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Top ten priorities for research

The PSP on Surgery for Common Shoulder Problems completed on June 5, 2015 with a Final Workshop of patients, carers and health professionals working to agree, through consensus, the top Ten priorities for future research. Professor Jonathan Rees, the clinical lead for the PSP, announced the Top Ten at the British Elbow and Shoulder Society conference on June 24, 2015.

Top ten questions with plain English explanations below each question

Q. For the main shoulder conditions of arthritis, frozen shoulder, impingement, rotator cuff tears and instability, can you predict which patients will do well with surgery to help them decide on whether to have surgery or not?

Patients suffer with shoulder pain and loss of movements caused by the four conditions highlighted by this question (shoulder arthritis, frozen shoulder, torn tendons, impinging of catching tendons and shoulder dislocation). This question asks if any research studies could be designed to provide information to patients and surgeons and physios to help predict and decide which patients would do well with surgery and which patients would not.

Q. In patients with three and four part proximal humeral fractures what is the long term outcome of reverse total shoulder replacement compared to hemiarthoplasty (half shoulder replacement)?

In older patients who have a shoulder fracture that is in a number of pieces (the common types are two, three and four-part with the severity of the fracture reflected by the number of parts) it can't be fixed (put back together) but needs an artificial shoulder joint. Traditionally that has been done by just replacing the broken ball (hemiarthroplasty) but recently the reverse shoulder replacement has started to be used. This question seeks to answer whether a reverse replacement is better in the long term than a hemiarthroplasty.

Q. Does arthroscopic (keyhole) subacromial decompression surgery in patients with degenerative rotator cuff tendon problems improve outcome and prevent further tendon degeneration and tears compared to patients with no surgical intervention?

Before shoulder tendons tear, it is thought that they catch a lot in the shoulder on a spur of bone. This question asks that if a keyhole operation is done to shave away the spur of bone before the tendon tears does that make the patient better and does it stop their tendons tearing in the future.

Q. Does early mobilisation and physiotherapy after shoulder surgery improve patient outcome compared to standard immobilisation and physiotherapy?

There are lots of different operations, some keyhole, some open but most patients are put in a sling afterwards and then depending on the operation will begin physiotherapy exercises in the weeks following surgery. This often varies throughout the UK. This question asks do patients get a better result and outcome if they get out of the sling sooner and start physio sooner.

Q. In patients with shoulder arthritis is a hemiarthroplasty (half shoulder replacement) or a total shoulder replacement or a reverse (ball on shoulder socket and socket on arm bone) replacement most effective?

In patients with established shoulder arthritis that requires a joint replacement there are three different types available. Replacing just the ball (hemiarthroplasty), replacing both the ball and socket (total), or replacing both the ball and socket but swapping them over (reverse). We currently have little evidence as to which is potentially the best.

Q. Are patients (including older age groups) with rotator cuff tendon tears in their shoulder best treated with surgery or physiotherapy?

Torn shoulder tendons are a very common problem. Some patients seem to do okay without surgery but others don't. Age may have something to do with this. This question is aimed at asking future researchers to do some research that will help predict which patients in which age groups are best treated with surgery or physiotherapy.

Q. How can we ensure the patients see the right doctors and clinicians promptly and correctly, and does this lead to better outcomes (results)?

Patients often find they have to see several different clinicians e.g. GP, physiotherapy, with a wait at each stage before they get to see the shoulder specialist (consultant or physiotherapist) that can correctly diagnose and treat their condition. This question seeks to address this issue and also whether improving the speed with which the patient gets to see the specialist improves the outcome.

Q. In patients with Frozen Shoulder, does early surgery improve outcome compared to non-surgery treatments such as injection and dilatation?

Frozen shoulder is a stiff, painful problem that usually gets better on its own but it can take one to two years. Because of this many patients and surgeons decide on having surgery to try and speed up the recovery. This question asks, does having surgery early actually make any difference than waiting for the shoulder to get better on its own or having injections.

Q. In patients with newly diagnosed calcific tendinitis (calcium in a shoulder tendon), is early surgical intervention more clinically effective than non-operative treatments?

Calcific tendonitis is relatively common and very painful. There are many different treatments offered, although usually initial treatment consists of injections and physiotherapy and surgery is reserved for those patients who don't get better. This questions seeks to determine if operating earlier would be more effective than physio and injections

.

Q. Do patients with partial thickness rotator cuff tendon tears benefit more from a surgical repair compared to a decompression and debridement (cleaning up operation) alone?

Before shoulder tendons tear, it is thought that they catch a lot in the shoulder on a spur of bone and then a partial tear (or some fraying) of the tendon occurs. Some surgons treat this by shaving the spur or bone away, others shave the spur or bone and try and repair the partial tear (bigger operation). This question asks that if a surgery is done, do you also need to try and repair a partial tear or can you just shave the bone and let the tendon repair itself?

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