British Elbow And Shoulder Society Research Articles

Rehabilitation following rotator cuff repair: A survey exploring clinical equipoise among surgical members of the British Elbow and Shoulder Society.

BackgroundWe investigated clinical equipoise across surgical members of the British Elbow and Shoulder Society (BESS) in relation to rehabilitation following rotator cuff repair.MethodAn online survey explored clinical equipoise regarding early patient-directed versus standard rehabilitation after rotator cuff repair to inform the design of a national randomised controlled trial (RCT). It described different clinical scenarios relating to patient age, tear size, location and whether other patient-related and intra-operative factors would influence equipoise.Results76 surgeons completed the survey. 81% agreed/ strongly agreed that early mobilisation might benefit recovery; 57% were neutral/ disagreed that this approach risks re-tear. 87% agreed/ strongly agreed that there is clinical uncertainty about the effectiveness of different approaches to rehabilitation. As age of the patient and tear size increased, the proportion of respondents who would agree to recruit and accept the outcome of randomisation reduced, and this was compounded if subscapularis was torn. Other factors that influenced equipoise were diabetes and non-secure repair.ConclusionSurgical members of BESS recognise uncertainty about the effectiveness of different approaches to rehabilitation following rotator cuff repair. We identified a range of factors that influence clinical equipoise that will be considered in the design of a new RCT.

The Management of Distal Clavicle Fractures - A Survey of UK Shoulder and Elbow Surgeons.

BackgroundDistal clavicle fractures (DCF) are a management challenge frequently encountered by shoulder surgeons. Despite an array of surgical fixation strategies, the indications and role of surgery are unclear, with there being no gold standard or consensus regarding their management. The aim of this study was to identify current United Kingdom (UK) clinical practices relating to DCFs and to inform a future randomised control trial (RCT).MethodsAn online survey was sent to the consultant surgeon members of the British Elbow and Shoulder Society (BESS). Questions covered respondent indications for surgical fixation, important factors considered for management of DCFs, fixation strategies, the volume of patients treated, and willingness to participate in the conduct of a randomized trial.ResultsThe response rate was 84/327 (26%). 64-67% of respondents reported surgically managing DCFs classified as Neer type 2A, 2B and 5. The most important factors considered by surgeons when deciding between operative and nonoperative intervention were degree of displacement (90%), clinical assessment of impending open fracture (87%), and age of the patient (74%). For conservatively managed DCFs, the preferred length of complete immobilization was 2-4 weeks (46%), followed by 4-8 weeks (17%). 30% reported not immobilizing their patients at all. For operative intervention, the locking plate was the preferred fixation method by most respondents (68%), although there was no clear consensus regarding other fixation methods. Most surgeons (52%) reported treating a low volume of patients with DCFs (0-10) per year. 58% of respondents were willing to randomize patients to non-operative treatment in a multi-centre RCT, with a further 22% undecided. Finally, 68% (n=79) of respondents would consider being co-investigators in such a trial.ConclusionThere is considerable heterogeneity in the management of patients with DCFs in the UK. The indications for surgery and the optimal surgical fixation method remain uncertain. There is a clear need for pragmatic multi-centre clinical research in this area.

Audit: sonographic report correlation against surgical findings during elective shoulder surgery.

Musculoskeletal diagnostic ultrasound is an expanding clinical tool and increasingly used at point of care in clinical practice. Criticism around the accuracy of this modality is often attributed to operator dependence. This study evaluated the accuracy of a sonographer's reporting against shoulder surgery. A musculoskeletal sonographer performed same-day ultrasound scans prior to elective shoulder surgery procedures. The sonographer was blinded to clinical history and previous investigations. A brief physical examination of resisted external rotation and resisted abduction strength was performed prior to scanning. Scan results were reported using British Elbow and Shoulder Society (BESS) reporting criteria. The sonographer attended surgery to gain immediate visual feedback. Sonographic reports and magnetic resonance imaging (MRI) reports were graded (1= complete agreement; 2 = minor discrepancy unlikely to alter patient care; 3 = potentially significant discrepancy; 4 = definite, significant discrepancy) against surgical findings. The accuracy of sonographic reporting was correlated with patients' body mass index (BMI). Fifty-four cases were compared and correlations evaluated. Grade 1 (complete agreement) was reported 87.0% (n = 47), Grade 2 (minor discrepancy) 9.3% (n = 5) and Grade 3 (potentially significant discrepancy) 3.7% (n = 2). Sonographic reports closely correlated (Grade 1 or 2 scores) with surgical findings in 96% of cases. The musculoskeletal sonographic reporting had a high correlation with surgery findings. Ultrasound was more accurate than MRI in reporting full thickness rotator cuff tears. Clinical weakness in resisted external rotation or abduction did not correlate with imaging. Ultrasound was found to be unreliable in detecting rotator cuff tears in participants with a BMI ≥ 35.

Surgical vs. Nonsurgical Management for Humeral Shaft Fractures; Preference Among Orthopaedic Surgeons.

Determining trends in managing humeral shaft fractures may help identify variation in practice which might benefit design of clinical guidance. We aimed to determine the practice of members of the British Elbow and Shoulder Society (BESS) in managing humeral shaft fractures. An electronic survey was sent to members of BESS. Questions related to preferred surgical and nonsurgical approaches for management of humeral shaft fractures. This was divided into management of proximal, middle and distal third diaphyseal fractures. 91 fully completed responses were analysed. Nonsurgical management was preferred by 90.1% (n=82) for middle-third and 80.2 % (n=73) for proximal third fractures, however 52.7% (n=48) favoured surgical treatment for distal third fractures. 1. The management preference for humeral shaft fractures amongst surgeons is highly variable. 2. This may be partly attributed to the sparsity of high-quality evidence. 3. Well-designed randomised trials or pro-spective cohort studies may help further guide management of these injuries.

Current practices in the management of anterior glenohumeral instability in rugby union players

BackgroundRugby has the highest incidence of traumatic injuries of any sport, and glenohumeral injuries result in the lengthy delay in return to play. The purpose of this study is to survey surgeons from the American Shoulder and Elbow Surgeons (ASES), and the British Elbow and Shoulder Society (BESS) to evaluate the current state of management of anterior glenohumeral instability, and compare the differences in practices. MethodsA survey of surgeons from ASES and BESS was conducted. Treatment options were proposed in a variety of clinical scenarios of glenohumeral instability. The time of immobilization post-operatively, return to play, and attitudes on current contact regulations. Results were compared using the chi-square test or t-test. ResultsNinety-seven surgeons responded to the survey. There was a significant difference in treatment between ASES and BESS surgeons in the setting of primary dislocation (p < 0.05), but not recurrent dislocation (p > 0.05). The period of immobilization following injury and surgery was different between both treating groups. There was a significant difference in return to play between ASES and BESS surgeons with arthroscopic stabilization and open Bankart repair (p < 0.05), but not following conservative treatment or the Latarjet procedure (p > 0.05). ConclusionsThere remains wide variance on the management of glenohumeral instability in rugby union players among surgeons. While immobilization times post-operatively were similar, the BESS surgeons were more confident in allowing earlier return to play. There is also a significant concern that contact levels should be regulated to protect player safety. Level of evidenceLevel 4 (case series).

The use of a patch to augment rotator cuff surgery - A survey of UK shoulder and elbow surgeons.

Rotator cuff tears are a common cause of shoulder pain and can result in prolonged periods of pain, disability and absence from work. Rotator cuff repair surgery is increasingly used in an attempt to resolve symptoms but has failure rates of around 40%. There is a pressing need to improve the outcome of rotator cuff repairs. Patch augmentation increasingly being used within the NHS in an attempt to reduce repair failures. The aim of this survey was to determine current UK practice and opinion relating to the factors that influence choice of patch, current patient selection and willingness to assist with generation of improved evidence. An online survey was sent to the surgeon members of the British Elbow and Shoulder Society (BESS). Questions covered respondent demographics, experience with patches, indications for patch augmentation and willingness to be involved in a randomised trial of patch augmented rotator cuff surgery. The response rate was 105/550 (19%). 58% of respondents had used a patch to augment rotator cuff surgery. 70% of patch users had undertaken an augmented repair within the last 6 months. A wide surgical experience in augmentation was reported (ranging 1 to 200 implants used). However, most surgeons reported low volume usage, with a median of 5 rotator cuff augmentation procedures performed. At least 10 different products had been used. Most of the patches used were constructed from human decellularised dermis tissue, although porcine derived and synthetic based patches had also been used. Only 3-5% stated they would undertake an augmented repair for small tears across ages, whereas 28-40% and 19-59% would do so for large or massive tears respectively. When assessing patient suitability, patient age seemed relevant only for those with large and massive tears. Half of the surgeons reported an interest in taking part in a randomised controlled trial (RCT) evaluating the role of patch augmentation for rotator cuff surgery, with a further 22% of respondent's undecided. A variety of patches have been used by surgeons to augment rotator cuff repair with a wide range of operator experience. There was substantial uncertainty about which patch to use and differing views on which patients were most suitable. There is a clear need for robust clinical evaluation and further research in this area.

Cementation technique for elbow arthroplasty; an international survey

BackgroundModern cementation techniques have markedly improved survivorship in lower limb arthroplasty, which have been heavily researched in the hip and knee but less so for upper limb procedures. Aseptic loosening is a leading cause of failure in total elbow arthroplasty (TEA) which could be related to the quality of cementation. The aim of this study was to investigate the cementation techniques used for TEA among practicing elbow surgeons. MethodsAn electronic questionnaire was emailed to members of the British elbow and shoulder society (BESS) and PubMed identified experts. Questions focused on the type of prosthesis, operative rates for elective and trauma cases, nature of cement used, canal preparation and cement insertion. Opinions regarding satisfaction with current techniques and mantle quality were also collected. ResultsA total of 26 surgeons completed the questionnaire. The Coonrad-Moorey was the most popular device amongst respondents. Most cemented both components, used antibiotic loaded cement, washed the canal with saline and inserted the cement retrograde. There was wide variation in cementation techniques used for the humerus and ulna, particularly regarding cement preparation, insertion, and use of a restrictor and pressurisation. ConclusionModern cementation techniques are not being utilised in TEA which could be contributing to implant loosening rates and longevity.

Surgical and non-surgical treatment of frozen shoulder. Survey on surgeons treatment preferences

frozen shoulder is a common condition and its management can be surgical or non-surgical. The aim was to determine current trends in the management of frozen shoulder amongst surgical members of the British Elbow and Shoulder Society (BESS). a single electronic questionnaire was emailed to surgical members of the BESS. Participants were asked about their surgical and non-surgical treatments of choice and the reasoning behind that, as well as which components of arthroscopic arthrolysis they favoured. 87 BESS members completed the questioner. The majority of respondents used physiotherapy as their preferred means of non-surgical management while arthroscopic arthrolysis was the most frequently used surgical intervention. A substantial proportion of surgeons based their choice on personal experience and training rather than published evidence. management of frozen shoulder amongst surgeons varies substantially and is highly based on personal experience and training rather than strong evidence. Arthroscopic arthrolysis is a heterogeneous procedure with a wide variation in the use of its various components. Our results highlight the need for high quality clinical trials to compare the management options available.

The Provision of Primary and Revision Elbow Replacement Surgery in the NHS.

BESS Surgical Procedure Guidelines (SPGs). Optimising Surgical Outcomes for Shoulder and Elbow patients. The British Elbow and Shoulder Society (BESS) SPGs are a series of evidence and consensus Best Practice Recommendations developed by BESS surgeons and physiotherapists to help drive quality improvement and achieve the best possible surgical outcomes for UK patients. This SPG on primary and revision elbow replacement surgery is supported and endorsed by both the British Orthopaedic Association (BOA) and the Getting It Right First Time (GIRFT) Programme.

Investigation and Management of Periprosthetic Joint Infection in the Shoulder and Elbow: Evidence and consensus based guidelines of the British Elbow and Shoulder Society.

1.1 Background Periprosthetic Joint Infection (PJI) is a relatively rare but potentially devastating complication affecting shoulder and elbow joint arthroplasty. The increasing use of these procedures in the surgical management of arthritis and trauma means that the incidence of PJI is also likely to rise. The much larger burden of PJI in hip and knee arthroplasty has made international groups develop consensus definitions on diagnosis and guidance on investigations required to confirm PJI.1–3 Infection reported as a cause for revision within the UK National Joint Registry (NJR) currently is 0.27% for shoulder arthroplasty and 1.13% for elbow arthroplasty.4 Although the numbers of PJI are relatively low with shoulder and elbow arthroplasty the impact on patients, the treating surgical teams and healthcare resources remains significant. Scoping reviews of the current body of literature on shoulder and elbow PJI confirmed a limited quality of published papers, mostly based on small retrospective case series and cohort studies.5,6 The British Elbow and Shoulder Society (BESS) has therefore developed these clinical guidelines on investigation and management of shoulder and elbow PJI by combining available evidence from the literature with consensus developed by a working group of BESS surgeons, infectious disease physicians and BESS physiotherapists.

Total Elbow Arthroplasty Survey 2015: Current Service Provision and Future Improvements (England and Wales).

The number of total elbow replacement (TER) procedures conducted is relatively low compared to other joint arthroplasties. We have established a survey about current service provision and possible future improvements in the UK. A British Elbow and Shoulder Society (BESS) approved online survey was circulated to its surgical members. In total, 153 members of BESS responded. Almost 31% of respondents performed two to five TER in 2014; 28% performed none and 22.7% performed five to ten. Two-thirds of respondents did not perform any revision surgery. The main indication for TER was rheumatoid arthritis (33%), followed by acute trauma (28.5%). In addition, 67% of surgeons have an available 'network' for advice, either locally or regionally. Most primary procedures (93%) were carried out within the local units. However, 34% of complex primary or revision procedures were referred to another centre. Furthermore, 52% of respondents agree that, to be proficient in TER, a minimum number of procedures per annum should be performed: 62% stated that five procedures per annum should be considered as the minimum required. Suggestions for improvement included a hub and spoke model (48%) and a dedicated TER surgeon within the unit (45%). The survey highlights the interest in exploring options for improving TER provision in the UK.

The Foundation of the British Elbow and Shoulder Society (BESS).

The Foundation of the British Elbow and Shoulder Society (BESS).

Corticosteroid and platelet-rich plasma injection therapy in tennis elbow (lateral epicondylalgia): a survey of current UK specialist practice and a call for clinical guidelines

BackgroundTennis elbow is a common condition with a variety of treatment options, but little is known about which of these options specialists choose most commonly. Corticosteroid injections in tennis elbow...

Treating the torn rotator cuff: current practice in the UK

The aim of this study was to characterise current rotator cuff repair activity in the UK with emphasis on the management of rotator cuff tears in the elderly population (over 70s). A one-page web-based survey was created. All British Elbow and Shoulder Society (BESS) members and surgeons who listed the shoulder as an area of specialist interest on the website http://www.specialistInfo.com/ were invited to complete this. A total of 103 surgeons completed the survey; most (n =89, 86%) were BESS members. They had spent a median of 10 years (range: 9 months - 30 years) in consultant practice and performed an annual median of 200 (range: 0-1,000) arthroscopic shoulder procedures. For rotator cuff repair the favoured method was arthroscopic for 47 consultants (46.5%), open or mini-open for 41 (40.6%) and both for 13 (12.9%). The annual median number of arthroscopic and open cuff repairs was 20 (range: 0-250) and 12 (range: 0-100) respectively. The longer the time in practice, the fewer the reported number of arthroscopic cuff repairs (r(s)=-0.22, p=0.027) and the greater the number of open and mini-open cuff repairs (r(s)=0.33, p=0.001). In the management of a full-thickness rotator cuff tear in a patient over 70 years of age, 27 (26.7%) would perform an open or mini-open repair, 43 (42.6%) an arthroscopic repair and 22 (21.8%) would not attempt a repair. Surgeons performing a higher volume of arthroscopic cuff repairs annually were more likely to repair cuff tears and they predicted significantly better outcomes of cuff repair for both pain and shoulder movement. Our results reflect the existing conflicting evidence regarding the indications for and methods of treatment of rotator cuff disease.

Management of traumatic anterior shoulder dislocation in the 17- to 25-year age group: a dramatic evolution of practice

Anterior shoulder dislocation in the young patient is a common problem, yet there is no universal agreement on its management. In this study, we comprehensively surveyed all members of the British Elbow and Shoulder Society (BESS) to ascertain their preferred methods of treating young patients with traumatic, anterior shoulder dislocation. We then repeated exactly the same survey 7 years later to find out whether practices had changed and if any consensus of opinion had been reached. The number of surgeons indicating their preferred stabilization procedure was arthroscopic more than quadrupled from only 16% in 2002 to 71% in 2009, while the numbers of those preferring an open technique fell in a correspondingly dramatic manner. The numbers who now potentially offer stabilization surgery to first-time dislocators virtually doubled from 35% to 68%. There was also a big rise in the use of magnetic resonance imaging (MRI) arthrograms as an investigation prior to surgery and in the use of bio-absorbable anchors during surgical stabilization. There remain, however, aspects of treatment and rehabilitation where little consensus exists. Rarely in the history of orthopaedic surgery has such a dramatic and widespread change in operative technique occurred in such a short space of time. Rarer still has such a change been prospectively documented.