Prof BJ Singh Publication Literature Update
Intra-articular distal radius fractures in elderly patients: a randomized prospective study of casting versus volar plating
Volume: 43 issue: 2, page(s): 142-147; https://doi.org/10.1177/1753193417727139
We compared outcomes in elderly patients with intra-articular distal radius fractures treated by closed reduction and plaster immobilization or open reduction and internal fixation with a volar plate. Ninety-seven patients older than 60 years were randomly allocated to conservative (47 patients) or surgical (50 patients) treatment. Over a 2-year period, we assessed patient-rated wrist evaluation score, DASH (disability arm, shoulder and hand) questionnaire, pain, wrist range of motion, grip strength, and radiological parameters. The functional outcomes and quality of life were significantly better after volar plating fixation compared with conservative treatment. We found that restoration of the articular surface, radial inclination, and ulnar variance affected the outcomes, but the articular step-off did not. Twenty-five per cent of the patients with conservative treatment had secondary loss of reduction. We conclude that surgical plating leads to better outcomes than conservative treatment for elderly patients with intra-articular distal radius fractures.
Commentary: This article suggests that each patient has to be treated on their individual basis. Every fracture and patient behaves differently. I always sit and discuss options with patients and what to expect of the treatment choices.
Smartphone photography utilized to measure wrist range of motion
Volume: 43 Issue: 2, page(s): 187-192; https://doi.org/10.1177/1753193417729140
The purpose was to determine if smartphone photography is a reliable tool in measuring wrist movement. Smartphones were used to take digital photos of both wrists in 32 normal participants (64 wrists) at extremes of wrist motion. The smartphone measurements were compared with clinical goniometry measurements. There was a very high correlation between the clinical goniometry and smartphone measurements, as the concordance coefficients were high for radial deviation, ulnar deviation, wrist extension and wrist flexion. The Pearson coefficients also demonstrated the high precision of the smartphone measurements. The Bland–Altman plots demonstrated 29–31 of 32 smartphone measurements were within the 95% confidence interval of the clinical measurements for all positions of the wrists. There was high reliability between the photography taken by the volunteer and researcher, as well as high inter-observer reliability. Smartphone digital photography is a reliable and accurate tool for measuring wrist range of motion.
Commentary: This is an exciting study which uses the newer technology to look at patient outcomes and will become more prevalent in future.
Comparing daily shoulder motion and frequency after anatomic and reverse shoulder arthroplasty
10. Daniel G. Langohr, PhD, John P. Haverstock, MD, FRCSC, James A. Johnson, PhD, George S. Athwal, MD, FRCSC; https://doi.org/10.1016/j.jse.2017.09.023
Both anatomic (TSA) and reverse total shoulder arthroplasty (RTSA) are common interventions for glenohumeral arthrosis, with the goal of relieving pain and restoring mobility. The purpose of this study was to measure and compare the total daily shoulder motion of patients after TSA and RTSA.
Thirty-six human subjects who had undergone shoulder arthroplasty wore a custom instrumented garment that tracked upper extremity motion for the waking hours of 1 day. The 3-dimensional orientation of each humeral sensor was transformed with respect to the torso to calculate total joint motion and frequency, with comparison of TSA to RTSA. In addition, the yearly motion of the shoulder was extrapolated.
The majority of shoulder motion occurred below 80° of elevation (P < .001), totalling on average 821 ± 45 and 783 ± 27 motions per hour for TSA and RTSA, respectively. Conversely, elevations >80° were significantly less frequent, totalling only 52 ± 44 (P < .001) and 38 ± 27 (P < .001) motions per hour for TSA and RTSA, respectively. No significant differences were detected between TSA and RTSA shoulders (P = .22) or their respective contralateral asymptomatic sides (P = .64, P = .62). When extrapolated, it was estimated that each TSA and RTSA shoulder elevated above 60° approximately 1 million and 0.75 million cycles per year, respectively.
Mean shoulder motions after TSA or RTSA were not significantly different from the contralateral asymptomatic side. In addition, no significant differences were detected in shoulder motion or frequency between TSA and RTSA
Commentary: Although historically we have been told that motion with Reverse Shoulder is less than anatomic, if done carefully the results are equally good.
Managing acromio-clavicular joint pain: a scoping review
Shoulder pain secondary to acromioclavicular joint pain is a common presentation in primary and secondary care but is often poorly managed as a result of uncertainty about optimal treatment strategies. Osteoarthritis is the commonest cause. Although acromioclavicular pain can be treated non-operatively and operatively, there appears to be no consensus on the best practice pathway of care for these patients, with variations in treatment being common place. The present study comprises a scoping review of the current published evidence for the management of isolated acromioclavicular pain (excluding acromioclavicular joint dislocation).
A comprehensive search strategy was utilized in multiple medical databases to identify level 1 and 2 randomised controlled trials, nonrandomised controlled trials and systematic reviews for appraisal.
Four systematic reviews and two randomised controlled trials were identified. No direct studies have compared the benefits or risks of conservative versus surgical management in a controlled environment.
High-level studies on treatment modalities for acromioclavicular joint pain are limited. As such, there remains little evidence to support one intervention or treatment over another, making it difficult to develop any evidenced-based patient pathways of care for this condition.
Commentary: This study confirms the importance of clinical examination prior to any surgical intervention. I published a study showing that imaging either MRI or plain radiographs are not good at picking clinically relevant painful joint.
Open release versus radiofrequency microtenotomy in the treatment of lateral epicondylitis: a prospective randomized controlled trial
Optimal surgical treatment of lateral epicondylitis remains uncertain. Recently, radiofrequency microtenotomy (RFMT) has been proposed as a suitable treatment. We compared RFMT with standard open release (OR) in this prospective randomized controlled trial.
In total, 41 patients with symptoms for at least 6 months were randomized into two groups: 23 patients had RFMT and 18 had OR. Two patients from RFMT withdrew. Each patient underwent Numerical Rating Scale (NRS) pain score, grip strength and Disabilities of the Arm, Shoulder and Hand (DASH) scores pre-operatively and at 6 weeks. Pain and DASH scores were repeated at 6 months and 12 months.
NRS pain scores improved by 4.8 points for RFMT and by 3.9 points for OR. There was a significant improvement in both groups from pre-operative scores, although there was no statistically significant difference between the groups at 1 year. Grip strength improved by 31% in the RFMT group compared to 38% in OR. There was no significant difference between the initial and 6 weeks scores or between treatments. At 1 year, DASH was 39.8 points for RFMT and 24.4 points for OR. There was a significant improvement in both groups from pre-operative scores, although there was no statistically significant difference between the groups at 1 year.
Both groups showed significant improvements and similar benefit to the patient. The results of the present study do not show any benefit of RFMT over the standard OR. As a result of the extra expense of RFMT, we therefore recommend that OR is offered as the standard surgical management.
Commentary: The use of radio frequency in tennis elbow is not new and was initially brought as a minimally invasive technique but there is additional cost involved. Hence, I always undertake the open release.