Tackling Injuries in Contact Athletes Joseph H. Guettler, M.D.

1. Tackling Injuries in Contact Athletes Joseph H. Guettler, M.D. Assistant Clinical Professor, OUWB Medical School Member, Board of Directors, AOSSM

2. Disclosure • Educational and research support from Depuy Mitek, Arthrex, Biomet, and Smith & Nephew • Consulting for Depuy Mitek and Smith and Nephew • Speakers Bureau for Genzyme

3. Three Hot Topics in the Shoulder • Clavicle Fractures – Pin vs. Plate? • AC Separations – What to do with the Condroversial Grade III? • Shoulder Dislocations – What do you tell the first time dislocator?

4. Three Hot Topics in the Knee • ACL Tears – Who gets what graft? • Patellar Dislocations – What do you do with the first-time dislocator? • Meniscus Tears - When do you trim and how far do you push the envelop when it comes to repairing the meniscus?

5. Clavicle Fractures

6. Traditional Treatment of Clavicle Fractures • “Put it in a sling and it should heal” • Usually 4 to 6 weeks and then avoidance of contact activity for 2 to 3 months • The Problems: • Not all fractures heal (fibrous union or nonunion) • Not all fractures heal right (malunion) • This can have a negative influence on the rest of the shoulder girdle

7. And Let’s Face it: Clavicle Fractures Can Land You in Jail

8. “Problem” Fractures • Complete displacement with lack of bony apposition • Shortening of greater than 1.5 to 2 cm • High Energy and comminution • Fractures in smokers Murray et al, JBJS 2013

9. The Trends • Fix Fractures with significant displacement and/or shortening • Greater than 100% displacement • Shortening of greater than 1.5 to 2 cm • 85% of fractures are midshaft and can be pinned or plated • And hence the great debate…

10. Pin Versus Plate

11. Now I’m Not Afraid to Use a Plate

12. It’s OK to be a “Pinhead” When it Comes to Fixing Midshaft Clavicle Fractures

19. Post-op Pin Management • Generally speaking, 4 weeks in a sling • Pendulums and elbow ROM usually instituted at 2 weeks • Motions to avoid early on: Elevation above 90 degrees and X-body adduction • Formal rehab usually begins between 4 and 6 weeks (But not all need it) • Pin removal 8 to 10 weeks • Return to sport 3 to 4 weeks later

20. Pin vs. Plate – Meta-analysis • After qualifying studies, four studies with 305 fractures included • No significant differences pin vs. plate in regards to outcome scores, nonunion, infxn, fixation failure, and hardware removal • More symptomatic hardware events occurred with plating • Duan et al, JSES 2011

21. Conclusions • Excellent results can be obtained with either intramedullary or plate fixation • Plate offers rigid fixation while pin acts as an internal splint • Pin is less invasive, but most contact athletes really don’t care about the size of the incision • Condition of the clavicle after hardware removal may have an impact on choice of fixation method

22. AC Separations

23. Anatomy and Biomechanics • Posterior and Superior AC Ligaments • Important in Horizontal stability • Conoid • 45 mm away from distal clavicle • Posterior ½ of the clavicle • Trapezoid • 30 mm away from distal clavicle • Anterior ½ of the clavicle • CC Ligaments important in Vertical Stability Image Courtesy of N Bontempo MD & A Mazzocca MD, Biomechanics and Treatment of AC and SC Joint Injuries, Br J Sports Med 2010

24. Mechanism of Injury • Direct – Most Common • Usually a fall on the superolateral shoulder with the arm adducted • Indirect • A fall on an outstretched arm or elbow with a superiorly directed force

25. Physical Exam Tenderness Deformity Pain with Cross-Body Adduction Pain with Obrien’s Type III can Usually be Reduced Type V Buttonholed through fascia

26. Radiographic Evaluation

27. Injury Classification Image Courtesy of N Bontempo MD & A Mazzocca MD, Biomechanics and Treatment of AC and SC Joint Injuries, Br J Sports Med 2010

28. The Controversial Grade 3 Another Meta-analysis of the Literature • A meta-analysis of the current evidence base • Of 724 citations, six retrospective case series studies met eligibility criteria • Operative management results in better cosmetic outcome, but greater duration of sick leave compared to non-op • No difference in strength, pain, throwing ability, and osteoarthritis • One study showed a higher Constant score for operatively managed separation Smith et al, J OrthopTraumatol 2011

29. The Controversial Grade 3 What About the Aussies? • 14 Australian Rules Football Players; 8 non-op, 6 operative, 2 converted to operative • Quicker return to sport-specific training & competive games, as well as higher subjective scores at final follow-up for the operative group Cardone et al, J Sci Med Sport 2002

30. The Controversial Grade 3 A Common Sense Approach • Recognized recent trend toward initial non-op management • Offered a treatment algorithm with more aggressive management based on factors including type of sport or labor, timing of injury relative to athletic season, or throwing demands in the dominant arm Trainer, Arciero, Mazzocca, Clin J Sport Med 2008

31. RepairAcuteSynthetic In 2016 Reconstruction Chronic Biologic vs. Image Courtesy of P Brady MD, AC Repair Using Dog Bone Button Technology, Arthrex Inc, 2013 Image Courtesy of A Mazzocca MD, R Arciero MD, & A Romeo MD, Anatomic Coracoclavicular Reconstruction Surgical Technique, Arthrex Inc, 2012

32. Repair of Acute Separations

35. Results of Button Fixation • Twelve patients with Grade III and IV AC separations • Treated with double-button fixation through mini-op incision • Mean age 27.5; Follow-up 18.25 months • Excellent Constant, Dash, and VAS scores • CC distance maintained and comparable to opposite shoulder • No radiographic AC arthritis Beris et al, Injury 2013

36. Post-Op Protocol • Sling for 1st 6 weeks • Pendulums at 2 weeks • Gentle PT with ROM at 5 weeks • Gentle Strengthening with acute repair at 6 weeks (8 weeks for reconstruction) • Nothing aggressive for 3 months either procedure • Return to contact sport 4 months (repair) and 6 months (reconstruction)

37. Traumatic 1st Time Shoulder Dislocation

38. Mechanism of Injury: Acute Anterior Dislocation

39. The Bankart TearThe Essential Lesion

40. The Trend:Stabilize High-Risk1st Time Dislocators

41. Contemporary Operative Considerations • Arthroscopic Bankart repair using suture anchors • Open Bankart repair using suture anchors • Addition of: • Rotator Interval Closure • Posterior Plication Suture • SLAP Repair • Treatment of Bony Deficiency of the Anterior/Inferior Labrum or Significant Engaging Hill Sachs Lesion

45. The Latest Debate

46. Arthroscopic vs. Open RepairAnother Meta-Analysis • Included 11 trials and 1022 patients • Open Bankart repair produced a more stable shoulder but the poorer motion compared to arthroscopic repair Wang et al, Med SciMonit, 2015

47. Ten Year Follow-up of Acute Arthroscopic Bankart Repair for Initial Shoulder Dislocation in Young Patients • 21 Patients under age 25 underwent arthroscopic Bankart repair within 30 days of injury • 35% failure rate with 5 recurrent dislocations and 2 subluxations Chapus et al, OrthopTraumatolSurg Res, 2015

48. Don’t Be Afraid to Go

49. Conclusions • First-time dislocations in young contact athletes should be repaired • Results are likely better when repaired early and when they are “ripe for the picking” • Trend back toward open repair in high risk contact athletes

50. The Contact Athlete’s Knee ACL