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. Aim. To compare the outcome in patients with primary frozen shoulder, who are treated by either MUA or MUA plus ACR. Methods. 56 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 19.6 pre-operatively, 78.3 at 6 months, and a mean of 80.1 at 12 months. The mean OSS was 32.5 pre-operatively, 53.6 at 6 months and 53.8 at 12 months. The patients who had a MUA had a mean ASES of 28.7 pre-operatively, 57.9 at 6 months and 58 at 12 months. The mean OSS was 33 pre-operatively, 42.5 at 6 months and 48 at 12 months. Conclusions. Both treatments give good results; MUA plus ACR give significantly superior results at 6 to 12 months post-operatively. However, there is no significant difference beyond 12 months

Purpose of study. Internal rotation (IR) contracture of the shoulder is a frequent complication of obstetric brachial plexus injury, even in the face of full neurological recovery. Surgical procedures to treat this complication include tendon transfers, capsular release and osteotomies. We compared the outcomes in patients who had arthroscopic release only and those who also underwent a tendon transfer. Methods. We retrospectively reviewed the clinical records of all patients with OBPI presenting to our unit in the years 2002–2012 who underwent surgical procedures for the treatment of an IR contracture of the shoulder. Increase in range of external rotation (ER) in adduction and abduction intra-operatively was recorded. At follow-up, active ER, the Mallet score, presence of an ER contracture and the “drop-arm” sign was recorded. Results. 25 procedures were performed in 22 patients. Mean intra-operative gain in ER was greatest in those patients who had simultaneous arthroscopic release and a tendon transfer (83.3° and 60.5° in adduction and abduction respectively). This group had the greatest average range of active ER at follow up (47.5°), the lowest incidence of a “drop-arm” sign (14%), but also the highest incidence of ER contracture (75%). Patients who underwent arthroscopic anterior shoulder release only, had the highest average Mallet score at final follow up (17.1 compared to 16.3 in the scope and tendon transfer group), 45% incidence of a “drop-arm” sign and also the lowest incidence of ER contracture (32%). General satisfaction was greatest in the scope plus tendon transfer group. Conclusion. Patients who had arthroscopic release and tendon transfer had better ER range and power but more severe ER contractures than patients who underwent arthroscopic release only. Patient satisfaction and Mallet scores were comparable between the two groups and therefore bring into question the need for early tendon transfer in these patients. NO DISCLOSURES

Introduction. Iliopsoas impingement is a well described cause of groin pain after direct anterior total hip arthroplasty (THA). We proposed to evaluate the incidence, natural history and response to treatment of iliopsoas impingement after direct anterior total hip arthroplasty. Methods. A retrospective chart review of 725 consecutive patients who underwent anterior approach total hip arthroplasty between 2009 and 2014 was conducted. All surgeries were performed by one of two surgeons. Patients were included if they underwent primary anterior approach THA and had a minimum of 2 years of follow up. Patients who had a posterior approach, revision surgery or had less than 2 years of follow up were excluded. Iliopsoas impingement was identified if patients reported groin pain at greater than 6 weeks of postoperative follow up and in association with pain with resisted seated hip flexion. The natural history and response to treatment was recorded for patients identified as having iliopsoas impingement. Results. 900 patients met inclusion criteria. Of these, 120 (13.4%) developed groin pain following direct anterior total hip arthroplasty. The average time of onset was at 21 months postoperatively. At 2 years postoperatively, 16% of patients had symptoms, whereas 84% had resolution. 28% of patients responded to structured physical therapy, 22% improved with home stretching, 19% improved after arthroscopic psoas release, 9% after psoas sheath injection, and 6% required acetabular component revision. Conclusion. In our study population, iliopsoas impingement is not an uncommon finding after direct anterior total hip arthroplasty, but nearly half of these patients responded well to home stretching or physical therapy. In some cases, psoas injection and arthroscopic release was necessary. Rarely, cup revision was required for symptomatic relief

We present a case series of patients who underwent 3 or 4 part proximal humerus fracture fixation using an intra-osseous suture technique. 18 patients are included in the study with follow up data obtained ranging from 1 to 4 years. Oxford Shoulder Scores (OSS) and range of movement measurements were taken for all patients. The mean OSS for the group was 50/60 with a mean forward flexion of 140°, abduction of 132°, external rotation of 48° and internal rotation to the level 10. th. thoracic vertebra. Three patients developed adhesive capsulitis, 2 requiring subsequent arthroscopic release. This data compares favourably to outcomes reported in the literature with hemiarthroplasty or locking plate fixation. An activity based costing analysis estimated that the treatment costs for proximal humerus fractures was approximately £2,055 when performing a soft tissue reconstruction, £3,114 when using a locking plate and £4,679 when performing a hemiarthroplasty. This demonstrates a significant financial saving when using intra-osseous fixation compared to other fixation techniques. We advocate the use of the intra-osseous suture fixation technique for certain 3 and 4 part fractures. It gives good functional outcomes, significant cost savings and potentially makes revision procedures easier when compared to other fixation techniques

Aims

Early large treatment effects can arise in small studies, which lessen as more data accumulate. This study aimed to retrospectively examine whether early treatment effects occurred for two multicentre orthopaedic randomized controlled trials (RCTs) and explore biases related to this.

Purpose. An open superior capsular shift is a well-established technique for the management of patients with multidirectional shoulder laxity and the absence of a Bankart lesion. Few studies have reported on functional and quality of life outcomes using arthroscopic technique for shoulder stabilization using superior capsular shift in patients with no Bankart lesion. The purpose of this study was to assess the functional and quality of life outcome scores following shoulder stabilization with a selective arthroscopic superior capsular shift with suture anchors, for treatment of multidirectional laxity and the absence of a Bankart lesion. Method. Case Series Level 4 Evidence. Thirty-six (36) patients with a mean age of 30.8 years, with a diagnosis of recurrent anterior atraumatic shoulder instability, and no Bankart lesion, were identified in a single surgeons practice. These patients underwent an arthroscopic shoulder stabilization with an anterior inferior to superior capsular shift. The labrum was arthroscopically released from the anterior/inferior glenoid and was shifted superiorly in conjunction with a capsular plication. A retrospective analysis was performed on prospectively collected outcome scores of patients who had with a minimum of 1 year of follow-up. The ASES and WOSI scores were administered pre-operatively and at 6 and 12 month follow-up. The presence of a positive post-operative apprehension sign was also recorded on follow-up. Results. After an arthroscopic capsular shift, the ASES and WOSI scores improved significantly from 57, 28 to 78, 68 respectively (P<0.001). Few patients had a positive apprehension sign at 1 year follow-up. Conclusion. An arthroscopic capsular shift is a reliable procedure that resulted in satisfactory outcomes in patients with shoulder instability and the absence of a Bankart lesion

Shoulder arthritis in the young adult is a deceptive title. The literature is filled with articles that separate outcomes based on an arbitrary age threshold and attempt to provide recommendations for management and even potential criteria for implanting one strategy over another using age as the primary determinant. However, under the age of 50, as few as one out of five patients will have arthritis that can be accurately classified as osteoarthritis. Other conditions such as post-traumatic arthritis, post-surgical arthritis including capsulorrhaphy arthropathy, and rheumatoid arthritis create a mosaic of pathologic bone and soft tissue changes in our younger patients that distort the conclusions regarding “shoulder arthritis” in the young adult. In addition, we are now seeing more patients with unique conditions that are still poorly understood, including arthritis of the pharmacologically performance-enhanced shoulder. Early arthritis in the young adult is often recognised at the time of arthroscopic surgery performed for other preoperative indications. Palliative treatment is the first option, which equals “debridement.” If the procedure fails to resolve the symptoms, and the symptoms can be localised to an intra-articular source, then additional treatment options may include a variety of cartilage restoration procedures that have been developed primarily for the knee and then subsequently used in the shoulder, including microfracture, and osteochondral grafting. The results of these treatments have been rarely reported with only case series and expert opinion to support their use. When arthritis is moderate or severe in young adults, non-arthroplasty interventions have included arthroscopic capsular release, debridement, acromioplasty, distal clavicle resection, microfracture, osteophyte debridement, axillary nerve neurolysis, and bicep tenotomy or tenodesis, or some combination of these techniques. Again, the literature is very limited, with most case series less than 5 years of follow-up. The results are typically acceptable for pain relief, some functional improvement, but not restoration to completely normal function from the patient's perspective. Attempts to resurface the arthritic joint have resulted in limited benefits over a short period of time in most studies. While a few remarkable procedures have provided reasonable outcomes, they are typically in the hands of the developer of the procedure and subsequently, other surgeons fail to achieve the same results. This has been the case with fascia lata grafting of the glenoid, dermal allografts, meniscal allografts, and even biologic resurfacing with large osteochondral grafts for osteoarthritis. Most surgical interventions that show high value in terms of improvement in quality of life require 10-year follow-up. It is unlikely that any of these arthroscopic procedures or resurfacing procedures will provide outcomes that would be valuable in terms of population healthcare; they are currently used on an individual basis to try to delay progression to arthroplasty, with surgeon bias based on personal experience, training, or expert opinion. Arthroplasty in the young adult remains controversial. Without question, study after study supports total shoulder arthroplasty over hemiarthroplasty once the decision has been made that joint replacement is the only remaining option

Shoulder resurfacing arthroplasty is a bone conserving option for patients with glenohumeral arthritis. We report the early results of this procedure at our unit with a minimum follow up of 2 years (mean follow up of 36 months). A historical analysis of prospectively collected clinical data was reviewed on a consecutive series of 22 patients (mean age of 73 years) with end stage gleno-humeral arthrosis who had undergone humeral resurfacing hemiarthroplasty performed by a single surgeon. Pain and function were assessed using the Oxford shoulder score and patient satisfaction was recorded. Radiographs were evaluated for implant loosening. 82% of patients had significant improvement in their oxford shoulder score from pre-operatively to two years post-operatively. Complications included one case of intra-operative conversion to a stemmed hemiarthroplasty due to fracture of the humeral head, one case of adhesive capsulitis that required MUA and arthroscopic capsular release and two cases of revision to a total shoulder replacement for pain. Humeral resurfacing arthroplasty is a viable treatment option for glenohumeral arthritis with good short term results

Background. Adhesive capsulitis (frozen shoulder) is a debilitating condition affecting 2–5% of the adult population. Its aetiology is still unclear and there is no consensus on the most effective treatment. The aim of this retrospective study was to investigate the mid-term functional outcome of one specific treatment protocol. Methods. Patients with a diagnosis of idiopathic adhesive capsulitis treated by one orthopaedic surgeon between 2004 and 2008 were identified from outpatient clinic letters. All patients had initially received conservative treatment, consisting of physiotherapy with capsular stretches and subacromial injections. Patients in whom conservative treatment failed underwent an arthroscopic capsular release. At a minimum of two years following diagnosis patients were sent the Oxford Shoulder Score (OSS [0 to 48]), Western Ontario Rotator Cuff Index (WORC [0 to 2100]) and a satisfaction questionnaire by post. In addition case notes were reviewed and type of treatment and range of movement (ROM) recorded. Results. 60 patients with the diagnosis of idiopathic adhesive capsulitis were identified. 42 patients (70%) returned the completed questionnaires. Range of movement data was available from 43 patients (72%). Mean OSS was 41 (SD 10.7) and mean WORC 307 (SD 437.1). Analysis showed that patients in whom conservative treatment was successful had significantly better functional outcome scores in OSS and WORC and better ROM than patients who underwent surgery. Overall 33 patients (79%) were satisfied or very satisfied with the outcome of their treatment. Conclusion. This study shows that patients who respond to conservative treatment have a better functional outcome than patients who undergo surgery following failed conservative treatment. Further studies are needed to directly compare the two types of treatment

Introduction. Acetabular component position is an important determinant of stability, wear and impingement following total hip arthroplasty (THA). Its optimum position and size in direct anterior approach (DAA) THA has not been clearly described in previous studies. Our aim was to study the evolution of the same with reference to stability and impingement as a part of a single surgeon's learning curve. Methods. Clinical and radiographic records of first 300 consecutive DAA THAs performed by a single surgeon from April 2009 to April 2011 were reviewed from a prospective database at a single center. Radiographic analysis was done by two observers to determine acetabular inclination and anteversion on 6 week postoperative standing radiographs. Native femoral head size, measured on preoperative radiographs after adjusting for magnification, was used to calculate the native acetabular cup size. The study population was divided into three groups; Group A– 1. st. 100 DAA THA cases, Group B – 2. nd. 100 and Group C – 3. rd. 100 corresponding to the use of intraoperative anterior stability assessment (Group B and C) and change in the cup size strategy (Group C). The incidence of instability and psoas impingement (PI) –related groin pain at 2 year follow-up was determined for the three groups. Statistical analysis was done to see if there were differences in these clinical and radiographic outcome measures in the three groups. Results. Mean values for abduction were similar in all the groups. Mean anteversion was significantly lower in Group B [12.5° (± 3.3°)] and C [13.6 °(± 2.3°)] as compared to group A [24.3°(± 7.5°)]. The difference between the implanted cup size and calculated native cup size was significantly higher in Group A [5.2(± 2.1) mm] and group B [5.8 (± 2.60 mm] as compared to group C [1.4 (± 1.4) mm] (Figure 1). There were 2 anterior dislocations in group A with none in the other groups. The incidence of PI-related groin pain was higher in group B (12%) as compared to group A (2%) and group C (2%). For PI related groin pain, an arthroscopic psoas release was performed in 3 patients and cup revision in 1 patient. Discussion. For optimum anterior stability, the target cup anteversion is lower in the DAA. Increasing the cup size makes the use of large heads possible. However, the implanted cup size should be as close to the native cup size with DAA THA to avoid anterior overhang (psoas impingement) or posterior overhang (cup-neck impingement and anterior instability)

Successful ORIF of proximal humeral fractures requires a careful assessment of the patient factors (age/osteoporosis/functional expectations), accurate identification the fracture segments (head/shaft/tuberosities) and accessory factors which are of vascular and surgical relevance (length of posteromedial metaphyseal head extension, integrity of medial soft tissue hinge, head split segments, tuberosity/head segments impacted to-gether or distracted apart). Fixation of the fracture can be achieved by a number of techniques because of the multiple factors that often apply—numerous techniques are usually required of the surgeon. The principles of fixation require accurate restoration of the head and tuberosity orientation, fixation of the metaphyseal segments (tuberosities) results in a stable circular platform on which the head segment rests. Thus, the fixation of choice acts as a load sharing device not a load bearing device. This fixation is often augmented with tension band and circlage suture fixation. These concepts are especially applicable to the osteoporotic patient. The order of fixation requires that the medial hinge not be disrupted. If it is disrupted in the younger patient it requires fixation first. All tuberosity segments are tagged with ethibond sutures. The head and the largest tuberosity segment are reduced and held with k-wire or canulated scews, avoiding the central medullary canal entry point. If the head tuberosity segment is unstable in relation to the shaft, the fixation implant of choice (plate/intramedullary) is chosen and the head/tuberosity complex is reduced to the shaft. Depending on the fracture segments and the degree of comminution this may require compression of distraction. Post-op the patient is immobilised in external rotation to balance the cuff forces. If very rigid fixation is achieved then early mobilisation is undertaken to minimise the adhesions due to opening of the subdeltoid space. If fixation is tenuous movement is commenced a 3–4 weeks. AVN of the humeral head with good tuberosity head architecure can be salvaged. The diagnosis of AVN is determned at three months with a MRI and consideration given to Zolidronate therapy. Post-traumatic stiffness with good architecture can be salvaged with an arthroscopic capsular release

The causes of a stiff elbow are numerous including: post-traumatic elbow, burns, head injury, osteoarthritis, inflammatory joint disease and congenital. Types of stiffness include: loss of elbow flexion, loss of elbow extension and loss of forearm rotation. All three have different prognoses in terms of the timing of surgery and the likelihood of restoration of function. Contractures can be classified into extrinsic and intrinsic (all intrinsic develop some extrinsic component). Functional impairment can be assessed medicolegally; however, in clinical practice the patient puts an individual value on the arc of motion. Objectively most functions can be undertaken with an arc of 30 to 130 degrees. The commonest cause of a Post-traumatic Stiff elbow is a radial head fracture or a complex fracture dislocation. Risk factors for stiffness include length of immobilisation, associated fracture with dislocation, intra-articular derangement, delayed surgical treatment, associated head injury, heterotopic ossification. Early restoration of bony columns and joint stability to allow early mobilisation reduces incidence of joint stiffness. Heterotopic ossification (HO) is common in fracture dislocation of the elbow. Neural Axis trauma alone causes HO in elbows in 5%. However, combined neural trauma and elbow trauma the incidence is 89%. Stiffness due to thermal injury is usually related to the degree rather than the site. The majority of patients have greater than 20% total body area involved. Extrinsic contractures are usually managed with a sequential release of soft tissues commencing with a capsular excision (retaining LCL/MCL), posterior bundle of the MCL +/− ulna nerve decompression (if there is loss of flexion to 100 degrees). This reliably achieved via a posterior incision, a lateral column exposure +/− ulna nerve mobilisation. A medial column exposure is a viable alternative. Arthroscopic capsular release although associated with a quicker easier rehabilitation is associated with increased neural injury. Timing of release is specific to the type of contracture, i.e. flexion contractures after approx. six months, extension contractures ASAP but after four months, loss of forearm rotation less 6 to 24 months. The use of Hinged Elbow Fixators is increasing. The indications include reconstructions that require protection whilst allowing early movement, persistent instability or recurrent/late instability or interposition arthroplasty. Post-operative rehabilitation requires good analgesia, joint stability and early movement. The role of CPM is often helpful but still being evaluated