Copyright © 2008 by The Journal of Bone and Joint Surgery, Inc.
Commentary & Perspective
Commentary & Perspective by
Matthew H. Griffith, MD, and Bertram Zarins, MD*,
Sports Medicine Service, Massachusetts General Hospital, Boston, Massachusetts
Posted May 2008
In their prospective study, Hovelius et al. report the
twenty-five-year follow-up data on patients who sustained an initial anterior
shoulder dislocation between the ages of twelve and forty years old. The
authors previously reported the results in this cohort at two, five, and ten years
after initial dislocation.
Over the fifteen-year interval since their last report, an
additional 3.5% of patients had surgery to stabilize the shoulder (23.5% at ten
years compared with 27% at twenty-five years). This shows that short-term
reports on the natural history of shoulder instability may not reflect the true
prevalence of recurrent instability.
Previous studies have shown very high recurrence rates of
shoulder instability in young patients. The initial study by Rowe in 1956
reported an 83% recurrence rate in patients younger than twenty years of age, and
other studies have reported recurrences rates near 100% in this age group1,2.
From our interpretation of the data from Hovelius et al., it appears that the
recurrence rate in the twelve to twenty-two-year-old age group is 53% at two
years, 64% at five years, 66% at ten years, and 72% at twenty-five years. This
shows that young patients who have had a shoulder dislocation and have not had
surgery may still be at risk of recurrent dislocation up to twenty-five years
after the initial injury.
Another finding of note is that the type of sports
participation (contact, noncontact, or no sports participation) had no effect
on the rate of recurrence. In fact, there was a trend toward higher rates in
patients who did not participate in sports activities at all. It is a general
belief that athletes who participate in contact and collision sports have a higher
risk of recurrence, and this has been demonstrated in studies in which patients
were followed after surgical stabilization3. The authors of the
current study note the difficulty of accurately defining the level of sports
participation, which may account for these results.
This study found that immobilization did not affect the rate
of recurrence after shoulder dislocation. This finding supports the findings in
previous reports by the same authors as well as others4-7. The
results from a more recent work by Itoi et al. indicated that there may be some
benefit to immobilization in external rotation after initial dislocation to
allow healing of the Bankart lesion in a more anatomic position8.
Results from the Disabilities of the Arm, Shoulder and Hand
(DASH) questionnaire showed a worse outcome in the group with recurrent
instability that had not stabilized at twenty-five years. There was no significant
difference between the patients who had a solitary dislocation, those whose
shoulder had stabilized over time, and those whose shoulder had been stabilized
surgically. It is a promising finding that there is no significant difference
in outcome score between these three groups.
A strength of this study is that all living patients
completed at least a basic questionnaire and 94% completed the DASH
questionnaire. (Eighteen patients had died since the reporting of the ten-year
results.) The characteristics of the patients who died were not defined, and it
is unclear whether this may have an effect on how the new results differ from
the ten-year data. Another limitation is that because this is a multicenter
study and designated examiners were not utilized, physical examination data were
considered unreliable and were therefore not included.
In their previous report on this cohort of patients after a
follow-up period of ten years, Hovelius et al. found radiographic evidence of
arthropathy in 20% of shoulders7. Although the authors report in the
current paper that radiographs were made for 223 of 229 shoulders at the time
of the twenty-five-year assessment, no radiographic data were included in the
report. The authors of the current study have supplied us with long-term data
on the recurrence rate of anterior shoulder dislocation after nonoperative
treatment, but they have not supplied us with data regarding the percentage of
patients who were able to return to their prior level of function or sport or the
percentage of patients who had arthritis develop over time. Limitations in the
original protocol prevent the analysis of return to full function after a
shoulder dislocation.
The results presented in this paper suggest that if all
young patients who sustain a first-time anterior shoulder dislocation were
treated with operative stabilization, 30% to 50% of them would undergo an
unnecessary surgical procedure. We agree with the concept of initial
conservative treatment after anterior shoulder dislocation; however, it remains
to be seen if surgical stabilization can prevent late degenerative changes.
*The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated.
References
1. Rowe CR. Prognosis in dislocations of the shoulder. J Bone Joint Surg Am. 1956;38:957-77.
2. Marans HJ, Angel KR, Schemitsch EH, Wedge JH. The fate of traumatic anterior dislocation of the shoulder in children. J Bone Joint Surg Am. 1992;74:1242-4.
3. O'Neill DB. Arthroscopic Bankart repair of anterior detachments of the glenoid labrum. A prospective study. J Bone Joint Surg Am. 1999;81:1357-66.
4. Robinson CM, Howes J, Murdock H, Will E, Graham C. Functional outcome and risk of recurrent instability after primary traumatic anterior shoulder dislocation in young patients. J Bone Joint Surg Am. 2006;88:2326-36.
5. Hovelius L, Eriksson K, Fredin H, Hagberg G, Hussenius Å, Lind B, Thorling J, Weckström J. Recurrences after initial dislocation of the shoulder. Results of a prospective study of treatment. J Bone Joint Surg Am. 1983;65:343-9.
6. Hovelius L. Anterior dislocation of the shoulder in teen-agers and young adults. Five-year prognosis. J Bone Joint Surg Am. 1987;69:393-9.
7. Hovelius L, Augustini BG, Fredin H, Johansson O, Norlin R, Thorling J. Primary anterior dislocation of the shoulder in young patients. A ten-year prospective study. J Bone Joint Surg Am. 1996;78:1677-84.
8. Itoi E, Hatakeyama Y, Sato T, Kido T, Minagawa H, Yamamoto N, Wakabayashi I, Nozaka K. Immobilization in external rotation after shoulder dislocation reduces the risk of recurrence. A randomized controlled trial. J Bone Joint Surg Am. 2007;89:2124-31.
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