Shoulder Instability—The First Time is the Best Time

Abstract & Commentary

Synopsis: Arthroscopic stabilization of first-time anterior shoulder dislocations resulting from trauma significantly reduces the rate of recurrence when compared with nonoperative treatments.

Source: Bottoni CR, et al. A prospective, randomized evaluation of arthroscopic stabilization versus nonoperative treatment in patients with acute, traumatic, first-time shoulder dislocations. Am J Sports Med. 2002;30(4):576-580.

Conventional, nonoperative treatment of first-time shoulder dislocations in young athletes has been shown to result in a high rate of recurrence and instability; whereas, other studies have suggested that operative treatment following shoulder dislocations significantly reduces the rate of recurrence. The present study compares nonoperative treatment of patients with first-time, traumatic shoulder dislocations with early arthroscopic Bankart repair with a bioabsorbable tack.

Patients between the ages of 18 and 26, from a population of active-duty military personnel, who sustained a primary, traumatic shoulder dislocation that required manual reduction, were prospectively randomized into 1 of 2 treatment groups. A total of 14 patients were treated nonoperatively and 10 patients were treated operatively.

The nonoperative patients had their shoulders immobilized for 4 weeks in a sling and underwent a rehabilitation regimen. After 4 months, the nonoperative patients returned to full active duty, including contact sports. The operative patients underwent arthroscopic stabilization using a Suretac (Acufex Corp, Mass) within 10 days of the injury. The operative patients followed the same rehabilitation regimen as the nonoperative patients, including 4 weeks immobilization in a sling after surgery, and returned to full active duty and contact sports 4 months postoperatively.

Patients were examined regularly with a minimum follow-up time of 24 months and a maximum of 56 months. The criteria for unsuccessful treatment was either a second dislocation, symptomatic subluxation or instability preventing return to active duty, or requiring an additional surgical stabilization procedure. Patients were evaluated using the single assessment number evaluation (SANE) method as described by Williams and associates1 and the L’Insalata shoulder evaluation.2

Three of the 24 patients were lost to follow-up resulting in 12 patients in the nonoperative group and 9 in the operative group. Nonoperative treatment failed in 9 of the 12 nonoperative patients (75%) while the operative treatment failed in only 1 of the 9 operative patients (11.1%). Six of the 9 nonoperative patients with failed treatment ultimately underwent an open Bankart reconstruction.

There was no statistical difference between the operative and nonoperative groups with respect to range of motion 6 months after the injury or surgery. Patients in the operative group scored higher (P < 0.002) in both the SANE and L’Insalata scores than the patients in the nonoperative group. Based on a patient survey, 6 of the 9 operative patients (67%) rated their shoulders "excellent" while only 3 of the 12 nonoperative patients (25%) provided the same rating.

Comment by Brian J. Cole, MD, & Nina Shervin

The rate of redislocation following an initial traumatic shoulder dislocation in younger patients has been variably reported. Such discrepancies may stem from the patient population evaluated (eg, West Point cadets vs civilians). The present study, although based upon active-duty military personnel, more closely approximates a relatively young, athletic group in the general population. The high rate of treatment success and lack of complications with the bioabsorbable tack strongly suggest that arthroscopic stabilization of first-time, traumatic shoulder dislocations is a safe and effective alternative to conventional, nonoperative treatment. It is possible, however, given our experience with the Suretac that patients treated with chronic recurrent instability may not fare as well due to the presence of secondary pathology, such as capsular stretch, contributing to their instability.

Dr. Cole, Assistant Professor, Orthopaedic Surgery, Rush Presbyterian Medical Center, Midwest Orthopaedics, Chicago, IL, is Associate Editor of Sports Medicine Reports.

References

1. Williams GN, et al. Comparison of the single assessment numeric evaluation method and two shoulder rating scales: Outcomes measures after shoulder surgery. Am J Sports Med. 1999;27:214-221.

2. L’Insalata JC, et al. A self-administered questionnaire for assessment of symptoms and function of the shoulder. J Bone Joint Surg. 1997;79A:738-748.