Adequate visual clarity is paramount to performing arthroscopic shoulder surgery safely, efficiently, and effectively. The addition of epinephrine in irrigation fluid, and the intravenous or local administration of tranexamic acid (TXA) have independently been reported to decrease bleeding thereby improving the surgeon's visualization during arthroscopic shoulder procedures. No study has compared the effect of systemic administered TXA, epinephrine added in the irrigation fluid or the combination of both TXA and epinephrine on visual clarity during shoulder arthroscopy with a placebo group. The purpose of this study is to determine if intravenous TXA is a safe alternative to epinephrine delivered by a pressure-controlled pump in improving arthroscopic shoulder visualization during arthroscopic procedures and whether using both TXA and epinephrine together has an additive effect in improving visualization. The design of the study was a double-blinded, randomized controlled trial with four 1:1:1:1 parallel groups conducted at one center. Patients aged ≥18 years undergoing arthroscopic shoulder procedures including rotator cuff repair, arthroscopic biceps tenotomy/tenodesis, distal clavicle excision, subacromial decompression and labral repair by five fellowship-trained upper extremity surgeons were randomized into one of four arms: Pressure pump-controlled regular saline irrigation fluid (control), epinephrine (1ml of 1:1000) mixed in irrigation fluid (EPI), 1g intravenous TXA (TXA), and epinephrine and TXA (EPI/TXA). Visualization was rated on a 4-point Likert scale every 15 minutes with 0 indicating ‘poor’ quality and 3 indicating ‘excellent’ quality. The primary outcome measure was the unweighted mean of these ratings. Secondary outcomes included mean arterial blood pressure (MAP), surgery duration, surgery complexity, and adverse events within the first postoperative week. One hundred and twenty-eight participants with a mean age (± SD) of 56 (± 11) years were randomized. Mean visualization quality for the control, TXA, EPI, and EPI/TXA groups were 2.1 (±0.40), 2.1 (±0.52), 2.6 (±0.37), 2.6 (±0.35), respectively. In a regression model with visual quality as the dependent variable, the presence/absence of EPI was the most significant predictor of visualization quality (R=0.525; p < 0 .001). TXA presence/absence had no effect, and there was no interaction between TXA and EPI. The addition of MAP and surgery duration strengthened the model (R=0.529; p < 0 .001). Increased MAP and surgery duration were both associated with decreased visualization quality. When surgery duration was controlled, surgery complexity was not a significant predictor of visualization quality. No adverse events were recorded in any of the groups. Intravenous administration of TXA is not an effective alternative to epinephrine in the irrigation fluid to improve visualization during routine arthroscopic shoulder surgeries although its application is safe. There is no additional improvement in visualization when TXA is used in combination with epinephrine beyond the effect of epinephrine alone

Adequate visual clarity is paramount to performing arthroscopic shoulder surgery safely, efficiently, and effectively. The addition of epinephrine in irrigation fluid, and the intravenous or local administration of tranexamic acid (TXA) have independently been reported to decrease bleeding thereby improving the surgeon's visualization during arthroscopic shoulder procedures. No study has compared the effect of systemic administered TXA, epinephrine added in the irrigation fluid or the combination of both TXA and epinephrine on visual clarity during shoulder arthroscopy with a placebo group. The purpose of this study is to determine if intravenous TXA is a safe alternative to epinephrine delivered by a pressure-controlled pump in improving arthroscopic shoulder visualization during arthroscopic procedures and whether using both TXA and epinephrine together has an additive effect in improving visualization. The design of the study was a double-blinded, randomized controlled trial with four 1:1:1:1 parallel groups conducted at one center. Patients aged ≥18 years undergoing arthroscopic shoulder procedures including rotator cuff repair, arthroscopic biceps tenotomy/tenodesis, distal clavicle excision, subacromial decompression and labral repair by five fellowship-trained upper extremity surgeons were randomized into one of four arms: Pressure pump-controlled regular saline irrigation fluid (control), epinephrine (1ml of 1:1000) mixed in irrigation fluid (EPI), 1g intravenous TXA (TXA), and epinephrine and TXA (EPI/TXA). Visualization was rated on a 4-point Likert scale every 15 minutes with 0 indicating ‘poor’ quality and 3 indicating ‘excellent’ quality. The primary outcome measure was the unweighted mean of these ratings. Secondary outcomes included mean arterial blood pressure (MAP), surgery duration, surgery complexity, and adverse events within the first postoperative week. One hundred and twenty-eight participants with a mean age (± SD) of 56 (± 11) years were randomized. Mean visualization quality for the control, TXA, EPI, and EPI/TXA groups were 2.1 (±0.40), 2.1 (±0.52), 2.6 (±0.37), 2.6 (±0.35), respectively. In a regression model with visual quality as the dependent variable, the presence/absence of EPI was the most significant predictor of visualization quality (R=0.525; p < 0 .001). TXA presence/absence had no effect, and there was no interaction between TXA and EPI. The addition of MAP and surgery duration strengthened the model (R=0.529; p < 0 .001). Increased MAP and surgery duration were both associated with decreased visualization quality. When surgery duration was controlled, surgery complexity was not a significant predictor of visualization quality. No adverse events were recorded in any of the groups. Intravenous administration of TXA is not an effective alternative to epinephrine in the irrigation fluid to improve visualization during routine arthroscopic shoulder surgeries although its application is safe. There is no additional improvement in visualization when TXA is used in combination with epinephrine beyond the effect of epinephrine alone

In the setting of traumatic elbow injuries involving coronoid fractures, the relative size of the coronoid fragment has been shown to relate to the stability of the joint. Currently, the challenge lies in accurately classifying the amount of bone loss in coronoid fractures. In comminuted fractures, bone loss is difficult to measure with plain radiographs or computed tomography. The purpose of this study is to describe a novel radiographic measure, the Coronoid Opening Angle (COA), on lateral elbow radiographs. We demonstrate the relationship of the COA to coronoid height and describe how this measure can be used to estimate bone loss and potentially predict elbow instability following coronoid fracture. Radiographs were drawn from a regional database in a consecutive fashion. Candidate radiographs were excluded on the basis of radiographic evidence of degenerative changes, previous surgery or injury, bony deformity, and inadequate lateral view of the elbow. The COA was measured as the angle between the long axis of the ulna at the level of the trochlear notch, and the tip of coronoid, from a common origin at the posterior cortex of the olecranon. Images were reviewed by a fellowship trained upper extremity surgeon, an upper extremity fellow, and a junior resident. Normal COA, coronoid height, and calculated COA at varying amounts of bone loss were calculated by three reviewers. A sensitivity analysis was performed to determine how the COA can most effectively predict bone loss at varying coronoid heights. Intraclass correlation coefficient (ICC) was calculated for 39 subjects. Seventy-two subjects were included for analysis (M=40, F=32). The normal coronoid opening angle is 33.19 degrees [32.2 – 34.2]. Coronoid height is 18.8 mm [18.1 – 19.6]. Extrapolating this baseline data, the COA at 20%, 33%, and 50% of coronoid bone loss was calculated to be 27.5, 23.5, and 18 degrees, respectively. ICC was found to be 0.90 or higher. Cutoff values were determined to maximize the sensitivity of the COA. A cutoff value of 21 degrees has a 92% sensitivity in detecting a minimum of 50% bone loss. The COA with similar sensitivity in predicting 20% and 33% bone loss are 32 and 27 degrees. The coronoid opening angle is a novel technique that can be used on a lateral elbow radiograph to predict the minimum coronoid bone loss. This can be used to guide clinical decision making and potentially predict instability. Future research will aim to validate this tool in the clinical setting in predicting instability

Introduction. The use of reverse total shoulder arthroplasty (RSA) is becoming increasingly common in the treatment of rotator cuff arthropathy. In recent years indications for use have expanded to include elderly patients in whom either internal fixation is not possible due to fracture configuration, poor bone quality, or presence of a rotator cuff deficiency. There is however relatively little evidence to support its use in these circumstances. Objective. This study aims to assess the viability of RSA as a salvage procedure in the treatment of complex proximal humeral fractures or irreducible dislocations, quantified in terms of functional outcome, complication rates and patient reported satisfaction. Methods. All patients presenting between January 2011 and December 2013 with a complex 3- or 4-part humeral fracture or a delayed presentation with an irreducible non-acute dislocation, treated with salvage RSA were eligible for inclusion. All operations were performed in a single centre by one of two specialist upper limb surgeons. Standard deltopectoral approach was performed. Tournier reverse fracture stem with two choices of inserts and graft hole in the stem with proximal hydroxyapatite coating was the implant of choice. All patients and underwent a standardised rehabilitation programme. Clinical outcome was measured at final follow up using (1) patient reported satisfaction, (2) clinician measured range of movement (3) complication rate. Results. A total of 16 patients were eligible for inclusion in this study. Mean age at time of operation was 72.8 years (41–91 years) with a mean follow-up of 7 months (2–13 months). At time of last follow-up 100 per cent of patients were satisfied with the results of their operation and functionally independent with activities of daily living. Mean oxford score was 39 (36–48). Range of movement post-operatively had a mean active forward extension 97° (70–150°) and abduction 101° (80–170°). 43% of patients were pain-free, whilst the remainder only required the use of occasional analgesia. One patient developed heterotrophic ossification post operatively and underwent surgical excision. One patient sustained a peri-prosthetic avulsion fracture at 18months treated non-operatively. Patients who underwent RSA for dislocation fared better than for those with proximal humeral fractures. The mean active forward extension was 107.5° (90–150°) and abduction 112.5° (90–170°) in the dislocation group (N=5) compared with those who had a fracture (N= 11) in which the forward extension was 91.4° (70–120°) and abduction 95° (80–120°). Conclusion. Reverse TSA should be considered in patients with complex proximal humeral fractures or delayed presentation with irreducible dislocation. Early results demonstrate good outcomes in terms of patient satisfaction, pain relief and preservation of function. These early result are encouraging however a further study with longer follow-up is required to confirm sustained benefit

Background. Steroid injections can be used safely to treat trigger fingers. We aimed to determine the accuracy of referring General Practitioner (GP) diagnoses of trigger finger made to an upper limb surgeon. We also aimed to determine the efficacy of a serial two steroid injection then surgery technique in the management of trigger fingers. Methods. Data was collected prospectively from a “one-stop” trigger finger clinic (based in a district general hospital). 200 trigger fingers identified from September 2005 to November 2008, giving a minimum 1 year follow-up. Data was analysed for correct referring diagnosis, resolution/recurrence rate following injection and the effect of age, injector grade, diabetes on the rate of recurrence. Results. GP diagnoses were correct in 94% of referrals. Recurrence free resolution after one steroid injection was achieved in 74% of cases, rising to 84% after a second injection. The grade of injector did not influence the rate of resolution (p=0.967) or recurrence (p=0.818). Age was the only statistically significant factor, with recurrences being 8.3 years younger (95% CI 4.1–12.6 yrs; p=0.0002). 15% required surgical release after failure of two steroid injections. Conclusions. Steroid injection for trigger finger is a safe, easily performed technique that can give recurrence free resolution in up to 84% using a serial two steroid injection technique. This is an easily acquired technique that has obvious potential to be performed in the primary care setting, thus reducing the burden on hospital based specialist upper limb services, as only 15% required surgical intervention

In this study we reviewed all Total Elbow Replacements (TER) done in our hospital over eight years period (1997 – 2005), 21 patients (16 females, 5 males) were available for follow up and four were lost (two died and two moved out of the region) with average age of 65 years (range 44 – 77), all procedures were done by two upper limb surgeons (CHB & RGW). 16 patients (14 females, 2 males) had the procedure for Rheumatoid Arthritis and 5 patients (3 males, 2 females) undergone the procedure for post-traumatic arthritis. The average follow up was 61 months (range 12 – 120 months), the Mayo Clinic performance index, the DASH scores and activities of daily living (adopted from Secec Elbow Score) assessment tools were used. In addition, all patients were assessed for loosening using standard AP and lateral radiographs. Sixteen patients had Souter-Starthclyde prosthesis whilst three had Kudo and two had Conrad-Moorey prosthesis. All procedures were done through dorsal approach and all were cemented, the ulnar nerve was not transposed in any of the cases. The average elbow extension lag was 27 degrees (range 15 – 35) with flexion up to 130 degrees (range 110 – 140). Supination was 65 degrees (range 15 – 90) and pronation was 77 (range 55 – 90). The average DASH score was 51.3 (range 19 – 95), the Mayo elbow score was 82 (range 55 – 100) and the average Activities of daily living Secec Score was 17 (range 10 – 20). There were four complications, three ulnar nerve paresis which recovered and one wound complication which needed a flap cover. Two needed revision surgery, one for a periprosthetic fracture and one for loosening. Two patients showed radiological signs of loosening but were asymptomatic. The survival rate with revision as the end point is 95% for aseptic loosening and 90% for any other reason. Our study proves TER has good medium term results with good functional outcome and high patient satisfaction rate

In this study we reviewed all Total Elbow Replacements (TER) done in our hospital over eight years period (1997 – 2005), 21 patients (16 females, 5 males) were available for follow up and four were lost (two died and two moved out of the region) with average age of 65 years (range 44 – 77), all procedures were done by two upper limb surgeons (CHB & RGW). 16 patients (14 females, 2 males) had the procedure for Rheumatoid Arthritis and 5 patients (3 males, 2 females) undergone the procedure for post-traumatic arthritis. The average follow up was 61 months (range 12 – 120 months), the Mayo Clinic performance index, the DASH scores and activities of daily living (adopted from Secec Elbow Score) assessment tools were used. In addition, all patients were assessed for loosening using standard AP and lateral radiographs. Sixteen patients had Souter-Starthclyde prosthesis whilst three had Kudo and two had Conrad-Moorey prosthesis. All procedures were done through dorsal approach and all were cemented, the ulnar nerve was not transposed in any of the cases. The average elbow extension lag was 27 degrees (range 15 – 35) with flexion up to 130 degrees (range 110 – 140). Supination was 65 degrees (range 15 – 90) and pronation was 77 (range 55 – 90). The average DASH score was 51.3 (range 19 – 95), the Mayo elbow score was 82 (range 55 – 100) and the average Activities of daily living Secec Score was 17 (range 10 – 20). There were four complications, three ulnar nerve paresis which recovered and one wound complication which needed a flap cover. Two needed revision surgery, one for a periprosthetic fracture and one for loosening. Two patients showed radiological signs of loosening but were asymptomatic. The survival rate with revision as the end point is 95% for aseptic loosening and 90% for any other reason. Our study proves TER has good medium term results with good functional outcome and high patient satisfaction rate

Purpose. There have been a number of described techniques for sizing the diameter of radial head implants. All of these techniques, however, are dependent on measurements of the excised native radial head. When accurate sizing is not possible due to extensive comminution or due to a previous radial head excision, it has been postulated that the proximal radioulnar joint (PRUJ) may be used as an intraoperative landmark for correct sizing. The purpose of this study was to: 1) determine if the PRUJ could be used as a reliable landmark for radial head implant diameter sizing when the native radial head in unavailable, and (2) determine the reliability of measurements of the excised radial head. Method. Twenty-seven fresh-frozen denuded ulnae and their corresponding radial heads (18 males, 9 females) were examined. The maximum diameter (MaxD), minimum diameter (MinD) and dish diameter (DD) of the radial heads were measured twice, 3–5 weeks apart, using digital calipers. Two fellowship-trained upper extremity surgeons, an upper extremity fellow and a senior orthopedic resident were then asked to independently select a radial head implant diameter based on the congruency of the radius of curvature of the PRUJ to that of the radial head trial implants. The examiners were blinded to the native radial head dimensions. This selection was repeated 3–5 weeks later by two of the investigators. Correlation between radial head measurements and radial head implant diameter sizes was assessed using Pearsons correlation coefficient (PCC) and inter and intra-observer reliability were assessed using intra-class correlation coefficient (ICC). Results. There was a positive correlation between each of the radial head measurements (MaxD, MinD and DD) and the selected radial head implant diameters (PCC of 0.56, 0.59 and 0.51 respectively; p<0.01). Measuring the MaxD, MinD and DD of the radial head showed excellent inter-observer reliability (ICC of 0.99, 1.00 and 0.82 respectively) and excellent intra-observer reliability (ICC of 0.99, 0.98 and 0.75 respectively). The PRUJ sizing method used to determine the diameter of the radial head implant showed poor inter-observer reliability with an ICC of 0.34 but good intra-observer reliability (ICC = 0.76). Conclusion. Measurements of the diameter of the excised radial head showed excellent intra and inter-observer reliability suggesting that the excised radial head, when available, should be used to select the radial head implant diameter. The inter-observer reliability of using the PRUJ for sizing the diameter of radial head implants was poor, indicating that this method is an unreliable technique for radial head implant diameter sizing. However, the high intra-observer reliability of the PRUJ method indicates that an observer tends to make the same size estimation, even weeks apart. This study suggests that the PRUJ radius of curvature may be different than that of the radial head. Further studies are needed to verify this hypothesis

Purpose. Pain and stiffness from elbow arthritides can be reliably improved with arthroscopic osteocapsular ulnohumeral arthroplasty (OUA) in selected patients. Post-operative continuous passive motion (CPM) may be helpful in reducing hemarthrosis, improving soft-tissue compliance and maintaining the range of motion (ROM) established intra-operatively. There is only one published series of arthroscopic OUA and CPM was used in a minority of those patients. We hypothesized that a standardized surgical and post-operative CPM protocol would lead to rapid recovery and sustained improvement in ROM. Method. Thirty patients with painful elbow contractures underwent limited open ulnar nerve decompression and arthroscopic OUA at our institution by a single fellowship trained upper limb reconstruction surgeon. All patients underwent CPM for three days in-hospital with a continuous peripheral nerve block, followed by gradual weaning of CPM at home over two weeks. ROM using a goniometer was assessed at discharge, cessation of CPM (2 weeks) and final follow-up. The main outcome was elbow flexion, extension and total arc of motion. Paired students t-test was used to compare pre and post-operative ROM. Results. The median age was 45 (14–68) years, 77% were male, 73% had the dominant side affected and the most common pre-operative diagnosis was arthritis (50% post-traumatic, 30% primary osteoarthritis). Mean last follow-up was 7 months (range 2 weeks to 2 years). The mean pre-operative range of motion was 119 flexion, −32 extension and a total arc of 8719. At cessation of CPM, the mean flexion was 135, extension −7 and total arc 12711. At last follow-up flexion was maintained at a mean of 134 (p=0.6) but some extension was lost (mean −15, p<0.05) and total arc of motion decreased to 11820 (p<0.05). However, only two patients failed to maintain a functional arc of >100 and the amount of pre-operative contracture was correlated (r=0.73) with final arc of motion. Complications included only two transient ulnar neuropraxias. Only three patients required post-CPM bracing or physiotherapy. Conclusion. We present excellent improvement in short-term ROM following arthroscopic OUA using a standardized post-operative CPM protocol. These results are equal or better than open and non-CPM results published in the literature and alleviate the need for lengthy post-operative physiotherapy and splinting protocols in the majority of patients. A comparative study of CPM and non-CPM post-operative regimens after arthroscopic OUA is warranted to determine the true influence of CPM