Arthroscopic lavage reduced the recurrence rate following primary anterior shoulder dislocation. A randomised multicentre study with 1-year follow-up

Arthroscopic Bankart repair versus conservative treatment for first-time traumatic anterior shoulder dislocation: a systematic review and meta-analysis

BACKGROUND

Shoulder is vulnerable to dislocation owing to its anatomical structure and the increasing popularity of contact sports in young population. The management of first-time anterior shoulder dislocation in this group is still controversial and the prognosis are varied. This review aimed to compare the results of arthroscopic Bankart repair and conservative management for first-time traumatic anterior shoulder dislocation in young active patients.

METHODS

Databases were searched till November 2021, and comparative studies between arthroscopic Bankart repair and conservative management for first-time traumatic anterior shoulder dislocation in young population were selected. Methodological quality of the studies was assessed according to the Cochrane Back Review Group 12-item scale. Outcome measures included recurrence of instability, return to play, subsequent instability surgery, and shoulder functional scores.

RESULTS

The search returned 12 eligible trials with 786 participants. All the trials were of prospective design. After arthroscopic Bankart repair, patients experienced significantly less re-dislocation (7.5% vs. 53.0%, p < 0.00001, I² = 0%), subluxation (3.1% vs. 24.2%, p < 0.0001, I² = 0%), positive apprehension test (7.3% vs. 25.8%, p = 0.002, I² = 11%), and subsequent surgical treatment for instability (5.6% vs. 37.8%, p < 0.00001, I² = 0%) when compared with those underwent conservative management. And more patients returned to play (83.5% vs. 66.0%, p = 0.03, I² = 81%) after arthroscopic Bankart repair. Outcomes regarding the functional scores did not reach a significant difference between the two cohorts.

CONCLUSIONS

Arthroscopic Bankart repair showed superiority over conservative management in terms of recurrence, return to play, and subsequent instability surgery during the follow-up in young active patients that encountered first episode of dislocation. As long-term prognosis is comparable, an immediate surgical stabilization might not be suitable for everyone.

Arthroscopic Bankart Repair Versus Immobilization for First Episode of Anterior Shoulder Dislocation Before the Age of 25: A Randomized Controlled Trial

BACKGROUND

The risk of recurrence after the first episode of anterior shoulder dislocation is high with nonoperative treatment in younger patients.

PURPOSE/HYPOTHESIS

The aim of this study was to compare the results of arthroscopic Bankart repair and nonoperative treatment for shoulder dislocation in patients younger than 25 years, with a minimum of 2 years of follow-up. The hypothesis was that surgery would decrease the risk of recurrence.

STUDY DESIGN

Randomized controlled trial; Level of evidence, 1.

METHODS

We included patients aged between 18 and 25 years after a first episode of anterior shoulder dislocation and divided them into 2 groups. The first group was treated surgically with an arthroscopic Bankart repair within 2 weeks after the dislocation; the second group was treated nonoperatively. Both groups were immobilized for 3 weeks in internal rotation and followed the same physical therapy protocol. Standard radiography and computed tomography were performed immediately after reduction of the dislocation, and follow-up was performed at 3, 6, 12, and 24 months. The primary outcome measure was instability recurrence, defined as another anterior shoulder dislocation requiring closed reduction by another person (the patient was unable to reduce the dislocated joint themselves), a subluxation, or a positive apprehension test. Secondary outcome measures included range of motion, return to sport, and functional scores such as the short version of the Disabilities of the Arm, Shoulder and Hand score the Walch-Duplay score, and the Western Ontario Shoulder Instability Index (WOSI).

RESULTS

A total of 20 patients were included in each group. The mean ± SD age was 21 ± 1.8 years, and there were 33 men (82.5%) and 7 women (17.5%) in the total sample. Recurrence of instability was significantly decreased in the surgical treatment group compared with the nonoperative group (2 [10%] vs 14 [70%], respectively; P = .0001). Fewer patients in the surgical treatment group versus the nonoperative group had another episode of dislocation (0 vs 6 [30%], respectively), subluxation (2 [10%] vs 13 [65%], respectively; P = .003), or a positive apprehension test (1 [5%] vs 11 [58%], respectively; P = .0005). The Walch-Duplay score (88.4 vs 70.3 points; P = .046) and WOSI (11.5 vs 17.7 points; P = .035) were significantly better in the surgical group versus the nonoperative group after a 2-year follow-up. Level of sport was the same or better in 89% of the surgical treatment group vs 53% of the nonoperative treatment group (P = .012). No surgical complication was recorded. We did not find any significant difference in range of motion.

CONCLUSION

In patients with first-time shoulder dislocations, arthroscopic labral repair (Bankart procedure) reduced the risk of secondary shoulder dislocation and improved functional outcome versus nonoperative treatment after a 2-year follow-up. Surgical treatment after a first episode of shoulder dislocation could be offered as a primary treatment option in a younger population if these results are confirmed by larger studies with a longer follow-up.

REGISTRATION

NCT03315819 (ClinicalTrials.gov identifier).

The financial burden associated with multiple shoulder dislocations and the potential cost savings of surgical stabilization

Introduction

Shoulder dislocation is a costly problem and can have a high risk for recurrent instability after initial dislocation based on well-defined patient characteristics. Patients with recurrent instability can be treated with shoulder stabilizing procedures. Although more costly, surgery may decrease the overall health care burden of managing a patient with multiple shoulder dislocations nonoperatively.

Methods

We performed a retrospective chart review of all patients who presented to the emergency department (ED) with a diagnosis of a shoulder dislocation at a level 1 academic trauma center during the year 2016. Patient information regarding the current dislocation episode, previous dislocations, shoulder surgeries, and postreduction follow-up was gathered. These data were then used to determine the average cost of an ED presentation for a shoulder dislocation episode as obtained from the hospital finance department. The average cost of shoulder stabilization surgery was used to conduct a cost-benefit analysis of operative vs. nonoperative management.

Results

Data were collected on 104 individuals who presented to the ED with shoulder dislocations. Of these, 65 were primary dislocations and 39 were recurrent dislocations. Twelve patients underwent shoulder stabilization surgery after their ED presentation. The average cost to the institution for an ED visit requiring the closed reduction of a shoulder dislocation was $2207 ($973.21 without sedation and $3744 with conscious sedation). The average cost of a shoulder stabilization procedure performed at this same institution was $7807.

Discussion and conclusion

Although shoulder stabilization has a higher cost on the front end, this intervention results in cost savings if it prevents 2-3 future shoulder dislocations resulting in ED visits. These findings suggest that, for patients with a high risk for recurrent instability, not only would stabilization surgery help prevent subsequent dislocation events but would also minimize health care costs.

Treatment after traumatic shoulder dislocation: a systematic review with a network meta-analysis

OBJECTIVE

To review and compare treatments (1) after primary traumatic shoulder dislocation aimed at minimising the risk of chronic shoulder instability and (2) for chronic post-traumatic shoulder instability.

DESIGN

Intervention systematic review with random effects network meta-analysis and direct comparison meta-analyses.

DATA SOURCES

Electronic databases (Ovid MEDLINE, Cochrane Clinical Trials Register, Cochrane Database of Systematic Reviews, Embase, Scopus, CINAHL, Ovid MEDLINE Epub Ahead of Print, In-Process & Other Non-Indexed Citations, Ovid MEDLINE Daily, DARE, HTA, NHSEED, Web of Science) and reference lists were searched from inception to 15 January 2018.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Randomised trials comparing any interventions either after a first-time, traumatic shoulder dislocation or chronic post-traumatic shoulder instability, with a shoulder instability, function or quality of life outcome.

RESULTS

Twenty-two randomised controlled trials were included. There was moderate quality evidence suggesting that labrum repair reduced the risk of future shoulder dislocation (relative risk 0.15; 95% CI 0.03 to 0.8, p=0.026), and that with non-surgical management 47% of patients did not experience shoulder redislocation. Very low to low-quality evidence suggested no benefit of immobilisation in external rotation versus internal rotation. There was low-quality evidence that an open procedure was superior to arthroscopic surgery for preventing shoulder redislocations.

CONCLUSIONS

There was moderate-quality evidence that half of the patients managed with physiotherapy after a first-time traumatic shoulder dislocation did not experience recurrent shoulder dislocations. If chronic instability develops, surgery could be considered. There was no evidence regarding the effectiveness of surgical management for post-traumatic chronic shoulder instability.

Anterior Shoulder Instability: A Systematic Review of the Quality and Quantity of the Current Literature for Surgical Treatment

Background

Anterior shoulder instability is the most common sequela of shoulder dislocation and can result in repeated dislocations or subluxation of the glenohumeral joint. Anterior shoulder instability can be treated conservatively or surgically with several procedures.

Purpose

To date, arthroscopic Bankart is the most common surgical procedure for the treatment of anterior shoulder instability. No previous studies have compared all anterior shoulder surgical procedures. In this study, the authors performed a systematic review of journal articles describing all surgical procedures for anterior shoulder instability to determine the scientific evidence and level of recommendation.

Study Design

Systematic review; Level of evidence, 4.

Method

A comprehensive literature search was conducted (July 19, 2016) with 4 reputed databases: PubMed, EMBASE, the Cochrane databases, and Web of Science. The articles found in the literature search were screened by 2 reviewers on the basis of their titles, abstracts, and full text. Data were extracted from relevant studies, and potentially relevant records were selected for full-text review. Included articles were classified according to their scientific quality (level of evidence, 1-5). The studies were then combined for each surgical procedure, and a grade of recommendation was assigned for each procedure: grade A, treatment recommendation based on level 1 evidence studies; B, based on level 2 or 3 evidence studies; C, based on level 4 or 5 evidence and could represent conflicting results; or I, insufficient evidence to recommend a treatment. As such, the grade of recommendation provides a summary score for the quality and quantity of available literature to support the surgical procedures reviewed here.

Results

The systematic literature review generated 11,281 articles. After screening, 655 articles were included. Results revealed 31 surgical procedures for shoulder instability following dislocation: 10 surgical procedures were given an A or B recommendation; 11, a C recommendation; and 10, an I recommendation.

Conclusion

This review identified many surgical procedures to treat anterior shoulder instability. Ten of these surgical procedures had an abundant amount of published articles to describe their safety and efficacy. Arthroscopic Bankart and open Bankart were the most commonly reported procedures that cite satisfactory postoperative outcomes and limited complications. Publications on the other surgical procedures were less common. Surgeons should be careful when recommending surgery, and they should choose the appropriate surgical procedure based on evidence-based literature.

Controversies in the Management of the First Time Shoulder Dislocation

Background:

Traditionally, initial management of first anterior shoulder dislocations consists of reduction of the glenohumeral joint followed by a period of immobilization and subsequent physical therapy to recover shoulder range of motion and strength. This traditional approach in management is now controversial due to the high rate of recurrence. The aim of this paper is to review and discuss the literature about the global management of patients presenting with first-time traumatic anterior glenohumeral dislocation, analyzing the factors that affect shoulder instability after the first episode of dislocation.

Methods:

Scientific publications about the management of first-time shoulder dislocations are reviewed. Pubmed is used for that and no limit in the year of publication are stablished. These papers and their conclusions are discussed.

Results:

Younger patients, patient´s activities and the kind of injury are the most important factors related to the shoulder instability after a first time traumatic dislocation. Authors that recommend surgical treatment after the first episode of dislocation argue that the possibilities of recurrence are high and therefore surgery should be performed before its occurrence. Other authors, however, argue that surgical treatment is demanding, and keep in mind that complications, such as recurrence, stiffness and pain after surgery, are still present.

Conclusion:

Currently, there is still no consensus in the literature with regard to the management of first episode of shoulder dislocation. It is necessary to analyze carefully every individual case to manage them more or less aggressive to obtain the best result in our practice.

Management of the first episode of traumatic shoulder dislocation

Shoulder joint dislocation is the most common joint dislocation seen in the emergency department.Traumatic dislocation may cause damage to the soft-tissues surrounding the shoulder joint and sometimes to the bone. The treatment, which aims at restoration of a fully functioning, pain-free and stable shoulder, includes either conservative or surgical management preceded by closed reduction of the acute dislocation.Conservative management usually requires a period of rest, generally involving immobilisation of the arm in a sling, even though it is still debated whether to immobilise the shoulder in internal or external rotation.Operative management, with no significant differences in term of re-dislocation rates between open and arthroscopic repair, incorporates soft-tissue reconstructions and/or bony procedures and is recommended in young male adults engaged in highly demanding physical activities.At our institution, non-operative management is favoured particularly for patients with multi-directional instability or soft-tissue laxity. Conservative measures are often preferred in older patients or younger patients that are not actively engaged in overhead activities. Immediate surgery on all first-time dislocations may subject many patients to surgery who would not have had any future subluxation.For these reasons, initially we will always try physical therapy and activity modification for the vast majority of our patients. Cite this article: EFORT Open Rev 2017;2:35-40.DOI: 10.1302/2058-5241.2.160018.

Ten-year follow-up of acute arthroscopic Bankart repair for initial anterior shoulder dislocation in young patients

INTRODUCTION

Early treatment of initial anterior glenohumeral dislocation in young patients is controversial and the interest of surgery, and notably arthroscopic stabilization, has not been demonstrated. A prospective study was therefore performed to assess (1) short-to-medium-term recurrence rate, (2) functional outcome, and (3) and medium-term osteoarthritis rate.

HYPOTHESIS

Early arthroscopic stabilization by anterior capsule-labrum reinsertion after initial anterior shoulder dislocation is associated with low recurrence rate.

MATERIALS AND METHODS

Twenty-one patients with initial anterior dislocation were included between June 2002 and February 2004. All patients underwent arthroscopic Bankart repair within 30 days of dislocation. Patients were followed up prospectively, with clinical (Duplay and Constant scores) and radiological assessment (osteoarthritis).

RESULTS

There were 5 recurrent dislocations (25%); 2 patients reported sensations of subluxation: i.e., 7 failures (35%). Mean Walch-Duplay score at 10 years was 88±1 (range, 30-100) and mean Rowe score 86±22 (range, 35-100). There was significant internal rotation deficit of one vertebral level between operated and contralateral shoulder (P < 0.005). At 10 years, 3 shoulders (15%) showed Samilson grade 1 centered glenohumeral osteoarthritis.

CONCLUSION

Early arthroscopic capsule-labrum reinsertion by the Bankart technique in the month following initial anterior dislocation of the shoulder in patients under 25 years of age provided a low recurrence rate (35%) compared to the literature, including dislocation (25%) and subluxation (10%). Functional outcome was satisfactory, and osteoarthritis rate was low (15% Samilson grade 1).

LEVEL OF EVIDENCE

IV, prospective non-comparative study.

Approach to the treatment of primary anterior shoulder dislocation: A review

Glenohumeral joint dislocation is common among younger, active patients. Anterior dislocation is the most common direction of instability following a traumatic event. Due to a high rate of recurrence following primary traumatic anterior shoulder dislocation, an evidence-based approach is necessary to determine the best treatment regime for a patient presenting with this problem. A history, physical examination, and radiographic imaging can help guide treatment recommendations by determining the extent of soft tissue damage following dislocation. Controversies in the treatment of the first-time dislocator include the length and position of immobilization following dislocation, and the role of initial surgical stabilization. This article outlines the treatment options for the first-time glenohumeral dislocator, with an emphasis on the available evidence in the literature. Where applicable, the criteria known as the Strength of Recommendation Taxonomy were used to summarize the strength of evidence available for recommendations.

First-time anterior shoulder dislocations: should they be arthroscopically stabilised?

The glenohumeral joint is inherently unstable because the large humeral head articulates with the small shadow glenoid fossa. Traumatic anterior dislocation of the shoulder is a relatively common athletic injury, and the high frequency of recurrent instability in young athletes after shoulder dislocation is discouraging to both the patient and the treating physician. Management of primary traumatic shoulder dislocation remains controversial. Traditionally, treatment involves initial immobilisation for 4-6 weeks, followed by functional rehabilitation. However, in view of the high recurrence rates associated with this traditional approach, there has been an escalating interest in determining whether immediate surgical intervention can lower the rate of recurrent shoulder dislocation, improving the patient's quality of life. This review article aims to provide an overview of the nature and pathogenesis of first-time primary anterior shoulder dislocations, the widely accepted management modalities, and the efficacy of primary surgical intervention in first-time primary anterior shoulder dislocations.

Management of primary acute anterior shoulder dislocation: systematic review and quantitative synthesis of the literature

PURPOSE

The aim of this study was to compare the clinical outcome of surgical versus conservative treatment of primary acute anterior dislocation of the shoulder.

METHODS

A systematic review of published studies on the treatment of primary acute anterior dislocation of the shoulder was performed. Three investigators independently conducted the research. A comprehensive search of PubMed, MEDLINE, CINAHL, Cochrane Library, EMBASE, and Google Scholar databases using various combinations of the keywords "shoulder," "dislocation," "treatment," "acute," and "primary" over the years 1994 to 2013 was performed. The following data were extracted: demographics, soft tissue lesions and bone defects, outcome measurements, type of management, recurrence of instability, and complications. A quantitative synthesis of the literature was performed to compare surgery and conservative management and immobilization by internal and external in patients undergoing conservative treatment.

RESULTS

Thirty-one studies were included in which 2,813 shoulders were evaluated. All patients sustained primary acute anterior shoulder dislocation. The mean Coleman Methodology Score (CMS) was 67 points (range, 19 to 84). Pooled results from comparative studies showed that the rate of recurrence was statistically significantly lower in the surgical group than in the conservative group (odds ratio, 12.71; 95% confidence interval [CI], 4.88 to 33.10; P < .00001). External rotation immobilization provided better results than internal rotation, being associated with a lower rate of recurrence (odds ratio, 2.28; 95% CI, 1.34 to 3.87; P = .002).

CONCLUSIONS

Although limited, the available evidence from randomized controlled trials (RCTS) supports primary surgery in young adults engaged in highly demanding sports or job activities. There is lack of evidence to determine whether surgical or nonsurgical treatment is better for other categories of injury.

LEVEL OF EVIDENCE

Level IV, systematic review of Level I to IV studies.

Systematic review of rehabilitation versus operative stabilization for the treatment of first-time anterior shoulder dislocations

CONTEXT

Primary anterior shoulder dislocation is a frequent injury in young active patients. Traditionally, conservative nonoperative primary treatment has been advocated for a majority of first-time dislocators, whereas operative stabilization has been reserved for recurrent dislocators or those involved in strenuous physical activity. Currently, no consensus exists on whether to treat a first-time anterior shoulder dislocation surgically.

OBJECTIVE

(1) To provide clinical recommendations regarding the therapeutic intervention for first-time anterior shoulder dislocators and (2) to determine if there is sufficient Level 1 or 2 evidence available for the establishment of a uniform, optimal treatment protocol.

DATA SOURCES

A systematic review of prospective randomized controlled trials with human participants was performed. PubMed, the Cochrane Database of Systematic Reviews, and secondary references were appraised for studies published between 1994 and 2009.

STUDY SELECTION

Inclusion criteria were English-language Level 1 or 2 studies involving the treatment of primary anterior shoulder dislocation. Exclusion criteria included non-English-language articles; Level 3, 4, or 5 studies; and studies examining treatment of recurrent/posterior shoulder dislocation or diagnoses other than primary anterior shoulder dislocations.

DATA EXTRACTION

Each author conducted an independent quality appraisal of the included studies, identifying strengths, weaknesses, and biases, then reached consensus regarding their values.

RESULTS

Five randomized controlled trials were included, and they supported the use of operative management in a focused population. No long-term follow-up data were available describing the effects of surgical intervention or the development of osteoarthritis. Each study design had weaknesses that decreased the validity of the findings.

CONCLUSIONS

While limited, the available evidence from randomized controlled trials supports operative stabilization as a reasonable alternative to nonoperative treatment for primary acute shoulder dislocation in young, active adults participating in highly demanding physical activities. Recommendations on the optimal surgical intervention cannot be provided. There is no conclusive evidence available to determine whether operative stabilization or conservative rehabilitation is superior for other patient or injury types.

A predictive model of shoulder instability after a first-time anterior shoulder dislocation

INTRODUCTION

Management of a first-time anterior shoulder dislocation (FTASD) involves important clinical and policy decisions. Predictive disease modeling can improve the quality of information disseminated in treatment discussions. In this paper, we describe a general-purpose, publicly available model and illustrate its potential as a tool for management of a FTASD.

METHODS

A Markov decision model of the natural history of a FTASD was constructed. Outcome probabilities and effectiveness were derived from the literature or estimated by expert opinion where necessary. Outcomes were the Western Ontario Shoulder Instability index (WOSI) and the probability of a patient experiencing recurrent instability, undergoing surgical stabilization, and having a stable shoulder at 10 years. The model was both internally and externally validated. Outcomes were examined for specific cases.

RESULTS

The model was effectively externally validated against two studies, a Swedish prospective cohort of Hovelius et al and Botonni et al's military cohort. It can produce detailed outcome predictions for individuals; eg, an 18-year-old man has a 77% risk of dislocation in year 1 and a 32% chance of having a stable shoulder in 10 years.

CONCLUSION

Detailed and specific information about prognosis is critical in the management of a FTASD. Disease modeling lends itself well to these needs and allows improved shared decision-making. Our model was externally validated and can predict specific outcomes. As a publically available resource, it will allow physicians to accurately predict the expected outcome of treatment based on covariates, patient demographics, and their own surgical success rates.

Do Bankart lesions heal better in shoulders immobilized in external rotation?

BACKGROUND AND PURPOSE

Immobilization in external rotation (ER) for shoulder dislocation has been reported to improve the coaptation of Bankart lesions to the glenoid. We compared the position of the labrum in patients treated with immobilization in ER or internal rotation (IR). A secondary aim was to evaluate the rate of Bankart lesions.

PATIENTS AND METHODS

55 patients with primary anterior shoulder dislocation, aged between 16 and 40 years, were randomized to immobilization in ER or IR. Computer tomography (CT) and magnetic resonance imaging (MRI) were performed shortly after the injury. After the immobilization, MRI arthrography was performed. We evaluated the rate of Bankart lesions and measured the separation and displacement of the labrum as well as the length of the detached part of the capsule on the glenoid neck.

RESULTS

Immobilization in ER reduced the number of Bankart lesions (OR = 3.8, 95% CI: 1.1 -13; p = 0.04). Separation decreased to a larger extent in the ER group than in the IR group (mean difference 0.6 mm, 95% CI: 0.1 - 1.1, p = 0.03). Displacement of the labrum and the detached part of the capsule showed no significant differences between the groups.

INTERPRETATION

Immobilization in ER results in improved coaptation of the labrum after primary traumatic shoulder dislocation.

Traumatic anterior shoulder instability: current concepts in management

This review will give an overview of the current management practice and ethos of recurrent anterior shoulder instability, a condition which continues to puzzle and intrigue the shoulder surgeon.

Which labral lesion can be best reduced with external rotation of the shoulder after a first-time traumatic anterior shoulder dislocation?

INTRODUCTION

Immobilization in external rotation after a first-time traumatic anterior shoulder dislocation has been shown to improve the position of the labroligamentous lesion relative to the glenoid rim. The purpose of the present study was to evaluate the effect of the external rotation position of the shoulder on different types of labroligamentous lesions in patients with first-time traumatic anterior shoulder dislocation by using MRI.

PATIENTS AND METHODS

We performed a standardized MRI in internal and external rotation of the shoulder after initial reduction in 34 patients with a first-time traumatic anterior shoulder dislocation. Labroligamentous lesions were classified as Bankart, Perthes, or nonclassifiable. Four distinct grades were used to classify the amount of plastic deformation of the anterior labroligamentous structures. The position of the labrum was defined relative to the tip of the glenoid rim by measuring the dislocation and separation.

RESULTS

In all patients, dislocation and separation of the labrum relative to the rim of the glenoid were significantly improved in shoulders in the external rotation position compared to those in the internal rotation position. We observed 15 Bankart, 15 Perthes, and 4 non-classifiable lesions. No HAGL or GLAD lesions were found. Fourteen patients showed a plastic deformation grade I, 16 showed grade II, 3 showed grade III, and 1 showed grade IV. In regression analysis, the odds ratio was 1.100 for the type of lesion and 1.660 for the grade of plastic deformation. Perthes lesions (with an intact anterior scapular periosteum) and grade I plastic deformations showed the best labral reduction on the external rotation MRI.

CONCLUSION

Placing the shoulder in external rotation after a first-time traumatic shoulder dislocation, significantly improves the position of the labroligamentous lesion on the glenoid rim. Perthes lesions that showed a low grade of plastic deformation displayed better reduction in external rotation and then compared to Bankart or other lesions that showed a high grade of plastic deformation. In conclusion, immobilization of the shoulder after a first-time traumatic shoulder dislocation is most effective in patients with Perthes lesions that show low grade plastic deformation.

Nonoperative treatment of primary anterior shoulder dislocation in patients forty years of age and younger. a prospective twenty-five-year follow-up

BACKGROUND

During 1978 and 1979, we initiated a prospective multicenter study to evaluate the results of nonoperative treatment of primary anterior shoulder dislocation. In the current report, we present the outcome after twenty-five years.

METHODS

Two hundred and fifty-five patients (257 shoulders) with an age of twelve to forty years who had a primary anterior shoulder dislocation were managed with immobilization (achieved by tying the arm to the torso with use of a bandage) or without immobilization. All 227 living patients (229 shoulders) completed the follow-up questionnaire, and 214 patients completed the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire.

RESULTS

Ninety-nine (43%) of 229 shoulders had not redislocated, and seventeen (7%) redislocated once. Thirty-three recurrent dislocations had become stable over time (14.4%), and eighteen were considered to be still recurrent (7.9%). Sixty-two shoulders (27%) had undergone surgery for the treatment of recurrent instability. Immobilization after the primary dislocation did not change the prognosis. Only two of twenty-four shoulders with a fracture of the greater tuberosity at the time of the primary dislocation redislocated (p < 0.001). When shoulders with a fracture of the greater tuberosity were excluded, forty-four (38%) of 115 shoulders in patients who had been twelve to twenty-five years of age at the time of the original dislocation and sixteen (18%) of ninety shoulders in patients who had been twenty-six to forty years of age had undergone surgical stabilization. At twenty-five years, fourteen (23%) of sixty-two shoulders that had undergone surgical stabilization were in patients who subsequently had a contralateral dislocation, compared with seven (7%) of ninety-nine shoulders in patients in whom the index dislocation had been classified as solitary (p = 0.01). Gender and athletic activity did not appear to affect the redislocation rate; however, women had worse DASH scores than men did (p = 0.006).

CONCLUSIONS

After twenty-five years, half of the primary anterior shoulder dislocations that had been treated nonoperatively in patients with an age of twelve to twenty-five years had not recurred or had become stable over time.

Primary arthroscopic stabilization for a first-time anterior dislocation of the shoulder. A randomized, double-blind trial

BACKGROUND

Anterior dislocation of the glenohumeral joint in younger patients is associated with a high risk of recurrence and persistent functional deficits. The aim of this study was to assess the efficacy of a primary arthroscopic Bankart repair, while controlling for the therapeutic effects produced by the arthroscopic intervention and joint lavage.

METHODS

In a single-center, double-blind clinical trial, eighty-eight adult patients under thirty-five years of age who had sustained a primary anterior glenohumeral dislocation were randomized to receive either an arthroscopic examination and joint lavage alone or together with an anatomic repair of the Bankart lesion. Assessment of the rate of recurrent instability, functional outcome (with use of three scores), range of movement, patient satisfaction, direct health-service costs, and treatment complications was completed for eighty-four of these patients (forty-two in each group) during the subsequent two years.

RESULTS

In the two years after the primary dislocation, the risk of a further dislocation was reduced by 76% and the risk of all recurrent instability was reduced by 82% in the Bankart repair group compared with the group that had arthroscopy and lavage alone. The functional scores were also better (p < 0.05), the treatment costs were lower (p = 0.012), and patient satisfaction was higher (p < 0.001) after arthroscopic repair. The improved functional outcome appeared to be mediated through the prevention of instability since the functional outcome in patients with stable shoulders was similar, irrespective of the initial treatment allocation. The patients who had a Bankart repair and played contact sports were also more likely to have returned to their sport at two years (relative risk = 3.4, p = 0.007).

CONCLUSIONS

Following a first-time anterior dislocation of the shoulder, there is a marked treatment benefit from primary arthroscopic repair of a Bankart lesion, which is distinct from the so-called background therapeutic effect of the arthroscopic examination and lavage of the joint. However, primary repair does not appear to confer a functional benefit to patients with a stable shoulder at two years after the dislocation.

Functional outcome and risk of recurrent instability after primary traumatic anterior shoulder dislocation in young patients

BACKGROUND

The prevalence and risk factors for recurrent instability and functional impairment following a primary glenohumeral dislocation remain poorly defined in younger patients. We performed a prospective cohort study to evaluate these outcomes. We also aimed to produce guidelines for the design of future clinical trials, assessing the efficacy of interventions designed to improve the outcome after a primary dislocation.

METHODS

We performed a prospective cohort study of 252 patients ranging from fifteen to thirty-five years old who sustained an anterior glenohumeral dislocation and were treated with sling immobilization, followed by a physical therapy program. Patients received regular clinical follow-up to assess whether recurrent instability had developed. Functional assessments were made and were compared for two subgroups: those who had not had instability develop and those who had received operative stabilization to treat recurrent instability.

RESULTS

On survival analysis, instability developed in 55.7% of the shoulders within the first two years after the primary dislocation and increased to 66.8% by the fifth year. The younger male patients were most at risk of instability, and 86.7% of all of the patients known to have recurrent instability had this complication develop within the first two years. A small but measurable degree of functional impairment was present at two years after the initial dislocation in most patients. Sample-size calculations revealed that a relatively small number of patients with a primary dislocation would be required in future clinical trials examining the effects of interventions designed to reduce the prevalence of recurrent instability and improve the functional outcome.

CONCLUSIONS

Recurrent instability and deficits of shoulder function are common after primary nonoperative treatment of an anterior shoulder dislocation. There is substantial variation in the risk of instability, with younger males having the highest risk and females having a much lower risk. Future clinical trials to evaluate primary interventions should evaluate the prevalence of recurrent instability and functional deficits, with use of an assessment tool specifically for shoulder instability, during the first two years after the initial dislocation.

Surgical versus non-surgical treatment for acute anterior shoulder dislocation

BACKGROUND

Acute anterior shoulder dislocation is the commonest type of shoulder dislocation. Subsequently, the shoulder is less stable and more susceptible to re-dislocation, especially in active young adults.

OBJECTIVES

We aimed to compare surgical versus non-surgical treatment for acute anterior dislocation of the shoulder.

SEARCH STRATEGY

We searched the Cochrane Musculoskeletal Injuries Group specialised register (August 2003), the Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 3, 2003), MEDLINE (1966 to September week 3 2003), EMBASE (1988 to 2003 week 39), the National Research Register (UK) (Issue 3, 2003), conference proceedings and reference lists of articles.

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials comparing surgical with conservative interventions for treating acute anterior shoulder dislocation.

DATA COLLECTION AND ANALYSIS

Selection of the included trials was by all three reviewers. Two reviewers independently assessed methodological quality and extracted data. Where appropriate, results of comparable studies were pooled.

MAIN RESULTS

Five studies were included. These involved a total of 239 young (mainly aged around 22 years) active and mainly male people, all of whom had had a primary (first time) traumatic anterior shoulder dislocation. Methodological quality was variable, but notably there was insufficient information to judge whether allocation was effectively concealed in all five trials. Two trials, involving 115 participants, were only reported in conference abstracts.One trial involving military personnel reported that all had returned to active duty. Another trial reported similar numbers in the two intervention groups with reduced sports participation, and a third trial reported that significantly fewer people in the surgical group failed to attain previous levels of sports activity. Pooled results from all five trials showed that subsequent instability, either redislocation or subluxation, was statistically significantly less frequent in the surgical group (relative risk (RR) 0.20; 95%confidence interval (CI) 0.11 to 0.33). This result remained statistically significant (RR 0.32, 95%CI 0.17 to 0.59) for the three trials reported in full. Half (17/33) of the conservatively treated patients with shoulder instability in these three trials opted for subsequent surgery.Different, mainly patient-rated, functional assessment measures for the shoulder were recorded in the five trials. The results were more favourable, usually statistically significantly so, in the surgically treated group. Aside from a septic joint in a surgically treated patient, there were no other treatment complications reported. There was no information on shoulder pain, long-term complications such as osteoarthritis or on service utilisation and resource use.

REVIEWER'S CONCLUSIONS

The limited evidence available supports primary surgery for young adults, usually male, engaged in highly demanding physical activities who have sustained their first acute traumatic shoulder dislocation. There is no evidence available to determine whether non-surgical treatment should not remain the prime treatment option for other categories of patient. Sufficiently powered, good quality and adequately reported randomised trials of good standard surgical treatment versus good standard conservative treatment for well-defined injuries are required; in particular, for patient categories at lower risk of activity-limiting recurrence. Long term surveillance of outcome, looking at shoulder disorders including osteoarthritis is also required. Reviews comparing different surgical interventions and different conservative interventions including rehabilitation are needed.

A prospective arthroscopic study of acute first-time anterior shoulder dislocation in the young: a five-year follow-up study

A prospective arthroscopic study was conducted on 31 patients with an acute first-time anterior shoulder dislocation (AFASD). The patients were aged between 16 and 39 years. The mean age was 24 years. None had a history of shoulder problems. All were evaluated after 1, 2, and 5 years. The Constant score, Rowe score, recurrence rate, and instability rate were evaluated, as well as patient satisfaction and sports participation. We conclude that after a prolonged follow-up, an increase in the instability rate in young patients with AFASD may become apparent. The overall instability rate was 55% (17/31) after 5-year follow-up. In patients aged younger than 18 years the instability rate was 71% (5/7). Age was the only predictive factor in shoulder instability. The mean Rowe score was 87 (range, 57-100; SD, 14). Three patients had undergone a stabilization operation at the 5-year follow-up. The intraarticular pathology found at arthroscopy was not predictive of shoulder instability. We could not find a correlation between sporting activities and shoulder instability. On the basis of our results, it appears unlikely that arthroscopic lavage reduces redislocation rates after AFASD in the young patient.

Traumatic anterior shoulder dislocation in adolescents

BACKGROUND

Recurrent instability is the most common complication after traumatic anterior shoulder dislocation in young patients.

HYPOTHESIS

The rate of recurrent instability in a homogeneous population of adolescents after initial traumatic anterior shoulder dislocation is significant and is associated with a guarded prognosis for full recovery.

STUDY DESIGN

Retrospective cohort study.

METHODS

We identified 32 patients 11 to 18 years of age treated at our institution for a radiographically documented traumatic anterior shoulder dislocation; we performed a functional outcome assessment on 30 patients with use of two standard scoring systems.

RESULTS

Overall, instability recurred in 24 of 32 patients, with 23 experiencing at least one recurrent dislocation. Persistent instability led 16 of 32 to undergo a shoulder stabilization procedure. There were no significant differences in the functional outcome of patients who had undergone surgical stabilization and those who were treated nonoperatively.

CONCLUSIONS

The recurrence rate of shoulder instability was 75%. Outcome scores were similar for patients treated with a surgical procedure and those treated nonoperatively.

CLINICAL SIGNIFICANCE

Treatment efforts must be aimed at optimizing shoulder strength and stability. Prognosis for full recovery remains guarded. Available outcome instruments may not discriminate well between patients who do and do not choose surgery.

Regional musculoskeletal conditions: shoulder pain

About half the population has at least one episode of shoulder pain yearly. History and clinical examination are cornerstones in the evaluation of the patient. Shoulder pain at the work place is associated with job strain: lack of control and work with elevated arms and hand tools. Clinical skills and knowledge about red and yellow flags and biomechanics are essential to perform a systematic and reliable evaluation. The diagnostic validity of clinical tests for rotator cuff tear, impingement syndrome and superior labral tears is equal or better than ultrasound and magnetic resonance imaging. Non-steroidal anti-inflammatory drugs and cortico-steroidal injections have documented short-term pain relief. Additionally, the physician should attempt to give the patient simple advice and reinforce active coping strategies. One randomized study suggests that a proper physiotherapy regimen and surgery are equally effective for the impingement syndrome. Further research should address the cost-effectiveness of diagnostic methods and treatments.

Management of shoulder dislocation--are we doing enough to reduce the risk of recurrence?

Young patients with shoulder dislocation are at high risk of recurrence. Traditionally, management has been conservative, but rehabilitative programmes are successful in fewer than 20% of patients. Recent studies suggest that early surgical intervention (arthroscopic lavage or stabilisation) can significantly reduce recurrence in young patients with primary traumatic anterior dislocation. This study demonstrated that in our region, 21% of all patients presenting with shoulder dislocation had already suffered recurrence at 1 year; in the 15-22 years age group this figure was 43%. We propose to offer young patients presenting with primary traumatic anterior dislocations arthroscopic lavage within 10 days of injury. The extra surgical workload is manageable within our current trauma service arrangements, and we believe that this form of treatment would be acceptable to patients.

A prospective, randomized evaluation of arthroscopic stabilization versus nonoperative treatment in patients with acute, traumatic, first-time shoulder dislocations

BACKGROUND

Nonoperative treatment of traumatic shoulder dislocations leads to a high rate of recurrent dislocations.

HYPOTHESIS

Early arthroscopic treatment for shoulder dislocation will result in a lower recurrence rate than nonoperative treatment.

STUDY DESIGN

Prospective, randomized clinical trial.

METHODS

Two groups of patients were studied to compare nonoperative treatment with arthroscopic Bankart repair for acute, traumatic shoulder dislocations in young athletes. Fourteen nonoperatively treated patients underwent 4 weeks of immobilization followed by a supervised rehabilitation program. Ten operatively treated patients underwent arthroscopic Bankart repair with a bioabsorbable tack followed by the same rehabilitation protocol as the nonoperatively treated patients. The average follow-up was 36 months.

RESULTS

Three patients were lost to follow-up. Twelve nonoperatively treated patients remained for follow-up. Nine of these (75%) developed recurrent instability. Six of the nine have required subsequent open Bankart repair for recurrent instability. Of the nine operatively treated patients available for follow-up, only one (11.1%) developed recurrent instability.

CONCLUSIONS

Arthroscopic stabilization of traumatic, first-time anterior shoulder dislocations is an effective and safe treatment that significantly reduces the recurrence rate of shoulder dislocations in young athletes when compared with conventional, nonoperative treatment.