The role of structured physiotherapy in treating patients with atraumatic shoulder instability: Medium term results from a case series.

BACKGROUND: Consensus favours conservative treatment for atraumatic shoulder instability, but literature is scarce on the topic. We therefore prospectively assessed the results of structured physiotherapy for these patients. METHODS: Patient reported outcomes were recorded prior to physiotherapy and on discharge. Notes review identified patients re-referred for the same condition. RESULTS: N = 85. Review range was 12-72 months post-treatment. Median Oxford Shoulder Instability Score (OSIS) improved from 21 (range: 2-47) to 39 (11-47). Median Western Ontario Shoulder Instability Index (WOSI) improved from 1117 (range: 306-2028) to 485 (0-1569). Patients with posterior instability demonstrated better results compared with other groups (OSIS change, p = 0.025; WOSI change, p = 0.060). Quicker referral to physiotherapy gave improved outcomes (OSIS change, p = 0.004, rs = -0.4; WOSI change, p = 0.047, rs = 0.24). Twenty-one patients (24.7%) were re-referred, seven of them for repeat physiotherapy and 14 of them for surgery. Previous surgery significantly affected the possibility of a further referral (p < 0.001), and initial diagnosis was significantly correlated with further surgery (p = 0.032). DISCUSSION: Early referral to physiotherapy may produce better results. Patients with posterior instability responded better to physiotherapy. Previous surgery increased the risk of re-referral. Re-referred patients with posterior instability tended to be managed with further physiotherapy.

Arthroscopic knotless anterior labral stabilization using labral tape and wide awake anaesthesia-short term results.

BACKGROUND: The shoulder is the least constrained of all joints of the body and is more susceptible to injury including dislocation. The rate of recurrent instability following primary stabilization procedure at 10 years of follow-up ranged from 3.4 to 20%. There is a lack of evidence in the literature regarding use of labral tape and anchors for anterior stabilization despite the growing market for this product. We describe the outcomes of 67 patients who underwent knotless arthroscopic anterior stabilisation under awake anaesthesia using 1.5 mm LabralTape with 2.9 mm Pushlock anchors for primary anterior instability by a single surgeon. METHODS: This was a retrospective analysis of prospectively collected outcome data for adult patients undergoing anterior stabilisation for primary traumatic anterior shoulder instability between 2013 and 2016 at two centres. Patients with > 25% glenoid bone loss, engaging Hill Sach's, and multidirectional instability were excluded. All cases underwent surgery using awake anaesthetic technique. The surgical technique and post-operative physiotherapy was standardized. Outcomes were measured at 6 months and 12 months. RESULTS: Of the 74 patients in our study, 7 were lost to follow up. Outcomes were measured using the Oxford Instability Shoulder Score (OISS) and clinical assessment including the range of motion. The OISS showed statistically significant improvement from a mean score and standard deviation (SD) of 24.72 ± 2.8 pre-surgery to 43.09 ± 3.5 after the procedure at 12 months with good to excellent outcomes in 66 cases (98.5%). The mean abduction was 134.2 ± 6.32 and external rotation was 72.55 ± 5.42 at 60-90 position at 12 months. We report no failures due to knot slippage or anchor pull-out. CONCLUSION: Our case series using the above technique has distinct advantages of combining a small non-absorbable implant with flat, braided, and high-strength polyethylene tape. This technique demonstrates superior medium term results to conventional suture knot techniques for labral stabilization thereby validating its use.

The Shoulder Objective Practical Assessment Tool: Evaluation of a New Tool Assessing Residents Learning in Diagnostic Shoulder Arthroscopy.

PURPOSE: To design and validate an objective practical assessment tool for diagnostic shoulder arthroscopy that would provide residents with a method to evaluate their progression in this field of surgery and to identify specific learning needs. METHODS: We designed and evaluated the shoulder Objective Practical Assessment Tool (OPAT). The shoulder OPAT was designed by us, and scoring domains were created using a Delphi process. The shoulder OPAT was trialed by members of the British Elbow & Shoulder Society Education Committee for internal consistency and ease of use before being offered to other trainers and residents. Inter-rater reliability and intrarater reliability were calculated. One hundred forty orthopaedic residents, of varying seniority, within 5 training regions in the United Kingdom, were questioned regarding the tool. A pilot study of 6 residents was undertaken. RESULTS: Internal consistency was 0.77 (standardized Cronbach α). Inter-rater reliability was 0.60, and intrarater reliability was 0.82. The Spearman correlation coefficient (r) between the global summary score for the shoulder OPAT and the current assessment tool used in postgraduate training for orthopaedic residents undertaking diagnostic shoulder arthroscopy equaled 0.74. Of the residents, 82% agreed or strongly agreed when asked if the shoulder OPAT would be a useful tool in monitoring progression and 72% agreed or strongly agreed with the introduction of the shoulder OPAT within the orthopaedic domain. CONCLUSIONS: This study shows that the shoulder OPAT fulfills several aspects of reliability and validity when tested. Despite the inter-rater reliability being 0.60, we believe that the shoulder OPAT has the potential to play a role alongside the current assessment tool in the training of orthopaedic residents. CLINICAL RELEVANCE: The shoulder OPAT can be used to assess residents during shoulder arthroscopy and has the potential for use in medical education, as well as arthroscopic skills training in the operating theater.

Scapular Winging.

This review explores the causes of scapula winging, with overview of the relevant anatomy, proposed aetiology and treatment. Particular focus is given to lesions of the long thoracic nerve, which is reported to be the most common aetiological factor.

Risk factors and predictors of mortality for proximal humeral fractures.

BACKGROUND: Risk factors for mortality after proximal humeral fracture, including socioeconomic status, are poorly defined. This retrospective review of prospectively collected data defines the epidemiology and predictors of mortality in association with proximal humeral fractures. METHODS: Patients who sustained proximal humeral fractures were identified from fragility fracture and trauma databases between May 2001 and September 2012. RESULTS: In total, 1880 patients with a mean age of 69 years and a male to female ratio of 2 : 3 were identified. Socioeconomic distribution is skewed towards the lowest and highest quintiles. Low-energy mechanisms caused 88% of fractures. Men sustain fractures when they are aged 10 years younger and via higher-energy mechanisms. In total, 536 patients (29%) died within the study period with a 1-year mortality of 9.8%, rising to 28.2% at 5 years. Female gender, increasing age, pathological fracture and increased number of co-morbidities were independent variables for increased mortality. CONCLUSIONS: The present study, which was conducted over an 11-year period, is the first to combine the epidemiology and risk factors for mortality with socioeconomic rank. One-year mortality risk is twice that of the background matched population. Patient counselling with respect to increased mortality should be considered, especially in higher-risk elderly females with multiple co-morbidities.

Does rectal examination have any value in the clinical diagnosis of cauda equina syndrome?

PURPOSE: This study aims to quantify the value of digital rectal examination (DRE) in the clinical diagnosis of cauda equina syndrome. METHODS: A retrospective case note review was performed on all patients referred to a University Teaching Hospital over a one-year period with documented suspicion of cauda equina syndrome. All Patients underwent MRI scanning to either confirm or rule out the diagnosis. RESULTS: Fifty-seven such patients were identified, 13 (23%) of whom had confirmation of cauda equina syndrome on MRI scanning. The DRE did not significantly discriminate for the outcome of MRI (p = 0.897, test accuracy 51%, diagnostic odds ratio 1.42). There was no correlation between the cumulative number of positive clinical findings in an individual patient and the likelihood of MRI diagnosis and no significant link between any individual clinical feature and the MRI result. CONCLUSIONS: Digital rectal examination has no significant value in the acute diagnosis of cauda equina syndrome. This study further confirms that there is no discreet clinical protocol applicable with which to confidently confirm or rule out this diagnosis. DRE is traditionally enshrined as an essential facet of clinical assessment in suspected cauda equina syndrome but it cannot be used as a discriminator to ration urgent MRI scanning.