Systematic review of rehabilitation versus operative stabilization for the treatment of first-time anterior shoulder dislocations

Abstract

Context: Primary anterior shoulder dislocation is a frequent injury in young active patients. Traditionally, conservative nonoperative primary treatment has been advocated for a majority of first-time dislocators, whereas operative stabilization has been reserved for recurrent dislocators or those involved in strenuous physical activity. Currently, no consensus exists on whether to treat a first-time anterior shoulder dislocation surgically.

Objective: (1) To provide clinical recommendations regarding the therapeutic intervention for first-time anterior shoulder dislocators and (2) to determine if there is sufficient Level 1 or 2 evidence available for the establishment of a uniform, optimal treatment protocol.

Data sources: A systematic review of prospective randomized controlled trials with human participants was performed. PubMed, the Cochrane Database of Systematic Reviews, and secondary references were appraised for studies published between 1994 and 2009.

Study selection: Inclusion criteria were English-language Level 1 or 2 studies involving the treatment of primary anterior shoulder dislocation. Exclusion criteria included non-English-language articles; Level 3, 4, or 5 studies; and studies examining treatment of recurrent/posterior shoulder dislocation or diagnoses other than primary anterior shoulder dislocations.

Data extraction: Each author conducted an independent quality appraisal of the included studies, identifying strengths, weaknesses, and biases, then reached consensus regarding their values.

Results: Five randomized controlled trials were included, and they supported the use of operative management in a focused population. No long-term follow-up data were available describing the effects of surgical intervention or the development of osteoarthritis. Each study design had weaknesses that decreased the validity of the findings.

Conclusions: While limited, the available evidence from randomized controlled trials supports operative stabilization as a reasonable alternative to nonoperative treatment for primary acute shoulder dislocation in young, active adults participating in highly demanding physical activities. Recommendations on the optimal surgical intervention cannot be provided. There is no conclusive evidence available to determine whether operative stabilization or conservative rehabilitation is superior for other patient or injury types.

Keywords: primary anterior shoulder dislocation; systematic review; treatment.