Treatment of acute distal biceps tendon ruptures - A survey of the British Elbow and Shoulder Society surgical membership

Background

Acute distal biceps tendon ruptures result in weakness and deformity. While in other jurisdictions the rate of surgical repair has outpaced rises in incidence, UK practice for distal biceps tendon ruptures is unknown. The aim of this survey was to characterise current UK clinical practice.

Methods

An online survey was sent to the surgeon members of the British Elbow and Shoulder Society. Questions covered respondent demographics, clinical decision making, surgical experience and willingness to be involved in future research.

Results

A total of 242 surgeons responded; 99% undertook acute distal biceps tendon repairs with 83% repairing at least half of all distal biceps tendon ruptures, and 84% of surgeons would have their own, hypothetical, acute distal biceps tendon rupture repaired in their dominant arm and 67% for their non-dominant arm. Patient age, occupation and restoration of strength were the commonest factors underpinning a recommendation of surgical fixation. Most surgeons (87%) supported a national trial to study operative and non-operative treatments.

Conclusions

UK upper limb surgeons currently advise surgical repair of acute distal biceps tendon ruptures for the majority of their patients. This is despite a paucity of evidence to support improved outcomes following surgical, rather than non-operative, management. There is a clear need for robust clinical evaluation in this area.

Radial head fractures

The shape and size of the radial head is highly variable but correlates to the contralateral side. The radial head is a secondary stabilizer to valgus stress and provides lateral stability. The modified Mason-Hotchkiss classification is the most commonly used and describes three types, depending on the number of fragments and their displacement. Type 1 fractures are typically treated conservatively. Surgical reduction and fixation are recommended for type 2 fractures, if there is a mechanical block to motion. This can be done arthroscopically or open. Controversy exists for two-part fractures with >2 mm and <5 mm displacement, without a mechanical bloc as good results have been published with conservative treatment. Type 3 fractures are often treated with radial head replacement. Although radial head resection is also an option as long-term results have been shown to be favourable. Radial head arthroplasty is recommended in type 3 fractures with ligamentous injury or proximal ulna fractures. Failure of primary radial head replacement may be due to several factors. Identification of the cause of failure is essential. Failed radial head arthroplasty can be treated by implant removal alone, interposition arthroplasty, revision radial head replacement either as a single stage or two-stage procedure.

Comparing leukocyte-rich platelet-rich plasma injection with surgical intervention for the management of refractory tennis elbow. A prospective randomised trial

BACKGROUND

Patients with ongoing symptoms after non-operative treatment of lateral epicondylosis are usually treated with surgical release. Platelet-rich plasma injection is an alternative treatment option. This study aims to determine whether there is a difference in outcome from platelet-rich plasma injection or surgical release for refractory tennis elbow.

METHOD

Eighty-one patients with a diagnosis of tennis elbow for a minimum of six months, treated with previous steroid injection and a minimum visual analogue scale pain score of 50/100 were randomised to open surgery release (41 patients) or leucocyte rich platelet-rich plasma (L-PRP) (40 patients). Patients completed the Patient-Rated Tennis Elbow Evaluation and Disability of the Arm Shoulder and Hand at baseline, 1.5, 3, 6 and 12 months post-intervention. The primary endpoint was change in Patient-Rated Tennis Elbow Evaluation pain score at 12 months.

RESULTS

Fifty-two patients completed final follow-up. Functional and pain scores improved in both groups. No differences in functional improvements were found but greater improvements in Patient-Rated Tennis Elbow Evaluation pain scores were seen after surgery. Thirteen patients crossed over from platelet-rich plasma to surgery within 12 months, and one surgical patient underwent a platelet-rich plasma injection.

CONCLUSION

L-PRP and surgery produce equivalent functional outcome but surgery may result in lower pain scores at 12 months. Seventy per cent of patients treated with platelet-rich plasma avoided surgical intervention.

Scoping review: Diagnosis and management of periprosthetic joint infection in elbow arthroplasty

BACKGROUND

Total elbow arthroplasty is an effective treatment for patients with painful elbow arthritis. Infection can be a serious complication. The aim of this scoping review was to document the available evidence on periprosthetic elbow infection.

METHODS

A search of Medline, Embase and PubMed was performed; two authors screened results independently. Systematic reviews, randomised controlled trials, cohort studies, case-control studies and case series including periprosthetic elbow infection were eligible.

RESULTS

A total of 46 studies were included. The median rate of periprosthetic elbow infection reported from recent published studies is 3.3%. The most commonly identified causative organisms are Staphylococcus aureus and Staphylococcus epidermidis. Risk factors include younger age, rheumatoid arthritis, obesity, previous surgery or infection to the elbow, and postoperative wound complications. Debridement, antibiotics and implant retention results in implant survival rates of 50-90%. Two-stage revision results in improved functional outcome scores, but with recurrent infection rates of 12-28%.

CONCLUSIONS

Total elbow arthroplasty carries a higher risk of infection when compared to other major joint replacements. The current body of literature is limited and is almost exclusively low volume retrospective case series. The best management of periprosthetic elbow infection is difficult to determine, but two-stage revision appears to be the gold standard.

Early migration of a partially cemented fluted glenoid component inserted using a cannulated preparation system

Aims

Radiostereometric analysis (RSA) allows an extremely accurate measurement of early micromotion of components following arthroplasty.

Patients and Methods

In this study, RSA was used to measure the migration of 11 partially cemented fluted pegged glenoid components in patients with osteoarthritis who underwent total shoulder arthroplasty using an improved surgical technique (seven men, four women, mean age 68). Patients were evaluated clinically using the American Shoulder and Elbow Surgeons (ASES) and Constant-Murley scores and by CT scans two years post-operatively.

Results

There were two patterns of migration, the first showing little, if any, migration and the second showing rotation by > 6° as early as three months post-operatively. At two years, these two groups could be confirmed on CT scans, one with osseointegration around the central peg, and the second with cystic changes. Patients with osteolysis around the central peg were those with early migration and those with osseointegration had minimal early migration. Both groups,however,had similar clinical results.

Conclusion

Rapid early migration associated with focal lucency and absence of osseointegration was observed in three of 11 glenoid components, suggesting that lack of initial stability leads to early movement and failure of osseointegration. Cite this article: Bone Joint J 2017;99-B:674–9.

Medium-term outcomes of the Universal-2 total wrist arthroplasty in patients with rheumatoid arthritis

AIMS

The aims of this study were to evaluate the clinical and radiological outcomes of the Universal-2 total wrist arthroplasty (TWA) in patients with rheumatoid arthritis.

PATIENTS AND METHODS

This was a retrospective review of all 95 Universal-2 TWAs which were performed in our institution between 2003 to 2012 in patients with rheumatoid arthritis. A total of six patients were lost to follow-up and two died of unrelated causes. A total of ten patients had bilateral procedures. Accordingly, 75 patients (85 TWAs) were included in the study. There were 59 women and 16 men with a mean age of 59 years (26 to 86). The mean follow-up was 53 months (24 to 120). Clinical assessment involved recording pain on a visual analogue score, range of movement, grip strength, the Quick Disabilities of the Arm, Shoulder and Hand (DASH) and Wrightington wrist scores. Any adverse effects were documented with particular emphasis on residual pain, limitation of movement, infection, dislocation and the need for revision surgery. Radiographic assessment was performed pre-operatively and at three, six and 12 months post-operatively, and annually thereafter. Arthroplasties were assessed for distal row intercarpal fusion and loosening. Radiolucent zones around the components were documented according to a system developed at our institution.

RESULTS

The mean worst pain was 8.1 (3 to 10) pre-operatively and 5.4 (0 to 10) at latest follow-up (p < 0.001). Movements were preserved with mean dorsiflexion of 29^o (0 ^o to 70 ^o) and palmar flexion of 21^o (0^o to 50^o). The mean grip strength was 4.8 kg (1.7 to 11.5) pre-operatively and 10 kg (0 to 28) at final follow-up (p < 0.001). The mean QuickDASH and Wrightington wrist scores improved from 61 (16 to 91) to 46 (0 to 89) and 7.9 (1.8 to 10) to 5.7 (0 to 7.8) (p < 0.001). A total of six patients (7%) had major complications; three required revision arthroplasty and three an arthrodesis. The Kaplan-Meier probability of survival using removal of the components as the endpoint was 91% at 7.8 years (95% confidence interval 84 to 91).

CONCLUSION

The Universal-2 TWA is recommended for use in patients with rheumatoid arthritis. Cite this article: Bone Joint J 2016;98-B:1642-7.

Randomized Trial of Buffered Versus Plain Lidocaine for Local Anaesthesia in open Carpal Tunnel Decompression

We performed a randomized double-blind case–control study in 64 consecutive patients undergoing open carpal tunnel decompression under local anaesthetic to assess the pain experienced on injection of plain lidocaine (pH 6.4) compared with lidocaine buffered with sodium bicarbonate (pH 7.4). The results showed no statistical difference in the pain scores reported by patients. The mean pain scores for all patients were low, and most patients reported that they were “not at all anxious” about receiving a similar injection in the future.

The Use of a Fine-Gauge Needle to Reduce Pain in Open Carpal Tunnel Decompression: A Randomized Controlled Trial

This randomized controlled study on 86 patients compared the level of pain experienced by patients on instillation of local anaesthetic into the palm with a 23-gauge and a 27-gauge (dental) needle in open carpal tunnel decompression. Patients were asked to score the amount of pain they experienced during the injection of the local anaesthetic and their level of anxiety about future injections using a visual analogue scale (VAS) and a four-point verbal response scale (VRS). The mean pain and anxiety scores on the VAS were significantly lower in the dental needle group. There was significant correlation between the pain and anxiety VAS scores. When infiltrating local anaesthetic into the palm for open carpal tunnel decompression, the use of a fine (dental) needle can reduce the pain on that occasion and the anxiety concerning future injections likely to be experienced by the patient.

The use of non-vascularised osteochondral autograft for reconstruction of articular surfaces in the hand and wrist

Bone loss involving articular surface is a challenging problem faced by the orthopaedic surgeon. In the hand and wrist, there are articular defects that are amenable to autograft reconstruction when primary fixation is not possible. In this article, the surgical techniques and clinical outcomes of articular reconstructions in the hand and wrist using non-vascularised osteochondral autografts are reviewed.

An objective assessment of safety to drive in an upper limb cast

Patients managed with upper limb cast immobilization often seek advice about driving. There is very little published data to assist in decision making, and advice given varies between healthcare professionals. There are no specific guidelines available from the UK Drivers and Vehicles Licensing Agency, police, or insurance companies. Evidence-based guidelines would enable clinicians to standardize the advice given to patients. Six individuals (three male, three female; mean age 36 years, range 27-43 years) were assessed by a mobility occupational therapist and driving standards agency examiner while completing a formal driving test in six different types of upper limb casts (above-elbow, below-elbow neutral, and below-elbow cast incorporating the thumb [Bennett's cast]) on both left and right sides. Of the 36 tests, participants passed 31 tests, suggesting that most people were able to safely drive with upper limb cast immobilization. However, driving in a left above-elbow cast was considered unsafe.

Carpal tunnel syndrome: the association with occupation at a population level

The aim of this study was to examine the association of occupation and gender with the incidence and severity of carpal tunnel syndrome (CTS). We examined 884 patients of working age, diagnosed with CTS, in a specialist hand clinic that was the only provider of hand services to a health board area. We categorized occupation using the Standard Occupational Classification 2010 (SOC2010) and used local census data to calculate the incidence in each of the nine major occupational groups. The greatest incidence was in caring and leisure occupations (197 per 100 000 population per year), while the lowest incidence was in the associate professional group (37 per 100 000). Professional occupations had a high incidence of CTS, along with skilled trades and elementary occupations. Women had a higher incidence of CTS than men in managerial, professional, skilled trades, and elementary occupations (OR 2.9-3.6). The Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) score varied across occupational groups (p < 0.001) and was worst in the caring and leisure group. As traditional heavy industry associated with previously described occupational risks declines, new patterns of occupational association may emerge. We recommend ongoing observational research of potential occupational risk factors to identify these new trends.

The outcome of carpal tunnel decompression in patients with diabetes mellitus

Diabetes mellitus is recognised as a risk factor for carpal tunnel syndrome. The response to treatment is unclear, and may be poorer than in non-diabetic patients. Previous randomised studies of interventions for carpal tunnel syndrome have specifically excluded diabetic patients. The aim of this study was to investigate the epidemiology of carpal tunnel syndrome in diabetic patients, and compare the outcome of carpal tunnel decompression with non-diabetic patients. The primary endpoint was improvement in the QuickDASH score. The prevalence of diabetes mellitus was 11.3% (176 of 1564). Diabetic patients were more likely to have severe neurophysiological findings at presentation. Patients with diabetes had poorer QuickDASH scores at one year post-operatively (p = 0.028), although the mean difference was lower than the minimal clinically important difference for this score. After controlling for underlying differences in age and gender, there was no difference between groups in the magnitude of improvement after decompression (p = 0.481). Patients with diabetes mellitus can therefore be expected to enjoy a similar improvement in function.

Pathological femoral fracture caused by primary bone tumour: a population-based study

This population-based study aimed to analyse the demographic, clinical and histological features of patients with a malignant primary bone tumour of the femur presenting with a pathological fracture. Eighty-four patients were identified from a prospectively gathered national tumour database between 1960 and 2004. Demographic data, presenting features, tumour location, histological diagnosis, treatment, local recurrence, metastasis and survival data were gathered. An estimate of the annual incidence was obtained using population data from the General Register Office and was 0.4 per million population per annum. The mean age was 56 years (range 4-87 years) with a bimodal distribution and 46% were men or boys. Forty-one percent of patients presented with a history of trauma. The average duration of symptoms before presentation was 1-3 months. The most common histological diagnoses were osteosarcoma (14 patients) and Paget's sarcoma (12 patients). The local recurrence rate was 38% and the overall five-year survival was 22%. The prognosis was made worse by local tumour recurrence, the development of metastasis and age at diagnosis greater than 21 years. Limb salvage surgery did not alter the prognosis. Patients who present with pathological fracture of a primary malignant bone tumour, carry a poor prognosis in all tumour types and no improvement in survival was identified over the period of the study.

Socioeconomic deprivation and the epidemiology of carpal tunnel syndrome

Deprivation has been recognized as a major determinant of health and is associated with several musculoskeletal conditions. This study examines the effect of deprivation on the incidence of carpal tunnel syndrome using a regional prospective audit database. Over a 6 year period there were 1564 patients diagnosed with CTS with an annual incidence of 72/100,000 population. There was a significant difference in population incidence of CTS from the most deprived (81/100,000) to the least deprived (62/100,000) (p = 0.003). Functional impairment was higher in the most deprived group compared with the least (DASH 56 vs 48, p = 0.001). The most deprived group exhibited the greatest exposure to occupation vibration (42.7%), and had the greatest risk of bilateral disease (OR = 2.33, p < 0.001). We report an association between socioeconomic deprivation and carpal tunnel syndrome, with the disease being more likely to be bilateral and have a poorer DASH score in the most deprived patients.

Bone grafts and bone substitutes for treating distal radial fractures in adults

BACKGROUND

Surgical treatment of fractures of the distal radius can involve the implantation of bone scaffolding materials (bone grafts and substitutes) into bony defects that frequently arise after fracture reduction.

OBJECTIVES

To review the evidence from randomised controlled trials evaluating the implanting of bone scaffolding materials for treating distal radial fractures in adults.

SEARCH STRATEGY

We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (June 2007), the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE and other databases, conference proceedings and reference lists. No language restrictions were applied.

SELECTION CRITERIA

Randomised or quasi-randomised controlled clinical trials evaluating the use of bone scaffolding for treating distal radial fracture in adults.

DATA COLLECTION AND ANALYSIS

Two people independently selected studies and undertook assessment and data collection.

MAIN RESULTS

Ten heterogenous trials involving 874 adults with generally unstable fractures were grouped into six comparisons. No trial had proven allocation concealment. Four trials (239 participants) found implantation of bone scaffolding (autogenous bone graft (one trial); Norian SRS - a bone substitute (two trials); methylmethacrylate cement (one trial)) improved anatomical outcomes compared with plaster cast alone; and two found it improved function. Reported complications of bone scaffolding were transient discomfort resulting from extraosseous deposits of Norian SRS; with surgical removal of one intra-articular deposit. One trial (323 participants) comparing bone substitute (Norian SRS) versus plaster cast or external fixation found no difference in functional or anatomical outcomes at one year. Statistically significant complications in the respective groups were extraosseous Norian SRS deposits and pin track infection. One trial (48 participants with external fixation) found that autogenous bone graft did not significantly change outcome. There was one serious donor-site complication. One trial (21 participants) found some indication of worse outcomes for hydroxyapatite bone cement compared with Kapandji's intrafocal pinning. Three trials (180 participants) found bone scaffolding (autogenous bone graft (one trial); Norian SRS (one trial); methylmethacrylate cement (one trial)) gave no significant difference in functional outcomes but some indication of better anatomical outcomes compared with external fixation. Most reported complications were associated with external fixation; extraosseous deposits of Norian SRS occurred in one trial. One trial (93 participants with dorsal plate fixation) found autografts slightly improved wrist function compared with allogenic bone material but with an excess of donor site complications.

AUTHORS' CONCLUSIONS

Bone scaffolding may improve anatomical outcome compared with plaster cast alone but there is insufficient evidence to conclude on functional outcome and safety; or for other comparisons.

MRI surveillance after resection for primary musculoskeletal sarcoma

This study reports the experience of one treatment centre with routine surveillance MRI following excision of musculoskeletal sarcoma. The case notes, MRI and histology reports for 57 patients were reviewed. The primary outcome was local tumour recurrence detected on either surveillance MRI in asymptomatic patients, or interval MRI in patients with clinical concern. A total of 47 patients had a diagnosis of soft-tissue sarcoma and ten of a primary bone tumour. A total of 13 patients (22%) had local recurrence. Nine were identified on a surveillance scan, and four by interval scans. The cost of surveillance is estimated to be £4414 per recurrence detected if low-grade tumours with clear resection margins are excluded. Surveillance scanning has a role in the early detection of local recurrence of bone and soft-tissue sarcoma.

Fractures of the distal humeral articular surface

Fractures of the distal humeral articular surface which do not involve the medial and lateral columns are often more extensive than is apparent from plain radiographs. This retrospective study describes the epidemiology of this injury using modern classification systems and compares pre-operative radiography with operative findings. The study group included 79 patients with a mean age of 47 years (13 to 91). The annual incidence was 1.5 per 100,000 population, and was highest in women over the age of 60. The majority of the fractures (59; 75%) were sustained in falls from standing height. Young males tended to sustain more high-energy injuries with more complex fracture patterns. In 24% of cases (19) there was a concomitant radial head fracture. Classification from plain radiographs often underestimates the true extent of the injury and computed tomography may be of benefit in pre-operative planning, especially in those over 60 years of age.

Assessment of a self-administration protocol for extended subcutaneous thromboprophylaxis in lower limb arthroplasty

The risk of venous thromboembolism in patients following arthroplasty may be reduced by continuing chemical thromboprophylaxis for up to 35 days post-operatively. This prospective cohort study investigated the compliance of 40 consecutive consenting patients undergoing lower limb arthroplasty with self-administration of a recommended subcutaneous chemotherapeutic agent for six weeks after surgery. Compliance was assessed by examination of the patient for signs of injection, number of syringes used, and a self-report diary at the end of the six-week period. A total of 40 patients, 15 men and 25 women, were recruited. One woman was excluded because immediate post-operative complications prevented her participation. Self-administration was considered feasible in 87% of patients (95% confidence interval (CI) 76 to 98) at the time of discharge. Among this group of 34 patients, 29 (85%) were compliant (95% CI 73 to 97). Patients can learn to self-administer subcutaneous injections of thromboprophylaxis, and compliance with extended prophylaxis to six weeks is good.

Venous thromboembolism associated with hip and knee replacement over a ten-year period

This population-based study investigated the incidence and trends in venous thromboembolic disease after total hip and knee arthroplasty over a ten-year period. Death or readmission for venous thromboembolic disease up to two years after surgery for all patients in Scotland was the primary outcome. The incidence of venous thromboembolic disease, including fatal pulmonary embolism, three months after surgery was 2.27% for primary hip arthroplasty and 1.79% for total knee arthroplasty. The incidence of fatal pulmonary embolism within three months was 0.22% for total hip arthroplasty and 0.15% for total knee arthroplasty. The majority of events occurred after hospital discharge, with no apparent trend over the period. The data support current advice that prophylaxis should be continued for at least six weeks following surgery. Despite the increased use of policies for prophylaxis and earlier mobilisation, there has been no change in the incidence of venous thromboembolic disease.

A postal survey of current thromboprophylactic practices of consultant orthopaedic surgeons in the treatment of fracture of the hip

Despite increasing scientific investigation, the best method for preventing post-operative deep-vein thrombosis remains unclear. In the wake of the publication of the Pulmonary Embolism Prevention trial and the Scottish Intercollegiate Guidelines Network (SIGN) on the prevention of thromboembolism, we felt that it was timely to survey current thromboprophylactic practices. Questionnaires were sent to all consultants on the register of the British Orthopaedic Association. The rate of response was 62%. The survey showed a dramatic change in practice towards the use of chemoprophylaxis since the review by Morris and Mitchell in 1976. We found that there was a greater uniformity of opinion and prescribing practices in Scotland, consistent with the SIGN guidelines, than in the rest of the UK. We argue in favour of the use of such documents which are based on a qualitative review of current scientific literature.

Congenital colonic atresia: should primary anastomosis always be the goal?

We report 4 cases of the rare condition, congenital colonic atresia, presenting over 9 years. Two patients had dilated loops of bowel noted on routine ante-natal ultrasound. Three had primary anastomosis for lesions in transverse or distal descending colon and one had a staged procedure with colostomy formation. All had type III atresia. One patient had an early leak following primary colo-colic anastomosis for atresia extending from the hepatic flexure to the sigmoid colon. If it is desired to preserve the proximal colon in a right sided lesion with significant loss of colonic length then primary anastomosis may not be safe and we would advocate a staged procedure. Otherwise we would support current moves towards primary anastomosis in this condition. We also urge early investigation in all patients who exhibit intestinal dilatation on antenatal ultrasound.

The provision of services for rural youth with serious emotional and behavioral problems: Virginia's Comprehensive Services Act

The problems of the delivery of mental health and social services to rural children and adolescents encapsulate many of the problems in the larger health care system. Consequently, many of the principles underlying the President's Health Security Plan are applicable to the reformation of this more specialized service system. The experience of the Commonwealth of Virginia in implementing the Comprehensive Services Act (CSA) highlights the scope of vision needed to transform an existing service delivery system into a coordinated system of care on a state-wide scale.

Health education: structural vs. behavioral perspectives

A study of alternative definitions and interpretations of health education in public policy resulted in the identification of a typology of differing perspectives. The two perspectives, behavioral and structural, are described in this paper, along with the three levels of health education programs. The study found: (1) an over-emphasis of public health education policies on individual behavioral changes and (2) a lack of focus in health education programs at the federal level. An analysis was done of the National Consumer Health Information and Health Promotion Act of 1976 to demonstrate these findings. The paper concludes that a balance between the two perspectives is needed, and it offers policy direction to support this conclusion.