Older shoulder dislocation patients usually need surgery for pain, instability

Study confirms the variability of shoulder dislocation pathology in patients older than 35 years.

HOLLYWOOD, Fla. — When patients over the age of 35 years experience shoulder dislocation, their pathology is significantly more variable than patients in a younger population.

Investigators at the New England Baptist Hospital in Boston identified the pathoanatomy of patients aged 35 years and older. Among 22 patients they found a 67% rate of rotator cuff repair, occurrences of both pain and instability and that surgical intervention is usually necessary.

“Many [patients] will require surgical intervention and we recommend aggressive imaging in this study population due to their high incidence of rotator cuff pathology to actually visualize their treatment,” Michael A. Kuhn, MD, of New England Baptist Hospital, said at the Arthroscopy Association of North America 25th Annual Meeting.

Evaluating the pathoanatomy

Over 3 years Kuhn and his colleagues reviewed 22 traumatic shoulder dislocation patients aged 37 to 72 years.

“[This study was] purely an attempt to report the pathoanatomy and not an attempt to look at outcome studies,” Kuhn said.

Researchers evaluated the operative and nonoperative arms, reason for surgery — either pain or instability — and arthroscopic findings and treatments. Exclusion criteria included posterior instability, major fractures, multidirectional instability or prior history of dislocation.

All patients underwent nonoperative rehabilitation, and each received a clinical exam, X-rays and MRIs.

“We looked at nonoperative treatment whenever applicable at first,” Kuhn said. “Four patients out of the 22 never required surgery and went on to, at this point, do well.”

Eight of the remaining 18 patients underwent surgery for recurrent instability, which was much higher than predicted, Kuhn said. Ten patients had surgery because of pain and three for pain and instability.

Based on the initial arthroscopic findings, researchers found eight Bankart lesions, of which six were repaired, and two Type II superior labrum anterior and posterior (SLAP) lesions that were repaired.

In addition, “there was a high prevalence of rotator cuff tears with 11 of the 18 with full-thickness rotator cuff tears and eight of 18 greater than 5 cm,” Kuhn said.

Researchers further found 4 partial rotator cuff tears, 1 biceps rupture and 2 humeral avulsion of glenohumeral ligament (HAGL) lesions. “Our HAGL numbers were high, although we had a small number in this study, so that could certainly bias the number,” Kuhn said.

All patients had Hill-Sachs lesions in varying sizes and depth, according to the abstract.

Surgical treatment

Surgeons performed arthroscopic rotator cuff repairs but treated the HAGL lesion patients with open surgery. “The surgical procedure taken was based on the patient’s symptoms with an attempt to do anything arthroscopic when possible,” Kuhn said.

He added: “Arthroscopic procedures are less invasive and allow for some return to function for these patients.”

The researchers found that surgery had a high success rate after failed nonoperative treatment. However, “there was some degree of arthrosis noted in most of these patients as we might expect,” Kuhn said.

Researchers plan to evaluate the patients’ shoulder scores at two-year follow-up. “At this point, just anecdotally, patients are doing well,” Kuhn said. “There’ve been … no problems with recurrent instability. [Patients] are returning to their activities and are overall highly satisfied with their results.”

For more information:
Ross G, Kuhn M, Curtis A. Shoulder dislocation over 35 years old: Spectrum of arthroscopic pathoanatomy. #SS-05. Presented at the Arthroscopy Association of North America 25th Annual Meeting. May 18-21, 2006. Hollywood, Fla.