X-ref For other Roundups in this issue that cross-reference with Shoulder & Elbow see: Trauma Roundup 4; Research Roundups 1 & 5.
Anxiety and depression once again proven to influence outcome following upper limb surgery
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There is a growing body of evidence in the orthopaedic literature to support an association between inferior patient-reported outcomes (PROs) and psychosocial diagnoses such as depression, anxiety and inadequate coping mechanisms.1 We have covered a number of articles in recent issues of 360 relating to poorer PROs and general quality-of-life scores in areas as disparate as spinal surgery, knee surgery and shoulder dislocations. In this study from Mansfield (UK) the authors sought to establish whether anxiety or depression had a bearing on post-operative outcomes. Their retrospective review of prospectively collected data reports the outcomes of just 55 patients who underwent arthroscopic subacromial decompression for shoulder impingement without evidence of a rotator cuff tear. The study team utilised the hospital anxiety and depression scale (HADS) prior to surgery, and patients completed the Oxford shoulder score (OSS) at six weeks and six months following surgery. As would be expected, the authors reported a clinical improvement in the OSS at six months following surgery across the group in general. However, those defined as not being depressed (n = 25) improved more rapidly and attained superior OSS scores at both six weeks and six months. As has been reported in other studies, there was a strong correlation between an increasing HADS score (more depressed) and a poorer outcome and reduced satisfaction at six months following surgery.2 The authors conclude that patients with a HADS score of ≥ 11 have a worse outcome following subacromial decompression and that this should be considered in pre-operative counselling. This small but interesting study adds to existing data in this area, which leads to two interesting questions: 1) Do we need to modify current patient-reported outcome measures (PROMs) to take into account the obvious influence of psychosocial status?; and 2) should large prospective randomised controlled trials rely solely on PROMs that can be so strongly influenced by the mental well-being of the patient?
Reverse shoulder arthroplasty on the rise for operatively managed proximal humeral fractures
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The reverse shoulder arthroplasty (RSA) is a procedure which seems to be increasing in application. There is no doubt from the small studies in existence that an excellent result can be achieved in the short term for a range of pathologies. However there is still some way to go as far as proving the longer-term advantages, or indeed the longevity of these replacements, when compared with traditional arthroplasties. There is an increasing amount of literature reporting on the use of RSA for fractures of the proximal humerus, but the national trends are still to be established. This large study from Fort Lauderdale, Florida (USA) includes the coded outcomes for 32 150 operatively managed proximal humeral fractures in the Medicare patient population database. The authors evaluated the trends and changes in treatment choice over the four-year period (2009 to 2012). There were no apparent significant changes in the number of fractures managed each year, however, the rate of surgical intervention declined significantly by 14%. Although open reduction and internal fixation was employed consistently, there was an almost threefold rise (11% to 28%) in the use of primary RSA with a corresponding significant decrease in the use of hemiarthroplasty (52% to 39%). Interestingly, the rise in the use of RSAs was seen both in patients older than 65 years of age (11% to 29%, almost threefold) and in those younger than 65 years (doubling, from 6% to 12%). With the recent results of the Proximal Fracture of the Humerus Evaluation by Randomisation (PROFHER) study3 reporting no difference in outcome at two years for displaced proximal humeral fractures managed operatively or non-operatively, it will be interesting to see if the operative decline reported in this study continues when subsequent years are analysed. Although the proportionate use of RSA is on the rise for proximal humeral fractures, the indications and long-term outcome are still to be fully defined.
Why repeat the radiograph? Radial head management revisited
This study from Boston, Massachusetts (USA) and Austin, Texas (USA) comes at an interesting time, given the current literature on isolated radial head and neck fractures. There is a growing body of short- and long-term outcome data supporting the non-operative management of isolated radial head and neck fractures.4 In conjunction with this, there are those who suggest that ‘virtual’ fracture clinical review is sufficient following a fracture of the radial head or neck with patient satisfaction reported at over 90%,5 although these studies are not large enough to establish the ‘miss’ rate of rarer injuries such as the Essex-Lopresti without a senior review. In this current analysis of 415 non-operatively managed, isolated Broberg and Morrey Mason type 1 or type 2 fractures, the authors set out to establish the value of secondary radiographs as a decision-making aid.6 The bottom line is ‘not a lot’, with 255 patients (suffering 262 fractures) receiving subsequent secondary radiographs following their initial injury radiographs, and only a single patient (0.4%) subsequently being offered surgery in light of a secondary radiograph. Amusingly, this was declined. This straightforward study demonstrates clearly that subsequent radiographs do not change the management plan of stable isolated radial head fractures, and it could be hypothesised that secondary displacement or symptomatic malunion or nonunion are likely to be exceedingly rare following such injuries.
Iatrogenic radial nerve palsy more common than previously thought in humeral nonunion
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The management of humeral shaft fractures remains controversial, with much of the data supporting non-operative management coming from the older literature championed by Sarmiento and his group for a number of decades. The summary is that essentially, with or without a radial nerve palsy the results have been comparable in other series but far from consistently reproducible.7 While long-term radial nerve outcomes are equivalent with initial presentation between operative treatment and bracing, there is little evidence in nonunions. This retrospective study from Cincinnati, Ohio (USA) reported the outcomes of 54 patients with humeral nonunions following conservative treatment to establish the outcomes with open reduction and internal fixation, with or without autogenous bone grafting. The headline result from this series is that in these authors’ hands, the rate of post-operative iatrogenic radial nerve palsy was found to be 18.5% (n = 10). However, of these, the vast majority (80%) were found to have complete resolution at just two and a half months following surgery. The study team was unable to identify any real risk factors for palsy. The authors note in their conclusion that this rate of iatrogenic radial nerve palsy is much higher when compared with existing literature for those undergoing acute stabilisation, as would be somewhat expected. Like many similar studies,8 it all depends on how complications are defined. Reading their results the other way around, only 3.7% of patients suffer a longer-term neuropraxia, which could be presented as a low incidence of palsy. When considering this study in context with existing literature, it is clear that more data are needed on the acute management of humeral diaphyseal fractures. The results of multicentre trials, such as the ongoing study in Canada comparing acute primary fixation with non-operative management for humeral shaft fractures, are eagerly awaited. Not only will the rate of recovery and the final patient-reported outcome measures be of interest, but also the incidence of radial nerve palsy when compared with that of nonunion surgery.
Why do rotator cuff repairs fail?
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The humble rotator cuff tear has been the recipient of possibly one of the fastest-evolving and most commercially aggressive ‘arms races’ between medical device companies of the last two decades. Once arthroscopic repair had made its debut and become the definitive surgical option in the majority of centres, the race was on for faster, stronger and more convenient and biocompatible anchors. We have moved through knotless, suture only, double row and countless other innovations, each proffering greater pull-out strength and superior usability at an incidentally higher cost. However, cuff repairs rarely fail due to suture fatigue or anchor pull-out. By far the more common mechanism of deficiency is failure of the tendon to heal, or for it to heal and this not to be associated with a restoration of function. We were delighted to come across this animal model study from La Jolla, California (USA) which appears to potentially shed some important light on the possible reasons why this might be.9 The authors used a rat model of a massive rotator cuff tear to investigate the changes in muscle biochemistry and architecturein rotator cuff muscles, in addition to morphology of the humerus and scapula. Outcomes were assessed at up to 16 weeks following injury, with and without chemical paralysis. The results themselves are interesting and accessible to the ‘everyday’ scientist. Essentially, the control animals continued to increase their muscle mass over time, while the intervention animals remained static (i.e. those with just a tenotomy). The addition of botulinum toxin not only altered the muscle architecture by increasing collagen content, but also resulted in a decreased cross-sectional area. Both intervention groups had characteristic bony changes suggestive of a decrease in loading across the shoulder. This study nicely illustrates that the repair and healing of a rotator cuff tear is not necessarily associated with restoration of function. Concomitant neurological insufficiency may contribute to the poor outcome after apparently successful surgery.
Platelet-rich plasma finding a mechanism?
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The application of platelet-rich plasma (PRP) to almost any indication in orthopaedics (and the complete lack of evidence for its efficacy) is remarkable in its ability to induce loyalty in its proponents. We have thus far at 360 failed to be completely convinced by the wild claims and steadfast support of a large group of orthopaedic surgeons. However, we were interested to read this randomised controlled trial from Manipal (India) designed to assess the potential for benefit in rotator cuff tears.10 A total of 102 patients were recruited into the study and randomised to either PRP application or control. Outcomes were assessed with a gamut of clinical scores at regular intervals, in addition to the use of ultrasound to assess cuff repair integrity. The results were almost universally in favour of PRP, with Constant-Murley scores and UCLA scores both superior after one year, with a lower re-tear rate in the PRP group. The ultrasound findings would suggest better vascularity in the PRP group. This article is somewhat at odds with other studies which do not show PRP benefits. However, it does demonstrate a potential mechanism of action. The increase in vascularity (potentially due to the promotion of a local pro-cytokine environment) is associated with an improvement in the likelihood of a successful outcome after rotator cuff repair. Questions remain as to how the local PRP environment is maintained in the clinical situation beyond the initial surgery. Given the differences between this and other studies in terms of assessment of efficacy, a meta-analysis would be helpful here.
Assessing the rotator cuff effectively
One of the current challenges facing clinicians is how to demonstrate the value of interventions, particularly those perceived to be of limited value. Repair of degenerative rotator cuff tears is one such intervention where healthcare funders have taken an interest in its potential benefits or lack thereof. Sadly, in many low-quality studies, the evaluation of the outcome of repair is often compromised by poor data or poor outcome measures. This paper from Nieuwegein (The Netherlands) demonstrates that patients maintain a true perception of their pre-operative status up to a year following rotator cuff repair.11 The investigators evaluated the outcomes and response shift of 36 patients undergoing rotator cuff repair. There is a common belief that a positive recalibration effect occurs over time, where previous symptoms appear worse and patients overestimate pre-operative disability. The authors applied the Western Ontario Rotator Cuff index at baseline and at regular intervals retrospectively, along with the EQ5D-3L, to establish what, if any, the response shift was over a year following surgery. There was really no response shift observed, although patients did have a negative recalibrated response shift for emotional disability at three months following the intervention. The major finding of this study is that patients remain cognisant of changes in their well-being for a useful period after intervention, and that scores can be applied retrospectively in an effective manner.
References
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