BESS 2022 abstracts - Podium

THE EFFECT OF SINGLE DOSE, PREOPERATIVE INTRAVENOUS TRANEXAMIC ON EARLY POSTOPERATIVE PAIN SCORES IN ROTATOR CUFF REPAIR: A DOUBLE BLIND RANDOMISED CONTROL TRIAL

SP Mackenzie, M Spasojevic, M Smith, O Mattern, RP Piggott, SSP Patel, N Bedaiwy, B Cass and AA Young

Sydney Shoulder Research Institute, Australia

Background: A double-blind randomised controlled trial to assess the effect of preoperative TXA on early postoperative pain scores after rotator cuff surgery.

Methods: A randomised double-blind trial was conducted in 89 patients undergoing RCR. Patients were randomised to either 2g of intravenous TXA or placebo at induction. The primary outcome was VAS-pain score at day three postoperative with secondary outcomes including VAS-pain, ASES and Constant Score at two weeks, eight weeks, 24 weeks and 52 weeks.

Results: There was no significant difference in VAS-pain between groups at day three postoperative. Pain scores were statistically better in the TXA group at 8 weeks. There was no difference between groups at any time point in the ASES or Constant score. The TXA group had improved motion at six months with a reduced rate of secondary adhesive capsulitis.

Conclusion: TXA did not improve postoperative pain scores after RCR, however, patients who received the intervention demonstrated a greater range of movement at six months with lower rates of secondary adhesive capsulitis.

IS A SUBLUXTED LONG HEAD OF BICEPS TENDON PATHOGNOMIC OF A SUBSCAPULARIS TENDON TEAR?

R Prakash, A Dekker, G Bhabra, C Modi, T Lawrence and S Drew

University Hospitals Coventry & Warwickshire, Coventry

Background: Pre-operative diagnosis of subscapularis tears remains a difficult challenge. Ultrasound has been shown to be ineffective at directly detecting subscapularis tears. It has been widely accepted that medial subluxation of the long head of the biceps tendon (LHBT) is associated with full-thickness subscapularis tears. The aims of this study are to assess whether LHBT subluxation on ultrasound scanning has any predictive value for subscapularis tears and to determine the relationship between LHBT subluxation and subscapularis tears at arthroscopy.

Methods and results: Pre-operative ultrasound and arthroscopic findings for patients undergoing arthroscopic rotator cuff repair at our institution between March 2011 and January 2016 were analysed. The accuracy of LHBT subluxation, on ultrasound and at arthroscopy, as a predictor of subscapularis tears at arthroscopy, was calculated. The correlation between LHBT subluxation and subscapularis tears was determined. A standardised technique was used for ultrasound scans and the grade of the sonographer was recorded. 359 Rotator cuff repairs were performed. 24 patients had a subluxated LHBT. Ultrasound was poorly sensitive (50%) and a subluxted LHBT on ultrasound only correlated very weakly with subscapularis tears at arthroscopy, R = 0.268.

Conclusions: Due to their close anatomical relationship, traditional teaching suggests subscapularis tears are associated with medial LHBT subluxation. Our data indicate that contrary to popular belief, the two are only weakly correlated. In our series, the majority of patients with subscapularis tears (83%) had their LHBT in-groove. The authors, therefore, recommend high vigilance during arthroscopy for the diagnosis and repair of subscapularis tears, regardless of pre-operative ultrasound findings and intra-operative position of the LHBT.

FROZEN SHOULDER: A REVISED SERVICE MODEL AND EVALUATION; USING A ONE-STOP SHOULDER CLINIC (DIAGNOSIS, IMAGING, GUIDED INJECTION, MANUAL THERAPY AND HOME EXERCISE PROGRAMME)

V Gallagher

IMSK Community Services, Conquest Hospital, St Leonards-on-Sea

Purpose: This study evaluates a redesigned musculoskeletal pathway for the management of frozen shoulder; to try and minimise the number of patient contacts from referral until definitive treatment and describes cost-saving initiatives for a Southeast of England National Health Service Trust.

Methods: Participants with suspected frozen shoulder were referred for an X-ray at paper triage and booked into a ‘Frozen Shoulder Clinic’. The clinic was run by an experienced advanced practitioner in musculoskeletal physiotherapy/sonography. Participants were adults (≥ 18 years) with unilateral frozen shoulders, characterised by restriction of passive external rotation (≥ 50%) in the affected shoulder. The clinician, evaluated X-ray results, performed a diagnostic clinical assessment and offered/performed ultrasound-guided injections, followed immediately with manual therapy. All participants were given a standardised home exercise program to follow. The primary outcome was the Oxford Shoulder Score (OSS; 0 – 48) at initial treatment and 6 – 12 months later (via telephone review). All clinician-led interventions (excluding the X-ray), were carried out at first contact, where possible.

Results: A total of 101 participants met the inclusion criteria. A change of six points in the OSS was required to demonstrate a clinically significant change. The mean group score on entry was 20.8 and 39.9 on review. Ninety-two participants (91.1%) demonstrated a clinically significant change. Eight participants (7.9%) did not demonstrate a clinically significant change. One participant (1.0%) was clinically worse on review. Six participants were unsatisfied with their outcome and elected for surgical referral. Clinical contacts required, pre-pathway redesign six, post-pathway redesign two.

Conclusions: This redesigned pathway, required less administrative/clinical time costs, for the employer and participants. X-ray at triage and using an Advanced Practitioner clinician offered time-saving benefits. Participant satisfaction rates were high with this new service. The overall OSS score was comparable to other recent studies, in the management of frozen shoulder (FROST trial).

CLINICAL AND RADIOLOGICAL OUTCOMES OF ROTATOR CUFF REPAIR USING ALL-SUTURE ANCHORS AS MEDIAL ROW ANCHORS

K Memon, R Dimcock, A Bernasconi, P Consigliere, M Imam and A Naravni

Rowley Bristow Unit, Ashford and St Peter's NHS Trust, Chertsey

Purpose: The aim of our study is to report the clinical and radiological outcomes of a series of prospectively enrolled patients who have had double-row transosseous equivalent rotator cuff repairs, where all suture anchors were used as medial-row anchors, with a minimum follow-up of 1 year.

Methods: Twenty-two consecutive patients underwent arthroscopic transosseous equivalent double-row rotator cuff repair using all-suture anchors as medial-row anchors. Oxford Shoulder Score, Constant Score and Visual Analogue Scale pain score, together with shoulder range of motion, were used preoperatively and at 3 months, 6 months and final follow-up. Radiological evaluation was performed with magnetic resonance imaging at one-year post-surgery to assess the structural integrity of the repair and the rate of cyst formation in greater tuberosity.

Results: The patient’s mean age was 61 years (range 46–75). The minimum follow-up was 1 year, and the mean final follow-up was 15 months (range 12–24). Healing failure in our patients was less than 5% (1/22 patients). There were significant improvements in shoulder function outcome scores at the final follow-up. The Constant and Oxford scores were 78 and 44 at the final follow-up, respectively. There were similar magnitudes of improvement in range of motion (combined abduction and rotation), pain score and supraspinatus strength at the final follow-up. The improvements in outcome scores were already statistically significant at 3 months.

Conclusions: It is safe to use all-suture anchors as medial-row anchors when performing double-row anchor transosseous equivalent rotator cuff repairs. The purported advantages of all-suture anchors may outweigh their perceived disadvantages in rotator cuff repair surgery.

IS THE EFFECTIVENESS OF HYDRODISTENTION FOR ADHESIVE CAPSULITIS INFLUENCED BY DIABETIC CONTROL AND THE USE OF INSULIN?

N Jenkins, J Bradshaw, E Rowbotham and P Cowling

Department of Trauma and Orthopaedics, Chapel Allerton Hospital, Leeds Teaching Hospitals NHS Trust, Leeds

Background: Adhesive capsulitis (AC) is commonly associated with poor outcomes for patients with diabetes mellitus (DM): This study aims to explore the impact of DM on the requirement for further intervention following hydrodistension, and to evaluate the significance of poor diabetic control and insulin dependence.

Methods: Interrogation of radiological databases allowed retrospective review of the medical records and imaging of 96 consecutive patients over a 2-year period undergoing hydrodistension at our institution, all with a minimum of 6 months follow-up.

Results: Of 96 patients, 56% were a female, mean age of 58 years. The mean duration of symptoms prior to hydrodistension was 22 months. Of the total cohort, 66 required no further intervention (68.8%). In the diabetic group, (n = 31 (32.3%)), 9 (29%) were insulin dependent, mean HbA1c = 68.2, with 29% having an HbA1c > 75. In the non-diabetic group, (n = 65 (67.7%)), mean HbA1c = 37.8 when measured. In the total cohort, 66 required no further intervention (68.8%), with the remaining 30 (31.2%) undergoing various further interventions: 15 required repeat hydrodistension, 12 underwent surgical intervention in the form of a capsular release, and three had an intra-articular steroid injection. Of the 30 requiring further intervention, 11 were diabetic (35.5%), of which two were on insulin. Of the 66 not requiring further intervention, 20 were diabetic (30.7%), of which seven were on insulin. Mean HbA1c of those requiring further intervention = 52.2 (range 30–112). Mean HbA1c of those not requiring further intervention = 50.4 (range 30−124).

Conclusion: Hydrodistension is a quick, safe and successful primary procedure for AC. Diabetic patients are more likely to require further intervention following hydrodistension. However, in our cohort, insulin dependence or poor diabetic control does not confer a greater risk of further intervention.

A ROOT CAUSE ANALYSIS OF DISSATISFACTION IN PATIENTS UNDERGOING SUB-ACROMIAL DECOMPRESSION SURGERY

T Desai, K Hoban, D Ridley and AC Jariwala

University of Dundee & NHS Tayside, Dundee

Purpose: Sub-acromial decompression (SAD) has been widely used to treat shoulder impingement; however, its validity recently has been questioned in multi-centric clinical trials. Even in those operated, dissatisfaction rates can be high (35%). It is difficult to predict which patients will benefit operatively as research into predictive factors is limited. The study’s aim was to conduct a root-cause analysis of reasons for dissatisfaction in a cohort of operated patients.

Methods: All patients who noted dissatisfaction with SAD in the local Upper Limb database (TULA) between 2015 and 2019 (n = 74/296) formed our study cohort. Patients were scored on Oxford shoulder score (OSS), Quick DASH score, EQ-5D-3L (TTO + VAS) at weeks 26 and 52 post-operatively and specifically enquired if satisfied with the surgery. Patients’ clinical history, radiographs, consultation, and operative notes were reviewed.

Results: Twenty-eight percent of patients were identified as being dissatisfied with surgery. The mean age of dissatisfied patients was 52.3 ± 13.4 years with equal gender distribution. 87% were operated arthroscopically. Of the 74 patients, 67% were in physically demanding occupations. There was a significant increase in OSS and Quick DASH at weeks 26 and 52 postoperatively. This is the first study to evaluate reasons for dissatisfaction following SAD. We noted high rates (28%) of dissatisfaction in our cohort and there was a predilection for those involved in physically demanding occupations.

Conclusions: We recommend meticulous pre-operative workup to identify co-existing pathologies and appropriate pre-operative counselling to warn about potential dissatisfaction rates. In addition, we recommend enquiring about patient satisfaction, in addition to PROMS to assess outcomes of SAD and similar surgical interventions.

ARE THE PURPORTED ADVANTAGES OF AUGMENTED ROTATOR CUFF REPAIRS REAL: A SYSTEMATIC REVIEW

A Nagi, M Imam, M Shehata, D Gerogiannis, R El Nashar, L Ernstbrunner, E Griffith and P Monga

Ashford and St Peter's University Hospitals, Chertsey

Background: The reported re-tear rates after rotator cuff repairs (RCRs) are still high (10–75%). A number of biomechanical, histological and clinical studies have been performed to investigate the outcome of RCR augmented with different varieties of patches. Recent literature is controversial; although some support good results and reduced re-tear rates when an augmentation patch is used, others did not show the same advantage. Objectives: A systematic review and meta-analysis to compare the clinical and radiological outcomes of augmented RCRs versus controls.

Methods: We searched PubMed, Embase, Cochrane Library, Scopus, EBSCO, and Web of science through October 2021 for studies of Augmented RC repair. Inclusion criteria were RCTs and observational studies that compared augmented RCR versus controls; studies where one group had augmented RCR; studies with a control group receiving non-augmented RC; continuous outcomes reliable for analysis and studies reporting the functional and radiological outcomes. The primary outcomes were the rate of RCR failure and adverse events. The secondary outcomes were functional & clinical outcomes including Constant scores, American Shoulder and Elbow score (ASES), and VAS for pain scores.

Results: Nine studies were included in the final analysis. The pooled estimate showed no significant difference between the graft and control groups in terms of the ASES and Constant scores. However, for allograft and autograft subgroups, the pooled estimate favoured the graft group (p = 0.01and p = 0.004, respectively). The graft group showed a better VAS score (p = 0.03). This effect estimate was consistent with subgroup analysis for allograft, synthetic, and autograft subgroups but not for the xenograft subgroup. No significant difference was found between the two groups in terms of adverse events.

Conclusions: RCR with patch augmentation is associated with a lower re-tear rate and no increased rate of adverse events compared with repairs without patch augmentation. Furthermore, auto and allograft patch augmentation showed significantly better functional outcomes and less postoperative pain.

DOES THE AETIOLOGY OF ADHESIVE CAPSULITIS AFFECT PATIENT OUTCOME FOLLOWING SHOULDER DISTENSION PROCEDURE?

M Howard, M Jones, R Clarkson and O Donaldson

Department of Orthopaedic Surgery, Yeovil District Hospital, Yeovil

Purpose: Adhesive capsulitis can develop following trauma or surgery or is idiopathic in nature (with a strong diabetic association); this study aimed to determine whether the underlying aetiology affected patient outcome following treatment with shoulder distension procedure.

Methods: Consecutive distension procedures from a single centre over a 5-year period were retrospectively analysed, using radiology records and outpatient clinic letters. All procedures were performed by a consultant radiologist under fluoroscopic guidance, with an intra-articular injection of 10 mL Bupivacaine, 40 mg Triamcinolone and a further 15 mL of air.

Results: A total of 111 patients with complete records were included (74F:37M, average age 56 (27–84)), with 60 (54%) idiopathic cases and 51 (46%) post-traumatic/surgical. There were 22 (20%) patients with diabetes, and 17 (15%) had a prior diagnosis of adhesive capsulitis in the contralateral shoulder. Subsequent clinic letters, with the latest follow-up at an average of 43 weeks post-procedure (4–207), showed that 67 (60%) patients experienced a good response and required no further intervention for their adhesive capsulitis. The remaining 44 (40%) experienced either temporary relief or no benefit; of this group, 29 (66%) went on to have further procedures (further distension ± arthroscopic capsular release). There was no statistical difference in outcome between traumatic/surgical vs idiopathic groups, and further sub-group analysis revealed that neither diabetes nor age (>60 years) appeared to have an effect. Interestingly, patients with a prior diagnosis in the contralateral shoulder were more likely to experience a good effect from the distension procedure (p = 0.0138).

Conclusion: This study confirms that distension can be effective in the treatment of adhesive capsulitis, with 60% of patients in this series achieving a good outcome, and 74% requiring no further intervention – avoiding the risk and cost of invasive surgery. No clear association between underlying aetiology and the post-procedure outcome has been shown here, and further prospective studies with recorded PROMs are indicated.

RECURRENCE OF FROZEN SHOULDER AFTER HYDRODILATION, WHAT IS THE TRUE INCIDENCE?

M Flintoft-Burt, P Stanier, A Planner, H Thahal and D Woods

The Ridgeway Hospital, Swindon

Purpose: To assess the outcome of hydrodilation for frozen shoulder in an independent hospital setting, in particular recurrence rates, and compares these with reported results from an NHS setting.

Methods: All patients who presented to a single surgeon shoulder clinic from August 2019 to July 2012 with a diagnosis of FS (Pain and restricted range of movement in all planes with a normal plain X-ray) were offered MUA or HD with equipoise. Data collected included age, sex, primary or secondary FS, length of symptoms, diabetic status and any comorbidities. An Oxford Shoulder Score (OSS) was completed prior to the procedure. Using Ultrasound guidance, 40 mg Triamcinolone and local anaesthetic (1025 mL depending on patient tolerance) was injected into the rotator interval. At a mean of 9 months, patients completed a questionnaire recording the level of pain of the procedure, subsequent progress and the need for further treatment, and included their current OSS.

Results: Of 55 patients, six patients had a failure to improve and 10 patients had a transient improvement followed by recurrence (29%). Three patients (5%) found the procedure painful, 14 (25%) moderately painful and 38 (70%) reported no pain. 2/21(9.5%) patients who had 25 mL injected had a recurrence of symptoms.

Conclusions: We report a high incidence of recurrence of FS (41%) in patients who undergo HD in the frozen stage of FS and cannot tolerate more than 20 mL of injection, and a higher incidence in primary versus secondary HD. Patients should be aware of this when choosing their treatment options.

NATIONAL SURVEY ON MANAGEMENT OF RADIAL HEAD FRACTURES

A Barakat, C Mcdonald and H Singh

Shoulder & Elbow Unit, University Hospitals of Leicester NHS Trust, Leicester

Background: This study aims to report on current practices in the management of radial head fractures in the UK.

Methods: A twelve-question online survey on RHF management was sent to surgeon members of the British Elbow and Shoulder Society (BESS) in 2020. Questions focussed on clinical assessment, indications for surgical treatment, patient and fracture-related factors considered in decision making, level of experience of the respondents, and willingness to participate in any future RCT. A non-systematic literature review was conducted to identify previous RCTs regarding RHF management.

Results: The response rate was 20.4% (n = 102). For minimally displaced RHFs, non-operative management with immediate mobilization of the elbow was reported by 90.2% of respondents (n = 92) as opposed to 9.8% (n = 10) for initial immobilization in plaster or brace. The commonest indication for surgical management was a concomitant terrible triad elbow injury in 97% (n = 99) of the responses. For younger patients with displaced RHF, 77.3% (n = 79) opted for radial head preservation either by screw or plate fixation in comparison to 76.4% (n = 78) opting for either replacement or excision in the middle or older-aged patients. The most frequently cited indication for radial head arthroplasty (RHA), as opposed to fixation, was increased patient age or low functional demand in 69.9% of responses (n = 71). Subsequent follow-up protocols also varied with 22.5% (n = 23) of respondents following up non-operatively managed patients for more than six weeks. Finally, 41.2% (n = 42) of respondents indicated the need for a future RCT concerning the management of RHF. Only five RCTs focussed on the management of RHF were returned by the literature review.

Conclusion: This National Survey demonstrates considerable variability in the management of RHF among an experienced cohort of surgeons with a paucity of high-quality RCTs in the existing literature to guide future management.

TERRIBLE TRIAD INJURY; NOT SO TERRIBLE?

M Baker, A Eyre-Brook, K Gokaraju, V Jones, D Thyagarajan, A Ali and S Booker

Department of Orthopaedic Surgery, Northern General Hospital, Sheffield

Introduction: Terrible triad (TT) elbow injuries are reported to have poor outcomes, therefore requiring surgical stabilisation. A 12-case study by Chan et al. advocated considering conservative management in patients with a congruent joint, no mechanical block, a stable range of motion (ROM) and Morrey type 1 or 2 coronoid fractures. We reviewed patients with TTs treated non-operatively within our department.

Methods: We retrospectively reviewed patients with TT injuries treated non-operatively from 2010 to 2020. Indications for conservative management included joint congruency on CT and significant co-morbidities pre-disposing to high-risk surgery or patient preference. We used Mason and Morrey classifications for the radial head (RH) and coronoid fractures respectively. All patients received standardised elbow-instability rehabilitation. Outcomes assessed were the Oxford Elbow Score (OES), ROM and complications.

Results: A total of 20 patients were included (mean age 48 ± 17years; 35% female). Injuries consisted of six Mason type 1, five type 2 and nine type 3 fractures and 12 Morrey type 1, five type 2 and three type 3. At a mean follow-up of 6 years (range 2–11), the mean OES was 45 ± 7. Mean ROM was 130 ± 11° flexion, 10 ± 9° extension, 83 ± 12° supination and 84 ± 13° pronation. All patients with a Mason 3 RH fracture and lesser Morrey-grading coronoid fracture achieved functional ROM. One patient required arthrolysis for stiffness, successfully improving ROM. One incongruent ulno-humeral joint developed clicking but maintained a stable functional ROM (no OES was obtained due to an unrelated death).

Conclusion: Non-operatively managed and appropriately rehabilitated TT injuries can achieve good function and ROM, regardless of Mason or Morrey classification. A Mason or Morrey type 3 injury in a TT does not automatically correlate with poor outcomes. We suggest conservative management as a viable option with a congruent joint and no mechanical block to forearm rotation in patients with significant co-morbidities or those refusing surgery, but patients must be assessed individually.

DOES INFERIOR TRANSLATION OF THE PROXIMAL RADIUS RELATIVE TO THE CAPITELLUM PREDICT THE NEED FOR COLLATERAL LIGAMENT RECONSTRUCTION IN TRANSOLECRANON FRACTURE DISLOCATIONS?

TD Stringfellow, P Subramanian and P Domos

Department of Orthopaedic Trauma, Barnet General Hospital – Royal Free London NHS Foundation Trust, Barnet

Background: Biomechanical studies have shown inferior translation of the proximal radius relative to the capitellum in the sagittal plane can predict the integrity of the collateral ligaments in a transolecranon fracture model; no studies have examined this in clinical practice.

Methods: Nineteen consecutive transolecranon fracture-dislocations were retrospectively reviewed. Data collection included: patient demographics, fracture classifications, surgical management and failure with instability. Distance between the centre of the radial head and the centre of the capitellum was measured on initial radiographs by two independent raters on several occasions. Statistical analysis was used to compare the mean inferior displacement between patients who required collateral ligament repair and those who did not.

Results: Sixteen cases with a mean age of 57 years (32–85) were analysed with an inter-rater Pearson coefficient of 0.89. Three cases were excluded due to inadequate imaging. Mean inferior displacement where collateral ligament repair was needed was 16.3 mm (SD ± 4.5) compared with 7.1 mm (SD ± 7.5) where collateral ligament repair was found not to be needed intra-operatively; p = 0.024. 75% of cases with ligament repair were classified as Wrightington D + , Ring III or Jupiter IIB types. Older patients are more likely required ligament repair (63 vs 50 years; p = 0.108). In three cases, ligament repair was not performed initially but deemed necessary later. Of these, the mean inferior displacement was 14.48 mm (SD ± 2.50) and two of these required revision fixations.

Conclusion: This clinical study can offer some guidance on the impact of radiographic sagittal inferior displacement on the management of transolecranon fracture-dislocations. Where inferior displacement on initial radiographs exceeded 10 mm lateral collateral ligament repair was required in all cases, except for one. If less than 5 mm, ligament repair was not required in any of the cases. Older patients associated with radial head fractures and posterior apex injuries showed a trend toward ligament repair.

OPERATIVE MANAGEMENT DOES NOT IMPROVE ISOMETRIC STRENGTH OR FUNCTIONAL OUTCOMES IN DISPLACED OLECRANON FRACTURES IN ELDERLY PATIENTS

DLJ Morris, A Bennett, K Horton, I Shelton, MP Espag, AA Tambe and DI Clark

Royal Derby Hospital, University Hospitals of Derby and Burton NHS Foundation Trust, Derby

Purpose: Management of displaced olecranon fractures in elderly patients is controversial; with sparse objective evidence to support increasing non-operative management. We aim to contribute additional objective outcomes and report the first isometric strength outcome data in this cohort.

Methods: Retrospective cohort analysis of patients > 70 years presenting with displaced olecranon fracture (Mayo 2/3) with minimum 6-month follow-up. Living patients were contacted to assess function requiring active elbow extension (push open a door, push out of a chair, perform normal activities) and perform an Oxford Elbow Score (OES) and a Visual Analogue Scale (VAS). Six patients (three non-operatives and three operatives) underwent elbow extension isometric strength assessment using a BTE PrimusRS dynamometer with a comparison of the fractured limb to the contralateral limb. A validated, standardised test protocol was utilised with three maximal contractions measured per limb and the mean compared.

Results: Fifty patients fulfilling inclusion criteria were identified; 27 were managed non-operatively and 23 operatively. No significant difference in age (82 vs 79 years), Charlson Comorbidity Index (4.1 vs 4.0) or range of movement achieved (flexion 129° vs 126°; extension 10° vs 13°) between groups. A total of 17 non-operative and 19 operative patients were available for functional outcome assessment. No significant differences in OES (42.5 vs 36.8), VAS (2.2 vs 3.1) or functional outcome between groups. Operative management included 13 tension-band wiring, nine plate fixation and one suture fixation. The complication rate was 35% (four revision fixations, two metalwork removal and two superficial infections). A patient managed non-operatively required subsequent operative intervention due to olecranon fragment migration compressing their ulnar nerve. The mean isometric strength deficit was 31% in non-operative and 25% in operative management.

Conclusions: No significant benefits in isometric strength or functional outcome are evident with operative management of displaced olecranon fractures in elderly patients. The significant operative complication rate supports non-operative management in this cohort.

COMPARISON OF HEMIARTHROPLASTY VERSUS OPEN REDUCTION INTERNAL FIXATION FOR INTRAARTICULAR DISTAL HUMERUS FRACTURES IN OLDER PATIENTS

M Dirckx, S Bellringer and J Phadnis

Royal Sussex County Hospital, University Hospitals Sussex, Brighton

Objectives: This study aims to compare clinical outcomes of patients over 60 years old treated with ORIF (Open Reduction Internal Fixation) or EHA (Elbow Hemiarthroplasty) for multi-fragmentary distal humerus fractures. Background: Intra-articular distal humerus fractures in the older population remain challenging to fix, due to the comminution of fragments and poor bone stock. Recently EHA has gained popularity to treat these fractures, however, no studies exist comparing EHA to ORIF.

Methods: Thirty-six patients (mean age 73 years) treated surgically for a multi-fragmentary intra-articular distal humeral fracture were followed up for a mean duration of 34 months (12–73 months). Eighteen patients were treated with ORIF and eighteen with EHA. The groups were matched for fracture type, demographic characteristics and follow-up time. Outcome measures collected included Oxford Elbow Score (OES), Visual Analogue Pain Score (VAS), range of motion (ROM), complications, re-operations and radiographic outcomes. The quality of ORIF was judged against set radiographic criteria in order to understand the effect of the sub-optimal ORIF technique.

Results: No significant clinical difference was found between EHA and ORIF in mean OES (42.5 vs 39.6, p = 0.28), mean VAS (0.5 vs 1.7, p = 0.08) or mean flexion-extension arc (123° vs 112°, p = 0.12). There were significantly more complications associated with ORIF compared to EHA (39% vs 6%, p = 0.04). ORIF executed with satisfactory radiographic fixation technique did not have a significantly higher complication rate compared to EHA (17% vs 6%, p = 0.6). Two ORIF patients required revision to Total Elbow Arthroplasty (TEA). None of the EHA patients required revision surgery.

Conclusion: This study demonstrated similar short-term functional outcomes between EHA and ORIF for the treatment of multifragmentary intra-articular distal humeral fractures in patients > 60 years of age. Early complications and reoperations were higher in the ORIF group, although this may be improved with strict attention to the ORIF technique.

OBSERVATIONAL STUDY OF ISOLATED GREATER TUBEROSITY FRACTURES

M Durand-Hill, SS Chitnis, A Korman and P Domos

Department of Trauma and Orthopaedic Surgery, Barnet General Hospital, Barnet

Purpose: Isolated greater tuberosity (GT) humerus fractures are common injuries. Our aim was to report the clinical and radiological outcomes.

Methods: Isolated GT fractures were identified in a 10-year period with minimum of 2 years follow-up. Clinical outcomes were assessed by Oxford Shoulder Score (OSS), DASH, VAS for pain and Subjective Shoulder Value (SSV). Radiological outcomes were described according to Mutch classification, degree of displacement and time to union. Correlations and statistical analysis were performed using SPSS.

Results: A total of 37 patients (14 males) were identified with complete data (median follow-up: 6.1 years). The median age at injury was 51.3 years with time to the union to 40.3 days. Delayed union occurred in 13.5%, it was associated with lower OSS (p = 0.023). One patient required an open reduction internal fixation. A total of 45.9% of patients had avulsion, 37.8% split and 13.5% depression fractures. The mean age in the depression group was lower (53 vs 55 vs 34 years, respectively; p = 0.033). Avulsion fractures had lower PROM scores, which borderline reached the Minimal Clinically Important Difference (MCID) threshold. Split fractures showed a trend for shorter time to union (36 vs 42 vs 42 days). A total of 40.5% of patients had undisplaced and 21.6% displaced (> 5 mm) fractures. The undisplaced group had better OSS (p = 0.415) and showed MCID threshold. Patient-acceptable symptom state (PASS = SSV > 71%, OSS > 43) had negative correlation with delayed union (p = 0.045, p = 0.002).

Conclusion: Our study reported a lower mean age for depression, worse PROMS in avulsion and faster union with split fractures. OSS/DASH scores were better in the undisplaced group.

ISOLATED SURGICAL NECK OF HUMERUS FRACTURES: RETROSPECTIVE ANALYSIS OF FUNCTIONAL OUTCOMES

O Al-Obaedi, S Madanipour, S Chitins, E Slade, M Chelli and P Domos

Department of Orthopaedic Surgery, Royal Free NHS Trust, Wellhouse Lane, Barnet

Purpose: Assess the functional and radiographic outcomes of isolated surgical neck of humerus (SNOH) fractures at a minimum one-year follow-up post-injury.

Methods: Radiological and clinical data were collected retrospectively. Initial and final neck-shaft angle (NSA), degree of head deformity, shaft displacement, and comminution were analysed. Patient survey at minimum 18 months post-injury was performed to obtain the Subjective Shoulder Value (SSV), Oxford Shoulder score (OSS), Quick DASH (QDASH), and the visual analogue scale (VAS) pain score.

Results: A total of 33 patients with a mean age of 66 years (22–93) were included with a mean follow-up of 57 months (18–106). The median VAS was 1.5 (0–8). The median OSS, QDASH and SSV scores were, respectively, 43 (17–48), 16 (0–75) and 77 (10–100). Fractures united in 32 patients (97%) within a mean time of 48 days (24–102). However, 39% had delayed union of greater than 45 days. This group had a greater mean medial hinge displacement (MHD) of 10.9 mm versus 5.8 mm in the non-delayed union group (p = 0.0235). Age > 65 years and male gender patients demonstrated shorter union time (p = 0.016 and p = 0.055, respectively). Mean NSA decreased by 6° between initial and follow-up radiographs (139; 117–162, p = 0.007).

Conclusion: Isolated SNOH fractures have good outcomes. Elderly and/or male patients had a quicker time to union with a tendency towards union in mild varus, but with no statistically significant effect on outcomes. MHD is a potential radiological predictor of delayed union.

CEMENTLESS TOTAL SHOULDER REPLACEMENT FOR THE TREATMENT OF ACUTE PROXIMAL HUMERUS FRACTURES: AN 8-YEARS FOLLOW-UP

P Anstasopolous, I Bachar Avnieli, P Consigliere, G Sforza and O Levy

Reading Shoulder Unit, Berkshire Independent Hospital, Reading

Purpose: The purpose of this study was to prospectively evaluate the clinical and radiographic outcomes of a cementless total shoulder replacement in acute proximal humerus fractures. Background rTSA (Reverse Total Shoulder Replacement) has gained popularity in recent years as a treatment for proximal humeral fractures. It has been traditionally performed with cement and it has shown favourable outcomes. An uncemented humeral prosthesis may provide several benefits over a cemented prosthesis, including a shorter operative time and avoiding cement-related morbidity and complications, especially in revision surgery.

Materials and methods: From 2007 to 2019, 50 patients underwent a cementless rTSA for acute proximal humerus fractures. Fifteen patients were excluded from postoperative evaluation. All operations were performed through the anterosuperior approach. Stemmed cementless implants were used. Tuberosities were fixed to the proximal humerus through drill holes in a double-row construct. The mean age was 80.23 years (± 10.39, range 40–94) with seven male (20%) and 28 female (80%) patients. The mean follow-up time was 25 months (± 24.17, range 2–106 months) and the mean time from fracture to rTSA was 2 weeks.

Results: At the last FU mean forward flexion was 125.4° (range 30^o–180° ± 42.7°), abduction 120° (range 30–180° ± 43.2°), internal rotation 70.2° (range, 30^o–90° ± 21.2°) and external rotation 27.7° (range 0^o–70° ± 17.9°). The mean Constant Score was 59.54 (range 24–92 ± 18) (age-adjusted, 90.97). Patient satisfaction was high, with 18 (51.43%) reporting excellent results, 13 (37.14%) good results, and the remaining 4 (11.43%) rated their outcome as fair. No patients were dissatisfied. No complications were recorded while tuberosity healing was achieved in 82.86% of the cases (n = 29).

Conclusion: Cementless RTSA for acute proximal humerus fractures demonstrates excellent results and patient satisfaction similar to cemented RTSA. Using a cementless implant did not result in early loosening making its use promising in the long term.

THE TREATMENT OF HUMERAL SHAFT FRACTURES IN THE ELDERLY: A FIVE-YEAR RETROSPECTIVE REVIEW IN A MAJOR TRAUMA CENTRE

M Gibby, C Fox and A Bott

Department of Trauma and Orthopaedics, Southmead Hospital, Bristol

Introduction: Humeral shaft fractures in elderly patients are routinely managed in a functional humeral brace, however, this can be associated with considerable morbidity. This study aims to assess the outcomes of humeral shaft fractures in the elderly in a major trauma centre.

Methods: Patients aged over 65 with a fracture of the humeral shaft from 2016 to 2020 were included. Pathological and periprosthetic fractures were excluded. Data was collected retrospectively using patient notes, electronic records and radiographs.

Results: Within the time period 61 patients with a mean age of 77 years (65–92 years, M:F 7:1) sustained a fracture of the humeral shaft. Injuries were the result of falls from standing height in 92% of cases, the remainder high energy polytraumas. 8% sustained an associated radial nerve palsy, half of which were high-energy injuries. One patient sustained an open fracture. 89% of patients were initially managed conservatively in a humeral brace. 64% of patients required inpatient admission. The average number of fracture clinic visits was 6 (range 1–19). 5% of patients experienced brace associated skin problems. 20% of patients developed a non-union and 16% required non-union surgery. At one-year post-injury, the mortality rate was 3% and 11% no longer live independently.

Conclusions: Our study demonstrates humeral shaft fractures in the elderly have a significant impact on both the patient and the healthcare system. These patients require significant support with both inpatient admission and frequent fracture clinic reviews. Furthermore, the rate of nonunion is high. We have shown high levels of morbidity in elderly patients with humeral shaft fractures. This opens the discussion as to whether non-operative management is optimal in this particular patient cohort.

ROUTINE FIXATION OF HUMERAL SHAFT FRACTURES IS COST-EFFECTIVE AT 5 YEARS POST-INJURY: COST-UTILITY ANALYSIS OF A RETROSPECTIVE COHORT OF 215 PATIENTS

WM Oliver, SG Molyneux, TO White, ND Clement and AD Duckworth

Edinburgh Orthopaedics, Trauma, Royal Infirmary of Edinburgh, Edinburgh

Purpose: The primary aim was to estimate the cost-effectiveness of routine fixation for patients with humeral shaft fractures, in order to prevent non-union following non-operative management. The secondary aim was to estimate the health economic implications of using the Radiographic Union Score for HUmeral fractures (RUSHU) to facilitate selective fixation for patients at risk of non-union.

Methods: From 2008 to 2017, 215 adult patients (mean age 57 years, 61% female) with a non-operatively managed humeral diaphyseal fracture were retrospectively identified. Union was achieved by 77% (n = 165/215) after initial management and 23% (n = 50/215) after non-union surgery. The EuroQol Five-Dimension health index (EQ-5D) was obtained via postal survey. Multiple regression was used to determine the independent influence of patient, injury and management factors upon the EQ-5D. An incremental cost-effectiveness ratio (ICER) of <£20,000 per quality-adjusted life-year (QALY) gained was considered cost-effective.

Results: At a mean of 5.4yrs (range 1.2–11.0), the mean EQ-5D was 0.736 (95% CI 0.697–0.775). The adjusted analysis demonstrated the EQ-5D was superior among patients who avoided non-union (beta = 0.103, p = 0.032). Offering routine fixation to all patients in order to prevent non-union was associated with increased overall treatment costs of £1656/patient but conferred a potential EQ5D benefit of 0.120/patient over the 5-year period of study follow-up. The ICER of routine humeral shaft fracture fixation was £13,830 per QALY gained. Selective fixation based on a RUSHU.

Conclusions: Routine fixation for patients with humeral shaft fractures, in order to prevent non-union following non-operative management, appears to be a cost-effective intervention at 5 years post-injury. Moreover, selective fixation of patients at risk of non-union based upon their RUSHU may confer even greater cost-effectiveness, given the potential cost savings involved.

Session 3: Elbow

DEVELOPMENT OF A CORE OUTCOME SET FOR LATERAL ELBOW TENDINOPATHY USING THE BEST AVAILABLE EVIDENCE AND AN INTERNATIONAL CONSENSUS PROCESS

M Bateman, JP Evans, V Vuvan, V Jones, AC Watts, J Phadnis, L Bisset and B Vicenzino

Derby Shoulder Unit, University Hospitals of Derby & Burton NHS Trust, Royal Derby Hospital, Derby

Objectives: To develop a Core Outcome Set for Lateral Elbow Tendinopathy (COS-LET) and to provide guidance for outcome evaluation in future research and clinical practice.

Methods: We implemented a multi-stage mixed-methods design combining two systematic reviews, domain-mapping of outcome measurement instruments to the core domains of tendinopathy, psychometric analysis of the instruments identified using the EMPRO scoring system, two patient focus groups and a Delphi study incorporating two surveys and an international consensus meeting. Following the OMERACT guidelines, we used a 70% threshold for consensus. We gained ethical approval from the University of Queensland research ethics committee (reference 2020001340) and registered the protocol with the COMET database (reference 1497).

Results: A total of 38 clinicians/researchers and nine patients participated. After reviewing 256 full-text papers, 60 outcome measurement instruments were identified and assessed for inclusion. The only instrument that was recommended for the COS-LET was the Patient Rated Tennis Elbow Evaluation (PRTEE) for the disability domain. For the other domains, we agreed to use the following interim measures: the PRTEE function sub-scale for the function domain; PRTEE pain sub-scale items 1, 4 and 5 for the pain over a specified time domain; pain-free grip strength for the physical function capacity domain; a numerical rating scale measuring pain on gripping for the pain on activity/loading domain; and time off work for the participation in life activities domain. No recommendations could be made for the quality-of-life, patient rating of condition and psychological factors domains.

Conclusions: The COS-LET comprises the PRTEE for the disability domain. Interim-use recommendations include PRTEE items, time off work, pain-free grip strength and a numerical rating scale measuring pain on gripping. Further work is required to validate these interim measures and develop suitable measures to capture the other domains.

THE COMPARATIVE PERFORMANCE OF RADIAL HEAD PROSTHESES IN PATIENTS YOUNGER THAN AND OLDER THAN 50 YEARS: A SYSTEMATIC REVIEW

J Heifner, A Rivera, L Wells and D Mercer

University of New Mexico Department of Orthopaedics and Rehabilitation, USA

Purpose: Although radial head arthroplasty cases occur across a broad age distribution, outcomes should be evaluated within more narrow age limits.

Methods: Article inclusion criteria for this systematic review required individual patient data for age, surgical treatment, and appropriate outcome metrics. Articles were grouped based on patient age of under 50 and over 50 years and within those age groups, based on the arthroplasty being performed as a primary or as a secondary procedure.

Results: There were no significant differences between the under 50 and the over 50 groups for the Mayo Elbow Performance Score (p = 0.79) and for implant revision/removal (p = 0.32). In the under 50 groups, RHA done as a primary procedure had significantly higher (p = 0.001) mean MEPS than RHA done as a secondary procedure. In the over 50 groups, the relative risk was 2.39 (95% CI 2.12–2.69) for implant revision/removal (p = 0.11) when comparing primary and secondary procedures.

Conclusion: Our findings provide guidance to surgeons who face a multifaceted decision when encountering younger adult patients with radial head fracture patterns that may not be amenable to fixation. Awareness of the age-specific performance of radial head implants is an important component of the decision for surgical treatment.

COMMON ELBOW CONDITIONS: RESEARCH PRIORITIES SETTING IN PARTNERSHIP WITH THE JAMES LIND ALLIANCE

P Raval, H Chong, P Divall, J Gower and H JLA Singh

Elbow Authorship Group University Hospitals of Leicester, Leicester

Objective: To establish the research priorities for common elbow conditions (CEC) and be representative of patients, carers, and healthcare professionals (HCP) Setting: This was a national study organised by the musculoskeletal research group based in Leicester.

Participants: Patients, over 18, who have or had elbow conditions, their carers and HCP in the UK are involved in the managing CEC.

Methods: The rigorous JLA priority setting methodology was followed. Electronic and paper scoping surveys were distributed nationally. Responses were reviewed and categorised. A literature search enabled cross-checking of categorised questions. Those questions, found to be unanswered, were taken to a second survey where respondents identified their top questions for future CEC research. Using the JLA methodology responses from HCP and patients were combined to create an overall list of the top 18 questions. These were taken to a multi-stakeholder workshop where the top 10 research priority questions (RPQs) were ratified.

Results: The process was completed over 24 months. The initial survey resulted in 467 questions from 165 respondents, 73% HCP and 27% being patients/carers. These questions were reviewed and classified into 46 summary questions broadly under tendinopathy, biceps tendon pathology, arthritis, stiffness, trauma, arthroplasty, and cubital tunnel syndrome. The second (interim prioritisation) survey had 250 respondents, 72% healthcare professionals and 28% being patients/carers. The top 18 ranked questions from this survey were taken to the final workshop where a consensus was reached on the top 10 RPQs.

Conclusions: The top 10 RPQs highlight uncertainties in the optimal treatment for a range of CEC including which non-surgical and surgical treatments are most effective. Furthermore, they highlight the paucity of research in optimising rehabilitation and pain management in CEC. Through this process, we hope to enable researchers and funders to provide salient answers on topics that will benefit patients, carers and treating HCPs.

THE NATIONAL JOINT REGISTRY DATA QUALITY AUDIT OF ELBOW ARTHROPLASTY: NJR DQA-ELBOWS

Z Hamoodi, J Shapiro, R Swinson and AC Watts

NJR DQA-Elbows Collaborative Upper Limb Unit, Wrightington Hospital, Wigan

Aim: This audit aims to assess and improve the completeness and accuracy of the National Joint Registry (NJR) elbow dataset.

Methods: A retrospective national audit was undertaken in collaboration with NJR, BOTA, BOA, BESS, and RCSEng. NJR elbow data was compared to the Hospital Episode Statistics dataset to identify missing episodes from April 2012 to April 2021. For data accuracy, implant components of each procedure were compared to the notified type of procedure, and mismatches were marked as inaccurate. Missing and inaccurate procedures were shared with each hospital to undertake a local audit to (1) confirm if the data was missing/inaccurate, (2) examine the causes and (3) add the missing and correct the inaccurate procedures in the NJR dataset. This is the first audit of its kind to recruit a trainee network to facilitate the audit process.

Results: The audit identified 5446 missing and 437 inaccurate procedures in 224 hospitals. Of those 224 hospitals, 177 are taking part and 70 already completed the audit. In those 70 hospitals, 2093 procedures were audited, 1921 missing and 172 were inaccurate procedures. For the missing procedures, 1434 (75%) were confirmed as missing and added to the dataset, 207 (11%) were already in the NJR, and 165 (9%) were not NJR elbow procedures. The majority of missing procedures (74%) were radial head arthroplasties. Out of the 172 inaccurate procedures, 137 (80%) had missing implants, 31 (18%) had the incorrect procedure and 4 (2%) had the wrong side reported to NJR. The audit finishes at the end of February 2022 and the final outcome will be presented.

Conclusion: The NJR elbow audit has identified challenges of data capture and accuracy, mainly with respect to radial head arthroplasty procedures, and has increased the number of recorded episodes substantially. Engagement with BOTA proved a successful method of audit completion.

NO TOURNIQUET TOTAL ELBOW ARTHROPLASTY

CW Jenkins, AC Wright, IA Trail and AC Watts

Upper Limb Unit, Wrightington Hospital, Wrightington, Wigan and Leigh NHS Foundation Trust, Wigan

Purpose: To evaluate whether tourniquet use during implantation of the prosthesis affects outcomes in total elbow arthroplasty.

Methods and results: A single-centre retrospective observational study was undertaken. All patients who had undergone primary total elbow arthroplasty with a Latitude prosthesis between January 2014 and June 2018 were eligible for inclusion. The subjective outcome was assessed using the Oxford Elbow Score (OES); the Quick Disabilities of the Arm Shoulder and Hand Questionnaire (QuickDASH); the patient completed portion of the American Shoulder and Elbow Surgeons Elbow Score (ASES-E); and the Mayo Elbow Performance Index (MEPI). The objective outcome was assessed by measuring elbow ranges of motion with a hand-held goniometer. A total of 20 patients eligible for inclusion had undergone review at a minimum of 2 years post-surgery. Tourniquets were utilised in 13 patients with a mean age of 59 (range: 33–83) years, surgery performed with administration of pre-operative tranexamic acid and no tourniquet in seven patients with a mean age of 68 (range: 59–76) years. A post-operative drain was inserted in one patient from each group. Indications for surgery (tourniquet versus no tourniquet) were rheumatoid arthritis (10/13 vs 5/7), fracture (2/13 vs 1/7) and osteoarthritis (1/13 vs 1/7). The mean decrease in haemoglobin was 11.6 g/L with tourniquet use compared to 10 g/L without a tourniquet, with no patients requiring post-operative transfusion. Active flexion-extension arc of motion was on average 13° higher without tourniquet use, 121° compared to 108° with a tourniquet. Mean outcome scores in the tourniquet versus no tourniquet groups were OES 38.5 versus 33.5, QuickDASH 43.2 versus 36.9, ASES-E 33.1 versus 31.2 and MEPS 89 versus 91.

Conclusion: Preliminary data suggests that total elbow arthroplasty without tourniquet use results in increased motion and functional outcome on average without increased blood loss or transfusion requirement.

THE ‘DETECT’ STUDY – DEFINING TENNIS ELBOW CHARACTERISTICS

AJ Paluch, E Burden, T Batten, B Knight, R Anaspure, S Aboelmagd, JP Evans and C Smith

Princess Elizabeth Orthopaedic Centre, Royal Devon and Exeter NHS Foundation Trust, Exeter

Introduction: Radiological findings on Magnetic Resonance Imaging (MRI) in patients with a clinical diagnosis of Lateral Elbow Tendinopathy (LET) are presumed pathological, however, no previous study has prospectively determined the prevalence of these changes in an asymptomatic population. This study aimed to assess the prevalence of radiographic lateral elbow pathology in an asymptomatic population using 3.0T MRI.

Methods: Bilateral elbow MRI was undertaken in thirty asymptomatic volunteers aged 35–65 years. Exclusion criteria included the presence of elbow pain within 3 months, history of elbow trauma or previous diagnosis of LET. Hand dominance, occupation and BMI were recorded along with baseline patient-reported outcome measures (QuickDASH and EQ-5D5L/VAS). Two fellowship-trained musculoskeletal radiologists reported the scans independently. Radiological abnormalities were graded using a previously published classification system, where the degree of injury at the common extensor tendon (CET) is described as normal (no thickening), mild (thickening), moderate (fluid-filled gap 80% of tendon thickness).

Funding: British Elbow and Shoulder Society pump priming grant.

Results: Thirty volunteers were categorised according to age; 35–45 (n = 10), 45–55 (n = 11), 55–65 (n = 9) with a 1:1 male to female ratio. QuickDASH score was zero in all but two who reported occasional shoulder pain. Kappa for the radiographic agreement was 0.91 (0.83–0.98). Radiological evidence of tendon injury was found in 37% of volunteers. The proportion with abnormal findings increased with age; 35–45 (10%), 45–55 (36%), 55–65 (67%) and BMI; healthy (23%), overweight (43%), obese (67%). Changes were classified as ‘mild’ or ‘moderate’, with a single volunteer showing ‘severe’ injury.

Conclusion: This study demonstrates that CET pathology on MRI is relatively common in an asymptomatic population and appears to increase in prevalence with age and BMI. The diagnostic and prognostic value of MRI imaging in LET, therefore, remains unclear.

ELBOW ARTHROPLASTY RESEARCH METHODS AND OUTCOME DOMAINS AND INSTRUMENTS IN CLINICAL OUTCOME STUDIES: A SCOPING REVIEW

AC Watts, Z Hamoodi, C McDaid and C Hewitt

Upper Limb Unit, Wrightington Hospital, Wigan

Aim: This review aims to map current research methods, outcome domains and instruments, and funding sources in elbow arthroplasty to inform the development of future research methods.

Methods: A scoping review was undertaken, adhering to the Joanna Briggs Institute (JBI) guidelines, using Medline, Embase, CENTRAL, and trial registries. Strict inclusion/exclusion criteria were used. The screening and study selection were undertaken by two reviewers. The results are presented as frequency counts of types of studies reported sample size, length of follow-up, clinical outcome domains and instruments used, funding sources and a narrative review.

Results: From a total of 2197 titles, 365 studies met the inclusion criteria. Most studies were retrospective 327/365 (91%) and observational 316/365 (87%). There were 11 prospective randomised controlled trials (RCTs) and one retrospective review of a previous RCT. Only one RCT stated the source of funding which was from a commercial source. The median sample size for all implant types is 36 implants (range 10–56379). The median of the reported mean length of follow-up for all study types is 56 months (range 1–216). A total of 583 outcome descriptors were identified and categorised into 18 domains; Adverse events, Physical function, MSK connective tissue, Need for further intervention, Nervous system, Hospital resources, Delivery of care, Social function, Role function, Perceived health, Mortality/Survival, Economic resource, Psychiatric, Emotional wellbeing, Quality of life, Cognitive function, Personal circumstances and Societal carer burden. A total of 105 instruments were used to measure 39 outcomes, of which 26 were clinical and 13 were radiographic outcomes.

Conclusion: This scoping review shows that the majority of published research into elbow arthroplasty consists of unfunded retrospective observational studies with small sample sizes and short follow-ups. A large number of different outcome descriptors with a high number of outcome instruments used indicates the need to define a core outcome set for elbow arthroplasty.

THE OPTIMAL DRILL ANGLE TO MINIMISE THE RISK OF POSTERIOR INTEROSSEOUS NERVE INJURY DURING DISTAL BICEPS TENDON SUSPENSION BUTTON REPAIR

S Arnold and H Vidakovic

Department of Orthopaedic Surgery, Canterbury District Health Board, Christchurch, New Zealand

Aim: Given the paucity of existing in vivo evidence, this study aimed to determine the optimal drill angle of the bicipital tuberosity to maximise the distance between the bone tunnel and the PIN, using the accurate modality of magnetic resonance imaging (MRI).

Methods: Ethical approval was obtained from the regional ethics committee. A retrospective study was undertaken using electronic imaging records. Thirty MRI neurography studies of the elbow were identified. The centre point of the footprint of the biceps tendon was identified, and from this point simulated a drill perpendicular to the anterior plane of the bicipital tuberosity was. From this perpendicular axis, we simulated ulnar, radial, proximal, and distal drill angles in 10° increments. The shortest distance between the simulated tunnel and the PIN was measured at each angle, along with the associated bone tunnel length. A bone tunnel length of 8 mm or greater was determined acceptable, based on current biomechanical strength modelling.

Results: We determined that 20° of ulnar angulation maximized the distance between the drill and the PIN (5.95 mm ± 0.5 mm) while maintaining a bone tunnel length of over 8 mm (8.35 mm ± 0.8 mm). We determined that 30° of distal angulation maximized the distance between the drill and the PIN (7.95 mm ± 0.4 mm) while maintaining a bone tunnel length over 8 mm (8.0mm ± 0.8 mm). Further angulation resulted in an average bone tunnel length of less than 8 mm, and reduced angulation endangered the PIN. A simulated combined drill angle of 20° ulnar and 30° of distal angulation provided the safest distance between the drill and the PIN (12.15 mm ± 0.9 mm) while maintaining an acceptable bone tunnel length (8.15 mm ± 0.5 mm).

Conclusion: This study suggests an optimal drill angle of the bicipital tuberosity is a combined 20° of ulnar and 30° distal angulation to minimise risk to the PIN, with acceptable bone tunnel length.

SENSITIVITY AND SPECIFICITY OF THE POSTEROLATERAL ROTATORY DRAWER TEST IN THE DIAGNOSIS OF LATERAL COLLATERAL LIGAMENT INSUFFICIENCY OF THE ELBOW

S Venkatakrishnan, A Stone and J Phadnis

Department of Trauma & Orthopaedics, Royal Sussex County Hospital, Brighton

Purpose: Calculate sensitivity and specificity of posterolateral rotatory drawer test (PLRDT) against accepted reference standards for diagnosis of lateral collateral ligament insufficiency.

Methods: Eighty-four consecutive patients with PLRDT performed during the outpatient clinical assessment were included. The PLRDT was graded as 0–3 where 0 was no reproducible posterolateral drawer; 1 was lax but equal to the normal elbow; 2 was greater than the normal elbow and 3 was positive with an obvious clunk. Grades 0 and 1 were considered PLRDT negative and 2 and 3 were considered PLRDT positive. The PLRDT was compared to either diagnostic arthroscopy (66 patients) or examination under anaesthetic (EUA) (81 patients) as reference standards for diagnosis of LCL insufficiency. PLRDT was compared to each reference standard individually and combined as there is no accepted gold standard. Sensitivity, specificity, Positive predictive value (PPV) and Negative predictive value (NPV) were calculated.

Results: Fifty-eight patients had a negative PLRDT, and 26 Patients had a positive PLRDT against a reference standard of diagnostic arthroscopy (n = 66), the PLRDT has a sensitivity of 92.3% and a specificity of 98.1% (PPV = 0.92, NPV = 0.98) Against a reference standard of EUA (n = 81), the PLRDT has a sensitivity of 96.2% and a specificity of 98.2% (PPV = 0.96, NPV = 0.98). There were no discrepancies in diagnosis in the 64 patients undergoing both reference tests. When comparing the PLRDT to the result of either reference test (n = 84), the PLRDT has a sensitivity of 96.2% and a specificity of 98.3% (PPV = 0.96, NPV of 0.98).

Conclusion: Commonly used clinical tests for posterolateral rotatory instability (PLRI) of the elbow show variable sensitivity and specificity. The PLRDT demonstrates high sensitivity and specificity in the diagnosis of LCL insufficiency when performed in the awake patient in the outpatient setting. We recommend this test as the primary clinical tool for the diagnosis of LCL insufficiency and PLRI of the elbow.

Session 4: Basic science and miscellaneous

DIAGNOSTIC ACCURACY OF PRIMARY AND INTERMEDIATE CARE TEAMS FOR SHOULDER DISORDERS; IS THIS INFLUENCED BY ULTRASOUND IMAGING?

D Birchall, P Kankanalu, A Ebinesan and B Roy

Manchester University NHS Foundation Trust, Manchester

Aim: The aim of this retrospective study is to determine the diagnostic accuracy of primary and intermediate care teams on shoulder disorders and to determine if ultrasound imaging influences the diagnostic accuracy.

Methods: Between January and December 2021, we retrospectively reviewed all consecutively referred primary and intermediate care team's referrals to specialist shoulder clinics at two hospitals within the same organisation. The source of referral, referral diagnosis, and imaging performed was collected from the referral document. Patient medical records were reviewed to obtain specialist clinic diagnoses and outcomes. Accuracy of diagnosis was established using the kappa(K) statistics.

Results: A total of 494 referrals were received of which General practitioners (GP) referred 396 (80%); Intermediate care (IC) 67 (13%) and First contact practitioners (FCP) 31 (6%). 50% were females with a mean age of 56 years (16–96). Overall, no diagnosis was stated in 221 (44%) with all of these referrals exclusively from GPs. When the diagnosis was stated in 273, the overall diagnostic agreement with the specialist clinic diagnosis measured using kappa statistic was 0.466 (Moderate agreement); 0.493 (moderate) for GPs; 0.398 (fair) for intermediate care and 0.370 (fair) for FCP referrals. Among the 230 (46%) patients who had ultrasound scans prior to referral, no diagnosis was stated in 154 (67%) referrals and when the diagnosis was stated in 76, the overall diagnostic agreement with the specialist clinic remained the same with a kappa of 0.441 (from 0.466). 55 (24%) of the 230 who had ultrasound scans prior to referral needed surgery.

Conclusion: In conclusion, the diagnostic accuracy of intermediate and primary care teams is fair to moderate when the diagnosis is stated. This does not substantially improve with the use of Ultrasound scans. Therefore, the recommendation is that ultrasound scans are not routinely performed in primary care.

FUNCTIONAL BRACING OF HUMERAL SHAFT FRACTURES – THERMOPLASTIC VERSUS COMMERCIAL BRACES

C Manwani, T Yarashi, K Studnicka and M Kent

Liverpool University Hospitals NHS Foundation Trust, Trauma and Orthopaedic Surgery Broadgreen Hospital, Liverpool

Background: Functional bracing of humeral shaft fractures is accepted as the gold standard for non-operative treatment. There remains limited research into the types of braces used to treat those fractures.

Aim: To compare the outcomes following the use of custom-made thermoplastic versus commercial humeral brace with regards to time to union, non-union rates, types of non-union and conversion to surgery.

Methods: All patients treated with a humeral brace between 2018 and 2020 at two major hospitals in the same city were reviewed. One hospital used a commercial brace for all patients and the other a custom thermoplastic brace. This allowed two consecutive case series. Only diaphyseal humerus fractures (AO 12) were included in the study. Demographic and health data was collected from the medical records. All X-rays were reviewed for union (three or more cortices united) and time to union.

Results: A total of 74 patients were treated with a thermoplastic brace and 71 with a commercial brace. Similar gender and age distribution with a mean age of 61 (29–91) years and 1:1.4 M:F ratio in the thermoplastic group in comparison with the mean age of 63 (25–95) years and 1:1.6 M:F ratio in the commercial one was identified. Union occurred in more patients treated with a thermoplastic brace 72% versus 55% (p = 0.04, chi-squared test). Although the time to union was similar in both groups (5.0 vs 5.4 months), hypertrophic non-union was twice as common with the commercial brace (4 vs 8 cases). Conversion to surgical treatment was also performed more frequently in this group (11 vs 14 cases).

Conclusion: In our study, the union rates were better with thermoplastic splints and there were more hypertrophic non-unions in the commercial group. This is most likely due to the combination of better fit provided by custom-made brace leading to improved fracture stability and compliance with the treatment.

A GENOME-WIDE ASSOCIATION STUDY OF FROZEN SHOULDER IDENTIFIES A COMMON VARIANT OF WNT7B AND HYPERGLYCEMIA AS CAUSAL RISK FACTORS

HD Green, JP Evans, A Jones, JI Chen, K Patel, AR Wood, RN Beaumont, J Tyrrell, TM Frayling, AT Hattersley, RA Oram, J Bowden, I Barroso, CD Smith and MN Weedon

Genetics of Complex Traits, University of Exeter Medical School, Exeter

Aims: This study aimed to identify genetic variants associated with frozen shoulders and to use Mendelian randomisation to test the causal role of diabetes and hyperglycaemia. Frozen shoulder is characterised by pain and limitation of movement. It is a cause of marked disability and can have a profound effect on the quality of life. Despite extensive study, little is known about the aetiology of the condition, but diabetes is a strongly associated risk factor.

Method: We performed a genome-wide association study (GWAS) of frozen shoulder in the UK Biobank using data from 2064 cases identified from ICD-10 codes. We used data from FinnGen for replication. We performed Mendelian randomisation (MR) analyses using genetic variants associated with type 1 diabetes, type 2 diabetes and HbA1c to test for a causal effect. Finally, we used rare GCK variants that cause lifelong stable hyperglycemia (∼10 mmol/mol raised HbA1c) as an independent instrument to test the causal role of long-term high blood sugar levels on frozen shoulders.

Results: We identified a single genome-wide significant locus (lead SNP rs62228062; OR = 1.34 (95% CI: 1.28, 1.41) p = 2 × 10⁻¹⁶) that contained WNT7B. Using MR, we found evidence for a causal role of T1D (p = 0.0029) and increased HbA1c (p = 1.7 × 10⁻⁶). In addition, the 83 carriers of pathogenic GCK variants were associated with frozen shoulder (OR 11.3 (95% CI: 3, 30.4) p = 0.00055). There was no evidence that obesity was causally associated with frozen shoulder, suggesting that diabetes influences the risk of the condition through glycemic rather than mechanical effects.

Conclusions: We have identified the first genetic variant associated with frozen shoulders. WNT7B is a potential causal gene at the locus. Diabetes and high lifelong blood sugar are likely causal risk factors. Our results provide evidence of biological mechanisms involved in this common and painful condition.

HOW DOES THE ANTERIOR DELTOID PROGRAM WORK: EMG STUDY INDICATES ROLE FOR PERI-SCAPULAR MUSCLES

H Tunnicliffe, D Elliot, MTG Pain, G Blenkinsop and A Armstrong

University Hospitals of Leicester, Loughborough University, Leicester

Purpose: To identify the effect of the anterior deltoid rehabilitation programme on muscle activations, as determined by surface electromyography (sEMG), in patients with acute massive rotator cuff tears Methods: Fifteen patients (77 + 5 years); four females with acute massive rotator cuff tear (> 3 cm) were treated with the Ainsworth (2006) physiotherapy programme. SEMG was recorded from 11 muscles around the shoulder pre and post-treatment. On each visit patients performed maximal isometric control contractions and functional tasks: arm raised to 90° from neutral and holding 0.5 kg, and ‘hand behind the back’. Tasks were repeated five times, self-paced. SEMG signals were normalised to maximum values per muscle, per patient, and per visit. Peak normalised sEMG amplitudes were statistically analysed (two-way mixed ANOVA, subscapularis torn or not, and time). SEMG was also separately assessed by ordinal ranking for improvements with activation patterns moving towards a healthy profile.

Results: All patients significantly improved objectively and subjectively in function and pain levels following physiotherapy (requiring no further treatment). All but one of the bottom seven ranked patients had a subscapularis tear (ST group). Flexion tasks had a significant interaction affect.

Conclusion: This study shows the programme works through changes in periscapular muscles, not just the deltoid. It may indicate a role for integrating them into the physiotherapy regime.

SCAPULAR MUSCLE ACTIVATION IN ELITE SWIMMERS WITH SHOULDER PAIN

S Sabzehparvar, OA Khaiyat, B Ganji Namin and H Minoonejad

Department of Physical Education and Sports Sciences, Karaj Branch, Islamic Azad University Karaj, Iran

Aim: The study aimed to determine and compare the activation pattern of selected shoulder girdle muscles in elite swimmers with and without shoulder pain.

Methods: Twelve professional swimmers with shoulder pain (mean age: 18.55 ± 3.16 years, body mass: 74.33 ± 2.91 kg and height: 179.00 ± 5.29 cm) and twelve swimmers without pain (mean age: 18.11 ± 1.61 years, body weight: 73.33 ± 6.06 kg and height: 178.33 ± 5.07 cm) were recruited. In a standardised seating position, participants made pencil marks in three circles in a counterclockwise direction with the affected hand. The circles had a dimension of 70 mm and formed the corners of an equilateral triangle with a distance of 23 cm between their centres in coordination with the metronome. Surface EMG signals were collected from seven upper limb muscles including Upper, Middle, and Lower Trapezius, Middle Deltoid, Latissimus Dorsi, Sternocleidomastoid, and Serratus Anterior. The normalised root-mean-square value was used to determine the muscular activation.

Results: Swimmers with shoulder pain demonstrated greater activation of the upper trapezius (pain group mean: 28.04 ± 10.37, control group mean: 13.40 ± 06.04; p = 0.002), serratus anterior (pain group mean: 30.78 ± 20.09, control group mean: 13.30 ± 5.52; p = 0.023) and latissimus dorsi (pain group mean: 27.05 ± 17.87, control group mean: 4.99 ± 3.90; p = 0.002) muscles. There was no difference in the activation of the middle and lower trapezius, middle deltoid and sternocleidomastoid. Swimmers with shoulder pain showed altered (increased) muscular activity of the upper trapezius, serratus anterior, and latissimus dorsi muscles during a low-load task compared to swimmers without shoulder pain.

Conclusion: While increased serratus anterior activity may occur to counterbalance increased upper trapezius activity in swimmers with shoulder pain, it may not be sufficient as activity of the middle and lower trapezius remained unchanged. Findings have implications for the rehabilitation of elite swimmers suffering from shoulder pain to restore normal muscle activations.

CHEST WALL SOFT TISSUE THICKNESS IS ASSOCIATED WITH HUMERAL SHAFT NONUNION: A RADIOGRAPHIC STUDY

AK Chowdhury, KA Peters, HB Colaco and IAR MacLeod

Hampshire Hospital NHS Foundation Trust, Hampshire

Background: Anecdotally, pendulous breasts have often been associated with inferior outcomes from non-operative management of diaphyseal humerus fractures. However, this assertion is without basis in the literature. Purpose: To produce radiographic measurements of chest wall soft tissue thickness and determine association with non-union and angulation in diaphyseal humerus fractures.

Methods: A total of 217 patients who underwent conservative management for a diaphyseal humeral fracture were identified retrospectively from 2008 to 2017. Radiographic chest wall soft tissue thickness (STT) measurements were taken at three standardised points (upper, middle and lower) using a simple reproducible method. Ratios were also derived, dividing these figures by the mid-humerus diameter, to address magnification differences. Bivariate and multivariate analysis was used to assess the association with non-union (with demographics, smoking, comorbidities and injury characteristics).

Results: The median patient age was 64 years (range 16-96) and 139 (64.1%) were female. There were 58 (26.7%) cases of nonunion. On multivariate analysis, the middle (OR 1.39, 95%, p < 0.001) and lower (OR 1.23, p = 0.009) STT measurements were independently associated with nonunion. Additionally, the middle (OR 1.85, p < 0.001), lower (OR 1.47, p = 0.005) and maximum (OR 1.40, p < 0.001) STT ratios were independently associated with nonunion. A receiver operating characteristic curve was used to determine threshold values for middle STT of 6.2cm (sensitivity 62.1%, specificity 61.6%) and middle STT ratio of 3.0 (sensitivity 69.0%, specificity 62.3%). A middle STT of ≥6.2cm (OR 2.68, p = 0.004) and a middle STT ratio of ≥3.0 (OR 3.73, p < 0.001) were each independently predictive of nonunion. The middle STT (rs 0.180, p = 0.008) and ratio (rs 0.149, p = 0.0028) were weakly correlated with 4-6 week humerus coronal angulation, though not with clinically significant malunion.

Conclusion: Chest wall soft tissue thickness is independently associated with humeral shaft non-union. A middle STT ratio of ≥ 3 was predictive of non-union. Threshold values can assist in decision making for these fractures.

Session 5: Shoulder arthroplasty

A LOWER CRITICAL CORACOID PROCESS ANGLE IS ASSOCIATED WITH TYPE-B OSTEOARTHRITIS: A RADIOLOGICAL STUDY OF NORMAL AND DISEASED SHOULDERS

W Wynell-Mayow, C Chi Chong, O Musbahi and E Ibrahim

West Middlesex University Hospital, London, United Kingdom, TW7 6AF

Purpose: Degenerative rotator cuff tears (RCT) 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. This study seeks to investigate the significance or axial scapular morphology through measurement of the Critical Coracoid Process Angle (CCPA), which incorporates coracoid tip position and glenoid version.

Design and methods: CCPA, CSA and glenoid retroversion were measured by three independent reviewers from the cross-sectional 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; (4) patients with MRI proven atraumatic tears of the posterosuperior rotator cuff.

Results: Interobserver agreement was excellent for all measured parameters. Median CCPA was significantly lower in the Type-B OA group (9.3^o) when compared to controls (18.7^o), but not significantly different in the other study groups. There was a trend towards greater glenoid retroversion in the Type-B OA group, but Receiver Operating Characteristic curve analysis demonstrated CCPA to be by far the most powerful discriminator for Type-B OA. The optimal cut-off value was calculated for CCPA at 14.3^o with a sensitivity of 93% and specificity of 90% for Type-B OA. Compared to controls, CSA was significantly higher than controls in the RCT 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^o) is strongly predictive of Type-B OA. The authors propose a simple model of pectoralis Major biomechanics to explain the effect of this axial plane anatomical variation.

RETURNING TO GOLF FOLLOWING ELECTIVE SHOULDER ARTHROPLASTY

L Hoggett, J Ranson, S Frankland, C Nevill and P Hughes

Department of Trauma & Orthopaedic Surgery, Lancashire Teaching Hospitals NHS Foundation Trust, Preston

Purpose: The purpose of this study was to objectively (in the form of handicap assessment) and subjectively (patient survey) assess the impact Shoulder Arthroplasty (SA) has on amateur golfer performance.

Methods and results: An open-access survey was sent to golfers via an electronic smartphone app used to track handicap data between 18/4/19 and 30/2/19. This combined a patient survey with in-app handicap data. 90 golfers responded to the survey (72M:18F). Mean age was 67 (35–84). 93% (84) were right-handed. 14% (13) had bilateral replacements, and 57% (51) had a right-sided replacement. The mean handicap change was  + 0.5 (−8− + 9), and no difference was demonstrated between the dominant and non-dominant shoulder. 85% (76) were able to play the same amount or more with 83% (75) able to play at least once per week. 80% (72) used a carry bag pre-SA, and 20% (18) were able to continue this following surgery. 21% (19) returned to iron shots at 6 weeks, and 76% (69) returned to iron shots at 3 months. 79 golfers participated in club competitions prior to joint replacement, all were able to return to these with 77% (64) doing so within 6 months. Following SA 77% (69) reported never having pain or only rarely having pain in the replaced joint.

Discussion: SA enables the majority of golfers to maintain or increase the amount of golf played and is effective for most in alleviating pain when playing golf. Generally, players can be expected to return to iron shots at 3 months and club competition at 6 months. Most patients will require assistance transporting clubs post-procedure. Across the cohort, there was minimal change in playing handicap however this was highly variable.

ACROMIAL STRESS FRACTURES AND REACTIONS AFTER REVERSE TOTAL SHOULDER ARTHROPLASTY: A CASE-CONTROL STUDY

F Weimer, S Bell and Coghlan J Monash

University, Melbourne Shoulder and Elbow Centre, Beach Rd, Sandringham, 3186, Australia

Purpose: Acromial stress fracture can occur after reverse total shoulder arthroplasty (RTSA). We performed this study to assess the incidence, risk factors, characteristics, and outcome of acromial stress fractures and reactions after RTSA.

Methods: We determined the incidence of acromial stress fractures and reactions in a cohort of patients who underwent RTSA and assessed risk factors using a case-control design. Each patient who developed an acromial stress fracture or reaction after RTSA (case) was matched with two patients who did not develop acromial stress fractures/reactions after RTSA (control subjects); univariate and multivariable analyses were performed to identify risk factors. Characteristics of acromial stress fractures/reactions are described. Outcomes were compared between cases and control subjects.

Results: The incidence of acromial stress fracture/reaction after RTSA was 10.9% (24/220 RTSAs, in 22 patients). Acromial stress fractures/reactions occurred at a median time of 5.5 months after RTSA (range: 20 days to 118 months) and most were fractures (18/24, 75%). Using a multivariable analysis, we found two factors to be independently associated with the occurrence of an acromial stress fracture/reaction after RTSA: use of steroids (adjusted OR: 9.61, 95% confidence interval: 1.07–86.14, p = 0.04) and previous shoulder surgery (adjusted OR: 7.22, 95% confidence interval: 1.42–36.61, p = 0.02). In this cohort, in which the management was exclusively conservative, the occurrence of post-RTSA acromial stress fracture/reaction was associated with a significantly worse functional outcome at the last follow-up visit, as compared with control subjects. This was illustrated by significantly lower ASES scores, higher SPADI and DASH scores, and worse forward elevation and internal rotation as compared with control patients who did not develop acromial stress fracture/reaction after RTSA.

Conclusions: Acromial stress fractures/reactions are relatively common after RTSA and are independently associated with steroid use and previous arthroscopic shoulder surgery.

MID- TO LONG-TERM OUTCOMES FOR A CEMENTED ALL-POLYTHENE PEGGED GLENOID COMPONENT IN ANATOMIC TOTAL SHOULDER ARTHROPLASTY

A Haque, J White, M Morgan, M Espag, DI Clark and A Tambe

Royal Derby Hospital, Derby

Background: The aim of this study was to evaluate mid- to long-term survival, clinical and radiological outcomes of an all-polyethylene pegged glenoid component used in anatomic total shoulder arthroplasty.

Methods: This was a retrospective analysis of a prospectively collected local arthroplasty register of consecutive patients undergoing total shoulder arthroplasty with an all-polyethylene pegged glenoid between January 2009 and December 2018. In total, 108 TSAs using this implant were performed within our unit in 98 patients (18 males and 80 females) with 10 patients having bilateral total shoulder arthroplasties. The mean follow-up was 5.1 years (range, 2–10.6 years). In addition to a survival analysis, clinical evaluation included postoperative Oxford Shoulder Score, Constant score, range of motion assessment and Pain VAS. Radiological outcomes included an assessment of radiolucency based on the Lazarus grade.

Results: Kaplan-Meier survival analysis revealed a six-year survival estimate of 94.1% for all-cause revision. Six patients had undergone revision with four for cuff failure and two for instability. The mean follow-up Oxford Shoulder Score was 38.2 (SD 12.3), the mean Constant Score 59.3 (SD 17.0) and the mean Pain VAS score 1.8 (SD 2.5). The mean forward elevation at the final follow-up was 111° (SD 26.6°) and the mean abduction was 102° (SD 34.0°). Clinical outcomes were maintained at long-term follow-up (> 8 years) with the exception of the Pain VAS score which increased by 2.1 points (p = 0.034). The radiological assessment revealed that 28 patients had radiolucency consistent with a Lazarus grade of three and above with clinical outcomes not being affected.

Conclusions: Mid- to Long-term follow-up indicates a low revision rate and good clinical survivorship for this cemented all-polyethylene glenoid component. No patients have so far been revised for glenoid loosening, but the radiographic follow-up has shown that 36% of implants have signs of radiolucency. Further follow-up is required to determine longer-term survivorship.

A NOVEL SHOULDER ARTHROPLASTY SMART DEVICE APPLICATION PROVIDES OUTCOME DATA AND GOOD PATIENT SATISFACTION

DLJ Morris, A Doshi, R Gogna, M Morgan, T Cresswell, MP Espag, AA Tambe and DI Clark

Royal Derby Hospital, University Hospitals of Derby and Burton NHS Foundation Trust Uttoxeter Road, Derby

Purpose: A shoulder arthroplasty smart device application (app) was developed and introduced at a UK shoulder unit; the first such app in Europe. This digital care management system (DCMS) provides information to patients and collects objective data on outcomes. We report our implementation experience, incorporating the app alongside an established enhanced recovery programme (ERP).

Methods: A DCMS was developed alongside an industry sponsor with content produced by our unit. Patient enrolment commenced in July 2021. Patients listed for shoulder arthroplasty were offered enrolment. The app provides patient information according to their operation date including preoperative guidance and postoperative instruction. Oxford Shoulder Score (OSS) and Visual Analogue Scale (VAS) questionnaires are administered by the app 1 week preoperatively and monthly for 6 months postoperatively. A ‘coach function’ is available whereby a family member can enrol on behalf of the patient.

Results: Sixty-two patients were recruited; of which 20 have undergone shoulder arthroplasty whilst enrolled (14 reverse and six anatomic total shoulder replacements). The mean patient age is 72 years. Five of these patients utilised the ‘coach function’. Mean OSS improved from 13 preoperatively to 37 at 6 months. Mean VAS improved from 72 preoperatively to five at 6 months. 74% found the app to be easy to access, use and understand. 89% reported app content helped preparation for surgery and 68% for discharge home postoperatively. 58% would opt for app guidance for future shoulder surgery and 21% would prefer to receive surgery and patient information solely via an app. 79% preferred the perioperative information provided in our face-to-face ERP session.

Conclusions: A shoulder arthroplasty app yields patient-reported outcome data and enrolled patients report good satisfaction. However, many patients prefer face-to-face education. Consequently, our recommendation is that a DCMS is used in addition to an ERP, or where such a service is not available.

MID-TERM RESULTS OF A PYROCARBON RESURFACING HEMIARTHROPLASTY

G Hoy, A McBride, M Ross, P Duke, R Page, Y Peng and F Taylor

Melbourne Orthopaedic Group, Monash University Dept. of Surgery, Victoria, Australia

Purpose: Despite potential benefits, improvement in survivorship of resurfacing and stemmed metal hemiarthroplasty has not been demonstrated from joint registry studies or other studies at mid-term follow-up, because of glenoid erosion and pain. The use of pyrolytic carbon (pyrocarbon) as a resurfacing material is thought to reduce glenoid erosion owing to a marked reduction in wear rates in vitro. This study aimed to compare the survivorship of shoulder hemi-resurfacing using pyrocarbon with shoulder hemi-resurfacing and stemmed hemiarthroplasty using metallic heads.

Methods and results: AOANJRR data were analysed for all patients aged prostheses had a statistically lower revision rate than other hemi-resurfacing prostheses (HR, 0.41; 95% confidence interval, 0.18–0.93; P = .032). Pain, prosthesis fracture, and infection were the key reasons for the revision. No pyrocarbon hemi-resurfacing cases were revised for glenoid erosion. In male patients, pyrocarbon humeral resurfacing had a lower cumulative percentage of revision compared with metal stemmed hemiarthroplasty (HR, 0.32; 95% confidence interval, 0.11–0.93; P = .037).

Conclusion: Pyrocarbon humeral resurfacing arthroplasty had statistically lower revision rates at mid-term follow-up in patients aged Level of evidence: Level III; Retrospective Cohort Comparison.

VIRTUAL CLINIC FOLLOW-UP AFTER SHOULDER ARTHROPLASTY: OUR EXPERIENCE

T Tanello, S Ferdinandus, D Henderson, S Vollans, M Philipson, D Limb and P Cowling

Department of Orthopaedics and Trauma, Chapel Allerton Hospital, Leeds Teaching Hospitals, Leeds

Purpose: As the number of shoulder replacements performed in the UK increases annually, we wished to investigate virtual follow-up to monitor patient outcomes following surgery.

Methods: From January 2018, all patients currently under follow-up after shoulder arthroplasty, and all future arthroplasty patients were transferred into a ‘Virtual Outcomes Clinic’ (VOC) comprising three outcomes: shoulder radiographs; PROMs returned via post (including Oxford Shoulder Score, pain scores and EQ-5D); telephone call performed by a specialist nurse. VOC review was planned to occur routinely at 1, 3, 5, 7 and 10 years following shoulder arthroplasty, but this could alter depending on VOC outcome.

Results: In total, 261 patients were reviewed in VOC (mean age 76, 71% female). The majority we reviewed at 1 year following shoulder arthroplasty (n = 166), with 29 at 3 years, 11 at 5 years and one at 7 years. Lack of post-operative VOC follow-up data was noted for the remaining 54 patients, with the main reasons being that patients were either awaiting surgery (20), or their surgery was within the last 12 months so still awaiting 1 year postoperative VOC review (13). When examining the largest VOC cohort (those at 1-year follow-up, n = 166), 78% went on to routine VOC follow-up at 3 years postoperatively. Of those reviewed sooner than anticipated due to poor VOC outcome, the main reasons were radiographic (loose implant, stress fracture) or patient-reported (sudden onset pain, limited movement). Data completion for this cohort was reasonable, with only 27 patients (16%) collecting incomplete data post-operatively. Three were lost to follow-up. A questionnaire found high satisfaction rates in patients followed up in VOC.

Conclusion: Virtual follow-up following shoulder arthroplasty is a successful method of safely reviewing outcomes with good patient satisfaction. It could have an important impact on future monitoring of shoulder replacement patients’ care, as well as health economics.

TWO-YEAR CLINICAL RESULTS OF ANATOMIC AND REVERSE TOTAL SHOULDER ARTHROPLASTY PERFORMED WITH A COMPUTER-NAVIGATED SURGERY SYSTEM

MG Smith, AT Greene, ME Kent, R Parmar, SV Polakovic, N Davis and CP Roche

Liverpool University Hospitals NHS Foundation Trust, Liverpool

Purpose: The purpose of this study is to evaluate the two-year clinical results of anatomic and reverse total shoulder arthroplasties (ATSA and RTSA) performed using a computer-navigated shoulder surgery system.

Methods: A total of 148 ATSA and 387 RTSA cases were performed at multiple centres with a single implant system utilizing a computer-navigated surgery system to assist in preoperative planning and intraoperative preparation and placement of the glenoid implant. A 2:1 age, gender, and follow-up matched cohort from cases performed at the same centres was used to compare clinical outcome metrics for both ATSA and RTSA.

Results: Average follow-up for navigated patients in both the ATSA and RTSA cohorts was 29 months. Navigated ATSA patients achieved significantly better internal and external rotation scores compared to the non-navigated cohort and reported no significant difference in any of the other shoulder outcome metrics. Navigated ATSA patients also reported lower but non-significant revision and adverse event rates compared to the non-navigated cohort. Navigated RTSA patients achieved significantly better external and internal rotation, were able to lift a significantly higher maximum weight and achieved significantly higher scores for the Simple Shoulder Test, Constant, American Shoulder and Elbow Surgeons, and Shoulder Arthroplasty Smart score metrics compared to the non-navigated cohort. Navigated RTSA patients also reported significantly lower intraoperative complications, revisions, and adverse events compared to the non-navigated cohort. A significantly higher number of augmented glenoid baseplates and a significantly lower number of glenoid baseplate screws were used in the navigated cohort.

Conclusion: These results show excellent clinical outcomes at a two-year minimum follow-up for ATSA and RTSA performed using computer-navigated surgery. The results indicate that computer-navigated surgery improves the safety and outcomes for patients undergoing RTSR surgery. Further clinical follow-up is required to study the long-term outcomes of the patients in this cohort.

ARE SUPRASCAPULAR NERVE BLOCKS AN EFFECTIVE FIRST-LINE MODALITY IN MANAGING SHOULDER ARTHRITIS?

PK Shanthi Ashokkumar, N Shah, R Badge, V Thiruvasagam and V Rentala

Department of Orthopaedic Surgery, Warrington and Halton NHS Foundation Trust, Warrington

Background: Primary Shoulder arthroplasty (Anatomic/Reverse) is a recommended surgical treatment for suitable patients with glenohumeral osteoarthritis (GHJOA) and rotator cuff arthropathy (RCA). Substantial increase in waiting times due to the pandemic situation has clearly affected patients' quality of life. Therefore, to support these patients and as well as those who are not suitable for surgery, we have opted for suprascapular nerve block as an interim measure for pain relief. Aim: To assess the effectiveness of ultrasound-guided Suprascapular nerve block (SSNB) as the first line modality in the management of patients with rotator cuff arthropathy and glenohumeral arthritis.

Method: A total of 107 consecutive patients who received SSNBs over a period of 2 years were included. Data related to the effectiveness of the SSNB, the need for repeat SSNBs, and final clinical outcomes were collected retrospectively.

Results: A total of 107 patients with GHOA or RCA were referred for SSNBs. The average age was 77.9 years and 64.4% (69) were females. 44 patients had GHOA and 63 patients had RCA. 98 patients (91.5%) underwent multiple SSNBs (average 2.4 SSNBS). 23 patients (21.5%) had permanent improvement of pain and were discharged. 68 patients (63.5%) had temporary pain relief among whom, 10 opted for shoulder surgery, 21 opted for radiofrequency suprascapular nerve ablation and the remaining 37 decided not to have surgery or ablation but decided to continue having multiple SSNBS. 16 patients (15%) had minimal or no pain relief at all among whom seven underwent surgery and the remaining nine decided against surgery and were referred to the chronic pain team. The pain relief provided by SSNBs helped postpone the need for definitive surgery by an average of 20 months, in the 17 patients who needed shoulder surgery.

Conclusion: SSNB provided satisfactory temporary pain relief in 85% of patients and can be an effective first-line modality in managing shoulder arthritis.

ANTIBIOTIC-LOADED DISSOLVABLE CALCIUM SULFATE BEADS WITH CEMENTLESS TSA FOR ONE-STAGE REVISION OF INFECTED SHOULDER ARTHROPLASTY

O Levy, I Bachar Avnieli, G Panagopoulos, A Leonidou, P Consigliere, and S Iyer

Reading Shoulder Unit, Berkshire Independent Hospital, Reading

Purpose: Clinical and radiographic outcomes of single-stage revision with cementless implants for infected shoulder arthroplasty with ALCSDB (antibiotic-loaded calcium sulphate dissolvable biodegradable) beads. Background: Treatment of infected shoulder arthroplasty is controversial. Conventional two-stage revision involves two surgical procedures, extended damage to the soft tissues and long recovery. The use of antibiotic-loaded cement requires using cemented implants. Antibiotic-loaded cement beads require future removal of the beads. We introduced a single-stage revision using ALCSDB beads with cementless implants.

Methods: Twenty-seven patients underwent revision TSA for suspected infection using ALCSDB beads. Following removal of the infected implants and meticulous debridement and washout, the biodegradable spheres were inserted into bones and soft tissue layers, before the re-implantation of cementless new implants. Demographics, radiographs and intraoperative cultures were prospectively collected. Constant Score, Subjective Shoulder Value and ROM were recorded. Radiographic analysis was performed in every FU.

Results: Mean age was 66.5 years. Of 27 patients, 25 patients underwent single-stage revision (seven TSA to rTSA, five resurfacing to rTSA, three infected plating to rTSA and three resection arthroplasty (post-infection) to rTSA). In two cases of acute infection, DAIR (exchange of modular components) was attempted and failed, followed by successful formal 2-stage revision using ALCSDB beads. Perioperative cultures grew C. acnes; Staphylococcus aureus and Streptococcus oralis. Several cultures of clinically evident low-grade infection failed to grow an organism. In one-year FU, infection was successfully eradicated and good function was restored in all patients. On radiographs: beads resorbed within 3–6 weeks post-op. No lucencies around the implants, loosening, subsidence or stress shielding were seen. Beads in bone-deficient areas were substituted by bone formation.

Conclusion: The use of ALCSDB beads is an effective and practical option for single-stage revision with cementless implants for infected TSA, with excellent outcomes and rapid recovery.

Session 6: Shoulder instability and physiotherapy

ONE STOP SHOULDER CLINIC: A PHYSIOTHERAPIST VIEWPOINT

J Lim, J Tyler, D Bowe, S Lalande and R Hunter

Physiotherapy Department, Airedale General Hospital, Keighley

Purpose: This study aimed to explore the perceptions of Musculoskeletal (MSK) Physiotherapists about working in the OneStop Shoulder Clinic (OSSC), which was introduced in 2020 in response to the COVID-19 pandemic.

Method: Semi-structured interviews were conducted with three MSK Physiotherapists working in the OSSC. Interviews explored Physiotherapists’ perceptions of the advantages, and challenges of working in the shoulder clinic. Interviews were transcribed verbatim and analysed using content analysis.

Results: Three main themes were identified: ‘advantages’, ‘challenges’ and ‘recommendation for future service development’. Within each theme, further sub-themes were identified. Advantages included clinical learning opportunities for a Band 5 MSK Physiotherapist from the Multi-Disciplinary Team (MDT), enhanced patient journey experience, reduced waiting times for the patient and accurate diagnosis. Challenges included finishing after normal working times due to consultant's referral, patients relying on orthopaedic treatments like Suprascapular Nerve Block (SSNB) or Subacromial injection and reduced therapeutic alliance as patients usually see the Physiotherapist last. Future recommendations included building a strong relationship with members of the MDT, focusing on educating the role of Physiotherapists in the OSSC, making OSSC a clinical rotation for junior Physiotherapists and increasing the efficiency of handover between members of the MDT in the clinic.

Conclusion: To our best knowledge, this is the first study that highlights Physiotherapists’ perception of working in the OSSC. The finding from this study suggest an acknowledgement of the significant benefits of this approach and identify areas for development. Further research would be of benefit including a larger sample size to allow for a more compressive analysis of this topic. It will also be of benefit to triangulate these findings with the annual financial reports, Patient Reported Outcome Measures (PROMs) and Patient Reported Experience Measures (PREMs) which have so far suggested a significant benefit to this approach.

STABLE TRAUMA EARLY ELBOW MOBILISATION: INTRODUCTION OF A STANDARDISED REGIME TO IMPROVE PATIENT OUTCOMES

H Tunnicliffe, J Coppin, V Palial and H Singh

University Hospitals of Leicester, Physiotherapy Department, Glenfield Hospital, Leicester

Purpose: To compare outcomes of surgically managed elbow trauma patients following the introduction of a standardised regime for early mobilisation.

Method: A standardised physiotherapy regime for surgically managed elbow fractures (±  MCL/LCL repair) was introduced and approved by the orthopaedic consultant team. Patients who had undergone surgery for traumatic elbow fractures were identified on the ward and referred for physiotherapy following the Stable Trauma Early Elbow Mobilisation regime (STEEM). This involved management in a sling, with hourly removal for gentle controlled exercise. Data was collected prospectively, including demographic information, comorbidities, complications documented and the outcome measures of active ROM, Extension deficit, MEPI and OES at initial assessment, 6-week follow-up and 12 weeks or discharge (whichever came first).

Results: Pre-introduction of the regime, data from a series of 35 patients managed with variable regimes was collected for comparison. Management included variable periods of immobilisation in a plaster cast and hinged braces (range 2–6 weeks). The mean arc of movement was 112.5°, MEPI scores 75, OES 35 and extension deficit was 22.4°. Post introduction of the STEEM regime, data for 12 patients was collected. The mean arc of movement increased to 122.5° (p = 0.22), MEPI to 89.5 (p = 0.03), OES to 42.25 (p = 0.05) and extension deficit decreased to 12.1° (p = 0.01). No complications were found associated with the regime.

Conclusion: The introduction of a standardised regime has helped to improve outcomes both in terms of the range of movement, extension deficit and function for surgically managed elbow fractures. This has shown that even the more extensive injuries such as terrible triad can achieve good outcomes, and in fact, it is safe to mobilise patients early in a gentle controlled manner.

INTRODUCTION OF A PHYSIOTHERAPIST SERVICE TO ELECTIVE SHOULDER CLINIC: A PDSA SERVICE IMPROVEMENT

H Tunnicliffe, J Coppin and A Armstrong

University Hospitals of Leicester, Physiotherapy Department, Glenfield Hospital, Leicester

Purpose: To eradicate the waiting time for receiving physiotherapy intervention in elective shoulder clinics.

Method: Following the pandemic waiting lists for physiotherapy were lengthy due to the cessation of routine appointments. Many patients were returning to elective shoulder clinics, having been referred to physiotherapy but not received any intervention. A physiotherapist was introduced to the clinic, enabling the patient’s treatment to be started immediately. Advice sheets were pre-prepared with self-management advice, and progression (levels 1–3) for common presentations seen in a clinic (the weak shoulder, the stiff shoulder, overhead weakness, and the unstable shoulder) so comprehensive patient information could be given to patients to take away. This creates a proactive approach to both waiting list management and ensures early, appropriate treatment and management for patients.

Results: Fifty-two patients were seen immediately in the clinic over a 12-week period. 17% felt able to self-manage with the advice given in the clinic and given open appointments from the physiotherapy department. The remainder continued to a course of physiotherapy but were booked in as follow-ups at a time requested by the treating physiotherapist (44% of these received telephone follow-up, 15% face-to-face and 4% went straight into a class). 20% were referred out of UHL. 16 had had a significant delay to treatment previously (the average delay in this population was 254 days). Satisfaction data was extremely positive, 100% of patients felt it was helpful seeing the physiotherapist in the clinic, and 94% of patients felt the advice given would help their current symptoms.

Conclusion: Delay to treatment is entirely eradicated by commencing comprehensive treatment on the day. Patients felt equipped with knowledge regarding their shoulder condition and the treatment options available, and commenced a best practice advice session with a physiotherapist.

THE RELATIONSHIP BETWEEN CLINICAL FEATURES AND BIPOLAR BONE LOSS IN ANTERIOR INSTABILITY

N Wei, J Kent, R Jeavons and R Liow

Department of Orthopaedics, University Hospital North Tees, North Tees and Hartlepool NHS Foundation Trust, Stockton on Tees

Objectives: To assess for correlations between the degree of glenoid bone loss, size of Hill-Sach's lesion, on- versus off-track bipolar interaction, and clinical factors, that is, number of dislocations events, duration of instability and Instability Severity Index Score (ISIS). To identify a cut-off number of dislocations whereby sub-critical (13.5%) glenoid bone loss has developed and confirm the number of instability events that is a predictor for glenoid bone loss.

Methods: Eighty-eight consecutive patients; arthroscopic stabilisation (n = 37), open Laterjet (n = 41), open Laterjet with Hill-Sach's osteochondral graft (n = 10) included. The number of dislocations, ISS and age at first dislocation were collated. Pre-operative MRI and CTs to assess the bony morphology and measure the linear and surface area of glenoid bone loss and Hill-Sachs lesions.

Results: Glenoid bone loss prevalence 82% (72/88) and Hill-Sach's lesion 91% (79/88). Critical and subcritical bipolar bone loss 25% (10/88) and 55% (48/88). Off-track bipolar lesions prevalence 12.5% (11/88). The inverse relationship between the size of the glenoid loss and Hill-Sach's. A moderate correlation between the number of dislocations with a duration of instability (r = 0.44, p 0.001) and linear glenoid loss with a duration of instability (r = 0.33, p 0.05), number of dislocations (ß = 0.06, SE 0.01, p > 0.001) and ISIS (ß = 0.02, SE 0.005, p > 0.001). Odds ratio with logistic regression, number of dislocations (1.4) and ISIS (2.3).

Conclusions: The number of dislocations and ISIS are the best predictors for subcritical glenoid bone loss and can be expected with nine dislocations and ISIS of > 6. The clinical factors that we examined do not fully explain the bone defects.

LONG-TERM OUTCOMES OF OPEN LATARJET PROCEDURE FOR THE SURGICAL MANAGEMENT OF HUMERAL AVULSION OF GLENOHUMERAL LIGAMENT (HAGL) LESIONS

K Gokaraju, G Walch and P Domos

Centre Orthopédique Santy, Lyon, France

Introduction: Limited long-term evidence is available for the management of recurrent anterior glenohumeral instability caused by humeral avulsion of the glenohumeral ligament (HAGL) so we present a retrospective review with long-term follow-up of patients treated with an open Latarjet procedure for recurrent anterior shoulder instability due to a HAGL.

Methods: Nineteen patients were operated on by a single surgeon at a single centre, undergoing standardised assessment, rehabilitation and follow-up. Sixteen patients with complete clinical and radiological data and a minimum 2-year follow-up were available for review. Outcomes assessed included range of motion (ROM), joint stability, Visual Analogue Score (VAS) for pain, Walch-Duplay score (WDS), Rowe score (RS), Constant-Murley score (CMS), Subjective Shoulder Value (SSV), satisfaction rating, return to sport and identification of clinical and radiological complications.

Results: Patients were all male with no hyperlaxity, had a median age at surgery of 28 years (18–42) and a median follow-up of 10 years (2.8–15). After surgery, the median movements showed recovered elevation of 175°, external rotation of 62° and internal rotation to T12 level. Post-operative VAS was 0.5, WDS 86, RS 95, CMS 77 and SSV 88%. 87% returned to the sport, 68% got back to the same pre-injury level and 93% were satisfied. There were no recurrent dislocations or subluxations but two patients had subjective apprehension, associated with a significant Hill-Sachs and medial-seated graft, although SSV was 80%. Other complications included a superficial infection (successfully treated), a delayed bone-graft union (healed at 1yr), a patient with mild long-term pain and another with persistent stiffness. 56% had mild post-operative arthritis but 13% already had pre-operative degenerative changes. None required further surgery.

Conclusions: The open Latarjet procedure provides good outcomes with acceptable complication rates in the long term, for symptomatic HAGL lesions. It is an effective treatment option and a safe alternative to arthroscopic or open HAGL repair.

USING COMPUTERISED TOMOGRAPHY TO ASSESS THE SUITABILITY OF THE DISTAL CLAVICLE AS A TREATMENT FOR ANTERIOR GLENOID BONE LOSS

H Selmi, P Connell, K Ambalawaner, A Davies, S Sabharwal, D Amiras and D Griffiths

Department of Trauma and Orthopaedic Surgery, Imperial College Healthcare NHS Trust, London

Aim: The purpose of this study was to use computerised tomography (CT) imaging and segmentation software, to assess the suitability of the distal clavicle as an augment for anterior glenoid bone loss in traumatic anterior glenohumeral (GHJ) instability.

Method: An online open-source data set of CT chest scans was used. The Digital Imaging and Communications in Medicine (DICOM) data from these studies was loaded onto a third-party software, 3D SlicerTM, allowing accurate segmentation of anatomical structures. In total, 18 scans were analysed. Eight were excluded as insufficient data prevented multi-planar reconstruction. The dimensions of the distal clavicle were measured and the available surface area was calculated, along with the measurement of the articular surface area of the glenoid. We then calculated the percentage surface area of the distal clavicle relative to the glenoid. The mean distance from the tip of the distal clavicle to the trapezoid ligament was also measured.

Results: The mean articular surface of the distal clavicle measured 97 mm² ± 7.2 SD. Mean glenoid articular surface measured 450 mm² ± 50.1 SD. The mean percentage surface area of the distal clavicle relative to the glenoid was 22% ± 2.2% SD. A mean distance of 12.4 mm ± 0.8 SD was measured from the tip of the distal clavicle to the trapezoid ligament.

Conclusion: We describe a methodology for assessing the suitability of the lateral clavicle in the management of anterior glenoid bone loss. From this limited series, we find that 22% surface area of glenoid bone loss can be augmented with distal clavicle autograft. We have also found that 10 mm of the lateral clavicle can safely be excised without risk of damage to the trapezoid ligament. We describe a surgical planning methodology for the suitability of the lateral clavicle autograft in the augmentation of glenoid deficient shoulders.

GLENOHUMERAL MORPHOLOGICAL PREDICTORS OF RECURRENT SHOULDER INSTABILITY FOLLOWING ARTHROSCOPIC BANKART REPAIR

J O’Grady, ET Hurley, MS Davey, ES Mojica, RA Delaney, M Gaafar and H Mullett

Sports Surgery Clinic, Ireland

Purpose: The purpose of this study was to evaluate glenohumeral morphological features on Magnetic Resonance Arthrogram (MRA) to determine risk factors for the recurrence of anterior shoulder instability following arthroscopic Bankart repair (ABR).

Methods: A retrospective review of patients who underwent ABR between July 2012 and March 2017 was performed to identify patients who had a recurrence of instability following stabilisation (Group 1). These were pair matched in a 2:1 ratio for age, gender and sport with a control (Group 2) who underwent arthroscopic Bankart repair without recurrence. Pre-operative MRAs were evaluated for glenoid version, chondral version, labral version, labral height, labral thickness, glenoid inclination, glenoid width, glenoid concavity, humeral head diameter, humeral head centricity, SLAP tears, GLAD lesions, Perthes lesions, rotator cuff pathology, and acromioclavicular joint degeneration. Glenoid bone loss and Hill-Sachs (HS) lesions were also measured. Multi-linear and multi-logistic regression models were used to evaluate factors affecting recurrence.

Results: Overall, 72 patients were included in this study, including 48 patients without recurrence and 24 patients with recurrent instability. There was a significant difference between the two groups in mean glenoid bone loss (Group 1: 7.3% vs Group 2: 5.7%).

Conclusion: Glenoid anteversion was risk factor for recurrent instability, whereas increased chondral version and humeral head diameter were associated with higher rates of success following arthroscopic Bankart repair. Glenoid bone loss, the presence of an offtrack Hill-Sachs lesion, increased Hill-Sachs width, and acromioclavicular degeneration were also associated with failure.

ASSESSING THE IMPACT OF OFF-TRACK INSTABILITY LESIONS FOLLOWING ARTHROSCOPIC ANTERIOR SHOULDER STABILISATION WITHOUT ADDITIONAL REMPLISSAGE RECONSTRUCTION

E Gerakopoulos, M Davies, A Tavakkolizadeh, J Sinha and T Colegate-Stone

Trauma and Orthopaedics Department, Kings College Hospital, London

Purpose: To assess the impact of off-track lesions on recurrent instability rates following arthroscopic stabilisation without any concomitant Remplissage surgery.

Background: Glenoid tracking lesions have been highlighted as a factor for shoulder instability. Recent studies have recommended concomitant management of off-track lesions in order to mitigate the risk of recurrent instability. Such studies advocate arthroscopic Remplissage in addition to Bankart repair. In turn, neglected off-track Hill-Sachs lesions of the humeral head are considered by some as a risk factor for recurrent instability after arthroscopic stabilisation and Bankart repair.

Methods: Patients were included if they had recurrent anterior glenohumeral instability with Bankart tears and Hill-Sachs lesions on MRI imaging. Patients were excluded if they had additional bony Bankart injuries or were revision procedures. Patients were managed with an arthroscopic anterior stabilisation, Bankart repair and capsular shift over a 5-year period. The primary outcome assessed was the presence of recurrent instability or the need for revision surgery. MRI pre-operative imaging was used to calculate: the glenoid track and the presence of on or off-track Hill-Sachs lesions. The minimal acceptable follow-up was 18 months.

Results: Fifty-two patients (male 90%, female 10%, average age 28 years; age range 18–41 years) were reviewed. The mean follow-up was 32 months. On-track lesions were present in 66% (n = 34) and off-track lesions in 34% (n = 18). The overall rate of recurrent instability or need for further surgery was 4% (n = 2/52). When assessed from the prism of glenoid tracking the on and off-track revision rates were 3% (n = 1/34) and 5% (n = 1/18), respectively. The difference in recurrence rates between these groups was not statistically significant (p > 0.05) on chi-squared testing.

Conclusion: In contrast to other work, this study suggests that arthroscopic stabilisation without Remplissage reconstruction can be a successful surgical strategy for patients with Bankart tears independent of whether there are on or off-track lesions.