Debate In season Shoulder Instability To operate or to wait? - - PowerPoint PPT Presentation

Debate In season Shoulder Instability To operate or to wait?

Anthony Miniaci MD FRCSC Professor of Surgery Cleveland Clinic Foundation

Conflicts of Interest

1. Royalties/stock/equity

• 1. Arthrosurface
• 2. Consulting/Honoraria

1.Stryker

• 2. Arthrosurface
• 3. Arthrex
• 4. Smith and Nephew
• 3. Educational/Research

Institutional

• 1. Stryker
• 2. Arthrex
• 3. Arthrosurface

Debate Instructions per Kevin Plancher

• 1. Tell why you wait till

seasons end for shoulder instability surgery

• 2. Tell why it is better than
• perating on everyone

during the season

• 3. I don’t care if that is

what you do or not !

Primary Question- Debate-Can they RTP?

In-Season Athlete RTP

• 1. NOT-What is the risk of

recurrence?

• 2. Can an in-season athlete

return to sport?

• 3. What is the harm in waiting?

1. does it change the treatment or result 2. What is the psychological or physical harm

• 4. Which dislocator needs to be

fixed immediately?

Lets not argue- # 1) Risk of recurrence?

• We know the risk is high

especially in contact sports and young patients

• Rates vary 27-82% for first time

dislocators

• Age<20, contact sport
• Pathology 80% Bankart, 15%

bony Bankart, 70 % Hill Sachs lesion

• Most will need surgery –BUT not

all !

• Do they need it now or can they

have another shot at it?

Author Recurrence rate Wheeler Arthroscopy 1989 82% Arciero AJSM. 1994 80% Jakobsen 1994 27% Bottoni AJSM. 2000 75% Sachs JBJS. 2007 46% LeClere Sport Health. 2013 52% Kirkley et al Arthroscopy 1999 47%

Mean Time to Return to Play 7 Days Return to Sport Distribution by Sport Fail Return to Sport

Football 66% Rugby 11% Wrestling 7% Baseball 4% Judo 6% Lacrosse 4% Boxing 2% Insuffienct Function 59% End of Season 33% Separated 8% Failed Return to Sport 25% Return to Sport 75%

Return to play and recurrent instability after in-season anterior shoulder instability: a prospective multicenter study. Dickens JF et al. AJSM 2014

75% Return to Play

Can they get back to play?

Return to Sport

Subluxation 42% Dislocation 58%

Subluxation

• Median RTP 3

days

• 76% completed

the season p=0.282 Dislocation

• Median RTP 7

days

• 56% completed

the Season

Subluxation 5.3x more likely to return to sport compared to dislocations (95%CI 1.00. 28.07; p=0.049)

Debate-Return to Sport after Shoulder Instability

• 30 patients, contact

and noncontact sports

• Mean 16 years old
• 90% return to sport
• Subjective: all athletes

at “same or near same level”

• Mean time lost from

sport: 10 days

Return to play

• 30 patients,19 dislocations,

11 subluxations

• 26/30 returned to their sport

for the complete season with an average missed time of 10.2 days

• 37% experienced an

additional episode

• 16 had off season surgery
• “ no further injuries

attributable to the shoulder instability”

Will the real Michael Freehill please stand up !

What happens when they do return to play?

Successful Return to Sport After Arthroscopic Shoulder Stabilization Versus Nonoperative Management in Contact Athletes With Anterior Shoulder Instability: A Prospective Multicenter Study.

• 39 with another season of

eligibility

• 10 chose rehab , no surgery
• 20 chose surgery after season
• 9 chose immediate surgery

after one event

• 10 electing nonoperative

treatment, 4 (40%) successful RTP without recurrence during the subsequent season

• 29 surgical, 26 (90%) RTP without

recurrence the following season

• No long term differences as to

timing

• Does waiting hurt?
• Does it give you more pathology
• r change the operation

Dickens JF Am J Sports Med.2017 Sep;45(11):2540-2546

Arthroscopy 2007

• 127 patients; diagnostic arthroscopy, x-rays (AP, Glenoid, West Point), MRI

Does waiting Hurt? Acute vs Chronic

But are 2 episodes really chronic?

• I think not !
• Successful Return to Sport After

Arthroscopic Shoulder Stabilization Versus Nonoperative Management in Contact Athletes With Anterior Shoulder Instability: A Prospective Multicenter Study.

• Dickens JF Am J Sports Med.2017

Sep;45(11):2540-2546

• 29/39 athletes surgical

stabilization

• there was no difference in

RTP between the 9 stabilized after a single instability event (90% RTP rate) and the 20 stabilized after multiple in-season recurrent instability events (89% RTP rate).

Does it change the surgery?

• Probably not !
• Patients are already high risk

because of age/competition/contact sport

• All hinges on the BONE LOSS
• Need to think about this when

you assess the patient

• Debate may be about type of

surgery not timing Balg & Boileau, JBJS-Br, ‘07

Psychologic effects of not playing

Mind, Body and Sport: How being injured affects mental health

• An excerpt from the Sport Science

Institute’s guide to understanding and supporting student-athlete mental wellness

• The team physician is ultimately

responsible for the return-to-play decision, and addressing psychological issues is a significant component of this decision.

• By Margot Putukian
• 1. Sadness
• 2. Isolation
• 3. Irritation
• 4. Lack of motivation
• 5. Anger
• 6. Frustration
• 7. Changes in appetite
• 8. Sleep disturbance
• 9. Disengagement

Importance of Team Play They are only young once!

• 1. Builds confidence
• 2. Provides consistent exercise
• 3. Develops relationships.
• 4. Contributes to stronger academics.
• 5. Helps put winning into perspective.
• 6. Teaches respect.
• 7. Encourages family involvement.
• 8. Chance to win as a team- very unique
• nce in a lifetime opportunities
• Dr. Freehill wants to take that away

from them !!

Summary- My position! Based on the Evidence

• RTP is possible after a first time

shoulder instability in season episode

• 75 % RTP in 7-10 days for

dislocation 3-5 subluxation

• 40 % may have a second in season

injury

• Up to 40 % may not have anything

even after 2 seasons

• 2 events and out
• Remember to assess for bone loss
• Remember you are treating the athlete

and not just their shoulder- avoid shattering dreams!

Anthony Miniaci M.D. FRCSC Professor of Surgery Cleveland Clinic