News Update January 2018
The month of November and December has again been academically and clinically very busy for Prof. Singh.
I undertook shoulder replacement on a patient whose socket had worn so badly that a custom made implant had to be ordered from USA. This type of prosthesis allows me to help patients who would otherwise have been left in pain as the standard shoulder replacement could not have been done here.
I was invited to two international meetings in India. One at the Annual Congress of the Indian Orthopaedic Association where I presented on managing complex shoulder fractures and participated in interactive case base discussion. I also chaired the session on ‘Emerging Trends in Orthopaedics’. I also went to a meeting of Association of Sports Medicine and Arthroscopy of Gujarat. Here I carried out live surgery on two patients, presented on shoulder & elbow problems. I also carry out some charity work where I saw and operated on complex shoulder & elbow conditions.
Caubere et al: Is the subscapularis normal after the open Latarjet procedure? An isokinetic and magnetic resonance imaging evaluation,
The Latarjet procedure consists of transferring a coracoid bone block to the anteroinferior neck of the glenoid after its passage through the subscapularis muscle. The procedure is indicated in young patients with anterior recurrent shoulder instability and who plays contact and overhead sports. The Latarjet procedure is considered to be a violation of the subscapularis muscle. This study evaluated the postoperative status of the subscapularis through isokinetic and magnetic resonance imaging analysis after splitting.
This was a case-control retrospective study of patients who underwent a Latarjet procedure between January 2013 and January 2015. A total of 20 patients were reviewed at 1 year postoperatively. With the patient seated, strength testing of both shoulders was done (concentric, eccentric, and fatigability) with a dynamometer. Atrophy and fatty infiltration were analyzed by magnetic resonance imaging.
At 1 year after the open Latarjet procedure, isokinetic testing showed a combined strength deficit in both internal and external rotation with a conserved muscle balance. Although no significant subscapularis fatty infiltration or atrophy was noted, there was a significant deficit in endurance compared with the healthy shoulder.
Comment: Prof. Singh has always had the concern about using the coracoid and hence uses a slightly different technique wherein he uses bone from pelvis so that the subscapularis muscle is preserved better – unlike the above technique where the bottom half of the muscle becomes weak.
Beard DJ et al: Arthroscopic subacromial decompression for subacromial shoulder pain (CSAW): a multicentre, pragmatic, parallel group, placebo-controlled, three-group, randomised surgical trial.
Lancet. 2017 Nov 20. doi: S0140-6736(17)32457-1. doi: 10.1016/S0140-6736(17)32457-1.
We did a multicentre, randomised, pragmatic, parallel group, placebo-controlled, three-group trial at 32 hospitals in the UK with 51 surgeons. Participants were patients who had subacromial pain for at least 3 months with intact rotator cuff tendons, were eligible for arthroscopic surgery, and had previously completed a non-operative management programme that included exercise therapy and at least one steroid injection. Exclusion criteria included a full-thickness torn rotator cuff. We randomly assigned participants (1:1:1) to arthroscopic subacromial decompression, investigational arthroscopy only, or no treatment (attendance of one reassessment appointment with a specialist shoulder clinician 3 months after study entry, but no intervention). Arthroscopy only was a placebo as the essential surgical element (bone and soft tissue removal) was omitted. Patients were followed up at 6 months and 1 year after randomisation; surgeons coordinated their waiting lists to schedule surgeries as close as possible to randomisation. The primary outcome was the Oxford Shoulder Score (0 [worst] to 48 [best]) at 6 months, analysed by intention to treat.
Surgical groups had better outcomes for shoulder pain and function compared with no treatment but this difference was not clinically important. Additionally, surgical decompression appeared to offer no extra benefit over arthroscopy only. The difference between the surgical groups and no treatment might be the result of, for instance, a placebo effect or postoperative physiotherapy.
Comment: This is a well conducted study and I was one of the surgeons who took part in the study. This type of surgery represents a small part of procedures that I undertake – typically less than 15% and all patients have exhausted non operative treatment prior to proceeding to surgery. So, this is unlikely to impact on my practice, but will certainly help me having a good discussion with patients requiring only ‘decompression’
D H Lalonde: Conceptual origins, current practice, and views of wide awake hand surgery
This article reviews historical background, essential practice principles, and the new emerging area of wide awake hand surgery. It outlines the reasons that wide awake, local anaesthesia, no tourniquet surgery has emerged so quickly in the last 10 years over the world. I explain the origin of the concepts and some of the challenges of getting the technique accepted; in particular, the debunking of the myth of epinephrine danger in the finger. I review the most recent developments in several operations in this rapidly changing field of the tourniquet-free approach. Finally, this review includes speculations on the future of this technique.
Comments: I routinely use local anaesthetic and regional anaesthesia for appropriate surgery. This helps patient have a smooth and safe procedure and post-operative recovery.