Currently, there is little information about the need for peri-operative
blood transfusion in patients undergoing shoulder arthroplasty. The purpose of this study was to identify the rate of transfusion
and its predisposing factors, and to establish a blood conservation
strategy. We identified all patients who had undergone shoulder arthroplasty
at our hospital between 1 January 2011 and 31 December 2013. The
rate of transfusion was determined from the patient’s records. While
there were exceptions, patients typically underwent transfusion
if they had a level of haemoglobin of <
7.5 g/dl if asymptomatic,
<
9.0 g/dl if they had a significant cardiac history or symptoms
of dizziness or light headedness. Multivariable regression analysis was undertaken to identify
predictors of transfusion. High- and low-risk cohorts for transfusion
were identified from a receiver operating characteristic (ROC) curve.Aims
Methods
The ageing population and an increase in both
the incidence and prevalence of cancer pose a healthcare challenge, some
of which is borne by the orthopaedic community in the form of osteoporotic
fractures and metastatic bone disease. In recent years there has
been an increasing understanding of the pathways involved in bone
metabolism relevant to osteoporosis and metastases in bone. Newer
therapies may aid the management of these problems. One group of
drugs, the antibody mediated anti-resorptive therapies (AMARTs)
use antibodies to block bone resorption pathways. This review seeks
to present a synopsis of the guidelines, pharmacology and potential pathophysiology
of AMARTs and other new anti-resorptive drugs. We evaluate the literature relating to AMARTs and new anti-resorptives
with special attention on those approved for use in clinical practice. Denosumab, a monoclonal antibody against Receptor Activator for
Nuclear Factor Kappa-B Ligand. It is the first AMART approved by
the National Institute for Health and Clinical Excellence and the
US Food and Drug Administration. Other novel anti-resorptives awaiting
approval for clinical use include Odanacatib. Denosumab is indicated for the treatment of osteoporosis and
prevention of the complications of bone metastases. Recent evidence
suggests, however, that denosumab may have an adverse event profile
similar to bisphosphonates, including atypical femoral fractures.
It is, therefore, essential that orthopaedic surgeons are conversant
with these medications and their safe usage. Take home message: Denosumab has important orthopaedic indications
and has been shown to significantly reduce patient morbidity in
osteoporosis and metastatic bone disease. Cite this article:
To date, there is insufficient evidence available to compare
the outcome of cemented and uncemented fixation of the humeral stem
in reverse shoulder arthroplasty (RSA). A systemic review comprising 41 clinical studies was performed
to compare the functional outcome and rate of complications of cemented
and uncemented stems in RSA. These included 1455 cemented and 329
uncemented shoulders. The clinical characteristics of the two groups
were similar. Variables were compared using pooled frequency-weighted means
and relative risk ratios (RR).Aims
Methods
We evaluated clinical and radiographic outcomes of total shoulder
arthroplasty (TSA) using the second-generation Trabecular Metal
(TM) Glenoid component. The first generation component was withdrawn
in 2005 after a series of failures were reported. Between 2009 and
2012, 40 consecutive patients with unilateral TSA using the second-generation
component were enrolled in this clinical study. The mean age of
the patients was 63.8 years (40 to 75) and the mean follow-up was
38 months (24 to 42). Patients were evaluated using the Constant score (CS), the American
Shoulder and Elbow Surgeons (ASES) score and routine radiographs.Aims
Methods
If a modular convertible total shoulder system
is used as a primary implant for an anatomical total shoulder arthroplasty,
failure of the prosthesis or the rotator cuff can be addressed by
converting it to a reverse shoulder arthroplasty (RSA), with retention
of the humeral stem and glenoid baseplate. This has the potential
to reduce morbidity and improve the results. In a retrospective study of 14 patients (15 shoulders) with a
mean age of 70 years (47 to 83) we reviewed the clinical and radiological
outcome of converting an anatomical shoulder arthroplasty (ASA)
to a RSA using a convertible prosthetic system (SMR system, Lima,
San Daniele, Italy). The mean operating time was 64 minutes (45 to 75). All humeral
stems and glenoid baseplates were found to be well-fixed and could
be retained. There were no intra-operative or early post-operative
complications and no post-operative infection. The mean follow-up was 43 months (21 to 83), by which time the
mean visual analogue scale for pain had decreased from 8 pre-operatively
to 1, the mean American Shoulder and Elbow Surgeons Score from 12
to 76, the mean Oxford shoulder score from 3 to 39, the mean Western
Ontario Osteoarthritis of the Shoulder Score from 1618 to 418 and
the mean Subjective shoulder value from 15 to 61. On radiological review, one patient had a lucency around the
humeral stem, two had stress shielding. There were no fatigue fractures
of the acromion but four cases of grade 1 scapular notching. The use of a convertible prosthetic system to revise a failed
ASA reduces morbidity and minimises the rate of complications. The
mid-term clinical and radiological results of this technique are
promising. Cite this article:
Dislocation of the acromioclavicular joint is
a relatively common injury and a number of surgical interventions
have been described for its treatment. Recently, a synthetic ligament
device has become available and been successfully used, however,
like other non-native solutions, a compromise must be reached when
choosing non-anatomical locations for their placement. This cadaveric
study aimed to assess the effect of different clavicular anchorage points
for the Lockdown device on the reduction of acromioclavicular joint
dislocations, and suggest an optimal location. We also assessed
whether further stability is provided using a coracoacromial ligament
transfer (a modified Neviaser technique). The acromioclavicular
joint was exposed on seven fresh-frozen cadaveric shoulders. The
joint was reconstructed using the Lockdown implant using four different
clavicular anchorage points and reduction was measured. The coracoacromial
ligament was then transferred to the lateral end of the clavicle,
and the joint re-assessed. If the Lockdown ligament was secured
at the level of the conoid tubercle, the acromioclavicular joint
could be reduced anatomically in all cases. If placed medial or
2 cm lateral, the joint was irreducible. If the Lockdown was placed
1 cm lateral to the conoid tubercle, the joint could be reduced
with difficulty in four cases. Correct placement of the Lockdown
device is crucial to allow anatomical joint reduction. Even when the
Lockdown was placed over the conoid tubercle, anterior clavicle
displacement remained but this could be controlled using a coracoacromial
ligament transfer. Cite this article:
Determining and accurately restoring the flexion-extension
axis of the elbow is essential for functional recovery after total
elbow arthroplasty (TEA). We evaluated the effect of morphological
features of the elbow on variations of alignment of the components
at TEA. Morphological and positioning variables were compared by
systematic CT scans of 22 elbows in 21 patients after TEA. There were five men and 16 women, and the mean age was 63 years
(38 to 80). The mean follow-up was 22 months (11 to 44). The anterior offset and version of the humeral components were
significantly affected by the anterior angulation of the humerus
(p = 0.052 and p = 0.004, respectively). The anterior offset and
version of the ulnar components were strongly significantly affected
by the anterior angulation of the ulna (p <
0.001 and p <
0.001). The closer the anterior angulation of the ulna was to the joint,
the lower the ulnar anterior offset (p = 0.030) and version of the
ulnar component (p = 0.010). The distance from the joint to the
varus angulation also affected the lateral offset of the ulnar component
(p = 0.046). Anatomical variations at the distal humerus and proximal ulna
affect the alignment of the components at TEA. This is explained
by abutment of the stems of the components and is particularly severe
when there are substantial deformities or the deformities are close
to the joint. Cite this article:
We assessed the age-related differences in the
use of total shoulder arthroplasty (TSA) and outcomes, and associated
time-trends using the United States Nationwide Inpatient Sample
(NIS) between 1998 and 2010. Age was categorised as <
50, 50
to 64, 65 to 79 and ≥ 80 years. Time-trends in the use of TSA were
compared using logistic regression or the Cochran Armitage test. The overall use of TSA increased from 2.96/100 000 in 1998 to
12.68/100 000 in 2010. Significantly lower rates were noted between
2009 and 2010, compared with between 1998 and 2000, for: mortality,
0.1% The rates of use of TSA/100 000 by age groups, <
50, 50 to
64, 65 to 79 and ≥ 80 years were: 0.32, 4.62, 17.82 and 12.56, respectively
in 1998 (p <
0.001); and 0.65, 17.49, 75.27 and 49.05, respectively
in 2010 (p <
0.001) with an increasing age-related difference
over time (p <
0.001). Across the age categories, there were
significant differences in the proportion: discharged to an inpatient
facility, 3.2% In a nationally representative sample, we noted a time-related
increase in the use of TSA and increasing age-related differences
in outcomes indicating a changing epidemiology of the use of TSA.
Age-related differences in outcomes suggest that attention should
focus on groups with the worst outcomes. Cite this article:
We report our experience of performing an elbow
hemiarthroplasty in the treatment of comminuted distal humeral fractures
in the elderly patients. A cohort of 42 patients (three men and 39 women, mean age 72;
56 to 84) were reviewed at a mean of 34.3 months (24 to 61) after
surgery. Functional outcome was measured with the Mayo Elbow Performance
Score (MEPS) and range of movement. The disabilities of the arm,
shoulder and hand questionnaire (DASH) was used as a patient rated
evaluation. Complications and ulnar nerve function were recorded.
Plain radiographs were obtained to assess prosthetic loosening,
olecranon wear and heterotopic bone formation. The mean extension deficit was 23.5° (0° to 60°) and mean flexion
was 126.8° (90° to 145°) giving a mean arc of 105.5° (60° to 145°).
The mean MEPS was 90 (50 to 100) and a mean DASH score of 20 (0
to 63). Four patients had additional surgery for limited range of
movement and one for partial instability. One elbow was revised
due to loosening, two patients had sensory ulnar nerve symptoms,
and radiographic signs of mild olecranon wear was noted in five
patients. Elbow hemiarthroplasty for comminuted intra-articular distal
humeral fractures produces reliable medium-term results with functional
outcome and complication rates, comparable with open reduction and
internal fixation and total elbow arthroplasty. Cite this article:
This study compared the clinical outcomes following
mini-open rotator cuff repair (MORCR) between early mobilisation
and usual care, involving initial immobilisation. In total, 189
patients with radiologically-confirmed full-thickness rotator cuff
tears underwent MORCR and were randomised to either early mobilisation
(n = 97) or standard rehabilitation (n = 92) groups. Patients were
assessed at six weeks and three, six, 12 and 24 months post-operatively.
Six-week range of movement comparisons demonstrated significantly
increased abduction (p = 0.002) and scapular plane elevation (p
= 0.006) in the early mobilisation group, an effect which was not
detectable at three months (p >
0.51) or afterwards. At 24 months
post-operatively, patients who performed pain-free, early active mobilisation
for activities of daily living showed no difference in clinical
outcomes from patients immobilised for six weeks following MORCR.
We suggest that the choice of rehabilitation regime following MORCR
may be left to the discretion of the patient and the treating surgeon. Cite this article:
To prevent insufficiency of the triceps after
total elbow arthroplasty, we have, since 2008, used a triceps-sparing ulnar
approach. This study evaluates the clinical results and post-operative
alignment of the prosthesis using this approach. We reviewed 25 elbows in 23 patients. There were five men and
18 women with a mean age of 69 years (54 to 83). There were 18 elbows
with rheumatoid arthritis, six with a fracture or pseudoarthrosis
and one elbow with osteoarthritis. Post-operative complications included one intra-operative fracture,
one elbow with heterotopic ossification, one transient ulnar nerve
palsy, and one elbow with skin necrosis, but no elbow was affected
by insufficiency of the triceps. Patients were followed for a mean of 42 months (24 to 77). The
mean post-operative Japanese Orthopaedic Association Elbow Score
was 90.8 (51 to 100) and the mean Mayo Elbow Performance score 93.8
(65 to 100). The mean post-operative flexion/extension of the elbow
was 135°/-8°. The Manual Muscle Testing score of the triceps was
5 in 23 elbows and 2 in two elbows (one patient). The mean alignment
of the implants examined by 3D-CT was 2.8° pronation (standard deviation
( The triceps-sparing ulnar approach allows satisfactory alignment
of the implants, is effective in preventing post-operative triceps
insufficiency, and gives satisfactory short-term results. Cite this article: 2015;97-B:1096–1101.
This pilot study reports the clinical outcomes
of a combination of partial subscapularis tendon transfer and small-head
hemiarthroplasty in patients with rotatator cuff arthropathy. A
total of 30 patients (30 shoulders; eight men and 22 women) with
a mean age of 74 years (55 to 84) were assessed at a mean follow-up
of 31 months (24 to 60). The inclusion criteria were painful cuff
tear arthropathy with normal deltoid function and a non-degenerative subscapularis
muscle and tendon and a preserved teres minor. Outcome was assessed using the University of California Los Angeles
score, the Japanese Orthopaedic Association score, and the Oxford
Shoulder Score. Radiographic measurements included the centre of
rotation distance and the length of the deltoid. All clinical scores were significantly improved post-operatively.
The active flexion and external rotation improved significantly
at the most recent follow-up (p <
0.035). Although the mean centre
of rotation distance changed significantly (p <
0.001), the mean
length of the deltoid did not change significantly from the pre-operative
value (p = 0.29). The change in the length of the deltoid with <
100° flexion was significantly less than that with >
100° (p <
0.001). Progressive erosion of the glenoid was seen in four patients.
No patient required revision or further surgery. A combination of partial subscapularis tendon transfer and small-head
hemiarthroplasty effectively restored function and relieved pain
in patients with rotator cuff arthropathy. Cite this article: 2015;97-B:1090–5.
Frozen shoulder is a recognised complication
following simple arthroscopic shoulder procedures, but its exact incidence
has not been reported. Our aim was to analyse a single-surgeon series
of patients undergoing arthroscopic subacromial decompression (ASD;
group 1) or ASD in combination with arthroscopic acromioclavicular
joint (ACJ) excision (group 2), to establish the incidence of frozen
shoulder post-operatively. Our secondary aim was to identify associated
risk factors and to compare this cohort with a group of patients
with primary frozen shoulder. We undertook a retrospective analysis of 200 consecutive procedures
performed between August 2011 and November 2013. Group 1 included
96 procedures and group 2 104 procedures. Frozen shoulder was diagnosed
post-operatively using the British Elbow and Shoulder Society criteria.
A comparative group from the same institution involved 136 patients
undergoing arthroscopic capsular release for primary idiopathic
frozen shoulder. The incidence of frozen shoulder was 5.21% in group 1 and 5.71%
in group 2. Age between 46 and 60 years (p = 0.002) and a previous
idiopathic contralateral frozen shoulder (p <
0.001) were statistically
significant risk factors for the development of secondary frozen
shoulder. Comparison of baseline characteristics against the comparator groups
showed no statistically significant differences for age, gender,
diabetes and previous contralateral frozen shoulder. These results suggest that the risk of frozen shoulder following
simple arthroscopic procedures is just over 5%, with no increased
risk if the ACJ is also excised. Patients aged between 46 and 60
years and a previous history of frozen shoulder increase the relative
risk of secondary frozen shoulder by 7.8 (95% confidence interval
(CI) 2.1 to 28.3)and 18.5 (95% CI 7.4 to 46.3) respectively. Cite this article:
Failed internal fixation of a fracture of the
proximal humerus produces many challenges with limited surgical options.
The aim of this study was to evaluate the clinical outcomes after
the use of a reverse shoulder arthroplasty under these circumstances.
Between 2007 and 2012, 19 patients (15 women and four men, mean
age 66 years; 52 to 82) with failed internal fixation after a proximal
humeral fracture, underwent implant removal and reverse shoulder arthroplasty
(RSA). The mean follow-up was 36 months (25 to 60). The mean American
Shoulder and Elbow Score improved from 27.8 to 50.1 (p = 0.019).
The mean Simple Shoulder Test score improved from 0.7 to 3.2 (p
= 0.020), and the mean visual analogue scale for pain improved from
6.8 to 4.3 (p = 0.012). Mean forward flexion improved from 58.7°
to 101.1° (p <
0.001), mean abduction from 58.7° to 89.1° (p
= 0.012), mean external rotation from 10.7° to 23.1° (p = 0.043)
and mean internal rotation from buttocks to L4 (p = 0.034). A major
complication was recorded in five patients (26%) (one intra-operative
fracture, loosening of the humeral component in two and two peri-prosthetic
fractures). A total of 15 patients (79%) rated their outcome as
excellent or good, one (5%) as satisfactory, and three (16%) as
unsatisfactory. An improvement in outcomes and pain can be expected when performing
a RSA as a salvage procedure after failed internal fixation of a
fracture of the proximal humerus. Patients should be cautioned about
the possibility for major complications following this technically
demanding procedure. Cite this article:
The purpose of this study was to evaluate the
expression of acid-sensing ion channels (ASICs) in the capsule and synovial
fluid of patients with frozen shoulder. Capsular tissue and synovial
fluid were obtained from 18 patients with idiopathic frozen shoulder
(FS group) and 18 patients with instability of the shoulder (control
group). The expressions of ASIC1, ASIC2, and ASIC3 in the capsule
were determined using the reverse transcriptase-polymerase chain
reaction, immunoblot analysis, and immunohistochemistry (IHC). The
concentrations in synovial fluid were evaluated using an enzyme-linked
immunosorbent assay. The mRNA expression of ASIC1, ASIC2 and ASIC3 in the capsule
were significantly increased in the FS group compared with the control
group. The protein levels of these three ASICs were also increased.
The increased expressions were confirmed by IHC. Of the ASICs, ASIC3
showed the greatest increase in both mRNA and levels of expression
compared with the control group. The levels of ASIC1 and ASIC3 in
synovial fluid were significantly increased in the FS group. This study suggests that ASICs may play a role as mediators of
inflammatory pain and be involved in the pathogenesis of frozen
shoulder. Cite this article:
Unlinked, linked and convertible total elbow
arthroplasties (TEAs) are currently available. This study is the
first to report the clinical results of the convertible Latitude
TEA. This was a retrospective study of a consecutive cohort of 63
patients (69 primary TEAs) with a mean age of 60 years (23 to 87).
Between 2006 and 2008 a total of 19 men and 50 women underwent surgery.
The mean follow-up was 43 months (8 to 84). The range of movement,
function and pain all improved six months post-operatively and either
continued to improve slightly or reached a plateau thereafter. The
complication rate is similar to that reported for other TEA systems.
No loosening was seen. Remarkable is the disengagement of the radial
head component in 13 TEAs (31%) with a radial head component implanted. Implantation of both the linked and the unlinked versions of
the Latitude TEA results in improvement of function and decreased
pain, and shows high patient satisfaction at mid-term follow-up. Cite this article:
The natural history of primary anterior dislocation
of the glenohumeral joint in adolescent patients remains unclear and
there is no consensus for management of these patients. The objectives of this study were to report the natural history
of primary anterior dislocation of the glenohumeral joint in adolescent
patients and to identify the risk factors for recurrent dislocation. We reviewed prospectively-collected clinical and radiological
data on 133 adolescent patients diagnosed with a primary anterior
dislocation of the glenohumeral joint who had been managed non-operatively
at our hospital between 1996 and 2008. There were 115 male (86.5%)
and 18 female patients (13.5%) with a mean age of 16.3 years (13
to 18) and a mean follow-up of 95.2 months (1 to 215). During follow-up, 102 (absolute incidence of 76.7%) patients
had a recurrent dislocation. The median interval between primary
and recurrent dislocation was ten months (95% CI 7.4 to 12.6). Applying
survival analysis the likelihood of having a stable shoulder one
year after the initial injury was 59% (95% CI 51.2 to 66.8), 38%
(95% CI 30.2 to 45.8%) after two years, 21% (95% CI 13.2 to 28.8)
after five years, and 7% (95% CI 1.1 to 12.9) after ten years. Neither
age nor gender significantly predicted recurrent dislocation during
follow-up. We conclude that adolescent patients with a primary anterior
dislocation of the glenohumeral joint have a high rate of recurrent
dislocation, which usually occurs within two years of their initial
injury: these patients should be considered for early operative
stabilisation. Cite this article:
The LockDown device (previously called Surgilig)
is a braided polyester mesh which is mostly used to reconstruct the
dislocated acromioclavicular joint. More than 11 000 have been implanted
worldwide. Little is known about the tissue reaction to the device
nor to its wear products when implanted in an extra-articular site
in humans. This is of importance as an adverse immunological reaction
could result in osteolysis or damage to the local tissues, thereby affecting
the longevity of the implant. We analysed the histology of five LockDown implants retrieved
from five patients over the last seven years by one of the senior
authors. Routine analysis was carried out in all five cases and
immunohistochemistry in one. The LockDown device acts as a scaffold for connective tissue
which forms an investing fibrous pseudoligament. The immunological
response at the histological level seems favourable with a limited
histiocytic and giant cell response to micron-sized wear particles.
The connective tissue envelope around the implant is less organised
than a native ligament. Cite this article:
We retrospectively reviewed 89 consecutive patients
(45 men and 44 women) with a mean age at the time of injury of 58
years (18 to 97) who had undergone external fixation after sustaining
a unilateral fracture of the distal humerus. Our objectives were
to determine the incidence of heterotopic ossification (HO); identify
risk factors associated with the development of HO; and characterise
the location, severity and resultant functional impairment attributable
to the presence of HO. HO was identified in 37 elbows (42%), mostly around the humerus
and along the course of the medial collateral ligament. HO was hazy
immature in five elbows (13.5%), mature discrete in 20 (54%), extensive
mature in 10 (27%), and complete bone bridges were present in two
elbows (5.5%). Mild functional impairment occurred in eight patients,
moderate in 27 and severe in two. HO was associated with less extension
(p = 0.032) and less overall flexion-to-extension movement (p =
0.022); the flexion-to-extension arc was <
100º in 21 elbows
(57%) with HO compared with 18 elbows (35%) without HO (p = 0.03).
HO was removed surgically in seven elbows. The development of HO was significantly associated with sustaining
a head injury (p = 0.015), delayed internal fixation (p = 0.027),
the method of fracture fixation (p = 0.039) and the use of bone
graft or substitute (p = 0.02).HO continues to be a substantial
complication after internal fixation for distal humerus fractures. Cite this article:
In this study we evaluated whether the Instability
Severity Index Score (ISIS) and the Western Ontario Shoulder Instability
Index (WOSI) could detect those patients at risk of failure following
arthroscopic Bankart repair. Between April 2008 and June 2010, the
ISIS and WOSI were recorded pre-operatively in 110 patients (87
male, 79%) with a mean age of 25.1 years (16 to 61) who underwent
this procedure for recurrent anterior glenohumeral instability. A telephone interview was performed two-years post-operatively
to determine whether patients had experienced a recurrent dislocation
and whether they had returned to pre-injury activity levels. In
all, six (5%) patients had an ISIS >
6 points (0 to 9). Of 100 (91%)
patients available two years post-operatively, six (6%) had a recurrent dislocation,
and 28 (28%) did not return to pre-injury activity. No patient who
dislocated had an ISIS >
6 (p = 1.0). There was no difference in
the mean pre-operative WOSI in those who had a re-dislocation and
those who did not (p = 0.99). The pre-operative WOSI was significantly
lower (p = 0.02) in those who did not return to pre-injury activity, whereas
the ISIS was not associated with return to pre-injury activity (p
= 0.13). In conclusion, neither the pre-operative ISIS nor WOSI predicted
recurrent dislocation within two years of arthroscopic Bankart repair.
Patients with a lower pre-operative WOSI were less likely to return
to pre-injury activity. Cite this article: