Shoulder Dislocations in Football
Shoulder Dislocations in Football
Abstract & Commentary
Synopsis: This study presents excellent results with open stabilization of shoulder dislocators who return to contact sports with relatively good preservation of motion and recommend this as a standard of care.
Source: Pagnani MJ, Dome DC. J Bone Joint Surg Am. 2002;84-A(5):711-715.
Historically, arthroscopic stabilization procedures have had limited success in reducing capsular volume and, therefore, have had a higher rate of redislocation. Patients engaged in contact sports, such as football, have been noted to be at increased risk for redislocation and consensus has been to perform open repair with a Bankart technique for these patients. This report by Pagnani and Dome specifically looks at the clinical results with football players who have had open Bankart reconstructions.
This is a retrospective case cohort type study in which there was no control group and there would have to be some element of selection bias. Basically over a 6-year period, the senior author performed open Bankart reconstructions for shoulder dislocators who played football. The technique is well described and involved taking down the subscapularis with repair of the Bankart lesion if present (46 of 58 patients). If a Bankart lesion was not present, or if capsular laxity was notable, a capsular shift was performed as well. A humeral-based capsular shift was performed in the absence of a Bankart lesion to maximize volume reduction.
Fifty-eight patients with an average age of 18 years were available at an average follow-up of 37 months or a minimum of 2 years. The patients all had good results with only 2 experiencing recurrent subluxations. Fifty-two of the 58 patients returned to football for at least 1 year. The shoulder scores of the American Shoulder and Elbow surgeons (97 points) and the Rowe and Zarins score (93.6) were good. Pagnani and Dome also note that motion was relatively good and within 5° of the contralateral shoulder in 84% of the patients. What they do not emphasize, however, is that the remaining patients had more notable loss of motion, such that the average motion was 9° less on the operative side for external rotation and 8° less for abduction. The conclusion was that open Bankart or capsular shift stabilization produces better results than what has been historically presented in the literature for arthroscopic techniques and should be the method of choice for football players.
Comment by David R. Diduch, MS, MD
Certainly Pagnani and Dome present a strong argument for open stabilization of football players with shoulder instability. Their results are good with only 2 subluxators out of 58 and a high return to competitive football. The vast majority of these players were at the high school level, but certainly some were at the collegiate level (11) and 4 were professional. The fact that they could return to football without further instability is a testimony to their surgical success and their techniques. The statement about their motion being preserved could be a little misleading I think, especially as it is listed in the abstract, as pointed out above. Certainly, about 16% of their patients did have more notable loss of motion, with an average loss of 6-9°. Loss of motion has always been the major shortcoming of an open stabilization procedure and a potential difference with arthroscopic techniques.
The biggest concern that I have is that this paper advocates one treatment (open) over another (arthroscopic) without directly comparing 2 patient populations in a controlled or prospective fashion. It is not fair to compare only to the literature, especially in this scenario. Arthroscopic techniques to which they are comparing are outdated and inferior. Primarily they involved tack stabilization without capsular shift or capsular mobilization. They may have also included fixation on the neck of the glenoid such as with transglenoid suture technique. Suture anchors today, either tied or knotless, allow an aggressive mobilization and shift of the capsule. We have been taught now that this is critical for arthroscopic techniques to succeed. As such, the capsular stretch can be reduced and we can reapproximate the anatomy onto the glenoid rim as a bumper. Certainly some arthroscopic proponents would argue that the anatomy could be restored even more accurately this way.
The sports medicine literature has learned the hard way that it is better to go to a 4-5-year follow-up for shoulder stabilization papers. It is a little bit surprising that this paper appeared in this journal with a minimum of 2 years follow-up in that regard. Interestingly, at the recent Arthroscopy Association of North America Meeting, a paper was discussed that surveyed professional football and hockey teams and found that roughly 40-50% of the professional teams had athletes that underwent arthroscopic stabilization.1 The report of the results was a little less precise but basically they were good. The conclusion was that a lot of these high-profile athletes at the professional level in contact sports are undergoing arthroscopic stabilization and this seems to be working.
So, my conclusion is that we can only take Pagnani and Dome’s paper for what it is: that is, they had excellent results with their methods in a high demand patient population. To make a comparison to older arthroscopic techniques is simply unfair. Hopefully we will see reports for similar patient populations critically evaluated with arthroscopic evaluation using modern methods so that we can make a more informed decision. Until then, we can certainly look to this study’s success as supporting open stabilization as an excellent treatment option for football players with shoulder instability.
Dr. Diduch, Associate Professor, Department of Orthopaedic Surgery, University of Virginia School of Medicine, Charlottesville, is Editor of Sports Medicine Reports.
Reference
1. Cohen NP, et al. Arthroscopic shoulder stabilization in professional contact athletes (SS-43). Paper presented at: Annual Meeting of the Arthroscopy Association of North America; April 24-28, 2002; Washington, DC.
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