Survivorship analysis of CAD-CAM total shoulder replacement.

Background: Glenoid bone loss represents a challenge in shoulder arthroplasty and often precludes standard implants. The CAD-CAM total shoulder replacement (TSR) is an option in these cases. This study aimed to assess survivorship and long-term patient outcomes of the CAD-CAM TSR. Methods: Fifty-eight patients that underwent a CAD-CAM TSR by three surgeons at a single tertiary referral centre between 2009 and 2017 were reviewed. The mean follow-up was 70 months (28-130). Data was collected on survivorship, range of movement, Oxford shoulder score (OSS, 0-48), subjective shoulder value (SSV, 0-100%), pain score (0-10), and overall patient satisfaction. Results: CAD-CAM TSR was undertaken as a primary procedure in 28% (n = 16) for end-stage arthritis with severe glenoid bone loss, and as a revision procedure in 72% (n = 42). Of the total, 17% (n = 10) required component revision at a mean of 24 months (4x prosthesis loosening, 3x infection, 3x periprosthetic fracture). Forward elevation improved from 45° ± 27° to 59° ± 29° (P = 0.0056), abduction from 43° ± 29° to 55° ± 26° (P = 0.034) and external rotation from 8° ± 11° to 16° ± 14° (P = 0.031). OSS improved from 15 ± 8 to 29 ± 9 (P = 0.0009), SSV from 18 ± 16 to 62 ± 23 (P < 0.0001), and pain score from 8 ± 2 to 2 ± 2 (P < 0.0001). 88% of patients would undergo the procedure again. Conclusion: CAD-CAM TSR is reserved for complex cases involving severe glenoid bone loss, offering significant improvements in pain and function with overall positive patient satisfaction.

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.

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.

SciKit-SurgeryGlenoid, an Open Source Toolkit for Glenoid Version Measurement.

Correct understanding of the geometry of the glenoid (the socket of the shoulder joint) is key to successful planning of shoulder replacement surgery. This surgery typically involves placing an implant in the shoulder joint to restore joint function. The most relevant geometry is the glenoid version, which is the angular orientation of the glenoid surface relative to the long axis of the scapula in the axial plane. However, measuring the glenoid version is not straightforward and there are multiple measurement methods in the literature and used in commercial planning software. In this paper we introduce SciKit-SurgeryGlenoid, an open source toolkit for the measurement of glenoid version. SciKit-SurgeryGlenoid contains implementations of the 4 most frequently used glenoid version measurement algorithms enabling easy and unbiased comparison of the different techniques. We present the results of using the software on 10 sets of pre-operative CT scans taken from patients who have subsequently undergone shoulder replacement surgery. We further compare these results with those obtained from a commercial implant planning software. SciKit-SurgeryGlenoid currently requires manual segmentation of the relevant anatomical features for each method. Future work will look at automating the segmentation process to build an automatic and repeatable pipeline from CT or radiograph to quantitative glenoid version measurement.

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.

Shoulder Pain Diagnosis, Treatment and Referral Guidelines for Primary, Community and Intermediate Care.

These care pathway guidelines for the shoulder have been written in collaboration with the NHS Evidence Based Interventions (EBI) programme. The EBI programme is a partnership between the Academy of Medical Royal Colleges, NHS Clinical Commissioners, the National Institute for Health and Care Excellence, as well as NHS England and Improvement.

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 Provision of Primary and Revision Elbow Replacement Surgery in the NHS.

BESS Surgical Procedure Guidelines (SPGs). Optimising Surgical Outcomes for Shoulder and Elbow patients. The British Elbow and Shoulder Society (BESS) SPGs are a series of evidence and consensus Best Practice Recommendations developed by BESS surgeons and physiotherapists to help drive quality improvement and achieve the best possible surgical outcomes for UK patients. This SPG on primary and revision elbow replacement surgery is supported and endorsed by both the British Orthopaedic Association (BOA) and the Getting It Right First Time (GIRFT) Programme.

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.

Anatomical shoulder arthroplasty in epileptic patients with instability arthropathy and persistent seizures.

PURPOSE: Epileptic seizures can cause shoulder dislocation, recurrent instability and eventually arthritis. The purpose of this study was to report the results, complications and rate of revision surgery following anatomical shoulder arthroplasty in epileptic patients with instability arthropathy. METHODS: A consecutive series of eight patients with epilepsy underwent anatomical shoulder arthroplasty for recurrent shoulder instability and were retrospectively reviewed after a mean of 4.7 years (range, 2-7.5 years). These included three total shoulder replacements and five humeral resurfacing hemiarthroplasty procedures. RESULTS: Mean age of the cohort was 33 years (range, 17-44). All patients experienced post-operative grand mal seizures. Two patients with hemiarthroplasty required further surgery due to painful glenoid erosion. No residual cases of instability were noted. Mean active forward elevation and external rotation improved following surgery. The Oxford Shoulder Score improved from 15 pre-operatively (range, 7-22) to 26 post-operatively (range, 12-45) ( p = 0.031). This was accompanied by an increase in the mean Subjective Shoulder Value, which improved from 29 (range, 10-80) pre-operatively to 53 (range, 15-90) post-operatively ( p=0.042). CONCLUSIONS: Anatomical shoulder arthroplasty may offer a solution for the treatment of instability arthropathy in patients with epilepsy and persistent seizures.

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.

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.

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.

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.

Latissimus dorsi tendon transfers for rotator cuff deficiency.

PURPOSE: Latissimus dorsi tendon transfers are increasingly being used around the shoulder. We aim to assess any improvement in pain and function following a latissimus dorsi tendon transfer for massive, irreparable postero-superior cuff deficiency. MATERIALS AND METHODS: At our institution, between 1996 and 2009, 38 latissimus dorsi tendon transfer procedures were performed. Sixteen of these were for massive irreparable rotator cuff deficiency associated with pain and impaired function. All patients were evaluated by means of interview or postal questionnaire and case note review. Pain and function were assessed using the Stanmore percentage of normal shoulder assessment (SPONSA) score, visual analogue scale and Oxford Shoulder Score. Forward elevation was also assessed and a significant improvement was thought to correlate with the success of the procedure at stabilizing the humeral head upon elevation. RESULTS: Mean follow-up time was 70 months. There was a significant reduction in pain on the visual analogue scale from 6.4 to 3.4 (P < 0.05), an improved SPONSA score from 32.5 to 57.5 (P < 0.05), and an improved Oxford Shoulder Score from 40.75 to 29.6 (P < 0.05). Forward elevation improved from 40° preoperatively to 75° postoperatively (P < 0.05). CONCLUSION: Our results add to the body of evidence that latissimus dorsi tendon transfers for irreparable postero-superior cuff deficiency in selected patients reduce pain and improve shoulder function in the medium term. LEVEL OF EVIDENCE: Level 4.