Commentary & Perspective on
"Surgical Treatment of Traumatic Anterior Shoulder Instability in American Football Players"
By Michael J. Pagnani, MD, and David C. Dome, MD

Commentary & Perspective by
Christopher D. Harner, MD*,
University of Pittsburgh Medical Center, Pittsburgh, PA

Arthroscopic techniques and indications have evolved over the last ten to fifteen years, but the central question is whether the use of arthroscopic techniques has improved patient outcomes. With many "new" procedures in orthopaedics there is usually great interest and application of the technique initially, followed by a decline in its popularity and by refinement of the indications for its use over time. The most recent example of this phenomenon is thermal capsulorrhaphy for the treatment of shoulder instability. Over the past four years that I have been following this technique, its use has declined precipitously. Initially, short-term data on surgeon-reported failure rates looked promising for thermal capsulorrhaphy (range, 8-10%)¹. However, in a more recent study that included a minimum follow-up of two years, 29% of the patients who had had anterior instability had an unsatisfactory treatment result, with either recurrent instability or pain².

This retrospective study involved a group of select athletes who underwent open stabilization for treatment of recurrent anterior shoulder instability. The authors provided adequate follow-up (average duration, thirty-seven months) and they used acceptable outcome measures (American Shoulder and Elbow Surgeons shoulder score and the Rowe and Zarins shoulder instability score). The authors made numerous comparisons of the results of open treatment with those of arthroscopic treatment but did not include any comparative data on the relative merits of the two approaches, and so their comments must remain speculative.

There is little question that the results of arthroscopic stabilization for the treatment of anterior inferior shoulder instability have improved^3-5. These improved results can be attributed to an improvement in our understanding of the appropriate indications and in patient selection as well as in technique. Burkhart and De Beer reviewed the results of arthroscopic Bankart repair with use of suture anchors in 194 patients at an average of twenty-four months postoperatively³. Included in this group was a population of 101 contact athletes (ninety-six South African rugby players and five American football players) who are arguably similar to the group of athletes in the study by Pagnani and Dome. Burkhart and De Beer found that the rate of recurrence was high when arthroscopic stabilization was performed in patients who had significant bone defects, such as an engaging Hill-Sachs lesion or an inverted-pear Bankart lesion. In contact athletes without significant bony defects, there was only a 6.5% recurrence rate, whereas in contact athletes with bony defects, there was an 89% recurrence rate. These data offer us new information that will help to elucidate the indications and improve results of arthroscopic shoulder stabilization. If the outcomes are similar, arthroscopic approaches offer obvious advantages over open techniques and so, until we have data from a truly prospective, randomized study, all comparisons of open versus arthroscopic methods of stabilization must be critically analyzed.

It must also be pointed out that in the study by Pagnani and Dome, magnetic resonance arthrograms and arthroscopic criteria for the assessment of shoulder pathology were not utilized for all patients. We have found that magnetic resonance arthrograms can be extremely helpful in identifying the location of the pathology and also as an aid in predicting which patients may benefit from arthroscopic approaches. The pathophysiology can then be delineated during examination under anesthesia, and arthroscopic criteria can be applied to determine the final diagnosis and method of treatment.

Finally, nonoperative management of these athletes can be considered as an interim strategy. These injuries often occur during the athlete's pre-season training or in-season play. The goal of the sports-medicine physician is to return the athlete to competition as soon and as safely as possible. In American football, different team positions carry different demands, and the team physician must weigh all of the issues before making a treatment decision. It is critical to discuss this with the player, athletic training staff, parents (especially those of high school athletes), and coaches. It is often possible to get an athlete through the season by bracing and limiting his/her playing time and to delay the surgery until the end of the season.

*The author did not receive grants or outside funding in support of his research or preparation of this manuscript. He did not receive payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the author is affiliated or associated.

References

1. Wong KL, Williams GR. Complications of thermal capsulorrhaphy of the shoulder. J Bone Joint Surg Am. 2001;83 Suppl 2 Part 2:151-5.
2. Sekiya JK, Ong BC, Bradley JP. Thermal capsulorrhaphy for shoulder instability. Instr Course Lect. 2002, in press.
3. Burkhart SS, De Beer JF. Traumatic glenohumeral bone defects and their relationship to failure of arthroscopic Bankart repairs: significance of the inverted-pear glenoid and the humeral engaging Hill-Sachs lesion. Arthroscopy. 2000;16:677-94.
4. Karlsson J, Magnusson L, Ejerhed L, Hultenheim I, Lundin O, Kartus J. Comparison of open and arthroscopic stabilization for recurrent shoulder dislocation in patients with a Bankart lesion. Am J Sports Med. 2001; 29:538-42.
5. DeBerardino TM, Arciero RA, Taylor DC, Uhorchak JM. Prospective evaluation of arthroscopic stabilization of acute, initial anterior shoulder dislocations in young athletes. Two- to five-year follow-up. Am J Sports Med. 2001; 29:586-92.