Effect of glenosphere size on reverse shoulder arthroplasty revision rate: an analysis from the Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR).

BACKGROUND: Modularity is an integral element of reverse total shoulder arthroplasty (RTSA). Glenosphere diameter is a key component, but its effect on revision rate is unknown. The aim of this study was to investigate the relationship between glenosphere size and revision rates in RTSA procedures. METHODS: Data from a large national arthroplasty registry were analyzed for the period April 2004 to 31 December 2019. The study population included all primary RTSA procedures using glenosphere sizes <38 mm, 38-40 mm, and >40 mm. A subanalysis of glenosphere sizes for each of the 3 most commonly implanted prostheses and further analyses by patient age and gender were also performed. The rate of revision was determined by Kaplan-Meier estimates, with comparisons by Cox proportional hazard models. RESULTS: There were 28,817 primary RTSA procedures. Glenosphere sizes <38 mm had a higher revision rate compared to 38-40-mm glenospheres (hazard ratio [HR] 1.28, 95% confidence interval [CI] 1.11, 1.48, P < .001) and >40-mm sizes (HR 1.35, 95% CI 1.15, 1.59, P < .001). Males with <38-mm and 38-40-mm glenospheres had significantly higher revision rates compared to >40-mm glenospheres (HR 1.49, 95% CI 1.21, 1.83, P < .001; and HR 1.28, 95% CI 1.03, 1.58, P = .025, respectively). Females with <38-mm and >40-mm glenospheres had higher revision rates compared to females with 38-40-mm glenospheres (HR 1.38, 95% CI 1.14, 1.68, P < .001; and HR 1.41, 95% CI 1.06, 1.88, P = .019, respectively). For patients aged 65-74 years, glenospheres >40 mm had a significantly lower revision rate than both the <38-mm glenospheres (entire period: HR 0.59, 95% CI 0.45, 0.76, P < .001) and 38-40-mm glenospheres (entire period: HR 0.72, 95% CI 0.54, 0.94, P = .017). For patients aged ≥75 years (n = 14,622), <38-mm glenospheres had a significantly higher rate of revision compared with 38-40-mm glenospheres after 3 months (HR  1.43, 95% CI 1.09, 1.86, P = .009). Analysis comparing glenosphere sizes within each of the 3 most commonly implanted prostheses found that the Delta Xtend with 38-40-mm glenospheres had higher revision rates compared with >40-mm glenospheres (HR 1.49, 95% CI 1.14, 1.92, P = .003). The SMR L1 (Lima) 38-40-mm glenospheres had a lower rate of revision compared with the <38-mm (HR 0.50, 95% CI 0.37, 0.67, P < .001) and >40-mm glenospheres (HR 0.60, 95% CI 0.43, 0.85, P = .004). CONCLUSIONS: Glenospheres <38 mm can be expected to increase revision rates in primary RTSAs. The optimum size of glenospheres is gender, age, and prosthesis specific, with revision rates lower for females with 38-40-mm glenospheres and lower for males with >40-mm glenospheres.

Allied health led post-operative hand clinic: Evaluation of an alternative model of care.

INTRODUCTION: To assist with the increasing orthopaedic workload, an allied health led hand therapy clinic was established to manage people having routine hand surgeries. The aim of this study was to evaluate patient and doctor satisfaction and safety of this alternative service delivery model. METHODS: Prospective multimethod design evaluation was undertaken by occupational therapists and physiotherapists working in the field of hand therapy. Satisfaction surveys were completed by orthopaedic doctors and patients. Patient outcomes were assessed at 6 weeks post operatively using the Quick Disability of Arm, Shoulder and Hand questionnaire, total active range of motion, Crawford Classification, sensation using light touch and pain with activity utilising Wong Baker FACES® Pain Rating Scale. Quantitative satisfaction survey data were analysed and presented as frequencies and percentages with open question responses analysed using a qualitative description approach. All complications and readmissions within a 3-month period were identified and recorded to assess safety of this model of care. RESULTS: For the 6-week post-operative review, 81 patients were seen by an allied health professional rather than a doctor. Patient satisfaction was high with 90% of patients satisfied with post-operative care provided by allied health; 2% of patients preferred to be seen by a doctor. Doctor satisfaction was also high with 95% of doctors being satisfied and confident with the quality of care provided. A high proportion of patients reported pain 2/10 or less with activity (82.72%), had full sensation (69.14%), excellent range of motion (82.72%), and Quick Disability Arm, Shoulder and Hand scores on average were below 25% indicating minimal functional deficits. Only five patients required doctor involvement post-operatively. CONCLUSION: The allied heath led service delivery model was demonstrated to be safe and have high patient and doctor satisfaction, indicating an acceptable alternate pathway for management of people following routine hand surgery.

Does the triceps-on approach affect alignment in total elbow arthroplasty? A cadaveric study.

BACKGROUND: The triceps-on approach for total elbow arthroplasty has gained popularity due to the theoretical benefit of preserving the extensor mechanism. However, there is concern that the exposure may be reduced in comparison to a triceps-off approach and may affect the implant alignment achieved. METHOD: Total elbow arthroplasties were implanted in 18 randomised, paired cadaveric elbows using the triceps-on or triceps-off approach. The bones were dissected out and the position of the implants measured relative to anatomical landmarks. The flexion/extension and varus/valgus angles, and the distance of centre of rotation from the anatomic centre of rotation in the sagittal plane for both components were obtained as well as the humeral component rotation relative to the transepicondylar axis. RESULTS: All humeral components were positioned in external rotation and all ulna components were placed in flexion. Seven components were positioned greater than 5° away from the ideal in one measurement, with no significant difference between the two approach groups. DISCUSSION: This unique study showed no significant difference in the alignment of the implants between the two approaches. These results support the theory that the triceps-on approach does not result in larger alignment errors in component positioning when performing total elbow arthroplasty.

Vibration therapy versus standard treatment for tennis elbow: A randomized controlled study.

AIM: To determine whether a mechanical, high-frequency vibration device (Tenease™) can improve pain and function for the treatment of tennis elbow (TE), compared with standard treatment. METHODS: Adults presenting to an elbow clinic with a clinical diagnosis of TE were randomized to standard treatment with physiotherapy, activity modification and analgesia or standard treatment plus Tenease therapy. Tenease therapy consisted of a 6-week period of treatment using the Tenease device with three 10-min episodes each day. The primary outcome measure was the quick Disabilities of the Arm, Shoulder and Hand score at 6 months, with scores also taken at 6 weeks. Secondary outcome measures were the Patient Rated Tennis Elbow Evaluation Score and EuroQol 5-Dimension Visual Analogue Scale at the same time points. RESULTS: Fifty-four patients were recruited into the study. Following randomization and initial dropout, 18 patients were included in the standard group and 27 in the Tenease group. Both groups reported improvements in primary outcome measure scores. The control group had a mean score of 44.3 (standard deviation (SD) = 18.8) at baseline, which dropped to 31.2 (SD = 17.2) at 6 months ( p = 0.002). The Tenease group had a mean score of 43.2 (SD = 22.7) at baseline, which dropped to 23.4 (SD = 15.0) at 6 months ( p = 0.064). Similar improvements were seen in secondary outcome measures with none reaching statistical significance. There were no statistically significant differences seen between the primary outcome scores at 6 weeks ( p = 0.9) or 6 months ( p = 0.5). No complications were noted in either group. CONCLUSIONS: Vibration therapy did not result in any statistically significant improvement in functional outcome scores compared to standard treatment for TE. It is important to note that this was a relatively small cohort and a high dropout rate was observed.

A randomized controlled trial of arthroscopic capsular release versus hydrodilatation in the treatment of primary frozen shoulder.

BACKGROUND: Arthroscopic capsular release (ACR) and hydrodilatation (HD) have been developed for the management of frozen shoulder refractory to conservative treatment. To date no randomized trial has directly compared the efficacy of both interventions. The aim of this trial was to determine whether the Oxford Shoulder Score (OSS) differs between patients with frozen shoulder randomized to treatment with ACR or HD. METHODS: Patients presenting with severe idiopathic frozen shoulder deemed suitable for surgical intervention by a consultant shoulder surgeon were randomized to ACR or HD. The primary outcome measure was OSS at 6 months, with secondary outcomes measures of the EuroQol-5D visual analog scale, external rotation, complications, and crossover rate also recorded. RESULTS: Between June 2013 and December 2016, 50 patients were randomized to HD or ACR. The average age of the HD and ACR cohorts was 55.2 and 52.6 years, respectively (P = .36). At 6 months after the intervention, 20 patients were available for follow-up in the HD cohort and 19 in the ACR cohort. Both groups demonstrated significant improvements in OSS from baseline, but the OSS was significantly higher in the ACR cohort than the HD cohort (43.8 vs. 38.5, P = .023). The OSS was noted to improve rapidly after the intervention, with 75% of improvement in OSS noted at 6 weeks after surgery in both groups. CONCLUSIONS: Patients randomized to ACR reported a significantly higher OSS at 6 months than those randomized to HD. Both groups, however, showed a significant improvement.

Distal triceps injuries (including snapping triceps): A systematic review of the literature.

AIM: To review current literature on types of distal triceps injury and determine diagnosis and appropriate management. METHODS: We performed a systematic review in PubMed, Cochrane and EMBASE using the terms distal triceps tears and snapping triceps on the 10th January 2017. We excluded all animal, review, foreign language and repeat papers. We reviewed all papers for relevance and of the papers left we were able to establish the types of distal triceps injury, how these injuries are diagnosed and investigated and the types of management of these injuries including surgical. The results are then presented in a review paper format. RESULTS: Three hundred and seventy-nine papers were identified of which 65 were relevant to distal triceps injuries. After exclusion we had 47 appropriate papers. The papers highlighted 2 main distal triceps injuries: Distal triceps tears and snapping triceps. Triceps tear are more common in males than females occurring in the 4th-5th decade of life and often due to a direct trauma but are also strongly associated with weightlifting and American football. The tears are diagnosed by history and clinically with a palpable gap. Diagnosis can be confirmed with the use of ultrasound (US) and magnetic resonance imaging. Treatment depends on type of tear. Partial tears can be treated conservatively with bracing and physio whereas acute tears need repair either open or arthroscopic using suture anchor or bone tunnel techniques with similar success. Chronic tears often need augmenting with tendon allograft or autograft. Snapping triceps are also seen more in men than women but at a mean age of 32 years. They are characterized by a snapping sensation mostly medially and can be associated with ulna nerve subluxation and ulna nerve symptoms. US is the diagnostic modality of choice due to its dynamic nature and to differentiate between snapping triceps tendon or ulna nerve. Treatment is conservative initially with activity avoidance and if that fails surgical management includes resection of triceps edge or transposition of the tendon plus or minus ulna nerve transposition. CONCLUSION: Distal triceps injuries are uncommon. This systematic review examines the evidence base behind diagnosis, imaging and treatment options of distal triceps injuries including tears and snapping triceps.

Distal Biceps and Triceps Injuries.

BACKGROUND: Rupture of the distal biceps and triceps tendons are relatively uncommon injuries typically occurring in middle-aged males as a result of eccentric loading of the tendon. METHODS: A literature search was performed and the authors' personal experiences reported. RESULTS: This review discusses the diagnosis, indications and guidelines for management of these injuries and provides a description of the authors' preferred operative techniques. CONCLUSION: Whilst non-operative treatment may be appropriate for patients with low functional demands, surgical management is the preferred option for the majority of patients. We have described a cortical button technique and osseous tunnel technique utilised at our institution for distal biceps and triceps tendon fixation respectively. For biceps or triceps tendon injuries, those receiving an early diagnosis and undergoing surgical intervention, an excellent functional outcome can be expected.

Distal Humeral Fractures-Current Concepts.

BACKGROUND: Distal humerus fractures constitute 2% of all fractures in the adult population. Although historically, these injuries have been treated non-operatively, advances in implant design and surgical technique have led to improved outcomes following operative fixation. METHODS: A literature search was performed and the authors' personal experiences are reported. RESULTS: This review has discussed the anatomy, classifications, treatment options and surgical techniques in relation to the management of distal humeral fractures. In addition, we have discussed controversial areas including the choice of surgical approach, plate orientation, transposition of the ulnar nerve and the role of elbow arthroplasty. CONCLUSION: Distal humeral fractures are complex injuries that require a careful planned approach, when considering surgical fixation, to restore anatomy and achieve good functional outcomes.

Treatment of acute tibial shaft fractures with an expandable nailing system: a systematic review of the literature.

Locked Intramedullary Nailing is an established method of treatment for tibial shaft fractures. Locking of tibial nails is however not without its drawbacks. Locking is time consuming, and is associated with a noteworthy complication rate. The Fixion IM nailing system is an expandable nail designed to eliminate some of these drawbacks. We have performed a systematic review of the literature to determine the safety and efficacy of this system. Publications examining the use of the Fixion system were identified from the MEDLINE and the Cochrane databases. Forty-one citations were generated by the MEDLINE search. Of these, two quasi-randomised trials and eight case series satisfied our selection criteria and were reviewed. Overall the average reoperation rate for the Fixion nail was 10.2%. Shortening occurred in 3% of cases and fracture propagation was reported in 2% of cases. The Fixion cohort united at an average of 12.2 weeks and the average operative time was 54 minutes. The Fixion system eliminated complications and reoperations associated with the use of locking screws. Further studies in the form of randomised controlled trials are needed to evaluate the Fixion system against conventional locked nails.

Total hip replacement in an adolescent patient with harlequin ichthyosis; a case report.

Harlequin ichthyosis (HI) is a rare autosomal recessive skin disorder. No orthopaedic procedure has previously been described on a patient with HI. We report the case of a 17-year-old patient with HI who presented with bilateral juvenile idiopathic arthritis of the hips who underwent bilateral total hip replacements. Our standard operative and postoperative regime was followed and no complications occurred. One year after the second procedure our patient had a Oxford hip score of 43 and was very satisfied with the result.

Tibial pilon fractures: a review of incidence, diagnosis, treatment, and complications.

Tibial pilon fractures are challenging to treat, as they are typically intra-articular and associated with extensive soft tissue damage. We briefly review the anatomy of the distal tibia, as well as the pathophysiology of pilon fractures. The treatment of tibial pilon fractures is still controversial in the literature, and we present some of the available options. Consideration is also given to peri-operative complications, such as preoperative oedema and blistering and late postoperative traumatic arthritis. Finally, we propose a treatment algorithm (used in our institution), taking into account the level of associated soft tissue injuries. The use of a 2-phase treatment protocol is recommended; however, to date, no absolute treatment protocol exists for these injuries.

Narrowing of the femoral neck after resurfacing arthroplasty of the hip: a comparison of cemented and uncemented femoral components.

We performed a radiographic review of a consecutive series of 87 resurfacing arthroplasties of the hip, performed between 2004 and 2006. There were 54 cemented femoral components and 33 uncemented femoral components. All of the procedures were performed by the same surgeon using the same approach. There was no difference between the groups with regards to gender, age, pre-operative diagnosis and the average diameter of the components. The primary outcome measured was the neck-prosthesis ratio on standard anterior-posterior pelvis radiographs taken post-operatively and at a minimum follow up of two years. The difference between the immediate post-operative ratio and the most recent radiograph was statistically significant in patients with cemented femoral components (p=0.006), but not in the group with uncemented components (p=0.173). We have demonstrated a difference in narrowing of the femoral neck between cemented and uncemented femoral components in the first two years following surgery.

Obesity in Tonga: A cross-sectional comparative study of perceptions of body size and beliefs about obesity in lay people and nurses.

BACKGROUND: Obesity is a major public health issue in Tonga, where prevalence is significantly higher than in Europe and North America. Obesity and its health-related complications are likely to increase as a result of western influences on diet and lifestyle. The aim of this study was to investigate perceptions of body size in Tongan lay people and nurses, and their beliefs about the causes of obesity and its consequences for health. METHODS: A cross-sectional comparative study was conducted. Medical and surgical inpatients and outpatients were recruited from Vaiola Hospital in Tonga, over a 4 week period. Hospital nurses were included for comparison. Overall, 73 lay public and 34 nurses completed questionnaires about their beliefs about obesity, perceptions of their own body size and the health conditions associated with obesity. Subjects were also weighed and measured for calculating body mass index (BMI). RESULTS: Both Tongan lay people and nurses underestimated their body weight and size, although the degree of underestimation was more marked in the lay group. The more accurate perception of body size in nurses may reflect their greater understanding of the health consequences of obesity. CONCLUSIONS: This study has provided some insight into how obesity is viewed in Tonga, in particular differences between lay people and nurses in their own perception of weight, beliefs about obese people and the health consequences of obesity. Future research should aim to explore Tongans views of the health consequences of obesity as well as their perceptions of how serious these consequences are.