Should arthroscopy in adolescents: Three years of clinical experience

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Abstract


Background.

Shoulder joint injuries and shoulder instability often occur in adolescents.

Materials and methods. 

During a 3-year period, we performed arthroscopic surgery on 42 patients with shoulder joint injuries.

Results and discussion. 

The majority (76.2%) of the patients on whom we performed arthroscopic shoulder joint surgery were male. This is likely due to more aggressive physical activity among males. Most of the patients were injured during exercise (n = 27, 64.3%). Arthroscopy is a highly effective surgical method for the treatment of shoulder joint injuries. Prolonged non-operative treatment with no well-established indications and an incorrect diagnosis can lead to rapid progression of degenerative and dystrophic changes of the shoulder joint and may result in shoulder joint dysfunction.


Introduction

Shoulder joint dysfunction, in particular, shoulder joint instability, is one of the most common pathologies in traumatology [1]. It is prevalent among young people actively involved in sports [2]. 

Currently, surgical treatment is recommended for young patients (younger than 30 years of age) even after one instance of shoulder dislocation. Late and insufficient medical treatment leads to rapid degenerative and dystrophy changes, and disorders of the shoulder joint occur even at a young age.

There are anatomical prerequisites for this condition. Articular surfaces are incongruent, such as spherical humeral head and essentially flat glenoid cavity, secured only by the glenoid labrum. Although this contributes to considerable freedom of movement in the joint, it also creates pre-conditions for frequent joint dislocations [3, 4].

Arthroscopy is a highly efficient method of intra-articular shoulder pathology treatment. In contrast to open surgery, arthroscopy provides enhanced direct visualization of the articular structures without damage to the muscles and tendons, which facilitates fast recovery after sur-gery [5, 6].

In addition to instability, there are a number of other indications for arthroscopy of the shoul-der joint, in adults as well as adolescents, such as tendinitis of the long head of biceps, intra-articular loose bodies, and superior labrum anterior to posterior lesion (SLAP lesion, damage to the glenoid labrum).

Materials and methods

At the Turner Scientific and Research Institute for Children’s Orthopedics, 42 adolescent pa-tients underwent arthroscopic surgery due to a shoulder joint pathology during 3 years (2013-2015). All patients (or responsible parents or legal guardians) signed a voluntary informed con-sent form to participate in the study and for performance of the surgery.

The average age of patients was 16.6 years (range, 14-18 years). The distribution of patients according to sex showed significant predominance of shoulder joint pathology in males [32 pa-tients (76.2% of all cases)], and female patients constituted 23.8% (10 cases). Most likely, this is the result of more aggressive physical activities in males. We found that most of the patients (27 patients, 64.3%) were injured during athletic 

activities.

As a part of the preoperative procedure and to determine the surgical intervention strategy, we performed magnetic resonance imaging (MRI) and computed tomography of both shoulder joints for all patients with the following indications: instability of the shoulder joint for determining whether there was a deficit of the scapula bone tissue (Bankart fracture) and/or humeral head (Hill-Sachs fracture) and intra-articular loose bodies for clarifying their localization.

The main indication for shoulder arthroscopy was a recurrent dislocation of the shoulder (27 cases, 64.3%), and there was only one patient (2.4%) who was recommended to undergo surgery by a primary physician after the first traumatic dislocation; in one case (2.4%), the indication for surgery was recurrent posterior shoulder joint instability with pronounced dysplastic changes in the joint, accompanied by pain syndrome. It should be mentioned that pronounced signs of shoulder joint dysplasia (flat glenoid cavity and increased mobility of both shoulder joints) were present in 30% of patients with recurrent shoulder dislocation. However, all patients experienced the first traumatic dislocation as an acute injury during excessive physical exercise. We per-formed mobilization of capsule at the level of the glenoid labrum tear and fixed it in the correct anatomical position with anchor fixators (Healix, DePuy Synthes Companies, Johnson & John-son, USA).

In 10 patients with SLAP lesion, we also performed glenoid labrum suture in the area with de-fects.

Tendinitis of the long head of the biceps that requires surgical intervention is not a frequent pa-thology in adolescents; we only encountered two cases (4.8%) in 3 years. These patients were treated with proximal tenodesis. The damaged tendon was attached to the intertubercular groove of the humeral head with biodegradable screws (Milagro, DePuy Synthes Companies, Johnson & Johnson, USA).

In one patient (2.4%), we removed a significant number of cartilaginous loose bodies that re-stricted movement in the shoulder joint and caused pain syndrome. Partial synovectomy was per-formed for this patient (Figs. 1 and 2). One month after surgery, this patient resumed his athletic activity, soccer, and did not report any further discomfort.

Results and discussion

The most common reason for arthroscopic surgery of the shoulder joint is a recurrent shoulder dislocation, and the majority of patients are athletes. In our study, in almost all adolescents with recurrent shoulder displacement, it was more than 1 year since the first occasion of instability, and almost all had multiple dislocations and were recommended conservative treatment at the primary care facility. The result of such undue delays of surgery was serious damage to the joint. Because of this damage, in 17 patients, in addition to the restoration of the glenoid labrum, it was necessary to perform the remplissage procedure and cartilage mosaicplasty (to smooth torn cartilages on the articular surfaces of the glenoid cavity and humeral head).

For almost all patients, we were able to achieve stability of the joint; the duration of the follow-up observation was up to 3 years. The joining of damaged labrum did not provide the desired result in only one patient with severe anterior subluxation of the humeral head (due to a weak anterior joint capsule wall and severe muscle hypotrophy). Within 2 months after surgery, the hu-meral head returned into the forced pathological position of subluxation. Revision surgery was recommended.

The patients who underwent arthroscopic intervention for other conditions (SLAP lesion, ten-dinitis of the long head of the biceps, removal of the intra-articular loose bodies) also noted sig-nificant improvements: pain relief, restoration of the range of movement, and improved muscle strength in the shoulder area within 1 year after surgery. Patients returned to the same level of physical activity as before the injury.

Thus, arthroscopy is a highly efficient method of correction of the shoulder joint pathology in adolescents. We note that one of the serious problems is the predilection of many primary care physicians for the long-term conservative management of such patients without full imaging studies (in the first place, without MRI of the shoulder joint) and, as a consequence, without a sound decision on the correct treatment strategy. It leads to significantly more serious surgical interventions, which could be avoided with timely surgical treatment of the patient.

Financial information and conflict of interests

This study was conducted at, and supported by, The Turner Scientific and Research Institute for Children’s Orthopedics, Saint Petersburg, Russian Federation. The authors declare no con-flicts of interest associated with the publication of this paper.

Ananstasiya I Brianskaia

The Turner Scientific and Research Institute for Children’s Orthopedics

Author for correspondence.
Email: a_bryanskaya@mail.ru

Russian Federation MD, PhD, research associate of the department of trauma effects and rheumatoid arthritis. The Turner Scientific and Research Institute for Children’s Orthopedics.

Alexei G Baindurashvili

The Turner Scientific and Research Institute for Children’s Orthopedics

Email: turner01@mail.ru

Russian Federation MD, PhD, professor, corresponding member of RAS, honored doctor of the Russian Federation, Director of The Turner Scientific and Research Institute for Children’s Orthopedics.

Mikhail A Konev

The Turner Scientific and Research Institute for Children’s Orthopedics

Email: m.a.konev@mail.ru

Russian Federation MD, chief of the department of trauma sequelae and rheumatoid arthritis. The Turner Scientific and Research Institute for Children’s Orthopedics

Evgeny V Prokopovich

The Turner Scientific and Research Institute for Children’s Orthopedics

Email: pev-turner@mail.ru

Russian Federation MD, PhD, orthopedic surgeon of the department of trauma sequelae and rheumatoid arthritis. The Turner Scientific and Research Institute for Children’s Orthopedics.

Maksim S Nikitin

The Turner Scientific and Research Institute for Children’s Orthopedics

Email: turner01@mail.ru

Russian Federation MD, orthopedic and trauma surgeon of the department of trauma effects and rheumatoid arthritis. The Turner Scientific and Research Institute for Children’s Orthopedics.

Polina P Sergeeva

The Turner Scientific and Research Institute for Children’s Orthopedics

Email: Polly-ser@yandex.ru

Russian Federation MD, PhD student the Turner Scientific and Research Institute for Children’s Orthopedics.

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Copyright (c) 2016 Brianskaia A.I., Baindurashvili A.G., Konev M.A., Prokopovich E.V., Nikitin M.S., Sergeeva P.P.

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