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
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.