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. Methods. Included RCTs were ProFHER (PROximal Fracture of the Humerus: Evaluation by Randomisation), a two-arm study of surgery versus non-surgical treatment for proximal humerus fractures, and UK FROST (United Kingdom Frozen Shoulder Trial), a three-arm study of two surgical and one non-surgical treatment for frozen shoulder. To determine whether early treatment effects were present, the primary outcome of Oxford Shoulder Score (OSS) was compared on forest plots for: the chief investigator’s (CI) site to the remaining sites, the first five sites opened to the other sites, and patients grouped in quintiles by randomization date. Potential for bias was assessed by comparing mean age and proportion of patients with indicators of poor outcome between included and excluded/non-consenting participants. Results. No bias in treatment effect was observed overall for the CI site, or the first five sites, compared with the remaining sites in either trial. An early treatment effect on the OSS was observed for the first quintile of participants recruited to ProFHER only (clinically relevant difference of seven points). Selection bias for age was observed in the ProFHER trial only, with slightly younger patients being recruited into the study. Both trials showed some selection bias for markers of poor prognosis, although these did not appear to change over time. Conclusion. No bias in treatment effects overall were found at the CI or early sites set-up. An early treatment effect was found in one of the two trials, which was likely a chance effect as this did not continue during the study. Selection bias was observed in both RCTs, however this was minimal and did not impact on outcome. Cite this article: Bone Jt Open 2023;4(2):96–103

Following arthroscopic arthrolysis for frozen shoulder, steroid injections may become necessary to improve ongoing pain and facilitate stretching exercises. The aim of this study was to evaluate the rate of steroid injections needed post-arthroscopic arthrolysis of frozen shoulder. Case series review carried out in a District General Hospital in UK. 30 consecutive patients who had arthroscopic arthrolysis under the care of the senior author were included. Patients’ records were analysed to identify the number of steroid injections administered post-operatively. 11 males and 19 females were examined, aged 46–83 years old (mean 56.1). 7 patients were diabetic. 10 patients (33.3%) received steroid injections post-operatively, with 8 of them receiving the injection within the first 6 post-operative months. The average post-operative time of steroid injection was 9.8 months. There was no association between diabetes and administration of a post-operative steroid injection P>0.01. Following arthroscopic arthrolysis a substantial proportion of patients may require one or more steroid injections to help pain and facilitate stretching exercises and physiotherapy. This study showed that 1 in 3 frozen shoulders treated with arthroscopic arthrolysis may need a subsequent steroid injection in the first year post surgery. Patients should be counselled preoperatively with regards to that, and be warned that arthroscopic arthrolysis is only the first step in the treatment pathway leading to recovery. Blackpool Victoria Hospital Orthopaedic Department

Introduction. Adhesive capsulitis is a common condition causing painful limitation of shoulder movements. Hydrodistension is one of the techniques, is well recognised and has shown good outcomes. However, the results of hydro distension release in secondary adhesive capsulitis are not clear. Patients and Methods. This is a retrospective study on patients undergoing hydro distension release. Patients who had any surgical intervention were classed as secondary whilst the rest were included in the primary group. The hydro distension is a standard technique where in the senior author locates the gleno humeral joint using radio opaque dye, followed by injection of 20 mls 0.5% L-bupivacaine and 80 mg of Triamcinolone, this is followed by use of 60 mls saline to perform the hydro distension. Results. We included 86 shoulders in 80 patients who underwent the procedure. There were 46 females and 34 males, with average age of 51.07 years (range 35 – 75). Left side was involved in 42 shoulders and right in 44. 25 patients showed associated risk factors of which 17 patients had diabetes, 12 had hypercholesterolemia and 5 had underactive thyroid. 65 of the shoulders were in the primary group whilst 21 in the secondary group. In the secondary group the procedures included 8 arthroscopic subacromial decompression with ACJ excision, 7 had rotator cuff repairs, 4 had biceps labral procedure and 2 ORIF clavicle. 3/21 patients required further intervention in secondary group, whilst 10/65 in the primary group required further intervention. Patients who have history of inflammatory arthritides were found to have higher incidence of revision surgery and poorer outcomes. 85% patients in both groups had improvement in their function and range of movements and were happy with the outcome. Conclusion. Hydrodistension provides safe and predictive results in both primary and secondary adhesive capsulitis and should be considered as an option before any invasive procedure

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

Manipulation under anaesthetic (MUA) is an established treatment for frozen shoulder. Frozen shoulder may coexist with other shoulder conditions, whose treatment may differ from MUA. One such condition is calcific tendonitis. Only one study to date documents treatment of patients with frozen shoulder and concurrent calcific tendinitis. The objective was to demonstrate that MUA and injection is a satisfactory treatment for concurrent diagnosis of frozen shoulder and calcific tendinitis. Patients with a clinical diagnosis of frozen shoulder and radiological evidence of calcific tendinitis were prospectively recruited from Jan 1999 – Jan 2009. Treatment by MUA and injection was performed. Clinical examination, Oxford Shoulder Scores and need for further treatment were used as outcome measures. Fourteen patients (median age 53.5 years) were identified with frozen shoulder and concurrent calcific tendinitis. Significant improvement in both Oxford Shoulder Score and range of movement was achieved following MUA (P values < 0.001). Two patients required further treatment (not for calcific tendinitis). This improvement was maintained in the long term (median 107 wks). It is our belief that MUA and injection is a safe and effective treatment, addressing the frozen shoulder with MUA takes priority, and as such frozen shoulder “trumps” other pathologies occurring simultaneously

Distension arthrography of the glenohumeral joint was adopted as a mainstream treatment for adhesive capsulitis before any randomised controlled trials were performed. Interpretation of the effectiveness of this procedure rests on data from cohort studies of which there are few of high quality. Papers reporting on the long-term results have either excluded diabetic patients or failed to report on patient orientated outcomes. We present a prospective cohort study of 51 patients with adhesive capsulitis of the shoulder who had a distension arthrogram performed by a single radiologist as a primary intervention. We included diabetic patients. Range of movement (ROM), Oxford shoulder score (OSS) and a visual analogue pain score (VAS) were recorded pre-procedure, at 2 days and 1 month. OSS and VAS were recorded again at a mean of 14 months post procedure (range 8–26 months). OSS improved from pre-procedure mean of 22.3 by 16.9 points at final follow up in September 2011 (p < 0.001) whilst VAS improved from a mean pre-procedure of 7.1 by −3.5 by September 2011 (p< 0.001). ROM improved with a mean increase of 39.3 degrees in flexion, 55.2 degrees in abduction and 19.5 degrees in external rotation by 1 month (p < 0.001 for all). The outcome in diabetic patients was the same as in non-diabetic patients. We conclude that distension arthrography is a safe and effective treatment for adhesive capsulitis

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

Manipulation under anaesthetic (MUA) for the treatment of frozen shoulder is well established and effective however timing of surgery remains controversial. Intervention before 9 months has previously been shown to be associated with improved outcome. We test this theory by measuring Oxford Shoulder Score (OSS), re-MUA and subsequent surgery rate. A retrospective review of a prospectively collected, single surgeon, consecutive patient series revealed 244 primary frozen shoulders treated by MUA within 4 weeks of presentation. The mean duration of antecedent symptoms was 28 weeks (95% CI 4-44 weeks) and time to follow up was 26 days (95% CI 11-41 days). The mean OSS improved by 16 points (2-tailed t test p< 0.001) with a mean follow up OSS of 43 (95% CI 38-48). 195 shoulders were manipulated before 38 weeks (9 months) and had the same mean change in OSS (16) as the 49 shoulders manipulated after 38 weeks. 48 shoulders, including 15 diabetic shoulders required further MUA. 8 shoulders had subsequent surgery. These events were also independent of antecedent symptom duration. Early MUA does not appear to produce improved outcomes when compared to later intervention but we note does result in an earlier return to function

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

Acromioclavicular joint (ACJ) dislocations is a common disorder amongst our population for which numerous techniques have been described. It is thought that by using this novel technique combining a CC and AC repair with a reconstruction will result in high maintenance of anatomical reduction and functional results. 12 consecutive patients ACJ dislocations were included. An open superior clavicular approach is used. Firstly, the CC ligaments are repaired after which a CC reconstruction is performed using a tendon allograft. Secondly, the AC ligaments are repaired using an internal brace construct combined with a tendon allograft reconstruction (Figure 1). The acute:chronic ratio was 6:6. Only IIIB, IV and V AC-joint dislocations were included. The Constant-Murley Score improved from 27.6 (8.0 – 56.5) up to 61.5 (42.0 – 92.0) at 12 months of follow up. Besides one frozen shoulder from which the patient recovered spontaneously no complications were observed with this technique. The CCD was reduced from 18.7 mm (13.0 – 24.0) to 10.0 mm (6.0 – 16.0) and 10.5 mm (8.0 – 14.0) respectively 12 weeks and 12 months postoperatively. There is some evidence, suggesting to address as well as the vertical (coracoclavicular (CC) ligaments) as the horizontal (acromioclavicular (AC) ligaments) direction of instability. This study supports addressing both entities however comparative studies discriminating chronic as acute cases should be conducted to further clarify this ongoing debate on treating ACJ instability. This study describes a novel technique to treat acute and chronic Rockwood stage IIIB – IV ACJ dislocations with promising short-term clinical and radiological results. This suggests that the combined repair and reconstruction of the AC and CC ligaments is a safe procedure with low complication risk in experienced hands. Addressing the vertical as well as horizontal stability in ACJ dislocation is considered key to accomplish optimal long-term results

Estimated to affect 2–5% of the population, adhesive capsulitis is a common cause of shoulder pain and dysfunction. The objective of this study is to determine if arthrographic injection of the shoulder joint with steroid, local anesthetic and contrast is an effective treatment modality for adhesive capsulitis and whether it is superior to arthrographic injection with local anesthetic and contrast alone. This is a double-blinded RCT of patients with a diagnosis of adhesive capsulitis who were randomly assigned to receive an image guided arthrographic glenohumeral injection with either triamcinalone (steroid), lidocaine (local anesthetic) and contrast or lidocaine and contrast alone. Outcome measures included active and passive shoulder range of motion (ROM) and functional outcomes assessed using the Shoulder Pain and Disability Index (SPADI), the Constant Score and a Visual Analog Scale for pain. Post-operative evaluation occurred at 3 weeks, 6 weeks and 12 weeks. Descriptive statistics were utilised to summarise patient demographics and other study parameters. One-way ANOVAs compared the VAS, Constant and SPADI scores across the different time points for both study groups. The post hoc Bonferroni correction was used to adjust for multiple comparisons. There were 37 shoulders injected with follow-up visits at 12 weeks. Twenty shoulders were randomised to receive local plus steroid and 17 shoulders received local anesthetic only. There were 21 females and 14 males with an average age of 54 years (range, 42–70). VAS scores for both patient groups were significantly improved (p<0.05) at all follow-up times. Goniometric testing demonstrated significant improvements in forward flexion and internal rotation at 90 degrees in the local group and only abduction in the local plus steroid group. There were no significant changes in the Constant scores for the local group (p=0.08), however, the Constant scores showed significant improvement for the local plus steroid group (p=0.003) at all follow-up time points. The local group showed significant improvement in their SPADI pain scores at the 12 week follow-up only (p=0.01). There were no significant differences in their SPADI disability scores (p=0.09). The local plus steroid group had significant improvement in SPADI pain and disability scores at all follow-up time points (p=0.001). The optimal treatment for adhesive capsulitis remains unclear. Our study demonstrated that patients receiving an arthrographic injection of either steroid and local anesthetic or local anesthetic alone had significantly improved post-injection pain scores. However, only the steroid and local anesthetic group demonstrated improved SPADI disability and Constant scores. Thus, we believe that either treatment may be a good option for patients with adhesive capsulitis and can reliably relieve pain, but we would recommend the steroid with local anesthetic over the local anesthetic alone as it may provide improved function

Abstract. Aim. The aim of this study was to present the results of treatment of displaced lateral clavicle fractures by an arthroscopically inserted tightrope device (‘Dogbone’, Arthrex). Methods. We performed a retrospective series of our patients treated with this technique between 2015 and 2019. Patients were identified using the ‘CRS Millennium’ software package and operation notes/clinic letters were analysed. We performed an Oxford Shoulder Score (OSS) on all the patients at final follow-up. Our electronic ‘PACS’ system was used to evaluate union in the post-operative radiographs. Results. We treated 26 patients with displaced lateral clavicle fractures between 2015 and 2019. There were 4 patients who were treated with a ‘dogbone’ and supplementary plate fixation and the remaining 22 were treated with a ‘dogbone’ alone. Radiological union was seen in 22 (84%) patients. The mean Oxford Shoulder Score (OSS) was 46. Apart from one patient who required removal of the superior endobutton and knot under local anaesthetic there was no other secondary surgery. There were no cases of infection, nerve injury or frozen shoulder. Conclusions. Arthroscopic ‘dogbone’ treatment of lateral clavicle fractures is a safe, cosmetically friendly technique with promising high rates of fracture union and return to normal function. We recommend its use over the more conventional treatment of a hook plate

Pain is a common presenting symptom of patients with shoulder conditions, yet there has been little work done to accurately describe its distribution and nature. We studied all patients attending the Royal Devon and Exeter Hospital shoulder clinic from August 2012 – 2013. Patients completed a questionnaire detailing their Oxford Shoulder Score and a validated neuropathic pain questionnaire. Patients were given diagrams to draw on their perceived location of pain or abnormal sensation. We analysed all patients with frozen shoulder (48), osteoarthritis (37) and rotator cuff arthropathy (17). We found that neuropathic pain is common in patients with shoulder conditions identified in 39% of OA patients, 42% with rotator cuff arthropathy and 57% with frozen shoulder. Pain outside the shoulder was reported in over 50% of patients, commonly the forearm, hand, neck and chest. Frozen shoulder was especially associated with pain outside of the shoulder with 39% describing symptoms in the neck or chest, 21% into the forearm and 18% into the hand. Interestingly, neuropathic pain radiating down the arm was not described in the rotator cuff arthropathy group. The high prevalence of neuropathic symptoms and pain felt outside the shoulder aids diagnosis and more accurately identifies these conditions

Adhesive capsulitis of the shoulder is a common debilitating condition with prevalence in the order of 2 to 5%. Whilst it is usually a self-limiting condition, patients are typically not willing, nor are they able, to wait to the end of the recovery phase. A number of treatment strategies have been described. Manipulation under anaesthesia can significantly increase motion in all planes, but carries a significant risk of fracture. Capsular release also significantly improves motion with fewer potential side effects. We hypothesise that performing an arthroscopic excision of the abnormal capsulitis tissue will give better results with least risk of recurrence. Data was collected both retrospectively and prospectively for patients undergoing this procedure. Range of motion and Oxford shoulder scores was documented pre-operatively and post-operatively, at 6 weeks, 3 months and 6 months. 41 patients were included. At 3 months mean flexion had increased from 101 to 152 degrees, abduction from 91 to 151 degrees, and external rotation from 18 to 44 degrees. Mean Oxford shoulder score had increased from 20.6 to 35.8 at 3 months. The results support the use of this technique for treating adhesive capsulitis. Larger patient numbers and longer term follow up will help compare it against the other well established techniques

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

We all aware about overuse syndrome, as compensation of other parts of body. Our famous poet Sa'adi: when part of our body sustains become painful, the other parts can't tolerate and reciprocate. Among our patients who underwent total Knee arthroplasty few of them have pain especially in 1st 3 months (Anterior Knee pain, effusion, ….) but almost 15 – 20 percents are not satisfied enough by this Procedure. In a Cohort historic study on 301 TKA with at least 2 years follow up 47 patients had not enough satisfaction in our clinic we tried to visit them to find out why?. Criteria's we chose, were:. Age. Osteopenia. Sarcopenia. Low back pain. Spinal canal stenosis. Shoulders. Unstable blood pressure. Neuropathy. Eyes dysfunction. We exclude those who had problem by their new knees. 11 patients, all have been over age 68 years, and duration of start of symptoms in knee (s) to the surgery were more than 12 years, clearly showed painful arch of shoulder motion or frozen shoulder or established gleno humeral alone or G.H. and A.C. joints OA. Conclusion. Because of abnormal stand up of long lasting knee OA patients, they start to put pressure on their shoulder to climb on their body. Even their cane or crutches use are not in regular and academic rules. So, we nominate this entity: shoulder knee syndrome as a negative criteria that interferes in out come

Introduction. Hypoplasia of the glenoid is a rare condition caused by incomplete ossification of the postero-inferior aspect of the developing glenoid. It may be isolated or associated with a more generalised condition. The clinical symptomatology is variable depending on the age at time of presentation. Materials and Methods. We performed a retrospective chart review of patients who presented with shoulder complaints, and in whom a radiographic diagnosis of glenoid hypoplasia had been made. From January 2002 to December 2012, 8 patients (9 shoulders) with radiological signs of glenoid hypoplasia were identified. The mean age at presentation was 39 years (range 23 to 77) and the mean symptom duration was 12.5 months (range 1 to 48). Results. The diagnoses encountered included: impingement with rotator cuff tendonitis (2 shoulders), rotator cuff dysfunction with biceps tendonitis (1 shoulder), a SLAP lesion (2 shoulders), calcific tendonitis (1 shoulder), a posterior labral tear (1shoulder), multidirectional instability (1 shoulder), and adhesive capsulitis (1 shoulder). Of these nine, six shoulders were managed non-operatively and three were managed surgically, all with satisfactory results. The mean follow-up period was 30 months (range 5 to 60) and the mean Oxford shoulder score was 46.7 (range 42 to 48). Conclusion. We present a series of patients, who have been managed for a variety of shoulder pathologies, and in whom underlying glenoid hypoplasia has been diagnosed. NO DISCLOSURES

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

Introduction. The conservative management of Sub-Acromial Impingement Syndrome (SAIS) of the shoulder includes both physiotherapy treatment and subacromial injection with local anaesthetic and steroids. The outcome from injection treatment has rarely been evaluated scientifically. Methods. Patients attending a designated shoulder clinic and diagnosed by an experienced shoulder surgeon as having a SAIS between January 2009 and December 2011 were considered for inclusion in the study. 67 of 86 patients screened completed the study (3 did not meet inclusion criteria; 9 declined to participate; 3 lost to follow-up; 4 developed frozen shoulder syndrome). Each patient had a pre-injection Oxford Shoulder Score (OSS) and was given one subacromial injection of 10ml 0.25% levobupivacaine(Chirocaine) + 40 mg triamcinolone(Kenalog) through the posterior route. Radiograph imaging was also assessed. Follow-up was carried out at 6 to 12 weeks post injection when OSS was repeated. A 6 month follow-up assessment to assess if the patient's improvement in functionality and absence of symptoms indicated that a subacromial decompression operation was not necessary. The percentage of patients showing improvement in OSS was calculated and the difference in OSS pre- and post-injection assessed using a Wilcoxon Signed Rank test. Results. The median OSS pre-injection was 29 (range 2–43) and post-injection was 40 (range 2–48) (p=< 0.001; z=−6.0; r=−0.5). 45/69 (71%) of patients benefited significantly from subacromial injection at 6 to 12 weeks post-injection. However only 28/53 (53%) benefited significantly from injection by 6 months post-injection. These results support the continued use of sub-acromial corticosteroid injections in the treatment of SAIS. 31% of these patients were subsequently treated with an arthroscopic subacromial decompression operation. Previous injection history had no impact on the results. Conclusions. We recommend that all patients with SAIS should be offered at least one subacromial injection before being considered for an arthroscopic subacromial decompression operation

Purpose of study. The outcomes of conservatively managed minimally displaced isolated greater tuberosity fractures are sparsely reported and the aim of this study was to look at the outcome of these fractures. patients and methods. Twenty-seven patients who had sustained a greater tuberosity fracture were identified. They were all managed by a single surgeon. All patients had a regime of initial immobilisation for 3 weeks followed by physiotherapy and range of motion exercises. They were all x-rayed at 1 week and 3 weeks after injury to monitor for any displacement. Four fractures occurred with an anterior dislocation. In seven patients the fracture was not visible on x-ray but was diagnosed on Ultrasound or MRI. Twenty-three of 27 patients were available for follow-up. For this follow up, the patients were telephonically contacted and the Oxford Shoulder Score (OSS) was completed to assess their outcome. Results. There were 12 males and 11 females in the review. The average age was 44 yrs (6–71 yrs) and the average follow up was 26.2 months (6–43 months). The OSS for the 23 patients ranged from 22–48 (average 44, median 47, mode of 48). Fourteen patients had LASI as part of their management after they started to develop pain and impingement symptoms. The ones with LASI had a slightly lower median OSS (46) compared to those without (48) but the modal scores were the same (48). One patient needed surgery after the initial fracture displaced at 3 weeks while another patient needed an acromioplasty at 10 months for impingement. Three patients developed a frozen shoulder but subsequently settled and had excellent outcome scores. Summary. In this study, 30% (7) of the fractures were not visible on the x-rays but diagnosed on ultrasound or MRI. Nearly half the patients required subacromial steroid injections to improve recovery. In only one patient did the fracture displace and require fixation. Conclusion. Conservative management of minimally displaced greater tuberosity fractures yields good functional results though a high percentage of patients require subacromial steroid injections. Secondary displacement is rare, however close vigilance of fracture is advised with x-rays done at 1 and 3 weeks postoperatively. NO DISCLOSURES