Introduction: The delivery of regional antibiotic prophylaxis has been described in reconstructive knee surgery as well as in the management of hand injuries. In this study, we describe a technique for the delivery of regional antibiotic prophylaxis to the upper extremity in patients undergoing elbow surgery, and compare tissue antibiotic concentrations achieved with this technique to those achieved with standard systemic intravenous antibiotic prophylaxis. Methods: We collected bone and fat samples from eight patients undergoing elective elbow surgery who had received regional antibiotic prophylaxis, and measured tissue antibiotic concentration by high performance liquid chromatography. In these patients, prior to the surgical incision, we exsanguinated the arm, inflated the tourniquet, and delivered a standard dose of Cephazolin into a dorsal hand vein. For comparison, we measured antibiotic concentrations in bone and fat samples taken from eight patients undergoing elective shoulder surgery who had received standard systemic antibiotic prophylaxis. Results: Mean tissue antibiotic concentrations were significantly higher in the patients who received regional antibiotic prophylaxis compared with those who received standard systemic prophylaxis (Bone: 1060 mcg/gm versus 41 mcg/gm; Fat: 649 mcg/gm versus 10 mcg/gm; p < 0.05.). Discussion/conclusions: The delivery of regional antibiotic prophylaxis in elbow surgery achieved higher tissue antibiotic concentrations than those achieved with standard systemic delivery. This technique may help reduce the risk of acute infection in elbow surgery, and may be especially valuable in elective surgery in predisposed patients (e.g. rheumatoid arthritis), in the management of open fractures, as well as in protection against particularly virulent organisms

Aims

The aim of this study was to evaluate the outcome of complex radial head fractures at mid-term follow-up, and determine whether open reduction and internal fixation (ORIF) or radial head arthroplasty (RHA) should be recommended for surgical treatment.

We investigated the incidence of and risk factors for venous thromboembolism (VTE) following surgery of the shoulder and elbow and assessed the role of thromboprophylaxis in upper limb surgery. All papers describing VTE after shoulder and elbow surgery published in the English language literature before 31 March 2012 were reviewed. A total of 14 papers were available for analysis, most of which were retrospective studies and case series. The incidence of VTE was 0.038% from 92 440 shoulder arthroscopic procedures, 0.52% from 42 261 shoulder replacements, and 0.64% from 4833 procedures for fractures of the proximal humerus (open reduction and internal fixation or hemiarthroplasty). The incidence following replacement of the elbow was 0.26% from 2701 procedures. Diabetes mellitus, rheumatoid arthritis and ischaemic heart disease were identified as the major risk factors.

The evidence that exists on thromboprophylaxis is based on level III and IV studies, and we therefore cannot make any recommendations on prophylaxis based on the current evidence. It seems reasonable to adopt a multimodal approach that involves all patients receiving mechanical prophylaxis, with chemical prophylaxis reserved for those who are at high risk for VTE.

Cite this article: Bone Joint J 2013;95-B:70–4.

Increasingly more emphasis is being placed on Patient Reported Outcome Measures (PROMs). There are many used and reported in clinical studies, but there are no universally accepted or preferred measures. It is important for a researcher with a non-clinical background to understand how these assessments are performed, the type of information provided by each of the measures, and which diseases states are best reported by each measure.

We developed a questionnaire to assess patient-reported outcome after surgery of the elbow from interviews with patients. Initially, 17 possible items with five response options were included. A prospective study of 104 patients (107 elbow operations) was carried out to analyse the underlying factor structure, dimensionality, internal and test-retest reliability, construct validity and responsiveness of the questionnaire items. This was compared with the Mayo Elbow performance score clinical scale, the Disabilities of the Arm, Shoulder and Hand questionnaire, and the Short-Form (SF-36) General Health Survey. In total, five questions were considered inappropriate, which resulted in the final 12-item questionnaire, which has been referred to as the Oxford elbow score. This comprises three unidimensional domains, ‘elbow function’, ‘pain’ and ‘social-psychological’; with each domain comprising four items with good measurement properties.

This new 12-item Oxford elbow score is a valid measure of the outcome of surgery of the elbow.

Purpose: Accurate determination of the flexion-extension axis of the elbow is critical to the successful placement of elbow arthroplasties, articulated external fixators and ligament reconstructions. We expect axis alignment using computer-assisted techniques to improve the outcome of these procedures. For image-based procedures, registration (i.e. the transformation needed to align two sets of points) during surgery is critical for accurate alignment. A surface-based registration technique, employing a hand-held laser scanner, was evaluated against a stand-alone paired-point registration method to determine whether it led to improved alignment of the elbow’s flexion-extension axis.

Methods: Twelve cadaveric distal-humeri were selected for registration. To perform paired-point (TP-PP) registration, key anatomical landmarks (capitellum, trochlear sulcus and distal humeral shaft) were digitized using a tracked-probe (TP) and an electromagnetic tracking device (Flock of Birds, Ascension Tech). Using the geometric centers of these landmarks, TP-PP registration to CT data was performed. Surface registration was achieved using the iterative closest point (ICP) least-squares algorithm and the results were evaluated for two devices; registration employing the tracked-probe (TP-ICP) and registration employing a hand-held laser scanner, HHS-ICP (FastSCAN, Polhemus). For surface registration, to be consistent with the amount of the joint exposed during a typical surgical procedure, only the articular surface was used for alignment.

Results: Registration error (Figure 1) was lowest for the HHS-ICP method with a mean of 0.8±0.3-mm (maximum error, 1.4-mm) in translation, compared with a mean error of 1.5±0.5-mm (maximum error, 2.4-mm) for the TP-ICP method and 1.9±1.0-mm (maximum error, 4.4-mm) for the TP-PP method (p< 0.001). Errors in TP-PP registration were greatest in the coronal plane while TP-ICP registration often resulted in an error along the transverse plane (Figure 2).

Conclusions: Overall, the reliability of surface-based registration combined with the implementation of the hand-held laser scanner demonstrated greater registration accuracy. A reliable surface-based registration technique may lead to a more accurate determination of the elbow’s flexion-extension axis during surgical procedures, leading to improved joint motion and implant longevity. The implications of these results can also be extended to other joints that employ comparable computer-assisted surgical techniques.

Accurate implant alignment with the flexion-extension axis of the elbow is likely critical for optimal function and durability following elbow replacement arthroplasty. Implant alignment can be optimised by imaging the contralateral normal elbow prior to surgery and transferring this information to the diseased elbow in the operating room through registration. Successful registration is dependent on the presence of unique anatomical landmarks. Bone loss can create a challenge for registration as key anatomical landmarks are absent, limiting the number of sampling areas. This study investigated the effect of intraoperative sampling area on registration accuracy. We hypothesised that a low registration error can be achieved by acquiring surface data from areas unlikely compromised due to injury and readily available to the surgeon during typical surgical exposures.

CT images of twenty cadaveric distal humeri were acquired. Surface data was acquired from nineteen anatomical landmarks of the distal humerus using a hand-held laser scanner (FastSCANTM, Polhemus). Registration to the CT image was performed for thirty-nine landmark combinations. Only six combinations are discussed for succinctness.

Combining data from the anterior articular surface and humeral shaft, the lowest registration error was achieved in translation (0.8±0.3 mm) and rotation (0.3±0.2°). However, using data from the posterior shaft and proximal medial supracondylar column, a registration error of 1.1±0.2 mm and 0.4±0.2° was achieved.

Based on the results of this study, a low registration error can be achieved by acquiring data from two areas that are located proximal to the articular surface (the proximal medial supracondylar column and posterior humeral shaft), readily available surgically, and unlikely compromised due to distal humeral fractures, non-unions or bone loss due to severe erosive arthritis. Registration error was similar to the reported resolution of the laser scanner. Overall, this study demonstrates the promise for a successful registration of the contralateral normal elbow to physical surface data of the diseased or injured elbow using only a small portion of undamaged bone structure.

Aims

The aim of this study was to analyze the results of two radiocapitellar prostheses in a large case series followed prospectively, with medium-term follow-up.

The NHS Plan (2000) identified the need for change in the way patients are asked to give consent for surgery to make the process more explicit. A new NHS operation consent form was introduced in April 2002 following the Bristol enquiry into deaths associated with Cardiac Surgery.

Methods: We have addressed the obtaining of consent for surgery as an evidence-based exercise. The published literature has been reviewed and we have attempted to accurately quantify the success rates for surgery, complication rates and poor outcomes in order to identify what the likely benefits and risks are for our common operations –

Shoulder – Arthroscopic Sub-Acromial Decompression, Anterior stabilisation, Rotator Cuff repair, excision lateral end of clavicle and Shoulder Arthroplasty.

Evidence was therefore been categorised into 4 levels:

National & International published results

Results: We have taken the standard NHS Consent Form and modified it in a printed format to present to the patient a clearer description of the anticipated outcome from their surgery (with percentages). This evidence based consent form was evaluated in a combined prospective and retrospective survey of 60 patients who attended our pre-operative assessment clinic. We will present the results of the survey and demonstrate the standardised Consent Forms.

Conclusions: The majority of the information the patient wished to know was Level 4 evidence!

Among the advanced technology developed and tested for orthopaedic surgery, the Rizzoli (IOR) has a long experience on custom-made design and implant of devices for joint and bone replacements. This follows the recent advancements in additive manufacturing, which now allows to obtain products also in metal alloy by deposition of material layer-by-layer according to a digital model. The process starts from medical image, goes through anatomical modelling, prosthesis design, prototyping, and final production in 3D printers and in case post-production. These devices have demonstrated already to be accurate enough to address properly the specific needs and conditions of the patient and of his/her physician. These guarantee also minimum removal of the tissues, partial replacements, no size related issues, minimal invasiveness, limited instrumentation. The thorough preparation of the treatment results also in a considerable shortening of the surgical and of recovery time. The necessary additional efforts and costs of custom-made implants seem to be well balanced by these advantages and savings, which shall include the lower failures and revision surgery rates. This also allows thoughtful optimization of the component-to-bone interfaces, by advanced lattice structures, with topologies mimicking the trabecular bone, possibly to promote osteointegration and to prevent infection. IOR's experience comprises all sub-disciplines and anatomical areas, here mentioned in historical order. Originally, several systems of Patient-Specific instrumentation have been exploited in total knee and total ankle replacements. A few massive osteoarticular reconstructions in the shank and foot for severe bone fractures were performed, starting from mirroring the contralateral area. Something very similar was performed also for pelvic surgery in the Oncology department, where massive skeletal reconstructions for bone tumours are necessary. To this aim, in addition to the standard anatomical modelling, prosthesis design, technical/technological refinements, and manufacturing, surgical guides for the correct execution of the osteotomies are also designed and 3D printed. Another original experience is about en-block replacement of vertebral bodies for severe bone loss, in particular for tumours. In this project, technological and biological aspects have also been addressed, to enhance osteointegration and to diminish the risk of infection. In our series there is also a case of successful custom reconstruction of the anterior chest wall. Initial experiences are in progress also for shoulder and elbow surgery, in particular for pre-op planning and surgical guide design in complex re-alignment osteotomies for severe bone deformities. Also in complex flat-foot deformities, in preparation of surgical corrections, 3D digital reconstruction and 3D printing in cheap ABS filaments have been valuable, for indication, planning of surgery and patient communication; with special materials mimicking bone strength, these 3D physical models are precious also for training and preparation of the surgery. In Paediatric surgery severe multi planar & multifocal deformities in children are addressed with personalized pre-op planning and custom cutting-guides for the necessary osteotomies, most of which require custom allografts. A number of complex hip revision surgeries have been performed, where 3D reconstruction for possible final solutions with exact implants on the remaining bone were developed. Elective surgery has been addressed as well, in particular the customization of an original total ankle replacement designed at IOR. Also a novel system with a high-tibial-osteotomy, including a custom cutting jig and the fixation plate was tested. An initial experience for the design and test of custom ankle & foot orthotics is also in progress, starting with 3D surface scanning of the shank and foot including the plantar aspect. Clearly, for achieving these results, multi-disciplinary teams have been formed, including physicians, radiologists, bioengineers and technologists, working together for the same goal

Background. The purpose of this study was to determine if thresholds regarding the percentage of maximal improvement in the Simple Shoulder Test (SST) and American Shoulder and Elbow Surgery (ASES) score exist that predict “excellent” patient s­atisfaction (PS) following reverse total shoulder arthroplasty (RSA). Methods. Patients undergoing RSA using a single implant system were evaluated pre-operatively and at a minimum 2-year follow-up. Receiver-operating-characteristic (ROC) curve analysis determined thresholds to predict “excellent” PS by evaluating the percentage of maximal improvement for SST and ASES. Pre-operative factors were analyzed as independent predictors for achieving SST and ASES thresholds. Results. 198 (SST) and 196 (ASES) patients met inclusion criteria. For SST and ASES, ROC analysis identified 61.3% (p<.001) and 68.2% (p<.001) maximal improvement as the threshold for maximal predictability of “excellent” satisfaction respectively. Significant positive correlation between the percentage of maximum score achieved and “excellent” PS for both groups were found (r=.440, p<.001 for SST score; r=0.417, p<.001 for ASES score). Surgery on the dominant hand, greater baseline VAS Pain, and cuff arthropathy were independent predictors for achieving the SST and ASES threshold. Conclusion. Achievement of 61.3% of maximal SST score improvement and 68.3% of maximal ASES score improvement represent thresholds for the achievement of “excellent” satisfaction following RSA. Independent predictors of achieving these thresholds were dominant sided surgery and higher baseline pain VAS scores for SST, and rotator cuff arthropathy for ASES. Keywords. Percentage of maximal improvement; Predictors; American Shoulder and Elbow Surgery Score; Simply Shoulder Test; Reverse shoulder Arthroplasty; Satisfaction. Level of Evidence. Level III

Aims. Our purpose was to determine the quality of current randomised controlled trials (RCTs) in hand surgery using standardised metrics. Materials and Methods. Based on five-year mean impact factors, we selected the six journals that routinely publish studies of upper extremity surgery. Using a journal-specific search query, 62 RCTs met our inclusion criteria. Then three blinded reviewers used the Jadad and revised Coleman Methodology Score (RCMS) to assess the quality of the manuscripts. Results. Based on the Jadad scale, 28 studies were of high quality and 34 were of low quality. Methodological deficiencies in poorly scoring trials included the absence of rate of enrolment, no power analysis, no description of withdrawal or dropout, and a failure to use validated outcomes assessments with an independent investigator. Conclusion. A large number of RCTs in hand, wrist, and elbow surgery were of suboptimal quality when judged against the RCMS and Jadad scales. Even with a high level of evidence, study design and execution of RCTs should be critically assessed. Methodological deficiencies may introduce bias and lead to statistically underpowered studies. Cite this article: Bone Joint J 2017;99-B:94–9

Data of high quality are critical for the meaningful interpretation of registry information. The National Joint Registry (NJR) was established in 2002 as the result of an unexpectedly high failure rate of a cemented total hip arthroplasty. The NJR began data collection in 2003. In this study we report on the outcomes following the establishment of a formal data quality (DQ) audit process within the NJR, within which each patient episode entry is validated against the hospital unit’s Patient Administration System and vice-versa. This process enables bidirectional validation of every NJR entry and retrospective correction of any errors in the dataset. In 2014/15 baseline average compliance was 92.6% and this increased year-on-year with repeated audit cycles to 96.0% in 2018/19, with 76.4% of units achieving > 95% compliance. Following the closure of the audit cycle, an overall compliance rate of 97.9% was achieved for the 2018/19 period. An automated system was initiated in 2018 to reduce administrative burden and to integrate the DQ process into standard workflows. Our processes and quality improvement results demonstrate that DQ may be implemented successfully at national level, while minimizing the burden on hospitals.

Cite this article: Bone Jt Open 2022;3(9):716–725.

Aims

The aim of this study was to evaluate the kinematics of the elbow following increasing length of the radius with implantation of radial head arthroplasties (RHAs) using dynamic radiostereometry (dRSA).

Aims

The aims of this study were to identify and evaluate the current literature examining the prognostic factors which are associated with failure of total elbow arthroplasty (TEA).

The December 2023 Shoulder & Elbow Roundup³⁶⁰ looks at: Clavicle fractures: is the evidence changing practice?; Humeral shaft fractures, and another meta-analysis…let’s wait for the trials now!; Hemiarthroplasty or total elbow arthroplasty for distal humeral fractures…what does the registry say?; What to do with a first-time shoulder dislocation?; Deprivation indices and minimal clinically important difference for patient-reported outcomes after arthroscopic rotator cuff repair; Prospective randomized clinical trial of arthroscopic repair versus debridement for partial subscapularis tears; Long-term follow-up following closed reduction and early movement for simple dislocation of the elbow; Sternoclavicular joint reconstruction for traumatic acute and chronic anterior and posterior instability.