Cost-Effectiveness Analysis of Primary Arthroscopic Stabilization Versus Nonoperative Treatment for First-Time Anterior Glenohumeral Dislocations

BESS/BOA Patient Care Pathways

“…Cost effectiveness analysis 69 showed cost saving and reduced recurrence with primary surgery for 15-yearold males and females and 25-year-old males compared to non-operative management. Primary surgery was not only more effective, but also more costly for 25-year-old females and 35-year-old males and females Expected-value decision analysis 70 , a tool evaluating patients' expectations for different disease states, was performed on arthroscopic repair versus non-operative management.…”

Interest of emergency arthroscopic stabilization in primary shoulder dislocation in young athletes

“…By 15 years after primary dislocation, surgery proved more effective and less costly than the non-operative option in a 15-year-old patient (male or female) and in a 25-year-old male; in a 25-year-old female and 35-year-olds of either gender, surgery was equally effective but more costly [57]. Invasiveness and possible iatrogenicity are arguments put forward by detractors of surgery; however, as in previous reports [27][28][29][30][31]33,34,58], the present series showed no major complications.…”

Management of the unstable shoulder

“…By contrast, a significantly lower rate of recurrence (3% v 54%) was found in a randomised trial of 76 young active patients undergoing surgery for a first time dislocation 27. Primary surgical repair has also been recognised to be more cost effective 28 29Clinical assessment and management of an acute shoulder dislocation

Clinical assessment

Look

Anterior dislocation—arm is typically held in abduction and slight internal rotation

Posterior dislocation—there is usually a posterior shoulder prominence with the arm held in internal rotation and against the chest wall (“the sling position”)

Loss of normal contour of the shoulder

Acromion may be palpable posteriorly and laterally

Feel

The humeral head may be palpable anteriorly or posteriorly

Move

Range of movement will be limited, so patients should be assessed with care

Vascular examination

Examine hands for temperature and pallor

Capillary refill time should be less than two seconds

Radial and ulnar pulses—these can be normal even when there is an arterial injury, because of the rich collateral circulation present in the arm

Neurological examination

Axillary nerve is most commonly affected, given its intimate relation to the shoulder joint

The prognosis of a brachial plexus injury after a shoulder dislocation is usually good, with most patients recovering completely31

Investigation

Radiographs are essential before reduction to look for concomitant fractures of the humerus and glenoid cavity and to confirm the direction of dislocation.

…”