Aims

The main objective of this study was to examine whether the Oxford Shoulder Score (OSS) demonstrated floor or ceiling effects when used to measure outcomes following shoulder arthroplasty in a large national cohort. Secondary objectives were to assess its pain and function subscales, and to identify independent predictors for patients achieving a postoperative ceiling score following shoulder arthroplasty.

Background

Chronic musculoskeletal pain increases an individual's risk of developing many chronic diseases and the risk of all-cause early mortality. There is irrefutable evidence supporting the role of physical activity (PA) in reducing these risks. Sustaining changes to PA behaviours is challenging and efforts are needed to understand the barriers and facilitators of change. Understanding these factors is a vital step in developing behaviour change interventions.

The correct prescription of antibiotics for in-patients is paramount to patient safety. Trust policy states that all in-patients on antibiotics must have a start date, duration, and indication for antibiotics documented on the drug-card. On a single day all drug-cards were reviewed assessing whether documentation was in line with policy. In the initial audit, 28 antibiotic courses were prescribed; of these courses only 15 (53.5%) had an indication documented and 15 (53.5%) had a review/stop date documented.

A monthly league table, coined ‘The Champions League’, was created. This named individuals who had correctly or incorrectly prescribed antibiotics, following identification in the monthly audit. It was published monthly and displayed in the doctors' office, on wards and circulated to all Consultants. After two published league tables, 19 antibiotic courses were prescribed. Indication was documented in 18 (94.7%) and 16 (84.2%) had the review date documented. This improvement has continued to the present day.

Prescribing standards appear to have improved with the use of this novel motivational tool. The competitive nature of surgical trainees has led to the Champions League becoming a talking point. Top placed doctors are rewarded with Premiership rugby tickets and those who consistently underperform are sensitively offered remedial instruction.

The management of patients with displaced intra-capsular hip fractures is usually a hip hemiarthoplasty procedure. NICE guideline 124 published in 2011 suggested that Total Hip Replacement (THR) surgery should be considered in a sub group of patients with no cognitive impairment, who walk independently and are medically fit for a major surgical procedure.

The Royal Devon and Exeter Hospital manages approximately 550 patients every year who have sustained a fracture of neck of femur, of which approximately 90 patients fit the above criteria. Prior to the guideline less than 20% of this sub-group were treated with a THR whereas after the guideline over 50% of patients were treated with THR, performed by sub-specialist Hip surgeons.

This practice is financially viable; there is no apparent difference in the overall cost of treating patients with THR. The effect of adoption of the NICE guideline was examined using 100 % complete data from 12 month post operative follow up. Only the Hemi-arthroplasty patients were significantly less likely to have stepped down a rung of independent living. Both THR and Hemi-arthroplasty patients were significantly less likely to have stepped down a rung of walking ability, but there was no significant difference between THR and Hemi-arthroplasty groups. Revision rates remained negligible.

NICE guidelines state that patients undergoing hip or knee arthroplasty should start as an in-patient and then continue pharmacological VTE prophylaxis for 28–35 days.

Retrospective review of all elective hip and knee arthroplasties during one calendar month gave a baseline measurement of how many patients had VTE prophylaxis prescribed on their discharge summary.

A new, electronically completed, bespoke Trauma and Orthopaedic discharge summary was created with a discreet area clearly marked for VTE prophylaxis, to serve as a reminder to prescribe it.

In March 2012, 93 patients underwent hip/knee arthroplasty. 76% (71/93) were prescribed VTE prophylaxis to take home, there was no clinical reason explaining the failure to prescribe prophylaxis in the remaining 24%.

In July 2013, after implementation of the change, 117 patients underwent hip/knee arthroplasty. 99% (116/117) were prescribed VTE prophylaxis to take home.

Repeat audit in October 2013 showed that 103 patients underwent hip/knee arthroplasty and 100% were prescribed VTE prophylaxis.

A simple but clear change to paperwork, brought about a rapid and seemingly lasting change in the prescription of out-patient VTE prophylaxis.

The improvement was seen before and after a change of the Junior Doctor workforce suggesting the change in documentation was the main influencing factor.

Introduction:

The mechanical stresses and strains surrounding orthopaedic implants can influence bone resorption and formation, micro-fracture, and consequently implant fixation or loosening. Experimental measurement of these internal parameters is generally not feasible. Computational predictions by finite element modeling are promising, but until recently have been limited to assuming the surrounding cancellous bone as a continuous volume, without modeling individual trabeculae. A recent study demonstrated errors in bone-implant stiffness exceeding 100% when using this continuum assumption [1]. Conversely, recently micro-finite element computer models have been built from high resolution imaging of trabecular bone. In the present study we developed such models of central pegs cemented into cadaveric glenoids. We hypothesized that additional applied cement would lead to stronger implant fixation, but less physiologic strains in the trabeculae.

The management of patients with displaced intra-capsular hip fractures is usually a hip hemiarthoplasty procedure. NICE guideline 124 published in 2011 suggested that Total Hip Replacement (THR) surgery should be considered in a sub group of patients with no cognitive impairment, who walk independently and are medically fit for a major surgical procedure.

The Royal Devon and Exeter Hospital manages approximately 600 patients every year who have sustained a fracture of neck of femur, of which approximately 90 patients fit the above criteria. Prior to the guideline less than 20% of this sub-group were treated with a THR whereas after the guideline over 50% of patients were treated with THR, performed by sub-specialist Hip surgeons. This change was achieved by active leadership, incorporation of ‘Firebreak’ lists, looking for cases, flexible use of theatre time and operating lists and the nomination of an individual senior doctor who was tasked with a mission to improve practice.

This practice is financially viable; the Trust makes over £1000 per THR for fracture. Complete outcome data at 120 days show significantly fewer patients stepping down a rung in terms of both independent living and independent walking.

We report a retrospective review of outcome after shoulder hemiarthroplasty for proximal humerus fractures. All patients managed with shoulder hemiarthroplasty for proximal humerus fractures between 1997 and 2008 were included. Clinical notes were reviewed and surviving patients completed postal Oxford Shoulder Score (OSS) questionnaires. Results were analysed to assess whether there was a difference in outcome for those above the age of 70 years. A total of 96 patients were treated during this period. Female to male ratio was 3.36:1 with mean age 72 ± 9.6 (45–93) years at time of fracture. At time of review 30.2% of patients were dead. Two patients were lost to follow-up after discharge. Complete case notes were available in 68 patients. Response rate to the OSS was 67.2%. There were 20 patients below 70 years and 48 patients above 70 years of age. The ASA grade was II in 60% of patients. Mean follow-up was 52 months. There were 2 in hospital post-operative deaths due to medical complications. Mean OSS was 27 (3–47) of a maximum of 48, with no significant difference between groups. Overall complication rate was 27.9%, with no significant difference between groups. Ten year survival was 96.9% overall with no significant difference between groups. There appears to be no significant difference in functional outcome, complication rate, or implant survival between patients below or above the age of 70 years treated with primary hemiarthroplasty for fracture of the proximal humerus. This procedure however carries a high complication rate in this group of patients.

This study describes the method and results of a new way of stabilising painful unstable sternoclavicular joints using the sternocleidomastoid tendon. Painful instability of the sternoclavicular joint is a rare condition whose cause is either of spontaneous onset in young principally females with generalised joint laxity or of traumatic onset. The direction of instability can be anterior, superior or posterior. Surgical stabilisation is difficult and has principally consisted of using periosteum or subclavius and reefing the joint to the first rib with its attendant risks and variable results. We describe eight cases of painful sternoclavicular joint instability treated by using the sternocleidomastoid tendon and passing it through the medial clavicle and onto the manubrium of the sternum to stabilise the joint. This method of treatment is simpler, is reproducible and avoids the potential risks of reefing the joint to the first rib. There is no decrease in function of the sternocleidomastoid muscle from this procedure. All directions of instability can be treated using this tendon by varying the position of the bone hole. The results show comparable outcome for stability with other studies. We conclude that using the sternocleidomastoid tendon to stabilise the sternoclavicular joint is a simpler and safer method of treating these injuries and gives comparable results to the other methods of surgical stabilisation.

The study investigated if suprascapular nerve(SSN) rhizolysis could give effective and longlasting pain relief to patients with chronic shoulder pain(massive cuff tears and /or osteoarthritis) some with significant comorbidity, who did not wish for or were unable to withstand surgery. Sixty two patients(12 male, 50 female, mean age 74years) with longstanding moderate to severe shoulder joint pain(massive rotator cuff tears, osteoarthritis, rheumatoid arthritis), who had failed conventional non-operative management and who were unsuitable for further shoulder surgery, were assessed for radiofrequency(RF) rhizolysis to the SSN. Most patients reported significant anaesthetic co-morbidity. All patients had received full orthopaedic or rheumatological assessment with investigations including Xray, ultrasound and MRI scan. Ninety-five percent of patients had undergone a SSN block which had afforded > 50% pain reduction for three to six months. The suprascapular notch was identified with Xray control. The SSN was located with 100 Hz and 2 Hz stimulation of an insulated 50mm needle. Once localised, 5 mls of 2% lignocaine was injected and a radiofrequency thermocoagulation lesion undertaken at 700C for 90 seconds. Eighty-five percent of patients reported> 50% pain relief still present at six months (as reported by VAS score). No serious adverse side effects were reported (pneumothoraces, haematomas, infection, neurological deficits). RF rhizolysis of the SSN may be a useful treatment for the group of patients with chronic shoulder pain for whom surgery is not an option.

We undertook this study to evaluate our results of Arthroscopic Capsular Shrinkage as a treatment of Multi Directional Instability of the shoulder. Patients with symptomatic multidirectional instability (MDI) have excess capsular laxity. Arthroscopic capsular shrinkage is a fairly new procedure, to treat laxity with variable results in the reported literature. We analysed the records of patients who under went 20 (10 males, nine females) arthroscopic thermal capsular shrinkage procedures for MDI of the shoulder, which were performed by the senior author between 2000 and 2004. The mean age was 28.3 years (median 29.4, range 18 to 46 years) and the mean follow up was 44.5 months (median 43, range 20 to 69 months). All patients had undergone specialist shoulder physiotherapy for four months or more prior to surgery. The type of shoulder instability was subcategorised (based upon the predominant symptomatology as perceived by the patient) as follows: dislocation (seven), subluxation +/− pain (nine), and impingement (four). The procedure and postoperative regimen were standardised. Clinical outcome measures were: patient satisfaction, pain and instability. Sixteen shoulders (80%) were symptom free and fully satisfied at last follow up. One patient (5%) had some pain but a stable shoulder. Three patients (15%) [two dislocators and one subluxator] had recurrent instability between six to eight months post operatively and underwent further surgery. The less the instability, the more likely it was, that the procedure would succeed. We conclude that out results are encouraging particularly in patients with less severe instability despite the small size (20) of our cohort of patients. We think that careful patient selection may be important for success from this surgery.

Healing of the subscapularis, documented by ultrasound, following total shoulder arthroplasty was examined in thirty shoulders. All had marked improvement in pain, SST, and ASES scores. Four subscapularis tears were identified but only one patient had a positive abdominal compression test, 7/26 patients had a positive compression test despite an intact cuff, and 4/7 patients had a significant internal rotation contracture. The abdominal compression test was not accurate in detecting sub-scapularis tears. There was a significant false positive rate, which may be related to a lack of internal rotation. Overall, the outcome was excellent and not related to the status of the subscapularis.

Very little information is available on healing of the subscapularis after shoulder arthroplasty. The purpose of this study was to document the subscapularis healing rate and relate it to post-operative function and the abdominal compression test.

Thirty consecutive shoulders (twenty-three patients) s/p total shoulder replacement had standardized pre- and post-operative examinations including quantitative strength assessment and specific subscapularis testing. Ultrasound (validated for postop accuracy) was performed to document tendon healing.

All thirty shoulders had marked improvements in pain, SST, and ASES scores. Four subscapularis tears were identified but only one patient had a positive abdominal compression test. Seven out of twenty-six patients had a positive compression test despite an intact cuff. Four of seven patients had a significant internal rotation contracture. Neither the status of the subscapularis nor a positive compression test appeared to affect outcome.

Although specific subscapularis tests are often positive, only a small percentage of subscapularis tendons appear to retear after shoulder arthroplasty. The abdominal compression test is not accurate in detecting subscapularis tears post arthroplasty. There is a significant false positive rate, which may be related to a lack of internal rotation. However, overall outcome of shoulder arthroplasty was excellent and did not appear to be dependant on the status of the subscapularis.

The strength of the intact and four reconstruction techniques (figure-eight, docking, single strand utilizing interference screws, and a single strand) of the medial collateral ligament (MCL) of the elbow were compared. Twenty cadaveric specimens were tested with a cyclic valgus loading protocol. The peak loads to failure of the MCL reconstructions were inferior compared to the intact ligament (p< 0.05). The docking and single strand reconstruction utilizing an endobutton for ulnar fixation were equivalent and had greater initial strength than the interference screws or figure-eight technique. It is suggested that improved interference screws are required for this repair.

The purpose of this study was to compare the initial strength of the intact medial collateral ligament (MCL) of the elbow and four reconstruction techniques.

The docking and endobutton reconstructions showed equivalent peak load to failure.

Improved interference screws are required before they are employed clinically.

The average peak load to failure or 5mm of joint gapping was 142.5±39.4N for the intact, 53.0±9.5N for the docking, 52.5±10.4N for the endobutton, 41.0±16.0N for the interference screw, and 33.3±7.1N for the figure-eight reconstructions. The peak load to failure was higher for the intact specimens compared to any of the reconstructions (p< 0.001). The docking reconstruction showed higher peak loads than the figure-eight or interference screw reconstruction, and the endobutton reconstruction showed higher peak loads than the figure-eight reconstruction (p< 0.004). There was no difference in peak loads between the docking and endobutton reconstructions (p> 0.05).

Twenty (ten pairs) unpreserved cadaveric upper extremities were mounted in a custom jig with the elbow at 90°, and a valgus force was applied 12cm from the elbow joint. The specimens were loaded starting at 20N with the load increased in increments of 10N (200 cycles at each load), until either complete ligament failure or a 5mm increase in the distance between the attachment sites of the MCL. The results support that a single strand or multistrand ligament reconstruction can be equivalent with respect to maximal peak loads and cyclic loading. There are concerns with regard to the use of interference screw fixation in the clinical situation.