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

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

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

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

5. 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

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

7. 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°

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

9. 65YO 6 months Arc movement 10° (around 90°)
Abundant Heterotopic ossification

10. 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

11. Early 6 months Late 2 years Early 6 months Late 2 years Early 6 months52
112
Recurrence
29%
27%
MEP
55 → ∆ 37
57 → ∆ 34
ROM arc
38 → 122 ∆ 84
Early 6 months
Late 2 years n 52
112
Recurrence
29%
27%
MEP
55 → ∆ 37
57 → ∆ 34
ROM arc
38 → 122 ∆ 84
39 → 124 ∆ 85
Early 6 months
Late 2 years n 52
112
Recurrence
29%
27%
MEP
55 → ∆ 37
57 → ∆ 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 → ∆ 37
57 → ∆ 34
Early 6 months
Late 2 years n 52
112
Recurrence
29%
27%
MEP
55 → ∆ 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

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

13. 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

14. 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

15. 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

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

17. 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

18. Anterior shoulder dislocation No benefit external rotation splinting

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

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

21. 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

22. 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

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

24. 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

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

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

28. 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

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

30. 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

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

32. 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