Editorial Commentary: Evidence to Support Surgical Intervention for First-Time Shoulder Instability: Stabilize Them Early!

Abstract

Historically, a primary anterior instability event has been treated nonoperatively. In the literature, a multitude of outcome scores and definitions for recurrence of instability complicates the interpretation and synthesis of evidencebased recommendations. However, there is an emerging body of high-quality evidence that early surgical stabilization yields better overall outcomes. A wait-and-see approach would be acceptable if it was without detrimental effects, but there is a cost to recurrence of instability events, such as more extensive soft-tissue, cartilage, and bony lesions. Young age, male sex, and contact sport participation have been identified as risk factors for recurrence of anterior shoulder instability, and today, these patients are routinely recommended surgical treatment. It is also paramount to identify concomitant injury following the primary anterior instability event. The sensitivity, specificity, and reliability of radiographs is suboptimal, and the threshold to obtain advanced imaging such as computed tomography or magnetic resonance imaging with 3-dimensional reconstructions should be low. Taking into account the low non-recurrence complication rate following arthroscopic stabilization, early surgical intervention should be considered following the first instability event.

Psychological Factors That Affect Return to Sport After Surgical Intervention for Shoulder Instability: A Systematic Review

“…There is an increasing body of evidence demonstrating excellent RTS outcomes after surgical intervention for shoulder instability. 6 , 7 , 28 , 38 , 39 Despite advances in surgical technique and rehabilitation, there is a persistent cohort of patients who are unable to achieve a full RTS after shoulder surgery. 12 We posit that psychological factors are a key contributor among this cohort of patients.…”

“…between 70% and 95%. [31][32][33][34][35][36][37][38][39][40][41][42][43] However, the estimates of the rate of return to preinjury levels of activity and competition are currently limited, potentially due to a lack of activity-level assessment standardization. 22,30,37 A recent meta-analysis identifying studies reporting RTS after surgery for shoulder instability found that, on average, 73% of people returned to any sport and 65% returned to their preinjury level of sport.…”

“… 34 , 54 Currently available data regarding rates of return to sport (RTS) vary with estimates ranging by surgical technique, injury mechanism, and patient-specific factors; however, estimates for RTS rates after shoulder surgery often range between 70% and 95%. 31 - 43 However, the estimates of the rate of return to preinjury levels of activity and competition are currently limited, potentially due to a lack of activity-level assessment standardization. 22 , 30 , 37 A recent meta-analysis identifying studies reporting RTS after surgery for shoulder instability found that, on average, 73% of people returned to any sport and 65% returned to their preinjury level of sport.…”

A Clinical Overview of Management of First time Anterior Shoulder Dislocation

“…However, the risk factors for recurrence are Young age, Glenoid bone loss, Hill-Sach lesion (seen in 93% of 1st time di slocators), ligamentous la x it y, multidirectional instability, prior ipsilateral dislocation, and contact or overhead sports participation [30]. Diffusely small labral morphology and increased number of preoperative dislocations before Bankart repair was associated with increased odds recurrent instability after surgery [31]. One must remember that there are some contraindications to primary repair like epilepsy, Multidirectional laxity and instability, other medical comorbidities , inabilit y to follow rehabilitation programme, and voluntary dislocators.…”