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The Bone & Joint Journal
Vol. 102-B, Issue 2 | Pages 232 - 238
1 Feb 2020
Javed S Hadi S Imam MA Gerogiannis D Foden P Monga P

Aims. Accurate measurement of the glenoid version is important in performing total shoulder arthroplasty (TSA). Our aim was to evaluate the Ellipse method, which involves formally defining the vertical mid-point of the glenoid prior to measuring the glenoid version and comparing it with the ‘classic’ Friedman method. Methods. This was a retrospective study which evaluated 100 CT scans for patients who underwent a primary TSA. The glenoid version was measured using the Friedman and Ellipse methods by two senior observers. Statistical analyses were performed using the paired t-test for significance and the Bland-Altman plot for agreement. Results. The mean glenoid version was -3.11° (-23.8° to 17.9°) using the Friedman method and -1.95° (-29.8° to 24.6°) using the Ellipse method (p = 0.002). In 16 patients the difference between methods was greater than 5°, which we considered to be clinically significant. There was poor agreement between methods with relatively large 95% limits of agreement. There was excellent inter-rater agreement between the observers for the Ellipse method and similarly, the intrarater agreement was excellent with a repeatability coefficient of 0.94. Conclusion. We recommend the use of the Ellipse modification to define the mid glenoid point prior to measuring the glenoid version in patients undergoing TSA. Cite this article: Bone Joint J 2020;102-B(2):232–238


The Bone & Joint Journal
Vol. 106-B, Issue 10 | Pages 1150 - 1157
1 Oct 2024
de Klerk HH Verweij LPE Doornberg JN Jaarsma RL Murase T Chen NC van den Bekerom MPJ

Aims. This study aimed to gather insights from elbow experts using the Delphi method to evaluate the influence of patient characteristics and fracture morphology on the choice between operative and nonoperative treatment for coronoid fractures. Methods. A three-round electronic (e-)modified Delphi survey study was performed between March and December 2023. A total of 55 elbow surgeons from Asia, Australia, Europe, and North America participated, with 48 completing all questionnaires (87%). The panellists evaluated the factors identified as important in literature for treatment decision-making, using a Likert scale ranging from "strongly influences me to recommend nonoperative treatment" (1) to "strongly influences me to recommend operative treatment" (5). Factors achieving Likert scores ≤ 2.0 or ≥ 4.0 were deemed influential for treatment recommendation. Stable consensus is defined as an agreement of ≥ 80% in the second and third rounds. Results. Of 68 factors considered important in the literature for treatment choice for coronoid fractures, 18 achieved a stable consensus to be influential. Influential factors with stable consensus that advocate for operative treatment were being a professional athlete, playing overhead sports, a history of subjective dislocation or subluxation during trauma, open fracture, crepitation with range of movement, > 2 mm opening during varus stress on radiological imaging, and having an anteromedial facet or basal coronoid fracture (O’Driscoll type 2 or 3). An anterolateral coronoid tip fracture ≤ 2 mm was the only influential factor with a stable consensus that advocates for nonoperative treatment. Most disagreement existed regarding the treatment for the terrible triad injury with an anterolateral coronoid tip fracture fragment ≤ 2 mm (O’Driscoll type 1 subtype 1). Conclusion. This study gives insights into areas of consensus among surveyed elbow surgeons in choosing between operative and nonoperative management of coronoid fractures. These findings should be used in conjunction with previous patient cohort studies when discussing treatment options with patients. Cite this article: Bone Joint J 2024;106-B(10):1150–1157


The Bone & Joint Journal
Vol. 102-B, Issue 3 | Pages 365 - 370
1 Mar 2020
Min KS Fox HM Bedi A Walch G Warner JJP

Aims. Patient-specific instrumentation has been shown to increase a surgeon’s precision and accuracy in placing the glenoid component in shoulder arthroplasty. There is, however, little available information about the use of patient-specific planning (PSP) tools for this operation. It is not known how these tools alter the decision-making patterns of shoulder surgeons. The aim of this study was to investigate whether PSP, when compared with the use of plain radiographs or select static CT images, influences the understanding of glenoid pathology and surgical planning. Methods. A case-based survey presented surgeons with a patient’s history, physical examination, and, sequentially, radiographs, select static CT images, and PSP with a 3D imaging program. For each imaging modality, the surgeons were asked to identify the Walch classification of the glenoid and to propose the surgical treatment. The participating surgeons were grouped according to the annual volume of shoulder arthroplasties that they undertook, and responses were compared with the recommendations of two experts. Results. A total of 59 surgeons completed the survey. For all surgeons, the use of the PSP significantly increased agreement with the experts in glenoid classification (x. 2. = 8.54; p = 0.014) and surgical planning (x. 2. = 37.91; p < 0.001). The additional information provided by the PSP also showed a significantly higher impact on surgical decision-making for surgeons who undertake fewer than ten shoulder arthroplasties annually (p = 0.017). Conclusions. The information provided by PSP has the greatest impact on the surgical decision-making of low volume surgeons (those who perform fewer than ten shoulder arthroplasties annually), and PSP brings all surgeons in to closer agreement with the recommendations of experts for glenoid classification and surgical planning. Cite this article: Bone Joint J 2020;102-B(3):365–370


The Bone & Joint Journal
Vol. 104-B, Issue 4 | Pages 486 - 494
4 Apr 2022
Liu W Sun Z Xiong H Liu J Lu J Cai B Wang W Fan C

Aims. The aim of this study was to develop and internally validate a prognostic nomogram to predict the probability of gaining a functional range of motion (ROM ≥ 120°) after open arthrolysis of the elbow in patients with post-traumatic stiffness of the elbow. Methods. We developed the Shanghai Prediction Model for Elbow Stiffness Surgical Outcome (SPESSO) based on a dataset of 551 patients who underwent open arthrolysis of the elbow in four institutions. Demographic and clinical characteristics were collected from medical records. The least absolute shrinkage and selection operator regression model was used to optimize the selection of relevant features. Multivariable logistic regression analysis was used to build the SPESSO. Its prediction performance was evaluated using the concordance index (C-index) and a calibration graph. Internal validation was conducted using bootstrapping validation. Results. BMI, the duration of stiffness, the preoperative ROM, the preoperative intensity of pain, and grade of post-traumatic osteoarthritis of the elbow were identified as predictors of outcome and incorporated to construct the nomogram. SPESSO displayed good discrimination with a C-index of 0.73 (95% confidence interval 0.64 to 0.81). A high C-index value of 0.70 could still be reached in the interval validation. The calibration graph showed good agreement between the nomogram prediction and the outcome. Conclusion. The newly developed SPESSO is a valid and convenient model which can be used to predict the outcome of open arthrolysis of the elbow. It could assist clinicians in counselling patients regarding the choice and expectations of treatment. Cite this article: Bone Joint J 2022;104-B(4):486–494


The Bone & Joint Journal
Vol. 102-B, Issue 8 | Pages 1041 - 1047
1 Aug 2020
Hamoodi Z Singh J Elvey MH Watts AC

Aims. The Wrightington classification system of fracture-dislocations of the elbow divides these injuries into six subtypes depending on the involvement of the coronoid and the radial head. The aim of this study was to assess the reliability and reproducibility of this classification system. Methods. This was a blinded study using radiographs and CT scans of 48 consecutive patients managed according to the Wrightington classification system between 2010 and 2018. Four trauma and orthopaedic consultants, two post CCT fellows, and one speciality registrar based in the UK classified the injuries. The seven observers reviewed preoperative radiographs and CT scans twice, with a minimum four-week interval. Radiographs and CT scans were reviewed separately. Inter- and intraobserver reliability were calculated using Fleiss and Cohen kappa coefficients. The Landis and Koch criteria were used to interpret the strength of the kappa values. Validity was assessed by calculating the percentage agreement against intraoperative findings. Results. Of the 48 patients, three (6%) had type A injury, 11 (23%) type B, 16 (33%) type B+, 16 (33%) Type C, two (4%) type D+, and none had a type D injury. All 48 patients had anteroposterior (AP) and lateral radiographs, 44 had 2D CT scans, and 39 had 3D reconstructions. The interobserver reliability kappa value was 0.52 for radiographs, 0.71 for 2D CT scans, and 0.73 for a combination of 2D and 3D reconstruction CT scans. The median intraobserver reliability was 0.75 (interquartile range (IQR) 0.62 to 0.79) for radiographs, 0.77 (IQR 0.73 to 0.94) for 2D CT scans, and 0.89 (IQR 0.77 to 0.93) for the combination of 2D and 3D reconstruction. Validity analysis showed that accuracy significantly improved when using CT scans (p = 0.018 and p = 0.028 respectively). Conclusion. The Wrightington classification system is a reliable and valid method of classifying fracture-dislocations of the elbow. CT scans are significantly more accurate than radiographs when identifying the pattern of injury, with good intra- and interobserver reproducibility. Cite this article: Bone Joint J 2020;102-B(8):1041–1047


The Bone & Joint Journal
Vol. 105-B, Issue 1 | Pages 56 - 63
1 Jan 2023
de Klerk HH Oosterhoff JHF Schoolmeesters B Nieboer P Eygendaal D Jaarsma RL IJpma FFA van den Bekerom MPJ Doornberg JN

Aims

This study aimed to answer the following questions: do 3D-printed models lead to a more accurate recognition of the pattern of complex fractures of the elbow?; do 3D-printed models lead to a more reliable recognition of the pattern of these injuries?; and do junior surgeons benefit more from 3D-printed models than senior surgeons?

Methods

A total of 15 orthopaedic trauma surgeons (seven juniors, eight seniors) evaluated 20 complex elbow fractures for their overall pattern (i.e. varus posterior medial rotational injury, terrible triad injury, radial head fracture with posterolateral dislocation, anterior (trans-)olecranon fracture-dislocation, posterior (trans-)olecranon fracture-dislocation) and their specific characteristics. First, fractures were assessed based on radiographs and 2D and 3D CT scans; and in a subsequent round, one month later, with additional 3D-printed models. Diagnostic accuracy (acc) and inter-surgeon reliability (κ) were determined for each assessment.


The Bone & Joint Journal
Vol. 106-B, Issue 9 | Pages 964 - 969
1 Sep 2024
Wang YC Song JJ Li TT Yang D Lv ZB Wang ZY Zhang ZM Luo Y

Aims

To propose a new method for evaluating paediatric radial neck fractures and improve the accuracy of fracture angulation measurement, particularly in younger children, and thereby facilitate planning treatment in this population.

Methods

Clinical data of 117 children with radial neck fractures in our hospital from August 2014 to March 2023 were collected. A total of 50 children (26 males, 24 females, mean age 7.6 years (2 to 13)) met the inclusion criteria and were analyzed. Cases were excluded for the following reasons: Judet grade I and Judet grade IVb (> 85° angulation) classification; poor radiograph image quality; incomplete clinical information; sagittal plane angulation; severe displacement of the ulna fracture; and Monteggia fractures. For each patient, standard elbow anteroposterior (AP) view radiographs and corresponding CT images were acquired. On radiographs, Angle P (complementary to the angle between the long axis of the radial head and the line perpendicular to the physis), Angle S (complementary to the angle between the long axis of the radial head and the midline through the proximal radial shaft), and Angle U (between the long axis of the radial head and the straight line from the distal tip of the capitellum to the coronoid process) were identified as candidates approximating the true coronal plane angulation of radial neck fractures. On the coronal plane of the CT scan, the angulation of radial neck fractures (CTa) was measured and served as the reference standard for measurement. Inter- and intraobserver reliabilities were assessed by Kappa statistics and intraclass correlation coefficient (ICC).


The Bone & Joint Journal
Vol. 106-B, Issue 11 | Pages 1293 - 1300
1 Nov 2024
O’Malley O Craven J Davies A Sabharwal S Reilly P

Aims

Reverse shoulder arthroplasty (RSA) has become the most common type of shoulder arthroplasty used in the UK, and a better understanding of the outcomes after revision of a failed RSA is needed. The aim of this study was to review the current evidence systematically to determine patient-reported outcome measures and the rates of re-revision and complications for patients undergoing revision of a RSA.

Methods

MEDLINE, Embase, CENTRAL, and the Cochrane Database of Systematic Reviews were searched. Studies involving adult patients who underwent revision of a primary RSA for any indication were included. Those who underwent a RSA for failure of a total shoulder arthroplasty or hemiarthroplasty were excluded. Pre- and postoperative shoulder scores were evaluated in a random effects meta-analysis to determine the mean difference. The rates of re-revision and complications were also calculated.


The Bone & Joint Journal
Vol. 106-B, Issue 11 | Pages 1273 - 1283
1 Nov 2024
Mahmud H Wang D Topan-Rat A Bull AMJ Heinrichs CH Reilly P Emery R Amis AA Hansen UN

Aims

The survival of humeral hemiarthroplasties in patients with relatively intact glenoid cartilage could theoretically be extended by minimizing the associated postoperative glenoid erosion. Ceramic has gained attention as an alternative to metal as a material for hemiarthroplasties because of its superior tribological properties. The aim of this study was to assess the in vitro wear performance of ceramic and metal humeral hemiarthroplasties on natural glenoids.

Methods

Intact right cadaveric shoulders from donors aged between 50 and 65 years were assigned to a ceramic group (n = 8, four male cadavers) and a metal group (n = 9, four male cadavers). A dedicated shoulder wear simulator was used to simulate daily activity by replicating the relevant joint motion and loading profiles. During testing, the joint was kept lubricated with diluted calf serum at room temperature. Each test of wear was performed for 500,000 cycles at 1.2 Hz. At intervals of 125,000 cycles, micro-CT scans of each glenoid were taken to characterize and quantify glenoid wear by calculating the change in the thickness of its articular cartilage.


The Bone & Joint Journal
Vol. 106-B, Issue 11 | Pages 1306 - 1311
1 Nov 2024
Watts AC McDaid C Hewitt C

Aims

A review of the literature on elbow replacement found no consistency in the clinical outcome measures which are used to assess the effectiveness of interventions. The aim of this study was to define core outcome domains for elbow replacement.

Methods

A real-time Delphi survey was conducted over four weeks using outcomes from a scoping review of 362 studies on elbow replacement published between January 1990 and February 2021. A total of 583 outcome descriptors were rationalized to 139 unique outcomes. The survey consisted of 139 outcomes divided into 18 domains. The readability and clarity of the survey was determined by an advisory group including a patient representative. Participants were able to view aggregated responses from other participants in real time and to revisit their responses as many times as they wished during the study period. Participants were able to propose additional items for inclusion. A Patient and Public Inclusion and Engagement (PPIE) panel considered the consensus findings.


The Bone & Joint Journal
Vol. 106-B, Issue 10 | Pages 1125 - 1132
1 Oct 2024
Luengo-Alonso G Valencia M Martinez-Catalan N Delgado C Calvo E

Aims

The prevalence of osteoarthritis (OA) associated with instability of the shoulder ranges between 4% and 60%. Articular cartilage is, however, routinely assessed in these patients using radiographs or scans (2D or 3D), with little opportunity to record early signs of cartilage damage. The aim of this study was to assess the prevalence and localization of chondral lesions and synovial damage in patients undergoing arthroscopic surgery for instablility of the shoulder, in order to classify them and to identify risk factors for the development of glenohumeral OA.

Methods

A total of 140 shoulders in 140 patients with a mean age of 28.5 years (15 to 55), who underwent arthroscopic treatment for recurrent glenohumeral instability, were included. The prevalence and distribution of chondral lesions and synovial damage were analyzed and graded into stages according to the division of the humeral head and glenoid into quadrants. The following factors that might affect the prevalence and severity of chondral damage were recorded: sex, dominance, age, age at the time of the first dislocation, number of dislocations, time between the first dislocation and surgery, preoperative sporting activity, Beighton score, type of instability, and joint laxity.


The Bone & Joint Journal
Vol. 106-B, Issue 12 | Pages 1461 - 1468
1 Dec 2024
Hamoodi Z Shapiro J Sayers A Whitehouse MR Watts AC

Aims

The aim of this audit was to assess and improve the completeness and accuracy of the National Joint Registry (NJR) dataset for arthroplasty of the elbow.

Methods

It was performed in two phases. In Phase 1, the completeness was assessed by comparing the NJR elbow dataset with the NHS England Hospital Episode Statistics (HES) data between April 2012 and April 2020. In order to assess the accuracy of the data, the components of each arthroplasty recorded in the NJR were compared to the type of arthroplasty which was recorded. In Phase 2, a national collaborative audit was undertaken to evaluate the reasons for unmatched data, add missing arthroplasties, and evaluate the reasons for the recording of inaccurate arthroplasties and correct them.


The Bone & Joint Journal
Vol. 106-B, Issue 10 | Pages 1133 - 1140
1 Oct 2024
Olsen Kipp J Petersen ET Falstie-Jensen T Frost Teilmann J Zejden A Jellesen Åberg R de Raedt S Thillemann TM Stilling M

Aims

This study aimed to quantify the shoulder kinematics during an apprehension-relocation test in patients with anterior shoulder instability (ASI) and glenoid bone loss using the radiostereometric analysis (RSA) method. Kinematics were compared with the patient’s contralateral healthy shoulder.

Methods

A total of 20 patients with ASI and > 10% glenoid bone loss and a healthy contralateral shoulder were included. RSA imaging of the patient’s shoulders was performed during a repeated apprehension-relocation test. Bone volume models were generated from CT scans, marked with anatomical coordinate systems, and aligned with the digitally reconstructed bone projections on the RSA images. The glenohumeral joint (GHJ) kinematics were evaluated in the anteroposterior and superoinferior direction of: the humeral head centre location relative to the glenoid centre; and the humeral head contact point location on the glenoid.


The Bone & Joint Journal
Vol. 104-B, Issue 10 | Pages 1148 - 1155
1 Oct 2022
Watts AC Hamoodi Z McDaid C Hewitt C

Aims

Arthroplasties of the elbow, including total elbow arthroplasty, radial head arthroplasty, distal humeral hemiarthroplasty, and radiocapitellar arthroplasty, are rarely undertaken. This scoping review aims to outline the current research in this area to inform the development of future research.

Methods

A scoping review was undertaken adhering to the Joanna Briggs Institute guidelines using Medline, Embase, CENTRAL, and trial registries, limited to studies published between 1 January 1990 and 7 February 2021. Endnote software was used for screening and selection, and included randomized trials, non-randomized controlled trials, prospective and retrospective cohort studies, case-control studies, analytical cross-sectional studies, and case series of ten or more patients reporting the clinical outcomes of elbow arthroplasty. The results are presented as the number of types of studies, sample size, length of follow-up, clinical outcome domains and instruments used, sources of funding, and a narrative review.


The Bone & Joint Journal
Vol. 104-B, Issue 1 | Pages 83 - 90
1 Jan 2022
Batten TJ Gallacher S Evans JP Harding RJ Kitson J Smith CD Thomas WJ

Aims

The use and variety of stemless humeral components in anatomical total shoulder arthroplasty (TSA) have proliferated since their advent in 2004. Early outcomes are reassuring but independent mid-term results are scarce. This independent study reports a consecutive series of 143 Eclipse stemless shoulder prostheses with a minimum five-year (5 to 10) follow-up.

Methods

Outcomes of 143 procedures undertaken for all indications in 131 patients were reviewed, with subset analysis of those for osteoarthritis (OA) (n = 99). The primary outcome was the Oxford Shoulder Score (OSS) at a minimum of five years. Secondary outcomes were ranges of motion and radiological analysis of humeral radiolucency, rotator cuff failure, and glenoid loosening.


The Bone & Joint Journal
Vol. 103-B, Issue 8 | Pages 1333 - 1338
2 Aug 2021
Kankanalu P Borton ZM Morgan ML Cresswell T Espag MP Tambe AA Clark DI

Aims

Reverse total shoulder arthroplasty (RTSA) using trabecular metal (TM)-backed glenoid implants has been introduced with the aim to increase implant survival. Only short-term reports on the outcomes of TM-RTSA have been published to date. We aim to present the seven-year survival of TM-backed glenoid implants along with minimum five-year clinical and radiological outcomes.

Methods

All consecutive elective RTSAs performed at a single centre between November 2008 and October 2014 were reviewed. Patients who had primary TM-RTSA for rotator cuff arthropathy and osteoarthritis with deficient cuff were included. A total of 190 shoulders in 168 patients (41 male, 127 female) were identified for inclusion at a mean of 7.27 years (SD 1.4) from surgery. The primary outcome was survival of the implant with all-cause revision and aseptic glenoid loosening as endpoints. Secondary outcomes were clinical, radiological, and patient-related outcomes with a five-year minimum follow-up.


The Bone & Joint Journal
Vol. 103-B, Issue 7 | Pages 1292 - 1300
1 Jul 2021
Märtens N Heinze M Awiszus F Bertrand J Lohmann CH Berth A

Aims

The purpose of this study was to compare clinical results, long-term survival, and complication rates of stemless shoulder prosthesis with stemmed anatomical shoulder prostheses for treatment of osteoarthritis and to analyze radiological bone changes around the implants during follow-up.

Methods

A total of 161 patients treated with either a stemmed or a stemless shoulder arthroplasty for primary osteoarthritis of the shoulder were evaluated with a mean follow-up of 118 months (102 to 158). The Constant score (CS), the Disabilities of the Arm, Shoulder and Hand (DASH) score, and active range of motion (ROM) were recorded. Radiological analysis for bone adaptations was performed by plain radiographs. A Kaplan-Meier survivorship analysis was calculated and complications were noted.


The Bone & Joint Journal
Vol. 103-B, Issue 2 | Pages 360 - 365
1 Feb 2021
Mahendraraj KA Shields MV Grubhofer F Golenbock SW Jawa A

Aims

Existing literature indicates that inferiorly inclined glenoid baseplates following reverse total shoulder arthroplasty (RSA) produce better outcomes compared to superiorly inclined baseplates. We aim to compare clinical outcomes for RSAs with superiorly and neutrally/inferiorly inclined lateralized glenospheres.

Methods

We retrospectively reviewed 154 consecutive patients undergoing RSA between July 2015 and July 2017 by one single-fellowship trained surgeon (AJ). Two raters (KAM and MVS) independently measured glenoid inclination in preoperative and minimum two year follow-up radiographs (anteroposterior/Grashey) using the RSA angle. Inclination was then compared to patient-reported outcomes, range of motion (ROM), and independently assessed degree of scapular notching and staging of heterotopic ossification at two year follow-up.


The Bone & Joint Journal
Vol. 102-B, Issue 11 | Pages 1549 - 1554
1 Nov 2020
Schwartz AM Farley KX Boden SH Wilson JM Daly CA Gottschalk MB Wagner ER

Aims

The impact of tobacco use on readmission and medical and surgical complications has been documented in hip and knee arthroplasty. However, there remains little information about the effect of smoking on the outcome after total shoulder arthroplasty (TSA). We hypothesized that active smokers are at an increased risk of poor medical and surgial outcomes after TSA.

Methods

Data for patients who underwent arthroplasty of the shoulder in the USA between January 2011 and December 2015 were obtained from the National Readmission Database, and 90-day readmissions and complications were documented using validated coding methods. Multivariate regression analysis was performed to quantify the risk of smoking on the outcome after TSA, while controlling for patient demographics, comorbidities, and hospital-level confounding factors.


The Bone & Joint Journal
Vol. 103-B, Issue 4 | Pages 718 - 724
1 Apr 2021
Cavalier M Johnston TR Tran L Gauci M Boileau P

Aims

The aim of this study was to identify risk factors for recurrent instability of the shoulder and assess the ability to return to sport in patients with engaging Hill-Sachs lesions treated with arthroscopic Bankart repair and Hill-Sachs remplissage (ABR-HSR).

Methods

This retrospective study included 133 consecutive patients with a mean age of 30 years (14 to 69) who underwent ABR-HSR; 103 (77%) practiced sports before the instability of the shoulder. All had large/deep, engaging Hill-Sachs lesions (Calandra III). Patients were divided into two groups: A (n = 102) with minimal or no (< 10%) glenoid bone loss, and B (n = 31) with subcritical (10% to 20%) glenoid loss. A total of 19 patients (14%) had undergone a previous stabilization, which failed. The primary endpoint was recurrent instability, with a secondary outcome of the ability to return to sport.