BJSM Online First, published on May 27, 2015 as 10.1136/bjsports-2015-094584
Predicting recurrent shoulder instability Mark R Hutchinson,1 Bob McCormack2 As sports orthopaedic surgeons and sports medicine clinicians, it was with great excitement that we first read the manuscript of Margie Olds and colleagues regarding ‘Risk factors which predispose first-time traumatic anterior shoulder dislocations to recurrent instability in adults: a systematic review and meta-analysis’.1 The authors had nicely defined their population and purpose, and for us as clinicians, it heralded great potential regarding patient education as well as treatment options (when should I pull the trigger and perform surgical stabilisation for a first time dislocator?). The authors have done a wonderful job reviewing the global topic with particular documentation on the impact on the New Zealand healthcare system. They remind us, with supported references, of the known risk factors, including age; gender; hypermobility; occupational demands; sports specific demands, particularly those of overhead or collision sports; and also about pathological factors such as Hill-Sach’s lesions or bony Bankart lesions. Their conclusions support commonly accepted dictums when caring for patients with first time dislocators: age is a key risk factor, males have higher risk of recurrent instability than females (most likely due to their sports specific demands), patients with hyperlaxity are at increased risk, and associated tuberosity fractures tend to imply reduced risk of recurrent injury. The authors’ conclusion that a bony Bankart may be protective against recurrent dislocations is, however, inconsistent with what we observe in practice. We suggest it represents the fact that patients with bony Bankarts were included in the data set and they were treated with success surgically. We are confident that a large bony Bankart or glenoid deficiency is a key factor leading to recurrent instability as this has been well established in the literature and in clinical practice. Systematic reviews depend completely on the quality of data included in the review. For example, if your systematic
review includes 995 level one papers but also includes 5 level five opinion papers, at best you can conclude a mixed consensus and the paper is no more valuable on evidence basis than level five or opinion. In this paper, the authors ultimately extrapolated data from 10 studies which they graded (2 high, 3 acceptable, and 5 low) with defined weakness that crossed over all studies. Ultimately, while we loved this article as a review piece that further supports what we know in the literature, based on quality of evidence, it was not able to meet our original excitement of ‘practice-changing’ impact. It would be very helpful to have a ‘formula’ that tells us the approximate risk of recurrence, particularly when multiple risk factors are present. Future studies that could develop such a tool would be worthwhile.
WHAT SHOULD CLINICIANS DO? Until the time that further high quality evidence is available, prudent clinical practice should be based on the best evidence currently available as well as the individual patient’s factors (figure 1). First, sideline clinicians should be expert at relocating shoulders with appropriate precautions.2 In the office consultation, factors providing high risk of recurrent instability include: age of 20 years, bony pathology such as large glenoid fractures or Hill-Sachs lesions, generalised ligamentous
Editorial
laxity, and participation in high-risk sport such as collision sports. In the absence of these risk factors, prudence would indicate a non-surgical course of rehabilitation which in turn forces the patient’s subsequent clinical course to define the patient as stable or unstable. For those patients with the classic risk factors, the clinician should base the decision of surgical or nonsurgical repair of a first time shoulder dislocation firmly in the hands of a wellinformed patient who understands the risk and benefits of each treatment option. The evidence for surgical treatment of first time shoulder dislocations in young military recruits, who must return to highdemand activities, is strongly supported by evidence. In summary, Olds and colleagues,1 provided additional support to the concept of risk factors related to recurrence after first time shoulder dislocations. They showed that overall risk for recurrence in the broad population was 39%. They also showed that people under the age of 40 years, men and patients with hyperlaxity were at increased risk of recurrent instability. Factors that seemed to indicate a lower risk of recurrence are an associated tuberosity fracture and a longer time frame from the original dislocation. Ultimately, these concepts are the key value of this paper as they can be used to further educate patients and clinicians regarding risk factors related to recurrence.3 This knowledge might assist the individual who has dislocated for the first time in choosing between a surgical and non-surgical approach. Unfortunately,
1
Department of Orthopaedics and Sports Medicine, University of Illinois at Chicago, Chicago, Illinois, USA; 2 Department of Orthopedic Surgery, University of British Columbia, New Westminster, British Columbia, Canada Correspondence to Dr Mark R Hutchinson, Orthopaedics and Sports Medicine, University of Illinois at Chicago, Chicago, IL 60612, USA; [email protected]
Figure 1 Until the time that further high quality evidence is available, prudent clinical practice should be based on the best evidence currently available as well as the individual patient factors.
Hutchinson MR, et al. Br J Sports Med Month 2015 Vol 0 No 0
Copyright Article author (or their employer) 2015. Produced by BMJ Publishing Group Ltd under licence.
1
Editorial there is still no algorithm that can be used for all patients. Contributors MRH provided initial review and evaluation of the manuscript, and BM provided additional review, perspective, and editorial clarifications. Competing interests None declared. Provenance and peer review Commissioned; externally peer reviewed. To cite Hutchinson MR, McCormack B. Br J Sports Med Published Online First: [ please include Day Month Year] doi:10.1136/bjsports-2015-094584
2
Accepted 5 May 2015
2
▸ http://dx.doi.org/10.1136/bjsports-2014-094342 3
Br J Sports Med 2015;0:1–2. doi:10.1136/bjsports-2015-094584
dislocations to recurrent instability in adults: a systematic review and meta-analysis. Br J Sports Med Published Online First: 21 Apr 2015 doi:10.1136/bjsports-2014-094342 Dala-Ali B, Penna M, McConnell J, et al. Management of acute anterior shoulder dislocation. Br J Sports Med 2014;48:1209–15. Verhagen E, Voogt N, Bruinsma A, et al. A knowledge transfer scheme to bridge the gap between science and practice: an integration of existing research frameworks into a tool for practice. Br J Sports Med 2014;48:698–701.
REFERENCES 1
Olds M, Ellis R, Donaldson K, et al. Risk factors which predispose first-time traumatic anterior shoulder
Hutchinson MR, et al. Br J Sports Med Month 2015 Vol 0 No 0
Predicting recurrent shoulder instability Mark R Hutchinson,1 Bob McCormack2 As sports orthopaedic surgeons and sports medicine clinicians, it was with great excitement that we first read the manuscript of Margie Olds and colleagues regarding ‘Risk factors which predispose first-time traumatic anterior shoulder dislocations to recurrent instability in adults: a systematic review and meta-analysis’.1 The authors had nicely defined their population and purpose, and for us as clinicians, it heralded great potential regarding patient education as well as treatment options (when should I pull the trigger and perform surgical stabilisation for a first time dislocator?). The authors have done a wonderful job reviewing the global topic with particular documentation on the impact on the New Zealand healthcare system. They remind us, with supported references, of the known risk factors, including age; gender; hypermobility; occupational demands; sports specific demands, particularly those of overhead or collision sports; and also about pathological factors such as Hill-Sach’s lesions or bony Bankart lesions. Their conclusions support commonly accepted dictums when caring for patients with first time dislocators: age is a key risk factor, males have higher risk of recurrent instability than females (most likely due to their sports specific demands), patients with hyperlaxity are at increased risk, and associated tuberosity fractures tend to imply reduced risk of recurrent injury. The authors’ conclusion that a bony Bankart may be protective against recurrent dislocations is, however, inconsistent with what we observe in practice. We suggest it represents the fact that patients with bony Bankarts were included in the data set and they were treated with success surgically. We are confident that a large bony Bankart or glenoid deficiency is a key factor leading to recurrent instability as this has been well established in the literature and in clinical practice. Systematic reviews depend completely on the quality of data included in the review. For example, if your systematic
review includes 995 level one papers but also includes 5 level five opinion papers, at best you can conclude a mixed consensus and the paper is no more valuable on evidence basis than level five or opinion. In this paper, the authors ultimately extrapolated data from 10 studies which they graded (2 high, 3 acceptable, and 5 low) with defined weakness that crossed over all studies. Ultimately, while we loved this article as a review piece that further supports what we know in the literature, based on quality of evidence, it was not able to meet our original excitement of ‘practice-changing’ impact. It would be very helpful to have a ‘formula’ that tells us the approximate risk of recurrence, particularly when multiple risk factors are present. Future studies that could develop such a tool would be worthwhile.
WHAT SHOULD CLINICIANS DO? Until the time that further high quality evidence is available, prudent clinical practice should be based on the best evidence currently available as well as the individual patient’s factors (figure 1). First, sideline clinicians should be expert at relocating shoulders with appropriate precautions.2 In the office consultation, factors providing high risk of recurrent instability include: age of 20 years, bony pathology such as large glenoid fractures or Hill-Sachs lesions, generalised ligamentous
Editorial
laxity, and participation in high-risk sport such as collision sports. In the absence of these risk factors, prudence would indicate a non-surgical course of rehabilitation which in turn forces the patient’s subsequent clinical course to define the patient as stable or unstable. For those patients with the classic risk factors, the clinician should base the decision of surgical or nonsurgical repair of a first time shoulder dislocation firmly in the hands of a wellinformed patient who understands the risk and benefits of each treatment option. The evidence for surgical treatment of first time shoulder dislocations in young military recruits, who must return to highdemand activities, is strongly supported by evidence. In summary, Olds and colleagues,1 provided additional support to the concept of risk factors related to recurrence after first time shoulder dislocations. They showed that overall risk for recurrence in the broad population was 39%. They also showed that people under the age of 40 years, men and patients with hyperlaxity were at increased risk of recurrent instability. Factors that seemed to indicate a lower risk of recurrence are an associated tuberosity fracture and a longer time frame from the original dislocation. Ultimately, these concepts are the key value of this paper as they can be used to further educate patients and clinicians regarding risk factors related to recurrence.3 This knowledge might assist the individual who has dislocated for the first time in choosing between a surgical and non-surgical approach. Unfortunately,
1
Department of Orthopaedics and Sports Medicine, University of Illinois at Chicago, Chicago, Illinois, USA; 2 Department of Orthopedic Surgery, University of British Columbia, New Westminster, British Columbia, Canada Correspondence to Dr Mark R Hutchinson, Orthopaedics and Sports Medicine, University of Illinois at Chicago, Chicago, IL 60612, USA; [email protected]
Figure 1 Until the time that further high quality evidence is available, prudent clinical practice should be based on the best evidence currently available as well as the individual patient factors.
Hutchinson MR, et al. Br J Sports Med Month 2015 Vol 0 No 0
Copyright Article author (or their employer) 2015. Produced by BMJ Publishing Group Ltd under licence.
1
Editorial there is still no algorithm that can be used for all patients. Contributors MRH provided initial review and evaluation of the manuscript, and BM provided additional review, perspective, and editorial clarifications. Competing interests None declared. Provenance and peer review Commissioned; externally peer reviewed. To cite Hutchinson MR, McCormack B. Br J Sports Med Published Online First: [ please include Day Month Year] doi:10.1136/bjsports-2015-094584
2
Accepted 5 May 2015
2
▸ http://dx.doi.org/10.1136/bjsports-2014-094342 3
Br J Sports Med 2015;0:1–2. doi:10.1136/bjsports-2015-094584
dislocations to recurrent instability in adults: a systematic review and meta-analysis. Br J Sports Med Published Online First: 21 Apr 2015 doi:10.1136/bjsports-2014-094342 Dala-Ali B, Penna M, McConnell J, et al. Management of acute anterior shoulder dislocation. Br J Sports Med 2014;48:1209–15. Verhagen E, Voogt N, Bruinsma A, et al. A knowledge transfer scheme to bridge the gap between science and practice: an integration of existing research frameworks into a tool for practice. Br J Sports Med 2014;48:698–701.
REFERENCES 1
Olds M, Ellis R, Donaldson K, et al. Risk factors which predispose first-time traumatic anterior shoulder
Hutchinson MR, et al. Br J Sports Med Month 2015 Vol 0 No 0
