Traumatic First Time Shoulder Dislocation: Surgery vs Non-Operative Treatment

Document Type: CURRENT CONCEPTS REVIEW

Authors

1 Rowley Bristow Unit, Ashford & St Peters NHS FT, London, UK

2 Chelsea & Westminster Hospital, London, UK

3 Reading Shoulder Unit, Reading, London, UK

4 Rowley Bristow Unit, Ashford & St Peters NHS FT Fortius Clinic, London, UK

Abstract

 
 Management of first shoulder dislocation following reduction remains controversial. The two main options are immobilisation and arthroscopic stabilisation. The aim of this article is to highlight some of the issues that influence decision making when discussing management options with these patients, including natural history of the first time dislocation, outcomes of surgery and non-operative management particularly on the risk of future osteoarthritis (OA), the effects of delaying surgery and the optimal method of immobilisation.
Extensive literature review was performed looking for previous publication addressing 4 points. i) Natural history of primary shoulder dislocation ii) Effect of surgical intervention on natural history iii) Risk of long term osteoarthritis with and without surgical intervention iv) Immobilisation techniques post reduction.
Individuals younger than 25 years old are likely to re-dislocate with non-operative management. Surgery reduces risk of recurrent instability. Patients with recurrent instability appear to be at a higher risk of OA. Those who have surgical stabilisation do not appear to be at a higher risk than those who dislocate just once, but are less likely to develop OA than those with recurrent instability. Delaying surgery makes the stabilisation more demanding due to elongation of capsule, progressive labro-ligamentous injury, prevalence and severity of glenoid bone loss. Recent studies have failed to match the preliminary outcomes associated with external rotation braces.
Defining the best timing and type of treatment remains a challenge and should be tailored to each individual’s age, occupation and degree of physical activity.

Keywords


  1. Brophy RH, Marx RG. The treatment of traumatic anterior instability of the shoulder: nonoperative and surgical treatment. Arthroscopy. 2009; 25(3):298–304.
  2. Kirkley A, Werstine R, Ratjek A, Griffin S. Prospective randomized clinical trial comparing the effectiveness of immediate arthroscopic stabilization versus immobilization and rehabilitation in first traumatic anterior dislocations of the shoulder: long-term evaluation. Arthroscopy. 2005; 21(1):55–63.
  3. Kirkley A, Griffin S, McLintock H, Ng L. The development and evaluation of a disease-specific quality of life measurement tool for shoulder instability. The Western Ontario Shoulder Instability Index (WOSI). Am J Sports Med. 1998; 26(6):764–72.
  4. Gill TJ, Micheli LJ, Gebhard F, Binder C. Bankart repair for anterior instability of the shoulder. Long-term outcome. J Bone Joint Surg Am. 1997; 79(6):850-7.
  5. Griffith JF, Antonio GE, Yung PS, Wong EM, Yu AB, Ahuja AT, et al. Prevalence, pattern, and spectrum of glenoid bone loss in anterior shoulder dislocation: CT analysis of 218 patients. AJR Am J Roentgenol. 2008; 190(5):1247-54.
  6. Hovelius L, Saeboe M. Neer Award 2008: Arthropathy after primary anterior shoulder dislocation--223 shoulders prospectively followed up for twenty-five years. J Shoulder Elbow Surg. 2009; 18(3):339-47.
  7. Paterson WH, Throckmorton TW, Koester M, Azar FM, Kuhn JE. Position and duration of immobilization after primary anterior shoulder dislocation: a systematic review and meta-analysis of the literature. J Bone Joint Surg Am. 2010; 92(18):2924-33.
  8. Rowe CR. Prognosis in dislocations of the shoulder. J Bone Joint Surg Am. 1956; 38-A(5):957–77.
  9. Sachs RA, Lin D, Stone ML, Paxton E, Kuney M. Can the need for future surgery for acute traumatic anterior shoulder dislocation be predicted? J Bone Joint Surg Am. 2007; 89(8):1665–74.
  10. te Slaa RL, Brand R, Marti RK. A prospective arthroscopic study of acute first-time anterior shoulder dislocation in the young: a five-year follow-up study. J Shoulder Elbow Surg. 2003; 12(6):529–34.
  11. Wintzell G, Hovelius L, Wikblad L, Saebo M, Larsson S. Arthroscopic lavage speeds reduction in effusion in the glenohumeral joint after primary anterior shoulder dislocation: a controlled randomized ultrasound study. Knee Surg Sports Traumatol Arthrosc. 2000; 8(1):56–60.
  12. Hovelius L, Olofsson A, Sandström B, Krantz L, Fredin H, Tillander B, et al. Nonoperative treatment of primary anterior shoulder dislocation in patients forty years of age and younger. a prospective twenty-five-year follow-up. J Bone Joint Surg Am. 2008; 90(5):945-52.
  13. Robinson CM, Howes J, Murdoch H, Will E, Graham C. Functional outcome and risk of recurrent instability after primary traumatic anterior shoulder dislocation in young patients. J Bone Joint Surg Am. 2006; 88(11):2326–36.
  14. Jakobsen BW, Johannsen HV, Suder P, Søjbjerg JO. Primary repair versus conservative treatment of first-time traumatic anterior dislocation of the shoulder: a randomized study with 10-year follow-up. Arthroscopy. 2007; 23(2):118-23.
  15. Millett PJ, Clavert P, Warner JJ. Open operative treatment for anterior shoulder instability: when and why? J Bone Joint Surg Am. 2005; 87(2):419-32.
  16. Chahal J, Marks PH, Macdonald PB, Shah PS, Theodoropoulos J, Ravi B, et al. Anatomic Bankart repair compared with nonoperative treatment and/or arthroscopic lavage for first-time traumatic shoulder dislocation. Arthroscopy. 2012; 28(4):565-75.
  17. Petrera M, Patella V, Patella S, Theodoropoulos J. A meta-analysis of open versus arthroscopic Bankart repair using suture anchors. Knee Surg Sports Traumatol Arthrosc. 2010; 18(12):1742-7.
  18. Wang C, Ghalambor N, Zarins B, Warner JJ. Arthroscopic versus open Bankart repair: analysis of patient subjective outcome and cost. Arthroscopy. 2005; 21(10):1219-22.
  19. Buscayret F, Edwards TB, Szabo I, Adeleine P, Coudane H, Walch G. Glenohumeral arthrosis in anterior instability before and after surgical treatment: incidence and contributing factors. Am J Sports Med. 2004; 32(5):1165–72.
  20. Gomoll AH, Kang RW, Williams JM, Bach BR, Cole BJ. Chondrolysis after continuous intra-articular bupivacaine infusion: an experimental model investigating chondrotoxicity in the rabbit shoulder. Arthroscopy. 2006; 22(8):813-9.
  21. Good CR, Shindle MK, Kelly BT, Wanich T, Warren RF. Glenohumeral chondrolysis after shoulder arthroscopy with thermal capsulorrhaphy. Arthroscopy. 2007; 23(7):797.e1-5.
  22. Hansen BP, Beck CL, Beck EP, Townsley RW. Postarthroscopic glenohumeral chondrolysis. Am J Sports Med. 2007; 35(10):1628-34.
  23. Kang RW, Frank RM, Nho SJ, Ghodadra NS, Verma NN, Romeo AA, et al. Complications associated with anterior shoulder instability repair. Arthroscopy. 2009; 25(8):909-20.
  24. Grumet RC, Bach BR Jr, Provencher MT. Arthroscopic stabilization for first-time versus recurrent shoulder instability. Arthroscopy. 2010; 26(2):239-48.
  25. Habermeyer P, Gleyze P, Rickert M. Evolution of lesions of the labrum-ligament complex in posttraumatic anterior shoulder instability: a prospective study. J Shoulder Elbow Surg. 1999; 8(1):66-74.
  26. Urayama M, Itoi E, Sashi R, Minagawa H, Sato K. Capsular elongation in shoulders with recurrent anterior dislocation. Quantitative assessment with magnetic resonance arthrography. Am J Sports Med. 2003; 31(1):64-7.
  27. Itoi E, Sashi R, Minagawa H, Shimizu T, Wakabayashi I, Sato K. Position of immobilization after dislocation of the glenohumeral joint. A study with use of magnetic resonance imaging. J Bone Joint Surg Am. 2001; 83-A(5):661-7.
  28. Itoi E, Hatakeyama Y, Kido T, Sato T, Minagawa H, Wakabayashi I, et al. A new method of immobilization after traumatic anterior dislocation of the shoulder: a preliminary study. J Shoulder Elbow Surg. 2003; 12(5):413-5.
  29. Itoi E, Hatakeyama Y, Sato T, Kido T, Minagawa H, Yamamoto N, et al. Immobilization in external rotation after shoulder dislocation reduces the risk of recurrence. A randomized controlled trial. J Bone Joint Surg Am. 2007; 89(10):2124-31.
  30. Finestone A, Milgrom C, Radeva-Petrova DR, Rath E, Barchilon V, Beyth S, et al. Bracing in external rotation for traumatic anterior dislocation of the shoulder. J Bone Joint Surg Br. 2009; 91(7):918-21.
  31. Handoll HH, Hanchard NC, Goodchild L, Feary J. Conservative management following closed reduction of traumatic anterior dislocation of the shoulder. Cochrane Database Syst Rev. 2006; 3(1):1-24.
  32. Liavaag S, Brox JI, Pripp AH, Enger M, Soldal LA, Svenningsen S. Immobilization in external rotation after primary shoulder dislocation did not reduce the risk of recurrence: a randomized controlled trial. J Bone Joint Surg Am. 2011; 93(10):897-904.