Hovelius (2009) — Neer Award 2008: Arthropathy after primary anterior shoulder dislocation–223 shoulders prospectively followed up for twenty-five years

Neer Award 2008: Arthropathy after Primary Anterior Shoulder Dislocation–223 Shoulders Prospectively Followed up for Twenty-Five Years

Hovelius, Saeboe·J Shoulder Elbow Surg·2009·346 citations·Shoulder & Elbow

This prospective 25-year Swedish multicenter study followed 223 shoulders after a first-time anterior dislocation in patients aged 12 to 40. It describes the natural history of dislocation arthropathy and identifies which patients are at highest risk. Radiographs were obtained in 97% of surviving shoulders, using the Samilson-Prieto grading system.

Study Snapshot

Design

Prospective multicenter cohort

Blinding: Open-label

Setting: 27 Swedish hospitals

Objective

Whether primary anterior shoulder dislocation leads to arthropathy and which factors predict its development over 25 years

Outcome(s)

Radiographic dislocation arthropathy grade at 25 years (Samilson-Prieto)

Subjects

223 shoulders (221 patients)

Inclusion

First-time anterior shoulder dislocation
Age 12 to 40 years
Enrolled 1978-1979

Exclusion

Deceased before follow-up
No radiographic imaging obtained

Follow-up

25 years

Statistics

Chi-square testFisher exact testLogistic regressionMann-Whitney U

Key Findings

At 25 years, 56% of shoulders had arthropathy and 26% had moderate/severe changes. Moderate/severe disease rose from 9% at 10 years, increasing roughly 1 percentage point per year.
Even shoulders that never recurred developed moderate/severe arthropathy in 18%. This confirms the dislocation trauma itself, not just recurrence, drives long-term joint damage.
All 7 of 7 alcoholic patients had severe arthropathy (vs 52 of 216 non-alcoholics, P < .001). The authors attribute this to more severe, uncontrolled trauma at the time of dislocation.
High-energy traumatic sports carried the highest risk at 37% moderate/severe vs 15% for nontraumatic sports (P = .009). Age over 25 at primary dislocation also increased risk (P = .01).
Surgically stabilized shoulders had arthropathy rates similar to solitary dislocations (P = .725) and less than shoulders that stabilized over time (P = .047). This challenges the belief that repair itself causes arthropathy.
Mild arthropathy at 10 years predicted moderate/severe arthropathy at 25 years in 63% (19 of 30), versus only 9% if normal at 10 years (P < .001).
Only severe arthropathy correlated with worse DASH scores (P = .0001). No patient underwent arthroplasty for arthropathy during the entire 25 years.

Board PearlEven a single anterior shoulder dislocation without recurrence causes moderate/severe arthropathy in about 18% of shoulders by 25 years.

Clinical Relevance

Counsel first-time dislocators honestly: even a single anterior dislocation without recurrence produces moderate/severe arthropathy in about 18% of shoulders by 25 years. The trauma itself damages the joint. This is the natural history you should know when a patient asks whether one dislocation matters long-term.

This study directly counters the long-held claim that stabilization surgery causes arthropathy. Operated shoulders fared no worse than solitary dislocations and better than shoulders that recurred repeatedly before stabilizing. Arthropathy after surgery reflects technical error, not the operation per se.

Risk stratification matters: age over 25, high-energy sports mechanism, recurrence, and alcohol abuse all predict worse joint outcomes. Radiographic arthropathy is usually well tolerated. Only severe changes hurt DASH scores, and no patient needed arthroplasty in 25 years, so radiographic findings alone do not justify prophylactic surgery.

Core

Neer Award 2008: Arthropathy after Primary Anterior Shoulder Dislocation–223 Shoulders Prospectively Followed up for Twenty-Five Years

Hovelius, Saeboe·J Shoulder Elbow Surg·2009·346 citations·Shoulder & Elbow

Neer Award 2008: Arthropathy after Primary Anterior Shoulder Dislocation–223 Shoulders Prospectively Followed up for Twenty-Five Years

Study Snapshot

Key Findings

Clinical Relevance

Related Articles

Neer Award 2008: Arthropathy after Primary Anterior Shoulder Dislocation–223 Shoulders Prospectively Followed up for Twenty-Five Years

Study Snapshot

Key Findings

Clinical Relevance

Related Articles

Neer Award 2008: Arthropathy after Primary Anterior Shoulder Dislocation–223 Shoulders Prospectively Followed up for Twenty-Five Years

Study Snapshot

Key Findings

Clinical Relevance

Related Articles

Neer Award 2008: Arthropathy after Primary Anterior Shoulder Dislocation–223 Shoulders Prospectively Followed up for Twenty-Five Years

Study Snapshot

Key Findings

Clinical Relevance

Related Articles