Comparison of Interventions for Lateral Elbow Tendinopathy: A Systematic Review and Network Meta-Analysis for Patient-Rated Tennis Elbow Evaluation Pain Outcome.

PURPOSE: There is controversy regarding the optimal treatment for lateral elbow tendinopathy (LET), and not all available treatment options have been compared directly with placebo/control. A network meta-analysis was conducted to compare the effectiveness of different LET treatments directly and indirectly against control/placebo based on a validated outcome, the Patient-Rated Tennis Elbow Evaluation (PRTEE) pain score. METHODS: Randomized, controlled trials comparing different treatment methods for LET were included, provided they reported outcome data using the PRTEE pain score. A network meta-analysis with random effect was used to combine direct and indirect evidence between treatments compared with placebo in the short term (up to six weeks) and midterm (more than six weeks and up to six months) after intervention. RESULTS: Thirteen studies with 12 comparators including control/placebo were eligible. The results indicated no significant improvement in PRTEE pain score in the short term across all treatments compared with control/placebo. In the midterm, physiotherapy/exercise showed benefit against placebo (mean difference: -4.32, 95% confidence interval: -7.58 and -1.07). Although steroid injections, dry needling, and autologous blood also exhibited potential treatment effects, it is crucial for the clinician to consider certain pitfalls when considering these treatments. The limited number of small studies and paucity of data call for caution in interpreting the results and need for further evidence. CONCLUSIONS: Patients should be informed that there is currently no strong evidence that any treatment produces more rapid improvement in pain symptoms when compared with control/placebo in the short and medium terms. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic I.

Total shoulder arthroplasty vs. hemiarthroplasty in patients with primary glenohumeral arthritis with intact rotator cuff: meta-analysis using the ratio of means.

BACKGROUND: Glenohumeral arthritis is a degenerative disease of the shoulder joint. There is limited evidence in the literature in superiority of outcomes between total shoulder arthroplasty (TSA) and hemiarthroplasty (HA) for patients when the rotator cuff is intact. The purpose of this systematic review was to compare patient-reported outcome measures (PROMs) and rate of complication between these 2 interventions in patients with primary glenohumeral arthritis and an intact rotator cuff. Previous systematic reviews have focused only on results from randomized controlled trials, demonstrating mixed outcomes in PROMs and no difference in postoperative complications or rate of revision. Our study is the first, to our knowledge, to assess all comparative studies including prospective and retrospective observational studies, assessing a combined 1317 patients. Using the ratio of means, data from different PROMs were pooled to analyze and compare the total combined relative effect change following intervention. METHODS: We undertook literature review of the reference databases until March 2021. We included randomized controlled trials in addition to comparative observational studies and case series (more than 10 patients). Study participants were adults who had primary glenohumeral arthritis with an intact rotator cuff. Meta-analysis was performed by the ratio of means for PROMs and risk ratio for revision and complication data. RESULTS: Comparing clinical outcome of TSA against HA from 10 studies, meta-analyses using ratio of means demonstrated an 8% significantly improved relative increase in the postoperative PROMs in the TSA cohort (ratio of means 1.08, 95% confidence interval [CI] 0.04-1.12, P < .01). The TSA cohort additionally demonstrated a significantly lower revision rate (relative risk 1.84, 95% CI 1.05-3.24, P = .03). Although the risk of complication was nonsignificant, pooling revision and complications data revealed a 2-fold increased risk in the HA group compared with TSA (relative risk 2.09, 95% CI 1.17-3.74, P = .01). CONCLUSIONS: In patients with primary glenohumeral osteoarthritis with an intact rotator cuff, TSA is favored to HA in terms of clinical outcome, risk of revision surgery, and postoperative complications.

Radial head replacement versus reconstruction for the treatment of the terrible triad injury of the elbow: a systematic review and meta-analysis.

INTRODUCTION: The terrible triad injury of the elbow (TTIE) remains challenging to manage and has been associated with high complication rates and poor outcomes. There is a trend towards performing radial head replacement (REP) in preference to radial head reconstruction (REC) as arthroplasty provides early stability and may allow mobilisation sooner, potentially resulting in a better functional outcome. This systematic review compares the outcome of patients with TTIE treated with either REC or REP. MATERIALS AND METHODS: MEDLINE, Embase, and CINAHL were searched for studies published in English involving at least ten patients exclusively with a TTIE managed operatively, including both patients with either REC or REP. Data collection was in accordance with the Preferred Reporting Items for Systematic Review and Meta-analysis protocol. The outcomes of interest were Mayo Elbow Performance Score (MEPS) and range of motion (ROM). Post-operative complications were also compared. RESULTS: 9 studies involving 210 patients were included (98 REPs and 112 RECs). There was no statistically significant difference (p = 0.51) demonstrated between in the mean MEPS of the REP group (mean 88.6) and REC group (mean 88.5). Similarly, there was no statistically significant difference demonstrated between the REP and REC groups in terms of ROM. The risk of re-operation was high in both the REP (18.4%) and REC (17.9%) group. The overall complication rate of all patients included in the study was high (65%). CONCLUSIONS: Comparable results with good outcomes in terms of functional scores and ROM can be achieved with both REP and REC when treating TTIE, although the re-operation rate for both remains relatively high. Given there is no apparent clear advantage between the two treatment groups, we would suggest that REC should be performed when a satisfactory fixation can be achieved as the longevity of REP in young patients with a TTIE is currently uncertain.

Agreement between patient-based and clinician-based assessment of the shoulder.

BACKGROUND: Patient home-based self-assessments after shoulder surgery have the potential to aid clinicians in reducing clinic time and decreasing follow-up requirements. The purpose of this systematic review was to determine the correlation between patient-based and physician-assessed outcome measures for range of motion (ROM), strength, and shoulder function. METHODS: This systematic review adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. MEDLINE, Embase, CINAHL, and Cochrane Central Register of Controlled Trials databases were searched. All studies comparing patient-reported and clinician-based assessments of shoulder ROM, strength, and function were eligible for inclusion. Studies that included patient or clinician assessment only, description of shoulder diseases or treatments only, and animal- or cadaveric-based studies were excluded. More than 250 abstracts were searched, and 4 studies were found eligible. RESULTS: Patients assessed their shoulder ROM, strength, and function with moderate-to-high accuracy compared with clinical assessment. There was less agreement between patients and clinicians regarding the symptomatic shoulder compared with the contralateral shoulder. There was less agreement between patients and clinicians on rotation than forward elevation. Patients who were less satisfied with their shoulder had less agreement with clinicians. CONCLUSION: There is moderate-to-high agreement between patients and clinicians in the assessment of the shoulder after surgery. Methods of assessment of rotation could be reviewed to create a more exact self-assessment tool.

A systematic review of management of scapular fractures.

There is no agreement within literature regarding management of scapula fractures. Our aim was to carry out a systematic review of literature on management of the scapular fractures. Our search across multiple medical databases for studies on the scapular fractures until February 2014 yielded 32 studies. We have excluded case series <7 patients, case reports, review articles, articles without abstract, observational studies and articles on fractures following shoulder arthroplasty. There were 8 prospective case series and one cohort study, however, majority of the included studies were retrospective studies. There were 1237 patients, follow up data were available for 941 patients who underwent either conservative (629) or operative management (512). Non-operative management scapular body fractures had satisfactory results. The scapular neck fractures displaced <10mm have satisfactory outcome following non-operative management. Operative management of displaced glenoid fossa fractures and scapular neck fractures displaced >10mm lead in a better functional outcome.

A preoperative scoring system to select patients for arthroscopic subacromial decompression.

BACKGROUND: This study investigated the clinical and radiographic factors that influence outcome after arthroscopic subacromial decompression (ASAD) for shoulder impingement syndrome. The goal was to develop a new preoperative scoring system to identify patients who would have a prompt and sustained benefit from ASAD. METHODS: We prospectively reviewed 112 consecutive patients with impingement syndrome who subsequently underwent ASAD. The Oxford Shoulder Score (OSS) was recorded preoperatively and 3 and 12 months postoperatively. A statistically significant improvement in OSS at 3 months after surgery was considered a good outcome. RESULTS: The variables associated with good outcome were shoulder pain with overhead activities, persistent symptoms for more than 6 months, symptoms persistent despite a 3-month course of supervised physiotherapy, consistently positive Hawkins test result, radiologic changes of impingement on both acromion and humerus in the subacromial region, and improvement for more than 1 week after a steroid injection. These 6 criteria were combined into a single score for this study, termed the preoperative score (PrOS). Sixty-two patients who had been symptomatic for 1 year with a preoperative score of 5 to 6 showed significant improvement in OSS at 3 months after surgery (P < .001). Thirty-eight patients with a score 3 to 4 had no statistically significant improvement in OSS at 3 months but had a further slight improvement at 1 year. Twelve patients with a score of ≤2 had no significant improvement in OSS at 3 months or 1 year. CONCLUSION: This scoring system can identify patients who would have a prompt benefit from ASAD. The impact of surgery in patients with a PrOS of ≤4 points is questionable.

Patterns of recontracture after surgical correction of Dupuytren disease.

PURPOSE: To study the evolution of deformity of the proximal interphalangeal joint over 5 years after good surgical correction of Dupuytren-induced contracture. METHODS: We assessed 63 patients (72 fingers; 69 hands) with Dupuytren disease for the degree of contracture, its correction after surgery, and the range of movement at the proximal interphalangeal joints at 3 and 6 months, and 1, 3, and 5 years after fasciectomy with or without the use of a firebreak graft. We investigated associations between the recurrence of contracture and preoperative patient and surgical factors. RESULTS: There were 4 patterns of evolution of contracture after surgical correction. A total of 31 patients (33 hands) showed good improvement that was maintained for 5 years (minimal recontracture group). Twenty patients (23 hands) showed good initial improvement, which mildly worsened (< 20°) but was then maintained over 5 years (mild early recontracture group). Four patients (5 hands) worsened in first 3 months after surgery (> 20°) but there was no further worsening (severe early recontracture group). Eight patients (8 hands) worsened progressively over 5 years (progressive recontracture group). Worsening of contracture more than 6° between 3 and 6 months after surgery predicted progressive recontracture at 5 years. CONCLUSIONS: Recurrence of contracture (not disease recurrence) could be predicted as early as 6 months after surgery for Dupuytren disease.

BESS patient care pathway: Tennis elbow.

This article provides a guidance summary for the management of lateral elbow tendinopathy (LET) using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system of the rating quality of the literature and grading the strength of available evidence. The process began by assembling a guideline development group of volunteers including orthopaedic surgeons, trainees, physiotherapists, rheumatologists, radiologists and patients. Virtual meetings were organised to set out explicit PICO questions, including specification of all important outcomes (including patient reported tennis elbow evaluation (PRTEE) as an important primary outcome) to determine the clinical effectiveness of common treatment options for LET compared with no treatment or placebo. Clinical librarian searched (date 31 April 2022) for available systematic reviews and randomised controlled trials reviewing the management of the LET January 2011 onwards and evidence was collected and summarized using explicit GRADE criteria for rating the quality of evidence that include study design, risk of bias, imprecision, inconsistency, indirectness, and magnitude of effect. Recommendations were characterized as strong or weak (alternative terms conditional or discretionary) according to the quality of the supporting evidence and the balance between desirable and undesirable consequences of alternative management options. This informative summary provides the quality of available evidence for the management of LET.

Radiological and Long-Term Functional Outcomes of Displaced Distal Clavicle Fractures.

OBJECTIVES: To investigate radiological and long-term functional outcomes in modified Neer 2a, 2b, and 5 distal clavicle fractures. DESIGN: Retrospective cohort study. SETTING: A single university teaching hospital. PATIENTS/PARTICIPANTS: One hundred fifteen patients sustaining displaced distal clavicle fractures between January 01, 2010 and December 12, 2017. INTERVENTION: Operative versus nonoperative management. MAIN OUTCOME MEASUREMENTS: Radiographs were reviewed for fracture management and union. A customised questionnaire consisting of QuickDASH (Disabilities of the Arm, Shoulder and Hand), work, sports/performing arts, global satisfaction, and complication modules was used to determine functional outcome. RESULTS: One hundred fifteen patients were included [mean age of 49 (18-89) years]. Thirty-three (29%) underwent early fixation (<6 weeks from injury) and were younger (37 vs. 53 years, P < 0.0001). Radiographs were available for 96 patients. Nonunion rate was 55% (53/96), and majority had undergone initial nonoperative management (49 vs. 4, P < 0.00001). Eleven patients with symptomatic nonunion were deemed appropriate for delayed fixation with all cases uniting. Of the operatively managed patients, 27% (12/44) underwent metalwork removal. There were no differences in functional outcome between operative versus nonoperative and union versus nonunion patient groups at a mean follow-up of 79 months ( P > 0.05). CONCLUSION: Functional outcome and patient satisfaction at long-term follow-up were similar regardless of operative fixation or radiological union. Nonunion in displaced distal clavicle fractures seemed to cause minimal functional deficit in most elderly sedentary individuals, or the outcome measures were not sensitive enough to capture these differences. An individualized approach should be adopted, with less active, comorbid, and elderly patients counseled regarding the minimal functional improvement of surgery and risk of reoperation. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Interposition GraftJacket allografts for irreparable rotator cuff tears.

AIMS: Long-term outcomes following the use of human dermal allografts in the treatment of symptomatic irreparable rotator cuff tears are not known. The aim of this study was to evaluate these outcomes, and to investigate whether this would be a good form of treatment in young patients in whom a reverse shoulder arthroplasty should ideally be avoided. METHODS: This prospective study included 47 shoulders in 45 patients who underwent an open reconstruction of the rotator cuff using an interposition GraftJacket allograft to bridge irreparable cuff tears, between January 2007 and November 2011. The Oxford Shoulder Score (OSS), pain score, and range of motion (ROM) were recorded preoperatively and at one year and a mean of 9.1 years (7.0 to 12.5) postoperatively. RESULTS: There was significant improvement in the mean OSS from 24.7 (SD 5.4) preoperatively to 42.0 (SD 6.3) at one year, and this improvement was maintained at 9.1 years (p < 0.001), with a score of 42.8 (SD 6.8). Similar significant improvements in the pain score were seen and maintained at the final follow-up from 6.1 (SD 1.6) to 2.1 (SD 2.3) (p < 0.001). There were also significant improvements in the ROM of the shoulder, and patient satisfaction was high. CONCLUSION: The use of an interposition human dermal allograft in patients with an irreparable rotator cuff tear leads to good outcomes that are maintained at a mean of nine years postoperatively. Cite this article: Bone Joint J 2022;104-B(1):91-96.

The management of displaced humeral shaft fractures - A survey of UK shoulder and elbow surgeons.

Introduction: Indications for surgical management of displaced humeral shaft fractures are not clearly established, leading to variations in practice. The aim of this study was to determine the scale of these variations in the UK practice to help design a future national trial. Methods: An online survey was sent to all surgeon members of British Elbow and Shoulder Society to help define humeral shaft fractures, fracture displacement as well as indications for operative and non-operative management. Patient and injury related factors considered important when managing humeral shaft fractures were investigated. Results: The survey achieved a response rate of 32% (104/327). There was a lack of consensus on definitions for humeral shaft fractures and fracture displacement. A functional brace was the most common form of non-operative treatment (63%). Majority immobilise humeral shaft fractures for 4-8 weeks or until callus are visible (62%) with a similar number considering operative treatment if adequate signs of healing are not present at around 12-16 weeks. Around half of our respondents exclusively use plates with variations in preference of approach and a minority (2%) exclusively use intra-medullary nails. Conclusion: The significant variation in management of displaced humeral shaft fractures in the UK suggests a clear need to evaluate clinical and cost effectiveness through a multi-centre randomised trial.

A meta-analysis of union rate after proximal scaphoid fractures: terminology matters.

Heterogeneity in the anatomical definition of 'proximal' affects the comparison of outcomes of these scaphoid fractures. This study aims to review published outcomes of all variants to determine both, differences in terminology, and union rate based upon definition. A literature search was conducted to identify articles that reported descriptions and union rate of all acute (<8 weeks of injury) proximal scaphoid fractures in adult patients (>16 years old). Proximal fractures were grouped as reported ('third', 'pole', 'fifth' or 'undefined'). The data were pooled using a fixed-effects method, and a meta-analysis was conducted to compare relative risk (RR) of non-union against non-proximal fractures. Qualitative analysis of 12 articles included three main definitions: 'proximal' (1 article), 'proximal third' (3 articles), and 'proximal pole' (8 articles). Only 6 articles adopted a specific anatomical or ratio description. In a pooled meta-analysis of union rates (15 articles), 'proximal third' and 'proximal pole' fractures demonstrated a relative risk (RR) of non-union of 2.3 and 3.4 in comparison to non-proximal fractures, respectively. Operative management yielded lower non-union rates than non-operative for all fracture types (6% vs. 18%). In conclusion, non-union risk varies depending on definition, with non-standardised classifications adding heterogeneity to reported outcomes. We recommend an approach utilizing fixed anatomical landmarks on plain radiographs (referencing scaphoid length and scapho-capitate joint) to standardise reporting of proximal fracture union in future studies. Abbreviations: CI: confidence intervals; CT: computer tomography; Df: degrees of freedom; DL: dersimonian and laird estimator; MRI: magnetic resonance imaging; NICE: national institute for health and care excellence; OTA: orthopaedic trauma association; PA: posterior-anterior; PRISMA: preferred reporting items for systematic reviews and meta analyses; RCT: randomised controlled trial; RR: relative risk; SNAC: scaphoid non-union advanced collapse; UK: United Kingdom.

Elbow conditions: research priorities setting in partnership with the James Lind Alliance.

OBJECTIVE: To undertake a UK-based James Lind Alliance (JLA) Priority Setting Partnership for elbow conditions and be representative of the views of patients, carers and healthcare professionals (HCPs). SETTING: This was a national collaborative study organised through the British Elbow and Shoulder Society. PARTICIPANTS: Adult patients, carers and HCPs who have managed or experienced elbow conditions, their carers and HCPs in the UK involved in managing of elbow conditions. METHODS: The rigorous JLA priority setting methodology was followed. Electronic and paper scoping surveys were distributed to identify potential research priority questions (RPQs). Initial responses were reviewed and a literature search was performed to cross-check categorised questions. Those questions already sufficiently answered were excluded and the remaining questions were ranked in a second survey according to priority for future elbow conditions research. Using the JLA methodology, responses from HCP and patients were combined to create a list of the top 18 questions. These were further reviewed in a dedicated multistakeholder workshop where the top 10 RPQs were agreed by consensus. RESULTS: The process was completed over 24 months. The initial survey resulted in 467 questions from 165 respondents (73% HCPs and 27% patients/carers). These questions were reviewed and combined into 46 summary topics comprising: tendinopathy, distal biceps pathology, arthritis, stiffness, trauma, arthroplasty and cubital tunnel syndrome. The second (interim prioritisation) survey had 250 respondents (72% HCP and 28% patients/carers). The top 18 ranked questions from this survey were taken to the final workshop where a consensus was reached on the top 10 RPQs. CONCLUSIONS: The top 10 RPQs highlight areas of importance that currently lack sufficient evidence to guide diagnosis, treatment and rehabilitation of elbow conditions. This collaborative process will guide researchers and funders regarding the topics that should receive most future attention and benefit patients and HCPs.

Protocol for a multi-site pilot and feasibility randomised controlled trial: Surgery versus PhysiothErapist-leD exercise for traumatic tears of the rotator cuff (the SPeEDy study).

BACKGROUND: Clinically, a distinction is made between types of rotator cuff tear, traumatic and non-traumatic, and this sub-classification currently informs the treatment pathway. It is currently recommended that patients with traumatic rotator cuff tears are fast tracked for surgical opinion. However, there is uncertainty about the most clinically and cost-effective intervention for patients with traumatic rotator cuff tears and further research is required. SPeEDy will assess the feasibility of a fully powered, multi-centre randomised controlled trial (RCT) to test the hypothesis that, compared to surgical repair (and usual post-operative rehabilitation), a programme of physiotherapist-led exercise is not clinically inferior, but is more cost-effective for patients with traumatic rotator cuff tears. METHODS: SPeEDy is a two-arm, multi-centre pilot and feasibility RCT with integrated Quintet Recruitment Intervention (QRI) and further qualitative investigation of patient experience. A total of 76 patients with traumatic rotator cuff tears will be recruited from approximately eight UK NHS hospitals and randomly allocated to either surgical repair and usual post-operative rehabilitation or a programme of physiotherapist-led exercise. The QRI is a mixed-methods approach that includes data collection and analysis of screening logs, audio recordings of recruitment consultations, interviews with patients and clinicians involved in recruitment, and review of study documentation as a basis for developing action plans to address identified difficulties whilst recruitment to the RCT is underway. A further sample of patient participants will be purposively sampled from both intervention groups and interviewed to explore reasons for initial participation, treatment acceptability, reasons for non-completion of treatment, where relevant, and any reasons for treatment crossover. DISCUSSION: Research to date suggests that there is uncertainty regarding the most clinically and cost-effective interventions for patients with traumatic rotator cuff tears. There is a clear need for a high-quality, fully powered, RCT to better inform clinical practice. Prior to this, we first need to undertake a pilot and feasibility RCT to address current uncertainties about recruitment, retention and number of and reasons for treatment crossover. TRIAL REGISTRATION: ClinicalTrials.gov ( NCT04027205 ) - Registered on 19 July 2019. Available via.

Mortality following combined fractures of the hip and proximal humerus.

BACKGROUND: Hip fractures and proximal humerus fractures are known to be associated with increased mortality, but the impact on mortality of combining these two common injuries is not well known. AIM: To compare mortality, inpatient stay and discharge destination for patients with combined hip and proximal humerus fractures with those sustaining isolated hip fractures. METHODS: Using the United Kingdom national hip fracture database, we identified all hip fracture patients over the age of 60 admitted to a single trauma unit from 2010-2016. Patients sustaining a proximal humerus fracture in addition to their hip fracture were identified using hospital coding data. We calculated the 30-d and one-year mortality for both the hip fracture cohort and the combined hip and proximal humerus fracture cohort. Other variables recorded included age, gender and whether the proximal humerus was treated with or without an operation. RESULTS: We identified 4131 patients with hip fractures within the study period and out of those 40 had sustained both a hip and a proximal humerus fracture. Mean age in the hip fracture cohort was 80.9 years and in the combined fracture group 80.3 years. Out of the 40 patients in the combined group four were treated operatively. The 30-d mortality for our hip fracture cohort was 7.2% compared to the mortality of our combined cohort of 12.5% (P = 0.163). The one-year mortality for our hip fracture cohort was 26.4% compared to 40% for the combined fracture cohort (P = 0.038). We also found patients with combined injuries were less likely to return to their own home. CONCLUSION: The 30-d and one-year mortality is higher for those patients who have sustained a combined hip and proximal humerus fracture when compared to those with a hip fracture alone.

Comparative Biomechanical Characteristics of Modified Side-to-Side Repair and Modified Pulvertaft Weaving Repair - In vitro Study.

BACKGROUND: Strong surgical repair is the mechanical basis of early mobilization and prerequisite for biological healing following tendon grafting. Side to side and pulvertaft repairs were developed to meets these demands. However, these techniques have later been modified to improve the strength of repair but their characteristics have not been compared. METHODS: We compared biomechanical strength of the modified side-to-side (SS) repair with the modified Pulvertaft (PT) repair technique in turkey tendons keeping overlap length, anchor points, type of suture, suture throw and amount of suture similar. Two investigators performed 34 repairs during one summer month to test the tensile strength of the repair using mechanical strength testing machine. Variables measured were maximum load, load to first failure, modulus, load at break, mode of failure, site of failure, tensile strain, tensile stress. The statistical comparison was carried by Levene's test and T test for means. RESULTS: The mean maximum load for modified SS repair was 50.3 (SD 13.7) N and modified PT repair was 46.9 (SD 16.4) N. The tensile stress at maximum load for SS and modified PT repair was 4.7 (SD 4) MPa and 4.2 (SD 3) MPa respectively. The suture cut through was the commonest mode of failure. CONCLUSIONS: We found no statistical difference between 2 repairs in load at which they started failing (p = 0.16), and maximum load repairs could withstand (p = 0.35). Our study uniquely compares two techniques under standard conditions, and contrary to existing evidence found no difference. However, in our opinion the number of anchor points may have a greater impact than number of weaves on the strength.

Outcome of partial repair of massive rotator cuff tears with and without human tissue allograft bridging repair.

BACKGROUND: The surgical management of massive rotator cuff tears remains a challenge. It is suggested that, even in a massive tear that appears irreparable, attempting to repair it as much as possible can be helpful in improving functional outcomes. However the results can be short term and variable. The purpose of our study was to determine if human tissue allograft bridged repair of massive irreparable rotator cuff tears to achieve a complete repair produces similar outcomes compared to partial repair alone. METHODS: We prospectively reviewed outcome scores in 13 patients who underwent partial repair alone for massive irreparable rotator cuff tears and compared them to 13 patients who had partial repairs bridged with allograft. Oxford and Constant scores were compared pre-operatively and at a minimum follow-up of 2 years (range 2 years to 5 years). RESULTS: The mean improvement in the Constant score at final follow-up compared to pre-operative scores was 27.7 points in the partial repair group and 42.8 points in the allograft group (p < 0.01). The Oxford Shoulder Score improved mean of 19.3 points in the partial repair group and 29 points in the allograft group (p < 0.02) at 2 years. CONCLUSIONS: Human tissue matrix allograft provides a better outcome for open bridging of irreparable rotator cuff tears than partial repair alone.

Effect of patient safety incident review and reflection in an extended morbidity and mortality meeting.

BACKGROUND: We modified the departmental mortality and morbidity (M&M) meetings to evaluate whether patient safety incident review as a part of this meeting was associated with reduced patient safety incidents. METHOD: A pilot programme of peer review of patient safety incidents (PSI) supported by education relevant to that event and follow-on action plan was introduced as a part of an extended morbidity and mortality meeting in a university hospital orthopaedic department. The pilot programme was conducted over six months (January 2012-June 2012). This programme involved junior and senior doctors including consultants although multidisciplinary groups were invited to attend. We investigated PSI rate/1000 hospital admissions for trauma and elective surgery, which were collected prospectively and independently between Jan 2011 to June 2013. We noted if the incident was caused by a medical or a nursing error and compared PSI rates. RESULTS: Rates of PSI (33/1000) were 7.8 times higher in trauma cases (80.2/1000) than in elective admissions (11.2/1000). There was 18% reduction in trauma and 27% reduction in planned elective admissions. The rate increased after the pilot programme finished but there was still a 7% reduction compared to the pre-pilot period. This study found a significant reduction in the PSI rate for medical error but no change in the rate of nursing error. CONCLUSION: This continuous reflection, education and action process, where safety events are reviewed as a part of the extended morbidity and mortality meeting, is associated with reduction of patient safety incidents. We recommend that PSI reflection should be introduced in Mortality and Morbidity meetings with mandated attendance of the entire multidisciplinary health care team.