RESUMEN

BACKGROUND: The prognostic factors for patients with full-thickness rotator cuff tears (RCTs) include tear size, muscle atrophy and fatty infiltration. However, the influence of early coexisting degenerative changes on RCT outcomes is unappreciated. The purpose of this study was to calculate the impact that pre-existing partial glenohumeral cartilaginous changes have on patients undergoing arthroscopic RCT repair. METHODS: A study of 54 patients undergoing arthroscopic RCT repair was undertaken. The presence of co-existing patches of glenohumeral degenerative cartilaginous changes and RCT size was recorded at surgery. Pre- and postoperative outcomes were assessed using traditional (Oxford Shoulder Score [OSS], 5-level EuroQol-5D [EQ-5D-5L] questionnaire and EuroQol visual analog scale [EQ-VAS]) and patient-centric re-formatted prisms. Outcomes were assessed as an entire dataset, and sub-group analysis was performed according to the grade of co-existing arthritis and tear size. RESULTS: Significant improvements (p<0.05) in clinical outcomes were recognized when assessed using either the traditional or reformatted prisms (average % improvements in OSS, EQ-5D-5L and EQ-VAS were 47%, 33% and 43%, respectively; average improvements in pain, function, and psychological well-being were 48%, 33% and, 29%, respectively). Positive gain was noted in all sub-groups of arthritic grading and tear size. CONCLUSIONS: Good clinical outcomes can be achieved following RCT repair even in the presence of local partial degenerative cartilage changes and advancing tear size. These benefits are patient-centered but require RCT repairability.

RESUMEN

HYPOTHESIS AND BACKGROUND: Open fractures about the elbow are an infrequent but complex injury with limited existing literature. The aims of the study were to review the treatment strategies of open elbows fractures, functional outcome and complication rates associated with the injury, and correlate the outcome with the topography of the fracture. METHODS: Patients (n = 21) with open elbow fractures injuries over a 2-year period were analyzed. They were assessed regarding the orthoplastic characteristics of their injury as well any other associated injuries. Outcomes were assessed objectively (achievement of bony union, range of movement, infection status, need for further procedures) and subjectively (Oxford Elbow Score, EQ-5D, EQ-VAS). RESULTS: The commonest grade of open injury was grade 3 (43%). Associated orthopedic injuries were present in 62% and associated system injuries in 57%. Almost half of the patients were noted to have had a significantly increased presenting mortality risk as per Injury Severity Score assessment. Mean time to first wound débridement was 31 hours. There were no cases of deep or chronic infection. Complete bony union was noted in 85% of patients, and 48% of patients required removal of metalwork. Subgroup analysis of the cohort by fracture topography (single unipolar elbow bone injury vs. multiple elbow bony injuries) demonstrated no significant difference (P > .05) regarding rate of complication or final Oxford Elbow Score, EQ-5D or EQ-VAS. Patients with injuries that involved the distal humerus had the highest rate for further procedures (P < .05). The average Oxford Elbow Score, EQ-5D, and EQ-VAS scores for the whole cohort at final follow-up were 37.4, 0.54, and 62.18, respectively. DISCUSSION: Open elbow injuries are usually from high-energy trauma and often combined with other significant injuries. As a result, the timelines to elbow surgery were often delayed. However, this did not impact the local infection rates nor did it necessitate further surgery, but made achieving all British Orthopaedic Association Standards for Trauma targets difficult. Chronic infection was not an issue in this cohort. Subgroup analysis indicates open distal humerus fractures carry the highest risk for further procedures. This is most commonly in the form of removal of metalwork and fibrinolysis. End outcomes for patients with open elbow fractures can be positive, despite the notable presenting Injury Severity Score. A subspecialist elbow and orthoplastic approach whenever possible is advocated.

Asunto(s)

RESUMEN

Septic arthritis is a serious condition that can lead to rapid destruction of joint if it is not rapidly diagnosed and treated appropriately. The reported annual incidence is 10 in 100 000 although this increases to 70 in 100 000 in those with risk factors for developing septic arthritis mainly rheumatoid arthritis and immune-compromised patients. The aim of this study is to examine the sensitivity and specificity, and thus the clinical usefulness, of gram stain results. This was a single centre, retrospective case series. All joint aspirates over a three year period from May 2015 to April 2018 were reviewed. The gram stain and final culture results noted. 830 samples were included from both native and replaced joints. Native joints accounted for a total of 701 cases (84%) of the aspirates, whilst those obtained from prosthetic joints 129 (16%). In 74 (9%) cases there was a discrepancy between the gram stain and culture results. The sensitivity of the gram stain in this case series is 22% and the specificity of the test is 99.6%. The clinician should have a low threshold for overlooking a negative gram stain result and place greater emphases on the clinical findings in conjunction with biochemical markers.

Asunto(s)

RESUMEN

Background Thumb carpometacarpal joint (CMCJ) osteoarthritis is common and can lead to significant morbidity making it a condition frequently treated by hand surgeons when initial conservative measures fail. The surrounding ligamentous structures are complex and important to maintain thumb CMCJ stability. Objectives The aim of this study was to review the normal and arthritic anatomy of the thumb CMCJ, focusing on morphology and position of osteophytes and the gap between metacarpal bases, and the effect of these on intermetacarpal ligament integrity. This may be the sole ligament suspending the first metacarpal following trapeziectomy and could determine the need for further stabilization during surgery, avoiding potential future failures. Methods Computed tomography (CT) scans of a normal cohort and those with arthritic changes who had undergone trapeziectomy following the scan were identified. The three-dimensional reconstructions were examined for osteophyte position on the saddle and the intermetacarpal distance. Results A total of 55 patients, 30 normal and 25 arthritic, were identified and studied. The most common anatomic position for osteophytes was the intermetacarpal ulnar aspect of the trapezium. The intermetacarpal distance increased by an average of 2.1 mm in the presence of the arthritic process. Conclusions The findings point to an increase in the intermetacarpal distance, and hence lengthening of the ligament with potential damage, possibly secondary to osteophyte formation and wear. Further prospective research is required to determine whether using preoperative CT scanning to define osteophyte position and measure the intermetacarpal distance would predict probable damage to the ligament, hence providing an indication for stabilization and reconstruction in trapeziectomy surgery. Level of Evidence This is a Level III, retrospective cohort study.

RESUMEN

Radial head fractures are the commonest fractures in the elbow. They are often associated with other injuries: ligamentous, cartilaginous or other fractures. Associated injuries are important determinant of the management of the radial head fracture. These should be carefully looked for, diagnosed and treated. The original Mason classification for this fracture has been modified to include the associated injuries and their treatment. CT scan is a helpful diagnostic tool and should be used if available. Radial head fractures can be treated either conservatively or operatively (by excision, open reduction and internal fixation or prosthetic replacement). Undisplaced or minimally displaced fractures should be treated non-operatively. Internal fixation by headless cannulated screws is the preferred treatment for displaced fractures. It provides satisfactory biomechanical stability, can be done through a smaller incision, has less complications and lesser requirement of later removal of screws. Small number of fractures with comminution of neck would require plate fixation. Unfixable fractures in elderly can be treated by excision while such fractures in younger population or associated with significant soft tissue or bony injuries would require prosthetic replacement.

RESUMEN

OBJECTIVE: Lateral humeral condyle fractures are the second most common elbow fractures in children. Both K-wire fixation and screw fixation have been advocated as suitable treatment options for displaced fractures. This study aimed to identify which fixation method was associated with the best functional outcomes. METHODS: A systematic review was conducted. Studies reporting functional outcomes following surgical fixation of lateral condyle fractures were included for review. The primary outcome measure was functional outcome. The secondary outcome measure was major complications. A narrative analysis was undertaken, as meta-analysis was felt to be inappropriate due to the differences between included studies. RESULTS: Ten retrospective non-randomised, comparative studies were eligible and included. No randomised-controlled trials were identified. The highest rate of excellent functional outcomes was seen with screw fixation (120/126 [95%]), compared with K-wire fixation (135/162 [86%]). The incidence of major complications was comparable, with complications in 6/95 (6%) of screw fixations and 6/141 (4%) K-wire fixations. A small sample of data on closed reduction demonstrated excellent functional results in 73 of 76 (96%) of patients. Closed reduction of displaced fractures is associated with a significant learning curve however. CONCLUSION: The evidence was of poor quality and comprised of retrospective case series. This prevented meta-analysis and any firm conclusions being drawn from the available data. Screw fixation may be associated with improved functional outcomes. Complication rates between the two methods are comparable. Further prospective studies are recommended.

RESUMEN

Isolated infection of the subacromial bursa is a rare entity. We present the case of a previously fit man who was found to have staphylococcal infection of the sub-acromial bursa, without an obvious precipitant. Preoperative MRI scanning determined the specific locus of infection, and the patient was successfully treated with arthroscopic washout of the sub-acromial bursa followed by empirical antibiotic therapy.