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factors have not been established (Murray and Rushton 1990; Jasty and Smith 1992; Schmalzried et al 1992; Howie et al 1993; Kossovsky et al 1993). We were unable to determine the sizes of the particles released from brushes but a wide range is possible.The long-term clinical effect of ‘brushdebris' will be difficult to establish, but it is known that polyethylene wear debris plays a role in the outcome ofjoint replacement. The selection of more appropriate material for brushes and the REFERENCES

Background: The present study aims to add to the body of evidence delineating the learning curve for a shoulder surgeon to become proficient in focussed ultrasound for the detection of full-thickness rotator cuff tears, as well as to describe a learning method for this skill. Methods: Consecutive patients who were scheduled to undergo an arthroscopy for rotator cuff disease were scanned immediately before surgery by a senior shoulder surgeon with limited previous experience of shoulder ultrasound. The presence or absence of a full-thickness rotator cuff tear on scan was compared with intra-operative findings as the gold standard. Results: Two hundred and ten shoulders were scanned over three equal learning periods. Comparing predictive values from the first to the third training period, sensitivity improved from 0.86 to 0.95, specificity from 0.92 to 0.98, negative predictive value from 0.94 to 0.98, and positive predictive value from 0.82 to 0.95. Conclusions: The high predictive values obtained in the present study for surgeon-led detection of cuff tears using ultrasound are comparable with those quoted for musculoskeletal radiologists in the literature. The present study adds evidence that a shoulder surgeon can achieve accelerated learning of this skill and offers some potentially time-saving and patient-friendly alternatives to existing guidelines.