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Patients with surgically treated first acute anterior shoulder dislocation have less instability than those treated nonsurgically
Clinical Question
Do patients treated surgically following acute anterior shoulder dislocations have less instability than those treated nonsurgically?
Bottom line
In this meta-analysis of only 5 studies, patients 15 to 39 years of age with acute anterior dislocations who were treated surgically were less likely to have recurrent instability than those who were treated nonsurgically. 1a
Reference
Study design: Meta-analysis (randomized controlled trials)
Funding: Unknown/not stated
Setting: Various (meta-analysis)
Synopsis
These authors searched 3 databases to identify randomized trials that compared surgical and nonsurgical approaches to managing patients with their first acute anterior shoulder dislocation. To be included, the studies had to report the frequency of recurrent instability and be published in English in a peer-reviewed journal. The authors ignored the potential for publication bias by not searching the gray literature or by not formally assessing it statistically or graphically. They included 5 trials with 259 patients between the ages of 15 and 39 years; nearly 90% were men. The follow-up intervals ranged from 2 years to 10 years. Although the authors report the overall study quality was good, all were unmasked, and only one included an outcome assessed by study personnel who were masked to treatment allocation. Four of the studies used similar surgical approaches; in all the studies, the control group was treated with immobilization. The physical therapy protocols for each treatment group were identical within each study, though there were slight differences among the 5 studies. Only 6.4% of the surgically treated patients had recurrent instability compared with 46.6% of those treated nonsurgically (number needed to treat = 3; 95% CI 2 - 4) with no statistical heterogeneity. Although the authors report that each study provided data on complications, they did not report the pooled event rate. However, the authors specifically comment that one surgically treated patient developed adhesive capsulitis that resolved within 18 months, and another patient developed septic arthritis requiring arthroscopic irrigation and antibiotics. It is likely that with only 259 total patients, this study lacks the power to detect rare events.
Reviewer
Henry C. Barry, MD, MS
Professor
Michigan State University
East Lansing, MI
Comments
Excellent new information.
Will change my approach to shoulder dislation
Impact assessment
Excellent
Treating anterior dislocation of shoulder by surgically and
Good to know
Recurrent shoulder instability in first time shoulder dislo
Despite the significant methodological limitations of the study the recurrent instability rate for surgical vs non-surgical treatment is quite impressive (6.4% vs 46.6%). I might not be ready to buy into this quite yet but it seems that further high quality studies are urgently needed.
Surgical intervention
There is no reference to whether this has long term risk or benefit — for instance, surgical intervention may not offer any advantage after a certain period of time.