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Recurrent shoulder dislocations: The truth about the misconceptions in the literature
Our chief medical editor asks 4 Questions of Raymond A. Sachs, MD, about the most effective treatment for recurrent dislocations.
Many surgeons identify patients who they think may be at risk for shoulder redislocation. Raymond A. Sachs, MD, was part of an excellent natural history study performed within the Kaiser Permanente system and published recently in the Journal of Bone and Joint Surgery. This particular study identified and followed a large number of primary shoulder dislocations. I feel the study raised several questions for the surgeon trying to determine if a given patient should have surgery at the time of dislocation or later if reoccurrence is an issue.
I appreciate Dr. Sachs participating in this interview and responding to my four questions to share some of the studies' findings.
Douglas W. Jackson, MD
Chief Medical Editor
Douglas W. Jackson, MD: Following a first-time traumatic dislocation of the shoulder, which subgroups in your study population were at highest risk of reoccurrence?
Raymond A. Sachs, MD: The highest risk of redislocation was in the youngest subgroup, from ages 12 to 19 years old.
Jackson: Are there any patients in your population for whom you would recommend a primary stabilization procedure at this time?
Sachs: I would not recommend primary stabilization for any patient population that we studied. Even in our highest-risk patients, at least one-third never had another instability event and did extremely well. Another one-third had at least one recurrence of instability but still chose not to have surgery. Only the last one-third was both unstable and desirous of surgery.
Jackson: Why do you think we have so many conflicting opinions in the literature on this topic?
Sachs: There are several general misunderstandings about shoulder dislocations. First, much of the literature has focused on specific subgroups of patients who do not represent the population as a whole. I believe that these studies have led to the misconception that most young athletic patients will have a redislocation rate around 90%. Our study and those of Hovelius and te Slaa have shown that these dire predictions do not hold in the young athletic patients seen by most orthopedic surgeons. Second, the literature treats all patients who redislocate as if they were a homogenous group, usually with the assumption that they are all have multiple painful dislocations. In fact, our study showed that over half of the patients redislocated only once during the follow-up period and many instability events were relatively painless. Third, we equate a stable shoulder with happiness and an unstable shoulder with unhappiness. Yet, many of our patients with shoulder instability had extremely high outcome scores, and half of them did not want surgery.
Unfortunately, any or all of these misconceptions might lead an author to recommend acute surgery too often, when in fact, with time, a patient may either self-stabilize or else be willing and able to modify his/her life to deal with an occasional instability event rather than have surgery.
Jackson: Based on your outcomes scores, how did the nonoperative group without recurrent dislocation compare with the surgical and recurrent dislocation nonoperative group?
Sachs: The group of patients who stabilized after their first dislocation and never had another instability event had high outcome scores equivalent to the patients who had a successful Bankart repair. Put another way, successful nonoperative treatment and successful surgical treatment produced the same outcome scores. Patients who had nonoperative treatment, but had at least one recurrent instability event, had lower outcome scores than either of the two groups above. However, they were not a homogenous group, and only half of these patients were unhappy enough that they requested surgery.
For more information:
- Raymond A. Sachs, MD, can be reached at Southern California Permanente Medical Group, Department of Orthopedic Surgery, 250 Travelodge Drive, El Cajon, CA 92020; 619-441-3037; e-mail: raymond.a.sachs@kp.org.
References:
- Hovelius L, Augustini BG, Fredin H, et al. Primary anterior dislocation of the shoulder in young patients. A ten-year prospective study. J Bone Joint Surg (Am). 1996;78:1677-1684.
- Sachs RA, Stone ML, Paxton E, et al. Can the need for future surgery for acute traumatic anterior shoulder dislocation be predicted? J Bone and Joint Surg (Am). 2007;89:1665-1674.
- Te Slaa RL, Brand R, Marti RK. A prospective arthroscopic study of acute first-time anterior shoulder dislocation in the young: a five-year follow-up study. J Shoulder Elbow Surg. 2003;12:529-534.