Arthroscopic Management of the Contact Athlete with Instability

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Key points

  • The shoulder is the most commonly dislocated joint in the body, with a greater incidence of instability in contact and collision athletes.

  • In contact and collision athletes that have failed nonoperative treatment, the most important factors to consider when planning surgery are amount of bone loss (glenoid, humeral head) and patient age.

  • Clinical outcomes, instability recurrence rate, and return to sport rate are not significantly different between arthroscopic suture anchor and open techniques.

Anatomy

The glenohumeral joint is remarkable in the amount of attainable motion across six degrees of freedom (Table 1). It is this superiority in motion, however, that also gives it the propensity for instability when any one of several static or dynamic structures involved in maintenance of stability is disrupted. Static restraints to glenohumeral subluxation or dislocation include the humeral head, proximal humerus, glenoid, labrum, and capsule. The inferior glenohumeral ligament's anterior band is

Incidence of instability in contact athletes

An important patient-specific factor that plays a significant role in instability incidence and recurrence is type of sport played. The glenohumeral joint is the most commonly dislocated articulation in the body. The overall incidence of dislocation is 2.39 per 1000 person-years in the general population presenting to emergency departments51 and 1.69 per 1000 person-years in a military population.52 During a 5-year period in US high schools, the largest number of shoulder dislocations occurred

History

Evaluation of the patient's history, physical examination, and imaging allows the clinician to make an appropriate diagnosis (Table 2). The history is especially important in the setting of shoulder instability in the contact athlete, because the timing and possibility of recurrence play a large role in selection of treatment. Furthermore, the wide range of shoulder motion makes it difficult to clearly determine the differences between normal motion, asymptomatic hypermobility or laxity, or

Treatment algorithm

Management of shoulder instability is multifactorial. Nonoperative treatment may allow return to sport, even at high levels, at a much faster rate than operative treatment. This strategy may be useful for the in-season athlete looking to complete the season and then undergo off-season stabilization. It may also be the most appropriate option in lower-demand patients that do not want surgery, with multidirectional instability, and without a traumatic cause. In patients that fail nonoperative

Arthroscopic management

The ideal candidate for arthroscopic stabilization is a patient with traumatic etiology, Bankart lesion, no glenoid rim fracture, with few recurrences, in the nondominant arm, in a noncollision, noncontact sport, and capsular laxity symmetric to the other shoulder. Presence of significant glenoid bone loss (>20%) or inverted pear shape (Fig. 5), with multiple recurrences, no Bankart lesion, poor-quality tissue, and abnormal capsular laxity are contraindications to arthroscopic treatment (Table 3

Outcomes

Clinical outcomes after arthroscopic shoulder stabilization are successful (Table 4). A recent systematic review of long-term outcomes after open or arthroscopic Bankart shoulder stabilization analyzed 26 studies and nearly 2000 patients.68 Although 92% of studies in the latter were either level III or IV evidence, the mean length of follow-up was 11 years with validated clinical outcomes. There was no significant difference in recurrence of instability between arthroscopic suture anchor (8.5%)

Summary

The shoulder is the most commonly dislocated joint in the body, with a greater incidence of instability in contact and collision athletes. In contact and collision athletes that have failed nonoperative treatment, the most important factors to consider when planning surgery are amount of bone loss (glenoid, humeral head); patient age; and shoulder hyperlaxity. Clinical outcomes, instability recurrence rate, and return to sport rate are not significantly different between arthroscopic suture

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  • Cited by (14)

    • Glenohumeral Instability

      2018, Essentials of Physical Medicine and Rehabilitation: Musculoskeletal Disorders, Pain, and Rehabilitation
    • Decision-Making, Bracing, and Other Adjuncts for Management of In-Season Contact Athletes With Shoulder Instability

      2016, Operative Techniques in Sports Medicine
      Citation Excerpt :

      When comparing open vs arthroscopic stabilization, patient-reported outcomes, return to sport, and incidence of recurrent instability are similar between the 2 procedures in athletes. As mentioned previously, the amount of bone loss should be taken into consideration, as significant glenoid bone loss is an indication for an open procedure.14 Yoneda et al examined 83 contact athletes who underwent a combined Bankart procedure augmented with coracoid transfer to treat their acute instability.

    • Return to Play Following Anterior Shoulder Dislocation and Stabilization Surgery

      2016, Clinics in Sports Medicine
      Citation Excerpt :

      In the setting of chronic instability, continued nonoperative management should not be recommended. Following the acute anterior shoulder dislocation, the young athlete may elect to undergo surgical stabilization due to continued and recurrent instability, preventing full return to sport or participation in an overhead, contact, or collision sports that requires a stable shoulder.47 Fig. 1 outlines the authors’ recommended treatment algorithm.

    • The shoulder in the collision athlete

      2015, Orthopaedics and Trauma
      Citation Excerpt :

      The reported complications include neurological injuries, hardware problems, non-union13,14 and arthrosis.15 Some author's believe that the results of arthroscopic Bankart repairs are as good as open Bankart repairs16 in the collision athlete, and in some centres, open Bankart repairs are now uncommon. Mazocca et al. reviewed the results of arthroscopic anterior stabilization in 13 collision athletes with average follow up of 37 months (range 24–66 months).17

    • Anterior shoulder instability in collision and contact athletes

      2018, Journal of Arthroscopy and Joint Surgery
      Citation Excerpt :

      Technological advancements have facilitated stronger and more anatomical repairs with suture anchors and now show comparable results to open repairs in most series.64,65 Risk factors for failure of an arthroscopic Bankart repair include male patients, age less than 22, more than 3 previous dislocations, surgery performed in the beach chair position compared to lateral decubitus, use of less than 3 suture anchors and engaging Hill Sachs lesions or significant glenoid bone loss.65–71 Balg and Boileau tried to aide surgical decision making with the Instability Severity Index Score, or ISIS.72

    View all citing articles on Scopus

    Funding Sources: None.

    Conflicts of Interest: Dr J.D. Harris: None. Dr A.A. Romeo: Arthrex (royalties, speakers bureau, paid consultant, research support), DJO Surgical (research support, material support); Smith & Nephew (research support); Ossur (research support); Saunders/Mosby Elsevier (royalties, financial, or material support from publishers); Medical publications editorial/governing board (Journal of Shoulder & Elbow Surgery, SLACK Inc, Sports Health); Board member (American Orthopedic Society for Sports Medicine, American Shoulder & Elbow Surgeons, Arthroscopy Association of North America, Techniques in Shoulder & Elbow Surgery).

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