First-time Shoulder Research Articles

Incidence of Posttraumatic Shoulder Dislocation in Poland.

BackgroundThe incidence of shoulder joint dislocation has been estimated at 11–26 per 100 000 population per year. In our opinion, basic epidemiological data need to be continually updated in studies of large populations.To study the incidence of posttraumatic dislocation of the shoulder joint in the Polish population.Material/MethodsWe retrospectively investigated the entire Polish population between 1 January 2010 and 1 January 2015. To identify the study group, data collected in the electronic database of the National Health Fund were used. The study group was divided into subgroups to detect possible differences in the incidence of shoulder dislocation with regard to age, sex, and season of the year (month) when the dislocation occurred.ResultsThe cumulative size of the study sample was 192.72 million over the 5 years of the study. We identified 51 409 patients with first posttraumatic shoulder dislocation, at a mean age of 50.83 years (SD 21.12), from 0 to 104 years. The incidence of traumatic shoulder dislocations for the entire study group ranged from 24.75/100 000/year (number of posttraumatic shoulder dislocations per 100 000 persons per year) to 29.09/100 000/year, for a mean of 26.69/100 000/year.ConclusionsIn this study, the overall incidence of first-time posttraumatic shoulder dislocations in the Polish general population was 26.69 per 100 000 persons per year. These results are higher than estimates presented by other authors. It is necessary to study, regularly update, and monitor this problem in the general population.

Anterior Shoulder Instability in the Military Athlete.

Context:Given its young, predominately male demographics and intense physical demands, the US military remains an ideal cohort for the study of anterior shoulder instability.Evidence Acquisition:A literature search of PubMed, MEDLINE, and the Cochrane Database was performed to identify all peer-reviewed publications from 1950 to 2016 from US military orthopaedic surgeons focusing on the management of anterior shoulder instability.Study Design:Clinical review.Level of Evidence:Level 4.Results:The incidence of anterior shoulder instability events in the military occurs at an order of magnitude greater than in civilian populations, with rates as high as 3% per year among high-risk groups. With more than 90% risk of a Bankart lesion and high risk for instability recurrence, the military has advocated for early intervention of first-time shoulder instability while documenting up to 76% relative risk reduction versus nonoperative treatment. Preoperative evaluation with advanced radiographic imaging should be used to evaluate for attritional bone loss or “off-track” engaging defects to guide comprehensive surgical management. With complex recurrent shoulder instability and/or cases of clinically significant osseous lesions, potential options such as remplissage, anterior open capsular procedures, or bone augmentation procedures may be preferentially considered.Conclusion:Careful risk stratification, clinical evaluation, and selective surgical management for at-risk military patients with anterior shoulder instability can optimize the recurrence risk and functional outcome in this population.

Management of First-Time Shoulder Dislocation in the Contact Athlete

First-time anterior shoulder dislocation in the contact and collision athlete represents a treatment challenge for the orthopaedic surgeon, especially if the athlete is in season. Treatment starts with immediate on-field management and transitions to a thorough history and physical examination off the field. Plain film and advanced imaging then help to guide the orthopaedic surgeon in the shared decision-making process. The decision to return an athlete to play in the same season carries a high risk of repeat dislocation or instability, and the surgeon must not only counsel the athlete on this but also protect the athlete from returning before safe to do so. The optimal surgical treatment—arthroscopic vs open vs bone block—remains controversial as well. Historically, open Bankart repair and stabilization has shown a decreased risk of recurrence compared with arthroscopic, but the current literature has support for either options. Additionally, some authors now advocate open osseous augmentation procedures as having the lowest recurrence rates. This article explores the decision-making process from first clinic contact through clinical management.

Management of shoulder instability: the current state of treatment among German orthopaedic surgeons.

The aim of this study was to evaluate the current state of treatment in traumatic anterior shoulder dislocation in Germany and to detect changes over the last 12years. Seven hundred ninety-six trauma and/or orthopaedic departments were found in the German hospital directory 2012. The websites of each department were searched for the email address of the responsible shoulder surgeon (if applicable) or the head of the department. Seven hundred forty-six email addresses were found, and emails with the request to participate in an online survey were sent in January 2013. Six hundred seventy-five emails probably reached the correct addressee. Seventy-one emails were rejected, and no contact could be made. One-hundred ninety-one (28%) participated in the study. The data were compared to similar data from a survey on shoulder dislocation performed in the same department and published in 2001. After the first-time traumatic shoulder dislocation in patients aged younger than 30years participating in sports, 14% of the participants would prefer conservative treatment, 83% arthroscopic, and 3% open surgery. When surgery was indicated, arthroscopic Bankart repair was the treatment of choice for 93% of the participants. In 2001, 27% had indicated conservative treatment after the first-time shoulder dislocation in active patients younger than 30years. When surgery was indicated, 66% had performed arthroscopic and 34% open stabilization. For the standard arthroscopic Bankart repair without concomitant injuries, 41% of the participants use two and 54% three suture anchors. Knotless anchors were preferred by 72%. In the case of glenoid bone loss greater than 25%, only 46% perform a procedure for glenoid bone augmentation. Fifteen percent of the participants always recommended immobilization in external rotation after traumatic first-time shoulder dislocation. The majority of participants recommend arthroscopic Bankart repair with two or three suture anchors in young persons with the first-time dislocations. Compared to 2001 less recommend conservative treatment, complex "open" surgical procedures are no longer used. The knowledge that a Bankart procedure likely fails in significant glenoid bone loss is not implemented in the clinical practice. Thus, there is a need to educate surgeons on this topic.

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

This study aimed to compare the frequency of intra-articular lesions between young patients with first-time shoulder dislocations and those with recurrent shoulder dislocations and to assess the correlation between intra-articular lesions and failure of arthroscopic stabilization. The study enrolled 33 patients who underwent arthroscopic Bankart repair after first-time shoulder dislocation before the age of 30 years. There were 89 age-matched patients who were treated arthroscopically for recurrent dislocation included as a control group. Among intra-articular pathologic findings, anterior glenoid erosion (P = .043) and anterior labral periosteal sleeve avulsion lesions (P = .048) were found more frequently in the recurrent dislocation group. There was no statistically significant difference between the 2 groups in American Shoulder and Elbow Surgeons (P = .675) and Rowe (P = .132) scores at the last follow-up. However, there was a significant difference in the failure rate after operation between the 2 groups (P = .039). In the first-time dislocation group, 1 patient had redislocation and none showed positive apprehension. In the recurrent dislocation group, 6 patients had redislocation and 10 patients had positive apprehension. Eight of 10 patients who showed positive apprehension had either anterior labral periosteal sleeve avulsion lesions or anterior glenoid erosion. The patients' satisfaction with daily activities was significantly better in the first-time dislocation group (93.0 ± 5.2) than in the recurrent dislocation group (82.7 ± 7.2; P < .001). Primary surgical treatment for first-time traumatic anterior shoulder dislocation provided satisfactory functional outcomes and improved quality of life. Primary arthroscopic stabilization can be considered one of the treatment options in patients younger than 30 years with first-time shoulder dislocation to prevent further intra-articular injuries that may contribute to recurrence.

Propionibacterium acnes in shoulder surgery: is loss of hair protective for infection?

Propionibacterium acnes (P acnes) has been linked to chronic infections in shoulder surgery. It was recently observed during first-time shoulder surgery in healthy patients at a rate between 36% and 56%. Male gender and the anterolateral approach were reported risk factors. Because the skin biology greatly differs, we aimed to correlate skin complaints with P acnes-positive intraoperative cultures from different tissue layer samples in patients undergoing shoulder surgery for the first time. Intraoperative samples (1 skin, 1 superficial, 1 deep tissue, and 1 control sample) from 112 patients (70 men, 42 women; aged 59.2 years) were cultured. The association between the presence of P acnes in the deep or superficial tissue, or both, and 10 items of a validated preoperative questionnaire for skin pathology was explored. The cultures were positive for P acnes in 38.4% (n = 43) of the cases. Skin samples were positive for P acnes in 8% (n = 9), superficial samples were positive in 23% (n = 26), and deep samples were positive in 30% (n = 34). Self-reported "loss of hair" was significantly negatively associated with the presence of P acnes in the superficial or deep tissue sample (P = .00028). Patients who report having "loss of hair" show fewer P acnes-positive cultures in intraoperative tissue samples taken during open shoulder surgery. Whether this subgroup is at a lesser risk for P acnes infections remains to be substantiated. Basic Science Study; Microbiology.

Clinical Outcomes and Intra-Articular Findings of First-Time Shoulder Dislocations after Arthroscopic Stabilization Procedure: A Comparative Study with Recurrent Shoulder Dislocations

Optimal treatment for the first-time shoulder dislocation is still debated despite high rates of recurrent shoulder dislocation rate in young patients. This study compared clinical outcomes of arthroscopic stabilization procedure between patients with first-time traumatic anterior dislocation and patients with recurrent shoulder dislocation. We also compared the intra-articular findings on arthroscopy between the two groups of patients younger than 30 years old.

Efficacy of topical benzoyl peroxide on the reduction of Propionibacterium acnes during shoulder surgery

Propionibacterium acnes infection is a significant problem after shoulder surgery. Residual P. acnes is found on the skin up to 29% of the time immediately after surgical skin preparation and in 70% of dermal biopsy specimens. These residual bacteria may be a source for infection. Identifying more ideal skin preparation may help reduce the risk of infection. The purpose of this study was to evaluate the effect that topical benzoyl peroxide (BPO), with chlorhexidine skin preparation, would have on the presence of P. acnes cultured at the time of shoulder surgery. We hypothesized that adding topical BPO to our skin preparation would reduce the number of positive P. acnes cultures identified during surgery. Fifty patients undergoing first-time shoulder surgery were treated with topical 5% BPO cream 48hours before surgery. After skin preparation, 13 samples per subject were obtained. Cultures were held for 14days. Fifty patients underwent arthroscopic shoulder surgery; 650 culture specimens were obtained. The skin was positive at the initiation of surgery in 6% of cases. Tissue samples were positive in 6%. The skin was positive in 10% at the end of surgery. None of these rates of positive culture were different from the 4% rate observed with a control swab. Application of BPO is an effective way to reduce P. acnes on skin at the beginning and, importantly, at the end of a surgical procedure. This may result in a lower risk for postoperative infection.

Presence of Propionibacterium acnes in primary shoulder arthroscopy: results of aspiration and tissue cultures

Infection after shoulder surgery has a serious impact on patient outcome and costs associated with care. Propionibacterium acnes infection may be insidious and manifest years after index surgery with resultant joint arthropathy or prosthesis infection. Our goal was to evaluate the presence of P. acnes in a group of patients undergoing primary arthroscopic shoulder surgery to better understand this organism. Samples were collected from 57 patients undergoing first-time shoulder arthroscopy. Demographic data and medical comorbidities were collected. A control, 2 skin swabs, synovial fluid, and 3 tissue samples were obtained. All samples were placed on aerobic plates, on anaerobic plates, and in thioglycolate broth and held for 28 days. Fifty-seven patients underwent arthroscopic shoulder surgery. The mean age was 51 years. Eighty-one samples (21.8%) were positive for P. acnes when cultures were held 14 days; 32 subjects (56%) had at least 1 culture that grew P. acnes. Positive skin cultures for P. acnes increased from 15.8% before incision to 40.4% at closure. This was even more pronounced in men as positive skin cultures increased from 31.3% before incision to 63.0% at closure. Thirteen patients (22.8%) had more than 3 cultures positive. None of the patients in this study have had signs or symptoms to suggest clinical P. acnes infection. Of all subjects studied, 56% had at least 1 positive culture; 21% (of all 371 culture specimens obtained) grew P. acnes. We suspect that it is a consequence of true positive cultures from imperfect skin preparation and dermal contamination.

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

We previously identified the positive result of the supine apprehension test after completion of rehabilitation following a first dislocation as a possible predictor of high risk for redislocation. We extend the follow-up of a previous cohort of patients with first-time shoulder dislocations to better assess this test. Fifty-three men aged 17 to 27 years who sustained a first traumatic shoulder dislocation were treated by shoulder immobilization for 4 weeks and then rehabilitated with a standard physical therapy protocol. At 6-week follow-up, a supine anterior apprehension test was performed to assess the risk of redislocation. The patients were observed prospectively for a minimum of 75months. Of the 53 participants, 52 (mean age, 20.2 years) completed the study follow-up. Of the 52 subjects, 41 (79%) were combat soldiers. Follow-up was between 75 and 112months. Of the 52 subjects, 31 (60%) redislocated at a range of 3 to 70months after the initial dislocation. Eleven of 14 subjects (79%; confidence interval, 52%-92%) with a positive anterior apprehension test result redislocated, compared with 20 of 38 patients (53%; confidence interval, 37%-68%) with a negative test result. Patients with a positive test result redislocated more and earlier (P=.02, PROC LIFETEST, SAS). The results of the supine apprehension test after a first shoulder dislocation and rehabilitation can help predict risk for recurrent instability. It potentially may be included as a variable in decision analysis models.

Propionibacterium acnes in shoulder surgery: true infection, contamination, or commensal of the deep tissue?

Propionibacterium acnes has been linked to chronic infections in shoulder surgery. Whether the bacterium is a contaminant or commensal of the deep tissue is unclear. We aimed to assess P. acnes in intraoperative samples of different tissue layers in patients undergoing first-time shoulder surgery. In 118 consecutive patients (mean age, 59.2years; 75men, 43 women), intraoperative samples were correlated to preoperative subacromial injection, the type of surgical approach, and gender. One skin, one superficial, one deep tissue, and one test sample were cultured for each patient. The cultures were positive for P. acnes in 36.4% (n=43) of cases. Subacromial injection was not associated with bacterial growth rates (P = .88 for P. acnes; P = .20 for bacteria other than P. acnes; P=.85 for the anterolateral approach; P=.92 for the deltopectoral approach; P=.56 for men; P=.51 for women). Skin samples were positive for P. acnes in 8.5% (n=10), superficial samples were positive in 7.6% (n=9), deep samples were positive in 13.6% (n=16), and both samples (superficialanddeep) were positive in 15.3% (n=18) of cases (P < .0001). P. acnes was detected in the anterolateral approach in 27.1% (n=32) of cases and in the deltopectoral approach in 9.3% (n=11) of cases (P = .01; relative risk, 1.93; 95% confidence interval, 1.08-3.43). Thirty-five of the P. acnes-positive patients were men (81.4%), and 8 patients were women (18.6%; P = .001; relative risk, 2.51; 95% confidence interval, 1.28-4.90). P. acnes was detected in more than one third of patients undergoing first-time shoulder surgery. Preoperative subacromial injection was not associated with bacterial growth. P. acnes was observed more frequently in the deep tissues than in the superficial tissues. The relative risk for obtaining a positive P. acnes culture was 2-fold greater for the anterolateral approach than for the deltopectoral approach, and the risk was 2.5-fold greater for men.

External Rotation Immobilization for Primary Shoulder Dislocation: A Randomized Controlled Trial

The traditional treatment for primary anterior shoulder dislocations has been immobilization in a sling with the arm in a position of adduction and internal rotation. However, recent basic science and clinical data have suggested recurrent instability may be reduced with immobilization in external rotation after primary shoulder dislocation. We performed a randomized controlled trial to compare the (1) frequency of recurrent instability and (2) disease-specific quality-of-life scores after treatment of first-time shoulder dislocation using either immobilization in external rotation or immobilization in internal rotation in a group of young patients. Sixty patients younger than 35 years of age with primary, traumatic, anterior shoulder dislocations were randomized (concealed, computer-generated) to immobilization with either an internal rotation sling (n = 29) or an external rotation brace (n = 31) at a mean of 4 days after closed reduction (range, 1-7 days). Patients with large bony lesions or polytrauma were excluded. The two groups were similar at baseline. Both groups were immobilized for 4 weeks with identical therapy protocols thereafter. Blinded assessments were completed by independent observers for a minimum of 12 months (mean, 25 months; range, 12-43 months). Recurrent instability was defined as a second documented anterior dislocation or multiple episodes of shoulder subluxation severe enough for the patient to request surgical stabilization. Validated disease-specific quality-of-life data (Western Ontario Shoulder Instability index [WOSI], American Shoulder and Elbow Surgeons evaluation [ASES]) were also collected. Ten patients (17%, five from each group) were lost to followup. Reported compliance with immobilization in both groups was excellent (80%). With the numbers available, there was no difference in the rate of recurrent instability between groups: 10 of 27 patients (37%) with the external rotation brace versus 10 of 25 patients (40%) with the sling redislocated or developed symptomatic recurrent instability (p = 0.41). WOSI scores were not different between groups (p = 0.74) and, although the difference in ASES scores approached statistical significance (p = 0.05), the magnitude of this difference was small and of uncertain clinical importance. Despite previous published findings, our results show immobilization in external rotation did not confer a significant benefit versus sling immobilization in the prevention of recurrent instability after primary anterior shoulder dislocation. Further studies with larger numbers may elucidate whether functional outcomes, compliance, or comfort with immobilization can be improved with this device. Level I, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.

Imaging in Anterior Glenohumeral Instability

In the shoulder, the advantages of range of motion are traded for the disadvantages of vulnerability to injury and the development of instability. Glenohumeral instability encompasses a broad spectrum of clinical complaints and presentations. The diagnosis can be obvious or entirely unsuspected. Imaging findings depend on numerous factors and range from gross osseous defects to equivocal labral abnormalities and undetectable capsular lesions. This review focuses on the imaging findings in three distinct clinical scenarios: acute first-time shoulder dislocation, chronic instability with repeated dislocation, and chronic instability without repeated dislocation. The biomechanics of dislocation and the pathophysiology of labral-ligamentous injury are discussed. The authors distinguish the findings that occur in the acutely traumatized shoulder from those that typify the chronic unstable joint. The roles of different imaging modalities are also distinguished, including magnetic resonance arthrography and the value of specialized imaging positions. The goal of imaging depends on the clinical scenario. Image interpretation and reporting may need to emphasize diagnosis and the identification of lesions that are associated with instability or the characterization of lesions for treatment planning.

Imaging in Anterior Glenohumeral Instability

In the shoulder, the advantages of range of motion are traded for the disadvantages of vulnerability to injury and the development of instability. Glenohumeral instability encompasses a broad spectrum of clinical complaints and presentations. The diagnosis can be obvious or entirely unsuspected. Imaging findings depend on nu merous factors and range from gross osseous defects to equivocal labral abnormalities and undetectable capsular lesions. This review focuses on the imaging findings in three distinct clinical scenarios: acute first-time shoulder dislocation, chronic instability with repeated dislocation, and chronic instability without repeated dislocation. The biomechanics of dislocation and the pathophysiology of labral-ligamentous injury are discussed. The authors distinguish the findings that occur in the acutely trauma tized shoulder from those that typify the chronic unstable joint. The roles of different imaging modalities are also distinguished, including magnetic resonance arthrography and the value of specialized imaging positions. The goal of imaging depends on the clinical scenario. Image interpretation and reporting may need to emphasize diagnosis and the identification of lesions that are associated with instability or the characterization of lesions for treatment planning. q RSNA, 2013

The interobserver reliability in diagnosing osseous lesions after first-time anterior shoulder dislocation comparing plain radiographs with computed tomography scans

Recurrence after first-time traumatic anterior shoulder dislocation is frequent. The prevalence of glenoid bone loss ranges from 41% after a first-time dislocation to 86% with recurrent dislocation. Postoperative recurrence can occur in up to 10% of cases. Thus, misdiagnosis of bony glenoid rim lesions has been assumed a major cause for failure. We evaluated the interobserver reliability of radiologic diagnoses after first-time traumatic shoulder dislocation based on radiographs and computed tomography (CT) images. Digital radiographs before and after reduction and CT images after reduction of 20 patients with a first-time shoulder dislocation were assessed by 6 observers. It was recorded whether they diagnosed a lesion at the greater tuberosity, a lesion at the glenoid rim, a Hill-Sachs lesion, or any other skeletal pathology. The average agreement among the investigators was evaluated, and radiographic diagnoses were compared with those based on CT images. Of the 10 cases that presented with a glenoid rim fracture, each investigator had overlooked at least 1 fracture (range, 1-4) on the radiographs. No investigator had diagnosed all 8 Hill-Sachs lesions on the presented images. The average overall agreement among the investigators and corresponding sensitivity and specificity were calculated. Agreement of diagnoses based on radiographs with those based on CT images was lowest for glenoid rim fractures and Hill-Sachs lesions. Radiographs seem inferior to CT scans for assessing osseous lesions especially at the glenoid rim. We suggest performing a CT scan of the shoulder after primary dislocation to apply the correct treatment early and potentially avoid further dislocations.

Immobilizing performances, comfort, and user-friendliness of the shoulder abduction-external rotation braces

Background.Shoulder external rotation braces used for patients with a first-time shoulder dislocation are designed with a variety of arm positions in abduction as well as external rotation. However, few studies have focused on their immobilizing performance, comfort, or user-friendliness. Especially, there have been no robust data of shoulder abduction-external rotation (A-ER) braces in comparison to those of external rotation (ER) braces.Methods.Four types of commercially available shoulder braces (two ER and two A-ER braces) were tested in 30 healthy participants. The angles of external rotation and abduction were measured for each brace at initial application, after simulated daily activities, and after reapplication. Then, subjects were asked to assess the discomfort of bracing and difficulty of reapplication using a visual analogue scale. Data were compared between the two ER braces and two A-ER braces as well as among the four braces.Results. For both external rotation angle and subjective assessment, there were no significant differences between the ER and A-ER braces. Among the four braces, the measurement of arm position demonstrated no significant differences, except the external rotation angles between the two ER braces. The A-ER braces were assessed to be significantly less comfortable than the ER braces in the subjective assessment.Conclusions. Immobilization using the A-ER braces could maintain the arm position in abduction-external rotation with comparable user-friendliness, although they tended to be less comfortable during daily activities compared to the ER braces.

Effectiveness of External-Rotation Immobilization After Initial Shoulder Dislocation in Reducing Recurrence Rates

Initial, traumatic shoulder dislocations, particularly in an anterior direction, are among the most common shoulder injuries. Traditionally, nonsurgical treatment for first-time shoulder dislocations consists of immobilization in internal rotation (IR). However, there is a high rate of recurrence after this course of treatment. Recent reports indicate that immobilization in external rotation (ER) instead of IR may more effectively reduce recurrence rates, resulting in a viable nonsurgical treatment option for patients sustaining an initial shoulder dislocation.

What is the current practice in Europe when difficult shoulder injuries are treated?

In this issue of the journal, a group of Italian researchers discusses the European orthopedic surgeon’s management of choice for several difficult clinical scenarios of shoulder pathologies [1]. They divided their survey into four scenarios; i.e., anterior shoulder dislocation, shoulder arthritis combined with rotator cuff tear, large rotator cuff tendon tears combined with major fatty infiltration of the infraspinatus muscle and instability of the long head of the biceps and finally adhesive capsulitis. It might be claimed that at least three out of four are difficult cases. Therefore, the answers are of great interest. The authors used an online Web-based questionnaire and it is obvious that a questionnaire of this kind has the potential to improve our knowledge about the current trends in modern technology and ultimately might be helpful in creating clinical guidelines on a large scale. The first scenario was related to anterior dislocation of the shoulder. Interestingly, more than 70 % of the orthopedic surgeons recommended arthroscopic Bankart reconstruction, approximately half as an acute procedure and the rest as a planned procedure. This is the case description: ‘‘21-year-old male, recreational soccer player, first-time shoulder dislocation, with a minimal Hill-Sachs lesion, and a Bankart lesion’’… Less than 30 % of the surgeons recommended non-surgical treatment, which is of interest. The question is whether we really know that an acute/ semi-acute surgical procedure is the correct way to approach this particular—and in fact very common— problem. There might be arguments for instance for a more conservative approach. Also interesting is the recommendation for a brace in internal or external rotation in almost 75 %. The second scenario is a 55-year-old female with painful shoulder arthritis, total supraspinatus tear and infraspinatus fatty infiltration. In this case, the majority of surgeons (more than 60 %) recommended surgical treatment, while less than 40 % would favor a conservative regimen. Supraspinatus tendon repair/reconstruction was recommended by 85 % of all surgeons, with or without biceps tenodesis/tenotomy. The question is whether we really know if biceps tenodesis/tenotomy is needed in a case like this? Again, the dominance of surgical approach is of great interest. Only few surgeons recommended either debridement or shoulder replacement (15 %) in this patient. The third scenario is a 65-year-old male manual worker,

Anatomic Bankart Repair Compared With Nonoperative Treatment and/or Arthroscopic Lavage for First-Time Traumatic Shoulder Dislocation

The objective of this systematic review was to determine the efficacy of anatomic Bankart repair in patients with a first-time shoulder dislocation compared with either arthroscopic lavage or traditional sling immobilization. We searched the Cochrane Central Register of Controlled Trials, Medline, Embase, CINAHL, Web of Science, LILACS, and a clinical trials registry for ongoing and completed randomized or quasi-randomized controlled trials comparing anatomic Bankart repair with either rehabilitation or arthroscopic lavage. Two reviewers selected studies for inclusion, assessed methodologic quality, and extracted data. Pooled analyses were performed by use of a random-effects model, and risk ratio (RR) and 95% confidence intervals (CIs) were computed. We included 3 randomized trials and 1 quasi-randomized trial comprising 228 patients. Of the included trials, 2 compared anatomic Bankart repair with sling immobilization whereas 2 compared Bankart repair with arthroscopic lavage. A meta-analysis of all 4 trials showed that the rate of recurrent instability was significantly lower among participants undergoing anatomic Bankart repair compared with those undergoing either immobilization or arthroscopic lavage (RR, 0.18; 95% CI, 0.10 to 0.33). Subgroup analysis showed that this effect persisted when Bankart repair was compared with arthroscopic lavage alone (2 studies) (RR, 0.14; 95% CI, 0.06 to 0.31) or sling immobilization alone (2 studies) (RR, 0.26; 95% CI, 0.10 to 0.67). Western Ontario Shoulder Instability scores were better with anatomic Bankart repair compared with either arthroscopic lavage or immobilization (2 studies) (mean difference, -232; 95% CI, -317 to -146). There is evidence to suggest treatment of young patients with a first-time shoulder dislocation with anatomic Bankart repair with the goal of lowering the rate of recurrent instability over the long-term and improving short-term quality of life. Level II, systematic review of Level I and II studies.

Acute first-time shoulder dislocation

Abstract The shoulder is the most frequently dislocated joint in the human body, anterior dislocation being the most common variant. For stability, the glenohumeral joint relies on both static and dynamic restraints and dislocation often results in damage to these restraints. For example, antero-inferior capsulolabral complex damage often occurs as a result of anterior dislocations (a ‘Bankart lesion') and impaction of the dislocated humeral head against the rim of the antero-inferior glenoid can result in a postero-lateral humeral head defect (the ‘Hill–Sachs lesion'). Prompt reduction of the dislocation is necessary to relieve pain and reduce the risk of complications, and should be performed as soon as possible in the emergency department, or in the operating theatre in cases with an associated shoulder fracture. Subsequent treatment of the dislocation is aimed at restoring function of the shoulder and minimizing the risk of recurrent instability. Non-surgical treatment is the conventional method of management after a successful closed reduction and involves immobilization of the affected shoulder for between 3 and 6 weeks coupled with, or followed by, physiotherapy. Young age at the time of the first anterior dislocation is associated with a high rate of recurrence and there is growing evidence that primary arthroscopic stabilization significantly reduces the rate of recurrent instability. This article outlines the current management strategies for dealing with this acute traumatic injury.