Validation of the Radiographic Union Score for HUmeral fractures (RUSHU): A retrospective study in an independent centre.

Background: Early diagnosis and fixation of fractures unlikely to unite can prevent months of morbidity. The Radiographic Union Score for Humeral fractures (RUSHU) is a summative scoring system developed to aid identification of patients at higher risk of developing humeral shaft non-union. Plain radiographs taken six weeks after injury are given a score between four and 12 based on signs of union. Our aim was to assess the validity of the RUSHU prognostic model in an external population. Methods: The radiographs of fifty-seven patients were scored independently according to RUSHU methodology by three reviewers (blinded to patient outcome). Interobserver intraclass correlation (ICC) was calculated. Results: Of the cohort, six (10.5%) progressed to non-union after six months. We observed an interobserver ICC co-efficient of 0.89 (95%CI0.84,0.93) in RUSHU score at six weeks. Median score was significantly higher in the union cohort (10v5 p < 0.001). Using the score of < 8 to predict non-union gave an area under the ROC curve of 0.87 (95%CI 0.83,0.90). Conclusions: In this retrospective single-centre study, we have demonstrated good inter-rater reliability. We would suggest that the RUSHU model be assessed in further external validation studies. RUSHU has the potential to reduce morbidity of delayed treatment of non-union.

Introducing A Day-Case Shoulder Arthroplasty Pathway In The UK - How We Did It.

Background: As the demand for elective orthopaedics grows, day-case arthroplasty is gaining popularity. The aim of this study was to create a safe and reproducible pathway for day-case shoulder arthroplasty (DCSA) based upon a literature review and discussion with the local multidisciplinary team (MDT). Methods: A literature review was performed using OVID MEDLINE and Embase databases reporting 90-day complication and admission rates following DCSA. Minimum follow-up was 30 days. Day-case was defined as discharge on the same day of surgery. Results: The literature review revealed a mean 90-day complication rate of 7.7% [range, 0-15.9%] and mean 90-day readmission rate of 2.5% [range 0-9.3%]. A pilot protocol was devised based upon the literature review and consisted of 5 phases: (1) pre-operative assessment, (2) intra-operative phase, (3) post-operative phase, (4) follow-up, and (5) readmission protocol. This was presented, discussed, amended, and ultimately ratified by the local MDT. In May 2021 the unit successfully completed its first day-case shoulder arthroplasty. Discussion: This study proposes a safe and reproducible pathway for DCSA. Patient selection, well-defined protocols and communication within the MDT are important factors to achieve this. Further studies with extended follow-up will be needed to gauge long-term success within our unit.

Non-operative management of distal humerus fractures in the elderly: a review of functional outcomes.

Comminuted distal humerus fractures in the elderly have traditionally been managed by ORIF or total elbow arthroplasty (TEA). This poses a treatment dilemma in elderly patients where anaesthetic and surgical risks combine with poor bone and wound healing. We aimed to assess the functional outcomes in patients managed non-operatively, with TEA being used as the salvage procedure. Retrospective analysis of patients over 65 years presenting to our unit between 2005 and 2015 was undertaken. Sixty-two patients were identified, 38 had died, and 5 were lost to follow-up leaving 5 with immediate TEA and 14 non-operatively managed, available for review. Mean follow-up was 55 months (range 17-131). Patient outcomes were measured using VAS scores for pain at rest and during activity, and the Oxford elbow score (OES) for TEA and non-operatively managed patients. Conversion to TEA for non-operative treatment and complications were also recorded. Notes interrogation of patients who had died or were lost to follow-up to ascertain outcomes was undertaken. The mean age at injury was 76 years (range 65-90) of which 79% (11/14) were females. The mean score on the OES was 46.2 (range 29-48). The mean VAS score at rest was 0.4 (range 0-6), and the mean VAS score during activity was 1.3 (range 0-9). 93% (13/14) of patients reported no pain in their injured elbow at rest and 79% (11/14) reported no pain during activity. No patients converted to TEA, and there were no complications. Of deceased patients, notes demonstrated one who had ongoing stiffness after physiotherapy, but no conversions to TEA were undertaken. Those managed primarily with TEA had worse OES (mean 40.8), but slightly better pain scores with means 0.2 at rest and 0.8 at activity. Non-operative management of comminuted distal humerus fractures should be considered for elderly patients, avoiding surgical risks whilst giving satisfactory functional outcomes in this low-demand group.

The Latarjet Procedure For Anterior Shoulder Instability : A Consecutive Prospective Series Of 50 Cases.

The Latarjet is a successful primary and revision option for anterior shoulder instability. However, recent reports have highlighted varying complication rates. Our study prospectively collected clinical, functional and radiological outcomes of patients undergoing the procedure. Forty-eight consecutive patients (fifty shoulders) underwent the Latarjet procedure in a single UK centre. Clinical, radiological and functional follow-up was performed. Mean clinical follow-up was 32 months and radiological follow-up 20 months. 95% shoulders were subjectively graded "excellent" or "good" and 5% "fair". Mean Rowe, Oxford Shoulder Instability Score, American Shoulder and Elbow selfassessment Score and Subjective Shoulder Value Score all improved post-operatively (p<0.001). No infections, dislocations, revisions or metalworkrelated complications occurred. There was one intra-operative coracoid fracture and five transient neurological injuries, resolving within three months. The long-term complication rate was 2%. The Latarjet procedure is safe and reliable for treating anterior shoulder instability with a very low long-term complication rate providing excellent clinical and functional outcomes.

Validation of the updated ArthroS simulator: face and construct validity of a passive haptic virtual reality simulator with novel performance metrics.

PURPOSE: To assess the construct and face validity of ArthroS, a passive haptic VR simulator. A secondary aim was to evaluate the novel performance metrics produced by this simulator. METHODS: Two groups of 30 participants, each divided into novice, intermediate or expert based on arthroscopic experience, completed three separate tasks on either the knee or shoulder module of the simulator. Performance was recorded using 12 automatically generated performance metrics and video footage of the arthroscopic procedures. The videos were blindly assessed using a validated global rating scale (GRS). Participants completed a survey about the simulator's realism and training utility. RESULTS: This new simulator demonstrated construct validity of its tasks when evaluated against a GRS (p ≤ 0.003 in all cases). Regarding it's automatically generated performance metrics, established outputs such as time taken (p ≤ 0.001) and instrument path length (p ≤ 0.007) also demonstrated good construct validity. However, two-thirds of the proposed 'novel metrics' the simulator reports could not distinguish participants based on arthroscopic experience. Face validity assessment rated the simulator as a realistic and useful tool for trainees, but the passive haptic feedback (a key feature of this simulator) is rated as less realistic. CONCLUSION: The ArthroS simulator has good task construct validity based on established objective outputs, but some of the novel performance metrics could not distinguish between surgical experience. The passive haptic feedback of the simulator also needs improvement. If simulators could offer automated and validated performance feedback, this would facilitate improvements in the delivery of training by allowing trainees to practise and self-assess.

Extracorporeal shockwave therapy (ESWT) for refractory Achilles tendinopathy: A prospective audit with 2-year follow up.

BACKGROUND: Achilles tendinopathy (AT) represents a triad of tendon pain, swelling and impaired performance. Extracorporeal shockwave therapy (ESWT) has been endorsed by the National Institute for Health and Care Excellence (NICE) for refractory AT. This audit investigates the long-term outcomes of patients treated with ESWT for refractory AT. METHODS: Forty-six patients treated with ESWT for AT between October 2010 and August 2011 completed visual analogue, satisfaction scores and functional assessment questionnaires over two years. Patients were subdivided into two groups depending on whether their AT was insertional (IAT) or non-insertional (NAT). RESULTS: Forty-six patients (mean age 58 years) completed all treatments and full 2 year follow up. There was significant improvement in pain at rest, on activity and of function within both NAT and IAT groups over the two-year period. Satisfaction scores were significant in the NAT group but not in the IAT group. CONCLUSIONS: ESWT appears to be of benefit in the long term improvement of pain at rest, on activity and functional outcome in patients with refractory AT. However, subjective patient opinion may not match the perceived clinical outcome observed in this audit in all patients and individuals should be counselled regarding this prior to treatment.

Interobserver Variability in Injury Severity Scoring After Combat Trauma: Different Perspectives, Different Values?

BACKGROUND: Anatomic measures of injury burden provide key information for studies of prehospital and in-hospital trauma care. The military version of the Abbreviated Injury Scale [AIS(M)] is used to score injuries in deployed military hospitals. Estimates of total trauma burden are derived from this. These scores are used for categorization of patients, assessment of care quality, and research studies. Scoring is normally performed retrospectively from chart review. We compared data recorded in the UK Joint Theatre Trauma Registry (JTTR) and scores calculated independently at the time of surgery by the operating surgeons to assess the concordance between surgeons and trauma nurse coordinators in assigning injury severity scores. METHODS: Trauma casualties treated at a deployed Role 3 hospital were assigned AIS(M) scores by surgeons between 24 September 2012 and 16 October 2012. JTTR records from the same period were retrieved. The AIS(M), Injury Severity Score (ISS), and New Injury Severity Score (NISS) were compared between datasets. RESULTS: Among 32 matched casualties, 214 injuries were recorded in the JTTR, whereas surgeons noted 212. Percentage agreement for number of injuries was 19%. Surgeons scored 75 injuries as "serious" or greater compared with 68 in the JTTR. Percentage agreement for the maximum AIS(M), ISS, and NISS assigned to cases was 66%, 34%, and 28%, respectively, although the distributions of scores were not statistically different (median ISS: surgeons: 20 [interquartile range (IQR), 9-28] versus JTTR: 17.5 [IQR, 9-31.5], p = .7; median NISS: surgeons: 27 [IQR, 12-42] versus JTTR: 25.5 [IQR, 11.5-41], p = .7). CONCLUSION: There are discrepancies in the recording of AIS(M) between surgeons directly involved in the care of trauma casualties and trauma nurse coordinators working by retrospective chart review. Increased accuracy might be achieved by actively collaborating in this process.

Assessing Arthroscopic Skills Using Wireless Elbow-Worn Motion Sensors.

BACKGROUND: Assessment of surgical skill is a critical component of surgical training. Approaches to assessment remain predominantly subjective, although more objective measures such as Global Rating Scales are in use. This study aimed to validate the use of elbow-worn, wireless, miniaturized motion sensors to assess the technical skill of trainees performing arthroscopic procedures in a simulated environment. METHODS: Thirty participants were divided into three groups on the basis of their surgical experience: novices (n = 15), intermediates (n = 10), and experts (n = 5). All participants performed three standardized tasks on an arthroscopic virtual reality simulator while wearing wireless wrist and elbow motion sensors. Video output was recorded and a validated Global Rating Scale was used to assess performance; dexterity metrics were recorded from the simulator. Finally, live motion data were recorded via Bluetooth from the wireless wrist and elbow motion sensors and custom algorithms produced an arthroscopic performance score. RESULTS: Construct validity was demonstrated for all tasks, with Global Rating Scale scores and virtual reality output metrics showing significant differences between novices, intermediates, and experts (p < 0.001). The correlation of the virtual reality path length to the number of hand movements calculated from the wireless sensors was very high (p < 0.001). A comparison of the arthroscopic performance score levels with virtual reality output metrics also showed highly significant differences (p < 0.01). Comparisons of the arthroscopic performance score levels with the Global Rating Scale scores showed strong and highly significant correlations (p < 0.001) for both sensor locations, but those of the elbow-worn sensors were stronger and more significant (p < 0.001) than those of the wrist-worn sensors. CONCLUSIONS: A new wireless assessment of surgical performance system for objective assessment of surgical skills has proven valid for assessing arthroscopic skills. The elbow-worn sensors were shown to achieve an accurate assessment of surgical dexterity and performance. CLINICAL RELEVANCE: The validation of an entirely objective assessment of arthroscopic skill with wireless elbow-worn motion sensors introduces, for the first time, a feasible assessment system for the live operating theater with the added potential to be applied to other surgical and interventional specialties.

Case series of pectoralis major rupture requiring operative intervention sustained on the Royal Marines 'Tarzan' assault course.

We present (with intra-operative imaging) four patients who sustained pectoralis major (PM) ruptures on the same piece of equipment of the 'Tarzan' assault course at the Commando Training Centre, Royal Marines (CTCRM). Recruits jump at running pace, carrying 21 lbs of equipment and a weapon (8 lbs) across a 6-feet gap onto a vertical cargo-net. The recruits punch horizontally through the net, before adducting their arm to catch themselves, and all weight, on their axilla. All patients presented with immediate pain and reduced function. Two had ruptures demonstrated on magnetic resonance imaging, one on an ultrasound scan and one via clinical examination. All four patients were found, at operation, to have sustained type IIIE injuries. All patients underwent PM repair using a unicortical button fixation and had an uneventful immediate postoperative course. Patient 1 left Royal Marines training after the injury (out of choice; not because of failure to rehabilitate). All other patients are under active rehabilitation, hoping to return to training. Review of 10 years of records at CTCRM reveal no documented PM rupture prior to our first case in October 2013. There has been no change to the obstacle or technique used and all patients deny the use of steroids.

The accuracy and reliability of pre-operative templating in revision total knee arthroplasty. A comparison of analogue and digital methods.

AIMS: To determine whether the size of the prostheses used in revision knee arthroplasty may be accurately and reproducibly predicted using analogue or digital pre-operative templating techniques. METHODS: Pre-operative radiographs were templated using analogue radiographs and acetate templates, digital radiographs and acetate templates and digital radiographs and digital templating software. RESULTS: Overall accuracy of predicting the size of implant used at surgery was 44%. There was no significant difference in the accuracy of the various templating techniques (p = 0.098). CONCLUSIONS: Templating in revision knee arthroplasty is neither of suitable accuracy nor reliability enough to safely recommend its use for implant size prediction.

Capstan screw rotator cuff repair: a novel two-row mini-open technique.

BACKGROUND: Prospective data collection occurred between 2000 and 2010 on 143 consecutive patients with symptomatic rotator cuff tears, aiming to examine the end-result of a new technique of mini-open double row repair: the Capstan screw technique. METHODS: All patients had a pre- and postoperative Oxford Shoulder Score (OSS), American Shoulder and Elbow Surgeons (ASES) score and range of movement measurements. All were followed up for a minimum of 1 year with an exit questionnaire. Subscapularis repairs, small (<1 cm) and massive (>5 cm) supraspinatus repairs were excluded. Ninety-nine patients fitted the inclusion and exclusion criteria of whom 87 had a complete data set. RESULTS: The mean (SD) pre-operative OSS was 21.85 (8.6) and the mean (SD) postoperative OSS was 44.58 (5.2) (p < 0.0001). The mean (SD) pre-operative ASES score was 51.5 (19.4) and the mean (SD) postoperative ASES score was 86.42 (17.06) (p < 0.0001). Flexion improved from a mean of 119° to 170° (p < 0.0001). The clinical re-tear rate was 3.4% and the imaged re-tear rate was 6.8%. In total, 91% of patients were satisfied with the procedure. There were no deep infections and two (2%) minor wound infections. There was no single instance of deltoid dysfunction. CONCLUSIONS: The Capstan screw technique represents a simple, rapid, strong and reliable mini-open technique.

Judet osteoperiosteal decortication for treatment of non-union: the Cornwall experience.

BACKGROUND: The treatment of non union can be challenging with a variety of surgical options available to achieve bone consolidation. Robert Judet first described a method of osteo-periosteal decortication in 1963. He stated that by elevating cortical chips that remain attached to the periosteum and overlying soft tissues surrounding the site of non-union, combined with mechanical support, the bone consolidated. Despite excellent results presented in 2008 of 99% union rates with a mean delay of 8 months, the technique has not yet become popularised. We aim to show that Judet's method of decortication can achieve good results in the management of failure of union in a hospital other than Judet's. METHODS: Retrospective analysis was performed from December 2002 to December 2008 of 40 cases in 39 patients of osteoperiosteal decortication for fracture non-union. Concurrent stabilisation was with internal fixation only. All procedures were performed by one surgeon (MN) using the Judet technique after learning the technique in the originators hospital. A preoperative non union scoring system was also used to assess its use in predicting persistent non-union. RESULTS: Union was successfully achieved in 36 of the 39 surviving cases (92.3%) after a median delay of 8 months (range 3-47, SD 9.2) Twenty-six patients (65%) achieved union following the decortication procedure without subsequent operations. Factors such as open fracture and smoking did not have a statistically significant effect on union. The mean number of procedures following decortication was 0.68 (range 0-4). Metalwork failure occurred in 11 cases (28%), the majority in femoral decortications (n=9, 82%). The femur was the site of all persistent non unions in the series. Three patients had superficial infections and two had deep infections. The pre-operative non union scoring system (0-100) means were noticeably worse for the persistent non union group 42.0 (20-46) compared with the union group 31.0 (range 4-52). CONCLUSIONS: Osteoperiosteal decortication remains a highly effective surgical technique in the management of failed fracture union. The non union scoring system is a reliable predictor of persistent non union after this type of surgery. CLINICAL RELEVANCE: Relevant to general trauma orthopaedic surgeon and specialist orthopaedic surgeons with an interest in fracture non-union.