Age, Hill-Sachs lesions may predict failure of nonoperative shoulder instability treatment
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Younger age, Hill-Sachs lesions on the MRI and degree of soft tissue injury may predict the failure of nonoperative anterior glenohumeral instability treatment, according to an orthopedic surgery resident at the Mayo Clinic - Rochester.
Nicholas C. Duethman, MD, presented findings of his U.S.-based, 10-year follow-up study at the American Orthopaedic Society for Sports Medicine Annual Meeting. The meeting was held virtually.
“We wanted to evaluate the factors that predict conversional surgery after initially being treated nonoperatively,” Duethman said in his presentation. “We studied a population of patients in the Rochester epidemiology project database ... and are representative of the U.S. population based upon figures to the rate. They were treated for anterior shoulder instability between 1991 and 2016,” he added.
Duethman and colleagues defined initial nonoperative treatment success as no conversion to surgery in the study period. Of the 379 patients who were nonoperatively treated in the first 6 months, 300 continued with nonoperative treatment and rehabilitation, while 79 were converted to surgery.
“[Factors associated with conversion to surgery] included continued instability after first evaluation, symptoms necessitating MRI evaluation, soft tissue and bony abnormalities on MRI, two or more subluxations upon first evaluation and age less than 22 [years],” Duethman said.
Specific factors associated with conversion to surgery that presented on MRI included anteroinferior labral tears, Hill-Sachs lesions and glenohumeral cartilage injuries, according to the study.
“Overall, 59% of patients experienced multiple instability events either prior to presentation or after. In the group that converted to surgery following 6 months of nonoperative treatment (group B), 86% were experiencing recurrent instability, and this decreased to 10% after surgical treatment,” Duethman said. “In the group treated definitively without surgical treatment (group A), recurrent instability was 22%. Combined recurrent instability after initial nonoperative treatment in groups A and B was 35%,” he added.
Duethman concluded that most patients treated nonoperatively within the first 6 months go on to definitive nonoperative treatment.
“In those who experienced recurrent instability, surgical intervention is very successful at lowering recurrent instability rates.” he said. “The final follow-up – 5% to 10% will report moderate to severe pain despite non-surgical or surgical intervention, and 13% will have glenohumeral arthritis at midterm follow-up,” Duethman added.
Perspective
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James P. Bradley, MD
Duethman and colleagues evaluated predictors for failure of nonoperative management after anterior shoulder instability. The authors found factors associated with need for surgical management included young age, glenohumeral cartilage lesions, Hill-Sachs lesions, anteroinferior labral tears, and two or more subluxations events prior to initial evaluation.
Anterior shoulder instability, especially in young athletes, presents a challenging treatment option for an orthopedic surgeon. Although initial nonoperative management is appropriate for many patients, there are certain patients that require more aggressive early surgical intervention. This study highlights important findings that should be considered in the workup for anterior shoulder instability. As this study concluded, predictors of failure of nonoperative management include age less than 22 years, multiple subluxation events, and concomitant bony and soft tissue injury. We agree that definitive treatment should therefore be individualized to each patient, taking into consideration the salient risk factors of age, activity level, bony and soft tissue injury on MRI, prior history of subluxations or dislocations, and future goals. Physicians should be cognizant and look for these issues as early surgical intervention may be warranted in patients with these risk factors.
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Duethman NC, et al. Presentation 52. Presented at: American Orthopaedic Society for Sports Medicine Annual Meeting; July 8-9, 2020 (virtual meeting).
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