The June 2023 Shoulder & Elbow Roundup³⁶⁰ looks at: Proximal humerus fractures: what does the literature say now?; Infection risk of steroid injections and subsequent reverse shoulder arthroplasty; Surgical versus non-surgical management of humeral shaft fractures; Core outcome set needed for elbow arthroplasty; Minimally invasive approaches to locating radial nerve in the posterior humeral approach; Predictors of bone loss in anterior glenohumeral instability; Does the addition of motor control or strengthening exercises improve rotator cuff-related shoulder pain?; Terminology and diagnostic criteria used in patients with subacromial pain syndrome.

Objectives

Modern metal-on-metal (MoM) hip resurfacing arthroplasty (HRA), while achieving good results with well-orientated, well-designed components in ideal patients, is contraindicated in women, men with head size under 50 mm, or metal hypersensitivity. These patients currently have no access to the benefits of HRA. Highly crosslinked polyethylene (XLPE) has demonstrated clinical success in total hip arthroplasty (THA) and, when used in HRA, potentially reduces metal ion-related sequelae. We report the early performance of HRA using a direct-to-bone cementless mono-bloc XLPE component coupled with a cobalt-chrome femoral head, in the patient group for whom HRA is currently contraindicated.

Objectives

The aim of this study was to review the current evidence and future application for the role of diagnostic and therapeutic ultrasound in fracture management.

INTRODUCTION. Venous thromboembolism (VTE), especially, deep vein thrombosis (DVT) in lower extremities, often seriously combined with pulmonary embolism (PE), is a major and critical complication after total hip arthroplasty (THA). For better disgonsis of VTEs, D-dimer test is one of the useful methods. The aim of this study was to evaluate the efficacy of D-dimer levels before THA. MATERIALS AND METHODS. Medical records of patients with osteoarthritis who received THA between April 2009 and March 2010 were reviewed. Value of D-dimer at preoperative day 1, postoperative day 3 and 14 was examined in those patients. D-dimer levels were examined by Latex Immunity Nephelometry Measurement Method and the Kit (Sysmex Corporation, Kobe, Japan). A total of 327 patients with D-dimer values were examined. The values D-dimer of the available patients were under 1.0 μg/ml. Ninety-nine patients (30%) had a high D-dimer level. DVT was diagnosed by doppler ultrasonography at preoperative day 1, postoperative day 3 and 14. The sensitivity and specificity of D-dimer in different cutoffs were verified by Receiver Operating Characteristic (ROC) curve. The ROC curve was constructed to describe the relationship between the sensitivity and the false positive rate for different values of D-dimer to patients suspected of VTEs. The study protocol was approved by the institutional ethics committee. RESULTS. Eighty-two patients (83%) were females and 17 (18%) were males. Mean age was 67.3 (51–88) years. Mean value of D-dimer was 2.6 (1.1–10.3) μg/mL. DVT was detected in 21 patients (21%) at the preoperative day 1 (DVT positive group). Average of age of this (or DVT positive) group was 71.9 (52–88) years. There was significant difference in D-dimer level between DVT negative group, DVT was not detected at the preoperative day 1, and DVT positive group (p<0.05). The areas under the receiver operating characteristic curve of D-dimer were larger than those of other parameters in the ROC curve (p=0.76). The cutoff value from the Youden index was 1.95 μg/mL, and the sensitivity and specificity values were 84.2% and 62.7%, respectively. The incidence of DVT in the positive group was 19% and 16%, respectively. DISCUSSION AND CONCLUSION. Even DVT in the calf has the potential to propagate proximally, which led to a risk of PE. Therefore, screening for detection of DVT is important, even if the DVT was asymptomatic distal DVT. In some countries, it is thought that if the value of D-dimer is less than 0.5 μg/mL, VTEs are excluded in patients without surgeries, but some D-dimer kits, frequently used in Japan, have different cutoff values for the exclusion of DVT. Assessment of D-dimer is simple and reliable, as to be one of the beneficial methods to detect high-risk patients of VT and/or occult DVT before THA. In conclusion, it is important to evaluate preoperative screening of VTE before THA, as the existence of pre-operative DVT has high risk of postoperative DVT occurrences. The D-dimer test is one of useful methods to evaluate the perioperative state of the patients with VTE risk

The October 2014 Research Roundup³⁶⁰ looks at: unpicking syndesmotic injuries: CT scans evaluated; surgical scrub suits and sterility in theatre; continuous passive motion and knee injuries; whether pain at night is melatonin related;venous thromboembolic disease following spinal surgery; clots in lower limb plasters; immune-competent cells in Achilles tendinopathy; and infection in orthopaedics.

The April 2014 Shoulder & Elbow Roundup³⁶⁰ looks at: arthroscopic capsular release successful after six months; MCIC in cuff surgery; analgesia following arthroscopic cuff repair; platelet-rich fibrin; and cuff tear and suprascapular nerve neuropathy?

The February 2014 Shoulder & Elbow Roundup³⁶⁰ looks at: whether arthroscopic acromioplasty is a cost-effective intervention; shockwave therapy in cuff tear; whether microfracture relieves short-term pain in cuff repair; the promising early results from L-PRF augmented cuff repairs; rehabilitation following cuff repair; supination strength following biceps tendon rupture; whether longer is better in humeral components; fatty degeneration in a rodent model; and the controversial acromioclavicular joint dislocation.

The February 2014 Research Roundup³⁶⁰ looks at: blood supply to the femoral head after dislocation; diabetes and hip replacement; bone remodelling over two decades following hip replacement; sham surgery as good as arthroscopic meniscectomy; distraction in knee osteoarthritis; whether joint replacement prevent cardiac events; tranexamic acid and knee replacement haemostasis; cartilage colonisation in bipolar ankle grafts; CTs and proof of fusion; atorvastatin for muscle re-innervation after sciatic nerve transection; microfracture and short-term pain in cuff repair; promising early results from L-PRF augmented cuff repairs; and fatty degeneration in a rodent model.

Objectives

We aimed to examine the characteristics of deep venous flow in the leg in a cast and the effects of a wearable neuromuscular stimulator (geko; FirstKind Ltd) and also to explore the participants’ tolerance of the stimulator.

It is important to be able to identify patients with an increased risk of venous thromboembolism (VTE) in order to minimise the risk of an event. We investigated the incidence and risk factors for post-operative VTE in 168 consecutive patients with a malignancy of the lower limb. The period of study included ten months before and 12 months after the introduction of chemical thromboprophylaxis. All data about the potential risk factors were identified and classified into three groups (patient-, surgery- and tumour-related). The outcome measure was a thromboembolic event within 90 days of surgery.

Of the 168 patients, eight (4.8%) had a confirmed symptomatic deep-vein thrombosis and one (0.6%) a fatal pulmonary embolism. Of the 28 variables tested, age > 60 years, higher American Society of Anesthesiologists grade and metastatic tumour were independent risk factors for VTE. The overall rate of symptomatic VTE was not significantly different between patients who received chemical thromboprophylaxis and those who did not. Knowledge of these risk factors may be of value in improving the surgical outcome of patients with a malignancy of the lower limb.

Cite this article: Bone Joint J 2013;95-B:558–62.

The August 2012 Foot & Ankle Roundup³⁶⁰ looks at: calcaneocuboid distraction arthrodesis with allograft for acquired flatfoot; direct repair of the plantar plate; thromboembolism after fixation of the fractured ankle; weight loss after ankle surgery; Haglund’s syndrome and three-portal endoscopic surgery; Keller’s procedure; arthroscopy of the first MTPJ; and Doppler spectra in Charcot arthropathy.

The aim of this study was to identify the incidence of post-operative symptomatic deep-vein thrombosis (DVT), as well as the risk factors for and location of DVT, in 665 patients (701 ankles) who underwent primary total ankle replacement. All patients received low-molecular-weight heparin prophylaxis. A total of 26 patients (3.9%, 26 ankles) had a symptomatic DVT, diagnosed by experienced radiologists using colour Doppler ultrasound. Most thrombi (22 patients, 84.6%) were localised distally in the operated limb. Using a logistic multiple regression model we identified obesity, a previous venous thromboembolic event and the absence of full post-operative weight-bearing as independent risk factors for developing a symptomatic DVT.

The incidence of symptomatic DVT after total ankle replacement and use of low-molecular-weight heparin is comparable with that in patients undergoing total knee or hip replacement.

Elastofibroma dorsi is an uncommon, benign, slow-growing soft-tissue tumour of uncertain aetiology. It classically presents as an ill-defined mass at the inferior pole of the scapula with symptoms which include swelling, discomfort, snapping, stiffness and occasionally pain.

We report the symptoms, function and outcome after treatment of 21 elastofibromas in 15 patients. All were diagnosed by MRI and early in the series four also underwent CT-guided biopsy to confirm the diagnosis. In all, 18 tumours were excised and three were observed. After excision, the mean visual analogue score for pain decreased from 4.6 (0 to 10) pre-operatively to 2.4 (0 to 8) post-operatively (p = 0.04). The mean shoulder function, at a mean follow-up of 4.2 years (3 months to 16 years), was 78.1% (30 to 100) using the Stanmore percentage of normal shoulder assessment scoring system. The mean range of forward flexion improved from 135° (70° to 180°) to 166° (100° to 180°) after excision (p = 0.005). In four patients a post-operative haematoma formed; one required evacuation. Three patients developed a post-operative seroma requiring needle aspiration and one developed a superficial infection which was treated with antibiotics.

Our findings support previous reports suggesting that a pre-operative tissue diagnosis is not necessary in most cases since the lesion can be confidently diagnosed by MRI, when interpreted in the light of appropriate clinical findings. Surgical excision in symptomatic patients, is helpful.

It has been suggested that elastofibroma is caused by a local tissue reaction and is not a true neoplastic process. A strong association has been noted between elastofibroma and repetitive use of the shoulder, which is supported by our findings.

Charcot osteoarthropathy of the foot is a chronic and progressive disease of bone and joint associated with a risk of amputation. The main problems encountered in this process are osteopenia, fragmentation of the bones of the foot and ankle, joint subluxation or even dislocation, ulceration of the skin and the development of deep sepsis. We report our experience of a series of 20 patients with Charcot osteoarthropathy of the foot and ankle treated with an Ilizarov external fixator. The mean age of the group was 30 years (21 to 50). Diabetes mellitus was the underlying cause in 18 patients. Five had chronic ulcers involving the foot and ankle. Each patient had an open lengthening of the tendo Achillis with excision of all necrotic and loose bone from the ankle, subtalar and midtarsal joints when needed. The resulting defect was packed with corticocancellous bone graft harvested from the iliac crest and an Ilizarov external fixator was applied. Arthrodesis was achieved after a mean of 18 weeks (15 to 20), with healing of the skin ulcers. Pin track infection was not uncommon, but no frame had to be removed before the arthrodesis was sound.

Every patient was able to resume wearing regular shoes after a mean of 26.5 weeks (20 to 45).

Introduction: In the evaluation of various treatments that may have an effect on bone, there are certain inherent difficulties in selecting an appropriate outcome measure to determine whether a specific treatment is efficacious. This is particularly true for clinical studies. Methods: Using Pubmed, a service of the U.S. National Library of Medicine that searches MEDLINE and other life science journals for citations of biomedical articles, a review of the current instruments used for outcome measures relating to osteonecrosis and bone blood flow was conducted. Abstracts from previous ARCO meetings were also reviewed. Results: For the treatment of osteonecrosis, most outcome measures have focused on pain relief, surgery or need for surgery, disease progression (advancing stage), and change in lesion size. The first three options may be influenced by investigator bias and knowledge/experience. The last option may also be influenced by the technique used. Imaging techniques continue to gain in sophistication. Gd-enhanced MRI can be used to assess perfusion of the diseased tissue. Doppler ultrasonography has also been used to estimate blood flow noninvasively. Near Infrared Spectroscopy (NIRS) can be used to measure tissue oxygenation. While there has been recent interest in using biomarkers or genetic markers in the diagnosis and analysis of disease progression, more research is needed to determine the sensitivity and specificity of these techniques with respect to osteonecrosis. Conclusion: Although there are a number of tests that can be used to evaluate the effect of a specific treatment on osteonecrosis, the definitive assessment will likely remain whether the disease progresses to the point that major surgery (resurfacing, vascularized fibular grafting, total joint replacement, e.g.) is required to relieve pain and restore function

Stable fractures of the ankle can be successfully treated non-operatively by a below-knee plaster cast. In some centres, patients with this injury are routinely administered low-molecular-weight heparin, to reduce the risk of deep-vein thrombosis (DVT). We have assessed the incidence of DVT in 100 patients in the absence of any thromboprophylaxis. A colour Doppler duplex ultrasound scan was done at the time of the removal of the cast.

Five patients did develop DVT, though none had clinical signs suggestive of it. One case involved the femoral and another the popliteal vein. No patient developed pulmonary embolism. As the incidence of DVT after ankle fractures is low, we do not recommend routine thromboprophylaxis.

Systemic emboli released during total knee replacement have been implicated as a cause of peri-operative morbidity and neurological dysfunction. We undertook a prospective, double-blind, randomised study to compare the cardiac embolic load sustained during computer-assisted and conventional, intramedullary-aligned, total knee replacement, as measured by transoesophageal echocardiography. There were 26 consecutive procedures performed by a single surgeon at a single hospital. The embolic load was scored using the modified Mayo grading system for echogenic emboli.

Fourteen patients undergoing computer-assisted total knee replacement had a mean embolic score of 4.89 (3 to 7) and 12 undergoing conventional total knee replacement had a mean embolic score of 6.15 (4 to 8) on release of the tourniquet. Comparison of the groups using a two-tailed t-test confirmed a highly significant difference (p = 0.004).

This study demonstrates that computer-assisted knee replacement results in the release of significantly fewer systemic emboli than the conventional procedure using intramedullary alignment.

We have managed 21 patients with a fracture of the tibia complicated by bone and soft-tissue loss as a result of an open fracture in 10, or following debridement of an infected nonunion in 11, by resection of all the devitalised tissues, acute limb shortening to close the defect, application of an external fixator and metaphyseal osteotomy for re-lengthening. The mean bone loss was 4.7 cm (3 to 11). The mean age of the patients was 28.8 years (12 to 54) and the mean follow-up was 34.8 months (24 to 75).

All the fractures united with a well-aligned limb. The mean duration of treatment for the ten grade-III A+B open fractures (according to the Gustilo-Anderson classification) was 5.7 months (4.5 to 8) and for the nonunions, 7.6 months (5.5 to 12.5). Complications included one refracture, one transient palsy of the peroneal nerve and one equinus contracture of 10°.

Introduction: It is unknown what effect distraction osteogenesis has on bone blood flow to the affected limb. Our study analyzed in vivo measurement of tibial blood flow during distraction osteogenesis using Doppler ultrasonography. Materials and Methods: Blood flow was measured in the femoral artery, with Doppler ultrasonography in five people treated with bi-focal tibial distraction osteogenesis. The normal leg was used as the control to correct for differences in cardiac output. Measurements for each leg were taken and means recorded preoperatively, at 1 week postoperatively, and at subsequent intervals up to 6 months. Results: Preoperative blood flow varied from 0.5 – 2.25. All treated legs demonstrated increases in flow from 2.25 – 5.75, with peaks in the first weeks following osteotomy. Significant increases in blood flow during treatment with distraction osteogenesis, confirming previous experimental studies. Discussion: Blood flow plays a significant role in the successful outcome of this treatment. Compression of the non-union at the time of peak blood flow gives more reliable union than bone transport methods, where docking takes place when blood flow has returned towards the control limb

Introduction. The aim of research was estimating risk factors for lower limbs DVT after hip and knee replacement. Material. We reviewed series of 80 patients (58 women and 22 men) who had performed 13 cemented THA, 38 uncemented THA, 19 TKA and 10 revisions after THA. Average patients age was 63 (range 45 to 82). Methods. All patients were preoperatively taken precise history data and examined physically. We noticed their age and BMI. All patients were asked about past DVT, cardiovascular diseases and others, past operations, drug taking, condiments. We examined both lower limbs in suspicion of DVT. All patients were taken laboratory tests, D-dimers test, and two-dimensional and Doppler ultrasonography. During the operation we noticed its time, kind of anaesthesia, amount of blood and other transfusions, loss of blood, time of using the tourniquet (in TKA). After operation we noticed amount of blood and other transfusions, loss of blood, time of patients postoperative tilting to vertical position. All patients were precisely examined physically every day after joint replacement. They were taken laboratory tests in 1st, 4th, 7th and 14th day after operation. In 7th and 14th day we performed two-dimensional and Doppler ultrasonography. In all patients we used the same scheme of DVT prophylaxis. We administered Enoxaparine once a day subcutaneously (first dose 12 hours before operation). Prophylaxis lasted 6 weeks after joint replacement. Results. Average DVT rate was 24,24%. We found the highest rate of DVT after replacement revisions (75%). The lowest rate was after uncemented THA (6,25%). There were no difference in DVT rate between women and men. We found significantly higher DVT rate in patient older than 60 yr. We found significantly higher DVT rate in patient with BMI over 30. We found significantly higher DVT rate in group of smokers. We found the operation was longer the DVT rate was higher. In case of delaying patients tilting to vertical position, DVT rate was higher. We did not find using tourniquet influence DVT rate. Conclusions. The risk factors for DVT after hip and knee replacement are: age over 60 yr, BMI over 30, smoking, long lasting operation, delayed tilting to vertical position, accompanying cardiovascular diseases and past DVT