Assessment and management of shoulder dislocation

Surgical Intervention Following a First Traumatic Anterior Shoulder Dislocation Is Worthy of Consideration

Up to 60% of patients experience recurrence after a first traumatic anterior shoulder dislocation (FTASD), which is often defined as having experienced either dislocation or subluxation. Thus surgical intervention after FTASD is worthy of consideration and is guided by the number of patients who need to receive surgical intervention to prevent 1 redislocation (i.e., number needed to treat), (subjective) health benefit, complication risk, and costs. Operative intervention through arthroscopic stabilization can be successful in reducing recurrence risk in FTASD, as has been shown in multiple randomized controlled trials. Nevertheless, there is a large "gray area" for the indication of arthroscopic stabilization, and it is therefore heavily debated which patients should receive operative treatment. Previous trials showed widely varying redislocation rates in both the intervention and control group, meta-analysis shows 2% to 19% after operative and 20% to 75% after nonoperative treatment, and redislocation rates may not correlate with patient-reported outcomes. The literature is quite heterogeneous, and a major confounder is time to follow-up. Furthermore, there is insufficient standardization of reporting of outcomes and no consensus on definition of risk factors. As a result, surgery is a reasonable intervention for FTASD patients, but in which patients it best prevents redislocation requires additional refinement.

"Nearly off-track lesions" or a short distance from the medial edge of the Hill-Sachs lesion to the medial edge of the glenoid track does not seem to be accurate in predicting recurrence after an arthroscopic Bankart repair in a military population: a case-control study

BACKGROUND

On-track lesions with a short distance from the medial edge of the Hill-Sachs lesion to the medial edge of the glenoid track (nearly off-track) may predispose recurrence after arthroscopic Bankart repair (ABR) in the general population. The aim of this study was to determine if a shorter distance between the medial edge of the Hill-Sachs lesion and the medial edge of the glenoid track could accurately predict recurrence after an ABR in a high-demand military population. It was hypothesized that a shorter distance would not accurately predict recurrence.

MATERIALS AND METHODS

A retrospective monocenter case-control study was performed at the Dutch Central Military Hospital. Patients with an on-track Hill-Sachs lesion who underwent a primary ABR between 2014 and 2019 with a minimal follow-up of 2 years and a preoperative magnetic resonance imaging (MRI) assessment received a questionnaire. The primary outcome was recurrence, defined as a complete dislocation or subluxation. Glenoid bone loss was assessed using a linear-based method on MRI. The distance from the medial edge of the Hill-Sachs lesion to the medial edge of the glenoid track was defined as the distance to dislocation (DTD). A receiver operating characteristic curve was created to determine the predictive value of the DTD for recurrence. Logistic regression was used to determine preoperative risk factors that predispose recurrence. Covariates were selected based on univariable analysis and included gender, body mass index, age at surgery and first dislocation, laterality, smoking habits, overhead shoulder activity during work, preoperative dislocations, sports type and level, bony or labral lesions on MRI, and DTD.

RESULTS

In total, 80 patients with an average follow-up of 4.8 ± 1.9 years completed the questionnaire and were included in the analyses. Seventeen patients (21%) experienced recurrence at the final follow-up. No difference in DTD was observed among patients who experienced recurrence (9 ± 4 mm) compared with patients who did not (9 ± 5 mm; P = .81). The receiver operating characteristic curve demonstrated no predictive power of DTD for recurrence (area under the curve = 0.49). Smoking at the time of surgery (odds ratio: 3.9; confidence interval: 1.2-12.7; P = .02) and overhead shoulder movement during work (odds ratio: 9.3; confidence interval: 1.1-78.0; P = .04) were associated with recurrence according to the logistic regression analysis.

CONCLUSION

A shorter DTD demonstrated no accuracy in predicting recurrence in a military population. Smoking at the time of surgery and overhead shoulder activity during work were associated with recurrence; however, these analyses were underpowered to draw valid conclusions.

Ninety-day complication rate based on 532 Latarjet procedures in Dutch hospitals with different operation volumes

BACKGROUND

In this study, we aimed to provide insight into the 90-day complication rates following the Latarjet procedure. Data from 2015 were collected from multiple hospitals in the Netherlands, with different volumes of Latarjet procedures. Our second aim was to examine which patient and surgical factors were associated with complications.

METHODS

We conducted a retrospective chart review of 13 hospitals between 2015 and 2022. Data regarding complications within 90 days of Latarjet procedures were extracted. The effect of sex, age, body mass index (BMI), smoking, previous shoulder operations, fixation material, hospital volume, screw size, and operation time on the complication rate was assessed by multivariable logistic regression analysis.

RESULTS

Of the 532 included patients, 58 (10.9%) had complications. The most common complications were material failure (n = 19, 3.6%) and nerve injury (n = 13, 2.4%). The risk of complications was lower for male patients than for female patients (odds ratio, 0.40; 95% confidence interval, 0.21-0.77; P = .006). Age, BMI, smoking, previous shoulder operations, type of fixation material, hospital volume, screw size, and operation time were not associated with complications.

CONCLUSION

The 90-day complication rate after the Latarjet procedure was 10.9% and was higher in female patients than in male patients. Age, BMI, smoking, previous shoulder operations, type of fixation material, hospital volume, screw size, and operation time did not affect complication rates. We advise setting up a national registry to prevent under-reporting of complications.

Clinical predictors of fracture in patients with shoulder dislocation: systematic review of diagnostic test accuracy studies

Background

Prereduction radiographs are conventionally used to exclude fracture before attempts to reduce a dislocated shoulder in the ED. However, this step increases cost, exposes patients to ionising radiation and may delay closed reduction. Some studies have suggested that prereduction imaging may be omitted for a subgroup of patients with shoulder dislocations.

Objectives

To determine whether clinical predictors can identify patients who may safely undergo closed reduction of a dislocated shoulder without prereduction radiographs.

Methods

A systematic review and meta-analysis of diagnostic test accuracy studies that have evaluated the ability of clinical features to identify concomitant fractures in patients with shoulder dislocation. The search was updated to 23 June 2022 and language limits were not applied. All fractures were included except for Hill-Sachs lesions. Quality assessment was undertaken using the Quality Assessment of Diagnostic Accuracy Studies 2 tool. Data were pooled and meta-analysed by fitting univariate random effects and multilevel mixed effects logistic regression models.

Results

Eight studies reported data on 2087 shoulder dislocations and 343 concomitant fractures. The most important potential sources of bias were unclear blinding of those undertaking the clinical (6/8 studies) and radiographic (3/8 studies) assessment. The prevalence of concomitant fracture was 17.5%. The most accurate clinical predictors were age >40 (positive likelihood ratio (LR+) 1.8, 95% CI 1.5 to 2.1; negative likelihood ratio (LR−) 0.4, 95% CI 0.2 to 0.6), female sex (LR+ 2.0, 95% CI 1.6 to 2.4; LR− 0.7, 95% CI 0.6 to 0.8), first-time dislocation (LR+ 1.7, 95% CI 1.4 to 2.0; LR− 0.2, 95% CI 0.1 to 0.5) and presence of humeral ecchymosis (LR+ 3.0–5.7, LR− 0.8–1.1). The most important mechanisms of injury were high-energy mechanism fall (LR+ 2.0–9.8, LR− 0.4–0.8), fall >1 flight of stairs (LR+ 3.8, 95% CI 0.6 to 13.1; LR− 1.0, 95% CI 0.9 to 1.0) and motor vehicle collision (LR+ 2.3, 95% CI 0.5 to 4.0; LR− 0.9, 95% CI 0.9 to 1.0). The Quebec Rule had a sensitivity of 92.2% (95% CI 54.6% to 99.2%) and a specificity of 33.3% (95% CI 23.1% to 45.3%), but the Fresno-Quebec rule identified all clinically important fractures across two studies: sensitivity of 100% (95% CI 89% to 100%) in the derivation dataset and 100% (95% CI 90% to 100%) in the validation study. The specificity of the Fresno-Quebec rule ranged from 34% (95% CI 28% to 41%) in the derivation dataset to 24% (95% CI 16% to 33%) in the validation study.

Conclusion

Clinical prediction rules may have a role in supporting shared decision making after shoulder dislocation, particularly in the prehospital and remote environments when delay to imaging is anticipated.

National incidence of joint dislocation in China: a retrospective survey of 512,187 individuals

BACKGROUND

Joint dislocations significantly impact public health. However, a comprehensive study on the incidence, distribution, and risk factors for joint dislocations in China is lacking. We conducted the China National Joint Dislocation Study, which is a part of the China National Fracture Study conducted to obtain the national incidence and risk factors for traumatic fractures, and to investigate the incidence and risk factors for joint dislocations.

METHODS

For this national retrospective epidemiological study, 512,187 participants were recruited using stratified random sampling and probability-proportional-to-size method from January 19 to May 16, 2015. Participants who sustained joint dislocations of the trunk, arms, or legs (skull, sternum, and ribs being excluded) in 2014 were personally interviewed to obtain data on age, educational background, ethnic origin, occupation, geographic region, and urbanization degree. The joint-dislocation incidence was calculated based on age, sex, body site, and demographic factors. The risk factors for different groups were examined using multiple logistic regression.

RESULTS

One hundred and nineteen participants sustained 121 joint dislocations in 2014. The population-weighted incidence rate of joint dislocations of the trunk, arms, or legs was 0.22 (95% confidence interval [CI]: 0.16, 0.27) per 1000 population in 2014 (men, 0.27 [0.20, 0.34]; women, 0.16 [0.10, 0.23]). For all ages, previous dislocation history (male: OR 42.33, 95% confidence interval [CI]: 12.03-148.90; female: OR 54.43, 95% CI: 17.37-170.50) and alcohol consumption (male: OR 3.50, 95% CI: 1.49-8.22; female: OR 2.65, 95% CI: 1.08-6.50) were risk factors for joint dislocation. Sleeping less than 7 h/day was a risk factor for men. Compared with children, women aged ≥15 years (female 15-64 years: OR 0.16, 95% CI: 0.04-0.61; female ≥65 years: OR 0.06, 95% CI: 0.01-0.41) were less likely to sustain joint dislocations. Women with more than three children were at higher dislocation risk than women without children (OR 6.92, 95% CI: 1.18-40.78).

CONCLUSIONS

The up-to-date data on joint dislocation incidence, distribution, and risk factors can be used as a reference for national healthcare, prevention, and management in China. Specific strategies for decreasing alcohol consumption and encouraging adequate sleeping hours should be developed to prevent or reduce dislocation incidents.

TRIAL REGISTRATION

Chinese Clinical Trial Registry, ChiCTR-EPR-15005878.

History of closed reduction techniques and initial management for shoulder dislocations: From classical antiquity to modern times

This review gives a summary of the records of shoulder dislocation management throughout history until the point that anaesthetics were introduced and modern medicine improved dislocation management exponentially. A dislocation is a mechanical injury that has been managed in different ways throughout history. The shoulder reduction methods described in Hippocrates Corpus have been described and adjusted throughout history by later physicians. For example, in ancient Greek, Hippocrates considered the ambe, a device used to reduce the shoulder, to be the most powerful tool. However, Cooper, a physician in the 19th century, considered it to be the last resort due to substantial damage to the ribs and discomfort of the patient. This review demonstrates that there were many physicians that contributed to shoulder dislocation management. These physicians paved the way for modern shoulder dislocation treatment strategies.

Recurrence in traumatic anterior shoulder dislocations increases the prevalence of Hill-Sachs and Bankart lesions: a systematic review and meta-analysis

PURPOSE

The extent of shoulder instability and the indication for surgery may be determined by the prevalence or size of associated lesions. However, a varying prevalence is reported and the actual values are therefore unclear. In addition, it is unclear whether these lesions are present after the first dislocation and whether or not these lesions increase in size after recurrence. The aim of this systematic review was (1) to determine the prevalence of lesions associated with traumatic anterior shoulder dislocations, (2) to determine if the prevalence is higher following recurrent dislocations compared to first-time dislocations and (3) to determine if the prevalence is higher following complete dislocations compared to subluxations.

METHODS

PubMed, EMBASE, Cochrane and Web of Science were searched. Studies examining shoulders after traumatic anterior dislocations during arthroscopy or with MRI/MRA or CT published after 1999 were included. A total of 22 studies (1920 shoulders) were included.

RESULTS

The proportion of Hill-Sachs and Bankart lesions was higher in recurrent dislocations (85%; 66%) compared to first-time dislocations (71%; 59%) and this was statistically significant (P < 0.01; P = 0.05). No significant difference between recurrent and first-time dislocations was observed for SLAP lesions, rotator-cuff tears, bony Bankart lesions, HAGL lesions and ALPSA lesions. The proportion of Hill-Sachs lesions was significantly higher in complete dislocations (82%) compared to subluxations (54%; P < 0.01).

CONCLUSION

Higher proportions of Hill-Sachs and Bankart were observed in recurrent dislocations compared to first-time dislocations. No difference was observed for bony Bankart, HAGL, SLAP, rotator-cuff tear and ALPSA. Especially when a Hill-Sachs or Bankart is present after first-time dislocation, early surgical stabilization may need to be considered as other lesions may not be expected after recurrence and to limit lesion growth. However, results should be interpreted with caution due to substantial heterogeneity and large variance.

LEVEL OF EVIDENCE

IV.

Age, participation in competitive sports, bony lesions, ALPSA lesions, > 1 preoperative dislocations, surgical delay and ISIS score > 3 are risk factors for recurrence following arthroscopic Bankart repair: a systematic review and meta-analysis of 4584 shoulders

PURPOSE

Determining the risk of recurrent instability following an arthroscopic Bankart repair can be challenging, as numerous risk factors have been identified that might predispose recurrent instability. However, an overview with quantitative analysis of all available risk factors is lacking. Therefore, the aim of this systematic review is to identify risk factors that are associated with recurrence following an arthroscopic Bankart repair.

METHODS

Relevant studies were identified by searching PubMed, Embase/Ovid, Cochrane Database of Systematic Reviews/Wiley, Cochrane Central Register of Controlled Trials/Wiley, CINAHL/Ebsco, and Web of Science/Clarivate Analytics from inception up to November 12th 2020. Studies evaluating risk factors for recurrence following an arthroscopic Bankart repair with a minimal follow-up of 2 years were included.

RESULTS

Twenty-nine studies met the inclusion criteria and comprised a total of 4582 shoulders (4578 patients). Meta-analyses were feasible for 22 risk factors and demonstrated that age ≤ 20 years (RR = 2.02; P < 0.00001), age ≤ 30 years (RR = 2.62; P = 0.005), participation in competitive sports (RR = 2.40; P = 0.02), Hill-Sachs lesion (RR = 1.77; P = 0.0005), off-track Hill-Sachs lesion (RR = 3.24; P = 0.002), glenoid bone loss (RR = 2.38; P = 0.0001), ALPSA lesion (RR = 1.90; P = 0.03), > 1 preoperative dislocations (RR = 2.02; P = 0.03), > 6 months surgical delay (RR = 2.86; P < 0.0001), ISIS > 3 (RR = 3.28; P = 0.0007) and ISIS > 6 (RR = 4.88; P < 0.00001) were risk factors for recurrence. Male gender, an affected dominant arm, hyperlaxity, participation in contact and/or overhead sports, glenoid fracture, SLAP lesion with/without repair, rotator cuff tear, > 5 preoperative dislocations and using ≤ 2 anchors could not be confirmed as risk factors. In addition, no difference was observed between the age groups ≤ 20 and 21-30 years.

CONCLUSION

Meta-analyses demonstrated that age ≤ 20 years, age ≤ 30 years, participation in competitive sports, Hill-Sachs lesion, off-track Hill-Sachs lesion, glenoid bone loss, ALPSA lesion, > 1 preoperative dislocations, > 6 months surgical delay from first-time dislocation to surgery, ISIS > 3 and ISIS > 6 were risk factors for recurrence following an arthroscopic Bankart repair. These factors can assist clinicians in giving a proper advice regarding treatment.

LEVEL OF EVIDENCE

Level IV.