Aims. Manipulation under anaesthetic (MUA) is a recognised form of treatment for patients with a frozen shoulder. However, not all patients benefit. Some have persistent or recurrent symptoms. There are no clear recommendations in the literature on the optimal management of recurrent frozen shoulder after a MUA. We aimed to address this issue in this study. Patients and Methods. We analysed a prospectively collected, single-surgeon, consecutive series of patients who underwent MUA for frozen shoulder between January 1999 and December 2015. The Oxford Shoulder Scores (OSS) and range of movement were the outcome measures. . Results. A total of 730 patients (792 shoulders) underwent MUA during the study period. A further MUA was undertaken in 141 shoulders (17.8%), for which we had complete data for 126. The mean improvement in OSS for all patients undergoing MUA was 16 (26 to 42), and the mean post-operative OSS in those requiring a further MUA was 14 (28 to 42; t-test, no difference between mean improvements, p = 0.57). Improvement was seen after a further MUA, regardless both of the outcome of the initial MUA, and of the time of recurrence. Patients with type-1 diabetes mellitus were at a 38% increased risk of requiring a further MUA, compared with the 18% increased risk of the group as a whole (p < 0.0001). Conclusion. Patients with a poor outcome or recurrent symptoms of a frozen shoulder after a MUA should be offered a further MUA with the expectation of a good outcome and a low complication rate. Cite this article: Bone Joint J 2017;99-B:812–17

Aims. To achieve expert clinical consensus in the delivery of hydrodilatation for the treatment of primary frozen shoulder to inform clinical practice and the design of an intervention for evaluation. Methods. We conducted a two-stage, electronic questionnaire-based, modified Delphi survey of shoulder experts in the UK NHS. Round one required positive, negative, or neutral ratings about hydrodilatation. In round two, each participant was reminded of their round one responses and the modal (or ‘group’) response from all participants. This allowed participants to modify their responses in round two. We proposed respectively mandating or encouraging elements of hydrodilatation with 100% and 90% positive consensus, and respectively disallowing or discouraging with 90% and 80% negative consensus. Other elements would be optional. Results. Between 4 August 2020 and 4 August 2021, shoulder experts from 47 hospitals in the UK completed the study. There were 106 participants (consultant upper limb orthopaedic surgeons, n = 50; consultant radiologists, n = 52; consultant physiotherapist, n = 1; extended scope physiotherapists, n = 3) who completed round one, of whom 97 (92%) completed round two. No elements of hydrodilatation were “mandated” (100% positive rating). Elements that were “encouraged” (≥ 80% positive rating) were the use of image guidance, local anaesthetic, normal saline, and steroids to deliver the injection. Injecting according to patient tolerance, physiotherapy, and home exercises were also “encouraged”. No elements were “discouraged” (≥ 80% negative rating) although using hypertonic saline was rated as being “disallowed” (≥ 90% negative rating). Conclusion. In the absence of rigorous evidence, our Delphi study allowed us to achieve expert consensus about positive, negative, and neutral ratings of hydrodilatation in the management of frozen shoulder in a hospital setting. This should inform clinical practice and the design of an intervention for evaluation. Cite this article: Bone Jt Open 2022;3(9):701–709

Aims. The primary aim of this study was to evaluate the efficacy of distension arthrography in the treatment of adhesive capsulitis of the shoulder. The secondary aim was to assess which patient and procedural factors predicted the recurrence of symptoms after the procedure. Methods. All patients referred to our shoulder clinic over a ten-year period, between 2008 and 2018, with a clinical diagnosis of capsulitis and symptoms persisting for more than six months, were offered treatment with a distension arthrogram. All procedures were performed by one of five musculoskeletal radiologists, with a combination of steroid, local anaesthetic, and a distention volume of 10 ml, 30 ml, or 50 ml. Patient demographics, procedural details, recurrence of symptoms, and the need for further intervention were evaluated. Results. A total of 2,432 distension arthrograms were performed during the study period. The mean time between arthrography and analysis was 5.4 years (SD 4.4; 1 to 11). Recurrent symptoms occurred in 184 cases (7.6%), all of whom had a repeat distension arthrogram at a median of nine months (interquartile range (IQR) 6.0 to 15.3). The requirement for further intervention for persistent symptoms following arthrography was significantly associated with diabetes (p < 0.001) and bilateral capsulitis (p < 0.001). The volume of distension, either with air or saline, showed a dose-dependent advantage. Distension of 50 ml versus 30 ml showed a significantly decreased odds ratio for recurrence of 2.2 (95% confidence interval (CI) 1.6 to 3.0; p < 0.001). Capsule rupture (p = 0.615) or steroid dose (p = 0.275) did not significantly affect the rate of recurrence. There were no infections or neurovascular injuries. Following the second distension arthrogram, the symptoms resolved in 137 cases (74.5%) with no further intervention being required. An arthroscopic capsular release was ultimately required in 41 cases, comprising 1.7% of the entire cohort. Conclusion. We found a low rate of repeat intervention following distension arthrography in patients with adhesive capsulitis of the shoulder, at long term follow-up. Greater volumes of distension are associated with lower rates of recurrence independent of capsule rupture. Cite this article: Bone Joint J 2020;102-B(5):606–610

Aims

Frozen shoulder is a common, painful condition that results in impairment of function. Corticosteroid injections are commonly used for frozen shoulder and can be given as glenohumeral joint (GHJ) injection or suprascapular nerve block (SSNB). Both injection types have been shown to significantly improve shoulder pain and range of motion. It is not currently known which is superior in terms of relieving patients’ symptoms. This is the protocol for a randomized clinical trial to investigate the clinical effectiveness of corticosteroid injection given as either a GHJ injection or SSNB.

Aims

The primary aim of this study was to assess the feasibility of recruiting and retaining patients to a patient-blinded randomized controlled trial comparing corticosteroid injection (CSI) to autologous protein solution (APS) injection for the treatment of subacromial shoulder pain in a community care setting. The study focused on recruitment rates and retention of participants throughout, and collected data on the interventions’ safety and efficacy.

Aims

The use and variety of stemless humeral components in anatomical total shoulder arthroplasty (TSA) have proliferated since their advent in 2004. Early outcomes are reassuring but independent mid-term results are scarce. This independent study reports a consecutive series of 143 Eclipse stemless shoulder prostheses with a minimum five-year (5 to 10) follow-up.

Aims

To report early (two-year) postoperative findings from a randomized controlled trial (RCT) investigating disease-specific quality of life (QOL), clinical, patient-reported, and radiological outcomes in patients undergoing a total shoulder arthroplasty (TSA) with a second-generation uncemented trabecular metal (TM) glenoid versus a cemented polyethylene glenoid (POLY) component.

Aims

Reverse total shoulder arthroplasty (RTSA) using trabecular metal (TM)-backed glenoid implants has been introduced with the aim to increase implant survival. Only short-term reports on the outcomes of TM-RTSA have been published to date. We aim to present the seven-year survival of TM-backed glenoid implants along with minimum five-year clinical and radiological outcomes.

Aims

Ultrasound (US)-guided injections are widely used in patients with conditions of the shoulder in order to improve their accuracy. However, the clinical efficacy of US-guided injections compared with blind injections remains controversial. The aim of this study was to compare the accuracy and efficacy of US-guided compared with blind corticosteroid injections into the glenohumeral joint in patients with primary frozen shoulder (FS).

Aims

The Mathys Affinis Short is the most frequently used stemless total shoulder prosthesis in the UK. The purpose of this prospective cohort study is to report the survivorship, clinical, and radiological outcomes of the first independent series of the Affinis Short prosthesis.

Aims

Despite recent advances in arthroscopic rotator cuff repair, re-tear rates remain high. New methods to improve healing rates following rotator cuff repair must be sought. Our primary objective was to determine if adjunctive bone marrow stimulation with channelling five to seven days prior to arthroscopic cuff repair would lead to higher Western Ontario Rotator Cuff (WORC) scores at 24 months postoperatively compared with no channelling.

Aims

Reverse shoulder arthroplasty (RSA) reliably improves shoulder pain and function for a variety of indications. However, the safety and efficacy of RSA in elderly patients is largely unknown. The purpose of this study was to report the mortality, morbidity, complications, reoperations, and outcomes of primary RSA in patients aged > 80 years.

Aims

In patients with a rotator cuff tear, tear pattern and tendon involvement are known risk factors for the development of pseudoparalysis of the shoulder. It remains unclear, however, why similar tears often have very different functional consequences. The present study hypothesizes that individual shoulder anatomy, specifically the moment arms (MAs) of the rotator cuff (RC) and the deltoid muscle, as well as their relative recruitment during shoulder abduction, plays a central role in pseudoparalysis.

Aim

The aim of this study was to report the long-term outcome and implant survival of the lateral resurfacing elbow (LRE) arthroplasty in the treatment of elbow arthritis.

Aims

Our aim was to investigate the prevalence of Propionibacterium (P.) acnes in the subcutaneous fat and capsule of patients undergoing shoulder surgery for frozen shoulder or instability.

Frozen shoulder is a recognised complication following simple arthroscopic shoulder procedures, but its exact incidence has not been reported. Our aim was to analyse a single-surgeon series of patients undergoing arthroscopic subacromial decompression (ASD; group 1) or ASD in combination with arthroscopic acromioclavicular joint (ACJ) excision (group 2), to establish the incidence of frozen shoulder post-operatively. Our secondary aim was to identify associated risk factors and to compare this cohort with a group of patients with primary frozen shoulder.

We undertook a retrospective analysis of 200 consecutive procedures performed between August 2011 and November 2013. Group 1 included 96 procedures and group 2 104 procedures. Frozen shoulder was diagnosed post-operatively using the British Elbow and Shoulder Society criteria. A comparative group from the same institution involved 136 patients undergoing arthroscopic capsular release for primary idiopathic frozen shoulder.

The incidence of frozen shoulder was 5.21% in group 1 and 5.71% in group 2. Age between 46 and 60 years (p = 0.002) and a previous idiopathic contralateral frozen shoulder (p < 0.001) were statistically significant risk factors for the development of secondary frozen shoulder. Comparison of baseline characteristics against the comparator groups showed no statistically significant differences for age, gender, diabetes and previous contralateral frozen shoulder.

These results suggest that the risk of frozen shoulder following simple arthroscopic procedures is just over 5%, with no increased risk if the ACJ is also excised. Patients aged between 46 and 60 years and a previous history of frozen shoulder increase the relative risk of secondary frozen shoulder by 7.8 (95% confidence interval (CI) 2.1 to 28.3)and 18.5 (95% CI 7.4 to 46.3) respectively.

Cite this article: Bone Joint J 2015; 97-B:963–6.

We examined the outcomes and levels of patient satisfaction in 202 consecutive cases of ultrasound-guided supraclavicular brachial plexus block (SBPB) in upper limb surgery performed between September 2007 and March 2010.

All blocks were performed by orthopaedic surgeons using ultrasound visualisation with a high-frequency linear probe. The probe was placed in the coronal–oblique plane in the supraclavicular fossa, and the puncture was ‘in-plane’ from lateral to medial. Most of the blocks were performed with 0.75% ropivacaine/1% lidocaine (1:1), with or without adrenaline in 1:200 000 dilution. In 201 patients (99.5%) the brachial plexus block permitted surgery without conversion to general anaesthesia. The mean procedure time for block was 3.9 min (2 to 12), the mean waiting time for surgery was 34.1 min (10 to 64), the mean surgical time was 75.2 min (6 to 232), and the mean duration of post-anaesthetic analgesia was 437 min (171 to 992). A total of 20 patients (10%) developed a transient Horner’s syndrome. No nerve injury, pneumothorax, arterial puncture or systemic anaesthetic toxicity were recorded. Most patients (96.7%) were satisfied with ultrasound-guided SBPB. This study demonstrates the efficacy and safety of ultrasound-guided SBPB for orthopaedic surgery on the upper limb.

Cite this article: Bone Joint J 2014;96-B:795–9.

This pilot study reports the clinical outcomes of a combination of partial subscapularis tendon transfer and small-head hemiarthroplasty in patients with rotatator cuff arthropathy. A total of 30 patients (30 shoulders; eight men and 22 women) with a mean age of 74 years (55 to 84) were assessed at a mean follow-up of 31 months (24 to 60). The inclusion criteria were painful cuff tear arthropathy with normal deltoid function and a non-degenerative subscapularis muscle and tendon and a preserved teres minor.

Outcome was assessed using the University of California Los Angeles score, the Japanese Orthopaedic Association score, and the Oxford Shoulder Score. Radiographic measurements included the centre of rotation distance and the length of the deltoid.

All clinical scores were significantly improved post-operatively. The active flexion and external rotation improved significantly at the most recent follow-up (p < 0.035). Although the mean centre of rotation distance changed significantly (p < 0.001), the mean length of the deltoid did not change significantly from the pre-operative value (p = 0.29). The change in the length of the deltoid with < 100° flexion was significantly less than that with > 100° (p < 0.001).

Progressive erosion of the glenoid was seen in four patients. No patient required revision or further surgery.

A combination of partial subscapularis tendon transfer and small-head hemiarthroplasty effectively restored function and relieved pain in patients with rotator cuff arthropathy.

Cite this article: 2015;97-B:1090–5.

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: Bone Joint J 2013;95-B:1158–64.

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: Bone Joint J 2013;95-B:1521–6.

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: Bone Joint J 2014;96-B:224–8.

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: Bone Joint J 2013;95-B:1232–8.