Early surgical stabilization reduces recurrence rates following a first-time shoulder dislocation in young active patients.
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Systematic reviews and clinical studies report that surgical stabilization significantly reduces the risk of recurrent instability compared to nonoperative management following a first-time anterior shoulder dislocation in young, active patients.
Abstract Purpose The purpose of this systematic review was to assess the surgical techniques, indications outcomes and complications for pediatric patients (≤ 19 years old) undergoing shoulder stabilization procedures for anterior shoulder instability. Methods The electronic databases MEDLINE, EMBASE, CINAHL, and Web of Science were searched from data inception to March 14, 2019 for articles addressing surgery for pediatric patients with anterior shoulder instability. The Methodological Index for Non‐randomized Studies (MINORS) tool was used to assess the quality of included studies. Results Overall 24 studies, with a total of 688 patients (696 shoulders) and a mean age of 16.6 ± 2.5 years met inclusion criteria. Mean follow‐up was 49 ± 26 months. The majority (59%) of studies only offered shoulder stabilization procedures to patients with more than one shoulder dislocation, however, three studies reported operating on pediatric patients after first time dislocations. Of the included patients 525 had arthroscopic Bankart repair (78%), 75 had open Bankart repair (11%), 34 had modified Bristow (5%), and 26 had Latarjet (4%) procedures. The overall complication rate was 26%. Patients undergoing arthroscopic Bankart repair experienced the highest recurrence rate of 24%. There were no significant differences in recurrent instability (n.s.) or loss of external rotation (n.s.) in pediatric patients treated with arthroscopic Bankart repair compared to open Latarjet. Patients had a 95% rate of return to sport at any level (i.e. preinjury level or any level of play) postoperatively (95%). Conclusions Pediatric patients are at high risk of recurrent instability after surgical stabilization. The majority of pediatric patients with anterior shoulder instability were treated with arthroscopic Bankart repair. Most studies recommend surgical stabilization only after more than one dislocation. However, given the high rates of recurrence with non‐operative management, it may be reasonable to perform surgery at a first‐time dislocation, particularly in those with other risk factors for recurrence. With the current evidence and limited sample sizes, it is difficult to directly compare the surgical interventions and their post‐operative efficacy (i.e. re‐dislocation rates or range of motion). There was an overall high rate of return to sport after surgical stabilization at final follow‐up. Level of evidence IV.
We treated 15 highly active young men (16 shoulders) with traumatic primary anterior shoulder dislocation or subluxation using 3-week external rotation immobilization. Fourteen patients (14 shoulders) were members of the Self-Defense Force and the other patient (2 shoulders) was a high school student who played club-level rugby. Average patient age at the time of the primary injury was 21.3 years (range, 17–26 years). Magnetic resonance imaging (MRI) was performed on 14 of 16 shoulders after the 3-week external rotation immobilization and showed that the anteroinferior labrum was reduced on the glenoid rim in 11 shoulders but remained medially displaced on the glenoid neck in 3 shoulders. Five shoulders, including these 3 shoulders, underwent arthroscopic Bankart repair after 3-week external rotation immobilization. Eleven shoulders continued nonoperative treatment after the immobilization. Four of 11 shoulders had no recurrence of symptoms for >2 years, and these patients were able to return to their preinjury activities. However, 7 shoulders experienced recurrence within 2 years.
We concluded that external rotation immobilization may not be as effective as mentioned previously in highly active young men with primary traumatic anterior shoulder dislocation or subluxation. Whether a patient has instability symptom recurrence after external rotation immobilization depends on more than the fact that the anteroinferior labrum is not reduced on MRI.
Background: Value-based decision-making regarding nonoperative management versus early surgical stabilization for first-time anterior shoulder instability (ASI) events remains understudied. Purpose: To perform (1) a systematic review of the current literature and (2) a Markov model–based cost-effectiveness analysis comparing an initial trial of nonoperative management to arthroscopic Bankart repair (ABR) for first-time ASI. Study Design: Economic and decision analysis; Level of evidence, 3. Methods: A Markov chain Monte Carlo probabilistic model was developed to evaluate the outcomes and costs of 1000 simulated patients (mean age, 20 years; range, 12-26 years) with first-time ASI undergoing nonoperative management versus ABR. Utility values, recurrence rates, and transition probabilities were derived from the published literature. Costs were determined based on the typical patient undergoing each treatment strategy at the authors’ institution. Outcome measures included costs, quality-adjusted life-years (QALYs), and the incremental cost-effectiveness ratio (ICER). Results: The Markov model with Monte Carlo microsimulation demonstrated mean (± standard deviation) 10-year costs for nonoperative management and ABR of $38,649 ± $10,521 and $43,052 ± $9352, respectively. Total QALYs acquired over the 10-year time horizon were 7.67 ± 0.43 and 8.44 ± 0.46 for nonoperative management and ABR, respectively. The ICER comparing ABR with nonoperative management was found to be just $5725/QALY, which falls substantially below the $50,000 willingness-to-pay (WTP) threshold. The mean numbers of recurrences were 2.55 ± 0.31 and 1.17 ± 0.18 for patients initially assigned to the nonoperative and ABR treatment groups, respectively. Of 1000 samples run over 1000 trials, ABR was the optimal strategy in 98.7% of cases, with nonoperative management the optimal strategy in 1.3% of cases. Conclusion: ABR reduces the risk for recurrent dislocations and is more cost-effective despite higher upfront costs when compared with nonoperative management for first-time ASI in the young patient. While all these factors are important to consider in surgical decision-making, ultimate treatment decisions should be made on an individual basis and occur through a shared decision-making process.
PURPOSE
This study aimed to compare the effectiveness of multiple treatments for first-time anterior shoulder dislocation in adolescents and young adults under 40 years of age.
METHODS
A systematic review and network meta-analysis of randomized controlled trials were conducted to compare five treatments for first-time anterior shoulder dislocation: arthroscopic Bankart repair, open Bankart repair, arthroscopic lavage, internal rotation immobilization and external rotation immobilization. The primary outcome was recurrent instability, with secondary outcomes including functional scores, return to normal activities and sports, and patient satisfaction.
RESULTS
A total of 10 randomized controlled trials were identified in the review, of which 8 RCTs involving 439 participants (mean age range: 20.0-25.3 years; maximum age 39 years) were included in the network meta-analysis. Surgical treatments, especially arthroscopic Bankart repair, exhibited lower recurrence risk, significantly outperforming external rotation immobilization (RR = 0.15, 95% CI: 0.03 to 0.73) and internal rotation immobilization (RR = 0.14, 95% CI: 0.04 to 0.40). Arthroscopic Bankart repair showed no statistically significant difference in risk of recurrent instability when compared to open Bankart repair (RR = 4.19, 95% CI:0.32 to 212.92) or when compared to arthroscopic lavage (RR = 0.3, 95% CI: 0.07 to 1.15). Both external rotation and internal rotation immobilization had the poorest outcomes, with no significant difference between them (RR = 0.91, 95% CI: 0.28 to 2.96). Surgical treatments were also associated with better functional outcomes, higher patient satisfaction, and higher rates of return to normal activities and sports.
CONCLUSION
Surgical treatments are more effective than conservative options in preventing recurrent instability in adolescents and young adults under 40 years of age with first-time anterior shoulder dislocation. Arthroscopic Bankart repair demonstrates comparable efficacy in preventing the recurrence of open Bankart repair. Both external rotation and internal rotation immobilization had the poorest outcomes in terms of reducing recurrence instability rates, with no significant difference between them.
LEVEL OF EVIDENCE
Systematic Review and Network Meta-Analysis; level 1.
Background: Anterior shoulder dislocations are common in athletes, particularly in contact sports. Surgical stabilization reduces recurrence, but the optimal timing—early versus delayed—remains uncertain, especially for in-season athletes. Methods: A systematic search of PubMed, Embase, and Cochrane (2013–2023) yielded 945 articles; 15 met the inclusion criteria. Data were charted on procedure type, outcomes, follow-up, patient group, and timing of surgery. Search terms, e.g., ‘shoulder’, ‘athlete’, ‘anterior’ and ‘shoulder dislocation’, were used in a broad search protocol casting a wide net to maximize the likelihood of capturing all available data. Results: Surgery was superior to conservative care in lowering recurrence and enabling return-to-play, with arthroscopic and combined procedures most effective in high-contact sports. Conservative management carried higher instability risk. Evidence directly comparing early versus delayed surgery was scarce, and therefore inconclusive. Conclusions: Surgical stabilization remains the treatment with better outcomes compared to conservative treatment for young athletes. Still, athletes opt to delay surgery until postseason, with the impact of delaying surgery being unclear. Further research is needed to evaluate early versus delayed surgery regarding recurrence, joint damage, and return to sport.
Shoulder instability, particularly anterior instability, remains a significant clinical and socioeconomic burden, especially in young, active populations. Recent advancements have refined our understanding of critical and subcritical bone loss, bipolar lesions, and dynamic stabilization concepts. This review synthesizes current evidence by analyzing recent clinical studies, biomechanical research, and technological developments related to the management of anterior shoulder instability. While traditional soft-tissue procedures such as the Bankart repair maintain a role in select low-risk patients, emerging data support earlier consideration of bony augmentation or dynamic stabilization in high-risk cohorts. Moreover, technologies such as dynamic anterior stabilization, arthroscopic Latarjet procedures, suture-button fixation, and biologic augmentation strategies are redefining treatment algorithms. Recent advances have reshaped the approach to shoulder instability, emphasizing individualized strategies based on bone loss, patient risk profile, and dynamic stabilizing techniques. An evidence-based framework is essential for optimizing clinical outcomes.
Objectives: Value based decision making regarding nonoperative management vs. early surgical stabilization for first-time anterior shoulder instability (ASI) events remains controversial. Thus, the purpose of this study was to perform 1) a systematic review of the current literature and 2) a Markov model-based cost-effectiveness analysis comparing an initial trial of nonoperative management to arthroscopic Bankart repair (ABR) for first-time ASI. Methods: A Markov Chain Monte Carlo probabilistic model (Figure 1) was developed to evaluate the outcomes and costs of 1,000 simulated patients (average age » 20 years old) with first-time ASI undergoing nonoperative management vs. ABR. Utility values, recurrence rates, and transition probabilities were derived from the published literature. Costs were determined based on the typical patient undergoing each treatment strategy at our institution. Outcome measures included costs, quality-adjust life-years (QALYs), and the incremental cost-effectiveness ratio (ICER). Probabilities of recurrence as well as the utility of each treatment strategy were obtained from the literature search as described above. Probabilities were pooled across studies to obtain a weighted average for both nonoperative treatment and ABR. Similarly, studies reporting scores on the Western Ontario Shoulder Instability Index (WOSI) scale were utilized to approximate shoulder-related quality of life after each treatment strategy and outcome. Costs for each treatment
sive evidence available to determine whether operative stabilization or conservative rehabilitation is superior for other patient or injury types. Keywords: systematic review, primary anterior shoulder dislocation, treatment
The shoulder joint is the most commonly dislocated joint in the human body with an incidence rate of 17 of 100 000 each year. 13 Acute anterior dislocation is the most common type of shoulder dislocation, constituting 96% of all shoulder dislocations. 20 , 37 A study documented an overall adjusted incidence of primary traumatic shoulder dislocation as 8.2 of 100 000 person years, whereas the incidence of all traumatic shoulder dislocations, initial and recurrent, was estimated to be at least 11.2 of 100 000 person years. 9 The same study estimated the prevalence of traumatic shoulder dislocations, expressed in terms of a cumulative incidence rate, to be 0.7% for men and 0.3% for women up to the age of 70 years. 9
The populations experiencing the highest incidence rates of shoulder dislocation comprise young men between 21 and 30 years old and elderly women between 61 and 80 years old. 13 Young men and women usually experience shoulder dislocation as a result of trauma, especially on the sports field, whereas the elderly are more likely to suffer a dislocation as a result of falling on an outstretched hand. 13 Subsequently, the shoulder is less stable and more susceptible to redislocation, especially in active young adults. Numerous recurrence rates, some as high as 94%, have been reported for anterior shoulder dislocation. 2 , 12 , 13 , 15 , 26 , 29 , 31 In a prospective 25-year follow-up study (the longest of its kind), Hovelius et al found that approximately half of all patients between the ages of 12 and 25 years who had undergone nonoperative treatment experienced subsequent recurrence. 15 The cost of this initial injury and consequent recurrences can be substantial with regard to time lost from sports and activities of daily living, quality
[Recurrent shoulder dislocation. On the sports capacity following surgical therapy].
The traumatic dislocation is one of the most seen dislocations of great joints. In 70% it happens to patients during sports and between 20 and 60% of cases are followed by instability of the shoulder. An explorative study informs about case history, postoperative course and sports participation after surgical treatment of recurrent dislocations of the shoulder. Good results of sports participation can be achieved with early diagnostic and therapeutic procedures.
Published in Sportverletzung Sportschaden : Organ der Gesellschaft fur Orthopadisch-Traumatologische Sportmedizin (1988)
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