powerpoint presentation - aossm€¦ · to review prevalence of, presentation of, and management...

11/3/2016

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Stephen F. Brockmeier, MD Associate Professor, Orthopaedic Surgery

University of Virginia

Team Physician UVA Athletics

ACSM/AMSSM/AOSSM

Advanced Team Physician Course

December 8-11, 2016

San Diego, CA

Learning Objectives

1. To review prevalence of, presentation of, and management strategies for in season shoulder instability in the contact athlete.

2. To critically review the current literature and evidence and potential research avenues to improve team physicians’ abilities to appropriately and safely treat shoulder instability in the in-season athlete.

University of Virginia Orthopaedic Surgery

Consultant – Zimmer Biomet, MicroAire

Speaker – Zimmer Biomet, Depuy, Arthrex

Clinical Trial (active) – Zimmer Biomet

Publishing Agreement/Royalties – Springer

Research Grant – Arthrex

Fellowship Grant – DJO, Depuy Mitek, Arthrex,

Editorial Board – TSES, OJSM

Board/Committee Appointments – AOSSM

Disclosures Shoulder Instability in the Contact Athlete

• Common

– NCAA Injury Surv. System

– Rate 0.12 per 1000 exposures

– Highest rates in contact sports (football, wrestling, hockey)

• Management Strategies:

– In game decision-making

– Return to play

– Algorithm to determine surgical intervention and timing


How Common?

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DR: 3rd year linebacker

– 1o Dislocation during 4th game of the season

– Reduced on field

– Returned to play and finished the game

Case #1



– 1o Dislocation during 4th game of the season

– Reduced on field

– Returned to play and finished the game

– MRI:

• Displaced ant/inf labral tear (2:00 – 6:00)

• GLAD lesion (8x8mm)

• Small HS lesion

Case #1



– Returned to practice that week w/protective harness

– Able to play remainder of the season

– Had a few recurrent events

– At completion of the season, underwent stabilization: • Ant/Post Labral repair

(5 anchors)

• Coverage of GLAD lesion

Case #1


D.R.


DR: 3rd year linebacker – Surgery 12/17/13

– Missed Spring FB

– Cleared to RTP fully in June, 2014

– Started and played full season (2nd leading tackler on defense)

– No recurrences

– Graduated and hopes to play at the next level

Case #1

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• AH: 4th year Safety

– No known history of prior instability

– First event, 3rd game of the season

– Subluxation (suspected)

– Recurrence the following game

Case #2







– MRI: • Osteocartilaginous Bankart

lesion

• Small HS lesion

Case #2







– MRI:

– CT: • Bony Bankart fracture

• 13% glenoid bone loss by 3D measurement

Case #2



– Exam essentially normal

– Minimal apprehension

– Fitted with harness and able to continue playing relatively symptom free

– Only two reported recurrent events but no time lost

– Underwent surgical repair at the end of the season:

• Arthroscopic bony bankart repair (dual row/bony bridge)

Case #2


Case #2



– Surgery 12/30/14

– 10 weeks postop

– Progressing ahead of schedule

– NFL combine

– Projected early to mid round pick in the draft

Case #2

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Case #3

• 29 yo Ortho resident

• Former kickboxer / MMA

• Many years of recurrent anterior instability (>20 dislocations)

• Now comes out with minimal trauma

• No prior surgeries

• Exam: • Apprehension at 90 and 45

degrees


Plain Films


MRI



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Diagnostic Scope


Technique

• Beach chair position

• Articulated arm positioner

• Axillary incision

• No paralysis

• Postop regional block

• EUA

• Diagnostic Scope


Technique

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Technique


Postop Films

Case #4

19M D1 Offensive Lineman

• Left shoulder posterior pain/instability while blocking in practice

• Had similar symptoms to a lesser degree in high school

– Never really evaluated

• PSH: right knee medial patellar retinaculum advancement

Case

• Physical Exam:

Full Motion

+ apprehension

++ load and shift

++ posterior load

5/5 cuff strength

- Biceps testing

MRI

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MRI A/S Posterior Stabilization

A/S Posterior Stabilization Case

• Labral tear from 1 to 6 w/ associated bony fragment and GLAD lesion

• Repaired with 4 anchors

• Able to return to camp in the fall without symptoms

• Enters the season playing first 6 games

Case

• FSU game – sustains reinjury

• Presentation c/w posterior subluxation

• Transient distal paresthesias

MRI

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CT SCAN CT SCAN

CT SCAN CT SCAN

CT SCAN CT SCAN

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Now What?? Scope

OPEN OC ALLOGRAFT FRESH DISTAL TIBIA OC ALLOGRAFT

OPEN OC ALLOGRAFT OPEN OC ALLOGRAFT

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Post-op Xrays


Shoulder Harness


• What is the literature?

• Are there guidelines?

Questions:




• How can we safely and effectively return athletes to play?

Questions:





• Is it wise to allow an athlete to return to play?

Questions:

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• Is it wise to allow an athlete to return to play?

• What are the potential consequences?

Questions:


Current Evidence


• AJSM, 2004

• Collegiate / HS athletes (multiple sports)

• In-season disloc/sublux

• 27 athletes, avg age 16.5yrs

• PT +/- brace (if appropriate)

• Avg 10 days competition missed

• Mean 1.4 recurrent episodes (some did not have them)

• 46% required surgery at the end of the season

Current Evidence


• AJSM, 2014 (Aircast Award, AOSSM Meeting 2014)

• Prospective study, Military, 3 institutions; multiple sports

• 45 athletes (2011, 2012 academic years)

• 33 (73%) were able to return for all or part of the season

• 12 (27%) completed season w/o recurrence

• 22/33 (67%) who returned completed the season

• Subluxation 5.3 times more likely to return (vs. dislocation)

Current Evidence


“While 73% of college athletes with in-season shoulder instability were able to return to sport during the same competitive season, the long-term outcomes and consequences associated with recurrent instability events in these patients who return to play remain unclear.”

Current Evidence


• Prospective

• Multicenter

– D1 Collegiate Football

– Consortium of institutions

– ACC conference wide initiative

• Surveillance study

• Collaborative effort

– ACC Team Physicians and ATCs

– UVA – Primary Site/IRB

– Registry (?)

Proposed Study

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1. Define the risk of injury or structural progression in contact athletes (football) who are allowed to continue to play after a shoulder instability event

Study Aims



Can we mitigate this risk by the use of a shoulder brace or harness?

Study Aims



Can we mitigate this risk by the use of a shoulder brace or harness?

Is this risk increased based on athlete position, # of exposures, type/severity of injury, or other factors

Study Aims


1. Define the risk of injury or structural progression in contact athletes (football) who are allowed to continue to play after a shoulder instability event Can we mitigate this risk by the use of a

shoulder brace or harness?

Is this risk increased based on athlete position, # of exposures, type/severity of injury, or other factors

2. Is a shoulder brace or harness effective in limiting in-season recurrent events and improving ability to play

Study Aims


1. Define the risk of injury or structural progression in contact athletes (football) who are allowed to continue to play after a shoulder instability event Can we mitigate this risk by the use of a

shoulder brace or harness? Is this risk increased based on athlete

position, # of exposures, type/severity of injury, or other factors

2. Is a shoulder brace or harness effective in limiting in-season recurrent events and improving ability to play

3. Does injury/structural progression lead to inferior outcomes, delay or inability to RTP, or increased risk of recurrence?

Study Aims


1. Shoulder instability injuries are common but often allow for in-season return to play with or without bracing

2. Continued play after an instability episode places the shoulder at risk for progression of injury

3. Shoulder braces provide a protective effect to the in-season unstable shoulder, allowing for continued play, delayed surgical repair, and limited progression of shoulder pathology

Hypotheses

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• Subjects

– NCAA D1 football players

• Enrollment / Inclusion

– Shoulder disloc / sublux

– In-season or Spring ball

– Evaluated by ATC and Team physician (History/PE)

– Demographics (position, year, …)

– MRI (+/- arthrogram per preference of treating center)

Methods


• Reviewed by Team MD

• Standardized data recorded:

– Labral pathology (Bankart, Perthes, ALPSA)

– Location (using clockface measurements)

– Anterior/Posterior/SLAP/270 degree

– Chondral lesion / GLAD

– Bony involvement

• Glenoid

• Humeral

– HAGL

– Concomitant findings (Cuff, biceps, etc.)

MRI Evaluation


• Determination made by Team MD:

1. Return to play

2. Brace, Harness, Sully, other precautions

***THIS IS A SURVEILANCE STUDY – all decisions are made based on current practice

Methods


Monitoring Data (in-season):

1. Time to RTP (days) with practices, games missed

2. Any recurrent events

• Player reported to ATC/MD

3. Compliance with brace use

4. Surgery

5. Other ?

Results / Data Points


Comparative Data (progression of pathology):

1. Interval repeat MRI study • At completion of the season / preop

• Or….after a fixed # of games, exposures (?)

• Do we do a repeat MRI, is it feasible??

2. Surgical Findings (compare to MRI findings) • Labral pathology (size, type, extension?)

• Capsular lesion

• Chondral pathology

• Bone loss

• Concomitant pathology



Outcomes Data:

• Athletes followed after surgery (or definitive treatment decision)

1. Subjective outcomes

2. Objective assessment

3. Time to RTP

4. Ability to RTP (level of competition)

5. Recurrences (?)

6. Revision surgery (?)

7. Transition to the next level (NFL, etc.)


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• Very common problem

• On the rise

• Some data…but limited

• Common practice to “manage” in-season instability

• Results in some time missed

• Ramifications of this are not known and need to be

In Summary A. Bobby Chhabra, MD Chairman, UVA Orthopaedics

powerpoint presentation - aossm€¦ · to review prevalence of, presentation of, and management...

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