What lessons can we learn from reading a study of eleven patients who had fixed anterior glenohumeral dislocations that were treated with unconstrained shoulder arthroplasty?
There are few common features shared by these patients. Some were relatively young (forty-six years old), others were older (eighty-seven years old); some had previous surgery; some had irreparable cuff tears; some had hemiarthroplasty, others had total shoulder arthroplasty; some required fixation of tuberosity factures; some had iliac crest autografts to the glenoid. Five of eleven patients had complications, and, essentially, each procedure was done by a different surgeon (10 surgeons, 11 patients). There are additional factors that may well have affected the results of the condition and the treatment, starting with the question, "What sort of patient is likely to have a dislocated shoulder for at least three weeks?" The conventional wisdom is that a group of such patients may tend to have a higher rate of dementia or chemical dependency than might the usual patient undergoing a shoulder arthroplasty, and these factors, if present, would tend to compromise the results.
The authors' speculations about a possible role for pectoralis transfer, altering humeral version, or allografts do not seem to add to the value of the paper. Also, it is not clear that this paper can be called a "multicenter case-control" study. It is further not clear that everyone would agree with the authors' judgment of "acceptable" patient satisfaction and "substantial" gains in pain relief and function, in view of the number of complications and reoperations in this series.
Nevertheless, there is great value in this series of case reports because it documents the associated pathology in these affected shoulders: cuff defects, tuberosity fractures, glenoid bone deficiencies, osteopenia, neurovascular injuries, and the compromised general physical and mental health status of these patients.
Thus we continue to look for guidance. When should a chronic anterior dislocation be treated surgically and when should it be left alone? If surgical treatment is considered for a particular patient, how might the surgeon select among the surgical options of glenoid bone augmentation, resection arthroplasty, conventional arthroplasty, reverse arthroplasty, or arthrodesis? Would the choice be affected if the patient were alcoholic, demented, or had Parkinson disease?
As always, the surgeon is the method, not only in doing the operation, but also in matching the patient to the procedure.
*The author did not receive grants or outside funding in support of his research for or preparation of this manuscript. The author received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity (DePuy). In addition, a commercial entity (DePuy) paid or directed, or agreed to pay or direct, benefits to a research fund, foundation, educational institution, or other charitable or nonprofit organization with which the author is affiliated or associated.