Best practice in shoulder arthroplasty-a reflective personal review.

Introduction: Shoulder arthroplasty is uncommon but increasing in number when compared to hip and knee arthroplasty. The average UK shoulder surgeon performs less than 10 a year and revision surgery is even more rare. The surgeon should be familiar with surgical approaches, implant designs and preferably be fellowship trained to produce good outcomes. Methods: Narrative review was undertaken and senior author's personal practice was discussed. Results: The need for a clear understanding of indications and contraindications for both anatomic shoulder arthroplasty and reverse total shoulder arthroplasty, good preoperative planning, protocol-based peri-operative management and good rehabilitation protocol in the post operative period cannot be overemphasized. Conclusion: We are still learning best practice and prosthesis designs have changed over the past years with extensive choices especially in Reverse arthroplasty. Each of these designs has unique biomechanical properties and require a deep understanding of indications. Good surgical training and the use of multi-disciplinary team meetings for complex cases should improve the safety and quality of surgery for patients and ultimately long-term outcome of shoulder arthroplasty.

Protocol for a multi-site pilot and feasibility randomised controlled trial: Surgery versus PhysiothErapist-leD exercise for traumatic tears of the rotator cuff (the SPeEDy study).

BACKGROUND: Clinically, a distinction is made between types of rotator cuff tear, traumatic and non-traumatic, and this sub-classification currently informs the treatment pathway. It is currently recommended that patients with traumatic rotator cuff tears are fast tracked for surgical opinion. However, there is uncertainty about the most clinically and cost-effective intervention for patients with traumatic rotator cuff tears and further research is required. SPeEDy will assess the feasibility of a fully powered, multi-centre randomised controlled trial (RCT) to test the hypothesis that, compared to surgical repair (and usual post-operative rehabilitation), a programme of physiotherapist-led exercise is not clinically inferior, but is more cost-effective for patients with traumatic rotator cuff tears. METHODS: SPeEDy is a two-arm, multi-centre pilot and feasibility RCT with integrated Quintet Recruitment Intervention (QRI) and further qualitative investigation of patient experience. A total of 76 patients with traumatic rotator cuff tears will be recruited from approximately eight UK NHS hospitals and randomly allocated to either surgical repair and usual post-operative rehabilitation or a programme of physiotherapist-led exercise. The QRI is a mixed-methods approach that includes data collection and analysis of screening logs, audio recordings of recruitment consultations, interviews with patients and clinicians involved in recruitment, and review of study documentation as a basis for developing action plans to address identified difficulties whilst recruitment to the RCT is underway. A further sample of patient participants will be purposively sampled from both intervention groups and interviewed to explore reasons for initial participation, treatment acceptability, reasons for non-completion of treatment, where relevant, and any reasons for treatment crossover. DISCUSSION: Research to date suggests that there is uncertainty regarding the most clinically and cost-effective interventions for patients with traumatic rotator cuff tears. There is a clear need for a high-quality, fully powered, RCT to better inform clinical practice. Prior to this, we first need to undertake a pilot and feasibility RCT to address current uncertainties about recruitment, retention and number of and reasons for treatment crossover. TRIAL REGISTRATION: ClinicalTrials.gov ( NCT04027205 ) - Registered on 19 July 2019. Available via.

External rotation bracing for first-time anterior dislocation of the shoulder: A discontinued randomised controlled trial comparing external rotation bracing with conventional sling.

INTRODUCTION: Itoi et al. introduced the concept of bracing in abduction and external rotation to treat traumatic anterior shoulder dislocations. However, controversy remains as studies have reported variable results. Our study investigates whether there is a difference in outcomes between treatment with a conventional sling or external rotation brace. METHODS: A prospective, multi-centre randomised control trial was conducted between 2006 and 2010. The study was discontinued early with 72 (36 cases in each group) first-time anterior shoulder dislocations recruited. RESULTS: The re-dislocation rate over 24 months was comparable 30% (95% CI: 17-47) sling vs. 24% (95% CI: 13-41) external rotation bracing. Sixteen percent (95% CI: 7-32) of sling patients and 12% (95% CI: 5-27) of external rotation-bracing patients had shoulder stabilisation surgery within 24 months of the initial dislocation (p > 0.05). There was no difference in OSI scores at 24 months between the two treatment groups and intolerability of the external rotation brace was high. CONCLUSION: Recruitment to this study was difficult, and lost-to-follow-up rates were high leading to early discontinuation of the study. The results suggest that ER bracing is unlikely to provide clinical benefit in traumatic first-time anterior shoulder dislocation.

Arthroscopic observation of capsulolabral reduction after shoulder dislocation.

The standard treatment for most first-time anterior shoulder dislocations is reduction and immobilization. This places the arm in a position of adduction and internal rotation. We question whether this position assists or hinders reduction of a displaced capsulolabral injury (Bankart lesion). This study examined the pathology present after traumatic first-time anterior shoulder dislocations and looked at the reduction of the Bankart lesion in internal and external rotation. A series of 25 patients with Bankart lesions were identified who underwent arthroscopy at a mean of 10.5 days after first-time anterior shoulder dislocations. We found that there is wide variation in pathology after anterior dislocation. In 23 of 25 patients in whom the capsulolabral complex was detached (Bankart lesion), we found that external rotation of the arm improved the reduction of the labrum (92%). We conclude that in patients with a displaced Bankart lesion, the standard treatment of immobilization in internal rotation may hinder anatomic healing of this injury.