Cambridge University Hospitals NHS trust Shoulder and Elbow for 2016 Lee Van Rensburg Cambridge University Hospitals NHS trust Cambridge

a systematic review of 232 patients Static progressive versus dynamic splinting for posttraumatic elbow stiffness: a systematic review of 232 patients Veltman et al

Functional arc 100° Extension 30° Flexion 130° J Bone Joint Surg Am. 1981;63:872-7

Functional arc 130° ± 7° Flexion 149°± 5° J Bone Joint Surg Am. 2011;93:471-7

Source of stiffness Problem joint surface Heterotopic ossification Extrinsic (extra-articular) Skin Subcutaneous tissue Muscles Collateral ligament Heterotopic ossifications Joint capsule Intrinsic (Intra articular) Loose bodies Articular adhesions Articular malalignment Loss of cartilage Combination Problem joint surface Heterotopic ossification Soft tissues

Static progressive stretching Increase arc of motion 40° Strongly supports Static progressive stretching Increase arc of motion 40° J Shoulder Elbow Surg (2013) 22, 1146-1152

a systematic review of 232 patients Static progressive versus dynamic splinting for posttraumatic elbow stiffness: a systematic review of 232 patients Veltman et al 8 papers (1 RCT, 7 Retrospective) Static Dynamic n 160 72 Pre Arc 72° 63° Post 108° 100° ∆ 36° 37° Static Dynamic n 160 72 Pre Arc 72° 63° Post 108° 100° Static Dynamic n 160 72 Static Dynamic n 160 72 Pre Arc 72° 63°

Elbow Stiffness - nonosseous Splinting 35° - Dynamic or static Continue 12 months No progress

65YO 6 months Arc movement 10° (around 90°) Abundant Heterotopic ossification

Early Vs late excision of HO The time point in surgical excision of heterotopic ossification of post-traumatic stiff elbow: recommendation for early excision followed by early exercise. Chen et al Retrospective n = 164 Early Vs late excision of HO

Early 6 months Late 2 years Early 6 months Late 2 years Early 6 months 52 112 Recurrence 29% 27% MEP 55 → 92 ∆ 37 57 → 91 ∆ 34 ROM arc 38 → 122 ∆ 84 Early 6 months Late 2 years n 52 112 Recurrence 29% 27% MEP 55 → 92 ∆ 37 57 → 91 ∆ 34 ROM arc 38 → 122 ∆ 84 39 → 124 ∆ 85 Early 6 months Late 2 years n 52 112 Recurrence 29% 27% MEP 55 → 92 ∆ 37 57 → 91 ∆ 34 ROM arc 38 → 122 ∆ 84 39 → 124 ∆ 85 Complications Similar Early 6 months Late 2 years n 52 112 Recurrence 29% 27% MEP 55 → 92 ∆ 37 57 → 91 ∆ 34 Early 6 months Late 2 years n 52 112 Recurrence 29% 27% MEP 55 → 92 ∆ 37 Early 6 months Late 2 years Early 6 months Late 2 years n 52 112 Early 6 months Late 2 years n 52 112 Recurrence 29% 27% Early 6 months

Heterotopic ossification No substantial benefit in delaying surgery past about 6 months

Clinical Outcomes of Semiconstrained Total Elbow Arthroplasty in Patients Who Were Forty Years of Age or Younger Park et al Retrospective n = 24 Male = 10 Female = 11 Semi constrained elbow (sloppy hinge) Coonrad Morrey Prichard Walker – II Aetiology Post traumatic = 9 Rheumatoid arthritis = 9 Haemophilia = 4 Post infection = 1

Clinical Outcomes of Semiconstrained Total Elbow Arthroplasty in Patients Who Were Forty Years of Age or Younger Park et al Good outcomes all Radiology No radiolucent lines 52% Humerus 6 (25%) Ulna 1 (4%) Both 4 (16%) Kaplan-Meier analysis 95% at eight years 90% at fifteen years

TER <40 Good outcomes, survivorship good, but 21 YO 91 months 7.6 yrs 1st revision at 28 ish 88 months 7.2 yrs 2nd revision 35 ish TER <40 Good outcomes, survivorship good, but

Immobilization in External Rotation Versus Internal Rotation After Primary Anterior Shoulder Dislocation: A Meta-analysis of Randomized Controlled Trials. Whelan et al

Immobilization in External Rotation Versus Internal Rotation After Primary Anterior Shoulder Dislocation: A Meta-analysis of Randomized Controlled Trials. Whelan et al 6 papers n = 632 No difference Recurrence Instability index scores

Anterior shoulder dislocation No benefit external rotation splinting

Anatomy does not predict pain J Bone Joint Surg Am. 2014;96:265

J Shoulder Elbow Surg (2013) 22, 1160-1166

No longer is it neck or shoulder, now brain or shoulder Psychological distress is associated with greater perceived disability and pain in patients presenting to a shoulder clinic. Menendez et al No longer is it neck or shoulder, now brain or shoulder SPADI (Shoulder Pain and Disability Index) Depression Catastrophic thinking Self-efficacy

No longer is it neck or shoulder, now brain or shoulder Psychological distress is associated with greater perceived disability and pain in patients presenting to a shoulder clinic. Menendez et al No longer is it neck or shoulder, now brain or shoulder SPADI (Shoulder Pain and Disability Index) Depression Catastrophic thinking Self-efficacy

Depression and the shoulder Variations in patient to patient reported Shoulder pain and disability is primarily mediated by psychological distress

Mental health SF36 MCS (mental component summary) Mental Health Has a Stronger Association with Patient-Reported Shoulder Pain and Function Than Tear Size in Patients with Full-Thickness Rotator Cuff Tears. Wylie et al n = 169 Anatomy of tear Mental health SF36 MCS (mental component summary) SF-36 MCS had the strongest correlation with the visual analog pain scale

Mental health may play an influential role in patient-reported pain and function in patients with full-thickness rotator cuff tears

The role of the peripheral and central nervous systems in rotator cuff disease. Bachasson et al

Overview how CNS and PNS interacts in Rotator cuff disease The role of the peripheral and central nervous systems in rotator cuff disease. Bachasson et al Overview how CNS and PNS interacts in Rotator cuff disease Extends the simplistic mechanical understanding of rotator cuff disease

PNS and CNS in RCT Furthers understanding its not just about the hole

Mini open rotator cuff repair Randomized controlled trial n=189 Early mobilisation following mini-open rotator cuff repair: a randomised control trial Sheps et al Mini open rotator cuff repair Randomized controlled trial n=189 Early ROM Vs Slow rehab (immobilized 6 weeks) As expected EM group better ROM 6 weeks No difference by 3 months HRQol, ROM Similar outcomes at 24 months Re tear rate similar

Rehab following RCR repair No Benefit in delaying range of movement exercises

Non osseous Elbow Stiffness Splinting 35° - Dynamic or static, 12 months, No progress Heterotopic ossification No substantial benefit in delaying surgery past about 6 months TER <40 Good outcomes, survivorship good, but Anterior shoulder dislocation No benefit external rotation splinting Complex interplay between mental health and subjective outcome scores, particularly pain Rehab following RCR repair No Benefit in delaying range of movement exercises