Written by Jason Lesnick
This meta-analysis found Boss-Holzach-Matter/Davos and FARES had the most favorable value for success rates, while both FARES and modified external rotation were more favorable in reduction times. FARES also had the most favorable score for pain during reduction.
Why does this matter?
Anterior shoulder dislocations are a commonly encountered pathology, and everyone seems to have their own preferred technique based mainly on personal experience. Evidence to help guide us as to the best techniques is welcome and could be practice changing.
Anterior shoulder dislocation technique preferences – how did your favorite FARES?
This meta-analysis aimed to compare methods for closed anterior shoulder dislocation reduction by looking at RCTs. They found 14 studies totaling 1,189 patients and analyzed them according to a pairwise meta-analysis (comparing 2 techniques studied in the same patient population) and a network meta-analysis (comparing multiple techniques across multiple different studies).
The authors note over 20 different reduction techniques have been described in the literature (if you’re like me and dislike eponyms, here is a link to appendix 2 which summarizes all of those investigated in this study). Techniques can be classified as: muscle balance/relaxation, traction, rotation/leverage, and combinations thereof.
They performed a systematic review and included RCTs or quasi-RCTs enrolling patients 15 or older with an acute anterior shoulder dislocation and compared one reduction method to another. The authors did a great job of summarizing their findings regarding risk of bias from these studies and noted there was significant heterogeneity as well.
By using the more traditional pairwise technique, there was only enough data (2 RCTs) to compare the Kocher method to the Hippocratic method, and there was no significant difference in success rates, pain reduction, or reduction time.
For the network meta-analysis, the Kocher method was used as the reference for comparison in the network forest plot, as it was investigated in the largest number of eligible studies.
In order to interpret their findings in the network meta-analysis the authors utilized surface under the cumulative ranking (SUCRA) to evaluate the superiority (ranking) of each method. In a cumulative ranking curve for SUCRA, each position on the horizontal axis is a possible rank to be used for treatment, and the vertical axis indicates the probability of each rank or higher.
The above figure demonstrates the primary findings – Boss-Holzach-Matter/Davos and FARES had the most favorable value for success rates while both FARES and modified external rotation were more favorable in reduction times. FARES also had the most favorable score for pain during reduction.
Out of all the studies, the authors note only one significant complication – a fracture when the Kocher technique was used with traction.
Hats off to the authors for undertaking this statistically complex study. In this study, the FARES method performed well; however, this doesn’t mean we should only perform FARES. Instead, each clinician should have a few options they are comfortable utilizing to reduce anterior shoulder dislocations – preferably from different technique classifications.
If you’re like me and need a refresher on how to interpret network meta-analyses, I found the first 31 minutes of this video useful and this video for interpreting SUCRA scores.
A Systematic Review With Pairwise and Network Meta-analysis of Closed Reduction Methods for Anterior Shoulder Dislocation. Annals of emergency medicine vol. 81,4 (2023): 453-465. doi:10.1016/j.annemergmed.2022.10.020
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