Immediate stabilization of young patients with first-time dislocations not supported

Long-term shoulder study finds surgery is not required in more than half of the cases.

Issue: April 2006

Findings from a long-term Swedish multicenter investigation of first-time shoulder dislocations in patients younger than 40 years old suggest that immediate stabilization does not alter the course of instability in most patients, nor does athletic injury obviate the need for surgery.

“This study has highly contributed to our knowledge,” said Lennart Hovelius, MD, professor of orthopedics, Gävle University, Gävle, Sweden. “Surgery for every first-time dislocation in these ages is, in our opinion, unnecessary in 50% of the cases.”

Hovelius made his presentation at the American Academy of Orthopaedic Surgeons 73rd Annual Meeting in Chicago.

Hovelius’ investigation involved a prospective 25-year review of 227 patients (229 shoulders) seen at various clinics and hospitals throughout Sweden between 1978 and 1979. Initially, there were 255 patients in the study; 162 patients were younger than 30 years old at the time. Athletic injuries accounted for 60% of the injuries in this age group.

Thirty-seven percent of the patients between the ages of 12 and 22 years had surgery to stabilize their shoulders, as did 28% of those aged 23-29 years old, and 13% of those between 30 and 40.

Hovelius said that all living patients from the original cohort were involved in the follow-up. All patients received X-ray evaluation of their shoulders, as well as Samilson-Pietro classification of overall shoulder function.

Time heals

Hovelius found that 115 shoulders (more than 50%) had not recurred or had recurred only once during the quarter-century time period. Sixty-two of the shoulders underwent surgery due to recurrent instability, and 17 were still recurrent at the time of follow-up. Moreover, he found that 35 of the shoulders that had two or more recurrences within the first 10 years had stabilized over time and did not have a recurrence in the past 15 years. “Time is a part of the natural history,” Hovelius said.

Of the patients between the ages of 12 and 22 years old who received surgery, 26% had moderate or severe arthropathy at the 25-year follow-up. Satisfaction scores indicated that less than one-third of this group were happy with the choice to have surgery. Likewise, 21% of the 23-to 29-year olds and 7% of the 30-to 40-year olds were satisfied with their surgical treatment.

Athletics not a predictor

Further examination of the data revealed that 38% of the patients with sports-related injuries underwent surgery, compared to 40% of those who did not have a sports-related injury. “Athletic injury did not worsen the prognosis,” Hovelius said.

He noted that 29% of the surgeries performed were considered failures; 7% went on to revision.

Classification of the injuries using the Samilson-Pietro scale indicated that after 25 years, 44% of the shoulders were normal, 29% had mild arthropathy, 9% moderate arthropathy and 17% demonstrated severe arthroplasty.

“In our opinion, this study does not support the idea of immediate stabilization of first-time shoulder dislocations, even in the young,” he reported.

For more information:
Hovelius L. Skoglund UIP. Sandstrom B. et al. Prognosis of first-time shoulder dislocation in the young. 229 shoulders followed for 25 years. #088. Presented at the American Academy of Orthopaedic Surgeons 73rd Annual Meeting. March 22-26, 2006. Chicago.