Arthroscopic Management of the Contact Athlete with Instability

Arthroscopic Stabilization After a First-Time Dislocation: Collision Versus Contact Athletes

BACKGROUND

There is no universally accepted definition of "contact" or "collision" sports in the literature. The few available studies evaluating contact and collision sports consider them to be synonymous. However, athletes in collision sports purposely hit or collide with each other or with inanimate objects with greater force and frequency than in contact sports, which could jeopardize functional outcomes.

PURPOSE

To compare the functional outcomes, return to sports, and recurrences in a series of contact and collision athletes with a first-time anterior shoulder dislocation treated using arthroscopic stabilization with suture anchors.

STUDY DESIGN

Cohort study; Level of evidence, 2.

METHODS

A total of 56 athletes were enrolled in this study, including 22 contact athletes and 34 collision athletes. All athletes underwent arthroscopic shoulder stabilization using suture anchors. Range of motion, the Rowe score, a visual analog scale (VAS) for pain, and the Athletic Shoulder Outcome Scoring System (ASOSS) were used to assess functional outcomes. Return to sports and recurrences were also evaluated.

RESULTS

The mean age at the time of surgery was 22.2 years, and the mean follow-up was 62.4 months (range, 36-94 months). No significant difference in shoulder motion was found between preoperative and postoperative results or between the contact and collision groups. The Rowe, VAS, and ASOSS scores showed statistical improvement in both groups after surgery (P = .001). Patients in the contact group returned to sports significantly faster than those in the collision group (5.2 vs 6.9 months, respectively; P = .01). In all, 43 athletes (76.8%) returned to near-preinjury sports activity levels (≥90% recovery) after surgery: 86.4% of patients in the contact group and 70.6% in the collision group (P = .04). The total recurrence rate was 8.9%. There were 5 recurrences (14.7%) in the collision group and no recurrences in the contact group (P < .01).

CONCLUSION

Arthroscopic stabilization for anterior instability of the shoulder is a reliable procedure with respect to shoulder function, range of motion, and postoperative return to sports in contact and collision athletes. Compared with the contact group (0%), the collision group yielded a higher failure rate (14.7%). Moreover, patients in the contact group returned significantly faster (5.2 vs 6.9 months, respectively) and to and more returned to preinjury or near-preinjury activity levels (86.4% vs 70.6% of patients, respectively) than patients in the collision group.

[Diagnostics and treatment concepts for anteroinferior shoulder instability : Current trends]

Shoulder instability arises when static or dynamic stabilizers deviate from the natural equilibrium. The most common form of shoulder instability is in an anteroinferior direction, affects young athletes in contact sports and can lead to permanent impairment of shoulder function and early degeneration of the joint. Conservative as well as operative therapy options have been controversially discussed for years. This article describes the current state of diagnostics, current trends in therapy decisions and relevant therapy options for anterior shoulder instability.

Return to Play After Shoulder Instability Surgery in National Collegiate Athletic Association Division I Intercollegiate Football Athletes

BACKGROUND

Recent attention has focused on the optimal surgical treatment for recurrent shoulder instability in young athletes. Collision athletes are at a higher risk for recurrent instability after surgery.

PURPOSE

To evaluate variables affecting return-to-play (RTP) rates in Division I intercollegiate football athletes after shoulder instability surgery.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Invitations to participate were made to select sports medicine programs that care for athletes in Division I football conferences (Pac-12 Conference, Southeastern Conference [SEC], Atlantic Coast Conference [ACC]). After gaining institutional review board approval, 7 programs qualified and participated. Data on direction of instability, type of surgery, time to resume participation, and quality and level of play before and after surgery were collected.

RESULTS

There were 168 of 177 procedures that were arthroscopic surgery, with a mean 3.3-year follow-up. Overall, 85.4% of players who underwent arthroscopic surgery without concomitant procedures returned to play. Moreover, 15.6% of athletes who returned to play sustained subsequent shoulder injuries, and 10.3% sustained recurrent instability, resulting in reduction/revision surgery. No differences were noted in RTP rates in athletes who underwent anterior labral repair (82.4%), posterior labral repair (92.9%), combined anterior-posterior repair (84.8%; P = .2945), or open repair (88.9%; P = .9362). Also, 93.3% of starters, 95.4% of utilized players, and 75.7% of rarely used players returned to play. The percentage of games played before the injury was 49.9% and rose to 71.5% after surgery ( P < .0001). Athletes who played in a higher percentage of games before the injury were more likely to return to play; 91% of athletes who were starters before the injury returned as starters after surgery. Scholarship status significantly correlated with RTP after surgery ( P = .0003).

CONCLUSION

The majority of surgical interventions were isolated arthroscopic stabilization procedures, with no statistically significant difference in RTP rates when concomitant arthroscopic procedures or open stabilization procedures were performed. Athletes who returned to play often played in a higher percentage of games after surgery than before the injury, and many played at the same or a higher level after surgery.

Effect of Arthroscopic Stabilization on In Vivo Glenohumeral Joint Motion and Clinical Outcomes in Patients With Anterior Instability

BACKGROUND

Glenohumeral joint (GHJ) dislocations are common, and the resulting shoulder instability is often treated with arthroscopic stabilization. These procedures result in favorable clinical outcomes, but abnormal GHJ motion may persist, which may place patients at risk for developing osteoarthritis. However, the effects of shoulder instability and arthroscopic stabilization on GHJ motion are not well understood.

HYPOTHESIS

GHJ motion is significantly influenced by anterior instability and arthroscopic stabilization, but postsurgical measures of GHJ motion are not different from those of control subjects.

STUDY DESIGN

Controlled laboratory study.

METHODS

In vivo GHJ motion was measured by applying a computed tomographic model-based tracking technique to biplane radiographic images acquired during an apprehension test in healthy control subjects (n = 11) and anterior instability patients (n = 11). Patients were tested before surgery and at 6 months after surgery. Control subjects were tested once. Shoulder strength, active range of motion (ROM), and the Western Ontario Shoulder Instability (WOSI) index were also measured.

RESULTS

Before surgery, the humerus of the instability patients during the apprehension test was located significantly more anteriorly on the glenoid (7.9% of glenoid width; 2.1 mm) compared with that of the controls (P = .03), but arthroscopic stabilization moved this joint contact location posteriorly on the glenoid (4.7% of glenoid width; 1.1 mm; P = .03). After surgery, GHJ excursion during the apprehension test was significantly lower (14.7% of glenoid width; 3.6 mm) compared with presurgical values (19.4% of glenoid width; 4.7 mm; P = .01) and with that of the controls (22.4% of glenoid width; 5.7 mm; P = .01). The external and internal rotation strength of patients was significantly lower than that of the controls before surgery (P < .05), but differences in strength did not persist after surgery (P > .17). External rotation ROM in patients was significantly lower than that in control subjects both before and after arthroscopic stabilization (P < .01). The WOSI score improved significantly, from 48.3 ± 13.1 presurgery to 86.3 ± 16.5 after surgery (P = .0002).

CONCLUSION

In patients with anterior instability, arthroscopic stabilization significantly improves measures of strength, ROM, and clinical outcome. However, GHJ excursion is not fully restored to levels seen in the control subjects.

CLINICAL RELEVANCE

Although arthroscopic stabilization satisfactorily restores most clinical outcome measures, GHJ excursion and external rotation ROM remain compromised compared with healthy control subjects and may contribute to the development of osteoarthritis in patients with anterior instability.

[Shoulder dislocation in athletes]

BACKGROUND

Shoulder dislocation is a common injury in athletes. Surgical and non-surgical therapy options are still the subject of controversial debate.

STUDY AIM

This article presents important considerations for decision-making and current concepts for the therapy of shoulder dislocation in athletes.

METHODS

A selective literature search was carried out in PubMed.

RESULTS

Surgical and non-surgical therapy options are described in the literature without yet defining a gold standard.

CONCLUSION

Early surgical stabilization is currently recommended in young athletes. For decision-making numerous sport and patient-related factors need to be considered. Most athletes are able to return to the pre-injury level after surgical stabilization.