Summary

Surgical stabilization of anterior shoulder instability, including for first-time dislocations, leads to reduced recurrence in paediatric patients.

Abstract

Purpose

Anterior shoulder dislocations are a common injury among children and adolescents due to unique anatomical features of the developing shoulder and increased participation in high-risk sports. This systematic review and meta-analysis aimed to evaluate the risk of recurrent instability following operative versus non-operative management of anterior shoulder dislocations in paediatric patients. A subgroup analysis was performed to compare management strategies in the setting of a first-time dislocation.

Methods

A systematic review and meta-analysis was conducted using PubMed, Embase, Medline, and Cochrane databases to identify studies comparing arthroscopic or open Bankart repairs versus non-operative management of anterior shoulder instability. Search terms included pediatric, adolescent, shoulder, glenohumeral, dislocation, management, and recurrence. Abstract, title screening, and full text review was performed in tandem by two independent reviewers. Exclusion criteria were as follows: adult patients over the age of 18, multidirectional instability, bony Bankart injuries requiring fixation, posterior instability, and non-comparative studies. A meta-analysis was performed using a random effects model. Subgroup analysis was performed for first-time shoulder dislocations, and for arthroscopic Bankart repair versus non-operative management. Quality and reporting assessments were performed using the Methodological Index for Non-Randomized Studies (MINORS).

Results

Seven studies met the inclusion criteria with a total of 368 patients, 273 males and 95 females. The median age was 15.2 years ranging from 12-18 years of age. Mean follow up was 6.7 years (95%CI: 4.5-8.7). Protocols for non-operative management varied considerably between studies with length of immobilization ranging from one to four weeks. The average rate of recurrence in patients managed non-operatively was 0.67 (95% CI: 0.56-0.89) and 0.14 (95%CI: 0.00-0.32) in patients managed with either open or arthroscopic Bankart repair. There was a significant reduction in risk of recurrence with operative compared to non-operative management, with a risk ratio (RR) of 0.31 (95% CI: 0.22-0.44). A subgroup analysis of patients managed operatively (either open or arthroscopic) compared to non-operatively for a first-time shoulder dislocation resulted in a RR of recurrent instability of 0.33 (95%CI: 0.23-0.46). Arthroscopic Bankart repair had a RR of recurrent instability of 0.21 (95%CI: 0.08-0.55). MINORS scores ranged from 9-21, indicating a low to moderate overall risk of bias.

Conclusions

Surgical stabilization of anterior shoulder instability is an effective treatment strategy for paediatric patients under the age of 18, with significantly lower rates of recurrent instability than non-operative treatment. Furthermore, there is growing evidence to support the role for surgery after a first-time anterior shoulder dislocation in this high-risk patient population to reduce the risk of recurrence.