Dr. Charalambos stresses the importance of counseling patients and points out that a thorough discussion of the patient's long term goals is critical to choosing the correct path. Prior to doing our study I would have agreed with this statement wholeheartedly. Now, however, we realize that there are significant limits to our ability to predict the future.

Dr. Charalambos also points out that a stable shoulder does not imply a fully satisfactory result if it required a lifestyle change. That is true. However, it is equally true that a lifestyle change does not necessarily imply an unsatisfactory result. Some patients are happy to compromise for the sake of avoiding surgery and others are not. Our population with stable shoulders had extremely high outcome scores and these scores were equal to the group of patients who had the best results from surgery. We do not know how many of these patients changed their lifestyle to accommodate their shoulders. We only know that they were highly satisfied.

We cannot, with any accuracy, predict which specific patients will redislocate or be unhappy. Thus, the validity of counseling is, in our hands, suspect. We, like other surgeons, love to operate and feel that we can "fix" almost anyone. It takes restraint to allow the natural history of shoulder instability to play out. None the less, it appears to us that the wisest course for most patients is to send them to therapy, let them experience their shoulder, and come to their own conclusion about whether or not they need surgery.

To The Editor:

We read with interest the article by Sachs et al.(1) We believe that the counselling and information given to patients with regard to the potential benefits and risks of surgery can influence their choice between operative and non-operative treatment. Were all the patients included in this study given standardised counselling with regard to the role of surgical intervention? If so, what was the information given to them?

As the authors rightly point out,sports participation and overhead activities may influence the development of clinical instability and risk of re-dislocation. Patients may modify their activities following a shoulder dislocation which would in turn influence the risk of subsequent symptomatic instability. Thus simply having a stable shoulder may not imply a fully satisfactory outcome if this required a lifestyle change. Did those patients reporting a stable shoulder change their lifestyle, and if they did were they troubled by such a change?

We feel that following an initial traumatic dislocation, a thorough discussion must be made with patients as to their expectations and long term aim in sports participation and overhead activities. Those patients wishing to continue with sports activities should be counselled as to the success rate, recovery process and risks associated with surgery, as part of making an informed treatment decision.

The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated.

References:

1. Sachs RA, Stone ML, Paxton E, Kuney M, Lin D. Can the need for future surgery for acute traumatic anterior shoulder dislocation be predicted? J Bone Joint Surg Am 2007;89:1665-1674.