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Augmentation of the anterior glenoid with bone graft is an established treatment for recurrent anterior instability due to critical glenoid bone loss. Both open and arthroscopic techniques have been described. Fixation with metal screws through an open approach is the most common technique, but the risk of metal screw–related complications remains a concern. A variety of arthroscopic techniques using suspensory fixation or suture anchors have been described in the literature. However, they all require a posterior incision to insert a targeting device or to manage sutures. We describe a technique for arthroscopic bone grafting of the anterior glenoid via a purely anterior approach with 2 linked knotless suture anchors, thereby avoiding posterior suture management and glenoid metalwork complications., Technique Video Video 1 Stepwise illustration of graft augmentation for glenoid bone loss using all-suture anchor fixation technique.

Aims The new COVID-19 variant was reported by the authorities of the UK to the World Health Organization (WHO) on 14 December 2020. We aim to describe the clinical characteristics and nosocomial infection rates in major trauma and orthopaedic patients comparing the first and second wave of COVID-19 infection. Methods A retrospective analysis of a prospectively collected trauma database was reviewed at a level 1 major trauma centre from 1 December 2020 to 18 February 2021 looking at demographics, clinical characteristics, and nosocomial infections and compared to our previously published first wave data (26 January 2020 to 14 April 2020). Results From 1 December 2020 to 18 February 2021, 522 major trauma patients were identified with a mean age of 54.6 years, and 53.4% (n = 279) were male. Common admissions were falls (318; 60.9%) and road traffic accidents (RTAs; 71 (13.6%); 262 of these patients (50.2%) had surgery. In all, 75 patients (14.4%) tested positive for COVID-19, of which 51 (68%) were nosocomial. Surgery on COVID-19 patients increased to 46 (61.3%) in the second wave compared to 13 (33.3%) in the first wave (p = 0.005). ICU admissions of patients with COVID-19 infection increased from two (5.1%) to 16 (20.5%), respectively (p = 0.024). Second wave mortality was 6.1% (n = 32) compared to first wave of 4.7% (n = 31). Cardiovascular (CV) disease (35.9%; n = 14); p = 0.027) and dementia (17.9%; n = 7); p = 0.030) were less in second wave than the first. Overall, 13 patients (25.5%) were Black, Asian and Minority ethnic (BAME), and five (9.8%) had a BMI > 30 kg/m2. The mean time from admission to diagnosis of COVID-19 was 13.9 days (3 to 44). Overall, 12/75 (16%) of all COVID-19 patients died. Conclusion During the second wave, COVID-19 infected three-times more patients. There were double the number of operative cases, and quadruple the cases of ICU admissions. The patients were younger with less dementia and CV disease with lower mortality. Concomitant COVID-19 and the necessity of major trauma surgery showed 13% mortality in the second wave compared with 15.4% in the first wave. In contrast to the literature, we showed a high percentage of nosocomial infection, normal BMI, and limited BAME infections. Cite this article: Bone Jt Open 2021;2(8):661–670.

Premature physeal arrest (PPA) of the distal radius is considered a rare complication of physeal wrist fractures. Standardised guidelines for duration of follow up do not exist. The aim of this review is to recognise the risk factors of PPA and guide follow up protocols. The secondary aim is to understand the typical presenting symptoms of PPA. A systematic review was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. PubMed, MEDLINE, EMBASE, the Cochrane Library, and grey literature were searched from inception to October 2020. Studies included were: (i) original articles, (ii) distal radius physeal injuries, (iii) with at least a partial study population that developed PPA. Thirteen studies were included with 616 physeal injuries. There were 114 PPAs reported with a mean age at time of injury of 10.6 years (1–16). The rate of PPA with radiological follow up was 7–23%. Intraarticular fractures and repeated manipulations increased the rate of PPA. K-wire fixation, open reduction and malunion did not. The most common presenting symptom of PPA was: pain (70%), deformity (55%), restricted range of movement (40%), reduced grip strength (40%) and snapping or clicking (30%). All patients with radial shortening of 10 mm or more were symptomatic. There were no risk factors that reliably predicted all PPA. The majority of patients who develop PPA will remain asymptomatic until significant shortening or deformity have occurred. We recommend a minimum of 18 months radiological follow up for every distal radius physeal injury.

Aims The first death in the UK caused by COVID-19 occurred on 5 March 2020. We aim to describe the clinical characteristics and outcomes of major trauma and orthopaedic patients admitted in the early COVID-19 era. Methods A prospective trauma registry was reviewed at a Level 1 Major Trauma Centre. We divided patients into Group A, 40 days prior to 5 March 2020, and into Group B, 40 days after. Results A total of 657 consecutive trauma and orthopaedic patients were identified with a mean age of 55 years (8 to 98; standard deviation (SD) 22.52) and 393 (59.8%) were males. In all, 344 (approximately 50%) of admissions were major trauma. Group A had 421 patients, decreasing to 236 patients in Group B (36%). Mechanism of injury (MOI) was commonly a fall in 351 (52.4%) patients, but road traffic accidents (RTAs) increased from 56 (13.3%) in group A to 51 (21.6%) in group B (p = 0.030). ICU admissions decreased from 26 (6.2%) in group A to 5 (2.1%) in group B. Overall, 39 patients tested positive for COVID-19 with mean age of 73 years (28 to 98; SD 17.99) and 22 (56.4%) males. Common symptoms were dyspnoea, dry cough, and pyrexia. Of these patients, 27 (69.2%) were nosocomial infections and two (5.1%) of these patients required intensive care unit (ICU) admission with 8/39 mortality (20.5%). Of the patients who died, 50% were older and had underlying comorbidities (hypertension and cardiovascular disease, dementia, arthritis). Conclusion Trauma admissions decreased in the lockdown phase with an increased incidence of RTAs. Nosocomial infection was common in 27 (69.2%) of those with COVID-19. Symptoms and comorbidities were consistent with previous reports with noted inclusion of dementia and arthritis. The mortality rate of trauma and COVID-19 was 20.5%, mainly in octogenarians, and COVID-19 surgical mortality was 15.4%. Cite this article: Bone Joint Open 2020;1-7:330–338.

Aims The amount of glenoid bone loss is an important factor in deciding between soft-tissue and bony reconstruction when managing anterior shoulder instability. Accurate and reproducible measurement of glenoid bone loss is therefore vital in evaluation of shoulder instability and recommending specific treatment. The aim of this systematic review is to identify the range methods and measurement techniques employed in clinical studies treating glenoid bone loss. Methods A systematic review of the PubMed, MEDLINE, and Embase databases was undertaken to cover a ten-year period from February 2011 to February 2021. We identified clinical studies that incorporated bone loss assessment in the methodology as part of the decision-making in the management of patients with anterior shoulder instability. The Preferred Reporting Items for Systematic Reviews (PRISMA) were used. Results A total of 5,430 articles were identified from the initial search, of which 82 studies met the final inclusion criteria. A variety of imaging methods were used: three studies did not specify which modality was used, and a further 13 used CT or MRI interchangeably. There was considerable heterogeneity among the studies that specified the technique used to quantify glenoid bone loss. A large proportion of the studies did not specify the technique used. Conclusion This systematic review has identified significant heterogeneity in both the imaging modality and method used to measure glenoid bone loss. The recommendation is that as a minimum for publication, authors should be required to reference the specific measurement technique used. Without this simple standardization, it is impossible to determine whether any published paper should influence clinical practice or should be dismissed. Cite this article: Bone Joint J 2022;104-B(1):12–18.

Elbow arthroplasty (EA) is an established technique for the treatment of select distal humeral fractures, yet little data exists regarding the safety and outcome of EA in the presence of an open distal humeral fracture where the risk of periprosthetic infection is an even greater concern. We hypothesized that EA does not carry an increased risk of infection or other postoperative complications when performed for simple open distal humeral fractures.Seventeen patients underwent total EA (n = 9) or hemiarthroplasty (n = 8) for an open distal humeral fracture. The open fracture component was classified according to the Orthopaedic Trauma Society system as "simple" or "complex." Outcome measures collected included the Mayo Elbow Performance Score (MEPS), range of motion, complications, and reoperations. Patients who underwent primary débridement and implantation were compared with those who underwent preliminary débridement procedures and subsequent staged arthroplasty. A systematic review of the existing literature was performed to analyze other reported cases and contextualize our findings.The mean follow-up was 46 months (range, 12-138 months). All fractures were multifragmentary and intra-articular. Sixteen patients had a "simple" open fracture and 1 had a "complex" fracture. The overall mean MEPS was 83 (range, 30-100; standard deviation ± 17), with a mean flexion-extension arc of 96°. Patients who underwent primary débridement and implantation demonstrated a higher mean flexion arc (116° vs. 79°, P = .02) than those who underwent staged arthroplasty. The mean MEPS was not significantly different between the groups (90 vs. 78, P = .12). Complications included asymptomatic ulna component loosening (n = 1), joint instability (n = 1), and symptomatic heterotopic ossification (n = 3). There were no deep or superficial infections recorded.EA is safe and effective when performed for simple open distal humeral fractures. Primary débridement and implantation may offer functional benefits over a staged approach.

Surgical simulation offers a solution to the problems of reduced training time and surgical exposure by allowing trainees to develop surgical skills outside of the operating room in a safe, cost-effective environment. We developed a highly detailed, procedure-specific shoulder arthroscopy simulator using 3-dimesional printing with the aim of providing greater access to cost-effective simulation support to trainees.

To evaluate the outcome of superior capsular reconstruction for isolated subscapularis tears using a decellularized porcine allograft as a superior capsular reconstruction.Patients who had symptomatic tears of supraspinatus who had failed to improve a conservative rehabilitation program were included. Previous surgery to the shoulder was not a bar to inclusion. Patients were assessed preoperatively and postoperatively with the Oxford Shoulder Score (OSS), the single assessment numeric evaluation (SANE) score, as well as clinically assessed for their shoulder range of motion (ROM). Patients were followed up with in-person clinic appointments for the first year, followed by a postal questionnaire and telephone consultation at a minimum of 2 years following surgery.Twenty patients (11 males and 9 females) with a mean age of 67.5 years were included (range: 54-72 years). The average follow-up period was 31 months (24-50). The mean improvement in OSS was 14 points (SCR appears to be a viable option for patients with symptomatic, isolated, and irreparable tears of the supraspinatus. Our results demonstrate that there are significant improvements in outcome scores and active range of motion, even in the subgroup in whom postoperative structural failure of the SCR was identified. We recommend caution in patients who have previously failed rotator cuff repair and in heavy smokers.Level IV, therapeutic case series.

Background The present study quantifies the field of view (FOV) from standard arthroscopy portals and aims to identify anatomical regions where the FOV is limited. Methods Eleven cadaveric elbows were examined through standard anteromedial, anterolateral and posterior portals. The FOV was marked with dye using a spinal needle. The articular surfaces were then exposed and the percentage FOV seen was calculated. FOV percentage areas were compared using a Student’s t-test (JMP, version 10, SAS Institute Inc., Cary, NC, USA). P Results The mean (SD) FOV percentage area seen from the anteromedial portal and anterolateral portal was 91.69% (3.63%) and 92.03% (3.93%), respectively, for the anterior humerus articular surface. There was no significant difference in the mean FOV percentage area seen from the anteromedial and anterolateral portals ( p = 0.99). The mean (SD) FOV percentage area of the posterior humerus articular surface was 84.69% (2.28%). The mean (SD) FOV percentage area seen of the radial head and trochlear was 16.05% (2.66%) and 4.14% (1.76%), respectively. Conclusions The present study is the first to quantify the FOV of elbow arthroscopy. The majority of the anterior and posterior humerus articular surface can be seen through standard portals. The limitations in FOV are primarily confined to the radial head and trochlear notch.

Objective We have developed a low-cost, portable shoulder simulator designed to train basic arthroscopic skills. This study aimed to establish the construct validity of the simulator by determining which parameters discriminated between experience levels and to assess the experience of using the simulator. Design Participants were given an introductory presentation and an untimed practice run of a 6-step triangulation task using hooks and rubber bands. A total of 6 consecutive attempts at the task were timed, and the number of times the participant looked at their hands during the task was recorded. Participants then completed a questionnaire on their experience of using the simulator. Setting St George's Hospital, London and the South West London Elective Orthopaedic Centre, Surrey. Participants Medical students, trainee doctors and surgeons, and consultant surgeons were approached to use the simulator. Participation was voluntary and nonincentivized. In total, 7 orthopedic consultants, 12 trainee doctors (ranging from foundation year 1 to clinical fellow post-Certificate of Completion of Training), and 9 medical students were recruited. Results The average time for medical students to complete the task was 161 seconds, compared to 118 seconds for trainees, and 84 seconds for consultants. The average fastest time for medical students was 105 seconds, 73 seconds for trainees, and 52 seconds for consultants. Students were significantly slower than trainees (p = 0.026) and consultants (p = 0.001). However, times did not differ significantly between trainees and consultants. Consultants looked at their hands 0.7 times on average during the task compared with 2.8 and 3.4 times for trainees and students, respectively. More than 95% of participants found the exercise interesting and agreed or strongly agreed that the simulator was easy to use, easily portable, and well designed and constructed. Discussion This study has established construct validity of the simulator by demonstrating the ability to distinguish between surgical experience levels. The learning curve shows improvement in individuals with or without arthroscopic or surgical experience. Simulation is becoming increasingly important in the training of medical students and surgical trainees; this study has established that low-cost portable arthroscopic box trainers may play a significant role.

Revision anterior stabilization of the shoulder presents a challenge to the surgeon and carries a higher risk of recurrent dislocation than primary repair. The Latarjet procedure may be more reliable than revision soft-tissue repair but may not be indicated in patients without significant glenoid bone loss. We describe an arthroscopic technique of conjoint tendon transfer using a combination of suspensory and interference screw fixation for patients without significant glenoid bone loss (

Shoulder arthroplasty is most commonly performed via a deltopectoral (DP) or anterosuperior (AS) approach, and several modifications of each have been described. Both approaches can be used for resurfacing, stemless and stemmed hemiarthroplasty, anatomic total shoulder arthroplasty (TSA), and reverse shoulder arthroplasty (RSA). This article aims to give a practical guide to performing both approaches, and a summary of the related evidence.

Computed tomography (CT) is widely used to assess component rotation in patients with poor results after total knee arthroplasty (TKA). The purpose of this study was to simultaneously determine the accuracy and reliability of CT in measuring TKA component rotation. TKA components were implanted in dry-bone models and assigned to two groups. The first group (n = 7) had variable femoral component rotations, and the second group (n = 6) had variable tibial tray rotations. CT images were then used to assess component rotation. Accuracy of CT rotational assessment was determined by mean difference, in degrees, between implanted component rotation and CT-measured rotation. Intraclass correlation coefficient (ICC) was applied to determine intra-observer and inter-observer reliability. Femoral component accuracy showed a mean difference of 2.5° and the tibial tray a mean difference of 3.2°. There was good intra- and inter-observer reliability for both components, with a femoral ICC of 0.8 and 0.76, and tibial ICC of 0.68 and 0.65, respectively. CT rotational assessment accuracy can differ from true component rotation by approximately 3° for each component. It does, however, have good inter- and intra-observer reliability.

Shoulder instability after a posterior glenoid rim fracture is rare and potentially difficult pathology to treat. Operative techniques often involve a large dissection to view the fragments resulting in local soft tissue injury. Internal fixation is often achieved with interfragmentary screws; however, this may not be possible with small or multifragmentary fracture patterns. We describe an arthroscopic technique for posterior glenoid rim fracture fixation using knotless suture anchors. These anchors can be inserted without cannulas allowing easier access to the posterior glenoid. This procedure is simple, safe, and offers good visualization of the glenohumeral joint whilst avoiding the detrimental effects of larger surgical dissection.

Background One potential limitation of interpreting the Oxford Shoulder Score (OSS) in longitudinal studies is that the observed score may be influenced by age and other variables, which may change over time. The purpose of the present study was to investigate the influence of increasing age and unreported non-shoulder upper limb and neck symptoms on the OSS. Methods We collected OSS data from a sample of our ethnically diverse local population. All subjects indicated whether they suffered from any neck, shoulder, elbow or wrist symptoms for which they had not sought a medical opinion. Those reporting no symptoms formed the asymptomatic group. Results We found a significant decline in OSS with increasing age in the whole study population, as well as in both the asymptomatic and symptomatic groups with previously unreported symptoms: Spearman correlation coefficient = −0.27, −0.28 and −0.33 respectively (p Conclusions We found the OSS to be affected by non-shoulder upper-limb and neck pathology as well as age. Within the limitations of the OSS, the differences we found do not exceed the minimal important change.

BackgroundThe glenoid labrum is integral to shoulder stability and can be difficult to assess clinically. Whilst it is a single anatomical structure, damage to different regions results in very different clinical manifestations. A large number of provocative tests have been described, all of which initially purport to have excellent diagnostic accuracy. Clinical experience suggests that this is not the case and decision making can be difficult for the non-expert. The purpose of this study is to review the current evidence for the most commonly used tests and to provide suggestions for tests which have the most evidence for efficacy.MethodsThe glenoid labrum was divided into anterior, superior and posterior regions. The English language literature describing labral tests was reviewed. The evidence provided by the authors and any subsequent studies was analysed.ResultsWhilst a large number if tests have been described with the primary authors reporting excellent results the evidence for most is poor when later tested critically.DiscussionNo single test will accurately diagnose labral pathology. The clinician must use evidence from the clinical history combined with selective use and interpretation of tests with which they are familiar.