Acute rehabilitation following traumatic anterior shoulder dislocation (ARTISAN): pragmatic, multicentre, randomised controlled trial.

OBJECTIVE: To assess the effects of an additional programme of physiotherapy in adults with a first-time traumatic shoulder dislocation compared with single session of advice, supporting materials, and option to self-refer to physiotherapy. DESIGN: Pragmatic, multicentre, randomised controlled trial (ARTISAN). SETTING AND PARTICIPANTS: Trauma research teams at 41 UK NHS Trust sites screened adults with a first time traumatic anterior shoulder dislocation confirmed radiologically, being managed non-operatively. People were excluded if they presented with both shoulders dislocated, had a neurovascular complication, or were considered for surgical management. INTERVENTIONS: One session of advice, supporting materials, and option to self-refer to physiotherapy (n=240) was assessed against the same advice and supporting materials and an additional programme of physiotherapy (n=242). Analyses were on an intention-to-treat basis with secondary per protocol analyses. MAIN OUTCOME MEASURES: The primary outcome was the Oxford shoulder instability score (a single composite measure of shoulder function), measured six months after treatment allocation. Secondary outcomes included the QuickDASH, EQ-5D-5L, and complications. RESULTS: 482 participants were recruited from 40 sites in the UK. 354 (73%) participants completed the primary outcome score (n=180 allocated to advice only, n=174 allocated to advice and physiotherapy). Participants were mostly male (66%), with a mean age of 45 years. No significant difference was noted between advice compared with advice and a programme of physiotherapy at six months for the primary intention-to-treat adjusted analysis (between group difference favouring physiotherapy 1.5 (95% confidence interval -0.3 to 3.5)) or at earlier three month and six week timepoints. Complication profiles were similar across the two groups (P>0.05). CONCLUSIONS: An additional programme of current physiotherapy is not superior to advice, supporting materials, and the option to self-refer to physiotherapy. TRIAL REGISTRATION: Current Controlled Trials ISRCTN63184243.

Musculoskeletal Ultrasonography Assessment of Functional Magnetic Stimulation on the Effect of Glenohumeral Subluxation in Acute Poststroke Hemiplegic Patients.

BACKGROUND: Glenohumeral subluxation (GHS) is common in patients with acute hemiplegia caused by stroke. GHS and upper limb function are closely related. OBJECTIVE: Using musculoskeletal ultrasonography (MSUS) to objectively evaluate the efficacy of functional magnetic stimulation (FMS) in the treatment of GHS in acute hemiplegic patients after stroke. METHODS: The study used prospective case control study. Stroke patients with GHS were recruited and assigned to control group and FMS group. Control group received electrode stimulation at the supraspinatus and deltoid muscles of the hemiplegic side, while FMS group was stimulated at the same locations. Before and after treatment, the distances of the acromion-greater tuberosity (AGT), acromion-lesser tuberosity (ALT), acromiohumeral distance (AHD), supraspinatus thickness (SST), and deltoid muscle thickness (DMT) in patients' bilateral shoulder joint were measured by MSUS, respectively. Meanwhile, Fugl-Meyer Assessment (FMA) was used to evaluate the improvement of upper limb function. RESULTS: 30 patients were recruited. After FMS treatment, there was a significant decrease in the difference value between ipsilateral side and contralateral side of AGT [t = 8.595, P < 0.01], ALT [t = 11.435, P < 0.01], AHD [t = 8.375, P < 0.01], SST [t = 15.394, P < 0.01], and DMT [t = 24.935, P < 0.01], and FMA score increased [t = -13.315, P < 0.01]. Compared with control group, FMS group decreased more significantly in the difference value between ipsilateral side and contralateral side of AGT [t = 2.161, P < 0.05], ALT [t = 3.332, P < 0.01], AHD [t = 8.768, P < 0.01], SST [t = 6.244, P < 0.01], and the DMT [t = 3.238, P < 0.01], and FMA score increased more significantly in FMS group [t = 7.194, P < 0.01]. CONCLUSION: The study preliminarily shows that the MSUS can objectively and dynamically evaluate the treatment effect of GHS in hemiplegic patients. Meanwhile, compared with control group, the FMS is more effective and has fewer side effects, and the long-term effect of FMS is worth further study. This trial is registered with ChiCTR1800015352.

Open Latarjet versus arthroscopic Latarjet: clinical results and cost analysis.

PURPOSE: The aim of this study was to compare the clinical results between open and arthroscopic Latarjet and perform a cost analysis of the two techniques. MATERIALS AND METHODS: A systematic review of articles present in PubMed and MEDLINE was performed in accordance with PRISMA guidelines. Studies concerning post-operative outcomes following Latarjet procedures for chronic anterior shoulder instability were selected for analysis. The clinical and radiographic results as well as the costs of the open and arthroscopic techniques were evaluated. RESULTS: Twenty-three articles, describing a total of 1317 shoulders, met the inclusion criteria: 17 studies were related to open Latarjet, and 6 to the arthroscopic technique. Despite the heterogeneity of the evaluation scales, the clinical results seemed very satisfactory for both techniques. We detected a statistically significant difference in the percentage of bone graft healing in favour of the open technique (88.6 vs 77.6 %). Recurrent dislocation was more frequent following open surgery (3.3 % after open surgery vs 0.3 % after arthroscopy), but this finding was biased by the large difference in follow-up duration between the two techniques. The direct costs of the arthroscopic procedure were double in comparison to open surgery (€2335 vs €1040). A lack of data prevented evaluation of indirect costs and, therefore, a cost-effectiveness analysis. CONCLUSIONS: The open and arthroscopic Latarjet techniques showed excellent and comparable clinical results. However, the much higher direct costs of the arthroscopic procedure do not seem, at present, to be justified by a benefit to the patient. LEVEL OF EVIDENCE: III.

Complication rate and implant survival for reverse shoulder arthroplasty versus total shoulder arthroplasty: results during the initial 2 years.

BACKGROUND: The use of reverse total shoulder arthroplasty (RTSA) has significantly increased in recent years. However, there is large variance in reported complication rates and sparse data on implant survival. This study used a statewide patient database to investigate complication rates and implant survival for RTSA. METHODS: All patients undergoing RTSA or total shoulder arthroplasty (TSA) from 2011 to 2013 were identified within a statewide database. The complication and revision rates at 30 days, 90 days, 1 year, and 2 years postoperatively were determined. Potential risk factors for complications were analyzed with logistic regression, and Kaplan-Meier survival curves were used to compare implant failure. RESULTS: During the 3-year period, 10,844 procedures (6,658 TSA; 4,186 RTSA) were found within the database. The all-cause complication rate at 90 days and 2 years postoperatively was significantly higher for RTSA (P < .001). RTSA patients had a significantly increased risk of infection (P < .05) and dislocation (P < .001) in the early and midterm postoperative course. Workers' compensation, male sex, preoperative anemia, and those aged younger than 65 years had a significantly higher risk for complications (P < .001). Although RTSA initially had a higher rate of implant failure than TSA during the early postoperative period, this rate equalized at approximately the 1-year mark. CONCLUSION: RTSA patients had significantly higher complication rates compared with TSA patients, with identifiable risk factors for all-cause complications postoperatively and equivalent accepted implant failure at 2 years. LEVEL OF EVIDENCE: Level III; Cross Sectional Design; Large Database Analysis.

Assessment of glenohumeral subluxation in poststroke hemiplegia: comparison between ultrasound and fingerbreadth palpation methods.

BACKGROUND: Glenohumeral subluxation (GHS) is a common poststroke complication. Treatment of GHS is hampered by the lack of objective, real-time clinical measurements. OBJECTIVE: The aims of this study were: (1) to compare an ultrasound method of GHS measurement with the fingerbreadth palpation method using a receiver operating characteristic curve (ROC) and (2) to report the sensitivity and specificity of this method. DESIGN: A prospective study was conducted. SETTING: The study was conducted in local hospitals and day centers in the southwest of England. PATIENTS: One hundred five patients who had one-sided weakness following a first-time stroke (51 men, 54 women; mean age=71 years, SD=11) and who gave informed consent were enrolled in the study. MEASUREMENTS: Ultrasound measurements of acromion-greater tuberosity (AGT) distance were used for the assessment of GHS. Measurements were undertaken on both shoulders by a research physical therapist trained in shoulder ultrasound with the patient seated in a standardized position. Fingerbreadth palpation assessment of GHS was undertaken by a clinical physical therapist based at the hospital, who also visited the day centers. RESULTS: The area under the ROC curve was 0.73 (95% confidence interval [95% CI]=0.63, 0.83), suggesting that the ultrasound method has good agreement compared with the fingerbreadth palpation method. A cutoff point of ≥0.2 cm AGT measurement difference between affected and unaffected shoulders generated a sensitivity of 68% (95% CI=51%, 75%), a specificity of 62% (95% CI=47%, 80%), a positive likelihood ratio of 1.79 (95% CI=1.1, 2.9), and a negative likelihood ratio of 0.55 (95% CI=0.4, 0.8). LIMITATIONS: Clinical therapists involved in the routine care of patients conducted the fingerbreadth palpation method. It is likely that they were aware of the patients' subluxation status. CONCLUSION: The ultrasound method can detect minor asymmetry (≤0.5 cm) and has the potential advantage over the fingerbreadth palpation method of identifying patients with minor subluxation.

A prospective study comparing conservative with operative treatment in patients with a 'floating shoulder' including assessment of the prognostic value of the glenopolar angle.

Both conservative and operative forms of treatment have been recommended for patients with a 'floating shoulder'. We compared the results of conservative and operative treatment in 25 patients with this injury and investigated the use of the glenopolar angle (GPA) as an indicator of the functional outcome. A total of 13 patients (ten male and three female; mean age 32.5 years (24.7 to 40.4)) were treated conservatively and 12 patients (ten male and two female; mean age 33.67 years (24.6 to 42.7)) were treated operatively by fixation of the clavicular fracture alone. Outcome was assessed using the Herscovici score, which was also related to changes in the GPA at one year post-operatively. The mean Herscovici score was significantly better three months and two years after the injury in the operative group (p < 0.001 and p = 0.003, respectively). There was a negative correlation between the change in GPA and the Herscovici score at two years follow-up in both the conservative and operative groups, but neither were statistically significant (r = -0.295 and r = -0.19, respectively). There was a significant difference between the pre- and post-operative GPA in the operative group (p = 0.017). When compared with conservative treatment, fixation of the clavicle alone gives better results in the treatment of patients with a floating shoulder. The GPA changes significantly with fixation of clavicle alone but there is no significant correlation between the pre-injury GPA and the final clinical outcome in these patients.

Is MRA an unnecessary expense in the management of a clinically unstable shoulder? A comparison of MRA and arthroscopic findings in 90 patients.

BACKGROUND AND PURPOSE: In detection of glenoid labrum pathology, MR arthrography (MRA) has shown sensitivities of 88-100% and specificities of 89-93%. However, our practice suggested that there may be a higher frequency of falsely negative reports. We assessed the accuracy of this costly modality in practice. PATIENTS AND METHODS: We retrospectively reviewed MRA reports of 90 consecutive patients with clinical shoulder instability who had undergone shoulder arthroscopy. All had a history of traumatic anterior shoulder dislocation and had positive anterior apprehension tests. All underwent arthroscopy and stabilization during the same procedure. We compared the findings, using arthroscopic findings as the gold standard in the identification of glenoid labrum pathology. RESULTS: 83 of the 90 patients had glenoid labrum tears at arthroscopy. Only 54 were correctly identified at MRA. All normal glenoid labra were identified at MRA. This gave a sensitivity of 65% and a specificity of 100% in identification of all types of glenoid labrum tear. 74 patients had anterior glenoid labral tears that were detected at an even lower rate of sensitivity (58%). INTERPRETATION: The sensitivity of MRA in this series was substantially lower than previously published, suggesting that MRA may not be as reliable a diagnostic imaging modality in glenohumeral instability as previously thought. Our findings highlight the importance of an accurate history and clinical examination in the management of glenohumeral instability. The need for MRA may not be as high as is currently believed.

[Damage to the glenoid labrum and expert assessment]. / Die Schäden des Labrum glenoidale und ihre Begutachtung.

AIM: Development of criteria for the medical-legal interpretation of different patterns of labral lesions according to the labrum pathology and mechanism of injury. METHODS: A metaanalysis of the literature concerning injuries and diseases of the shoulder involving the glenoid labrum was performed. RESULTS: Lesions of the superior, anterior and posterior labrum are rare and of different severity. Arthroscopically they are divided into distinct types. They develop either spontaneously together with intraarticular diseases, due to chronic fatigue or by injury. In this field the stability of the shoulder joint and the tension of the long head of the biceps tendon play an important role. There is no correlation between the type of lesion and mechanism of injury. With respect to medical-legal interpretation, the currently used classification of labral lesions is not very helpful or is even confusing. We therefore propose a new classification according to the meniscus pathology which shows a striking similarity to labral pathology. There are two types of labral lesions: Type one shows degenerative defects, which may be influenced by mechanical loading; type two follows from shoulder instability. CONCLUSIONS: Medical-legal interpretation of labral lesions should follow the same principles that were shown to be useful in knee joint instability and meniscal tears. Only traumatic luxations of the shoulder joint may lead to labral tears without any other alterations.

Magnetic resonance arthrography in the assessment of anterior instability of the shoulder: comparison with double-contrast computed tomography arthrography.

Forty-seven shoulders with traumatic anterior instability were studied by magnetic resonance arthrography (MRA) and computed tomography arthrography (CTA) to compare the diagnostic performance of these examinations in the evaluation of Bankart lesions. All shoulders were examined by arthroscopy to verify the lesions. Labral damage evaluated by MRA and by CTA correlated significantly with arthroscopic findings (MRA, r = 0.55, p < 0.0001; CTA, r = 0.45, p = 0.0050). MRA possessed higher sensitivity in detecting torn labra (MRA, sensitivity = 87%, specificity = 75%; CTA, sensitivity = 33%, specificity = 88%). In detecting displaced labra, sensitivity and specificity were 65% and 94% for MRA and 75% and 69% for CTA. The inferior glenohumeral ligament was depicted as a lax structure in 74% by MRA but in only 21% by CTA. We conclude that MRA is superior to CTA in detecting lesions associated with shoulder instability.

[Shoulder dislocation and periarthrosis humeroscapularis]. / Schulterluxation und Periarthrosis humeroscapularis.

1232 injuries involving shoulder luxations in 1984 were investigated on the basis of the insurance dossier. 1/3 of the injured persons have sequelae: 10.5% habitual tendency to luxation, 9% peritendinitis, 2% omarthritis and 2% a shoulder instability. 1/5 in each case still experience pain and restricted movement. The 108 cases where peritendinitis has occurred following shoulder luxations are shown divided up according to various symptoms. Peritendinitis ankylosis or frozen shoulder represents the major share in almost half of the cases. Various characteristics, complications and risk factors for the possibility of contracting peritendinitis following shoulder luxation are being worked out. In conclusion, the insurance-relevant parameters for peritendinitis after shoulder luxation are shown: in cases with peritendinitis, integrity compensation was awarded 12 times more frequently than in cases without peritendinitis; in the case of shoulder luxation with peritendinitis, the entire insurance benefits were 10 times higher than in cases without peritendinitis.