Shoulder & Elbow

Reverse shoulder arthroplasty: the key is in the greater tuberosity

Shoulder arthroplasty may improve the driving performance of patients

It must be one of the most common questions asked by a peri-operative patient: When can I get back to driving? Despite this, there is very little detail available to inform these decisions, with advice routinely given with caution and a lack of data! This elegant study from New York, New York (USA)³ caught our eye at 360 HQ as it addresses this simple question. The investigators used a driving simulator to assess 30 patients, all of whom underwent shoulder arthroplasty surgery (20 anatomic and ten reverse). Patients were assessed pre-operatively and at two, six and 12 weeks post-operatively by analysing a variety of characteristics including total number of collisions and off-road excursions, as well as VAS pain score and the Shoulder Pain and Disability Index (SPADI). Despite the mean number of collisions increasing at week two, as would be expected, driving performance returned to pre-operative levels by six weeks and patients performed better than pre-operatively at 12 weeks post-surgery! Multivariate analysis found that poorer VAS pain scores, increasing age and less driving experience were predictive of a poorer driving performance. The authors concluded that clinicians can suggest a six- to 12-week window post-surgery that can be used for a gradual return to driving, with this being closer to 12 weeks for older patients or in those with less driving experience or higher pain levels. These findings are consistent with a recent paper reporting on driving performance post-arthroscopic shoulder surgery,⁴ which reported impaired driving performance for a minimum of six weeks post-surgery and a return to normal driving by 12 weeks.

The debate regarding early fixation of acute clavicle fractures continues

Surgery is successful for refractory medial epicondylitis in the longer term

The role of surgery for medial and lateral epicondylitis of the elbow continues to be debated, as does pretty much every other aspect of management. This confusion is likely to be due in part to the heterogeneous nature of some of the series which have been reported, and the natural relapsing remitting history of the condition, making firm conclusions difficult to draw. Most surgeons would, however, agree that surgery may be of benefit when it is reserved for refractory cases. In this single-centre single-surgeon retrospective case series from Gyeonggi (South Korea) the authors report the outcomes of 55 patients treated with 63 cases of medial epicondylitis.⁹ All patients underwent non-operative interventions prior to consideration for surgery, including treatment for a minimum of one year with at least two steroid injections (a mean of five). At an average follow-up of seven years following surgery, the authors report a significant improvement in the mean visual analogue scale score, grip strength, Mayo Elbow Performance score and the Disabilities of the Arm, Shoulder and Hand score. The post-operative recovery was substantial, with the time to return to work just shy of three months and return to exercise at around five months. The overall reported success rate was 93%, with the Nirschl and Pettrone grades rated 43% as excellent and 51% as good. There was a single case of heterotrophic ossification. This study provides good long-term results supporting the use of surgery for refractory cases of medial epicondylitis of the elbow. We would suggest, here at 360, that this study highlights the importance of emphasising to patients the possibility of a prolonged recovery period¹⁰ after such surgery, with patients requiring an average of almost three months off work.

Further evidence to suggest corticosteroid injections are not beneficial in the management of tennis elbow

There is now a strong body of evidence to suggest that corticosteroid injections are not beneficial in the long- or short-term management of enthesopathy of the extensor carpi radialis brevis, otherwise known as ‘tennis elbow’. This large meta-analysis from a team in Boston, Massachusetts (USA) included seven randomised controlled trials (RCTs) identified following a thorough search of the indexed literature.¹¹ All seven included trials compared the effect of corticosteroid injection with a placebo injection on the symptoms of tennis elbow. The authors reported no difference in outcomes between steroid and placebo in terms of pain at three and six months following injection. However, they did report marginal but significantly reduced pain levels at one month post-injection. Grip strength and the Disabilities of the Arm, Shoulder and Hand scores were comparable at all of the time points analysed. Given these findings, the authors concluded that steroid injections for tennis elbow are ‘neither meaningfully palliative nor disease modifying’. This adds further weight against the use of steroid injection for this common condition, with an additional study from this group suggesting that the use of steroids was associated with an increased rate of surgery for the condition.¹²

Muscle atrophy and fatty infiltration in rotator cuff tears: can surgery stop muscular degenerative changes?

If a rotator cuff tear is left untreated, the natural progression is the secondary development of dysfunction of the cuff musculature, usually the supraspinatus muscle. This is part of the development of a ‘cuff tear arthropathy’. Subsequent management of cuff tear arthropathy is complex, with poor functional outcomes and development of secondary arthroses in the joint, although recently reverse total shoulder arthroplasty has been introduced. The question of course has always been: how does the pathophysiology relate to surgical intervention? Is the die cast at the time of injury? Surgeons from Rome (Italy) have reported their study of 41 patients, all with an MRI-proven rotator cuff tear.¹³ Although the study was retrospective, the authors were able to identify two subgroups: those who had undergone rotator cuff repairs and those who had not. Outcomes were assessed using a range of shoulder outcome measures and an interval MRI scan at 50 months following diagnosis. The authors established that there were better results in terms of fatty infiltration of the muscle belly in the operative group with no progression of fatty changes, while the non-operative group had significant increases in tendon retraction and tear size. Although this doesn’t establish causation, it does provide some evidence to suggest that tendon repair is able to prevent secondary muscle degeneration.

Anterior plating stronger in the clavicle?

Optimising treatment in olecranon bursitis

As a mostly non-operative diagnosis, olecranon bursitis has been somewhat neglected on the research front over the past decade, with little progress made in treatment despite the comparative frequency of presentation. We were delighted to see this randomised controlled trial from Seoul (South Korea), testing three treatments: compression bandaging and NSAIDs versus steroid injections versus aspiration.¹⁵ They report the outcomes of 133 patients randomised to one or other treatment and reported at four weeks’ follow-up. Outcomes were assessed as resolution at four weeks and median time to resolution. Sadly this study did not detect any differences between the three interventions, although the study was only powered to detect a 30% difference. The authors sensibly suggest that this study should be regarded as a pilot, and a large study capable of detecting a greater difference should be undertaken.