Is Surgery indicated after a 1st time shoulder dislocation?

[mtomaino]

Dwyane Wade of the Miami Heat decided not to in 2007, and was backing playing in 6 weeks. But it appears as though many young athletes are being advised to have surgery right away if they experience a 1st time shoulder dislocation--and this concerns me.

First, the often cited 80-90% redislocation rate is overstated. There is no study that is level 1 or 2 evidence that proves this as fact. Rather, our hunch that this might be true is used to advocate early operative intervention. But if there is a 50% chance that you may never dislocate again after nonoperative treatment, even if you participate in sports, query is--why would you have surgery?

What prompted this post is the fact that I saw a 17 yo patient yesterday who dislocated his shoulder for the first time 1 week ago in a footbal game. He was relocated in an emergency room, and 2 days later got an MRI which showed a small impaction fracture and a SLAP lesion.Over the 1st week he has regained absolutely full range of motion, and has just a little ache now. Further, he has great cuff strength and on provacative testing for apprehension he has none.

However, the "Sports Doc" who was brought into the fold informed him (after examinig the MRI BUT NOT HIM), that he'd probably have a 80-90% chance of redislocating without surgery. And, therefore, strongly urged surgery.

My first reaction is that the MRI has guided the recommendation here, not this individual's exam. Further, this recommendation seems to discount the 2008 prospective study by Hovelius (see the PDF on the Shoulder page of this website, under the Popular Topics--Shoulder Dislocation), which showed that conservative treatment was successful 50% of the time.

I would submit that the exam is very critical to decision-making--and that 4-6 weeks of PT and reassessment is not only conscientious, but also good medicine---and that this approach burns absolutely no bridges.

That having been said, if, after a first time dislocation,a young athlete has a rotator cuff tear, a displaced glenoid fracture or tuberosity fracture, a large engaging hill sachs lesion, a frankly unstable shoulder with persistent pain after 1-2 weeks, then "acute" repair might very well be indicated. In summary, there's a role for individualizing treatment in 2010.

Protocols, percentage-risks, MRI scan results, published studies, notwithstanding, a patient-centered approach continues to be the most optimal, and this means careful consideration of the patient's physical exam too!!

[mtomaino]

Just an update to support my contention in the post above. This 17 yo active athlete was treated nonoperatively and he has regained full range of motion, has no pain, and has not had any symptoms or signs of instability. I did check a nerve study, and he has a resolving axillary nerve injury, which is not entirley unusual. The take home message here is that every patient needs to be treated individually, based on sound assessment of xray, physical exam, and subjective complaint.