Immobilization in External Rotation and Abduction Versus Arthroscopic Stabilization After First-Time Anterior Shoulder Dislocation: A Multicenter Randomized Controlled Trial

Marvin Minkus, Matthias Königshausen, Stephan Pauly, Dirk Maier, Frieder Mauch, Thomas Stein, Stefan Greiner, Mohamed Moursy, Markus Scheibel, Marvin Minkus, Matthias Königshausen, Stephan Pauly, Dirk Maier, Frieder Mauch, Thomas Stein, Stefan Greiner, Mohamed Moursy, Markus Scheibel

Abstract

Background: Treatment of first-time shoulder dislocation (FSD) is a topic of debate. After high rates of recurrent instability after nonoperative management were reported in the literature, primary repair of FSD significantly increased. At the same time, new concepts were proposed that had promising results for immobilization in external rotation (ER) and abduction (ABD).

Purpose: The aim of this study was to evaluate the recurrence rates (primary outcome) and clinical outcomes (secondary outcome parameters) of immobilization in ER+ABD versus arthroscopic primary stabilization after FSD.

Study design: Randomized controlled trial; Level of evidence, 1.

Methods: In a multicenter randomized controlled trial, patients with FSD were randomized to either treatment with immobilization in 60° of ER plus 30° of ABD (group 1) or surgical treatment with arthroscopic Bankart repair (group 2). Clinical evaluation was performed 1, 3, and 6 weeks as well as 6, 12, and 24 months postoperatively or after reduction, including range of motion, instability testing, subjective shoulder value, Constant-Murley score, Rowe score, and Western Ontario Shoulder Instability Index. Recurrent instability events were prospectively recorded.

Results: Between 2011 and 2017, a total of 112 patients were included in this study. Of these, 60 patients were allocated to group 1 and 52 to group 2. At the 24-month follow-up, 91 patients (81.3%) were available for clinical examination. The recurrence rate was 19.1% in group 1 and 2.3% in group 2 (P = .016). No significant differences were found between groups regarding clinical shoulder scores (P > .05). Due to noncompliance with the immobilization treatment protocol, 4 patients (6.7%) were excluded.

Conclusion: Immobilization in ER+ABD versus primary arthroscopic shoulder stabilization for the treatment of FSD showed no differences in clinical shoulder scores. However, recurrent instability was significantly higher after nonoperative treatment.

Keywords: first-time shoulder dislocation; immobilization in external rotation and abduction; shoulder instability; shoulder stabilization.

Conflict of interest statement

One or more of the authors has declared the following potential conflict of interest or source of funding: Financial support was provided by the Wilhelm Julius Teufel Company, which assisted this study. M.S., D.M., F.M., T.S., and S.G. received consultant payments from Arthrex that were not related to this work. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto.

Figures

Figure 1.
Figure 1.
Immobilization in 60° of external rotation and 30° of abduction in the Bledsoe ARC XR brace.
Figure 2.
Figure 2.
Flowchart of trial. ER+ABD = 60° of external rotation and 30° of abduction.
Figure 3.
Figure 3.
Comparison of recurrent instability events at 24-month follow-up between patients treated nonoperatively with immobilization in external rotation and abduction (ER+ABD) (group 1) and patients treated surgically with arthroscopic shoulder stabilization (group 2).
Figure 4.
Figure 4.
Comparison of range of motion at 24-month follow-up between patients treated nonoperatively with immobilization in external rotation and abduction (ER+ABD) (group 1) and patients treated surgically with arthroscopic shoulder stabilization (group 2). Significant differences in external rotation and abduction were found between the 2 groups at 6 weeks after reduction (group 1) or postoperatively (group 2) and in external rotation in 90° of abduction at 24-month follow-up. *Significant differences between the different time points and between the 2 groups.
Figure 5.
Figure 5.
Longitudinal comparison of (A) subjective shoulder value (SSV), (B) Constant-Murley score, (C) Rowe score, and (D) Western Ontario Shoulder Instability Index (WOSI) at different time points between patients treated nonoperatively with immobilization in external rotation and abduction (ER+ABD) (group 1) and patients treated surgically with arthroscopic shoulder stabilization (group 2). No significant differences were noted at any time point between the 2 groups. *Significant differences between the different time points.

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