Shoulder & Elbow

Operative stabilisation of long segment periarticular, periprosthetic and pathological fractures in humerus is a challenging problem.

A total of 18 patients were treated by open reduction and internal fixation using the long proximal humeral internal locking system (PHILOS) plate. The types of fractures treated were long segment periarticular fractures extending into the diaphysis (11 of 18), periprosthetic fractures around humeral resurfacing (five of 18) and pathological fractures (two of 18). This study is a retrospective case series review of these cases with a final follow-up observation. The mean follow-up was for 13 months (range 4 months to 48 months). There were 11 women and seven men with a mean age of 52 years (range 19 years to 86 years). Outcomes were assessed using the Constant and Visual Analogue Score.

There was no incidence of loss of fixation, malunion or a vascular necrosis. The mean time to radiological union was 15 weeks (range 9 weeks to 22 weeks). The mean Constant score for posttraumatic fractures at final review was 76/100 (range 64 to 100). The mean Visual Analogue Score was 0.8 (range 0 to 3). The patients with pathological fractures survived for a mean 5 months (4 to 6 months).

The long PHILOS plate fixation provides reliable secure fixation for the treatment of complex humeral fractures, especially long segment periarticular fractures, segmental fractures involving proximal humerus and shaft, periprosthetic fractures around well-fixed humeral resurfacing prosthesis and pathological fractures.

The Constant–Murley score (CMS) is a widely used scoring system. However, its objective component is open to inter-rater variability. The present study aimed to assess the inter-rater reliability of the objective component of the CMS.

Fifteen clinicians of varying experience were given 18 standardized photographs of 10 normal subjects of varying age and build, equating to 24 fixed shoulder positions. Each rater visually estimated the angle of each shoulder and repeated the process at 1 week using a goniometer. These angles were converted to their appropriate CMS. The intraclass correlation coefficient (ICC) was calculated using SPSS (SPSS Inc., Chicago, IL, USA) to assess inter-rater reliability.

The mean postgraduate experience of our raters was 7.13 years. There were a total of 360 CMS estimated visually. The inter-rater ICC was 0.909 [95% confidence interval (CI) 0.854 to 0.952]. The goniometer-based CMS were similar: ICC 0.950 (95% CI 0.907 to 0.976) (Cronbach's alpha = 0.993). Comparing CM scores between visual estimation and goniometry demonstrated an inter-rater ICC of 0.409 (95% CI–0.0301 to 0.827).

To our knowledge, this is the first attempt to define the reliability of the objective component of the CMS using large numbers of observers and patients. We have shown that the CMS is highly reliable between raters providing that the same method is used. In the present study, visual estimation was found to be as reliable between raters as the goniometer. However, the reliability of the score is dramatically affected if the two methods are interchanged between raters.

Suturing of portals following arthroscopic shoulder surgery is the standard method of closure, but may be unnecessary. We carried out a randomised controlled trial to compare patients whose arthroscopic portals were closed by suturing and those that were covered by a simple dressing. We randomised 60 patients undergoing diagnostic shoulder arthroscopy, arthroscopic subacromial decompression and arthroscopic acromioclavicular joint excision.

At 10 to 12 days following surgery, patients attended the GP surgery for a wound check and removal of sutures as required. At 3 weeks and 3 months every patient was reviewed by a designated, blinded, observer and the wounds assessed. The patients completed a questionnaire including visual analogue scores to determine their satisfaction with wound appearance and any complications such as infection.

At 3 weeks and 3 months no patients had needed antibiotics with no wound erythema or signs of infection. The number of dressings needed was comparable in both groups (p=0.73). The difference in the level of patient satisfaction was not statistically significant in either group (p=0.46). The wound cosmesis score was not statistically different in either group (p=0.66).

We conclude that both closure techniques were equivalent but the non-suture technique is cheaper with lower morbidity. From our study there is no need to suture shoulder arthroscopy portal wounds.

The present study aimed to assess the accuracy of high-resolution ultrasonography in the detection of articular-sided partial thickness rotator cuff tears.

Two-hundred and forty-six shoulders of 245 patients underwent ultrasonography and subsequent shoulder arthroscopy. All scans were performed by an experienced specialist musculoskeletal radiologist and arthroscopies were carried out by a single surgeon.

Fifty-eight partial thickness tears (of which 56 were articular-sided) were found at arthroscopy. Of the remaining shoulders, 90 had full thickness tears and 98 had intact rotator cuffs. Ultrasonography correctly identified 21 of 56 articular-sided tears as partial thickness tears. It had a sensitivity of 7%, a specificity of 98% and an accuracy of 74% for the diagnosis of articular-sided partial thickness tears. If a full thickness tear was considered as a true positive, the sensitivity increased to 89%, specificity to 98% and accuracy to 96%.

Ultrasonography is not sufficiently accurate to diagnose articular-sided partial thickness tears. A higher accuracy can be achieved if a full thickness tear is considered a positive finding. Ultrasonography should not be considered a first line investigation for a clinically suspected partial thickness rotator cuff tear. An articular-sided partial thickness rotator cuff tear should be considered in all patients undergoing an arthroscopic rotator cuff procedure.

Scar flexion elbow contracture is a common complication of burns that restricts upper limb function and requires surgical elimination. In spite of the many surgical techniques that have been suggested, the contracture reconstruction still presents a challenge for surgeons.

One hundred and twenty-six patients with 174 edge elbow contractures were operated on. Edge elbow contracture, comprising 70% of all elbow contractures, is characterized by the presence of the fold located on the medial or/and lateral edge of cubital fossa. A crescent-shaped fold consists of a lateral sheet, comprising scars; the medial sheet and cubital fossa consists of healthy skin. The fold's crest is the edge of the scar sheet. The contracture is caused by the scar sheet's surface deficit in length; the scar's surface deficit is present all the way from the fold's crest to the joint rotation axis, and possesses a trapezoid shape. The best tissue for scar sheet deficit compensation and contracture elimination the comprises healthy skin of the cubital fossa and medial fold sheet. After fold sheet division, scar sheet dissection and joint extension, the trapeze-shaped wound is formed as a rule. The adipose-cutaneous trapezoid flap, which includes all the cubital fossa and medial fold sheet surface, is elevated. The flap advances on the wound with tension. As a result of flap tension, the adjacent skin of the contralateral side and the back surfaces of the elbow are displaced towards the cubital fossa, participating in donor wound coverage and contracture elimination.

Mild edge elbow contractures were eliminated with a single trapezoid flap. In the case of moderate and severe contractures, additional trapezoid adipose-scar flaps were elevated from the scar sheet in order to cover the donor wound on the sides of the main flap. The adipose-cutaneous and adipose-scar trapezoid flaps are large, have no acute angles, do not undergo rotation and have steady blood circulation. Contractures were eliminated completely in 166 cases. Local flap end necrosis of the adipose-scar flap occurred in eight cases. The extended healthy flap's skin continued to grow. Full range of flexion and extension was achieved in all cases, except for eight cases with articular changes; there was no contracture recurrence and no re-operations were needed. The cubital fossa as the donor site preserved a normal shape as a result of growth of the stretched skin.

The single-staged trapeze-flap technique using cubital fossa flap is easy to plan and perform; edge elbow contractures of different severity were eliminated in full and definitively without skin grafting, pedicled and free flaps.

There are no current North American population-based incidence studies of elbow dislocations. This creates further challenges in assessing associated outcomes and complication rates. The present study aimed to determine the population-based incidence of elbow dislocations in a large Canadian city.

From April 2002 to March, 2005, consecutive cases of elbow dislocation were documented. Age-specific, gender-specific and age-adjusted rates for simple and complex dislocations were calculated according to patient demographic and 2001 Canadian census data. All rates were reported per 10,000 persons per year.

One hundred thirty-seven dislocations (53 simple and 84 complex) were identified. Simple dislocations occurred at a rate of 0.262 (95% confidence interval [CI] = 0.191 to 0.332). Fracture-dislocations occurred at a rate of 0.415 (95% CI = 0.326 to 0.504). The overall age-adjusted incidence was 0.671 (95% CI = 0.638 to 0.704). With the exception of the 18 years to 29 years (rate = 0.916, 95% CI = 0.648 to 1.183) and ≥80 years groups (rate = 0.906, 95% CI = 0.112 to 1.700), all age groups had an approximate rate of 0.600.

The results obtained in the present study are similar to those obtained in a previous European study. True population-based estimates of elbow dislocation incidence are provided, which may facilitate the assessment of outcomes and complication rates of such injuries.

We aimed to identify the treatments used by health care professionals in current practice for the management of patients with idiopathic frozen shoulder and the need for further research in this area, specifically a randomized trial.

Three hundred and three health care professionals (i.e. general practitioners, physiotherapists and orthopaedic surgeons) completed an online survey about idiopathic frozen shoulder management and research priorities. The results were analyzed using descriptive statistics, chi-square statistics and thematic analysis of qualitative data.

Conservative treatment and physical therapy were identified as the most common interventions for treating patients presenting with frozen shoulder in the early ‘painful’ phase. Approximately half of the respondents would recommend surgery for patients with ‘resolution’ phase frozen shoulder, although there was some disagreement about the role of pain as an indicator for surgery. Most respondents (221/251) considered that more research was needed using a randomized trial design, in particular aiming to investigate the effectiveness of physical therapy and surgery.

Health professionals manage frozen shoulders differently for different phases of the condition. More research is needed to compare different interventions for the management of patients with idiopathic frozen shoulder.

To assess the effectiveness of a peri-operative pain control regimen for day-case shoulder surgery, including open and complex procedures.

A prospective cohort study of all patients undergoing day-case shoulder surgery in a single hospital over a 1-year period, using a comprehensive pain control regimen. The regimen included patient education, interscalene block, analgesics, nonsteroidal anti-inflammatory medications and a cold compression shoulder wrap. All patients were followed up with a telephone call 24 hours after surgery to assess their pain levels, compliance and any ill effects.

There were 187 patients in the time period, with 90.4% reporting that their pain was well controlled. Twenty-eight patients (15%) experienced moderate and severe pain 24 hours postoperatively. These were limited to five common procedures, with arthroscopic rotator cuff repair and arthroscopic stabilization being the most common, comprising 75% of the reported painful procedures. Only four patients reported severe pain (2%). Two of these took no medication at all. Three of these four patients had 360° labral repairs and the other a massive, revision arthroscopic rotator cuff repair.

Postoperative pain after day-case shoulder surgery can be effectively managed with a comprehensive analgesic regimen. This includes open shoulder surgery and complex arthroscopic procedures.

The present study aimed to describe the comorbidity burden of a rotator cuff disease cohort and to examine the effects of patient comorbidities on general health and shoulder-specific outcome measures.

A retrospective cohort of patients with rotator cuff disease was identified using the coding of the International Classification of Diseases, Ninth Revision, Clinical Modification. Demographic variables and numbers of systemic and musculoskeletal comorbid conditions were collected. General health and shoulder-specific tools were used to assess disability. Analyses using regression, correlation and analysis of variance were performed to assess the impact of comorbidity upon outcome measures.

Three hundred and seventy-three patients with rotator cuff disease were identified. Two-thirds of the group reported at least one systemic comorbidity. Non-shoulder musculoskeletal comorbidities were reported by 80% of the cohort. Women reported a significantly greater number of comorbid conditions than men (p < 0.02). Baseline health-related quality of life and self-reported shoulder function were impacted significantly by comorbidity when controlling for patient demographic characteristics.

Comorbidities are common in this population and significantly affect health-related quality of life and self-reported shoulder pain and disability in patients presenting with rotator cuff-related symptoms. Comorbidities should be considered when shoulder disability measures are utilized in clinical practice and when studying outcomes.