Patients >40 years with a glenohumeral dislocation have a lower incidence of Symptomatic Rotator Cuff Tear than previously reported and can be managed safely without routine advanced imaging

Background Incidence of rotator cuff tears (RCT) following primary anterior glenohumeral dislocation in patients over 40 years is thought to be high. Current guidelines recommend specialist clinic review and advanced imaging for all patients. The aim of this study was to report the incidence of symptomatic RCT in a large cohort of patients and to assess the safety and efficacy of a physiotherapy led virtual protocol where patients were selectively investigated and treated based on symptoms. Methods 238 consecutive patients over 40 years of age with a primary anterior glenohumeral dislocation were identified between January 2015 and June 2018 (42 months). All patients were managed initially through a physiotherapy led virtual clinic with selective referral of patients with red flag symptoms to a specialist shoulder clinic. Advanced imaging (MRI or USS) was performed at the discretion of the shoulder specialist following patient assessment. The incidence of symptomatic RCT was assessed and compared between two groups (Group 1: 40-70 years, Group 2: >70 years). All surgical interventions were recorded. Patients were assessed at a mean of 22 months (range 10-54) using the Oxford shoulder score; patient satisfaction and return to pre-injury functional level. Cost analysis was performed to compare management using this protocol versus published guidelines.Results A total of 238 patients were identified with mean age of 65 years (range 40-96). 69% (n=164/238) were symptomatic and were referred to specialist clinic. The other 31% (n=74/238) were asymptomatic and were discharged to physiotherapy. Of those referred to a specialist clinic, only 46% (n=75/164) were sent for advanced imaging following clinical examination. The incidence of symptomatic RCTs was 31% (n=51/164) in this group and only 22% (n=11/51) of those underwent subsequent surgical repair of their rotator cuff. Of those patients discharged to physiotherapy, 62% (n=47/74) responded to the questionnaire with 89% fully satisfied, 85% returned to pre-injury level and mean Oxford score was 42 (33-38, SD 3.2) indicating excellent shoulder function. With all patients pooled excluding those lost to follow-up (n=27), the incidence of symptomatic RCTs was 24% (51/211). The incidence in group 1 was 16% (n=22/137) and was significantly lower than in group 2 which was 39% (n=29/74) (p<0.05). Cost analysis demonstrated 49% cost reduction using this protocol.Conclusion Incidence of symptomatic cuff tears following a primary glenohumeral dislocation in patients over 40 years was lower than previously reported. A protocol based on selective referral and investigation for symptomatic patients was cost effective and safe.

Soft or Hard Law

Historically, international regimes regulating maritime transport have aimed to develop uniform rules. However, these rules are relatively static and have been implemented differently based on different national understandings in a de-centralised, State-based manner. This article argues that greater global uniformity in maritime transport rules could be achieved through the framework of the World Trade Organization (‘wto’). The wto could update these rules dynamically, and could also enforce them. A wto-based negotiating forum could generate substantive, uniform seaborne cargo rules in two ways. Through a selective referral approach, it could incorporate the existing rules — including the un-administered rules — within the wto framework. It could also develop new uniform rules. The wto also provides international communities with a quasi-judicial procedure — the wto dispute settlement mechanism (‘dsm’) — which could also be used to protect and promote the global uniformity of seaborne cargo rules. Such an approach could further reduce divergent interpretations of uniform transport rules by providing a centralised system for the implementation of those rules.