Immobilization In Internal Rotation Research Articles

Immobilization in External Rotation Versus Arthroscopic Stabilization After Primary Anterior Shoulder Dislocation: A Systematic Review of Level 1 and 2 Studies

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.

Long-Term Effects of Immobilization in External Rotation after First-time Dislocation of the Shoulder: An 18-Year Follow-Up

Immobilization in external rotation after a first-time shoulder dislocation has been introduced to reduce the risk of recurrence compared to immobilization in internal rotation; however, its long-term effects remain unknown. This study aimed to determine the long-term effect of immobilization in external rotation after a first-time shoulder dislocation.

Long-term effect of immobilization in external rotation after first-time shoulder dislocation: an average 18-year follow-up.

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. 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. 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. Immobilization in ER reduced the risk of surgical intervention compared with IR in the long term.

Mid- to long-term results of postoperative immobilization in internal vs. external rotation after arthroscopic anterior shoulder stabilization.

BackgroundThere is still a disagreement on the postoperative rehabilitation concerning position of immobilization of the shoulder after arthroscopic anterior shoulder stabilization and its influence on the clinical outcome. The aim of this study was to evaluate the clinical results and the recurrence rate after arthroscopic anteroinferior shoulder stabilization and postoperative immobilization in internal rotation vs. external rotation.MethodsTwenty-five patients (22 male and 3 female, mean age 28.5 years) were included in this prospective nonrandomized cohort study. In group I (11 male, 2 female, mean age 28 years), the postoperative functional immobilization was carried out in internal rotation of 60°, and in group II (11 male, 1 female, mean age 30 years), 15° of external rotation of the arm for 4 weeks in both groups. The clinical follow-up was performed at 2, 4, and 6 weeks as well as at 3, 6, and 12 months postoperatively including assessment of range of motion and functional shoulder scores (Subjective Shoulder Value, Constant score, Rowe score, Walch Duplay score, Melbourne Instability Shoulder Score). Furthermore, shoulder instability was evaluated using the apprehension, relocation, and surprise tests. Mid-term follow-up data were additionally assessed after a minimum of 4 years.ResultsTwenty patients (19 male and 1 female) with an average age of 28 years were followed up for 62 (53-72) months after arthroscopic stabilization. The comparison of both groups showed almost equal results regarding the range of motion without any significant differences (P > .05). The evaluation of the shoulder function scores also showed no significant differences with an average Subjective Shoulder Value of 95% vs. 91%, Constant score of 89 vs. 88 points, Rowe score of 96 vs. 94 points, Walch Duplay score of 86 vs. 89 points, Melbourne Instability Shoulder Score of 96 points, and Western Ontario Shoulder Instability Index of 88% vs. 84% (P > .05). There was no recurrent dislocation in both groups.ConclusionThe type of immobilization after arthroscopic shoulder stabilization does not influence the clinical results after a mid- to long-term follow-up.

Conservative management following closed reduction of traumatic anterior dislocation of the shoulder.

Conservative management following closed reduction of traumatic anterior dislocation of the shoulder.

Immobilization in external rotation after primary shoulder dislocation reduces the risk of recurrence in young patients. A randomized controlled trial

IntroductionPatients that sustain anterior shoulder dislocation frequently experience recurrence. Immobilisation in external rotation has been proposed as a treatment that could lower this risk. HypothesisThere is a difference in recurrence rates between immobilization in internal or external rotation following a first-time anterior shoulder dislocation. Patients and methodsSingle-center randomized controlled trial. Fifty patients with a first episode of traumatic anterior dislocation were randomly assigned to immobilization in internal rotation (IR; 25 patients) or external rotation (ER; 25 patients) for three weeks. Clinical follow-up: 24 months. Additionally, some patients underwent a magnetic resonance imaging with intra-articular contrast (MR arthrography) within seven days after trauma, and then at three months. Primary outcome: recurrence of dislocation. Secondary outcome: healing rate of labral lesions on MR arthrography. ResultsFollow-up rate in the IR and ER group was 92% and 96% respectively. Recurrence rate did not show a statistically significant difference overall (IR 47.8% vs. ER 29.2%; p=0.188), but showed a significant difference favouring ER in the 20–40 years subgroup (IR 50% vs. ER 6.4%; p=0.044). Labral lesions’ healing rate was 46.2% vs. 60% (IR vs ER; p=0.680). The recurrence rate among those with healed vs. non-healed labrum (regardless of immobilization) was 11.1% vs. 77.7% (p=0.001). DiscussionThis study suggests that immobilization in ER compared to IR reduces the risk of recurrence after a first-time anterior shoulder dislocation in patients aged between 20 and 40 years. Level of evidenceII, low-powered prospective randomized trial.

First-time anterior shoulder dislocation natural history and epidemiology: immobilization versus early surgical repair

Traumatic anterior shoulder dislocations are a common problem. There is a high rate of recurrent instability, especially in patients <30 years of age that are involved in high level sports. The purpose of this review is to discuss the natural history after a first-time shoulder dislocation and provide a brief overview of management options. Initial nonoperative management consists of immobilization in internal rotation for 1–3 weeks. The current evidence does not support immobilization in external rotation or for longer periods of time. For those patients who are at a high risk of recurrent instability, the evidence suggests that early surgical repair to address the pathology can be undertaken. This has shown to be clinically and fiscally effective while improving patient outcomes.

Position of Immobilization After First-Time Traumatic Anterior Glenohumeral Dislocation: A Literature Review.

Anterior glenohumeral dislocation affects about 2% of the general population during the lifetime. The incidence of traumatic glenohumeral dislocation ranges from 8.2 to 26.69 per 100 000 population per year. The most common complication is recurrent dislocation occurring in 17–96% of the patients. The majority of patients are treated conservatively by closed reduction and immobilization in internal rotation for 2–3 weeks. However, no clear conservative treatment protocol exists. Immobilization in external rotation can be considered an alternative. A range of external rotation braces are commercially available.The purpose of this work was to review the current literature on conservative management of glenohumeral dislocation and to compare the results of immobilization in internal and external rotation.A comprehensive literature search and review was performed using the keywords “glenohumeral dislocation”, “shoulder dislocation”, “immobilization”, “external rotation”, and “recurrent dislocation” in PubMed, MEDLINE, Cochrane Library, Scopus, and Google Scholar databases from their inceptions to May 2016.Three cadaveric studies, 6 imaging studies, 10 clinical studies, and 4 meta-analyses were identified. The total number of 734 patients were included in the clinical studies.Literature analysis revealed better coaptation of the labrum on the glenoid rim in external rotation in cadaveric and imaging studies. However, this tendency was not confirmed by lower redislocation rates or better quality of life in clinical studies.On the basis of the available literature, we cannot confirm the superiority of immobilization in external rotation after glenohumeral dislocation when compared to internal rotation. A yet-to-be-determined group of patients with specific labroligamentous injury pattern may benefit from immobilization in external rotation. Further studies are needed to identify these patients.

Immobilization in External Rotation Versus Internal Rotation After Primary Anterior Shoulder Dislocation

Background: The recurrence rate after primary anterior shoulder dislocation is high, especially in young, active individuals. Recent studies have suggested external rotation immobilization as a method to reduce the rate of recurrent shoulder dislocation in comparison to traditional sling immobilization. Purpose: To assess and summarize evidence from randomized controlled trials on the effect of internal rotation versus external rotation immobilization on the rate of recurrence after primary anterior shoulder dislocation. Study Design: Meta-analysis. Methods: PubMed, MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials, and abstracts from recent proceedings were searched for eligible studies. Two reviewers selected studies for inclusion, assessed methodological quality, and extracted data. Results: Six randomized controlled trials (632 patients) were included in this review. Demographic and prognostic variables measured at baseline were similar in the pooled groups. The average age was 30.1 years in the pooled external rotation group and 30.3 years in the pooled internal rotation group. Two studies found that external rotation immobilization reduced the rate of recurrence after initial anterior shoulder dislocation compared with conventional internal rotation immobilization, whereas 4 studies failed to find a significant difference between the 2 groups. This meta-analysis suggested no overall significant difference in the rate of recurrence among patients treated with internal rotation versus external rotation immobilization (risk ratio, 0.69; 95% CI, 0.42-1.14; P = .15). There was no significant difference in the rate of compliance between internal and external rotation immobilization (P = .43). The Western Ontario Shoulder Instability Index scores were pooled across 3 studies, and there was no significant difference between the 2 groups (P = .54). Conclusion: Immobilization in external rotation is not significantly more effective in reducing the recurrence rate after primary anterior shoulder dislocation than immobilization in internal rotation. Additionally, this review suggests that there is minimal difference in patients’ perceptions of their health-related quality of life after immobilization in internal versus external rotation.

Posterior Shoulder Instability with a Reverse Hill-Sachs Defect: Repair with Use of Combined Arthroscopic Labral Repair and Fracture Disimpaction: A Case Report.

Acute traumatic posterior glenohumeral dislocations are rare; they are typically caused by high-velocity trauma, epileptic seizures, or electrocution1,2. Anterior impression fractures of the humeral head (reverse Hill-Sachs defect) occur in over 80% of individuals following a posterior dislocation of the shoulder3. The size of reverse Hill-Sachs defects varies and has been reported to be as large as 55% of the cartilage surface4. Defects affecting less than 10% of the articular surface can be treated conservatively with closed reduction, and immobilization may produce excellent stability with a low risk for redislocation1. However, traditional sling immobilization in internal rotation puts the shoulder at risk to redislocate. Therefore, surgical treatment is recommended in defects that affect between 10% and 20% of the articular surface; they can be treated either with an arthroscopic approach, open remplissage, bone-grafting, or prosthetic replacement5. Compared with traditional posterior Hill-Sachs defects that occur with anterior dislocations, the extent of osseous and cartilaginous destruction of the anterior humeral head is usually more extensive in reverse Hill-Sachs defects6. Therefore, to stabilize the glenohumeral joint and avoid potential progressive cartilage destruction, which may lead to early osteoarthritis, reverse Hill-Sachs defects affecting more than 20% of the articular surface are nearly always treated surgically7. Several techniques have been described, including subscapularis transfer with or without the lesser tuberosity into the humeral head defect, disimpaction and bone-grafting, allograft reconstruction of the humeral articular surface, and arthroplasty8. If the joint becomes unstable, repair of the posterior capsulolabral structures can be performed to restore stability, as described for treatment of symptomatic posterior subluxation9,10. Large defects of greater than 40% of the articular surface typically require initial arthroplasty because of the increased risk of osteoarthritis, …

Arthroscopic Versus Conservative Treatment of First Anterior Dislocation of the Shoulder in Adolescents

Conservative treatment of posttraumatic antero-inferior shoulder instability leads to a high failure rate in a young and active population. However, treatment in an adolescent age group is not well documented. We conducted a prospective study with adolescent patients (age 15 to 18 y) who suffered a first traumatic anterior dislocation of the shoulder. Two groups of patients were formed. The first group was treated with early arthroscopic stabilization and the second was treated conservatively. There were 43 shoulders in the operative group and 29 shoulders in the conservative group. The rehabilitation protocol was the same for both groups. All patients were followed up prospectively after 12, 24, and 36 months using Rowe Score. A total of 38 shoulders in the surgical group and 27 shoulders in the conservative group could be completely evaluated. From the conservative group, 19 patients (70.3%) suffered a recurrence of the instability. From the arthroscopic group, 5 patients (13.1%) suffered a recurrence of the instability. In an adolescent population (15 to 18 y), conservative treatment after first traumatic shoulder dislocation including immobilization in internal rotation leads to a significantly higher and unacceptable high failure rate compared with early arthroscopic stabilization. Level II-prospective comparative study.

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.

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.

Immobilization in External Rotation After Primary Shoulder Dislocation Did Not Reduce the Risk of Recurrence

The treatment of primary traumatic anterior shoulder dislocation varies widely from no immobilization, to two or three weeks of immobilization in internal rotation with the arm in a sling, to treatment with a brace in external rotation. The aim of the present clinical trial was to compare immobilization in internal and external rotation after anterior shoulder dislocation. One hundred and eighty-eight patients with a primary anterior traumatic dislocation of the shoulder were randomly assigned to treatment with immobilization in either internal rotation (ninety-five patients) or external rotation (ninety-three patients) for three weeks. The primary outcome measure was a recurrent dislocation within twenty-four months of follow-up. The follow-up rate after a minimum period of two years was 97.9% (ninety-three of ninety-five) in the internal rotation group and 97.8% (ninety-one of ninety-three) in the external rotation group. The compliance rate with the immobilization was 47.4% (forty-five of ninety-five) in the internal rotation group and 67.7% (sixty-three of ninety-three) in the external rotation group. The intention-to-treat analyses showed that the recurrence rate was 24.7% (twenty-three of ninety-three) in the internal rotation group and 30.8% (twenty-eight of ninety-one) in the external rotation group (p = 0.36). Immobilization in external rotation does not reduce the rate of recurrence for patients with first-time traumatic anterior shoulder dislocation.

Position and Duration of Immobilization After Primary Anterior Shoulder Dislocation

Immobilization after closed reduction has long been the standard treatment for primary anterior dislocation of the shoulder. To determine the optimum duration and position of immobilization to prevent recurrent dislocation, a systematic review of the relevant literature was conducted. Of 2083 published studies that were identified by means of a literature review, nine Level-I and Level-II studies were systematically reviewed. The outcome of interest was recurrent dislocation. Additional calculations were performed by pooling data to identify the ideal length and position (external or internal rotation) of immobilization. Six studies (including five Level-I studies and one Level-II study) evaluated the use of immobilization in internal rotation for varying lengths of time. Pooled data analysis of patients younger than thirty years old demonstrated that the rate of recurrent instability was 41% (forty of ninety-seven) in patients who had been immobilized for one week or less and 37% (thirty-four of ninety-three) in patients who had been immobilized for three weeks or longer (p = 0.52). An age of less than thirty years at the time of the index dislocation was significantly predictive of recurrence in most studies. Three studies (including one Level-I and two Level-II studies) compared recurrence rates with immobilization in external and internal rotation. Analysis of the pooled data demonstrated that the rate of recurrence was 40% (twenty-five of sixty-three) for patients managed with conventional sling immobilization in internal rotation and 25% (twenty-two of eighty-eight) for those managed with bracing in external rotation (p = 0.07). Analysis of the best available evidence indicates there is no benefit of conventional sling immobilization for longer than one week for the treatment of primary anterior shoulder dislocation in younger patients. An age of less than thirty years at the time of injury is significantly predictive of recurrence. Bracing in external rotation may provide a clinically important benefit over traditional sling immobilization, but the difference in recurrence rates did not achieve significance with the numbers available.

Bracing in external rotation for traumatic anterior dislocation of the shoulder

We undertook a prospective study in 51 male patients aged between 17 and 27 years to ascertain whether immobilisation after primary traumatic anterior dislocation of the shoulder in external rotation was more effective than immobilisation in internal rotation in preventing recurrent dislocation in a physically active population. Of the 51 patients, 24 were randomised to be treated by a traditional brace in internal rotation and 27 were immobilised in external rotation of 15 degrees to 20 degrees. After immobilisation, the patients undertook a standard regime of physiotherapy and were then assessed clinically for evidence of instability. When reviewed at a mean of 33.4 months (24 to 48) ten from the external rotation group (37%) and ten from the internal rotation group (41.7%) had sustained a further dislocation. There was no statistically significant difference (p = 0.74) between the groups. Our findings show that external rotation bracing may not be as effective as previously reported in preventing recurrent anterior dislocation of the shoulder.

Upright™ MRI of the Shoulder Demonstrates Labrum Dynamics

Conservative treatment of anterior shoulder luxation includes immobilization in internal rotation. This has been increasingly debated, but imaging techniques in supine position do not reflect the influence of gravity. To examine glenoid labrum dynamics, the shoulders of 15 healthy subjects were imaged in standing position at different (0, 15, 30) degrees of external rotation using the Upright MRI. The functional length of the anterior labrum was measured. Due to an increasing tension of the anterior capsule, functional labrum length increased the more, the more the humerus was externally rotated. The results underline the usefulness of the Upright MRI and support the concept of immobilization in the position of external rotation.

Über die Funktion der passiven Stabilisatoren des glenohumeralen Gelenkes - Eine Biomechanische Untersuchung

In a biomechanical study we evaluated the passive stabilizing ligaments of 9 fresh shoulder specimens with mercury bands. While preparing the specimens we found two interesting entities: there are fibers of the coracohumeral ligament running from the humeral head to the coracoacromial ligament and there was an reproducible thickening in the posterior joint capsule. Functional evaluation shows that the coracohumeral ligament limits external rotation independently of the amount of abduction as well as inferior subluxation. The mediale glenohumeral ligament shows the highest tension in external rotation and 30 degrees abduction. The anterior inferior ligament strengthens the joint capsule in abduction and external rotation. The posterior inferior ligament shows the highest tension in abduction and internal rotation. Immobilization in internal rotation and adduction may lead to shortening of the coracohumeral ligament, which may result in severe limitation of external rotation and abduction. Resection of the coracoacromial ligament relaxes the coracohumeral ligament leading to an increased cranio-caudal instability. The posterior inferior ligament is complementary to the anterior inferior ligament thus stabilizing the shoulder joint in abduction and internal rotation. Sparing this structure in arthroscopy with dorsal portals and restoring in the case of a rupture seems to be of value for a normal joint function.

Immobilization in External Rotation After Shoulder Dislocation Reduces the Risk of Recurrence

An initial anterior dislocation of the shoulder becomes recurrent in 66% to 94% of young patients after immobilization of the shoulder in internal rotation. Magnetic resonance imaging and studies of cadavera have shown that coaptation of the Bankart lesion is better with the arm in external rotation than it is with the arm in internal rotation. Our aim was to determine the benefit of immobilization in external rotation in a randomized controlled trial. One hundred and ninety-eight patients with an initial anterior dislocation of the shoulder were randomly assigned to be treated with immobilization in either internal rotation (ninety-four shoulders) or external rotation (104 shoulders) for three weeks. The primary outcome measure was a recurrent dislocation or subluxation. The minimum follow-up period was two years. The follow-up rate was seventy-four (79%) of ninety-four in the internal rotation group and eighty-five (82%) of 104 in the external rotation group. The compliance rate was thirty-nine (53%) of seventy-four in the internal rotation group and sixty-one (72%) of eighty-five in the external rotation group (p = 0.013). The intention-to-treat analysis revealed that the recurrence rate in the external rotation group (twenty-two of eighty-five; 26%) was significantly lower than that in the internal rotation group (thirty-one of seventy-four; 42%) (p = 0.033) with a relative risk reduction of 38.2%. In the subgroup of patients who were thirty years of age or younger, the relative risk reduction was 46.1%. Immobilization in external rotation after an initial shoulder dislocation reduces the risk of recurrence compared with that associated with the conventional method of immobilization in internal rotation. This treatment method appears to be particularly beneficial for patients who are thirty years of age or younger.

Survey Of The Management Of Acute Traumatic Unilateral First-Time Anterior Shoulder Dislocation (AFSD) Among Orthopaedic Surgeons In USA

Aim: To identify the current trend in managing acute traumatic first-time anterior shoulder dislocation (AFSD) among orthopaedic surgeons in USA and to draw comparisons with previous UK study1. Design: Postal Questionnaire among Orthopaedic Surgeons in Northern America. Method: 200 questionnaires were sent out to a random list of active members of The American Orthopaedic Society for Sports Medicine (AOSSM) throughout USA. Questions were laid out in two 'workgroups'. Basic demographic data such as type of practice and surgical specialisation were recorded. In 'Workgroup One' questions regarding method and duration of immobilisation were analysed. In 'Workgroup Two', two case scenarios stratified by age, were analysed to look into the 'postreduction' management, focusing on trend in technique of stabilisation employed. Results: The response rate was 55% (109 of 200). 26 percent of respondents derived from academic practices and the remaining 74% of respondents were from privatised institution. Majority of the respondents were regarded as 'surgeons with special interest in sports medicine' (87 of 109, 80%). This was followed by 'shoulder and elbow surgeons' and 'general orthopaedic surgeons' (12% and 8% respectively). The most popular choice of immobilisation was internal rotation (72.5%). However, 24.8% of respondents preferred the external rotation method for immobilisation as advocated by Itoi et al. The mean duration of immobilisation was 2.5 weeks (1/2 weeks to 8 weeks, Std Deviations 1.2weeks). 42.2% (46 of 109) of respondents would perform an immediate arthroscopic stabilisation in young, fit patients presenting with this type of injury. On the other hand, an overwhelming majority of the respondent opted for non-operative management in older patient presented with this problem (98%). The current trend of management in the young, active age group comprised of arthroscopic stabilisation using suture anchors, followed by immobilisation in internal rotation for average 3-4 weeks and return to sports/work at average 5 months post-surgery. Conclusion: This survey revealed variations among orthopaedic surgeons in managing AFSD on the 'front-line' within USA. There are also observational differences between the findings of this and the UK study previously published. There is a need to address the issue of immobilisation technique. Majority of surgeons used age as a criterion in determining definitive management for this injury. The current trend in managing AFSD in young and active patient who presented with AFSD is arthroscopic stabilisation using suture anchors.