News Update February 2018
January involved running two courses locally, one was the FRCS Ortho Revision course which is now rated one of the best in the country by candidates was successfully carried out on 12th & 13th January 2018. The second teaching session involved GP training in examination and assessment of patients with upper limb conditions in the primary care. This involved interactive short group discussions.
Outcomes for subscapularis management techniques in shoulder arthroplasty: a systematic review
- Stephen Choate, MD, Adam Kwapisz, MD, PhD, Amit M. Momaya, MD, Richard J. Hawkins, MD, John M. Tokish, MD
JSES, Feb 2018, Vol 27(2), P 363 – 370
This systematic review aims to synthesize published data for the most common subscapularis takedown and repair to compare outcomes in the setting of shoulder arthroplasty.
Searches of MEDLINE and Cochrane Library databases identified studies that reported clinical or radiologic outcomes for subscapularis management in the setting of shoulder arthroplasty. Comparisons included musculotendinous integrity, subscapularis testing and strength, shoulder range of motion, and functional outcome scores.
The 14 included studies reported considerable variability in techniques, outcomes, and musculotendinous integrity. Lesser tuberosity osteotomy (LTO) demonstrated better healing rates (93.1%) than subscapularis peel (SP; 84.1%) and midsubstance tenotomy (ST; 75.7%), although not significantly different. A statistically significant increase in fatty infiltration was found after surgery across techniques, and range of motion and strength were similar. Mean rates of normal results for belly-press and lift-off tests were uniformly better for LTO (79.1% and 80.7%) over ST (66.7% and 65.6%), although multiple studies showed poor correlation between subscapularis functional testing and musculotendinous integrity. Mean total Constant and Western Ontario Osteoarthritis of the Shoulder Index outcome scores were slightly better for LTO (77.6, 84.2) than for SP (71.8 and 82.7). Mean American Shoulder and Elbow Surgeons scores favoured the ST group (80.8) over the SP (79.1) and LTO (73) groups.
The data suggest no significant differences exist for postoperative musculotendinous integrity or clinical outcomes among the subscapularis management techniques in shoulder arthroplasty. Subscapularis healing and integrity appear to favour the lesser tuberosity takedown method. Additional randomized controlled comparisons with long-term follow-up are needed to more effectively compare these surgical approaches.
Comment: Prof. Singh has used a subscapularis peel or tenotomy depending on the quality of tendon and bone. Sometimes in older age group patients the bone quality may be poor to provide a decent transosseous repair and in those situations a tenotomy is better.
Results after radial head arthroplasty in unstable fractures
Ariana Lott, BA, Kari Broder, BA, Abraham Goch, MD, Sanjit R. Konda, MD, Kenneth A. Egol, MD
JSES, Feb 2018, Vol 27(2), P 270 – 75
Whereas most radial head fractures are stable injuries, they sometimes occur as part of complex injury patterns with associated elbow instability. Radial head arthroplasty has been favoured in patients with unreconstructable radial head fractures and unstable elbow injuries. The purpose of this study was to review radiographic outcomes, functional outcomes, and complications after radial head arthroplasty for radial head fracture in unstable elbow injuries.
This study was a retrospective review of radial head fractures treated with radial head arthroplasty by a single surgeon during a 15-year period. Demographics of the patients, injury details, operative reports, radiographic and clinical outcomes, and any complications were recorded. Patients were divided into stable and unstable elbow injury groups.
A total of 68 patients were included. There were 50 unstable fractures that were compared with 18 stable fractures. Patients with unstable radial head fractures with associated elbow dislocation achieved mean flexion and mean forearm rotational arc of motion similar to that of patients with stable radial head fractures. However, supination loss was greater in the unstable group than in the stable fracture group, with a mean difference of 10°. Radiographic outcomes and complication rates did not differ between injury groups. There was no observed decrease in implant longevity in patients with unstable elbow injuries.
Radial head arthroplasty is an effective option for treatment of unstable elbow injuries, with recovery of functional elbow range of motion and no difference in complication rate or implant survivorship compared with those patients with stable injuries.
Osteosynthesis of AO/OTA 13-C3 distal humeral fractures in patients older than 70 years
JSES, Feb 2018, Vol 27(2), P 291 – 97
Eric R. Wagner, MD, Matthew T. Houdek, MD, Daniel Mascarenhas, BS, Raymond A. Pensy, MD, Walter A. Eglseder, MD
The purpose of this retrospective case series was to examine the AO Foundation and Orthopaedic Trauma Association (AO/OTA) 13-C3 distal humeral fractures treated with open reduction–internal fixation (ORIF) in patients older than 70 years.
During an 8-year period, 21 patients older than 70 years with AO/OTA 13-C3 distal humeral fractures were treated with ORIF performed by 2 senior upper extremity traumatologists. There were 16 patients with >1 year of follow-up, with a mean age of 78 (70-84) years.
At a mean follow-up of 4 years (1-8 years), all 16 patients demonstrated radiographic signs of bone union. Three patients underwent reoperations, including irrigation and débridement for postoperative infections (n = 2) and removal of implant for symptomatic olecranon intramedullary screw (n = 1). The mean postoperative total arc of ulnohumeral motion was 97° (80°-145°), including a mean flexion of 117° (106°-126°) and flexion contracture of 20° (14°-26°). The mean pronation was 69° (55°-85°), and supination was 78° (74°-9°0). The mean Quick Disabilities of the Arm, Shoulder, and Hand score was 19 (standard deviation, 6.9; confidence interval, 15.4-22.8), and the mean Mayo Elbow Performance Score was 91 (standard deviation, 8.2; confidence interval, 86-95).
ORIF remains a reliable option for treatment of AO/OTA 13-C3 distal humeral fractures in elderly patients. Excellent clinical outcomes can be achieved with preservation of motion and arm function through anatomic reduction, rigid internal fixation, and early mobilization.
Comments: Prof Singh believes to restore normal anatomy as long as its possible without causing too much complications.
Fixation of proximal pole scaphoid non-union with non-vascularized cancellous autograft
JHS(E)Volume: 43 issue: 1, page(s): 66-72
We present 20 patients with established proximal pole scaphoid nonunions treated with curettage and cancellous autograft from the distal radius and screw fixation. Fractures with significant proximal pole fragmentation were excluded. Patients were treated at a mean of 26 weeks after injury (range 12–72). Union occurred in 18 of 20 patients (90%) based on computed tomographic imaging. The two nonunions that did not heal were treated with repeat curettage and debridement and iliac crest bone grafting without revision of fixation. Union was achieved in both at a mean of 11 weeks after the revision procedures. Our findings suggest that non-vascularized cancellous autograft and antegrade fixation is a useful option for the treatment of proximal pole scaphoid nonunions.
Non-vascularized iliac bone grafting for scaphoid nonunion with avascular necrosis
JHS(E), Volume: 43 issue: 1, page(s): 24-31
We present the surgical outcomes of non-vascularized bone grafting taken from the iliac crest in 24 patients with scaphoid nonunion and avascular necrosis. The Fisk-Fernandez technique was used in 11 patients, and cancellous bone grafting was used in 13 patients. Bony union was achieved in 22 of the 24 patients. Non-vascularized iliac bone grafting can be used for the surgical management of scaphoid nonunion with avascular necrosis. Although revascularization of the proximal fragment after surgery was not evaluated, bony union was confirmed in nearly all patients.