Tandem surgery better for shoulder dislocation

By: Peter Pollack

By Peter Pollack

According to the results of a Level 1, prospective, randomized, double-blind controlled trial, tandem surgery—primary arthroscopic examination and repair of a Bankart lesion—reduces the risk of subsequent instability, and that benefit is distinct from any therapeutic effect of arthroscopic examination and lavage of the glenohumeral joint. The study results were outlined by Paul J. Jenkins, MBChB, MRCS, during yesterday’s podium presentations.

ABR yields better outcomes
Study participants (88 patients between 15 and 35 years of age) had sustained a first-time glenohumeral dislocation and were randomly divided into two groups—arthroscopic/lavage only (ALO) or arthroscopic/Bankart repair (ABR). All procedures were performed by a single surgeon.

The two groups had no statistically significant differences in patient demographics, initial treatment, or pattern of injury. Outcome measures, evaluated during the first two years after injury, were completed by 84 of the patients—42 in each group.

Compared to the patients in the ALO group, the patients in the ABR group had a 75 percent reduced risk of a further radiologically confirmed dislocation. Patients in the ABR group also had an 81 percent reduced risk of any recurrent instability compared to patients in the ALO group during the first two years after the primary dislocation.

At 2-year follow-up, patients in the ABR group had functional assessment scores that were significantly better than those in the ALO group (P<0.05), and the levels of patient satisfaction were higher (P<0.001).

No significant differences were found between the two groups in the range of active or passive flexion, extension, or abduction at any of the three postoperative assessments during the first 2 years of follow-up. Additionally, the initial timing for return to work was found to be dependent on the type of work the patient performed, but there was no statistically significant difference between the two groups in that criteria.

Among the 65 patients (33 ALO, 32 ABR) who played regular collision sports prior to their injury, those in the ABR group were more likely to be playing collision sports 2 years after injury (relative risk, 3.4; 95 percent confidence interval, 1.3 to 9.2; P = 0.007).

Researchers calculated the cost of arthroscopic Bankart repair to be lower overall compared to arthroscopic lavage alone. Although initial costs were higher in the ABR group, the reduced need for treatment of recurrent dislocations, further operative stabilization procedures, and postoperative physiotherapy treatment offset the initial costs, with the result that the overall cost of treatment was significantly lower (P = 0.012) in the experimental group.

Other considerations
The researchers’ analysis determined that the development of recurrent instability was the sole independent predictor of the functional outcome. Therefore, they concluded that the improved functional outcomes in the ABR group were primarily due to the prevention of recurrence.

Although the double-blind, single- surgeon design limited the study, it also allowed for a greater standardization of technique than would have been possible with multiple surgeons.

Coauthors for “Primary Arthroscopic Stabilization for Acute Primary Anterior Dislocation of the Shoulder” included Christopher Michael Robinson, BMedSci, FRCS; Timothy O. White, MD, FRCS; Andrew M. Ker, BSc; and Elizabeth Will, MSCP. The authors report no conflicts of interest.

Peter Pollack is a staff writer for AAOS Now. He can be reached at