The Journal of Bone and Joint Surgery (American). 2007;89:2124-2131.
doi:10.2106/JBJS.F.00654
© 2007 The Journal of Bone and Joint Surgery, Inc.
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Immobilization in External Rotation After Shoulder Dislocation Reduces the Risk of Recurrence

A Randomized Controlled Trial

Eiji Itoi, MD1, Yuji Hatakeyama, MD2, Takeshi Sato, MD3, Tadato Kido, MD4, Hiroshi Minagawa, MD5, Nobuyuki Yamamoto, MD5, Ikuko Wakabayashi, MD6 and Koji Nozaka, MD5

1 Department of Orthopaedic Surgery, Tohoku University School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai 980-8574, Japan
2 Department of Orthopaedic Surgery, Nakadori General Hospital, 3-15 Misonomachi, Minamidori, Akita 010-8577, Japan
3 Department of Orthopaedic Surgery, Yamamoto Kumiai General Hospital, Uemaeda, Ochiai, Noshiro 016-0014, Japan
4 Department of Orthopaedic Surgery, Akita Rosai Hospital, Shimotai 30, Karuizawa, Odate 018-5604, Japan
5 Department of Orthopaedic Surgery, Akita University School of Medicine, Hondo 1-1-1, Akita 010-8543, Japan
6 Department of Orthopaedic Surgery, Honjo Daiichi Hospital, 110 Iwabuchishita, Detomachi, Honjo 015-8567, Japan

Investigation performed at Akita University School of Medicine, Akita, Japan

Disclosure: In support of their research for or preparation of this work, one or more of the authors received, in any one year, outside funding or grants of less than $10,000 from Alcare, Tokyo, Japan. One or more of the authors, or a member of his or her immediate family, received, in any one year, payments or other benefits of less than $10,000 or a commitment or agreement to provide such benefits from a commercial entity (Alcare, Tokyo, Japan). No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated.

Background: An initial anterior dislocation of the shoulder becomes recurrent in 66% to 94% of young patients after immobilization of the shoulder in internal rotation. Magnetic resonance imaging and studies of cadavera have shown that coaptation of the Bankart lesion is better with the arm in external rotation than it is with the arm in internal rotation. Our aim was to determine the benefit of immobilization in external rotation in a randomized controlled trial.

Methods: One hundred and ninety-eight patients with an initial anterior dislocation of the shoulder were randomly assigned to be treated with immobilization in either internal rotation (ninety-four shoulders) or external rotation (104 shoulders) for three weeks. The primary outcome measure was a recurrent dislocation or subluxation. The minimum follow-up period was two years.

Results: The follow-up rate was seventy-four (79%) of ninety-four in the internal rotation group and eighty-five (82%) of 104 in the external rotation group. The compliance rate was thirty-nine (53%) of seventy-four in the internal rotation group and sixty-one (72%) of eighty-five in the external rotation group (p = 0.013). The intention-to-treat analysis revealed that the recurrence rate in the external rotation group (twenty-two of eighty-five; 26%) was significantly lower than that in the internal rotation group (thirty-one of seventy-four; 42%) (p = 0.033) with a relative risk reduction of 38.2%. In the subgroup of patients who were thirty years of age or younger, the relative risk reduction was 46.1%.

Conclusions: Immobilization in external rotation after an initial shoulder dislocation reduces the risk of recurrence compared with that associated with the conventional method of immobilization in internal rotation. This treatment method appears to be particularly beneficial for patients who are thirty years of age or younger.

Level of Evidence: Therapeutic Level II. See Instructions to Authors for a complete description of levels of evidence.


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Letters to the Editor:

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Results of Using A Shoulder External Rotation Brace For Primary Dislocation Of The Shoulder
Nakul Kain, et al.
JBJS Online, 16 Jun 2009 [Full text]
Dr. Itoi and colleagues respond to Dr. Kain and colleagues
Eiji Itoi, MD, PhD, et al.
JBJS Online, 24 Jun 2009 [Full text]