Reliability of stemless shoulder arthroplasty in rheumatoid arthritis: observation of early lysis around the humeral component.

PURPOSE: To evaluate whether stemless shoulder implants in rheumatoid arthritis (RA) patients provide comparable functional outcomes to patients with osteoarthritis or post-traumatic arthritis. In addition, the study assessed for differences in incidence of radiolucent lines or proximal humeral bone loss during radiographic follow-up. METHODS: Consecutive stemless shoulder arthroplasties performed in RA patients and a matched control group were retrospectively identified between February 2012 and 2018. Thirty-five patients were included in each group: 24 total shoulder arthroplasty (TSA) and 11 hemiarthroplasty (HA). Patients were evaluated annually using the Oxford Shoulder Score (OSS) and radiographically. RESULTS: The mean OSS significantly improved in all groups until 24 months. The mean improvement for RA TSA and HA patients at 24 months was 19.86 (95% CI 10.66-29.05, p = 0.0004) and 19.71 (95% CI 7.33-32.31, p = 0.0084), respectively. The mean improvement in the control TSA and HA patients at 24 months was 20.86 (95% CI 17-24.71, p = 0.0001) and 17.86 (95% CI 1.36-34.35, p = 0.0381), respectively. During the study period, two patients in the RA TSA group (8%), one patient in the control TSA group (4%) and one patient in the control HA group (9%) required revision. The proportion of progressive proximal humeral bone loss after TSA was 33% in the RA group and 13% in the control group. CONCLUSION: Stemless shoulder implants can provide significant improvement in functional scores in RA patients in the short term. However, early bone loss around the humeral implant is a concern and the authors recommend long-term clinical and radiological follow-up.

Thromboprophylaxis in pelvic and acetabular trauma surgery. The role of early treatment with low-molecular-weight heparin.

We prospectively studied the outcome of a protocol of prophylaxis for deep vein thrombosis (DVT) in 103 consecutive patients undergoing surgical stabilisation of pelvic and acetabular fractures. Low-molecular-weight heparin (LMWH) was administered within 24 hours of injury or on achieving haemodynamic stability. Patients were screened for proximal DVT by duplex ultrasonography performed ten to 14 days after surgery. The incidence of proximal DVT was 10% and of pulmonary embolus 5%. Proximal DVT developed in two of 64 patients (3%) who had received LMWH within 24 hours of injury, but in eight of 36 patients (22%) who received LMWH more than 24 hours after the injury (p < 0.01). We conclude that LMWH, when begun without delay, is a safe and effective method of thromboprophylaxis in high-risk patients with major pelvic or acetabular fractures.

Thermal capsular shrinkage for shoulder instability. Mid-term longitudinal outcome study.

We present the short- and medium-term clinical results of thermal shrinkage in selected groups of patients with multidirectional or capsular stretch-type instability. We treated 56 patients (61 shoulders) by laser-assisted capsular shrinkage (LACS) and 34 patients (38 shoulders) by radiofrequency (RF) capsular shrinkage. The two groups were followed for mean periods of 40 months and 23 months, respectively. In the LACS group the mean Walch-Duplay score improved to 90 points 18 months after the operation, but then declined to a plateau of about 80 points; 59% of patients considered their shoulders to be 'much better' or 'better' but there was a failure rate of 36.1%. For the RF group the mean Walch-Duplay and Constant scores were 80 points at the various follow-up times; 76.3% of patients considered their shoulder to be 'much better' or 'better'. RF failed in nine shoulders (23.7%). These results match some clinical series of patients with multidirectional instability, undergoing open inferior capsular shift, with a similar rate of failure. We believe that the minimal morbidity involved makes thermal shrinkage a viable alternative to open capsular shift in this difficult group of patients.

Manipulation under anesthesia for primary frozen shoulder: effect on early recovery and return to activity.

Frozen shoulder is still an enigma of shoulder surgery. It is reported that at 2 years from onset, most patients will have recovered whether treated or not. However, the duration of morbidity has major implications for patient function and satisfaction. In view of this fact, we have focused on the early effect of manipulation under anesthesia on shoulder function. We prospectively assessed 39 shoulders in 37 patients who were given the diagnosis of primary frozen shoulder between June 1997 and June 1998 and were treated with manipulation under anesthesia of the affected shoulder. The median preoperative Constant score rose from 24 of 100 to 63 of 100 at 3 to 6 weeks and to 69 of 100 at 3 months. Improvement was maintained at a mean follow-up of 11 months after surgery (range 6 to 18 months). Overall, 94% of patients were satisfied with the procedure. At 3 months 59% (23 shoulders) were rated as having no or mild disability only, 28.2% (11 shoulders) as having a moderate degree of disability, and 12.8% (5 shoulders) as having a severe degree of disability. Of the 5 cases scoring less than 50 of 100 (mean 40) at 3-month follow-up, 1 had unmasked symptoms of a subacromial impingement syndrome that has required further treatment. There was no relationship between the initial Constant score or the initial range of movement after manipulation and the eventual result. We recommend the use of manipulation under anesthetic in primary frozen shoulder to restore early range of movement and to improve early function in this often protracted and frustrating condition.

The shoulder in patients with muscular dystrophy.

Shoulder weakness and instability are not usually a major part of the clinical picture of muscular dystrophies. Problems usually do not arise until the patient is wheelchair bound, at which time assistive appliances may be required. The majority of orthopaedic intervention is confined to the rare facioscapulohumeral dystrophy. Facioscapulohumeral dystrophy causes muscular weakness of the face, shoulder girdle, and upper arm with selective sparing of the deltoid muscle. This leads to scapular winging and a marked decrease in flexion and abduction of the shoulder. As the muscles stabilizing the scapula become involved, the scapula starts to wing. The deltoid is spared, but its action is wasted because of the unstable scapula. The deltoid contracts and the arm attempts to move in a normal fashion, but because the scapula is no longer stable, it wings and rotates under the forces of the long lever arm of the upper limb and scapula complex. Mechanical fixation of the scapula to the thoracic wall provides a stable fulcrum on which the deltoid can exert its powerful action on the humerus and abduct the arm without rotation of the scapula. Twenty thoracoscapular fusions were performed on 13 patients. Ten patients (14 shoulders) were available for long term followup. The long term results showed that this operation is successful in achieving stability of the scapula, while greatly improving function and cosmesis. Although the course of this type of muscular dystrophy is variable, the benefits of surgery have not deteriorated with progression of the disease during a maximum followup of 44 years.

Proximal thigh pain after femoral nailing. Causes and treatment.

We have reviewed retrospectively 80 patients who were treated for traumatic fractures of the femur with a Grosse-Kempf nail to assess the incidence and causes of persisting pain in the proximal thigh. At a mean of 21 months after operation 33 patients had residual pain severe enough to interfere with their lifestyle or mobility. This was in the region of the scar on the greater trochanter in three-quarters of the patients. Only four showed no radiological abnormality. There was nonunion of the fracture in two, Paget's disease in one, breakage of the nail in two and prominence of the proximal locking screw in five, although we found no correlation between prominence of the nail and pain. There was a strong relationship between pain and heterotopic ossification at the proximal end of the implant; this was present in 64% of the patients with pain as compared with those without pain (p < 0.001, Mann-Whitney U test). Of the 80 patients, 27 had the implant removed after 18 months, 17 of them because of pain. In six of these 17, the pain was not relieved. Prominence of the nail proximally was not associated with pain, but protuberance of laterally-based proximal locking screws caused problems. We found a strong association between heterotopic bone formation and pain, but it is uncertain whether this is the true cause or merely an indication of some other factor such as traumatic damage to the glutei during insertion of the nail. Removal of the implant does not always cure such pain.

The shoelace technique for wound closure in open fractures: report of early experience.

A simple, reliable method of wound closure in open fractures is presented which has been used in this department. The necessity for split-skin grafting or flap cover, with the associated morbidity and cost implications, has been avoided by using this method. It has not been associated with any major complications in the patients studied, but it should be recognized that this method is not universally suitable in the treatment of all open injuries. We recommend this method as a simple way of achieving soft tissue cover in open injuries which are thoroughly debrided and cleaned, and in which there is no evidence of raised intracompartmental pressure.

Noise in the orthopaedic operating theatre.

Little has been written about noise levels produced in operating theatres. The noise output of orthopaedic air tools is measured in this survey. At the levels found in this survey it is possible to exceed the safe levels of noise exposure in the workplace as recommended by the Health & Safety Executive although it is difficult to quantify the risk to hearing that this represents.

Orthopaedic implant removal at Royal Naval Hospital Stonehouse: a three-year review.

A recent study stated that 11% of all elective orthopaedic procedures performed at a Regional Orthopaedic Unit involved removal of orthopaedic implants. Indications for certain orthopaedic implant removal remain unclear. As budgets are squeezed even tighter throughout all branches of the Royal Navy, we looked at each operation performed for orthopaedic implant removal at Royal Naval Hospital Stonehouse and questioned their effectiveness with respect to finance and working days lost for serving personnel.

'Correctable undetected visual acuity deficit' in patients aged 65 and over attending an accident and emergency department.

The rate of occurrence of correctable undetected visual acuity deficit (CUVAD) in a population of patients aged 65 and over was investigated, using a pinhole screening method, to compare the sociodemographic and optical eye care habits of patients with or without a functionally significant CUVAD. Of 136 patients 46 (34%) were found to have a functionally significant CUVAD in one or both eyes which was not significantly associated with optician or general practitioner contact, age, sex, social class, living situation, or number of medications. Half the patients with significant CUVAD had not attended for 2 years mainly because of financial considerations. Three quarters attended of their own volition; only one in seven were prompted by opticians' postal invitations. It was concluded that a significant degree of CUVAD could be detected using a simple procedure which can be carried out by general practitioners as part of their general elderly health screen.

The role of perichondrium in modifying curved cartilage: an experimental study.

A study of 11 strips of curved cartilage harvested from 11 pigs' ears was undertaken to compare quantitatively the forces required to bend the strips before and after modification. The results show no statistical difference between the intact curvature and curvature produced when skin and perichondrium were resutured over 4 full-thickness, cartilaginous crosscuts. These in vitro findings suggest that, when one attempts to modify the shape of curved cartilage, lasting results may be obtained by shortening the convex surface length using a wedge excision method. The perichondrium is incised on the concave surface or the surface that will become longer with cartilage scoring, such as in otoplasty. If the cartilage surface will require elongation for ultimate straightening, the perichondrium as well as the cartilage must be incised.