Reverse shoulder arthroplasty (RSA) is commonly performed for complex proximal humeral fractures in older adults when fixation or anatomic reconstruction is unlikely to provide reliable outcomes. Recurrent instability following RSA remains a devastating complication, particularly in medically frail patients with poor bone quality and compromised soft tissue balance. Salvage strategies after repeated failed revisions are limited and often associated with poor functional outcomes. A 75-year-old man with severe chronic obstructive pulmonary disease, hypertension, hypercholesterolaemia, transitional cell carcinoma, rectal polyposis, active smoking history, and frailty sustained a comminuted, displaced left proximal humeral fracture with subglenoid humeral head dislocation following a mechanical fall. He underwent hybrid reverse-polarity total shoulder replacement. One week postoperatively, the shoulder developed anterior instability requiring closed manipulation under anaesthesia. Despite a temporary reduction, recurrent instability persisted during rehabilitation, necessitating two subsequent open revision procedures, including liner exchange with adjustment of implant inclination and later glenosphere cup modification. Persistent instability led to referral and multidisciplinary review at a tertiary shoulder centre. The failed RSA was ultimately converted to a large-head bipolar hemiarthroplasty as a salvage procedure. The hemiarthroplasty later dislocated anteriorly, with migration of the prosthetic head into the anterior deltopectoral/coracoid region and severe upper-limb dysfunction suggestive of brachial plexus neuropraxia. Given the patient's significant comorbidities and elevated operative risk, further reconstruction was deemed unsuitable after shared decision-making, and conservative management was pursued. The patient subsequently developed septic arthritis of the contralateral shoulder, further worsening overall functional status. Serial imaging through 2025 demonstrated persistence of the dislocated bipolar implant without evidence of implant fracture or gross stem loosening. This case illustrates the catastrophic progression of recurrent instability following fracture-related RSA in a medically frail patient with compromised bone and soft tissue conditions. It underscores the importance of careful patient selection, accurate restoration of implant positioning and soft tissue tension, prompt tertiary multidisciplinary involvement after failed stabilisation, and realistic counselling regarding the limited salvage potential and persistent complications associated with hemiarthroplasty conversion after failed RSA. This case highlights that, in medically frail patients with multiple risk factors for instability, early recognition of recurrent dislocation and timely referral to specialist shoulder centres may help guide management decisions, optimise patient expectations, and avoid repeated interventions with diminishing likelihood of durable success.

Objectives Worldwide, there are 15 established trauma databases collecting data to better understand the patterns of injury and effectiveness of interventions, but interpreting the information is hampered by the varied approaches. The aim of this study was to determine the impact, practices, evolution in design and methods of analysis that are standardised and comparable within registries.Design A thematic analysis using a narrative synthesis was used to develop threads for future study and identify the limitations in current practice.Data sources PubMed, Ovid, Scopus and EMBASE were searched on the 2 October 2025. At the same time, ChatGPT (Open artificial intelligence) identified the most cited articles in orthopaedic trauma registries, cross-referencing lists as a form of triangulation to aid in snowballing references.Eligibility criteria The review included 174 papers from trials and observational studies that analyse data from established trauma orthopaedic registries published in English.Data extraction and synthesis Two independent reviewers used standardised methods to search, screen and code included studies assessing the papers using the Strengthening the Reporting of Observational Studies in Epidemiology checklist to assess the observational and cohort studies and the Downs and Black Quality Criteria for the remaining papers.Results Outcome measures other than mortality are poorly collected, undermining the value of registries. Trauma patients reported considerable impairment 6 and 12 months after injury. Association between level of trauma care and mortality is evident for major trauma populations, but does not hold for general trauma populations. Level I trauma centres produce improved survival in severely injured, but this association could not be proven for non-fatal outcomes in general populations. There is a disparity between resources allocated to save and salvage cases within major trauma units, and hence, routine cases often have lower priority and delayed care.Conclusions There is a need to develop a standardised and reproducible method to evaluate data quality in trauma registries. National performance guidelines and trauma centre audits are integral steps towards optimum results. Routine collection of postinjury outcome measures beyond mortality will enable the development of quality improvement metrics that better reflect patient outcomes.

Background Distal biceps tendon ruptures typically occur in middle-aged men following eccentric loading activities. While surgical repair is common, comparative data on operative versus nonoperative outcomes remain limited. We conducted a retrospective study to compare the outcomes of operative versus nonoperative management in Queen's Hospital Burton. Methods We reviewed the records of 72 patients (52 operative, 20 nonoperative) treated during the period of 2016-2023 for complete distal biceps tendon ruptures. All diagnoses were confirmed clinically and radiologically. Operative management was via a single anterior incision or a modified two-incision technique using cortical button fixation. Complications, range of motion, and return to activity were abstracted from clinical records documented at the time of care. Validated outcome measures, such as the Disabilities of the Arm, Shoulder, and Hand (DASH) and the Mayo Elbow Performance Score (MEPS), were not collected as part of routine care. Results Operative management was associated with a higher rate of complications, including nerve injuries and wound issues, though most patients ultimately regained a full range of motion and function. Nonoperative management resulted in minimal complications, with patients reporting return to their previous activity levels and only minor subjective strength deficits. Overall, operative repair offered greater strength recovery, particularly in supination, but at the cost of increased morbidity, whereas nonoperative management provided excellent functional outcomes with lower risk. Conclusion Nonoperative management appeared to be a reasonable option for selected patients in this cohort. Operative repair is effective but associated with a higher complication rate. Treatment should be individualised, balancing patient activity level, expectations, and risk profile.

Background There is ample evidence but conflicting reports to justify decision making for open versus arthroscopic elbow debridement and release for stiffness and pain once non-surgical measures have failed. The aim of this retrospective study is to report the clinical and functional outcomes of arthroscopic and open surgery for patients presenting with elbow pain, stiffness and loss of function. Methods A consecutive series of patients who had completed a minimum of 6 months of non-surgical treatment of elbow stiffness were identified over a 15-year period between July 2008 and January 2023 from a single centre. Results 96 patients were treated with arthroscopic surgery with 75 open surgery. Mean age was 51 years. Pre-operative pathology included osteoarthritis, inflammatory arthropathy and post-traumatic stiffness. Post-traumatic stiffness was more commonly treated with open surgery. The flexion-extension arc, pronosupination arc, pain score, Mayo elbow performance score (MEPS) and satisfaction scores improved in all patients (p < 0.05). The arthroscopic group had a lower pain score (p < 0.05), a higher satisfaction score (p < 0.05), higher MEPS (p < 0.05), greater flexion-extension arc (P < 0.01), greater pronosupination arc (P < 0.01) and fewer patients had ongoing symptoms of pain and stiffness which limited function (P < 0.05) with fewer repoerations (p > 0.05) than the open group. Conclusions Both arthroscopic and open surgical approaches for elbow stiffness improved elbow range of movement and function. Arthroscopic treatment was better than open surgery and may represent a more favorable approach. Level of evidence Level 4 (case series)

Aims:Capitellar fractures are uncommon, accounting for 0.5-1 % of all elbow fractures. These fractures are best managed surgically to restore articular congruity. Dubberley type A fractures treated with anterolateral or lateral surgical approaches have been associated with high complication rates. The 'Global' approach to elbow has been conceptualised in order to comprehensively approach elbow injuries. The aim of this study was to evaluate the clinical outcomes of fractures of the capitellum treated using global surgical approach. Methods:Data was prospectively collected for all patients presenting between 1998 and 2020.Patient's demographics, mechanism of injury, Mayo Elbow Performance Index MEPI, Grip Strength and radiographs were retrospectively collected and analysed. Results:31 patients met the inclusion criteria with a mean age of 47yrs (IQR 12-81yrs) years, 18 males: 13 female patients. According to Dubberley classification, 24 were type I, 5 were type II and 2 were type III. 4 patients sustained associated collateral ligament injuries and 2 patients had radial head fractures. Global approach with an inside Kaplan approach was used in 26 patients, others were treated with an inside Kocher or anterior approaches. Almost all fractures were fixed using headless screws alone (n = 25),6 patients had fixation augmented with bioabsorbable rods or a posterior buttress plate. Mean follow up was 46 months. Mean MEPI was 89 (SD8), Extension 9.35 ± 5.32, Flexion 130.29 ± 8.7, Pronation 59.16 ± 7.034, Supination 63.97 ± 7.1. Mean Grip strength was 22.94 ± 4.5. These were significantly better following surgery (p < 0.001). Further surgery was only required in 1 case for stiffness. Overall complication rate was 9.6 %. There were no infections or cases of instability following fixation. Conclusion:This study is one of the largest case series reporting good functional outcomes in Dubberley type A fractures treated with headless screws using global surgical approach. We report lowest complication rate,100 % fracture union rate and good MEPI scores.

Introduction: The United Kingdom (UK) and world's population is aging with patients living longer, often with many co-morbidities. It is expected that patients of extreme old age would have poor outcomes following trauma; however, this assumption is not clearly evidenced. This study aims to present the outcomes of patients aged 100 or older admitted to a single hospital trust following admission for orthopaedic trauma. Method: A prospective cohort of patients aged 100 years and over admitted to the trauma and orthopaedic departments of two hospitals within the same trust between 2008 and 2022 was reviewed. Age was median 101 years (100-106 years). Outcome measures were length of stay, survival, complications and change in accommodation. Results: 80 patients met the inclusion criteria (71female, 9 male). Mean age at discharge was 102.5 years with survival mean 4.2 years. 2 patients with peri-prosthetic fracture survived a further 5 years. Mean length of stay was 17 days. 57 patients returned to their original place of residence. 72 patients (90 %) survived the acute hospital admission. Conclusion: Survival rates for patients aged over 100 years were high and most returned to the previous place of residence. This study supports the surgical management of trauma and helps inform patients and families expectations for mortality risk.

Displaced fractures of the glenoid require surgical fixation. This poses multiple problems, including a difficult approach and achieving adequate reduction with current implants. We provide a surgical technical tip for fixing scapula neck and glenoid rim fractures with an Acu-Loc distal radius plate (Acumed, Weyhill, UK), illustrated with two recent case reports. Here, we present two cases of a 58-year-old female and a 51year-old male presenting to a hospital following a fall, both sustaining an isolated right glenoid intraarticular fracture evident on plain radiographs. CT scans revealed a displaced and fragmented glenoid surface. A reverse Judet posterior approach facilitated exposure to enable the reduction of the glenoid, an uncommon approach. Current plate designs provide surgeons with limited options to fix complex fractures of the scapula and were not suitable here. The lateral scapula border and inferior glenoid have a similar anatomical shape to the distal radius. An Acu-Loc locking distal radius plate with a radial styloid plate was trialled and provided a good reduction to the fragmented glenoid. A distal radius plate can be a useful option to consider in complex scapula neck and glenoid rim fractures. A better understanding of glenoid shape will facilitate the further development of orthopaedic implants. Familiarity with various surgical approaches is needed to operate on these complex fractures.

Background When seeking healthcare, patients often struggle to understand the information provided by healthcare professionals regarding their condition and treatment plan. Additionally, patient satisfaction with their experience can vary widely. Improved patient understanding and satisfaction are linked to better outcomes. This study aims to explore the factors influencing patient understanding to help healthcare professionals enhance these aspects. Objective This study evaluated the level of understanding and satisfaction among patients attending outpatient appointments. It also investigated factors influencing understanding by examining differences in results across various patient groups and analyzing these variations. Methods This study was conducted at Queens' Hospital Burton, a level III trauma unit, over a three-week period in September 2023. Patients attending their orthopedic outpatient appointments were given a questionnaire, which included both bipolar 1-5 scale questions and open-ended text response questions. Results Patients generally reported high levels of understanding and satisfaction, averaging 90.34% and 96.20%, respectively. Those seen in a nurse-led clinic demonstrated significantly greater understanding of their condition compared to those seen by a physician (p = 0.0377). Additionally, trauma patients had a significantly higher level of understanding (p = 0.0167) and satisfaction (p = 0.0115). Conclusions To achieve better patient outcomes, it is crucial to optimize both patient understanding and satisfaction. Nurse-led clinics demonstrate higher levels of understanding, so identifying and incorporating the factors that contribute to this success into physician-led clinics is essential. These factors may include differences in communication methods, the resources provided, or the consultation setting. Additionally, the educational methods used with trauma patients appear more effective than those used for elective cases and should be evaluated to determine if they can enhance understanding and outcomes in other settings. Implementing evidence-based strategies for effective patient communication, such as maintaining good eye contact, avoiding medical jargon, and establishing rapport, could improve understanding and satisfaction and ultimately lead to better patient outcomes.

Charcot neuroarthropathy (CN) is a chronic degenerative disorder of bones and joints, mostly associated with diabetes mellitus and human immunodeficiency virus. CN of the upper limb is rare, with only 58 case reports identified on PubMed with the majority of cases being closely associated with syringomyelia. Very rarely, cervical spondylotic myelopathy (CSM) is associated with CN of the upper limb; with very few literature reporting this association. This case report presents a rare case of Charcot arthropathy of the shoulder caused by CSM. A 57-year-old female presented to the emergency department following trauma to the right shoulder. On clinical examination, there was evidence of tenderness, extensive swelling, and bruising with a lack of range of motion along with numbness in the right arm and legs. Through radiographic and laboratory investigations, a diagnosis of CN secondary to CSM was made. A reverse total shoulder arthroplasty was performed however, this was complicated at two weeks with an atraumatic glenoid fracture and dislocation. First-stage revision surgery was then performed to allow fracture healing pending second-stage revision surgery. This report provides insight into the very rare possibility of the association of CN of the shoulder with CSM. A review of the literature suggests reverse shoulder arthroplasty is the gold standard for cases of severe bone and soft tissue damage. When undergoing investigations for Charcot neuroarthropathy, physicians must undertake a full detailed history along with a detailed neurological examination and imaging of the cervical spine to not miss the association with CSM.

INTRODUCTION:The COVID-19 Pandemic brought clinical placements to a halt for many UK medical students. A University Hospitals Trust offered clinical phase students the opportunity to support the National Health Service (NHS) in newly defined roles as Doctors' Assistants (DAs). This study evaluates the experience of students working in a single NHS Trust. To our knowledge, this is the first report of medical students' perspectives on taking up a novel clinical role in the UK.METHODS:An anonymised novel electronic survey was sent to all 40 DAs across a single University Hospitals Trust via email to determine student perceptions of several aspects of the role, including its value to learning and development, impact on well-being, and benefit to the clinical environment. A formal statistical analysis was not required.RESULTS:Of the total cohort participating in the programme, 32 DAs responded (80% response rate). The experience was considered valuable to multiple aspects of learning and development, particularly familiarisation with the role of a Foundation doctor. Levels of confidence in training and support were high, and most DAs felt valued as part of the clinical team, and experienced no mental health issues resulting from their role. 53% of the participants felt their work was necessary or valuable to the team, and all reported a positive experience overall.CONCLUSION:A new role allowed medical students to effectively provide clinical assistance during the COVID-19 pandemic. This provided immediate support to clinical teams as well as learning opportunities for the participants without detriment to their mental well-being, and could be a model for effective retention of medical students in clinical environments in the face of resurgence of COVID-19.

Proper component positioning is a critical and challenging step in shoulder arthroplasty. Novel computer-assisted surgical techniques have been shown to improve the accuracy and reliability of surgical results. However, the long-term clinical benefits of navigated surgery are yet to be proven.

Objectives: To externally validate the Radiographic Union Score for HUmeral fractures (RUSHU) and to quantify the predictive relationship of fracture motion on physical examination to nonunion. Design: Retrospective cohort study. Setting: Single institutional center (University teaching hospital). Patients: Ninety-two consecutive patients undergoing nonoperative treatment of a diaphyseal humeral shaft fracture were identified over a 4-year period. The average age of the population was 62 years and 42% of the cohort was men. Intervention: Clinical examination for fracture stability was routinely performed on patients by the treating physicians. Radiographic assessment of fracture callus (RUSHU score) at 6 weeks was retrospectively determined. Patients were followed up until union. Main Outcome Measurements: Stability was graded as motion at the fracture site or the humerus moving as a single functional unit. Results: Fractures with a RUSHU score <= 7 were 14 times more likely to proceed to nonunion at 6 months (78% sensitivity, 80% specificity). The time to union was 49 weeks for a RUSHU score of <= 7 versus 16 weeks for a RUSHU score of >= 8. The number of operations needed to avoid one nonunion was 1.7. Fractures mobile at 6 weeks were 6.5 times more likely to proceed to nonunion at 6 months (77% specificity, 67% sensitivity). Mobile fractures had a longer time to union (41 weeks) than nonmobile fractures (17 weeks). Conclusion: The RUSHU score and clinical assessment of fracture mobility are effective and valid tools in identifying patients at risk of developing nonunion of humeral shaft fractures and can enhance early decision making in fracture management.

There are few studies reporting the outcomes from arthroscopic shoulder stabilisation using all-suture soft anchors. The aim of this study was to assess the clinical outcomes and failure rate for arthroscopic shoulder stabilisation using these anchors. A retrospective cohort analysis of a consecutive series of patients in a single unit undergoing arthroscopic shoulder stabilisation using JuggerKnot all-suture soft anchors by four consultant shoulder surgeons was performed. Exclusion criteria were revision procedures, engaging Hill-Sachs lesions and glenoid bone loss greater than 20%. The primary outcome measure was failure (dislocation or subluxation as perceived by the patient with subsequent revision surgery). The secondary outcome measure was function as assessed by the Oxford Shoulder Instability Score (OSIS). 67 patients with a mean age at the time of surgery of 32.6 years (range 15–55 years) met the inclusion criteria. Median follow up was 34.5 months (minimum 13 months). No patient experienced a postoperative dislocation. However, three patients experienced painful subluxations; two underwent revision arthroscopic stabilisation and one required open stabilisation due to glenoid bone loss. Consequently, failure rate was 4.5%. Mean post-operative OSIS was 39/48 (n = 49). This series supports the use of all-suture soft anchors in arthroscopic shoulder stabilisation. The failure rate compares favourably with that previously reported in literature for conventional anchors. Level IV: Case series with no comparison group.

Background: A multi-modal, technology-enabled, patient engagement and pathway management solution (PES) for patients undergoing primary total knee arthroplasty (TKA) was evaluated. The primary outcome measure was length of stay (LoS). The secondary outcome measures were clinical and patient-reported outcomes (PROMs). Methods: Retrospective analysis of a consecutive series of 1256 TKA patients before (n = 783) and after (n = 473) implementation of the PES. LoS, PROMs, complications, readmissions, and return to theatre were measured. Results were analysed using bivariate and multivariable regression using general linear models, and a sensitivity analysis on LoS was conducted using interrupted time series (ITS) methods. Results: Patients in the PES cohort had a significantly shorter mean LoS of two days (mean 4.7 days) versus the Pre-PES patients (mean 6.7 days: p < 0.001) in multivariate analysis. PES was also associated with a significant reduction in rates of reoperation within 60 days compared with Pre-PES (adjusted rate 22% versus 5.0%, p = 0.031). There were no statistically significant differences in the 60-day complication rate and 30-day readmission rate. All PROMs in the PES cohort demonstrated significant improvement (change from baseline to six months postoperative) compared with Pre-PES (Oxford Knee Score, 20.1 versus 15.5, p < 0.001; EQ-5D Index, 0.40 versus 0.32, p = 0.005; and EQ VAS, 22.9 versus 83, p < 0.001). Conclusions: Outcomes following TKA performed in enhanced recovery programs may be improved using technology to more effectively engage patients and streamline their surgical pathway. Integration of such solutions may significantly reduce LoS and improve PROMs without negatively impacting clinical outcomes. (C) 2019 Elsevier B.V. All rights reserved.

BACKGROUND:Medium-term clinical results and survival of the Copeland resurfacing hemiarthroplasty of the shoulder (CRHA) in a large consecutive group are presented with a comparison of outcomes for underlying pathologies.METHODS:A consecutive series of patients undergoing CRHA over 14 years was retrospectively analysed with no exclusions. Patients had a minimum 2-year follow-up by an independent assessor. Functional outcome was assessed using the Oxford Shoulder Score (OSS) and Constant-Murley Score (CMS). Pain and satisfaction was assessed using a visual analogue score.RESULTS:279 CRHAs were performed in 242 patients between 2002 and 2016. The mean follow-up was 6 years. The indication for surgery was osteoarthritis (OA) in 212, inflammatory arthropathy (RA) in 35, rotator cuff tear arthropathy (CTA) in 22 and avascular necrosis (AVN) in 2. For the OA group, 5-year survival was 90%, 10-year survival was 83% and mean survival was 13.2 years (95% CI 12.5-13.9). The mean OSS was 35.0 and mean CMS 49.9. CRHA for CTA had significantly poorer (p < 0.001) 5-year survival (55%), 10-year survival (41%) and mean survival (5.9 years, 95% CI 4.7-7.2). Mean OSS was 23.6 and mean CMS 30.3, which was poorer than for OA (p < 0.001). A subgroup analysis of OA patients found significantly better survival (p = 0.013) in those aged over 65 years but no difference in functional outcome.CONCLUSION:CRHA remains a reasonable option for OA in patients with an intact rotator cuff and with sufficient bone stock, especially in those aged over 65 years. With poorer functional outcomes and survival, CRHA should not be offered in those with CTA.LEVEL OF EVIDENCE:Level III (retrospective comparative study).

Background. Neuropathic foot ulcers are common and difficult to treat. Calcium sulfate (CAS) has been used for antibiotic delivery in the treatment of osteomyelitis with success. Recent case series suggest success in treating osteomyelitis of the foot with CAS in a mean time to healing of 4 months; however, few studies with a control group for comparison exist. Objective. This study aims to determine if antibiotic-impregnated CAS beads improved the healing of neuropathic foot ulcers with proven osteomyelitis undergoing surgical debridement. Materials and Methods. A consecutive retrospective cohort study of 50 patients undergoing surgical debridement of neuropathic foot ulcers for osteomyelitis from December 2015 to May 2016 was performed. Exclusion criteria consisted of amputations and microbiology findings inconsistent with osteomyelitis. Patients were divided into 2 groups: the surgical debridement (SD) group was treated with SD alone and the other (CAS) was treated with debridement and implantation of vancomycin-and gentamicin-impregnated CAS beads. Results. After exclusion criteria, 42 patients were included: 13 in the SD group and 29 in the CAS group. In the SD group, the mean time to healing was 5.8 months (range, 2-9 months), and in the CAS group, it was 5.5 months (range, 2-13 months). There was no significant difference in ulcer healing (P = .81), time to healing (P = .79), reoperation rate (P = .51), length of stay (P = .74), or mortality (P = .13) between the 2 groups. Conclusions. Ulcer healing in patients treated with antibiotic-impregnated CAS beads did not show statistical significance. Healing rates in both groups were similar to those in recent literature. Surgical debridement alone may be as effective as supplementation with local antibiotics in a bioabsorbable carrier.

BACKGROUND Little published evidence exists on the incidence of continuing acromioclavicular joint pain with no published outcomes for revision surgery. This study aimed to establish the incidence and outcomes of revision acromioclavicular joint excision surgery. MATERIALS AND METHODS A consecutive retrospective cohort of patients undergoing revision arthroscopic or open acromiocla-vicular joint excision was identified. Patients were identified from a prospectively collected database. Inclusion criteria were revision acromioclavicular joint excisions over a 14-year period between 2001 and 2015. Exclusion criteria were previous surgery for acromioclavicular joint instability or shoulder arthroplasty. Outcome measures were Oxford Shoulder scores and a satisfaction survey. RESULTS Forty-three consecutive cases of revision acromioclavicular joint excision over 14 years (37 after arthroscopic excision with subacromial decompression, 5 after arthroscopic excision with rotator cuff repair, 1 after open excision). Continuing acromioclavicular joint pain was associated with incomplete resection from arthroscopic surgery, which was the primary indication for revision surgery. Revision occurred a mean 14.2 months after primary surgery (standard deviation 7.6 months). Mean Oxford Shoulder score was preoperatively 18 (standard deviation 8.1) and 23.4 (standard deviation 11.1) after primary surgery, which did not reach significance until after revision surgery with a mean 31.7 (standard deviation 13.6; P= 0.021). Median follow up was 15 months (interquartile range 4-31 months). A survey at a mean of 6 years (standard deviation 2.3) post-revision surgery found that 65% of patients felt improved, 77% would have their surgery again and 69% of patients felt satisfied. The incidence of postoperative frozen shoulder was 14.3%. CONCLUSION Functional outcomes after revision surgery showed improvement from scores taken before primary surgery; however, long-term satisfaction rates were relatively low.

Background: Subacromial impingement is common and frequently treated with arthroscopic subacromial decompression (ASD); however, its efficacy has recently been questioned. Poor surgical outcomes have been associated with anxiety and depression within other orthopedic subspecialties but not within this group of patients. We hypothesized that anxiety and depression are associated with worse outcomes after ASD.Methods: A retrospective review of prospectively collected data was carried out of patients undergoing ASD. Inclusion criteria were short-term relief with injection therapy and presence of Hawkins sign. Rotator cuff tears were excluded. Patients completed the Oxford Shoulder Score (OSS), Hospital Anxiety and Depression Scale (HADS), and visual analog scale for pain before and after surgery in outpatient clinic followup at 6 weeks and by postal questionnaire at 6 months.Results: The 86 patients who participated in the study were analyzed in 2 groups defined by HADS scores, group A being depressed and group B nondepressed. Both groups had less pain and improved OSS at 6 months; however, group B improved faster with improved scores at 6 weeks, which were maintained to 6 months. Group B had less pain and higher OSS at 6 months than group A. There was strong negative correlation (P < .01) between preoperative HADS score and 6-week and 6-month OSS and HADS scores. There was strong positive correlation (P < .01) between HADS score and 6-week and 6-month pain scores. High preoperative HADS score was negatively correlated to 6-month satisfaction (P < .05).Conclusion: Patients with HADS score > 11 before ASD have worse outcomes. This should be taken into account when counseling patients for surgery. (C) 2016 Journal of Shoulder and Elbow Surgery Board of Trustees.

The objective of this study was to present an unusual low velocity transorbital penetrating injury. The study design was a clinical record (case report). A 38-year-old gentleman tripped and fell face first onto the wing of an ornamental brass eagle. This penetrated the inferomedial aspect of the right orbit, breaching the lamina papyracea to extend into the ethmoid sinuses and reaching the dura of the anterior cranial fossa. The foreign body was removed in theater under a joint ophthalmology and ENT procedure. The patient was left with reduced visual acuity in the right eye but no other long-term sequelae. Transorbital penetrating injury presents unusual challenges to investigation and management requiring a multidisciplinary approach to prevent significant morbidity and mortality. If managed well the prognosis is good.