Patient-Rated Elbow Evaluation Research Articles

LUCL reconstruction of the elbow: clinical midterm results based on the underlying pathogenesis

PurposeTraumatic and atraumatic insufficiency of the lateral ulnar collateral ligament (LUCL) can cause posterolateral rotatory instability (PLRI) of the elbow. The influence of the underlying pathogenesis on functional outcomes remains unknown so far. The objective of this study was to determine the impact of the initial pathogenesis of PLRI on clinical outcomes after LUCL reconstruction using an ipsilateral triceps tendon autograft.MethodsThirty-six patients were reviewed in this retrospective study. Depending on the pathogenesis patients were assigned to either group EPI (atraumatic, secondary LUCL insufficiency due to chronic epicondylopathia) or group TRAUMA (traumatic LUCL lesion). Range-of-motion (ROM) and posterolateral joint stability were evaluated preoperatively and at follow-up survey. For clinical assessment, the Mayo elbow performance (MEPS) score was used. Patient-reported outcomes (PROs) consisting of visual analogue scale (VAS) for pain, disability of arm, shoulder and hand (DASH) score, patient-rated elbow evaluation (PREE) score and subjective elbow evaluation (SEV) as well as complications were analyzed.ResultsThirty-one patients (group EPI, n = 17; group TRAUMA, n = 14), 13 men and 18 women with a mean age of 42.9 ± 11.0 were available for follow-up evaluation (57.7 ± 17.5 months). In 93.5%, posterolateral elbow stability was restored (n = 2 with re-instability, both group TRAUMA). No differences were seen between groups in relation to ROM. Even though group EPI (98.9 ± 3.7 points) showed better results than group TRAUMA (91.1 ± 12.6 points) (p = 0.034) according to MEPS, no differences were found for evaluated PROs (group A: VAS 1 ± 1.8, PREE 9.3 ± 15.7, DASH 7.7 ± 11.9, SEV 92.9 ± 8.3 vs. group B: VAS 1.9 ± 3.2, PREE 22.4 ± 26.1, DASH 16.0 ± 19.4, SEV 87.9 ± 15.4. 12.9% of patients required revision surgery.ConclusionLUCL reconstruction using a triceps tendon autograft for the treatment of PLRI provides good to excellent clinical outcomes regardless of the underlying pathogenesis (traumatic vs. atraumatic). However, in the present case series, posterolateral re-instability tends to be higher for traumatic PLRI and patient-reported outcomes showed inferior results.Level of evidenceTherapeutic study, LEVEL III.

The Efficacy of Tele-Rehabilitation Program for Improving Upper Limb Function among Adults Following Elbow Fractures: A Pilot Study

Background: Active mobilization post-elbow fractures reduces the incidence of complications. Occupational therapists use tele-rehabilitation, incorporating technology into their practices. There is a lack of evidence-based trials regarding the integration of tele-rehabilitation during treatment. We therefore aimed to compare tele-rehabilitation treatment outcomes with conventional rehabilitation in improving the upper limb function post-elbow fractures. Methods: Eighteen participants post-elbow surgery due to fracture were divided into two groups according to age and fracture type. The groups received one month of treatment: the tele-rehabilitation group (N = 9, median age 33.0 ± 27.9 years, range 18.5–61.0) received 1–2 tele-rehabilitation treatments per week via a biofeedback system of elbow motion (the ArmTutor and 3D Tutor systems, MediTouch Ltd., Netanya, Israel) and 1–2 treatments in an outpatient clinic, and the control group (N = 9, median age 60.0 ± 37.0 years, range 20.5–73.0) received 3–4 treatments per week in the clinic. Both groups were instructed to self-practice at home. Four evaluations were performed: before and after the intervention, and 3 months and 1 year from surgery. The outcome measures included the Jebsen–Taylor hand function test; the disabilities of the arm, shoulder, and hand questionnaire; the patient-rated elbow evaluation; satisfaction; passive and active range of motion (ROM); and strength measurements. Results: Findings demonstrated a significant improvement in the ROM and in functional assessments in both groups. No statistically significant differences were found between the groups. The subjects in the tele-rehabilitation group reported a higher level of satisfaction and needed less help from a family member during practice. Conclusions: Tele-rehabilitation programs could be incorporated in the framework of treatment following elbow fractures. Tele-rehabilitation is a cost-effective treatment, suitable for patients with accessibility difficulties or who have difficulty arriving at the clinic.

Hidden instability in posttraumatic stiff elbows.

Hidden instability could be one of the reasons for reoccurring stiffness after arthrolysis in posttraumatic elbows. Associated instability in stiff posttraumatic elbows is clinically hard to detect. Surgical treatment for instability and stiffness in the same surgical setting is challenging and has not been evaluated as of yet. The primary hypothesis assumes (1) the existence of a posttraumatic "stiff and unstable elbow" and (2) that coexisting instability can be detected by arthroscopic instability testing. The secondary objective was to report the midterm results after arthrolysis and ligament stabilization in the stiff and unstable elbow. From 2005 to 2015, 55 patients received arthroscopic arthrolysis of the elbow due to posttraumatic elbow stiffness at our institution. The arthroscopic instability was categorized into three grades with a switching stick: grade I (= stable), grade II (mild instability) and grade III (grossly instable). In cases of persisting instability (grade II-III), a ligament stabilization procedure was performed and all patients were followed up clinically at a minimum of 12months. Besides ROM and clinical joint stability, PROs (patient reported outcomes) were assessed with the PREE-score (patient-rated elbow evaluation) and the Oxford-Elbow-score (OES). Furthermore, the MEPS (Mayo-elbow-performance-score) was assessed. Out of 55 cases presenting for arthrolysis, coexisting elbow instability was detected during arthroscopic instability testing in 22 cases (40%). All 22 patients received additional ligament stabilization. At final follow-up 62.7 ± 35.7months postoperatively, 20 patients (12 men; 8 women) with a mean age of 42 ± 16.8 were available. PREE, OES and MEPS were 19.8 ± 25.3, 37.5 ± 9.8 and 80 ± 14.5, respectively. ROM improved significantly from 95° ± 29° to 110° ± 24° postoperatively (p = 0.045). Five patients required revision arthrolysis within the follow-up period (20%). One patient demonstrated persisting instability (5%). Intraoperative instability diagnostics during arthroscopic arthrolysis helps detect persisting posttraumatic instability and may provide a solid indication for a concurrent ligament stabilization procedure. This study is the first to present the postoperative results after arthrolysis with stabilization of the posttraumatic, stiff and unstable elbow. However, the results are heterogenic with 25% requiring revision arthrolysis. Therefore, the stiff but unstable elbow remains a complex clinical presentation in need of further investigations. IV.

Results of Linked Convertible Total Elbow Arthroplasty for the Management of Distal Humeral Fractures in the Elderly

Total elbow arthroplasty (TEA) is increasingly used for the management of comminuted distal humeral fractures in elderly patients. There are limited data on the outcome of modern elbow arthroplasty designs in larger patient cohorts. The aim of the current study was to review the outcomes and complications using a cemented convertible TEA system in a linked configuration in patients with distal humeral fractures. Patients with distal humeral fractures treated with TEA and a minimum of 2 years' follow-up were reviewed. Demographic information, patient-reported outcome, functional and radiographic outcome assessments, and complications were reported. Forty patients met inclusion criteria; 35 were female. Median follow-up was 4 years (range, 2-13 years). Average age of patients at the index procedure was 79 ± 9 years. All implants were linked. Range of motion was: extension 16° ± 13°, flexion 127° ± 14°, supination 79° ± 11°, and pronation 73° ± 20°. Patient-reported outcome scores were: Patient-Rated Elbow Evaluation 37 ± 35, Quick-Disabilities of the Arm, Shoulder, and Hand 31 ± 31, and Mayo Elbow Performance Index 90 ± 18. Seven patients had heterotopic ossification. Lucent lines were noted predominantly in humeral implant zone V. No lucent lines were noted around the ulnar component in any radiographic zone. Complications occurred in 9 patients (22%) and 2 revisions were performed: one for infection and one for a late periprosthetic fracture. Total elbow arthroplasty for fracture in elderly patients provides pain relief, functional range of motion, and good patient-reported outcome scores. No implant-related complications of this convertible implant system were encountered, but longer-term follow-up is needed. Therapeutic IV.

Distal Biceps Tendon Ruptures: Acute Repair Versus Chronic Reconstruction Using the “Anatomic Length Method” and Concomitant Bicipital Aponeurosis Repair: A Group-matched Comparative Retrospective Study

Chronic disruption of the distal biceps tendon is a challenging problem and can lead to considerable disability. We conducted a group-matched retrospective study comparing clinical outcomes of chronic distal biceps reconstruction using our previously described “Anatomic Length Method” and those with an acute distal rupture and primary repair. Forty-six patients were included into the analysis; 23 underwent acute distal biceps repair, and 23 underwent chronic distal biceps reconstruction. Demographic and surgical data were reviewed retrospectively. Patients were evaluated and clinical outcome measures were obtained at least 1 year after surgical treatment. There were no significant differences in Patient-Rated Elbow Evaluation scores (6.0 vs. 4.4, respectively; P=0.53) and biceps shape contour satisfaction (19/19 vs. 6/7, respectively; P=0.093). No significant difference emerged in complication rates. This study suggests that chronic reconstruction of the distal biceps tendon using the “Anatomic Length Method” is a safe technique that produces similar clinical results to acute distal biceps primary repair.

Reproducibility and reliability of performance indicators to evaluate the therapeutic effectiveness of biofeedback therapy after elbow surgery: An observational case series.

Electromyographic biofeedback (EMG-BF) therapy provides information on the state of contraction of the targeted muscles and relaxation of their antagonists, which can facilitate early active range of motion (RoM) after elbow surgery. Our aim in this study was to calculate the minimum detectable change (MDC) during EMG-BF therapy, initiated in the early postoperative period after elbow surgery.This study is an observational case series. EMG-BF of muscle contraction and relaxation was provided during active elbow flexion and extension exercises. Patients completed 3 sets of 10 trials each of flexion and extension over 4 weeks. The total range of flexion-extension motion and scores on the Japanese Society for Surgery of the Hand version of the disability of the arm, shoulder, and hand questionnaire and the Japanese version of the Patient-Rated Elbow Evaluation were obtained at baseline and weekly during the 4-week intervention period. A prediction formula was developed from the time-series data obtained during the intervention period, using the least-squares method. The estimated value was calculated by removing the slope from the prediction formula and adding the initial scores to residuals between the measured scores and predicted scores individually. Systematic error, MDC at the 95th percentile cutoff (MDC95), repeatability of the measures, and the change from the baseline to each time-point of intervention were assessed.The MDC95 was obtained for all 3 outcome measures and the range of values was as follows: RoM, 8.3° to 22.5°; Japanese version of the Patient-Rated Elbow Evaluation score, 17.6 to 30.6 points; and disability of the arm, shoulder, and hand questionnaire subscale: disability and symptoms score, 14.2 to 22.9 points.The efficacy of EMG-BF after elbow surgery was reflected in earlier initiation of elbow RoM after surgery and improvement in patient-reported upper limb function scores. The calculated MDC95 cut-offs could be used as reference values to assess the therapeutic effects of EMG-BF in individuals.

Mid-term outcomes of surgical management of complex, isolated radial head fractures: a multicentre collaboration.

The available literature discussing optimal surgical management of Mason II and III radial head (RH) fractures without concomitant bone or ligamentous injuries is limited. We aim to help determine the appropriate management of these functionally significant injuries. We present our retrospective cohort study of outcomes of surgically managed isolated, displaced RH fractures SETTING: Study from three trauma centres. Adults who underwent surgical treatment for isolated displaced RH fractures. RH open reduction internal fixation (ORIF), replacement or excision MAIN OUTCOME MEASUREMENTS: Elbow range of motion (ROM), pain and function using Oxford Elbow Score (OES), Mayo Elbow Performance Score (MEPS), Patient-Rated Elbow Evaluation (PREE) and QuickDASH (QD). Of 46 patients included (mean age 47 years and mean follow-up 48 months), 12 type II fractures were treated with ORIF and 34 type III injuries had ORIF (16), replacement (12) or resection (6). ROM was comparable in all groups, with mean arcs of flexion-extension of 131° and pronation-supination of 147°. Mean visual analogue score for pain was 1.3 in those treated with ORIF compared to 1.9 with arthroplasty and 2.5 with excision. Mean functional scores were 41, 92, 14 and 14 for OES, MEPS, PREE and QD, respectively. Complication rates were 39% for ORIF, 33% for arthroplasty and 33% for resection. Overall re-operation rate was 13%. Functional outcome is similar in all groups of surgically treated patients with isolated, displaced RH fractures. Complication rates are higher than that reported previously in the literature but with low re-operation rates. IV.

The Patient-Rated Elbow Evaluation and the American Shoulder and Elbow Surgeons—Elbow form capture aspects of functioning that are important to patients with elbow injuries

Study DesignThis is a cross-sectional study. IntroductionThe Patient-Rated Elbow Evaluation (PREE) and the self-report section of the American Shoulder Elbow Surgeons–elbow form (pASES-e) are two important elbow-specific self-report measures used in routine clinical practice. Purpose of the StudyTo use the International Classification of Functioning Disability and Health (ICF) to link aspects of functioning that are reported using the Patient-Specific Functional Scale by a cohort of patients with elbow disorders and compare it to the content of the PREE and the pASES-e. MethodsOne hundred patients with a variety of elbow disorders (mean age and SD 53.88 (14.51); M: F 48: 52) were recruited from the Roth-McFarlane Hand and Upper Limb Centre. They self-reported important aspects of functioning using the Patient-Specific Functional Scale. These concerns were linked to the ICF using formal linking procedures. These ICF categories were compared to the categories related to the PREE and the pASES-e. Linking was carried out by two independent raters, and agreement was calculated using percentage agreement. ResultsA total of 423 self-reported functional activities were linked to 25 second-level ICF categories from the activity and participation domain. Commonly reported activities were D640 doing housework (52%); D540 dressing (47%); and D475 driving (35%). PREE had better coverage of the patient concerns (71%) than pASES-e (50%). D475–driving (35%) and D440–fine hand use (24%) were the 2 major categories that were not captured by the questionnaires. Agreement between the raters was 90.5%. DiscussionThis study established that the PREE and the pASES-e were able to capture aspects of functioning important to patients and that align with the ICF, with this happening to a greater extent on the PREE than the pASES-e. Because all patients reported concerns from the activity and participation section (‘d’ categories) of the ICF, this validated that these PROMs measure this conceptual domain. ConclusionThe PREE provided more comprehensive coverage of patients' functional concerns than the pASES-e.

Strategy for the treatment of lateral epicondylitis of the elbow using denervation surgery

BackgroundA number of treatments for lateral epicondylitis of the elbow have been described. We have developed a strategy for the treatment of this condition.MethodsWe diagnosed lateral epicondylitis of the elbow in 86 patients. Conservative treatment resulted in resolution in 71 patients. Surgery was required in the remaining 15 patients. If the posterior branch of the posterior cutaneous nerve of the forearm showed a positive response to local anesthesia (block test), we performed denervation surgery on the posterior branch of the posterior cutaneous nerve of the forearm. Patients were asked to rate the degree of pain and sensory disturbance using a visual analog scale; the 11-item version of the Disabilities of the Arm, Shoulder and Hand measure; and the Patient-Rated Elbow Evaluation.ResultsA positive response to the block test was seen in 10 elbows (67%). After denervation surgery, pain relief was seen in 9 of 10 elbows (90%). The mean follow-up period was 30.4 months. At final follow-up, the average scores on the visual analog scale, 11-item version of the Disabilities of the Arm, Shoulder and Hand, and Patient-Rated Elbow Evaluation were 4.3 mm, 10.45 points, and 5.9 points, respectively. In the early period after denervation surgery, sensory disturbance was observed in 9 cases (90%).ConclusionOur strategy of denervation surgery for lateral epicondylitis of the elbow was effective for pain relief among patients showing a positive response to the block test.

Distal Humerus Fractures Managed With Elbow Hemiarthroplasty.

BackgroundDistal humerus fractures not amenable to open reduction internal fixation (ORIF) present a unique dilemma, especially for patients that weight bear through assistive devices. The one accepted operative treatment for irreparable distal humerus fractures is total elbow arthroplasty (TEA). However, TEA commonly requires lifetime weight lifting restrictions and has limited long term results. Elbow hemiarthroplasty (EHA) represents an alternative treatment modality. This study reviews patients treated with EHA permitted to weight bear postoperatively.MethodsTwelve patients underwent EHA for comminuted distal humerus fractures deemed non-reconstructable by ORIF. Patient survey data was collected retrospectively. All patients were allowed to weight bear as tolerated through the operative extremity. Outcome measures included Patient rated elbow evaluation (PREE), Mayo elbow performance score (MEPS), and whether revision surgery was required.ResultsThe average MEPS score was 76.1 indicating fair outcomes and the average PREE score was 41. One patient required revision. Average follow up was 44.1 months. Three patients required an assistive device prior to injury.DiscussionEHA serves as a viable option for non-reconstructable distal humerus fractures. EHA does not require a weight lifting restriction, which is a benefit over TEA. Overall, patients reported preserved functional capabilities but did report moderate pain. EHA demonstrated durability, although one patient required revision.ConclusionWith growing interest in use of EHA, further studies are required to evaluate EHA as a superior treatment for patients with nonreconstructable traumatic distal humerus fractures; however, this study does support use in elderly patients with intermediate follow up.

Open reduction and internal fixation for radial head fractures: A prospective observational study

Objective: To evaluate the effect of open reduction and internal fixation on radial head fracture and assess the post-operative function. Methods: This prospective observational study was conducted from June 2016 to July 2017 at Liaquat National Hospital and Medical College, Karachi. Altogether, 28 patients with radial head and neck fractures were enrolled in our study. These patients were admitted to the hospital and their fractures were fixed with open reduction and internal fixation. Baseline information of the patients was collected, and patient-rated elbow evaluation scores were calculated. Results: Out of the 28 patients, 21 were male and 7 were female. Besides, 16 fractures were on the right side and 12 were on the left side and 17 involving the dominant hands. In addition, 8 patients had Mason type II fracture and 20 had Mason type III fracture. The mean age of patients was (31.0 ± 8.0) years, and the mean follow-up is (1.2 ± 0.5) years. The mean average patient-rated elbow evaluation scores were (27.64 ± 1.60) at 1-year follow-up. Conclusions: The majority of the patients who had radial head fractures and treated by open reduction and internal fixation have attained an excellent range of motion postoperatively.

Management of rheumatoid arthritis of the elbow with a convertible total elbow arthroplasty

Total elbow arthroplasty (TEA) is commonly performed in patients with rheumatoid arthritis (RA). The purpose of this study was to compare outcomes and complications of unlinked and linked TEA using a convertible system in patients with RA. All patients with RA who underwent TEA at a single center with a minimum of 2 years' follow-up were reviewed. Demographic information, patient-reported outcome scores, functional outcome assessments, and radiographic parameters were evaluated at most recent follow-up. We evaluated 82 patients (27 with unlinked TEA and 55 with linked TEA) with RA. The mean age at surgery was 61 ± 10 years, with a mean follow-up period of 6 ± 4 years. Demographic characteristics were similar between groups, with the exception of longer follow-up in the unlinked group (8 years vs. 5 years, P = .001). No differences in range of motion were noted. Elbow strength was similar other than pronation strength (74% ± 8% for unlinked vs. 100% ± 8% for linked, P = .03). The mean Mayo Elbow Performance Index was 83 ± 16; Patient Rated Elbow Evaluation score, 15 ± 18; and QuickDASH (short version of the Disabilities of the Arm, Shoulder and Hand questionnaire) score, 34 ± 20. No differences in the rates of reoperation (17% vs. 24%, P = .4), complications (32% vs. 31%, P = .4), or revisions (13% vs. 17%, P = .3) were found between unlinked and linked devices. Four patients with instability, all with unlinked designs, underwent revision to a linked design. Four patients, all with linked designs, underwent revision for aseptic loosening of smooth short-stem ulnar components. TEA using a convertible implant design provides good patient-reported outcomes at mid-term follow-up in patients with RA. Our study was unable to detect a difference in the use of either unlinked or linked implant designs; further large comparison trials are needed.

Can preoperative imaging predict the outcomes after arthroscopic release for elbow arthritis?

IntroductionThe primary symptoms of elbow osteoarthritis are the progressive development of stiffness along with pain at the end range of motion due to osteophyte impingement. Surgical treatment involves resecting these “bone stops”. In the literature, these osteophytic lesions are more common than cartilage lesions, which suggests they may occur beforehand. The aim of our study was to confirm osteophytes are more common than cartilage lesions, and also to establish a link between these lesions and the functional outcomes. MethodsThis was a prospective multicenter (8 hospitals) study conducted in the context of a symposium of the Francophone Arthroscopy Society (SFA). Eighty-seven patients with elbow osteoarthritis treated by arthroscopic release were included. The clinical outcomes (range of motion in flexion, extension and pronation-supination; strength; pain at rest and during activity; satisfaction; Andrews and Carson score; QuickDASH, Patient-Rated Elbow Evaluation (PREE), Mayo Elbow Performance Score (MEPS), Self-Evaluation Elbow (SEE) were determined before the procedure and at the 6-month follow-up visit. A standard radiographic assessment was done before the surgery and at the last follow-up visit. A CT arthrogram was done before the procedure. The presence of joint narrowing, osteophytes, filling of fossa along with secondary osteochondroma was evaluated in terms of their location, severity, size and/or number. The presence of radial head subluxation was recorded. The Bröberg & Morrey and Rettig & Hastings classification systems were applied. All the postoperative clinical data along with their change (difference between preoperative and postoperative values) were compared to the imaging findings. ResultsOsteophytes were found in 95% of our patients. They were located at the olecranon in 85% of cases and at the coronoid process in 81%. Filled fossae found in 94% of cases. The olecranon, coronoid and radial fossa were filled in 83%, 80% and 60% of elbows, respectively. On the initial X-rays, joint narrowing was found in 68% of elbows. CT arthrogram identified narrowing in 70% of cases. Narrowing was present in the humeroradial joint in 60% of cases and in the humeroulnar joint in 23% of cases. The presence of joint narrowing on CT arthrogram was a negative prognostic factor for pain during activity (p<0.05) along with the Quick DASH (p<0.01) and PREE (p<0.05). Involvement of the humeroradial joint impacted pain at rest (p<0.01). Narrowing of the humeroulnar joint was associated with worse outcomes in terms of pain at rest (p<0.05) and during activity (p<0.05), QuickDASH (p<0.005), MEPS (p<0.05), PREE (p<0.05) and the SEE (p<0.05). The presence of loose bodies before the procedure was associated with better outcomes in terms of pain at rest (p<0.05), QuickDASH (p<0.001), MEPS (p<0.001), Andrews & Carson score (p<0.05) and PREE (p<0.005). The osteoarthritis stage in the Bröberg & Morrey or the Rettig & Hastings classification systems did not impact the various clinical parameters or functional outcome scores. Discussion/ConclusionIn the imaging work-up, signs of impingement (osteophytes and filling of fossa) are more common than signs of joint narrowing. The presence of humeroulnar and/or humeroradial impingement when there are no cartilage lesions visible may correspond to a pre-arthritic stage. The outcomes of arthroscopic release are better in elbows with isolated impingement than in those with cartilage lesions, especially at the humeroulnar joint. Excision of secondary osteochondromas is also an excellent surgical indication. Current classification systems cannot be used to determine the prognosis before arthroscopic release of elbow osteoarthritis cases. Level of evidenceIII, Prospective multicenter observational cohort study

Arthroscopic debridement for osteoarthritis of the elbow: Results and analysis of predictive factors

IntroductionOsteoarthritis is the second most frequent cause of elbow stiffness, after trauma sequelae. Surgical treatment mainly consists of debridement. The main aim of the present study was to assess the efficacy of arthroscopic treatment of osteoarthritis of the elbow on Andrews-Carson score. Secondary objectives comprised assessment of the impact of associated procedures and of epidemiological factors on functional results. MethodA prospective multicenter study involving 8 centers, in a symposium held by the French Society of Arthroscopy (SFA), included patients treated by arthroscopy for primary or secondary osteoarthritis of the elbow between January 2017 and March 2018, with a minimum 6 months’ follow-up. Clinical assessment was based on change in Andrews-Carson functional score (AC), specific to osteoarthritis of the elbow, and on other functional scores: QuickDash (QD), Patient-Rated Elbow Evaluation (PREE), Mayo Elbow Performance Score (MEPS) and Self-Evaluation Elbow (SEE). Progression in pain on visual analog scale (VAS) and range of motion (RoM) was also assessed. Initial imaging work-up comprised standard X-ray and CT arthrography; paraclinical follow-up was based on X-ray. The impact of the following procedures associated to arthroscopic debridement was analyzed: radial head resection, ulnar nerve release, humeral fenestration, lateral ramp release, and medial collateral ligament posterior bundle release. The functional impact of epidemiological factors (age, handedness, manual occupation, smoking, body-mass index, and work accident/occupational disease status) and radiographic factors (foreign bodies, joint impingement, osteophytes, and fossa filling) was also assessed. ResultsThe series comprised 87 patients: 75 male (86.2%); mean age, 49 years (range, 18–73 years). Arthroscopic debridement significantly improved all functional scores at a minimum 6 months, and notably the specific AC score: 113.6±25.4 (40–180) versus 178.7±20.2 (110–200) (P<0.0001). Pain diminished significantly: 6.4±2.1 (0–10) versus 1.7±1.8 (0–8) (P<0.0001). RoM increased significantly: flexion/extension, 93.44±20.5° (5–130°) versus 124.2±13.8° (90–160°) (P<0.0001); pronation/supination, 147.6±25.6° (60–180°) versus 162.5±20.6° (100–180°) (P<0.0001). Strength (kg) increased in flexion (8.8±4.0 (4 to 20) versus 15.3±5.1 (3 to 32) (P<0.0008) and in grip [33.1±12.3 (10 to 58) versus 42.1±14.0 (2 to 68) (P<0.0001)]. Epidemiologically, males showed better recovery than females for both pain and strength. There was a significant positive impact of manual work on functional recovery, pain and also strength. There was a significant negative impact of work-accident/occupational disease on pain and strength. Regarding associated procedures, lateral ramp debridement improved AC score, with a gain of 75.4±25.3 points (−5 to 110) vs. 49.6±23.5 (10 to 100) (P<0.0001), and pain on VAS, with a fall of −5.6±2.1 points (−10 to −1) vs. −3.6±3.0 (−8.5 to 1) (P=0.0013). Ulnar nerve release, radial head resection and humeral fenestration had no positive impact. Preoperative foreign body was a factor for good prognosis. Cartilage wear, especially in the humeroulnar compartment, was associated with poorer functional results. Discussion/conclusionArthroscopic treatment of osteoarthritis of the elbow significantly improved clinical results at 6 months, with significant improvements in functional scores, pain, strength and range of motion. Gender, type of work and work-accident/occupational disease status influenced clinical results. Lateral ramp release is an often overlooked technical factor improving functional results. Radiologically, the best candidates are those presenting with a foreign body and no humeroulnar impingement. Level of evidenceIII, Prospective observational multicenter cohort study.

Outcome of Distal Biceps Tendon Repair With and Without Concomitant Bicipital Aponeurosis Repair.

Background:The bicipital aponeurosis (BA) can often be torn concomitantly with a distal biceps tendon (DBT) rupture. Its repair, although recommended by some, has not commonly been addressed during the surgical management of DBT ruptures, and to date, surgical repair of the BA with DBT repair has not been evaluated clinically.Purpose:To utilize subjective and objective outcome measures to examine the safety and efficacy of 2-incision DBT repair with and without repair of the BA in patients with a DBT rupture.Study Design:Cohort study; Level of evidence, 3.Methods:Demographic and surgical data were reviewed retrospectively. Patients returned to the clinic to complete subjective outcome measures and objective measurements of range of motion, strength, and biceps contour. All patients were evaluated at least 1 year after surgical treatment.Results:Data from 24 male patients with a DBT rupture were used for the analysis; 13 (54%) underwent concomitant DBT and BA repair, and 11 (46%) underwent isolated DBT repair. There were no complications at 1 year in either group. The DBT + BA repair group returned to recreational activities faster (77% within 6 months and 100% within 1 year) than the isolated DBT repair group (36% within 6 months, 91% within 1 year, and 100% after more than 2 years) (P = .05). There was a trend toward better Patient-Rated Elbow Evaluation pain scores in the DBT + BA repair group than in the isolated DBT repair group (1.2 vs 5.3, respectively; P = .18). A trend also emerged toward closer return to subjective preinjury strength (77% vs 44%, respectively; P = .14). No significant difference emerged in patient satisfaction with the biceps contour, subjective scores on functional activities and disability, or objective measurements of strength, contour, and range of motion.Conclusion:This pilot study suggests that repair of the BA in conjunction with DBT repair leads to a faster return to recreational activities compared with isolated DBT repair. Also noted was a trend toward subjectively improved pain and greater perceived strength, after DBT + BA repair, although this was not statistically significant. Further investigation with a larger population is required to better elucidate these potential differences.

Cross-cultural adaptation, validity, and reliability of the Turkish version of the Patient-Rated Elbow Evaluation.

The Patient-Rated Elbow Evaluation (PREE) is a joint-specific, self-administered outcome measure used to determine the level of pain and disability in patients with various elbow pathologies. The aim of this study was to cross-culturally adapt the PREE into Turkish (PREE-T) and to test its reliability and validity. Fifty-nine patients with elbow disorders were included in the present study. The original version of the PREE was translated and culturally adapted into Turkish by following standard procedure. Test-retest reliability and internal consistency were determined using intraclass correlation coefficient and Cronbach's alpha, respectively. Construct validity of PREE-T was determined with Disabilities of the Arm, Shoulder, and Hand (DASH) and Short Form-36 (SF-36) questionnaires by using Pearson's correlation coefficient analysis. Floor and ceiling effects were also analyzed. A high internal consistency (Cronbach's alpha of 0.959) and an excellent test-retest reliability (the intraclass correlation coefficient of 0.970) indicated that the PREE-T was reliable. Neither floor nor ceiling effects were observed in sub-parameters (0-1.7%) and the total score (0%) of PREE-T. Correlation coefficients between the PREE-T total score and DASH disability/symptom and work sub-parameters were 0.636 and 0.461, respectively. PREE-T pain and function sub-parameters correlated with related sub-parameters of the SF-36 bodily pain (r = - 0.721) and physical functioning (r = - 0.263). The Turkish version of the PREE is a valid and reliable outcome measure for assessing patients with elbow disorders. It is recommended to be used in research and clinical settings. Key Points • The Turkish version of the Patient-Rated Elbow Evaluation was successfully translated into Turkish and validated in a population with various elbow pathologies according to established guidelines • The Turkish version of the Patient-Rated Elbow Evaluation has high internal consistency and test-retest values • The Turkish version of the Patient-Rated Elbow Evaluation is valid and reliable.

Management of chronic distal biceps tendon ruptures: primary repair vs. semitendinosus autograft reconstruction

Delayed presentation of distal biceps tendon ruptures can make primary repair difficult, in which case reconstruction using a tendon graft is an option. The aim of this study was to compare outcomes and complications between delayed distal biceps tendon ruptures managed with repair vs. semitendinosus autograft reconstruction. Nineteen delayed distal biceps tendon rupture cases treated with a tendon reconstruction were compared with 16 delayed primary repair cases (>21 days). The reconstructions were performed using a semitendinosus autograft looped through a transosseous tunnel in the bicipital tuberosity and secured with a Pulvertaft weave to the remnant distal biceps tendon. The patient groups were reviewed and completed functional outcomes testing including range of motion, isometric elbow flexion and supination strength, Disabilities of the Arm, Shoulder, and Hand, Patient-Rated Elbow Evaluation, Single Assessment Numeric Evaluation, and Mayo Elbow Performance Index. Mean patient age (49 ± 9 vs. 46 ± 8 years, P = .65) and follow-up (47 ± 25 vs. 45 ± 27 months, P = .45) were similar between delayed primary repair and reconstruction groups. Range of motion (P = .62), supination strength (P = .26), elbow flexion strength (P = .93), Disabilities of the Arm, Shoulder, and Hand (P = .08), and Single Assessment Numeric Evaluation (P = .22) were not significantly different between groups. The Patient-Rated Elbow Evaluation (P = .02) and Mayo Elbow Performance Index (P = .04), however, were better in the delayed repair group compared with the reconstruction group. Complications were similar between groups (P = .87). Delayed reconstruction of irreparable distal biceps tendon ruptures with semitendinosus autograft produces similar strength, range of motion, and complication rates but slightly worse functional outcome scores compared with delayed primary repair. This suggests that when possible direct repair is preferred, however, if not possible, reconstruction with an autologous tendon graft results in predictably good outcomes.

Establishing the psychometric properties of 2 self-reported outcome measures of elbow pain and function: A systematic review

Study DesignSystematic review. IntroductionThe Patient-Rated Elbow Evaluation (PREE) and the self-report section of the American Shoulder and Elbow Surgeons—elbow form (pASES-e) are 2 patient-reported outcome measures (PROMs) commonly used to assess pain and disability arising from elbow disorders. Purpose of the StudyTo systematically review and summarize the quality and content of the evidence that is available on the psychometric properties of the PREE and pASES-e. MethodsWe systematically searched the online databases PubMed, EMBASE, ProQuest, Scopus, Cumulative Index to Nursing and Allied Health Literature, UptoDate, ProQuest Dissertations & Theses, and Google Scholar. Ninety-one articles were retrieved, and after screening, 9 were included in the final analysis. Data extraction and quality appraisal was performed by 2 independent raters. Descriptive synthesis of the reviewed studies was completed. ResultsSeven of the 9 studies had a quality score of 75% or higher. Agreement between the raters was good (kappa, 0.81). Both the PROMs did not demonstrate any floor and ceiling effects except for the satisfaction subscale of the pASES-e. Factor analysis revealed multidimensionality in the function subscale for both the PROMs. Construct validity was good with correlations above 0.70. Both were highly reliable with interclass correlation coefficient of >0.90. They were also highly responsive with an effect size and standardized response mean above 1. The minimal clinical important difference was not estimated for either measures. DiscussionThis study concluded that strong clinical measurement properties exist for both the PREE and the pASES-e. We identified gaps in the current evidence for both the ASES-e and the PREE. Future studies need to calculate clinically important estimates like MCID, SEM, and others; and provide clear and specific conclusions. ConclusionThe PREE and pASES-e have been established to be valid, reliable, and sensitive to change in both clinical and research settings based on high-quality evidence.

Treatment of Modified Mason Type III or IV Radial Head Fracture: Open Reduction and Internal Fixation versus Arthroplasty.

Background:The treatment of modified Mason Type III or IV fractures is controversial. Many authors report open reduction and internal fixation (ORIF) with reconstruction of the radial head, but others advocate radial head arthroplasty (RHA). This study compares the clinical and radiological outcomes of ORIF and RHA in modified Mason Type III or IV radial head fracture and evaluates correlations between prognostic factors and postoperative clinical outcomes.Materials and Methods:42 patients with modified Mason Type III or IV radial head fractures who were surgically treated between January 2010 and January 2014 were retrospectively analyzed (20 patients with RHA and 22 patients with ORIF group were selected). Clinically, the patient rated elbow evaluation (PREE), the disabilities of the arm, shoulder and hand (DASH), and the range of motion (ROM) were measured. Radiologically, plain radiographs and computed tomography scans were taken.Results:The mean PREE scores were 13.9 for the RHA group and 13.0 for the ORIF group, and mean DASH scores were 9.5 and 10.7, respectively. The differences were not statistically significant. When comparing ROM, the patients in the RHA group showed greater movement at all measured angles. In multiple regression analysis, age was the only variable significantly associated with both PREE and DASH.Conclusion:Overall, there were no significant differences in clinical outcomes of modified Mason Type III or IV radial head fractures treated with ORIF or RHA. However, a subgroup of younger patients had better clinical outcomes with ORIF treatment. Therefore, ORIF should be the First line of treatment, particularly if the reduction is possible.

Delayed repair of distal biceps tendon ruptures is successful: a case-control study

The literature has shown an increased complication rate with a delay to surgical repair of acute distal biceps tendon ruptures; however, little has been documented regarding the outcome of delayed repairs. This case-control study compared a study cohort of delayed (>21 days) distal biceps tendon repairs with a control cohort repaired acutely (<21 days). Sixteen delayed repair cases were reviewed and matched with acute controls (1:3) based on repair technique, age, and workers' compensation status. The delayed cohort was reviewed and completed isometric strength testing and the Disabilities of the Arm, Shoulder and Hand questionnaire; Patient-Rated Elbow Evaluation; and American Shoulder and Elbow Surgeons elbow questionnaire. The time to surgery averaged 37 ± 12 days in the delayed cohort versus 10 ± 6 days in the acute cohort. Complications occurred in 63% of patients in the delayed cohort versus 29% in the acute cohort (P = .04); however, 90% of the delayed cohort's complications consisted of transient paresthesias. Follow-up scores on the Patient-Rated Elbow Evaluation, Disabilities of the Arm, Shoulder and Hand questionnaire, and American Shoulder and Elbow Surgeons elbow questionnaire were not statistically different between cohorts (P > .37, P > .22, and P > .46, respectively). Despite a high rate of initial complications, patients treated with distal biceps tendon repair after a delay (>21 days) can expect similar functional outcomes to those treated acutely.