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

Carpal tunnel syndrome (CTS) is the most common peripheral mononeuropathy seen in clinical practice. Approximately 34% of CTS patients undergo carpal tunnel decompression (CTD) surgery, in the UK. We investigated the change in epidemiology of CTD based on sex, age, socio-economic deprivation and geographical location, in Scotland, over the last 20 years. 76,076 CTD were performed between 1996–2015 (71% female, M:F ratio 1:2.4). The overall incidence rate of CTD was 73/100,000 person years. The mean age was 50–59 years old for both sexes. Socio-economic deprivation was associated with higher incidence rates of CTD (most deprived 89/100,000 person years and least deprived 64/100,000 person years) (p<0.01). NHS health boards with low populations and a more rural location had higher incidence rates; mean 98/100,000 person years (range 4–238/100,000 person years) compared to high population heath boards in urban locations; mean 74/100,000 person years (range 4–149/100,000 person years) (p<0.01). There has been a significant increase in number and overall incidence of CTD, in Scotland, during the study period: in 1996, 1,156 CTD performed (incidence 23/100,000 person years) vs. 2015, 5,292 CTD performed (incidence 87/100,000 person years) (p<0.01). We conclude that middle aged females are still the most common demographic undergoing CTD but the incidence rate is increasing over time. There appears to be an association between CTD and socio-economic deprivation. The incidence of CTD, and change over time, differs between health boards

We reviewed 59 bone graft substitutes marketed by 17 companies currently available for implantation in the United Kingdom, with the aim of assessing the peer-reviewed literature to facilitate informed decision-making regarding their use in clinical practice. After critical analysis of the literature, only 22 products (37%) had any clinical data. Norian SRS (Synthes), Vitoss (Orthovita), Cortoss (Orthovita) and Alpha-BSM (Etex) had Level I evidence. We question the need for so many different products, especially with limited published clinical evidence for their efficacy, and conclude that there is a considerable need for further prospective randomised trials to facilitate informed decision-making with regard to the use of current and future bone graft substitutes in clinical practice.

Cite this article: Bone Joint J 2013;95-B:583–97.