Modified American Shoulder Research Articles

Assessment of the Arthroscopic Double-Row Restoration Technique's Reliability and Operational Results for Shoulder Cuff Reconstruction

Objective: This study aims at evaluating the effectiveness of shoulder cuff restoration by arthroscopic surgery in dual row repair mode and shows 30 months of practical results, an ASES-based scoring system was developed. Methods: This study was conduced at mayo hospital Lahore in orthopedics department and the duration of this study was from October 2021 to march 2023. 23 patients who had significant rotator cuff tears repaired arthroscopically in a double-row fashion are included in this cross-sectional research. The operating surgeon performed a clinical assessment on patients who had been admitted for surgery in the outpatient setting both before and after surgery, as well as during follow-up visits at six weeks, three months, six months, and one year. The last examination took place on average 30 months after surgery. Using a scoring system based on a modified ASES score, the function of the patient was evaluated both preoperatively and postoperatively, and the results were compared. Based on the Modified American Shoulder and Elbow Society (ASES) score, a patient-rated questionnaire was utilized to assess shoulder and elbow function. Three parts make up the questionnaire, the first of which included questions regarding pain and had six components with a total weight of 30 points. The existence of pain, its location, and if the patients had discomfort at night were all questions that were posed to the patients. A visual analog pain scale from 0 to 10 was used to assess the degree of the patient’s pain as well as their usage of drugs. The second phase, which included 10 components and a weighted average of 50 points, examined candidates' capacity to carry out everyday tasks. On a scale of 0 to 5, patients were asked to assess their level of competence to accomplish tasks while accounting for any challenges they may have encountered. The shoulder instability was evaluated in the last portion using a visual analog scale with a range of 0 to 10. Patients were divided into four groups based on the grading system: Excellent result (score >75), Good outcome (score 50-75), Fair outcome (score 25-50), and Poor outcome (score < 25) Results: At the time of the last follow-up, there was a substantial improvement in the mean operational result scores depending on the Patient Self-Assessed Questionnaire (p-value < 0.01). By using magnetic resonance imaging to evaluate repair integrity 12 months after surgery, it was discovered that 16 patients had type-I repairs, 2 patients had type-II repairs, and only 1 patient had type-III repairs. For enormous tears, the study's retear rate was 5%. Comparing the type-III repaired shoulders to the other kinds of repaired shoulders, the type-III repaired shoulders showed substantially worse functional outcomes in terms of total scores and strength (p-value < 0.01). Practical Implication: In the practical implication of this study we discovered that the arthroscopic double-row restoration approach is a successful treatment for repairing large rotator cuff injuries with a low chance of re-tear and a big increase in activity levels. Conclusions: In this research, we discovered that the arthroscopic double-row restoration approach is a successful treatment for repairing large rotator cuff injuries with a low chance of re-tear and a big increase in activity levels. Keywords: double-row technique, restoration, shoulder cuff, arthroscopically, resonance imaging

Outcome reporting in elbow arthritis: a systematic review

BackgroundDegenerative disease of the elbow is a unique dilemma due to the different pathologies of arthritis. Outcome measures are used by physicians to provide a quantitative measure of patient progression. While there has been a substantial number of case series and studies on treatment of elbow arthritis, the heterogeneity of outcome measures reported in the literature makes it difficult for surgeons to compare results between treatment options. There is no consensus on outcome measure reporting as no measure has been found to be superior to others in the literature. The purpose of this study was to examine the elbow arthritis literature for the most commonly reported outcomes measures after treatment of elbow arthritis and recommend a guideline for reporting in future studies in an attempt to standardize the literature. MethodsA query was performed of all studies written in English literature from 2010 to 2020 using PubMed and Scopus databases utilizing PRISMA guidelines. Articles that met inclusion criteria were reviewed for reporting of patient-reported outcome, range of motion, return to work/sport, complication rate, satisfaction rate, revision rate, number of patients, minimum and mean follow-up time, type of treatment, journal, journal impact factor, level of evidence, and number of citations as of April 2020. ResultsEighty three studies met inclusion criteria with a mean number of 39 patients per study with a mean age of 53 years. Mayo elbow performance score (MEPS) was the most commonly reported outcome measure (81%) followed by quick Disabilities of Arm Shoulder Hand (qDASH; 23%), DASH (16%), and modified American Shoulder and Elbow Surgeons score (m-ASES; 16%). The average number of outcome measures per study was 1.6. Studies that reported MEPS had higher number of citations compared to studies that did not (14.21 vs. 7.62 citations; P = .031). Studies that reported MEPS were found to publish more in journals with higher impact factors (ie, impact factor of ≥2) (88% vs. 71%; P = .051). DiscussionOutcome measures are inconsistently reported in elbow arthritis literature. Studies that report MEPS were found to be cited more. We recommend reporting of at least two outcome measures in future studies as well as range of motion for easier cross-study analysis. Additional measures such as return to work/sport, satisfaction rate, complication rate, and revision rate should be reported to provide more complete understanding of post-treatment outcome. ConclusionIncreased standardization of outcome measure reporting may improve future patients’ outcomes following treatment of elbow arthritis. Levels of EvidenceLevel IV

Chronic complex persistent elbow instability: a consecutive and prospective case series and review of recent literature

Chronic complex persistent elbow instability (CCPEI) is a condition that even expert elbow surgeons find challenging to treat. The results of the few studies that have dealt with the treatment of this condition are conflicting. We describe the surgical results of a consecutive prospective series of patients with CCPEI and provide a review of the recent literature. We assessed 21 patients with previous failed surgical or conservative treatment, with a terrible-triad injury in 13,Monteggia-like lesion in 6,humeral shear fracture-dislocation in 1, andradial head fracture-dislocation in 1. Overall, 21 open débridement procedures, 15 ulnar nerve transpositions, 6 ulnar in situ neurolysis procedures, 7 total elbow arthroplasties, 8 radial head arthroplasties, 1 radial head resection with humeroradial anconeus interpositional arthroplasty, 4 coronoid graft reconstructions, 14 ligament retensioning procedures, 3 ulnar nonunion treatments, and 2 ulnar osteotomies were performed. Two dynamic external fixators were applied. The Mayo Elbow Performance Score, quick Disabilities of the Arm, Shoulder and Hand score, and modified American Shoulder and Elbow Surgeons score were used preoperatively and postoperatively. The mean follow-up period was 29.4 months. A significant improvement was found between preoperative and postoperative clinical scores and range-of-motion values. The reintervention and major complication rates were 19% and 23%, respectively. Arthritic evolution was observed in 71% of the cases. CCPEI is a challenging condition with an uncertain prognosis. The variability in patients' pathoanatomicconditions requires customized surgical treatment aimed at elbow stabilizerreconstruction when the ulnohumeral joint is preserved or aimed at joint replacement in case of severe articular degeneration. The time interval between the initial trauma and index surgical procedure significantly affects the feasibility of reconstructive procedures.

Postoperative results of Ogawa type IIB meta-acromion fracture fixation with a 90° twisted reconstruction plate

Acromion fractures are rare and difficult to treat. There is no consensus on type of fixation. Due to the rarity of the injury, it is difficult to compare different techniques of osteosynthesis. The aim of this study was to present the long-term results of an alternative method of plating Ogawa type IIB meta-acromion fractures and to review the literature. Retrospective study. We present a case series of 11 consecutive patients with displaced Ogawa type IIB meta-acromion fracture, treated with open reduction internal fixation using a 3.5-mm contoured pelvic reconstruction plate with a 90° twist. Patients' mean age was 53.3years (23-80years) and the mean follow-up was 48.3months (15months-9years). The outcomes related to pain and shoulder function were evaluated by Modified American Shoulder and Elbow Surgeons Score (ASES) and SF-36 score. All patients were asked about their satisfaction level. Nine out of eleven patients were included in this study. Eight of them obtained union and all were satisfied with the final outcome. The mean ASES and SF-36 score were 69.75 (42.4-98.14) and 61.37 (41.64-94.99), respectively, with poor scores to be largely associated with comorbidities and concomitant injuries. The use of 3.5-mm reconstruction plate with a 90° twist for open reduction internal fixation (ORIF) of meta-acromion fractures presents satisfactory results and could be technically a more stable biomechanical construct in comparison to the existing surgical techniques.

Post-traumatic proximal radioulnar synostosis: results of surgical treatment and review of the literature

Post-traumatic proximal radioulnar synostosis is a very rare and disabling condition whose surgical treatment has traditionally been viewed with pessimism. The results of the few case series in the literature are conflicting. Our aims were (1) to describe the clinical results of a case series treated surgically by a single elbow surgeon and (2) to review the literature. Twelve patients were evaluated. Preoperative radiographs and computed tomography scans were performed. According to the Viola and Hastings classification, there was 1 case of type IC synostosis; 3, type IIA; 2, type IIIA; and 8, type IIIB. Two patients had a double synostosis. The synostosis was excised in 10 cases; in addition, radial head excision, radial head arthroplasty, and proximal radial diaphyseal resection were performed in 1, 3, and 2 cases, respectively. The Mayo Elbow Performance Score, modified American Shoulder and Elbow Surgeons score, and QuickDASH (short version of Disabilities of the Arm, Shoulder and Hand questionnaire) score were used for the preoperative and postoperative evaluation. The nonparametric Wilcoxon signed rank test was used for the statistical analysis. The mean follow-up period was 20.5 months. The final mean extension-flexion and pronation-supination arcs were 116° and 123°, respectively. Significant improvements were found in the Mayo Elbow Performance Score (P = .005), modified American Shoulder and Elbow Surgeons score (P = .012), and QuickDASH score (P = .002), with mean values of 24, 28, and 17, respectively. One synostosis recurrence and one late disassembly of the radial head arthroplasty were observed. Post-traumatic proximal radioulnar synostosis surgery is effective, but careful preoperative planning based on the pathoanatomiccharacteristics of each type of synostosis and associated lesions is mandatory. Synostosis excision is performed in most cases, whereas additional surgical procedures should be considered in selected cases.

Arthroscopic capsular release and subacromial decompression for treatment of refractory posttraumatic frozen shoulder

Introduction Bony or soft tissue trauma to the shoulder can lead to a degree of posttraumatic stiffness or pain. The stiffness is due to a combination of capsular contracture and extracapsular adhesions. The initial management is usually conservative. When it fails, treatment that is more aggressive should be done.Objectives To evaluate the effectiveness of arthroscopic capsular release and subacromial decompression for treatment of refractory posttraumatic frozen shoulder.Patients and methods The study included 22 patients, with mean age of 43.5±12.2 years. A total of 12 patients had fracture proximal humeral end, three patients had mid-shaft fracture, and seven patients had shoulder soft tissue injury. Patients underwent arthroscopic circumferential capsular and subacromial release under general anesthesia, without violation of the subscapularis tendon or the labrumResults Collective visual analog pain scores (at rest, with normal activities, with strenuous activities) showed progressive highly statistically significant decrease throughout the follow-up period from 18.8±2.6 preoperatively to 4±1.6 6 months postoperatively (P=0.0001). The mean modified American shoulder and elbow surgeon scores improved from 45.5 preoperatively to 59.3 postoperatively. Forward flexion improved from 93° preoperatively to 140° postoperatively. Adduction-external rotation improved from 26.9 preoperatively to 42.2° postoperatively. Abduction external rotation improved from 24.8° preoperatively to 47° postoperatively.Conclusion Arthroscopic capsular release and subacromial decompression is an effective method in the treatment of refractory posttraumatic frozen shoulder, alleviating pain and restoring a functional range of motion to the shoulder.

Comparative study of radiological and clinical outcomes by using single and double interlocking distal screws for humerusshaft fractures

Background: The aim of this study was to make a comparative analysis of radiological and clinical outcomes of using either one or two interlocking distal screws on ahumerus intramedullary nail for the internal fixation of humeral shaft fractures. Methods: From April 2010 to April 2015, 30 patients were enrolled with humeral shaft fractures who were operated on using intra medullary humerus nails. The patients were divided into 2 groups according to how many interlocking distal screws were used to lock the humerus nail: in group 1, a single interlocking distal screw was used in 16 patients; and in group 2, double interlocking distal screws, in 14 patients. We compared the degree of recovery of the displaced fracture fragments between the two groups. Shoulder function of patients wereassessed by modified American Shoulder and Elbow Surgeons (ASES) score. Results: We found that 15 (93.7%) fractures achieved union in group 1, and 13 (92.8%) of fractures, in group 2. There was no meaningful difference in the time to bone union and the recovery of displaced fracture fragments between the two groups. At the final follow-up, we found that the scores for shoulder joint modified ASES was 76.2 for group 1 and 79. 1 for group 2. Conclusions: This study shows that if locked appropriately, even a single screw on a humerusnail can provide satisfactory radiological union and improved clinical outcome after intramedullary nailing of humeral shaft fractures.

Treatment of terrible triad injuries at a mean follow-up of nine years.

To evaluate the sustainability of the early clinical and radiological outcomes of terrible triad injuries at long-term follow-up. Twelve consecutive patients who underwent fixation of terrible triad injuries with minimum of seven years of follow-up. Functional and radiological outcomes at one year and final follow-up were compared. We assessed Mayo Elbow Performance Score, Quick-Disability of the Arm Shoulder and Hand, and modified-American Shoulder and Elbow Surgeons Scores. Radiological evaluation included Broberg and Morrey classification and Hastings classification for heterotopic ossification. The mean age of patients was 55 years, with a median follow-up of 9.3 years. At final evaluation, mean flexion, extension, supination, and pronation were 145°, 6°, 82°, and 80°, respectively; mean Mayo Elbow Performance Score, modified-American Shoulder and Elbow Surgeons Scores, and Quick-Disability of the Arm Shoulder and Hand scores were, respectively, 97, 92, and 4.9 points. There was no statistical difference between early and final follow-up range of motion, Mayo Elbow Performance Score, and Quick-Disability of the Arm Shoulder and Hand. However, radiological changes were observed in 66% of the patients at final follow-up. Two patients underwent reoperation, with final satisfactory results. Our results suggested that using a standardized protocol, satisfactory clinical outcomes at early follow-up could be maintained over time. However, early complications and osteoarthritic changes at long-term follow-up can be expected. Therapeutic IV Cases series.

ONE-STAGE SURGICAL TREATMENT FOR CONCOMITANT ROTATOR CUFF TEARS WITH SHOULDER STIFFNESS HAS COMPARABLE RESULTS WITH ISOLATED ROTATOR CUFF TEARS: A SYSTEMATIC REVIEW

Background Addressing preoperative shoulder stiffness before rotator cuff repair (RCR) is advocated, but the effectiveness of this approach is debatable. We hypothesized that 1-stage treatment of concomitant rotator cuff tear (RCT) with shoulder stiffness has comparable results with isolated RCT. Methods Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, the databases including MEDLINE, Embase, Cochrane Library, and Scopus were searched using the keywords of “shoulder stiffness” OR “adhesive capsulitis” OR “frozen shoulder” AND “rotator cuff.” Studies that met all the criteria compared the 2 arms of isolated RCT vs. RCT with concomitant shoulder stiffness, received no physical therapy before surgery, and reported data of preoperative and postoperative range of motion (ROM) and functional outcomes after surgery. Results Four level III studies met the inclusion criteria. The non-stiff group (isolated RCT) included 460 patients who underwent RCR; the stiff group (RCT with concomitant shoulder stiffness) included 111 patients who underwent RCR and manipulation under anesthesia with or without capsular release. There were significant differences in preoperative ROM between stiff and non-stiff groups. At final follow-up, there were no statistical differences in all ROM between the 2 groups. There was no significant difference in comparing preoperative and postoperative outcome scores including visual analog scale for pain, Constant, modified American Shoulder and Elbow Surgeons, and University of California–Los Angeles scores. Conclusions Concomitant surgical treatment of nonmassive RCT and moderate shoulder stiffness in 1 stage may have comparable results to the surgical treatment of RCT in patients without preoperative stiffness. Therefore, a physical therapy regimen before surgical intervention may not be necessary.

Results of primary repair of distal triceps tendon ruptures in a general population: a multicentre study.

The aim of the study was to analyze the results of primary tendon reinsertion in acute and chronic distal triceps tendon ruptures (DTTRs) in the general population. A total of 28 patients were operated on for primary DTTR reinsertions, including 21 male patients and seven female patients with a mean age of 45 years (14 to 76). Of these patients, 23 sustained an acute DTTR and five had a chronic injury. One patient had a non-simultaneous bilateral DTTR. Seven patients had DTTR-associated ipsilateral fracture or dislocation. Comorbidities were present in four patients. Surgical treatment included transosseous and suture-anchors reinsertion in 22 and seven DTTRs, respectively. The clinical evaluation was performed using Mayo Elbow Performance Score (MEPS), the modified American Shoulder and Elbow Surgeons Score (m-ASES), the Quick Disabilities of the Arm, Shoulder and Hand score (QuickDASH), and the Medical Research Council (MRC) Scale. A total of 27 patients (28 DTTRs) were available for review at a mean of 47.5 months (12 to 204). The mean MEPS, QuickDASH, and m-ASES scores were 94 (60 to 100), 10 (0 to 52), and 94 (58 to 100), respectively. Satisfactory results were observed in 26 cases (93%). Muscle strength was 5/5 and 4/5 in 18 and ten DTTRs, respectively. One patient with chronic renal failure experienced a traumatic rerupture of distal triceps. One patient (1 DTTR) experienced mild elbow stiffness. Primary repair of acute and chronic DTTRs in a general population yields satisfactory results in the majority of patients with a low rerupture rate. Cite this article: Bone Joint J 2018;100-B:610-16.

Two-stage revision of infected shoulder arthroplasty using prosthesis of antibiotic-loaded acrylic cement: minimum three-year follow-up.

This study aimed to evaluate the clinical outcomes and persistent infection rate of two-stage revision of infected shoulder arthroplasty. We enrolled 12 patients who developed an infection after undergoing shoulder arthroplasty between January 2009 and January 2014. They underwent a two-stage revision with PROSTALAC implantation and shoulder re-implantation in the first- and second-stage surgery, respectively. The mean follow-up period was 40.88months (range, 36-52months). After the second-stage re-implantation, clinical scores, erythrocyte sedimentation rate, as well as C-reactive protein level were evaluated, and the presence of re-infection and complications were analyzed. Infection was improved in all the cases after PROSTALAC insertion. The mean range of motion of forward elevation, external rotation, and internal rotation at the final follow-up after the second-stage re-implantation were 81.67°, 40.42°, and 16.67° (vertebral level), respectively. The mean visual analog scale score improved from 7.08 points before surgery to 2.33 points after surgery. The Modified American Shoulder and Elbow Surgeons score improved from 32.25 before surgery to 64.17 after surgery (P < 0.05). The Constant shoulder score also improved from 30.92 before surgery to 66.08 after surgery (P < 0.05). Infection had not recurred until the final follow-up. However, dislocation and separation of components were found in two patients who needed a structural allograft because of segmental bone defects. Using PROSTALAC in two-stage revision arthroplasty is effective for infection control and produced good clinical outcomes after second-stage shoulder re-implantation. However, cases involving segmental bone defects require additional precautions in maintaining the appropriate tension and height to prevent complications.

Interposition Dermal Matrix Xenografts: A Successful Alternative to Traditional Treatment of Massive Rotator Cuff Tears

Background: Management of massive rotator cuff tears in shoulders without glenohumeral arthritis remains problematic for surgeons. Repairs of massive rotator cuff tears have failure rates of 20% to 94% at 1 to 2 years postoperatively as demonstrated with arthrography, ultrasound, and magnetic resonance imaging. Additionally, inconsistent outcomes have been reported with debridement alone of massive rotator cuff tears, and limitations have been seen with other current methods of operative intervention, including arthroplasty and tendon transfers. Hypothesis: The use of interposition porcine acellular dermal matrix xenograft in patients with massive rotator cuff tears will result in improved subjective outcomes, postoperative pain, function, range of motion, and strength. Study Design: Case series; Level of evidence, 4. Methods: Sixty patients (61 shoulders) were prospectively observed for a mean of 50.3 months (range, 24-63 months) after repair of massive rotator cuff tears with porcine acellular dermal matrix xenograft as an interposition graft. Subjective outcome data were obtained with visual analog scale for pain score (0-10, 0 = no pain) and Modified American Shoulder and Elbow Surgeons (MASES) score. Active range of motion in flexion, external rotation, and internal rotation were recorded. Strength in the supraspinatus and infraspinatus muscles was assessed manually on a 10-point scale and by handheld dynamometer. Ultrasound was used to assess the integrity of the repair during latest follow-up. Results: Mean visual analog scale pain score decreased from 4.0 preoperatively to 1.0 postoperatively (P < .001). Mean active forward flexion improved from 140.7° to 160.4° (P < .001), external rotation at 0° of abduction from 55.6° to 70.1° (P = .001), and internal rotation at 90° of abduction from 52.0° to 76.2° (P < .001). Supraspinatus manual strength increased from 7.7 to 8.8 (P < .001) and infraspinatus manual strength from 7.7 to 9.3 (P < .001). Mean dynamometric strength in forward flexion was 77.7 N in nonoperative shoulders (shoulder that did not undergo surgery) and 67.8 N (P < .001) in operative shoulders (shoulder that underwent rotator cuff repair with interposition porcine dermal matrix xenograft). Mean dynamometric strength in external rotation was 54.5 N in nonoperative shoulders and 50.1 N in operative shoulders (P = .04). Average postoperative MASES score was 87.8. Musculoskeletal ultrasound showed that 91.8% (56 of 61) of repairs were fully intact; 3.3% (2 of 61), partially intact; and 4.9% (3 of 61), not intact. Conclusion: Patients who underwent repair of massive rotator cuff tears with interposition porcine acellular dermal matrix graft have good subjective function as assessed by the MASES score. Patients have significant improvement in pain, range of motion, and manual muscle strength. Postoperative ultrasound demonstrated that the repair was completely intact in 91.8% of patients, a vast improvement compared with results previously reported for primary repairs of massive rotator cuff tears.

Arthroscopic extended rotator interval release for treating refractory adhesive capsulitis.

To present the clinical results of arthroscopic extended rotator interval release with a stretching program for treating refractory adhesive capsulitis. Case series; level of evidence, 4. Arthroscopy-assisted extended rotator interval tissue release including anterior capsular was performed in 26 patients with refractory adhesive capsulitis. All rotator interval tissues, except the medial sling of the biceps, were excised and the excursion of the subscapularis tendon was restored and freely mobilized. The preoperative mean passive forward flexion was 101°, whereas external rotation at the side was 10°. Patients were followed for a minimum of 2 years and their visual analog scale for pain, muscle power, range of motion, Constant score, modified American Shoulder and Elbow Surgeons Shoulder Evaluation Form score, and modified University of California at Los Angeles score were recorded. Visual pain scale and the aforementioned clinical scores improved postoperatively. The patients exhibited a significant postoperative difference in forward flexion, external rotation, and internal rotation. Postoperative mean passive forward flexion was 172°, whereas external rotation at the side was 58°. There was no difference in the muscle power postoperatively including abduction, internal rotation, and external rotation. Our study revealed satisfactory subjective and objective clinical results after a 2-year follow-up. Arthroscopy-assisted extended rotator interval release with a stretching program could be an alternative treatment for refractory adhesive capsulitis.

Ultrasonography Technique in the Evaluation of Massive Rotator Cuff Tears Repaired using a Porcine Acellular Dermal Matrix Xenograft through a Mini-open Approach

ABSTRACT Purpose Massive rotator cuff tears (RCT) have been notoriously difficult to treat, but recently the novel use of interposition biologic scaffold grafts in repair of massive RCT has had promising results. However, there are no published guidelines regarding postoperative imaging evaluation of massive RCT repaired with xenograft. The purpose of this study was to (1) describe how to use ultrasound to evaluate a porcine acellular dermal matrix xenograft after repair of massive RCT and (2) evaluate healing of a xenograft using high-resolution ultrasound. Materials and methods A total of 37 consecutive patients underwent ultrasound evaluation of a repaired RCT at a mean of 33 months follow-up (23–48). Postoperative ultrasound findings were correlated to preoperative and postoperative functional (visual analog scale, Short-form 12, and Modified American shoulder and elbow score) and clinical outcomes (active range of motion and strength). Results Of the 37 patients, ultrasound showed that 33 (89.2%) of the cuff repairs were fully intact, 3 (8.1%) had partial thickness tears, and 1 (2.7%) had a full thickness tear. In this study, the integrity of the repair based on high-resolution ultrasound correlates with functional and clinical outcomes. Conclusion Ultrasound is an effective method to evaluate xenograft interposition grafts used in rotator cuff repair. Neumann JA, Rickert KD, Toth AP, Boggess BR. Ultrasonography Technique in the Evaluation of Massive Rotator Cuff Tears Repaired using a Porcine Acellular Dermal Matrix Xenograft through a Mini-open Approach. The Duke Orthop J 2016;6(1):26-34.

Terrible triad of the elbow: is it still a troublesome injury?

Terrible triad injury (TTI), one of the main patterns of complex elbow instability, is difficult to treat and yields conflicting surgical results. We analyzed prospectively a series of patient affected by TTI and treated according to the current diagnostic and surgical protocols to investigate whether their application allow to obtain more predictable outcomes. We analyzed 26 patients with a mean age of 52 years. Preoperative X-rays and CT were performed; all patients were operated by the same elbow surgeon and underwent the same surgical and rehabilitation treatment. Final functional outcome was assessed by the Mayo Elbow Performance Score (MEPS), Quick-Disability of the Arm Shoulder and Hand-score (Q-DASH) and the modified-American Shoulder and Elbow Surgeons score (m-Ases). A radiographic evaluation was also performed. Mean follow-up was 31 months. At final evaluation, mean flexion, extension, supination and pronation were 137°, 10°, 77° and 79°, respectively; mean MEPS, m-ASES and Q-DASH scores were respectively 96, 91 and 8 points. Complications observed after first surgery were: elbow stiffness in 5 cases, mild posterolateral instability in 3 cases, chronic subluxation in 1 case. Radiographic evaluation showed secondary arthritis in 9 cases, symptomatic HO in 3 cases and late hardware displacement in 2 cases. Six out of 26 patient underwent reoperation with final satisfactory results. The current diagnostic and therapeutic protocols allow obtaining satisfactory clinical outcomes in majority of cases but a high number of major and minor unpredictable complications persist yet. In this series, low compliance, obesity, and extensive soft elbow tissue damage caused by high-energy trauma represented negative prognostic factors unrelated to surgery. On the other hand, the strict application of current algorithms by an expert elbow surgeon appears to improve clinical results by reducing the influence of other avoidable negative prognostic factors well known in current literature, such as the incomplete recognition of injuries, delayed treatment, inadequate treatment of bony and ligamentous injuries, prolonged immobilization and, last but not least, the surgeon's inexperience. Level IV, Case series, Treatment study.

Predictive Value Of Preseason Screening In Collegiate Baseball Pitchers

Objectives:High level baseball pitchers are prone to shoulder and elbow injuries, resulting in significant morbidity and missed time from sport. This is the first study to use both subjective and objective preseason evaluations of baseball pitchers to predict injuries that occur in-season. We hypothesize that athletes reporting unfavorable scores on subjective questionnaires, and athletes falling outside the established pre-season normative values for objective data are more likely to develop injuries in season.Methods:Over three collegiate baseball seasons from 2011 through 2013, a cohort of collegiate Division I baseball pitchers underwent both objective and subjective evaluation prior to the start of the fall collegiate season. Preseason analysis included range of motion (ROM) in 5 planes, upper extremity manual muscle testing (MMT), Functional Movement Screen (FMS) assessment, a Kerlan-Jobe Orthopaedic Clinic (KJOC) Overhead Athlete Shoulder and Elbow score, an Upper Extremity Patient History (UEPH) questionnaire, and a Modified American Shoulder Elbow Score (MASES) questionnaire. This cohort was monitored over the course of the subsequent season for the development of injury and missed game time. A descriptive analysis for each questionnaire and all objective variables was performed. Univariate and multivariate regression models were used to explore potential risk factors for upper extremity (UE) injuries. Scatter plots, Spearman's correlation coefficients, and corresponding p-values were used to examine the relationship between subjective responses, objective physical parameters, and injury days missed.Results:Forty-two athletes participated in the study over three consecutive collegiate baseball seasons. Our preseason normative values for ROM, MMT, and the KJOC questionnaire are shown in Tables 1, 2, and 3. The mean KJOC score for our cohort was 86.93/100 (SD 12.49), and the mean MASES score was 88.4/100 (SD 21.7). The mean FMS score in our cohort was 15/21 (SD 3). Injury data for our cohort are shown in Table 4. After three full seasons, a lower KJOC score significantly correlated with injury days missed (Spearman's rho = 0.63, P-value 0.0122). Through the first two seasons, pitchers with a 1% higher UE rating on the UEPH questionnaire had 9.5% lower odds of developing injury during the season (OR 0.9149, 95% CI 0.8525-0.9819, P Value 0.014). Pitchers reporting every 1 unit higher of subjective instability had 61.27% higher odds of developing an UE injury (OR 0.6127, 95% CI 1.1044-2.3549, P value 0.013). However, by the end of the third season, and after adjusting for the use of pain medication, these variables failed to reach significance in our multiple regression analysis. Dominant shoulder TAM, rotator cuff strength, and glenohumeral internal rotation deficit (GIRD) were not predictive of injury in our cohort; although having over 5 degrees of difference in TAM vs the non-dominant shoulder approached significance (P-value 0.0598).Conclusion:This is the first study to demonstrate predictive value of subjective questionnaires. The KJOC Overhead Athlete Shoulder and Elbow Score can be used as part of the standardized preseason athlete evaluation to target pitchers at risk for developing injuries in-season. Objective parameters - notably TAM, GIRD, and rotator cuff strength - were not predictive of injuries in our cohort, which contradicts prior reports. To our knowledge, normative FMS data has not yet been established in baseball pitchers.

Comparing the Use of Single and Double Interlocking Distal Screws on a Polarus Intramedullary Nail for Humeral Shaft Fractures

Background: Our aim was to make a comparative analysis of radiological and clinical outcomes of using either one or two interlocking distal screws on a Polarus intramedullary nail for the internal fixation of humeral shaft fractures. Methods: From January 2008 to March 2014, we enrolled 26 patients with humeral shaft fractures who were operated on using intramedullary nails. The patients were divided into 2 groups according to how many interlocking distal screws were used to lock the Polarus nail: in group 1, a single interlocking distal screw was used in 12 patients; and in group 2, double interlocking distal screws, in 14 patients. We compared the degree of recovery of the displaced fracture fragments between the two groups. To compare the nonunion and shoulder function, we assessed each patient’s modified American Shoulder and Elbow Surgerns (ASES) score. Results: We found that 10 of 12 fractures achieved union in group 1, and 13 of 14 fractures, in group 2. We did not find a meaningful difference in the time to bone union between the two groups. The percentage of recovery of displaced fracture fragments until union was 66.9% for group 1 and 59.41% for group 2. At the final follow-up, we found that the scores for shoulder joint modified ASES was 78.7 for group 1 and 80.7 for group 2. Conclusions: Our results show that if locked appropriately, even a single screw on a Polarus nail can provide satisfactory radiological union and improved clinical outcome after intramedullary nailing of humeral shaft fractures.

Biceps Tenotomy Versus Tenodesis in Active Patients Younger Than 55 Years: Is There a Difference in Strength and Outcomes?

Background:Proximal biceps pathology is a significant factor in shoulder pain. Surgical treatment options include biceps tenotomy and subpectoral biceps tenodesis. Tenotomy is a simple procedure, but it may produce visible deformity, subjective cramping, or loss of supination strength. Tenodesis is a comparatively technical procedure involving a longer recovery, but it has been hypothesized to achieve better outcomes in younger active patients (<55 years).Hypothesis:This study investigated the outcomes of younger patients who underwent either a biceps tenotomy or tenodesis as part of treatment for shoulder pain. The hypothesis was that, apart from cosmetic deformity, there will be no difference in outcome between the 2 treatment options.Study Design:Cohort study; Level of evidence, 3.Methods:Isometric strength and endurance testing of operative and nonoperative shoulders for forearm supination (FS) and elbow flexion (EF) were tested utilizing an isometric dynamometer. Objective physical assessment was also performed. Subjective outcomes using the modified American Shoulder and Elbow Surgeons score (ASES); Disability of the Arm, Shoulder, and Hand (DASH); visual analog scale (VAS); and perceived biceps symptoms were collected.Results:A total of 42 patients (22 tenotomy, 20 tenodesis) with an average follow-up of 3.3 years were studied. The average age at follow-up was 49.9 years. Thirty-five percent (7/20) of tenotomy patients exhibited a “Popeye” deformity, compared with 18.2% (4/22) of tenodesis patients. Strength prior to fatiguing exercise was similar between tenodesis and tenotomy for FS (6.9 vs 7.3 lbs; P < .05), EF in neutral (35.4 vs 35.4 lbs), and EF in supination (33.8 vs 34.2 lbs). Strength was not significantly different between groups for isometric strength and endurance measures. Subjective functional outcome measured by the DASH, ASES, and VAS scores were similar between groups. Frequency of complaints of cramping was higher in the tenotomy group (4/20 vs 1/22), and complaints of pain were higher in the tenodesis group (11/22 vs 5/20).Conclusion:Despite increased demands and activity placed on biceps function in a younger population, this study showed no differences in functional and subjective outcome measurements. The choice between biceps tenotomy and tenodesis for pathology of the proximal biceps tendon can continue to be based on surgeon and patient preference.

Discovery Elbow System: 2- to 5-Year Results in Distal Humerus Fractures and Posttraumatic Conditions: A Prospective Study on 24 Patients

To prospectively evaluate preliminary results of the Discovery Elbow System (DES) used for acute distal humerus fractures and posttraumatic conditions. We analyzed 24 patients (9 men and 15 women), with a mean age of 69 years (range, 45-89 y). Ten had comminuted distal humerus fractures (group I), and 14 had severe post-traumatic arthritis, chronic instability, or nonunion (group II). Clinical and radiographic evaluations were performed. The preoperative (group II) and postoperative (both groups) evaluations were assessed with the Mayo Elbow Performance Score and Mayo Elbow Performance Index, the Quick Disabilities of the Arm, Shoulder, and Hand score, and the modified American Shoulder and Elbow Surgeons score. Patient satisfaction was evaluated on a 4-point scale. Mean follow-up was 41 months (range, 29-63 mo). At the last evaluation, average flexion, extension, pronation, and supination were 136°, 17°, 80°, and 83°, respectively. The average Mayo Elbow Performance Score, Quick Disabilities of the Arm, Shoulder, and Hand score, and the modified American Shoulder and Elbow Surgeons score were 96, 20, and 84, respectively, and without significant intergroup differences. According to the Mayo Elbow Performance Index, there were 20 excellent, 3 good, and 1 fair result. Twenty patients were very satisfied or satisfied with the outcome. A significant increase in the functional scores was observed in group II compared with preoperative results. Radiological evaluation showed 1 patient with progressive radiolucency and 1 with a nonprogressive radiolucency at the final follow-up. No mechanical failures were observed. Two transient ulnar neuropathies, 1 wound infection, and 1 epicondyle fracture were observed. The DES yielded promising 2- to 5-year results in the treatment of acute fractures and posttraumatic conditions regarding pain relief, functional improvement, and patient satisfaction, achieving excellent results in most cases. The DES may represent an effective linked-implant option for total elbow replacement in such patients. However, long-term studies are needed. Therapeutic IV.

Factors affecting choice of open surgical techniques in elbow stiffness

We analyzed the clinical outcomes of stiff elbow open treatment to assess factors affecting the choice of surgical procedures in a consecutive series of patients followed up prospectively. Forty-one patients, mean aged 48years, were evaluated. Elbow stiffness was caused by post-traumatic osteoarthritis in 32 patients, primary osteoarthritis in seven and rheumatoid arthritis in two. Stiffness was classified as mixed and extrinsic in 28 and 13 cases, respectively. Seventeen ulno-humeral arthroplasties (UHA), seven UHA with radiocapitellar replacement, six UHA with radial head replacement, ten total elbow replacement and one UHA with anconeus interposition were performed. Mayo Elbow Performance Score (MEPS), modified-American Shoulder and Elbow Surgeons (m-ASES) and Q-DASH scores were used for the pre- and post-operative evaluation. Mean follow-up was 25months. The average increase in MEPS and m-ASES was 45 and 41, respectively. The average decrease in Q-DASH and the average increase in m-ASES pain were 43 and 21, respectively. The mean increase in flection, extension, pronation and supination was 29°, 25°, 18° and 17°, respectively. All the differences were statistically significant. Strictly customized open surgery of elbow stiffness, by taking into account the clinical value of each patient's pathoanatomical conditions, yields satisfactory functional results in majority of cases. In particular, the degree and site of elbow cartilage wear proved to be the factors affecting the choice of treatment most. Treatment should be aimed at removing the causes of pain and at recovering range of motion.