Debating Treatment Options for First-time Shoulder Dislocators

    A patient presents as a first-time shoulder dislocator. Is the right course of treatment surgery to stabilize the shoulder? Or is rehabilitation, with a period of immobilization, the way to go?

    At ICJR’s annual Shoulder Course in Las Vegas, Brian J. Cole, MD, MBA, from Rush University Medical Center, and Robin R. Richards, MD, FRCSC, from the University of Toronto, debated the issue.

    Dr. Cole favors surgical treatment to prevent recurrence of dislocation. He said the literature shows:

    There are high recurrence rates in young patients. The 10 most recent papers on young athletes have demonstrated a 50% to 100% chance of a recurrence after the first shoulder dislocation.

    The pathology worsens without surgical intervention. Single dislocations are typically associated with acute pathology; these patients are good candidates for arthroscopic repair. However, as the injury becomes chronic, with multiple recurrences, pathologic changes occur, such as attritional bone loss, degraded tissue, inferior glenohumeral ligament deformation, and arthritis.

    Surgical stabilization is less likely to be successful with recurrence. Wasserstein’s large population study in Ontario reviewed more than 5,900 shoulder stabilizations performed between 2003 and 2008 and found a recurrence rate of only 6.9%. When analyzed for risk factors for failure, the two most important factors were three or more recurrent dislocations prior to the operative stabilization, and age less than 20 years.

    There is a progression of arthrosis with recurrence of dislocation. In a paper by Hovelius & Saeboe that followed 223 shoulders prospectively for up to 25 years, patients with more than 1 recurrence of dislocation had a 40% chance of developing glenohumeral arthritis. Those who had no recurrences had an18% chance of developing glenohumeral arthritis. The authors concluded that recurrent instability was associated with worse post-traumatic arthropathy.

    Operative stabilization is successful. While operative stabilization has been shown to be successful, conversely non-operative treatment has been shown to be unsuccessful. In a 2007 study by Jakobsen et al, 75% of high-risk patients in the non-operative group had unsatisfactory results in 10 years of follow-up, while in the operative group, 85% had good to excellent results.

    Dr. Cole’s presentation can be found here.

    Dr. Richards, who admits he “loves doing shoulder surgery,” believes rehabilitation, rather than surgery, can be the right choice for first-time dislocators. He said these patients:

    • Usually do not have extensive intra-articular injuries
    • Have intact secondary stabilizers
    • Have good potential for healing of the damaged soft tissues

    Recurrence of dislocation, while not uncommon, is not universal, Dr. Richards said, and a rehabilitation program that includes a period of immobilization can be effective.

    While acknowledging that recurrence of dislocation is high in the younger patient population, Dr. Richards said that is not the case for all patients. In a Level I prospective cohort study by Hovelius, 55% of patients overall had a recurrence of dislocation. However, the rate was only 12% for patients over age 30 – which means for most patients over age 30, surgery would have been unnecessary.

    The “textbook” treatment of first-time dislocation is immobilization, Dr. Richards said. In his practice, he uses a “sling and swath” immobilization for 1 month, only allowing the sling to be removed for bathing. In randomized controlled trials, about one third of first-time dislocators treated with immobilization have a recurrence. Newer studies employing immobilization in external rotation suggest even better outcomes.

    Dr. Richards pointed out that non-operative treatment is not without its downsides. The extent of labral injury is more significant with increasing frequency of recurrence, and Dr. Richards emphasized the importance of following first-time dislocations so that surgery can be offered as an option in case of recurrence.

    Dr. Richards’ presentation can be found here.