Shoulder & Elbow

Pectoralis major transfer for irreparable anterosuperior rotator cuff tears

It is well known that a large tear of the rotator cuff is hard to repair. Although there are excellent reported outcomes from anterior deltoid retraining in some patients, this isn’t enough and large cuff tears in particular need treating before the patient progresses to an advanced cuff tear arthropathy. The problem, of course, is that treatment is easier said than done. When combined with the retraction of the cuff and degeneration of the tissues seen both pre- and post-cuff tear, it can sometimes feel as if there are no reconstructive options. Surgical device companies have attempted to solve the problem with cuff augments to attach to the cuff but these are reported to have mixed levels of success. One potential option, however, is the transfer of the pectoralis major tendon. The authors of this study from Salzburg (Austria) and Berlin (Germany) report on the long-term outcomes of 27 patients with anterosuperior cuff tears without an established arthropathy treated with a pectoralis major transfer.¹ The surgical procedure was a partial subcoracoid pectoralis major tendon transfer and the outcomes here are reported at ten years. Outcomes presented included Visual Analogue Scale (VAS) pain score, objective strength and range-of-motion assessments, the Constant-Murley score and the Simple Shoulder Test (SST). The authors also arranged and reported the outcomes of plain radiographs and ultrasound imaging of the shoulders.The procedure itself appears to be a success, with the Constant scores improving from 54% pre-operatively to 87% at the initial follow-up, and maintaining the improvement, for the most part, to the long-term follow-up with a mean score of 83%. In terms of modification of the long-term sequelae of arthropathy, these authors reported the patient cohort roughly split into thirds, with one third reporting no progression, one third progression by a single grade, and one third significant progression of arthropathy over the ten-year period of the study. This shoulder-sparing procedure should perhaps receive more press in the mainstream orthopaedic literature. The inevitable consequence of non-operative management of these kinds of symptoms is ongoing pain, degeneration, and eventually a cuff tear arthropathy and arthroplasty. If a pectoralis major transfer can reduce this incidence, it should be considered.

The deltoid insertion in humeral fractures

Long-term results of reverse total shoulder arthroplasty

The position of the reverse shoulder arthroplasty as a successful, and in some cases essential, device in shoulder arthroplasty is now beyond doubt. Although there are still some concerns about longevity and the reporting of high complication rates with some implants and in some indications, the literature is reflective of an established and increasing use of reverse total shoulder arthroplasty in both elective and trauma practice.³ Despite the growing popularity of the implants, the precise indications and the long-term outcomes for these prostheses are yet to be fully defined. This large study from the team in Lyon (France) offers one of the few long-term studies evaluating reverse shoulder arthroplasty, and authors report the outcomes and survival at a minimum of ten years following surgery. This work was based on data from their original previously reported study of 186 patients with 191 Grammont-style prostheses implanted for a range of chronic pathologies.⁴ The authors were able to update this with their current study including 84 of these patients with 87 prostheses followed-up for a mean of 12.5 years. Within this cohort, radiographic assessment was available in 64 patients with 67 prostheses. The authors report a mean absolute Constant score of 55 and a mean relative Constant score of 86, which not unsurprisingly was significantly decreased when compared with the scores from the previous mid-term study. A total of 73% (49 shoulders) of cases demonstrated evidence of scapular notching and 29% (47) had complications, with dislocation and infection most commonly seen. There were 12% (16) of the original patients who had undergone revision surgery, with the overall ten-year survival at 93% when using revision as the endpoint. These results are consistent with shorter-term studies documenting a survival rate of 89% to 95%. This study adds important information regarding the long-term outcome of these implants, but without doubt more data are needed. As the technology matures, the long-term outcomes of these prostheses will become more and more important. We can’t help thinking that there may be more failures than the reported 12%, but given the difficulties of revising a reverse shoulder arthroplasty, many more may be poorly performing but still in situ due to the lack of a reasonable alternative.

Depression influences outcome following total shoulder replacement… but it is still worth doing?

Psychological factors such as depression, anxiety and inadequate coping mechanisms are known to influence both surgeon- and patient-reported outcomes for a variety of pathological conditions of the upper extremity.^5,6 Nonetheless, there is certainly more work to do in determining whether such patients still benefit from surgery and whether anything can be done to influence or optimise these psychological factors in order to improve outcome. In this retrospective case-control study, the team from the Hospital for Special Surgery, New York, New York (USA) examined the outcomes of 264 patients, all of whom underwent primary total shoulder arthroplasty (TSA) for osteoarthritis of the shoulder with a minimum of two years of follow-up. Outcomes were assessed using the American Shoulder and Elbow Surgeons (ASES) Score, and a subgroup of 88 patients with a pre-operative diagnosis of depression were compared with a control group of 176 patients. Cases were matched according to age and gender in a 2:1 ratio. As perhaps is to be expected, the only difference in baseline characteristics were the Short Form-12 (SF-12) Mental Component scores. There was a significant improvement seen in the ASES scores across the board, both for the patients with depression and the control group. However, the patients with depression reported final ASES scores that were significantly lower, and improved to a significantly lesser degree, than those of the comparative patients in the control group. This was echoed with significantly lower SF-12 Physical Component scores reported as well. The authors attempted to unpick the aetiology with multivariate analysis, and pre-operative depression was an independent predictor associated with a reduced improvement in the ASES score. The authors’ comment was that this is not a clinically relevant difference and should perhaps not discourage patients with a pre-operative depression diagnosis from undergoing TSA. However, there is clearly a take home message for surgeons that counselling patients prior to surgery as to what to expect may have a positive benefit. This message, although sometimes seemingly a standard conclusion of all outcome factor papers, is starting to accumulate evidence for its efficacy, and we would also draw the attention of 360 readers to the recent prospective randomised clinical trials already supporting the positive effects of pre-operative priming and patient-reported outcome scores.⁷

Predicting revision surgery for lateral epicondylitis of the elbow

Lateral epicondylitis of the elbow, otherwise known as ‘tennis elbow’, continues to be not only one of the most common presentations in elbow clinics, but one of the most disheartening to treat. Patients complain bitterly of pain, and although clinicians have no trouble making the diagnosis there are few excellent options for treatment. Previously, the mainstay of treatment was corticosteroid injections, with a subsequent escalation to surgical release offered by most surgeons. However, with some data finding that corticosteroid injections are associated with an increased rate of surgery for the condition,^8,9 and randomised studies far from convincing on the potential benefits of pretty much every available treatment, the orthopaedic community finds itself yet again evaluating the efficacy of an established treatment. In this large national database study from the US, the authors explore the outcomes of 3863 patients who underwent surgery for lateral epicondylitis of the elbow. The primary outcome measure was the need for revision surgery within two years of the original procedure, and, in common with all studies of this type, little is known about the patients themselves, just their treatment outcomes. Patient and pre-surgery management factors (such as number of steroid injections) were analysed, and these authors were in a unique position, given the numbers of patients, in that they were able to undertake a proper multivariate binomial logistic regression analysis with the aim of determining the risk factors for revision surgery. The authors reported a very low overall rate of revision (1.5%), with risk factors for revision including age <65 years, male gender, morbid obesity, smoking, inflammatory arthritis and three or more pre-operative ipsilateral corticosteroid injections. The latter was the most significant risk factor for revision surgery. However, as the authors comprehensively point out, the overall revision rate following surgery for tennis elbow is low and this would support existing evidence that tennis elbow release is appropriate in certain patients. Those with an increased risk of revision surgery can now be counselled regarding the potential for requiring further intervention. Although two steroid injections were not a risk factor for revision surgery in this study, the role of corticosteroid injections for this condition appears of doubtful benefit, and perhaps delaying surgery for repeated injections would not really be advocated in this case.

Hemiarthroplasty of the elbow a promising start

No evidence for the use of stem cell therapy for tendon disorders

Stem cell therapy is another attractive option that has yet to find real traction with either widespread clinical opinion or research papers to support its use in any specific indication. However, the promising concept, combined with some difficult problems to solve, has continued to push the orthopaedic community towards the potential applications of stem cell therapies for conditions where healing is either through scarring or difficult, such as cartilage defects and tendinopathies. A review team from Amsterdam (The Netherlands) have put the evidence for the use of stem cell therapies in tendinopathies through the rigour of the systematic review process.¹⁵ The study team perfomed an exhaustive search and identified seven published and unpublished trials that reported the outcomes of stem cell therapies in tendinopathies. As perhaps would be expected, these were a heterogeneous group reporting applications in rotator cuff disease (two trials), epicondylar tendinopathy (a single trial) and patellar tendinopathy, but, overall, the outcomes of just 79 patients were available for inclusion in this review. The authors report that although there were some positive results reported in the trials they reviewed, all were level IV evidence at best and there were high risks of bias associated with every study included in the review. At present, therefore, the authors conclude that there is little to no evidence to support the use of bone marrow-derived stem cells in any tendinopathy-related condition and, with some adverse events reported, their use cannot be supported.