Aims

Rotator cuff (RC) injuries are characterized by tendon rupture, muscle atrophy, retraction, and fatty infiltration, which increase injury severity and jeopardize adequate tendon repair. Epigenetic drugs, such as histone deacetylase inhibitors (HDACis), possess the capacity to redefine the molecular signature of cells, and they may have the potential to inhibit the transformation of the fibro-adipogenic progenitors (FAPs) within the skeletal muscle into adipocyte-like cells, concurrently enhancing the myogenic potential of the satellite cells.

Aims. The outcomes following nonoperative management of minimally displaced greater tuberosity (GT) fractures, and the factors which influence patient experience, remain poorly defined. We assessed the early patient-derived outcomes following these injuries and examined the effect of a range of demographic- and injury-related variables on these outcomes. Methods. In total, 101 patients (53 female, 48 male) with a mean age of 50.9 years (19 to 76) with minimally displaced GT fractures were recruited to a prospective observational cohort study. During the first year after injury, patients underwent experiential assessment using the Disabilities of the Arm, Shoulder and Hand (DASH) score and assessment of associated injuries using MRI performed within two weeks of injury. The primary outcome was the one-year DASH score. Multivariate analysis was used to assess the effect of patient demographic factors, complications, and associated injuries, on outcome. Results. The mean DASH score improved from 42.3 (SD 9.6) at six weeks post-injury, to 19.5 (SD 14.3) at one-year follow-up (p < 0.001), but outcomes were mixed, with 30 patients having a DASH score > 30 at one year. MRI revealed a range of associated injuries, with a full-thickness rotator cuff tear present in 19 patients (19%). Overall, 11 patients (11%) developed complications requiring further operative intervention; 20 patients (21%) developed post-traumatic secondary shoulder stiffness. Multivariate analysis revealed a high-energy mechanism (p = 0.009), tobacco consumption (p = 0.033), use of mobility aids (p = 0.047), a full-thickness rotator cuff tear (p = 0.002), and the development of post-traumatic secondary shoulder stiffness (p = 0.035) were independent predictors of poorer outcome. Conclusion. The results of nonoperative management of minimally displaced GT fractures are heterogeneous. While many patients have satisfactory early outcomes, a substantial subgroup fare much worse. There is a high prevalence of rotator cuff injuries and post-traumatic shoulder stiffness, and their presence is associated with poorer patient experience. Furthermore, patients who have a high-energy injury, smoke, or use walking aids, have worse outcomes. Cite this article: Bone Joint J 2023;105-B(5):534–542

Aims. An objective technological solution for tracking adherence to at-home shoulder physiotherapy is important for improving patient engagement and rehabilitation outcomes, but remains a significant challenge. The aim of this research was to evaluate performance of machine-learning (ML) methodologies for detecting and classifying inertial data collected during in-clinic and at-home shoulder physiotherapy exercise. Methods. A smartwatch was used to collect inertial data from 42 patients performing shoulder physiotherapy exercises for rotator cuff injuries in both in-clinic and at-home settings. A two-stage ML approach was used to detect out-of-distribution (OOD) data (to remove non-exercise data) and subsequently for classification of exercises. We evaluated the performance impact of grouping exercises by motion type, inclusion of non-exercise data for algorithm training, and a patient-specific approach to exercise classification. Algorithm performance was evaluated using both in-clinic and at-home data. Results. The patient-specific approach with engineered features achieved the highest in-clinic performance for differentiating physiotherapy exercise from non-exercise activity (area under the receiver operating characteristic (AUROC) = 0.924). Including non-exercise data in algorithm training further improved classifier performance (random forest, AUROC = 0.985). The highest accuracy achieved for classifying individual in-clinic exercises was 0.903, using a patient-specific method with deep neural network model extracted features. Grouping exercises by motion type improved exercise classification. For at-home data, OOD detection yielded similar performance with the non-exercise data in the algorithm training (fully convolutional network AUROC = 0.919). Conclusion. Including non-exercise data in algorithm training improves detection of exercises. A patient-specific approach leveraging data from earlier patient-supervised sessions should be considered but is highly dependent on per-patient data quality. Cite this article: Bone Joint Res 2023;12(3):165–177

Traumatic rotator cuff injuries can be a leading cause of prolonged shoulder pain and disability, and contribute to significant morbidity and healthcare costs. Previous studies have shown evidence of socio-demographic disparities with these injuries. The purpose of this nationwide study was to better understand these disparities based on ethnicity, sex, and socio-economic status, in order to inform future healthcare strategies. Accident Compensation Corporation (ACC) is a no-fault comprehensive compensation scheme encompassing all of Aotearoa/New Zealand (population in 2018, 4.7 million). Using the ACC database, traumatic rotator cuff injuries were identified between January 2010 and December 2018. Injuries were categorized by sex, ethnicity, age and socioeconomic deprivation index of the claimant. During the 9-year study period, there were 351,554 claims accepted for traumatic rotator cuff injury, which totalled over $960 million New Zealand Dollars. The greatest proportion of costs was spent on vocational support (49.8%), then surgery (26.3%), rehabilitation (13.1%), radiology (8.1%), general practitioner (1.6%) and “Other” (1.1%). Asian, Māori (Indigenous New Zealanders), and Pacific peoples were under-represented in the age-standardized proportion of total claims and had lower rates of surgery than Europeans. Māori had higher proportion of costs spent on vocational support and lower proportions spent on radiology, rehabilitation and surgery than Europeans. Males had higher number and costs of claims and were more likely to have surgery than females. There were considerably fewer claims from areas of high socio-economic deprivation. This large nation-wide study demonstrates the important and growing economic burden of rotator cuff injuries. Indirect costs, such as vocational supports, are a major contributor to the cost suggesting improving treatment and rehabilitation protocols would have the greatest economic impact. This study has also identified socio-demographic disparities which need to be addressed in order to achieve equity in health outcomes

Aims. Rotator cuff muscle atrophy and fatty infiltration affect the clinical outcomes of rotator cuff tear patients. However, there is no effective treatment for fatty infiltration at this time. High-intensity interval training (HIIT) helps to activate beige adipose tissue. The goal of this study was to test the role of HIIT in improving muscle quality in a rotator cuff tear model via the β3 adrenergic receptor (β3AR). Methods. Three-month-old C57BL/6 J mice underwent a unilateral rotator cuff injury procedure. Mice were forced to run on a treadmill with the HIIT programme during the first to sixth weeks or seventh to 12th weeks after tendon tear surgery. To study the role of β3AR, SR59230A, a selective β3AR antagonist, was administered to mice ten minutes before each exercise through intraperitoneal injection. Supraspinatus muscle, interscapular brown fat, and inguinal subcutaneous white fat were harvested at the end of the 12th week after tendon tear and analyzed biomechanically, histologically, and biochemically. Results. Histological analysis of supraspinatus muscle showed that HIIT improved muscle atrophy, fatty infiltration, and contractile force compared to the no exercise group. In the HIIT groups, supraspinatus muscle, interscapular brown fat, and inguinal subcutaneous white fat showed increased expression of tyrosine hydroxylase and uncoupling protein 1, and upregulated the β3AR thermogenesis pathway. However, the effect of HIIT was not present in mice injected with SR59230A, suggesting that HIIT affected muscles via β3AR. Conclusion. HIIT improved supraspinatus muscle quality and function after rotator cuff tears by activating systemic sympathetic nerve fibre near adipocytes and β3AR. Cite this article: Bone Joint Res 2023;12(8):455–466

Objectives. Triamcinolone acetonide (TA) is widely used for the treatment of rotator cuff injury because of its anti-inflammatory properties. However, TA can also produce deleterious effects such as tendon degeneration or rupture. These harmful effects could be prevented by the addition of platelet-rich plasma (PRP), however, the anti-inflammatory and anti-degenerative effects of the combined use of TA and PRP have not yet been made clear. The objective of this study was to determine how the combination of TA and PRP might influence the inflammation and degeneration of the rotator cuff by examining rotator cuff-derived cells induced by interleukin (IL)-1ß. Methods. Rotator cuff-derived cells were seeded under inflammatory stimulation conditions (with serum-free medium with 1 ng/ml IL-1ß for three hours), and then cultured in different media: serum-free (control group), serum-free + TA (0.1mg/ml) (TA group), serum-free + 10% PRP (PRP group), and serum-free + TA (0.1mg/ml) + 10% PRP (TA+PRP group). Cell morphology, cell viability, and expression of inflammatory and degenerative mediators were assessed. Results. Exposure to TA significantly decreased cell viability and changed the cell morphology; these effects were prevented by the simultaneous administration of PRP. Compared with the control group, expression levels of inflammatory genes and reactive oxygen species production were reduced in the TA, PRP, and TA+PRP groups. PRP significantly decreased the expression levels of degenerative marker genes. Conclusions. The combination of TA plus PRP exerts anti-inflammatory and anti-degenerative effects on rotator cuff-derived cells stimulated by IL-1ß. This combination has the potential to relieve the symptoms of rotator cuff injury. Cite this article: T. Muto, T. Kokubu, Y. Mifune, A. Inui, R. Sakata, Y. Harada, F. Takase, M. Kurosaka. Effects of platelet-rich plasma and triamcinolone acetonide on interleukin-1ß-stimulated human rotator cuff-derived cells. Bone Joint Res 2016;5:602–609. DOI: 10.1302/2046-3758.512.2000582

Os acromiale is a developmental defect caused by failure of fusion of the anterior epiphysis of the acromion between the ages of 22 and 25. The prevalence of os acromiale in the general population ranges from 1.4% to 15%. Os acromiale has been reported as a contributory factor to shoulder impingement symptoms and rotator cuff injuries, despite being a common incidental observation. In this retrospective study, we examined the prevalence of os acromiale in black African patients with shoulder pain. We retrospectively reviewed the clinical records, radiographs, and magnetic resonance imaging (MRI) scans of 119 patients who presented with atraumatic and minor traumatic shoulder pain at a single institution over a one-year period. Anteroposterior, scapula Y-view, and axillary view plain images were initially evaluated for the presence of os acromiale, and this was corroborated with axial MRI image findings. Patients with verified os acromiale had their medical records reviewed to determine their first complaint and the results of their clinical examination and imaging examination. Radiographs and MRI on 24 patients (20%) revealed an osacromiale. This cohort had a mean age of 59.2 years, and there were significantly more females (65%) than males. Meso-acromion was identified as the most prevalent type (n=11), followed by pre-os acromion (n=7). All patients underwent bilateral shoulder x-rays, and 45 percent of patients were found to have bilateral meso- acromion. Most patients (70%) were reported to have unstable os acromiale with subacromial impingement symptoms, and nine patients (36%) had confirmed rotator cuff tears based on clinical and Mri findings. Surgery was necessary for 47% of the 24 patients with confirmed Os acromiale (arthroscopic surgery, n=7; open surgery, n=1) in order to treat their symptoms. The prevalence of os acromiale in our African patients with atraumatic shoulder symptoms is greater than that reported in the general population. Os acromiale is a rare condition that should always be considered when evaluating shoulder pain patients

Abstract. Background. Rotator cuff injuries have traditionally been managed by either single-row or double-row arthroscopic repair techniques. Novel and more complex single-row methodologies have recently been proposed as a biomechanically stronger alternative. However, no rigorous meta-analysis has evaluated the effectiveness of complex single-row against double-row repair. This meta-analysis aims to evaluate clinical outcomes in patients with full-thickness rotator cuff injuries treated with both simple and complex single-row, as well as transosseous-equivalent double-row procedures. Methods. An up-to-date literature search was performed using the pre-defined search strategy. All studies that met the inclusion criteria were assessed for methodological quality and included in the meta-analysis. Pain score, functional score, range-of-motion and Re-tear rate were all considered in the study. Conclusion. The results of this meta-analysis suggest the there is no significant difference between simple single-row and TOE double-row in any of the observed outcomes. However, there are significantly improved ASES functional scores and lower re-tear rates with TOE DR when compared to sSR. The available data in the literature would therefore advocate the use of transosseous-equivalent double-row fixation for the treatment of full thickness cuff tears. This paper has highlighted other significant limitations in the included studies where further, more extensive literature is required on the subject to draw more robust conclusions

The June 2013 Children’s orthopaedics Roundup. 360 . looks at: whether reaching a diagnosis is more difficult than previously thought; adolescent and paediatric DDH; the A-frame orthosis and Legg-Calvé-Perthes’ disease; failure of hip surgery in patients with cerebral palsy; adolescent rotator cuff injuries; paediatric peripheral nerve injuries; predicting residual deformity following Ponseti treatment; and the Dunn procedure.

Introduction. The highest incidence of recurrent shoulder instability is in young patients, surgical repair can reduce recurrent instability and improve shoulder function. This has led to an increasing rate of stabilisation and use of MRI to identify associated injuries in first time dislocations. MRA has the benefit of distending the joint and is becoming increasingly used. The aim of this study is to establish the sensitivity and specificity of MRA in the investigation of patients with traumatic anterior shoulder dislocations. Methods. A retrospective analysis of patients undergoing both magnetic resonance arthrography and arthroscopy after a traumatic anterior shoulder dislocation between January 2011 and 2014. Images were interpreted by eight musculoskeletal radiologists and arthroscopic findings were obtained from surgical notes and used as a reference. The sensitivity, specificity and positive predictive value for the different injuries were calculated. Results. 60 patients were reviewed; 88% were male, mean age was 28 years (range 18 to 50) and 27% were primary dislocations. The overall sensitivity and specificity of MRA to all associated injuries was 0.9 (CI 0.83–0.95) and 0.94 (CI 0.9–0.96) retrospectively. The lowest sensitivity was seen in osseous Bankart 0.8 (CI 0.44–0.96) and SLAP lesions 0.5 (CI 0.14–0.86). Conclusion. MRA has a high sensitivity when used to identify associated injuries in shoulder dislocation although in 8 patients (13%) arthroscopy identified an additional injury. The overall agreement between MRA and arthroscopic findings was good but identification of GHL and rotator cuff injuries was poor. Level of Evidence. IV. Conflict of Interests. The authors confirm that they have no relevant financial disclosures or conflicts of interest. Ethical approval was not sought as this was a systematic review

Objectives . Rotator cuff tears are among the most common and debilitating upper extremity injuries. Chronic cuff tears result in atrophy and an infiltration of fat into the muscle, a condition commonly referred to as ‘fatty degeneration’. While stem cell therapies hold promise for the treatment of cuff tears, a suitable immunodeficient animal model that could be used to study human or other xenograft-based therapies for the treatment of rotator cuff injuries had not previously been identified. Methods . A full-thickness, massive supraspinatus and infraspinatus tear was induced in adult T-cell deficient rats. We hypothesised that, compared with controls, 28 days after inducing a tear we would observe a decrease in muscle force production, an accumulation of type IIB fibres, and an upregulation in the expression of genes involved with muscle atrophy, fibrosis and inflammation. Results . Chronic cuff tears in nude rats resulted in a 30% to 40% decrease in muscle mass, a 23% reduction in production of muscle force, and an induction of genes that regulate atrophy, fibrosis, lipid accumulation, inflammation and macrophage recruitment. Marked large lipid droplet accumulation was also present. Conclusions . The extent of degenerative changes in nude rats was similar to what was observed in T-cell competent rats. T cells may not play an important role in regulating muscle degeneration following chronic muscle unloading. The general similarities between nude and T-cell competent rats suggest the nude rat is likely an appropriate preclinical model for the study of xenografts that have the potential to enhance the treatment of chronically torn rotator cuff muscles. Cite this article: Bone Joint Res 2014;3:262–72

Purpose of the study:. To describe the incidence, nature, and risk factors associated with upper limb injuries in athletes participating in the London 2012 Paralympic Games. Materials and methods:. This study formed a component of the large prospective cohort study conducted over the 14-day period of the London 2012 Paralympic Games, coordinated through the IPC Medical Committee. Daily injury data were collected by team physicians in 3 329 athletes (46 606 athlete days) participating in the study, and 258 upper limb injuries were recorded. The incidence proportion (IP=number of injuries per 100 athletes), and incidence (number of injuries per 1000 athlete days) of upper limb injuries was calculated. Results:. The overall IP (with 95% CI) of upper limb injuries was 7,2 (6,4–8,1), with an incidence of 5,2 (4,6–5,8). Shoulder injuries were encountered most frequently with an overall incidence of 2,2 (1,85–2,7) and caused the greatest amount of time lost from sport. The incidence of shoulder injuries by sport was 8,8 (5,4–13,5) in powerlifting, 5,0 (2,1–9,8) in Judo, 2,8 (1,2–5,6) in wheelchair basketball, and 2,7 (1,6–4,2) in swimming. The incidence of injuries of the wrist and hand was 3,9 (1,4–8,5) in goal ball, 3,2 (1,5–6,0) in wheelchair basketball, and 2,8 (1,3–5,4) in table tennis. The majority of upper limb injuries occurred in athletes with spinal cord injuries (38,3%) and athletes with amputation or limb deficiency (28,4%). Rotator cuff impingement syndrome and chronic rotator cuff injury were the most frequent specific diagnoses in the upper limb injuries. Conclusion:. To date, this is the largest study evaluating upper limb injuries at the Paralympic Games. The shoulder is the anatomical region most frequently injured and caused the greatest time lost from sport. Type of sport, older age group, and athlete disability category were identified as risk factors for upper limb injuries

With respect to glenoid neck malunion and rotator cuff injury, conservative treatment is often considered best for extra-articular glenoid neck fractures. More recent studies reveal that outcomes are not uniformly good, but the cause of poor outcomes has not been investigated. We reviewed nine patients who had sustained a glenoid neck fracture of the scapula within the last 10 years and who had been treated conservatively with immobilisation and then early active motion. Their functional and anatomical outcomes were analysed by clinical examination and validated scoring systems, including the Oxford questionnaire and Constant shoulder score. Plain radiographs and MRI studies were correlated with outcome. None of the nine patients was free of pain and some had poor Oxford and Constant scores. Pain was associated with glenoid malunion and evidence of subacromial bursitis and/or rotator cuff tendinopathy

Shoulder pain or loss of normal range of motion is a frequent complaint in the outpatient clinic. Of these presentations, rotator cuff injury is a common cause. This can range from mild, transient inflammation of the tendons, to partial tears of tendons, or even full thickness tears. Disruption of the tendons can occur from forceful forward throwing actions undertaken in some sports, for example baseball pitching, more commonly in the UK however, chronic impingement can lead eventually to a tendon tear-usually seen in an older population. Current methods of investigation of such injuries after clinical history and examination, includes plain film radiography, ultrasonography, magnetic resonance imaging and arthrography. We decided to look at how ultrasound can be used in the district general hospital for investigation of such injuries. Aims. To determine the accuracy of ultrasound as an investigative tool for clinically suspected rotator cuff tears. Methods. Seventy-five consecutive ultrasonographic study reports, in patients who subsequently underwent arthroscopic examination, were scrutinised and correlated with surgical findings. From this, sensitivity and specificity of ultrasound at this district general hospital were calculated. In addition, this data was compiled for each of the three Consultant Radiologists in order to assess the operator dependent nature of ultrasound. Results. Of the 74 cases analysed, 43 (58.1%) had full correlation with the arthroscopy findings, 13 (17.6%) had mixed correlation, and 18 cases (24.3%) had no correlation between the ultrasound and arthroscopy report. The sensitivity and specificity of ultrasound at our institution was 0.76 and 0.8 respectively with regards to a tear being detected at ultrasound and then visualised during surgery. Conclusions. There is no current national guidance as to which imaging modality should be first line following clinical examination. Magnetic resonance arthrography, widely thought of as being the gold standard investigation, is not only expensive and possible only in certain centres, but is also invasive, time consuming, and has many relative contraindications. Ultrasound offers a clinical advantage by allowing the radiologist to speak to the patient and assess their range of motion whilst performing the study. This interaction is lost totally in MRI, CT and even MR arthrography. Our study shows that ultrasonography can be quite accurate in identifying a rotator cuff tear. Although it is operator-dependent, ultrasound should be considered more often as a first-line imaging tool for suspected rotator cuff tears as it is relatively inexpensive, quick, and most importantly dynamic

Background. Acute anterior dislocation of the glenohumeral joint may be complicated by injury to neighboring structures. These injuries are best considered a spectrum of injury ranging from an isolated dislocation (unifocal injury), through injuries associated with either nerve or osteoligamentous injury (bifocal injury), to injuries where there is evidence of both nerve and osteoligamentous injury. The latter combination has previously been described as the “terrible triad,” although we prefer the term “trifocal,” recognizing that this is the more severe end of an injury spectrum and avoiding confusion with the terrible triad of the elbow. We evaluated the prevalence and risk factors for nerve and osteoligamentous injuries associated with an acute anterior glenohumeral dislocation in a large consecutive series of patients treated in our Unit. Materials and Methods. 3626 consecutive adults (mean age 48yrs) with primary traumatic anterior shoulder dislocation treated at our unit were included. All patients were interviewed and examined by an orthopaedic trauma surgeon and underwent radiological assessment within a week of injury. Where rotator cuff injury or radiologically-occult greater tuberosity fracture was suspected, urgent ultrasonography was used. Deficits in neurovascular function were assessed clinically, with electrophysiological testing reserved for equivocal cases. Results. Unifocal injuries occurred in 2228 (61.4%) of patients. There was a bimodal distribution in the prevalence of these injuries, with peaks in the 20–29 age cohort (34.4% patients) and after the age of 60 years (23.0% patients). Of the 1120 (30.9%) patients with bifocal dislocations, 920 (82.1%) patients had an associated osteotendinous injury and 200 (17.9%) patients had an associated nerve injury. Trifocal injuries occurred in 278 (7.7%) of cases. In bifocal and trifocal injuries, rotator cuff tears and fractures of the greater tuberosity or glenoid were the most frequent osteotendinous injuries. The axillary nerve was most frequently injured neurological structure. We were unable to elicit any significant statistical differences between bifocal and trifocal injuries with regards to patient demographics. However, when compared with unifocal injuries, bifocal or trifocal injuries were more likely to occur in older, female patients resulting from low energy falls (p<0.05). Conclusions. We present the largest series reporting the epidemiology of injury patterns related to traumatic anterior shoulder dislocation. Increased understanding and awareness of these injuries among clinicians will improve diagnosis and facilitate appropriate treatment

This randomized clinical trial utilizing the validated rotator cuff disease specific quality of life outcome measure (RC-QOL) and adequate power demonstrates no difference in outcome for full thickness rotator cuff tears comparing open to mini-open surgical techniques. The purpose of the study was to compare standard open rotator cuff repair versus mini-open rotator cuff repair by measuring the disease specific quality of life in patients with rotator cuff injury. This randomized clinical trial utilizing a validated disease specific outcome measure and adequate power demonstrates no difference in outcome for full thickness rotator cuff tears comparing open to mini-open surgical techniques. The miniopen approach utilizing an arthroscoic acromioplasty provides no additional beneifit to the patient undergoing a rotator cuff repair. The mean one year RC-QOL score for the open and mini-open groups were 85.3 (SD = 15.6) and 87.4 (SD = 12.0) out of a maximum of one hundred, respectively. This difference was not statistically significant (p = 0.572). Seventy-two patients (forty-eight males/twenty-four females) with an average age of 56.4 years (thirty-three to eighty-two years) consented to participate in the study. Inclusion criteria involved: unremitting pain, failed conservative treatment of at least three months, weakness of rotator cuff, and positive diagnostic imaging indicating a full-thickness rotator cuff tear. Massive rotator cuff tears were excluded. Prior to surgery, patients were randomized to either open or mini-open rotator cuff repair. Patients were assessed and outcomes were collected at three, six and twelve months after surgery. Primary Outcome Measure: Patient quality of life was quantified using the validated disease specific, reliable and responsive Rotator Cuff Quality of Life Questionnaire (RC-QOL) measured on a one hundred point visual analogue scale format. Secondary Outcomes: Range of motion, strength, American Shoulder and Elbow Surgeons Score, and the Shoulder Rating Questionnaire

Aims

Mechanical stimulation is a key factor in the development and healing of tendon-bone insertion. Treadmill training is an important rehabilitation treatment. This study aims to investigate the benefits of treadmill training initiated on postoperative day 7 for tendon-bone insertion healing.

A powered, randomised control trial was instigated to evaluate the advantages of subacromial injection of Methylprednisolone over conservative treatment in the management of partial rotator cuff injuries of the shoulder. Consecutive patients with possible partial rotator cuff tears were reviewed at 1 week. Inclusion criteria for a diagnosis of partial rotator cuff tear included; traumatic mechanism, greater tuberosity tenderness, painful arc, and complete resolution of disability post-Bupivicaine block. Exclusion criteria included; age < 16 years, chronic shoulder disease, acromioclavicular tenderness, and abnormal shoulder radiograph. Patients were randomly allocated to receive either 1 immediate subacromial injection of 40mg Methylprednisolone (group S) or no injection (group N). Initial outcomes measured were; visual analogue pain score (0–10) and active abduction (nearest 5°), repeated at 3, 6, and 12 weeks. All patients were instructed in analgesia usage and given identical shoulder exercises. Of 279 patients reviewed over 3 years, 90 met the inclusion criteria (6/90 patients were lost to follow-up). 50 patients were randomised to group S, 40 to group N. Mean pain score improvement at 12 weeks was comparable (S=4.95, N=4.44) (p> 0.1, CI=0.16–0.86). In patients aged > 40 years group S had significantly higher mean improvement in abduction at completion (64.28°) compared to group N (34.63°) (p< 0.02, CI 1.29–58.01). Conversely in patients aged < 40 years group S had lower mean improvements in abduction (40.55°) compared to group N (77.73°), though this was not statistically significant (p=0.1, CI 2.06–72.29). Methylprednisolone injection is more efficacious than conservative treatment alone in some patients. This benefit appears age-dependent and consequently such treatment should be reserved for patients aged > 40 years

Aim: End result study of closed intramedullary nailing of humerus fractures. Materials & methods: Between 1995–2003, 42 patients with fracture of the humeral shaft, were selected to be treated by I.N. The average age was 48 years old (17years–82years) The Selection criteria were: α) loss of closed reduction (24 patients), b) pathological fractures (5 patients), c) non-union following external fixation (2 patients) and d) delay of union (7 patients). The intramedullary nail was inserted through a proximal entry point via a transdeltoid incision. In 25 cases the entry point was below the greater tuberosity to avoid rotator cuff injury and in 18 cases the entry point was intraarticular. All nails were locked either proximal (41) or distally (1). Open technique was required for 21 cases. Passive full range of motion of elbow and shoulder joint was encouraged after the second postoperative day. Active assisted exercises were initiated the second postoperative week. Bone healing was confirmed by clinical and radiological findings. Shoulder mobility was evaluated by the Constant-Murley scoring system. Results: The average follow-up time was 21 months (9 months–8 years).All fractures were finally healed. The average healing time was 13 weeks (8weeks–13weeks). Patients with extraarticular entry point of the nail had full passive shoulder motion between the 2th and the 4th postoperative week, whereas patients with intraarticular nail application presented delayed passive shoulder motion with final limitation of the normal range of motion. Seven patients had painful shoulder motion 3 months postoperatively. There were 4 patients with neurapraxia of the radial nerve installed posttraumatic, who had full recovery 3 months later. There was one proximal migrated nail, which required revision. None of the patients required nail removal. Conclusions: Intramedullary nailing of humeral shaft fractures seems to be a reliable method of treatment. Shoulder mobilization after anterograde insertion of the nail can be easily restored with proper choice of entry point and proper physiotherapy program. The advantages of this method include: shorter operative time, less blood loss, small incision with minimal soft tissue damage. Extraarticular nail insertion should be the entry point of choice as there is no trauma to the rotator cuff

Aims

Orthopaedic surgery requires grafts with sufficient mechanical strength. For this purpose, decellularized tissue is an available option that lacks the complications of autologous tissue. However, it is not widely used in orthopaedic surgeries. This study investigated clinical trials of the use of decellularized tissue grafts in orthopaedic surgery.

The current 6th Edition of the AMA Guides presents a paradigm shift from objective impairment assessment to one of disability rating based not only on functional activity but on participation in a life situation. AMA 6 evaluates disability more strongly than previous editions. The methodology is to base assessment on diagnosed based impairment (DBI) using DBI grids that have been formulated for each diagnosed condition, each as a class of diagnosis (CDX) eg. rotator cuff injury. These grids are further modified internally by using grade modifiers for:. Functional History (GMFH). Physical Examination (GMPE). Clinical Studies (GMCS). These internal grades allow the assessor to grade each DBI within its class and fine tune the assessment to promote greater reliability. NB. Adjustment factors only allow change within that class. The 6th Edition emphasises the importance of causation in forming the diagnosis and it differs from previous guides in that it allows for impaction on activities of daily living to apply not just to the spine but to the upper and lower limbs. These ADL’s can be normal activities such as swimming and bathing, or Instrumental ADL’S such as meal preparation. Considerable weight is given to functional assessment and aids the functional history and includes:. QuickDash for the upper limb. AAOS Lower Limbs Outcomes Questionnaire. PDQ score (Pain and Disability) applied to the spine. Pain Rated Impairment (PRI) allows up to a 3% modifier in certain circumstances. Burden of Treatment Compliance (BOTC) allows an additional modifier up to 2 of 3% when it can be reasonable assessed that but for medication, the claimant would have had a higher WPI. There are special tables for entrapment syndromes, amputation impairment and complex regional pain syndrome (CRPS). Mental and behavioural problems and chronic pain resulting from musculo-skeletal disorders is usually captured within the rating of that disorder itself and, as such, independent mental health impairment rating is considered to be double dipping. The final figure for impairment is based on the net adjustment formula as set out in the guides. (GMFH−CDX) + (GMPE − CDX) + (GMCS − CDX). The AMA 6th Edition, relies on diagnosis based impairment, rated on disability, and certain unreliable physical examinations have been excluded, such as the range of motion in the spine, grip strength measurements and using certain operative procedures to delineate assessment rather than the functional outcome of that procedure. A comparison of range of motion bilaterally is now mandatory and sensory deficit is based on two point discrimination when there has been nerve division and monofilament testing when there is decreased light touch. Here nerve conduction studies have assumed particular importance with entrapment syndromes. AMA 6 guides represents a new approach to impairment assessment based on disability rating which requires greater clinical acumen and cannot be achieved without adequate medical knowledge. ComCare is obliged to use the new guides under current legislation and this is already in use in several jurisdictions around the world

The August 2023 Shoulder & Elbow Roundup360 looks at: Motor control or strengthening exercises for rotator cuff-related shoulder pain? A multi-arm randomized controlled trial; Does the choice of antibiotic prophylaxis influence reoperation rate in primary shoulder arthroplasty?; Common shoulder injuries in sport: grading the evidence; The use of medial support screw was associated with axillary nerve injury after plate fixation of proximal humeral fracture using a minimally invasive deltoid-splitting approach; MRI predicts outcomes of conservative treatment in patients with lateral epicondylitis; Association between surgeon volume and patient outcomes after elective shoulder arthroplasty; Arthroscopic decompression of calcific tendinitis without cuff repair; Functional outcome after nonoperative management of minimally displaced greater tuberosity fractures and predictors of poorer patient experience.

Aims

Distal third clavicle (DTC) fractures are increasing in incidence. Due to their instability and nonunion risk, they prove difficult to treat. Several different operative options for DTC fixation are reported but current evidence suggests variability in operative fixation. Given the lack of consensus, our objective was to determine the current epidemiological trends in DTC as well as their management within the UK.

Aims

The aim of this systematic review and meta-analysis was to gather epidemiological information on selected musculoskeletal injuries and to provide pooled injury-specific incidence rates.

Aims

It has been established that mechanical stimulation benefits tendon-bone (T-B) healing, and macrophage phenotype can be regulated by mechanical cues; moreover, the interaction between macrophages and mesenchymal stem cells (MSCs) plays a fundamental role in tissue repair. This study aimed to investigate the role of macrophage-mediated MSC chondrogenesis in load-induced T-B healing in depth.

Aims

To compare the functionality of adults with displaced mid-shaft clavicular fractures treated either operatively or nonoperatively and to compare the relative risk of nonunion and reoperation between the two groups.

Purpose of the study: When repairing rotator cuff tears, injury to the infraspinatus is generally a posterior extension of a supraspinatus tear. The description of isolated tears of the infraspinatus has not been to our knowledge reported in the literature. We report a series of 13 cases with more than one year follow-up. Material and methods: Thirteen patients underwent surgery for an isolated tear of the infraspinatus between 1995 and 2004. There were ten men and three women. Mean age at surgery was 47 years (range 34–62). The right shoulder was involved in seven of the thirteen cases, and the dominant shoulder in eight. A progressive onset was observed in eleven patients and nine had a history of treated calcified tendinopathy. Clinically, pain was the predominant symptom. The Jobe test was deficient in all patients as was external rotation (except one patient). The preoperative Constant score was 70 (range 62–87). X-rays revealed type C posterior calcification in nine patients. A full-thickness tear was observed in seven cases, a partial deep tear in three, and a partial superficial tear in three. Isolated fatty degeneration of the infraspinatus noted Goutallier grade 2 or greater was observed in seven patients. Open surgical repair was preformed in all patients. Results: Mean time to revision was 29 months (range 12–82). Subjectively, six patients were very satisfied, six were satisfied, and one was disappointed (failure by secondary tear). Two shoulder-hand syndromes were noted in the postoperative period. At last follow-up, the Constant score was 83.5 (range 64–97). All patients except one were satisfied with pain relief but the lack of force was significant. Discussion and conclusion: Isolated tears of the infra-spinatus are rare, but there is a notable relationship with calcifying tendinopathy of the same tendon. Repair should be undertaken before the development of fatty degeneration in order to improve the chances of force recovery

Objectives

Metabolic syndrome and low-grade systemic inflammation are associated with knee osteoarthritis (OA), but the relationships between these factors and OA in other synovial joints are unclear. The aim of this study was to determine if a high-fat/high-sucrose (HFS) diet results in OA-like joint damage in the shoulders, knees, and hips of rats after induction of obesity, and to identify potential joint-specific risks for OA-like changes.

Aims

Manipulation under anaesthetic (MUA) is a recognised form of treatment for patients with a frozen shoulder. However, not all patients benefit. Some have persistent or recurrent symptoms. There are no clear recommendations in the literature on the optimal management of recurrent frozen shoulder after a MUA. We aimed to address this issue in this study.

The April 2015 Shoulder & Elbow Roundup³⁶⁰ looks at: Distal clavicular resection not indicated in cuff repair?; Platelet-rich plasma in rotator cuff repair; Radial head geometry: time to change?; Heterotopic ossification in elbow trauma; Another look at heterotopic ossification in the humerus; Triceps on for total elbow arthroplasty?; Predicting outcomes in rotator cuff repair; Deltoid fatty infiltration and reverse shoulder arthroplasty

The aim of this study was to review the role of clinical trial networks in orthopaedic surgery. A total of two electronic databases (MEDLINE and EMBASE) were searched from inception to September 2013 with no language restrictions. Articles related to randomised controlled trials (RCTs), research networks and orthopaedic research, were identified and reviewed. The usefulness of trainee-led research collaborations is reported and our knowledge of current clinical trial infrastructure further supplements the review. Searching yielded 818 titles and abstracts, of which 12 were suitable for this review. Results are summarised and presented narratively under the following headings: 1) identifying clinically relevant research questions; 2) education and training; 3) conduct of multicentre RCTs and 4) dissemination and adoption of trial results. This review confirms growing international awareness of the important role research networks play in supporting trials in orthopaedic surgery. Multidisciplinary collaboration and adequate investment in trial infrastructure are crucial for successful delivery of RCTs.

Cite this article: Bone Joint Res 2014;3:169–74.

Tendinopathy is a debilitating musculoskeletal condition which can cause significant pain and lead to complete rupture of the tendon, which often requires surgical repair. Due in part to the large spectrum of tendon pathologies, these disorders continue to be a clinical challenge. Animal models are often used in this field of research as they offer an attractive framework to examine the cascade of processes that occur throughout both tendon pathology and repair. This review discusses the structural, mechanical, and biological changes that occur throughout tendon pathology in animal models, as well as strategies for the improvement of tendon healing.

Cite this article: Bone Joint Res 2014;3:193–202.

The role of inflammatory cells and their products in tendinopathy is not completely understood. Pro-inflammatory cytokines are upregulated after oxidative and other forms of stress. Based on observations that increased cytokine expression has been demonstrated in cyclically-loaded tendon cells we hypothesised that because of their role in oxidative stress and apoptosis, pro-inflammatory cytokines may be present in rodent and human models of tendinopathy. A rat supraspinatus tendinopathy model produced by running overuse was investigated at the genetic level by custom micro-arrays. Additionally, samples of torn supraspinatus tendon and matched intact subscapularis tendon were collected from patients undergoing arthroscopic shoulder surgery for rotator-cuff tears and control samples of subscapularis tendon from ten patients with normal rotator cuffs undergoing arthroscopic stabilisation of the shoulder were also obtained. These were all evaluated using semiquantitative reverse transcription polymerase chain-reaction and immunohistochemistry.

We identified significant upregulation of pro-inflammatory cytokines and apoptotic genes in the rodent model (p = 0.005). We further confirmed significantly increased levels of cytokine and apoptotic genes in human supraspinatus and subscapularis tendon harvested from patients with rotator cuff tears (p = 0.0008).

These findings suggest that pro-inflammatory cytokines may play a role in tendinopathy and may provide a target for preventing tendinopathies.