Sub-acromial decompression surgery (SAD) has been widely used to treat shoulder impingement. Its validity has been questioned in multi-centric clinical trials and dissatisfaction rates can be high (35%). It is difficult to predict which patients will benefit operatively as research into predictive factors is limited. The study aim was to conduct a root-cause analysis of reasons for dissatisfaction in a cohort of operated patients. All patients with SAD dissatisfaction in the local Upper Limb database between 2015-19 (n=74/296) formed our study cohort. Patients were scored on Oxford shoulder score (OSS), QuickDASH score, EQ-5D-3L (TTO+VAS) at weeks 26 and 52 post-operatively. Patients' clinical history, radiographs, consultation and operative notes were reviewed. 28% of patients were dissatisfied with surgery. Mean age =52.3±13.4 years with equal gender distribution. 87% were operated arthroscopically. 67% were in physically demanding occupations. There was a significant increase in OSS and QuickDASH at weeks 26 and 52 post-operatively (p<0.05), similar improvement was not noted in VAS pain score. Pain followed by stiffness were the main contributors of dissatisfaction. Multiple implicating factors were noted, the most common being acromio-clavicular joint arthritis (25.7%), suggesting concomitant pathologies as an additional cause for patient dissatisfaction. This is the first study to evaluate reasons for dissatisfaction following SAD. We noted high rates (28%) of dissatisfaction and a predilection for those involved in physically demanding occupations. We recommend meticulous pre-operative workup to identify co-existing pathologies and appropriate pre-operative counselling to improve outcomes in selected patients needing SAD following failure of conservative management

We randomised prospectively 44 patients with fractures of the shaft of the humerus to open reduction and internal fixation by either an intramedullary nail (IMN) or a dynamic compression plate (DCP). Patients were followed up for a minimum of six months. There were no significant differences in the function of the shoulder and elbow, as determined by the American Shoulder and Elbow Surgeons’ score, the visual analogue pain score, range of movement, or the time taken to return to normal activity. There was a single case of shoulder impingement in the DCP group and six in the IMN group. Of these six, five occurred after antegrade insertion of an IMN. In the DCP group three patients developed complications, compared with 13 in the IMN group. We had to perform secondary surgery on seven patients in the IMN group, but on only one in the DCP group (p = 0.016). Our findings suggest that open reduction and internal fixation with a DCP remains the best treatment for unstable fractures of the shaft of the humerus. Fixation by IMN may be indicated for specific situations, but is technically more demanding and has a higher rate of complications