Long-term clinical outcomes of arthroscopic supraspinatus tendon repair using the single anchor tension band technique - Minimum 5-years follow-up.

Background: The primary aim of this study was to assess the long-term patient reported outcomes of arthroscopic rotator cuff tear (ARCR) using a single anchor tension band (TB) technique for small and medium supraspinatus tears at minimum 5-years follow-up. Methods: A retrospective cohort study of consecutive ARCRs of small and medium supraspinatus tears using a knotless single anchor TB technique with minimum 5-year follow-up was carried out. Outcomes of interest included: range of motion (ROM) on examination under anaesthesia (EUA), visual analogue scale (VAS), American Shoulder and Elbow Surgeons (ASES) scores, Oxford Shoulder Score (OSS) and Short-Form (SF-12). Results: From 243 consecutive ARCR procedures, 82 patients with a mean age of 55 ± 9.5 years met the inclusion criteria at 6.7 ± 1.5 years follow-up. There were significant improvements in VAS (5.5 ± 2.2 vs. 0.7 ± 1.5), ASES (47.6 ± 16.8 vs. 92.8 ± 13.0), OSS (31.3 ± 7.2 vs. 45.3 ± 3.5) and SF-12 (37.6 ± 7.6 vs. 50.3 ± 7.7) post-operatively (all p < 0.001). Conclusions: The single anchor TB ARCR technique has excellent patient reported outcomes at a minimum of 5 years and is suitable for supraspinatus tears smaller than 20 mm in the sagittal plane. Level of evidence: Level IV; Consecutive Case Series.

Traumatic posterior sternoclavicular joint dislocation - Current aspects of management.

The posterior sternoclavicular joint dislocation is a rare and potentially life-threatening injury, as massive haemorrhage can occur at the time of trauma, during reduction manoeuvres and drilling. These injuries are rare and a collective experience of managing them is of paramount importance. We present our multidisciplinary experience of managing several of these injuries in our centre, with learning points we have identified. Assessment should include Computerised Tomography Angiography (CTA) to assess the anatomy of the joint including the proximity to the underlying innominate vein and to identify any bleeding. Both closed reduction and open reconstruction have the potential for massive haemorrhage which can be controlled successfully with direct access to the underlying vessel. We recommend that all reductions should be performed in the presence of a cardiothoracic surgeon who can gain vascular control in the head, neck, and thorax. In specific high-risk cases, pre-emptive venous catheterisation can also be considered. We recommend that a discussion and rehearsal for intra-operative bleeding should be undertaken with the whole theatre team, with roles assigned pre-emptively and to allow identification of any deficiencies in staff expertise or equipment. Of the five recent cases managed in our centre one patient had a closed reduction and four had open reductions. Success of closed reductions within 48 h is high and these can be attempted up to 10 days after injury. Our patient undergoing closed reduction had a favourable outcome and returned to professional rugby at five months. Open reduction was performed in a physeal fracture as there was a delay to surgery and callus had begun to form and had the potential to adhere to the underlying vessel. In this case we performed open reduction and stabilised with tunnelled suture fixation. Our preferred method of reconstruction uses a palmaris graft with internal figure of eight bracing. One patient had a subsequent fracture of the medial clavicle around the drill holes that healed without further intervention. Despite good reduction and stability achieved following palmaris reconstructions, two patients are experiencing ongoing symptoms of globus and one with voice change without any objective underlying cause.

Type IV acromioclavicular joint dislocation associated with a mid-shaft clavicle malunion.

This reports presents the case of a combined clavicle fracture malunion and chronic Type IV acromioclavicular (AC) joint dislocation. The patient was seen acutely in the emergency department following a mountain bike accident at which time the clavicle fracture was identified and managed conservatively however the AC dislocation was not diagnosed. The patient presented 25 months following the injury with persistent pain and disability and was treated with clavicle osteotomy and AC stabilization. We document the clinical details, surgical treatment and outcome.

Total elbow arthroplasty in obese patients.

BACKGROUND: The prevalence of obesity in the United States has increased in recent decades. The aim of this study was to evaluate the influence of obesity in patients undergoing primary total elbow arthroplasty. METHODS: From 1987 to 2006, 723 primary semiconstrained, linked total elbow arthroplasties were performed in 654 patients. The average patient age (and standard deviation) at the time of surgery was 62.3 ± 13.7 years, with 550 total elbow arthroplasties (76%) performed in women. Total elbow arthroplasties were used to treat inflammatory conditions in patients undergoing 378 total elbow arthroplasties (52%) and to treat acute traumatic or posttraumatic conditions in patients undergoing 310 total elbow arthroplasties (43%). Patients were classified as non-obese (having a body mass index of <30 kg/m2) in 564 total elbow arthroplasties (78%) and as obese (having a body mass index of ≥30 kg/m2) in 159 total elbow arthroplasties (22%). The median duration of follow-up was 5.8 years (range, zero to twenty-five years). Survivorship of total elbow arthroplasty was estimated with use of the Kaplan-Meier method. The effect of obesity on risk of total elbow arthroplasty revision was estimated with use of Cox regression models, adjusting for age, sex, body mass index, and indication. RESULTS: A total of 118 revisions (16%) were performed. The ten-year survival rate for total elbow arthroplasty revision for any reason was 86% (95% confidence interval, 82% to 89%) in non-obese patients compared with 70% (95% confidence interval, 60% to 79%) in obese patients (p < 0.05). The ten-year survival rate for total elbow arthroplasty revision for mechanical failure was 88% (95% confidence interval, 84% to 91%) in non-obese patients compared with 72% (95% confidence interval, 61% to 81%) in obese patients (p < 0.05). Severely obese patients (those with a body mass index of 35 to <40 kg/m2) had a significantly higher risk of total elbow arthroplasty revision for any reason (hazard ratio, 3.08 [95% confidence interval, 1.61 to 5.45]; p < 0.05) and mechanical failure (hazard ratio, 3.10 [95% confidence interval, 1.47 to 5.89]; p < 0.05) compared with non-obese patients. CONCLUSIONS: Obesity adversely influences the performance of elbow replacement after primary total elbow arthroplasty. Obese patients being considered for elbow replacement surgery should be counseled accordingly.

Validation of the Stanmore percentage of normal shoulder assessment.

BACKGROUND AND PURPOSE: The Stanmore Percentage of Normal Shoulder Assessment (SPONSA) is a patient-reported outcome measure (PROM). The score assesses pain, range of movement, strength, stability and function of the shoulder. The aim of this work was to formally validate the SPONSA. MATERIALS AND METHODS: Validation of this score was carried out by measuring reproducibility, construct validity and sensitivity to change. Time to completion was also recorded. The Oxford Shoulder Score (OSS) and Constant Score (CS) were used for comparison. These assessments were performed with 61 individuals undergoing shoulder interventions. RESULTS: There was excellent preoperative reproducibility in both intra- and inter-observer groups. The SPONSA had a 0.79 correlation with the OSS and 0.78 with the CS. The overall effect size of the SPONSA was 0.72, which was comparable to OSS (0.65) and greater than CS (0.34), implying equal or better sensitivity to change. CONCLUSIONS: The SPONSA is practical and quick to perform and also a reproducible and a sensitive instrument. This simple PROM is a commendable addition to the existing validated scoring methods for the shoulder. LEVEL OF EVIDENCE: I; testing of previously developed diagnostic criteria on consecutive patients (with universally applied reference "gold" standard).

Prospective blinded comparison of surface versus wire electromyographic analysis of muscle recruitment in shoulder instability.

BACKGROUND: This pilot study assesses level of agreement between surface and fine-wire electromyography (EMG), in order to establish if surface is as reliable as fine wire in the diagnosis and treatment of abnormal muscle patterning in the shoulder. METHOD: Eighteen participants (11 female) with unstable shoulders were recruited after written consent and ethical approval. Anthropometric information and mean skinfold size for triceps, subscapular, biceps and suprailiac sites were obtained. Triple-stud self-adhesive surface electrodes ('Triode'; Thermo Scientific, Physio Med Services, Glossop, Derbyshire, England) were placed over pectoralis major (PM), latissimus dorsi (LD), anterior deltoid (AD) and infraspinatus (IS) at standardized locations. Participants performed five identical uniplanar standard movements (flexion, abduction, external rotation, extension and cross-body adduction). After a 20-minute rest period, a dual-needle technique for fine-wire insertion was performed and the standard movements were repeated. An experienced examiner in each technique reported if muscle activation patterns differed from agreed normal during any movement and were blinded to the other test results. Sensitivity, specificity and Kappa values for level of agreement between methods were calculated for each muscle according to the method of Altman (1991). RESULTS: Fifteen participants were successfully tested. Sensitivity, specificity and Kappa values between techniques for each muscle were PM (57%, 50%, 0.07), LD (38%, 85%, 0.22), AD (0%, 76%, -0.19) and IS (85%, 75%, 0.6). Only IS demonstrated high sensitivity and specificity and a moderate level of agreement between the two techniques. There was no correlation between skinfold size and agreement levels. CONCLUSION: The use of surface EMG may help to classify types of shoulder instability and recognize abnormal muscle patterns. It may allow physiotherapists to direct specific rehabilitation strategies, avoiding strengthening of inappropriate muscles. It has a reasonable degree of confidence to evaluate IS but may have poor sensitivity in detecting abnormal patterns in PM, LD and AD. Further work is required to see if investigator interpretation may have been a factor for the poor level of agreement.