title: The external rotation immobilisation does not reduce recurrence rates or improve quality of life after primary anterior shoulder dislocation: a systematic review and meta-analysis.
abstract: OBJECTIVE
  Conducting a systematic review and meta-analysis of prospective randomised controlled trials directly comparing (1) the rates of recurrence and (2) patient-based quality-of-life assessments after the external rotation (ER) or internal rotation (IR) immobilisation after primary anterior shoulder dislocation.
  
  
  METHODS
  PubMed, EMBASE, the Cochrane Library and ISI Web of Science were searched up to January 2013, using the Boolean operators as follows: (bankart lesion OR shoulder anterior dislocation) AND ((external rotation AND internal rotation) OR immobilisation). All prospective randomised controlled trials directly comparing recurrence rate and patient-based quality-of-life assessments between the ER and IR immobilisations were retrieved. No limitation of the language or publication year existed in our analysis.
  
  
  RESULTS
  Seven of 896 studies involving 663 patients were included, 338 in the ER group and 325 in the IR group. No significant difference was observed in the recurrence rate at all ages (risk ratio (RR)=0.65; 95% confidence interval, 0.41-1.03; p=0.067), at the age stratum of ≤30 years (RR=0.70; 95% confidence interval, 0.38-1.29; p=0.250) and >30 years (RR=0.86; 95% confidence interval, 0.38-1.97; p=0.722). Four trials adopted quality-of-life assessments, using the Constant-Murlay functional scoring system, the Rowe scoring system, the Western Ontario Shoulder Instability index (WOSI), the Disabilities of arm, shoulder and hand (DASH) and the American Shoulder and Elbow Surgeons evaluation form (ASES). Only one trial demonstrated borderline statistical significance (p=0.05) and probable superiority of the ER group based on the ASES. No significant difference was observed in other three trials.
  
  
  CONCLUSIONS
  Based on the results of our analysis, the ER immobilisation could not reduce the rates of recurrence after primary anterior shoulder dislocation or improve the quality of life compared with the IR immobilisation. More rigorous and adequately powered prospective randomised controlled trials with long-term follow-ups are required to elucidate a more objective outcome.
authors.affiliation: Department of Orthopaedic Surgery, Second Affiliated Hospital, School of Medicine, Zhejiang University, 310009 Hangzhou, People's Republic of China.
authors.forename: An
authors.initials: A
authors.lastname: Liu
authors.affiliation: Department of Orthopaedic Surgery, Second Affiliated Hospital, School of Medicine, Zhejiang University, 310009 Hangzhou, People's Republic of China.
authors.forename: Xinghe
authors.initials: X
authors.lastname: Xue
authors.affiliation: Department of Orthopaedic Surgery, Second Affiliated Hospital, School of Medicine, Zhejiang University, 310009 Hangzhou, People's Republic of China.
authors.forename: Yunlin
authors.initials: Y
authors.lastname: Chen
authors.affiliation: Department of Orthopaedic Surgery, Second Affiliated Hospital, School of Medicine, Zhejiang University, 310009 Hangzhou, People's Republic of China.
authors.forename: Fanggang
authors.initials: F
authors.lastname: Bi
authors.affiliation: Department of Orthopaedic Surgery, Second Affiliated Hospital, School of Medicine, Zhejiang University, 310009 Hangzhou, People's Republic of China. Electronic address: zrjwsj@zju.edu.cn.
authors.forename: Shigui
authors.initials: S
authors.lastname: Yan
mesh_terms: D006801:Humans; D007103:Immobilization; D007593:Joint Instability / Q000503:physiopathology / Q000628:therapy*; D019637:Orthopedic Procedures / Q000379:methods*; D011446:Prospective Studies; D011788:Quality of Life; D016032:Randomized Controlled Trials as Topic; D016059:Range of Motion, Articular; D012008:Recurrence; D012783:Shoulder Dislocation / Q000503:physiopathology / Q000628:therapy*; D013997:Time Factors; D016896:Treatment Outcome
keywords: External rotation; Immobilisation; Internal rotation; Primary anterior shoulder dislocation; Systematic review