Functional outcome of open acromioclavicular joint stabilization for instability following distal clavicle resection.

BACKGROUND: Acromioclavicular joint instability following distal clavicle resection can result in considerable pain and dysfunction. METHOD: We present a review of 13 patients who underwent ACJ stabilization following one or more distal clavicle resection procedures. RESULTS: The mean Quick DASH and CM scores were 26(0-57) and 73(46-100) respectively. All but one patient reported an improvement in the pain component of their CM score and in the work component of the Quick DASH score. DISCUSSION: Open ACJ stabilization to treat instability following distal clavicle resection resulted in improved functional scores, pain scores and facilitated return to work in most patients.Level of evidence IV.

Paediatric fracture clinic re-design: Incorporating a virtual fracture clinic.

INTRODUCTION: The use of virtual fracture clinics (VFCs) and home management protocols is increasing. The main aim of this research is to determine whether a paediatric home management programme and VFC can be used safely to manage a range of suitable fractures in children. MATERIALS AND METHODS: Protocols for the home management of stable paediatric fractures were designed by two consultant paediatric orthopaedic surgeons. These were for children between the ages of 18 months and 15 years 364 days. A new tariff was negotiated with the clinical commissioning groups (CCGs) for a VFC new patient review. A prospective analysis was performed for the first 2 months of the programme. Further review periods were undertaken 6 months later and 12 months after that. RESULTS: Sixty-five patients were reviewed in the first 10 VFCs (mean 6.5 cases per week). After 6 months, 164 patients were reviewed in a 3-month period in the VFC, a mean of 11 cases per week. A year later the number of patients reviewed in the VFC had continued to increase with a total of 253 patients in 3 months, mean 21 cases per week. This gave a saving to the CCG of £45,000 per year and to the hospital of £106,000 per year. There were no serious adverse consequences to any patients from the use of the pathway. DISCUSSION AND CONCLUSION: We have reported on the introduction of a paediatric VFC and a home management programme for stable paediatric fractures. We are not aware of any reports in the orthopaedic literature that have described such a comprehensive and innovative re-organisation of paediatric fracture services. We estimate that the NHS could save approximately £10.1 million if all hospitals in England introduced this.

Simple elbow dislocation.

The elbow is the second most commonly dislocated major joint in adults. Good long-term outcomes have been reported after non-operative management; however, a small proportion (<10%) of patients have a poor outcome and some do require surgical intervention. A review of the anatomy, pathoanatomy, management and outcomes of simple elbow dislocations is presented. Emphasis is placed on emerging concepts regarding the soft tissue injury, the stabilising structures that are injured, the sequence and mechanism of injury and the relationship to elbow stability. The benefits of nonsurgical and surgical management are discussed and a treatment algorithm based on the pathoanatomy is proposed.

Randomized controlled trial of supervised physiotherapy versus a home exercise program after hydrodilatation for the management of primary frozen shoulder.

HYPOTHESIS AND BACKGROUND: Hydrodilatation and physiotherapy are commonly used treatments for primary frozen shoulder. Little is known about the optimal form of physiotherapy. This study reports a randomized controlled trial comparing 2 forms of physiotherapy after hydrodilatation. The null hypothesis was that there would be no difference between the 2 groups at 1 year as measured by the Oxford Shoulder Score (OSS). METHODS: We randomized 41 patients undergoing hydrodilatation for primary frozen shoulder into 2 treatment groups: group 1 (n = 20) underwent supervised physiotherapy in addition to a home exercise program, and group 2 (n = 21) followed a self-directed home exercise program in isolation. Assessment was carried out by a blinded research nurse at baseline, 4 weeks, 3 months, 6 months, and 1 year. The primary outcome measure was the OSS. Other measures were range of movement, visual analog scale pain score, and EQ-5D index. RESULTS: There was no significant difference between the treatment groups at any time point as measured by the OSS or EQ-5D index. In group 1, the OSS improved significantly from 25.00 (95% confidence interval [CI], 21.92-28.08) at baseline to 38.29 (95% CI, 34.01-42.58; P < .0001) at 4 weeks and 43.71 (95% CI, 41.61-45.80; P < .0001) at 1 year. In group 2, the OSS improved significantly from 26.60 at baseline (95% CI, 22.50-30.70) to 40.07 (95% CI, 36.77-43.36; P < .0001) at 4 weeks and 43.00 (95% CI, 39.69-46.31; P < .0001) at 1 year. All outcome measures improved significantly from baseline to 4 weeks. CONCLUSION: In this group of patients, after a hydrodilatation procedure for the treatment of primary frozen shoulder, there was no significant difference in clinical outcomes between supervised physiotherapy in addition to a home exercise program and a self-directed home exercise program in isolation.

Boxer's elbow: internal impingement of the coronoid and olecranon process. A report of seven cases.

BACKGROUND: Boxer's elbow has been described in the literature as an extension and hyperextension injury. However, in our experience, there is a coexisting impingement lesion in the anterior compartment of the elbow that has not previously been described. We report a series of professional boxers with elbow disease treated arthroscopically. The aim of the paper was to accurately describe the pathoanatomy of the condition, the key points in its diagnosis, and the outcomes of surgical treatment. METHODS: Seven professional boxers were treated for symptomatic elbow disease. Clinical evaluation included range of motion and Disabilities of the Arm, Shoulder, and Hand score. The arthroscopic findings and procedures were documented. RESULTS: Symptoms were mainly those of anterior and posterior impingement; 6 elbows had an anterior impingement lesion and 6 had a posterior impingement lesion. Postoperatively, the mean Disabilities of the Arm, Shoulder, and Hand score was 2.7 (range, 0-13.3) at a median of 15 (range, 6-36) months postoperatively. All boxers returned to their previous level of competition and 5 won their next bout. All of the boxers used an orthodox stance, and in all but 1 case the left elbow was the pathologic elbow. CONCLUSION: Boxers are prone to development of anterior and posterior elbow impingement. The side of the pathologic process is related to the boxer's stance, with the lead arm being more vulnerable. Arthroscopic débridement is an effective treatment, enabling return to a high competitive level. Surgeons, sports medicine physicians, and physiotherapists should be aware of the condition.

Accuracy of patient-reported range of elbow motion.

BACKGROUND: Patient-reported outcome meaures (PROMs) not only provide valuable insights into subjective indices of joint health, but also may provide limited objective information about range of motion (ROM). We sought to evaluate the accuracy of patient-reported range of elbow motion compared to measured ROM. METHODS: Sixty clinic patients were recruited, of whom 26 had elbow pathologies and 34 had pathologies other than at the elbow joint. Each patient independently estimated ROM for extension, flexion, pronation and supination before this was measured by a clinician using a universal goniometer, with the mean being the gold standard. RESULTS: We found that patients' ROM estimates were significantly different from measured ROM (p < 0.00001 at 95% confidence interval). There was no statistically significant difference between elbow pathology and non-elbow pathology patients' estimated ROM. CONCLUSIONS: There was great disparity between patient-estimated and measured ROM, although estimates of patients with known elbow pathology did not demonstrate any significant difference from their healthy counterparts. These differences may be too great for patient-estimated range of motion to be used as a reliable tool for assessing outcomes.

The Boyd Interval: A Modification for Use in the Management of Elbow Trauma.

Surgical exposure of the radial head, proximal radius, capitellum, and proximal ulna can be achieved through several different approaches. The most commonly used are: the Kocher, Kaplan, and extensor digitorum communis splitting. Each of these approaches has its own limitations and dangers. In this article we describe a modified version of the less commonly used Boyd approach. We have used this approach with a transosseous lateral collateral ligament and annular ligament repair for operative treatment of fractures involving the radial head, proximal radius, proximal ulna including the coronoid, capitellum, and lateral column of the distal humerus. In our experience, the approach results in superior exposure of the lateral elbow while minimizing the risk of injury to the posterior interosseous nerve.

Changing transfusion practice in total hip arthroplasty: observational study of the reduction of blood use over 6 years.

Patients undergoing primary total hip arthroplasty (THA) have historically been over-transfused. In a district general hospital setting, the authors observed a significant downward trend in blood transfusion requirements in these patients over 6 years after a change in transfusion policy. The purpose of this study was to retrospectively analyze the change in transfusion practice and present the results of the restrictive transfusion policy. All patients undergoing primary THA between January 2003 and December 2008 were identified from hospital records. Pre- and postoperative hemoglobin levels, transfusion trigger hemoglobin, blood transfusion requirements, patient age and sex, 30-day mortality, and length of stay data were analyzed for all patients. A total of 1169 primary THAs were performed. Annual allogeneic blood transfusion requirements reduced progressively from 151 units in 2003 to 90 units in 2008 despite an increase in the number of patients undergoing THA. During this period, the proportion of patients transfused decreased from 35% to 17%. A reduction of mean transfusion trigger hemoglobin from 79 to 73 g/L was observed over the study period. No patient experienced any significant complications as a result of undertransfusion. The authors' institution has steadily restricted the use of blood transfusion in patients undergoing THA to those symptomatic of anemia. Increasing confidence among medical and nursing staff that reduced postoperative hemoglobin levels can be safely tolerated has resulted in a 55% reduction in blood transfusion in patients undergoing THA with no other change of practice.

Foreign body reaction associated with Artelon: report of three cases.

The Artelon carpometacarpal joint implant is a degradable interposition arthroplasty spacer intended for use in thumb carpometacarpal joint osteoarthritis. Recently there have been reported cases of foreign body reaction attributed to the Artelon implant, which raise concerns about the use of this implant. The implant's manufacturers claim excellent biocompatibility. We report 3 cases of persistent pain after thumb carpometacarpal joint arthroplasty performed using Artelon implants. In all 3 cases that required removal of the Artelon implant and trapeziectomy to achieve subsequent symptom relief, foreign body-type reaction associated with the Artelon was seen histologically.

The effect of pharmaceuticals on the nanoscale structure of PEO-PPO-PEO micelles.

We present results on the effects of various hydrophobic drugs and additives on the micellar structure of Pluronic F127 solutions. Small-angle neutron scattering experiments on 5wt% F127 solutions were used to measure micelle core size (R(1)), micelle corona size (R(2)), intermicellar interaction distance (R(int)), polydispersity (sigma), and aggregation number (N(agg)); dynamic light scattering was used to measure critical micelle concentration (CMC); and ultraviolet spectroscopy was used to measure drug solubility and apparent micelle-water partition coefficient (K(mw)). The core and corona size were found to generally increase in the presence of the drugs, as did R(int). Both sigma and N(agg) were found to decrease in the presence of most of the drugs, and the CMC was found to vary considerably with no clear correlation. A design of experiments (DOE) approach was used to analyze the results and build empirical correlations. All of the parameters from the SANS experiments were found to depend strongly on drug solubility, with a weak dependence on K(mw) in most cases. The aggregation number, however, was found to depend strongly on both K(mw) and solubility. The correlations can be used to roughly predict the structural parameters of F127 micelles for other hydrophobic drugs.