Understanding and addressing discrepancies in the management of first-time shoulder dislocations: a multifaceted approach

Abstract

This thesis addresses the ongoing debate on the optimal management of first-time shoulder dislocations (FTSDs), focusing on the choice between surgical and non-surgical care. Despite the prevalence of FTSDs, there is no consensus on the best approach, as treatment strategies vary widely based on clinical evidence, healthcare provider preferences, and patient-specific factors. This research advances knowledge by systematically reviewing existing evidence, analyzing professional perspectives, and proposing a trial to directly compare management strategies. Chapter 2 presents a systematic review and meta-analysis showing that early arthroscopic Bankart repair (ABR) reduces recurrent instability and revision surgeries and improves patient-reported outcomes compared to non-operative management. However, the review also highlights that clinicians should ultimately consider factors such as age, athletic involvement, and functional goals to inform treatment decisions. Chapter 3 explores physiotherapists’ perceptions of FTSD management through a cross-sectional survey. Despite working predominantly with athletic populations, most physiotherapists reported that FTSD patients typically pursue initial conservative management over surgery. This preference contrasts with evidence suggesting the benefit of surgical intervention for athletes, possibly due to demographic factors, healthcare system differences, and patient preferences. Chapter 4 is also a cross-sectional survey, now focusing on sport physicians’ perspectives, revealing that while many follow guideline-based management, a significant number, especially older practitioners, still rely on personal experience rather than standardized protocols. Although most respondents expressed confidence in evidence supporting surgical stabilization for FTSDs, they noted inconsistencies in rehabilitation guidelines, indicating room for improvement in non- operative care practices. Chapter 5 presents the REDUCE pilot trial protocol to compare surgical and conservative care, incorporating both randomized and non-randomized cohorts to balance high-quality evidence with real-world relevance. By integrating evidence synthesis, professional insights, and trial planning, this thesis contributes to the understanding of FTSD management, advocating for evidence-based, patient-centered practices to address clinical inconsistencies.