Controversies in the Management of the First Time Shoulder Dislocation

MPFL reconstruction results in lower redislocation rates and higher functional outcomes than rehabilitation: a systematic review and meta-analysis

PURPOSE

To determine the effect of early MPFL reconstruction versus rehabilitation on the rate of recurrent patellar dislocations and functional outcomes in skeletally mature patients with traumatic, first-time patellar dislocation.

METHODS

Three online databases MEDLINE, PubMed and EMBASE were searched from database inception (1946, 1966, and 1974, respectively) to August 20th, 2021 for literature addressing the management of patients sustaining acute first-time patellar dislocations. Data on redislocation rates, functional outcomes using the Kujala score, and complication rates were recorded. A meta-analysis was used to pool the mean postoperative Kujala score, as well as calculate the proportion of patients sustaining redislocation episodes using a random effects model. Quality assessment of included studies was performed for all included studies using the MINORS and Detsky scores.

RESULTS

A total of 19 studies and 1,165 patients were included in this review. The pooled mean redislocation rate in 14 studies comprising 734 patients in the rehabilitation group was 30% (95% CI 25-36%, I² = 67%). Moreover, the pooled mean redislocation rate in 5 studies comprising 318 patients undergoing early MPFL reconstruction was 7% (95% CI 2-17%, I² = 70%). The pooled mean postoperative Kujala anterior knee pain score in 7 studies comprising 332 patients in the rehabilitation group was 81 (95% CI 78-85, I² = 78%), compared to a score of 87 (95% CI 85-89, I² = 0%, Fig. 4) in 3 studies comprising 54 patients in the reconstruction group.

CONCLUSION

Management of acute first-time patellar dislocations with MPFL reconstruction resulted in a lower rate of redislocation of 7% in the reconstruction group vs 30% in the rehabilitation group and a higher Kujala score compared to the rehabilitation group. The information this review provides will help surgeons guide their decision to choose early MPFL reconstruction versus rehabilitation when treating patients with first-time patellar dislocations and may guide future studies on the topic.

LEVEL OF EVIDENCE

IV.

Variations in common operations in athletes and non-Athletes

Background

Achieving pre-injury activity level after an injury is the fundamental goal of any orthopedic treatment for an athlete. Unfortunately, pre-injury activity levels differ significantly in different patient categories, especially in athletes and non-athlete. Hence, an outcome suitable to a non-athlete may not be adequate for an athlete. This has led to variations in the surgical approach to the same injury in an athlete and non-athlete.There is plenty of literature published comparing the outcome in athletes and non-athletes after a particular surgery. Scattered discussion about variations in these surgeries based on functional demand was done in many publications. But there was a lack of a comprehensive narrative review summarizing variations in common operations among athletes and non-athletes.

Aim

This review attempted to summarize variations in common sports operations between high functional demand patients and low demand patients and discuss the variations from the author's perspective.

Methods

A review of all the relevant papers were conducted focusing on athletes and non-athletes. Most commonly performed sports surgeries were ACL reconstruction, Meniscal repair, PCL reconstruction, and Shoulder instability surgery. A literature search was done for each commonly performed surgery using relevant keywords in PubMed and Google Scholars. Summary of papers pertinent to athletes and non-athletes were compiled to prepare this narrative review.

Results

There is a lack of papers directly comparing results in athletes and non-athletes. However, many research papers discussed surgical variations in athletes (high demand) and non-athletes (low demand) patients. There are controversies in all commonly performed surgeries, and none of the papers gives a definitive guideline on the approach to athletes and non-athlete.

Conclusion

Rather than a common suggestion on surgical variation, an individualized approach would be appropriate to decide on variation in particular surgery in both athletes and non-athletes.

Treatment of first-time traumatic anterior shoulder dislocation: the UK TASH-D cohort study

BACKGROUND

Shoulder dislocations are the most common joint dislocations seen in emergency departments. Most traumatic cases are anterior and cause recurrent dislocations. Management options include surgical and conservative treatments. There is a lack of evidence about which method is most effective after the first traumatic anterior shoulder dislocation (TASD).

OBJECTIVES

To produce UK age- and sex-specific incidence rates for TASD. To assess whether or not surgery within 6 months of a first-time TASD decreases re-dislocation rates compared with no surgery. To identify clinical predictors of recurrent dislocation.

DESIGN

A population-based cohort study of first-time TASD patients in the UK. An initial validation study and subsequent propensity-score-matched analysis to compare re-dislocation rates between surgery and no surgery after a first-time TASD. Prediction modelling was used to identify potential predictors of recurrent dislocation.

SETTING

UK primary and secondary care data.

PARTICIPANTS

Patients with a first-time TASD between 1997 and 2015.

INTERVENTIONS

Stabilisation surgery within 6 months of a first-time TASD (compared with no surgery). Stabilisation surgery within 12 months of a first-time TASD was also carried out as a sensitivity analysis.

MAIN OUTCOME MEASURE

Re-dislocation rate up to 2 years after the first TASD.

METHODS

Eligible patients were identified from the Clinical Practice Research Datalink (CPRD) (1997-2015). Accuracy of shoulder dislocation coding was internally validated using the CPRD General Practitioner questionnaire service. UK age- and sex-specific incidence rates for TASD were externally validated against rates from the USA and Canada. A propensity-score-matched analysis using linked CPRD and Hospital Episode Statistics (HES) data compared re-dislocation rates for patients aged 16-35 years, comparing surgery with no surgery. Multivariable Cox regression models for predicting re-dislocation were developed for the surgical and non-surgical cohorts.

RESULTS

Shoulder dislocation was coded correctly for 89% of cases in the CPRD [95% confidence interval (CI) 83% to 95%], with a 'primary' dislocation confirmed for 76% of cases (95% CI 67% to 85%). Far fewer patients than expected received stabilisation surgery within 6 months of a first TASD, leading to an underpowered study. Around 20% of re-dislocation rates were observed for both surgical and non-surgical patients. The sensitivity analysis at 12 months also showed little difference in re-dislocation rates. Missing data on risk factors limited the value of the prediction modelling; however, younger age, epilepsy and sex (male) were identified as statistically significant predictors of re-dislocation.

LIMITATIONS

Far fewer than the expected number of patients had surgery after a first-time TASD, resulting in an underpowered study. This and residual confounding from missing risk factors mean that it is not possible to draw valid conclusions.

CONCLUSIONS

This study provides, for the first time, UK data on the age- and sex-specific incidence rates for TASD. Most TASD occurs in men, but an unexpected increased incidence was observed in women aged > 50 years. Surgery after a first-time TASD is uncommon in the NHS. Re-dislocation rates for patients receiving surgery after their first TASD are higher than previously expected; however, important residual confounding risk factors were not recorded in NHS primary and secondary care databases, thus preventing useful recommendations.

FUTURE WORK

The high incidence of TASD justifies investigation into preventative measures for young men participating in contact sports, as well as investigating the risk factors in women aged > 50 years. A randomised controlled trial would account for key confounders missing from CPRD and HES data. A national TASD registry would allow for a more relevant data capture for this patient group.

STUDY REGISTRATION

Independent Scientific Advisory Committee (ISAC) for the Medicines and Healthcare Products Regulatory Agency (ISAC protocol 15_0260).

FUNDING

The National Institute for Health Research Health Technology Assessment programme.