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Kearney R, Ellard D, Parsons H, Haque A, Mason J, Nwankwo H, Bradley H, Drew S, Modi C, Bush H, Torgerson D, Underwood M. Advice only versus advice and a physiotherapy programme for acute traumatic anterior shoulder dislocation: the ARTISAN RCT. Health Technol Assess 2024; 28:1-94. [PMID: 38695098 PMCID: PMC11089447 DOI: 10.3310/cmyw9226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/15/2024] Open
Abstract
Background The extra benefit of a programme of physiotherapy in addition to advice alone, following first-time traumatic shoulder dislocation, is uncertain. We compared the clinical and cost-effectiveness of a single session of advice with a single session of advice and a programme of physiotherapy. Objective The primary objective was to quantify and draw inferences about observed differences in the Oxford Shoulder Instability Score between the trial treatment groups 6 months post randomisation, in adults with a first-time traumatic shoulder dislocation. Design A pragmatic, multicentre, superiority, randomised controlled trial with embedded qualitative study. Setting Forty-one hospitals in the UK NHS. Participants Adults with a radiologically confirmed first-time traumatic anterior shoulder dislocation, being managed non-operatively. People with neurovascular complications or bilateral dislocations, and those unable to adhere to trial procedures or unable to attend physiotherapy within 6 weeks of injury, or who had previously been randomised, were excluded. Interventions All participants received the same initial shoulder examination followed by advice to aid self-management, lasting up to 1 hour and administered by a physiotherapist (control). Participants randomised to receive an additional programme of physiotherapy were offered sessions lasting for up to 30 minutes, over a maximum duration of 4 months from the date of randomisation (intervention). Main outcome measures The primary outcome measure was the Oxford Shoulder Instability Score. This is a self-completed outcome measure containing 12 questions (0-4 points each), with possible scores from 0 (worst function) to 48 (best function). Measurements were collected at 6 weeks, 3 months, 6 months and 12 months by postal questionnaire; 6 months was the primary outcome time point. The primary health outcome for economic evaluation was the quality-adjusted life-year, in accordance with National Institute of Health and Care Excellence guidelines. Results Between 14 November 2018 and 14 March 2022, 482 participants were randomised to advice (n = 240) or advice and a programme of physiotherapy (n = 242). Participants were 34% female, with a mean age of 45 years, and treatment arms were balanced at baseline. There was not a statistically significant difference in the primary outcome between advice only and advice plus a programme of physiotherapy at 6 months for the primary intention-to-treat adjusted analysis (favours physiotherapy: 1.5, 95% confidence interval -0.3 to 3.5) or at earlier 3-month and 6-week time points on the Oxford Shoulder Instability Score (0-48; higher scores indicate better function). The probability of physiotherapy being cost-effective at a willingness-to-pay threshold of £30,000 was 0.95. Conclusions We found little difference in the primary outcome or other secondary outcomes. Advice with additional physiotherapy sessions was found likely to be cost-effective. However, small imprecise incremental costs and quality-adjusted life-years raise questions on whether it is the best use of scarce physiotherapy resources given current service demands. Limitations Loss to follow-up was 27%; however, the observed standard deviation was much smaller than anticipated. These changes in parameters reduced the number of participants required to observe the planned target difference of four points. Our post hoc sensitivity analysis, accounting for missing data, gives similar results. Future work Further research should be directed towards optimising self-management strategies. Study registration This study is registered as ISRCTN63184243. Funding This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: 16/167/56) and is published in full in Health Technology Assessment; Vol. 28, No. 22. See the NIHR Funding and Awards website for further award information.
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Affiliation(s)
| | - David Ellard
- Warwick Medical School, University of Warwick, Coventry, UK
- University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Helen Parsons
- Warwick Medical School, University of Warwick, Coventry, UK
- University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Aminul Haque
- Warwick Medical School, University of Warwick, Coventry, UK
| | - James Mason
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Henry Nwankwo
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Helen Bradley
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Steve Drew
- University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Chetan Modi
- University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Howard Bush
- University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | | | - Martin Underwood
- Warwick Medical School, University of Warwick, Coventry, UK
- University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
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2
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Kearney RS, Ellard DR, Parsons H, Haque A, Mason J, Nwankwo H, Bradley H, Drew S, Modi C, Bush H, Torgerson D, Underwood M. Acute rehabilitation following traumatic anterior shoulder dislocation (ARTISAN): pragmatic, multicentre, randomised controlled trial. BMJ 2024; 384:e076925. [PMID: 38233068 PMCID: PMC10792684 DOI: 10.1136/bmj-2023-076925] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/04/2023] [Indexed: 01/19/2024]
Abstract
OBJECTIVE To assess the effects of an additional programme of physiotherapy in adults with a first-time traumatic shoulder dislocation compared with single session of advice, supporting materials, and option to self-refer to physiotherapy. DESIGN Pragmatic, multicentre, randomised controlled trial (ARTISAN). SETTING AND PARTICIPANTS Trauma research teams at 41 UK NHS Trust sites screened adults with a first time traumatic anterior shoulder dislocation confirmed radiologically, being managed non-operatively. People were excluded if they presented with both shoulders dislocated, had a neurovascular complication, or were considered for surgical management. INTERVENTIONS One session of advice, supporting materials, and option to self-refer to physiotherapy (n=240) was assessed against the same advice and supporting materials and an additional programme of physiotherapy (n=242). Analyses were on an intention-to-treat basis with secondary per protocol analyses. MAIN OUTCOME MEASURES The primary outcome was the Oxford shoulder instability score (a single composite measure of shoulder function), measured six months after treatment allocation. Secondary outcomes included the QuickDASH, EQ-5D-5L, and complications. RESULTS 482 participants were recruited from 40 sites in the UK. 354 (73%) participants completed the primary outcome score (n=180 allocated to advice only, n=174 allocated to advice and physiotherapy). Participants were mostly male (66%), with a mean age of 45 years. No significant difference was noted between advice compared with advice and a programme of physiotherapy at six months for the primary intention-to-treat adjusted analysis (between group difference favouring physiotherapy 1.5 (95% confidence interval -0.3 to 3.5)) or at earlier three month and six week timepoints. Complication profiles were similar across the two groups (P>0.05). CONCLUSIONS An additional programme of current physiotherapy is not superior to advice, supporting materials, and the option to self-refer to physiotherapy. TRIAL REGISTRATION Current Controlled Trials ISRCTN63184243.
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Affiliation(s)
| | - David R Ellard
- Warwick Clinical Trials Unit, University of Warwick, Warwick, UK
| | - Helen Parsons
- Warwick Clinical Trials Unit, University of Warwick, Warwick, UK
| | - Aminul Haque
- Warwick Clinical Trials Unit, University of Warwick, Warwick, UK
| | - James Mason
- Warwick Clinical Trials Unit, University of Warwick, Warwick, UK
| | - Henry Nwankwo
- Warwick Clinical Trials Unit, University of Warwick, Warwick, UK
| | - Helen Bradley
- Warwick Clinical Trials Unit, University of Warwick, Warwick, UK
| | - Stephen Drew
- University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Chetan Modi
- University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Howard Bush
- University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | | | - Martin Underwood
- Warwick Clinical Trials Unit, University of Warwick, Warwick, UK
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3
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Liew Z, Mazuquin B, Ellard DR, Karasouli E, Drew S, Modi C, Bush H, Underwood M, Kearney RS. Development of a single-session physiotherapy and self-management intervention for the treatment of primary traumatic anterior shoulder dislocation for the 'Acute Rehabilitation following Traumatic anterior shoulder dISlocAtioN (ARTISAN)' multi centre RCT. Physiotherapy 2021; 113:80-87. [PMID: 34607077 PMCID: PMC8612274 DOI: 10.1016/j.physio.2021.06.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Revised: 05/04/2021] [Accepted: 06/14/2021] [Indexed: 11/18/2022]
Abstract
Objective Optimum physiotherapy management for people with a conservatively managed primary traumatic anterior shoulder dislocation is not known. The purpose of the ARTISAN trial is to compare the clinical and cost-effectiveness of a course of usual care physiotherapy with a single session of physiotherapy and self-management, the ARTISAN intervention. ARTISAN is a UK multi-centre, two-arm, parallel group, randomised controlled trial with 1:1 treatment allocation. Design The intervention was developed following the Medical Research Council framework for developing and evaluating complex interventions and will be reported in line with the template for intervention description and replication checklist (TIDieR) and the Consensus on Exercise Reporting Template (CERT). It was informed by published research, national clinical guidelines, current clinical practice and patient and public involvement. Results The ARTISAN intervention comprises education (Phase 1), progressive exercise (Phase 2 and Phase 3) and an optional return to sport component (Phase 4). Behaviour change strategies are embedded throughout intervention. The single session of physiotherapy is delivered by a chartered physiotherapist, within the first six weeks of injury, in an NHS outpatient setting. At the end of the initial session, paper-based booklets and/or a patient website with the same content are provided to participants to aid self-management and progression though the four phases of the trial intervention. Conclusion The ARTISAN intervention was successfully implemented throughout the internal pilot and is suitable for testing in the subsequent definitive RCT ARTISAN trial.
Trial Registration Number ISRCTN63184243
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Affiliation(s)
- ZiHeng Liew
- University of Warwick, Clinical Trials Unit, Gibbet Hill Road, Coventry, CV4 7AL, United Kingdom.
| | - Bruno Mazuquin
- Manchester Metropolitan University, Manchester, M15 6BH, United Kingdom.
| | - David R Ellard
- University of Warwick, Clinical Trials Unit, Gibbet Hill Road, Coventry, CV4 7AL, United Kingdom.
| | - Eleni Karasouli
- University of Warwick, Clinical Trials Unit, Gibbet Hill Road, Coventry, CV4 7AL, United Kingdom.
| | - Stephen Drew
- University Hospitals Coventry & Warwickshire NHS Trust, Trauma and Orthopaedics, Clifford Bridge Road, Coventry, CV2 2DX, United Kingdom.
| | - Chetan Modi
- University Hospitals Coventry & Warwickshire NHS Trust, Trauma and Orthopaedics, Clifford Bridge Road, Coventry, CV2 2DX, United Kingdom.
| | - Howard Bush
- University Hospitals Coventry & Warwickshire NHS Trust, Trauma and Orthopaedics, Clifford Bridge Road, Coventry, CV2 2DX, United Kingdom.
| | - Martin Underwood
- University of Warwick, Clinical Trials Unit, Gibbet Hill Road, Coventry, CV4 7AL, United Kingdom; University Hospitals Coventry & Warwickshire NHS Trust, Trauma and Orthopaedics, Clifford Bridge Road, Coventry, CV2 2DX, United Kingdom.
| | - Rebecca S Kearney
- University of Warwick, Clinical Trials Unit, Gibbet Hill Road, Coventry, CV4 7AL, United Kingdom; University Hospitals Coventry & Warwickshire NHS Trust, Trauma and Orthopaedics, Clifford Bridge Road, Coventry, CV2 2DX, United Kingdom.
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4
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Kadantsev PM, Logvinov AN, Ilyin DO, Ryazantsev MS, Afanasiev AP, Korolev AV. [Shoulder instability: review of current concepts of diagnosis and treatment]. Khirurgiia (Mosk) 2021:109-124. [PMID: 33977706 DOI: 10.17116/hirurgia2021051109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To conduct a systematic review of modern literature data on the modern approaches in diagnosis and treatment of shoulder instability. MATERIAL AND METHODS Searching for literature data was performed using the Pubmed and Google Scholar databases. RESULTS The authors analyzed the results of conservative treatment of patients with shoulder instability and emphasized higher risk of instability recurrence, degeneration of anatomical structures and functional impairment in these patients. Surgery is advisable to restore shoulder stability and normalize its function. Several methods for stabilizing the shoulder have been proposed. The approaches to diagnosis and treatment of shoulder instability have been updated. CONCLUSION Successful treatment of shoulder instability is based on qualitative and complete assessment of soft tissues and bone structures. An individual approach considering bone tissue deficiency and individual needs of the patient is required.
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Affiliation(s)
- P M Kadantsev
- European Clinic of Sports Traumatology and Orthopedics (ECSTO), Moscow, Russia.,Peoples Friendship University of Russia, Moscow, Russia
| | - A N Logvinov
- European Clinic of Sports Traumatology and Orthopedics (ECSTO), Moscow, Russia
| | - D O Ilyin
- European Clinic of Sports Traumatology and Orthopedics (ECSTO), Moscow, Russia.,Peoples Friendship University of Russia, Moscow, Russia
| | - M S Ryazantsev
- European Clinic of Sports Traumatology and Orthopedics (ECSTO), Moscow, Russia
| | - A P Afanasiev
- European Clinic of Sports Traumatology and Orthopedics (ECSTO), Moscow, Russia
| | - A V Korolev
- European Clinic of Sports Traumatology and Orthopedics (ECSTO), Moscow, Russia.,Peoples Friendship University of Russia, Moscow, Russia
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Minkus M, Königshausen M, Maier D, Mauch F, Stein T, Greiner S, Moursy M, Scheibel M. Immobilization in External Rotation and Abduction Versus Arthroscopic Stabilization After First-Time Anterior Shoulder Dislocation: A Multicenter Randomized Controlled Trial. Am J Sports Med 2021; 49:857-865. [PMID: 33596092 PMCID: PMC7961655 DOI: 10.1177/0363546520987823] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Treatment of first-time shoulder dislocation (FSD) is a topic of debate. After high rates of recurrent instability after nonoperative management were reported in the literature, primary repair of FSD significantly increased. At the same time, new concepts were proposed that had promising results for immobilization in external rotation (ER) and abduction (ABD). PURPOSE The aim of this study was to evaluate the recurrence rates (primary outcome) and clinical outcomes (secondary outcome parameters) of immobilization in ER+ABD versus arthroscopic primary stabilization after FSD. STUDY DESIGN Randomized controlled trial; Level of evidence, 1. METHODS In a multicenter randomized controlled trial, patients with FSD were randomized to either treatment with immobilization in 60° of ER plus 30° of ABD (group 1) or surgical treatment with arthroscopic Bankart repair (group 2). Clinical evaluation was performed 1, 3, and 6 weeks as well as 6, 12, and 24 months postoperatively or after reduction, including range of motion, instability testing, subjective shoulder value, Constant-Murley score, Rowe score, and Western Ontario Shoulder Instability Index. Recurrent instability events were prospectively recorded. RESULTS Between 2011 and 2017, a total of 112 patients were included in this study. Of these, 60 patients were allocated to group 1 and 52 to group 2. At the 24-month follow-up, 91 patients (81.3%) were available for clinical examination. The recurrence rate was 19.1% in group 1 and 2.3% in group 2 (P = .016). No significant differences were found between groups regarding clinical shoulder scores (P > .05). Due to noncompliance with the immobilization treatment protocol, 4 patients (6.7%) were excluded. CONCLUSION Immobilization in ER+ABD versus primary arthroscopic shoulder stabilization for the treatment of FSD showed no differences in clinical shoulder scores. However, recurrent instability was significantly higher after nonoperative treatment.
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Affiliation(s)
- Marvin Minkus
- Department for Shoulder and Elbow Surgery, Center for Musculoskeletal Surgery, Charité Universitaetsmedizin Berlin, Berlin, Germany
| | - Matthias Königshausen
- Department of Trauma Surgery and Orthopaedics, Ruhr-University Hospital Bergmannsheil Bochum, Bochum, Germany
| | - Dirk Maier
- Department of Orthopedics and Trauma Surgery, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Frieder Mauch
- Department of Shoulder and Elbow Surgery, Sportklinik Stuttgart, Stuttgart, Germany
| | - Thomas Stein
- Department of Sport Traumatology, Knee and Shoulder Surgery, Berufsgenossenschaftliche Unfallklinik, Frankfurt am Main, Germany,Department of Sports Medicine, Goethe University Frankfurt, Frankfurt am Main, Germany
| | | | - Mohamed Moursy
- Orthopedics & Trauma Centre, Medical Faculty of Mannheim, University of Heidelberg, Mannheim, Germany,Department of Orthopedics and Traumatology, Paracelsus Medical University, Salzburg, Austria
| | - Markus Scheibel
- Department for Shoulder and Elbow Surgery, Center for Musculoskeletal Surgery, Charité Universitaetsmedizin Berlin, Berlin, Germany,Department of Shoulder and Elbow Surgery, Schulthess Clinic Zurich, Zurich, Switzerland,Markus Scheibel, MD, Department of Shoulder and Elbow Surgery, Center for Musculoskeletal Surgery, Charité-Universitaetsmedizin Berlin, Augustenburger Platz 1, Berlin, 13353, Germany ()
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6
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Fox A, Bonacci J, Gill SD, Page RS. Evaluating the effects of arthroscopic Bankart repair and open Latarjet shoulder stabilisation procedures on shoulder joint neuromechanics and function: a single-centre, parallel-arm trial protocol. BMJ Open Sport Exerc Med 2021; 7:e000956. [PMID: 33692905 PMCID: PMC7907843 DOI: 10.1136/bmjsem-2020-000956] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/18/2021] [Indexed: 11/16/2022] Open
Abstract
Introduction Shoulder instability injuries are common in sports involving collisions and overhead movements. Arthroscopic Bankart repair and the open Latarjet are two commonly used surgical stabilisation procedures. There is a lack of knowledge surrounding movement strategies, joint loading and muscle strength after each of these procedures. This study will compare: (1) shoulder joint neuromechanics during activities of daily living and an overhead sporting task; (2) shoulder range of motion; (3) shoulder strength; and (4) self-reported shoulder function and health status, between individuals who have undergone an arthroscopic Bankart repair versus open Latarjet. Methods and analysis This is a prospective cohort, single-centre, non-randomised parallel arm study of surgical interventions for athletic shoulder instability injuries. Thirty participants will be recruited. Of these, 20 will have experienced one or more traumatic shoulder instability injuries requiring surgical stabilisation—and will undergo an arthroscopic Bankart repair or open Latarjet procedure. The remaining 10 participants will have no history of shoulder instability injury and act as controls. Participants will undergo baseline testing and be followed up at 3, 6 and 12 months. A two-way (group×time) analysis of variance with repeated measures on one factor (ie, time) will compare each outcome measure between groups across time points. Ethics and dissemination This study was approved by the Barwon Health and Deakin University Human Research Ethics Committees. Outcomes will be disseminated through publications in peer-reviewed journals and presentations at relevant scientific conferences. Trial registration number Australian and New Zealand Clinical Trials Registry (ACTRN12620000016932).
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Affiliation(s)
- Aaron Fox
- Centre for Sport Research, School of Exercise and Nutrition Sciences, Deakin University, Waurn Ponds, Victoria, Australia.,Barwon Centre for Orthopaedic Research and Education (B-CORE), Barwon Health, Geelong, Victoria, Australia
| | - Jason Bonacci
- Centre for Sport Research, School of Exercise and Nutrition Sciences, Deakin University, Waurn Ponds, Victoria, Australia
| | - Stephen D Gill
- Barwon Centre for Orthopaedic Research and Education (B-CORE), Barwon Health, Geelong, Victoria, Australia.,School of Medicine, Deakin University, Geelong, Victoria, Australia
| | - Richard S Page
- Barwon Centre for Orthopaedic Research and Education (B-CORE), Barwon Health, Geelong, Victoria, Australia.,School of Medicine, Deakin University, Geelong, Victoria, Australia.,Orthopaedic Department, University Hospital Geelong, Geelong, Victoria, Australia
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Kearney RS, Dhanjal G, Parsons N, Ellard D, Parsons H, Haque A, Karasouli E, Mason J, Nwankwo H, Brown J, Liew Z, Drew S, Modi C, Bush H, Torgerson D, Underwood M. Acute Rehabilitation following Traumatic anterior shoulder dISlocAtioN (ARTISAN): protocol for a multicentre randomised controlled trial. BMJ Open 2020; 10:e040623. [PMID: 33444204 PMCID: PMC7678365 DOI: 10.1136/bmjopen-2020-040623] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION First-time traumatic anterior shoulder dislocation (TASD) is predominantly managed non-operatively. People sustaining TASD have ongoing pain, disability and future risk of redislocation. There are no published randomised controlled trials (RCTs) comparing different non-operative rehabilitation strategies to ascertain the optimum clinically effective approach after TASD. METHODS AND ANALYSIS In this multicentre adaptive RCT, with internal pilot, adults with a radiologically confirmed first time TASD treated non-surgically will be screened at a minimum of 30 sites. People with neurovascular complications, bilateral dislocations or are unable to attend physiotherapy will be excluded.Randomisation will be on a 1:1 treatment allocation, stratified by age, hand dominance and site. Participants will receive a single session of advice; or a single session of advice plus offer of further physiotherapy (maximum 4 months). The primary analysis will be the difference in Oxford Shoulder Instability Score at 6 months. A sample size of a minimum of 478 participants will allow us to show a four point difference with 90% power.An embedded qualitative study will explore the participants' experiences of the trial interventions. ETHICS, REGISTRATION AND DISSEMINATION Funded by NIHR HTA (16/167/56), 1 June 2018; National Research Ethic Committee approved (18/WA/0236), 26 July 2018. First site opened 5 November 2018 and final results will be updated on trial registries and submitted to a peer-reviewed journal and will inform rehabilitation strategies after a TASD. Study Within A Trial (SWAT) funded by MRC (MR/R013748/1), 1 May 2019; registered on the MRC-HTMR All-Ireland Hub (reference number SWAT 121). TRIAL REGISTRATION NUMBER ISRCTN63184243. (Trial stage: Pre-results).
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Affiliation(s)
| | - Gurmit Dhanjal
- Warwick Medical School, University of Warwick, Coventry, UK
| | | | - David Ellard
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Helen Parsons
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Aminul Haque
- Warwick Medical School, University of Warwick, Coventry, UK
| | | | - James Mason
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Henry Nwankwo
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Jaclyn Brown
- Warwick Medical School, University of Warwick, Coventry, UK
| | - ZiHeng Liew
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Stephen Drew
- Trauma and Orthopaedics, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Chetan Modi
- Trauma and Orthopaedics, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Howard Bush
- Trauma and Orthopaedics, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
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8
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Kraeutler MJ, Belk JW, Carver TJ, McCarty EC, Khodaee M. Traumatic Primary Anterior Glenohumeral Joint Dislocation in Sports: A Systematic Review of Operative versus Nonoperative Management. Curr Sports Med Rep 2020; 19:468-478. [PMID: 33156033 DOI: 10.1249/jsr.0000000000000772] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Anterior shoulder (glenohumeral joint [GHJ]) dislocations are relatively common injuries in sports. Previous studies have evaluated clinical outcomes of operative and nonoperative management for primary traumatic anterior GHJ dislocations. The purpose of this study was to systematically review the literature in an effort to provide a thorough analysis of patients after undergoing closed reduction of a traumatic anterior GHJ dislocation, particularly among the athletic population. Two independent reviewers performed a comprehensive search of PubMed and the Cochrane Library through February 23, 2020. Unfortunately, the quantity and quality of published articles on this subject is very limited. In many studies, younger age (between 21 and 30 years) was associated with greater risk for recurrence of GHJ dislocations. Twelve studies (total N = 753) directly compared outcomes of operative versus nonoperative management. It seems that operative management significantly reduces recurrence rates with patients treated operatively among the young and active population. Operative management should be considered as a treatment option for young and athletic patients presenting with a first-time anterior GHJ dislocation.
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Affiliation(s)
- Matthew J Kraeutler
- Department of Orthopaedic Surgery, St. Joseph's University Medical Center, Paterson, NJ
| | | | | | | | - Morteza Khodaee
- Department of Family Medicine and Orthopedics, University of Colorado School of Medicine, Denver, CO
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9
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Joukainen A, Mattila VM, Lepola V, Lehtinen J, Kukkonen J, Paloneva J. Trends of shoulder instability surgery in Finland: a nationwide register study. BMJ Open 2020; 10:e040510. [PMID: 33028564 PMCID: PMC7539571 DOI: 10.1136/bmjopen-2020-040510] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Revised: 07/30/2020] [Accepted: 09/11/2020] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE Rate of shoulder instability surgery (SIS) has increased in different specific populations. We analysed nationwide trend of SIS in adults in Finland between 1997 and 2014. DESIGN A retrospective register study. SETTING National Hospital Discharge Register of Finland. PARTICIPANTS A total of 22 550 adult patients with SIS in Finland (1997-2014). PRIMARY AND SECONDARY OUTCOME MEASURES Analysis included appropriate diagnosis (International Classification of Diseases 10) and procedure coding combinations applicable for SIS. The primary outcome variable was the incidence of SIS per 100 000 person-years, and the secondary outcomes were the study year, sex, age groups (18-29, 30-49 and over 50 years of age) and the type of hospital (public or private). RESULTS The overall nationwide rate of SIS in adults increased 177% between 1997 and 2014 in Finland. The rate was the lowest (13/100 000 person-years) in 1997, and the peak rate (40/100 000 person-years) was noted in 2007. The increase in rate was rapid between 1997 and 2007, after which the rate became stable. During the study period, the highest increases were noted in the young adults age group (270%), and especially in the middle-aged group who were operated on in private hospitals (930%). CONCLUSIONS The rate of SIS increased almost threefold in Finland from 1997 to 2014. The increase was most significant in young and middle-aged adults (18-50 years), in men, and in private hospitals.
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Affiliation(s)
- Antti Joukainen
- Department of Orthopaedics, Traumatology and Hand Surgery, Kuopio University Hospital, Kuopio, Finland
| | - Ville M Mattila
- Department of Orthopaedics and Traumatology, Tampere University Hospital, Tampere, Finland
| | | | - Janne Lehtinen
- Hatanpää Unit, Tampere University Hospital, Tampere, Finland
| | - Juha Kukkonen
- Department of Orthopaedics and Traumatology, Turku University Hospital, Turku, Finland
| | - Juha Paloneva
- Department of Surgery, Central Finland Hospital Nova, Jyvaskyla, Finland
- University of Eastern Finland, Kuopio, Finland
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10
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Updegrove GF, Buckley PS, Cox RM, Selverian S, Patel MS, Abboud JA. Latarjet Procedure for Anterior Glenohumeral Instability: Early Postsurgical Complications for Primary Coracoid Transfer Versus Revision Coracoid Transfer After Failed Prior Stabilization. Orthop J Sports Med 2020; 8:2325967120924628. [PMID: 32587873 PMCID: PMC7294484 DOI: 10.1177/2325967120924628] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Accepted: 02/15/2020] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND The Latarjet procedure (coracoid transfer) is often used to successfully treat failed instability procedures. However, given the reported increased complication rates in primary Latarjet surgery, there is a heightened concern for complications in performing the Latarjet procedure as revision surgery. PURPOSE To evaluate the early outcomes and complications of the Latarjet procedure as primary surgery compared with revision surgery. STUDY DESIGN Cohort study; Level of evidence, 3. METHODS A total of 157 patients were included and retrospectively reviewed: 103 patients in the revision group and 54 patients in the primary group. Patients were evaluated by physical examination findings as well as by documentation of complications and reoperations extracted from their electronic medical records. RESULTS The mean follow-up was 7.8 ± 11.0 months for the primary group and 7.0 ± 13.2 months for the revision group. There were no significant differences in overall complication rates between the primary and revision groups (16.7% vs 8.7%, respectively; P = .139). The complication rate was significantly higher in patients in the revision group who had undergone a prior open procedure compared with those who had undergone only arthroscopic procedures (30.0% vs 4.1%, respectively; P < .001). Of those patients who sustained a complication, 7 of the 9 underwent a reoperation in the primary group (13.0%), and 7 of the 9 did so in the revision group (6.8%); the risk of reoperations was not different between groups (P = .198). There were 4 patients in the primary group (7.4%) and 5 patients in the revision group (4.9%) who experienced recurrent dislocations during the follow-up period (P = .513). There was no difference in postoperative range of motion. CONCLUSION The Latarjet procedure is a reasonable option for the treatment of failed arthroscopic instability repair with an early complication rate similar to that found in primary Latarjet surgery.
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Affiliation(s)
- Gary F. Updegrove
- Department of Orthopaedics and Rehabilitation, Penn State Health Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA
| | - Patrick S. Buckley
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Ryan M. Cox
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Stephen Selverian
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Manan S. Patel
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Joseph A. Abboud
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
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11
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Baden DN, Roetman MH, Boeije T, Mullaart-Jansen N, Burg MD. A Survey of Emergency Providers Regarding the Current Management of Anterior Shoulder Dislocations. J Emerg Trauma Shock 2020; 13:68-72. [PMID: 32395054 PMCID: PMC7204951 DOI: 10.4103/jets.jets_87_18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2018] [Accepted: 01/25/2019] [Indexed: 11/17/2022] Open
Abstract
Background: Anterior shoulder dislocations (ASDs) are frequent painful injuries commonly treated in the emergency department. The last decade new potentially less traumatic and painful reduction techniques for ASDs have been introduced. Recent literature comparing best reduction techniques, medication use, and approaches is limited. To better guide future research including the use of these newer techniques, information about the current use of different reduction techniques and medication is needed. Methods: Our primary aim was to survey the techniques used by emergency practitioners to reduce ASDs. Our secondary objective was to gather data on medication usage during reduction. To these ends, we surveyed members of the Netherlands Society of Emergency Physicians. Results: Forty-four percent of respondents reported using a traction-based technique (Hippocrates or Stimson). Biomechanical techniques were used by 40% of respondents. Twelve percent reported using the Kocher leverage-based technique. Five percent of the techniques used could not be classified. A wide variety of procedural sedation and pain management interventions were reported, with an opioid and propofol being used most commonly. Approximately 9% of the reductions were attempted without any medications. Conclusions: To our knowledge, this is the first study of its kind on ASD management by emergency practitioners. Our results indicate that Dutch emergency practitioners employ all three classes of reduction techniques: traction-countertraction most commonly, closely followed by biomechanical techniques. Medication use during repositioning varied widely. Per our survey, emergency practitioners are desirous of an evidence-based guideline for ASD management.
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Affiliation(s)
- D N Baden
- Department of Emergency Medicine, Dijklander Ziekenhuis, Hoorn, Netherlands
| | - M H Roetman
- Department of Emergency Medicine, Flevoziekenhuis, Almere, Netherlands
| | - T Boeije
- Department of Emergency Medicine, Dijklander Ziekenhuis, Hoorn, Netherlands
| | - N Mullaart-Jansen
- Department of Emergency Medicine, Dijklander Ziekenhuis, Hoorn, Netherlands
| | - M D Burg
- Department of Emergency Medicine, UCSF/Fresno, Fresno, CA, USA
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12
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Panzram B, Kentar Y, Maier M, Bruckner T, Hetto P, Zeifang F. Mid-term to long-term results of primary arthroscopic Bankart repair for traumatic anterior shoulder instability: a retrospective study. BMC Musculoskelet Disord 2020; 21:191. [PMID: 32220253 PMCID: PMC7102425 DOI: 10.1186/s12891-020-03223-3] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2019] [Accepted: 03/19/2020] [Indexed: 01/26/2023] Open
Abstract
Background The arthroscopic method offers a less invasive technique of Bankart repair for traumatic anterior shoulder instability. The aim of the study is to determine the mid−/long-term functional outcome, failure rates and predictors of failure after primary arthroscopic Bankart repair for traumatic anterior shoulder instability. Methods A total of 100 patients were primarily operated using arthroscopic Bankart repair after traumatic anterior shoulder instability. Medical records were retrospectively reviewed, and patients were assessed using postal questionnaire after a mean follow-up of 8.3 years [3–14]. Clinical assessment was performed using Constant score, Rowe score, and American Shoulder and Elbow Surgeons score. Results The overall recurrence rate was 22%. The Kaplan-Meier failure-free survival estimates. were 80% at 5 years and 70% at 10 years. Nearly half (54.5%) of recurrences occurred at 2 years postoperative. Compared with normal shoulder, there were statistical differences in all 3 scores. Failure rate was significantly affected by age at the time of surgery with 86% of recurrence cases observed in patients aged 30 years or younger. Nevertheless, Younger age at the time of surgery (P = 0.007) as well age at the time of initial instability (P = 0.03) was found to correlate negatively with early recurrence within 2 years of surgery. Among those with recurrent instability, recurrence rate was found to be higher if there had been more than 5 instability episodes preoperatively (P = 0.01). Return to the preinjury sport and occupational level was possible in 41 and 78%, respectively. Conclusion Failure-free survival rates dropped dramatically over time. Alternative reconstruction techniques should be considered in those aged ≤30 years due to the high recurrence rate.
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Affiliation(s)
- Benjamin Panzram
- Department of Orthopaedic Surgery, Trauma Surgery and Spinal Cord Injury, University of Heidelberg, Heidelberg, Germany. .,Heidelberg University Hospital, Clinic for Orthopaedics and Trauma Surgery, Schlierbacher Landstraße 200A, 69118, Heidelberg, Germany.
| | - Yasser Kentar
- Department of Orthopaedic Surgery, Trauma Surgery and Spinal Cord Injury, University of Heidelberg, Heidelberg, Germany
| | - Michael Maier
- Department of Orthopaedic Surgery, Trauma Surgery and Spinal Cord Injury, University of Heidelberg, Heidelberg, Germany
| | - Thomas Bruckner
- Institute of Medical Biometry and Informatics, University of Heidelberg, Heidelberg, Germany
| | - Pit Hetto
- Department of Orthopaedic Surgery, Trauma Surgery and Spinal Cord Injury, University of Heidelberg, Heidelberg, Germany
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13
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Hardy A, Sabatier V, Laboudie P, Schoch B, Nourissat G, Valenti P, Kany J, Deranlot J, Solignac N, Hardy P, Vigan M, Werthel JD. Outcomes After Latarjet Procedure: Patients With First-Time Versus Recurrent Dislocations. Am J Sports Med 2020; 48:21-26. [PMID: 31647689 PMCID: PMC7052409 DOI: 10.1177/0363546519879929] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND The preoperative number of dislocations has been previously proved to be a major factor influencing the results after Bankart repair with more preoperative dislocations correlated with higher recurrence rates and more reoperations. This could possibly be because of the lower quality of the tissue repaired during the procedure after multiple dislocations. On the other hand, the Latarjet procedure does not "repair" but rather reconstructs and augments the anterior glenoid. PURPOSE/HYPOTHESIS The main objective was to report the clinical outcomes of patients undergoing a Latarjet procedure after 1 dislocation versus multiple (≥2) dislocations. The hypothesis was that the preoperative number of dislocations would not influence clinical results. STUDY DESIGN Cohort study; Level of evidence, 3. METHODS Patients older than 18 years who had undergone a primary Latarjet procedure for shoulder instability with at least 2 years of follow-up were included. Three different techniques were used: a mini-open technique using 2 screws, an arthroscopic technique using 2 screws, and an arthroscopic technique using 2 cortical buttons. Patients were evaluated and answered a questionnaire to assess the number of episodes of dislocation before surgery, the time between the first dislocation and surgery, recurrence of the dislocation, revision surgery, the Walch-Duplay score, the Simple Shoulder Test score, and the visual analog scale (VAS) score for pain. RESULTS A total of 308 patients were included for analysis with a mean follow-up of 3.4 ± 0.8 years. Of that, 83 patients were included in the first-time dislocation group and 225 in the recurrent dislocation group. At last follow-up, the rates of recurrence and reoperation were not significantly different between groups: 4.8% in the first-time dislocation group versus 3.65% in the recurrent dislocation group and 6.1% versus 4.0%, respectively. The overall Walch-Duplay scores at last follow-up were also comparable between the 2 groups, 67.3 ± 24.85 and 71.8 ± 25.1, even though the first-time dislocation group showed a lower pain subscore (15.0 ± 8.6 vs 18.0 ± 7.5; P = .003). The VAS for pain was also significantly higher in the first-time dislocation group compared with the recurrent dislocation group (1.8 ± 2.3 vs 1.2 ± 1.7; P = .03). CONCLUSION The number of episodes of dislocation before surgery does not affect postoperative instability rates and reoperation rates after the Latarjet procedure. However, patients with first-time dislocations had more postoperative pain compared with patients with recurrent dislocations before surgery.
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Affiliation(s)
- Alexandre Hardy
- Clinique du Sport Paris, Paris,
France,Alexandre Hardy, MD,
Clinique du Sport Paris, 36 Boulevard Saint Marcel, 75005, Paris, France (
)
| | | | - Pierre Laboudie
- Department of Orthopaedic Surgery,
Cochin Hospital, Paris, France
| | - Bradley Schoch
- Department of Orthopedic Surgery, Mayo
Clinic, Jacksonville, Florida, USA
| | | | | | | | | | | | | | - Marie Vigan
- Institut Curie, PSL Research University,
DRCI, Biométrie, Saint-Cloud, France
| | - Jean-David Werthel
- Department of Orthopedic Surgery, Mayo
Clinic, Jacksonville, Florida, USA,Department of Orthopaedic Surgery,
Ambroise Paré Hospital, Boulogne, France
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14
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Xu Y, Wu K, Ma Q, Zhang L, Zhang Y, Xu W, Guo JJ. Comparison of clinical and patient-reported outcomes of three procedures for recurrent anterior shoulder instability: arthroscopic Bankart repair, capsular shift, and open Latarjet. J Orthop Surg Res 2019; 14:326. [PMID: 31627759 PMCID: PMC6798357 DOI: 10.1186/s13018-019-1340-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2019] [Accepted: 08/21/2019] [Indexed: 12/15/2022] Open
Abstract
Background Best surgical of recurrent anterior shoulder instability remained controversial. We knew little about the superiority and choice between traditional open and modern arthroscopic techniques. We hypothesized that outcomes of all patients will be similar regardless of surgical technique. Methods A retrospective case-cohort analysis of 168 patients who had recurrent anterior shoulder instability was conducted from September 2010 to December 2013. All cases (mean age 30.8 [range 18–50] years) were performed with arthroscopic Bankart repair (33 males/20 females), open Latarjet (34 males/18 females), and capsular shift (31 males/14 females). The average follow-up was 67.6 months (range 60–72). The shoulder instability index score (ISIS) was more than 3 with an average of 6.4. Results All treatments proved to be effective in improving shoulder functional status and reducing symptoms, while Latarjet had an advantage over subjective perception. The Rowe scores in arthroscopic Bankart, open Latarjet, and capsular shift group were 92.3 ± 1.5, 96.2 ± 2.1, and 93.2 ± 2.3, respectively, with significant difference. There was no significant difference in other functional outcomes. However, the Latarjet group in subjective results (subjective shoulder value (SSV) and subjective shoulder value for sport practice (SSV Sport)) was superior to the others (P < 0.05). There were two relapsed cases in arthroscopic Bankart and capsular shift group, respectively, and no recurrence in open Latarjet group. Conclusion Arthroscopic Bankart repair has the advantage of mini-invasion and rapid recovery. Capsular shift offers stabilizing of inferior or multidirectional type, especially for little bone defect. Latarjet was more effective in reducing recurrence with higher stability. Level of evidence Therapeutic level III
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Affiliation(s)
- Yingjie Xu
- Department of Orthopedics, The First Affiliated Hospital of Soochow University, Suzhou, 215006, China
| | - Kailun Wu
- Department of Orthopedics, Suzhou Dushuhu Public Hospital (Dushuhu Public Hospital Affiliated to Soochow University), Suzhou, China
| | - Qianli Ma
- Department of Orthopedics, Fuzhou Second Hospital Affiliated to Xiamen University, Fuzhou, China
| | - Lei Zhang
- Department of Orthopedics, The First Affiliated Hospital of Soochow University, Suzhou, 215006, China
| | - Yong Zhang
- Department of Orthopedics, The First Affiliated Hospital of Soochow University, Suzhou, 215006, China
| | - Wu Xu
- Department of Orthopedics, The First Affiliated Hospital of Soochow University, Suzhou, 215006, China
| | - Jiong Jiong Guo
- Department of Orthopedics, The First Affiliated Hospital of Soochow University, Suzhou, 215006, China.
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15
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Prada C, Bhandari M. Cochrane in CORR®: Conservative Management Following Closed Reduction of Traumatic Anterior Dislocation of the Shoulder. Clin Orthop Relat Res 2019; 477:1984-1990. [PMID: 31415013 PMCID: PMC7000072 DOI: 10.1097/corr.0000000000000907] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Accepted: 07/05/2019] [Indexed: 01/31/2023]
Affiliation(s)
- Carlos Prada
- C. Prada, M. Bhandari, Division of Orthopaedics, Department of Surgery, McMaster University, Hamilton, ON Canada, Centre for Evidence-Based Orthopaedics, 293 Wellington St. N, Suite 110, Hamilton, ON L8L 8E7 Canada
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16
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Braun C, McRobert CJ. Conservative management following closed reduction of traumatic anterior dislocation of the shoulder. Cochrane Database Syst Rev 2019; 5:CD004962. [PMID: 31074847 PMCID: PMC6510174 DOI: 10.1002/14651858.cd004962.pub4] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
BACKGROUND Acute anterior shoulder dislocation, which is the most common type of dislocation, usually results from an injury. Subsequently, the shoulder is less stable and is more susceptible to re-dislocation or recurrent instability (e.g. subluxation), especially in active young adults. After closed reduction, most of these injuries are treated with immobilisation of the injured arm in a sling or brace for a few weeks, followed by exercises. This is an update of a Cochrane Review first published in 2006 and last updated in 2014. OBJECTIVES To assess the effects (benefits and harms) of conservative interventions after closed reduction of traumatic anterior dislocation of the shoulder. These might include immobilisation, rehabilitative interventions or both. SEARCH METHODS We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register, the Cochrane Central Register of Controlled Trials, MEDLINE, Embase, CINAHL, PEDro and trial registries. We also searched conference proceedings and reference lists of included studies. Date of last search: May 2018. SELECTION CRITERIA We included randomised or quasi-randomised controlled trials comparing conservative interventions with no treatment, a different intervention or a variant of the intervention (e.g. a different duration) for treating people after closed reduction of a primary traumatic anterior shoulder dislocation. Inclusion was regardless of age, sex or mechanism of injury. Primary outcomes were re-dislocation, patient-reported shoulder instability measures and return to pre-injury activities. Secondary outcomes included participant satisfaction, health-related quality of life, any instability and adverse events. DATA COLLECTION AND ANALYSIS Both review authors independently selected studies, assessed risk of bias and extracted data. We contacted study authors for additional information. We pooled results of comparable groups of studies. We assessed risk of bias with the Cochrane 'Risk of bias' tool and the quality of the evidence with the GRADE approach. MAIN RESULTS We included seven trials (six randomised controlled trials and one quasi-randomised controlled trial) with 704 participants; three of these trials (234 participants) are new to this update. The mean age across the trials was 29 years (range 12 to 90 years), and 82% of the participants were male. All trials compared immobilisation in external rotation (with or without an additional abduction component) versus internal rotation (the traditional method) following closed reduction. No trial evaluated any other interventions or comparisons, such as rehabilitation. All trials provided data for a follow-up of one year or longer; the commonest length was two years or longer.All trials were at some risk of bias, commonly performance and detection biases given the lack of blinding. Two trials were at high risk of selection bias and some trials were affected by attrition bias for some outcomes. We rated the certainty of the evidence as very low for all outcomes.We are uncertain whether immobilisation in external rotation makes a difference to the risk of re-dislocation after 12 months' or longer follow-up compared with immobilisation in internal rotation (55/245 versus 73/243; risk ratio (RR) 0.67, 95% confidence interval (CI) 0.38 to 1.19; 488 participants; 6 studies; I² = 61%; very low certainty evidence). In a moderate-risk population with an illustrative risk of 312 per 1000 people experiencing a dislocation in the internal rotation group, this equates to 103 fewer (95% CI 194 fewer to 60 more) re-dislocations after immobilisation in external rotation. Thus this result covers the possibility of a benefit for each intervention.Individually, the four studies (380 participants) reporting on validated patient-reported outcome measures for shoulder instability at a minimum of 12 months' follow-up found no evidence of a clinically important difference between the two interventions.We are uncertain of the relative effects of the two methods of immobilisation on resumption of pre-injury activities or sports. One study (169 participants) found no evidence of a difference between interventions in the return to pre-injury activity of the affected arm. Two studies (135 participants) found greater return to sports in the external rotation group in a subgroup of participants who had sustained their injury during sports activities.None of the trials reported on participant satisfaction or health-related quality of life.We are uncertain whether there is a difference between the two interventions in the number of participants experiencing instability, defined as either re-dislocation or subluxation (RR 0.84, 95% CI 0.62 to 1.14; 395 participants, 3 studies; very low certainty evidence).Data on adverse events were collected only in an ad hoc way in the seven studies. Reported "transient and resolved adverse events" were nine cases of shoulder stiffness or rigidity in the external rotation group and two cases of axillary rash in the internal rotation group. There were three "important" adverse events: hyperaesthesia and moderate hand pain; eighth cervical dermatome paraesthesia; and major movement restriction between 6 and 12 months. It was unclear to what extent these three events could be attributed to the treatment. AUTHORS' CONCLUSIONS The available evidence from randomised trials is limited to that comparing immobilisation in external versus internal rotation. Overall, the evidence is insufficient to draw firm conclusions about whether immobilisation in external rotation confers any benefit over immobilisation in internal rotation.Considering that there are several unpublished and ongoing trials evaluating immobilisation in external versus internal rotation, the main priority for research on this question consists of the publication of completed trials and the completion and publication of ongoing trials. Meanwhile, evaluation of other interventions, including rehabilitation, is warranted. There is a need for sufficiently large, good-quality, well-reported randomised controlled trials with long-term follow-up. Future research should aim to determine the optimal immobilisation duration, precise indications for immobilisation, optimal rehabilitation interventions, and the acceptability of these different interventions.
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Affiliation(s)
- Cordula Braun
- Medical Center ‐ University of FreiburgInstitute for Evidence in Medicine (for Cochrane Germany Foundation)Breisacher Str. 153FreiburgGermany79110
| | - Cliona J McRobert
- Institute of Clinical Sciences, University of LiverpoolSchool of Health SciencesBrownlow HillLiverpoolMerseysideUKL69 3GB
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17
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Eshoj H, Rasmussen S, Frich LH, Jensen SL, Søgaard K, Juul-Kristensen B. Patients with non-operated traumatic primary or recurrent anterior shoulder dislocation have equally poor self-reported and measured shoulder function: a cross-sectional study. BMC Musculoskelet Disord 2019; 20:59. [PMID: 30736761 PMCID: PMC6368725 DOI: 10.1186/s12891-019-2444-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2017] [Accepted: 01/30/2019] [Indexed: 01/16/2023] Open
Abstract
Background Patients with non-operated traumatic primary anterior shoulder dislocation (PASD) are assumed to have less shoulder impairment than patients with recurrent anterior shoulder dislocations (RASD). This may impact treatment decision strategy. The aim was to study whether patients with non-operated traumatic PASD have less shoulder impairment than those with RASD. Methods In a cross-sectional study baseline data from patients with PASD and RASD in a randomised controlled trial of non-operative shoulder exercise treatment were used. Shoulder function was self-reported (Western Ontario Shoulder Instability (WOSI), Tampa Scale of Kinesiophobia (TSK), General Health (EQ-5D-VAS), Numeric Pain Rating Scale (NPRS)), and measured (Constant-Murley shoulder Score (CMS total), CMS - Range of Motion (CMS-ROM, CMS – strength, proprioception, clinical tests). Results In total, 56 patients (34 (28 men) with PASD and 22 (21 men) with RASD) (mean age 26 years) participated. WOSI total was 1064 and 1048, and TSK above 37 (indicating high re-injury fear) was present in 33 (97%) and 21 (96%) of the groups with PASD and RASD, with no group difference. CMS total (66.4 and 70.4), CMS-ROM (28.7 and 31.5), CMS-strength (injured shoulder: 7.6 kg and 9.1 kg), proprioception and clinical tests were the same. Furthermore, 26 (76%) with PASD and 13 (59%) with RASD reported not to have received non-operative shoulder treatment. Conclusions Non-operated patients with PASD and self-reported shoulder trouble three-six weeks after initial injury do not have less shoulder impairment (self-reportedly or objectively measured) than non-operated patients RASD and self-reported shoulder trouble three-six weeks after their latest shoulder dislocation event.
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Affiliation(s)
- Henrik Eshoj
- Quality of Life Research Center, Department of Hematology, Odense University Hospital, J. B. Winsløws Vej 4, DK-5000, Odense, Denmark. .,Department of Sports Science and Clinical Biomechanics, University of Southern, Campusvej 55, DK-5230, Odense, Denmark.
| | - Sten Rasmussen
- Orthopaedic Research Unit, Aalborg University Hospital, Aalborg, Denmark, Hobrovej 18-22, DK-9000, Aalborg, Denmark.,Department of Clinical Medicine, Aalborg University, Hobrovej 18-22, DK-9000, Aalborg, Denmark
| | - Lars Henrik Frich
- Department of Orthopaedics and Traumatology, Odense University Hospital, J. B. Winsløws Vej 4, DK-5000, Odense, Denmark.,Department of Clinical Research, University of Southern Denmark, Campusvej 55, DK-5230, Odense, Denmark
| | - Steen Lund Jensen
- Department of Clinical Medicine, Aalborg University, Hobrovej 18-22, DK-9000, Aalborg, Denmark.,Shoulder sector, Orthopaedic Department, Aalborg University Hospital, Farsoe, Denmark
| | - Karen Søgaard
- Department of Clinical Research, University of Southern Denmark, Campusvej 55, DK-5230, Odense, Denmark.,Department of Sports Science and Clinical Biomechanics, University of Southern, Campusvej 55, DK-5230, Odense, Denmark
| | - Birgit Juul-Kristensen
- Department of Sports Science and Clinical Biomechanics, University of Southern, Campusvej 55, DK-5230, Odense, Denmark
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Abstract
Because of the lack of bony restraints and minimal articular contact, the glenohumeral joint can attain significant range of motion; however, this results in the propensity for instability. The most generic form of instability, traumatic anterior instability, reliably produces a series of pathoanatomic findings. While reliable, these findings contribute to the complexities of caring for patients after an initial instability event. Numerous studies have examined this issue and determined that careful consideration of patient factors can guide successful treatment, whether it be surgical or nonsurgical, after initial instability. Such forms of treatment have shown to provide a good functional outcome and decreases morbidity. To be able to provide successful treatment requires a thorough understanding of the pathoanatomic of an instability event and the intricacies of the evaluation of a patient after an initial instability event.
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19
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Wang SI. Management of the First-time Traumatic Anterior Shoulder Dislocation. Clin Shoulder Elb 2018; 21:169-175. [PMID: 33330172 PMCID: PMC7726393 DOI: 10.5397/cise.2018.21.3.169] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2018] [Revised: 07/28/2018] [Accepted: 07/30/2018] [Indexed: 11/25/2022] Open
Abstract
Traumatic anterior dislocation of the shoulder is one of the most common directions of instability following a traumatic event. Although the incidence of shoulder dislocation is similar between young and elderly patients, most studies have traditionally focused on young patients due to relatively high rates of recurrent dislocations in this population. However, shoulder dislocations in older patients also require careful evaluation and treatment selection because they can lead to persistent pain and disability due to rotator cuff tears and nerve injuries. This article provides an overview of the nature and pathology of acute primary anterior shoulder dislocation, widely accepted management modalities, and differences in treatment for young and elderly patients.
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Affiliation(s)
- Sung Il Wang
- Department of Orthopaedic Surgery, Chonbuk National University Medical School, Research Insitute for Endocrine Sciences and Research Insitute of Clinical Medicine of Chonbuk National University-Biomedical Research Insitute of Chonbuk National University Hospital, Jeonju, Korea
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20
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Jeon YS, Jeong HY, Lee DK, Rhee YG. Borderline Glenoid Bone Defect in Anterior Shoulder Instability: Latarjet Procedure Versus Bankart Repair. Am J Sports Med 2018; 46:2170-2176. [PMID: 29879363 DOI: 10.1177/0363546518776978] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND The optimal procedure for anterior shoulder instability with a borderline (15%-20%) bone defect on the anterior rim of the glenoid is still controversial. PURPOSE To compare the clinical outcome and recurrence rate between the arthroscopic Bankart repair and Latarjet procedure among patients with recurrent anterior shoulder instability and a borderline glenoid bone defect. STUDY DESIGN Cohort study; Level of evidence, 3. METHODS The authors retrospectively reviewed cases of arthroscopic Bankart repair and the Latarjet procedure for recurrent anterior shoulder instability with a borderline (15%-20%) glenoid bone defect. Enrollment comprised 149 patients (Bankart group, n = 118; Latarjet group, n = 31). The mean follow-up and age at operation were 28.9 ± 7.3 months (range, 24-73 months) and 26 ± 5 years (range, 16-46 years), respectively. RESULTS Rowe and UCLA (University of California, Los Angeles) shoulder scores significantly improved from 42.0 ± 14.3 and 22.9 ± 3.2 preoperatively to 90.9 ± 15.4 and 32.5 ± 3.3 postoperatively in the Bankart group ( P < .001) and from 41.0 ± 17.9 and 22.3 ± 3.4 to 91.1 ± 16.1 and 32.3 ± 3.4 in the Latarjet group ( P < .001), respectively. There were no significant between-group differences in Rowe ( P = .920) or UCLA ( P = .715) scores at the final follow-up. Mean postoperative loss of motion during forward flexion, external rotation in abduction, and internal rotation to the posterior was 3.0° ± 6.2°, 11.6° ± 10.2°, and 0.6 spinal segment in the Bankart group and 3.7° ± 9.8°, 10.3° ± 12.8°, and 0.9 spinal segment in the Latarjet group, respectively. These differences were not significant. However, the loss of external rotation at the side was significantly greater in the Bankart group (13.3° ± 12.9°) than in the Latarjet group (7.3° ± 18.1°, P = .034). The overall recurrence rate was significantly higher in the Bankart group (22.9%) than in the Latarjet group (6.5%), ( P = .040). CONCLUSION The Latarjet procedure and arthroscopic Bankart repair both provided satisfactory clinical outcome scores and pain relief for anterior shoulder instability with a borderline glenoid bone defect. However, the Latarjet procedure resulted in significantly lower recurrences and less external rotation limitation than the arthroscopic Bankart repair. Therefore, the Latarjet procedure could be a more reliable surgical option in anterior recurrent instability with a borderline glenoid bone defect.
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Affiliation(s)
- Yoon Sang Jeon
- Department of Orthopedic Surgery, College of Medicine, Inha University Hospital, Incheon, Republic of Korea
| | - Ho Yeon Jeong
- Shoulder and Elbow Clinic, Department of Orthopaedic Surgery, College of Medicine, Kyung Hee University, Seoul, Republic of Korea
| | - Dong Ki Lee
- Shoulder and Elbow Clinic, Department of Orthopaedic Surgery, College of Medicine, Kyung Hee University, Seoul, Republic of Korea
| | - Yong Girl Rhee
- Shoulder and Elbow Clinic, Department of Orthopaedic Surgery, College of Medicine, Kyung Hee University, Seoul, Republic of Korea
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Berendes T, Mathijssen N, Verburg H, Kraan G. The open-modified Bankart procedure: long-term follow-up 'a 16-26-year follow-up study'. Arch Orthop Trauma Surg 2018; 138:597-603. [PMID: 29299668 DOI: 10.1007/s00402-017-2866-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2017] [Indexed: 11/25/2022]
Abstract
INTRODUCTION A Bankart procedure is a surgical technique for the repair of recurrent shoulder joint dislocations. This study reports the long-term results of the 'open'-modified Bankart procedure. METHODS We performed a retrospective cohort study in which patients are studied who had open-modified Bankart surgery for instability problems in the absence of a substantial osseous glenoid defect after a traumatic shoulder dislocation, 16-26 years ago, in a large regional hospital. Instability was measured with the Rowe and Oxford shoulder instability score. Furthermore, we measured physical functioning with the Constant-Murley score and the Dutch simple shoulder test. Pain was measured with the NRS for pain. Osteoarthritis was scored according the Samilson-Prieto score. Quality of life was measured with the SF-12 score. The operated shoulder was compared to the non-operated contralateral shoulder regarding instability and osteoarthritis. RESULTS 39 patients were included with an average follow-up of 21 years (range 16-26 years). The number of patients with redislocations of their shoulder after surgery was 4 (10%). 23% of the study group described moments of subluxation or positive apprehension. Radiological signs of osteoarthritis were present in 20 shoulders (51%), of which 75% had grade 1 arthropathy according to the Samilson Prieto score. The incidence of osteoarthritis of the operated shoulder was significantly greater compared to the non-operated shoulder. The mean Rowe score was 85 points (25-100) and the Constant score 92 points (70-100). CONCLUSION We conclude that the open-modified Bankart procedure is a reliable surgical procedure with good long-term results, 16-26 years after surgery. However, it does not prevent the development of shoulder osteoarthritis, since a high number of patients had (mainly mild) radiological osteoarthritis.
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Affiliation(s)
- Thomas Berendes
- Department of Orthopaedic Surgery and Traumatology, Meander Medisch Centrum, Maatweg 3, 3813 TZ, Amersfoort, The Netherlands.
| | - Nina Mathijssen
- Reinier de Graaf Gasthuis, Reinier de Graafweg 5, 2625 AD, Delft, The Netherlands
| | - Hennie Verburg
- Department of Orthopaedic Surgery and Traumatology, Reinier de Graaf Gasthuis, Reinier de Graafweg 5, 2625 AD, Delft, The Netherlands
| | - Gerald Kraan
- Department of Orthopaedic Surgery and Traumatology, Reinier de Graaf Gasthuis, Reinier de Graafweg 5, 2625 AD, Delft, The Netherlands
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Frank RM, Chalmers PN, Moric M, Leroux T, Provencher MT, Romeo AA. Incidence and Changing Trends of Shoulder Stabilization in the United States. Arthroscopy 2018; 34:784-792. [PMID: 29225018 DOI: 10.1016/j.arthro.2017.08.289] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2017] [Revised: 08/16/2017] [Accepted: 08/16/2017] [Indexed: 02/02/2023]
Abstract
PURPOSE To determine the incidence and demographic characteristics of shoulder stabilization in the United States, with particular focus on age, sex, and inpatient versus outpatient treatment. METHODS The National Hospital Discharge Survey and the National Survey of Ambulatory Surgery databases were searched using a combination of International Classification of Diseases, Ninth Revision diagnosis and procedure codes, encompassing open and arthroscopic shoulder stabilization procedures. Incidence was determined using National Survey of Ambulatory Surgery, National Hospital Discharge Survey, and US census data, and the results were stratified by age, sex, facility, and concomitant diagnoses. Data were analyzed between 1994 and 2006, the most recent year for which data are available within these sources. RESULTS The incidence of shoulder stabilization in the United States was 5.84 per 100,000 person-years (n = 15,514; 95% confidence interval, 11,975-19,053) in 1994 to 1996 and 6.89 per 100,000 person-years (n = 20,588; 95% confidence interval, 16,254-24,922) in 2006 (P = .0697). The number of inpatient procedures decreased significantly whereas the number of outpatient procedures increased significantly over the same period (P < .0001 for both). The incidence of stabilization increased in patients aged 45 to 64 years (P < .0001) and patients aged 65 years or older (P = .0008) but was unchanged in patients aged 44 years or younger (P = .4745). The average age of patients undergoing stabilization increased over the study period, from 30 years to 47 years for inpatients (P = .01) and from 27 years to 34 years for ambulatory patients (P = .05). The incidence of stabilization increased significantly in male patients (P = .0075) but remained stable in female patients (P = .8057) over the same period. Diagnoses related to rotator cuff pathology and shoulder derangement were the most common concurrent diagnosis codes. CONCLUSIONS The overall incidence of shoulder stabilization in the United States is 6.89 per 100,000 person-years. The incidence increased by 18% between 1994 and 2006. During the study period, shoulder stabilization shifted to become a largely outpatient procedure, and the average age increased significantly. LEVEL OF EVIDENCE Level IV, therapeutic case series.
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Affiliation(s)
- Rachel M Frank
- CU Sports Medicine, Department of Orthopedics, University of Colorado School of Medicine, Boulder, Colorado, U.S.A..
| | - Peter N Chalmers
- Department of Orthopaedic Surgery, University of Utah, Farmington, Utah, U.S.A
| | - Mario Moric
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Timothy Leroux
- Division of Orthopaedic Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | | | - Anthony A Romeo
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A
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Abstract
PURPOSE OF REVIEW The purpose of this review is to outline the natural history and best clinical practices for nonoperative management of anterior shoulder instability. RECENT FINDINGS Recent studies continue to demonstrate a role for nonoperative treatment in the successful long-term management of anterior glenohumeral instability. The success of different positions of shoulder immobilization is reviewed as well. There are specific patients who may be best treated with nonoperative means after anterior glenohumeral instability. There are also patients who are not good nonoperative candidates based on a number of factors that are outlined in this review. There continues to be no definitive literature regarding the return to play of in-season athletes. Successful management requires a thorough understanding of the epidemiology, pathoanatomy, history, physical examination, diagnostic imaging modalities, and natural history of operative and nonoperative treatment.
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An VVG, Sivakumar BS, Phan K, Trantalis J. A systematic review and meta-analysis of clinical and patient-reported outcomes following two procedures for recurrent traumatic anterior instability of the shoulder: Latarjet procedure vs. Bankart repair. J Shoulder Elbow Surg 2016; 25:853-63. [PMID: 26809355 DOI: 10.1016/j.jse.2015.11.001] [Citation(s) in RCA: 157] [Impact Index Per Article: 19.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2015] [Revised: 11/09/2015] [Accepted: 11/10/2015] [Indexed: 02/01/2023]
Abstract
BACKGROUND The Bankart repair and Latarjet procedure are both viable surgical options for recurrent traumatic anterior instability of the shoulder joint. The anatomic repair is the more popular option, with 90% of surgeons internationally choosing the Bankart repair as the initial treatment. There has been no previous review directly comparing the 2 techniques. Hence, we aimed to systematically review studies to compare the outcomes of Bankart repairs vs. the Latarjet procedure for recurrent instability of the shoulder. METHODS Six electronic databases were searched for original, English-language studies comparing the Bankart and Latarjet procedures. Studies were critically appraised using the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) checklist. Data were extracted from the text, tables, and figures of the selected studies. RESULTS Eight comparative studies were identified with 795 shoulders; 416 of them underwent open or arthroscopic Bankart repairs, and 379 were repaired by the open Latarjet procedure. Primary and revision procedures were studied. The Latarjet procedure conferred significantly lower risk of recurrence and redislocation. There was no significant difference in the rates of complication requiring reoperation between the two procedures. Rowe scores were higher and loss of external rotation lower in the Latarjet group compared with the Bankart repair group. CONCLUSIONS Our studies demonstrate that the Latarjet procedure is a viable and possibly superior alternative to the Bankart repair, offering greater stability with no significant increase in complication rate. However, the studies identified were retrospective and of limited quality, and therefore randomized controlled trials with large populations of patients or prospective assessment of national orthopedic registries should be employed to confirm our findings.
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Affiliation(s)
- Vincent Vinh Gia An
- Sydney Medical School, University of Sydney, Sydney, NSW, Australia; Department of Orthopaedic Surgery, Royal Prince Alfred Hospital, Sydney, NSW, Australia.
| | | | - Kevin Phan
- Sydney Medical School, University of Sydney, Sydney, NSW, Australia
| | - John Trantalis
- Department of Orthopaedic Surgery, Concord Repatriation General Hospital, Sydney, NSW, Australia
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