The use of shoulder scoring systems and outcome measures in the UK

INTRODUCTION

In future, outcomes following shoulder surgery may be subject to public survey. Many outcome measures exist but we do not know whether there is a consensus between shoulder surgeons in the UK. The aim of this study was to survey the preferred outcome measures used by National Health Service (NHS) shoulder surgeons operating in the UK.

METHODS

A total of 350 shoulder surgeons working in NHS hospitals were asked to complete a short written questionnaire regarding their use of scoring systems and outcome measures. Questionnaires were sent and responses were received by post.

RESULTS

Overall, 217 responses were received (62%). Of the respondents, 171 (79%) use an outcome measure in their shoulder practice while 46 (21%) do not. There were 118 surgeons (69%) who use more than one outcome measure. The Oxford shoulder score was most commonly used by 150 surgeons (69%), followed by the Constant score with 106 (49%), the Oxford shoulder instability score with 82 (38%), and the Disabilities of the Arm, Shoulder and Hand score with 54 (25%). The less commonly used outcome measures were the SF-36® and SF-12® health questionnaires with 19 (9%), the University of California at Los Angeles activity score with 8 (4%), the American Shoulder and Elbow Surgeons shoulder assessment form with 8 (4%) and the EQ-5D™ with 10 (3%). Conclusions Validated outcome measures should be adopted by all practising surgeons in all specialties. This will allow better assessment of treatments in addition to assessment of surgical performance in a transparent way.

Fewer anchors achieves successful arthroscopic shoulder stabilization surgery: 114 patients with 4 years of follow-up

BACKGROUND

The shoulder is the most frequently dislocated joint, with an incidence of 10 to 20 per 100,000 each year. The optimum number of anchors to use in arthroscopic stabilization is a topic of growing interest; most surgeons use 3. Our stabilization technique is to commonly use only a single suture anchor to purse-string the capsulolabral tissue up and toward the glenoid. This study aimed to ascertain whether successful stabilization can be achieved with fewer than 3 anchors.

METHODS

Our study comprised 114 consecutive patients with anterior instability and a Bankart lesion undergoing arthroscopic stabilization with 4 years of follow-up. Outcome was measured by Oxford Instability Score (OIS) and recurrence of instability or dislocation. Patient demographics were 86.8% male, 13.2% female, mean age of 31 years, 76.3% Hill-Sachs lesions, 13.2% bony Bankart lesions, 13.2% glenoid defects, and 9.6% SLAP lesions. The majority of patients, 71 patients (62.3%), received only 1 anchor; 40 patients (35.1%) received 2 anchors, and 3 patients (2.6%) had 3 anchors.

RESULTS

The mean OIS was 44.3 preoperatively and 17.3 postoperatively (P < .0001). There was no difference in OIS improvement between the patients who received a single anchor and those who received 2 or 3 anchors (P > .05). Even with minor bony Bankart lesions and glenoid defects, a single suture anchor can be sufficient. Our failure rate of 6.1% is comparable with that of other published series.

CONCLUSION

Successful shoulder stabilization can be achieved with fewer than 3 anchors, and a single anchor is usually sufficient.

Titanium elastic stable intramedullary nailing of displaced midshaft clavicle fractures: A review of 38 cases

INTRODUCTION

Clavicle fractures accounting for 3 to 5% of all adult fractures are usually treated non-operatively. There is an increasing trend toward their surgical fixation. The aim of our study was to investigate the outcome following titanium elastic stable intramedullary nailing (ESIN) for midshaft non-comminuted clavicle fractures with >20 mm shortening/displacement.

MATERIALS AND METHODS

A total of 38 patients, which met inclusion criteria, were reviewed retrospectively. There were 32 males and six females. The mean age was 27.6 years. The patients were assessed for clinical/radiological union and by Oxford Shoulder and QuickDASH scores. 71% patients required open reduction.

RESULTS

100% union was achieved at average of 11.3 weeks. The average follow-up was 12 months. The average Oxford Shoulder and QuickDASH scores were 45.6 and 6.7, respectively. 47% patients had nail removal. One patient had lateral nail protrusion while other required its medial trimming.

CONCLUSION

In our hands, ESIN is safe and minimally invasive with good patient satisfaction, cosmetic appearance, and overall outcome.

An anatomical way of treating ankle syndesmotic injuries

Treatment of tibiofibular syndesmotic ankle injury remains controversial in regard to the best method, although surgeons agree that the goal of treatment is reduction and operative stabilization. Ideally, the implant should stabilize the syndesmosis and allow physiologic micromotion and early mobilization, and conventional screws are limited in this regard. We reviewed use of the Ankle TightRope(®) fixation device for repair of syndesmotic injuries. From April to September 2006, 16 patients with evidence of syndesmotic injury were treated by means of ankle fracture open reduction with internal fixation, combined with use of the Ankle TightRope(®) device for repair of the syndesmosis. The mean age of the 16 patients was 36.6 ± 16.71 (range 15 to 69) years; they were followed up for at least 2 years. Mean follow-up duration was 26 ± 3.94 (range 24 to 38) months. The mean American Orthopaedic Foot and Ankle Society score at 2-year follow-up was 86.88 ± 11.49 (range 48 to 100). The mean time to full weight-bearing was 4.5 ± 0.87 weeks. Two (12.5%) patients had postoperative superficial wound infections, each of which was treated with oral antibiotics. One (6.25%) patient had the TightRope(®) removed because of irritation from the knot. There was no failure of syndesmotic fixation, despite early weight-bearing in the postoperative phase. The results of this case series indicate that tibiofibular syndesmosis repair with the Ankle TightRope(®) yields satisfactory results.

Intramedullary nailing for displaced proximal humeral fractures

PURPOSE

To evaluate outcomes of 28 patients who underwent intramedullary nailing for displaced proximal humeral fractures.

METHODS

24 women and 4 men aged 38 to 87 (mean, 65) years underwent intramedullary nailing for displaced proximal humeral fractures. 17 (61%) of them were aged >70 years. Fractures were classified into 2-part (n = 8), 3-part (n = 17), and 4-part (n = 3), and corresponded to AO 11 A3 (n = 8), B1 (n = 3), B2 (n = 9), and C2 (n = 8) types. The Constant and Oxford scores were assessed at the final follow-up.

RESULTS

All patients had bone union except for one who had tuberosity failure. 23 (82%) patients had satisfactory-to-excellent and 5 had poor Constant scores; outcomes were worse with more complex fractures. 20 (71%) patients had satisfactory Oxford scores. Seven (25%) patients had impingement of a nail tip. Other complications included avascular necrosis (n = 1), proximal locking screw back-out (n = 1), and screw penetration into the joint (n = 1).

CONCLUSION

Intramedullary nailing provides a stable fixation with minimal soft tissue dissection for displaced proximal humeral fractures. It enables early mobilisation and functional recovery.

Mid-term clinical and sonographic outcome of arthroscopic repair of the rotator cuff

We have conducted a prospective study to assess the mid-term clinical results following arthroscopic repair of the rotator cuff. Patients were evaluated using the Constant score, subjective satisfaction levels and post-operative ultrasound scans.

Of 115 consecutive patients who underwent arthroscopic repair of the rotator cuff at our institution, 102 were available for follow-up. The mean period of follow-up was for 35.8 months (24 to 73). The mean age of the patients was 57.3 years (23 to 78). There were 18 small (≤ 1 cm in diameter), 44 medium (1 cm to 3 cm in diameter), 34 large (3 cm to 5 cm in diameter) and six massive (> 5 cm in diameter) tears. There was a statistically significant increase in the size of the tear with increasing age (p = 0.0048).

The mean pre-operative Constant score was 41.4 points (95% confidence interval, 37.9 to 44.9), which improved to 84.5 (95% confidence interval, 82.2 to 86.9). A significant inverse association (p = 0.0074), was observed between the size of the tear and the post-operative Constant score, with patients having smaller tears attaining higher Constant scores after repair. Post-operatively, 80 patients (78.4%) were able to resume their occupations and 84 (82.4%) returned to their pre-injury leisure activities. Only eight (7.8%) of 102 patients were not satisfied with the outcome.

Recurrent tears were detected by ultrasound in 19 (18.6%) patients, and were generally smaller than the original ones. Patients with recurrent tears experienced a mean improvement of 31.6 points (95% confidence interval, 23.6 to 39.6) in their post-operative Constant scores. Those with intact repairs had significantly improved (p < 0.0001) Constant scores (mean improvement 46.3 points, 95% confidence interval, 41.9 to 50.6). Patient satisfaction was high in 94 cases (92%), irrespective of the outcome of the Constant score. Recurrent tears appear to be linked to age-related degeneration.

Arthroscopic repair of the rotator cuff leads to high rates of satisfaction (92%) and good functional results, albeit with a recurrence rate of 18.6% (19 of 102).

Measurement of blood flow in the rotator cuff using laser Doppler flowmetry

The aim of this study was to define the microcirculation of the normal rotator cuff during arthroscopic surgery and investigate whether it is altered in diseased cuff tissue. Blood flow was measured intra-operatively by laser Doppler flowmetry. We investigated six different zones of each rotator cuff during the arthroscopic examination of 56 consecutive patients undergoing investigation for impingement, cuff tears or instability; there were 336 measurements overall. The mean laser Doppler flowmetry flux was significantly higher at the edges of the tear in torn cuffs (43.1, 95% confidence interval (CI) 37.8 to 48.4) compared with normal cuffs (32.8, 95% CI 27.4 to 38.1; p = 0.0089). It was significantly lower across all anatomical locations in cuffs with impingement (25.4, 95% CI 22.4 to 28.5) compared with normal cuffs (p = 0.0196), and significantly lower in cuffs with impingement compared with torn cuffs (p < 0.0001). Laser Doppler flowmetry analysis of the rotator cuff blood supply indicated a significant difference between the vascularity of the normal and the pathological rotator cuff. We were unable to demonstrate a functional hypoperfusion area or so-called 'critical zone' in the normal cuff. The measured flux decreases with advancing impingement, but there is a substantial increase at the edges of rotator cuff tears. This might reflect an attempt at repair.

Arthroscopic capsular release for posttraumatic shoulder stiffness

Severe pain and shoulder stiffness after soft tissue trauma or fracture is a major cause of dysfunction. Some patients may have residual, resistant, significant shoulder stiffness that causes long-term functional impairment. This study reports the results of arthroscopic capsular release in 21 patients who presented with posttraumatic stiff shoulders resistant to nonoperative therapy. They underwent arthroscopic circumferential capsular and subacromial release of adhesions under interscalene block, followed with immediate regular physiotherapy. A highly significant improvement in the range of motion (ROM) was achieved immediately postoperatively (P < .0001). At 6 months, a mean 48% of the ROM gain was lost. Thereafter, ROM steadily improved to a mean net gain of 110% compared with the immediate postoperative time (mean follow-up, 33 months). Most patients (95%) expressed satisfaction with their outcome. Arthroscopic capsular release is a useful treatment for resistant posttraumatic stiff shoulder, particularly to alleviate of pain and restore a functional ROM.

Peripheral paresthesia in patients with subacromial impingement syndrome

INTRODUCTION

Some patients presenting with subacromial impingement syndrome complain of tingling and numbness radiating to hand. In the current literature, there is no description of such paresthesia being a part of the clinical picture of impingement syndrome.

OBJECTIVE

This observational study aimed at looking whether these symptoms resolve with successful arthroscopic decompression of the impingement.

MATERIAL AND METHODS

One hundred consecutive patients undergoing arthroscopic surgery were enlisted for the study.

RESULTS

Fifty-four percent reported paresthesia during the course of the shoulder problem (63% of them had radial sided symptoms, 29.6% ulnar-sided symptoms and 7.4% involving all fingers). Significant association was observed between the occurrence of paresthesia and worst pain levels (P = 0.0053), age of the patient (P = 0.0104) and the acromial impingement grade (P = 0.0377). Nerve conduction studies done in seven patients (with paresthesia) selected by systematic random sampling did not show any significant attributable entrapment neuropathy. Up to 12 months follow-up, 48 of 54 (88%) had complete relief of pain and paresthesia and 50 (92.5%) were satisfied.

CONCLUSION

Some patients with subacromial impingement syndrome report associated peripheral paresthesia radiating to hand, which is strongly associated with the age, pain level and the grade of impingement. In most (88%) of such cases, these symptoms are relieved after treatment of the impingment lesion. The incidence and aetiology of such paresthesia is the subject of further studies.

Early experience with the PlantTan Fixator Plate for 2 and 3 part fractures of the proximal humerus

This study reports the early results for clinical and radiological outcome of fixation of completely displaced or grossly angulated (>90 degrees ) 2 and 3 part fractures of the proximal humerus using the PlantTan Fixator Plate (Medizentechnik, Aachen, Germany). Using a deltopectoral approach the humeral head articular fragment was reduced onto the humeral shaft and fixed with the implant, tuberosity fragments were held with transosseous sutures. Early passive, progressing to active, physiotherapy was instituted from the first postoperative day. No other fixation or bone graft was used. In 15 patients, with 16 injured shoulders and an average age of 63 years the mean follow up was 17 months. As a percentage of the normal side the Constant-Murley score for those patients retaining the implant was mean 74% (range 36%-100%). There were six shoulders with score >80% (Good), four shoulders with score between 60 and 79% (Satisfactory) and four shoulders <60% (Poor). Four shoulders (all in patients over the age of 70 years), developed avascular necrosis. Of these, one patient underwent shoulder replacement hemiarthroplasty and one patient underwent removal of the implant. We have demonstrated functional outcome similar to other modes of internal fixation in patients under 70 years. It cannot be recommended for elderly patients (over 70 years) as it is associated with a high incidence of avascular necrosis and fixation failure.

An easy and accurate preoperative method for determining tibial nail lengths

Estimating the correct nail length for solid tibial nails can be problematic. Most techniques reported in the literature for determining tibial nail length are not accurate. In a retrospective study of 16 patients in our unit, only three had ideal nail sizes. In these patients, as part of phase I of our study, we measured their normal leg's length from knee joint line to ankle joint line. An ideal nail length for each of these patients was estimated from a whole length radiograph of the nailed tibia. Comparing these two data, we found that deducting 20 mm from the leg measurement gave appropriate nail lengths. We also compared this with three other anthropometric measurements; tibial tuberosity to medial malleolus, joint line to medial malleolus and olecranon to head of V metacarpal head distance. The joint line to joint line measurement was the most reliable and showed the best correlation with ideal nail lengths (0.982). In phase II, a prospective study on 15 patients, we used the joint line to joint line measurement to determine nail sizes. A postoperative review of the radiographs showed all the nails to be of adequate length. This strengthened the fact that the joint line to joint line measurement is the most accurate and easy method to determine tibial nail lengths.

The influence of age on outcome after operation for the carpal tunnel syndrome

Decompression of the carpal tunnel is a common surgical procedure. Although the incidence of the carpal tunnel syndrome increases with age, there is no clear information available on the outcome of surgery in relation to age. We studied prospectively 87 consecutive patients who underwent decompression, using a validated self-administered questionnaire, and found that improvement in symptoms and function decreased with increasing age. This was most marked in patients over the age of sixty years.

The influence of age on outcome after operation for the carpal tunnel syndrome. A prospective study

Decompression of the carpal tunnel is a common surgical procedure. Although the incidence of the carpal tunnel syndrome increases with age, there is no clear information available on the outcome of surgery in relation to age. We studied prospectively 87 consecutive patients who underwent decompression, using a validated self-administered questionnaire, and found that improvement in symptoms and function decreased with increasing age. This was most marked in patients over the age of sixty years.

Extending fixation beyond the working length of an intramedullary nail with a linked intramedullary and extramedullary fixation in complex femoral fractures; a brief series

We report the use of a fixed-angle side-plate device linked to an intramedullary nail in the femur with the interlocking screws applied through the plate. The 95 degrees device extends the effective length of the nail and increases the stability of the fixation. This technique is one of various adaptations that can be recommended to stabilise a complex combination of femoral fractures. This is a report of four such patients.