What is the current practice in Europe when difficult shoulder injuries are treated?

Abstract

In this issue of the journal, a group of Italian researchers discusses the European orthopedic surgeon’s management of choice for several difficult clinical scenarios of shoulder pathologies [1]. They divided their survey into four scenarios; i.e., anterior shoulder dislocation, shoulder arthritis combined with rotator cuff tear, large rotator cuff tendon tears combined with major fatty infiltration of the infraspinatus muscle and instability of the long head of the biceps and finally adhesive capsulitis. It might be claimed that at least three out of four are difficult cases. Therefore, the answers are of great interest. The authors used an online Web-based questionnaire and it is obvious that a questionnaire of this kind has the potential to improve our knowledge about the current trends in modern technology and ultimately might be helpful in creating clinical guidelines on a large scale. The first scenario was related to anterior dislocation of the shoulder. Interestingly, more than 70 % of the orthopedic surgeons recommended arthroscopic Bankart reconstruction, approximately half as an acute procedure and the rest as a planned procedure. This is the case description: ‘‘21-year-old male, recreational soccer player, first-time shoulder dislocation, with a minimal Hill-Sachs lesion, and a Bankart lesion’’… Less than 30 % of the surgeons recommended non-surgical treatment, which is of interest. The question is whether we really know that an acute/ semi-acute surgical procedure is the correct way to approach this particular—and in fact very common— problem. There might be arguments for instance for a more conservative approach. Also interesting is the recommendation for a brace in internal or external rotation in almost 75 %. The second scenario is a 55-year-old female with painful shoulder arthritis, total supraspinatus tear and infraspinatus fatty infiltration. In this case, the majority of surgeons (more than 60 %) recommended surgical treatment, while less than 40 % would favor a conservative regimen. Supraspinatus tendon repair/reconstruction was recommended by 85 % of all surgeons, with or without biceps tenodesis/tenotomy. The question is whether we really know if biceps tenodesis/tenotomy is needed in a case like this? Again, the dominance of surgical approach is of great interest. Only few surgeons recommended either debridement or shoulder replacement (15 %) in this patient. The third scenario is a 65-year-old male manual worker,