Physiotherapy treatment for reverse total shoulder arthroplasty: Results of a patient-centred rehabilitation guideline using functional and patient-reported outcome measures.

Rehabilitation after primary reverse total shoulder arthroplasty (RTSA) is accepted to be an essential component to successful outcome achievement, but successful rehabilitation approaches have yet to be well described in the literature. This retrospective review documents the outcomes of a cohort of 29 patients undergoing RTSA surgery with rehabilitation following the Upper Limb Treatment and Rehabilitation Advice (ULTRA) guideline (Appendix 1). The Oxford Shoulder Score, Quick Disabilities of the Arm, Shoulder and Hand score, range of movement (degrees of flexion, abduction and external rotation) and numerical rating score for pain were prospectively collected pre-operatively and at one- and two-years post-operatively. Scores were then evaluated to establish whether or not there were any significant changes over time. Statistically significant improvements were seen in all outcome domains from pre-operative to one-year post-operative. All improvements met the threshold for achieving substantial clinical benefit as well as exceeding the minimum clinically important difference, and all improvements were maintained at the two-year post-operative time point. The present study showed that following the ULTRA guideline after elective RTSA can give statistically significant improvements in range of movement, pain score and patient-reported outcome at one-year post-operatively, which can be maintained up to two-years post-operatively.

Diagnosing the direction of shoulder instability in rugby players.

The muscular characteristics of rugby players may make diagnosing the direction of shoulder instability and labral pathology challenging. This study aimed to assess the accuracy of clinical examination and specifically instability tests, in diagnosing the direction of shoulder instability in rugby players. One-hundred-and-forty rugby players, who had undergone a shoulder stabilization procedure, over a 55-month period, were included in this study. The mean age was 21.5 years with 137 males. Data collected included clinical examination and intraoperative findings. The two were compared to calculate the diagnostic accuracy of special tests for instability. The Anterior Apprehension Test had good sensitivity (82.7%), specificity (100%) and PPV (100%) but poor NPV (55.8%). All posterior instability tests demonstrated a sensitivity of over 85%, but all had a specificity of 25% or less. In 83.6% of cases the direction of instability was correctly identified from history and examination. Anterior instability was correctly diagnosed in 78.9% of cases and posterior in 100.0%. The poor NPV of the anterior apprehension test suggests that clinicians should be suspicious of anterior instability in rugby shoulders even in the light of negative examination findings. Positive posterior instability tests are highly suggestive of posterior instability in rugby players.

Shoulder Pain Diagnosis, Treatment and Referral Guidelines for Primary, Community and Intermediate Care.

These care pathway guidelines for the shoulder have been written in collaboration with the NHS Evidence Based Interventions (EBI) programme. The EBI programme is a partnership between the Academy of Medical Royal Colleges, NHS Clinical Commissioners, the National Institute for Health and Care Excellence, as well as NHS England and Improvement.

The Provision of Primary and Revision Elbow Replacement Surgery in the NHS.

BESS Surgical Procedure Guidelines (SPGs). Optimising Surgical Outcomes for Shoulder and Elbow patients. The British Elbow and Shoulder Society (BESS) SPGs are a series of evidence and consensus Best Practice Recommendations developed by BESS surgeons and physiotherapists to help drive quality improvement and achieve the best possible surgical outcomes for UK patients. This SPG on primary and revision elbow replacement surgery is supported and endorsed by both the British Orthopaedic Association (BOA) and the Getting It Right First Time (GIRFT) Programme.

The incidence and causative organisms of infection in elective shoulder surgery.

BACKGROUND: Deep infection remains a serious complication of orthopaedic surgery. Knowledge of infection rates and causative organisms is important to guide infection control measures. The aim of the present study was to determine infection rates and causative organisms in elective shoulder surgery. METHODS: Cases complicated by infection were identified and prospectively recorded over a 2-year period. All patients undergoing elective shoulder surgery in the concurrent period at a single Specialist Upper Limb Unit in the UK were identified from the hospital electronic database. RESULTS: In total, 1574 elective shoulder cases were performed: 1359 arthroscopic (540 with implant insertion) and 215 open (197 with implant insertion). The overall infection rate in open surgery of 2.5% was significantly higher than arthroscopic implant cases at 0.7% (p < 0.005). The overall infection rate in implant arthroscopic surgery was significantly higher at 0.7% compared to 0% in non-implant related surgery. (p < 0.05). CONCLUSIONS: Patients undergoing open shoulder surgery have a significantly higher risk of infection compared to arthroscopic shoulder surgery. Arthroscopic surgery with implant insertion has a statistically significantly higher risk of developing deep infection compared to procedures with no implant insertion. We recommend prophylactic antibiotics in open shoulder surgery and arthroscopic shoulder surgery with implant insertion.

Accelerated rehabilitation after arthroscopic Bankart repair in professional footballers.

BACKGROUND: Advances in arthroscopic surgery have resulted in biomechanically stronger repairs that might allow for accelerated rehabilitation protocols and hence faster return to play. Evidence for such regimes in the shoulder, particularly in elite athletes, is lacking. METHODS: This prospective single surgeon (PB) series included 34 professional footballers undergoing an accelerated rehabilitation programme following arthroscopic soft tissue stabilization subsequent to traumatic anterior shoulder dislocation. Data were collected on time to regain elevation range, external rotation range, return to play and rate of recurrence. RESULTS: Mean follow-up time was 4.8 years (range 2 years to 10 years). Full range of forward elevation was regained at a mean of 5 weeks (range 3 weeks to 7 weeks) and external rotation range (in neutral) at a mean of 6 weeks (range 4 weeks to 8 weeks). Mean return to play time was 11 weeks (range 9 weeks to 14 weeks). Three players (9%) reported a recurrent episode of dislocation at a mean of 19 months. CONCLUSIONS: An accelerated rehabilitation programme resulted in a return to play time of 11 weeks compared to previously reported times of between 5 months and 9 months in the contact sports population. A recurrence rate of 9% compares favourably to other published studies following similar surgery (5.1% to 28.6%) but which employed more conservative postoperative rehabilitation regimes.

Limited capsular release and controlled manipulation under anaesthesia for the treatment of frozen shoulder.

BACKGROUND: In light of recent interest in the cost-effectiveness of the treatment options available for frozen shoulder, we aimed to determine the results of limited anterior capsular release and controlled manipulation under anaesthesia (MUA) in the treatment of primary frozen shoulder in terms of patient-related outcomes measure, range of motion and re-intervention rates. METHODS: This single-surgeon series included prospectively collected data on all patients undergoing capsular release with MUA from March 2011 until June 2013, with a minimum follow-up of 6 months from the index procedure. Outcome measures included pre- and postoperative Oxford Shoulder Score (OSS), range of motion and need for re-intervention. RESULTS: Fifty-four procedures were performed in 52 patients. Mean age 50 years (range 42 years to 59 years); male: female ratio = 11: 41. There was a highly statistically significant improvement in both pain and function modules of the OSS (p < 0.005) and range of motion (p < 0.005) at 6 months. The median postoperative score was 41 from a maximum of 48 points, with an average mean improvement of 24 points. Seventeen patients were diabetics. There was no significant difference in pre-operative and postoperative OSS or range of motion between the diabetic group and the non-diabetic groups. No patients required surgical re-intervention. CONCLUSIONS: A combination of limited capsular release and MUA for the treatment of primary frozen shoulder is a safe and effective procedure resulting in marked improvement in pain, function and range of motion.

Long contoured locking plate fixation of traumatic proximal humeral fractures with distal extension.

BACKGROUND: There is a paucity of data available with respect to outcome on long contoured locking plate fixation for proximal humerus fractures with distal fracture extension. METHODS: Thirty-four patients with traumatic proximal humerus fractures with distal extension underwent fixation with long contoured locking plates. Twenty-five patients (74%) were included in the study: one patient died, two patients had unrelated illnesses resulting in them being unable to complete follow-up assessment and six were lost to follow-up. Patients' case notes and radiographs were retrospectively reviewed, and patients were contacted to assess functional outcome using the Visual Analogue Scale (VAS) for pain, Disabilities of the Arm, Shoulder and Hand (DASH) score, Oxford Shoulder Score (OSS) and Stanmore Percentage of Normal Shoulder Assessment (SPONSA). RESULTS: Mean follow-up was 27 months (range 11 months to 60 months). Mean pain at final follow-up was 3.6 [95% confidence interval (CI) = 2.5 to 4.8] with only four patients having residual pain greater than 5 on the VAS scale. Mean DASH score was 41.2 (95% CI = 32.0 to 50.4), mean OSS was 29.1 (95% CI = 24.3 to 33.9) and mean SPONSA was 63.9% (95% CI = 50.8 to 77.2). There was one wound infection. Three patients had non-unions that required bone grafting and revision internal fixation. CONCLUSIONS: We feel long contoured locking plates represent a useful treatment option for complex proximal humerus fractures.

Transverse divergent dislocation of elbow in a child: a case report and review of current literature.

We present a case report on transverse divergent dislocation of the elbow, highlighting the spatial relation among the proximal radius, ulna, and distal humerus in this rare pediatric elbow injury and reasons leading to misinterpretation of radiographs. Elbow dislocation is a rare injury in children. It comprises only 6% of pediatric elbow injuries. Most pure dislocations are posterior, but they can occur in any direction. Divergent dislocation of the elbow is a subgroup of posterior dislocation, which is extremely rare. It is important that the pediatric emergency physician is aware, able to identify, and manage this injury. It is defined as a specific elbow dislocation in which the distal humerus is forced between the proximal radius and ulna, resulting in the divergence of the proximal forearm bones. Joint laxity is said to be a predisposing cause in pediatric age group. Atraumatic divergent dislocation of the elbow has been reported in the adults with rheumatoid arthritis. Imaging is challenging because there is no defined specific radiological views, therefore making the diagnosis difficult. This often leads to misdiagnosis or inappropriate treatment. A thorough understanding of mechanism of injury and basis for atypical radiological findings will help in identifying the injury early, and the simple Thompson technique to relocate the elbow will give an excellent functional outcome.

Repair of distal biceps tendon ruptures using suture anchors through a single anterior incision.

PURPOSE: The purpose of this study was to review the results of distal biceps tendon repair via suture anchors through a single anterior incision. METHODS: This is a retrospective review of 17 patients (18 repairs) treated for complete distal biceps tendon rupture between 1998 and 2005 by use of G4 Superanchors (DePuy Mitek, Raynham, MA) in our unit. The length of follow-up was 14 to 70 months (mean, 45 months). RESULTS: There was a mean loss of 5.3 degrees (range, 0 degrees to 50 degrees ; SD, 14.12) of extension when compared with the uninjured side. Of the 17 patients, 6 achieved full extension when compared with the uninvolved elbow. The mean loss of flexion was 6.2 degrees (range, 0 degrees to 15 degrees; SD, 6.11). There was a mean loss of 11.0 degrees of pronation (range, 0 degrees to 30 degrees; SD, 11.34) and 6.4 degrees of supination (range, 0 degrees to 45 degrees; SD, 17.45). Flexion in supination strength measured by a handheld dynamometer was 82.1% of that of the injured side (range, 59% to 102%; SD, 11.26). There were two complications in our series: transient superficial radial nerve palsy in one case and heterotopic ossification in the other. The mean Disabilities of the Arm, Shoulder and Hand score was 14.45 (range, 0 to 55.17; SD, 4.76). Six months after surgery, all patients but one returned to their preinjury levels of activity and employment. CONCLUSIONS: Our study shows that repair of distal biceps tendon ruptures via suture anchors is safe and yields clinically objective and functional results comparable to measurements in the other, uninjured extremity. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

Irreducible anterior dislocation of the shoulder due to soft tissue interposition of subscapularis tendon.

The shoulder joint is the most unstable joint in the body and is easily dislocated. Anterior shoulder dislocation is the commonest and can be associated with glenoid and humeral fractures. Anterior shoulder dislocations are not infrequently associated with cuff tendon tears; however, anterior shoulder dislocation is easily reducible. Irreducible anterior dislocation of the glenohumeral joint is uncommon, and this could be due to bony as well as soft tissue causes. Persistent anterior dislocation due to torn subscapularis interposition in the glenohumeral joint is very rare, and only a few operative cases have been reported in the literature. We present MR features of one such case and a literature review.

Early versus late mobilization after hemiarthroplasty for proximal humeral fractures.

This randomized controlled trial compares 2 mobilization regimens after shoulder hemiarthroplasty for acute 3- and 4-part fractures. The aim was to establish whether the length of immobilization plays a role in the functional outcome, tuberosity healing, and subsequent range of motion. The same prosthesis and surgical technique were used. We recruited 59 patients into the study; 31 were randomized to early (2 weeks) mobilization and 28 to late (6 weeks) mobilization. Greater tuberosity migration was assessed with a series of radiographs, and the functional outcome was assessed with the Constant Shoulder Assessment and Oxford shoulder scores. Of the patients, 49 (mean age, 70 years) met the inclusion criteria and were followed up for 12 months. Greater tuberosity migration occurred in 3 cases in the early mobilization group and once in the late mobilization group (P > .10). There was no significant difference in the Constant Shoulder Assessment and Oxford scores between the 2 groups. Although there was a decreased incidence of tuberosity migration in the group undergoing late mobilization, this was not statistically significant.

Arthroscopic stabilization of the shoulder: a prospective randomized study of absorbable versus nonabsorbable suture anchors.

PURPOSE: The aim of this study was to evaluate, prospectively, outcomes following arthroscopic Bankart repair performed with 2 types of suture anchor--the G II (DePuy Mitek, Raynham, MA) nonabsorbable anchor and the Panalok (DePuy Mitek) absorbable anchor. METHODS: Patients with a diagnosis of recurrent traumatic anterior instability of the shoulder who were seen in a single unit between April of 2000 and June of 2003 were considered for inclusion in the study. Patients were assessed preoperatively and postoperatively by means of a subjective, patient-related outcome measurement tool (Oxford Instability Score), a visual analogue scale for pain and instability (VAS Pain and VAS Instability), and a quality-of-life questionnaire (Short Form-12 [SF-12]). Length of follow-up was 1.5 to 5 years (mean, 2.6 y). The incidence of recurrent instability and the level of sporting ability were recorded. Patients were randomized to undergo surgical repair with nonabsorbable or absorbable anchors. RESULTS: A total of 130 patients were included in this study, of whom 6 were lost to follow-up; therefore 124 patients (95%) completed the study. Both types of anchor were highly effective. No differences in rate of recurrence or in any of the scores were noted between the 2 groups. In all, 4 patients in the nonabsorbable group and 3 in the absorbable group experienced additional episodes of dislocation after a traumatic event. Rate of redislocation in the whole series was therefore 6%. In addition, 4 patients, all of them from the absorbable group (4%), described ongoing symptoms of instability but no true dislocations. In all, 85% of the patient group have returned to their previous level of sporting activity. CONCLUSIONS: No differences in outcomes of arthroscopic Bankart repair were seen whether absorbable or nonabsorbable anchors were used. Both are highly effective, with a redislocation rate of 6%. LEVEL OF EVIDENCE: Level I, therapeutic randomized controlled trial.

Clavicular hook plate for lateral end fractures:- a prospective study.

AIM: A prospective study was undertaken over a period of 4 years to evaluate the clinical and radiological outcomes following fixation with a clavicular hook plate for Neer types II and III fractures of lateral end clavicle. MATERIALS: Thirty-one patients (M:F; 24:7) with a mean age of 49 years (range 25-86 years) were recruited for the study. The mean follow-up duration was 40 months (range 18-68 months). Twenty-three patients were treated primarily and eight patients were treated for symptomatic delayed union. RESULTS: All the patients achieved clinical and radiological union over a mean of 12 weeks (range 6-18 weeks). Mean constant score at and after 3 months was 94 (range 82-100). Mean ASES score at and after 3 months was 26 out of a maximum of 30. CONCLUSION: The clinical result of fracture fixation of lateral end clavicle using hook plate appeared good in terms of fracture union and function. The principal advantages of this method were anatomical reduction of the fracture and early rehabilitation which lead to good shoulder girdle function.