Nonoperative Treatment of Anterior Glenoid Rim Fractures After First-Time Traumatic Anterior Shoulder Dislocation

Abstract

Background: Primary traumatic anterior shoulder dislocations can be associated with displaced anterior glenoid rim fractures. Nonoperative treatment of such fractures has been shown to have excellent results in a small cohort of patients; as such, we have been treating these fractures nonoperatively, regardless of fragment size and degree of displacement, provided that post-reduction computed tomography scans revealed an anteroposteriorly centered humeral head. The aim of this study was to analyze the medium- to long-term results of nonoperative treatment of displaced anterior glenoid rim fractures, assessing in particular the residual instability and development of osteoarthritis. Methods: In a 2-center study, 30 patients with a mean age of 48 years (range, 29 to 67 years) were evaluated clinically with use of the Subjective Shoulder Value, Constant score, American Shoulder and Elbow Surgeons score, and Western Ontario Shoulder Instability index, as well as radiographically with use of radiographs and computed tomography scans at a mean follow-up of 9 years (range, 5 to 14 years). Results: Fracture-healing was documented in all patients. Seven patients (23%) had post-fracture onset of osteoarthritis (5 with Samilson grade I and 2 with Samilson grade IV). Of these, 1 patient had recurrent instability that was successfully treated with hemiarthroplasty 9 years after the index injury (relative Constant score, 101%), and was excluded from further analysis. No other patient had a recurrent redislocation, subluxation, or positive apprehension. The other 6 patients with new-onset radiographic osteoarthritis were pain-free (mean Constant score pain scale, 15 points) with good shoulder function (relative Constant score, 84% to 108%). A total of 26 patients (90%) rated their functional outcome as good or very good, and 3 patients (10%) rated it as fair. The mean relative Constant score was 97% (range, 61% to 108%), the mean American Shoulder and Elbow Surgeons score was 92 points (range, 56 to 100 points), and the mean Western Ontario Shoulder Instability index score was 126 points (range, 0 to 660 points). All patients returned to full-time work. Conclusions: Nonoperative treatment of anterior glenoid rim fractures following primary traumatic anterior shoulder dislocation results in excellent clinical outcomes with a very low rate of residual instability and, thus, treatment failure. Asymptomatic radiographic osteoarthritis occurred in roughly 1 of 4 patients. Level of Evidence: Therapeutic Level IV . See Instructions for Authors for a complete description of levels of evidence.

Instability and results after non-operative treatment of large anterior glenoid rim fractures: is there a correlation between fragment size or displacement and recurrence?

“…A further study confirmed those results in ten patients, and no recurrence or signs of clinical instability were reported [18]. Within these studies, no further complications or concomitant lesions were found [18,21,38]. Salomonsson et al reviewed 12 cases of GRF and found that bony bankart was a positive predictive factor for stability [30].…”

“…Thus, in our eyes, the age of the patient group has to be considered for interpretation of the data because of the well-known fact that younger individuals have a higher risk for recurrence [22,29,36]. This finding is confirmed by the fact that the patient series of the above-mentioned studies of non-operative treated GRF had a mean age of 53 years [21], 57 years [18] and 48 years with only one case of instability [38].…”

“…Within the existing studies of non-operative treated GRF, mild osteoarthritis was found in one study in three (of 14) patients with grade I-II Samilson/Prieto (after a mean of 5.6 years) [21], within another study after 2 years in one (of 10 cases) (grade I Samilson/Prieto) [18], and a further study reported seven (of 30 cases) with OA (grad I-IV Samilson/Prieto) [38]. OA was also reported within studies of operative treatment of GRF.…”

“…[13]. Maquieira et al published the first analysis of a patient group of non-operatively treated large GRF with measured displacement of the fragment in 14 patients and found excellent clinical results without reinstability [21], and another recently published trial (with 30 patients) detected excellent results with only one case of reinstability [38]. A further study confirmed those results in ten patients, and no recurrence or signs of clinical instability were reported [18].…”

“…Therapy for large GRF is still controversial within the literature. Most studies of large GRF address operative (open or arthroscopic) treatment [3,4,20,24,26,27,32,33], whereas two different study centers demonstrated good functional results after non-operative treatment with only one case of re-instability but without relevant clinical osteoarthritis (OA) [18,21,38]. However, clinical outcomes of non-operatively treated larger patient groups and the influence of size and dislocation of the fragment on recurrence after non-operative treatment has never been investigated.…”