Shoulder & Elbow

The present study aimed to assess the accuracy of radiology department ultrasound scans in identifying rotator cuff tears at our institution, a regional specialist orthopaedic centre.

Pre-operative ultrasound scan reports were obtained from 64 consecutive patients who subsequently underwent arthroscopic subacromial decompression and/or rotator cuff repair. The ultrasound reports were compared with the arthroscopic findings as a reference standard.

If both full- and partial-thickness tears are counted as true positives, ultrasound has a sensitivity of 70%, a specificity of 67% and a positive predictive value of 81%. If only partial tears are counted as true positives, sensitivity decreases to 8% and positive predictive value to 10%. The mean time lag from scan to surgery was 44 weeks.

A positive pre-operative ultrasound scan at our institution predicts an actual rotator cuff tear in 70% of cases. However, it is not accurate with respect to identifying partial-thickness tears or distinguishing them from full-thickness defects. Ultrasound scanning is highly operator dependent and, in addition, its accuracy may be affected by the lengthy time period from scanning to surgery. Clinicians should be cautious in proceeding to surgery based on the ultrasound findings.

The present study reports our experience of Copeland shoulder cementless surface replacement arthroplasty (CSRA) and whether glenoid microfracture influences the progression of glenoid erosion.

One-hundred-and-twelve CSRAs were performed in 101 patients between 2002 and 2007. Eighty-three patients were alive at the median follow-up time of 72 months (range 9 to 121 months; interquartile range 46 to 93 months). Assessment included an Oxford shoulder score (OSS), patient satisfaction score and plain radiographs.

The mean (range) OSS was 27 (7 to 48) and 64 of 73 (87.7%) patients were ‘very satisfied’ or ‘satisfied’ with their shoulder. Twenty-three (20.5%) shoulders had over 2 mm of glenoid erosion. Microfracture was performed in 43 of 112 shoulders (38.4%) and did not influence the progression of glenoid erosion. Further surgery was performed in 27 (24.1%) shoulders, including 15 revisions, eight arthrolyses and four subacromial decompressions. Revision to total shoulder arthroplasty was performed in 14 : 10 for glenoid erosion; one each for loosening, periprosthetic fracture, deep infection, and chronic pain. One was revised to reverse arthroplasty for chronic pain.

CSRA performed in an independent centre reproduces the functional outcomes reported by the designer. Glenoid erosion, however, was a common occurrence and the main cause of revision – microfracture did not influence its progression.

More than 30 different scoring systems are available for evaluating outcomes of shoulder surgery. Unfortunately, given the multitude of scoring systems, there is no objective method to compare results between studies when different scoring systems are utilized.

We compared the American Shoulder and Elbow Society score (ASES) and the Oxford Shoulder Score (OSS) in patients undergoing reverse shoulder arthroplasty for cuff tear arthropathy. Twenty-nine patients had the ASES and OSS recorded pre-operatively, and at 6 and 12 months follow-up. The paired scores were assessed for their degree of correlation and sensitivity to change over time. Linear regression analysis was used to formulate a regression equation to predict one score from the other.

The ASES and OSS correlated well with a Pearson’s correlation coefficient of 0.91 (p < 0.0001, n = 87). Both scores were sensitive to change. Regression analysis yielded a formula to predict the ASES from the OSS and vice versa with good accuracy (r²= 0.83, F_1,85 = 422.6, p < 0.0001).

Where good correlation exists, regression formulae can be used to accurately predict one score from the other in a specific population that it has been validated for. This can be of benefit when objectively comparing outcomes between studies using these two scoring systems.

Nerve injury is an acknowledged complication of total shoulder arthroplasty (TSA). Although the incidence of postoperative neurological deficit has been reported to be between 1% and 16%, the true incidence of nerve damage is considered to be higher. The present study aimed to identify the rate of intraoperative nerve injury during total shoulder arthroplasty and to determine potential risk factors.

A prospective study of nerve conduction in 21 patients who underwent primary or revision TSA was carried out over a 12-month period. Nerve conduction was monitored by measuring intraoperative sensory evoked potentials (SEP). A significant neurophysiological signal change was defined as either a unilateral or bilateral decrease in SEP signal of ≥50%, a latency increase of ≥10% or a change in waveform morphology, not caused by operative or anaesthetic technique.

Seven (33%) patients had a SEP signal change. The only significant risk factor identified for signal change was male sex (odds ratio 15.00, 95% confidence interval). The median nerve was the most affected nerve in the operated arm. All but one signal change returned to normal before completion of the operation and no patient had a persisting postoperative clinical neurological deficit.

The incidence of intraoperative nerve damage may be more common than previously reported. However, the loss of SEP signal is reversible and does not correlate with persisting clinical neurological deficits. The median nerve appears to be most at risk. Monitoring SEPs in the operated limb during TSA may be a valuable tool during TSA.

Risk factors for mortality after proximal humeral fracture, including socioeconomic status, are poorly defined. This retrospective review of prospectively collected data defines the epidemiology and predictors of mortality in association with proximal humeral fractures.

Patients who sustained proximal humeral fractures were identified from fragility fracture and trauma databases between May 2001 and September 2012.

In total, 1880 patients with a mean age of 69 years and a male to female ratio of 2 : 3 were identified. Socioeconomic distribution is skewed towards the lowest and highest quintiles. Low-energy mechanisms caused 88% of fractures. Men sustain fractures when they are aged 10 years younger and via higher-energy mechanisms.

In total, 536 patients (29%) died within the study period with a 1-year mortality of 9.8%, rising to 28.2% at 5 years. Female gender, increasing age, pathological fracture and increased number of co-morbidities were independent variables for increased mortality.

The present study, which was conducted over an 11-year period, is the first to combine the epidemiology and risk factors for mortality with socioeconomic rank. One-year mortality risk is twice that of the background matched population. Patient counselling with respect to increased mortality should be considered, especially in higher-risk elderly females with multiple co-morbidities.

The present study was conducted to determine the quality and content of research on the functional outcomes and complications post-metal radial head arthroplasty (RHAP).

A comprehensive search of medical databases for studies reporting on functional outcomes of patients undergoing metallic RHAP was conducted. The Structured Effectiveness Quality Evaluation Scale (SEQES) was used to evaluate quality of the studies.

We identified 21 Sackett’s Level IV studies reporting on 391 radial heads. The mean duration of follow-up was 47.2 months and the mean (SD) age of patients was 48.4 years (6.9 years). The male to female ratio was found to be 1.05 : 1 and the dominant arm was involved in 54% of patients. When functional outcomes achieved post-RHAP were compared with normative scores, the comparison suggested that RHAP has good to excellent functional outcomes in short- to mid-term follow-up. The weighted mean (SD) Mayo Elbow Performance Score was 85.8 (4.1) (95% confidence interval 85.3 to 86.3). Incidences of implant removal (3.06%) and revision (2.22%) were found to be low.

There is consistent low-quality evidence of positive functional outcomes following RHAP. The heterogeneity of type of implant, patient characteristics and outcome measures used, along with an inadequate reporting of study details, restrict any definitive conclusions being made.

The elbow is an important but complex structure, with movement in both the sagittal plane in flexion and extension, as well as the rotational plane in forearm supination and pronation. Trauma is a common cause of elbow stiffness, which significantly hampers daily function. There are currently no gold-standard management guidelines for post-traumatic elbow stiffness, and most of the published literature focuses solely on the sagittal plane of motion.

This is a retrospective case series reviewing all patients who underwent a surgical release for treatment of post-traumatic elbow stiffness during a 36-month period. Motion range and the shortened version of the Disabilities of the Arm, Shoulder and Hand scores were serially measured and analyzed.

The results obtained showed that both the sagittal and rotational range of motion directly influenced upper limb function; however, the relationship between these two motion planes was weak, meaning that both sagittal and rotational motion in the elbow need be addressed individually. Post-traumatic elbow stiffness could be aptly managed by various surgical approaches, including arthroscopic-assisted procedures; these were all effective in increasing both the sagittal and rotational range of motion. More importantly, this gain in range translated to a statistically significant improvement in upper limb function.

Management of elbow stiffness needs to be tackled in both the sagittal and rotational motion planes.

Various surgical strategies have been described for the treatment of cubital tunnel syndrome, including medial epicondylectomy. This aims to decompress the ulnar nerve and allow a ‘mini anterior transposition’. The major concern over medial epicondylectomy is the potential for postoperative iatrogenic valgus instability.

We utilized a surgical landmark for medial epicondylectomy based on the medial aspect of the ulnar nerve with the elbow in 90° of flexion in 12 cadaveric upper limbs. The size of the resultant fragment was measured and, subsequently, the medial collateral ligament was dissected and the elbow stressed to assess its integrity.

This technique resulted in the excision of a fragment of mean width 8 mm (range 6 mm to 11 mm) and allowed the ulnar nerve to smoothly translate anteriorly in flexion. The anterior band of the ulnar collateral ligament was macroscopically preserved in all cases and there was no valgus instability.

The medial border of the ulnar nerve is a simple, safe and reliable surgical landmark for medial epicondylectomy. This technique offers advantages over other described methods of assessing the location at which to perform a medial epicondylectomy.

Interposition arthroplasty (IA) is mostly performed in younger patients where total joint replacement is contraindicated and an arthrodesis is unattractive. The outcome and complications of an IA were evaluated.

We retrospectively reviewed 18 consecutive cases of interposition arthroplasty (IA) (one case was excluded as a result of incomplete records). Pre- and postoperative pain and function were evaluated. Complications, re-operations and revisions were recorded.

The mean age was 41 years (range 19 years to 59 years) at time of surgery. The primary diagnosis was post-traumatic osteoarthritis in 12 cases and inflammatory arthritis in five cases. The median follow-up was 54 months (range 8 months to 120 months). In 15 cases, at least one re-operation was performed. Seven cases were revised, with four of these to a total elbow replacement, an arthrodesis was performed in two cases and a re-do interposition was carried out in one case. The median interval from the interposition to revision was 23 months (range 8 months to 88 months). In 10 patients with the interposition currently in situ, mean visual analogue scale score for pain improved from 7.4 to 2.4 and mean Mayo Elbow Performance Score improved from 42 to 76 points.

IA offered an improvement in pain and function but at a high cost. It is associated with a high complication rate the need for revision surgery.

There is a paucity of research that describes the patient-reported benefits of physiotherapy rehabilitation for atraumatic posterior instability despite non-operative treatment being considered the initial treatment of choice. This retrospective case series review describes the patient-reported outcomes following a physiotherapy rehabilitation programme for atraumatic posterior shoulder instability.

Nineteen consecutive patients with a clinical diagnosis of atraumatic posterior shoulder subluxation completed our physiotherapy programme. All patients completed Oxford Instability Shoulder scores (OISS) and Western Ontario Shoulder Instability Index (WOSI) scores before and after physiotherapy intervention.

Patients reported a statistically significant clinical improvement in the main outcome measures following physiotherapy intervention. The OISS showed a mean improvement of 18.6 points, whereas the WOSI score showed a mean improvement of 37.2%. Following physiotherapy rehabilitation, all patients reported that their shoulder did not prevent them from performing their work/studies or their chosen hobbies/sports.

Our results support the view that specialized physiotherapy rehabilitation is a valuable treatment option for atraumatic posterior shoulder instability and reveal significant clinically important improvements in patient-reported outcomes.