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      Implementation of a Shoulder Soft Tissue Injury Triage Service in a UK NHS Teaching Hospital Improves Time to Surgery for Acute Rotator Cuff Tears.

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          Abstract

          Shoulder problems account for 2.4% of GP consultations in the United Kingdom and of those 70% are related to the rotator cuff. Many rotator cuff tears are of a degenerate nature but they can occur as a result of trauma in 8% of cases. Evidence suggests that patients with traumatic rotator cuff tears gain a better outcome in terms of pain and function if the tear is repaired early after injury.

          A specialist shoulder soft tissue injury clinic was set up in a large UK NHS teaching hospital with the primary purpose in the first year to halve the length of time patients with traumatic rotator cuff tears had to wait to consult a specialist and double the number of patients undergoing surgical repair within three months. The secondary purpose was to ensure that the new clinic was utilised to capacity by the end of the first year. The clinic was later expanded to manage patients with acute glenohumeral joint (GHJ) or acromioclavicular joint (ACJ) dislocations and identify those patients requiring surgical stabilisation. The new service involved referral of all patients presenting to the Accident & Emergency department with recent shoulder trauma and either an inability to raise the arm over shoulder height with a normal set of radiographs, or a confirmed GHJ or ACJ dislocation; to a specialist clinic run by an experienced upper limb physiotherapist. Patients were reassessed and referred for further imaging if required. Those patients found to have traumatic rotator cuff tears or structural instability lesions were listed for expedited surgery. The clinic ran alongside a consultant-led fracture clinic giving fast access to surgical decision-making. The service was reviewed after 3, 6, and 12 months and findings compared to a sample of 30 consecutive patients having undergone rotator cuff repair surgery via the previous pathway.

          144 patients were referred to the clinic in the first year: 62 with rotator cuff symptoms, 38 with GHJ instability, 13 with ACJ instability, and 33 others. 7 missed fractures were identified. 12 patients subsequently underwent rotator cuff repair surgery, 10 GHJ stabilisation, and 1 ACJ stabilisation. Mean referral time to first clinical assessment improved from 37 days to 8 days. For rotator cuff repair: mean referral to surgery time was 86 days compared with 115 days on the old pathway. 58% of patients underwent surgery within 90 days of injury compared with 20% previously.

          Our new service resulted in surgical repair of traumatic rotator cuff tears 29 days faster than the traditional system with an extra 38% of patients having surgery within 90 days of injury - a benchmark thought to improve outcome. Future work will aim to improve this percentage further and include long term patient follow up of outcome measures after surgery.

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          A comparison of early versus delayed repair of traumatic rotator cuff tears.

          The purpose of this study was to compare the clinical and magnetic resonance imaging (MRI) results between early and delayed operative treatment in patients with traumatic rotator cuff tears (RCT). Thirty-five patients with a traumatic RCT who have been treated surgically during a 4-year period were included in the study. The results of early versus delayed repair of traumatic rotator RCT were assessed using the Constant and UCLA scores. In addition, all patients underwent a postoperative MRI to evaluate repair integrity. Early repair (within 3 weeks) was performed in 15 patients (group I) and delayed repair (after 3 weeks) in the rest 20 patients (group II). The time interval between injury and operation was 12 and 131 days on average for group I and II, respectively. Follow-up time was 34 and 38 months for group I and II, respectively. Postoperatively, the UCLA score was 31 and 26 (P < 0.05) for group I and II, respectively. The Constant score was 82 and 70 (P < 0.05) for group I and II, respectively. Range of motion was significantly better in group I. According to MRI, 5 patients (33%) in the group I and 7 patients (35%) in the group II had a retear. Early repair of a traumatic RCT provides better results in terms of shoulder function in comparison with a delayed repair. A delayed diagnosis of a traumatic RCT leads to difficulties in surgery and less good results. Level III, therapeutic, retrospective, comparative study.
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            Time to surgery in acute rotator cuff tear

            Aims We performed a systematic review of the literature to determine whether earlier surgical repair of acute rotator cuff tear (ARCT) leads to superior post-operative clinical outcomes. Methods The MEDLINE, Embase, CINAHL, Web of Science, Cochrane Libraries, controlled-trials.com and clinicaltrials.gov databases were searched using the terms: ‘rotator cuff’, or ‘supraspinatus’, or ‘infraspinatus’, or ‘teres minor’, or ‘subscapularis’ AND ‘surgery’ or ‘repair’. This gave a total of 15 833 articles. After deletion of duplicates and the review of abstracts and full texts by two independent assessors, 15 studies reporting time to surgery for ARCT repair were included. Studies were grouped based on time to surgery 3 months (group B, eight studies). Weighted means were calculated and compared using Student’s t-test. Results Group B had a significantly higher pre-operative Constant score (CS) (p < 0.001), range of movement in external rotation (p = 0.003) and abduction (p < 0.001) compared with group A. Both groups showed clinical improvement with surgical repair; group A had a significantly improved Constant score, University of California, Los Angeles (UCLA) shoulder score, abduction and elevation post-operatively (all p < 0.001). Group B had significantly improved Constant score (p < 0.001) and external rotation (p < 0.001) post-operatively. The mean Constant score improved by 33.5 for group A and by 27.5 for group B. Conclusion These findings should be interpreted with caution due to limitations and bias inherent to case-series. We suggest a trend that earlier time to surgery may be linked to better Constant score, and active range of movement in abduction and elevation. Additional prospective studies are required.
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              Surgery within 6 months of an acute rotator cuff tear significantly improves outcome

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                Author and article information

                Journal
                BMJ Qual Improv Rep
                BMJ Qual Improv Rep
                bmjqir
                bmjqir
                BMJ Quality Improvement Reports
                British Publishing Group
                2050-1315
                2016
                6 June 2016
                : 5
                : 1
                Affiliations
                Derby Teaching Hospitals NHS Foundation Trust, UK
                Author notes
                [Correspondence to ] Marcus Bateman marcus.bateman@ 123456nhs.net
                Article
                bmjquality_uu211254.w4531
                10.1136/bmjquality.u211254.w4531
                4915307
                27335643
                © 2016, Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/

                This is an open-access article distributed under the terms of the Creative Commons Attribution Non-commercial License, which permits use, distribution, and reproduction in any medium, provided the original work is properly cited, the use is non commercial and is otherwise in compliance with the license. See:

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                1506
                1796

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