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.

Prevalence of Clinical Depression among Patients after Shoulder Stabilization Repair: A Prospective Study

Objectives: Young, athletic patients who sustain a musculoskeletal injury can suffer from major depressive disorder (MDD), either pre-existing the injury, or in response to injury. Depression can have deleterious effects on mental and physical well-being, and can ultimately lead to suicide. In fact, suicide may represent over 7% of deaths in young, high-level athletes. Therefore, it is paramount among surgeons to recognize vulnerable patient populations. The purpose of the present investigation was to determine the prevalence of MDD in patients with shoulder instability and its’ effect on outcomes in patients undergoing primary arthroscopic shoulder stabilization. Methods: Eighty-eight patients undergoing primary arthroscopic shoulder stabilization were prospectively enrolled and queried at 6 weeks, 3 months, 6 months, and 1 year. Depression symptoms were assessed with the Quick Inventory of Depressive Symptomatology (QIDS-SR16). MDD diagnosis was defined as a QIDS-SR16 score ≥6. Shoulder functionality was assessed with the Western Ontario Shoulder Instability Index (WOSI). Patients were grouped based on their MDD symptomatology preoperatively into MDD and Non-MDD groups. T-test analysis was used to compare outcomes between the groups. Results: The average age of patients on the day of surgery was 29.9 years old. Seventy-four (84.1%) participants were male, while 14 (15.9%) were female. Of the 88 patients enrolled, 44 (50%) met MDD criteria. Baseline averaged WOSI scores for the MDD cohort were worse than the non-MDD group (p= 0.016), 64.9% and 55.0%, respectively. Shoulder function, measured via the WOSI score, significantly improved throughout the study except at the 6-week follow-up point; however, the MDD group continued to have worse shoulder function at 6 weeks post-op (p= 0.04), 6 months post-op (p=0.03) and 1 year post-op (p< 0.01). There was no significant difference in mean WOSI score between the MDD and non-MDD group at 3 months (p= 0.16). WOSI scores at 1-year for the MDD and non-MDD cohort were 21.1% and 8.9%, respectively. MDD diagnosis increased at the 6-week time point (p= 0.023); however, it declined during the rest of the study period (p< 0.01). Conclusion: A significant proportion of patients with shoulder instability exhibit depression symptoms (50% in this series). Our results suggest that pre-operative depression negatively correlates with shoulder outcome functionality. Interestingly, arthroscopic shoulder stabilization can lead to post-operative depression; however, by 3-months there is a strong reversal of this effect, with significant reduction of depression symptoms in all patients. This effect may be secondary to the significant physical limitations caused by shoulder immobilization protocols for the first 6 weeks. As patients regain shoulder strength, stability and function, they exhibit less depression symptoms, indicating surgical intervention can significantly decrease depression symptoms that are secondary to musculoskeletal injuries.