Browsing by Author "Roche, Stephen"

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    A Cross Sectional Evaluation of a Shoulder and Elbow Fellowship in a Low to Middle Income Country: Fellows' Perspective
    (2022) Boskovic, Viseslav-Willy; Roche, Stephen
    Background: There is a growing trend towards sub specialization and fellowship training in orthopaedic surgery. Data from the United States has shown that over 90% of orthopaedic residents plan to pursue fellowship training and there is a trend in the orthopaedic job market toward seeking fellowship-trained orthopaedic surgeons. Objectives: This study aimed to elucidate graduate perceptions of how undertaking the shoulder and elbow fellowship offered by the Department of Surgery, University of Cape Town (UCT) impacted their professional and personal development and to identify potential means of improving the quality of the programme. Methods: A descriptive, cross-sectional survey analysis was performed using an online questionnaire posing questions related to various aspects of the training programme. Subjects consisted of nine qualified orthopaedic surgeons who had completed the UCT Shoulder and Elbow fellowship. Survey questions were predetermined through discussion and agreement among the researchers. Results: All emails sent drew responses to the survey. An overall good to excellent level of satisfaction with the various aspects of the training program was reported by the fellowship candidates. Post-fellowship increase in arthroscopic and open surgical skill level, as well as understanding of research, was found to be significant. The majority agreed that the fellowship had adequately prepared them for work in their current setting. The candidates strongly agreed that the fellowship enhanced their abilities, when compared to their peers, in pre-operative decision making, intra-operative decision making, formulating ethical judgements, operative surgical skills and teaching ability. Conclusion: The results confirm the positive impact of the fellowship on post-training levels of confidence across clinical, research, decision-making and educational domains by Fellows. The study highlights the benefits of post-graduate fellowship training with the analysis being broadly applicable to similar training programmes globally. It underscores the importance of continuous evaluation of fellowship programmes.
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    Amputation rate following tibia fractures with associated popliteal artery injuries
    (2017) Roussot, Mark; Maqungo, Sithombo; Roche, Stephen
    Objectives: 1. Determine the amputation rate; and 2. identify risk factors in patients with tibia fractures and associated popliteal artery injuries. Intervention: Amputation or limb salvage. Design: Retrospective case-control study. Setting: Level 1 trauma center. Patients: Thirty popliteal artery injuries with ipsilateral tibial fractures. Outcome measures: Primary and delayed amputation rates were determined. Risk factors tested for significance (Fischer's Exact) included: mechanism of injury, signs of threatened viability, compartment syndrome, fracture pattern, surgical sequence, and time delay from injury or presentation to revascularization. Results: The study group consisted of 22 males and 8 females, with a mean age of 31 years. Motor vehicle accidents and gunshot wounds constituted the mechanism in 17 and 11 patients respectively. Twenty-one were polytrauma victims. Intra/extra16 articular metaphyseal fractures (OTA 41 A-C) were recorded in 19 and diaphyseal (OTA 42 A-C) in 7 patients. Primary amputation was performed in 7 and delayed in 10 patients (overall rate 57%). No individual risk factors were predictive of amputation; however, the "miserable triad" of a proximal tibia fracture (OTA 41) with signs of threatened viability, and delay to revascularization ≥ 6 hours from injury or ≥ 2 hours from presentation was predictive of amputation (p = 0,036 and p = 0,018 respectively). Conclusions: We should aim to intervene within 6 hours following injury or 2 hours following presentation to reduce the risk of amputation. This provides a target for trauma teams even with uncertain time of injury. Level of Evidence: III.
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    An assessment of undergraduate musculoskeletal training at Medical Schools in South Africa
    (2012) Dachs, Robert; Roche, Stephen
    Includes abstract. Includes bibliographical references.
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    Biomechanical assessment of RTSA functional outcomes towards optimising the prosthesis configuration
    (2018) Glenday, Jonathan Daniel; Sivarasu, Sudesh; Roche, Stephen
    Reverse total shoulder arthroplasty (RTSA) alleviates pain and restores function to patients with cuff tear arthropathies or massive rotator cuff tears. The procedure uses a semi-constrained prosthesis to reverse the orientation of the glenohumeral joint, thereby altering the biomechanics of the deltoid and allowing it to restore shoulder function in the presence of an irreparably damaged rotator cuff. However, there are complications that can impact long-term success of RTSA. Adaptations to the design and placement of the prosthesis have been investigated to address these complications and this has led medical device manufacturers to develop divergent implants. This divergence, as well as previous literature regarding RTSA biomechanics, suggest that a configuration that optimises reverse shoulder functional outcomes has yet to be determined and that it can be obtained by combining multiple modifications. A biomechanical assessment framework was established to characterise reverse shoulder function and the effect of modifying prosthesis configuration. It utilised the Newcastle Shoulder Model (NSM) and a custom-made impingement detection algorithm to simulate seven standardised motions that either elevated or rotated the humerus. Four outcome measures (deltoid elongation, deltoid moment arm, joint stability and impingement-free range of motion) were evaluated for each motion. The framework took anatomical variability into consideration by performing the simulations using a subject-specific reverse shoulder cohort. Further, 36 modified configurations of the prosthesis (based on offsets to the placement of glenosphere, humeral tray and greater tuberosity) were evaluated. The effect of each of these modifiable parameters on the outcome measures was characterised as beneficial, detrimental, or negligible, in comparison to a default prosthesis configuration. Seven of the most beneficial parameters were then selected for combination and evaluated using the assessment framework. Due to an antagonistic relationship between the outcome measures, and differing functional requirements of the motions, none of the configurations were able to simultaneously maximise all outcome measures. Rather, the optimised configuration (which inferiorly translated the glenosphere and posteromedially translated the humeral tray) provided balanced, moderate improvements to majority of the outcome measures. Overall, the deltoid did not excessively elongate, and deltoid moment arms, joint stability, and impingement-free range of motion improved by 17.9%, 57.1%, and 32.1%, respectively compared to the default configuration. Subsequently, comparisons between the effect of the default and optimised configurations on muscle fatigue and micromotion at the bone-implant interface were made. Muscle fatigue was assessed by adapting the NSM, and micromotion was assessed through a finite element analysis of a subset of the reverse shoulder cohort. The optimised configuration had a beneficial impact on the time to initiate muscle fatigue by decreasing the force required by the middle deltoid to initially elevate the humerus, and it had no appreciable effect on micromotion. In summary, an optimised RTSA configuration has been presented in this thesis. For a rotator cuff deficient reverse shoulder, the proposed configuration provided balanced, moderate improvements to majority of the functional outcomes. Additionally, the configuration was able to mitigate the effect of muscle fatigue and did not affect micromotion. Future studies should look to experimentally validate these findings, determine their clinical significance, and enhance both the assessment techniques and framework.
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    Design and Development Towards a Novel Prosthesis for Total Shoulder Arthroplasty to Reduce Aseptic Glenoid Loosening
    (2018) Dey, Roopam; Sivarasu, Sudesh; Roche, Stephen
    Total shoulder arthroplasty (TSA) is the most common surgical solution, that helps in restoring the structural and functional integrity of a diseased glenohumeral (GH) joint with intact rotator-cuff. A 300% increase in the usage of TSA has been observed since 2007, along with 2.5% increase in revision rate. Aseptic glenoid loosening accounts for 37% of postsurgical failures in TSA. Eccentric loading of the prosthetic glenoid cup, leading to the “rocking horse” effect, is one of the prevalent causes of aseptic glenoid loosening. Current anatomical total shoulder prosthesis (ATSP) geometry does not consider all the GH morphometric features, for example the elliptical shape of the humeral head. Moreover, the morphometric studies leading to the initial ATSP design did not consider the GH morphology of any sub-Saharan population. Hence, there exists a gap in understanding of the implications of certain morphometric features on the functionality of a post-TSA GH joint. This thesis had two primary aims to address this gap in knowledge. Firstly, to study the GH morphometric variations between cohorts representing native European (Swiss) and native sub-Saharan (South African) populations. Secondly, to develop anatomically inspired ATSP design concepts and test them using biomechanical and finite element (FE) models, insilico, under standardised testing protocols. The morphometric analysis suggested that an average Swiss humeral head radius of curvature was larger (P<0.05) than the average South African humeral head. By comparing the biological head sizes, across both the populations, with the dimensions of the commercially available humeral heads, it can be inferred that suitable humeral prostheses are currently not available for individuals with head sizes >28mm or <19mm. Considering both the populations, the inherent shape of an average humeral head was found to be elliptical. The thickest region of the head was found to lie in the posterior region and not at the geometric center. Hertzian contact theory was applied to calculate the GH stresses produced by symmetric and asymmetric elliptical heads. Higher concentric stresses (P<0.001), within the acceptable limit for polyethylene, were observed to be imparted by the asymmetric heads. Population-specific musculoskeletal models were developed to study the post-TSA kinematic variation. When an identical range of motion (RoM) was performed by these models, population-specific variation in muscle moment arms was observed. The novel glenoid designs were not found to alter the post-surgical kinematics. FE models of the biradial, compartmental and pear-shaped glenoid implant designs were subjected to compressive and shear loading according to the American Society for Testing and Materials (ASTM). Using the bi-radial the glenoid cup, with thickened posterior-superior surface, anatomically relevant force distribution patterns could be replicated. Compartmentalising the glenoid prosthesis into concentric and eccentric regions with the gaps, proved to be highly beneficial. When compared to a commercially available glenoid prosthesis, the compartmental prosthesis was able to contain the GH forces to the concentric region for longer, delaying the eccentric loading and therefore potentially reducing the “rocking horse” effect. In the light of the above observations, two conclusions can be drawn from this thesis. Firstly, it would be beneficial if population-specific ATSP were made available for natives of certain geographic locations. Secondly, glenoid prosthesis designs could be compartmentalised to contain the GH joint forces within the concentric regions of the cup which might aid in the reduction of post-TSA complications.
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    Design Optimization and in-vitro Verification of a Bone-Retentive Device to Repair Comminuted Radial Head Fractures
    (2019) Gasant, Muhammad Saadiq; Sivarasu, Sudesh; Roche, Stephen
    Introduction: Radial head fractures are common, accounting for approximately 30% of all elbow fractures. Mason type III fractures involve comminuted fractures of the radial head, with two or more articular fragments. There is conflict in the literature regarding optimal surgical treatment of these fractures. Current protocol indicates a preference towards bone retention, as this has a minimal impact on the elbow biomechanics. Thus, the preferred surgical open reduction and fixation (ORIF) methods which involve stabilizing the fracture using metal plates and screws. The main drawbacks of this method involve failure of fixation, particularly in more severely comminuted fractures. In these cases, revision surgery is needed. In addition, the metal ware interferes with surrounding tendons and ligaments, leading to discomfort. However, should the fracture be too severe for ORIF repair, the radial head is excised and replaced by a prosthesis. Unfortunately, this affects the biomechanics of the elbow and a loss of motion and strength is likely to result. Thus, there is need for a novel way of treating complex fractures of the radial head. The RadFix™ Fracture Fixation Solution was conceptualized to improve functional healing for these fractures. The concept involved three treatment options which focused on native bone retention and the preservation of radio-capitellar articulation and included a contingency plan in the event of failure of fixation. The main benefit of the device involved the concept of a central stem component and a partial prosthesis, which aimed to replace only the damaged portions of the radial head, whilst preserving the intact native bone. It is hypothesized that this will aid functional healing of the radial head. Aim The aim of the study is to optimize the existing design and experimentally verify the stability of a novel fixation device for comminuted radial head fractures to increase native bone retention. Methodology The existing anatomic prototypes were optimized to include different radial head sizes using Solidworks 3D-modelling software after which prototypes were manufactured from Nylon 12 at the Central University of Technology (CUT). A first pilot test was conducted to evaluate these prototypes - a stem and half-head prosthesis were implanted into a cadaver arm in a procedure which mimicked fracture to the lateral half of the radial head. Radiographic evaluation of the fixation showed stability of the prosthetic components. Recommendations for further development included remodelling the anatomic shape of the prosthetic heads to a generic shape (to allow repair to any quadrant of the radial head) and the development of a drill assist device to aid in the drilling process for stem implantation. The subsequent design modifications were made to the prosthetic head design and a drill assist guide was developed to aid in the relevant surgical processes. These new generic prostheses were 3D-printed from ABS plastic and were evaluated in a second pilot test. Once again, a stem and a half-head prosthetic head were implanted into a cadaver arm after a fracture to the radial head was imitated. Radiographic evaluation of the fixation showed that stability was achieved but that the drill assist device required modifications to its drill guide attachment and stabilizing mechanism. Once the modifications were completed, five more cadaver arms were used to conduct a wider scale study, in which one-third head, half head and full head prostheses were implanted. Each repair was radiographically evaluated before the subsequent repair was performed. Radiographic stabilization involved the evaluation of prosthesis reduction - a measurement of gaps between the prosthetic heads and the adjacent bone (gaps smaller than 2mm were acceptable, gaps bigger than 2mm were not) and an evaluation of screw fixation - optimal screw position involved penetration of cortical bone whilst any protrusion of a screw from the bone was not acceptable. Results Cadaver Arm 1 was used to conduct a half-head prosthetic repair followed by a full-head prosthetic repair. Radiographic analysis of the half-head repair showed that there was correct implant positioning, correct reduction of the prosthesis and correct screw placement. This meant that the repair was classified as successful. The full-head repair was classified as unsuccessful due to a large ulnar-sided overhang and a radial-sided recess, likely caused by movement of the stem during the transition between repairs. Cadaver Arm 2 was used to conduct a one-third head prosthetic repair. Radiographic analysis showed correct implant positioning and correct screw placement, however the repair was classified as unsuccessful due to a 2.04 mm gap between the prosthesis and the adjacent bone on the articular surface of the radial head. Cadaver Arm 3 was used to conduct a one-third head repair, followed by a half-head prosthetic repair and a full-head prosthetic repair. Radiographic analysis classified both the one-third and halfhead repairs as successful. Lastly, radiographic analysis of the full-head prosthetic repair showed that the distal (oblique) screw was too large and protruded from the radial head at both ends, leading to an unsuccessful repair. Cadaver Arm 4 was used to conduct a one-third head repair, followed by a half-head prosthetic repair and a full-head prosthetic repair. Radiographic analysis of the one-third repair saw it classified as successful. The half-head repair was classified as unsuccessful due to a 2.53 mm overhang on the distal-radial edge of the prosthesis. The full-head repair was classified as unsuccessful due to unsuccessful screw placement. Lastly, Cadaver Arm 5 was used to conduct a one-third head prosthetic repair followed by a full-head prosthetic repair. Radiographic analysis of the one-third head repair showed that there was a 2.97 mm gap between the prosthesis and the adjacent bone on the articular surface of the radial head, resulting in an incorrect reduction. This saw the repair classified as unsuccessful. Radiographic analysis of the full-head repair classified it as successful. Conclusion: The aims of the study were successfully completed.
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    Humeral stem loosening following reverse shoulder arthroplasty - systematic review and meta-analysis
    (2017) Grey, Barend Christiaan; Roche, Stephen
    Background: Aseptic stem loosening following reverse shoulder arthroplasty (RSA) is an uncommon complication. The majority of literature on RSA consists of case series with short follow-up periods. It remains unknown which factors contribute to aseptic stem loosening in RSA. Our analysis aimed to compare the incidence of aseptic stem loosening, humeral radiolucent lines (RLL) and revision for stem loosening between: 1) cemented and uncemented stems, and 2) different etiological subgroups Methods: In a systematic review 75 articles were included after assessment of study methodology and a meta-analysis of 1660 cemented and 805 uncemented stems was performed. We compared the incidence of aseptic stem loosening, humeral RLL, and revision for stem loosening between: 1) cemented and uncemented stems from cohorts with short (< 5 years) mean follow-up periods, long (≥ 5 years) mean follow-up periods, and all cohorts combined; and 2) different etiological subgroups. Results: The overall incidence of aseptic stem loosening was 1%. When comparing cemented to uncemented stems, there was no significant difference in the incidence of aseptic stem loosening or of revision for stem loosening in both the short and long term follow-up groups. Humeral RLL were more common with cemented stems (15.9% versus 9.5%, p = 0.002). The highest incidence of aseptic stem loosening occurred in the tumor subgroup (10.81%), followed by RSA as revision for failed arthroplasty (3.66%). No stem loosening was seen in the acute fracture or fracture sequelae groups. Conclusion: Aseptic stem loosening occurred more commonly in cohorts with long follow-up times (2% vs 0.8%, p = 0.01). There was no difference in the incidence of aseptic stem loosening or revision for stem loosening between cemented and uncemented stems. Humeral RLL occurred more frequently when cemented stems were used. Patients treated with RSA following excision of proximal humerus tumors and RSA as revision for failed arthroplasty were at greater risk of aseptic stem loosening.
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    Identifying risk factors contributing to the development of shoulder pain and injury in male, adolescent water polo players
    (2020) Jameson,Yale; Gray, Janine; Roche, Stephen
    Water polo is a fast-growing adolescent sport that consists of swimming, defending and overhead shooting in an aquatic environment. The high demands on the shoulder to complete these tasks are proposed to cause the high injury incidence reported in the sport. The novelty of this research rests in its clinically valuable contribution to understanding shoulder injury aetiology in adolescent water polo players as overhead throwing athletes. The overall research aim of this thesis explores the musculoskeletal profile of a male adolescent water polo players shoulder and the intrinsic factors associated with shoulder injury risk. An overview of the literature (Chapter 2) explores the biomechanics of water polo including swimming and overhead throwing; the musculoskeletal adaptations of overhead throwing in water polo compared to other overhead sports; and the epidemiology of shoulder injury in water polo players relative to other overhead sports. Due to the absence of a consensus-based definition of injury in water polo comparison of existing quality epidemiological studies in the sport was limited. Additionally, although a limited amount of studies have proposed potential risk factors to shoulder injury in water polo players, significant correlations are yet to be found. As with other overhead sports, the water polo shoulder is prone to injury due to the generation of high force during a modified upright swimming posture, repetitive swimming stroke and overhead throwing at high velocities. Male adolescent water polo players were recruited for this study. Chapter 3 describes the adolescent water polo player's shoulder musculoskeletal profile and its association with shoulder injury prevalence throughout a single water polo season. The musculoskeletal variables included pain provocation, range of motion, strength, flexibility and shoulder stability tests which have been used previously in overhead athletes to investigate injury prevention and performance. There were three steps in the data collection process. Firstly, informed consent and assent, demographic, competition, training and injury history, and a shoulder-specific functional questionnaire was acquired from participants. Secondly, a battery of pre-season musculoskeletal tests was performed. The battery of tests included: anthropometry, pain-provocation, glenohumeral and upward scapula range of motion, glenohumeral and scapula muscle strength, glenohumeral flexibility and shoulder stability measurements. Thirdly, at the end of the season participants completed an injury report and training load questionnaire. Participants who experienced shoulder pain, with or without medical management, were categorised into the injury group and those who did not were categorised as uninjured. Chapter 3 documents the adolescent water polo players shoulder musculoskeletal profile, shoulder injury prevalence and the association between these intrinsic risk factors and injury. Specifically, adolescent water polo players present with significant side-to-side asymmetry in the lower trapezius (p = 0.01), upward scapula rotation ROM at 90° glenohumeral elevation (p = 0.03), glenohumeral internal and external rotation ROM (p = 0.01), glenohumeral internal and external strength (p = 0.05 and p = 0.01 respectively) and the pectoralis minor index (p = 0.01). Twenty-four participants (49%) sustained a shoulder injury during the season with the dominant shoulder more commonly affected (54.2%). The most common aggravating factors were identified as throwing (41.7%) and shooting (20.8%). Although significantly lower scores on the pre-season shoulder-specific functional questionnaire (p = 0.01) and significantly greater upward scapula rotation at 90° glenohumeral elevation (p = 0.01) on the dominant shoulder was found in the injured group compared to the uninjured group, no factors were significantly associated with increased injury risk. In conclusion, the findings suggest that male adolescent water polo players are a high-risk population for shoulder injury. It is suggested that improving the players, coaches and parents' health literacy, particularly of the shoulder, and incorporating preventative exercises, targeting modifiable risk factors and side-to-side asymmetry, into pre-season conditioning programmes may reduce the prevalence of shoulder injury in this sporting population. While this research contributes to the epidemiology of shoulder injuries in water polo players, further research is needed to continue to report on injury incidence and associated risk factors, particularly training and workload characteristics in the water polo population.
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    Long term follow up of rotator cuff Magnetic resonance imaging changes in patients who underwent acromioplasty without repair of full thickness supraspinatus tendon tears
    (2015) Chivers, David Andrew; Roche, Stephen
    Aim: To assess the MRI pathoanatomical changes 10 years after unrepaired full thickness supraspinatus tears in a population of patients that had acromioplasty done for symptomatic impingement with a rotator cuff tear.
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    Optimisation of insertion point during latissimus dorsi tendon transfer
    (2018) Thompson, Seth Mkhanyisi; Sivarasu, Sudesh; Roche, Stephen
    Problem and Motivation: Posterior rotator cuff injuries are common (Yamaguchi et al., 2006), (Neri et al., 2009) and often debilitating and irreparable (Sim et al., 2001). Latissimus dorsi (LD) tendon transfers have been shown to be an effective treatment for these massive or irreparable tears (Habermeyer, 2006), (De Casas et al., 2014). This procedure can have unpredictable outcomes (Ling et al., 2009). This is partially caused by discrepancies in the suggested insertion site for the LD tendon during transfers. The current literature is composed of in-silico studies which ignore the practicalities of the human body (Magermans et al., 2004), in-vivo studies which use subjective pain scores, and small scale cadaver trials. For these reasons, a study is needed that uses the power of in-silico modeling in a way that is verified using in-vitro testing on cadavers. Aims and Objectives: The aim of this study is to determine the effects of varying the insertion point of the LD tendon on the humeral head to treat posterior rotator cuff tears in terms of the effects on strength, primarily in rotation and in flexion over a range of motion. The objectives are to use an in-silico model to define the effects of various insertion points and validate this model using a cadaver trial before presenting the final findings. Methods: In-silico Model The Upper Extremity Model (Holzbaur et al., 2005) was used to simulate tendon transfers. The moment arms in flexion and rotation were measured and recorded at angles of 0° and 90° of forward ix elevation. The moment arms at each point were then projected onto humeral maps to display the results. Cadaver Trial Four fresh frozen cadaver torsos (eight shoulders) were mounted into a specifically designed rig. The LD was transferred to 7 points illustrative of the humeral head. The strain generated by the humerus in rotation on the clamps was measured at 0° and 90° of forward flexion for each point. These were then compared. Results In-silico Model The in-silico moment arm maps were generated and analysed. The optimal point for external rotation at 0° of flexion was the lesser tuberosity. Moment arms to produce external rotation were found over the entire greater tuberosity. Flexion was only generated on the posterior edge of the greater tuberosity. At 90° of flexion, little to no rotation generating moment arms were found in the lesser tuberosity and the anterior ridge of the greater tuberosity. Rotation generating moment arms were not significantly different between the posterior edge and the face of the greater tuberosity. No areas generated flexion moment arms. Cadaver Trial At 0° of flexion, the lesser tuberosity (point 1) generated the most flexion, with the greater tuberosity (points 2-7) also generating external rotation, but at reduced levels. At 90° of flexion, the lesser tuberosity and the anterior ridges of the greater tuberosty (points 1-3) generated no significant rotation. The posterior ridge and face of the greater tuberosity generated similar amounts of flexion, greater than points 1-3 Conclusions: The in-silico model was validated in rotation by the cadaver trials and this validation was extended to flexion. For maximum rotation strength at 0° of flexion and no flexion strength, the x lesser tuberosity is the optimal point. For maximum rotation strength and no flexion throughout the motion of flexion, the middle of the face of the greater tuberosity is the optimal area. For maximum rotation throughout the motion of flexion, points 4 and 5 (the posterior edge of the greater tuberosity) represent the optimal area for insertion. This area represents the optimal compromise in terms of range of motion and strength.
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    Perspectives on the management of humerus fractures due to gunshot trauma: an inter- and intra-observer agreement and reliability study
    (2017) Engelmann Esmee Wilhelmina, Maria; Roche, Stephen
    Background: Upper extremity fractures due to gunshot trauma are frequently treated at the level I trauma unit of Groote Schuur Hospital. There is no gold standard for the classification and management of such complex upper extremity fractures available to date and only few retrospective case studies on gunshots of the humerus were available. Interobserver agreement studies reported low levels of intra- and inter-rater reliability (IRR) for the classification of proximal humerus fractures using Neer and AO/OTA classification. The complexity of the fractures, the inconsistency of classification systems outcomes and the wide variety of treatment modalities demand evidence-based medicine. Aim: The primary aim was to assess the inter- and intraobserver agreement between surgeons in the classification and treatment of humerus fractures caused by gunshot trauma in a gunshot violence endemic area. The secondary aims were to analyse interobserver agreement with respect to debridement, removal of the bullet, the use of external fixators in patients with gunshot humerus fractures and to evaluate the effect of clinical scenarios surrounding surgical decision-making. Methods: This is an agreement study performed with a fixed panel of 32 observers who answered a set of 14 questions regarding classification and treatment by rating multiple X-ray views of a fixed set of 22 cases. The panel included junior registrars, senior registrars, orthopaedic trauma specialist and upper extremity specialists. Cases were extracted from the electronic Trauma Health Record between June 2014 and July 2016. Observers reviewed 16 midshaft and 6 proximal humerus fractures cases at 2 sessions with a 2-week interval. Descriptive statistics, Cohen's and Fleiss Kappa and rate of agreement were used to analyse data. Kappa was interpreted according to Landis and Koch guidelines. Results: There was slight yet significant overall interobserver agreement on the AO classification (k=0.20); the highest interobserver agreement ('fair') was achieved by the upper extremity specialists and senior registrars (k=0.28, 0.27). Overall interobserver reliability of agreement on preferred treatment was similar to classification agreement (k=0.18). Only trauma specialists achieved fair agreement with a significant difference compared to senior registrars and upper extremity specialists (k=0.26, 95%CI 0.21-0.32). Overall intraobserver reliability was fair for classification and moderate for treatment (k=0.39, 0.42). There was fair overall agreement on debridement of the wound (k=0.26) and removal of the bullet (k=0.31) and close to poor agreement for the use of temporary external fixators (k=0.03). Vascular injury was rated as influential factor on decision-making by the majority of observers (53.7%), followed by bilateral (37.1%) and other fractures (26.8%). Conclusions: This is the first intra- and interobserver agreement study that evaluated classification and treatment of gunshot humerus fractures in the light of a broader spectrum of patient- and fracture-related factors. Consistent with previous studies, there was low interobserver agreement for the classification and treatment of proximal humerus fractures, thereby contributing to the field of knowledge with specific evidence regarding gunshot trauma. Future research should further assess predictive factors in surgical decision-making and analyse global preferences in order to develop evidence-based classification and treatment guidelines for the management of patients with humerus fractures.
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    Screening for risk factors associated with non-specific shoulder pain in mail adolescent water polo players
    (2022) Tully, Paula Lauren; Gray, Janine; Roche, Stephen
    Water polo is a fast-growing aquatic sport that combines swimming, overhead throwing, defending and grappling. There are great demands placed on the shoulder to complete these activities and shoulder pain is the most common musculoskeletal complaint among water polo players. The aetiology of shoulder injury amongst water polo players is not well understood and there is limited research investigating the adolescent water polo population. The aim of this thesis was to identify the incidence of shoulder pain over a 12-week period and determine the contribution of intrinsic and extrinsic risk factors in the development of non-specific shoulder pain in male adolescent water polo players. An overview of the literature (Chapter 2) includes the biomechanics of throwing and swimming; the epidemiology of shoulder injury in water polo players; and the current understanding of risk factors for shoulder injuries and the screening thereof. Risk factors for shoulder injury in swimming have been identified as weakness of the glenohumeral (GH) internal rotator muscles, altered GH range of motion (ROM), GH joint laxity, high training loads, pectoralis minor tightness and altered scapular control. In other overhead throwing sports the risk factors include altered GH ROM and glenohumeral internal rotation deficit (GIRD), shoulder muscles weakness, altered scapular control, pitching velocity, age, height, early sport specialisation, throwing with arm fatigue and a heavy workload. A few studies have proposed potential risk factors for shoulder injury in water polo players but significant associations have not been found and little is known about the musculoskeletal risk factors. However, water polo players are susceptible to shoulder pain due to repetitive overheard throwing at high velocities, the repetitive swimming stroke as well as the unique upright swimming style. Chapter 3 presents the research findings. This study recruited male adolescent water polo players between the ages of 14-18 who were not currently experiencing shoulder pain. Participants underwent a pre-season screening session followed by a period of in-season monitoring for 12 weeks. The pre-season screening included a demographic questionnaire, the Kerlan-Jobe Orthopaedic Clinic (KJOC) Shoulder and Elbow Score, anthropometry and maturation testing as well as shoulder specific tests to assess for shoulder pain, shoulder range of movement, shoulder strength, shoulder flexibility and shoulder stability. The experience of shoulder pain and participant training load was then monitored using a selfreport questionnaire. Participants were categorised into two groups (shoulder pain and no shoulder pain) based on their report of pain, irrespective of a medical diagnosis. The shoulder musculoskeletal profile of the water polo players, the incidence of shoulder pain and the player's training loads are presented (Chapter 3). Shoulder pain was reported by 52% of the participants at least once during the 12-week monitoring period, with pain in both the shoulders simultaneously (56%) or the dominant shoulder only (42%) commonly reported. The onset of activity was reported most commonly as swimming (55%) followed by throwing (38%). Participants with shoulder pain had mean KJOC scores lower than 90, and were significantly older (p = 0.003), heavier (p = 0.050) and the predicted years from peak height velocity (PHV) was greater (p = 0.029) than those without shoulder pain. An interaction was found between pain/no pain and dominant/non-dominant side for isometric internal rotation (IR) strength (p = 0.049), with stronger IR muscles in the dominant shoulder of the group with shoulder pain. Significant shoulder asymmetries were identified, however there was no association between the variables and the development of shoulder pain. In general, the participants presented with greater external rotation (ER) ROM and total range of motion (TROM) in the dominant shoulder, greater isometric strength of the IR muscles, serratus anterior (SA), upper trapezius (UT) and lower trapezius (LT) muscles, as well as reduced pectoralis minor length (PML) and a lower pectoralis minor index (PMI) on the dominant side. There was a significant difference between pain/no pain and the hours of water polo matches in weeks 3-4, with a higher work load in the shoulder pain group compared to the no shoulder pain group (p = 0.008). Participants with shoulder pain reported significantly lower selfperceived strength scores for passing, shooting, swimming, defending and gym training compared to those without shoulder pain. In conclusion (Chapter 4), there is a high incidence of shoulder pain among male adolescent water polo players, which is in line with the findings from other studies. The players who developed shoulder pain were significantly older, heavier and had a higher predicated age from PHV than those without shoulder pain. This may suggest a trend towards cumulative overloading and it's likely that the key players of water polo teams may be at greater risk of developing shoulder pain. Greater IR strength was observed in the dominant shoulder of those players with shoulder pain, indicating that the more powerful throwers are developing shoulder pain. The relative weakness of the ER muscles suggests that players are unable to effectively control through deceleration of the throwing motion. This cohort presented with significant asymmetries in GH ROM, rotator and scapular muscle strength, and shoulder flexibility; however, these variables were not associated with shoulder pain. Asymmetries have been associated with pain in previous studies, so these variables should not be ruled out as risk factors for injury. Participants of this study reported the activity most commonly associated with shoulder pain was swimming, not throwing, and bilateral shoulder pain was commonly reported. This would suggest that the musculoskeletal profile of the non-dominant side is indeed important and that the implications of significant asymmetries should be evaluated further in a larger population. KJOC scores seem to be in line with those for baseball players and a score below 90 may indicate an at-risk athlete. An increase in competitive match play was associated with an increase in shoulder pain. This should inform coaches to structure training and recovery appropriately during tournaments or weeks with a high load of matches. This study provides a basis for further investigation into shoulder injuries among adolescent water polo players, as well as the prevention and management thereof. It is advised that coaches and medical staff endeavour to identify at-risk players. Rehabilitation programs should be implemented to target the modifiable risk factors identified in this study, in order to reduce the incidence and prevalence of shoulder pain.