Intervention Review

Surgical interventions for anterior shoulder instability in adults

  1. Ramnadh S Pulavarti1,*,
  2. Tom H Symes2,
  3. Amar Rangan2

Editorial Group: Cochrane Bone, Joint and Muscle Trauma Group

Published Online: 7 OCT 2009

Assessed as up-to-date: 25 JUN 2008

DOI: 10.1002/14651858.CD005077.pub2


How to Cite

Pulavarti RS, Symes TH, Rangan A. Surgical interventions for anterior shoulder instability in adults. Cochrane Database of Systematic Reviews 2009, Issue 4. Art. No.: CD005077. DOI: 10.1002/14651858.CD005077.pub2.

Author Information

  1. 1

    Lancashire Teaching Hospitals NHS Foundation Trust, Department of Orthopaedics and Traumatology, Preston, Lancashire, UK

  2. 2

    The James Cook University Hospital, Trauma & Orthopaedic Department, Middlesbrough, Cleveland, UK

*Ramnadh S Pulavarti, Department of Orthopaedics and Traumatology, Lancashire Teaching Hospitals NHS Foundation Trust, Sharoe Green Lane, Preston, Lancashire, PR2 9HT, UK. rspulavarti@yahoo.co.uk. ajayteja@doctors.org.uk.

Publication History

  1. Publication Status: New
  2. Published Online: 7 OCT 2009

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Abstract

  1. Top of page
  2. Abstract
  3. Plain language summary
  4. 摘要

Background

The shoulder is the most common joint to develop recurrent instability. Repair of labral tears of the joint and reconstruction of damaged capsule and torn ligaments either by open or arthroscopic methods remain the cornerstone of current management.

Objectives

To compare the effectiveness of various surgical interventions performed to treat recurrent anterior instability of the shoulder in adults.

Search methods

We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (December 2007), the Cochrane Central Register of Controlled Trials (The Cochrane Library 2008, Issue 1), MEDLINE (1950 to March 2008), EMBASE and other databases. We searched conference proceedings and the reference lists of papers.

Selection criteria

Randomised or quasi-randomised controlled trials comparing different surgical interventions for treating anterior shoulder instability in adults.

Data collection and analysis

The authors independently selected trials, assessed methodological quality and extracted data. Only limited pooling was done.

Main results

Included are three randomised controlled trials involving 184 people (predominantly active young men) with unidirectional anterior shoulder instability generally following a traumatic event. All three trials compared arthroscopic versus open surgery, generally involving the repair of Bankart lesions. The three trials were inadequately reported but appeared well-conducted with minimum follow-ups of two years.

Pooled results showed no statistically significant difference between the two groups in recurrent instability or re-injury (7/92 versus 5/85, risk ratio (RR) 0.89, 95% confidence interval (CI) 0.09 to 8.72; random-effects model), in subsequent instability-related surgery (RR 0.66, 95% CI 0.05 to 8.97; random-effects model) or surgery for all reasons (RR 0.55, 95% CI 0.04 to 7.18; random-effects model). For other outcomes, including shoulder function, there were either no statistically significant differences between the two groups or the differences were clinically insignificant where statistically significant differences occurred.

Authors' conclusions

There is insufficient evidence from randomised trials comparing arthroscopic with open surgery for treating anterior shoulder instability. Further research is needed on this subject and for other surgical interventions. Sufficiently powered, good quality, well reported randomised controlled trials with validated outcome measures and long-term follow up are required.

 

Plain language summary

  1. Top of page
  2. Abstract
  3. Plain language summary
  4. 摘要

Surgical interventions for the treatment of anterior shoulder instability

Shoulder instability represents a spectrum from micro-instability through subluxation (partial dislocation) to frank dislocation and may occur as a result of different underlying pathologies. Anterior shoulder instability occurs when the humeral head moves out of its shallow joint socket in forward direction, usually following an injury such as a fall on the outstretched hand. Dislocation occurs when the head of the humerus moves completely out of the socket. As it does so, various ligaments around the joint may be torn and the bone of the humeral head or of the socket may be damaged. Recurrent episodes of dislocation are common unless complete healing of the damaged structures occurs. A 'Bankart lesion' is a type of tear involving the lining of the socket part of the shoulder joint. Such a tear predisposes the shoulder dislocate easily and in a recurrent manner. If recurrent episodes are troublesome, surgical repair using an open or minimally invasive (keyhole) technique may be advised and this principally involves the repair of 'Bankart lesion'.

This systematic review compared different techniques of surgical repair for anterior shoulder instability. Only three randomised controlled trials, involving a total of 184 people with anterior shoulder instability that usually followed a traumatic event, are included in the review. All three trials compared arthroscopic (key hole) surgery with open surgery, generally involving the repair of Bankart lesions. All three trials were inadequately reported but appeared well-conducted with minimum follow-ups of two years.

The limited data available showed no statistically significant differences between the two groups in recurrent instability or re-injury, in subsequent instability-related surgery or surgery for all reasons. Data for other outcomes, including shoulder function, also showed no significance differences between the two groups. In all the available evidence was insufficient to draw conclusions and further well designed randomised controlled trials are required.

 

摘要

  1. Top of page
  2. Abstract
  3. Plain language summary
  4. 摘要

背景

成人肩關節向前不穩定的外科處置

肩部是最常發生反覆性不穩定的關節。無論是利用開放性手術或關節鏡手術修補肩盂唇裂傷以及重建受損的關節囊和拉傷的的韌帶仍然是當前最主要的處置。

目標

比較各種成人肩關節向前不穩定的外科處置的效果。

搜尋策略

我們搜尋的資料庫包括了the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (December 2007), the Cochrane Central Register of Controlled Trials (The Cochrane Library 2008, Issue 1), MEDLINE (1950 to March 2008), EMBASE 以及其他的資料庫。我們搜尋了研討會論文以及列在其中的參考資料。

選擇標準

比較各種成人肩關節向前不穩定的外科處置的隨機或半隨機對照試驗

資料收集與分析

作者分別選擇試驗,評估方法學的品質並擷取數據。其中只有有限的資料能匯整。

主要結論

共有三個隨機對照試驗被納入,總共184人(絕大部分為活動力強的年輕男性)在外傷後有單一方向的肩關節向前不穩定。三個試驗皆比較關節鏡手術和開放性手術,主要是針對修補Bankart氏病灶。這三個試驗皆不是當地被報告出來,但似乎都起碼有二年良好的追蹤。資料聚集後二組之間在反覆性不穩定或是再受傷上 (7/92 對 5/85, risk ratio (RR) 0.89, 95% confidence interval (CI) 0.09 to 8.72; randomeffects model)、在後續與不穩定相關的手術上 (RR 0.66, 95% CI 0.05 to 8.97; randomeffects model) 、或在任何原因的手術上 (RR 0.55, 95% CI 0.04 to 7.18; randomeffects model) 皆沒有達到統計上的顯著差異。在其他的結果上,包括肩關節的功能,這二組也都沒有達到統計上的顯著差異,抑或雖然有統計上的顯著差異但在臨床上並無意義。

作者結論

從隨機試驗中並沒有足夠的實證據可以比較開放性手術或關節鏡手術在治療肩關節向前不穩定的效果。需要更進一步的研究不管是在這個議題上或是針對其他的外科處置。此外,也需要有足夠考驗力、良好的品質、良好的報告的隨機化控制試驗且有經過驗證的測量結果的方法和長期的追蹤。

翻譯人

本摘要由臺灣大學附設醫院黃全敬翻譯。

此翻譯計畫由臺灣國家衛生研究院 (National Health Research Institutes, Taiwan) 統籌。

總結

成人肩關節向前不穩定的外科處置:肩關節不穩定可以從部分脫位到完全脫位,而且可以是各種不同病理學的結果。當肱骨頭肩從淺淺的關節臼中向前位移即為肩關節向前脫位,而這通常是由於在手張開的狀態下跌倒所致。當肱骨頭從關節臼中完全脫離即為脫位。當這樣的情況發生時,許多關節周圍的韌帶會被拉傷,肱骨頭及關節臼的骨頭也會受損。反覆性脫位是很常見的除非受損的組織完全復原。 ‘Bankart氏病灶’ 是涉及肩關節臼周圍的一種拉傷。這樣的拉傷讓肩關節很容易脫位,並且反覆發生。如果反覆脫位令人困擾,不論是開放性或微創 (keyhole) 修補手術都是建議的,而這主要是修補 ‘Bankart氏病灶’ 。這篇回顧比較了肩關節向前不穩定的外科處置。共有三個隨機化控制試驗被納入,總共184人,在外傷後有單一方向的肩關節向前不穩定。這三個研究皆比較開放性手術和關節鏡手術,主要是修補 ‘Bankart氏病灶’ 。這三個研究皆不是當地被報告出來,但似乎都起碼有二年良好的追蹤。有限的資料對二組之間在反覆性不穩定或是再受傷上、在後續與不穩定相關的手術上、或在任何原因的手術上皆沒有達到統計上的顯著差異。在其他的結果上,包括肩關節的功能,這二組也都沒有達到統計上的顯著差異。從所有可得的證據上並無法得到結論,需要更進一步經過良好設計的隨機對照試驗。