Review Br J Sports Med: first published as 10.1136/bjsports-2017-098539 on 23 June 2018. Downloaded from Treatment after traumatic shoulder dislocation: a systematic review with a network meta-analysis Lauri Kavaja,1,2 Tuomas Lähdeoja,1,3,4 Antti Malmivaara,5,6 Mika Paavola4 ► Additional material is ABStract Acute treatment of a dislocated shoulder is closed published online only. To view Objective To review and compare treatments (1) reduction, which should be performed as soon as please visit the journal online after primary traumatic shoulder dislocation aimed at possible, either on the field or in an emergency (http:// dx. doi. org/ 10. 1136/ 14 bjsports- 2017- 098539). minimising the risk of chronic shoulder instability and (2) department. Some patients develop recurrent for chronic post-traumatic shoulder instability. dislocations or symptomatic subluxations even in 1Medical Faculty, University of Design Intervention systematic review with random daily activities. This has prompted suggestions that Helsinki, Helsinki, Finland effects network meta-analysis and direct comparison surgical stabilisation may be indicated after the first 2Department of Surgery, South Carelia Central Hospital, meta-analyses. dislocation—a treatment strategy that has been Lappeenranta, Finland Data sources Electronic databases (Ovid MEDLINE, investigated in several randomised controlled trials 3Finnish Center of Evidence- Cochrane Clinical Trials Register, Cochrane Database (RCT), with mixed results.3 4 6 7 15 16 based Orthopaedics (FICEBO), of Systematic Reviews, Embase, Scopus, CINAHL, Ovid There is considerable variation in the manage- University of Helsinki, Helsinki, ment of patients after a primary traumatic shoulder Finland MEDLINE Epub Ahead of Print, In-Process & Other 4Department of Orthopaedics Non-Indexed Citations, Ovid MEDLINE Daily, DARE, dislocation (both between surgeons and disci- and Traumatology, Helsinki HTA, NHSEED, Web of Science) and reference lists were plines).17 18 Most patients with chronic post-trau- University Hospital, Töölö searched from inception to 15 January 2018. matic shoulder instability are offered stabilisation Hospital, Helsinki, Finland Eligibility criteria for selecting surgery, while the surgical methods vary widely.17–20 5Centre for Health and Social Economics, Institute of Health studies Randomised trials comparing any Some evidence suggests that in the management of and Welfare, Helsinki, Finland interventions either after a first-time, traumatic musculoskeletal conditions patients are more likely 6Orton Orthopaedic Hospital shoulder dislocation or chronic post-traumatic shoulder to undergo surgical treatment if the treating physi- and Orton Research Institute, instability, with a shoulder instability, function or cian is a surgeon versus a non-surgical specialty (eg, Orton Foundation, Helsinki, physiotherapy),21 and that surgeons more easily Finland quality of life outcome. Results Twenty-two randomised controlled trials recommend surgical treatment if the evidence Correspondence to were included. There was moderate quality evidence regarding the effectiveness of surgery is inconclu- 19 Dr Lauri Kavaja, Medical Faculty, suggesting that labrum repair reduced the risk of future sive. Thus, to provide the best care, physiothera- University of Helsinki, Helsinki shoulder dislocation (relative risk 0.15; 95% CI 0.03 to pists, physical medicine specialists, sports medicine 00290, Finland; 0.8, p=0.026), and that with non-surgical management specialists and orthopaedic surgeons should know lauri. kavaja@ helsinki. fi 47% of patients did not experience shoulder what is the best quality evidence for treatment of LK and TL contributed equally. redislocation. Very low to low-quality evidence suggested shoulder instability. no benefit of immobilisation in external rotation versus Therefore, we aimed to assess the current http://bjsm.bmj.com/ Received 17 September 2017 internal rotation. There was low-quality evidence that an evidence regarding the effectiveness of interven- Revised 8 May 2018 open procedure was superior to arthroscopic surgery for tions after primary traumatic shoulder dislocation Accepted 16 May 2018 preventing shoulder redislocations. and in chronic post-traumatic shoulder instability. Conclusions There was moderate-quality evidence Our systematic review focused on two clinical that half of the patients managed with physiotherapy effectiveness questions regarding post-traumatic after a first-time traumatic shoulder dislocation did not shoulder instability: (1) What are the best treat- experience recurrent shoulder dislocations. If chronic ments to reduce the incidence of chronic shoulder on September 29, 2021 by guest. Protected copyright. instability develops, surgery could be considered. There instability after a first-time traumatic shoulder was no evidence regarding the effectiveness of surgical dislocation? and (2) How can the clinician best management for post-traumatic chronic shoulder treat a patient with chronic post-traumatic shoulder instability. instability? METHODS We followed the Preferred Reporting Items for INTRODUCTION Systematic Reviews and Meta-Analyses statement22 The shoulder is the most commonly dislocated large when conducting and reporting this prospectively joint.1 A traumatic shoulder dislocation is often registered systematic review (PROSPERO registra- accompanied by a labral lesion,2–7 which predis- tion ID: CRD42015020303). We use dislocation to poses the patient to developing chronic shoulder refer to a true dislocation of the joint and insta- instability.8–11 The incidence of primary shoulder bility to refer to dislocations, subluxations or other dislocation varies between 15.31 and 56.312 per symptoms of instability either alone or together. 100 000 person-years. Most patients are men aged By recurrent dislocation(s) and redislocation(s) we To cite: Kavaja L, Lähdeoja T, under 40 years and most dislocations are sports mean one or more dislocations after the primary Malmivaara A, et al. Br J Sports Med Epub ahead injuries. Both these facts make shoulder disloca- episode, and by chronic post-traumatic instability of print: [please include Day tion and possible subsequent chronic instability an we mean recurrent dislocation(s), subluxations or Month Year]. doi:10.1136/ important health issue for young, active patients other symptoms of instability occurring after a first- bjsports-2017-098539 and their treating clinicians.13 time traumatic shoulder dislocation. Kavaja L, et al. Br J Sports Med 2018;0:1–11. doi:10.1136/bjsports-2017-098539 1 Review Br J Sports Med: first published as 10.1136/bjsports-2017-098539 on 23 June 2018. Downloaded from Data sources and searches criteria; with a judgement of ‘yes’, ‘unclear’ or ‘no’. If at least six We searched Ovid MEDLINE, Cochrane Central Register of of the 12 criteria were judged to be at low risk of bias (‘yes’), the Controlled Trials, Cochrane Database of Systematic Reviews, risk of bias in the publication was considered low.23 Embase, Scopus, CINAHL, Ovid MEDLINE Epub Ahead of Print, To assess possible selective reporting of results, we compared In-Process & Other Non-Indexed Citations, Ovid MEDLINE the outcome measures specified in the methods section of the Daily, Database of Abstracts of Reviews of Effect (DARE), Health publication and in the trial registry (if available) to what was Technology Assessment Database, NHS Economic Evaluation reported in the results section of the publication. For the analysis Database and Web of Science on 15 January 2018. There were of the timing of the outcome assessment, we deemed a deviation no restrictions on language or publication date. We adjusted the of 3 months (in a 2-year follow-up) to be an acceptable range. search strategies to meet the specifications of the individual data- Disagreements between the two reviewers on the retrieved bases (online supplementary appendix 1). We reviewed the refer- data were resolved by consensus. If any item was unclear, we ence lists of included publications and earlier reviews to identify contacted the authors by email to clarify the issue. any additional studies that were missed in the electronic data- Researcher conflict of interest and industry sponsorship have base search. We also searched the WHO International Clinical been identified as potential sources of bias.24–26 We evaluated Trials Registry Platform (WHO ICTRP) (www.who. int/ ictrp) on and noted the existence of these potential sources of bias in the 23 January 2018 for registrations of the included RCTs, possible studies. completed but unpublished RCTs and ongoing RCTs. Data synthesis and analysis Study selection We performed meta-analyses of clinically homogenous studies We included RCTs that compared any interventions after a (patient populations, indications of treatment, intervention pairs first-time, traumatic shoulder dislocation or chronic post-trau- and outcomes). If studies with same intervention-control pairs matic shoulder instability with a follow-up of at least 1 year. We were not sufficiently homogenous, we performed multiple pair- required an outcome measure related to shoulder instability, wise meta-analyses of the trials with poolable patients and data. shoulder function or quality of life. We excluded studies of treat- In the analysis of surgical treatment after first-time shoulder ment of non-traumatic shoulder instability, cadaveric or biome- dislocation, we performed a frequentist network meta-analysis chanical studies and studies on secondary