Anterior glenohumeral capsular ligament reconstruction with hamstring autograft for internal impingement with anterior instability of the shoulder in baseball players: preliminary surgical outcomes

Clinical outcomes and return-to-play in dynamic anterior glenohumeral capsular ligament tensioning procedure for overhead-throwing athletes with traumatic shoulder dislocation on the throwing side

BACKGROUND

Although arthroscopic Bankart repair for shoulder instability after a traumatic shoulder dislocation is a standard procedure, return-to-play rates for overhead-throwing athletes with shoulder instability on the throwing side have been reported to be lower than those in nonoverhead athletes or in nonthrowing shoulders. A recent technical report showed that the dynamic anterior glenohumeral capsular ligament tensioning (DAGHT) procedure in abducted external rotation, which mimics the late cocking phase of the throwing motion during surgery, may provide optimal tensioning of the anterior glenohumeral ligament. This study compared clinical outcomes and return-to-play after arthroscopic Bankart repair between DAGHT and a conventional procedure for overhead-throwing athletes with traumatic dislocation on the throwing side.

METHODS

We retrospectively examined patients with traumatic anterior shoulder dislocation who underwent arthroscopic Bankart repair. The inclusion criteria were being an overhead-throwing athlete, having the injury on the throwing side, evidence of anterior shoulder dislocation, and evidence of Bankart lesions on magnetic resonance imaging. Clinical scores were evaluated using Jobe's postoperative grading system; the Kerlan-Jobe Orthopaedic Clinic Overhead Athletes Shoulder and Elbow Score; the Western Ontario Shoulder Instability Index; the Disabilities of the Arm, Shoulder, and Hand sports module; return to play; and return to the same level.

RESULTS

Thirty-four patients (8 females and 26 males; mean age, 18.0 ± 4.0 years) were divided into 2 groups: 16 with shoulder stabilization in the resting position (control group) and 18 with shoulder stabilization with DAGHT (DAGHT group). Jobe's score was significantly greater in the DAGHT group than in the control group (88.9% and 18.8% in excellent rate, respectively; P < .001). External rotation at abduction and the Kerlan-Jobe Orthopaedic Clinic, Western Ontario Shoulder Instability Index, and Disabilities of the Arm, Shoulder, and Hand scores were significantly greater in the DAGHT group than in the control group (94.5 vs. 85.0; 81.1 vs. 55.7; 83.8 vs. 58.4; 11.8 vs. 27.0; P = .008, <.001, <.001, and =.019, respectively). Although return-to-play rates were not significantly different between the control and DAGHT groups (93.8% vs. 100%; P = .47), return-to-the-same-level rates were significantly better in the DAGHT group than in the control group (77.8% vs. 37.5%; P = .035).

CONCLUSION

Arthroscopic shoulder stabilization with the DAGHT procedure on the throwing side of overhead-throwing athletes resulted in lesser restriction of external rotation, better clinical outcomes, and higher return-to-the-same-level rate than arthroscopic shoulder stabilization with conventional tensioning. The DAGHT procedure in abduction and external rotation may represent a solution for a traumatic shoulder instability on the throwing side in overhead-throwing athletes.

Dynamic Anterior Glenohumeral Capsular Ligament Tensioning During Arthroscopic Shoulder Stabilization in Overhead-Throwing Athletes

Although the most common surgical treatment for traumatic anterior shoulder instability is arthroscopic Bankart repair (ABR), which has shown good postoperative results, a potential risk of postoperative external rotation deficit exists. For overhead-throwing athletes, recovery of postoperative range of motion during abduction and external rotation is essential to return to preinjury performance levels. We consider that the key to returning to play after ABR on the dominant side in overhead-throwing athletes is to simultaneously gain anterior stability and mobility of the shoulder. However, no gold standard method for determining the appropriate tension of the glenohumeral capsular ligaments in overhead-throwing athletes exists. This Technical Note presents the dynamic anterior glenohumeral capsular ligament tensioning in the abduction and external rotation positions during ABR for the dominant side in overhead-throwing athletes. We consider this surgical technique to be reliable for traumatic anterior instability of the dominant shoulder in athletes who wish to return to overhead-throwing sports.

Current Concepts on the Management of Shoulder Instability in Throwing Athletes

PURPOSE OF REVIEW

The management of shoulder instability in throwing athletes remains a challenge given the delicate balance between physiologic shoulder laxity facilitating performance and the inherent need for shoulder stability. This review will discuss the evaluation and management of a throwing athlete with suspected instability with a focus on recent findings and developments.

RECENT FINDINGS

The vast majority of throwing athletes with shoulder instability experience subtle microinstability as a result of repetitive microtrauma rather than episodes of gross instability. These athletes may present with arm pain, dead arms or reduced throwing velocity. Recent literature reinforces the fact that there is no "silver bullet" for the management of these athletes and an individualized, tailored approach to treatment is required. While initial nonoperative management remains the hallmark for treatment, the results of rehabilitation protocols are mixed, and some patients will ultimately undergo surgical stabilization. In these cases, it is imperative that the surgeon be judicious with the extent of surgical stabilization as overtightening of the glenohumeral joint is possible, which can adversely affect athlete performance. Managing shoulder instability in throwing athletes requires a thorough understanding of its physiologic and biomechanical underpinnings. Inconsistent results seen with surgical stabilization has led to a focus on nonoperative management for these athletes with surgery reserved for cases that fail to improve non-surgically. Overall, more high quality studies into the management of this challenging condition are warranted.

Arthroscopic findings of the glenohumeral joint in symptomatic anterior instabilities: comparison between overhead throwing disorders and traumatic shoulder dislocation

BACKGROUND

The term shoulder instability refers to a variety of mechanisms and clinical presentations. One of the common pathologies of throwing disorders is internal impingement with anterior instability. Most throwing athletes with symptomatic internal impingement with anterior instability exhibit positive apprehension and relocation test results, whereas those with recurrent anterior shoulder instability display positive apprehension test results. While the glenoid labrum-inferior glenohumeral ligament complex is a significant critical stabilizer for the prevention of anterior shoulder dislocation, the characteristics of the essential lesion in internal impingement with anterior instability have not been determined yet. This study aimed to compare the intra-articular lesion of athletes with internal impingement related to the overhead throwing motion in athletes with a traumatic shoulder dislocation.

METHODS

Sixty-one athletes (all men; mean age, 25.2 ± 12.6 yr) who underwent an arthroscopic procedure were divided into 2 groups: 25 in the throwing group and 36 in the dislocation group. All shoulders had subtle glenohumeral instability defined by a positive anterior apprehension test and a relocation test. Those with voluntary and multidirectional instability and large glenoid bone loss (more than 25%) were excluded from the current study. All shoulders were evaluated for the following evidence: rotator cuff injury, superior labrum tear anterior and posterior lesions, labral pathologies including Bankart lesions, osteochondral lesions to the humeral head, biceps tendon fraying or rupture, and inferior glenohumeral ligament and middle glenohumeral ligament (MGHL) conditions.

RESULTS

Arthroscopic findings of the throwing group showed more supraspinatus injuries (92% and 25%, P < .001), type II superior labrum tear anterior and posterior lesions (60% and 3%, P < .001), posterosuperior labral lesions (92% and 39%, P < .001), and hypoplastic MGHLs (56% and 6%, P < .001) and lesser Bankart lesions (8% and 92%, P < .05) than those of the dislocation group.

CONCLUSIONS

These results indicate that the characteristic lesions of internal impingement with anterior instability in throwing athletes include partial thickness rotator cuff tears, superior labrum tear anterior and posterior lesions, posterosuperior labral tears, and hypoplastic MGHLs. As expected, the physiopathology of internal impingement with anterior instability in throwing athletes may be related to the dysfunction of the anterosuperior glenohumeral capsular ligament, including the MGHL, rather than the inferior glenohumeral ligament as in traumatic anterior shoulder dislocations. These findings would be useful for defining treatment strategies for internal impingement with anterior instability in overhead throwing athletes.