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© 1998 The Journal of Bone and Joint Surgery, Inc.
CorrespondenceTO THE EDITOR: We have several comments regarding "Primary Anterior Dislocation of the Shoulder in Young Patients. A Ten-Year Prospective Study" (78-A: 1677–1684, Nov. 1996), by Hovelius et al. First, we commend the authors for this ten-year follow-up evaluation of 247 primary anterior dislocations. It is unparalleled with regard to duration of follow-up. At first glance, the rates of 48 per cent for overall recurrence, 23 per cent for recurrence necessitating operative stabilization, and 20 per cent for dislocation arthropathy appear to be reasonable long-term results. Certainly, a 48 per cent rate of recurrence in young patients appears much lower than the reported rates of 65 to 95 per cent1-6. The authors concluded that after a primary glenohumeral dislocation the prognosis "is not as devastating as was previously believed." We believe that this conclusion is substantially overstated. In this study, patients who were forty years old or less were classified as young. Furthermore, 37 per cent (ninety-one) of the total follow-up group was thirty to forty years old, and the rate of recurrence in these patients was 20 per cent. We know from Rowe4 that patients who are thirty to forty years old have a much lower rate of recurrence than those who are fifteen to twenty-two years old. Because almost 40 per cent of the study population was thirty years old or more, the overall rate of recurrence (48 per cent) appears low. In contrast, the younger patients in this study (those who were twenty-five years old or less) had rates of recurrence that were much higher: between 60 and 72 per cent. Furthermore, the rate of operative stabilization in the patients who were twenty-five years old or less was between 30 and 40 per cent, which is not low. In general orthopaedic terms, patients who are thirty to forty years old are considered young. However, with regard to recurrent anterior instability of the shoulder, this study and previous ones1-6 indicate that there is a substantial difference between young patients who are thirty years old or more and those who are twenty-five years old or less. The results do not support the overall conclusion that the prognosis "is not as devastating as previously believed," especially for patients who are less than twenty-five years old. Second, there is no mention in the report of the functional level of these patients either before or after the dislocation. We know from several studies that the level of activity also plays a part in the prognosis after anterior dislocation of the shoulder. Simonet and Cofield reported a 66 per cent overall rate of recurrence after acute dislocations5. However, when they evaluated athletes who were thirty years old or less, they found the rate of recurrence to be 82 per cent. Indeed, Hovelius, in a previous study of Swedish hockey players (who are obviously at risk because of the collision and contact requirements of the sport), provided additional evidence of a relationship between a young age and a high level of activity and recurrence of anterior dislocation of the shoulder3. In that study, he noted a 90 per cent rate of recurrence in the hockey players who were less than twenty years old and a 65 per cent rate in those who were twenty to twenty-five years old. Henry and Genung reported a 95 per cent rate of recurrence in a series of more than 100 patients, most of whom were athletes2. In addition, nearly three-quarters of their patients needed operative stabilization in order to continue participating in sports2. These studies demonstrate that young patients who return to high-demand athletic activities are at increased risk for recurrence. In the study by Hovelius et al., less than half of the primary dislocations were secondary to a sports activity. This fact and the high percentage of patients who were more than thirty years old suggest that the study population included a substantial number of non-athletic, sedentary patients. The low rate of recurrent dislocation in the entire study population could thus be due to a low number of patients who were involved in activities (such as athletic activities, strenuous labor, and so on) that are considered to put the individual at high risk for dislocation of the shoulder both before and after the primary dislocation. We are also interested in the authors' remarks about evidence of spontaneous healing or spontaneous stabilization at the ten-year follow-up examination. Do they believe that the shoulders stabilize spontaneously and "heal" ten years after injury? Or is this spontaneous stabilization secondary to age-related changes in the capsule or, even more likely, to decreased physical demands as the patient ages? We believe that the conclusions made in this study are weakened by the lack of a detailed functional assessment to determine any restrictions in activity imposed by the injury, the lack of an assessment of apprehension or functional limitations, and the grouping of patients who were thirty to forty years old with those who were fifteen to twenty-five years old. Since we do not know the functional level of these patients, what risk factors the shoulders were subjected to, or what demands were placed on the shoulders after the injury, it is incorrect to state that these findings indicate a benign prognosis after primary glenohumeral dislocation, even in younger patients. Not all young patients are the same, and their activities differ with regard to collision, contact, and overhead requirements. In order to truly answer the question concerning rates of recurrence, the need for operative treatment, and so on, patients should be grouped within specific age-ranges and by similar activity demands before and after the injury. The authors implied that a twenty-year-old intercollegiate football player has the same prognosis as a sedentary thirty-five-year-old business executive and therefore the treatment considerations initially should be similar. This study, while it is an excellent long-term follow-up of a group of patients who had primary glenohumeral dislocation, does not provide the ultimate answer as to the natural history of this problem. The conclusions made regarding prognosis and treatment are in no way supported by the methods in which the study was performed.
Lieutenant Colonel Robert A. Arciero: United States Military Academy, West Point, New York 10996 Lieutenant Colonel Dean C. Taylor: Keller Army Community Hospital, West Point, New York 10996
Dr. Hovelius, Dr. Augustini, Dr. Fredin, Dr. Johansson, Dr. Norlin, and Dr. Thorling reply: When we planned this study in 1977, the aim was to evaluate prospectively the effect of immobilization for the treatment of primary anterior dislocation of the shoulder. We then decided that forty years was an appropriate upper age-limit. Carter Rowe wrote to one of us (L. H.) many years ago, wondering why we did not include dislocations in patients of all ages. We still think that something valuable would have been missing from the message conveyed by the histogram on page 1681 (Fig. 4) if the patients who were thirty to forty years old had been left out. We would like to know what lower age-limit Arciero and Taylor would consider to be appropriate in a study on dislocations in older patients. Where do they find themselves in the histogram? The numbers given in the Abstract regarding recurrences were for the whole series of dislocations, which means that patients who had a fracture of the greater tuberosity were included. Most of the other questions raised by Arciero and Taylor are answered by studying Figure 4. About 38 per cent of the patients who were twelve to twenty-two years old and did not have a fracture of the tuberosity had an operation within ten years. Approximately 30 per cent more had at least two recurrences. However, half of these patients had no dislocations during the last five to eight years of the study (the shoulders had stabilized over time). Our explanation for this curious finding is found in the Discussion. However, the question remains as to why more patients who had at least two recurrences were not operated on by ten years. Perhaps because of Swedish mentality? Not even half of the patients who were twenty-five years old or less and had a recurrence needed an operation during the ten-year follow-up. A routine prophylactic operation is therefore unnecessary in more than 50 per cent of patients. Health-care resources are scarce in most European countries; therefore, each operative procedure must be justified by long-term follow-up studies of the natural history of the actual disease. Anything else should be considered unethical! We understand that the desire to perform a routine prophylactic operation also may be a question of the ambition of the orthopaedic surgeon and of different surgical cultures. The level of activity of the patients was discussed when we wrote this manuscript. However, it was suggested during the editorial process that this part be removed. Seventy-five per cent of the patients who were twelve to twenty-two years old, 66 per cent who were twenty-three to twenty-nine years old, and 50 per cent who were thirty to forty years old participated in some kind of athletic activity. We classified all patients according to four levels of activity on the basis of the risk of a redislocation. A high level of activity (seventy-six patients) indicated that the patient participated in hockey or other contact sports; a moderate level of activity (forty-six patients), racquet sports involving the dominant upper extremity or activities associated with similar risk for recurrence; a low level of activity (thirty-two patients), racquet sports involving the non-dominant upper extremity, golf, running, and so on; and a sedentary level (ninety-three patients), no athletic activity at all. We were surprised—as we think every reader will be—to find that the long-term prognosis concerning recurrent dislocation was the same for patients who had a high level of activity as for those who had a sedentary level (Fig. 1). We did not mean to imply that a twenty-year-old intercollegiate football player has the same prognosis after a dislocated shoulder as a thirty-five-year-old business executive who is sedentary. However, if these patients were the same age, our findings suggest that they would have the same prognosis!
The differences regarding the prognosis in this study compared with that in other studies may be explained by the fact that our study was prospective. We never stated that a primary dislocation in a young person is a benign event; again, we direct the reader's attention to Figure 4. However, a primary dislocation with one or two recurrences is not a disaster per se. An operation is, in our opinion, indicated only when the symptoms of instability are manifest. Of course, our study did not provide the ultimate answer to the question of what constitutes the natural history of this problem. We are, however, happy to have presented a study in which almost no patients were lost to follow-up. We only reported what the follow-up examination showed. How the findings are interpreted will differ in different countries and also according to the attitude of the reader. Within six years, we hope (if we are alive) to start the twenty-five-year follow-up, and perhaps then we will know a little more about, for example, arthropathy after dislocation. Perhaps some of the observations made at the ten-year follow-up examination will be found to be incorrect while others will still be correct.
L. Hovelius, M.D.: Orthopedic Department, Gävle Hospital, 801 87 Gävle, Sweden B. G. Augustini, M.D.: Orthopedic Department, Regionsjukhuset, 701 85 Örebro, Sweden H. Fredin, M.D.: Orthopedic Department, Malmö Allmänna sjukhus, 214 01 Malmö, Sweden O. Johansson, M.D.: Orthopedic Department, Karlstad Hospital, 651 85 Karlstad, Sweden R. Norlin, M.D.: Orthopedic Department, University Hospital, 581 85 Linköping, Sweden J. Thorling, M.D.: Orthopedic Department, Falun Hospital, 791 82 Falun, Sweden
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