Lacking evidence for rehabilitation following arthroscopic Bankart repair: a systematic review

Rehabilitation guidelines following arthroscopic shoulder stabilisation surgery for traumatic instability - a Delphi consensus

BACKGROUND

There is no consistent approach to rehabilitation following arthroscopic shoulder stabilisation surgery (ASSS) in the UK. The aim of this study was to agree a set of post-operative guidelines for clinical practice.

METHOD

Expert stakeholders (surgeons, physiotherapists and patients) were identified via professional networks and patient involvement and engagements groups. A three-stage online Delphi study was undertaken. Consensus was defined by the OMERACT threshold of 70% agreement.

RESULTS

11 surgeons, 22 physiotherapists and 4 patients participated. It was agreed patients should be routinely immobilised in a sling for up to 3 weeks but can discard earlier if able. During the immobilisation period, patients should move only within a defined "safe zone." Permitted functional activities include using cutlery, lifting a drink, slicing bread, using kitchen utensils, wiping a table, light dusting, pulling up clothing, washing/drying dishes. Closing car doors or draining saucepans should be avoided. Through range movements can commence after 4 weeks, resisted movements at 6 weeks. Patients can resume light work as they feel able and return to manual work after 12 weeks. Return to non-contact sports when functional markers for return to play are met was agreed. Return to contact sport is based on function & confidence after a minimum of 12 weeks. Additional factors to consider when determining rehabilitation progression: functional/physical milestones, patient's confidence and presence of kinesiophobia. The preferred outcome measure is the Oxford Instability Shoulder Score.

CONCLUSION

This consensus provides expert recommendations for the development of rehabilitation guidelines following ASSS. CONTRIBUTION OF THE PAPER.

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.

Rehabilitation after arthroscopic Bankart repair: a systematic scoping review identifying important evidence gaps

BACKGROUND

Evidence to develop best rehabilitation practices after Arthroscopic Bankart Repair (ABR) is lacking, leading to heterogeneity in rehabilitation approaches.

OBJECTIVES

This systematic scoping review investigated current evidence for rehabilitation and associated outcomes following ABR, including rehabilitation parameters, evaluative approaches (outcomes/outcome measures, follow-up timing/duration).

DATA SOURCES

A systematic search was performed of CINAHL, MEDLINE, and Embase databases in May 2019.

STUDY SELECTION

Prospective studies detailing rehabilitation protocols following ABR reporting at least one postoperative assessment within 1 year of surgery (to measure impact of rehabilitation) were included.

DATA EXTRACTION AND SYNTHESIS

Two blinded reviewers independently selected studies using standardized criteria and extracted study characteristics and outcomes of interest. Quality of evidence was assessed using Joanna Brigg's quality assessment tool. A narrative analysis was conducted and evidence gaps were identified.

RESULTS

Nine studies evaluating 11 rehabilitation protocols with a total of 384 participants were included. Considerable variability was seen in rehabilitation protocols and evaluation parameters. Return to sports/activity was frequently measured, but not well-defined. Strengthening was an important component of rehabilitation protocols, but rarely reported as an outcome. Follow-up was variable, with 4 studies ending follow-up before 24-months postoperatively. Overall, patient outcomes improved postoperatively.

CONCLUSIONS

There is a paucity of evidence investigating the impact of rehabilitation approaches following ABR. Although patient outcomes improve after ABR, selected outcomes/measures are highly variable with limited evidence on those important to measure rehabilitation success, particularly strength and return to activity. Identified evidence gaps should be addressed in future research.

Ten percent re-dislocation rate 13 years after the arthroscopic Bankart procedure

PURPOSE

The aim of the present study was to determine the long-term outcome after the arthroscopic Bankart procedure, in terms of recurrent instability, shoulder function, glenohumeral arthropathy and patient satisfaction.

METHODS

Patients who underwent the arthroscopic Bankart procedure between January 1999 and the end of December 2005 were invited to complete a set of Patient Reported Outcome Measures (PROMs) and visit the hospital for clinical and radiological assessment. PROMs included the Western Ontario Shoulder Instability Index (WOSI), the Oxford Shoulder Instability Score (OSIS) and additional questions on shoulder instability and patient satisfaction. Clinical assessment included the apprehension test and the Constant-Murley score. The Samilson-Prieto classification was used to assess arthropathy on standard radiographs. The primary outcome was a re-dislocation that needed reduction. Secondary outcomes in terms of recurrent instability included patient-reported subluxation and a positive apprehension test.

RESULTS

Of 104 consecutive patients, 71 patients with a mean follow-up of 13.1 years completed the PROMs, of which 53 patients (55 shoulders) were also available for clinical and radiological assessment. Re-dislocations had occurred in 7 shoulders (9.6%). Subluxations occurred in 23 patients (31.5%) and the apprehension test was positive in 30 (54.5%) of the 55 shoulders examined. Median functional outcomes were 236 for WOSI, 45 for OSIS, and 103 for the normalized Constant-Murley score. Of all 71 patients (73 shoulders), 29 (39.7%) reported being completely satisfied, 33 (45.2%) reported being mostly satisfied and 8 (11%) reported being somewhat satisfied. Glenohumeral arthropathy was observed in 33 (60%) of the shoulders.

CONCLUSION

Despite 10% re-dislocations and frequent other signs of recurrent instability, shoulder function and patient satisfaction at 13 years after arthroscopic Bankart repair were good.

LEVEL OF EVIDENCE

Level IV.