Clinical Outcomes, Survivorship, and Return to Sport After Arthroscopic Capsular Repair With Suture Anchors for Adolescent Multidirectional Shoulder Instability: Results at 6-Year Follow-up

Abstract

Background: Multidirectional shoulder instability (MDI) refractory to rehabilitation can be treated with arthroscopic capsulolabral reconstruction with suture anchors. To the best of our knowledge, no studies have reported on outcomes or examined the risk factors that contribute to poor outcomes in adolescent athletes.

Purpose: To identify risk factors for surgical failure by comparing anatomic, clinical, and demographic variables in adolescents who underwent intervention for MDI.

Study design: Case series; Level of evidence, 4.

Methods: All patients 20 years or younger who underwent arthroscopic shoulder surgery at a single institution between January 2009 and April 2017 were evaluated. MDI was defined by positive drive-through sign on arthroscopy plus positive sulcus sign and/or multidirectional laxity on anterior and posterior drawer tests while under anesthesia. A 2-year minimum follow-up was required, but those whose treatment failed earlier were also included. Demographic characteristics and intraoperative findings were recorded, as were scores on the Single Assessment Numeric Evaluation (SANE), Pediatric and Adolescent Shoulder Survey (PASS), and short version of the Disabilities of the Arm, Shoulder and Hand (QuickDASH).

Results: Overall, 42 adolescents (50 shoulders; 31 female, 19 male) were identified as having undergone surgical treatment for MDI with minimum 2-year follow-up or failure. The mean follow-up period was 6.3 years (range, 2.8-10.2 years). Surgical failure, defined as recurrence of subluxation and instability, was noted in 13 (26.0%) shoulders; all underwent reoperation at a mean of 1.9 years (range, 0.8-3.2 years). None of the anatomic, clinical, or demographic variables tested, or the presence of generalized ligamentous laxity, was associated with subjective outcomes or reoperation. Number of anchors used was not different between shoulders that failed and those that did not fail. Patients reported a mean SANE score of 83.3, PASS score of 85.0, and QuickDASH score of 6.8. Return to prior level of sport occurred in 56% of patients.

Conclusion: Adolescent MDI refractory to nonsurgical management appeared to have long-term outcomes after surgical intervention that were comparable with outcomes of adolescent patients with unidirectional instability. In patients who experienced failure of capsulorrhaphy, results showed that failure most likely occurred within 3 years of the index surgical treatment.

Keywords: anterior shoulder; glenoid labrum; multidirectional instability; pediatric and adolescent; posterior shoulder.

Figure 1.

Representative case demonstrating positive sulcus sign. Images courtesy of SD Peds Ortho.

Figure 2.

Sagittal T2-weighted, fat-saturated magnetic resonance image with arthrogram demonstrating intact circumferential labrum (arrow) with capacious capsule evident posterior and inferior (asterisk). Image courtesy of SD Peds Ortho.

Figure 3.

Representative case demonstrating (A) presence of drive-through sign of the glenohumeral joint as viewed through the posterior portal at the beginning of the case and (B) subsequent absence of drive-through sign after adequate capsular repair had been achieved. Images courtesy of SD Peds Ortho.

Figure 4.

Representative case demonstrating a glenolabral articular disruption (GLAD) lesion (A) in the anterior aspect with intact anteroinferior labrum and (B) posterior labrum, both viewed from a superior position. Plication of the capsule was performed from inferior to superior (arrow direction) to perform an anteroinferior and posteroinferior capsulorrhaphy via placement of anchors (asterisks) in the glenoid (these represent the 4-, 5-, 7-, and 8-o’clock positions, with 5- and 7-o’clock anchors already tied with knots visible). The device was shuttled under the labrum to include that anatomic feature in the construct. Images courtesy of SD Peds Ortho.

Figure 5.

Survivorship curve demonstrating overall survivorship of 96% at 1 year after surgery and 76% at 3 years.