Operative versus nonoperative treatment after primary traumatic anterior glenohumeral dislocation: expected-value decision analysis

Predicting recurrence of instability after a primary traumatic anterior shoulder dislocation

Aims

The risk factors for recurrent instability (RI) following a primary traumatic anterior shoulder dislocation (PTASD) remain unclear. In this study, we aimed to determine the rate of RI in a large cohort of patients managed nonoperatively after PTASD and to develop a clinical prediction model.

Methods

A total of 1,293 patients with PTASD managed nonoperatively were identified from a trauma database (mean age 23.3 years (15 to 35); 14.3% female). We assessed the prevalence of RI, and used multivariate regression modelling to evaluate which demographic- and injury-related factors were independently predictive for its occurrence.

Results

The overall rate of RI at a mean follow-up of 34.4 months (SD 47.0) was 62.8% (n = 812), with 81.0% (n = 658) experiencing their first recurrence within two years of PTASD. The median time for recurrence was 9.8 months (IQR 3.9 to 19.4). Independent predictors increasing risk of RI included male sex (p < 0.001), younger age at PTASD (p < 0.001), participation in contact sport (p < 0.001), and the presence of a bony Bankart (BB) lesion (p = 0.028). Greater tuberosity fracture (GTF) was protective (p < 0.001). However, the discriminative ability of the resulting predictive model for two-year risk of RI was poor (area under the curve (AUC) 0.672). A subset analysis excluding identifiable radiological predictors of BB and GTF worsened the predictive ability (AUC 0.646).

Conclusion

This study clarifies the prevalence and risk factors for RI following PTASD in a large, unselected patient cohort. Although these data permitted the development of a predictive tool for RI, its discriminative ability was poor. Predicting RI remains challenging, and as-yet-undetermined risk factors may be important in determining the risk.

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.

Characterizing the Practices of Canadian Orthopedic Surgeons in the Management of patients With Anterior Glenohumeral Instability

OBJECTIVE

To determine the practice patterns of Canadian orthopedic surgeons in the management of patients with anterior glenohumeral instability (AGHI).

DESIGN

Cross-sectional survey.

SETTING

Canada.

PATIENTS OR OTHER PARTICIPANTS

Canadian orthopedic surgeons with membership in the Canadian Orthopedic Association or Canadian Shoulder and Elbow Surgeon group who had managed at least 1 patient with AGHI in the previous year.

INTERVENTIONS

A survey including demographics and questions on the management of patients with AGHI was completed. Statistical comparisons (χ 2 ) were completed with responses stratified using the instability severity index score (ISIS) in practice, years of practice, and surgical volumes.

MAIN OUTCOME MEASURES

Summary statistics were compiled, and response frequencies were considered for consensus (75%). Case series responses were stratified on use of the ISIS in practice, years of experience, and annual procedure volumes (χ 2 , P < 0.05).

RESULTS

Eighty orthopedic surgeons responded, with consensus on areas of diagnostic workup of AGHI, nonoperative management, and operative techniques. There was no consensus on indications for soft tissue and bony augmentation or postoperative management. There was no difference in practices based on the use of ISIS, years in practice, or surgical volumes.

CONCLUSIONS

Canadian orthopedic surgeons manage AGHI consistently with consensus achieved in preoperative diagnostics and operative techniques, although debate remains as to the indications for soft tissue and bony augmentation procedures.

Editorial Commentary: Urgency Toward Arthroscopic Bankart Repair Is Essential for Anterior Shoulder Dislocation: You Don't Have to Fix After the First Dislocation, but Definitely Before the Second!

While still hotly debated, primary arthroscopic management of the first-time anterior shoulder dislocation has an extensive list of known benefits: lower overall health care costs, improved patient-reported outcomes, a vast reduction in secondary instability, and higher quality-of-life measures. Yet, despite these meaningful contributions to health care quality, we continue to bypass the predictable success of an acute arthroscopic Bankart repair in order to tempt fate with "a trial" of nonoperative care for our young, high-risk collision athletes. Whether for the in-season athlete, the "early responder" with limited apprehension, subluxations with spontaneous reduction, or those stoically committed to nonsurgical care, we as physicians are often complicit in this shared risk taking and ceremonial weighing of the risks and benefits for treatment options after primary shoulder instability. Even just 1 additional episode of instability recurrence can double (or triple) the rate of glenohumeral bone loss. Furthermore, subsequent anterior shoulder instability compromises subjective shoulder function, heightens risk of secondary recurrence and/or revision, and increases the likelihood of requiring more advanced surgical management, such as with a Latarjet or other anterior bone block procedure. We must maintain a sense of urgency toward surgical treatment, particularly in young, high-demand athletes with persistent instability. To parrot the wisdom of our shoulder mentors, hear my humble plea: you don't have to fix the shoulder after the first anterior dislocation, but you should definitely do it before the second!

Clinical and Radiologic Outcomes of All-Arthroscopic Latarjet Procedure With Modified Suture Button Fixation: Excellent Bone Healing With a Low Complication Rate

PURPOSE

To investigate the clinical outcomes and radiologic evaluation of an all-arthroscopic Latarjet procedure with modified button fixation.

METHODS

Patients who received all-arthroscopic Latarjet procedure with modified suture button fixation between September 2015 to September 2016 were retrospectively reviewed. Indications for surgery were recurrent anterior shoulder dislocation with any 1 of these 3 conditions: glenoid defect >15%, contact-sport athlete, or failure after Bankart repair. Inclusion criteria included cases who received this surgery. Clinical outcomes were evaluated by University of California Los Angeles, ASES and Rowe score with a minimal follow-up of 3 years. Radiologic assessment on 3D computed tomography scan was performed preoperatively and postoperatively at different time points. Complications were also recorded.

RESULTS

A total of 30 patients were eventually included in this study. The mean follow-up time was 38.0 ± 2.5 months. There were 25 patients who performed contact sports. Of them, 10 patients were without glenoid defect >15% or failed Bankart repair. The remaining 20 patients had glenoid defect >15%, including 2 failed Bankart cases. Ten patients had glenoid defect < 13.5%, and the rest 20 patients had > 13.5%. UCLA, American Shoulder and Elbow Surgeons, and Rowe score significantly improved during follow-up, and the improvement exceeded MCID for all patients. No severe complications were noted. In total, 86.7% of the graft positioning was measured as flush and 13.3% as medial. The bone union rate was 96.7% at 3 months postoperatively and at final follow-up. The remodeling process for the restoration of the normal anatomy of the lower part of glenoid was noted.

CONCLUSIONS

All-arthroscopic Latarjet with modified suture button fixation can achieve stable fixation of the coracoid, good clinical outcomes (all patients with improvement exceeding MCID), low complications rate. Furthermore, the bone remodeling process contributes to the recovery of the normal anatomy of anteroinferior glenoid.

STUDY DESIGN

Case series; Level of evidence, 4.

Biomechanical Studies for Glenoid Based Labral Repairs With Suture Anchors Do Not Use Consistent Testing Methods: A Critical Systematic Review

PURPOSE

The purpose of this systematic review was to investigate variability in biomechanical testing protocols for laboratory-based studies using suture anchors for glenohumeral shoulder instability and SLAP lesion repair.

METHODS

A systematic review of Medline, Embase, Scopus, and Google Scholar using Covidence software was performed for all biomechanical studies investigating labral-based suture anchor repair for shoulder instability and SLAP lesions. Clinical studies, technical notes or surgical technique descriptions, or studies treating glenoid bone loss or capsulorrhaphy were excluded. Risk of bias (ROB) was assessed with the ROBINS-I tool. Study quality was assessed with the Quality Appraisal for Cadaveric Studies. Heterogeneity was assessed with the I² statistic.

RESULTS

A total of 41 studies were included. ROB was serious and critical in 27 studies, moderate in 13, and low in 1; 6 studies had high quality, 21 good quality, 10 moderate quality, 2 low quality, and 2 very low quality. Thirty-one studies used and 22 studies included cyclic loading. Angle of anchor insertion was reported by 33 studies. The force vector for displacement varied. The most common directions were perpendicular to the glenoid (n = 9), and anteroinferior or anterior (n = 8). The most common outcome measures were load to failure (n = 35), failure mode (n = 23), and stiffness (n = 21). Other outcome measures included load at displacement, displacement at failure, tensile load at displacement, translation, energy absorbed, cycles to failure, contact pressure, and elongation.

CONCLUSION

This systematic review demonstrated a clear lack of consistency in those cadaver studies that investigated biomechanical properties after surgical repair with suture anchors for shoulder instability and SLAP lesions. Testing methods between studies varied substantially with no universally applied standard for preloading, load to failure and cyclic loading protocols, insertion angles of suture anchors, or direction of loading. To allow comparability between studies standardization of testing protocols is strongly recommended.

Editorial Commentary: The Nonoperative Instability Severity Index Score Can, in Part, Help to Predict Failure After Nonoperative Management of Anterior Shoulder Instability: Fix Them All Versus Wait and See?

The optimal management of anterior shoulder instability remains a heated topic of debate, particularly after first-time shoulder dislocation. From expedited rehabilitation to arthroscopic Bankart repair and Latarjet coracoid transfer, the shoulder community has staunchly defended its approach with carefully tailored data describing patient satisfaction, instability recurrence, revision surgery, and timeline to return to play or preinjury activity. However, not all patients require surgical stabilization, and a "wait-and-see" approach can often result in favorable outcome. The Nonoperative Instability Severity Index Score has been proposed as a unique tool to stratify risk for failure among athletes after an anterior shoulder instability event. While not a standalone tool for predicting further shoulder dislocation in a broader athletic population, the Nonoperative Instability Severity Index Score reflects a movement toward personalized medicine, where clinical decision making is executed on the individual level based on unique risk factors and circumstances.

Differences in Outcomes Between Anterior and Posterior Shoulder Instability After Arthroscopic Bankart Repair: A Systematic Review and Meta-analysis

Background:

The glenohumeral joint is one of the most frequently dislocated joints in the body, particularly in young, active adults.

Purpose:

To conduct a systematic review and meta-analysis to evaluate and compare outcomes between anterior versus posterior shoulder instability.

Study Design:

Systematic review; Level of evidence, 4.

Methods:

A systematic review was performed using the PubMed, Cochrane Library, and MEDLINE databases (from inception to September 2019) according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Studies were included if they were published in the English language, contained outcomes after anterior or posterior shoulder instability, had at least 1 year of follow-up, and included arthroscopic soft tissue labral repair of either anterior or posterior instability. Outcomes including return-to-sport (RTS) rate, postoperative instability rate, and pre- and postoperative American Shoulder and Elbow Surgeons (ASES) scores were recorded and analyzed.

Results:

Overall, 39 studies were included (2077 patients; 1716 male patients and 361 female patients). Patients with anterior instability had a mean age of 23.45 ± 5.40 years (range, 11-72 years), while patients with posterior instability had a mean age of 23.08 ± 8.41 years (range, 13-61 years). The percentage of male patients with anterior instability was significantly higher than that of female patients (odds ratio [OR], 1.36; 95% CI, 1.04-1.77; P = .021). Compared with patients with posterior instability, those with anterior instability were significantly more likely to RTS (OR, 2.31; 95% CI, 1.76-3.04; P < .001), and they were significantly more likely to have postoperative instability (OR, 1.53; 95% CI, 1.07-2.23; P = .018). Patients with anterior instability also had significantly higher ASES scores than those with posterior instability (difference in means, 6.74; 95% CI, 4.71-8.77; P < .001). There were no significant differences found in postoperative complications between the anterior group (11 complications; 1.8%) and the posterior group (3 complications; 1.6%) (OR, 1.12; 95% CI, 0.29-6.30; P = .999).

Conclusion:

Patients with anterior shoulder instability had higher RTS rates but were more likely to have postoperative instability compared with posterior instability patients. Overall, male patients were significantly more likely to have anterior shoulder instability, while female patients were significantly more likely to have posterior shoulder instability.

Surgical treatment for recurrent shoulder instability: factors influencing surgeon decision making

BACKGROUND

The optimal surgical approach for recurrent anterior shoulder instability remains controversial, particularly in the face of glenoid and/or humeral bone loss. The purpose of this study was to use a contingent-behavior questionnaire (CBQ) to determine which factors drive surgeons to perform bony procedures over soft tissue procedures to address recurrent anterior shoulder instability.

METHODS

A CBQ survey presented each respondent with 32 clinical vignettes of recurrent shoulder instability that contained 8 patient factors. The factors included (1) age, (2) sex, (3) hand dominance, (4) number of previous dislocations, (5) activity level, (6) generalized laxity, (7) glenoid bone loss, and (8) glenoid track. The survey was distributed to fellowship-trained surgeons in shoulder/elbow or sports medicine. Respondents were asked to recommend either a soft tissue or bone-based procedure, then specifically recommend a type of procedure. Responses were analyzed using a multinomial-logit regression model that quantified the relative importance of the patient characteristics in choosing bony procedures.

RESULTS

Seventy orthopedic surgeons completed the survey, 33 were shoulder/elbow fellowship trained and 37 were sports medicine fellowship trained; 52% were in clinical practice ≥10 years and 48% <10 years; and 95% reported that the shoulder surgery made up at least 25% of their practice. There were 53% from private practice, 33% from academic medicine, and 14% in government settings. Amount of glenoid bone loss was the single most important factor driving surgeons to perform bony procedures over soft tissue procedures, followed by the patient age (19-25 years) and the patient activity level. The number of prior dislocations and glenoid track status did not have a strong influence on respondents' decision making. Twenty-one percent glenoid bone loss was the threshold of bone loss that influenced decision toward a bony procedure. If surgeons performed 10 or more open procedures per year, they were more likely to perform a bony procedure.

CONCLUSION

The factors that drove surgeons to choose bony procedures were the amount of glenoid bone loss with the threshold at 21%, patient age, and their activity demands. Surprisingly, glenoid track status and the number of previous dislocations did not strongly influence surgical treatment decisions. Ten open shoulder procedures a year seems to provide a level of comfort to recommend bony treatment for shoulder instability.

Anterior glenohumeral instability: Current review with technical pearls and pitfalls of arthroscopic soft-tissue stabilization

The glenohumeral joint (GHJ) allows for a wide range of motion, but is also particularly vulnerable to episodes of instability. Anterior GHJ instability is especially frequent among young, athletic populations during contact sporting events. Many first time dislocators can be managed non-operatively with a period of immobilization and rehabilitation, however certain patient populations are at higher risk for recurrent instability and may require surgical intervention for adequate stabilization. Determination of the optimal treatment strategy should be made on a case-by-case basis while weighing both patient specific factors and injury patterns (i.e., bone loss). The purpose of this review is to describe the relevant anatomical stabilizers of the GHJ, risk factors for recurrent instability including bony lesions, indications for arthroscopic vs open surgical management, clinical history and physical examination techniques, imaging modalities, and pearls/pitfalls of arthroscopic soft-tissue stabilization for anterior glenohumeral instability.

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

Introduction

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

Methods

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

Results

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

Discussion and conclusion

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

Altered shoulder kinematics using a new model for multiple dislocations-induced Bankart lesions

BACKGROUND

Many active individuals undergo multiple dislocations during the course of a season before surgical treatment without considering the implications of each successive injury. Therefore, the purpose of this study was to develop a multiple dislocation model for the glenohumeral joint and evaluate the resulting changes in joint function.

METHODS

Eight cadaveric shoulders were evaluated using a robotic testing system. A simulated clinical exam was performed by applying a 50 N anterior load to the humerus at 60° of glenohumeral abduction and external rotation. Each joint was then dislocated. The same loads were applied again and the resulting kinematics were recorded following each of 10 dislocations. The force required to achieve dislocation was recorded and capsulolabral status was assessed.

FINDINGS

A reproducible Bankart lesion was repeatedly created following the dislocation protocol. The force required for all dislocations significantly decreased following the 1st dislocation. In addition, even lower forces were required to achieve the 5th and subsequent dislocations (p < 0.05). Anterior translation in response to an anterior load during the simulated clinical exam increased between the intact and injured joints (p < 0.05). However, anterior translation reached a plateau following the 3rd to 10th dislocations and was increased compared with the 1st dislocation (p < 0.05).

INTERPRETATION

A repeatable Bankart lesion was not surgically made, but created by our new dislocation model. Joint function appeared to reach a constant level after the 3rd to 5th dislocations. Thus, multiple dislocations result in a deleterious dose dependent effect suggesting additional damage is not sustained after the fifth dislocation.

LEVEL OF EVIDENCE

Controlled laboratory study.

Who will redislocate his/her shoulder? Predicting recurrent instability following a first traumatic anterior shoulder dislocation

Objective

To develop a multivariate tool that would predict recurrent instability after a first-time traumatic anterior shoulder dislocation.

Methods

Participants (aged 16–40 years) were recruited across New Zealand into a prospective cohort study. Baseline data were collected during a telephone interview and through examination of radiology records. Variables associated with recurrent instability were selected for the multivariate logistic regression model using backwards selection (p<0.10). Coefficients for those variables retained in the model were used to develop the predictive tool.

Results

Among the 128 participants, 36% had redislocated at least once in the first 12 months. Univariate analysis showed an increased likelihood of recurrent dislocation with bony Bankart lesions (OR=3.65, 95% CI 1.05 to 12.70, p=0.04) and participants who had: not been immobilised in a sling (OR = 0.38, 95% CI 0.15 to 0.98, p=0.05), higher levels of shoulder activity (OR=1.13, 95% CI 1.01 to 1.27, p=0.03), higher levels of pain and disability (OR=1.03, 95% CI 1.01 to 1.06, p=0.02), higher levels of fear of reinjury (OR=1.12, 95% CI 1.01 to 1.26, p=0.04) and decreased quality of life (OR=1.01, 95% CI 1.00 to 1.02, p=0.05). There was no significant difference in those with non-dominant compared with dominant shoulder dislocations (p=0.10) or in those aged 16–25 years compared with 26–40 years (p=0.07).

Conclusion

Six of seven physical and psychosocial factors can be used to predict recurrent shoulder instability following a first-time traumatic anterior shoulder dislocation.

Editorial Commentary: Beach Chair Versus Lateral Decubitus for Arthroscopic Posterior Shoulder Stabilization-Here We Go Again

Recent literature has suggested that patient positioning matters when it comes to arthroscopic anterior shoulder stabilization. Although advocates of the lateral decubitus position argue that only in this position can the anteroinferior and posteroinferior aspects of the glenoid be adequately visualized and instrumented, outcomes following posterior shoulder stabilization appear independent of patient position.

Surgical treatment outcomes after primary vs recurrent anterior shoulder instability

INTRODUCTION

The aim of this study is to compare the outcomes of surgical management after primary anterior shoulder dislocation to the outcomes of patients who have surgical stabilization after recurrent anterior shoulder instability.

METHODS

A Medline (PubMed) search was performed in November of 2016 using the following key terms: shoulder, labrum, Bankart, instability, repair, outcome, recurrent. In May 2017 a Cochrane search was performed using similar key terms to ensure we included all studies. Only level I and II studies were included.

RESULTS

There were three studies that compared primary repair to delayed repair. In all three studies, the rate of recurrence was higher in group R than group S. When pooled, there was not a statistically significant difference between these groups, but there was a slightly higher odds of recurrence in group R (pooled OR 2.08, CI 0.69-6.26, p = 0.19). No significant differences were appreciated in functional outcomes or complications in these two groups.

CONCLUSION

Further level I and level II studies to compare surgical treatment after first time and recurrent instability are needed. This study failed to find a statistically significant difference in recurrence rates in patients who had stabilization acutely after a single episode compared to patients with recurrent instability events, although results suggest there may be a small benefit in primary stabilization.

Nonoperative treatment of five common shoulder injuries: A critical analysis

Economic pressure highlights the critical need for appropriate diagnosis and treatment of various shoulder pathologies since under-diagnosis and under-treatment can result in increased costs to society in the form of disability and lost production. On the other hand, aggressive over-treatment can further inflate already burgeoning health-care costs and potentially harm the patient. Therefore, it is crucial to distinguish the indications between operative and nonoperative management, especially in common shoulder pathologies such as rotator cuff tears, anterior shoulder instability, biceps tendinitis, lesions to the acromioclavicular joint, and proximal humeral fractures. As a result, a detailed analysis of individual risk factors for potential failures should be performed and treatment should be based on individualized care with consideration given to each patient’s particular injury pattern, functional demands, and long-term goals.

Open reduction-internal fixation versus intramedullary nailing for humeral shaft fractures: an expected value decision analysis

BACKGROUND

Previous randomized controlled studies and meta-analyses have failed to collectively favor either open reduction-internal fixation (ORIF) or intramedullary nailing (IMN) fixation. The purpose of our investigation was to elucidate the optimal decision between ORIF and IMN for acute traumatic operative humeral shaft fractures through an expected value decision analysis.

METHODS

We performed an expected value decision analysis and sensitivity analysis to elucidate the difference between ORIF and IMN fixation for patients with acute traumatic humeral shaft fractures. We surveyed 100 consecutive, randomly selected volunteers for their outcome preferences. Outcomes included union, delayed union, major complications, minor complications, and infection. A literature review was used to establish probabilities for each of these respective outcomes. A decision tree was constructed and a fold-back analysis was performed to find an expected patient value for each treatment option.

RESULTS

The overall patient expected values for ORIF and IMN were 12.7 and 11.2, respectively. Despite artificially decreasing the rates of major complications, infection, delayed union, and nonunion each to 0% for IMN fixation (sensitivity analysis), ORIF continued to maintain a greater overall patient expected value (12.7 vs. 11.4, 11.2, 11.2, and 12.1, respectively). Only if the rate of nonunion after ORIF was increased from 6.1% to 16.8% did the overall expected outcome after ORIF equal that of IMN (11.2).

CONCLUSION

Our expected value decision analysis demonstrates that patients favor ORIF over IMN as the optimal treatment decision for an acute traumatic humeral shaft fracture.

Traumatic anterior instability of the shoulder

The shoulder is the most unstable joint in the human body. Traumatic anterior instability of the shoulder is a common condition, which, especially in young patients, is associated with high recurrence rates. The effectiveness of non-surgical treatments when compared to surgical ones is still controversial. The purpose of this study was to review the literature for current concepts and updates regarding the treatment of this condition.

Intra-articular lesions and their relation to arthroscopic stabilization failure in young patients with first-time and recurrent shoulder dislocations

BACKGROUND

This study aimed to compare the frequency of intra-articular lesions between young patients with first-time shoulder dislocations and those with recurrent shoulder dislocations and to assess the correlation between intra-articular lesions and failure of arthroscopic stabilization.

METHODS

The study enrolled 33 patients who underwent arthroscopic Bankart repair after first-time shoulder dislocation before the age of 30 years. There were 89 age-matched patients who were treated arthroscopically for recurrent dislocation included as a control group.

RESULTS

Among intra-articular pathologic findings, anterior glenoid erosion (P = .043) and anterior labral periosteal sleeve avulsion lesions (P = .048) were found more frequently in the recurrent dislocation group. There was no statistically significant difference between the 2 groups in American Shoulder and Elbow Surgeons (P = .675) and Rowe (P = .132) scores at the last follow-up. However, there was a significant difference in the failure rate after operation between the 2 groups (P = .039). In the first-time dislocation group, 1 patient had redislocation and none showed positive apprehension. In the recurrent dislocation group, 6 patients had redislocation and 10 patients had positive apprehension. Eight of 10 patients who showed positive apprehension had either anterior labral periosteal sleeve avulsion lesions or anterior glenoid erosion. The patients' satisfaction with daily activities was significantly better in the first-time dislocation group (93.0 ± 5.2) than in the recurrent dislocation group (82.7 ± 7.2; P < .001).

CONCLUSIONS

Primary surgical treatment for first-time traumatic anterior shoulder dislocation provided satisfactory functional outcomes and improved quality of life. Primary arthroscopic stabilization can be considered one of the treatment options in patients younger than 30 years with first-time shoulder dislocation to prevent further intra-articular injuries that may contribute to recurrence.

Anterior Shoulder Instability in the Military Athlete

CONTEXT

Given its young, predominately male demographics and intense physical demands, the US military remains an ideal cohort for the study of anterior shoulder instability.

EVIDENCE ACQUISITION

A literature search of PubMed, MEDLINE, and the Cochrane Database was performed to identify all peer-reviewed publications from 1950 to 2016 from US military orthopaedic surgeons focusing on the management of anterior shoulder instability.

STUDY DESIGN

Clinical review.

LEVEL OF EVIDENCE

Level 4.

RESULTS

The incidence of anterior shoulder instability events in the military occurs at an order of magnitude greater than in civilian populations, with rates as high as 3% per year among high-risk groups. With more than 90% risk of a Bankart lesion and high risk for instability recurrence, the military has advocated for early intervention of first-time shoulder instability while documenting up to 76% relative risk reduction versus nonoperative treatment. Preoperative evaluation with advanced radiographic imaging should be used to evaluate for attritional bone loss or "off-track" engaging defects to guide comprehensive surgical management. With complex recurrent shoulder instability and/or cases of clinically significant osseous lesions, potential options such as remplissage, anterior open capsular procedures, or bone augmentation procedures may be preferentially considered.

CONCLUSION

Careful risk stratification, clinical evaluation, and selective surgical management for at-risk military patients with anterior shoulder instability can optimize the recurrence risk and functional outcome in this population.

The role of the scapula in preventing and treating shoulder instability

The shoulder is a closed-chain mechanism that balances the mobility required by the ranges of motion in normal activities with the stability required to act as a stable ball and socket base for those activities. The scapula plays key roles in the closed-chain mechanism by being mobile enough to place the glenoid in optimal relation to the humerus to facilitate concavity/compression and by being a stable base for coordinated muscle activation to compress the humerus into the glenoid. Scapular dyskinesis alters these roles and is frequently present in many types of glenohumeral instability. It may create or exacerbate the abnormal glenohumeral kinematics in instability. Clinical evaluation methods can demonstrate scapular dyskinesis, and if dyskinesis is present, rehabilitation for the dyskinesis should be included in the non-operative, preoperative, or post-operative treatment. Rehabilitation for scapular dyskinesis can be performed by specific protocols and is more successful in muscle-predominant instabilities such as multidirectional instability and repetitive microtrauma instability. Level of evidence V.

Operative Management Options for Traumatic Anterior Shoulder Instability in Patients Younger Than 30 Years

Anterior instability of the glenohumeral joint is a relatively common problem in the young population. Identification and treatment is essential to reduce the risk of recurrent instability, whether that is re-dislocation or subluxation events. Non-operative treatment for first-time dislocations was the classic option; however, a relatively high rate of recurrent dislocations has led to earlier operative management in some cases. Surgical treatment through either an open or arthroscopic approach has continued to be an area of research and debate. The decision depends partly on the exact etiology of the instability and the extent of soft tissue or bony deficiency. As arthroscopic techniques and experience improve, surgical procedures for arthroscopic anterior shoulder instability continue to evolve. This review serves as an in-depth overview of the treatment options for traumatic anterior shoulder instability in the patient younger than 30 years, generally focusing on non-rotator cuff-associated etiologies for recurrent instability.

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

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

The supine apprehension test helps predict the risk of recurrent instability after a first-time anterior shoulder dislocation

BACKGROUND

We previously identified the positive result of the supine apprehension test after completion of rehabilitation following a first dislocation as a possible predictor of high risk for redislocation. We extend the follow-up of a previous cohort of patients with first-time shoulder dislocations to better assess this test.

METHODS

Fifty-three men aged 17 to 27 years who sustained a first traumatic shoulder dislocation were treated by shoulder immobilization for 4 weeks and then rehabilitated with a standard physical therapy protocol. At 6-week follow-up, a supine anterior apprehension test was performed to assess the risk of redislocation. The patients were observed prospectively for a minimum of 75 months.

RESULTS

Of the 53 participants, 52 (mean age, 20.2 years) completed the study follow-up. Of the 52 subjects, 41 (79%) were combat soldiers. Follow-up was between 75 and 112 months. Of the 52 subjects, 31 (60%) redislocated at a range of 3 to 70 months after the initial dislocation. Eleven of 14 subjects (79%; confidence interval, 52%-92%) with a positive anterior apprehension test result redislocated, compared with 20 of 38 patients (53%; confidence interval, 37%-68%) with a negative test result. Patients with a positive test result redislocated more and earlier (P = .02, PROC LIFETEST, SAS).

CONCLUSIONS

The results of the supine apprehension test after a first shoulder dislocation and rehabilitation can help predict risk for recurrent instability. It potentially may be included as a variable in decision analysis models.

Interest of emergency arthroscopic stabilization in primary shoulder dislocation in young athletes

INTRODUCTION

The recurrence rate after primary shoulder dislocation in young subjects with high functional demand is close to 75%. The present study assessed the interest of emergency arthroscopic stabilization in this specific population.

MATERIAL AND METHODS

A non-randomized prospective study included 31 athletes under 30 years of age with primary anterior shoulder dislocation. Fifteen were offered emergency stabilization; after informed consent, 14 were enrolled in the "emergency stabilization" group. This was compared to a group matched for age, sport and lesion, managed 1 year previously by "non-operative" treatment (n=17), divided into 2 subgroups: "immobilization" and "secondary stabilization". Continuous prospective assessment of recurrence, return to sport and function (QuickDASH, QDsport, Duplay and Rowe scores) enabled comparison between the 3 groups.

RESULTS

Mean follow-up was 19 months for the "emergency stabilization" group and 25 months for the "non-operative" group. There were no failures in the "emergency stabilization" group, compared to a 77% rate in the "non-operative" group with onset at a mean 7.5 months and a mean 2.6 episodes of recurrence. Seven (54%) of the failures of non-operative treatment required secondary stabilization. Ninety-three percent of the "emergency stabilization" group, 44% of the "immobilization" group and 71% of the "secondary stabilization" group resumed sport at least at their pre-dislocation level. Mean Quick DASH was 1.46 in the "emergency stabilization" group, versus 15.28 the "immobilization" group (P<0.05) and 16.96 in the "secondary stabilization" group. Mean Duplay and Rowe scores were respectively 92.9 and 95 in the "emergency stabilization" group, versus 59.44 and 61.1 in the "immobilization" group (P<0.05) and 85 and 93.57 in the "secondary stabilization" group.

DISCUSSION

Emergency arthroscopic stabilization limits recurrence (Kirkley et al.), with better functional results than for secondary stabilization, lesion "freshness" providing a more favorable environment for labral and ligamentary healing. These encouraging results need confirmation over longer follow-up.

Outcomes of arthroscopic anterior shoulder instability in the beach chair versus lateral decubitus position: a systematic review and meta-regression analysis

PURPOSE

This study aimed to systematically review the clinical outcomes and recurrence rates after arthroscopic anterior shoulder stabilization in the beach chair (BC) and lateral decubitus (LD) positions.

METHODS

The authors performed a systematic review of multiple medical databases using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. All English-language literature from 1990 to 2013 reporting clinical outcomes after arthroscopic anterior shoulder stabilization with suture anchors or tacks with a minimum 2-year follow-up period were reviewed by 2 independent reviewers. Data on recurrent instability rate, return to activity/sport, range of motion, and subjective outcome measures were collected. Study methodological quality was evaluated with the Modified Coleman Methodology Score (MCMS) and the Quality Appraisal Tool (QAT). To quantify the structured review of observational data, meta-analytic statistical methods were used.

RESULTS

Sixty-four studies (38 BC position, 26 LD position) met inclusion criteria. A total of 3,668 shoulders were included, with 2,211 of patients in the BC position (average age, 26.7 ± 3.8 years; 84.5% male sex) and 1,457 patients in the LD position (average age, 26.0 ± 3.0 years; 82.7% male sex). The average follow-up was 49.8 ± 29.5 months in the BC group compared with 38.7 ± 23.3 months in the LD group. Average overall recurrent instability rates were 14.65 ± 8.4% in the BC group (range, 0% to 38%) compared with 8.5% ± 7.1% in the LD group (range, 0% to 30%; P = .002). The average postoperative loss in external rotation motion (in abduction) was reported in 19 studies in the BC group and in13 studies in the LD group, with an average loss of 2.4° ± 1.0° and 3.6° ± 2.6° in each group, respectively (P > .05).

CONCLUSIONS

Excellent clinical outcomes with low recurrence rates can be obtained after arthroscopic anterior shoulder stabilization in either the BC or the LD position; however, lower recurrence rates are noted in the LD position. Additional long-term randomized clinical trials comparing these positions are needed to better understand the potential advantages and disadvantages of each position.

LEVEL OF EVIDENCE

Level IV, systematic review of studies with Level I through Level IV evidence.

Traumatic shoulder injuries: a force mechanism analysis-glenohumeral dislocation and instability

OBJECTIVE

Acute traumatic glenohumeral dislocation is one of the most commonly encountered shoulder injuries and can produce a complex combination of associated bony and soft-tissue injuries, the full extent of which is often initially underappreciated. The objectives of this article are to illustrate the relevant anatomy of the shoulder and provide a more intuitive understanding of the complex biomechanics of traumatic glenohumeral instability through the use of 3D modeling and animation to improve the radiologist's awareness of some of the most common injury patterns, and potentially improve the detection of associated injuries. Emphasis is placed on the most critical injuries to determine the ultimate treatment modality, and imaging recommendations are provided.

CONCLUSION

Understanding the force mechanisms responsible for traumatic glenohumeral dislocation can potentially improve detection of associated secondary injuries, which can guide more effective injury classification and ultimately direct more appropriate and timely intervention.

History of shoulder instability and subsequent injury during four years of follow-up: a survival analysis

BACKGROUND

Little is known about the risk factors for glenohumeral joint instability. We hypothesized that a prior history of instability would be a significant risk factor for subsequent injury.

METHODS

We conducted a prospective cohort study over a four-year period within a high-risk group of young athletes to address the research hypothesis. Subjects were freshmen entering the U.S. Military Academy in June of 2006. Part of the baseline assessment included documenting a prior history of glenohumeral instability on entry into the study. All subjects were followed for subsequent glenohumeral joint instability events until graduation in May of 2010. The primary outcome of interest in this study was time to glenohumeral instability event during the follow-up period. We examined injury outcomes, looking for any instability, anterior instability, and posterior instability events. Cox proportional-hazards regression models were used to analyze the data.

RESULTS

Among the 714 subjects, eight shoulders were excluded from the analyses due to prior surgical stabilization, leaving 1420 shoulders, of which 126 had a self-reported prior history of instability. There were forty-six (thirty-nine anterior and seven posterior) acute instability events documented in the cohort during the follow-up period. Subjects with a prior history of instability were over five times (p < 0.001) more likely to sustain an acute (anterior or posterior) instability event during the follow-up period. Subjects with a history of instability were also 5.6 times (p < 0.001) more likely to experience a subsequent anterior instability event and 4.6 times (p = 0.068) more likely to experience a posterior instability event during follow-up. Similar results were observed in multivariable models after controlling for the influence of demographic and baseline physical examination findings.

CONCLUSIONS

Despite meeting the rigorous physical induction standards for military service, subjects with a prior history of glenohumeral joint instability were approximately five times more likely to experience a subsequent instability event, regardless of direction, within this high-risk athletic population.

Cost-effectiveness analysis of primary arthroscopic stabilization versus nonoperative treatment for first-time anterior glenohumeral dislocations

PURPOSE

The purpose of this study was to compare the cost-effectiveness of initial observation versus surgery for first-time anterior shoulder dislocation.

METHODS

The clinical scenario of first-time anterior glenohumeral dislocation was simulated using a Markov model (where variables change over time depending on previous states). Nonoperative outcomes include success (no recurrence) and recurrence; surgical outcomes include success, recurrence, and complications of infection or stiffness. Probabilities for outcomes were determined from published literature. Costs were tabulated from Medicare Current Procedural Terminology data, as well as hospital and office billing records. We performed microsimulation and probabilistic sensitivity analysis running 6 models for 1,000 patients over a period of 15 years. The 6 models tested were male versus female patients aged 15 years versus 25 years versus 35 years.

RESULTS

Primary surgery was less costly and more effective for 15-year-old boys, 15-year-old girls, and 25-year-old men. For the remaining scenarios (25-year-old women and 35-year-old men and women), primary surgery was also more effective but was more costly. However, for these scenarios, primary surgery was still very cost-effective (cost per quality-adjusted life-year, <$25,000). After 1 recurrence, surgery was less costly and more effective for all scenarios.

CONCLUSIONS

Primary arthroscopic stabilization is a clinically effective and cost-effective treatment for first-time anterior shoulder dislocations in the cohorts studied. By use of a willingness-to-pay threshold of $25,000 per quality-adjusted life-year, surgery was more cost-effective than nonoperative treatment for the majority of patients studied in the model.

LEVEL OF EVIDENCE

Level II, economic and decision analysis.