Background Manipulation under anaesthesia and arthroscopic capsular release are costly and invasive treatments for frozen shoulder, but their effectiveness remains uncertain. We compared these two surgical interventions with early structured physiotherapy plus steroid injection. MethodsIn this multicentre, pragmatic, three-arm, superiority randomised trial, patients referred to secondary care for treatment of primary frozen shoulder were recruited from 35 hospital sites in the UK. Participants were adults (≥18 years) with unilateral frozen shoulder, characterised by restriction of passive external rotation (≥50%) in the affected shoulder. Participants were randomly assigned (2:2:1) to receive manipulation under anaesthesia, arthroscopic capsular release, or early structured physiotherapy. In manipulation under anaesthesia, the surgeon manipulated the affected shoulder to stretch and tear the tight capsule while the participant was under general anaesthesia, supplemented by a steroid injection. Arthroscopic capsular release, also done under general anaesthesia, involved surgically dividing the contracted anterior capsule in the rotator interval, followed by manipulation, with optional steroid injection. Both forms of surgery were followed by postprocedural physiotherapy. Early structured physiotherapy involved mobilisation techniques and a graduated home exercise programme supplemented by a steroid injection. Both early structured physiotherapy and postprocedural physiotherapy involved 12 sessions during up to 12 weeks. The primary outcome was the Oxford Shoulder Score (OSS; 0-48) at 12 months after randomisation, analysed by initial randomisation group. We sought a target difference of 5 OSS points between physiotherapy and either form of surgery, or 4 points between manipulation and capsular release. The trial registration is ISRCTN48804508.

There is conflicting evidence regarding the effectiveness of carpal tunnel release in older patients. This is a prospective study which evaluates the impact of age and gender upon symptoms, self-reported disability and surgical outcome in a series of 97 patients with carpal tunnel syndrome. Symptom severity, hand function and patient satisfaction were assessed using the Boston Carpal Tunnel Questionnaire and the Patient Evaluation Measure. A statistical correlation of age and gender with symptoms, hand function and surgical outcome was performed with questionnaires administered before open carpal tunnel decompression and 6 months after surgery. Women reported greater pre-operative symptoms and disability than men, but there was no gender-related difference in surgical outcome or patient satisfaction. There was no difference in surgical outcome between patients 60 and 70 years of age and younger patients. The majority of patients over the age of 70 reported an improvement in symptoms and function, but they were less satisfied with their treatment than younger patients. Some patients had problems with persistent numbness and loss of dexterity following surgery. The outcome of carpal tunnel release in terms of improvement in the symptom and functional scores is sufficient to justify surgery in the elderly, but surgical outcomes are less predictable than in younger patients and we recommend that this is explained to them when obtaining consent for surgery.

We retrospectively assessed the union and shoulder function following hook plate fixation in 18 patients with Neer type 2 fractures of the lateral end of the clavicle. The average age was 40 (range 22-62) years, and the mean follow-up was 25 (range 6-48) months. Fifteen patients had acute fractures and the rest were non-unions. Complications included two non-unions, one following a deep infection. There were no iatrogenic fractures. Acromial osteolysis was seen in five patients who had their plates in situ. The average pain score at rest was 1 (range 0-4), and the average pain score on abduction was 2.2 (range 0-5). The average Constant score was 88.5 (range 63-100). Patients were asked to rate their shoulder function; three rated it as normal, 11 as nearly normal and one as not normal. Hook plate fixation appears to be a valuable method of stabilising Neer type 2 fractures of the clavicle, resulting in high union rates and good shoulder function. These plates need to be removed after union to prevent acromial osteolysis.

In a prospective study, we have evaluated the impact of psychological disturbance on symptoms, self-reported disability and the surgical outcome in a series of 110 patients with carpal tunnel syndrome. Self-reported severity of symptoms and disability were assessed using the patient evaluation measure and the Boston carpal tunnel questionnaire. Psychological distress was assessed using the hospital anxiety and depression scale. There was a significant association between psychological disturbance and the pre-operative symptoms and disability. However, there was no significant association between pre-operative psychological disturbance and the outcome of surgery at six months. We concluded that patients with carpal tunnel syndrome should not be denied surgery because of pre-operative psychological disturbance since it does not adversely affect the surgical outcome.

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