X-ref For other Roundups in this issue that cross-reference with Shoulder & Elbow see: Trauma Roundup 3; Children’s orthopaedics Roundups 3 and 6.
Is surgery needed for extra-articular scapular fractures?
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We suspect that the rarity of the injury and the technical difficulty of the surgery have a part to play in the decision-making process surrounding fixation, or otherwise, of scapular fractures. The indications for surgery are far from agreed, although the majority of surgeons would concur that for significantly displaced glenoid fractures, surgery should be considered. There is less consensus with extra-articular fractures, although the glenoid can be significantly displaced and this will alter the lever arm and mechanical advantages of the rotator cuff muscles. With a fresh look at what the operative indications in extra-articular fractures ought to be, surgeons from St Paul, Minnesota (USA) report the outcomes from their series.1 The authors were able to report the functional outcomes of 49 of 61 patients with acute operatively managed extra-articular scapular fractures. Functional outcomes were reported to 33 months following surgery, and the authors are open about the operative indications which are well documented in the paper and are based on the limited existing literature. The authors report a 100% union rate, with DASH and SF-36 scores approaching normative values for the population at 33 months of follow-up. Excellent strength and range of motion, compared with the contralateral arm, were also found in the group. There were nine complications apparent in eight patients, with implant removal and secondary manipulation of the shoulder under anaesthesia most commonly seen. The authors concluded that operatively managed displaced glenoid neck and scapular body fractures give expected good functional outcomes. There are two significant limitations to this large series of patients which somewhat hamper the interpretation of the results. Firstly there is no non-operative control group in the study, so there is no evidence to suggest that surgery provides a superior outcome for these injuries. Second, only three patients in this series sustained low-energy trauma. This is not consistent with current epidemiological data that suggest an increasing incidence of low-energy scapular fractures in women,2 where non-operative treatment may be more appropriate.
Propionibacterium acnes in primary shoulder arthroplasty: is it a technical surgical issue?
In the last edition of 360, we discussed a paper evaluating the role of single-stage revision shoulder arthroplasty in patients with subclinical infection, where almost half of all revised cases had more than two positive cultures for Propionibacterium acnes (P. acnes).3P. acnes is known to be associated with indolent infection leading to osteolysis and loosening of shoulder prostheses, and is of great concern to shoulder surgeons. In this thought-provoking study from Australia, microbiological samples were obtained from a range of potential contaminant sites in 40 consecutive patients undergoing primary shoulder arthroplasty. These authors from St Leonards (Australia)4 designed a study where cultures via swab were obtained from consecutive patients undergoing primary shoulder arthroplasty. In each patient, specimens were taken from the subdermal layer, the tip of the surgeon’s glove, the deep scalpel blade, forceps and the skin incision scalpel blade. The study is based on the results of 40 patients, all undergoing shoulder arthroplasty. Of these, one third had at least a single culture positive for P. acnes, with 8% of females (n = 2/25) and 73% of males (n = 11/15) having more than a single positive culture. The most common site of contamination was the subdermal tissue (12 positive samples), however, there was a worrying rate of contamination of surgical gloves (seven samples) and forceps (seven samples). Allowing for the difficulties that culture of P. acnes poses in the laboratory, it is certainly possible that there were still more positive samples. The authors determined that males had a 66-fold increased chance of having a positive microbiological culture for subdermal colonisation and not unreasonably concluded that P. acnes can be found throughout the surgical field. This seemingly ever-present microbe is a persistent problem to shoulder surgeons and, as the team from Australia have suggested, given the high rate of surgeon contamination presented here new approaches are certainly needed to try to reduce the risk of colonisation at the time of primary surgery.
Primary elbow arthroplasty in distal humeral fractures
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The use of primary total elbow replacement (TER) for distal humeral fractures is on the rise but the reasons for this are unclear. Is this trend due to improved surgical results or a change in the pattern of presentation of these fractures? As the number of elderly complex osteoporotic distal humeral fractures grows, there is an increasing interest in the role of TER for these injuries. In 2009, McKee and the COTS group provided the best evidence (although flawed) to date with their multicentre prospective randomised controlled trial of ORIF versus TER for distal humeral fractures in the elderly. The results of this trial were in favour of TER, with more predictable and superior functional outcomes for TER when compared with ORIF.5 In this registry study from Los Angeles, California (USA) utilising the Nationwide Inpatient Sample database, the authors sought to establish what were the trends in the use of TER for distal humeral fractures in elderly patients (⩾ 65 years of age).6 The study analysed data over a ten-year period from 2002 to 2012. The take-home message from this registry-based study is that there was a 2.6-fold annual increase in the use of TER for these injuries. Surgery accounted for 13% of surgically managed distal humeral fractures in 2012, a significant increase from the baseline value of 5.1% seen in 2002. In terms of overall costs, TER was over $16,000 more expensive than ORIF. Interestingly, the authors comment that, given the ‘complexity, long-term restrictions and risks associated with TER’, this increasing trend needs to be monitored closely. Here at 360, we would echo the conclusion of the COTS group’s study that arthroplasty is really only a preferred treatment method in these elderly patients when the complexity of the fracture means that stable fixation is not attainable. The rise in the use of TER highlighted in this study seems likely to be related to the rise in the number of osteoporotic distal humeral fractures, meaning that TER needs to be utilised on an increasing basis. However, most would agree that the indications and long-term outcome of TER for trauma are still to be fully defined, especially for an intervention reported to cost in excess of $85,000.
How ‘terrible’ is the Terrible Triad?
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A terrible triad fracture-dislocation of the elbow is a complex injury, which is ‘terrible’ due to the noted potential for post-operative instability and stiffness. Classically said to involve the radial head, coronoid and lateral ligament complex, the ‘terrible triad’ presents as a combination of significant soft-tissue disruption and instability. Nonetheless, improved results in the literature have been documented, particularly since the well cited standardised surgical protocol on how to manage these injuries was put forward by the team in Toronto (Canada).7 This approach focuses on the fixation or replacement of the radial head, fixation of the coronoid where possible and repair of the lateral collateral ligamentous (LCL) complex. In this retrospective cohort study from the groups in Boston, Massachusetts and Austin, Texas (USA), the authors aimed to establish the reason for this treatment protocol’s success.8 The study revolves around the results of 107 patients, all of whom underwent surgical management for a terrible triad injury (TTI). The patients themselves were assessed for subsequent recurrent instability using radiographic evidence of subluxation of the ulnohumeral joint as an endpoint. The authors determined that 93% of patients had no eventual radiographic evidence of instability, with just 2% of patients having evidence of the so-called ‘drop sign’ that was successfully managed with active exercises. Of the 5% of patients presenting with recurrent instability following fixation, 3% were successfully managed within two weeks of injury. The authors concluded that with early surgery within two weeks of injury, involving repair of the LCL and replacement of the radial head, there is a very low rate of recurrent subluxation/dislocation. For patients managed after this period, supplementary stabilisation, such an external fixator, may be required.
Interscalene block better than we thought?
In a very interesting study from Seoul (South Korea), clinical trialists put to the test the hypothesis that a single-dose interscalene block would not only improve analgesia following a rotator cuff repair, but that there would be measurably lower pain and stress response biomarkers – a tall order.9 They designed their randomised controlled trial to test a single-dose interscalene block and general anaesthesia against general anaesthetic only. Outcomes were assessed at 48 hours as this is an early pain control study with both a VAS pain score and measured biomarkers (insulin, dehydroepiandrosterone sulfate (DHEA-S), and fibrinogen). The study reports the outcomes of 62 patients randomised to one of the two interventions, and outcomes are reported at 18, 42 and 66 hours post-operatively. All of the patients had a 1 cm to 4 cm rotator cuff tear, and, perhaps not surprisingly, the VAS pain scores were significantly lower in the block + general anaesthetic group when compared with the general anaesthetic alone group (2.5 vs 3.8) across the whole day. This difference was most marked at six hours post-operatively (2.4 vs 4.2). Perhaps more unpredictably, this improved pain control had a marked difference on the biomarkers measured, with significantly lower insulin levels in the intervention group (10.6 μU/mL vs 20.4 μU/mL). There were, however, no differences in the DHEA-S or fibrinogen levels between the groups. This study raises some interesting questions for study design, as well as reinforcing the value of regional analgesia in post-operative pain control in shoulder surgery. The authors here have not only been able to identify a treatment effect, but also shed some light on the biological implications for this. A hard demonstration of reduced insulin levels following surgery with a block may help to explain the stress response, and in particular what some of the drivers for this may be.
Open and arthroscopic rotator cuff repair comparable
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Although the standard in most centres worldwide is arthroscopic treatment of rotator cuff repairs, there remains much debate about not just the indications, but also the operative technique and efficacy of rotator cuff repairs. The team in Oxford (UK) have set out to add another piece to this increasingly complicated jigsaw puzzle.10 Their randomised controlled trial compares open and arthroscopic rotator cuff repair for patients with degenerative cuff tear arthropathy. The UKUFF study has now reported and 273 patients were successfully enrolled, 136 to arthroscopic surgery and 137 to open surgery. The outcomes were assessed at two years post-operatively with (perhaps predictably) the Oxford Shoulder Score as the primary outcome measure. Overall, there were significant improvements in outcomes between baseline and two-year follow-up, and the authors were also able to report that both the arthroscopic (26.3 to 41.7) and open (25 to 41.5) subgroups had a significant improvement in their Oxford Shoulder Scores. There was, however, no difference between the groups at all. There were no differences in surgical outcomes, either in terms of re-tear rates, or complications. Perhaps unsurprisingly, those patients with healed tears had the most improved surgical outcomes. This study adds a lot to the literature. It is one of the only intervention studies to randomise patients to different techniques, and it can be incredibly difficult to recruit to these studies. The results of this study are, nevertheless, conclusive; the only difference between the groups was the surgical approach. Both showed significant improvements over baseline, and both had a similar outcome.
References
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