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Background Four-part fractures of the proximal humerus account for 3% of all humeral fractures and are regarded as the most difficult fractures to treat in the elderly. Various authors recommend nonoperative treatment or hemiarthroplasty, but the literature is unclear regarding which provides better quality of life and function. Questions/purposes We therefore performed a randomized controlled trial to compare (1) function, (2) strength, and (3) pain and disability in patients 65 years and older with four-part humeral fractures treated either nonoperatively or with hemiarthroplasty. Methods We randomly allocated 50 patients to one of the two approaches. There were no differences in patient demographics between the two groups. The Constant-Murley score was the primary outcome measure. Secondary outcome measures were the Simple Shoulder Test, abduction strength test as measured by a myometer, and VAS scores for pain and disability. All patients were assessed at 12 months. Results We found no between-group differences in Constant-Murley and Simple Shoulder Test scores at 3- and 12-months followup. Abduction strength was better at 3 and 12 months in the nonoperatively treated group although the nonoperatively treated patients experienced more pain at 3 months; this difference could not be detected after 12 months. Conclusions We observed no clear benefits in treating patients 65 years or older with four-part fractures of the proximal humerus with either hemiarthroplasty or nonoperative treatment. Level of Evidence Level I, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.

BackgroundLabral repair and biceps tenodesis are routine operations for superior labrum anterior posterior (SLAP) lesion of the shoulder, but evidence of their efficacy is lacking. We evaluated the effect of labral repair, biceps tenodesis and sham surgery on SLAP lesions.MethodsA double-blind, sham-controlled trial was conducted with 118 surgical candidates (mean age 40 years), with patient history, clinical symptoms and MRI arthrography indicating an isolated type II SLAP lesion. Patients were randomly assigned to either labral repair (n=40), biceps tenodesis (n=39) or sham surgery (n=39) if arthroscopy revealed an isolated SLAP II lesion. Primary outcomes at 6 and 24 months were clinical Rowe score ranging from 0 to 100 (best possible) and Western Ontario Shoulder Instability Index (WOSI) ranging from 0 (best possible) to 2100. Secondary outcomes were Oxford Instability Shoulder Score, change in main symptoms, EuroQol (EQ-5D and EQ-VAS), patient satisfaction and complications.ResultsThere were no significant between-group differences at any follow-up in any outcome. Between-group differences in Rowe scores at 2 years were: biceps tenodesis versus labral repair: 1.0 (95% CI −5.4 to 7.4), p=0.76; biceps tenodesis versus sham surgery: 1.6 (95% CI −5.0 to 8.1), p=0.64; and labral repair versus sham surgery: 0.6 (95% CI −5.9 to 7.0), p=0.86. Similar results—no differences between groups—were found for WOSI scores. Postoperative stiffness occurred in five patients after labral repair and in four patients after tenodesis.ConclusionNeither labral repair nor biceps tenodesis had any significant clinical benefit over sham surgery for patients with SLAP II lesions in the population studied.Trial registration numberClinicalTrials.gov identifier: NCT00586742

Background Although patients with shoulder complaints are frequently referred to physiotherapy, putative predictive factors for outcomes are still unclear. In this regard, only a limited amount of scientific data for patients with subacromial pain syndrome exist, with inconsistent results. An improved knowledge about the ability of baseline variables to predict outcomes could help patients make informed treatment decisions, prevent them from receiving ineffective treatments, and minimize the risk of developing chronic pain. Aim The aims of this secondary longitudinal analysis are threefold: First, to investigate baseline differences between patients with and without successful long-term outcomes following physiotherapy. Second, to compare the predictive ability of two sets of putative predictive variables on outcomes, one based on the literature and one based on the data of the original trial. Third, to explore the contribution of short-term follow-up data to predictive models. Methods Differences between responders and nonresponders were calculated. The predictive ability of variables defined through literature and of variables based on the Akaike Information Criterion (AIC) from the original trial dataset on the Shoulder Pain and Disability Index and the Patients’ Global Impression of Change at the one-year follow-up were analyzed. To test the robustness of the results, different statistical models were used. To investigate the contribution of follow-up data to prediction, short-term data were included in the analyses. Results A sample of 87 patients with subacromial pain syndrome was analyzed. 77% ( n  = 67) of these participants were classified as responders. Higher expectations and short-term change scores were positive, and higher fear avoidance beliefs, greater baseline disability and pain levels were negative predictors of long-term outcomes in patients with subacromial pain syndrome. Conclusions Although our results are in line with previous research and support the use of clinical factors for prediction, our findings suggest that psychological factors, especially patient expectations and fear avoidance beliefs, also contribute to long-term outcomes and should therefore be considered in the clinical context and further research. However, the hypotheses and recommendations generated from our results need to be confirmed in further studies due to their explorative nature. Trial registration The original trial was registered at Current Controlled Trials under the trial registration number ISRCTN86900354 on March 17, 2010.

Background Proximal humeral fractures are common in older patients. The majority are minimally displaced and are associated with good outcomes after nonoperative treatment. Poorer outcomes are associated with displaced, multipart fractures. There is no clear benefit from surgical fracture fixation compared to nonoperative treatment. Replacement of the fractured humeral head with a hemiarthroplasty is another treatment option, but has not been shown to be clearly superior to nonoperative treatment or internal fixation. Recently, reverse total shoulder arthroplasty has been used to treat these fractures, particularly in the older population with several case series demonstrating good outcomes. No comparative trial has been performed to test the effectiveness of reverse total shoulder arthroplasty against nonoperative treatment. Methods/design ReShAPE (Reverse Shoulder Arthroplasty for the treatment of Proximal humeral fractures in the Elderly) is a multicenter combined randomized and observational study. The primary objective is to compare pain and function 12 months post fracture using the American Shoulder and Elbow Society (ASES) score in patients aged 70 years or older with three- and four-part proximal humeral fractures treated by either reverse shoulder arthroplasty or nonoperative treatment. Secondary outcome measures will include the DASH (Disability of the Arm, Shoulder and Hand) score, the EQ-5D (EuroQol Health Survey), the EQ-VAS, pain, radiological parameters and complications. Discussion The study will assess the effectiveness of reverse shoulder arthroplasty for complex proximal humeral fractures and thereby guide treatment of a common injury in the older population. Trial registration World Health Organization Universal Trial Number (WHO UTN): U1111-1180-5452 . Registered on 10 March 2016. Australian and New Zealand Clinical Trials Registry (ANZCTR): 12616000345482 . Registered on 16 March 2016.

Co-published with the Arthroscopy Association of North America, The Shoulder: AANA Advanced Arthroscopic Surgical Techniques is a comprehensive technique-based book that presents the latest diagnostic and reconstructive techniques in arthroscopic surgery for the shoulder.The Shoulder: AANA Advanced Arthroscopic Surgical Techniques is authored by premier arthroscopic surgeons Drs. Richard K.N. Ryu, Richard L. Angelo, and Jeffrey S. Abrams, and their international list of expert contributors. This comprehensive resource includes preferred physical examination testing and diagnostic imaging choices in pre-operative planning and patient selection, state-of-the-art step-by-step description of the procedures, detailed surgical equipment lists to perform each procedure, clear and precise indications for surgery and the thoughtful rationale behind stated contraindications, controversial indications, post-operative protocols, and potential complications.The written text is supported by numerous color images and a website with invaluable, narrated video clips depicting disease-specific arthroscopic techniques specific to the shoulder.Features inside The Shoulder: AANA Advanced Arthroscopic Surgical Techniques Narrated video accompanies all surgical techniques, focusing on the stepwise approach to each operation Consistent organization throughout the book results in a bulleted and user-friendly interface for a quick reference or prolonged study Top 5 Technical Pearls for each procedure to enhance outcomes and to avoid common pitfalls and complications High-quality artwork and figures to complement clinical images Equipment and surgical technique checklists for quick reference prior to surgery Each expert contributor was chosen for his or her expertise for a specific topic related to The Shoulder, so the reader benefits by the highest quality and treatment recommendations to provide state-of-the-art care to his or her patient.Some chapter topics include: Arthroscopic Latarjet Stabilization Arthroscopic A-cromioclavicular Joint Reconstruction Arthroscopic Subscapularis Repair: The Extra-Articular Technique Arthroscopic Suprascapular Nerve Release Arthroscopic Suprapectoral Biceps Tenodesis

To compare the effects of High-Intensity Laser Therapy (HILT) versus Low-Level Laser Therapy (LLLT) on shoulder pain and disability, shoulder Range of Motion (ROM), Pain Pressure Threshold (PPT), and sleep quality of patients having Subacromial Impingement Syndrome (SAIS). Forty-two patients with SAIS were randomly assigned into three groups, the HILT group ( n  = 14), the LLLT group ( n  = 14), and control group ( n  = 14). All groups received an exercise program consisted of shoulder muscles stretching and strengthening exercises. Along with the exercise program, the HILT group received HILT at 810 nm /980 nm, and LLLT group received LLLT at 904 nm, three times weekly for three weeks. The primary outcome was the change in shoulder pain and disability measured by Shoulder Pain and Disability Index (SPADI). Secondary outcomes included shoulder ROM using a standard goniometer, PPT measured by pressure algometer, and sleep quality by Pittsburgh Sleep Quality Index (PSQI). Measurements were taken both before and after a 3-week intervention to assess the outcomes. After 3-wk intervention, both the HILT and LLLT groups exhibited significant improvements in all parameters when compared to the control group ( p  < 0.05). Additionally, there were clinically significant differences between groups supported by a large ES favoring the HILT group for SPADI pain (ηp 2  = 0.71), SPADI disability (ηp 2  = 0.54), SPADI total (ηp 2  = 0.82), PPT (ηp 2  = 0.63), and PSQI (ηp 2  = 0.42). The combination of HILT with exercises proved to be more beneficial in enhancing pain and function, PPT, and sleep quality compared to LLLT combined with exercises in treating patients with SAIS.

Background Instability after shoulder arthroplasty remains a complication with limited salvage options. Reoperation for instability with anatomic designs has led to high rates of persistent instability, therefore we aimed to evaluate the use of RSA for treatment of prosthetic instability. Questions/purposes (1) After revision shoulder arthroplasty to a reverse prosthesis (RSA), what is the survivorship free from dislocations at 2 and 5 years? (2) What factors are associated with dislocations? (3) What is the survivorship free from revision after revision to RSA? (4) From preoperation to postrevision to RSA, what are the clinical outcomes—the proportion of patients with moderate to severe pain, shoulder elevation and external rotation ROM, American Shoulder and Elbow Surgeons scores, and Simple Shoulder Test scores? Methods All shoulder arthroplasties revised for prosthetic instability using RSA components between January 2004 and July 2014 were retrospectively studied. During the period in question, we performed 82 revisions for instability of an anatomic total shoulder arthroplasty (TSA) (n = 62), hemiarthroplasty (n = 13), or reverse TSA (n = 7). We typically used a reverse TSA to treat this problem, but we identified 12 treated in other ways, including revision of a TSA to hemiarthroplasty (n = 3), revision of a reverse TSA to hemiarthroplasty (n = 2), revision of hemiarthroplasty to a hemiarthroplasty (n = 1), and revision of an anatomic TSA to another anatomic TSA (n = 6). This left 70 patients for evaluation; of those, 65 (93%) were available for analysis at a mean of 3 years (range, 2–10 years). A total of seven patients died. Eight of the 65 shoulders were not evaluated during the last 5 years, including three in patients who died earlier. The mean age of the patients at the time of revision RSA was 65 years (range, 40–89 years). Data were obtained from a longitudinally maintained institutional joint registry. Instability was defined as severe subluxation confirmed on clinical and radiographic examinations. We evaluated pain and ROM, and Kaplan-Meier curves were used to estimate survivorship. Results The survivorship free from dislocation at 2 and 5 years was 87% (95% CI, 80%–94%) and 79% (95% CI, 67%–91%) respectively, with 10 of 65 (15%) patients having an episode of dislocation after revision surgery. Persistent instability was more common in those with a BMI greater than 35 kg/m 2 (hazard ratio [HR], 5; 95% CI, 2–16; p = 0.008) and prior hemiarthroplasty (HR, 5; 95% CI, 2–16; p = 0.005), whereas patients who had undergone a previous TSA were less likely to have persistent instability (HR, 0.08; 95% CI, 0.0–0.30; p < 0.001) The survival free from rerevision for any indication at 2 and 5 years was 85% (95% CI, 76%–94%) and 78% (95% CI, 66%–90%) respectively; with the numbers available, we were not able to find associated factors. Fewer patients had moderate or severe pain after revision to RSA (preoperative: 48 of 65 [74%]; postoperative: nine of 65 [14%]; p < 0.001). After surgery, patients showed improvement in shoulder elevation (preoperative: 42° [± 30°], postoperative: 112° [42°]; mean difference, 70° [95% CI, − 83 o to 57°]; p < 0.001) and external rotation (preoperative: 20° [± 22°], postoperative: 42° [± 23°]; mean difference, 22° [95% CI, − 30° to − 14°]; p < 0.001). American Shoulder and Elbow Surgeons scores improved (preoperative: 21 [± 10], postoperative: 68 [± 14], mean difference, 46 [95% CI, − 58 to − 35]; p < 0.001); where a higher score is better. Simple Shoulder Test scores also improved (preoperative: 2/12 [± 2], postoperative: 7/12 [± 3]; mean difference, 5 [95% CI, − 7 to − 2.17]; p < 0.001); where a higher score is better. Conclusions Revision RSA for prosthetic instability after shoulder arthroplasty is associated with reasonable implant survival and few complications. Approximately one in seven patients will have a recurrent dislocation. In patients with persistent instability or with risk factors for instability, consideration should be given for use of larger glenospheres and increasing the lateral offset at the time of RSA. Level of Evidence Level IV, therapeutic study.

Background Rotator cuff tear is a common cause of shoulder disability and results in patients predominantly complaining of pain and loss of motion and strength. Traumatic rotator cuff tears are typically managed surgically followed by ~ 20 weeks of rehabilitation. However, the timing and intensity of the postoperative rehabilitation strategy required to reach an optimal clinical outcome is unknown. Early controlled and gradually increased tendon loading has been suggested to positively influence tendon healing and recovery. The aim of this trial is therefore to examine the effect of a progressive rehabilitation strategy on pain, physical function and quality of life compared to usual care (that limits tendon loading in the early postoperative phase) in patients who have a rotator cuff repair of a traumatic tear. Methods The current study is a randomized, controlled, outcome-assessor blinded, multicenter, superiority trial with a two-group paralleled design. A total of 100 patients with surgically repaired traumatic rotator cuff tears will be recruited from up to three orthopedic departments in Denmark, and randomized to either a progressive early passive and active movement program or a limited early passive movement program (usual care). The primary outcome measure will be the change from pre-surgery to 12 weeks post-surgery in the Western Ontario Rotator Cuff Index questionnaire. Secondary outcomes include the Disabilities Arm, Shoulder and Hand questionnaire (DASH), range of motion, strength and tendon healing characteristics from ultrasound measurements at 12 months follow up. Discussion We hypothesized that patients who receive the progressive rehabilitation strategy will benefit more with respect to pain reduction, physical function and quality of life than those who receive care as usual. If this is confirmed our study can be used clinically to enhance the recovery of patients with traumatic rotator cuff tear. Trial registration ClinicalTrials.gov, NCT02969135 . Registered on 15 November 2016.