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.

Fracture-related infection: Analysis of healthcare utilisation and associated costs.

AIMS: A consensus definition of fracture related infection (FRI) has been created with the aim of standardising diagnosis and eliminating heterogeneity that prevents accurate comparison between existing studies. FRI remains one of the most challenging complications in musculoskeletal trauma surgery and carries with it a significant cost burden. A review of UK finances has not been completed utilising consensus diagnostic criteria. The goal of this study was to investigate the hospital-associated healthcare cost related to the treatment of FRI within an NHS major trauma centre. METHOD: Through retrospective case-control analysis, 1240 patients with close fractures were identified. Of those, 21 patients with FRI were compared to 63 uninfected patients. Patients were matched based on fracture location, type of procedure and proximity in age. The costs assessed included hospitalisation, imaging, outpatient consultation, pharmaceuticals and procedure charges. Cost data was retrieved from healthcare resource group (HRG) guidelines, NHS Business Service Authority's (NBSA) prescription rates and internal costing. RESULTS: The FRI group were found to incur a 2.51 increase in total medial healthcare cost compared to the control group (£22,058 vs £8798 [p < 0.001]), which was primarily due to increased procedural costs (£13,020 vs £6291 [p < 0.001]) and length of hospital stay (£7552 vs £2124 [p < 0.001]). CONCLUSION: Whilst diagnosis of FRI has a more rigorous definition following the new consensus, prevalence and cost outcomes are similar to previous studies. Given the deficiency in funding and ongoing challenges of resource allocation to the NHS, it is prudent to incorporate studies such as this into stratifying departmental budgets and quality improvement. LEVEL OF EVIDENCE: III.

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.

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.

Urgent Arthroplasty Interventions During the COVID-19 Pandemic: Operating Risks in Low-Prevalence Areas.

Background and objective Orthopaedic services have reorganised their delivery of care in response to the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic. In this study, we aimed to share our operating experience during the coronavirus disease 2019 (COVID-19) pandemic and analyse its effect on urgent hip and knee arthroplasty. Our study involved a comparative analysis between a cohort of patients from 2019 (pre-COVID) and another from 2020. Methods Tha data relating to patients undergoing urgent operations requiring arthroplasty interventions such as for infection, periprosthetic fracture (PPF) and neck of femur fracture (NOF) between April and July of 2020 and 2019 were reviewed prospectively and retrospectively. Patients were categorised according to the Royal College of Surgeons (RCS) case prioritisation and the COVID-19 risk assessment. Data were collected on 30-day mortality, readmissions, reoperations, complications, length of hospital stay and theatre efficiency. This was analysed, matched and compared. Statistical analysis was performed on categorical variables including the time to the theatre as well as dual consultant operating. Results A total of 46 consecutive patients were included in the 2020 cohort with a mean age of 78 years (range: 58-108 years). The median length of stay was 6.5 days (range: 3-35 days) and the median time to theatre for NOF patients was 23.8 hours (range: 16.2-87.7 hours). There were six complications and two deaths; one of the deaths was COVID-19-related. A total of 56 patients were included from 2019 with a mean age of 74.6 years (range: 45-88 years). The median length of stay was five days (range: 1-18 days) and the median time to theatre for NOF patients was 40.8 hours (range: 18.9-167 hours). There were four complications and one death. Conclusion Based on our findings, it is safe to perform complex surgery in a region of low community prevalence of COVID-19, and the outcomes were comparable to those from a pre-COVID-19 cohort.

Quality of life after in-hospital cardiopulmonary resuscitation for patients over the age of 80 years.

OBJECTIVES: Success of in-hospital resuscitation decreases with age; however, national data show that 11.3% of patients over 80 years survive to discharge. There are few published qualitative data about the quality of life for these patients postsuccessful resuscitation. We aimed to investigate postresuscitation quality of life in patients over the age of 80 through a series of case studies. METHODS: All patients over the age of 80 years, who received cardiopulmonary resuscitation (CPR) at our district general hospital in 2015-2016, were included. Success of resuscitation, survival at day 1 and to discharge were recorded. For patients who survived to 1 day and beyond, case reports were written to create individual patient stories. RESULTS: 47 patients over the age of 80 years received CPR at Musgrove Park Hospital over a 2-year period. Five (10.6%) survived to discharge. Of those surviving to discharge, two had substantial functional decline, requiring discharge to nursing homes having previously been independent. Of the five families/patients who commented on their experience, only one expressed a positive view. When discussed, the majority of patients/families opted for a Do Not Attempt CPR. CONCLUSION: Our results have shown that there is a risk of substantial functional decline associated with successful CPR in those patients over the age of 80 years. The majority of patients and relatives contacted after successful resuscitation expressed a negative view of the experience. Our study highlights the importance of having early informed discussions with patients and families about CPR in order to avoid detrimental outcomes and ensure patient wishes are correctly represented.