Optimising the use of physiotherapy resources after manipulation under anaesthetic for frozen shoulder

INTRODUCTION

Manipulation under anaesthetic (MUA) is a successful treatment for frozen shoulder (FS), and the recovery period and recurrence rates may be reduced by postoperative physiotherapy. This study evaluates two physiotherapy pathways for patients undergoing MUA for FS.

METHODS

Between 2016 and 2018, 248 age- and sex-matched patients presented to either a NHS secondary care upper limb service or the lead author's independent practice with a diagnosis of FS. The patients had differential access to postprocedure physiotherapy based on which service they presented to. In Group 1, physiotherapy advice only was given to the patient. In Group 2, supervised hydrotherapy and physiotherapy occurred postoperatively. Pre- and postprocedure Oxford Shoulder Scores (OSS) were collected for each group. Analysis of covariance (ANCOVA) was used to measure the effect of physiotherapy on postoperative OSS.

RESULTS

Group 2 showed a significantly greater improvement in postprocedure OSS when compared with Group 1 (18.2 vs 16.7) p<0.001). The estimated maximum effect of physiotherapy on postoperative OSS was an increase of 3.2.

CONCLUSION

Following MUA for FS, a statistically significant increase in OSS was detected in patients receiving postprocedure physiotherapy compared with advice alone. There was no difference in recurrence rates. The increase in OSS (3.2) is below the minimal clinically important difference, raising questions regarding the relative importance of postprocedure physiotherapy in a resource-limited environment.

1419 Targeted Use of Physiotherapy Resources in The COVID Era: How Does Face to Face Physiotherapy Compare with Simple Advice Sheets After Manipulation Under Anaesthetic for Frozen Shoulder?

Introduction

This study compares two pathways for patients undergoing MUA for FS, one where physiotherapy advice is only given to the patient (Group 1), and the other where supervised hydrotherapy and physiotherapy occur post operatively (Group 2).

Method

A descriptive analysis of pre- and post-operative Oxford Shoulder Scores and change scores were performed. Analysis of covariance (ANCOVA) was used to measure the effect of physiotherapy on post-operative OSS, with pre-operative OSS as the only covariate.

Results

The results for post-operative OSS were significantly greater for Group 2 than for Group 1 (40.7 for NHS and 44.7 for private, improvement of 17.32 for NHS and 18.23 for Private). The effect of physiotherapy was significant (p &lt; 0.001). The estimated effect of physiotherapy on postoperative OSS was an increase of 3.2 (95% confidence interval 1.5 – 4.8).

Conclusions

We detected a statistically significant increase in post-operative OSS in patients treated for frozen shoulder with MUA + physiotherapy compared with patients receiving MUA plus advice alone. These results suggest that physiotherapy does confer a real benefit, however the increased OSS is below the clinically significant level. Therefore, in a resource poor environment, such as may exist during and after COVID in many health care systems, MUA plus physio advice alone gives an excellent outcome for the treatment of FS.

653 DRAFFT Dodging? Fixation Methods for Distal Radial Fractures Since 2014 In A UK Trauma Unit

Introduction

The 2014 randomised, controlled Distal Radius Acute Fracture Fixation Trial (DRAFFT) compared K-wires to internal fixation for management of dorsally displaced distal radius fractures. The authors found no clinical difference between the two fixation methods, concluding ‘The results of this trial will reverse the trend towards locking-plate fixation for this injury’. Our study aimed to measure local change in practice since 2014.

Method

From the DRAFFT CONSORT diagram, we calculated just 10.7% of eligible cases required locking plate fixation. 300 patients, 50 per year from 2014-19 meeting DRAFFT eligibility criteria undergoing fixation, were randomly selected from an electronic trauma database. Radiographs were reviewed to see whether patients received internal fixation or K-wires.

Results

Age and sex distributions of the study sample were not significantly different to the DRAFFT population (p &lt; 0.05). Over 60% of recruited patients received internal fixation each year. No increasing trend in use of K-wires was detected (p = 0.27). No trend was observed in either fixation method adjusting for intra versus extra-articular fractures (p = 0.36).

Conclusions

Local practice remains unchanged in fixation of dorsally displaced distal radius fractures since 2014. Internal fixation remains the most prevalent surgery, and there has been no detectable increase in use of K-wires.

18 Manipulation Under Anaesthetic for Frozen Shoulder: Does Post-Operative Supervised Physiotherapy Affect the Outcome?

Introduction

This study compares two pathways for patients undergoing MUA for FS, one where physiotherapy advice is only given to the patient (Group 1), and the other where supervised hydrotherapy and physiotherapy occur post operatively (Group 2).

Method

A descriptive analysis of pre- and post-operative Oxford Shoulder Scores and change scores were performed.

Analysis of covariance (ANCOVA) was used to measure the effect of physiotherapy on post-operative OSS, with pre-operative OSS as the only covariate.

Results

The results for post-operative OSS were significantly greater for Group 2 than for Group 1 (40.7 for NHS and 44.7 for private, improvement of 17.32 for NHS and 18.23 for Private). The estimated effect of physiotherapy on postoperative OSS was an increase of 3.2 (95% confidence interval 1.5 – 4.8).

Conclusions

We detected a statistically significant increase in post-operative OSS in patients treated for frozen shoulder with MUA + physiotherapy compared with patients receiving MUA plus advice alone. These results suggest that physiotherapy does confer a real benefit, however the increased OSS is below the clinically significant level. Therefore, in a resource poor environment, such as may exist after COVID in many health care systems, MUA plus physio advice alone gives an excellent outcome for the treatment of FS.

Impact of the 2020 COVID-19 pandemic on the workload of the orthopaedic service in a busy UK district general hospital

INTRODUCTION

The COVID -19 outbreak has had a profound effect on the management of healthcare service provision in the UK. Orthopaedic departments have been no exception to this and have needed to adapt to the changing circumstances by releasing resources and focusing on 'essential' activity. The aim of this study is to quantify the reduction in trauma and, in addition, describe any changes in the type of referrals to the trust which may have been affected by the pandemic itself and the social distancing measures employed by the UK government.

METHODS

The study was performed in a UK District Hospital which is also a Trauma Unit providing trauma and orthopaedic care to a population of 625,000 people. The trust based electronic database of trauma referrals was used to compare the numbers of, and types of referral to our trauma service during the COVID-19 pandemic and the corresponding time periods in the previous 3 years.

RESULTS

The mean number of referrals per week to the service reduced by 33% in the time period following the confirmation of the outbreak as a pandemic (p<0.0001). Number of operations performed per week reduced by 26% (p = 0.001). There was no change in the number of referrals relating to domestic abuse or non-accidental injury. In addition, numbers of hip fractures, periprosthetic fractures and prosthetic joint dislocations were unchanged. There was a significant reduction in the number of referrals for simple fractures, native joint dislocations, wounds and soft tissue injuries. Within the paediatric population, similarly, a reduction in simple fracture referrals was demonstrated.

DISCUSSION

An association between the outbreak of the pandemic and a reduction in referral numbers to our department has been demonstrated. The direct cause of this may be multifactorial but proposing that it is, in part, due to the social distancing measures introduced by the government is certainly conceivable. The patterns of injury would reflect this also with low energy and fragility trauma persisting whilst injuries associated with younger people have reduced. We would suggest that information such as this could be useful in healthcare planning and resource allocation in future pandemic situations.