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.

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.

Revision shoulder arthroplasty for failed humeral head resurfacing hemiarthroplasty.

BACKGROUND: The purpose of the present study was to analyze and report the clinical outcomes following revision shoulder arthroplasty for failed humeral head resurfacing hemiarthroplasty (HHRH). METHODS: All patients who underwent revision shoulder arthroplasty for failed HHRH at our institution were retrospectively reviewed. Twenty-two shoulders in 20 patients were available for analysis. Mean age at the time of HHRH was 60 years (range 42 years to 75 years). The cohort consisted of 17 females and three males. RESULTS: The mean time from HHRH to revision was 5 years (range 1 year to 8 years). Mean age at the time of revision surgery was 62 years (range 44 years to 80 years). Patients were followed-up for a mean of 3.3 years (range 2 years to 4 years) after revision. Following revision surgery, there was an increase in forward elevation from 67° (range 0° to 130°) to 97° (range 40° to 160°) (p = 0.04). This was accompanied by an improvement in both the Oxford Shoulder Score and the subjective shoulder value, which increased from 13 (range 2 to 28) to 39 (range 24 to 48) (p = 0.000) and from 23 (range 0 to 65) to 79 (range 25 to 100) (p = 0.000) respectively. CONCLUSIONS: Revision shoulder arthroplasty for failed HHRH improves functional outcome.

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.

Glenohumeral arthrodesis for recurrent types II and III shoulder instability.

BACKGROUND: This study reports the clinical outcome after glenohumeral arthrodesis for recurrent type II (atraumatic structural) and type III (muscle patterning nonstructural disorder) shoulder instability. METHODS: A retrospective review was conducted at a single facility. Eight consecutive patients (7 women and 1 man) with recurrent shoulder instability underwent arthrodesis and were monitored for a mean of 57 months (range, 24-123 months). Mean age at the time of surgery was 47 years (range, 21-73 years). RESULTS: Bony union was achieved in all patients at a mean time to fusion of 3 months (range, 1-11 months). No complications, such as routine removal of the metalwork or loosening, were noted. No residual perceived glenohumeral instability was reported, and no patient developed scapulothoracic instability or painful scapular dyskinesis. The mean Oxford Shoulder Instability Score improved from 8 preoperatively (range, 0-19) to 32 postoperatively (range, 16-41; P = .001). This was accompanied by an increase in the mean subjective shoulder value, which improved from 22 (range, 0-50) preoperatively to 73 (range, 50-100) postoperatively (P = .004). CONCLUSION: In our series, glenohumeral arthrodesis was associated with no complications and was able to reduce pain, eliminate instability, and improve functional outcome. It should therefore be considered in this patient population.

Constrained fixed-fulcrum reverse shoulder arthroplasty improves functional outcome in epileptic patients with recurrent shoulder instability.

AIM: To report the results of fixed-fulcrum fully constrained reverse shoulder arthroplasty for the treatment of recurrent shoulder instability in patients with epilepsy. METHODS: A retrospective review was conducted at a single facility. Cases were identified using a computerized database and all clinic notes and operative reports were reviewed. All patients with epilepsy and recurrent shoulder instability were included for study. Between July 2003 and August 2011 five shoulders in five consecutive patients with epilepsy underwent fixed-fulcrum fully constrained reverse shoulder arthroplasty for recurrent anterior shoulder instability. The mean duration of epilepsy in the cohort was 21 years (range, 5-51) and all patients suffered from grand mal seizures. RESULTS: Mean age at the time of surgery was 47 years (range, 32-64). The cohort consisted of four males and one female. Mean follow-up was 4.7 years (range, 4.3-5 years). There were no further episodes of instability, and no further stabilisation or revision procedures were performed. The mean Oxford shoulder instability score improved from 8 preoperatively (range, 5-15) to 30 postoperatively (range, 16-37) (P = 0.015) and the mean subjective shoulder value improved from 20 (range, 0-50) preoperatively to 60 (range, 50-70) postoperatively (P = 0.016). Mean active forward elevation improved from 71° preoperatively (range, 45°-130°) to 100° postoperatively (range, 80°-90°) and mean active external rotation improved from 15° preoperatively (range, 0°-30°) to 40° (20°-70°) postoperatively. No cases of scapular notching or loosening were noted. CONCLUSION: Fixed-fulcrum fully constrained reverse shoulder arthroplasty should be considered for the treatment of recurrent shoulder instability in patients with epilepsy.

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.

Clinical outcome after reconstruction for sternoclavicular joint instability using a sternocleidomastoid tendon graft.

BACKGROUND: Anterior instability of the sternoclavicular joint is uncommon and usually follows a benign course, although symptomatic patients may require surgical intervention. The optimal treatment for symptomatic instability of the sternoclavicular joint remains unclear. The aim of this study was to evaluate the clinical outcome after reconstruction of the sternoclavicular joint with use of a sternocleidomastoid tendon graft to treat chronic debilitating anterior instability of the sternoclavicular joint. METHODS: Thirty-two patients underwent surgical reconstruction of the sternoclavicular joint for chronic debilitating anterior instability using the tendon of the sternal head of the ipsilateral sternocleidomastoid muscle and were followed for a mean of forty-four months. The etiology of instability was posttraumatic in fourteen patients, generalized hyperlaxity in seven patients, and degenerative instability in eleven patients. Outcome measures included the Oxford instability shoulder score, subjective shoulder value, pain rating, and postoperative grading of sternoclavicular joint stability. RESULTS: Clinical scores and pain rating were similar for the three groups before surgery and improved significantly in all of the groups to the same extent after the surgery. At the time of the latest follow-up, eleven of fourteen patients in the posttraumatic group, six of seven patients in the generalized hyperlaxity group, and eight of eleven patients in the degenerative group reported the sternoclavicular joint as stable with no functional limitation. Two patients reported that the joint remained unstable. No other complications occurred. CONCLUSIONS: Sternoclavicular joint reconstruction using a sternocleidomastoid tendon graft is safe and offers reliable pain relief and functional improvement for patients with chronic debilitating anterior instability of the sternoclavicular joint.

Increased-offset reverse shoulder arthroplasty for the treatment of failed post-traumatic humeral head replacement.

BACKGROUND: Late complications after humeral head replacement (HHR) for comminuted proximal humeral fractures are common and may necessitate revision surgery. This study evaluated the outcome of revision surgery of failed post-traumatic HHR with a less medialized reverse shoulder prosthesis. METHODS: Thirty-three patients with failed post-traumatic HHR due to rotator-cuff insufficiency and glenoid erosion, but with sufficient preservation of the glenoid bone stock to permit primary stability of an inverted glenoid implant, underwent revision using the Bayley-Walker reverse shoulder prosthesis (Stanmore Implants, Elstree, UK) and were monitored up for a mean of 31 months. Outcome measures included the Oxford Shoulder Score, subjective shoulder value, pain rating, active range of motion, and shoulder radiographs. RESULTS: The average postrevision Oxford Shoulder Score and subjective shoulder value improved from 50 ± 6 to 29 ± 11 and from 23 ± 19 to 51 ± 23, respectively (P < .001). Pain level decreased from 6.2 ± 2.1 to 1.4 ± 2.0 (P < .001). Active forward flexion increased from 34° ± 22° to 63° ± 30° and external rotation from 11° ± 14° to 20° ± 16°(P < .01). More patients were able to use their affected arm to reach a functional triangle consisting the mouth, opposite armpit, and ipsilateral buttock after revision (24% vs 73%; P < .001). Seven patients (21%) had postrevision complications. No glenoid loosening or scapular notching occurred. CONCLUSION: Revision of failed post-traumatic HHR with the Bayley-Walker shoulder offers reliable pain relief and improvement in shoulder function with a complication rate similar to other reverse prostheses. Nevertheless, revision shoulder arthroplasty remains challenging with a high rate of complications.

Revision arthroplasty with a hip-inspired computer-assisted design/computer-assisted manufacturing implant for glenoid-deficient shoulders.

BACKGROUND: Revision arthroplasty for failed post-traumatic humeral head replacement associated with rotator cuff and glenoid deficiency is challenging. Current surgical solutions are fraught with complications, and no best-practice strategy has been established. We hypothesized that the computer-assisted design/computer-assisted manufacturing (CAD/CAM) shoulder (Stanmore Implants, Elstree, UK), a total shoulder design resembling a total hip prosthesis, can offer a reliable alternative in this surgically challenging subset of patients with rotator cuff deficiency and advanced glenoid bone loss. METHODS: Twenty-one patients with failed post-traumatic humeral head replacement associated with rotator cuff and glenoid deficiency underwent revision with CAD/CAM shoulders between 2005 and 2010. Clinical data were collected prospectively and analyzed at a mean follow-up of 3 years. RESULTS: After revision, the pain rating at rest (on a 0-10 numerical scale) decreased from 5.6 ± 1.3 to 1.1 ± 1.3 (P < .001) and pain during activity decreased from 7.4 ± 1.2 to 2.1 ± 1.8 (P < .001). The Oxford shoulder score improved from 47 ± 6 to 31 ± 9 (P < .001), and the subjective shoulder value (on a 0%-100% scale) improved from 22% ± 14% to 45% ± 18% (P < .001). Active shoulder range of motion was similar before and after revision. Postoperative complications occurred in 9 patients and included 1 infection, 2 periprosthetic fractures, 2 prosthetic dislocations, and 4 fixation screw fractures. No case of glenoid loosening occurred. CONCLUSION: The CAD/CAM shoulder offers a reliable method of securing a glenoid component in shoulders with advanced glenoid deficiency and should be considered as an alternative to other surgical methods in these challenging cases. At 3 years' follow-up, pain and clinical scores improved significantly and no case of glenoid loosening occurred.

Intraoperative nerve monitoring during total shoulder arthroplasty surgery.

BACKGROUND: Nerve injury is an acknowledged complication of total shoulder arthroplasty (TSA). Although the incidence of postoperative neurological deficit has been reported to be between 1% and 16%, the true incidence of nerve damage is considered to be higher. The present study aimed to identify the rate of intraoperative nerve injury during total shoulder arthroplasty and to determine potential risk factors. METHODS: A prospective study of nerve conduction in 21 patients who underwent primary or revision TSA was carried out over a 12-month period. Nerve conduction was monitored by measuring intraoperative sensory evoked potentials (SEP). A significant neurophysiological signal change was defined as either a unilateral or bilateral decrease in SEP signal of ≥50%, a latency increase of ≥10% or a change in waveform morphology, not caused by operative or anaesthetic technique. RESULTS: Seven (33%) patients had a SEP signal change. The only significant risk factor identified for signal change was male sex (odds ratio 15.00, 95% confidence interval). The median nerve was the most affected nerve in the operated arm. All but one signal change returned to normal before completion of the operation and no patient had a persisting postoperative clinical neurological deficit. CONCLUSIONS: The incidence of intraoperative nerve damage may be more common than previously reported. However, the loss of SEP signal is reversible and does not correlate with persisting clinical neurological deficits. The median nerve appears to be most at risk. Monitoring SEPs in the operated limb during TSA may be a valuable tool during TSA.

Clavicle lengthening by distraction osteogenesis for congenital clavicular hypoplasia: case series and description of technique.

BACKGROUND: Malformation and hypoplasia of the clavicle can result in pain, impaired function, restricted shoulder movement, subjective feeling of instability, and cosmetic deformity. There are no reports of clavicle lengthening by osteotomy and distraction osteogenesis (DO). METHODS: This is a retrospective review of 5 patients (7 clavicles) who underwent clavicle lengthening by DO using a monolateral external fixator for clavicular hypoplasia. There were 3 males and 2 females with the mean age of 15 years (9 to 23 y) and mean follow-up of 35 months (12 to 66 mo). Preoperative diagnoses included Klippel-Feil syndrome, cleidocranial dysplasia with hemihypertrophy and torticollis, congenital myopathy and Noonans syndrome, and obstetric brachial plexus injury. RESULTS: Mean length gained was 31 mm (15 to 41 mm) that represents an average of 24.7% of overall bone length. Mean time in fixator was 174 days (161 to 263 d) and mean external fixation index was 56 d/cm. Two patients required internal fixation after fixator removal to consolidate union and 1 required additional internal fixation for atrophic regeneration. Mean preoperative oxford shoulder score improved from 28.5 to 41 and all patients were extremely satisfied with their result. Two patients developed pin-site infections. CONCLUSIONS: Clavicular lengthening by DO for congenital clavicular hypoplasia is a previously unreported technique that enables gradual correction of deformity without risking brachial plexus traction injury after acute correction. It has the potential to improve shoulder pain, function, range of movement, and cosmesis. Distraction ≥25% of overall bone length may require additional plate fixation to consolidate union. LEVEL OF EVIDENCE: Level IV-therapeutic study.

A survey of orthopaedic journal editors determining the criteria of manuscript selection for publication.

BACKGROUND: To investigate the characteristics of editors and criteria used by orthopaedic journal editors in assessing submitted manuscripts. METHODS: Between 2008 to 2009 all 70 editors of Medline listed orthopaedic journals were approached prospectively with a questionnaire to determine the criteria used in assessing manuscripts for publication. RESULTS: There was a 42% response rate. There was 1 female editor and the rest were male with 57% greater than 60 years of age. 67% of the editors worked in university teaching hospitals and 90% of publications were in English. The review process differed between journals with 59% using a review proforma, 52% reviewing an anonymised manuscript, 76% using a routine statistical review and 59% of journals used 2 reviewers routinely. In 89% of the editors surveyed, the editor was able to overrule the final decision of the reviewers. Important design factors considered for manuscript acceptance were that the study conclusions were justified (80%), that the statistical analysis was appropriate (76%), that the findings could change practice (72%). The level of evidence (70%) and type of study (62%) were deemed less important. When asked what factors were important in the manuscript influencing acceptance, 73% cited an understandable manuscript, 53% cited a well written manuscript and 50% a thorough literature review as very important factors. CONCLUSIONS: The editorial and review process in orthopaedic journals uses different approaches. There may be a risk of language bias among editors of orthopaedic journals with under-representation of non-English publications in the orthopaedic literature.

Osteosarcoma associated with diamond-blackfan anaemia: a case of a child receiving growth hormone therapy.

PURPOSE: Diamond-Blackfan anaemia (DBA) is a rare pure congenital red cell aplasia, usually presenting in infancy or early childhood. The literature suggests a predisposition to haemopoietic malignancy but in addition solid tumours have been reported, with five cases of osteosarcoma described. PATIENT: A sixth case of a 12-year-old girl with DBA who developed an osteosarcoma of the distal femur is presented. RESULTS: She was treated with methotrexate followed by tumour excision and distal femoral replacement. The patient is currently alive with multiple pulmonary metastases. DISCUSSION: We discuss the association between the administration of growth hormone and future development of malignancy in patients with DBA.