ORIGINAL ARTICLE
Arthroscopic Versus Conservative Treatment of First Anterior Dislocation of the Shoulder in Adolescents Ioannis Gigis, MD,* Roderich Heikenfeld, MD,w Arion Kapinas, MD,* Rico Listringhaus, MD,w and Georgios Godolias, MDw
Background: Conservative treatment of posttraumatic anteroinferior shoulder instability leads to a high failure rate in a young and active population. However, treatment in an adolescent age group is not well documented. Methods: We conducted a prospective study with adolescent patients (age 15 to 18 y) who suffered a first traumatic anterior dislocation of the shoulder. Two groups of patients were formed. The first group was treated with early arthroscopic stabilization and the second was treated conservatively. There were 43 shoulders in the operative group and 29 shoulders in the conservative group. The rehabilitation protocol was the same for both groups. All patients were followed up prospectively after 12, 24, and 36 months using Rowe Score. Results: A total of 38 shoulders in the surgical group and 27 shoulders in the conservative group could be completely evaluated. From the conservative group, 19 patients (70.3%) suffered a recurrence of the instability. From the arthroscopic group, 5 patients (13.1%) suffered a recurrence of the instability. Conclusions: In an adolescent population (15 to 18 y), conservative treatment after first traumatic shoulder dislocation including immobilization in internal rotation leads to a significantly higher and unacceptable high failure rate compared with early arthroscopic stabilization. Level of Evidence: Level II—prospective comparative study. Key Words: shoulder instability, shoulder arthroscopy, arthroscopic Bankart repair, adolescents, conservative treatment (J Pediatr Orthop 2014;34:421–425)
T
he shoulder is the major joint that most commonly dislocates.1,2 In fact, the glenohumeral dislocation occurs more often than all other joint dislocations altogether.3 A total of 98% of the dislocations are anterior,4 whereas the posterior rate is very small.
From the *2nd Orthopaedic Department, Aristotle University of Thessaloniki, Thessaloniki, Greece; and wCenter for Orthopedics and Traumatology, St Anna Hospital Herne, University of Witten/ Herdecke, Herne, Germany. The authors declare no conflict of interest. Reprints: Roderich Heikenfeld, MD, Center for Orthopedics and Traumatology, St Anna Hospital Herne, University of Witten/Herdecke, Hospitalstr. 19, Herne D-44649, Germany. E-mail: r.heikenfeld@ annahospital.de. Copyright r 2013 by Lippincott Williams & Wilkins
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In patients younger than 30 years old, reduction of the dislocation and conservative treatment, including immobilization and physical therapy, leads to unacceptable high rates of recurrences because of anterior instability of the shoulder after the first injury. There are studies that estimate recurrence rates up to 92%.5–7 The most important factor for recurrence seems to be the age of the patient at the time of the first dislocation.8,9 Many studies have compared the results of conservative treatment versus operative stabilization after a first traumatic shoulder dislocation. It is also documented that it is necessary to address and repair the structural damage of the capsule-labrum complex once the decision for surgery is made.10 With arthroscopic techniques getting more popular nowadays, an operative stabilization for primary acute shoulder dislocation in young (under 20 y) active patients, participating in highly demanding physical activities, is supported.11 In contrast, Cordischi et al12 and Postacchini et al5 found that patients younger than 14 years old have good or excellent results with low recurrence rates after conservative treatment. Therefore, those patients who might benefit more from an early operative stabilization are those who suffered their first dislocation at the age of 14 to 20 years. To the best of our knowledge, there are no studies comparing the results of nonoperative versus operative stabilization after the first traumatic dislocation in such an adolescent population. We conducted a prospective study with adolescent patients (age 15 to 18 y) who suffered a first traumatic anterior dislocation of the shoulder. Two groups of patients were formed. The first group was treated with early arthroscopic stabilization and the second was treated conservatively. The hypothesis of this study was that early arthroscopic stabilization after a first traumatic anterior dislocation would lead to a lower recurrence rate compared with conservative treatment in an adolescent population.
METHODS Seventy-two adolescent patients who suffered a first traumatic anterior dislocation of the shoulder were included in the study. Inclusion criteria to this study were: patients between 15 and 18 years old, first traumatic anterior shoulder dislocation with radiographic proof and without neurological complications, the dislocation required manual reduction by a physician, no history of www.pedorthopaedics.com |
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atraumatic or voluntary shoulder instability on the affected or contralateral side, subluxation, or fracture. Exclusion criteria to this study were: bone loss or bony damage of the anterior glenoid. All shoulders were initially treated in one of the 2 participating trauma centers or were referred to them within 7 days after the incident.
Preoperative Evaluation After closed reduction of the dislocation, all shoulders were initially immobilized and antero-posterior, and axially view radiographs were performed. A magnetic resonance image (MRI) was obtained within 7 days after the dislocation (Fig. 1). If structural damage of the capsule-labrum complex with or without a Hill Sachs lesion was found in the MRI, an arthroscopic stabilization of the affected shoulder was recommended to all patients and their parents. The arthroscopic stabilization was scheduled within 21 days of the trauma. A thorough history was obtained for each patient, including mechanism of injury and atraumatic instability history of both shoulders. In addition, the dominant upper arm was noted in all cases. The range of active flexion, extension, abduction, adduction, and internal and external rotation was recorded for both shoulders. Any sign of hyperlaxity (external rotation of the contralateral shoulder, sulcus sign, hyperabduction test, hyperextension of the elbows) was noted. The apprehension test was conducted as a clinical test for instability. Twenty-nine adolescent patients with their parents decided against surgery after the preoperation discussion and were therefore switched to the conservative treatment. Two groups were formed with 43 shoulders in the operative and 29 shoulders in the conservative group. All patients were followed prospectively after 12, 24, and 36 months using Rowe Score. Redislocation or subluxation
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of the shoulder was rated as failure of the treatment. Redislocation was defined as an episode of shoulder instability that required manual reduction. Subluxation was defined as an episode where the shoulder popped out of place, causing a brief period of pain or discomfort that shortly resolved without formal medical intervention. The Mann-Whitney U test was used to compare the differences between treatment groups, preoperative and postoperative (surgical group), or initial and follow-up (conservative group) Rowe score and DASH score. Comparison between the conservative and surgical group was also statistically analyzed by nonparametric method, using the Mann-Whitney U test. The level of significance was set up at P < 0.05.
Arthroscopic Treatment All patients in the surgical group were treated with arthroscopic stabilization under general anesthesia and placed in the lateral decubitus position. The arm was suspended with longitudinal traction of 5 kg. In all cases, a diagnostic arthroscopy was performed through a standard posterior portal. We also used an anterior and anterior-superior portal. A cannula was placed in the anterior portal. The posterior portal was used to assess a Hill Sachs lesion, if present, and to evaluate the stability of the superior labral complex. The arthroscope was then switched to the anterior-superior portal to have a better visualization of the anterior capsule-labrum complex. The labral lesion was identified and a release of any scar tissue between labrum and glenoid was performed. The release was complete if the muscular fibers of the M. subscapularis were visible. The anterior bony surface of the glenoid was debrided and any remaining soft tissue was removed. Suture anchors were placed on the glenoid rim. We used absorbable single-loaded suture anchors. Two or 3 suture anchors were inserted for the repair. The sutures were pulled through the capsule-labrum complex using curved penetrating devices. Both limbs of a suture were pulled through the tissue to form a horizontal stitch before tying the knots. Figure 2 shows a completed repair of the anterior capsule-labrum complex viewed from a superior portal.
Postoperative and Conservative Treatment
FIGURE 1. Preoperative magnetic resonance image with Bankart lesion ( * ).
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The rehabilitation protocol was the same for both groups. In the first 3 weeks, the arm was immobilized in a sling with only passive physiotherapy permitted. External rotation with the arm by the side and the elbow flexed was allowed, and therefore patients were able and encouraged to write. Active elbow, wrist, and hand motion was allowed. For the next 5 weeks, until the eighth week, active physiotherapy was recommended to restore the range of motion of the joint. After the eighth week, the patients were permitted full range of motion of the joint. At the 12th week, exercises for strengthening began and return to sports involving the shoulder was allowed at the fifth month after the injury. r
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FIGURE 2. Arthroscopic view of the Bankart repair from a suprabicipital portal.
RESULTS Five patients from the surgical group and 2 patients from the conservative group were lost during follow-up, leaving 38 shoulders in the surgical group and 27 shoulders in the conservative group that could be completely evaluated. The MRI scans of all patients proved a Bankart lesion. The mean age of all 65 patients was 16.7 years (range, 15 to 18 y). Forty-one were male and 24 were female. The dominant arm was affected in 36 cases. Fortysix patients sustained a sports-related trauma that led to shoulder dislocation. Table 1 shows the distribution of demographic data in both groups. From the conservative group, 19 patients (70.3%) suffered a recurrence of the instability. Twelve of them happened during the first year after the initial injury, 5 of them during the second year, and the remaining 2 during the third year. Only 1 patient reported an appropriate trauma for shoulder dislocation. This shoulder dislocated 3 years after the initial incident. From the arthroscopic group, 5 patients (13.1%) suffered a recurrence of the instability. No recurrences happened during the first year, 2 occurred during the
Treatment of Anterior Dislocation of Shoulder
second year, and 3 during the last year of follow-up. Three of them reported a new trauma that could be appropriate to provoke a shoulder dislocation. All 5 patients agreed to have an arthroscopic procedure again. A detachment of the capsule-labrum complex at the site of the prior repair could be identified and successfully repaired arthroscopically. Figure 3 shows the development of recurrent dislocations over time. The difference in redislocation rates between conservative and arthroscopic treatment was statistically significant (P < 0.05). The failures of each group were excluded for the analysis of the Rowe score. Figure 4 shows the results of the Rowe score evaluation. There was no statistical difference in the outcome of a successful conservative or arthroscopic treatment. There was also no statistical difference relating to sex, dominant arm, sports-related trauma, and hyperlaxity. Girls were more likely to be hyperlax than boys (P < 0.05). There was a tendency that the Apprehension test was more likely to be positive after successful conservative treatment compared with the surgical group (Table 2). Of the 46 patients with a sportsrelated trauma, 12 performed contact sports (soccer, handball, judo) at a competitive level. There was no statistical difference in the rate of return to sports after a successful conservative or operative treatment (Table 3).
DISCUSSION Many studies have documented the high rate of recurrence after first traumatic anterior dislocation of the shoulder in a young population when treated conservatively.9,13–17 Mc Laughlin and MacLellan7 reported a recurrence rate up to 95%. It is well documented that young and active patients are at a high risk for a recurrence. Hovelius et al9 reported long-term results with a 25-year follow-up. Although there seemed to be a subgroup of patients in his study that became stable over time, almost 60% of the patients younger than 19 years at the time of the first dislocation became surgically stabilized or still suffered from recurrent instability. In contrast, Cordischi et al,12 found that in adolescents between 10 and 13 years of age, conservative treatment can lead to an acceptable rate of stable shoulders with a recurrence rate of 21.4% after a mean follow-up of 5.6 years. Postacchini et al5 observed a recurrence rate of 33% in a subgroup of their cases younger than 13 years of age after conservative treatment compared with 92% in the age group of 14 to 17 years.
TABLE 1. Demographic Data Male Conservative
Operative
Conservative
Operative
17 16.4 9 13
24 16.8 13 18
10 16.9 5 6
14 16.3 9 9
No. Age Dominant arm Sports-related trauma
r
Female
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FIGURE 3. Time to redislocation (x-axis: months; y-axis: %).
Because of these high recurrence rates, some authors prefer initial surgical stabilization. It has to be taken into consideration that each recurrence can increase the structural damage of both bony structures and soft tissues.18 In conclusion, the age group just under the age of 18 seems to be at the highest risk for a recurrence after a first traumatic shoulder dislocation. Despite this fact, the treatment of this specific age group is not so well documented. Only few reports deal with the results of current arthroscopic stabilization techniques. Probably because of the numbers available, most studies reporting on postoperative results include this specific age group in a larger group of up to the age of 25 or even older. The aim of our study was to compare the recurrence rates and clinical results of conservative versus immediate arthroscopic stabilization in adolescents aged between 15 and 18 years. Our hypothesis was that conservative treatment will lead to an unacceptably high failure rate and that arthroscopic stabilization will recreate the stability of the shoulder. To increase the number of affected shoulders, we combined the cases of 2 trauma centers experienced in shoulder arthroscopy.
With the current data available, it is in our opinion that it is not ethical to conduct a prospective randomized study to compare the 2 different treatment options. We tried to solve this problem by creating this study design. This design is also a major weakness of our study, because we are not able to control a possible selection bias. Looking at the results of our arthroscopic stabilizations, we found a recurrence rate of 13.1%. Kirkley et al19 reported a recurrence rate of 18.7% in their surgical group of 16 shoulders in a young active population using an arthroscopic transglenoidal repair technique. Jones et al20 reported a recurrence rate of 12.5% in their primary arthroscopic Bankart repair group after a mean follow-up of 25 months. Castagna21 observed a recurrence rate of 21% in his study population of adolescent athletes; it has to be kept in mind that all recurrences in this study occurred in patients with at least 2 instability episodes before arthroscopic stabilization. Looking at the recurrence rates of primary arthroscopic stabilization including patients up to 40 years of age, it is remarkable that the reported recurrence rates range from as low as 2.4% up to 20%.22,23 Probably, the recurrence rates after primary arthroscopic stabilization TABLE 2. Instability Evaluation Male
Female
Conservative Operative Conservative Operative
FIGURE 4. Rowe score with failures of each group excluded.
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N Failures [n (%)] Hyperlaxity [n (%)] Postapprehension initially [n (%)] Postapprehension at 36 mo (failures excluded) [n (%)]
17 12 (70.6) 4 (23.5)
24 3 (12.5) 7 (29.2)
10 7 (70) 6 (60)
14 2 (14.3) 7 (50)
15 (88.3)
21 (87.5)
9 (90)
12 (85.7)
2 (40)
2 (9.5)
r
1 (33.3)
2 (16.6)
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Treatment of Anterior Dislocation of Shoulder
TABLE 3. Activity Level Male
Female
Conservative Operative Conservative Operative Sports-related trauma Contact sports at competitive level Return to sports at previous level
13
18
6
9
3
7
0
2
10
17
5
8
in an adolescent population are comparable with those of an older subgroup of patients. If we excluded the failures of both groups in our study, we found that the Rowe score had no statistical significant difference. This means that both treatment options can lead to the same result if it is successful. To the best of our knowledge, this is the first study reporting on results after conservative versus arthroscopic stabilization after first traumatic shoulder dislocation in an adolescent population. There are certain limitations to this study. As mentioned above, it is not a properly randomized trial, a selection bias cannot be excluded. For conservative treatment, we did not immobilize the patients in external rotation, which seems to lead to lower recurrence rates after conservative treatment compared with immobilization in internal rotation.24
CONCLUSIONS In an adolescent population (15 to 18 y), conservative treatment after first traumatic shoulder dislocation including immobilization in internal rotation leads to a significantly higher and unacceptable high failure rate compared with early arthroscopic stabilization. REFERENCES 1. Itoi E, Hatakeyama Y, Kido T, et al. A new method of immobilization after traumatic anterior dislocation of the shoulder. A preliminary study. J Shoulder Elbow Surg. 2003;12:413–415. 2. Johnson DH, Pedowitz RA. Practical Orthopaedic Sports Medicine and Arthroscopy. ISBN: 13:978-0-7817-5812-3. Philadelphia, PA: Lippincott Williams & Wilkins; 2007. 3. Rowe CR. Anterior dislocation of the shoulder. Prognosis and treatment. Surg Clin North Am. 1963;43:1609–1614. 4. Smith T. Immobilization following traumatic anterior glenohumeral joint dislocation. A literature review. Injury. 2006;37:228–237. 5. Postacchini F, Gumina S, Cinotti G. Anterior shoulder dislocation in adolescents. J Shoulder Elbow Surg. 2000;9:470–474.
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6. Walton J, Paxinos A, Tzannes A, et al. The unstable shoulder in adolescent athlete. Am J Sports Med. 2002;30:758–767. 7. McLaughlin H, MacLellan D. Recurrent anterior dislocation of the shoulder: II. A comparative study. J Trauma.; 1967:191–201. 8. Rowe CR, Patel D, Southmayd WW. The Bankart procedure: a long-term end-result study. J Bone Joint Surg Am. 1978;60:1–16. 9. Hovelius L, Oloffson A, Sandstrom B, et al. Nonoperative treatment of primary anterior shoulder dislocation in patients forty years of age and younger. A prospective twenty-five year follow-up. J Bone Joint Surg Am. 2008;90:945–952. 10. Robinson CM, Jenkins PJ, White TO, et al. Primary arthroscopic stabilization for a first-time anterior dislocation of the shoulder. A randomized, double-blind trial. J Bone Joint Surg Am. 2008;90: 708–721. 11. Godin J, Sekiya J. Systematic review of rehabilitation versus operative stabilization for the treatment of first time anterior shoulder dislocation. Sports Health. 2010;2:156–165. 12. Cordischi K, Li X, Busconi B. Intermediate outcomes after primary traumatic anterior shoulder dislocation in skeletally immature patient aged 10 to 13 years. Orthopedics. 2009;32. 13. Hovelius L, Saeboe M. Neer Award 2008. Arthropathy after primary anterior shoulder dislocation: 223 shoulders prospectively followed up for twenty five years. J Shoulder Elbow Surg. 2009;18:339–347. 14. Kralinger FS, Golser K, Wischatta R, et al. Predicting recurrence after primary anterior shoulder dislocation. Am J Sports Med. 2002; 30:116–120. 15. Robinson CM, Howes J, Murdoch H, et al. Functional outcome and risk of recurrent instability after primary traumatic anterior shoulder dislocation in young patients. J Bone Joint Surg Am. 2006;88:2326–2336. 16. Rowe CR. Acute and recurrent anterior dislocations of the shoulder. Orthop Clin North Am. 1980;11:253–270. 17. Sachs R, Lin D, Stone ML, et al. Can the need for future surgery for acute traumatic anterior shoulder dislocation be predicted? J Bone Joint Surg Am. 2007;89:1665–1674. 18. Habermeyer P, Gleyze P, Rickert M. Evolution of lesions of the labrum-ligament complex in posttraumatic anterior shoulder instability: a prospective study. J Shoulder Elbow Surg. 1999;8:66–74. 19. Kirkley A, Werstine R, Ratjek A, et al. Immobilization and rehabilitation in first traumatic anterior dislocations of the shoulder: long term evaluation. Arthroscopy. 2005;21:55–63. 20. Jones KJ, Wiesel B, Ganley TJ, et al. Functional outcomes of early arthroscopic bankart repair in adolescents aged 11 to 18 years. J Pediatr Orthop. 2007;27:209–213. 21. Castagna A, Rose GD, Borroni M, et al. Arthroscopic stabilization of the shoulder in adolescent athletes participating in overhead or contact sports. Arthroscopy. 2012;28:309–315. 22. Porcellini G, Paladini P, Campi F, et al. Long-term outcome of acute versus chronic bony Bankart lesions managed arthroscopically. Am J Sports Med. 2007;35:2067–2072. 23. Valentin A, Winge S, Engstrom B. Early arthroscopic treatment of primary traumatic anterior shoulder dislocation. A follow-up study. Scand J Med Sci Sports. 1998;8:405–410. 24. Itoi E, Sashi R, Minagawa H, et al. Position of immobilization after dislocation of the glenohumeral joint. A study with use of magnetic resonance imaging. J Bone Joint Surg Am. 2001;83:661–667.
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Arthroscopic Versus Conservative Treatment of First Anterior Dislocation of the Shoulder in Adolescents Ioannis Gigis, MD,* Roderich Heikenfeld, MD,w Arion Kapinas, MD,* Rico Listringhaus, MD,w and Georgios Godolias, MDw
Background: Conservative treatment of posttraumatic anteroinferior shoulder instability leads to a high failure rate in a young and active population. However, treatment in an adolescent age group is not well documented. Methods: We conducted a prospective study with adolescent patients (age 15 to 18 y) who suffered a first traumatic anterior dislocation of the shoulder. Two groups of patients were formed. The first group was treated with early arthroscopic stabilization and the second was treated conservatively. There were 43 shoulders in the operative group and 29 shoulders in the conservative group. The rehabilitation protocol was the same for both groups. All patients were followed up prospectively after 12, 24, and 36 months using Rowe Score. Results: A total of 38 shoulders in the surgical group and 27 shoulders in the conservative group could be completely evaluated. From the conservative group, 19 patients (70.3%) suffered a recurrence of the instability. From the arthroscopic group, 5 patients (13.1%) suffered a recurrence of the instability. Conclusions: In an adolescent population (15 to 18 y), conservative treatment after first traumatic shoulder dislocation including immobilization in internal rotation leads to a significantly higher and unacceptable high failure rate compared with early arthroscopic stabilization. Level of Evidence: Level II—prospective comparative study. Key Words: shoulder instability, shoulder arthroscopy, arthroscopic Bankart repair, adolescents, conservative treatment (J Pediatr Orthop 2014;34:421–425)
T
he shoulder is the major joint that most commonly dislocates.1,2 In fact, the glenohumeral dislocation occurs more often than all other joint dislocations altogether.3 A total of 98% of the dislocations are anterior,4 whereas the posterior rate is very small.
From the *2nd Orthopaedic Department, Aristotle University of Thessaloniki, Thessaloniki, Greece; and wCenter for Orthopedics and Traumatology, St Anna Hospital Herne, University of Witten/ Herdecke, Herne, Germany. The authors declare no conflict of interest. Reprints: Roderich Heikenfeld, MD, Center for Orthopedics and Traumatology, St Anna Hospital Herne, University of Witten/Herdecke, Hospitalstr. 19, Herne D-44649, Germany. E-mail: r.heikenfeld@ annahospital.de. Copyright r 2013 by Lippincott Williams & Wilkins
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In patients younger than 30 years old, reduction of the dislocation and conservative treatment, including immobilization and physical therapy, leads to unacceptable high rates of recurrences because of anterior instability of the shoulder after the first injury. There are studies that estimate recurrence rates up to 92%.5–7 The most important factor for recurrence seems to be the age of the patient at the time of the first dislocation.8,9 Many studies have compared the results of conservative treatment versus operative stabilization after a first traumatic shoulder dislocation. It is also documented that it is necessary to address and repair the structural damage of the capsule-labrum complex once the decision for surgery is made.10 With arthroscopic techniques getting more popular nowadays, an operative stabilization for primary acute shoulder dislocation in young (under 20 y) active patients, participating in highly demanding physical activities, is supported.11 In contrast, Cordischi et al12 and Postacchini et al5 found that patients younger than 14 years old have good or excellent results with low recurrence rates after conservative treatment. Therefore, those patients who might benefit more from an early operative stabilization are those who suffered their first dislocation at the age of 14 to 20 years. To the best of our knowledge, there are no studies comparing the results of nonoperative versus operative stabilization after the first traumatic dislocation in such an adolescent population. We conducted a prospective study with adolescent patients (age 15 to 18 y) who suffered a first traumatic anterior dislocation of the shoulder. Two groups of patients were formed. The first group was treated with early arthroscopic stabilization and the second was treated conservatively. The hypothesis of this study was that early arthroscopic stabilization after a first traumatic anterior dislocation would lead to a lower recurrence rate compared with conservative treatment in an adolescent population.
METHODS Seventy-two adolescent patients who suffered a first traumatic anterior dislocation of the shoulder were included in the study. Inclusion criteria to this study were: patients between 15 and 18 years old, first traumatic anterior shoulder dislocation with radiographic proof and without neurological complications, the dislocation required manual reduction by a physician, no history of www.pedorthopaedics.com |
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atraumatic or voluntary shoulder instability on the affected or contralateral side, subluxation, or fracture. Exclusion criteria to this study were: bone loss or bony damage of the anterior glenoid. All shoulders were initially treated in one of the 2 participating trauma centers or were referred to them within 7 days after the incident.
Preoperative Evaluation After closed reduction of the dislocation, all shoulders were initially immobilized and antero-posterior, and axially view radiographs were performed. A magnetic resonance image (MRI) was obtained within 7 days after the dislocation (Fig. 1). If structural damage of the capsule-labrum complex with or without a Hill Sachs lesion was found in the MRI, an arthroscopic stabilization of the affected shoulder was recommended to all patients and their parents. The arthroscopic stabilization was scheduled within 21 days of the trauma. A thorough history was obtained for each patient, including mechanism of injury and atraumatic instability history of both shoulders. In addition, the dominant upper arm was noted in all cases. The range of active flexion, extension, abduction, adduction, and internal and external rotation was recorded for both shoulders. Any sign of hyperlaxity (external rotation of the contralateral shoulder, sulcus sign, hyperabduction test, hyperextension of the elbows) was noted. The apprehension test was conducted as a clinical test for instability. Twenty-nine adolescent patients with their parents decided against surgery after the preoperation discussion and were therefore switched to the conservative treatment. Two groups were formed with 43 shoulders in the operative and 29 shoulders in the conservative group. All patients were followed prospectively after 12, 24, and 36 months using Rowe Score. Redislocation or subluxation
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of the shoulder was rated as failure of the treatment. Redislocation was defined as an episode of shoulder instability that required manual reduction. Subluxation was defined as an episode where the shoulder popped out of place, causing a brief period of pain or discomfort that shortly resolved without formal medical intervention. The Mann-Whitney U test was used to compare the differences between treatment groups, preoperative and postoperative (surgical group), or initial and follow-up (conservative group) Rowe score and DASH score. Comparison between the conservative and surgical group was also statistically analyzed by nonparametric method, using the Mann-Whitney U test. The level of significance was set up at P < 0.05.
Arthroscopic Treatment All patients in the surgical group were treated with arthroscopic stabilization under general anesthesia and placed in the lateral decubitus position. The arm was suspended with longitudinal traction of 5 kg. In all cases, a diagnostic arthroscopy was performed through a standard posterior portal. We also used an anterior and anterior-superior portal. A cannula was placed in the anterior portal. The posterior portal was used to assess a Hill Sachs lesion, if present, and to evaluate the stability of the superior labral complex. The arthroscope was then switched to the anterior-superior portal to have a better visualization of the anterior capsule-labrum complex. The labral lesion was identified and a release of any scar tissue between labrum and glenoid was performed. The release was complete if the muscular fibers of the M. subscapularis were visible. The anterior bony surface of the glenoid was debrided and any remaining soft tissue was removed. Suture anchors were placed on the glenoid rim. We used absorbable single-loaded suture anchors. Two or 3 suture anchors were inserted for the repair. The sutures were pulled through the capsule-labrum complex using curved penetrating devices. Both limbs of a suture were pulled through the tissue to form a horizontal stitch before tying the knots. Figure 2 shows a completed repair of the anterior capsule-labrum complex viewed from a superior portal.
Postoperative and Conservative Treatment
FIGURE 1. Preoperative magnetic resonance image with Bankart lesion ( * ).
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The rehabilitation protocol was the same for both groups. In the first 3 weeks, the arm was immobilized in a sling with only passive physiotherapy permitted. External rotation with the arm by the side and the elbow flexed was allowed, and therefore patients were able and encouraged to write. Active elbow, wrist, and hand motion was allowed. For the next 5 weeks, until the eighth week, active physiotherapy was recommended to restore the range of motion of the joint. After the eighth week, the patients were permitted full range of motion of the joint. At the 12th week, exercises for strengthening began and return to sports involving the shoulder was allowed at the fifth month after the injury. r
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FIGURE 2. Arthroscopic view of the Bankart repair from a suprabicipital portal.
RESULTS Five patients from the surgical group and 2 patients from the conservative group were lost during follow-up, leaving 38 shoulders in the surgical group and 27 shoulders in the conservative group that could be completely evaluated. The MRI scans of all patients proved a Bankart lesion. The mean age of all 65 patients was 16.7 years (range, 15 to 18 y). Forty-one were male and 24 were female. The dominant arm was affected in 36 cases. Fortysix patients sustained a sports-related trauma that led to shoulder dislocation. Table 1 shows the distribution of demographic data in both groups. From the conservative group, 19 patients (70.3%) suffered a recurrence of the instability. Twelve of them happened during the first year after the initial injury, 5 of them during the second year, and the remaining 2 during the third year. Only 1 patient reported an appropriate trauma for shoulder dislocation. This shoulder dislocated 3 years after the initial incident. From the arthroscopic group, 5 patients (13.1%) suffered a recurrence of the instability. No recurrences happened during the first year, 2 occurred during the
Treatment of Anterior Dislocation of Shoulder
second year, and 3 during the last year of follow-up. Three of them reported a new trauma that could be appropriate to provoke a shoulder dislocation. All 5 patients agreed to have an arthroscopic procedure again. A detachment of the capsule-labrum complex at the site of the prior repair could be identified and successfully repaired arthroscopically. Figure 3 shows the development of recurrent dislocations over time. The difference in redislocation rates between conservative and arthroscopic treatment was statistically significant (P < 0.05). The failures of each group were excluded for the analysis of the Rowe score. Figure 4 shows the results of the Rowe score evaluation. There was no statistical difference in the outcome of a successful conservative or arthroscopic treatment. There was also no statistical difference relating to sex, dominant arm, sports-related trauma, and hyperlaxity. Girls were more likely to be hyperlax than boys (P < 0.05). There was a tendency that the Apprehension test was more likely to be positive after successful conservative treatment compared with the surgical group (Table 2). Of the 46 patients with a sportsrelated trauma, 12 performed contact sports (soccer, handball, judo) at a competitive level. There was no statistical difference in the rate of return to sports after a successful conservative or operative treatment (Table 3).
DISCUSSION Many studies have documented the high rate of recurrence after first traumatic anterior dislocation of the shoulder in a young population when treated conservatively.9,13–17 Mc Laughlin and MacLellan7 reported a recurrence rate up to 95%. It is well documented that young and active patients are at a high risk for a recurrence. Hovelius et al9 reported long-term results with a 25-year follow-up. Although there seemed to be a subgroup of patients in his study that became stable over time, almost 60% of the patients younger than 19 years at the time of the first dislocation became surgically stabilized or still suffered from recurrent instability. In contrast, Cordischi et al,12 found that in adolescents between 10 and 13 years of age, conservative treatment can lead to an acceptable rate of stable shoulders with a recurrence rate of 21.4% after a mean follow-up of 5.6 years. Postacchini et al5 observed a recurrence rate of 33% in a subgroup of their cases younger than 13 years of age after conservative treatment compared with 92% in the age group of 14 to 17 years.
TABLE 1. Demographic Data Male Conservative
Operative
Conservative
Operative
17 16.4 9 13
24 16.8 13 18
10 16.9 5 6
14 16.3 9 9
No. Age Dominant arm Sports-related trauma
r
Female
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FIGURE 3. Time to redislocation (x-axis: months; y-axis: %).
Because of these high recurrence rates, some authors prefer initial surgical stabilization. It has to be taken into consideration that each recurrence can increase the structural damage of both bony structures and soft tissues.18 In conclusion, the age group just under the age of 18 seems to be at the highest risk for a recurrence after a first traumatic shoulder dislocation. Despite this fact, the treatment of this specific age group is not so well documented. Only few reports deal with the results of current arthroscopic stabilization techniques. Probably because of the numbers available, most studies reporting on postoperative results include this specific age group in a larger group of up to the age of 25 or even older. The aim of our study was to compare the recurrence rates and clinical results of conservative versus immediate arthroscopic stabilization in adolescents aged between 15 and 18 years. Our hypothesis was that conservative treatment will lead to an unacceptably high failure rate and that arthroscopic stabilization will recreate the stability of the shoulder. To increase the number of affected shoulders, we combined the cases of 2 trauma centers experienced in shoulder arthroscopy.
With the current data available, it is in our opinion that it is not ethical to conduct a prospective randomized study to compare the 2 different treatment options. We tried to solve this problem by creating this study design. This design is also a major weakness of our study, because we are not able to control a possible selection bias. Looking at the results of our arthroscopic stabilizations, we found a recurrence rate of 13.1%. Kirkley et al19 reported a recurrence rate of 18.7% in their surgical group of 16 shoulders in a young active population using an arthroscopic transglenoidal repair technique. Jones et al20 reported a recurrence rate of 12.5% in their primary arthroscopic Bankart repair group after a mean follow-up of 25 months. Castagna21 observed a recurrence rate of 21% in his study population of adolescent athletes; it has to be kept in mind that all recurrences in this study occurred in patients with at least 2 instability episodes before arthroscopic stabilization. Looking at the recurrence rates of primary arthroscopic stabilization including patients up to 40 years of age, it is remarkable that the reported recurrence rates range from as low as 2.4% up to 20%.22,23 Probably, the recurrence rates after primary arthroscopic stabilization TABLE 2. Instability Evaluation Male
Female
Conservative Operative Conservative Operative
FIGURE 4. Rowe score with failures of each group excluded.
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N Failures [n (%)] Hyperlaxity [n (%)] Postapprehension initially [n (%)] Postapprehension at 36 mo (failures excluded) [n (%)]
17 12 (70.6) 4 (23.5)
24 3 (12.5) 7 (29.2)
10 7 (70) 6 (60)
14 2 (14.3) 7 (50)
15 (88.3)
21 (87.5)
9 (90)
12 (85.7)
2 (40)
2 (9.5)
r
1 (33.3)
2 (16.6)
2013 Lippincott Williams & Wilkins
J Pediatr Orthop
Volume 34, Number 4, June 2014
Treatment of Anterior Dislocation of Shoulder
TABLE 3. Activity Level Male
Female
Conservative Operative Conservative Operative Sports-related trauma Contact sports at competitive level Return to sports at previous level
13
18
6
9
3
7
0
2
10
17
5
8
in an adolescent population are comparable with those of an older subgroup of patients. If we excluded the failures of both groups in our study, we found that the Rowe score had no statistical significant difference. This means that both treatment options can lead to the same result if it is successful. To the best of our knowledge, this is the first study reporting on results after conservative versus arthroscopic stabilization after first traumatic shoulder dislocation in an adolescent population. There are certain limitations to this study. As mentioned above, it is not a properly randomized trial, a selection bias cannot be excluded. For conservative treatment, we did not immobilize the patients in external rotation, which seems to lead to lower recurrence rates after conservative treatment compared with immobilization in internal rotation.24
CONCLUSIONS In an adolescent population (15 to 18 y), conservative treatment after first traumatic shoulder dislocation including immobilization in internal rotation leads to a significantly higher and unacceptable high failure rate compared with early arthroscopic stabilization. REFERENCES 1. Itoi E, Hatakeyama Y, Kido T, et al. A new method of immobilization after traumatic anterior dislocation of the shoulder. A preliminary study. J Shoulder Elbow Surg. 2003;12:413–415. 2. Johnson DH, Pedowitz RA. Practical Orthopaedic Sports Medicine and Arthroscopy. ISBN: 13:978-0-7817-5812-3. Philadelphia, PA: Lippincott Williams & Wilkins; 2007. 3. Rowe CR. Anterior dislocation of the shoulder. Prognosis and treatment. Surg Clin North Am. 1963;43:1609–1614. 4. Smith T. Immobilization following traumatic anterior glenohumeral joint dislocation. A literature review. Injury. 2006;37:228–237. 5. Postacchini F, Gumina S, Cinotti G. Anterior shoulder dislocation in adolescents. J Shoulder Elbow Surg. 2000;9:470–474.
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6. Walton J, Paxinos A, Tzannes A, et al. The unstable shoulder in adolescent athlete. Am J Sports Med. 2002;30:758–767. 7. McLaughlin H, MacLellan D. Recurrent anterior dislocation of the shoulder: II. A comparative study. J Trauma.; 1967:191–201. 8. Rowe CR, Patel D, Southmayd WW. The Bankart procedure: a long-term end-result study. J Bone Joint Surg Am. 1978;60:1–16. 9. Hovelius L, Oloffson A, Sandstrom B, et al. Nonoperative treatment of primary anterior shoulder dislocation in patients forty years of age and younger. A prospective twenty-five year follow-up. J Bone Joint Surg Am. 2008;90:945–952. 10. Robinson CM, Jenkins PJ, White TO, et al. Primary arthroscopic stabilization for a first-time anterior dislocation of the shoulder. A randomized, double-blind trial. J Bone Joint Surg Am. 2008;90: 708–721. 11. Godin J, Sekiya J. Systematic review of rehabilitation versus operative stabilization for the treatment of first time anterior shoulder dislocation. Sports Health. 2010;2:156–165. 12. Cordischi K, Li X, Busconi B. Intermediate outcomes after primary traumatic anterior shoulder dislocation in skeletally immature patient aged 10 to 13 years. Orthopedics. 2009;32. 13. Hovelius L, Saeboe M. Neer Award 2008. Arthropathy after primary anterior shoulder dislocation: 223 shoulders prospectively followed up for twenty five years. J Shoulder Elbow Surg. 2009;18:339–347. 14. Kralinger FS, Golser K, Wischatta R, et al. Predicting recurrence after primary anterior shoulder dislocation. Am J Sports Med. 2002; 30:116–120. 15. Robinson CM, Howes J, Murdoch H, et al. Functional outcome and risk of recurrent instability after primary traumatic anterior shoulder dislocation in young patients. J Bone Joint Surg Am. 2006;88:2326–2336. 16. Rowe CR. Acute and recurrent anterior dislocations of the shoulder. Orthop Clin North Am. 1980;11:253–270. 17. Sachs R, Lin D, Stone ML, et al. Can the need for future surgery for acute traumatic anterior shoulder dislocation be predicted? J Bone Joint Surg Am. 2007;89:1665–1674. 18. Habermeyer P, Gleyze P, Rickert M. Evolution of lesions of the labrum-ligament complex in posttraumatic anterior shoulder instability: a prospective study. J Shoulder Elbow Surg. 1999;8:66–74. 19. Kirkley A, Werstine R, Ratjek A, et al. Immobilization and rehabilitation in first traumatic anterior dislocations of the shoulder: long term evaluation. Arthroscopy. 2005;21:55–63. 20. Jones KJ, Wiesel B, Ganley TJ, et al. Functional outcomes of early arthroscopic bankart repair in adolescents aged 11 to 18 years. J Pediatr Orthop. 2007;27:209–213. 21. Castagna A, Rose GD, Borroni M, et al. Arthroscopic stabilization of the shoulder in adolescent athletes participating in overhead or contact sports. Arthroscopy. 2012;28:309–315. 22. Porcellini G, Paladini P, Campi F, et al. Long-term outcome of acute versus chronic bony Bankart lesions managed arthroscopically. Am J Sports Med. 2007;35:2067–2072. 23. Valentin A, Winge S, Engstrom B. Early arthroscopic treatment of primary traumatic anterior shoulder dislocation. A follow-up study. Scand J Med Sci Sports. 1998;8:405–410. 24. Itoi E, Sashi R, Minagawa H, et al. Position of immobilization after dislocation of the glenohumeral joint. A study with use of magnetic resonance imaging. J Bone Joint Surg Am. 2001;83:661–667.
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