Aims. It is unclear whether acute plate fixation facilitates earlier return of normal shoulder function following a displaced mid-shaft clavicular fracture compared with nonoperative management when union occurs. The primary aim of this study was to establish whether acute plate fixation was associated with a greater return of normal shoulder function when compared with nonoperative management in patients who unite their fractures. The secondary aim was to investigate whether there were identifiable predictors associated with return of normal shoulder function in patients who achieve union with nonoperative management. Methods. Patient data from a randomized controlled trial were used to compare acute plate fixation with nonoperative management of united fractures. Return of shoulder function was based on the age- and sex-matched Disabilities of the Arm, Shoulder and Hand (DASH) scores for the cohort. Independent predictors of an early recovery of normal shoulder function were investigated using a separate prospective series of consecutive nonoperative displaced mid-shaft clavicular fractures recruited over a two-year period (aged ≥ 16 years). Patient demographics and functional recovery were assessed over the six months post-injury using a standardized protocol. Results. Data from the randomized controlled trial consisted of 86 patients who underwent operative fixation compared with 76 patients that united with nonoperative treatment. The recovery of normal shoulder function, as defined by a DASH score within the predicted 95% confidence interval for each respective patient, was similar between each group at six weeks (operative 26.7% vs nonoperative 25.0%, p = 0.800), three months (52.3% vs 44.2%, p = 0.768), and six months post-injury (86.0% vs 90.8%, p = 0.349). The mean DASH score and return to work were also comparable at each timepoint. In the prospective cohort, 86.5% (n = 173/200) achieved union by six months post-injury (follow-up rate 88.5%, n = 200/226). Regression analysis found that no specific patient, injury, or fracture predictor was associated with an early return of function at six or 12 weeks. Conclusion. Return of normal shoulder function was comparable between acute plate fixation and nonoperative management when union was achieved. One in two patients will have recovery of normal shoulder function at three months, increasing to nine out of ten patients at six months following injury when union occurs, irrespective of initial treatment. Cite this article: Bone Jt Open 2021;2(7):522–529

Purpose: This study was to assess shoulder function after breast reconstruction surgery using latissimus dorsi flap. Materials and Method: Sixty-eight patients (72 breasts) had this operation between September 1999 and June 2002. fifty-four patients (58 breasts) were assessed. The average age was 50 year (range 30 – 66 year). Average follow up was 38 month (range 24 – 54 month). DASH and Constant-Murley were used for clinical assessment. Results: Twenty-nine (50%) shoulders found to have a normal function; whereas, 11 (19%) shoulders had mild disability, 10 (17%) shoulders had moderate disability and 8 (14%) shoulders had severe disability. Only 6 (10%) patients reported being unsatisfied with their outcome; these were, from a shoulder function point view, 4 patients with sever disability, 1 patient with moderate disability and 1 patient with normal shoulder function. However, all these 6 patients were not satisfied with their breast reconstruction outcome. Conclusion: This study confirms that following breast reconstruction surgery using latissimus dorsi flap, there is a considerable deterioration of shoulder function of varying degrees. Nevertheless, shoulder function is not the main concern of this group of patients

The purpose of this study was to assess shoulder function after breast reconstruction surgery using latissimus dorsi flap. Sixty-eight patients (72 breasts) had this operation. Average follow up was 38 months (range 24 to 54 months). DASH and Constant-Murley were used for clinical assessment. Twenty-nine shoulders found to have a normal function; whereas, 11 shoulders had mild disability, 10 shoulders had moderate disability and 8 shoulders had severe disability. However, only 6 patients reported being unsatisfied with their outcome. Furthermore, all these 6 patients were not satisfied with their breast reconstruction outcome. This study confirms that following breast reconstruction surgery using latissimus dorsi flap, there is a considerable deterioration of shoulder function of varying degrees. Nevertheless, shoulder function is not the main concern of this group of patients

The purpose of this study is the assessment of the shoulder function after a proximal humeral nail insertion for trauma, using a minimal invasive approach. Material and methods: 22 patients had osteosynthesis for proximal humeral fractures using the Telegraph Nail. 15 patients underwent percutaneous osteosynthesis. The indication for the percutaneous procedure was determined at the per-operative control under fluoroscopy when the fracture was reducible by external manoeuvres. 12 of the fractures involved the surgical neck and 3 fractures were three-part fractures of the proximal humerus. The proximal interlocking was made using two screws in all the cases. The distal static interlocking was made with a single screw in all the cases. All the patients followed a standardised rehabilitation protocol including early mobilisation and passive and active assisted muscular activity. The shoulder function was assessed using the Simple Shoulder Test (SST) and the Constant score. The mobility was assessed using the flexibility ratio described by Harryman as compared to the opposite healthy arm. The patients were assessed at 6, 12, 26 and 52 weeks after surgery. Results: All the fractures showed consolidation within 6 weeks. Two fractures united with internal rotation and presented at controls with limited external rotation. Stable results were obtained at an average of 3 months. Return to previous activities was possible between 8 and 10 weeks after surgery in all the cases excepting two. In one case subacromial conflict between the nail and the rotator cuff was due to malpositioning of the proximal part of the nail and of the screws and required early removal and cuff repair. Average forward elevation was 12O25. Average external rotation was 4515. The SST score reached an average of 8.2/12 within 6 months and practically was unchanged at 12 months for all the series. The pondered Constant score was 76.7/1OO at six months. All the patients were improved after surgery. Conclusion and discussion: The percutaneous insertion of a proximal humeral nail for shoulder fractures is a minimally invasive alternative to heavy open surgery. The results are acceptable for the patients and stable in time. The advantage of minimal bleeding and short hospital stay recommend this technique in all the cases when reduction is possible without opening, as showed by the fluoroscopy

Abstract. Objective. Radial to axillary nerve and spinal accessory (XI) to suprascapular nerve (SSN) transfers are standard procedures to restore function after C5 brachial plexus dysfunction. The anterior approach to the SSN may miss concomitant pathology at the suprascapular notch and sacrifices lateral trapezius function, resulting in poor restoration of shoulder external rotation. A posterior approach allows decompression and visualisation of the SSN at the notch and distal coaptation of the medial XI branch. The medial triceps has a double fascicle structure that may be coapted to both the anterior and posterior division of the axillary nerve, whilst preserving the stabilising effect of the long head of triceps at the glenohumeral joint. Reinnervation of two shoulder abductors and two external rotators may confer advantages over previous approaches with improved external rotation range of motion and strength. Methods. Review of the clinical outcomes of 22 patients who underwent a double nerve transfer from XI and radial nerves. Motor strength was evaluated using the MRC scale and grade 4 was defined as the threshold for success. Results. 18/22 patients had adequate follow-up (Mean: 29.5 months). Of these, 72.2% achieved ≥grade 4 power of shoulder abduction and a mean range of motion of 103°. 64.7% achieved ≥grade 4 external rotation with a mean range of motion of 99.6°. Conclusions. The results suggest the use of the combined nerve transfer for restoration of shoulder function via a posterior approach, involving the medial head branch of triceps to the axillary nerve and the XI to SSN

Purpose: To evaluate the assumption that reaming is the main reason for problems of shoulder function (pain – restricted range of motion) after antegrade intramedullary nailing of humerus (unless impingement of fixation material on the rotator cuff or acromion occurs). Materials – Methods: From January 1999 until March 2003 55 patients underwent unreamed antegrade intra-medullary nailing for treatment of recent fractures of the humeral shaft. Two different intramedullary nailing systems were used, that do not protrude from the humeral shaft and that do not require reaming for insertion. Patients with concomitant problems or complications that could affect the final functional result were excluded from the study (e.g. multiple injuries, brachial plexus lesions, etc.). The remaining 32 patients were examined for postoperative pain and functional problems in the shoulder joint. Results: No patient complained of persistent shoulder pain. Range of motion was found comparable to that of the other shoulder. Conclusions: Reaming seems to exert a harmful influence on the rotator cuff, due to direct injury caused by the reamers as they are inserted and withdrawn from the humeral head. Furthermore it is possible that bone reaming products, accumulating under the rotator cuff, contribute to the persistence of pain and loss of motion

Introduction: We performed a clinical and radiological study to determine the functional outcome in terms of union and shoulder function and other related complications associated with treatment of humeral diaphyseal fractures with Intramedullary nailing. Methods and Patients: A review of 100 consecutive humeral nailing over a period of four years performed solely for diaphyseal fractures using Russell Taylor nails. 51 male and 49 female. Average age of 48.0 (25.3–63.8IQR). 45 Simple, 46 comminuted and 9 pathological fractures. 70 were isolated and 10 were part of multiple trauma fractures. 91 closed and 9 open fractures. 52 fractures due to simple falls, 30 road traffic accident,9 pathological fracture,8 work related and 1 unknow cause. Out of 100 nails, 90 were statically locked while 9 were locked proximally and 1 was locked only distally. The outcomes were assessed clinically, radiologically and using the Disability of Arm Shoulder and Hand (DASH) function scoring system. Statistically Cronbach’s alphas were calculated for the three scales of the DASH instrument. These scales were the function/symptom scale consisting of 30 items, sports/music module containing 4 items, and work module comprising 4 items. Medians (interquartile ranges) and ranges are presented for numerical variables. Mann-Whitney U tests (two-tailed) and Univariate and multivariate regression analysis were used. Results: 90% fractures united initially and 4% had delayed union, giving cumulative union rate of 94%. Six non unions required a second procedure. The DASH function scale scores was categorised into good 71 patients 85.5% (Score 0-< 25),. Medium 4 patients 4.8% (Score 25-< 40) and Poor 8 patients 9.6% (Score 40+). Univariate and multivariate regression analysis showed, Increasing age (adjusted OR=0.96,95%CI 0.93–0.99,P< 0.01) and communited compared to simple fractures (adjusted OR=0.12,95%CI 0.03–0.45,P< 0.01) were associated with reduced likelihood of attaining full range of motion. Male patients (unadjusted OR=2.37,95%CI 0.90–6.25,P=0.08) and patients involved in RTA compared to falls (unadjusted OR=4.5,95%CI 0.96–21.07,P=0.06) were associated with higher likelihood of attaining full range of motion. 85 % had no complication, while 15 % had complications. One nerve palsy and one case of infection. Seven patients required nail removal and 3 required removal of proximal locking screw. Conclusion: To date, we have the largest series in the literature of antegrade nailing for diaphyseal fractures. In our series the vast majority of patients achieved desired functional outcome and union, hence we recommend the use of intramedullary nailing for humeral diaphyseal fractures. By eliminating surgical technique errors, complications can be reduced further and even higher union rates can be achieved

The aim of this study was to evaluate how three different scoring systems (Constant, Reichelt, and UCLA scores) perform in individuals with normal shoulder function. Scoring systems to evaluate the outcome of surgical treatment around the shoulder are well established. A total of 201 individuals were enrolled in this study. They were divided in four age groups and divided by sex: Group 1: Under 50 years of age: 25 female, 21 male; Group II: From 50 to 59 years of age: 17 female, 21 male; Group III: From 60 to 69 years of age: 18 female, 12 male; Group IV: 70 years of age and older: 24 female, 15 male. All underwent clinical examination, ultrasound examination for detection of cuff tears, and radiograph examination in three planes. In all cases the dominant arm was enrolled. Twelve patients were excluded from the study because ultrasound depicted cuff tear or radiograph showed more than mild osteoarthritis according to the criteria of Hawkins, et al. (1990). The main factor influencing the over-all score was the age-dependent decrease of muscle force measured in forward arm flexion (max. 12.5kp). The score was also influenced by the limitation of internal rotation (Group I: 13%, Group II: 26%, Group III: 40%, Group IV: 41%). According to the Reichelt and UCLA scores, males in Groups I, II and III reached a 100% top score in the UCLA and Reichelt scoring systems. In Group IV composed of older male patients, 20% scored less that the top score because of loss in active motion and muscle force. Only females in Groups I and II scored maximum results. Females in Group III scored 11% and in Group IV composed of older female patients, 50% scored less than the top score because of loss in active motion and muscle force. Due to the natural aging process, males and females in Group IV could not accomplish maximum scores. We recommend that the top scores for the oldest age group be adjusted in order to avoid drawing erroneous conclusions from the scores in this age group

Introduction This prospective study was carried out to assess the outcome of manipulation of the shoulder with interscalene block as a treatment for adhesive capsulitis of the shoulder. Materials and Methods 31 patients underwent manipulation under general anaesthesia and interscalene block followed by intra-articular glenohumeral injection of steroid and local anaesthetic. Physiotherapy was started on the day of surgery. Shoulder function was assessed with range of movement, Constant score and DASH score (Disability of the Arm, Shoulder and Hand) by specialist upper limb physiotherapists, pre-operatively, and post-operatively at 6 weeks, 3, 6 and 12 months. Results The DASH score improved from a mean of 60.1 pre-operatively to a mean of 24.1 at final follow up. Constant scores improved from a mean of 34.4 pre-operatively to 65.8. The mean improvement in Constant scores was 31.5 points. Pre-operative range of movement (expressed as a percentage of the total ROM of the unaffected side) was 51.5%. The mean post-operative ROM was 85.4%. External rotation improved from 41.7% of the unaffected side preoperatively to 77.7% at final review. Abduction improved from 47.4% to 85.4% and forward flexion improved from 59.1% to 90%. No patients required further manipulation. Discussion All outcome measures improved following treatment. These improvements were sustained at 12 months follow-up. In particular external rotation, which was the most restricted movement preoperatively, was seen to improve and this improvement was maintained throughout follow-up. Conclusion We conclude that manipulation of the shoulder under interscalene block and general anaesthetic for adhesive capsulitis results in a sustained improvement in function and movement

The Constant score is widely used as a measure of assessing outcome from surgery. The pre and post-operative Scores are usually compared to assess outcome. The expected Scores for an age-matched population however are not known.

Patients attending fracture and general orthopaedic clinics with lower limb problems only were assessed. Age, handedness, occupation and Constant Score results were recorded. The score for differing sections of the Constant score were reviewed and analysed in combination with the above parameters.

The overall Constant Score decreased with age, as one would expect. However the decrease in the strength measurement was out of all proportion to that of the remainder of the Score-79% of total strength in the under 40 year age group compared with 11.2% of total strength in the over 80 year age group. This compared with a percentage of 97.8% for the remainder of the Score in the under 40 year group compared to 70.4% in the over 80 year age group. If one is using the Constant Score as a measure of surgical outcome one should be aware of the expected age-matched figures and in particular the poor strength measurements in the older populations. We suggest that a more useful measurement would be one without strength and just score out of 75.

Introduction: Clinical outcome scores such as the DASH shoulder score suffer from subjectivity, a ceiling effect and pain dominance masking functional changes which shall be assessable to address rising patient demands and improve the clinical validation of modern therapeutic improvements. Lab based motion analysis may provide such data but it is too costly, time consuming and complex for routine clinical follow-up. Inertia sensor based motion analysis (IMA) can produce objective movement parameters while being fast, cheap and easy to operate.

In this study, a simple and clinical feasible inertia sensor based motion analysis (IMA) shoulder test is defined and tested for its

reliability,

Methods: An inertia sensor (41x63x24mm, 39g) comprising 3D accelerometers (±5g) and 3D gyroscopes (±300°/sec) was taped onto the humerus in a standardised position. Healthy subjects (n=100, 40.6 ±15.7yrs) and 50 patients (55.6 ±12.7yrs, m/f 17/33) with confirmed unilateral shoulder pathology (39 subacromial impingement, 11 other) were measured. Two motion tasks (hand-behind-head, hand-to-back) were performed on both shoulders. Using automated algorithms, a simple motion parameter was calculated by adding the peak-to-peak angular rates per axis. The relative asymmetry between both shoulder sides was scored (healthy control within subject). Patients were also assessed using the DASH score and the Simple Shoulder Test (SST).

Results: The test produced high intra- (r2=0.90) and inter-observer reliability (r2=0.83). Asymmetry was > 3 times higher in patients (36.3%) than healthy controls (9.6%, p< 0.001). Using a threshold (> 16% asymmetry) healthy and pathological subjects could be distinguished with high diagnostic sensitivity (98.0%) and specificity (81.0%). The non-affected shoulders of the patient group did not differ from the shoulder of the healthy group (p=0.18). Sub-group analysis comparing the 30 best performing healthy to the 10 highest asymmetry pathological shoulders also revealed sign. lower range of motion, shorter motion path and longer cycle times (p< 0.01). Visual signal analysis exposed specific motion patterns (e.g. healthy: overshooting at point of task achievement, pathological: drift or tremble at rest position). IMA asymmetry was only weakly correlated with DASH or SST (r2< 0.25).

Discussion: The IMA shoulder test and asymmetry score showed high reliability and diagnostic power meeting or exceeding common clinical scores. The fast assessment (t< 60s) of a simple motion tasks makes it suitable for routine clinical follow-up to supplement classic scores. Weak correlations with DASH and SST show that the test adds an objective functional dimension to outcome assessment.

Purpose: Few studies have investigated the relationship between patients requiring rotator cuff surgery and their body mass index (BMI). The objective of this retrospective study was to evaluate the association between BMI and pre-operative pain and function in patients awaiting rotator cuff repair surgery as measured by the American Shoulder and Elbow Surgery (ASES) form and Simple Shoulder Score (SST). A second objective was to evaluate the role of several other factors in predicting patient pre-operative scores.

Method: Patients selected for this study were those who underwent arthroscopic rotator cuff repair performed by the same surgeon between 2002 and 2007. Their medical record included documentation of age, height, weight, smoking status, worker’s compensation status (WCB), and pre-operative ASES and SST scores. Correlation between BMI and ASES and SST scores was performed to determine the association between these variables. In addition, multiple stepwise regression was performed to assess the predictive value of other demographic and lifestyle factors.

Results: Fifty-four patients were included in the study (39 men, 15 women). No significant correlation was found between BMI and either ASES or SST scores. Based on multiple regression analysis, only WCB status was identified as a significant predictor of pre-operative ASES score (p=0.003) while sex, age, BMI, and smoking status were not. Patients with WCB claims had lower ASES scores than those without. Sex was found to have the strongest association with SST scores (r2 = 0.502) with men having greater SST scores than women. The model with the most significant value in predicting SST scores included sex, WCB and smoking status (r2 -= 0.640). Patients that did not fall under a WCB claim and were non-smokers had better SST scores pre-operatively.

Conclusion: BMI did not have a significant relationship to ASES and SST scores in patients awaiting rotator cuff repair surgery. A prospective study including pre- and post-surgical follow-up and a detailed analysis of the role between BMI and other demographic and lifestyle factors would be beneficial. Such a risk factor analysis may shed light on the indications for rotator cuff surgery or non-operative management, depending on the patient population.

The choice of whether to perform antegrade intramedullary nailing (IMN) or plate fixation (PF) poses a conundrum for the surgeon who must strike the balance between anatomical restoration while reducing elbow and shoulder functional impairment. Most humeral middle third shaft fractures are amenable to conservative management given the considerable acceptable deformity and anatomical compensation by patients. This study is concerned with the patient reported outcomes regarding shoulder and elbow function for IMN and PF respectively. A prospective cohort study following up all the cases treated surgically for middle third humeral fractures from 2016 to 2022 at a single centre. Telephonically an analogue pain score, an American Shoulder and Elbow Society (ASES) score for shoulder function and the Oxford Elbow score (OES) for elbow function were obtained. One hundred and three patients met the inclusion criteria. Twenty four patients participated in the study, fifteen had IMN (62.5%) and nine had PF (37.5%.). The shoulder function outcomes showed no statistical difference with an average ASES score of sixty-six for the IMN group and sixty-nine for the PF group. Women and employed individuals expressed greater functional impairment. Hand dominance has no impact on the scores of elbow and shoulder function post operatively. The impairment of abduction score post antegrade nailing was higher in the antegrade nailing group than the plated group. The OES demonstrated greater variance in elbow function in the PF group with the IMN group expressing greater elbow disfunction. This study confirms that treatment of middle third humerus shaft fractures by plate fixation is marginally superior to antegrade intramedullary nailing in preserving elbow function and abduction ability

Aims. Rotator cuff disease (RCD) can considerably decrease quality of life. Here, we investigated whether health-related quality of life (HRQoL) influences the need for surgery in patients with RCD. Methods. We performed an analysis of 417 patients with symptomatic RCD who were recruited from two hospitals between June 2008 and December 2014 to be randomized to receive non-surgical or surgical treatment. After a three-month rehabilitation period, 36-Item Short-Form Health Survey questionnaire (SF-36), shoulder pain (visual analogue scale (VAS)), and shoulder function (Constant-Murley score) data were available from 191 still-symptomatic patients who were eligible for surgery. A control group was formed from 87 excluded patients who were no longer eligible for surgery due to relief of symptoms. Results. Mean pain on the VAS was 51.3 (SD 20.1) in the patients eligible for surgery and 41.7 (SD 21.2) in the control group. The following domains of the SF-36 were associated with being eligible for surgery in univariate analyses: bodily pain, general health, vitality, social functioning, and emotional wellbeing. In multivariate analysis, only bodily pain was associated with pursuing surgical treatment. The RCD population’s values for physical role, bodily pain, and physical functioning were poorer compared to the values of the general population. Conclusion. Lower HRQoL, as indicated by the lower bodily pain score on the SF-36, was associated with the decision to undergo surgical treatment in patients with RCD. Therefore, HRQoL should be considered when determining treatment options for RCD. Cite this article: Bone Jt Open 2024;5(9):793–799

Osteoarthritis (OA) is a disease of the synovial joint with synovial inflammation, capsular contracture, articular cartilage degradation, subchondral sclerosis and osteophyte formation contributing to pain and disability. Transcriptomic datasets have identified genetic loci in hip and knee OA demonstrating joint specificity. A limited number of studies have directly investigated transcriptional changes in shoulder OA. Further, gene expression patterns of periarticular tissues in OA have not been thoroughly investigated. This prospective case control series details transcriptomic expression of shoulder OA by analysing periarticular tissues in patients undergoing shoulder replacement for OA as correlated with a validated patient reported outcome measure of shoulder function, an increasing (clinically worsening) QuickDASH score. We then compared transcriptomic expression profiles in capsular tissue biopsies from the OA group (N=6) as compared to patients undergoing shoulder stabilisation for recurrent instability (the control group, N=26). Results indicated that top ranked genes associated with increasing QuickDASH score across all tissues involved inflammation and response to stress, namely interleukins, chemokines, complement components, nuclear response factors and immediate early response genes. Some of these genes were upregulated, and some downregulated, suggestive of a state of flux between inflammatory and anti-inflammatory signalling pathways. We have also described gene expression pathways in shoulder OA not previously identified in hip and knee OA, as well as novel genes involved in shoulder OA

Abstract. Reverse shoulder arthroplasty (RSA) is being increasingly used for complex, displaced fractures of the proximal humerus. The main goal of the current study was to evaluate the functional and radiographic results after primary RSA of three or four-part fractures of the proximal humerus in elderly patients. Between 2012 and 2020, 70 consecutive patients with a recent three- or four-part fracture of the proximal humerus were treated with an RSA. There were 41 women and 29 men, with a mean age of 76 years. The dominant arm was involved in 42 patients (60%). All surgeries were carried out within 21 days. Displaced three-part fracture sustained in 16 patients, 24 had fracture dislocation and 30 sustained a four-part fracture of the proximal humerus. Patients were followed up for a mean of 26 months. The mean postoperative OSS at the end of the follow-up period was 32.4. The mean DASH score was 44.3. Tuberosity non-union occurred in 18 patients (12.6%), malunion in 7 patients (4.9%), heterotopic ossification in 4 patients (2.8%) and scapular notching in one patient. Anatomical reconstruction was achieved in 25 patients (17.5%), the influence of greater tuberosity healing on shoulder function could not be demonstrated. Heterotopic ossification seems to affect OSS and QDASH, we found statistically significant relation between HO and clinical outcomes. Patients with heterotopic ossification had significantly lower postoperative scores on DASH and OSS (P = .0527). Despite expecting good functional outcome with low complication rate after RSA, the functional outcome was irrespective of healing of the tuberosities

The periclavicular space is a conduit for the brachial plexus and subclavian-axillary vascular system. Changes in its shape/form generated by alteration in the anatomy of its bounding structures, e.g. clavicle malunion, cause distortion of the containing structures, particularly during arm motion, leading to syndromes of thoracic outlet stenosis etc., or alterations of scapular posture with potential reduction in shoulder function. Aim of this study was developing an in vitro methodology for systematic and repeatable measurements of the clinically poorly characterized periclavicular space during arm motion using CT-imaging and computer-aided 3D-methodologies. A radiolucent frame, mountable to the CT-table, was constructed to fix an upper torso in an upright position with the shoulder joint lying in the isocentre. The centrally osteotomized humerus is fixed to a semi-circular bracket mounted centrally at the end of the frame. All arm movements (ante-/retroversion, abduction/elevation, in-/external rotation) can be set and scanned in a defined and reproducible manner. Clavicle fractures healed in malposition can be simulated by osteotomy and fixation using a titanium/carbon external fixator. During image processing the first rib served as fixed reference in space. Clavicle, scapula and humerus were registered, segmented, and triangulated. The different positions were displayed as superimposed surface meshes and measurements performed automatically. Initial results of an intact shoulder girdle demonstrated that different arm positions including ante-/retroversion and abduction/elevation resulted solely in a transverse movement of the clavicle along/parallel to the first rib maintaining the periclavicular space. A radiolucent frame enabling systematic and reproducible CT scanning of upper torsos in various arm movements was developed and utilized to characterize the effect on the 3D volume of the periclavicular space. Initial results demonstrated exclusively transverse movement of the clavicle along/parallel to the first rib maintaining the periclavicular space during arm positions within a physiological range of motion

Interstitial supraspinatus tears can cause persistent subacromial impingement symptoms despite non operative treatment. Autologous tendon cell injection (ATI) is a non-surgical treatment for tendinopathies and tear. We report a randomised controlled study of ATI compared to corticosteroid injection (CS) as treatment for interstitial supraspinatus tears and tendinopathy. Inclusion criteria were patients with symptom duration > 6 months, MRI confirmed intrasubstance supraspinatus tear, and prior treatment with physiotherapy and ≥ one CS or PRP injection. Participants were randomised to receive ATI to the interstitial tear or corticosteroid injection to the subacromial bursa in a 2:1 ratio, under ultrasound guidance. Assessments of pain (VAS) and function (ASES) were performed at baseline, and 1, 3, 6 and 12 months post treatment. 30 participants (19 randomised to ATI) with a mean age of 50.5 years (10 females) and a mean duration of symptoms of 23.5 months. Baseline VAS pain and ASES scores were comparable between groups. While mean VAS pain scores improved in both groups at 3 months after treatment, pain scores were superior with ATI at 6 months (p=0.01). Mean ASES scores in the ATI group were superior to the CS group at 3 months (p=0.026) and 6 months (p=0.012). Seven participants in the CS group withdrew prior to 12 months due to lack of improvement. At 12 months, mean VAS pain in the ATI group was 1.6 ± 1.3. The improvements in mean ASES scores in the ATI group at 6 and 12 months were greater than the MCID (12.0 points). At 12 months, 95% of ATI participants had an ASES score > the PASS (patient acceptable symptom state). This is the first level one study using ATI to treat interstitial supraspinatus tear. ATI results in a significant reduction in pain and improvement in shoulder function

Introduction and Objective. Only few studies have investigated the outcome of exercises in patients with glenohumeral osteoarthritis (OA) or rotator cuff tear arthropathy (CTA), and furthermore often excluded patients with a severe degree of OA. Several studies including a Cochrane review have suggested the need for trials comparing shoulder arthroplasty to non-surgical treatments. Before initiation of such a trial, the feasibility of progressive shoulder exercises (PSE) in patients, who are eligible for shoulder arthroplasty should be investigated. The aim was to investigate whether 12 weeks of PSE is feasible in patients with OA or CTA eligible for shoulder arthroplasty. Moreover, to report changes in shoulder function and range of motion (ROM) following the exercise program. Materials and Methods. Eighteen patients (11 women, 14 OA), mean age 70 years (range 57–80), performed 12 weeks of PSE with 1 weekly physiotherapist-supervised and 2 weekly home-based sessions. Feasibility was measured by drop-out rate, adverse events, pain and adherence to PSE. Patients completed Western Ontario Osteoarthritis of the Shoulder (WOOS) score and Disabilities of the Arm, Shoulder and Hand (DASH). Results. Two patients dropped out and no adverse events were observed. Sixteen patients (89%) had high adherence to the physiotherapist-supervised sessions. Acceptable pain levels were reported. WOOS improved mean 23 points (95%CI:13;33), and DASH improved mean 13 points (95%CI:6;19). Conclusions. PSE is feasible, safe and may improve shoulder pain, function and ROM in patients with OA or CTA eligible for shoulder arthroplasty. PSE is a feasible treatment that may be compared with arthroplasty in a RCT setting

Aims. This systematic review places a recently completed multicentre randomized controlled trial (RCT), UK FROST, in the context of existing randomized evidence for the management of primary frozen shoulder. UK FROST compared the effectiveness of pre-specified physiotherapy techniques with a steroid injection (PTSI), manipulation under anaesthesia (MUA) with a steroid injection, and arthroscopic capsular release (ACR). This review updates a 2012 review focusing on the effectiveness of MUA, ACR, hydrodilatation, and PTSI. Methods. MEDLINE, Embase, PEDro, Science Citation Index, Clinicaltrials.gov, CENTRAL, and the World Health Organization (WHO) International Clinical Trials Registry were searched up to December 2018. Reference lists of included studies were screened. No language restrictions applied. Eligible studies were RCTs comparing the effectiveness of MUA, ACR, PTSI, and hydrodilatation against each other, or supportive care or no treatment, for the management of primary frozen shoulder. Results. Nine RCTs were included. The primary outcome of patient-reported shoulder function at long-term follow-up (> 6 months and ≤ 12 months) was reported for five treatment comparisons across four studies. Standardized mean differences (SMD) were: ACR versus MUA: 0.21 (95% confidence interval (CI) 0.00 to 0.42), ACR versus supportive care: -0.13 (95% CI -1.10 to 0.83), and ACR versus PTSI: 0.33 (95% CI 0.07 to 0.59) and 0.25 (95% CI -0.34 to 0.85), all favouring ACR; MUA versus supportive care: 0 (95% CI -0.44 to 0.44) not favouring either; and MUA versus PTSI: 0.12 (95% CI -0.14 to 0.37) favouring MUA. None of these differences met the threshold of clinical significance agreed for the UK FROST and most confidence intervals included zero. Conclusion. The findings from a recent multicentre RCT provided the strongest evidence that, when compared with each other, neither PTSI, MUA, nor ACR are clinically superior. Evidence from smaller RCTs did not change this conclusion. The effectiveness of hydrodilatation based on four RCTs was inconclusive and there remains an evidence gap. Cite this article: Bone Jt Open 2021;2(9):773–784