Early Surgery Best for Some Shoulder Dislocations

QUEBEC CITY — Athletic patients under age 30 years with a first-time shoulder dislocation might benefit from early surgical repair rather than conservative therapy, said Dr. Robert McCormack at the joint annual meeting of the Canadian Academy of Sport Medicine and the Association Québécoise des Médecins du Sport.

“The [standard] is to keep patients in a sling for a few weeks and send them to physiotherapy. But the evidence is that most will redislocate. … In a select group of athletic people, there is evidence to support a more aggressive approach,” said Dr. Robert McCormack, an orthopedic surgeon at the University of British Columbia, Vancouver, in an interview. Collision and contact sports such as rugby and football, as well as skiing and rock climbing, present high risk for dislocation, he noted.

Dr. McCormack, who is also chief medical officer for the Canadian Olympic Team, outlined factors to consider when selecting candidates for early surgery. “I wouldn't go so far as to say that everyone needs to have primary surgical stabilization. What we can say is that studies have shown that in high-demand people, who are young and have risk of recurrence, we can change that natural history.”

A Cochrane review of five studies suggests a fivefold greater risk of recurrent instability in young, active patients treated conservatively, compared with surgically (Cochrane Database Syst. Rev. 2004;[1]:CD004325). Similarly, a 10-year follow-up of first-time shoulder dislocations randomized to conservative or surgical repair showed a 72% rate of good to excellent results in the surgical group, compared with a 75% rate of dissatisfaction in the conservative therapy group (Arthroscopy 2007;23:118–23).

In balancing the risks of surgery, which are considered low, especially when done arthroscopically, against the risk of repeat dislocation, Dr. McCormack said the patient's lifestyle and athletic aspirations are a top consideration. “If the most aggressive thing they do is reach for the television remote, it's not a big deal, but if they're going to go back to playing football, the majority will face recurrent dislocations,” he said. “Most of the patients I see are skeletally mature, and already have an idea of how athletically demanding their lifestyle is going to be. I would be less aggressive in a 10- or 12-year-old. I wouldn't want them to redislocate six or seven times, but I would probably give them a trial of conservative therapy.”

Bracing should also be considered as an alternative to a sling in conservative management, he noted. “A sling puts the shoulder in internal rotation, but the brace causes external rotation which pulls the ligaments back so that they may hopefully heal back down in the right position.”

For patients who fail conservative management and redislocate, there is evidence that secondary surgical repair is not as effective. “Some people will never need surgery, either because they are not active enough, or they change their sport, or do well with conservative management. So by doing primary surgery, there is a chance you may overtreat.” Patients need to make their own informed decisions, balancing the risks against the benefits.

With conservative management, patients aged 40 years and older have a lower risk for redislocation, compared with younger patients, largely because the nature of the injury is usually different in this age group. “The over-40 group tends to tear their rotator cuff and younger people have Bankart lesions, where ligaments are pulled off the glenoid.”

An anteroposterior x-ray of a shoulder shows that it is dislocated anteriorly. Courtesy Dr. Robert McCormack

QUEBEC CITY — Athletic patients under age 30 years with a first-time shoulder dislocation might benefit from early surgical repair rather than conservative therapy, said Dr. Robert McCormack at the joint annual meeting of the Canadian Academy of Sport Medicine and the Association Québécoise des Médecins du Sport.

“The [standard] is to keep patients in a sling for a few weeks and send them to physiotherapy. But the evidence is that most will redislocate. … In a select group of athletic people, there is evidence to support a more aggressive approach,” said Dr. Robert McCormack, an orthopedic surgeon at the University of British Columbia, Vancouver, in an interview. Collision and contact sports such as rugby and football, as well as skiing and rock climbing, present high risk for dislocation, he noted.

Dr. McCormack, who is also chief medical officer for the Canadian Olympic Team, outlined factors to consider when selecting candidates for early surgery. “I wouldn't go so far as to say that everyone needs to have primary surgical stabilization. What we can say is that studies have shown that in high-demand people, who are young and have risk of recurrence, we can change that natural history.”

A Cochrane review of five studies suggests a fivefold greater risk of recurrent instability in young, active patients treated conservatively, compared with surgically (Cochrane Database Syst. Rev. 2004;[1]:CD004325). Similarly, a 10-year follow-up of first-time shoulder dislocations randomized to conservative or surgical repair showed a 72% rate of good to excellent results in the surgical group, compared with a 75% rate of dissatisfaction in the conservative therapy group (Arthroscopy 2007;23:118–23).

In balancing the risks of surgery, which are considered low, especially when done arthroscopically, against the risk of repeat dislocation, Dr. McCormack said the patient's lifestyle and athletic aspirations are a top consideration. “If the most aggressive thing they do is reach for the television remote, it's not a big deal, but if they're going to go back to playing football, the majority will face recurrent dislocations,” he said. “Most of the patients I see are skeletally mature, and already have an idea of how athletically demanding their lifestyle is going to be. I would be less aggressive in a 10- or 12-year-old. I wouldn't want them to redislocate six or seven times, but I would probably give them a trial of conservative therapy.”

Bracing should also be considered as an alternative to a sling in conservative management, he noted. “A sling puts the shoulder in internal rotation, but the brace causes external rotation which pulls the ligaments back so that they may hopefully heal back down in the right position.”

For patients who fail conservative management and redislocate, there is evidence that secondary surgical repair is not as effective. “Some people will never need surgery, either because they are not active enough, or they change their sport, or do well with conservative management. So by doing primary surgery, there is a chance you may overtreat.” Patients need to make their own informed decisions, balancing the risks against the benefits.

With conservative management, patients aged 40 years and older have a lower risk for redislocation, compared with younger patients, largely because the nature of the injury is usually different in this age group. “The over-40 group tends to tear their rotator cuff and younger people have Bankart lesions, where ligaments are pulled off the glenoid.”

An anteroposterior x-ray of a shoulder shows that it is dislocated anteriorly. Courtesy Dr. Robert McCormack

QUEBEC CITY — Athletic patients under age 30 years with a first-time shoulder dislocation might benefit from early surgical repair rather than conservative therapy, said Dr. Robert McCormack at the joint annual meeting of the Canadian Academy of Sport Medicine and the Association Québécoise des Médecins du Sport.

“The [standard] is to keep patients in a sling for a few weeks and send them to physiotherapy. But the evidence is that most will redislocate. … In a select group of athletic people, there is evidence to support a more aggressive approach,” said Dr. Robert McCormack, an orthopedic surgeon at the University of British Columbia, Vancouver, in an interview. Collision and contact sports such as rugby and football, as well as skiing and rock climbing, present high risk for dislocation, he noted.

Dr. McCormack, who is also chief medical officer for the Canadian Olympic Team, outlined factors to consider when selecting candidates for early surgery. “I wouldn't go so far as to say that everyone needs to have primary surgical stabilization. What we can say is that studies have shown that in high-demand people, who are young and have risk of recurrence, we can change that natural history.”

A Cochrane review of five studies suggests a fivefold greater risk of recurrent instability in young, active patients treated conservatively, compared with surgically (Cochrane Database Syst. Rev. 2004;[1]:CD004325). Similarly, a 10-year follow-up of first-time shoulder dislocations randomized to conservative or surgical repair showed a 72% rate of good to excellent results in the surgical group, compared with a 75% rate of dissatisfaction in the conservative therapy group (Arthroscopy 2007;23:118–23).

In balancing the risks of surgery, which are considered low, especially when done arthroscopically, against the risk of repeat dislocation, Dr. McCormack said the patient's lifestyle and athletic aspirations are a top consideration. “If the most aggressive thing they do is reach for the television remote, it's not a big deal, but if they're going to go back to playing football, the majority will face recurrent dislocations,” he said. “Most of the patients I see are skeletally mature, and already have an idea of how athletically demanding their lifestyle is going to be. I would be less aggressive in a 10- or 12-year-old. I wouldn't want them to redislocate six or seven times, but I would probably give them a trial of conservative therapy.”

Bracing should also be considered as an alternative to a sling in conservative management, he noted. “A sling puts the shoulder in internal rotation, but the brace causes external rotation which pulls the ligaments back so that they may hopefully heal back down in the right position.”

For patients who fail conservative management and redislocate, there is evidence that secondary surgical repair is not as effective. “Some people will never need surgery, either because they are not active enough, or they change their sport, or do well with conservative management. So by doing primary surgery, there is a chance you may overtreat.” Patients need to make their own informed decisions, balancing the risks against the benefits.

With conservative management, patients aged 40 years and older have a lower risk for redislocation, compared with younger patients, largely because the nature of the injury is usually different in this age group. “The over-40 group tends to tear their rotator cuff and younger people have Bankart lesions, where ligaments are pulled off the glenoid.”

An anteroposterior x-ray of a shoulder shows that it is dislocated anteriorly. Courtesy Dr. Robert McCormack