Opinion editorial—glenohumeral instability in the young patient

ABOUT THE EXPERT

Frank A. Cordasco MD, MS, is an attending orthopedic surgeon in the Sports Medicine Institute and a senior scientist in the Research Division at the Hospital for Special Surgery. He holds an academic appointment as professor of orthopedic surgery at Weill Cornell Medical College of Cornell University, and he served as the 35th president of the American Shoulder and Elbow Surgeons from 2018 to 2019. Dr. Cordasco specializes in surgery for sports-related injuries of the shoulder and knee. The primary focus of his practice includes arthroscopic and open shoulder instability repair including bone augmentation reconstruction, pectoralis major tendon repair, rotator cuff tendon repair, bicep tendon repair, clavicle fracture repair, acromioclavicular joint separation repair and reconstruction, anterior cruciate ligament reconstruction, meniscus repair, and multiligament knee reconstruction in the pediatric, adolescent, and adult athlete, and patellar and quadriceps tendon repair. Dr. Cordasco’s research and education activities parallel and complement these clinical areas of expertise.

This Opinion Editorial regarding a challenging population of young athletes and patients is my opinion based upon 3 decades of clinical experience and is supported by the literature. This clinical experience has resulted in an evolution of my indications for operative intervention and the surgical approach that I use in the management of this athletic and active population. The discussion is limited to anterior instability for the purposes of this opinion piece. Much of the material in this editorial is available in more detail in Chapter 31 : Anterior Instability: Arthroscopic Surgery and Outcomes, but the information presented here is clearly biased in that it is based on my personal experience. Although the thoughts expressed in this opinion piece have led to success when applied with my patients, it may not necessarily be generalizable to all surgeons.

The young athlete represents the largest cohort of patients who sustain anterior glenohumeral instability events, and they are at the highest risk for recurrence, particularly with respect to males. My early practice experience has guided me in the past decade to counsel 14- to 21-year-old athletes and their families, predominantly males but increasingly females as well, to consider surgical management following the first-time traumatic dislocation event. The data regarding these issues are not new information; Carter Rowe reported in 1956 that of his 500 cases of anterior instability, adolescents represented the largest group. The recurrence rate was highest during the second decade (92%), and age at the time of the first dislocation was inversely related to recurrence rate. The US Military Academy experience with anterior instability demonstrated convincingly that the nonoperative treatment of West Point cadets following a first-time dislocation resulted in unacceptably poor outcomes. In retrospect, it is surprising to me that it has taken nearly 3 decades for the US orthopedic shoulder and sports medicine community to definitively recommend surgical management for the first-time dislocation in young athletes. The spectrum of collision sports in our country is for the most part quite different from that of Europe, the Pacific Rim, and the rest of the world, with the exception of a few outliers, such as rugby in Australia, South Africa, and Europe.

Leroux and colleagues reported a series of 1937 children and adolescents between the ages of 10 and 16 years who were followed after a primary anterior shoulder dislocation. They concluded that the rate of primary and recurrent closed reductions of a shoulder dislocation in 14- to 16-year-old patients mirrored that of high-risk adults age 17 to 20 years. They advised clinicians to counsel patients, particularly males between 14 and 16 years, of the increased risk of recurrence with nonoperative treatment. Robinson and colleagues prospectively followed 252 patients between the ages of 15 and 35 years for a minimum of 2 years following a closed reduction of a primary anterior dislocation and found that there was a sex-specific difference related to recurrence. Females achieved a 50% recurrence rate with nonoperative treatment at 16 years of age, whereas it took males an additional 11 years to achieve a 50% recurrence rate with nonoperative treatment at 27 years of age. Recently, the American Shoulder and Elbow Surgeons Neer Circle, which is a service recognition group composed of thought leaders in the field, published a consensus statement regarding the management of the first-time shoulder dislocation. This was a comprehensive Delphi initiative that surveyed the entire group of 112 Neer Circle members over several months in 2019, finishing with a final questionnaire of 162 clinical scenarios. A total of 89% of Neer Circle members completed the survey. They had very high levels of recommending surgery (>96%) with very strong (Likert) recommendations (>4) to do so in contact athletes between the ages of 14 and 22 years with apprehension and meaningful bone loss (>13.5% glenoid bone loss).

My personal opinion is that, although the Neer Circle consensus statements regarding this clinical problem have contributed significantly and will provide guidance to the providers of shoulder and sports medical care globally, the consensus statements did not go far enough. I believe that, specifically, the high school athlete (ages 14 to 18 years), given the natural history of the first-time dislocation in this patient cohort, should be indicated for surgery whether the dislocation occurs at the beginning, middle, or end of the season and whether or not meaningful bone loss is present. The data are compelling regarding the risk of recurrence with nonoperative treatment as well as the risk of failure following arthroscopic stabilization in those athletes who have increasing numbers of preoperative instability events. Gasparini and colleagues noted an odds ratio for failure equal to 3.8 in the recurrent instability group compared with those with only one preoperative dislocation after arthroscopic stabilization. Shin et al. reported an 11% failure rate in patients who underwent arthroscopic stabilization with recurrent instability compared with 3% in those with only one preoperative dislocation. My personal series of 67 athletes between ages 13 and 21 years treated with an arthroscopic stabilization with three or fewer preoperative instability episodes demonstrated an overall revision rate of 6% and a return-to-sport (RTS) rate of 88%. The four athletes requiring a revision all had more than one preoperative instability event, whereas the 42 athletes who had only one dislocation preoperatively sustained no recurrences, and the revision rate was 0%. Nakagawa and colleagues compared a group of primary instability patients with a group of recurrent instability patients. The bipolar defect size was greater and the recurrence rate higher in the recurrent instability group. As we know, our role as physicians and surgeons is to educate the patient and the family regarding the pathology, natural history, and risks and complications of the various treatment options. The patient or athlete can then take that information and make informed decisions. In this way, shared decision making can move forward appropriately. I believe that the best outcomes (low recurrence and revision rates as well as high RTS rates) following arthroscopic stabilization in 14- to 21-year-old athletes occur after the first dislocation and before the second dislocation.

The question regarding the timing of the surgical intervention during the season is a ubiquitous topic when managing our athletes on a daily basis in the clinic and training rooms at our athletic facilities. This is a complicated issue because there are many variables. In general, acute surgery has been recommended when the presence of greater degrees of pathology exist, such as displaced bony Bankart lesions, humeral avulsion of the glenohumeral ligament lesions, significant long head biceps pathology, subscapularis and/or posterior rotator cuff tears, articular cartilage avulsions, or displaced fractures of the humerus. In the absence of these lesions, the general rule has been that, if the dislocation occurs in the early or mid-season, recommendations are to place the athlete in a harness and begin rehabilitation until range of motion and strength return to normal and the athlete no longer has apprehension, at which time they may RTS. It has been established in multiple reports that it is possible for the athlete to RTS within a short period after sustaining an anterior dislocation and more than half the time finish the season, albeit with the possibility of recurrences. Many of these athletes require surgery either later in the season or, if they successfully complete the season, at the end of the season. I believe it is fair to separate this discussion between high school, collegiate, and professional athletes. Sport, position within the sport, and level within the aforementioned divisions have influenced these recommendations. A freshman in high school or college might be managed differently than a senior. A professional athlete early in his or her career might be managed differently than one at the end of his or her career. At the elite collegiate and professional level, draft and contractual components apply to this discussion as well. I believe 14- to 18-year-old high school athletes, given their high risk of recurrence, should be managed surgically as soon after the initial incident as is practical. If the athlete and the family elect to proceed with nonoperative treatment, I inform them that they may lose the opportunity to have a successful arthroscopic stabilization and that they will more likely require an open or even bone augmentation procedure when they eventually receive surgical treatment.

Orthopedic surgeons who work in this space should be facile with all components of the menu of operations, which may be used in the setting of anterior glenohumeral instability. These surgical treatment options include arthroscopic stabilization, open stabilization, and bone augmentation procedures. My surgical treatment profile has changed during the course of the past 3 decades. When I began my practice in 1990 after completing a fellowship with Dr. Neer, 100% of the anterior shoulder stabilizations that I performed were open capsulolabral repairs. Arthroscopic techniques developed and evolved in the subsequent decade, and by 2000, 95% of the anterior shoulder stabilizations I performed were arthroscopic. It subsequently became quite clear that arthroscopic stabilization would result in higher failure rates if specific risk factors were not carefully evaluated. Bone loss in this setting became a focus, as several investigators identified this factor as a significant risk for failure following arthroscopic stabilization. As a result, the indications for arthroscopic stabilization were modified in the face of significant bone loss. Balg and Boileau developed the Instability Severity Index score. This is a 10-point score for which 5 points are based on demographics (age <20 years, competitive sport, and contact or forced overhead sports), 1 point for generalized laxity, and 4 points for radiographic findings associated with bone loss. Essentially 100% of young athletes in my practice would start with a score of 5 before evaluation of the physical exam and radiographic findings. Many of the European thought leaders have advocated for a bone augmentation procedure with an Instability Severity Index score of 3 or more. Many other North American surgeons and I do not agree with this approach.

My personal belief is that a more relevant risk factor in this cohort is the number of preoperative instability episodes, as I previously stated. In 2019, my practice profile demonstrated that of anterior stabilization surgeries, 69% were performed arthroscopically, 11% were open, and 20% were bone augmentation procedures (predominantly Latarjet and, to a lesser extent, distal tibial allograft [DTA]). As can be seen from my 30-year practice profile, the pendulum has swung back and forth. It is somewhat “back to the future,” in that I was trained in open techniques and developed arthroscopic skills throughout the course of my career, but over the past 10 to 15 years, I have returned to open surgical techniques with and without bone augmentation in more than 30% of my patients undergoing primary anterior stabilization. Of course, these data are influenced by many factors, including practice demographics, patient characteristics, and referral patterns.

The collective data reviewed earlier suggest that our role in managing these athletes should be to intervene surgically after the first, but prior to the second, dislocation. When that is not practical or possible, we need to consider the entire menu of procedures that we have within the anterior instability surgical treatment armamentarium. The selection from the surgical treatment menu, like all areas of surgery, is predicated upon patient characteristics.

My current approach for the young athletic patient is as follows. For males 14 to 21 years of age, representing most high school and college-age athletes, who sustain their first anterior dislocation, I recommend an arthroscopic stabilization unless there is meaningful bone loss, which is discussed later in this piece. So-called advanced arthroscopic techniques have been described to differentiate them from a standard single-row arthroscopic stabilization. These include double-row capsulolabral repairs, ^, posteroinferior capsulolabral repairs, ^, remplissage, and rotator interval closure. I use double-row capsulolabral repairs particularly in the case of a healed anterior labral posterior sleeve avulsion or in particularly high-risk individuals. I use posteroinferior capsulolabral repairs in the majority of young athletes at the time of arthroscopic anterior stabilization. As noted in my series mentioned earlier, 42 of 67 (63%) were treated in this manner. I have rarely found rotator interval closure or remplissage to be useful in the young population of athletes, particularly throwers. There have been significant time zero biomechanical studies and clinical follow-up series published in the literature with many thought leaders advocating for the use of rotator interval closure and remplissage. For me, rotator interval closure has a role in the management of patients with multidirectional instability or significant capsular redundancy. I prefer to manage significant Hill-Sachs lesions from an anterior approach, either with an open stabilization or with a bone augmentation procedure. In older and less active adults with recurrent instability, I have found the remplissage procedure to be a useful adjunct to an arthroscopic stabilization.

There has been discussion in the literature suggesting improved outcomes with the use of the lateral decubitus compared with the beach chair position, as mentioned in Chapter 31 . I have used both the beach chair and lateral decubitus patient positioning techniques in my career and have found the beach chair position with a “bump” in the axilla and with an arm positioning device to provide equally successful outcomes. The beach chair position allows for seamless conversion to an open procedure as well.

For females within this age group following a first-time anterior dislocation, my approach is similar, although the decision is dependent to some degree upon the sport and the overall goals and athletic trajectory of the female athlete. Sports such as field hockey and lacrosse do not generate the same forces and risks as in male football and lacrosse, in my experience, although this may change over time as female sports continue to become more competitive and aggressive. My threshold for attempting a course of nonoperative treatment in female high school and collegiate athletes following a first-time dislocation is admittedly lower than that for males. This is supported by the work from Robinson et al. mentioned earlier.

For the cohort of young athletes with recurrent shoulder instability, I begin to consider open stabilization and, of course, proceed with advanced imaging to identify significant bone loss more intently, even if not apparent upon plain radiographs. In addition to magnetic resonance imaging, I often obtain three-dimensional (3D) computed tomography scan reconstructions. Although my institution has had 3D magnetic resonance imaging available for the past few years, I continue to prefer 3D computed tomography to assess bone loss because I have found it to be more predictable and reproducible. Dickens and colleagues studied a series of collegiate D1 athletes from the US Military Academy and the US Naval Academy who were followed throughout their college careers. Those who sustained a first-time dislocation on average demonstrated 6.8% anterior glenoid bone loss. Those in the recurrent group sustained greater anterior glenoid bone loss from a baseline of 10.2% to 22.8% with the recurrence. Within the first-time dislocation group, no athlete was found to have greater than 20% anterior glenoid bone loss; however, meaningful bone loss (>13.5%) was noted in 17% of them. For those athletes who sustain a first-time dislocation and have meaningful bone loss (>13.5% anterior glenoid loss) or significant bipolar lesions, I will indicate them for open stabilization and, in most cases, will consider bone augmentation, discussed later in this chapter.

In the young athlete with two or three recurrences and without meaningful bone loss, I begin to consider open stabilization. As noted earlier, arthroscopic stabilization has been associated with less successful outcomes when young athletes sustain greater numbers of preoperative recurrences. When considering surgery, our role is to provide an excellent outcome, which includes the prevention of a second surgery to the extent possible. This decision includes an assessment of bone loss, but even in the absence of meaningful bone loss, these athletes are at higher risk for recurrence when compared with those sustaining only one dislocation. Open stabilization has been reported to provide outstanding outcomes in young athletes, including American football players, those with primary and recurrent instability, and those with and without bone defects. Nevertheless, in those patients who have sustained two or three recurrences without meaningful bone loss, I will entertain an arthroscopic stabilization with a low threshold to move to an open stabilization, based upon the examination under anesthesia and intraoperative findings.

My technique for an open stabilization begins with an arthroscopic approach. I believe that much can be learned from a quick diagnostic arthroscopy, including the evaluation of the posterior capsulolabral structures, the presence of a humeral avulsion of the glenohumeral ligament lesion that may have been missed on preoperative imaging, the status of the articular cartilage, the rotator cuff, and the biceps-labral complex. We must of course be mindful of the relative costs as they relate to public health resource allocations, but my primary concern is to obtain as much information for the athlete or patient undergoing the procedure, thereby directing the surgical approach and providing the best outcomes, low recurrence rates, and high RTS or return-to-activity rates. There are certain situations where a hybrid approach, combining an arthroscopic repair with an arthrotomy, has been useful in my experience. I have used this approach in the “floating inferior glenohumeral ligament” situation by performing an arthroscopic capsulolabral repair and a transverse subscapularis split to repair the humeral component of the inferior glenohumeral ligament avulsion. I have also found this approach helpful when combining an arthroscopic posterior capsulolabral repair with an anterior arthrotomy, for management of the capsule and/or bone loss. For most open stabilizations, following the diagnostic arthroscopy, an incision is made using a limited Leslie and Ryan incision. I perform a lateral capsular approach as described by Neer, which affords the ability to perform a capsular plication or shift from inferior to superior (with or without a transverse split) and a medial capsulolabral repair. The decision regarding the management of the capsular approach depends upon the degree to which capsular redundancy is present. If it appears to be a primary component of the pathology, I split the capsule as described by Neer and, following the Bankart repair, shift the inferior flap superiorly and the superior flap inferiorly while closing the superior cleft as well. If the capsulolabral avulsion is the principle component, I shift the entire capsule superiorly to the degree indicated after repairing the medial capsulolabral component.

After the athlete sustains a fourth preoperative instability episode, in the vast majority of cases I indicate them for an open procedure, particularly if they plan to continue to engage in competitive sports. If there is an on-track, nonengaging lesion, I perform an open stabilization as described earlier. If the degree of bone loss is substantial with off-track, engaging bipolar lesions, my preference has been and continues to be to use the classic Latarjet performed with two screws. I believe the risk of coracoid fracture is higher with the congruent arc Latarjet and, as a result, have not used it significantly in my practice. Although the Bristow, in which the osteotomized portion of the coracoid is fixed directly to the glenoid (the so-called standing position), has been very successful as well, I like the larger bone surface area for healing provided by the classic Latarjet with the use of two screws for fixation to maintain rotational control.

Regarding revision anterior stabilization, the principles that I have outlined remain relevant. My revision anterior stabilization profile in 2019 is, as expected, skewed toward the open and bone augmentation procedures. The percentages in the revision setting were 16% arthroscopic, 42% open, 26% Latarjet, 14% DTA, and 2% iliac crest. The DTA procedures were performed to revise Latarjet reconstructions or manage glenoid bone loss determined to be too large for a coracoid transfer. The iliac crest procedures were performed in patients who did not want an allograft reconstruction for revision Latarjet reconstructions or when the glenoid defect was too large.

Although I have defined a set of criteria for selecting an arthroscopic, open, or bone augmentation approach, from a practical and operational standpoint, much of the decision making is based upon multiple variables. The athlete’s history, sport, position within the sport, presence of generalized ligamentous laxity (Beighton score), number of preoperative instability episodes, physical exam findings (apprehension below shoulder level), imaging findings, aspirations regarding sport and activity, and career trajectory all play a role in the decision tree. For those cases “on the bubble,” it is often more of a gestalt based upon my collective experience.

In summary, the young patient athlete with anterior glenohumeral instability is a stimulating and challenging population. This group requires an athlete-specific approach, accounting for their sport, position within the sport, and the degree of pathology in each case. A meticulous approach to the history, physical exam, imaging findings, examination under anesthesia, and arthroscopic inspection will lead to the appropriate selection from the surgical menu and, as a result, an excellent outcome with low recurrence and revision rates and high RTS rates.