The Treatment of Traumatic Anterior Instability of the Shoulder: Nonoperative and Surgical Treatment

doi:10.1016/j.arthro.2008.12.007

Arthroscopy: The Journal of Arthroscopic & Related Surgery

Volume 25, Issue 3, March 2009, Pages 298-304

https://doi.org/10.1016/j.arthro.2008.12.007 Get rights and content

Purpose

Traumatic anterior instability of the shoulder is a common condition associated with a high recurrence rate in young patients. The role of nonoperative versus operative treatment and the optimal surgical approach for this condition is debated. The purpose of this study was to review the literature for the latest evidence comparing outcomes of treatment for traumatic anterior instability of the shoulder.

Methods

A systematic review of the literature was performed to identify studies comparing operative versus nonoperative treatment for traumatic anterior shoulder instability and studies comparing open versus arthroscopic stabilization for traumatic anterior shoulder instability.

Results

Surgical treatment was associated with a significantly lower rate of recurrent instability at 2 years of follow-up (7% v 46%) and at longer-term follow-up (10% v 58%) for first-time traumatic anterior shoulder dislocation, all in younger patients. The rates of recurrent instability were roughly equal after arthroscopic stabilization with suture anchors and open stabilization with anchors (open, 8.2%; arthroscopic, 6.4%).

Conclusions

Rates of recurrent instability after a first-time anterior shoulder dislocation, particularly in young active male patients, are reduced by surgical intervention compared with nonoperative treatment. If surgical treatment is indicated, an arthroscopic approach using suture anchors appears to have similar results in terms of recurrent instability to an open approach using suture anchors.

Section snippets

Methods

We identified all published studies in English addressing the treatment of traumatic anterior shoulder instability. We then focused on inclusion criteria for our 2 areas of interest. First, we identified studies comparing surgical treatment to nonoperative treatment for first-time traumatic anterior shoulder dislocation. We then identified comparisons of open surgical treatment to arthroscopic surgical treatment using suture anchors for anterior shoulder instability. Studies were excluded if

Results

The PubMed search identified 2,494 articles. We identified 6 articles that related to our issue of immediate surgical stabilization versus nonoperative treatment for first-time anterior shoulder dislocation (Table 1). Two of these articles represented the early and late results in the same cohort, and these data were included accordingly.19, 21

We identified 20 articles that compared arthroscopic treatment of anterior shoulder instability with open treatment (Table 2). However, suture anchors

Discussion

Traumatic anterior shoulder instability is a common problem with an accepted treatment algorithm of initial nonsurgical treatment, with surgical stabilization indicated after recurrent instability. Open stabilization is considered the gold standard for surgical treatment of this problem. Our review suggests that early surgical stabilization has the advantage of a significantly lower recurrence rate for young active patients. However, early surgical intervention will result in some patients

Conclusions

Rates of recurrent instability after a first-time anterior shoulder dislocation, particularly in young active male patients, are reduced by surgical intervention compared to nonoperative treatment. If surgical treatment is indicated, an arthroscopic approach using suture anchors appears to have similar results in terms of recurrent instability to an open approach using suture anchors.

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Return to play decision after shoulder dislocation in upper limb athletes: Critical analysis between the habits of medical professionals and the literature
2024, Orthopaedics and Traumatology: Surgery and Research
The return to field is a critical moment for an athlete who has dislocated his shoulder as there is a significant risk of recurrence. The decision to return to field made by the doctor will therefore be crucial for the smooth continuation of the athlete's career.
This objective is to compare the criteria most used by specialists in clearing an overhead athlete to return to competition after a first episode of antero-internal dislocation of the glenohumeral joint with or without surgery and those mentioned in the literature.
The target population consisted of French-speaking physicians in orthopedic surgery, physical medicine and rehabilitation or sports medicine. This study was conducted by the means of a questionnaire. The questionnaire was validated by three experts in sports medicine and published on an online survey website.
Sixty-three medical specialists responded to the questionnaire. On average, they use more than nine criteria to decide if an athlete is fit to return to competition. Over the 12 criteria proposed, four are used by more than 90% of respondents: laxity/instability, pain, range of motion and patient's subjective feeling. The methods used to evaluate certain criteria such as pain, joint range or muscular strength are often subjective and very often not validated by the literature.
Doctors use a set of criteria to allow an overhead athlete to return to competition. This study highlights that the techniques employed to evaluate these criteria are not always thoroughly validated by literature reviews.
III; observational study.
Arthroscopic capsular shift from inferior to superior has an exceptional safety profile and short-term outcomes
2024, Journal of ISAKOS
Arthroscopic Bankart for anterior shoulder instability has a good safety profile but with a relatively high recurrence index. Open surgery has been used to decrease recurrence rates but with a higher complication rate. Arthroscopic capsular shift from inferior to superior (ACSIS) was designed to decrease the recurrence rates without the added morbidity of open surgery.
An observational retrospective study was conducted to analyze perioperative complications and patient reported outcomes of patients treated with ACSIS to determine the safety profile of the procedure. The patients with anterior traumatic shoulder instability treated with ACSIS between January 2015 and December 2021 were included for the study. The analysis was conducted using SPSS (Version 27). The pre vs. postoperative Western Ontario Shoulder Instability Index scores were compared using a paired sample t-test or Wilcoxon signed ranks test depending on the results of the normality test and Levene's test. The significance level was 0.05 in all analyses. Thirty-six patients were included in this study, the mean age of the population is 30.8 ± 11.4 years, with a male dominance of 86.1% (N = 31), and a mean clinical follow-up of 2.7 ± 1.2 years.
No intraoperative complications, including bleeding or neurovascular injury, were noted. Additionally, no early postoperative complications, including infection or hospital readmission, were noted. During the follow-up, one patient (3%) had persistent apprehension. The mean Western Ontario Shoulder Instability index decreased from 66.6 ± 13.10% to 27.9 ± 22% postoperatively (P < 0.001).
ACSIS procedure is safe and has good short-term outcomes with a low recurrence rate at 1-year minimum follow-up.
3 (Observational study).
Measurement instruments to assess factors of importance in rehabilitation of athletes to return to sport after Bankart repair, a scoping review
2023, Sports Orthopaedics and Traumatology
Traumatic unidirectional instability of the glenohumeral joint occurs frequently in athletes. Treatment by surgical repair through a Bankart repair results in higher rates of successful return to sport (RTS) compared to conservative treatment. Nevertheless, one third of athletes are not able to RTS to their pre-injury level after Bankart repair and the recurrence rate of instability at 5 years after surgery is 10%. Currently only subjective factors like pain and time after surgery are used in the decision making in the RTS decision-making process. However, several factors are of importance according to literature: pain, range of motion, strength, stability, psychological factors, and proprioception. Furthermore, it is not described clearly how to measure the factors objectively. This scoping review identifies measurement instruments that are available for assessing the factors that can be of importance for RTS in athletes.
A scoping literature search was conducted in Pubmed to map available measurement instruments for the factors of importance. Twenty-five articles were identified and assessed for methodological quality. The measurement instruments were rated according to the criteria for good measurement properties from the COnsensus-based Standards for the selection of health Measurement INstrument guidelines.
The current scoping review provides an overview of the available measurement instruments for measuring important factors which might help in RTS decision-making after Bankart repair.
Level of Evidence: 2.
Eine traumatische unidirektionale Instabilität des Glenohumeralgelenks tritt häufig bei Sportlern auf. Die Behandlung durch chirurgische Reparatur durch eine Bankart-Reparatur führt im Vergleich zur konservativen Behandlung zu höheren Raten einer erfolgreichen Rückkehr zum Sport (RTS). Dennoch ist ein Drittel der Athleten nach der Bankart-Reparatur nicht in der Lage, das RTS-Niveau vor der Verletzung zu erreichen, und die Rezidivrate der Instabilität 5 Jahre nach der Operation beträgt 10 %. Derzeit werden im RTS-Entscheidungsprozess nur subjektive Faktoren wie Schmerz und Zeit nach der Operation in die Entscheidungsfindung einbezogen. Laut Literatur sind jedoch mehrere Faktoren von Bedeutung: Schmerz, Bewegungsumfang, Kraft, Stabilität, psychologische Faktoren und Propriozeption. Außerdem wird nicht klar beschrieben, wie die Faktoren objektiv zu messen sind. Dieser Scoping-Review identifiziert Messinstrumente, die zur Verfügung stehen, um die Faktoren zu beurteilen, die für RTS bei Sportlern von Bedeutung sein könnten.
Eine Scoping-Literaturrecherche wurde in Pubmed durchgeführt, um verfügbare Messinstrumente für die Faktoren von Bedeutung abzubilden. 25 Artikel wurden identifiziert und hinsichtlich ihrer methodischen Qualität bewertet. Die Messinstrumente wurden nach den Kriterien für gute Messeigenschaften aus den 'COnsensus-based Standards for the selection of health Measurement INstrument guidelines' bewertet.
Der aktuelle Scoping-Review gibt einen Überblick über die verfügbaren Messinstrumente zur Messung wichtiger Faktoren, die bei der RTS-Entscheidungsfindung nach der Bankart-Reparatur hilfreich sein könnten.
Beweisgrad: 2.
Patients Aged >50 Years With Anterior Shoulder Instability Have a Decreased Risk of Recurrent Dislocation After Operative Treatment Compared With Non-Operative Treatment
2023, Arthroscopy, Sports Medicine, and Rehabilitation
To compare the clinical outcomes of operative and nonoperative management, identify risk factors for recurrent instability, and identify risk factors for progression to surgery after failed nonoperative management for patients with first-time anterior shoulder dislocation after the age of 50 years.
An established geographic medical record system was used to identify patients who experienced a first-time anterior shoulder dislocation after the age of 50 years. Patient medical records were reviewed to identify treatment decisions and outcomes of interest, including rates of frozen shoulder and nerve palsy, progression to osteoarthritis, recurrent instability, and progression to surgery. Outcomes were evaluated using Chi-square tests and survivorship curves were generated using Kaplan-Meier methods. A Cox model was developed to evaluate for potential risk factors of recurrent instability and progression to surgery after an initial trail of at least 3 months of nonoperative treatment.
179 patients were included with a mean follow-up of 11 years. 14% (n = 26) underwent early surgery within 3 months and 86% (n = 153) were initially treated nonoperatively. Mean age (59 years), was similar for both groups, but those that underwent early surgery had an increased rate of full-thickness rotator cuff tears (82% vs 55%; P = .01), labral tears (24% vs 8.0%; P = .01), and humeral head fracture (23% vs 8.5%; P = .03). When comparing the early surgery group to the nonoperative group, there were similar rates of persistent moderate-severe pain (19% vs 17%; P = .78) and frozen shoulder (8 vs 9%, respectively; P = .87) at final follow-up. Although nerve palsy (19% vs 8%; P = .08) and progression to osteoarthritis (20% vs 14%; P = .40) were more common in surgical patients, they experienced lower rates of recurrent instability after surgical intervention (0% vs 15%; P = .03) compared to nonoperatively treated patients. Increasing number of instability events prior to presentation was the greatest risk factor for recurrent instability (HR 232; P < .01). Fourteen percent (n = 21) failed initial nonoperative treatment and proceeded to surgical intervention at an average of 4.6 years after the initial instability event, and the greatest risk factors for progression to surgery were recurrent instability (HR 3.41; P < .01).
Although the majority of patients >50 years that experience ASI are treated nonoperatively, those that require surgery tend to have more significant injury pathology, a lower risk of recurrent instability after surgery, but a higher progression to osteoarthritis compared to patients that do not require surgical intervention. There was no difference in pain severity at final follow-up, rates of frozen shoulder or nerve palsy between patients who underwent initial nonoperative treatment after instability and those who underwent surgery. A history of multiple instability episodes prior to presentation was the greatest predictor of recurrent instability and failure of nonoperative treatment and progression to surgery.
Level III, retrospective cohort study.
Physical Therapy for the Treatment of Shoulder Instability
2023, Physical Medicine and Rehabilitation Clinics of North America
Comparison of perioperative complications following surgical treatment of shoulder instability
2022, JSES International
Surgical repair for shoulder instability includes arthroscopic Bankart, open Bankart, and Latarjet-Bristow.
This is a cohort study of patients who underwent arthroscopic Bankart, open Bankart, or Latarjet-Bristow procedures that were identified within the National Surgical Quality Improvement Program database (2007-2019). Unadjusted and adjusted analyses were performed (α = 0.05). Outcomes included 30-day adverse events, readmission, and operative time.
This study included 10,955 patients (9128 arthroscopic Bankart, 1148 open Bankart, and 679 Latarjet-Bristow). Compared with arthroscopic Bankart, Latarjet-Bristow had longer operative times (129.96 [95% CI: 126.49-133.43] vs. 86.35 [85.51-87.19] minutes), along with a higher percentage of serious adverse events (2.5% vs. 0.4%), reoperation (1.9% vs. 0.1%), readmission (1.8% vs. 0.3%), thromboembolic complications (0.4% vs. 0.1%), and sepsis (0.4% vs. 0.0%) (P < .05 for all). Open Bankart had longer operative times (98.17 [95.52-100.82] vs. 86.35 [85.51-87.19] minutes) and a higher percentage of sepsis (0.2% vs. 0.0%) (P < .05 both). Latarjet-Bristow had increased odds of a serious adverse event (odds ratio [OR]: 7.68 [4.19-14.07]), reoperation (OR: 17.32 [7.58-39.56]), readmission (OR: 5.73 [2.84-11.54]), and deep wound complications (OR: 14.98 [3.92-57.23]) (P < .05 for all). In comparing the relative utilization of arthroscopic versus open Bankart, arthroscopic Bankart increased (83.4% to 91.2%) while open Bankart decreased (16.6% to 8.8%) from the 2011-2013 time period to 2017-2019 (P_trend < .001).
In addition to a low complication rate, the relative utilization of arthroscopic Bankart increased compared with open Bankart over the past decade. Furthermore, Latarjet-Bristow was associated with a higher incidence of serious adverse events than arthroscopic Bankart.

View all citing articles on Scopus

: The authors report no conflict of interest.

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Evidence-Based Medicine Systematic ReviewSystematic ReviewThe Treatment of Traumatic Anterior Instability of the Shoulder: Nonoperative and Surgical Treatment

Purpose

Methods

Results

Conclusions

Section snippets

Methods

Results

Discussion

Conclusions

Incidence of anterior shoulder dislocation in Olmsted County, Minnesota

Clin Orthop Relat Res

Anterior glenohumeral instability

Orthopedics

Anterior instability of the shoulder after trauma

J Bone Joint Surg Br

The fate of traumatic anterior dislocation of the shoulder in children

J Bone Joint Surg Am

Recurrent or habitual dislocation of the shoulder joint

BMJ

Bankart's operation for recurrent dislocation of the shoulder

J Bone Joint Surg Br

The Bankart procedure: A long-term end result study

J Bone Joint Surg Am

Bankart repair for anterior instability of the shoulderLong-term outcome

J Bone Joint Surg Am

Arthroscopic anterior labral reconstruction using a transglenoid suture techniqueResults in active-duty military patients

Am J Sports Med

Arthroscopic shoulder stabilization using transglenoid suturesA four-year minimum followup

Am J Sports Med

Arthroscopic shoulder capsulorrhaphy using metal staples

Orthop Clin North Am

Management of recurrent anterior dislocation of the shoulderDu Toit-type or staple capsulorrhaphy

Clin Orthop Relat Res

An arthroscopic technique for anterior stabilization of the shoulder with a bioabsorbable tack

J Bone Joint Surg Am

Arthroscopic Bankart repair with the Suretac devicePart I: Clinical observations

Arthroscopy

Arthroscopic versus open treatment of anterior shoulder instability

Instr Course Lect

Arthroscopic treatment of anterior glenohumeral instability: Indications and techniques

Instr Course Lect

Suture anchors are superior to transglenoid sutures in arthroscopic shoulder stabilization

Arthroscopy

Arthroscopic Bankart repair versus nonoperative treatment for acute, initial anterior shoulder dislocations

Am J Sports Med

A prospective, randomized evaluation of arthroscopic stabilization versus nonoperative treatment in patients with acute, traumatic, first-time shoulder dislocations

Am J Sports Med

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

Prospective randomized clinical trial comparing the effectiveness of immediate arthroscopic stabilization versus immobilization and rehabilitation in first traumatic anterior dislocations of the shoulder

Arthroscopy

Primary repair versus conservative treatment of first-time traumatic anterior dislocation of the shoulder: A randomized study with 10-year follow-up

Arthroscopy

Treating the initial anterior shoulder dislocation—An evidence-based medicine approach

Sports Med Arthrosc

Evidence-Based Medicine Systematic Review
Systematic Review
The Treatment of Traumatic Anterior Instability of the Shoulder: Nonoperative and Surgical Treatment