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Competitive Sports

Traumatic Primary Anterior Glenohumeral Joint Dislocation in Sports: A Systematic Review of Operative versus Nonoperative Management

Kraeutler, Matthew J. MD1; Belk, John Wilson BA2; Carver, Trevor J. BA2; McCarty, Eric C. MD2; Khodaee, Morteza MD, MPH, FACSM3

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Current Sports Medicine Reports: November 2020 - Volume 19 - Issue 11 - p 468-478
doi: 10.1249/JSR.0000000000000772
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Abstract

Introduction

Anterior shoulder (glenohumeral joint [GHJ]) dislocations are among the most common shoulder injuries in adolescent athletes (1,2), though also may occur following other trauma or during seizure activity (3,4). Glenohumeral joint dislocations occur most frequently in young males as a result of sporting activities, and also are most likely to reoccur in this same demographic group (3,5–7). While it is often thought that increased involvement in athletics, whether competitive or recreational, increases the recurrence rate of dislocation, age (between 21 and 30 years) has been the only factor found by some authors to be associated with recurrence rates (5).

The recurrence rate of anterior GHJ dislocation has been reported in the range of 19% to 88% (8), though recent systematic reviews report a recurrence rate between 40% and 50% (9,10). A majority of redislocations occur within the first year after the first GHJ dislocation (8). Risk factors for GHJ instability include male sex, younger than 40 years, other concurrent injuries (e.g., bony Bankart or greater tuberosity fracture), and shorter time from the initial dislocation (8,10,11). Thus, it is important to optimize management of primary GHJ dislocations. Historically, nonoperative treatment has been the most common method of managing first-time dislocators, though recently, there has been a trend toward offering surgical treatment to select patients, particularly young patients who participate in high-risk activities (5,11,12). The primary purpose of this study was to systematically review the literature in an effort to provide a thorough analysis of patients after undergoing primary closed reduction of a traumatic anterior GHJ dislocation. The main outcome measure was recurrence rate. Our secondary purpose was to compare postreduction outcomes among athletes.

Materials and Methods

Two independent reviewers (M.J.K. and M.K.) performed a comprehensive search of PubMed and the Cochrane Library through February 23, 2020. using various combinations of the keywords/phrases “primary closed reduction,” “anterior shoulder dislocation,” “traumatic,” “primary,” “treatment,” “management,” “surgical,” “operative,” “nonoperative,” “external rotation,” and “conservative.” Studies were required to be written in English. Exclusion criteria included case reports, studies specifically pertaining to combined humeral shaft fracture-dislocations or chronic/recurrent shoulder dislocations, posterior shoulder dislocations, and studies that did not distinguish between patients with first-time versus recurrent dislocations.

Results and Discussion

An initial search identified 712 articles. Following a title, abstract, and/or manuscript review, 109 articles were found to pertain specifically to primary anterior shoulder dislocations. Among these, 12 articles (13–24) directly compared outcomes between patients undergoing operative versus nonoperative management, six articles (25–30) compared outcomes among patients undergoing nonoperative treatment with immobilization in different positions, and one article (31) compared outcomes between patients undergoing open versus arthroscopic surgical repair following a primary shoulder dislocation (Fig., Table).

Figure
Figure:
Flow diagram showing the study selection process.
Table - Summary of studies addressing management following primary closed reduction of traumatic anterior GHJ dislocation.
Study Design Randomization Sports-related (%) Sample Size (Female %) Mean Age ± SD b (Range) in yr Postreduction Management (n) Mean Follow-up (Range) in Months Recurrence Rate Conclusion
Nonoperative management only
Kralinger et al., 2002 (5) Retrospective No Yes (NR) 241 (27) 45.7 (13 to 86) Immobilization in ER 43 (13 to 76) 29.4% Recommend surgical repair following traumatic shoulder dislocation, especially for 21 to 30 yr-olds
Itoi et al., 2003 (72) Prospective Yes Yes (58) 40 (28) 39 (17 to 84) Immobilization in ER and IR 16 ER 0%; IR 30% Immobilization in ER over IR reduces risk of recurrent dislocation
Itoi et al., 2007 (26) Prospective Yes Yes (68) 198 (31) 36 (12 to 90) Immobilization in ER and IR 26 ER 26%; IR 42% Immobilization in ER over IR reduces risk of recurrent dislocation
Hovelius et al., 2008 (38) Prospective (case series) No Yes (40 to 57) 229 (18) NR (12 to 25) Immobilization in ER and IR 300 57% Biologic predisposition and age should be considered with respect to recurrence rate
Cordischi et al., 2009 (45) Retrospective (case series) No Yes (100) 14 (86) 12.2 (10 to 13) Immobilization in ER and IR 67 21.4% NO treatment in pediatric patients results in lower shoulder instability recurrence rates and sound functional outcomes
Tanaka et al., 2010 (41) Prospective (case series) No Yes (100) 15 (0) 21.3 (17 to 26) Immobilization in ER 3 wk NR MRI evaluation on the labrum
Finestone et al., 2010 (73) Prospective Yes NR 51 (0%) 20 (17 to 27) Immobilization in ER and IR 31 ER 37%; IR 42 No difference in outcomes between immobilization in ER versus IR
Taskoparan et al., 2010 (29) Prospective Yes Yes (48) 33 (6) 29 & 35 (15 to 75) Immobilization in ER and IR 21 ER 6%; IR 29% Immobilization in ER over IR reduces risk of recurrent dislocation
Liavaag et al., 2011 (27) Prospective Yes NR 188 (19) 27 (16 to 40) Immobilization in ER and IR 29 ER 31%; IR 25% No difference in outcomes between immobilization in ER versus IR
Whelan et al., 2014 (44) Prospective Yes NR 60 (8) 23 (14 to 35) Immobilization in ER and IR 25 ER 22%; IR 32% No difference in outcomes between immobilization in ER versus IR
Heidari et al., 2014 (25) Prospective Yes Yes (68) 102 (11) 36 ± 9 a Immobilization in abduction/ER and adduction/IR 24 ER 4%; IR 33% Immobilization in ER/adduction over IR/adduction reduces risk of recurrent dislocation
Konigshausen et al., 2014 (74) Prospective (case series) No NR 28 (7) 29 (15 to 45) Immobilization in ER 60 15% Most re-dislocations occurred within the first 2 yr
Murray et al., 2020 (28) Prospective Yes NR 50 (14) 27.0 (18 to 47) Immobilization in ER and IR 24 ER 29.2%; IR 47.8% No Sig. differences between Immobilization in ER or IR for risk of recurrent dislocation
Operative management only
Uribe et al., 1993 (49) Prospective (case series) No Yes (100) 11 (18.2) 20 (NR) Arthroscopic Bankart suture repair (11) NR 9% Arthroscopic surgical repair Sig. improves outcomes
Valentin et al., 1998 (61) Prospective (case series) No Yes (80) 15 (0) NR (17 to 34) Arthroscopic Bankart suture repair (15) 34 (26 to 51) 13% Arthroscopic Bankart suture repair Sig. decreases recurrence rate
Roberts et al., 1999 (31) Retrospective (case series) No Yes (100) 44 (0) 19.9 (14 to 38) Arthroscopic suture repair, arthroscopic Bankart repair with absorbable tack, or open capsular shift with repair of Bankart lesion 29.4 (12 to 65) Arthroscopic suture repair (70%), arthroscopic Bankart repair with absorbable tack (0%), or open capsular shift with repair of Bankart lesion (31%) High-demand athletes wishing to return to sport should proceed with an open surgical procedure
Boszotta et al., 2000 (57) Prospective (case series) No Yes (NR) 72 (15.3) 27.2 (19 to 39) Arthroscopic surgical repair with transglenoid suture technique (72) 66 (24 to 108) 7% Arthroscopic surgical repair provides good outcomes
Deberardino et al., 2001 (46) Prospective (case series) No Yes (100) 49 (6.3) 20 (17 to 23) Arthroscopic primary repair (49) 37 (24 to 60) 12% Arthroscopic surgical repair Sig. improves outcomes
Robinson et al., 2008 (60) Prospective Yes Yes (56) 88 (6.8) 24.8 (NR) Arthroscopic Bankart suture repair (45) or arthroscopic lavage only (43) 24 Arthroscopic Bankart suture repair (7%) or arthroscopic lavage only (37%) Arthroscopic Bankart suture repair Sig. improves outcomes
Raiss et al., 2009 (66) Retrospective (case series) No Yes (97) 29 (10.3) 41.6 (17 to 68) Open reduction internal fixation (29) 78 (30 to 144) 0% ORIF in the context of large glenoid rim fractures decreases recurrence rate
Owens et al., 2009 (63) Prospective (case series) No Yes (NR; military) 39 (5.1) 20.3 (17 to 23) Arthroscopic Bankart suture repair (39) 140 (109 to 167) 15% Arthroscopic Bankart suture repair provides good outcomes
Ozturk et al., 2013 (68) Prospective (case series) No Yes (100) 53 (20.8) 19.5 (12 to 24) Arthroscopic capsulolabral repair (53) 27 (20 to 32) 13% Arthroscopic stabilization provides good outcomes in young athletes
Kim et al., 2014 (65) Retrospective (case series) No Yes (68) 34 (5.9) 28.5 (17 to 43) Capsulolabral repair (16) or glenoid ORIF (18) 34 (24 to 60) 6% OP management is necessary to reduce recurrence rate
Milchteim et al., 2016 (59) Retrospective (case series) No Yes (93) 94 (NR) 21.9 (15 to 43) Arthroscopic Bankart suture repair (94) 60 (36 to 99.6) 6% Arthroscopic surgical repair provides good outcomes
Gibson et al., 2016 (70) Prospective (case series) No Yes (100) 34 (0) 23.0 (17 to 33) Arthroscopic stabilization (34) 57.6 (24 to 120) 9% Accelerated rehab program following arthroscopic stabilization provides early return to sport in young athletes
Shin et al., 2016 (67) Retrospective (case series) No NR 33 (12.1) 26.1 (NR) Arthroscopic Bankart repair (33) 32.6 (24 to 68) 3% Arthroscopic Bankart suture repair provides good outcomes
Terra et al., 2019 (55) Retrospective (case series) No Yes (100) 54 (13) 30.9 (18 to 40) Arthroscopic surgical repair (54) 27 2% Arthroscopic surgical repair Sig. improved outcomes
Yapp et al., 2020 Prospective Yes Yes (65) 65 (7.7) 24.2 (NR) Arthroscopic Bankart repair (33) vs. arthroscopic washout (32) 170.4 (144 to 192) Arthroscopic Bankart repair (12%) vs. arthroscopic washout (47%) Arthroscopic Bankart suture repair Sig. improves outcomes
Operative versus nonoperative management
Wheeler et al., 1989 (22) Prospective No Yes (100; military) 47 (2.1) 18.7 (17 to 22) Arthroscopic stabilization (9) or immobilization in ER and IR (38) 14 92% (NO), 22% (OP) OP management Sig. decreases recurrence rates
Arciero et al., 1994 (13) Prospective No Yes (100; military) 36 (NR) 20 (18 to 24) Arthroscopic Bankart suture repair (21) or immobilization in ER and IR (15) 28 (15 to 45) 80% (NO), 14% (OP) OP management Sig. decreases recurrence rates
DeBerardino et al., 1996 (15) Prospective No Yes (100; all military) 127 (NR) 19.5 (17 to 23) Arthroscopic stabilization (72) or immobilization in ER and IR (55) 22 85% (NO), 11% (Op) OP management Sig. decreases recurrence rates
Taylor et al., 1997 (21) Prospective No Yes (NR; military) 116 (4.3) 19.6 (17 to 23) Arthroscopic stabilization (63) or immobilization in ER and IR (53) NR 91% (NO), NR (OP) OP management Sig. decreases recurrence rates
Kirkley et al., 1999 (18) Prospective Yes Yes (70) 40 (12.5) 22.4 (16 to 30) Arthroscopic stabilization (19) or immobilization in ER and IR (21) 32.4 (18.1 to 54.2) 52% (NO), 26% (OP) OP management Sig. decreases recurrence rates
Larrain et al., 2001 (20) Prospective No Yes (100) 46 (4.3) 21.0 (17 to 27) Arthroscopic repair (28) or immobilization in ER and IR (18) 67.4 (28 to 120) 94% (NO), 4% (OP) OP management Sig. decreases recurrence rates
Bottoni et al., 2002 (24) Prospective Yes Yes (100) 21 (0) 22.4 (19 to 26) Arthroscopic stabilization (9) or immobilization in ER and IR (12) 36 (16 to 56) 75% (NO), 11% (OP) OP management Sig. decreases recurrence rates
Yanmis et al., 2003 (23) Prospective No Yes (84; military) 21 (6.3) 21 (18 to 32) Arthroscopic stabilization (30) or immobilization in ER and IR (33) 37 (10 to 63) 36% (NO), 3% (OP) OP management Sig. decreases recurrence rates
Kirkley et al., 2005 (19) Prospective Yes Yes (89) 27 (14.8) 23.0 (skeletally mature <30) Arthroscopic stabilization (16) or immobilization in ER and IR (15) 79 (51 to 102) 19% (NO), 60% (OP) OP management Sig. decreases recurrence rates
Jakobsen et al., 2007 (17) Prospective Yes Yes (49) 76 (18.4) 21.5 (15 to 39) Arthroscopic Bankart suture repair (37) or immobilization in ER and IR (39) 24 54% (NO), 3% (OP) OP management sig. decreases recurrence rates
Gigis et al., 2014 (16) Prospective No Yes (70) 65 (36.9) 16.7 (15 to 18) Arthroscopic stabilization (38) or immobilization in IR (27) 36 70% (NO), 13% (OP) OP management Sig. decreases recurrence rates
De Carli et al., 2019 (14) Prospective No Yes (100) 130 (6.9) 21.8 (15 to 25) Arthroscopic stabilization (60) or immobilization in ER and IR (70) 92.3 (24 to 149) 71% (NO), 13% (OP) OP management Sig. decreases recurrence rates and increases return to sport rates
aStandard deviation.
bIf reported.
NO, nonoperative; OP, operative; Sig., significant; NR, not reported; ORIF, open reduction internal fixation.

Pathologic Changes

Three studies were found which specifically focused on the pathologic changes associated with first-time shoulder dislocations (21,32,33). Several other studies described these changes in association with arthroscopic evaluation. Among patients with first-time, acute traumatic anterior GHJ dislocations, hemarthrosis is a universal finding (21,33). Bankart lesions are very common and are portrayed by detachment of the anterior-inferior labrum from the underlying glenoid (33). Another common finding is a Hill-Sachs (HS) lesion, represented by cortical depression of the posterolateral humeral head. It is unknown how frequently HS lesions occur in first-time dislocators, though different case series have suggested between 55% and 100% (3,32–34). Sensitivity of plain radiography in detecting Bankart or HS lesions is relatively low (32). In patients with recurrent anterior GHJ dislocations, these lesions are significantly more common (34) and can grow as the humeral head repeatedly impacts on the anterior glenoid, though HS lesions are typically small in patients with one dislocation event (21,34). Rupture of the glenohumeral ligaments was found by magnetic resonance imaging (MRI) evaluation in 20 (67%) of 30 patients in one case series (32). Fracture of the glenoid rim or bony Bankart lesion is relatively uncommon in first-time dislocators, and the inverted pear-shaped glenoid is unseen in this population (3,33,34). Other potential accompanying changes include anterior labrum periosteal sleeve avulsion (ALPSA) lesions, fracture of the greater tuberosity, superior labral anterior posterior tears, rotator cuff tears, and dislocation of the long head of the biceps tendon (21,33–35). Few studies showed that accompanying greater tuberosity fracture is correlated with less risk of instability (8,10).

Nonoperative Management

Duration of immobilization

After a primary traumatic anterior GHJ dislocation, nonoperative management has traditionally been the preferred treatment option. In two previous European studies, 81% to 98% of cases of primary traumatic anterior GHJ dislocations were treated with nonoperative management (36,37). Nonoperative management typically consists of a period of immobilization followed by rehabilitation. However, there is much controversy surrounding the proper duration and position of immobilization. One study reported on the duration of immobilization during nonoperative management (38). The authors randomized 255 patients with a primary traumatic anterior GHJ dislocation to either 4 wk of immobilization or treatment without immobilization (38). A third group also was formed in this study of patients who were noncompliant with the study protocol, resulting in less than 4 wk of immobilization (38). All patients were instructed to follow the same rehabilitation protocol. At 25-year follow-up, there was no difference in reported instability or recurrence rates between the groups (38). Kane et al. (39) reviewed the available literature on the duration of immobilization following a primary traumatic anterior shoulder dislocation. The authors concluded that patients should be immobilized for 1 wk to 3 wk for comfort alone, but that the duration of immobilization had no effect on the rate of recurrence (39). Additionally, Paterson et al. (40) performed a meta-analysis examining patients who were immobilized for 1 wk or less versus 3 wk or longer. They found no statistical difference in the recurrence rate between groups (40). Based on this literature, it would appear that a minimum amount of immobilization may not have an impact on the outcome of conservative treatment of traumatic anterior shoulder dislocations.

Position of immobilization

Six studies (25–30) reported on the position of immobilization during nonoperative management of primary traumatic anterior GHJ dislocations (Table). A recent approach has been to immobilize patients in external rotation (ER) with the goal of creating increased contact between the detached anteroinferior labrum and the glenoid rim (41). The six studies directly compared the incidence of recurrence when immobilizing patients in ER versus internal rotation (IR) (25–30). These studies consisted of 631 patients, of whom 320 were immobilized in ER and 311 were immobilized in IR. Five of these studies randomized patients to immobilization in ER versus IR (25–28,30). For patients immobilized in ER, four studies did so in adduction (26–30), while one study did so in abduction (25). All patients immobilized in IR were in traditional adduction. The period of immobilization was 3 wk across all six studies. Two of the studies found significantly reduced recurrence rates following immobilization in ER compared with IR (25,26). In a subanalysis of patients aged 20 to 40 years, another study found patients in the ER group to experience significantly reduced recurrence rates when compared to the IR group (28). Otherwise, this and the remaining three studies found no significant difference in overall recurrence rates between the ER and IR groups (27–30). Four meta-analyses also were identified that analyzed the outcomes of immobilization in ER versus IR in level I or II studies (40,42–44). While two of these meta-analyses (40,43) found a trend in the data suggesting lower recurrence rates with ER, none of the meta-analyses were able to achieve statistical significance in this regard. In addition to recurrence rates, two meta-analyses (42,44) also evaluated patient-reported outcomes (PROs) including the Constant-Murley functional scoring system; the Rowe scoring system; the Western Ontario Shoulder Instability Index (WOSI); the Disabilities of Arm, Shoulder, and Hand score; and the American Shoulder and Elbow Surgeons (ASES) score. Again, neither meta-analysis found a statistically significant difference between immobilization in ER versus IR for any of these PROs.

Outcomes of nonoperative management

Fifteen studies reported on clinical outcomes of nonoperative management for primary traumatic anterior GHJ dislocations (5,13,15–20,22,24,45–49). The efficacy of nonoperative management in reducing the recurrence of GHJ dislocation is still unclear (13,22,50). In one retrospective study of 440 patients, nonoperative management did not reduce the risk of recurrence (5). Two studies (45,47), one of which examined 10- to 13-year-old patients (45), showed recurrence rates of 21.4% and 23%. Three other studies (13,20,22) reported recurrence rates of over 80% following nonoperative management. Additionally, one study found that 74% (29,39) of patients treated with nonoperative management had an unfavorable result due to recurrence, instability, or pain and stiffness (17). However, many of these studies focused on younger and active patient populations that are at a higher risk of recurrence. Furthermore, most of these studies are outdated with weak methodology. Hovelius et al. (38) found that patients aged 30 to 40 years are significantly less likely to experience instability or recurrence following nonoperative management (17%) compared with all younger patient groups (47%). Pevny et al. (51) also analyzed an older population of 52 patients aged 40 years or older. All patients underwent nonoperative management with only 4% reporting an episode of recurrence and 79% reporting good to excellent modified Rowe shoulder scores. Therefore, nonoperative management may be indicated for older patient populations, but could lead to increased risk of recurrence in young, active patient populations (8,9).

Return to sport following nonoperative management

Four studies (14,22,52,53) reported on return to sport following nonoperative management of primary traumatic anterior GHJ dislocations in athletes. Owens et al. (52) suggested that nonoperative management of an in-season injury can allow a quick return to play in as little as 7 d to 21 d. However, the authors also suggested that this places the athlete at an increased risk for recurrence or further instability, especially if that athlete is a throwing or overhead athlete (52). Pensak et al. (53) expressed similar concerns that a speedy return to play with nonoperative management may increase the risk of recurrence. One study (22) focusing on young cadets treated with nonoperative management reported that 92% experienced a recurrent dislocation. Finally, De Carli et al. (14) found that while 88.6% of 15- to 25-year-old athletes undergoing nonoperative management returned to sport, 71.4% experienced recurrent dislocations. If the decision is made to undergo nonoperative management to allow a quick return to play, an athlete must exhibit pain-free range of motion of the shoulder, full strength, no difficulty with sport-specific tasks, and absence of subjective or objective instability (52,54).

Operative Management

Arthroscopic versus open surgery

Arthroscopic techniques for management of anterior GHJ instability are continuing to progress, and it has been shown that the number of physicians who prefer an arthroscopic technique has increased over time (12). One study treated 37 patients with open Bankart repair and reported a recurrence rate of 3% (17). Two separate studies reported similar recurrence rates of 4% among 28 young athletes and 2% among 54 young athletes treated with arthroscopic repair (20,55). Roberts et al. (31) was the only study found that directly compared the outcomes of arthroscopic versus open surgery. The authors compared the results of three different surgical techniques for management of initial anterior GHJ subluxation or dislocation among Australian Rules football (ARF) players (31). These included arthroscopic suture repair (n = 10), arthroscopic Bankart repair with an absorbable tack (n = 21), and open capsular shift with repair of the Bankart lesion (n = 13). At a mean follow-up of 29.4 months, rates of recurrent subluxation or dislocation upon return to ARF were as follows: arthroscopic suture repair 70%, arthroscopic repair with an absorbable tack 38%, open repair 30% (31). These differences were not statistically significant due to the low sample sizes used. The limitations of this study should be noted, however (31). In particular, sample sizes were limited and patients were not randomized to the three surgical options. Patients underwent open repair only if arthroscopic repair was considered unsuitable or unlikely to succeed by the surgeon. In addition, arthroscopic techniques for Bankart repair have improved considerably since this study was published in 1999.

Murray et al. (56) reviewed the literature on open and arthroscopic repair for primary anterior GHJ dislocations in a young and athletic population. The authors found open repair to be a proven technique that reduces the recurrence rate compared to nonoperative management. The authors also found that, as arthroscopic techniques continue to develop, studies utilizing these techniques have shown improved outcomes that are comparable to open repair (56).

Outcomes of operative management

Nineteen studies (13–20,23,24,46,52,55,57–62) reported on clinical outcomes of patients undergoing operative management for a primary traumatic anterior GHJ dislocation. Operative management has been shown to reduce the recurrence rate in young patients at a higher risk of recurrence (14,15,20,57–60,62). In two studies (60,62), 153 total patients under the age of 35 were randomized to either arthroscopic joint lavage/examination or arthroscopic Bankart repair. In one of these studies (60), the risk of further dislocation was significantly reduced by 76% in the Bankart repair group compared with the placebo group at 2-year follow-up, and in the other study (62) by 35% at 10-year follow-up. In the 1990s, when many surgical techniques for Bankart repair were still in their infancy, studies utilizing operative management reported recurrence rates ranging from 7% to 22% (13,15,61). As surgical techniques further developed and became popularized in the 2000s, additional studies utilizing operative management reported recurrence rates as low as 2% to 14.3% (14,20,46,55,57–59,62,63). Complications, if any, were rare in studies, but included infection, nerve injury, stiffness, bleeding, and hardware complications (13,57). PROs such as the Constant-Murley score, Short Form-36, Rowe scoring system, WOSI, ASES, and visual analog scale have been assessed in several studies with improved outcomes in all parameters following operative management (14,20,23,46,55,57–59,62,63).

Operative management with associated pathologies

Four studies (64–67) reported on clinical outcomes of operative management for traumatic anterior shoulder dislocations in patients with associated pathologies. The quantity and severity of associated pathologies increases with recurrent anterior shoulder dislocations and have been thought to further increase instability in the affected joint (67). Shin et al. (67) analyzed 33 patients undergoing operative management for either primary or recurrent anterior shoulder dislocation. The authors found a significantly greater number of patients with glenoid rim erosion and ALPSA lesions in the recurrent group compared to the primary group, and subsequently significantly increased failure rates following operative management (67). Additionally, 8 of 10 patients in the recurrent group who reported positive apprehension following operative management presented with one of these lesions (67). Other associated pathologies, such as a bony Bankart lesion, also have been suggested to induce further instability in the shoulder, and are typically recommended for surgical intervention (65,66). One study of patients with bony Bankart lesions consisting of 12.5% to 25% of the glenoid rim reported a recurrence rate of 5.6% and excellent Rowe scores following arthroscopic stabilization (65). Therefore, some authors advocate for operative management in primary dislocators with associated lesions, as well as in those without associated lesions in order to prevent their formation with recurrent dislocations (65,67). Finally, Hardy et al. (64) found that while the number of dislocation episodes before surgery does not affect postoperative instability and reoperation rates after treatment with a Latarjet procedure, patients with only one dislocation before surgery experienced more postoperative pain when compared to patients with more than one preoperative dislocation (64).

Return to sport following operative management

Eight studies (14,15,46,55,57,59,63,68) were identified that examined the return to sport rates of athletes following operative management of a primary traumatic anterior GHJ dislocation. One study (46) focusing on active, young military cadets found that 100% of patients were able to return to sport at their pre-injury performance levels postoperatively. The remaining seven studies (14,15,55,57,59,63,68) reported return to sport rates of 82.5% to 93.3% with return to pre-injury performance rates of 69% to 90%. Athletes who are in-season and elect to undergo operative management will not be able to return to sport during the same season due to the necessary rehabilitation following surgery (69). However, in a study of professional football players, Gibson et al. (70) found that with improved arthroscopic surgical techniques, accelerated rehabilitation protocols provide satisfactory return-to-play rates and may reduce the time athletes spend away from sport after a primary anterior shoulder dislocation.

Conservative Management versus Surgery

Twelve studies (13–24) were found which directly compared recurrent dislocation rates of operative versus nonoperative management for primary traumatic anterior GHJ dislocation (Table). These studies included a total of 753 overlapping patients, including 399 undergoing operative repair and 353 undergoing conservative management. Four of these studies randomized patients to operative versus nonoperative management (17–19,24). Among patients treated operatively in these studies, arthroscopic staple repair was performed in two studies (15,22), arthroscopic transglenoid suture repair was performed in two studies (15,20), arthroscopic Bankart suture repair was performed in five studies (13,14,16,18–20), arthroscopic Bankart repair with a bioabsorbable tack was performed in three studies (15,23,24), and open repair with suture anchors was performed in one study (17). All 12 of these studies found a significantly reduced risk of recurrence following arthroscopic stabilization or open repair compared with immobilization and rehabilitation (13–24). In a Cochrane review, authors concluded that there was limited evidence to support surgical intervention for primary anterior GHJ dislocation among young and active individuals (71). They found no strong evidence to determine which treatment was better for the other group of patients (71).

Limitations

The strengths of this study include the use of a comprehensive systematic review performed by two independent reviewers. The limitations of this study also should be noted. There is a significant lack of methodologically sound studies on this topic which makes it difficult to make any strong conclusions regarding appropriate treatment of patients presenting with a first-time anterior GHJ dislocation. Most of these published studies are underpowered, nonrandomized, and have significant weaknesses. In addition, there are substantial variations in treatment modalities across studies, thereby preventing meaningful comparisons. Finally, some of the studies included in this review published results of arthroscopic Bankart repair during the 1990s, when arthroscopic techniques for this procedure were not as fully developed as they are currently.

Conclusions

A majority of studies on the management of primary traumatic anterior GHJ dislocation are methodologically weak, which makes a solid conclusion difficult. Based on current evidence, it seems that operative management for primary traumatic anterior GHJ dislocations can both reduce the recurrence rate and provide improved quality of life postoperatively, particularly in younger patients. Therefore, surgery should be considered in young patients to decrease recurrent episodes of shoulder instability. In athletes wishing to return to sport, improved surgical techniques reduce recurrence, and may reduce the time athletes spend away from sport after a primary anterior dislocation. As arthroscopic techniques continue to develop, they should be considered as a less invasive approach that provides similar results to open surgery for treatment of primary dislocations. Nonoperative management may be indicated in patients older than 30 years, who are at a lower risk of recurrence. It seems immobilization in ER may reduce recurrence rates of dislocation better than immobilization in IR. Further high-quality, multicenter, randomized-controlled studies are necessary to investigate appropriate management for different populations, particularly, elite athletes.

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