Objective To review and compare treatments (1) after primary traumatic shoulder dislocation aimed at minimising the risk of chronic shoulder instability and (2) for chronic post-traumatic shoulder instability.
Design Intervention systematic review with random effects network meta-analysis and direct comparison meta-analyses.
Data sources Electronic databases (Ovid MEDLINE, Cochrane Clinical Trials Register, Cochrane Database of Systematic Reviews, Embase, Scopus, CINAHL, Ovid MEDLINE Epub Ahead of Print, In-Process & Other Non-Indexed Citations, Ovid MEDLINE Daily, DARE, HTA, NHSEED, Web of Science) and reference lists were searched from inception to 15 January 2018.
Eligibility criteria for selecting studies Randomised trials comparing any interventions either after a first-time, traumatic shoulder dislocation or chronic post-traumatic shoulder instability, with a shoulder instability, function or quality of life outcome.
Results Twenty-two randomised controlled trials were included. There was moderate quality evidence suggesting that labrum repair reduced the risk of future shoulder dislocation (relative risk 0.15; 95% CI 0.03 to 0.8, p=0.026), and that with non-surgical management 47% of patients did not experience shoulder redislocation. Very low to low-quality evidence suggested no benefit of immobilisation in external rotation versus internal rotation. There was low-quality evidence that an open procedure was superior to arthroscopic surgery for preventing shoulder redislocations.
Conclusions There was moderate-quality evidence that half of the patients managed with physiotherapy after a first-time traumatic shoulder dislocation did not experience recurrent shoulder dislocations. If chronic instability develops, surgery could be considered. There was no evidence regarding the effectiveness of surgical management for post-traumatic chronic shoulder instability.
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LK and TL contributed equally.
Contributors LK, TL, AM and MP all participated in the conception and design of the study. LK and TL acquired the data. LK performed the analyses and TL, AM and MP participated in interpreting the analyses. TL and LK drafted the manuscript. All authors critically revised and approved the final version of the manuscript.
Funding LK has received a research grant from Finnish Research Foundation for Orthopaedics and Traumatology (FRFOT) and from the Helsinki Academic Medical Centre. TL has received a research grant from the FRFOT.
Disclaimer The funders had no role in any part of the study or in any decision about publication.
Competing interests None declared.
Patient consent Not required.
Provenance and peer review Not commissioned; externally peer reviewed.
Data sharing statement The study protocol is available from the PROSPERO registry, https://www.crd.york.ac.uk/prospero/ with the identifier CRD42015020303. Statistical codes are available for the Netmeta package in program R (online supplementary appendix 2) and RevMan (online supplementary appendix 3). Full data are presented in online supplementary appendix tables 2–7.
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