[논문]Arthroscopic Repair versus Non-operative Treatment of First-time Traumatic Anterior Shoulder Dislocations: A Numbers-needed-to-treat Analysis for Prevention of Recurrent Dislocations

Park, Jihong; Cosby, Nicole L.

doi:10.5397/cise.2016.19.2.110

Arthroscopic Repair versus Non-operative Treatment of First-time Traumatic Anterior Shoulder Dislocations: A Numbers-needed-to-treat Analysis for Prevention of Recurrent Dislocations 원문보기

Clinics in shoulder and elbow, v.19 no.2, 2016년, pp.110 - 116

Park, Jihong (Athletic Training Laboratory, Department of Sports Medicine, Kyung Hee University) , Cosby, Nicole L. (Point Loma Nazarene University)

Abstract ▼ AI-Helper

Background: Arthroscopic surgical repair is a better intervention than non-operative (conservative) treatment for patients with shoulder dislocations. This systematic review determined the numbers-needed-to-treat (NNT) and relative risk reduction (RRR) associated with arthroscopic surgical repair versus non-operative treatment in reducing recurrence rates among patients with first-time traumatic anterior shoulder dislocations. Methods: We searched Google Scholar, MEDLINE, SPORTDiscus, and CINAHL from inception in 2015. All articles had to compare arthroscopic surgical repair and non-operative treatment and be written in English. We used the total number of subjects and the number of recurrent dislocations within each treatment to calculate the NNT and RRR for each study and the pooled data. Results: Six articles were selected and all clearly demonstrated that the arthroscopic surgical repair was more effective than non-operative treatment in reducing the recurrence episodes. The pooled NNT was 1.76 (95% confidence interval [CI]=NNT to benefit 1.50-2.13) and the pooled RRR was 86.0% (95% CI=77.0%-92.0%) among individuals who underwent arthroscopic repair. The average follow-up time was 56 months. Conclusions: A Strength of Recommendation Taxonomy level of evidence of 1 with a grade A recommendation supports the use of arthroscopic surgical repair over non-operative treatment in prevention of first-time traumatic anterior shoulder dislocations. We suggest that sports medicine practitioners consider the patients' age, occupation, and physical activity level when making a clinical decision.

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문제 정의

The purpose of this review was to evaluate the effectiveness of arthroscopic surgical treatment (Bankart repair) when compared to non-operative treatment at reducing recurrent anterior shoulder dislocation in patients with first-time traumatic anterior shoulder dislocations. Our search and calculations clearly demonstrated that reduction of recurrence rates in all studies was much higher in the arthroscopic surgical treatment than the non-operative treatment.

가설 설정

⁵⁾ Simply, the NNT is an inverse of the absolute risk reduction (ARR),⁶⁾ indicating the number of interventions in order to receive clinical benefit or risk.⁷⁾ The ideal NNT would be 1. This means that for every patient who received a specific intervention, one recurrent event would be prevented.

제안 방법

After applying selection criteria, a total of 1,554 articles were initially identified but 1,543 studies were excluded based on the exclusion criteria. More specifically, these articles included a comparison between different surgical techniques (e.g., open vs. arthroscopic), patients with shoulder dislocations rather than anterior direction (e.g., posterior instability), patients with multiple dislocations (e.g., not first-time), different outcome measures (e.g., cost effectiveness), only recorded outcome measures from the surgical treatment (e.g., absence of the control). Among the remaining 11 relevant studies,^12-22) five articles^18-22) were further excluded.
The studies selected in this systematic review used Bankart repair for the arthroscopic surgery. Open surgical techniques are also currently being used in treatment of first-time traumatic anterior shoulder dislocations.
Citations were also cross-referenced for identification of studies not found using the original search terms. We further limited the search by applying additional selection criteria: (1) full manuscripts written in English, (2) acute first-time traumatic anterior dislocations only, (3) an arthroscopic capsulolabral repair had to be compared with a non-operative treatment, and (4) an outcome measure of dislocation recurrence rates within the arthroscopic surgical repair and nonoperative treatments had to be included.

대상 데이터

After applying selection criteria, a total of 1,554 articles were initially identified but 1,543 studies were excluded based on the exclusion criteria. More specifically, these articles included a comparison between different surgical techniques (e.

데이터처리

The RRR is indicative of the ability of the arthroscopic treatment to reduce the risk of recurrent dislocation when compared to the non-operative treatment. Positive RRRs indicated reduced risk with arthroscopic treatment and negative values indicated increased risk associated with the arthroscopic treatment in comparison with the non-operative treatment; 95% CI and the point estimates for the NNT, ARR, and RRR were calculated using a statistical software program (Confidence Interval Analysis ver. 2.1; University of Southampton, Southampton, UK).

성능/효과

13), indicating that two arthroscopic surgical repairs would need to be performed in order to prevent one recurrent episode. The pooled RRR was 86.0% (95% CI=77.0% to 92.0%) indicating that the risk of a recurrent shoulder dislocation in a patient treated with arthroscopic surgical repair would be 87% lower compared to a patient treated non-operatively.
The result of the heterogeneity test was 66%, indicating that the level of patient heterogeneity in the pooled data was moderate.

후속연구

We evaluated the methods of previous RCTs and calculated NNT and RRR. The pooled results of this study would increase the strength of current evidence and be helpful in development of guidelines for clinical decision making.
This systematic review did not include any study with open surgical technique. Therefore, the results and analysis in this study can only be applicable to the arthroscopic Bankart repair, not the general surgical intervention.

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