Management of primary acute anterior shoulder dislocation: systematic review and quantitative synthesis of the literature

Abstract

Purpose: The aim of this study was to compare the clinical outcome of surgical versus conservative treatment of primary acute anterior dislocation of the shoulder.

Methods: A systematic review of published studies on the treatment of primary acute anterior dislocation of the shoulder was performed. Three investigators independently conducted the research. A comprehensive search of PubMed, MEDLINE, CINAHL, Cochrane Library, EMBASE, and Google Scholar databases using various combinations of the keywords "shoulder," "dislocation," "treatment," "acute," and "primary" over the years 1994 to 2013 was performed. The following data were extracted: demographics, soft tissue lesions and bone defects, outcome measurements, type of management, recurrence of instability, and complications. A quantitative synthesis of the literature was performed to compare surgery and conservative management and immobilization by internal and external in patients undergoing conservative treatment.

Results: Thirty-one studies were included in which 2,813 shoulders were evaluated. All patients sustained primary acute anterior shoulder dislocation. The mean Coleman Methodology Score (CMS) was 67 points (range, 19 to 84). Pooled results from comparative studies showed that the rate of recurrence was statistically significantly lower in the surgical group than in the conservative group (odds ratio, 12.71; 95% confidence interval [CI], 4.88 to 33.10; P < .00001). External rotation immobilization provided better results than internal rotation, being associated with a lower rate of recurrence (odds ratio, 2.28; 95% CI, 1.34 to 3.87; P = .002).

Conclusions: Although limited, the available evidence from randomized controlled trials (RCTS) supports primary surgery in young adults engaged in highly demanding sports or job activities. There is lack of evidence to determine whether surgical or nonsurgical treatment is better for other categories of injury.

Level of evidence: Level IV, systematic review of Level I to IV studies.