TO THE EDITOR:
Although most of the information in "Primary Anterior Dislocation of the Shoulder in Young Patients. A Ten-Year Prospective Study" (78-A: 1677—1684, Nov. 1996), by Hovelius et al., was extremely helpful, I think that some of the conclusions were not justified by the data presented. The authors stated that only "one-third of the patients who had had the initial dislocation before the age of thirty years needed operative stabilization." The authors admitted that the criteria for recommendation of an operation were likely varied and not specifically known.
Figure 4 shows that, in the younger age-groups (those twenty-five years old or less), the prevalence of recurrent instability (at least two redislocations) that was not treated operatively combined with that of recurrent instability leading to operative treatment approached 70 per cent. This percentage would be even higher if the patients who did not have a recurrent dislocation but who believed that the shoulder was unstable and those who had a dislocation that spontaneously reduced had been considered as having an unstable shoulder. Most shoulder surgeons consider ongoing recurrent dislocations or subluxations and poor function due to a feeling of instability without dislocation (a so-called apprehensive shoulder) as indications for stabilization.
A more minor point is that the authors did not comment on the modification of activity that is necessary for the patient to remain symptom-free. In general, one of the goals of operative treatment is to return the patient to his or her desired level of function. If a patient does not have recurrent dislocations because he or she no longer participates in sports or work activities, can the outcome of the treatment truly be considered satisfactory?
My colleagues and I performed a randomized clinical trial comparing traditional treatment (immobilization followed by rehabilitation) with immediate operative stabilization in young patients who had a primary anterior dislocation of the shoulder2. At a minimum of two years postoperatively, we found a strong trend toward better overall function of the shoulder, as measured with a validated disease-specific quality-of-life instrument (the Western Ontario Shoulder Instability Index1), in the group treated with stabilization than in the traditionally treated group. This was the case even when only the patients who had not had a redislocation were considered. This finding supports our clinical impression that many patients who have not had an operation and never have a redislocation have considerable functional problems involving the shoulder.
In summary, the conclusion of Hovelius et al. regarding young patients who have a primary dislocation grossly underestimates the functional problems experienced by these patients. Although, at this time, I do not routinely recommend immediate operative stabilization for young patients, it may very well be that this is the ideal treatment, and I eagerly await the long-term results of our study2 and those of other investigators who are addressing this issue in their clinical research.
Sandy Kirkley, M.D., F.R.C.S.(C): Fowler Kennedy Sport Medicine Clinic, 3M Centre, University of Western Ontario, London, Ontario N6A 3K7, Canada
Dr. Hovelius, Dr. Augustini, Dr. Fredin, Dr. Johansson, Dr. Norlin, and Dr. Thorling reply:
Some of Dr. Kirkley's concerns are addressed in our reply to Dr. Arciero and Dr. Taylor. In addition, we would like to point out that, as shown in Figure 4, by the time of the ten-year follow-up roughly one-third of the patients who were twenty-five years old or less had had an operation, one-third had had more than one recurrence but no operative treatment, and one-third had had no or only one recurrence. Every second patient in the group that had had recurrent dislocation but had not had operative treatment considered the shoulder as having had complete or almost complete recovery by ten years. This means that if every patient in this series who had had a primary dislocation by the age of twenty-five years had had an operation, 50 per cent would have had an unnecessary procedure.
One of us (L. H.) has worked closely with ice-hockey players since 1971. During those years, he has learned that, in most patients, the disability associated with a dislocation or subluxation is not pronounced. Furthermore, many ice-hockey players do not want to "take it easy" postoperatively if the operation is performed during hockey season. If an operation is necessary, they prefer to have it performed during the off-season.
Future studies, such as that by Dr. Kirkley and colleagues, will help to reveal the level of disability associated with untreated primary dislocations.
L. Hovelius, M.D.: Orthopedic Department, Gävle Hospital, 801 87 Gävle, Sweden
B. G. Augustini, M.D.: Orthopedic Department, Regionsjukhuset, 701 85 Örebro, Sweden
H. Fredin, M.D.: Orthopedic Department, Malmö Allmänna sjukhus, 214 01 Malmö, Sweden
O. Johansson, M.D.: Orthopedic Department, Karlstad Hospital, 651 85 Karlstad, Sweden
R. Norlin, M.D.: Orthopedic Department, University Hospital, 581 85 Linköping, Sweden
J. Thorling, M.D.: Orthopedic Department, Falun Hospital, 791 82 Falun, Sweden