When a patient initially presents with multiple shoulder instability events, nonoperative treatment will most likely not be successful in treating their traumatic anterior shoulder instability, a new study finds.
In “Multiple Instability Events at Initial Presentation Are the Major Predictor of Failure of Nonoperative Treatment for Anterior Shoulder Instability,” published in the August, 2021 issue of the journal Arthroscopy, the researchers sought to determine the success rate of initial nonoperative treatment for these patients in the U.S.
They also wanted to evaluate the factors that predict conversion to surgery after initial nonoperative management and analyze long-term outcomes.
The researchers used the Rochester Epidemiology Project database to gather data on patients between the ages of 14 and 39 between 1994 and 2016. All patient demographic characteristics, comorbidities, injury characteristics, and imaging were collected and analyzed. So were long-term outcomes including recurrence rate, pain at last follow-up and radiographic outcomes.
A total of 379 patients were included in the study. The average age of the patients was 23.9 years. The average follow-up period was 10.2 years. One hundred percent of the instability events were related to a traumatic event.
Seventy-one or 20.1% of the shoulders ended up failing the initial nonoperative treatment requiring a conversion to surgery. Overall, the rate of recurrent instability was 52.3% in the group treated definitively without surgery while the recurrence rate decreased from 92.4% to 10.1% in patients who were converted to surgical treatment.
The factors associated with conversion to surgery were two or more subluxations prior to the first evaluation (hazard ration [HR], 1.82; p = .002), two or more dislocations prior to the first evaluation (HR, 1.76; p = .006), and recurrent instability at follow-up (HR, 4.21; p < .001).
“Most patients younger than 40 years with shoulder instability who were initially treated nonoperatively for 6 months were definitive treated without surgery. Ultimately 35% of these patients experienced recurrent dislocations after 6 months of conservative treatment and 20% underwent surgical treatment,” they wrote.
“In most patients who underwent conversion to surgical treatment, surgery was performed within 12.5 years of their first instability event. Patients who experienced multiple instability events before or after consultation were more likely to undergo conversion to surgery after initial nonoperative management.”
In an editorial accompanying the study, Ujash Sheth, M.D., of the University of Toronto, wrote, “Considering the suboptimal clinical outcomes associated with arthroscopic stabilization of patients with recurrent instability and the greater risk profile associated with bone block augmentation procedures (i.e., Latarjet), an argument could be made to treat all first-time dislocators with early surgical stabilization, as opposed to a wait-and-see approach. However, the results of the current study by Duethman et al. highlight the challenge in employing such a tactic, as 80% of the study cohort was definitely treated nonoperatively, despite the fact that over half of all patients in this group experienced episodes of recurrent instability during follow-up.
“This finding once again underscores the notion that there is no one-size-fits-all approach when managing patients with anterior shoulder instability. Instead, we should continue to use the available evidence within the literature to help risk stratify patients and develop an individualized treatment plan through a shared decision-making process with the patient.”
