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Should first time anterior shoulder dislocations be surgically stabilized?
Point Counterpoint
Should First Time Anterior Shoulder Dislocations Be Surgically Stabilized? F. Alan Barber, M.D., Richard K. N. Ryu, M.D., and Joseph C. Tauro, M.D.
T
his point counterpoint debate considers the issue, should first time traumatic anterior shoulder dislocators be surgically (arthroscopically) stabilized? Drs. Ryu and Tauro advance opposing points of view. While disagreeing on the treatment, there are areas of agreement. Both recognize that age plays a significant role in the risk of recurrence. Younger patients are far more likely to redislocate than older patients. This requires the surgeon to decide what “failure rate” for nonoperative treatment is unacceptable. Where is the balance between watchful waiting and intervention to avoid further damage? We would certainly be concerned about a surgical treatment that had a 30% to 40% failure rate, but would that apply to nonoperative treatments too? Next, the potential for further soft-tissue or bony damage from subsequent dislocations must be considered. Unfortunately, there are no reports that provide any insight on how much additional damage is done with a second, third, or fourth dislocation. This must also be balanced by the time to failure. If failure (redislocation) occurs 2 years after a 16-year-old’s initial dislocation, is the success of a subsequent surgery greater at 18 years than it would have been at 16 years of age? Even if that is true, is this advantage outweighed by the risks of additional glenohumeral damage that might occur during the subsequent dislocation? Finally, the technique must be considered, including the success rate and risks to the patient. Clearly the
patient’s activities play a role here. Neither side disagrees that the collision athlete has a significant risk of redislocation, but what about the young person who does not participate in these activities or who is willing to change sports? What is the best approach in that instance? Will immediate surgery improve the quality of life over a patient treated without surgery? The debate by Drs. Ryu and Tauro gives us some insight into this complex subject and should assist surgeons in making these choices. F. ALAN BARBER, M.D. Plano, Texas
WHY ARTHROSCOPIC STABILIZATION FOR FIRST TIME ANTERIOR DISLOCATION MAKES SENSE The argument supporting arthroscopic stabilization for a first-time anterior shoulder dislocation is a cogent one. As with any successful arthroscopic procedure, proper patient selection is critical. There exists compelling evidence that a subset of first-time dislocators experience a recurrence rate which is unacceptably high. Numerous studies1-10 have highlighted and defined this group to consist of the 18- to 30-year-old athlete with a dominant-side shoulder injury participating in a collision or overhand sport. Risk
Address corresponence and reprint requests to Richard Ryu, M.D., 533 E. Micheltorena St, Santa Barbara, CA 93103; Joseph Tauro, M.D., Ocean County Sports Medicine Center, 9 Hospital Dr, Toms River, NJ 08755, U.S.A. © 2003 by the Arthroscopy Association of North America 0749-8063/03/1903-3664$30.00/0 doi:10.1053/jars.2003.50085
Stratified studies assessing risk have revealed recurrence rates ranging from 17% to 96% with a mean of 67%. McLaughlin and MacLellan11 reported a 90% recurrence rate in those younger than 20 years and Rowe9 documented a 94% redislocation rate in the same population. Henry and Genung5 as well as Ar-
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 19, No 3 (March), 2003: pp 305-309
305
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F. A. BARBER, R. RYU, AND J. TAURO
ciero et al.2 also reported recurrence rates approaching 90% in this at-risk population. Additionally, 2 prospective and randomized studies, evaluating the benefit of immediate stabilization compared with “traditional” nonoperative methods both confirmed the high redislocation rate as well as the benefit of early intervention. Kirkley et al.12 described a 47% recurrence rate in those treated with nonoperative measures compared with a recurrence rate of 15% following immediate anterior stabilization. Bottoni et al.,3 again evaluating this high risk subset of patients, discovered a recurrence rate of 79% in those treated with traditional methods compared with an 11% redislocation incidence after immediate stabilization.
attenuation, rotator cuff injury, and damage to the superior labrum and biceps anchor (Fig 1). Quality of Life In 1999 Kirkley et al.12 reported on the diseasespecific quality of life as it pertains to shoulder instability utilizing the WOSI (Western Ontario Shoulder Instability) index. There were statistically significant quality of life improvements in the stabilized group versus those treated nonoperatively. The improvements included all 4 domains: physical symptoms and pain, sport and sport function, lifestyle and social functioning, and emotional well-being. Rationale
Dislocation Pathology In addition to the very high recurrence rate within this subset of instability patients, the associated dislocation pathology is prominent. Baker13 reported that, after an acute first time anterior dislocation, an 87% incidence of Bankart lesions was noted with 64% exhibiting a Hill-Sachs bony injury with an 18% incidence of both capsular tearing and rotator cuff injuries. Taylor and Arciero14 also documented similar findings in their study, with a 90% Bankart and HillSach’s incidence and SLAP pathology in 10% as well. Although there are no current studies that have longitudinally followed recurrent dislocators and subsequent pathology, my experience, and I think that of many others, would confirm that progressive intraarticular pathology is common following multiple dislocations. This would include greater bone loss, both humeral head and anterior glenoid, as well as capsular
Three major criteria supporting immediate stabilization have been identified: 1. The risk of recurrence is unacceptably high in the young, athletic population. 2. Significant and progressive soft-tissue and bony trauma are sustained with recurrent instability episodes. 3. The quality of life is clearly improved with early stabilization compared with the nonoperative group. Is early intervention in the first-time anterior shoulder dislocator analogous to the patient with an acute anterior cruciate ligament tear? With regard to recurrence, progressive tissue damage, and quality of life in the at-risk group, the answer would be a resounding yes. This naturally begs the question, “Why are we willing to intervene early for an anterior cruciate lig-
FIGURE 1. (A) Acute Bankart lesion. Note the robust nature of the labrum and glenoid. (B) Chronic Bankart lesion with attenuation, tissue loss, and hemosiderin staining from recurrent hemarthroses.
POINT COUNTERPOINT ament tear, yet unwilling to immediately stabilize the at-risk patient with anterior instability?” Perhaps it is because the anterior cruciate ligament injury is more common and that, individually, all of us have greater experience with this injury. Our results with surgery are predictable and our surgical techniques are refined and very user-friendly. Why don’t we routinely intervene for the first time dislocator in the high-risk category? Perhaps because the injury is less commonly encountered, and that convincing follow-up, especially in the at-risk group, may be lacking. Could it be that the reported success rate with arthroscopic stabilization continues to be worrisome with failure rates averaging 15% to 20%?1,3,4,9,15 I believe it is safe to say that arthroscopic shoulder stabilization is a technique in evolution and is not yet “user-friendly.” Finally one does not want to garner the reputation as being an overly aggressive surgeon in his or her community. It is my contention that, after the initial dislocation, conditions for surgical intervention are optimal. The inflammatory reaction and ensuing enzymatic cascade create a healing environment, ideal for soft-tissue repair. Although bony injury may have occurred, there is a much lower risk of significant bony deficiencies, which have been associated with a much higher failure rate.16 There is less risk of capsular elongation, which occurs with recurrent instability and may indeed be one of the primary causes for arthroscopic failures.17 The reason we do not immediately stabilize the first-time dislocator in the subset of high-risk patients is not a philosophical issue, but rather a technical one. If an arthroscopic stabilization were associated with a 95% success rate and could be performed with ease and reproducibly, I believe that early stabilization would be readily adopted as a routine intervention for the at-risk population. The key concept in the argument espousing immediate stabilization for first-time anterior dislocators, much like the anterior cruciate ligament algorithm, is one of selection. Certainly not every person with a first time dislocation requires surgery, but there is a subset of patients in whom immediate stabilization is the most appropriate course of intervention. Permit me to summarize: 1. First-time anterior shoulder dislocators in the high-risk recurrence group need immediate stabilization. Further soft-tissue and bone damage is avoided, and the risk of a higher failure rate in subsequent arthroscopic intervention is less-
307
ened. In the immediate stabilization group, quality of life issues are clearly enhanced. 2. We need to improve our results with arthroscopic stabilization. 3. Numerous skilled and experienced arthroscopic surgeons16,18-21 have achieved single-digit recurrence rates, and it is simply a matter of time and innovation before the orthopaedic community at large achieves the same level of success. There is little doubt that we will make technical advances that will in turn make arthroscopic stabilization reliable and user-friendly. For this reason, it is imperative that we not confuse sound surgical rationale with technical issues when deciding on the most appropriate treatment for our patients. RICHARD K. N. RYU, M.D. Santa Barbara, California REFERENCES 1. Arciero RA, Taylor DC, Snyder RJ, Uhorchak JM. Arthroscopic bioabsorbable tack stabilization of initial anterior shoulder dislocations: A preliminary report. Arthroscopy 1995;11: 410-417. 2. Arciero RA, Wheeler JH, Ryan JB, McBride JT. Arthroscopic Bankart repair versus non-operative treatment for acute, initial anterior shoulder dislocations. Am J Sports Med 1994;22:589594. 3. Bottoni CR, DeBernardino TM, Wilckens JH, D’Alleyrand JC. A prospective randomized evaluation of arthroscopic stabilization versus nonoperative treatment of acute, traumatic, firsttime shoulder dislocation. Arthroscopy 2000;16:432. 4. DeBernardino TM, Arciero RA, Taylor DC. Arthroscopic stabilization of acute initial anterior shoulder dislocation: The West Point experience. J Soc Orthop Assoc 1996;5:236-271. 5. Henry JH, Genung JA. Natural history of glenohumeral dislocation-revisited. Am J Sports Med 1982;10:135-137. 6. Hovelius L, Augustini BG, Fredin H, Johansson O, Norlin R, Thorling J. Primary anterior dislocation of the shoulder in young patients. A ten year prospective study. J Bone Joint Surg Am 1996;78:1677-1684. 7. Kralinger FS, Golser K, Wischatta R, Wambacher M, Sperner G. Predicting recurrence after primary anterior shoulder dislocation. Am J Sports Med 2002;30:116-120. 8. Marans HJ, Angel KR, Schemitsch EH, Wedge JH. The fate of traumatic anterior dislocation of the shoulder in children. J Bone Joint Surg Am 1992;74:1242-1244. 9. Rowe CR. Acute and recurrent dislocations of the shoulder. Orthop Clin North Am 1980;11:253-270. 10. Simonet WT, Cofield RH. Prognosis in anterior shoulder dislocation. Am J Sports Med 1984;10:19-24. 11. McLaughlin HL, MacLellan DI. Recurrent anterior dislocation of the shoulder. J Trauma 1967;7:191-201. 12. Kirkley A, Griffin S, Richards C, Miniaci A, Mohtadi N. Prospective randomized clinical trial comparing the effectiveness of immediate arthroscopic stabilization versus immobilization and rehabilitation in first traumatic anterior dislocations of the shoulder. Arthroscopy 1999;15:507-514. 13. Baker CL. Arthroscopic evaluation of acute initial shoulder dislocations. Instr Course Lect 1996;45:83-89.
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F. A. BARBER, R. RYU, AND J. TAURO
14. Taylor DC, Arciero RA. Pathologic changes associated with shoulder dislocations. Arthroscopic and physical examination findings in first-time traumatic anterior dislocations. Am J Sports Med 1997;25:306-311. 15. Nelson, BJ, Arciero RA. Arthroscopic management of glenohumeral instability Am J Sports Med 2000;28:602-614. 16. Burkhart SS, De Beer JF. Traumatic glenohumeral bone defects and their relationship to failure of arthroscopic Bankart repairs: Significance of the inverted-pear glenoid and the humeral engaging Hill-Sachs lesion. Arthroscopy 2000;6:677694. 17. Levin WN, Flatow EL. The pathophysiology of shoulder instability. Am J Sports Med 2000;28:910-917. 18. Bacilla P, Field LD, Savoie FH. Arthroscopic Bankart repair in a high demand patient population. Arthroscopy 1997;13:51-60. 19. Kim SH, Ha KI, et al. Suture anchor capsulorrhaphy in the traumatic anterior shoulder instability: Open versus arthroscopic technique. Presented at the Annual Meeting of the Arthroscopy Association of North America, Miami, FL, 2000. 20. Romeo AA, Carreira D. Outcome analysis of arthroscopic Bankart repair: minimum two year follow-up. Presented at the Annual Meeting of the Arthroscopy Association of North America, Miami, FL, 2000. 21. Mishra DK, Fanton GS. Two-year outcome of arthroscopic Bankart repair and electrothermal-assisted capsulorraphy for recurrent traumatic anterior shoulder instability. Arthroscopy 2001;17:844-849.
ARTHROSCOPIC REPAIR IN FIRST TIME DISLOCATORS IS NOT NECESSARY One of the main arguments for fixing first-time dislocators is the high recurrence rate reported by some authors. So, let us begin with a review of the literature on recurrence rates after first time dislocation. There is great variability in the published studies depending on the activity level and age of the patients. Studies by Wheeler et al.1 and Arciero et al.2 on cadets have shown recurrence rates between 80% and 92%, but a study of midshipmen by Aronen and Regan showed only a 25% recurrence rate with aggressive rehabilitation.3 It should be noted that these were relatively small studies. In a larger group of 256 patients who were first time dislocators, Hovelius4 found a 55% recurrence rate in patients under 22 years of age, a 37% recurrence rate in patients 23 to 29 years old, and a 12% recurrence rate in patients over 30 years. Simonet and Cofield5 found a similar age-related trend with similar recurrence rates in a study of 116 patients. In this study, patients over 40 had no recurrences. The overall redislocation rate was 82% in athletes but only 30% in nonathletes. Therefore, based on our review of the literature, there is certainly no indication for surgery on first-time dislocators who are over 30 years of age and in younger patients who are not athletic. Do recurrent dislocations cause more complex re-
constructive problems or higher recurrence rates if arthroscopic repair is delayed? The first dislocation causes a capsular injury (either a Bankart lesion and/or plastic deformation of the capsule). Recurrent dislocations are a result of this initial injury and there is no evidence to suggest that they cause any further softtissue injury. Larger Hill-Sachs lesions or glenoid erosions have been shown to lead to increased failure rates after arthroscopic repair. It would stand to reason that many repetitive dislocations could cause greater bone damage and thus higher failure rates. However, after an extensive review of the literature, there is no evidence that 1 or 2 recurrent dislocations cause enough damage to compromise a delayed repair. Arthroscopic stabilization procedures are technically demanding and many orthopaedic surgeons are not sufficiently trained to perform them. Even among experienced surgeons, significant failure rates have been reported. Walch et al.6 reported 58% fair and poor results with transglenoid technique and Grana et al.7 reported a 44% failure rate. Even with newer suture anchor techniques, Koss et al.8 reported a 30% failure rate. Roberts et al.9 reported a 70% recurrence rate with suture anchors and a 38% recurrence rate with tacks in contact athletes. It is true that some authors report better results. Arciero’s latest study reported an overall 12% failure rate.10 In our own study using the capsular split/shift technique, we experienced a 7% failure rate in chronic dislocators.11 Certainly, an arthroscopic repair does not guarantee success. If good results can be obtained even in chronic dislocators, why operate on some patients who may not need surgery? Sometimes it is hard not to feel like a car salesman when recommending an operation to a new patient. The orthopaedic surgeon down the road will probably not recommend an acute repair. God forbid you get a recurrence or a complication! In conclusion, I try to present the facts and statistics to my patients when they come to me after a first dislocation. The older, nonathletic patients I definitely lead away from acute repair (that does not mean I don’t look for a rotator cuff tear in the older patients). In the athlete under 20, I admit it, if they want an acute repair, I will do it. Most will wait to see if they get a recurrence. It’s a safe call for them. . .and the surgeon!
JOSEPH C. TAURO, M.D. Toms River, New Jersey
POINT COUNTERPOINT REFERENCES 1. Wheeler JH, Ryan JB, Arciero RA, Molinari RN. Arthroscopic versus nonoperative treatment of acute shoulder dislocations in young athletes. Arthroscopy 1989;5:213-217. 2. Arciero RA, Wheeler JH. Arthroscopic Bankart repair versus nonoperative treatment for acute, initial anterior shoulder dislocations. Am J Sports Med 1994;22:589-594. 3. Aronen JG, Regan K. Decreasing the incidence of recurrence of first time anterior shoulder dislocations with rehabilitation. Am J Sports Med 1984;12:283-291. 4. Hovelius L. Anterior dislocation of the shoulder in teenagers and young adults. J Bone Joint Surg Am 1987;69:393-399. 5. Simonet WT, Cofield RH. Prognosis in anterior shoulder dislocation. Am J Sports Med 1984;12:19-24. 6. Walch G, Boileau P, Levigne C, Mandrino A, Neyret P, Donell S. Arthroscopic stabilization for recurrent anterior shoulder
7. 8. 9.
10.
11.
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dislocation: Results of 59 cases. Arthroscopy 1995;11:173179. Grana WA, Buckley PD, Yates CK. Arthroscopic Bankart suture repair. Am J Sports Med 1993;21:348-353. Koss S, Richmond JC, Woodward JS. Two- to five-year follow-up of arthroscopic Bankart reconstruction using a suture anchor technique. Am J Sports Med 1997;25:809-812. Roberts SN, Taylor DE, Brown JN, Hayes MG, Saies A. Open and arthroscopic techniques for the treatment of traumatic anterior shoulder instability in Australian rules football players. J Shoulder Elbow Surg 1999;8:403-409. DeBernardino TM, Arciero RA, Taylor DC, Uhorchak JM. Prospective evaluation of arthroscopic stabilization of acute, initial anterior shoulder dislocations in young athletes. Two- to five-year follow-up. Am J Sports Med 2001;29:586-592. Tauro JC. Arthroscopic inferior capsular split and advancement for anterior and inferior shoulder instability. Arthroscopy 2000;16:451-456.
Should First Time Anterior Shoulder Dislocations Be Surgically Stabilized? F. Alan Barber, M.D., Richard K. N. Ryu, M.D., and Joseph C. Tauro, M.D.
T
his point counterpoint debate considers the issue, should first time traumatic anterior shoulder dislocators be surgically (arthroscopically) stabilized? Drs. Ryu and Tauro advance opposing points of view. While disagreeing on the treatment, there are areas of agreement. Both recognize that age plays a significant role in the risk of recurrence. Younger patients are far more likely to redislocate than older patients. This requires the surgeon to decide what “failure rate” for nonoperative treatment is unacceptable. Where is the balance between watchful waiting and intervention to avoid further damage? We would certainly be concerned about a surgical treatment that had a 30% to 40% failure rate, but would that apply to nonoperative treatments too? Next, the potential for further soft-tissue or bony damage from subsequent dislocations must be considered. Unfortunately, there are no reports that provide any insight on how much additional damage is done with a second, third, or fourth dislocation. This must also be balanced by the time to failure. If failure (redislocation) occurs 2 years after a 16-year-old’s initial dislocation, is the success of a subsequent surgery greater at 18 years than it would have been at 16 years of age? Even if that is true, is this advantage outweighed by the risks of additional glenohumeral damage that might occur during the subsequent dislocation? Finally, the technique must be considered, including the success rate and risks to the patient. Clearly the
patient’s activities play a role here. Neither side disagrees that the collision athlete has a significant risk of redislocation, but what about the young person who does not participate in these activities or who is willing to change sports? What is the best approach in that instance? Will immediate surgery improve the quality of life over a patient treated without surgery? The debate by Drs. Ryu and Tauro gives us some insight into this complex subject and should assist surgeons in making these choices. F. ALAN BARBER, M.D. Plano, Texas
WHY ARTHROSCOPIC STABILIZATION FOR FIRST TIME ANTERIOR DISLOCATION MAKES SENSE The argument supporting arthroscopic stabilization for a first-time anterior shoulder dislocation is a cogent one. As with any successful arthroscopic procedure, proper patient selection is critical. There exists compelling evidence that a subset of first-time dislocators experience a recurrence rate which is unacceptably high. Numerous studies1-10 have highlighted and defined this group to consist of the 18- to 30-year-old athlete with a dominant-side shoulder injury participating in a collision or overhand sport. Risk
Address corresponence and reprint requests to Richard Ryu, M.D., 533 E. Micheltorena St, Santa Barbara, CA 93103; Joseph Tauro, M.D., Ocean County Sports Medicine Center, 9 Hospital Dr, Toms River, NJ 08755, U.S.A. © 2003 by the Arthroscopy Association of North America 0749-8063/03/1903-3664$30.00/0 doi:10.1053/jars.2003.50085
Stratified studies assessing risk have revealed recurrence rates ranging from 17% to 96% with a mean of 67%. McLaughlin and MacLellan11 reported a 90% recurrence rate in those younger than 20 years and Rowe9 documented a 94% redislocation rate in the same population. Henry and Genung5 as well as Ar-
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 19, No 3 (March), 2003: pp 305-309
305
306
F. A. BARBER, R. RYU, AND J. TAURO
ciero et al.2 also reported recurrence rates approaching 90% in this at-risk population. Additionally, 2 prospective and randomized studies, evaluating the benefit of immediate stabilization compared with “traditional” nonoperative methods both confirmed the high redislocation rate as well as the benefit of early intervention. Kirkley et al.12 described a 47% recurrence rate in those treated with nonoperative measures compared with a recurrence rate of 15% following immediate anterior stabilization. Bottoni et al.,3 again evaluating this high risk subset of patients, discovered a recurrence rate of 79% in those treated with traditional methods compared with an 11% redislocation incidence after immediate stabilization.
attenuation, rotator cuff injury, and damage to the superior labrum and biceps anchor (Fig 1). Quality of Life In 1999 Kirkley et al.12 reported on the diseasespecific quality of life as it pertains to shoulder instability utilizing the WOSI (Western Ontario Shoulder Instability) index. There were statistically significant quality of life improvements in the stabilized group versus those treated nonoperatively. The improvements included all 4 domains: physical symptoms and pain, sport and sport function, lifestyle and social functioning, and emotional well-being. Rationale
Dislocation Pathology In addition to the very high recurrence rate within this subset of instability patients, the associated dislocation pathology is prominent. Baker13 reported that, after an acute first time anterior dislocation, an 87% incidence of Bankart lesions was noted with 64% exhibiting a Hill-Sachs bony injury with an 18% incidence of both capsular tearing and rotator cuff injuries. Taylor and Arciero14 also documented similar findings in their study, with a 90% Bankart and HillSach’s incidence and SLAP pathology in 10% as well. Although there are no current studies that have longitudinally followed recurrent dislocators and subsequent pathology, my experience, and I think that of many others, would confirm that progressive intraarticular pathology is common following multiple dislocations. This would include greater bone loss, both humeral head and anterior glenoid, as well as capsular
Three major criteria supporting immediate stabilization have been identified: 1. The risk of recurrence is unacceptably high in the young, athletic population. 2. Significant and progressive soft-tissue and bony trauma are sustained with recurrent instability episodes. 3. The quality of life is clearly improved with early stabilization compared with the nonoperative group. Is early intervention in the first-time anterior shoulder dislocator analogous to the patient with an acute anterior cruciate ligament tear? With regard to recurrence, progressive tissue damage, and quality of life in the at-risk group, the answer would be a resounding yes. This naturally begs the question, “Why are we willing to intervene early for an anterior cruciate lig-
FIGURE 1. (A) Acute Bankart lesion. Note the robust nature of the labrum and glenoid. (B) Chronic Bankart lesion with attenuation, tissue loss, and hemosiderin staining from recurrent hemarthroses.
POINT COUNTERPOINT ament tear, yet unwilling to immediately stabilize the at-risk patient with anterior instability?” Perhaps it is because the anterior cruciate ligament injury is more common and that, individually, all of us have greater experience with this injury. Our results with surgery are predictable and our surgical techniques are refined and very user-friendly. Why don’t we routinely intervene for the first time dislocator in the high-risk category? Perhaps because the injury is less commonly encountered, and that convincing follow-up, especially in the at-risk group, may be lacking. Could it be that the reported success rate with arthroscopic stabilization continues to be worrisome with failure rates averaging 15% to 20%?1,3,4,9,15 I believe it is safe to say that arthroscopic shoulder stabilization is a technique in evolution and is not yet “user-friendly.” Finally one does not want to garner the reputation as being an overly aggressive surgeon in his or her community. It is my contention that, after the initial dislocation, conditions for surgical intervention are optimal. The inflammatory reaction and ensuing enzymatic cascade create a healing environment, ideal for soft-tissue repair. Although bony injury may have occurred, there is a much lower risk of significant bony deficiencies, which have been associated with a much higher failure rate.16 There is less risk of capsular elongation, which occurs with recurrent instability and may indeed be one of the primary causes for arthroscopic failures.17 The reason we do not immediately stabilize the first-time dislocator in the subset of high-risk patients is not a philosophical issue, but rather a technical one. If an arthroscopic stabilization were associated with a 95% success rate and could be performed with ease and reproducibly, I believe that early stabilization would be readily adopted as a routine intervention for the at-risk population. The key concept in the argument espousing immediate stabilization for first-time anterior dislocators, much like the anterior cruciate ligament algorithm, is one of selection. Certainly not every person with a first time dislocation requires surgery, but there is a subset of patients in whom immediate stabilization is the most appropriate course of intervention. Permit me to summarize: 1. First-time anterior shoulder dislocators in the high-risk recurrence group need immediate stabilization. Further soft-tissue and bone damage is avoided, and the risk of a higher failure rate in subsequent arthroscopic intervention is less-
307
ened. In the immediate stabilization group, quality of life issues are clearly enhanced. 2. We need to improve our results with arthroscopic stabilization. 3. Numerous skilled and experienced arthroscopic surgeons16,18-21 have achieved single-digit recurrence rates, and it is simply a matter of time and innovation before the orthopaedic community at large achieves the same level of success. There is little doubt that we will make technical advances that will in turn make arthroscopic stabilization reliable and user-friendly. For this reason, it is imperative that we not confuse sound surgical rationale with technical issues when deciding on the most appropriate treatment for our patients. RICHARD K. N. RYU, M.D. Santa Barbara, California REFERENCES 1. Arciero RA, Taylor DC, Snyder RJ, Uhorchak JM. Arthroscopic bioabsorbable tack stabilization of initial anterior shoulder dislocations: A preliminary report. Arthroscopy 1995;11: 410-417. 2. Arciero RA, Wheeler JH, Ryan JB, McBride JT. Arthroscopic Bankart repair versus non-operative treatment for acute, initial anterior shoulder dislocations. Am J Sports Med 1994;22:589594. 3. Bottoni CR, DeBernardino TM, Wilckens JH, D’Alleyrand JC. A prospective randomized evaluation of arthroscopic stabilization versus nonoperative treatment of acute, traumatic, firsttime shoulder dislocation. Arthroscopy 2000;16:432. 4. DeBernardino TM, Arciero RA, Taylor DC. Arthroscopic stabilization of acute initial anterior shoulder dislocation: The West Point experience. J Soc Orthop Assoc 1996;5:236-271. 5. Henry JH, Genung JA. Natural history of glenohumeral dislocation-revisited. Am J Sports Med 1982;10:135-137. 6. Hovelius L, Augustini BG, Fredin H, Johansson O, Norlin R, Thorling J. Primary anterior dislocation of the shoulder in young patients. A ten year prospective study. J Bone Joint Surg Am 1996;78:1677-1684. 7. Kralinger FS, Golser K, Wischatta R, Wambacher M, Sperner G. Predicting recurrence after primary anterior shoulder dislocation. Am J Sports Med 2002;30:116-120. 8. Marans HJ, Angel KR, Schemitsch EH, Wedge JH. The fate of traumatic anterior dislocation of the shoulder in children. J Bone Joint Surg Am 1992;74:1242-1244. 9. Rowe CR. Acute and recurrent dislocations of the shoulder. Orthop Clin North Am 1980;11:253-270. 10. Simonet WT, Cofield RH. Prognosis in anterior shoulder dislocation. Am J Sports Med 1984;10:19-24. 11. McLaughlin HL, MacLellan DI. Recurrent anterior dislocation of the shoulder. J Trauma 1967;7:191-201. 12. Kirkley A, Griffin S, Richards C, Miniaci A, Mohtadi N. Prospective randomized clinical trial comparing the effectiveness of immediate arthroscopic stabilization versus immobilization and rehabilitation in first traumatic anterior dislocations of the shoulder. Arthroscopy 1999;15:507-514. 13. Baker CL. Arthroscopic evaluation of acute initial shoulder dislocations. Instr Course Lect 1996;45:83-89.
308
F. A. BARBER, R. RYU, AND J. TAURO
14. Taylor DC, Arciero RA. Pathologic changes associated with shoulder dislocations. Arthroscopic and physical examination findings in first-time traumatic anterior dislocations. Am J Sports Med 1997;25:306-311. 15. Nelson, BJ, Arciero RA. Arthroscopic management of glenohumeral instability Am J Sports Med 2000;28:602-614. 16. Burkhart SS, De Beer JF. Traumatic glenohumeral bone defects and their relationship to failure of arthroscopic Bankart repairs: Significance of the inverted-pear glenoid and the humeral engaging Hill-Sachs lesion. Arthroscopy 2000;6:677694. 17. Levin WN, Flatow EL. The pathophysiology of shoulder instability. Am J Sports Med 2000;28:910-917. 18. Bacilla P, Field LD, Savoie FH. Arthroscopic Bankart repair in a high demand patient population. Arthroscopy 1997;13:51-60. 19. Kim SH, Ha KI, et al. Suture anchor capsulorrhaphy in the traumatic anterior shoulder instability: Open versus arthroscopic technique. Presented at the Annual Meeting of the Arthroscopy Association of North America, Miami, FL, 2000. 20. Romeo AA, Carreira D. Outcome analysis of arthroscopic Bankart repair: minimum two year follow-up. Presented at the Annual Meeting of the Arthroscopy Association of North America, Miami, FL, 2000. 21. Mishra DK, Fanton GS. Two-year outcome of arthroscopic Bankart repair and electrothermal-assisted capsulorraphy for recurrent traumatic anterior shoulder instability. Arthroscopy 2001;17:844-849.
ARTHROSCOPIC REPAIR IN FIRST TIME DISLOCATORS IS NOT NECESSARY One of the main arguments for fixing first-time dislocators is the high recurrence rate reported by some authors. So, let us begin with a review of the literature on recurrence rates after first time dislocation. There is great variability in the published studies depending on the activity level and age of the patients. Studies by Wheeler et al.1 and Arciero et al.2 on cadets have shown recurrence rates between 80% and 92%, but a study of midshipmen by Aronen and Regan showed only a 25% recurrence rate with aggressive rehabilitation.3 It should be noted that these were relatively small studies. In a larger group of 256 patients who were first time dislocators, Hovelius4 found a 55% recurrence rate in patients under 22 years of age, a 37% recurrence rate in patients 23 to 29 years old, and a 12% recurrence rate in patients over 30 years. Simonet and Cofield5 found a similar age-related trend with similar recurrence rates in a study of 116 patients. In this study, patients over 40 had no recurrences. The overall redislocation rate was 82% in athletes but only 30% in nonathletes. Therefore, based on our review of the literature, there is certainly no indication for surgery on first-time dislocators who are over 30 years of age and in younger patients who are not athletic. Do recurrent dislocations cause more complex re-
constructive problems or higher recurrence rates if arthroscopic repair is delayed? The first dislocation causes a capsular injury (either a Bankart lesion and/or plastic deformation of the capsule). Recurrent dislocations are a result of this initial injury and there is no evidence to suggest that they cause any further softtissue injury. Larger Hill-Sachs lesions or glenoid erosions have been shown to lead to increased failure rates after arthroscopic repair. It would stand to reason that many repetitive dislocations could cause greater bone damage and thus higher failure rates. However, after an extensive review of the literature, there is no evidence that 1 or 2 recurrent dislocations cause enough damage to compromise a delayed repair. Arthroscopic stabilization procedures are technically demanding and many orthopaedic surgeons are not sufficiently trained to perform them. Even among experienced surgeons, significant failure rates have been reported. Walch et al.6 reported 58% fair and poor results with transglenoid technique and Grana et al.7 reported a 44% failure rate. Even with newer suture anchor techniques, Koss et al.8 reported a 30% failure rate. Roberts et al.9 reported a 70% recurrence rate with suture anchors and a 38% recurrence rate with tacks in contact athletes. It is true that some authors report better results. Arciero’s latest study reported an overall 12% failure rate.10 In our own study using the capsular split/shift technique, we experienced a 7% failure rate in chronic dislocators.11 Certainly, an arthroscopic repair does not guarantee success. If good results can be obtained even in chronic dislocators, why operate on some patients who may not need surgery? Sometimes it is hard not to feel like a car salesman when recommending an operation to a new patient. The orthopaedic surgeon down the road will probably not recommend an acute repair. God forbid you get a recurrence or a complication! In conclusion, I try to present the facts and statistics to my patients when they come to me after a first dislocation. The older, nonathletic patients I definitely lead away from acute repair (that does not mean I don’t look for a rotator cuff tear in the older patients). In the athlete under 20, I admit it, if they want an acute repair, I will do it. Most will wait to see if they get a recurrence. It’s a safe call for them. . .and the surgeon!
JOSEPH C. TAURO, M.D. Toms River, New Jersey
POINT COUNTERPOINT REFERENCES 1. Wheeler JH, Ryan JB, Arciero RA, Molinari RN. Arthroscopic versus nonoperative treatment of acute shoulder dislocations in young athletes. Arthroscopy 1989;5:213-217. 2. Arciero RA, Wheeler JH. Arthroscopic Bankart repair versus nonoperative treatment for acute, initial anterior shoulder dislocations. Am J Sports Med 1994;22:589-594. 3. Aronen JG, Regan K. Decreasing the incidence of recurrence of first time anterior shoulder dislocations with rehabilitation. Am J Sports Med 1984;12:283-291. 4. Hovelius L. Anterior dislocation of the shoulder in teenagers and young adults. J Bone Joint Surg Am 1987;69:393-399. 5. Simonet WT, Cofield RH. Prognosis in anterior shoulder dislocation. Am J Sports Med 1984;12:19-24. 6. Walch G, Boileau P, Levigne C, Mandrino A, Neyret P, Donell S. Arthroscopic stabilization for recurrent anterior shoulder
7. 8. 9.
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dislocation: Results of 59 cases. Arthroscopy 1995;11:173179. Grana WA, Buckley PD, Yates CK. Arthroscopic Bankart suture repair. Am J Sports Med 1993;21:348-353. Koss S, Richmond JC, Woodward JS. Two- to five-year follow-up of arthroscopic Bankart reconstruction using a suture anchor technique. Am J Sports Med 1997;25:809-812. Roberts SN, Taylor DE, Brown JN, Hayes MG, Saies A. Open and arthroscopic techniques for the treatment of traumatic anterior shoulder instability in Australian rules football players. J Shoulder Elbow Surg 1999;8:403-409. DeBernardino TM, Arciero RA, Taylor DC, Uhorchak JM. Prospective evaluation of arthroscopic stabilization of acute, initial anterior shoulder dislocations in young athletes. Two- to five-year follow-up. Am J Sports Med 2001;29:586-592. Tauro JC. Arthroscopic inferior capsular split and advancement for anterior and inferior shoulder instability. Arthroscopy 2000;16:451-456.