Background: Atraumatic shoulder instability (type II glenohumeral instability) poses a unique challenge in management, with limited historical evidence supporting surgical intervention. This study evaluates outcomes of arthroscopic inferior capsular shift for type II instability in a specialized tertiary unit. Methods: A retrospective analysis of 72 shoulders in 70 patients undergoing arthroscopic inferior capsular shift between 2013 and 2017 was conducted. Inclusion criteria included atraumatic recurrent instability with a minimum follow-up of two years. Patients with traumatic or structural instability were excluded. Pre-operative and post-operative patient-reported outcome measures, recurrence rates, and predictors of recurrence were analyzed. Results: The cohort had a mean age of 27.4 years and included 46 females. At a mean follow-up of 2.7 years, significant improvements were observed in pain scores (7.3-2.7), Stanmore Percentage Of Normal Shoulder Assessment (43.8%-71.6%), and Oxford Shoulder Scores (29.6-39.1). Despite these improvements, 39% of patients reported recurrent instability, with 8.5% requiring revision surgery. Recurrence was more common in females and patients under 30 years of age, while hypermobility (Beighton score ≥5) was not predictive of outcome. Discussion and Conclusion: Arthroscopic inferior capsular shift demonstrated substantial functional and pain improvements but was associated with a higher-than-expected instability recurrence rate. Predictors of recurrence included younger age and female gender. These findings highlight the need for patient-specific surgical decision-making and thorough pre-operative counseling. Arthroscopic inferior capsular shift has been shown to be effective for improving pain and function in type II instability in patients recalcitrant to other management options. Despite this, patients should be counseled regarding the elevated risk of recurrence, especially younger females under 30 years.

Background Fractures of the distal humerus are a common fragility fracture in older adults. The purpose of this study was to systematically review the literature to produce pooled estimates of the outcomes of treatment using total elbow arthroplasty (TEA), open reduction and locking plate fixation (ORIF), hemiarthroplasty or with conservative management. Methods A systematic review of PUBMED and EMBASE databases was conducted for studies reporting outcomes of intra-articular fractures in older adults. Data extracted included patient-reported outcome measures as well as clinical outcomes including ROM, adverse events and all-cause reoperation rates. Results Forty-eight studies met the inclusion criteria and included 1838 acute, intra-articular distal humeral fractures. There was no clinically important difference in patient-reported pain and function measured on the Mayo Elbow Performance Score (TEA = 89.3 (SD 20.0), Hemi = 88.4 (SD 10.6), internal fixation = 85.0 (SD 14.7), non-operative = 85.1 (SD 11.0)). Discussion Each of the treatment modalities studies resulted in a reasonable level of elbow function. The included studies were largely non-comparative and at considerable risk of bias. As elbow replacement surgery becomes centralised in the UK, there is a real need for high-quality comparative research studies to inform practice.

Background:Glenoid bone loss represents a challenge in shoulder arthroplasty and often precludes standard implants. The CAD-CAM total shoulder replacement (TSR) is an option in these cases. This study aimed to assess survivorship and long-term patient outcomes of the CAD-CAM TSR. Methods:Fifty-eight patients that underwent a CAD-CAM TSR by three surgeons at a single tertiary referral centre between 2009 and 2017 were reviewed. The mean follow-up was 70 months (28-130). Data was collected on survivorship, range of movement, Oxford shoulder score (OSS, 0-48), subjective shoulder value (SSV, 0-100%), pain score (0-10), and overall patient satisfaction. Results:CAD-CAM TSR was undertaken as a primary procedure in 28% (n = 16) for end-stage arthritis with severe glenoid bone loss, and as a revision procedure in 72% (n = 42). Of the total, 17% (n = 10) required component revision at a mean of 24 months (4x prosthesis loosening, 3x infection, 3x periprosthetic fracture). Forward elevation improved from 45° ± 27° to 59° ± 29° (P = 0.0056), abduction from 43° ± 29° to 55° ± 26° (P = 0.034) and external rotation from 8° ± 11° to 16° ± 14° (P = 0.031). OSS improved from 15 ± 8 to 29 ± 9 (P = 0.0009), SSV from 18 ± 16 to 62 ± 23 (P < 0.0001), and pain score from 8 ± 2 to 2 ± 2 (P < 0.0001). 88% of patients would undergo the procedure again. Conclusion:CAD-CAM TSR is reserved for complex cases involving severe glenoid bone loss, offering significant improvements in pain and function with overall positive patient satisfaction.

ObjectivesTo determine the effect of arthroscopic capsular shift surgery on pain and functional impairment for people with atraumatic shoulder (glenohumeral) joint instability.MethodsWe conducted a randomised, placebo-controlled clinical trial in a specialist secondary care facility. Patients aged 18 years and over who reported insecurity (apprehension) in their shoulder joint and had evidence of capsulolabral damage on arthroscopic examination were included. Patients were excluded if their shoulder apprehension symptoms were precipitated by a high velocity shoulder injury, they had bony or neural damage, a rotator cuff or labral tear, or previous surgery on the symptomatic shoulder. Sixty-eight participants were randomised and received diagnostic arthroscopy, followed by arthroscopic capsular shift or diagnostic arthroscopy alone. All participants received the same postoperative clinical care. The primary outcome was pain and functional impairment measured with the Western Ontario Shoulder Instability Index. The prespecified minimum clinically important effect was a reduction in pain and disability of 10.4 points.ResultsMean reductions in pain and functional impairment for both groups were similar. Compared with diagnostic arthroscopy, arthroscopic capsular shift increased pain and functional impairment by means of 5 points (95% CI −6 to 16 points) at 6 months, 1 point (95% CI −11 to 13 points) at 12 months and 2 points (95% CI −12 to 17 points) at 24 months.ConclusionsCompared with diagnostic arthroscopy alone, arthroscopic capsular shift confers, at best, only minimal clinically important benefit in the medium term.Trial registration numberNCT01751490.

Introduction Atraumatic shoulder instability (ASI) occurs in the absence of significant trauma and can impair shoulder function. Arthroscopic capsular shift (ACS) is recommended in persistent symptoms. The primary objective of this trial was to determine the effect of ACS in ASI. Materials and Methods A single-centre, two-arm, randomized, placebo-controlled clinical trial incorporating concealed intervention assignment, blinded assessment, and analysis by intention-to-treat was conducted. Patients over 18 years, with positive apprehension tests and evidence of capsulo-labral damage on arthroscopy, were eligible for inclusion. Participants were randomised to ACS or arthroscopy only. All patients received the same post-operative care. The primary outcome was the Western Ontario Shoulder Instability Index (WOSI), a change of 10.4 points was considered to be clinically significant. Secondary outcomes included global perceived change and episodes of dislocations. Patients were followed up at 6, 12 and 24 months. Results 68 patients, average age 25.6 (SD 6.4), 53 females (77.9%) were randomised into the trial. Complete primary outcome data were available for 61 (90%), 59 (87%) and 56 (82%) at 6, 12 and 24 months respectively. Mean change on the WOSI scores at 6, 12 and 24 months were 5, 1 and 2 points respectively. Confidence intervals were narrow enough to rule out a clinically worthwhile beneficial effect of ACS at 6 months and the confidence intervals were nearly narrow enough to rule out clinically worthwhile effects at 12 and 24 months. Conclusion The data suggest that ACS has no additional benefit in management of ASI compared to placebo.

Background: The COVID-19 pandemic interrupted the delivery of face-to-face pain services including pain management programmes in the United Kingdom with considerable negative impact on patients with chronic musculoskeletal pain. We aimed to develop and implement a remotely delivered pain management programme (PMP) using video-conferencing technology that contains all the core components of a full programme: the ‘virtual PMP’ (vPMP). By reporting on the process of this development, we endeavour to help address the paucity of literature on the development of remote pain management programmes. Methods: The vPMP was developed by an inter-disciplinary group of professionals as a quality improvement (QI) project. The Model for Improvement Framework was employed with patient involvement at the design phase and at subsequent improvements. Improvement was measured qualitatively with frequent and repeated qualitative data collection leading to programme change. Quantitative patient demographic comparisons were made with a patient cohort who had been on a face-to-face PMP pathway. Results: Sixty-one patients on the PMP waiting list were contacted and 43 met the criteria for the programme. Fourteen patients participated in three vPMP cycles. Patient involvement and comprehensive stakeholder consultation were essential to a robust design for the first vPMP. Continued involvement of patient partners during the QI process led to rapid resolution of implementation problems. The most prominent issues that needed action were technical challenges including training needs, participant access to physical and technological resources, participant fatigue and concerns about adequate communication and peer support. Conclusion: This report demonstrates how a remotely delivered PMP, fully in line with national guidance, was rapidly developed and implemented in a hospital setting for patients with chronic musculoskeletal pain. We also discuss the relevance of our findings to the issues of cost, patient experience, patient preferences and inequities of access in delivering telerehabilitation for chronic pain.

Introduction There is limited medium-term outcome data regarding the predictors of functional outcome and patient satisfaction after arthroscopic rotator cuff repair. Methods 287 patients that underwent arthroscopic rotator cuff repair under a high-volume single surgeon were contacted at a minimum of 4 years following surgery. Patient demographics, tear size and co-morbidities were pre-operatively recorded. The Oxford shoulder score, EuroQol 5-dimensional score and patient satisfaction were recorded at final follow-up. Results 234 (81.5%) patients completed follow-up at a mean of 5.5 (4–9) years. There were 126 males and 108 females with a mean age of 60 (range 25–83) years. The majority of patients (n = 211, 90%) were satisfied with their final outcome. Multivariate linear regression analysis (R2 = 0.64) identified that increasing tear size (p = 0.04), worsening general health assessed by the EuroQol 5-Dimensional (p < 0.001), and smoking (p = 0.049) were associated with a worse Oxford shoulder score. Logistic regression analysis (R2 = 0.13) identified that worsening general health assessed by the EuroQol 5-Dimensional (p < 0.001), and smoking (p = 0.01) were associated with an increased risk of patient dissatisfaction. Conclusion General health status and smoking are independent predictors of functional outcome and patient satisfaction at medium-term follow-up following arthroscopic rotator cuff repair.

Background Clinical coders are dependent on clear data regarding diagnoses and procedures to generate an accurate representation of clinical activity and ensure appropriate remuneration is received. The accuracy of this process may potentially be improved by collaboration with the surgical team. Methods Between November 2017 and November 2019, 19 meetings took place between the Senior Clinical Fellow of our tertiary Shoulder & Elbow Unit and the coding validation lead of our Trust. At each meeting, the Clinical Fellow assessed the operative note of cases in which uncertainty existed as to the most suitable clinical codes to apply and selected the codes which most accurately represented the operative intervention performed. Results Over a 24-month period, clinical coding was reviewed in 153 cases (range 3–14 per meeting, mean 8). Following review, the clinical coding was amended in 102 (67%) of these cases. A total of £115,160 additional income was generated as a result of this process (range £1677–£15,796 per meeting, mean £6061). Only 6 out of 28 (21%) cases initially coded as arthroscopic sub-acromial decompressions were correctly coded as such. Discussion Surgeon input into clinical coding greatly improves data quality and increases remuneration received for operative interventions performed.

BACKGROUND:There remains no gold standard management for deep shoulder periprosthetic joint infection (PJI). This case series aims to present our experience of two-stage revision arthroplasty, including eradication of infection and reoperation rates.METHODS:We retrospectively reviewed patients undergoing revision arthroplasty for shoulder PJI between 2006 and 2015. Cases were confirmed using Musculoskeletal Infection Society (MSIS) and American Academy of Orthopaedic Surgeons (AAOS) guidelines. TSA removal, debridement and irrigation preceded antibiotic-loaded cement spacer insertion and a minimum of six weeks intravenous antibiotics. Reimplantation was performed as a second stage following a negative aspirate.RESULTS:Twenty-eight patients underwent a first stage procedure (mean age 69 years; 16 male, 12 female). Propionibacterium acnes, Methicillin-sensitive Staphylococcus aureus, Coagulase-negative Staphylococcus and Staphylococcus epidermidis were the commonest microorganisms cultured. Five cases had mixed growths and six cases provided no growth. Three patients did not proceed to a second stage. Twenty-five patients underwent reimplantation (mean interval 6.7 months), with 80% remaining infection-free (mean follow-up 38.3 months).DISCUSSION:Managing complex and late presentation shoulder PJI with two-stage revision is associated with high rates of infection eradication (80%). In the absence of a management consensus, our experience supports two-stage revision arthroplasty for eradicating infection in this complex patient group.

The National Joint Registry (NJR) was established in 2003, and was extended to include ankle arthroplasty on 1st April 2010, and shoulder and elbow arthroplasty in April 2012.The aim of this study was to evaluate the uptake of the NJR for ankle arthroplasty over its first 3 years. This is compared to the first 3 years of hip and knee data, and the first year of shoulder and elbow data.The methods of measuring compliance are also evaluated. NJR compliance is measured by comparing the number of procedures submitted to the NJR, against the number of levies raised through implant sales. This applies to all of the UK, and both independent and NHS providers. However, compliance can also be measured by comparing NJR submissions with data submitted to the Hospital Episode Statistics (HES) database. This only relates to NHS institutions in England.The NJR ankle data was compared to implant data, and adjusted to compare to HES data, to evaluate the different methods of measuring compliance.We also compared these fi...

Diaphyseal tibial fractures are the most common long bone fracture. There are a variety of treatment options, both operative and non-operative, and satisfactory outcomes are reliant on a thorough understanding of the strengths and weaknesses of the different treatment modalities, and their most useful applications. Certain fracture patterns present particular difficulties and these must be recognized pre-operatively so that an appropriate surgical strategy can be planned. Compartment syndrome can be a devastating complication, and must be kept in mind at all times.