Recurrence Rates Following Arthroscopic Shoulder Stabilization are Improved Following a Criteria Based Return to Sport Testing Protocol

Objectives: Recurrent shoulder instability after arthroscopic shoulder stabilization is a challenging complication that often manifests after return to sports. Many physicians use an arbitrary minimum of 5 months from surgery for clearance, although there is little data to support the use of temporal based criteria. Prior literature on ACL reconstruction has demonstrated overwhelming evidence for improved failure rates following return to sport after criteria based testing compared to time based clearance, but no such studies to date have evaluated the use of objective return to play testing protocols on recurrence rates following arthroscopic shoulder stabilization. We have prior presented on a return to sport criteria-based protocol that has demonstrated that a majority of athletes have residual strength and functional limitations which would preclude them from full clearance and return to play at 6 months postoperatively. The purpose of this study is to analyze the impact of a return to play criteria-based testing protocol on recurrent instability following arthroscopic shoulder stabilization. We hypothesized that patients who meet return to play criteria would have less recurrent instability compared to those who did not undergo the testing and were cleared to return based on time from surgery. Methods: Forty eight patients (group I) who underwent arthroscopic shoulder stabilization surgery from 2016 to 2018 with minimum 1 year follow up and were referred during postoperative rehabilitation for functional testing to evaluate readiness for return to sport were included in this retrospective case controlled study. These patients were compared to a control group of forty-eight historical consecutive cases (group II) who did not undergo return to sports testing and were cleared for sports after a minimum of 5 months following surgery. Patients with critical glenoid bone loss or off-track Hill-Sach’s lesions necessitating a remplissage or bone augmentation procedure were excluded from the study. ANOVA and independent t test were performed to analyze recurrence shoulder instability rates defined as dislocations or subluxation symptoms. Results: There was no difference between groups with regard to age ( p=0.64), sex (p=0.24), hand dominance (p=0.84), or participation in contact sports (p=0.66). Patients who underwent return to play criteria based testing protocol had a statistically significant difference in the rate of recurrent shoulder instability (10% vs. 31%, odds ratio=3.9, p<0.001). Conclusion: Athletes who undergo an objective return to play criteria based testing protocol have lower rates of recurrent instability following arthroscopic shoulder stabilization surgery than those cleared by time from surgery. Based on our findings, we strongly recommend the utilization of a criteria based testing protocol for return to play following arthroscopic shoulder stabilization, particularly for sports that have known higher risks of recurrence.

ARTHROSCOPIC SHOULDER STABILIZATION IN HIGH SCHOOL FOOTBALL PLAYERS: RECURRENT INSTABILITY WITH RETURN TO CONTACT SPORT

Background: The etiology of recurrent shoulder instability after arthroscopic surgery in the high school American football population remains unknown. Purpose/Hypothesis: To determine the risk of recurrent instability after shoulder arthroscopy upon return to competitive football. The hypothesis was that the rate of recurrence would be greater in high school players with more years of eligibility remaining (YER), suggesting greater likelihood of return to football after surgery. Methods: Consecutive male high school football players with at least one year of eligibility remaining who sustained traumatic in-season shoulder instability episode(s) and underwent arthroscopic labral stabilization by two Orthopaedic Sports surgeons at Rady Children’s Hospital San Diego between 2012 and 2017 were identified. 64 subjects aged 14-17 met inclusion criteria of which 45 were able to be contacted and included in analyses. Average follow up period was 4.06 years. Patients and/or families were contacted by phone to discuss (1) recurrent instability episodes and (2) return to competitive sport and/or recreational athletic activity. Statistics were conducted using chi square analysis to compare recurrence of instability with return to sport. Results: Surgery itself was career ending in 50% of cases due to reported fear of recurrent football-related injury. The hypothesis that career longevity in terms of years of eligibility remaining (YER) affects return to game play in this young active population remains unclear although preliminary results suggest positive exponential correlation. Comparative analysis demonstrates a statistically significant difference between rate of recurrence in high school football players that return to contact sports vs transition to non-contact activity after arthroscopic shoulder stabilization. Interestingly, football players who concurrently played baseball during high school demonstrated decreased risk of postoperative instability episodes. Conclusion: Risk of recurrent instability after shoulder arthroscopy is increased in high school football players who return to competitive contact sports whereas transition to non-contact and/or recreational activity likely confers protective effect. High school football players who play baseball may derive functional benefit from cross training. [Figure: see text]

Risk of Recurrent Instability After Arthroscopic Stabilization for Shoulder Instability in Adolescent Patients

Background: With the rise of adolescent sports participation, there has been a concomitant increase in not only the incidence but also the treatment of traumatic shoulder instability. Yet, there have been limited data on the failure rates of arthroscopic shoulder stabilization in this population as well as the potential risk factors. Purpose/Hypothesis: The purpose of this study was to determine the failure rates of adolescent patients who underwent arthroscopic labral reconstruction for traumatic anterior shoulder instability. We hypothesized that adolescent failure rates would be significantly higher than what has been reported in the adult population with regard to recurrent instability after surgical intervention. Study Design: Case series; Level of evidence, 4. Methods: This was a retrospective cohort study performed at a single center. Inclusion criteria consisted of all adolescent-aged patients identified who (1) had traumatic anterior shoulder instability, (2) had radiographic findings consistent with anteroinferior capsulolabral injury, and (3) underwent arthroscopic shoulder stabilization. Patient demographics, clinical presentation, imaging, intraoperative findings, and postoperative outcomes were analyzed. Results: A total of 36 patients were identified, with a mean ± SD follow-up of 35.6 ± 13.8 months. The mean patient age at the time of the index procedure was 16.03 ± 1.67 years. All patients underwent arthroscopic shoulder stabilization consisting of arthroscopic Bankart repair. Twelve patients (33.3%) reported either recurrent instability or apprehension, of whom 9 (25.0%) developed recurrent dislocation/subluxation at a mean of 20.67 months postoperatively (range, 16-51 months). No single sport was associated with a statistically significant increased risk of redislocation, although a trend was seen toward those with postoperative participation in high-risk sporting activity. Patients who redislocated their shoulders had a higher frequency of a Hill-Sachs lesion on magnetic resonance imaging (89%) compared with those who did not (52%, P = .048). History of multiple preoperative dislocations, presence of bony Bankart pathology, off-track lesions, and number of anchors utilized were not associated with postoperative dislocation/subluxation. Conclusion: This study demonstrates that adolescent patients treated with arthroscopic shoulder stabilization have a high rate of recurrent instability. The adolescent population may benefit from other stabilization strategies and/or activity modification. Further studies are necessary to determine the reasons for the high rate of redislocation and to develop strategies for prevention.

Comparison of Knotless Versus Traditional Glenoid Anchors in Early Outcomes Following Arthroscopic Shoulder Stabilization

Objectives: To compare knotless versus traditional glenoid anchors as well as use of all-suture versus non-all suture anchor material in early outcomes after arthroscopic shoulder stabilization. We hypothesize there is no difference in outcomes between anchor type or material. Methods: Patients who were prospectively enrolled in the Multicenter Orthopaedic Outcomes Network (MOON) Shoulder Group instability database completed a series of patient reported outcomes (PROs) pre and post-operatively at 2 years. At the time of surgery, physicians documented technique utilized and materials employed. The incidence of subsequent shoulder surgeries, re-dislocations or subluxations, and return to sport (RTS) were obtained. Patients were stratified by anchor type (knotless [KL] versus knotted [KT]) and then by anchor material (all-suture [AS] versus non-all suture [NS]). Bivariate analyses were performed to compare outcomes between groups, including the Wilcoxon signed-rank test and chi-square test. Results: A total of 447 patients who underwent primary arthroscopic shoulder stabilization were evaluated, with 112 patients in the KL group (90.2% male) and 335 in the KT group (82.4% male; p > .05). Then there were 70 patients in the AS group (74.3% male) and 377 in the NS group (86.2% male; p = .01). The KT group (24.6 ± 8.9 years) was significantly older than the KL group (21.3 ±7.8 years; p = .0003) while the AS group (26.8 ±9.1 years) was significantly older than the NS group (23.2 ±8.6 years; p = .003). Significantly more patients in the KL group (87.5%) underwent surgery in the beach chair (BC) position than the KT group (45.4%; p < .0001) and significantly more patients in the NS group (59.9%) underwent surgery in the BC position than the AS group (34.3%; p < .0001). The primary direction of instability was anterior, with 78.6% in the KL group, 71.3% in the KT group, 82.9% in the AS group and 71.4% in the NS group. The number of contact athletes was similar in each group, with 75.0% in the KL group, 66.0% in the KT group, 70.0% in the AS group, and 67.9% in the NS group. Significantly more anchors were used in the KL group (4.2 ± 1.6) compared to the KT group (3.9 ± 1.8; p = .003) and significantly more anchors were used in the AS group (5.3 ± 2.4) compared to the NS group (3.7 ± 1.4; p < .0001). Significantly more patients had a redislocation in the KL group (11.6%) compared to the KT group (5.7%; p = .03), and significantly more patients had a redislocation in the NS group (8.2%) compared to the AS group (1.4%; p = .04). There were no significant differences in improvement of any PROs, incidence of RTS, subsequent shoulder surgeries or subluxations between anchor type or material groups. Conclusion: Compared to traditional knotted glenoid anchors, patients undergoing arthroscopic shoulder stabilization with knotless anchors can expect to experience similar clinical outcomes. However, use of knotless anchors may be a significant risk factor for subsequent dislocation 2 years after arthroscopic shoulder stabilization surgery, which may be related to patients’ age. Moreover, use of all-suture based anchors may be associated with lower rates of subsequent dislocation which may be attributed to the size of their footprint and the apparent inclination of surgeons using these to utilize more anchors per labral repair, thus increasing points of labral fixation. Continued investigation of potential confounding variables is necessary to identify the direct effect of anchor type and material on patient outcomes.

Return To Sport Testing At 6 Months After Arthroscopic Shoulder Stabilization Demonstrates Residual Functional Deficits

Objectives: A good outcome after arthroscopic stabilization for recurrent shoulder instability is often characterized by a successful return to sport while minimizing complications. While many physicians use a minimum of 5 months as a time to return, there is currently no consensus regarding timing or objective criteria for return to sport. The objective of this study is to evaluate the ability of postoperative patients to meet expected goals of achieving appropriate strength and using standardized objective evaluations of strength and physical function. Methods: 33 consecutive patients who underwent arthroscopic shoulder stabilization surgery from 2012 until 2018 and completed their postoperative rehabilitation with the same institution were subjected to functional testing to evaluate their readiness for return to sport. Isometric unilateral external rotation to internal rotation (ER/IR) ratio was measured using a hand held dynamometer at 0 and 90 degrees of shoulder abduction. Posterior rotator cuff activation was evaluated using a repetition to failure technique with 5% body weight at 0 and 90 degrees of abduction. Prone trapezius activation was measured in repetitions to failure with a prone Y exercise. A subset of throwing athletes (N= 11) were evaluated for total arc of motion. Results: Isometric testing at revealed that 18% (6/33, mean ratio 71%) patients met the expected goal of 80% ER/IR strength at both 0 and 90 degrees of abduction, with mean ratios of 71% and 62%, respectively. 73% (24/33) and 42% (14/33) of patients met goal of 90% of the contralateral ER repetitions to failure in rotator cuff activation testing at 0 and 90 degress of abduction, respectively. 55% (18/33) of patients met goal of 90% of contralateral prone Y repetitions to failure on lower trapezius activation testing, with mean. Mean total arc of postoperative motion for the 11 throwers was 91.6% of the contralateral shoulder. Thirty-six percent (4/11) patients did not reach 90% of the total arc of motion of the uninvolved shoulder. Conclusion: A substantial number of athletes in our cohort do not meet the expected goals for their operative shoulder in achieving appropriate strength, particularly in ER, nor arc of motion compared to the contralateral shoulder.