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Tennent DJ, Slaven SE, Slabaugh MA, Cameron KL, Posner MA, Owens BD, LeClere LE, Rue JPH, Tokish JM, Dickens JF. Recurrent Instability and Surgery Are Common After Nonoperative Treatment of Posterior Glenohumeral Instability in NCAA Division I FBS Football Players. Clin Orthop Relat Res 2021; 479:694-700. [PMID: 33724975 PMCID: PMC8083809 DOI: 10.1097/corr.0000000000001471] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Accepted: 08/05/2020] [Indexed: 01/31/2023]
Abstract
BACKGROUND In-season return to play after anterior glenohumeral instability is associated with high rates of recurrent instability and the need for surgical stabilization. We are not aware of previous studies that have investigated in-season return to play after posterior glenohumeral instability; furthermore, as posterior shoulder instability in collision athletes occurs frequently, understanding the expected outcome of in-season athletes may improve the ability of physicians to provide athletes with a better understanding of the expected outcome of their injury and their ability to return to sport. QUESTIONS/PURPOSES (1) What proportion of athletes returned to play during the season after posterior instability in collegiate football players? (2) How much time did athletes lose to injury, what proportion of athletes opted to undergo surgery, and what proportion of athletes experienced recurrent instability after a posterior instability episode during a collegiate football season? METHODS A multicenter, prospective, observational study of National Collegiate Athletic Association (NCAA) Division 1 Football Bowl Subdivision athletes was performed at three US Military Service Academies. Ten athletes who sustained a posterior instability event during the regular football season and who pursued a course of nonoperative treatment were identified and prospectively observed through the subsequent season. All athletes in the observed cohort attempted an initial course of nonoperative treatment during the season. All athletes sustained subluxation events initially identified through history and physical examination at the time of injury. None of the athletes sustained a dislocation event requiring a manual reduction. Intraarticular pathology consisting of posterior labral pathology was further subsequently identified in all subjects via MRI arthrogram. Return to play was the primary outcome of interest. Time lost to injury, surgical intervention, and subsequent instability were secondary outcomes. RESULTS Of the 10 athletes who opted for a trial of initial nonoperative management, seven athletes were able to return to play during the same season. Although these seven athletes returned within 1 week of their injury (median of 1 day), 5 of 7 athletes sustained recurrent subluxation events with a median (range) of four subluxation events per athlete (0 to 8) during the remainder of the season. Seven athletes were treated surgically after the completion of their season, four of whom returned to football. CONCLUSION This study suggests that although collegiate football players are able to return to in-season sport after a posterior glenohumeral instability event, they will likely sustain multiple recurrent instability events and undergo surgery after the season is completed. The results of this study can help guide in-season management of posterior shoulder instability by allowing more appropriate postinjury counseling and decision making through the identification of those athletes who may require additional attention from medical staff during the season and possible modifications to training regimens to minimize long-term disability. Further prospective studies involving a larger cohort over several seasons should be performed through collaborative studies across the NCAA that better assess function and injury risk factors before beginning collegiate athletics. This would better characterize the natural history and associated functional limitations that athletes may encounter during their collegiate careers. LEVEL OF EVIDENCE Level IV, prognostic study.
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Affiliation(s)
- David J Tennent
- D. J. Tennent, K. L. Cameron, M. A. Posner, J. F. Dickens, John A. Feagin Jr. Orthopaedic Sports Medicine Fellowship at West Point, West Point, NY, USA
- D. J. Tennent, Department of Surgery, Evans Army Community Hospital, Fort Carson, CO, USA
- S. E. Slaven, J. F. Dickens, Department of Orthopaedic Surgery, Walter Reed National Military Medical Center, Bethesda, MD, USA
- S. E. Slaven, K. L. Cameron, J. F. Dickens, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
- M. A. Slabaugh, United States Air Force Academy, Colorado Springs, CO, USA
- B. D. Owens, Department of Orthopedic Surgery, Brown University, East Providence, RI, USA
- L. E. LeClere, J.-P. H. Rue, United States Naval Academy, Annapolis, MD, USA
- J. M. Tokish, Mayo Clinic, Phoenix, AZ, USA
| | - Sean E Slaven
- D. J. Tennent, K. L. Cameron, M. A. Posner, J. F. Dickens, John A. Feagin Jr. Orthopaedic Sports Medicine Fellowship at West Point, West Point, NY, USA
- D. J. Tennent, Department of Surgery, Evans Army Community Hospital, Fort Carson, CO, USA
- S. E. Slaven, J. F. Dickens, Department of Orthopaedic Surgery, Walter Reed National Military Medical Center, Bethesda, MD, USA
- S. E. Slaven, K. L. Cameron, J. F. Dickens, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
- M. A. Slabaugh, United States Air Force Academy, Colorado Springs, CO, USA
- B. D. Owens, Department of Orthopedic Surgery, Brown University, East Providence, RI, USA
- L. E. LeClere, J.-P. H. Rue, United States Naval Academy, Annapolis, MD, USA
- J. M. Tokish, Mayo Clinic, Phoenix, AZ, USA
| | - Mark A Slabaugh
- D. J. Tennent, K. L. Cameron, M. A. Posner, J. F. Dickens, John A. Feagin Jr. Orthopaedic Sports Medicine Fellowship at West Point, West Point, NY, USA
- D. J. Tennent, Department of Surgery, Evans Army Community Hospital, Fort Carson, CO, USA
- S. E. Slaven, J. F. Dickens, Department of Orthopaedic Surgery, Walter Reed National Military Medical Center, Bethesda, MD, USA
- S. E. Slaven, K. L. Cameron, J. F. Dickens, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
- M. A. Slabaugh, United States Air Force Academy, Colorado Springs, CO, USA
- B. D. Owens, Department of Orthopedic Surgery, Brown University, East Providence, RI, USA
- L. E. LeClere, J.-P. H. Rue, United States Naval Academy, Annapolis, MD, USA
- J. M. Tokish, Mayo Clinic, Phoenix, AZ, USA
| | - Kenneth L Cameron
- D. J. Tennent, K. L. Cameron, M. A. Posner, J. F. Dickens, John A. Feagin Jr. Orthopaedic Sports Medicine Fellowship at West Point, West Point, NY, USA
- D. J. Tennent, Department of Surgery, Evans Army Community Hospital, Fort Carson, CO, USA
- S. E. Slaven, J. F. Dickens, Department of Orthopaedic Surgery, Walter Reed National Military Medical Center, Bethesda, MD, USA
- S. E. Slaven, K. L. Cameron, J. F. Dickens, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
- M. A. Slabaugh, United States Air Force Academy, Colorado Springs, CO, USA
- B. D. Owens, Department of Orthopedic Surgery, Brown University, East Providence, RI, USA
- L. E. LeClere, J.-P. H. Rue, United States Naval Academy, Annapolis, MD, USA
- J. M. Tokish, Mayo Clinic, Phoenix, AZ, USA
| | - Matthew A Posner
- D. J. Tennent, K. L. Cameron, M. A. Posner, J. F. Dickens, John A. Feagin Jr. Orthopaedic Sports Medicine Fellowship at West Point, West Point, NY, USA
- D. J. Tennent, Department of Surgery, Evans Army Community Hospital, Fort Carson, CO, USA
- S. E. Slaven, J. F. Dickens, Department of Orthopaedic Surgery, Walter Reed National Military Medical Center, Bethesda, MD, USA
- S. E. Slaven, K. L. Cameron, J. F. Dickens, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
- M. A. Slabaugh, United States Air Force Academy, Colorado Springs, CO, USA
- B. D. Owens, Department of Orthopedic Surgery, Brown University, East Providence, RI, USA
- L. E. LeClere, J.-P. H. Rue, United States Naval Academy, Annapolis, MD, USA
- J. M. Tokish, Mayo Clinic, Phoenix, AZ, USA
| | - Brett D Owens
- D. J. Tennent, K. L. Cameron, M. A. Posner, J. F. Dickens, John A. Feagin Jr. Orthopaedic Sports Medicine Fellowship at West Point, West Point, NY, USA
- D. J. Tennent, Department of Surgery, Evans Army Community Hospital, Fort Carson, CO, USA
- S. E. Slaven, J. F. Dickens, Department of Orthopaedic Surgery, Walter Reed National Military Medical Center, Bethesda, MD, USA
- S. E. Slaven, K. L. Cameron, J. F. Dickens, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
- M. A. Slabaugh, United States Air Force Academy, Colorado Springs, CO, USA
- B. D. Owens, Department of Orthopedic Surgery, Brown University, East Providence, RI, USA
- L. E. LeClere, J.-P. H. Rue, United States Naval Academy, Annapolis, MD, USA
- J. M. Tokish, Mayo Clinic, Phoenix, AZ, USA
| | - Lance E LeClere
- D. J. Tennent, K. L. Cameron, M. A. Posner, J. F. Dickens, John A. Feagin Jr. Orthopaedic Sports Medicine Fellowship at West Point, West Point, NY, USA
- D. J. Tennent, Department of Surgery, Evans Army Community Hospital, Fort Carson, CO, USA
- S. E. Slaven, J. F. Dickens, Department of Orthopaedic Surgery, Walter Reed National Military Medical Center, Bethesda, MD, USA
- S. E. Slaven, K. L. Cameron, J. F. Dickens, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
- M. A. Slabaugh, United States Air Force Academy, Colorado Springs, CO, USA
- B. D. Owens, Department of Orthopedic Surgery, Brown University, East Providence, RI, USA
- L. E. LeClere, J.-P. H. Rue, United States Naval Academy, Annapolis, MD, USA
- J. M. Tokish, Mayo Clinic, Phoenix, AZ, USA
| | - John-Paul H Rue
- D. J. Tennent, K. L. Cameron, M. A. Posner, J. F. Dickens, John A. Feagin Jr. Orthopaedic Sports Medicine Fellowship at West Point, West Point, NY, USA
- D. J. Tennent, Department of Surgery, Evans Army Community Hospital, Fort Carson, CO, USA
- S. E. Slaven, J. F. Dickens, Department of Orthopaedic Surgery, Walter Reed National Military Medical Center, Bethesda, MD, USA
- S. E. Slaven, K. L. Cameron, J. F. Dickens, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
- M. A. Slabaugh, United States Air Force Academy, Colorado Springs, CO, USA
- B. D. Owens, Department of Orthopedic Surgery, Brown University, East Providence, RI, USA
- L. E. LeClere, J.-P. H. Rue, United States Naval Academy, Annapolis, MD, USA
- J. M. Tokish, Mayo Clinic, Phoenix, AZ, USA
| | - John M Tokish
- D. J. Tennent, K. L. Cameron, M. A. Posner, J. F. Dickens, John A. Feagin Jr. Orthopaedic Sports Medicine Fellowship at West Point, West Point, NY, USA
- D. J. Tennent, Department of Surgery, Evans Army Community Hospital, Fort Carson, CO, USA
- S. E. Slaven, J. F. Dickens, Department of Orthopaedic Surgery, Walter Reed National Military Medical Center, Bethesda, MD, USA
- S. E. Slaven, K. L. Cameron, J. F. Dickens, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
- M. A. Slabaugh, United States Air Force Academy, Colorado Springs, CO, USA
- B. D. Owens, Department of Orthopedic Surgery, Brown University, East Providence, RI, USA
- L. E. LeClere, J.-P. H. Rue, United States Naval Academy, Annapolis, MD, USA
- J. M. Tokish, Mayo Clinic, Phoenix, AZ, USA
| | - Jonathan F Dickens
- D. J. Tennent, K. L. Cameron, M. A. Posner, J. F. Dickens, John A. Feagin Jr. Orthopaedic Sports Medicine Fellowship at West Point, West Point, NY, USA
- D. J. Tennent, Department of Surgery, Evans Army Community Hospital, Fort Carson, CO, USA
- S. E. Slaven, J. F. Dickens, Department of Orthopaedic Surgery, Walter Reed National Military Medical Center, Bethesda, MD, USA
- S. E. Slaven, K. L. Cameron, J. F. Dickens, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
- M. A. Slabaugh, United States Air Force Academy, Colorado Springs, CO, USA
- B. D. Owens, Department of Orthopedic Surgery, Brown University, East Providence, RI, USA
- L. E. LeClere, J.-P. H. Rue, United States Naval Academy, Annapolis, MD, USA
- J. M. Tokish, Mayo Clinic, Phoenix, AZ, USA
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Bayomy AF, Schickendantz MS, Briskin IN, Farrow LD, Grobaty LE, Jones MH, McCoy BW, Miniaci A, Ricchetti ET, Rosneck JT, Sosic E, Spindler KP, Stearns KL, Strnad GJ, Williams J, Saluan PM. What Are the Predictors of Poor Patient-Reported Outcomes After Shoulder Instability Surgery? Orthop J Sports Med 2020; 8:2325967120966343. [PMID: 33447618 PMCID: PMC7780330 DOI: 10.1177/2325967120966343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Accepted: 06/16/2020] [Indexed: 12/04/2022] Open
Abstract
Background: Prospectively collected responses to Patient Acceptable Symptom State (PASS) questions after shoulder instability surgery are limited. Responses to these outcome measures are imperative to understanding their clinical utility. Purpose/Hypothesis: The purpose of this study was to evaluate which factors predict unfavorable patient-reported outcomes after shoulder instability surgery, including “no” to the PASS question. We hypothesized that poor outcomes would be associated with male adolescents, bone loss, combined labral tears, and articular cartilage injuries. Study Design: Cohort study; Level of evidence, 2. Methods: Patients aged ≥13 years undergoing shoulder instability surgery were included in point-of-care data collection at a single institution across 12 surgeons between 2015 and 2017. Patients with anterior-inferior labral tears were included, and those with previous ipsilateral shoulder surgery were excluded. Demographics, American Shoulder and Elbow Surgeons (ASES) and Single Assessment Numeric Evaluation (SANE) scores, and surgical findings were obtained at baseline. ASES and SANE scores, PASS responses, and early revision surgery rates were obtained at a minimum of 1 year after the surgical intervention. Regression analyses were performed. Results: A total of 234 patients met inclusion criteria, of which 176 completed follow-up responses (75.2%). Nonresponders had a younger age, greater frequency of glenoid bone loss, fewer combined tears, and more articular cartilage injuries (P < .05). Responders’ mean age was 25.1 years, and 22.2% were female. Early revision surgery occurred in 3.4% of these patients, and 76.1% responded yes to the PASS question. A yes response correlated with a mean 25-point improvement in the ASES score and a 40-point improvement in the SANE score. On multivariate analysis, combined labral tears (anterior-inferior plus superior or posterior tears) were associated with greater odds of responding no to the PASS question, while both combined tears and injured capsules were associated with lower ASES and SANE scores (P < .05). Sex, bone loss, and grade 3 to 4 articular cartilage injuries were not associated with variations on any patient-reported outcome measure. Conclusion: Patients largely approved of their symptom state at ≥1 year after shoulder instability surgery. A response of yes to the PASS question was given by 76.1% of patients and was correlated with clinically and statistically significant improvements in ASES and SANE scores. Combined labral tears and injured capsules were negative prognosticators across patient-reported outcome measures, whereas sex, bone loss, and cartilage injuries were not.
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Affiliation(s)
| | - Ahmad F Bayomy
- Investigation performed at the Cleveland Clinic, Cleveland, Ohio, USA
| | | | - Isaac N Briskin
- Investigation performed at the Cleveland Clinic, Cleveland, Ohio, USA
| | - Lutul D Farrow
- Investigation performed at the Cleveland Clinic, Cleveland, Ohio, USA
| | - Lauren E Grobaty
- Investigation performed at the Cleveland Clinic, Cleveland, Ohio, USA
| | - Morgan H Jones
- Investigation performed at the Cleveland Clinic, Cleveland, Ohio, USA
| | - Brett W McCoy
- Investigation performed at the Cleveland Clinic, Cleveland, Ohio, USA
| | - Anthony Miniaci
- Investigation performed at the Cleveland Clinic, Cleveland, Ohio, USA
| | - Eric T Ricchetti
- Investigation performed at the Cleveland Clinic, Cleveland, Ohio, USA
| | - James T Rosneck
- Investigation performed at the Cleveland Clinic, Cleveland, Ohio, USA
| | - Elizabeth Sosic
- Investigation performed at the Cleveland Clinic, Cleveland, Ohio, USA
| | - Kurt P Spindler
- Investigation performed at the Cleveland Clinic, Cleveland, Ohio, USA
| | - Kim L Stearns
- Investigation performed at the Cleveland Clinic, Cleveland, Ohio, USA
| | - Greg J Strnad
- Investigation performed at the Cleveland Clinic, Cleveland, Ohio, USA
| | - James Williams
- Investigation performed at the Cleveland Clinic, Cleveland, Ohio, USA
| | - Paul M Saluan
- Investigation performed at the Cleveland Clinic, Cleveland, Ohio, USA
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