Outcomes for centenarian patients admitted with orthopaedic trauma.

INTRODUCTION: The United Kingdom (UK) and world's population is aging with patients living longer, often with many co-morbidities. It is expected that patients of extreme old age would have poor outcomes following trauma; however, this assumption is not clearly evidenced. This study aims to present the outcomes of patients aged 100 or older admitted to a single hospital trust following admission for orthopaedic trauma. METHOD: A prospective cohort of patients aged 100 years and over admitted to the trauma and orthopaedic departments of two hospitals within the same trust between 2008 and 2022 was reviewed. Age was median 101 years (100-106 years). Outcome measures were length of stay, survival, complications and change in accommodation. RESULTS: 80 patients met the inclusion criteria (71female, 9 male). Mean age at discharge was 102.5 years with survival mean 4.2 years. 2 patients with peri-prosthetic fracture survived a further 5 years. Mean length of stay was 17 days. 57 patients returned to their original place of residence. 72 patients (90 %) survived the acute hospital admission. CONCLUSION: Survival rates for patients aged over 100 years were high and most returned to the previous place of residence. This study supports the surgical management of trauma and helps inform patients and families expectations for mortality risk.

Anxiety and depression predict poor outcomes in arthroscopic subacromial decompression.

BACKGROUND: Subacromial impingement is common and frequently treated with arthroscopic subacromial decompression (ASD); however, its efficacy has recently been questioned. Poor surgical outcomes have been associated with anxiety and depression within other orthopedic subspecialties but not within this group of patients. We hypothesized that anxiety and depression are associated with worse outcomes after ASD. METHODS: A retrospective review of prospectively collected data was carried out of patients undergoing ASD. Inclusion criteria were short-term relief with injection therapy and presence of Hawkins sign. Rotator cuff tears were excluded. Patients completed the Oxford Shoulder Score (OSS), Hospital Anxiety and Depression Scale (HADS), and visual analog scale for pain before and after surgery in outpatient clinic follow-up at 6 weeks and by postal questionnaire at 6 months. RESULTS: The 86 patients who participated in the study were analyzed in 2 groups defined by HADS scores, group A being depressed and group B nondepressed. Both groups had less pain and improved OSS at 6 months; however, group B improved faster with improved scores at 6 weeks, which were maintained to 6 months. Group B had less pain and higher OSS at 6 months than group A. There was strong negative correlation (P < .01) between preoperative HADS score and 6-week and 6-month OSS and HADS scores. There was strong positive correlation (P < .01) between HADS score and 6-week and 6-month pain scores. High preoperative HADS score was negatively correlated to 6-month satisfaction (P < .05). CONCLUSION: Patients with HADS score >11 before ASD have worse outcomes. This should be taken into account when counseling patients for surgery.

Experiences and outcomes in shoulder replacements in a district general hospital over 19 years.

BACKGROUND: This study aimed to evaluate the changing experiences of shoulder surgeons working in a district general hospital. METHODS: A consecutive series of 395 shoulders (225 male, 170 female) over a 19-year period (2000-2019) with a minimum follow-up of 2 years were analyzed. Outcome measures were length of stay, operating time, satisfaction visual analog score (VAS), pain VAS, Oxford Shoulder Score (OSS), Constant-Murley score, range of movement, complications, and implant survival. RESULTS: The incidence of a diagnosis of osteoarthritis as the surgical indication increased over time. The number of cases by surgeon per year increased from three cases in 2,000 to a peak of 33 in 2011. Up to seven implant manufacturers were used. The incidence of hemiarthroplasties decreased, and more numerous reverse polarity and anatomic arthroplasties were performed (P<0.001). More glenoid and humeral components were cemented and more short-stem implants were used in later years (P<0.001). Length of stay was a median of 1 day with a trend towards daytime surgery in recent years. Patients were satisfied (VAS 8/10) and OSS improved by 8 points on average throughout the observation period. CONCLUSIONS: Despite frequent introductions of new implants, patient outcome, satisfaction, and complication rates remained good. There appears to be a need for large-scale, generalizable studies to understand why technological advancements leading to changes in implants do not influence clinical outcomes. Level of evidence: III.

Glenoid Fracture Fixation Using an Acu-Loc Distal Radius Plate.

Displaced fractures of the glenoid require surgical fixation. This poses multiple problems, including a difficult approach and achieving adequate reduction with current implants. We provide a surgical technical tip for fixing scapula neck and glenoid rim fractures with an Acu-Loc distal radius plate (Acumed, Weyhill, UK), illustrated with two recent case reports. Here, we present two cases of a 58-year-old female and a 51-year-old male presenting to a hospital following a fall, both sustaining an isolated right glenoid intra-articular fracture evident on plain radiographs. CT scans revealed a displaced and fragmented glenoid surface. A reverse Judet posterior approach facilitated exposure to enable the reduction of the glenoid, an uncommon approach. Current plate designs provide surgeons with limited options to fix complex fractures of the scapula and were not suitable here. The lateral scapula border and inferior glenoid have a similar anatomical shape to the distal radius. An Acu-Loc locking distal radius plate with a radial styloid plate was trialled and provided a good reduction to the fragmented glenoid. A distal radius plate can be a useful option to consider in complex scapula neck and glenoid rim fractures. A better understanding of glenoid shape will facilitate the further development of orthopaedic implants. Familiarity with various surgical approaches is needed to operate on these complex fractures.

Charcot Neuroarthropathy of the Shoulder Caused by Cervical Spondylotic Myelopathy: A Case Report and Literature Review.

Charcot neuroarthropathy (CN) is a chronic degenerative disorder of bones and joints, mostly associated with diabetes mellitus and human immunodeficiency virus. CN of the upper limb is rare, with only 58 case reports identified on PubMed with the majority of cases being closely associated with syringomyelia. Very rarely, cervical spondylotic myelopathy (CSM) is associated with CN of the upper limb; with very few literature reporting this association. This case report presents a rare case of Charcot arthropathy of the shoulder caused by CSM. A 57-year-old female presented to the emergency department following trauma to the right shoulder. On clinical examination, there was evidence of tenderness, extensive swelling, and bruising with a lack of range of motion along with numbness in the right arm and legs. Through radiographic and laboratory investigations, a diagnosis of CN secondary to CSM was made. A reverse total shoulder arthroplasty was performed however, this was complicated at two weeks with an atraumatic glenoid fracture and dislocation. First-stage revision surgery was then performed to allow fracture healing pending second-stage revision surgery. This report provides insight into the very rare possibility of the association of CN of the shoulder with CSM. A review of the literature suggests reverse shoulder arthroplasty is the gold standard for cases of severe bone and soft tissue damage. When undergoing investigations for Charcot neuroarthropathy, physicians must undertake a full detailed history along with a detailed neurological examination and imaging of the cervical spine to not miss the association with CSM.

Is It Time to Rethink the Relationship Between Subscapularis Tears and the Long Head of Biceps Tendon?

Introduction Pre-operative diagnosis of subscapularis tears remains a difficult challenge. Ultrasound has been shown to be ineffective at directly detecting subscapularis tears. It has been widely accepted that medial subluxation of the long head of biceps tendon (LHBT) is associated with full-thickness subscapularis tears. The aims of this study are to assess whether LHBT subluxation on ultrasound scanning has any predictive value for subscapularis tears and to determine the relationship between LHBT subluxation and subscapularis tears at arthroscopy. Methods Pre-operative ultrasound and arthroscopic findings for patients undergoing arthroscopic rotator cuff repair at our institution between March 2011 and January 2016 were analysed. The accuracy of LHBT subluxation on ultrasound and at arthroscopy as a predictor of subscapularis tears at arthroscopy was calculated. The correlation between LHBT subluxation and subscapularis tears was determined. A standardised technique was used for ultrasound scans, and the grade of the sonographer was recorded. Results Three hundred fifty-nine rotator cuff repairs were performed. Twenty-four patients had a subluxed LHBT. Ultrasound was poorly sensitive (50%), and a subluxed LHBT on ultrasound only correlated very weakly with subscapularis tears at arthroscopy (R = 0.268, p<0.001). At arthroscopy, 92 patients had full-thickness subscapularis tears. Of these, only 16 patients (17%) had a subluxed/dislocated LHBT. Of the 24 patients with a subluxed LHBT, eight had no subscapularis tears. Thus, LHBT subluxation/dislocation only correlated weakly with full-thickness subscapularis tears (R=0.252, p<0.001). Conclusion Due to their close anatomical relationship, traditional teaching suggests subscapularis tears are associated with medial LHBT subluxation. Our data indicate that, contrary to popular belief, the two are only weakly correlated. In our series, the majority of patients with subscapularis tears (83%) had their LHBT in-groove. The authors therefore recommend high vigilance during arthroscopy for the diagnosis and repair of subscapularis tears, regardless of pre-operative ultrasound findings and the intra-operative position of the LHBT.

Persistent lateral elbow pain from overlooked posterolateral impingement of the elbow: a literature review and guidance for treatment.

Posterolateral impingement is sometimes diagnosed as a cause of refractory elbow pain, often after other treatments have been tried for common conditions such as lateral epicondylitis (tennis elbow) or subtly different conditions common in throwing athletes, such as valgus extension overload syndrome. Arthroscopic surgical treatment is effective when targeting abnormal anatomy such as plical folds. Partial excision of the olecranon must be undertaken with caution because it can lead to instability. This systematic review of the current literature uses a narrative synthesis to identify anatomical morphological variations of the olecranon, humeral and capitellar geometry, and overloading of the lateral part of the elbow as causative factors for this condition and discusses how arthroscopic techniques can resolve symptoms. Further understanding of the static and dynamic anatomy of the lateral part of the elbow will help to develop future treatment and preventive strategies.

Right Shoulder Luxatio Erecta: Inferior Shoulder Fracture Dislocation.

Here, we present the case of a 68-year-old female presenting with an inferior shoulder dislocation of the glenohumeral joint. Accounting for a minority of all shoulder dislocations, the rarity of this injury makes it a unique and interesting presentation in patients. Following successful reduction and neurovascular assessment, the patient recovered adequately without any complications typically associated with this type of injury. The aim of this report is to outline the mechanism of action of the injury and describe the typical patient presentation alongside discussing management techniques and associated complications.

Teaching Professionalism during and Posta Pandemic to Surgical Trainees: A Survey of the Impact of a Workshop on Trainers and Trainees.

Introduction: Focussed professionalism training improves surgical trainees' communication, information gathering, and counselling skills. This study reviews the impact of a professionalism workshop for surgical trainees within a large trust in the United Kingdom developed during the pandemic to support the trainees and help them develop resilience and appropriate behaviours during the time of increased pressure. Methods: A workshop involving case-based discussions and reflections on professionalism was developed from the themes and methods of training noted to be effective on a literature search of Medline, EMBASE, and PsycINFO databases carried out in May 2020. The impact of Covid on surgical trainees and educator's professionalism training and the techniques of training preferred by trainees was evaluated by a survey of trainees and trainers after the intervention to evolve future training initiatives. During the workshop, a behavioural marker checklist was used to improve feedback on the observed behaviours. Results: 83 trainers and trainees were surveyed following a professional behaviour workshop training 63 surgeons at various stages of training. Surgical list availability had reduced by at least 5-10 a month for all the trainees within the trust during the pandemic. Most trainees surveyed (49 (60%)) felt that this had reduced the opportunities to train technical skills and develop professional non-technical skills like teamwork and communication skills, adversely impacting the trainee's clinical performance. The increased support offered by the workshop helped 50 trainees (80%) to improve non-technical skill performance objectively by referencing to behavioural markers and this was felt to have become embedded in practice when surveyed 4 weeks later in 38 trainees (60%). The majority of those surveyed (47 (75%)) felt trainers and trainees had acted professionally during the pandemic and subsequently. The workshop discussions also helped (56 (67%)) trainers and trainees to consider how best to engage professionally with new ways of working as work, and training switched to virtual or telemedicine platforms during the pandemic. Conclusions: Professionalism-based education facilitates surgical trainee development, making them stronger team members and helping to restore team working skills and embrace new working practices.

Rising to the challenge: medical students as Doctors' Assistants; an evaluation of a new clinical role.

INTRODUCTION: The COVID-19 Pandemic brought clinical placements to a halt for many UK medical students. A University Hospitals Trust offered clinical phase students the opportunity to support the National Health Service (NHS) in newly defined roles as Doctors' Assistants (DAs). This study evaluates the experience of students working in a single NHS Trust. To our knowledge, this is the first report of medical students' perspectives on taking up a novel clinical role in the UK. METHODS: An anonymised novel electronic survey was sent to all 40 DAs across a single University Hospitals Trust via email to determine student perceptions of several aspects of the role, including its value to learning and development, impact on well-being, and benefit to the clinical environment. A formal statistical analysis was not required. RESULTS: Of the total cohort participating in the programme, 32 DAs responded (80% response rate). The experience was considered valuable to multiple aspects of learning and development, particularly familiarisation with the role of a Foundation doctor. Levels of confidence in training and support were high, and most DAs felt valued as part of the clinical team, and experienced no mental health issues resulting from their role. 53% of the participants felt their work was necessary or valuable to the team, and all reported a positive experience overall. CONCLUSION: A new role allowed medical students to effectively provide clinical assistance during the COVID-19 pandemic. This provided immediate support to clinical teams as well as learning opportunities for the participants without detriment to their mental well-being, and could be a model for effective retention of medical students in clinical environments in the face of resurgence of COVID-19.

Predicting the Behavior of Humeral Shaft Fractures: An Independent Validation Study of the Radiographic Union Score for HUmeral Fractures and Value of Assessing Fracture Mobility.

OBJECTIVES: To externally validate the Radiographic Union Score for HUmeral fractures (RUSHU) and to quantify the predictive relationship of fracture motion on physical examination to nonunion. DESIGN: Retrospective cohort study. SETTING: Single institutional center (University teaching hospital). PATIENTS: Ninety-two consecutive patients undergoing nonoperative treatment of a diaphyseal humeral shaft fracture were identified over a 4-year period. The average age of the population was 62 years and 42% of the cohort was men. INTERVENTION: Clinical examination for fracture stability was routinely performed on patients by the treating physicians. Radiographic assessment of fracture callus (RUSHU score) at 6 weeks was retrospectively determined. Patients were followed up until union. MAIN OUTCOME MEASUREMENTS: Stability was graded as motion at the fracture site or the humerus moving as a single functional unit. RESULTS: Fractures with a RUSHU score ≤7 were 14 times more likely to proceed to nonunion at 6 months (78% sensitivity, 80% specificity). The time to union was 49 weeks for a RUSHU score of ≤7 versus 16 weeks for a RUSHU score of ≥8. The number of operations needed to avoid one nonunion was 1.7. Fractures mobile at 6 weeks were 6.5 times more likely to proceed to nonunion at 6 months (77% specificity, 67% sensitivity). Mobile fractures had a longer time to union (41 weeks) than nonmobile fractures (17 weeks). CONCLUSION: The RUSHU score and clinical assessment of fracture mobility are effective and valid tools in identifying patients at risk of developing nonunion of humeral shaft fractures and can enhance early decision making in fracture management. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Improving resource utilisation and outcomes after total knee arthroplasty through technology-enabled patient engagement.

BACKGROUND: A multi-modal, technology-enabled, patient engagement and pathway management solution (PES) for patients undergoing primary total knee arthroplasty (TKA) was evaluated. The primary outcome measure was length of stay (LoS). The secondary outcome measures were clinical and patient-reported outcomes (PROMs). METHODS: Retrospective analysis of a consecutive series of 1256 TKA patients before (n = 783) and after (n = 473) implementation of the PES. LoS, PROMs, complications, readmissions, and return to theatre were measured. Results were analysed using bivariate and multivariable regression using general linear models, and a sensitivity analysis on LoS was conducted using interrupted time series (ITS) methods. RESULTS: Patients in the PES cohort had a significantly shorter mean LoS of two days (mean 4.7 days) versus the Pre-PES patients (mean 6.7 days; p < 0.001) in multivariate analysis. PES was also associated with a significant reduction in rates of reoperation within 60 days compared with Pre-PES (adjusted rate 2.2% versus 5.0%, p = 0.031). There were no statistically significant differences in the 60-day complication rate and 30-day readmission rate. All PROMs in the PES cohort demonstrated significant improvement (change from baseline to six months postoperative) compared with Pre-PES (Oxford Knee Score, 20.1 versus 15.5, p < 0.001; EQ-5D Index, 0.40 versus 0.32, p = 0.005; and EQ VAS, 22.9 versus 8.3, p < 0.001). CONCLUSIONS: Outcomes following TKA performed in enhanced recovery programs may be improved using technology to more effectively engage patients and streamline their surgical pathway. Integration of such solutions may significantly reduce LoS and improve PROMs without negatively impacting clinical outcomes.

6-Year clinical results and survival of Copeland Resurfacing hemiarthroplasty of the shoulder in a consecutive series of 279 cases.

BACKGROUND: Medium-term clinical results and survival of the Copeland resurfacing hemiarthroplasty of the shoulder (CRHA) in a large consecutive group are presented with a comparison of outcomes for underlying pathologies. METHODS: A consecutive series of patients undergoing CRHA over 14 years was retrospectively analysed with no exclusions. Patients had a minimum 2-year follow-up by an independent assessor. Functional outcome was assessed using the Oxford Shoulder Score (OSS) and Constant-Murley Score (CMS). Pain and satisfaction was assessed using a visual analogue score. RESULTS: 279 CRHAs were performed in 242 patients between 2002 and 2016. The mean follow-up was 6 years. The indication for surgery was osteoarthritis (OA) in 212, inflammatory arthropathy (RA) in 35, rotator cuff tear arthropathy (CTA) in 22 and avascular necrosis (AVN) in 2. For the OA group, 5-year survival was 90%, 10-year survival was 83% and mean survival was 13.2 years (95% CI 12.5-13.9). The mean OSS was 35.0 and mean CMS 49.9. CRHA for CTA had significantly poorer (p < 0.001) 5-year survival (55%), 10-year survival (41%) and mean survival (5.9 years, 95% CI 4.7-7.2). Mean OSS was 23.6 and mean CMS 30.3, which was poorer than for OA (p < 0.001). A subgroup analysis of OA patients found significantly better survival (p = 0.013) in those aged over 65 years but no difference in functional outcome. CONCLUSION: CRHA remains a reasonable option for OA in patients with an intact rotator cuff and with sufficient bone stock, especially in those aged over 65 years. With poorer functional outcomes and survival, CRHA should not be offered in those with CTA. LEVEL OF EVIDENCE: Level III (retrospective comparative study).

Do Antibiotic-impregnated Calcium Sulfate Beads Improve the Healing of Neuropathic Foot Ulcers With Osteomyelitis Undergoing Surgical Debridement?

BACKGROUND: Neuropathic foot ulcers are common and difficult to treat. Calcium sulfate (CAS) has been used for antibiotic delivery in the treatment of osteomyelitis with success. Recent case series suggest success in treating osteomyelitis of the foot with CAS in a mean time to healing of 4 months; however, few studies with a control group for comparison exist. OBJECTIVE: This study aims to determine if antibiotic-impregnated CAS beads improved the healing of neuropathic foot ulcers with proven osteomyelitis undergoing surgical debridement. MATERIALS AND METHODS: A consecutive retrospective cohort study of 50 patients undergoing surgical debridement of neuropathic foot ulcers for osteomyelitis from December 2015 to May 2016 was performed. Exclusion criteria consisted of amputations and microbiology findings inconsistent with osteomyelitis. Patients were divided into 2 groups: the surgical debridement (SD) group was treated with SD alone and the other (CAS) was treated with debridement and implantation of vancomycin- and gentamicin-impregnated CAS beads. RESULTS: After exclusion criteria, 42 patients were included: 13 in the SD group and 29 in the CAS group. In the SD group, the mean time to healing was 5.8 months (range, 2-9 months), and in the CAS group, it was 5.5 months (range, 2-13 months). There was no significant difference in ulcer healing (P = .81), time to healing (P = .79), reoperation rate (P = .51), length of stay (P = .74), or mortality (P = .13) between the 2 groups. CONCLUSIONS: Ulcer healing in patients treated with antibiotic-impregnated CAS beads did not show statistical significance. Healing rates in both groups were similar to those in recent literature. Surgical debridement alone may be as effective as supplementation with local antibiotics in a bioabsorbable carrier.

An unusual transorbital penetrating injury and principles of management.

The objective of this study was to present an unusual low velocity transorbital penetrating injury. The study design was a clinical record (case report). A 38-year-old gentleman tripped and fell face first onto the wing of an ornamental brass eagle. This penetrated the inferomedial aspect of the right orbit, breaching the lamina papyracea to extend into the ethmoid sinuses and reaching the dura of the anterior cranial fossa. The foreign body was removed in theater under a joint ophthalmology and ENT procedure. The patient was left with reduced visual acuity in the right eye but no other long-term sequelae. Transorbital penetrating injury presents unusual challenges to investigation and management requiring a multidisciplinary approach to prevent significant morbidity and mortality. If managed well the prognosis is good.

Transformation of solitary osteochondroma to dedifferentiated chondrosarcoma arising in the distal radius: a case report.

We present the case of a 35-year-old patient suffering from an untreated solitary osteochondroma and subsequent rare transformation to a dedifferentiated chondrosarcoma. This case highlights the potential risk of malignant transformation and raises the question of patient and clinician responsibility in identifying changes in a premalignant condition.

The influence of computer navigation on trainee learning in hip resurfacing arthroplasty.

Computer navigation in arthroplasty surgery is a form of concurrent augmented feedback. Motor learning theory suggests such feedback may be detrimental to learning as a result of the learner either developing a dependence on the additional feedback or being distracted from using intrinsic feedback. To determine whether computer navigation influences the learning curve of novices performing hip resurfacing arthroplasty, a systematic review and critical appraisal of the current English-language literature on the topic was conducted. There is some evidence that use of navigation by trainees facilitates more accurate placement of arthroplasty components as compared to conventional instrumentation. However, there is no evidence that training with computer navigation impairs performance in retention or transfer tests. Thus, although the published literature has significant limitations, there is no evidence that supports concerns regarding the impact of computer navigation on the learning curve of arthroplasty trainees.