The risk of recurrent anterior instability of the shoulder
tends to increase with the activity level of the patient. In particular, athletes
involved in so-called contact and collision sports can be subjected
to sizable loads on the shoulder
1
. American football players have been shown to be at high risk for
failure after arthroscopic stabilization procedures
2-5
. However, most reported series of patients treated with open anterior
stabilization of the shoulder have consisted of a heterogeneous
population, and few studies have presented the results of open repair
with specific regard to athletic participation. Furthermore, we
are not aware of any studies of open stabilization in a large series
of American football players. In the study most closely resembling
our current investigation, Uhorchak et al.
6
recently reported that, of sixty-six West Point cadets involved in
contact and collision sports, 22% had some degree of instability
at the time of a minimum two-year follow-up after open stabilization.
We studied a consecutive series of American football players in
whom anterior shoulder instability had been treated with an open
stabilization procedure by the senior author (M.J.P.) in the period
from August 1993 through January 1999. The patients were evaluated
at twenty-four to eighty months (average, thirty-seven months) after
the operation.
Seventy-one consecutive male American football players were treated
for recurrent shoulder instability with an open anterior stabilization
procedure. Five players who had undergone a prior operation for
instability were excluded from the study, as were two who had been
operated on for posterior instability. Six patients were lost to
follow-up during the study period, leaving fifty-eight available
for the final evaluation.
The patients' ages ranged from fifteen to twenty-nine years (average,
18.2 years). Forty-three patients played football at the high-school
level, eleven played at the collegiate level, and four were professional
football players. Although shoulder dysfunction interfered with
the activities of daily life of some of the patients, the primary
symptom in all patients was recurrent instability, shoulder pain,
and apprehension during participation in American football. Forty-seven
patients had frank dislocations, whereas the remaining eleven had
symptoms and signs consistent with recurrent anterior glenohumeral
subluxation. Forty-one of the forty-seven patients with dislocations
reported that at least one episode required manipulative reduction
by a health-care professional. The number of recurrent episodes
of instability ranged from three to twenty-five.
All patients had persistent signs and symptoms of anterior instability
on physical examination, and all had a history of trauma that was
believed to have initiated the instability. An anterior apprehension
test with the arm abducted and externally rotated was performed
on all patients. The examiner progressively increased the degree
of external rotation while noting the development of apprehension
on the part of the patient. The test was considered positive when
the maneuver induced anxiety and protective muscular contraction
as the shoulder was brought into a position associated with anterior instability
7
.
The signs and symptoms of anterior subluxation were often more
subtle than those of dislocation. Eight of the eleven patients remembered
a specific injury, which typically occurred with extreme external
rotation combined with either abduction or hyperextension. The chief
symptom in the athletes with subluxation was more vague, such as
a sense of movement, pain, or clicking with certain activities.
Several athletes noted repeated transitory episodes of severe pain,
particularly when tackling. After an acute episode, the severe pain
usually subsided quickly but the shoulder remained sore and weak.
Plain radiographs revealed an osseous Bankart lesion in five patients
and a Hill-Sachs lesion in nineteen. Magnetic resonance imaging
of the shoulder was not routinely performed in this series.
All patients were treated with the operation after failure of
a rehabilitation program that emphasized strengthening of the rotator
cuff and scapular rotator muscles. In the later stages of the rehabilitation,
proprioceptive neuromuscular feedback exercises were incorporated.
The duration of nonoperative treatment ranged from nine weeks to
thirty-seven months. All patients had recurrent instability or persistent
apprehension despite completion of the rehabilitation program.
Forty-one of the fifty-eight patients underwent arthroscopic examination
of the shoulder prior to the open stabilization procedure. In the
early part of the study, we did not routinely perform arthroscopy
when traumatic anterior instability was to be treated with an open
repair. However, we now routinely perform an arthroscopic inspection
of the shoulder with the patient in the beach-chair position prior
to the open portion of the procedure. We find the arthroscopic examination
to be helpful for identifying concomitant lesions in the rotator
cuff and labrum. In addition, by identifying the presence or absence
of a Bankart lesion, the arthroscopy aids in the planning of our
method of stabilization
8
. In particular, we shift the capsule on its lateral margin if no Bankart
lesion is present.
Operative Technique
Our general approach to open anterior stabilization has been described
previously
7,9
. A slight modification of our previously reported technique is described
below.
The patient is positioned supine with the head of the operating table
raised 30° and the involved upper extremity abducted 45°
on an arm-board. Folded sheets are placed beneath the elbow to maintain
the arm in the coronal plane of the thorax and to minimize extension
of the shoulder. The skin is incised along the anterior axillary
crease in a longitudinal fashion along the Langer lines. The incision
is placed lateral to the coracoid process. The deltopectoral interval
is identified, the cephalic vein is retracted laterally, and the
interval is developed. The clavipectoral fascia is then incised
at the lateral border of the conjoined tendon at its coracoid attachment, and
the coracoacromial ligament is divided to facilitate exposure of
the superior aspect of the capsule and, particularly, the rotator
interval area.
The bicipital groove and the lesser tuberosity are identified.
A vertical tenotomy of the subscapularis tendon is performed with
electrocautery approximately 1 cm medial to its insertion on the
lesser tuberosity. The medial portion of the tendon is tagged with
heavy, number-1, nonabsorbable braided polyester (Ethibond) sutures
(Ethicon, Somerville, New Jersey). The interval between the anterior
aspect of the capsule and the subscapularis tendon is then carefully
developed with a combination of blunt and sharp dissection.
The laxity and quality of the capsule are then assessed. If there
is a lesion in the rotator interval, it is generally closed at this
point with number-1 nonabsorbable braided polyester (Ethibond) sutures.
A transverse capsulotomy is then performed, and a ring (Fukuda)
retractor is placed intra-articularly. The glenohumeral joint is
explored for evidence of a Bankart lesion, and the joint is irrigated
to remove any loose bodies.
If a Bankart lesion is noted, the capsulolabral separation at
the anteroinferior aspect of the glenoid neck is extended medially with
use of an elevator or knife to allow placement of a retractor along
the glenoid neck. The glenoid neck is then roughened with an osteotome
or a motorized burr to provide a bleeding surface. Two or three
metallic suture anchors are placed in the anteroinferior aspect
of the glenoid neck near, but not on, the articular margin of the
glenoid. The capsule and labrum are reattached to the anterior aspect
of the glenoid with slight medial and superior mobilization of the
capsule. The goal is not to reduce external rotation but to obliterate excess
capsular volume and to restore the competency of the inferior glenohumeral
ligament at its glenoid insertion.
After repair of the Bankart lesion (or in the absence of a Bankart
lesion), an anterior capsulorrhaphy is performed to eliminate excess
capsular laxity. The arm is placed in 45° of abduction and
45° of external rotation, and the superior and inferior
capsular flaps are reapproximated with forceps. The shoulder is
held in a reduced position. If the capsular flaps can be overlapped,
the capsule is shifted to eliminate excess capsular volume with
the arm maintained in position. If £5 mm of overlap is present when
the inferior flap is pulled superiorly in relation to the superior
flap, the capsule is simply imbricated. With >5 mm of capsular overlap,
the capsulotomy is extended in a vertical direction near its lateral insertion
on the humeral neck, and a T-plasty capsular shift is performed.
The inferior capsular flap is shifted superolaterally, and the superior
flap is moved over the inferior flap in an inferolateral direction.
The transverse portion of the capsulotomy is then closed.
After the capsule has been addressed satisfactorily, the subscapularis
is reapproximated, but not shortened, with nonabsorbable suture.
The deltopectoral interval is loosely closed with absorbable suture.
Routine wound closure is then performed.
Postoperative Rehabilitation Protocol
A standard rehabilitation program was prescribed throughout the
course of the study (
Table I
).
Data Collection and Follow-up
All patients were examined after a minimum of two years of follow-up.
The patient self-evaluation form developed by the Research Committee
of the American Shoulder and Elbow Surgeons was administered
10
. Patients were specifically questioned regarding the occurrence
of any episodes of instability.
The physician assessment was performed by one or both of the
authors. Again, this portion of the examination was guided by the
recommendations of the Research Committee of the American Shoulder
and Elbow Surgeons
10
. A shoulder score index was then tabulated on the basis of the patient
self-assessment and physician assessment portions of the evaluation.
In addition, a second score was derived with the shoulder instability
scoring system of Rowe and Zarins
11
.
Arthroscopic and Operative Findings
A Bankart lesion was noted in forty-six of the fifty-eight patients.
Forty-three of the forty-seven patients with a history of recurrent
dislocation and three of the eleven patients with a history of recurrent
subluxation had a Bankart lesion. Three patients had an osseous
Bankart lesion that was of sufficient size to require excision and
repair of the remaining capsule and labrum to the underlying osseous
defect. No lateral capsular lesions were noted in this series.
One patient (a professional athlete) had an associated bucket-handle
tear of the superior aspect of the labrum; it was treated with excision
of the fragment during the arthroscopy. This labral tear included
approximately 15% of the supraglenoid insertion of the biceps brachii.
The biceps tendon in this patient was noted to be frayed and degenerated
proximally. Seven other patients had fraying of the superior part
of the labrum.
Capsular laxity was corrected by a T-plasty capsular shift in sixteen
patients. All twelve patients who did not have a Bankart lesion
underwent a T-plasty capsular shift.
A Hill-Sachs lesion was noted in thirty-seven of the forty-one patients
who underwent arthroscopy. Two patients had a small partial-thickness
tear on the articular surface of the supraspinatus tendon. Each
tear was thought to represent <10% of the tendon attachment.
The small partial tears were treated with d�bridement during arthroscopy.
Loose bodies were found and removed from four shoulders. Three
patients had small, displaced osseous fragments of the anterior
aspect of the glenoid, which were adherent to the anterior aspect
of the capsule and labrum. These fragments were sharply dissected
from the soft tissue and excised. The capsule was then repaired
to the underlying osseous bed.
Postoperative Instability
None of the patients had dislocation of the shoulder postoperatively.
Two patients reported postoperative episodes of subluxation, and
each continued to have a positive anterior apprehension test on
their follow-up examinations. Both of these individuals had had
subluxation preoperatively, and neither had had dislocations. One
of the two patients had a Bankart lesion; the other did not. Neither
had a Hill-Sachs lesion. Both patients experienced the initial postoperative
episode of instability while they were playing football.
The patients with preoperative subluxation had a higher rate of
postoperative instability than did those with preoperative dislocation
(Fisher exact test, p = 0.044).
Return to Sports
Fifty-two of the fifty-eight patients returned to full participation
in American football for at least one year. Forty-one participated
for at least two years, and twenty-four of them participated for
three or more years. Eleven high-school athletes went on to play
at least one year of collegiate football. All eleven collegiate
players returned to their college teams, and one of the eleven became
a professional player. All four professional players returned to
their sport.
One of the two patients (a high-school player) with postoperative
subluxation could not continue playing football after one year because
of persistent instability. He did not have instability with activities
of daily life and did not wish to undergo another surgical procedure.
The other patient with postoperative subluxation (a collegiate player)
continued to participate, despite occasional episodes of subluxation,
for two years.
Two patients decided to give up the sport because of instability
of the contralateral shoulder. Three other patients decided not
to continue their participation in American football for reasons
unrelated to the shoulder.
Range of Motion
Forward flexion on the involved side averaged 174° (range,
146° to 180°) compared with 180° on the
contralateral side. External rotation with the arm at the side averaged
67° (range, 30° to 95°) compared with 76°
on the contralateral side (p < 0.05). External rotation with
the arm in 90° of abduction averaged 96° (range,
60° to 120°), representing a loss of 8°
compared with the value on the contralateral side (p < 0.05).
No patient lost more than 15° of external rotation compared
with the value on the contralateral side. Forty-nine (84%) of the
fifty-eight involved shoulders had a range of flexion and external
rotation within 5° of those of the contralateral shoulder.
Postoperative Radiographs
Anteroposterior and axillary lateral radiographs were available
for forty-five of the patients during the postoperative period.
The metallic suture anchors were in satisfactory position; none
appeared to have migrated or become misplaced. Radiographs of one
patient (a professional player) demonstrated mild degenerative changes
of the glenohumeral joint. No other major radiographic anomalies
were noted.
Functional Testing
The average postoperative shoulder score according to the scale
of the American Shoulder and Elbow Surgeons
10
was 97.0 points (range, 70 to 100 points). Only one patient received
a score of <80 points.
The Rowe and Zarins shoulder instability score
11
ranged from 49 to 100 points, with an average of 93.6 points. According
to this scoring system, there were fifty-three excellent results,
two good results, two fair results, and one failure. Ninety-five
percent of the patients had a good or excellent result.
Complications
A subcutaneous hematoma that required surgical evacuation and
drainage developed in one patient. He had an uncomplicated recovery.
We and many others have previously described high recurrence
rates after arthroscopic stabilization procedures in athletes who
participate in so-called contact sports
2-5,12
. As a result, we stopped recommending arthroscopic stabilization
as a treatment option to American football players in 1993. We believed
that the recurrence rates associated with arthroscopic procedures
outweighed any perceived advantages in terms of appearance or less
perioperative pain.
O'Neill
3
recently reported excellent results after arthroscopic stabilization
in a carefully selected group of athletes. However, two of the seventeen
American football players in his series had postoperative subluxation
and a score of <80 points according to the scale of the American
Shoulder and Elbow Surgeons. As a result, O'Neill advised, "football
players must be warned about the greater probability of instability
on returning to their sport after an arthroscopic procedure." In
comparing the results of arthroscopic and open anterior stabilization
procedures, Cole et al.
2
noted that all episodes of instability after an arthroscopic Bankart
repair resulted from a fall or participation in a contact sport.
Bacilla et al.
13
reported a 10% failure rate after arthroscopic Bankart repair in
a high-demand population that included twenty-one American football
players. The patients were studied for a minimum of eighteen months,
and the specific results in football players were not reported.
Gill et al.
14
showed excellent objective long-term results after the Bankart
procedure, which confirmed findings in earlier reports by Rowe et
al.
15
and Zarins et al.
16
. Our technique is basically a modification of these methods. Wirth
et al.
17
reported that 97% of patients treated for traumatic anterior instability,
with a somewhat different open method devised by Rockwood, had normal
stability and a negative apprehension test after surgery. While
athletes were included in each of these studies, the results in
football players were not specifically analyzed.
It was our belief that the open technique offers certain advantages
that are difficult to duplicate with current arthroscopic technology.
First, the ability to restore tension to the capsule in a precise
manner is facilitated by freeing the capsule from the adherent subscapularis
tendon. Second, the shoulder can be maintained in an optimal position
during the capsular repair with less concern about visualization.
Third, the capsular structures can be overlapped with ease with
use of the open technique. (The ability to reinforce and thicken
a damaged capsule may be especially important in an athletic population.)
Fourth, the rotator interval, which is difficult to visualize properly
through the arthroscope, can be directly observed and properly repaired
with the open technique.
One of the presumed advantages of arthroscopic techniques of shoulder
stabilization is an improvement in postoperative shoulder motion.
In our series, 84% of the patients regained all or nearly all of
their shoulder motion. Our results in terms of range of motion approximate
those in reports on arthroscopic stabilization in similar patients
3,18
. We do, however, think that there may be a role for arthroscopic
stabilization in selected patients. We continue to consider arthroscopic
techniques for the treatment of throwing athletes with subtle anterior
instability and lower-demand individuals who have a Bankart lesion.
In summary, we believe that open stabilization is a predictable method
of restoring shoulder stability in American football players. Motion
and function need not be sacrificed in exchange for stability. Our
results appear to be superior to those reported after arthroscopic
stabilization in a similar population.