David I. Clark

Risk factors in lateral epicondylitis (tennis elbow): a case-control study

Lateral epicondylitis is a common condition, but relatively little is known about its aetiology and associated risk factors. We have undertaken a large case-control study using The Health Improvement Network database to assess and quantify the relative contributions of some constitutional and environmental risk factors for lateral epicondylitis in the community. Our dataset included 4998 patients with lateral epicondylitis who were individually matched with a single control by age, sex, and general practice. The median age at diagnosis was 49 (interquartile range 42–56) years . Multivariate analysis showed that the risk factors associated with lateral epicondylitis were rotator cuff pathology (OR 4.95), De Quervain’s disease (OR 2.48), carpal tunnel syndrome (OR 1.50), oral corticosteroid therapy (OR 1.68), and previous smoking history (OR 1.20). Diabetes mellitus, current smoking, trigger finger, rheumatoid arthritis, alcohol intake, and obesity were not found to be associated with lateral epicondylitis.

An epidemiological study of rotator cuff pathology using The Health Improvement Network database

Little is known about the incidence of rotator cuff pathology or its demographic associations in the general population. We undertook a large epidemiological study of rotator cuff pathology in the United Kingdom using The Health Improvement Network (THIN) database. The incidence of rotator cuff pathology was 87 per 100,000 person-years. It was more common in women than in men (90 cases per 100,000 person-years in women and 83 per 100,000 person-years in men; p < 0.001). The highest incidence of 198 per 100,000 person-years was found in those aged between 55 and 59 years. The regional distribution of incidence demonstrated an even spread across 13 UK health authorities except Wales, where the incidence was significantly higher (122 per 100,000 person-years; p < 0.001). The lowest socioeconomic group had the highest incidence (98 per 100,000 person-years). The incidence has risen fourfold since 1987 and as of 2006 shows no signs of plateauing. This study represents the largest general population study of rotator cuff pathology reported to date. The results obtained provide an enhanced appreciation of the epidemiology of rotator cuff pathology and may help to direct future upper limb orthopaedic services.

The Value of Crossed Intrinsic Transfer after Metacarpophalangeal Silastic Arthroplasty: A Comparative Study:

Seventy three hands in patients with rheumatoid arthritis undergoing primary index to small finger metacarpophalangeal joint replacements were studied retrospectively. In twenty eight hands a crossed intrinsic transfer was performed and in forty five hands it was not. A similar splintage and rehabilitation programme was followed in each group. The two treatment groups had similar preoperative ulnar drift (crossed intrinsic transfer group mean 278, comparative group 298). At a mean follow up of 50 months the crossed intrinsic transfer group had statistically less ulnar drift (crossed intrinsic transfer group mean 68, comparative group mean 148, P=0.01). There were no other significant differences at follow up.

Medium-term clinical results of a linked total elbow replacement system

Medium-term results of the Discovery elbow replacement are presented. We reviewed 51 consecutive primary Discovery total elbow replacements (TERs) implanted in 48 patients. The mean age of the patients was 69.2 years (49 to 92), there were 19 males and 32 females (37%:63%) The mean follow-up was 40.6 months (24 to 69). A total of six patients were lost to follow-up. Statistically significant improvements in range movement and Oxford Elbow Score were found (p < 0.001). Radiolucent lines were much more common in, and aseptic loosening was exclusive to, the humeral component. Kaplan-Meier survivorship at five years was 92.2% (95% CI 74.5% to 96.4%) for aseptic loosening. In four TERs, periprosthetic infection occurred resulting in failure. A statistically significant association between infection and increased BMI was found (p = 0.0268). Triceps failure was more frequent after the Mayo surgical approach and TER performed after previous trauma surgery. No failures of the implant were noted. Our comparison shows that the Discovery has early clinical results that are similar to other semi-constrained TERs. We found continued radiological surveillance with particular focus on humeral lucency is warranted and has not previously been reported. Despite advances in the design of total elbow replacement prostheses, rates of complication remain high.

Corticosteroid and platelet-rich plasma injection therapy in tennis elbow (lateral epicondylalgia): a survey of current UK specialist practice and a call for clinical guidelines

Background Tennis elbow is a common condition with a variety of treatment options, but little is known about which of these options specialists choose most commonly. Corticosteroid injections in tennis elbow may reduce pain in the short-term but delay long-term recovery. We have undertaken a UK-wide survey of upper limb specialists to assess current practice. Methods Cross-sectional electronic survey of current members of the British Elbow and Shoulder Society (BESS) and the British Society for Surgery of the Hand (BSSH). Results 271 of 1047 eligible members responded (25.9%); consultant surgeons constituted the largest group (232/271, 85%). 131 respondents (48%) use corticosteroid injections as their first-line treatment for tennis elbow. 206 respondents (77%) believed that corticosteroid injections are not potentially harmful in the treatment of tennis elbow, while 31 (11%) did not use them in their current practice. In light of recent evidence of the potential harmful effects of corticosteroid therapy, 136 (50%) had not changed their practice while 108 (40.1%) had reduced or discontinued their use. 43 respondents (16%) reported having used platelet-rich plasma injections. Conclusions Recent high-quality evidence that corticosteroids may delay recovery in tennis elbow appears to have had a limited effect on current practice. Treatment is not uniform among specialists and a proportion of them use platelet-rich plasma injections.

Nonunion of a scapular spine fracture: Case report and management with open reduction, internal fixation, and bone graft

Fractures of the scapular spine are relatively uncommon. We report a case of a 39 year old male who developed an atrophic non-union scapular spine fracture entering the spino-glenoid notch. We describe our experience with this rare fracture pattern and identify the need for early internal fixation in the young, active and working population.

Reverse total shoulder arthroplasty using a trabecular metal glenoid base plate: functional and radiological outcomes at two to five years

AIM We present the medium-term clinical results of a reverse total shoulder arthroplasty with a trabecular metal glenoid base plate. PATIENTS AND METHODS We reviewed 125 consecutive primary reverse total shoulder arthroplasties (RTSA) implanted in 124 patients for rotator cuff arthropathy. There were 100 women and 24 men in the study group with a mean age of 76 years (58 to 89). The mean follow-up was 32 months (24 to 60). No patient was lost to follow-up. RESULTS There were statistically significant improvements in the mean range of movement and Oxford Shoulder Score (p < 0.001). Kaplan-Meier survivorship at five years was 96.7% (95% confidence interval 91.5 to 98.7) with aseptic glenoid failure as the end point. Radiologically, 63 shoulders (50.4%) showed no evidence of notching, 51 (40.8%) had grade 1 notching, ten (8.0%) had grade 2 notching and one (0.8%) had grade 4 notching. Radiolucency around the glenoid base plate was found in one patient (0.8%) and around the humeral stem in five (4.0%). In all, three RTSA (2.4%) underwent revision surgery for aseptic mechanical failure of the glenoid within 11 months of surgery due to malseating of the glenosphere. CONCLUSION The clinical results of this large independent single unit series are comparable to those from previous series of RTSA reported in the literature. A trabecular metal base plate is safe and effective in the medium-term. Cite this article: Bone Joint J 2016;98-B:969-75.

Study of lateral epicondylitis (tennis elbow) using the health improvement network database

Background Lateral epicondylitis has been studied mainly in work related and occupational groups, however little is known about the incidence or demographic associations in the general population. We have undertaken a large study using The Health Improvement Network (THIN) database to examine the epidemiology of lateral epicondylitis in the UK general population. Methods Diagnoses of lateral epicondylitis between 1987 and 2006 were used to calculate the incidence stratified by age, gender, deprivation score, UK health authority, and year. The age standardised rates for lateral epicondylitis in the UK were calculated with reference to the European Standard Population. Results The incidence rate of lateral epicondylitis was 2.45 per 1000 person-years. This was more common in males than females (males 2.63, females 2.55 per 1000 person-years, p < 0.001). After direct standardization, the age adjusted rates were 2.38 for males and 2.43 for females. The highest incidence rate of 7.35 per 1000 person-years was found in the age group 45-50 years. Regional distribution of the incidence rates showed a fairly even spread across 13 UK Health Authorities with the exception of London where incidence rates were significantly lower (1.75 per 1000 person-years, p < 0.001). Social deprivation was assessed using the Townsend score. The least deprived areas of the population had the highest incidence rates (2.86 per 1000 person years). Conclusions Our study represents the largest general population study of lateral epicondylitis reported to date. The results obtained provide the clinician with a better understanding of the epidemiology of lateral epicondylitis in the community.

Assessing elbow assessment, past, present and future

The state of elbow assessment is reviewed using a timeline of past, present and future. Empirical evidence is provided supporting the conclusions made in recent years that patient self-assessed evaluation of elbow function is valid, consistent and reliable. This form of assessment is so robust that it does not appear to matter whether the scale is composed of four, five or seven categories or even a visual analogue scale per item. The raw scores are not linear but can be constructed as such using Rasch modelling. Items included in any one scale have been identified as being on a continuum of difficulty, and the continuum itself can be considered as a ‘ruler’ of difficulty. Finally, the health of the elbow cannot be summarized as just one domain. We suggest that health of the elbow be considered by an expert panel (BESS) where the concepts of pain, function and impairment are fitted to the International Classification of Functioning, Disability and Health framework, so that a standardized assessment regime is available on a national basis.

Management of tennis elbow: a survey of UK clinical practice:

Background Tennis elbow is a common condition in the UK but there are no guidelines on how best to manage the condition. The purpose of the present study was to establish the current UK practice in managing patients with chronic tennis elbow. Methods A cross-sectional online survey of UK surgeons and therapists was conducted in June 2017. Results In total, 275 responses were received, the majority from consultant surgeons and experienced physiotherapists. In total, 81% recommended exercise-based physiotherapy as the first-line intervention. Second-line treatments varied widely, with corticosteroid injections being the most popular (27%), followed by shockwave therapy, platelet-rich plasma injection, surgery, acupuncture and a wait-and-see policy. Conclusions There is wide variability of treatments offered when physiotherapy fails patients with tennis elbow. The majority of second-line interventions lack evidence to support their use and, in the case of corticosteroid injections, may even be harmful in the long term. There is a clear need for national guidance based on best evidence to aid clinicians in their treatment approach.