A systematic review and pooled analysis of the prevalence of rotator cuff disease with increasing age

Hypothesis and background: Abnormalities of the rotator cuff are more common with age, but the exact prevalence of abnormalities and the extent to which the presence of an abnormality is associated with symptoms are topics of debate. Our aim was to review the published literature to establish the prevalence of abnormalities of the rotator cuff and to determine if the prevalence of abnormalities increases with older age in 10-year intervals. In addition, we assessed prevalence in 4 separate groups: (1) asymptomatic patients, (2) general population, (3) symptomatic patients, and (4) patients after shoulder dislocation.

METHODS

We searched PubMed, EMBASE, and the Cochrane Library up to February 24, 2014, and included studies reporting rotator cuff abnormalities by age. Thirty studies including 6112 shoulders met our criteria. We pooled the individual patient data and calculated proportions of patients with and without abnormalities per decade (range, younger than 20 years to 80 years and older).

RESULTS

Overall prevalence of abnormalities increased with age, from 9.7% (29 of 299) in patients aged 20 years and younger to 62% (166 of 268) in patients aged 80 years and older (P < .001) (odds ratio, 15; 95% confidence interval, 9.6-24; P < .001). There was a similar increasing prevalence of abnormalities regardless of symptoms or shoulder dislocation.

DISCUSSION AND CONCLUSION

The prevalence of rotator cuff abnormalities in asymptomatic people is high enough for degeneration of the rotator cuff to be considered a common aspect of normal human aging and to make it difficult to determine when an abnormality is new (e.g., after a dislocation) or is the cause of symptoms.

The incidence and characteristics of shoulder instability at the United States Military Academy

BACKGROUND

The literature provides little information detailing the incidence of traumatic shoulder instability in young, healthy athletes.

HYPOTHESIS

Shoulder instability is common in young athletes.

STUDY DESIGN

Descriptive epidemiologic study.

METHODS

We prospectively captured all traumatic shoulder instability events at the United States Military Academy between September 1, 2004, and May 31, 2005. Throughout this period, all new traumatic shoulder instability events were evaluated with physical examination, plain radiographs, and magnetic resonance imaging. Instability events were classified according to direction, chronicity, and type (subluxation or dislocation). Subject demographics, mechanism of injury, and sport were evaluated.

RESULTS

Among 4141 students, 117 experienced new traumatic shoulder instability events during the study period; 11 experienced multiple events. The mean age of these 117 subjects was 20.0 years; 101 students were men (86.3%), and 16 were women (13.7%). The 1-year incidence proportion was 2.8%. The male incidence proportion was 2.9% and the female incidence proportion was 2.5%. Eighteen events were dislocations (15.4%), and 99 were subluxations (84.6%). Of the 99 subluxations, 45 (45.5%) were primary events, while 54 (54.5%) were recurrent. Of the 18 dislocations, 12 (66.7%) were primary events, while 6 (33.3%) were recurrent. The majority of the 117 events were anterior in nature (80.3%), while 12 (10.3%) were posterior, and 11 (9.4%) were multidirectional. Forty-four percent (43.6%) of the instability events experienced were as a result of contact injuries, while 41.0% were a result of noncontact injuries, including 9 subluxations caused by missed punches during boxing; information was unavailable for the remaining 15%.

CONCLUSION

Glenohumeral instability is a common injury in this population, with subluxations comprising 85% of instability events.

The epidemiology of shoulder dislocations

In an urban population of a quarter of a million, all shoulder dislocations that occurred in a 5-year period were recorded. A total of 216 shoulder dislocations were seen, 53.3% in men. The overall incidence rate was 17/100,000 per year. Incidence peaks were found in the age-group 21-30 years among men and in the age-group 61-80 years among women. Significantly more patients in the older age groups, and especially women, dislocated at home by falling on an outstretched arm, whereas the younger age-groups most frequently dislocated outside the home, e.g., on sports fields. A considerable number of patients (18.6%) were hospitalized, and 85.5% of the patients required outpatient follow-up. Prophylactic measures should be taken especially to increase the safety of the elderly in their homes.

Incidence and causes of shoulder girdle injuries in an urban population

In a prospective population-based study of all shoulder injuries seen at Malmö General Hospital during 1987, the incidence and causes of major injuries involving fractures of the clavicle, scapula, or proximal humerus and glenohumeral or acromioclavicular dislocations were investigated in children, adults, and the elderly. Seventy-five shoulder injuries occurred in children. Sixty-five of them were fractures of the clavicle. In this age group no sex-related differences were seen in incidence, and 37 of 73 injuries were related to sports or playing. One hundred eighty-one injuries occurred in adults. Sixty fractures of the proximal humerus, 67 fractures of the clavicle, and 31 primary glenohumeral dislocations were seen. The injuries in this group were significantly more frequent in men, with most of them caused by traffic and sport injuries. Two hundred forty-eight injuries occurred in elderly people. Two hundred one were fractures of the proximal humerus. The incidence was significantly higher in women; 147 of 247 injuries were caused by an indoor fall. The variations among age groups are probably attributable to age-related differences in activity, mobility, and fragility.

Evolution of lesions of the labrum-ligament complex in posttraumatic anterior shoulder instability: a prospective study

The aim of this study was to evaluate the evolution of intraarticular disease in posttraumatic shoulder instability. Ninety-one patients with posttraumatic shoulder instability were examined arthroscopically. The intraarticular disease was recorded on a special documentation sheet (containing 67 descriptive items). The patients were divided into 5 subgroups: first-time dislocation (n = 9); first or second recurrence (n = 12); 3 to 5 recurrences (n = 23); 6 or more recurrences (n = 32); and chronic subluxations (n = 15). All data were examined statistically. Each lesion was correlated with stage of evolution, age, and number of recurrences. The most frequent lesions were regrouped into "lesion families." The initial and most constant lesion was the periosteal disinsertion of the anteroinferior labrum (single lesion). The labral detachment was succeeded in a second stage by the disinsertion of the glenohumeral ligament complex (double lesion). With additional recurrences, stress mechanisms altered the detached structures through tissue damage (triple lesion). The fourth stage saw the extension of the degenerative process, which led to failure at the insertion site and destruction of the labrum-ligament complex (quadruple lesion). This study reveals that recurrences progressively damage stabilizing structures. A pathophysiological classification into 4 stages is proposed, however, that would permit a precise therapeutic strategy for arthroscopic shoulder stabilization.

Predicting recurrence after primary anterior shoulder dislocation

We evaluated the factors influencing the recurrence rate after primary anterior traumatic shoulder dislocation, especially sports activity. A significant number of patients changed to athletic activities that produce less shoulder strain. The natural assumption would be that sports activity directly influences recurrence. However, age-adjusted logistic regression analysis revealed that the correlation between sports and recurrence rate was false. Our statistical findings also clearly showed that physical therapy and immobilization do not reduce the risk of recurrence. The only factor associated with recurrence was age between 21 and 30 years. Patients in this age group who participate in high-risk sports activities should undergo primary surgical stabilization because of the increased risk of recurrence.

Complication rates, dislocation, pain, and postoperative range of motion after reverse shoulder arthroplasty in patients with and without repair of the subscapularis

BACKGROUND

Despite improved results with reverse shoulder arthroplasty (RSA), questions still remain regarding certain technical aspects of the operation. One particular area of question is the effect of subscapularis repair on complication rates, dislocation, pain, and overall range of motion. Some authors suggest that when a deltopectoral approach is used, not repairing the subscapularis leads to a higher complication rate, especially for dislocation.

MATERIALS AND METHODS

From a reverse total shoulder arthroplasty database of 3 surgeons at 1 institution, we identified 55 patients who underwent RSA using the deltopectoral approach without subscapularis repair and 65 patients with subscapularis repair.

RESULTS

Complications were documented in 11 of 55 shoulders (20%) without subscapularis repair and in 13 of 65 shoulders (20%) with subscapularis repair. Dislocation occurred in 3 shoulders in the nonrepair group and in 2 shoulders in the repair group. These data indicate that nonrepair of the subscapularis did not have a significant effect on the risk of any complication, dislocation, infection, disassociation, or function.

CONCLUSION

Repairing the subscapularis has no appreciable effect on complication rate, dislocation events, or range of motion gains and pain relief.

First-time shoulder dislocation: High prevalence of labral injury and age-related differences revealed by MR arthrography

PURPOSE

To evaluate abnormalities and age-related differences after first-time shoulder dislocation.

MATERIALS AND METHODS

MRA images of first-time dislocators were assessed for labral-ligamentous-capsular / rotator cuff abnormalities and analyzed the age-related differences (< and >/=30 years old).

RESULTS

Sixty-six patients (34 <30 years old vs. 32 >/=30 years; 51 males; all anterior dislocations) were imaged. Forty-eight patients (73%) showed anteroinferior labral avulsion, consisting of: 6% (4/34 vs. 0/32) Perthes; 23% (8/34 vs. 7/32) free ALPSA (anterior labrum periosteal sleeve avulsion) lesion); 6% (1/34 vs. 3/32) adherent ALPSA; 23% (9/34 vs. 6/32) Bankart; 14% (5/34 vs. 4/32) inferiorly displaced avulsed labrum; 2% (1/34 vs. 0/32) GLAD. Extensive labral detachment (extended above 3 o'clock position) was present in 31% (11/28 vs. 4/20). There were 14% (6/34 vs. 3/32) superior labrum anterior-posterior (SLAP) lesion; 27% (1/34 vs. 17/34) rotator cuff tendon tear; 71% (25/34 vs. 22/32) Hill-Sachs defect. Young patients were more likely to have extensive labral avulsions (P = 0.054), but less likely to have rotator cuff tears (P < 0.001).

CONCLUSION

A high prevalence and wide variety of labral avulsions after first-time shoulder dislocation, especially adherent ALPSA, inferiorly displaced avulsed labrum, or GLAD lesion, may influence treatment choice and outcome, suggesting a role for early MRA to assist in treatment triage.

Posterior shoulder dislocation in infants with neonatal brachial plexus palsy

BACKGROUND

Glenoid dysplasia and posterior shoulder subluxation with resultant shoulder stiffness is a well-recognized complication in infants with neonatal brachial plexus palsy. It is generally considered to be the result of a slowly progressive glenohumeral deformation secondary to muscle imbalance, physeal trauma, or both. Recent publications about infantile posterior shoulder dislocation have suggested that the onset of dysplasia occurs at an earlier age than has been previously recognized. The prevalence of early dislocation in infants with this disorder has not been previously reported, to our knowledge.

METHODS

We studied 134 consecutive infants with neonatal brachial plexus palsy who were seen at our institution over a period of two years. All infants were examined at monthly intervals to assess neurological recovery and the status of the upper extremity until recovery occurred or a treatment plan was established. The type of brachial plexus involvement was classified. Specific clinical signs associated with subluxation and dislocation were recorded. These included asymmetry of skin folds of the axilla or the proximal aspect of the arm, apparent shortening of the humeral segment, a palpable asymmetric fullness in the posterior region of the shoulder, or a palpable click during shoulder manipulation. The infants who were identified as having these clinical signs were evaluated with ultrasonographic imaging studies.

RESULTS

Eleven (8%) of the 134 infants had a posterior shoulder dislocation. The mean age at the time of diagnosis was six months (range, three to ten months). There was no correlation between the occurrence of dislocation and the type of initial neurological deficit. A rapid loss of passive external rotation between monthly examinations indicated a posterior shoulder dislocation.

CONCLUSIONS

Posterior shoulder dislocation can occur earlier (before the age of one year) and more rapidly in infants with neonatal brachial plexus palsy than has been appreciated previously. As with developmental dysplasia of the hip, a high index of suspicion, recognition of clinical signs, and the use of ultrasonography will allow the diagnosis to be established. Following early diagnosis, attention should be focused on improving the stability and congruency of the shoulder joint.

Shoulder dislocation in Swedish ice hockey players

1. Humeroscapular dislocation, primary or recurrent, is found in 8% of elite ice hockey players in Sweden. 2. The dislocation recurs in 90% of greater than 20-year-old players and the frequency diminishes with increasing age. 3. The duration of immobilization after the first dislocation bears no sure relation to the risk of recurrence. 4. In 80% of the cases, the operated shoulder was the one that predominates in ice hockey, usually the left. Of the 32 operated players, 30 have been able to continue with ice hockey and relatively marked postoperative loss of mobility has been tolerated well. 5. Even without an operation, a recurrent shoulder dislocation did not prevent one-third of the players from continuing with ice hockey.

Prognosis of primary anterior shoulder dislocation in young adults

From 1982 to 1987, 194 patients with 196 primary traumatic anterior shoulder dislocations were treated in our hospital. One hundred and sixty-six patients with 168 shoulder dislocations (87%) were available for study at follow-up an average of 4 years after treatment. The most important prognostic factor in relation to recurrence was the age of the patient at the time of the primary dislocation. The highest recurrence rate was found in patients of 30 years and younger (64%). Athletes in this age group had no worse a prognosis as to recurrence than non-athletes. A fracture of the greater tuberosity improved the prognosis significantly (P less than 0.01). Neither the presence of a Hill-Sachs lesion nor the period of immobilization influenced the recurrence rate in patients aged 30 years and younger.

Arthroscopic transglenoid multiple suture repair: 2 to 8 year results in 150 shoulders

One hundred fifty-six arthroscopic transglenoid multiple suture repairs were performed for chronic anterior shoulder instability. In 150 shoulders (96% follow-up), the outcome with respect to recurrence of instability and the Bankart Score was determined a minimum of 2 years and a mean of 4.1 years after surgery (range, 2 to 8.2 years). During the follow-up interval, 11 shoulders (7.3%) redislocated. Fourteen other shoulders (9.3%) had at least one episode that we interpreted as recurrent subluxation. Shoulders with a Bankart lesion and younger patients had a higher probability of recurrent instability (P < .05). We concluded that this method is most effective in shoulders without a Bankart lesion and in patients older than 25 years of age (regardless of pathology).

Imaging methods for quantifying glenoid and Hill-Sachs bone loss in traumatic instability of the shoulder: a scoping review

BACKGROUND

Glenohumeral instability is a common problem following traumatic anterior shoulder dislocation. Two major risk factors of recurrent instability are glenoid and Hill-Sachs bone loss. Higher failure rates of arthroscopic Bankart repairs are associated with larger degrees of bone loss; therefore it is important to accurately and reliably quantify glenohumeral bone loss pre-operatively. This may be done with radiography, CT, or MRI; however no gold standard modality or method has been determined. A scoping review of the literature was performed to identify imaging methods for quantifying glenohumeral bone loss.

METHODS

The scoping review was systematic in approach using a comprehensive search strategy and standardized study selection and evaluation. MEDLINE, EMBASE, Scopus, and Web of Science were searched. Initial selection included articles from January 2000 until July 2013, and was based on the review of titles and abstracts. Articles were carried forward if either reviewer thought that the study was appropriate. Final study selection was based on full text review based on pre-specified criteria. Consensus was reached for final article inclusion through discussion amongst the investigators. One reviewer extracted data while a second reviewer independently assessed data extraction for discrepancies.

RESULTS

Forty-one studies evaluating glenoid and/or Hill-Sachs bone loss were included: 32 studies evaluated glenoid bone loss while 11 studies evaluated humeral head bone loss. Radiography was useful as a screening tool but not to quantify glenoid bone loss. CT was most accurate but necessitates radiation exposure. The Pico Method and Glenoid Index method were the most accurate and reliable methods for quantifying glenoid bone loss, particularly when using three-dimensional CT (3DCT). Radiography and CT have been used to quantify Hill-Sachs bone loss, but have not been studied as extensively as glenoid bone loss.

CONCLUSIONS

Radiography can be used for screening patients for significant glenoid bone loss. CT imaging, using the Glenoid Index or Pico Method, has good evidence for accurate quantification of glenoid bone loss. There is limited evidence to guide imaging of Hill-Sachs bone loss. As a consensus has not been reached, further study will help to clarify the best imaging modality and method for quantifying glenohumeral bone loss.

Glenohumeral subluxation in hemiplegia: An overview

This review summarizes the recent advances in glenohumeral subluxation (GHS) in hemiplegic patients and analyzes the reliability and validity of clinical evaluation and the effectiveness of different treatment approaches. GHS, a common complication of stroke, can be considered an important risk factor for shoulder pain and other problems. GHS is a complex phenomenon, and its pathomechanics are not yet fully understood. Radiographic measurements are considered the best method of quantifying GHS. Clinical evaluation can be useful as screening assessment. Functional electrical stimulation and strapping are effective in an acute stage of hemiplegia; some types of slings have been shown to be effective and may be used together with other strategies.

Alpine ski injuries and their prevention

Alpine skiing is a popular sport with significant risk of injury. Since the 1970s, injury rates have dropped from approximately 5 to 8 per 1000 skier-days to about 2 to 3 per 1000 skier-days. The nature of the injuries has also been transformed over the same period. Lower leg injuries are becoming less common while the incidence of knee sprains and upper extremity injuries is becoming more common. Much of this change can be attributed to advancements in binding technology, which effectively reduces lower leg injury, but does not adequately address the issue of knee sprains. Along with design, binding adjustment and maintenance are important preventative factors. Poorly adjusted bindings have been correlated with increased injury rates. Upper extremity injuries constitute approximately one-third of skiing injuries, with ulnar collateral ligament sprains and shoulder injuries being the most common. Strategies to prevent these include proper poling technique and avoidance of non-detachable ski pole retention devices. Spinal injuries in skiers have been traditionally much less common than in snowboarders, but this disparity is likely to diminish with the recent trend of incorporating snowboarding moves into skiing. Strategies to help reduce these injuries include promoting the development of terrain parks and focussing on proper technique during such moves. Head injuries have been increasing in incidence over recent decades and account for more than half of skiing-related deaths. The issue of ski helmets remains controversial while evidence for their efficacy remains under debate. There is no evidence to demonstrate that traditional ski instruction reduces injury frequency. More specific programmes focussed on injury prevention techniques are effective. The question of pre-season conditioning to prevent injuries needs further research to demonstrate efficacy.

Primary anterior dislocation of the shoulder: long-term prognosis at the age of 40 years or younger

PURPOSE

We describe the long-term prognosis in 257 first-time anterior shoulder dislocations (255 patients, aged 12-40 years) registered at 27 Swedish emergency units between 1978 and 1979.

METHODS

Half the shoulders were immobilised for 3-4 weeks after repositioning. Follow-ups were performed after two (questionnaire), five (questionnaire), 10 (questionnaire and radiology) and 25 (questionnaire and radiology) years in 227 patients (229 shoulders). Twenty-eight patients died during the 25 years of observation.

RESULTS

Early movement or immobilisation after the primary dislocation resulted in the same long-term prognosis. Recurrences increased up to 10 years of follow-up, but, after 25 years, 29 % of the shoulders with ≥2 recurrences appeared to have stabilised over time. Arthropathy increased from 9 % moderate to severe and 11 % mild at 10 years, to 34 % moderate to severe and 27 % mild after 25 years. Alcoholics had a poorer prognosis with respect to dislocation arthropathy (P < 0.001). Age <25 years and/or bilateral instability represent a poorer prognosis, where stabilising surgery is necessary in every second shoulder. Fracture of the greater tuberosity means a good prognosis, and we have found no evidence that athletic activity, gender, a Hill-Sachs lesion and minor rim fractures had any prognostic impact. During the 25 years in which these patients were followed, 28/255 died (11 %), representing a mortality rate (SMR) that was more than double that of the general Swedish population (P < 0.001).

CONCLUSION

Almost half of all first-time dislocations at the age of <25 years will have stabilising surgery and two-thirds will develop different stages of arthropathy within 25 years.

Arthroscopic stabilization of the shoulder: a prospective randomized study of absorbable versus nonabsorbable suture anchors

PURPOSE

The aim of this study was to evaluate, prospectively, outcomes following arthroscopic Bankart repair performed with 2 types of suture anchor--the G II (DePuy Mitek, Raynham, MA) nonabsorbable anchor and the Panalok (DePuy Mitek) absorbable anchor.

METHODS

Patients with a diagnosis of recurrent traumatic anterior instability of the shoulder who were seen in a single unit between April of 2000 and June of 2003 were considered for inclusion in the study. Patients were assessed preoperatively and postoperatively by means of a subjective, patient-related outcome measurement tool (Oxford Instability Score), a visual analogue scale for pain and instability (VAS Pain and VAS Instability), and a quality-of-life questionnaire (Short Form-12 [SF-12]). Length of follow-up was 1.5 to 5 years (mean, 2.6 y). The incidence of recurrent instability and the level of sporting ability were recorded. Patients were randomized to undergo surgical repair with nonabsorbable or absorbable anchors.

RESULTS

A total of 130 patients were included in this study, of whom 6 were lost to follow-up; therefore 124 patients (95%) completed the study. Both types of anchor were highly effective. No differences in rate of recurrence or in any of the scores were noted between the 2 groups. In all, 4 patients in the nonabsorbable group and 3 in the absorbable group experienced additional episodes of dislocation after a traumatic event. Rate of redislocation in the whole series was therefore 6%. In addition, 4 patients, all of them from the absorbable group (4%), described ongoing symptoms of instability but no true dislocations. In all, 85% of the patient group have returned to their previous level of sporting activity.

CONCLUSIONS

No differences in outcomes of arthroscopic Bankart repair were seen whether absorbable or nonabsorbable anchors were used. Both are highly effective, with a redislocation rate of 6%.

LEVEL OF EVIDENCE

Level I, therapeutic randomized controlled trial.

Shoulder injuries during alpine skiing

We retrospectively reviewed alpine skiing injuries at a destination ski resort during three seasons to characterize the incidence and types of shoulder injuries. A total of 3451 injuries in 3247 patients were reviewed. The overall injury rate was 4.44 injuries per 1000 skier-days. Injuries to the upper extremity represented 29.1% (N = 1004) of all alpine ski injuries. Injuries involving the shoulder complex (393 injuries in 350 patients) accounted for 39.1% of upper extremity injuries and 11.4% of all alpine skiing injuries. The rate of shoulder injury was 0.51 injuries per 1000 skier-days. Patients with shoulder injuries had a mean age of 35.4 years, and the male-to-female ratio of these patients was 3:1. Falls represented the most common mechanism of shoulder injury (93.9%) in addition to collisions with skiers (2.8%), pole planning (2.3%), and collisions with trees (1%). The most common shoulder injuries were rotator cuff strains (24.2%), anterior glenohumeral dislocations or subluxations (21.6%), acromioclavicular separations (19.6%), and clavicle fractures (10.9%). Less common shoulder injuries included greater tuberosity fractures (6.9%), trapezius muscle strains (6.4%), proximal humeral fractures (3.3%), biceps tendon strains (2.3%), glenoid fractures (1.5%), scapular fractures (1%), humeral head fractures (1%), sternoclavicular separations (0.5%), an acromial fracture (0.3%), a posterior glenohumeral dislocation (0.3%), and a biceps tendon dislocation (0.3%).

An epidemiological study of high school ice hockey injuries

Between 1976 and 1983, 42 spinal cord injuries among ice hockey participants were documented in Canada; within a recent 3-week period, three cases involving fractured necks were reported in a metropolitan area of Minnesota. The purpose of this comprehensive epidemiological study was to document rates, types, and severities of injuries incurred among high school varsity hockey players in Minnesota, as a result of participation in the 1982-1983 season, and to determine the variables associated with these injuries. Within a 30-mile radius of the state's major metropolitan area, 12 high school varsity hockey teams were selected for participation. Specific techniques were used to ensure confidentiality, high response rates, and validation of information. Among the players an injury rate of 75 injuries per 100 players was documented. Head and neck injuries accounted for 22% of the total injuries. Increased risks of injury were associated with multiple health-care provision variables and equipment utilized. Potential strategies are identified as a result of these findings.

Incidence of shoulder dislocations in the UK, 1995-2015: a population-based cohort study

OBJECTIVE

This cohort study evaluates the unknown age-specific and gender-specific incidence of primary shoulder dislocations in the UK.

SETTING

UK primary care data from the Clinical Practice Research Datalink (CPRD) were used to identify patients aged 16-70 years with a shoulder dislocation during 1995-2015. Coding of primary shoulder dislocations was validated using the CPRD general practitioner questionnaire service.

PARTICIPANTS

A cohort of 16 763 patients with shoulder dislocation aged 16-70 years during 1995-2015 were identified.

PRIMARY OUTCOME MEASURE

Incidence rates per 100 000 person-years and 95% CIs were calculated.

RESULTS

Correct coding of shoulder dislocation within CPRD was 89% (95% CI 83% to 95%), and confirmation that the dislocation was a 'primary' was 76% (95% CI 67% to 85%). Seventy-two percent of shoulder dislocations occurred in men. The overall incidence rate in men was 40.4 per 100 000 person-years (95% CI 40.4 to 40.4), and in women was 15.5 per 100 000 person-years (95% CI 15.5 to 15.5). The highest incidence was observed in men aged 16-20 years (80.5 per 100 000 person-years; 95% CI 80.5 to 80.6). Incidence in women increased with age to a peak of 28.6 per 100 000 person-years among those aged 61-70 years.

CONCLUSIONS

This is the first time the incidence of shoulder dislocations has been studied using primary care data from a national database, and the first time the results for the UK have been produced. While most primary dislocations occurred in young men, an unexpected finding was that the incidence increased in women aged over 50 years, but not in men. The reasons for this are unknown. Further work is commissioned by the National Institute for Health Research to examine treatments and predictors for recurrent shoulder dislocation.

STUDY REGISTRATION

The design of this study was approved by the Independent Scientific Advisory Committee (15_260) for the Medicines & Healthcare products Regulatory Agency.

Risk factors for early failure after thermal capsulorrhaphy

Thermal capsular shrinkage has rapidly become a common procedure for a variety of shoulder conditions usually associated with instability, although clinical data on outcomes are limited. The objective of this study was to identify risk factors for poor outcome after thermal capsulorrhaphy. Of 106 patients who underwent thermal shrinkage, 15 patients with treatment failures were identified. The mean time to failure after the procedure was 6.3 months (range, 1 to 16). Previous operations and multiple recurrent dislocations were associated with poor outcome at a highly significant level. Multidirectional instability and participation in contact sports did not attain statistical significance as risk factors. However, statistical power in these two comparisons was insufficient to exclude them as potential risk factors. A concomitant procedure at the time of thermal capsulorrhaphy was not associated with poor outcome. The data from early treatment failures can be useful in guiding patient selection for thermal capsulorrhaphy. This procedure may be of limited value for patients who have had prior operations or have a history of multiple dislocations. The data also suggest that thermal capsulorrhaphy should be used cautiously in patients with multidirectional instability or in those who are involved in contact sports.

Arthroscopic versus open Bankart repair: analysis of patient subjective outcome and cost

PURPOSE

Although the comparative efficacy of open and arthroscopic Bankart repair remains a matter of debate, little data exist on relative costs. We analyzed the patient outcomes, cost, and resource utilization of both procedures to determine if differences exist between open versus arthroscopic Bankart repair.

TYPE OF STUDY

Retrospective case-control study.

METHODS

We compared 22 patients who had open Bankart repair with 20 patients who had arthroscopic Bankart repair. Total operating times and all charges were obtained from records. Patients were evaluated using the American Shoulder and Elbow Surgeons (ASES) shoulder score, and any recurrence of dislocation was noted at minimum 24-month follow-up.

RESULTS

For arthroscopic Bankart repairs, operating times were shorter, but operating room equipment charges were greater. Overall charges were greater for open repairs as all open repair patients were admitted postoperatively. ASES shoulder scores were not significantly different between treatment groups. Four of 17 evaluable patients with open Bankart repair (including 1 shoulder in a patient who underwent bilateral repairs) had recurrent dislocation. One of the 18 evaluable patients with arthroscopic Bankart repair had recurrent dislocation.

CONCLUSIONS

Arthroscopic Bankart repair as same-day surgery has lower overall charges than open repair, although this difference would be negligible if all patients went home immediately after surgery.

LEVEL OF EVIDENCE

Level III, therapeutic, retrospective cohort study.

Adolescent traumatic dislocations of the shoulder with open epiphyses

Nine of 212 cases of traumatic anterior shoulder dislocations occurred in children with clearly open epiphyses (4.7% incidence). All cases associated with psychological or physical abnormalities were excluded. A high recurrence rate of 80% (8 of 10) was noted requiring operative intervention. Two of the three remaining unoperated cases had a history of "subluxation" after their initial dislocation.