Little has been written about the results of isolated acromioclavicular joint (ACJ) resection using the superior approach. We report the results of our large series.

Between June 1994 and October 2003, a single surgeon performed 155 isolated ACJ resections, using the direct superior approach. Exclusion criteria were previous ipsilateral shoulder surgery, simultaneous arthroscopic procedures and OA. We asked 90 of the patients (94 shoulders) to complete the Simple Shoulder Test questionnaire by telephone. The median age of the 72 males and 18 females was 38 years (16 to 62). The dominant shoulder was involved in 54 patients. There was a history of trauma in 44 patients, with 11 rugby injuries. The median follow-up period was 29 months (6 to 118).

One portal infection resolved with debridement and antibiotics. Five revision procedures were done, four open revision Mumfords and one subacromial decompression. The mean postoperative Simple Shoulder score was 11.5 (6 to 12). Patients rated outcome as excellent in 63 shoulders, good in 22, moderate in five and poor in four.

The technique provides consistently good or excellent results (90%) and allows rapid return to normal function. There was complete resolution of pain in 73 of the 94 shoulders. All rugby players returned to the same level of play.

Aims. The aim of this study was to examine the recent trend in delivery of arthroscopic subacromial decompression (ASD) in Scotland and to determine if this varies by geographical location. Methods. Scottish Morbidity Records were reviewed retrospectively between March 2014 and April 2018 to identify records for every admission to each NHS hospital. The Office of Population Censuses and Surveys (OPCS-4) surgical codes were used to identify patients undergoing primary ASD. Patients who underwent acromioclavicular joint excision (ACJE) and rotator cuff repair (RCR) were identified and grouped separately. Procedure rates were age and sex standardized against the European standard population. Results. During the study period the number of ASDs fell by 649 cases (29%) from 2,217 in the first year to 1,568 in the final year. The standardized annual procedure rate fell from 41.6 (95% confidence interval (CI) 39.9 to 43.4) to 28.9 (95% CI 27.4 to 30.3) per 100,000. The greatest reduction occurred between 2017 and 2018. The number of ACJEs rose from 41 to 188 (a 3.59-fold increase). The number of RCRs fell from 655 to 560 (-15%). In the year 2017 to 2018 there were four (28.6%) Scottish NHS board areas where the ASD rate was greater than 3 standard deviations (SDs) from the national average, and two (14.3%) NHS boards where the rate was less than 3 SDs from the national average. Conclusion. There has been a clear decline in the rate of ASD in Scotland since 2014. Over the same period there has been an increase in the rate of ACJE. The greatest decline occurred between 2017 and 2018, corresponding to the publication of epidemiological studies demonstrating a rise in ASD, and awareness of studies which questioned the benefit of ASD. This paper demonstrates the potential impact of information from epidemiological studies, referral guidelines, and well-designed large multicentre randomized controlled trials on clinical practice. Cite this article: Bone Joint J 2020;102-B(3):360–364

This study looks at the outcomes of 112 full thickness rotator cuff tears treated by arthroscopic decompression, without repair of the rotator cuff, from 1994. The decision not to repair the tear was taken only if four criteria were met. First, if there was no clinical weakness on manual testing of the individual rotator cuff muscles, secondly, if there was full abduction, thirdly, if there was no riding up of the humeral head on the anteroposterior radiograph and fourthly, if there was well-developed ‘cable’ on arthroscopic visualisation of the rotator cuff. The mean age of the patients, 38% of whom were men, was 62 years (47 to 83). In 44% the right shoulder was operated on. There were 32% type-II acromions and 68% type-III. There were 58% C2 tears and 42% C3 tears. All had arthroscopic acromioplasty and acromioclavicular joint excision. Later, three required an open acromioclavicular joint excision with one open cuff repair. At a mean follow-up time of 71 months (11 to 110), the clinical and surgical notes and radiographs were reviewed and a modified Simple Shoulder Test (SST) used to evaluate outcomes by telephone. The mean postoperative SST was 11.5 out of 12 (3 to 12). Complete relief was reported in 84% of cases. These subjective results suggest that, with careful selection, not all full thickness tears of the rotator cuff need repair

There is concern that intra-articular electrosurgical ablation may cause thermal soft tissue damage, particularly chondrolysis, if excessive temperatures are reached. The aim of this study was to determine whether the intra-articular temperature during arthroscopic subacromial decompression using a monopolar electrosurgical ablator remains below a safe level. Data was collected prospectively from consecutive shoulder arthroscopic subacromial decompressions performed at our institution. Shoulder arthroscopy was performed using three standard portals. Evaluation of the glenohumeral joint and subacromial space was performed in a standard manner. Soft tissue resection of the subacromial bursa was performed using a monopolar electrosurgical ablator probe with continuous integral suction. Additional procedures such as acromioclavicular joint excision and rotator cuff debridement or repair were performed as appropriate. Bone resection, if required was performed using an arthroscopic burr. The temperature of the fluid within the shoulder and subacromial space was continuously monitored using a sterile digital temperature probe. The surgeon performing the procedure was blinded the collection of data. Data from thirty subacromial decompressions has been collected. 8 patients had full thickness cuff tears of which 6 were debrided, and 2 repaired arthroscopically. 13 patients had acromioclavicular joint excision. Mean operating time was 46 minutes (30–107). The infusion pressure ranged from 40 to 65 mmHg. The median volume of infused fluid was 3900 ml (1500 to 9000). The starting temperature ranged from 18.3 to 21.9. The mean maximum temperature reached was 27.6 (range 22.7 to 41.8 °C). The results suggest that the intra-articular temperature is maintained within safe levels when a monopolar electrosurgical ablator with integral suction is used to perform soft tissue subacromial decompression

Suturing of portals following arthroscopic shoulder surgery may be unnecessary. We carried out a randomised controlled trial to compare patients whose arthroscopic portals were closed by suturing and those that weren’t. We randomised 60 patients undergoing diagnostic shoulder arthroscopy, arthroscopic subacromial decompression and arthroscopic acromioclavicular joint excision. At 10 to 12 days following surgery patients attended the GP surgery for a wound check and removal of sutures as required. At 3 weeks and 3 months every patient was reviewed by a designated, blinded, observer and the wounds assessed. The patients completed a questionnaire including visual analogue scores to determine their satisfaction with wound appearance and any complications such as infection. At 3 weeks and 3 months no patients had needed antibiotics with no wound erythema or signs of infection. The number of dressings needed was comparable in both groups. The level of patient satisfaction was not statistically different in either group. (T-test 0.91, SD 15.16) The wound cosmesis score was not statistically different in either group. (T-test 0.29, SD 6.66). We conclude that both closure techniques were equivalent but the non-suture technique is cheaper with lower morbidity. From our study there is no need to suture shoulder arthroscopy portal wounds

Introduction The value of collecting continuous prospective patient data, including operation records and outcome scores, is well known. In 1994, a systematic prospective patient data collection was initiated on all patients attending the Reading Shoulder Unit (RSU). Initially this was done with hand written records. In 1995 a Windows Access ® database was formulated on a portable laptop. This was used continuously through until September 2005 when an Internet web-based database was introduced. We present this collective data and trends in practice from a busy shoulder unit over this decade. Results Between 1995 and 2005, 10005 entries were made to the Reading Shoulder Unit database. 3233 patient visits to outpatient clinics were recorded. 6772 operations were recorded – this includes: arthroscopic decompressions (ASD) + AC joint excisions − 3514, MUA for frozen shoulder 842, shoulder arthroplasty 432, open stabilisation 356, arthroscopic stabilisation 192, arthroscopic rotator cuff repair (RCR) 402, open cuff repair 290, arthroscopic capsular release 78 and 248 trauma cases. Changes in the unit practice include the move from open to arthroscopic reconstructive surgery (RC and stabilisation), RCR rather than ASD alone in elderly patients with impingement and cuff weakness, and repairing partial rotator cuff tears when previously we did not. Conclusions With over 10000 continuous and prospective entries – the RSU database is invaluable for continuous audit of practice and assessment of outcomes of the different procedures. Several practices have changed through the decade; most notably from predominately open reconstructive surgery through to arthroscopic reconstructive surgery. We would recommend to every surgeon and unit to collect his own data prospectively to enable him to analyse and assess his results

The purpose of this study is to report the 1 to 5 year results of arthroscopic Rotator Cuff repairs. Between November 2001 to May 2003, 115 consecutive patients were operated (73 males and 42 females) with arthroscopic repair. 13 patients were lost to follow up, leaving 102 patients available for follow up. Patients were evaluated using the Constant score, satisfaction levels and ultrasound scan to evaluate cuff integrity. Failures were defined as dissatisfied patients and those who had had a re-operation. Re-tear rate was recorded. The mean follow up time was 23.8 months (range 12–61). Mean age was 57.3 years (range 23–78). 47% had a history of trauma. There were 107 patients (95.5%) with full thickness tears and 5 (4.5%) had partial thickness tears. Of the full thickness tears, 8 (7.6%) were massive in size, 36 (34%) large, 44 (41.5%) medium and 18(17%) small. Isolated Supraspinatus (SSP) tear was recorded in 83.5% and subscapularis tear in 7 %. A combination of SSP tear with infraspinatus and teres minor was found in 9.6%. 86% had Acromioplasty (ASD) with or without an AC joint excision arthroplasty. Two patients had Bankart repairs in addition at the time of cuff repair. The mean pre op Constant score was 40.9 points (95% CI 37.3 to 44.5), which had improved to 84.8 (CI 82.2 to 86.9) at last follow-up. 78% returned to same work and 82% returned to pre injury leisure activity. There were 20 re-tears (19.6%). eight of the 102 patients were not satisfied. Five of these patients had revision operation. Arthroscopic cuff repair shows high satisfaction rate (92%) and good functional results with 20% re-tear rate, while offering all the advantages of arthroscopic surgery

Arthroscopic Rotator cuff repair is gaining popularity in recent years; however, the results of arthroscopic repairs are yet to be reported. Between November 2001 to May 2003, 115 consecutive patients were operated (73 males and 42 females) with arthroscopic repair. 13 patients were lost to follow up, leaving 102 patients available for follow up. The mean follow up time was 23.8 months (range 12–61). There were 107 patients (95.5%) with full thickness tears and 5 (4.5%) had partial thickness tears. Of the full thickness tears, 8 (7.6%) were massive in size, 36 (34%) large, 44 (41.5%) medium and 18(17%) small. Mean age was 57.3 years (range 23–78). 47% had a history of trauma. Mainly Supraspinatus (SSP) tear was recorded in 83.5% and isolated subscapularis tear in 7%. A combination of SSP tear with infraspinatus and teres minor minor (posterior tear) was found in 9.6%. 86% had Acromioplasty (ASD) with or without an AC joint excision arthroplasty. Two patients had Bankart repairs in addition at the time of cuff repair. Patients were evaluated using the Constant score, satisfaction levels and ultrasound scan to evaluate cuff integrity. Failures were defined as dissatisfied patients and those who had had a re-operation. Re-tear rate was recorded. The mean pre op Constant score was 40.9 points (95% CI 37.3 to 44.5), which had improved to 84.8 (CI 82.2 to 86.9) at last follow-up. 78% returned to same work and 82% returned to pre injury leisure activity. There were 20 ultrasound demonstrated re-tears (19.6%). However, the majority of patients with radiological re-tears had good function, pain relief and were satisfied. Eight of the 102 patients were not satisfied. Five of these patients had revision operation. Arthroscopic cuff repair shows high satisfaction rate (92%) and good functional results while offering all the advantages of arthroscopic surgery

All known shoulder surgeons in Scotland have made a voluntary registration of shoulder replacements since 1996. Information regarding diagnostic and demographic characteristics of the patients, rotator cuff status and type of procedure performed were collated. 20 surgeons have contributed to the register, performing a varied number of shoulder arthroplasties (2 to 79). By five years the total number of shoulder replacements performed was 451. 23. 2 % of patients were male and 76. 8% female. 397 patients had a hemiarthroplasty and 54 (12 %) had a total shoulder replacement. 204/451 (45 %) humeral components used were cemented. In comparison 48/54 (89%) glenoid components used were cemented. The most common condition requiring shoulder arthroplasty was inflammatory arthritis (184 cases), followed by trauma (128 cases), of which 60 % were for acute trauma and 40 % for old trauma. The remainder consisted of osteoarthritis (87 cases), avascular necrosis (27 cases), and others (25 cases). The consultant in 425 cases and the trainee in 26 cases performed the operation. In 85/451 (18. 9%) of the cases, associated procedures were performed which included cuff repair (26 cases), coracoacromial ligament excision (43 cases), coracoid osteotomy (14 cases) and acromioclavicular joint excision (2 cases). There were 24 intra-operative complications and 9 patients had a revision. Comparison with figures from the Information and statistics division in Scotland however indicated that our register collected only 53 % of all the arthroplasties performed. In addition it was noted that 30 % of shoulder replacements were performed by surgeons who performed three or fewer shoulder replacements a year. In an age of clinical governance we believe that a register can provide detailed and accurate information. It is useful for demonstrating current practice and can highlight future changes in practice. This register supports the need for a national register and surveillance of shoulder replacements. However, in addition to the voluntary data registration, it is proposed that dedicated data collection staff are employed to coordinate the data collection process

Aims

Multiple secondary surgical procedures of the shoulder, such as soft-tissue releases, tendon transfers, and osteotomies, are described in brachial plexus birth palsy (BPBP) patients. The long-term functional outcomes of these procedures described in the literature are inconclusive. We aimed to analyze the literature looking for a consensus on treatment options.

The incidence of frozen shoulder (FS) as a complication of simple arthroscopic shoulder surgery has yet to be defined. A single-surgeon case series of patients undergoing arthroscopic subacromial decompression (ASD) or ASD with arthroscopic acromioclavicular joint (ACJ) excision was analysed to establish FS rate, this cohort was then compared to a matched group of primary FS patients. Retrospective analysis of 200 consecutive cases was undertaken. All procedures listed, performed and reviewed by the senior author. 96 underwent ASD and 104 underwent ASD and ACJ excision. 6-months follow-up minimum. Incidence of frozen shoulder was 5.21% (ASD) and 5.71% (ASD+ACJ excision). Mean age was 52.3 years (95% CI: 47.4 to 57.2) of the patients that developed FS, compared to 57.2 years (95% CI: 55.2 to 59.2) in the patients who did not and 52 years (95% CI: 50.7 to 53.3) in the primary FS cohort (n=136). 9.1% of post-operative FS were diabetic compared to 17.1% of primary FS. 63.6% were female in the post-operative FS group, 47.1% in the primary FS group. Our results suggest that the risk of FS following simple arthroscopic procedures is 5%, with no increased risk if the ACJ is also excised. This cohort has the same average age as a primary FS. There is a trend toward female sex and diabetes does not increase the risk

Introduction: Acromioclavicular (AC) joint injuries are common in both the sporting and working populations. Most injuries are grade I in severity and settle with an appropriate non-operative treatment program. Arthroscopic soft tissue debridement of the AC Joint without excising the distal clavicle, is a bone sparing procedure that, to our knowledge, has never been reported in the literature. This paper is a retrospective review of patients with chronic recalcitrant AC joint injuries, who underwent arthroscopic soft tissue debridement of the AC joint. Materials and Methods: Fourteen patients underwent arthroscopic AC joint soft tissue debridement. All patients had failed a non-operative treatment program including physiotherapy, anti-inflammatory tablets and corticosteroid injections. All patients had been symptomatic for a minimum of four months prior to surgery. The surgery involves a glenohumeral joint arthroscopy, subacromial bursoscopy and AC joint arthroscopy. Excision of the torn AC joint meniscus, AC joint synovectomy and soft tissue clearance were performed in all cases. Surgery was performed as a day-only procedure. Results: Ten out of fourteen patients obtained good pain relief and a corresponding increase in function. One patient was lost to follow-up. One patient subsequently underwent an open AC joint reconstruction for chronic instability. Five patients had previously undiagnosed SLAP tears. Conclusion. Arthroscopic soft tissue debridement for recalcitrant AC joint injuries gave good results in 77% of cases. Arthroscopy of the glenohumeral joint in patients with presumed isolated AC joint disease is important as there is a significant proportion of patients who have associated significant superior labral tears. Soft tissue arthroscopic AC joint debridement allows quick post-operative rehabilitation, an early return to sport and work and avoids having to excise bone from the distal clavicle. Arthroscopic AC joint debridement is contraindicated in patients who have grade II or grade III AC joint instability

The October 2015 Shoulder & Elbow Roundup³⁶⁰ looks at: Culture time important in propionibacterium acnes; Microvascularisation of the cuff footprint; Degenerative cuff tears: evidence for repair; Middle ground in distal humeral fractures?; Haste needed in elbow heterotopic ossification; Iatrogenic frozen shoulder; Salvage of failed humeral fixation

Frozen shoulder is a recognised complication following simple arthroscopic shoulder procedures, but its exact incidence has not been reported. Our aim was to analyse a single-surgeon series of patients undergoing arthroscopic subacromial decompression (ASD; group 1) or ASD in combination with arthroscopic acromioclavicular joint (ACJ) excision (group 2), to establish the incidence of frozen shoulder post-operatively. Our secondary aim was to identify associated risk factors and to compare this cohort with a group of patients with primary frozen shoulder.

We undertook a retrospective analysis of 200 consecutive procedures performed between August 2011 and November 2013. Group 1 included 96 procedures and group 2 104 procedures. Frozen shoulder was diagnosed post-operatively using the British Elbow and Shoulder Society criteria. A comparative group from the same institution involved 136 patients undergoing arthroscopic capsular release for primary idiopathic frozen shoulder.

The incidence of frozen shoulder was 5.21% in group 1 and 5.71% in group 2. Age between 46 and 60 years (p = 0.002) and a previous idiopathic contralateral frozen shoulder (p < 0.001) were statistically significant risk factors for the development of secondary frozen shoulder. Comparison of baseline characteristics against the comparator groups showed no statistically significant differences for age, gender, diabetes and previous contralateral frozen shoulder.

These results suggest that the risk of frozen shoulder following simple arthroscopic procedures is just over 5%, with no increased risk if the ACJ is also excised. Patients aged between 46 and 60 years and a previous history of frozen shoulder increase the relative risk of secondary frozen shoulder by 7.8 (95% confidence interval (CI) 2.1 to 28.3)and 18.5 (95% CI 7.4 to 46.3) respectively.

Cite this article: Bone Joint J 2015; 97-B:963–6.

Impingement syndrome in the shoulder has generally been considered to be a clinical condition of mechanical origin. However, anomalies exist between the pathology in the subacromial space and the degree of pain experienced. These may be explained by variations in the processing of nociceptive inputs between different patients. We investigated the evidence for augmented pain transmission (central sensitisation) in patients with impingement, and the relationship between pre-operative central sensitisation and the outcomes following arthroscopic subacromial decompression.

We recruited 17 patients with unilateral impingement of the shoulder and 17 age- and gender-matched controls, all of whom underwent quantitative sensory testing to detect thresholds for mechanical stimuli, distinctions between sharp and blunt punctate stimuli, and heat pain. Additionally Oxford shoulder scores to assess pain and function, and PainDETECT questionnaires to identify ‘neuropathic’ and referred symptoms were completed. Patients completed these questionnaires pre-operatively and three months post-operatively.

A significant proportion of patients awaiting subacromial decompression had referred pain radiating down the arm and had significant hyperalgesia to punctate stimulus of the skin compared with controls (unpaired t-test, p < 0.0001). These are felt to represent peripheral manifestations of augmented central pain processing (central sensitisation).

The presence of either hyperalgesia or referred pain pre-operatively resulted in a significantly worse outcome from decompression three months after surgery (unpaired t-test, p = 0.04 and p = 0.005, respectively).

These observations confirm the presence of central sensitisation in a proportion of patients with shoulder pain associated with impingement. Also, if patients had relatively high levels of central sensitisation pre-operatively, as indicated by higher levels of punctate hyperalgesia and/or referred pain, the outcome three months after subacromial decompression was significantly worse.