A focus on the Shoulder and Elbow in 2024

Listen to Andrew Duckworth, Duncan Tennent, Adam Watts, and Fares Haddad discuss the editorial 'A focus on the Shoulder and Elbow in 2024' published in the October 2024 issue of The Bone & Joint Journal.

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[00:00:00] Welcome everyone to our BJJ podcast for the month of October. I'm Andrew Duckworth and a warm welcome back to you all from your team here at The Bone & Joint Journal. As always, we'd like to thank you all for your continued comments and support, as well as a big gratitude to our many authors and colleagues who take part in the series that highlights just some of the great work published by our authors each month.

So today for our monthly podcast, I have the pleasure of being joined by three editorial board colleagues and authors from an editorial published in this month's edition of the BJJ entitled 'A focus on the Shoulder and Elbow in 2024'. 

So firstly, I'm very pleased to be joined by our Speciality Editor for Shoulder, Professor Duncan Tennent. Duncan, great to have you with us. Oh, thank you very much for inviting me. Secondly, joining Duncan is another of our editorial board colleagues, and the Speciality Editor for Elbow, Professor Adam Watts. Adam, great to have you with us. Thanks very much Andy, it's great to be here. And finally, we are delighted to welcome back our awesome Editor-in-Chief here at the BJJ, Professor Fares Haddad. Prof, great to have you back with us again. Dux, thank you. Great, great to be with you. 

So Prof, maybe I'll start with yourself. This editorial is really a sort of an introduction and, and based on a range of papers that are going to be published over the next few months in the journal and this was following a call we made regarding [00:01:00] Shoulder and Elbow manuscripts. So just maybe for our listeners, a bit of background about how this came about and why you chose to do this. 

No, I think this is really important as you say, it's, it's a preface to some papers that will be published particularly this month and next month. As you know, we pride ourselves on being a very broad church, on being a journal that caters to the international community across the depth and breadth of trauma and orthopaedics.

Yet in reality, the work we see is dominated by certain subspecialties, particularly hip, knee and trauma. And so we, we look every now and then to see what we can do to emphasize those other areas that are really important in trauma and orthopaedics. And on this occasion, we thought the focus should be on shoulder and elbow just to see really what was out there from the shoulder and elbow community, to encourage the shoulder and elbow community to see The Bone & Joint Journal and BJO and BJR as their home for [00:02:00] their high-quality research that they want to disseminate nationally and internationally. And because there is also learning to be had across subspecialties in orthopaedics.

I think those who really progress their fields will not just look at what they are doing and their peers are doing, but will look across both within orthopaedics and outside orthopaedics. So we thought having a focus on what the shoulder and elbow community was doing was going to be really important.

And, you know, Duncan and Adam have done a phenomenal job of engaging, seeking the, the, the, the help of their colleagues and sourcing some excellent papers and hopefully a continued flow of papers as we move forward. Absolutely Prof, that's a great overview and why it came about and Duncan, if I could maybe come to yourself, you know, building on what Fares has just said, what are your sort of own experiences as a Specialty Editor for Shoulder with regards this?

I think Fares is absolutely right that there's an awful lot of hip and knee stuff and I think a lot of people see the BJJ as very much a hip, knee and trauma [00:03:00] journal and there are not that many that made one or two shoulder and elbow papers, each edition and therefore it's difficult to get the sort of the traction going.

So when it was suggested that we do this I thought this was a fantastic idea because we actually can get out, get people out there and go, this is somewhere to submit. And I think Fares is absolutely right, there's an awful lot we can learn, I read the hip and knee things, although I'm not a hip and knee surgeon, we'll talk about themes in a minute, but I'm very much aware that a lot of people are very general surgeons or they do trauma. And so instability, shoulder instability is a big part of people's fracture clinic practice. Yeah. So trying to bring that sort of message across was quite important for me. 

No, absolutely Duncan. I totally agree. And, and Adam, if I come to you as well, you know, it's obviously a similar question, but I know often shoulder and elbow are sort of badged together, but obviously very different in terms of the content that we receive and publish.

Yeah, they are different. I mean, I think there are some, some common themes around why possibly people have been more reticent to [00:04:00] submit elbow research to the BJJ. I think possibly a feeling that it's a bit niche or, or maybe of less interest to the broad readership, but actually what's, what was interesting was the reflection of, of large volume of trauma papers, which is relevant really to everybody in orthopaedic practice. Who's going to be seeing the the trauma cases coming through around the elbow. And even if they're not going to provide the ultimate the final management for that case, having an understanding of the discussions and the debates and the research that's being done in, around the elbow is really valuable.

And we were really impressed by the response that we had to the call, really both in shoulder and elbow, a fantastic response with a large volume of papers and some really good quality papers that made it to the journal, which is great to see. Absolutely. Absolutely Adam. I totally, I totally agree. And so Duncan, if I could come back to you, if we do maybe just focus for a brief moment on some of the shoulder papers that have and are going to be [00:05:00] published.

You know, I suppose two things, not only what themes did you see, but so there was, there was quite a breadth of the type of paper as well, wasn't there? It wasn't just original research.

It was, it, it I was a bit worried when the call went out because obviously with the shoulder, there's a whole range, you know, you've got arthroplasty, you've got cuff, you've got some basic science stuff, all these bits and pieces, instability.

But actually there were two themes that very much appeared one, as I mentioned before is instability. And we had some review work, we had some original, prospective actual patient data work, what we could talk about from Edinburgh, looking at their huge database, which was really useful and then a review paper that I asked for on what we do with the bone loss.

So there's a whole, as you said, there's a whole range of things there. Again, with the arthroplasty papers, which sort of come in a separate group. We've got some stuff on CT analysis. We do a lot of blueprinting. We're way behind the, the hip and knee surgeons, but preoperative blueprinting and some really important work on how actually we're not necessarily getting the information that we think we are getting out of our [00:06:00] blueprints.

So yeah, the two big things came out of it. I was really surprised at when the, in the submissions. No absolutely Duncan, you mentioned the Edinburgh paper, which was by Makaram et al, and that was, that's a large database study, isn't it? Sort of giving us some interesting data about the rate of recurrent instability and sort of the timing of it as well.

Yeah. So they looked at nearly 1,300, patients from their database. And they had a great age range, because it's the age range that we see. And I thought that the importance of this paper is it's very applicable to our practice. They were looking at the 15 to 35s. As you'd expect, most of them were male.

And what they were really trying to do is produce some sort of predictive model. Yeah. And the sort of the headline is they failed. But I thought that what I liked about this paper was that, first of all, they said we're trying to do this and it didn't work. Therefore, there has to be more in this than we are seeing because they looked at all of the things that we'd expect, which is being male, younger age, contact sports, and a bony Bankart lesion.

They [00:07:00] identified all of these as independently associated with increased rate of dislocation, but they couldn't put the model together on mass. Yeah. Yeah. Really important. We're missing a trick here. We don't know what it is, but we're missing something. Yeah. I like that as well. I think it was just, it was very clear, very honest.

And actually, like I said, like you said, there's something else out there that we need to figure out what's going on. No, I totally agree. That's why I really liked it. Yeah, absolutely. And it was like that, so there was also related to that the Saleem et al paper, which was a meta analysis of almost 8,000 shoulders, I think it was. And that was sort of a different approach to how you can potentially look at this. Yes, I'm, I was very surprised that I'm one of the authors on this paper. So it was submitted and credit to the BJJ because it's a totally boring process. And I was most surprised when it was accepted and, you know, ended up in this edition.

So this would came out again, a clinical question where we're confronted with patients all the time in the clinic. And I go, yep, I've dislocated my shoulder. Should I have surgery now? Yeah. And [00:08:00] there's lots in the literature where they push on about having primary instability surgery, first dislocation.

And I asked the question, well, what are the outcomes? Does it make any difference if I have third, fourth, fifth dislocation? Cause, you've got feeling is, yeah, that should be worse. And what we found in looking at all the data, was that actually, there's no difference. Yeah. Though, you don't have to rush to have an operation after your first dislocation.

You have time to think. Now certainly, there's evidence you probably have another one, but that doesn't matter. Yeah. So you have an opportunity to think about it. The big limitation with this paper, and I'll put my hands up with it, is that we don't know what's going to happen to your bone loss. And we don't yet know if that increases and are we missing a trick therefore, but I think it gives us the opportunity to step back, not panic and just say, take a breather and have an operation if you want it.

Yeah, no, absolutely Duncan. I thought that was very interesting and sort of, you know, sort of moving on from that. There was the, the paper that [00:09:00] that's in there looking at you know, PROMs versus redislocation, you know, looking at, you know, what, what does matter to the patient? What is the outcome? We really should be using in the potential issues with those two.

And I think that's, that's quite interesting because it's not only like, well, we've already talked about a theme that's not unique to shoulder. It's unique throughout orthopaedics. And you know, I know Prof and Nick Clement have recently written a paper about the MCID and the potential issues with that.

And I think it is a theme that is starting to come out more and more in the literature. 

Yeah. And again, with instability, I think it's interesting because we tend to look at it being very binary. Your operation is a success if the patient doesn't redislocate. But obviously it's a little bit more nuanced than that.

Yeah. And what I liked again about this paper was they're trying to, to first of all, sort out not only the, the MCID, but try to give us a patient acceptable symptom score for a range of outcome measures that we may want to use. And then there's this conversation about what is it that the patient wants? What is then that acceptable level? And it [00:10:00] surprised me because I just assumed that everybody would be you know, I've made you stable, you'll be happy. But again, I think we're, we're missing something somewhere with these factions. Yeah. And this doesn't answer everything in it, but it, it certainly says things like, the patients who have the contact sports or the overhead athletes are less likely to achieve their patient acceptable symptom score.

Yeah. And I think that's a really important message, and it gives us a chance to have a conversation with the patient about, what they can expect, not just, yeah, we'll stop you dislocating. Yeah, absolutely, absolutely. And so the final paper, you know, sort of, that builds on from that, that we were going to talk about was this, obviously, the one about addressing glenoid bone loss.

And you talk about how, you know, it's been more than 20 years since the importance of it has been recognized and how the evidence can continue to come out. But this sort of brings a little bit of that together, doesn't it, really? 

Yeah, so I, I asked for this paper because I, as you say, 20 odd years ago, we realized that probably glenoid bone loss was important.

And there really was one go to operation and that was the Latarjet, the [00:11:00] coracoid transfer. And that's become the, as it were, the gold standard. And a lot of people, that's all they'll do. But we know that it's got a complication rate. We know there's some real issues with it. And over the last ten years, there have been a whole variety of grafting options and fixation options.

And I wanted to try and pull it together to summarize it for people so they can say well, actually, I don't just have to do a Latarjet. I know when I should do an operation we think but I've got options that maybe they're metal-free. They, we can use iliac crest, scapular spine, all these things and to try and put it together with a little bit of the evidence.

And I thought it was a really nicely brought together summary of, of where we are at the moment. No, absolutely Duncan. I couldn't agree more. And I think that's a really nice overview, and like you say, those themes that have come through with the shoulder papers. 

So maybe Adam, I'll come to yourself with the elbow papers, you know, were there any particular themes that you see or you wanted to highlight? And I know we've got a couple of papers, particularly around the treatment of fractures, which we're going to [00:12:00] talk about. And there is a sort of a mix. There's some clinical papers and also there's some RSA work in cadavers as well, isn't there? Yeah, so as I alluded to earlier, obviously trauma was a fairly major theme in the submissions and that makes the bulk of the October issue for the elbow, elbow section.

In November, there'll be more papers around elbow arthroplasty and looking at NJR data as well. So the, you know, there is some I think a breadth of, of topics being covered in the submissions that have been made, but, but trauma is clearly a major focus for, for research around the elbow and, and is really growing quite rapidly.

The, and, and the quality of research was, as you say, you know, using lots of of different methods to, increase our understanding. Yeah. But also couching though that, that research in, in, in good quality methodologies following established guidelines as to how that research should be conducted.

Yeah. No absolutely Adam. [00:13:00] And I think the sort of first one that what sort of wanted to discuss was the, the Delphi survey of elbow surgeons. And that was regarding the management of coronoid fractures. And I thought this was, I think, was quite interesting and, and, and maybe not surprising given the literature that's come out recently, but I thought it was, it was, it was interesting to see the divide there. Yeah, I mean I, I have mixed views about Delphi studies because of course, if at one point you asked the, the, did a Delphi study, was the world flat? You would have got the answer. Yes, it was. So there is a risk that you're just condensing what is established opinion, which may be wrong.

Yeah, but in areas where we struggled to do, to obtain primary research data, either because of low volumes or because of lack of resources in terms of investment in research, it can be useful to get an understanding of what is the consensus opinion in terms of our understanding and the management of conditions.

And the treatment of coronoid fractures is important as, as you [00:14:00] know, I bang on about this all the time. Coronoid is the key to managing elbow injuries. And, and this survey, this Delphi survey looked at consensus views as to which coronoids we should be operating on, which could be left alone.

And it, you know, it's, it's a, it's challenging. It's a contentious area. I think if you put you know, group of specialist elbow surgeons in a room, you'll be able to divide them fairly evenly between for some of the injuries as to, as to those that would operate and those that wouldn't. I think the nice thing about the, the, this study was that they had a breadth of opinion from around the world.

I think that's that's really valuable and from different domains. Yeah. And they had a good response rate, I think, for a Delphi survey. And importantly, it was a three-round survey and they managed to keep most of the respondents going to the end of the survey. So, so and as, as alluded to earlier, you know, they, they were aligned, their methodology to temporary guidelines for conducting online [00:15:00] consensus surveys. So I think the methodology was sound and the reporting was, was good. And you know, was it surprising what they reported? It may, maybe not that surprising. The sort of, you know, the, the, the. factors, favoring operative treatment being things like being an elite athlete having an open fracture, but some subtle signs that may be new to some people, such as crepitation with movement.

And the, the, the use of CT scans to determine the, the, the. amount of coronoid involved. I think the, the, the, the really interesting thing was the complete lack of consensus about whether we should be fixing coronoid fractures in a terrible triad injury where the lateral facet is injured with alongside the radial head.

And there you could, you could split the respondents into thirds. So a third thought you should fix them. A third felt that should be left alone. And a third couldn't decide either way. So clearly an area that needs further [00:16:00] investigation to determine what, what is their appropriate management for those types.

I thought that was the thing Adam, wasn't it? I think the fact that there's a variance in opinion and practice is actually very helpful and useful information moving forward. No, I totally agree. And if you sort of move on from that, there were, there were a couple of papers looking at fix versus replace of the radial head and obviously, you know, very interesting data, but it's quite a hard area to report on because it's such a really heterogeneous group often of, of injuries that are often seen when you look at this. 

Do you agree? It is and you know, people talk about doing randomized controlled trials of, of osteosynthesis versus arthroplasty and of course it would be a very difficult trial to do. Yeah. Because if, if you can fix it, you'd probably fix it. If you can't fix it, you'll replace it. So it would be hard to to do such a, such a trial. But I thought that the group Jakobi et al ,did a really interesting attempt to try and answer this question by using propensity score matching. So they tried to [00:17:00] minimize the bias in their observational study where they had a group of patients treated with osteosynthesis and a group treated with with radial head arthroplasty in whom they tried to do fixation first off.

They, they matched the, the patients based on age, sex, BMI, the type of injury, number of fragments, ligament injury and whether there was, it was an open or closed closed injury. And what they concluded from their study was that actually osteosynthesis produces a better outcome using sort of outcome measures such as range of movement, Mayo Elbow score, Oxford or DASH scores.

And with similar complication rates between the two groups. They also reported that, that, you know, if you did try to fix it and that fixation failed, then, and you then do a radial head replacement as salvage, then that will also do, do equally well. So it's the, it challenges in [00:18:00] this area. It's different from the findings of recent recent meta-analysis of published trials, which concluded actually there's very little difference between the two.

My only worry, and the authors acknowledge this, is that despite the use of, of propensity match score matching, to try to minimize the bias. It's very difficult to be certain that the soft-tissue injuries were the same between the two groups. One hundred percent, yeah. There was a reason why they couldn't fix those fractures and they had to do a radial head replacement and it was only one type of radial head replacement so the generalized and it was done in one centre so the generalizability of the findings need to be called into question as well.

So I think it's an interesting methodology, interesting progress to try and get us further to an answer. But ultimately, I suspect where, it leaves us in a similar situation where, well, if you can fix it, definitely fix it. But sometimes you [00:19:00] can't. 

Yeah, no, absolutely. And that sort of leads on into the, the, the final paper I just want to discuss, which was the, you know, it was a, a cadaveric study, you know, looking at RSA and, and basically looking you know, at the kinematics of the elbow and the length of the radial head, particularly when you're replacing it. And I thought that was quite a different study as well. Yeah, so, so very much related to that previous study, because of course, one of the problems with radial head arthroplasty is, is that it's not just the design of the implant, it's how it's implanted. Yeah. And there isn't a lot of training for surgeons in how to implant radial head replacements. There are lots of different, completely fundamentally different concepts in terms of the design of the radial head replacements. And so It, it's possibly not surprising given the low numbers that are performed, that people run into problems.

And one of the common problems is, is overstuffing, which is which is what was being addressed in this in this [00:20:00] cadaveric study. So overstuffing is where the radius is, is is effectively anatomically lengthened by a regular head that's not fully seated or, or is too long for, for the to restore the anatomy accurately. So they had eight cadaveric specimens. The methodology was really interesting in terms of the tech, the techniques they use to try and minimize bias of their findings and improve the accuracy of measurement. I won't go into it in detail, but it's definitely worth reading to to look at how they how they tried to standardize things and increase their accuracy.

And of course, what they found was that if you if you overstuff the joint by four millimeters, then that has really bad effects on elbow kinematics. That's likely to lead to increased joint contact pressures, which is likely to lead to pain and wear in the joint. Again is that surprising? It's not surprising, [00:21:00] but it's really useful data to see the effect that it has, and how that incremental increase in overstuffing leads to incremental increases in the alterations in the kinematics of the elbow. And the central, the essential message is, I think, that you need to know your implant, you need to know how to put it in and you need to make sure that you restore the joint line accurately and making sure that your implant never comes proximal to the proximal extent of the lesser sigmoid notch with poor pronation don't rely on radiographs. The only time you can tell whether you've overstuffed is, is at the time of surgery. The surgery. No, absolutely. I don't know. I think very well said. And, and thanks to you both for a really good overview of those, those really interesting papers. And like you say, that themes that come out, maybe just to wrap up, I'll, I'll come back to you Prof.

No, I suppose firstly, just, you know, what your thoughts on the published papers are and overall your assessment of this, you know, this process that we've had [00:22:00] of call for papers and, and something that you would consider doing again. I think it's been an enjoyable and productive process. I think the papers are great.

They're going to generate discussion. You know, none of them are perfect, but they, they are just what we need in terms of putting the focus on this area and getting people to interrogate them, discuss them and be involved in this conversation. So I'm glad we've covered them tonight. I think for me, it's been a very successful process and one that we will undoubtedly repeat in other areas in years to come.

Excellent Prof. Yeah, that's that's very good to hear. Well afraid that's all we have time for. So thank you so much to you all for taking the time to join us and a big thank you to you all and to our authors for the efforts that have come into producing these great set of papers for the journal. And to our listeners, we do hope you've enjoyed joining us and encourage you to share your thoughts or any comments on the various platforms about what we've chatted about here today.

But thanks again for joining us. Take care, everyone.