Primary Arthroscopic Stabilization for a First-Time Anterior Dislocation of the Shoulder: A Randomized, Double-Blind Trial
Authors: Robinson CM, Jenkins PJ, White TO, Ker A, Will E.
References: J Bone Joint Surg Am. 2008 Apr;90(4):708-21.
BACKGROUND: Anterior dislocation of the glenohumeral joint in younger patients is associated with a high risk of recurrence and persistent functional deficits. The aim of this study was to assess the efficacy of a primary arthroscopic Bankart repair, while controlling for the therapeutic effects produced by the arthroscopic intervention and joint lavage.
METHODS: In a single-center, double-blind clinical trial, eighty-eight adult patients under thirty-five years of age who had sustained a primary anterior glenohumeral dislocation were randomized to receive either an arthroscopic examination and joint lavage alone or together with an anatomic repair of the Bankart lesion. Assessment of the rate of recurrent instability, functional outcome (with use of three scores), range of movement, patient satisfaction, direct health-service costs, and treatment complications was completed for eighty-four of these patients (forty-two in each group) during the subsequent two years.
RESULTS: In the two years after the primary dislocation, the risk of a further dislocation was reduced by 76% and the risk of all recurrent instability was reduced by 82% in the Bankart repair group compared with the group that had arthroscopy and lavage alone. The functional scores were also better (p < 0.05), the treatment costs were lower (p = 0.012), and patient satisfaction was higher (p < 0.001) after arthroscopic repair. The improved functional outcome appeared to be mediated through the prevention of instability since the functional outcome in patients with stable shoulders was similar, irrespective of the initial treatment allocation. The patients who had a Bankart repair and played contact sports were also more likely to have returned to their sport at two years (relative risk = 3.4, p = 0.007).
CONCLUSIONS: Following a first-time anterior dislocation of the shoulder, there is a marked treatment benefit from primary arthroscopic repair of a Bankart lesion, which is distinct from the so-called background therapeutic effect of the arthroscopic examination and lavage of the joint. However, primary repair does not appear to confer a functional benefit to patients with a stable shoulder at two years after the dislocation.
Summarised data from article:
"The findings of the study, therefore, support the rejection of our original null hypothesis, and they confirm that an anatomic repair of the Bankart lesion should be performed if a primary arthroscopic intervention is used to treat a patient with a firsttime anterior dislocation of the shoulder."
First time dislocators:
- Males under 28yrs age and females under 17yrs age have a recurrent instability risk of >50%
- Younger male patients, who have the greatest preoperative risk of later recurrent instability after nonoperative treatment8, have the greatest risk reduction from an arthroscopic repair.
Advantages of Primary Arthroscopic Stabilisation:
- Risk of redislocation was reduced by 76%
- Risk of recurrent instability was reduced by 82%
- Patients who had a Bankart repair and played contact sports were also more likely to have returned to their sport at two years (relative risk = 3.4, p = 0.007) compared to lavage group
- To prevent one patient from sustaining a further radiographically confirmed dislocation 4.7 patients would need to be treated with an arthroscopic stabilisation, and 3.2 patients would need to be treated by this method to prevent one patient from having recurrent instability develope.
- 7% incidence of post-operative frozen shoulder
Comment from Matsen (JBJSA, Suppl)
"A Bankart repair of a first-time dislocation must be considered a prophylactic procedure (to prevent recurrent dislocation). In that light, the decision of whether or not to perform a Bankart repair must take into account not only the potential benefit (minimization of risk) but also the drawbacks of the procedure itself (such as the cost, time off from work and other activities, and surgical complications). The results of this study may not be generalizable to the practice of other surgeons, who may have different rates of benefit and drawbacks. This study surely cannot be considered a green light to operate on individuals with first-time shoulder dislocations without other, patient-specific indications."
A useful quote from the paper also:
"If a policy of primary arthroscopic Bankart repair for all young patients with a first time dislocation was adopted, a substantial degree of overtreatment would be required in patients who might not have instability develop, in order to prevent recurrence in the smaller number who would have this complication develop when treated nonoperatively."