Diabetic patients are almost twice as likely to experience complications from arthroscopic rotator cuff repair.

AIMS: Large population-based studies have demonstrated increased prevalence of rotator cuff disease amongst diabetics. Recent studies have suggested comparable clinical outcomes from rotator cuff repair despite suggestions of increased complication rates amongst diabetics. However, there is a relative paucity of studies considering the effect of diabetes upon complication rate. We aim to report and quantify the effect of diabetes on complication rates following arthroscopic rotator cuff repair. MATERIALS AND METHODS: A retrospective review of a consecutive series of patients undergoing arthroscopic rotator cuff repair between January 2011 and December 2014 was performed. Diabetic status and complication data defined as infection, frozen shoulder, re-tear or re-operation were collected and interrogated. RESULTS: A total of 462 patients were included at median follow-up of 5.6 years. Diabetics were significantly more likely to experience frozen shoulder (15.8% vs. 4.4%, p = 0.001), re-tear (26.3% vs. 15.6%, p = 0.042) or at least one complication following surgery (35.1% vs. 22.7%, p = 0.041) compared to non-diabetics. These equated to odds ratios of 4.03, 1.94 and 1.84, respectively. CONCLUSIONS: Diabetic patients are almost twice as likely to experience complications following arthroscopic rotator cuff repair, including double the risk of repair failure and more than four times the risk of frozen shoulder.

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.

Redescription of Pulvinaria indica Avasthi Shafee, 1985 (Hemiptera: Coccomorpha: Coccidae) with new host and distribution records.

The soft scale Pulvinaria indica (Hemiptera: Coccomorpha: Coccidae) was described by Avasthi Shafee in 1985 from four females collected on Duranta repens Linn. from Simhachalam, Visakhapatnam, Andhra Pradesh, India. The original description, however, was scanty and attempts to locate the type material were unsuccessful. To facilitate the identification and separation of P. indica from other similar species, we redescribe and illustrate the adult female, based on newly collected specimens found on an economically important new host plant. Management options in the event of its future occurrence are discussed briefly.

Current concepts in the surgical management of adolescent idiopathic scoliosis.

Adolescent idiopathic scoliosis (AIS) is a complex 3D deformity of the spine. Its prevalence is between 2% and 3% in the general population, with almost 10% of patients requiring some form of treatment and up to 0.1% undergoing surgery. The cosmetic aspect of the deformity is the biggest concern to the patient and is often accompanied by psychosocial distress. In addition, severe curves can cause cardiopulmonary distress. With proven benefits from surgery, the aims of treatment are to improve the cosmetic and functional outcomes. Obtaining correction in the coronal plane is not the only important endpoint anymore. With better understanding of spinal biomechanics and the long-term effects of multiplanar imbalance, we now know that sagittal balance is equally, if not more, important. Better correction of deformities has also been facilitated by an improvement in the design of implants and a better understanding of metallurgy. Understanding the unique character of each deformity is important. In addition, using the most appropriate implant and applying all the principles of correction in a bespoke manner is important to achieve optimum correction. In this article, we review the current concepts in AIS surgery. Cite this article: Bone Joint J 2018;100-B:415-24.

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.

A validation of the Oswestry Spinal Risk Index.

PURPOSE: The purpose of this study was to validate the Oswestry Spinal Risk Index (OSRI) in an external population. The OSRI predicts survival in patients with metastatic spinal cord compression (MSCC). METHODS: We analysed the data of 100 patients undergoing surgical intervention for MSCC at a tertiary spinal unit and recorded the primary tumour pathology and Karnofsky performance status to calculate the OSRI. Logistic regression models and survival plots were applied to the data in accordance with the original paper. RESULTS: Lower OSRI scores predicted longer survival. The OSRI score predicted survival accurately in 74% of cases (p = 0.004). CONCLUSIONS: Our study has found that the OSRI is a significant predictor of survival at levels similar to those of the original authors and is a useful and simple tool in aiding complex decision making in patients presenting with MSCC.

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.

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

Anterior cruciate ligament insufficiency: does delay in index surgery affect outcome in recreational athletes.

The aim of the study was to see if delay in anterior cruciate ligament (ACL) reconstruction affects post-reconstruction outcome in recreational athletes. Sixty-two recreational athletes who had arthroscopic ACL reconstructions using quadruple hamstring grafts between 1997 and 2000 were retrospectively evaluated. Patients with less than 2 years' follow-up, those with multi-ligament injuries, reconstructions for previous failed repairs, those whose injury date was unknown, those with pre-injury Tegner activity level greater than 7 (competitive athletes) and those lost to follow-up were all excluded. Forty-six patients (38 males) were entered. The mean follow up was 38 months and the mean time from injury to index ACL reconstruction was 27 months. Apart from two revisions there were no other significant complications. Forty-one (89%) patients were evaluated in a review clinic. There was a significant improvement in the post-reconstruction Lysholm scores and an improvement in the Tegner scores. The Spearman's correlation coefficient between postoperative Lysholm score and the delay until surgery was -0.18 and the correlation coefficient between postoperative Tegner scores and the delay until surgery was 0.14. Thirty-five patients returned to sporting activity. Thirty-seven rated their knee as being normal or nearly normal and 35 said that their knee function was as they had expected it to be. Late ACL reconstruction does not adversely affect the outcome in recreational athletes. ACL reconstruction should be offered to these patients as there is a significant improvement in the knee function and patients are satisfied with the results.

Fractures of the distal third of the clavicle treated by hook plating.

We retrospectively assessed the union and shoulder function following hook plate fixation in 18 patients with Neer type 2 fractures of the lateral end of the clavicle. The average age was 40 (range 22-62) years, and the mean follow-up was 25 (range 6-48) months. Fifteen patients had acute fractures and the rest were non-unions. Complications included two non-unions, one following a deep infection. There were no iatrogenic fractures. Acromial osteolysis was seen in five patients who had their plates in situ. The average pain score at rest was 1 (range 0-4), and the average pain score on abduction was 2.2 (range 0-5). The average Constant score was 88.5 (range 63-100). Patients were asked to rate their shoulder function; three rated it as normal, 11 as nearly normal and one as not normal. Hook plate fixation appears to be a valuable method of stabilising Neer type 2 fractures of the clavicle, resulting in high union rates and good shoulder function. These plates need to be removed after union to prevent acromial osteolysis.

Scaphoid non-union: the role of vascularized grafting in recalcitrant non-unions of the scaphoid.

Achieving union using conventional grafts has a high chance of failure in patients with recalcitrant non-union (persistent pseudarthrosis) of the scaphoid bone, an avascular proximal fragment and previous failed surgeries because of poor host bed vascularity. Eleven patients with long-standing non-union were treated with vascularized pedicle bone grafting and supplementary corticocancellous grafting. Five had screw fixation and six were fixed with K-wires. The average age of the patients was 28 years, average duration of the non-union was 39 months and mean radiological follow-up was 32 months. There were no significant skeletal complications, although two patients developed neuromata. At review, only six of the 11 non-unions were united. Whilst this is a difficult clinical problem and achieving union is a formidable challenge, we believe that there is a role for such extensive surgery in order to achieve good postoperative function.

In scaphoid non-union, does the source of graft affect outcome? Iliac crest versus distal end of radius bone graft.

Iliac crest bone grafts are sometimes preferred to other bone grafts for the treatment of non-unions of fractures of the scaphoid as they are claimed to have better osteogenic potential and biomechanical properties. We retrospectively studied a consecutive cohort of 68 symptomatic established scaphoid non-unions treated by bone grafting. An iliac crest graft was used in 44 cases and a distal radius graft in the other 24. The two treatment groups were comparable in terms of location of the fracture, duration of the non-union and the fixation implants used. Overall union was achieved in 45 of the 68 patients (66%) and the union rate was not influenced by the type of bone graft used. Twenty-nine of the 44 treated with iliac crest bone graft (66%) and 16 of the 24 (67%) treated with distal radial graft united. Donor site pain over the iliac crest was present in nine of the 44 patients in this group.

Wrist fusion versus limited carpal fusion in advanced Kienbock's disease.

We treated 18 patients with advanced Kienbock's disease surgically. Six had total wrist fusions and 12 had limited carpal fusions. The average age was 39.6 yrs and the average follow up was 61.8 months and 66.8 months respectively. The visual analogue pain scores, the patient satisfaction scores and the SF 12 were better in the total wrist fusion group. The DASH (Disabilities of the Arm, Shoulder and Hand) scores, the range of movement and the grip strengths were better in the limited carpal fusions group but this was not statistically significant. Four patients with limited carpal fusions had a non-union that required revising. We believe that total wrist fusion should be offered earlier to patients with advanced stages of the disease, as there are less surgical failures, more satisfied patients, better post operative pain scores and consistent long-term results with less potential for further deterioration with time as compared to other treatment methods.

Post-operative hyponatraemia in orthopaedic injury.

Post-operative hyponatraemia can be dangerous and can go unrecognised as the presenting signs and symptoms are often confused with post-operative or post-anaesthesia sequelae. Infusion of dextrose containing fluids in the peri-operative period is a well-documented cause of this electrolyte imbalance. We conducted a retrospective study to identify the incidence of hyponatraemia following surgery for orthopaedic injury. Medical notes and fluid charts of the patients were scrutinised. We detected 32 cases of post-operative hyponatraemia over a period of 1 year. Eleven hundred and thirty-one patients underwent orthopaedic surgery during this period. Calculated incidence of hyponatraemia was 2.8%. In the hyponatraemic group, the mean pre-operative sodium was 134 mmol/l and mean post-operative sodium was 126 mmol/l. There was a statistically significant difference between mean pre-operative and mean post-operative serum sodium concentration (P<0.0001, two sample t-test). The mean volume of dextrose containing fluids received by each patient was 3.26 l. There is a significant risk of hyponatraemia following orthopaedic surgery, especially in the elderly. Orthopaedic units need to be aware of this easily avoidable condition. Fluid infusion regimes should be carefully formulated with exclusion of dextrose containing fluids to prevent the danger of hyponatraemia.

"Spinolith": case report of a loose body in the spinal canal.

STUDY DESIGN: Case report. A hitherto unreported finding of a bony loose body found lying in the spinal canal causing spinal canal stenosis is presented. SUMMARY OF CLINICAL DETAILS: A 68-year-old, fit man presented with a history of progressive neurologic claudication and neurologic deficit in both his lower limbs. Clinical examination revealed excellent range of movements in his lumbar spine and bilaterally normal straight leg raising. He had no significant pain in his back. Neurologic examination showed affection of L5 and S1 dermatomes and myotomes bilaterally. Magnetic resonance imaging scan showed severe localized lumbar spinal stenosis at L4-L5. In the absence of any obvious pathology on the scan, it was presumed that the stenosis was the result of infolding of the redundant ligamentum flavum. His walking distance and neurologic deficit continued to deteriorate, although sphincters were not involved. He underwent a posterior spinal decompression of L4-L5. On performing the laminectomy an ovoid and well-defined pearly white loose body was discovered lying loose in the spinal canal causing stenosis. Histologically, the loose body consisted of trabecular bone with areas of cartilage. The patient made a speedy recovery after surgery and was back to his previous level of activity within a month. DISCUSSION: Several different types of foreign body have been identified in the spinal canal. However, this case of an autologous loose body in the spinal canal causing symptomatic canal stenosis is unique. Because the authors could not identify the source of this loose body, they have termed it "spinolith."

Acrosome intactness and seminal hyaluronidase activity: relationship with conventional seminal parameters.

Seminal hyaluronidase activity was estimated after liquefaction in semen samples of 100 male partners of infertile couples including 16 azoospermic (no spermatozoon) men and 48 fertility proven men by a method based on measurement of the area of digestion of substrate (hyaluronic acid) in agar plate. Semen samples were also evaluated for Acrosomal Intactness (AI) test except the azoospermics of the studied samples. Seminal hyaluronidase activity was completely absent in azoospermic specimens confirming its cellular origin. Seminal hyaluronidase activity was found to be significantly correlated, statistically, with sperm density (r = 0.708, p < 0.001), % motility (r = 0.6478, p < 0.001) and % normal sperm morphology (r = 0.5724, p < 0.001). Acrosomal Intactness (AI) test scores were also well correlated with sperm density (r = 0.6477, p < 0.001), % motility (r = 0.5965, p < 0.001) and % normal morphology (r = 0.6237, p < 0.001). Both values were higher in semen samples with normal routine parameters (proven fertility and normozoospermic infertile groups) than those compared with abnormal routine parameters (oligozoospermic). We also found very highly significant correlation (r = 0.8442) between seminal hyaluronidase activity and Acrosomal Intactness scores, statistically (p < 0.001). This could be because; normal germinal semineferous epithelium generates abundant number of sperms with normal motility and morphology that are also having intact acrosome. Intact acrosome prevents loss of acrosomal enzymatic activity (e.g. hyaluronidase) until released after liquefaction during seminal analysis and during acrosomal reaction in female genital tract prior to fertilization. Seminal hyaluronidase activity, thus determined, is primarily dependent upon the intact status of acrosome. As each sperm contributes to the seminal hyaluronidase activity, it is directly correlated with sperm density; but at the same time it exhibits goods correlation with % motility and % normal morphology. Therefore AI score and seminal hyaluronidase activity can be considered as good indicators of sperm function.