Remote Follow-up of Shoulder Arthroplasty Patients During COVID-19 Pandemic - Is This the way Forward?

BACKGROUND: The COVID-19 Pandemic has affected the way health care systems function across the globe. Apart from eliminating the risk of being in a vulnerable environment during the pandemic such as a hospital setting, virtual arthroplasty follow-up reduces the demand on funding and resources on the National Health Services (NHS). METHODS: We retrospectively reviewed our shoulder arthroplasty patients (55) operated between October 2018 to November 2020 at both our hospital sites. For remote follow-up, patients were contacted on a scheduled appointment date via telephone by an orthopaedic surgeon to enquire about their wound, pain and function. Patients were questioned as per questionnaire from the Oxford Shoulder Score (OSS) and American Shoulder and Elbow Surgeons (ASES) Standardised Assessment form. RESULTS: 50 patients were included in the final data set after excluding those who had died (5 patients). All patients had had final x-rays with full Covid-19 precautions at the time of final follow-up. No patient had wound problems except one who had concerns of wound appearance. There were no cases of notching, impingement, deep infection, dislocation or nerve injury. Of the 50 patients, 40 (80%) patients were satisfied to have a remote follow-up. 36 (72%) patients said they wouldn't mind a remote follow-up appointment. CONCLUSION: Remote follow-up via audio consultation may be an effective alternative to in person visits after shoulder arthroplasty. Patients in this series demonstrated a high level of satisfaction with virtual visits and post-operative complications were effectively identified.

Reliability analysis of radiologic and intraoperative loosening in total elbow arthroplasty.

BACKGROUND: Revisions of total elbow arthroplasties (TEAs) are commonly performed because of prosthetic loosening. UK National Joint Registry data show that TEA revisions are becoming increasingly common, with 123 TEA revisions performed in 2018 and 76 performed in 2017. TEA radiologic assessment is based on subjective interpretation with no published criteria. We defined TEA loosening by the presence of at least one of the following criteria: (1) progressive widening of the bone-cement, bone-prosthesis, or cement-prosthesis interface; (2) fragmentation or fracture of cement; (3) prosthetic component migration; and (4) bead shedding in porous-coated prostheses. Using this definition, we looked at interobserver and intraobserver agreement on radiologic loosening and compared this assessment with intraoperative findings. METHODS: In our tertiary care center, we conducted a retrospective review to identify TEA revisions performed between November 2008 and July 2018. Radiologic implant loosening was independently assessed by 5 orthopedic surgeons. Interobserver agreement (κ coefficient) was calculated. The majority's view of radiologic loosening was compared with intraoperative findings. RESULTS: We identified 93 sets of radiographs with implant stability clearly documented in their operative notes. The κ coefficient between assessors for humeral implant loosening was 0.87 (almost perfect). The κ coefficient for ulnar loosening was 0.75 (substantial). The κ coefficients for radiologic and intraoperative findings of humeral loosening and ulnar loosening were 0.67 and 0.71 (substantial), respectively. Intraobserver reliability was almost perfect for humeral loosening (κ = 0.86) and substantial for ulnar loosening (κ = 0.74). CONCLUSION: Our definition of loosening provides reproducible interobserver and intraobserver agreement on radiographic component loosening. In our center's experience, radiologic findings may not translate to intraoperative findings, and we would advise that surgical strategies for TEA revision include the possibility of needing to perform a dual-implant exchange.

Revision total elbow arthroplasty: Is it safe to perform a single-stage revision for presumed aseptic loosening based on clinical assessment, normal inflammatory markers, and a negative aspiration?

BACKGROUND: Revision total elbow arthroplasty (TEA) is a challenging procedure that is becoming increasingly common. In our unit, we regard it as essential to exclude infection as the underlying cause of TEA loosening. In all patients with arthroplasty loosening, we undertake a careful history and examination, perform radiographs, monitor inflammatory markers, and undertake a joint aspiration. If any investigation suggests infection as the etiology, then a 2-stage revision is undertaken. Open biopsies are not routinely performed. The aim was to ascertain from our outcomes whether it is safe to perform a single-stage revision for presumed aseptic loosening using these criteria. METHODS: A retrospective review of a consecutive series of revision TEAs was performed in our unit over a 10-year period (2008-2018). Single-stage revisions performed for presumed aseptic loosening were identified. Case notes, radiographs, bloods, aspiration results, and microbiology of tissue samples taken at revision were reviewed. RESULTS: A total of 123 revision elbow arthroplasty cases were performed in the study period. Sixty cases were revised for preoperatively proven infection, instability, or implant failure and were excluded from this study. In 63 cases, aseptic loosening was diagnosed based on history, clinical examination, blood markers, and aspiration. There were 21 dual-component and 42 single-component revisions. In the dual-component revision group, tissue samples taken at the time of revision were positive in only 1 case (5%). In the single-component revision group, positive culture samples were present in 3 cases (7%). χ2 analysis showed no significant difference between single- and dual-component revisions (P = .76). No cases with positive culture samples from either group have required subsequent revision surgery. CONCLUSION: Given the results of this study, we conclude that is safe to perform single-stage revision arthroplasty for implant loosening based on history, examination, normal inflammatory markers, and negative aspiration results without the need for open biopsy.