1
|
Al-Asadi M, Sherren M, Abdel Khalik H, Leroux T, Ayeni OR, Madden K, Khan M. The Continuous Fragility Index of Statistically Significant Findings in Randomized Controlled Trials That Compare Interventions for Anterior Shoulder Instability. Am J Sports Med 2024; 52:2667-2675. [PMID: 38258495 PMCID: PMC11344964 DOI: 10.1177/03635465231202522] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Accepted: 07/31/2023] [Indexed: 01/24/2024]
Abstract
BACKGROUND Evidence-based care relies on robust research. The fragility index (FI) is used to assess the robustness of statistically significant findings in randomized controlled trials (RCTs). While the traditional FI is limited to dichotomous outcomes, a novel tool, the continuous fragility index (CFI), allows for the assessment of the robustness of continuous outcomes. PURPOSE To calculate the CFI of statistically significant continuous outcomes in RCTs evaluating interventions for managing anterior shoulder instability (ASI). STUDY DESIGN Meta-analysis; Level of evidence, 2. METHODS A search was conducted across the MEDLINE, Embase, and CENTRAL databases for RCTs assessing management strategies for ASI from inception to October 6, 2022. Studies that reported a statistically significant difference between study groups in ≥1 continuous outcome were included. The CFI was calculated and applied to all available RCTs reporting interventions for ASI. Multivariable linear regression was performed between the CFI and various study characteristics as predictors. RESULTS There were 27 RCTs, with a total of 1846 shoulders, included. The median sample size was 61 shoulders (IQR, 43). The median CFI across 27 RCTs was 8.2 (IQR, 17.2; 95% CI, 3.6-15.4). The median CFI was 7.9 (IQR, 21; 95% CI, 1-22) for 11 studies comparing surgical methods, 22.6 (IQR, 16; 95% CI, 8.2-30.4) for 6 studies comparing nonsurgical reduction interventions, 2.8 for 3 studies comparing immobilization methods, and 2.4 for 3 studies comparing surgical versus nonsurgical interventions. Significantly, 22 of 57 included outcomes (38.6%) from studies with completed follow-up data had a loss to follow-up exceeding their CFI. Multivariable regression demonstrated that there was a statistically significant positive correlation between a trial's sample size and the CFI of its outcomes (r = 0.23 [95% CI, 0.13-0.33]; P < .001). CONCLUSION More than a third of continuous outcomes in ASI trials had a CFI less than the reported loss to follow-up. This carries the significant risk of reversing trial findings and should be considered when evaluating available RCT data. We recommend including the FI, CFI, and loss to follow-up in the abstracts of future RCTs.
Collapse
Affiliation(s)
- Mohammed Al-Asadi
- Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | | | - Hassaan Abdel Khalik
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Timothy Leroux
- Division of Orthopaedic Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Olufemi R. Ayeni
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Kim Madden
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Moin Khan
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| |
Collapse
|
2
|
Ganokroj P, Adriani M, Whalen RJ, Provencher MT. Treatment of Shoulder Cartilage Defects in Athletes. Sports Med Arthrosc Rev 2024; 32:87-94. [PMID: 38978202 DOI: 10.1097/jsa.0000000000000404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/10/2024]
Abstract
Articular cartilage defects in the glenohumeral joint may be found in laborers, the elderly, and young athletes, among others. Various factors can contribute to cartilage damage, including prior surgery, trauma, avascular necrosis, inflammatory arthritis, joint instability, and osteoarthritis. There is a wide variety of treatment options, from conservative treatment, injections, and surgical options, including arthroscopic debridement, microfracture, osteochondral autograft transfer, osteochondral graft transplantation, autologous chondrocyte implantation, and the newly emerging techniques such as biologic augmentation. There is a challenge to determine the optimal treatment options, especially for young athletes, due to limited outcomes in the literature. However, there are many options which are viable to address osteochondral defects of the glenohumeral joint.
Collapse
Affiliation(s)
- Phob Ganokroj
- Steadman Philippon Research Institute, Vail, CO
- Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok
| | - Marco Adriani
- Steadman Philippon Research Institute, Vail, CO
- Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | | | | |
Collapse
|
3
|
Cong T, Charles S, Greiner JJ, Cordle A, Andrews C, Darwiche S, Reddy RP, Como M, Drain N, Hughes JD, Lesniak BP, Lin A. Magnetic Resonance Arthrogram Outperforms Standard Magnetic Resonance Imaging 2 Weeks After First Shoulder Dislocation for Labral Tear Diagnosis. Arthroscopy 2024:S0749-8063(24)00155-5. [PMID: 38403199 DOI: 10.1016/j.arthro.2024.02.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2023] [Revised: 02/05/2024] [Accepted: 02/15/2024] [Indexed: 02/27/2024]
Abstract
PURPOSE To determine the comparative accuracy and precision of routine magnetic resonance imaging (MRI) versus magnetic resonance (MR) arthrogram in measuring labral tear size as a function of time from a shoulder dislocation. METHODS We retrospectively evaluated consecutive patients who underwent primary arthroscopic stabilization between 2012 and 2021 in a single academic center. All patients completed a preoperative MRI or MR arthrogram of the shoulder within 60 days of injury and subsequently underwent arthroscopic repair within 6 months of imaging. Intraoperative labral tear size and location were used as standards for comparison. Three musculoskeletal radiologists independently interpreted tear extent using a clock-face convention. Accuracy and precision of MR labral tear measurements were defined based on location and size of the tear, respectively. Accuracy and precision were compared between MRI and MR arthrogram as a function of time from dislocation. RESULTS In total, 32 MRIs and 65 MR arthrograms (total n = 97) were assessed. Multivariate analysis demonstrated that intraoperative tear size, early imaging, and arthrogram status were associated with increased MR accuracy and precision (P < .05). Ordering surgeons preferred arthrogram for delayed imaging (P = .018). For routine MRI, error in accuracy increased by 3.4° per day and error in precision increased by 2.3° per day (P < .001) from time of injury. MR arthrogram, however, was not temporally influenced. Significant loss of accuracy and precision of MRI compared with MR arthrogram occurred at 2 weeks after an acute shoulder dislocation. CONCLUSIONS Compared with MR arthrogram, conventional MRI demonstrates time-dependent loss of accuracy and precision in determining shoulder labral tear extent after dislocation, with statistical divergence occurring at 2 weeks. LEVEL OF EVIDENCE Level II, retrospective radiographic diagnostic study.
Collapse
Affiliation(s)
- Ting Cong
- UPMC Freddie Fu Center for Sports Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, U.S.A
| | - Shaquille Charles
- UPMC Freddie Fu Center for Sports Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, U.S.A
| | - Justin J Greiner
- UPMC Freddie Fu Center for Sports Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, U.S.A
| | - Andrew Cordle
- UPMC Freddie Fu Center for Sports Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, U.S.A
| | - Carol Andrews
- UPMC Freddie Fu Center for Sports Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, U.S.A
| | - Sophie Darwiche
- UPMC Freddie Fu Center for Sports Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, U.S.A
| | - Rajiv P Reddy
- UPMC Freddie Fu Center for Sports Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, U.S.A
| | - Matthew Como
- UPMC Freddie Fu Center for Sports Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, U.S.A
| | - Nicholas Drain
- UPMC Freddie Fu Center for Sports Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, U.S.A
| | - Jonathan D Hughes
- UPMC Freddie Fu Center for Sports Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, U.S.A
| | - Bryson P Lesniak
- UPMC Freddie Fu Center for Sports Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, U.S.A
| | - Albert Lin
- UPMC Freddie Fu Center for Sports Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, U.S.A..
| |
Collapse
|
4
|
Potyk AG, Belk JW, Bravman JT, Seidl AJ, Frank RM, McCarty EC. Immobilization in External Rotation Versus Arthroscopic Stabilization After Primary Anterior Shoulder Dislocation: A Systematic Review of Level 1 and 2 Studies. Am J Sports Med 2024; 52:544-554. [PMID: 36867050 DOI: 10.1177/03635465231155199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/04/2023]
Abstract
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.
Collapse
Affiliation(s)
- Andrew G Potyk
- University of Colorado School of Medicine, Department of Orthopaedics, University of Colorado, Aurora, Colorado, USA
| | - John W Belk
- University of Colorado School of Medicine, Department of Orthopaedics, University of Colorado, Aurora, Colorado, USA
| | - Jonathan T Bravman
- University of Colorado School of Medicine, Department of Orthopaedics, University of Colorado, Aurora, Colorado, USA
| | - Adam J Seidl
- University of Colorado School of Medicine, Department of Orthopaedics, University of Colorado, Aurora, Colorado, USA
| | - Rachel M Frank
- University of Colorado School of Medicine, Department of Orthopaedics, University of Colorado, Aurora, Colorado, USA
| | - Eric C McCarty
- University of Colorado School of Medicine, Department of Orthopaedics, University of Colorado, Aurora, Colorado, USA
| |
Collapse
|
5
|
Li ZI, Hurley ET, Garra S, Blaeser AM, Markus DH, Shen M, Campbell KA, Strauss EJ, Jazrawi LM, Gyftopoulos S. Arthroscopic Bankart repair versus nonoperative management for first-time anterior shoulder instability: A cost-effectiveness analysis. Shoulder Elbow 2024; 16:59-67. [PMID: 38435039 PMCID: PMC10902416 DOI: 10.1177/17585732231187123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Revised: 06/10/2023] [Accepted: 06/24/2023] [Indexed: 03/05/2024]
Abstract
Purpose Arthroscopic Bankart repair (ABR) may be more effective than nonoperative management for patients with anterior shoulder instability following first-time dislocation. The purpose of the study was to determine the most cost-effective treatment strategy by evaluating the incremental cost-effectiveness ratio (ICER) for ABR versus nonoperative treatment. Methods This cost-effectiveness study utilized a Markov decision chain and Monte Carlo simulation. Probabilities, health utility values, and outcome data regarding ABR and nonoperative management of first-time shoulder instability derived from level I/II evidence. Costs were tabulated from Centers for Medicaid & Medicare Services. Probabilistic sensitivity analysis was performed using >100,000 repetitions of the Monte Carlo simulation. A willingness-to-pay (WTP) threshold was set at $50,000. Results The expected cost for operative management higher than nonoperative management ($32,765 vs $29,343). However, ABR (5.48 quality-adjusted life years (QALYs)) was the more effective treatment strategy compared to nonoperative management (4.61 QALYs). The ICER for ABR was $3943. Probabilistic sensitivity analysis showed that ABR was the most cost-effective strategy in 100% of simulations. Discussion ABR is more cost-effective than nonoperative management for first-time anterior shoulder dislocation. The threshold analysis demonstrated that when accounting for WTP, ABR was found to be the more cost-effective strategy.
Collapse
Affiliation(s)
- Zachary I Li
- Department of Orthopedic Surgery, New York University Langone Health, New York, NY, USA
| | - Eoghan T Hurley
- Department of Orthopedic Surgery, New York University Langone Health, New York, NY, USA
| | - Sharif Garra
- Department of Orthopedic Surgery, New York University Langone Health, New York, NY, USA
| | - Anna M Blaeser
- Department of Orthopedic Surgery, New York University Langone Health, New York, NY, USA
| | - Danielle H Markus
- Department of Orthopedic Surgery, New York University Langone Health, New York, NY, USA
| | - Michelle Shen
- Department of Orthopedic Surgery, New York University Langone Health, New York, NY, USA
| | - Kirk A Campbell
- Department of Orthopedic Surgery, New York University Langone Health, New York, NY, USA
| | - Eric J Strauss
- Department of Orthopedic Surgery, New York University Langone Health, New York, NY, USA
| | - Laith M Jazrawi
- Department of Orthopedic Surgery, New York University Langone Health, New York, NY, USA
| | | |
Collapse
|
6
|
Chiddarwar V, de Zoete RMJ, Dickson C, Lathlean T. Effectiveness of combined surgical and exercise-based interventions following primary traumatic anterior shoulder dislocation: a systematic review and meta-analysis. Br J Sports Med 2023; 57:1498-1508. [PMID: 37451706 DOI: 10.1136/bjsports-2022-106422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/28/2023] [Indexed: 07/18/2023]
Abstract
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.
Collapse
Affiliation(s)
| | - Rutger M J de Zoete
- School of Allied Health Science and Practice, The University of Adelaide Faculty of Health and Medical Sciences, Adelaide, South Australia, Australia
| | - Cameron Dickson
- School of Allied Health Science and Practice, The University of Adelaide Faculty of Health and Medical Sciences, Adelaide, South Australia, Australia
| | - Timothy Lathlean
- Adelaide Medical School, The University of Adelaide Faculty of Health and Medical Sciences, Adelaide, South Australia, Australia
- South Australian Health and Medical Research Institute Limited, Adelaide, South Australia, Australia
| |
Collapse
|
7
|
Verweij LPE, Sierevelt IN, van der Woude HJ, Hekman KMC, Veeger HEJD, van den Bekerom MPJ. Surgical Intervention Following a First Traumatic Anterior Shoulder Dislocation Is Worthy of Consideration. Arthroscopy 2023; 39:2577-2586. [PMID: 37597706 DOI: 10.1016/j.arthro.2023.07.060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2023] [Accepted: 07/31/2023] [Indexed: 08/21/2023]
Abstract
Up to 60% of patients experience recurrence after a first traumatic anterior shoulder dislocation (FTASD), which is often defined as having experienced either dislocation or subluxation. Thus surgical intervention after FTASD is worthy of consideration and is guided by the number of patients who need to receive surgical intervention to prevent 1 redislocation (i.e., number needed to treat), (subjective) health benefit, complication risk, and costs. Operative intervention through arthroscopic stabilization can be successful in reducing recurrence risk in FTASD, as has been shown in multiple randomized controlled trials. Nevertheless, there is a large "gray area" for the indication of arthroscopic stabilization, and it is therefore heavily debated which patients should receive operative treatment. Previous trials showed widely varying redislocation rates in both the intervention and control group, meta-analysis shows 2% to 19% after operative and 20% to 75% after nonoperative treatment, and redislocation rates may not correlate with patient-reported outcomes. The literature is quite heterogeneous, and a major confounder is time to follow-up. Furthermore, there is insufficient standardization of reporting of outcomes and no consensus on definition of risk factors. As a result, surgery is a reasonable intervention for FTASD patients, but in which patients it best prevents redislocation requires additional refinement.
Collapse
Affiliation(s)
- Lukas P E Verweij
- Amsterdam UMC, University of Amsterdam, Department of Orthopedic Surgery and Sports Medicine, Amsterdam, the Netherlands; Amsterdam Movement Sciences, Musculoskeletal Health Program, Amsterdam, the Netherlands; Amsterdam Shoulder and Elbow Centre of Expertise (ASECE), Amsterdam, the Netherlands.
| | - Inger N Sierevelt
- Xpert Clinics, Department of Orthopedic Surgery, Amsterdam, the Netherlands; Spaarnegasthuis Academy, Orthopedic Department, Hoofddorp, the Netherlands
| | - Henk-Jan van der Woude
- Amsterdam Shoulder and Elbow Centre of Expertise (ASECE), Amsterdam, the Netherlands; Department of Radiology, OLVG, Amsterdam, the Netherlands
| | - Karin M C Hekman
- Amsterdam Shoulder and Elbow Centre of Expertise (ASECE), Amsterdam, the Netherlands; Shoulder Center IBC Amstelland, Amstelveen, the Netherlands
| | - H E J DirkJan Veeger
- Department of Biomechanical Engineering, Delft University of Technology, Delft, the Netherlands
| | - Michel P J van den Bekerom
- Amsterdam Shoulder and Elbow Centre of Expertise (ASECE), Amsterdam, the Netherlands; Department of Orthopedic Surgery, Medical Center Jan van Goyen, Amsterdam, the Netherlands; Department of Orthopedic Surgery, Shoulder and Elbow Unit, OLVG, Amsterdam, the Netherlands; Department of Human Movement Sciences, Faculty of Behavioural and Movement Sciences, Vrije Universiteit Amsterdam, Amsterdam Movement Sciences, Amsterdam, the Netherlands
| |
Collapse
|
8
|
Yildiz TI, Turhan E, Ocguder DA, Yaman F, Huri G, Duzgun I. Functional Performance Tests Reveal Promising Results at 6 Months After Shoulder Stabilization Surgery. Sports Health 2023; 15:878-885. [PMID: 36539969 PMCID: PMC10606971 DOI: 10.1177/19417381221141075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2023] Open
Abstract
BACKGROUND Although athletes are mostly allowed to return to play 6 months after shoulder stabilization surgery, there are inadequate data about their functional status during this period. HYPOTHESES Performance tests would reveal insufficiency in the functional capacity of shoulder 6 months after stabilization surgery. STUDY DESIGN Prospective cohort study. LEVEL OF EVIDENCE Level 3. METHODS A total of 32 male athletes with arthroscopic anterior capsulolabral repair (AACR) were included in the study. Shoulder internal and external rotator (IR-ER) strength was assessed using isokinetic dynamometer at 60°/s and 180°/s angular velocities preoperatively and 6 months postoperatively. Shoulder function was assessed with closed kinetic chain upper extremity stability (CKCUES) test, Y balance test-upper quarter (YBT-UQ), and unilateral seated shot-put test (USSPT) at 6 months postoperation. Western Ontario shoulder instability index (WOSI) and Tampa scale of kinesiophobia (TSK) were used for the self-assessment of the shoulder. Mixed-model ANOVA was used to analyze the changes in the IR-ER strength on both shoulders. Limb symmetry index (LSI) was calculated for the IR-ER strength, YBT-UQ, and USSPT scores. RESULTS Shoulder IR strength was higher at 6 months postoperatively compared with preoperatively. The LSI was 76.4% and 76.6% for ER strength, and 94.2% and 94% for IR strength at 60°/s and 180°/s angular velocities, respectively, at the postoperative 6 month timepoint. The mean CKCUES test score was 21.8 ± 2.6 touches and the LSI was 94.7% for the YBT-UQ and 102.5% for the USSPT. WOSI (P < 0.001) and TSK (P = 0.001) scores were significantly lower at 6 months postoperatively. CONCLUSION Functional status of the patients with shoulder stabilization surgery improved considerably 6 months after surgery, yet they did not fully recover function. CLINICAL RELEVANCE Exercise programs focusing on shoulder ER strength and shoulder performance should be emphasized after stabilization surgery.
Collapse
Affiliation(s)
- Taha Ibrahim Yildiz
- Faculty of Physical Therapy and Rehabilitation, Hacettepe University, Turkey
| | - Egemen Turhan
- Department of Orthopedy and Traumatology, Hacettepe University, Turkey
| | - Durmus Ali Ocguder
- Department of Orthopedics and Traumatology, Ankara Şehir Hastanesi, Turkey
| | - Firat Yaman
- Department of Orthopedics and Traumatology, Ankara Şehir Hastanesi, Turkey
| | - Gazi Huri
- Department of Orthopedy and Traumatology, Hacettepe University, Turkey
| | - Irem Duzgun
- Faculty of Physical Therapy and Rehabilitation, Hacettepe University, Turkey
| |
Collapse
|
9
|
Hu B, Hong J, Zhu H, Yan S, Wu H. Arthroscopic Bankart repair versus conservative treatment for first-time traumatic anterior shoulder dislocation: a systematic review and meta-analysis. Eur J Med Res 2023; 28:260. [PMID: 37501089 PMCID: PMC10373227 DOI: 10.1186/s40001-023-01160-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Accepted: 04/10/2023] [Indexed: 07/29/2023] Open
Abstract
BACKGROUND Shoulder is vulnerable to dislocation owing to its anatomical structure and the increasing popularity of contact sports in young population. The management of first-time anterior shoulder dislocation in this group is still controversial and the prognosis are varied. This review aimed to compare the results of arthroscopic Bankart repair and conservative management for first-time traumatic anterior shoulder dislocation in young active patients. METHODS Databases were searched till November 2021, and comparative studies between arthroscopic Bankart repair and conservative management for first-time traumatic anterior shoulder dislocation in young population were selected. Methodological quality of the studies was assessed according to the Cochrane Back Review Group 12-item scale. Outcome measures included recurrence of instability, return to play, subsequent instability surgery, and shoulder functional scores. RESULTS The search returned 12 eligible trials with 786 participants. All the trials were of prospective design. After arthroscopic Bankart repair, patients experienced significantly less re-dislocation (7.5% vs. 53.0%, p < 0.00001, I2 = 0%), subluxation (3.1% vs. 24.2%, p < 0.0001, I2 = 0%), positive apprehension test (7.3% vs. 25.8%, p = 0.002, I2 = 11%), and subsequent surgical treatment for instability (5.6% vs. 37.8%, p < 0.00001, I2 = 0%) when compared with those underwent conservative management. And more patients returned to play (83.5% vs. 66.0%, p = 0.03, I2 = 81%) after arthroscopic Bankart repair. Outcomes regarding the functional scores did not reach a significant difference between the two cohorts. CONCLUSIONS Arthroscopic Bankart repair showed superiority over conservative management in terms of recurrence, return to play, and subsequent instability surgery during the follow-up in young active patients that encountered first episode of dislocation. As long-term prognosis is comparable, an immediate surgical stabilization might not be suitable for everyone.
Collapse
Affiliation(s)
- Bin Hu
- Department of Orthopedic Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, 1511# JiangHong Road, Hangzhou, 310009, China
- Orthopaedics Research Institute of Zhejiang University, Hangzhou, China
| | - Jianqiao Hong
- Department of Orthopedic Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, 1511# JiangHong Road, Hangzhou, 310009, China
- Orthopaedics Research Institute of Zhejiang University, Hangzhou, China
| | - Hanxiao Zhu
- Department of Orthopedic Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, 1511# JiangHong Road, Hangzhou, 310009, China
- Orthopaedics Research Institute of Zhejiang University, Hangzhou, China
| | - Shigui Yan
- Department of Orthopedic Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, 1511# JiangHong Road, Hangzhou, 310009, China
- Orthopaedics Research Institute of Zhejiang University, Hangzhou, China
| | - Haobo Wu
- Department of Orthopedic Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, 1511# JiangHong Road, Hangzhou, 310009, China.
- Orthopaedics Research Institute of Zhejiang University, Hangzhou, China.
| |
Collapse
|
10
|
Alzahrani WM, Tashkandi NF, Faqeeh MH, Almatrafi WS, Amer Bugnah AA, Kazim AH. Clinical Outcomes and Return to Sports After Arthroscopic Repair of Humeral Avulsion of the Glenohumeral Ligament: A Meta-Analysis. Cureus 2023; 15:e40848. [PMID: 37489209 PMCID: PMC10363328 DOI: 10.7759/cureus.40848] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/22/2023] [Indexed: 07/26/2023] Open
Abstract
This study aimed to evaluate the clinical outcomes and the frequency of return to sport after the arthroscopic repair of a humeral avulsion of the inferior glenohumeral ligament (HAGL) lesion. Web of Science, Scopus, and Medline via PubMed and OVID were searched to identify the relevant citations. Screening and data extraction were performed independently. The Comprehensive Meta-Analysis software was used for all statistical analyses (CMA; USA version 3.3.070). A total of 18 articles (n = 832 patients; of whom, 379 patients had HAGL) were included. The fixed-effect estimate showed that the percentage of patients who returned to their sports was 89.1% (95% CI = 85% to 92.2%). The mean duration to return was estimated to be 6.65 months (95% CI = 5.10 to 8.20). Postoperatively, the mean Western Ontario Shoulder Instability Index (WOSI), Oxford Shoulder Instability Score (OSIS), and Subjective Shoulder Value (SSV) scores were 88.60 (95% CI = 86.18 to 90.98), 15.02 (95% CI = 7.42 to 22.63), and 86.90 (95% CI = 80.79 to 93.00), respectively. The Rowe score improved significantly postoperatively with a mean difference (MD) of 54.47 (95% CI = 39.28 to 69.66). The University of California - Los Angeles (UCLA) shoulder score increased significantly post-arthroscopic repair (MD = 10.91, 95% CI = 10.07 to 11.76). The current evidence suggests that arthroscopic repair of HAGL lesions is associated with a high percentage of return to sports and improved Rowe score, WOSI, UCLA shoulder score, OSIS scale, and SSV score. The quality of the included studies is moderate; however, these findings are promising and call for further multicenter, prospective studies.
Collapse
Affiliation(s)
- Wael M Alzahrani
- Department of Surgery, College of Medicine, Najran University, Najran, SAU
| | | | - Mawddah H Faqeeh
- Department of Family Medicine, College of Medicine, Umm Al-Qura University, Makkah, SAU
| | | | | | | |
Collapse
|
11
|
Lei D, Tang B, Li Y, Fan C. Arthroscopic Repair Versus Conservative Treatment for First-time Anterior Shoulder Dislocation. Int J Sports Med 2023; 44:169-176. [PMID: 36529129 DOI: 10.1055/a-1982-3624] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
To systematically compare the clinical efficacy of conservative treatment and arthroscopic one-stage repair for patients with first-time anterior dislocation of the shoulder. A retrieval and systematic review of randomized controlled studies of primary anterior shoulder dislocation with conservative versus arthroscopic repair was conducted and further pooled analysis was performed to compare the overall difference in clinical outcomes, including redislocation and revision surgery rates, shoulder function scores and related complications. Preliminary meta-analysis showed that the risk of anterior shoulder redislocation was 4.73-fold higher in patients treated conservatively than those undergoing arthroscopic repair (RR:4.73 [2.95-7.58], p<0.000; I2=0%, p=0.920),and that the revision surgery rate was 5.91 times higher in the conservative group than in the arthroscopic repair group (RR:5.91 [2.82-12.39], p<0.000; I2=0%, p=0.560).Early arthroscopic repair can significantly reduce the redislocation and revision surgery rates and also improve the shoulder joint function score, without serious complications. However, it is necessary to recognize the subset of patients with a higher risk of redislocation in young patients through a high quality, blinded, prospective cohort study when early arthroscopic repair intervention in this subset of high-risk patients will be of significant clinical value.
Collapse
Affiliation(s)
- Dengqiang Lei
- Orthopedic, Xining First People's Hospital, Xining, China
| | - Bo Tang
- Sports medicine, Xining First People's Hospital, Xining, China
| | - Yongjuan Li
- Sports medicine, Xining First People's Hospital, Xining, China
| | - Cheng Fan
- Sports medicine, Xining First People's Hospital, Xining, China
| |
Collapse
|
12
|
Fox MA, Drain NP, Rai A, Zheng A, Carlos NB, Serrano Riera R, Sabzevari S, Hughes JD, Popchak A, Rodosky MW, Lesniak BP, Lin A. Increased Failure Rates After Arthroscopic Bankart Repair After Second Dislocation Compared to Primary Dislocation With Comparable Clinical Outcomes. Arthroscopy 2023; 39:682-688. [PMID: 36740291 DOI: 10.1016/j.arthro.2022.10.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Revised: 09/23/2022] [Accepted: 10/10/2022] [Indexed: 12/12/2022]
Abstract
PURPOSE The purpose of this study was to compare rates of recurrent dislocation and postsurgical outcomes in patients undergoing arthroscopic Bankart repair for anterior shoulder instability immediately after a first-time traumatic anterior dislocation versus patients who sustained a second dislocation event after initial nonoperative management. METHODS A retrospective chart review was performed of patients undergoing primary arthroscopic stabilization for anterior shoulder instability without concomitant procedures and minimum 2-year clinical follow-up. Primary outcome was documentation of a recurrent shoulder dislocation. Secondary clinical outcomes included range of motion, Visual Analog Scale (VAS), American Shoulder and Elbow Surgeons Shoulder Score (ASES), and Shoulder Activity Scale (SAS). RESULTS Seventy-seven patients (mean age 21.3 years ± 7.3 years) met inclusion criteria. Sixty-three shoulders underwent surgical stabilization after a single shoulder dislocation, and 14 underwent surgery after 2 dislocations. Average follow-up was 35.9 months. The rate of recurrent dislocation was significantly higher in the 2-dislocation group compared to single dislocations (42.8% vs 14.2%, P = .03). No significant difference was present in range of motion, VAS, ASES, and SAS scores. The minimal clinically important difference (MCID) was 1.4 for VAS and 1.8 for SAS scores. The MCID was met or exceeded in the primary dislocation group in 31/38 (81.6%) patients for VAS, 23/31 (74.1%) for ASES, and 24/31 for SES (77.4%) scores. For the second dislocation cohort, MCID was met or exceeded in 7/9 (77.8%) for VAS, 4/7 (57.1%) for ASES, and 5/7 for SES (71.4%) scores. CONCLUSION Immediate arthroscopic surgical stabilization after a first-time anterior shoulder dislocation significantly decreases the risk of recurrent dislocation in comparison to those who undergo surgery after 2 dislocation events, with comparable clinical outcome scores. These findings suggest that patients who return to activities after a primary anterior shoulder dislocation and sustain just 1 additional dislocation event are at increased risk of a failing arthroscopic repair. STUDY DESIGN Retrospective comparative study; Level of evidence, 3.
Collapse
Affiliation(s)
- Michael A Fox
- Pittsburgh Shoulder Institute, Department of Orthopedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania.
| | - Nicholas P Drain
- Pittsburgh Shoulder Institute, Department of Orthopedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Ajinkya Rai
- Pittsburgh Shoulder Institute, Department of Orthopedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Aaron Zheng
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Noel B Carlos
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Rafael Serrano Riera
- Pittsburgh Shoulder Institute, Department of Orthopedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Soheil Sabzevari
- Pittsburgh Shoulder Institute, Department of Orthopedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Jonathan D Hughes
- Pittsburgh Shoulder Institute, Department of Orthopedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Adam Popchak
- Department of Physical Therapy, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Mark W Rodosky
- Pittsburgh Shoulder Institute, Department of Orthopedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Bryson P Lesniak
- Pittsburgh Shoulder Institute, Department of Orthopedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Albert Lin
- Pittsburgh Shoulder Institute, Department of Orthopedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| |
Collapse
|
13
|
Zink S, Pfeiffenberger T, Müller A, Krisam R, Unglaub F, Pötzl W. The arthroscopic Bankart operation: a 10-year follow-up study. Arch Orthop Trauma Surg 2022; 142:3367-3377. [PMID: 34999993 DOI: 10.1007/s00402-021-04282-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Accepted: 11/27/2021] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Traumatic shoulder instability most frequently occurs in young people often during sports events. Currently, the arthroscopic Bankart repair is the therapy of choice in the absence of extensive glenoid bone loss and has proved to be a safe and effective procedure. Nevertheless, we see recurrence of instability-especially if new trauma happens-and further data are needed to guide the right decision-making for these often young patients. The purpose of this study was to determine the long-term outcome 10 years after arthroscopic Bankart operation in terms of satisfaction of the patient, functional result, complications, recurrent instability, and development of osteoarthritis, and to look after possible risk factors for recurrence of instability and statistical proof of these. MATERIALS AND METHODS Thirty-nine out of 49 patients underwent physical examination of both shoulders. We could perform a postoperative shoulder a-p X-ray in 28 patients. According to Samilson, [24] the extent of osteoarthritis was measured. The Constant score and the postoperative ROWE score were determined for both shoulders as well as the WOSI Score. In 25 cases, we calculated the ISIS Score. RESULTS We could reach out to 89.6% of patients and 79.6% could be physically examined. The vast majority of 95.5% are either very satisfied or satisfied with the result at the time we ended the follow-up. The mean Constant score of 95.5 reflects this result. In contrast to this, we found at the same time in 15.3% ongoing clinical signs of instability of the concerning shoulder, even though 9.1% had to be re-operated for recurrent instability in between the follow-up timeline and we found in the X-rays (57.1% of all patients) in 35.7% at least moderate and in 10.7% severe signs of osteoarthritis. The Constant score but not the ROWE score differed significantly in patients with no or mild compared to those with moderate-to-severe osteoarthritis. CONCLUSIONS The arthroscopic Bankart stabilization procedure showed after 10 years to be a very safe operation and to be able to produce a satisfying and functional very good long-term result-reflected by the Constant score. We assume that the extent of osteoarthritis seems to be the determining factor of the very good functional result, even though ongoing instability was present in 15.3% of the patients.
Collapse
Affiliation(s)
- S Zink
- Department of Shoulder and Ellbow Surgery, Vulpiusklinik, Vulpiusstrasse 29, 74906, Bad Rappenau, Germany.
| | - T Pfeiffenberger
- Department of Shoulder and Ellbow Surgery, Vulpiusklinik, Vulpiusstrasse 29, 74906, Bad Rappenau, Germany
| | - A Müller
- Department of Shoulder and Ellbow Surgery, Vulpiusklinik, Vulpiusstrasse 29, 74906, Bad Rappenau, Germany
| | - R Krisam
- Institute of Biometry, University of Heidelberg, Heidelberg, Germany
| | - F Unglaub
- Department of Hand Surgery, Vulpiusklinik, Bad Rappenau, Germany
- Medical Faculty Mannheim, University of Heidelberg, Heidelberg, Germany
| | - W Pötzl
- Department of Shoulder and Ellbow Surgery, Vulpiusklinik, Vulpiusstrasse 29, 74906, Bad Rappenau, Germany
| |
Collapse
|
14
|
Liechti DJ, Shepet KH, Glener JE, Neumann EJ, Sraj S. A Systematic Review of Acute Irreducible Shoulder Dislocations in the 21st Century. Orthop J Sports Med 2022; 10:23259671221121633. [PMID: 36147793 PMCID: PMC9486286 DOI: 10.1177/23259671221121633] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Accepted: 06/09/2022] [Indexed: 11/16/2022] Open
Abstract
Background Rarely, closed reduction cannot be achieved in patients with acute shoulder dislocation, necessitating open management. A paucity of literature exists regarding these cases. Purpose To perform a systematic review on the mechanism, management, and outcome data of acute irreducible shoulder dislocations. Study Design Systematic review; Level of evidence, 4. Methods A systematic review of the literature was performed using the Cochrane Database of Systematic Reviews, the Cochrane Central Register of Controlled Trials, PubMed, and MEDLINE between 2000 and 2020. Inclusion criteria were as follows: human participants, acute irreducible shoulder dislocation requiring open management, English language, and publication within the past 20 years. We excluded basic science articles, technique articles, reviews, editorials, and studies of chronic shoulder dislocations or dislocations with ipsilateral humeral shaft fractures. Results Twelve articles fit the inclusion criteria and were considered for review. All studies were single case reports (level 4 evidence). Ten of the 12 studies were of male patients. The direction of dislocation included 7 anterior/anteroinferior, 2 posterior, 1 inferior, 1 bilateral inferior, and 1 superolateral. Most dislocations were irreducible owing to a mechanical block to reduction. The most common type of block was an incarcerated long head of the biceps tendon, followed by interposition of 1 of the rotator cuff tendons. The axillary and musculocutaneous nerves, displaced fracture fragments, and Hill-Sachs and bony Bankart lesions were other causes of blocks to reduction. Eleven patients were treated with open surgery, while 1 patient was treated arthroscopically. Procedures performed were dependent on concurrent pathology. Final follow-up ranged from 6 weeks to 2 years, with no repeat dislocation episodes reported. Complications after open reduction included 1 case of brachial plexopathy (posterior cord) and 1 case of musculocutaneous nerve palsy. Conclusion There is a paucity of literature on the management of irreducible acute shoulder dislocations. The most common irreducible dislocation found in this systematic review was anterior with a mechanical block attributed to interposition of the long head of the biceps tendon. When patients were treated with an open or arthroscopic procedure, recurrence was low, with none reporting recurrent dislocation in limited follow-up.
Collapse
Affiliation(s)
- Daniel J Liechti
- Department of Orthopaedics, West Virginia University, Morgantown, West Virginia, USA.,Black Hills Orthopedic and Spine Center, GIllette, WY, USA
| | - Kevin H Shepet
- Bellin Health Titletown Sports Medicine and Orthopedics, Green Bay, Wisconsin, USA
| | - Julie E Glener
- Department of Orthopaedics, West Virginia University, Morgantown, West Virginia, USA
| | - Eric J Neumann
- Department of Orthopaedics, West Virginia University, Morgantown, West Virginia, USA
| | - Shafic Sraj
- Department of Orthopaedics, West Virginia University, Morgantown, West Virginia, USA
| |
Collapse
|
15
|
Markes AR, Cevallos N, Lansdown DA, Ma CB, Feeley BT, Zhang AL. Risk for recurrent instability and reoperation following arthroscopic and open shoulder stabilization in a large cross-sectional population. JSES Int 2022; 6:730-735. [PMID: 36081703 PMCID: PMC9446191 DOI: 10.1016/j.jseint.2022.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Background Recurrent shoulder instability is an orthopedic problem with potentially long-term functional ramifications. Although arthroscopic stabilization has become increasingly utilized over open stabilization, optimal surgical intervention to minimize recurrent instability remains controversial. Methods The PearlDiver Mariner database was queried for all cases of open and arthroscopic shoulder stabilization from 2010 to 2019. Utilization trends were aggregated after identifying cohorts of 107,210 and 13,217 patients who respectively underwent arthroscopic or open stabilization using Current Procedural Terminology codes. Subsets from those cohorts with laterality-specific International Classification of Diseases, Tenth Revision codes for shoulder instability were used to evaluate 2-year rates of recurrent instability (presence of shoulder dislocation or revision open or arthroscopic stabilization). Linear regression and chi-squared analysis were used to analyze utilization trends and to compare recurrent instability. Results Arthroscopic stabilization comprised 90% of all stabilization procedures with annual utilization continuing to increase into 2019. Latarjet utilization increased from 15% to 42% of all open stabilization procedures while open Bankart repair utilization decreased from 56% to 35%. The rate of recurrent instability was 10.2% after arthroscopic stabilization and 12.3% after open stabilization (P = .01). Rates of redislocation (4.0% vs. 2.6%, P < .01), conversion to shoulder arthroplasty (1.2% vs. 0.4%, P < .01), and revision open stabilization (6.8% vs. 2.3%, P < .01) after index open stabilization were significantly higher than after index arthroscopic stabilization. There was no difference in revision stabilization or dislocation rates between open procedures. Conclusion Despite increasing utilization of coracoid transfer, arthroscopic stabilization is still the dominant modality used for surgical treatment of shoulder instability and in our analysis, showed lower 2-year rates of dislocation, revision open stabilization, and conversion to shoulder arthroplasty.
Collapse
Affiliation(s)
- Alexander R. Markes
- Corresponding author: Alexander R. Markes, MD, 1500 Owens Street, San Francisco, CA 94158, USA.
| | | | | | | | | | | |
Collapse
|
16
|
Alkhatib N, Abdullah ASA, AlNouri M, Ahmad Alzobi OZ, Alkaramany E, Ishibashi Y. Short- and long-term outcomes in Bankart repair vs. conservative treatment for first-time anterior shoulder dislocation: a systematic review and meta-analysis of randomized controlled trials. J Shoulder Elbow Surg 2022; 31:1751-1762. [PMID: 35398165 DOI: 10.1016/j.jse.2022.02.032] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Revised: 02/12/2022] [Accepted: 02/24/2022] [Indexed: 02/01/2023]
Abstract
BACKGROUND First-time anterior shoulder dislocations are associated with a high rate of residual instability. Therefore, many surgeons support initial Bankart repair surgery over conservative management to address this issue. However, the optimal treatment remains controversial because of uncertainty regarding long-term surgical outcomes. The primary objective of this systematic review and meta-analysis was to compare the short- and long-term rates of residual instability following Bankart repair or conservative management after a first-time anterior shoulder dislocation. METHODS PubMed/MEDLINE, Embase, The Cochrane Library, Web of Science, CINAHL, and ScienceDirect databases were accessed for randomized controlled trials (RCTs) comparing Bankart repair to conservative management. RoB (Risk of Bias) 2 was used to check study quality. The Grading of Recommendations, Assessment, Development and Evaluation (GRADE) guidelines were followed in assessing primary outcomes. The inverse-variance method for continuous variables and the Mantel-Haenszel method for dichotomous variables was used. RESULTS A total of 348 patients from 6 RCTs published across 8 articles, with a mean age of 23.7 years, were included. Bias was graded low in 3 studies, some concerns in 3 studies, and high in 2 studies. In the short term (2-3 years), surgery lowered recurrent instability (risk ratio [RR] 0.15, 95% confidence interval [CI] 0.08, 0.27; I2 = 0%; P < .0001). Similar findings were seen in the long term (5-12 years) (RR 0.23, 95% CI 0.14, 0.39; I2 = 0%; P < .0001). No difference was observed in return to sport (RR 1.18, 95% CI 0.91, 1.52; I2 = 78%; P = .21). Initial surgery lowered subsequent stabilization surgery in the short (RR 0.19, 95% CI 0.09, 0.43; I2 = 0%; P < .0001) and long term (RR 0.17, 95% CI 0.07, 0.39; I2 = 25%; P < .0001). Western Ontario Shoulder Instability Index (WOSI) scores did not differ in the short term (MD, 2.54, 95% CI -0.51, 5.59; I2 = 48%; P = .1) but were higher in the surgical group at long-term follow-up. Patient satisfaction was also higher with surgery (RR 1.75, 95% CI 1.4, 2.2; I2 = 88%; P < .0001). Certainty of evidence was low for only 1 long-term outcome measure. CONCLUSION Bankart repair surgery for first-time anterior shoulder dislocation results in a large reduction in the risk of recurrent shoulder instability and subsequent stabilization surgery in both short- (2-3 years) and long-term (5-12 years) follow-up intervals. Additionally, slight improvements in overall patient satisfaction and WOSI score can be seen at long-term follow-up. However, surgical intervention failed to significantly improve the rate of return to sport when compared with conservative management.
Collapse
Affiliation(s)
- Nedal Alkhatib
- Sports Medicine & Orthopaedic Center, Mercy Health - Cincinnati, Cincinnati, OH, USA
| | - Abdullah Saad A Abdullah
- Division of Orthopaedic Surgery, University Health Network, Toronto Western Hospital, Toronto, ON, Canada.
| | - Mason AlNouri
- Department of Orthopaedic Surgery, Graduate School of Medicine, Hirosaki University, Hirosaki, Aomori, Japan
| | | | - Eslam Alkaramany
- Orthopaedic Surgery Department, Hamad Medical Corporation, Doha, Qatar
| | - Yasuyuki Ishibashi
- Department of Orthopaedic Surgery, Graduate School of Medicine, Hirosaki University, Hirosaki, Aomori, Japan
| |
Collapse
|
17
|
Benefits and Harms of Interventions With Surgery Compared to Interventions Without Surgery for Musculoskeletal Conditions: A Systematic Review With Meta-analysis. J Orthop Sports Phys Ther 2022; 52:312-344. [PMID: 35647883 DOI: 10.2519/jospt.2022.11075] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To estimate the benefits and harms of interventions with and without surgery for musculoskeletal (MSK) conditions. DESIGN Intervention systematic review with meta-analysis of randomized controlled trials (RCTs). LITERATURE SEARCH MEDLINE, EMBASE, CINAHL, Web of Science, and CENTRAL, all up to January 7, 2021. STUDY SELECTION CRITERIA RCTs (English, German, Danish, Swedish, and Norwegian) of interventions with and without surgery conducted in any setting for any non-fracture MSK condition in adults (mean age: 18+ years) evaluating the outcomes on a continuous (benefits) or count (harms) scale. Outcomes were pain, self-reported physical function, quality of life, serious adverse events (SAEs), and death at 1 year. DATA SYNTHESIS Random-effects metaanalyses for MSK conditions where there were data from at least 2 trials. RESULTS One hundred RCTs (n = 12 645 patients) across 28 different conditions at 9 body sites were included. For 9 out of 13 conditions with data on pain (exceptions include some spine conditions), 11 out of 11 for function, and 9 out of 9 for quality of life, there were no clinically relevant differences (standardized mean difference of 0.50 or above) between interventions with and without surgery. For 13 out of 16 conditions with data on SAEs and 16 out of 16 for death, there were no differences in harms. Only 6 trials were at low risk of bias. CONCLUSION The low certainty of evidence does not support recommending surgery over nonsurgical alternatives for most MSK conditions with available RCTs. Further high-quality RCTs may change this conclusion. J Orthop Sports Phys Ther 2022;52(6):312-344. doi:10.2519/jospt.2022.11075.
Collapse
|
18
|
Jassim SS, Amaranath J, Taylor DM, Warby SA, Hoy G. Unicortical Fixation Does Not Compromise Bony Union in the Latarjet Procedure. JSES Int 2022; 6:555-562. [PMID: 35813149 PMCID: PMC9264013 DOI: 10.1016/j.jseint.2022.04.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Affiliation(s)
| | | | - David McD. Taylor
- Department of Medicine, University of Melbourne, Melbourne, VIC, Australia
- The Austin Hospital, Melbourne, VIC, Australia
| | - Sarah Ann Warby
- Melbourne Shoulder Group, Melbourne, VIC, Australia
- La Trobe University, Department of Rehabilitation, Nutrition and Sport, Corner of Kingsbury Drive and Plenty Road Bundoora, Melbourne, VIC, Australia
- Corresponding author: Sarah Ann Warby, PhD, B.Physio (Hon), Melbourne Shoulder Group, 305 High Street, Prahran, VIC 3181, Australia
| | - Gregory Hoy
- Melbourne Orthopaedic Group, Melbourne, VIC, Australia
- Monash University, Department of Surgery, Melbourne, VIC, Australia
| |
Collapse
|
19
|
Davey MS, Hurley ET, Doyle TR, Dashti H, Gaafar M, Mullett H. The Fragility Index of Statistically Significant Findings From Randomized Controlled Trials Comparing the Management Strategies of Anterior Shoulder Instability. Am J Sports Med 2022:3635465221077268. [PMID: 35414266 DOI: 10.1177/03635465221077268] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Debate centering on the management of anterior shoulder instability (ASI) in recent years has led to many randomized controlled trials (RCTs) being published on the topic. The fragility index (FI) has subsequently emerged as a novel method of assessing significant findings reported in RCTs, particularly those with small sample sizes. PURPOSE To evaluate the FI of statistically significant findings in RCTs that reported the outcomes of management strategies of patients with ASI. STUDY DESIGN Systematic review; Level of evidence, 1. METHODS Using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, 2 independent reviewers performed a systematic review of RCTs focusing on the outcomes of management strategies of patients with ASI. There were 3 main categories of RCTs included: (1) nonoperative management in internal rotation (IR) versus external rotation (ER), (2) nonoperative management versus a surgical intervention, and (3) surgical management with arthroscopic Bankart repair versus open Bankart repair. The Fisher exact test was utilized to calculate the FI for the reversal of statistical significance in all statistically significant dichotomous outcomes. RESULTS A total of 21 RCTs were included, including 1589 shoulders (mean age, 29.4 years) with a mean follow-up of 26.8 months. There were 10 RCTs (831 shoulders) that reported outcomes after the nonoperative management of ASI in IR versus ER, with a mean FI of 6.8. There were 5 RCTs (324 shoulders) that reported outcomes comparing the nonoperative and operative management of ASI, with a mean FI of 3.5. There were 6 RCTs (434 shoulders) that reported outcomes after the operative management of ASI with either arthroscopic Bankart repair or open Bankart repair, with a mean FI of 9.6. CONCLUSION The overall FI of RCTs reporting the outcomes of management strategies for patients with ASI was high, suggesting a moderate fragility of statistically significant outcomes including recurrence, revision stabilization, and return to play.
Collapse
|
20
|
Kawakami J, Yamamoto N, Itoi E, Henninger H, Tashjian R, Chalmers PN. Morphology of Glenoid Cartilage Defects in Anteroinferior Glenohumeral Instability. Orthop J Sports Med 2022; 10:23259671221086615. [PMID: 35400145 PMCID: PMC8984858 DOI: 10.1177/23259671221086615] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Accepted: 01/10/2022] [Indexed: 11/29/2022] Open
Abstract
Background: Glenoid cartilage defects may contribute to anterior shoulder instability
recurrence and progression to osteoarthritis, but their morphology remains
unknown. Purpose/Hypothesis: The purpose was to determine the shape, size, and location of glenoid
cartilage defects and the prevalence and risk factors for cartilage defects
in the setting of anterior glenohumeral instability. It was hypothesized
that glenoid cartilage defects would be common, would be associated with
recurrence of dislocation, and would share similar morphology with glenoid
osseous defects. Study Design: Cross-sectional study; Level of evidence, 3. Methods: In this retrospective study, all patients who underwent arthroscopic surgical
treatment for anterior glenohumeral instability between January 2012 and May
2019 were included; excluded were patients with documented posterior or
multidirectional instability or previous glenohumeral surgery. For each
patient, the operative report, arthroscopic images, and preoperative
magnetic resonance imaging (MRI) scans were reviewed to determine the
prevalence of cartilage injury. For those patients with an Outerbridge grade
3 or 4 defect, the cartilage surfaces on the MRI scans were segmented to
make 3-dimensional (3-D) segmentations. From these 3-D segmentations, we
measured length, width, and surface area of the glenoid and defect, and the
orientation of the defect relative to the superior and inferior poles of the
glenoid. A multivariable analysis was conducted to determine correlates with
cartilage damage. Results: In 322 patients treated operatively for anterior glenohumeral instability,
38% had a concomitant cartilage defect. The mean cartilage defect was
located directly anteriorly at the 3:07 clockface position (range,
2:10-4:05) and encompassed 6.5% ± 3.5% of the glenoid surface area. However,
defects ranged up to >56% of glenoid length and up to 27% of glenoid
width, and the largest defect encompassed 19.5% of the glenoid cartilage
surface area. Patients with a cartilage defect were more likely to be male
(P = .031) and to have undergone a concomitant
posterior labral repair (P = .018). Conclusion: Cartilage defects were common in patients with operatively treated anterior
glenohumeral instability, occurring in 38% of patients. These defects were
located directly anteriorly at 3:07, similar to osseous glenoid defects.
Future prospective studies with cartilage-specific MRI sequences should be
conducted.
Collapse
Affiliation(s)
- Jun Kawakami
- Department of Orthopaedic Surgery, Tohoku University, Sendai, Miyagi, Japan
| | - Nobuyuki Yamamoto
- Department of Orthopaedic Surgery, Tohoku University, Sendai, Miyagi, Japan
| | - Eiji Itoi
- Department of Orthopaedic Surgery, Tohoku University, Sendai, Miyagi, Japan
| | - Heath Henninger
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, Utah, USA
| | - Robert Tashjian
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, Utah, USA
| | - Peter N. Chalmers
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, Utah, USA
| |
Collapse
|
21
|
Long-term effect of immobilization in external rotation after first-time shoulder dislocation: an average 18-year follow-up. J Shoulder Elbow Surg 2022; 31:601-607. [PMID: 34656781 DOI: 10.1016/j.jse.2021.09.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2021] [Revised: 09/06/2021] [Accepted: 09/17/2021] [Indexed: 02/01/2023]
Abstract
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.
Collapse
|
22
|
Zhang M, Liu J, Jia Y, Zhang G, Zhou J, Wu D, Jiang J, Yun X. Risk factors for recurrence after Bankart repair: a systematic review and meta-analysis. J Orthop Surg Res 2022; 17:113. [PMID: 35184753 PMCID: PMC8859902 DOI: 10.1186/s13018-022-03011-w] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2021] [Accepted: 02/09/2022] [Indexed: 12/05/2022] Open
Abstract
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.
Collapse
|
23
|
Goodrich E, Wolf M, Vopat M, Mok A, Baker J, Bernard C, Tarakemeh A, Vopat B. Sex-specific differences in outcomes after anterior shoulder surgical stabilization: a meta-analysis and systematic review of literature. JSES Int 2021; 6:123-131. [PMID: 35141686 PMCID: PMC8811409 DOI: 10.1016/j.jseint.2021.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background Methods Results Conclusion
Collapse
Affiliation(s)
- Ezra Goodrich
- Corresponding author: Ezra Goodrich, BA, University of Kansas Medical Center, 3901 Rainbow Blvd, Kansas City, KS 66160, USA.
| | | | | | | | | | | | | | | |
Collapse
|
24
|
García-Vega M, De La Cuadra-Virgil P, Jiménez-Cristobal J, Occhi-Gómez B, Boserman-Pérez-de Villaamil M. Arthroscopic bankart repair for the management of anterior shoulder instability: Mid- and long-term results. ACTA ACUST UNITED AC 2021. [PMID: 34112445 DOI: 10.1016/j.recote.2021.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
INTRODUCTION Arthroscopic stabilisation is a well-recognised surgical technique with a variable rate of failure reported between 0-35%. The aim of this study was to evaluate the outcome of this technique and our second aim was to identify risk factors that could be associated to recurrence rate. MATERIAL AND METHODS 41 patients that underwent arthroscopic shoulder stabilisation for glenohumeral instability between 2001-2015 were included. Different items such as epidemiologic, recurrence, age at first dislocation, preoperative sport practice, and number of fixation devices used were collected. The results were evaluated using functional scales (WOSI, Rowe y Walch-Duplay) and radiological study was assessed using the Samilson-Prieto score. Data from the medical history were recognised in order to assess possible risk factors. RESULTS The overall redislocation rate was 9.4%. The average follow-up was 83 months. The 54.3% of the patients achieved excellent/good results in the functional assessment scales. The range of motion was complete in 90% of the cases. On the radiographs, only 4.88% of the patients present advanced osteoarthritis. It was not possible to identify risk factors related to a worse outcome after surgery. CONCLUSION The arthroscopic Bankart repair with suture anchors is considered the gold standard for treatment of anterior glenohumeral instability. The long-term follow-up shows a favourable outcome, with a redislocation rate of 9% and low complication rate.
Collapse
Affiliation(s)
- M García-Vega
- Hospital Universitario Puerta de Hierro, Majadahonda, Madrid, Spain.
| | | | | | - B Occhi-Gómez
- Hospital Universitario Puerta de Hierro, Majadahonda, Madrid, Spain
| | | |
Collapse
|
25
|
Return to play criteria among shoulder surgeons following shoulder stabilization. J Shoulder Elbow Surg 2021; 30:e317-e321. [PMID: 33618019 DOI: 10.1016/j.jse.2021.01.026] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Revised: 01/11/2021] [Accepted: 01/18/2021] [Indexed: 02/07/2023]
Abstract
PURPOSE The purpose of this study was to survey the members of North American and European shoulder surgery and sports medicine societies to evaluate their criteria for deciding when an athlete can safely return to play (RTP) following shoulder stabilization surgery. METHODS A survey was sent to the members of the American Shoulder and Elbow Surgeons (ASES), American Orthopaedic Society for Sports Medicine (AOSSM), European Society for Sports Traumatology, Knee Surgery and Arthroscopy (ESSKA), and European Society for Surgery of the Shoulder and the Elbow (SECEC). Surgeons were asked which criteria they used to determine when an athlete can return to play following the arthroscopic Bankart repair and Latarjet procedures, with additional questions on how time from surgery and participation in collision sports affect return. RESULTS Overall, 317 surgeons responded to the survey. Following arthroscopic Bankart repair, the most common criteria used were time (98.7%), strength (74.8%), and range of motion (70%). The most commonly reported time point was 4 months (43.8%), and the majority used an additional time period, most commonly 2 months (38.2%), before allowing a collision athlete to return to play (75.4%). Interestingly, the addition of a remplissage procedure did not affect decision making regarding RTP in most cases (92.1%). Following the Latarjet procedure, the most common criteria used were time (98.4%), strength (67.5%), and range of motion (65.9%). Less than half reported using imaging to assess for radiographic union before allowing patients to return to play (47%), and the most common modality was plain radiography (80%). The most common time point was 4 months (33.1%), and the majority reported waiting an additional period of time, most commonly by 2 months (25.9%), before allowing a collision athlete to return to play (59.6%). CONCLUSION Despite the absence of evidence-based guidelines on when athletes can safely return to play following shoulder stabilization surgery, there exists minimal variability in recommendations between North American and European shoulder surgeons. Further research is required to better define criteria for RTP after the arthroscopic Bankart repair and Latarjet procedures.
Collapse
|
26
|
Vopat ML, Coda RG, Giusti NE, Baker J, Tarakemeh A, Schroeppel JP, Mullen S, Randall J, Provencher MT, Vopat BG. Differences in Outcomes Between Anterior and Posterior Shoulder Instability After Arthroscopic Bankart Repair: A Systematic Review and Meta-analysis. Orthop J Sports Med 2021; 9:23259671211006437. [PMID: 34104660 PMCID: PMC8155769 DOI: 10.1177/23259671211006437] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Accepted: 02/18/2021] [Indexed: 11/25/2022] Open
Abstract
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.
Collapse
Affiliation(s)
- Matthew L Vopat
- University of Kansas School of Medicine-Wichita, Wichita, Kansas, USA
| | - Reed G Coda
- University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Nick E Giusti
- University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Jordan Baker
- University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Armin Tarakemeh
- University of Kansas Medical Center, Kansas City, Kansas, USA
| | | | - Scott Mullen
- University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Jeffrey Randall
- University of Kansas School of Medicine-Wichita, Wichita, Kansas, USA
| | | | - Bryan G Vopat
- University of Kansas Medical Center, Kansas City, Kansas, USA
| |
Collapse
|
27
|
Nakagawa S, Sahara W, Kinugasa K, Uchida R, Mae T. Bipolar Bone Defects in Shoulders With Primary Instability: Dislocation Versus Subluxation. Orthop J Sports Med 2021; 9:23259671211003553. [PMID: 34036111 PMCID: PMC8127765 DOI: 10.1177/23259671211003553] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Accepted: 12/08/2020] [Indexed: 11/16/2022] Open
Abstract
Background: In shoulders with traumatic anterior instability, a bipolar bone defect has been recognized as an important indicator of the prognosis. Purpose: To investigate bipolar bone defects at primary instability and compare the difference between dislocation and subluxation. Study Design: Cohort study; Level of evidence, 3. Methods: There were 156 shoulders (156 patients) including 91 shoulders with dislocation and 65 shoulders with subluxation. Glenoid defects and Hill-Sachs lesions were classified into 5 size categories on 3-dimensional computed tomography (CT) scans and were allocated scores ranging from 0 (no defect) to 4 points (very large defect). To assess the combined size of the glenoid defect and Hill-Sachs lesion, the scores for both lesions were summed (range, 0-8 points). Patients in the dislocation and subluxation groups were compared regarding the prevalence of a glenoid defect, a bone fragment of bony Bankart lesion, a Hill-Sachs lesion, a bipolar bone defect, and an off-track Hill-Sachs lesion. Then, the combined size of the bipolar bone defects was compared between the dislocation and subluxation groups and among patients stratified by age at the time of CT scanning (<20, 20-29, and ≥30 years). Results: Hill-Sachs lesions were observed more frequently in the dislocation group (75.8%) compared with the subluxation group (27.7%; P < .001), whereas the prevalence of glenoid defects was not significantly different between groups (36.3% vs 29.2%, respectively; P = .393). The combined defect size was significantly larger in the dislocation versus subluxation group (mean ± SD combined defect score, 2.1 ± 1.6 vs 0.8 ± 0.9 points, respectively; P < .001) due to a larger Hill-Sachs lesion at dislocation than subluxation (glenoid defect score, 0.5 ± 0.9 vs 0.3 ± 0.6 points [P = .112]; Hill-Sachs lesion score, 1.6 ± 1.2 vs 0.4 ± 0.7 points [P < .001]). Combined defect size was larger in older patients than younger patients in the setting of dislocation (combined defect score, <20 years, 1.6 ± 1.2 points; 20-29 years, 1.9 ± 1.5 points; ≥30 years, 3.4 ± 1.6 points; P < .001) but was not different in the setting of subluxation (0.8 ± 1.0, 0.7 ± 0.9, and 0.8 ± 0.8 points, respectively; P = .885). An off-track Hill-Sachs lesion was observed in 2 older patients with dislocation but was not observed in shoulders with subluxation. Conclusion: The bipolar bone defect was significantly more frequent, and the combined size was greater in shoulders with primary dislocation and in older patients (≥30 years).
Collapse
Affiliation(s)
- Shigeto Nakagawa
- Department of Orthopaedic Sports Medicine, Yukioka Hospital, Osaka, Japan
- Shigeto Nakagawa, MD, PhD, Department of Orthopaedic Sports Medicine, Yukioka Hospital, 2-2-3 Ukita, Kita-ku, Osaka, Osaka 530-0021, Japan ()
| | - Wataru Sahara
- Department of Orthopaedic Surgery, Osaka University, Graduate School of Medicine, Suita, Japan
| | - Kazutaka Kinugasa
- Department of Orthopaedic Sports Medicine, Osaka Rosai Hospital, Sakai, Japan
| | - Ryohei Uchida
- Department of Orthopaedic Sports Medicine, Kansai Rosai Hospital, Amagasaki, Japan
| | - Tatsuo Mae
- Department of Orthopaedic Surgery, Osaka University, Graduate School of Medicine, Suita, Japan
| |
Collapse
|
28
|
Alkaduhimi H, Connelly JW, van Deurzen DFP, Eygendaal D, van den Bekerom MPJ. High Variability of the Definition of Recurrent Glenohumeral Instability: An Analysis of the Current Literature by a Systematic Review. Arthrosc Sports Med Rehabil 2021; 3:e951-e966. [PMID: 34195665 PMCID: PMC8220632 DOI: 10.1016/j.asmr.2021.02.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Accepted: 02/11/2021] [Indexed: 12/12/2022] Open
Abstract
Purpose To determine the definitions for recurrence used in the literature, assess the consensus in using these definitions, and determine the impact of these definitions on recurrence rates. Methods A literature search was performed in PubMed and EMBASE including studies from 2000 to 2020 reporting on recurrence rates after anterior arthroscopic shoulder instability surgery. Dislocation, apprehension, subluxation and recurrence rates were compared. Results Ninety-one studies were included. In 68% of the eligible studies, recurrence rates are not well defined. Thirty (33%) studies did not report on dislocations, 45 (49%) did not report on subluxations, and 58 (64%) did not report on apprehension. Seventeen different definitions for recurrence of instability, 4 definitions of dislocations, and 8 definitions of subluxation were used. Conclusion Recurrence rates are poorly specified and likely underreported in the literature, hampering comparison with results of other studies. This highlights the need for a consensus on definition of recurrence across shoulder instability studies. We recommend not using the definition recurrence of instability anymore. We endorse defining dislocations as a radiographically confirmed dislocation or a dislocation that is manually reduced, subluxations as the feeling of a dislocation that can be (spontaneously) reduced without the need for a radiographically confirmed dislocation, and a positive apprehension sign as fear of imminent dislocation when placing the arm in abduction and external rotation during physical examination. Reporting on the events resulting in a dislocation or subluxation aids in making an estimation of the severity of instability. Level of Evidence Level IV, systematic review.
Collapse
Affiliation(s)
| | - James W Connelly
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, Massachusetts, U.S.A
| | | | - Denise Eygendaal
- Orthopaedic Department, Amphia Ziekenhuis, Breda, the Netherlands.,Amsterdam University Medical Centres, Amsterdam, the Netherlands
| | - Michel P J van den Bekerom
- Shoulder and Elbow Unit, Joint Research, Amsterdam, the Netherlands.,Amsterdam University Medical Centres, Amsterdam, the Netherlands
| |
Collapse
|
29
|
Pougès C, Hardy A, Vervoort T, Amouyel T, Duriez P, Lalanne C, Szymanski C, Deken V, Chantelot C, Upex P, Maynou C. Arthroscopic Bankart Repair Versus Immobilization for First Episode of Anterior Shoulder Dislocation Before the Age of 25: A Randomized Controlled Trial. Am J Sports Med 2021; 49:1166-1174. [PMID: 33705240 DOI: 10.1177/0363546521996381] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND The risk of recurrence after the first episode of anterior shoulder dislocation is high with nonoperative treatment in younger patients. PURPOSE/HYPOTHESIS The aim of this study was to compare the results of arthroscopic Bankart repair and nonoperative treatment for shoulder dislocation in patients younger than 25 years, with a minimum of 2 years of follow-up. The hypothesis was that surgery would decrease the risk of recurrence. STUDY DESIGN Randomized controlled trial; Level of evidence, 1. METHODS We included patients aged between 18 and 25 years after a first episode of anterior shoulder dislocation and divided them into 2 groups. The first group was treated surgically with an arthroscopic Bankart repair within 2 weeks after the dislocation; the second group was treated nonoperatively. Both groups were immobilized for 3 weeks in internal rotation and followed the same physical therapy protocol. Standard radiography and computed tomography were performed immediately after reduction of the dislocation, and follow-up was performed at 3, 6, 12, and 24 months. The primary outcome measure was instability recurrence, defined as another anterior shoulder dislocation requiring closed reduction by another person (the patient was unable to reduce the dislocated joint themselves), a subluxation, or a positive apprehension test. Secondary outcome measures included range of motion, return to sport, and functional scores such as the short version of the Disabilities of the Arm, Shoulder and Hand score the Walch-Duplay score, and the Western Ontario Shoulder Instability Index (WOSI). RESULTS A total of 20 patients were included in each group. The mean ± SD age was 21 ± 1.8 years, and there were 33 men (82.5%) and 7 women (17.5%) in the total sample. Recurrence of instability was significantly decreased in the surgical treatment group compared with the nonoperative group (2 [10%] vs 14 [70%], respectively; P = .0001). Fewer patients in the surgical treatment group versus the nonoperative group had another episode of dislocation (0 vs 6 [30%], respectively), subluxation (2 [10%] vs 13 [65%], respectively; P = .003), or a positive apprehension test (1 [5%] vs 11 [58%], respectively; P = .0005). The Walch-Duplay score (88.4 vs 70.3 points; P = .046) and WOSI (11.5 vs 17.7 points; P = .035) were significantly better in the surgical group versus the nonoperative group after a 2-year follow-up. Level of sport was the same or better in 89% of the surgical treatment group vs 53% of the nonoperative treatment group (P = .012). No surgical complication was recorded. We did not find any significant difference in range of motion. CONCLUSION In patients with first-time shoulder dislocations, arthroscopic labral repair (Bankart procedure) reduced the risk of secondary shoulder dislocation and improved functional outcome versus nonoperative treatment after a 2-year follow-up. Surgical treatment after a first episode of shoulder dislocation could be offered as a primary treatment option in a younger population if these results are confirmed by larger studies with a longer follow-up. REGISTRATION NCT03315819 (ClinicalTrials.gov identifier).
Collapse
Affiliation(s)
- Cécile Pougès
- Lille-Hauts de France University, Lille, France.,Department of Orthopaedic Surgery, Lille University Hospital Salengro, Lille, France
| | - Alexandre Hardy
- Lille-Hauts de France University, Lille, France.,Department of Orthopaedic Surgery, Lille University Hospital Salengro, Lille, France
| | - Thomas Vervoort
- Lille-Hauts de France University, Lille, France.,Department of Orthopaedic Surgery, Lille University Hospital Salengro, Lille, France.,Arcachon Clinic, La Teste-de-Buch, France
| | - Thomas Amouyel
- Lille-Hauts de France University, Lille, France.,Department of Orthopaedic Surgery, Lille University Hospital Salengro, Lille, France
| | - Pauline Duriez
- Lille-Hauts de France University, Lille, France.,Department of Orthopaedic Surgery, Lille University Hospital Salengro, Lille, France
| | - Clément Lalanne
- Lille-Hauts de France University, Lille, France.,Department of Orthopaedic Surgery, Lille University Hospital Salengro, Lille, France
| | - Christophe Szymanski
- Lille-Hauts de France University, Lille, France.,Department of Orthopaedic Surgery, Lille University Hospital Salengro, Lille, France
| | - Valérie Deken
- Lille-Hauts de France University, Lille, France.,Methodology Unit-Biostatistics and Data Management, Lille University, France
| | - Christophe Chantelot
- Lille-Hauts de France University, Lille, France.,Department of Orthopaedic Surgery, Lille University Hospital Salengro, Lille, France
| | - Peter Upex
- Orthopedic Department, Saint Joseph Hospital, Paris, France
| | - Carlos Maynou
- Lille-Hauts de France University, Lille, France.,Department of Orthopaedic Surgery, Lille University Hospital Salengro, Lille, France
| |
Collapse
|
30
|
García-Vega M, De La Cuadra-Virgil P, Jiménez-Cristobal J, Occhi-Gómez B, Boserman-Pérez-de Villaamil M. Arthroscopic bankart repair for the management of anterior shoulder instability: Mid- and long- term results. Rev Esp Cir Ortop Traumatol (Engl Ed) 2021. [PMID: 33773949 DOI: 10.1016/j.recot.2020.10.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Abstract
INTRODUCTION Arthroscopic stabilization is a well-recognized surgical technique with a variable rate of failure reported between 0-35%. The aim of this study was to evaluate the outcome of this technique and our second aim was to identify risk factors that could be associated to recurrence rate. MATERIAL AND METHODS 41 patients that underwent arthroscopic shoulder stabilization for glenohumeral instability between 2001-2015 were included. Different items such as epidemiologic, recurrence, age at first dislocation, preoperative sport practice, and number of fixation devices used were collected. The results were evaluated using functional scales (WOSI, Rowe y Walch-Duplay) and radiological study was assessed using the Samilson-Prieto score. Data from the medical history were recognized in order to assess possible risk factors. RESULTS The overall redislocation rate was 9.4%. The average follow-up was 83 months. The 54.3% of the patients achieved excellent / good results in the functional assessment scales. The range of motion was complete in 90% of the cases. On the radiographs, only 4.88% of the patients present advanced osteoarthritis. It was not possible to identify risk factors related to a worse outcome after surgery. CONCLUSION The arthroscopic Bankart repair with suture anchors is considered the gold standard for treatment of anterior glenohumeral instability. The long-term follow-up shows a favorable outcome, with a redislocation rate of 9% and low complication rate.
Collapse
Affiliation(s)
- M García-Vega
- Hospital Universitario Puerta de Hierro, Majadahonda, Madrid, España.
| | | | | | - B Occhi-Gómez
- Hospital Universitario Puerta de Hierro, Majadahonda, Madrid, España
| | | |
Collapse
|
31
|
Caldwell JME, Youssefzadeh K, Limpisvasti O. A method for calculating the fragility index of continuous outcomes. J Clin Epidemiol 2021; 136:20-25. [PMID: 33684509 DOI: 10.1016/j.jclinepi.2021.02.023] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Revised: 02/09/2021] [Accepted: 02/24/2021] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Clinicians' overdependence on p-values to determine significance in clinical trials is common yet potentially misleading. The Fragility Index (FI) describes how robust a significant result is by determining the number of events the statistical significance hinges on. However, this concept cannot be applied to nondichotomous variables. We describe a method to calculate a Continuous Fragility Index (CFI) for continuous variables. We further provide a method to estimate CFI when original data is not available. STUDY DESIGN AND SETTING An iterative substitution algorithm is described to calculate CFI prospectively from data or retrospectively from summary statistics and its response to variations in the data is reported. We then apply this method to a previously published review as a proof-of-concept. RESULTS The CFI increases linearly with sample size, logarithmically with mean difference, and decreases exponentially with standard deviation. Forty-eight studies were included of which 30 had significant non-dichotomous outcomes. CFI and FI were uncorrelated and mean CFI was significantly higher than FI (9 vs. 2, P< 0.001). CONCLUSION Our algorithm extends fragility to continuous outcomes, expanding the applications of the fragility concept. The fragility of outcomes within a single study may vary based on variable type and should be evaluated independently.
Collapse
Affiliation(s)
| | | | - Orr Limpisvasti
- Cedars-Sinai Kerlan-Jobe Orthopedic Institute, Los Angeles, CA
| |
Collapse
|
32
|
Minkus M, Königshausen M, Maier D, Mauch F, Stein T, Greiner S, Moursy M, Scheibel M. Immobilization in External Rotation and Abduction Versus Arthroscopic Stabilization After First-Time Anterior Shoulder Dislocation: A Multicenter Randomized Controlled Trial. Am J Sports Med 2021; 49:857-865. [PMID: 33596092 PMCID: PMC7961655 DOI: 10.1177/0363546520987823] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Treatment of first-time shoulder dislocation (FSD) is a topic of debate. After high rates of recurrent instability after nonoperative management were reported in the literature, primary repair of FSD significantly increased. At the same time, new concepts were proposed that had promising results for immobilization in external rotation (ER) and abduction (ABD). PURPOSE The aim of this study was to evaluate the recurrence rates (primary outcome) and clinical outcomes (secondary outcome parameters) of immobilization in ER+ABD versus arthroscopic primary stabilization after FSD. STUDY DESIGN Randomized controlled trial; Level of evidence, 1. METHODS In a multicenter randomized controlled trial, patients with FSD were randomized to either treatment with immobilization in 60° of ER plus 30° of ABD (group 1) or surgical treatment with arthroscopic Bankart repair (group 2). Clinical evaluation was performed 1, 3, and 6 weeks as well as 6, 12, and 24 months postoperatively or after reduction, including range of motion, instability testing, subjective shoulder value, Constant-Murley score, Rowe score, and Western Ontario Shoulder Instability Index. Recurrent instability events were prospectively recorded. RESULTS Between 2011 and 2017, a total of 112 patients were included in this study. Of these, 60 patients were allocated to group 1 and 52 to group 2. At the 24-month follow-up, 91 patients (81.3%) were available for clinical examination. The recurrence rate was 19.1% in group 1 and 2.3% in group 2 (P = .016). No significant differences were found between groups regarding clinical shoulder scores (P > .05). Due to noncompliance with the immobilization treatment protocol, 4 patients (6.7%) were excluded. CONCLUSION Immobilization in ER+ABD versus primary arthroscopic shoulder stabilization for the treatment of FSD showed no differences in clinical shoulder scores. However, recurrent instability was significantly higher after nonoperative treatment.
Collapse
Affiliation(s)
- Marvin Minkus
- Department for Shoulder and Elbow Surgery, Center for Musculoskeletal Surgery, Charité Universitaetsmedizin Berlin, Berlin, Germany
| | - Matthias Königshausen
- Department of Trauma Surgery and Orthopaedics, Ruhr-University Hospital Bergmannsheil Bochum, Bochum, Germany
| | - Dirk Maier
- Department of Orthopedics and Trauma Surgery, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Frieder Mauch
- Department of Shoulder and Elbow Surgery, Sportklinik Stuttgart, Stuttgart, Germany
| | - Thomas Stein
- Department of Sport Traumatology, Knee and Shoulder Surgery, Berufsgenossenschaftliche Unfallklinik, Frankfurt am Main, Germany,Department of Sports Medicine, Goethe University Frankfurt, Frankfurt am Main, Germany
| | | | - Mohamed Moursy
- Orthopedics & Trauma Centre, Medical Faculty of Mannheim, University of Heidelberg, Mannheim, Germany,Department of Orthopedics and Traumatology, Paracelsus Medical University, Salzburg, Austria
| | - Markus Scheibel
- Department for Shoulder and Elbow Surgery, Center for Musculoskeletal Surgery, Charité Universitaetsmedizin Berlin, Berlin, Germany,Department of Shoulder and Elbow Surgery, Schulthess Clinic Zurich, Zurich, Switzerland,Markus Scheibel, MD, Department of Shoulder and Elbow Surgery, Center for Musculoskeletal Surgery, Charité-Universitaetsmedizin Berlin, Augustenburger Platz 1, Berlin, 13353, Germany ()
| |
Collapse
|
33
|
Hurley ET, Fried JW, Alaia MJ, Strauss EJ, Jazrawi LM, Matache BA. Immobilisation in external rotation after first-time traumatic anterior shoulder instability reduces recurrent instability: a meta-analysis. J ISAKOS 2020; 6:22-27. [PMID: 33833042 DOI: 10.1136/jisakos-2020-000511] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Revised: 11/12/2020] [Accepted: 11/24/2020] [Indexed: 11/04/2022]
Abstract
IMPORTANCE Cadaveric and MRI findings have demonstrated significantly less labral separation and displacement when the shoulder is placed in external rotation as compared with internal rotation. OBJECTIVE The purpose of the current study is to meta-analyse the randomised controlled trials in the literature to compare immobilisation in external versus internal rotation after first-time anterior shoulder dislocation. EVIDENCE REVIEW A literature search of MEDLINE, EMBASE and the Cochrane Library was performed based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Randomised controlled trials comparing immobilisation in external rotation versus internal rotation for first-time anterior shoulder dislocation were included. FINDINGS Nine randomised controlled trials with 795 patients were included. The mean age of included patients was 29 years, 82.4% were male and the mean follow-up was 25.5 months. As compared with immobilisation in internal rotation, compliance was significantly higher (74.5% vs 67.4%, p=0.01), and the rate of recurrent dislocations was significantly lower (22.2% vs 33.4%, p=0.02) with immobilisation in external rotation. Additionally, in patients 20-40 years old the rate of recurrent dislocations was significantly lower in those treated with immobilisation in external rotation than internal rotation (12.1% vs 31.4%, p=0.006). Immobilisation in external rotation also resulted in a higher rate of return to preinjury level of play (60.1% vs 42.6%, p=0.0001). CONCLUSIONS AND RELEVANCE Immobilisation of the shoulder in external rotation after a traumatic first-time anterior shoulder dislocation results in a higher compliance rate, a lower recurrent dislocation rate and a higher rate of return to play as compared with immobilisation in internal rotation. LEVEL OF EVIDENCE Level I.
Collapse
Affiliation(s)
- Eoghan T Hurley
- Department of Orthopedic Surgery, NYU Langone Health, New York, New York, USA .,Department of Surgery, National University of Ireland Galway, Galway, Ireland
| | - Jordan W Fried
- Department of Orthopedic Surgery, NYU Langone Health, New York, New York, USA
| | - Michael J Alaia
- Department of Orthopedic Surgery, NYU Langone Health, New York, New York, USA
| | - Eric J Strauss
- Department of Orthopedic Surgery, NYU Langone Health, New York, New York, USA
| | - Laith M Jazrawi
- Department of Orthopedic Surgery, NYU Langone Health, New York, New York, USA
| | - Bogdan A Matache
- Department of Orthopedic Surgery, NYU Langone Health, New York, New York, USA
| |
Collapse
|
34
|
Kraeutler MJ, Belk JW, Carver TJ, McCarty EC, Khodaee M. Traumatic Primary Anterior Glenohumeral Joint Dislocation in Sports: A Systematic Review of Operative versus Nonoperative Management. Curr Sports Med Rep 2020; 19:468-478. [PMID: 33156033 DOI: 10.1249/jsr.0000000000000772] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Anterior shoulder (glenohumeral joint [GHJ]) dislocations are relatively common injuries in sports. Previous studies have evaluated clinical outcomes of operative and nonoperative management for primary traumatic anterior GHJ dislocations. The purpose of this study was to systematically review the literature in an effort to provide a thorough analysis of patients after undergoing closed reduction of a traumatic anterior GHJ dislocation, particularly among the athletic population. Two independent reviewers performed a comprehensive search of PubMed and the Cochrane Library through February 23, 2020. Unfortunately, the quantity and quality of published articles on this subject is very limited. In many studies, younger age (between 21 and 30 years) was associated with greater risk for recurrence of GHJ dislocations. Twelve studies (total N = 753) directly compared outcomes of operative versus nonoperative management. It seems that operative management significantly reduces recurrence rates with patients treated operatively among the young and active population. Operative management should be considered as a treatment option for young and athletic patients presenting with a first-time anterior GHJ dislocation.
Collapse
Affiliation(s)
- Matthew J Kraeutler
- Department of Orthopaedic Surgery, St. Joseph's University Medical Center, Paterson, NJ
| | | | | | | | - Morteza Khodaee
- Department of Family Medicine and Orthopedics, University of Colorado School of Medicine, Denver, CO
| |
Collapse
|
35
|
First-time Glenohumeral Dislocations: Current Evidence and Considerations in Clinical Decision Making. Sports Med Arthrosc Rev 2020; 28:122-131. [PMID: 33156225 DOI: 10.1097/jsa.0000000000000283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The decision to manage first-time shoulder dislocations conservatively or operatively has become increasingly complex because of conflicting literature. Although shoulder dislocations have traditionally been managed with reduction and immobilization, recent evidence has suggested high rates of subsequent recurrence. Surgical intervention is thought to better restore stability and decrease recurrence rates; however, it also has the potential for additional morbidity and financial cost. As such, recent literature has sought to better define patient risk profiles to identify optimal candidates for both conservative and operative management. The purpose of the current review is to provide a comprehensive and evidence-based assessment of the most recent literature to better delineate an appropriate treatment algorithm for this challenging clinical scenario.
Collapse
|
36
|
The Arthroscopic Bankart Repair: State of the Art in 2020: Decision-making and Operative Technique. Sports Med Arthrosc Rev 2020; 28:e25-e34. [PMID: 33156227 DOI: 10.1097/jsa.0000000000000290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Traumatic anterior shoulder instability is prevalent among young athletes, and recurrent dislocations can result in compromised upper extremity function, increasing glenohumeral bone loss, and ultimately, posttraumatic arthritis. Although management algorithms have evolved in response to contemporary data and technical innovation, the arthroscopic Bankart repair continues to be a mainstay for the primary surgical management of first-time or recurrent anterior shoulder instability with marginal attritional glenoid bone loss (ie, <10% to 15%) and/or "on track" Hill-Sachs defects. The advantages of arthroscopic stabilization include its minimally invasive technique, high cost effectiveness, and relatively low recurrence rates and propensity for perioperative complications. The current article reviews contemporary indications/contraindications, management of the first-time dislocator, critical glenoid bone loss, surgical technique, and reported clinical outcomes of the arthroscopic Bankart repair.
Collapse
|
37
|
Smith CS, Mollon B, Vannabouathong C, Fu JM, Sales B, Bhandari M, Whelan DB. An Assessment of Randomized Controlled Trial Quality in The Journal of Bone & Joint Surgery: Update from 2001 to 2013. J Bone Joint Surg Am 2020; 102:e116. [PMID: 33086352 DOI: 10.2106/jbjs.18.00653] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The quality of reporting of randomized controlled trials (RCTs) published in The Journal of Bone & Joint Surgery (JBJS) from 1988 to 2000 was previously analyzed. The purpose of this current study was to analyze the quality of reporting of RCTs published in JBJS from 2001 to 2013 to identify trends over time and potential areas of improvement for future clinical trials. METHODS A manual search of the JBJS database identified RCTs published between January 2001 and December 2013. Quality assessments, using the Detsky quality-of-reporting index (Detsky score), a modified Cochrane risk-of-bias tool, and abstraction of relevant data identifying predictors of quality, were conducted. RESULTS A total of 5,780 publications were identified in JBJS from 2001 to 2013, with 285 RCTs (4.9%), representing an increase from the prior 13-year period. The overall mean transformed Detsky score (and standard error) increased significantly (p < 0.001) from 68.1% ± 1.67% to 76.24% ± 0.72%. The percentage of multicenter RCTs decreased from 67% to 31%. The percentage of positive trials also decreased from 80% to 50.5%, as did the mean sample size (212 to 166). Regression analysis indicated that trials with an epidemiologist as the first author and nonsurgical trials were significantly associated (p = 0.001) with a higher overall trial quality score. The categories of the lowest mean methodology scores were randomization and concealment, eligibility criteria, and reasons for patient exclusion, as identified with the Detsky score, and patient and assessor blinding, as identified with the risk-of-bias assessment. CONCLUSIONS The quantity and quality of published RCTs in JBJS have increased in the 2001 to 2013 time period compared with the previous time period. Although these improvements are encouraging, trends to smaller, single-center trials were also observed. To efficiently determine the efficacy of orthopaedic treatments and limit bias, high-quality randomized trials of appropriate sample size and rigorous design are needed.
Collapse
Affiliation(s)
| | - Brent Mollon
- Soldiers' Memorial Hospital, Orillia, Ontario, Canada
| | | | - Joyce M Fu
- Department of Orthopaedics, University of Toronto, Toronto, Ontario, Canada
| | | | - Mohit Bhandari
- Department of Clinical Epidemiology & Biostatistics, McMaster University, Hamilton, Ontario, Canada
| | - Daniel B Whelan
- University of Toronto Orthopaedic Sports Medicine, St. Michael's and Women's College Hospitals, Toronto, Ontario, Canada
| |
Collapse
|
38
|
Comadoll SM, Landry Jarvis D, Yancey HB, Graves BR. The financial burden associated with multiple shoulder dislocations and the potential cost savings of surgical stabilization. JSES Int 2020; 4:584-586. [PMID: 32939490 PMCID: PMC7479037 DOI: 10.1016/j.jseint.2020.04.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
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.
Collapse
Affiliation(s)
- Shea M Comadoll
- Department of Orthopaedic Surgery, Wake Forest Baptist Hospital, Winston Salem, NC, USA
| | - D Landry Jarvis
- Department of Orthopaedic Surgery, Wake Forest Baptist Hospital, Winston Salem, NC, USA
| | - Hunter B Yancey
- Department of Orthopaedic Surgery, Wake Forest Baptist Hospital, Winston Salem, NC, USA
| | - Benjamin R Graves
- Department of Orthopaedic Surgery, Wake Forest Baptist Hospital, Winston Salem, NC, USA
| |
Collapse
|
39
|
Hurley ET, Manjunath AK, Bloom DA, Pauzenberger L, Mullett H, Alaia MJ, Strauss EJ. Arthroscopic Bankart Repair Versus Conservative Management for First-Time Traumatic Anterior Shoulder Instability: A Systematic Review and Meta-analysis. Arthroscopy 2020; 36:2526-2532. [PMID: 32389771 DOI: 10.1016/j.arthro.2020.04.046] [Citation(s) in RCA: 70] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2020] [Revised: 04/17/2020] [Accepted: 04/23/2020] [Indexed: 02/02/2023]
Abstract
PURPOSE To perform a meta-analysis of the current evidence in the literature comparing arthroscopic Bankart repair versus conservative management for first-time anterior shoulder dislocation. METHODS A literature search of the MEDLINE, Embase, and Cochrane Library databases was performed based on the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines. Prospective studies comparing arthroscopic Bankart repair versus conservative management as treatment for first-time anterior shoulder dislocation were included. Recurrence, further treatment, and return to play were compared, with all statistical analysis performed using Review Manager, version 5.3. P < .05 was considered statistically significant. RESULTS Ten prospective studies with 569 patients were included. Arthroscopic Bankart repair resulted in a lower rate of total recurrent instability (9.7% vs 67.4, I2 = 0, P < .0001) and further surgical treatment for anterior shoulder instability (5.9% vs 46.7%, I2 = 0, P < .0001). Additionally, arthroscopic Bankart repair resulted in a higher rate of return to play (92.8% vs 80.8%, I2 = 0, P = .002). CONCLUSIONS Arthroscopic Bankart repair resulted in a 7-fold lower recurrence rate and a higher rate of return to play than conservative management. Thus, arthroscopic Bankart repair may be advisable to perform routinely in patients with first-time dislocation who participate in sports. LEVEL OF EVIDENCE Level II, systematic review of Level I and II studies.
Collapse
Affiliation(s)
- Eoghan T Hurley
- Department of Orthopaedic Surgery, New York University Langone Health, New York, New York, U.S.A.; Sports Surgery Clinic, Dublin, Ireland.
| | - Amit K Manjunath
- Department of Orthopaedic Surgery, New York University Langone Health, New York, New York, U.S.A
| | - David A Bloom
- Department of Orthopaedic Surgery, New York University Langone Health, New York, New York, U.S.A
| | | | | | - Michael J Alaia
- Department of Orthopaedic Surgery, New York University Langone Health, New York, New York, U.S.A
| | - Eric J Strauss
- Department of Orthopaedic Surgery, New York University Langone Health, New York, New York, U.S.A
| |
Collapse
|
40
|
Shinagawa K, Sugawara Y, Hatta T, Yamamoto N, Tsuji I, Itoi E. Immobilization in External Rotation Reduces the Risk of Recurrence After Primary Anterior Shoulder Dislocation: A Meta-analysis. Orthop J Sports Med 2020; 8:2325967120925694. [PMID: 32596407 PMCID: PMC7297495 DOI: 10.1177/2325967120925694] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Accepted: 10/25/2019] [Indexed: 11/15/2022] Open
Abstract
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.
Collapse
Affiliation(s)
- Kiyotsugu Shinagawa
- Department of Orthopaedic Surgery, Tohoku University School of Medicine, Sendai, Japan
| | - Yumi Sugawara
- Division of Epidemiology, Department of Health Informatics and Public Health, Tohoku University School of Public Health, Graduate School of Medicine, Sendai, Japan
| | - Taku Hatta
- Department of Orthopaedic Surgery, Tohoku University School of Medicine, Sendai, Japan
| | - Nobuyuki Yamamoto
- Department of Orthopaedic Surgery, Tohoku University School of Medicine, Sendai, Japan
| | - Ichiro Tsuji
- Division of Epidemiology, Department of Health Informatics and Public Health, Tohoku University School of Public Health, Graduate School of Medicine, Sendai, Japan
| | - Eiji Itoi
- Department of Orthopaedic Surgery, Tohoku University School of Medicine, Sendai, Japan
| |
Collapse
|
41
|
Yapp LZ, Nicholson JA, Robinson CM. Primary Arthroscopic Stabilization for a First-Time Anterior Dislocation of the Shoulder: Long-Term Follow-up of a Randomized, Double-Blinded Trial. J Bone Joint Surg Am 2020; 102:460-467. [PMID: 31895236 DOI: 10.2106/jbjs.19.00858] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
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.
Collapse
Affiliation(s)
- Liam Z Yapp
- Royal Infirmary of Edinburgh, Edinburgh, United Kingdom
| | | | | |
Collapse
|
42
|
A systematic review of patient-reported outcome measures used in shoulder instability research. J Shoulder Elbow Surg 2020; 29:381-391. [PMID: 31495706 DOI: 10.1016/j.jse.2019.07.001] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Revised: 06/28/2019] [Accepted: 07/01/2019] [Indexed: 02/01/2023]
Abstract
BACKGROUND Shoulder instability is extremely common, with various outcome scores used to assess its progression after treatment. This review was performed to identify the scores most commonly used and to evaluate them according to the 4 core domains of shoulder trials (according to the Core Outcome Measures in Effectiveness Trials [COMET] initiative) and their respective psychometric qualities. METHODS A systematic review of the literature of 3 databases (MEDLINE, Embase, PubMed) was undertaken. Studies were identified using eligibility criteria and critically appraised by 2 authors. Data were extracted using an a priori template. Outcome scores were identified and assessed regarding COMET domain inclusion and their psychometric properties. RESULTS The most frequently used scores were the Rowe (58%), Constant (33%), Western Ontario Shoulder Instability Index (WOSI; 24%), and American Shoulder and Elbow Surgeons (23%) scores. The majority of outcome scores assessed pain and all assessed physical functioning. Quality of life and a global assessment of treatment success were rarely incorporated. No single outcome score considered all core COMET domains. The WOSI was the most acceptable measure of those assessed with respect to its validity, reliability, and responsiveness. CONCLUSIONS The WOSI incorporated 3 of the 4 core domains for shoulder trials (pain, physical functioning, and health-related quality of life). It had the most psychometric testing of the identified scores, confirming its reliability, validity, and responsiveness in the setting of shoulder instability. We recommend its use in this setting; however, it should be supplemented with additional outcome scores, such as the University of California-Los Angeles score, to cover all of the core COMET domains.
Collapse
|
43
|
Nakagawa S, Hirose T, Uchida R, Tanaka M, Mae T. Postoperative Recurrence of Instability After Arthroscopic Bankart Repair for Shoulders With Primary Instability Compared With Recurrent Instability: Influence of Bipolar Bone Defect Size. Am J Sports Med 2020; 48:48-55. [PMID: 31684736 DOI: 10.1177/0363546519880496] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND In shoulders with traumatic anterior instability, a bipolar bone defect has recently been recognized as an important indicator of the prognosis. PURPOSE To investigate the influence of bipolar bone defects on postoperative recurrence after arthroscopic Bankart repair performed at primary instability. STUDY DESIGN Cohort study; Level of evidence, 3. METHODS The study group consisted of 45 patients (45 shoulders) who underwent arthroscopic Bankart repair at primary instability before recurrence and were followed for at least 2 years. The control group consisted of 95 patients (95 shoulders) with recurrent instability who underwent Bankart repair and were followed for at least 2 years. Glenoid defects and Hill-Sachs lesions were classified into 5 size categories on 3-dimensional computed tomography and were allocated scores ranging from 0 for no defect to 4 for the largest defect. The shoulders were classified according to the total score for both lesions (0-8 points). The postoperative recurrence rate was investigated for each score of bipolar bone defects and was compared between patients with primary instability and patients with recurrent instability. The same analysis was performed for the age at operation (<20 years, 20-29 years, or ≥30 years) and for the presence of an off-track Hill-Sachs lesion. RESULTS Bipolar bone defects were smaller in shoulders with primary instability (mean ± SD defect score, 1.4 ± 1.5 points) than in those with recurrent instability (3.6 ± 1.9 points) and were larger in older patients than in younger patients at the time of primary instability. The postoperative recurrence rate was low (6.7%) in shoulders with primary instability regardless of the size of the bipolar bone defect and the patient's age, whereas the postoperative recurrence rate was high (23.2%) in shoulders with recurrent instability, especially among patients younger than 20 years with bipolar bone defects of 2 points or greater. An off-track Hill-Sachs lesion was found in only 1 patient in the oldest age group (2.2%) at primary instability, but it was found in 19 patients (20%) at recurrent instability, including 14 patients younger than 30 years. Among patients with an off-track lesion, the postoperative recurrence rate was significantly higher in patients younger than 20 years with recurrent instability (recurrence rates: <20 years, 71.4%; 20-29 years, 14.3%; ≥30 years, 0%). CONCLUSION The recurrence rate was consistently low in patients with primary instability and was significantly influenced by bipolar bone defect size and patient age in patients with recurrent instability.
Collapse
Affiliation(s)
- Shigeto Nakagawa
- Department of Orthopaedic Sports Medicine, Yukioka Hospital, Osaka, Japan
| | - Takehito Hirose
- Department of Orthopaedic Surgery, Osaka University, Graduate School of Medicine, Suita, Japan
| | - Ryohei Uchida
- Department of Orthopaedic Sports Medicine, Yukioka Hospital, Osaka, Japan
| | - Makoto Tanaka
- Department of Orthopaedic Surgery, Daini Osaka Police Hospital, Osaka, Japan
| | - Tatsuo Mae
- Department of Orthopaedic Surgery, Osaka University, Graduate School of Medicine, Suita, Japan
| |
Collapse
|
44
|
An Algorithmic Approach to the Management of Shoulder Instability. JOURNAL OF THE AMERICAN ACADEMY OF ORTHOPAEDIC SURGEONS GLOBAL RESEARCH AND REVIEWS 2019; 3:JAAOSGlobal-D-19-00168. [PMID: 32072126 PMCID: PMC7004496 DOI: 10.5435/jaaosglobal-d-19-00168] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
The recurrence of anterior shoulder instability can be as high as 86.7% in high-risk patients who are treated nonoperatively after their first incident of instability. CT and MR arthrography are necessary for preoperative imaging and assessment of glenoid bone loss. Patient expectations in conjunction with appropriate preoperative imaging are critical for surgical planning. Arthroscopic shoulder stabilization is often sufficient in most cases where glenoid bone loss is minimal, with recurrent dislocation rates close to 4% in the literature. Open stabilization procedures are generally indicated in patients with greater than 20% glenoid bone loss.
Collapse
|
45
|
Li NY, Lemme NJ, Defroda SF, Nunez E, Hartnett DA, Owens BD. Performance After Operative Versus Nonoperative Management of Shoulder Instability in the National Basketball Association. Orthop J Sports Med 2019; 7:2325967119889331. [PMID: 31858014 PMCID: PMC6913052 DOI: 10.1177/2325967119889331] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Although nonoperative management after shoulder instability injury allows an athlete to return to play sooner than operative intervention, higher rates of recurrence have been observed after nonoperative management. However, no study has investigated the differences in performance of National Basketball Association (NBA) players after index shoulder instability events managed nonoperatively versus operatively. PURPOSE/HYPOTHESIS The purpose of this study was to identify shoulder instability events in NBA athletes and assess differences in performance after injury with nonoperative versus operative management. We hypothesized that players who undergo operative intervention have reduced risk of recurrence and are able to continue their elite level of play as opposed to those who undergo nonoperative management. STUDY DESIGN Cohort study; Level of evidence, 3. METHODS Publicly available injury data from the 1986-1987 through 2017-2018 seasons were reviewed to identify NBA athletes sustaining a shoulder instability event. In addition to characteristics, player performance information, including games played, player efficiency rating (PER), and win shares, was analyzed before and for 3 seasons after injury. Statistical learning models were applied to identify performance variables that have the greatest predictive value to determine players who would benefit from surgery. RESULTS A total of 60 players with shoulder instability events were identified between 1986 and 2018. After injury, 37 players (61.7%) eventually underwent surgery and 23 players (38.3%) did not. Players who were treated nonoperatively had significantly decreased PER, games played, and offensive win shares in the season after injury (P < .05). Players who underwent surgery did not see a decline in PER, games played, or win shares. Random forest modeling found that true shooting percentage and win shares per 48 minutes were the performance variables most predictive in determining which players would benefit from surgery after shoulder instability. CONCLUSION Players who underwent surgical intervention for shoulder instability maintained their PER, games played, and win share performance characteristics, whereas players who did not undergo surgery had declines in these parameters. Given the demands of shoulder function in basketball and the risk of recurrence after an instability event, surgery enhances a player's opportunity to maintain a high level of performance after injury.
Collapse
Affiliation(s)
- Neill Y. Li
- Department of Orthopaedic Surgery, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Nicholas J. Lemme
- Department of Orthopaedic Surgery, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Steven F. Defroda
- Department of Orthopaedic Surgery, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Elvis Nunez
- Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Davis A. Hartnett
- Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Brett D. Owens
- Department of Orthopaedic Surgery, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| |
Collapse
|
46
|
Ruzbarsky JJ, Rauck RC, Manzi J, Khormaee S, Jivanelli B, Warren RF. The fragility of findings of randomized controlled trials in shoulder and elbow surgery. J Shoulder Elbow Surg 2019; 28:2409-2417. [PMID: 31420227 DOI: 10.1016/j.jse.2019.04.051] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2019] [Revised: 04/21/2019] [Accepted: 04/24/2019] [Indexed: 02/01/2023]
Abstract
BACKGROUND Considered the gold standard of study designs, randomized controlled trials' (RCTs) results shape clinical practice, effect policy, and influence reimbursement. The fragility index (FI) can be used to quantitate the relative robustness of RCT results, with higher scores indicating more stout results. Unfortunately, most RCTs in surgery have fragile results. The aim of this study was to report on the FI in addition to a qualitative assessment of recent RCTs within the field of shoulder and elbow surgery. METHODS A systematic review was performed identifying recently published shoulder/elbow RCTs that included 1:1 allocated parallel study arms, dichotomous primary outcome variables, and statistical significance. The FI was calculated by sequentially modifying outcome groups by exchanging a nonevent in one group to an event until the P value for the outcome comparison, as calculated by the Fisher exact test, was increased above the .05 threshold. RESULTS Thirty RCTs were included. The median FI was 4. Sixty percent trials had a FI of 2 or less. Fifty-three percent studies reported that participants were lost to follow-up. In 87.5% of these studies, the losses to follow-up exceeded their respective FIs. Only 53% of studies defined a primary outcome variable and 60% studies performed a prestudy power analysis. CONCLUSIONS The median FI reported in the recent shoulder/elbow literature is 4; however, a high proportion of included RCTs display significant methodological concerns. The FI is a useful adjunct to analyze RCT results, but careful analysis of trial methods should be employed in each circumstance before drawing conclusions.
Collapse
Affiliation(s)
- Joseph J Ruzbarsky
- Department of Orthopaedics, Hospital for Special Surgery, New York, NY, USA.
| | - Ryan C Rauck
- Department of Orthopaedics, Hospital for Special Surgery, New York, NY, USA
| | - Joseph Manzi
- Weill Cornell School of Medicine, New York, NY, USA
| | - Sariah Khormaee
- Department of Orthopaedics, Hospital for Special Surgery, New York, NY, USA
| | - Bridget Jivanelli
- Department of Orthopaedics, Hospital for Special Surgery, New York, NY, USA
| | - Russell F Warren
- Department of Orthopaedics, Hospital for Special Surgery, New York, NY, USA
| |
Collapse
|
47
|
Williams HLM, Evans JP, Furness ND, Smith CD. It's Not All About Redislocation: A Systematic Review of Complications After Anterior Shoulder Stabilization Surgery. Am J Sports Med 2019; 47:3277-3283. [PMID: 30525905 DOI: 10.1177/0363546518810711] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND The surgical treatment of recurrent shoulder instability has evolved in recent years to include a variety of soft tissue and bone block procedures, undertaken with either an open or arthroscopic approach. Although the utilization of such techniques has rapidly expanded, the associated risk of complications remains poorly defined. This information is vital for clinical decision making and patient counseling. PURPOSE To quantify the complication rate associated with all types of surgery for anterior glenohumeral joint dislocation. STUDY DESIGN Systematic review. METHODS A systematic search was undertaken of studies reporting complications from anterior shoulder stabilization surgery. Inclusion criteria were studies published in English between 2000 and 2017 with a minimum 2-year follow-up. Methodological quality of the included studies was assessed with the Methodological Index for Non-Randomized Studies criteria. Complication rates for all undesirable events contributing to the patient outcome were extracted and cumulative rates calculated. RESULTS Out of 1942 references, 56 studies were included, totaling 4362 procedures among 4336 patients. Arthroscopic soft tissue repair had a complication rate of 1.6% (n = 2805). When repair was combined with arthroscopic remplissage, the rate was 0.5% (n = 219). Open soft tissue repair had a complication rate of 6.2% (n = 219) and open labral repair with remplissage, a rate of 2.3% (n = 79). An open bone block procedure had a complication rate of 7.2% (n = 573) and an arthroscopic bone block procedure, a rate of 13.6% (n = 163). CONCLUSION This large systematic review demonstrates the overall complication rates (not purely recurrence rates) in modern shoulder stabilization surgery. With the growing interest in bone block stabilization procedures, including those performed arthroscopically, surgeons should be aware of the 10-fold increase in complications for these procedures over soft tissue arthroscopic surgery and counsel their patients accordingly.
Collapse
|
48
|
Lemme NJ, Kuczmarski AS, Goodman AD, Ready LV, Dickens JF, Owens BD. Management and Outcomes of In-Season Anterior Shoulder Instability in Athletes. JBJS Rev 2019; 7:e2. [DOI: 10.2106/jbjs.rvw.19.00010] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
|
49
|
Kanatli U, Özer M, Gem M, Öztürk BY, Ataoğlu MB, Çetinkaya M, Ayanoğlu T. Multiple Subscapularis Tendon Sign: A New Risk Factor for Recurrence After Arthroscopic Anterior Shoulder Instability Surgery. Orthop J Sports Med 2019; 7:2325967119853507. [PMID: 31276003 PMCID: PMC6598329 DOI: 10.1177/2325967119853507] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Background: Being able to predict recurrence after the treatment of shoulder instability would be helpful in planning the appropriate treatment. Purpose: To define the multiple subscapularis tendon sign (MSTS) as a novel anatomic variant and a possible risk factor for the recurrence of shoulder instability after anterior stabilization and to evaluate it, together with the other risk factors as described in the literature. Study Design: Case-control study; Level of evidence, 3. Methods: A total of 87 patients met the study criteria and underwent arthroscopic stabilization for anterior shoulder instability. The MSTS was evaluated in this study group. Age, sex, hand dominance, number of preoperative shoulder dislocations, history of overhead or contact sports participation, type of labral lesion, number of anchors used in surgery, presence of the drive-through sign, presence of the MSTS, Oxford Shoulder Score results, and the association of these parameters with recurrence were assessed. The mean follow-up time was 81.0 ± 27.9 months (range, 48-139 months). Results: Nine (10.3%) patients experienced recurrent instability. The presence of the MSTS (P = .009), existence of an anterior labroligamentous periosteal sleeve avulsion (ALPSA) lesion (P = .04), and history of overhead or contact sports participation (P = .04) were significant risk factors for recurrence. The recurrence rates were as follows: 30.7% with the MSTS; 40% with the MSTS and an ALPSA lesion; and 75% with the MSTS, an ALPSA lesion, and a history of overhead or contact sports participation. Conclusion: The MSTS is a variation of the anterior shoulder joint capsule. It is a sign of capsular insufficiency or thinning, which may be a risk factor for recurrence after anterior stabilization. Considering the low success rates of anterior capsulolabral repair in patients participating in overhead or contact sports, especially when an ALPSA lesion is present, encountering the MSTS during surgery in this at-risk group may be an indicator for the surgeon to choose the surgical procedure more carefully.
Collapse
Affiliation(s)
- Ulunay Kanatli
- Department of Orthopaedics and Traumatology, Faculty of Medicine, Gazi University, Ankara, Turkey
| | - Mustafa Özer
- Department of Orthopaedics and Traumatology, Meram Faculty of Medicine, Necmettin Erbakan University, Konya, Turkey
| | - Mehmet Gem
- Department of Orthopaedics and Traumatology, Faculty of Medicine, Dicle University, Diyarbakir, Turkey
| | - Burak Yağmur Öztürk
- Department of Orthopaedics and Traumatology, Fatih Sultan Mehmet Training and Research Hospital, Istanbul, Turkey
| | - Muhammet Baybars Ataoğlu
- Department of Orthopaedics and Traumatology, Faculty of Medicine, Gazi University, Ankara, Turkey
| | - Mehmet Çetinkaya
- Department of Orthopaedics and Traumatology, Mengucek Gazi Training and Research Hospital, Erzincan University, Erzincan, Turkey
| | - Tacettin Ayanoğlu
- Department of Orthopaedics and Traumatology, Yozgat City Hospital, Yozgat, Turkey
| |
Collapse
|
50
|
Terra BB, Ejnisman B, Belangero PS, Figueiredo E, De Nadai A, Ton A, Cohen M. Arthroscopic Treatment of First-Time Shoulder Dislocations in Younger Athletes. Orthop J Sports Med 2019; 7:2325967119844352. [PMID: 31205964 PMCID: PMC6537070 DOI: 10.1177/2325967119844352] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Background: The glenohumeral joint is characterized by its large degree of movement and consequently is the most susceptible joint to dislocations. There are few studies on the first episode of a shoulder dislocation in younger athletes. Purpose: To report the results of arthroscopic treatment for the first episode of a glenohumeral dislocation in younger athletes. Study Design: Case series; Level of evidence, 4. Methods: In this retrospective study, 53 patients younger than 40 years (N = 54 shoulders) sustained their first anterior shoulder dislocation and underwent arthroscopic surgery. Surgery was undertaken in the lateral decubitus position. Standard posterior, anteroinferior, and anterosuperior portals were used, and the number of anchors and the degree of capsular plication were individualized and based on the arthroscopic findings of each patient. The minimum follow-up was 2 years (mean, 2.31 years), and patients were evaluated with the Rowe functional score, Athletic Shoulder Outcome Rating Scale (EROE; acronym in Portuguese), and visual analog scale (VAS) for pain. Results: The mean EROE score was 93.8, with 98% of results being good or excellent, and the mean Rowe score was 95.0, with 98% good or excellent results. The mean VAS pain score was <1.0. The rate of recurrence of dislocations was 2%. The return-to-sports rate was 83%; patients with associated superior labral anterior-posterior (SLAP) lesions had a lower return-to-sports rate (P = .001) and lower EROE (P = .017) and Rowe (P = .019) scores. Conclusion: The present study showed favorable results for arthroscopic surgical treatment after the first dislocation episode in young athletes. It was an effective and safe treatment option in this population.
Collapse
Affiliation(s)
- Bernardo Barcellos Terra
- Orthopedic Department, Federal University of São Paulo, São Paulo, Brazil.,Santa Casa Hospital, Vitória, Brazil
| | - Benno Ejnisman
- Orthopedic Department, Federal University of São Paulo, São Paulo, Brazil
| | | | - Eduardo Figueiredo
- Orthopedic Department, Federal University of São Paulo, São Paulo, Brazil
| | - Anderson De Nadai
- Orthopedic Department, Federal University of São Paulo, São Paulo, Brazil.,Santa Casa Hospital, Vitória, Brazil
| | | | - Moisés Cohen
- Orthopedic Department, Federal University of São Paulo, São Paulo, Brazil
| |
Collapse
|