ReviewThe external rotation immobilisation does not reduce recurrence rates or improve quality of life after primary anterior shoulder dislocation: A systematic review and meta-analysis
Introduction
The glenohumeral joint is a typical ball-and-socket joint, which significantly improves the range of motion (ROM), but reduces shoulder stability as a compromise [1]. As a result, shoulder dislocations are common injuries in our daily life, especially the anterior dislocation. It was estimated that the incidence rate of shoulder dislocation as 23.9 per 100,000 person-year in the US from emergency cases [2]. Sling immobilisation at internal rotation (IR) position has been the traditional intervention after manipulative reduction for more than 2000 years [3]. However, it is ineffective in decreasing the incidence of recurrent dislocation [4], which is a major complication after primary anterior dislocation and quite frequent among young patients [2], [5]. The Bankart lesion, mostly found with primary shoulder dislocation, correlates closely to the recurrence rate. On the basis of a magnetic resonance imaging (MRI) assisted study [6], the Bankart lesion could get better coaptation by the external rotation (ER) immobilisation with the anatomic reduction of less separation and displacement of anteroinferior potion of the labrum than by the IR immobilisation. Then, a preliminary prospective study [7] demonstrated that patients bracing at ER position had a significant decrease of recurrence rates compared with those immobilised at IR position.
However, several following prospective trials demonstrated contradiction on this issue, showing that recurrence rates had no difference in both two groups. One systematic review in 2010 [8] showed that bracing in ER might provide a lower recurrence rate than traditional sling immobilisation in IR without achieving significance (p = 0.07) from data synthesis of two prospective trials. In addition, patients without recurrence may not satisfy with the shoulder because of residual symptomatic instability and probable pain, which could greatly impact their daily life. Therefore, patient-based quality-of-life assessments, such as the Western Ontario Shoulder Instability index (WOSI) [9], the American Shoulder and Elbow Surgeons evaluation form (ASES) [10], the Rowe scoring system [11] and the Constant–Murlay functional scoring system [12], should be taken into account in order to evaluate patients’ status comprehensively after the treatment of immobilisation.
The purpose of this study were to conduct a systematic review and meta-analysis of prospective randomised controlled trials directly comparing (1) the rate of recurrence and (2) patient-based quality-of-life assessments after the ER or internal rotation IR immobilisation after primary anterior shoulder dislocation.
Section snippets
Literature search
Electronic databases (PubMed, EMBASE, Cochrane Central Register of Controlled Trials, ISI Web of Science and China National Knowledge Infrastructure (CNKI)) were searched without limit by three independent investigators (AL, XX, YC). Results were last updated on January 19, 2013. Boolean operators were used as follows: (bankart lesion OR shoulder anterior dislocation) AND ((external rotation AND internal rotation) OR Immobilisation) with no restriction of publication year or language. We also
Literature review
Literature search initially yielded 896 relevant citations, among which there were 275 duplicates leaving 621 trials. After titles and abstracts scan according to the eligible criteria, only 14 were retrieved in full text. Among them two were not controlled trials, five trials lacked of any clinical follow-up data of more than 1 year. Therefore, aforementioned seven trials were excluded. Finally, seven prospective randomised controlled trials [7], [15], [16], [17], [18], [19], [20] met
Discussion
Since the prospective trial of Ioti et al. [7] showed superiority of the ER immobilisation over the IR in reducing the rate of recurrence after primary anterior shoulder dislocation, orthopedists have made a great effort to pursue the optimal immobilisation method in order to get a relatively lower rate of recurrence of the shoulder. However, the inconclusive debate still remains. In this meta-analysis of level I or II trials, the data of recurrence rate at all ages and stratified by age (≤30
Conclusion
Based on the results of our analysis, the ER immobilisation could not reduce the rate of recurrence after primary anterior shoulder dislocation or improve the quality of life compared with the IR immobilisation. Given possible biases in our study, more rigorous and adequately powered prospective randomised controlled trials with long-term follow-ups are required to elucidate a more objective outcome.
Conflict of interest statement
The authors declare no conflict of interest.
Acknowledgements
We thank all the corresponding authors from the included trials for their kind assistance in obtaining additional data that contributed to our meta-analysis.
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Long-term effect of immobilization in external rotation after first-time shoulder dislocation: an average 18-year follow-up
2022, Journal of Shoulder and Elbow SurgeryCitation Excerpt :However, the conclusions of these meta-analyses were controversial. Some concluded that ER immobilization was effective in reducing the recurrence rate,28,32,40 but others reported that it was not.8,27,42,43 The most recent meta-analyses have shown that ER immobilization results in a lower recurrence rate and a higher rate of return to play.14,39
Decision making in treatment after a first-time anterior glenohumeral dislocation: A Delphi approach by the Neer Circle of the American Shoulder and Elbow Surgeons
2020, Journal of Shoulder and Elbow SurgeryCitation Excerpt :There are many studies in the literature that have reported on the dangers of neglecting the unstable shoulder. Recurrence of instability events is associated with higher failure rates with surgery,15,27 as well as the development of glenohumeral joint osteoarthritis.3,13,17 Jakobsen et al14 performed a randomized clinical trial of operative vs. nonoperative treatment with 10-year follow-up.
Immobilization in external rotation versus internal rotation after shoulder dislocation: A meta-analysis of randomized controlled trials
2020, Orthopaedics and Traumatology: Surgery and ResearchCitation Excerpt :The two trials show no difference between the ER group and IR group in OSIS scores. Several previous meta-analyses [7,33–36] have reported on the same topic, as presented in Table 6. Differences between the present meta-analysis and the previous ones are as follows.
Immobilization in external rotation after primary shoulder dislocation reduces the risk of recurrence in young patients. A randomized controlled trial
2020, Orthopaedics and Traumatology: Surgery and ResearchCitation Excerpt :On the contrary, Finestone et al. [14], Whelan et al. [15] and Liavaag et al. [11] found no significant benefit in the recurrence rate when comparing both types of immobilization. In two recent meta-analysis, Liu et al. [8] and Whelan et al. [9] could not demonstrate any significant advantage of immobilization in ER over the traditional method of treatment. These conflicting evidences can be explained by a few numbers of factors.
Immobilization in external rotation after primary shoulder dislocation reduces the risk of recurrence in young patients. A randomized controlled trial
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2018, Orthopaedics and TraumaCitation Excerpt :Itoi22 recommended external rotation bracing in order to reduce the torn anterior structures back to a more anatomical location with the effect of lowering recurrence rates in their series from 30% in the standard treatment group to 0% in the external rotation group. However, the early promising results with this technique have not been reproduced and a meta-analyses by Liu et al,23 involving 663 patients in seven studies, showed that there was no significant difference in recurrence rates at all ages. Physiotherapy is an important part of both operative and non-operative management and should be focused at strengthening the dynamic stabilizers of the shoulder as well as restoring the complex feedback mechanisms that maintain shoulder stability.15