Athletes With Anterior Shoulder Instability: A Prospective Study on Player Perceptions of Injury and Treatment

Background:

Many in-season athletes choose to delay or avoid surgery in order to continue playing and avoid downtime such as missed games or seasons.

Purpose:

To learn about the attitudes toward the injury and treatment of in-season shoulder instability in competitive athletes who have suffered a shoulder dislocation.

Study Design:

Cross-sectional study; Level of evidence, 3.

Methods:

A study-specific questionnaire about athletes’ perceptions of injury and treatment was administered to injured players. Secondary outcomes included the American Shoulder and Elbow Surgeons (ASES) score and the Western Ontario Shoulder Instability Index (WOSI). Mean scores and standard deviations were calculated, and between-group analyses with t tests were performed to compare the ASES and WOSI scores. The Mann-Whitney U test was used for analyses performed on the following groups: early operative versus nonoperative management; age <18 versus ≥18 years; first-time dislocators versus recurrent dislocators; self-reducing subluxations versus dislocations requiring assistance; and dominant arm affected versus nondominant arm.

Results:

There were 45 patients included in this study (33 male, 12 female) with a mean age of 18 ± 2.8 years. Several sports were represented, with the most common being football, baseball, soccer, and rugby. In this study of in-season athletes with shoulder instability, 13 (28.9%) chose early surgery, 4 (8.9%) chose surgery at season’s end, while 28 (62.2%) chose physical therapy followed by a wait-and-see approach, with 13 (46.4%) of these patients ultimately requiring surgery. Athletes who chose nonoperative treatment were statistically more likely to believe that their shoulder would heal on its own (P < .001) or with physical therapy (P < .025); they were also more likely to agree that they would rather stop sports than undergo surgery (P < .04). Athletes with worse ASES and WOSI scores at injury were more likely to choose surgery (P < .03 and P < .05, respectively). Athletes with >1 dislocation were less likely to believe that the shoulder would heal without surgery (P < .025). Most athletes agreed that seasonal timing and recruitment prospects were an important factor in their decision in favor of surgery (P < .038), and most agreed that their doctor influenced their ultimate treatment decision (P < .006). Most athletes also agreed that a repeat dislocation would cause further injury to the shoulder.

Conclusion:

Treatment decisions were most strongly related to the athletes’ perceptions of injury severity and the influence of the treating surgeon.

Treatment of nonunions of the humeral shaft with nonvascularized fibular strut allograft: postoperative outcomes and review of a surgical technique

Hypothesis

Persistent humeral shaft nonunions result in continued pain and disability of the affected arm and are difficult to treat even with several surgical procedures and locked plating. A fibular allograft provides bony purchase for fixation as well as rotational stability and bridging of nonunion defects.

Methods

We conducted a retrospective review of a single surgeon's clinical practice between July 1995 and January 2011. The inclusion criteria were patients aged ≥ 18 years who underwent revision surgery for a humeral shaft nonunion by open reduction and revision internal fixation with a supplementary fibular strut allograft.

Results

Thirteen patients who met the inclusion criteria were evaluated with physical examinations, validated functional outcome measures, and radiographs to assess union rates. The mean follow-up period was 7.5 years (range, 0.5-15.6 years); there were 11 women (85%) and 2 men (15%). Of the patients, 3 (23%) had proximal-third nonunions, 7 (54%) had middle-third nonunions, and 3 (23%) had distal-third nonunions. After revision surgery with fibular allograft, 10 of 13 patients went on to achieve healing, giving a union rate of 76.9%. The mean postoperative Disabilities of the Arm, Shoulder and Hand score was 38.1 points (standard deviation [SD], 27.6 points). The mean Constant score was 55.2 points (SD, 24.0 points), representing a 62% return of function compared with the contralateral side. The mean postoperative American Shoulder and Elbow Surgeons score was 65.4 points (SD, 28.5 points), and the average visual analog scale pain score (out of 10) was 2.1 (SD, 3.3) at final follow-up.

Conclusion

Fibular allograft is an effective and straightforward option for treating humeral midshaft and distal-shaft nonunions; however, treatment of proximal-third nonunions remains challenging.

Arthroscopic Management of Elbow Fractures

Several types of elbow fractures are amenable to arthroscopic or arthroscopic-assisted fracture fixation, including fractures of the coronoid, radial head, lateral condyle, and capitellum. Other posttraumatic conditions may be treated arthroscopically, such as arthrofibrosis or delayed radial head excision. Arthroscopy can be used for assessment of stability or intra-articular fracture displacement. The safest portals are the midlateral (soft spot portal), proximal anteromedial, and proximal anterolateral. Although circumstances may vary according to the injury pattern, a proximal anteromedial portal is usually established first. Arthroscopy enables a less invasive surgical exposure that facilitates visualization of the fracture fragments in select scenarios.

Sports activity after reverse total shoulder arthroplasty with minimum 2-year follow-up

There is limited information on activity levels of patients with reverse total shoulder arthroplasty (RTSA). We conducted a study of the types of sporting activities in which 78 patients with RTSA could participate. Mean follow-up was 4.8 years. Mean (SD) age at surgery was 75.3 (7.5) years. Seventy-five percent of the patients were women. Sixty-one percent underwent surgery for cuff tear arthropathy, 31% for revision of previous arthroplasty or internal fixation, 7% for complex fractures, and 1% for tumor. Mean (SD) postoperative ASES (American Shoulder and Elbow Surgeons) Standardized Shoulder Assessment Form score was 77.5 (23.4). After surgery, mean active forward elevation was 140°, mean external rotation was 48°, and mean internal rotation was to S1. Four patients played golf; none were able to play tennis. Eighteen patients (23.1%) engaged in 24 high-intensity activities, such as hunting, golf, and skiing; 48.7% engaged in moderate-intensity activities, such as swimming, bowling, and raking leaves; and 28.2% engaged only in low-intensity activities. Regarding reasons for their limited activity, 59% of the patients cited medical problems, 19.2% cited shoulder limitations, 2.5% cited fear of injury, and 19.2% reported not being limited. RTSA results in good pain relief and motion, with a variety of postoperative overhead activities enjoyed by some patients who are not limited by comorbidities.

Metal-on-metal hip resurfacing compared with total hip arthroplasty: two to five year outcomes in men younger than sixty five years

PURPOSE

There are limited studies examining the long-term survivorship for the current generation of metal-on-metal hip resurfacing (MOMHR) implants in the young male population, and fewer studies have been published on prospectively collected outcomes data for total hip resurfacing in the USA. The purpose of this study was to demonstrate the efficacy of MOMHR in comparison with total hip arthroplasty (THA) using validated outcome measures, survivorship and complication rates.

METHODS

The study prospectively followed 136 implants in 123 male patients <65 years, all with a primary diagnosis of osteoarthritis and similar comorbidities as determined by the American Society of Anesthesiologists (ASA) score. A single-surgeon cohort of 89 MOMHRs was compared with a similar cohort of 47 THAs. Outcomes were prospectively assessed with the Short-Form Health Survey of 12 questions (SF-12) and Western Ontario and McMaster Universities (WOMAC) questionnaires pre- and postoperatively at yearly intervals. Minimum follow-up was two years, and average follow-up was 3.9 years.

RESULTS

Diagnosis, body mass index (BMI), American Association of Anesthesiologists (ASA) and pre-operative pain and function scores were not significantly different between groups. There was no difference in SF-12 scores postoperatively. At one and two years postoperatively, the MOMHR group had better WOMAC scores than the THA group, but no difference was seen at three to five years postoperatively. There were no revisions in either group over the study period.

CONCLUSIONS

This study demonstrated good results for hip resurfacing in men <65 years five years postoperatively and similar function to THA patients.