This news release describes the results of a study presented at an annual meeting showing that athletes who dislocated their shoulders for the first time and underwent surgery had lower rates of postoperative instability and re-operation when compared with patients who had recurrent dislocations before undergoing surgery.
It contains lots of numbers, which we applaud.
These numbers are important because they add to the limited database available to help guide treatment for athletes who have suffered a shoulder dislocation. As one study put it in 2014, “there is no consensus on the optimal treatment of in-season athletes with anterior shoulder instability, and limited data are available to guide return to play.”
But, in stating a causal relationship, the news release goes beyond what the data support. Specifically, the news release says that the study “demonstrated that surgery after a first-time shoulder dislocation lowered the re-injury risks and need for follow-up surgery when compared to those who were initially treated non-operatively and experienced a repeat dislocation prior to surgery.” The study, which was observational in nature, can only show associations between shoulder surgery and subsequent outcomes — not that surgery after a first-time dislocation was the cause of reduced risks. Also missing from the release: harms, alternative therapies, costs and study limitations.
This matters because, in the 2014 prospective study, just 27% of athletes whose shoulders were made unstable due to injury “returned to play and completed the season without subsequent instability.”
According to the study abstract, the shoulder is the most common joint dislocation, affecting 2% of the general population, most of them males. And there’s a 50% likelihood of another dislocation after a first one, according to the background into given by the study authors.
According to the U.S. Centers for Disease and Control and Prevention, there were some 63 million visits to non-federally employed, office-based physicians specializing in orthopedic surgery in the United States in 2010. Shoulder symptoms ranked among the top four reasons given by patients for visiting orthopedic surgeons.
The news release does not mention costs.
The news release encapsulates the differences observed: “The study examined 121 patients at an average of 51 months post-surgery,” it says. “Of this group, 68 patients had experienced their first dislocation, while 53 had recurrent dislocations after being initially treated non-operatively. After treatment with an arthroscopic bankart repair, the postoperative dislocation rate in the first-time injury group was 29%, compared to 62% in those who did not have surgery after their initial injury.”
And 7% of those with surgery after the initial dislocation vs 32% after a recurrent dislocation had to have another surgery, according to the release.
The news release does not say whether there were any drawbacks associated with undergoing surgery. This quote from the lead author appears to acknowledge their existence: “While young athletes and parents may be wary of surgery, our study shows the advantages of this treatment approach,” commented Marshall.
But it does not spell out what those drawbacks might be.
The study was based on a retrospective chart review to identify subjects. More than half of identified subjects (296 of 439) were then excluded for various reasons for the next phase of the study, which was a survey, with an 85 percent response rate reported. The study was not a randomized trial, which would have made the results more clear, and which would have allowed a more definitive statement about management of the problem. The release would have been stronger had it pointed out the limitations of retrospective studies and surveys.
The news release doesn’t engage in disease mongering. Nor does it say how many people are affected by shoulder instability or even what “shoulder instability” is, how it’s caused, or what its impact is. Any or all of these would have provided useful context.
It would have been helpful had the news release noted that Alabama Orthopedic Spine & Sports Medicine Associates carried out the surgeries.
The news release refers to “non-operative” interventions, but does not say what they are.
The news release does not say how available either procedure is. The release would have been stronger if it had clarified whether all orthopedic surgeons perform this procedure or if it is a specialized procedure only available at certain clinics.
The news release does not say anything about the novelty of the surgical intervention or of the non-surgical approaches. Is this the first time this issue has been studied? The release gives no sense as to how this study fits into the wider body of research.
The release doesn’t rely on sensational language or make overtly unjustified claims. However, as noted above under the summary and evidence headings, we have some concerns about the way the study findings were presented in the release.
The news release says that the research “demonstrated that surgery after a first-time shoulder dislocation lowered the re-injury risks and need for follow-up surgery when compared to those who were initially treated non-operatively and experienced a repeat dislocation prior to surgery.”
But the study abstract itself does not justify going that far. Instead, it says simply that “first time dislocators had lower postoperative instability rates and reoperation rates when compared to patients with recurrent dislocations prior to surgical intervention.”
Association v. Causation 101.
And a quote from the lead author offers a curious view of the role of the physician: “Deciding between a non-operative program or going forward with surgery can be a challenging decision for medical professionals treating shoulder injuries in young athletes,” says Dr. Marshall.
That statement implies that treatment decisions are made by medical professionals alone. But the agenda paper offers a more inclusive take: “Young, athletic patients with shoulder instability should be offered early surgical intervention to lower the risk of postoperative instability and reoperation,” it says.