Predicting Recurrence of Shoulder Dislocation
Abstract & Commentary
Synopsis: This retrospective review of a large series of patients confirms that young age at the time of first shoulder dislocation (in this series 21-30 years) is the only predictor of recurrence of shoulder instability.
Source: Kralinger FS, et al. Am J Sports Med. 2002;30: 116-120.
Kralinger and associates from the University Hospital of Innsbruck, Austria, attempted to define predictive factors for recurrence of instability following a primary anterior shoulder dislocation. They reviewed the records of 241 patients, of which they were able to clinically and radiographically evaluate 166 at an average of 43 months (range, 13-76 months) after the first dislocation. The goal was to determine what factors may be present that suggest early surgery may be indicated.
Kralinger et al found that young age at the time of the initial dislocation is associated with recurrence. The overall recurrence rate for their patient population with an average age of 46 years (range, 13-76) was 29%. Their highest risk group of patients included those between the ages of 21 and 30 years, with a recurrence rate of 63%. They also noted an increased risk of recurrent dislocation for those with large Hill Sachs lesions (> 2.5 cm2). They noted reduced external rotation and less recurrent instability in those with greater tuberosity fractures. Those without fracture who did have recurrence of instability had near equal external rotation, while stable shoulders tended to have less rotation as compared with the unaffected shoulder.
Kralinger et al found that sports activities are not an independent variable for recurrence of shoulder instability. Physical therapy or immobilization did not affect the recurrence rate in their subjects. Kralinger et al recommend surgery after a first time anterior dislocation of the shoulder in young athletes (21-30 years of age). They also note that they do not recommend surgery for any other group, including similarly aged individuals who do not participate in sports.
Comment by Marc R. Safran, MD
Though proposed in the 1980s, there has been much recent enthusiasm for surgical stabilization after a primary dislocation of the shoulder in the last several years. This may be due in part to the purported lower morbidity and potentially better results with arthroscopic stabilization, in addition to the reproducible results of open stabilization. Many authors have shown that recurrence of shoulder instability is age-related, including the landmark prospective work by Hovelius. Though many investigators have tried to show a correlation with sports activities, no prospective study has been able to confirm an increased risk of recurrence when controlled for age of the athletes, and this study reaffirms these known facts. Kralinger et al also found that size of Hill Sachs lesion does correlate to risk of recurrence. This is controversial as much of the earlier research suggested that these lesions are not associated with recurrence, though recent work by Burkhart and others challenge this notion. It is the feeling of this reviewer that the reason Kralinger et al were able to show that a Hill Sachs lesion is associated with recurrence may be that stratification of the size of the impression fracture allows for more critical analysis.
The effect of physical therapy and immobilization on recurrence is controversial in the literature, and this study adds more evidence for the lack of effect. The range of motion finding as a risk factor is a new proposed risk factor that is consistent with this reviewer’s experience. However, it is likely that the degree of motion difference reported is within clinical measurement error. Thus, more study is necessary.
The prospective study by Hovelius revealed that the risk of recurrent dislocation is 52% at 10 years, while only 23% underwent surgery for shoulder instability. Interestingly, in a comprehensive review of the literature, it appears that approximately 50% of those having recurrent instability request surgery. Other factors to consider when determining if early intervention is indicated include a consideration of quality of life, although there is not much data in the literature on this topic.
In summary, Kralinger et al made a fine attempt on retrospective review to determine predictive factors for early surgery on subjects with a first time shoulder dislocation. It is likely that there is a subgroup of patients that would benefit from surgical intervention after the primary dislocation, however who these patients are is unknown as of yet. More study is necessary in this area before early surgery can be recommended.
Dr. Safran, Co-Director, Sports Medicine, Associate Professor, UCSF Department of Orthopaedic Surgery, San Francisco, CA, is Associate Editor of Sports Medicine Reports.
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