BESS ABSTRACT- PODIUM

GLENOID RECONSTRUCTION USING BONE GRAFTING DURING REVERSE SHOULDER ARTHROPLASTY – A COHORT STUDY WITH MINIMUM 2 YEARS FOLLOW-UP

Authors: Acquaah F, Fontalis A, Desai A, Rudge W, Majed A, Higgs D, Butt D, Falworth M

Main Institution: Shoulder and Elbow Unit, Royal National Orthopaedic Hospital

Introduction: Management of large glenoid defects poses a surgical challenge in reverse shoulder arthroplasty. We present our experience of morselised and structural bone grafting with a monobloc glenoid baseplate that is secured by a centralised bone screw, allowing for compression, and four peripheral locking screws.

Methods: We retrospectively reviewed all patients who underwent shoulder arthroplasty at our institution using the Reverse Shoulder Prosthesis (RSP, DJO Global), where the glenoid was augmented with bone graft. Pre and post-operative outcome measures included; range of shoulder movement, Single Assessment Numeric Evaluation (SANE) score, Oxford Shoulder Score (OSS), EQ-5D and numerical pain score (0-10).

Results: We identified 60 patients with a mean age of 66±10.7 years. Primary arthroplasty was performed in 15(25%) and revision in 45(75%). The mean follow-up duration was 33 months. Morselised allograft was used in 24(40%) patients, morselised autograft was used in 11(18.3%), structural allograft was used in 10(16.7%), and structural autograft was used in 15(25%). Baseline pre-operative characteristics with respect to range of shoulder movement, SANE, OSS and pain were significantly worse in patients who received structural bone graft compared to morselised bone graft; reflecting the severity of their glenoid bone loss. Participants experienced statistically significant improvements in all outcome measures (

Conclusion: The use of a monoblock glenoid baseplate, with compression and locking screws, combined with both morselised and structural bone graft can be used to successfully address glenoid defects during reverse shoulder arthroplasty. Clinical outcomes are encouraging with significant improvements in subjective outcome measures, and complication rates comparable to other published series.

MID-TERM RESULTS OF THE ARTHREX ECLIPSE TOTAL SHOULDER ARTHROPLASTY

Authors: Batten TJ, Gallacher S, Evans JP, Harding RJ, Kitson J, Smith CD, Thomas WJ

Main Institution: Shoulder & Elbow Unit, Department of Trauma & Orthopaedic Surgery, Princess Elizabeth Orthopaedic Centre, Royal Devon & Exeter Hospital

Aim: The use and selection of stemless humeral components in anatomical shoulder arthroplasty has expanded since their introduction, but independent mid-term results are lacking. This study reviews the outcomes of a consecutive series of 146 Eclipse stemless shoulder prostheses for all indications with a minimum 5 years (5-10) follow-up.

Methods: Procedures undertaken for all indications were reviewed for outcomes. The primary outcome was Oxford Shoulder Score (OSS) at minimum 5 years. Secondary outcomes were range of movement and radiographic analysis of humeral radiolucency, rotator cuff failure and glenoid loosening.

Results: Mean OSS was 40, with no statistically significant difference by indication for implantation (p=0.17) or time dependent change between 2 years and 5 years (p=0.19). Range of movement significantly improved compared to pre-operative assessments and did not deteriorate between 2 and 5 years. Average external rotation was 38O and forward elevation of 151O. A radiolucent line was present in 26% of humeral components. The majority were incomplete, less than 2mm and in a single anatomical zone. No humeri were loose. A radiolucent line was present in 15% of glenoid components, of which 10% of components had failed. 15% had evidence of rotator cuff failure. Average time to either failure was more than 3 years post implantation. Survivorship was 96.6% at 5 years and 94.4% at 7 years. This compares favourably to best available results taken from both the Australian joint registry and the UK NJR.

Conclusion: Functional and radiographic outcomes of the Eclipse stemless total shoulder replacement are excellent with no humeral implant loosening at minimum 5 years follow-up. The presence of radiolucent lines are of interest and require long term observation, but have not so far impacted clinical results. Where revision is undertaken this is predominantly for glenoid and rotator cuff failure.

MIX AND MATCH IN ANATOMICAL TOTAL SHOULDER ARTHROPLASTY

Authors: Batten TJ, Gallacher S, Jones ADR, Evans JP, Kitson J, Smith CD, Thomas WJ,

Main Institution: Shoulder & Elbow Unit, Department of Trauma & Orthopaedic Surgery, Princess Elizabeth Orthopaedic Centre, Royal Devon & Exeter Hospital

Background: The use of implants from different manufacturers to create an arthroplasty construct is termed as mix and match. The practise could be considered “off licence” and may invalidate the manufacturer's guarantee. However, evidence investigating the outcomes of this practice is lacking. We aim to compare clinical and radiological outcomes of 2 patient cohorts, undergoing anatomical total shoulder arthroplasty (TSA) with either a mixed manufacturer construct or matched construct.

Materials and Methods: A retrospective review of data collected prospectively of 2 groups of 32 consecutive patients was undertaken. One group received a mixed construct utilising the Arthrex Eclipse stemless humeral prosthesis and the Tornier Aequalis flat-backed keeled polyethylene glenoid. This was compared to 32 patients receiving a matched TSA utilising the Eclipse humerus with the curved back Arthrex keeled glenoid. Clinical review was undertaken at minimum of 5 years following surgery. Primary outcome was the Oxford Shoulder Score (OSS), with survivorship, radiographic glenoid loosening and rotator cuff failure as secondary outcomes.

Results: There was no statistically significant difference (p=0.43) in mean OSS between the groups at minimum 5 year follow-up (matched = 40.3 (95% CI 36.8-43.8), mixed = 39.9 (95% CI 36.3-43.5)). One patient in each group underwent revision with identical 5-year survivorship between groups. There was no statistically significant difference in rates of rotator cuff failure and glenoid loosening between the construct groups.

Conclusion: The mix and match use of an Arthrex Eclipse humerus with a Tornier keeled polyethylene glenoid, does not infer any inferiority compared to an Arthrex Eclipse humerus and Arthrex keeled polyethylene glenoid in this study.

SURVIVAL OF THE DELTA-III REVERSE SHOULDER ARTHROPLASTY AT A MINIMUM 15-YEAR FOLLOW-UP - A CLINICAL AND RADIOGRAPHIC STUDY

Authors: Batten TJ, Evans JP, Smith CD

Main Institution: Shoulder & Elbow Unit, Department of Trauma & Orthopaedic Surgery, Princess Elizabeth Orthopaedic Centre, Royal Devon & Exeter Hospital

Background: The known long term outcomes of reverse total shoulder arthroplasty (RSA) are limited with only one publication having previously reported beyond 10 years. We aim to report the clinical and radiographic outcomes of a consecutive series of 45 RSA at a minimum of 15 years following implantation.

Methods: A single centre, single surgeon consecutive cohort study was performed using a retrospective review of a series of 45 Delta III RSA. Prostheses were implanted between May 2000 and December 2005 with an average age at surgery of 77 years. All procedures were undertaken for cuff tear arthropathy. Pre-operative ASES scores were compared with scores obtained at average 2.5 years and minimum 15 years following implantation. All-cause construct survival was assessed alongside radiographic assessment for complications including dislocation, fracture, evidence of metalwork failure, notching and evidence of loosening or radiolucency around both humeral and glenoid components.

Results: All cause survival at 15 years was 87.3% (95% CI 68.0-95.3). 4 patients underwent revision, each to further RSA. 2 were undertaken for infection, 1 for early stem subsidence in an uncemented component and 1 for recurrent dislocation. 2 further patients underwent re-operation, 1 for acromial stress fracture and the other an MUA for dislocation. Average ASES improved from 20.3 (12.2) pre-operatively to 66.3 (17.4) at 2.5 years post-operation falling to 58 (16.5) at minimum 15 years. Excluding patients who underwent revision, radiographs demonstrate no cases of humeral component loosening. Notching occurred in 69% of cases, 16% grade 1, 21% grade 2, 42% grade 3 and 21% grade 4.

Conclusion: In an elderly patient cohort, survivorship of 87.3% at 15 years, with maintained improvement in patient outcomes, demonstrates RSA to be an intervention that provides an acceptable long-term results. Registry data will, with time, enable long-term scrutiny of multiple RSA implants.

THE BICIPITAL GROOVE AS A LANDMARK FOR HUMERAL VERSION REFERENCE DURING SHOULDER ARTHROPLASTY – A CT STUDY OF NORMAL HUMERAL ROTATION

Authors: P Dacombe, D Young, L Moulton, M Prentice, Travis Falconer, J Spencer

Main Institution: Sir Charles Gairdner Hospital, Nedlands, Perth, Australia

Background: Accurate reproduction of humeral version is vital in shoulder arthroplasty. Traditional referencing relative to the transepicondylar axis (TEA) is prone to error as it is absent in pre-operative imaging and inaccurately reproduced intra-operatively. The bicipital groove is present in pre-operative imaging and operative field so may be a useful landmark for accurate reproduction of humeral version.

Materials and Methods: 101 full humerus CT scans of patients undergoing a myeloma screening protocol were analysed by two trained observers. Measurements of humeral retroversion relative to TEA (Angle A), humeral articular axis retroversion relative to bicipital groove (Angle B) and the bicipital groove axis relative to the TEA (Angle C) were made with comparison of the measurement properties of each.

Results: Humeral retroversion relative to TEA was 23.7° +-8°, with a range of 0.2° to 48.7°, 95% confidence interval 22-26°. The humeral articular axis was retroverted to the bicipital groove axis (Angle B) by 33.5° +-9.4°, range of 15.5°-61.7°, 95% confidence interval 32-35°. Overall inter-rater reliability was 0.88.

Conclusion: Measurement of humeral head retroversion relative to the bicipital groove is not inferior to the gold standard measurement. The bicipital groove is present in both pre-operative imaging and the operative field, making it a potential reference landmark for accurate reproduction of humeral version in shoulder arthroplasty.

FLOOR AND CEILING EFFECTS IN THE OXFORD SHOULDER SCORE: AN ANALYSIS FROM THE NATIONAL JOINT REGISTRY

Authors: Singh HP, Haque A, Taub N, Modi A, Armstrong AL, Rangan A, Pandey R

Main Institution: Department of Orthopaedic Surgery, University Hospitals of Leicester, Leicester

Aims: The main objective of this study was to examine whether the Oxford Shoulder Score (OSS) demonstrated a floor or ceiling effect when used to measure outcomes following shoulder arthroplasty in a large national cohort. Secondary objective was to identify independent predictors preoperatively for patients achieving a postoperative ceiling score after shoulder arthroplasty.

Methods: Secondary database analysis of a national audit conducted in England and Wales on patients undergoing shoulder arthroplasty. Primary outcome measure was the OSS. Secondary outcome measures were the OSS-Function Component Subscale (FCS) and OSS-Pain Component Subscale (PCS). Floor and ceiling effects were considered to be present if >15% of patients scored either the lowest (0/48) or highest (48/48) possible score. Logistic regression analysis was used to identify independent predictors for scoring the highest possible score postoperatively.

Results: Preoperatively 1% of the population achieved the lowest possible score (0) and 0.4% of patients achieved the highest possible score (48). Postoperatively less than 1% of patients achieved the lowest possible score at all time points, but the percentage achieving the highest score at 6 months was 8.3%, at 3-years 16.9% and at 5-years 17%. Furthermore pain and function subscales exhibited greater ceiling effects at 3-years and 5-years when compared to the overall OSS questionnaire. Logistic regression analysis showed that gender, procedure type and preoperative OSS score were independent predictors for scoring the highest possible score at 5 years.

Conclusion: Based on the National Joint Registry (NJR) PROMs data the overall OSS does not exhibit a ceiling effect at 6 months but does at 3-years and 5-years largely due to outcome scores of ApTSA. Subscale analysis does indicate limitations due to ceiling effects in the OSS-PCS and OSS-FCS. Pre-operative OSS, age, male gender and ApTSA are independent predictors of achieving a ceiling score.

EFFECT OF SUBSCAPULARIS REPAIR IN PATIENTS WITH AN INTACT ROTATOR CUFF UNDERGOING REVERSE TOTAL SHOULDER ARTHROPLASTY

Authors: Harries L, Roche C, Routman H, Friedman R, Donaldson O

Main Institution: Department of Trauma and Orthopaedics, Yeovil District General Hospital

Background: There remains considerable debate as to whether to repair subscapularis or not following reverse total shoulder arthroplasty (rTSA). This study aims to assess the effects of SSC repair on postoperative shoulder function and patient reported scores in patients with an intact rotator cuff undergoing rTSA.

Methods: Patients undergoing rTSA for osteoarthritis with a minimum of two years follow-up were identified from an international shoulder registry. Patients with rotator cuff tears, cuff arthropathy, or post-traumatic arthritis were excluded. They were then divided into age and gender matched groups based on whether they had SSC repaired or not; 436 patients were analyzed in total, 218 in each group. Outcome measures of shoulder range of motion, complication rates, and seven patient reported shoulder scores, were compared using a two tailed paired T-Test.

Results: In both groups, improvement in average shoulder movement and patient reported shoulder scores exceeded the threshold for substantial clinical benefit (SCB). 93% reported their symptoms were better or much better in both groups. Those who had SSC repaired demonstrated a statistically significantly better mean active forward flexion (144° vs 138°, p=0.021) and mean internal rotation score (4.8 vs 4.0, p=

Conclusion: For the majority of patient reported scores and shoulder movements there was no significant difference between SSC repaired and non repaired groups, and where statistically significant differences were noted, the difference did not exceed the MCID in any measure.

A NOVEL RADIOGRAPHIC PARAMETER TO GUIDE ACCURATE RESTORATION OF THE AXIS OF FOREARM ROTATION IN RADIAL HEAD ARTHROPLASTY

Authors: Ormsby N, Prinja A, Watts A C.

Main Institution: Upper Limb Unit, Wrightington, Wigan and Leigh Teaching Hospitals NHS Foundation Trust Wrightington Hospital

A novel radiographic parameter to guide accurate restoration of the axis of forearm rotation in radial head arthroplasty

Introduction: The key to good outcomes following radial head arthroplasty is to effectively reconstruct the mechanical axis of the forearm (AFR). This is often done with neck-retaining implants by aiming the stem toward the ulnar styloid intraoperatively, but this can be challenging, and difficult to confirm with narrow field fluoroscopy.

Aims: The purpose of this study was to identify a reliable intraoperative parameter which could be used as a surrogate for AFR to improve implant alignment.

Methods: Novel parameters were devised following analysis of 50 normal forearm AP radiographs by two independent assessors, to identify if there was a consistent crossing point of the AFR on the radius. A line was drawn up the ulnar cortex of the proximal radius, up to the radial neck, and at the point which the bicipital tuberosity rose ulnarly from this line a perpendicular was dropped and termed the distal bicipital tuberosity(DBT). The AFR was estimated by drawing a line from the tip of the ulnar styloid to the centre of the radial head. The point at which the AFR crossed the DBT line was termed the intersection point(ISP) and its proximity to the bicipital tuberosity was measured. Interobserver reliability of this measurement was assessed using intraclass correlation kappa.

Results: In all 50 patients, the ISP fell within 1mm of the distal origin of the bicipital tuberosity, and demonstrated excellent interobserver reliability (k=0.94).

Conclusion: In a supinated AP forearm radiograph, the AFR will reliably cross the radius at the distal end of the bicipital tuberosity. This can be correlated intraoperatively, by palpating the tuberosity, and aiming the radial head arthroplasty stem towards this point. This can then be confirmed in the narrow field of intraoperative fluoroscopy.

ANATOMICAL MONOPOLAR PRESS-FIT RADIAL HEAD ARTHROPLASTY; HIGH RATE OF LOOSENING AT MID-TERM FOLLOW UP

Authors: Samra I, Kwaees T, Mati W, Blundell C, Lane S, Harrison J, Charalambous C

Main Institution: Blackpool Victoria Hospital

Introduction: Radial head arthroplasty (RHA) is used for the management of unstable or unreconstructable injuries of the radial head. Our aim was to investigate clinical and radiographic mid-term outcomes in patients treated with the Acumed anatomical radial head press-fit system for trauma.

Methods: Clinical and radiographic assessment analysis of RHA undertaken for trauma at a single institution with minimum 2-year follow-up.

Results: 16 consecutive patients, mean age 53 (21 - 62) with a mean 66 month ± 27 (26-122) clinical follow-up were included. Clinical outcomes were acceptable with mean flexion of 129°, extension deficit of 10°, pronation of 76°, and supination of 69°. Median VAS score was 1 (0-10), QuickDASH 9.1 (0-40.9), and MEPS score was 95 (70 - 100). There were marked radiographic changes with 11/16 showing periprosthetic lucent lines and 13/16 showing subcollar osteolysis. These radiographic changes occurred early post-surgery. Stem loosening was associated with a larger cantilever quotient (0.47 vs 0.38, p=0.004). Survivability of the prosthesis was 81.2%, with 2 RHAs removed due to loosening and 1 removed for stiffness.

Conclusion: Mid-term clinical functional outcomes following the Acumed anatomical RHA are acceptable in most cases. However, in view of the high rate of radiological subcollar osteolysis, extensive loosening and surgical removal due to loosening, we urge caution when using the short stem of this prosthesis, especially if a large collar is anticipated.

OPTIMISED PHYSIOTHERAPY FOR LATERAL ELBOW TENDINOPATHY – A CONSENSUS DEVELOPED USING AN ONLINE MODIFICATION OF THE NOMINAL GROUP TECHNIQUE

Authors: Bateman M, Saunders B, Littlewood C, Hill J.

Main Institution: Derby Shoulder Unit, University Hospitals of Derby & Burton NHS Foundation Trust, Royal Derby Hospital

Background: There are a wide range of physiotherapy treatment options for people with lateral elbow tendinopathy (LET), however, previous studies have reported inconsistent approaches to treatment and a lack of evidence demonstrating clinical effectiveness. This study aimed to combine best available research evidence with stakeholder opinion to develop key components of an optimised physiotherapist-led treatment package for testing in a future randomised controlled trial in the UK NHS.

Methods: An online Nominal Group Technique (NGT) approach was used, hosted on Microsoft Teams. Physiotherapists were approached to take part via an email advertisement to BESS members. Patients volunteered from the project's PPIE group and managers were identified from pre-agreed trial sites. Participants were sent an evidence summary prior to the first meeting, which focussed on agreeing the types of intervention to include. The second meeting focussed on specific details of intervention delivery. All treatment options were discussed before anonymous voting and ranking of priority. Consensus for inclusion was set at 70% based on OMERACT guidelines. Options with 30-69% agreement were discussed again and a second vote was held allowing for a change of opinion.

Results: Meetings were attended by 10 physiotherapists with special interest in LET (mean 18.7y qualified), 2 NHS physiotherapy service managers and 3 patients. The optimised physiotherapist-led treatment package included: advice & education, exercise therapy and orthotics. Specific components for each of these interventions were also agreed such as: condition-specific advice, health promotion advice, exercise types, exercise into ‘acceptable’ levels of pain, exercise dosage and type of orthoses. Other treatment options including electrotherapy, acupuncture and manual therapy, were excluded.

Conclusion: Online NGT consensus successfully developed an optimised physiotherapist-led treatment package for people with LET. This intervention is now ready for testing in a future pilot randomised controlled trial to contribute much needed evidence about the treatment of LET.

EFFICACY OF PLATELET RICH PLASMA FOR EPICONDYLAR TENDINITIS USING ARTHREX ACP IN SHORT TO MID TERM FOLLOW UP

Authors: Abir M, Gavai PV, Bidwai A, Blacknall J, Curtis S

Main Institution: Trauma and Orthopaedic Department, King's Mill Hospital

Purpose: To evaluate the efficacy of PRP injections for patients with tendinitis around elbow.

Methods: Prospective cohort study of 78 patients with elbow tendinitis with 12 months follow up face to face and patient record review further treatment for up to 5 years. Patients received dedicated physiotherapy program, Elbow scores and grip strength analysis before injection. Thirty-six patients had previous steroid injection for the same condition. The PRP was using Arthrex ACP system with standardized method and was injected with strict aseptic precautions.

Results: Male Female ratio was equal. Average time between the onset of pain and PRP injection was 29 months. Most cases had tennis elbow (n=57) vs Golfer's elbow (n=20), one patient had both. Right side was more involved (n=48). Average age was 49.33 years. Patients had gradual improvement with Oxford elbow score. At 6 weeks, 6 months and 12 months’ time mean improvement was 8.72 (±8.04 SD), 14.24 (±10.16 SD), 16.79 (±13.29 SD) respectively, these changes were significant in paired T-test at each stage (2.5E-08, 1.59E-08, 1.58E-05) PREE score showed reduction of pain and improved function at 6 weeks, 6 months and 12 months’ time mean improvement was 21.48, 33.87, 46.27. Mean Grip strength difference of the affected arm compared to the normal arm improved from 10.88 at pre injection stage to 4.12, 5.65 and 5.01 at those time intervals. Eight patients needed further surgery for tendon release. No significant complications occurred in the study group.

Conclusion: PRP injection for elbow tendinitis shows gradual improvement in symptoms as evident by improvement of elbow scores, grip strength. It is a safe and cost-effective method with low rate of conversion to surgery. This study used a pre-injection physiotherapy program and same system was used for all the patients to ensure appropriate patient selection and consistent method.

A COHORT STUDY ASSESSING THE CLINICAL EFFICACY AND COST EFFECTIVNESS OF HYLAURONIC ACID INJECTIONS FOR THE TREATMENT OF LATERAL EPICONDYLITIS

Authors: Harries L, Donaldson O

Main Institution: Yeovil District General Hospital

Aim: To assess the clinical efficacy and cost effectiveness of hyaluronic acid injections for the treatment of lateral epicondylitis

Methods: Patients with a diagnosis of lateral epicondylitis, persisting more than 6 months despite physiotherapy and/or injections of corticosteroid, were prospectively identified over 2 years. They underwent outpatient injection of Hyaluronic acid (HA) 30mg (4ml) into the common extensor origin, and provided oxford elbow scores (OES), prior to injection, at 3 months in clinic, and subsequent time points over the phone.

Results: Sixteen patients underwent HA injection, with follow up ranging from 3-24 months (median 12 months). There was a statistically significant improvement in OES following injection at 3 months (p=0.0001, CI -20.28 TO -7.47, paired t-test). Average OES prior to injection was 17, the average OES 3 months after treatment was 29. Twelve of the 16 patients exceeded the minimal clinically important difference (MCID) of 8.2 for the OES; 2 showed an improvement under this threshold at 3 months but over it at 6 months; 2 patients did not improve and went on to undergo open extensor release. This represents a success rate of 88%, with none having had a re-occurrence at last follow up. The cost of an HA injection in our unit is £38, of platelet rich plasma injection (PRP) £200, and of operative open release £1137. Factoring in the cost of operative release for 2 refractory patients the cost of treating this cohort was £2882, which is £18 192 cheaper than operative management and £318 cheaper than managing with PRP (even assuming 100% success with PRP).

Conclusion: Injection of HA for lateral epicondylitis in this cohort was clinically and cost effective. We believe this validates its ongoing use and warrants a randomised control trial to further compare it to other common treatments.

TIPS FOR A SUCCESSFUL OUTCOME AFTER PRP INJECTION IN ELBOW TENDINITIS BASED ON A MINIMUM 1-YEAR FOLLOW-UP OF 265 INJECTIONS

Authors: Ramesh R, Munn D, Open D

Main Institution: Torbay and South Devon NHS Foundation Trust, Torbay Hospital

Purpose: To evaluate the results and present the key parameters for a successful outcome with Platelet Rich Plasma (PRP) injection for elbow tendinitis in a case series of 265 injections with minimum 1 year follow up.

Background: Poor patient selection, comparing different harvest equipment, methods of injection, post-injection management, and a shorter follow-up may be some of the reasons for the lack of clarity in the published literature.

Methods: This prospective case series study from a single centre was conducted over a period of 6 years. 230 patients with 265 sides referred for surgery for chronic elbow tendinitis were offered PRP injection. 208 sides had tennis elbow and 57 had golfers’ elbow. 11 patients had failed to improve after previous surgery. Accelerate PRP system (Exactech) was used. PRP was injected under ultrasound guidance as an outpatient procedure. The minimum follow-up was 1 year. QuickDASH score was used to measure the outcome. A drop of 15 points was considered to be the minimum for a clinically important difference. Conversion to surgery was considered to be a failure.

Results: The mean QuickDASH score was 55.67 pre-injection and 29.62 post-injection with a statistically significant improvement of 26.05 (p

Conclusions: We summarise five practical tips for a successful outcome:

1) Use a PRP system that gives a good harvest of active platelets.

2) Inject into tendinopathic area under ultrasound guidance.

3) Use a large-bore needle with a shorter length.

4) Use wrist splints post-injection, and

5) Avoid using anti-inflammatory medications pre and post injections.

MANAGEMENT OF OSTEOCHONDRITIS DISSECANS OF THE ELBOW TROCHLEA IN THE ADOLESCENT POPULATION: A SYSTEMATIC REVIEW

Authors: Rasidovic D, Saeed A, Jordan RW, Simon MacLean, Gregory Bond, Malik SS

Main Institution: Department of Orthopaedic Surgery, Worcestershire Royal Hospital

Purpose: There is currently limited information on OCD of the elbow trochlea, the aim of this systematic review is to assess the outcomes of its management.

Methods: The study was prospectively registered on PROSPERO prior to conducting searches of the EMBASE and MEDLINE databases. Studies were screened by two reviewers independently and those reporting on trochlea OCD in an adolescent population were included for analysis. A risk of bias assessment was performed for all included studies using the MINORS score.

Results: 16 studies met our inclusion criteria which reported on a total of 75 elbows with trochlea OCD. Mean age was 14 years (8-19 years) of which 46 were male and 24 female. The mean follow-up time was 17 months (5-50 months). The dominant side was involved in 73% of patients (n=48) and when reported 90% of patients were involved in overhead sports. The main presenting symptoms were pain (95%), loss of motion (44%) and crepitus (25%). The location of trochlea OCD lesions was lateral in 77% and medial in 23%. Non-operative care was reported in 86% (n=63) of elbows as the initial modality of treatment with resolution of symptoms in 76% (48 out of 63), consequently 15 required surgery for ongoing symptoms. Surgical management was described as the only form of treatment in 10 elbows (14%) however incorporating the failed non-operative group results in 33% (n=25) of elbows undergoing operative care. There were equal number of arthroscopic (n=13) and open procedures (n=12) and overall 94% had successfully resolution of symptoms after surgery.

Conclusion: Elbow trochlea OCD is a rare pathology and one that can be managed non-operatively in majority of cases with good resolution of symptoms. However, if this fails, operative options are available with excellent results reported.

POST-OPERATIVE REHABILITATION FOLLOWING TRAUMATIC ANTERIOR SHOULDER DISLOCATION: A SCOPING REVIEW

Authors: Coyle M, Chester R, Weatherburn L, Daniell H, Jaggi A

Main Institution: University of East Anglia

Objective: This systematic scoping review aimed to describe the content of post-operative rehabilitation programmes, and selected outcome measures following stabilisation surgery for traumatic anterior shoulder dislocation (TASD).

Methods: An electronic search of Medline, EMBASE, CINAHL and AMED was conducted (2000 to 2020). Any cohort or clinical trial of patients receiving post-operative TASD rehabilitation were included. Study selection, data extraction and appraisal of study quality were undertaken by two independent reviewers. The study protocol was registered onto the International Prospective Register of Systematic Reviews (registration number CRD42020201438).

Results: Twelve studies including fourteen treatment programmes were eligible. Period of post-operative immobilisation ranged from 1 day to 6 weeks, with exercise being introduced between 1 and 7 weeks. Strengthening exercises were introduced between 1 and 12 weeks. Only 2 studies, described “accelerated” rehabilitation programmes, but differed in immobilisation period and exercise milestones. Progressive accelerated rehabilitation had no detrimental effect on recurrence rates for professional footballers but are unknown for the general population. Two studies compared rehabilitation programmes, one of which was not randomised and the other 18 years old. There was variability in the use of outcomes measures, with no more than 4 studies using a common outcome.

Conclusion: There is a lack of evidence to guide post-operative rehabilitation, variability in the post-operative immobilisation period and when each type of exercise is introduced. There is no consensus on the definition of accelerated rehabilitation, or outcome measures. Clinical consensus of standardised terminology and stages of rehabilitation is required prior to developing a randomised controlled trial.

OPEN LATARJET PROCEDURE IN ATHLETES WITH PRIMARY INSTABILITY VERSUS RECURRENT INSTABILITY VERSUS FAILED PRIOR SURGERY – A RETROSPECTIVE COMPARATIVE STUDY

Authors: Davey MS, Hurley ET, Gaafar M, Pauzenberger L, Mullett H

Main Institution: Sports Surgery Clinic, Dublin, Ireland

Purpose: To compare the outcomes of OL in athletes with primary shoulder instability versus those with recurrent instability versus those undergoing OL for failed prior instability surgery.

Methods: A retrospective review of patients who underwent OL with a minimum of 12-month follow-up was performed. Additionally, these were pair matched in a 1:2:1 ratio for age, gender, sport, level of pre-operative play, and follow-up length for primary instability, recurrent instability and failed prior instability surgery. Return to sport, the level of return and the timing of return were assessed. Additionally, recurrence, Visual Analogue Scale for pain (VAS), Subjective Shoulder Value (SSV), Rowe score, Shoulder Instability-Return to Sport after Injury (SIRSI) score, satisfaction, and whether they would undergo the same surgery again were compared.

Results: A total of 200 patients (50 for primary instability, 100 for recurrent instability and 50 for failed prior instability surgery) were included (mean age 22.7 years) with mean follow-up of 38.8 months. There were no significant difference in any of the clinical outcome scores (VAS, Rowe, SIRSI, SSV) utilized for the three groups (p > 0.05 for all). However, there was a significantly lower rate of return to play for those undergoing OL for failed prior instability surgery (82.2% vs 92.2% vs 62.2%, p Conclusion: OL result in excellent clinical outcomes, and low recurrence rates for primary shoulder instability, those with recurrent instability, or those undergoing OL for failed prior instability surgery. However, in those undergoing OL for failed prior shoulder there was a lower rate of return to play.

ARTHROSCOPIC BANKART REPAIR VS THE OPEN LATARJET PROCEDURE FOR FIRST TIME SHOULDER DISLOCATIONS IN ATHLETES

Authors: Hurley ET, Davey MS, Montgomery C, O'Doherty R, Gaafar M, Pauzenberger L, Mullett H

Main Institution: Sports Surgery Clinic, Dublin, Ireland

Purpose: The purpose of this study was to compare the outcomes of ABR and OL in athletes with a first-time shoulder dislocation.

Methods: A retrospective review of patients who underwent primary ABR and OL for first time dislocations, with a minimum of 24-month follow-up was performed. Indications for OL over ABR in this population were those considered at high risk for recurrence, including those with glenohumeral bone loss Additionally, these were pair matched in a 2:1 ratio for age, gender, sport and level of pre-operative play. Rate, level and timing of return to play (RTP), and Shoulder Instability-Return to Sport after Injury (SIRSI) score were evaluated. Additionally, recurrence, Visual Analogue Scale (VAS) score, Subjective Shoulder Value (SSV), Rowe score, satisfaction, and whether they would undergo the same surgery again were compared.

Results: Overall, 80 athletes who underwent ABR and 40 patients who underwent OL were included with a mean follow-up of 50.3 months. There was no significant difference between ABR and OL for rate of RTP (81.3% vs 80%, p = 1.0), RTP at the same pre-injury level (66.3% vs 62.5%, p = 0.69), time to return (6.4 ± 2.7 months vs 5.9 months, p = 0.38), or SIRSI score (67.1 ± 24.3 vs 70.2 ± 21.6, p = 0.50). There was no significant differences (all p > 0.05) in recurrent dislocation rate (6.3% vs 0%), VAS score (2.4 ± 2.2 vs 1.9 ± 1.8), SSV (84.8 ± 17.4 vs 85.3 ± 12), Rowe score (80.1 ± 19 vs 87.6 ± 13.1), satisfaction (85% vs 90%), or whether they would undergo surgery again (88.8% vs 85%).

Conclusion: Both ABR and OL result in excellent clinical outcomes, with high rates of RTP, and low recurrence rates. Additionally, there were no differences between the two procedures in collision athletes.

ANALYSIS OF PATIENTS THAT DID NOT RETURN TO PLAY FOLLOWING THE OPEN LATARJET PROCEDURE

Authors: Hurley ET, Davey MS, Gaafar M, Pauzenberger L, Jazrawi LM, Mullett H

Main Institution: Sports Surgery Clinic, Dublin, Ireland

Purpose: The purpose of this study was to analyze patients that did not RTP following open Latarjet procedure compared to those who did RTP, and analyze factors associated with those not RTP.

Methods: A retrospective review of patients who underwent the open Latarjet procedure, and subsequently did not RTP after a minimum of 12-month follow-up was performed. Additionally, these were pair matched in a 2:1 ratio for age, gender, sport and level of pre-operative play with a control group who returned to play. Patients were evaluated for their psychological readiness to return to sport using the Shoulder Instability-Return to Sport after Injury (SIRSI) score. Additionally, reasons for not returning to play, Visual Analogue Scale for pain (VAS), Subjective Shoulder Value (SSV), and satisfaction were evaluated. Multivariate regression models were used to evaluate factors affecting RTP.

Results: The study included a total of 35 patients who were unable to RTP and 70 who did RTP. All patients were male with a mean age of 27.9 years, and a mean follow-up of 41.5 months. Seven patients (20%) passed the SIRSI benchmark of 56 with a mean overall score of 41.5 ± 21.9, in those who returned 81.4% passed the SIRSI benchmark of 56 with a mean overall score of 74.5 ± 19.8 (p

Conclusion: Following the open Latarjet procedure, those that do not RTP exhibit poor psychological readiness to RTP. Additionally, patients who did not RTP reported higher pain scores, and lower SSV.

LATARJET VS CORACOID FREE GRAFT FOR THE TREATMENT OF ANTERIOR INSTABILITY IN PATIENTS OLDER THAN 40 YEARS: SLING EFFECT NECESSARY?

Authors: Domos P, Chelli M, Potter D, Walch G

Main Institution: Barnet and Chase Farm Hospitals, Royal Free London NHS Foundation Trust

Aim: comparative retrospective study of the outcomes of patients older than 40-years-old who underwent open Latarjet with those who had open coracoid free graft procedure. Methods: 68 patients were included in this study: 40 patients in the Latarjet (LAT) and 28 in the coracoid free graft (CFG) with a mean age at surgery of 43 years (40 – 58). The two groups were comparable regarding the basic demographics. Clinical outcomes were assessed by Constant-Murley, Walch-Duplay and Rowe scores, Subjective Shoulder Value. Radiographs were reviewed for osteoarthritis (OA), complications. Results: At a mean follow up of 11 years (5 – 21 years), we did not observe any statistically significant difference in functional results between the two groups. However, the active external rotation was clinically significantly higher in the LAT group (60° vs 40°, p=0.073) as well as the return to sport level (84% vs 50%, p=0.057). The overall complication rate was 17% in the LAT group, 28% in the CFG group (p=0.238). Two patients in each group suffered a redislocation. Subjective persistent apprehension in abduction-external rotation (microinstability) was observed in 4 patients in the LAT group and in 10 patients in the CFG group (10% vs 35%, p=0.106). Reoperation was required in 5% of patients in the LAT group and 11% in the CFG group (p=0.627). 21% of patients had OA on preoperative radiographs (25% in the LAT group, 14% in patients in the CFG group, p=0.153). OA developed in 24% more patients in CFG group (64% vs 40%) and patients’ pre-existing OA progressed in 17% more patients in CFG group (67% vs 50%), (p=0.195 and p=0.299, respectively). Conclusion: Both procedures provide good overall outcomes with similar complication, reoperation and redislocation rates. The sling effect can be important to reduce microinstability and translation which can potentially lead to reduced OA in the long-term.

INCIDENCE OF SHOULDER DISLOCATION DURING THE COVID PANDEMIC

Authors: A Ardakani, A Raghu, S Kyriacou, M Guilliatt, C Yeoh, A Assiotis, A Rumian, H Uppal

Main Institution: Lister Hospital Stevenage

Aim: To evaluate the incidence and follow up rate of patients presenting to our accident and emergency (AE) department with an anterior shoulder dislocation during the first peak of the COVID-19 pandemic and comparing this to a pre-pandemic time frame.

Methods: We undertook a retrospective review of the case notes of patients who attended our accident and emergency department with an anterior shoulder dislocation between August 2019 and August 2020. Data was collected on attendance as well as follow up.

Results: The study identified a total of 157 patients who presented to our AE department with an anterior shoulder dislocation over the 1-year period analysed. There were 97 attendances in the pre-COVID time period (August 2019 – February 2020) and 60 during the first 6 months of the COVID pandemic (March 2020 – August 2020). In the pre COVID timeframe further imaging was booked for 36 (37%) of the patients who presented. 37 (38%) patients where discharged from AE without further imaging. During the COVID pandemic further imaging was booked 19 (32%) patients and 33 patients (55%) where discharged from AE without an orthopaedic follow up or review.

Conclusion: The total number of patients presenting to AE with a shoulder dislocation reduced during the first wave of the COVID pandemic. There were a similar proportion of patients who presented with a fracture dislocation. We noticed a slight reduction in the number of further investigations organised for these patients as well as a significantly higher number of patients discharged from the AE department without any further follow up. The recommendation moving forwards is to encourage all trusts to review their outcomes in a similar way and follow up patients who might have received a substandard of care to ensure their clinical needs are met.

PRIMARY BICEPS TENODESIS VS SECONDARY BICEPS TENODESIS FOLLOWING FAILED SLAP REPAIR

Authors: Hurley ET, Lorentz NA, Markus DH, Colasanti CA, Campbell KA, Jazrawi LM, Strauss EJ

Main Institution: Division of Sports Medicine, Department of Orthopedic Surgery, NYU Langone Health, New York, USA

Purpose: The purpose of the current study was to compare satisfaction and return to play rates between patients undergoing primary biceps tenodesis for a symptomatic superior-labrum anterior to posterior (SLAP) tear and patients undergoing secondary biceps tenodesis following a failed SLAP repair.

Methods: A retrospective review of patients who underwent primary biceps tenodesis for a SLAP tear, as well as those who underwent biceps tenodesis following failed SLAP repair was performed. The American Shoulder & Elbow Surgeons (ASES) score, Visual Analogue Scale (VAS), Subjective Shoulder Value (SSV), patient satisfaction, willingness to undergo surgery again, revisions, and return to play (RTP) were evaluated. A p value of RESULTS: The current study included 76 patients in total; 57 primary biceps tenodesis patients, and 19 secondary biceps tenodesis patients. The mean age was 39 (19-48), 100% were males, and the mean follow-up was 54 months (16-99 months). Overall, we found that primary biceps tenodesis patients reported higher ASES scores (89.9 vs 76.4, p=0.0162), lower VAS scores (1.0 vs 3.1, p=0.0034), and higher SSV scores (86.7 vs 64.7, p=0.0004). Overall, there was no significant difference in the total rate of RTP (84% vs 75%, p=0.5025), or timing of RTP (8.2 months vs 8.1 months, p=0.9529) between patient groups. No patients required a further shoulder surgery after undergoing biceps tenodesis.

Conclusion: This study found that patients undergoing primary biceps tenodesis had significantly better functional outcomes compared to secondary biceps tenodesis following a failed SLAP repair.

OPEN VS ARTHROSCOPIC LATARJET FOR ANTERIOR SHOULDER INSTABILITY

Authors: Hurley ET, Ben Ari E, Lorentz NA, Colasanti CA, Matache BA, Jazrawi LM, Virk M, Meislin RJ

Main Institution: Division of Sports Medicine, Department of Orthopedic Surgery, NYU Langone Health, New York, USA

Purpose: The purpose of this study is to evaluate the outcomes of open Latarjet (OL) compared to arthroscopic Latarjet (AL) for anterior shoulder instability.

Methods: A retrospective review of patients who underwent either OL or AL for anterior shoulder instability between 2011 and 2019 was performed. Recurrent instability, Visual Analogue Scale (VAS) score, Subjective Shoulder Value (SSV), Western Ontario Shoulder Instability (WOSI) score, patient satisfaction, willingness to undergo surgery again, and return to work/sport were evaluated. A p-value of RESULTS: Our study included 80 patients in total; 50 patients treated with OL, and 30 treated with AL. There was no demographic differences between the two groups (p>0.05 for all). At final follow up, there was no difference between those that underwent OL or AL in reported WOSI score (29.7% vs 27.1%, p=0.67), VAS score (1.2 vs 1.3, p=0.83), VAS during sports (1.5 vs 2.2, p=0.59), SSV (70 vs 75.7, p=0.30), SIRSI score (63.4 vs 66.7, p=0.55), satisfaction (89.4% vs 85.6%, p=0.32), or whether they would undergo surgery again (96% vs 93.7%, p=0.60). Overall, there was no significant difference in the total rate of RTP (63% vs 60.9%, p=0.88), or timing of RTP (8 months vs 7 months, p=0.21). Overall, 3 patients in the OL group and 2 patients in the AL group had recurrent instability events (6% vs 6.7%, p=0.91); with no significant difference in the rate of recurrent dislocation (2% vs 3.3%, p=0.71).

Conclusion: In patients with anterior shoulder instability both the OL and AL were shown to be reliable treatments, with a low rate of recurrent instability, and excellent patient reported outcomes.

A SYSTEMATIC REVIEW TO COMPARE PHYSIOTHERAPY TREATMENT PROGRAMMES FOR ATRAUMATIC SHOULDER INSTABILITY

Authors: Griffin J, Chester R, Daniell H, Jaggi A.

Main Institution: University of East Anglia

Purpose: Optimal rehabilitation programmes and exercise prescription is uncertain for atraumatic shoulder instability (ASI), the primary aim of this systematic scoping review was to compare physiotherapy treatment programmes for people with ASI.

Methods: CINAHL, EMBASE and Medline databases were searched for studies, except single case studies, published between 1950 and January 2021. Several published guidelines, quality assessment criteria and the authors’ own assessments with respect to treatment programmes were amalgamated to create the quality assessment. There were 12 items covering three domains; internal validity, transferability to wider population and reporting. A secondary objective was to examine the relationship between programmes and outcomes.

Results: Ten studies were included; one randomised controlled trial, 6 cohort studies and 3 case series. There was a total of 490 participants. Treatment programmes included education, functional training, movement re-education, shoulder muscle strengthening, static posture correction, and adjuncts, with variable duration and frequency of treatment sessions. Psychological factors were rarely discussed. Only one study reported an adverse event attributed to exercise soreness, resolving within 48 hours. Classification of ASI was often unclear, with inconsistent use of terminology. Although varied, all studies used patient reported outcome measures (PROMs), 7 of which reported a statistically significant improvement (p

Conclusion: There is a lack of consensus on classification criteria and which PROM to report as the primary outcome for ASI. Exercise and education is the mainstay of treatment with limited integration of psychosocial factors within assessment and management or as a prognostic factor for outcome. We recommend a consensus study to provide i) a universal definition of ASI and ii) recommendations for outcome measures, prior to further research investigating the effectiveness of integrating a psychological approach to existing education and exercise.

USE OF THE FIFA 11+S AS PART OF POST-OPERATIVE REHABILITATION FROM ARTHROSCOPIC SHOULDER STABILISATION RESULTS IN A HIGHER OXFORD SHOULDER INSTABILITY SCORE AND LOWER DISLOCATION RATE

Authors: Ranson J, Hoggett L, Jain N

Main Institution: Northern Care Alliance

Introduction: Arthroscopic shoulder stabilisation is an established treatment for recurrent instability. The FIFA 11+ has been used to decrease the rate of injury in sport as part of injury prevention. The FIFA11+S is focused on the Upper Limb and in particular the shoulder.

Aim: To report the clinical findings from a series of patients undergoing arthroscopic shoulder stabilisation and the effects of incorporating the FIFA 11+S into their post-operative rehabilitation.

Method: A retrospective series of 30 patients undergoing arthroscopic shoulder stabilisation was reviewed. Two paired groups of 15 patients each were identified, those receiving the FIFA11+S (FIFA) as part of their rehabilitation and those who did not (No FIFA). Each patient underwent arthroscopic shoulder stabilisation in the form of labral (Bankart) repair using knotless anchor fixation and suture tape. Each was assessed for number of post-operative dislocations and Oxford Shoulder Instability Score (OSIS).

Results: The mean post-op OSIS for the FIFA group was 43.6 and there were no post-operative dislocations. The mean post-op OSIS for the No FIFA group was 39.4 with 2 post-operative dislocations in this group. There was no statistically significant difference observed (p=0.19). A sample size of 39 patients in each group was calculated to be required to observe a statistical difference.

Conclusion: The FIFA 11+S has been introduced as an injury prevention technique, we suggest it should also be used to supplement rehabilitation following shoulder stabilisation surgery as it is suggested that its use provides a beneficial effect on post-operative outcome.

Implications: We believe that the FIFA 11+S should be used as an adjunct to post-operative shoulder stabilisation rehabilitation. A larger study would confirm the suggested benefit.

ARTHROSCOPIC BONE BLOCK STABILISATION PROCEDURES FOR GLENOID BONE LOSS IN ANTERIOR GLENOHUMERAL INSTABILITY: A SYSTEMATIC REVIEW OF CLINICAL AND RADIOLOGICAL OUTCOMES

Authors: Tahir M, Malik S, Jordan R, Kronberga M, D'Alessandro P, Saithna A

Main Institution: Trauma and orthopaedic surgery, Queen Elizabeth Hospital Birmingham

Introduction: Recurrent shoulder instability is frequently associated with glenohumeral bone loss. Recently there has been a surge of interest in arthroscopically performed bone block procedures. This systematic review aims to determine the clinical and radiological outcomes of arthroscopic glenoid bone block stabilisation for recurrent anterior dislocation.

Methods: This systematic review was performed in accordance with PRISMA guidelines. Studies reporting either clinical or radiological outcomes following arthroscopic bone block stabilisation for recurrent anterior dislocation were included. Primary outcomes were function and instability scores. Pooled analysis was performed when an outcome was uniformly reported by more than one study.

Results: Fifteen eligible studies were included; 12 used iliac crest bone graft while 3 used distal tibial allograft. The overall population comprised 265 patients (mean age range, 25.5–37.5 years; 79% participants were men). All post-operative outcome scores were significantly improved, and the overall rate of recurrent instability was low (weighted mean 6.6%, range 0 - 18.2%) at mean follow up of 30.4 months. The Rowe score was the most frequently reported outcome measure, improving on average by 53.9 points at final follow-up, exceeding the minimal clinically important difference (MCID) threshold. Graft union rates ranged between 92-100% in 8 out of 10 studies at mean follow up range 6-78.7 months but two reported lower rates ranging from 58.3 - 84% for autografts and 37.5% for allografts. Graft resorption rates averaged between 10-16% for autografts and 32% for allografts. Hardware-related complications occurred in 2%.

Conclusion: Arthroscopic bone block stabilisation is associated with high rates of graft union, significant improvements in the WOSI, Rowe, Constant and SSV scores (exceeding MCID thresholds where known), and a low rate of complications, including re-dislocation in the short to mid-term. Graft union rates were high, but the long-term implications of graft resorption (which occurs more frequently with allograft) are unknown.

A STRUCTURED PHYSIOTHERAPY PROTOCOL FOR ATRAUMATIC ANTERIOR STERNOCLAVICULAR JOINT INSTABILITY: EXPERIENCE IN A TERTIARY CENTRE

Authors: Tunnicliffe H, Armstrong A, Athanatos L, Singh H

Main Institution: Physiotherapy Department, Glenfield hospital

Purpose: To present the results of our experience of patients treated with physiotherapy for atraumatic sternoclavicular joint instability. Also to present a standardised method of assessing and treating these patients effectively with a structured physiotherapy programme.

Background: Atraumatic sternoclavicular joint (SCJ) instability is rare, with literature for outcomes being variable.

Objectives: Long term outcomes are presented for patients with atraumatic anterior instability of the SCJ, managed with physiotherapy. A standardised method of assessment and treatment with a structured physiotherapy programme is also presented.

Methods: A prospectively collected case series (2011-2019) of atraumatic patients were assigned to a structured physiotherapy programme. Outcome measures (including subjective SCJ grading of joint stability, Oxford shoulder instability score (OSIS adapted for SCJ) and visual analogue scale (VAS) for pain) were collected on discharge and at long term follow up (via postal questionnaire). Physiotherapy assessment and approach to treatment is described in detail.

Results: 26 patients (29 SCJ's, 3 bilateral cases) responded (return rate 81%). Median follow up was 5.1 years (range 0.9-8.3 years). 20/29 SCJs were in patients exhibiting hyperlaxity. 93% (27/29) of SCJs achieved a stable SCJ. Median OSIS score achieved at long term follow up was 37 (range 3-48) and VAS was 2 (range 0-9). 95% (18/19) of SCJs who were compliant with physiotherapy had a stable SCJ (mean OSIS 37.8 (SD 7.3) and VAS 1.6 (SD 2.1)). Those non-compliant had 90% (9/10) stability but lower function (mean OSIS 25 (SD 14, p=0.02) and more pain, VAS 4.9 (SD 2.9, p=0.006).

Conclusion: The structured physiotherapy programme is highly effective in carefully selected patients. Compliance was essential in ensuring better outcomes. All but 2 joints achieved a stable SCJ after treatment, with stability maintained at a median of 5.1 years.

SHOULDER INSTABILITY IN UK MILITARY PERSONNEL: DIAGNOSIS AND OUTCOMES OF ARTHROSCOPIC STABILISATION

Authors: Woods A, De Toledo A, Menon K, Granville-Chapman J.

Main Institution: Heatherwood and Wexham Park Hospital

Purpose: This study assessed the clinical course of military personnel with shoulder instability. We assessed the pattern of labral tears experienced by serving UK military personnel; the reliability of pre-operative diagnostic methods (arthrogram vs. clinical examination) and; finally, assessed their outcomes both in terms of satisfaction, pain, and return to full deployment.

Methods: Retrospective demographic and clinical data was collected for patients listed for arthroscopic stabilisation between September 2016 and January 2019 at our institution. For service evaluation, patient-reported outcome measures (PROMS) data and occupational outcome data were gathered.

Results: 41 patients were treated surgically. 24.4% had an isolated anterior tear, 41.5% had complex 2-zone or pan-labral tears on arthroscopy. Clinical examination showed higher sensitivity, accuracy and negative predictive value for picking up labral tear patterns compared to MRA. Mean pre-op OSIS score was 18.58 (SE ±1.67), and mean post-op score was 41.4 (SE ± 1.13). 69.69% returned to full deployment during the study period and 68.30% had returned to sport. Mean VAS score at rest was 0.8 (SE ±0.23), and 1.81 (SE ±0.54) during military fitness tests.

Conclusions: Complex labral tear patterns appear to be more common in military personnel with shoulder instability and clinical examination appears to be more effective than imaging at predicting injury pattern. Patients respond well to arthroscopic stabilisation with good rates of return to work and sport, regardless of chronicity of injury.

Clinical Relevance: History and focused examination findings should guide clinicians treating high-demand users, such as military personnel or sports people, with shoulder instability to have a high index of suspicion for complex labral tears and a low threshold for referral on to surgical care.

MODELLING FOR VARIATION IN SHOULDER POSTOPERATIVE THERAPY PROVISION

Authors: D Birchall, K Hodson, B Roy

Main Institution: Manchester University NHS Foundation Trust, Physiotherapy Department, Trafford General Hospital

Purpose: Our aim was to analyse post-operative physiotherapy provision in order to benchmark average number of treatments required for different shoulder surgeries, as review of the literature returned limited evidence regarding the practical implementation of a standardised protocol for post-operative physiotherapy following surgical management of shoulder pathologies.

Methods: We performed a five hospital, single trust, multi-surgeon retrospective review of all elective shoulder surgery patients between January 2018-March 2020, who were referred onto the physiotherapy service. Metrics included duration and number of treatments, and number of appointments cancelled or unattended (DNA), with subgroup analysis for each procedure. Multivariate analysis of variance (MANOVA) was used for analysis.

Results: 807 patients (mean age 55 years, range 14-89) were included. Age had no significant impact on any of the metrics. Average number of treatments was highest in the reverse TSA group (7.3 sessions), but outliers were also seen in this group (range 1-32, IQR 4.5). Duration of treatment was lowest in the ACJ reconstruction subgroup (mean 4.3, range 1-8, IQR 2.5). Patients undergoing arthroscopic subacromial decompression was the only group that required significantly fewer treatments and had a significantly lower duration of treatment. Duration of treatment was not correlated with the number of DNAs.

Conclusion: There is variation between the duration of physiotherapy required post elective shoulder surgery, with significant differences seen between subgroups of surgeries. These findings reveal which surgeries require a higher number of treatments, and thus which place a higher demand on therapy resources. Identification of treatment benchmarks can facilitate appropriate allocation of services and resources.

DIAGNOSTIC NEEDLE ARTHROSCOPY OF THE SHOULDER: A VALIDATION STUDY

Authors: Chowdhury A, Gibson C, MacLeod IA, Nicholls AJ, Ghazal L, Colaco HB

Main Institution: Department of Trauma & Orthopaedics, Hampshire Hospitals NHS Foundation Trust, Royal Hampshire County Hospital

Aims: Diagnostic needle arthroscopy has been developed to offer benefits over magnetic resonance imaging (MRI) in the diagnosis of intra-articular pathology. This is the first study to assess the usefulness of needle arthroscopy in the shoulder, in terms of diagnostic accuracy compared to MRI and the view of specific intra-articular structures when compared to conventional arthroscopy.

Methods: 22 patients underwent needle arthroscopy of the shoulder by a single fellowship-trained shoulder surgeon between November 2018 and February 2020. 20/22 patients had a preoperative MRI reported by a single musculoskeletal radiologist. A standardised 12-point non-instrumented diagnostic arthroscopy was performed on each patient using a 0˚ needle arthroscope followed by a 30˚ 4mm diameter conventional arthroscope under a general anaesthetic and regional block. Intra-operative images were randomised and reviewed by two independent blinded fellowship-trained shoulder surgeons for identification of pathology and anatomical structures.

Results: For the identification of rotator cuff pathology, needle arthroscopy (sensitivity 75.0%, specificity 100.0%) was superior to MRI (sensitivity 75.0%, specificity 75.0%) with an inter-observer reliability of 0.703. For long head of biceps pathology, needle arthroscopy (sensitivity 66.7%, specificity 94.7%) was superior to MRI (sensitivity 0.0%, specificity 82.4%). It was less accurate in the identification of labral (sensitivity 33.3%, specificity 50.0%, kappa 0.522) and articular cartilage pathology (sensitivity 0.0%, specificity 94.4%, kappa 0.353). The number of anatomical structures that could be clearly identified was 8.35/12 (69.56%) for needle arthroscopy versus 10.35/12 (86%) for standard arthroscopy.

Conclusion: We found diagnostic needle arthroscopy of the shoulder to be more accurate than MRI for the diagnosis of rotator cuff and long head biceps pathology, but less accurate for labral and cartilage pathology. The field of view of a 0˚needle arthroscope is not equivalent to a 30˚ conventional arthroscope, but is a useful diagnostic modality that may have applications in an outpatient setting.

INTRA-ARTICULAR STEROID AT THE TIME OF ARTHROSCOPIC CAPSULAR RELEASE DOES NOT INCREASE THE RISK OF SEPTIC ARTHRITIS

Authors: Eves T, Nadeem N, Booker S, Thyagarajan D, V Jones, Ali A

Main Institution: Northern General Hospital

Aim: To determine if intra-articular administration of steroid at surgery increases the risk of septic arthritis.

Background: Adhesive capsulitis/Frozen shoulder (FS) results in restricted glenohumeral joint (GHJ) range of motion. Its aetiology is unknown, but, the literature supports its association with multiple factors; female gender, diabetes, cardiovascular and thyroid disease. The pathology in Primary FS is partly attributed to myofibroblasts; causing capsular scarring and stiffening. Hettrich et al., demonstrated that steroid administration decreases the number of myofibroblasts with improvements in movement and pain scores at four weeks. The administration of intra-articular steroids at surgery is controversial, it suppress the immune system potentially increases the risk of infection. This study reviews our practice of giving steroid at the time capsular release with the aim of determining our rate of septic arthritis.

Method: We retrospectively searched our electronic records, identifying patients who underwent arthroscopic capsular release with steroid steroid injection, between January 2008 - January 2021. Further information regarding readmission and past medical history was collected. Three upper limb surgeons in our department manage primary FS identically: Under direct visualisation electrocautery is used to clear adhesions within the rotator interval, distally capsular release is continued to 5 o'clock. Subsequent joint manipulation completes the inferior capsular release. The trocar is reintroduced and steroid is injected though the valve into the GHJ.

Results: We identified 183 patients (Male:Female 78:103) with an average age of 52.5 yrs (range 28-78yrs). There were no readmissions for septic arthritis, or, wound site infections at the 2 week post-operative review. Our findings corroborate the reported risk factors; diabetes in 25% (DM2 -16%, DM1 - 9%), cardiovascular disease 34% and thyroid disease in 9%.

Conclusion: The use of intra-articular steroids in the surgical management of FS is safe and does not increase the rate of post-operative infection.

TEACHING SHOULDER JOINT CLINICAL EXAMINATION: IS THERE A ROLE FOR EDUCATIONAL VIDEOS TO AUGMENT TEACHING? A RANDOMISED SINGLE BLINDED CONTROL TRIAL

Authors: E Flatt, P Brewer, M Racy, F Mushtaq, R Ashworth, J Tomlinson, F Ali

Main Institution: University of Sheffield Medical School

Background: Good clinical examination skills can both increase the quality of care and reduce its cost. A These skills are often lacking in undergraduate and postgraduate trainees. A previous study by our group demonstrated face-to-face training is the gold standard for teaching skills in examination of the shoulder joint. It is unclear if high quality educational videos can augment this teaching.

Aim: To establish if a custom educational video significantly augments learning when compared with the gold standard of face-to-face teaching alone for shoulder joint clinical examination skills.

Methods: 42 Medical Students naïve to shoulder joint examination were recruited and block randomised to two groups. The control group had face-to-face (F2F) teaching alone. The intervention group (F2FV) had their teaching augmented with a custom educational video designed for this study and accessed via a web portal. Participants were assessed on their examination of a shoulder joint using a previously standardised assessment tool at baseline and seven days post intervention. Assessors were blinded to intervention type.

Results: There was no significant difference in the mean baseline scores. Mean baseline scores were 3.35 (F2F control group) and 2.65 (F2FV intervention group) [p=0.137]. There was a significant difference in post-intervention scores. Mean post-intervention scores were 18.5 (F2F control group) and 23.4 (F2FV intervention group) [p=0.005].

Conclusion: A custom-made educational video significantly improves the teaching of clinical examination of the shoulder joint. Given the critical importance of clinical examination skills there is a role for these resources in augmenting traditional teaching.

Implications: High quality educational video resources can augment face-to-face teaching of shoulder joint examination skills, thus increasing quality of patient care. Given the cost implications of poor examination skills teaching there is also the potential for a significant return on investment, although cost effectiveness studies are needed to assess this further.

INVESTIGATING MIRELS’ SCORING FOR UPPER LIMB METASTASIS- SHOULD THE CUT-OFF FOR PROPHYLACTIC SURGERY BE DIFFERENT?

Authors: Hoban K, Downie S, Adamson D, MacLean J, Cool P & Jariwala A.

Main Institution: Department of Trauma and Orthopaedics, Ninewells Hospital & Medical School

Mirels’ score predicts the likelihood of sustaining pathological fractures using pain, lesion site, size and morphology. Its reproducibility and reliability are questioned in the upper limb given small number of patients with metastasis here. The aim is to investigate its reproducibility, reliability and accuracy in upper limb bony metastatic disease and validate its use in pathological fracture prediction. A retrospective cohort study of patients with upper limb metastases, referred to a UK Orthopaedic Trauma Centre over 6-years (2013-18). Mirels’ score was calculated in 32 patients; plain radiographs at index presentation scored using Mirels’ system by 6 raters. The radiological aspects (lesion size &radiological appearance) were scored twice by each rater (2-weeks apart). Inter- and intra-observer reliability were calculated using Fleiss’ kappa test. Bland-Altman plots compared variances of individual score components and total Mirels’ score. Mirels’ score of ≥9 did not accurately predict lesions which would fracture (11% 5/46 versus 65.2% Mirels’ score ≤8, p Kappa values for interobserver variability were k=0.358 (fair, 0.288-0.429) for lesion size, k=0.107 (poor, 0.02-0.193) for radiological appearance and k=0.274 (fair, 0.229-0.318) for total Mirels’ score. Values for intraobserver variability were k=0.716 (good, 95% CI 0.432-0.999) for lesion size, k=0.427 (moderate, 95% CI 0.195-0.768) for radiological appearance and 0.580 (moderate, 0.395-0.765) for total Mirels’ score. We showed moderate to substantial agreement between and within raters using Mirels’ score on upper limb radiographs. This study demonstrates Mirels’ has poor sensitivity and specificity in predicting upper limb fractures. We recommend the score cut-off for prophylactic surgery in upper limb metastases should be lower than that recommended for lower limb lesions.

CORTICOSTEROID INJECTIONS ARE SAFE TO USE IN THE SHOULDER AND ELBOW DURING THE COVID-19 PANDEMIC

Authors: Raval P, Baguley M, Bhatt R, Pandey R

Main Institution: University of Hospitals of Leicester NHS Trust

Background: During the initial part of the COVID-19 pandemic corticosteroid injections (CSI) were stopped. Subsequently the BOA/NHS advised a cautious approach to CSI including a reduced dose, suggesting it could lead to greater susceptibility to COVID-19 or more severe symptoms.

Aim: Review whether patients undergoing CSI for shoulder and elbow conditions have an increased risk of developing COVID-19 infection or have worse symptoms.

Methods: Patients who underwent CSI to the shoulder and elbow between July 2020- February 2021 were included. Patients were consented for the possible increased risk of COVID-19 . CSIs were performed in outpatient setting using 40mg or 20mg of Depomedrone with 0.5% Marcaine. Patient were followed up at 6 and 12 weeks and asked in detail from an exhaustive list about COVID-19 symptoms/tests which were recorded.

Results: All 76 patients who had CSI were included. Mean age 57 (29-76). Female: Male (32: 44). 4 patients had diabetes. Only 3 patients received 20mg of Depomedrone, the rest had 40mg. Indications were: 11 Acromioclavicular Joint osteoarthritis (OA), 17 Frozen shoulder and 1 elbow OA. 35 patients for subacromial impingement or calcific tendonitis, 10 Tennis elbow and 2 for Golfer's elbow. At follow up no patient had suffered any COVID-19 symptoms, from the comprehensive list, nor required testing. 10 patients subsequently went on to have surgery, requiring pre-operative COVID-19 testing and were all negative. Additionally, post-surgery no patients has yet developed COVID-19 symptoms.

Conclusion: In our study group no patients who was given a CSI for shoulder and elbow conditions developed clinical symptoms of COVID-19 nor tested positive post injection. We suggest that CSI is a safe intervention in the shoulder and elbow during the pandemic especially when opportunities for surgical intervention are limited. Appropriate precautions like mask wearing and hand washing as well as clear discussion with patients are important.

CLINICAL AUDIT OF SHOULDER IMAGING IN PATIENTS REFERRED FROM GENERAL PRACTICE TO THE SHOULDER SERVICE OF OUR INSTITUTION

Authors: T Siempis, R Mahajan, R Pradhan

Main Institution: Department of Orthopaedic Surgery, George Eliot Hospital

Background: MRI and U/S are routinely used to investigate shoulder pathology. Given their high cost, it is important to understand referral patterns from primary care so that we can improve care, reduce cost and patient burden.

Aims: To assess the MRI and US requests from General Practice in patients referred to the shoulder service of our institution.

Methods: We retrospectively retrieved all GP referrals to the upper limb consultants and the physiotherapists from January 2019 to January 2020 and looked at whether an MRI or US was ordered by a clinician in primary care before the patient was seen by a shoulder specialist. The audit was registered with our local audit department and anonymised data was collected and analysed using Microsoft Excel. The results were presented in our clinical governance meeting.

Results: A total of 257 referrals to the shoulder service were identified. MRIs and/or US shoulder were ordered directly from a primary care setting in 14% and 36% of the patients respectively. Only a small proportion of these patients (22% and 36% respectively) ended up needing surgical intervention. On the contrary, when an MRI was requested by a shoulder specialist, the proportion of patients who underwent surgery was 50%.

Conclusion: According to NICE guidelines a shoulder US or MRI should not be ordered in primary care setting. Looking at our results, it appears that the majority of patients who had shoulder imaging organised by their GPs did not need surgery and these investigations could have been avoided. An unnecessary imaging request could delay referral to an upper limb consultant and compromise patient care. For this reason, as part of our audit a letter has been sent to the GPs raising this issue. We are now in the process of re-auditing and our results will be available in due course.

UPPER LIMB SPECIALIST INPUT IN TO INTENSIVE CARE TO PREVENT PRONING ASSOCIATED COMPLICATIONS: LEICESTER'S EXPERIENCE

Authors: Tunnicliffe H

Main Institution: University Hospitals of Leicester, Glenfield Hospital

Purpose: Impact of musculoskeletal upper limb specialist physiotherapy into Intensive Care Unit (ICU) on patient outcomes during the second wave of the pandemic is presented.

Method: Unilateral upper limb complaints associated with proning presented during the COVID19 pandemic. Following the first wave of the COVID19 pandemic, an electronic referral pathway was implemented directly to an extended scope physiotherapist (ESP) to assess/treat upper limb complaints in post COVID19 patients. The proning standard operating procedure was amended in response. January 2021, the COVID19 second wave dramatically increased numbers on ICU. Direct ESP input on ICU was initiated focussing on optimal positioning, risks of sustained positions/compression and traction risks to the brachial plexus. Ideal positioning visual references and peripheral nerve injury screening tools were created and distributed on all units. The ESP assisted with proning, repositioning and directly educating ICU staff. Sedated patients were assessed for joint stiffness/restrictions and mobilisations performed. Upon sedation reduction, assessments addressed specific upper limb deficits, patients engaged in active upper limb rehabilitation, and individual programmes created.

Results: Between March 2020-2021, 598 COVID positive patients were treated in Leicester's ICU's, many with prolonged length of stay. Two comparable 6-week windows were examined reflecting wave 1 and 2 of the pandemic (survivors data). Wave 1: 11 patients were identified/treated in physiotherapy post ICU discharge (all proned) (4 neuropathies, 2 frozen shoulder, 4 ACJ/impingement symptoms, 1 non-specific shoulder¬¬_pain) In comparison, Wave 2: 3 patients required post discharge follow up for overhead weakness (cuff) and loss of elbow extension. Such presentations can be associated with prolonged length of stay (average of 53.3 days) rather than proning complications.

Conclusion: Musculoskeletal therapy input to ICU focusing on education, proning, assessing and commencing early upper limb rehabilitation was extremely positive. This has identified a role for MSK input in the acutely critically unwell patient.

DOES ACROMIOCLAVICULAR JOINT TENDERNESS AFFECT THE OUTCOME OF ROTATOR CUFF REPAIR? A PROSPECTIVE COHORT STUDY

Authors: Amit P, Malik S, Massoud S.

Main Institution: The Royal Orthopaedic Hospital NHS Foundation Trust

Purpose: The purpose of this study was to assess the functional outcome of rotator cuff repair (RCR) without distal clavicle excision (DCE) in patients with degenerative rotator cuff tear and acromioclavicular joint (ACJ) tenderness.

Methods: A cohort of 70 patients undergoing arthroscopic RCR were prospectively evaluated. None of the patients underwent DCE. Preoperative parameters as demographic details and ACJ arthritis on imaging; and intraoperative parameters including long head of biceps tendon (LHBT) pathology were recorded. The ACJ tenderness and clinical outcome scores including Oxford shoulder score (OSS) and Quick-Disability of arm, shoulder and hand score (qDASH) were evaluated pre-operatively and at one-year post-operatively. Twelve-months outcomes were compared between two groups of patients (tender and non-tender ACJ).

Results: Four patients were lost to follow up. Of remaining 66 patients, ACJ tenderness was found in 50% (33 patients) of the total study population. The mean age of patients was 65.5 (10.2) and 58.1 (11.1) years in tender and non-tender ACJ groups respectively (p = 0.006). ACJ tenderness showed significant positive correlation with biceps tendinopathy (R = 0.37, p = 0.002), whereas there was no association of ACJ tenderness with ACJ arthritis. Post-operatively, there was significant improvements in clinical outcome scores which was comparable in both groups of patients (tender and non-tender ACJ groups). One patient in both the groups underwent revision rotator cuff repair, however there was no revision surgery due to symptomatic ACJ. Among patients with tender ACJ, seven patients (21.3%) had residual tenderness at one-year post-surgery who also demonstrated inferior outcome scores than patients with resolved tenderness.

Conclusion: The ACJ tenderness has no effect on outcome following RCR without DCE in short-term follow-up and therefore routine DCE in symptomatic ACJ is not necessary. Furthermore, patients with ACJ tenderness have higher incidence of LHBT tendinopathy.

COMBINING BRIEF INTERVENTIONS FOR MODIFIABLE HEALTH BEHAVIOURS WITH A BEST PRACTICE ADVICE INTERVENTION FOR PEOPLE WITH A ROTATOR CUFF DISORDER

Authors: Bury J, Littlewood C, Yeowell G, Selfe J, Jinks C.

Main Institution: Doncaster & Bassetlaw Teaching Hospitals NHS Foundation Trust, Physiotherapy Department, Doncaster Royal Infirmary

Purpose: To inform a future trial, a physiotherapist-supported treatment package ‘The COMBINED approach’ was developed that combined current best practice with strategies to assess and address modifiable lifestyle behaviours including smoking, physical inactivity, and overweight/obesity.

Methods: The treatment package was developed through a series of virtual stakeholder engagement workshops, using principles of co-design. Stakeholders included patients, physiotherapists, GP's, orthopaedic surgeons, academics, public health experts and health psychologists. Each workshop was video-recorded and, with the text chat, grouped into related themes and assessed against COM-B to help identify barriers and facilitators of physiotherapists delivering the combined intervention and their training needs. This iteratively informed the subsequent workshop, and generated a number of collective recommendations with regards to the design of The COMBINED approach and training package.

Results: Each multi-disciplinary workshop involved up to 25 stakeholders. The COMBINED approach was based on the principles of ‘Moving Medicine’ to address modifiable lifestyle behaviours. This included a simple and standardised approach that is time-limited; a ‘way-in’ with conversation starters; and resources such as scripts and patient infographics. Potential barriers to delivering this combined intervention were identified, including therapist confidence and fear in discussing lifestyle behaviours; skills required to deliver health behaviour change conversations; lack of understanding of the links with the lifestyle behaviours; and a lack of resources and time, which need to be factored in to a comprehensive training package.

Conclusions: Collective recommendations generated through the stakeholder workshops have informed the development of The COMBINED approach, including current best practice for people with rotator cuff disorders and an approach to identifying and addressing modifiable lifestyle behaviours associated with the onset and progression of rotator cuff disorders. The COMBINED approach will be developed further and tested in a future study, with the overall aim of improving outcomes for people with a rotator cuff disorder.

ARTHROSCOPIC SUPERIOR CAPSULAR RECONSTRUCTION: DOES GRAFT POSITION AFFECT OUTCOME?

Authors: Cross GWV, Barnett J, Morgan B, Makki D

Main Institution: Department of Trauma & Orthopaedic Surgery, Watford General Hospital

Introduction: Superior capsular reconstruction (SCR) has shown to be an effective joint preservation technique for irreparable tears of the supraspinatus tendon. Recent use of acellular dermal allografts have been shown to reduce surgical time and donor site morbidity. Ideal graft placement has not been explored to date. This study aims to assess if graft placement affects the patient reported Oxford Shoulder Score (OSS).

Method: The patient's OSS were carried out pre-operatively and at 12 months post-operatively. MRI of the shoulder was performed at 3-months post-operatively. These MRI scans were analysed and multiple measurements were taken by two independent, blinded Orthopaedic Surgeons. Measurements were taken on both the sagittal and coronal views. These measurements allow us to calculate the ‘comparative laterality of the graft footprint’ (coronal plane), ‘comparative size of graft’ and ‘centrality of graft’ (sagittal plane).

Results: A total of 35 cases of SCR were carried out from 2016-2020, with 5 being excluded from this study due to failure. The average pre-operative OSS was 16.89, which post-operatively increased to 35.07 (p

Conclusion: In patients undergoing SCR, the OSS significantly improved compared to pre-operatively (P

RECONSTRUCTION OF IRREPARABLE ROTATOR CUFF TEARS WITH AN ACELLULAR DERMAL MATRIX ALLOGRAFT AS AN INTERPOSITION GRAFT: A 9-YEAR FOLLOW UP STUDY

Authors: Modi A, Haque A, Deore V, Singh HP, Pandey R

Main Institution: Department of Orthopaedic Surgery, University Hospitals of Leicester

Background: The surgical management of irreparable rotator cuff tears in the younger population remains challenging. Most treatment options have unpredictable outcomes and some with significant morbidity. Long term outcomes following interposition grafting with an acellular dermal matrix allograft have not been reported previously. The purpose of the study was to evaluate long term outcomes of using acellular dermal allograft as an interposition graft for irreparable rotator cuff tears.

Methods: This was a prospective study reviewing long term clinical outcomes of 47 shoulders in 45 patients treated with an open cuff reconstruction using an acellular dermal matrix allograft to interpose irreparable cuff tears. All surgeries were performed between January 2007 and November 2011. Pre-operative, 1 year and mean 9.1 year (range, 7 years to 12.5 years) Oxford Shoulder Scores (OSS), pain scores and range of motion data were available for review.

Results: The average age at time of review was 70 years (range, 55 years to 81 years) with 32 males and 13 females. There was significant improvement in the OSS from 24.7 pre-operatively to 42 at 1 year and this improvement was maintained at 9.1 years with a score of 42.8 (P=0.0001). Similar improvements in the pain score were seen and maintained at final follow up from 6.1 to 2.1 (P=0.0001). There were significant improvements in all shoulder movements and patient satisfaction was high. No differences in outcome were observed based on tear size. No patients in this cohort have required revision surgery or conversion to a reverse shoulder replacement.

Conclusions: Results of this study show that the use of human dermal allograft in irreparable rotator cuff tears as an interposition graft leads to good outcomes that are maintained over 9 years.

REHABILITATION FOLLOWING ROTATOR CUFF REPAIR: A SURVEY EXPLORING CLINICAL EQUIPOISE AMONG SURGICAL MEMBERS OF BESS

Authors: C Littlewood, B Mazuquin, M Bateman, A Realpe, S Drew, J Rees

Main Institution: Department of Health Professions, Faculty of Health, Psychology and Social Care, Manchester Metropolitan University

Purpose: To inform a new national trial, we aimed to determine the factors that influence clinical equipoise across surgical members of BESS in relation to rehabilitation following rotator cuff repair.

Methods: We developed an online survey to explore clinical equipoise and inform the design of a national multicentre randomised controlled trial (RCT). The RCT will compare early patient-directed rehabilitation (early mobilisation) versus standard rehabilitation (delayed mobilisation) in patients undergoing surgical repair of full thickness rotator cuff tears. The survey described different clinical scenarios relating to patient age, tear size and location. We also asked whether other factors, including smoking status, diabetes, non-secure repair would influence equipoise. A link to the survey was emailed by BESS to its members and was open for one month.

Results: 76 surgeons completed the survey. 81% agreed/ strongly agreed that early mobilisation might benefit recovery and 57% were neutral/ disagreed that this approach risks re-tear. 87% agreed/ strongly agreed that there is clinical uncertainty about the effectiveness of different approaches to rehabilitation and 72% agreed/ strongly agreed that they would be interested in taking part in our future RCT. As age of the patient and size of tear increases, the proportion of respondents who would agree to recruit and accept the outcome of randomisation reduced, and this was compounded if subscapularis was torn. Other factors that would influence the decision of respondents to recruit patients to the RCT were diabetes, non-secure repair, and poor tissue quality.

Conclusion: Surgical members of BESS recognise uncertainty about the effectiveness of different approaches to rehabilitation following rotator cuff repair and are willing to participate in a future RCT. We have identified a range of factors that influence clinical equipoise, and a range of different opinions that will be considered and addressed in the design of a new national RCT.

EFFECTIVENESS OF EARLY VERSUS DELAYED REHABILITATION AFTER ROTATOR CUFF REPAIR: SYSTEMATIC REVIEW AND META-ANALYSES

Authors: Mazuquin B, Moffatt M, Gill P, Selfe J, Rees J, Drew S, Littlewood C.

Main Institution: Manchester Metropolitan University, Faculty of Health, Psychology and Social Care

Purpose: We investigated the effectiveness of early versus delayed mobilisation after rotator cuff repair for pain, function, range of movement, muscle strength, and repair integrity.

Methods: We searched databases and included randomised controlled trials (RCTs) comparing early versus delayed mobilisation after rotator cuff repair. We assessed risk of bias and used the GRADE framework to rate the certainty of the evidence.

Results: Twenty RCTs (n=1841 patients) were included. The majority of the RCTs were of high or unclear risk of overall bias. We found no differences for pain. We found a difference for the outcome measure Single Assessment Numeric Evaluation (single-item patient reported outcome; 0-100%, higher score indicates better outcome) at six months (MD: 6.54; 95%CI: 2.24-10.84, moderate certainty), and for shoulder flexion at six weeks three, six and 12 months in favour of early mobilisation. Similar results were found for other planes of movement. We found no difference for repair integrity at one year (OR: 1.26; 95%CI: 0.82-1.93, low certainty). Fifty-five percent reported the use of a standard sling and 30% reported the use of an abduction sling. The most common time in the sling was six weeks (40%); this varied from ‘no sling’ to eight weeks. Protocols were variable and cautious. Rehabilitation programmes followed a similar exercise progression starting with passive, advancing to active-assisted, active and strengthening. The timing for exercise progression varied. Most had a time-driven protocol and did not consider early active movements, whereas three used a more progressive patient-led approach.

Conclusion(s): Early mobilisation may help with a faster recovery of range of movement, without increased risk to repair integrity.

THE EFFECT OF CRYOTHERAPY ON PAIN POST ARTHROSCOPIC ROTATOR CUFF REPAIR (RCR): FEASIBILITY RANDOMISED CONTROLLED TRIAL

Authors: J Norris, S Garnham, CP Roberts, SZ Imam

Main Institution: East Suffolk and North Essex NHS Trust (ESNEFT)

Purpose: Feasibility study of a RCT to investigate whether cryotherapy using a self-applied ICEBAND® device reduces pain in the early post-operative period following arthroscopic RCR.

Method: Patients were randomised in theatre following arthroscopic RCR to either standard care (n=18) or standard care plus cryotherapy (n=20) and an ICEBAND® applied to those in the cryotherapy group and worn for one hour. Patients were instructed to reapply it as frequently as possible during the first 2 days post-operatively, then as per patient preference. VAS pain and sleep were self-completed daily for 2 weeks, at 4 and 6 weeks.

Results: 2 patients were withdrawn pre-randomisation as had another procedure, 1 patient withdrew due to post-op complications. 81% (n=30) of diaries were returned, of which 40% (n=12) were fully completed. During the first 2 days 100% of cryotherapy patients (n=17) wore the ICEBAND® at least 6 times, with 56.2% applying it at least 12 times in this period. 47%(n=8) reported they needed help to apply it. The mean pain VAS was lower in the cryotherapy group at every time point from day 1. This difference reached statistical significance on days 2, 3, 10, 12, 13 (P The mean sleep VAS was lower in the cryotherapy group at every time point from day 2, but only reached statistical significance on days 6 and 14 (P A power calculation performed for day 14 VAS pain showed a full power study requires 34 patients per group.

Conclusion: The study design is feasible, but more support may be needed to increase the frequency of ICEBAND® usage and diary completion and submission. There is tentative evidence that the use of cryotherapy reduces pain in the early post-operative period, but this is based on small numbers and a larger RCT is needed.

OUTCOME COMPARISON OF SUPERIOR CAPSULE RECONSTRUCTION AND SUBACROMIAL BALLOON SPACER FOR THE TREATMENT OF MASSIVE ROTATOR CUFF TEARS: A SYSTEMATIC REVIEW

Authors: O'Hanlon C, Al-Tawil K, Singh S, Sinha J

Main Institution: Department of Orthopaedic Surgery, King's College Hospital

Aim: To summarise the evidence available for both SCR and SBS in the context of massive rotator cuff tears and narrowly characterise patient subsets that may benefit from each intervention.

Background: Superior Capsule Reconstruction (SCR) and Subacromial Balloon Spacers (SBS) are novel treatments with similar biomechanical principles used in patients with massive rotator cuff tears. Medium term outcomes and indications for use in both SCR and ISB remain uncertain.

Methods: A systematic review was performed by searching Embase, Medline, PubMed and the Cochrane Library on 28 June 2020. Inclusion and exclusion criteria were applied to retrieve all records investigating SCR and SBS use in patients with MRCT. MINORS criteria were used to assess risk of bias.

Results: 26 Studies were included in this review. There were 442 shoulders in 13 SCR studies and 300 shoulders in 13 SBS studies. Mean follow up was 31.35 and 30.58 months respectively. Mean participant age was 62.90 in SCR and 65.87 in SBS. Both patient groups had medium to high grade fatty infiltration and minimal degenerative changes. Greater mean difference in ASES score at final follow was observed in SCR: 44.19 (10/13, n= 321) vs 36.46 (5/13, n=86) in SBS. Mean difference in CM of 30.02 observed in SBS (10/13, n=306). SBS had lower complication rates (3.5% vs 20 6.42%) and revision rates (4.21% vs 7.54%). Greater improvement in pain, strength and return to activity was observed following SCR. Both interventions significantly improved ROM and had high rates of patient satisfaction.

Conclusion: SCR demonstrates superior outcomes in younger, high demand populations. SBS can restore functionality in low demand patients or those not suitable for invasive surgery. Both interventions demonstrate outcomes comparable with established treatments at 5 years. Well-designed RCTs are required to improve an evidence base consisting of only non-randomised studies.

CLINICAL EFFECTIVENESS OF TENOTOMY VERSUS TENODESIS FOR LONG HEAD OF BICEPS PATHOLOGY: A SYSTEMATIC REVIEW AND META-ANALYSIS

Authors: Hartland AW, Islam R, Teoh KH, Rashid MS

Main Institution: The Princess Alexandra Hospital

Background: There remains much debate regarding the optimal method for the surgical management of patients with long head of biceps pathology. The purpose of this study was to compare the outcomes of tenotomy versus tenodesis using data synthesised from randomised controlled trials.

Methods: This systematic review and meta-analysis was registered on PROSPERO (ref: CRD42020198658). Electronic databases searched included EMBASE, Medline, PsycINFO, and Cochrane Library. Randomised controlled trials (RCTs) comparing tenotomy versus tenodesis were included. Risk of bias within studies was assessed using the Cochrane risk of bias v2.0 tool and the Jadad score. The primary outcome included patient reported functional outcome measures (PROMs). PROMs were pooled and reported using standardised mean difference (SMD) and a random effects model. Secondary outcome measures included visual analogue scale (VAS), rate of cosmetic deformity (Popeye sign), range of motion, operative time, and elbow flexion strength.

Results: 729 patients from 9 RCTs demonstrated (358 tenotomy vs 371 tenodesis) were included in the meta-analysis. Pooled analysis of all PROMs data demonstrated comparable outcomes between tenotomy vs tenodesis (SMD 0.12 95% CI -0.08 to 0.32, p=0.09). Sensitivity analysis comparing RCTs involving patients with and without an intact rotator cuff did not change the primary outcome. Secondary outcomes including VAS, shoulder external rotation, and elbow flexion strength did not reveal any significant difference. Tenodesis resulted in a lower rate of Popeye deformity (OR 0.27 95% CI 0.16 to 0.45, p

Conclusion/Findings: Aside from a lower rate of cosmetic deformity, tenodesis yielded no measurable significant benefit to tenotomy for addressing pathology in the long head of biceps. This finding was irrespective of the whether the rotator cuff was intact.

SUPERIOR CAPSULAR RECONSTRUCTION VERSUS BRIDGING GRAFT: A PROSPECTIVE RANDOMIZED CONTROLLED TRIAL

Authors: Thangarajah T, Tsuchiya S, Ono Y, More K, Lo IK

Main Institution: University of Calgary, Department of Trauma and Orthopaedic Surgery, Calgary, Alberta, Canada

Purpose: To compare arthroscopic superior capsular reconstruction (SCR) to bridging graft for massive irreparable rotator cuff tears.

Methods: A prospective double-blind randomized study was conducted to compare SCR versus bridging graft for massive irreparable rotator cuff tears. Fifty patients (mean age: 60.2 +/- 6.0 years) with chronic tears (mean duration of symptoms: 5 +/- 5.2 years) were intra-operatively randomized, following partial repair, to either bridging graft or SCR using human dermal allograft. All patients underwent a standardized rehabilitation program and were followed at 3, 6, 12 and 24 months clinically and radiographically. Graft integrity was assessed at 12 months using magnetic resonance imaging (MRI).

Results: 46 patients were available for follow-up at 2-years. The SCR group demonstrated significantly greater abduction (p

Conclusions: At 2 years follow-up there was no significant difference in patient reported outcome measures between bridging and SCR constructs. Compared to ruptured grafts though, intact grafts were associated with superior functional outcome scores and a higher acromiohumeral interval.

ARTHROSCOPIC INTERPOSITIONAL BRIDGING DERMAL ALLOGRAFT FOR REVISION ROTATOR CUFF REPAIR

Authors: Thangarajah T, Tsuchiya S, Lo IK

Main Institution: University of Calgary, Department of Trauma and Orthopaedic Surgery, Calgary, Alberta, Canada

Purpose: To report the clinical outcomes of arthroscopic interpositional bridging dermal allograft for revision rotator cuff repair.

Methods: 23 patients (26 shoulders) were retrospectively reviewed at a minimum follow-up of 24 (mean, 47; range, 24-77) months after an arthroscopic interpositional bridging dermal allograft for revision rotator cuff repair. All patients had one previous rotator cuff repair that went onto structural failure before having the bridging graft. The study group comprised 17 males and 6 females. Active range of motion in flexion and external rotation were recorded. Clinical outcomes were assessed using the American Shoulder and Elbow Surgeons (ASES) score and Western Ontario Rotator Cuff (WORC) Index. Graft integrity was assessed using magnetic resonance imaging (MRI).

Results: Mean age at the time of surgery was 56 (range, 40-74) years. The interval between the primary rotator cuff repair and interpositional bridging graft was a mean of 82 (range, 7-192) months. Forward flexion improved from a mean of 145° (range, 60-180°) preoperatively to 152° (range, 135-170°) postoperatively (p=0.3561). There was a decrease in external rotation from a mean of 50° (range, 20-80°) preoperatively to 37° (range, 0-45°) postoperatively (p=0.0021). Functional outcome scores were available for 12 shoulders. In these, the ASES score improved (p=0.0263) from a mean of 56 (range, 10-88) to 79 (range, 43-97), and the WORC index improved (p=0.0041) from a mean of 37 (range, 5-90) to 60 (range, 32-93). The graft was intact in 39% (7 of 18) of patients on MRI. Out of 11 retears, no patients underwent further surgery. No complications were noted.

Conclusions: Interpositional bridging grafting for revision rotator cuff repair leads to a significant improvement in patient reported outcome measures but is associated with a reduction in external rotation. Despite 39% of repairs being intact, no further surgery was required.

CEMENTLESS TOTAL SHOULDER REPLACEMENT FOR THE TREATMENT OF ACUTE PROXIMAL HUMERUS FRACTURES : RESULTS AFTER 8 YEARS OF FOLLOW UP

Authors: Consigliere P, Anastasopoulos P, Leonidou A, Panagopoulos G, Bachar Anvieli I, Qawasmi F, Sforza G, Levy O

Main Institution: Reading Shoulder Unit, The Berkshire Independent Hospital

Aim: The purpose of this study was to prospectively evaluate the clinical and radiographic outcomes of a cementless total shoulder replacement in acute proximal humerus fractures.

Materials and methods: From 2007 to 2019 50 patients underwent a cementless reverse shoulder replacement for acute proximal humerus fractures in our institution. Fifteen patients were excluded from postoperative evaluation. All operations were performed using the Neviaser - McKenzie approach and a completely cementless technique. All fractures were acute. Mean age was 80.23 years (± 10.39, range 40-94) and there were 7 male (20%) and 28 female (80%) patients. The mean follow up time was 25 months (± 24.17, range 2-106 months) and the mean time to surgery was 2 weeks.

Results: At the last follow up mean forward flexion was 125.4° (range, 30- 180°±42.7°), abduction 120° (range, 30-180°±43.2°), internal rotation 70.2° (range, 30-90°± 21.2°) and external rotation 27.7° (range,0-70° ±17.9°). The mean Constant Score was 59.54 (range, 24-92± 18) (age adjusted, 90.97). Eighteen (51.43%) patients reported excellent results, 13 (37.14%) had good results, and the remaining 4 (11.43%) rated their outcome as fair while there were no dissatisfied patients. There were no complications in the study group while tuberosity healing was achieved in 82.86% of the cases (n=29).

Conclusion: Cementless RTSA for acute proximal humerus fractures demonstrates excellent clinical, radiographic results and patient satisfaction similar to cemented RTSA. In our series the cementless implant did not result in early loosening making its use promising in the long term.

IMPROVING HUMERAL SHAFT FRACTURE MANAGEMENT: IMPLEMENTATION OF A NEW CLINICAL PATHWAY

Authors: SJ Arnold, AP Dekker AP, M Espag, AA Tambe, DI Clark

Main Institution: Royal Derby Hospital

Background: Humeral shaft fractures have traditionally been treated using functional braces with perceived low costs and high union rates whilst avoiding the risks of surgery. The Radiographic Union Score for HUmeral fractures (RUSHU) and fracture mobility at 6 weeks have recently been shown to predict union by 6 months in patients treated conservatively. This study assesses the effectiveness of a new clinical pathway which incorporates the RUSHU score and fracture mobility implemented in our department.

Methods: An audit of consecutive conservatively managed humeral shaft fractures was identified prior to implementation of the pathway (Sept-Nov 2019) was undertaken. A new management pathway for humeral shaft fractures was created stipulating review in an upper limb specific fracture clinic at 6 weeks for assessment of RUSHU score and fracture mobility. A decision should then be made whether to proceed with conservative management or consider ORIF if the patient is at risk of non union (RUSHU

Results: The implementation of our management pathway has reduced the number of X-Rays (Mean 6.2 vs 5.1), fracture clinic appointments (mean 5.3 vs 3.4) and occupational therapy appointments (mean 12.4 vs 10.1) that the patient has to attend. All humeral shaft fractures are seen in an upper limb fracture clinic. Examination for fracture mobility at 6 weeks increased from 33% to 64%, RUSHU score was calculated in 46% of patients, helping to reduce time to definitive decision making from a mean of 11.3 weeks to 6 weeks.

Conclusions: Implementation of a new clinical pathway has initially improved practice; reducing patient attendances to hospital, earlier definitive management decisions and therefore avoidance of prolonged unsuccessful conservative treatment in patients likely to go on to non union.

MINIMALLY INVASIVE STRAIN REDUCTION SCREW FIXATION FOR NON UNIONS AROUND THE ELBOW

Authors: Bellringer SF, Dirckx M, Jukes C, Guryel E, Phadnis J.

Main Institution: University Hospitals Sussex NHS Trust

Background: Non-unions following fracture fixation result in significant patient morbidity and financial burden. Traditional management of hypertrophic non-union around the elbow consists of removal of metalwork, debridement of the non-union and re-fixation with compression, often with bone grafting. In the lower limb, there is recent evidence that select non-unions can be managed with minimally invasive placement of screws across the non-union in order to reduce inter-fragmentary strain and facilitate union. To our knowledge, this has not been described around the elbow, where traditional more invasive techniques continue to be employed.

Aims: The aim of this study was to describe the application of strain reduction screws for management of select non-unions around the elbow.

Methods & Results: We describe 4 cases (two humeral shaft, one distal humerus and one proximal ulna) of established non-union following previous internal fixation, where minimally invasive placement of strain reduction screws was performed. In all cases, no existing metal work was removed, the non-union site was not opened and no bone grafting or biologic stimulation was used. Surgery was performed between 9 and 24 months after the original fixation. 2.7mm or 3.5 standard cortical screws were placed across the nonunion without lagging. Three fractures went on to unite with no further intervention required. One fracture required revision fixation using traditional techniques. Failure of the technique in this case did not adversely affect the subsequent revision procedure and has allowed refinement of the indications.

Conclusion: Strain reduction screws can be used successfully for treatment of select non-unions around the elbow. This technique has potential to be a paradigm shift in the management of these highly complex cases and is the first description in the upper limb to our knowledge.

ACUTE DISTAL BICEPS TENDON REPAIR USING CORTICAL BUTTON FIXATION RESULTS IN EXCELLENT SHORT AND LONG-TERM PATIENT OUTCOME: A SINGLE-CENTRE EXPERIENCE OF 102 PATIENTS

Authors: Carter TH, Karunaratne BJ, Oliver WM, Murray IR, White TO, Reid JT, Duckworth AD

Main Institution: Edinburgh Orthopaedic Trauma, Royal Infirmary of Edinburgh

Purpose: The purpose of this study was to report the short- and long-term outcome of acute distal biceps tendon repair using cortical button fixation.

Methods: Between 2010-2018, 102 patients (101 males; mean age 43 years) underwent acute (6 weeks) distal biceps tendon repair using cortical button fixation. The primary short-term outcome was complications. The primary long-term outcome was the Quick-DASH (Q-DASH). Secondary outcomes included the Oxford Elbow Score (OES), EuroQol-5D-3L (EQ-5D), satisfaction and return to function.

Results: There were eight patients (7.8%) that had a major complication and 34 patients (33.3%) a minor complication. Major complications included re-rupture (n=3, 2.9%), unrecovered nerve injury (n=4, 3.9%) and surgery for heterotopic ossification excision (n=1, 1.0%). Three patients (2.9%) required surgery for a complication. Thirty-three nerve injuries occurred in 31 patients (30.4%). Minor complications included neurapraxia (n=27, 26.5%) and superficial infection (n=7, 6.9%). At a mean follow-up of 5 years (1 – 9.8) outcomes were available for 86 patients (84.3%). The median Q-DASH, OES, EQ-5D and satisfaction scores were 1.2 (IQR 0 – 5.1), 48 (IQR, 46 – 48), 0.80 (IQR, 0.72 – 1.0) and 100/100 (IQR, 90 – 100) respectively. A majority of patients returned to sport (82.3%) and employment (97.6%) following surgery. Unrecovered nerve injury was associated with a poor outcome according to the Q-DASH, OES, EQ-5D, and satisfaction (all p

Conclusions: Acute distal biceps tendon repair using cortical button fixation results in excellent patient reported outcomes and health-related quality of life in the setting in which it was studied. Although rare, unrecovered nerve injury adversely affects outcome.

BRACE IT OR FIX IT? – DELAYED HUMERUS FIXATION PROLONGS HEALING TIME

Authors: Arnold SJ , Chuttha S, Dekker AP, Clark DI, Tambe AA

Main Institution: Royal Derby Hospital

Background: Humeral shaft fractures have traditionally been treated conservatively using functional braces with perceived low costs and high union rates whilst avoiding the additional risks of surgery. More contemporary studies have identified high rates of nonunion with conservative management. This study aims to determine the factors associated with delayed union and compare acute versus delayed surgical fixation.

Methods: A consecutive series of humeral shaft fractures was identified over a 4-year period (April 2015–May 2019). Retrospective analysis of case notes and radiographs was performed. Fractures were analysed in two main groups; conservatively treated fractures and operatively treated fractures.

Results: 141 fractures were identified. 99 were treated conservatively and 42 with acute surgical fixation (within 6-weeks). Of the conservatively treated fractures (42M, 57F), 61 had united by 6-months and 38 had not. Factors associated with non-union at 6-months were a clinically mobile fracture at 6-weeks and less visible callus on radiographs as assessed by the Radiographic Union Score for HUmeral fracutres (RUSHU). Median weeks to union was 17(IQR 13). A longer time to union was seen in smokers (25.5 weeks vs 16 weeks;P=0.04); fractures in the lower-third of the humerus (30 weeks) vs middle-third (16-weeks) and upper-third(19-weeks;P=0.039); mobile fracture at 6-weeks(29 weeks vs 16-weeks;P=0.008); RUSHU score 8+(16-weeks) vs Acutely operated fractures healed at mean 19-weeks(SD11.8) vs 27.2 weeks(SD16) from time of surgery in those with delayed fixation(P=0.034) which was in addition to the time spent being treated conservatively in a brace (median 30 weeks).

Conclusions: Treatment of humeral shaft fractures in a humeral brace is effective; however, the importance of identifying those at risk for delayed or nonunion can avoid delayed fixation which is associated with a longer healing time than acute fixation.

Disclosure: None to declare.

COMPLICATION PROFILES OF TENSION BAND WIRING, SINGLE DORSAL PLATING AND LOW-PROFILE DOUBLE PLATING FOLLOWING FIXATION OF ISOLATED OLECRANON FRACTURES

Authors: Singhania K, Donald N, Fisher N, White A, Robinson PM.

Main Institution: Department of Trauma and Orthopaedics, Peterborough City Hospital, North West Anglia NHS Foundation Trust

Aims: To compare the complication profiles of three methods of olecranon fracture fixation.

Methods: Retrospective analysis of surgically treated isolated olecranon fractures from a single centre comparing three techniques; tension band wiring (TBW), single dorsal plating and low-profile double plating. Patients were identified using a local database between January 2014 and December 2020 and fractures classified using the Mayo classification. Electronic patient records, operation notes, x-rays and clinic letters were used to identify the sequelae of treatment.

Results: We identified 114 surgically treated, isolated olecranon fractures; 51 TBW (24% ≥Mayo 2B), 17 single dorsal plates (77% ≥Mayo 2B) and 46 low-profile double plates (80% ≥Mayo 2B). The rate of complications requiring surgical intervention varied within each group; single dorsal plating 8(47%), TBW 20(39%) and low-profile double plating 7(15%). Of these, prominent metalwork requiring removal was the most common; single dorsal plating 7(41%), TBW 15(29.4%) and low-profile double plating 5(11%). Failure of fixation requiring further surgery occurred in 1(2%) double plating, 3(6%) TBW and 0(0%) single dorsal plating. One patient in each group required surgery for an infection related complication.

Conclusion: Whilst indications for fixation technique vary, we can extrapolate from our data that the overall complication rates post-operatively were lowest using a low-profile double plating system, despite this technique being utilised to fix a higher proportion of comminuted and displaced fractures. To our knowledge this study represents the largest reported cohort of low-profile double plates used for this indication.

RELIABILITY OF A NEW CLASSIFICATION FOR PROXIMAL ULNA FRACTURE DISLOCATIONS OF THE ELBOW

Authors: Ghori H, Bagga R, Murphy R, Tathgar A, Phadnis J

Main Institution: Department of Orthopaedic Surgery, Royal Sussex County Hospital

Background: Proximal ulna fracture dislocations encompass a range of injuries with different eponymous names and classifications. Consequently, they can be confusing to describe, classify and manage. The Radius, Proximal Ulna, Coronoid, Soft tissue (RUCs) system was developed to simplify assessment by concentrating on the surgically important components and their effect on outcome.

Purpose: This study evaluates inter- and intra-observer reliability of this new classification.

Methods: 177 patients with a proximal ulna fracture and associated ulnohumeral and/or proximal radio-ulnar joint dislocation were included. X-rays and CT scans were reviewed by four observers on two different occasions with a 4-week interval. The Radius (R), Proximal Ulna (U) and Coronoid (C) components were each scored for severity from 0-2 depending on pre-determined parameters. The soft tissue component (‘s’) was not rated as this is an intra-operative component. Inter- and intra-observer reliability was calculated using Cohen's weighted kappa. X-ray and CT reliability were compared. The Landis and Koch criteria was used to interpret the strength of the kappa statistics.

Results: 119 patients had only X-rays and 58 patients had X-ray and CT scans. In the X-ray cohort, there was ‘almost perfect’ inter-observer agreement for the radius (k=0.94) and coronoid (k=0.83), and ‘substantial’ agreement (k=0.68) for the proximal ulna across observing both sets. For the X-ray and CT cohort, inter-observer reliability was ‘almost perfect’ using both modalities for the radius (k=0.88 and k=0.93, respectively) and ‘moderate’ for the ulna component (k=0.48 and k=0.52, respectively). The coronoid component showed ‘substantial’ X-ray agreement and ‘almost perfect’ CT agreement (k=0.74 and k=0.89, respectively). Intra-observer agreement was ‘almost perfect’ for all components, other than CT assessment of the ulna which was ‘substantial’ (k=0.74).

Conclusion: The RUCs classification demonstrated strong inter- and intra-observer reliability when using both X-ray and CT scans supporting its reliability in classifying proximal ulna fracture dislocations.

RADIOLOGICAL ANALYSIS AND OUTCOMES OF ISOLATED GREATER TUBEROSITY FRACTURE DISLOCATIONS

Authors: Saleem J, Guevel B, Gillott E, Domos P

Main Institution: Royal Free NHS Foundation Trust

Purpose: The purpose of this study was to investigate different radiological characteristics for isolated greater tuberosity (GT) fracture dislocations and their effect on complication and reoperation rates.

Methods: We performed a two-centre, retrospective review of all patients who sustained an isolated GT fracture dislocation with minimum 1 year follow-up. Patients were split into Group A

Results: 101 patients were included in this study and significantly more males were found in Group A (p = 0.019). 87% of the dislocations were subcoracoid type and avulsion fracture type were the most common (61%). 66% of fractures had some degree of comminution with higher rates of non-union in group B (33%)(p=0.172). 41% of fractures had a complication, with an overall 27% non-union rate. No non-unions occurred in fractures reduced in theatre compared to 29% non-union in fractures reduced in ED (p

Conclusion: This study highlights the high complication rates associated with isolated GT fracture dislocations. Certain radiological parameters such as fracture type and size should be taken into consideration when risk stratifying, as should reducing these fractures in a theatre setting, especially in patients≥65 years where the complication risk is higher.

RANDOMISED PROSPECTIVE COMPARATIVE ANALYSIS OF FUNCTIONAL OUTCOME OF OSTEOSYNTHESIS OF INTRA-ARTICULAR DISTAL HUMERUS FRACTURE USING TRICEPS REFLECTING AND TRANSOLECRENON APPROACH

Authors: Jagadeesh N, Shivalingappa V

Main Institution: Department of Orthopedics, Vydehi Institute Of Medical Sciences, Bangalore, Karnataka, India

Background: Intra articular fractures of distal humerus is one of the demanding injuries to manage due to its complex anatomy. Open reduction internal fixation is able to achieve painless, stable and mobile joint but the ideal approach for fixation is controvertial. This study is aimed at comparing functional outcome of patients treated with triceps reflecting and olecranon osteotomy approach.

Methods: A hospital based randomized comparative study of 40 patients who diagnosed with distal humerus intraarticular fracture admitted in our hospital from April 2017 to March 2019 and radomization was done using computer software before the surgery. Triceps reflecting approach (group A) was used in 20 patients and olecranon osteotomy approach (group B) in 20 patients. Elbow range of movements and Mayo elbow performance score (MEPS) was used to compare outcome.

Results: The mean elbow range of motion is 95.8±13.5 degree at 1 year follow up in group A and 94.5±9.3 degree in 1 year follow up at 1 year follow up in group B. The mean MEP score at end of 1 year in group A was 93.8±2.9 and in group B was 91.5±3.2 shows excellent results but there was no statistically significant difference between MEP scores of two groups. We observed 6 patients developed extension lag less than 10 degree in group A which was clinically insignificant to patients and 7 patients developed hardware prominence in group B.

Conclusions: Triceps reflecting Bryan Morrey approach is equally effective as olecranon osteotomy approach in treatment of distal humerus intra articular fracture with less complication and operative time.

A VIDEO ANALYSIS OF DISTAL BICEP TENDON RUPTURES: CHALLENGING THE TRADITIONALLY ACCEPTED MECHANISM OF INJURY

Authors: Jukes C, Dirckx M, Chaundy W, Bellringer S, Phadnis J

Main Institution: Department of Trauma & Orthopaedics, Brighton & Sussex University Hospitals NHS Trust

Aim: To utilise online video evidence of distal bicep tendon ruptures (DBTR) to assess the mechanism of injury.

Methods: Google and social media channel ‘YouTube’ were used to search for documented videos of DBTR in the public domain. Only videos with clear visual evidence of a distal biceps rupture were included. Videos were reviewed separately by 3 surgeons to document sagittal plane elbow position, forearm rotation, and type of muscle contraction at the moment of rupture. The Fleiss Kappa method was used to assess inter-observer agreement between raters.

Results: After exclusions, 56 videos of a DBTR were available for review. All ruptures occurred in men, with 35 (63%) affecting the left arm. Activities causing the rupture included: 38 deadlifts (68%); 5 bicep curls (9%); 5 calisthenic 'planches' (9%); 4 arm-wrestling (7%); 3 lifting a heavy object (5%); and 1 boxing (2%). At the moment of rupture, 55 (98%) forearms were in supination, and 50 (89%) were in 0-10° elbow flexion. Muscle contraction was isometric in 49 (88%), concentric in 3(5%) and eccentric in 4(7%). Inter-observer agreement was “excellent” for elbow position and forearm rotation, and “good” for muscle contraction.

Conclusion: Contrary to many classical descriptions of DBTR, the most commonly documented mechanism in this series was an isometric muscle force with the forearm fully supinated and the elbow at or near full extension. This has implications for training across a range of sports but with particular reference to deadlifting technique.

RADIAL HEAD ARTHROPLASTY FOR TRAUMA: MEDIUM TO LONG TERM OUTCOMES OF PRESS-FIT RADIAL HEAD ARTHROPLASTY

Authors: Kankanalu P, Eyre-Brook A, Majowski L, Jones V, Thyagarajan D, Ali A, Booker S

Main Institution: Northern General Hospital, Sheffield Teaching Hospitals NHS Foundation Trust

Aim: To evaluate the long-term survival of radial head arthroplasty (RHA) for unreconstructable radial head fractures and to report on the clinical, radiological, and patient-reported outcomes.

Patients and Methods: Retrospective review of consecutive primary RHA's for trauma at a single trauma centre between 2007 and 2020. The primary outcome was survivorship of the implant. Secondary outcomes were clinical, radiographic, and patient-reported outcomes; Oxford Elbow Score(OES) and Mayo Elbow Performance Score(MEPS).

Results: One hundred RHA's in 63 men and 37 women with a mean age of 44years(SD 15) were included. Indications for RHA were unreconstructable radial head fractures with concomitant elbow instability(39); terrible triad injury(32); complex proximal ulna fracture-dislocations(25) and Essex-Lopresti injury(4). Eight patients subsequently underwent excision of the RHA. An additional 15 patients underwent a further procedure. Kaplan-Meier cumulative survival was 90.1% at 10-years. Seventy-five patients were available for review. The median time of review was 80 months(range 13 to 164) from injury. The mean flexion arc was 980(5 to 140), supination 690 and pronation 740. The mean OES was 36.1(7 to 48) and the mean MEPS was 82.4(15 to 100). 72% of patients reported full and 13% partial return to their pre-injury activity level. Mean time from injury to the last radiographic assessment was 17 months (SD 23.1). Capitellar erosion was noted in 16; Radiographic loosening of the stem in 32; Bone resorption around the neck of the prosthesis in 43; heterotrophic ossification in 15. The stem position in the canal was central in 80 patients. The was no statistically significant difference in OES or MEPS in patients with and without radiological loosening(p=0.221).

Conclusion: Our series has demonstrated that despite the high incidence of clinical and radiological complications, press-fit RHA for unreconstructable radial head fractures yields a 10-year survival of 90.1% with good patient-reported outcomes.

ACUTE PLATE FIXATION OF DISPLACED MIDSHAFT CLAVICLE FRACTURES IS NOT ASSOCIATED WITH EARLIER RETURN OF NORMAL SHOULDER FUNCTION WHEN UNION IS ACHIEVED

Authors: Nicholson JA, Clement ND, Clelland A, Macdonald D, Simpson AHRW, Robinson CM

Main Institution: Department of Trauma and Orthopaedics, Royal Infirmary of Edinburgh

Purpose: It is unclear whether acute plate fixation facilitates earlier return of normal shoulder function following a displaced midshaft clavicle fracture compared to non-operative management when union occurs.

Methods: Patient data from a randomized controlled trial was used to compare acute plate fixation with non-operative management of united fractures. Return of shoulder function was based on the age and sex matched DASH scores for the cohort. Independent predictors of an early recovery of normal shoulder function was investigated using a separate prospective series of consecutive non-operative displaced midshaft clavicle fractures recruited over a two-year period (≥16 years). Patient demographics and functional recovery were assessed over the six months post-injury using a standardized protocol.

Results: Data from the randomized controlled trial consisted of 86 patients who underwent operative fixation compared to 76 patients that united with non-operative treatment. The recovery of normal shoulder function, as defined by a DASH score within the predicted 95% confidence interval for each respective patient, was similar between each group at six-weeks (operative 26.7% vs non-operative 25.0%, p=0.80), three-months (52.3% vs 44.2%, p=0.77) and six-months post-injury (86.0% vs 90.8%, p=0.35). The mean DASH score and return to work was also comparable at each time point. In the prospective cohort 86.5% (n=173/200) achieved union by six months post-injury (follow-up rate 88.5%, n=200/226). Regression analysis found no specific patient, injury or fracture predictor was associated with an early return of function at six or twelve weeks.

Discussion: Return of normal shoulder function was comparable between acute plate fixation and non-operative management when union was achieved. One in two patients will have recovery of normal shoulder function at three months, increasing to nine out of ten patients at six months following injury when union occurs irrespective of initial treatment.

ADOLESCENT DISPLACED LATERAL-END CLAVICLE FRACTURES ARE NOT COMPARABLE TO THE ADULT VARIANT. EPIDEMIOLOGY, FRACTURE PATTERNS AND OUTCOME OF NON-OPERATIVE MANAGEMENT

Authors: Teed R, Ng Nathan, Chen P, Nicholson JA

Main Institution: Department of Trauma and Orthopaedics, Royal Infirmary of Edinburgh

Purpose: Displaced lateral-end clavicle fractures in adolescents are uncommon injuries. It is unclear if this injury has a risk of nonunion comparable to that in the adult population. The primary aim of this study was to determine the epidemiology of lateral-end clavicle fractures in the adolescent population. The secondary aim was to assess outcome following non-operative management.

Methods: A retrospective review of all adolescent clavicle fractures (aged 13-17) that presented to our region over a 10-year period was undertaken. Fracture classification, patient demographics, management and complications were analysed. Long-term outcomes of non-operatively managed displaced Neer type IIA and IIB fractures were obtained using the QuickDASH and EQ-5D.

Results: 677 clavicle fractures occurred over the study period but only 8.7% were lateral-end fractures (n=59/677). The median age was 14.6 (range 13-17) and 92% were male (n=54/59). The most common fractures were undisplaced (Neer 1 n=28), physeal (Neer type IV n=14) and intra-articular minimally displaced (V n=2). Fifteen fracture were completely displaced with no cortical contact (Neer IIA n=8 and IIB n=7). The incidence of displaced lateral-end fractures in adolescents was approximately 0.17 per 100,000 population per year. Approximately one third of the displaced fractures underwent acute fixation and united without complications (n=5/15). Of the non-operatively managed displaced fractures (n=10/15) there was one case of nonunion in a malnourished patient with systemic co-morbidities (10%). Mean age (15.3 vs 14.7,p=0.21) and overall fracture displacement (16.7mm vs 14.8mm,p=0.34) was comparable between operative and non-operative groups. Long-term follow-up was undertaken at 8.7 years post-injury in the non-operative displaced fractures that united (n=5/9) The mean QuickDASH was 3.2 and EQ-5D was 1.0.

Conclusion: Displaced lateral-end clavicle fractures are rare injuries in the adolescent population. Nonunion is rare and would appear to be less than the adult variant of these injuries.

LONGER-TERM OUTCOMES FOLLOWING A HUMERAL SHAFT FRACTURE: RESULTS FOR 291 PATIENTS AT A MINIMUM ONE-YEAR FOLLOW-UP

Authors: Oliver WM, Searle HKC, Molyneux SG, White TO, Clement ND, Duckworth AD

Main Institution: Edinburgh Orthopaedics – Trauma, Royal Infirmary of Edinburgh

Purpose: The primary aim was to assess patient-reported outcomes at a minimum of one year following a humeral diaphyseal fracture. The secondary aim was to compare the outcomes of patients who united after initial management (operative/non-operative) with those who united after nonunion surgery.

Methods: From 2008-2017, 291 patients (mean age 55yrs [17-86], 58% [n=168/291] female) were retrospectively identified and available for follow-up. Sixty-four (22%) were managed operatively (within 12wks of injury) and 227 (78%) non-operatively. After initial management, 227 patients (78%) united (n=62 operative, n=165 non-operative), two had a delayed union (both non-operative) and 62 (21%) developed a nonunion (n=2 operative, n=60 non-operative). Fifty-two of 56 patients (93%) subsequently united after nonunion surgery. Patient-reported outcomes (QuickDASH, EuroQol 5-Dimension [EQ-5D] and Visual Analogue Scale [EQ-VAS], 12-item Short Form Health Survey score [SF-12]) were obtained via postal survey at a mean of 5.5yrs (1.2-11.0) post-injury.

Results: The mean QuickDASH was 20.8, EQ-5D 0.730, EQ-VAS 74, SF-12 pain component summary (PCS) 44.8 and mental component summary 50.2. Patients who united after nonunion surgery reported a worse functional outcome (mean QuickDASH 27.9 vs. 17.6, p=0.003) and health-related quality of life (HRQoL; mean EQ-5D 0.639 vs. 0.766, p=0.008; EQ-VAS 66 vs. 76, p=0.036; SF-12 PCS 41.8 vs. 46.1, p=0.036) than those who united after initial management. When adjusting for confounders, union after nonunion surgery was independently associated with poorer function (difference in QuickDASH 8.1, p=0.019) and HRQoL (difference in EQ-5D -0.102, p=0.028).

Conclusions: Longer-term patient-reported outcomes following a humeral shaft fracture were satisfactory. Patients achieving union after nonunion surgery reported poorer limb-specific function and HRQoL when compared to those who united after initial management. Strategies to identify and target early operative intervention to patients at risk of nonunion may have an important role, given the potential impact of nonunion on longer-term outcome.

RETURN TO WORK AND SPORT FOLLOWING A HUMERAL SHAFT FRACTURE

Authors: Oliver WM, Molyneux SG, White TO, Clement ND, Duckworth AD

Main Institution: Edinburgh Orthopaedics – Trauma, Royal Infirmary of Edinburgh

Purpose: The primary aim was to determine the rate of return to work and sport following a humeral diaphyseal fracture. The secondary aim was to identify factors associated with failure to return to work and sport.

Methods: From 2008-2017, all patients with a humeral diaphyseal fracture were retrospectively identified. Details of pre- and post-injury work and sport were obtained via postal survey. The Work Group comprised 177 patients in employment prior to injury (mean age 47yrs [17-78], 50.8% female [n=90/177]) and the Sport Group comprised 182 patients involved in sport (mean age 52yrs [range 18-85], 57.1% female [n=104/182]).

Results: Mean follow-up for the Work Group was 5.8yrs (1.3-11). Eighty-five percent (n=151/177) returned to work at a mean of 14wks post-injury (range 0-104). Of these, 59.9% (n=106/177) returned full-time to their previous employment. Female sex (OR 2.5, p=0.042), alcohol-abstinence (OR 3.0, p=0.024), heavy-manual work (OR 5.5, p=0.031), sustaining a right- (OR 2.8, p=0.019) or dominant-sided injury (OR 2.4, p=0.044) and proximal-third fracture (OR 4.6, p=0.014) were associated with failure to return to work. Mean follow-up for the Sport Group was 5.4 years (1.3-11). The mean University of California, Los Angeles Activity Score reduced from 6.9 before injury to 6.1 afterwards (p

Conclusions: Most patients successfully return to work and sport following a humeral diaphyseal fracture. Specific risk factors exist for failure to return to work and sport, which may be useful for surgeons counselling patients about expected return to activity after these injuries.

RADIOLOGICAL AND LONG-TERM FUNCTIONAL OUTCOMES OF DISPLACED DISTAL CLAVICLE FRACTURES: A SINGLE CENTRE EXPERIENCE

Authors: Srinivasan A, Haque A, Kheiran A, Singh H

Main Institution: Department of Trauma and Orthopaedic Surgery, Leicester Royal Infirmary

Purposes of the study: The purpose of this study was to investigate the long-term functional outcome of patients with displaced distal clavicle fractures.

Methods: A retrospective review of patients with distal clavicle fractures was undertaken at a single large trauma unit from 1/1/2010 to 31/12/2017. Demographic and management data were obtained from hospital electronic databases. Radiographs were reviewed for fracture characteristics, classification, fixation and union using Picture Archiving Systems. Patients completed a Distal Clavicle Fracture Outcome Measure questionnaire which included QuickDASH (Disabilities of the Arm, Shoulder and Hand), Work, Sports/ Performing Arts, Global Satisfaction and complication modules.

Results: Over seven years, 539 patients were treated for distal clavicle fractures of which 21% were displaced (115 patients, mean age 49 (18-89) years). 29% (33/115) received early surgery (0.05). 50% of surgically managed patients reported wound complications.

Conclusion: Functional outcome and satisfaction were similar regardless of definitive management strategy or radiological union. An individualised approach should be adopted with less active, comorbid and elderly patients counselled about the risk of surgical complications including a 27% chance of reoperation.

MORPHOLOGICAL CHARACTERISTICS AND MANAGEMENT OF GREATER TUBEROSITY FRACTURES ASSOCIATED WITH ANTERIOR GLENOHUMERAL JOINT DISLOCATIONS: A SINGLE CENTRE 10-YEAR RETROSPECTIVE REVIEW

Authors: Srinivasan A, Boksh K, Perianayagam G, Singh H; Modi A

Main Institution: Department of Trauma and Orthopaedic Surgery, Leicester Royal Infirmary, University Hospitals of Leicester NHS Trust

Purposes of the study: The purpose of this study was to explore the morphological characteristics of greater tuberosity (GT) fractures associated with anterior glenohumeral (AGH) dislocations in order to optimise their management.

Methods: A retrospectively review of all shoulder radiographs with GT fractures associated with AGH dislocations was undertaken at a single large trauma unit between 01/12/2009 and 31/12/2019. Special considerations were given to fracture morphology (single, two and multi-fragmentary), presence and site of fracture comminution (superior, inferior and widespread), degree of displacement, need for surgical intervention and radiological outcome.

Results: Over the ten year study period, 133 patients were identified with a mean age of 63 (18–96) years. Majority of GT fractures associated with AGH dislocations were multi-fragmentary (86.5%), occurred in the elderly (≥ 65 years), and were located antero- or postero-superiorly (68.7%). Superiorly comminuted GT fractures were twice as likely to displace compared to other sites of comminution (43% vs. 21%, p = 0.03), and undergo surgery (p = 0.03). Irrespective of comminution site, GT fragments with minimal displacement on post reduction films were more likely to undergo secondary migration if conservatively treated (p = 0.01). Those treated surgically with double-row suture anchors (DRSA) had satisfactory radiological outcome at two months.

Conclusion: GT fractures associated with AGH dislocations are predominantly comminuted and difficult to treat. GT fragments that are comminuted postero- and antero-superiorly are more likely to require surgical fixation and have better outcomes with DRSA repair (or equivalent) even if <5mm displacement. Otherwise, close follow-up with serial radiographs for the first several weeks is warranted to detect early secondary migration.