Anterior Dislocation: The In-Season Collision Athlete Fix It Now! - - PowerPoint PPT Presentation

Anterior Dislocation:

The In-Season Collision Athlete “Fix It Now! Don’t Wait!”

Michael T. Freehill M.D.

Associate Professor of Orthopaedic Surgery University of Michigan

Orthopaedic Summit

Las Vegas, Nevada

December 8, 2017

Disclosures

Consultant for Smith and Nephew Research support: Smith & Nephew Committee member : AAOS, ASES, ISKAOS, AOSSM

What to do?

• First time dislocator
• In-season
• Collision athlete

Fix It Now!

The Great Dr. Anthony Miniaci

• Professor

– World expert

• Instability

– 24 Peer Reviewed PubMed

First hand Experience

Former Head Team Physician Cleveland Browns

First hand Experience

Robinson et al JBJS 2006

Recurrent Instability Risk

• Prospective 25 year follow-up

– 12-25y/o at primary dislocation (n=115) – 50% had not redislocated or became stable over time – Concluded: prognosis for younger ages, neither very good or very bad – Unnecessary surgeries in 30-50%

Hovelius et al. JBJS 2008

Fixing it now is right thing to do!

• Need to change antiquated views!
• Need to debunk the myths!
• Are we providing the best care for the athlete?
• r taking the OITE?

Modern Suture Anchor Technique: Arthroscopic

Recurrence

• Carreira et al.

AJSM 2006  10%

• Castgana et al.

AJSM 2010  23%

• Voos et al. AJSM 2010 

18%

• Van der Linde et al. AJSM 2011 

35%

• Ozturk et al. Arth 2013 

13%

• Aboalata et al. AJSM 2016 

18%

Age and Gender

• 22 years or younger and male:

Recurrence

–Porcellini et al. JBJS 2009  13% –Voos et al. AJSM 2010  18% –Castagna et al. Arth 2012  21% –Gigis et al. JPO 2014  13%

(Failure rate after arthroscopic primary Bankart repair)

37% “at least 1” additional episode during season

AJSM 2006

Buss et al. AJSM 2006

• Tolerance
• Restricted motion
• Sport specific tasks

– position

• Controversy exists
• Limited data to guide treatment

JAAOS 2012

AJSM 2014

45 intercollegiate athletes

Only 27% completed season without recurrence

19/24 Instability Manuscripts: Recurrent Instability Bone Defects

“arthroscopic stabilization may afford better disease-specific quality of life than taking a wait- and-see approach”

Identified Risk Factors for Recurrent Instability

• Age
• Ligamentous laxity
• Poor tissue quality
• Contact/collision sports
• Delay from initial injury to surgery
• Number of pre-op dislocations
• Bone loss

Myths

• We can get you through season
• A brace will protect you
• Worse case- recurrent subluxation/dislocation

– Going to have surgery at end of season anyway

• The damage was already done
• It won’t change what I’m going to do

Wait until the end of the season:

“Let them experience another dislocation”

• Articular surface lesions
• glenoid, humeral head
• Bone defects
• Repetitive subfailure strains
• capsular and ligament elongation
• additional laxity induced with recurrence

Pollack et al, JSES 2000 Urayama, Itoi AJSM 2003 Buscayret, Szabo, Walch, et al AJSM 2004

Tissue Trauma:

Longitudinal Studies

• Urayama, Itoi AJSM 2003

– MR study showing progressive capsular elongation with recurrence – Anteroinferior 19% elongation with recurrence

• Pollack, Owens, Flatow, Bigliani JBJS 2000

– Capsular elongation with repetitive dislocation

Cumulative Soft Tissue Trauma

Early Late

Courtesy Rick Ryu MD

Conclusion: In-Season Collision Athlete

“Waiting To Do Surgery”

• Jeopardize tissue quality

– Increasing ligamentous laxity – Increasing risk of recurrence post-stabilization

• Articular lesions
• Potential bone loss
• Frustration

Thank you