Trends in the surgical management of proximal humerus fractures in Ireland from 2009 to 2022: An increasing usage of reverse shoulder arthroplasty

BACKGROUND

Proximal humeral fractures are a common injury accounting for a significant workload across orthopaedic departments. Though often managed non-operatively, surgical management is indicated for a proportion of patients.

AIMS

The aim of this study is to examine the trends in the management of proximal humeral fractures within Ireland over the past 13 years.

METHODS

A retrospective review of Irish Hospital In-Patient Enquiry (HIPE) data was performed between January 2009 and December 2022. Information regarding demographics including age and gender, along with procedure type were collated after patients with proximal humerus fractures, were identified using relevant ICD 10 codes.

RESULTS

Demographic details remained stable with females and those within the 55-69 year age bracket accounting for the highest proportion of patients. The mean annual number of procedures performed across the study period was 365 (273-508), with an increase from 288 cases in 2009 to 441 in 2022. Open reduction and internal fixation were the most common procedures accounting for 76.4% of cases. There has been a rising usage of total shoulder arthroplasty for fixation with an increase from < 5 cases in 2016 to 84 in 2022. A decrease in the usage of hemiarthroplasty and closed reduction internal fixation was also observed.

CONCLUSIONS

There has been an increasing volume of operatively managed proximal humeral fractures in Ireland, which sustained despite the 2015 publication of the highly publicised PROPHER trial. The increasing utilisation of total shoulder arthroplasty in acute trauma management is notable and necessitates appropriate training for trauma theatre personnel.

The clinical utility of immediate post-operative PACU plain film radiographs following uncomplicated open Latarjet procedure - An institutional series of consecutive patients

Background

Immediate post-operative plain film radiograph x-rays in PACU following open Latarjet procedure are often ordered as routine. However, such radiographs utilize institutional cost and time, whilst potentially exposing patients to often-unnecessary additional radiation. This study sought to evaluate whether routine immediate post-operative radiographs following uncomplicated open Latarjet procedures impacted clinical decision-making in our institution.

Methods

From 2017 to 2020, patients who underwent open Latarjet procedure by one of four fellowship-trained upper limb surgeons at a single institution were included in this study. Post-operative radiographs taken immediately in PACU were reviewed to determine if any reported radiographic findings impacted on clinical decision-making in the immediate post-operative setting. SPSS was used for descriptive statistics.

Results

A total of 337 patients underwent an X-ray in PACU immediate after uncomplicated open Latarjet procedure. Overall, 98.5% were male (n = 332), the mean patient age of included patients was 22.9 ± 4.2 years. No patient had an abnormal finding on their post-operative x-ray. Two patients returned to the operating room in the immediate post-operative period, both requiring washout and debridement due to haemtoma or superficial wound infection.

Conclusion

The findings of this study suggest that the use of post-operative plain films in PACU following open Latarjet procedure remains a costly use of resources, with little ultimate impact on clinical decision making in the short-term post-operatively.

Level of Evidence

IV - Institutional Case Series of Consecutive Patients.

Shoulder arthroplasty in the setting of previous stabilization surgery: a systematic review of matched case control studies at minimum 2 years follow-up

Background

Anterior shoulder instability causes considerable patient morbidity and the volume of shoulder stabilization surgery being performed annually is rising. Despite stabilization surgery, instability arthropathy in the long-term may arise requiring consideration of shoulder arthroplasty. This study evaluated the outcomes of shoulder arthroplasty following previous stabilization surgery with their associated changes in bony anatomy or soft tissue structure.

Methods

A systematic review was performed as per Preferred Reporting Items for Systematic Review and Meta-Analysis guidelines to identify all studies reporting outcomes of shoulder arthroplasty in the setting of previous stabilization surgery. Studies of >10 patients with a minimum of 24 months follow-up were included.

Results

Overall, 377 shoulder arthroplasties composed of 247 anatomical total shoulder arthroplasties (aTSAs), 102 reverse total shoulder arthroplasties (RTSAs), and 28 hemiarthroplasties (HAs) were reported across 14 included studies at mean age 55.4 years, with 203 compared to 451 control shoulders in 7 matched case-control studies. The mean interval from arthroplasty to stabilization procedure was 19.7 years, with 27.2% of patients having undergone multiple procedures and 39.5% bone transfer procedures. Improvements in patient outcomes were observed both for patients who had underwent aTSA or RTSA, with the American Shoulder and Elbow Surgeons score the most commonly used scoring system. Across matched studies comparing to control, large improvements in American Shoulder and Elbow Surgeons were seen for both aTSA and RTSA implants, 38.1-80.5 and 34.9-82.3, which compared to control groups 38.0-85.5 and 35.5-82.3, respectively. There were differences observed in complication profiles between aTSA and RTSA procedures, with lower revision rates in the short-term to medium-term for RTSA implants in present literature. A significantly higher rate of aTSA revision was observed compared to matched control patients undergoing aTSA for primary osteoarthritis without previous stabilization surgery, 9.4% (13/139) vs. 4.1% (11/269) (P = .044). Aseptic loosening posed a particular challenge in the aTSA group, with significantly higher rates of 5.0% (7/139 f = 54.6 months) compared to control 0.74% (2/269 f = 49.1 months, P = .0088). No significant difference in infection rate was observed between matched study and control groups, 1.5% vs. 2.2% (P = .76).

Conclusion

Shoulder arthroplasty may improve functional outcomes for patients experiencing instability arthropathy with a history of stabilization surgery. Careful consideration of potential complications is warranted both in surgical planning and patient counselling given the altered anatomy and biomechanics, with significantly higher revision and loosening rates observed following aTSA compared to control.

Locking plate external fixation and negative pressure wound therapy for treatment of a primary infection in a closed clavicle fracture

Infection in a clavicle fracture is uncommon, but remains a challenging problem. A paucity of soft tissue coverage often combined with significant displacement and interfragmentary movement add complexity to an already difficult situation for effective infection treatment. External fixation in principle offers a means of achieving fracture stability, while the infection is being eradicated. We present the case of a closed clavicle fracture, initially treated conservatively, that presented 5 weeks later with infection. The fracture was definitively treated with external fixation using a locking plate positioned superficially to the skin, plus negative pressure wound therapy and subsequent secondary closure and antibiotic therapy. This case illustrates a novel method of treatment in this unusual presentation that was well tolerated by the patient and resulted in a good clinical outcome.

Availability of accessible and high-quality information on the Internet for patients regarding the diagnosis and management of rotator cuff tears

BACKGROUND

In the era of informed patient decision-making, educated patients are vital contributors. The Internet provides a vast information source that patients will access. It is imperative that this information be relevant and understandable. Various treatments, each with advantages and disadvantages, are available. We sought to examine the standard of information about the diagnosis and management of rotator cuff tears available to patients on the Internet.

METHODS

We identified 125 websites from searching "rotator cuff tear" in the 5 most popular Internet search engines. The websites were examined for readability by measuring the Flesch Reading Ease Score, the Flesch-Kincaid Grade Level, and the Gunning Fog Index. The quality of the websites was measured by the DISCERN instrument, the Journal of the American Medical Association benchmark criteria, and Health on the Net Foundation certification.

RESULTS

There were 59 individual URLs analyzed. Overall, the quality was poor, with the average DISCERN score being only 39.47. Furthermore, the mean reading grade level was above 9 (recommended level, 6). Health on the Net Foundation certification did correspond to significantly worse readability scores (P = .004) but did not correlate with improved DISCERN scores. Those that satisfied more of the Journal of the American Medical Association benchmark criteria had significantly better DISCERN scores (P < .001).

CONCLUSION

Information about rotator cuff tears is of a low standard and is in many cases written at too high a level for the general population. There are instruments of which we, as surgeons, must be aware to evaluate the resources available and to recommend them to patients to ensure that they understand their condition and treatment options.

Radial head replacement with pyrocarbon prosthesis: early clinical results

BACKGROUND

Comminuted radial head fractures are challenging to treat with open reduction and internal fixation. Radial head arthroplasty is a favourable technique for the treatment of complex radial head fractures. The purpose of this study was to evaluate the functional and radiological outcomes of radial head arthroplasty using modular pyrocarbon radial head prosthesis.

METHODS

We retrospectively reviewed 21 consecutive patients requiring radial head arthroplasty for unreconstructible radial head fractures between July 2003 and July 2009. Patients completed a Short Form-36 (SF-36), the Disabilities of the Arm, Shoulder and Hand questionnaire, and the Mayo Elbow Performance Index. Patients were independently physically examined and their post-operative radiographs were reviewed.

RESULTS

Twenty-one patients (nine males and 12 females) were reviewed at a minimum of 12 months follow-up. The mean Disabilities of the Arm, Shoulder and Hand score was 10.8 (0-34.1), mean SF-36 physical score was 76.9 (35-96), mean SF-36 mental score was 83.8 (60-94), and their Mayo Elbow Performance Index score was 86.4 (70-100). Patients maintained 90% of their grip strength when compared with their uninjured arm and had 17.5° of fixed flexion in the affected arm. Radiologically, 14 cases had some degree of post-traumatic osteoarthritis, 12 cases had evidence of heterotrophic ossification, five had some evidence of periprosthetic lucency and three patients were radiologically, but not functionally 'overstuffed'.

CONCLUSION

Radial head arthroplasty with pyrocarbon radial head prosthesis is an acceptable option when treating unreconstructable radial head fractures yielding good functional and radiological outcomes.

The 25 most cited articles in arthroscopic orthopaedic surgery

PURPOSE

The purpose of this study was to use Web of Knowledge to determine which published arthroscopic surgery-related articles have been cited most frequently by other authors by ranking the 25 most cited articles. We furthermore wished to determine whether there is any difference between a categorical "journal-by-journal" analysis and an "all-database" analysis in arthroscopic surgery and whether such a search methodology would alter the results of previously published lists of "citation classics" in the field. We analyzed the characteristics of these articles to determine what qualities make an article important to this subspecialty of orthopaedic surgery.

METHODS

Web of Knowledge was searched on March 7, 2011, using the term "arthroscopy" for citations to articles related to arthroscopy in 61 orthopaedic journals and using the all-database function. Each of the 61 orthopaedic journals was searched separately for arthroscopy-related articles to determine the 25 most cited articles. An all-database search for arthroscopy-related articles was carried out and compared with a journal-by-journal search. Each article was reviewed for basic information including the type of article, authorship, institution, country, publishing journal, and year published.

RESULTS

The number of citations ranged from 189 to 567 in a journal-by-journal search and from 214 to 1,869 in an all-database search. The 25 most cited articles on arthroscopic surgery were published in 11 journals: 8 orthopaedic journals and 3 journals from other specialties. The most cited article in arthroscopic orthopaedic surgery was published in The New England Journal of Medicine, which was not previously identified by a journal-by-journal search.

CONCLUSIONS

An all-database search in Web of Knowledge gives a more in-depth methodology of determining the true citation ranking of articles. Among the top 25 most cited articles, autologous chondrocyte implantation/transplantation is currently the most cited and most popular topic in arthroscopic orthopaedic surgery and research.

CLINICAL RELEVANCE

Analysis of the 25 most cited articles allows us to identify the most popular field of research in arthroscopic orthopaedic surgery and gives us insight into the quality and characteristics that are required for an article to become highly cited.

A cadaveric model for suprascapular nerve injury during glenoid component screw insertion in reverse-geometry shoulder arthroplasty

BACKGROUND

Reverse-geometry shoulder replacement requires fixation of a baseplate (called a metaglene) to the glenoid, to which a convex glenosphere is attached. Most systems use screws to achieve this fixation. The suprascapular nerve passes close to the glenoid and is known to be at risk of injury when devices and sutures are inserted into the glenoid. We investigate the risk posed to the suprascapular nerve by placement of metaglene fixation screws.

MATERIALS AND METHODS

Ten cadaveric shoulder specimens were used. A metaglene was inserted and fixed by use of 4 screws. The suprascapular nerve was dissected and its branches identified. The screw tips and their proximity to the nerve and branches were identified and recorded.

RESULTS

The superior and posterior screws posed the most risk to the suprascapular nerve. The nerve was engaged by the posterior screw on 4 occasions and was within 5 mm of the nerve or a branch of it in 5 others. The superior screw was extraosseous on 4 occasions, making contact with the nerve in 3 of those 4 specimens and being within 2 mm of it in the fourth specimen.

CONCLUSION

Metaglene fixation with screws poses a significant risk to the suprascapular nerve. Caution should be used when inserting the posterior and superior screws in particular. Short locking screws may allow adequate fixation while minimizing the risk of neurologic injury.

Free-hand versus novel specialised jig guidance for the passing of intramedullary wires in olecranon fracture fixation: a comparative study

The treatment of olecranon fractures frequently involves the use of tension-band fixation. Although associated with high union rates, this method has a high incidence of morbidity associated with soft tissue compromise and limitation of range of movement requiring frequent re-operation for removal of metal. We describe the use of a simple jig to ensure intramedullary placement of longitudinal K-wires and compare the accuracy of placement of Kirschner (K)-wires using this device with the traditional free-hand method. We found the distance from the centre of the medullary canal, the range and standard deviations of K-wire positions to be significantly more precise when the jig was used. This has applications for the use of the device, both with standard metallic radio-opaque wires and potentially with bio-absorbable pins.

Popliteal angle as an indicator for successful closed reduction of developmental dysplasia of the hip

PURPOSE

To evaluate the use of the popliteal angle as an indicator for successful closed reduction of developmental dysplasia of the hip (DDH) in children with delayed presentation.

METHODS

29 patients aged 6 to 18 months underwent successful closed reduction for unilateral DDH under general anaesthesia. Using a graduated goniometer, the popliteal angle was measured with the hip abducted within the safe zone (to avoid redislocation and injury to the femoral capital epiphysis) before and after reduction and after 6 weeks of spica casting.

RESULTS

The mean popliteal angles before and after reduction and after 6 weeks of spica casting were 5.1, 37.5, and 17.9 degrees, respectively (p<0.0001, paired t test). Because of discomfort, the spica casts were altered in 3 patients (2 at week 1 and one at week 3).

CONCLUSION

Reduction of the hip in DDH results in an increased popliteal angle of >20 degree. This may be used to indicate the diagnosis and safe closed reduction.

Anti-biofilm activity of sub-inhibitory povidone-iodine concentrations against Staphylococcus epidermidis and Staphylococcus aureus

Biomaterial-related infections continue to hamper the success of reconstructive and arthroplasty procedures in orthopaedic surgery. Staphylococci are the most common etiologic agents, with biofilm formation representing a major virulence factor. Biofilms increase bacterial resistance to antimicrobial agents and host immune responses. In staphylococci, production of polysaccharide intercellular adhesin (PIA) by the enzyme products of the icaADBC operon is the best understood mechanism of biofilm development, making the ica genes a potential target for biofilm inhibitors. In this study we report that the antibacterial agent povidone-iodine (PI) also has anti-biofilm activity against Staphylococcus epidermidis and Staphylococcus aureus at sub-inhibitory concentrations (p < 0.001). Inhibition of biofilm by PI correlated with decreased transcription of the icaADBC operon, which in turn correlated with activation of the icaR transcriptional repressor in Staphylococcus epidermidis. These data reveal an additional therapeutic benefit of PI and suggest that studies to evaluate suitability of PI as biomaterial coating agent to reduce device-related infections are merited.

Increasing financial burden of revision total knee arthroplasty

We reviewed the peri-operative and financial data of patients who underwent revision total knee arthroplasty in our institution between 1997 and 2006. The aims were to compare difference in cost between aseptic and septic cases and to identify the sources of preventable cost increase in revision knee procedure. The study group comprised 117 women (65%) and 62 men (35%). The median age of patients decreased from 73 years (37-83 years) in 1997-2001 to 70 years (15-91 years) in 2002-2006, a decline of 4% (P < 0.05). The mean ASA scores also dropped from 3 to 2 between the two periods. Despite this, the mean total cost of revision knee procedure continued to increase. Patients undergoing revision arthroplasty because of infection had much higher (P = 0.0001) cost compared to their aseptic counterpart. Increase in the costs of investigations (P < 0.05) and implant (P < 0.05) was the major contributing factors. The cost of implants increased by 32-35% (P < 0.05) depending on implant selection. Changing demographics will increase the requirement for this surgery and thus increase its overall cost to society. Cost increases associated with unnecessary investigations, prolonged hospital stay and use of expensive implants should be avoided.

Hydrogen peroxide induced repression of icaADBC transcription and biofilm development in Staphylococcus epidermidis

Expression of the icaADBC-encoded polysaccharide intercellular adhesion by Staphylococcus epidermidis promotes biofilm formation and represents an important virulence factor in biomaterial-related infections following orthopedic surgery. Biofilm development by the pathogen can be viewed as a protective reaction to environmental stressors including osmotic stress, thermal stress, and antimicrobial chemotherapy. Oxidative stress, arising from the release of toxic oxygen radicals by polymorphonuclear cells, is encountered by bacteria entering the body perioperatively. Evasion of this and other cell-mediated immune responses by pathogenic bacteria plays an important role in the development of chronic biomaterial-related infection. Here we investigated the impact of sublethal oxidative stress induced by H2O2 (<18 mM) on S. epidermidis biofilm formation. S. epidermidis grown in brain heart infusion (BHI) media supplemented with 5 mM H2O2 or 10 mM H2O2 formed significantly less biofilm (p < 0.01 and p < 0.001, respectively) than bacteria grown in BHI alone. Consistent with this, using reverse transcription-polymerase chain reaction expression of the ica locus was also shown to be reduced by subinhibitory concentrations of H2O2. Furthermore, diminished ica operon expression correlated with increased expression of icaR, which encodes a repressor of icaADBC. Thus, these data suggest that mild oxidative stress downregulates biofilm development by S. epidermidis and may have potential in a therapeutic context.