Introduction and Aims: To determine if the surface area of partial thickness (< 50%), Bursal side tears of the cuff influence outcome following Subacromial Decompression.

Method: Shoulder function using Constant score (CS) was recorded before and a minimum of one year after Arthroscopic Subacromial Decompression (ASD) in patients undergoing surgery for primary impingement. In patients who had partial thickness, Bursal side tears (BT), the length of the tear in its largest dimension (surface area) was measured. These patients were divided into two groups according to the tear surface area (≤9 mm and ≥10mm) .To determine whether having a BT (< 50% thickness) or its surface area affect pre- and post-operative CS, t-tests were performed.

Results: 110 patients underwent ASD over a one-year period for primary impingement. Twenty-two patients with partial thickness BT and 18 patients with intact rotator cuff were included in this study. In 10 patients, the BT was ≤9 mm (mean 7 mm) and in 12 patients BT was ≥10mm (mean 13 mm).

Statistical analysis of pre- and post-operative Constant scores showed that, in ≤9 mm group CS increased significantly by 21.5, p=0.02, 95% CI (4.9, 38.1). CS increased in ≥10mm group by 22.8, p< 0.01, 95%(11.5, 34.1). Comparing the change in CS between these two groups with different tears size, there was no significant difference (2-sample t-test, t=0.15, 20df, p=0.88).

To determine whether having BT tear affects pre- and post-operative Constant scores, all BTs were grouped together and compared with the group of patients with intact cuff.

In the group with BTs, average Constant scores increased significantly (paired t-test, t=5.24, 21df, p< 0.01) by 22.2 with 95% CI (13.4, 31.0).

In the group with no tears, average Constant scores increased significantly (paired t-test, t=5.17, 17df, p< 0.01) by 26.6, 95% CI (15.8, 37.5).

Comparing the levels of absolute change in Constant scores from pre- to post-operation between the two groups there is no difference in outcome between patients with a tear and those without a tear (2-sample t-test, t=1.03, 38df, p=0.31).

Conclusion: We conclude that ASD yields satisfactory results in patients with BTs involving < 50% thickness, irrespective of the surface area of the tear.

Purpose: To analyse preliminary outcomes of a new synthetic ligament used for reconstructing coraco-clavicular ligament in acromio-clavicular joint disruption.

Methods: Patients who underwent acromio-clavicular joint stabilisation using Nottingham Surgilig were followed up at average of 40 months (range 6–80 months) post operation. Apart from clinical and radiological assessment, the Constant-Murley scoring system and the Imatani scores were also used to measure outcome.

Results: Twenty patients underwent this operation and data was available on 19 of them. These patients had their operation after an average of 18 months following injury, during which period they had conservative treatment, except in 2 cases where a Weaver Dunn operation was performed initially.

The mean Constant score was 88 (s.d. 12). The mean Imatani score was 86 (s.d. 16). Most patients were satisfied with the operation (90%). There was one case of rupture through the central portion of the Surgilig, and following extensive laboratory analysis, the ligament has been modified since. One patient had a fracture of his coracoid while lifting heavy weights. In 4 patients there was clinical and radiological evidence of loosening of the screw but only 1 complained of this being a problem.

Conclusion: This is an initial medium term outcome analysis of the Nottingham Surgilig. Our results are promising and justify further use and evaluation of this relatively new technique.

Systematic studies are required to examine the effects on outcomes of alternative treatments and surgical techniques in the management of Orthopaedic conditions. Functional outcome scores provide reliable and valid judgments of health status and benefits of the treatment. We undertook a prospective study to assess the functional outcome in patients treated conservatively for proximal humeral fractures.

103 patients treated conservatively for a proximal humeral fracture were followed prospectively. Constant shoulder score and Oxford shoulder score were recorded at 3 months and 12 months follow-up.

A trend towards lesser degrees of improvement in the outcome scores was noted with increasing age. The degree of improvement in the outcome scores was not affected by sex, limb dominance or fracture type (Neer’s classification).

This information gives a guide to average behaviour in different groups of individuals with conservative treatment for proximal humeral fractures. We could then using this data postulate what would constitute a clinically relevant difference and calculate study numbers required while assessing other form of treatments for such fractures

Aim: The prevalence of rotator cuff tears increases with advancing age. Proximal humeral fracture are also common in the elderly, but the influence of a coexistent rotator cuff tear on clinical outcome following fracture has not been previously investigated.

Method: In this study 85 patients treated conservatively for proximal humeral fractures were evaluated with ultrasonography to determine the status of the rotator cuff. Outcome was evaluated using the Constant shoulder score and Oxford shoulder score, and recorded at 3 months and 12 months follow up. The null hypothesis is that there is no correlation between the presence of absence of cuff tear following fracture and clinical outcome.

The data was analysed to determine if the presence of a full thickness rotator cuff tear influenced functional outcome in these patients.

The null hypothesis has not been disproved. There is no statistically significant difference in outcome with presence of an associated full thickness rotator cuff tear with proximal humeral fractures.

Conclusion: At present this study suggests that there is no indication for routine ultrasonography evaluation of the rotator cuff following proximal humerus fracture.

To determine if the surface area of partial thickness (< 50%), Bursal side tears of the cuff influence outcome following Subacromial Decompression.

Shoulder function using Constant score (CS) was recorded before and a minimum of one year after Arthroscopic Subacromial Decompression (ASD) in patients undergoing surgery for primary impingement. In patients who had partial thickness, Bursal side tears (BT), the length of the tear in its largest dimension (surface area) was measured. These patients were divided into two groups according to the tear surface area (≤9 mm and ≥10mm) .To determine whether having a BT (< 50% thickness) or its surface area affect pre and postoperative CS, t-tests were performed.

110 patients underwent ASD over a one-year period for primary impingement. 22 patients with partial thickness BT and18 patients with intact rotator cuff were included in this study. In 10 patients, the BTwas ≤9 mm (mean7mm) and in 12 patients BTwas ≥10mm(mean13mm). Statistical analysis of Pre-& postoperative Constant scores showed that, in ≤9 mm group CS increased significantly by 21.5, p=0.02, 95% CI (4.9, 38.1). CS increased in ≥10mm group by 22.8, p< 0.01, 95%(11.5, 34.1). Comparing the change in CS between these two groups with different tears size, there was no significant difference (2-sample t-test, t=0.15, 20df, p=0.88).

To determine whether having BT tear affects pre- and post-operative Constant scores, all BTs were grouped together and compared with the group of patients with intact cuff.

In the group with BTs, average Constant scores increased significantly (paired t-test,t=5.24,21df,p< 0.01) by 22.2 with 95% CI (13.4, 31.0). In the group with no tears, average Constant scores increased significantly (paired t-test,t=5.17,17df,p< 0.01) by 26.6, 95% CI (15.8, 37.5).

Comparing the levels of absolute change in Constant scores from pre- to post-operation between the two groups there is no difference in outcome between patients with a tear and those without a tear (2-sample t-test, t=1.03, 38df, p=0.31).

We conclude that ASD yields satisfactory results in patients with BTs involving < 50% thickness, irrespective of the surface area of the tear.

Aim: We investigated the accuracy of clinical signs for the diagnosis of rotator cuff disease.

Methods: Fifty patients with history of rotator cuff disease (subacromial impingement syndrome or rotator cuff tear) were examined by two observers to determine the accuracy of clinical tests for the condition. The observers were a consultant (cons.) with an established shoulder practice and a senior registrar (reg.) with an interest in shoulder surgery. The clinical signs evaluated include the painful arc, the drop arm test, Neer’s sign and Hawkins’ sign. For rotator cuff pathology we evaluated the strength of abduction initiation and at 90 degrees abduction for supraspinatus, Speed’s and Yergason’s tests for biceps, strength of shoulder external rotation for infraspinatus and the Gerber lift-off test for subscapularis. We compared our clinical accuracy against a positive subacromial injection test for impingement syndrome, and the findings of rotator cuff tears at arthroscopy.

Results: The consultant and the registrar did not differ significantly in their assessments (paired t-test, p> 0.05). The highly sensitive tests have poor specificity. The most sensitive tests for impingement syndrome were the Hawkins’ sign (cons: 100%, reg: 97%) and the Neer’s sign (cons: 94%, reg: 81%). The Hawkins’ sign also had high negative and positive predictive values. The painful arc and the drop arm tests both had low sensitivity and specificity. Testing the supraspinatus strength at 90 degrees abduction was more sensitive for full thickness cuff tear than testing strength of abduction initiation (cons: 100% vs 67%; reg: 90% vs 50%). These tests were poor at differentiating partial thickness tears from full thickness tears.

Conclusion: The Neer’s and Hawkins’ signs were the most sensitive for impingement syndrome. Testing the supraspinatus at 90 degrees abduction was more sensitive than abduction initiation for full thickness supraspinatus tear.

We aimed to devise a simple and reproducible method of shoulder strength measurement with reference to the Constant and Murley shoulder score.

Fifteen male and 15 female patients were tested. The average age was 32 years. None had previous shoulder pathology. We used a simple spring balance and an electronic load cell to measure force. The system was attached to the floor and connected to the patients arm with an adjustable strap. Strength was measured at 90 degrees of flexion and abduction (in the plane of the scapula), with both dominant and non-dominant limbs. The strap was placed on the upper arm a fixed distance from the tip of the acromion. In addition measurements were taken with the strap attached at the patients wrist. Measurements were repeated after a rest period.

There was no significant difference between strength measured in abduction or flexion or between dominant and non-dominant limbs. The mean measurement for females (13.38kg) is 56 of the male mean (23.92kg). The mean measurement with the strap at the wrist was 47.6 of the mean measurement with the strap on the arm for females and 56.25 for males.

In their original description Constant and Murley use the method described by Moseley to measure shoulder strength. This involved the examiner pulling down on a spring balance held at arms length by the patient. The value assigned to the scale (0.5 kg scores one point to a maximum of 25) is arbitrary. By placing the strap on the upper arm the lever arm is shortened and a higher strength measurement is obtained, the position is standardised by measuring a fixed distance from the tip of the acromion. By adjusting the scoring scale accordingly a greater margin for error and thus greater accuracy and reproducibility can be obtained. In addition there is a large difference in mean strength between males and females that is not taken into account in the Constant and Murley score. A simple multiplier could be used to correct this factor.

We suggest minor modifications to strength measurement for the Constant and Murley score could improve accuracy and reproducibility and correct scoring differences between the sexes.

We investigated the accuracy of clinical signs for the diagnosis of rotator cuff disease. Fifty patients with history suggestive of rotator cuff disease (subacromial impingement syndrome or rotator cuff tear) were examined by two observers to determine the accuracy of commonly used clinical tests for the condition. The observers were a consultant (cons.) with an established shoulder practice and a senior registrar (reg.) with an interest in shoulder surgery. The clinical signs of impingement syndrome we evaluated include the painful arc, the drop arm test, Neer’s sign and Hawkins’ sign. For rotator cuff pathology we evaluated the strength of abduction initiation and at 90 degrees abduction for supraspinatus, Speed’s and Yergason’s tests for biceps, strength of shoulder external rotation for infraspinatus and the Gerber lift-off test for subscapularis. We compared our clinical accuracy against a positive subacromial injection test for impingement syndrome, and the findings of rotator cuff tears at arthroscopy.

The consultant and the registrar did not differ significantly in their assessments (paired t-test, p> 0.05). The highly sensitive tests have poor specificity. The most sensitive tests for impingement syndrome were the Hawkins’ sign (cons:100%, reg: 97%) and the Neer’s sign (cons: 94%, reg: 81%). The Hawkins’ sign also had high negative and positive predictive values. The painful arc and the drop arm tests both had low sensitivity and specificity. Testing the supraspinatus strength at 90 degrees abduction was more sensitive for full thickness cuff tear than testing strength of abduction initiation (cons: 100% vs 67%; reg: 90% vs 50%). These tests were poor at differentiating partial thickness tears from full thickness tears.

Our findings echoed the conclusions of other papers in that the Neer’s and Hawkins’ signs are the most sensitive for impingement syndrome. Testing the supraspinatus at 90 degrees abduction was more sensitive than abduction initiation for full thickness supraspinatus tear.

A pilot study of a physiotherapy led shoulder clinic was initiated in January 1999 as a direct response to increasing orthopaedic consultant out-patient clinic waiting times.

The orthopaedic consultant reviews letters from GP’s to the orthopaedic clinic. Patients with benign musculoskeletal shoulder problems are referred to Shoulder Assessment Clinic (SHAC). The physiotherapist completes a subjective and objective assessment and a shoulder score is recorded using Constant and Murley Shoulder (Constant and Murley 1985). The scoring system has a maximum of 100 points indicating perfect, pain-free movement and function. The Constant and Murley Shoulder score remains most widely used and validated scoring system in Europe for the shoulder.

A total of 130 patients were referred to SHAC between January 1999 and December 1999. Sixty-six patients were treated and discharged by physiotherapy alone with an average increase in shoulder score of 40 points. Twenty-seven had surgery, 19 had steroid injection. Overall waiting time to be seen in SHAC was 58 days. Since this initial pilot, 320 patients have been assessed and treated in the SHAC.

Our experience of physio-led shoulder clinic shows patients can be assessed and treated with a far shortened waiting time, and the improved shoulder scores suggest effective treatment. This allows more patients of an appropriate type to be seen in the outpatient orthopaedic clinic.