain and loss of function, a posterior labral abnormality is increasingly recognized as an important clinical entity. Posterior shoulder instability was traditionally estimated to account for only 2% to 12% of shoulder instability cases overall; however, a recent large consecutive case series of 1763 patients by Mohr and colleagues³² found that the posterior labrum was involved in approximately 65% of labral tears and accounted for approximately 20% of isolated labral tears. Football players are at a particularly high risk, with rates of posterior shoulder instability up to 15 times higher than in the general population.^3,14

Contact athletes and football players are at an increased risk of posterior glenoid labral injuries due to either acute trauma or repetitive microtrauma by shear forces on an adducted, internally rotated, and forward-flexed upper extremity.^{6,14,21,27,37,55} Careful evaluations of chronicity, age, activity level, tissue quality, and concomitant conditions help to determine candidates for nonoperative versus operative management.²³ Nonoperative management has demonstrated up to 70% subjective functional improvements and return-to-sport (RTS) rates as the primary treatment modality for athletes with tears associated with repetitive microtrauma rather than single traumatic events.^20,33,47 Surgical interventions have demonstrated excellent functional outcomes in those who failed nonoperative management or in those with traumatic causes and/or osseous abnormalities, with low recurrence rates and good RTS rates.^‡ Arthroscopic posterior labral repair with suture anchors has been utilized for over 3 decades.⁵⁰ Specifically, posterior labral repair with hard-body suture anchors and capsulorrhaphy has demonstrated effectiveness, even among populations at a high risk of reinjuries,^4,39 such as football players.^{4,7,8,11,19,22,36,43}

In recent years, advancements in surgical anchor technology have led to the development of all-suture soft anchors for labral repair.^30,50,53 These anchors were intentionally developed with low-profile constructs that minimize damage to surrounding bony and soft tissue upon anchor placement and/or failure, allowing more fixation points with less articular cartilage damage while demonstrating comparable biomechanical properties to traditional hard anchors, such as metal, bioabsorbable, biocomposite, or polyetheretherketone suture anchors.^§ Contact athletes may additionally benefit from the preserved structural integrity of the glenoid rim and a decreased risk of postage-stamp fractures from compressive forces after repair with smaller diameter all-suture anchors compared with wider hard anchors.²⁶ Because of these advantages, all-suture anchors make an especially attractive option for football players and contact athletes at a high risk of injuries^21,27 after labral repair for shoulder instability.⁴⁸ Despite recent encouraging reports of positive outcomes after labral repair with all-suture anchors,^15,16,52,53 to our knowledge, there are no clinical studies that have investigated the performance of all-suture anchors in posterior glenoid labral repair in football athletes.

Given the paucity of literature on the topic, we sought to evaluate the clinical outcomes of arthroscopic posterior labral repair with all-suture anchors among football athletes. We hypothesized that patient-reported function would significantly improve, that revision rates would be low, that RTS rates would be high, and that clinical outcomes would be comparable with those seen after arthroscopic repair performed with traditional solid anchors among football players.

Methods

Study Design and Participants

Before the initiation of this study, we obtained institutional review board approval (No. 6284), and all patients provided informed consent before their participation in this study. For the development, conduct, and reporting presented in this article, we followed the STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) guidelines.⁵¹ As part of a larger study on outcomes after labral repair with all-suture anchors, we retrospectively identified all glenoid labral repair procedures performed by 1 of 4 sports medicine subspecialty–trained orthopaedic surgeons (M.A.R., B.A.E., J.R.D., E.L.C.), between 2015 and 2021, at the Andrews Sports Medicine and Orthopaedic Center, a high-volume outpatient sports medicine institution. Potential participants were included in the current subset analysis if they (1) underwent primary arthroscopic posterior glenoid labral repair using only all-suture soft anchors, (2) were competitive football athletes at the time of injury/surgery, (3) were enrolled in our ongoing data repository with preoperative patient-reported outcomes collected, and (4) were at least 2 years after surgery. Potential participants were excluded from the current study if they (1) underwent revision labral repair as the index procedure, (2) underwent an open labral repair procedure, (3) underwent arthroscopic labral repair with any hard anchor, (4) underwent concomitant rotator cuff repair or any bone/tendon transfer procedures (excluding biceps tenodesis) alongside labral repair, or (5) had glenohumeral osteoarthritis identified intraoperatively. Patients who underwent concomitant biceps tenodesis as well as those who had labral repair performed in locations in addition to the posterior labrum were included in the current study. We included football players of all ages and levels of competition.

Surgical Technique

Our standard posterior labral repair technique utilized a lateral decubitus position, with the operative extremity in suspended traction with the arm in approximately 45° of abduction and 20° of forward flexion. Standard posterior, anterior, and accessory posterior portals were routinely used for diagnostic arthroscopic examination and repair. If anterior labral fixation was necessary, then an accessory anterior subscapularis portal was created. The labrum was elevated from the glenoid using a soft tissue elevator, and the glenoid was prepared with an arthroscopic shaver to create a bleeding bony bed, taking care to avoid damaging glenoid or humeral chondral surfaces. The labrum was repaired from inferior to superior with 1 anchor for every hour of the clockface using knotted and/or knotless all-suture 1.8-mm and/or 2.6-mm anchors (FiberTak Soft Anchor; Arthrex). A curved drill guide was used to ensure appropriate suture anchor placement and fixation. We subsequently used a suture passer to shuttle the anchor’s stitch through the capsulolabral complex, and then the shuttle stitch was used to convert the knotless mechanism of the anchor before tensioning appropriately. The suture limbs were left intact and docked through an accessory portal to allow for sequential retensioning of all anchors once they had been placed to reduce creep within the repair construct.¹⁹ Subsequent anchors were placed in a similar fashion until adequate labral repair had been achieved.¹⁹ Capsular repair of the capsulotomy site was performed in some cases for additional stability if a patulous capsule was identified intraoperatively.

Patients were referred to a physical therapist immediately on postoperative day 1, with the shoulder immobilized in a sling for 4 weeks for standard posterior tears <180° and for 6 weeks for tears >180°. Patients followed a progressive rehabilitation protocol to improve range of motion and strength, and athletes were allowed to return to sport according to the surgeon’s discretion after demonstrating symmetric strength and full range of motion, usually beginning around 4 months after surgery.

Data Collection

Clinical and Surgical Data

For eligible athletes, we first collected demographic, injury, and surgical data via a review of their electronic health records, including age, sex, football position, level of competition, labral tear location and size, presence of a chondral defect at the time of surgery, presence of a bony Bankart lesion at the time of surgery, presence of a Hill-Sachs lesion at the time of surgery, concomitant labral repair performed, number and type of anchors utilized, and whether the operative shoulder underwent revision surgery at our institution. We carefully reviewed operative reports as well as intraoperative photographs to ensure the use of all-suture anchors for index labral repair. We did not routinely collect postoperative imaging as part of clinical follow-up visits, and these data are thus not reported in the current analysis. Clinical data were collected and managed using REDCap (Research Electronic Data Capture) tools hosted at Ascension St Vincent’s and the American Sports Medicine Institute. REDCap is a secure web-based software platform designed to support data capture for research studies.^17,18

Patient-Reported Outcomes

To collect baseline patient-reported functional data, we enrolled patients undergoing labral repair into an ongoing electronic data repository platform (OBERD; Universal Research Solutions) before surgery and administered preoperative surveys. The OBERD system then periodically distributed outcome surveys to enrolled patients using automated emails and/or SMS messages over time at regular intervals, including at 2 years postoperatively. We contacted those who did not respond to the electronic survey request via institutional review board–approved methods of communication up to 15 times, including telephone, text, email, and/or social media, to attempt to collect postoperative patient-reported outcomes. Functional outcome surveys administered preoperatively and at least 2 years after surgery included the patient-reported component of the American Shoulder and Elbow Surgeons (ASES) score and the Western Ontario Shoulder Instability Index (WOSI).^30,38,45 The ASES score and WOSI are both validated instruments for the evaluation of shoulder function in patients with labral abnormalities, with reported minimal clinically important difference values of 6.4-7.8^31,44 and 14 points,^2,24,42 respectively. Lastly, we collected data on return to preinjury levels of sport and the reasons/contextual factors associated with successful or unsuccessful return as well as revision shoulder surgery at outside institutions after index posterior labral repair.

Statistical Analysis

We calculated summary statistics for baseline and/or follow-up demographic, clinical, surgical, and outcome data across football athletes. We compared baseline and follow-up ASES and WOSI scores using a paired t test across the entire cohort as well as within high school and collegiate athlete groups separately. Using an independent t test, we also compared follow-up ASES and WOSI scores between those who underwent combined Bankart repair and posterior labral repair and those who underwent posterior labral repair only, between those who underwent any combined procedure and those who underwent isolated posterior labral repair, between those who underwent labral repair with knotted all-suture anchors and those who underwent labral repair with knotless all-suture anchors, between those who underwent capsular closure/repair and those who did not, between athletes in blocking positions (offensive linemen, defensive linemen, tight ends, fullbacks) and athletes in nonblocking positions (all others), and lastly between collegiate athletes and high school athletes. Finally, we examined the association between preinjury demographic variables (age and follow-up time) and ASES and WOSI scores or successful RTS at follow-up using linear regression and logistic regression, respectively. For all analyses, we considered P < .05 to be statistically significant. All statistical analyses were performed using SPSS Statistics (Version 28.0; IBM).

Results

From an initial potential sample of 201 athletes (all sports), 74 football athletes were eligible and enrolled in our ongoing registry, underwent posterior glenoid labral repair with all-suture anchors, and had baseline (preoperative) data collected (Figure 1). We successfully collected postoperative patient-reported outcomes from 52 of the 74 male football athletes (70%) (Figure 1) at a mean follow-up time of 3.8 years. Demographic, injury, and surgical data for the included cohort are shown in Table 1. The majority of football athletes participated at the high school level (79%), followed by the collegiate level (21%), at the time of injury/surgery (Table 1). Offensive linemen and linebackers were the most common positions, and of those with position data available, 41% (17/41) were in blocking positions, and 59% (24/41) were in nonblocking positions (Table 1). Isolated posterior labral repair constituted the majority of repair procedures performed. Concomitant labral repair with posterior labral repair procedures are shown in Table 1, with the most common being anterior (Bankart) repair (29%). Additionally, 2 athletes (4%) had chondral defects, and 4 athletes (8%) had Hill-Sachs lesions, identified at the time of surgery (Table 1). None had reverse Hill-Sachs lesions. Also, 2 athletes (4%) underwent concomitant biceps tenodesis during labral repair because of extension of the labral tear into the biceps anchor (Table 1). The median number of all-suture anchors used for labral repair was 4 (range, 3-8), and 77% were 1.8 mm in size.

Figure 1.

Flowchart of cohort composition.

Table 1

Demographic, Injury, and Surgical Data (n = 52) ^a

	Mean ± SD or n (%)
Age at surgery, y	18.5 ± 3.6
Follow-up time, y	3.8 ± 1.3
Male sex	52 (100)
Position at time of injury/surgery
Offensive lineman	8 (15)
Defensive lineman	6 (12)
Defensive back	5 (10)
Linebacker	8 (15)
Safety	1 (2)
Tight end	2 (4)
Running back	1 (2)
Quarterback	4 (8)
Wide receiver	5 (10)
Fullback	1 (2)
Unknown/unable to determine	11 (21)
Level of competition at time of injury/surgery
Collegiate	11 (21)
High school	41 (79)
Isolated posterior labral repair	27 (52)
Concomitant repair with posterior labral repair
Bankart (anterior)	15 (29)
SLAP	3 (6)
270°	5 (10)
360°	2 (4)
All-suture anchor type
Knotted	13 (25)
Knotless	33 (63)
Combined	6 (12)
Presence of chondral defect at time of surgery	2 (4)
Presence of Hill-Sachs lesion at time of surgery	4 (8)
Presence of bony Bankart (anterior) lesion at time of surgery	2 (4)
Concomitant biceps tenodesis	2 (4)
Capsular repair/closure	14 (27)

SLAP, superior labrum anterior to posterior.

ASES and WOSI scores at baseline (preoperative) and follow-up for the entire cohort and stratified by level of competition (high school and collegiate) are shown in Table 2. Within the overall cohort (n = 52), both ASES and WOSI scores significantly improved from baseline to follow-up. Within each level of competition (high school and collegiate), ASES and WOSI scores also significantly improved from baseline to follow-up.

Table 2

Patient-Reported Outcome Scores ^a

	Baseline	Follow-up	P
All athletes (n = 52)
ASES score	63.2 ± 20.5	97.1 ± 6.3	<.001
WOSI score	48.1 ± 23.1	94.0 ± 9.7	<.001
High school athletes (n = 41)
ASES score	63.8 ± 20.0	96.9 ± 6.9	<.001
WOSI score	48.3 ± 22.8	94.2 ± 9.8	<.001
Collegiate athletes (n = 11)
ASES score	60.4 ± 23.9	98.1 ± 3.0	.007
WOSI score	46.8 ± 27.3	92.7 ± 10.3	.016

Data are presented as mean ± SD. The ASES and WOSI are scaled from 0 to 100, with 100 representing best shoulder function. All P values were calculated using a paired-samples t test. ASES, American Shoulder and Elbow Surgeons; WOSI, Western Ontario Shoulder Instability Index.

Follow-up ASES and WOSI scores did not differ between athletes who underwent anterior (Bankart) repair in combination with posterior labral repair and those who underwent isolated posterior labral repair (ASES: 97.2 ± 7.2 and 96.7 ± 6.2, respectively; P = .84) (WOSI: 94.2 ± 7.3 and 92.0 ± 15.1, respectively; P = .61). Similarly, follow-up ASES and WOSI scores did not differ between athletes who underwent any concomitant labral repair with posterior labral repair and those who underwent isolated posterior labral repair (ASES: 97.7 ± 6.3 and 96.4 ± 6.6, respectively; P = .48) (WOSI: 94.7 ± 6.6 and 91.4 ± 15.9, respectively; P = .42).

Compared with athletes who underwent labral repair with knotted all-suture anchors (n = 13), those who underwent labral repair with knotless all-suture anchors (n = 33) reported higher ASES scores (92.9 ± 8.8 and 98.1 ± 5.1, respectively; P = .02) and WOSI scores (85.5 ± 20.5 and 95.6 ± 8.5, respectively; P = .03) at follow-up. However, we found that the knotless and knotted anchor groups differed in follow-up time (shorter in knotless group), and when controlling for follow-up time on linear regression, anchor type was no longer associated with follow-up ASES or WOSI scores. Athletes who did (n = 14) and did not (n = 38) undergo capsular repair/closure did not differ in follow-up ASES or WOSI scores (ASES: 95.9 ± 7.4 and 97.2 ± 6.1, respectively; P = .53) (WOSI: 94.0 ± 9.1 and 92.1 ± 14.7, respectively; P = .66).

Lastly, follow-up ASES and WOSI scores did not differ between collegiate football athletes and high school football athletes (ASES: 98.1 ± 3.0 and 96.9 ± 6.9, respectively; P = .74) (WOSI: 92.7 ± 10.3 and 94.2 ± 9.8, respectively; P = .26). Follow-up ASES and WOSI scores also did not differ between blocking and nonblocking positions (P = .33 and P = .46, respectively).

Examining the predictors of follow-up ASES scores, a longer follow-up time was associated with lower ASES scores at follow-up (P = .03). Age at the time of surgery was not associated with follow-up ASES scores (P = .72). For the WOSI, neither age (P = .86) nor follow-up time (P = .10) was associated with WOSI scores at follow-up.

RTS outcomes are shown in Table 3. A total of 14 athletes did not attempt to return to preinjury sport after their labral repair. The most common reasons for not attempting to return included graduation and lack of sufficient talent to move to the next level (12/14), followed by decreased interest (2/14) (Table 3). Of those who attempted to return, 37 of 38 (97%) were able to return to their preinjury level of sport. One athlete attempted to return but was unable to, citing decreased shoulder performance in sport after his labral surgery. At final follow-up, to our knowledge, there were no cases of recurrent instability requiring subsequent revision surgery in this cohort, either at our institution or at outside centers.

Table 3

Return-to-Sport Outcomes (n = 52)

	n (%)
Athletes who returned to preinjury sport after surgery	37 (71)
Athletes able to return to preinjury sport who attempted to return after surgery (n = 38) ^a	37 (97)
Reason for not returning to preinjury sport
Graduated and not talented enough for next level	12 (23)
Limited by labral repair	1 (2)
Personal reasons or decreased interest	2 (4)
Revision surgery for recurrent instability or reinjury	0 (0)

Those who attempted to return to play excludes those who did not return because of graduation/insufficient talent or for personal reasons (n = 14).

Discussion

Multiple techniques for posterior labral repair are successful in terms of improving pain and function^{3
-8,11,27,37,43} and enabling RTS, utilizing a variety of hard-body suture anchors.^{4,7,8,11,22,36,39} We performed this retrospective analysis to examine the outcomes of posterior labral repair using both knotted and knotless all-suture anchors in a population of football players at a higher risk of injuries than the general population.^{14,27,37,39,48} We confirmed our hypotheses that these athletes would demonstrate statistically significant and clinically important improvements in patient-reported function and high rates of return to preinjury levels of sport for those who attempted to return.

The low-profile construct and smaller cross-sectional area of all-suture soft anchors preserve bone stock and permit the placement of glenoid fixation points, with a decreased risk of chondral damage, osteolysis, or glenoid rim fractures upon anchor placement and/or pullout relative to traditional hard anchor materials, while demonstrating comparable biomechanical properties.^‖ Early clinical and radiographic studies have validated the use of all-suture anchors in glenoid labral repair.^{1,12,15,16,29,46,52,53} With a 15% probability of subsequent shoulder injuries and a 10% probability of recurrent instability after labral repair,³⁹ football players and other contact athletes may benefit from labral repair with all-suture anchors because of the preserved bone stock and structural integrity of the glenoid better tolerating repetitive compressive forces, a decreased risk of osteochondral damage upon anchor pullout, and decreased artifacts upon reimaging of subsequent injuries.^35,37

Our findings are comparable to those for arthroscopic repair among football athletes with hard-body anchors and/or anchorless repair. We found mean improvements in the ASES score of 33 points and the WOSI score of 45 points from baseline to follow-up, which are markedly greater than the reported minimal clinically important difference values in the literature.^44,49 Of the football players in our cohort who attempted RTS at their previous level or higher, 97% of patients were able to do so. Arner and colleagues⁴ reported a 93% RTS rate among football athletes undergoing arthroscopic posterior capsulolabral repair with (n = 44) and without (n = 12) suture anchors, with 79% returning to preinjury levels and no difference between anchor types regarding function or stability. Similarly, Bradley and colleagues^7,8 reported RTS rates of 92%, with 68% returning to preinjury levels, in separate case series of 100 and 200 shoulders with posterior labral injuries, demonstrating the superiority of anchored over anchorless repair in their later study. Additionally, we found a significant improvement in early functional outcomes using knotless anchors compared with knotted anchors in our cohort. After controlling for follow-up time, our findings were consistent with a review by Matache and colleagues,²⁹ showing no significant difference in clinical outcomes between knotted and knotless anchors for various types of labral repair. In a study that did not specify the type of arthroscopic repair performed, Robins and colleagues³⁹ evaluated RTS among National Collegiate Athletic Association (NCAA) Division I football players, including 38% of players with isolated posterior instability, reporting that approximately 85% returned to sport overall. The same study also reported a significant increase in the percentage of games played and returning to play at the same or higher level after labral repair.³⁹ No athletes in our cohort required revision surgery at our institution, and to our knowledge, none underwent revision at outside centers. In contrast, 10% of football players in the Robins et al³⁹ study required reduction and/or revision surgery for recurrent instability.

Regarding modern all-suture anchors, clinical outcome studies evaluating repair of distinct types of labral injuries with all-suture anchors have found good functional outcomes.^15,16,52 To our knowledge, this is the first study reporting the clinical outcomes of posterior labral repair with all-suture anchors in football players. The earliest clinical outcome case series evaluating glenoid labral repair with all-suture anchors in the general population demonstrated significant improvements in functional outcomes for anterosuperior tears⁵³ and 360° labral tears¹ at 1 and 2 years, respectively. More recent retrospective and prospective studies on glenoid labral repair for anterior, posterior, and/or multidirectional instability have also demonstrated significant postoperative improvements in functional scores and low rates of instability and redislocations in the general population.^15,16,52 However, there remains a paucity of experimental studies comparing clinical outcomes and RTS rates between all-suture anchors and hard-body anchors for glenoid labral repair. Among imaging outcome studies, a randomized controlled trial found significantly decreased levels of glenoid osteolysis at 6 months after labral repair with all-suture anchors compared with biocomposite anchors,⁴⁶ and multiple case series have found minimal bony edema, subchondral cyst formation, or tunnel expansion at 1 to 2 years postoperatively.^1,53 To date, and to our knowledge, the current study is the largest cohort of posterior labral repair cases using all-suture anchors and the only one in football athletes specifically.

Posterior labral tears were most common in our cohort among offensive linemen, defensive linemen, and linebackers, which is consistent with the report by Mannava and colleagues²⁸ on elite collegiate athletes at the National Football League Combine. An increased prevalence of posterior labral injuries in these positions has been attributed to repetitive microtrauma from blocking- and block shedding–type activities inherent to these positions.²¹ However, despite these positions being most represented, there were no significant differences in either functional outcomes or RTS rates between blocking and nonblocking positions. We conducted a sensitivity analysis comparing isolated posterior labral repair with all combinations of concomitant repair procedures and found no significant differences in outcomes. There were no differences in RTS rates or functional outcomes based on whether athletes had more extensive labral injuries and concomitant labral repair with posterior labral repair, despite our cohort having 15 patients undergoing Bankart repair, 5 with 270° labral tears, and 2 with 360° tears. These findings are consistent with previous reports of nonsignificant differences in RTS rates among NCAA Division I football athletes who underwent anterior, posterior, or combined anterior and posterior repair.³⁹ Additionally, there was no significant difference in outcomes between those who underwent capsular repair and those who did not. As RTS rates are highly contextual, it must be noted that all athletes in our cohort were football players, with football being a contact sport that permits tighter capsulolabral repair without loss of function compared with other overhead sports, such as baseball, in which pitchers notoriously have more difficulty returning to baseline performance levels after labral repair because of the unique overhead shoulder biomechanics involved.^4,7,8,11,22 These results should be interpreted with caution in our cohort because 14 patients did not attempt to return for various reasons. Their RTS success, had they attempted to return, could not be evaluated.

Related to the RTS findings in the current study, only 1 patient in our cohort who attempted to return to sport was unable to return to his previous level because of his shoulder function specifically, citing decreased shoulder-related performance. The other 14 of 15 patients who did not return to competitive football were because of insufficient talent to move to the next level of competition (eg, from high school to college), disinterest, or other personal reasons. Similar reasons have been cited by previous reports that included high school athletes.^4,7,8,11,22 This was not unexpected, given that the mean age of our cohort was 18.5 years, an age at which athletes typically graduate from high school and often lose the opportunity to play organized football. Indeed, only 7.5% of high school athletes go on to play football at the collegiate level across all divisions,³⁴ and many of these athletes would likely not have returned to play football at the next level, regardless of their labral injury.

Most anchors used in the present study were 1.8 mm in size; however, some 2.6-mm anchors were used early on because of concerns over the first-generation 1.8-mm anchors’ deployment mechanism. Surgeons transitioned to the second-generation 1.8-mm anchors that addressed these concerns when they were released. Although the larger diameter 2.6-mm anchors theoretically increase the risk of glenoid rim fractures because of the loss of osseous structural integrity,^26,54 no cases of glenoid rim fractures were identified, regardless of anchor diameter, in this cohort of football athletes with a median of 4 anchors per repair. Among the included cases, no instances of all-suture anchor failure during placement or tensioning were identified either.

Limitations related to this study include the size of the included cohort and that we were only able to collect postoperative patient-reported outcomes in 70% of eligible football athletes after posterior labral repair. It is possible that players for whom we were unable to collect postoperative patient-reported outcomes had different outcomes than those included in the present study. While revision surgical procedures at our center were captured via an electronic health record review, it is possible that patients unavailable for follow-up may have undergone revision surgery at outside institutions. Additionally, the retrospective nature of our study was an important limitation, as we were only able to collect data based on routine postoperative encounters and follow-up patient-reported outcomes. Postoperative radiological imaging data were not routinely obtained, unless clinically indicated, and thus were not available to assess for osteolysis and/or glenoid rim fractures. Among cases in which the anchor size was known, 77% were 1.8 mm; however, these data were not documented reliably in all cases, limiting our ability to evaluate the effect of anchor size on outcomes. The retrospective nature of our study may have been associated with recall bias, particularly for details related to RTS and timing/contextual factors. It is possible that those with worse outcomes were more likely to remember their experience and respond to our survey, contributing to declining ASES scores with longer follow-up times.²⁵ Midterm to long-term follow-up studies on all-suture anchors are planned to evaluate the significance of these outcomes over time. The number of patients who did not return to football for reasons other than their shoulder (eg, insufficient talent or personal reasons) may have also affected the outcomes that we found, as it is possible that some of these patients could have been limited by their shoulder if they had the opportunity to continue playing. The relatively high percentage of concomitant anterior or superior labral injuries is another limitation when evaluating outcomes of posterior labral tears. However, it is reassuring that patients overall did well, despite the high percentage of more significant labral injuries, and that those who underwent combined repair did not have different outcomes than those who underwent isolated posterior repair. Lastly, our results may not be generalized to all football players, as our patient population included a majority of high school athletes.

Conclusion

This study found that using all-suture anchors for posterior labral repair in football athletes demonstrated clinical outcomes similar to those of other posterior labral repair techniques while possibly minimizing potential complications associated with hard-anchor repair. In the present study, patient-reported outcomes at least 2 years after surgery were high. While 29% did not return to football, 97% of those who attempted to return to sport did so at their preinjury level. This study shows encouraging results for the use of all-suture anchors for posterior labral repair in this specific population of athletes.

Footnotes

Final revision submitted January 29, 2025; accepted February 24, 2025.

Presented as a poster at the annual meeting of the AOSSM, Nashville, Tennessee, USA, July 2025.

One or more of the authors has declared the following potential conflict of interest or source of funding: This study was funded in part by Arthrex (RDGT0696). The funding agency had no role in the collection, analysis, or interpretation of the data presented herein. Additionally, the funding agency had no involvement in the writing of the article or the decision to submit the study for publication. A.E.L. has received support for education from Arthrex, Smith & Nephew, and Zimmer Biomet. M.A.R. has received support for education from Arthrex, Smith & Nephew, and Zimmer Biomet and nonconsulting fees from Arthrex. B.A.E. has received consulting fees and royalties from Arthrex. J.R.D. has received consulting fees from Arthrex, Bioventus, DJO, Royal Biologics, and Smith & Nephew and royalties from Arthrex and In2Bones. E.L.C. has received support for education from Prime Surgical and Zimmer Biomet; consulting fees from Arthrex, DJO, Smith & Nephew, and Zimmer Biomet; nonconsulting fees from Medical Device Business Services; royalties from Arthrex; and hospitality payments from Encore Medical. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto.

Ethical approval for this study was obtained from Sterling IRB (No. 6284).

Notes

References

Agrawal

Pietrzak

WS.

Triple labrum tears repaired with the JuggerKnot soft anchor: technique and results. Int J Shoulder Surg. 2015;9(3):81-89.

Angst

Schwyzer

Aeschlimann

Simmen

Goldhahn

Measures of adult shoulder function: Disabilities of the Arm, Shoulder, and Hand Questionnaire (DASH) and its short version (QuickDASH), Shoulder Pain and Disability Index (SPADI), American Shoulder and Elbow Surgeons (ASES) Society standardized shoulder assessment form, Constant (Murley) Score (CS), Simple Shoulder Test (SST), Oxford Shoulder Score (OSS), Shoulder Disability Questionnaire (SDQ), and Western Ontario Shoulder Instability Index (WOSI). Arthritis Care Res (Hoboken). 2011;63(Suppl 11):S174-S188.

Antoniou

Harryman

DT.

Posterior instability. Orthop Clin North Am. 2001;32(3):463-473.

Arner

McClincy

Bradley

JP.

Arthroscopic stabilization of posterior shoulder instability is successful in American football players. Arthroscopy. 2015;31(8):1466-1471.

Bateman

Black

Lazarus

Abboud

JA.

Outcomes following arthroscopic repair of posterior labral tears in patients older than 35 years. Orthopedics. 2017;40(2):e305-e311.

Bottoni

Franks

Moore

DeBerardino

Taylor

Arciero

RA.

Operative stabilization of posterior shoulder instability. Am J Sports Med. 2005;33(7):996-1002.

Bradley

Baker

Kline

Armfield

Chhabra

Arthroscopic capsulolabral reconstruction for posterior instability of the shoulder: a prospective study of 100 shoulders. Am J Sports Med. 2006;34(7):1061-1071.

Bradley

McClincy

Arner

Tejwani

SG.

Arthroscopic capsulolabral reconstruction for posterior instability of the shoulder: a prospective study of 200 shoulders. Am J Sports Med. 2013;41(9):2005-2014.

Buckup

Welsch

Petchennik

, et al. Arthroscopic Bankart repair: how many knotless anchors do we need for anatomic reconstruction of the shoulder? A prospective randomized controlled study. Int Orthop. 2023;47(5):1285-1293.

10.

Chan

O’Brien

Waterman

Chan

Pallis

Kilcoyne

KG.

Low risk of recurrence after posterior labral repair of the shoulder in a high-risk United States military population. Arthrosc Sports Med Rehabil. 2020;2(1):e47-e52.

11.

DeLong

Jiang

Bradley

JP.

Posterior instability of the shoulder: a systematic review and meta-analysis of clinical outcomes. Am J Sports Med. 2015;43(7):1805-1817.

12.

Ergun

Akgun

Barber

Karahan

The clinical and biomechanical performance of all-suture anchors: a systematic review. Arthrosc Sports Med Rehabil. 2020;2(3):e263-e275.

13.

Erickson

Chiarappa

Haskel

, et al. Biomechanical comparison of a first- and a second-generation all-soft suture glenoid anchor. Orthop J Sports Med. 2017;5(7):2325967117717010.

14.

Escobedo

Richardson

Schulz

Hunter

Green

Messick

KJ.

Increased risk of posterior glenoid labrum tears in football players. AJR Am J Roentgenol. 2007;188(1):193-197.

15.

Freeman

Hao

Hones

, et al. Correction: pain scores and functional outcomes of patients with shoulder labral repair using all-suture anchors versus conventional anchors. Eur J Orthop Surg Traumatol. 2024;34(3):1517.

16.

Gul

Okutan

Ayas

MS.

Arthroscopic glenoid labral lesion repair using all-suture anchor for traumatic anterior shoulder instability:short-term results. J Shoulder Elbow Surg. 2019;28(10): 1991-1997.

17.

Harris

Taylor

Minor

, et al. The REDCap Consortium: building an international community of software platform partners. J Biomed Inform. 2019;95:103208.

18.

Harris

Taylor

Thielke

Payne

Gonzalez

Conde

JG.

Research Electronic Data Capture (REDCap): a metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform. 2009;42(2):377-381.

19.

Hassebrock

Sylvia

McCarthy

Stokes

Shinsako

Frank

RM.

Posterior labral repair using knotless “all-suture” suture anchors. Arthrosc Tech. 2023;12(7):e1219-e1224.

20.

Hurley

Anderson

Dear

Andrish

Bergfeld

Weiker

GG.

Posterior shoulder instability: surgical versus conservative results with evaluation of glenoid version. Am J Sports Med. 1992;20(4):396-400.

21.

Kaplan

Flanigan

Norwig

Jost

Bradley

Prevalence and variance of shoulder injuries in elite collegiate football players. Am J Sports Med. 2005;33(8):1142-1146.

22.

Kercher

Runner

McCarthy

Duralde

XA.

Posterior labral repairs of the shoulder among baseball players: results and outcomes with minimum 2-year follow-up. Am J Sports Med. 2019;47(7):1687-1693.

23.

Khaleel

Oladeji

Smith

DeFroda

Nuelle

CW.

Two-portal arthroscopic knotless all-suture anchor posterior labral repair. Arthrosc Tech. 2024;13(5):102928.

24.

Kirkley

Griffin

McLintock

The development and evaluation of a disease-specific quality of life measurement tool for shoulder instability: the Western Ontario Shoulder Instability Index (WOSI). Am J Sports Med. 1998;26(6):764-772.

25.

Kopec

Esdaile

JM.

Bias in case-control studies: a review. J Epidemiol Community Health. 1990;44(3):179-186.

26.

Lobao

Abbasi

Svoboda

SJ.

How many anchors to use in arthroscopic Bankart repairs? A biomechanical study of postage-stamp glenoid fractures. J Shoulder Elbow Surg. 2023;32(12):2541-2549.

27.

Mair

Zarzour

Speer

KP.

Posterior labral injury in contact athletes. Am J Sports Med. 1998;26(6):753-758.

28.

Mannava

Frangiamore

Murphy

, et al. Prevalence of shoulder labral injury in collegiate football players at the National Football League Scouting Combine. Orthop J Sports Med. 2018;6(7):2325967118783982.

29.

Matache

Hurley

Kanakamedala

, et al. Knotted versus knotless anchors for labral repair in the shoulder: a systematic review. Arthroscopy. 2021;37(4):1314-1321.

30.

Mazzocca

Chowaniec

Cote

, et al. Biomechanical evaluation of classic solid and novel all-soft suture anchors for glenoid labral repair. Arthroscopy. 2012;28(5):642-648.

31.

Michener

McClure

Sennett

BJ.

American Shoulder and Elbow Surgeons standardized shoulder assessment form, patient self-report section: reliability, validity, and responsiveness. J Shoulder Elbow Surg. 2002;11(6):587-594.

32.

Mohr

Nammour

Marcaccio

Arner

Bradley

JP.

Location of shoulder glenoid labral tears: a study of 1763 consecutive patients. Am J Sports Med. 2024;52(8):2063-2070.

33.

Nammour

James

Arner

Bradley

JP.

Arthroscopic posterior labral repair for posterior shoulder instability. Video J Sports Med. 2023;3(4):26350254231178325.

34.

National Collegiate Athletic Association. Estimated probability of competing in college athletics. 2024. Accessed January 2, 2025. https://ncaaorg.s3.amazonaws.com/research/pro_beyond/2023RES_ProbabilityBeyondHSFiguresMethod.pdf

35.

Ntalos

Huber

Sellenschloh

, et al. All-suture anchor pullout results in decreased bone damage and depends on cortical thickness. Knee Surg Sports Traumatol Arthrosc. 2021;29(7):2212-2219.

36.

Pennington

Sytsma

Gibbons

, et al. Arthroscopic posterior labral repair in athletes: outcome analysis at 2-year follow-up. Arthroscopy. 2010;26(9):1162-1171.

37.

Provencher

LeClere

King

, et al. Posterior instability of the shoulder: diagnosis and management. Am J Sports Med. 2011;39(4):874-886.

38.

Richards

Bigliani

, et al. A standardized method for the assessment of shoulder function. J Shoulder Elbow Surg. 1994;3(6):347-352.

39.

Robins

Daruwalla

Gamradt

, et al. Return to play after shoulder instability surgery in National Collegiate Athletic Association Division I intercollegiate football athletes. Am J Sports Med. 2017;45(10):2329-2335.

40.

Ruder

Dickinson

Peindl

Habet

Trofa

Fleischli

JE.

Cyclic and load-to-failure properties of all-suture anchors in human cadaveric shoulder glenoid bone. Arthroscopy. 2019;35(7):1954-1959.e4.

41.

Rupp

Rutledge

Dey Hazra

Haskel

Millett

PJ.

Arthroscopic labral repair and pancapsular shift with knotless all-suture anchors in the setting of multidirectional instability of the shoulder. Arthrosc Tech. 2023;12(8):e1289-e1295.

42.

Salomonsson

Ahlström

Dalén

Lillkrona

The Western Ontario Shoulder Instability Index (WOSI): validity, reliability, and responsiveness retested with a Swedish translation. Acta Orthop. 2009;80(2):233-238.

43.

Savoie

Holt

Field

Ramsey

JR.

Arthroscopic management of posterior instability: evolution of technique and results. Arthroscopy. 2008;24(4):389-396.

44.

Scanaliato

Green

Sandler

Hurley

Hettrich

Parnes

Establishing the minimal clinically important difference, substantial clinical benefit, and patient acceptable symptomatic state after arthroscopic posterior labral repair for posterior glenohumeral instability. Am J Sports Med. 2024;52(1):207-214.

45.

Schmidt

Ferrer

González

, et al. Evaluation of shoulder-specific patient-reported outcome measures: a systematic and standardized comparison of available evidence. J Shoulder Elbow Surg. 2014;23(3):434-444.

46.

Stewart

CMB

Raja

Torrance

Funk

. In vivo randomized controlled study of the bone response of all-suture anchors and biocomposite anchors. Orthop J Sports Med. 2020;8(4):2325967120914965.

47.

Tibone

Bradley

JP.

The treatment of posterior subluxation in athletes. Clin Orthop Relat Res. 1993;(291):124-137.

48.

Torrance

Clarke

Monga

Funk

Walton

MJ.

Recurrence after arthroscopic labral repair for traumatic anterior instability in adolescent rugby and contact athletes. Am J Sports Med. 2018;46(12):2969-2974.

49.

van der Linde

van Kampen

van Beers

van Deurzen

DFP

Saris

DBF

Terwee

CB.

The responsiveness and minimal important change of the Western Ontario Shoulder Instability Index and Oxford Shoulder Instability Score. J Orthop Sports Phys Ther. 2017;47(6):402-410.

50.

Visscher

Jeffery

Gilmour

Anderson

Couzens

The history of suture anchors in orthopaedic surgery. Clin Biomech (Bristol). 2019;61:70-78.

51.

von Elm

Altman

Egger

, et al. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. Lancet. 2007;370(9596):1453-1457.

52.

Wallace

Calvo

Ardèvol Cuesta

, et al. Safety and efficacy of second-generation all-suture anchors in labral tear arthroscopic repairs: prospective, multicenter, 1-year follow-up study. JSES Int. 2024;8(4):763-768.

53.

Willemot

Elfadalli

Jaspars

, et al. Radiological and clinical outcome of arthroscopic labral repair with all-suture anchors. Acta Orthop Belg. 2016;82(2):174-178.

54.

Woolnough

Shah

Sheean

Lesniak

Wong

de Sa

. “Postage stamp” fractures: a systematic review of patient and suture anchor profiles causing anterior glenoid rim fractures after Bankart repair. Arthroscopy. 2019;35(8):2501-2508.e2.

55.

Ashman

Jones

The POLPSA lesion: MR imaging findings with arthroscopic correlation in patients with posterior instability. Skeletal Radiol. 2002;31(7):396-399.

Outcomes After Arthroscopic Posterior Labral Repair With All-Suture Anchors in Football Players

Abstract

Background:

Hypothesis:

Study Design:

Methods:

Results:

Conclusion:

Keywords

Methods

Study Design and Participants

Surgical Technique

Data Collection

Clinical and Surgical Data

Patient-Reported Outcomes

Statistical Analysis

Results

Discussion

Conclusion

Footnotes

Notes

References