Shoulder instability in military personnel: diagnosis and outcomes of arthroscopic stabilisation.

INTRODUCTION: Shoulder instability is a common problem for military personnel due to the highly physical demands of work and training. This study assessed the pattern of glenoid labrum tears suffered by serving UK military personnel, the reliability of preoperative diagnostic methods (magnetic resonance arthrogram (MRA) vs clinical examination) and, finally, the outcomes of arthroscopic stabilisation in terms of satisfaction, pain, and return to sport and full deployment. METHODS: Retrospective demographic and clinical data were collected for all patients within our unit who underwent arthroscopic shoulder stabilisation between September 2016 and January 2019. Patients underwent clinical examination for instability and subsequent imaging with MRA. For service evaluation, patient-reported outcome measure data and occupational outcome data were gathered preoperatively and postoperatively. RESULTS: 41 military patients with shoulder instability were treated with arthroscopic stabilisation. 24.4% had an isolated anterior tear, and 41.5% had complex two-zone or pan-labral tears identified on arthroscopy. Clinical examination showed higher sensitivity, accuracy and negative predictive value for all labral tear patterns compared with MRA. Mean preoperative Oxford Shoulder Instability Score score was 18.58 (SE ±1.67) and mean postoperative score was 41.5 (SE ±1.13). 82.14% of the patients returned to full deployment during the study period and 85% had returned to sports. CONCLUSION: Complex labral tear patterns are common in military personnel with shoulder instability, and clinical examination appears to be more effective than imaging at predicting injury pattern. Patients respond well to arthroscopic stabilisation with good rates of return to work and sport, regardless of chronicity of injury.

Reconstruction of the glenoid using autologous bone-graft and the SMR Axioma TT metal-backed prosthesis: the first 45 sequential cases at a minimum of two years' follow-up.

AIMS: We present our experience of using a metal-backed prosthesis and autologous bone graft to treat gross glenoid bone deficiency. PATIENTS AND METHODS: A prospective cohort study of the first 45 shoulder arthroplasties using the SMR Axioma Trabecular Titanium (TT) metal-backed glenoid with autologous bone graft. Between May 2013 and December 2014, 45 shoulder arthroplasties were carried out in 44 patients with a mean age of 64 years (35 to 89). The indications were 23 complex primary arthroplasties, 12 to revise a hemiarthroplasty or resurfacing, five for aseptic loosening of the glenoid, and five for infection. RESULTS: Of the 45 patients, 16 had anatomical shoulder arthroplasties (ASA) and 29 had reverse shoulder arthroplasties (RSA). Postoperatively, 43/45 patients had a CT scan. In 41 of 43 patients (95%), the glenoid peg achieved > 50% integration. In 40 of 43 cases (93%), the graft was fully or partially integrated. There were seven revisions (16%) but only four (9%) required a change of baseplate. Four (25%) of the 16 ASAs were revised for instability or cuff failure. At two-year radiological follow-up, five of the 41 cases (11%) showed some evidence of lucent lines. CONCLUSION: The use of a metal baseplate with a trabecular titanium surface in conjunction with autologous bone graft is a reliable method of addressing glenoid bone defects in primary and revision RSA setting in the short term. ASAs have a higher rate of complications with this technique.

The Rockwood classification in acute acromioclavicular joint injury does not correlate with symptoms.

PURPOSE: Rockwood classified acromioclavicular (AC) joint injuries by displacement of the joint on radiographs. This classification has driven the management dogma of acute AC dislocation. The correlation between Rockwood grade and symptoms has not been described in acute injury. This study assesses that relationship. METHODS: This series included 77 patients with acute AC joint injury (<6 weeks), treated between 2006 and 2015. Objective and patient-reported measures enabled correlation between clinical measures and Rockwood grade. RESULTS: The mean age was 32 years (±11.86; range 17-59 years); 88% were male. Forty-four per cent were professional athletes and 43% suffered injury during rugby. The mean time from injury to presentation was 2 weeks (±1.64; range 0-5 weeks). There was poor correlation between Rockwood classification and pain (visual analogue scale) ( rs = 0.05; p = 0.752). Poor correlation was noted between Rockwood grade and functional deficit (elevation ( rs = 0.18; p = 0.275), abduction ( rs = 0.19; p = 0.246) and strength ( rs = 0.09; p = 0.579) vs. contralateral side). Oxford and Constant scores did not correlate with Rockwood grade ( rs = 0.13; p = 0.972 and 0.01; p = 0.448, respectively). CONCLUSION: The Rockwood grade does not correlate with clinical symptoms in acute AC joint injury. Previous evidence demonstrates the Rockwood classification's limitations in predicting the structures injured. Therefore, the reliability of using the Rockwood grade as a decision-making tool in the management of acute AC joint dislocation is unclear.

Displaced intracapsular neck of femur fractures: Outcome of 810 hydroxyapetite coated (HAC) uncemented hemiarthroplasties.

A Cochrane review influenced new NICE guidelines, which recommended surgeons: Offer cemented implants to patients undergoing surgery with arthroplasty. However our trust routinely uses HAC uncemented stem (Taperloc®, Biomet) hemiarthroplasties. A review of a consecutive series of uncemented HAC stem hemiarthroplasties including measures such as intro-operative complications, mortality and revision surgery. Prospectively collected data between January 2008 and June 2014 was used, with medical record and radiographic reviews performed. 810 consecutive Taperloc uncemented hemiarthroplasty with monopolar heads were performed in 763 patients, with a minimum 12 month follow-up (12-90) follow-up. Mean age 83yrs; 71% female. Meantime to operation was 28.5h. 30day mortality: 4.4% (33/763). One year mortality was 11.2% (89/763). 2.5% (20/810) were admitted on a separate admission with the periprosthetic fracture. 0.6% (5/810) were revised to total hip replacement for subsidence and associated pain. Only 1% (8/810) had intraoperative calcar fractures, all of which were treated with intraoperative cabling with no evidence of clinically relevant subsidence or medium term complications requiring revision surgery within a year. To the author's knowledge this is largest outcome series for modern design uncemented hemiarthroplasty. Our study shows comparable data to cemented hemiarthroplasty but no deaths in the first 2days post-op. Our series also demonstrates a well below average mortality figures which are clearly multifactorial but believe uncemented prosthesis play a role. We believe that uncemented proven stem design hemiarthroplasty remains a safe and good surgical option for displaced intracapsular fractures.

Freehand 'figure 4' technique for tibial intramedullary nailing: introduction of technique and review of 87 cases.

Intramedullary nailing of tibial fractures is commonplace, and freehand operative techniques are increasingly popular. The standard freehand method has the knee of the injured leg flexed over a radiolucent bolster. This requires the theatre fluoroscope to swing from antero-posterior to lateral position several times. Furthermore, guide wire placement, reaming and nail insertion are all performed well above most surgeons' shoulder height. Alternatively the leg is hung over the edge of the table, and the assistant must crouch and hold the leg until the nail is passed beyond the fracture. We describe a freehand figure 4 position technique for tibial nailing which is easier both for the surgeons and the radiographer, and present a series of 87 consecutive cases utilising this method.

Pre-hospital haemostatic dressings: a systematic review.

BACKGROUND: Uncontrolled haemorrhage is a leading cause of prehospital death after military and civilian trauma. Exsanguination from extremity wounds causes over half of preven military combat deaths and wounds to the anatomical junctional zones provide a particular challenge for first responders. Commercial products have been developed, which claim to outperform standard gauze bandages in establishing and maintaining non-surgical haemostasis. Since 2004, two advanced haemostatic dressing products, HemCon and QuikClot have been widely deployed in military operations. Newer products have since become available which aim to provide more efficient haemostasis than and thus supersede HemCon and QuikClot. AIM: To conduct a systematic review of clinical and preclinical evidence to compare the relative efficacy and safety of available haemostatic products, which are of relevance to pre-hospital military and civilian emergency medical providers. METHOD: An English language literature search was performed, using PubMed and Web of Knowledge Databases, with cross-referencing, focussed product searches and communication with product manufacturers. For studies employing animal models, the injury model was required to produce fatal haemorrhage. Products were categorised by primary mode of action as either factor concentrators,mucoadhesive agents or procoagulant supplementors. RESULTS: From 60 articles collated, 6 clinical papers and 37 preclinical animal trials were eligible for inclusion in this review. Products have been tested in three different types of haemorrhage model: low pressure, high volume venous bleeding, high pressure arterial bleeding and mixed arterial-venous bleeding. The efficacy of products varies with the model adopted. Criteria for the 'ideal battle field haemostatic dressing' have previously been defined by Pusateri, but no product has yet attained suchstatus. Since 2004, HemCon (a mucoadhesive agent) and QuikClot (a factor concentrator) have been widely deployed by United States and United Kingdom Armed Forces; retrospective clinical data supports their efficacy. However, in some recent animal models of lethal haemorrhage, WoundStat(mucoadhesive), Celox (mucoadhesive) and CombatGauze (procoagulant supplementor) have all outperformed both HemCon and QuikClot products. CONCLUSION: HemCon and QuikClot have augmented the haemostatic capabilities of the military first aid responder, but newer products demonstrate potential to be more effective and should be considered as replacements for current in service systems. These products could have utility for civilian pre-hospital care.

A follow-up survey of alcohol consumption and knowledge in medical students.

We surveyed a medical school's students' drinking habits and knowledge 12 years after a previous survey. In this current survey from two academic years, final year students drank less than second year students did. Women in their second year drank as much as men. Overall, 28% of students drank more than the safe limits; 27% of students were problem drinkers, as measured by the CAGE questionnaire, and 52%, as measured by the AUDIT questionnaire. The proportion of students not drinking any alcohol rose from 6% in the previous survey to 27% in the current survey, possibly due to context and demographic changes. In spite of this difference, there have been no statistically significant reductions in either unsafe drinking levels or CAGE scores over 12 years. A third of students overestimated the safe levels of drinking. All medical schools should write and implement an alcohol policy.