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1.  Pain, depression and the postoperative stiff shoulder 
Background
The surgical repair of shoulder pathologies, including rotator cuff disease and acromio-clavicular joint arthritis, have undergone many technical advances. However the debilitating postoperative stiff shoulder remains a common and significant complication of these surgeries, occurring in 4.9 to 23.2 % of patients undergoing rotator cuff repairs.
The pathology of the pathological postoperative stiff shoulder and its associated condition “frozen shoulder” are poorly understood and both lack formal objective clinical diagnostic criteria. Additionally, although factors associated with the development of idiopathic frozen shoulder have been well described, multiple studies looking at predictors of postoperative stiff shoulder have produced conflicting results. It has been hypothesised that increased pain in the postoperative period, and depression may be predictors of the development of postoperative stiff shoulder.
Method
A prospective cohort study involving 132 consecutive participants. Preoperatively, participants undergoing arthroscopic subacromial decompression and/or excision of the distal clavicle and/or rotator cuff repair will complete questionnaires about their levels of shoulder pain using a numerical rating scale from 0 to 10, and answer a Patient Health Questionnaire – 9 depression questionnaire. Postoperatively, the participants’ pain levels will be self-assessed at two, five and seven days and weeks four, seven and ten. They will complete the depression questionnaire twice, at the time of their routine first and final postoperative appointments with the treating surgeon. At the final appointment, approximately three months postoperatively, the treating surgeon will clinically diagnose participants as having a postoperative stiff shoulder or not. Their shoulders’ range of motion will be measured. The incidence of postoperative stiff shoulder will be determined, both pain and depression will be analysed as predictors for its development and incidences determined by different objective criteria will be compared.
Discussion
This trial will add to clinical understanding of the postoperative stiff shoulder by providing further insight into the incidence of this condition following shoulder surgery and assessing whether perioperative pain and depression can be used as clinical predictors of postoperative stiff shoulder or markers for possible early intervention. This study will also allow the comparison of incidences determined by different objective criteria in the same cohort.
Trial registration
Australian New Zealand Clinical Trials Registry (ANZCTR).
ACTRN12613001271796.
17-11-2013.
Electronic supplementary material
The online version of this article (doi:10.1186/s12891-015-0841-6) contains supplementary material, which is available to authorized users.
doi:10.1186/s12891-015-0841-6
PMCID: PMC4669665  PMID: 26637238
Postoperative stiff shoulder; Shoulder; Surgery; Subacromial decompression; Excision of distal clavicle; Distal clavicular resection; Rotator cuff repair; Pain; Depression
2.  Ultrasound-guided platelet-rich plasma injection for distal biceps tendinopathy 
Shoulder … Elbow  2015;7(2):110-114.
Background
Distal biceps tendinopathy is an uncommon cause of elbow pain. The optimum treatment for cases refractory to conservative treatment is unclear. Platelet-rich plasma has been used successfully for other tendinopathies around the elbow.
Methods
Six patients with clinical and radiological evidence of distal biceps tendinopathy underwent ultrasound-guided platelet-rich plasma (PRP) injection. Clinical examination findings, visual analogue score (VAS) for pain and Mayo Elbow Performance scores were recorded.
Results
The Mayo Elbow Performance Score improved from 68.3 (range 65 to 85) (fair function) to 95 (range 85 to 100) (excellent function). The VAS at rest improved from a mean of 2.25 (range 2 to 5) pre-injection to 0. The VAS with movement improved from a mean of 7.25 (range 5 to 8) pre-injection to 1.3 (range 0 to 2). No complications were noted.
Discussion
Ultrasound-guided PRP injection appears to be a safe and effective treatment for recalcitrant cases of distal biceps tendinopathy. Further investigation with a randomized controlled trial is needed to fully assess its efficacy.
doi:10.1177/1758573214567558
PMCID: PMC4935115  PMID: 27582965
Distal biceps; PRP injection; tendinopathy; ultrasound-guided
3.  Outcomes for intra-substance free coracoid graft in patients with antero-inferior instability and glenoid bone loss in a population of high-risk athletes at a minimum follow-up of 2 years 
Shoulder … Elbow  2014;7(1):36-43.
Background
The aim of this retrospective case series study was to assess the outcomes of patients with recurrent anterior shoulder instability with antero-inferior glenoid bone loss treated with a specific open stabilization technique using intra-substance coracoid bone-grafting and Bankart repair.
Methods
Over a 4-year period, 34 shoulders in all male patients of mean age 21 years were stabilized with this technique. Pre- and postoperative function, motion and stability were assessed as part of Rowe stability scoring, and American Shoulder and Elbow Surgeons (ASES) and Oxford Instability were recorded, with at least 2 years of follow-up in all patients. Union of the graft was determined by post-operative computed tomography (CT) of the affected shoulder.
Results
For all cases, two redislocations (5.9%) and two subluxations occurred when continuing high-risk sport after 2 years. Post-operative scores [median, mean (SD): Rowe 77.5, 77.2 (19.5); ASES 94.2, 92 (7.7); Oxford 43, 41.2 (6)]. CT scans on 28 shoulders at a mean of 4.5 months after surgery showed non-union in three cases (10%).
Conclusions
These results demonstrate a high rate of success in cases of glenoid bone loss in the young contact athlete with recurrent instability treated with open stabilization and bone grafting.
doi:10.1177/1758573214557147
PMCID: PMC4935099  PMID: 27582955
bone graft; glenoid deficiency; glenoid reconstruction; shoulder instability
4.  The use of four-dimensional computed tomography to diagnose costoclavicular impingement causing thoracic outlet syndrome 
Shoulder … Elbow  2014;6(4):273-275.
Thoracic outlet syndrome is caused by compression of the neurovascular structures crossing the interscalene triangle, costoclavicular space or retropectoralis minor space. The costoclavicular space is the most frequent site of arterial compression and is mainly a result of anatomical variations and masses occupying the costoclavicular space causing a compression effect on the vascular or neural structures within it. We present a case of thoracic outlet syndrome caused by dynamic impingement of the clavicle and the second rib diagnosed by four-dimensional computed tomography scanning.
doi:10.1177/1758573214533781
PMCID: PMC4935040  PMID: 27582945
Costoclavicular impingement; four-dimensional computed tomography; thoracic outlet syndrome
5.  Short stem shoulder replacement 
Context:
It is agreed that it is important to anatomically reproduce the proximal humeral anatomy when performing a prosthetic shoulder replacement. This can be difficult with a long stemmed prosthesis, in particular if there is little relationship of the metaphysis to the humeral shaft. The ‘short stem’ prosthesis can deal with this problem.
Aims:
A prospective study assessed the results of total shoulder arthroplasty using a short stem humeral prosthesis, a ceramic humeral head, and a pegged cemented polyethylene glenoid.
Materials and methods:
Patients with primary shoulder osteoarthritis were recruited into this prospective trial and pre-operatively had the ASES, Constant, SPADI, and DASH scores recorded. The patients were clinically reviewed at the two weeks, eight weeks, one year, and two year mark with completion of a data form. Radiological evaluation was at the eight week, one year and two year follow-up. At the one and two year follow-up the satisfaction rating, the range of passive and active motion, Constant, ASES, SPADI, DASH and pain results were recorded and analysed with SPPS 20.
Results:
During the study period 97 short stem, ceramic head total shoulder replacements were carried out. At the time of follow-up 12 were two years from operation and 38 one year from operation. Active elevation was overall mean 160 degrees. Constant scores were 76 at 1 year, and 86 at 2 years, ASES 88 and 93, and satisfaction 96% and 98% respectively at one and 2 year follow up. There were no problems during insertion of the humeral prosthesis, or any radiolucent lines or movement of the prosthesis on later radiographs.
Conclusion:
The short stem prosthesis had no complications, and on follow up radiographs good bone fixation. These fairly short term clinical results were overall good.
doi:10.4103/0973-6042.140113
PMCID: PMC4168655  PMID: 25258497
Ceramic prosthesis; short stem humeral prosthesis; shoulder arthroplasty; shoulder replacement; stemless
6.  Low‐flow priapism needs recognition and early correct treatment 
Emergency Medicine Journal : EMJ  2007;24(3):209-210.
Low‐flow priapism is a rare condition whereby there is a persistent, painful erection. The patient often presents late because of embarrassment. Failure to recognise this as an emergency and instigate immediate treatment may lead to cavernosal tissue ischaemia, fibrosis and subsequent long‐term impotence. A case of low‐flow priapism, that demonstrated a lack of urgency and understanding is discussed. An internet‐based literature search provided a treatment regimen with resolution of tumescence.
doi:10.1136/emj.2005.028894
PMCID: PMC2660032  PMID: 17351229
7.  Efficacy and safety of a subacromial continuous ropivacaine infusion for post-operative pain management following arthroscopic rotator cuff surgery: A protocol for a randomised double-blind placebo-controlled trial 
Background
Major shoulder surgery often results in severe post-operative pain and a variety of interventions have been developed in an attempt to address this. The continuous slow infusion of a local anaesthetic directly into the operative site has recently gained popularity but it is expensive and as yet there is little conclusive evidence that it provides additional benefits over other methods of post-operative pain management.
Methods/Design
This will be a randomised, placebo-controlled trial involving 158 participants. Following diagnostic arthroscopy, all participants will undergo arthroscopic subacromial decompression with or without rotator cuff repair, all operations performed by a single surgeon. Participants, the surgeon, nurses caring for the patients and outcome assessors will be blinded to treatment allocation. All participants will receive a pre-incision bolus injection of 20 mls of ropivacaine 1% into the shoulder and an intra-operative intravenous bolus of parecoxib 40 mg. Using concealed allocation participants will be randomly assigned to active treatment (local anaesthetic ropivacaine 0.75%) or placebo (normal saline) administered continuously into the subacromial space by an elastomeric pump at 5 mls per hour post-operatively. Patient controlled opioid analgesia and oral analgesics will be available for breakthrough pain. Outcome assessment will be at 15, 30 and 60 minutes, 2, 4, 8, 12, 18 and 24 hours, and 2 or 4 months for decompression or decompression plus repair respectively.
The primary end point will be average pain at rest over the first 12-hour post-operative period on a verbal analogue pain score. Secondary end points will be average pain at rest over the second 12-hour post-operative period, maximal pain at rest over the first and second 12-hour periods, amount of rescue medication used, length of inpatient stay and incidence of post-operative adhesive capsulitis.
Discussion
The results of this trial will contribute to evidence-based recommendations for the effectiveness of pain management modalities following arthroscopic rotator cuff surgery. If the local anaesthetic pain-buster provides no additional benefits over placebo then valuable resources can be put to better use in other ways.
Trial registration
Australian Clinical Trials Register Number ACTR12606000195550
doi:10.1186/1471-2474-9-56
PMCID: PMC2386465  PMID: 18430210
8.  Community pharmacy services to optimise the use of medications for mental illness: a systematic review 
The objective of this systematic review was to evaluate the impact of pharmacist delivered community-based services to optimise the use of medications for mental illness. Twenty-two controlled (randomised and non-randomised) studies of pharmacists' interventions in community and residential aged care settings identified in international scientific literature were included for review. Papers were assessed for study design, service recipient, country of origin, intervention type, number of participating pharmacists, methodological quality and outcome measurement. Three studies showed that pharmacists' medication counselling and treatment monitoring can improve adherence to antidepressant medications among those commencing treatment when calculated using an intention-to-treat analysis. Four trials demonstrated that pharmacist conducted medication reviews may reduce the number of potentially inappropriate medications prescribed to those at high risk of medication misadventure. The results of this review provide some evidence that pharmacists can contribute to optimising the use of medications for mental illness in the community setting. However, more well designed studies are needed to assess the impact of pharmacists as members of community mental health teams and as providers of comprehensive medicines information to people with schizophrenia and bipolar disorder
doi:10.1186/1743-8462-2-29
PMCID: PMC1345690  PMID: 16336646

Results 1-8 (8)