News Update May 2018 + Feeback & Literature Update

News Update May 2018 + Feeback & Literature Update

March and April were quite busy month. Prof. Singh was at the Annual Congress of American Academy of Orthopaedic Surgeons in New Orleans, show casing the work he has been doing at Medway for last 6 years. He presented on use of a ‘Special Balloon’ interposition in patients whose rotator cuff (rotary cuff) cannot be repaired.

This is an alternative to doing a shoulder replacement and 5 year results show that only 10% patients need that surgery. It’s done via Key Hole with minimul morbidity and complications are virtually negligible. If you need detailed information, please contact my secretary or ask at the time of consultation.

In April Prof. Singh organised the FRCS Ortho Revision course which was very successful and extremely good feed back from candidates attending the session and also the patients who help him with the course. He is ever so grateful to the patients for helping with the course.

Feedback:

1st May 2018

I have experienced a wrist pain after an accident for 3 and half years before I have been referred to Prof. Singh. He is very professional, friendly and approachable. I was very quickly put an ease. Prof. Singh has quickly made diagnoses and explained every part of the surgery, I could not wished for a better treatment.

Mr Singh is great and so are the outpatients team at Maritime. The NHS for the first time let me down leaving me in pain for nearly a year and then my operation was cancelled. This really affected my overall health and compromised my ability to do my job considerably. It’s not their fault but this Government seriously need to fund these amazing professional people and hospitals properly. I shouldn’t have had to wait this like long and become so unwell! Can I just also say the aneathestic staff and post operative care I received was the best ever. Thank you for that.

25th April 2018

Professor Singh in my opinion works in a very person centred manner. I felt listened to and my hopes and concerns regarding my treatment were considered thoroughly. Professor Singh also took into account my agenda regarding when treatment would be carried out to give the least disruption possible to my work commitments. My consultation was not rushed and I felt valued at all times. It was a pleasure to see this gentleman

This doctor explained in detail what was wrong with me, and what he was going to do to correct it. He showed me my scans and showed me what the problem was and was easy to understand (didn’t’ use long medical terms) used plain english. Very polite and gentle.

12th April 2018

The Doctor listened to my concerns and asked the right questions in order to make the diagnosis and to present me with the treatment options. At all stages I felt included and was presented with the options and given details of the risks and possible outcomes. At all stages I felt my best interests were being considered. I understood the procedures that were going to be undertaken and was treated very well at all stages from arrival to departure following the operation. My treatment has been very well managed and I would have no hesitation in using the doctor again should the need arise. Thank you for everything.

Please visit the website: www.iwantgreatcare.org  to leave feedback.

Literature Update:

Surgical stabilization for first-time shoulder dislocators: a multicenter analysis, Rugg et al: JSES, April 2018, 27(4), 674 – 685. DOI: https://doi.org/10.1016/j.jse.2017.10.041

Anterior shoulder dislocations in young patients are associated with high rates of recurrent instability. Although some surgeons advocate for surgical stabilization after a single dislocation event in this population, there is sparse research evaluating surgical treatment for first-time dislocators.

Patients undergoing surgical stabilization for anterior shoulder instability were prospectively enrolled at multiple institutions from 2015-2017 and stratified by number of dislocations before surgery.

The study included 172 patients (mean age, 25.3 years; 79.1% male patients) for analysis (58 patients with 1 dislocation, 69 with 2-5 dislocations, 45 with >5 dislocations). There were no intergroup differences in demographic characteristics, preoperative patient-reported outcomes, or physical examination findings. Preoperative imaging revealed increased glenoid bone loss in patients with multiple dislocation events (P = .043). Intraoperatively, recurrent dislocators were more likely to have bony Bankart lesions (odds ratio [OR], 3.26; P = .024) and biceps pathology (OR, 6.27; P = .013). First-time dislocators more frequently underwent arthroscopic Bankart repair and/or capsular plication (OR, 2.22; P = .016), while recurrent dislocators were more likely to undergo open Bristow-Latarjet procedures (OR, 2.80; P = .049) and surgical treatment for biceps pathology (OR, 5.03; P = .032).

First-time shoulder dislocators who undergo stabilization are more likely to undergo an arthroscopic procedure and less likely to have bone loss or biceps pathology compared with recurrent dislocators. Future studies are needed to ascertain long-term outcomes of surgical stabilization based on preoperative dislocation events

 Commentary: There is still no certainty on whether the first time dislocators should have their shoulder stabilised as some of them may not need any surgery. The current UK standard is to have physical therapy initially after the first dislocation and then if the problem recurs – i.e patient become recurrent dislocators then consider surgery and vast majority of them benefit through key hole (arthroscopic) surgery.

McLaughlin et al: Multimodal analgesia decreases opioid consumption after shoulder arthroplasty: a prospective cohort study, JSES, 27(4), p 686 – 691.

DOI: https://doi.org/10.1016/j.jse.2017.11.015

Studies on perioperative pain control in shoulder arthroplasty focus on regional anesthesia, with little research on other approaches. Perioperative multimodal analgesia regimens decrease opioid intake and opioid-related side effects in lower-extremity arthroplasty. In this study we compare pain scores, opioid consumption, length of stay, and readmission rates in postoperative shoulder arthroplasty patients treated with a standard or multimodal analgesia regimen.

A prospective cohort analysis was performed at a single institution. Patients undergoing elective shoulder arthroplasty were treated with either a standard opioid-based regimen or a multimodal analgesia regimen perioperatively. Outcome measures included inpatient pain scores, opioid use, length of stay, and 30- and 90-day emergency department visits and readmission rates.

Seventy-five patients were included in each cohort. Patients treated with the multimodal analgesia regimen had lower postoperative day 0 pain scores (mean, 1.5 vs 2.2; P = .027). Opioid use in the multimodal cohort was lower on all days: 47% lower on postoperative day 0, 37% on day 1, and 44% on day 2 (all P < .01). The length of inpatient stay was significantly shorter for multimodal patients than for patients treated with the standard regimen (1.44 days vs 1.91 days, P < .01). There was no difference in the rate of 30- or 90-day emergency department visits or readmission.

Patients undergoing shoulder arthroplasty have decreased postoperative pain and opioid consumption and shorter hospital stays when given a multimodal analgesia regimen. There is no increase in short-term complications or unplanned readmissions, indicating that this is a safe and effective means to control postoperative pain.

Commentary: All my patients receive a multi modal analgesia and my average length of stay is less than 24 hours  following shoulder arthroplasty.

Haglin et al: Open surgical elbow contracture release after trauma: results and recommendations, JSES, 27(3), 418 – 426. DOI: https://doi.org/10.1016/j.jse.2017.10.023

Post-traumatic elbow contracture is a debilitating complication after elbow trauma. The purpose of this study was to characterize the affected patient population, operative management, and outcomes after operative elbow contracture release for treatment of post-traumatic elbow contracture.

A retrospective record review was conducted to identify all patients who underwent post-traumatic elbow contracture release performed by 1 of 3 surgeons at one academic medical center

The study included 103 patients who met inclusion criteria. At the time of contracture release, patients were a mean age of 45.2 ± 15.6 years. Contracture release resulted in a significant mean increase to elbow extension/flexion arc of motion of 52° ± 18° (P < .0005). Not including recurrence of contracture, a subsequent complication occurred in 10 patients (10%). Radiographic recurrence of heterotopic ossification (HO) occurred in 14 patients (14%) after release. Ten patients (11%) elected to undergo a secondary operation to gain more motion.

Soft tissue and bony elbow contracture release is effective. Patients with post-traumatic elbow contracture can make significant gains to their arc of motion after contracture release surgery and can expect to recover a functional elbow arc of motion. Patients with severe preoperative contracture may benefit from concomitant ulnar nerve decompression. HO prophylaxis did not affect the rate of HO recurrence or ultimate elbow range of motion. However, patients must be counseled that contracture may reoccur, and some patients may require or elect to have more than one procedure to achieve functional motion. 

Commentary: Prof. Singh undertakes similar procedure arthroscopically (key Hole) with equally good results and less complications. 

Gaucci et al: Anatomical total shoulder arthroplasty in young patients with osteoarthritis, all-polyethylene versus metal-backed glenoid, https://doi.org/10.1302/0301-620X.100B4.BJJ-2017-0495.R2

A total of 69 consecutive aTSAs were performed in 67 patients aged < 60 years with primary glenohumeral OA. Their mean age at the time of surgery was 54 years (35 to 60). Of these aTSAs, 46 were undertaken using a cemented polyethylene component and 23 were undertaken using a cementless metal-backed component. The age, gender, preoperative function, mobility, premorbid glenoid erosion, and length of follow-up were comparable in the two groups. The patients were reviewed clinically and radiographically at a mean of 10.3 years (5 to 12, sd 26) postoperatively. Kaplan–Meier survivorship analysis was performed with revision as the endpoint.

A total of 26 shoulders (38%) underwent revision surgery: ten (22%) in the polyethylene group and 16 (70%) in the metal-backed group (p < 0.0001). At 12 years’ follow-up, the rate of implant survival was 74% (sd 0.09) for polyethylene components and 24% (sd 0.10) for metal-backed components (p < 0.0002). Glenoid loosening or failure was the indication for revision in the polyethylene group, whereas polyethylene wear with metal-on-metal contact, instability, and insufficiency of the rotator cuff were the indications for revision in the metal-backed group.

Preoperative posterior subluxation of the humeral head with a biconcave/retroverted glenoid (Walch B2) had an adverse effect on the survival of a metal-backed component.

The survival of a cemented polyethylene glenoid component is three times higher than that of a cementless metal-backed glenoid component ten years after aTSA in patients aged < 60 years with primary glenohumeral OA. Patients with a biconcave (B2) glenoid have the highest risk of failure.

Commentary: Prof. Singh does not use metal back glenoid in any of his anatomical total shoulder replacements due to higher failure rates.

Houghton et al: Can we improve the outcome of hydrodilatation for adhesive capsulitis? Shoulder & Elbow, 10(2), 93 – 98, https://doi.org/10.1177/1758573217706199

Hydrodilatation (HD) has been shown to improve pain and function in patients with adhesive capsulitis (AC). There is no consensus concerning how HD should be performed or what volume should be injected. It has distinct advantages compared to surgery; however, it is a painful procedure and is often poorly tolerated.

We retrospectively reviewed all patients referred for HD over a 2.5-year period aiming to assess whether volume injected influences outcome.

There were 107 patients treated with HD; of these, 76 (43 female, 32 male) had full data for analysis. The majority were classified as primary AC (n = 57) with an average age of 55.5 years. The mean improvement in Oxford Shoulder Score (OSS) was 12.1, with females (13.9) and post-traumatic cases of AC (14.1) demonstrating the best outcome. No complications were observed during the HD process. There was a negative correlation observed between volume injected and OSS improvement. Only two patients experienced a poor outcome and required further treatment with manipulation +/– arthroscopic arthrolysis.

The present study supports the use of HD as a first line treatment for AC regardless of the underlying cause, and also demonstrates that the volume injected does appear to influence the outcome.

Commentary: Prof Singh undertakes gleno humeral joint release (HD) on a regular basis and more than 90% patients get significant improvement and avoid surgery. Patients especially within 9 months of their onset of symptoms do very well following the procedure. There are certain groups where surgery is required more frequently.