Distal biceps repair through a single incision with the use of a knotless cortical button device: Mid-term results.

Background: Distal biceps rupture presents with an increasing incidence and evidence suggests that although a surgical repair is not mandatory, it results in superior functional outcomes when compared to non-operative management. As implant technology has advanced, several devices have been utilised and studied in managing this pathology. We present our single-centre experience with the use of the ToggleLoc Ziploop reattachment device, a knotless cortical button implant, using a single-incision technique. Methods: Retrospective series of 70 consecutive distal biceps tendon repairs, at a mean follow-up of 45.6 months after surgery, using a standardised single implant, single-incision technique, and post-operative rehabilitation programme. Results: There was one (1.4%) re-rupture in our patient cohort. The range of motion was complete in all patients except for one patient who had symptomatic heterotopic ossification, causing limitation in pronation. Complications were minor with the commonest being transient neuropraxia of the lateral cutaneous nerve of the forearm. The mean Oxford elbow score was 46.9 out of 48, and the patient global impression of change scale was 7 out of 7 in 77% of cases. Conclusion: Our data support this technique and implant combination when dealing with acute and chronic distal biceps tendon rupture.

The response of regional well-being to place-based policy interventions.

Enhancing the well-being of its citizens is the central remit of the EU's regional policy, but as yet, there is no analysis of the effects of EU regional policy on local well-being. The aim of this paper is to examine this relationship. To do this, we define a novel regionalised well-being measure and we exploit a dataset on regional expenditure in a continuous treatment framework. Based on both parametric and semi-parametric approaches, our analysis demonstrates that the EU regional development policy does influence regional well-being differently from GDP. We find evidence of a linear monotonic response of well-being growth to total transfers, although this effect varies according to the time lag considered and the level of development of the region.

Does preservation of columns affect the medium-term outcome in distal humerus hemiarthroplasty for acute unreconstructable fractures?

BACKGROUND: We assessed distal humeral column preservation effects on clinical, radiographic and patient reported outcomes following distal humerus hemiarthroplasty for acute unreconstructable fractures. METHODS: Thirty-seven consecutive patients (mean age, 75; range, 29-93 years) with an average follow-up of 61 months (range, 24-105 months) after distal humerus hemiarthroplasty using a triceps preserving approach were studied. QuickDASH and Oxford Elbow Score assessed patient reported outcomes. Clinical and radiographic assessments comprised range of motion, grip strength, instability, implant loosening, chondral wear, heterotopic ossification and condylar union. RESULTS: Average QuickDASH was 14.9 (range, 0-63) and Oxford Elbow Score 40.35 (range, 25-48). Mean flexion arc was 108°, extension deficit 17° and pronosupination arc 155°. Average operative sided grip strength was 31.05 kg versus 31.13 kg contralaterally. Column preservation had no statistically significant effect on QuickDASH (p = 0.75), Oxford Elbow Score (p = 0.78), flexion-extension (p = 0.87), pronosupination (p = 0.78) or grip strength (p = 0.87). No progressive radiographic loosening or symptomatic chondral wear occurred. All fixed columns united. Three cases of immediate post-operative laxity fully resolved on elbow mobilisation. Four post-operative complications required further surgery: one ulnar neuropathy, one heterotopic ossification, one wound breakdown and one traumatic dislocation. CONCLUSION: Medium-term outcome of distal humerus hemiarthroplasty for acute unreconstructable distal humeral fractures is reliable irrespective of condylar preservation.

Medium-term rates of radiolucency after primary total shoulder arthroplasty using a cementless metal-backed pegged polyethylene glenoid.

BACKGROUND: Total shoulder arthroplasty is an established treatment with the commonest cause of failure loosening of the glenoid component. Hydroxyapatite metal-backed glenoid components could offer better survivorship due to improved fixation. The aim of this study was to investigate periprosthetic radiolucency rates associated with an uncemented, metal-backed polyethylene glenoid component with medium-term results. METHODS: A single centre retrospective study examining radiological outcomes of the Epoca metal-backed glenoid component. Radiographs were analysed for post-operative adequacy of glenoid seating and radiographs at follow-up assessed for periprosthetic lucencies and any revision procedures were recorded. RESULTS: Forty-one patients were followed up with a mean follow-up time of 5.5 years (3-8 years). Primary indication for total shoulder arthroplasty was osteoarthritis (80%). Mean age was 69 years (53-86 years). Ninety-five per cent of glenoid components were completely seated. At follow-up six patients had undergone revision (14.6%). Thirty of the remaining patients (86%) did not demonstrate any radiolucency on follow-up radiographs. Complete glenoid seating post-operatively was associated with lower rate of subsequent radiolucency and revision (P < 0.01). CONCLUSION: Low rates of radiolucency at medium-term follow-up with an uncemented metal-backed glenoid, however significant rates of revision. Complete seating of the glenoid component was associated with lower rates of radiolucency and revision.

Short-term rates of radiolucency after primary total shoulder arthroplasty using a cementless metal-backed pegged polyethylene glenoid.

BACKGROUND: Total shoulder arthroplasty has shown good clinical efficacy in treating primary and secondary degenerative conditions of the glenohumeral joint. Glenoid loosening, however, remains the commonest cause of failure. The purpose of this study was to investigate the rate of radiographic periprosthetic lucency associated with the use of an uncemented, pegged, metal-backed polyethylene glenoid component. MATERIALS AND METHODS: A retrospective, single-centre study using the Epoca (Synthes, Paoli, Pennsylvania) metal-backed glenoid component. Operations were performed by two experienced consultant upper limb surgeons. Radiographs were analysed for immediate post-operative component seating and periprosthetic radiolucent lines at predefined regular post-operative intervals. Intra- and inter-observer reliability was assessed to improve validity of results. RESULTS: Mean age and follow-up was 72 (48-91) years and 2.5 years (2-5), respectively. Main indications for total shoulder arthroplasty were primary osteoarthritis, rheumatoid arthritis, revision for failed hemi-arthroplasty and acute fracture. Ninety-six per cent of components were completely seated post-operatively. Fifty-four (95%) of the 57 shoulders had no periprosthetic radiolucent lines at most recent follow-up. Complete post-operative glenoid seating was significantly associated with the absence of later periprosthetic radiolucency (p < 0.01). CONCLUSION: This study reports low early radiolucency rates with the pegged, uncemented, metal-backed polyethylene glenoid prosthesis used. Excellent post-operative glenoid seating is associated with a significantly lower rate of radiolucency. Longer follow-up data are required to confirm these early promising results.Level of evidence: Therapeutic, level IV.

The Effect of Simple Cost Effective Interventions in Improving Enhanced Recovery in Neck of Femur Fracture Care.

Aim Due to the frequency and high mortality and morbidity associated with neck of femur fractures, pathways of care have been established in the United Kingdom. These include the Enhanced Recovery Program (ERP), which aims to maximise the quality of care whilst reducing their length of stay, and the Best Practice Tariff (BPT) which if adhered to warrants £1335 per neck of femur fracture. We conducted a prospective audit to assess adherence to these pathways in a trauma unit. Methods An audit was carried out between November 2015 and May 2016. The information was obtained from neck of femur fracture proformas, anaesthetic charts and drug charts by two investigators. Results Nine out of the 10 ERP components were adhered to in all 31 patients. This highlighted a deficiency in requesting day one post-operative osteoporosis bloods, which was only carried out in 61.3% of patients. As an intervention, a reminder sticker was placed on the operation note as an intervention. Re-audit following the introduction of the stickers showed a marked improvement of 90%. During the initial admission 38.7% of patients adhered to the BPT. The main area for improvement was fracture prevention assessment, specifically Fracture Risk Assessment Tool (FRAX) scores and Nottingham Hip Fracture Scores. To improve this these sections were highlighted in the proformas to promote their importance. Additionally, a smartphone application was made available to doctors to aid with ease of calculation. Following these interventions, 93% of patients had this data entered, with an improvement in overall tariff attainment to 63.3%. Conclusions The introduction of simple measures is beneficial both for patient safety and economically for hospitals.

Proximal Humerus Fractures: Reliability of Neer Versus AO Classification on Plain Radiographs and Computed Tomography.

INTRODUCTION: Several classifications for proximal humeral fractures exist, with excellent reliability and reproducibility of such classifications being a desirable feature. Despite their widespread use, these systems are variable in both reliability and accuracy. We aimed to, a) assess and compare the reliability of the Neer (complete and abbreviated versions) and Arbeitsgemeinschaft für Osteosynthesefragenbeing (AO) classifications, and b) identify if computed tomography (CT) made any difference to the reliability of Neer and AO classifications when compared to plain radiographs alone.  Materials and methods: This is a single-centre retrospective study identifying all proximal humeral fractures presenting between February 2016 and February 2017 as a result of trauma that subsequently proceeded to CT. Two specialty orthopaedic trainees analysed the plain radiographs as well as CT images over two rounds, spaced two weeks apart. The Neer 16-grade, abbreviated Neer 6-grade and AO classifications were used. Intra- and inter-observer reliability of each classification system was assessed using the Kappa coefficient.  Results: Twenty-two patients were included. The mean age was 62 years (SD 14.5). Management changed in 9/22 patients based on CT. Computed tomography changed Neer-16 type in 16% observations, Neer-6 in 10%, and AO in 23%. This was significant when comparing Neer-6 and AO classifications (p = 0.04). Neer-6 had the best inter-observer reliability (0.737) with the management of one patient changing after CT. On X-ray and CT, intra-observer agreement was substantial, >0.7, using Neer-16 and Neer-6 (p<0.005). Inter-observer agreement for Neer-16 and Neer-6 was substantial, >0.7 (p<0.005). In comparison, intra- and inter-observer agreements for AO were lower on X-ray and CT, 0.4-0.6, (p<0.005). CONCLUSION: Our study shows that simplicity is key with a high degree of reliability in the abbreviated Neer classification. Computed tomography allowed greater reliability than radiographs in classifying fractures, affecting management decisions in 41% of patients. The comprehensive Neer classification showed similar intra- and inter-observer reliabilities to AO.

The influence of fatty infiltration and muscle atrophy of the rotator cuff muscles on midterm functional outcomes in total shoulder resurfacing at six years' follow-up.

BACKGROUND: We report functional outcomes at six years in patients with varying degrees of fatty infiltration and atrophy of the rotator cuff muscles who have undergone anatomic total shoulder replacement. METHODS: A retrospective analysis of case notes and magnetic resonance imaging scans of patients undergoing total shoulder replacement for primary glenohumeral arthritis was performed. Patients were grouped based upon their pre-operative magnetic resonance imaging findings for fatty infiltration, muscle area and tendinopathy. Post-operative functional outcomes were assessed using the Oxford Shoulder Score and Quick Disabilities of the Arm, Shoulder and Hand score. Post-operative measurements were made for active shoulder movements. RESULTS: Thirty-two patients were reviewed at a mean of 67 months following surgery. All patients demonstrated fatty infiltration on their pre-operative magnetic resonance imaging scan. Muscle atrophy was shown in 22 patients and 12 had tendinopathy. Multiple regression analysis showed no correlation between the Oxford Shoulder Score (p = 0.443), the Quick Disabilities of the Arm, Shoulder and Hand score (p = 0.419), forward flexion (p = 0.170), external rotation (p = 0.755) and any of the pre-operative independent variables. DISCUSSION: The degree of fatty infiltration, muscle atrophy and tendinopathy of the rotator cuff muscle on pre-operative magnetic resonance imaging scanning is not associated with functional outcome score or functional movement at medium-term follow-up following total shoulder replacement. LEVEL OF EVIDENCE: IV.

Learning from the rubble: the case of Christchurch, New Zealand, after the 2010 and 2011 earthquakes.

Learning after a disaster is crucial in creating more resilient places. However, many societies are repeatedly overwhelmed by disasters. This can be because of missed opportunities to learn in post-disaster settings or because of actions implemented that seem to be highly relevant to recovery in the short term, but potentially constrain aspirations in the longer term. This paper assesses learning processes among state and non-state actors and the ways in which these are bridged and scaled up to wider improvements in governance. Aiming to enrich understanding of post-disaster learning, it explores different actors' response actions after the earthquakes in Christchurch, New Zealand, in 2010 and 2011. On the one hand, 'learning by doing' is occurring, yet, on the other hand, systemic learning is hindered by mismatches between top-down steering and bottom-up initiatives. The study concludes that better linking and synergising of learning processes among different levels is vital for enhancing resilience in post-disaster societies.

Complex instability of the elbow.

Injuries to the elbow are commonly encountered in orthopaedic practice. They range from low energy, simple isolated fractures, to high energy complex fracture dislocations with severe ligamentous disruption. Recognising the precise pattern of injury is critical in restoring elbow function and preventing chronic instability, pain and weakness. This article discusses the important osseous and ligamentous stabilisers of the elbow joint and provides management protocols for the common patterns of complex injury encountered by the practising surgeon.

Do postoperative platelet-rich plasma injections accelerate early tendon healing and functional recovery after arthroscopic supraspinatus repair? A randomized controlled trial.

BACKGROUND: Tendon-bone healing after rotator cuff repair directly correlates with a successful outcome. Biological therapies that elevate local growth-factor concentrations may potentiate healing after surgery. PURPOSE: To ascertain whether postoperative and repeated application of platelet-rich plasma (PRP) to the tendon repair site improves early tendon healing and enhances early functional recovery after double-row arthroscopic supraspinatus repair. STUDY DESIGN: Randomized controlled trial; Level of evidence, 1. METHODS: A total of 60 patients underwent arthroscopic double-row supraspinatus tendon repair. After randomization, half the patients received 2 ultrasound-guided injections of PRP to the repair site at postoperative days 7 and 14. Early structural healing was assessed with MRI at 16 weeks, and cuff appearances were graded according to the Sugaya classification. Functional scores were recorded with the Oxford Shoulder Score; Quick Disability of the Arm, Shoulder and Hand; visual analog scale for pain; and Short Form-12 quality-of-life score both preoperatively and at postoperative weeks 6, 12, and 16; isokinetic strength and active range of motion were measured at 16 weeks. RESULTS: PRP treatment did not improve early functional recovery, range of motion, or strength or influence pain scores at any time point after arthroscopic supraspinatus repair. There was no difference in structural integrity of the supraspinatus repair on MRI between the PRP group (0% full-thickness retear; 23% partial tear; 77% intact) and the control group (7% full-thickness retear; 23% partial tear; 70% intact) at 16 weeks postoperatively (P = .35). CONCLUSION: After arthroscopic supraspinatus tendon repair, image-guided PRP treatment on 2 occasions does not improve early tendon-bone healing or functional recovery.

Recurrent Fusobacterium pyogenic myositis of the rotator cuff A case report of recurrent Fusobacterium pyogenic myositis of the rotator cuff.

Pyogenic myositis is uncommon. It normally affects the large muscle groups in the lower limb or trunk and the most common causative organism is Staphylococcus aureus. We present a case of an immunocompetent man who, unusually, had a recurring form of the disease in subscapularis and teres minor. The causative organism was also highly unusual (Fusobacterium).

A simple, safe and reliable surgical landmark for medial epicondylectomy.

BACKGROUND: Various surgical strategies have been described for the treatment of cubital tunnel syndrome, including medial epicondylectomy. This aims to decompress the ulnar nerve and allow a 'mini anterior transposition'. The major concern over medial epicondylectomy is the potential for postoperative iatrogenic valgus instability. METHODS: We utilized a surgical landmark for medial epicondylectomy based on the medial aspect of the ulnar nerve with the elbow in 90° of flexion in 12 cadaveric upper limbs. The size of the resultant fragment was measured and, subsequently, the medial collateral ligament was dissected and the elbow stressed to assess its integrity. RESULTS: This technique resulted in the excision of a fragment of mean width 8 mm (range 6 mm to 11 mm) and allowed the ulnar nerve to smoothly translate anteriorly in flexion. The anterior band of the ulnar collateral ligament was macroscopically preserved in all cases and there was no valgus instability. CONCLUSIONS: The medial border of the ulnar nerve is a simple, safe and reliable surgical landmark for medial epicondylectomy. This technique offers advantages over other described methods of assessing the location at which to perform a medial epicondylectomy.

Thermal damage during humeral reaming in total shoulder resurfacing.

INTRODUCTION: Total shoulder resurfacing (TSR) provides a reliable solution for the treatment of glenohumeral arthritis. It confers a number of advantages over traditional joint replacement with stemmed humeral components, in terms of bone preservation and improved joint kinematics. This study aimed to determine if humeral reaming instruments produce a thermal insult to subchondral bone during TSR. PATIENTS AND METHODS: This was tested in vivo on 13 patients (8 with rheumatoid arthritis and 5 with osteoarthritis) with a single reaming system and in vitro with three different humeral reaming systems on saw bone models. Real-time infrared thermal video imaging was used to assess the temperatures generated. RESULTS: Synthes (Epoca) instruments generated average temperatures of 40.7°C (SD 0.9°C) in the rheumatoid group and 56.5°C (SD 0.87°C) in the osteoarthritis group (P = 0.001). Irrigation with room temperature saline cooled the humeral head to 30°C (SD 1.2°C). Saw bone analysis generated temperatures of 58.2°C (SD 0.79°C) in the Synthes (Epoca) 59.9°C (SD 0.81°C) in Biomet (Copeland) and 58.4°C (SD 0.88°C) in the Depuy Conservative Anatomic Prosthesis (CAP) reamers (P = 0.12). CONCLUSION: Humeral reaming with power driven instruments generates considerable temperatures both in vivo and in vitro. This paper demonstrates that a significant thermal effect beyond the 47°C threshold needed to induce osteonecrosis is observed with humeral reamers, with little variation seen between manufacturers. Irrigation with room temperature saline cools the reamed bone to physiological levels and should be performed regularly during this step in TSR.

Magnetic resonance scanning vs axillary radiography in the assessment of glenoid version for osteoarthritis.

BACKGROUND: Osteoarthritic shoulders are mainly associated with glenoid retroversion. Total shoulder arthroplasty with the glenoid component implanted in retroversion predisposes to loosening of the glenoid prosthesis. Correction of glenoid retroversion through anterior eccentric reaming, before glenoid component implantation, is performed to restore normal joint biomechanics. Accurate preoperative assessment is required to ascertain the degree of retroversion and calculate the degree of reaming. MATERIALS AND METHODS: We assessed the utility of magnetic resonance imaging (MRI) for the assessment of glenoid version in glenohumeral osteoarthritis compared with standard plain axillary radiography (AXR). Two independent observers reviewed both types of imaging in 48 primary osteoarthritic shoulders on 2 separate occasions. RESULTS: The mean glenoid version measured was -14.3° on MRI and -21.6° on AXR (mean difference, -7.36°; P < .001). Intraobserver and interobserver reliability coefficients were 0.96 and 0.9, respectively, for MRI and 0.8 and 0.71, respectively, for AXR. Glenoid retroversion was greater in 73% of AXR. CONCLUSION: We demonstrated that MRI is more reproducible in the assessment of glenoid version in osteoarthritis and provides excellent intraobserver and interobserver reliability. MRI is useful for preoperative osseous imaging for total shoulder arthroplasty because it offers a more precise method of determining glenoid version compared with x-ray imaging in addition to the standard assessment of rotator cuff integrity.

The influence of rotator cuff pathology on functional outcome in total shoulder replacement.

INTRODUCTION: Total shoulder replacement (TSR) is a reliable treatment for glenohumeral osteoarthritis. In addition to proper component orientation, successful arthroplasty requires accurate restoration of soft tissues forces around the joint to maximize function. We hypothesized that pathological changes within the rotator cuff on preoperative magnetic resonance imaging (MRI) adversely affect the functional outcome following TSR. MATERIALS AND METHODS: A retrospective analysis of case notes and MRI of patients undergoing TSR for primary glenohumeral osteoarthritis over a 4-year period was performed. Patients were divided into three groups based upon their preoperative MRI findings: (1) normal rotator cuff, (2) the presence of tendonopathy within the rotator cuff, or (3) the presence of a partial thickness rotator cuff tear. Intra-operatively tendonopathy was addressed with debridement and partial thickness tears with repair. Functional outcome was assessed with the Oxford Shoulder Score (OSS), and quick disabilities of the arm, shoulder and hand score (quick-DASH). RESULTS: We had a full dataset of complete case-notes, PACS images, and patient reported outcome measures available for 43 patients, 15 in group 1, 14 in group 2, and 14 in group 3. Quick-DASH and OSS were calculated at a minimum of 24 months following surgery. There was no statistically significant difference between the results obtained between the three groups of either the OSS (P = 0.45), or quick-DASH (P = 0.46). CONCLUSIONS: TSR is an efficacious treatment option for patients with primary glenohumeral osteoarthritis in the medium term, even in the presence of rotator cuff tendonopathy or partial tearing. Minor changes within the cuff do not significantly affect functional outcome following TSR.

Complications of definitive open reduction and internal fixation of pilon fractures of the distal tibia.

A series of 49 pilon fractures in a tertiary referral centre treated definitively by open reduction and internal fixation have been assessed and the complications of such injuries examined. A retrospective analysis of case notes, radiographs and computerised tomographs over a seven-year period from 1999-2006 was performed. Infection was the most common postoperative problem. There were seven cases of superficial infection. There was a single case of deep infection requiring intravenous antibiotics and removal of metalwork. Other notable complications were those of secondary osteoarthritis (three cases) and malunion (one case). The key finding of this paper is the 2% incidence of deep infection following the direct operative approach to these fractures. The traditional operative approach to such injuries (initially advocated by Rüedi and Allgöwer in Injury 2:92-99, 1969) consisted of extensive soft tissue dissection to gain access to the distal tibia. Our preferred method is to access the tibia via the "direct approach" which involves direct access to the fracture site with minimal disturbance of the soft tissue envelope. We therefore believe that open reduction and internal fixation of pilon fractures via the direct approach to be a safe technique in the treatment of such devastating injuries.

Case report: a novel solution to penile zipper injury--the needle holder.

Penile injuries are relatively uncommon. The crush injury mediated by entrapment of the skin between the teeth and fastener of a zipper mechanism has been described. It is seen more commonly in uncircumcised children than adults. A number of treatment methods have been mentioned in the literature. An adult case presentation and novel method of management using two small needle holders is illustrated.