C.M. Robinson and P.J. Jenkins reply:
We thank Mr. Patel and Mr. Leith for their comments on our study, and we are grateful for the opportunity to respond. They rightly point out that operative shoulder reconstruction for the treatment of recurrent instability is a different entity from operative shoulder reconstruction for the treatment of a first-time dislocation. Recurrent dislocations are more likely to be associated with secondary osseous lesions (large Hill-Sachs lesions and anteroinferior osseous glenoid rim defects), which recently have been shown to deleteriously affect the outcome of arthroscopic repair1,2. The primary aim of our study was to determine the rate of instability following arthroscopic stabilization or lavage in the acute setting.
All patients were operated on within fourteen days, and the mean times to surgery in the Bankart repair and lavage groups were 7.6 and 7.9 days, respectively. The operative procedures were able to be performed so early in our study because of a special arrangement in our unit whereby all acute dislocations are referred directly to a specialist clinic and there is early access to acute operating theater time. We acknowledge that it is unusual to have such early access to operating room time.
We are uncertain as to whether delaying the acute arthroscopic reconstruction would have an adverse effect on outcome as this was not examined in our study. However, we believe that it is most logical to perform the reconstruction as soon as possible after the primary dislocation as we rest the arm in a sling for four weeks after surgery. Performing the surgery as a delayed "elective" procedure, some weeks after the primary dislocation, would subject the patient to an additional period of enforced inactivity and might further delay his or her rehabilitation and return to normal activities.
We agree with Mr. Patel and Mr. Leith that additional prospective studies are required to investigate the optimal timing and form of treatment for shoulder instability. However, it is necessary to bear in mind that there are important differences between performing the procedure as a prophylactic measure after a first-time dislocation and performing the procedure as a therapeutic measure in a patient with recurrent instability. This may lead to some complex methodological problems in the design of such studies in the future.
These letters originally appeared, in slightly different form, on . They are still available on the web site in conjunction with the article to which they refer.