Systematic Review
Management of Primary Acute Anterior Shoulder Dislocation: Systematic Review and Quantitative Synthesis of the Literature

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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.

Section snippets

Methods

We performed a systematic review of the literature according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines with a PRISMA checklist and algorithm.17 The search algorithm according to the PRISMA guidelines is shown in Fig 1. 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

Results

The literature search and cross-referencing resulted in a total of 1,109 references, 1,068 of which were rejected because of off-topic abstracts, failure to fulfill the inclusion criteria, or both (Fig 2). After reading the remaining full-text articles, another 10 articles were excluded because of insufficient details and uncertain diagnosis and outcome measures.

Finally, 31 articles on the treatment of patients with primary acute anterior shoulder dislocation were included. An exclusively

Discussion

The most important finding of this study is that surgical management of primary acute dislocation of shoulder is associated with a lower rate of recurrence when compared with conservative treatment. Moreover, the immobilization in external rotation provides a lower rate of recurrence compared with the immobilization in internal rotation.

We performed a quantitative synthesis of the literature to compare conservative and surgical approaches. The surgical treatment reported in the included studies

Conclusions

Although limited, the available evidence from RCTs supports primary surgery in young adults engaged in highly demanding sports or job activities. There is a lack of evidence to determine whether surgical or nonsurgical treatment is better for other categories of injuries.

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    The authors report that they have no conflicts of interest in the authorship and publication of this article.

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