Management of First-Time Anterior Shoulder Dislocation—A Systematic Review and Meta-analysis: Arthroscopy Association of Canada Position Statement

Abstract

Background:

While surgical stabilization is typically recommended for patients with recurrent shoulder instability, the management of first-time shoulder dislocation (FTSD) presents a unique challenge for health care providers.

Purpose:

To assess the efficacy of arthroscopic Bankart repair (ABR) compared with nonoperative management for FTSDs.

Study Design:

Review.

Methods:

MEDLINE, EMBASE, and CENTRAL were searched from inception to December 26, 2023, for comparative studies assessing ABR versus nonoperative management of FTSDs. Outcomes of interest included rates of shoulder redislocation, cumulative shoulder instability (redislocation, subluxation, and/or subjective instability), subsequent shoulder stabilization surgery, return-to-sport rates, and patient-reported outcomes (Western Ontario Shoulder Instability [WOSI] score and Rowe score). Meta-analyses were performed on outcomes reported across a minimum of 3 comparative studies.

Results:

Eleven comparative studies with 694 patients (695 shoulders) were included in the final analysis. Patient demographics were comparable across arthroscopic stabilization (367 shoulders) and nonoperative management (328 shoulders) groups with a mean age of 21.6 ± 2.5 years across all studies, and 13.7% ± 13.6% of patients being female. The mean follow-up across all studies was 54.2 ± 28.5 months, with a mean loss to follow-up of 8.1% ± 10.3%. Meta-analyses demonstrated a reduction in the odds of cumulative instability in favor of the ABR group (odds ratio [OR], 0.04 [95% CI, 0.02 to 0.08]; P < .01), as well as reductions in the odds of shoulder redislocation (OR, 0.06 [95% CI, 0.02 to 0.17]; P < .01) and subsequent stabilization surgery (OR, 0.07 [95% CI, 0.03 to 0.14]; P < .01) in favor of ABR. Compared with the nonoperative group, patients in the ABR group were 3.87 times more likely to return to sport at the preoperative or higher level (OR, 3.87 [95% CI, 1.57 to 9.52]; P < .01). No differences were found across postoperative WOSI scores (mean difference, 8.08 [95% CI, –1.54 to 17.69]; P = .10). Subgroup analyses demonstrated similar outcomes between randomized controlled trials and observational studies.

Conclusion:

Early ABR of first-time anterior shoulder dislocations consistently demonstrated decreased subsequent rates of cumulative instability events, shoulder redislocations, and revision surgeries relative to nonoperative management.

Keywords

anterior shoulder instability anterior shoulder dislocation arthroscopic Bankart repair shoulder stabilization surgery

The shoulder is the most commonly dislocated joint in the body, with shoulder dislocations accounting for half of all major joint dislocations.² Anterior shoulder dislocations are the most common, representing approximately 97% of all shoulder dislocations.² Their incidence rate is higher in young and active individuals, and the condition primarily affects male patients.^32,38,58 Anterior shoulder dislocations are often complicated by recurrent instability and redislocations.^32,43,46 Biomechanical data has shown that after a first dislocation, injury to the joint alters the normal biomechanics and increases the risk of recurrent instability. This, in turn, can lead to further joint damage that is amplified with each subsequent dislocation,^37,57 highlighting the need for timely and effective management. While surgical stabilization is typically recommended for patients with recurrent instability (≥2 dislocations), the optimal management of first-time shoulder dislocation (FTSD) remains controversial and presents a unique challenge for health care providers.

Two initial treatment options exist for patients with an FTSD: nonoperative management and surgical stabilization. Currently, the vast majority of FTSDs are initially treated conservatively with a brief period of immobilization followed by a functional rehabilitation protocol.²⁵ Proponents of this approach argue that around 50% of FTSDs can be effectively managed nonoperatively and that patients at higher risk for recurrent instability (younger, male, partaking in contact sports, high degree of bone loss) can be identified appropriately and offered surgical management, while the remainder can be treated nonoperatively.^26,48 Advocates for primary surgical stabilization argue that rates of redislocation after primary nonoperative management are high enough to warrant immediate operative repair of the dislocated joint, particularly for young and active patients.¹⁹ Additionally, delay in effective treatment causes further damage to the joint, increasing the surgical complexity and associated risk of subsequent treatment failure, as well as potentially increasing the risk of future shoulder arthropathy.^{14,20,34,37,57} Arthroscopic Bankart repair (ABR) is a soft tissue stabilization procedure commonly used to treat anterior shoulder instability, particularly in the setting of minimal bone loss.^24,39 Arthroscopic techniques are minimally invasive and have evolved to demonstrate comparable postoperative outcomes when compared with open techniques.^22,23

The aim of this review was to evaluate the efficacy of ABR compared with nonoperative management for FTSDs. This position statement provides a synthesis of available evidence in the form of a systematic review and meta-analysis and is intended to help guide decision making for this challenging clinical scenario.

Methods

This systematic review was performed according to the guidelines set by the Cochrane handbook¹⁸ and the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses).³⁶

Comprehensive Search Strategy

MEDLINE, EMBASE, and CENTRAL (Cochrane Central Register of Controlled Trials) were electronically searched from database inception through December 26, 2023, by 2 reviewers (H.A.K. and D.D.) for literature related to arthroscopic stabilization surgery for anterior FTSDs. Search terms utilized included “first-time shoulder dislocation,”“arthroscopic,” and “stabilization surgery” (Appendix Table A1).

The inclusion criteria for this review were (1) ABR surgery, (2) stabilization surgery occurring after a first-time anterior shoulder dislocation, (3) comparative studies, (4) clinical and/or functional outcomes reported, (5) both skeletally mature and skeletally immature patient populations, (6) human studies, and (7) English-language publication. Excluded from this review were (1) biomechanical studies and (2) review articles. In situations where multiple studies included the same population, the most recent study was selected for inclusion, although preference was given to comparative data.

Study Screening

Two authors (H.A.K. and D.D.) independently screened studies at both the title/abstract and the full-text stages of the review. To prevent premature exclusion, disagreements at the title/abstract stage were advanced to the full-text stage. Conflicts at the full-text stage were resolved by the senior author (M.K.). The kappa (κ) score was calculated after each step of the screening process to determine the level of agreement between reviewers. The categorization of κ values was defined a priori according to Landis and Koch³⁰ as follows: 1.00 > κ≥ 0.81 indicated almost perfect agreement, 0.80 > κ≥ 0.61 indicated substantial agreement, 0.60 > κ≥ 0.41 indicated moderate agreement, 0.40 > κ≥ 0.21 indicated fair agreement, 0.20 > κ≥ 0.00 indicated slight agreement, and κ = 0 indicated no agreement.

Assessment of Study Quality

The risk of bias and quality assessment of included studies was independently assessed by 2 authors (H.A.K. and D.D.). The Cochrane risk-of-bias tool was used to assess risk of bias for randomized controlled trials (RCTs),¹⁷ and the methodological index for non-randomized studies (MINORS) was used for quality assessment for the non-RCTs.⁴⁵ The Cochrane risk-of-bias tool consists of 6 domains including selection bias, performance bias, detection bias, attrition bias, reporting bias, and other bias.¹⁷ Reviewers rate the bias in each domain as either high risk, unclear risk, or low risk. The MINORS questionnaire consists of 8 items for noncomparative studies, and 4 additional items for comparative studies. Each item is given a score of 2 if reported and adequate, 1 if reported but inadequate, and zero if not reported. Noncomparative studies can have a maximum score of 16, and comparative studies can have a maximum score of 24.

Data Abstraction From the Included Studies

Data abstraction was performed by 3 reviewers (H.A.K., D.D., and D.L.L.). Each reviewer independently abstracted the data from one-half of the studies while the other reviewed the accuracy of the abstracted data. The data were abstracted into a Google Sheets spreadsheet designed a priori. The following data were abstracted from the included studies: study characteristics (authors, study design, publication year, etc), number of patients, patient demographics (age, sex, etc.), follow-up length, postoperative complication rates, recurrent shoulder redislocation rates, cumulative instability rates, rates of subsequent stabilization surgery, and return to sport/work rates, as well as subjective and objective outcome measures. The level of evidence for the studies was determined based on the American Academy of Orthopaedic Surgeons evidence-based practice committee guidelines.⁵⁴

Outcomes of interest included rates of shoulder redislocation, cumulative instability, reoperation after arthroscopic shoulder stabilization, rate of return to sport, index surgery complication rates, and patient-reported outcomes. Cumulative instability rates were defined as being inclusive of redislocation, subjective feelings of instability, and/or subluxation events.^6,24,50 Shoulder redislocation rates were presented as an additional, separate value only if they were explicitly reported as such by included studies. Patient-reported outcomes included the Western Ontario Shoulder Instability Index (WOSI) score and the Rowe score.^27,42

Statistical Analysis

Descriptive statistics were calculated using R (RStudio). These included weighted means with standard deviations as well as 95% CIs. Depending on the outcome, either the number of patients or the number of shoulders in each study was used as the frequency weight.

A pairwise meta-analysis was performed on all outcomes reported across ≥3 studies using a DerSimonian and Laird random-effects model.¹² Odds ratios (ORs) were calculated for dichotomous variables and mean difference was calculated for continuous variables, along with their respective 95% CIs to confirm the effect size estimation. For studies reporting median and interquartile range, the mean and standard deviation was estimated using a previously outlined method by Wan et al.⁵² Missing standard deviations were calculated as per the methodology of the Cochrane Handbook for Systematic Reviews of Interventions Version 6.1.¹⁸ The meta-analysis was performed on DataParty. Meta-analyses were stratified by study design (RCTs vs observational studies). Heterogeneity was quantified using the chi-square test for heterogeneity and the I² statistic. We considered I² values of <25% to indicate low heterogeneity and >75% to indicate considerable heterogeneity. Subgroup analyses were also planned for studies to evaluate the effect of study design. Outcomes not amenable to meta-analysis were presented in a narrative manner.

Results

Study Characteristics and Quality

The search identified 6356 studies, with 4178 remaining after exclusion of duplicates. After screening, 11 studies^¶¶ were included in the final analysis (Figure 1). Both the title/abstract and full-text stages had almost perfect interobserver agreement (κ = 0.81 [95% CI, 0.70-0.92] and κ = 0.88 [95% CI, 0.71-1.00], respectively). The 4 included RCTs^7,28,35,41 were all rated as having an unclear risk of bias (Figure 2). All 4 RCTs commonly lacked blinding of participants and personnel and blinding of outcome assessment, and they had a significant loss to follow-up potentially resulting in attrition bias. The mean MINORS score for the included non-RCTs was 17.4 (range, 14-21) (Table 1). The characteristics of the included studies are summarized in Table 1.

Figure 1.

PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) diagram of the study inclusion process. FT, full text.

Figure 2.

Risk-of-bias assessment for the included randomized controlled trials.^7,28,35,41

Table 1

Overview of Included Studies (N = 11)^a

Study, Lead Author (year)	Study Design, LOE	Intervention Groups	Patients/ Shoulders, n	Age, y^b	Female, %	Follow-up, mo^b	Loss to Follow-up, %	Time From Dislocatito Arthroscopic Stabilization	MINORS Score
Arciero (1994)⁵	Prospective cohort; 3	(1) Nonop (2) ABR	(1) 15/15 (2) 21/21	(1) 19.5 (18-21) (2) 20.5 (18-24)	(1) 0 (2) 0	(1) 23 (15-39) (2) 32 (15-45)	(1) 0 (2) 0	(1) NA (2) Mean, 5.5 d after dislocation	20
Bottoni (2002)⁷	RCT; 1	(1) Nonop (2) ABR	(1) 14/14 (2) 10/10	(1) 23 (19-26) (2) 21.6 (19-26)	(1) 0 (2) 0	(1) 37 (16-56) (2) 35 (17-56)	(1) 14.3 (2) 10	(1) NA (2) ≤10 d after injury	NA
De Carli (2019)¹⁰	Prospective cohort; 2	(1) Nonop (2) ABR	(1) 96/96 (2) 64/64	(1) 20.8 ± 2.9 (2) 22.8 ± 3.2	(1) 34.4 (2) 9.4	(1) 103.6 (24-149) (2) 82.3 (24-134)	(1) 27.1 (2) 6.3	(1) NA (2) Decision for surgery ≤1 wk	20
DeBerardino (2001)¹¹	Prospective cohort; 2	(1) Nonop (2) ABR	(1) 6/6 (2) 48/49	(1) NR (2) 20 (17-23)	(1) NR (2) 6.3	(1) NR (2) 37 (24-60)	(1) 0 (2) 0	(1) NA (2) ≤10 d after injury	15
Gigis (2014)¹⁵	Prospective cohort; 2	(1) Nonop (2) ABR	(1) 27/27 (2) 38/38	(1) 16.6 (2) 16.6	(1) 37 (2) 36.8	(1) 36 (2) 36	(1) 0 (2) 0	(1) NA (2) ≤21 d after injury	14
Kirkley (2005)²⁸	RCT; 2	(1) Nonop (2) ABR	(1) 15/15 (2) 16/16	(1) 22.7 (2) 23.3	(1) 6.7 (2) 6.3	79^c (51-102)	(1) 28.6 (2) 15.8	(1) NA (2) ≤4 wk after dislocation	NA
Larrain (2001)³¹	Prospective cohort; 2	(1) Nonop (2) ABR	(1) 18/18 (2) 28/28	21^c (17-27)	NR	67.4^c (28-120)	0	(1) NA (2) NR	16
Minkus (2021)³⁵	RCT; 1	(1) Nonop (2) ABR	(1) 60/60 (2) 52/52	(1) 26.7 ± 5.8 (2) 25.7 ± 6.2	(1) 8.3 (2) 7.7	24	(1) 21.7 (2) 15.4	(1) NA (2) ≤3 wk after injury	NA
Pougès (2021)⁴¹	RCT; 1	(1) Nonop (2) ABR	(1) 20/20 (2) 20/20	(1) 21.3 (20-22.5) (2) 21.5 (20.5-22.5)	(1) 10 (2) 25	(1) 24 (2) 24	(1) 5 (2) 5	(1) NA (2) ≤15 d after injury	NA
Shih (2011)⁴⁴	Prospective cohort; 2	(1) Nonop (2) ABR	(1) 25/25 (2) 39/39	(1) 22.9 (17-29) (2) 21.5 (18-29)	(1) 0 (2) 0	(1) 70.4 (60-84) (2) 72.6 (62-88)	(1) 0 (2) 0	(1) NA (2) Mean, 5 d (range, 1-12 d)	21
Yanmis (2003)⁵⁵	Prospective cohort; 2	(1) Nonop (2) ABR	(1) 32/32 (2) 30/30	(1) 22.1 (19-32) (2) 21.2 (18-26)	(1) 12.5 (2) 0	(1) 40 (18-63) (2) 33 (10-60)	(1) 0 (2) 0	(1) NA (2) Mean, 10.5 d (range, 5-23 d)	16

ABR, arthroscopic Bankart repair; LOE, level of evidence; MINORS, methodological index for non-randomized studies; NA, not applicable; Nonop, nonoperative; NR, not reported; RCT, randomized controlled trial.

Data are presented as mean, mean (range), or mean ± SD, unless otherwise indicated.

Median.

A total of 694 patients (695 shoulder dislocations) were included in this review (Table 1). The mean age of patients across all studies was 21.8 ± 2.6 years, with 13.7% ± 13.6% of participants being female. Comparable patient and study demographics were seen across both ABR and nonoperative groups (Table 2). The mean follow-up across all studies was 54.2 ± 28.5 months, with a mean loss to follow-up of 8.1% ± 10.3%. The mean time to surgery for participants in the ABR group was 7.0 ± 2.5 days, reported in 3 studies.^5,44,55 The remaining studies reported threshold time frames within which surgery took place, ranging from within 10 days to 4 weeks from initial injury (Table 1).

Table 2

Summary of Characteristics of Patients in the Included Studies Overall and by Intervention Group^a

Characteristic	All	Arthroscopic Bankart Repair	Nonoperative Management
Intervention arms, n	22	11	11
Initial shoulder dislocations, n	695	367	328
Age, y	21.8 ± 2.6 (20.7-22.9)	21.6 ± 2.5 (20.1-23.2)	22.1 ± 2.8 (20.2-23.9)
Female, %	13.7 ± 13.6 (7.2-20.1)	8.8 ± 10.9 (1.7-16)	19.0 ± 14.1 (9.2-28.8)
Follow-up, mo	54.2 ± 28.5 (42.0-66.4)	46.5 ± 22.6 (31.8-61.3)	57.9 ± 34.5 (34.0-81.8)
Loss to follow-up, %	8.1 ± 10.3 (3.8-12.3)	3.8 ± 5.5 (0.6-7.0)	12.8 ± 12.1 (5.6-20.0)

Data are presented as mean ± SD (95% CI) unless otherwise indicated.

Outcomes

Subsequent Instability, Redislocation, and Surgery

Cumulative subsequent instability rates were 9.6% ± 4.8% and 64.0% ± 25.7% across ABR and nonoperative groups, respectively (Table 3). All 11 included studies^¶¶ were included in the meta-analysis, which demonstrated that the odds of cumulative subsequent instability were decreased by 96% when FTSDs were treated with ABR compared with nonoperative management (OR, 0.04 [95% CI, 0.02-0.08]; P < .01) (Appendix Figure A1). This trend was consistent across both observational studies and RCTs.

Table 3

Summary of Primary Outcomes

Outcome	Arthroscopic Bankart Repair		Nonoperative Management		All
Outcome	No. of Studies	Mean ± SD (95% CI)	No. of Studies	Mean ± SD (95% CI)	No. of Studies	Mean ± SD (95% CI)
Shoulder redislocation	9	6.2 ± 5.3 (2.8-9.7)	9	50.6 ± 30.2 (30.9-70.3)	18	26.0 ± 30.2 (12.1-40)
Cumulative subsequent instability	11	9.6 ± 4.8 (6.8-12.5)	11	64.0 ± 25.7 (48.8-79.2)	22	34.0 ± 32.2 (20.5-47.4)
Subsequent stabilization surgery	8	6.1 ± 3.7 (3.5-8.7)	7	39.2 ± 20.9 (23.7-54.6)	15	19.7 ± 21.2 (8.9-30.4)

Shoulder redislocation rates were 6.2% ± 5.3% and 50.6% ± 30.2% across ABR and nonoperative groups, respectively. Overall, 9 studies^## were eligible for meta-analysis, which demonstrated that the odds of redislocation were 94% lower in the ABR group compared with the nonoperative group (OR, 0.06 [95% CI, 0.02-0.17]; P < .01) (Appendix Figure A2).

Rates of subsequent stabilization surgery were 6.1% ± 3.7% and 39.2% ± 20.9% across ABR and nonoperative groups, respectively (Table 3). Meta-analysis performed on 7 eligible studies^{5,7,10,11,35,41,44} demonstrated that the odds of undergoing subsequent stabilization surgery were 93% smaller in FTSDs managed with ABR compared with nonoperative management (OR, 0.07 [95% CI, 0.03-0.14]; P < .01) (Appendix Figure A3).

The rate of postoperative complications after ABR was 1.8% ± 4.3% across 6 studies.^{5,10,11,31,35,41}

Return to Sport

Return to sport at preoperative levels or higher was 79.2 ± 10.7 and 48.5 ± 18.1 for ABR and nonoperative groups, respectively (Table 4). Meta-analysis performed on 5 studies^{5,10,15,28,41} demonstrated that patients in the ABR group were 3.87 times more likely to return to sport at preoperative levels or higher when compared with nonoperative management (OR, 3.87 [95% CI, 1.57-9.52]; P < .01) (Appendix Figure A4). Two studies^10,41 assessed return-to-sport rates at any level, which precluded a meta-analysis, although rates were comparable across ABR and nonoperative management (93.7% ± 0.7% and 84.2% ± 8.4%, respectively).

Table 4

Return-to-Sport Outcomes^a

Study	n^b	Sporting Activity Level, n (%)	Return to Sport, %
Study	n^b	Sporting Activity Level, n (%)	At Same/Higher Level	At Any Level	Outcomes
Arthroscopic Bankart Repair
Arciero (1994)⁵	21	Varsity/club: 8 (38) Intramural: 6 (29) Required physical activity: 7 (33)	85.70		NR
De Carli (2019)¹⁰	60	Professional: 12 (20)Amateur: 16 (27)Recreational: 32 (53)	70.00	93.30	• RTS at any level: P = .35• RTS at same/higher level: P = .001
DeBerardino (2001)¹¹	49	Military cadets: 49 (100)	89.60		NR
Gigis (2014)¹⁵	38	NR	65.80		No significance
Kirkley (2005)²⁸	16	NR	93.80		NR
Pougès (2021)⁴¹	20	None: 5 (25)Recreational: 9 (45)Competition: 6 (30)	89.00	95.00	RTS at same/higher level: P = .12
Overall mean ± SD (95% CI)			79.2 ± 10.7(70.6-87.8)	93.7 ± 0.7(92.7-94.7)
Nonoperative Management
Arciero (1994)⁵	15	Varsity/club: 10 (67)Intramural: 2 (13)Required physical activity: 3 (20)	20.00		NR
De Carli (2019)¹⁰	70	Professional: 12 (17)Amateur: 32 (46)Recreational: 26 (37)	41.40	88.60	• RTS at any level: P = .35• RTS at same/higher level: P = .001
Gigis (2014)¹⁵	27	NR	55.60		No significance
Kirkley (2005)²⁸	15	NR	93.30		NR
Pougès (2021)⁴¹	20	None: 2 (10)Recreational: 14 (70)Competition: 4 (20)	53.00	68.00	RTS at same/higher level: P = .12
Overall mean ± SD (95% CI)			48.5 ± 18.1(32.6-64.4)	84.2 ± 8.4(72.5-95.9)

NR, not reported; RTS, return to sport.

Number of shoulders at final follow-up.

Patient-Reported Outcomes

Mean WOSI scores were 91.5 ± 2.9 and 82.2 ± 6.5 for ABR and nonoperative groups, respectively, with a higher score representing better outcomes (Table 5). Meta-analysis across 5 eligible studies^{10,28,35,41,44} demonstrated a pooled mean difference of 8.08 points in favor of the ABR group (95% CI, –1.54 to 17.69; P = .10).

Table 5

Patient-Reported Outcome Scores^a

Study	Arthroscopic Bankart Repair		Nonoperative Management		P
Study	n^b	Score	n^b	Score	P
WOSI
De Carli (2019)¹⁰	60	94.5 ± 4.0	70	76.5 ± 5.2	<.001
Kirkley (2005)²⁸	16	86	15	74.8	.17
Minkus (2021)³⁵	44	92.7 ± 8.1	47	91.5 ± 7.9	NS
Pougès (2021)⁴¹	19	88.5	19	82.3	.04
Shih (2011)⁴⁴	39	89.1	25	84.9	.18
Overall mean ± SD (95% CI)		91.5 ± 2.9(88.9-94.0)		82.2 ± 6.5(76.5-87.8)
Rowe
Arciero (1994)⁵	21	Excellent: 16 (76.2)Good: 2 (9.5)Poor: 3 (14.3)	15	NR	NA
De Carli (2019)¹⁰	60	94.2 ± 5.3	70	75.3 ± 5.5	<.001
DeBerardino (2001)¹¹	49	92 (30-100)	6	NR	NA
Larrain (2001)³¹	28	Excellent: 25 (89.3)Good: 2 (7.1)Poor: 1 (3.6)	18	Excellent: 1 (5.6)Poor: 17 (94.4)	NR
Minkus (2021)³⁵	44	88.5 ± 11.2	47	89.1 ± 7.1	NS
Overall mean ± SD (95% CI)		91.9 ± 2.3(89.2-94.5)		80.8 ± 6.8(71.5-90.2)

Data presented as mean ± standard deviation (range) or n (%), unless otherwise indicated; NA, not applicable; NR, not reported; NS, not significant; WOSI, Western Ontario Shoulder Instability Index.

Number of patients at final follow-up.

Mean postoperative Rowe scores were 91.9 ± 2.3 and 80.8 ± 6.8 for ABR and nonoperative groups, respectively (Table 5). Only 2 studies reported postoperative mean values, precluding meta-analysis: DeCarli et al¹⁰ reported results largely in favor of ABR compared with nonoperative management (94.2 ± 5.3 vs 75.3 ± 5.5, respectively; P < .001), while Minkus et al³⁵ reported results in favor of nonoperative management compared with ABR (89.1 vs 88.5, respectively), although this difference was negligible.

Discussion

In this review, we aimed to evaluate the effects of ABR compared with nonoperative management in patients with an anterior FTSD. We included 11 studies with 694 patients (695 shoulders). The main findings were that ABR decreased the odds of subsequent instability, redislocation, and subsequent stabilization surgery compared with nonoperative management. Patients who underwent ABR were also more likely to return to sport at preoperative levels or higher. WOSI scores favored ABR, with the observed mean difference surpassing the minimally clinically important difference for WOSI scores reported in the literature.⁴⁰

Relation to Previous Literature

The results of this review are consistent with previous literature. A review by Hurley et al²⁴ found concordant results, reporting that ABR resulted in a lower recurrence rate and higher rate of return to sport when compared to non-operative management. Hurley et al²⁴ also noted that patients who underwent ABR experienced low complication rates, similar to the results of the current review (1.6% and 1.8%, respectively). A more recent meta-analysis by Hu et al²¹ further solidifies these findings, concluding that ABR showed superiority over conservative management with respect to recurrence, return to play, and subsequent instability surgery in young, active patients presenting with an FTSD. Additionally, Kraeutler et al²⁹ reported that operative management for anterior FTSDs can both reduce the recurrence rate and provide improved quality of life postoperatively, particularly in younger patients. A review by Longo et al³³ found similar results in pediatric populations (aged ≤18 years), reporting lower recurrence rates in patients who underwent surgical treatment.

Our findings contribute to this body of evidence by further demonstrating the benefits of ABR compared with nonoperative approaches. Specifically, our review emphasized the consistent improvement in recurrence rates, return to sport, and overall shoulder stability. While prior systematic reviews and meta-analyses do exist on this topic, their strength and the generalizability of their conclusions may be questioned due to the methodology utilized. For example, a prior review by Adam et al³ included comparative studies including studies comparing ABR after a single dislocation compared with either nonoperative management or Bankart repair after recurrent dislocation, 2 inherently different populations. Another meta-analysis by Alkhatib et al⁴ only included 6 RCTs for analysis and did not stratify between cumulative instability and confirmed redislocation events. Similarly, a study by Hurley et al²⁴ across prospective studies did not delineate between cumulative instability and redislocation events. Ultimately, the agreement of this meta-analysis with existing literature along with the granularity of provided data underscores the reliability of ABR as an effective intervention and provides a strong foundation for future research to explore optimal surgical techniques and rehabilitation protocols.

Consensus Statements and Risk Factors

Various consensus statements have sought to standardize the diagnosis and treatment of FTSDs, especially considering the heterogeneity of presenting patients. A notable consensus statement on the management of FTSDs utilizing the Delphi approach was by the Neer Circle of American Shoulder and Elbow Surgeons, wherein they presented recommendations for all patients as well as stratified by the following categories: (1) active-duty military population, (2) nonathlete population, (3) noncontact athlete population, and (4) contact athlete population.⁴⁷ Patients <14 or >30 years of age had a decreased likelihood of being operatively managed irrespective of category. Strong predictors of surgery across all patient categories were meaningful bone loss as well as a positive apprehension test. Interestingly, the inclusion of bone loss in the final survey was debated by committee members as not being clinically relevant, though prior studies have demonstrated the rate of bone loss after an FTSD to be as high as 41%.¹⁶ Nonetheless, the degree of bone loss may not be clinically relevant, with Dickens et al¹³ demonstrating that the mean amount of glenoid bone loss after a single anterior shoulder dislocation was only 6.5%. Therefore, it is up to clinicians to weigh the benefits and risks of proceeding with computed tomography (CT) imaging with the associated radiation exposure in often young patients to accurately assess bone loss.

Another notable Delphi study by the Anterior Shoulder Instability International Consensus Group asked their participants about the ordering of advanced imaging in the setting of anterior shoulder instability.²⁵ Strong consensus (90%) existed regarding ordering advanced imaging (CT scan or magnetic resonance imaging [MRI]) in patients deemed to have a high risk of recurrence, and moderate consensus (84%) existed for ordering a CT scan if there was concern for bone loss.²⁵ While this study did not explicitly assess patient factors associated with high risk of recurrence, robust evidence to-date suggests male sex, younger age, and ligamentous laxity are associated with recurrent instability after a single dislocation event.³⁸ Further, while this consensus statement provided recommendations for the management of anterior shoulder instability, their recommendations were not specifically directed at the patient experiencing an FTSD.

Ultimately, while the current review demonstrated strong evidence in favor of surgical management of FTSDs, there are several considerations that cannot be captured in RCTs, including but not limited to a patient’s functional objectives, whether the patient is in-season with strict return to sport timelines, and associated bone loss. Therefore, it is recommended by the Arthroscopy Association of Canada (AAC) to consider surgical management in patients with FTSD in the presence of certain risk factors, including male sex, young age at first dislocation, ligamentous laxity, and participation in contact sport, through a shared decision-making process with the patient.^38,53

Methodological Limitations

Consensus statements and expert surveys are restricted by the methodological limitations of the available literature, including statistically fragile results as well as the limited generalizability of findings. The development and execution of high-quality trials to assess operative versus nonoperative management of FTSDs are challenging due to the logistics of running surgical RCTs as well as the competing priorities often faced by the affected patient population (ie, young male athletes) that may preclude their involvement from trials that limit their playing time. While several trials have sought to compare operative versus nonoperative management of FTSD, the statistical robustness of their findings is limited, with mean and median fragility indices of 3.5 and 2, respectively.^1,9 As per the seminal study on the fragility index by Walsh et al,⁵¹ the median fragility index of RCTs assessing operative versus nonoperative management of FTSD falls below the 25th percentile of 399 trials published in high-impact journals. Further, the generalizability of RCTs assessing surgical management of FTSD is limited to a narrow patient population often studied by these trials, that of young, predominantly male patients. While epidemiologic studies indicate that young, male patients are at higher risk of shoulder dislocation, even when standardizing for type of sporting activity, this does not preclude focused studies on less represented patient populations.⁴⁹ In terms of running larger trials to increase the statistical robustness of findings, several practical limitations exist such as a patient’s in-season status. As demonstrated by Buss et al,⁸ 90% of athletes with an in-season shoulder dislocation were able to return to sports at a mean time of 10 days after injury, with recurrent instability being noted in 37% of patients, an informed risk an athlete may wish to take to avoid missing an entire season for surgery.

Limitations

This study is not without its limitations. First, to increase the number of included studies, this review included both RCTs and observational studies rather than limiting the inclusion to RCTs only. Nonetheless, meta-analyses stratified by study design (RCTs vs observational studies) demonstrated concordant results. Second, the included studies largely comprised young, male patients, which limits the generalizability of the findings. Third, the timing of surgery was heterogeneously reported across studies, ranging from as early as 1 day after dislocation to upward of 4 weeks. Further research is needed to evaluate the role of early intervention in this patient population. Fourth, follow-up periods varied notably across studies. However, the mean follow-up period for eligible studies was 54.2 months, which was sufficient in duration to adequately capture repeat dislocation or instability events.⁵⁶ Included studies also lacked consistency in the reporting of recurrent instability events despite subjective instability, subluxation, and redislocation all having their unique adverse sequalae. To account for the more severe adverse outcomes associated with redislocation (ie, bone loss), this meta-analysis included all recurrent instability, subluxation, or redislocation events under cumulative instability rates while also presenting redislocation rates as a separate entity, where possible. Last, this meta-analysis solely compared ABR with nonoperative management of FTSD, whereas other surgical techniques do exist to manage the same or more complex sequalae of shoulder dislocation including open Bankart repair and the role of remplissage, as well as various bone restorative techniques including the Latarjet procedure. Future directions include both high-quality RCTs assessing the management of FTSD using modern surgical techniques in young male patients, as they are typically more affected by this pathology, and smaller case series that include less often affected patient populations such as female athletes.

Summary of Recommendations

ABR in the setting of a first-time anterior shoulder dislocation is recommended in patients with known risk factors for recurrence including male sex, young age, and participation in a contact sport.

The timing of surgical management is multifactorial and should consider patient preferences including return to play timelines and/or employment obligations while also minimizing the risk of recurrence.

While advanced imaging is the gold standard for the assessment of bone loss, radiography should be effectively used to maximize diagnostic accuracy prior to consideration of CT and/or MRI, especially in single-payer health care systems. Recommended views include anteroposterior, lateral, and axillary views.

CT assessments of the shoulder are only recommended if there is concern for bone loss or bony Bankart fracture that may warrant bony reconstruction surgery.

MRI is of value particularly to assess for potential concomitant pathology (ie, rotator cuff tears or humeral avulsions of the glenohumeral ligament), and as such, timely access to MRI is critical to avoid delays in surgical care in the setting of FTSDs.

Conclusion

Early ABR of first-time anterior shoulder dislocation consistently demonstrated decreased subsequent rates of cumulative instability events, shoulder redislocation, and revision surgeries, as well as improved patient-reported outcomes when compared with nonoperative management.

Footnotes

Appendix

Table A1

Search Strategy: MEDLINE, EMBASE, and CENTRAL via OVID Search Engine

1. exp Shoulder/ or shoulder.mp.
2. glenohumeral.mp.
3. exp Shoulder Joint/
4. dislocation.mp. or exp Shoulder Dislocation/
5. instability.mp.
6. stabilisation.mp.
7. stabilization.mp.
8. exp Bankart Lesions/ or bankart.mp.
9. latarjet.mp.
10. coracoid transfer.mp.
11. distal tibia.mp.
12. Surgery.mp.
13. Surgical.mp.
14. capsular shift.mp.
15. rotator interval closure.mp.
16. capsulorrhaphy.mp.
17. 1 or 2 or 3
18. 4 or 5
19. 6 or 7 or 8 or 9 or 10 or 11 or 12 or 13 or 14 or 15 or 16
20. 17 and 18 and 19
21. first time.mp.
22. traumatic.mp.
23. initial.mp.
24. acute.mp.
25. 21 or 22 or 23 or 24
26. 20 and 25

Final revision submitted August 7, 2024; accepted September 11, 2024.

One or more of the authors has declared the following potential conflict of interest or source of funding: J.G. has received research support from Arthrex, JRF Ortho, Vericel, and Aesculap Biologics; education payments from Arthrex; nonconsulting fees from Arthrex and ConMed; and consulting/nonconsulting fees from Vericel, JRF Ortho, and Tactile Orthopaedics. B.A.M. has received consulting fees from Arthrex. R.K.M. has received education payments from Arthrex and Smith & Nephew. M.P. has received consulting fees from Arthrex and ConMed. B.S. has received nonconsulting fees from ConMed and Smith & Nephew. M.S. has received consulting fees from Arthrex. I.W. has received consulting fees from DePuy Mitek, Smith & Nephew, and ConMed and nonconsulting fees from DePuy Mitek, Smith & Nephew, ConMed, and Bioventus. He is a paid associate editor for The Orthopaedic Journal of Sports Medicine. 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.

Authors

Contributing members of the Arthroscopy Association of Canada: Alexandra Brooks-Hill, MD (The University of British Columbia, Vancouver, British Columbia, Canada); Michael Carroll, MD (Queen Elizabeth Hospital, Charlottetown, Prince Edward Island, Canada); Rachael DaCunha, MD (Queen’s University, Kingston, Ontario, Canada); Ryan Degen, MD (Western University, London, Ontario, Canada); John Grant, MD (University of Michigan, Ann Arbor, Michigan, USA); Jillian Karpyshyn, MD (University of Alberta, Edmonton, Alberta, Canada); Adam Kwapisz, MD (University of Manitoba, Winnipeg, Manitoba, Canada); Devin Lemmex, MD (University of Calgary, Calgary, Alberta, Canada); Ryan Martin, MD (Queen Elizabeth Hospital, Charlottetown, Prince Edward Island, Canada); Jessica Page, MD (Lethbridge Orthopaedics, Lethbridge, Alberta, Canada); Michael Pickell, MD (University of Ottawa, Ottawa, Ontario, Canada); Brendan Sheehan, MD (Saint John Orthopaedics, Saint John, New Brunswick, Canada); and Allison Tucker, MD (Nova Scotia Health Authority, Halifax, Nova Scotia, Canada).

ORCID iDs

Hassaan Abdel Khalik

Danielle Dagher

Darius Luke Lameire

Eva Gusnowski

Michaela Kolpka

Marie-Eve LeBel

R. Kyle Martin

Moin Khan

¶¶

References 5, 7, 10, 11, 15, 28, 31, 35, 41, 44, .

##

References 5, 10, 11, 28, 31, 35, 41, 44, .

References

Abdel Khalik

Lameire

Leroux

Bhandari

Khan

Arthroscopic stabilization surgery for first-time anterior shoulder dislocations: a systematic review and meta-analysis. J Shoulder Elbow Surg. 2024;33(8):1858-1872. doi:10.1016/j.jse.2024.01.037

Abrams

Akbarnia

Shoulder dislocations overview. In: StatPearls. StatPearls Publishing; 2024. Accessed March 4, 2024. http://www.ncbi.nlm.nih.gov/books/NBK459125

Adam

Attia

Alhammoud

Aldahamsheh

Al Ateeq

Dosari

Ahmed

Arthroscopic Bankart repair for the acute anterior shoulder dislocation: systematic review and meta-analysis. Int Orthop. 2018;42(10):2413-2422. doi:10.1007/s00264-018-4046-0

Alkhatib

Abdullah

ASA

AlNouri

Ahmad Alzobi

Alkaramany

Ishibashi

Short- and long-term outcomes in Bankart repair vs. conservative treatment for first-time anterior shoulder dislocation: a systematic review and meta-analysis of randomized controlled trials. J Shoulder Elbow Surg. 2022;31(8):1751-1762. doi:10.1016/j.jse.2022.02.032

Arciero

Wheeler

Ryan

McBride

JT.

Arthroscopic Bankart repair versus nonoperative treatment for acute, initial anterior shoulder dislocations. Am J Sports Med. 1994;22(5):589-594. doi:10.1177/036354659402200504

Belk

Wharton

Houck

, et al. Shoulder stabilization versus immobilization for first-time anterior shoulder dislocation: a systematic review and meta-analysis of level 1 randomized controlled trials. Am J Sports Med. 2023;51(6):1634-1643. doi:10.1177/03635465211065403

Bottoni

Wilckens

DeBerardino

, et al. A prospective, randomized evaluation of arthroscopic stabilization versus nonoperative treatment in patients with acute, traumatic, first-time shoulder dislocations. Am J Sports Med. 2002;30(4):576-580. doi:10.1177/03635465020300041801

Buss

Lynch

Meyer

Huber

Freehill

MQ.

Nonoperative management for in-season athletes with anterior shoulder instability. Am J Sports Med. 2004;32(6):1430-1433. doi:10.1177/0363546503262069

Davey

Hurley

Doyle

Dashti

Gaafar

Mullett

The fragility index of statistically significant findings from randomized controlled trials comparing the management strategies of anterior shoulder instability. Am J Sports Med. 2023;51(8):2186-2192. doi:10.1177/03635465221077268

10.

De Carli

Vadalà

Lanzetti

, et al. Early surgical treatment of first-time anterior glenohumeral dislocation in a young, active population is superior to conservative management at long-term follow-up. Int Orthop. 2019;43(12):2799-2805. doi:10.1007/s00264-019-04382-2

11.

DeBerardino

Arciero

Taylor

Uhorchak

JM.

Prospective evaluation of arthroscopic stabilization of acute, initial anterior shoulder dislocations in young athletes: two- to five-year follow-up. Am J Sports Med. 2001;29(5):586-592. doi:10.1177/03635465010290051101

12.

DerSimonian

Laird

Meta-analysis in clinical trials. Control Clin Trials. 1986;7(3):177-188. doi:10.1016/0197-2456(86)90046-2

13.

Dickens

Slaven

Cameron

, et al. Prospective evaluation of glenoid bone loss after first-time and recurrent anterior glenohumeral instability events. Am J Sports Med. 2019;47(5):1082-1089. doi:10.1177/0363546519831286

14.

Fox

Drain

Rai

, et al. Increased failure rates after arthroscopic Bankart repair after second dislocation compared to primary dislocation with comparable clinical outcomes. Arthroscopy. 2023;39(3):682-688. doi:10.1016/j.arthro.2022.10.012

15.

Gigis

Heikenfeld

Kapinas

Listringhaus

Godolias

Arthroscopic versus conservative treatment of first anterior dislocation of the shoulder in adolescents. J Pediatr Orthop. 2014;34(4):421-425. doi:10.1097/BPO.0000000000000108

16.

Griffith

Antonio

Yung

PSH

, et al. Prevalence, pattern, and spectrum of glenoid bone loss in anterior shoulder dislocation: CT analysis of 218 patients. AJR Am J Roentgenol. 2008;190(5):1247-1254. doi:10.2214/AJR.07.3009

17.

Higgins

JPT

Altman

Gøtzsche

, et al. The Cochrane Collaboration’s tool for assessing risk of bias in randomised trials. BMJ. 2011;343(7829):D5928. doi:10.1136/bmj.d5928

18.

Higgins

JPT

Thomas

Chandler

, et al. Cochrane Handbook for Systematic Reviews of Interventions Version 6.1. Updated September 2021. Cochrane; 2020. www.training.cochrane.org/handbook

19.

Hovelius

Olofsson

Sandström

, et al. Nonoperative treatment of primary anterior shoulder dislocation in patients forty years of age and younger. a prospective twenty-five-year follow-up. J Bone Joint Surg Am. 2008;90(5):945-952. doi:10.2106/JBJS.G.00070

20.

Hovelius

Saeboe

Neer Award 2008: arthropathy after primary anterior shoulder dislocation—223 shoulders prospectively followed up for twenty-five years. J Shoulder Elbow Surg. 2009;18(3):339-347. doi:10.1016/j.jse.2008.11.004

21.

Hong

Zhu

Yan

Arthroscopic Bankart repair versus conservative treatment for first-time traumatic anterior shoulder dislocation: a systematic review and meta-analysis. Eur J Med Res. 2023;28:260. doi:10.1186/s40001-023-01160-0

22.

Hurley

Davey

Montgomery

, et al. Arthroscopic Bankart repair versus open Latarjet for first-time dislocators in athletes. Orthop J Sports Med. 2021;9(8):23259671211023803. doi:10.1177/23259671211023803

23.

Hurley

Lim Fat

Farrington

Mullett

Open versus arthroscopic Latarjet procedure for anterior shoulder instability: a systematic review and meta-analysis. Am J Sports Med. 2019;47(5):1248-1253. doi:10.1177/0363546518759540

24.

Hurley

Manjunath

Bloom

, et al. Arthroscopic Bankart repair versus conservative management for first-time traumatic anterior shoulder instability: a systematic review and meta-analysis. Arthroscopy. 2020;36(9):2526-2532. doi:10.1016/j.arthro.2020.04.046

25.

Hurley

Matache

Wong

, et al; Anterior Shoulder Instability International Consensus Group. Anterior shoulder instability part I—diagnosis, nonoperative management, and Bankart repair—an international consensus statement. Arthroscopy. 2022;38(2):214-223. doi:10.1016/j.arthro.2021.07.022

26.

Kavaja

Lähdeoja

Malmivaara

Paavola

Treatment after traumatic shoulder dislocation: a systematic review with a network meta-analysis. Br J Sports Med. 2018;52(23):1498-1506. doi:10.1136/bjsports-2017-098539

27.

Kirkley

Griffin

McLintock

The development and evaluation of a disease-specific quality of life measurement tool for shoulder instability. Am J Sports Med. 1998;26(6):764-772.

28.

Kirkley

Werstine

Ratjek

Griffin

Prospective randomized clinical trial comparing the effectiveness of immediate arthroscopic stabilization versus immobilization and rehabilitation in first traumatic anterior dislocations of the shoulder: long-term evaluation. Arthroscopy. 2005;21(1):55-63. doi:10.1016/j.arthro.2004.09.018

29.

Kraeutler

Belk

Carver

McCarty

Khodaee

Traumatic primary anterior glenohumeral joint dislocation in sports: a systematic review of operative versus nonoperative management. Curr Sports Med Rep. 2020;19(11):468-478. doi:10.1249/JSR.0000000000000772

30.

Landis

Koch

GG.

The measurement of observer agreement for categorical data. Biometrics. 1977;33(1):159-174. doi:10.2307/2529310

31.

Larrain

Botto

Montenegro

Mauas

DM.

Arthroscopic repair of acute traumatic anterior shoulder dislocation in young athletes. Arthroscopy. 2001;17(4):373-377. doi:10.1053/jars.2001.23226

32.

Leroux

Wasserstein

Veillette

, et al. Epidemiology of primary anterior shoulder dislocation requiring closed reduction in Ontario, Canada. Am J Sports Med. 2014;42(2):442-450. doi:10.1177/0363546513510391

33.

Longo

van der Linde

Loppini

Coco

Poolman

Denaro

Surgical versus nonoperative treatment in patients up to 18 years old with traumatic shoulder instability: a systematic review and quantitative synthesis of the literature. Arthroscopy. 2016;32(5):944-952. doi:10.1016/j.arthro.2015.10.020

34.

Marshall

Vega

Siqueira

Cagle

Gelber

Saluan

Outcomes after arthroscopic Bankart repair: patients with first-time versus recurrent dislocations. Am J Sports Med. 2017;45(8):1776-1782. doi:10.1177/0363546517698692

35.

Minkus

Königshausen

Pauly

, et al. Immobilization in external rotation and abduction versus arthroscopic stabilization after first-time anterior shoulder dislocation: a multicenter randomized controlled trial. Am J Sports Med. 2021;49(4):857-865. doi:10.1177/0363546520987823

36.

Moher

Liberati

Tetzlaff

Altman

; PRISMA Group. Preferred Reporting Items for Systematic reviews and Meta-Analyses: the PRISMA statement. PLoS Med. 2009;6(7):e1000097. doi:10.1371/journal.pmed.1000097

37.

Nazzal

Herman

Engler

Dalton

Freehill

Lin

First-time traumatic anterior shoulder dislocation: current concepts. J ISAKOS. 2023;8(2):101-107. doi:10.1016/j.jisako.2023.01.002

38.

Olds

Ellis

Donaldson

Parmar

Kersten

Risk factors which predispose first-time traumatic anterior shoulder dislocations to recurrent instability in adults: a systematic review and meta-analysis. Br J Sports Med. 2015;49(14):913-922. doi:10.1136/bjsports-2014-094342

39.

Owens

DeBerardino

Nelson

, et al. Long-term follow-up of acute arthroscopic Bankart repair for initial anterior shoulder dislocations in young athletes. Am J Sports Med. 2009;37(4):669-673. doi:10.1177/0363546508328416

40.

Park

Lee

Hyun

Lee

Shin

SJ.

Minimal clinically important differences in Rowe and Western Ontario Shoulder Instability Index scores after arthroscopic repair of anterior shoulder instability. J Shoulder Elbow Surg. 2018;27(4):579-584. doi:10.1016/j.jse.2017.10.032

41.

Pougès

Hardy

Vervoort

, et al. Arthroscopic Bankart repair versus immobilization for first episode of anterior shoulder dislocation before the age of 25: a randomized controlled trial. Am J Sports Med. 2021;49(5):1166-1174. doi:10.1177/0363546521996381

42.

Rowe

Patel

Southmayd

WW.

The Bankart procedure: a long-term end-result study. J Bone Joint Surg Am. 1978;60(1):1-16.

43.

Saxena

D’Aquilla

Marcoon

, et al. T1ρ magnetic resonance imaging to assess cartilage damage after primary shoulder dislocation. Am J Sports Med. 2016;44(11):2800-2806. doi:10.1177/0363546516655338

44.

Shih

Hung

Shih

Lee

YJ.

Comparison of arthroscopic treatment with conservative treatment for acute first-time traumatic anterior shoulder dislocation in a high-demand population. Formos J Musculoskelet Disord. 2011;2(1):16-19. doi:10.1016/j.fjmd.2010.12.010

45.

Slim

Nini

Forestier

Kwiatkowski

Panis

Chipponi

Methodological index for non-randomized studies (MINORS): development and validation of a new instrument. ANZ J Surg. 2003;73(9):712-716. doi:10.1046/j.1445-2197.2003.02748.x

46.

Souleiman

Zderic

Pastor

, et al. Cartilage decisively shapes the glenoid concavity and contributes significantly to shoulder stability. Knee Surg Sports Traumatol Arthrosc. 2022;30(11):3626-3633. doi:10.1007/s00167-022-06968-7

47.

Tokish

Kuhn

Ayers

, et al. Decision making in treatment after a first-time anterior glenohumeral dislocation: a Delphi approach by the Neer Circle of the American Shoulder and Elbow Surgeons. J Shoulder Elbow Surg. 2020;29(12):2429-2445. doi:10.1016/j.jse.2020.08.011

48.

Tokish

Thigpen

Kissenberth

, et al. The Nonoperative Instability Severity Index Score (NISIS): a simple tool to guide operative versus nonoperative treatment of the unstable shoulder. Sports Health. 2020;12(6):598-602. doi:10.1177/1941738120925738

49.

Trojan

Meyer

Edgar

Brown

Mulcahey

MK.

Epidemiology of shoulder instability injuries in collision collegiate sports from 2009 to 2014. Arthroscopy. 2020;36(1):36-43. doi:10.1016/j.arthro.2019.07.008

50.

van Spanning

Verweij

LPE

Priester-Vink

van Deurzen

DFP

van den Bekerom

MPJ

. Operative versus nonoperative treatment following first-time anterior shoulder dislocation: a systematic review and meta-analysis. JBJS Rev. 2021;9(9):e20.00232. doi:10.2106/JBJS.RVW.20.00232

51.

Walsh

Srinathan

McAuley

, et al. The statistical significance of randomized controlled trial results is frequently fragile: a case for a fragility index. J Clin Epidemiol. 2014;67(6):622-628. doi:10.1016/j.jclinepi.2013.10.019

52.

Wan

Wang

Liu

Tong

Estimating the sample mean and standard deviation from the sample size, median, range and/or interquartile range. BMC Med Res Methodol. 2014;14:135. doi:10.1186/1471-2288-14-135

53.

Wasserstein

Sheth

Colbenson

, et al. The true recurrence rate and factors predicting recurrent instability after nonsurgical management of traumatic primary anterior shoulder dislocation: a systematic review. Arthroscopy. 2016;32:2616-2625. doi:10.1016/j.arthro.2016.05.039

54.

Wright

. Levels of Evidence and Grades of Recommendations: An Evaluation of Literature. AAOS Bulletin; 2005. Accessed February 1, 2024. https://www.researchgate.net/publication/238721645

55.

Yanmis

Tunay

Kömürcü

Yildiz

Tunay

Gür

Outcomes of acute arthroscopic repair and conservative treatment following first traumatic dislocation of the shoulder joint in young patients. Ann Acad Med Singapore. 2003;32(6):824-827.

56.

Yapp

Nicholson

Robinson

CM.

Primary arthroscopic stabilization for a first-time anterior dislocation of the shoulder: long-term follow-up of a randomized, double-blinded trial. J Bone Joint Surg Am. 2020;102(6):460-467. doi:10.2106/JBJS.19.00858

57.

Yoshida

Takenaga

Chan

Musahl

Debski

Lin

Location and magnitude of capsular injuries varies following multiple anterior dislocations of the shoulder: implications for surgical repair. J Orthop Res. 2021;39(3):648-656. doi:10.1002/jor.24860

58.

Zacchilli

Owens

BD.

Epidemiology of shoulder dislocations presenting to emergency departments in the United States. J Bone Joint Surg Am. 2010;92(3):542-549. doi:10.2106/JBJS.I.00450