The role of scapular morphology in traumatic rotator cuff tears and greater tuberosity fractures: A retrospective study.

Background: Traumatic postero-superior Rotator Cuff Tears (RCT) and isolated Greater Tuberosity fractures (GTF) are equivalent injuries resulting in significant shoulder dysfunction if left retracted or displaced. The difference in morphometric aetiology is unclear. A raised critical shoulder angle (CSA) has been associated with rotator cuff degeneration. We hypothesised that traumatic RCT is associated with a raised CSA when compared to GTF. Methods: A retrospective study was conducted across the two trauma units in our institution. All patients between the period of 2010 and 2020 with Traumatic GTF or RCT assessed on cross-sectional imaging (CT or MRI) were identified. Patients were case-matched by age, gender, mechanism and laterality of injury. The primary outcome measurement was the Critical Shoulder Angle (CSA). Other radiographic features of subacromial degenerative change, mechanism of injury, association with shoulder dislocation and delay to diagnosis were also compared. Results: Eighty patients met the inclusion criteria(40 traumatic RCT and 40 GTF). The mean age was 61.8 years with 58(72.5%) left-sided injuries. Thirty-four (43%) were female.The mean CSA was 3.96° higher in the RCT group (95% CI 2.5 to 5.41, p < 0.05). A CSA of 33.73 gave a sensitivity of 0.68 and a specificity of 0.8 to differentiate between RCT and GTF. Patients with RCT were far more likely to display subacromial degenerate changes and experience a significant delay in diagnosis, whereas those with GTF were more likely to have suffered a shoulder dislocation. Conclusions: Patients with traumatic RCT have radiographic features and scapular morphology associated with degenerative rotator cuff disease compared to those with GTF. This supports the theory that tears occur on the background of pre-existing tendon degeneration. Careful assessment of these parameters, combined with clinical assessment, may help guide the provision of appropriate diagnostic imaging. Level of evidence: III.

A lower critical coracoid process angle is associated with type-B osteoarthritis: a radiological study of normal and diseased shoulders.

Background: Degenerative rotator cuff tears and osteoarthritis (OA) are associated with differences in coronal plane scapular morphology, with particular focus on the effect of the critical shoulder angle (CSA) on shoulder biomechanics. The effect, if any, of axial plane scapular morphology is less well established. We have noticed wide disparity of axial coracoid tip position in relation to the face of the glenoid and sought to investigate the significance of this through measurement of the critical coracoid process angle (CCPA), which incorporates coracoid tip position and glenoid version. Methods: CCPA, CSA, and glenoid retroversion were measured by three independent reviewers from the cross-sectional two-dimensional computed tomography (CT) and magnetic resonance imaging of 160 patients in four equal and matched case-control groups: (1) a control group of patients with a radiologically normal shoulder and no history of shoulder symptoms who had a CT thorax for another reason, (2) patients with primary OA with Walch type-A glenoid wear pattern on CT scan, (3) patients with type-B glenoid primary OA, and (4) patients with magnetic resonance imaging-proven atraumatic tears of the posterosuperior rotator cuff. Results: Interobserver agreement was excellent for all measured parameters. The median CCPA was significantly lower in the type-B OA group (9.3˚) than that in controls (18.7˚), but not significantly different in the other study groups. There was a trend toward greater glenoid retroversion in the type-B OA group, but receiver operating characteristic curve analysis demonstrated the CCPA to be by far the most powerful discriminator for type-B OA. The optimal cutoff value was calculated for the CCPA at 14.3˚ with a sensitivity of 93% and specificity of 90% for type-B OA. Compared with controls, the CSA was significantly higher in the rotator cuff tear group and lower in both OA groups, but did not differentiate between type-A and type-B OA. Conclusion: Combined with a lower CSA, a lower CCPA (<14.3˚) is strongly predictive of type-B glenoid OA. The authors propose a simple model of pectoralis major biomechanics to explain the effect of this axial plane anatomical variation, which requires further investigation.

Current concepts in the management of bisphosphonate associated atypical femoral fractures.

Bisphosphonates are a class of drugs used as the mainstay of treatment for osteoporosis. Bisphosphonates function by binding to hydroxyapatite, and subsequently targeting osteoclasts by altering their ability to resorb and remodel bone. Whilst aiming to reduce the risk of fragility fractures, bisphosphonates have been associated with atypical insufficiency fractures, specifically in the femur. Atypical femoral fractures occur distal to the lesser trochanter, until the supracondylar flare. There are a number of the differing clinical and radiological features between atypical femoral fractures and osteoporotic femoral fractures, indicating that there is a distinct difference in the respective underlying pathophysiology. At the point of presentation of an atypical femoral fracture, bisphosphonate should be discontinued. This is due to the proposed inhibition of osteoclasts and apoptosis, resulting in impaired callus healing. Conservative management consists primarily of cessation of bisphosphonate therapy and partial weightbearing activity. Nutritional deficiencies should be investigated and appropriately corrected, most notably dietary calcium and vitamin D. Currently there is no established treatment guidelines for either complete or incomplete fractures. There is agreement in the literature that nonoperative management of bisphosphonate-associated femoral fractures conveys poor outcomes. Currently, the favoured methods of surgical fixation are cephalomedullary nailing and plate fixation. Newer techniques advocate the use of both modalities as it gives the plate advantage of best reducing the fracture and compressing the lateral cortex, with the support of the intramedullary nail to stabilise an atypical fracture with increased ability to load-share, and a reduced bending moment across the fracture site. The evidence suggests that cephalomedullary nailing of the fracture has lower revision rates. However, it is important to appreciate that the anatomical location and patient factors may not always allow for this. Although causation between bisphosphonates and atypical fractures is yet to be demonstrated, there is a growing evidence base to suggest a higher incidence to atypical femoral fractures in patients who take bisphosphonates. As we encounter a growing co-morbid elderly population, the prevalence of this fracture-type will likely increase. Therefore, it is imperative clinicians continue to be attentive of atypical femoral fractures and treat them effectively.

Introduction of an enhanced recovery programme for total shoulder arthroplasty: report of a novel pathway.

BACKGROUND: Enhanced recovery (ER) programmes are well established in hip and knee arthroplasty, but are not yet commonplace for total shoulder arthroplasty (TSA). This study analyses the effect of implementing an ER programme with TSA, on length of stay (LOS), functional outcome and patient satisfaction. LOCAL PROBLEM: No established programme applying ER to the specifics of upper-limb arthroplasty existed at our unit. METHODS: A three-cycle plan-do-study-act quality improvement methodology was applied, involving development of our multifactorial programme, a pilot phase and wider roll-out. A consecutive series of patients who underwent TSA and were enrolled in an ER programme were compared with a matched control group of consecutive patients who underwent TSA in the year before the programme started. For all patients, LOS as well as mean Oxford Shoulder Score (OSS) and Constant Score (CS) were quantified and patient satisfaction assessed. INTERVENTIONS: A dedicated multidisciplinary team led preoperative class involving patient education, advice and occupational therapy assessment. A standardised perioperative anaesthetic regime based on regional anaesthetic techniques with preoperative analgesic and nutritional loading was introduced. Postoperative rehabilitation was also standardised with slings for comfort only and early safe-zone mobilisation. New patient information was developed. RESULTS: 71 patients were included in matched cohorts. Mean LOS was reduced from 2.4 nights to 1.9 nights. The single night stay rate improved from 40% to 49%. Across the ER cohort, 15 less nights were required to complete same volume of surgeries as in the non-ER cohort.Parity in OSS and CS measured at 3 and 12 months after surgery were observed in both cohorts.Satisfaction was already high before ER but scores stayed the same or improved across all areas surveyed.Absolute complication rates of 9.9% in the non-ER group and 7% in the ER group were recorded. CONCLUSION: Our ER programme benefited patients and the Trust by reducing time in hospital and improving patient satisfaction without an adverse effect on complication rate.

Scapular Spine Stress Fracture Following Reverse Total Shoulder Arthroplasty: Successful Management with Low-Intensity Pulsed Ultrasound.

Scapular spine stress fractures are a rare but well-recognised complication following reverse total shoulder arthroplasty (RTSA). They present a challenge with no consensus on management. Both operative fixation and conservative measures are associated with high rates of mal- or non-union and decreased functional outcomes.  We present the case of a 60-year-old female, who presented with a scapular spine fracture one year following RTSA. Treatment consisted of initial immobilisation, physiotherapy and the application of a portable low-intensity pulsed ultrasound (LIPUS) system (EXOGENÒ Ultrasound Bone Healing System, Bioventus, Durham NC, Netherlands). Following a three-month treatment course, there was a significant improvement in patient-reported pain and functional scores (Oxford Shoulder Score from 5/48 to 38/48). Sequential radiographic imaging confirmed fracture union. Clinicians may consider the use of LIPUS therapy as a potential adjunctive treatment modality to promote the union of scapular spine stress fractures following RTSA.

Severe Neurovascular Compromise Associated with Plastic Deformation of Ulna Elastic Nail Following Forearm Re-fracture.

We present a case of periprosthetic re-fracture of the forearm in a child with previous intramedullary elastic nailing of the ulna and plate fixation of the radius for a both-bone forearm fracture. In-situ plastic deformation of the ulna elastic nail resulted in persistent angulation and subsequent severe neurovascular compromise. The angulation was resistant to emergent attempts at closed manipulation and therefore nail removal, open reduction, and internal fixation were performed. At final follow-up, fracture union was demonstrated and there was no residual neurological deficit.

Eight-year follow-up of resurfacing hemiarthroplasty for advanced glenohumeral osteoarthritis following total acromionectomy.

Total acromionectomy is now a largely historical procedure due to a number of biomechanical sequelae caused by defunctioning of the deltoid, although its overall effect on joint kinematics is uncertain. This presents a challenge when considering arthroplasty for subsequent glenohumeral arthritis. We report on successful management of such a case, treated with resurfacing hemiarthroplasty 57 years following acromionectomy. The patient continues to enjoy excellent functional outcome of the shoulder at 8 years after arthroplasty.

Resurfacing hemiarthroplasty of the shoulder for patients with juvenile idiopathic arthritis.

BACKGROUND: This study reports the outcome of resurfacing hemiarthroplasty (RHA) in a cohort of patients with juvenile idiopathic arthritis (JIA) affecting the shoulder joint METHODS: Fourteen uncemented RHA procedures were performed for 11 consecutive patients who required surgery because of JIA. Mean age at surgery was 36.4 years. Mean clinical follow-up was 10.4 years (range, 5.8-13.9 years). A significant humeral head defect (up to 40% surface area) was found in 5 shoulders and filled with autograft from the distal clavicle or femoral head allograft. RESULTS: At latest follow-up, no patient required revision. There was excellent relief from pain. The mean Oxford Shoulder Score and Constant-Murley Score improved significantly. No shoulder had a poor outcome, and 6 had a very good or excellent outcome. Worse outcome was associated with an intraoperative finding of significant humeral head erosion. Two shoulders required early arthroscopic subacromial decompression, but there were no other reoperations. There were no instances of radiographic implant loosening or proximal migration. Painless glenoid erosion was seen in 5 shoulders but was not associated with worse outcome. CONCLUSIONS: The midterm results of RHA for JIA are at least comparable to those for stemmed hemiarthroplasty, with the added benefit of bone conservation.

Linked semiconstrained and unlinked total elbow replacement in juvenile idiopathic arthritis: a case comparison series with mean 11.7-year follow-up.

BACKGROUND: Few series report the results of total elbow replacement (TER) in patients with juvenile idiopathic arthritis (JIA). Most report the use of a linked implant. There are theoretical benefits to using an unlinked prosthesis, and thus we report our experience of the clinical benefit and survivorship of both this implant and a linked semiconstrained prosthesis. METHODS: There were 21 elbows replaced in 14 JIA patients (12 women and 2 men; 14 unlinked, 7 linked). Mean age at surgery was 39.5 years (range, 26-52 years). Mean clinical follow-up was 11.7 years (range, 5.4-17.6 years). RESULTS: Reoperation, including implant revision, was required in 9 elbows (42.9%). Using revision as an end point, survivorship was 95% (95% confidence interval [CI], 74%-99%) at 5 years and 68% (95% CI, 45%-86%) at 10 years. The 10-year survival was 70% (95% CI, 40%-89%) for the unlinked group and 69% (95% CI, 28%-94%) for the linked group. The need for bilateral TER was found to be a risk factor for revision within 10 years of primary surgery (6/11 vs. 0/7 elbows; P = .037). The rate of aseptic loosening seen on radiographs was high in the unlinked group (12/14, 85.7%), but many of these patients continue to function well without need for revision. CONCLUSION: Both the unlinked Kudo 5 and linked Coonrad-Morrey prostheses for TER can provide benefits in the long-term for most patients with JIA. The need for bilateral TER in this group is associated with higher rate of revision at 10 years.

Mental imagery and learning: a qualitative study in orthopaedic trauma surgery.

CONTEXT: Good preparation for surgical procedures has been linked to better performance and enhanced learning in the operating theatre. Mental imagery is increasingly used to enhance performance in competitive sport and there has been recent interest in applying this in surgery. OBJECTIVES: This study aims to identify the mental imagery components of preoperative preparation in orthopaedic trauma surgery and to locate these practices in existing socio-material theory in order to produce a model useful for surgical skills training. METHODS: Semi-structured interviews were conducted with nine orthopaedic surgeons. Participants were identified by personal recommendation as regularly performing complex trauma operations to a high standard, and by affiliation to an international instruction course in trauma surgery. Interviews were audio-recorded and transcripts were independently analysed using thematic analysis. RESULTS: Analysis revealed that surgeons interact intensively with multiple colleagues and materials during their preparatory activities. Such interactions stimulate mental imagery in order to build strategy and rehearse procedures, which, in turn, stimulate preparatory interactions. Participants identified the discussion of a preoperative 'plan' as a key engagement tool for training junior surgeons and as a form of currency by which a trainee may increase his or her participation in a procedure. CONCLUSIONS: Preoperative preparation can be thought of as a socio-material ontology requiring a surgeon to negotiate imaginal, verbal and physical interactions with people, materials and his or her own mental imagery. Actor-network theory is useful for making sense of these interactions and for allowing surgeons to interrogate their own preparative processes. We recommend supervisors to use a form of preoperative plan as a teaching tool and to encourage trainees to develop their own preparatory skills. The ability of a trainee to demonstrate sound preparation is an indicator of readiness to perform a procedure.

Ultrasound for the detection of full-thickness rotator cuff tears: the learning curve for an orthopaedic surgeon using a novel training method.

BACKGROUND: The present study aims to add to the body of evidence delineating the learning curve for a shoulder surgeon to become proficient in focussed ultrasound for the detection of full-thickness rotator cuff tears, as well as to describe a learning method for this skill. METHODS: Consecutive patients who were scheduled to undergo an arthroscopy for rotator cuff disease were scanned immediately before surgery by a senior shoulder surgeon with limited previous experience of shoulder ultrasound. The presence or absence of a full-thickness rotator cuff tear on scan was compared with intra-operative findings as the gold standard. RESULTS: Two hundred and ten shoulders were scanned over three equal learning periods. Comparing predictive values from the first to the third training period, sensitivity improved from 0.86 to 0.95, specificity from 0.92 to 0.98, negative predictive value from 0.94 to 0.98, and positive predictive value from 0.82 to 0.95. CONCLUSIONS: The high predictive values obtained in the present study for surgeon-led detection of cuff tears using ultrasound are comparable with those quoted for musculoskeletal radiologists in the literature. The present study adds evidence that a shoulder surgeon can achieve accelerated learning of this skill and offers some potentially time-saving and patient-friendly alternatives to existing guidelines.

The development and validation of a questionnaire for rotator cuff disorders: The Functional Shoulder Score.

BACKGROUND: The purpose of the present study was to validate the Functional Shoulder Score (FSS), a new patient-reported outcome score specifically designed to evaluate patients with rotator cuff disorders. METHODS: One hundred and nineteen patients were assessed using two shoulder scoring systems [the FSS and the Constant-Murley Score (CMS)] at 3 weeks pre- and 6 months post-arthroscopic rotator cuff surgery. The reliability, validity, responsiveness and interpretability of the FSS were evaluated. RESULTS: Reliability analysis (test-retest) showed an intraclass correlation coefficient value of 0.96 [95% confidence interval (CI) = 0.92 to 0.98]. Internal consistency analysis revealed a Cronbach's alpha coefficient of 0.93. The Pearson correlation coefficient FSS-CMS was 0.782 pre-operatively and 0.737 postoperatively (p < 0.0005). There was a statistically significant increase in FSS scores postoperatively, an effect size of 3.06 and standardized response mean of 2.80. The value for minimal detectable change was ±8.38 scale points (based on a 90% CI) and the minimal clinically important difference for improvement was 24.7 ± 5.4 points. CONCLUSIONS: The FSS is a patient-reported outcome measure that can easily be incorporated into clinical practice, providing a quick, reliable, valid and practical measure for rotator cuff problems. The questionnaire is highly sensitive to clinical change.