News Update October / November 2017
The month of September & October has been particularly busy for Prof. Singh with giving a lecture and presenting another paper at the British Orthopaedic Association Annual Congress, held in Liverpool from 16 – 19 September.
He presented the largest study ever undertaken in the elderly patients undergoing surgery for Hip Fracture (Fracture Neck of Femur). The study enrolled over 500 patients into two groups one which had clips to the skin and another group which had dissolvable stitches (subcuticular sutures). This showed a significant reduced complication rates in patients who had their wound closed with dissolvable stitches including infection and wound discharge. This study recommends use of dissolvable sutures in all patients undergoing hip fracture surgery.
He also gave a lecture on ‘Complex Elbow’ injury at the same meeting.
Following this he went to India for the Vidharba Orthopaedic Society Conference held in the historic city of Amravati. Here he was the invited overseas faculty – talking about ‘Salvage of Proximal Humerus Fracture in Young Adults’, Tennis Elbow Surgery, Acromio Clavicular Joint Dislocation Surgery.
He visited the famous ‘Pench Tiger Reserve’ and was lucky enough to have a siting of the Indian Tiger.
Prof. Singh has published two articles in the last two months.
Magnetic resonance imaging scans are not a reliable tool for predicting symptomatic acromioclavicular arthritis.
Prof. B Singh et al, Shoulder & Elbow, doi:/10.1177/1758573217724080
We investigated whether magnetic resonance imaging (MRI) scans can accurately diagnose arthritis of the acromioclavicular joint (ACJ) because it has recently been suggested that bone marrow oedema on MRI scans is a predictive sign of symptomatic ACJ arthritis.
The MRI scans of 43 patients (50 shoulders) who underwent ACJ excision for clinically symptomatic ACJ arthritis were compared to a control group of 43 age- and sex-matched patients (48 shoulders) who underwent an MRI scan for investigation of shoulder pain but did not have clinical symptoms or signs of ACJ arthritis. The scans were evaluated by an experienced musculoskeletal radiologist, who was blinded to the examination findings.
Bone marrow oedema was present in only 15 (30%) shoulders in the ACJ excision group, although this was higher than the six shoulders in the asymptomatic group (p = 0.03). Forty-one (82%) shoulders in the symptomatic group had grade III/IV ACJ arthritis compared to 31 (65%) in the asymptomatic group (p = 0.05). However, 44 out of 48 (92%) shoulders in the asymptomatic group had signs of osteoarthritis on MRI scans.
In contrast to recent reports, the present study shows that MRI is not helpful in making the diagnosis of ACJ arthritis. A focused history and clinical examination should remain the mainstay for surgical decision making.
Current Concepts in the diagnosis and treatment of shoulder impingement.
Bijayendra Singh et al: Indian Journal of Orthopaedics, Vol 51(5), Oct 2017, p 516 – 23. DOI:10.4103/ortho.IJOrtho_187-17
Subacromial impingement syndrome (SIS) is a very common cause of shoulder pain in the young adults. It can cause debilitating pain, dysfunction, and affects the activities of daily living. It represents a spectrum of pathology ranging from bursitis to rotator cuff tendinopathy which can ultimately lead to degenerative tear of the rotator cuff. Various theories and concepts have been described and it is still a matter of debate. However, most published studies suggest that both extrinsic and intrinsic factors have a role in the development of SIS. The management is controversial as both nonoperative and operative treatments have shown to provide good results. This article aims to provide a comprehensive current concepts review of the pathogenesis, etiologies, clinical diagnosis, appropriate use of investigations, and discussion on the management of SIS.
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.
Comment: This article talks about undertaking hand surgery under regional / local anaesthesia i.e. without putting patients to sleep. Prof. Singh uses many of these techniques highlighted in this article in his practice. The advantage of this technique is that there is no side effect of general anaesthesia like nausea or vomiting. The patient is comfortable and can go home sooner.
A systematic review of medial epicondylectomy as a surgical treatment for cubital tunnel syndrome
The aim of this study was to review the literature of decompression of the cubital tunnel with medial epicondylectomy and to assess outcomes and complications. Twenty-one case series reported on 886 medial epicondylectomies. The mean percentage of patients obtaining improvement of one or more McGowan grade was 79%. The mean percentage obtaining a good/excellent Wilson Krout grade of outcome was 83%. Of six comparative studies, two showed no significant differences in outcomes between medial epicondylectomy and transposition procedures, and three reported better outcomes with medial epicondylectomy. One reported similar outcomes with medial epicondylectomy and simple decompression. The existing literature on medial epicondylectomy is of limited methodological quality and does not allow for firm conclusions to be drawn regarding its efficacy compared with other surgical techniques. Further studies should aim for high methodological quality, randomized comparison with simple decompression or anterior transposition and should utilize standardized outcome measures.
Comment: This article looks at different options for surgery on ulnar nerve compression, often understood by patients as ‘funny bone’ This is the nerve that passes around the back of elbow and can cause problems with fingers and hands. Prof. Singh uses a different technique which is less invasive and provides good outcome.