A. Jariwala

A blinded, randomized, controlled trial assessing conservative management strategies for frozen shoulder

BACKGROUND There is little evidence for the optimal form of nonoperative treatment in the management of frozen shoulder. This study assesses the efficacy of current physiotherapy strategies. METHODS All primary care referrals of frozen shoulder to our physiotherapy department were included during a 12-month period. Of these referrals, 17% met the inclusion criteria for primary idiopathic frozen shoulder. The 75 patients were randomly assigned to 1 of 3 groups: group exercise class, individual physiotherapy, and home exercises alone. A single independent physiotherapist, who was blinded to the treatment groups, made all assessments. Range of motion, Constant score, Oxford Shoulder Score, Short Form 36, and Hospital Anxiety and Disability Scale (HADS) outcome measures were performed at baseline, 6 weeks, 6 months, and 1 year. RESULTS The exercise class group improved from a mean Constant score of 39.8 at baseline to 71.4 at 6 weeks and 88.1 at 1 year. There was a significant improvement in shoulder symptoms on Oxford and Constant scores (P < .001). This improvement was greater than with individual physiotherapy or home exercises alone (P < .001). The improvement in range of motion was significantly greater in both physiotherapy groups over home exercises (P < .001). HADS scores significantly improved during the course of treatment (P < .001). The improvement in HADS anxiety score was significantly greater in both physiotherapy intervention groups than in home exercises alone. CONCLUSIONS A hospital-based exercise class can produce a rapid recovery from a frozen shoulder with a minimum number of visits to the hospital and is more effective than individual physiotherapy or a home exercise program.

Patients and the Internet: A demographic study of a cohort of orthopaedic out-patients

The Internet is a rich source of medical information but relatively few studies have evaluated its use by patients who seek medical information. The purpose of this study is to assess the demographics of Internet access and attitudes towards the Internet in a cohort of orthopaedic out-patients. Four hundred and three patients attending the orthopaedic outpatient fracture clinic completed a questionnaire consisting of six divisions including personal information, facility to access the Internet and their attitudes towards the information retrieved. Fifty per cent of the patients accessed the Internet, either from home or office and the maximum usage being in the younger age group. Twenty-nine per cent of the patients were aware of the medical information available through the Internet. 19% patients would like to have a consultation through the Internet, the maximum being in the middle-aged group. 70% of those patients who accessed the medical information reported that the Internet information was different than that obtained at consultation with the doctor at the out-patient clinic. This study reveals that the Internet use by patients is still limited. If an increased percentage of medical conditions is to be addressed through the Internet, involving patient information, on-line consultations, prescriptions and referrals, then a substantial amount of patient education and training is required

Prescribing a website.

Aim: To assess the value of directing the attention of patients to sources of medical information on the internet. Design: Prospective qualitative study in an orthopaedic outpatient clinic. Participants: 253 patients agreed to complete electronic questionnaires before and after reviewing information relevant to their conditions on the internet. Patients were allocated randomly into two groups; one group was given indications of general sites and the other recommended specific non-commercial sites. Completed questionnaires were received from 44 patients. Results: 95% of the patients found the internet information easy to understand and 84% said that it was helpful for coping. 86% of the patients were satisfied that their current treatment was appropriate in the light of what they had learned from the internet. Ten patients out of the 36 who expressed a view thought that the internet information contradicted that provided by the doctor. Despite these results most patients still said that the doctor represented the best source of patient education. Conclusions: Increasing numbers of patients are familiar with the internet. Most of our patients felt that the internet was, on balance, helpful in providing information. The main difficulties with the internet are the sheer volume of information, the potential for misleading and the danger of misunderstanding. We feel that there is a real place for the specific prescription of an internet site by a clinician who has personally reviewed it to a patient thought to be able to benefit from it.

Assessing the Accuracy of Bone Resection by Cutting Blocks in Patient-Specific Total Knee Replacements

Introduction. The key to a successful total knee arthroplasty (TKA) is the restoration of the mechanical axis with balanced flexion and extension gaps. Patient-specific cutting block technique has been the latest development in total knee arthroplasty. This technique uses a magnetic resonance image (MRI) of the patients symptomatic knee to create bone models and cutting jigs. This study was designed to evaluate the intraoperative accuracy of the patient-specific cutting block as compared to the preoperative template. Methods. Visionaire (Smith and Nephew, Genesis 2 Knee Arthroplasty) patient-specific TKA was used in all patients. An independent research officer was responsible for measuring all the resected articular surfaces of femur and tibia during surgery and compared it to the cutting block manufactured according to the preoperative template. Seven different measurements from each patient were obtained; four different measurements from the femur and three from the tibia were recorded. The differences between the actual resections made intraoperatively, as compared to the original pre-operative templates, were noted as the error. The surgical team was blinded to the measurements of the resections and the calculations of the errors. Results. Twenty-six Visionaire patient-specific TKA were included in the study. A total of 182 readings of bone resections made intraoperatively (seven for each patient). Eighty five percent of all collected readings were below the error margin of ≤1.5 mm. Size of resection had no effect on the error margin. All patients had satisfactory post-operative alignment, and at discharge all 26 patients achieved more than 90° of knee flexion. Conclusion. This observational study provides evidence that patient-specific TKA is comparable to other forms of TKA and may have some distinct advantages. In addition, we have shown that the cutting blocks are able to consistently deliver accurate cuts that are reproducible. We recommend intra-operative measurement of the bone resection and its comparison with the cutting block as a routine surgical step to confirm the MRI scan data, block placement, and instant validation of the bony resection before implant placement.

Total hip replacement for neck of femur fracture: Comparing outcomes with matched elective cohort

INTRODUCTION Current literature suggests that total hip replacement (THR) is superior to hemiarthroplasty (HA) for neck of femur fracture in selected group of patients. The outcomes of THR undertaken for trauma setting remain unclear when comparing with elective THR. We compared the outcomes of THR trauma cohort with best-matched elective cohort. METHODS We retrospectively reviewed 102 patients that underwent THR due to trauma from 2011 to 2013. We had access to 90 cases with complete records. Another 90 matched elective cases were obtained from local arthroplasty database. The elective cases were matched for gender, surgical approaches, surgeons grade, types of implant, patients age at operation date of ±5 years and operation date of ±60days. Subsequently, the selection criteria were relaxed to patients age at operation date of ±10 years and operation date of ±60days. Unmatched cases were excluded. Complications and death rate were compared. RESULTS The average age for both cohorts was 70 years. The trauma cohort had statistically significant lower BMI and longer hospital stay (p=0.001). The Functional Comorbidity Index (FCI) and Charlson Age Comorbidity Index (CACI) were the same for both cohorts, reflecting an active patient selection for THR in our centre. The trauma cohort had higher surgical complication rate (9% vs 4%), particularly higher dislocation rate (7% vs 1%); and higher medical complication rate (32% vs 6%). These were consistent with the literature. Contrary to literature, the trauma cohort had six dislocations that five of them were done via anterolateral approach. Among the eight trauma cases with surgical complications, six cases were performed by trainees. The cause of surgical complications remains unclear due to the nature of retrospective study. The trauma cohort had higher death rate than the elective cohort (14% vs 4%), with one post-operative cardiac arrest in the trauma cohort. The rest were non-orthopaedic related deaths, ranging between four months to four years. CONCLUSION A more robust way of selecting trauma patients for THR is warranted to reduce morbidity and mortality. Follow-up for the trauma cohort is warranted, as the patients are likely to outlive the implants.

Outcome analysis of cubital tunnel decompression

Background Cubital tunnel decompression is a commonly undertaken upper limb procedure. Most studies compare the different techniques of decompression; however, only a few have specifically investigated the outcome of ulnar nerve decompression. Aim The aim of this study was to investigate the outcome of ulnar nerve decompression following cubital tunnel syndrome. Methods and results A total of 174 ulnar nerve decompression cases were identified from the upper limb surgery database with complete data available for 136 cases. Simple decompression was performed in 110 (80.88%) cases, and in 26 (19.12%), anterior subcutaneous transposition was also supplemented. These operations were performed at three different hospitals by surgeons of different levels of experience. The most common cause of cubital tunnel syndrome was idiopathic. The outcome was satisfactory in 86% of cases. No obvious association was demonstrated between the outcome of surgery and duration of symptoms, presence of co-morbidities or the type of surgery performed. Conclusion This is the largest outcome analysis of the results of ulnar nerve decompression at the elbow. Good results following nerve decompression were attained in 86% of cases without any significant effect of duration of symptoms or co-morbidities on the outcome of surgery. It is hoped that the findings of the current study will help general practitioners, junior doctors and surgeons in their management and pre-operative consultation with patients having cubital tunnel syndrome.

Medium term outcomes of primary and revision Coonrad-Morrey total elbow replacement

Background: Total elbow replacement (TER) is indicated in inflammatory arthritis, osteoarthritis and fractures that are not amenable to reconstruction. There is no series in literature, to the best of our knowledge, regarding the results of revision of the Souter-Strathclyde prosthesis (SSP) to the Coonrad-Morrey prosthesis (CMP). The aim of this study is to present the medium term results of primary CMP total elbow replacement and revision of the SSP to CMP. Materials and Methods: 50 primary CMPs (Group I) and 11 revision CMPs (Group II) were included in the study. Demographic, operative, followup and radiological data were analysed. The indication for revision of the primary implant was peri-prosthetic fracture in six cases, aseptic loosening in four cases and instability in one case. Results: The mean age in Group I was 67.28 ± 12.45 years and in Group II was 57.09 ± 11.25 years. The mean period of followup was 8.08 ± 2.95 years and 7.46 ± 2.39. There was a significant improvement in range of motion and pain in both groups. The complications seen were nerve palsy, infection, fractures and heterotopic ossification. The 5-year survival rate in Group I was 94%. The results were good in 36 elbows, fair in 8 elbows and poor in 5 elbows. In Group II, the results were good in 8 elbows, fair in 2 elbows and poor in 1 elbow. The complications seen were nerve palsy, fractures and heterotopic ossification. Discussion: Primary CMP TER provides a functionally useful range of movement of 100° which is enough to perform most activities of daily living. It also produces a pain free and stable joint. Similar results are achieved after revision of the SSP to CMP. The unique toggle-hinge mechanism of articulation provides inherent stability and good survivorship. Conclusion: Semiconstrained prostheses like CMP provide good functional results and survivorship and are the implant of choice in both primary and revision total elbow replacements.

Important Anatomical Relationships of the Posterior Interosseous Nerve in the Distal Forearm for Surgical Planning: A Cadaveric Study

A thorough knowledge of the anatomy of the terminal branch of the posterior interosseous nerve (PIN) and its relationship to the anterior interosseous nerve (AIN) is essential in facilitating regional anesthetic blocks and planning surgical exposures for wrist surgery and arthrodesis of wrist and proximal row carpectomy. This cadaveric study focused on the anatomy and course of the PIN and its anatomical relationships at the distal forearm. Thirty embalmed cadaver forearms were dissected using microsurgical techniques. A structured pro forma was used to collect data. The PIN was consistently found in the fourth extensor compartment in all specimens. The last motor branch was given off 46.9 ± 8.4 mm (mean ± standard deviation) from the most proximal part of the ulnar head. The AIN was found lying consistently on the anterior aspect of the interosseous membrane, being on average 2.8 ± 0.2 mm (mean ± standard deviation) from the PIN. This knowledge will facilitate the planning of diagnostic and therapeutic procedures associated with the wrist.

Numbness Around the Total Knee Arthroplasty Surgical Scar: Prevalence and Effect on Functional Outcome

BACKGROUND Numbness around the surgical scar can be a source of discomfort or dissatisfaction in a proportion of patients undergoing total knee arthroplasty (TKA). Literature reports wide variation in its prevalence and the consequence of numbness on the outcome of TKA is not clear. We investigated the prevalence of numbness, along with contributing factors, and assessed its effect on the functional outcome of TKA. METHODS In total, 258 knees were included in this prospective patient-reported outcome measure case-control study. Demographic details, type and length of incision, pre-operative and 1-year post-operative Knee Society Scores were recorded and compared. RESULTS The prevalence of numbness at 1 year was 53%, with a female preponderance. Patients older than 70 years were less affected. Discomfort due to numbness was recorded in 8.7% of the patients, 75% of which were female. The length of the incision correlated positively with the presence of numbness. The Knee Society Scores did not correlate with the presence or area of numbness. CONCLUSION Our findings indicate a high prevalence of numbness after TKA. Nevertheless, numbness does not affect the functional outcome.

Cruciate Retaining compared with Posterior Stabilised Nexgen total knee arthroplasty: results at 10 years in a matched cohort

INTRODUCTION Debate has persisted for many years about whether to sacrifice or replace the posterior cruciate ligament when performing total knee arthroplasty. A paucity of long‐term follow‐up studies comparing outcomes between cruciate‐retaining and posterior‐stabilised knees exist. We aimed to compare results at ten‐year follow‐up. METHODS A matched paired study comparing a cohort of 107 Zimmer Nexgen® Cruciate Retaining (CR) patients with a cohort of 107 Nexgen Posterior‐Stabilised (PS) knees matched for age, sex, body mass index and preoperative American Knee Society score was undertaken. All patients underwent independent clinical assessment and knee society scoring preoperatively and at 1, 3, 5, 7 and 10 years postoperatively. RESULTS Fifty‐three patients (49.5%) in the CR group and 44 patients (41.1%) in the PS group were alive at 10‐year follow‐up. There were no significant differences between the CR and PS groups with regards to functional assessment (P = 0.95), overall range of movement (P = 0.46) or patient satisfaction (P = 1.0) at 10 years. However, there was a significantly better score improvement in range of movement in PS knees compared with CR knees (P = 0.027). There were six revisions (5.6%) in the PS group and 1 (0.93%) in the CR group (P = 0.12). Both CR and PS knees showed excellent survivorship with no significant difference at 10 years (P = 0.068). CONCLUSIONS There were no significant differences in functional score, overall range of motion or patient satisfaction between the Nexgen cruciate retaining and posterior stabilised total knee arthroplasty at 10‐year follow‐up. However, PS knees had a greater score improvement in range of motion compared with CR knees.