What is the recommended treatment for a patient with recurrent shoulder dislocation, 9 months post-injury?

Treatment of Recurrent Shoulder Dislocation at 9 Months Post-Injury

For a patient with recurrent shoulder dislocation presenting 9 months after the last injury, surgical stabilization is the recommended treatment, as conservative management is associated with unacceptably high recurrence rates (75-100% in young patients), and early surgical intervention prevents progressive labro-ligamentous injury. 1, 2, 3

Initial Diagnostic Workup

Obtain MR arthrography as the gold standard imaging study (appropriateness rating 9/9) to evaluate the full extent of pathology including labral tears, capsular injuries, glenoid bone loss, Hill-Sachs lesions, and glenohumeral ligament injuries. 4, 5, 1 This is superior to non-contrast MRI for detecting anterior labral injuries and glenohumeral ligament pathology. 4

Key Pathology to Identify:

• Bankart lesions (avulsion of capsule and labrum from anterior glenoid rim) - present in 84% of recurrent instability cases 6
• Glenoid bone loss - found in up to 10% of recurrent instability patients and critical for surgical planning 4, 5, 1
• Hill-Sachs lesions - present in 76% of recurrent cases 6
• Capsular laxity - found in 83% of failed repairs 6

If MRI is contraindicated, use CT arthrography as an alternative (appropriateness rating 5/9), though it is inferior for assessing rotator cuff pathology. 4, 1

Treatment Algorithm

Surgical Stabilization is Indicated Because:

• Delayed surgery leads to progressive labro-ligamentous injury 1
• Recurrence rates with conservative management are 75-96% in young active patients 2, 3
• Surgical stabilization reduces recurrence to 11-12% compared to 75% with conservative treatment 2
• At 9 months post-injury, this represents established recurrent instability requiring definitive treatment 1, 7

Surgical Approach Based on Pathology:

For standard recurrent instability without significant bone loss (<20% glenoid deficiency):

• Arthroscopic or open Bankart repair with capsular plication 3, 6
• Both approaches show similar recurrence rates 7

For significant glenoid bone loss (>20%):

• Latarjet procedure is recommended to restore the bony architecture 1

Success Rates:

• Reoperation success rate is 92% (8% recurrence rate) when addressing the underlying pathology 6
• Return to previous activity levels occurs in 88-89% of surgically treated patients 2

Conservative Management is NOT Recommended

Conservative treatment at this stage would be inappropriate because:

• The patient has already demonstrated recurrent instability, indicating failure of natural healing 1, 2
• Physical therapy alone shows poor results with only 1 excellent outcome in 7 non-operative cases in recurrent instability 6
• Progressive structural damage occurs with each dislocation episode 1

Critical Pitfalls to Avoid:

• Do not attempt conservative management in established recurrent instability - this leads to continued dislocations and progressive bone/soft tissue damage 1, 2
• Do not proceed to surgery without MR arthrography - inadequate preoperative assessment of bone loss and soft tissue pathology leads to surgical failure 4, 1
• Do not perform standard Bankart repair if >20% glenoid bone loss is present - this requires bone grafting procedures like Latarjet 1
• Do not overlook capsular laxity - this is present in 83% of cases and must be addressed surgically 6

Referral Pathway:

Refer to orthopedic surgery specializing in shoulder instability for surgical planning after obtaining MR arthrography. 1 The 9-month timeframe allows for optimal surgical timing while avoiding further episodes of instability that worsen the underlying pathology.