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

Outcomes of total shoulder arthroplasty in patients with prior anterior shoulder instability: minimum 5-year follow-up

BACKGROUND

Patients with a history of anterior shoulder instability (ASI) commonly progress to glenohumeral arthritis or even dislocation arthropathy and often require total shoulder arthroplasty (TSA). The purposes of this study were to (1) report patient-reported outcomes (PROs) after TSA in patients with a history of ASI, (2) compare TSA outcomes of patients whose ASI was managed operatively vs. nonoperatively, and (3) report PROs of TSA in patients who previously underwent arthroscopic vs. open ASI management.

METHODS

Patients were included if they had a history of ASI and had undergone TSA ≥5 years earlier, performed by a single surgeon, between October 2005 and January 2017. The exclusion criteria included prior rotator cuff repair, hemiarthroplasty, or glenohumeral joint infection before the index TSA procedure. Patients were separated into 2 groups: those whose ASI was previously operatively managed and those whose ASI was treated nonoperatively. This was a retrospective review of prospective collected data. Data collected was demographic, surgical and subjective. The PROs used were the American Shoulder and Elbow Surgeons score, Single Assessment Numerical Evaluation score, QuickDASH (Quick Disabilities of the Arm, Shoulder and Hand) score, and 12-item Short Form physical component score. Failure was defined as revision TSA surgery, conversion to reverse TSA, or prosthetic joint infection. Kaplan-Meier survivorship analysis was performed.

RESULTS

This study included 36 patients (27 men and 9 women) with a mean age of 56.4 years (range, 18.8-72.2 years). Patients in the operative ASI group were younger than those in the nonoperative ASI group (50.6 years vs. 64.0 years, P < .001). Operative ASI patients underwent 10 open and 11 arthroscopic anterior stabilization surgical procedures prior to TSA (mean, 2 procedures; range, 1-4 procedures). TSA failure occurred in 6 of 21 patients with operative ASI (28.6%), whereas no failures occurred in the nonoperative ASI group (P = .03). Follow-up was obtained in 28 of 30 eligible patients (93%) at an average of 7.45 years (range, 5.0-13.6 years). In the collective cohort, the American Shoulder and Elbow Surgeons score, Single Assessment Numerical Evaluation score, QuickDASH (Quick Disabilities of the Arm, Shoulder and Hand) score, and 12-item Short Form physical component score significantly improved, with no differences in the postoperative PROs between the 2 groups. We found no significant differences when comparing PROs between prior open and prior arthroscopic ASI procedures or when comparing the number of prior ASI procedures. Kaplan-Meier analysis demonstrated a 79% 5-year survivorship rate in patients with prior ASI surgery and a 100% survivorship rate in nonoperatively managed ASI patients (P = .030).

CONCLUSION

At mid-term follow-up, patients with a history of ASI undergoing TSA can expect continued improvement in function compared with preoperative values. However, TSA survivorship is decreased in patients with a history of ASI surgery compared with those without prior surgery.

Dynamic Anterior Stabilization with Hill-Sachs Remplissage Can be Employed in Skeletally Immature Patients-Operative Technique

BACKGROUND

Numerous studies indicate that glenoid bony augmentation raises the risk of complications during and after surgery. On the other hand, repairing the labrum alone in cases with subcritical glenoid bone loss results in recurrent instability and persistent apprehension. As a result, recent advancements in shoulder instability surgery prioritize fully restoring the anterior shoulder restraint.

OPERATIVE TECHNIQUE

A novel method for treating recurrent anterior shoulder instability with subcritical glenoid bone loss and off-track Hill-Sachs lesion in skeletally immature patients is suggested: the use of dynamic anterior stabilization technique incorporating the long head of the biceps tendon onto the anterior glenoid rim via trans-subscapular transfer, in conjunction with Hill-Sachs remplissage. A practical, step-by-step surgical technique for a complete reconstruction of the anterior capsule-labral-ligamentous complex is provided. This involves utilizing a soft-tissue dynamic anterior sling, achieved through the trans-subscapularis transfer of the long head of the biceps tendon at the glenoid level. The procedure concludes with a Hill-Sachs remplissage to further prevent off-track events and alleviate apprehension.

CONCLUSION

Dynamic anterior stabilization is a suitable approach for addressing recurring anterior shoulder instability in skeletally immature patients who have subcritical glenoid bone loss and bipolar bone lesions.

Immobilization in External Rotation Versus Arthroscopic Stabilization After Primary Anterior Shoulder Dislocation: A Systematic Review of Level 1 and 2 Studies

BACKGROUND

Arthroscopic stabilization has been established as a superior treatment option for primary glenohumeral instability when compared with immobilization in internal rotation. However, immobilization in external rotation (ER) has recently gained interest as a viable nonoperative treatment option for patients with shoulder instability.

PURPOSE

To compare the rates of recurrent instability and subsequent surgery in patients undergoing treatment for primary anterior shoulder dislocation with arthroscopic stabilization versus immobilization in ER.

STUDY DESIGN

Systematic review; Level of evidence, 2.

METHODS

A systematic review was performed by searching PubMed, the Cochrane Library, and Embase to identify studies that'evaluated patients being treated for primary anterior glenohumeral dislocation with either arthroscopic stabilization or immobilization in ER. The search phrase used various combinations of the keywords/phrases "primary closed reduction,""anterior shoulder dislocation,""traumatic,""primary,""treatment,""management,""immobilization,""external rotation,""surgical,""operative,""nonoperative," and "conservative." Inclusion criteria included patients undergoing treatment for primary anterior glenohumeral joint dislocation with either immobilization in ER or arthroscopic stabilization. Rates of recurrent instability, subsequent stabilization surgery, return to sports, positive postintervention apprehension tests, and patient-reported outcomes were evaluated.

RESULTS

The 30 studies that met inclusion criteria included 760 patients undergoing arthroscopic stabilization (mean age, 23.1 years; mean follow-up time, 55.1 months) and 409 patients undergoing immobilization in ER (mean age, 29.8 years; mean follow-up time, 28.8 months). Overall, 8.8% of operative patients experienced recurrent instability at latest follow-up compared with 21.3% of patients who had undergone ER immobilization (P < .0001). Similarly, 5.7% of operative patients had undergone a subsequent stabilization procedure at latest follow-up compared with 11.3% of patients who had undergone ER immobilization (P = .0015). A higher rate of return to sports was found in the operative group (P < .05), but no other differences were found between groups.

CONCLUSION

Patients undergoing arthroscopic treatment for primary anterior glenohumeral dislocation with arthroscopic stabilization can be expected to experience significantly lower rates of recurrent instability and subsequent stabilization procedures compared with patients undergoing ER immobilization.

Effectiveness of combined surgical and exercise-based interventions following primary traumatic anterior shoulder dislocation: a systematic review and meta-analysis

OBJECTIVE

To investigate the effectiveness, risk of recurrence and return to activity (RTA) of surgery combined with exercise-based interventions (EBI) versus EBI alone after traumatic anterior shoulder dislocation (ASD).

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

Systematic literature search (MEDLINE, Web of Science, Scopus, Google Scholar).

ELIGIBILITY

Studies focused on EBI or EBI as a part of postoperative care for adults with an ASD, written in English, and published after 1990. We excluded diagnostic, assessment-based studies on individuals experiencing recurrent shoulder dislocations, concomitant shoulder injury, animal or cadaveric studies. Primary outcomes were dislocation RTA. Secondary outcomes were self-reported outcome measures, strength and range of motion. Random-effects meta-analysis was used to estimate the effect of EBI (SMD; Hedges' g, RR). The Grading of Recommendations Assessment, Development and Evaluation approach was used to assess the certainty of evidence.

RESULTS

Sixty studies were included (n=3598); seven were meta-analysed (n=345). The mean age of participants in the included studies was 26.71±9.19 and 56% of those included were male. Of the 60 studies included in the systematic review, 29 were fair quality (48.3%), 15 studies were good quality (25%) and 16 studies were poor quality (26.7%), (k=0.66). Individuals who underwent EBI alone were 2.03 times more likely to experience recurrent instability than individuals who underwent EBI in conjunction with surgery (RR 2.03, 95% CI 1.03 to 3.97). Individuals who underwent EBI with surgery appeared 1.81 times more likely to RTA than those who underwent EBI alone, although results were not statistically significant (RR 1.81, 95% CI 0.96 to 3.43).

CONCLUSIONS

Surgery combined with EBI is more effective in reducing the risk of recurrence and possibly increasing RTA than EBI alone after traumatic ASD.

Prevalence and risk factors for nerve injury following shoulder dislocation

BACKGROUND

The glenohumeral joint dislocation can be associated with major nerve injury. The reported prevalence and risk factors for major nerve injury are variable and this injury can have a severe and life-long impact on the patient. The objectives of this study were to analyse the prevalence of major nerve injury following shoulder dislocation and examine risk factors. Management and outcomes of nerve injury were explored.

METHODS

A 1 year retrospective cohort study of 243 consecutive adults who presented with a shoulder dislocation was performed. Data were collected on patient demographics, timings of investigations, treatment, follow-up, and nerve injury prevalence and management. The primary outcome measure was prevalence of nerve injury. Risk factors for this were analysed using appropriate tests with Stata SE15.1.

RESULTS

Of 243 patients with shoulder dislocation, 14 (6%) had neurological deficit. Primary dislocation (p = 0.004) and older age (p = 0.02) were significantly associated with major nerve injury. Sex, time to successful reduction and force of injury were not associated with major nerve injury in this cohort. Patients with nerve injury made functional recovery to varying degrees. Recurrent shoulder dislocation was common accounting for 133/243 (55%) attendances.

CONCLUSIONS

Shoulder dislocation requires careful assessment and timely management in the ED. A 6% rate of nerve injury following shoulder dislocation was at the lower border of reported rates (5-55%), and primary dislocation and older age were identified as risk factors for nerve injury. We emphasise the importance of referring patients with suspected major nerve injury to specialist services.

Results of arthroscopic treatment for anteroinferior shoulder instability using a single anterior working portal using birdbeak

BACKGROUND

The shoulder joint is the joint with the most dislocations in all joints. The arthroscopic surgery method is considered the gold standard because it creates less soft tissue damage, shorter hospitalization and surgery time, and less restriction of movement after surgery in shoulder instability. Anterior single portal technique has become popular recently. In this study, it was aimed to evaluate the results of the anterior single portal repair technique using "birdbeak". We try to evaluate if this technique is a reliable technique and has the same or more advantages of two portal arthroscopic surgery and make the surgery easier for surgeons.

METHODS

In the total of 40 patients who underwent arthroscopic surgery for traumatic recurrent anterior shoulder dislocation between January 2017 and February 2020, this study included 19 patients with the surgical technique of arthroscopic isolated anterior labrum tear repair using a birdbeak from the anterior single working portal. Clinical results were evaluated with the Simple Shoulder Test (SST), Rowe Score for Instability (RWS) and Oxford Shoulder Instability Score (OSIS) tests before and after surgery. The relationship between the time to surgery after the first dislocation and clinical outcomes was also examined in the study. Kolmogorov-Smirnov and Shapiro-Wilk tests were used to control the assumption of normality. In addition, Pearson correlation and Spearman correlation analyzes were used to test the relationship between the variables.

RESULTS

The mean follow-up period of the 19 patients included in this study was 33.1 months. The mean time to surgery after the first dislocation was 18.4 months. The mean preoperative number of dislocations was 5.3. The mean number of anchors used in the repair was 2.1. No recurrent dislocations were observed after surgery. A significant difference was observed between preoperative and postoperative SST, RWS and OSIS scores (respectively, p = 0.000 < 0.001, p = 0.000 < 0.001, p = 0.000 < 0.001). There was no statistically significant relationship between the time elapsed after the first dislocation and the postoperative SST, RWS, OSIS scores (respectively, p = 0.43 > 0.05, p = 0.39 > 0.05, p = 0.31 > 0.05).

CONCLUSION

It has been observed that the repair technique applied using the "birdbeak" from the anterior single working portal is a successful treatment, and further studies are required due to the limited literature.

Management of Shoulder Instability in Patients with Underlying Hyperlaxity

PURPOSE OF REVIEW

Shoulder instability in patients with underlying joint hyperlaxity can be challenging to treat. Poorly defined terminology, heterogeneous treatments, and sparse reports on clinical outcomes impair the development of best practices in this patient population. This article provides a review of the current literature regarding optimal management of patients suffering from shoulder instability with concomitant hyperlaxity of the shoulder, from isolated shoulder joint hyperlaxity to congenital hypermobility spectrum disorders (HSD).

RECENT FINDINGS

Current research shows specialized physiotherapy protocols focused on strengthening of periscapular muscles and improvement of sensorimotor control are a promising non-surgical therapeutic avenue in certain patients, which can be augmented by device-based intervention in select cases. If surgical treatment is warranted, arthroscopic techniques such as pancapsular shift or plication continue to demonstrate favorable outcomes and are currently considered the benchmark for success. The long-term success of more recent innovations such as coracoid process transfers, conjoint tendon transfers, subscapularis tendon augmentation, and capsular reconstruction remains unproven. For patients affected by connective tissue disorders, treatment success is generally less predictable, and the entire array of non-operative and operative interventions needs to be considered to achieve the best patient-specific treatment results. In the treatment of shoulder instability and concomitant hyperlaxity, specialized physiotherapy protocols augmented by device-based interventions have emerged as powerful, non-operative treatment options for select patients. Successful surgical approaches have been demonstrated to comprehensively address capsular redundancy, labral lesions, and incompetence of additional passive stabilizers in a patient-specific fashion, respective of the underlying connective tissue constitution.

Impact of Prior Anterior Instability on Shoulder Arthroplasty Outcomes: A Systematic Review

Background

Anterior shoulder instability (ASI) is a frequently encountered pathology. Patients with a history of ASI have an increased rate of developing glenohumeral osteoarthritis and becoming candidates for shoulder arthroplasty. This systematic review aims to synthesize outcomes for patients undergoing shoulder arthroplasty with a history of ASI.

Methods

A comprehensive literature review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) using PubMed, Embase, OVID Medline, Scopus, CINAHL, Web of Science, and Cochrane databases for studies evaluating the impact of prior ASI on total shoulder arthroplasty (TSA), reverse TSA, and/or hemiarthroplasty outcomes, with a minimum follow-up of 12 months. Studies were graded by level of evidence and data concerning patient demographics and outcomes were extracted.

Results

Sixteen articles met the inclusion criteria, including 596 patients (413 male, 181 female). The average age of the control and prior ASI groups were 57.5 and 57.0 years, respectively. Overall, 251 patients were treated operatively, 132 nonoperatively, and 213 were controls without a history of prior ASI. Shoulder arthroplasty techniques included TSA (436 shoulders), reverse TSA (130 shoulders), and hemiarthroplasty (14 shoulders). Prior anterior stabilization management included soft tissue repair, bony augmentation, and nonoperative treatment. Almost all studies reported no significant difference in subjective and functional arthroplasty outcomes between control and prior ASI groups, or between patients with prior ASI treated nonoperatively vs. surgically.

Conclusion

Shoulder arthroplasty in the setting of prior ASI results in improved subjective and functional outcome scores that are comparable to patients without a history of instability.

Outcomes of Arthroscopic Anterior Labroligamentous Periosteal Sleeve Avulsion Lesions: A Minimum 2-Year Follow-up

BACKGROUND

Anterior labroligamentous periosteal sleeve avulsion (ALPSA) lesions can occur in recurrent anterior shoulder instability, which may lead to the labrum scarring medially to the glenoid. ALPSA lesions have also been associated with greater preoperative dislocations, larger Hill-Sachs lesions, and greater degrees of glenoid bone loss. Therefore, patients with these lesions have historically had a higher failure rate after repair, with nearly double the recurrent instability rate compared with those undergoing standard arthroscopic Bankart repair.

PURPOSE

To compare minimum 2-year outcomes of arthroscopic mobilization and anatomic repair of ALPSA lesions with those after standard arthroscopic Bankart repair.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Consecutive patients who underwent arthroscopic repair of ALPSA lesions were matched in a 1-to-3 fashion to patients who underwent standard Bankart repair by age, sex, number of previous ipsilateral shoulder instability surgical procedures, and number of anchors used. Patient-reported outcome (PRO) scores were compared preoperatively and postoperatively (American Shoulder and Elbow Surgeons [ASES]; 12-Item Short Form Health Survey [SF-12] Physical Component Summary [PCS]; Single Assessment Numeric Evaluation [SANE]; shortened version of Disabilities of the Arm, Shoulder and Hand; and satisfaction). Recurrent instability, on- versus off-track Hill-Sachs lesion, and reoperation rates were analyzed.

RESULTS

A total of 100 shoulders (25 ALPSA and 75 Bankart) with an overall mean age of 25.7 years were evaluated. Patients in the ALPSA group demonstrated significant improvements in the ASES (preoperative, 74.8; postoperative, 89.7; P = .041) and SF-12 PCS (preoperative, 46.9; postoperative, 53.4; P = .021) scores but not the SANE score (preoperative, 65.2; postoperative, 75.3; P = .311). Patients in the Bankart group had significant improvements in all outcome scores at final follow-up: ASES (preoperative, 67.1; postoperative, 90.3), SANE (preoperative, 58.0; postoperative, 85.7), and SF-12 PCS (preoperative, 45.3; postoperative, 52.9) (all P < .001). There were no significant differences in PRO scores between the groups preoperatively or postoperatively (P > .05). The median satisfaction for the ALPSA group was 10 of 10 and for the Bankart group it was 9 of 10 (P = .094). There was a significantly higher rate of recurrent dislocation in the ALPSA group (8/25 [32.0%]) compared with the Bankart group (10/75 [13.3%]) (P = .040). Additionally, 5 patients (20.0%) in the ALPSA group underwent revision surgery at a mean of 5.6 years, and 8 patients (10.7%) in the Bankart group underwent revision surgery at a mean of 4.4 years (P = .311).

CONCLUSION

Despite improvements in the recognition of and surgical techniques for ALPSA lesions, they still lead to significantly higher postoperative dislocation rates; however, no differences in PRO scores were found. These findings highlight the importance of early surgical interventions in anterior shoulder instability with the hope of lessening recurrent instability and the risk of developing an ALPSA lesion, as well as careful assessment of the quality of soft tissues and other risk factors for recurrence when considering what type of shoulder stabilization procedure to perform.

Bone Fragment Resorption and Clinical Outcomes of Traumatic Bony Bankart Lesion Treated With Arthroscopic Repair Versus Open Latarjet

BACKGROUND

Bony Bankart lesions can perpetuate chronic anterior glenohumeral instability. When surgical treatment is pursued, several factors need to be considered to obtain optimal outcomes.

PURPOSE

To (1) quantitatively describe patterns of bone fragment resorption and associated risk factors for developing glenoid bone loss (GBL) and (2) to compare clinical and radiological results of attritional bone loss treated with either the arthroscopic Bankart or the open Latarjet procedure.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

A retrospective analysis of prospectively collected data was conducted for patients who underwent arthroscopic stabilization (group A1, 10%-20% GBL; group A2, >20% GBL) or open Latarjet (group B, >10% GBL) for recurrent shoulder instability with bony Bankart lesion. Patient characteristics, number of dislocations, and Western Ontario Shoulder Instability Index (WOSI) scores were obtained. Pre- and postoperative computed tomography imaging was used to quantitatively describe patterns of bone fragment resorption.

RESULTS

A total of 120 consecutive patients (group A1, 40; group A2, 23; group B, 57) were included in the study, with a mean age of 25.6 years (range, 19-35 years). The average follow-up was 5.0 years for all groups (range, 4.83-5.16 years in group A1, 4.58-5.41 years in group A2, and 4.33-5.67 years in group B). The mean times between dislocation event and surgery were 12.8 months (range, 6-32 months) and 13.6 months (range, 6-38 months) for groups A and B, respectively. Redislocation rates were 7.5% in group A1 versus 13.0% in group A2, and only occurred in patients with ≥13.5% GBL. There were no redislocations for group B (0%). Patients had better WOSI scores in group B (234.1 ± 126.9) than in group A (576.1 ± 224.6) (P < .0001). In group A, smaller preoperative bone fragment size displayed a higher percentage of resorption after surgery (r = -0.64; P < .05).

CONCLUSION

A significant inverse relationship exists between preoperative bone fragment size and percentage of postoperative resorption. Patients treated with arthroscopic bony Bankart repair who had final GBL ≥13.5% had worse outcomes. When planned GBL approaches 13.5% in high-demand patients, a smaller fragment size can result in worse clinical outcomes because of resorption. In these cases, choosing the open Latarjet procedure leads to better clinical results.

Long-term effect of immobilization in external rotation after first-time shoulder dislocation: an average 18-year follow-up

BACKGROUND

Immobilization in external rotation (ER) after a first-time shoulder dislocation was introduced to reduce the risk of recurrence compared with immobilization in internal rotation (IR), but its efficacy remains controversial. The purpose of this study was to determine the long-term effect of immobilization in ER after a first-time shoulder dislocation.

METHODS

Between October 2000 and March 2004, 198 patients with a first-time anterior dislocation of the shoulder (average age 37) were randomly assigned to immobilization in ER (ER group = 104 shoulders) or IR (IR group = 94 shoulders) for 3 weeks. At an average 2-year follow-up, 159 patients (80.3%) were available for evaluation. In the current study, these 159 patients were further followed up and interviewed by telephone. The following items were evaluated: recurrent instability, apprehensive feeling, surgical intervention, limitation in the range of motion, return to sports, and the Single Assessment Numeric Evaluation (SANE) score.

RESULTS

The average follow-up period was 18.2 years (range, 16-20 years). Fifty-six patients were available for follow-up with the follow-up rate of 35%. The number of recurrent patients was 6 of 27 (22%) in the ER group and 6 of 29 (21%) in the IR group (P = .889). The number of surgically stabilized patients was 3 of 27 (11%) in the ER group and 10 of 29 (34%) in the IR group (P = .038). In total, the recurrence rate was 33% (9 of 27) in the ER group and 55% (16 of 29) in the IR group (P = .100). Adding the surgical cases and those with the SANE score ≤70% as failure cases, the failure rate in the ER group (26%) was significantly lower than that in the IR group (52%) (P = .048). Among those who survived without surgical intervention, there were no significant differences in apprehensive feeling, return to sports, limited range of motion, and the SANE score between the groups.

CONCLUSIONS

Immobilization in ER reduced the risk of surgical intervention compared with IR in the long term.

Double-Pulley Remplissage in Active-Duty Military Population With Off-Track Anterior Shoulder Instability Results in Improved Outcomes and Low Recurrence at Minimum 4-Year Follow-Up

PURPOSE

To report mid-term outcomes of active-duty patients with anterior shoulder instability following our technique for double-pulley remplissage (DPR) with concomitant anterior labral repair.

METHODS

All consecutive patients from 1/2010 through 12/2016 that underwent DPR by the senior surgeon with complete outcome scores were identified. All patients had experienced a shoulder dislocation following a traumatic event, and had subsequent instability recalcitrant to conservative management. Patients were excluded if they were lost to follow-up (3) of if they underwent stabilization procedures other than DPR (148). Outcome measures were completed by patients within 1 week prior to surgery and at latest follow-up. Twenty-four patients met the inclusion criteria for the study, and all were active-duty military at the time of surgery.

RESULTS

20/24 (83.3%) patients met the patient acceptable symptomatic state (PASS), while 21/24 (87.5%) achieved substantial clinical benefit (SCB) and 22/24 (91.7%) exceeded the minimal clinically important difference (MCID) for their operative shoulder, as determined by the American Shoulder and Elbow Surgeons (ASES) Score. 21/24 (87.5%) patients met the PASS, while 19/24 (79.2%) achieved SCB and 20/24 (83.3%) exceeded the MCID for their operative shoulder, as determined by the single assessment numeric evaluation (SANE). In addition, 23/24 (95.8%) patients exceeded the MCID for their operative shoulder, as determined by the Rowe Instability score. Preoperative and postoperative range of motion did not vary significantly. All patients had decreased pain postoperatively (P < .0001); 22/24 (91.67%) of patients remained on active-duty status. Failure rate, defined as recurrent subluxation or dislocation, was 4.2%.

CONCLUSIONS

Mid-term outcomes in this population of active-duty patients undergoing DPR for shoulder instability without glenoid bone loss demonstrate a statistically and clinically significant improvement in patient-reported outcomes, a significant decrease of pain and an overall return to active-duty rate of 91.67%.

LEVEL OF EVIDENCE

IV, therapeutic case series.

Risk factors for recurrence after Bankart repair: a systematic review and meta-analysis

Background

The aim of this literature review was to identify preoperative risk factors associated with recurrent instability after Bankart repair.

Methods

The PubMed, Web of Science, Embase, and Cochrane Library databases were searched for potentially eligible articles. Two reviewers independently screened the titles and abstracts using prespecified criteria. Articles were included if they clearly stated the risk factors for recurrence after Bankart repair. Data on patient characteristics and recurrence rate were collected from each study. A random-effects model was used for the meta-analysis and the statistical analysis was performed using Review Manager 5.4 software.

Results

Nineteen studies that included 2922 participants met the inclusion criteria. The overall pooled prevalence of recurrent instability was 15.3% (range 6.9–42). The mean follow-up duration was 40.5 months (18–108). Twenty-one risk factors were identified, 10 of which were explored quantitatively. Statistically significant risk factors for recurrent instability following a Bankart procedure were age under 20 years (odds ratio [OR] 4.24, 95% confidence interval [CI] 2.8–96.23, p < 0.00001), a Hill-Sachs lesion (OR 3.61, 95% CI 2.06–6.33, p < 0.00001), a glenoid bone lesion (OR 2.8, 95% CI 1.96–4.01, p < 0.00001), shoulder hyperlaxity (OR 4.55, 95% CI 2.19–9.44, p < 0.0001), and an off-track lesion (OR 5.53, 95% CI 2.21–13.86, p = 0.0003). There was moderate evidence indicating that male sex (OR 1.6, 95% CI 1.07–2.37, p = 0.02) and playing contact sports (OR 1.54, 95% CI 0.96–2.45, p = 0.07) were further risk factors. Dominant side, a superior labrum from anterior to posterior (SLAP) lesion, and more than five preoperative dislocations were not found to be risk factors.

Conclusions

Patients younger than 20 years of age, a Hill–Sachs lesion, a glenoid bone lesion, shoulder hyperlaxity, and an off-track lesion appear to be significant predictors of recurrent instability following a Bankart procedure. Factors such as male sex and playing contact sports were associated with recurrent instability. Dominant side, a SLAP lesion, and more than five preoperative dislocations were not significant risk factors.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13018-022-03011-w.

Shoulder Stabilization Versus Immobilization for First-Time Anterior Shoulder Dislocation: A Systematic Review and Meta-analysis of Level 1 Randomized Controlled Trials

BACKGROUND

Multiple studies have compared redislocation rates after stabilization and immobilization for patients experiencing a traumatic, first-time anterior shoulder dislocation (ASD).

PURPOSE

To systematically review the literature to compare rates of recurrent instability and subsequent instability surgery in patients undergoing treatment for a first-time ASD with surgical stabilization versus shoulder immobilization.

STUDY DESIGN

Systematic review and meta-analysis; Level of evidence, 1.

METHODS

A systematic review was performed by searching PubMed, the Cochrane Library, and Embase to identify level 1 randomized studies that compared outcomes of surgical stabilization versus immobilization for treatment of primary ASD. The following search phrase was used: (glenohumeral OR anterior shoulder) AND (conservative OR nonoperative OR nonsurgical OR physiotherapy) AND (Bankart OR repair OR stabilization OR surgical OR surgery OR arthroscopic OR arthroscopy) AND (instability OR dislocation). Patients with soft tissue disruption alone as well as those with additional minor bony lesions (Hill-Sachs, Bankart) were included. Recurrent instability and subsequent instability surgery rates, the Western Ontario Shoulder Instability Index (WOSI), and range of motion were evaluated.

RESULTS

A total of 5 studies met inclusion criteria, including 126 patients undergoing surgical stabilization (mean age, 23.6 years; range, 15.0-39.0 years) and 133 patients undergoing treatment with sling immobilization only (mean age, 23.1 years; range, 15.0-31.0 years). Mean follow-up was 59.7 months. Overall, 6.3% of operative patients experienced recurrent instability at latest follow-up compared with 46.6% of nonoperative patients (P < .00001). Similarly, 4.0% of operative patients underwent a subsequent instability surgery compared with 30.8% of nonoperative patients (P < .00001). These same trends were demonstrated when data were isolated to nonoperative patients immobilized in internal rotation. When comparing the operative and nonoperative groups at latest follow-up, 1 study found significantly improved WOSI scores among operative patients (P = .035) and 1 study found significantly improved abducted external rotation in nonoperative patients (P = .02).

CONCLUSION

Patients, particularly active men in their 20s and 30s, undergoing treatment for a first-time ASD with a surgical stabilization procedure can be expected to experience significantly lower rates of recurrent instability and a significantly decreased need for a future stabilization procedure when compared with patients treated nonoperatively.

Fracture of the humeral surgical neck and shoulder dislocation following an epileptic seizure: Case report

Epilepsy is a pathological condition characterized by seizures of muscle tension and convulsions in which the patient is unable to control himself, resulting in various complications and injuries. In this paper we talk about a rare case that combines a shoulder dislocation with a fracture of the surgical neck of the humerus after an epileptic seizure. The patient came to the hospital with clinical symptoms directed at dislocating the shoulder after an epileptic seizure, but careful examination and radiography revealed the presence of a fracture of the surgical neck of the humerus, so the management needed experience to repair two serious traumatic injuries. In the light of the foregoing, the need for clinical knowledge regarding such injuries in terms of diagnosis and methods of management and treatment is very necessary especially that neglect or wrong diagnosis will lead to very bad results, the most important of which are chronic pain, disability and stiffness.

•

Recurrent epileptic seizures characterize epilepsy, which is a category of non-communicable neurological illnesses.

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After an epileptic episode, a shoulder dislocation with a fracture of the surgical neck of the humerus is an uncommon occurrence.

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The application philos pate with tention band sutures for rotated cuff is the best treatment currently.

Overview of Sport-Specific Injuries

Athletes are at risk for a variety of injuries not typically sustained in everyday life. The team physician must be capable of not only identifying and treating injuries as they occur, but he or she must be armed with the knowledge to minimize the risk of injuries before they occur. This review serves to provide an overview of the various sport-specific injuries typically encountered by team physicians. Injuries are grouped by body part and/or organ system, when possible. We do not aim to cover in detail the various treatments for these injuries; rather, we hope that this article provides a comprehensive overview of sport-specific injury, and demonstrate the well-roundedness in skills that must be possessed by team physicians.

Instability Severity Index Score Does Not Predict the Risk of Shoulder Dislocation after a First Episode Treated Conservatively

The first purpose of this study was to verify the association between Instability Severity Index Score (ISIS) and Recurrent Shoulder Dislocation (RSD) after a first episode treated conservatively. The second aim is to identify the risk factors associated with RSD after a primary acute shoulder anterior dislocation treated conservatively. A total of 111 patients with first traumatic anterior shoulder dislocation treated at a single trauma centre between January 2014 and March 2016 were enrolled. The main predictive variables of risk factors and the ISIS score were calculated. Among the 85 patients included, 26 cases of RSD were observed (30.6%). Considering the whole population, no significant association between ISIS and RSD were reported. Regarding other risk factors, high-risk working activities and rotator cuff injury had a significantly higher RSD risk. Sex, dominant limb, familiar history, hyperlaxity, contact or overhead sports, competitive sport, post-reduction physiokinesitherapy, return to sports activity time, Hill-Sachs lesion, bony Bankart lesion and great tuberosity fracture did not seem to influence the risk of RSD. No correlation between ISIS score and RSD in patients treated conservatively after a first episode of shoulder dislocation were reported. The only risk factors with a significant association to RSD were high-risk working activities and rotator cuff injury.

Operative Versus Nonoperative Treatment Following First-Time Anterior Shoulder Dislocation

BACKGROUND

There is an ongoing debate about whether to perform operative or nonoperative treatment following a first-time anterior dislocation or wait for recurrence before operating. The aim of this systematic review is to compare recurrence rates following operative treatment following first-time anterior dislocation (OTFD) with recurrence rates following (1) nonoperative treatment (NTFD) or (2) operative treatment after recurrent anterior dislocation (OTRD).

METHODS

A literature search was conducted by searching PubMed (Legacy), Embase/Ovid, Cochrane Database of Systematic Reviews/Wiley, Cochrane Central Register of Controlled Trials/Wiley, and Web of Science/Clarivate Analytics from 1990 to April 15, 2020, according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The revised tool to assess risk of bias in randomized trials (RoB 2) developed by Cochrane was used to determine bias in randomized controlled trials, and the methodological index for non-randomized studies (MINORS) was used to determine the methodological quality of non-randomized studies. The certainty of evidence was assessed with the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach using GRADEpro software.

RESULTS

Of the 4,096 studies for which the titles were screened, 9 comparing OTFD and NTFD in a total of 533 patients and 6 comparing OTFD and OTRD in a total of 961 patients were included. There is high-quality evidence that OTFD is associated with a lower rate of recurrence (10%) at >10 years of follow-up compared with NTFD (55%) (p < 0.0001). There is very low-quality evidence that patients receiving OTFD had a lower recurrence rate (11%) compared with those receiving OTRD (17%) (p < 0.0001).

CONCLUSIONS

There is high-quality evidence showing a lower recurrence rate at >10 years following OTFD compared with NTFD (or sham surgery) in young patients. There is evidence that OTFD is more effective than OTRD, but that evidence is of very low quality.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Common animal models lack a distinct glenoid labrum: a comparative anatomy study

Purpose

Development and validation of an animal model of labral healing would facilitate translation of novel surgical and biological strategies to improve glenolabral healing. The purpose of this study was to characterize the anatomic and histological properties of the shoulder labrum in rat, rabbit, dog, pig, goat, and humans. Given the demonstrated similarities in size and structural morphology in other joints, it was hypothesized that the goat glenoid with surrounding capsulolabral complex would most closely resemble that of humans in terms of dimensions and structure, as observed grossly and histologically.

Methods

Cadaveric glenohumeral joints from rats (n = 8), New Zealand white rabbits (n = 13), Mongrel dogs (n = 9), Spanish goats (n = 10), Yorkshire pigs (n = 10), and humans (n = 9) were freshly harvested. Photographs were taken of the glenoid with its surrounding capsulolabral complex. Linear dimensions of the glenoid articular surface were measured. It was determined where the capsulolabral complex was continuous with, or recessed from, the articular glenoid surface. The glenoid was divided into 6 equal segments radiating out toward 12, 2, 4, 6, 8, and 10 o’clock positions. Samples were sectioned and stained with Safranin O/Fast green and Mallory Trichrome. Insertion of the capsulolabral tissue onto the glenoid was qualitatively assessed and compared with gross morphology.

Results

Dimensions of the goat glenoid most closely paralleled dimensions of the human glenoid. A capsulolabral complex was continuous with the glenoid surface from ~ 9 to 12 o’clock in the rats, 7 to 12 o’clock in rabbits, 5 to 12 o’clock in the dogs, and 9 to 12 o’clock in goats, 6 to 12 o’clock in pigs, and 2 to 8 o’clock in humans. In contrast to humans, no other species demonstrated an organized fibrocartilaginous labrum either macroscopically or histologically.

Conclusion

The animals in the present study did not possess a discrete fibrocartilaginous labrum by gross or histological evaluation, as directly compared to humans. While models using these animals may be acceptable for examining other shoulder pathologies, they are not adequate to evaluate labral pathology.

Level of evidence

Basic Science Study; Anatomy and Histology; Cadaveric Animal Model.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40634-021-00383-6.

Failed Latarjet procedure: a systematic review of surgery revision options

Background

Revision surgery after the Latarjet procedure is a rare and challenging surgical problem, and various bony or capsular procedures have been proposed. This systematic review examines clinical and radiographic outcomes of different procedures for treating persistent pain or recurrent instability after a Latarjet procedure.

Methods

A systematic review of the literature was performed using the Medline, Cochrane, EMBASE, Google Scholar and Ovid databases with the combined keywords “failed”, “failure”, “revision”, “Latarjet”, “shoulder stabilization” and “shoulder instability” to identify articles published in English that deal with failed Latarjet procedures.

Results

A total of 11 studies (five retrospective and six case series investigations), all published between 2008 and 2020, fulfilled our inclusion criteria. For the study, 253 patients (254 shoulders, 79.8% male) with a mean age of 29.6 years (range: 16–54 years) were reviewed at an average follow-up of 51.5 months (range: 24–208 months).

Conclusions

Eden–Hybinette and arthroscopic capsuloplasty are the most popular and safe procedures to treat recurrent instability after a failed Latarjet procedure, and yield reasonable clinical outcomes. A bone graft procedure and capsuloplasty were proposed but there was no clear consensus on their efficacy and indication.

Level of evidence

Level IV

Trial registration PROSPERO 2020 CRD42020185090—www.crd.york.ac.uk/prospero/

[Emergency treatment of dislocation of large joints]

Joint dislocations are always accompanied by rupture of the joint capsule. Depending on the forces exerted on the joint as well as individual bone quality, fractures (dislocation fractures) and injuries to ligaments occur. As blood vessels and nerves can also be damaged, reduction is an urgent measure. Only impaired peripheral perfusion, loss of motor function or sensation justify reduction without radiological documentation. As reduction can be a painful procedure, analgosedation is nearly always necessary. Evidence for superiority of individual maneuvers is weak. Reduction is followed by immobilization and documented by another control X‑ray. Follow-up treatment depends on concomitant injuries, age and individual demands on joint function. Even with correct follow-up treatment, deficits often persist. This article deals with the diagnostics and treatment of dislocations of the shoulder, elbow, hip, patella and knee.

Epidemiology of shoulder instability in Italy: A 14-years nationwide registry study

INTRODUCTION

The aim of this study is to estimate the annual number of shoulder dislocation hospitalizations in Italy from 2001 to 2014, to explore geographical variation in access to hospitalizations between the 3 macro-regions of Italy (North, Centre and South) and to perform statistical projections of hospitalizations volumes and rates based on data from 2001 to 2014.

MATERIALS AND METHODS

Data of the Italian Ministry of Health regarding the National Hospital Discharge records (SDO) were analysed for the period of the survey (2001-2014). These data are anonymous and include the patient's age, sex, domicile, region of hospitalization, length of the hospitalization, and type of reimbursement (public or private).

RESULTS

During the 14-year study period, 92,784 hospitalizations to treat shoulder dislocation were performed in Italy, which represented an incidence of 11.2 hospitalizations for every 100,000 Italian inhabitants. 56,514 patients underwent hospitalization for non-surgical treatment. 36,270 patients underwent hospitalization for surgical treatment. The higher hospitalizations rate was among males from 15 to 64 years of age.

CONCLUSIONS

Increasing rates of surgical hospitalization and decreasing rates of hospitalization for non-surgical treatment of shoulder dislocation are observed over a 14-year period. This study confirms that the socioeconomic burden of shoulder dislocation surgery heavily affects the working population. Most shoulder instability procedures were performed on males. The present study provides a description of the frequency and national distribution of shoulder instability in Italy. This study shows an increase in surgical procedures for shoulder instability in Italy.

Assessment and Trends in the Methodological Quality of the Top 50 Most Cited Articles in Shoulder Instability

Background:

Citation counts have often been used as a surrogate for the scholarly impact of a particular study, but they do not necessarily correlate with higher-quality investigations. In recent decades, much of the literature regarding shoulder instability is focused on surgical techniques to correct bone loss and prevent recurrence.

Purpose:

To determine (1) the top 50 most cited articles in shoulder instability and (2) if there is a correlation between the number of citations and level of evidence or methodological quality.

Study Design:

Cross-sectional study.

Methods:

A literature search was performed on both the Scopus and the Web of Science databases to determine the top 50 most cited articles in shoulder instability between 1985 and 2019. The search terms used included “shoulder instability,” “humeral defect,” and “glenoid bone loss.” Methodological scores were calculated using the Modified Coleman Methodology Score (MCMS), Jadad scale, and Methodological Index for Non-Randomized Studies (MINORS) score.

Results:

The mean number of citations and mean citation density were 222.7 ± 123.5 (range, 124-881.5) and 16.0 ± 7.9 (range, 6.9-49.0), respectively. The most common type of study represented was the retrospective case series (evidence level, 4; n = 16; 32%) The overall mean MCMS, Jadad score, and MINORS score were 61.1 ± 10.1, 1.4 ± 0.9, and 16.0 ± 3.0, respectively. There were also no correlations found between mean citations or citation density versus each of the methodological quality scores.

Conclusion:

The list of top 50 most cited articles in shoulder instability comprised studies with low-level evidence and low methodological quality. Higher-quality study methodology does not appear to be a significant factor in whether studies are frequently cited in the literature.

The effectiveness of battlefield acupuncture in addition to standard physical therapy treatment after shoulder surgery: a protocol for a randomized clinical trial

INTRODUCTION

There is a large incidence of shoulder instability among active young athletes and military personnel. Shoulder stabilization surgery is the commonly employed intervention for treating individuals with instability. Following surgery, a substantial proportion of individuals experience acute post-operative pain, which is usually managed with opioid pain medications. Unfortunately, the extended use of opioid medications can have adverse effects that impair function and reduce military operational readiness, but there are currently few alternatives. However, battlefield acupuncture (BFA) is a minimally invasive therapy demonstrating promise as a non-pharmaceutical intervention for managing acute post-operative pain.

METHODS

This is a parallel, two-arm, single-blind randomized clinical trial. The two independent variables are intervention (2 levels, standard physical therapy and standard physical therapy plus battlefield acupuncture) and time (5 levels, 24 h, 48 h, 72 h, 1 week, and 4 weeks post shoulder stabilization surgery). The primary dependent variables are worst and average pain as measured on the visual analog scale. Secondary outcomes include medication usage, Profile of Mood States, and Global Rating of Change.

DISCUSSION

The magnitude of the effect of BFA is uncertain; current studies report confidence intervals of between-group differences that include minimal clinically important differences between intervention and control groups. The results of this study may help determine if BFA is an effective adjunct to physical therapy in reducing pain and opioid usage in acute pain conditions.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04094246 . Registered on 16 September 2019.

Feasibility of the SINEX program for patients with traumatic anterior shoulder instability

Background

An optimal treatment for traumatic anterior shoulder instability (TASI) remains to be identified. A shoulder instability neuromuscular exercise (SINEX) program has been designed for patients with TASI, but has not yet been tested in patients eligible for surgery. The purpose of this study was to investigate and evaluate the feasibility and safety of the SINEX program for patients diagnosed with TASI and eligible for surgery.

Methods

A feasibility study with an experimental, longitudinal design using both quantitative and qualitative research methods. A total of seven participants underwent the SINEX program, a 12-week exercise program including physiotherapist-supervised sessions. Feasibility data on recruitment, retention, compliance, acceptability and safety was collected through observation and individual semi-structured interviews. Clinical tests and self-report questionnaires were completed at baseline and 12 weeks follow-up. Clinical assessments included apprehension and relocation tests, shoulder joint position sense (SJPS), shoulder sensorimotor control measured by center of pressure path length (COPL) on a force platform, isometric strength measured by Constant Score-Isometric Maximal Voluntary Contraction (CS-iMVC), self-report questionnaires including Western Ontario Shoulder Instability Index (WOSI), Tampa Scale of Kinesiophobia (TSK) and Global Perceived Effect questionnaire (GPE).

Results

With one participant recruited every 2 weeks, the recruitment rate was 50% lower than expected. Two of seven participants achieved compliance, defined as at least 66% completion of the scheduled home exercises and at least 50% attendance for the physiotherapist supervised sessions. Barriers for successful compliance were (1) inability to take along exercise equipment when travelling, (2) sick leave, (3) holidays and (4) lack of time/busy days. Four adverse events occurred, one of which was related to the intervention (patellar redislocation). All participants expressed satisfaction with the intervention and felt safe during the exercises. All participants improved in the GPE. Change greater than minimal detectable change (MDC) was reported in four participants in some of the outcome assessments. One of the seven participants declined surgery.

Conclusion

Further assessment is required on several areas before performing an RCT evaluating the efficacy of the SINEX program for patients with TASI considered eligible for surgery. No adverse events suggest that the program is safe, but patients with general hypermobility may need additional adjustments to prevent adverse events in other areas of the body.

Trial registration

ClinicalTrials.gov: NCT04152304, retrospectively registered

A systematic review of pre-hospital shoulder reduction techniques for anterior shoulder dislocation and the effect on patient return to function

PURPOSE

The majority of acute anterior shoulder dislocations are sustained during sports and wilderness activities. The management of acute dislocations in the pre-hospital setting is currently without guidelines based on the evidence. The study aims to assess the risk of acute complications in pre-hospital shoulder reduction and identify which pre-hospital reduction technique has the highest success rate in the published literature.

METHODS

The involved databases were Allied and Complementary Medicine, CENTRAL, CINAHL, Cochrane Database of Systematic Reviews, Embase, Europe PMC, Ovid MEDLINE®, Pedro, Proquest, Trip, and World Health Organization International Clinical Trials Registry platform. Only original research of high methodological quality was included, which was defined by the recently developed assessment tool-assessing the methodological quality of published papers (AMQPP) and investigated the management of acute anterior shoulder dislocations in the pre-hospital setting.

RESULTS

Two hundred and ninety-eight articles were identified and screened. A full text review was performed on 40 articles. Four articles published between 2015 and 2018 met the inclusion criteria. A total of 181 patients were included with the study duration ranging from 6 to 60 months. All studies reported zero immediate complication following pre-hospital reduction and there were no documented subsequent adverse events regardless of the technique used. Prompt resolution of neurological symptoms was observed following the early and successful pre-hospital reduction. First attempt success rate, when performed by skilled practitioners, ranged from 72.3% to 94.9%.

CONCLUSION

Pre-hospital shoulder reduction appears to be a safe and feasible option when carried out with the appropriate expertise. A novel reduction technique adapted from the mountain medicine diploma course at the University of Paris North was found to have the highest first attempt reduction success rate of 94.9%. Other techniques described in the literature included Hippocratic, Stimson's, Counter-traction and external rotation with the success rates ranging from 54% to 71.7%.

Does Functional Bracing of the Unstable Shoulder Improve Return to Play in Scholastic Athletes? Returning the Unstable Shoulder to Play

BACKGROUND

Functional bracing is often used as an adjunct to nonoperative treatment of anterior shoulder instability, but no study has evaluated the effectiveness of in-season bracing. The purpose of this study was to examine successful return to play in a nonoperative cohort of adolescent athletes with in-season shoulder instability and compare those athletes treated with bracing to those who were not.

HYPOTHESIS

The use of functional bracing will improve success rates in a cohort of athletes treated nonoperatively for in-season shoulder instability.

STUDY DESIGN

Cohort study.

LEVEL OF EVIDENCE

Level 3.

METHODS

A total of 97 athletes with anterior shoulder instability were followed for a minimum of 1 year. The mean age was 15.8 ± 1.4 years (range, 12.0-18.0 years). All athletes were treated with initial nonoperative management. Twenty athletes (21%) were also treated with bracing while 77 (79%) were not. The athlete completing the current season and 1 subsequent season without surgery or time lost from shoulder injury was defined as a successful outcome.

RESULTS

There was no statistical difference in nonoperative success rates between the braced and nonbraced athletes (P = 0.33). Braced athletes (n = 20) returned to play 80% of the time, while nonbraced athletes (n = 77) returned at a rate of 88%. Of the braced athletes, 85% were football players (n = 17). A football-only comparison demonstrated no difference between braced failures (26%) and nonbraced failures (16%) (P = 0.47).

CONCLUSION

This is the first study to evaluate the utility of functional bracing in returning an athlete to sport and completing a full subsequent season without surgery or time loss due to injury of the shoulder. In adolescent athletes with shoulder instability treated nonoperatively, functional bracing did not result in increased success rates when compared with no bracing.

CLINICAL RELEVANCE

The data from this study indicate that functional bracing may not improve success rates for athletes with shoulder instability.

Posterior shoulder instability: a systematic review

INTRODUCTION

This review aims to provide information on outcomes of surgical procedures for soft tissue or bony glenoid and/or humeral abnormalities in case of posterior shoulder instability.

SOURCE OF DATA

A systematic review of the literature according to the PRISMA guidelines was performed. A comprehensive search of PubMed, Medline, CINAHL, Cochrane, Embase, Ovid and Google Scholar databases using various combinations of the keywords 'shoulder', 'posterior instability', 'dislocation', 'reversed bony bankart', 'reversed Hill Sachs', and 'capsulolabral' was performed.

AREAS OF AGREEMENT

A total of 847 shoulders in 810 patients were included. A redislocation event occurred in 33 (8.7%) of 411 shoulders with soft tissue abnormalities and in 12 (9.1%) of 132 shoulders with bony abnormalities of the glenoid, humeral head or both.

AREAS OF CONTROVERSY

The optimal treatment modalities for posterior shoulder dislocation remain to be defined.

GROWING POINTS

Operative stabilization for posterior shoulder instability should be lesion-specific and should correct all components of the posterior instability.

AREAS TIMELY FOR DEVELOPING RESEARCH

Future prospective studies should aim to establish the optimal treatment modalities for posterior shoulder instability.

Immobilization in External Rotation Reduces the Risk of Recurrence After Primary Anterior Shoulder Dislocation: A Meta-analysis

Background

The best method for nonsurgical treatment after primary dislocation of the shoulder is not clear. The efficacy of immobilization with the arm in external rotation (ER) compared with internal rotation (IR) remains controversial.

Purpose

To determine the efficacy of ER immobilization versus IR immobilization on recurrence rate after primary dislocation of the shoulder from the evidence of randomized controlled trials.

Study Design

Systematic review; Level of evidence, 2.

Methods

Electronic databases (MEDLINE [Ovid SP], PubMed, Web of Science, EBM reviews, and CINAHL) and available proceedings according to the abstracts of major international meetings related to or including shoulder injuries and trauma were used to search for randomized controlled trials. Two independent investigators determined eligibility and carried out data extraction from the selected studies.

Results

A total of 9 studies (817 patients) were selected for this meta-analysis. They included 668 male and 149 female patients, with a mean age ranging from 20.3 to 37.5 years. In the 9 pooled studies, the recurrence rate of shoulder dislocation was 21.5% (84/390) in the ER group versus 34.9% (130/373) in the IR group. ER immobilization significantly reduced the recurrence rate compared with IR immobilization (risk ratio, 0.56; P = .007). In the subgroup analysis of those immobilized full-time, ER immobilization was significantly more effective than IR immobilization in reducing the recurrence rate (risk ratio, 0.57; P = .01). In the subgroup analysis of age, ER immobilization was significantly more effective than IR immobilization in those aged 20 to 40 years but not in those younger than 20 years.

Conclusion

This meta-analysis demonstrates that ER immobilization reduces the recurrence rate after primary shoulder dislocation compared with IR immobilization in patients older than 20 years. When treating a patient with primary shoulder dislocation, the clinician should provide this information to the patient before a treatment method is selected.

Epidemiology of Paediatric Shoulder Dislocation: A Nationwide Study in Italy from 2001 to 2014

Limited knowledge is accessible concerning the tendencies of hospitalization for skeletally immature patients with episodes of shoulder dislocation. Our research aim was to evaluate annual hospitalizations for shoulder dislocation in paediatric patients in Italy from 2001 to 2014, on the basis of the official data source as hospitalization reports. The second purpose was to investigate geographical diversification in hospitalization for shoulder dislocation in regions of Italy. The last aim was to make statistical predictions of the number of shoulder dislocation hospitalization volumes and rates in skeletally immature patients based on data from 2001 to 2014. An examination of the National Hospital Discharge records (SDO) kept at the Italian Ministry of Health regarding the 14 years of our study (2001 through 2014) was conducted. These data are anonymous and include patient's age, gender, domicile, region and time of hospitalization, and the kind of reimbursement (public or private). In the 14-year study time, 344 hospitalizations for shoulder dislocation of patients aged 0-14 years took place in Italy. The male/female hospitalization ratio varied from a maximum of 3.0 (2001) to a minimum of 1.1 (2013), with a mean average ratio in the 2001-2014 timespan of 2.0. Almost half of the hospitalizations (49.1%) were performed in the South. The mean incidence of hospitalizations in Italy for shoulder dislocation in patients with less than 14 years was 0.3 for every 100,000 inhabitants in the same class of age. The most common treatment was a closed reduction (60.8%), followed by open stabilization (16.6%) and arthroscopic procedures (13.7%). The present registry study shows a low incidence of hospitalization for shoulder dislocation in young patients. The most common treatment for a shoulder dislocation in paediatric patients is a closed shoulder reduction. Regions from the south and the centre of Italy are marked by an inferior number of operations and a higher number of hospitalization for closed shoulder reduction.

Primary Arthroscopic Stabilization for a First-Time Anterior Dislocation of the Shoulder: Long-Term Follow-up of a Randomized, Double-Blinded Trial

BACKGROUND

The aim of this study was to evaluate the long-term efficacy of arthroscopic Bankart repair (ABR).

METHODS

Eighty-eight patients with an age of ≤35 years who had sustained a primary anterior glenohumeral dislocation were enrolled in a single-center, double-blinded clinical trial. Subjects were randomized to receive either an arthroscopic washout (AWO) or ABR. Participants were reassessed after a minimum of 10 years postoperatively. Data regarding recurrent instability, revision surgery, satisfaction, and function (Disabilities of the Arm, Shoulder and Hand [DASH] and Western Ontario Shoulder Instability Index [WOSI]) scores were collected.

RESULTS

Sixty-five patients (74%; 32 in the AWO group and 33 in the ABR group) were included and had an average follow-up of 14.2 years (range,12 to 16 years). The rate of recurrent dislocation was significantly higher in the AWO group than the ABR group (47% and 12%, respectively; p = 0.002). Kaplan-Meier curves were plotted for event-free survival using recurrent instability and/or revision surgery as clinical end points. This analysis demonstrated a sustained significant difference between the groups at 10 years after surgery (58% for the AWO group versus 79% for the ABR group; log-rank test [Mantel-Cox]; p = 0.018). Long-term WOSI scores were significantly better in the ABR group. The presence of recurrent instability was associated with significantly poorer WOSI and DASH scores.

CONCLUSIONS

This study demonstrates a long-term benefit in overall shoulder stability and functional outcome in high-risk patients who have undergone ABR for first-time anterior dislocation.

LEVEL OF EVIDENCE

Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Neuromuscular Exercises Improve Shoulder Function More Than Standard Care Exercises in Patients With a Traumatic Anterior Shoulder Dislocation: A Randomized Controlled Trial

Background:

There is an important gap in knowledge about the effectiveness of nonoperative treatment (exercise) for patients with traumatic primary and recurrent anterior shoulder dislocations (ASDs).

Purpose/Hypothesis:

The purpose of this study was to assess the efficacy and safety of physical therapist–supervised, shoulder instability neuromuscular exercise (SINEX) versus self-managed, home-based, standard care shoulder exercise (HOMEX) in patients with traumatic ASDs. The hypothesis was that SINEX would have a larger effect and fewer adverse events compared with HOMEX.

Study Design:

Randomized controlled trial; Level of evidence, 2.

Methods:

A total of 56 participants with radiographically verified, trauma-initiated primary or recurrent ASDs and self-reported decreased shoulder function were randomized to 12 weeks of either SINEX or HOMEX. The SINEX program consisted of 7 exercises, individually progressing from basic (2 × 20 repetitions each day) to elite (2 × 10 repetitions, 3 times weekly). The HOMEX program included 5 shoulder exercises performed 3 times weekly (2 × 10 repetitions). The primary outcome was the Western Ontario Shoulder Instability Index (WOSI) score, ranging from 0 (best possible) to 2100. The between-group minimal clinically important difference at 12 weeks was 250 points. Secondary outcomes included WOSI subdomain scores, patient-reported ratings of kinesiophobia and pain, objective shoulder function, patient satisfaction, and number of adverse events.

Results:

The between-group mean difference in the WOSI total score at 12 weeks significantly favored SINEX over HOMEX (–228.1 [95% CI, –430.5 to –25.6]). SINEX was furthermore superior to HOMEX in most of the secondary outcomes (3/4 subdomains of the WOSI and pain level during the past 7 days as well as clinical signs of anterior shoulder instability). Also, although not statistically significant, less than half the proportion of the SINEX patients compared with the HOMEX patients (3/27 [11%] vs 6/24 [25%], respectively; P = .204) underwent or were referred for shoulder stabilizing surgery. Satisfaction with both exercise programs was high, and no serious adverse events were reported.

Conclusion:

Neuromuscular shoulder exercise (SINEX) was superior to standard care exercise (HOMEX) in patients with traumatic ASDs. Further long-term follow-ups on treatment effects are needed.

Registration:

NCT02371928 (ClinicalTrials.gov identifier).

Arthroscopy Annual Awards, a 35th Anniversary…and More

With sincere appreciation to the Arthroscopy Association of North America Education Foundation for their generous support, we announce our 2020 Annual Awards for the best Clinical Research, Basic Science Research, Resident/Fellow Research, and Systematic Reviews published in 2019, as well as the Most Downloaded and Most Cited papers published 5 years ago. Our January cover is a throwback in honor of the 35th anniversary of our journal, and our cover will sport a festive banner each month this year. We introduce our 2020 masthead and team, including a new Social Media Board. Finally, our Editor-in-chief, Assistant Editors, and Associate Editors update their disclosures of potential conflicts of interest.

Arthroscopic Latarjet for Recurrent Shoulder Instability

Background and Objectives: The all-arthroscopic Latarjet (aL) procedure was introduced to manage recurrent shoulder instability. Our study aimed to report the outcomes of aL procedures with the Rowe, University of California-Los Angeles (UCLA), simple shoulder test (SST) scores, and range of motion (ROM) in external rotation at a minimum follow-up of 2 years. Material and Methods: A total of 44 patients presenting recurrent shoulder instability were managed with aL procedure. Clinical outcomes were assessed at a mean follow-up of 29.6 ± 6.9 months. The postoperative active ROM was measured and compared with the contralateral shoulder. The Rowe, UCLA, and SST scores were administered preoperatively and postoperatively. Results: No patients experienced infections or neuro-vascular injuries. Seven (15%) patients required revision surgery. After surgery, the external rotation was statistically lower compared to the contralateral shoulder, but it improved; clinical outcomes also improved in a statistically significant fashion. Conclusions: The aL produced good results in the management of recurrent shoulder instability, but the complication rate was still high even in the hands of expert arthroscopist.

Editorial Commentary: Taming Hard Problems With Soft Tissues? Anterior Shoulder Instability After Prior Bone Block Stabilization

Recurrent anterior shoulder instability after prior bone block stabilization is a therapeutically challenging condition. Historically, repeated glenoid bone grafting has been advocated in such cases to achieve lasting shoulder stability. However, recent insights into the pathomechanics of shoulder instability, especially regarding bipolar bony lesions, have renewed our interest in the arthroscopic treatment of Hill-Sachs lesions and the role of soft-tissue interventions after bone block procedures.

The Natural History of Pediatric and Adolescent Shoulder Dislocation

BACKGROUND

Twenty percent of shoulder dislocations occur in people younger than 20 years old. Management of anterior shoulder instability in young patients remains an evolving and controversial topic. Herein we review the natural history of anterior shoulder dislocation in young patients.

METHODS

The English-language literature was searched for studies examining the natural history of pediatric and adolescent shoulder dislocation. Recurrent dislocation was the primary outcome of interest in most studies.

RESULTS

Most studies found that recurrent instability was likely in young patients. Several systematic reviews reported the recurrence rate for young patients to be >70%. Recurrent instability was likely to cause greater damage to the joint and may result in more extensive and costly surgery.

CONCLUSIONS

Most studies agree that recurrent anterior shoulder instability is likely in young patients. Some authors advocate for consideration of early surgery in this high-risk population.

Conservative management following closed reduction of traumatic anterior dislocation of the shoulder

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.

Editorial Commentary: Unsolved Problems in Shoulder Instability-The Dilemma of Bone Loss!

Bone loss in the setting of shoulder instability is an unsolved problem. Procedures restoring bone stock on the glenoid side vary from minimally invasive arthroscopic techniques of arthroscopic bone block procedures to traditional transposition of the coracoid or bone transplant. These techniques are evolving, and several tips and tricks have been optimized to improve outcomes and to reduce the risk of complications, even though the most terrible complication of transposition of the coracoid remains osteoarthritis in the young adult. The major innovation in the past few years has been the use of remplissage. The aim of our surgical procedures is to restore the anatomy as much as possible. Therefore, gentle handling of bone defects on both the humeral and glenoid sides by means of an arthroscopic bone block and combined remplissage seems to be the future of our surgical procedures.

Is the Instability Severity Index Score a Valid Tool for Predicting Failure After Primary Arthroscopic Stabilization for Anterior Glenohumeral Instability?

PURPOSE

To assess the validity of the Instability Severity Index Score in predicting the rate of recurrence of dislocation in patients undergoing arthroscopic Bankart repair.

METHODS

The inclusion criteria were recurrent anterior traumatic glenohumeral instability and a minimum follow-up of 5 years. According to the preoperative Instability Severity Index Score, patients were divided into the following groups: ≤3 points (A), 4 to 6 points (B), and >6 points (C). The recurrence rate was determined by telephone interviews. The estimated overall rate of success at 5 years was defined as the estimated overall percentage of patients free of recurrence at 5 years.

RESULTS

Six hundred seventy patients (572 men and 98 women) were included. The average age was 27 years (range, 18 to 39 years) at the time of surgery. One hundred fourteen of 670 patients had a recurrence of instability, with an overall recurrence rate of 17% (95% confidence interval [CI] 14.2%-19.9%). The Instability Severity Index Score had a significant association with recurrence. Compared with patients in group A, those in group B had double the risk of recurrence (hazard ratio [HR] = 2.43, 95% CI 1.38-4.28, P = .002), and patients in group C a 9 times greater risk of recurrence (HR = 9.42, 95% CI 5.20-17.7, P < .001). The estimated overall rate of success at 5 years was 84.8% (95% CI 81.8-87.3). The rate of success with an Instability Severity Index Score ≤3 points was 93.7% (95% CI 89.6-96.2), but it dropped to 85.7% (95% CI 81.7-88.9) in those with an Instability Severity Index Score of 4 to 6 points and became 54.6% (95% CI 42.8-64.9) in those with an Instability Severity Index Score >6 points. On multivariable analysis, the Instability Severity Index Score was found to significantly affect the risk of recurrence, corrected by type of sport and glenoid bone loss.

CONCLUSIONS

The Instability Severity Index Score is a validated tool with which to assess the recurrence rate of dislocation after arthroscopic surgery in patients with shoulder instability. Arthroscopic stabilization in patients with an Instability Severity Index Score ≤3 is associated with a significantly lower risk of recurrence of glenohumeral instability compared with that in patients with an Instability Severity Index Score >3 points.

LEVEL OF EVIDENCE

III, case-control study.

Arthroscopic Bankart repair with remplissage for non-engaging Hill-Sachs lesion in professional collision athletes

BACKGROUND

The present study aimed to determine whether arthroscopic remplissage with Bankart repair is an effective treatment for improving outcomes for collision athletes with Bankart and non-engaging Hill-Sachs lesions.

METHODS

Twenty collision athletes underwent arthroscopic Bankart repair with posterior capsulotenodesis (B&R group) and were evaluated retrospectively, using pre- and postoperative WOSI (Western Ontario Shoulder Instability), EQ-5D (EuroQOL five dimensions), EQ-VAS (EuroQol-visual analogue scale) scores and Subjective Shoulder Value (SSV). The recurrence and re-operation rates were compared to a matched group with isolated arthroscopic Bankart repair (B group).

RESULTS

The mean age was 25 years with an mean follow-up of 26 months. All mean scores improved with SSV of 90%. There was a mean deficit in external rotation at the side of 10°. One patient was treated with hydrodilatation for frozen shoulder. One patient had residual posterior discomfort but no apprehension in the B&R group compared to 5% persistent apprehension in the B group. In comparison, the recurrence and re-operation rates were 5% and 30% (p = 0.015), 5% and 35% (p = 0.005) in the B&R and B groups, respectively.

CONCLUSIONS

This combined technique demonstrated good outcomes, with lower recurrence rates in high-risk collision athletes. The slight restriction in external rotation does not significantly affect any clinical outcomes and return to play.

Top orthopedic sports medicine procedures

Orthopedic sports medicine is a subspecialty of Orthopedics that focuses on managing pathological conditions of the musculoskeletal system arising from sports practice. When dealing with athletes, timing is the most difficult issue to face. Typically, athletes aim to return to play as soon as possible and at the pre-injury level. This means that management should be optimized to combine the need for prompt return to sport and to the biologic healing time of the musculo-skeletal. This poses a great challenge to sport medicine surgeons, who need to follow with attention to the latest scientific evidence to offer their patients the best available treatment options. We briefly review the most commonly performed orthopedic sports medicine procedures, outlining the presently available scientific evidence on their indications and outcomes.

Are collision athletes at a higher risk of re-dislocation after an open Bristow-Latarjet procedure? A systematic review and meta-analysis

BACKGROUND

The primary aim of the present study was to review, summarize and compare the redislocation risk for collision athletes and noncollision athletes after an open Bristow-Latarjet procedure. Our secondary aim was to summarize return to sport, satisfaction, pain and complications.

METHODS

We conducted a systematic review in PubMed and EMBASE of articles until 1 July 2016. We included all studies describing Bristow-Latarjet like procedures as a result of glenohumeral instability, mentioning redislocation rates in collision athletes with >2 years of follow-up. We pooled the data using random-effects meta-analysis for redislocation risk-differences (RD) between collision and noncollision athletes, and assessed heterogeneity with I² and Tau² tests.

RESULTS

From 475 titles and abstracts, 11 studies were included and eight studies were meta-analyzed. The pooled RD to develop a postoperative redislocation between collision athletes and noncollision athletes was -0.00 (95% confidence interval: -0.03 to 0.03, p = 0.370). Return to sports rates were high (67-100%), and patients reported high satisfaction scores (93-100% satisfied) and low pain scores (mean visual analogue scale score of 1.6); however, postoperative complication rates varied from 0.8% to 19.2%.

CONCLUSIONS

Collision athletes are not more at risk for redislocation rates after an open Bristow-Latarjet procedure compared to noncollision athletes. Overall postoperative outcomes were good, although numerous complications occurred.

Medical speciality, medication or skills: key factors of prehospital joint reduction. A prospective, multicenter cohort study

PURPOSE

Joint dislocations occur frequently in prehospital settings. The medical specialities of emergency physicians are heterogeneous. Decision making and the success rates of reduction attempt can vary greatly. The aim of this prospective multicentre study was to identify the factors most crucial for achieving successful prehospital reduction.

METHODS

Study was conducted from 05/2012-05/2015 investigating cases of shoulder, patella and ankle joint dislocations in 16 emergency physician rescue stations. Parameters included: affected joint, type and use of medication, incidence and circumstances of reduction or reduction attempt and medical specialty as well as subjective skill status.

RESULTS

In total 118 patients could be included. Mean age was 40.1 ± 21.3 years. Medical specialties were: n = 61 (51.7%) anaesthesiologists (A), n = 41 (34.5%) surgeons (S), and n = 16 (13.5%) internal medicine/others (I/O). Reduction attempt was performed in n = 97 (82.2%). With taking into account the complexity of the reduction (S) had significantly the highest success rates followed by (A) and (I/O). Regarding the applied medication there was neither a significant correlation between pain (p = 0.161) nor success of reduction (p = 0.09). A higher number of attempts does not improve the success rate (p ≤ 0.001), the pain level was no predictor for success of reduction attempt (p = 0.88).

CONCLUSION

A successful reduction is determined by the trias of affected joint, skill level and medical specialty of the physician. In each case this trias should be considered by the physician in charge and he must evaluate limitations and circumstances.