To The Editor:
We read with great interest the article entitled "Primary Arthroscopic Stabilization for a First-Time Anterior Dislocation of the Shoulder. A Randomized, Double-Blind Trial" (2008;90:708-21), by Robinson et al. We would like to congratulate the authors on a very thorough, well-designed, and well-conducted study.
We at our institution have long held the same belief that if surgery is considered for the management of this specialized group of patients, Bankart repair for first-time dislocation results in greater patient satisfaction and a reduction in the risk of recurrent instability as compared with other surgical treatments. We are also encouraged by the report of greater cost-effectiveness in the longer term.
If one is to consider arthroscopic lavage for the treatment of this group of patients, then clearly the benefit lies in performing this procedure as soon after the dislocation as is safe and possible. In the article, the authors state, "it seems unlikely that performing arthroscopic stabilization as a primary intervention has a clear advantage over the use of this technique as a delayed procedure for patients with recurrent instability after the primary dislocation." With regard to the time to surgery, therefore, we would be interested to know the mean time to surgery for both groups of patients in the study. In our practice, although consultation may occur two to four weeks following the dislocation, even if surgery is planned and agreed on, waiting lists and operating room time availability may delay treatment to a point at which, in the least, lavage is futile.
In reality, most surgeons perform arthroscopic Bankart repair as an elective procedure. The interval between consultation and surgery can result in further episodes of instability or dislocation, perhaps causing further intra-articular damage and jeopardizing the success of the planned procedure. Do the authors maintain that time to surgery really has no bearing on outcome, or would they concede that performing a Bankart repair any time prior to a second-time recurrent dislocation improves outcome?
We believe that this question highlights the need for a further prospective study in which the outcome of arthroscopic Bankart repair performed for patients who have had only one dislocation is compared with the outcome for patients who have multiple dislocations.