Treatment Outcomes of Simple Elbow Dislocations: A Systematic Review of 1,081 Cases.

BACKGROUND: The treatment of simple elbow dislocations (SEDs) has become more functional last decade with a tendency to shorter immobilization of the elbow, whereas simultaneously, surgical stabilization has been promoted by some authors. The primary aim of this study was to systematically review the literature and analyze the outcomes and complications of different treatment options for acute and persistent SEDs, including operative and nonoperative treatments with varying immobilization periods. METHODS: A literature search was performed based on the online medical databases MEDLINE, Embase, and the Cochrane databases. Articles presenting patients with a SED were eligible for inclusion. When an SED persists for >3 weeks, it is categorized as persistent. Various outcome measures were assessed, including the range of motion (ROM), patient-reported outcome measures, and complication rates. To get insight into the severity of complications, all complications were categorized as minor or major. The Methodological Index for Nonrandomized Studies was used to assess the methodological quality of nonrandomized studies. The risk of bias in the randomized studies was assessed with the Cochrane risk-of-bias tool. RESULTS: A total of 37 articles were included with 1,081 dislocated elbows (1,078 patients). A fair quality of evidence was seen for the nonrandomized studies and a low risk of bias for the randomized study. Nonoperative treatment was administered to 710 elbows, with 244 elbows treated with early mobilization, 239 with 1- to 3-week immobilization, and 163 with ≥3-week immobilization. These groups showed a ROM flexion-extension arc (ROM F/E) of 137, 129, and 131°, respectively. Surgical treatment as open reduction and ligament repair or reconstruction was performed in 228 elbows and showed a ROM F/E of 128°. All persistent SEDs were treated surgically and showed a ROM F/E of 90°. CONCLUSION: The early mobilization treatment showed the most consistent satisfactory outcomes in the literature compared with the other treatment options. Nevertheless, there remains ambiguity regarding which patients would benefit more from surgery than nonoperative treatment. LEVEL OF EVIDENCE: Level IV. See Instructions for Authors for a complete description of levels of evidence.

Changes in Scapular Function, Shoulder Strength, and Range of Motion Occur After Latarjet Procedure.

Purpose: To evaluate the current literature on the effects of anatomic changes caused by the Latarjet procedure and to identify areas for future research. Methods: English-language studies that addressed the consequences of anatomic alterations after the open Latarjet procedure were included. Articles written in languages other than English, reviews, and case reports were excluded. Titles and abstracts were screened by 2 authors. Studies that met the inclusion criteria were screened by the same authors. The following data were extracted from the included studies: authors, year of publication, journal, country of origin, aims or purpose, study population and sample size, methods, procedure, intervention type, and key findings that relate to the scoping review questions. Results: Twenty-two studies were included for analysis, yielding the following findings: First, the Latarjet procedure may change the position of the scapula owing to pectoralis minor tenotomy and/or transfer of the conjoint tendon. Second, dissection of the coracoacromial ligament may result in increased superior translation of the humeral head. The impact of this increased translation on patients' function remains unclear. Third, the subscapularis split shows, overall, better internal rotation strength compared with subscapularis tenotomy. Fourth, passive external rotation may be limited after capsular repair. Fifth, despite the movement of the conjoint tendon, elbow function seems unchanged. Finally, the musculocutaneous nerve is lengthened with a changed penetration angle into the coracobrachialis muscle, but the clinical impact seems limited. Conclusions: The Latarjet procedure leads to anatomic and biomechanical changes in the shoulder. Areas of future research may include better documentation of scapular movement (bilateral, as well as preoperative and postoperative) and elbow function, the effect of (degenerative) rotator cuff ruptures after the Latarjet procedure on shoulder function, and the impact of capsular closure and its contribution to the development of glenohumeral osteoarthritis. Clinical Relevance: This comprehensive overview of anatomic changes after the Latarjet procedure, with its effects on shoulder and elbow function, showed gaps in the current literature. Orthopaedic shoulder surgeons and physical therapists could use our findings when providing patient information and performing future clinical research.

Prescribing Cascades with Recommendations to Prevent or Reverse Them: A Systematic Review.

BACKGROUND: To reduce prescribing cascades occurring in clinical practice, healthcare providers require information on the prescribing cascades they can recognize and prevent. OBJECTIVE: This systematic review aims to provide an overview of prescribing cascades, including dose-dependency information and recommendations that healthcare providers can use to prevent or reverse them. METHODS: The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) was followed. Relevant literature was identified through searches in OVID MEDLINE, OVID Embase, OVID CINAHL, and Cochrane. Additionally, Web of Science and Scopus were consulted to analyze reference lists and citations. Publications in English were included if they analyzed the occurrence of prescribing cascades. Prescribing cascades were included if at least one study demonstrated a significant association and were excluded when the adverse drug reaction could not be confirmed in the Summary of Product Characteristics. Two reviewers independently extracted and grouped similar prescribing cascades. Descriptive summaries were provided regarding dose-dependency analyses and recommendations to prevent or reverse these prescribing cascades. RESULTS: A total of 95 publications were included, resulting in 115 prescribing cascades with confirmed adverse drug reactions for which at least one significant association was found. For 52 of these prescribing cascades, information regarding dose dependency or recommendations to prevent or reverse prescribing cascades was found. Dose dependency was analyzed and confirmed for 12 prescribing cascades. For example, antipsychotics that may cause extrapyramidal syndrome followed by anti-parkinson drugs. Recommendations focused on dosage lowering, discontinuing medication, and medication switching. Explicit recommendations regarding alternative options were given for three prescribing cascades. One example was switching to ondansetron or granisetron when extrapyramidal syndrome is experienced using metoclopramide. CONCLUSIONS: In total, 115 prescribing cascades were identified and an overview of 52 of them was generated for which recommendations to prevent or reverse them were provided. Nonetheless, information regarding alternative options for managing prescribing cascades was scarce.

Why do patients with anterior shoulder instability not return to sport after surgery? A systematic review of 63 studies comprising 3545 patients.

Purpose: To review athletes' reasons not to return to sport (RTS) after surgical treatment of anterior shoulder instability, comparing capsulolabral repair and bony reconstruction procedures. The hypothesis is that the most common reason for patients unable to RTS is not due to physical inability of the shoulder. Methods: A systematic review was performed using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analysis) guidelines. PubMed, Embase/Ovid, Cochrane Database of Systematic Reviews/Wiley, Cochrane Central Register of Controlled Trials/Wiley, SPORTDiscus/Ebsco, and Web of Science/Clarivate Analytics were searched in collaboration with an information specialist up to August 11, 2022. Observational and interventional studies reporting reasons for no RTS following surgical treatment of anterior shoulder instability were included. Quality assessment of studies was conducted using the Methodological Index for Non-Randomized Studies (MINORS) criteria and Risk of Bias (RoB) assessment. Forest plots were generated to show an overview of the proportion shoulder function independent reasons for each study. Results: Sixty-three studies were included reporting on 3545 athletes, of which 2588 (73%) underwent capsulolabral repair versus 957 (27%) who underwent surgical treatment with bony reconstruction procedures. A total of 650 athletes (18%) were unable to RTS. The reason not to RTS was most frequently shoulder function independent (70%) compared to shoulder function dependent (30%) following both capsulolabral repair and bony reconstruction procedures. Most cited reasons for no RTS after capsulolabral repair were fear of reinjury (17%), personal reasons or change of priorities (11%) and retirement/discharge of military service or sports team (10%). Of these reasons, 106 (22%) were not specified other than being shoulder function dependent or shoulder function independent. Most cited reasons for no RTS after bony reconstruction procedures were fear of reinjury (12%), shoulder pain (10%), and retirement/discharge of military service or sports team (9%). Of these reasons, 74 (44%) were not specified other than being shoulder function dependent or shoulder function independent. Forest plots showed a variation from 0% to 100% shoulder independent reasons for both capsulolabral repair and bony reconstruction procedures. Conclusion: The majority of athletes who did not RTS following surgical treatment for anterior shoulder instability did so due to shoulder function independent reasons, such as fear of reinjury. However, there was a high variety between studies and many reasons were unspecified, warranting unified definitions for reasons of patients that do not RTS.

Wide Range in Complication Rates Following Elbow Arthroscopy in Adult and Pediatric Patients: A Systematic Review.

PURPOSE: To perform a systematic review of complications associated with elbow arthroscopy in adults and children. METHODS: A literature search was performed in the PubMed, EMBASE, and Cochrane databases. Studies reporting complications or reoperations after elbow arthroscopy with at least 5 patients were included. Based on the Nelson classification, the severity of complications was categorized as minor or major. Risk of bias was assessed using the Cochrane risk-of-bias tool for randomized clinical trials, and nonrandomized trials were assessed using the Methodological Items for Non-randomized Studies (MINORS) tool. RESULT: A total of 114 articles were included with 18,892 arthroscopies (16,815 patients). A low risk of bias was seen for the randomized studies and a fair quality for the nonrandomized studies. Complication rates ranged from 0% to 71% (median 3%; 95% confidence interval [CI], 2.8%-3.3%), and reoperation rates from 0% to 59% (median 2%; 95% CI, 1.8%-2.2%). A total of 906 complications were observed, with transient nerve palsies (31%) as the most frequent complication. According to Nelson classification, 735 (81%) complications were minor and 171 (19%) major. Forty-nine studies reported complications in adults and 10 studies in children, showing a complication rate ranging from 0% to 27% (median 0%; 95% CI, 0%-0.4%) and 0% to 57% (median 1%; 95% CI, 0.4%-3.5%), respectively. A total of 125 complications were observed in adults, with transient nerve palsies (23%) as the most frequent complication, and 33 in children, with loose bodies after surgery (45%) as the most frequent complication. CONCLUSIONS: Predominantly low-level evidence studies demonstrate varying complication rates (median 3%, range 0%-71%) and reoperation rates (median 2%, range 0%-59%) after elbow arthroscopy. Higher complication rates are observed after more complex surgery. The incidence and type of complications can aid surgeons in patient counseling and refining surgical techniques to further reduce the complication rates. LEVEL OF EVIDENCE: Level IV; systematic review of Level I-IV studies.

Bony reconstruction after failed labral repair is associated with higher recurrence rates compared to primary bony reconstruction: a systematic review and meta-analysis of 1319 shoulders in studies with a minimum of 2-year follow-up.

BACKGROUND: There is uncertainty with regard to the optimal revision procedure after failed labral repair for anterior shoulder instability. An overview of outcomes of these procedures with quantitative analysis is not available in literature. The aim of this review is (1) to compare recurrence rates after revision labral repair (RLR) and revision bony reconstruction (RBR), both following failed labral repair. In addition, (2) recurrence rates after RBR following failed labral repair and primary bony reconstruction (PBR) are compared to determine if a previous failed labral repair influences the outcomes of the bony reconstruction. METHODS: Randomized controlled trials and cohort studies with a minimum follow-up of 2 years and reporting recurrence rates of (1) RBR following failed labral repair and PBR and/or (2) RLR following failed labral repair and RBR following failed labral repair were identified by searching PubMed, Embase/Ovid, Cochrane Database of Systematic Reviews/Wiley, Cochrane Central Register of Controlled Trials/Wiley, and Web of Science/Clarivate Analytics. RESULTS: Thirteen studies met the inclusion criteria and comprised 1319 shoulders. Meta-analyses showed that RBR has a significantly higher recurrence rate than PBR (risk ratio [RR] 0.51, P < .008) but found no significant difference in the recurrence rates for RLR and RBR (RR 1.40, P < .49). Also, no significant differences were found between PBR and RBR in return to sport (RR 1.07, P < .41), revision surgery (RR 0.8, P < .44), and complications (RR 0.84, P < .53). Lastly, no significant differences between RLR and RBR for revision surgery (RR 3.33, P < .19) were found. CONCLUSION: The findings of this meta-analyses show that (1) RBR does not demonstrate a significant difference in recurrence rates compared with RLR and that (2) RBR has a significantly higher recurrence rate than PBR.

Recurrence in traumatic anterior shoulder dislocations increases the prevalence of Hill-Sachs and Bankart lesions: a systematic review and meta-analysis.

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.

Age, participation in competitive sports, bony lesions, ALPSA lesions, > 1 preoperative dislocations, surgical delay and ISIS score > 3 are risk factors for recurrence following arthroscopic Bankart repair: a systematic review and meta-analysis of 4584 shoulders.

PURPOSE: Determining the risk of recurrent instability following an arthroscopic Bankart repair can be challenging, as numerous risk factors have been identified that might predispose recurrent instability. However, an overview with quantitative analysis of all available risk factors is lacking. Therefore, the aim of this systematic review is to identify risk factors that are associated with recurrence following an arthroscopic Bankart repair. METHODS: Relevant studies were identified by searching PubMed, Embase/Ovid, Cochrane Database of Systematic Reviews/Wiley, Cochrane Central Register of Controlled Trials/Wiley, CINAHL/Ebsco, and Web of Science/Clarivate Analytics from inception up to November 12th 2020. Studies evaluating risk factors for recurrence following an arthroscopic Bankart repair with a minimal follow-up of 2 years were included. RESULTS: Twenty-nine studies met the inclusion criteria and comprised a total of 4582 shoulders (4578 patients). Meta-analyses were feasible for 22 risk factors and demonstrated that age ≤ 20 years (RR = 2.02; P < 0.00001), age ≤ 30 years (RR = 2.62; P = 0.005), participation in competitive sports (RR = 2.40; P = 0.02), Hill-Sachs lesion (RR = 1.77; P = 0.0005), off-track Hill-Sachs lesion (RR = 3.24; P = 0.002), glenoid bone loss (RR = 2.38; P = 0.0001), ALPSA lesion (RR = 1.90; P = 0.03), > 1 preoperative dislocations (RR = 2.02; P = 0.03), > 6 months surgical delay (RR = 2.86; P < 0.0001), ISIS > 3 (RR = 3.28; P = 0.0007) and ISIS > 6 (RR = 4.88; P < 0.00001) were risk factors for recurrence. Male gender, an affected dominant arm, hyperlaxity, participation in contact and/or overhead sports, glenoid fracture, SLAP lesion with/without repair, rotator cuff tear, > 5 preoperative dislocations and using ≤ 2 anchors could not be confirmed as risk factors. In addition, no difference was observed between the age groups ≤ 20 and 21-30 years. CONCLUSION: Meta-analyses demonstrated that age ≤ 20 years, age ≤ 30 years, participation in competitive sports, Hill-Sachs lesion, off-track Hill-Sachs lesion, glenoid bone loss, ALPSA lesion, > 1 preoperative dislocations, > 6 months surgical delay from first-time dislocation to surgery, ISIS > 3 and ISIS > 6 were risk factors for recurrence following an arthroscopic Bankart repair. These factors can assist clinicians in giving a proper advice regarding treatment. LEVEL OF EVIDENCE: Level IV.

Operative Versus Nonoperative Treatment Following First-Time Anterior Shoulder Dislocation: A Systematic Review and Meta-Analysis.

BACKGROUND: There is an ongoing debate about whether to perform operative or nonoperative treatment following a first-time anterior dislocation or wait for recurrence before operating. The aim of this systematic review is to compare recurrence rates following operative treatment following first-time anterior dislocation (OTFD) with recurrence rates following (1) nonoperative treatment (NTFD) or (2) operative treatment after recurrent anterior dislocation (OTRD). METHODS: A literature search was conducted by searching PubMed (Legacy), Embase/Ovid, Cochrane Database of Systematic Reviews/Wiley, Cochrane Central Register of Controlled Trials/Wiley, and Web of Science/Clarivate Analytics from 1990 to April 15, 2020, according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The revised tool to assess risk of bias in randomized trials (RoB 2) developed by Cochrane was used to determine bias in randomized controlled trials, and the methodological index for non-randomized studies (MINORS) was used to determine the methodological quality of non-randomized studies. The certainty of evidence was assessed with the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach using GRADEpro software. RESULTS: Of the 4,096 studies for which the titles were screened, 9 comparing OTFD and NTFD in a total of 533 patients and 6 comparing OTFD and OTRD in a total of 961 patients were included. There is high-quality evidence that OTFD is associated with a lower rate of recurrence (10%) at >10 years of follow-up compared with NTFD (55%) (p < 0.0001). There is very low-quality evidence that patients receiving OTFD had a lower recurrence rate (11%) compared with those receiving OTRD (17%) (p < 0.0001). CONCLUSIONS: There is high-quality evidence showing a lower recurrence rate at >10 years following OTFD compared with NTFD (or sham surgery) in young patients. There is evidence that OTFD is more effective than OTRD, but that evidence is of very low quality. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.