Discovery Elbow System arthroplasty polyethylene bearing exchange: outcomes and experience.

BACKGROUND: The Discovery Elbow System (DES) utilizes a polyethylene bearing within the ulnar component. An exchange bearing requires preoperative freezing and implantation within 2 minutes of freezer removal to allow insertion. We report our outcomes and experience using this technique. METHODS: This was an analysis of a two-surgeon consecutive series of DES bearing exchange. Inclusion criteria included patients in which exchange was attempted with a minimum 1-year follow-up. Clinical and radiographic review was performed 1, 2, 3, 5, 8 and 10 years postoperative. Outcome measures included range of movement, Oxford Elbow Score (OES), Mayo Elbow Performance Score (MEPS), complications and requirement for revision surgery. RESULTS: Eleven DESs in 10 patients were included. Indications were bearing wear encountered during humeral component revision (n=5); bearing failure (n=4); and infection treated with debridement, antibiotics and implant retention (DAIR; n=2). Bearing exchange was conducted on the first attempt in 10 cases. One case required a second attempt. One patient developed infection postoperatively managed with two-stage revision. Mean follow-up of the bearing exchange DES was 3 years. No further surgery was required, with no infection recurrence in DAIR cases. Mean elbow flexion-extension and pronosupination arcs were 107° (±22°) and 140° (±26°). Mean OES was 36/48 (±12) and MEPS was 83/100 (±19). CONCLUSIONS: Our results support the use of DES bearing exchange in cases of bearing wear with well-fixed stems or acute infection. This series provides surgeons managing DES arthroplasty with management principles, successful and reproducible surgical techniques and expected clinical outcomes in performing DES polyethylene bearing exchange. Level of evidence: IV.

Should Femoral Shaft fractures in Patients Age Over 60 Years be Managed Using a Hip Fracture Pathway?

INTRODUCTION: The British Orthopaedic Association published 2019 guidelines 'The Older or Frail Orthopaedic Trauma Patient'. This implements principles of the hip fracture pathway to all fragility fractures. Like hip fractures, femoral shaft fractures in the elderly are also suggested to represent fragility fractures. Femoral shaft fractures in older patients are rare and there is scarce literature detailing their outcomes. We aim to review outcomes of femoral shaft fractures in patients age 60 years and over at our institution and compare them to that of the hip fracture population. MATERIALS AND METHODS: We retrospectively reviewed clinical records of a consecutive cohort of patients aged 60 years and over, who sustained a femoral shaft fracture, over a five-year period at our institution. Outcome measures studied were time to surgery, mean length of admission, readmission rate within 30 days, medical and orthopaedic complications, one month and one year mortality. RESULTS: We identified 53 patients with a mean age of 78.7 years. On average patients each had 2.7 medical comorbidities. Mean length of admission was 20.0 days and readmission rate within 30 days was 19.1% (n=9). Medical complications affected 41.5% of patients (n=22) and orthopaedic complications affected 9.4% of patients (n=5). Two patients demonstrated nonunion and one patient required revision surgery. Thirty day mortality rate was 13.2% (n=7) which increased to a one year mortality of 26.4% (n=14). CONCLUSION: Patients age 60 years and over with femoral shaft fractures have poor medical outcomes and prolonged length of admission. Compared to patients with hip fractures, medical complication rates are at least twice the 13-20% reported for hip fractures. The 30 day mortality rate in patients with femoral shaft fractures was also more than double the 6.1% reported for hip fracture patients by The National Hip Fracture Database in 2018. Femoral shaft fractures are associated with high medical morbidity and mortality. The hip fracture pathway is encompassed in the British Orthopaedic Association guidelines and emphasizes early medical input and a multidisciplinary approach to patient management. Hence, our study supports implementation of these guidelines with aim to improve morbidity and mortality of this vulnerable patient group.

Continuing acromioclavicular joint pain after excision arthroplasty: is further surgery effective?

BACKGROUND: Little published evidence exists on the incidence of continuing acromioclavicular joint pain with no published outcomes for revision surgery. This study aimed to establish the incidence and outcomes of revision acromioclavicular joint excision surgery. MATERIALS AND METHODS: A consecutive retrospective cohort of patients undergoing revision arthroscopic or open acromioclavicular joint excision was identified. Patients were identified from a prospectively collected database. Inclusion criteria were revision acromioclavicular joint excisions over a 14-year period between 2001 and 2015. Exclusion criteria were previous surgery for acromioclavicular joint instability or shoulder arthroplasty. Outcome measures were Oxford Shoulder scores and a satisfaction survey. RESULTS: Forty-three consecutive cases of revision acromioclavicular joint excision over 14 years (37 after arthroscopic excision with subacromial decompression, 5 after arthroscopic excision with rotator cuff repair, 1 after open excision). Continuing acromioclavicular joint pain was associated with incomplete resection from arthroscopic surgery, which was the primary indication for revision surgery. Revision occurred a mean 14.2 months after primary surgery (standard deviation 7.6 months). Mean Oxford Shoulder score was preoperatively 18 (standard deviation 8.1) and 23.4 (standard deviation 11.1) after primary surgery, which did not reach significance until after revision surgery with a mean 31.7 (standard deviation 13.6; P = 0.021). Median follow up was 15 months (interquartile range 4-31 months). A survey at a mean of 6 years (standard deviation 2.3) post-revision surgery found that 65% of patients felt improved, 77% would have their surgery again and 69% of patients felt satisfied. The incidence of postoperative frozen shoulder was 14.3%. CONCLUSION: Functional outcomes after revision surgery showed improvement from scores taken before primary surgery; however, long-term satisfaction rates were relatively low.

Nightstick Fractures, Outcomes of Operative and Non-Operative Treatment.

INTRODUCTION: A nightstick fracture is an isolated fracture of the ulnar shaft. Although operative and non-operative treatments have been commonly decided by the degree of displacement of the fracture, still there is a controversy specially in those moderately displaced. Herein we report our experience with nightstick fractures. OBJECTIVE: To evaluate operative and non-operative treatment of nightstick fracture. MATERIALS AND METHODS: We retrospectively reviewed the clinical notes, physiotherapy letters and radiographs of 52 patients with isolated ulnar shaft fractures. Outcome Measurements included radiographic healing, post-operative range of motion and complications. RESULTS: The study included 13 females and 39 males, with a mean age of 26 years [range, 18-93 years]. The mean Follow-up period was 32 months ranged from 12 to 54 months. Ten patients were treated non-operatively; forty-two patients had open reduction and internal fixation including six open fractures. The average wait for surgery was 2.5 days. Mobilisation was commenced immediately after the surgeries non-load bearing. 40 patients had no complications post-operatively with good outcome and average of four visits follow-up. In the non-operative group, five out ten failed and had a mean follow-up of nine visits. CONCLUSION: Satisfactory outcome is to be expected with open reduction and internal fixation. Fractures with less than 50% displacement should be treated on individual bases, considering; age, pre-morbid functional status, co-morbidities, compliance and associated injuries.

Management of type IIB and IIIB olecranon fractures. Case series.

OBJECTIVES: to report and evaluate the functional outcome of plate fixation in comminuted olecranon fractures (Mayo types IIB and IIIB). METHOD: 23 consecutive patients with comminuted fractures of the olecranon presenting to our unit Between Feb 2011 and Jan 2015, at a mean follow-up of thirty-six months. Main outcome measurements include radiographic healing, post-operative range of motion, complications, outcome score and patient satisfaction. RESULTS: Our study included thirteen females and ten males with a mean age of 55(18-97). Fourteen were Mayo type IIB and nine were Mayo type IIIB. Eighteen patients had no complications post-operatively with good outcome with mean oxford score of 45, full rotational ROM and mean flexion arc of 20-130°. Five patients had range of motion between 40-90° with full rotational ROM and mean oxford score of 24. Two patients out of five required metal work removal. No non-unions were noted in our series. CONCLUSION: Plate fixation of complex olecranon fracture is an effective, reliable method of treatment with low risk of non-union. Restoration of a functional flexion arc of movement can be expected with application of correct technique.

Reverse total shoulder arthroplasty using a trabecular metal glenoid base plate: functional and radiological outcomes at two to five years.

AIM: We present the medium-term clinical results of a reverse total shoulder arthroplasty with a trabecular metal glenoid base plate. PATIENTS AND METHODS: We reviewed 125 consecutive primary reverse total shoulder arthroplasties (RTSA) implanted in 124 patients for rotator cuff arthropathy. There were 100 women and 24 men in the study group with a mean age of 76 years (58 to 89). The mean follow-up was 32 months (24 to 60). No patient was lost to follow-up. RESULTS: There were statistically significant improvements in the mean range of movement and Oxford Shoulder Score (p < 0.001). Kaplan-Meier survivorship at five years was 96.7% (95% confidence interval 91.5 to 98.7) with aseptic glenoid failure as the end point. Radiologically, 63 shoulders (50.4%) showed no evidence of notching, 51 (40.8%) had grade 1 notching, ten (8.0%) had grade 2 notching and one (0.8%) had grade 4 notching. Radiolucency around the glenoid base plate was found in one patient (0.8%) and around the humeral stem in five (4.0%). In all, three RTSA (2.4%) underwent revision surgery for aseptic mechanical failure of the glenoid within 11 months of surgery due to malseating of the glenosphere. CONCLUSION: The clinical results of this large independent single unit series are comparable to those from previous series of RTSA reported in the literature. A trabecular metal base plate is safe and effective in the medium-term. Cite this article: Bone Joint J 2016;98-B:969-75.

Increased prenatal IGF2 expression due to the porcine intron3-G3072A mutation may be responsible for increased muscle mass.

A SNP (IGF2 G3072A) within intron 3 of disrupts a binding site for the repressor zinc finger BED-type containing 6 (ZBED6), leading to increased carcass lean yields in pigs. However, the relative contributions of prenatal as opposed to postnatal increased IGF2 expression are unclear. As muscle fiber number is set at birth, prenatal and neonate skeletal muscle development is critical in determining mature growth potential. Therefore, the objectives of this study were to determine the contributions of hyperplasia and hypertrophy to increased muscle mass and to delineate the effect of the mutation on the expression of myogenic genes during prenatal and postnatal growth. Sows (IGF2 A/A) were bred to a single heterozygous (IGF2 A/G) boar. For fetal samples, sows were euthanized at 60 and 90 d of gestation (d60 and d90) to obtain fetuses. Male and female offspring were also euthanized at birth (0d), weaning (21d), and market weight of approximately 130 kg (176d). At each sampling time, the LM, psoas major (PM), and semitendinosus (ST) muscles were weighed. Samples of the LM were used to quantify the expression of IGF family members, myogenic regulatory factors (MRF), myosin heavy chain isoforms, and growth factors, myostatin, and . Liver samples were used to quantify and expression. At 176d, weights of LM, PM, and ST muscles were all increased approximately 8% to 14% (P < 0.01) in pigs with paternal A (A(Pat)) alleles compared with those with paternal G (G(Pat)) alleles. Additionally, total muscle fiber number in the ST at 176d tended to be greater (P = 0.10), whereas muscle fiber cross-sectional area tended to be reduced ( P= 0.08) in A(Pat) pigs compared with G(Pat) pigs. In addition to the expected 2.7- to 4.5-fold increase (P ≤ 0.02) in expression in the LM in A(Pat) compared with G(Pat) pigs at postnatal sampling times (21d and 176d), IGF2 expression was also increased (P ≤ 0.06) 1.4- to 1.5-fold at d90 of gestation and at birth. At d90, expression of myogenic factor 5 (MYF5), a MRF expressed in proliferating myoblasts, in the LM was greater (P = 0.01) in A (Pat) pigs than in G(Pat) pigs. Interestingly, at 21d hepatic expression was greater (P = 0.01), whereas expression decreased (P = 0.01) in A(Pat) pigs compared with G(Pat) pigs; however, there were no differences (P ≥ 0.18) in hepatic expression between genotypes at 0d and 176d. These data suggest that prenatal hyperplasia of muscle fibers stimulated by increased IGF2 expression may contribute to increased muscle mass of A(Pat) pigs.

Medium-term clinical results of a linked total elbow replacement system.

Medium-term results of the Discovery elbow replacement are presented. We reviewed 51 consecutive primary Discovery total elbow replacements (TERs) implanted in 48 patients. The mean age of the patients was 69.2 years (49 to 92), there were 19 males and 32 females (37%:63%) The mean follow-up was 40.6 months (24 to 69). A total of six patients were lost to follow-up. Statistically significant improvements in range movement and Oxford Elbow Score were found (p < 0.001). Radiolucent lines were much more common in, and aseptic loosening was exclusive to, the humeral component. Kaplan-Meier survivorship at five years was 92.2% (95% CI 74.5% to 96.4%) for aseptic loosening. In four TERs, periprosthetic infection occurred resulting in failure. A statistically significant association between infection and increased BMI was found (p = 0.0268). Triceps failure was more frequent after the Mayo surgical approach and TER performed after previous trauma surgery. No failures of the implant were noted. Our comparison shows that the Discovery has early clinical results that are similar to other semi-constrained TERs. We found continued radiological surveillance with particular focus on humeral lucency is warranted and has not previously been reported. Despite advances in the design of total elbow replacement prostheses, rates of complication remain high.

An epidemiological study of rotator cuff pathology using The Health Improvement Network database.

Little is known about the incidence of rotator cuff pathology or its demographic associations in the general population. We undertook a large epidemiological study of rotator cuff pathology in the United Kingdom using The Health Improvement Network (THIN) database. The incidence of rotator cuff pathology was 87 per 100,000 person-years. It was more common in women than in men (90 cases per 100,000 person-years in women and 83 per 100,000 person-years in men; p < 0.001). The highest incidence of 198 per 100,000 person-years was found in those aged between 55 and 59 years. The regional distribution of incidence demonstrated an even spread across 13 UK health authorities except Wales, where the incidence was significantly higher (122 per 100,000 person-years; p < 0.001). The lowest socioeconomic group had the highest incidence (98 per 100,000 person-years). The incidence has risen fourfold since 1987 and as of 2006 shows no signs of plateauing. This study represents the largest general population study of rotator cuff pathology reported to date. The results obtained provide an enhanced appreciation of the epidemiology of rotator cuff pathology and may help to direct future upper limb orthopaedic services.

Risk factors in lateral epicondylitis (tennis elbow): a case-control study.

Lateral epicondylitis is a common condition, but relatively little is known about its aetiology and associated risk factors. We have undertaken a large case-control study using The Health Improvement Network database to assess and quantify the relative contributions of some constitutional and environmental risk factors for lateral epicondylitis in the community. Our dataset included 4998 patients with lateral epicondylitis who were individually matched with a single control by age, sex, and general practice. The median age at diagnosis was 49 (interquartile range 42-56) years . Multivariate analysis showed that the risk factors associated with lateral epicondylitis were rotator cuff pathology (OR 4.95), De Quervain's disease (OR 2.48), carpal tunnel syndrome (OR 1.50), oral corticosteroid therapy (OR 1.68), and previous smoking history (OR 1.20). Diabetes mellitus, current smoking, trigger finger, rheumatoid arthritis, alcohol intake, and obesity were not found to be associated with lateral epicondylitis.

Characteristics of patients dying within 30 days of diagnosis of breast or colorectal cancer in Scotland, 2003-2007.

BACKGROUND: Recent research has shown that most of the excess risk of death following breast and colorectal cancer in England compared with Norway and Sweden occurs in older age groups during the first year, and especially in the first month of follow-up. The aim of this study was to explore the characteristics of patients dying within 30 days of being diagnosed with one of these cancers in Scotland during 2003-2007. METHODS: Anonymised cancer registry records linked to hospital discharge and death records were extracted. The study population was divided into patients who died within 30 days of diagnosis (cases) and those who survived beyond this threshold (controls). Differences in patient-, tumour-, and health service-related characteristics were assessed using the χ(2)-test and logistic regression. RESULTS: Patients dying within 30 days were more likely to be elderly and to have experienced emergency admission to non-surgical specialities. Their tumours were less likely to have been verified microscopically, but they appeared more likely to be of high grade and advanced in stage. A substantial number of patients died from causes other than their cancer. CONCLUSION: These results suggest that early mortality after a diagnosis of breast or colorectal cancer may be partly due to comorbidity and lifestyle factors, as well as due to more advanced disease. Further research is required to determine the precise explanation for these findings and, in particular, if any potentially avoidable factors such as delays in presentation, referral, or diagnosis exist.

Nonunion of a Scapular Spine Fracture: Case Report and Management with Open Reduction; Internal fixation; and Bone Graft

Fractures of the scapular spine are relatively uncommon. We report a case of a 39 year old male who developed an atrophic non-union scapular spine fracture entering the spino-glenoid notch. We describe our experience with this rare fracture pattern and identify the need for early internal fixation in the young; active and working population

An unusual case of retinopathy of prematurity.

AIMS: Stage 3 retinopathy of prematurity (ROP) usually develops in the very small babies. An infant born at 30 (2) weeks' gestation and of birth weight 2102 g was found to have stage 3 ROP bilaterally. The unusual severity of the disease in a child of birth weight >2000 g prompted further investigation. The aim was to look for any genetic causes for ROP. METHODS: Chromosomal analysis followed by vasculoendothelial growth factor (VEGF) analysis. RESULTS: Unbalanced translocation 18p (monosomy) and 6p (trisomy). Overexpression of VEGF. CONCLUSIONS: Overexpression of VEGF contributed to the unusual severity of ROP in this relatively large baby.

Tension band suturing for the treatment of displaced type 2 lateral end clavicle fractures.

INTRODUCTION: Non-operative treatment of Neer type 2 lateral end clavicle fractures presents a difficult problem due to the high incidence of non-union, delayed union and resulting shoulder girdle instability. Operative techniques described may require extensive soft tissue reconstruction, implant removal or lead to implant failure. MATERIALS AND METHODS: We report a modified tension band suturing technique for the treatment of these lateral end displaced clavicle fractures that avoids these problems of extensive soft tissue dissection, implant removal or implant failure. Ten patients were reviewed clinically, radiologically and with Constant assessment score outcomes using the tension band suture for the treatment of these fractures. RESULTS: All the fractures had healed at a mean follow-up of 9.2 weeks (range 6-16 weeks) with a mean Constant score of 91 and the power was comparable to the normal shoulder using the Nottingham Myometer. CONCLUSION: The results of this pilot study for treatment of Neer's type 2 lateral end clavicle fractures are very encouraging. We do recommend the need for a prospective larger study of this technique for the treatment of Neer type 2 lateral end clavicle fracture to evaluate this technique further.

Can a urinary tract symptom score predict the development of postoperative urinary retention in patients undergoing lower limb arthroplasty under spinal anaesthesia? A prospective study.

INTRODUCTION: There is no general consensus amongst orthopaedic surgeons on how best to manage the urinary tract and its complications after lower limb arthroplasty. This prospective audit investigates whether postoperative urinary retention can be predicted pre-operatively using the validated International Prostate Symptom Severity score (IPSS). PATIENTS AND METHODS: A total of 182 patients undergoing lower limb arthroplasty under spinal anaesthetic were given the IPSS questionnaire to complete pre-operatively and an audit into numbers catheterised postoperatively was performed. RESULTS: Overall, 69% of males and 39% of females required catheterisation. Following logistic regression analysis there was 0.85 predicted probability that males over 70 years would require catheterisation. The IPSS score was not useful in predicting retention in either sex at any age. CONCLUSIONS: We propose that all males over 70 years undergoing this type of surgery should be catheterised pre-operatively and all other patients should be catheterised postoperatively with close monitoring of bladder volumes to prevent established urinary retention.

Dupuytren's disease risk factors.

Dupuytren's is a common problem, but little is known about its aetiology. We have undertaken a large case-control study to assess and quantify the relative contributions of diabetes and epilepsy as risk factors for Dupuytren's in the community. Cases were patients with a diagnosis of Dupuytren's disease and, for each, two controls were individually matched by age, sex, and general practice. Our dataset included 821 cases and 1,642 controls. Five hundred and eighty-eight (72%) of the cases were men. The mean age at diagnosis was 62 (range 24-97) years. Diabetes was a significant risk factor for Dupuytren's disease (OR=1.75) and there was an increased risk for medicinally treated diabetes (metformin--OR=3.56; sulphonylureas--OR=1.75) and particularly insulin controlled (OR=4.38) rather than diet-controlled diabetes. Epilepsy (OR=1.12) and anti-epileptic medications were not associated with Dupuytren's disease. Ascertainment bias in previous studies may explain the reported association with epilepsy.

Risk factors in carpal tunnel syndrome.

We have undertaken a large case-control study using the UK General Practice Research Database to quantify the relative contributions of the common risk factors for carpal tunnel syndrome (CTS) in the community. Cases were patients with a diagnosis of CTS and, for each, four controls were individually matched by age, sex and general practice. Our dataset included 3,391 cases, of which 2,444 (72%) were women, with a mean age at diagnosis of 46 (range 16-96) years. Multivariate analysis showed that the risk factors associated with CTS were previous wrist fracture (OR=2.29), rheumatoid arthritis (OR=2.23), osteoarthritis of the wrist and carpus (OR=1.89), obesity (OR=2.06), diabetes (OR=1.51), and the use of insulin (OR=1.52), sulphonylureas (OR=1.45), metformin (OR=1.20) and thyroxine (OR=1.36). Smoking, hormone replacement therapy, the combined oral contraceptive pill and oral corticosteroids were not associated with CTS. The results were similar when cases were restricted to those who had undergone carpal tunnel decompression.

Early results of the Souter-Strathclyde unlinked total elbow arthroplasty in patients with osteoarthritis.

We have carried out a retrospective review of 11 Souter-Strathclyde primary total elbow arthroplasties in ten patients with osteoarthritis, over a period of nine years. The diagnosis was primary osteoarthritis in nine elbows and post-traumatic arthritis in two. The mean follow-up was 68 months (15 to 117). Although no patient was symptomatic, radiological review revealed evidence of loosening affecting three humeral and two ulnar components, one of which subsequently failed and was revised at 97 months. There were no dislocations, deep infections or mechanical failures. Complications included two superficial wound infections and two neurapraxias of the ulnar nerve which resolved. This study shows that the unlinked Souter-Strathclyde total elbow arthroplasty can be considered for patients with osteoarthritis and gives good symptomatic relief and improvement in function.

Elbow osteoarthritis: prognostic indicators in ulnohumeral debridement--the Outerbridge-Kashiwagi procedure.

A consecutive series of 43 patients (44 elbows) underwent ulnohumeral debridement for elbow osteoarthritis. Thirty-five patients (36 elbows) were reviewed after a mean follow-up of 39 months. Eighty-one percent of patients were satisfied, with 12 good, 19 fair, and 5 poor outcomes. The mean flexion/extension arc, pain score, and locking were all significantly improved, but a significant number of patients had rest pain. Patients who had symptoms for less than 2 years, considerable preoperative pain, or cubital tunnel syndrome had a significantly increased chance of a good outcome. The absence of preoperative locking was associated with a significantly increased chance of a poor outcome. A history of trauma, preoperative range of movement, and radiograph score did not predict outcome.

Hip abductor strength following total hip arthroplasty: a prospective comparison of the posterior and lateral approach in 100 patients.

We studied the hip abductor strength and Trendelenburg test prospectively in 100 patients undergoing total hip replacement via a lateral or posterior approach. In 49 patients, we used the lateral approach to implant the Charnley total hip replacement, and in 51 patients, the posterior approach to implant the Exeter total hip. Isometric abductor strength was measured with the kinetic communicator device and the Trendelenburg test was recorded preoperatively and at 3 and 12 months postoperatively. Of the original 100 patients, 83 were available for study at 3 months and 73 at 12 months. Hip abductor strength and the Trendelenburg test improved postoperatively in both groups, but we found no difference in hip abductor strength recovery at 3 and 12 months between the lateral approach and the posterior approach. Similarly there was no difference in the Trendelenburg test between the two groups 3 and 12 months following hip replacement.