We have compared the outcome of hemiarthroplasty of the shoulder in three distinct diagnostic groups, using survival analysis as used by the United Kingdom national joint registers, patient-reported outcome measures (PROMs) as recommended by Darzi in the 2008 NHS review, and transition and satisfaction questions. A total of 72 hemiarthroplasties, 19 for primary osteoarthritis (OA) with an intact rotator cuff, 22 for OA with a torn rotator cuff, and 31 for rheumatoid arthritis (RA), were followed up for between three and eight years. All the patients survived, with no revisions or dislocations and no significant radiological evidence of loosening. The mean new Oxford shoulder score (minimum/worst 0, maximum/best 48) improved significantly for all groups (p < 0.001), in the OA group with an intact rotator cuff from 21.4 to 38.8 (effect size 2.9), in the OA group with a torn rotator cuff from 13.3 to 27.2 (effect size 2.1) and in the RA group from 13.7 to 28.0 (effect size 3.1). By this assessment, and for the survival analysis, there was no significant difference between the groups. However, when ratings using the patient satisfaction questions were analysed, eight (29.6%) of the RA group were ‘disappointed’, compared with one (9.1%) of the OA group with cuff intact and one (7.7%) of the OA group with cuff torn. All patients in the OA group with cuff torn indicated that they would undergo the operation again, compared to ten (90.9%) in the OA group with cuff intact and 20 (76.9%) in the RA group. The use of revision rates alone does not fully represent outcome after hemiarthroplasty of the shoulder. Data from PROMs provides more information about change in pain and the ability to undertake activities and perform tasks. The additional use of satisfaction ratings shows that both the rates of revision surgery and PROMs need careful interpretation in the context of patient expectations

The different attributes of the Patient Evaluation Measure (PEM) questionnaire were investigated in 80 patients with a fracture of the scaphoid. Assessments were made at 2, 8, 12, 26 and 52 weeks. Reliability was assessed by measurement of the internal consistency of the different questions in 275 completed PEM forms. Cronbach’s alpha, which needs to lie between 0.7 and 0.9, was 0.9 for the PEM. Pain, tenderness, swelling, wrist movement and grip strength correlated with the PEM score confirming the validity of the assessment. Changes in the different variables between visits correlated significantly with changes in the PEM score; its effect size and standardised response mean were comparable to those of grip strength and movement, confirming the responsiveness of this questionnaire. Gender, dominance and the side injured did not influence the scores. Older patients had a poorer outcome as assessed by the score which appeared to be a true effect and not age bias. Our study confirmed that the PEM is a reliable, valid and responsive instrument in assessing outcomes of disorders of the hand

Diabetes mellitus is recognised as a risk factor for carpal tunnel syndrome. The response to treatment is unclear, and may be poorer than in non-diabetic patients. Previous randomised studies of interventions for carpal tunnel syndrome have specifically excluded diabetic patients. The aim of this study was to investigate the epidemiology of carpal tunnel syndrome in diabetic patients, and compare the outcome of carpal tunnel decompression with non-diabetic patients. The primary endpoint was improvement in the QuickDASH score. The prevalence of diabetes mellitus was 11.3% (176 of 1564). Diabetic patients were more likely to have severe neurophysiological findings at presentation. Patients with diabetes had poorer QuickDASH scores at one year post-operatively (p = 0.028), although the mean difference was lower than the minimal clinically important difference for this score. After controlling for underlying differences in age and gender, there was no difference between groups in the magnitude of improvement after decompression (p = 0.481). Patients with diabetes mellitus can therefore be expected to enjoy a similar improvement in function

We developed a questionnaire to assess patient-reported outcome after surgery of the elbow from interviews with patients. Initially, 17 possible items with five response options were included. A prospective study of 104 patients (107 elbow operations) was carried out to analyse the underlying factor structure, dimensionality, internal and test-retest reliability, construct validity and responsiveness of the questionnaire items. This was compared with the Mayo Elbow performance score clinical scale, the Disabilities of the Arm, Shoulder and Hand questionnaire, and the Short-Form (SF-36) General Health Survey. In total, five questions were considered inappropriate, which resulted in the final 12-item questionnaire, which has been referred to as the Oxford elbow score. This comprises three unidimensional domains, ‘elbow function’, ‘pain’ and ‘social-psychological’; with each domain comprising four items with good measurement properties. This new 12-item Oxford elbow score is a valid measure of the outcome of surgery of the elbow

We reviewed the outcome of arthroscopic stabilisation of anterior glenohumeral instability in young adults using the transglenoid suture technique. A questionnaire was sent to 455 consecutive patients who had undergone this procedure between 1992 and 2000. Of these, 312 patients (68.5%) with 313 affected shoulders and a mean age of 20 years (18 to 28) responded. Outcome was determined by the number of re-dislocations or, in patients who had not re-dislocated, by the disease-specific quality of life as measured by the Western Ontario Shoulder Instability index. During a mean follow-up of 6.4 years (1 to 14), 177 patients (56%) sustained a re-dislocation, including 70 who required a further operation. In 136 patients (44%) who reported neither re-dislocation nor re-operation, the index scores were good (median 90.4%; 28.9% to 100%). No significant peri- or pre-operative predictors of re-dislocation or re-operation were found. We found a high rate of re-dislocation after transglenoid suture repair in young, physically active patients

We compared the outcome of arthroscopic repair of the rotator cuff in 32 diabetic patients with the outcome in 32 non-diabetic patients matched for age, gender, size of tear and comorbidities. The Constant-Murley score improved from a mean of 49.2 (24 to 80) pre-operatively to 60.8 (34 to 95) post-operatively (p = 0.0006) in the diabetic patients, and from 46.4 (23 to 90) pre-operatively to 65.2 (25 to 100) post-operatively (p = 0.0003) in the non-diabetic patients at six months. This was significantly greater (p = 0.0002) in non-diabetic patients (18.8) than in diabetics (11.6). There was no significant change in the mean mental component of the Short-Form 12, but the mean physical component increased from 35 to 41 in non-diabetics (p = 0.0001), and from 37 to 39 (p = 0.15) in diabetics. These trends were observed at one year. Patients with diabetes showed improvement of pain and function following arthroscopic rotator cuff repair in the short term, but less than their non-diabetic counterparts

We have conducted a prospective study to assess the mid-term clinical results following arthroscopic repair of the rotator cuff. Patients were evaluated using the Constant score, subjective satisfaction levels and post-operative ultrasound scans. Of 115 consecutive patients who underwent arthroscopic repair of the rotator cuff at our institution, 102 were available for follow-up. The mean period of follow-up was for 35.8 months (24 to 73). The mean age of the patients was 57.3 years (23 to 78). There were 18 small (≤ 1 cm in diameter), 44 medium (1 cm to 3 cm in diameter), 34 large (3 cm to 5 cm in diameter) and six massive (> 5 cm in diameter) tears. There was a statistically significant increase in the size of the tear with increasing age (p = 0.0048). The mean pre-operative Constant score was 41.4 points (95% confidence interval, 37.9 to 44.9), which improved to 84.5 (95% confidence interval, 82.2 to 86.9). A significant inverse association (p = 0.0074), was observed between the size of the tear and the post-operative Constant score, with patients having smaller tears attaining higher Constant scores after repair. Post-operatively, 80 patients (78.4%) were able to resume their occupations and 84 (82.4%) returned to their pre-injury leisure activities. Only eight (7.8%) of 102 patients were not satisfied with the outcome. Recurrent tears were detected by ultrasound in 19 (18.6%) patients, and were generally smaller than the original ones. Patients with recurrent tears experienced a mean improvement of 31.6 points (95% confidence interval, 23.6 to 39.6) in their post-operative Constant scores. Those with intact repairs had significantly improved (p < 0.0001) Constant scores (mean improvement 46.3 points, 95% confidence interval, 41.9 to 50.6). Patient satisfaction was high in 94 cases (92%), irrespective of the outcome of the Constant score. Recurrent tears appear to be linked to age-related degeneration. Arthroscopic repair of the rotator cuff leads to high rates of satisfaction (92%) and good functional results, albeit with a recurrence rate of 18.6% (19 of 102)

We have examined 167 patients who had a hemiarthroplasty for three- and four-part fractures and fracture-dislocations of the head of the humerus in a multicentre study involving 12 Austrian hospitals. All patients were followed for more than a year. Anatomical healing of the tuberosity significantly influenced the outcome as measured by the Constant score and subjective patient satisfaction. With regard to pain, the outcome was generally satisfactory but only 41.9% of patients were able to flex the shoulder above 90°. The age of the patient and the type of prosthesis significantly influenced the healing of the tuberosity, but bone grafting did not. Achievement of healing of the tuberosity was inferior in institutions at which less than 15 hemiarthroplasties had been performed (Mann-Witney U test, p = 0.0001)

Impingement syndrome in the shoulder has generally been considered to be a clinical condition of mechanical origin. However, anomalies exist between the pathology in the subacromial space and the degree of pain experienced. These may be explained by variations in the processing of nociceptive inputs between different patients. We investigated the evidence for augmented pain transmission (central sensitisation) in patients with impingement, and the relationship between pre-operative central sensitisation and the outcomes following arthroscopic subacromial decompression. We recruited 17 patients with unilateral impingement of the shoulder and 17 age- and gender-matched controls, all of whom underwent quantitative sensory testing to detect thresholds for mechanical stimuli, distinctions between sharp and blunt punctate stimuli, and heat pain. Additionally Oxford shoulder scores to assess pain and function, and PainDETECT questionnaires to identify ‘neuropathic’ and referred symptoms were completed. Patients completed these questionnaires pre-operatively and three months post-operatively. A significant proportion of patients awaiting subacromial decompression had referred pain radiating down the arm and had significant hyperalgesia to punctate stimulus of the skin compared with controls (unpaired t-test, p < 0.0001). These are felt to represent peripheral manifestations of augmented central pain processing (central sensitisation). The presence of either hyperalgesia or referred pain pre-operatively resulted in a significantly worse outcome from decompression three months after surgery (unpaired t-test, p = 0.04 and p = 0.005, respectively). These observations confirm the presence of central sensitisation in a proportion of patients with shoulder pain associated with impingement. Also, if patients had relatively high levels of central sensitisation pre-operatively, as indicated by higher levels of punctate hyperalgesia and/or referred pain, the outcome three months after subacromial decompression was significantly worse

We analysed the outcome of the Coonrad-Morrey total elbow replacement used for fracture of the distal humerus in elderly patients with no evidence of inflammatory arthritis and compared the results for early versus delayed treatment. We studied a total of 32 patients with 15 in the early treatment group and 17 in the delayed treatment group. The mean follow-up was 56.1 months (18 to 88). The percentage of excellent to good results based on the Mayo elbow performance score was not significantly different, 84% in the early group and 79% in the delayed group. Subjective satisfaction was 92% in both the groups. One patient in the early group developed chronic regional pain syndrome and another type 4 aseptic loosening. Two elbows in the early group also showed type 1 radiological loosening. Two patients in the delayed group had an infection, two an ulnar nerve palsy, one developed heterotopic ossification and one type 4 aseptic loosening. Two elbows in this group also showed type 1 radiological loosening. The Kaplan-Meier survivorship analysis for the early and delayed treatment groups was 93% at 88 months and 76% at 84 months, respectively. No significant difference was found between the two groups

Scapulothoracic fusion (STF) for painful winging of the scapula in neuromuscular disorders can provide effective pain relief and functional improvement, but there is little information comparing outcomes between patients with dystrophic and non-dystrophic conditions. We performed a retrospective review of 42 STFs in 34 patients with dystrophic and non-dystrophic conditions using a multifilament trans-scapular, subcostal cable technique supported by a dorsal one-third semi-tubular plate. There were 16 males and 18 females with a mean age of 30 years (15 to 75) and a mean follow-up of 5.0 years (2.0 to 10.6). The mean Oxford shoulder score improved from 20 (4 to 39) to 31 (4 to 48). Patients with non-dystrophic conditions had lower overall functional scores but achieved greater improvements following STF. The mean active forward elevation increased from 59° (20° to 90°) to 97° (30° to 150°), and abduction from 51° (10° to 90°) to 83° (30° to 130°) with a greater range of movement achieved in the dystrophic group. Revision fusion for nonunion was undertaken in five patients at a mean time of 17 months (7 to 31) and two required revision for fracture. There were three pneumothoraces, two rib fractures, three pleural effusions and six nonunions. The main risk factors for nonunion were smoking, age and previous shoulder girdle surgery. STF is a salvage procedure that can provide good patient satisfaction in 82% of patients with both dystrophic and non-dystrophic pathologies, but there was a relatively high failure rate (26%) when poor outcomes were analysed. Overall function was better in patients with dystrophic conditions which correlated with better range of movement; however, patients with non-dystrophic conditions achieved greater functional improvement

In a prospective study, we have evaluated the impact of psychological disturbance on symptoms, self-reported disability and the surgical outcome in a series of 110 patients with carpal tunnel syndrome. Self-reported severity of symptoms and disability were assessed using the patient evaluation measure and the Boston carpal tunnel questionnaire. Psychological distress was assessed using the hospital anxiety and depression scale. There was a significant association between psychological disturbance and the pre-operative symptoms and disability. However, there was no significant association between pre-operative psychological disturbance and the outcome of surgery at six months. We concluded that patients with carpal tunnel syndrome should not be denied surgery because of pre-operative psychological disturbance since it does not adversely affect the surgical outcome

We report the outcome at a mean of 93 months (73 to 110) of 71 patients with an acute fracture of the scaphoid who were randomised to Herbert screw fixation (35) or below-elbow plaster cast immobilisation (36). These 71 patients represent the majority of a randomised series of 88 patients whose short-term outcome has previously been reported. Those patients available for later review were similar in age, gender and hand dominance. There was no statistical difference in symptoms and disability as assessed by the mean Patient Evaluation Measure (p = 0.4), or mean Patient-Rated Wrist Evaluation (p = 0.9), the mean range of movement of the wrist (p = 0.4), mean grip strength (p = 0.8), or mean pinch strength (p = 0.4). Radiographs were available from the final review for 59 patients. Osteoarthritic changes were seen in the scaphotrapezial and radioscaphoid joints in eight (13.5%) and six patients (10.2%), respectively. Three patients had asymptomatic lucency surrounding the screw. One non-operatively treated patient developed nonunion with avascular necrosis. In five patients who were treated non-operatively (16%) there was an abnormal scapholunate angle ( > 60°), but in four of these patients this finding was asymptomatic. No medium-term difference in function or radiological outcome was identified between the two treatment groups

In a prospective, randomised study on the repair of tears of the rotator cuff we compared the clinical results of two suture techniques for which different suture materials were used. We prospectively randomised 100 patients with tears of the rotator cuff into two groups. Group 1 had transosseous repair with No. 3 Ethibond using modified Mason-Allen sutures and group 2 had transosseous repair with 1.0 mm polydioxanone cord using modified Kessler sutures. After 24 to 30 months the patients were evaluated clinically using the Constant score and by ultrasonography. Of the 100 patients, 92 completed the study. No significant statistical difference was seen between the two groups: Constant score, 91% vs 92%; rate of further tear, 18% vs 22%; and revision, 4% vs 4%. In cases of further tear the outcome in group 2 did not differ from that for the intact repairs (91% vs 91%), but in group 1 it was significantly worse (94% vs 77%, p = 0.005). Overall, seven patients had complications which required revision surgery, in four for pain (two in each group) and in three for infection (two in group 1 and one in group 2)

We compared the outcome of peri-operative humeral condylar fractures in patients undergoing a Coonrad-Morrey semiconstrained total elbow replacement with that of patients with rheumatoid arthritis undergoing the same procedure without fractures. In a consecutive series of 40 elbows in 33 patients, 13 elbows had a fracture in either condyle peri-operatively, and 27 elbows were intact. The fractured condyle was either fixed internally or excised. We found no statistical difference in the patients’ background, such as age, length of follow-up, immobilisation period, Larsen’s radiological grade, or Steinbrocker’s stage and functional class. There was also no statistical difference between the groups in relation to the Mayo Elbow Performance Score, muscle strength, range of movement, or radiolucency around the implants at a mean of 4.8 years (1.1 to 8.0) follow-up. We conclude that fractured condyles can be successfully treated with either internal fixation or excision, and cause no harmful effect

This study identified variables which influence the outcome of surgical management on 126 ununited scaphoid fractures managed by internal fixation and non-vascular bone grafting. The site of fracture was defined by a new method: the ratio of the length of the proximal fragment to the sum of the lengths of both fragments, calculated using specific views in the plain radiographs. Bone healing occurred in 71% (89) of cases. Only the site of nonunion (p = 1 × 10. −6. ) and the delay to surgery (p = 0.001) remained significant on multivariate analysis. The effect of surgical delay on the probability of union increased as the fracture site moved proximally. A prediction model was produced by stepwise logistic regression analysis, enabling the surgeon to predict the success of surgery where the site of the nonunion and delay to surgery is known

A consecutive series of 372 patients who underwent surgery for disorders of the rotator cuff involving arthroscopic subacromial decompression and open or arthroscopic repairs of the cuff were prospectively investigated as to the comparability of subjective and objective assessment scores of shoulder function. Assessments were made before operation and at 3, 6, 12, 18 and 24 months after surgery using the Disabilities of the Arm, Shoulder, and Hand score, the Oxford shoulder score and the Constant-Murley score, which was used as a reference. All scores were standardised to a scale of 0 to 100 for comparison. Statistical analysis compared the post-operative course and the mean score for the subjective Disabilities to the Arm, Shoulder and Hand score and Oxford shoulder score, with the objective Constant score at each interval. A strong correlation was evident between both subjective scores and the Constant score. We concluded that both the subjective scores would be useful substitutes for the Constant score, obviating the need for a trained investigator and the specialist equipment required to perform the Constant score.

Restoration of hand function is rarely achieved after a complete closed traction lesion of the supraclavicular brachial plexus. We describe the injury, treatment, rehabilitation and long-term results of two patients who regained good function of the upper limb and useful function in the hand after such an injury. Successful repairs were performed within six days of injury. Tinel’s sign proved accurate in predicting the ruptures and the distribution of pain was accurate in predicting avulsion. The severe pain that began on the day of injury resolved with the onset of muscle function.

Recovery of muscle function preceded recovery of sensation. Recovery of the function of C and Aδ fibres was the slowest of all.

We reviewed 39 patients with displaced three- and four-part fractures of the humerus. In 21 patients (group A) we had used an anatomical prosthesis for the humeral head and in 18 (group B) an implant designed for fractures.

When followed up at a mean of 29.3 months after surgery the overall Constant score was 51.9 points; in group A it was 51.5 and in group B 52.4 points. The subjective satisfaction of the patients was assessed using a numerical rating scale and was similar in both groups. In group A complete healing of the tuberosities was found in 29% and 50% in group B. Partial integration was seen in 29% of group A and in only one patient in group B, while resorption was noted in 43% of group A and 44% of group B. The functional outcome was significantly better in patients with complete or partial healing of the tuberosities (p = 0.022). The specific trauma prosthesis did not lead to better healing of the tuberosities. The difference in clinical outcome obtained by the two designs did not reach statistical significance.

Aims. An objective technological solution for tracking adherence to at-home shoulder physiotherapy is important for improving patient engagement and rehabilitation outcomes, but remains a significant challenge. The aim of this research was to evaluate performance of machine-learning (ML) methodologies for detecting and classifying inertial data collected during in-clinic and at-home shoulder physiotherapy exercise. Methods. A smartwatch was used to collect inertial data from 42 patients performing shoulder physiotherapy exercises for rotator cuff injuries in both in-clinic and at-home settings. A two-stage ML approach was used to detect out-of-distribution (OOD) data (to remove non-exercise data) and subsequently for classification of exercises. We evaluated the performance impact of grouping exercises by motion type, inclusion of non-exercise data for algorithm training, and a patient-specific approach to exercise classification. Algorithm performance was evaluated using both in-clinic and at-home data. Results. The patient-specific approach with engineered features achieved the highest in-clinic performance for differentiating physiotherapy exercise from non-exercise activity (area under the receiver operating characteristic (AUROC) = 0.924). Including non-exercise data in algorithm training further improved classifier performance (random forest, AUROC = 0.985). The highest accuracy achieved for classifying individual in-clinic exercises was 0.903, using a patient-specific method with deep neural network model extracted features. Grouping exercises by motion type improved exercise classification. For at-home data, OOD detection yielded similar performance with the non-exercise data in the algorithm training (fully convolutional network AUROC = 0.919). Conclusion. Including non-exercise data in algorithm training improves detection of exercises. A patient-specific approach leveraging data from earlier patient-supervised sessions should be considered but is highly dependent on per-patient data quality. Cite this article: Bone Joint Res 2023;12(3):165–177

Aims

The optimal choice of management for proximal humerus fractures (PHFs) has been increasingly discussed in the literature, and this work aimed to answer the following questions: 1) what are the incidence rates of PHF in the geriatric population in the USA; 2) what is the mortality rate after PHF in the elderly population, specifically for distinct treatment procedures; and 3) what factors influence the mortality rate?

Aims

The aim of this study was to create artificial intelligence (AI) software with the purpose of providing a second opinion to physicians to support distal radius fracture (DRF) detection, and to compare the accuracy of fracture detection of physicians with and without software support.

Aims

Rotator cuff tear (RCT) is the leading cause of shoulder pain, primarily associated with age-related tendon degeneration. This study aimed to elucidate the potential differential gene expressions in tendons across different age groups, and to investigate their roles in tendon degeneration.

Aims

This study aimed to define the histopathology of degenerated humeral head cartilage and synovial inflammation of the glenohumeral joint in patients with omarthrosis (OmA) and cuff tear arthropathy (CTA). Additionally, the potential of immunohistochemical tissue biomarkers in reflecting the degeneration status of humeral head cartilage was evaluated.

Aims

Rotator cuff muscle atrophy and fatty infiltration affect the clinical outcomes of rotator cuff tear patients. However, there is no effective treatment for fatty infiltration at this time. High-intensity interval training (HIIT) helps to activate beige adipose tissue. The goal of this study was to test the role of HIIT in improving muscle quality in a rotator cuff tear model via the β3 adrenergic receptor (β3AR).

Aims

Rotator cuff (RC) injuries are characterized by tendon rupture, muscle atrophy, retraction, and fatty infiltration, which increase injury severity and jeopardize adequate tendon repair. Epigenetic drugs, such as histone deacetylase inhibitors (HDACis), possess the capacity to redefine the molecular signature of cells, and they may have the potential to inhibit the transformation of the fibro-adipogenic progenitors (FAPs) within the skeletal muscle into adipocyte-like cells, concurrently enhancing the myogenic potential of the satellite cells.

Aims

Rotator cuff (RC) tears are common musculoskeletal injuries which often require surgical intervention. Noninvasive pulsed electromagnetic field (PEMF) devices have been approved for treatment of long-bone fracture nonunions and as an adjunct to lumbar and cervical spine fusion surgery. This study aimed to assess the effect of continuous PEMF on postoperative RC healing in a rat RC repair model.

Aims

To evaluate if union of clavicle fractures can be predicted at six weeks post-injury by the presence of bridging callus on ultrasound.

Objectives. The objective of this study was to perform a meta-analysis of all randomised controlled trials (RCTs) comparing surgical and non-surgical management of fractures of the proximal humerus, and to determine whether further analyses based on complexity of fracture, or the type of surgical intervention, produced disparate findings on patient outcomes. Methods. A systematic review of the literature was performed identifying all RCTs that compared surgical and non-surgical management of fractures of the proximal humerus. Meta-analysis of clinical outcomes was performed where possible. Subgroup analysis based on the type of fracture, and a sensitivity analysis based on the type of surgical intervention, were also performed. Results. Seven studies including 528 patients were included. The overall meta-analysis found that there was no difference in clinical outcomes. However, subgroup and sensitivity analyses found improved patient outcomes for more complex fractures managed surgically. Four-part fractures that underwent surgery had improved long-term health utility scores (mean difference, MD 95% CI 0.04 to 0.28; p = 0.007). They were also less likely to result in osteoarthritis, osteonecrosis and non/malunion (OR 7.38, 95% CI 1.97 to 27.60; p = 0.003). Another significant subgroup finding was that secondary surgery was more common for patients that underwent internal fixation compared with conservative management within the studies with predominantly three-part fractures (OR 0.15, 95% CI 0.04 to 0.63; p = 0.009). Conclusion. This meta-analysis has demonstrated that differences in the type of fracture and surgical treatment result in outcomes that are distinct from those generated from analysis of all types of fracture and surgical treatments grouped together. This has important implications for clinical decision making and should highlight the need for future trials to adopt more specific inclusion criteria. Cite this article: S. Sabharwal, N. K. Patel, D. Griffiths, T. Athanasiou, C. M. Gupte, P. Reilly. Trials based on specific fracture configuration and surgical procedures likely to be more relevant for decision making in the management of fractures of the proximal humerus: Findings of a meta-analysisBone Joint Res 2016;5:470–480. DOI: 10.1302/2046-3758.510.2000638

Aims. The aim of this study was to compare the pain caused by the application of a tourniquet after exsanguination of the upper limb with that occurring after simple elevation. . Patients and Methods. We used 26 healthy volunteers (52 arms), each of whom acted as their own matched control. The primary outcome measure was the total pain experienced by each volunteer while the tourniquet was inflated for 20 minutes. This was calculated as the area under the pain curve for each individual subject. Secondary outcomes were pain at each time point; the total pain experienced during the recovery phase; the ability to tolerate the tourniquet and the time for full recovery after deflation of the tourniquet. . Results. There was a significant difference in the area under the pain curves in favour of exsanguination (mean difference 8.4; 95% confidence interval (CI) 3.0 to 13.7, p = 0.004). There was no difference between the dominant and non-dominant arms (mean difference -0.2; 95% CI -23.2 to 22.8, p = 0.99). The area under both recovery curves were similar (mean difference 0.7; 95% CI -6.0 to 4.6, p = 0.78). There was no statistical difference in recovery time, the actual mean difference being 30 seconds longer in the elevation group (p = 0.06). Conclusion. Many orthopaedic and plastic surgery procedures are done under local anaesthetic or regional block where a bloodless field and a motionless patient are essential. Optimising patient comfort during surgery with the tourniquet inflated is thus a priority. This study is useful in that it compares two common methods of preparation of the upper limb prior to tourniquet inflation and which have not previously been compared in this context. Following on the results of this study, we can confidently conclude that exsanguinating the upper limb before inflating a tourniquet is more comfortable than simply elevating the arm for patients undergoing a procedure under local or regional block, both during the procedure and in the recovery phase. . Take home message: Exsanguination rather than elevation is recommended in order to minimise patient discomfort and optimise the surgical field. Cite this article: Bone Joint J 2016;98-B:519–25

The sternoclavicular joint (SCJ) is a pivotal articulation in the linked system of the upper limb girdle, providing load-bearing in compression while resisting displacement in tension or distraction at the manubrium sterni. The SCJ and acromioclavicular joint (ACJ) both have a small surface area of contact protected by an intra-articular fibrocartilaginous disc and are supported by strong extrinsic and intrinsic capsular ligaments. The function of load-sharing in the upper limb by bulky periscapular and thoracobrachial muscles is extremely important to the longevity of both joints. Ligamentous and capsular laxity changes with age, exposing both joints to greater strain, which may explain the rising incidence of arthritis in both with age. The incidence of arthritis in the SCJ is less than that in the ACJ, suggesting that the extrinsic ligaments of the SCJ provide greater stability than the coracoclavicular ligaments of the ACJ. Instability of the SCJ is rare and can be difficult to distinguish from medial clavicular physeal or metaphyseal fracture-separation: cross-sectional imaging is often required. The distinction is important because the treatment options and outcomes of treatment are dissimilar, whereas the treatment and outcomes of ACJ separation and fracture of the lateral clavicle can be similar. Proper recognition and treatment of traumatic instability is vital as these injuries may be life-threatening. Instability of the SCJ does not always require surgical intervention. An accurate diagnosis is required before surgery can be considered, and we recommend the use of the Stanmore instability triangle. Most poor outcomes result from a failure to recognise the underlying pathology. There is a natural reluctance for orthopaedic surgeons to operate in this area owing to unfamiliarity with, and the close proximity of, the related vascular structures, but the interposed sternohyoid and sternothyroid muscles are rarely injured and provide a clear boundary to the medial retroclavicular space, as well as an anatomical barrier to unsafe intervention. This review presents current concepts of instability of the SCJ, describes the relevant surgical anatomy, provides a framework for diagnosis and management, including physiotherapy, and discusses the technical challenges of operative intervention. Cite this article: Bone Joint J 2013;95-B:721–31

In order to compare the outcome from surgical repair and physiotherapy, 103 patients with symptomatic small and medium-sized tears of the rotator cuff were randomly allocated to one of the two approaches. The primary outcome measure was the Constant score, and secondary outcome measures included the self-report section of the American Shoulder and Elbow Surgeons score, the Short Form 36 Health Survey and subscores for shoulder movement, pain, strength and patient satisfaction. Scores were taken at baseline and after six and 12 months by a blinded assessor. Nine patients (18%) with insufficient benefit from physiotherapy after at least 15 treatment sessions underwent secondary surgical treatment. Analysis of between-group differences showed better results for the surgery group on the Constant scale (difference 13.0 points, p − 0.002), on the American Shoulder and Elbow surgeons scale (difference 16.1 points, p < 0.0005), for pain-free abduction (difference 28.8°, p = 0.003) and for reduction in pain (difference on a visual analogue scale −1.7 cm, p < 0.0005)

We report a randomised controlled trial to examine the effectiveness and cost-effectiveness of arthroscopic acromioplasty in the treatment of stage II shoulder impingement syndrome. A total of 140 patients were randomly divided into two treatment groups: supervised exercise programme (n = 70, exercise group) and arthroscopic acromioplasty followed by a similar exercise programme (n = 70, combined treatment group). The main outcome measure was self-reported pain on a visual analogue scale of 0 to 10 at 24 months, measured on the 134 patients (66 in the exercise group and 68 in the combined treatment group) for whom endpoint data were available. An intention-to-treat analysis disclosed an improvement in both groups but without statistically significant difference in outcome between the groups (p = 0.65). The combined treatment was considerably more costly. Arthroscopic acromioplasty provides no clinically important effects over a structured and supervised exercise programme alone in terms of subjective outcome or cost-effectiveness when measured at 24 months. Structured exercise treatment should be the basis for treatment of shoulder impingement syndrome, with operative treatment offered judiciously until its true merit is proven

A total of 159 patients (84 women and 75 men, mean age of 53 (20 to 87)) with subacromial impingement were randomised to treatment with subacromial injections using lidocaine with one of hyaluronic acid (51 patients), corticosteroid (53 patients) or placebo (55 patients). Patients were followed up for 26 weeks. The primary outcome was pain on a visual analogue score (VAS), and secondary outcomes included the Constant Murley score, shoulder pain score, functional mobility score, shoulder disability questionnaire and pain-specific disability score. The different outcome measures showed similar results. After three, six and 12 weeks corticosteroid injections were superior to hyaluronic acid injections and only at six weeks significantly better than placebo injections. The mean short-term reduction in pain on the VAS score at 12 weeks was 7% (. sd. 2.7; 97.5% confidence interval (CI) 0.207 to 1.55; p = 0.084) in the hyaluronic acid group, 28% (. sd. 2.8; 97.5% CI 1.86 to 3.65; p < 0.001) in the corticosteroid group and 23% (. sd. 3.23; 97.5% CI 1.25 to 3.26; p < 0.001) in the placebo group. At 26 weeks there was a reduction in pain in 63% (32 of 51) of patients in the hyaluronic acid group, 72% (38 of 53) of those in the corticosteroid group and 69% (38 of 55) of those in the placebo group. We were not able to show a convincing benefit from hyaluronic acid injections compared with corticosteroid or placebo injections. Corticosteroid injections produced a significant reduction in pain in the short term (three to 12 weeks), but in the long term the placebo injection produced the best results

This study was performed to review the safety and outcome of total shoulder replacements in patients who are ≥ 80 years of age. A total of 50 total shoulder replacements in 44 patients at a mean age of 82 years (80 to 89) were studied. Their health and shoulder status, the operation and post-operative course were analysed, including pain, movement, patient satisfaction, medical and surgical complications, radiographs, the need for revision surgery, and implant and patient survival. A total of 27 patients had an ASA classification of III or IV and medical abnormalities were common. Of the 13 shoulders with bony deficiency of the glenoid, nine required grafting. The duration of hospital stay was prolonged and blood transfusions were common. There were no peri-operative deaths. The mean follow-up was for 5.5 years (2 to 12). Pain was significantly reduced (p < 0.001) and movement improved in active elevation and both external and internal rotation (p < 0.001). Using the Neer scale for assessing outcome, 40 (80%) shoulders had an excellent or satisfactory result. There were medical or surgical complications in 17 cases. Four shoulders developed radiological evidence of loosened glenoid components, and three of these had a poor outcome. Three other shoulders required revision, two for instability. By the time of this review 39 of the patients had died from unrelated causes at a mean of 7.5 years (0.8 to 16.4) after surgery. Total shoulder replacement is a relatively effective treatment in this elderly group of patients. However, there is a requirement for more intense patient care in the peri-operative period, and non-fatal medical or surgical complications are common. Most of these elderly patients will have a comfortable functional shoulder for the rest of their lives

Objectives. Local corticosteroid infiltration is a common practice of treatment for lateral epicondylitis. In recent studies no statistically significant or clinically relevant results in favour of corticosteroid injections were found. The injection of autologous blood has been reported to be effective for both intermediate and long-term outcomes. It is hypothesised that blood contains growth factors, which induce the healing cascade. Methods. A total of 60 patients were included in this prospective randomised study: 30 patients received 2 ml autologous blood drawn from contralateral upper limb vein + 1 ml 0.5% bupivacaine, and 30 patients received 2 ml local corticosteroid + 1 ml 0.5% bupivacaine at the lateral epicondyle. Outcome was measured using a pain score and Nirschl staging of lateral epicondylitis. Follow-up was continued for total of six months, with assessment at one week, four weeks, 12 weeks and six months. Results. The corticosteroid injection group showed a statistically significant decrease in pain compared with autologous blood injection group in both visual analogue scale (VAS) and Nirschl stage at one week (both p < 0.001) and at four weeks (p = 0.002 and p = 0.018, respectively). At the 12-week and six-month follow-up, autologous blood injection group showed statistically significant decrease in pain compared with corticosteroid injection group (12 weeks: VAS p = 0.013 and Nirschl stage p = 0.018; six months: VAS p = 0.006 and Nirschl p = 0.006). At the six-month final follow-up, a total of 14 patients (47%) in the corticosteroid injection group and 27 patients (90%) in autologous blood injection group were completely relieved of pain. Conclusions. Autologous blood injection is efficient compared with corticosteroid injection, with less side-effects and minimum recurrence rate

Advanced osteoarthritis of the wrist or the distal articulation of the lunate with the capitate has traditionally been treated surgically by arthrodesis. In order to maintain movement, we performed proximal row carpectomy with capsular interposition arthroplasty as an alternative to arthrodesis in eight patients with advanced arthritis and retrospectively reviewed their clinical and radiographic outcomes after a mean follow-up of 41 months (13 to 53). The visual analogue scale (VAS) for pain at its worst and at rest, and the patient-rated wrist evaluation score improved significantly after surgery, whereas ranges of movement and grip strength were maintained at the pre-operative levels. Progression of arthritis in the radiocapitate joint was observed in three patients, but their outcomes were not significantly different from those without progression of arthritis. Proximal row carpectomy with capsular interposition arthroplasty is a reasonable option for the treatment of patients with advanced arthritis of the wrist

Displaced fractures of the lateral end of the clavicle in young patients have a high incidence of nonunion and a poor functional outcome after conservative management. Operative treatment is therefore usually recommended. However, current techniques may be associated with complications which require removal of the fixation device. We have evaluated the functional and radiological outcomes using a novel technique of open reduction and internal fixation. A series of 16 patients under 60 years of age with displaced fractures of the lateral end were treated by open reduction and fixation using a twin coracoclavicular endobutton technique. They were followed up for the first year after their injury. At one year the mean Constant score was 87.1 and the median Disabilities of the Arm, Shoulder and Hand score was 3.3. All fractures had united, except in one patient who developed an asymptomatic fibrous union. One patient had post-traumatic stiffness of the shoulder, which resolved with physiotherapy. None required re-operation. This technique produces good functional and radiological outcomes with a low prevalence of complications and routine implant removal is not necessary

We have previously described the short-term outcome of the use of reverse shoulder arthroplasty in the treatment of acute complex proximal humeral fractures in the elderly. We now report the clinical and radiological outcome of 36 fractures at a mean of 6.6 years (1 to 16). Previously, at a mean follow-up of 6 years (1 to 12) the mean Constant score was 58.5; this was reduced to 53 points with the further follow-up. A total of 23 patients (63%) had radiological evidence of loosening of the glenoid component. Nevertheless, only one patient had aseptic loosening of the baseplate at 12 years’ follow-up. The reduction in the mean Constant score with longer follow-up and the further development of scapular notching is worrying. New developments in design, bearing surfaces and surgical technique, and further follow-up, will determine whether reverse shoulder arthroplasty has a place in the management of complex proximal humeral fractures in the elderly

We report the long-term clinical and radiological outcomes of the Aequalis total shoulder replacement with a cemented all-polyethylene flat-back keeled glenoid component implanted for primary osteoarthritis between 1991 and 2003 in nine European centres. A total of 226 shoulders in 210 patients were retrospectively reviewed at a mean of 122.7 months (61 to 219) or at revision. Clinical outcome was assessed using the Constant score, patient satisfaction score and range of movement. Kaplan-Meier survivorship analysis was performed with glenoid revision for loosening and radiological glenoid loosening (. sd. ) as endpoints. The Constant score was found to improve from a mean of 26.8 (. sd. 10.3) pre-operatively to 57.6 (. sd. 20.0) post-operatively (p < 0.001). Active forward flexion improved from a mean of 85.3° (. sd. 27.4) pre-operatively to 125° (. sd. 37.3) postoperatively (p < 0.001). External rotation improved from a mean of 7° (. sd. 6.5) pre-operatively to 30.3° (. sd. 21.8°) post-operatively (p < 0.001). Survivorship with revision of the glenoid component as the endpoint was 99.1% at five years, 94.5% at ten years and 79.4% at 15 years. Survivorship with radiological loosening as the endpoint was 99.1% at five years, 80.3% at ten years and 33.6% at 15 years. Younger patient age and the curettage technique for glenoid preparation correlated with loosening. The rate of glenoid revision and radiological loosening increased with duration of follow-up, but not until a follow-up of five years. Therefore, we recommend that future studies reporting radiological outcomes of new glenoid designs should report follow-up of at least five to ten years

We have carried out a prospective double-blind randomised controlled trial to compare the efficacy of a single subacromial injection of the non-steroidal anti-inflammatory drug, tenoxicam, with a single injection of methylprednisolone in patients with subacromial impingement. A total of 58 patients were randomly allocated into two groups. Group A received 40 mg of methylprednisolone and group B 20 mg of tenoxicam as a subacromial injection along with lignocaine. The Constant-Murley shoulder score was used as the primary outcome measure and the Disability of Arm, Shoulder and Hand (DASH) and the Oxford Shoulder Score (OSS) as secondary measures. Six weeks after injection the improvement in the Constant-Murley score was significantly greater in the methylprednisolone group (p = 0.003) than in the tenoxicam group. The improvement in the DASH score was greater in the steroid group and the difference was statistically significant and consistent two (p < 0.01), four (p < 0.01) and six weeks (p < 0.020) after the injection. The improvement in the OSS was consistently greater in the steroid group than in the tenoxicam group. Although the difference was statistically significant at two (p < 0.001) and four (p = 0.003) weeks after the injection, it was not at six weeks (p = 0.055). Subacromial injection of tenoxicam does not offer an equivalent outcome to subacromial injection of corticosteroid at six weeks. Corticosteroid is significantly better than tenoxicam for improving shoulder function in tendonitis of the rotator cuff after six weeks

The aim of this study was to determine the functional outcome and rate of re-tears following mini-open repair of symptomatic large and massive tears of the rotator cuff using a two-row technique. The 24 patients included in the study were assessed prospectively before and at a mean of 27 months (18 to 53) after surgery using the Constant and the Oxford Shoulder scores. Ultrasound examination was carried out at follow-up to determine the integrity of the repair. Patient satisfaction was assessed using a simple questionnaire. The mean Constant score improved significantly from 36 before to 68 after operation (p < 0.0001) and the mean Oxford Shoulder score from 39 to 20 (p < 0.0001). Four of the 24 patients (17%) had a re-tear diagnosed by ultrasound. A total of 21 patients (87.5%) were satisfied with the outcome of their surgery. The repair remained intact in 20 patients (83%). However, the small number of re-tears (four patients) in the study did not allow sufficient analysis to show a difference in outcome in relation to the integrity of the repair

We have investigated the outcome of arthroscopic revision surgery for recurrent instability of the shoulder after failed primary anterior stabilisation. We identified 40 patients with failed primary open or arthroscopic anterior stabilisation of the shoulder who had been treated by revision arthroscopic capsulolabral reconstruction and followed up for a mean of 36 months (12 to 87). There were 34 men and six women with a mean age of 33.1 years (15 to 48). Details of the patients, the technique of the primary procedure, the operative findings at revision and the clinical outcome were evaluated by reviewing the medical records, physical examination and the use of the Western Ontario shoulder instability index score, the American Shoulder and Elbow Surgeons score and the health status questionnaire 12. Recurrent instability persisted in four patients after the revision arthroscopic procedure. At the final follow-up, the mean American Shoulder and Elbow Surgeons score was 81.1 (17.5 to 99.5) and the mean Western Ontario shoulder instability index score was 68.2 (20 to 98.2). Quality-of-life scoring showed good to excellent results in most patients. Arthroscopic revision capsulolabral reconstruction can provide a satisfactory outcome in selected patients for recurrent instability of the shoulder provided that no large Hill-Sachs lesion is present

Aims

Plating displaced proximal humeral fractures is associated with a high rate of screw perforation. Dynamization of the proximal screws might prevent these complications. The aim of this study was to develop and evaluate a new gliding screw concept for plating proximal humeral fractures biomechanically.

Most patients with a nightstick fracture of the ulna are treated conservatively. Various techniques of immobilisation or early mobilisation have been studied. We performed a systematic review of all published randomised controlled trials and observational studies that have assessed the outcome of these fractures following above- or below-elbow immobilisation, bracing and early mobilisation. We searched multiple electronic databases, related bibliographies and other studies. We included 27 studies comprising 1629 fractures in the final analysis. The data relating to the time to radiological union and the rates of delayed union and nonunion could be pooled and analysed statistically. We found that early mobilisation produced the shortest radiological time to union (mean 8.0 weeks) and the lowest mean rate of nonunion (0.6%). Fractures treated with above- or below-elbow immobilisation and braces had longer mean radiological times to union (9.2 weeks, 9.2 weeks and 8.7 weeks, respectively) and higher mean rates of nonunion (3.8%, 2.1% and 0.8%, respectively). There was no statistically significant difference in the rate of non- or delayed union between those treated by early mobilisation and the three forms of immobilisation (p = 0.142 to p = 1.000, respectively). All the studies had significant biases, but until a robust randomised controlled trial is undertaken the best advice for the treatment of undisplaced or partially displaced nightstick fractures appears to be early mobilisation, with a removable forearm support for comfort as required. Cite this article: Bone Joint J 2013;95-B:952–9

Our aim in this prospective study was to evaluate the outcome of total shoulder replacement in the treatment of young and middle-aged active patients with primary glenohumeral osteoarthritis. We reviewed 21 patients (21 shoulders) with a mean age of 55 years (37 to 60). The mean follow-up was seven years (5 to 9). The same anatomical, third-generation, cemented implant had been used in all patients. All the patients were evaluated radiologically and clinically using the Constant and Murley score. No patients required revision. In one a tear of the supraspinatus tendon occurred. Overall, 20 patients (95%) were either very satisfied (n = 18) or satisfied (n = 2) with the outcome. Significant differences (p < 0.0001) were found for all categories of the Constant and Murley score pre- and post-operatively. The mean Constant and Murley score increased from 24.1 points (10 to 45) to 64.5 points (39 to 93), and the relative score from 30.4% (11% to 50%) to 83% (54% to 116%). No clinical or radiological signs of loosening of the implant were seen. For young and middle-aged patients with osteoarthritis, third-generation total shoulder replacement is a viable method of treatment with a low rate of complications and excellent results in the mid-term

While frequently discussed as a standard treatment for the management of an infected shoulder replacement, there is little information on the outcome of two-stage re-implantation. We examined the outcome of 17 consecutive patients (19 shoulders) who were treated between 1995 and 2004 with a two-stage re-implantation for the treatment of a deep-infection after shoulder replacement. All 19 shoulders were followed for a minimum of two years or until the time of further revision surgery. The mean clinical follow-up was for 35 months (24 to 80). The mean radiological follow-up was 27 months (7 to 80). There were two excellent results, four satisfactory and 13 unsatisfactory. In 12 of the 19 shoulders (63%) infection was considered to be eradicated. The mean pain score improved from 4.2 (3 to 5 (out of 5)) to 1.8 (1 to 4). The mean elevation improved from 42° (0° to 140°) to 89° (0° to 165°), mean external rotation from 30° (0° to 90°) to 43° (0° to 90°), and mean internal rotation from the sacrum to L5. There were 14 complications. Our study suggests that two-stage re-implantation for an infected shoulder replacement is associated with a high rate of unsatisfactory results, marginal success at eradicating infection and a high complication rate

We retrospectively reviewed 21 patients (22 shoulders) who presented with deep infection after surgery to the shoulder, 17 having previously undergone hemiarthroplasty and five open repair of the rotator cuff. Nine shoulders had undergone previous surgical attempts to eradicate their infection. The diagnosis of infection was based on a combination of clinical suspicion (16 shoulders), positive frozen sections (> 5 polymorphonuclear leukocytes per high-power field) at the time of revision (15 shoulders), positive intra-operative cultures (18 shoulders) or the pre-operative radiological appearances. The patients were treated by an extensive debridement, intravenous antibiotics, and conversion to a reverse shoulder prosthesis in either a single- (10 shoulders) or a two-stage (12 shoulders) procedure. At a mean follow-up of 43 months (25 to 66) there was no evidence of recurrent infection. All outcome measures showed statistically significant improvements. Mean abduction improved from 36.1° (. sd. 27.8) pre-operatively to 75.7° (. sd. 36.0) (p < 0.0001), the mean forward flexion from 43.1° (. sd. 33.5) to 79.5° (. sd. 43.2) (p = 0.0003), and mean external rotation from 10.2° (. sd. 18.7) to 25.4° (. sd. 23.5) (p = 0.0037). There was no statistically significant difference in any outcome between the single-stage and the two-stage group

Objectives. To report the five-year results of a randomised controlled trial examining the effectiveness of arthroscopic acromioplasty in the treatment of stage II shoulder impingement syndrome. Methods. A total of 140 patients were randomly divided into two groups: 1) supervised exercise programme (n = 70, exercise group); and 2) arthroscopic acromioplasty followed by a similar exercise programme (n = 70, combined treatment group). Results. The main outcome measure was self-reported pain as measured on a visual analogue scale. At the five-year assessment a total of 109 patients were examined (52 in the exercise group and 57 in the combined treatment group). There was a significant decrease in mean self-reported pain on the VAS between baseline and the five-year follow-up in both the exercise group (from 6.5 (1 to 10) to 2.2 (0 to 8); p < 0.001) and the combined treatment group (from 6.4 (2 to 10) to 1.9 (0 to 8); p < 0.001). The same trend was seen in the secondary outcome measures (disability, working ability, pain at night, Shoulder Disability Questionnaire and reported painful days). An intention-to-treat analysis showed statistically significant improvements in both groups at five years compared with baseline. Further, improvement continued between the two- and five-year timepoints. No statistically significant differences were found in the patient-centred primary and secondary parameters between the two treatment groups. Conclusions. Differences in the patient-centred primary and secondary parameters between the two treatment groups were not statistically significant, suggesting that acromioplasty is not cost-effective. Structured exercise treatment seems to be the treatment of choice for shoulder impingement syndrome

We describe the outcome at a mean follow-up of 8.75 years (7.6 to 9.8) of seven patients who had undergone osteochondral autologous transplantation for full-thickness cartilage defects of the shoulder between 1998 and 2000. These patients have been described previously at a mean of 32.6 months when eight were included. One patient has been lost to follow-up. The outcome was assessed by the Constant shoulder score and the Lysholm knee score to assess any donor-site morbidity. Standard radiographs and MR scores were obtained and compared with the pre-operative findings and the results from the previous review. No patient required any further surgery on the shoulder. The mean Constant score improved significantly until the final follow-up (p = 0.018). The Lysholm score remained excellent throughout. There was a significant progression of osteoarthritic changes from the initial surgery to the first and final follow-up but this did not appear to be related to the size of the defect, the number of cylinders required or the Constant score (p = 0.016). MRI showed that all except one patient had a congruent joint surface at the defect with full bony integration of all osteochondral cylinders. The results have remained satisfactory over a longer period with very good objective and subjective findings

In adults with brachial plexus injuries, lack of active external rotation at the shoulder is one of the most common residual deficits, significantly compromising upper limb function. There is a paucity of evidence to address this complex issue. We present our experience of isolated latissimus dorsi (LD) muscle transfer to achieve active external rotation. This is a retrospective review of 24 adult post-traumatic plexopathy patients who underwent isolated latissimus dorsi muscle transfer to restore external rotation of the shoulder between 1997 and 2010. All patients were male with a mean age of 34 years (21 to 57). All the patients underwent isolated LD muscle transfer using a standard technique to correct external rotational deficit. Outcome was assessed for improvement in active external rotation, arc of movement, muscle strength and return to work. The mean improvement in active external rotation from neutral was 24° (10° to 50°). The mean increase in arc of rotation was 52° (38° to 55°). Mean power of the external rotators was 3.5 Medical Research Council (MRC) grades (2 to 5). A total of 21 patients (88%) were back in work by the time of last follow up. Of these, 13 had returned to their pre-injury occupation. Isolated latissimus dorsi muscle transfer provides a simple and reliable method of restoring useful active external rotation in adults with brachial plexus injuries with internal rotational deformity. Cite this article: Bone Joint J 2013;95-B:660–3

The outcome of an anatomical shoulder replacement depends on an intact rotator cuff. In 1981 Grammont designed a novel large-head reverse shoulder replacement for patients with cuff deficiency. Such has been the success of this replacement that it has led to a rapid expansion of the indications. We performed a systematic review of the literature to evaluate the functional outcome of each indication for the reverse shoulder replacement. Secondary outcome measures of range of movement, pain scores and complication rates are also presented

Although the outcome of fractures of the distal radius is traditionally assessed using objective clinical variables such as grip strength and range of movement of the wrist, the extent to which they reflect function and outcomes of importance for the patient is uncertain. This may cause considerable inconsistencies in the assessment of outcome using current scoring systems. We prospectively studied 31 patients recovering from unstable fractures of the distal radius in order to investigate the association between objective variables and the level of post-traumatic disability of the wrist as measured by the patient-rated wrist evaluation (PRWE) score. Multiple regression showed considerable differences in the extent to which limitations in specific objective clinical variables reflected the level of disability of the wrist. Grip strength was shown to be a significant predictor of the PRWE score (regression coefficient −1.09, 95% confidence interval −1.76 to −0.42, p < 0.01) and thus appears to be a sensitive indicator of return of function of the wrist. Forearm rotation and flexion and extension of the wrist were not significantly associated with the PRWE score. These observations should be taken into account during the evaluation of methods of treatment and in constructing future clinical outcome scoring systems

We present the outcome of 47 Souter-Strathclyde replacements of the elbow with a mean follow-up of 82 months (12 to 129). The clinical results were assessed using a condition-specific outcome measure. The mean total score (maximum 100) before the operation was 47.21 and improved to 79.92 (p < 0.001). The mean pain score (maximum 50) improved from 21.41 to 46.70 (p < 0.001) and the mean functional component of the score (maximum 30) from 11.19 to 18.65 (p < 0.001). There was negligible change in the score for the range of movement although a significant improvement in mean flexion from 124° to 136° was noted (p < 0.001). Revision surgery was required in four patients, for dislocation, wound dehiscence and early infection in one, late infection in two and aseptic loosening in one. The cumulative survival was 75% at nine years for all causes of failure and 97% at ten years for aseptic loosening alone. Our study demonstrates the value of the Souter-Strathclyde total elbow arthroplasty in providing relief from pain and functional improvement in rheumatoid patients

The outcome of 260 repairs of the radial and posterior interosseous nerves, graded by Seddon’s modification of the Medical Research Council Special Committee’s system, was analysed according to four patterns of injury; open ‘tidy’, open ‘untidy’, closed traction, and those associated with injury to the axillary or brachial artery. We studied the effect on the outcome of delay in effecting repair and of the length of the defect in the nerve trunk. Of the 242 repairs of the radial nerve we found that 30% had good results and 28% fair; 42% of the repairs had failed. The violence of injury was the most important factor in determining the outcome. Of the open ‘tidy’ repairs, 79% achieved a good or fair result, and 36% of cases with arterial injury also reached this level. Most repairs failed when the defect in the nerve trunk exceeded 10 cm. When the repairs were carried out within 14 days of injury, 49% achieved a good result; only 28% of later repairs did so. All repairs undertaken after 12 months failed. Of the 18 repairs of the posterior interosseous nerve, 16 achieved a good result

We systematically reviewed all the evidence published in the English language on proximal interphalangeal joint (PIPJ) replacement, to determine its effectiveness on the function of the hand and the associated post-operative complications. Original studies were selected if they reported clinical outcome with a minimum of one year’s follow-up. Quality was assessed using the Cowley systematic review criteria modified for finger-joint replacements. Of 319 articles identified, only five were adequately reported according to our quality criteria; there were no randomised controlled trials. PIPJ replacements had a substantial effect size on hand pain of -23.2 (95% confidence interval (CI) -27.3 to -19.1) and grip strength 1.2 (95% CI -10.7 to 13.1), and a small effect on range of movement 0.2 (95% CI -0.4 to 0.8). A dorsal approach was most successful. Post-operative loosening occurred in 10% (95% CI 3 to 30) of ceramic and 12.5% (95% CI 7 to 21) of pyrocarbon replacements. Post-operative complications occurred in 27.8% (95% CI 20 to 37). We conclude that the effectiveness of PIPJ replacement has not been established. Small observational case studies and short-term follow-up, together with insufficient reporting of patient data, functional outcomes and complications, limit the value of current evidence. We recommend that a defined core set of patients, surgical and outcome data for this intervention be routinely and systematically collected within the framework of a joint registry

We describe the intermediate results of lateral ligamentous repair or reconstruction for posterolateral rotatory instability of the elbow. Between 1986 and 1999, we performed 12 direct repairs and 33 ligament reconstructions with a tendon autograft. One patient was lost to follow-up and 44 were retrospectively studied at a mean of six years (2 to 15). Surgery restored stability in all except five patients. In two the elbow became stable after a second procedure. The mean post-operative Mayo elbow performance score was 85 points (60 to 100). The result was classified as excellent in 19, good in 13, fair in seven and poor in five patients. Thirty-eight patients (86%) were subjectively satisfied with the outcome of the operation. Better results were obtained in patients with a post-traumatic aetiology (p = 0.03), those with subjective symptoms of instability at presentation (p = 0.006) and those who had an augmented reconstruction using a tendon graft (p = 0.04). Reconstruction using a tendon graft seems to provide better results than ligament repair and the results do not seem to deteriorate with time. The outcome of this procedure is less predictable in patients with no subjective instability

We present the electromyographic (EMG) results ten years after open decompression of the median nerve at the wrist and compare them with the clinical and functional outcomes as judged by Levine’s Questionnaire. This retrospective study evaluated 115 patients who had undergone carpal tunnel decompression at a mean of 10.47 years (9.24 to 11.36) previously. A positive EMG diagnosis was found in 77 patients (67%), including those who were asymptomatic at ten years. It is necessary to include both clinical and functional results as well as electromyographic testing in the long-term evaluation of patients who have undergone carpal tunnel decompression particularly in those in whom revision surgery is being considered. In doubtful cases or when there are differing outcomes, self-administered scales such as Levine’s Questionnaire should prevail over EMG results when deciding on the need for revision surgery

The purpose of this study was to assess the clinical and radiological outcomes of dorsal intercarpal ligament capsulodesis for the treatment of static scapholunate instability at a minimum follow-up of four years. A total of 59 patients who underwent capsulodesis for this condition were included in a retrospective analysis after a mean of 8.25 years (4.3 to 12). A total of eight patients underwent a salvage procedure at a mean of 2.33 years (0.67 to 7.6) and were excluded. The mean range of extension/flexion was 88° (15° to 135°) and of ulnar/radial deviation was 38° (0° to 75°) at final follow-up. The mean Disabilities of the Arm Shoulder and Hand (DASH) score and Mayo wrist scores were 28 (0 to 85) and 61 (0 to 90), respectively. After significant improvement immediately post-operatively (p < 0.001 and p = 0.001, respectively), the mean scapholunate and radiolunate angles deteriorated to 70° (40° to 90°) and 8° (-15° to 25°), respectively, at final follow-up, which were not significantly different from their pre-operative values (p = 0.6 and p = 0.4, respectively). The mean carpal height index decreased significantly from 1.53 (1.38 to 1.65) to 1.48 (1.29 to 1.65) indicating progressive carpal collapse (p < 0.001); 40 patients (78%) had radiological evidence of degenerative arthritis. Capsulodesis did not maintain carpal reduction over time. Although the consequent ongoing scapholunate instability resulted in early arthritic degeneration, most patients had acceptable long-term function of the wrist

Reverse total shoulder replacement (RTSR) depends on adequate deltoid function for a successful outcome. However, the anterior deltoid and/or axillary nerve may be damaged due to prior procedures or injury. The purpose of this study was to determine the compensatory muscle forces required for scapular plane elevation following RTSR when the anterior deltoid is deficient. The soft tissues were removed from six cadaver shoulders, except for tendon attachments. After implantation of the RTSR, the shoulders were mounted on a custom-made shoulder simulator to determine the mean force in each muscle required to achieve 30° and 60° of scapular plane elevation. Two conditions were tested: 1) Control with an absent supraspinatus and infraspinatus; and 2) Control with anterior deltoid deficiency. Anterior deltoid deficiency resulted in a mean increase of 195% in subscapularis force at 30° when compared with the control (p = 0.02). At 60°, the subscapularis force increased a mean of 82% (p < 0.001) and the middle deltoid force increased a mean of 26% (p = 0.04). Scapular plane elevation may still be possible following an RTSR in the setting of anterior deltoid deficiency. When the anterior deltoid is deficient, there is a compensatory increase in the force required by the subscapularis and middle deltoid. Attempts to preserve the subscapularis, if present, might maximise post-operative function

We performed open acromioplasty for intractable impingement syndrome on 96 shoulders (93 patients) with an intact rotator cuff. All the shoulders were examined by ultrasound after a mean interval of nine years. Those showing pathological findings, a poor or fair subjective result, or deterioration of the primary excellent outcome had MRI and/or arthrography. The mean Constant score for the affected shoulders was 70 points and that for 48 non-involved, symptom-free shoulders, 84 points. The subjective outcome was excellent in 45, good in 24, fair in 18 and poor in 9 shoulders. Complete tears were found in 12 shoulders and partial tears in seven. A total of 14 shoulders was symptom-free after acromioplasty, but after an average of five years became painful again and showed deterioration. Of these, six had complete tears and four partial tears of the cuff. The tear rate was 4% in shoulders initially judged to be excellent, 25% in good, 33% in fair and 55% in poor shoulders. The tear rate was 71% in shoulders which subsequently deteriorated. The incidence was higher in men (25%) than in women (11%). We conclude that a tear of the rotator cuff may appear after acromioplasty, although there was no evidence of a tear at the time of operation. This is usually the reason for deterioration in a shoulder with an initially good operative outcome

We describe a technique of soft-tissue reconstruction which is effective for the treatment of chronic lunotriquetral instability. Part of extensor carpi ulnaris is harvested with its distal attachment preserved. It is passed through two drill holes in the triquetrum and sutured to itself. This stabilises the ulnar side of the wrist. We have reviewed 46 patients who underwent this procedure for post-traumatic lunotriquetral instability with clinical signs suggestive of ulnar-sided carpal instability. Standard radiographs were normal. All patients had pre-operative arthroscopy of the wrist at which dynamic lunotriquetral instability was demonstrated. A clinical rating system for the wrist by the Mayo clinic was used to measure the outcome. In 19 patients the result was excellent, in ten good, in 11 satisfactory and in six poor. On questioning, 40 (87%) patients said that surgery had substantially improved the condition and that they would recommend the operation. However, six (13%) were unhappy with the outcome and would not undergo the procedure again for a similar problem. There were six complications, five of which related to pisotriquetral problems. The mean follow-up was 39.1 months (6 to 100). We believe that tenodesis of extensor carpi ulnaris is a very satisfactory procedure for isolated, chronic post-traumatic lunotriquetral instability in selected patients. In those with associated pathology, the symptoms were improved, but the results were less predictable

The use of passive stretching of the elbow after arthrolysis is controversial. We report the results of open arthrolysis in 81 patients. Prospectively collected outcome data with a minimum follow-up of one year were analysed. All patients had sustained an intra-articular fracture initially and all procedures were performed by the same surgeon under continuous brachial plexus block anaesthesia and with continuous passive movement (CPM) used post-operatively for two to three days. CPM was used to maintain the movement achieved during surgery and passive stretching was not used at any time. A senior physiotherapist assessed all the patients at regular intervals. The mean range of movement (ROM) improved from 69° to 109° and the function and pain of the upper limb improved from 32 to 16 and from 20 to 10, as assessed by the Disabilities of the Arm Shoulder and Hand score and a visual analogue scale, respectively. The greatest improvement was obtained in the stiffest elbows: nine patients with a pre-operative ROM < 30° achieved a mean post-operative ROM of 92° (55° to 125°). This study demonstrates that in patients with a stiff elbow after injury, good results may be obtained after open elbow arthrolysis without using passive stretching during rehabilitation

Radial osteotomy is currently advocated for patients with Lichtman’s stages II and IIIA of Kienböck’s disease; its place in the treatment of patients with stage IIIB disease remains controversial. The purpose of this study was to evaluate the medium-term results of this procedure and to compare the outcome in patients with stage IIIB disease and those with earlier stages (II and IIIA). A total of 18 patients (18 osteotomies) were evaluated both clinically and radiologically at a mean follow-up of 10.3 years (4 to 18). Range of movement, grip strength and pain improved significantly in all patients; the functional score (Nakamura Scoring System (NSSK)) was high and self-reported disability (Disabilities of Arm, Shoulder and Hand questionnaire) was low at the final follow-up in all patients evaluated. Patients with stage IIIB disease, however, had a significantly lower grip strength, lower NSSK scores and higher disability than those in less advanced stages. Radiological progression of the disease was not noted in either group, despite the stage. Radial osteotomy seems effective in halting the progression of disease and improving symptoms in stages II, IIIA and IIIB. Patients with less advanced disease should be expected to have better clinical results

Surgical repair of posterosuperior rotator cuff tears has a poorer outcome and a higher rate of failure compared with repairs of supraspinatus tears. In this prospective cohort study 28 consecutive patients with an irreparable posterosuperior rotator cuff tear after failed conservative or surgical treatment underwent teres major tendon transfer. Their mean age was 60 years (48 to 71) and the mean follow-up was 25 months (12 to 80). The mean active abduction improved from 79° (0° to 150°) pre-operatively to 105° (20° to 180°) post-operatively (p = 0.011). The mean active external rotation in 90° abduction improved from 25° (0° to 70°) pre-operatively to 55° (0° to 90°) post-operatively (p < 0.001). The mean Constant score improved from 43 (18 to 78) pre-operatively to 65 (30 to 86) post-operatively (p < 0.001). The median post-operative VAS (0 to 100) for pain decreased from 63 (0 to 96) pre-operatively to 5 (0 to 56) post-operatively (p < 0.001). In conclusion, teres major transfer effectively restores function and relieves pain in patients with irreparable posterosuperior rotator cuff tears and leads to an overall clinical improvement in a relatively young and active patient group with limited treatment options. Cite this article: Bone Joint J 2013;95-B:523–9

Malunion is the most common complication of the distal radius with many modalities of treatment available for such a problem. The use of bone grafting after an osteotomy is still recommended by most authors. We hypothesised that bone grafting is not required; fixing the corrected construct with a volar locked plate helps maintain the alignment, while metaphyseal defect fills by itself. Prospectively, we performed the procedure on 30 malunited dorsally-angulated radii using fixed angle volar locked plates without bone grafting. At the final follow-up, 22 wrists were available. Radiological evidence of union, correction of the deformity, clinical and functional improvement was achieved in all cases. Without the use of bone grafting, corrective open wedge osteotomy fixed by a volar locked plate provides a high rate of union and satisfactory functional outcomes

Mason type III fractures of the radial head are treated by open reduction and internal fixation, resection or prosthetic joint replacement. When internal fixation is performed, fixation of the radial head to the shaft is difficult and implant-related complications are common. Furthermore, problems of devascularisation of the radial head can result from fixation of the plate to the radial neck. In a small retrospective study, the treatment of Mason type III fractures with fixation of the radial neck in 13 cases (group 2) was compared with 12 cases where no fixation was performed (group 1). The mean clinical and radiological follow-up was four years (1 to 9). The Broberg-Morrey index showed excellent results in both groups. Degenerative radiological changes were seen more frequently in group 2, and removal of the implant was necessary in seven of 13 cases. Post-operative evaluation of these two different techniques revealed similar ranges of movement and functional scores. We propose that anatomical reconstruction of the radial head without metalwork fixation to the neck is preferable, and the outcome is the same as that achieved with the conventional technique. In addition degenerative changes of the elbow joint may develop less frequently, and implant removal is not necessary

Spinal accessory nerve palsy leads to painful disability of the shoulder, carrying an uncertain prognosis. We reviewed the long-term outcome in 16 patients who were treated for pain, weakness of active elevation and asymmetry of the shoulder and the neck due to chronic paralysis of the trapezius muscle, as a result of nerve palsy. Of four patients who were treated conservatively, none regained satisfactory function, although two became pain-free. The other 12 patients were treated operatively with transfer of the levator scapulae to the acromion and the rhomboid muscles to the infraspinatus fossa (the Eden-Lange procedure). At a mean follow-up of 32 years, the clinical outcome of the operatively treated patients was excellent in nine, fair in two, and poor in one patient, as determined by the Constant score. Pain was adequately relieved in 11 and overhead function was restored in nine patients. Pre-operative electromyography had been carried out in four patients. In two, who eventually had a poor outcome, a concomitant long thoracic and dorsal scapular nerve lesion had been present. The Eden-Lange procedure gives very satisfactory long-term results for the treatment of isolated paralysis of trapezius. In the presence of an additional serratus anterior palsy or weak rhomboid muscles, the procedure is less successful in restoring shoulder function

We have reviewed 38 surgically treated cases of spontaneous posterior interosseous nerve palsy in 38 patients with a mean age of 43 years (13 to 68) in order to identify clinical factors associated with its prognosis. Interfascicular neurolysis was performed at a mean of 13 months (1 to 187) after the onset of symptoms. The mean follow-up was 21 months (5.5 to 221). Medical Research Council muscle power of more than grade 4 was considered to be a good result. A further 12 cases in ten patients were treated conservatively and assessed similarly. Of the 30 cases treated surgically with available outcome data, the result of interfascicular neurolysis was significantly better in patients < 50 years old (younger group (18 nerves); good: 13 nerves (72%), poor: five nerves (28%)) than in cases > 50 years old (older group (12 nerves); good: one nerve (8%), poor: 11 nerves (92%)) (p < 0.001). A pre-operative period of less than seven months was also associated with a good result in the younger group (p = 0.01). The older group had a poor result regardless of the pre-operative delay. Our recommended therapeutic approach therefore is to perform interfascicular neurolysis if the patient is < 50 years of age, and the pre-operative delay is < seven months. If the patient is > 50 years of age with no sign of recovery for seven months, or in the younger group with a pre-operative delay of more than a year, we advise interfascicular neurolysis together with tendon transfer as the primary surgical procedure

We present the long-term outcome, at a median of 18 years (12.8 to 23.5) of open posterior bone block stabilisation for recurrent posterior instability of the shoulder in a heterogenous group of 11 patients previously reported on in 2001 at a median follow-up of six years. We found that five (45%) would not have chosen the operation again, and that four (36%) had further posterior dislocation. Clinical outcome was significantly worse after 18 years than after six years of follow-up (median Rowe score of 60 versus 90 (p = 0.027)). The median Western Ontario Shoulder Index was 60% (37% to 100%) at 18 years’ follow-up, which is a moderate score. At the time of surgery four (36%) had glenohumeral radiological osteoarthritis, which was present in all after 18 years. This study showed poor long-term results of the posterior bone block procedure for posterior instability and a high rate of glenohumeral osteoarthritis although three patients with post-traumatic instability were pleased with the result of their operations

We analysed the long-term results of arthrodesis of the shoulder after infection in 15 patients. At the time of operation, 14 cultures were positive for Staphylococcus aureus. The mean follow-up was 8.3 years (3 to 14) and 90% of the patients were satisfied with the outcome. There were complications in five patients (33%); in three there was nonunion with loosening of the implant. One patient had a sound bony union but with a persistent sinus six years after arthrodesis and another had a sinus which healed after the metal was removed. Four of these five patients (80%) were heavy smokers (> 20 cigarettes/day). Cancellous bone grafting did not affect the incidence of complications. The mean age of the patients with complications was 58.6 v 48.6 years for those without (p = 0.2808 ; not significant). Those with complications had had more previous operations (6.4 v 2.5, p < 0.05). Antibiotics, as determined by the bacteriological cultures, were administered for six weeks. The complication rate was higher in patients with active sepsis but the younger the patient and the fewer number of previous operations (< 50 years, < four previous operations), the better was the outcome. Considering the rate of complications, we recommend early surgery in these patients

The outcome of surgery in patients with medial epicondylitis of the elbow is less favourable in those with co-existent symptoms from the ulnar nerve. We wanted to know whether we could successfully treat such patients by using musculofascial lengthening of the flexor-pronator origin with simultaneous deep transposition of the ulnar nerve. We retrospectively reviewed 19 patients who were treated in this way. Seven had grade I and 12 had grade IIa ulnar neuropathy. At a mean follow-up of 38 months (24 to 48), the mean visual analogue scale pain scores improved from 3.7 to 0.3 at rest, from 6.6 to 2.1 with activities of daily living, and from 7.9 to 2.3 at work or sports, and the mean disabilities of the arm, shoulder and hand scores improved from 42.2 to 23.5. These results suggest that this technique can be effective in treating patients with medial epicondylitis and coexistent ulnar nerve symptoms

We treated 32 displaced mallet finger fractures by a two extension block Kirschner-wire technique. The clinical and radiological outcomes were evaluated at a mean follow-up of 49 months (25 to 84). The mean joint surface involvement was 38.4% (33% to 50%) and 18 patients (56%) had accompanying joint subluxation. All 32 fractures united with a mean time to union of 6.2 weeks (5.1 to 8.2). Congruent joint surfaces and anatomical reduction were seen in all cases. The mean flexion of the distal interphalangeal joints was 83.1° (75° to 90°) and the mean extension loss was 0.9° (0° to 7°). No digit had a prominent dorsal bump or a recurrent mallet deformity. We believe that this technique, when properly applied, produces satisfactory results both clinically and radiologically

We report the results of a series of 59 unconstrained total arthroplasties of the elbow after a mean follow-up of 6.5 years (4 to 10). All the patients had rheumatoid arthritis. The indication for surgery was pain in all but one. Outcome was assessed by the Mayo Elbow Performance Index (MEPI). Of the 59 arthroplasties, two were lost to follow-up. Ten patients died, but as two of their arthroplasties were failures we included them in the results. The outcome in the remaining 49 was excellent in 26 (53%), good in 15 (31%), fair in one (2%) and poor or a failure in seven (14%). There was an improvement in the pain score (p < 0.001), movement (p < 0.001) and function (p < 0.001). Two patients developed instability, but neither required further surgery. There was a mean increase of 21° in flexion and of 7° in extension. The overall rate of complications was 33.9%. Lesions of the ulnar nerve, one of which did not recover, occurred in four patients, deep infection in two and stiffness in five. The rates of complications were similar to those in recent reports of other elbow arthroplasties. We carried out a radiological analysis of 39 arthroplasties which showed radiolucent lines around the humeral component in 22 and the ulnar component in 15. There were lower scores on the MEPI for those with radiolucent lines around the humeral component

We performed a prospective, randomised trial on 106 patients to compare the effects of local corticosteroid injections with physiotherapy as advocated by Cyriax in the treatment of tennis elbow. The main outcome measures were the severity of pain, pain provoked by resisted dorsiflexion of the wrist, and patient satisfaction. At six weeks 22 of 53 patients in the injection group were free from pain compared with only three in the physiotherapy group. In the corticosteroid-treated group 26 patients had no pain on resisted dorsiflexion of the wrist compared with only three in the physiotherapy group. Thirty-five patients who had injections and 14 who had physiotherapy were satisfied with the outcome of treatment at six weeks. At the final assessment there were 18 excellent and 18 good results in the corticosteroid group and one excellent and 12 good results in the physiotherapy group. There was a significant increase in grip strength in both groups but those with injections had a significantly better result. After one year there were no significant differences between the two groups. Half of the patients, however, had received only the initial treatment, 20% had had combined therapy and 30% had had surgery. We conclude that at six weeks, treatment with corticosteroid injections was more effective than Cyriax physiotherapy and we recommend it because of its rapid action, reduction of pain and absence of side-effects

Fractures of the proximal humerus can lead to malalignment of the humeral head, necrosis and post-traumatic osteoarthritis. In such cases surface replacement might be a promising option. A total of 28 shoulders with glenohumeral arthritis subsequent to a fracture underwent surface replacement arthroplasty of the humeral head in patients with a mean age of 60 years (35 to 83). On the basis of the inclination of the impacted head, post-traumatic arthritis was divided into three types: type 1, an impacted fracture of the head in an anatomical position (seven cases); type 2, a valgus impacted fracture (13 cases); type 3, a varus impacted fracture (eight cases). The outcome was measured by means of the Constant score. According to the Boileau classification of the sequelae of fractures of the proximal humerus, all 28 patients had a final result of intra-capsular category 1. The mean Constant score for the 28 shoulders increased from 23.2 points (2 to 45) pre-operatively to 55.1 points (20 to 89) at a mean of 31 months (24 to 66) post-operatively. Valgus impacted fractures had significantly better results (p < 0.039). Surface replacement arthroplasty can provide good results for patients with post-traumatic osteoarthritis of the shoulder. Their use avoids post-operative complications of the humeral shaft, such as peri-prosthetic fractures. Further surgery can be undertaken more easily as the bone stock is preserved

We reviewed the outcome of 28 patients who had been treated using the Aequalis fracture prosthesis for an acute fracture of the proximal humerus at a mean follow-up of 39.3 months (24 to 63). The mean age of the patients at the time of the fracture was 66.3 years (38 to 80). The mean Constant score was 68.2 (37 to 84) for the operated shoulder, which represented 89.5% of the mean score for the uninjured side (p < 0.001). The quality of the reconstruction as shown on the immediate post-operative radiographs was categorised into three types, anatomical, acceptable, and unacceptable, depending on the position of the tuberosities relative to the prosthetic head and the humeral shaft. Anatomical reconstruction was associated with a higher mean Constant score as well as higher mean values of anterior forward elevation, abduction and external rotation than the other types, but the differences were not statistically significant (p > 0.231). A total of 18 patients had active anterior elevation ≥150°. Their mean active abduction and external rotation were 163.6° and 31.3°, respectively. In seven of the 28 patients, the mean active anterior elevation, abduction and external rotation were 130.7°, 129.2° and 22.8°, respectively. In all, 12 patients were very satisfied with the results, 12 were satisfied, two were dissatisfied and two were disappointed; 26 reported no or only mild pain while only two had moderate pain. In five patients proximal migration of the humeral head was shown on the anteroposterior radiographs of the shoulder. No evidence of loosening was found in any prosthesis

Ulnar neuropathy presents as a complication in 5% to 10% of total elbow replacements, but subsequent ulnar neurolysis is rarely performed. Little information is available on the surgical management of persistent ulnar neuropathy after elbow replacement. We describe our experience with the surgical management of this problem. Of 1607 total elbow replacements performed at our institution between January 1969 and December 2004, eight patients (0.5%) had a further operation for persistent or progressive ulnar neuropathy. At a mean follow-up of 9.2 years (3.1 to 21.7) six were clinically improved and satisfied with their outcome, although, only four had complete recovery. When transposition was performed on a previously untransposed nerve the rate of recovery was 75%, but this was reduced to 25% if the nerve had been transposed at the time of the replacement

We retrospectively compared wrist arthrodesis using the Mannerfelt technique in 19 or an AO-plate in 23 patients with long-standing rheumatoid arthritis. The mean follow-up was for 76 months. Compared with the Mannerfelt fusion group, patients in the AO-plate group reported greater satisfaction with their wrist function (74% vs 37%, p = 0.015). Complications were reported in six wrists in the AO-plate group and two wrists in the Mannerfelt fusion group (p = 0.258). At final follow-up, 95% of patients (41) reported either no pain or only mild pain. There was improvement in flexion of the finger joints in both groups but no significant improvement in the extension lag in either group. Both methods relieve pain and improve function. Overall, the activities of daily living scores and the patients’ subjective assessment of outcome tended to be higher in the AO-plate group than in the Mannerfelt fusion group, although the difference was not statistically significant. Similarly, although more postoperative complications occurred in the AO-plate group, the difference between the two groups was not statistically significant

We have investigated the mid-term outcome of total shoulder replacement using a keeled cemented glenoid component and a modern cementing technique with regard to the causes of failure and loosening of the components. Between 1997 and 2003 we performed 96 total shoulder replacements on 88 patients, 24 men and 64 women with a mean age of 69.7 years (31 to 82). The minimum follow-up was five years and at the time of review 87 shoulders (77 patients) were examined at a mean follow-up of 89.1 months (60 to 127). Cumulative survival curves were generated with re-operations (accomplished and planned), survivorship of the proshesis, loosening of the glenoid (defined as tilt > 5° or subsidence > 5 mm), the presence of radiolucent lines and a Constant score of < 30 as the endpoints. There were two re-operations not involving revision of the implants and the survival rate of the prosthesis was 100.0% for the follow-up period, with an absolute Constant score of > 30 as the endpoint the survival rate was 98%. Radiological glenoid loosening was 9% after five years, and 33% after nine years. There was an incidence of 8% of radiolucent lines in more than three of six zones in the immediate post-operative period, of 37.0% after the first year which increased to 87.0% after nine years. There was no correlation between the score of Boileau and the total Constant score at the latest follow-up, but there was correlation between glenoid loosening and pain (p = 0.001). We found that total shoulder replacement had an excellent mid-term survivorship and clinical outcome. The surgical and cementing techniques were related to the decrease in radiolucent lines around the glenoid compared with earlier studies. One concern, however, was the fact that radiolucent lines increased over time and there was a rate of glenoid loosening of 9% after five years and 33% after nine years. This suggests that the design of the glenoid component, and the implantation and cementing techniques may need further improvement

The type II Monteggia (posterior) lesion is a rare injury which is sometimes associated with ulnohumeral instability. We have reviewed 23 of 28 patients with this injury. A clinical and radiographic assessment was undertaken at follow-up. Functional outcome scores, including the Broberg and Morrey Index and the Disabilities of the Arm, Shoulder or Hand (DASH), were used. The results from the six patients with associated posterior ulnohumeral dislocation were compared with 17 without ulnohumeral injury. Those with dislocation had reduced movement of the elbow and had outcome scores indicative of greater disability compared to those without associated dislocation

This study reports our experience with total elbow replacement for fused elbows. Between 1982 and 2004, 13 patients with spontaneously ankylosed elbows were treated with a linked semi-constrained non-custom total elbow implant. The mean age at operation was 54 years (24 to 80). The stiffness was a result of trauma in ten elbows, juvenile rheumatoid arthritis in one, and rheumatoid arthritis in two. The patients were followed for a mean of 12 years (2 to 26) and were evaluated clinically using the Mayo Elbow Performance Score, as well as radiologically. A mean arc from 37° of extension to 118° of flexion was achieved. Outcomes were good or excellent for seven elbows at final review. Ten patients felt better or much better after total elbow replacement. However, there was a high complication rate and re-operation was required in over half of patients. Two developed peri-operative soft-tissue breakdown requiring debridement. A muscle flap with skin grafting was used for soft-tissue cover in one. Revision was undertaken in one elbow following fracture of the ulnar component. Three patients developed a deep infection. Three elbows were manipulated under anaesthesia for post-operative stiffness. Prophylactic measures for heterotopic ossification were unsuccessful. Total elbow replacement for the ankylosed elbow should be performed with caution. However, the outcome can be reliable in the long term and have a markedly positive impact on patient function and satisfaction. The high potential for complications must be considered. We consider total elbow replacement to be an acceptable procedure in selected patients with reasonable expectations

We report the outcome of a modified Bankart procedure using suture anchors in 31 patients (31 shoulders) with a mean follow-up of 11 years (10 to 15). The mean age of the patients was 28 years (16 to 39). At follow-up, the mean Rowe score was 90 points (66 to 98) and the Constant score was 96 points (85 to 100). A total of 26 shoulders (84%) had a good or excellent result. The rate of recurrence varied between 6.7% and 9.7% and depended on how recurrence was defined. Two patients had a significant new injury at one and nine years, respectively after operation. The overall rate of instability (including subluxations) varied between 12.9% and 22.6%. All patients returned to work, with 29 (94%) resuming their pre-operative occupation and level of activity. Mild radiological osteoarthritis was seen in nine shoulders (29%) and severe osteoarthritis in one. We conclude that the open modified Bankart procedure is a reliable surgical technique with good long-term results

Cubitus varus and valgus are the most common complications of supracondylar and lateral condylar fractures. Various combinations of osteotomy and fixation have been described to correct these deformities but each is associated with significant complications. In this study, we used distraction osteogenesis and Ilizarov frame fixation to treat 24 elbows in 23 patients with cubitus varus or valgus. Their clinical outcome was evaluated using the protocol of Bellemore et al. The mean time to follow-up was 18.3 months (10 to 36) and the mean time to frame removal was 13.5 weeks (8 to 20). The mean carrying angle was corrected from −18.7° (−10° to −30°) to 6.1° (2° to 10°) in patients with cubitus varus and from 36.5° (25° to 45°) to 9.4° (4° to 15°) in patients with cubitus valgus. There were 18 excellent and six good results. The Ilizarov method with gradual distraction is a safe, stable, adjustable and versatile method of treating deformities at the elbow without the problems of an unsightly scar or limited range of movement, and gives a good clinical and radiological outcome. Tardy ulnar nerve palsy should be treated first by anterior transposition

We have examined the relief from pain and the functional outcome in 18 patients who underwent resection arthroplasty of the shoulder as a salvage operation between 1988 and 2002. The indications included failed shoulder replacement in 17, with infection in 13, and chronic septic arthritis in one. The mean follow-up was 8.3 years (2.5 to 16.6). Two intra-operative fractures of the humerus occurred, both of which healed. The level of pain was significantly decreased (t-test, p < 0.001) but five patients continued to have moderate to severe pain. The mean active elevation was 70° (0° to 150°) postoperatively and represented an improvement from 39° (0° to 140°) (t-test, p = 0.003), but internal and external rotation were hardly changed. The mean number of positive answers on the 12-question Simple Shoulder Test was 3.1 (0 to 12) but the shoulder was generally comfortable when the arm was positioned at rest by the side. The mean post-operative American Shoulder and Elbow Surgeon’s score was 36 (8 to 73). Despite applying this procedure principally to failed shoulder replacements, the results were similar to those reported in the literature for patients after severe fracture-dislocation. Reduction of pain is possible in one half to two-thirds of patients. The outcome of this operation in providing relief from pain cannot be guaranteed, but the shoulder is usually comfortable at rest, albeit with profound functional limitations

In a prospective randomised trial of calcifying tendinitis of the rotator cuff, we compared the efficacy of dual treatment sessions delivering 2500 extracorporeal shock waves at either high- or low-energy, via an electromagnetic generator under fluoroscopic guidance. Patients were eligible for the study if they had more than a three-month history of calcifying tendinitis of the rotator cuff, with calcification measuring 10 mm or more in maximum dimension. The primary outcome measure was the change in the Constant and Murley Score. A total of 80 patients were enrolled (40 in each group), and were re-evaluated at a mean of 110 (41 to 255) days after treatment when the increase in Constant and Murley score was significantly greater (t-test, p = 0.026) in the high-energy treatment group than in the low-energy group. The improvement from the baseline level was significant in the high-energy group, with a mean gain of 12.5 (−20.7 to 47.5) points (p < 0.0001). The improvement was not significant in the low-energy group. Total or subtotal resorption of the calcification occurred in six patients (15%) in the high-energy group and in two patients (5%) in the low-energy group. High-energy shock-wave therapy significantly improves symptoms in refractory calcifying tendinitis of the shoulder after three months of follow-up, but the calcific deposit remains unchanged in size in the majority of patients

We treated surgically 16 shoulders with an isolated traumatic rupture of the subscapularis tendon over a six-year period. Nine patients had a total and seven a partial tear of the subscapularis tendon. Repair was undertaken through a small deltopectoral groove approach. The mean Constant score improved in total tears from 38.7 to 89.3 points (p = 0.003) and in partial tears from 50.7 to 87.9 points (p = 0.008). The total tears were significantly more improved by surgery than the partial tears (p = 0.001). The delay between trauma and surgery was inversely proportional to the improvement in the Constant score suggesting that early diagnosis and surgical repair improves outcome

We present the outcome of the treatment of chronic post-traumatic contractures of the proximal interphalangeal joint by gradual distraction correction using an external fixator. A total of 30 consecutive patients with a mean age of 34 years (17 to 54) had distraction for a mean of 16 days (10 to 22). The fixator was removed after a mean of 29 days (16 to 40). Assessment at a mean of 34 months (18 to 54) after completion of treatment showed that the mean active range of movement had significantly increased by 63° (30° to 90°; p < 0.001). The mean active extension gained was 47° (30° to 75°). Patients aged less than 40 years fared slightly better with a mean gain in active range of movement of 65° (30° to 90°) compared with those aged more than 40 years, who had a mean gain in active range of movement of 55° (30° to 70°) but the difference was not statistically significant (p = 0.148). The use of joint distraction to correct chronic flexion contracture of the proximal interphalangeal joint is a minimally-invasive and effective method of treatment

Excision is not a suitable treatment for all comminuted fractures of the radial head. In elbows where instability can be predicted, a replacement arthroplasty of the radial head is more effective. The aim of this paper was to present the medium-term results of the Judet floating radial head prosthesis. This operation was performed on 14 patients between 1992 and 2003, of whom 12 were reviewed at a mean follow-up of five years and three months (1 to 12 years). The outcome was assessed using the Mayo elbow performance score and a modified Disability of Arm Shoulder Hand (DASH) questionnaire. There were six excellent results, four good, one fair and one poor, as graded by the Mayo score. The mean DASH score was 23.9/100 (0 to 65.8/100). The only significant complication occurred in one patient who developed a severe complex regional pain syndrome. There were no patients with secondary instability of the elbow, implant loosening, cubitus valgus, osteoporosis of the capitellum, or pain in the forearm and wrist. Our experience, combined with that of other authors using this device, has encouraged us to continue using the Judet prosthesis in comminuted fractures of the elbow where instability is a potential problem

The Acclaim total elbow replacement is a modular system which allows implantation in both unlinked and linked modes. The results of the use of this implant in primary total elbow replacement in 36 patients, operated on between July 2000 and August 2002, are presented at a mean follow-up of 36 months (24 to 49). Only one patient did not have good relief of pain, but all had improved movement and function. No implant showed clinical or radiological loosening, although one had a lucent area in three of seven humeral zones. The short-term results of the Acclaim total elbow replacement are encouraging. However, 11 patients (30.5%) suffered an intra-operative fracture of the humeral condyle. This did not affect the outcome, or the requirement for further surgery, except in one case where the fracture failed to unite. This problem has hopefully been addressed by redesigning the humeral resection guide. Other complications included three cases of ulnar neuropathy (8.3%) and one of deep infection (2.8%)

There have been few reports in the literature of total elbow arthroplasty extending beyond 10 to 15 years. We reviewed 40 patients (41 elbows) with a mean age of 56 years (19 to 83) who had undergone a Coonrad/Coonrad-Morrey elbow arthroplasty by one surgeon for various diagnoses between 1974 and 1994. Surgical selection excluded patients with previous elbow infection or who refused to accept a sedentary level of elbow activity postoperatively. Objective data were collected from charts, radiographs, clinical photographs and supplemented by the referring orthopaedic surgeons’ records and radiographs if health or distance prevented a patient from returning for final review. Subjective outcome was defined by patient satisfaction. Of the 41 elbows, 21 were functional between 10 and 14 years after operation, ten between 15 and 19 years and ten between 20 and 31 years. There were 14 complications and 13 revisions, but no cases of acute infection, or permanent removal of any implant

This is a prospective study of 107 repairs of obstetric brachial plexus palsy carried out between January 1990 and December 1999. The results in 100 children are presented. In partial lesions operation was advised when paralysis of abduction of the shoulder and of flexion of the elbow persisted after the age of three months and neurophysiological investigations predicted a poor prognosis. Operation was carried out earlier at about two months in complete lesions showing no sign of clinical recovery and with unfavourable neurophysiological investigations. Twelve children presented at the age of 12 months or more; in three more repair was undertaken after earlier unsuccessful neurolysis. The median age at operation was four months, the mean seven months and a total of 237 spinal nerves were repaired. The mean duration of follow-up after operation was 85 months (30 to 152). Good results were obtained in 33% of repairs of C5, in 55% of C6, in 24% of C7 and in 57% of operations on C8 and T1. No statistical difference was seen between a repair of C5 by graft or nerve transfer. Posterior dislocation of the shoulder was observed in 30 cases. All were successfully relocated after the age of one year. In these children the results of repairs of C5 were reduced by a mean of 0.8 on the Gilbert score and 1.6 on the Mallett score. Pre-operative electrodiagnosis is a reliable indicator of the depth of the lesion and of the outcome after repair. Intra-operative somatosensory evoked potentials were helpful in the detection of occult intradural (pre-ganglionic) injury

We randomised 79 patients (84 hands, 90 fingers) with Dupuytren’s contracture of the proximal interphalangeal joint to have either a ‘firebreak’ skin graft (39 patients, 41 hands, 44 fingers) or a fasciectomy (40 patients, 43 hands, 46 fingers) if, after full correction, the skin over the proximal phalanx could be easily closed by a Z-plasty. Patients were reviewed after three, six, 12, 24 and 36 months to note any complications, the range of movement and recurrence. Both groups were similar in regard to age, gender and factors considered to influence the outcome such as bilateral disease, family history, the presence of diabetes, smoking and alcohol intake. The degree of contracture of the metacarpophalangeal and interphalangeal joints of the operated fingers was similar in the two groups and both were comparable in terms of grip strength, range of movement and disability at each follow-up. The recurrence rate was 12.2%. We did not identify any improvement in correction or recurrence of contracture after firebreak dermofasciectomy up to three years after surgery

We examined the effects of previous resection of the radial head and synovectomy on the outcome of subsequent total elbow arthroplasty in patients with rheumatoid arthritis. Fifteen elbows with a history of resection and synovectomy were compared with a control group of patients who had elbow arthroplasty with an implant of the same design. The mean age in both groups was 63 years. In the study group, resection of the radial head and synovectomy had been undertaken at a mean of 8.9 years before arthroplasty. The mean radiological follow-up for the 13 available patients in the study group was 5.89 years (0.3 to 11.0) and in the control group was 6.6 years (2.2 to 12.6). There were no revisions in either group. The mean Mayo elbow performance score improved from 29 to 96 in the study group, with similar improvement in the control group (28 to 87). The study group had excellent results in 13 elbows and good results in two. The control group had excellent results in seven and good results in six. Our experience indicates that previous resection of the radial head and synovectomy are not associated with an increased rate of revision following subsequent arthroplasty of the elbow. However, there was a higher rate of complication in the study group compared with the control group

We describe a method for stabilising the distal radioulnar joint using a double breasted slip of extensor retinaculum. This is a retrospective series of 30 patients with a painful wrist secondary to instability of the distal radioulnar joint. The results were assessed by a modified Mayo Score. The mean follow-up was for 38.1 months (13 months to 8 years). Twelve patients had excellent, 16 good and 2 fair outcomes. One patient had experienced temporary numbness in the distribution of the dorsal branch of the ulnar nerve. The modified Mayo wrist score increased from a pre-operative mean of 23.89 (10 to 50) to a final mean of 94.4 (85 to 100). Stabilisation of the distal radioulnar joint by the method of using a double breasted slip of the extensor retinaculum gives satisfactory results. The procedure is simple and reproducible

Locognosia, the ability to localise touch, is one aspect of tactile spatial discrimination which relies on the integrity of peripheral end-organs as well as the somatosensory representation of the surface of the body in the brain. The test presented here is a standardised assessment which uses a protocol for testing locognosia in the zones of the hand supplied by the median and/or ulnar nerves. The test-retest reliability and discriminant validity were investigated in 39 patients with injuries to the median or ulnar nerve. Intraclass correlation coefficients were used to calculate the test-retest reliability. Discriminant validity was assessed by comparing the injured with the unaffected hand. Excellent test-retest reliability was demonstrated for the injuries to the median (intraclass correlation coefficient 0.924, 95% confidence interval 0.848 to 1.00) and the ulnar nerves (intraclass correlation coefficient 0.859, 95% confidence interval 0.693 to 1.00). The magnitude of the difference in scores between affected and unaffected hands showed good discriminant validity. For injuries to the median nerve the mean difference was 11.1 points (1 to 33; . sd. 7.4), which was statistically significant (p < 0.0001, paired t-test) and for those of the ulnar nerve it was 4.75 points (1 to 13.5; . sd. 3.16), which was also statistically significant (paired t-test, p < 0.0001). The locognosia test has excellent test-retest reliability, is a valid test of tactile spatial discrimination and should be included in the evaluation of outcome after injury to peripheral nerves

We studied 21 patients with a spontaneous palsy of the anterior interosseous nerve. There were 11 men and 10 women with a mean age at onset of 39 years (17 to 65). Pain around the elbow or another region (forearm, shoulder, upper arm, systemic arthralgia) was present in 17 patients and typically lasted for two to three weeks. It had settled within six weeks in every case. In ten cases the palsy developed as the pain settled. A complete palsy of flexor pollicis longus and flexor digitorum profundus to the index finger was seen in 13 cases and an isolated palsy of flexor pollicis longus in five. All patients were treated without operation. The mean time to initial muscle contraction was nine months (2 to 18) in palsy of the flexor digitorum profundus to the index finger, and ten months (1 to 24) for a complete palsy of flexor pollicis longus. An improvement in muscle strength to British Medical Research Council grade 4 or better was seen in all 15 patients with a complete palsy of the flexor digitorum profundus and in 16 of 18 with a complete palsy of flexor pollicis longus. There was no significant correlation between the duration of pain and either the time to initial muscle contraction or final muscle strength. Prolonged pain was not always associated with a poor outcome but the age of the patient when the palsy developed was strongly correlated. Recovery occurred within 12 months in patients under the age of 40 years who achieved a final British Medical Research Council grade of 4 or better. Surgical decompression does not appear to be indicated for young patients with this condition

This study prospectively evaluated the outcome of manipulation under anaesthesia and hydrodilatation as treatments for adhesive capsulitis. A total of 36 patients (38 shoulders) were randomised to receive either method, with all patients being treated in stage II of the disease process. The mean age of the patients was 55.2 years (44 to 70) and the mean duration of symptoms was 33.7 weeks (12 to 76). Eighteen shoulders (17 patients) underwent manipulation under anaesthesia and 20 (19 patients) had hydrodilatation. There were three insulin-dependent diabetics in each group. The mean visual analogue score in the manipulation under anaesthesia group was 5.7 (3 to 8.5; n = 18) before treatment, 4.7 (0 to 8.5; n = 16) at two months (paired t-test p = 0.02), and 2.7 (0 to 9; n = 16) at six months (paired t-test, p = 0.0006). The mean score in the hydrodilatation group was 6.1 (4 to 10; n = 20) before treatment, 2.4 (0 to 8; n = 18) at two months (paired t-test, p = 0.001), and 1.7 (0 to 7; n = 18) at six months (paired t-test, p = 0.0006). The visual analogue scores in the hydrodilatation group were significantly better than in the manipulation under anaesthesia group over the six-month follow-up period (p < 0.0001). The mean Constant score in those manipulated was 36 (26 to 66) before treatment, 58.5 (24 to 90) at two months (paired t-test, p = 0.001) and 59.5 (23 to 85) at six months (paired t-test, p = 0.0006). In the hydrodilatation group it was 28.8 (18 to 55) before treatment, 57.4 (17 to 80) at two months (paired t-test, p = 0.0004) and 65.9 (28 to 92) at six months (paired t-test, p = 0.0005). The Constant scores in the hydrodilatation group were significantly better than in the manipulated group over the six-month period of follow-up (p = 0.02). The range of movement improved in all patients over the six months, but was not significantly different between the groups. At the final follow-up, 94% of patients (17 of 18) were satisfied or very satisfied after hydrodilatation compared with 81% (13 of 16) of those receiving a manipulation. Most of our patients were treated successfully, but those undergoing hydrodilatation did better than those who were manipulated

Outcome studies of revision surgical treatment for recurrent or persistent neuropathy of the ulnar nerve at the elbow are relatively rare and none involves patient self-assessment. In this study of 40 patients (41 elbows), a clear discrepancy is shown between clinical assessment and the patient’s own view. From clinical assessment, 20% of patients had an excellent result, whereas only one (2.5%) patient self-reported a complete cure. More reports using patient self-assessment and validated scores are required

We carried out a prospective, randomised controlled trial on two groups of 40 patients with painful calcific tendonitis and a mean age of 48.4 years (32.5 to 67.3). All were to undergo arthroscopic removal of the calcific deposit within six months after randomisation. The 40 patients in group I received ultrasound-guided needling followed by high-energy shock-wave therapy and the 40 in group II had shock-wave therapy alone. In both groups one treatment consisting of 2500 impulses of shock waves with an energy flux density of 0.36 mJ/mm. 2. was applied. The clinical and radiological outcome was assessed using the 100-point Constant shoulder scoring system and standardised radiographs. The mean follow-up was 4.1 months and no patient was lost to follow-up. Both groups had significant improvement in their Constant shoulder score. Radiographs showed disappearance of the calcific deposit in 60.0% of the shoulders in group I and in 32.5% of group II (p < 0.05). Significantly better clinical and radiological results were obtained in group I than in group II. Arthroscopic removal of the deposit was avoided in 32 patients of group I and in 22 of group II. No severe side-effects were recorded. Ultrasound-guided needling in combination with high-energy shock-wave therapy is more effective than shock-wave therapy alone in patients with symptomatic calcific tendonitis, giving significantly higher rates of elimination of the calcium deposits, better clinical results and reduction in the need for surgery