Abstract

Despite the high success rates of Reverse Shoulder replacements, complications of instability & scapular notching are a concern. Factors reducing relative motion of implant to underlying bone which include lateral offset to centre of rotation, screw & central peg insertion angle and early osteo-integration are maximized in the Trabecular Metal Reverse total shoulder system. We present clinico-radiological outcomes over 72 months.

Analysis of a single surgeon series of 140 Reverse total shoulder replacements in 135 patients was done. Mean age was 72(range 58– 87 yrs); 81 females: 54 males. Indications were Rotator cuff arthropathy {n= 88} (63%); Osteo-arthritis with dysfunctional cuff {n= 22}(15%); post-trauma{n=23} (15%); revision from hemiarthroplasty {n=3} (2.4%) and from surface replacement {n=4} (2.8%)

All patients were assessed using pre-operative Constants and Oxford scores and clinical & radiographic reviews with standard X-Rays at 6 weeks, 3, 6,12 months and yearly thereafter. X rays included an AP view in 45 degrees of external rotation and modified axillary view. Inferior Scapular notching using the Nerot-Sirveaux grades and Peg Glenoid Rim Distance were looked into by a consultant musculoskeletal radiologist/ Orthopaedic surgeon/ Senior Fellow (post CCT) or a specialist Trainee (ST4 and above). Pain on the visual analogue scale decreased by 98% (9.1 to 0.8) (p<0.01). Constant score improved by 81.8% (12.4 to 68.1) (p<0.05), Oxford shoulder score by 76.7% (56 to 13) (p<0.05). 95.6% of Humeral stems had no radiolucent lines and 4.4% had < 2mm of lucency. Scapular notching was calculated using Sirveaux grades with Peg scapular base angle distance (PSBA) measurements on PACS with Siemens calibration (grade 1= 4 (2.8%); grade 2 =1; grade 3 =0; grade 4=0). 3.57% showed radiographic signs of scapular notching at 72 months. Range of Peg Glenoid Rim Distance was 1.66 to 2.31 cm. Power analysis showed 65 patients were needed to have an 80% power to detect relation of Peg Glenoid Rim Distance to Scapular notching. A likelihood ratio test from Logistic regression model to check correlation of Peg Glenoid Rim Distance to Scapular notching gave a p value of 0.0005. A likelihood ratio from Logistic regression gave a p value of 0.0004 for Infraglenoid Scapular spurs. Highest incidence of spurring was seen in Reverse Total Shoulder Replacements done for Trauma and lowest in patients who got the procedure for Osteoarthritis. Complications included two glenosphere revisions; two stitch abscesses and two Acromial fractures in patients who had a fall two years after the procedure. Improved surgical outcomes can be attributed to surgical technique and implant characteristics. Trabacular metal promotes early osteointegration which resists shearing action of Deltoid on Glenoid component. This allows early mobilisation. Deltoid split approach preserves integrity of Subscapularis and Acromial osteotomy and lateral clavicle excision improve exposure and prevent Acromion fracture. Positioning the Glenoid component inferiorly on the Glenoid decreases incidence of Scapular notching.

Our mid-term validated outcomes are promising with only 3.57% Grade I/II radiographic signs of scapular notching. Long term studies (10 year follow ups) are necessary to confirm its efficacy.

Background

Successful use of bioabsorbable anchors for capsulolabral and rotator cuff repair is well documented. The bioknotless anchor (DePuy mitek) has demonstrated reliable fixation of these pathologies. However, this poly (L-lactide) polymer has recently demonstrated some similar complications to those documented for the earlier polyglycolic acid implants; namely synovitis and chondral damage with osteolysis. We report three cases with osteolysis and chondral damage associated with bioknotless anchors.

Introduction and Aim: The metacarpal fractures constitute 10% of skeletal fractures in general affecting mainly children and young adults. There is a lot of discrepancy and lack of evidence with regards to correctly managing the little finger metacarpal fractures. Our study was aimed at investigating the current practice of management little finger metacarpal fractures among upper limb surgeons in United Kingdom.

Methods: We conducted an online survey between June 2006 and June 2007 consisting of 10 multiple-choice questions that was e-mailed to 278 upper limb orthopaedic specialist surgeons. The response rate was 58% (n = 158) from the upper limb surgeons. Four questionnaires had to be excluded due to multiple responses to each question or incomplete forms.

Results: 43% upper limb surgeons prefer neighbour strapping alone for non-operative management of little finger metacarpal fractures. Ulnar gutter cast or splint was the next choice among 19% upper limb surgeons while 13% respondents apply neighbour strapping to ring finger along with a splint. There was mixed response regarding period of immobilisation. 40% of surgeons were in favour of 3 weeks of immobilisation, 23% for 2 weeks while 28% do not immobilise these fractures at all.

With regard to considering the most important indication(s) for surgical intervention, rotational deformity was the most common indication (84%), followed by open fracture (70%), intra-articular fracture (44%), associated 4th metacarpal fracture (26%), shortening > 5mm (21%) and volar angulation – (15%). If treated non-operatively, the most preferred period of fracture clinic follow up was one visit at 3 weeks by 40% while 36% thought that no follow up is required once decision is made to treat them conservatively.

Conclusion: Isolated undisplaced fractures of little metacarpal are usually managed conservatively using a plethora of methods of immobilisation. The indications for operative intervention are open fracture, rotational deformity, intra-articular fractures and shortening. Many clinical studies have demonstrated that in the conservative care of boxer’s fractures (casting, with or without reduction), between 20 degrees and 70 degrees of dorsal angulation is acceptable. We conclude that contemporary literature provides no evidence as to whether conservative or operative methods of the treatment of these fractures is superior, but rather suggests that they are equally effective. We conclude from our survey that there is no consensus even among the upper limb surgeons with regards to management of little finger metacarpal fractures in United Kingdom.

Aggressive digital papillary adenocarcinoma (ADPACa) is a rare skin adnexal tumour, which has a predilection for the digits. We report a case with this tumour in a 51 year old insulin dependent diabetic man, who presented as a paronychia of right index finger. After histopathological confirmation as an ADPACa partial amputation was performed. This case emphasizes the presentation of this tumour as a simple nail bed infection occasionally.

Introduction This prospective study was carried out to assess the outcome of manipulation of the shoulder with interscalene block as a treatment for adhesive capsulitis of the shoulder.

Materials and Methods 31 patients underwent manipulation under general anaesthesia and interscalene block followed by intra-articular glenohumeral injection of steroid and local anaesthetic. Physiotherapy was started on the day of surgery. Shoulder function was assessed with range of movement, Constant score and DASH score (Disability of the Arm, Shoulder and Hand) by specialist upper limb physiotherapists, pre-operatively, and post-operatively at 6 weeks, 3, 6 and 12 months.

Results The DASH score improved from a mean of 60.1 pre-operatively to a mean of 24.1 at final follow up. Constant scores improved from a mean of 34.4 pre-operatively to 65.8. The mean improvement in Constant scores was 31.5 points. Pre-operative range of movement (expressed as a percentage of the total ROM of the unaffected side) was 51.5%. The mean post-operative ROM was 85.4%. External rotation improved from 41.7% of the unaffected side preoperatively to 77.7% at final review. Abduction improved from 47.4% to 85.4% and forward flexion improved from 59.1% to 90%. No patients required further manipulation.

Discussion All outcome measures improved following treatment. These improvements were sustained at 12 months follow-up. In particular external rotation, which was the most restricted movement preoperatively, was seen to improve and this improvement was maintained throughout follow-up.

Conclusion We conclude that manipulation of the shoulder under interscalene block and general anaesthetic for adhesive capsulitis results in a sustained improvement in function and movement.

Aims: Necrosis of fingers secondary to the use of digital tourniquet has been reported. Harmful effects of tourniquet are due to the high pressures generated beneath the tourniquet.

The aim of this study is to compare the pressures beneath the three different types of digital tourniquet namely rolled rubber glove, commercially available band and urinary catheter on human volunteers using a standardised device which directly measures the pressure and to assess pain score using visual analogue scale. Methods: Twenty healthy volunteers with eighty fingers in total were blinded and the pressures were measured for the three different types of tourniquet in a random fashion. Standard technique of tourniquet application was used. Result and Conclusion: The variation in pressures for each finger and between three different types of tourniquet was examined using the standard analysis of variance. This showed that there was no statistically significant variation between the fingers (F=1.87, 3,234 df) for one type of tourniquet. However the pressures in the catheter tourniquet group was significantly higher (F=53.59, 2,237 df). Analysis of pain perception showed that the catheter tourniquet led to substantially higher pain. We conclude that the catheter tourniquet generates high pressures and thereby increasing the potential risk of neurovascular complications.