A systematic review of the treatment of distal humerus fractures in older adults: A comparison of surgical and non-surgical options.

Background: Fractures of the distal humerus are a common fragility fracture in older adults. The purpose of this study was to systematically review the literature to produce pooled estimates of the outcomes of treatment using total elbow arthroplasty (TEA), open reduction and locking plate fixation (ORIF), hemiarthroplasty or with conservative management. Methods: A systematic review of PUBMED and EMBASE databases was conducted for studies reporting outcomes of intra-articular fractures in older adults. Data extracted included patient-reported outcome measures as well as clinical outcomes including ROM, adverse events and all-cause reoperation rates. Results: Forty-eight studies met the inclusion criteria and included 1838 acute, intra-articular distal humeral fractures. There was no clinically important difference in patient-reported pain and function measured on the Mayo Elbow Performance Score (TEA = 89.3 (SD 20.0), Hemi = 88.4 (SD 10.6), internal fixation = 85.0 (SD 14.7), non-operative = 85.1 (SD 11.0)). Discussion: Each of the treatment modalities studies resulted in a reasonable level of elbow function. The included studies were largely non-comparative and at considerable risk of bias. As elbow replacement surgery becomes centralised in the UK, there is a real need for high-quality comparative research studies to inform practice.

Arthroscopic capsular shift surgery in patients with atraumatic shoulder joint instability: a randomised, placebo-controlled trial.

OBJECTIVES: To determine the effect of arthroscopic capsular shift surgery on pain and functional impairment for people with atraumatic shoulder (glenohumeral) joint instability. METHODS: We conducted a randomised, placebo-controlled clinical trial in a specialist secondary care facility. Patients aged 18 years and over who reported insecurity (apprehension) in their shoulder joint and had evidence of capsulolabral damage on arthroscopic examination were included. Patients were excluded if their shoulder apprehension symptoms were precipitated by a high velocity shoulder injury, they had bony or neural damage, a rotator cuff or labral tear, or previous surgery on the symptomatic shoulder. Sixty-eight participants were randomised and received diagnostic arthroscopy, followed by arthroscopic capsular shift or diagnostic arthroscopy alone. All participants received the same postoperative clinical care. The primary outcome was pain and functional impairment measured with the Western Ontario Shoulder Instability Index. The prespecified minimum clinically important effect was a reduction in pain and disability of 10.4 points. RESULTS: Mean reductions in pain and functional impairment for both groups were similar. Compared with diagnostic arthroscopy, arthroscopic capsular shift increased pain and functional impairment by means of 5 points (95% CI -6 to 16 points) at 6 months, 1 point (95% CI -11 to 13 points) at 12 months and 2 points (95% CI -12 to 17 points) at 24 months. CONCLUSIONS: Compared with diagnostic arthroscopy alone, arthroscopic capsular shift confers, at best, only minimal clinically important benefit in the medium term. TRIAL REGISTRATION NUMBER: NCT01751490.

Tear size, general health status and smoking influence functional outcome at 5 years following arthroscopic rotator cuff repair.

Introduction: There is limited medium-term outcome data regarding the predictors of functional outcome and patient satisfaction after arthroscopic rotator cuff repair. Methods: 287 patients that underwent arthroscopic rotator cuff repair under a high-volume single surgeon were contacted at a minimum of 4 years following surgery. Patient demographics, tear size and co-morbidities were pre-operatively recorded. The Oxford shoulder score, EuroQol 5-dimensional score and patient satisfaction were recorded at final follow-up. Results: 234 (81.5%) patients completed follow-up at a mean of 5.5 (4-9) years. There were 126 males and 108 females with a mean age of 60 (range 25-83) years. The majority of patients (n = 211, 90%) were satisfied with their final outcome. Multivariate linear regression analysis (R 2 = 0.64) identified that increasing tear size (p = 0.04), worsening general health assessed by the EuroQol 5-Dimensional (p < 0.001), and smoking (p = 0.049) were associated with a worse Oxford shoulder score. Logistic regression analysis (R 2 = 0.13) identified that worsening general health assessed by the EuroQol 5-Dimensional (p < 0.001), and smoking (p = 0.01) were associated with an increased risk of patient dissatisfaction. Conclusion: General health status and smoking are independent predictors of functional outcome and patient satisfaction at medium-term follow-up following arthroscopic rotator cuff repair.

Rapid design and implementation of a virtual pain management programme due to COVID-19: a quality improvement initiative.

Background: The COVID-19 pandemic interrupted the delivery of face-to-face pain services including pain management programmes in the United Kingdom with considerable negative impact on patients with chronic musculoskeletal pain. We aimed to develop and implement a remotely delivered pain management programme (PMP) using video-conferencing technology that contains all the core components of a full programme: the 'virtual PMP' (vPMP). By reporting on the process of this development, we endeavour to help address the paucity of literature on the development of remote pain management programmes. Methods: The vPMP was developed by an inter-disciplinary group of professionals as a quality improvement (QI) project. The Model for Improvement Framework was employed with patient involvement at the design phase and at subsequent improvements. Improvement was measured qualitatively with frequent and repeated qualitative data collection leading to programme change. Quantitative patient demographic comparisons were made with a patient cohort who had been on a face-to-face PMP pathway. Results: Sixty-one patients on the PMP waiting list were contacted and 43 met the criteria for the programme. Fourteen patients participated in three vPMP cycles. Patient involvement and comprehensive stakeholder consultation were essential to a robust design for the first vPMP. Continued involvement of patient partners during the QI process led to rapid resolution of implementation problems. The most prominent issues that needed action were technical challenges including training needs, participant access to physical and technological resources, participant fatigue and concerns about adequate communication and peer support. Conclusion: This report demonstrates how a remotely delivered PMP, fully in line with national guidance, was rapidly developed and implemented in a hospital setting for patients with chronic musculoskeletal pain. We also discuss the relevance of our findings to the issues of cost, patient experience, patient preferences and inequities of access in delivering telerehabilitation for chronic pain.

Surgeon involvement in clinical coding to improve data accuracy and remuneration in a shoulder and elbow unit.

BACKGROUND: Clinical coders are dependent on clear data regarding diagnoses and procedures to generate an accurate representation of clinical activity and ensure appropriate remuneration is received. The accuracy of this process may potentially be improved by collaboration with the surgical team. METHODS: Between November 2017 and November 2019, 19 meetings took place between the Senior Clinical Fellow of our tertiary Shoulder & Elbow Unit and the coding validation lead of our Trust. At each meeting, the Clinical Fellow assessed the operative note of cases in which uncertainty existed as to the most suitable clinical codes to apply and selected the codes which most accurately represented the operative intervention performed. RESULTS: Over a 24-month period, clinical coding was reviewed in 153 cases (range 3-14 per meeting, mean 8). Following review, the clinical coding was amended in 102 (67%) of these cases. A total of £115,160 additional income was generated as a result of this process (range £1677-£15,796 per meeting, mean £6061). Only 6 out of 28 (21%) cases initially coded as arthroscopic sub-acromial decompressions were correctly coded as such. DISCUSSION: Surgeon input into clinical coding greatly improves data quality and increases remuneration received for operative interventions performed.

Atraumatic shoulder instability: patient characteristics, comorbidities, and disability.

BACKGROUND: Atraumatic shoulder instability of the shoulder is well described, and numerous extrinsic factors have been identified as having a negative influence on long-term shoulder function, including age, sex, smoking, and workers' compensation status. Furthermore, physical factors such as acute or chronic pain, as well as psychological comorbidities such as depression and suicidal thoughts, are common in shoulder-related conditions. METHODS: Patients with atraumatic shoulder instability were recruited from a review of outpatient logbook and inpatient rehabilitation center admission records. Average and worst pain visual analogue scale rates were recorded for acute and chronic shoulder pain. Disability was measured using the "Disability of the Arm and Hand" score, as well as the Stanmore Percentage of Normal Shoulder Assessment (SPONSA). Depression was assessed using Becks Depression Inventory II, and further single psychological items were selected from other psychological assessment questionnaires. RESULTS: We included 64 patients, of which 51 (79.7%) were female. Mean visual analogue scale pain scores were in average 5.11 (standard deviation 2.24) and 5.58 (standard deviation 2.34) for acute and chronic shoulder pain, respectively. A stepwise, multiple linear regression revealed that only chronic shoulder pain remained significantly related to disability (F(1,61) = 46.13, P < .001). A second linear regression analysis was performed and showed a significant association between the overall Disability of the Arm, Shoulder and Hand score and overall Becks Depression Inventory score (F(1,62) = 12.78, P < .001). A further stepwise, multiple linear regression analysis indicated that chronic pain and depression remain independent variables in the prediction of disability. CONCLUSION: In addition to sociodemographic factors, pain and psychological comorbidities were found to have a negative impact on patient's functional outcome. This study further supports the need for an multidisciplinary team, holistic approach in the management of atraumatic shoulder instability patients with particular emphasis on chronic pain management and psychological support.

The management of infected shoulder arthroplasty by two-stage revision.

BACKGROUND: There remains no gold standard management for deep shoulder periprosthetic joint infection (PJI). This case series aims to present our experience of two-stage revision arthroplasty, including eradication of infection and reoperation rates. METHODS: We retrospectively reviewed patients undergoing revision arthroplasty for shoulder PJI between 2006 and 2015. Cases were confirmed using Musculoskeletal Infection Society (MSIS) and American Academy of Orthopaedic Surgeons (AAOS) guidelines. TSA removal, debridement and irrigation preceded antibiotic-loaded cement spacer insertion and a minimum of six weeks intravenous antibiotics. Reimplantation was performed as a second stage following a negative aspirate. RESULTS: Twenty-eight patients underwent a first stage procedure (mean age 69 years; 16 male, 12 female). Propionibacterium acnes, Methicillin-sensitive Staphylococcus aureus, Coagulase-negative Staphylococcus and Staphylococcus epidermidis were the commonest microorganisms cultured. Five cases had mixed growths and six cases provided no growth. Three patients did not proceed to a second stage. Twenty-five patients underwent reimplantation (mean interval 6.7 months), with 80% remaining infection-free (mean follow-up 38.3 months). DISCUSSION: Managing complex and late presentation shoulder PJI with two-stage revision is associated with high rates of infection eradication (80%). In the absence of a management consensus, our experience supports two-stage revision arthroplasty for eradicating infection in this complex patient group.

The management of infected elbow arthroplasty by two-stage revision.

BACKGROUND: Deep prosthetic infection is a potentially devastating complication after total elbow arthroplasty, with an incidence of up to 12%. This study examined the demographics, microbiologic profile, and outcomes of infected total elbow arthroplasty treated with 2-stage revision in a tertiary referral unit. METHODS: We identified 19 consecutive patients (mean age, 65 years) undergoing revision arthroplasty for deep prosthetic infection. All patients underwent a first-stage procedure with removal of implants, débridement, and insertion of an antibiotic-loaded cement spacer, followed by at least 6 weeks of intravenous antibiotics. Fourteen patients required a second-stage revision. RESULTS: Five patients did not undergo a second-stage procedure because of patient choice (n = 2), medical or surgical risk factors (n = 2), and death from an unrelated cause (n = 1). Of the 19 patients undergoing a first-stage procedure, 16 (84%) remained infection free, and 11 of the 14 patients (79%) undergoing reimplantation of an elbow prosthesis remained infection free. Six patients required further surgery (3 for recurrent infection, 3 for noninfective indications). The commonest infecting organism was Staphylococcus aureus (47%). A degree of postoperative ulnar nerve dysfunction occurred in 37% of patients, but all resolved fully without further treatment. CONCLUSIONS: Management of prosthetic joint infection using 2-stage revision can result in high rates of eradication, although rates of reoperation and transient ulnar nerve dysfunction are high.

Shoulder linked arthroplasty in patients with obstetric brachial plexus palsy can improve quality of life and function at short-term follow-up.

BACKGROUND: Patients with obstetric brachial plexus palsy (OBPP) are prone to develop degenerative shoulder disease at a younger age than the general population. To date, no reports have been published on the complexities or outcome of shoulder arthroplasty (SA) in this unique patient group. METHODS: We reviewed of 9 SAs in 9 patients (3 men and 6 women) with OBPP with mean follow-up 5.1 years (range, 2.6-7.6 years). Patients were a mean age of 29 years (range, 16-56 years). Patients had undergone a mean of 3 previous operations (range, 2-6). All patients underwent linked constrained SA. RESULTS: The mean Oxford Shoulder Score increased from 8 (range, 3-10) preoperatively to 21 (range, 12-32) at the final follow-up (P < .001) predominantly due to pain relief. Mean range of active forward elevation and abduction improved from 35° and 39° to 46° and 45°, respectively. Patients improved significantly in 2 of 8 Short-Form 36-Item health-related quality of life domains, bodily pain (P = .013) and mental health (P = .035), and the overall physical component summary score (P = .006). Range of motion had mild improvements. Three required reoperation (33%), comprising 1 excision of heterotopic ossification, 1 trimming of a prominent screw, and 1 deltoid rupture repair. CONCLUSIONS: SA is effective at relieving pain and health-related quality of life for young patients with OBPP; however, compared with the general population, the complication rate is high and functional gains are small.