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Can the Need for Future Surgery for Acute Traumatic Anterior Shoulder Dislocation Be Predicted?
Raymond A. Sachs, MD1; Mary Lou Stone, RPT1; Elizabeth Paxton, MA1; Mary Kuney, LVN1; David Lin, MD2
1 Southern California Permanente Medical Group, 250 Travelodge Drive, El Cajon, CA 92020. E-mail address for R.A. Sachs: Raymond.a.sachs@kp.org
2 Muir Orthopedics Specialist, 2405 Shadelandas Drive, Walnut Creek, CA 94597
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Disclosure: The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated.
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Investigation performed at Southern California Permanente Medical Group, San Diego, California

The Journal of Bone and Joint Surgery, Incorporated
J Bone Joint Surg Am, 2007 Aug 01;89(8):1665-1674. doi: 10.2106/JBJS.F.00261
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Abstract

Background: Some surgeons believe that they can identify patients who are at high risk for shoulder redislocation and that these patients are best served by immediate surgical stabilization. This natural history study was performed to examine the validity of this concept and to determine whether it is possible to predict the need for future surgery at the time of the index injury and examination.

Methods: One hundred and thirty-one patients were followed for an average of four years after their first shoulder dislocation. An extensive history was recorded and a thorough physical examination was performed on each patient. Final evaluation consisted of a physical examination, radiographic evaluation, and determination of three outcome measurements.

Results: Twenty-nine (22%) of the 131 patients requested surgery during the follow-up period. There were twenty Bankart repairs and nine rotator cuff repairs. Forty-three patients (33%) had at least one recurrent dislocation. Thirty-nine of these patients were in the group of ninety patients under the age of forty years. Thirty-seven of these thirty-nine patients either participated in contact or collision sports or used the arm at or above chest level in their occupation. Eighteen (49%) of these thirty-seven patients had surgery. Only two of the more sedentary patients had redislocation, and none had surgery. Four (10%) of the forty-one patients over the age of forty had a redislocation, but none required a Bankart repair. However, eight (20%) of the forty-one patients required a rotator cuff repair. Eighty-eight (67%) of the 131 patients never had a redislocation. Their outcome scores were high and equivalent to those of the cohort of patients who had had a successful Bankart repair of an unstable shoulder. Patients who had redislocation but chose to cope with the instability rather than have surgery had lower outcome scores. Twenty-two (51%) of the forty-three patients who had recurrent instability had only one redislocation during the entire follow-up period, whereas some patients had as many as twelve complete redislocations.

Conclusions: Younger patients involved in contact or collision sports or who require overhead occupational use of the arm are more likely to have a redislocation of the shoulder than are their less active peers or older persons. However, even in the highest-risk groups, only approximately half of patients with shoulder redislocation requested surgery within the follow-up period. Early surgery based on the presumption of future dislocations, unhappiness, and disability cannot be justified.

Level of Evidence: Prognostic Level I. See Instructions to Authors for a complete description of levels of evidence.

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    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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    Raymond A. Sachs, M.D.
    Posted on September 24, 2007
    Dr. Sachs et al. respond to Dr. Charalambous et al.
    Kaiser Permanente, Southern CA

    Dr. Charalambos stresses the importance of counseling patients and points out that a thorough discussion of the patient's long term goals is critical to choosing the correct path. Prior to doing our study I would have agreed with this statement wholeheartedly. Now, however, we realize that there are significant limits to our ability to predict the future.

    Dr. Charalambos also points out that a stable shoulder does not imply a fully satisfactory result if it required a lifestyle change. That is true. However, it is equally true that a lifestyle change does not necessarily imply an unsatisfactory result. Some patients are happy to compromise for the sake of avoiding surgery and others are not. Our population with stable shoulders had extremely high outcome scores and these scores were equal to the group of patients who had the best results from surgery. We do not know how many of these patients changed their lifestyle to accommodate their shoulders. We only know that they were highly satisfied.

    We cannot, with any accuracy, predict which specific patients will redislocate or be unhappy. Thus, the validity of counseling is, in our hands, suspect. We, like other surgeons, love to operate and feel that we can "fix" almost anyone. It takes restraint to allow the natural history of shoulder instability to play out. None the less, it appears to us that the wisest course for most patients is to send them to therapy, let them experience their shoulder, and come to their own conclusion about whether or not they need surgery.

    Charalambos P Charalambous
    Posted on September 13, 2007
    The Role of Counselling Patients Who Have Sustained A Shoulder Dislocation
    Shoulder Unit, Stepping Hill hospital, Stockport, Manchester, United Kingdom

    To The Editor:

    We read with interest the article by Sachs et al.(1) We believe that the counselling and information given to patients with regard to the potential benefits and risks of surgery can influence their choice between operative and non-operative treatment. Were all the patients included in this study given standardised counselling with regard to the role of surgical intervention? If so, what was the information given to them?

    As the authors rightly point out,sports participation and overhead activities may influence the development of clinical instability and risk of re-dislocation. Patients may modify their activities following a shoulder dislocation which would in turn influence the risk of subsequent symptomatic instability. Thus simply having a stable shoulder may not imply a fully satisfactory outcome if this required a lifestyle change. Did those patients reporting a stable shoulder change their lifestyle, and if they did were they troubled by such a change?

    We feel that following an initial traumatic dislocation, a thorough discussion must be made with patients as to their expectations and long term aim in sports participation and overhead activities. Those patients wishing to continue with sports activities should be counselled as to the success rate, recovery process and risks associated with surgery, as part of making an informed treatment decision.

    The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated.

    References:

    1. Sachs RA, Stone ML, Paxton E, Kuney M, Lin D. Can the need for future surgery for acute traumatic anterior shoulder dislocation be predicted? J Bone Joint Surg Am 2007;89:1665-1674.

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