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Aims To investigate the safety and cost-effectiveness of interscalene brachial plexus block/regional anaesthesia (ISB-RA) in patients undergoing reverse total shoulder replacement. Patients and methods This retrospective study included 15 patients with symptomatic rotator cuff arthropathy who underwent reverse total shoulder arthroplasty (rTSA) under ISB-RA without general anaesthesia in the beach chair position from 2010 to 2018. The mean patient age was 77 years (range 59-82 years). Patients had associated medical comorbidities: American Society of Anesthesiologists (ASA) grade 2-4. Assessed parameters were: duration of anaesthesia, intra-operative systolic blood pressure variation, sedation and vasopressor use, duration of post-operative recovery, recovery scores, length of stay, and complications. A robust cost analysis was also performed. Results The mean (range) duration of anaesthesia was 38.66 (20-60) min. Maximum and minimum intra-operative systolic blood pressure ranges were 130-210 and 75-145 mmHg, respectively (mean [range] drop, 74.13 [33-125] mmHg). Mean (range) propofol dose was 1.74 (1-3.0) mg/kg/h. The Median (interquartile range) post-operative recovery time was 30 (20-50) min. The mean (range) postoperative recovery score (local scale, range 5-28 where lower values are superior) was 5.2 (5-8). The mean (range) length of stay was 8 (1-20 days); the two included patients with ASA grade 2 were both discharged within 24 hours. One patient with predisposing history developed pneumonia; however, there were no complications related to ISB-RA. The mean (range) cost per patient was £101.36 (£59.80-£132.20). Conclusions Our data demonstrate that rTSA under ISB-RA is safe, comfortable, and cost-effective. Notably, patients with ASA grade 2 who underwent rTSA under ISB-RA had a reduced length of stay and were discharged within 24 hours. Clinical relevance rTSA under ISB-RA is potentially a safe, cost-effective, and viable alternative for patients with multiple comorbidities.

Introduction Mucous cyst is the commonest soft tissue tumor in the dorsum of the distal interphalangeal joint (DIPJ) of the finger. We report the first case of a recurring eccrine tumor (nodular hidradenoma), mimicking a mucous/ganglion cyst, on the dorsum of the DIPJ. Case report A 54 year old man presented with painless, hemispherical, colored swelling on the dorsum of his right middle finger (dominant hand), which appeared to have recurred from a previous surgery. The lesion was excised and operative findings from the medical notes showed the gross appearance to be a soft, white, glistening, smooth-surfaced, myxoid nodule resembling a “ganglion cyst”. Immunohistochemistry showed the tumour to be positive for S100, smooth muscle actin and cytokeratin 7. Ductal differentiation was confirmed by staining for epithelial membrane antigen and carcinoembryonic antigen. The histological features were that of atypical and solid cystic hidradenoma. Discussion This is the first reported case of this rare tumour presenting as mucous cyst. We conduct a review of the literature of nodular hidradenomas, illustrating the immunohistologic findings in this tumour to emphasise the atypical features.We emphasise the importance of considering hidradenoma in the differential diagnosis of such lesions of the finger, in view of its high recurrence rate and the possibility of malignant transformation., Highlights • We describe the rare phenomenon of an atypical cystic hidradenoma mimicking in presentation a mucous ganglion cyst on the DIPJ of the finger. • We put this rarity into context by performing a literature review of reported presentations of such tumours. • We emphasise the importance of a thorough and systematic assessment in patients presenting with such lesions. • Also highlighted is the importance of considering these tumours in the differential diagnosis of lesions of the DIPJ. • Thorough immunohistochemistry of resulting biopsies is invaluable in aiding diagnosis in these scenarios of ambiguous soft tissue swellings.

Background: Ulnar shortening osteotomy is a well-established treatment for ulnar impaction syndrome. Controversy remains regarding the most effective system to achieve efficient bony union, whilst minimising incidence of complications, particularly hardware irritation. We present outcomes at 2 years using the recently released low profile AO osteotomy system.Methods: 32 consecutive patients with significant pain from ulnar impaction syndrome (idiopathic or post-traumatic), without degenerative changes of the distal radio-ulnar joint, were included. Time to union, range of motion, grip strength, pain and complications were recorded.Results: Median time to union was 10.14 weeks (9.27–11.01, 95%CI), with one nonunion. Visual Analogue Pain score, grip strength and range of motion improved significantly. No patient experienced hardware irritation. No plate required removal. Positive ulnar variance was reduced by 3.8 mm (mean).Conclusions: The low profile AO system appears effective in achieving bony union whilst minimising incidence of hardware irritation, at a follow up of 2 years

The successful use of suture anchors in arthroscopic surgery of the shoulder is well documented. 12 The benefits of a secure fixation with implant degradation and eventual tissue incorporation have led to the development of many bioabsorbable materials including the isomers of polyglycolic acid implants. 11 We look at an anchor produced from poly-L-lactic acid (PLLA) and note recent reports of this bioabsorbable anchor and its associated complications. 2 Although the use of PLLA polymers has demonstrated promising results of lower incidence of lysis, slow degradation, and reduced loosening, recent reports of synovitis and chondral damage with osteolysis have emerged. 2,10 We report 3 cases of capsulolabral detachment, osteolysis, and severe chondral damage using the bioknotless anchors (DePuy Mitek, Raynham, Massachusetts). However, unlike previous reports suggesting that use of numerous (5) anchors is related to complications, we used comparatively fewer anchors with similar destructive findings. 2 .

The long head of the biceps (LHB) is a subject of interest to shoulder surgeons and physiotherapist alike. Since the advent of shoulder arthroscopy, knowledge of and interest in the LHB has increased. We discuss the current knowledge on anatomic variants of the LHB. Several cadaveric studies have refined the standard textbook description of the LHB origin, showing that it originates from the superior glenoid labrum and the supraglenoid tubercle. These studies have provided important information for the assessment of the LHB, guiding the treatment of lesions such as superior labral anterior posterior (SLAP) tears. Described variants to the anterosuperior glenoid labrum should be noted, from the superior sublabral recess to the Buford complex. Congenital absence of the LHB should be appreciated. Only 4 previous cases have been reported. We have experience in treating 3 further cases. Further information on the function of the LHB has been gleaned from electomyographic, cadaveric, and clinical studies. These have shown that it has a role in stabilizing the humeral head. It has been stated that it may have a proprioceptive function. Classification systems for symptomatic LHB lesions and congenital absence of the LHB tendon are proposed. The management of LHB lesions is also discussed.

Background Mountain and road bike accidents are particularly common with the increased popularity of the sport. We reviewed the attendances in our emergency department over a 4-year period looking at cycling injuries to detect the level and grade of these injuries and their outcomes. Method Royal Blackburn Hospital caters for a population of 550 000. A search through the Hospital information system revealed 104 patients with fractures following mountain bike injuries. These were looked at in more detail. We present a series of 5 severe shoulder girdle injuries following mountain bike accidents in this cohort, to highlight the serious level of injury sustained in this sport. We searched MEDLINE and EMBASE databases over the past 10 years using the keywords, mountain, biking and fracture. This yielded 7 papers. We compared our series with the literature. Results 104 fractures following mountain bike accidents between 2008 and 2011. Fractures of the upper limb were the most common (88.5%) with the clavicle being the most commonly fractured bone (28.8%). Conclusions Major scapular injuries with destruction or disruption of the four bar linkage of the shoulder girdle are very common following mountain accidents. Clavicular fractures are the commonest upper limb injury. It is easy to miss a disruption to the four-bar linkage associated with a clavicular injury. This paper highlights the severity of the injuries sustained in mountain bike accidents of the upper limb and requirement of adequate protection in this exhilarating sport.

Digital tourniquets have been condemned because of the reported occurrence of neurovascular complications. This study compares the pressures and pain perception between three different tourniquets, namely the rubber glove finger stall, Foley's urinary catheter and the commercial band tourniquet. The subjects involved were 20 volunteers with 80 fingers studied in total. A direct pressure measuring technique was used. The pressures recorded were highest and most variable with the catheter tourniquet, whereas the rubber glove tourniquet recorded the lowest pressures. Correspondingly, visual analogue scale in relation to patient discomfort showed high scores with the catheter tourniquet and low scores with the rubber glove tourniquet. We conclude that catheter tourniquet use should be avoided as it generates extreme and variable pressures, whereas rubber glove finger stall tourniquets appear as a better alternative.