Management of glenoid bone loss with impaction and structural bone grafting in reverse shoulder arthroplasty.

INTRODUCTION: Glenoid bone loss is a commonly encountered problem in complex primary and revision shoulder arthroplasty. Addressing glenoid bone loss is critical to avoid complications like early loosening, impingement, notching and instability. A large number of techniques like bone grafting using autograft or allograft, eccentric reaming, augmented base plates, patient-specific instrumentations and custom-made implants are available to tackle bone loss. MATERIALS AND METHODS: We prospectively collected the data of all patients with glenoid defects undergoing primary or revision reverse shoulder replacement between 2004 and 2017. This included demographic data, ranges of motion, Constant-Murley score and Subjective Shoulder Value (SSV). A pre-operative CT scan was done as well to plan the surgery and calculate the glenoid version. At each follow-up, the clinical function and shoulder scores were assessed. Additionally, the radiographs were assessed for graft incorporation, evidence of lysis and calculation of glenoid version. RESULTS: Between 2004 and 2017, 37 patients underwent glenoid bone grafting during reverse shoulder arthroplasty. Average age was 72 years (range 46-88). Indications for surgery were cuff tear arthropathy (6 patients); revision of failed other prosthesis (23); primary osteoarthritis (4); rheumatoid arthritis (3); and second-stage revision for infection (1). The glenoid defect was contained in 24 patients, and therefore, impaction graft with a combination of bone graft substitute and/or humeral head autograft was performed. In 13 patients the glenoid defect was severe and uncontainable and therefore a graft-implant composite glenoid was implanted using humeral head autograft or allograft. Average follow-up was 3.6 years (range 1-10). Mean Constant score improved from 34 before surgery to 63 after surgery. Mean SSV score improved from 0.9/10 to 8.3/10. Active movements improved significantly with forward elevation increasing from 54° to 123°; abduction from 48° to 123°; external rotation from 24° to 38°; internal rotation from 57° to 70°. Radiographs at final follow-up showed no radiolucencies around the glenoid component and no evidence of loosening of the implant. In 2 cases there was a grade I notching. There was 100% survivorship at the last follow-up. CONCLUSION: Impaction bone grafting along with structural grafting when required is an effective and reproducible way of managing severe glenoid bone loss. This technique gives consistent and good clinical and radiological results.

Reverse shoulder replacement versus hemiarthroplasty for proximal humeral fracture in elderly patients: a systematic review.

This systematic review of the literature aims to analyse current knowledge to inform choice between hemiarthroplasty (HA) and reverse total shoulder arthroplasty (rTSA) for managing proximal humerus fractures (PHF) in elderly patients; the aim is to understand if rTSA can be considered the gold standard for treating PHF in the elderly when surgical fixation or conservative treatment is not viable options. Studies reporting outcomes and complications of PHF treated with shoulder arthroplasty in the elderly were included. Studies were in English and published after 2008. Evidence levels I, II, III and IV were included. According to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, a comprehensive literature search was conducted using Medline, CINAHL (Cumulative Index to Nursing and Allied Health Literature) and PubMed search engines, as well as the Cochrane Central Register of Controlled Trials. General data collected were study design, number of patients treated with HA and rTSA, age of patients (mean, mean and SD, mean and range), length of follow-up, type of implant, and clinical outcomes. rTSA can be regarded as the gold standard for surgical management of displaced 3 and 4-part fractures in the elderly. However, the literature offers mostly low-quality studies, thereby requiring further work to achieve a full understanding of this important topic.

COVID-19 - Changes in Workload and Clinical Practice in Trauma and Orthopaedics in a District General Hospital in the United Kingdom.

INTRODUCTION: COVID-19 has had a significant impact on the entire health system. The trauma and orthopaedic service has been compelled to alter working practices to respond proactively and definitively to the crisis. The aim of this study is to summarise the impact of this outbreak on the trauma and orthopaedic workload and outline the response of the department. MATERIALS AND METHODS: We retrospectively collected data comparing patient numbers pre-COVID-19, and prospectively during the early COVID-19 pandemic. We have collected the numbers and nature of outpatient orthopaedic attendances to fracture clinics and elective services, inpatient admissions and the number of fracture neck of femur operations performed. RESULTS: The number of outpatient attendances for a musculoskeletal complaint to Accident and Emergency and the number of virtual fracture clinic reviews reduced by almost 50% during COVID-19. The number of face-to-face fracture clinic follow-ups decreased by around 67%, with a five-fold increase in telephone consultations. Inpatient admissions decreased by 33%, but the average number of fracture neck of femur operations performed has increased by 20% during COVID-19 compared to pre-COVID-19 levels. CONCLUSION: We have noted a decrease in some aspects of the trauma and orthopaedic outpatient workload, such as leisure and occupational-related injuries but an increase in others, such as fracture neck of femurs. Many injuries have significantly reduced in numbers and we consider that a model could be developed for treating these injuries away from the acute hospital site entirely, thereby allowing the acute team to focus more appropriate major trauma injuries.

COVID-19 – Changes in Workload and Clinical Practice in Trauma and Orthopaedics in a District General Hospital in the United Kingdom

@#Introduction: COVID-19 has had a significant impact on the entire health system. The trauma and orthopaedic service has been compelled to alter working practices to respond proactively and definitively to the crisis. The aim of this study is to summarise the impact of this outbreak on the trauma and orthopaedic workload and outline the response of the department. Materials and Methods: We retrospectively collected data comparing patient numbers pre-COVID-19, and prospectively during the early COVID-19 pandemic. We have collected the numbers and nature of outpatient orthopaedic attendances to fracture clinics and elective services, inpatient admissions and the number of fracture neck of femur operations performed. Results: The number of outpatient attendances for a musculoskeletal complaint to Accident and Emergency and the number of virtual fracture clinic reviews reduced by almost 50% during COVID-19. The number of face-to-face fracture clinic follow-ups decreased by around 67%, with a five-fold increase in telephone consultations. Inpatient admissions decreased by 33%, but the average number of fracture neck of femur operations performed has increased by 20% during COVID-19 compared to pre-COVID-19 levels. Conclusion: We have noted a decrease in some aspects of the trauma and orthopaedic outpatient workload, such as leisure and occupational-related injuries but an increase in others, such as fracture neck of femurs. Many injuries have significantly reduced in numbers and we consider that a model could be developed for treating these injuries away from the acute hospital site entirely, thereby allowing the acute team to focus more appropriate major trauma injuries.

Atypical mycobacterium infection of sternoclavicular joint: A unique case.

We report a rare case of atypical Mycobacterium intracellulare infection encountered in a left sternoclavicular joint of an immunocompetent patient. The 34-year-old female patient presented with a one-year history of left sternoclavicular joint pain and swelling. The patient had multiple radiological investigations, which were suspicious for an infective cause. The patient had a biopsy of the joint, which returned showing acid-fast bacilli. The patient consequently received a prolonged course of medical treatment for M. intracellulare.

Accuracy of hand-held ultrasound scanning in detecting meniscal tears.

The diagnosis of a meniscal tear may require MRI, which is costly. Ultrasonography has been used to image the meniscus, but there are no reliable data on its accuracy. We performed a prospective study investigating the sensitivity and specificity of ultrasonography in comparison with MRI; the final outcome was determined at arthroscopy. The study included 35 patients with a mean age of 47 years (14 to 73). There was a sensitivity of 86.4% (95% confidence interval (CI) 75 to 97.7), a specificity of 69.2% (95% CI 53.7 to 84.7), a positive predictive value of 82.6% (95% CI 70 to 95.2) and a negative predictive value of 75% (95% CI 60.7 to 81.1) for ultrasonography. This compared favourably with a sensitivity of 86.4% (95% CI 75 to 97.7), a specificity of 100.0%, a positive predictive value of 100.0% and a negative predictive value of 81.3% (95% CI 74.7 to 87.9) for MRI. Given that the sensitivity matched that of MRI we feel that ultrasonography can reasonably be applied to confirm the clinical diagnosis before undertaking arthroscopy. However, the lower specificity suggests that there is still a need to improve the technique to reduce the number of false-positive diagnoses and thus to avoid unnecessary arthroscopy.

Measurement of blood flow in the rotator cuff using laser Doppler flowmetry.

The aim of this study was to define the microcirculation of the normal rotator cuff during arthroscopic surgery and investigate whether it is altered in diseased cuff tissue. Blood flow was measured intra-operatively by laser Doppler flowmetry. We investigated six different zones of each rotator cuff during the arthroscopic examination of 56 consecutive patients undergoing investigation for impingement, cuff tears or instability; there were 336 measurements overall. The mean laser Doppler flowmetry flux was significantly higher at the edges of the tear in torn cuffs (43.1, 95% confidence interval (CI) 37.8 to 48.4) compared with normal cuffs (32.8, 95% CI 27.4 to 38.1; p = 0.0089). It was significantly lower across all anatomical locations in cuffs with impingement (25.4, 95% CI 22.4 to 28.5) compared with normal cuffs (p = 0.0196), and significantly lower in cuffs with impingement compared with torn cuffs (p < 0.0001). Laser Doppler flowmetry analysis of the rotator cuff blood supply indicated a significant difference between the vascularity of the normal and the pathological rotator cuff. We were unable to demonstrate a functional hypoperfusion area or so-called 'critical zone' in the normal cuff. The measured flux decreases with advancing impingement, but there is a substantial increase at the edges of rotator cuff tears. This might reflect an attempt at repair.

Prevalence of rheumatic diseases in a rural population in western India: a WHO-ILAR COPCORD Study.

BACKGROUND: COPCORD (Community oriented program from control of rheumatic diseases) is a global initiative of the WHO/International League of Associations from Rheumatology (ILAR). The prevalence data from the first Indian COPCORD survey (Stage 1), carried out in village Bhigwan (Dist. Pune), in 1996, is presented. AIM: To study the rural prevalence of rheumatic-musculoskeletal symptoms/diseases (RMSD). METHODS: A cross-sectional survey of the village (non-randomised selection) was completed in five weeks, using validated questionnaires, served by 21 trained volunteers. 746 patients (18.2%, 95% CI: 17-1-19-4) were identified (Phase 1) from 4092 adults (response 89%), and systematically evaluated (Phase 2 and 3) by a medical team, including a rheumatologist; limited investigations were carried out and diagnosis confirmed during a planned 12 week initial follow-up. Standard clinical criteria were used for the diagnosis; point prevalence estimates (prev)/confidence interval (CI) are shown in parenthesis. RESULTS: There was a dominant distribution of 'pain at all sites' (articular/soft tissues) in the females; painful neck (9.5%), back (17.3%), and calf (8.5%) appeared significant when compared to the Bhigwan males and the Indonesian and the Chinese rural COPCORD results. 55% RMSD were due to soft tissue rheumatism (5.5%) and an ill-defined/unclassifiable symptom-related-diagnosis (7.1%). Osteoarthritis (5.8%) and inflammatory arthritis (IA) were seen in 29% and 10% patients respectively. 240 patients (5.9%) with chronic knee pains did not show any clinical evidence of OA. The prev of rheumatoid arthritis (0.5%, 95% CI: 0.3-0.7), as classified by the American College of Rheumatology, was the highest ever reported from an Asian rural COPCORD study. Though unclassifiable IA (0.9%, 95% CI: 0.6-1.1) was seen, well defined reactive arthritis, TB, leprosy and connective tissue disorders were not observed. Gout was diagnosed in five patients (0.12%). CONCLUSIONS AND DISCUSSION: The Bhigwan COPCORD survey demonstrates a significant rural spectrum of RMSD. It provides a reasonable speculation about the Indian rheumatological burden. Further, an eight year prospective study is in progress to identify new cases and risk factors, and educate people (Stages 2 and 3).