Improved range of motion after manipulation under anesthesia versus physiotherapy for stage two frozen shoulder: a randomized controlled trial.

Background: Frozen shoulder (FS) is a common cause of shoulder pain and stiffness. Conservative treatment is sufficient for the majority of patients with long-term recovery of shoulder function. Manipulation under anesthesia (MUA) is known as a well-established treatment option if conservative treatment fails. It is unknown whether MUA does indeed shorten the duration of symptoms or leads to a superior outcome compared to conservative treatment. The objective of the current trial is to evaluate the effectiveness of MUA followed by a physiotherapy (PT) program compared to a PT program alone in patients with stage 2 FS. Methods: A prospective, single-center randomized controlled trial was performed. Patients between 18 and 70 years old with stage 2 FS were deemed eligible if an initial course of conservative treatment consisting of PT and intra-articular corticosteroid infiltration was considered unsatisfactory. Patients were randomized, and data was collected with an online data management platform (CASTOR). MUA was performed by a single surgeon under interscalene block, and intensive PT treatment protocol was started within 4 hours after MUA. In the PT group, patients were referred to instructed physiotherapist, and treatment was guided by tissue irritability. The primary outcome was the Shoulder Pain and Disability Index (SPADI) score. Secondary outcomes were pain, range of motion (ROM), Oxford Shoulder Score, quality of life, and ability to work. Results: In total, 82 patients were included, 42 in the PT group and 40 in the MUA group. There was a significant improvement in SPADI, Oxford Shoulder Score, pain, ROM, and quality of life in both groups at 1-year follow-up. SPADI scores at three months were significantly improved in favor of MUA. MUA showed a significantly bigger increase in anteflexion and abduction compared to PT at all points of follow-up. No significant differences between both groups were found for all other parameters. No fractures, dislocations, or brachial plexus injuries occurred in this trial. Conclusion: MUA in stage 2 FS can be considered safe and results in a faster recovery of ROM and improved functional outcome, measured with SPADI scores, compared to PT alone in the short term. After 1 year, except for slightly better ROM scores for MUA, the result of MUA is equal to PT.

Fractures around the shoulder in the skeletally immature: A scoping review.

Fractures around the shoulder girdle in children are mainly caused by sports accidents. The clavicle and the proximal humerus are most commonly involved. Both the clavicle and the proximal humerus have a remarkable potential for remodeling, which is why most of these fractures in children can be treated conservatively. However, the key is to understand when a child benefits from surgical management. Clear indications for surgery of these fractures are lacking. This review focuses on the available evidence on the management of clavicle and proximal humerus fractures in children. The only strict indications for surgery for diaphyseal clavicle fractures in children are open fractures, tenting of the skin with necrosis, associated neurovascular injury, or a floating shoulder. There is no evidence to argue for surgery of displaced clavicle fractures to prevent malunion since most malunions are asymptomatic. In the rare case of a symptomatic malunion of the clavicle in children, corrective osteosynthesis is a viable treatment option. For proximal humerus fractures in children, treatment is dictated by the patient's age (and thus remodeling potential) and the amount of fracture displacement. Under ten years of age, even severely displaced fractures can be treated conservatively. From the age of 13 and onwards, surgery has better outcomes for severely displaced (Neer types III and IV) fractures. Between 10 and 13 years of age, the indications for surgical treatment are less clear, with varying cut-off values of angulation (30-60 degrees) or displacement (1/3 - 2/3 shaft width) in the current literature.

Ninety-day complication rate based on 532 Latarjet procedures in Dutch hospitals with different operation volumes.

BACKGROUND: In this study, we aimed to provide insight into the 90-day complication rates following the Latarjet procedure. Data from 2015 were collected from multiple hospitals in the Netherlands, with different volumes of Latarjet procedures. Our second aim was to examine which patient and surgical factors were associated with complications. METHODS: We conducted a retrospective chart review of 13 hospitals between 2015 and 2022. Data regarding complications within 90 days of Latarjet procedures were extracted. The effect of sex, age, body mass index (BMI), smoking, previous shoulder operations, fixation material, hospital volume, screw size, and operation time on the complication rate was assessed by multivariable logistic regression analysis. RESULTS: Of the 532 included patients, 58 (10.9%) had complications. The most common complications were material failure (n = 19, 3.6%) and nerve injury (n = 13, 2.4%). The risk of complications was lower for male patients than for female patients (odds ratio, 0.40; 95% confidence interval, 0.21-0.77; P = .006). Age, BMI, smoking, previous shoulder operations, type of fixation material, hospital volume, screw size, and operation time were not associated with complications. CONCLUSION: The 90-day complication rate after the Latarjet procedure was 10.9% and was higher in female patients than in male patients. Age, BMI, smoking, previous shoulder operations, type of fixation material, hospital volume, screw size, and operation time did not affect complication rates. We advise setting up a national registry to prevent under-reporting of complications.

Kitesurf injury trauma evaluation study: A prospective cohort study evaluating kitesurf injuries.

BACKGROUND: Kitesurfing is an increasingly popular and potentially dangerous extreme water sport. We hypothesized that kitesurfing has a higher injury rate than other (contact) sports and that the minority of injuries are severe. AIM: To investigate the incidence and epidemiology of kitesurfing injuries in a Dutch cohort during a complete kitesurfing season. METHODS: Injury data of 194 kitesurfers of various skill levels, riding styles and age were surveyed prospectively during a full kitesurf season. The participants were recruited through the Dutch national kitesurf association, social media, local websites and kitesurf schools. Participants completed digital questionnaires monthly. The amount of time kitesurfing was registered along with all sustained injuries. If an injury was reported, an additional questionnaire explored the type of injury, injury location, severity and the circumstances under which the injury occurred. RESULTS: The mean age of participants was 31 years (range, 13-59) and the majority of the study population was male (74.2%). A total of 177 injuries were sustained during 16816 kitesurf hours. The calculated injury rate was 10.5 injuries per 1000 h of kitesurfing. The most common injuries were cuts and abrasions (25.4%), followed by contusions (19.8%), joint sprains (17.5%) and muscle sprains (10.2%). The foot and ankle were the most common site of injury (31.8%), followed by the knee (14.1%) and hand and wrist (10.2%). Most injuries were reported to occur during a trick or jump. Although the majority of injuries were mild, severe injuries like an anterior cruciate ligament tear, a lumbar spine fracture, a bimalleolar ankle fracture and an eardrum rupture were reported. CONCLUSION: The injury rate of kitesurfing is in the range of other popular (contact) sports. Most injuries are relatively mild, although kitesurfing has the potential to cause serious injuries.

Manipulation under anaesthesia for frozen shoulders: outdated technique or well-established quick fix?

Manipulation under anaesthesia (MUA) for frozen shoulder (FS) leads to a considerable increase in range of motion and Oxford shoulder score, a significant reduction in pain and around 85% satisfaction.A clearly defined indication for MUA in FS patients cannot be extracted from this review or the available literature. The associating criteria before proceeding to MUA vary widely.All but one study in this review lacked a control group without intervention. Therefore, firm conclusions about the role of MUA in the treatment of FS cannot be drawn from the current literature.An overall complication rate of 0.4% was found and a re-intervention rate of 14%, although most of the included papers were not designed to monitor complications.The following criteria before proceeding to MUA are proposed: a patient unable to cope with a stiff and painful shoulder; clinical signs of a stage 2 idiopathic FS; lessening pain in relation to stage 1; external rotation < 50% compared to contralateral shoulder joint; a minimal duration of symptoms of three months; and failure to respond to an intra-articular corticosteroid infiltration. Cite this article: EFORT Open Rev 2019;4:98-109. DOI: 10.1302/2058-5241.4.180044.

Manipulation under anesthesia for frozen shoulders : a retrospective cohort study.

ABBREVIATIONS: MUA, manipulation under anesthesia ; FS, frozen shoulder ; SPADI, Shoulder Pain and Disability Score ; OSS, Oxford Shoulder Score ; NPRS, Numeric Paind Rating Scale. Manipulation under anesthesia is a well-established, but controversial, treatment for frozen shoulders. We will evaluate our results of manipulation and physiotherapy in stage two frozen shoulders. Questionnaires were sent to 65 patients with stage 2 frozen shoulders, treated with manipulation under anaesthesia between January 2012 and January 2014. Outcome parameters consisted of SPADI, OSS, EQ-5D, pain and satisfaction. A response rate of 75% was obtained. Mean follow up was 21 months (range 11-36). The median SPADI score was 11.2 (IQR 0.8-25.2) and median OSS was 39.0 (IQR 30-43). Only 72% of patients reported that they reached their pre injury level of functioning. A satisfaction rate of 92% was reported. Manipulation is a relatively easy intervention with a high satisfaction rate. We assume that manipulation could shorten the duration of symptoms. However, this needs to be confirmed in a randomized trial with a control group.

Corticosteroid injection alone vs additional physiotherapy treatment in early stage frozen shoulders.

AIM: To investigate the additional value of physiotherapy after a corticosteroid injection in stage one or two idiopathic frozen shoulders (FSs). METHODS: A two center, randomized controlled trial was done. Patients with a painful early stage idiopathic FS were eligible for inclusion. After written consent, patients were randomly allocated into two groups. All patients received an ultrasound-guided intra-articular corticosteroid injection. One group underwent additional physiotherapy treatment (PT) and the other group did not (non-PT). The primary outcome measure was the Shoulder Pain and Disability Index (SPADI). Secondary outcomes were pain (numeric pain rating scale), range of motion (ROM), quality of life (RAND-36 score), and patient satisfaction. Follow-up was scheduled after 6, 12 and 26 wk. RESULTS: Twenty-one patients were included, 11 patients in the non-PT and ten in the PT group, with a mean age of 52 years. Both treatment groups showed a significant improvement at 26 wk for SPADI score (non-PT: P = 0.05, PT: P = 0.03). At the 6 wk follow-up, median SPADI score was significant decreased in the PT group (14 IQR: 6-38) vs the non-PT group (63 IQR: 45-76) (P = 0.01). Pain decreased significantly in both groups but no differences were observed between both treatment groups at any time point, except for night pain at 6 wk in favor of the PT group (P = 0.02). Significant differences in all three ROM directions were observed after 6 wk in favor of the PT group (P ≤ 0.02 for all directions). A significantly greater improvement in abduction (P = 0.03) and external rotation (P = 0.04) was also present in favor of the PT group after 12 wk. RAND-36 scores showed no significant differences in health-related quality of life at all follow-up moments. At 26 wk, both groups did not differ significantly with respect to any of the outcome parameters. No complications were reported in both groups. CONCLUSION: Additional physiotherapy after corticosteroid injection improves ROM and functional limitations in early-stage FSs up to the first three months.

Manipulation under anesthesia versus physiotherapy treatment in stage two of a frozen shoulder: a study protocol for a randomized controlled trial.

BACKGROUND: There is no consensus about the optimal treatment strategy for frozen shoulders (FS). Conservative treatment consisting of intra-articular corticosteroid infiltrations and physiotherapy are considered appropriate for most patients. However, with a conservative strategy, patients experience a prolonged rehabilitation period with a considerable amount of pain and disabilities in daily life. Also, at long term, a residual amount of pain and restriction of range of motion is frequently reported. Manipulation under anesthesia is a short and relative simple procedure with the potential to rapidly reduce symptoms and restore the range of motion. The objective of this trial is to evaluate the effectiveness of MUA followed by a PT program compared to a PT program alone, in the treatment of patients with a stage two FS. We hypothesize that the course of the disease can be shortened with MUA with a quicker functional recovery. METHODS: This is a prospective, single center, randomized controlled trial. Eligible patients will be allocated to either the manipulation (MUA) group or the physiotherapy alone (PT) group. In the MUA group manipulation will be performed under interscalene block, directly followed by an intensive physiotherapy treatment protocol, with the goal to maintain the obtained range of motion. Patients allocated to the PT group are given advice and education and receive a written protocol to hand out to their physical therapist based on the recent guideline of the Dutch Shoulder Network for the treatment of frozen shoulders. Descriptive statistics will be used to describe the sample size, patients demographics, presence of diabetes mellitus, range of motion, duration of symptoms till randomization and will be presented for each treatment group. The SPADI is used as primary functional outcome parameter. Secondary outcome parameters are; OSS, NPRS, EQ-5D 3-L, passive range of motion, WORQ-UP, duration of symptoms, usage of analgesics and adverse events. A sample size of 41 subjects in each group was calculated. Follow up is planned after 1,3 and 12 months. The length of physiotherapy treatment in both groups is variable, depending on individual progression. Differences between groups in outcome parameters will be analysed using the linear mixed modelling and the restricted maximum likelihood ratio technique for estimating the model parameters. DISCUSSION: Successful completion of this trial will provide evidence on the best treatment strategy for patients with a stage two frozen shoulder. The results of this study can lead to a better understanding for the role of manipulation in the treatment of frozen shoulders. TRIAL REGISTRATION: This trial is registered in the Dutch Trial Register under the number NTR6182 on the 20th of February 2017.

How to treat a frozen shoulder? A survey among shoulder specialists in the Netherlands and Belgium.

A frozen shoulder is a common cause of a painful and stiff shoulder. A web-based survey was conducted to obtain insight in the current preferences about the diagnosis and treatment of a frozen shoulder. A response rate of 54% was reached among shoulder specialized orthopaedic surgeons from the Netherlands and Belgium. Non-steroidal anti-inflammatory drugs and intra-articular corticosteroid injections are used frequently in the first phase of the condition. Physiotherapy is assumed to be more important in the final phase. The results of the survey indicate a wide variety of treatment strategies in the different phases of a frozen shoulder. Three out of four respondents considered that the management of a frozen shoulder could benefit from a written guideline. The development of a written guideline should lead to an improved level of consensus and a more standardized approach in the treatment of a frozen shoulder among shoulder specialists in the Netherlands and Belgium.

Low-dose dexamethasone during arthroplasty: What do we know about the risks?

Dexamethasone is commonly applied during arthroplasty to control post-operative nausea and vomiting (PONV). However, conflicting views of orthopaedic surgeons and anaesthesiologists regarding the use of dexamethasone raise questions about risks of impaired wound healing and surgical site infections (SSI).The aim of this systematic review is to determine the level of evidence for the safety of a peri-operative single low dose of dexamethasone in hip and knee arthroplasty.We systematically reviewed literature in PubMed, EMBASE and Cochrane databases and cited references in articles found in the initial search from 1980 to 2013 based on predefined inclusion criteria. The review was completed with a 'pro' and 'con' discussion.After identifying 11 studies out of 104, only eight studies met the inclusion criteria. In total, 1335 patients were studied without any incidence of SSI. Causes of SSI are multifactorial. Therefore, 27 205 patients would be required (power = 90%, alpha = 0.05) to provide substantiated conclusions on safety of a single low dose of dexamethasone.Positively, many studies demonstrated showed convincing effects of low-dose dexamethasone on prevention of PONV and dose-dependent effects on post-operative pain and quality of recovery. Dexamethasone induces hyperglycaemia, but none of the studies demonstrated a concomitant SSI.Conversely, animal studies showed that high dose dexamethasone inhibits wound healing.A team approach of anaesthesiologists and orthopaedic surgeons is mandatory in order to balance the risk-benefit ratio of peri-operatively applied steroids for individual arthroplasty patients.We did not find evidence that a single low dose of dexamethasone contributes to SSI or wound healing impairment from the current studies. Cite this article: Wegener JT, Kraal T, Stevens MF, Hollman MW, Kerkhoffs GMMJ, Haverkamp D. Low-dose dexamethasone during arthroplasty: what do we know about the risks? EFORT Open Rev 2016;1:303-309. DOI: 10.1302/2058-5241.1.000039.