Defining tennis elbow characteristics - The assessment of magnetic resonance imaging defined tendon pathology in an asymptomatic population.

Background: This radiological study aims to assess the prevalence of lateral elbow pathology in an asymptomatic population using 3.0T magnetic resonance imaging (MRI). Methods: Bilateral elbow MRI was undertaken in 30 asymptomatic volunteers. Exclusion criteria included elbow pain within 3 months, elbow trauma or previous diagnosis of lateral epicondylar tendinopathy. Baseline patient-reported outcome measures were recorded along with age and body mass index (BMI). Two musculoskeletal radiologists independently graded the degree of abnormality at the common extensor tendon. Results: Thirty volunteers were categorised according to age; 35-44 (n = 10), 45-54 (n = 11), and 55-65 (n = 9) with a 1:1 male-to-female ratio. Radiological evidence of tendon abnormality was found in 37% of volunteers. The proportion with abnormal findings increased with age; 35-44 (10%), 45-54 (36%), 55-65 (67%) and BMI; 18-24.9 (23%), 25-29.9 (43%), > 30 (67%). Changes were generally 'mild' or 'moderate', with a single volunteer showing 'severe' pathology. Kappa for the radiographic agreement was 0.91 (0.83-0.98). Discussion: This study has demonstrated MRI findings suggestive of pathology at the common extensor tendon to be prevalent in an asymptomatic population, increasing with age and BMI. This draws into question the diagnostic and prognostic value of MRI imaging in lateral epicondylar tendinopathy, especially in older patients.

C.acnes in the joint, is it all just a false positive?

BACKGROUND: Cutibacterium Acnes (C.acnes) has been linked to several shoulder pathologies. An alternative hypothesis suggests it only occurs in the joint secondary to previous instrumentation. Our hypothesis was patients with previous instrumentation would have C.acnes in their joint if it was in skin. MATERIALS AND METHODS: Sixty-six patients undergoing arthroscopic shoulder surgery had biopsies taken from the affected joint at the time of surgery, along with control biopsies of subdermal fat. The extended culture results were assessed and correlated to previous intervention. RESULTS: 35% tested positive for C.acnes in their joint. 78% were male. 53% had absence of C.acnes in both skin and joint and 29% had presence in both (p = 0.0001). 15% with previous surgery had C.acnes. 53% with previous injection had C.acnes. 25% of patients with virgin joints had C.acnes. There was no statistical difference in the presence of C.acnes in the joint between those with previous instrumentation and without. CONCLUSION: The significant factors for joint C.acnes were male sex and the presence of the bacteria in the fat. Previous instrumentation was not correlated with C.acnes in the joint. This raises the question of whether the process of biopsy itself may lead to inoculation of the joint.

Hemiarthroplasty or total elbow arthroplasty for unreconstructable distal humeral fractures in patients aged over 65 years : a systematic review and meta-analysis of patient outcomes and complications.

AIMS: Arthroplasty is being increasingly used for the management of distal humeral fractures (DHFs) in elderly patients. Arthroplasty options include total elbow arthroplasty (TEA) and hemiarthroplasty (HA); both have unique complications and there is not yet a consensus on which implant is superior. This systematic review asked: in patients aged over 65 years with unreconstructable DHFs, what differences are there in outcomes, as measured by patient-reported outcome measures (PROMs), range of motion (ROM), and complications, between distal humeral HA and TEA? METHODS: A systematic review of the literature was performed via a search of MEDLINE and Embase. Two reviewers extracted data on PROMs, ROM, and complications. PROMs and ROM results were reported descriptively and a meta-analysis of complications was conducted. Quality of methodology was assessed using Wylde's non-summative four-point system. The study was registered with PROSPERO (CRD42021228329). RESULTS: A total of 29 studies met the inclusion and exclusion criteria. The mean Disabilities of the Arm, Shoulder and Hand questionnaire (DASH) score was 19.6 (SD 7.5) for HA and 38 (SD 11.9) for TEA and the mean abbreviated version of DASH was 17.2 (SD 13.2) for HA and 24.9 (SD 4.8) for TEA. The Mayo Elbow Performance Score was the most commonly reported PROM across included studies, with a mean of 87 (SD 5.3) in HA and 88.3 (SD 5) in TEA. High complication rates were seen in both HA (22% (95% confidence interval (CI) 5 to 44)) and TEA (21% (95% CI 13 to 30), but no statistically significant difference identified. CONCLUSION: This systematic review has indicated PROMs and ROM mostly favouring HA, but with a similarly high complication rate in the two procedures. However, due to the small sample size and heterogeneity between studies, strength of evidence for these findings is low. We propose further research in the form of a national randomized controlled trial. Cite this article: Bone Joint J 2022;104-B(5):559-566.

Mid-term results of Eclipse total shoulder arthroplasty.

AIMS: The use and variety of stemless humeral components in anatomical total shoulder arthroplasty (TSA) have proliferated since their advent in 2004. Early outcomes are reassuring but independent mid-term results are scarce. This independent study reports a consecutive series of 143 Eclipse stemless shoulder prostheses with a minimum five-year (5 to 10) follow-up. METHODS: Outcomes of 143 procedures undertaken for all indications in 131 patients were reviewed, with subset analysis of those for osteoarthritis (OA) (n = 99). The primary outcome was the Oxford Shoulder Score (OSS) at a minimum of five years. Secondary outcomes were ranges of motion and radiological analysis of humeral radiolucency, rotator cuff failure, and glenoid loosening. RESULTS: Mean OSS at mean follow-up of 6.67 years (5.0 to 10.74) was 40.12 (9 to 48), with no statistically significant difference between those implanted for a non-OA indication and those for OA (p = 0.056) or time-dependent deterioration between two years and five years (p = 0.206). Ranges of motion significantly improved compared with preoperative findings and were maintained between two and five years with a mean external rotation of 38° (SD 18.1, 0 to 100) and forward elevation of 152° (SD 29.9, 90 to 180). Of those components with radiographs suitable for analysis (n = 83), 23 (28%) were found to have a least one humeral radiolucent line, which were predominantly incomplete, less than 2 mm, and in a single anatomical zone. No humeral components were loose. A radiolucent line was present around 22 (15%) of glenoid components, and 15 (10%) of components had failed. Rotator cuff failure was found in 21 (15%) components. The mean time to either glenoid or rotator cuff failure was greater than three years following implantation. Survivorship was 96.4% (95% CI 91.6 to 98.5, number at risk 128) at five years, and 94.3% (95% CI 88.2 to 97.3, number at risk 76) at seven years, both of which compare favourably with best results taken from available registries. CONCLUSION: Functional and radiological outcomes of the Eclipse stemless TSA are excellent, with no loose humeral components at minimum five-year follow-up. The presence of radiolucent lines is of interest and requires long-term observation but does not impact on the clinical results. Of the eight revisions required, this was predominantly for glenoid and rotator cuff failure. Cite this article: Bone Joint J 2022;104-B(1):83-90.

The management of the shoulder skin microbiome (Cutibacterium acnes) in the context of shoulder surgery: a review of the current literature.

BACKGROUND: This review aims to establish current knowledge of the shoulder skin microbiome and how to manage the bacteria that reside within it. METHODS: A review was undertaken of the current literature through OvidSP. All abstracts were reviewed by three independent researchers. RESULTS: Thirty-five studies met the inclusion criteria. With forward referencing an additional 14 were included. None commented on organisms specific to the shoulder microbiome other than Cutibacterium acnes. Therefore, this review is focussed on the current knowledge of C. acnes. DISCUSSION: C. acnes is a skin commensal within the pilo-sebaceous glands reported to be the primary pathogen in up to 86% of shoulder joint infections. Pre-operative culture of unprepared skin can be indicative of underlying joint infection in shoulder arthroplasty revision. Intra-articular biopsies may have a high false positive due to skin contamination. Correlating the number of positive samples and certain associated signs can give a greater than 90% probability of a true infection. Standard surgical skin preparation, peri-surgical intravenous antibiotics and oral pre-operative antibiotics do not reduce bacterial load within the skin. However, topical benzoyl peroxide and clindamycin have both demonstrated significantly reduced bacteria load. Phylogenetically there are six main types. Patients may have more than one phenotype present during infection.

A systematic review of the complications of contemporary total elbow arthroplasty.

BACKGROUND: Total elbow arthroplasty is a low volume procedure. We aimed to evaluate complication rates and cumulative percentages associated with the most frequently used contemporary implants and for the commonest indications. METHODS: A systematic literature search of all studies reporting complications following total elbow arthroplasty with 12-month minimum follow-up was undertaken. Quality of studies was assessed with the Methodological-Index-for-Non-Randomised-studies criteria. British NJR data identified the most common UK prostheses and indications. The complication rates for all undesirable events contributing to patient outcome were extracted and cumulative percentages were calculated. RESULTS: One hundred seventeen studies were screened, 12 studies included, totalling 815 procedures. Mean follow-up was 3.8 years. The overall complication cumulative percentage was 60.7%, significantly higher than that seen in other joint arthroplasty, including a 6.5% deep infection rate. Nerve injury was comparable between implants at around 4.1%. Radiographic loosening had a cumulative rate of 17.2%. Revision for symptomatic aseptic loosening was 6.3%. CONCLUSIONS: This is the largest systematic review of the complications of total elbow arthroplasty. Surgeons should be aware of differing complications related to their implant of choice, each having its own specific complication. Trauma as an indication appears to have an increased complication rates compared to inflammatory arthropathy. There is a lack of literature regarding the independent results of osteoarthritis as a specific indication for total elbow arthroplasty.

Survival of the Aequalis total shoulder replacement at a minimum 20-year follow-up: a clinical and radiographic study.

AIMS: Shoulder replacement is increasingly performed for end-stage arthritis. Information on the long-term survival and patient outcomes is very limited. This study aimed to quantify the survival and clinical outcome at a minimum of 20-yr follow-up. METHODS: A single-center, single-surgeon, consecutive cohort study was performed. Forty-four shoulder replacements in 40 patients (age at surgery 68.5 years, 82.5% female, preoperative visual analog scale [VAS] pain score 5.1/10, standard deviation [SD] 2.7) implanted between 1996 and 2000 were assessed. All-cause construct survival, radiographic glenoid and humeral stem loosening, radiographic humeral head migration, and patient-reported outcome measures were assessed. RESULTS: Survival with all-cause revision as an endpoint was 84.1% (95% confidence interval [CI] 60.7, 94.1) at 20 years, glenoid loosening was seen in all patients who survived to the 20-year follow-up. Survival of rotator cuff integrity was 16.8% (95% CI 3.5, 38.5) at 20 years. VAS pain scores demonstrated improvement at 10 years (mean change -4/10) but not at 20 years (effect size -0.15, mean change 0.4/10, SD 2.7). At 20 years, 72% of patients had died with the prosthesis in situ. CONCLUSION: Older patients undergoing total shoulder arthroplasty are unlikely to require revision in their lifetime. However, beyond 10 years, a large proportion of implants demonstrate glenoid loosening, humeral head migration, and declining patient outcomes. This information will be of use to patients and clinicians when discussing the potential outcomes of surgery.

Reverse total shoulder arthroplasty.

AIMS: This systematic review asked which patterns of complications are associated with the three reverse total shoulder arthroplasty (RTSA) prosthetic designs, as classified by Routman et al, in patients undergoing RTSA for the management of cuff tear arthropathy, massive cuff tear, osteoarthritis, and rheumatoid arthritis. The three implant design philosophies investigated were medial glenoid/medial humerus (MGMH), medial glenoid/lateral humerus (MGLH), and lateral glenoid/medial humerus (LGMH). METHODS: A systematic review of the literature was performed via a search of MEDLINE and Embase. Two reviewers extracted data on complication occurrence and patient-reported outcome measures (PROMs). Meta-analysis was conducted on the reported proportion of complications, weighted by sample size, and PROMs were pooled using the reported standardized mean difference (SMD). Quality of methodology was assessed using Wylde's non-summative four-point system. The study was registered with PROSPERO (CRD42020193041). RESULTS: A total of 42 studies met the inclusion and exclusion criteria. Rates of scapular notching were found to be significantly higher in MGMH implants (52% (95% confidence interval (CI) 40 to 63)) compared with MGLH ((18% (95% CI 6 to 34)) and LGMH (12% (95% CI 3 to 26)). Higher rates of glenoid loosening were seen in MGMH implants (6% (95% CI 3 to 10)) than in MGLH implants (0% (95% CI 0 to 2)). However, strength of evidence for this finding was low. No significant differences were identified in any other complication, and there were no significant differences observed in PROMs between implant philosophies. CONCLUSION: This systematic review has found significant improvement in PROMS and low complication rates across the implant philosophies studied. Scapular notching was the only complication found definitely to have significantly higher prevalence with the MGMH implant design. Cite this article: Bone Joint J 2021;103-B(5):813-821.

Arthroscopy of the symptomatic shoulder arthroplasty.

BACKGROUND: Assessment of a painful or stiff shoulder arthroplasty can be challenging. The cause of pain can sometimes be easily identified. However, some patients have normal levels of inflammatory markers, normal plain films, and no clinical signs to indicate a diagnosis. Indolent organisms may not raise blood marker levels or result in obvious radiologic findings such as loosening. We report the utility of performing arthroscopy in these patients for a diagnostic advantage. METHODS: We retrospectively reviewed the health records of all patients who underwent diagnostic shoulder arthroscopy over a 3-year period. Patients were included if they were aged 18 years or older, had undergone previous arthroplasty surgery, and had symptoms of shoulder pain or stiffness. Patients were excluded if they had any traditional symptoms of infection or had a raised serum white cell count or C-reactive protein level prior to diagnostic arthroscopy. RESULTS: Fourteen patients met the initial inclusion criteria. The mean interval between index surgery and arthroscopic evaluation was 65.4 months (standard deviation, 58 months; range, 17-192 months). Arthroscopic biopsy specimens returned positive culture results in 3 patients (21%). Rotator cuff tears were noted in 8 patients (57%). Capsular contraction requiring release was noted in 2 patients (10%). In all patients, the diagnostic arthroscopy directed the next stage of management. CONCLUSIONS: Diagnostic arthroscopy allows a full assessment of implants, the rotator cuff, the native articular surfaces, and scar tissue, as well as biopsy specimens to be obtained for indolent infection, in patients considering revision arthroplasty surgery. This allows a more informative consent process for patients, directs surgical management, and on occasion, allows for therapeutic intervention in a painful or stiff shoulder arthroplasty.

Percutaneous screw fixation for painful non-union of lateral malleolus ankle fractures.

INTRODUCTION: Lateral malleolus non-union can cause pain and loss of function. Standard treatment involves open approach with debridement, bone-grafting and plate stabilisation, with published surgical site infection rates to 17%. To minimise the risk of soft tissue complications and allow early mobilisation, we describe a technique for percutaneous cannulated screw stabilisation. MATERIALS AND METHODS: Retrospective case review for all percutaneous lateral malleolus non-union stabilisation procedures undertaken in our hospital between 2011 and 2017 was performed. Fracture union was diagnosed by resolution of pain and swelling, with a return to full weight-bearing mobilisation and two-view radiographs consistent with union. RESULTS: Twelve cases were reviewed. All fractures united. There was one superficial wound infection treated with oral antibiotics, and one early case with drill-piece fracture requiring conversion to open procedure with plate stabilisation. CONCLUSION: We believe this to be the first report of percutaneous stabilisation for non-union of lateral malleolus fractures. We demonstrate this to be a safe and effective technique.

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.

A comparison of energy consumption between the use of a walking frame, crutches and a Stride-on rehabilitation scooter.

BACKGROUND: Following foot and ankle surgery, patients may be required to mobilise non-weight bearing, requiring a walking aid such as crutches, walking frame or a Stride-on rehabilitation scooter, which aims to reduce the amount of work required. The energy consumption of mobilising using a Stride-on scooter has not previously been investigated, and we aim to establish this. METHODS: Ten healthy volunteers (5 males:5 females) aged 20-40 years mobilised independently, then with each mobility device for 3min at 1km/h on a treadmill, with rest periods, whilst undergoing Cardio-Pulmonary Exercise Testing (CPET). Oxygen consumption (VO2), carbon dioxide excretion (VCO2), minute ventilation (MV), respiratory rate (RR) and pulse (HR) were measured at baseline, and after 3min of walking, without and with all 3 devices. Wilcoxon signed rank test was carried out to calculate significance with non-parametric values with Bonferroni correction. RESULTS: Three-point crutch mobilisation demonstrated significant increases in VO2 (0.7L), VCO2 (0.7L), MV (16.7L/min), pulse (24.8bpm) and RR (11.4breaths/min) compared to walking (p<0.05). Mobilisation with a frame produced significant (p<0.05) increases compared to walking; VO2 (0.7L), VCO2 (0.7L), MV (18.3L/min), pulse (35.9bpm), and RR (11.7breaths/min). Tests using the Stride-on demonstrated no significant increase compared to walking with regards to VO2 (0.1L; p=0.959), VCO2 (0.2L; p=0.332), pulse (10.1bpm; p=0.575), and RR (4.7breaths/min; p=0.633). The MV was significantly higher compared to walking (4.3L/min; p<0.05). DISCUSSION: Energy required for unit distance ambulation with a Stride-on device is similar to walking, and significantly lower than with a walking frame in single legged stance and three-point crutch mobilisation. This justifies its use as part of routine practice aiding early mobilisation of patients requiring restricted weight bearing or single legged weight bearing, especially in those with reduced cardio-pulmonary reserve as it is less physiologically demanding and does not rely on upper body strength.

Open carpal tunnel decompression by specialist versus nurse practitioner.

PURPOSE: To compare the outcome after open carpal tunnel decompression by specialists versus a nurse practitioner. METHODS: Of 1361 cases of open carpel tunnel decompression under local anaesthesia from 1996 to 2008, 807 were performed by specialists (consultant, specialist registrar, or specialty and associate specialist) and 554 by a nurse practitioner (since May 2006). The 2 groups were compared in terms of surgical time, total theatre time, postoperative pain, and patient satisfaction with the service. RESULTS: The mean surgical time was shorter in cases performed by specialists (13 vs. 18 minutes, p<0.0001), as was the mean total theatre time (26 vs. 29 minutes, p=0.0154). The rate of postoperative pain was higher in cases performed by specialists (31.5% vs. 24.5%, p=0.0125), as was the rate of patient dissatisfaction (1.6% vs. 0.18%, 0.0113). Nonetheless, since May 2006, outcome was comparable for specialists and the nurse practitioner. This could be due to the change from short-acting to long-acting/mixed local anaesthetic, and the technique for infiltration. The waiting time for surgery reduced from a mean of 16 to 3 weeks. CONCLUSION: Specialists and the nurse practitioner achieved comparable outcome after open carpal tunnel decompression.