Treatment after traumatic shoulder dislocation: a systematic review with a network meta-analysis

Key points

1. 01Labrum repair (Bankart repair) reduced redislocation risk by 85% compared to physiotherapy alone at 2 years (RR 0.15; 95% CI 0.03 to 0.8)
2. 02Approximately 47-53% of patients treated non-surgically did not experience a redislocation, questioning the need for routine early surgery
3. 03Immobilisation in external rotation was no better than internal rotation for preventing redislocation, with very low to low quality evidence
4. 04For chronic instability, open labrum repair was statistically superior to arthroscopic repair (RR 0.43; 95% CI 0.19 to 0.97), though evidence quality was low
5. 05No randomised trials exist comparing surgery versus non-surgical treatment for chronic post-traumatic shoulder instability, a critical evidence gap

How it was conducted

Design

Systematic review with random effects network meta-analysis and direct comparison meta-analyses of randomised controlled trials

Participants

22 RCTs included; mean participant age ranged from 20.3 to 36 years; majority were young men with sports-related dislocations

Search date

Databases searched from inception to 15 January 2018

Primary outcome

Shoulder redislocation rate at 1 and 2 years; secondary outcomes included recurrent instability, function scores, and quality of life

Quality assessment

GRADE approach used; evidence rated from very low to moderate quality

What they found

• Labrum repair vs non-surgical management at 2 years: RR 0.15 (95% CI 0.03 to 0.8, p=0.026), four RCTs, 243 patients - moderate quality evidence
• Labrum repair vs arthroscopic lavage at 2 years: RR 0.21 (95% CI 0.05 to 0.91, p=0.037, I2=63.6%), four RCTs
• NNT to prevent one redislocation at 2 years: 2.0-4.7 based on included trial data; 2.5-5.6 based on external data
• Immobilisation ER vs IR in younger patients (mean age ~25 years, three RCTs, 287 patients): RR 1.07 (95% CI 0.76 to 1.50, p=0.70, I2=0%) - no benefit for ER
• Immobilisation ER vs IR in older patients (mean age ~35 years, two RCTs, 261 patients): RR 0.31 (95% CI 0.06 to 1.68, p=0.17, I2=82%) - very low quality, no significant benefit
• Open vs arthroscopic labrum repair for chronic instability - redislocation rate (three RCTs, 269 patients): RR 0.43 (95% CI 0.19 to 0.97, p=0.04, I2=0%) - low quality evidence favouring open
• Open vs arthroscopic labrum repair for chronic instability - recurrent instability (two RCTs, 223 patients): RR 0.49 (95% CI 0.26 to 0.92, p=0.03, I2=0%)
• NNH for arthroscopic vs open technique: approximately 12 (one additional redislocation per 12 patients treated arthroscopically instead of open)
• Absorbable vs non-absorbable suture anchors for chronic instability (three RCTs, 232 patients): RR 0.62 (95% CI 0.21 to 1.86, p=0.40, I2=0%) - no significant difference, moderate quality
• Harms: 19 patients (1.5%) had temporary pain or stiffness, 17 (1.3%) transient nerve injuries, 5 (0.39%) superficial wound infections, 3 (0.24%) adhesive capsulitis, 1 (0.08%) septic arthritis

Limitations

• Most included trials lacked blinding (only 41% used any blinding), leading to downgraded evidence quality across all comparisons
• Five unpublished RCTs on external vs internal rotation immobilisation were identified but provided no data, raising concerns of publication bias
• No RCTs compared surgery versus non-surgical treatment for chronic post-traumatic shoulder instability, leaving a major evidence gap
• Study populations consisted mostly of young male athletes, limiting generalisability to women, older patients, and non-athletes

Why it matters

For patients

If you dislocate your shoulder for the first time, roughly half of patients recover without surgery and never dislocate again, so surgery is not always necessary right away.

For clinicians

Labrum repair after first-time dislocation significantly reduces redislocation risk (NNT 2-5.6), but a watchful waiting approach after physiotherapy is defensible given that about half of patients avoid redislocation without surgery; for chronic instability, open Bankart repair has better redislocation outcomes than arthroscopic repair based on low-quality evidence.

For readers

This review provides the most rigorous RCT-only comparison of shoulder dislocation treatments to date, using network meta-analysis, but key evidence gaps remain, particularly the absence of any randomised trials on surgery versus rehabilitation for established chronic shoulder instability.