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First Time Dislocators

Evidence based outcome from a first time dislocation of the shoulder

Peter Brownson
Liverpool Upper Limb Unit

Prevalence

Hovelius 1982 Clinical Orthopaedics

  • Population study
  • Random sample of 2092 people
  • 18-70 years
  • 35 reported a dislocation (1.7%)
  • M:F 3:1
  • M:F 9:1 21-30 yrs age group
  • Prevalence Simonet 1984 Clinical Orthopaedics
  • Cumulative incidence up to 70 years
  • Male 0.7%
  • Female 0.3%

Recurrence

The reported rate of redislocation is 17% to 96% with a mean of 67%
Increased rate of recurrence in younger age groups

Primary anterior dislocation of the shoulder in young patients. A 10 year prospective study - Hovelius 1996 JBJS(A)

  • Multi centre study
  • 10 year follow up
  • 245 patients
  • Age 12-40 years
  • 57% sporting injury
  • Non-operative management
  • 52% no additional dislocation
  • 8 shoulders considered unstable but no dislocation
  • 23% operative treatment
  • In 12 to 22 year age group operation in 34%
  • Hill -Sachs lesion associated with a worse prognosis
  • Greater tuberosity fracture associated with a better prognosis
  • Immobilisation method not relevant

The prognosis following acute primary glenohumeral dislocation - Slaa et al JBJS(B) 2004

  • 105 patients
  • Mean follow up 5 years
  • Recurrence of 26% within 4 years overall
  • Age most significant prognostic factor
  • Under 20 years recurrence in 64%
  • Over 40 years recurrence in 6%

Surgical versus non-surgical treatment for acute shoulder dislocations
A prospective, randomised evaluation of arthroscopic stabilization versus nonoperative treatment in patients with acute, traumatic, first-time shoulder dislocations - Bottoni et al AM J Sports Med 2002

  • 24 patients randomised
  • Non-operative treatment with sling for 4 weeks
  • Operative arthroscopic  repair within 10 days using Suretac
  • Failure due to redislocation or instability symptoms preventing return to full duty
  • Average follow up 36 months
  • 3 patients lost to follow up
  • Non-operative failed in 9/12 (75%)
  • Operative failed in 1/9 (11%)

Prospective randomised clinical trial comparing the effectiveness of immediate arthroscopic stabilization versus immobilization and rehabilitation in first traumatic anterior dislocations of the shoulder - Kirkley et al 1999 Arthroscopy

  • Prospective randomised single blind study
  • 40 patients under 30 years of age
  • Traumatic first time dislocation
  • Non-operative treatment with shoulder immobilization for 3 weeks
  • Operative treatment within 4 weeks using arthroscopic transglenoid sutures
  • Mean age 24 years
  • All patients except 1 had Bankart lesion
  • Minimum follow up 24 months
  • Non-operative 9/19 (47%) redislocation
  • Operative 3/19 (16%) redislocation
  • WOSI 16% better in operative group
  • 1 post operative infection treated with antibiotics

Arthroscopic lavage compared with nonoperative treatment for traumatic anterior shoulder dislocation: A two year follow- up of a prospective randomised study. Wintzell JSES 1999

  • 30 consecutive patients
  • Traumatic primary dislocation
  • Randomised
  • Mean age 24 years
  • Non-operative with immobilization up to 1 week
  • Operative with arthroscopic lavage within 10 days
  • 2 year follow up
  • Redislocation in 3/15 (20%) of lavage group
  • Redislocation in 9/15 (60%) of non-operative group

Primary repair after traumatic anterior dislocation of the shoulder joint Jackobsen 1997 Orthop transactions

  • Randomised
  • 76 patients
  • Median age 22 years
  • Operative open repair within 1 week
  • Non-operative treatment with sling for 1 week2 year follow up

Primary repair after traumatic anterior dislocation of the shoulder joint Jackobsen 1997 Orthop transactions

  • Redislocation in 1/37 patients treated operatively
  • Redislocation in 20/39 treated operatively

Cochrane review Surgical versus non-surgical treatment for acute anterior shoulder dislocation Handoll et al 2004

  • 5 studies included
  • 239 patients
  • Typically male aged 22 years
  • Primary traumatic anterior shoulder dislocation
  • Primary outcomes
    • Pooled results show subsequent instability, either dislocation or subluxation, was highly statistically significantly less in the surgical group RR 0.2
  • Secondary outcomes
    • Objective instability ( positive ant app test) was significantly less common in the surgical group
  • Only complication was 1 septic joint
  • No data pertaining to stiffness or muscle strength
  • Evidence appears reliable but with reservations
  • Long term prognosis relating to arthritis remains uncertain

Conclusions

"The limited evidence available from randomised controlled trials supports primary surgery in young adults (usually male( engaged in highly demanding physical activities who have sustained their first acute traumatic shoulder dislocation. 
   There is no evidence available to determine  whether surgical or non-surgical treatment is better for other categories of patient or injury.
   In particular there is no evidence available to determine whether non-surgical treatment  should not remain the prime treatment option after primary dislocation in those patients who are at a much lower risk of redislocation."

See the full Presentation HERE

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