Operative versus nonoperative treatment after primary traumatic anterior glenohumeral dislocation: expected-value decision analysis

Background: The optimal management strategy for primary traumatic anterior glenohumeral dislocation remains controversial. Patients have traditionally been managed nonoperatively, but high recurrence rates in certain populations have led to increased interest in early operative stabilization. The purpose of this study was to use expected-value decision analysis to determine the optimal management strategy--nonoperative treatment or arthroscopic stabilization--for a first-time traumatic anterior shoulder dislocation.

Materials and methods: Probabilities for the occurrences of the potential outcomes after nonoperative and arthroscopic treatment of a first-time traumatic anterior glenohumeral dislocation were determined from a systematic review of the literature. Utilities for these outcomes were obtained from a questionnaire on patient preferences completed by 42 subjects without a history of shoulder injury. A decision tree was constructed, fold-back analysis was performed to determine optimal management, and sensitivity analyses were used to determine the effect on decision making of varying outcome probabilities and utilities.

Results: Nonoperative treatment was associated with a utility value of 5.9 and early arthroscopic surgery with a value of 7.6. On sensitivity analysis, it was found that when the rate of recurrence after nonoperative treatment falls below 32% or when the utility value for successful arthroscopic stabilization falls below 6.6, nonoperative treatment is the preferred management strategy.

Conclusions: Arthroscopic stabilization was the preferred strategy after a primary anterior glenohumeral dislocation. In clinical settings where the likelihood of recurrent instability is low after nonoperative care or when an informed patient has an aversion to surgery, nonoperative treatment may be the preferred treatment strategy.