Accelerated rehabilitation following reverse total shoulder arthroplasty.

BACKGROUND: Postoperative rehabilitation is considered essential and indeed routine practice following rTSA. However, the optimal approach to postoperative rehabilitation is unknown, based on protocols for anatomic TSA, and published literature is sparse, as is the quantity and quality of research evidence. The aim of this study is to outline the accelerated rehabilitation protocol (with immediate activity and no immobilization at all) following reverse total shoulder arthroplasty (rTSA) and assess its safety and effectiveness compared to the more conservative rehabilitation protocols of immobilization in a sling for 6 weeks and for 3 weeks. MATERIALS AND METHODS: Between July 2005 and October 2017, a total of 357 consecutive rTSA in 320 patients underwent a primary rTSA and were included in the study. Patients were divided into 3 groups depending on rehabilitation protocol (6 and 3 weeks' postoperative immobilization, respectively, for groups 1 and 2, and no immobilization for group 3). Patients were assessed preoperatively and reviewed at 3 weeks, 3, 6, and 12 months, and yearly thereafter postoperatively. Constant score (CS), Subjective Shoulder Value (SSV), patient satisfaction, and pain scores were used at each appointment and patients assessed both clinically and radiographically. RESULTS: Mean age at surgery was 76 years (range 40-93). At 1-year follow-up, the CS improved from 16.6 (adjusted 23.9) to 63.2 (adjusted 91.5) in group 1 (n = 114), from 21.5 (adjusted 30.7) to 67.7 (adjusted 98.4) in group 2 (n = 125), and from 22.6 (adjusted 31.3) to 66.6 (adjusted 94.9) in group 3 (n = 118). Pain score improved from 3.1/15 preoperatively to 12.5/15 postoperatively in group 1, from 3.5/15 to 13/15 in group 2, and from 3.7/15 to 12.5/15 in group 3. SSV improved to 8.5/10, 8.6/10, and 8.1/10 for groups 1, 2, and 3, respectively. Mean range of motion (ROM) improved to 142° elevation and 131° abduction in group 1, 153° elevation and 144° abduction in group 2, and 149° elevation and 146° abduction in group 3. No statistically significance differences were observed in CS, SSV, patient satisfaction, pain, and ROM between the 3 groups. Less postoperative complications were observed in group 3 (No immobilization). CONCLUSION: Accelerated rehabilitation regime post rTSA without immobilization is safe and lead to reliable good clinical results and quick return to function. This study confirms noninferiority of the accelerated rehabilitation regime with fewer postoperative complications related to falls. Accelerated rehabilitation regime post rTSA have further psychological and emotional advantage to the patient, with earlier return to normal function and regaining independence. We recommend the accelerated rehabilitation regime without immobilization following rTSA.

Cement Calcaneoplasty: An Innovative Method for Treating Nonunion in Calcaneal Insufficiency Fracture.

Insufficiency type stress fractures are common in older patients with osteoporosis. Persistent pain after nonunion of these fractures can be disabling, with the management options often limited. We aimed to assess the suitability of fluoroscopic-guided injection of bone cement into a persistently symptomatic nonuniting calcaneal insufficiency fracture. To the best of our knowledge, this technique has not previously been described in the published data. After local subcutaneous anesthesia, the midpoint of the fracture site was accessed by trocar insertion under radiographic guidance, and bone cement was injected directly into the site. A preprocedure visual analog scale pain score of 90 of 100 was recorded. This had improved to 0 of 100 at the 12-month follow-up point after the procedure. The aim of the present case report was to raise awareness of percutaneous calcaneoplasty, which we believe to be a safe and well-tolerated technique for the management of osteoporotic insufficiency fracture of the calcaneus. We propose that this technique be considered when conservative methods aimed at promoting fracture healing have failed.

A comparative study of radiation dose and screening time between mini C-arm and standard fluoroscopy in elective foot and ankle surgery.

BACKGROUND: Mini C-arm devices have gained popularity in extremity surgery. There is little evidence of the benefits of this technique in the clinical setting of foot and ankle surgery. We used dose area product (DAP) to compare radiation usage between mini C-arm and standard fluoroscopy. METHODS: We prospectively reviewed 127 cases requiring intra-operative screening during elective foot and ankle surgery. RESULTS: Mini C-arm was used in 55 patients and standard fluoroscopy in 72 patients. There was a statistically significant reduction in mean DAP using the mini C-arm, 3.46 Gy cm² vs 7.43 Gy cm² (P=0.0013). There was no difference in screening time. The annual saving from using the mini C-arm could be £9391, saving the total cost of the device over 5 years. CONCLUSION: The mini C-arm reduces radiation risk and costs when compared to standard fluoroscopy. We recommend its regular use in foot and ankle surgery.

Prospective assessment of dorsal cheilectomy for hallux rigidus using a patient-reported outcome score.

Compared with other surgical procedures for hallux rigidus, dorsal cheilectomy involves relatively less bone removal, maintains joint motion, and leaves the potential for further salvage surgery. The Manchester-Oxford Foot and Ankle Questionnaire (MOXFQ) has a maximum score of 64 (worst foot health) and has been endorsed by the British Foot and Ankle Society to measure surgical outcome. We prospectively assessed patient-reported outcomes after dorsal cheilectomy for hallux rigidus using the MOXFQ. Patients were deemed suitable for dorsal cheilectomy if they had painful restriction of terminal dorsiflexion, with absence of pain in the mid-range of passive movement, and radiographic evidence of dorsal osteophytosis. Twenty-five patients with a mean age of 62 years (range, 39-80 years), including 17 (68%) women, underwent dorsal cheilectomy for hallux rigidus. The mean preoperative MOXFQ score was 33.0 (95% confidence interval = 27.4-38.6), and, at a mean of 17 months (range, 9-27 months) follow-up, the mean postoperative score was 9.6 (95% confidence interval = 6.0-13.2). Eighty-four percent of patients experienced clinically significantly improved walking domain, 68% in the social domain, and 59% in the pain domain of the MOXFQ. Four patients failed cheilectomy, including 3 who subsequently underwent arthrodesis for persistent pain and 1 who experienced no improvement in any domain of the MOXFQ. This prospective study provided further evidence of the success of dorsal cheilectomy as a treatment for hallux rigidus and demonstrated the potential usefulness of the MOXFQ in assessing surgical outcomes in foot surgery.

The management of periprosthetic fractures Oxford trimodular femoral stem. A survivorship study.

A consecutive series of 40 periprosthetic femoral fractures, treated with revision hip surgery using the Oxford trimodular femoral stem, were retrospectively studied, with an average follow-up of 7.9 years. Fractures were classified according to the Vancouver classification. There were 5 type B1 fractures, 28 type B2, and 7 type C. Radiographic union was achieved in 38 (95%) hips. The mean time to fracture union was 3.5 months. The prosthesis survival at 5 years was 95% (confidence interval, 88%-100%). Clinical results were good with a mean Oxford hip score of 30 (hip score maximum, 48). Complications included 1 nonunion, 1 infection, 1 dislocation, and 2 aseptic loosening. The Oxford trimodular femoral component is a safe and reliable prosthesis for the treatment of periprosthetic femoral fractures with satisfactory medium-term results.

Determination of femoral component size in unicompartmental knee replacement.

It is difficult to determine the ideal size of femoral component when a unicompartmental knee replacement (UKR) is implanted with a minimally invasive approach. The aim of the study was to identify the best method of determining femoral component size pre-operatively. This was done by assessing the accuracy with which it could be predicted by pre-operative templating, patient height, gender and tibial component size. One hundred patients who had had Oxford UKR were studied. Pre-operative radiographs were templated and patient height, gender and implanted tibial component size were recorded. From a review of post-operative radiographs and the known size of component used the ideal size of component that should have been used was established. By relating patient height, gender and tibial component size to the ideal femoral component size the range of these various parameters that best predicted each component size was identified. The reliability of these predictions was assessed assuming that a component one size off ideal was acceptable and two sizes off was unacceptable. Templating was correct in 67% of cases, acceptable in 33% and was never unacceptable. Height alone was correct in 56%, acceptable in 38% and unacceptable in 6%. Height based on gender was correct in 75%, acceptable in 25% and was never unacceptable. Tibial size was correct in 56%, acceptable in 41% and unacceptable in 3%. We conclude that both templating and height based on gender are reliable methods of assessing femoral component size. However because errors can occur surgeons are advised to use both.

Coracoclavicular screw fixation for unstable distal clavicle fractures.

Fifteen patients with Neer type II distal clavicle fracture were treated surgically. Operative treatment included open reduction and fixation of the proximal clavicular fragment to the coracoid process using a 6.5-mm cancellous screw and repair of the coracoclavicular ligaments. Fracture union occurred at a mean of 7 weeks postoperatively without any serious complications. All patients returned to the pre-injury level of activity with no residual pain or dysfunction.

Open reduction and internal fixation of distal radial fractures using the Pi-plate.

The authors reviewed 22 patients with 23 fractures of the distal radius, who were treated by open reduction and internal fixation using the low profile contourable titanium dorsal distal radius AO Pi-plate. There were four men and 18 women with a mean age of 57 years. The mean follow up period was 26 months (range, 12-48 months). The modified Lidstrom's radiographic scoring system and the modified Gartland and Werley' functional scoring systems were used for evaluation of the outcome. An excellent clinical outcome was present in four patients, a good in 10, a fair in seven, and a poor in two. Radiographic results were excellent in 12 patients, good in 10, and fair in one patient. Seven patients required removal of the plate for median nerve compression and tendonitis. The Pi-plate can be used in a wide spectrum of distal radial fractures including complex comminuted intra-articular (AO type C3) fractures with satisfactory functional outcome and low rate of complication.