Shoulder Instability in the Contact Athlete - I do it arthroscopically Brian J. Cole, MD, MBA

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1 Shoulder Instability in the Contact Athlete - I do it arthroscopically Brian J. Cole, MD, MBA bcole@rushortho.com Key points: o Greater incidence of anterior shoulder instability in contact and collision athletes o Most important factors to consider when planning surgery: patient age, sport, and glenoid/humeral head bone loss o Clinical outcomes, recurrence rate, and return to sport rate are not significantly different between arthroscopic suture anchor and open techniques (at > 5 year follow-up) o Lateral decubitus positioning and four portal (including 7 and 5 o'clock positions) techniques allow for 360 degree access to the glenoid rim, with at least three anchors below 3 o'clock (author preference) o In patients with significant glenoid bone loss (>20-25%, "inverted pear" glenoid), open bone augmentation techniques are considered and may lead to relative contraindication to open techniques o Three-dimension computed tomography (3D-CT) is most accurate imaging modality for evaluation of glenoid bone loss Age-related risk of recurrence dislocation without surgery- < 20 years old >90% risk of re-dislocation "Inverted pear" glenoid = significantly greater glenoid bone loss (8.6mm, 36% inferior glenoid width) than those without "inverted pear." -Lo, et al. Arthroscopy o Cadaver study: creation "inverted pear" requires mm defect (28.8% glenoid width). o Critical size 20-25% anteroinferior glenoid (6-8 mm). Bhatia & Romeo. Sports Health "Engaging" (larger and more horizontally-positioned) Hill-Sachs lesion is predictor for recurrence following arthroscopic stabilization - Burkhart et al. Arthroscopy. 2000; Cho et al, AJSM, Increased recurrence following arthroscopic treatment if bone loss > 19-25% o Boileau JBJS Am, ; Burkhart et al. Arthroscopy. 2000; Tauber et al, JSES o Assess ISIS (Instability Severity Index Score) - Balg & Boileau, JBJS Br, /6 points of ISIS are devoted to contact athletes. Type of sport played o 5 year period of US High Schools - largest number of dislocations in football and wrestling Kerr et al, Clin J Sports Med, o Level I prognostic study of 131 subjects with a first-time dislocation with 4 years follow-up 43 recurrent dislocation, 37 contact/collision athletes (86%) - Sachs, JBJS Am 2007 Considerations o Timing (start of season, end of season, off-season), contract, scholarship, bonus, expected vs desired length of career, "weekend warrior", other sources of input (family, spouse, friend, agent, trainer, coach, manager, teammate, owner). o Concomitant connective tissue (e.g. Marfan's, Ehlers-Danlos, etc). Surgical goal (regardless of approach - open vs arthroscopic) o Fully define the pathologic lesion, establish healing potential, anatomically repair the pathology with secure fixation and appropriate ligament tensioning, and avoid complications.

2 Outcomes o Recent systematic review (Harris et al, Arthroscopy 2013) of 26 studies, ~2,000 subjects o Mean 11 year follow-up with validated clinical outcomes and radiographs o Modern arthroscopic suture anchor technique vs open techniques 8.5% (scope) vs 8.0% (open) (p=0.82) recurrent dislocation 87% (scope) vs 89% (open) (p=0.43) rate of return to sport 26% (scope) vs 33% (open) (p=0.06) rate of radiographic OA o Meta-analysis (Petrera et al, Knee Surg Sports Traumatol Arthrosc 2010) similar conclusions regarding recurrence rate, clinical outcomes, rate of return to sport, radiographic OA.

3 ***Pearls of shoulder anatomy and pathoanatomy in instability Key shoulder anatomy Glenohumeral joint has largest range of motion in body Most important passive soft tissue stabilizers are inferior glenohumeral ligament complex and glenoid labrum, especially in abduction and external rotation Glenoid is wider inferiorly than superiorly, "pear-shaped" Glenoid "socket" is only 5 mm deep in anterior-posterior direction (minimal articular conformity-based constraint) 25% - 30% of humeral head contacts glenoid at any range of motion ***Pearls of history and physical examination in shoulder instability Key history items Age at time of first dislocation Exact injury situation description (mechanism, arm position, nerve symptoms) Number of dislocations Sport(s) played, timing in relation to season, desire to return to sport, career length Other joints dislocated (hypermobility syndromes) Prior treatments (e.g. immobilization, surgery) ***Pearls and pitfalls for arthroscopic shoulder stabilization Pearls Successful interscalene regional block anesthesia Lateral decubitus position, with slight (~30 degrees) posterior body tilt Longitudinal and overhead lateral traction Accurate and precise portal placement (including 7 and 5 o'clock portals..can be percutaneous) At least three anchors below 3 o'clock Recognition of concomitant hypermobility and tissue quality, thus allowing individualized greater degrees of capsular plication as necessary o Appropriate ligament tensioning Appropriate rehabilitation - know your physical therapist Key shoulder pathoanatomy in instability Glenohumeral joint is most commonly dislocated joint in the body Shoulder laxity (asymptomatic) is normal; instability is pathologic (symptomatic) Bankart (anteroinferior labral tear) and Hill Sachs (posterolateral humeral head) lesions and anteroinferior capsular stretch are frequently associated with anterior shoulder instability Do not miss less common causes of instability: HAGL, ALPSA, GLAD, SLAP "Inverted pear" glenoid is indicative of significant glenoid bone loss (>20-25%) Key physical examination items Inspection: atrophy, prominence/fullness of humeral head, ecchymosis, winging Palpation: glenohumeral joint line, acromioclavicular joint, cervical spine, periscapular, upper extremity Motion: active and passive; forward elevation, internal and external rotation Strength: deltoid, rotator cuff, biceps and triceps brachii Special: Identify correct direction of instability (anterior, posterior, inferior) o Apprehension, relocation, load-and-shift o Posterior jerk test, load-and-shift o Sulcus sign, Beighton's criteria Pitfalls Poor patient positioning and visualization, with body tilted straight upright or leaning forward Poor portal placement, avoid iatrogenic articular cartilage damage Failure to recognize significant glenoid bone loss (>20-25%), "inverted pear" Failure to identify other pathology: HAGL, ALPSA, SLAP, GLAD, rotator cuff tear Failure to completely mobilize the capsulolabral Bankart / inferior glenohumeral ligament complex off the glenoid neck Inability to access 4 to 8 o'clock on glenoid Fewer than three suture anchors

4 ***Outcomes after arthroscopic stabilization in contact or collision athletes. Study Castagna A et al, 2012 Castagna A et al, 2010 Banerjee S et al, 2009 Thal R et al, 2007 Larrain MV et al, Rhee YG et al, Cho NS et al, Calvo E et al, 2005 Mazzocca et al, 2005 Ide J et al, 2004 Hubbell J et al, 2004 Burkhart S et al, 2000 Level of evidence Number subjects Mean age (years) Population Length of follow-up (years) IV IV Contact 10.9 IV 3 23 Contact 2 IV Contact 4.5 IV IV III vs noncollision 5.2 IV Contact 3.7 IV II III IV O'Neill DB, 1999 IV Outcomes Following arthroscopic suture anchor repair, 26% rate of recurrent dislocation (rugby, soccer) Post-operatively: mean SANE 87%, mean Rowe 85%, mean ASES 84. Significant association (p=.002) between recurrence and type of sport (collision vs non-collision) Following arthroscopic suture anchor repair, 84% overall satisfaction 19% and 9.5% rate of atraumatic and traumatic recurrent dislocation, respectively 3 rugby players had recurrent instability during rugby after arthroscopic repair (6-24 months) Imaging (CT) and arthroscopy confirmed glenoid fracture at anchors Following arthroscopic suture anchor repair, 7.1% recurrence rate in contact/collision sports 6.7% recurrence rate in non-contact or non-collision athletes (p=.95) No difference in Rowe (p=.9) and ASES (p=.32) between contact and non-contact athletes Following arthroscopic suture anchor repair, 4.4% rate of recurrent dislocation (rugby) Good/excellent results in 95% and 92% of 1st-time and recurrent instability groups, respectively 100% and 84% rate of return to rugby in 1st-time and recurrent instability groups, respectively VAS, Rowe, Constant significantly improved after both open and arthroscopic repair No significant difference between open and arthroscopic groups (VAS, Rowe, Constant) Greater number of recurrent dislocations in arthroscopic group (19% vs 9.4%; p=0.04) Significantly (p<.05) improved Rowe, Constant, VAS following arthroscopic suture anchor repair Greater recurrence rate (29%; 4/14) in collision group vs non-collision group (7%; 1/15) 57% (8/14) return to sport in collision vs non-collision group (73%; 11/15) Significantly (p<0.05) improved Rowe scores following arthroscopic trans-glenoid suture repair Overall, 20% rate of recurrence (recurrence mean 23 years of age; no recurrence mean 29) 58% rate of recurrence in contact athletes (7/12) vs 11% recurrence in non-contact (4/38) 11% rate of recurrence (0% contact, 15% collision) following arthroscopic suture anchor repair Significant improvements (p<0.05) in ASES, SST, VAS, Rowe, and SF-12 PCS 100% return to sport at previous level of play (mean 5.7 months) by 10 months after surgery Significantly (p<0.05) improved Rowe scores following arthroscopic suture anchor repair No difference (p>0.05) in recurrence rate between contact (10%) and non-contact (6%) athletes 80% return to sport at previous level of play (44/55) at mean 5.8 months Significantly (p<.05) greater rate of recurrent dislocation in arthroscopic vs open (44% vs 0%) 100% return to sport at previous level (9/9) in arthroscopic group Following arthroscopic suture anchor repair: 6.5% recurrence rate in contact athletes without significant bone loss (inverted pear glenoid) 89% recurrence rate in contact athletes with significant bone loss 12% rate of recurrent subluxation (2/17) following arthroscopic trans-glenoid suture repair

5 References: Lo IK, Parten PM, Burkhart SS. The inverted pear glenoid: an indicator of significant glenoid bone loss. Arthroscopy. Feb 2004;20(2): Bhatia S, Ghodadra NS, Romeo AA, et al. The importance of the recognition and treatment of glenoid bone loss in an athletic population. Sports Health. Sep 2012;3(5): Burkhart SS, De Beer JF. Traumatic glenohumeral bone defects and their relationship to failure of arthroscopic Bankart repairs: significance of the inverted-pear glenoid and the humeral engaging Hill-Sachs lesion. Arthroscopy. Oct 2000;16(7): Cho SH, Cho NS, Rhee YG. Preoperative analysis of the Hill-Sachs lesion in anterior shoulder instability: how to predict engagement of the lesion. Am J Sports Med. Nov 2011;39(11): Boileau P, Villalba M, Hery JY, Balg F, Ahrens P, Neyton L. Risk factors for recurrence of shoulder instability after arthroscopic Bankart repair. J Bone Joint Surg Am. Aug ;88(8): Tauber M, Resch H, Forstner R, Raffl M, Schauer J. Reasons for failure after surgical repair of anterior shoulder instability. J Shoulder Elbow Surg. May-Jun 2004;13(3): Balg F, Boileau P. The instability severity index score. A simple pre-operative score to select patients for arthroscopic or open shoulder stabilisation. J Bone Joint Surg Br. Nov 2007;89(11): Kerr ZY, Collins CL, Pommering TL, Fields SK, Comstock RD. Dislocation/separation injuries among US high school athletes in 9 selected sports: Clin J Sport Med. Mar 2011;21(2): Sachs RA, Lin D, Stone ML, Paxton E, Kuney M. Can the need for future surgery for acute traumatic anterior shoulder dislocation be predicted? J Bone Joint Surg Am. Aug 2007;89(8): Petrera M, Patella V, Patella S, Theodoropoulos J. A meta-analysis of open versus arthroscopic Bankart repair using suture anchors. Knee Surg Sports Traumatol Arthrosc. Dec 2010;18(12): Harris JD, Gupta AK, Mall NA, et al. Long-Term Outcomes After Bankart Shoulder Stabilization. Arthroscopy. Feb ;29(5): Castagna A, Markopoulos N, Conti M, Rose GD, Papadakou E, Garofalo R. Arthroscopic bankart suture-anchor repair: radiological and clinical outcome at minimum 10 years of follow-up. Am J Sports Med. Oct 2010;38(10): Castagna A, Delle Rose G, Borroni M, et al. Arthroscopic stabilization of the shoulder in adolescent athletes participating in overhead or contact sports. Arthroscopy. Mar 2012;28(3): Thal R, Nofziger M, Bridges M, Kim JJ. Arthroscopic Bankart repair using Knotless or BioKnotless suture anchors: 2- to 7-year results. Arthroscopy. Apr 2007;23(4): Larrain MV, Montenegro HJ, Mauas DM, Collazo CC, Pavon F. Arthroscopic management of traumatic anterior shoulder instability in collision athletes: analysis of 204 cases with a 4- to 9-year follow-up and results with the suture anchor technique. Arthroscopy. Dec ;22(12): Rhee YG, Ha JH, Cho NS. Anterior shoulder stabilization in collision athletes: arthroscopic versus open Bankart repair. Am J Sports Med. Jun ;34(6): Cho NS, Lubis AM, Ha JH, Rhee YG. Clinical results of arthroscopic bankart repair with knot-tying and knotless suture anchors. Arthroscopy. Dec ;22(12): Calvo E, Granizo JJ, Fernandez-Yruegas D. Criteria for arthroscopic treatment of anterior instability of the shoulder: a prospective study. J Bone Joint Surg Br. May 2005;87(5): Mazzocca AD, Brown FM, Jr., Carreira DS, Hayden J, Romeo AA. Arthroscopic anterior shoulder stabilization of collision athletes. Am J Sports Med. Jan 2005;33(1): Ide J, Maeda S, Takagi K. Arthroscopic Bankart repair using suture anchors in athletes: patient selection and postoperative sports activity. Am J Sports Med. Dec 2004;32(8): O'Neill DB. Arthroscopic Bankart repair of anterior detachments of the glenoid labrum. A prospective study. J Bone Joint Surg Am. Oct 1999;81(10): Banerjee S, Weiser L, Connell D, Wallace AL. Glenoid rim fracture in contact athletes with absorbable suture anchor reconstruction. Arthroscopy. May 2009;25(5): Hubbell JD, Ahmad S, Bezenoff LS, Fond J, Pettrone FA. Comparison of shoulder stabilization using arthroscopic transglenoid sutures versus open capsulolabral repairs: a 5-year minimum follow-up. Am J Sports Med. Apr-May 2004;32(3):

Patient ID. Case Conference. Physical Examination. Image examination. Treatment 2011/6/16

Patient ID. Case Conference. Physical Examination. Image examination. Treatment 2011/6/16 Patient ID Case Conference R3 高逢駿 VS 徐郭堯 55 y/o female C.C.: recurrent right shoulder dislocation noted since falling down injury 2 years ago Came to ER because of dislocation for many times due to minor