Background

Frozen Shoulder is a common condition which causes significant morbidity in people of working age. The 2 most popular forms of surgical treatment for this condition are Manipulation under Anaesthesia (MUA) or MUA plus Arthroscopic Capsular Release (ACR). Both treatment modalities are known to give good results, but no-one has compared the two to see which is better.

Background – Frozen Shoulder is a common condition which causes significant morbidity in people of working age. The 2 most popular forms of surgical treatment for this condition are Manipulation under Anaesthesia (MUA) or MUA plus Arthroscopic Capsular Release (ACR). Both treatment modalities are known to give good results, but no-one has compared the 2 to see which is better.

Aim – To compare the outcome in patients with primary frozen shoulder, who are treated by either MUA or MUA plus ACR.

Method – 61 patients with primary frozen shoulder were treated by either MUA or MUA plus ACR. Each patient had their American Shoulder and Elbow Score (ASES), and their Oxford Shoulder Score (OSS) measured pre and post-operatively.

Results – The patients who had MUA plus ACR had a mean ASES of 24.8 preoperatively, 64 at 4 months, and a mean of 75.4 at 12 months. The mean OSS was 32.5 pre-operatively, 48.5 at 4 months and 53.4 at 12months. The patients who had a MUA had a mean ASES of 28.7 pre-operatively, 60.9 at 4months and 69.6 at 12months. The mean OSS was 33 preoperatively, 46.5 at 4 months and 50.9 at 12 months.

Conclusions – Both treatments give good results. MUA plus ACR give superior numerical results at 6 to 12 months post-operatively, however, these figures did not reach statistical significance

The aim of this study was to review the results of surgery on patients who had recurrent instabilty of the shoulder associated with significant bone loss who were treated by autogenous iliac crest tricortical grafts. Ten consecutive patients were reviewed. All had significant loss of glenoid bone stock as assessed by CT scan. All were treated by use of tricortical bone graft harvested from the iliac crest and fashioned to reconstitute the anterior glenoid defect. This was fixed intra-articularly with cannulated screws. The antero-inferior capsule was then repaired to this new “glenoid rim”. All patients had a standard rehabilitation regime. All patients had an assessment of the Oxford Shoulder Instability Score (OIS) and the American Shoulder and Elbow Surgeons Score (ASES) before and after the operation. At an average follow-up of 26 months, the mean OIS had improved from 38.3 to 22.3 and the mean ASES had increased from 40.5 to 86.6. None had had a recurrent dislocation. The use of autogenous iliac crest bone graft to treat recurrent shoulder instability associated with significant glenoid bone loss is an effective treatment for this difficult condition.

Arthroscopic rotator cuff repair has evolved significantly in the last decade and has become a standard treatment. Satisfactory results of arthroscopic subacromial decompression (ASD) in the treatment of rotator cuff tears have also been reported (1). The aim of this study was to compare the outcome following arthroscopic repair versus decompression alone in patients with small & medium rotator cuff tears (Classification of Post, Silver & Singh (2). There were 114 patients in the ASD group and 96 in the Arthroscopic rotator cuff repair group (RCR). The groups were statistically comparable in terms of patient age & gender. Clinical follow-up was performed at a minimum of 12 months post -operatively (average 36 months). The average Post-op Constant score was 69.8 for the ASD group and 86.4 for the RCR group. The average post-op pain score (S.D) in the ASD group was 10.9 (± 4.3) and in the RCR group was 13.6 (± 3.1). Post operative strength was 7.6 (± 3.6) in the ASD group and 16.7 (± 5.4) in the RCR group.26 patients (22.8%) in the ASD group and 3 (3.3%) of the RCR group required futher surgery. Patient satisfaction (maximum 10 points) was 7.4% in the ASD group and 8.9 (± 1.4) in the RCR. The results of this study support arthroscopic rotator cuff repair. Shoulder strength is improved and there is significant reduction in the need for revision surgery.

Purpose: To evaluate the short to medium term outcome of fifty-four consecutive patients (58 shoulders) treated exclusively with radiofrequency capsular shrinkage for atraumatic instability.

Methods: Twenty-three men and thirty-one women (35 shoulders) with a mean age of twenty-four years (range, 14 to 53), who failed a 12 months course of physiotherapy. Instability was multidirectional in 26 patients (29 shoulders), antero-inferior in 24 patients (25 shoulders) and postero-inferior in 4 patients.

Results: The Rowe score improved from 33.1 to 74.1 points at thirty-two months (range, 19 to 48) (p< 0.001). Instability recurred in 20 of 58 (34.5%) shoulders. Recurrent instability was related to the type of instability (10 of 13 shoulders for voluntary instability, 10 of 33 shoulders for involuntary instability and none of 12 shoulders for instability pain, p< 0.001) and previous instability surgery (7 of 10 shoulders, p< 0.01).

Outcome was not related to the direction of instability, type of radiofrequency probe, age or ligamentous laxity. Two patients had a transient reduction in sensation in the axillary nerve distribution. 22 of 38 (57.9%) patients returned to their pre-instability level of sporting activity.

Conclusion: Radiofrequency capsular shrinkage produces satisfactory results in instability pain and in involuntary instability in patients who had no previous instability surgery.

Introduction: Thermal shrinkage has been used to reduce the volume of redundant capsule in patients with multidirectional instability. Concerns have been expressed that thermal shrinkage may char or burn the capsule compromising future attempts at surgical stabilization. The purpose of the current study was to assess whether laser assisted capsular shrinkage adversely affects the result of a subsequent open inferior capsular shift.

Patients: A prospective study of ten consecutive patients treated by open inferior capsular shift following a failed laser assisted capsular shrinkage. They were five men and five women with an average age of 29 years. Six patients had true multidirectional instability, two had antero-inferior instability with multidirectional laxity and two had postero-inferior instability with multidirectional laxity. An anterior approach was used and a humeral side capsular shift performed. The mean period of follow-up was 33 months (range, 18–47 months).

Results: According to the system of Rowe et al., nine patients had an excellent rating and one poor at final follow-up. The mean score improved from 37.5 to 94 points on the Rowe scale, from 73 to 90.0 points on the Constant score and from 1.6 to 7.6 points on a numerical satisfaction scale. The one poor result was in the only patient who had multiple attempts at open stabilization prior to laser assisted capsular shrinkage. There were no complications.

Conclusion: The results of an inferior capsular shift following failed laser assisted capsula-shrinkage are comparable with the results of a primary capsular shift for multidirectional instability.

The aim of this study was to assess the outcome of subacromial decompression alone for small and medium size rotator cuff tears.

Between January 1996 and Mach 1999, one hundred and fourteen patients had a subacromial decompression for small and medium cuff tears. They were sixty men (63 shoulders) and fifty women (51 shoulders) with a mean age of 61 years (range, 37 to 87 years). The mean duration of symptoms was 25 months (range, 3 to 225 months). There were 31 manual workers, 28 sedentary workers 55 were retired.

There were 26 small and 88 medium size tears. The mean follow-up was 40 months (range, 24 to 62 months). Patients were assessed using the constant score and a patient satisfaction scale. The mean (SD) Constant score was 70 (+/−16.8). The procedure was considered a failure, if the patient had subsequent surgery or was dissatisfied with the result. There were 29 (25.4%) unsatisfactory results. Twenty-five patients (21.9%) had revision surgery.

An unsatisfactory outcome was related to manual work (p< 0.001) and symptoms of more than 12 months (p< 0.05). Results were unsatisfactory in 40.4% of patients under the age of 60 years and 12.9% over the age of 60 years (p< 0.001). Unsatisfactory results were not related to arm dominance, sex, history of trauma, tear size, biceps pathology or presence of acromio-clavicular osteophytes (p> 0.5 for all).

The mean duration between subacromial decompression and subsequent surgery in 25 patients was 13 months (range: three to 35 months). At revision surgery, three (42.8%) of seven small tears had progressed to medium size tears and three (16.6%) of eighteen medium tears had progressed to large size tears.

Subacromial decompression for small and medium sized tears has an unsatisfactory outcome in patients under the age of sixty years and manual workers but may be a suitable alternative to cuff repair in patients above the age of sixty years. Some small and medium sized cuff tears progress in spite of adequate subacromial decompression.

The aim of this study was to assess the medium-term results of the Copeland cementless surface replacement of the shoulder for rheumatoid arthritis.

Between 1986 and 1998, 75 patients with rheumatoid arthritis had a cementless surface replacement. They were 58 females and 17 males with a mean age 60 years (range: 24 to 88 years). The mean follow-up was 6 years (range: 2 to 14 years). The functional outcome was assessed using the Constant score and a patient satisfaction scale. The mean Constant score was 53.4 points for total shoulder replacements (76 age/ sex adjusted) and 47.9 points for hemiarthroplasty (71 age/ sex adjusted). Forward elevation improved from 50 degrees to 104 degrees for total shoulder replacements and from 47 degrees to 101 degrees for hemiarthroplasty. Seventytwo patients (96%) considered the shoulder to be better or much better. 3 patients (4%) felt the shoulder was the same.

The deltopectoral approach was used in 38 while the antero-superior (Mackenzie) approach was used in 37 shoulders. The rotator cuff was intact in 24 shoulders, thin but intact in 21 shoulders, had a full thickness tear in 26 shoulders and a massive tear in four shoulders.

Sixty-eight patients were available for radiological review. Fifty-six (82.4%) humeral components showed no lucent lines. Eleven (16.2%) showed localised lucent lines < 1mm and one was loose. Of the 39 glenoid components, 19 (48.7%) showed no lucent lines, 19 (48.7%) showed lucent lines < 1mm and one was loose. No lucencies were observed in the hydroxyapatite coated implants.

Two patients in the total shoulder group with massive cuff tears required revision for component loosening. One patient in the hemiarthroplasty group was revised to a total due to pain, with complete pain relief.

The results of CSRA are at least comparable to stemmed prosthesis in rheumatoid arthritis. However, CSRA preserves bone stock and allows easier revision in this relatively young group of patients. It also reduces the risk of humeral shaft fractures compared to a stemmed implant, especially when an elbow replacement is needed.

The purpose of this study was to report the results of the vertical apical suture Bankart lesion repair.

Fifty-nine patients (52 men and seven women) with a mean age of twenty-seven years (range, 16–53 years) underwent this procedure. The mean duration of instability was 4 years and mean follow-up was 42 months (minimum of two years).

A laterally based T-shape capsular incision is performed with the horizontal component directed towards the glenoid neck and into the Bankart lesion. A vertical apical suture through the superior and inferior flaps of the Bankart lesion, tighten the anterior structures to allow them to snug onto the convex decorticated surface of the anterior glenoid.

At final review, according to the system of Rowe et al., 94.9% (56 patients) had a rating of good or excellent. Three patients had a recurrent dislocation due to further trauma.

The mean loss of forward elevation was 1 degree, external rotation with the arm at the side was 2.4 degrees and external rotation in 90 degrees abduction was 2.2 degrees. Of forty-four patients participating in sport, thirty-five (79.5%) returned to the same sport at the same level of activity, even returned to the same sport at a reduced level of activity and two patients did not return to sport.

The vertical apical suture repair offers a 94.9 percent success rate in terms of stability, a maintained range of motion and a 79.5% return to pre-injury level of sporting activity. It is technically less demanding than the Bankart procedure. All sutures used are absorbable. Complications related to non-absorbable implants and absorbable anchors and tacks are avoided.