Surgical versus nonsurgical treatment in first traumatic anterior dislocation of the shoulder in athletes

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

LEVEL OF EVIDENCE

IV.

Outcomes of the arthroscopic Bankart procedure in Irish collision sport athletes

BACKGROUND

While there is an abundance of research examining the outcomes of the arthroscopic Bankart repair in collision athletes, very few studies have involved the unique Irish collision sport athlete population. The previously held belief that collision athletes need to be treated with open surgery, due to the high traumatic forces the shoulder is subjected to in these sports, may no longer be true in the context of modern arthroscopic techniques and implants.

AIMS

To report the outcomes of the arthroscopic Bankart procedure in the unique Irish collision athlete population.

METHOD

Retrospective review conducted in 2018. Data was obtained from collision sport athletes using customised questionnaires and validated, standardised outcome measure tools. Participants were selected using inclusion and exclusion criteria.

RESULTS

Fifty-four patients were included in the study. The average age at primary injury was 19.9 years (range 13-35 years). The rate of recurrent dislocation was 21% (12/57) with a mean follow up time of 24 months (range 7 to 48 months). The mean patient reported outcome measure (PROM) scores were as follows: ASES = 90.8, WOSI = 316.4, SSV = 79%. Six patients failed to return to their sport. Eighty-seven percent of the cohort returned to their sport, with a mean time to return of 7.25 months. Patients who experienced recurrent instability after arthroscopic Bankart had a younger age at primary dislocation (P = 0.0005) and lower ASES (P = 0.0056) and WOSI scores (0.00132) at latest follow-up, compared to those who remained stable postsurgery.

CONCLUSION

The arthroscopic Bankart procedure has a high rate of recurrence of dislocation in Irish collision sport athletes. The current international literature suggests that the arthroscopic Bankart has similar rates of recurrence to the open procedure in collision athletes; however, this may not hold true for Irish collision sport athletes. Further research is required to determine the optimum surgical procedure for anterior shoulder instability in this population, particularly those patients with subcritical bone loss.

Arthroscopic Treatment of First-Time Shoulder Dislocations in Younger Athletes

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.

Pitch-side management of acute shoulder dislocations: a conceptual review

The shoulder, specifically the glenohumeral joint, by virtue of its anatomical characteristics and biomechanics confers a large range of movement, which ultimately results in a joint that is inherently prone to becoming unstable. The incidence of acute traumatic shoulder dislocation varies within the sporting environment, commonly occurring following direct trauma. Anterior dislocations account for nearly 90% of all dislocations. While most are referred and managed in the emergency department, pitch-side relocation by experienced clinicians does occur prior to referral. The aim of this study was to delineate a guideline specifically for the pitch-side management of this common injury. A literature search of PubMed and Medline using the keywords ‘prehospital’, ‘pitch-side’, ‘shoulder dislocation’ and ‘reduction’ or ‘relocation technique’ was performed, and the available literature was reviewed and collated. Articles focusing on reduction techniques were then reviewed, with particular consideration on their applicability to a pitch-side setting. While studies exist that compare and contrast examination and reduction techniques, most are based in a hospital setting. To date, there is no standardised management protocol published for the initial management of an anterior dislocated shoulder in a pitch-side setting. This article addresses this discrepancy and proposes a structured, algorithmic approach to the pitch-side management of a shoulder dislocation. The article addresses factors to consider in a pitch-side setting, suitable techniques and postreduction care. While a systematic approach has been delineated in this article, we recommend those pitch-side medical practitioners who provide this form of support should have attended appropriate training and ensure adequate malpractice cover.

Does the position of shoulder immobilization after reduced anterior glenohumeral dislocation affect coaptation of a Bankart lesion? An arthrographic comparison

Background

The position of immobilization after anterior shoulder dislocation has been a controversial topic over the past decade. We compared the effect of post-reduction immobilization, whether external rotation or internal rotation, on coaptation of the torn labrum.

Materials and methods

Twenty patients aged <40 years with primary anterior shoulder dislocation without associated fractures were randomized to post-reduction external rotation immobilization (nine patients) or internal rotation (11 patients). After 3 weeks, magnetic resonance arthrography was performed. Displacement, separation, and opening angle parameters were assessed and analyzed.

Results

Separation (1.16 ± 1.11 vs 2.43 ± 1.17 mm), displacement (1.73 ± 1.64 vs 2.28 ± 1.36 mm), and opening angle (15.00 ± 15.84 vs 27.86 ± 14.74 °) in the externally rotated group were decreased in comparison to the internally rotated group. A statistically significant difference between groups was seen only for separation (p = 0.028); p values of displacement and opening angle were 0.354 and 0.099, respectively.

Conclusion

External rotation immobilization after reduction of primary anterior shoulder dislocation could result in a decrease in anterior capsule detachment and labral reduction.

Level of evidence

Level 2.