Early surgical treatment of first-time anterior glenohumeral dislocation in a young, active population is superior to conservative management at long-term follow-up

Carli, Angelo De; Vadalà, Antonio; Lanzetti, Riccardo Maria; Lupariello, Domenico; Gaj, Edoardo; Ottaviani, Guglielmo; Patel, Bhavik H.; Lu, Yining; Ferretti, Andrea

doi:10.1007/s00264-019-04382-2

Cited by 27 publications

(44 citation statements)

References 21 publications

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“…This study further demonstrates that for patients who are considered high risk for redislocation or recurrent shoulder instability, surgical stabilization after the initial dislocation may confer an additional benefit of cost savings in addition to decreasing the risk of redislocation. 2 , 5 , 7 , 11 …”

Section: Discussionmentioning

confidence: 99%

“… 9 , 10 , 14 , 15 , 16 , 19 , 20 The overall incidence rate varies between 11.2 and 23.9 per 100,000 people each year. 1 , 5 , 10 , 16 , 20 Over the past 10 years at our institution, there have been 2186 (approximately 210/yr) separate hospital encounters due to shoulder dislocations. These patients often require treatment consisting of shoulder reduction using local anesthesia, conscious sedation, or general anesthesia in an urgent care or emergency department (ED) setting.…”

mentioning

confidence: 99%

“…Shoulder dislocations, for younger male patients, can carry an increased risk of recurrent instability. 2 , 5 , 6 , 8 , 10 , 13 , 14 , 15 , 16 , 17 , 19 The risk of recurrent instability after an initial shoulder dislocation treated nonoperatively has been reported in some studies to be extraordinarily high (26%-90%). 1 , 3 , 4 , 6 , 9 , 10 , 19 Recurrent instability events result in recurrent ED visits for additional reductions in the following weeks, months, or years.…”

mentioning

confidence: 99%

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The financial burden associated with multiple shoulder dislocations and the potential cost savings of surgical stabilization

Comadoll¹,

Jarvis²,

Yancey³

et al. 2020

JSES International

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Introduction Shoulder dislocation is a costly problem and can have a high risk for recurrent instability after initial dislocation based on well-defined patient characteristics. Patients with recurrent instability can be treated with shoulder stabilizing procedures. Although more costly, surgery may decrease the overall health care burden of managing a patient with multiple shoulder dislocations nonoperatively. Methods We performed a retrospective chart review of all patients who presented to the emergency department (ED) with a diagnosis of a shoulder dislocation at a level 1 academic trauma center during the year 2016. Patient information regarding the current dislocation episode, previous dislocations, shoulder surgeries, and postreduction follow-up was gathered. These data were then used to determine the average cost of an ED presentation for a shoulder dislocation episode as obtained from the hospital finance department. The average cost of shoulder stabilization surgery was used to conduct a cost-benefit analysis of operative vs. nonoperative management. Results Data were collected on 104 individuals who presented to the ED with shoulder dislocations. Of these, 65 were primary dislocations and 39 were recurrent dislocations. Twelve patients underwent shoulder stabilization surgery after their ED presentation. The average cost to the institution for an ED visit requiring the closed reduction of a shoulder dislocation was $2207 ($973.21 without sedation and $3744 with conscious sedation). The average cost of a shoulder stabilization procedure performed at this same institution was $7807. Discussion and conclusion Although shoulder stabilization has a higher cost on the front end, this intervention results in cost savings if it prevents 2-3 future shoulder dislocations resulting in ED visits. These findings suggest that, for patients with a high risk for recurrent instability, not only would stabilization surgery help prevent subsequent dislocation events but would also minimize health care costs.

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Section: Discussionmentioning

confidence: 99%

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confidence: 99%

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confidence: 99%

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The financial burden associated with multiple shoulder dislocations and the potential cost savings of surgical stabilization

Comadoll¹,

Jarvis²,

Yancey³

et al. 2020

JSES International

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“…20,27,31 The position of immobilization was listed specifically in 5 studies and varied among them. In 2 studies, the arm was positioned in adduction and internal rotation but used different types of immobilization; Jones et al 21 used a shoulder immobilizer, and De Carli et al 6 used a sling and swathe brace when positioning patients in adduction and internal rotation. One study used a sling with an abduction pillow.…”

Section: Quality Assessmentmentioning

confidence: 99%

Postoperative Management Following Arthroscopic Bankart Repair in Adolescents and Young Adults: A Systematic Review

Kim

Saper

2020

Arthroscopy, Sports Medicine, and Rehabilitation

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Purpose The purpose of this study was to review systematically the literature concerning postoperative management following arthroscopic Bankart repair for traumatic anterior shoulder instability in adolescent and young adult (≤ 25 years) athletes. Methods The Pubmed, Medline, EMBASE, EBSCO (CINAHL), and Google Scholar databases were systematically searched according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines to identify all studies reporting postoperative rehabilitation guidelines following arthroscopic Bankart repair in the adolescent and young adult population. The Methodological Index for Nonrandomized Studies instrument and Modified Coleman Methodology Score were used for quality assessment of the included studies. All aspects of rehabilitation were extracted and analyzed, including type/duration of immobilization, range of motion, strength, and return to sport (RTS) criteria. Results Screening yielded 17 eligible studies with a total of 675 patients and an average age of 18.3 years. There was considerable variation with regard to reported postoperative rehabilitation guidelines. Of the 17 studies, 15 reported the duration of immobilization; there was a mean of 4 weeks (range, 2-6 weeks). Range of motion and strength restrictions were reported in 15 (88.2%) and 13 (76.4%) studies, respectively. All of the 17 studies included an expected timeframe for RTS, but only 5 of the studies (29.4%) included either subjective or objective criteria to determine safe RTS. Differences in outcomes were unable to be assessed due to large study heterogeneity. Conclusion Considerable variation is reported in postoperative rehabilitation guidelines following arthroscopic Bankart repair for traumatic shoulder instability in the adolescent and young adult population. All studies used time-based criteria for determining RTS, but subjective and/or objective criteria were lacking in the majority of studies. The current literature lacks data to generate evidence-based rehabilitation protocols in this young athletic population. Level of Evidence Level IV, systematic review of Level II-IV studies.

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“…reports American Academy of Orthopaedic Surgeons, American Orthopaedic Society for Sports Medicine, and American Shoulder and Elbow Surgeons (board or committee member); Arthrex (IP royalties; paid consultant; paid presenter or speaker); Arthroscopy (editorial or governing board); Arthroscopy Association of North America (board or committee member); International Society of Arthroscopy, Knee Surgery, and Orthopaedic Sports Medicine (board or committee member); Joint Restoration Foundation ( have greater, or even partially increased risk of recurrence, the time to stabilize is early after dislocation. [4][5][6][7][8] What is increasingly demonstrated in the literature is that there is a cost to recurrence of instability of the glenohumeral joint. There is no question that with more recurrent instability events (meaning heredmore than 2), there are (1) more anterior labroligamentous periosteal sleeve avulsion (ALPSA) tears, which carry with them an increased risk of failure after surgical stabilization 9,10 ;…”

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confidence: 99%

Editorial Commentary: Evidence to Support Surgical Intervention for First-Time Shoulder Instability: Stabilize Them Early!

Provencher

Midtgaard

2020

Arthroscopy: The Journal of Arthroscopic & Related Surgery

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Historically, a primary anterior instability event has been treated nonoperatively. In the literature, a multitude of outcome scores and definitions for recurrence of instability complicates the interpretation and synthesis of evidencebased recommendations. However, there is an emerging body of high-quality evidence that early surgical stabilization yields better overall outcomes. A wait-and-see approach would be acceptable if it was without detrimental effects, but there is a cost to recurrence of instability events, such as more extensive soft-tissue, cartilage, and bony lesions. Young age, male sex, and contact sport participation have been identified as risk factors for recurrence of anterior shoulder instability, and today, these patients are routinely recommended surgical treatment. It is also paramount to identify concomitant injury following the primary anterior instability event. The sensitivity, specificity, and reliability of radiographs is suboptimal, and the threshold to obtain advanced imaging such as computed tomography or magnetic resonance imaging with 3-dimensional reconstructions should be low. Taking into account the low non-recurrence complication rate following arthroscopic stabilization, early surgical intervention should be considered following the first instability event.

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Early surgical treatment of first-time anterior glenohumeral dislocation in a young, active population is superior to conservative management at long-term follow-up

Cited by 27 publications

References 21 publications

The financial burden associated with multiple shoulder dislocations and the potential cost savings of surgical stabilization

The financial burden associated with multiple shoulder dislocations and the potential cost savings of surgical stabilization

Postoperative Management Following Arthroscopic Bankart Repair in Adolescents and Young Adults: A Systematic Review

Editorial Commentary: Evidence to Support Surgical Intervention for First-Time Shoulder Instability: Stabilize Them Early!

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