Primary Anterior Dislocation 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.

Outcome of Immobilization in External Rotation Position after Closed Reduction in Traumatic Anterior Shoulder Dislocation

Background: As documented in many studies, anterior shoulder dislocation can be effectively immobilized in both external and internal rotation positions, with favorable outcomes. However, controversy exists about the superiority of the technique of immobilization to achieve the reduced rate of redislocation. We conducted this study to assess the functional outcome of immobilization of shoulder in external rotation position after relocation in patients with acute anterior shoulder dislocation.&#x0D; Methods: This is hospital based cross-sectional study in total of 36 patients of primary anterior dislocation of shoulder. They were managed with closed reduction and immobilization in external rotation position and followed up for up to twelve months. Functional outcome (including re-dislocation rate) during each follow-up visit was assessed by using ROWE Score.&#x0D; Results: The mean age of the participants was 29.6±7.9 years (range: 17-44 years). Of them, 89.9% were male; and 55.6% were involved in risky jobs. Similarly, 50% of them sustained injury due to slip and fall, 72.2% presented to the hospital within 12 hours; and 69.4% had their right side involved. All the patients were compliant with treatment regime; 77.8% tolerated the brace well and the redislocation rate was 8.3%. ROWE score was found to be significantly increased between subsequent follow-up visits (p&lt;0.05), except between six months and 12 months (p&gt;0.05). Overall, ROWE score varied significantly across the total follow-up period (p&lt;0.05).&#x0D; Conclusions: Immobilization in external rotation position in traumatic anterior shoulder dislocation was a simple and easy method of conservative treatment with good patient compliance, less incidence of re-dislocation and good functional outcome.

Arthroscopic Bankart repair versus conservative treatment after primary anterior glenohumeral dislocation in patients under 25 years of age: A prospective randomized study

Background:Conservative treatment after primary anterior shoulder dislocation (ASD) is associated with a high recurrence rate in young patients. The main objective was to compare primary arthroscopic Bankart repair and conservative treatment 2 years after primary ASD in patients less than 25 years old.Methods:A prospective randomized study was conducted in patients between 18 to 25 years old after primary ASD. The first group had arthroscopic Bankart repair within 15 days and the second group was treated conservatively. Patients in both groups were immobilized in internal rotation for 3 weeks and followed the same rehabilitation protocol. Patients were clinically monitored in 3, 6, 12 and 24 months. The main outcome criterion was recurrent dislocation, subluxation or apprehension when the arm was placed in 90° abduction and external rotation. Secondary outcome criteria were functional scores (Quick-DASH, Walch-Duplay, WOSI), joint mobility and resumption of sports.Results:40 patients were included (20 in the surgical group and 20 conservative group). The average age was 21 +/- 1.8 years with 33 men (82.5%) and 7 women (17.5%). Patients in the surgical group underwent surgery within an average of 4.3 +/- 2.4 days. In the surgical group, instability at 2 years was significantly less than in the conservative group (2 (10%) compared to 14 (70%); p=0.0001). Fewer patients had a recurrence (0 versus 6 (30%)), subluxation (2 (10%) versus 13 (65%); p=0.003), and apprehension (1 (5%) versus 11 (58%); p=0.0005). The Quick-DASH (6.5 versus 11.2 points), Walch-Duplay (88.4 versus 70.3 points; p=0.007) and WOSI (11.5 versus 17.7 points; p=0.035) functional scores were better in the surgical group at 2 years. 95% had resumed sport in the surgical group compared to 68% in conservative group. No per- or postoperative complications were reported. There was no significant difference in joint mobility.Conclusion:After primary ASD in young patients, arthroscopic Bankart repair decreased recurrent instability at 2 years and provided better functional recovery than conservative treatment.

Primary Arthroscopic Stabilization for a First-Time Anterior Dislocation of the Shoulder: Long-Term Follow-up of a Randomized, Double-Blinded Trial.

The aim of this study was to evaluate the long-term efficacy of arthroscopic Bankart repair (ABR). 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. 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. 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. Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Contraindications and complications of the Latarjet procedure.

The Latarjet procedure is a well-known, safe and reliable technique to treat primary or recurrent anterior dislocations or subluxations, with or without hyperlaxity, with or without glenoid bone loss. Both the open and the arthroscopic methods produce excellent clinical results, with a low rate of recurrent instability. There have been concerns of a higher surgical complication rate associated with this procedure, however, large reviews reported an overall complication rate in the open Latarjet procedure of 15%. Meticulous surgical technique and a good understanding of the local anatomy can help to avoid the complications but postoperative shoulder arthritis and frequent bone block osteolysis remain unsolved additional challenges, which require further research. There are 2 main factors to further improve the clinical outcome and patient satisfaction: careful patient selection with good surgical indication, and reducing complications with adequate surgical techniques. The aim of this study is to provide the current overview of the contraindications and complications of the Latarjet procedure.

Primary anterior dislocation of the shoulder: long-term prognosis at the age of 40 years or younger

We describe the long-term prognosis in 257 first-time anterior shoulder dislocations (255 patients, aged 12-40 years) registered at 27 Swedish emergency units between 1978 and 1979. Half the shoulders were immobilised for 3-4 weeks after repositioning. Follow-ups were performed after two (questionnaire), five (questionnaire), 10 (questionnaire and radiology) and 25 (questionnaire and radiology) years in 227 patients (229 shoulders). Twenty-eight patients died during the 25 years of observation. Early movement or immobilisation after the primary dislocation resulted in the same long-term prognosis. Recurrences increased up to 10 years of follow-up, but, after 25 years, 29 % of the shoulders with ≥2 recurrences appeared to have stabilised over time. Arthropathy increased from 9 % moderate to severe and 11 % mild at 10 years, to 34 % moderate to severe and 27 % mild after 25 years. Alcoholics had a poorer prognosis with respect to dislocation arthropathy (P < 0.001). Age <25 years and/or bilateral instability represent a poorer prognosis, where stabilising surgery is necessary in every second shoulder. Fracture of the greater tuberosity means a good prognosis, and we have found no evidence that athletic activity, gender, a Hill-Sachs lesion and minor rim fractures had any prognostic impact. During the 25 years in which these patients were followed, 28/255 died (11 %), representing a mortality rate (SMR) that was more than double that of the general Swedish population (P < 0.001). Almost half of all first-time dislocations at the age of <25 years will have stabilising surgery and two-thirds will develop different stages of arthropathy within 25 years.

The Epidemiology of Primary Anterior Shoulder Dislocations in Patients Aged 10-16 Years and Age-Stratified Risk of Recurrence

Objectives:Most clinical studies pertaining to shoulder dislocation use age cutoffs of 16 years, and at present, only small case series of patients aged 10-16 years guide our management. Using a general population cohort aged 10 to 16 years, we sought to: 1) determine the overall and demographic-specific incidence density rate (IDR) of primary anterior shoulder dislocation requiring closed reduction (CR), and 2) determine the rate of and risk factors for repeat shoulder CR.Methods:Using administrative databases, we identified all patients who underwent CR of a primary anterior shoulder dislocation by a physician in Ontario between April 2002 and September 2010 (the index event). Exclusion criteria included age (16 years), posterior dislocation, and prior shoulder dislocation or surgery. The IDR was calculated for the entire cohort and compared by age and sex subgroups. The main outcome, repeat shoulder CR, was sought until September 2012. A time-to-event analysis (cumulative incidence function) was used to determine the incidence of repeat shoulder CR at six-months, one-year, two-years, and five-years for the entire cohort and subgroups based on age (10-12, 13, 14, 15, and 16 years). A competing risk model identified risk factors for repeat shoulder CR, which were reported using hazard ratios (HR) with 95% confidence intervals (CI).Results:We identified 2,066 patients aged 10-16 years who underwent CR following a primary anterior shoulder dislocation, of which, 1,937 met the exclusion criteria. The median age was 15.0 years and 79.7% were male. The IDR was 20.1 per 100,000 person-years, and was highest among 16 year-old males (164.4 per 100,000 person-years). In contrast, primary anterior shoulder dislocation was rare among patients aged 10-12 years [5.9% (N=115) of all primary dislocations]. Repeat shoulder CR was observed in 740 patients (38.2%) after a median of 0.8 years. The overall cumulative incidence of repeat shoulder CR at six-months, one-year, two-years, and five-years was 13.0%, 21.3%, 29.2%, and 36.2%, respectively; however, the cumulative incidence by age (Figure 1) revealed the rate of repeat shoulder CR to be highest among 14-16 year-olds (37.2-42.3%), and considerably less among patients aged 10-13 years (0-25.0%). Male sex (HR 1.2, p=0.04; interpreted as a 20% increased risk for males as compared to females) and patient age (HR 1.2, p<0.001; interpreted as a 20% increased risk for each year over age 10) significantly influenced the risk of a repeat shoulder CR. Overall, 31.2% (N=604) of patients underwent shoulder stabilization, of which, half underwent surgery following the index shoulder CR (49.9%, N=369).Conclusion:Primary anterior shoulder dislocations are common among 14-16 year olds, and the rate of recurrence in this age group following non-operative management mirrors that of 17-20 year olds in previously published data. In contrast, both the incidence of primary anterior dislocation and rate of recurrence are considerably lower for patients aged 10-13 years. Going forward, clinicians should treat and counsel patients aged 14-16 years, particularly males, as they do older adolescents (17-20 years); however, patients 13 years of age or younger should be counselled regarding their low risk for recurrence.

The natural history of primary anterior dislocation of the glenohumeral joint in adolescence.

The natural history of primary anterior dislocation of the glenohumeral joint in adolescent patients remains unclear and there is no consensus for management of these patients. The objectives of this study were to report the natural history of primary anterior dislocation of the glenohumeral joint in adolescent patients and to identify the risk factors for recurrent dislocation. We reviewed prospectively-collected clinical and radiological data on 133 adolescent patients diagnosed with a primary anterior dislocation of the glenohumeral joint who had been managed non-operatively at our hospital between 1996 and 2008. There were 115 male (86.5%) and 18 female patients (13.5%) with a mean age of 16.3 years (13 to 18) and a mean follow-up of 95.2 months (1 to 215). During follow-up, 102 (absolute incidence of 76.7%) patients had a recurrent dislocation. The median interval between primary and recurrent dislocation was ten months (95% CI 7.4 to 12.6). Applying survival analysis the likelihood of having a stable shoulder one year after the initial injury was 59% (95% CI 51.2 to 66.8), 38% (95% CI 30.2 to 45.8%) after two years, 21% (95% CI 13.2 to 28.8) after five years, and 7% (95% CI 1.1 to 12.9) after ten years. Neither age nor gender significantly predicted recurrent dislocation during follow-up. We conclude that adolescent patients with a primary anterior dislocation of the glenohumeral joint have a high rate of recurrent dislocation, which usually occurs within two years of their initial injury: these patients should be considered for early operative stabilisation.

Immobilization in external rotation combined with abduction reduces the risk of recurrence after primary anterior shoulder dislocation

We aimed to compare the effectiveness of immobilization in abduction and external rotation vs immobilization in adduction and internal rotation after primary anterior dislocation of the shoulder. The study randomized 102 patients (age range, 15-55 years) with the diagnosis of primary anterior dislocation of the shoulder to receive immobilization in adduction and internal rotation (AdIR, n = 51) using sling and swathe bandage or immobilization in abduction and external rotation (AbER, n = 51) with a stabilizer brace. Patients received a rehabilitation program 3 weeks after the intervention. After a 24-month follow-up, 33.3% in the AdIR group and 3.9% in the AbER group had recurrence (P < .001). The difference in the recurrence rate was greater in the subgroup aged between 31 and 40 years (44.8% in the AdIR group and 3.8% in the AbER group, P < .001). Ten patients in the AbER group (19.6%) and 3 in the AdIR group (5.8%) discontinued shoulder immobilization before 3 weeks (P = .03). In patients without recurrence, the anterior apprehension test was positive in 6 of 34 in the AdIR group (17.6%) and in 4 of 49 in the AbER group (8.1%, P = .19). Immobilization with the shoulder joint in abduction and external rotation is an effective method to reduce the risk of recurrence after primary anterior shoulder dislocations and should be preferred to the traditional method of immobilization in adduction and internal rotation in clinical practice.

外傷性肩関節前方脱臼(初回例)のMRアルトログラムについて―特に年齢との関係

外傷性肩関節前方脱臼(初回例)のMRアルトログラムについて―特に年齢との関係

Injuries Associated with Traumatic Anterior Glenohumeral Dislocations

A number of shoulder girdle injuries are associated with acute anterior glenohumeral dislocations. In the present study we evaluated the prevalence of neurological deficits, greater tuberosity fractures, and rotator cuff injuries in a population of unselected patients who presented with a traumatic anterior glenohumeral dislocation. A prospective trauma database was used to record the demographic details on 3633 consecutive patients (2250 male patients and 1383 female patients with a mean age of 47.6 years) who had sustained a traumatic anterior glenohumeral dislocation between 1995 and 2009. On the basis of these data, we assessed the prevalence of and risk factors for ultrasound-proven rotator cuff tears, tuberosity fractures, and neurological deficits occurring in association with the dislocation. Of the 3633 patients who had a dislocation, 492 patients (13.5%) had a neurological deficit following reduction and 1215 patients (33.4%) had either a rotator cuff tear or a greater tuberosity fracture. A dislocation with a neurological deficit alone was found in 210 patients (5.8%), a dislocation with a rotator cuff tear or a greater tuberosity fracture was found in 933 patients (25.7%), and a combined injury pattern was found in 282 patients (7.8%). Female patients with an age of sixty years or older who were injured in low-energy falls were more likely to have a rotator cuff tear or a greater tuberosity fracture. The likelihood of a neurological deficit after an anterior glenohumeral dislocation was significantly increased for patients who had a rotator cuff tear or a greater tuberosity fracture (relative risk, 1.9 [95% confidence interval, 1.7 to 2.1]; p < 0.001). The prevalence of rotator cuff tear, greater tuberosity fracture, or neurological deficit following primary anterior glenohumeral dislocation is greater than previously appreciated. These associated injuries may occur alone or in combined patterns. Dislocations associated with axillary nerve palsy have similar demographic features to isolated dislocations. Injuries associated with a rotator cuff tear, greater tuberosity fracture, or complex neurological deficit are more common in patients sixty years of age or older. Careful evaluation of rotator cuff function is required for any patient with a dislocation associated with a neurological deficit, and vice versa.

Regarding: “Operative versus nonoperative treatment after primary traumatic anterior glenohumeral dislocation: expected-value decision analysis”: appropriate assessment of uncertainty

Regarding: “Operative versus nonoperative treatment after primary traumatic anterior glenohumeral dislocation: expected-value decision analysis”: appropriate assessment of uncertainty

Operative versus nonoperative treatment after primary traumatic anterior glenohumeral dislocation: expected-value decision analysis

The optimal management strategy for primary traumatic anterior glenohumeral dislocation remains controversial. Patients have traditionally been managed nonoperatively, but high recurrence rates in certain populations have led to increased interest in early operative stabilization. The purpose of this study was to use expected-value decision analysis to determine the optimal management strategy--nonoperative treatment or arthroscopic stabilization--for a first-time traumatic anterior shoulder dislocation. Probabilities for the occurrences of the potential outcomes after nonoperative and arthroscopic treatment of a first-time traumatic anterior glenohumeral dislocation were determined from a systematic review of the literature. Utilities for these outcomes were obtained from a questionnaire on patient preferences completed by 42 subjects without a history of shoulder injury. A decision tree was constructed, fold-back analysis was performed to determine optimal management, and sensitivity analyses were used to determine the effect on decision making of varying outcome probabilities and utilities. Nonoperative treatment was associated with a utility value of 5.9 and early arthroscopic surgery with a value of 7.6. On sensitivity analysis, it was found that when the rate of recurrence after nonoperative treatment falls below 32% or when the utility value for successful arthroscopic stabilization falls below 6.6, nonoperative treatment is the preferred management strategy. Arthroscopic stabilization was the preferred strategy after a primary anterior glenohumeral dislocation. In clinical settings where the likelihood of recurrent instability is low after nonoperative care or when an informed patient has an aversion to surgery, nonoperative treatment may be the preferred treatment strategy.

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.

Arthroscopic repair for combined Bankart and superior labral anterior posterior lesions: a comparative study between primary and recurrent anterior dislocation in the shoulder

The purpose of this study was to compare clinical outcomes between a primary dislocation group (group P) and a recurrent dislocation group (group R) with combined lesion of Bankart and type II SLAP lesions (type V SLAP lesion) and to evaluate incidence of type V SLAP lesion. In addition, the authors evaluated clinical outcomes of these patients by dividing two groups according to the sequence for Bankart and SLAP lesion suture. From May 2000 to May 2005, 310 patients who gave informed consent, underwent the diagnostic arthroscopy and magnetic resonance arthrography (MRA). One hundred and ten patients met the following criteria: (1) post-traumatic primary or recurrent anterior shoulder instability, (2) a normal contralateral shoulder, (3) a type V SLAP lesion, and (4) minimum follow-up of two years. Group P included 42 patients, and group R, 68 patients. Among all patients, 58 patients who had Bankart lesions sutured first were included in group B, and 52 who had their SLAP lesions sutured beforehand, group S. Visual analogue scale, range of motion, Rowe and Constant score were used to compare results between group P and group R, also group B and group S. The incidence rates of type V SLAP lesion were 42.8% in group P and 32.0% in group R. The overall treatment results in our study were good. Even if the difference between the two groups was statistically insignificant, group P showed greater recovery of range of motion than group R in external rotation. No significant difference was found between the two different operative methods according to suture sequence. The incidence rates of type V SLAP lesion were 42.8% in the primary dislocation group and 32.0% in the recurrent dislocation group. The overall treatment results in our study were good. Although there was no statistical significance in surgical time between the two groups, when both SLAP and Bankart lesions are present, the Bankart lesion must be sutured first to reduce surgical time.

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.

Prevalence Comparison of Accompanying Lesions between Primary and Recurrent Anterior Dislocation in the Shoulder

Background Many authors have reported the presence of intra-articular lesions after primary dislocation of the shoulder joint. However, few studies have focused on their prevalence or the differences in accompanying lesions between primary and recurrent dislocations of the shoulder joint. Purpose This study was undertaken to investigate and analyze accompanying lesions, including types of anteroinferior labrum injuries, using diagnostic arthroscopy and magnetic resonance arthrography (MRA) in 144 patients with traumatic anterior dislocation of the shoulder joint. Study Design Cohort study; Level of evidence, 3. Methods There were 33 patients with 33 dislocations in the primary dislocation group and 111 patients with 111 dislocations in the recurrent dislocation group. Preoperative magnetic resonance arthrography and diagnostic arthroscopy were performed on all patients. Results In the primary dislocation group, 8 Bankart lesions, 9 free anterior labrum periosteal sleeve avulsion (ALPSA) lesions, 4 bony Bankart lesions, and 1 adhesive ALPSA lesion were observed. In the recurrent dislocation group, 68 Bankart lesions, 11 free ALPSA lesions, 13 bony Bankart lesions, 16 adhesive ALPSA lesions, and 1 glenoid articular rim disruption lesion were found. There were 22 (66.6%) and 109 (98.1%) patients with lesions in the anteroinferior labrum in the primary and recurrent groups, respectively. There was a statistically significant difference between the 2 groups (P = .002). Also, there was a significant difference between the 2 groups in the prevalence of the Hill-Sachs lesion and inverted pear-shaped glenoid lesion (P = .008/P = .047). Inverted pear-shaped glenoids were observed in 15 patients in the recurrent group. In 139 of 144 patients, surgical findings of accompanying lesions coincided with magnetic resonance arthrography findings (96.5%). Conclusion Various forms of anteroinferior labral lesions were seen in patients with traumatic anterior dislocation of shoulder. The recurrent dislocation group showed a significantly higher prevalence of anteroinferior labral lesions and bony lesions in comparison with the primary group. In our study, magnetic resonance arthrography was an accurate method to assess accompanying lesions in first-time and recurrent anterior dislocation of the shoulder, suggesting that this may be a useful tool for determining a treatment method.

Is MRI useful to assess labral reduction following acute anterior shoulder dislocation?

Better knowledge of the anatomical lesions following primary anterior dislocation of the shoulder could help to resolve the issue of the recommended position of immobilization. The aim of this study was to describe such early lesions and to evaluate labral reducibility in both external and internal rotation of the arm. Fifteen shoulders were investigated by MRI without intra-articular injection. The 15 patients (14 men and one woman) had a mean age of 28 years (range: 17-42 years). Labral lesions were classified on a system based on Gleyze and Habermeyer's endoscopic assessment and reducibility was assessed on Itoi's criteria. Constant hemarthrosis allowed an arthrogram type effect. The Hill-Sachs lesion was small in five cases, medium in eight cases and large in two. There were seven labral lesions of type I, seven of type II and one of type III. External rotation (mean: 30.6 degrees; range: 15 degrees-65 degrees), reduced the labrum in six cases (40%). The present study failed to confirm the constant reduction of the labrum reported by Itoi, perhaps because external rotation was less than that obtained in his study (m=52 degrees; range: 35 degrees-81 degrees). Reduction was partly due to posterior migration of the hemarthrosis obtained by external rotation. MRI assessment of labral reducibility after primary anterior shoulder dislocation may be considered for patients at high risk of recurrence, in order to decide the ideal position of immobilization. Level IV. Retrospective diagnostic study.

Primary Arthroscopic Stabilization for a First-Time Anterior Dislocation of the Shoulder

Anterior dislocation of the glenohumeral joint in younger patients is associated with a high risk of recurrence and persistent functional deficits. The aim of this study was to assess the efficacy of a primary arthroscopic Bankart repair, while controlling for the therapeutic effects produced by the arthroscopic intervention and joint lavage.In a single-center, double-blind clinical trial, eighty-eight adult patients under thirty-five years of age who had sustained a primary anterior glenohumeral dislocation were randomized to receive either an arthroscopic examination and joint lavage alone or together with an anatomic repair of the Bankart lesion. Assessment of the rate of recurrent instability, functional outcome (with use of three scores), range of movement, patient satisfaction, direct health-service costs, and treatment complications was completed for eighty-four of these patients (forty-two in each group) during the subsequent two years.In the two years after the primary dislocation, the risk of a further dislocation was reduced by 76% and the risk of all recurrent instability was reduced by 82% in the Bankart repair group compared with the group that had arthroscopy and lavage alone. The functional scores were also better (p < 0.05), the treatment costs were lower (p = 0.012), and patient satisfaction was higher (p < 0.001) after arthroscopic repair. The improved functional outcome appeared to be mediated through the prevention of instability since the functional outcome in patients with stable shoulders was similar, irrespective of the initial treatment allocation. The patients who had a Bankart repair and played contact sports were also more likely to have returned to their sport at two years (relative risk = 3.4, p = 0.007).Following a first-time anterior dislocation of the shoulder, there is a marked treatment benefit from primary arthroscopic repair of a Bankart lesion, which is distinct from the so-called background therapeutic effect of the arthroscopic examination and lavage of the joint. However, primary repair does not appear to confer a functional benefit to patients with a stable shoulder at two years after the dislocation.

Ruhigstellung in Außenrotation bei primärer Schulterluxation

The standard method of treating acute primary dislocation of the glenohumeral joint is immobilization of the arm in adduction and internal rotation with a sling. The recurrence rate for anterior instability after nonoperative treatment in young active patients is extremely high (up to 90%) and well reported. A new method of immobilization with the arm in external rotation improves the position of the displaced labrum on the glenoid rim. With the use of control MRI before and after immobilization in external rotation, a study on this new repositioning of the labrum is evaluated. Ten patients (mean age 30.4 years) with primary anterior dislocation of the shoulder and Bankart lesion as shown on MRI but with no hyperlaxity of the contralateral side were immobilized in 10-20 degrees of external rotation for 3 weeks. Scans with MRI were taken in internal and external shoulder rotation post trauma and in internal rotation after 6 weeks. All patients were reevaluated after 6 and 12 months. Dislocation and separation of the labrum were both significantly less with the arm in external rotation due to the tension of the anterior capsule and the tendon of the subscapularis muscle. In the MRI taken in internal rotation 6 weeks post trauma, all Bankart lesions were fixed in reposition after three weeks of immobilization in external rotation. At 12-month follow-up, the average Constant Score was 96.1 points (range 63-100), and the Rowe Score was 91.5 points (range 25-100). One patient had traumatic redislocation after 8 months. After primary shoulder dislocation, immobilizing the arm in 10-20 degrees external rotation provided stable fixation of the Bankart lesion in an anatomic position. First long-term indications from an ongoing prospective study of recurrence rates after immobilization in external rotation are promising.