Sachs R, Lin D, Stone M, Paxton E, Kuney M.
American Journal of Bone and Joint Surgery 2007;89(A):1665-74.
There is a common conception that the younger a patient is following his or her shoulder dislocation then the higher the chance of further dislocation(s) and so surgeons would advocate early stabilisation surgery. This is especially now the case as arthroscopic methods are improving.
Traditionally we were more guarded and only offered surgery if the shoulder redislocated or the patient wanted surgery for their symptoms of instability. So what is the right answer?
The authors performed a natural history study to determine whether it is possible to predict the need for a surgical operation based at the time of the initial injury and examination. This would be quit beneficial as we could avoid the additional resources that unnecessary surgery would provide if an individual was not likely to need it in the long run.
131 patients completed the study in which they were assessed with the Western Ontario Shoulder Instability Index (WOSI), the American Shoulder and Elbow Score (ASES) and the Constant-Murley score. Of the 131 patients 102 were treated non-operatively, 20 had a Bankart repair and 9 had a rotator Cuff repair. The patient population was unsurprisingly a young one (mean 33yrs). The mean follow up of the non operative group was 4 years (range 2 to 7 years) and no patient was followed up for less than 2 years.
The results of this study are similar to other natural history studies of large populations, in that 50% of patients who have a traumatic shoulder dislocation will not have an additional instability event within a 5 year follow up period. The rest of these people will go on to have one or more dislocations but the symptomatic degree of further instability is quite variable such that only 25% of patients will undergo surgery.
It is usually the younger patient who needs his/her arm for overhead activity/work and is involved in contact sports. This is a high risk group and the study suggested that only half of these patients actually request surgery with the other half opting out and coping with their instability. Patients whose shoulders stabilised after the first dislocation had excellent scores similar to those achieved with Bankart repairs. Patients who opted out of surgery with redislocations had lower outcome scores.
The authors conclude that early surgery cannot be based on the presumption that patients will get further dislocations, disability with their shoulder and unhappiness. It is far more sensible to adopt a wait and see strategy as there are no studies that suggest that recurrent instabilities suffer any potential consequences by not being operated on so acutely.
