To The Editor:
We compliment Robinson et al., the authors of "Primary Arthroscopic Stabilization for a First-Time Anterior Dislocation of the Shoulder. A Randomized, Double-Blind Trial (2008;90:708-21)," for a well-planned study.
Primary anterior dislocations of the shoulder are associated with a high risk of instability in young adults1. We presume that the initial impetus for this study came from the studies by Wintzell et al.2,3, who proposed that arthroscopic lavage alone conferred an improved outcome in comparison with conservative management. Their one-year results demonstrated a 13% redislocation rate in the lavage group (sixty patients) as opposed to a 43% redislocation rate in the conservatively managed group (thirty patients)2. Interestingly, their two-year results demonstrated a 20% dislocation rate in the lavage group (thirty patients), but it appears that half the patients in that group had been lost to follow-up3. The present study demonstrated that lavage alone was associated with a 38% dislocation rate at two years.
Even though Robinson et al. did not study a nonoperatively managed group, their previous study4 showed a 68% dislocation rate at five years in conservatively managed patients with a first-time dislocation. This percentage is almost twice the percentage in the lavage group.
The lavage group was managed with a sling, with the shoulder in internal rotation. Itoi et al.5 reported a 26% rate of redislocation in association with an external rotation brace at a minimum of four years, even with less-than-perfect compliance. What would be of interest would be to compare a lavage group in an external rotation brace postoperatively.
We accept the point that previous trials of primary stabilization may have included a narrow group of patients, such as the West Point experience6, but the authors' own data showed that the average age of the patients was twenty-five years and that sixty-five patients played sports, thirty professionally.
In essence, this paper adds weight to the growing evidence that primary stabilization should be offered to young, male patients with a first-time dislocation. Common sense says that performing an arthroscopy but not stabilizing the patient has to be missing a golden opportunity to fix the problem.