Aims. The objective of this study was to compare simulated range of motion (ROM) for reverse total shoulder arthroplasty (rTSA) with and without adjustment for scapulothoracic orientation in a global reference system. We hypothesized that values for simulated ROM in preoperative planning software with and without adjustment for scapulothoracic orientation would be significantly different. Methods. A statistical shape model of the entire humerus and scapula was fitted into ten shoulder CT scans randomly selected from 162 patients who underwent rTSA. Six
Aims. Patient-specific instrumentation has been shown to increase a surgeon’s precision and accuracy in placing the glenoid component in shoulder arthroplasty. There is, however, little available information about the use of patient-specific planning (PSP) tools for this operation. It is not known how these tools alter the decision-making patterns of
Objectives. To explore whether orthopaedic surgeons have adopted the Proximal Fracture of the Humerus: Evaluation by Randomisation (PROFHER) trial results routinely into clinical practice. Methods. A questionnaire was piloted with six orthopaedic surgeons using a ‘think aloud’ process. The final questionnaire contained 29 items and was distributed online to surgeon members of the British Orthopaedic Association and British Elbow and Shoulder Society. Descriptive statistics summarised the sample characteristics and fracture treatment of respondents overall, and grouped them by whether they changed practice based on PROFHER trial findings. Free-text responses were analysed qualitatively for emerging themes using Framework Analysis principles. Results. There were complete responses from 265 orthopaedic and trauma surgeons who treat patients with proximal humeral fractures. Around half (137) had changed practice to various extents because of PROFHER, by operating on fewer PROFHER-eligible fractures. A third (43) of the 128 respondents who had not changed practice were already managing patients non-operatively. Those who changed practice were more likely to be younger, work in a trauma unit rather than a major trauma centre, be specialist
This study compared patients who underwent arthroscopic repair of large to massive rotator cuff tears (LMRCTs) with isolated incomplete repair of the tear and patients with incomplete repair with biceps tendon augmentation. We aimed to evaluate the additional benefit on clinical outcomes and the capacity to lower the re-tear rate. We retrospectively reviewed 1,115 patients who underwent arthroscopic rotator cuff repair for full-thickness tears between October 2011 and May 2019. From this series, we identified 77 patients (28 male, 49 female) with a mean age of 64.1 years (50 to 80). Patients were classified into groups A (n = 47 incomplete) and B (n = 30 with biceps augmentation) according to the nature of their reconstruction. Clinical scores were checked preoperatively and at six months, one year, and two years postoperatively. In preoperative MRI, we measured the tear size, the degree of fatty infiltration, and muscle volume ratio of the supraspinatus. In postoperative MRI, the integrity of the repaired rotator cuff tendon was assessed using the Sugaya classification. Tendon thickness at the footprint was evaluated on T2-weighted oblique coronal view.Aims
Methods
The aim of this study is to evaluate the change in incidence rate of shoulder arthroplasty, indications, and surgeon volume trends associated with these procedures between January 2003 and April 2021 in the province of Nova Scotia, Canada. A total of 1,545 patients between 2005 and 2021 were analyzed. Patients operated on between 2003 and 2004 were excluded due to a lack of electronic records. Overall, 84.1% of the surgeries (n = 1,299) were performed by two fellowship-trained upper limb surgeons, with the remainder performed by one of the 14 orthopaedic surgeons working in the province.Aims
Methods
The August 2024 Shoulder & Elbow Roundup360 looks at: Comparing augmented and nonaugmented locking-plate fixation for proximal humeral fractures in the elderly; Elevated five-year mortality following shoulder arthroplasty for fracture; Total intravenous anaesthesia with propofol reduces discharge times compared with inhaled general anaesthesia in shoulder arthroscopy: a randomized controlled trial; The influence of obesity on outcomes following arthroscopic rotator cuff repair; Humeral component version has no effect on outcomes following reverse total shoulder arthroplasty: a prospective, double-blinded, randomized controlled trial; What is a meaningful improvement after total shoulder arthroplasty by implant type, preoperative diagnosis, and sex?; The safety of corticosteroid injection prior to shoulder arthroplasty: a systematic review; Mortality and subsequent fractures of patients with olecranon fractures compared to other upper limb osteoporotic fractures.
Optimal glenoid positioning in reverse shoulder arthroplasty (RSA) is crucial to provide impingement-free range of motion (ROM). Lateralization and inclination correction are not yet systematically used. Using planning software, we simulated the most used glenoid implant positions. The primary goal was to determine the configuration that delivers the best theoretical impingement-free ROM. With the use of a 3D planning software (Blueprint) for RSA, 41 shoulders in 41 consecutive patients (17 males and 24 females; means age 73 years (SD 7)) undergoing RSA were planned. For the same anteroposterior positioning and retroversion of the glenoid implant, four different glenoid baseplate configurations were used on each shoulder to compare ROM: 1) no correction of the RSA angle and no lateralization (C-L-); 2) correction of the RSA angle with medialization by inferior reaming (C+M+); 3) correction of the RSA angle without lateralization by superior compensation (C+L-); and 4) correction of the RSA angle and additional lateralization (C+L+). The same humeral inlay implant and positioning were used on the humeral side for the four different glenoid configurations with a 3 mm symmetric 135° inclined polyethylene liner.Aims
Methods
Steroid injections are used for subacromial pain syndrome and can be administered via the anterolateral or posterior approach to the subacromial space. It is not currently known which approach is superior in terms of improving clinical symptoms and function. This is the protocol for a randomized controlled trial (RCT) to compare the clinical effectiveness of a steroid injection given via the anterolateral or the posterior approach to the subacromial space. The Subacromial Approach Injection Trial (SAInT) study is a single-centre, parallel, two-arm RCT. Participants will be allocated on a 1:1 basis to a subacromial steroid injection via either the anterolateral or the posterior approach to the subacromial space. Participants in both trial arms will then receive physiotherapy as standard of care for subacromial pain syndrome. The primary analysis will compare the change in Oxford Shoulder Score (OSS) at three months after injection. Secondary outcomes include the change in OSS at six and 12 months, as well as the Pain Numeric Rating Scale (0 = no pain, 10 = worst pain), Disabilities of Arm, Shoulder and Hand questionnaire (DASH), and 36-Item Short-Form Health Survey (SF-36) (RAND) at three months, six months, and one year after injection. Assessment of pain experienced during the injection will also be determined. A minimum of 86 patients will be recruited to obtain an 80% power to detect a minimally important difference of six points on the OSS change between the groups at three months after injection.Aims
Methods
The primary aim of this study was to assess the feasibility of recruiting and retaining patients to a patient-blinded randomized controlled trial comparing corticosteroid injection (CSI) to autologous protein solution (APS) injection for the treatment of subacromial shoulder pain in a community care setting. The study focused on recruitment rates and retention of participants throughout, and collected data on the interventions’ safety and efficacy. Participants were recruited from two community musculoskeletal treatment centres in the UK. Patients were eligible if aged 18 years or older, and had a clinical diagnosis of subacromial impingement syndrome which the treating clinician thought was suitable for treatment with a subacromial injection. Consenting patients were randomly allocated 1:1 to a patient-blinded subacromial injection of CSI (standard care) or APS. The primary outcome measures of this study relate to rates of recruitment, retention, and compliance with intervention and follow-up to determine feasibility. Secondary outcome measures relate to the safety and efficacy of the interventions.Aims
Methods
Vascular compromise due to arterial injury is a rare but serious complication of a proximal humeral fracture. The aims of this study were to report its incidence in a large urban population, and to identify clinical and radiological factors which are associated with this complication. We also evaluated the results of the use of our protocol for the management of these injuries. A total of 3,497 adult patients with a proximal humeral fracture were managed between January 2015 and December 2022 in a single tertiary trauma centre. Their mean age was 66.7 years (18 to 103) and 2,510 (72%) were female. We compared the demographic data, clinical features, and configuration of those whose fracture was complicated by vascular compromise with those of the remaining patients. The incidence of vascular compromise was calculated from national population data, and predictive factors for its occurrence were investigated using univariate analysis.Aims
Methods
Glenoid bone loss is a significant problem in the management of shoulder instability. The threshold at which the bone loss is considered “critical” requiring bony reconstruction has steadily dropped and is now approximately 15%. This necessitates accurate measurement in order that the correct operation is performed. CT scanning is the most commonly used modality and there are a number of techniques described to measure the bone loss however few have been validated. The aim of this study was to assess the accuracy of the most commonly used techniques for measuring glenoid bone loss on CT. Anatomically accurate models with known glenoid diameter and degree of bone loss were used to determine the mathematical and statistical accuracy of six of the most commonly described techniques (relative diameter, linear ipsilateral circle of best fit (COBF), linear contralateral COBF, Pico, Sugaya, and circle line methods). The models were prepared at 13.8%, 17.6%, and 22.9% bone loss. Sequential CT scans were taken and randomized. Blinded reviewers made repeated measurements using the different techniques with a threshold for theoretical bone grafting set at 15%.Aims
Methods
This study aimed to quantify the shoulder kinematics during an apprehension-relocation test in patients with anterior shoulder instability (ASI) and glenoid bone loss using the radiostereometric analysis (RSA) method. Kinematics were compared with the patient’s contralateral healthy shoulder. A total of 20 patients with ASI and > 10% glenoid bone loss and a healthy contralateral shoulder were included. RSA imaging of the patient’s shoulders was performed during a repeated apprehension-relocation test. Bone volume models were generated from CT scans, marked with anatomical coordinate systems, and aligned with the digitally reconstructed bone projections on the RSA images. The glenohumeral joint (GHJ) kinematics were evaluated in the anteroposterior and superoinferior direction of: the humeral head centre location relative to the glenoid centre; and the humeral head contact point location on the glenoid.Aims
Methods
We sought to compare functional outcomes and survival between non-smokers, former smokers, and current smokers who underwent anatomical total shoulder arthroplasty (aTSA) in a large cohort of patients. A retrospective review of a prospectively collected shoulder arthroplasty database was performed between August 1991 and September 2020 to identify patients who underwent primary aTSA. Patients were excluded for preoperative diagnoses of fracture, infection, or oncological disease. Three cohorts were created based on smoking status: non-smokers, former smokers, and current smokers. Outcome scores (American Shoulder and Elbow Surgeons (ASES), Constant-Murley score, Shoulder Pain and Disability Index (SPADI), Simple Shoulder Test (SST), University of California, Los Angeles activity scale (UCLA)), range of motion (external rotation (ER), forward elevation (FE), internal rotation, abduction), and shoulder strength (ER, FE) evaluated at two- to four-year follow-up were compared between cohorts. Evaluation of revision-free survival was performed using the Kaplan-Meier method to final follow-up.Aims
Methods
The open Latarjet procedure is a widely used treatment for recurrent anterior instability of the shoulder. Although satisfactory outcomes are reported, factors which influence a patient’s experience are poorly quantified. The aim of this study was to evaluate the effect of a range of demographic factors and measures of the severity of instability on patient-reported outcome measures in patients who underwent an open Latarjet procedure at a minimum follow-up of two years. A total of 350 patients with anterior instability of the shoulder who underwent an open Latarjet procedure between 2005 and 2018 were reviewed prospectively, with the collection of demographic and psychosocial data, preoperative CT, and complications during follow-up of two years. The primary outcome measure was the Western Ontario Shoulder Instability Index (WOSI), assessed preoperatively, at two years postoperatively, and at mid-term follow-up at a mean of 50.6 months (SD 24.8) postoperatively. The secondary outcome measure was the abbreviated version of the Disabilities of the Arm, Shoulder and Hand (QuickDASH) score. The influence of the demographic details of the patients, measurements of the severity of instability, and the complications of surgery were assessed in a multivariate analysis.Aims
Methods
Both anatomical and reverse total shoulder arthroplasty (aTSA and rTSA) provide functional improvements. A reported benefit of aTSA is better range of motion (ROM). However, it is not clear which procedure provides better outcomes in patients with limited foward elevation (FE). The aim of this study was to compare the outcome of aTSA and rTSA in patients with glenohumeral osteoarthritis (OA), an intact rotator cuff, and limited FE. This was a retrospective review of a single institution’s prospectively collected shoulder arthroplasty database for TSAs undertaken between 2007 and 2020. A total of 344 aTSAs and 163 rTSAs, which were performed in patients with OA and an intact rotator cuff with a minimum follow-up of two years, were included. Using the definition of preoperative stiffness as passive FE ≤ 105°, three cohorts were matched 1:1 by age, sex, and follow-up: stiff aTSAs (85) to non-stiff aTSAs (85); stiff rTSAs (74) to non-stiff rTSAs (74); and stiff rTSAs (64) to stiff aTSAs (64). We the compared ROMs, outcome scores, and complication and revision rates.Aims
Methods
Corticosteroid injections are often used to manage glenohumeral arthritis in patients who may be candidates for future total shoulder arthroplasty (TSA) or reverse shoulder arthroplasty (rTSA). In the conservative management of these patients, corticosteroid injections are often provided for symptomatic relief. The purpose of this study was to determine if the timing of corticosteroid injections prior to TSA or rTSA is associated with changes in rates of revision and periprosthetic joint infection (PJI) following these procedures. Data were collected from a national insurance database from January 2006 to December 2017. Patients who underwent shoulder corticosteroid injection within one year prior to ipsilateral TSA or rTSA were identified and stratified into the following cohorts: < three months, three to six months, six to nine months, and nine to 12 months from time of corticosteroid injection to TSA or rTSA. A control cohort with no corticosteroid injection within one year prior to TSA or rTSA was used for comparison. Univariate and multivariate analyses were conducted to determine the association between specific time intervals and outcomes.Aims
Methods
Despite recent advances in arthroscopic rotator cuff repair, re-tear rates remain high. New methods to improve healing rates following rotator cuff repair must be sought. Our primary objective was to determine if adjunctive bone marrow stimulation with channelling five to seven days prior to arthroscopic cuff repair would lead to higher Western Ontario Rotator Cuff (WORC) scores at 24 months postoperatively compared with no channelling. A prospective, randomized controlled trial was conducted in patients undergoing arthroscopic rotator cuff repair. Patients were randomized to receive either a percutaneous bone channelling of the rotator cuff footprint or a sham procedure under ultrasound guidance five to seven days prior to index surgery. Outcome measures included the WORC, American Shoulder and Elbow Surgeons (ASES), and Constant scores, strength, ultrasound-determined healing rates, and adverse events.Aims
Methods
The purpose of this study was to evaluate the cost of reverse shoulder arthroplasty (RSA) for patients with a proximal humerus fracture, using time-driven activity based costing (TDABC), and to compare treatment costs with reimbursement under the Healthcare Resource Groups (HRGs). TDABC analysis based on the principles outlined by Kaplan and a clinical pathway that has previously been validated for this institution was used. Staffing cost, consumables, implants, and overheads were updated to reflect 2019/2020 costs. This was compared with the HRG reimbursements.Aims
Methods
The purpose of this study was to determine whether there were long-term differences in outcomes of reverse shoulder arthroplasty (RSA) undertaken for acute proximal humeral fracture versus rotator cuff deficiency with a minimum follow-up of five years. This was a prospective cohort study comparing 67 patients with acute complex proximal humeral fracture and 64 patients with irreparable rotator cuff deficiency who underwent primary RSA. In the fracture group, there were 52 (77.6%) females and 15 (22.4%) males, with a mean age of 73.5 years (51 to 85), while in the arthropathy group, there were 43 (67.1%) females and 21 (32.9%) males, with a mean age of 70.6 years (50 to 84). Patients were assessed by the Constant score, University of California Los Angeles shoulder score (UCLA), short version of the Disability of the Arm Shoulder and Hand score (QuickDASH), and visual analogue scales (VAS) for pain and satisfaction. Radiological evaluation was also performed.Aims
Methods
The aim of this study was to compare patient-reported outcome measures (PROMs) and the Single Assessment Numerical Evaluation (SANE) score in patients treated with a volar locking plate for a distal radial fracture. This study was a retrospective review of a prospective database of 155 patients who underwent internal fixation with a volar locking plate for a distal radial fracture between August 2014 and April 2017. Data which were collected included postoperative PROMs (Disabilities of the Arm, Shoulder, and Hand questionnaire (DASH) and Patient-Rated Wrist Evaluation (PRWE)), and SANE scores at one month (n = 153), two months (n = 155), three months (n = 144), six months (n = 128), and one year (n = 73) after operation. Patients with incomplete data were excluded from this study. Correlation and agreement between PROMs and SANE scores were evaluated. Subgroup analyses were carried out to identify correlations according to variables such as age, the length of follow-up, and subcategories of the PRWE score.Aims
Methods
The long head of the biceps (LHB) is often resected in shoulder surgery and could therefore serve as a cell source for tissue engineering approaches in the shoulder. However, whether it represents a suitable cell source for regenerative approaches, both in the inflamed and non-inflamed states, remains unclear. In the present study, inflamed and native human LHBs were comparatively characterized for features of regeneration. In total, 22 resected LHB tendons were classified into inflamed samples (n = 11) and non-inflamed samples (n = 11). Proliferation potential and specific marker gene expression of primary LHB-derived cell cultures were analyzed. Multipotentiality, including osteogenic, adipogenic, chondrogenic, and tenogenic differentiation potential of both groups were compared under respective lineage-specific culture conditions.Objectives
Methods
Reverse shoulder arthroplasty (RSA) reliably improves shoulder pain and function for a variety of indications. However, the safety and efficacy of RSA in elderly patients is largely unknown. The purpose of this study was to report the mortality, morbidity, complications, reoperations, and outcomes of primary RSA in patients aged > 80 years. Between 2004 and 2013, 242 consecutive primary RSAs were performed in patients aged > 80 years (mean 83.3 years (Aims
Patients and Methods
A number of methods have been described to remove a well-fixed humeral implant as part of revision shoulder arthroplasty. These include the use of cortical windows and humeral osteotomies. The router bit extraction technique uses a high-speed router bit to disrupt the bone-implant interface. The implant is then struck in a retrograde fashion with a square-tip impactor and mallet. The purpose of this study was to determine the characteristics and frequency of the different techniques needed for the removal of a well-fixed humeral stem in revision shoulder arthroplasty. Between 2010 and 2018, 288 revision shoulder arthroplasty procedures requiring removal of a well-fixed humeral component were carried out at a tertiary referral centre by a single surgeon. The patient demographics, indications for surgery, and method of extraction were collected.Aims
Patients and Methods
To compare complication-related reoperation rates following primary arthroplasty for proximal humerus fractures (PHFs) We identified patients aged 50 years and over, who sustained a PHF between 2004 and 2015, from linkable datasets. We used intervention codes to identify patients treated with initial ORIF or arthroplasty, and those treated with ORIF who returned for revision arthroplasty within two years. We used multilevel logistic regression to compare reoperations between groups.Aims
Patients and Methods
To date, no study has considered the impact of acromial morphology on shoulder range of movement (ROM). The purpose of our study was to evaluate the effects of lateralization of the centre of rotation (COR) and neck-shaft angle (NSA) on shoulder ROM after reverse shoulder arthroplasty (RSA) in patients with different scapular morphologies. 3D computer models were constructed from CT scans of 12 patients with a critical shoulder angle (CSA) of 25°, 30°, 35°, and 40°. For each model, shoulder ROM was evaluated at a NSA of 135° and 145°, and lateralization of 0 mm, 5 mm, and 10 mm for seven standardized movements: glenohumeral abduction, adduction, forward flexion, extension, internal rotation with the arm at 90° of abduction, as well as external rotation with the arm at 10° and 90° of abduction.Objectives
Methods
The primary aim of this study was to establish the cost-effectiveness of the early fixation of displaced midshaft clavicle fractures. A cost analysis was conducted within a randomized controlled trial comparing conservative management (n = 92) Aims
Patients and Methods
Failure of healing is a well-known problem after repair of the rotator cuff. This study aimed to investigate if early repair of trauma-related full-thickness rotator cuff tears (FTRCTs) could prevent this failure. In this prospective trial, 62 consecutive patients (14 women (23%), 48 men (77%); median age 61 years (interquartile range (IQR) 54 to 65)) with trauma-related FTRCT underwent arthroscopic single-row repair within six weeks of trauma. Tendon integrity was assessed one year after surgery using the Sugaya score on MR images. Patients were followed up with Western Ontario Rotator Cuff (WORC) index, EuroQol visual analogue scale (EQ VAS), and the Constant–Murley score (CS) two years after repair.Aims
Patients and Methods
The aim of this study was to report the outcomes of different treatment options for glenoid loosening following reverse shoulder arthroplasty (RSA) at a minimum follow-up of two years. We retrospectively studied the records of 79 patients (19 men, 60 women; 84 shoulders) aged 70.4 years (21 to 87) treated for aseptic loosening of the glenosphere following RSA. Clinical evaluation included pre- and post-treatment active anterior elevation (AAE), external rotation, and Constant score.Aims
Patients and Methods
Indocyanine green (ICG) fluorescence angiography is an emerging technique that can provide detailed anatomical information during surgery. The purpose of this study is to determine whether ICG fluorescence angiography can be used to evaluate the blood flow of the rotator cuff tendon in the clinical setting. Twenty-six patients were evaluated from October 2016 to December 2017. The participants were categorized into three groups based on their diagnoses: the rotator cuff tear group; normal rotator cuff group; and adhesive capsulitis group. After establishing a posterior standard viewing portal, intravenous administration of ICG at 0.2 mg/kg body weight was performed, and fluorescence images were recorded. The time from injection of the drug to the beginning of enhancement of the observed area was measured. The hypovascular area in the rotator cuff was evaluated, and the ratio of the hypovascular area to the anterolateral area of the rotator cuff tendon was calculated (hypovascular area ratio).Objectives
Methods
Nerve transfer has become a common and often effective reconstructive strategy for proximal and complex peripheral nerve injuries of the upper limb. This case-based discussion explores the principles and potential benefits of nerve transfer surgery and offers in-depth discussion of several established and valuable techniques including: motor transfer for elbow flexion after musculocutaneous nerve injury, deltoid reanimation for axillary nerve palsy, intrinsic re-innervation following proximal ulnar nerve repair, and critical sensory recovery despite non-reconstructable median nerve lesions.Abstract
The Walch Type C dysplastic glenoid is characterized by excessive
retroversion. This anatomical study describes its morphology. A total of 29 shoulders with a dysplastic glenoid were analyzed.
CT was used to measure retroversion, inclination, height, width,
radius-of-curvature, surface area, depth, subluxation of the humeral
head and the Goutallier classification of fatty infiltration. The
severity of dysplasia and deficiency of the posterior rim of the
glenoid were recorded.Aims
Patients and Methods
Controversy about the use of an anatomical total shoulder arthroplasty
(aTSA) in young arthritic patients relates to which is the ideal
form of fixation for the glenoid component: cemented or cementless.
This study aimed to evaluate implant survival of aTSA when used
in patients aged < 60 years with primary glenohumeral osteoarthritis (OA),
and to compare the survival of cemented all-polyethylene and cementless
metal-backed glenoid components. A total of 69 consecutive aTSAs were performed in 67 patients
aged < 60 years with primary glenohumeral OA. Their mean age
at the time of surgery was 54 years (35 to 60). Of these aTSAs,
46 were undertaken using a cemented polyethylene component and 23
were undertaken using a cementless metal-backed component. The age, gender,
preoperative function, mobility, premorbid glenoid erosion, and
length of follow-up were comparable in the two groups. The patients
were reviewed clinically and radiographically at a mean of 10.3
years (5 to 12, Aims
Materials and Methods
Our aim was to investigate the prevalence of A total of 46 patients undergoing either an arthroscopic capsular
release or stabilisation had biopsies taken from the subcutaneous
fat and capsule of the shoulder at the time of surgery. These samples
were sent for culture in enrichment, and also for Nucleic Acid Amplification
testing. The prevalence of Aims
Patients and Methods
Accurate characterisation of fractures is essential in fracture management trials. However, this is often hampered by poor inter-observer agreement. This article describes the practicalities of defining the fracture population, based on the Neer classification, within a pragmatic multicentre randomised controlled trial in which surgical treatment was compared with non-surgical treatment in adults with displaced fractures of the proximal humerus involving the surgical neck. The trial manual illustrated the Neer classification of proximal humeral fractures. However, in addition to surgical neck displacement, surgeons assessing patient eligibility reported on whether either or both of the tuberosities were involved. Anonymised electronic versions of baseline radiographs were sought for all 250 trial participants. A protocol, data collection tool and training presentation were developed and tested in a pilot study. These were then used in a formal assessment and classification of the trial fractures by two independent senior orthopaedic shoulder trauma surgeons.Objectives
Methods
The aim of the study was to develop a quantitative scoring system
to predict whether a large-to-massive rotator cuff tear was arthroscopically
reparable prior to surgery. We conducted a retrospective review of the pre-operative MR imaging
and surgical records of 87 patients (87 shoulders) who underwent
arthroscopic repair of a large-to-massive rotator cuff tear. Patients
were divided into two groups, based on the surgical outcome of the
repair. Of the 87 patients, 53 underwent complete repair (Group
I) and 34 an incomplete repair (Group II). Pre-operative MR images
were reviewed to quantify several variables. Between-group differences
were evaluated and multiple logistic regression analysis was used
to calculate the predictive value of significant variables. The
reparability index (RI) was constructed using the odds ratios of
significant variables and a receiver operating characteristic curve
analysis performed to identify the optimal RI cutoff to differentiate
between the two groups.Aims
Patients and Methods
Heterotopic ossification (HO) occurs after arthroplasty, especially
total hip arthroplasty. In this study we describe the incidence,
evolution, morphology and clinical consequences of HO following
reverse shoulder arthroplasty. This is a single-centre retrospective study of 132 consecutive
patients who received a Delta III or Delta Xtend reverse total shoulder
arthroplasty between 2006 and 2013 for the treatment of cuff tear
arthropathy. There were 96 women and 36 men. Their mean age at the
time of surgery was 69 years (49 to 89) and the mean follow-up was
36 months (12 to 84). The incidence, evolution, morphology and clinical
consequences of HO using the Constant-Murley score (CS) were analysed.
A modified Brooker classification of HO of the hip was used.Aims
Patients and Methods
Our aim was to investigate the outcomes of patients with a displaced
fracture of the glenoid fossa who are treated conservatively. There
is little information in the literature about the treatment of these
rare injuries non-operatively. We reviewed 24 patients with a mean age of 52 years (19 to 81)
at a mean of 5.6 years (11 months to 18 years) after the injury.Aims
Patients and Methods
The December 2014 Shoulder &
Elbow Roundup360 looks at: cuff tears and plexus injury; corticosteroids and physiotherapy in SAI; diabetes and elbow arthroplasty; distal biceps tendon repairs; shockwave therapy in frozen shoulder; hydrodilation and steroids for adhesive capsulitis; just what do our patients read?; and what happens to that stable radial head fracture?
The eccentric glenosphere was principally introduced into reverse
shoulder arthroplasty to reduce the incidence of scapular notching.
There is only limited information about the influence of its design
on deltoid power and joint reaction forces. The aim of our study was to investigate how the diameter and
eccentricity of the glenosphere affect the biomechanics of the deltoid
and the resultant joint reaction forces. Different sizes of glenosphere and eccentricity were serially
tested in ten cadaveric shoulders using a custom shoulder movement
simulator.Aims
Methods
In this study, we evaluated patient-reported
outcomes, the rate of revision and the indications for revision
following resurfacing hemiarthroplasty of the shoulder in patients
with osteoarthritis. All patients with osteoarthritis who underwent primary resurfacing
hemiarthroplasty and reported to the Danish Shoulder Arthroplasty
Registry (DSR), between January 2006 and December 2010 were included.
There were 772 patients (837 arthroplasties) in the study. The Western
Ontario Osteoarthritis of the Shoulder (WOOS) index was used to
evaluate patient-reported outcome 12 months (10 to 14) post-operatively.
The rates of revision were calculated from the revisions reported
to the DSR up to December 2011 and by checking deaths with the Danish National
Register of Persons. A complete questionnaire was returned by 688 patients (82.2%).
The mean WOOS was 67 (0 to 100). A total of 63 hemiarthroplasties
(7.5%) required revision; the cumulative five-year rate of revision
was 9.9%. Patients aged <
55 years had a statistically significant
inferior WOOS score, which exceeded the minimal clinically important
difference, compared with older patients (mean difference 14.2 (8.8;
95% CI 19.6; p <
0.001), but with no increased risk of revision.
There was no significant difference in the mean WOOS or the risk
of revision between designs of resurfacing hemiarthroplasty. Cite this article:
The August 2013 Shoulder &
Elbow Roundup360 looks at: the sternoclavicular joint revisited; surgical simulators: more than just a fancy idea?; arthroscopic tennis elbow release; costly clavicle stabilisation; a better treatment for tennis elbow?; shock news: surgeons and radiologists agree; overhead athletes and SLAP repair; and total shoulder arthroplasty more effective than hemiarthroplasty
This study compared the clinical outcomes following
mini-open rotator cuff repair (MORCR) between early mobilisation
and usual care, involving initial immobilisation. In total, 189
patients with radiologically-confirmed full-thickness rotator cuff
tears underwent MORCR and were randomised to either early mobilisation
(n = 97) or standard rehabilitation (n = 92) groups. Patients were
assessed at six weeks and three, six, 12 and 24 months post-operatively.
Six-week range of movement comparisons demonstrated significantly
increased abduction (p = 0.002) and scapular plane elevation (p
= 0.006) in the early mobilisation group, an effect which was not
detectable at three months (p >
0.51) or afterwards. At 24 months
post-operatively, patients who performed pain-free, early active mobilisation
for activities of daily living showed no difference in clinical
outcomes from patients immobilised for six weeks following MORCR.
We suggest that the choice of rehabilitation regime following MORCR
may be left to the discretion of the patient and the treating surgeon. Cite this article:
Failed internal fixation of a fracture of the
proximal humerus produces many challenges with limited surgical options.
The aim of this study was to evaluate the clinical outcomes after
the use of a reverse shoulder arthroplasty under these circumstances.
Between 2007 and 2012, 19 patients (15 women and four men, mean
age 66 years; 52 to 82) with failed internal fixation after a proximal
humeral fracture, underwent implant removal and reverse shoulder arthroplasty
(RSA). The mean follow-up was 36 months (25 to 60). The mean American
Shoulder and Elbow Score improved from 27.8 to 50.1 (p = 0.019).
The mean Simple Shoulder Test score improved from 0.7 to 3.2 (p
= 0.020), and the mean visual analogue scale for pain improved from
6.8 to 4.3 (p = 0.012). Mean forward flexion improved from 58.7°
to 101.1° (p <
0.001), mean abduction from 58.7° to 89.1° (p
= 0.012), mean external rotation from 10.7° to 23.1° (p = 0.043)
and mean internal rotation from buttocks to L4 (p = 0.034). A major
complication was recorded in five patients (26%) (one intra-operative
fracture, loosening of the humeral component in two and two peri-prosthetic
fractures). A total of 15 patients (79%) rated their outcome as
excellent or good, one (5%) as satisfactory, and three (16%) as
unsatisfactory. An improvement in outcomes and pain can be expected when performing
a RSA as a salvage procedure after failed internal fixation of a
fracture of the proximal humerus. Patients should be cautioned about
the possibility for major complications following this technically
demanding procedure. Cite this article:
The February 2014 Shoulder &
Elbow Roundup360 looks at: whether arthroscopic acromioplasty is a cost-effective intervention; shockwave therapy in cuff tear; whether microfracture relieves short-term pain in cuff repair; the promising early results from L-PRF augmented cuff repairs; rehabilitation following cuff repair; supination strength following biceps tendon rupture; whether longer is better in humeral components; fatty degeneration in a rodent model; and the controversial acromioclavicular joint dislocation.
The October 2014 Shoulder &
Elbow Roundup360 looks at: PRP is not effective in tennis elbow; eccentric physiotherapy effective in subacromial pain; dexamethasone in shoulder surgery; arthroscopic remplissage for engaging Hill-Sach’s lesions; a consistent approach to subacromial impingement; delay in fixation of proximal humeral fractures detrimental to outcomes.
In the UK we have many surgeon inventors – surgeons who innovate and create new ways of doing things, who invent operations, who design new instruments to facilitate surgery or design new implants for using in patients. However truly successful surgeon inventors are a rare breed and they need to develop additional knowledge and skills during their career in order to push forward their devices and innovations. This article reviews my own experiences as a surgeon inventor and the highs and lows over the whole of my surgical career.
Short uncemented humeral stems can preserve humeral
bone stock and facilitate revision surgery but may be prone to malalignment
or loosening, especially when used in reverse total shoulder replacement
(TSR). We undertook a retrospective review of 44 patients with a
mean age of 76 years (59 to 92) who underwent primary reverse TSR
with a short uncemented humeral stem. There were 29 females. The
indications for joint replacement included cuff tear associated
arthropathy (33), avascular necrosis (six), post-traumatic arthritis
(two), and inflammatory arthritis (three). At a mean follow-up of
27 months (24 to 40), pain was rated as mild or none in 43 shoulders
(97.7%). The mean active elevation improved from 54° Cite this article:
This protocol describes a pragmatic multicentre
randomised controlled trial (RCT) to assess the clinical and cost
effectiveness of arthroscopic and open surgery in the management
of rotator cuff tears. This trial began in 2007 and was modified
in 2010, with the removal of a non-operative arm due to high rates
of early crossover to surgery. Cite this article:
While the Cochrane Collaboration have been busy over the last four months, only a handful of their published reviews have been of any relevance to orthopaedic and trauma surgeons. Those that are provide the reader with an overview of work on imaging modalities, antibiotic therapy, changes to the surgical site dressing and practices surrounding post-operative wound management, including post-op bathing and negative pressure wound therapy for use in the treatment of diabetic foot wounds.
The December 2013 Shoulder &
Elbow Roundup360 looks at: Platelet-rich plasma; Arthroscopic treatment of sternoclavicular joint osteoarthritis; Synchronous arthrolysis and cuff repair; Arthroscopic arthrolysis; Regional blockade in the beach chair; Recurrent instability; Avoiding iatrogenic nerve injury in elbow arthroscopy; and Complex reconstruction of total elbow revisions
We explored the trends over time and the geographical
variation in the use of subacromial decompression and rotator cuff
repair in 152 local health areas (Primary Care Trusts) across England.
The diagnostic and procedure codes of patients undergoing certain
elective shoulder operations between 2000/2001 and 2009/2010 were extracted
from the Hospital Episode Statistics database. They were grouped
as 1) subacromial decompression only, 2) subacromial decompression
with rotator cuff repair, and 3) rotator cuff repair only. The number of patients undergoing subacromial decompression alone
rose by 746.4% from 2523 in 2000/2001 (5.2/100 000 (95% confidence
interval (CI) 5.0 to 5.4) to 21 355 in 2009/2010 (40.2/100 000 (95%
CI 39.7 to 40.8)). Operations for rotator cuff repair alone peaked
in 2008/2009 (4.7/100 000 (95% CI 4.5 to 4.8)) and declined considerably
in 2009/2010 (2.6/100 000 (95% CI 2.5 to 2.7)). Given the lack of evidence for the effectiveness of these operations
and the significant increase in the number of procedures being performed
in England and elsewhere, there is an urgent need for well-designed
clinical trials to determine evidence of clinical effectiveness. Cite this article: Bone Joint J 2014;96-B:70–4.
We have compared three different methods of treating
symptomatic non-traumatic tears of the supraspinatus tendon in patients
above 55 years of age. A total of 180 shoulders (173 patients) with
supraspinatus tendon tears were randomly allocated into one of three
groups (each of 60 shoulders); physiotherapy (group 1), acromioplasty and
physiotherapy (group 2) and rotator cuff repair, acromioplasty and
physiotherapy (group 3). The Constant score was assessed and followed
up by an independent observer pre-operatively and at three, six
and twelve months after the intervention. Of these, 167 shoulders were available for assessment at one
year (follow-up rate of 92.8%). There were 55 shoulders in group
1 (24 in males and 31 in females, mean age 65 years (55 to 79)),
57 in group 2 (29 male and 28 female, mean age 65 years (55 to 79))
and 55 shoulders in group 3 (26 male and 29 female, mean age 65
years (55 to 81)). There were no between-group differences in the
Constant score at final follow-up: 74.1 ( Cite this article:
The October 2013 Shoulder &
Elbow Roundup360 looks at: Deltoid impairment not necessarily a contra-indication for shoulder arthroplasty; The tricky radiograph; Not so asymptomatic cuff tears; Total shoulder arthroplasty: kinder on the glenoid; Barbotage for calcific tendonitis; What happens to the arthritic glenoid?; Two screws a screw too few?; Sloppy hinge best for elbow arthroplasty.
Instability after arthroplasty of the shoulder
is difficult to correct surgically. Soft-tissue procedures and revision surgery
using unconstrained anatomical components are associated with a
high rate of failure. The purpose of this study was to determine
the results of revision of an unstable anatomical shoulder arthroplasty
to a reverse design prosthesis. Between 2004 and 2007, 33 unstable
anatomical shoulder arthroplasties were revised to a reverse design.
The mean age of the patients was 71 years (53 to 86) and their mean
follow-up was 42 months (25 to 71). The mean time to revision was
26 months (4 to 164). Pain scores improved significantly (pre-operative
visual analogue scale (VAS) of 7.2 ( Cite this article:
This review discusses the pathogenesis and surgical treatment of tears of the rotator cuff.
The August 2012 Shoulder &
Elbow Roundup360 looks at: platelet-rich fibrin matrix and the torn rotator cuff; ultrasound, trainees, and ducks out of water; the torn rotator cuff and conservative treatment; Bankart repair and subsequent degenerative change; proprioception after shoulder replacement; surgery for a terrible triad, with reasonable short-term results; and the WORC Index.
The aim of this study was to determine whether there is any significant
difference in temporal measurements of pain, function and rates
of re-tear for arthroscopic rotator cuff repair (RCR) patients compared
with those patients undergoing open RCR. This study compared questionnaire- and clinical examination-based
outcomes over two years or longer for two series of patients who
met the inclusion criteria: 200 open RCR and 200 arthroscopic RCR
patients. All surgery was performed by a single surgeon. Objectives
Methods
Radiological changes and differences between cemented and uncemented components of Grammont reverse shoulder arthroplasties (DePuy) were analysed at a mean follow-up of 9.6 years (8 to 12). Of 122 reverse shoulder arthroplasties implanted in five shoulder centres between 1993 and 2000, a total of 68 (65 patients) were available for study. The indications for reversed shoulder arthroplasty were cuff tear arthropathy in 48 shoulders, revision of shoulder prostheses of various types in 11 and massive cuff tear in nine. The development of scapular notching, bony scapular spur formation, heterotopic ossification, glenoid and humeral radiolucencies, stem subsidence, radiological signs of stress shielding and resorption of the tuberosities were assessed on standardised true anteroposterior and axillary radiographs. A scapular notch was observed in 60 shoulders (88%) and was associated with the superolateral approach (p = 0.009). Glenoid radiolucency was present in 11 (16%), bony scapular spur and/or ossifications in 51 (75%), and subsidence of the stem and humeral radiolucency in more than three zones were present in three (8.8%) and in four (11.8%) of 34 cemented components, respectively, and in one (2.9%) and two (5.9%) of 34 uncemented components, respectively. Radiological signs of stress shielding were significantly more frequent with uncemented components (p <
0.001), as was resorption of the greater (p <
0.001) and lesser tuberosities (p = 0.009).
We report the long-term clinical and radiological outcomes of the Aequalis total shoulder replacement with a cemented all-polyethylene flat-back keeled glenoid component implanted for primary osteoarthritis between 1991 and 2003 in nine European centres. A total of 226 shoulders in 210 patients were retrospectively reviewed at a mean of 122.7 months (61 to 219) or at revision. Clinical outcome was assessed using the Constant score, patient satisfaction score and range of movement. Kaplan-Meier survivorship analysis was performed with glenoid revision for loosening and radiological glenoid loosening ( Younger patient age and the curettage technique for glenoid preparation correlated with loosening. The rate of glenoid revision and radiological loosening increased with duration of follow-up, but not until a follow-up of five years. Therefore, we recommend that future studies reporting radiological outcomes of new glenoid designs should report follow-up of at least five to ten years.
There are many types of treatment used to manage the frozen shoulder, but there is no consensus on how best to manage patients with this painful and debilitating condition. We conducted a review of the evidence of the effectiveness of interventions used to manage primary frozen shoulder using the Cochrane Database of Systematic Reviews, the Database of Abstracts of Reviews of Effects, the Physiotherapy Evidence Database, MEDLINE and EMBASE without language or date restrictions up to April 2009. Two authors independently applied selection criteria and assessed the quality of systematic reviews using the Assessment of Multiple Systematic Reviews (AMSTAR) tool. Data were synthesised narratively, with emphasis placed on assessing the quality of evidence. In total, 758 titles and abstracts were identified and screened, which resulted in the inclusion of 11 systematic reviews. Although these met most of the AMSTAR quality criteria, there was insufficient evidence to draw firm conclusions about the effectiveness of treatments commonly used to manage a frozen shoulder. This was mostly due to poor methodological quality and small sample size in primary studies included in the reviews. We found no reviews evaluating surgical interventions. More rigorous randomised trials are needed to evaluate the treatments used for frozen shoulder.
In an osteological collection of 3100 specimens, 70 were found with unilateral clavicular fractures which were matched with 70 randomly selected normal specimens. This formed the basis of a study of the incidence of arthritis of the acromioclavicular joint and the effect of clavicular fracture on the development of arthritis in the ipsilateral acromioclavicular joint. This was graded visually on a severity scale of 0 to 3. The incidence of moderate to severe arthritis of the acromioclavicular joint in normal specimens was 77% (100 specimens). In those with a clavicular fracture, 66 of 70 (94%) had arthritis of the acromioclavicular joint, compared to 63 of 70 (90%) on the non-injured contralateral side (p = 0.35). Clavicles with shortening of 15 mm or less had no difference in the incidence of arthritis compared to those with shortening greater than 15 mm (p = 0.25). The location of the fracture had no effect on the development of arthritis.
Muscle atrophy has been demonstrated in patients suffering from osteoarthritis of the hip, but little is known about muscular recovery after total hip replacement (THR). A total of 20 patients with unilateral osteoarthritis of the hip were assessed before, six months and two years after THR. The cross-sectional area and radiological density of the muscles of the hip, thigh, calf and back were measured using CT. We hypothesised that the muscles would not recover fully after operation. After two years comparison of the limb with the THR with the healthy limb showed that there was such a reduction in the cross-sectional area in iliopsoas (7.0%; p = 0.006) and the hip adductors (8.4%, p = 0.003) and in the radiological density in gluteus maximus (10.1 Hounsfield units; p <
0.001), gluteus medius/minimus (5.6 Hounsfield units; p = 0.011), iliopsoas (3.9 Hounsfield units; p <
0.001) and the adductors (2.4 Hounsfield units; p = 0.022). Thus, there was persistent muscle atrophy in muscles acting about the hip two years after THR. We suggest that an earlier operation or a more intensive rehabilitation may reverse these changes.
In a prospective randomised study we compared the results of arthroscopic subacromial bursectomy alone with debridement of the subacromial bursa followed by acromioplasty. A total of 57 patients with a mean age of 47 years (31 to 60) suffering from primary subacromial impingement without a rupture of the rotator cuff who had failed previous conservative treatment were entered into the trial. The type of acromion was classified according to Bigliani. Patients were assessed at follow-up using the Constant score, the simple shoulder test and visual analogue scores for pain and functional impairment. One patient was lost to follow-up. At a mean follow-up of 2.5 years (1 to 5) both bursectomy and acromioplasty gave good clinical results. No statistically significant differences were found between the two treatments. The type of acromion and severity of symptoms had a greater influence on the clinical outcome than the type of treatment. As a result, we believe that primary subacromial impingement syndrome is largely an intrinsic degenerative condition rather than an extrinsic mechanical disorder.
We performed a comprehensive systematic review of the literature to examine the role of hemiarthroplasty in the early management of fractures of the proximal humerus. In all, 16 studies dealing with 810 hemiarthroplasties in 808 patients with a mean age of 67.7 years (22 to 91) and a mean follow-up of 3.7 years (0.66 to 14) met the inclusion criteria. Most of the fractures were four-part fractures or fracture-dislocations. Several types of prosthesis were used. Early passive movement on the day after surgery and active movement after union of the tuberosities at about six weeks was described in most cases. The mean active anterior elevation was to 105.7° (10° to 180°) and the mean abduction to 92.4° (15° to 170°). The incidence of superficial and deep infection was 1.55% and 0.64%, respectively. Complications related to the fixation and healing of the tuberosities were observed in 86 of 771 cases (11.15%). The estimated incidence of heterotopic ossification was 8.8% and that of proximal migration of the humeral head 6.8%. The mean Constant score was 56.63 (11 to 98). At the final follow-up, no pain or only mild pain was experienced by most patients, but marked limitation of function persisted.
In a prospective, randomised study on the repair of tears of the rotator cuff we compared the clinical results of two suture techniques for which different suture materials were used. We prospectively randomised 100 patients with tears of the rotator cuff into two groups. Group 1 had transosseous repair with No. 3 Ethibond using modified Mason-Allen sutures and group 2 had transosseous repair with 1.0 mm polydioxanone cord using modified Kessler sutures. After 24 to 30 months the patients were evaluated clinically using the Constant score and by ultrasonography. Of the 100 patients, 92 completed the study. No significant statistical difference was seen between the two groups: Constant score, 91% Overall, seven patients had complications which required revision surgery, in four for pain (two in each group) and in three for infection (two in group 1 and one in group 2).
