Shoulder Stabilization Versus Immobilization for First-Time Anterior Shoulder Dislocation: A Systematic Review and Meta-analysis of Level 1 Randomized Controlled Trials

Background: Multiple studies have compared redislocation rates after stabilization and immobilization for patients experiencing a traumatic, first-time anterior shoulder dislocation (ASD). Purpose: To systematically review the literature to compare rates of recurrent instability and subsequent instability surgery in patients undergoing treatment for a first-time ASD with surgical stabilization versus shoulder immobilization. Study Design: Systematic review and meta-analysis; Level of evidence, 1. Methods: A systematic review was performed by searching PubMed, the Cochrane Library, and Embase to identify level 1 randomized studies that compared outcomes of surgical stabilization versus immobilization for treatment of primary ASD. The following search phrase was used: (glenohumeral OR anterior shoulder) AND (conservative OR nonoperative OR nonsurgical OR physiotherapy) AND (Bankart OR repair OR stabilization OR surgical OR surgery OR arthroscopic OR arthroscopy) AND (instability OR dislocation). Patients with soft tissue disruption alone as well as those with additional minor bony lesions (Hill-Sachs, Bankart) were included. Recurrent instability and subsequent instability surgery rates, the Western Ontario Shoulder Instability Index (WOSI), and range of motion were evaluated. Results: A total of 5 studies met inclusion criteria, including 126 patients undergoing surgical stabilization (mean age, 23.6 years; range, 15.0-39.0 years) and 133 patients undergoing treatment with sling immobilization only (mean age, 23.1 years; range, 15.0-31.0 years). Mean follow-up was 59.7 months. Overall, 6.3% of operative patients experienced recurrent instability at latest follow-up compared with 46.6% of nonoperative patients ( P < .00001). Similarly, 4.0% of operative patients underwent a subsequent instability surgery compared with 30.8% of nonoperative patients ( P < .00001). These same trends were demonstrated when data were isolated to nonoperative patients immobilized in internal rotation. When comparing the operative and nonoperative groups at latest follow-up, 1 study found significantly improved WOSI scores among operative patients ( P = .035) and 1 study found significantly improved abducted external rotation in nonoperative patients ( P = .02). Conclusion: Patients, particularly active men in their 20s and 30s, undergoing treatment for a first-time ASD with a surgical stabilization procedure can be expected to experience significantly lower rates of recurrent instability and a significantly decreased need for a future stabilization procedure when compared with patients treated nonoperatively.