The Treatment Of Primary And Recurrent Anterior Shoulder Dislocation:a Systematic Review

Background The incidence of traumatic shoulder dislocations is the highest in all major joints, the rate was at least11.2/100,000person-years. There are still dispute about the treatment of it. The traditional therapy of primary shoulder dislocation is conservative treatment and internal fixation, while it fails to decrease the recurrence of it and especially, the recurrence of it is proximal90%in young patients. On account of cadaveric and MRI studies, it helps to decrease the recurrence of shoulder dislocation when the shoulder is at external fixation. Itoi and Liavaag did some clinical studies about external and internal fixation respectively, while there is difference between their conclusions. Otherwise, surgical Bankart repair can decrease the recurrence of primary shoulder dislocation, which is proved by several studies. Compared with conservative treatment, we need to do more studies on surgical treatment. Recurrent Anterior Shoulder Instability happens most in adults, and the conservative treatment of it has limited benefits. Currently, the popular therapy is arthroscopic repair and open surgery. Traditional open Bankart repair and capsulorrhaphy for recurrent anterior shoulder instability have been considered the gold standard. Initial studies of arthroscopic repair for recurrent anterior shoulder instability reported unacceptably high rates of failure when compared with open procedures. However, recent advances in arthroscopic techniques and reports in the literature of their use have suggested that arthroscopic repair using suture anchors augmented with capsular plication may be a viable alternative that more closely parallels the open repair technique. Thereby, this article will compare the therapeutic effect of each therapy for primary and recurrent shoulder dislocation by Meta-analysis and we can provide evidence for the choice of therapeutic plan.Objective1To compare the clinical therapeutic effects for primary shoulder dislocation in the two groups:Group Ⅰ, immobilization in external rotation versus internal rotation; Group Ⅱ, surgical versus conservative treatment.2To compare the therapeutic effects between arthroscopic and open Repairs for recurrent anterior shoulder instability in adults.Methods1.After put forward a question, an detailed inclusion and exclusion criteria were established according to PICO steps, and then comprehensive search strategy of literature were made to search the relevant Randomized Controlled Trials(RCTs).2.According to Cochrane systematic review, Cochrane library, Medline, Embase, CNKI, VIP, and Chinese Biomedical Database were retrieved for randomized controlled trials(RCTs) comparing relevant interventions for the treatment of displaced femoral neck fractures in elder patients before the end of September2009.Furthermore,we also hand searched relevant reference and some Chinese orthopedic journals. Finally, RCTs which met the specific inclusion and exclusion criteria were included. These RCTs were associated with the compare of the therapeutic effect of each therapy for primary and recurrent shoulder dislocation3.The methodology quality of each inclusion study was critically assessed according to the quality criteria of RCT which include four items:randomization, allocation concealment, blindness and follow-up. The validity of each trail was referred to as A, B or C scale according to Cochrane handbook for systematic reviews.4. After critical appraisal, data of each RCT on relevant outcome parameter were extracted. Software Revman5.1the Cochrane Collaboration provided were used for meta-analysis. For each study,relative risk(RR) and95%confidence intervals(95%CI)were calculated for dichotomous outcomes and weighted mean differences(WMD) and95%confidence intervals(95%CI) were calculated for dichotomous outcomes. Before outcome measures of each trial were pooled, clinical heterogeneity should be considered. If interventions of each trial were different, subgroup analysis should be applied. The results of individually randomized trials were pooled whenever possible, with use of the fixed effects model of Mantel-Haenszel. Heterogeneity between comparable studies was tested, with the use of a standard chi·square test. The random-effects model of Der Simonian and Laird was used when there was statistical evidence of heterogeneity(P<0.1). However, if the results of certain outcome measures were not pooled or if the outcome events rarely happened, evaluation should rely on detailed description.Results1. Search resultsFive randomized controlled trials were involved in Group Ⅰ, immobilization in external rotation versus internal rotation; four randomized controlled trials and two non-randomized controlled trials were involved in Group Ⅱ, surgical versus conservative treatment. Otherwise, five randomized controlled trials involving278 patients met the criteria of the present study about arthroscopic and open Repairs for recurrent anterior shoulder instability in adults.2. Meta-analysis results2.1Primary shoulder dislocation2.1.1Immobilization in external rotation versus internal rotationFive randomized controlled trials were involved in Group Ⅰ.The Meta-analysis revealed that immobilization in external rotation has no statistically significant differences with internal rotation in the intention-to-treat group(RR=0.77,95%CI0.58～1.02), the per-protocol group(RR=0.76,95%CI0.51～1.13) and the older than30years group(RR=0.79,95%CI0.29～2.11). There were statistically significant differences in the younger than30years(RR=0.52,95% CI0.36～0.76). For preventing the recurrence of primary shoulder dislocation, the external rotation has advantage over traditional internal rotation in the younger than30years.2.1.2Surgical versus conservative treatmentFour randomized controlled trials and two non-randomized controlled trials were involved in Group Ⅱ.The Meta-analysis revealed that surgical treatment has no statistically significant differences with conservative treatment in surgical versus traditional conservative treatment group(RR=0.22,95%CI0.12～0.40), arthroscopic repair versus arthroscopic lavage group(RR=0.11,95%CI0.04～0.30) and subgroup analysis(RR=0.17,95%CI0.10～0.29). For preventing the recurrence of primary shoulder dislocation, the surgical treatment has superiority over conservative treatment.2.2Recurrent shoulder dislocationOnly five randomized controlled trials involving278patients met the criteria of the present study. The Meta-analysis revealed that arthroscopic repairs were associated with higher Rowe scores (weight mean difference=4.43,95%confidence interval=2.27to6.59) than open methods. For other outcomes, including shoulder recurrent instability or recurrent dislocation (RR=1.31,95%CI0.51～3.34), nerve injuries(RR=0.51,95%CI0.11～2.32), re-operation(RR=0.49,95%CI0.11～2.27) and return to pre-injury level of activity(RR=0.96,95%CI0.80～1.15), there were no statistically significant differences between the two Groups.Conclusion1、For prevening the recurrence of primary shoulder dislocation, the external rotation has advantage over traditional internal rotation in the younger than30years; and the surgical treatment has superiority over conservative treatment.2、For adult patients with recurrent anterior shoulder instability, arthroscopic approaches resulted in better function as reflected by the Rowe scores,but no statistically significant differences in others.3、For better health, we need to more carefully consider issues of long-term outcomes and intraoperative and preoperative factors and report them in a liable, consistent and standardised manner.