Reverse total shoulder arthroplasty pain and function: new perspectives from a 10-year multicenter study at the 7-year follow-up.

BACKGROUND: Reverse total shoulder arthroplasty (RTSA) can decrease shoulder pain and improve function. However, results reportedly deteriorate as patients approach mid-term follow-up and little is known about how this impacts physical health-related quality of life (PHRQOL) and mental health-related quality of life (MHRQOL). The study hypothesis was that shoulder function, pain, and medication use for pain would influence PHRQOL and MHRQOL. METHODS: This prospective cohort study involving subjects from 6 orthopedic clinics and 12 fellowship-trained surgeons evaluated the influence of RTSA on PHRQOL, MHRQOL, shoulder function, pain, instability, and medication use over the initial 7 years of a 10-year study, and device survivorship and revision rates. Clinical examination, the American Shoulder and Elbow Surgeons (ASES) score, Short Form (SF)-12 PHRQOL and MHRQOL assessments, the single assessment numeric shoulder function evaluation (SANE), visual analog scale (VAS) shoulder pain and instability scores, shoulder pain, medication use for pain, surgery satisfaction, survivorship and revision rate data were collected pre-RTSA, and at 6-week, 6-month, 1-year, 2-year, 3-year, 5-year, and 7-year follow-ups. RESULTS: Two hundred participants (108 female) of 69 ± 8.3 years of age, with gross rotator cuff deficiency (poor tissue quality or impaired dynamic stability) (n = 92), glenohumeral joint osteoarthritis (n = 88), failed primary total shoulder arthroplasty (n = 8), non-united humeral head fracture (n = 6) or 3-4 section comminuted humeral head fracture (n = 6) underwent pre-RTSA evaluation. Device survivorship was 94%. Friedman two-way ANOVA and Wilcoxon test pairwise comparisons revealed that compared to pre-RTSA, median active shoulder flexion (+ 25°) and external rotation (+ 10°) mobility improved by 6 months (p < 0.0001) and remained improved. Shoulder flexion (+ 1 grade), abduction, external rotation (+ 0.5 grade), and internal rotation strength (+ 1 grade) also improved by 6 months (p < 0.0001) and remained improved. ASES (+ 26.8), SANE (+ 17.5) and VAS pain (- 5.7) scores improved by 6 weeks (p < 0.0001) and remained improved, as medication use for shoulder pain decreased (- 24.6%) (p < 0.0001). SF-12 PHRQOL scores improved by 6 months (+ 11.5) and remained improved (p < 0.0001). Significant Spearman Rho correlations were observed between shoulder function (ASES or SANE) and SF-12 PHRQOL (r ≥ 0.52) and MHRQOL (r ≥ 0.20) scores (p < 0.0001) supporting the relationship between shoulder function and quality of life. Trend analysis revealed changing shoulder function, pain, and PHRQOL relationships between 2 and 3 years, and 5 and 7 years post-RTSA (Chi-Square, p < 0.05). CONCLUSION: Excellent device survival and good-to-excellent perceived shoulder function, and PHRQOL improvements were observed. Secondary objectives of improved shoulder mobility, strength, pain and instability were also achieved. In contrast to previous reports, subjects did not display shoulder mobility or perceived function deterioration by the 7-year follow-up. Following chronic pain relief at 6 weeks post-RTSA, subjects appear to balance PHRQOL and shoulder pain relationships at the 6-month and 1-year post-RTSA follow-ups. Careful evaluation at this time may help patients with higher pain levels and lower function expectations reverse these trends, or patients with lower pain levels and higher function expectations to optimize RTSA use and longevity.

Radiological outcomes following surgical fixation with wires versus moulded cast for patients with a dorsally displaced fracture of the distal radius: a radiographic analysis from the DRAFFT2 trial.

Aims: The primary aim of this study was to report the radiological outcomes of patients with a dorsally displaced distal radius fracture who were randomized to a moulded cast or surgical fixation with wires following manipulation and closed reduction of their fracture. The secondary aim was to correlate radiological outcomes with patient-reported outcome measures (PROMs) in the year following injury. Methods: Participants were recruited as part of DRAFFT2, a UK multicentre clinical trial. Participants were aged 16 years or over with a dorsally displaced distal radius fracture, and were eligible for the trial if they needed a manipulation of their fracture, as recommended by their treating surgeon. Participants were randomly allocated on a 1:1 ratio to moulded cast or Kirschner wires after manipulation of the fracture in the operating theatre. Standard posteroanterior and lateral radiographs were performed in the radiology department of participating centres at the time of the patient's initial assessment in the emergency department and six weeks postoperatively. Intraoperative fluoroscopic images taken at the time of fracture reduction were also assessed. Results: Patients treated with surgical fixation with wires had less dorsal angulation of the radius versus those treated in a moulded cast at six weeks after manipulation of the fracture; the mean difference of -4.13° was statistically significant (95% confidence interval 5.82 to -2.45). There was no evidence of a difference in radial shortening. However, there was no correlation between these radiological measurements and PROMs at any timepoint in the 12 months post-injury. Conclusion: For patients with a dorsally displaced distal radius fracture treated with a closed manipulation, surgical fixation with wires leads to less dorsal angulation on radiographs at six weeks compared with patients treated in a moulded plaster cast alone. However, the difference in dorsal angulation was small and did not correlate with patient-reported pain and function.

Safety and Cost-Effectiveness of Interscalene Brachial Plexus Block With Sedation in Reverse Total Shoulder Replacement.

Aims To investigate the safety and cost-effectiveness of interscalene brachial plexus block/regional anaesthesia (ISB-RA) in patients undergoing reverse total shoulder replacement. Patients and methods This retrospective study included 15 patients with symptomatic rotator cuff arthropathy who underwent reverse total shoulder arthroplasty (rTSA) under ISB-RA without general anaesthesia in the beach chair position from 2010 to 2018. The mean patient age was 77 years (range 59-82 years). Patients had associated medical comorbidities: American Society of Anesthesiologists (ASA) grade 2-4. Assessed parameters were: duration of anaesthesia, intra-operative systolic blood pressure variation, sedation and vasopressor use, duration of post-operative recovery, recovery scores, length of stay, and complications. A robust cost analysis was also performed. Results The mean (range) duration of anaesthesia was 38.66 (20-60) min. Maximum and minimum intra-operative systolic blood pressure ranges were 130-210 and 75-145 mmHg, respectively (mean [range] drop, 74.13 [33-125] mmHg). Mean (range) propofol dose was 1.74 (1-3.0) mg/kg/h. The Median (interquartile range) post-operative recovery time was 30 (20-50) min. The mean (range) postoperative recovery score (local scale, range 5-28 where lower values are superior) was 5.2 (5-8). The mean (range) length of stay was 8 (1-20 days); the two included patients with ASA grade 2 were both discharged within 24 hours. One patient with predisposing history developed pneumonia; however, there were no complications related to ISB-RA. The mean (range) cost per patient was £101.36 (£59.80-£132.20). Conclusions Our data demonstrate that rTSA under ISB-RA is safe, comfortable, and cost-effective. Notably, patients with ASA grade 2 who underwent rTSA under ISB-RA had a reduced length of stay and were discharged within 24 hours. Clinical relevance  rTSA under ISB-RA is potentially a safe, cost-effective, and viable alternative for patients with multiple comorbidities.

Digital tourniquets: a comparative analysis of pressures and pain perception.

Digital tourniquets have been condemned because of the reported occurrence of neurovascular complications. This study compares the pressures and pain perception between three different tourniquets, namely the rubber glove finger stall, Foley's urinary catheter and the commercial band tourniquet. The subjects involved were 20 volunteers with 80 fingers studied in total. A direct pressure measuring technique was used. The pressures recorded were highest and most variable with the catheter tourniquet, whereas the rubber glove tourniquet recorded the lowest pressures. Correspondingly, visual analogue scale in relation to patient discomfort showed high scores with the catheter tourniquet and low scores with the rubber glove tourniquet. We conclude that catheter tourniquet use should be avoided as it generates extreme and variable pressures, whereas rubber glove finger stall tourniquets appear as a better alternative.

Anatomic variations in the long head of biceps: contribution to shoulder dysfunction.

The long head of the biceps (LHB) is a subject of interest to shoulder surgeons and physiotherapist alike. Since the advent of shoulder arthroscopy, knowledge of and interest in the LHB has increased. We discuss the current knowledge on anatomic variants of the LHB. Several cadaveric studies have refined the standard textbook description of the LHB origin, showing that it originates from the superior glenoid labrum and the supraglenoid tubercle. These studies have provided important information for the assessment of the LHB, guiding the treatment of lesions such as superior labral anterior posterior (SLAP) tears. Described variants to the anterosuperior glenoid labrum should be noted, from the superior sublabral recess to the Buford complex. Congenital absence of the LHB should be appreciated. Only 4 previous cases have been reported. We have experience in treating 3 further cases. Further information on the function of the LHB has been gleaned from electomyographic, cadaveric, and clinical studies. These have shown that it has a role in stabilizing the humeral head. It has been stated that it may have a proprioceptive function. Classification systems for symptomatic LHB lesions and congenital absence of the LHB tendon are proposed. The management of LHB lesions is also discussed.

Hidradenoma masquerading digital ganglion cyst: A rare phenomenon.

INTRODUCTION: Mucous cyst is the commonest soft tissue tumor in the dorsum of the distal interphalangeal joint (DIPJ) of the finger. We report the first case of a recurring eccrine tumor (nodular hidradenoma), mimicking a mucous/ganglion cyst, on the dorsum of the DIPJ. CASE REPORT: A 54 year old man presented with painless, hemispherical, colored swelling on the dorsum of his right middle finger (dominant hand), which appeared to have recurred from a previous surgery. The lesion was excised and operative findings from the medical notes showed the gross appearance to be a soft, white, glistening, smooth-surfaced, myxoid nodule resembling a "ganglion cyst". Immunohistochemistry showed the tumour to be positive for S100, smooth muscle actin and cytokeratin 7. Ductal differentiation was confirmed by staining for epithelial membrane antigen and carcinoembryonic antigen. The histological features were that of atypical and solid cystic hidradenoma. DISCUSSION: This is the first reported case of this rare tumour presenting as mucous cyst. We conduct a review of the literature of nodular hidradenomas, illustrating the immunohistologic findings in this tumour to emphasise the atypical features.We emphasise the importance of considering hidradenoma in the differential diagnosis of such lesions of the finger, in view of its high recurrence rate and the possibility of malignant transformation.

Complex shoulder girdle injuries following mountain bike accidents and a review of the literature.

BACKGROUND: Mountain and road bike accidents are particularly common with the increased popularity of the sport. We reviewed the attendances in our emergency department over a 4-year period looking at cycling injuries to detect the level and grade of these injuries and their outcomes. METHOD: Royal Blackburn Hospital caters for a population of 550 000. A search through the Hospital information system revealed 104 patients with fractures following mountain bike injuries. These were looked at in more detail. We present a series of 5 severe shoulder girdle injuries following mountain bike accidents in this cohort, to highlight the serious level of injury sustained in this sport. We searched MEDLINE and EMBASE databases over the past 10 years using the keywords, mountain, biking and fracture. This yielded 7 papers. We compared our series with the literature. RESULTS: 104 fractures following mountain bike accidents between 2008 and 2011. Fractures of the upper limb were the most common (88.5%) with the clavicle being the most commonly fractured bone (28.8%). CONCLUSIONS: Major scapular injuries with destruction or disruption of the four bar linkage of the shoulder girdle are very common following mountain accidents. Clavicular fractures are the commonest upper limb injury. It is easy to miss a disruption to the four-bar linkage associated with a clavicular injury. This paper highlights the severity of the injuries sustained in mountain bike accidents of the upper limb and requirement of adequate protection in this exhilarating sport.