Decision making for treatment of Anterior shoulder Instability in the young contact athlete

1. Anterior GHJ Instability
in theYounger Athlete
Lennard Funk
Wrightington Upper Limb Unit
@theshoulderdoc

2. Who?
• 16-25 yrs
• Traumatic
• Anterior

3. Why?
• High recurrence rates
• Bigger, faster, stronger
• Different rates of growth
• Higher demands
• Economic pressures
• Higher expectations

4. Recurrence Non-op
• 70-100% in most studies
(Rowe, 1963; McGlaughlin, 1967;Wagner, 1983)
• 49% with Physical Therapy (Lawton, 2002)
• 66% ‘Much Better’

5. • 31% recurrence within 5 years
• All Contact Sports Injuries
• 18% revision surgery
• 35% Arthoscopic
• 65% Latarjet
• Nixon & Funk et al.; JPOB, 2014
Arthroscopic Stabilisation

6. • Rate of recurrence under 16 = 68%
• Rate of recurrence over 16 = 27%
• Relative risk 2.5x if under 16
compared to 16-18 years (p=0.0002)
Torrance,Walton, Monga,Watts Funk;
AJSM, 2018
Arthroscopic Stabilisation

7. Development
• Glenoid concavity formed by 10yrs age
• Glenoid has two ossification centres:
• Upper 2/3
• from coracoid base
• closes by 16-18 years age
•Lower 1/3
•closes by 25 years age

8. Lesions
47%
17 ALPSA
22%
20%4%
5%
3%
Funk et al. 2012
143 Scopes

9. Latarjet Procedure

10. Latarjet Outcomes
• 30 over 8 years (2010-2018)
• All Male; Mean age 16.4yrs (15-17)
• 89% rugby
• FU = 18months
• No recurrences
• 70% return to pre-op level sport
• One loose screw - removed
DuPlay, Martin,Walton, Funk; OJSM, 2020
Adolescents
DuPlay & Funk; OOJ, 2019
Adults
• 81 over 3 years (2012-2015)
• 96% Male; Mean age 24yrs (18-50)
• 69% rugby
• FU = 3yrs
• 4% Recurrence
• 85% return to pre-op level sport
• 10% complication rate

11. Recurrence Non-op
• 70-100% in most studies
(Rowe, 1963; McGlaughlin, 1967;Wagner, 1983)
• 49% with Physical Therapy (Lawton, 2002)
• 66% ‘Much Better’
• Lawton et al. J Ped Orth 2002

12. • Most of the athletes were able to return to their sport and
complete their seasons after an episode of anterior shoulder
instability,
• although 37% experienced at least 1 additional episode of
instability during the season.

13. ‘Facts’ Summary
• Young Athletes:
• Bigger, faster, stronger
• Expectations, Economics
• High recurrence rates non-op - 70-110%
• Physical closure up to 25yrs age
• Arth Stab high recurrence rates
• BUT:
• In-season many can return to play
• ? up to 50% RTP Non-op

14. Rugby Injury
• 24 year old
• Semi-Pro Rugby player
• Tackling injury
• Unable to continue
• Mid-season
• Struggling with weights
• Unable to play at same level

15. Decision Making
Does he need surgery?
Why?
When?
How?

16. Considerations
PATHOLOGY PRESSURES
PATIENT
Why?

17. Lesions
Major ‘Minor’
• Bony Bankart
• ALPSA
• Rotator Cuff Tear
• HAGL
• Hill-Sachs Lesion
• Undisplaced Labral Tear
• Partial Cuff Tear

18. Timing of Surgery
•Early Surgery:
• Large structural lesions
• Late in Season
• Unable to Return
•Rehab & Return:
• Minor lesions
• Early season
When?

19. Latarjet inYoung Athletes
• Anterior Instability
• Revision surgery (even without bone loss)
• Chronic Bony Bankart (> 3months)
• Any Bony Glenoid Loss
• True dislocation in Front Row forward
(Rugby Union)
• Higher level of sports
How?

20. Three P’s
Patient
Pathology ParticipationPATHOLOGY PRESSURES
PATIENT
1. Season
2. Events
3. Pressure
4. Targets
1. Major
1. Bony
2. ALPSA
3. HAGL
4. FTCT
2. Minor
1. Labral
2. PTCT
1. Age
2. Gender
3. Laxity
4. Fatigue
5. Sport
6. Position
@theshoulderdoc

21. ThankYou
lenfunk@shoulderdoc.co.uk
@theshoulderdoc