The incidence and treatment of symptomatic acromioclavicular joint osteoarthritis following total shoulder arthroplasty.

Background: Acromioclavicular joint (ACJ) Osteoarthritis (OA) is very common in the general population. Despite this, there is little mention of concomitant glenohumeral and ACJ arthropathy in the literature, and no documented incidence of symptomatic ACJ OA post total shoulder arthroplasty (TSA). We present the incidence and timescale of the problem, and the response to treatments. Methods: Patients who had developed ACJ-related symptoms following a TSA were retrieved from a prospectively collected database. It was determined that these symptoms were not related to the prosthesis or other non-ACJ pathology. Results: There were 230 primary anatomic total shoulder replacements carried out over a 9-year period, with 219 with adequate follow-up for analysis. Thirty-five (16%) developed a symptomatic ACJ. The majority developed symptoms within the first two years however there was one patient who developed symptoms eight years later. Twenty six percent of patients responded to a period of rest. Seventy one percent had a cortisone injection in the ACJ and in 44% of patients this was effective. Twelve (34%) patients had an arthroscopic excision of distal clavicle with good resolution of the symptoms. Discussion: ACJ symptoms following a total shoulder replacement appears more common than thought and can be treated successfully.

Encouraging outcomes of stemless ceramic head anatomic shoulder arthroplasty in severe primary osteoarthritis (Walch type B glenoids).

Background: We report the radiological and functional outcomes at five years in patients with severe osteoarthritis of the glenohumeral joint and a Walch type B glenoid who have undergone stemless anatomic total shoulder replacement. Methods: A retrospective analysis of case notes, computed tomography scans and plain radiographs of patients undergoing anatomic total shoulder replacement for primary glenohumeral osteoarthritis were performed. Patients were grouped by the severity of their osteoarthritis using the modified Walch classification, glenoid retroversion and posterior humeral head subluxation. An evaluation was made using modern planning software. Functional outcomes were assessed using the American shoulder and elbow surgeons score, shoulder pain and disability index and visual analogue scale. Annual Lazarus scores were reviewed as regard to glenoid loosening. Results: Thirty patients were reviewed at 5 years. Analysis of all patient-reported outcome measures demonstrated significant improvement at 5-year review, American shoulder and elbow surgeons (p = <0.0001), shoulder pain and disability index (p = 0.0001), visual analogue scale (p = 0.0001). Radiological associations between Walch scores and Lazarus scores were not statistically significant (p = 0.1251) at 5 years. There were no associations between features of glenohumeral osteoarthritis and patient-reported outcome measures. Discussion: The severity of osteoarthritis did not show any association with glenoid component survivorship or with patient-reported outcome measures at 5 years review. Level of evidence: IV.

Shoulder Replacement in the Elderly with Anatomic versus Reverse Total Prosthesis? A Prospective 2-Year Follow-Up Study.

BACKGROUND: In older patients requiring a total shoulder replacement (TSR) and with an intact rotator cuff, there is currently uncertainty on whether an anatomic TSR (aTSR) or a reverse TSR (rTSR) is best for the patient. This comparison study of same-aged patients aims to assess clinical and radiological outcomes of older patients (≥75 years) who received either an aTSR or an rTSR. METHODS: Consecutive patients with a minimum age of 75 years who received an aTSR (n = 44) or rTSR (n = 51) were prospectively studied. Pre- and post-operative clinical evaluations included the ASES score, Constant score, SPADI score, DASH score, range of motion (ROM) and pain and patient satisfaction for a follow-up of 2 years. Radiological assessment identified glenoid and humeral component osteolysis, including notching with an rTSR. RESULTS: We found postoperative improvement for ROM and all clinical assessment scores for both groups. There were significantly better patient reported outcome scores (PROMs) in the aTSR group compared with the rTSR patients (p < 0.001). Both groups had only minor osteolysis on radiographs. No revisions were required in either group. The main complications were scapular stress fractures for the rTSR (n = 11) patients and acromioclavicular joint pain for both groups (aTSR = 2; rTSR = 6). CONCLUSIONS: This study of older patients (≥75 years) demonstrated that an aTSR for a patient with good rotator cuff muscles can lead to a better clinical outcome and less early complications than an rTSR. LEVEL OF EVIDENCE: Level II-prospective cohort study.

Mid-term outcomes of a stemless ceramic head anatomic total shoulder replacement.

BACKGROUND: In an anatomic shoulder replacement (aTSR) good results have been reported with the use of a stemless humeral prosthesis. In vitro a ceramic articulation with polyethylene has been shown to produce less polyethylene wear particles than with metal. This study aims to evaluate clinical and radiographic results of a stemless aTSR with a ceramic head articulating with a polyethylene glenoid component, with mid-term follow-up. METHODS: All patients (n = 92) in this prospective study had an aTSR utilizing a stemless humeral component with a ceramic head and a cemented double pegged cemented polyethylene glenoid component for glenohumeral osteoarthritis. Pre- and postoperative clinical evaluations at 2 years were performed using the ASES score, Constant score, SPADI score, DASH score, VAS pain score, patient satisfaction and range of motion. There was a 5-year evaluation of SPADI, ASES, pain, and satisfaction, plus radiographic assessment of glenoid component radiolucent lines and humeral osteolysis. RESULTS: Seventy-four cases (68.1 ± 7.1 years) had a five-year follow-up and demonstrated active elevation improvement from 91.3° preoperatively to 151.1° (p < 0.001). Further improvement was identified with the ASES from 41.6 to 94.3, the SPADI from 62.9 to 4.3, VAS pain from 5.6 to 0.4 (0-10), and satisfaction levels were at 96%. Sixty-two cases had no glenoid radiolucent lines with a maximum Lazarus score of 2 in one patient. Constant scores, available up to 2 years, improved significantly from 30.3 to 77.9 (p < 0.001). There was one case that required revision for glenoid loosening. CONCLUSIONS: Overall, the 5-year results of this ceramic head prosthesis demonstrated good radiographic and clinical outcomes. TRIAL REGISTRATION: ACTRN12613001183774 . Registered: 29 October 2013 - Retrospectively registered. Australian New Zealand Clinical Trials Registry (ANZCTR).

Shoulder injections with autologous conditioned serum reduce pain and disability in glenohumeral osteoarthritis: longitudinal observational study.

BACKGROUND: Currently, non-surgical treatments for glenohumeral osteoarthritis (GH-OA) mainly aim to reduce pain. Autologous conditioned serum (ACS), Orthokine, an interleukin-1 inhibitor from the patient's own blood has an anti-inflammatory effect. The objective was to determine whether intra-articular injections of this ACS improved symptoms in patients with GH-OA and delayed the need for a shoulder replacement. METHODS: A total of 36 consecutive patients, 40 shoulders, with OA received up to 6-weekly intra-articular injections of ACS were included. Imaging of GH-OA, range of motion, visual analogue scale (VAS) pain, Shoulder Pain And Disability Index (SPADI), American Shoulder and Elbow Surgeons and Constant scores were assessed pre-injection and post treatment at 3 months. At a minimum of 2 years, VAS and SPADI scores and whether anyone had progressed to a shoulder replacement were recorded. RESULTS: Outcomes 3 months post-ACS injections demonstrated on average statistically significant improvement (P < 0.05) of all measurements: SPADI (54.3 ± 21.5 vs 43.7 ± 23.7), Constant score (50.5 ± 14.1 vs 57.1 ± 17.4), VAS pain (4.8 ± 2.2 vs 3.7 ± 2.4) and range of motion. Of these, 16 shoulders progressed to a shoulder replacement, nine cases quickly (0.6 ± 0.2 years) and seven cases were delayed by 3.1 ± 1.7 years. The other 18 cases had significant improvement in pain, SPADI (58.0 ± 19.6 to 31.8 ± 21.4; P < 0.01) scores and no progression to a shoulder replacement at 3.6 ± 1.0 years follow-up. There was no correlation of glenoid Walch score or joint space with clinical outcome parameters. CONCLUSION: ACS injections in the shoulder joint for OA can reduce pain and disability, and postpone the need for a shoulder replacement.

Proximal humeral osteolysis and glenoid radiolucent lines in an anatomic shoulder arthroplasty: a comparison of a ceramic and a metal humeral head component.

BACKGROUND: In vitro wear studies demonstrate decreased polyethylene wear with a ceramic compared with a metal humeral head. In this in vivo study, we analyzed prospectively collected 5-year data, comparing the outcomes of 2 types of humeral implants. METHODS: Sixty-two anatomic total shoulder arthroplasties (TSAs) (59 patients) were performed using the same glenoid component and 2 types of modular humeral implants (metal-head long-stem prosthesis in group A vs. ceramic-head stemless prosthesis in group B). Radiographic analysis for proximal humeral osteolysis and glenoid component radiolucent lines was performed at an average of 5.5 years. Functional outcomes were prospectively evaluated according to the visual analog scale score for pain; satisfaction level; American Shoulder and Elbow Surgeons score; active elevation; Shoulder Pain and Disability Index score; and Disabilities of the Arm, Shoulder and Hand score. RESULTS: There were 39 TSAs in group A (mean age, 68.1 years) and 23 TSAs in group B (mean age, 67 years). Clinical improvement was similar for both groups. Some proximal humeral osteolysis occurred in 56% of all TSAs. Group A showed increased osteolysis compared with group B (72% vs. 30%, P = .005). Glenoid radiolucent lines were far more frequent in group A, and group A showed a direct relationship between the extent of humeral osteolysis and the severity of glenoid radiolucent lines (P < .001). CONCLUSION: The stemless ceramic-head replacements showed fewer glenoid radiolucent lines and less humeral osteolysis than the long-stem metal-head replacements. In the group with metal-head replacements, correlation was shown between glenoid radiolucent lines and humeral osteolysis.

The effect of vitamin E-enhanced cross-linked polyethylene on wear in shoulder arthroplasty-a wear simulator study.

BACKGROUND: Wear of the polyethylene glenoid component and subsequent particle-induced osteolysis remains one of the most important modes of failure of total shoulder arthroplasty. Vitamin E is added to polyethylene to act as an antioxidant to stabilize free radicals that exist as a byproduct of irradiation used to induce cross-linking. This study was performed to assess the in vitro performance of vitamin E-enhanced polyethylene compared with conventional polyethylene in a shoulder simulator model. METHODS: Vitamin E-enhanced, highly cross-linked glenoid components were compared with conventional ultrahigh-molecular-weight polyethylene glenoids, both articulating with a ceramic humeral head component using a shoulder joint simulator over 500,000 cycles. Unaged and artificially aged comparisons were performed. Volumetric wear was assessed by gravimetric measurement, and wear particle analysis was also subsequently performed. RESULTS: Vitamin E-enhanced polyethylene glenoid components were found to have significantly reduced wear rates compared with conventional polyethylene in both unaged (36% reduction) and artificially aged (49% reduction) comparisons. There were no differences detected in wear particle analysis between the 2 groups. CONCLUSION: Vitamin E-enhanced polyethylene demonstrates improved wear compared with conventional polyethylene in both unaged and artificially aged comparisons and may have clinically relevant benefits.

Structural integrity of rotator cuff at 16 years following repair: good long-term outcomes despite recurrent tears.

BACKGROUND: There are few studies reporting long-term rotator cuff integrity following repair. The present study reports a case series of surgically repaired supraspinatus tendons followed up with clinical outcomes and ultrasound imaging after an average of 16 years. METHODS: The prospectively studied clinical outcomes at short-, medium- and long-term follow-up in 27 shoulders in 25 patients treated with arthroscopic subacromial decompression and mini-open rotator cuff repair have been reported previously. The functional outcomes scores recorded were the University of California Los Angeles (UCLA), American Shoulder and Elbow Surgeons (ASES) and Simple Shoulder Test (SST) measures. These patients then underwent an ultrasound scan with respect to the long-term assessment of the shoulder and the integrity of the repair. RESULTS: A recurrent tear was noted in 37% of patients at 16.25 years after surgery, of which 50% were small. Two patients required repeat surgery. Patients had a mean UCLA score of 30, an ASES score of 91.3 and a SST score of 9.5 with a 85% level of satisfaction with surgery. Patients with a recurrent tear had outcome scores equivalent to those with an intact cuff with no significant pain. No independent risk factors were identified as predictors for recurrent tear. CONCLUSIONS: Patients showed sustained benefit and satisfaction at long-term follow-up despite a 37% recurrence of full-thickness supraspinatus tear.

The medium-term results of acromioclavicular joint arthroscopy with chondral and meniscal debridement.

PURPOSE: Surgical management of a young patient with a stable but painful acromioclavicular (AC) joint but normal imagining is a challenging problem. A standard arthroscopic excision of distal clavicle seems too aggressive. An alternative procedure is arthroscopic debridement of the joint, particularly the often torn meniscus, and chondroplasty. This study demonstrates in younger patients the medium-term result of arthroscopic debridement of a painful AC joint. METHODS: Fifty-three young adult patients with a stable but painful AC joint, and virtually normal magnetic resonance imaging (MRI) scan, had arthroscopic debridement of the AC joint. Follow-up was with questionnaire and American Shoulder and Elbow Surgeons Shoulder Score (ASES). RESULTS: Mean age was 29 years (18-39), 41 male, 31 dominant arm. Twenty-two patients demonstrated additional shoulder pathology. Two patients had a later distal clavicle excision. Five patients had later surgery to other areas of the shoulder but had an asymptomatic AC joint. Thirty-eight patients completed the ASES questionnaire at mean 44 months (24-86) post-operation. The mean ASES score was 82.8 (52-100). There was no association between ASES score and AC joint disease severity found at operation ( p = 0.25). Seven patients had ongoing shoulder symptoms, although none were severe enough to warrant any treatment. CONCLUSION: In this young group of patients with arthroscopic AC joint debridement, most had good relief of the AC joint related symptoms. This is a worthwhile procedure in the young patient, with quick recovery, and does not preclude further AC joint surgery later.

Acromial and scapular spine fractures after reverse total shoulder arthroplasty.

Acromial and scapular spine fractures after reverse total shoulder arthroplasty occur predominantly as a result of bony insufficiency secondary to patient and intra-operative technical factors. The spectrum of the pathology can range from a stress reaction to an undisplaced or displaced fracture. Prompt diagnosis of these fractures requires a high suspicion in the postoperative patient with a clinical presentation of acute onset of pain along the acromion or scapular spine and/or deterioration of shoulder function. Conventional shoulder radiographs are frequently unreliable in identifying these fractures, especially if they are undisplaced. Computed tomography (CT) and/or single photon emission computed tomography/CT scans are useful imaging modalities for obtaining a definitive diagnosis. Early diagnosis and non-operative treatment of a stress reaction or undisplaced fracture is essential for preventing further displacement and potential disability. The management of displaced fractures is challenging for the orthopaedic surgeon as a result of high rates of mal-union or non-union, decreased functional outcomes, and variable results after open reduction and internal fixation. Strategies for preventing these fractures include optimizing the patient's bone health, correct glenoid baseplate screw length and position, and avoiding excessive deltoid tension. Further research is required to identify the specific patient and fracture characteristics that will benefit from conservative versus operative management.

Pain, depression and the postoperative stiff shoulder.

BACKGROUND: The surgical repair of shoulder pathologies, including rotator cuff disease and acromio-clavicular joint arthritis, have undergone many technical advances. However the debilitating postoperative stiff shoulder remains a common and significant complication of these surgeries, occurring in 4.9 to 23.2 % of patients undergoing rotator cuff repairs. The pathology of the pathological postoperative stiff shoulder and its associated condition "frozen shoulder" are poorly understood and both lack formal objective clinical diagnostic criteria. Additionally, although factors associated with the development of idiopathic frozen shoulder have been well described, multiple studies looking at predictors of postoperative stiff shoulder have produced conflicting results. It has been hypothesised that increased pain in the postoperative period, and depression may be predictors of the development of postoperative stiff shoulder. METHOD: A prospective cohort study involving 132 consecutive participants. Preoperatively, participants undergoing arthroscopic subacromial decompression and/or excision of the distal clavicle and/or rotator cuff repair will complete questionnaires about their levels of shoulder pain using a numerical rating scale from 0 to 10, and answer a Patient Health Questionnaire - 9 depression questionnaire. Postoperatively, the participants' pain levels will be self-assessed at two, five and seven days and weeks four, seven and ten. They will complete the depression questionnaire twice, at the time of their routine first and final postoperative appointments with the treating surgeon. At the final appointment, approximately three months postoperatively, the treating surgeon will clinically diagnose participants as having a postoperative stiff shoulder or not. Their shoulders' range of motion will be measured. The incidence of postoperative stiff shoulder will be determined, both pain and depression will be analysed as predictors for its development and incidences determined by different objective criteria will be compared. DISCUSSION: This trial will add to clinical understanding of the postoperative stiff shoulder by providing further insight into the incidence of this condition following shoulder surgery and assessing whether perioperative pain and depression can be used as clinical predictors of postoperative stiff shoulder or markers for possible early intervention. This study will also allow the comparison of incidences determined by different objective criteria in the same cohort. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry (ANZCTR). ACTRN12613001271796. 17-11-2013.

Four-dimensional computed tomography scans facilitate preoperative planning in snapping scapula syndrome.

HYPOTHESIS: Because a 4-dimensional CT scan (4D CT) is able to provide a moving 3-dimensional (3D) image in real time in patients with snapping scapula syndrome, a 4D CT scan should be able to demonstrate bony impingement of the scapula on the posterior thorax. This study was performed to determine if 4D CT scans aid the clinician in defining the size and location of the scapular bone causing impingement in patients with snapping scapula syndrome. MATERIALS AND METHODS: Between October 2009 and August 2013, 12 patients (median age, 26.5 years; range 15-55 years) with snapping scapula syndrome were investigated with 4D CT. The images formed produced a dynamic volume-rendered reconstruction of the scapulothoracic joint that displayed its movements and any dynamic area of impingement of the scapula on surrounding bony structures. Asymmetry between symptomatic and asymptomatic scapulae was used to determine the radiologic cause of the patient's symptoms. After the failure of conservative management, 8 patients underwent surgery for their condition. RESULTS: Five patients demonstrated bony contact of the scapula on the posterior thoracic ribs. Four patients demonstrated no bony contact but close apposition of the scapula to the posterior thoracic ribs. Three patients demonstrated no bony impingement but abnormal movement of the second and third rib caused by a soft-tissue tethering structure. CONCLUSION: The 4D CT scan images defined pathology well in patients with snapping scapula syndrome and improved assessment of the amount and location of the scapular bone and soft tissue causing symptoms.

Outcomes for intra-substance free coracoid graft in patients with antero-inferior instability and glenoid bone loss in a population of high-risk athletes at a minimum follow-up of 2 years.

BACKGROUND: The aim of this retrospective case series study was to assess the outcomes of patients with recurrent anterior shoulder instability with antero-inferior glenoid bone loss treated with a specific open stabilization technique using intra-substance coracoid bone-grafting and Bankart repair. METHODS: Over a 4-year period, 34 shoulders in all male patients of mean age 21 years were stabilized with this technique. Pre- and postoperative function, motion and stability were assessed as part of Rowe stability scoring, and American Shoulder and Elbow Surgeons (ASES) and Oxford Instability were recorded, with at least 2 years of follow-up in all patients. Union of the graft was determined by post-operative computed tomography (CT) of the affected shoulder. RESULTS: For all cases, two redislocations (5.9%) and two subluxations occurred when continuing high-risk sport after 2 years. Post-operative scores [median, mean (SD): Rowe 77.5, 77.2 (19.5); ASES 94.2, 92 (7.7); Oxford 43, 41.2 (6)]. CT scans on 28 shoulders at a mean of 4.5 months after surgery showed non-union in three cases (10%). CONCLUSIONS: These results demonstrate a high rate of success in cases of glenoid bone loss in the young contact athlete with recurrent instability treated with open stabilization and bone grafting.

Ultrasound-guided platelet-rich plasma injection for distal biceps tendinopathy.

BACKGROUND: Distal biceps tendinopathy is an uncommon cause of elbow pain. The optimum treatment for cases refractory to conservative treatment is unclear. Platelet-rich plasma has been used successfully for other tendinopathies around the elbow. METHODS: Six patients with clinical and radiological evidence of distal biceps tendinopathy underwent ultrasound-guided platelet-rich plasma (PRP) injection. Clinical examination findings, visual analogue score (VAS) for pain and Mayo Elbow Performance scores were recorded. RESULTS: The Mayo Elbow Performance Score improved from 68.3 (range 65 to 85) (fair function) to 95 (range 85 to 100) (excellent function). The VAS at rest improved from a mean of 2.25 (range 2 to 5) pre-injection to 0. The VAS with movement improved from a mean of 7.25 (range 5 to 8) pre-injection to 1.3 (range 0 to 2). No complications were noted. DISCUSSION: Ultrasound-guided PRP injection appears to be a safe and effective treatment for recalcitrant cases of distal biceps tendinopathy. Further investigation with a randomized controlled trial is needed to fully assess its efficacy.

Short stem shoulder replacement.

CONTEXT: It is agreed that it is important to anatomically reproduce the proximal humeral anatomy when performing a prosthetic shoulder replacement. This can be difficult with a long stemmed prosthesis, in particular if there is little relationship of the metaphysis to the humeral shaft. The 'short stem' prosthesis can deal with this problem. AIMS: A prospective study assessed the results of total shoulder arthroplasty using a short stem humeral prosthesis, a ceramic humeral head, and a pegged cemented polyethylene glenoid. MATERIALS AND METHODS: Patients with primary shoulder osteoarthritis were recruited into this prospective trial and pre-operatively had the ASES, Constant, SPADI, and DASH scores recorded. The patients were clinically reviewed at the two weeks, eight weeks, one year, and two year mark with completion of a data form. Radiological evaluation was at the eight week, one year and two year follow-up. At the one and two year follow-up the satisfaction rating, the range of passive and active motion, Constant, ASES, SPADI, DASH and pain results were recorded and analysed with SPPS 20. RESULTS: During the study period 97 short stem, ceramic head total shoulder replacements were carried out. At the time of follow-up 12 were two years from operation and 38 one year from operation. Active elevation was overall mean 160 degrees. Constant scores were 76 at 1 year, and 86 at 2 years, ASES 88 and 93, and satisfaction 96% and 98% respectively at one and 2 year follow up. There were no problems during insertion of the humeral prosthesis, or any radiolucent lines or movement of the prosthesis on later radiographs. CONCLUSION: The short stem prosthesis had no complications, and on follow up radiographs good bone fixation. These fairly short term clinical results were overall good.

Long-term longitudinal follow-up of mini-open rotator cuff repair.

BACKGROUND: Rotator cuff tears are a common clinical problem, and few long-term studies concerning the outcomes of rotator cuff repairs have been performed. The purpose of this study was to report the fifteen-year outcomes of arthroscopic subacromial decompression with mini-open rotator cuff repair. METHODS: The study included seventy-nine patients who had undergone arthroscopic subacromial decompression with mini-open rotator cuff repair from 1993 to 1996. Outcomes were reviewed in 1997, 2002, and 2010. At the final review, forty-nine patients (forty-nine shoulders) were available or were suitable for evaluation. There were eight large tears, forty medium tears, and one small tear. The patients were assessed with the University of California, Los Angeles (UCLA) score at each evaluation. The mean age of the patients at the time of follow-up was 70.1 years, and the mean follow-up period was 15.6 years. RESULTS: At the time of final follow-up, the outcome was good or excellent in thirty-four patients (69%), fair in seven, and poor in eight. Three patients required a reoperation. Between the two and fifteen-year evaluations, twenty-nine patients (59%) had maintained their good or excellent result; the overall raw scores had deteriorated for fifteen patients (31%), and they had improved for twenty-four (49%). Forty-one patients (84%) were satisfied with the final outcome of the shoulder surgery. CONCLUSIONS: This study shows that arthroscopic subacromial decompression with mini-open rotator cuff repair can provide a lasting, durable, and satisfactory outcome for a large proportion of patients fifteen years after surgery. Patient satisfaction at the final evaluation did not necessarily correspond with a good or an excellent UCLA score.

The new 4-dimensional computed tomographic scanner allows dynamic visualization and measurement of normal acromioclavicular joint motion in an unloaded and loaded condition.

OBJECTIVE: Using 4-dimensional computed tomographic scanner to determine the motion pattern of the acromioclavicular (AC) joint during adduction of the arm, with and without resisted superior elevation. METHODS: Sixteen healthy volunteers (5 women and 11 men; mean ± SD age, 42 ± 11 years). Four different motions were measured: AC joint width, anteroposterior translation, superoinferior translation, and opening of the superior aspect of the joint. Measurements between arm positions of neutral, adduction, and loaded were compared. RESULTS: Predominant movement is posterior translation (1.1 ± 0.9 mm, P = 0.001); in the coronal plane, superior translation of the clavicle (0.6 ± 0.5 mm, P = 0.001) and some opening of the superior joint space. Changes in the AC joint width and anteroposterior translation were significantly related to age (P = 0.016 and P = 0.006). CONCLUSIONS: Four-dimensional computed tomographic scans record the motion pattern of an asymptomatic AC joint and demonstrated that in adduction plus resisted elevation of the arm, the main movement of the AC joint is posterior and superior translation of the clavicle.

Efficacy of subacromial ropivacaine infusion for rotator cuff surgery. A randomized trial.

BACKGROUND: Local anesthetic administered directly to the operative site by slow infusion has become a popular supplementary pain management strategy following rotator cuff surgery, but it is expensive and there is little conclusive evidence that it provides additional benefits. The purpose of this study was to determine the effectiveness and safety of ropivacaine infusion following arthroscopic or mini-incision rotator cuff surgery. METHODS: We performed a randomized, participant and outcome assessor-blinded, placebo-controlled trial. Participants, stratified by operative procedure (either arthroscopic decompression or rotator cuff repair), were given preemptive 1% ropivacaine (20 mL) and intraoperative intravenous parecoxib (40 mg) and were randomly assigned to 0.75% ropivacaine or placebo by elastomeric pump at 5 mL/hr. Pain at rest was reported on a verbal analogue scale at fifteen, thirty, and sixty minutes and at two, four, eight, twelve, eighteen, and twenty-four hours. The use of alternative analgesia, delay in discharge, and adverse events, including development of stiff painful shoulder, infection, and leakage, were also assessed. RESULTS: Eighty-eight participants received arthroscopic decompression (forty-three in the placebo arm and forty-five in the ropivacaine arm) and seventy received rotator cuff repair (thirty-five participants in each treatment arm). Compared with placebo, ropivacaine infusion resulted in a significant but clinically unimportant improvement in average pain in the first twelve hours following both procedures (the average pain score was 1.62 and 2.16 for the ropivacaine and placebo arms, respectively, in the arthroscopic decompression group and 2.12 and 2.82 in the rotator cuff repair group, with a pooled difference between groups of 0.61; 95% confidence interval, 0.22 to 1.01; p = 0.003). When adjusted for opioid use, the pooled difference between groups was 0.49 (95% confidence interval, 0.12 to 0.86; p = 0.009). No difference was detected between groups with regard to the maximum pain in the first twelve hours or the average or maximum pain in the second twelve hours, with or without adjustment for opioid use, and no difference was found between groups with regard to the amount of oral analgesia used. No difference was detected between groups with regard to the prevalence of nausea and vomiting, catheter leakage, delayed discharge, or stiff painful shoulder, and no participant in either group had a postoperative infection develop. CONCLUSIONS: We found minimal evidence to support the use of ropivacaine infusion for improving outcomes following rotator cuff surgery in the setting of preemptive ropivacaine and intraoperative parecoxib.

Efficacy and safety of a subacromial continuous ropivacaine infusion for post-operative pain management following arthroscopic rotator cuff surgery: a protocol for a randomised double-blind placebo-controlled trial.

BACKGROUND: Major shoulder surgery often results in severe post-operative pain and a variety of interventions have been developed in an attempt to address this. The continuous slow infusion of a local anaesthetic directly into the operative site has recently gained popularity but it is expensive and as yet there is little conclusive evidence that it provides additional benefits over other methods of post-operative pain management. METHODS/DESIGN: This will be a randomised, placebo-controlled trial involving 158 participants. Following diagnostic arthroscopy, all participants will undergo arthroscopic subacromial decompression with or without rotator cuff repair, all operations performed by a single surgeon. Participants, the surgeon, nurses caring for the patients and outcome assessors will be blinded to treatment allocation. All participants will receive a pre-incision bolus injection of 20 mls of ropivacaine 1% into the shoulder and an intra-operative intravenous bolus of parecoxib 40 mg. Using concealed allocation participants will be randomly assigned to active treatment (local anaesthetic ropivacaine 0.75%) or placebo (normal saline) administered continuously into the subacromial space by an elastomeric pump at 5 mls per hour post-operatively. Patient controlled opioid analgesia and oral analgesics will be available for breakthrough pain. Outcome assessment will be at 15, 30 and 60 minutes, 2, 4, 8, 12, 18 and 24 hours, and 2 or 4 months for decompression or decompression plus repair respectively. The primary end point will be average pain at rest over the first 12-hour post-operative period on a verbal analogue pain score. Secondary end points will be average pain at rest over the second 12-hour post-operative period, maximal pain at rest over the first and second 12-hour periods, amount of rescue medication used, length of inpatient stay and incidence of post-operative adhesive capsulitis. DISCUSSION: The results of this trial will contribute to evidence-based recommendations for the effectiveness of pain management modalities following arthroscopic rotator cuff surgery. If the local anaesthetic pain-buster provides no additional benefits over placebo then valuable resources can be put to better use in other ways. TRIAL REGISTRATION: Australian Clinical Trials Register Number ACTR12606000195550.

Comparison of self-administered University of California, Los Angeles, shoulder score with traditional University of California, Los Angeles, shoulder score completed by clinicians in assessing the outcome of rotator cuff surgery.

To determine whether the University of California, Los Angeles (UCLA) shoulder score completed by the patient is comparable to that obtained by the clinician, 110 patients who had undergone either arthroscopic subacromial decompression (ASD) or rotator cuff repair (RCR) completed the UCLA score questionnaire by mail at 2 months (ASD subgroup) or 4 months (RCR subgroup). Patients were then assessed by 2 clinicians in random order. There was a very good level of agreement for the overall UCLA score for the total cohort (N = 100 with complete data) (intraclass correlation coefficient [ICC], 0.910; 95% confidence interval [CI], 0.87 to 0.94) and for ASD (n = 46) (ICC, 0.951; 95% CI, 0.92 to 0.97) and good agreement for RCR (n = 54) (ICC, 0.734; 95% CI, 0.61 to 0.83). Agreement between patient and assessor 1, patient and assessor 2, and assessors 1 and 2 was also very good (with whole-cohort ICCs of 0.875, 0.910, and 0.935, respectively). Bland-Altman plots showed little systematic disagreement and consistently narrow limits of agreement. Patient self-administration of the UCLA shoulder score yields acceptable results.