Recent Submissions

  • Glenoid Fracture Fixation Using an Acu-Loc Distal Radius Plate

    Ashwood, Neil; Dekker, Andrew (2024-05)
    Displaced fractures of the glenoid require surgical fixation. This poses multiple problems, including a difficult approach and achieving adequate reduction with current implants. We provide a surgical technical tip for fixing scapula neck and glenoid rim fractures with an Acu-Loc distal radius plate (Acumed, Weyhill, UK), illustrated with two recent case reports. Here, we present two cases of a 58-year-old female and a 51-year-old male presenting to a hospital following a fall, both sustaining an isolated right glenoid intra-articular fracture evident on plain radiographs. CT scans revealed a displaced and fragmented glenoid surface. A reverse Judet posterior approach facilitated exposure to enable the reduction of the glenoid, an uncommon approach. Current plate designs provide surgeons with limited options to fix complex fractures of the scapula and were not suitable here. The lateral scapula border and inferior glenoid have a similar anatomical shape to the distal radius. An Acu-Loc locking distal radius plate with a radial styloid plate was trialled and provided a good reduction to the fragmented glenoid. A distal radius plate can be a useful option to consider in complex scapula neck and glenoid rim fractures. A better understanding of glenoid shape will facilitate the further development of orthopaedic implants. Familiarity with various surgical approaches is needed to operate on these complex fractures.
  • Does long-term follow-up and monitoring of primary shoulder arthroplasty identify failing implants requiring revision?

    Morris, D.L.J.; Dover, Caroline; Walstow, Katherine; Pitt, Lisa; Morgan, Marie; Espag, Marius; Clark, David; Tambe, Amol
    BACKGROUND: Published scoping review has identified evidence paucity related to long-term follow-up of shoulder arthroplasty. We aim to report effectiveness of elective primary shoulder arthroplasty surveillance in identifying failing implants requiring revision. METHODS: A prospective database recording shoulder arthroplasty and subsequent follow-up surveillance in a shoulder unit was analyzed. Shoulder arthroplasty was performed by 4 fellowship-trained shoulder surgeons for accepted elective indications including the use of anatomic arthroplasty in arthritic shoulders with intact rotator cuff and a reverse prosthesis being used in rotator cuff-deficient shoulders and rotator cuff-competent arthritic shoulders when deemed preferable by the treating surgeon. All shoulder arthroplasty implants used had achieved a minimum 7A Orthopaedic Data Evaluation Panel (ODEP) rating. The included shoulder arthroplasties were performed between May 1, 2004, and December 31, 2021, with minimum 1-year follow-up. Surveillance program involves specialist physiotherapist review at 1, 2, 3, 5, 8, 10, and 15 years postoperatively, including clinical examination, outcome scoring, and radiographs. Patient-initiated review occurred between time points if a patient requested assessment because of symptoms. Outcome measures include ratio of failing implants identified by surveillance and patient-initiated review, with number of surveillance reviews offered and proportion that identified a failing implant requiring revision calculated. RESULTS: A total of 1002 elective primary shoulder arthroplasty with minimum 1-year follow-up were performed (547 reverse total shoulder arthroplasty [rTSA], 234 anatomic total shoulder arthroplasty [aTSA], and 221 hemiarthroplasty [HA]). A total of 238 patients died prior to December 31, 2022, resulting in 4019 surveillance appointments offered. Thirty-eight prostheses required revision ≥1 year postoperatively (6 rTSA, 9 aTSA, and 23 HA), with surveillance identifying requirement in 53% (33% rTSA, 56% aTSA, and 57% HA) and patient-initiated review in 47%. Mean years from implantation to revision was 5.2 (2.7 rTSA, 3.6 aTSA, and 6.6 HA). Revision indications included rotator cuff failure (56% aTSR and 43% HA) and glenoid erosion (57% HA). CONCLUSION: This is the first series reporting effectiveness of shoulder arthroplasty surveillance in identifying implants requiring revision. Surveillance identified more than half of implants requiring revision, although only 0.5% of appointments identified revision requirement. Surveillance enrolment may influence patient-initiated review utilization; therefore, similar studies using only patient-initiated follow-up would help inform recommendations.
  • Emotion Regulation and Psychological Dependence on Pain Medication among Hospital Outpatients with Chronic Spinal Pain: The Influence of Rumination about Pain and Alexithymia.

    Bateman, AH
    Objective: To examine the extent to which pain acceptance, pain catastrophising and alexithymia moderate associations between pain intensity and psychological pain medication dependence. Methods: Participants (106 hospital outpatients with chronic spinal pain) completed the Leeds Dependence Questionnaire (LDQ) to measure psychological dependence on pain medication, and the Chronic Pain Acceptance Questionnaire-8 (CPAQ-8), the Pain Catastrophising Scale (PCS) and the Toronto Alexithymia Scale-20 (TAS-20), plus the Depression, Anxiety and Stress Scale-21 (DASS-21). Results: Multiple linear regression showed that degree of psychological dependence (measured dimensionally across the range of LDQ scores) was associated with TAS subscale difficulty identifying feelings (DIF) (β = 0.249, p = <0.002) and PCS subscale rumination (β = 0.193, p = 0.030), independently of pain intensity and risk behaviors for medication misuse. The effect of pain intensity was moderated by rumination, with pain intensity more strongly associated with dependence when rumination was high (interaction β = 0.192, p = 0.004). Logistic regression showed that the effect of pain intensity on severe dependence (measured categorically as LDQ score ≥ 20) was moderated by alexithymia, so that severe dependence was independently associated with the combination of intense pain and high alexithymia (interaction odds ratio = 7.26, 95% CIs = 1.63-32.42, p = 0.009). Conclusions: Rumination and alexithymia moderated the associations between pain intensity and psychological pain medication dependence, consistent with emotion regulation theory. This raises the possibility that specifically targeting rumination about pain and symptoms of alexithymia could potentially improve the effectiveness of psychological interventions for chronic pain and help people to avoid or reduce their psychological dependence on pain medication.
  • Identifying clusters of objective functional impairment in patients with degenerative lumbar spinal disease using unsupervised learning.

    Klukowska, Anita
    OBJECTIVES: The five-repetition sit-to-stand (5R-STS) test was designed to capture objective functional impairment (OFI), and thus provides an adjunctive dimension in patient assessment. It is conceivable that there are different subsets of patients with OFI and degenerative lumbar disease. We aim to identify clusters of objectively functionally impaired individuals based on 5R-STS and unsupervised machine learning (ML). METHODS: Data from two prospective cohort studies on patients with surgery for degenerative lumbar disease and 5R-STS times of ≥ 10.5 s-indicating presence of OFI. K-means clustering-an unsupervised ML algorithm-was applied to identify clusters of OFI. Cluster hallmarks were then identified using descriptive and inferential statistical analyses. RESULTS: We included 173 patients (mean age [standard deviation]: 46.7 [12.7] years, 45% male) and identified three types of OFI. OFI Type 1 (57 pts., 32.9%), Type 2 (81 pts., 46.8%), and Type 3 (35 pts., 20.2%) exhibited mean 5R-STS test times of 14.0 (3.2), 14.5 (3.3), and 27.1 (4.4) seconds, respectively. The grades of OFI according to the validated baseline severity stratification of the 5R-STS increased significantly with each OFI type, as did extreme anxiety and depression symptoms, issues with mobility and daily activities. Types 1 and 2 are characterized by mild to moderate OFI-with female gender, lower body mass index, and less smokers as Type I hallmarks. CONCLUSIONS: Unsupervised learning techniques identified three distinct clusters of patients with OFI that may represent a more holistic clinical classification of patients with OFI than test-time stratifications alone, by accounting for individual patient characteristics.
  • Frequency and reporting of complications after Dupuytren's contracture interventions: A systematic review and meta-analysis.

    Johnson, Nick
    INTRODUCTION: Numerous complications are reported following interventions for Dupuytren's contracture; however, their incidence, management, and outcomes remain poorly reported. The aims of this review were to report the proportions of complications, compare likelihood of complications between interventions, and evaluate reporting of complications, including assessment, grading, management, and subsequent reporting of their impact on patient outcomes. METHODS: Extracted data included patient demographics, intervention details, complications, their management, and final outcomes. Analysis of descriptive data enabled review of complications reporting. Meta-analysis(MA) of non-comparative datasets enabled estimation of proportions of patients experiencing complications. Network meta-analysis(NMA) of comparative studies estimated the relative occurrence of complications between interventions. Risk of bias analysis was performed. RESULTS: 26 studies, comprising 10,831 patients, were included. Interventions included collagenase injection, percutaneous needle fasciotomy(PNF), limited fasciectomy(LF), open fasciotomy(OF), and dermofasciectomy(DF). Overall quality and consistency of outcomes reporting was poor. MA enabled estimates of probabilities for three common complications(infection, nerve injury, complex regional pain syndrome(CRPS)) across all interventions; the reported rates for LF were 4.5% for infection, 3% for nerve injury, and 3.3% for CRPS. As the commonest intervention, LF was used as the reference intervention for comparison of the commonest complications via NMA, including haematoma [OF OR 0.450(0.277, 0.695); PNF OR 0.245(0.114, 0.457)], infection [PNF OR 0.2(0.0287, 0.690); DF OR 2.02(1.02, 3.74)], and neuropraxia [PNF OR 0.0926(0.00553, 0.737)]. We noted that the complication incidence was higher the more invasive the intervention. CONCLUSIONS: There was limited reporting of complication occurrence, management, and outcomes following interventions, contributing to a gap in information for informed patient consent. MA was possible for reporting of proportions for infection, nerve injury, and CRPS across interventions. NMA enabled direct comparison of the six commonest complications between interventions. These findings can guide intervention selection. Improving consistency and quality in complications reporting is essential to aid counselling of patients regarding the true rates and consequences of the risks of interventions. TYPE OF STUDY/LEVEL OF EVIDENCE: 2.
  • Emotion Regulation and Psychological Dependence on Pain Medication among Hospital Outpatients with Chronic Spinal Pain: The Influence of Rumination about Pain and Alexithymia.

    Bateman, AH
    Objective: To examine the extent to which pain acceptance, pain catastrophising and alexithymia moderate associations between pain intensity and psychological pain medication dependence. Methods: Participants (106 hospital outpatients with chronic spinal pain) completed the Leeds Dependence Questionnaire (LDQ) to measure psychological dependence on pain medication, and the Chronic Pain Acceptance Questionnaire-8 (CPAQ-8), the Pain Catastrophising Scale (PCS) and the Toronto Alexithymia Scale-20 (TAS-20), plus the Depression, Anxiety and Stress Scale-21 (DASS-21). Results: Multiple linear regression showed that degree of psychological dependence (measured dimensionally across the range of LDQ scores) was associated with TAS subscale difficulty identifying feelings (DIF) (β = 0.249, p = <0.002) and PCS subscale rumination (β = 0.193, p = 0.030), independently of pain intensity and risk behaviors for medication misuse. The effect of pain intensity was moderated by rumination, with pain intensity more strongly associated with dependence when rumination was high (interaction β = 0.192, p = 0.004). Logistic regression showed that the effect of pain intensity on severe dependence (measured categorically as LDQ score ≥ 20) was moderated by alexithymia, so that severe dependence was independently associated with the combination of intense pain and high alexithymia (interaction odds ratio = 7.26, 95% CIs = 1.63-32.42, p = 0.009). Conclusions: Rumination and alexithymia moderated the associations between pain intensity and psychological pain medication dependence, consistent with emotion regulation theory. This raises the possibility that specifically targeting rumination about pain and symptoms of alexithymia could potentially improve the effectiveness of psychological interventions for chronic pain and help people to avoid or reduce their psychological dependence on pain medication.
  • Trauma outcomes at higher-level trauma centres compared with lower level trauma centres: a systematic review and meta-analysis

    Ashwood, Neil
    The introduction of trauma systems has helped reduce mortality in severely injured patients. This fall in mortality, however, appears to be concentrated in higher-level trauma centres (TCs) in comparison to lower-level TCs, but the evidence is inconsistent. Therefore, we undertook a systematic review with the aim of comparing outcomes in lower-level TCs (i.e. level III and IV trauma centres) with higher-level TCs (i.e. level I and II centres). This systematic review was performed in accordance with the guidelines defined in the preferred reporting items for systematic reviews and meta-analyses statement (PRISMA). The review was registered on PROSPERO (CRD42019111933). Mortality data were combined using the Mantel-Haenszel random-effects method for meta-analysis, using Review Manager (RevMan v5.3.5). We found 28 eligible articles from an initial total of 10,816 identified abstracts. Our meta-analysis revealed no evidence of a difference in mortality risk in severely injured patients between lower-level and higher-level TCs (RR 1.55; 95% CI 0.97 to 2.50; p=0.07), but there was considerable heterogeneity (I2=92%) in the dataset. The risk of death in lower-level TCs in patients with neurological trauma, however, was statistically lower than in higher-level TCs (RR 0.80; 95% CI 0.73 to 0.86; I2=78%; p<00001). There was a higher risk of death in patients with neurological trauma managed at higher-level TCs and this is likely to be due to the higher severity of injury (intracranial and extracranial) sustained by patients at higher-level TCs. However, the high level of heterogeneity in the risk estimates of evaluated studies reduces the certainty of our interpretations.
  • To plate, or not to plate? A systematic review of functional outcomes and complications of plate fixation in patellar fractures.

    Ilo, Kevin
    PURPOSE: Poor outcomes and high complication and reoperation rates have been reported with tension-band wiring (TBW) in the management of patellar fractures and particularly the comminuted ones. The purpose of this study was to investigate the functional outcomes and complication rates of patellar fractures managed with open reduction and internal fixation (ORIF) with a plate. METHODS: MEDLINE, EMCare, CINAHL, AMED and HMIC were searched, and the PRISMA guidelines were followed. Two independent reviewers extracted the data from the included studies and assessed them for the risk of bias. RESULTS: Plating of patellar fractures is associated with satisfactory range of movement (ROM) and postoperative function and low pain levels. We found a 10.44% complication rate and a low reoperation rate. Reoperations were mainly performed for metalwork removal. CONCLUSION: ORIF with plating of patellar fractures is a safe alternative in the management of patellar fractures and may be associated with a lower complication and reoperation rate compared to TBW. Future randomized prospective studies are needed to validated the results of the present systematic review.
  • Assessing the use of the frequency, etiology, direction, and severity classification system for shoulder instability in physical therapy research - A scoping review.

    Bateman, Marcus
    OBJECTIVE: The aim of this study is to review the implementation of the Frequency, Etiology, Direction, and Severity (FEDS) classification for shoulder instability by the physical therapy scientific community since its publication in 2011. METHODS: A systematic search was conducted on January 10, 2024 in the MEDLINE, EMBASE, SPORTDiscus, Scopus, Web of Science, Cochrane, and SciELO databases, as well as Google Scholar. Studies investigating physical therapy interventions in people with shoulder instability, and reporting selection criteria for shoulder instability were considered eligible. A narrative synthesis was conducted. RESULTS: Twenty-six studies were included. None reported using the FEDS classification as eligibility criteria for shoulder instability. Only 42% of the studies provided data of all four criteria of the FEDS classification. The most reported criterion was direction (92%), followed by etiology (85%), severity (65%), and frequency (58%). The most common reported descriptor for profiling shoulder instability was "dislocation" (83.3%), followed by "first-time" (66.7%), "anterior" (62.5%), and "traumatic" (59.1%). Regarding other instability classifications, only one study (4%) used the Thomas & Matsen classification, and two (8%) the Stanmore classification. CONCLUSIONS: The FEDS classification system has not been embraced enough by the physical therapy scientific community since its publication in 2011.
  • Artificial Intelligence ChatGPT’s Perspective on Implementation of Augmented Intelligence within Orthopaedic Practice—A Comparative Narrative Synthesis?

    Ashwood, Neil; Dekker, Andrew
    ChatGPT has obvious benefits in the way it can interrogate vast amounts of reference information and utilise metadata generation to answer questions posed to it and is freely available having been developed through human feedback. Already there are ethical and practical implications on its impact on learning and research. Artificial Intelligence (AI) has been seen as a way of improving healthcare provision by delivering more robust outcomes but measuring these and implementing AI within this setting is at present limited and disjointed. Methods: ChatGPT was interrogated to see what it felt were the barriers to its implementation within healthcare and in particular ortho paedic practice. The evidence for this determination was then examined for validity and applicability for a practical roll out at a Trust, Regional or Na tional level. Results: AI can synthesise a vast amount of information to help it answer specific questions. The context and structure of any question will de termine the usefulness of the answer which can then be used to develop prac tical solutions based on experience and resource limitations. Conclusions: AI has a role in service development and can quickly focus a working group to areas to consider when practically implementing change
  • The incidence and severity of diabetic hand infection presentations during the COVID-19 pandemic.

    Morris, H; Gillott, E.; Bainbridge, Chris; Johnson, Nick
    Diabetic hand infections are difficult to treat and can present with high morbidity. We set out to identify any changes in presentation and disease severity during the COVID-19 pandemic. A total of 61 pre-COVID and 32 during COVID patients with diabetes with a hand infection requiring intravenous antibiotics were included in the study. The pandemic caused a decrease in the number and proportion of presentations. Hospital admissions reduced as service provision was amended to enable increased outpatient treatment. However, there was a significant increase in surgical management (25 vs. 21, p = 0.02), total complications (5 vs. 8, p < 0.05) and incidence of amputations (2 vs. 4, p = 0.09). Mean haemoglobin A1C was also higher (48 mmol/L vs. 40 mmol/L, p < 0.05). While fewer patients attended the service during the pandemic, we witnessed an increased severity of hand infections in those we treated. There is a role for daily outpatient administration of intravenous antibiotics in selected patients to reduce the number of hospital admissions.
  • Systematic review of nerves at risk at the wrist in common surgical approaches to the forearm: Anatomical variations and surgical implications

    Ashwood, Neil
    Three commonly used approaches to the forearm in orthopedic surgery are Henry's, Thompson's, and the ulnar approach, each of which has the potential to cause injury to nerves around the wrist. Preserving these nerves is important to prevent complications such as neuroma formation and motor and sensory changes to the hand. We conducted a review of the literature to assess the nerves at risk and whether ‘safe zones’ exist to avoid these nerves. An independent reviewer conducted searches in Embase and MEDLINE of the literature from 2010 to 2020. A total of 68 papers were identified, with 18 articles being included in the review. Multiple nerves were identified as being at risk for each of the approaches described. In the anterior approach, the palmar cutaneous branch of the median nerve (PCBMN) is most at risk of injury. An incision immediately radial to the flexor carpi radialis (FCR) or directly over the FCR is most likely to avoid injury to both superficial branch of the radial nerve (SBRN) and PCBMN. With Thompson's approach, the safest zone for an incision is directly over or slightly radial to Lister's tubercle to avoid injury to SBRN and lateral cutaneous nerve of the forearm. For the ulnar approach, a safe zone was shown to be on the ulnar side of the wrist around the ulnar styloid (US) when the forearm was in supination or a neutral position to avoid injury to the dorsal branch of the ulna nerve (DBUN). Care must be taken around the US due to the density of nerves and the proximity of the last motor branch of the posterior interosseous nerve to the ulnar head. This review highlighted the proximity of nerves to the three most common surgical incisions used to access the forearm. In addition, anatomical variations may exist, and each of the nerves identified as being at risk has multiple branches. Both factors increase the potential of intraoperative damage if the anatomy is not properly understood. The surgeon must adhere carefully to the established approaches to the wrist and distal forearm to minimize damage to nerves and optimize surgical outcomes for the patient.
  • Day case orthopaedic trauma surgery effectiveness: a systematic review

    Ashwood, Neil
    Day case surgery facilitates effective orthopaedic care for ambulatory trauma cases and can act as an effective pathway in times of reduced resource availability within acute hospitals. A systematic review of the available literature was performed using a narrative synthesis to look for themes underpinning day case trauma practice. A 25 papers were selected from a total of 9956 papers screened to identify those papers that considered day case trauma surgery and its impact on clinical outcome, patient satisfaction and feasibility of delivery within the UK. 9014 patients had day case trauma operations within the 25 papers identified, 86% had general anaesthesia and 14% either regional or local anaesthesia. The mean reported age was 37.5 years with a wide age range (2-83) years treating roughly similar proportions of men and women with a high satisfaction rate when recorded. All areas of the upper limb were operated on apart from the scapula the commonest being the wrist. In the lower limb surgery was undertaken in the knee, ankle or foot with removal of foreign body or ankle fixation being the commonest procedures undertaken. Prevalence of complications at 0.0156% of cases undergoing day case surgery was seen to be lower than in a similar group of inpatient cases. resources are stretched. Day case surgery for trauma procedures within orthopaedics is safe, cost effective and well tolerated by patients. It frees up resources to facilitate treatment and should be utilised within each hospital to enable timely care.
  • Identifying clusters of objective functional impairment in patients with degenerative lumbar spinal disease using unsupervised learning.

    Klukowska, Anita
    OBJECTIVES: The five-repetition sit-to-stand (5R-STS) test was designed to capture objective functional impairment (OFI), and thus provides an adjunctive dimension in patient assessment. It is conceivable that there are different subsets of patients with OFI and degenerative lumbar disease. We aim to identify clusters of objectively functionally impaired individuals based on 5R-STS and unsupervised machine learning (ML). METHODS: Data from two prospective cohort studies on patients with surgery for degenerative lumbar disease and 5R-STS times of ≥ 10.5 s-indicating presence of OFI. K-means clustering-an unsupervised ML algorithm-was applied to identify clusters of OFI. Cluster hallmarks were then identified using descriptive and inferential statistical analyses. RESULTS: We included 173 patients (mean age [standard deviation]: 46.7 [12.7] years, 45% male) and identified three types of OFI. OFI Type 1 (57 pts., 32.9%), Type 2 (81 pts., 46.8%), and Type 3 (35 pts., 20.2%) exhibited mean 5R-STS test times of 14.0 (3.2), 14.5 (3.3), and 27.1 (4.4) seconds, respectively. The grades of OFI according to the validated baseline severity stratification of the 5R-STS increased significantly with each OFI type, as did extreme anxiety and depression symptoms, issues with mobility and daily activities. Types 1 and 2 are characterized by mild to moderate OFI-with female gender, lower body mass index, and less smokers as Type I hallmarks. CONCLUSIONS: Unsupervised learning techniques identified three distinct clusters of patients with OFI that may represent a more holistic clinical classification of patients with OFI than test-time stratifications alone, by accounting for individual patient characteristics.
  • Scoping review: Evidence for long-term follow-up and monitoring in shoulder and elbow arthroplasty

    Tambe, Amol
    AIMS: Long-term follow-up and monitoring of asymptomatic shoulder and elbow arthroplasty remains contentious, with a wide spectrum of non-evidence-based mechanisms used. This scoping review aims to outline related evidence, thereby informing research requirements. METHODS: Studies relevant to shoulder and elbow arthroplasty follow-up, surveillance and time-related failure were included. The review included randomised controlled trials, systematic reviews and economic studies indexed in MEDLINE, Embase, Cochrane CDSR and Cochrane CENTRAL since 1 January 2012. In addition, all registry studies, follow-up studies, cohort studies and case reports indexed in MEDLINE since 1 January 2020 were included. The screening was undertaken by two reviewers. Key characteristics of each study were described, alongside a narrative review. RESULTS: Twenty-one articles were included. We were unable to identify evidence that long-term follow-up and monitoring of asymptomatic shoulder and elbow arthroplasty identifies failure or leads to a revision that is of reduced patient morbidity and cost. In addition, no evidence was apparent to inform whether patients will self-present with a failing implant. Several surveillance mechanisms were identified. CONCLUSION: This scoping review highlights the paucity of evidence related to long-term follow-up and monitoring of shoulder and elbow arthroplasty, and the need for high-quality data to inform the development of evidence-based care pathways.
  • Physiotherapist-led exercise versus usual care (waiting-list) control for patients awaiting rotator cuff repair surgery: A pilot randomised controlled trial (POWER).

    Beckhelling, Jacqueline; Davis, Daniel; Pitt, Lisa
    BACKGROUND: Once a decision to undergo rotator cuff repair surgery is made, patients are placed on the waiting list. It can take weeks or months to receive surgery. There has been a call to move from waiting lists to 'preparation' lists to better prepare patients for surgery and to ensure it remains an appropriate treatment option for them. OBJECTIVE: To evaluate the feasibility, as measured by recruitment rates, treatment fidelity and follow-up rates, of a future multi-centre randomised controlled trial to compare the clinical and cost-effectiveness of undertaking a physiotherapist-led exercise programme while waiting for surgery versus usual care (waiting-list control). DESIGN: Two-arm, multi-centre pilot randomised controlled trial with feasibility objectives in six NHS hospitals in England. METHOD: Adults (n = 76) awaiting rotator cuff repair surgery were recruited and randomly allocated to a programme of physiotherapist-led exercise (n = 38) or usual care control (n = 38). RESULTS: Of 302 eligible patients, 76 (25%) were randomised. Of 38 participants randomised to physiotherapist-led exercise, 28 (74%) received the exercise programme as intended. 51/76 (67%) Shoulder Pain and Disability Index questionnaires were returned at 6-months. Of 76 participants, 32 had not received surgery after 6-months (42%). Of those 32, 20 were allocated to physiotherapist-led exercise; 12 to usual care control. CONCLUSIONS: A future multi-centre randomised controlled trial is feasible but would require planning for variable recruitment rates between sites, measures to improve treatment fidelity and opportunity for surgical exit, and optimisation of follow-up. A fully powered, randomised controlled trial is now needed to robustly inform clinical decision-making.
  • Comparison between intra-articular injections of corticosteroids, hyaluronic acid, PRP and placebo for thumb base osteoarthritis: A frequentist network meta-analysis.

    Johnson, Nick
    BACKGROUND AND AIMS: Current evidence for the use of intra-articular injections for thumb base osteoarthritis (TBOA) is equivocal. This study aims to investigate the efficacy of intra-articular corticosteroids, hyaluronic acid and platelet-rich plasma. METHODS: A Frequentist network meta-analysis was conducted comparing outcomes at short (≤3 months) and medium-term (>3-12 months) time points. RESULTS: Data from 7 RCTs and 1 non-RCT (446 patients) were collected, consisting of corticosteroids (n = 7), hyaluronic acid (n = 7), platelet-rich plasma (n = 2) and placebo (n = 2). At the short-term time point, no intra-articular injection demonstrated superiority over placebo at reducing pain. At the medium-term time point, superiority of platelet-rich plasma at reducing pain over placebo and corticosteroids was seen following sensitivity analysis (RCTs only) (SMD -1.48 95 % CI -2.71; -0.25). No injection proved superior at improving function at short or medium-term time points. CONCLUSIONS: Overall, despite the promising result for platelet-rich plasma, the evidence quality was limited to two studies only justifying the need for further and larger methodologically robust trials investigating corticosteroids, hyaluronic acid and platelet-rich plasma vs each other and placebo.
  • The Pathogenesis of Chiari Malformation and Syringomyelia: A Case Report and Systematic Review of Current Theories

    Ashwood, Neil
    We report a case of a 42-year-old female presenting with left axillary pain radiating down the arm and weakness in the ipsilateral hand. Specialist examinations of neurological and musculoskeletal systems were insignificant. Magnetic resonance imaging (MRI) of the whole spine and brain revealed cerebellar tonsillar herniation of 9-10mm indicating a Chiari type 1 malformation and a large tubular T2 high-intensity lesion in the cervical cord, extending from the C2/3-disc level down to C6/C7 as well as a similar but smaller lesion behind the bodies of C7 and T1. Both lesions were consistent with syringomyelia. Surgical intervention was deemed inappropriate, and she was treated with three months of physiotherapy. Regular follow-up for two years showed gradual symptom resolution, syrinx shrinkage, and no further complications arising secondary to Chiari type 1 malformation. Chiari malformation is an anatomical anomaly of the cranio-cervical junction. It is often incidentally found on MRI, but although asymptomatic in the population, complications associated with the condition such as syringomyelia are a common initial presentation. The relationship between Chiari malformation, particularly Chiari type 1 malformation, and syringomyelia is close with the majority of patients often presenting with idiopathic syringomyelia also found to have a Chiari type 1 malformation. Considerable discussion about the pathogenic mechanisms for syringomyelia development in Chiari malformation is recognized and advancing continually.
  • Does long-term follow-up and monitoring of primary shoulder arthroplasty identify failing implants requiring revision?

    Dover, Caroline; Walstow, Katherine; Pitt, Lisa; Morgan, Marie; Espag, Marius; Clark, David; Tambe, Amol
    BACKGROUND: Published scoping review has identified evidence paucity related to long-term follow-up of shoulder arthroplasty. We aim to report effectiveness of elective primary shoulder arthroplasty surveillance in identifying failing implants requiring revision. METHODS: Analysis of a prospective database recording shoulder arthroplasty and subsequent follow-up surveillance in a shoulder unit. Shoulder arthroplasty were performed by 4 fellowship-trained shoulder surgeons for accepted elective indications including the use of anatomic arthroplasty in arthritic shoulders with intact rotator cuff and a reverse prosthesis being utilized in rotator cuff deficient shoulders and rotator cuff competent arthritic shoulders when deemed preferable by the treating surgeon. All shoulder arthroplasty implants utilized had achieved a minimum 7A Orthopaedic Data Evaluation Panel (ODEP) rating. Included shoulder arthroplasty were performed 01/05/2004-31/12/2021 with minimum 1-year follow-up. Surveillance program involves specialist physiotherapist review at 1, 2, 3, 5, 8, 10, and 15-years postoperatively including clinical examination, outcome scoring and radiographs. Patient-initiated review occurred between timepoints if a patient requested assessment due to symptoms. Outcome measures include ratio of failing implants identified by surveillance and patient-initiated review, with number of surveillance reviews offered and proportion that identified a failing implant requiring revision calculated. RESULTS: 1002 elective primary shoulder arthroplasty with minimum 1-year follow-up were performed (547 reverse total shoulder arthroplasty [rTSA], 234 anatomic total shoulder arthroplasty [aTSA], 221 hemiarthroplasty [HA]). 238 patients died prior to 31/12/2022 resulting in 4019 surveillance appointments offered. 38 prostheses required revision ≥ 1-year postoperatively (6 rTSA, 9 aTSA, 23 HA) with surveillance identifying requirement in 53% (33% rTSA, 56% aTSA, 57% HA) and patient-initiated review in 47%. Mean years from implantation to revision was 5.2 (2.7 rTSA, 3.6 aTSA, 6.6 HA). Revision indications included rotator cuff failure (56% aTSR, 43% HA) and glenoid erosion (57% HA). CONCLUSION: This is the first series reporting effectiveness of shoulder arthroplasty surveillance in identifying implants requiring revision. Surveillance identified over half of implants requiring revision though only 0.5% of appointments identified revision requirement. Surveillance enrolment may influence patient-initiated review utilization therefore similar studies utilizing only patient-initiated follow-up would help inform recommendations.
  • The incidence and severity of diabetic hand infection presentations during the COVID-19 pandemic.

    Morris, H; Gillott, E.; Bainbridge, Chris; Johnson, Nicholas
    No abstract available.

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