Peter Brownson

Repair of Distal Biceps Tendon Ruptures Using Suture Anchors Through a Single Anterior Incision

PURPOSE The purpose of this study was to review the results of distal biceps tendon repair via suture anchors through a single anterior incision. METHODS This is a retrospective review of 17 patients (18 repairs) treated for complete distal biceps tendon rupture between 1998 and 2005 by use of G4 Superanchors (DePuy Mitek, Raynham, MA) in our unit. The length of follow-up was 14 to 70 months (mean, 45 months). RESULTS There was a mean loss of 5.3 degrees (range, 0 degrees to 50 degrees ; SD, 14.12) of extension when compared with the uninjured side. Of the 17 patients, 6 achieved full extension when compared with the uninvolved elbow. The mean loss of flexion was 6.2 degrees (range, 0 degrees to 15 degrees; SD, 6.11). There was a mean loss of 11.0 degrees of pronation (range, 0 degrees to 30 degrees; SD, 11.34) and 6.4 degrees of supination (range, 0 degrees to 45 degrees; SD, 17.45). Flexion in supination strength measured by a handheld dynamometer was 82.1% of that of the injured side (range, 59% to 102%; SD, 11.26). There were two complications in our series: transient superficial radial nerve palsy in one case and heterotopic ossification in the other. The mean Disabilities of the Arm, Shoulder and Hand score was 14.45 (range, 0 to 55.17; SD, 4.76). Six months after surgery, all patients but one returned to their preinjury levels of activity and employment. CONCLUSIONS Our study shows that repair of distal biceps tendon ruptures via suture anchors is safe and yields clinically objective and functional results comparable to measurements in the other, uninjured extremity. LEVEL OF EVIDENCE Level IV, therapeutic case series.

Subacromial shoulder pain

Definition Subacromial shoulder pain is commonly located to the top and lateral side of the shoulder. It is exaggerated by overhead activity and can be associated with night pain. It is usually associated with full passive range of movement of the glenohumeral joint. The pain originates from the subacromial space of the shoulder, an area made up of the rotator cuff tendons and the subacromial bursa. This area is separate to the main glenohumeral joint. Pain from this area is mainly caused by rotator cuff tendinopathy, also referred to as ‘shoulder impingement’. Impingement occurs between the undersurface of the acromion (roof of shoulder) and the rotator cuff tendons. These tendons can be either intact or torn. A number of other terms such as supraspinatus tendinopathy, tendinitis and bursitis are also used across different disciplines but the diagnosis is essentially the same and referred to in this document as rotator cuff tendinopathy/impingement.

Limited capsular release and controlled manipulation under anaesthesia for the treatment of frozen shoulder.

Background In light of recent interest in the cost-effectiveness of the treatment options available for frozen shoulder, we aimed to determine the results of limited anterior capsular release and controlled manipulation under anaesthesia (MUA) in the treatment of primary frozen shoulder in terms of patient-related outcomes measure, range of motion and re-intervention rates. Methods This single-surgeon series included prospectively collected data on all patients undergoing capsular release with MUA from March 2011 until June 2013, with a minimum follow-up of 6 months from the index procedure. Outcome measures included pre- and postoperative Oxford Shoulder Score (OSS), range of motion and need for re-intervention. Results Fifty-four procedures were performed in 52 patients. Mean age 50 years (range 42 years to 59 years); male: female ratio = 11: 41. There was a highly statistically significant improvement in both pain and function modules of the OSS (p < 0.005) and range of motion (p < 0.005) at 6 months. The median postoperative score was 41 from a maximum of 48 points, with an average mean improvement of 24 points. Seventeen patients were diabetics. There was no significant difference in pre-operative and postoperative OSS or range of motion between the diabetic group and the non-diabetic groups. No patients required surgical re-intervention. Conclusions A combination of limited capsular release and MUA for the treatment of primary frozen shoulder is a safe and effective procedure resulting in marked improvement in pain, function and range of motion.

A Kinematic Assessment of Normal Elbow Movement in Activities of Modern Day Living

Background The range of functional elbow movement has previously been studied. The data obtained have been used to provide an objective basis for the determination of disability, to determine the optimum position for elbow splinting arthrodesis and to assist in the design of elbow prostheses. The present study aimed to evaluate the functional range of elbow movement as applied to a predetermined list of activities of daily living, which might be considered relevant to modern day life. This includes the use of computers and driving, which has not been studied earlier. Methods Twenty normal volunteers were studied and the range of elbow motion required for specific activities was recorded by means of a ‘Polhemus Fastrak’ magnetic tracking measurement system. The results obtained suggests that the functional range of elbow flexion is from 1.33° to 146.57° and the rotation arc is from 56° of pronation to 104° of supination. Conclusion This data compliments the work previously carried out, and defines the functional range of movement for some of the common activities of daily living.

Arthroscopic capsular release: a prospective double-blind randomized study comparing two types of rehabilitation regime. A pilot study

Background The aim of this study was to evaluate, prospectively, outcomes following arthroscopic capsular release on patients with a clinical diagnosis of frozen shoulder, comparing immediate mobilization (IM) vs immediate mobilization plus external rotation splintage at night for 10 nights (IM+EXT). Methods Patients with a clinical diagnosis of non-traumatic frozen shoulder seen in a single unit from May 2005 to December 2006 were considered for inclusion. Patients were assessed using the Constant score, Oxford shoulder questionnaire, and a visual analogue scale for pain (VAS pain). Patients were randomized to have immediate mobilization (IM) or immediate mobilization plus external rotation splintage at night for 10 nights (IM+EXT). Results Thirty patients were included and both groups showed significant improvement in all scores. Mean length of follow-up was 17 months. There was early (4 weeks post-operatively) significant improvement in shoulder function in both groups. The rehabilitation regime used did not affect the overall outcome. Conclusions Arthroscopic capsular release produces early symptom improvement in primary frozen shoulder. The use of an external rotation splint at night does not appear to improve outcome over simple early mobilization.

The incidence and causative organisms of infection in elective shoulder surgery

Background Deep infection remains a serious complication of orthopaedic surgery. Knowledge of infection rates and causative organisms is important to guide infection control measures. The aim of the present study was to determine infection rates and causative organisms in elective shoulder surgery. Methods Cases complicated by infection were identified and prospectively recorded over a 2-year period. All patients undergoing elective shoulder surgery in the concurrent period at a single Specialist Upper Limb Unit in the UK were identified from the hospital electronic database. Results In total, 1574 elective shoulder cases were performed: 1359 arthroscopic (540 with implant insertion) and 215 open (197 with implant insertion). The overall infection rate in open surgery of 2.5% was significantly higher than arthroscopic implant cases at 0.7% (p < 0.005). The overall infection rate in implant arthroscopic surgery was significantly higher at 0.7% compared to 0% in non-implant related surgery. (p < 0.05) Conclusions Patients undergoing open shoulder surgery have a significantly higher risk of infection compared to arthroscopic shoulder surgery. Arthroscopic surgery with implant insertion has a statistically significantly higher risk of developing deep infection compared to procedures with no implant insertion. We recommend prophylactic antibiotics in open shoulder surgery and arthroscopic shoulder surgery with implant insertion.

The Provision of Primary and Revision Elbow Replacement Surgery in the NHS

BESS Surgical Procedure Guidelines (SPGs). Optimising Surgical Outcomes for Shoulder and Elbow patients. The British Elbow and Shoulder Society (BESS) SPGs are a series of evidence and consensus Best Practice Recommendations developed by BESS surgeons and physiotherapists to help drive quality improvement and achieve the best possible surgical outcomes for UK patients. This SPG on primary and revision elbow replacement surgery is supported and endorsed by both the British Orthopaedic Association (BOA) and the Getting It Right First Time (GIRFT) Programme.

Long contoured locking plate fixation of traumatic proximal humeral fractures with distal extension

Background There is a paucity of data available with respect to outcome on long contoured locking plate fixation for proximal humerus fractures with distal fracture extension. Methods Thirty-four patients with traumatic proximal humerus fractures with distal extension underwent fixation with long contoured locking plates. Twenty-five patients (74%) were included in the study: one patient died, two patients had unrelated illnesses resulting in them being unable to complete follow-up assessment and six were lost to follow-up. Patients’ case notes and radiographs were retrospectively reviewed, and patients were contacted to assess functional outcome using the Visual Analogue Scale (VAS) for pain, Disabilities of the Arm, Shoulder and Hand (DASH) score, Oxford Shoulder Score (OSS) and Stanmore Percentage of Normal Shoulder Assessment (SPONSA). Results Mean follow-up was 27 months (range 11 months to 60 months). Mean pain at final follow-up was 3.6 [95% confidence interval (CI) = 2.5 to 4.8] with only four patients having residual pain greater than 5 on the VAS scale. Mean DASH score was 41.2 (95% CI = 32.0 to 50.4), mean OSS was 29.1 (95% CI = 24.3 to 33.9) and mean SPONSA was 63.9% (95% CI = 50.8 to 77.2). There was one wound infection. Three patients had non-unions that required bone grafting and revision internal fixation. Conclusions We feel long contoured locking plates represent a useful treatment option for complex proximal humerus fractures