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AbstractObjectiveTo assess the effects of an additional programme of physiotherapy in adults with a first-time traumatic shoulder dislocation compared with single session of advice, supporting materials, and option to self-refer to physiotherapy.DesignPragmatic, multicentre, randomised controlled trial (ARTISAN).Setting and participantsTrauma research teams at 41 UK NHS Trust sites screened adults with a first time traumatic anterior shoulder dislocation confirmed radiologically, being managed non-operatively. People were excluded if they presented with both shoulders dislocated, had a neurovascular complication, or were considered for surgical management.InterventionsOne session of advice, supporting materials, and option to self-refer to physiotherapy (n=240) was assessed against the same advice and supporting materials and an additional programme of physiotherapy (n=242). Analyses were on an intention-to-treat basis with secondary per protocol analyses.Main outcome measuresThe primary outcome was the Oxford shoulder instability score (a single composite measure of shoulder function), measured six months after treatment allocation. Secondary outcomes included the QuickDASH, EQ-5D-5L, and complications.Results482 participants were recruited from 40 sites in the UK. 354 (73%) participants completed the primary outcome score (n=180 allocated to advice only, n=174 allocated to advice and physiotherapy). Participants were mostly male (66%), with a mean age of 45 years. No significant difference was noted between advice compared with advice and a programme of physiotherapy at six months for the primary intention-to-treat adjusted analysis (between group difference favouring physiotherapy 1.5 (95% confidence interval −0.3 to 3.5)) or at earlier three month and six week timepoints. Complication profiles were similar across the two groups (P>0.05).ConclusionsAn additional programme of current physiotherapy is not superior to advice, supporting materials, and the option to self-refer to physiotherapy.Trial registrationCurrent Controlled Trials ISRCTN63184243.

Background The diagnosis of posterior shoulder dislocation (PSD) is often overlooked as these injuries are not common, since clinical signs may be subtle and easily overlooked unless specifically evaluated. This study aimed to determine the factors related to clinical outcomes in patients with chronic locked PSD treated with the modified McLaughlin procedure. Methods The study included 22 patients from 5 different clinics who were diagnosed with chronic (> 6 weeks) locked PSD and underwent the modified McLaughlin procedure. The pre- and postoperative values of shoulder forward flexion, abduction, and external rotation were recorded for each patient. At the final follow-up examination, the patient-reported clinical outcomes were evaluated through Constant-Murley Score (CMS), the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire, and the University of California-Los Angeles (UCLA) shoulder scale. Defect depth and defect angle were measured on axial computed tomography sections. Result Evaluation was made of 14 males and 8 females aged 25–58 years. The mean time interval between the dislocation and surgery was 18.4 ± 7.4 weeks. The postoperative scale scores were DASH mean 17.1 ± 5.6, CMS median 70.0 [35.0–83.0] and UCLA shoulder scale mean 25.5 ± 6.6. Strong to excellent correlations were determined between the functional scores and the duration of dislocation. Regardless of age, gender, depth and degree of the defect, and immobilization duration, the duration of dislocation (weeks) was associated with the DASH score (beta:0.513, 95% CI:0.931–7.528, p  = 0.015), CMS (beta: -0.916, 95% CI: -1.959 to -1.293, p  < 0.001), and the UCLA shoulder scale (beta: -0.899, 95% CI: 0.983 to -0.618, p  < 0.001). Conclusion In patients with locked PSD, the primary factor influencing clinical outcomes is the duration of the dislocation, rather than humeral head defect size or patient age. PSD should be suspected in patients with shoulder trauma who present with limitations in forward flexion and abduction.

Anterior shoulder dislocation is a common orthopedic emergency. While many reduction methods require sedation, the FARES (FAst, REliable, and Safe) and Spaso methods allow reduction without anesthesia. We conducted a single-center, prospective, randomized controlled trial comparing the FARES and Spaso methods for anterior shoulder dislocation reduction. Patients aged 20 to 90 years were enrolled. The assigned closed reduction procedures were performed without patient sedation by trained orthopedic residents. If two attempts with the assigned method failed, the alternative method was used. The primary outcome was the first-attempt success rate, while secondary outcomes included overall success rate with both methods, reduction time, and pain scores. During November 2013 and December 2015, a total of 32 patients were randomized to the FARES (n = 17) or Spaso (n = 15) method. The first-attempt success rates were 71.6% for the FARES group and 80.0% for the Spaso group ( p  = 0.691). Among patients with failed closed reduction using the first technique, all patients in the Spaso-following-FARES group achieved successful reduction, whereas none in the FARES-following-Spaso group achieved successful reduction ( p  = 0.092). Pain scores during reduction were comparable between the FARES (4.29 ± 1.69) and Spaso (3.80 ± 2.65) techniques, with no statistically significant difference ( p  = 0.542). Follow-up data were available for 28/32 patients (87.5%; mean 5.3 ± 2.2 years). Four patients were lost (3 FARES, 1 Spaso; p  = 0.726). Recurrent dislocation occurred in 3 patients (10.7%; 1 FARES, 2 Spaso; p  = 0.947), and 2 patients (1 per group; p  = 0.876) underwent surgery (arthroscopic stabilization and rotator cuff repair). Both the FARES and Spaso methods were effective for reducing anterior shoulder dislocations. Combining these methods may improve overall reduction rates. Clinical trial registration: This trial was registered at ClinicalTrials.gov (Registration number: NCT01979237) on 08/11/2013.

Background The traditional treatment for primary anterior shoulder dislocations has been immobilization in a sling with the arm in a position of adduction and internal rotation. However, recent basic science and clinical data have suggested recurrent instability may be reduced with immobilization in external rotation after primary shoulder dislocation. Questions/purposes We performed a randomized controlled trial to compare the (1) frequency of recurrent instability and (2) disease-specific quality-of-life scores after treatment of first-time shoulder dislocation using either immobilization in external rotation or immobilization in internal rotation in a group of young patients. Methods Sixty patients younger than 35 years of age with primary, traumatic, anterior shoulder dislocations were randomized (concealed, computer-generated) to immobilization with either an internal rotation sling (n = 29) or an external rotation brace (n = 31) at a mean of 4 days after closed reduction (range, 1–7 days). Patients with large bony lesions or polytrauma were excluded. The two groups were similar at baseline. Both groups were immobilized for 4 weeks with identical therapy protocols thereafter. Blinded assessments were completed by independent observers for a minimum of 12 months (mean, 25 months; range, 12–43 months). Recurrent instability was defined as a second documented anterior dislocation or multiple episodes of shoulder subluxation severe enough for the patient to request surgical stabilization. Validated disease-specific quality-of-life data (Western Ontario Shoulder Instability index [WOSI], American Shoulder and Elbow Surgeons evaluation [ASES]) were also collected. Ten patients (17%, five from each group) were lost to followup. Reported compliance with immobilization in both groups was excellent (80%). Results With the numbers available, there was no difference in the rate of recurrent instability between groups: 10 of 27 patients (37%) with the external rotation brace versus 10 of 25 patients (40%) with the sling redislocated or developed symptomatic recurrent instability (p = 0.41). WOSI scores were not different between groups (p = 0.74) and, although the difference in ASES scores approached statistical significance (p = 0.05), the magnitude of this difference was small and of uncertain clinical importance. Conclusions Despite previous published findings, our results show immobilization in external rotation did not confer a significant benefit versus sling immobilization in the prevention of recurrent instability after primary anterior shoulder dislocation. Further studies with larger numbers may elucidate whether functional outcomes, compliance, or comfort with immobilization can be improved with this device. Level of Evidence Level I, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.

Purpose The extent of shoulder instability and the indication for surgery may be determined by the prevalence or size of associated lesions. However, a varying prevalence is reported and the actual values are therefore unclear. In addition, it is unclear whether these lesions are present after the first dislocation and whether or not these lesions increase in size after recurrence. The aim of this systematic review was (1) to determine the prevalence of lesions associated with traumatic anterior shoulder dislocations, (2) to determine if the prevalence is higher following recurrent dislocations compared to first-time dislocations and (3) to determine if the prevalence is higher following complete dislocations compared to subluxations. Methods PubMed, EMBASE, Cochrane and Web of Science were searched. Studies examining shoulders after traumatic anterior dislocations during arthroscopy or with MRI/MRA or CT published after 1999 were included. A total of 22 studies (1920 shoulders) were included. Results The proportion of Hill–Sachs and Bankart lesions was higher in recurrent dislocations (85%; 66%) compared to first-time dislocations (71%; 59%) and this was statistically significant ( P  < 0.01; P  = 0.05). No significant difference between recurrent and first-time dislocations was observed for SLAP lesions, rotator-cuff tears, bony Bankart lesions, HAGL lesions and ALPSA lesions. The proportion of Hill–Sachs lesions was significantly higher in complete dislocations (82%) compared to subluxations (54%; P  < 0.01). Conclusion Higher proportions of Hill–Sachs and Bankart were observed in recurrent dislocations compared to first-time dislocations. No difference was observed for bony Bankart, HAGL, SLAP, rotator-cuff tear and ALPSA. Especially when a Hill–Sachs or Bankart is present after first-time dislocation, early surgical stabilization may need to be considered as other lesions may not be expected after recurrence and to limit lesion growth. However, results should be interpreted with caution due to substantial heterogeneity and large variance. Level of evidence IV.

Background Arthroscopic Bankart repair alone cannot restore shoulder stability in patients with glenoid bone loss involving more than 20% of the glenoid surface. Coracoid transposition to prevent recurrent shoulder dislocation according to Bristow-Latarjet is an efficient but controversial procedure. Questions/purposes We determined whether an arthroscopic Bristow-Latarjet procedure with concomitant Bankart repair (1) restored shoulder stability in this selected subgroup of patients, (2) without decreasing mobility, and (3) allowed patients to return to sports at preinjury level. We also evaluated (4) bone block positioning, healing, and arthritis and (5) risk factors for nonunion and coracoid screw pullout. Methods Between July 2007 and August 2010, 79 patients with recurrent anterior instability and bone loss of more than 20% of the glenoid underwent arthroscopic Bristow-Latarjet-Bankart repair; nine patients (11%) were either lost before 2-year followup or had incomplete data, leaving 70 patients available at a mean of 35 months. Postoperative radiographs and CT scans were evaluated for bone block positioning, healing, and arthritis. Any postoperative dislocation or any subjective complaint of occasional to frequent subluxation was considered a failure. Physical examination included ROM in both shoulders to enable comparison and instability signs (apprehension and relocation tests). Rowe and Walch-Duplay scores were obtained at each review. Patients were asked whether they were able to return to sports at the same level and practice forced overhead sports. Potential risk factors for nonhealing were assessed. Results At latest followup, 69 of 70 (98%) patients had a stable shoulder, external rotation with arm at the side was 9° less than the nonoperated side, and 58 (83%) returned to sports at preinjury level. On latest radiographs, 64 (91%) had no osteoarthritis, and bone block positioning was accurate, with 63 (90%) being below the equator and 65 (93%) flush to the glenoid surface. The coracoid graft healed in 51 (73%), it failed to unite in 14 (20%), and graft osteolysis was seen in five (7%). Bone block nonunion/migration did not compromise shoulder stability but was associated with persistent apprehension and less return to sports. Use of screws that were too short or overangulated, smoking, and age higher than 35 years were risk factors for nonunion. Conclusions The arthroscopic Bristow-Latarjet procedure combined with Bankart repair for anterior instability with severe glenoid bone loss restored shoulder stability, maintained ROM, allowed return to sports at preinjury level, and had a low likelihood of arthritis. Adequate healing of the transferred coracoid process to the glenoid neck is an important factor for avoiding persistent anterior apprehension. Level of Evidence Level IV, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.

Background Posterior shoulder dislocations are rare injuries that are often missed on initial presentation. Cases left untreated for more than three weeks are considered chronic, cannot be reduced closely (they become locked) and are usually associated with a significant reverse Hill-Sachs defect. The aim of this study was to evaluate the outcomes of chronic locked posterior shoulder dislocations treated with the McLaughlin procedure (classic or modified). Methods This retrospective study included 12 patients with chronic locked posterior shoulder dislocation operated on between 2000 and 2021 by two surgeons in two institutions. Patients received a thorough clinical examination and radiological assessment before and after surgery. Shoulders were repaired with the McLaughlin or modified McLaughlin procedure. Outcomes were assessed by comparing pre- and postoperative values of clinical variables. Results Most of the dislocations were of traumatic origin. The average delay between dislocation and surgical reduction was 13.5 ± 9.7 weeks. Postoperative clinical outcomes were favourable, with an average subjective shoulder value of 86.4 ± 11.1 and a normalized Constant –Murley score of 90 ± 8.3. None of the patients had a recurrence of shoulder dislocation, but one patient developed avascular necrosis of the humeral head and two patients developed glenohumeral osteoarthritis. Conclusions In this group of patients with chronic locked posterior shoulder dislocation, the clinical outcomes of McLaughlin and modified McLaughlin procedures were satisfactory, even when surgery was significantly delayed.

Background Instability after shoulder arthroplasty remains a complication with limited salvage options. Reoperation for instability with anatomic designs has led to high rates of persistent instability, therefore we aimed to evaluate the use of RSA for treatment of prosthetic instability. Questions/purposes (1) After revision shoulder arthroplasty to a reverse prosthesis (RSA), what is the survivorship free from dislocations at 2 and 5 years? (2) What factors are associated with dislocations? (3) What is the survivorship free from revision after revision to RSA? (4) From preoperation to postrevision to RSA, what are the clinical outcomes—the proportion of patients with moderate to severe pain, shoulder elevation and external rotation ROM, American Shoulder and Elbow Surgeons scores, and Simple Shoulder Test scores? Methods All shoulder arthroplasties revised for prosthetic instability using RSA components between January 2004 and July 2014 were retrospectively studied. During the period in question, we performed 82 revisions for instability of an anatomic total shoulder arthroplasty (TSA) (n = 62), hemiarthroplasty (n = 13), or reverse TSA (n = 7). We typically used a reverse TSA to treat this problem, but we identified 12 treated in other ways, including revision of a TSA to hemiarthroplasty (n = 3), revision of a reverse TSA to hemiarthroplasty (n = 2), revision of hemiarthroplasty to a hemiarthroplasty (n = 1), and revision of an anatomic TSA to another anatomic TSA (n = 6). This left 70 patients for evaluation; of those, 65 (93%) were available for analysis at a mean of 3 years (range, 2–10 years). A total of seven patients died. Eight of the 65 shoulders were not evaluated during the last 5 years, including three in patients who died earlier. The mean age of the patients at the time of revision RSA was 65 years (range, 40–89 years). Data were obtained from a longitudinally maintained institutional joint registry. Instability was defined as severe subluxation confirmed on clinical and radiographic examinations. We evaluated pain and ROM, and Kaplan-Meier curves were used to estimate survivorship. Results The survivorship free from dislocation at 2 and 5 years was 87% (95% CI, 80%–94%) and 79% (95% CI, 67%–91%) respectively, with 10 of 65 (15%) patients having an episode of dislocation after revision surgery. Persistent instability was more common in those with a BMI greater than 35 kg/m 2 (hazard ratio [HR], 5; 95% CI, 2–16; p = 0.008) and prior hemiarthroplasty (HR, 5; 95% CI, 2–16; p = 0.005), whereas patients who had undergone a previous TSA were less likely to have persistent instability (HR, 0.08; 95% CI, 0.0–0.30; p < 0.001) The survival free from rerevision for any indication at 2 and 5 years was 85% (95% CI, 76%–94%) and 78% (95% CI, 66%–90%) respectively; with the numbers available, we were not able to find associated factors. Fewer patients had moderate or severe pain after revision to RSA (preoperative: 48 of 65 [74%]; postoperative: nine of 65 [14%]; p < 0.001). After surgery, patients showed improvement in shoulder elevation (preoperative: 42° [± 30°], postoperative: 112° [42°]; mean difference, 70° [95% CI, − 83 o to 57°]; p < 0.001) and external rotation (preoperative: 20° [± 22°], postoperative: 42° [± 23°]; mean difference, 22° [95% CI, − 30° to − 14°]; p < 0.001). American Shoulder and Elbow Surgeons scores improved (preoperative: 21 [± 10], postoperative: 68 [± 14], mean difference, 46 [95% CI, − 58 to − 35]; p < 0.001); where a higher score is better. Simple Shoulder Test scores also improved (preoperative: 2/12 [± 2], postoperative: 7/12 [± 3]; mean difference, 5 [95% CI, − 7 to − 2.17]; p < 0.001); where a higher score is better. Conclusions Revision RSA for prosthetic instability after shoulder arthroplasty is associated with reasonable implant survival and few complications. Approximately one in seven patients will have a recurrent dislocation. In patients with persistent instability or with risk factors for instability, consideration should be given for use of larger glenospheres and increasing the lateral offset at the time of RSA. Level of Evidence Level IV, therapeutic study.

ObjectivesTo compare the success rates of arthroscopic Bankart and open Latarjet procedure in the treatment of traumatic shoulder instability in young males.DesignMulticentre randomised controlled trial.SettingOrthopaedic departments in eight public hospitals in Finland.Participants122 young males, mean age 21 years (range 16–25 years) with traumatic shoulder anteroinferior instability were randomised.InterventionsArthroscopic Bankart (group B) or open Latarjet (group L) procedure.Main outcome measuresThe primary outcome measure was the reported recurrence of instability, that is, dislocation at 2-year follow-up. The secondary outcome measures included clinical apprehension, sports activity level, the Western Ontario Shoulder Instability Index, the pain Visual Analogue Scale, the Oxford Shoulder Instability Score, the Constant Score and the Subjective Shoulder Value scores and the progression of osteoarthritic changes in plain films and MRI.Results91 patients were available for analyses at 2-year follow-up (drop-out rate 25%). There were 10 (21%) patients with redislocations in group B and 1 (2%) in group L, p=0.006. One (9%) patient in group B and five (56%) patients in group L returned to their previous top level of competitive sports (p=0.004) at follow-up. There was no statistically significant between group differences in any of the other secondary outcome measures.ConclusionsArthroscopic Bankart operation carries a significant risk for short-term postoperative redislocations compared with open Latarjet operation, in the treatment of traumatic anteroinferior instability in young males. Patients should be counselled accordingly before deciding the surgical treatment.Trial registration numberNCT01998048.

Purpose We describe the long-term prognosis in 257 first-time anterior shoulder dislocations (255 patients, aged 12–40 years) registered at 27 Swedish emergency units between 1978 and 1979. Methods Half the shoulders were immobilised for 3–4 weeks after repositioning. Follow-ups were performed after two (questionnaire), five (questionnaire), 10 (questionnaire and radiology) and 25 (questionnaire and radiology) years in 227 patients (229 shoulders). Twenty-eight patients died during the 25 years of observation. Results Early movement or immobilisation after the primary dislocation resulted in the same long-term prognosis. Recurrences increased up to 10 years of follow-up, but, after 25 years, 29 % of the shoulders with ≥2 recurrences appeared to have stabilised over time. Arthropathy increased from 9 % moderate to severe and 11 % mild at 10 years, to 34 % moderate to severe and 27 % mild after 25 years. Alcoholics had a poorer prognosis with respect to dislocation arthropathy ( P  < 0.001). Age <25 years and/or bilateral instability represent a poorer prognosis, where stabilising surgery is necessary in every second shoulder. Fracture of the greater tuberosity means a good prognosis, and we have found no evidence that athletic activity, gender, a Hill–Sachs lesion and minor rim fractures had any prognostic impact. During the 25 years in which these patients were followed, 28/255 died (11 %), representing a mortality rate (SMR) that was more than double that of the general Swedish population ( P  < 0.001). Conclusion Almost half of all first-time dislocations at the age of <25 years will have stabilising surgery and two-thirds will develop different stages of arthropathy within 25 years.