Little is known about the incidence of rotator
cuff pathology or its demographic associations in the general population.
We undertook a large epidemiological study of rotator cuff pathology
in the United Kingdom using The Health Improvement Network (THIN)
database. The incidence of rotator cuff pathology was 87 per 100
000 person-years. It was more common in women than in men (90 cases
per 100 000 person-years in women and 83 per 100 000 person-years
in men; p <
0.001). The highest incidence of 198 per 100 000
person-years was found in those aged between 55 and 59 years. The
regional distribution of incidence demonstrated an even spread across
13 UK health authorities except Wales, where the incidence was significantly
higher (122 per 100 000 person-years; p <
0.001). The lowest
socioeconomic group had the highest incidence (98 per 100 000 person-years).
The incidence has risen fourfold since 1987 and as of 2006 shows
no signs of plateauing. This study represents the largest general population study of
rotator cuff pathology reported to date. The results obtained provide
an enhanced appreciation of the epidemiology of rotator cuff pathology
and may help to direct future upper limb orthopaedic services. Cite this article:
We retrospectively assessed the value of identifying
impinging osteophytes using dynamic computer simulation of CT scans
of the elbow in assisting their arthroscopic removal in patients
with osteoarthritis of the elbow. A total of 20 patients were treated
(19 men and one woman, mean age 38 years (19 to 55)) and followed
for a mean of 25 months (24 to 29). We located the impinging osteophytes
dynamically using computerised three-dimensional models of the elbow
based on CT data in three positions of flexion of the elbow. These
were then removed arthroscopically and a capsular release was performed. The mean loss of extension improved from 23° (10° to 45°) pre-operatively
to 9° (0° to 25°) post-operatively, and the mean flexion improved
from 121° (80° to 140°) pre-operatively to 130° (110° to 145°) post-operatively.
The mean Mayo Elbow Performance Score improved from 62 (30 to 85)
to 95 (70 to 100) post-operatively. All patients had pain in the
elbow pre-operatively which disappeared or decreased post-operatively.
According to their Mayo scores, 14 patients had an excellent clinical
outcome and six a good outcome; 15 were very satisfied and five
were satisfied with their post-operative outcome. We recommend this technique in the surgical management of patients
with osteoarthritis of the elbow. Cite this article:
We determined the short-term clinical outcome
and migration within the bone of the humeral cementless component
of the Instrumented Bone Preserving (IBP) total elbow replacement
in a series of 16 patients. There were four men and 12 women with
a mean age at operation of 63 years (40 to 81). Migration was calculated
using radiostereometric analysis. There were no intra-operative
complications and no revisions. At two-year follow-up, all patients
showed a significant reduction in pain and functional improvement
of the elbow (both p <
0.001). Although ten components (63%)
showed movement or micromovement during the first six weeks, 14
(88%) were stable at one year post-operatively. Translation was
primarily found in the proximal direction (median 0.3 mm (interquartile range
(IQR) -0.09 to 0.8); the major rotational movement was an anterior
tilt (median 0.7° (IQR 0.4° to 1.6°)). One malaligned component
continued to migrate during the second year, and one component could
not be followed beyond three months because migration had caused
the markers to break off the prosthesis. This study shows promising early results for the cementless humeral
component of the IBP total elbow replacement. All patients had a
good clinical outcome, and most components stabilised within six
months of the operation. Cite this article:
We assessed the clinical results, radiographic
outcomes and complications of patients undergoing total shoulder replacement
(TSR) for osteoarthritis with concurrent repair of a full-thickness
rotator cuff tear. Between 1996 and 2010, 45 of 932 patients (4.8%)
undergoing TSR for osteoarthritis underwent rotator cuff repair.
The final study group comprised 33 patients with a mean follow-up
of 4.7 years (3 months to 13 years). Tears were classified into small
(10), medium (14), large (9) or massive (0). On a scale of 1 to
5, pain decreased from a mean of 4.7 to 1.7 (p = <
0.0001), the
mean forward elevation improved from 99° to 139° (p = <
0.0001),
and the mean external rotation improved from 20° (0° to 75°) to
49° (20° to 80°) (p = <
0.0001). The improvement in elevation
was greater in those with a small tear (p = 0.03). Radiographic
evidence of instability developed in six patients with medium or
large tears, indicating lack of rotator cuff healing. In all, six
glenoid components, including one with instability, were radiologically
at risk of loosening. Complications were noted in five patients,
all with medium or large tears; four of these had symptomatic instability
and one sustained a late peri-prosthetic fracture. Four patients
(12%) required further surgery, three with instability and one with
a peri-prosthetic humeral fracture. Consideration should be given to performing rotator cuff repair
for stable shoulders during anatomical TSR, but reverse replacement
should be considered for older, less active patients with larger
tears. Cite this article:
We have compared three different methods of treating
symptomatic non-traumatic tears of the supraspinatus tendon in patients
above 55 years of age. A total of 180 shoulders (173 patients) with
supraspinatus tendon tears were randomly allocated into one of three
groups (each of 60 shoulders); physiotherapy (group 1), acromioplasty and
physiotherapy (group 2) and rotator cuff repair, acromioplasty and
physiotherapy (group 3). The Constant score was assessed and followed
up by an independent observer pre-operatively and at three, six
and twelve months after the intervention. Of these, 167 shoulders were available for assessment at one
year (follow-up rate of 92.8%). There were 55 shoulders in group
1 (24 in males and 31 in females, mean age 65 years (55 to 79)),
57 in group 2 (29 male and 28 female, mean age 65 years (55 to 79))
and 55 shoulders in group 3 (26 male and 29 female, mean age 65
years (55 to 81)). There were no between-group differences in the
Constant score at final follow-up: 74.1 ( Cite this article:
Treatment of an infected total elbow replacement
(TER) is often successful in eradicating or suppressing the infection.
However, the extensor mechanism may be compromised by both the infection
and the surgery. The goal of this study was to assess triceps function
in patients treated for deep infection complicating a TER. Between
1976 and 2007 a total of 217 TERs in 207 patients were treated for
infection of a TER at our institution. Superficial infections and
those that underwent resection arthroplasty were excluded, leaving
93 TERs. Triceps function was assessed by examination and a questionnaire.
Outcome was measured using the Mayo Elbow Performance Score (MEPS). Triceps weakness was identified in 51 TERs (49 patients, 55%).
At a mean follow-up of five years (0.8 to 34), the extensor mechanism
was intact in 13 patients, with the remaining 38 having bone or
soft-tissue loss. The mean MEPS was 70 points (5 to 100), with a
mean functional score of 18 (0 to 25) of a possible 25 points. Infection following TER can often be eradicated; however, triceps
weakness occurs in more than half of the patients and may represent
a major functional problem. Cite this article:
We explored the trends over time and the geographical
variation in the use of subacromial decompression and rotator cuff
repair in 152 local health areas (Primary Care Trusts) across England.
The diagnostic and procedure codes of patients undergoing certain
elective shoulder operations between 2000/2001 and 2009/2010 were extracted
from the Hospital Episode Statistics database. They were grouped
as 1) subacromial decompression only, 2) subacromial decompression
with rotator cuff repair, and 3) rotator cuff repair only. The number of patients undergoing subacromial decompression alone
rose by 746.4% from 2523 in 2000/2001 (5.2/100 000 (95% confidence
interval (CI) 5.0 to 5.4) to 21 355 in 2009/2010 (40.2/100 000 (95%
CI 39.7 to 40.8)). Operations for rotator cuff repair alone peaked
in 2008/2009 (4.7/100 000 (95% CI 4.5 to 4.8)) and declined considerably
in 2009/2010 (2.6/100 000 (95% CI 2.5 to 2.7)). Given the lack of evidence for the effectiveness of these operations
and the significant increase in the number of procedures being performed
in England and elsewhere, there is an urgent need for well-designed
clinical trials to determine evidence of clinical effectiveness. Cite this article: Bone Joint J 2014;96-B:70–4.
The aim of this review is to address controversies
in the management of dislocations of the acromioclavicular joint. Current
evidence suggests that operative rather than non-operative treatment
of Rockwood grade III dislocations results in better cosmetic and
radiological results, similar functional outcomes and longer time
off work. Early surgery results in better functional and radiological
outcomes with a reduced risk of infection and loss of reduction compared
with delayed surgery. Surgical options include acromioclavicular fixation, coracoclavicular
fixation and coracoclavicular ligament reconstruction. Although
non-controlled studies report promising results for arthroscopic
coracoclavicular fixation, there are no comparative studies with
open techniques to draw conclusions about the best surgical approach.
Non-rigid coracoclavicular fixation with tendon graft or synthetic
materials, or rigid acromioclavicular fixation with a hook plate,
is preferable to fixation with coracoclavicular screws owing to
significant risks of loosening and breakage. The evidence, although limited, also suggests that anatomical
ligament reconstruction with autograft or certain synthetic grafts
may have better outcomes than non-anatomical transfer of the coracoacromial
ligament. It has been suggested that this is due to better restoration
horizontal and vertical stability of the joint. Despite the large number of recently published studies, there
remains a lack of high-quality evidence, making it difficult to
draw firm conclusions regarding these controversial issues. Cite this article:
We report our experience of staged revision surgery
for the treatment of infected total elbow arthroplasty (TEA). Between
1998 and 2010 a consecutive series of 33 patients (34 TEAs) underwent
a first-stage procedure with the intention to proceed to second-stage
procedure when the infection had been controlled. A single first-stage procedure
with removal of the components and cement was undertaken for 29
TEAs (85%), followed by the insertion of antibiotic-impregnated
cement beads, and five (15%) required two or more first-stage procedures.
The most common organism isolated was coagulase-negative A second-stage procedure was performed for 26 TEAs (76%); seven
patients (seven TEAs, 21%) had a functional resection arthroplasty
with antibiotic beads There were three recurrent infections (11.5%) in those patients
who underwent a second-stage procedure. The infection presented
at a mean of eight months (5 to 10) post-operatively. The mean Mayo
Elbow Performance Score (MEPS) in those who underwent a second stage
revision without recurrent infection was 81.1 (65 to 95). Staged revision surgery is successful in the treatment of patients
with an infected TEA and is associated with a low rate of recurrent
infection. However, when infection does occur, this study would
suggest that it becomes apparent within ten months of the second
stage procedure. Cite this article:
The aim of this study was to determine the effect
of radial extracorporeal shock-wave therapy (rESWT) on patients with
chronic tendinitis of the rotator cuff. This was a randomised controlled
trial in which 82 patients (mean age 47 years (24 to 67)) with chronic
tendinitis diagnosed clinically were randomly allocated to a treatment
group who received low-dose rESWT (three sessions at an interval
10 to 14 days, 2000 pulses, 0.11 mJ/mm2, 8 Hz) or to
a placebo group, with a follow-up of six months. The patients and
the treating orthopaedic surgeon, who were both blinded to the treatment,
evaluated the results. A total of 44 patients were allocated to
the rESWT group and 38 patients to the placebo group. A visual analogue
scale (VAS) score for pain, a Constant–Murley (CMS) score and a simple
shoulder test (SST) score significantly improved in both groups
at three and six months compared with baseline (all p ≤ 0.012).
The mean VAS was similar in both groups at three (p = 0.43) and
six months (p = 0.262). Also, the mean CMS and SST scores were similar
in both groups at six months (p = 0.815 and p = 0.834, respectively). It would thus seem that low-dose rESWT does not reduce pain or
improve function in patients chronic rotator cuff tendinitis compared
with placebo treatment. Cite this article:
Osteoarthritis results in changes in the dimensions
of the glenoid. This study aimed to assess the size and radius of curvature
of arthritic glenoids. A total of 145 CT scans were analysed, performed
as part of routine pre-operative assessment before total shoulder
replacement in 91 women and 54 men. Only patients with primary osteoarthritis and
a concentric glenoid were included in the study. The CT scans underwent
three-dimensional (3D) reconstruction and were analysed using dedicated
computer software. The measurements consisted of maximum superoinferior height,
anteroposterior width and a best-fit sphere radius of curvature
of the glenoid. The mean height was 40.2 mm ( With current shoulder replacement systems using a unique backside
radius of curvature for the glenoid component, there is a risk of
undertaking excessive reaming to adapt the bone to the component
resulting in sacrifice of subchondral bone or under-reaming and
instability of the component due to a ’rocking horse‘ phenomenon. Cite this article:
We measured the tension in the interosseous membrane
in six cadaveric forearms using an Cite this article:
The most prevalent disorders of the shoulder are related to the
muscles of rotator cuff. In order to develop a mechanical method
for the evaluation of the rotator cuff muscles, we created a database
of isometric force generation by the rotator cuff muscles in normal
adult population. We hypothesised the existence of variations according
to age, gender and dominancy of limb. A total of 400 healthy adult volunteers were tested, classified
into groups of 50 men and women for each decade of life. Maximal
isometric force was measured at standardised positions for supraspinatus,
infraspinatus and subscapularis muscles in both shoulders in every
person. Torque of the force was calculated and normalised to lean body
mass. The profiles of mean torque-time curves for each age and gender
group were compared.Objectives
Methods
Some surgeons are reluctant to perform a reverse
total shoulder arthroplasty (RTSA) on both shoulders because of concerns
regarding difficulty with activities of daily living post-operatively
as a result of limited rotation of the shoulders. Nevertheless,
we hypothesised that outcomes and patient satisfaction following
bilateral RTSA would be comparable to those following unilateral
RTSA. A single-surgeon RTSA registry was reviewed for patients who underwent
bilateral staged RTSA with a minimum follow-up of two years. A unilateral
RTSA matched control was selected for each shoulder in those patients
undergoing bilateral procedures. The Constant–Murley score (CMS), American
Shoulder and Elbow Surgeons (ASES) score, Subjective Shoulder Values
(SSV), visual analogue scale (VAS) for pain, range of movement and
strength were measured pre- and post-operatively. The mean CMS,
ASES, SSV, VAS scores, strength and active forward elevation were
significantly improved
(all p <
0.01) following each operation in those undergoing bilateral
procedures. The mean active external rotation (p = 0.63 and p =
0.19) and internal rotation (p = 0.77 and p = 0.24) were not significantly
improved. The improvement in the mean ASES score after the first
RTSA was greater than the improvement in its control group (p =
0.0039). The improvement in the mean CMS, ASES scores and active
forward elevation was significantly less after the second RTSA than
in its control group (p = 0.0244, p = 0.0183, and p = 0.0280, respectively).
Pain relief and function significantly improved after each RTSA
in those undergoing a bilateral procedure. Bilateral RTSA is thus a reasonable form of treatment for patients
with severe bilateral rotator cuff deficiency, although inferior
results may be seen after the second procedure compared with the
first. Cite this article:
Lateral epicondylitis, or ’tennis elbow’, is
a common condition that usually affects patients between 35 and
55 years of age. It is generally self-limiting, but in some patients
it may continue to cause persistent symptoms, which can be refractory
to treatment. This review discusses the mechanism of disease, symptoms
and signs, investigations, current management protocols and potential
new treatments. Cite this article:
The indications for reverse shoulder arthroplasty
(RSA) continue to be expanded. Associated impairment of the deltoid
muscle has been considered a contraindication to its use, as function
of the RSA depends on the deltoid and impairment of the deltoid
may increase the risk of dislocation. The aim of this retrospective
study was to determine the functional outcome and risk of dislocation
following the use of an RSA in patients with impaired deltoid function.
Between 1999 and 2010, 49 patients (49 shoulders) with impairment
of the deltoid underwent RSA and were reviewed at a mean of 38 months
(12 to 142) post-operatively. There were nine post-operative complications (18%),
including two dislocations. The mean forward elevation improved
from 50° ( These results suggest that pre-operative deltoid impairment,
in certain circumstances, is not an absolute contraindication to
RSA. This form of treatment can yield reliable improvement in function
without excessive risk of post-operative dislocation. Cite this article:
The glenopolar angle assesses the rotational
alignment of the glenoid and may provide prognostic information
and aid the management of scapula fractures. We have analysed the
effect of the anteroposterior (AP) shoulder radiograph rotational
offset on the glenopolar angle in a laboratory setting and used
this to assess the accuracy of shoulder imaging employed in routine
clinical practice. Fluoroscopic imaging was performed on 25 non-paired scapulae
tagged with 2 mm steel spheres to determine the orientation of true
AP views. The glenopolar angle was measured on all the bony specimens
rotated at 10° increments. The mean glenopolar angle measured on
the bone specimens in rotations between 0° and 20° and thereafter
was found to be significantly different (p <
0.001). We also obtained
the AP radiographs of the uninjured shoulder of 30 patients treated
for fractures at our centre and found that none fitted the criteria
of a true AP shoulder radiograph. The mean angular offset from the
true AP view was 38° (10° to 65°) for this cohort. Radiological
AP shoulder views may not fully project the normal anatomy of the scapular
body and the measured glenopolar angle. The absence of a true AP
view may compromise the clinical management of a scapular fracture. Cite this article: