Optimizing Oxford Shoulder Scores with computerized adaptive testing reduces redundancy while maintaining precision.

Aims: The Oxford Shoulder Score (OSS) is a 12-item measure commonly used for the assessment of shoulder surgeries. This study explores whether computerized adaptive testing (CAT) provides a shortened, individually tailored questionnaire while maintaining test accuracy. Methods: A total of 16,238 preoperative OSS were available in the National Joint Registry (NJR) for England, Wales, Northern Ireland, the Isle of Man, and the States of Guernsey dataset (April 2012 to April 2022). Prior to CAT, the foundational item response theory (IRT) assumptions of unidimensionality, monotonicity, and local independence were established. CAT compared sequential item selection with stopping criteria set at standard error (SE) < 0.32 and SE < 0.45 (equivalent to reliability coefficients of 0.90 and 0.80) to full-length patient-reported outcome measure (PROM) precision. Results: Confirmatory factor analysis (CFA) for unidimensionality exhibited satisfactory fit with root mean square standardized residual (RSMSR) of 0.06 (cut-off ≤ 0.08) but not with comparative fit index (CFI) of 0.85 or Tucker-Lewis index (TLI) of 0.82 (cut-off > 0.90). Monotonicity, measured by H value, yielded 0.482, signifying good monotonic trends. Local independence was generally met, with Yen's Q3 statistic > 0.2 for most items. The median item count for completing the CAT simulation with a SE of 0.32 was 3 (IQR 3 to 12), while for a SE of 0.45 it was 2 (IQR 2 to 6). This constituted only 25% and 16%, respectively, when compared to the 12-item full-length questionnaire. Conclusion: Calibrating IRT for the OSS has resulted in the development of an efficient and shortened CAT while maintaining accuracy and reliability. Through the reduction of redundant items and implementation of a standardized measurement scale, our study highlights a promising approach to alleviate time burden and potentially enhance compliance with these widely used outcome measures.

Surgical management of cubital tunnel syndrome: A systematic review and meta-analysis of randomised trials.

Background: Cubital tunnel syndrome (CUTS) is a common upper limb compression neuropathy with significant consequences when left untreated. Surgical decompression remains gold-standard treatment for moderate to severe disease, however the optimal operative technique remains unclear. This network meta-analysis (NMA) of Level I and II randomised prospective studies aims to discern superiority between open in-situ, endoscopic and anterior transposition (subcutaneous or submuscular techniques) with respect to the primary outcome of response-to-treatment and secondary outcomes which include complications, post-operative chronic pain VAS scale, return to work and re-operation. Methods: This NMA adhered to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. PubMed, Web of Science, Cochrane Central, Science direct and Embase were searched. The MESH database was further searched with the terms 'cubital tunnel' to improve sensitivity of the search. Data pertaining to the primary and secondary outcomes were pooled for NMA. Results: Following abstract and full-text screening, 10 randomised prospective trials were included. There was no statistical difference in the response-to-treatment between the four studied techniques. Endoscopic decompression conferred a significantly higher complication rate compared to open decompression (Odds Ratio [OR], 4.21; 95% CI, 1.22-14.59). Endoscopic decompression had a statistically significant lower risk of post-operative chronic pain compared to open in-situ decompression (OR, 0.03, 95% CI, 0.00-0.32). There were no differences between techniques with respect to return to work or re-operation rates. Conclusion: Response-to-treatment was similar between the four operative techniques for CUTS. Endoscopic decompression was found to be more hazardous when compared to open-in situ decompression but conferred significantly less post-operative chronic pain. There was significant heterogeneity in reported outcomes between the included articles. The authors suggest conducting more high-quality research with standardised outcome reporting to facilitate comparison. Level of evidence ii: Systematic Review and Meta-analysis of Randomised Prospective Trials- Therapeutic study.

Surgical management of SLAP lesions: Which technique has better surgical outcomes?

Background: The gold-standard surgical management for superior labral anterior to posterior (SLAP) lesions is unclear. This meta-analysis compares the outcomes of different surgical SLAP lesion management techniques including labral repair, long head of biceps (LHB) tenodesis and LHB tenotomy with consideration to clinical scores, return to sports, re-operation, range-of-motion and patient satisfaction. Methods: PRISMA guidelines were adhered. Web of Science, PubMed, Cochrane Central, Science direct and EMBASE were searched using relevant keywords. Eligible studies were screened, data extracted and synthesised using Review Manager (Version 5.4.1). Bayesian network meta-analysis (NMA) was conducted. Randomised control and clinical trials regarding SLAP lesion management in patients over 18 years old were included. Studies were excluded if patients had concomitant massive tears of the rotator cuff, Bankart lesions or instability of the shoulder. Results: Patient satisfaction with LHB tenodesis was superior to superior labral repair. No difference was demonstrated with respect to ASES score, pain VAS score, return to sports and pre-injury activities, reoperation rate or range-of-motion. LHB tenodesis and LHB tenotomy show no difference in ASES score or post operative deformity in management of SLAP lesions. Discussion: High-quality, standardised randomised control studies between the different surgical techniques is warranted.

Use of patient reported experience measure and patient reported outcome measures to evaluate differences in surgical or non-surgical management of humeral shaft fractures.

Background: The aim of this study was to evaluate the use of patient reported experience measures (PREMs) in humeral shaft fractures managed with or without surgery against patient reported outcome measures (PROMs). Methods: Adult patients treated for a humeral shaft fracture between June 2015 and August 2017 were included in non-surgery and surgery (early and late surgery) groups. The PREM questionnaire was based on patient and clinician feedback obtained during focus groups and was posted to patients. PROMs included the short form-12 (SF-12) and visual analogue scale (VAS) for pain, stiffness, function and satisfaction. Results: Eighty-one patients responded, 54 patients were treated in a brace and 27 with surgery (13 early, 14 late). There was moderate positive correlation between PREM and VAS satisfaction and function and moderate negative correlation with VAS pain and stiffness. There was also moderate positive correlation between PREM and SF-12 mental and weak positive correlation with SF-12 physical. The late surgery group had poorer PREMs (expectations, p = 0.002 and friends & family test, p = 0.0001) and PROMs (VAS satisfaction, p = 0.005) compared to the early surgery group. Conclusions: PREMs can be used in conjunction with PROMs to improve the patient's quality of care and as a means of identifying, at an early stage, those patients not doing well and to offer surgery.

Distal third clavicle fractures : a nationwide trainee-led collaborative review of current practice.

AIMS: Distal third clavicle (DTC) fractures are increasing in incidence. Due to their instability and nonunion risk, they prove difficult to treat. Several different operative options for DTC fixation are reported but current evidence suggests variability in operative fixation. Given the lack of consensus, our objective was to determine the current epidemiological trends in DTC as well as their management within the UK. METHODS: A multicentre retrospective cohort collaborative study was conducted. All patients over the age of 18 with an isolated DTC fracture in 2019 were included. Demographic variables were recorded: age; sex; side of injury; mechanism of injury; modified Neer classification grading; operative technique; fracture union; complications; and subsequent procedures. Baseline characteristics were described for demographic variables. Categorical variables were expressed as frequencies and percentages. RESULTS: A total of 859 patients from 18 different NHS trusts (15 trauma units and three major trauma centres) were included. The mean age was 57 years (18 to 99). Overall, 56% of patients (n = 481) were male. The most common mechanisms of injury were simple fall (57%; n = 487) and high-energy fall (29%; n = 248); 87% (n = 748) were treated conservatively and 54% (n = 463) were Neer type I fractures. Overall, 32% of fractures (n = 275) were type II (22% type IIa (n = 192); 10% type IIb (n = 83)). With regards to operative management, 89% of patients (n = 748) who underwent an operation were under the age of 60. The main fixation methods were: hook plate (n = 47); locking plate (n = 34); tightrope (n = 5); and locking plate and tight rope (n = 7). CONCLUSION: Our study is the largest epidemiological review of DTC fractures in the UK. It is also the first to review the practice of DTC fixation. Most fractures are being treated nonoperatively. However, younger patients, suffering a higher-energy mechanism of injury, are more likely to undergo surgery. Hook plates are the predominantly used fixation method followed by locking plate. The literature is sparse on the best method of fixation for optimal outcomes for these patients. To answer this, a pragmatic RCT to determine optimal fixation method is required.Cite this article: Bone Jt Open 2022;3(12):953-959.

Midterm results of chronic anterior instability of the sternoclavicular joint managed using a standardized treatment algorithm.

AIMS: There remains a lack of consensus regarding the management of chronic anterior sternoclavicular joint (SCJ) instability. This study aimed to assess whether a standardized treatment algorithm (incorporating physiotherapy and surgery and based on the presence of trauma) could successfully guide management and reduce the number needing surgery. METHODS: Patients with chronic anterior SCJ instability managed between April 2007 and April 2019 with a standardized treatment algorithm were divided into non-traumatic (offered physiotherapy) and traumatic (offered surgery) groups and evaluated at discharge. Subsequently, midterm outcomes were assessed via a postal questionnaire with a subjective SCJ stability score, Oxford Shoulder Instability Score (OSIS, adapted for the SCJ), and pain visual analogue scale (VAS), with analysis on an intention-to-treat basis. RESULTS: A total of 47 patients (50 SCJs, three bilateral) responded for 75% return rate. Of these, 31 SCJs were treated with physiotherapy and 19 with surgery. Overall, 96% (48/50) achieved a stable SCJ, with 60% (30/50) achieving unrestricted function. In terms of outcomes, 82% (41/50) recorded good-to-excellent OSIS scores (84% (26/31) physiotherapy, 79% (15/19) surgery), and 76% (38/50) reported low pain VAS scores at final follow-up. Complications of the total surgical cohort included a 19% (5/27) revision rate, 11% (3/27) frozen shoulder, and 4% (1/27) scar sensitivity. CONCLUSION: This is the largest midterm series reporting chronic anterior SCJ instability outcomes when managed according to a standardized treatment algorithm that emphasizes the importance of appropriate patient selection for either physiotherapy or surgery, based on a history of trauma. All but two patients achieved a stable SCJ, with stability maintained at a median of 70 months (11 to 116) for the physiotherapy group and 87 months (6 to 144) for the surgery group.Cite this article: Bone Jt Open 2022;3(10):815-825.

Floor and ceiling effects in the Oxford Shoulder Score : an analysis from the National Joint Registry.

AIMS: The main objective of this study was to examine whether the Oxford Shoulder Score (OSS) demonstrated floor or ceiling effects when used to measure outcomes following shoulder arthroplasty in a large national cohort. Secondary objectives were to assess its pain and function subscales, and to identify independent predictors for patients achieving a postoperative ceiling score following shoulder arthroplasty. METHODS: Secondary database analysis of the National Joint Registry (NJR), which included 48,270 patients undergoing shoulder arthroplasty, was conducted. The primary outcome measure was the OSS. Secondary outcome measures were the OSS-Function Component Subscale and OSS-Pain Component Subscale. Floor and ceiling effects were considered to be present if > 15% of patients scored either the lowest or highest possible score. Logistic regression analysis was used to identify independent predictors for scoring the highest possible OSS score postoperatively. RESULTS: Preoperatively, 1% of patients achieved the lowest possible OSS score (0) and 0.4% of patients achieved the highest possible score (48). Postoperatively, < 1% of patients achieved the lowest score at all timepoints, but the percentage achieving the highest score at six months was 8.3%, at three years 16.9%, and at five years 17%. Male patients, those aged between 60 and 89 years, and those undergoing an anatomical total shoulder arthroplasty (ATSA) were more likely to contribute to the ceiling effect seen in the OSS questionnaire. Pain and function subscales exhibited greater ceiling effects at three years and five years when compared with the overall OSS questionnaire. Logistic regression analysis showed that sex, procedure type, and preoperative OSS score were independent predictors for scoring the highest possible OSS at years. CONCLUSION: Based on NJR patient-reported outcome measures data, the OSS does not exhibit a ceiling effect at six months, but does at three years and five years, in part due to outcome scores of ATSA. Preoperative OSS, age, male sex, and ATSA are independent predictors of achieving a ceiling score. Cite this article: Bone Joint J 2021;103-B(11):1717-1724.

Biomechanical Comparison of Periprosthetic Femoral Fracture Risk in Three Femoral Components in a Sawbone Model.

BACKGROUND: The increasing use of orthopedic total hip arthroplasty implants has led to a consequent rise in the incidence of associated periprosthetic fractures (PPFs). Analysis of the National Joint Registry data showed the choice of cemented hip stem influenced the risk of a PPF occurring. However, the effect of implant design in relation to the risk of PPFs has not been investigated. METHODS: The main objective is to compare the biomechanics of PPFs as a failure of the Exeter V40, CPT, and DePuy C-Stem stems in a composite Sawbone model to identify whether a difference in the risk of fracture exists between them. Twenty-six Sawbones were divided into 3 groups, cemented with the Stryker Exeter, Zimmer CPT, or DePuy C-Stem and then torqued to fracture. RESULTS: When compared with the Exeter, the CPT- and C-Stem-implanted Sawbone models would sustain PPFs at a statistically significantly lower rotation to failure (20.1° and 26.7° vs 33.6°, P < .01) and torque to failure (124 Nm and 143 Nm vs 174 Nm, P < .01) values. The energy release rate at failure for the Exeter was significantly higher than that for the CPT and C-Stem (61.2 Nm vs 21.8 Nm and 38.6 Nm, P < .01), which led to more comminution. CONCLUSION: The CPT- and C-Stem-implanted femurs, although fracturing earlier, fractured in a simple pattern with less comminution. The differences in stem design mean higher stress at the critical point of failure in the CPT implanted femur compared with the Exeter and DePuy, which is likely the reason behind the observed increased risk of PPFs with the CPT implant.

Cat bite: an injury not to underestimate.

Domestic cat bites are common and are often treated by simple wound care with good outcome. However, delayed presentation may lead to significant morbidity or even mortality. Twenty cases of cat bites to the hand and wrist were retrospectively reviewed between 2014 and 2018. Data included patient demographics, anatomical site of injury, microbiology results, method of treatment and surgical outcome. The subjects were 18 females and two males aged 27-86 years (mean age of 58 years). Eleven patients (Group A) were presented within 48 hours of their injury. Nine patients (Group B) presented later than 48 hours. Of these, 78% (n = 7) underwent multiple operations secondary to septic arthritis, osteomyelitis, necrotising fasciitis and deep collection. Mean length of hospital stay was 3.4 days in Group A, and 9.2 days in Group B, (p < .01). Four patients underwent digital or ray amputations. The index finger was the most common site of injury (45%). Almost 40% of cases had flexor tendon sheath infection of the fingers. Pasteurella species was isolated from 35% of infected wounds. Mean duration of antibiotic treatment and length of hospital stay were significantly longer in Group B (p < .05). Delayed presentation of infected cat bites increased the likelihood of more complicated surgeries such as amputation. Diabetic fingers with established peripheral neuropathy were more likely to undergo amputation. We recommend that any symptomatic cat bites to the upper limb, especially hand and wrist, must be treated promptly, essentially within 48 hours of injury, particularly in immunocompromised population.

The Effect of Extensor Tendon Adhesions on Finger Motion.

PURPOSE: To quantify the amount and pattern of finger range of motion loss at the metacarpophalangeal (MCP), proximal interphalangeal (PIP), and distal interphalangeal (DIP) joints with a simulated extensor tendon adhesion at the level of the proximal phalanx or metacarpal. METHODS: In 10 cadaveric specimens, traction sutures were placed in the forearm extensor digitorum communis and flexor digitorum profundus tendons of the middle and ring fingers. Active motion was simulated by suspending weights from the traction sutures via pulleys. The angles of the MCP, PIP, and DIP joints were measured at the position of maximum flexion and extension. Extensor tendon adhesions were simulated alternately at the proximal phalanx and metacarpal levels of the middle and ring fingers, using suture anchors. Repeat measurements were taken using the same amount of force. RESULTS: There was an average total loss of flexion of 38° and of extension of 6° with a proximal phalanx adhesion, with a greater contribution of flexion loss at the PIP joint. The loss of flexion was 17° and of extension was 50° with a metacarpal adhesion, with a loss of extension mostly at the MCP joint. CONCLUSIONS: The results of this study identified clear patterns of motion loss that are associated with isolated simulated adhesions in different locations along the extensor mechanism. The greatest motion loss occurred at the joint immediately distal to the simulated adhesion. CLINICAL RELEVANCE: Although extrapolation of these findings to clinical relevance remains unclear, the ability to predict the level of adhesion by the pattern of motion restriction may allow for a targeted tenolysis procedure. This would reduce the amount of soft tissue dissection required, which in turn, could be expected to reduce the degree of repeat adhesion formation.