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Hanai H, Hirose T, Nakai H, Jacob G, Kotani Y, Kuratani K, Fujii T, Nakami H, Sahara W, Okada S, Hayashida K, Tanaka M. Early muscular training and immobilization in external rotation could reduce the recurrence rate in first-time shoulder dislocators among young rugby athletes. J Shoulder Elbow Surg 2025; 34:e446-e454. [PMID: 39805392 DOI: 10.1016/j.jse.2024.11.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2024] [Revised: 11/05/2024] [Accepted: 11/10/2024] [Indexed: 01/16/2025]
Abstract
BACKGROUND Among rugby players, anterior shoulder dislocation is challenging to treat during the in-season period. It often leads to recurrent shoulder instability and requires prolonged rest postsurgery. No studies have determined the effectiveness of immobilization, early muscle strength training, or both in preventing reinjury in this population. Thus, the present study aimed to determine the impact of treatment outcomes between different immobilization methods and early muscle strength training in the conservative treatment of first-time anterior shoulder dislocation among young rugby players. METHODS Rugby players under 23 years of age who chose conservative treatment for first-time anterior shoulder dislocation were included. The recurrence rate and recurrence-free period in a season and 2 years after return to sport (RTS) were retrospectively investigated for each immobilization method. The subjects were classified into 3 groups based on the immobilization method used: IIR group (incomplete immobilization in internal rotation was advised), iER group (strength training was started after 3-4 weeks of immobilization in external rotation [ER]), and iER + T group (early muscle strength training was combined immediately after the start of ER immobilization). All groups were allowed to RTS 8 weeks after injury or later. The endpoint was defined as a dislocation episode or the subjective feeling of shoulder subluxation, to a degree where the player could no longer continue to play the rest of the season. RESULTS Thirty-four shoulders of 34 patients (31 males and 3 females; median age at injury: 17 [range: 15-22] years) were included (IIR group, 8 shoulders; iER group, 8 shoulders; and iER + T group 18 shoulders). The recurrence rates during the first season after RTS were 100%, 87.5%, and 55.6% in the IIR, iER, and iER + T groups, respectively, with statistically significant difference between groups (P = .037). Compared with the IIR and iER groups, the iER + T group showed a longer survival curve with significant difference in the transition of each curve for the treatment success rate (P = .045). In the IIR, iER, and iER + T groups, approximately 0%, 11.7%, and 50.0% of patients were able to continue to play for more than half of the remaining season without any recurrence of instability, and the overall probability of recurrence in 2 years was estimated to be 100%, 100%, and 81.7%, respectively. CONCLUSION The combination of iER and early muscle strength training may be an effective treatment for anterior shoulder dislocation during the in-season period.
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Affiliation(s)
- Hiroto Hanai
- Department of Orthopaedic Surgery, Osaka University Graduate School of Medicine, Osaka, Japan; Department of Orthopaedic Surgery, Osaka University Hospital, Osaka, Japan
| | - Takehito Hirose
- Department of Orthopaedic Surgery, Osaka International Medical & Science Center, Osaka, Japan
| | - Hidekazu Nakai
- Department of Orthopaedic Surgery, Osaka International Medical & Science Center, Osaka, Japan
| | - George Jacob
- Department of Orthopaedics, VPS Lakeshore Hospital, Ernakulam, Kerala, India
| | - Yuki Kotani
- Department of Orthopaedic Surgery, Toyonaka Municipal Hospital, Toyonaka, Japan
| | - Kosuke Kuratani
- Department of Orthopaedic Surgery, Japan Community Healthcare Organization Osaka Hospital, Osaka, Japan
| | - Takahiro Fujii
- Department of Rehabilitation, Osaka International Medical & Science Center, Osaka, Japan
| | - Hitoshi Nakami
- Department of Rehabilitation, Osaka International Medical & Science Center, Osaka, Japan
| | - Wataru Sahara
- Department of Orthopaedic Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Seiji Okada
- Department of Orthopaedic Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Kenji Hayashida
- Department of Orthopaedic Surgery, Osaka Central Hospital, Osaka, Japan
| | - Makoto Tanaka
- Department of Orthopaedic Surgery, Osaka International Medical & Science Center, Osaka, Japan; Center for Sports Medicine, Osaka International Medical & Science Center, Osaka, Japan.
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Patro DR, Balaji G, Nema S, Vigneswar R. No Difference in Pain and Activities of Daily Living Between Immobilization in External and Internal Rotation Following Acute Anterior Shoulder Dislocation: Results of a Randomized Controlled Trial. Cureus 2025; 17:e81732. [PMID: 40330406 PMCID: PMC12050356 DOI: 10.7759/cureus.81732] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/04/2025] [Indexed: 05/08/2025] Open
Abstract
Background The conventional treatment for anterior shoulder dislocations is immobilising the arm in adduction and internal rotation. However, recent basic science and clinical data indicate that immobilization in external rotation can reduce recurrent instability. The use of external rotation brace is not widespread, due to compliance and convenience issues. The purpose of our study is to compare pain and restriction in day-to-day activities experienced by patients after being immobilized in the two types of braces (external rotation and internal rotation) at the end of one week. Methods Between February 2023 to July 2024, 50 patients with acute shoulder dislocation (primary or recurrent) were randomized (concealed, computer-generated) to immobilization with either an internal rotation brace (n=26) or an external rotation brace (n=24). Validated scores (Pain-visual analog scale (VAS) for pain, Katz Index for independence in activities of daily living) were used to collect data on the day of Immobilization and at the end of one week of immobilization. Results There was no statistically significant difference (P>0.05) in Pain-VAS and Katz Index scores among the two brace types (external rotation and internal rotation) at the end of one week of follow-up. There was no loss in follow-up in either of our study groups. Conclusion Immobilization in external rotation after reduction of acute shoulder dislocation did not significantly differ from immobilization in internal rotation in terms of pain and limitations in activities of daily living experienced by the patient in the first week of immobilization.
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Affiliation(s)
- Deepak Ranjan Patro
- Orthopaedics, Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry, IND
| | - Gopisankar Balaji
- Orthopaedics, Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry, IND
| | - Sandeep Nema
- Orthopaedics, All India Institute of Medical Sciences, Raipur, Raipur, IND
| | - Raja Vigneswar
- Orthopaedics, Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry, IND
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Kazim YH. A Literature Review on Whether Immobilization of the Shoulder in External Rotation Improves Healing and Prevents the Recurrence of Acute Shoulder Dislocations. Cureus 2025; 17:e80713. [PMID: 40099309 PMCID: PMC11912951 DOI: 10.7759/cureus.80713] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/17/2025] [Indexed: 03/19/2025] Open
Abstract
Shoulder dislocations are one of the most frequent joint dislocations, with recurrent dislocations being a common complication. Common practice is to immobilize the shoulder in internal rotation for two to three weeks following closed reduction. However, recent literature suggests immobilization in external rotation can be an alternative management strategy. External rotation braces have been manufactured over the years to support and maintain this position. This literature review aims to gather current evidence on the conservative management of primary traumatic anterior shoulder dislocations and compare the immobilization of the shoulder joint in internal and external rotation. A literature search and review was performed using PubMed and Google Scholar. Key phrases and words that were used in the search engines included "shoulder immobilization" AND "external rotation", "anterior shoulder dislocation immobilization" AND "external rotation", "reduced recurrence rate of shoulder dislocation" AND "external rotation", "external rotation immobilization" AND "Bankart lesion" and "internal versus external rotation" AND "shoulder dislocation". The reviewed articles included were dated from 2014 to 2024 but additional valuable studies dating earlier than 2014 were also included to provide a foundation of understanding to this review. Included were nine clinical studies and randomized controlled trials, three cadaveric studies, eight studies focusing on magnetic resonance imaging (MRI), magnetic resonance arthrography (MRA) or arthroscopy, and seven systematic reviews and meta-analyses. Research revealed improved coaptation of the labrum on the glenoid rim in external rotation not only in cadavers but also in patients with the aid of various imaging techniques. However, these findings were not consistently observed when translated into clinical trials. Based on the available data presented in this literature review, there remains a deficiency in evidence to exclusively support the use of external rotation immobilization over conventional internal rotation immobilization after primary traumatic anterior shoulder dislocations. External rotation immobilization may benefit a specific population, particularly those that fall in the 20-40-year-old age group, with a specific injury pattern, such as Bankart lesions and greater tuberosity fractures; therefore, further studies are required to determine who will benefit the most from such interventions.
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Affiliation(s)
- Yasmin H Kazim
- Emergency Department, Rashid Hospital, Dubai Health Authority, Dubai, ARE
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Devanand DB, Gardiner MD, Kedgley AE. A Compact Orthosis Compliance Monitoring Device Using Pressure Sensors and Accelerometers: Design and Proof-of-Concept Testing. SENSORS (BASEL, SWITZERLAND) 2025; 25:1352. [PMID: 40096180 PMCID: PMC11902658 DOI: 10.3390/s25051352] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/06/2024] [Revised: 02/16/2025] [Accepted: 02/19/2025] [Indexed: 03/19/2025]
Abstract
Monitoring orthosis compliance using patient diaries is subjective, as patients can overestimate their levels of device use. An objective way to monitor compliance is required because if an orthotic prescription is not followed, the orthosis will not work as intended. This study aimed to develop and validate a device that monitors orthosis compliance objectively using pressure and acceleration. Fifteen participants were recruited to test the device's ability to estimate wear time during the performance of several grip patterns and whilst completing selected activities of daily living. Sensor threshold values were used to discern whether users were wearing their orthosis or not. No differences between pressure sensor and accelerometer-based wear time estimations were found. The device's pressure-based wear time estimations were found to have a specificity of 92.7 ± 16.4% and sensitivity of 74.0 ± 41.3%, whilst accelerometer-based wear time estimates had a specificity of 66.1 ± 34.7% and sensitivity of 86.2 ± 8.0%. This study successfully demonstrated the feasibility of monitoring hand orthosis compliance using pressure or acceleration. This device has the potential to provide insight into the effectiveness of both existing and novel orthotics, benefitting both clinical practice and research.
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Affiliation(s)
| | - Matthew D. Gardiner
- Kennedy Institute of Rheumatology, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), University of Oxford, Oxford OX3 7FY, UK;
- Department of Plastic Surgery, Wexham Park Hospital, Frimley Health NHS Foundation Trust, Slough SL2 4HL, UK
| | - Angela E. Kedgley
- Department of Bioengineering, Imperial College London, London SW7 2AZ, UK;
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Nagawa K, Hara Y, Shimizu H, Matsuura K, Inoue K, Kozawa E, Sakaguchi K, Niitsu M. Sectional measurements of shoulder muscle volume and computed tomography density in anterior shoulder instability. Sci Rep 2024; 14:27436. [PMID: 39523442 PMCID: PMC11551204 DOI: 10.1038/s41598-024-79065-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2024] [Accepted: 11/06/2024] [Indexed: 11/16/2024] Open
Abstract
In patients with anterior shoulder instability (ASI), a chronic imbalance might exist between the anterior and posterior shoulder muscles (i.e., subscapular [Ssc] vs. infraspinatus and teres minor [Isp + TM]). The balance could be evaluated as the ratio of volume (VR Ssc/Isp+TM) and computed tomography density (CT-DR Ssc/Isp+TM) using a 3D sectional approach. A total of 28 CT images (19 patients) of non-pathological shoulders (clavicular fracture [CF]) and 17 CT images (17 patients) of ASI were used. Segmentation of Ssc and Isp + TM muscles was performed; the reconstructed models were separated by the Y-view plane and the planes situated 2.5 cm and 5 cm medial to the Y-view plane to generate muscle models. VR Ssc/Isp+TM and CT-DR Ssc/Isp+TM were measured in each section of both the groups, as well as in whole muscle measurements in the CF group. VR Ssc/Isp+TM and CT-DR Ssc/Isp+TM obtained through a 3D sectional approach in the CF group were comparable to the whole muscle measurements, with a value of 1.06 for both. In the ASI group, the VR Ssc/Isp+TM was higher, whereas the CT-DR Ssc/Isp+TM was lower than those in the CF group. The VR Ssc/Isp+TM and CT-DR Ssc/Isp+TM appeared to be balanced in the CF group. However an imbalance was observed in the ASI group. Our 3D sectional measurement approach has the potential to assess the balance between the anterior and posterior shoulder muscles in ASI.
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Affiliation(s)
- Keita Nagawa
- Department of Radiology, Saitama Medical University, 38 Morohongou, Moroyama-machi, Iruma-gun, Saitama, Japan.
| | - Yuki Hara
- Department of Radiology, Saitama Medical University, 38 Morohongou, Moroyama-machi, Iruma-gun, Saitama, Japan
| | - Hirokazu Shimizu
- Department of Radiology, Saitama Medical University, 38 Morohongou, Moroyama-machi, Iruma-gun, Saitama, Japan
| | - Koichiro Matsuura
- Department of Radiology, Saitama Medical University, 38 Morohongou, Moroyama-machi, Iruma-gun, Saitama, Japan
| | - Kaiji Inoue
- Department of Radiology, Saitama Medical University, 38 Morohongou, Moroyama-machi, Iruma-gun, Saitama, Japan
| | - Eito Kozawa
- Department of Radiology, Saitama Medical University, 38 Morohongou, Moroyama-machi, Iruma-gun, Saitama, Japan
| | - Katsunobu Sakaguchi
- Department of Orthopedics, Saitama Medical University, 38 Morohongou, Moroyama-machi, Iruma-gun, Saitama, Japan
| | - Mamoru Niitsu
- Department of Radiology, Saitama Medical University, 38 Morohongou, Moroyama-machi, Iruma-gun, Saitama, Japan
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Karasuyama M, Tsuruta T, Yamamoto S, Ariie T, Kawakami J, Minamikawa T, Ohzono H, Moriyama H, Gotoh M. Comparative efficacy of treatments for a first-time traumatic anterior shoulder dislocation: a systematic review and network meta-analysis. J Shoulder Elbow Surg 2024; 33:2505-2514. [PMID: 39025357 DOI: 10.1016/j.jse.2024.05.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Revised: 05/01/2024] [Accepted: 05/19/2024] [Indexed: 07/20/2024]
Abstract
BACKGROUND First-time traumatic anterior shoulder dislocation (FASD) is a common trauma associated with shoulder dysfunction. Although several randomized controlled trials have compared conservative and surgical treatments for FASD, the comparative efficacy of these treatments is poorly understood. In this network meta-analysis (NMA), we compared the available evidence on the efficacy of various interventions in patients with FASD. METHODS We searched the Cochrane Central Register of Controlled Trials, MEDLINE, and EMBASE databases in March 2023. This NMA included randomized controlled trials comparing conservative and surgical treatments for FASD, including arthroscopic Bankart repair, arthroscopic lavage, external rotation (ER) immobilization, and internal rotation (IR) immobilization. The primary outcomes were redislocation rates, Western Ontario Shoulder Instability Index (WOSI) scores, and adverse events (AEs). We conducted random-effects NMA within the frequentist framework. To rank the treatments, the Surface Under the Cumulative Ranking curve was calculated using a Bayesian framework. We evaluated confidence in each outcome using the CINeMA tool. RESULTS Of the 2999 reviewed studies, 15 were included and analyzed. Regarding the primary outcomes, arthroscopic Bankart repair likely results in a large reduction in redislocation rates compared to IR immobilization (risk ratio [RR], 0.15; 95% confidence interval [CI], 0.07-0.33). Both arthroscopic lavage (RR, 0.47; 95% CI, 0.20-1.11) and ER immobilization (RR 0.70; 95% CI, 0.50-1.00) may reduce the redislocation rates slightly compared with IR immobilization. According to these results, arthroscopic Bankart repair ranked first in terms of reducing the redislocation rate, followed by arthroscopic lavage, ER and IR immobilization. Regarding the WOSI score, no substantial differences were observed in the WOSI scores among the four treatments. AEs showed that ER immobilization tended to cause greater shoulder stiffness than IR immobilization, and postoperative erythema, swelling, and adhesive capsulitis were observed after arthroscopic Bankart repair and lavage. However, a meta-analysis was not performed because the definitions of AEs differed between the studies. CONCLUSION Arthroscopic Bankart repair showed a significant effect in reducing the redislocation rate compared to IR immobilization. Although both arthroscopic lavage and ER immobilization seemed to be effective in reducing the redislocation rates, it was not statistically significant. Moreover, these four treatments may result in little to no difference in disease-specific quality of life and there is no clear evidence of AEs.
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Affiliation(s)
- Masaki Karasuyama
- Department of Rehabilitation, Minamikawa Orthopedic Hospital, Fukuoka, Japan.
| | - Takashi Tsuruta
- Department of Rehabilitation, Minamikawa Orthopedic Hospital, Fukuoka, Japan
| | - Shuhei Yamamoto
- Department of Rehabilitation, Shinshu University Hospital, Matsumoto, Japan
| | - Takashi Ariie
- Department of Physical Therapy, School of Health Sciences at Fukuoka, International University of Health and Welfare, Okawa, Japan
| | - Junichi Kawakami
- Department of Anatomy, The Nippon Dental University School of Life Dentistry, Niigata, Japan
| | - Tomohiko Minamikawa
- Department of Orthopedic Surgery, Minamikawa Orthopedic Hospital, Fukuoka, Japan
| | - Hiroki Ohzono
- Department of Orthopedic Surgery, Kurume University Medical Center, Kurume, Japan
| | - Hiroaki Moriyama
- Department of Orthopedic Surgery, Kurume University Medical Center, Kurume, Japan
| | - Masafumi Gotoh
- Department of Orthopedic Surgery, Kurume University Medical Center, Kurume, Japan
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Wright A, Ness B, Spontelli-Gisselman A, Gosselin D, Cleland J, Wassinger C. Risk Factors Associated with First Time and Recurrent Shoulder Instability: A Systematic Review. Int J Sports Phys Ther 2024; 19:522-534. [PMID: 38707855 PMCID: PMC11065770 DOI: 10.26603/001c.116278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Accepted: 02/29/2024] [Indexed: 05/07/2024] Open
Abstract
Background Shoulder instabilities constitute a large proportion of shoulder injuries and have a wide range of presentations. While evidence regarding glenohumeral dislocations and associated risk factors has been reported, less is known regarding the full spectrum of instabilities and their risk factors. Purpose The purpose of this systematic review was to identify modifiable risk factors to guide patient management decisions with regards to implementation of interventions to prevent or reduce the risk of shoulder instability. Study Design Systematic Review. Methods A systematic, computerized search of electronic databases (CINAHL, Cochrane, Embase, PubMed, SportDiscus, and Web of Science) was performed. Inclusion criteria were: (1) a diagnosis of shoulder instability (2) the statistical association of at least one risk factor was reported, (3) study designs appropriate for risk factors, (4) written in English, and (5) used an acceptable reference standard for diagnosed shoulder instability. Titles and abstracts were independently screened by at least two reviewers. All reviewers examined the quality studies using the Newcastle-Ottawa Scale (NOS). At least two reviewers independently extracted information and data regarding author, year, study population, study design, criterion standard, and strength of association statistics with risk factors. Results Male sex, participation in sport, hypermobility in males, and glenoid index demonstrated moderate to large risk associated with first time shoulder instability. Male sex, age \<30 years, and history of glenohumeral instability with concomitant injury demonstrated moderate to large risk associated with recurrent shoulder instability. Conclusion There may be an opportunity for patient education in particular populations as to their increased risk for suffering shoulder instability, particularly in young males who appear to be at increased risk for recurrent shoulder instability. Level of Evidence Level III.
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Affiliation(s)
- Alexis Wright
- Department of Rehabilitation SciencesTufts University
| | - Brandon Ness
- Department of Rehabilitation SciencesTufts University
| | | | - Dora Gosselin
- Pediatric Physical Therapy and Occupational TherapyDuke Health
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Cirigliano G, Altorfer C.S. F, Meisterhans M, Borbas P, Wieser K, Grubhofer F. Anterior shoulder dislocation with avulsion fracture of the greater tuberosity results in reliable good outcomes after closed reduction. JSES Int 2024; 8:423-428. [PMID: 38707548 PMCID: PMC11064708 DOI: 10.1016/j.jseint.2023.12.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/07/2024] Open
Abstract
Background Avulsion of the greater tuberosity (GT) due to traumatic anterior shoulder dislocation (ASD) is a commonly observed fracture pattern. After closed reduction of the dislocated humerus, the GT typically reduces itself into its anatomic position enabling the patient to undergo conservative treatment. The aim of this study was to retrospectively review a consecutive series of patients with conservatively treated GT avulsion fractures after closed reduction of an ASD and analyze radiographic outcome, shoulder function and glenohumeral stability and the conversion rate to surgical treatment. Methods All patients who underwent closed reduction of a GT avulsion fracture after ASD with the primary intention of conservative treatment between 2017 and 2022 were included. Complications (i.e. conversion to surgical treatment), shoulder function assessed with the American Shoulder and Elbow Surgeons score and subjective shoulder value, instability assessed with the Western Ontario Shoulder Instability score, radiological impingement (greater tuberosity index = GTI and impingement index = II) and GT fracture pattern were assessed as outcome measurements. Results A total of 29 patients (mean age 44 years, 27% female) with a mean follow-up of 32.6 (range, 8-96) months were enrolled. Seven patients (24%) underwent surgery due to secondary displacement (n = 4, 14%) or impingement symptoms (n = 3, 10%). All patients who underwent secondary surgery showed a multifragmentary fracture pattern of the GT. Shoulder stiffness (n = 7) and neuropraxia of the axillary nerve (n = 3) were observed temporarily and resolved during the follow-up period. The American Shoulder and Elbow Surgeons and subjective shoulder value of the conservatively treated patients at the last follow-up was 89.2 ± 19.1 respectively 86 ± 18.2%. No recurrent glenohumeral dislocation was documented. The mean Western Ontario Shoulder Instability score at last follow-up was 8(0-71). The mean GTI decreased from 1.2 ± 0.1 after ASD to 1.1 ± 0.1 at the last follow-up (P = .002). The mean II decreased from 0.6 ± 0.5 after ASD to 0.4 ± 0.3 at the last follow-up (P = .110). Conclusion The GT avulsion fragment reduces typically into a close to anatomic position after closed reduction and the GTI even improves with further conservative treatment over time. Close radiological follow-up is necessary to rule out secondary displacement which occurs typically in a multifragmentary fracture pattern. Patients without the need for surgery showed good clinical outcomes without recurrence of glenohumeral instability.
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Affiliation(s)
- Gabriele Cirigliano
- Department of Orthopedics, University of Zurich, Balgrist University Hospital, Zurich, Switzerland
| | - Franziska Altorfer C.S.
- Department of Orthopedics, University of Zurich, Balgrist University Hospital, Zurich, Switzerland
| | - Michel Meisterhans
- Department of Orthopedics, University of Zurich, Balgrist University Hospital, Zurich, Switzerland
| | - Paul Borbas
- Department of Orthopedics, University of Zurich, Balgrist University Hospital, Zurich, Switzerland
| | - Karl Wieser
- Department of Orthopedics, University of Zurich, Balgrist University Hospital, Zurich, Switzerland
| | - Florian Grubhofer
- Department of Orthopedics, University of Zurich, Balgrist University Hospital, Zurich, Switzerland
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Potyk AG, Belk JW, Bravman JT, Seidl AJ, Frank RM, McCarty EC. Immobilization in External Rotation Versus Arthroscopic Stabilization After Primary Anterior Shoulder Dislocation: A Systematic Review of Level 1 and 2 Studies. Am J Sports Med 2024; 52:544-554. [PMID: 36867050 DOI: 10.1177/03635465231155199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/04/2023]
Abstract
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.
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Affiliation(s)
- Andrew G Potyk
- University of Colorado School of Medicine, Department of Orthopaedics, University of Colorado, Aurora, Colorado, USA
| | - John W Belk
- University of Colorado School of Medicine, Department of Orthopaedics, University of Colorado, Aurora, Colorado, USA
| | - Jonathan T Bravman
- University of Colorado School of Medicine, Department of Orthopaedics, University of Colorado, Aurora, Colorado, USA
| | - Adam J Seidl
- University of Colorado School of Medicine, Department of Orthopaedics, University of Colorado, Aurora, Colorado, USA
| | - Rachel M Frank
- University of Colorado School of Medicine, Department of Orthopaedics, University of Colorado, Aurora, Colorado, USA
| | - Eric C McCarty
- University of Colorado School of Medicine, Department of Orthopaedics, University of Colorado, Aurora, Colorado, USA
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10
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Kenmoku T, Miyajima G, Tazawa R, Ishii D, Inoue K, Matsumoto M, Takaso M. Kinematic analysis of damaged capsulolabral structure in patients with anterior shoulder instability using cine-magnetic resonance imaging. JSES Int 2023; 7:2330-2336. [PMID: 37969497 PMCID: PMC10638605 DOI: 10.1016/j.jseint.2023.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2023] Open
Abstract
Background We assessed damaged anterior capsulolabral motion during axial shoulder rotation in patients with anterior shoulder instability. Methods Twenty-nine shoulders of 28 patients with anterior shoulder instability who underwent cine-magnetic resonance imaging during axial rotation of the adducted arm were included. The motion was captured after an intra-articular injection of saline solution (10-20 mL). During imaging, the shoulder was rotated passively from maximum internal rotation to maximum external rotation in the first 10 s and then back to maximum internal rotation in the subsequent 10 s. We assessed the rotational angles of the damaged labrum during compressing and pulling the humeral head against the glenoid. Evaluation of the rotational angles was performed on a series of axial images through the humeral head center. Results The mean angles that damaged labrum compressed and pulled off against the glenoid were 12.0 ± 19.1° and 2.8 ± 21.2°, respectively. Additionally, seven of the 29 shoulders showed that the damaged labrum compressed on the glenoid rim before the rotational angle exceeded 0° during external rotation. In 13 shoulders, the damaged labrum could remain repositioned on the glenoid rim over the neutral position during internal rotation. In two shoulders, the damaged labrum was not compressed against the glenoid at the maximum external rotation. The injected saline moved from the posterior to the anterior side of the glenohumeral joint during internal rotation in each shoulder. Conclusion The damaged labrum could be positioned on the glenoid when the arm was in a traditional internal immobilization.
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Affiliation(s)
- Tomonori Kenmoku
- Department of Orthopedic Surgery, Kitasato University School of Medicine, Sagamihara, Japan
| | - Genyo Miyajima
- Department of Orthopedic Surgery, Kitasato University School of Medicine, Sagamihara, Japan
| | - Ryo Tazawa
- Department of Orthopedic Surgery, Kitasato University School of Medicine, Sagamihara, Japan
| | - Daisuke Ishii
- Department of Orthopedic Surgery, Kitasato University School of Medicine, Sagamihara, Japan
| | - Kosuke Inoue
- Department of Orthopedic Surgery, Kitasato University School of Medicine, Sagamihara, Japan
| | - Mitsuyoshi Matsumoto
- Department of Orthopedic Surgery, Kitasato University School of Medicine, Sagamihara, Japan
| | - Masashi Takaso
- Department of Orthopedic Surgery, Kitasato University School of Medicine, Sagamihara, Japan
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11
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Devanand DB, Kedgley AE. Objective Methods of Monitoring Usage of Orthotic Devices for the Extremities: A Systematic Review. SENSORS (BASEL, SWITZERLAND) 2023; 23:7420. [PMID: 37687876 PMCID: PMC10490645 DOI: 10.3390/s23177420] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Revised: 08/16/2023] [Accepted: 08/23/2023] [Indexed: 09/10/2023]
Abstract
Orthoses are commonly prescribed to relieve symptoms for musculoskeletal and neurological conditions; however, patients stop wearing orthoses as recommended for many reasons. When considering the effectiveness of orthoses, there needs to be an objective way to monitor whether participants wear the orthosis as instructed, because if this is not followed, the orthoses will not work as intended. This review aimed to identify, summarise, and compare objective methods used to measure compliance with orthoses applied to the extremities. Databases (Scopus, Web of Science, Embase, CINAHL, and MEDLINE) were searched for eligible studies. Twenty-three studies were accepted in the final review, including five studies that employed upper limb orthoses, two that employed hip orthoses, and fifteen that employed lower limb orthoses. To measure compliance objectively, studies utilised temperature sensors, pressure sensors, accelerometers, a step counter, or a combination of sensors. All sensor types have their own advantages and disadvantages and should be chosen based on study-specific parameters. Sensor-derived monitoring provides quantitative, objective data that are beneficial in both clinical and research settings. The ideal solution to monitoring compliance would consist of both objective and user-reported aspects that, in combination, would provide an all-encompassing picture of the orthotic treatment prescribed.
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Affiliation(s)
| | - Angela E. Kedgley
- Department of Bioengineering, Imperial College London, London SW7 2AZ, UK;
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12
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Safran O, Beyth S, Milgrom C, Milgrom Y, Nir D, Finestone AS. At long-term follow-up many first-time male traumatic shoulder dislocators remain symptomatic. J Sci Med Sport 2023:S1440-2440(23)00046-4. [PMID: 36997416 DOI: 10.1016/j.jsams.2023.03.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Revised: 02/27/2023] [Accepted: 03/14/2023] [Indexed: 03/30/2023]
Abstract
OBJECTIVES To assess the status at 13 to 17 years follow-up of a cohort of young male traumatic shoulder dislocators. STUDY DESIGN Prospective cohort study. METHODS A prospective study of first-time young male traumatic shoulder dislocators, began in 2004. Subjects were evaluated by the apprehension test after completing rehabilitation 6 to 9 weeks post dislocation. Between March 2021 and July 2022, a telephone questionnaire was administered to ascertain their current shoulder status. Subjects were questioned about avoidance of activities of daily living and sport, participation in sports, current instability, and self-assessed shoulder function by the SANE score. RESULTS 50/53 (94.3%) of the study subjects, mean age 20.4 years, completed a mean follow-up of 181.8 ± 12 months. The non-redislocation survival was 13% for those with a positive apprehension test and 49% for those with a negative test (p = 0.007). SANE scores were 64.3 ± 23.7 for those with a positive apprehension test and 83.7 ± 19.7 for those with a negative test (p = 0.001). In the year before the follow-up, 33.3% of those treated conservatively and 42.9% treated surgically experienced subluxation (p = 0.5). Fifty-seven percent of those who were treated conservatively and 56% of those who underwent surgery avoided some ADL or sports because of their shoulder. CONCLUSIONS For young male first time traumatic shoulder dislocators a positive apprehension test after rehabilitation is associated with a high risk for reoccurrence and poorer long-term results. Most subjects were still dealing with shoulder symptoms at long-term follow-up.
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Affiliation(s)
- Ori Safran
- Department of Orthopedics, Hadassah Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Israel
| | - Shaul Beyth
- Department of Orthopedics, Hadassah Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Israel
| | - Charles Milgrom
- Military Track, Hadassah Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, 911200, Israel.
| | - Yael Milgrom
- Department of Medicine, Hadassah Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Israel
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13
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Davey MS, Hurley ET, Doyle TR, Dashti H, Gaafar M, Mullett H. The Fragility Index of Statistically Significant Findings From Randomized Controlled Trials Comparing the Management Strategies of Anterior Shoulder Instability. Am J Sports Med 2022:3635465221077268. [PMID: 35414266 DOI: 10.1177/03635465221077268] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Debate centering on the management of anterior shoulder instability (ASI) in recent years has led to many randomized controlled trials (RCTs) being published on the topic. The fragility index (FI) has subsequently emerged as a novel method of assessing significant findings reported in RCTs, particularly those with small sample sizes. PURPOSE To evaluate the FI of statistically significant findings in RCTs that reported the outcomes of management strategies of patients with ASI. STUDY DESIGN Systematic review; Level of evidence, 1. METHODS Using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, 2 independent reviewers performed a systematic review of RCTs focusing on the outcomes of management strategies of patients with ASI. There were 3 main categories of RCTs included: (1) nonoperative management in internal rotation (IR) versus external rotation (ER), (2) nonoperative management versus a surgical intervention, and (3) surgical management with arthroscopic Bankart repair versus open Bankart repair. The Fisher exact test was utilized to calculate the FI for the reversal of statistical significance in all statistically significant dichotomous outcomes. RESULTS A total of 21 RCTs were included, including 1589 shoulders (mean age, 29.4 years) with a mean follow-up of 26.8 months. There were 10 RCTs (831 shoulders) that reported outcomes after the nonoperative management of ASI in IR versus ER, with a mean FI of 6.8. There were 5 RCTs (324 shoulders) that reported outcomes comparing the nonoperative and operative management of ASI, with a mean FI of 3.5. There were 6 RCTs (434 shoulders) that reported outcomes after the operative management of ASI with either arthroscopic Bankart repair or open Bankart repair, with a mean FI of 9.6. CONCLUSION The overall FI of RCTs reporting the outcomes of management strategies for patients with ASI was high, suggesting a moderate fragility of statistically significant outcomes including recurrence, revision stabilization, and return to play.
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14
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Editorial Commentary: A Consensus of Experts Complements the Clinical Evidence on Diagnosis and Treatment of Anterior Glenohumeral Instability. Arthroscopy 2022; 38:243-246. [PMID: 35123705 DOI: 10.1016/j.arthro.2021.08.034] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Accepted: 08/26/2021] [Indexed: 02/02/2023]
Abstract
The current diagnostic and treatment strategies for anterior glenohumeral instability have been refined by high-quality clinical and basic science studies, but many controversies remain. These include the bone loss threshold for arthroscopic Bankart repair and the influence of other clinical factors on this decision, the optimal bracing position following anterior glenohumeral dislocation, and the optimal coracoid graft orientation during the Latarjet procedure. Randomized clinical trials often present conflicting results, and many of these are small-sample and fragile studies. Obtaining an expert consensus on the topic, by means of the Delphi method, is an attractive alternative to such clinical trials. Several studies employing variations of the Delphi method have addressed the diagnosis and treatment of anterior glenohumeral instability. These have stressed the importance of a meticulous technique during arthroscopic Bankart repair and of recognition of glenoid and humeral bone loss and treating this appropriately. These studies have also helped identify areas where consensus is modest or lacking to motivate additional clinical research study.
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15
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Bao MH, DeAngelis JP, Wu JS. Imaging of traumatic shoulder injuries – Understanding the surgeon’s perspective. Eur J Radiol Open 2022; 9:100411. [PMID: 35265737 PMCID: PMC8899241 DOI: 10.1016/j.ejro.2022.100411] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Revised: 02/13/2022] [Accepted: 02/23/2022] [Indexed: 12/18/2022] Open
Abstract
Imaging plays a key role in the assessment and management of traumatic shoulder injuries, and it is important to understand how the imaging details help guide orthopedic surgeons in determining the role for surgical treatment. Imaging is also crucial in preoperative planning, the longitudinal assessment after surgery and the identification of complications after treatment. This review discusses the mechanisms of injury, key imaging findings, therapeutic options and associated complications for the most common shoulder injuries, tailored to the orthopedic surgeon’s perspective.
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16
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Mid- to long-term results of postoperative immobilization in internal vs. external rotation after arthroscopic anterior shoulder stabilization. JSES Int 2021; 5:960-966. [PMID: 34766070 PMCID: PMC8568811 DOI: 10.1016/j.jseint.2021.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Background There 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. Methods Twenty-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. Results Twenty 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. Conclusion The type of immobilization after arthroscopic shoulder stabilization does not influence the clinical results after a mid- to long-term follow-up.
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17
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Joshi S, Rao V, Shetty UC, Rai S, Arora S, Kumar SR. Functional Outcome of Open Latarjet Procedure in Non-Athletic Middle-Aged Patients. Malays Orthop J 2021; 15:151-158. [PMID: 34429836 PMCID: PMC8381674 DOI: 10.5704/moj.2107.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Accepted: 05/19/2021] [Indexed: 11/17/2022] Open
Abstract
Introduction: The movement and steadiness of the shoulder joint is due to both the dynamic and static stabilisers. Recurrent anterior shoulder instability is common due to the Bankart lesion or the Hill Sachs lesion. The bone loss and soft tissue failure due to these lesions causing instability is well compensated by Latarjet procedure which acts by triple blocking effect of the bone graft, the sling effect of the conjoint tendon of subscapularis and the ligament of the coracoacromial ligament stump. Materials and methods: Middle-aged patients with recurrent anterior shoulder dislocation and a mid-range instability on clinical assessment with an isolated glenoid bone loss of 20% or Bankart lesion with engaging Hill Sachs lesion were selected for the study. The surgical procedure included a subscapularis split to expose the glenoid. The coracoid graft harvested was prefixed with Kirschner wires and placed flush over the glenoid ensuring no medial or lateral overhang and fixed with 4.0mm cancellous screws with the washer. The functional outcome was measured with the ROWE score and ASES score and the movements were evaluated. Results: A total of 24 patients fulfilled the inclusion criteria. Post-operatively at final follow-up, the mean ROWE score was 97.08 ±8.45 and the mean ASES score was 94.4±9.10. One patient had screw breakage as a complication and another had restriction of movement which was managed with physiotherapy. Conclusion: Open Latarjet is an effective procedure for recurrent anterior shoulder instability in non-athletic middle-aged patients as a excellent functional outcome was achieved with this technique. We therefore recommend open Latarjet as an alternative to arthroscopic treatment in developing countries where patient affordability and the availability of the resources are the issues.
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Affiliation(s)
- S Joshi
- Department of Orthopaedics, Government Medical College Kota, Kota, India
| | - Vkv Rao
- Department of Orthopaedics, Government Medical College Kota, Kota, India
| | - U C Shetty
- Department of Orthopaedics, Kundapur Hospital, Kundapur, India
| | - S Rai
- Department of Orthopaedics, Orthocity Hospital, Varanasi, India
| | - S Arora
- Department of Orthopaedics, Government Medical College Kota, Kota, India
| | - S R Kumar
- Department of Orthopaedics, Government Medical College Kota, Kota, India
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18
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Abstract
Anterior shoulder instability commonly occurs in young and active individuals, particularly those participating in contact or collision sports. At the intercollegiate level, rates of anterior instability have been reported to be 0.12 events per 1000 athlete exposures. The treatment of in-season athletes with anterior instability presents a challenge for the team physician. The desire to return to play within the same season with nonoperative management must be weighed against the increased risk of recurrence as well as athlete and team specific demands. The purpose of this chapter is to discuss the key considerations for the management of the athlete with anterior shoulder instability that occurs within the competitive season.
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19
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Minkus M, Königshausen M, Maier D, Mauch F, Stein T, Greiner S, Moursy M, Scheibel M. Immobilization in External Rotation and Abduction Versus Arthroscopic Stabilization After First-Time Anterior Shoulder Dislocation: A Multicenter Randomized Controlled Trial. Am J Sports Med 2021; 49:857-865. [PMID: 33596092 PMCID: PMC7961655 DOI: 10.1177/0363546520987823] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Treatment of first-time shoulder dislocation (FSD) is a topic of debate. After high rates of recurrent instability after nonoperative management were reported in the literature, primary repair of FSD significantly increased. At the same time, new concepts were proposed that had promising results for immobilization in external rotation (ER) and abduction (ABD). PURPOSE The aim of this study was to evaluate the recurrence rates (primary outcome) and clinical outcomes (secondary outcome parameters) of immobilization in ER+ABD versus arthroscopic primary stabilization after FSD. STUDY DESIGN Randomized controlled trial; Level of evidence, 1. METHODS In a multicenter randomized controlled trial, patients with FSD were randomized to either treatment with immobilization in 60° of ER plus 30° of ABD (group 1) or surgical treatment with arthroscopic Bankart repair (group 2). Clinical evaluation was performed 1, 3, and 6 weeks as well as 6, 12, and 24 months postoperatively or after reduction, including range of motion, instability testing, subjective shoulder value, Constant-Murley score, Rowe score, and Western Ontario Shoulder Instability Index. Recurrent instability events were prospectively recorded. RESULTS Between 2011 and 2017, a total of 112 patients were included in this study. Of these, 60 patients were allocated to group 1 and 52 to group 2. At the 24-month follow-up, 91 patients (81.3%) were available for clinical examination. The recurrence rate was 19.1% in group 1 and 2.3% in group 2 (P = .016). No significant differences were found between groups regarding clinical shoulder scores (P > .05). Due to noncompliance with the immobilization treatment protocol, 4 patients (6.7%) were excluded. CONCLUSION Immobilization in ER+ABD versus primary arthroscopic shoulder stabilization for the treatment of FSD showed no differences in clinical shoulder scores. However, recurrent instability was significantly higher after nonoperative treatment.
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Affiliation(s)
- Marvin Minkus
- Department for Shoulder and Elbow Surgery, Center for Musculoskeletal Surgery, Charité Universitaetsmedizin Berlin, Berlin, Germany
| | - Matthias Königshausen
- Department of Trauma Surgery and Orthopaedics, Ruhr-University Hospital Bergmannsheil Bochum, Bochum, Germany
| | - Dirk Maier
- Department of Orthopedics and Trauma Surgery, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Frieder Mauch
- Department of Shoulder and Elbow Surgery, Sportklinik Stuttgart, Stuttgart, Germany
| | - Thomas Stein
- Department of Sport Traumatology, Knee and Shoulder Surgery, Berufsgenossenschaftliche Unfallklinik, Frankfurt am Main, Germany,Department of Sports Medicine, Goethe University Frankfurt, Frankfurt am Main, Germany
| | | | - Mohamed Moursy
- Orthopedics & Trauma Centre, Medical Faculty of Mannheim, University of Heidelberg, Mannheim, Germany,Department of Orthopedics and Traumatology, Paracelsus Medical University, Salzburg, Austria
| | - Markus Scheibel
- Department for Shoulder and Elbow Surgery, Center for Musculoskeletal Surgery, Charité Universitaetsmedizin Berlin, Berlin, Germany,Department of Shoulder and Elbow Surgery, Schulthess Clinic Zurich, Zurich, Switzerland,Markus Scheibel, MD, Department of Shoulder and Elbow Surgery, Center for Musculoskeletal Surgery, Charité-Universitaetsmedizin Berlin, Augustenburger Platz 1, Berlin, 13353, Germany ()
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20
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Hurley ET, Fried JW, Alaia MJ, Strauss EJ, Jazrawi LM, Matache BA. Immobilisation in external rotation after first-time traumatic anterior shoulder instability reduces recurrent instability: a meta-analysis. J ISAKOS 2020; 6:22-27. [PMID: 33833042 DOI: 10.1136/jisakos-2020-000511] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Revised: 11/12/2020] [Accepted: 11/24/2020] [Indexed: 11/04/2022]
Abstract
IMPORTANCE Cadaveric and MRI findings have demonstrated significantly less labral separation and displacement when the shoulder is placed in external rotation as compared with internal rotation. OBJECTIVE The purpose of the current study is to meta-analyse the randomised controlled trials in the literature to compare immobilisation in external versus internal rotation after first-time anterior shoulder dislocation. EVIDENCE REVIEW A literature search of MEDLINE, EMBASE and the Cochrane Library was performed based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Randomised controlled trials comparing immobilisation in external rotation versus internal rotation for first-time anterior shoulder dislocation were included. FINDINGS Nine randomised controlled trials with 795 patients were included. The mean age of included patients was 29 years, 82.4% were male and the mean follow-up was 25.5 months. As compared with immobilisation in internal rotation, compliance was significantly higher (74.5% vs 67.4%, p=0.01), and the rate of recurrent dislocations was significantly lower (22.2% vs 33.4%, p=0.02) with immobilisation in external rotation. Additionally, in patients 20-40 years old the rate of recurrent dislocations was significantly lower in those treated with immobilisation in external rotation than internal rotation (12.1% vs 31.4%, p=0.006). Immobilisation in external rotation also resulted in a higher rate of return to preinjury level of play (60.1% vs 42.6%, p=0.0001). CONCLUSIONS AND RELEVANCE Immobilisation of the shoulder in external rotation after a traumatic first-time anterior shoulder dislocation results in a higher compliance rate, a lower recurrent dislocation rate and a higher rate of return to play as compared with immobilisation in internal rotation. LEVEL OF EVIDENCE Level I.
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Affiliation(s)
- Eoghan T Hurley
- Department of Orthopedic Surgery, NYU Langone Health, New York, New York, USA .,Department of Surgery, National University of Ireland Galway, Galway, Ireland
| | - Jordan W Fried
- Department of Orthopedic Surgery, NYU Langone Health, New York, New York, USA
| | - Michael J Alaia
- Department of Orthopedic Surgery, NYU Langone Health, New York, New York, USA
| | - Eric J Strauss
- Department of Orthopedic Surgery, NYU Langone Health, New York, New York, USA
| | - Laith M Jazrawi
- Department of Orthopedic Surgery, NYU Langone Health, New York, New York, USA
| | - Bogdan A Matache
- Department of Orthopedic Surgery, NYU Langone Health, New York, New York, USA
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21
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Kraeutler MJ, Belk JW, Carver TJ, McCarty EC, Khodaee M. Traumatic Primary Anterior Glenohumeral Joint Dislocation in Sports: A Systematic Review of Operative versus Nonoperative Management. Curr Sports Med Rep 2020; 19:468-478. [PMID: 33156033 DOI: 10.1249/jsr.0000000000000772] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Anterior shoulder (glenohumeral joint [GHJ]) dislocations are relatively common injuries in sports. Previous studies have evaluated clinical outcomes of operative and nonoperative management for primary traumatic anterior GHJ dislocations. The purpose of this study was to systematically review the literature in an effort to provide a thorough analysis of patients after undergoing closed reduction of a traumatic anterior GHJ dislocation, particularly among the athletic population. Two independent reviewers performed a comprehensive search of PubMed and the Cochrane Library through February 23, 2020. Unfortunately, the quantity and quality of published articles on this subject is very limited. In many studies, younger age (between 21 and 30 years) was associated with greater risk for recurrence of GHJ dislocations. Twelve studies (total N = 753) directly compared outcomes of operative versus nonoperative management. It seems that operative management significantly reduces recurrence rates with patients treated operatively among the young and active population. Operative management should be considered as a treatment option for young and athletic patients presenting with a first-time anterior GHJ dislocation.
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Affiliation(s)
- Matthew J Kraeutler
- Department of Orthopaedic Surgery, St. Joseph's University Medical Center, Paterson, NJ
| | | | | | | | - Morteza Khodaee
- Department of Family Medicine and Orthopedics, University of Colorado School of Medicine, Denver, CO
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22
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Smith CS, Mollon B, Vannabouathong C, Fu JM, Sales B, Bhandari M, Whelan DB. An Assessment of Randomized Controlled Trial Quality in The Journal of Bone & Joint Surgery: Update from 2001 to 2013. J Bone Joint Surg Am 2020; 102:e116. [PMID: 33086352 DOI: 10.2106/jbjs.18.00653] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The quality of reporting of randomized controlled trials (RCTs) published in The Journal of Bone & Joint Surgery (JBJS) from 1988 to 2000 was previously analyzed. The purpose of this current study was to analyze the quality of reporting of RCTs published in JBJS from 2001 to 2013 to identify trends over time and potential areas of improvement for future clinical trials. METHODS A manual search of the JBJS database identified RCTs published between January 2001 and December 2013. Quality assessments, using the Detsky quality-of-reporting index (Detsky score), a modified Cochrane risk-of-bias tool, and abstraction of relevant data identifying predictors of quality, were conducted. RESULTS A total of 5,780 publications were identified in JBJS from 2001 to 2013, with 285 RCTs (4.9%), representing an increase from the prior 13-year period. The overall mean transformed Detsky score (and standard error) increased significantly (p < 0.001) from 68.1% ± 1.67% to 76.24% ± 0.72%. The percentage of multicenter RCTs decreased from 67% to 31%. The percentage of positive trials also decreased from 80% to 50.5%, as did the mean sample size (212 to 166). Regression analysis indicated that trials with an epidemiologist as the first author and nonsurgical trials were significantly associated (p = 0.001) with a higher overall trial quality score. The categories of the lowest mean methodology scores were randomization and concealment, eligibility criteria, and reasons for patient exclusion, as identified with the Detsky score, and patient and assessor blinding, as identified with the risk-of-bias assessment. CONCLUSIONS The quantity and quality of published RCTs in JBJS have increased in the 2001 to 2013 time period compared with the previous time period. Although these improvements are encouraging, trends to smaller, single-center trials were also observed. To efficiently determine the efficacy of orthopaedic treatments and limit bias, high-quality randomized trials of appropriate sample size and rigorous design are needed.
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Affiliation(s)
| | - Brent Mollon
- Soldiers' Memorial Hospital, Orillia, Ontario, Canada
| | | | - Joyce M Fu
- Department of Orthopaedics, University of Toronto, Toronto, Ontario, Canada
| | | | - Mohit Bhandari
- Department of Clinical Epidemiology & Biostatistics, McMaster University, Hamilton, Ontario, Canada
| | - Daniel B Whelan
- University of Toronto Orthopaedic Sports Medicine, St. Michael's and Women's College Hospitals, Toronto, Ontario, Canada
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Shinagawa K, Sugawara Y, Hatta T, Yamamoto N, Tsuji I, Itoi E. Immobilization in External Rotation Reduces the Risk of Recurrence After Primary Anterior Shoulder Dislocation: A Meta-analysis. Orthop J Sports Med 2020; 8:2325967120925694. [PMID: 32596407 PMCID: PMC7297495 DOI: 10.1177/2325967120925694] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Accepted: 10/25/2019] [Indexed: 11/15/2022] Open
Abstract
Background The best method for nonsurgical treatment after primary dislocation of the shoulder is not clear. The efficacy of immobilization with the arm in external rotation (ER) compared with internal rotation (IR) remains controversial. Purpose To determine the efficacy of ER immobilization versus IR immobilization on recurrence rate after primary dislocation of the shoulder from the evidence of randomized controlled trials. Study Design Systematic review; Level of evidence, 2. Methods Electronic databases (MEDLINE [Ovid SP], PubMed, Web of Science, EBM reviews, and CINAHL) and available proceedings according to the abstracts of major international meetings related to or including shoulder injuries and trauma were used to search for randomized controlled trials. Two independent investigators determined eligibility and carried out data extraction from the selected studies. Results A total of 9 studies (817 patients) were selected for this meta-analysis. They included 668 male and 149 female patients, with a mean age ranging from 20.3 to 37.5 years. In the 9 pooled studies, the recurrence rate of shoulder dislocation was 21.5% (84/390) in the ER group versus 34.9% (130/373) in the IR group. ER immobilization significantly reduced the recurrence rate compared with IR immobilization (risk ratio, 0.56; P = .007). In the subgroup analysis of those immobilized full-time, ER immobilization was significantly more effective than IR immobilization in reducing the recurrence rate (risk ratio, 0.57; P = .01). In the subgroup analysis of age, ER immobilization was significantly more effective than IR immobilization in those aged 20 to 40 years but not in those younger than 20 years. Conclusion This meta-analysis demonstrates that ER immobilization reduces the recurrence rate after primary shoulder dislocation compared with IR immobilization in patients older than 20 years. When treating a patient with primary shoulder dislocation, the clinician should provide this information to the patient before a treatment method is selected.
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Affiliation(s)
- Kiyotsugu Shinagawa
- Department of Orthopaedic Surgery, Tohoku University School of Medicine, Sendai, Japan
| | - Yumi Sugawara
- Division of Epidemiology, Department of Health Informatics and Public Health, Tohoku University School of Public Health, Graduate School of Medicine, Sendai, Japan
| | - Taku Hatta
- Department of Orthopaedic Surgery, Tohoku University School of Medicine, Sendai, Japan
| | - Nobuyuki Yamamoto
- Department of Orthopaedic Surgery, Tohoku University School of Medicine, Sendai, Japan
| | - Ichiro Tsuji
- Division of Epidemiology, Department of Health Informatics and Public Health, Tohoku University School of Public Health, Graduate School of Medicine, Sendai, Japan
| | - Eiji Itoi
- Department of Orthopaedic Surgery, Tohoku University School of Medicine, Sendai, Japan
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Methods for assessment of patient adherence to removable orthoses used after surgery or trauma to the appendicular skeleton: a systematic review. Trials 2020; 21:507. [PMID: 32513246 PMCID: PMC7278128 DOI: 10.1186/s13063-020-04456-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2019] [Accepted: 05/24/2020] [Indexed: 11/18/2022] Open
Abstract
Background Patient adherence to treatment is a key determinant of outcome for healthcare interventions. Whilst non-adherence has been well evidenced in settings such as drug therapy, information regarding patient adherence to orthoses, particularly in the acute setting, is lacking. The aim of this systematic review was to identify, summarise, and critically appraise reported methods for assessing adherence to removable orthoses in adults following acute injury or surgery. Methods Comprehensive searches of the Ovid versions of MEDLINE, Embase, AMED, CINAHL, Central, the Cochrane Database of Systematic Reviews, and SPORTDiscus identified complete papers published in English between 1990 and September 2018 reporting measurement of adherence to orthoses in adults following surgery or trauma to the appendicular skeleton. Only primary studies with reference to adherence in the title/abstract were included to maintain the focus of the review. Data extraction included study design, sample size, study population, orthosis studied, and instructions for use. Details of methods for assessing adherence were extracted, including instrument/method used, frequency of completion, number of items (if applicable), and score (if any) used to evaluate adherence overall. Validity and reliability of identified methods were assessed together with any conclusions drawn between adherence and outcomes in the study. Results Seventeen papers (5 randomised trials, 10 cohort studies, and 2 case series) were included covering upper (n = 13) and lower (n = 4) limb conditions. A variety of methods for assessing adherence were identified, including questionnaires (n = 10) with single (n = 3) or multiple items (n = 7), home diaries (n = 4), and discussions with the patient (n = 3). There was no consistency in the target behaviour assessed or in the timing or frequency of assessment or the scoring systems used. None of the measures was validated for use in the target population. Conclusions Measurement and reporting of adherence to orthosis use is currently inconsistent. Further research is required to develop a measurement tool that provides a rigorous and reproducible assessment of adherence in this acute population. Trial registration PROSPERO: CRD42016048462. Registered on 17/10/2016.
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Zhang B, Sun Y, Liang L, Yu X, Zhu L, Chen S, Wei Y, Wen G. Immobilization in external rotation versus internal rotation after shoulder dislocation: A meta-analysis of randomized controlled trials. Orthop Traumatol Surg Res 2020; 106:671-680. [PMID: 32446811 DOI: 10.1016/j.otsr.2020.03.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Revised: 02/14/2020] [Accepted: 03/03/2020] [Indexed: 02/03/2023]
Abstract
INTRODUCTION Recurrence rates after primary traumatic shoulder dislocation are distinctly high. Whether the early external immobilization (ER) is better than the internal immobilization (IR) is still controversial. HYPOTHESIS To perform a systematic review of randomized clinical trials (RCTs) that assessed the ability of external immobilization to reduce the recurrence in patients with primary anterior shoulder instability. MATERIAL AND METHOD As with the original review, we used the search strategies recommended by the Cochrane Back Review Group for the identification of RCTs. Thirteen RCTs were included in the systematic review, and 11 studies were included in the quantitative synthesis. RESULT A total of 1042 participants with primary shoulder dislocation were involved. The meta-analysis of 11 trials revealed that ER therapy leading to less recurrence rates than participants treated with IR therapy (RR=0.55; 95%CI: 0.36 to 0.82; Z=2.88; p=0.004), and less complications (RR=0.6; 95%CI: 0.39 to 0.92; Z=2.33; p=0.02) from the 5 independent trials. The meta-analysis of three trials revealed that there are not statistically significant in compliance rate (RR=1.08; 95%CI: 0.89 to 1.29; Z=0.78; p=0.44). The GRADE level of evidence is high for adverse events, but moderate for recurrence rate and Compliance rate. The Begg test showed that no significant publication bias was detected (p=0.062). DISCUSSION This meta-analysis suggests that external immobilization is recommended to reduce the recurrence rate and prevent complications. LEVEL OF PROOF II, low-powered systematic review and meta-analysis (systematic review, meta-analysis).
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Affiliation(s)
- Bingbing Zhang
- Wangjing Hospital of China Academy of Chinese Medical Sciences, 100102 Beijing, China; Dongzhimen Hospital, Beijing University of Chinese Medicine, 100700 Beijing, China
| | - Yongsheng Sun
- Wangjing Hospital of China Academy of Chinese Medical Sciences, 100102 Beijing, China.
| | - Long Liang
- Wangjing Hospital of China Academy of Chinese Medical Sciences, 100102 Beijing, China; Beijing Key Laboratory of Orthopedics of Traditional Chinese Medicine, 100102 Beijing, China
| | - Xing Yu
- Dongzhimen Hospital, Beijing University of Chinese Medicine, 100700 Beijing, China.
| | - Liguo Zhu
- Wangjing Hospital of China Academy of Chinese Medical Sciences, 100102 Beijing, China; Beijing Key Laboratory of Orthopedics of Traditional Chinese Medicine, 100102 Beijing, China
| | - Si Chen
- Wangjing Hospital of China Academy of Chinese Medical Sciences, 100102 Beijing, China
| | - Yifei Wei
- Wangjing Hospital of China Academy of Chinese Medical Sciences, 100102 Beijing, China
| | - Guannan Wen
- Wangjing Hospital of China Academy of Chinese Medical Sciences, 100102 Beijing, China
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Friedman LGM, Lafosse L, Garrigues GE. Global Perspectives on Management of Shoulder Instability: Decision Making and Treatment. Orthop Clin North Am 2020; 51:241-258. [PMID: 32138862 DOI: 10.1016/j.ocl.2019.11.008] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
The glenohumeral joint is prone to instability. Patients with instability should have a physical examination. Imaging studies can provide additional information. Classification schemes that into account soft tissue pathology, neuromuscular control, bone loss, and activity level. An arthroscopic Bankart repair is the mainstay for unidirectional instability. Bone block procedures are indicated for patients with bone loss or a failed attempt at stabilization surgery. The arthroscopic Latarjet is a promising option for these patients. For patients with multidirectional instability, prolonged rehabilitation is indicated, followed by capsular plication or inferior capsular shift if instability is unresponsive to physical therapy.
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Affiliation(s)
- Lisa G M Friedman
- Midwest Orthopaedics at Rush, Rush University Medical Center, 1611 West Harrison Street, Chicago, IL 60612, USA.
| | - Laurent Lafosse
- Clinique Générale, Alps Surgery Institute, 4 Chemin de la Tour la Reine, 74000 Annecy, France
| | - Grant E Garrigues
- Midwest Orthopaedics at Rush, Rush University Medical Center, 1611 West Harrison Street, Chicago, IL 60612, USA. https://twitter.com/Grant_Garrigues
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Murray JC, Leclerc A, Balatri A, Pelet S. Immobilization in external rotation after primary shoulder dislocation reduces the risk of recurrence in young patients. A randomized controlled trial. Orthop Traumatol Surg Res 2020; 106:217-222. [PMID: 30502026 DOI: 10.1016/j.otsr.2018.10.007] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2018] [Revised: 10/24/2018] [Accepted: 10/26/2018] [Indexed: 02/03/2023]
Abstract
INTRODUCTION Patients that sustain anterior shoulder dislocation frequently experience recurrence. Immobilisation in external rotation has been proposed as a treatment that could lower this risk. HYPOTHESIS There is a difference in recurrence rates between immobilization in internal or external rotation following a first-time anterior shoulder dislocation. PATIENTS AND METHODS Single-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. RESULTS Follow-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). DISCUSSION This 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 EVIDENCE II, low-powered prospective randomized trial.
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Affiliation(s)
- Jean-Christophe Murray
- Department of orthopaedic surgery, CHU de Québec, hôpital Enfant-Jésus, 1401, 18(e) rue, G1J 1Z4 Québec, Canada
| | - Alexandre Leclerc
- Department of orthopaedic surgery, CHU de Québec, CHUL, 2705, boulevard Laurier, G1V 4G2 Québec, Canada
| | - Amerigo Balatri
- Department of orthopaedic surgery, CHU de Québec, hôpital Enfant-Jésus, 1401, 18(e) rue, G1J 1Z4 Québec, Canada
| | - Stéphane Pelet
- Department of orthopaedic surgery, CHU de Québec, hôpital Enfant-Jésus, 1401, 18(e) rue, G1J 1Z4 Québec, Canada; Centre de recherche FRQS du CHU de Québec, hôpital Enfant-Jésus, 1401, 18(e) rue, G1J 1Z4 Québec, Canada.
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Chan SKL, Bentick KR, Kuiper JH, Kelly CP. External rotation bracing for first-time anterior dislocation of the shoulder: A discontinued randomised controlled trial comparing external rotation bracing with conventional sling. Shoulder Elbow 2019; 11:256-264. [PMID: 31316586 PMCID: PMC6620796 DOI: 10.1177/1758573218768521] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2017] [Revised: 03/04/2018] [Accepted: 03/12/2018] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Itoi et al. introduced the concept of bracing in abduction and external rotation to treat traumatic anterior shoulder dislocations. However, controversy remains as studies have reported variable results. Our study investigates whether there is a difference in outcomes between treatment with a conventional sling or external rotation brace. METHODS A prospective, multi-centre randomised control trial was conducted between 2006 and 2010. The study was discontinued early with 72 (36 cases in each group) first-time anterior shoulder dislocations recruited. RESULTS The re-dislocation rate over 24 months was comparable 30% (95% CI: 17-47) sling vs. 24% (95% CI: 13-41) external rotation bracing. Sixteen percent (95% CI: 7-32) of sling patients and 12% (95% CI: 5-27) of external rotation-bracing patients had shoulder stabilisation surgery within 24 months of the initial dislocation (p > 0.05). There was no difference in OSI scores at 24 months between the two treatment groups and intolerability of the external rotation brace was high. CONCLUSION Recruitment to this study was difficult, and lost-to-follow-up rates were high leading to early discontinuation of the study. The results suggest that ER bracing is unlikely to provide clinical benefit in traumatic first-time anterior shoulder dislocation.
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Affiliation(s)
- Samuel KL Chan
- The Hand and Upper Limb Unit, The Robert Jones and Agnes Hunt Hospital, Oswestry, UK
| | - Kieran R Bentick
- Royal Shrewsbury Hospital, Mytton Oak Road, Shrewsbury, Shropshire, UK
| | - Jan H Kuiper
- Institute for Science & Technology in Medicine, Keele University, Keele, Staffordshire, UK
| | - Cormac P Kelly
- The Hand and Upper Limb Unit, The Robert Jones and Agnes Hunt Hospital, Oswestry, UK,Cormac P Kelly, The Hand and Upper Limb Unit, The Robert Jones and Agnes Hunt Hospital, Oswestry, Shropshire, SY10 7AG, England.
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Cui X, Liang L, Zhang H, Zhao J, Li Y, Cheng H, Wang S, Zhang Y. Immobilization in external rotation vs internal rotation after shoulder dislocation: A systematic review and meta-analysis protocol. Medicine (Baltimore) 2019; 98:e16707. [PMID: 31393375 PMCID: PMC6709056 DOI: 10.1097/md.0000000000016707] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Dislocation of shoulder joint is the most prone to occurrence in all joints of human body, which is common in young people and has a high recurrence rate. It is mainly treated by conservative treatment. External rotation and internal rotation fixation are 2 common conservative therapies in clinical practice. Therefore, we conduct this systematic review and meta-analysis to evaluate the efficacy and safety of the 2 treatments. METHODS Nine electronic databases, PubMed, Web of Science, Embase, Cochrane Library, Cochrane Central Register of Controlled Trials (CENTRAL), and ClinicalTrials.gov, CNKI, Wanfang Database and VIP Database, will be searched to find and include randomized controlled trials that meet inclusion criteria. RevMan5.3 will be used for data analysis and synthesis in this study. Subgroup analysis and sensitivity analysis will also be performed if necessary. In addition, GRADE will be used in the evaluation of evidence hierarchy. RESULTS This study will analyze and integrate the original evidence so far for clinical efficacy and safety of immobilization in external rotation and internal rotation on shoulder dislocation. CONCLUSION The conclusion of this study will conclude higher evidence and suggestions for the treatment of shoulder dislocation, so as to further guide clinical decision making. PROSPERO REGISTRATION NUMBER CRD42018106030.
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Affiliation(s)
- Xin Cui
- Institute of Basic Research in Clinical Medicine, China Academy of Chinese Medical Sciences
- Wangjing Hospital, China Academy of Chinese Medical Sciences, Beijing
| | - Long Liang
- Wangjing Hospital, China Academy of Chinese Medical Sciences, Beijing
| | - Hongyan Zhang
- Guangzhou University of Traditional Chinese Medicine, Guangzhou
| | - Jing Zhao
- Institute of Basic Research in Clinical Medicine, China Academy of Chinese Medical Sciences
| | - Yongyao Li
- Wangjing Hospital, China Academy of Chinese Medical Sciences, Beijing
| | - Hao Cheng
- Wangjing Hospital, China Academy of Chinese Medical Sciences, Beijing
| | - Shiheng Wang
- China Institute for History of Medicine and Medical Literature, China Academy of Chinese Medical Sciences, Beijing
| | - Yue Zhang
- Longhua Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China
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Braun C, McRobert CJ. Conservative management following closed reduction of traumatic anterior dislocation of the shoulder. Cochrane Database Syst Rev 2019; 5:CD004962. [PMID: 31074847 PMCID: PMC6510174 DOI: 10.1002/14651858.cd004962.pub4] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
BACKGROUND Acute anterior shoulder dislocation, which is the most common type of dislocation, usually results from an injury. Subsequently, the shoulder is less stable and is more susceptible to re-dislocation or recurrent instability (e.g. subluxation), especially in active young adults. After closed reduction, most of these injuries are treated with immobilisation of the injured arm in a sling or brace for a few weeks, followed by exercises. This is an update of a Cochrane Review first published in 2006 and last updated in 2014. OBJECTIVES To assess the effects (benefits and harms) of conservative interventions after closed reduction of traumatic anterior dislocation of the shoulder. These might include immobilisation, rehabilitative interventions or both. SEARCH METHODS We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register, the Cochrane Central Register of Controlled Trials, MEDLINE, Embase, CINAHL, PEDro and trial registries. We also searched conference proceedings and reference lists of included studies. Date of last search: May 2018. SELECTION CRITERIA We included randomised or quasi-randomised controlled trials comparing conservative interventions with no treatment, a different intervention or a variant of the intervention (e.g. a different duration) for treating people after closed reduction of a primary traumatic anterior shoulder dislocation. Inclusion was regardless of age, sex or mechanism of injury. Primary outcomes were re-dislocation, patient-reported shoulder instability measures and return to pre-injury activities. Secondary outcomes included participant satisfaction, health-related quality of life, any instability and adverse events. DATA COLLECTION AND ANALYSIS Both review authors independently selected studies, assessed risk of bias and extracted data. We contacted study authors for additional information. We pooled results of comparable groups of studies. We assessed risk of bias with the Cochrane 'Risk of bias' tool and the quality of the evidence with the GRADE approach. MAIN RESULTS We included seven trials (six randomised controlled trials and one quasi-randomised controlled trial) with 704 participants; three of these trials (234 participants) are new to this update. The mean age across the trials was 29 years (range 12 to 90 years), and 82% of the participants were male. All trials compared immobilisation in external rotation (with or without an additional abduction component) versus internal rotation (the traditional method) following closed reduction. No trial evaluated any other interventions or comparisons, such as rehabilitation. All trials provided data for a follow-up of one year or longer; the commonest length was two years or longer.All trials were at some risk of bias, commonly performance and detection biases given the lack of blinding. Two trials were at high risk of selection bias and some trials were affected by attrition bias for some outcomes. We rated the certainty of the evidence as very low for all outcomes.We are uncertain whether immobilisation in external rotation makes a difference to the risk of re-dislocation after 12 months' or longer follow-up compared with immobilisation in internal rotation (55/245 versus 73/243; risk ratio (RR) 0.67, 95% confidence interval (CI) 0.38 to 1.19; 488 participants; 6 studies; I² = 61%; very low certainty evidence). In a moderate-risk population with an illustrative risk of 312 per 1000 people experiencing a dislocation in the internal rotation group, this equates to 103 fewer (95% CI 194 fewer to 60 more) re-dislocations after immobilisation in external rotation. Thus this result covers the possibility of a benefit for each intervention.Individually, the four studies (380 participants) reporting on validated patient-reported outcome measures for shoulder instability at a minimum of 12 months' follow-up found no evidence of a clinically important difference between the two interventions.We are uncertain of the relative effects of the two methods of immobilisation on resumption of pre-injury activities or sports. One study (169 participants) found no evidence of a difference between interventions in the return to pre-injury activity of the affected arm. Two studies (135 participants) found greater return to sports in the external rotation group in a subgroup of participants who had sustained their injury during sports activities.None of the trials reported on participant satisfaction or health-related quality of life.We are uncertain whether there is a difference between the two interventions in the number of participants experiencing instability, defined as either re-dislocation or subluxation (RR 0.84, 95% CI 0.62 to 1.14; 395 participants, 3 studies; very low certainty evidence).Data on adverse events were collected only in an ad hoc way in the seven studies. Reported "transient and resolved adverse events" were nine cases of shoulder stiffness or rigidity in the external rotation group and two cases of axillary rash in the internal rotation group. There were three "important" adverse events: hyperaesthesia and moderate hand pain; eighth cervical dermatome paraesthesia; and major movement restriction between 6 and 12 months. It was unclear to what extent these three events could be attributed to the treatment. AUTHORS' CONCLUSIONS The available evidence from randomised trials is limited to that comparing immobilisation in external versus internal rotation. Overall, the evidence is insufficient to draw firm conclusions about whether immobilisation in external rotation confers any benefit over immobilisation in internal rotation.Considering that there are several unpublished and ongoing trials evaluating immobilisation in external versus internal rotation, the main priority for research on this question consists of the publication of completed trials and the completion and publication of ongoing trials. Meanwhile, evaluation of other interventions, including rehabilitation, is warranted. There is a need for sufficiently large, good-quality, well-reported randomised controlled trials with long-term follow-up. Future research should aim to determine the optimal immobilisation duration, precise indications for immobilisation, optimal rehabilitation interventions, and the acceptability of these different interventions.
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Affiliation(s)
- Cordula Braun
- Medical Center ‐ University of FreiburgInstitute for Evidence in Medicine (for Cochrane Germany Foundation)Breisacher Str. 153FreiburgGermany79110
| | - Cliona J McRobert
- Institute of Clinical Sciences, University of LiverpoolSchool of Health SciencesBrownlow HillLiverpoolMerseysideUKL69 3GB
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Innovationen in der konservativen Therapie der Schulterinstabilität. ARTHROSKOPIE 2019. [DOI: 10.1007/s00142-018-0240-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Kavaja L, Lähdeoja T, Malmivaara A, Paavola M. Treatment after traumatic shoulder dislocation: a systematic review with a network meta-analysis. Br J Sports Med 2018; 52:1498-1506. [PMID: 29936432 PMCID: PMC6241619 DOI: 10.1136/bjsports-2017-098539] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2017] [Revised: 05/08/2018] [Accepted: 05/16/2018] [Indexed: 01/26/2023]
Abstract
OBJECTIVE To review and compare treatments (1) after primary traumatic shoulder dislocation aimed at minimising the risk of chronic shoulder instability and (2) for chronic post-traumatic shoulder instability. DESIGN Intervention systematic review with random effects network meta-analysis and direct comparison meta-analyses. DATA SOURCES Electronic databases (Ovid MEDLINE, Cochrane Clinical Trials Register, Cochrane Database of Systematic Reviews, Embase, Scopus, CINAHL, Ovid MEDLINE Epub Ahead of Print, In-Process & Other Non-Indexed Citations, Ovid MEDLINE Daily, DARE, HTA, NHSEED, Web of Science) and reference lists were searched from inception to 15 January 2018. ELIGIBILITY CRITERIA FOR SELECTING STUDIES Randomised trials comparing any interventions either after a first-time, traumatic shoulder dislocation or chronic post-traumatic shoulder instability, with a shoulder instability, function or quality of life outcome. RESULTS Twenty-two randomised controlled trials were included. There was moderate quality evidence suggesting that labrum repair reduced the risk of future shoulder dislocation (relative risk 0.15; 95% CI 0.03 to 0.8, p=0.026), and that with non-surgical management 47% of patients did not experience shoulder redislocation. Very low to low-quality evidence suggested no benefit of immobilisation in external rotation versus internal rotation. There was low-quality evidence that an open procedure was superior to arthroscopic surgery for preventing shoulder redislocations. CONCLUSIONS There was moderate-quality evidence that half of the patients managed with physiotherapy after a first-time traumatic shoulder dislocation did not experience recurrent shoulder dislocations. If chronic instability develops, surgery could be considered. There was no evidence regarding the effectiveness of surgical management for post-traumatic chronic shoulder instability.
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Affiliation(s)
- Lauri Kavaja
- Medical Faculty, University of Helsinki, Helsinki, Finland
- Department of Surgery, South Carelia Central Hospital, Lappeenranta, Finland
| | - Tuomas Lähdeoja
- Medical Faculty, University of Helsinki, Helsinki, Finland
- Finnish Center of Evidence-based Orthopaedics (FICEBO), University of Helsinki, Helsinki, Finland
- Department of Orthopaedics and Traumatology, Helsinki University Hospital, Töölö Hospital, Helsinki, Finland
| | - Antti Malmivaara
- Centre for Health and Social Economics, Institute of Health and Welfare, Helsinki, Finland
- Orton Orthopaedic Hospital and Orton Research Institute, Orton Foundation, Helsinki, Finland
| | - Mika Paavola
- Department of Orthopaedics and Traumatology, Helsinki University Hospital, Töölö Hospital, Helsinki, Finland
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The position of sling immobilization influences the outcomes of anatomic total shoulder arthroplasty: a randomized, single-blind, prospective study. J Shoulder Elbow Surg 2018; 27:2120-2128. [PMID: 30446231 DOI: 10.1016/j.jse.2018.08.030] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2018] [Revised: 08/13/2018] [Accepted: 08/19/2018] [Indexed: 02/01/2023]
Abstract
BACKGROUND To date, no studies have been published that have assessed the optimal position of sling immobilization after anatomic total shoulder arthroplasty for glenohumeral osteoarthritis. METHODS Thirty-six patients undergoing anatomic total shoulder arthroplasty for osteoarthritis were randomized to a neutral rotation sling versus an internal rotation sling. The primary outcomes assessed included the Disabilities of the Arm, Shoulder and Hand score; Western Ontario Osteoarthritis of the Shoulder score; Single Assessment Numeric Evaluation score; visual analog scale (VAS) scores for pain and satisfaction; compliance ratings; and radiographic and range-of-motion measurements. Primary outcomes were assessed at baseline and postoperatively at 2 weeks, 6 weeks, 3 months, 6 months, and 1 year. RESULTS All patient-determined outcome scores for both groups revealed statistically significant improvements (P < .0001) from enrollment to final follow-up. There were statistically significant advantages to the neutral rotation sling group compared with the internal rotation sling group when we evaluated the improvements in (1) active external rotation (42° vs 25°, P = .03), (2) passive external rotation (44° vs 26°, P = .02), (3) passive horizontal adduction (7.7 cm vs 3.7 cm, P = .05), and (4) pain relief with passive adduction (VAS score, 6.2 cm vs 3.5 cm; P = .002). There was a trend toward greater improvements in the neutral rotation sling group when we measured (1) active horizontal adduction (8.3 cm vs 2.9 cm, P = .06) and (2) active internal rotation behind the back (18 cm vs 11.1 cm, P = .09). At 2 weeks, the neutral rotation sling group had significantly less night pain than the internal rotation sling group (mean VAS score, 18 mm vs 34 mm; P = .047). CONCLUSIONS Neutral rotation sling use after anatomic total shoulder arthroplasty resulted in statistically significant improvements in external rotation and adduction, as well as decreased night pain, compared with an internal rotation sling.
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Abstract
Anterior shoulder dislocations, subluxations, and recurrent instability of the shoulder joint are common problems usually affecting a young active population. However, it can be a problem for patients up to the late decades in life and can lead to major shoulder arthropathy if left untreated or improperly treated. This article discusses the natural history, pathologic morphologic changes of the shoulder joint associated with anterior instability along with normal anatomic variants. We will also discuss current treatment recommendations and possible causes of the patient with recurrent instability despite prior stabilization procedures.
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Watson L, Balster S, Warby SA, Sadi J, Hoy G, Pizzari T. A comprehensive rehabilitation program for posterior instability of the shoulder. J Hand Ther 2018. [PMID: 28641736 DOI: 10.1016/j.jht.2017.05.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/09/2023]
Abstract
Posterior shoulder instability is recognised as being less prevalent than anterior instability, however the diagnosis of this pathology is easily overlooked or missed and this may contribute to an underestimation of prevalence. Recently, there has been increasing recognition of this condition and consequently a greater requirement for knowledge of diagnostic procedures and treatment directions. Currently there is limited research into the conservative management of posterior instability, although it is recommended as first-line treatment prior to surgical review, particularly in those with an atraumatic instability mechanism. The aim of this paper is to outline a comprehensive rehabilitation program for the conservative management of posterior instability with a focus on scapular and humeral head control. The information provided includes extensive written information, flowcharts, figures and a table of management parameters that will provide therapists with adequate detail to replicate the program in the clinical setting.
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Affiliation(s)
- Lyn Watson
- Department of Rehabilitation, Nutrition and Sport, College of Science, Health and Engineering, La Trobe University, Bundoora, Victoria, Australia; LifeCare Prahran Sports Medicine Centre, Prahran, Victoria, Australia; Melbourne Orthopedic Group, Melbourne, Victoria, Australia
| | - Simon Balster
- LifeCare Prahran Sports Medicine Centre, Prahran, Victoria, Australia; Melbourne Orthopedic Group, Melbourne, Victoria, Australia
| | - Sarah Ann Warby
- Department of Rehabilitation, Nutrition and Sport, College of Science, Health and Engineering, La Trobe University, Bundoora, Victoria, Australia; LifeCare Prahran Sports Medicine Centre, Prahran, Victoria, Australia; Melbourne Orthopedic Group, Melbourne, Victoria, Australia
| | | | - Greg Hoy
- Melbourne Orthopedic Group, Melbourne, Victoria, Australia
| | - Tania Pizzari
- Department of Rehabilitation, Nutrition and Sport, College of Science, Health and Engineering, La Trobe University, Bundoora, Victoria, Australia.
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Avila Lafuente JL, Moros Marco S, García Pequerul JM. Controversies in the Management of the First Time Shoulder Dislocation. Open Orthop J 2018; 11:1001-1010. [PMID: 29430264 PMCID: PMC5789581 DOI: 10.2174/1874325001711011001] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2016] [Revised: 10/21/2016] [Accepted: 10/28/2016] [Indexed: 01/18/2023] Open
Abstract
Background: Traditionally, initial management of first anterior shoulder dislocations consists of reduction of the glenohumeral joint followed by a period of immobilization and subsequent physical therapy to recover shoulder range of motion and strength. This traditional approach in management is now controversial due to the high rate of recurrence. The aim of this paper is to review and discuss the literature about the global management of patients presenting with first-time traumatic anterior glenohumeral dislocation, analyzing the factors that affect shoulder instability after the first episode of dislocation. Methods: Scientific publications about the management of first-time shoulder dislocations are reviewed. Pubmed is used for that and no limit in the year of publication are stablished. These papers and their conclusions are discussed. Results: Younger patients, patient´s activities and the kind of injury are the most important factors related to the shoulder instability after a first time traumatic dislocation. Authors that recommend surgical treatment after the first episode of dislocation argue that the possibilities of recurrence are high and therefore surgery should be performed before its occurrence. Other authors, however, argue that surgical treatment is demanding, and keep in mind that complications, such as recurrence, stiffness and pain after surgery, are still present. Conclusion: Currently, there is still no consensus in the literature with regard to the management of first episode of shoulder dislocation. It is necessary to analyze carefully every individual case to manage them more or less aggressive to obtain the best result in our practice.
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Shields DW, Jefferies JG, Brooksbank AJ, Millar N, Jenkins PJ. Epidemiology of glenohumeral dislocation and subsequent instability in an urban population. J Shoulder Elbow Surg 2018; 27:189-195. [PMID: 29133074 DOI: 10.1016/j.jse.2017.09.006] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2017] [Revised: 09/06/2017] [Accepted: 09/09/2017] [Indexed: 02/01/2023]
Abstract
BACKGROUND Glenohumeral dislocation is the most commonly encountered adult joint instability. The epidemiology in the United Kingdom and worldwide is unclear and often limited to young, active groups that are not representative of general populations. Information regarding epidemiology and outcome from a first dislocation is useful for trauma service planning and patient counseling. We calculated the incidence of shoulder instability after a first dislocation in our urban population and investigated predictors of recurrent instability. METHODS A prospectively collected trauma database was retrospectively examined to identify patients with a first-time dislocation. Demographics, subsequent dislocation, and instability details were collected from electronic patient records. RESULTS In a 38-month study period, 329 first dislocations occurred in a population of 475,147 with mean follow-up 28.5 months (range, 10-50 months). The overall incidence for first-time dislocations in this population was 21.9 per 100,000 population, of which 7.9% sustained a redislocation and 6.1% had further symptomatic instability. There were 18.8% with associated greater tuberosity fractures, 8.8% sustained a nerve injury, and 2.7% were posterior dislocations. A bimodal distribution was observed for males (peak incidence per 100,000 of 42.1 and 50.9 in 15-24 and ≥85 age groups, respectively), and unimodal for females (peak 45.7 in the 65-74 age group). CONCLUSION We demonstrate a previously unreported burden of dislocation in older age groups and suggest a rate of recurrence lower than previously reported in the United Kingdom. The group aged 15 to 19 years was at the highest risk of recurrent dislocation and instability. Gender was not a significant predictor of instability.
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Affiliation(s)
- David W Shields
- Department of Trauma & Orthopaedic Surgery, Glasgow Royal Infirmary, Glasgow, UK
| | - James G Jefferies
- Department of Trauma & Orthopaedic Surgery, Glasgow Royal Infirmary, Glasgow, UK.
| | - Andrew J Brooksbank
- Department of Trauma & Orthopaedic Surgery, Glasgow Royal Infirmary, Glasgow, UK
| | - Neal Millar
- Institute of Infection, Inflammation and Immunology, College of Medicine, Veterinary and Life Sciences, University of Glasgow, Glasgow, UK
| | - Paul J Jenkins
- Department of Trauma & Orthopaedic Surgery, Glasgow Royal Infirmary, Glasgow, UK
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Abstract
PURPOSE OF REVIEW The purpose of this review is to discuss the epidemiology, pathoanatomy, diagnosis, and clinical management of pediatric and adolescent patients following a first-time shoulder dislocation. RECENT FINDINGS Shoulder instability is becoming increasingly common as pediatric and adolescent patients engage in earlier organized sports competition. Recommended treatment following a first-time glenohumeral dislocation event in adolescents depends on several factors, but surgical stabilization is becoming more frequently performed. Surgical indications include bony Bankart lesion, ALPSA lesion, bipolar injury (e.g. Hill-Sachs humeral head depression fracture) or off-season injury in an overhead or throwing athlete. Complications following surgical treatment are rare but most commonly are associated with recurrent instability. Young children (eg. open proximal humerus growth plate), individuals averse to surgery, or in-season athletes who accept the risk of redislocation may complete an accelerated rehabilitation program for expedited return to play in the absence of the structural abnormalities listed above. SUMMARY Following a first-time dislocation event in pediatric and adolescent patients, a detailed discussion of the risks and benefits of nonoperative versus operative management is critical to match the recommended treatment with the patient's injury pattern, risk factors, and activity goals.
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Conti M, Garofalo R, Castagna A, Massazza G, Ceccarelli E. Dynamic brace is a good option to treat first anterior shoulder dislocation in season. Musculoskelet Surg 2017; 101:169-173. [PMID: 28770511 DOI: 10.1007/s12306-017-0497-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2017] [Accepted: 07/19/2017] [Indexed: 06/07/2023]
Abstract
PURPOSE We evaluate the ability of in-season competitive athletes to return to competition after an anterior shoulder instability treated conservatively with a new dynamic brace combined with a specific rehabilitation program. METHODS Twenty soccer players affected by traumatic anterior shoulder dislocation have been enrolled in the "Footballer In Season Fast Rehab" project during 2 consecutive football seasons. We excluded patients affected by rotator cuff tears and the bony defect over 25%. All the players have been treated the day after the first dislocation with a new dynamic brace used until the end of the second month after the first glenohumeral dislocation combined with a specific rehab protocol. Athletes were evaluated for the time necessary to completely resume sport activities, to complete the season, and for the recurrence of dislocation. RESULTS All the athletes enrolled in this study were able to come back on the ground in approximately 40 days after the dislocation except 2 of them. Only two athletes claimed a slight discomfort at the return to play. One athlete had a traumatic relapse of the instability, 50 days after the dislocation. Another athlete claimed to have had a subluxation during a training session 45 days after the dislocation. 90% of the athletes were able to end the season without any shoulder discomfort. CONCLUSIONS The dynamic brace combined to the rehabilitation protocol represents the solution that allows a quick start of resumption of training while maintaining a stable pain-free shoulder. LEVEL OF EVIDENCE Level 4.
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Affiliation(s)
- M Conti
- MedSport Human Performance Lab, Como, Italy
| | - R Garofalo
- Ospedale Generale Regionale "F. Miulli" Acquaviva delle Fonti, Bari, Italy
| | - A Castagna
- Istituto Clinico Humanitas, Rozzano, Milan, Italy
| | - G Massazza
- Physical Medicine and Rehabilitation, University of Turin, Turin, Italy
| | - E Ceccarelli
- Ospedale Casilino, Via Casilina, 1040, Rome, Italy.
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Rosa JRP, Checchia CS, Miyazaki AN. Traumatic anterior instability of the shoulder. Rev Bras Ortop 2017; 52:513-520. [PMID: 29062813 PMCID: PMC5643896 DOI: 10.1016/j.rboe.2017.09.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2016] [Accepted: 09/01/2016] [Indexed: 01/10/2023] Open
Abstract
The shoulder is the most unstable joint in the human body. Traumatic anterior instability of the shoulder is a common condition, which, especially in young patients, is associated with high recurrence rates. The effectiveness of non-surgical treatments when compared to surgical ones is still controversial. The purpose of this study was to review the literature for current concepts and updates regarding the treatment of this condition.
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Affiliation(s)
- João Roberto Polydoro Rosa
- Faculdade de Ciências Médicas da Santa Casa de São Paulo (FCM-SCSP), Departamento de Ortopedia e Traumatologia, São Paulo, SP, Brazil
| | - Caio Santos Checchia
- Faculdade de Ciências Médicas da Santa Casa de São Paulo (FCM-SCSP), Departamento de Ortopedia e Traumatologia, São Paulo, SP, Brazil
| | - Alberto Naoki Miyazaki
- Faculdade de Ciências Médicas da Santa Casa de São Paulo (FCM-SCSP), Departamento de Ortopedia e Traumatologia, São Paulo, SP, Brazil
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Abstract
PURPOSE OF REVIEW The purpose of this review is to outline the natural history and best clinical practices for nonoperative management of anterior shoulder instability. RECENT FINDINGS Recent studies continue to demonstrate a role for nonoperative treatment in the successful long-term management of anterior glenohumeral instability. The success of different positions of shoulder immobilization is reviewed as well. There are specific patients who may be best treated with nonoperative means after anterior glenohumeral instability. There are also patients who are not good nonoperative candidates based on a number of factors that are outlined in this review. There continues to be no definitive literature regarding the return to play of in-season athletes. Successful management requires a thorough understanding of the epidemiology, pathoanatomy, history, physical examination, diagnostic imaging modalities, and natural history of operative and nonoperative treatment.
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Shah R, Chhaniyara P, Wallace WA, Hodgson L. Pitch-side management of acute shoulder dislocations: a conceptual review. BMJ Open Sport Exerc Med 2017; 2:e000116. [PMID: 28879022 PMCID: PMC5569260 DOI: 10.1136/bmjsem-2016-000116] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/09/2017] [Indexed: 01/20/2023] Open
Abstract
The shoulder, specifically the glenohumeral joint, by virtue of its anatomical characteristics and biomechanics confers a large range of movement, which ultimately results in a joint that is inherently prone to becoming unstable. The incidence of acute traumatic shoulder dislocation varies within the sporting environment, commonly occurring following direct trauma. Anterior dislocations account for nearly 90% of all dislocations. While most are referred and managed in the emergency department, pitch-side relocation by experienced clinicians does occur prior to referral. The aim of this study was to delineate a guideline specifically for the pitch-side management of this common injury. A literature search of PubMed and Medline using the keywords ‘prehospital’, ‘pitch-side’, ‘shoulder dislocation’ and ‘reduction’ or ‘relocation technique’ was performed, and the available literature was reviewed and collated. Articles focusing on reduction techniques were then reviewed, with particular consideration on their applicability to a pitch-side setting. While studies exist that compare and contrast examination and reduction techniques, most are based in a hospital setting. To date, there is no standardised management protocol published for the initial management of an anterior dislocated shoulder in a pitch-side setting. This article addresses this discrepancy and proposes a structured, algorithmic approach to the pitch-side management of a shoulder dislocation. The article addresses factors to consider in a pitch-side setting, suitable techniques and postreduction care. While a systematic approach has been delineated in this article, we recommend those pitch-side medical practitioners who provide this form of support should have attended appropriate training and ensure adequate malpractice cover.
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Affiliation(s)
- Rohi Shah
- Department of Trauma and Orthopaedic Surgery, Kettering General Hospital, The University of Nottingham, Nottingham, UK
| | - Puja Chhaniyara
- Queens Medical Centre, Department of Emergency Medicine, The University of Nottingham, Nottingham, UK
| | - W Angus Wallace
- Queens Medical Centre, Department of Trauma and Orthopaedic Surgery, The University of Nottingham, Nottingham, UK
| | - Lisa Hodgson
- Queens Medical Centre, Department of Academic Orthopaedics and Sports Trauma, The University of Nottingham, Nottingham, UK
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Abstract
BACKGROUND In the current literature a consensus on the specific management of primary anterior traumatic shoulder instability has not been reached. While the steps of the initial diagnostic and therapeutic procedures are mostly well-defined, a variety of factors need to be considered for the planning of further treatment. OBJECTIVE This article aims at giving an overview of the essential aspects of the initial management in the rescue center, clinical and radiological diagnostic procedures and the subsequent treatment options. MATERIAL AND METHODS The content of this article is based on our own clinical experiences in combination with a systematic literature search for relevant clinical and baseline studies. RESULTS Besides a detailed anamnesis and clinical examination, X‑rays in two planes are important for the diagnosis. Potential nerve injuries or fractures need to be borne in mind before and after reduction of the joint and documented accordingly. The Matsen's maneuver can be recommended as it enables a careful repositioning. In rare cases of an irreducible shoulder dislocation due to soft tissue or bony articular interpositions, an open reduction might be necessary. Further therapeutic concepts should be adapted to patient age, activity level and accompanying pathologies, which determine the risk of a recurrent dislocation. A surgical approach for stabilization of the shoulder is highly recommended in cases of concomitant bony defects as well as in young and physically active patients. CONCLUSION A well-structured treatment plan is essential for the initial management of primary anterior traumatic shoulder instability. A generally applicable algorithm for further management is not yet established. The treatment should therefore be individually planned based on patient-specific characteristics.
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Gutkowska O, Martynkiewicz J, Gosk J. Position of Immobilization After First-Time Traumatic Anterior Glenohumeral Dislocation: A Literature Review. Med Sci Monit 2017; 23:3437-3445. [PMID: 28710344 PMCID: PMC5523960 DOI: 10.12659/msm.901876] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
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.
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Affiliation(s)
- Olga Gutkowska
- Department of Traumatology, Clinical Department of Traumatology and Hand Surgery, Wrocław Medical University, Wrocław, Poland
| | - Jacek Martynkiewicz
- Department of Traumatology, Clinical Department of Traumatology and Hand Surgery, Wrocław Medical University, Wrocław, Poland
| | - Jerzy Gosk
- Department of Traumatology, Clinical Department of Traumatology and Hand Surgery, Wrocław Medical University, Wrocław, Poland
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Gaballah A, Zeyada M, Elgeidi A, Bressel E. Six-week physical rehabilitation protocol for anterior shoulder dislocation in athletes. J Exerc Rehabil 2017; 13:353-358. [PMID: 28702449 PMCID: PMC5498094 DOI: 10.12965/jer.1734976.488] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2016] [Accepted: 06/10/2017] [Indexed: 11/22/2022] Open
Abstract
Anterior shoulder dislocations are common in young athletes. The mechanism for the first or primary shoulder dislocation may involve a collision or a fall typically with the arm in an abducted and externally rotated position. The aim of this study was to design a physical rehabilitation program using the elastic band and resistive exercise to improve joint strength and range of motion in individuals diagnosed with a first-time shoulder dislocation. Twelve physically active males with a first-time acute shoulder dislocation were asked to volunteer. Participants began a physical rehabilitation program 2 weeks after the shoulder dislocation, which was confirmed by a referring physician. The rehabilitation program was 6 weeks in duration and required the participants to engage in progressive resistive loads/duration using elastic bands and weights 5 days per week. Pretest and posttest measures included shoulder strength and range of motion. All outcome measures were compared between the injured and uninjured shoulder, which served as the control condition in this study. There were statistically significant differences between the injured and uninjured shoulder for measures of strength and range of motion during pretests (P<0.01) but not post-tests (P<0.53). Finally, there were no differences between shoulders in regards to the volume measure suggesting that any changes in muscle atrophy or swelling were not detected. The physical rehabilitation program proposed in this study was effective at improving strength and range of motion in the injured shoulder as evidenced by the similarity in posttest values between the injured and uninjured shoulder.
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Affiliation(s)
- Ahmed Gaballah
- Department of Kinesiology and Health Science, Utah State University, Logan, UT, USA.,Department of Sports Health Science, Damietta University, Damietta, Egypt
| | - Mohamed Zeyada
- Department of Sports Health Science, Mansoura University, Mansoura, Egypt
| | - Adham Elgeidi
- Department of Orthopaedic Surgery, Mansoura University, Mansoura, Egypt
| | - Eadric Bressel
- Department of Kinesiology and Health Science, Utah State University, Logan, UT, USA
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Marshall T, Vega J, Siqueira M, Cagle R, Gelber JD, Saluan P. Outcomes After Arthroscopic Bankart Repair: Patients With First-Time Versus Recurrent Dislocations. Am J Sports Med 2017; 45:1776-1782. [PMID: 28384005 DOI: 10.1177/0363546517698692] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND The young athletic population makes up the largest portion of shoulder instability and, when treated nonoperatively, has a recurrent dislocation rate as high as 71%. It is unknown how the outcomes of those who have a recurrent dislocation are affected versus those who have a stabilization procedure after a first-time dislocation. PURPOSE To report the postoperative outcomes of patients with first-time dislocations versus patients with recurrent dislocations before surgery. STUDY DESIGN Cohort study; Level of evidence, 3. METHODS Current Procedural Terminology codes were used to identify patients who had arthroscopic Bankart repair between 2003 and 2013. A total of 173 eligible patients were identified across 8 fellowship-trained surgical practices. The first phase of the study was a retrospective chart review. Patients were identified as having a first-time dislocation or as having recurrent dislocations when they had >1 dislocation before surgical intervention. The second phase consisted of a survey to record a Simple Shoulder Test score and return to sport and to report postoperative instability and whether patients had further surgery on the shoulder. RESULTS A total of 121 patients participated, providing 70% follow-up at an average of 51 months. There were 53 patients in the recurrent dislocation group and 68 in the first-time dislocation group. The postoperative instability rate was 29% in the first-time dislocation group and 62% in the recurrent dislocation group; this difference was significant ( P < .001). The odds of postoperative instability were 4 times higher in the recurrent dislocation group (odds ratio = 4.14). The first-time dislocation group reported a 7% rate of repeat operation to address instability, whereas the recurrent dislocation group reported a rate of 32%; this difference was significant ( P < .001). The odds of needing additional surgery on the index shoulder was 6 times higher in the recurrent dislocation group (odds ratio = 6.01). CONCLUSION Patients with first-time dislocations had lower postoperative instability rates and reoperation rates when compared with patients with recurrent dislocations before surgery. Young patients with shoulder instability should be offered early surgical intervention to lower the risk of postoperative instability and reoperation.
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Affiliation(s)
- Tyler Marshall
- Alabama Ortho Spine and Sports, Birmingham, Alabama, USA
| | - Jose Vega
- Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | | | - Robert Cagle
- Cleveland Clinic Foundation, Cleveland, Ohio, USA
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Çiçek H, Tuhanioğlu Ü, Oğur HU, Seyfettinoğlu F, Çiloğlu O, Beyzadeoğlu T. Single anterior portal: A better option for arthroscopic treatment of traumatic anterior shoulder instability? ACTA ORTHOPAEDICA ET TRAUMATOLOGICA TURCICA 2017; 51:298-302. [PMID: 28687191 PMCID: PMC6197563 DOI: 10.1016/j.aott.2017.03.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/24/2015] [Revised: 08/23/2016] [Accepted: 09/15/2016] [Indexed: 01/02/2023]
Abstract
OBJECTIVE The aim of this study was to compare single and double anterior portal techniques in the arthroscopic treatment of traumatic anterior shoulder instability. METHODS A total of 91 cases who underwent arthroscopic Bankart repair for anterior shoulder instability were reviewed. The patients were divided into 2 groups as Group 1 (47 male and 2 female; mean age: 25.8 ± 6.8) for arthroscopic single anterior portal approach and Group 2 (41 male and 1 female; mean age: 25.4 ± 6.6) for the classical anterior double portal approach. The groups were compared for clinical scores, range of motion, analgesia requirement, complications, duration of surgery, cost and learning curve according to a short questionnaire completed by the relevant healthcare professionals. RESULTS No statistically significant difference was found between the 2 groups in terms of pre-operative and post-operative Constant and Rowe Shoulder Scores, range of motion and complications (p > 0.05). In Group 2 patients, the requirement for post-operative analgesics was significantly higher (p < 0.001), whereas the duration of surgery was statistically significantly shorter in Group 1 (p < 0.001). In the assessment of the questionnaire, it was seen that a single portal anterior approach was preferred at a higher ratio (p = 0.035). The cost analysis revealed that the cost was 5.7% less for patients with a single portal. CONCLUSION In the arthroscopic treatment of traumatic anterior shoulder instability accompanied by a Bankart lesion, the anterior single portal technique is as successful in terms of clinical results as the conventional double portal approach. The single portal technique has advantages such as less postoperative pain, a shorter surgical learning curve and lower costs. LEVEL OF EVIDENCE Level III, Therapeutic study.
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Affiliation(s)
- Hakan Çiçek
- Adana Numune Training and Research Hospital, Adana, Turkey.
| | | | | | | | - Osman Çiloğlu
- Adana Numune Training and Research Hospital, Adana, Turkey
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Comfort and acceptability of various immobilization positions using a shoulder external rotation and abduction brace. J Orthop Sci 2017; 22:285-288. [PMID: 27863887 DOI: 10.1016/j.jos.2016.10.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2016] [Revised: 09/10/2016] [Accepted: 10/26/2016] [Indexed: 11/24/2022]
Abstract
BACKGROUND Immobilization with shoulder braces is used for conservative treatment of an initial shoulder dislocation. Various arm positions have been investigated to determine optimal position in terms of the anatomical reduction of the Bankart lesion. Recently, the effect of immobilization in shoulder abduction as well as in external rotation has been reported. However, there are few studies assessing subjects' acceptability of the brace in various arm positions. We hypothesized that a certain arm position regarding abduction or external rotation for immobilization would induce significant discomfort during activities of daily living. METHODS A dominant arm of 20 healthy participants was immobilized with a shoulder brace in 4 different positions; adduction and internal rotation (Add-IR), adduction and external rotation (Add-ER), 30° of abduction and 30° of external rotation (Abd-30ER), and 30° of abduction and 60° of external rotation (Abd-60ER). After completing immobilization for 24 h, subjects were asked to assess the discomfort of bracing for overall and individual activities, using a visual analogue scale. Data were compared among the four positions. RESULTS For overall activities and several activities (eating, reading books, and removing and putting on pants), Abd-60ER was significantly more uncomfortable than adducted arm positions. Abd-30ER did not show any differences compared to the other arm positions. CONCLUSION Immobilization in abduction and external rotation seems to be acceptable although the arm position in 30° of abduction and 60° of external rotation is less comfortable than the others. Our results might be useful in determining and developing the ideal shoulder brace which could keep patients' compliance and improve their outcomes.
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50
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Anthony CA, Glass NA, Hancock K, Bollier M, Wolf BR, Hettrich CM. Performance of PROMIS Instruments in Patients With Shoulder Instability. Am J Sports Med 2017; 45:449-453. [PMID: 28146398 DOI: 10.1177/0363546516668304] [Citation(s) in RCA: 94] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Shoulder instability is a relatively common condition occurring in 2% of the population. PROMIS (Patient-Reported Outcome Measurement Information System) was developed by the National Institutes of Health in an effort to advance patient-reported outcome (PRO) instruments by developing question banks for major health domains. PURPOSE To compare PROMIS instruments to current PRO instruments in patients who would be undergoing operative intervention for recurrent shoulder instability. STUDY DESIGN Cohort study (diagnosis); Level of evidence, 2. METHODS A total of 74 patients with a primary diagnosis of shoulder instability who would be undergoing surgery were asked to fill out the American Shoulder and Elbow Surgeons shoulder assessment form (ASES), Marx shoulder activity scale (Marx), Short Form-36 Health Survey Physical Function subscale (SF-36 PF), Western Ontario Shoulder Instability Index (WOSI), PROMIS physical function computer adaptive test (PF CAT), and PROMIS upper extremity item bank (UE). Correlation between PRO instruments was defined as excellent (>0.7), excellent-good (0.61-0.7), good (0.4-0.6), and poor (0.2-0.3). RESULTS Utilization of the PROMIS UE demonstrated excellent correlation with the SF-36 PF ( r = 0.78, P < .01) and ASES ( r = 0.71, P < .01); there was excellent-good correlation with the EQ-5D ( r = 0.66, P < .01), WOSI ( r = 0.63, P < .01), and PROMIS PF CAT ( r = 0.63, P < .01). Utilization of the PROMIS PF CAT demonstrated excellent correlation with the SF-36 PF ( r = 0.72, P < .01); there was excellent-good correlation with the ASES ( r = 0.67, P < .01) and PROMIS UE ( r = 0.63, P < .01). When utilizing the PROMIS UE, ceiling effects were present in 28.6% of patients aged 18 to 21 years. Patients, on average, answered 4.6 ± 1.8 questions utilizing the PROMIS PF CAT. CONCLUSION The PROMIS UE and PROMIS PF CAT demonstrated good to excellent correlation with common shoulder and upper extremity PRO instruments as well as the SF-36 PF in patients with shoulder instability. In patients aged ≤21 years, there were significant ceiling effects utilizing the PROMIS UE. While the PROMIS PF CAT appears appropriate for use in adults of any age, our findings demonstrate that the PROMIS UE has significant ceiling effects in patients with shoulder instability who are ≤21 years old, and we do not recommend use of the PROMIS UE in this population.
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Affiliation(s)
- Chris A Anthony
- Department of Orthopaedic Surgery and Rehabilitation, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Natalie A Glass
- Department of Orthopaedic Surgery and Rehabilitation, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Kyle Hancock
- Department of Orthopaedic Surgery and Rehabilitation, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Matt Bollier
- Department of Orthopaedic Surgery and Rehabilitation, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Brian R Wolf
- Department of Orthopaedic Surgery and Rehabilitation, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Carolyn M Hettrich
- Department of Orthopaedic Surgery and Rehabilitation, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
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