Prognosis After Arthroscopic Superior Medial Scapuloplasty for Snapping Scapula Syndrome Improves After a Transient Beneficial Response With an Ultrasound-Guided Subscapular Cortisone Injection.

PURPOSE: To evaluate the prognostic value of an ultrasound-guided subscapular local anesthetic and cortisone injection in a consecutive series of patients who underwent an arthroscopic superior medial scapuloplasty for snapping scapula syndrome (SSS) and had been refractory to conservative treatment. METHODS: We undertook an arthroscopic superior medial scapuloplasty on patients with a clinical diagnosis of SSS who had failed a structured physiotherapy program and had either gained a good response or no to minimal response to preoperative ultrasound-guided subscapular local anesthetic and cortisone injection. The patients were assessed preoperatively and at final follow-up with the QuickDASH and Constant scores, and their pain was assessed with a visual analog scale (VAS). RESULTS: Between January 2009 and December 2016, 47 patients were included in the study, with a minimal follow-up of 2 years. There were 29 female and 18 male patients, and the mean age at the time of surgery was 27.4 years (range 15 to 61). Forty-two patients were available at final follow-up. There were 31 patients in the good response group and 11 patients in the no to minimal response group. For all patients, the mean time to follow-up was 41.8 months (range 24 to 108). There was a significant improvement after surgery in the mean QuickDASH score (from 39 to 20, P < .001) (minimal clinically important difference [MCID] 15.91) , Constant score (from 57 to 87, P < .001) (MCID 10.4), and VAS (from 6 to 2, P < .001) (MCID 3). For the good response group, there was a significant improvement after surgery in the mean QuickDASH score (from 38 to 18, P < .001) (MCID 15.91), the Constant score (from 57 to 89) (MCID 10.4), and the VAS (from 6 to 2, P < .001) (MCID 3). For the no to minimal response group, there was a significant improvement after surgery in the mean QuickDASH score (from 42 to 24, P < .01) (MCID 15.91), the Constant score (from 58 to 80, P < .002) (MCID 10.4), and the VAS (from 6 to 2, P < .01) (MCID 3). The difference in postoperative improvement of the QuickDASH and Constant scores between the good response and the no to minimal response groups was statistically significant (P < .05). CONCLUSION: The results of this study suggest that arthroscopic scapuloplasty can lead to a significant improvement in pain and function in all patients with a clinical diagnosis of snapping scapula syndrome refractory to conservative treatment. Patients who gained a good transient response to a preoperative ultrasound-guided subscapular cortisone injection obtained a significantly better recovery than those who did not. A preoperative ultrasound-guided subscapular cortisone injection appeared to be of prognostic value.

Arthroscopic Excision Arthroplasty of the Sternoclavicular Joint for Osteoarthritis: A Case Series of 50 Patients.

PURPOSE: to report the results of a consecutive series of 50 patients who underwent an arthroscopic excision of the sternoclavicular joint (SCJ) for primary osteoarthritis refractory to conservative treatment. METHODS: We undertook an arthroscopic excision of the SCJ in 50 patients with primary osteoarthritis refractory to conservative treatment. This included an adequate course of physiotherapy and at least 1 ultrasound-guided cortisone injection. There were 26 female and 24 male patients and the mean age at the time of surgery was 54.5 years (range 39-72 years). Patients were assessed preoperatively and at final follow-up with the Constant, Rockwood SCJ, and Quick-DASH scores. The mean follow-up was 41.8 months (range 24-73 months). Surgery was undertaken as a day-case with no shoulder immobilization. RESULTS: Forty-five patients were available at final-follow up. The median Constant score had increased from 55 (range 37-79) to 72 (range 38-92), Rockwood score from 6 (range 4-9) to 13 (range 4-15), and Quick-DASH 36 (range 18-69) to 12 (range 0-51). All of these changes were statistically significant (P < .0001). There were no complications and, specifically, no problems with joint instability. Forty-four of the 45 patients were pleased with the results of their surgery and indicated that they would be happy to have the procedure again. CONCLUSIONS: The results of this study show that arthroscopic excision arthroplasty of the SCJ is a satisfactory treatment for primary SCJ osteoarthritis refractory to conservative treatment. LEVEL OF EVIDENCE: Level IV case series.

Proximal radioulnar translocations in adults: a tertiary centre study.

We present three cases of proximal radioulnar translocation in adults. Although rare, it is most commonly seen in paediatric cases. There have been three previously documented cases in adults, all requiring surgery and associated with ulnohumeral dislocations. Two of our cases required operative intervention, whilst one was reduced closed and did not require stabilisation. Furthermore, we have for the first time shown that proximal radioulnar translocations can occur in isolation in adults without an ulnohumeral dislocation. LEVEL OF EVIDENCE: Level IV.

Current concepts in the techniques, indications and outcomes of meniscal repairs.

Knee arthroscopy for meniscal tears is one of the most commonly performed orthopaedic procedures. In recent years, there has been an increasing incidence of meniscal repairs, as there are concerns that meniscectomy predisposes patients to early osteoarthritis. Indications for meniscal repair are increasing and can now be performed in older patients who are active, even if the tear is in the avascular zone. Options for meniscal tear management broadly fall into three categories: non-operative management, meniscal repair or meniscectomy. With limited evidence directly comparing each of these options optimal management strategies can be difficult. Decision making requires thorough assessment of patient factors (e.g. age and comorbidities) and tear characteristics (e.g. location and reducibility). The purpose of this paper is, therefore, to review the management options of meniscal tears and summarize the evidence for meniscal tear repair.

Digital tomography is an effective investigation for sternoclavicular joint pathology.

OBJECTIVE: Plain radiographs of the sternoclavicular joint (SCJ) are difficult to interpret, and a CT or MRI scan is the usual investigation of choice. At our hospital, we use digital SCJ tomograms as our first-line investigation for all SCJ pathologies. We wanted to ascertain whether this is a safe and appropriate first-line imaging investigation. MATERIALS AND METHODS: We retrospectively reviewed every patient who had undergone an SCJ digital tomogram (DT) over a 4-year period. We cross-referenced each patient with their records to assess the reason for referral, result, requirement for further investigation, diagnosis and management. RESULTS: We identified 132 SCJ tomograms over the study period. Twelve patients were referred from other hospitals with pre-existing imaging and were excluded. The reasons for radiological investigation in the remaining 120 patients were pain/lump without trauma (54.2%), pain/lump with trauma (30.8%) and post-operative review (15%). Of the 102 patients who had DT as their initial investigation, the most common diagnoses identified included osteoarthritis, normal SCJ, fracture and dislocation among others. Only 18 (17.6%) of these patients required further investigation with CT and/or MRI. CONCLUSION: Our study is the first to assess digital tomography in SCJ pathology. We have shown that digital tomograms are an accurate and economically beneficial investigation for SCJ pathology and propose that it should be used as a first-line imaging investigation.

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.

Systematic review of outcomes following fixed angle intramedullary fixation of distal radius fractures.

PURPOSE: There remains little consensus regarding the optimal management of distal radius fractures. Fixed angle volar devices have gained recent popularity, but have also been associated with soft tissue complications. Intramedullary (IM) devices offer fixed angle stabilisation with minimally invasive surgical technique and low, IM profile. No formal review of outcomes could be identified. METHODS: We conducted a systematic review of clinical studies regarding the use of fixed angle IM devices in acute extra-articular or simple intra-articular distal radius fractures. Preferred Reporting Items for Systematic Reviews (PRISMA) guidance was followed. Numerical data regarding functional scores, ranges of movement, radiological outcomes and complications were pooled to produce aggregate means and standard deviation. RESULTS: A total of 310 titles and abstracts were identified. Fourteen papers remained for analysis. Total patient number was 357, mean age 63.72 years and mean follow-up 12.77 months. Mean functional scores were all rated as 'excellent'. Aggregate means: flexion 53.62°, extension 56.38°, pronation 69.10°, supination 70.29°, ulnar deviation 28.35°, radial deviation 18.12°, radial height 8.98 mm, radial inclination 16.51°, volar tilt 5.35°, ulnar variance 0.66 mm and grip strength 90.37 %. Overall complication rate was 19.6 %. Tendon rupture was unreported. Tendon irritation was 0.88 %. Radial nerve paraesthesia was 11.44 %. CONCLUSIONS: Fixed angle IM devices facilitate excellent functional outcomes, with radiological and clinical parameters at least equivalent to volar plate devices. Low rates of tendon irritation and absence of tendon rupture are advantageous. Significant limitations include a lack of application for complex articular injuries and the propensity to cause a transient neuritis of the superficial branch of the radial nerve.

Reverse shoulder arthroplasty in 41 patients with cuff tear arthropathy with a mean follow-up period of 5 years.

BACKGROUND: Reverse shoulder arthroplasty (RSA) is an accepted treatment for patients with pseudoparalysis due to cuff tear arthropathy. There have been limited studies with midterm clinical and radiologic results. We present our results for a single surgeon from a district general hospital. METHODS: Forty-one consecutive Delta III RSAs were performed by an anterosuperior approach in 37 patients (29 women and 8 men) with pseudoparalysis due to cuff tear arthropathy. The patients' mean age was 79 years (range, 68-91 years). The mean follow-up period was 5 years. All patients were available for final review, and none were lost to follow-up. RESULTS: The mean age-adjusted Constant and Oxford scores improved from 34.2 points to 71.0 points and 15 points to 33 points, respectively. Mean abduction and forward flexion improved from 64° to 100° and 55° to 110°, respectively. Scapular notching was seen in 68% of patients, but there was no deterioration in function or satisfaction scores. Stress shielding of the proximal humerus was seen in 10% of patients. One patient underwent revision to a hemiarthroplasty because of glenoid component failure after a fall. There were no early postoperative dislocations in our series. CONCLUSION: RSA for pseudoparalysis due to cuff tear arthropathy provides good functional results at 5 years; however, there is a high rate of scapular notching, which does not seem to affect overall functional outcomes.

Complex shoulder arthroplasty in patients with skeletal dysplasia can decrease pain and improve function.

BACKGROUND: Patients with skeletal dysplasia are prone to the development of degenerative shoulder disease requiring shoulder arthroplasty at a younger age than in the general population. To date there have been no published reports on the complexities or outcome of shoulder arthroplasty in this unique patient group. METHODS: This is a review of 13 shoulder arthroplasties in 10 patients with skeletal dysplasia with mean follow-up of 7 years (2-17.6 years). There were 4 men and 6 women with a mean age of 53.1 years (23-76 years), mean height of 148 cm (122-177 cm), and mean weight of 60 kg (27-80 kg). RESULTS: The mean Oxford Shoulder Score increased from 13 (5-20) preoperatively to 28 (18-38) at final follow-up. Patients improved significantly in 2 of 8 Short Form 36 health-related quality of life domains: physical function (P = .04) and bodily pain (P = .04). Function was better in those who underwent nonconstrained total shoulder arthroplasty as opposed to hemiarthroplasty. Four (31%) required reoperation: 1 excision of heterotopic ossification, 1 relocation for anterior instability, and 2 revisions for periprosthetic fracture and glenoid erosion. CONCLUSION: Shoulder arthroplasty is effective at relieving pain, optimizing movement, and improving function for patients with skeletal dysplasia; however, compared with the general population, there is a higher complication rate and function is not as good. Furthermore, this procedure is less effective at restoring health-related quality of life than total hip arthroplasty or total shoulder arthroplasty performed for osteoarthritis in the general population. Custom implants may be required to compensate for short stature and rotator cuff and glenoid deficiency.

Proposal of a modified tip apex distance for prediction of lag screw cut-out in trochanteric hip fractures.

INTRODUCTION: Lag screw cut-out is a serious complication of dynamic hip screw fixation of trochanteric hip fractures. The lag screw position has been acknowledged as one of the important factors affecting the lag screw cut-out. We propose a modification of the Tip Apex Distance (TAD) and hypothesise that it could improve the reliability of predicting lag screws cut-out in these injuries. MATERIALS AND METHODS: A retrospective study was conducted for hip fracture entries in the period from Jan 2018 to July 2022. A hundred and nine patients were suitable for the final analysis. The modified TAD was measured in millimetres based on the sum of the traditional TAD in the lateral view and the net value of two distances in the AP view, the first distance is from the tip of the lag screw to the opposite point on the femoral head along the axis of the lag screw while the second distance is from that point to the femoral head apex. The first distance is a positive value, whereas the second distance is positive if the lag screw is superior and negative if inferior. A receiver operating characteristic curve was used to evaluate the reliability of the different parameters assessing the lag screw position within the femoral head. RESULTS: Reduction quality, fracture pattern as per the AO/OTA classification, TAD, Calcar Referenced TAD, Axis Blade Angle, Parker's ration in the AP view, Cleveland Zone 1, and modified TAD were statistically associated with lag screw cut-out. Among the tested parameters, the modified TAD had 90.1% sensitivity and 90.9% specificity for lag screw cut-out at a cut-off value of 25 mm with a P-value < 0.001. CONCLUSION: The modified TAD had the highest reliability in the prediction of lag screw cut-out. A value ≤ 25 mm could potentially protect against lag screw cut-out in trochanteric hip fractures.

How to read a postoperative knee replacement radiograph.

Knee replacement surgery is the most common joint replacement surgery in England and Wales. Postoperative radiographs are associated with long-term outcome at both early and late stages, and their correct interpretation is therefore vital. These radiographs will commonly be assessed by surgical trainees, emergency doctors, orthopaedic surgeons, nurse practitioners, and radiologists. The aim of this paper is to provide the reader with a systematic approach to assessing these radiographs, whether it be in the immediate postoperative period or during subsequent follow-ups, and to provide sufficient knowledge to critique the procedure. An outline of prostheses and their indications alongside a comprehensive review of the assessment of important angles, alignment, and correct positioning of femoral and tibial components is presented.

Cementless surface replacement arthroplasty of the shoulder for osteoarthritis: results of fifty Mark III Copeland prosthesis from an independent center with four-year mean follow-up.

PURPOSE: Few studies have reported the outcome of cementless surface replacement (CSRA). We initiated this study to analyze results of the Mark III Copeland prosthesis used as a hemiarthroplasty in patients with glenohumeral osteoarthritis. MATERIALS AND METHODS: We retrospectively reviewed 53 consecutive Mark III Copeland CRSA hemiarthroplasties in 46 patients (30 women, 16 men) with glenohumeral osteoarthritis from an independent institution by a single surgeon. Patients were a mean age of 69 years (range, 45-94 years). Mean follow-up was 4.2 years (range, 2-8 years). Fifty uncemented hemiarthroplasties were available for review. RESULTS: Mean (range) age-adjusted Constant and Oxford scores improved from 38.5 (15-61) and 22 (9-31) to 75.1 (38-87) and 42 (18-48), respectively. Anterosuperior escape of the humeral head developed in 1 patient who had an oversized humeral component due to progressive rotator cuff failure at 2 years. Moderate glenoid erosion was present in 12% and correlated with oversizing of the humeral component. There was one revision to a stemmed cemented hemiarthroplasty for periprosthetic fracture. No patients have required revision for aseptic loosening, rotator cuff failure, or glenoid erosion to date. CONCLUSIONS: Copeland surface replacement hemiarthroplasty for glenohumeral osteoarthritis can provide functional results similar to modular stemmed prostheses, with a relatively low revision rate at 4.2 years of follow-up; however, there is high rate of glenoid erosion that may complicate future revision surgery, and we did not achieve the same functional improvement as that achieved from the designer's institution.

Smartphones in orthopaedics.

With the introduction of the European Working Time Directive, surgical trainees are facing limited training opportunities and doctors are required to maximise their training opportunities. Smartphone sales have been rapidly increasing over the last five years and can be used as a training tool for the orthopaedic trainee and surgeon. Common uses include applications (AO, eLogbook and PubMed), Ebooks, online Logbooks, Guidelines and surgical techniques. In addition, smartphones can be used to immediately complete work-based assessments, in the absence of computers, hopefully increasing completion rates and reliability. Some journals now provide podcasts and video tutorials which may be accessed on smartphones, which is useful for higher examinations. Smartphones can also be used in the clinical setting to take photographs of wounds. Smartphones are enjoying increased uptake and application in the workplace and we review their use for orthopaedic surgeons and trainees to allow them to make the most out of their training opportunities.

Causes of a painful total knee arthroplasty. Are patients still receiving total knee arthroplasty for extrinsic pathologies?

PURPOSE: Whilst patients undergoing total knee replacements generally have good relief of their symptoms, up to 20% complain of persisting pain. Revision rates have therefore been rising, particularly so for unexplained pain. We reviewed the causes of painful total knee replacements including extrinsic causes. METHODS: Forty-five consecutive patients referred to our department with painful total knee replacement were reviewed with our standard protocol, including history and examination, inflammatory markers and radiological studies including radiographs of the hip and knee and computed tomography scan of the knee joint. RESULTS: Of the 45 patients, 15 patients had degenerative hip and lumbar spine disease which resolved after injections of the relevant joints. Nine patients had unexplained pain. CONCLUSIONS: Patients may still be undergoing knee arthroplasty for degenerative lumbar spine and hip osteoarthritis. We suggest heightened awareness at pre- and post-operative assessment and thorough history and examination with the use of diagnostic injections to identify the cause of pain if there is doubt.

The effect of smoking on fracture healing and on various orthopaedic procedures.

Ten percent of all fractures lead to problems with healing. Smoking is said to be a cause. There are 13.5 million smokers in the U.K. Healing of tibial fractures, for instance, requires two more months in smokers. Nicotine, carbon monoxide and hydrogen cyanide are most often seen as the offenders, among the 4000 chemicals found in cigarettes. Many studies plead for the negative effect of smoking in general, yet there is uncertainty as to the precise role of nicotine. The authors recommend that patients should attempt smoking cessation therapy before elective orthopaedic treatment.

Do bisphosphonates cause femoral insufficiency fractures?

In recent years, several reports have suggested an association between the use of bisphosphonates and subtrochanteric insufficiency fractures. Research from animal studies and in some cases from histomorphometric data collected from patients provide evidence of a possible pathophysiological mechanism behind this phenomenon. Despite this, it has not yet been possible to confirm a causal relationship. The small number of cases, the lack of consistency in defining these atypical fractures, the absence of homogeneity between studies, and the fact that most data available are derived from retrospective observational studies, are some of the difficulties encountered in the evaluation of evidence. Despite the proven benefit of bisphosphonates at providing protection against osteoporotic fractures, caution should be used before continuing therapy for longer than 5 years.

Promises and difficulties with the use of femoral intra-medullary lengthening nails to treat limb length discrepancies.

Limb lengthening using external fixation may be associated with problems such as pin-track infections, poor patient acceptance, muscle transfixation, secondary axial deformity and re-fractures. Intramedullary lengthening nails have been designed to address these issues. We present our results for femoral limb lengthening in adults managed by intramedullary lengthening nails. A retrospective review was undertaken for 8 femoral lengthening procedures performed in adults using intra-medullary lengthening nails over a three-year period. The average age of our patients was 34 years; the average duration of follow-up was 26.5 months (range: 8 to 40 months). An Albizzia nail was used in 5 procedures, an Intra-medullary Skeletal Kinetic Distractor (ISKD nail) in 3 procedures. Target lengthening was achieved in 6 out of 8 femurs with an average of 38.77 mm (range: 0 to 70 mm) length gained. The distraction index (length gained per day) was 0.58 on average (range: 0-1.25) and the consolidation index average was 5039 (range: 0-79) days/cm. Premature consolidation was noted in 4 cases, runaway acute lengthening in one patient; prominent metalwork--noted in 4 patients--and a bent nail were frequent obstacles and meant multiple visits to theatre. Femoral lengthening with an intramedullary lengthening nail is a reasonable alternative to external fixators, thereby avoiding problems associated with callotasis using external fixation methods. It is however, important to counsel patients regarding possibilities of significant obstacles including failure and multiple visits to theatre during the process.

The incidence of medial end clavicle fractures is higher than had previously been considered.

BACKGROUND: Previous X-ray epidemiological studies have estimated the incidence of medial end clavicle fractures to account for 2-3% of all clavicle fractures. MATERIALS AND METHODS: At our institution X-rays of every patient attending the Emergency Department are reviewed at a Virtual Fracture Clinic by a Consultant Orthopaedic Surgeon. Patients with a fracture are referred to the Shoulder and Elbow Fracture Clinic. Patients without a fracture are contacted and, if there are on-going concerns, are referred to the Shoulder and Elbow Fracture Clinic. Over an 18-month period we identified every patient that attended our Emergency Department that had sustained a clavicle fracture. RESULTS: In total 558 clavicle fractures were identified (139 (24.9%) - lateral, 360 (64.5%) - middle, 59 (10.6%) - medial). Of the 59 medial end fractures, 31 (52.5%) were identified on presentation at the Emergency Department, 13 (22%) at the Virtual Fracture Clinic, 6 (10.2%) on computed tomography scan at the Shoulder and Elbow Fracture Clinic and 9 (15.3%) were admitted directly to the trauma unit. CONCLUSION: The results of this study suggest that the incidence of medial end clavicle fractures in the general population is higher than had previously been considered. LEVEL OF EVIDENCE: IV.

A comparative study of 5 different antibiotic prophylaxis regimes in 4500 total knee replacements.

AIM: To compare the incidence of surgical site infection with different antibiotic regimes in elective total knee arthroplasty. We hypothesise that a single high dose of Teicoplanin and Gentamicin is as effective as other regimes. METHODS: A retrospective study of prospectively collected data on a total of 4500 elective knee replacements over a 9-year period was conducted in a district general hospital. Data were collected on antibiotic regime, patient characteristics, infection (treatment, infective agents, sensitivities) and complications. RESULTS: Five different antibiotic regimes that have been used in elective knee arthroplasty were identified in our institution. 40 patients in total were identified who had a deep infection. Rates of deep surgical site infection were not significantly different between the five groups (p = 0.83). CONCLUSION: A single pre-operative dose of Teicoplanin and Gentamicin has similar efficacy of prophylaxis to other regimes for patients undergoing primary elective total knee replacements. We recommend the choice of prophylaxis regimen is made locally based on pathogen virulence, drug resistance and cost.

Smartphones in orthopaedics: a decade of innovation.

Smartphones have become a mainstream feature in medicine since the introduction of the Apple iPhone in 2007. Over the last decade they have taken on increasing prominence with multiple uses in daily practice. They have long been used for group messaging and accessing patient's electronic records while mobile. More recently, however, smartphones have allowed clinicians to improve patient assessment in clinic and manage follow-up appointments remotely. Furthermore they have been used to aid procedural tasks in surgery and provide a medium for simulation training for junior doctors. The role of smartphones in the future is predicted to increase exponentially and there will no doubt be countless further roles for them in the ever-expanding field of orthopaedics.