Table 1.
Success of nonoperative treatment of anterior glenohumeral instability
| Study | Level of evidence | No. of patients | Age | Treatment/intervention | Recurrence rate/outcomes | Length of follow-up |
|---|---|---|---|---|---|---|
| Henry and Genung, Am J Sports Med, 1982 | IV | 120 young athletes | 19 years | 62 immobilized with shoulder immobilizer and sling and swath 3–6 weeks; 59 with no immobilization | 90% recurrence in immobilized patients, 85% recurrence when not immobilized | 18 months |
| Simonet et al., Clin Orthop Relat Res, 1984 | IV | 116/124 (93.5% follow-up) | N/A | Nonoperative | 33% overall; 82% in young athletes (< 20 years) | 4.6 years |
| Wheeler et al., Arthroscopy, 1989 | II | 47 | Military cadets | Arthroscopic repair (9) vs. nonoperative (38) treatment | Nonoperative, 92% recurrence Operative, 22% recurrence |
14 months |
| Arciero et al., Am J Sports Med, 1994 | I | 36 | Avg 20 years | Arthroscopic repair and rehabilitation (21); nonoperative, 1 month immobilization, and rehabilitation, full activity at 4 months (15) | Nonoperative, 80% recurrence Operative, 14% recurrence |
Avg 32 months |
| Bottoni et al., Am J Sports Med, 2002 | I | 21/24 (87.5% follow-up) | Avg 22.4 years | Nonoperative: 4 weeks of immobilization followed by rehab Operative: arthroscopic Bankart repair followed by the same rehab |
Nonoperative, 75% recurrence Operative, 11.1% recurrence |
3 years |
| Brophy and Marx, Arthroscopy, 2009 | IV (systematic review) | All studies comparing operative vs. nonoperative treatment | N/A | Nonoperative vs. operative stabilization | Nonoperative, 46% recurrence Operative, 7% recurrence |
2 years |
| Kirkley et al., Arthroscopy, 2005 [33] | II | 31 | Avg 23 years (all patients < 30 years) | Nonoperative: immobilization (3 weeks) and rehabilitation Operative: arthroscopic stabilization |
Nonoperative, 60%; operative, 19% No significant difference in shoulder function by ASES/DASH Minimal significant improvement with WOSI in the operative group |
75 months |
| Robinson et al., J Bone Joint Surg Am, 2006 | III | 252 | 15–35 years | Sling followed by physical therapy | 55.7% had recurrence in first 2 years, and 66.8% by 5 years | 5 years |
| Jakobsen et al., Arthroscopy, 2007 | I | 76 | 15–39 years | Conservative: diagnostic arthroscopy and 1-week sling, followed by therapy Operative: open Bankart repair |
At 2 years, 54% recurrence in the conservative group, 3% in the operative group At 10 years, 74% unsatisfactory results in conservative, 72% good or excellent results in the operative group |
10 years |
| Spiegl et al., BMC Musculoskelet Disord, 2013 [34] | IV | 25 with bony Bankart lesions | 12 nonop, 13 op | Operative if bony Bankart ≥ 5% Nonoperative if bony Bankart < 5% |
Nonoperative: good/excellent Rowe score in 83% with 25% subjective instability Operative: good to excellent Rowe score in 85% with 8% subjective instability |
2 years |
| Dickens et al., Am J Sports Med, 2014 | II | 45, in-season collegiate athletes | Avg 20.7 years | Accelerated rehabilitation without immobilization | 73% return to sport all or some of the season; 67% completed season; 27% completed without recurrence; 64% returned to play but had recurrence | Single season |
| Gigis et al., JPO, 2014 [35] | II | 65 (38 operative and 27 conservative) | 15–18 years | Nonoperative: immobilization and rehabilitation Operative: arthroscopic stabilization |
Nonoperative, 70.3% recurrence Operative, 13.1% recurrence |
36 months |
| Kawasaki et al., J Shoulder Elb Surg, 2014 | III | 378; in-season high school rugby players | 14–18 years | Nonoperative | 14.8% incidence of dislocation with recurrence rate of 54.3% | Single season |
| Khan et al., Bone Joint J, 2014 [36] | IV | 49/80 (61.3% follow-up) | Skeletally immature patients | Conservative treatment vs. Latarjet procedure | 92% operative returned to same level of activity vs. 52% for nonoperative |
N/A |
| Konigshausen, Musculoskelet Surg, 2014 [37] | III | 26/28 (93% follow-up) | 29.3 years | Immobilized in external rotation | 15% recurrence rate | 5 years |
| Leroux et al., Am J Sports Med, 2014 [38] | II | 20,719 | 17–69 years (avg 35 years) | All-comers receiving closed reduction of an anterior shoulder dislocation | 19% incidence of repeat closed reduction Highest in ≤ 20 years Reduction by orthopedist, humeral tuberosity fracture, older age, and more medical comorbidities are protective. Males and low-income areas are risk factors |
2 years |
| Liu et al., Injury, 2014 [39] | I, meta-analysis | 663 | N/A | 338 external immobilization vs. 325 internal immobilization | No difference in recurrence rates between the two types of immobilization | N/A |
| Longo, Arthroscopy, 2014 [40] | IV, systematic review | 2813 | N/A | Compared recurrence in nonoperative vs. operative patients | Recurrence is lower with operative treatment (OR 12.71; 95% CI 5.88–33.1; p < 0.00001) | N/A |
| Olds et al., Br J Sports Med, 2015 | IV, meta-analysis | 1324 | > 18 years with primary anterior shoulder dislocation | Nonoperative | 39% recurrence rate Risk factors are < 40 years, men, and hyperlaxity Protective factors are greater tuberosity fracture |
N/A |
| Riccio et al., Musculoskelet Surg, 2015 | IV | 32 | 20–44 | 3-month conservative treatment protocol | Rowe score for instability improved from 44.5 to 79.8; 78% of patients with good to excellent results with nonoperative treatment | 2 years |
| Roberts et al., Bone Joint J, 2015 | III | 133 | 16.3 years (13–18) | Nonoperative | 76.7% recurrence at mean of 10 months | 95.2 months |
| Leroux et al., Am J Sports Med, 2015 | II | 1937 | 10–16 years (avg 15 years) | All-comers receiving closed reduction of an anterior shoulder dislocation | 38.2% incidence of repeat closed reduction Higher in 14–16 years old Male sex and older age are risk factors for recurrence |
Min of 2 years |
| Hovelius et al., KSSTA, 2016 [41] | III | 257 | 12–40 years | Half of patients immobilized 3–4 weeks and half started with early motion | Recurrence increased up to 10-year follow-up After 25 years, 29% of shoulders with ≥ 2 recurrences stabilized over time. 34% moderate to severe and 27% mild arthropathy at 25 years Age < 25 years and bilateral instability equal to poor prognosis while greater tuberosity fracture equals to a favorable prognosis |
25 years |
| Olds et al., Br J Sports Med, 2016 [42] | IV, meta-analysis | N/A | < 19 years with primary anterior shoulder dislocation | Nonoperative | 73% recurrence Risk factors: older age, male sex, shoulder dominance and injury side, mechanism of injury, state of physis closure, and Hill–Sachs and Bankart lesions |
N/A |
| Wasserstein et al., Arthroscopy, 2016 | II, systematic review | N/A | N/A | Nonoperative | 19–88% recurrence rate with nonoperative treatment Male sex and age < 20 years are risk factors. Greater tuberosity fracture is protective |
2 years |
| Watson et al., Sports Health, 2016 | IV, systematic review | N/A | N/A | In-season athlete return to play considerations | 37–90% | Single season |
| Whalen et al., Am J Sports Med, 2016 [57] | I, meta-analysis | 632 | 30.1 years in ER vs. 30.3 in IR | External vs. internal immobilization | No difference in recurrence (RR 0.69, 95% CI, 0.042–1.14, p = 0.15) | N/A |