Introduction of an enhanced recovery programme for total shoulder arthroplasty: report of a novel pathway.

BACKGROUND: Enhanced recovery (ER) programmes are well established in hip and knee arthroplasty, but are not yet commonplace for total shoulder arthroplasty (TSA). This study analyses the effect of implementing an ER programme with TSA, on length of stay (LOS), functional outcome and patient satisfaction. LOCAL PROBLEM: No established programme applying ER to the specifics of upper-limb arthroplasty existed at our unit. METHODS: A three-cycle plan-do-study-act quality improvement methodology was applied, involving development of our multifactorial programme, a pilot phase and wider roll-out. A consecutive series of patients who underwent TSA and were enrolled in an ER programme were compared with a matched control group of consecutive patients who underwent TSA in the year before the programme started. For all patients, LOS as well as mean Oxford Shoulder Score (OSS) and Constant Score (CS) were quantified and patient satisfaction assessed. INTERVENTIONS: A dedicated multidisciplinary team led preoperative class involving patient education, advice and occupational therapy assessment. A standardised perioperative anaesthetic regime based on regional anaesthetic techniques with preoperative analgesic and nutritional loading was introduced. Postoperative rehabilitation was also standardised with slings for comfort only and early safe-zone mobilisation. New patient information was developed. RESULTS: 71 patients were included in matched cohorts. Mean LOS was reduced from 2.4 nights to 1.9 nights. The single night stay rate improved from 40% to 49%. Across the ER cohort, 15 less nights were required to complete same volume of surgeries as in the non-ER cohort.Parity in OSS and CS measured at 3 and 12 months after surgery were observed in both cohorts.Satisfaction was already high before ER but scores stayed the same or improved across all areas surveyed.Absolute complication rates of 9.9% in the non-ER group and 7% in the ER group were recorded. CONCLUSION: Our ER programme benefited patients and the Trust by reducing time in hospital and improving patient satisfaction without an adverse effect on complication rate.

Reliability analysis of radiologic and intraoperative loosening in total elbow arthroplasty.

BACKGROUND: Revisions of total elbow arthroplasties (TEAs) are commonly performed because of prosthetic loosening. UK National Joint Registry data show that TEA revisions are becoming increasingly common, with 123 TEA revisions performed in 2018 and 76 performed in 2017. TEA radiologic assessment is based on subjective interpretation with no published criteria. We defined TEA loosening by the presence of at least one of the following criteria: (1) progressive widening of the bone-cement, bone-prosthesis, or cement-prosthesis interface; (2) fragmentation or fracture of cement; (3) prosthetic component migration; and (4) bead shedding in porous-coated prostheses. Using this definition, we looked at interobserver and intraobserver agreement on radiologic loosening and compared this assessment with intraoperative findings. METHODS: In our tertiary care center, we conducted a retrospective review to identify TEA revisions performed between November 2008 and July 2018. Radiologic implant loosening was independently assessed by 5 orthopedic surgeons. Interobserver agreement (κ coefficient) was calculated. The majority's view of radiologic loosening was compared with intraoperative findings. RESULTS: We identified 93 sets of radiographs with implant stability clearly documented in their operative notes. The κ coefficient between assessors for humeral implant loosening was 0.87 (almost perfect). The κ coefficient for ulnar loosening was 0.75 (substantial). The κ coefficients for radiologic and intraoperative findings of humeral loosening and ulnar loosening were 0.67 and 0.71 (substantial), respectively. Intraobserver reliability was almost perfect for humeral loosening (κ = 0.86) and substantial for ulnar loosening (κ = 0.74). CONCLUSION: Our definition of loosening provides reproducible interobserver and intraobserver agreement on radiographic component loosening. In our center's experience, radiologic findings may not translate to intraoperative findings, and we would advise that surgical strategies for TEA revision include the possibility of needing to perform a dual-implant exchange.

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.

Triceps on approach for total elbow arthroplasty: worth preserving? A review of approaches for total elbow arthroplasty.

Total elbow arthroplasty can be a rewarding operation and is becoming increasingly used in the elderly fracture population. Multiple approaches are represented in the literature and deciding on the best approach is difficult. This review discusses approaches and their reported outcomes, aiming to allow surgeons to make an informed choice about which approach to use.

Surgery within 6 months of an acute rotator cuff tear significantly improves outcome.

BACKGROUND: To determine the effect of time to repair on the outcome after an acute rotator cuff tear. METHODS: We performed a retrospective analysis of prospectively collected data on patients presenting with acute rotator cuff tear to our shoulder clinic. Patient-reported outcomes were assessed using the Oxford Shoulder Score, and symptomatic retears were diagnosed by clinical assessment plus imaging. RESULTS: Twenty patients underwent rotator cuff repair within 6 months of injury via initial referral through the Acute Shoulder Injury Clinic (early repair group; mean age, 60 years; age range, 39-77 years). Twenty age- and sex-matched patients were identified who had undergone delayed repair (6-18 months after injury; mean age, 60 years; age range, 40-78 years). The mean follow-up period was 10 months for the early repair group versus 11 months for the delayed repair group. Both groups had clinically significant improvements in their Oxford scores, although the early repair group had an improvement that was nearly double that of the delayed repair group (20.3 for early vs 10.4 for delayed, P = .0014). Postoperative Oxford scores were significantly higher in the early repair group (mean of 43.8 for early vs 35.8 for delayed, P = .0057). There were 2 symptomatic retears in the early repair group versus 5 in the delayed repair group. CONCLUSION: Our results show improved outcomes with early repair (within 6 months) of acute rotator cuff tears and support the provision of an acute shoulder injury referral clinic.

Corticosteroid and platelet-rich plasma injection therapy in tennis elbow (lateral epicondylalgia): a survey of current U.K. specialist practice and a call for clinical guidelines.

BACKGROUND: Tennis elbow is a common condition with a variety of treatment options, but little is known about which of these options specialists choose most commonly. Corticosteroid injections in tennis elbow may reduce pain in the short-term but delay long-term recovery. We have undertaken a UK-wide survey of upper limb specialists to assess current practice. METHODS: Cross-sectional electronic survey of current members of the British Elbow and Shoulder Society (BESS) and the British Society for Surgery of the Hand (BSSH). RESULTS: 271 of 1047 eligible members responded (25.9%); consultant surgeons constituted the largest group (232/271, 85%). 131 respondents (48%) use corticosteroid injections as their first-line treatment for tennis elbow. 206 respondents (77%) believed that corticosteroid injections are not potentially harmful in the treatment of tennis elbow, while 31 (11%) did not use them in their current practice. In light of recent evidence of the potential harmful effects of corticosteroid therapy, 136 (50%) had not changed their practice while 108 (40.1%) had reduced or discontinued their use. 43 respondents (16%) reported having used platelet-rich plasma injections. CONCLUSIONS: Recent high-quality evidence that corticosteroids may delay recovery in tennis elbow appears to have had a limited effect on current practice. Treatment is not uniform among specialists and a proportion of them use platelet-rich plasma injections.