A validation of the Nottingham Clavicle Score: a clavicle, acromioclavicular joint and sternoclavicular joint-specific patient-reported outcome measure.

BACKGROUND: Patients with acromioclavicular joint (ACJ) and sternoclavicular joint (SCJ) injuries and with clavicle fractures are typically younger and more active than those with other shoulder pathologies. We developed the Nottingham Clavicle Score (NCS) specifically for this group of patients to improve sensitivity for assessing the outcomes of treatment of these conditions compared with the more commonly used Constant Score (CS) and Oxford Shoulder Score (OSS). MATERIALS AND METHODS: This was a cohort study in which the preoperative and 6-month postoperative NCS evaluations of outcome in 90 patients were compared with the CS, OSS, Imatani Score (IS), and the EQ-5D scores. Reliability was assessed using the Cronbach α. Reproducibility of the NCS was assessed using the test/retest method. Effect sizes were calculated for each score to assess sensitivity to change. Validity was examined by correlations between the NCS and the CS, OSS, IS, and EQ-5D scores obtained preoperatively and postoperatively. RESULTS: Significant correlations were demonstrated preoperatively with the OSS (P = .025) and all subcategories of the EQ-5D (P < .05) and postoperatively with the OSS (P < .001), CS (P = .008), IS (P < .001), and all subcategories of EQ-5D (P < .02). The NCS had the largest effect size (1.92) of the compared scores. Internal consistency was excellent (Cronbach α = 0.87). CONCLUSION: The NCS has been proven to be a valid, reliable and sensitive outcome measure that accurately measures the level of function and disability in the ACJ, SCJ and clavicle after traumatic injury and in degenerative disease.

Surgery within 6 months of an acute rotator cuff tear significantly improves outcome.

BACKGROUND: To determine the effect of time to repair on the outcome after an acute rotator cuff tear. METHODS: We performed a retrospective analysis of prospectively collected data on patients presenting with acute rotator cuff tear to our shoulder clinic. Patient-reported outcomes were assessed using the Oxford Shoulder Score, and symptomatic retears were diagnosed by clinical assessment plus imaging. RESULTS: Twenty patients underwent rotator cuff repair within 6 months of injury via initial referral through the Acute Shoulder Injury Clinic (early repair group; mean age, 60 years; age range, 39-77 years). Twenty age- and sex-matched patients were identified who had undergone delayed repair (6-18 months after injury; mean age, 60 years; age range, 40-78 years). The mean follow-up period was 10 months for the early repair group versus 11 months for the delayed repair group. Both groups had clinically significant improvements in their Oxford scores, although the early repair group had an improvement that was nearly double that of the delayed repair group (20.3 for early vs 10.4 for delayed, P = .0014). Postoperative Oxford scores were significantly higher in the early repair group (mean of 43.8 for early vs 35.8 for delayed, P = .0057). There were 2 symptomatic retears in the early repair group versus 5 in the delayed repair group. CONCLUSION: Our results show improved outcomes with early repair (within 6 months) of acute rotator cuff tears and support the provision of an acute shoulder injury referral clinic.

Radiographic appearance of the distal clavicle in relation to the acromion after acromioclavicular joint reconstruction using a braided polyester mesh.

ACJ stabilization using a braided polyester mesh has become popular in ACJ injuries. However, concerns have been raised about excessive anterior clavicle displacement. The purpose of this study was to report radiographic position of the distal clavicle in relation to the acromion after ACJ reconstruction using this device immediately postoperative and after 6 months follow-up compared with a healthy control group. Thirty-eight patients with ACJ instability treated with a braided polyester mesh were compared within group (pre-/postoperatively) and between groups (with age/sex matched controls). Biplane radiographic measurements by 2 observers were made preoperatively, immediate postoperatively and at 6 months follow-up. Inter-observer reliability was assessed and clinical outcome scores were recorded. ACJ stabilization significantly reduced vertical displacement immediately postoperatively (13.8 ±â€¯4.2 to 3.5 ±â€¯5.5 mm; p < 0.0001) towards controls (1.7 ±â€¯2.3 mm,p < 0.0873). Slight further superior displacement (4.4 mm) occurred at 6 months follow-up compared to immediately postoperative (p = 0.0029) and 6.2 mm more than mean controls (p < 0.0001). In the axial plane, significant early reduction of posterior displacement was achieved (10.3 ±â€¯8.0 to 1.1 ±â€¯5.1 mm,p = 0.0240) and the clavicle settled back to a more posterior position at 4.5 ±â€¯6.7  mm at 6 months post-surgery (p = 0.3062). At both time points, posterior displacement was comparable with the controls (3.4 ±â€¯3.0 mm,p = 0.4371 postoperative, p = 0.563 at 6 months follow-up). Excessive anterior displacement has been observed in 2 of the 5 available axial radiographs early postoperative and in 4 of 14 available axial radiographs at 6 months. Constant, Oxford Shoulder and Nottingham Clavicle scores significantly improved (25 ±â€¯12 to 43 ±â€¯7:p < 0.0001, 46 ±â€¯27 to 80 ±â€¯19:p = 0.0038, 53 ±â€¯14 to 80 ±â€¯17:p < 0.0001). ACJ stabilization using a braided polyester device in ACJ instability is effective at reducing both superior and posterior clavicle displacement with excellent clinical outcome. Overcorrection in the axial plane seems to occur, however this is of no clinical and radiographic significance. Posterior displacement is significantly reduced towards control values at 6 months follow-up.

Hip extension strength following hamstring tendon harvest for ACL reconstruction.

Hamstring autograft harvest for ACL reconstruction may have an effect on hip extension strength and this may be important especially in sports that involve high speed running such as soccer, rugby, American football and the sprint disciplines of track and field. This aspect of hamstring tendon harvesting has not been looked at before. We have performed a non-randomised prospective case control study comparing isokinetic hip extension strength following four strand semitendinosus and gracilis tendons (4SHS) and bone-patellar tendon-bone (BPTB) autografts in ACL reconstruction. Isokinetic hip extension was assessed at 3 and 12 months post-operatively using a Kin-Com machine at a speed of 30 degrees per second. Three months post-operatively there was a significant decrease (p<0.05) in the peak force of concentric hip extension in the 4SHS group. There was no evidence that hip extension is weaker following ACL reconstruction with 4SHS tendon autograft than ACL reconstruction with BPTB autograft at 12 months post-operatively. We find no contra-indication to the use of 4SHS tendon autografts in ACL reconstruction in patients who wish to preserve hip extension strength for their sporting activities.

Scapular Winging.

This review explores the causes of scapula winging, with overview of the relevant anatomy, proposed aetiology and treatment. Particular focus is given to lesions of the long thoracic nerve, which is reported to be the most common aetiological factor.

Risk factors and predictors of mortality for proximal humeral fractures.

BACKGROUND: Risk factors for mortality after proximal humeral fracture, including socioeconomic status, are poorly defined. This retrospective review of prospectively collected data defines the epidemiology and predictors of mortality in association with proximal humeral fractures. METHODS: Patients who sustained proximal humeral fractures were identified from fragility fracture and trauma databases between May 2001 and September 2012. RESULTS: In total, 1880 patients with a mean age of 69 years and a male to female ratio of 2 : 3 were identified. Socioeconomic distribution is skewed towards the lowest and highest quintiles. Low-energy mechanisms caused 88% of fractures. Men sustain fractures when they are aged 10 years younger and via higher-energy mechanisms. In total, 536 patients (29%) died within the study period with a 1-year mortality of 9.8%, rising to 28.2% at 5 years. Female gender, increasing age, pathological fracture and increased number of co-morbidities were independent variables for increased mortality. CONCLUSIONS: The present study, which was conducted over an 11-year period, is the first to combine the epidemiology and risk factors for mortality with socioeconomic rank. One-year mortality risk is twice that of the background matched population. Patient counselling with respect to increased mortality should be considered, especially in higher-risk elderly females with multiple co-morbidities.