© Springer International Publishing AG 2018Arthur Jason De Luigi (ed.)Adaptive Sports Medicinedoi.org/10.1007/978-3-319-56568-2_7
7. Surgical Considerations in the Adaptive Athlete
Department of Orthopaedics, Georgetown University Hospital, Washington, DC, USA
Department of Orthopaedics, Penn State Hershey Medical Center, Hershey, PA, USA
Department of Orthopaedics, Washington Hospital Center, 106 Irving St. NW, Physicians Office Building Suite 5000 N Tower, Washington, DC, 20010, USA
KeywordsAdaptive athleteWheelchair athleteParaplegiaParalympicsRotator cuff injurySpinal cord injurySurgical outcomesSports medicineOrthopedic surgery
As the world of competitive sports continues to expand and evolve, there are more opportunities than ever for adaptive athletes. For example, the Paralympic Games are now the second largest sporting event in the world . There are ten classes of participation based on impairment type, and there are various subclasses within each class. Competitions now recognize athletes with a range of disabilities from impaired muscle power, limited passive range of motion, limb deficiency, visual impairment, as well as to those with intellectual disabilities.
The benefits of exercise in this population appear to be numerous with multiple studies showing increases in quality of life, mental health, and physical health [2, 3]. As Dr. Ludwig Guttmann, founder of the Paralympic Movement, stated, “The aims of sport embody the same principles for the disabled as they do for the able-bodied; in addition, however, sport is of immense therapeutic value and plays an essential part in the physical, psychological and social rehabilitation of the disabled.”
This diverse group of athletes presents unique challenges in the surgical management of their injuries. With such a diverse patient group, high quality research is limited. To complicate matters, many adaptive athletes are hesitant to undergo surgery for fear of adverse outcomes or a loss of independence. With an ever-growing need for treatment, clinicians are increasingly being called upon to treat this specialized population. Because this group of athletes requires such specialized care, there is a need for greater understanding of treatment strategies, expected outcomes, and therapeutic goals.
This chapter will explore published surgical outcomes, define the prevalence of injury based on impairment type and injury pattern, discuss the most common comorbid conditions and how they affect the postoperative course, and provide our recommendations for future steps to be taken to improve the care given to the adaptive athlete.
There are few published research studies on surgical outcomes in the adaptive athlete. There are two possible reasons for this limited information. First, only recently has there been a demand for surgery in this group. The ability to perform at an elite level is a relatively new development in the world of adaptive athletics. The bulk of information relating to surgery focuses on maximizing quality of life, rather than enhancing performance. For example, rotator cuff repair in a wheelchair-bound patient is more commonly examined through the lens of ability to perform activities of daily living (ADLs) after surgery rather than the length of time before return to sport. Second, surgery in this group is a much more extensive undertaking. Not only can it be more difficult to heal from the surgery, but the further disability imposed by surgery imposes significant limitations on this population. Loss of function in one arm affects lifestyle in myriad ways ; ADLs, transfers, locomotion, and employment become nearly impossible without assistance. This makes adaptive athletes much less likely to undergo surgery simply for performance enhancement or the ability to return to sport.
Injuries encountered in adaptive athletes are most common in the upper extremity. Overuse injuries of the shoulder are especially common, and overhead sports are noted to be an independent risk factor for rotator cuff disease in paraplegic athletes . Bicipital tendon injury, rotator cuff tears, and impingement syndrome are all common in adaptive athletes [6–8]. Elbow pain secondary to lateral epicondylitis, olecranon bursitis, and triceps tendonitis are seen in wheelchair athletes . Upper extremity entrapment neuropathies are also very common at the carpal tunnel and Guyon’s canal with some postulating that repetitive microtrauma is causative force. Prevalence of these neuropathies is estimated to be nearly 50% and most frequently encountered in the paraplegic weightlifters [7, 10].
While there is a wide range of possible upper extremity injuries in the adaptive athlete population, the majority of surgical outcomes research has focused on shoulder pathology. Paraplegics have a high prevalence of shoulder pain and injury with reported rates between 32 and 72% [6, 7, 11]. Shoulder injuries are especially common in adaptive athletes participating in track, road racing, and basketball . This is an important consideration because nearly all adaptive athletes rely on at least one functional upper extremity for sport. For example, 16 out of 20 summer Paralympic sports use a wheelchair at least some of the time. Consequently, we will be referring primarily to the shoulder when we refer to surgical outcomes. However, while the shoulder is likely to be the most commonly encountered area of injury, it is not an exclusive focus; there are many possibilities that can present themselves. It is imperative that the surgeon and athlete collaborate to find the best solutions and extrapolate their approach based on the best available outcomes.
Before continuing, it is important to understand the issues that factor into the high prevalence of rotator cuff injuries (RCIs) and shoulder pain in wheelchair-bound patients. First, there is increased load on the shoulder when using a wheelchair with the shoulder becoming the weight- bearing joint of the body [13–18]. During transfers and wheelchair propulsion, the vertical forces on the shoulder increase by over 300% . This significant force has been postulated to result in superior translation of the humeral head, leading to increased stress on subacromial structures ultimately resulting in RCI. Second, even in the healthy population, RCIs increase with age. This effect is exacerbated in paraplegics due to the increased loads and strain placed on their shoulders. Third, the level of spinal cord injury (SCI) can determine functionality and degree of impairment of the shoulder, and it is not uncommon to have referred pain from the neck that is felt in the shoulder [20, 21]. Thus, it is necessary to determine the correct source of pain prior to treatment.
We will now examine the most commonly reported metrics used to evaluate results and measure progress. As previously stated, there are very few clinical studies with reported surgical results. A literature review revealed only seven papers dealing with shoulder surgery in paraplegics. Five discussed rotator cuff repair and two discussed arthroplasty. There are several common themes that appear repeatedly and are similar to those reported in the literature related to non-impaired patients. These are the American Shoulder and Elbow Surgeons Standardized Assessment (ASES) score, Constant score, strength, range of motion, the role of radiography, patient demographics, and pain.
It is standard practice to employ objective rating scales as a means to determine functional outcomes. They allow the clinician to have a standard method to evaluate all patients, they remove bias, and they also streamline and balance subjectivity by using the same set of questions and rating scales.
Some of the most common rating systems are the ASES and Constant scores. The ASES score is a patient questionnaire that attempts to quantify pain, function, and disability. There are various scoring options, but the most common uses a 100-point scale with 100 being less pain and better function. The Constant score combines patient responses with clinical examination in order to assess pain, ability to perform activities of daily living, ROM, and strength. These scales are popular because they require little training to perform or evaluate, can be completed quickly, and are validated [22, 23].
Other scales used are the Neer and Functional Independence Measure (FIM) classifications. The Neer is based on the classic principles developed by Charles Neer over half a century ago and evaluates pain, motion, strength, function, and patient satisfaction. Results are reported as excellent, satisfactory, or unsatisfactory. The FIM gauges a patient’s ability to function independently, and scores range from 18 to 126.
There were several problems encountered during review of available literature. First, outcome measures utilized vary widely. This made comparison difficult. Second, several studies did not use any objective measure but rather used subjective measures (e.g., “no improvement” versus “improved”). Third, follow-up duration varied widely with a range of 2.5–84 months [4, 11, 16, 24–27]. Lastly, many of the studies focused on the SCI population instead of the adaptive athlete population. Surgical repairs and physical healing occur at different intervals, and without a common follow-up time, it is impossible to compare results. However, overall trends were apparent for the two most reported surgeries: shoulder arthroplasty and rotator cuff repairs.
There are but two published papers on shoulder arthroplasty in paraplegic patients [25, 26]. Garreau de Loubresse et al. required a multicenter retrospective review in order to identify a total of five patients who had undergone the procedure. In total, 11 paraplegic patients in published literature have received shoulder arthroplasty. Thus, there is little formal guidance for those considering the procedure.
The two papers showed similar demographic data. The average age of the patient at the time of surgery was 70 and 69 years old. The average length of time they had been paraplegic prior to surgery was 20 and 41 years. Interestingly, all 11 patients were female. The average time of follow-up was 30 and 84 months. Garreau de Loubresse et al. did not comment on how many different surgeons performed the five cases, but seeing as it was a multicenter study there were likely multiple. Hattrup and Cofield reported five surgeons for six cases. However, there was not any commonality regarding the type of implant used. For example, some used cement while others did not, and multiple styles of implants were used. Hattrup and Cofield reported surgeries being performed from 1982 to 2006. They point out that there has been a significant evolution in technique and implants over that time. So, though the patient demographics were similar, the procedures performed were not .