This prospective 25-year multicenter study followed 255 patients (257 shoulders) aged 12-40 after a first-time anterior shoulder dislocation treated nonoperatively. It answers the question: what is the true natural history, and does immobilization matter? All 227 surviving patients completed follow-up — an extraordinary retention rate for a quarter-century study.
The instinct to immobilize a young patient after first-time anterior dislocation is deeply ingrained — and this paper definitively refutes it. Across all age groups and at every follow-up interval over 25 years, immobilization made no difference in redislocation rate (p = 0.705). Prescribe a sling for comfort only.
When a 16-year-old presents after a first dislocation, counsel them honestly: roughly 50% will eventually need surgery, but half of young patients either never redislocate or become stable spontaneously over time. Routine immediate stabilization in all young patients produces at least 30-50% unnecessary operations.
Two findings should change what you look for on the initial radiograph. A greater tuberosity fracture drops recurrence risk to ~8%. Cite this when counseling a patient who might otherwise push for early surgery. A Hill-Sachs or small glenoid rim fracture, by contrast, does not affect prognosis at 25 years.
The patient who keeps dislocating and has bilateral shoulder involvement is a different animal. That pattern (23% bilateral rate in surgical patients vs. 7% in solitary dislocators) reflects constitutional laxity or glenoid morphology, not bad luck. That individual deserves earlier consideration for stabilization than a straightforward traumatic first event alone would suggest.
This prospective 25-year multicenter study followed 255 patients (257 shoulders) aged 12-40 after a first-time anterior shoulder dislocation treated nonoperatively. It answers the question: what is the true natural history, and does immobilization matter? All 227 surviving patients completed follow-up — an extraordinary retention rate for a quarter-century study.
The instinct to immobilize a young patient after first-time anterior dislocation is deeply ingrained — and this paper definitively refutes it. Across all age groups and at every follow-up interval over 25 years, immobilization made no difference in redislocation rate (p = 0.705). Prescribe a sling for comfort only.
When a 16-year-old presents after a first dislocation, counsel them honestly: roughly 50% will eventually need surgery, but half of young patients either never redislocate or become stable spontaneously over time. Routine immediate stabilization in all young patients produces at least 30-50% unnecessary operations.
Two findings should change what you look for on the initial radiograph. A greater tuberosity fracture drops recurrence risk to ~8%. Cite this when counseling a patient who might otherwise push for early surgery. A Hill-Sachs or small glenoid rim fracture, by contrast, does not affect prognosis at 25 years.
The patient who keeps dislocating and has bilateral shoulder involvement is a different animal. That pattern (23% bilateral rate in surgical patients vs. 7% in solitary dislocators) reflects constitutional laxity or glenoid morphology, not bad luck. That individual deserves earlier consideration for stabilization than a straightforward traumatic first event alone would suggest.