The impact of COVID-19 pandemic on the mortality and morbidity of patients undergoing trauma surgery: a report from the UK Corona TRAUMA Surge (UKCoTS) study.

PURPOSE: To assess the impact of the COVID-19 pandemic on the outcomes of the patients who underwent trauma surgery during the peak of the pandemic. METHODS: The UKCoTS collected the postoperative outcomes of consecutive patients who underwent trauma surgery across 50 centres during the peak of the pandemic (April 2020) and during April 2019. RESULTS: Patients who were operated on during 2020 were less likely to be followed up within a 30-day postoperative period (57.5% versus 75.6% p <0.001). The 30-day mortality rate was significantly higher during 2020 (7.4% versus 3.7%, p <0.001). Likewise, the 60-day mortality rate was significantly higher in 2020 than in 2019 (p <0.001). Patients who were operated on during 2020 had lower rates of 30-day postoperative complications (20.7% versus 26.4%, p <0.001). CONCLUSIONS: Postoperative mortality was higher during the first wave of the COVID-19 pandemic compared to the same period in 2019, but with lower rates of postoperative complications and reoperation.

Global impact of COVID-19 on surgeons and team members (GlobalCOST): a cross-sectional study.

OBJECTIVES: To investigate the impact of COVID-19 on the well-being of surgeons and allied health professionals as well as the support provided by their institutions. DESIGN: This cross-sectional study involved distributing an online survey through medical organisations, social media platforms and collaborators. SETTING: It included all staff based in an operating theatre environment around the world. PARTICIPANTS: 1590 complete responses were received from 54 countries between 15 July and 15 December 2020. The average age of participants was 30-40 years old, 64.9% were men and 32.5% of a white ethnic background. 79.5% were surgeons with the remainder being nurses, assistants, anaesthetists, operating department practitioners or classified other. MAIN OUTCOME MEASURES: Participants that had experienced any physical illness, changes in mental health, salary or time with family since the start of the pandemic as well as support available based on published recommendations. RESULTS: 32.0% reported becoming physically ill. This was more likely in those with reduced access to personal protective equipment (OR 4.62; CI 2.82 to 7.56; p<0.001) and regular breaks (OR 1.56; CI 1.18 to 2.06; p=0.002). Those with a decrease in salary (29.0%) were more likely to have an increase in anxiety (OR 1.50; CI 1.19 to 1.89; p=0.001) and depression (OR 1.84; CI 1.40 to 2.43; p<0.001) and those who spent less time with family (35.2%) were more likely to have an increase in depression (OR 1.74; CI 1.34 to 2.26; p<0.001). Only 36.0% had easy access to occupational health, 44.0% to mental health services, 16.5% to 24/7 rest facilities and 14.2% to 24/7 food and drink facilities. Fewer measures were available in countries with a low Human Development Index. CONCLUSIONS: This work has highlighted a need and strategies to improve conditions for the healthcare workforce, ultimately benefiting patient care.

The Effect of the COVID-19 Pandemic on Theatre Efficiency, Lessons to be Learned for Subsequent Waves.

Background: This study aims to demonstrate the impact of the COVID-19 pandemic on providing trauma services at our district general hospital. We aim to identify the impact on specific areas of theatre delay to help optimize theatre efficiency and generate better protocols and improve patient flow for future pandemic waves. Methods: Patients who underwent orthopaedic trauma surgery at our hospital between July-August 2019 (pre-COVID-19) and 2020 (first UK wave of COVID-19) were identified retrospectively and grouped by year of operation. Type of operation was recorded, including time for sending, anaesthetic induction, surgical preparation, operating time, and time for transfer to recovery. The two groups were compared for analysis. Results: Case numbers were similar in both 2019 and 2020 (215vs.213 operations), with a similar proportion being hip fractures (39.1% and 36.6%), respectively. Median sending time (40vs.23 minutes, P <0.00001) and induction time (13vs.8 minutes, P<0.00001) were increased in 2020, a 74% and 63% increase compared to 2019, respectively. Median surgical preparation time (35vs.37 minutes, P=0.06) and operating time (56vs.50 minutes, P=0.16) were not statistically significant. Transfer time in 2020 (16vs.13 minutes, P<0.00001) was significantly increased. Overall case time increased in 2020 (2:40vs.2:11, P<0.00001) by 29 minutes. Conclusion: COVID-19 had a significant impact on theatre efficiency in our hospital, causing multiple points of delay. As hospitals across the UK restart crucial elective services, focus should be given to maximizing theatre efficiency by providing rapid access COVID-19 testing for patients undergoing emergency surgery. We have proposed and implemented several steps for better theatre utilization.

The Effect of Type of Femoral Component Fixation on Mortality and Morbidity after Hip Hemiarthroplasty: A Systematic Review and Meta-Analysis.

BACKGROUND: Hip hemiarthroplasty is a well-established treatment of displaced femoral neck fracture, although debate exists over whether cemented or uncemented fixation is superior. Uncemented prostheses have typically been used in younger, healthier patients and cemented prostheses in older patients with less-stable bone. Also, earlier research has suggested that bone cement has cytotoxic effects and may trigger cardiovascular and respiratory adverse events. QUESTIONS/PURPOSES: The aim of this systematic review and meta-analysis was to compare morbidity and mortality rates after cemented and uncemented hemiarthroplasty for the treatment of displaced femoral neck fractures in elderly patients. METHODS: Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, we searched seven medical databases for randomized clinical trials and observational studies. We compared cemented and uncemented hemiarthroplasty using the Harris Hip Score (HHS), as well as measures of postoperative pain, mortality, and complications. Data were extracted and pooled as risk ratios or standardized mean difference with their corresponding 95% confidence intervals in a meta-analysis model. RESULTS: The meta-analysis included 34 studies (12 randomized trials and 22 observational studies), with a total of 42,411 patients. In the pooled estimate, cemented hemiarthroplasty was associated with less risk of postoperative pain than uncemented hemiarthroplasty. There were no significant differences between groups regarding HHS or rates of postoperative mortality, pulmonary embolism, cardiac arrest, myocardial infarction, acute cardiac arrhythmia, or deep venous thrombosis. CONCLUSIONS: While we found that cemented hemiarthroplasty results in less postoperative pain than uncemented hemiarthroplasty in older patients with femoral neck fracture, the lack of significant differences in functional hip scores, mortality, and complications was surprising. Further high-level research is needed.

Sliding hip screws versus cancellous screws for femoral neck fractures: a systematic review and meta-analysis.

PURPOSE: Both sliding hip screws (SHS) and cancellous screws are used in the surgical management of intracapsular femoral neck fracture. However, there is paucity of information as to which is the superior treatment modality. We performed this systematic review and meta-analysis study to compare the clinical outcomes of SHS and cancellous screws for the treatment of femoral neck fractures in adult patients. METHODS: We searched PubMed, Scopus, Web of Science, and Cochrane CENTRAL, up to December 2017. Randomized controlled trials (RCTs) directly comparing the clinical outcomes of SHS and cancellous screws for femoral neck fractures were retrieved with no language or publication year restrictions. Data retrieved included operative details, nonunion rate, avascular necrosis, reoperation, infection and mortality, hip pain, functional hip scores, and medical complications. These were pooled as risk ratio or mean difference (MD) with their corresponding 95% confidence interval (CI). Heterogeneity was assessed by Chi-square test. RESULTS: Ten RCTs involving 1934 patients were included in the final analysis. The pooled estimate showed that the SHS group was associated with more intraoperative blood loss (MD = 110.01 ml, 95% CI [52.42, 167.60], p = 0.00002) than the cancellous screws. There was no significant difference in terms of operative time, postoperative hip function, nonunion, avascular necrosis, reoperation rate, infection, fracture healing, hip pain, medical complications, and mortality rate. CONCLUSION: Based on our study, the cancellous screws group was associated with less intraoperative blood loss in comparison with the SHS group. No other significant differences were found between the two interventions.

Unipolar versus bipolar hemiarthroplasty for displaced femoral neck fractures: A pooled analysis of 30,250 participants data.

PURPOSE: To assess the clinical outcomes of unipolar versus bipolar hemiarthroplasty for displaced intracapsular femoral neck fractures in older patients and to report whether bipolar implants yield better long-term functional results. METHODS: We searched PubMed, Scopus, EBSCO, and Cochrane Library for relevant randomized clinical trials (RCTs) and observational studies, comparing unipolar and bipolar hemiarthroplasty. Data were extracted from eligible studies and pooled as relative risk (RR) or mean difference (MD) with corresponding 95% confidence intervals (CI) using RevMan software for Windows. RESULTS: A total of 30 studies were included (13 RCTs and 17 observational studies). Analyses included 30,250 patients with a mean age of 79 years and mean follow-up time of 24.6 months. The overall pooled estimates showed that bipolar was superior to unipolar hemiarthroplasty in terms of hip function, range of motion and reoperation rate, but at the expense of longer operative time. In the longer term the unipolar group had higher rates of acetabular erosion compared to the bipolar group. There was no significant difference in terms of hip pain, implant related complications, intraoperative blood loss, mortality, six-minute walk times, medical outcomes, and hospital stay and subsequently cost. CONCLUSIONS: Bipolar hemiarthroplasty is associated with better range of motion, lower rates of acetabular erosion and lower reoperation rates compared to the unipolar hemiarthroplasty but at the expense of longer operative time. Both were similar in terms of mortality, and surgical or medical outcomes. Future large studies are recommended to compare both methods regarding the quality of life.

Correction to: Contemporary cemented versus uncemented hemiarthroplasty for the treatment of displaced intracapsular hip fractures: a meta-analysis of forty-two thousand forty-six hips.

The author name "Muhammad Shawqi" was incorrectly presented as "Muhammad Shawq".

Contemporary cemented versus uncemented hemiarthroplasty for the treatment of displaced intracapsular hip fractures: a meta-analysis of forty-two thousand forty-six hips.

INTRODUCTION: Controversy exists regarding the use of cement for hemiarthroplasty to treat displaced intracapsular hip fractures. The aim of this systematic review and meta-analysis was to compare the clinical outcomes between contemporary cemented and contemporary uncemented hemiarthroplasty for the treatment of displaced femoral neck fractures. METHODS: Literature searches of PubMed, Scopus, Web of Science, and Cochrane Central, up to May 2017, were performed. We included randomized controlled trials (RCTs) and observational studies comparing contemporary cemented with contemporary uncemented hemiarthroplasty. Data were pooled as mean difference (MD) or risk ratio (RR) with 95% confidence interval (CI) in a meta-analysis model. Studies with the Thompson and Austin Moore prostheses were excluded. RESULTS: A total of 29 studies (9 RCTs and 20 observational studies), with a total of 42,046 hips, were included. Meta-analysis showed that the cemented group was associated with fewer periprosthetic fractures (RR = 0.44, 95% CI [0.21, 0.91]), longer operative time (MD = 11.25 min, 95% CI [9.85, 12.66]), more intraoperative blood loss (MD = 68.72 ml, 95% CI [50.76, 86.69]), and higher heterotopic ossification (RR = 1.79, 95% CI [1.11, 2.88]) compared with the uncemented group. Meta-analysis showed no significant difference in terms of post-operative hip function, hip pain, reoperation rate, prosthetic dislocations, aseptic loosening, wound infection, and hospital stay. CONCLUSIONS: This meta-analysis shows that contemporary cemented prostheses have less intra-operative and post-operative fractures, but longer operative time, more intra-operative blood loss, and heterotopic ossifications. Otherwise, there were no significant differences between both groups.

A systematic review of the concept and clinical applications of bone marrow aspirate concentrate in tendon pathology.

Tendon pathologies are a group of musculoskeletal conditions frequently seen in clinical practice. They can be broadly classified into traumatic, degenerative and overuse-related tendinopathies. Rotator cuff tears, Achilles tendinopathy and tennis elbow are common examples of these conditions. Conventional treatments have shown inconsistent outcomes and might fail to provide satisfactory clinical improvement. With the growing trend towards the use of mesenchymal stem cells (MSCs) in other branches of medicine, there is an increasing interest in treating tendon pathologies using the bone marrow MSC. In this article, we provide a systematic literature review documenting the current status of the use of bone marrow aspirate concentrate (BMAC) for the treatment of tendon pathologies. We also asked the question on the safety of BMAC and whether there are potential complications associated with BMAC therapy. Our hypothesis is that the use of BMAC provides safe clinical benefit when used for the treatment of tendinopathy or as a biological augmentation of tendon repair. We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist while preparing this systematic review. A literature search was carried out including the online databases of PubMed, EMBASE, ClinicalTrial.gov and the Cochrane Library from 1960 to the end of May 2015. Relevant studies were selected and critically appraised. Data from eligible studies were extracted and classified per type of tendon pathology. We included 37 articles discussing the application and use of BMAC for the treatment of tendon pathologies. The Critical Appraisal Skills Program (CASP) appraisal confirmed a satisfactory standard of 37 studies. Studies were sub-categorised into: techniques of extraction, processing and microscopic examination of BMAC (n = 18), where five studies looked at the evaluation of aspiration techniques (n = 5), augmentation of rotator cuff tears (n = 5), augmentation of tendo-achilles tendon (n = 1), treatment of gluteal tendon injuries (n = 1), management of elbow epicondylitis (n = 2), management of patellar tendinopathy (n = 1) and complications related to BMAC (n = 5). Multiple experimental studies investigated the use of BMAC for tendon repair; nonetheless, there are only limited clinical studies available in this field. Unfortunately, due to the scarcity of studies, which were mainly case series, the current level of evidence is weak. We strongly recommend further future randomised controlled studies in this field to allow scientists and clinicians make evidence-based conclusions.

A systematic review of the clinical applications and complications of bone marrow aspirate concentrate in management of bone defects and nonunions.

PURPOSE: Fracture healing encompasses a succession of dynamic multifactorial metabolic events, which ultimately re-establishes the integrity of the biomechanical properties of the bone. Up to 10% of the fractures occurring annually will need additional surgical procedures because of impaired healing. The aim of this article is to review the current literature regarding the use of bone marrow aspirate concentrate (BMAC) and its effectiveness in the management of bone defects. METHODS: We have included all published clinical literature investigating the development, techniques and applications of BMAC. Language, design and risk of bias did not deter the initial inclusion of any study. Our search was exclusively limited to studies involving human subjects. A PRISMA compliant search was carried out as published in 2009. This included the online databases: PubMed, EMBASE, clinical trial.gov and the Cochrane library from 1960 to the end of May 2015. MeSH terms used included: "Bone" AND "Marrow" AND "Aspirate" AND "Concentrate" AND "Bone Defects" AND "NONUNION". Eligible studies were independently appraised by two authors using the Critical Appraisal Skills Program checklist. For the purpose of narrative review, relevant studies were included irrespective of methodology or level of evidence. RESULTS: Thirty-four of the 103 (48 PubMed and 55 EMBASE) results yielded by the preliminary search were included. Exclusions included three duplicate records, six letters, 17 non-orthopaedics related studies and four records irrelevant to our search topic. The CASP appraisal confirmed a satisfactory standard of 31 studies. They all had clearly defined objectives, were well designed and conducted appropriately to meet them. The published studies reported the use of BMAC in non-union and fracture healing (15 studies), bone defects (nine studies), spine fusion (two studies), distraction osteogensis (two studies) and complications related to the use of BMAC (seven studies). CONCLUSIONS: Stem cells found in BMAC have the potential to self-renew, undertake clonal expansion and differentiate into different musculoskeletal tissues. The commercial processing of BMAC needs to be optimized in order to achieve a consistent end product, which will provide predicable and translatable results. The future potential of cell characterization in order to determine the optimum cell for repair/regeneration of bone also needs to be explored. LEVEL OF EVIDENCE: Systematic Review of minimum level IV studies.

Reverse shoulder arthroplasty with a cementless short metaphyseal humeral implant without a stem: clinical and radiologic outcomes in prospective 2- to 7-year follow-up study.

BACKGROUND: Reverse shoulder prostheses are increasingly used in recent years for treatment of glenohumeral arthropathy with deficient rotator cuff. Bone preservation is becoming a major goal in shoulder replacement surgery. Metaphyseal humeral components without a stem were developed to minimize bone resection and preserve bone. This study evaluated the clinical and radiologic outcomes at 2 to 7 years using a novel short metaphyseal reverse total shoulder arthroplasty (rTSA) prosthesis without a diaphyseal stem. METHODS: Between 2005 and 2010, 102 consecutive patients underwent rTSA with this implant, and 98 (20 men, 78 women) were available for follow-up. Mean age was 74.4 years (range, 38-93 years). Indications were cuff tear arthropathy, 65; fracture sequelae, 12; rheumatoid arthritis, 13; failed rotator cuff repair, 3; cuff deficiency with loosening of anatomic prosthesis, 3; and acute trauma, 2; with 17 of these as revisions. RESULTS: Patients' satisfaction (Subjective Shoulder Value) improved from 8 of 100 to 85 of 100. The Constant score improved from 14 to 59 (age- and sex-adjusted, 86; P < .0001). Range of motion improved from 47° to 129° in elevation, 10° to 51° in external rotation, and 21° to 65° in internal rotation. Radiographic analysis showed no lucencies, subsidence, or stress shielding around the humeral or glenoid components. Glenoid notching was found in 21 patients (18 grade 1-2; 3 grade 3). CONCLUSIONS: The short metaphyseal rTSA design without a diaphyseal stem shows encouraging short- to midterm results, with excellent pain relief and shoulder function, restoration of good active range of motion, and high patient satisfaction scores. The design of this implant seems to result in improved rotational movements, low incidence of glenoid notching, and no implant loosening, subsidence, or stress shielding.

Surface replacement arthroplasty for glenohumeral arthropathy in patients aged younger than fifty years: results after a minimum ten-year follow-up.

BACKGROUND: The role of cementless surface replacement arthroplasty (CSRA) in young individuals is currently unclear. The aim of this study was to evaluate CSRA long-term results for glenohumeral arthritis in young patients. METHODS: Between 1990 and 2003, 54 CSRAs were performed on 49 patients (25 men, 24 women) aged younger than 50 years. Mean age was 38.9 years (range, 22-50 years). Three patients (4 shoulders) died over time and 8 were lost to follow-up, leaving 38 patients (42 shoulders) with a mean follow-up of 14.5 years (range, 10-25 years). There were 17 total shoulder replacements with metal back glenoid, and 37 underwent humeral head resurfacing with microfracture of the glenoid. RESULTS: The indications were avascular necrosis, 16; rheumatoid arthritis, 20; instability arthropathy, 7; primary osteoarthritis, 5; fracture sequelae, 3; postinfection arthritis, 2; and psoriatic arthritis, 1. The mean relative Constant score increased from 11.5% to 71.8% (P < .0001), and the mean patient satisfaction at final follow-up was 8.7 of 10. The mean relative Constant score for the humeral head resurfacing with microfracture of the glenoid improved to 77.7% compared with 58.1% for total resurfacing arthroplasty. Two required early arthrodesis due to instability and deep infection. Seven were revised to stemmed prosthesis: 1 for traumatic fracture and 1 for glenoid erosion 16 years after the index procedure. Five shoulders in 4 patients (4 rheumatoid arthritis, 1 avascular necrosis) were revised at 8 to 14 years after surgery for cuff failure and loosening. Three were revised to stemless reverse total shoulder arthroplasty due to rotator cuff failure at 23, 16, and 13 years after surgery. CONCLUSIONS: CSRA provides good long-term symptomatic and functional results in the treatment of glenohumeral arthropathy in patients aged younger than 50 years in 81.6% of the patients. This improvement is maintained over more than 10 years after surgery, with high patient satisfaction (8.7 of 10). However, 10 shoulders (of 54) (18.5%) underwent revision arthroplasty. Resurfacing offers a valuable tool in treating young patients with glenohumeral arthritis, providing reasonably good long-term results in 81.6% of the patients, while allowing preservation of bone stock if the need for revision arises. All the revision arthroplasty options are preserved, including less invasive procedures.

Reverse shoulder arthroplasty with a short metaphyseal humeral stem.

PURPOSE: Reverse shoulder prostheses have been gaining popularity in recent years. A short metaphyseal stem design will allow bone stock preservation and minimize stem related complications. We examined the clinical and radiographic short-term outcome of a short metaphyseal stem reverse shoulder arthroplasty. METHODS: Thirty-one patients, with a mean follow-up of 36 months (24-52), were evaluated clinically with the Constant-Murley score, patient satisfaction and pain relief scores. The fixation of the glenoid and humeral components, subsidence and notching were evaluated on radiographs. The indications were cuff tear arthropathy (22), fracture sequelae (five) and rheumatoid arthritis (four). RESULTS: The average Constant score improved from 12.7 (range two to 31) pre-operatively to 56.2 (range 17-86) postoperatively. It rose from 13.5 to 58.3 in patients with Cuff arthropathy, from 15.8 to 62.0 in revision arthroplasty, from 10.2 to 47.4 in those with fracture sequelae, and from 11.5 to 55.3 in patients with rheumatoid arthritis. The overall mean patient satisfaction score improved from 2.4/10 to 8.5/10 and mean pain score improved from 0.8/15 to 12.5/15. We found an overall improvement in active forward flexion from 46.8 to 128.5° and from 41.6 to 116.5° in abduction. No humeral loosening or subsidence was observed. Two cases of grade 1-2 glenoid notching were reported. Overall there were three intra-operative fractures that did not affect the operation and healed without affecting the good results. There were five late traumatic periprosthetic fractures, only one of them required a revision surgery to a stemmed implant and the rest healed without surgery. There were two early dislocations that had to be revised. CONCLUSIONS: The clinical and radiographic evaluation of a bone preserving metaphyseal humeral component in reverse shoulder arthroplasty is promising, with good clinical results, no signs of loosening or subsidence.

Acromioclavicular joint acceleration-deceleration injury as a cause of persistent shoulder pain: Outcome after arthroscopic resection.

BACKGROUND: Shoulder pain in general and acromioclavicular joint (ACJ) pain specifically is common after acceleration-deceleration injury following road traffic accident (RTA). The outcome of surgical treatment in this condition is not described in the literature. The aim of the present study was to report the outcome of arthroscopic resection of the ACJ in these cases. MATERIALS AND METHODS: Nine patients with localized ACJ pain, resistant to nonoperative treatment were referred on an average 18 months after the injury. There were 3 male and 6 females. The right shoulder was involved in seven patients and the left in two. The average age was 38.9 years (range 29-46 years). All presented with normal X-rays but with torn acromioclavicular joint disc and effusion on magnetic resonance imaging (MRI). Arthroscopic ACJ excision arthroplasty was performed in all patients. RESULTS: At a mean followup of 18 month, all patients had marked improvement. The Constant score improved from 36 to 81, the pain score from 3/15 to 10/15 and the patient satisfaction improved from 3.5/10 to 9.3/10. CONCLUSION: Arthroscopic ACJ excision arthroplasty, gives good outcomes in patients not responding to conservative management in ACJ acceleration-deceleration injury.

Medium to long-term outcome of thoracoscapular arthrodesis with screw fixation for facioscapulohumeral muscular dystrophy.

BACKGROUND: Shoulder girdle muscle weakness is the most constant feature of facioscapulohumeral muscular dystrophy and leads to scapular winging. Mechanical fixation of the scapula to the thoracic wall provides a stable fulcrum on which the deltoid muscle can exert its action on the humerus. The aim of this study was to evaluate the medium to long-term outcome of thoracoscapular arthrodesis with screw fixation (the modified Howard-Copeland technique). METHODS: All patients with facioscapulohumeral dystrophy who underwent thoracoscapular arthrodesis with screw fixation and bone-grafting from July 1997 to July 2010 were retrospectively reviewed. Preoperative and postoperative clinical assessment included active shoulder elevation, the Constant score, a patient satisfaction score, and cosmetic satisfaction. Union was determined both clinically and radiographically. RESULTS: Thoracoscapular arthrodesis was performed in thirty-five shoulders in twenty-four patients; eleven patients underwent bilateral procedures. The principal study group consisted of thirty-two shoulders in twenty-one patients with a minimum follow-up of twenty-four months (mean, eighty-eight months; range, twenty-four to 174 months). The mean Constant score increased from 30 (range, 17 to 41) preoperatively to 61 (range, 30 to 90) postoperatively. The mean satisfaction score increased from 1 (range, 0 to 4) to 8.4 (range, 4 to 10). Early complications consisted of one pneumothorax, one superficial wound infection, and four early failures, two of which were associated with noncompliance with the postoperative regimen. Late complications consisted of one posttraumatic fracture resulting in loosening and one painful nonunion; both were treated successfully with revision. CONCLUSIONS: Thoracoscapular arthrodesis with screw fixation prevented scapular winging and improved short-term and long-term shoulder function in patients with facioscapulohumeral dystrophy. LEVEL OF EVIDENCE: Therapeutic level IV. See instructions for authors for a complete description of levels of evidence.

The 'hand squeeze' test for posterior 'muscle patterning instability' of the shoulder.

Muscular patterning can be a contributor of positional posterior shoulder instability. Failure to recognize this pattern may lead to unnecessary surgical treatment with high failure rate. We analyzed the results of a new simple clinical test (hand squeeze test). The test is regarded positive, if during squeezing with the contralateral hand and elevation of the involved arm, in pronation, no posterior shoulder dislocation occurs. The test is regarded negative if posterior dislocation does occur regardless of the "hand squeeze". The patients with positive test were treated conservatively. Ten patients (12 shoulders) were treated between July 2006 and July 2010. The 'hand squeeze' test was positive in 8 patients (10 shoulders) and negative in 2 patients (2 shoulders). Both patients with a negative sign had structural lesions in the glenohumeral joint confirmed on arthro-MRI and were treated operatively.

Management of first-time dislocations of the shoulder in patients older than 40 years: the prevalence of iatrogenic fracture.

OBJECTIVE: To evaluate the prevalence of iatrogenic humeral neck fracture after attempted closed reduction in patients older than 40 years who present with a first-time anterior dislocation. DESIGN: Retrospective cohort study, evidence-based medicine level IV. PATIENTS: Ninety-two patients older than 40 years (mean 66.6 years of age) with a first-time anterior dislocation of the shoulder. INTERVENTION: Closed reductions by the emergency medicine physicians under conscious sedation, in the emergency department. MAIN OUTCOME MEASUREMENTS: Prevalence of iatrogenic fracture on postreduction radiographs. RESULTS: Nineteen (20.7%) patients were diagnosed with a concomitant greater tuberosity fracture on initial radiograph. In the postreduction radiographs, 5 patients (5.4%) were identified with a postreduction humeral neck fracture, and all of them had a greater tuberosity fracture on initial radiographs. A highly significant association (P < 0.0001) was observed between the finding of a greater tuberosity fracture on the initial radiographs and the occurrence of iatrogenic humeral neck fracture after close reduction. DISCUSSION: Previous case reports have described an iatrogenic humeral neck fracture with reduction attempt of shoulder dislocation. In our retrospective study, 21% of the cohort of patients older than 40 years had a concomitant greater tuberosity fracture; 26% of them had an iatrogenic humeral neck fracture after reduction attempt under sedation in the emergency room. These patients ended up with poor outcome. CONCLUSIONS: Patients older than 40 years, presenting with a first-time anterior shoulder dislocation with an associated fracture of the greater tuberosity have a significant rate of iatrogenic humeral neck fracture during closed reduction under sedation.

Arthroscopically assisted internal fixation of the symptomatic unstable os acromiale with absorbable screws.

BACKGROUND: Symptomatic meso- type os acromiale is a common pathology with inconsistent outcomes of treatment with various surgical techniques. We report the outcome of a new technique for arthroscopic fusion of symptomatic os acromiale with absorbable screws. MATERIALS AND METHODS: The study included 8 shoulders in 8 patients with symptomatic meso- type os acromiale who were treated with the use of a new technique for arthroscopic fusion with absorbable screws. The mean age was 54 years (range, 38-67 years), and the mean time from onset of symptoms to surgery was 18 months (range, 9-25 months). No patients reported a specific traumatic event before the onset of symptoms, and all noted the insidious onset of pain with no precipitating event. RESULTS: The average length of follow-up was 22 months (range, 12-36 month). The average Constant score improved from 49 points (range, 35-57 points) to 81 points (range, 75-86 points). The average satisfaction score improved from 4.5 of 10 (range, 2-6) to 8.5 of 10 (range 7-9). All patients made a good clinical recovery at 3 to 6 months after surgery. At the last follow-up, full radiographic union was observed in 6 patients, partial union in 1 patient, and persistent radiologic nonunion in 1 patient. Anterior bulging of the absorbable screws was noted in 2 patients, and the screws were trimmed 6 months after the first procedure. CONCLUSIONS: We have found that this new arthroscopic technique of fixation of os acromiale with absorbable screws provides promising clinical, cosmetic, and radiologic results with high patient satisfaction.