Treatment and healing impact return to play after glenohumeral stabilization

Initial return to play rates of 90% are reported in noncontact athletes who stay out 4 to 6 months.

Issue: October 2009

Appropriate use of immobilization, arthroscopic stabilization and open surgery can help athletes with glenohumeral instability return safely to play, an upper extremity specialist said.

Neal S. ElAttrache, MD, described glenohumeral stability as multifactorial in a presentation to the American Orthopaedic Society for Sports Medicine 2009 Annual Meeting. For a strategy to be effective at reducing episodes of instability and keeping athletes safely playing sports, including overhead athletes, he said it should take into consideration the sport played and its physical demands, the treatment method and its timing and the bony architecture of the glenohumeral joint.

“Nonoperative management in some cases is possible, but the majority is surgical,” he said. “Early surgical repair in athletes seems to provide lower recurrence rates and earlier return.”

Bracing athletes

ElAttrache said bracing is sometimes a viable short-term treatment option. Its downsides include limited range of motion that can affect performance and a higher-than-usual risk of recurrent glenohumeral instability, which he estimated at 30% to 50%.

He reported success limiting his use of bracing to in-season contact athletes who have no signs of bone loss in the glenohumeral joint, normal shoulder strength and a normal neurovascular examination. These athletes usually return to sport in about 2 weeks.

For other contact athletes, whether ElAttrache uses an open or arthroscopic procedure depends on the extent of bone loss. Return to play in these cases is highly individualized and based mostly on histologic healing, he said.

According to preclinical data, including research Scott A. Rodeo, MD, published on ACL healing principles, “at about 12 weeks we have histologic and biomechanical evidence to permit stress on the repair site,” he said.

“I prefer acute or subacute arthroscopic stabilization if there is less than 20% glenoid bone loss. If there is more than 20% glenoid bone loss I prefer an open Bristow-Latarjet procedure with secure bony fixation and bone-to-bone healing. The time to return for either of these procedures then would be about 4 to 6 months.”

The type of glenohumeral instability also determines the treatment to some extent, ElAttrache said, citing his good results performing arthroscopic repairs in individuals with traumatic unidirectional instability.

“Almost 90% return to sport, 67% at pre-injury levels. It is important to use anchors in your recurrent instability posteriorly, especially if it is bilateral, because typically you will have glenoid retroversion from the glenoid,” he said.

Overhead athletes

Overhead athletes require special attention due to their issues of instability and joint imbalance. However, data are limited concerning their prospects for successful return to sports.

“It depends more on the mechanics, coordination and proprioception and less on biological healing in contrast to contact athletes,” said ElAttrache, who recommended avoiding Bristow-Lattarjet procedures in this population.

Perspectives

Orthopedics Today Editorial Board members Joseph P. Iannotti, MD, PhD, and John A. Bergfeld, MD, provided their perspectives on these strategies.

“These recommendations reflect sound clinical judgment derived from an extensive amount of clinical experience,” Iannotti said.

Bergfeld added, “ElAttrache indicates that an in-season athlete may return to sport after a glenohumeral dislocation, but must be monitored and wear a restrictive brace. The eventual surgical procedure must be individualized taking into consideration the specific sport needs and anatomy of the injury.”

For more information:

Neal S. ElAttrache, MD, can be reached at Kerlan-Jobe Orthopaedic Clinic, 6801 Park Terrace Drive, Suite 500, Los Angeles, CA 90045-1539; 310-665-7257; e-mail: elattrache@aol.com. He is a consultant to Arthrex Inc.

John A. Bergfeld, MD, is the Director, Operating Rooms, Cleveland Clinic. He can be reached at 9500 Euclid Ave. E-21, Cleveland OH 44195; 216-445-4836; e-mail: bergfej@ccf.org.

Joseph P. Iannotti, MD, PhD, is Chairman of the Cleveland Clinic Orthopaedic and Rheumatologic Institute. He can be reached at Cleveland Clinic, 9500 Euclid Ave. A-41, Cleveland, OH 44195; 216-445-5151; e-mail: iannotj@ccf.org.

Reference:

ElAttrache NS. Lessons learned: Return to play — Are we kidding ourselves? Glenohumeral instability. Presented at the American Orthopaedic Society for Sports Medicine 2009 Annual Meeting. July 9-12, 2009. Keystone, Colo.