Postoperative Active Range Of Motion Research Articles

Thresholds For Diminishing Returns In Postoperative Range Of Motion After Total Shoulder Arthroplasty

BackgroundSatisfaction following shoulder arthroplasty (TSA), which is commonly reported using patient-reported outcome measures (PROMs), is partially dependent upon restoring shoulder range of motion (ROM). We hypothesized there exists a minimum amount of ROM necessary to perform functional tasks queried in PROM questionnaires, beyond which further ROM may provide no further improvement in PROMs. MethodsA retrospective review of a multicenter international shoulder arthroplasty database was performed between 2004-2020 for patients undergoing anatomic or reverse TSA (aTSA, rTSA) with minimum 2-year follow-up. Our primary outcome was to determine the threshold in postoperative active ROM (abduction, forward elevation [FE], external rotation [ER], and internal rotation [IR] score) whereby additional improvement was not associated with additional improvement in PROMs (Simple Shoulder Test [SST], American Shoulder and Elbow Surgeons [ASES] score, and the Shoulder Pain and Disability Index [SPADI]). For comparison, we also evaluated the Shoulder Arthroplasty Smart (SAS) score, which is not subject to the ceiling effect. ResultsWe included 4,459 TSAs (1,802 aTSAs, 2,657 rTSAs) with minimum 2-year follow-up (mean, 56±32 months). The threshold in postoperative ROM that were associated with no further improvement were: active abduction, 107-113° for PROMs versus 163° for the SAS score; active FE, 149-162° for PROMs versus 176° for the SAS score; active ER, 50-52° for PROMs versus 72° for the SAS score; IR score, 4-5 points for all PROMs versus 6 points for the SAS score. Out of 3,508 TSAs with complete postoperative ROM data, 8.5% achieved or exceeded all ROM thresholds (14.5% aTSAs, 4.8% rTSAs). ConclusionsOur findings demonstrate that postoperative ROM exceeding 113° of abduction, 162° of FE, 52° of ER, and IR to L1 is associated with minimal additional improvement in PROMs. While individual patient needs vary, the thresholds may provide helpful targets for patients undergoing postoperative rehabilitation.

Preoperative radius head dislocation affects forearm rotation after mobilization of congenital radioulnar synostosis

BackgroundThe present study was carried out to answer three questions: 1) How much forearm rotation can be expected after mobilization of congenital radioulnar synostosis (CRUS)? 2) Does preoperative radius head dislocation affect forearm rotation after mobilization? 3) What factors other than radius head dislocation affect postoperative forearm rotation? MethodsWe performed mobilization of CRUS with a free vascularized fascio-fat graft and a radius osteotomy (Kanaya’s procedure) on 26 forearms of 25 patients. The age at the surgery ranged from 5.3 to 13.4 years. The follow-up duration ranged 24–111 months. We classified CRUS into 3 groups according to the dislocation of the radius head: posterior dislocation (N = 13), anterior dislocation (N = 9) and no dislocation (N = 4). Since major complaints of patients and parents were poor forearm rotation and lack of supination, they were evaluated separately. ResultsMean preoperative forearm ankylosis angle was 34.8° (range; neutral to 90° pronation). Preoperative pronation ankylosis angle was higher in the posterior dislocation group (mean 55.3°) than the anterior dislocation (mean 11.6°) and no dislocation groups (mean 5.0°). There was no re-ankylosis after mobilization and the mean postoperative active range of motion (ROM) was 86.5°. The mean active ROM was 75.7° in the posterior dislocation group, 96.1° in anterior dislocation group and 100.0° in no dislocation group. The mean active supination was 6.9, 33.9 and 47.5° respectively. The posterior dislocation group showed less ROM and less supination than other groups. Preoperative pronation ankylosis angle showed negative correlation with postoperative ROM (ρ = − 0.59) and postoperative supination (ρ = − 0.73). ConclusionThe mean postoperative active ROM of this mobilization was 86.5°. Posterior dislocation group showed higher pronation ankylosis angle preoperatively, and less postoperative ROM and less supination than anterior and no dislocation groups. Preoperative pronation ankylosis angle showed negative correlation with postoperative ROM and supination.

Partial Superior Capsular Reconstruction to Augment Arthroscopic Repair of Massive Rotator Cuff Tears Using Autogenous Biceps Tendon: Effect on Retear Rate

Background: Massive rotator cuff tears have a high incidence of postoperative retear that can reach 90%. It is still unclear which intervention may reduce the incidence of retear and improve the functional and clinical outcomes. Purpose/Hypothesis: The purpose of this study was to investigate the clinical and structural outcomes at 2 years after repair of reparable massive rotator cuff tears with and without the use of partial superior capsular reconstruction (pSCR), using the autologous long head of the biceps tendon (LHBT) as a graft. It was hypothesized that augmentation with a pSCR would decrease retear rates. Study Design: Cohort study; Level of evidence, 3. Methods: The authors compared arthroscopic repair of massive posterosuperior rotator cuff tears with and without augmentation using the LHBT for pSCR between 2015 and 2017. After applying the selection criteria, 106 patients were included in the study and distributed into 2 groups of 50 and 56 patients. Patients in the first group (50 patients) underwent arthroscopic repair without use of the LHBT (AR group), and patients in the second group (56 patients) underwent arthroscopic repair with use of the LHBT for pSCR (AR-LHBT group). The structural outcome was evaluated by ultrasound at 2 years of follow-up. Function and pain were evaluated preoperatively and at the 2-year follow-up using the American Shoulder and Elbow Surgeons (ASES) score and visual analog scale (VAS). Pre- and postoperative active range of motion, including forward elevation, external rotation, and abduction, were also documented. Results: No significant differences were found between groups regarding the baseline characteristics. After 24 months, both groups showed significant improvement from preoperative ASES scores, VAS score, and active range of motion (P < .01 for all). Patients in the AR-LHBT group showed significant improvements in postoperative functional and pain scores compared with the AR group in all measurements at the 2-year follow-up (ASES score: 77.23 ± 7.45 vs 71.04 ± 9.28, P < .01; VAS score: 1.64 ± 1.03 vs 2.12 ± 1.06, P < .01). Final range of motion was significantly increased for the AR-LHBT group for forward elevation (155 [interquartile range {IQR}, 150-160] vs 150 [IQR, 140-170]; P < .01) and abduction (150 [IQR, 140-157.5] vs 120 [IQR, 100-140]; P < .01), but external rotation was significantly greater for the AR group (54.43 ± 10.55 vs 59.5 ± 10.55; P < .01). Postoperative ultrasonography at the 2-year follow-up revealed a higher retear rate in the AR group than in the AR-LHBT group (46% vs 14%; P < .01). Conclusion: Use of the LHBT for pSCR to augment massive rotator cuff tears resulted in markedly lower retear rates and modestly improved pain and function outcomes compared with repair alone.

A Systematic Review of the Outcomes of Flexor Tenolysis in Zones 2-5.

Background: Although numerous surgical techniques have been described and deployed, flexor tenolysis remains one of the most challenging procedures in hand surgery and there is no standardised way of recording the outcomes. The aim of this study is to systematically review the evidence supporting current concepts and outcomes in flexor tenolysis. Methods: The systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Medline and EMBASE databases were searched for articles published in English using the keyword search terms 'flexor' or 'tendon' and 'tenolysis' or 'tenoarthrolysis'. A total of 555 articles were listed and further screening provided fourteen studies remaining for final inclusion. The parameters for data extraction included number of digits operated on, age of the patients, initial injury mechanism requiring flexor tenolysis, outcome assessment method, follow-up period, results and complications. The primary outcome was postoperative active range of motion. Results: 556 digits were included across all studies and the age of patients ranged between 1 and 75 years. Eleven out of fourteen of the articles used the Strickland criteria to report their outcomes. Other outcome measures used were total active motion (TAM), Buck-Gramcko and pulp-to-palm distance. In the studies which used the Strickland criteria, the average percentage of outcomes reported as 'good' or 'excellent' was 68% with a range between 45% and 91%. Three other studies used Buck-Gramcko, TAM and pulp-to-palm distance outcome reporting and achieved 72% 'good' or 'excellent', 84% improvement and 30% able to touch distal palm crease respectively. Conclusions: Although the literature contains a limited number of observational studies, the current evidence shows that 68% of well-selected patients who undergo flexor tenolysis achieve a good or excellent outcome as measured by the Strickland criteria. Level of Evidence: Level III (Therapeutic).

Are the best anatomic total shoulder arthroplasties better than the best reverse total shoulder arthroplasties?

BackgroundSurgeons often state anecdotally that their best anatomic shoulder arthroplasties (TSAs) do better than their best reverse shoulder arthroplasties (RSAs). Limited data exist comparing patients at the upper limits of outcomes between RSA and TSA. MethodsA retrospective study was performed in patients undergoing TSA and RSA with minimum 2-year follow-up. Baseline patient demographic information as well as preoperative and postoperative active range of motion, American Shoulder and Elbow Surgeons (ASES) score, Single Assessment Numeric Evaluation, and Visual Analog Scale score for pain were collected. Patients in the top 20% of postoperative ASES scores were identified as those with the best outcomes. Descriptive statistics, univariate, and multivariate analyses were performed to evaluate differences between patients in the top 20% of ASES scores undergoing TSA and RSA. ResultsA total of 40 TSAs and 88 RSAs were included in the top 20% of each group, from a total of 205 TSAs and 447 RSAs, with a mean postoperative follow-up of 33 ± 14 months. Baseline patient-reported outcome measures and range of motion did not differ between groups (P > .05). There were no significant differences in the change of preoperative to postoperative Visual Analog Scale-pain (P = .539), Single Assessment Numeric Evaluation (P = .388), ASES (P = .912), and forward elevation (P = .439). The median (interquartile range) change in external rotation (40° [30°, 50°] vs. 30° [20°, 50°]; P = .017) and internal rotation (4.0 [2.0, 6.0] vs. 2.0 [1.0, 4.0]; P = .005) was statistically different between the TSA and RSA groups, respectively. A minimal clinically important difference for ASES was achieved by 100% of patients in both groups. A substantial clinical benefit was achieved by 100% of patients in the TSA group and 98% (n = 86) of patients in the RSA group. ConclusionWhile there is a common notion that patients treated with TSA have a greater potential for excellent outcomes, our findings show that clinical outcomes of the best TSAs are comparable to those of the best RSAs. Longer follow-up is needed to identify long-term differences in outcomes including revision and implant durability.

The Syringe External Fixator: Short- and Medium-Term Functional Outcomes From This Inexpensive and Customizable Treatment for Comminuted Intra-Articular Fractures of the Hand

Comminuted intra-articular fractures and fracture dislocations of the metacarpophalangeal (MCP) and interphalangeal joints are challenging. Dynamic external fixation, permitting early joint motion while still minimizing forces across the healing joint, can result in acceptable postoperative active range of motion (AROM). However, some fractures are not initially stable enough for early dynamic motion; further, many available dynamic external fixation systems are costly and cumbersome. We reviewed our experience using an external fixator made from a 1-mL syringe and K-wires and report outcomes using it as a static fixator, dynamic fixator, or configured as a static fixator and then converted to a dynamic fixator in the clinic. Patients with intra-articular fractures and fracture dislocations of the MCP and proximal interphalangeal (PIP) joints treated between 2014 and 2020 using syringe external fixators were retrospectively reviewed. We reviewed demographics, mechanisms, treatment types and durations, and postoperative AROM, as well as complications including infection, pin loosening, nonunion, hardware failure, and need for further surgery. Patients were analyzed by the level of joint injury (MCP versus PIP) and by treatment pattern. After excluding 23 patients with 25 joint injuries who were lost to follow-up or had inadequate outcome data, 27 patients with 29 joint injuries were reviewed. The average follow-up was 171 days after surgery. The postoperative AROM at the MCP level averaged 55° for static fixation and 30° for static-to-dynamic fixation. The postoperative AROM at the PIP level averaged 64° for static fixation, 66° for static-to-dynamic fixation, and 80° for dynamic fixation. Three pin site infections and 2 loose pins were reported. The syringe external fixator is an inexpensive, effective, and customizable treatment for intra-articular MCP and interphalangeal fractures and fracture dislocations, and results in acceptable postoperative AROM outcomes and complication rates. Therapeutic IV.

Does Digital Nerve Injury Affect Range of Motion Recovery After Zone 2 Flexor Tendon Repair?

Evidence surrounding the impact of concomitant digital nerve injury on the outcome of zone 2 flexor tendon repair is sparse and conflicting. The purpose of this study is to assess the impact of digital nerve injury on the range of motion recovery after zone 2 flexor tendon repair. We hypothesized that digital nerve injury is independently associated with decreased motion after zone 2 flexor digitorum profundus (FDP) repair. This is a single-institution, multisurgeon retrospective analysis of patients treated with primary zone 2 FDP repair. Patients with or without digital nerve injuries were included. Patients with fracture, extensor tendon injury, dysvascularity, follow-up duration of less than 10 weeks, and younger than 15 years were excluded. The primary outcome measure was Strickland percentage at the last therapy visit. Bivariate analysis was performed using simple linear regression. These results were used to guide backward stepwise multivariable analysis of qualifying exploratory variables. Forty-one patients with a total of 54 zone 2 FDP injuries qualified. Mean follow-up duration was 24 ± 10 weeks, and mean age was 38 ± 18 years. Thirty-three digits had a concomitant digital nerve injury, 26 digits had multidigit involvement, and 42 digits had combined FDP and flexor digitorum superficialis (FDS) injuries. Both older age and concomitant FDS injury exhibited independent relationships with poorer range of motion outcomes (P < .05). Digital nerve injury, follow-up duration, gender, and multidigit involvement did not influence final digital motion. In patients undergoing zone 2 FDP repair, concomitant digital nerve injury is not independently associated with poorer postoperative active range of motion.

Arthroscopic-Assisted Removal of Proximal Humerus Locking Plates With Capsular Release Significantly Improves Range of Motion and Function

PurposeTo investigate the clinical outcomes following the arthroscopic removal of proximal humerus locking plates for symptomatic hardware after open reduction and internal fixation (ORIF) of proximal humerus fractures.MethodsPatients who underwent arthroscopic removal of hardware (ROH) with capsular release due to pain and/or immobility after receiving locking plates to treat proximal humerus fractures from 2009 to 2016 were identified. Operative and clinic records were reviewed to obtain demographic information, concomitant procedures during ROH, and pre- and postoperative active shoulder range of motion. Postoperative patient-reported outcomes included the QuickDASH, PROMIS Pain Intensity, Constant, and University of California, Los Angeles shoulder rating scale.ResultsIn total, 88 patients were included. Patients were evaluated at a minimum of 6 weeks postoperatively after ROH. Patients with pre- and postoperative active range of motion values demonstrated significant improvements in mean forward elevation (n = 69; 78.4%; 115.1° to 152.1°, P < .001), abduction (n = 29; 33.0%; 70.9° to 138.7°, P < .001), external rotation (n = 49; 55.7%; 43.7° to 58.6°, P = .012), and internal rotation (n = 45; 51.1%; 25.7° to 61.9°, P < .001). Patients also reported positive patient-reported scores, including the QuickDASH (4.1 ± 7.8), PROMIS Pain Intensity (3.5 ± 0.9), Constant (84.6 ± 10.7), and University of California, Los Angeles shoulder rating scale (33 ± 2.9), which were measured 70.6 ± 26.6 months postoperatively. There were no surgical complications, no arthroscopic cases were converted to open, but 2 reported refractures (2.3%).ConclusionsArthroscopic-assisted removal of proximal humerus locking plates significantly improves motion and function while allowing for management of concomitant shoulder pathology and potentially avoiding open surgery complications. Given that patients undergoing this procedure frequently have multiple comorbidities, arthroscopic-assisted removal with smaller incisions may minimize risks while restoring shoulder mobility. Therefore, arthroscopic ROH for patients experiencing symptomatic hardware after ORIF is recommended.Level of EvidenceLevel IV, therapeutic case series.

Factors Affecting the Range of Motion of the Elbow after Open Reduction of Olecranon Fractures.

Background: Although postoperative outcomes of olecranon fractures are relatively favorable, postoperative stiffness of the elbow joint occurs occasionally. We aimed to identify negative prognostic factors for unfavorable outcomes following olecranon fractures. Methods: We retrospectively reviewed the records of 100 patients with olecranon fractures and collected data on the conducted procedures, age, fracture condition, postoperative reduced position, and postoperative active range of motion (AROM) of the elbow joint. The primary outcome was the regaining of an AROM of > 130° flexion and < -30° extension of the elbow joint at the final follow-up. We performed multivariate logistic regression analysis to identify the negative prognostic factors. Results: The mean follow-up period was 11 months. All patients regained an average AROM of 121 degrees. Eighty-one patients regained a favorable AROM of the elbow joint. On univariate logistic regression analysis, diabetes mellitus (OR, 8.2; 95%CI, 1.6-41.7), comminution of the fractured site (OR, 23.1; 95% CI, 13.2-165.0), and utilization of the tension band wiring (TBW) technique (OR, 7.5; 95% CI, 1.16-48.2) were significant factors in aggravating the final result of elbow AROM. On multivariate analysis, patients with diabetes mellitus (OR, 10.9; 95% CI, 2.83-41.9), comminuted fractures (OR, 11.4; 95% CI, 2.61-50.2), or undergoing the tension band wiring technique (TBW) (OR, 5.5; 95% CI, 1.35-50.2) showed reduced postoperative AROM of the elbow joint; postoperative malreduction of the articular surface was not a negative prognostic factor. Seven of 51 patients treated with TBW underwent revision surgery because of non-union or postoperative displacement. Conclusions: TBW for olecranon fractures is a simple and cost-effective procedure; however, negative effects could develop when regaining sufficient postoperative AROM of the elbow joint. Therefore, rigid fixation without reoperation may lead to a favorable outcome. Postoperative malreduction does not always worsen the postoperative AROM of the elbow joint, at least not in the early postoperative period.

Bipolar Latissimus Dorsi Transfer for Arthrogryposis Multiplex Congenita: Minimum 10-Month Follow-Up

To examine the outcomes of patients who have undergone bipolar latissimus dorsi transfer for loss of elbow flexion in arthrogryposis multiplex congenita (AMC). This study retrospectively evaluated 6 cases (5 patients) of bipolar latissimus dorsi transfer performed to restore active elbow flexion in pediatric patients with AMC. Elbow range of motion and strength were evaluated before and after surgery. Functional outcomes were evaluated by the patients' ability to perform activities of daily living. Complications and patient satisfaction were also evaluated at final follow-up. The patients were a mean age of 7.8 ± 3 years. The mean follow-up was 30.2 months (range, 10-44 months). At most recent follow-up, all cases reported improved function of the surgical extremity when performing activities of daily living and overall satisfaction. The postoperative active range of motion was 76° ± 14°. All cases had active elbow flexion against gravity. One patient was noted to have decreased muscle activation of the transfer 6 months after surgery, but strength improved by the 10-month follow-up. No other complications were noted. We recommend bipolar latissimus dorsi transfer as a reliable option to restore functional elbow flexion in patients with AMC. Meticulous pedicle handling and assessment of the latissimus dorsi viability is paramount. Therapeutic V.

The functional outcomes and complications of different reconstruction methods for Giant cell tumor of the distal radius: comparison of Osteoarticular allograft and three-dimensional-printed prosthesis

BackgroundEn bloc excision has been increasingly used for the management of giant cell tumors (GCTs) in the distal radius. An osteoarticular allograft has been used extensively for decades, and custom-made prosthesis reconstruction has been more recently applied. We aimed to compare the clinical outcomes of the two procedures.MethodsWe retrospectively analyzed 30 patients with Campanacci III or recurrent GCTs of the distal radius for follow-up at a mean of 33.2 months. In total, 15 underwent osteoarticular allograft reconstruction (allograft group) and 15 received cementless three-dimensional (3D)-printed prosthesis reconstruction (prosthesis group) between March 18, 2013, and May 20, 2018. All patients underwent by clinical and radiological examinations, including pre- and postoperative active range of motion (ROM) of the wrist, VAS score, grip strength, degenerative change of wrist, Mayo wrist score and Musculoskeletal Tumor Society (MSTS) score. Complications were evaluated using the Henderson classification.ResultsBoth groups showed significantly increased ROM, grip strength, Mayo score and MSTS score postoperatively. Furthermore, the extension, flexion, MSTS, and Mayo score were significantly higher in the prosthesis group. There was no significant difference in grip strength and VAS between the groups. In allograft group, one patient had a late infection one had resorption of allograft without allograft bone fracture. and four had wrist subluxation. All patients had degenerative changes (mean 9 months). In the prosthesis group, three patients developed wrist subluxation, three had separation of the distal radioulnar joint, and none of the patients developed wrist degeneration.ConclusionsOur study compared the objective functional outcomes and complications of two reconstructive methods for Campanacci III or recurrent GCT in the distal radius. 3D-printed prosthesis replacement can partially preserve wrist function better than allograft reconstruction in the short-term. During the design of 3D-printed prosthesis, preoperative morphological assessment of the affected proximal row carpal is helpful to control postoperative dislocation. After allograft reconstruction, wrist degeneration, which has been demonstrated in all patients, severely influence their wrist function. Therefore, compared to allograft reconstruction, 3D-printed prosthesis reconstruction has irreplaceable advantages at early-stage application, especially in wrist function, however, further studied with a larger number of cases and longer follow-up.

Flexible Stable Intramedullary Nailing for the Management of Metacarpal Neck Fractures

Introduction When dealing with metacarpal neck fractures, the aim of treatment should include clinical and radiological objectives. The aim of this study was to assess the efficacy of flexible stable intramedullary nailing for the management of metacarpal neck fractures.Materials and Methods A total of twenty four patients (22 males and 2 females; mean age: 28.2 ± 7.7 years) with metacarpal neck fractures (second in 7 patients and fifth in 17 patients) whether isolated or associated with other body injuries and managed by percutaneous flexible stable intramedullary nailing were reviewed for a retrospective case series. Personal interviews were conducted together with clinical and radiological assessments. The final results were recorded at the time of personal interviews.Results The mean duration of surgery was 19.3 ± 2.5 minutes. The mean time of radiological union was 5 ± 1.3 weeks. The mean postoperative active range of motion of the metacarpophalangeal joint was 102.4 ± 11 degrees. The mean supination power of the involved hand in comparison to the contralateral side was 97.8 ± 3.4%, whereas the pronation power percentage was 99.2% ± 1.6. The mean power grip percentage to the contralateral side was 96.4 ± 2.9%, whereas the mean percentage of the pinch grip was 96.1 ± 4.2%. The mean postoperative DASH (Disability of Arm, Shoulder, and Hand) score was 0.3 ± 0.5.Conclusion Percutaneous flexible stable intramedullary nailing for the treatment of metacarpal neck fractures has expanded the armamentarium of the orthopaedic surgeons as an easy, cost-effective technique overcoming all possible deformities and allowing early and reliable active rehabilitation.Level of Evidence This is a Type IV, therapeutic retrospective case series.

Chronic Long Head Biceps Tendinitis Secondary to Anomalous Origins in Young Patients: A Case Series.

To describe a case series of young adult patients with isolated chronic proximal biceps tendinitis refractory to conservative care found to have anatomic long head biceps tendon (LHBT) origin variations who underwent arthroscopic-assisted subpectoral biceps tenodesis. Patients were included in this retrospective case series if they met all the following criteria: 1) had an anomalous origin of the LHBT without any pre-operative or concurrent pathologies at the time of surgery, 2) had non-traumatic anterior shoulder pain refractory to conservative care for >6 months, 3) pain relief with ultrasound guided steroid injections into the bicipital tendon sheath, and 4) routine radiographs and MRI-arthrogram demonstrating no pathology. All patients underwent arthroscopic assisted mini-open subpectoral biceps tenodesis. Pre- and post-operative active range of motion (ROM), strength, visual analog scale (VAS) for pain, and subjective shoulder values (SSV) were evaluated. Statistical analysis was done using repeated measure ANOVA. Seven patients mean age of 18.4 ± 3.5 years old were included in this study. Arthroscopic examination revealed anomalous origins of the LHBT in all patients with the following distribution: medial to superior labrum (x2), proximal insertion to the supraspinatus confluent with the superior labrum (x2), insertion into the superior capsular tissues at the rotator interval (x2), and bifid LHBT (x1). VAS score and SSV were significantly improved at 3 months (p <0.001 and = 0.024 respectively) and final follow-up. Anomalous origins of the LHBT may be a predisposing factor for chronic biceps tendinitis refractory to non-operative treatment in young adults. Biceps tenodesis seems to offer improvements in function and pain.

Arthroscopic Latarjet for Recurrent Shoulder Instability.

Background and Objectives: The all-arthroscopic Latarjet (aL) procedure was introduced to manage recurrent shoulder instability. Our study aimed to report the outcomes of aL procedures with the Rowe, University of California-Los Angeles (UCLA), simple shoulder test (SST) scores, and range of motion (ROM) in external rotation at a minimum follow-up of 2 years. Material and Methods: A total of 44 patients presenting recurrent shoulder instability were managed with aL procedure. Clinical outcomes were assessed at a mean follow-up of 29.6 ± 6.9 months. The postoperative active ROM was measured and compared with the contralateral shoulder. The Rowe, UCLA, and SST scores were administered preoperatively and postoperatively. Results: No patients experienced infections or neuro-vascular injuries. Seven (15%) patients required revision surgery. After surgery, the external rotation was statistically lower compared to the contralateral shoulder, but it improved; clinical outcomes also improved in a statistically significant fashion. Conclusions: The aL produced good results in the management of recurrent shoulder instability, but the complication rate was still high even in the hands of expert arthroscopist.

Clinical Outcomes and Tendon Integrity in Patients With Chronic Retracted Subscapularis Tear After Arthroscopic Single-Row Oblique Mattress Suture Repair Technique

To evaluate clinical outcomes and tendon integrity in patients with chronic retracted subscapularis tears using an arthroscopic single-row oblique mattress suture repair technique. Patients with full-thickness subscapularis tears retracted to the glenoid level and with at least 2years of follow-up were included. Tendon retraction level was measured on preoperative axial magnetic resonance images and confirmed during arthroscopic surgery. The subscapularis tendon was repaired arthroscopically using the single-row oblique mattress suture technique on the medial margin of the lesser tuberosity. Two double-loaded suture anchors were used to obtain firm fixation between the tendon and the footprint. Clinical outcomes were assessed for all patients preoperatively and postoperatively using active range of motion, a visual analog scale score for pain, and American Shoulder and Elbow Surgeons and Constant scores. To evaluate structural integrity of the repaired tendon, all patients underwent magnetic resonance imaging at 6months and ultrasonography at 1year after surgery. The shoulder function of the 33 patients analyzed was improved significantly after a mean follow-up period of 26.3 ± 3.5months compared with preoperative values (American Shoulder and Elbow Surgeons score of 52.0 ± 7.9 preoperatively vs 79.6 ± 7.0 at last follow-up, P < .001, and Constant score of 43.0 ± 13.4 preoperatively vs 76.7 ± 9.2 at last follow-up, P < .001). Postoperative active range of motion improved significantly in forward flexion, external rotation, and internal rotation (P < .001). The mean visual analog scale pain score decreased by 3.42 (5.2 ± 1.6 preoperatively vs 1.9 ± 1.4 at last follow-up, P < .001). In 4 patients (12.1%), subscapularis retears were confirmed on postoperative magnetic resonance imaging. Despite significant retraction, arthroscopic repair using a single-row oblique mattress suture technique in patients who had chronic subscapularis tears with retraction to the glenoid level yielded satisfactory clinical outcomes and reliable tendon healing. Level IV, therapeutic case series.

Outcomes of Secondary Combined Proximal Interphalangeal Joint Release and Zone II Flexor Tenolysis.

Background: Tendon adhesions and capsular contractures following trauma to the proximal interphalangeal joint (PIPJ) may significantly reduce hand function. Traditional, staged surgical management prioritizes restoration of PIPJ passive range of motion with joint release prior to restoration of active range of motion (AROM) with tenolysis. This is expensive and burdensome for patients. Our objective was to evaluate functional outcomes of combined PIPJ release and zone II flexor tenolysis. Methods: We retrospectively reviewed patients who underwent combined PIPJ release and flexor tenolysis. Replantation and tendon graft cases were excluded. Data were collected on pre- and postoperative AROM, total active motion (TAM), tip to distal palmar crease (DPC) distance, and grip strength. Functional outcomes were graded using the Boyes, American Society for Surgery of the Hand, and modified Strickland scores. Results: Twelve patients (9 men and 3 women, median age = 40 years) with a total of 15 digits underwent combined PIPJ release and flexor tenolysis a median of 10.1 months after injury. At a median follow-up of 4.0 months, there were significant improvements in median PIPJ AROM (15° to 70°), TAM (105° to 223°), tip to DPC distance (6.0 to 2.0 cm), and grip strength (35% to 54% of unaffected hand). Modified Strickland score was good in 46% of digits and excellent in 38%. There were no tendon ruptures, surgical site infections, or devascularized digits. Conclusion: Proximal interphalangeal joint stiffness is a challenging complication of hand trauma. Although a complete return to premorbid range of motion and function is rarely attained with surgery, improved outcomes may be consistently achieved with secondary combined PIPJ release and zone II flexor tenolysis.

Comparison of radiographic and clinical outcomes of revision reverse total shoulder arthroplasty with structural versus nonstructural bone graft

Revision shoulder arthroplasty in the setting of glenoid bone loss poses substantial surgical challenges. This study's purpose was to compare radiographic and clinical results of patients requiring structural iliac crest bone autograft (ICBA) for severe bone loss versus patients with less severe bone loss treated with nonstructural bone allograft (NSBA) in the setting of revision reverse total shoulder arthroplasty (RSA). A retrospective cohort of 30 patients (70% of the 43 patients who met the inclusion criteria) undergoing revision RSA with ICBA (n = 15) or NSBA (n = 15) between 2007 and 2015 were analyzed at a minimum 2-year follow-up. Radiographic assessment included bone graft integration, bone graft resorption, glenosphere tilt, glenosphere version, and the presence of scapular notching. Clinical assessment included active range of motion, Penn Shoulder Score, Veterans RAND 12-item health survey, and need for revision surgery. No radiographic difference was found between the ICBA and NSBA groups with regard to implant position, graft integration, scapular notching, implant shift, or failure of fixation (P > .05). Of 15 patients with ICBA, 14 (93%) had at least partial integration of the bone graft. Some degree of resorption of the bone graft was noted in 6 of 15 patients (40%). There was no significant difference in postoperative active range of motion, Penn Shoulder Score, or Veterans RAND 12-item health survey score (P > .05 for all comparisons). One patient in the ICBA group underwent revision surgery for glenoid baseplate failure. Revision RSA with glenoid bone grafting resulted in good clinical and radiographic outcomes at short-term follow-up. Patients requiring structural ICBA were not at increased risk of component failure, radiographic or clinical complications, or inferior clinical outcomes.

Multiple joint procedures in haemophilia: benefit of self-reported activities

Abstract This paper presents a long-term follow-up (mean 6 years) of three cases, providing insight into individual changes in self-reported activities of persons with haemophilia (PWH) who underwent multiple joint procedures (MJP). The procedures include one bilateral ankle pan arthrodesis by means of an ankle arthrodesis nail (case 1) and two times bilateral total knee arthroplasty (TKA), both type Genesis II (cases 2 and 3). MJP are defined as any combination of total hip arthroplasty (THA), total knee arthroplasty (TKA) and ankle arthrodesis (AA) during one hospital admission (one session or staged). The results of MJP need meticulous long-term follow-up, including tools with the capacity to provide detailed measurements for levels of activity. Measurements performed before and after surgery included active range of motion (AROM), the Hemophilia Activities List (HAL) sub-scores for basic and complex lower extremity and the McMaster Toronto Arthritis patient disability questionnaire (MACTAR). Pain scores were only available post-surgery and were by means of a visual analogue scale (VAS), 0 indicating no pain and 10 maximum pain. Post-operative VAS scores were 0.3 on average (range 0-1), indicating only minimal pain. Pre-operative pain was the actual indication for MJP. However, it was measured with a different score, the WFH score. Regarding post-operative AROM, case 1 showed a decreased ankle plantar flexion averaging 15˚ (range 10-20˚) and dorsiflexion averaging 7.5˚ (range 5-10˚), results expected after surgical fixation of the tibiotalar joint. Cases 2 and 3 showed an increased active flexion of both knee joints, on average 6° (range 5-10˚), and extension of 11° (range 0-20˚). From these two cases the HAL showed improvement in both basic (Δ 40 and Δ 30) and complex lower extremity (Δ 40 and Δ 3,5) activities. When considering the standard deviations of the HAL normalised total score of 18, it can be appreciated that these improvements are clinically relevant (effect size Δ 1). The MACTAR showed individual progress, with emphasis on walking, standing, riding a bicycle and walking stairs. These MJP cases provide insight on the benefits of self-reported activities, as well as the relationship between body and activity of the ICF. For the long-term follow-up of this very specific population, self-reported activities should be included.

Subcutaneous flexor tendon rupture in patients with rheumatoid arthritis

Objective: We examined the clinical features and functional outcomes of surgically repaired subcutaneous flexor tendon ruptures in patients with rheumatoid arthritis (RA).Methods: This retrospective study included 41 fingers of 24 RA patients who underwent surgical treatment for flexor tendon ruptures. Evaluations performed at the time of presentation following rupture were C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), and disease activity score in 28 joints (DAS28)-ESR, as well as Larsen grading for carpal bone destruction. The ruptured tendon and postoperative active range of motion (ROM) of digits were also examined.Results: The mean CRP was 2.4 mg/dl, ESR was 52 mm/h, and the DAS28-ESR was 4.5. Carpal bone destruction according to Larsen grade IV–V was observed in 18/24 patients. Affected digits were most commonly the thumb (12) and the ring and little fingers (9 each). Tendon ruptures were most common in the carpal tunnel in zone IV. The mean postoperative finger ROM (flexion/extension) was 38°/2° for the interphalangeal (IP) joint of the thumb and 23°/−2° for the distal interphalangeal joint of the other four fingers.Conclusions: Patients with flexor tendon ruptures present with high disease activity and advanced bone destruction. It is important to reduce the risk of progressive bone destruction and subsequent tendon rupture via tight control of disease activity.

Suturing of the flexor digitorum profundus tendon to the entire volar plate in distal zone I injuries

Purpose: The author conducted an anatomical and a prospective clinical study to address the technique and complications of using the entire volar plate (VP) as a distally-based flap for distal Zone I flexor digitorum profundus (FDP) tendon repair. Methods: In the anatomical study, eight fresh finger specimens were dissected to study the anatomy of the VP as well as the stability of the distal interphalangeal joint (DIPJ) after raising the entire VP as a distally-based flap. In the clinical series, six patients underwent repair of distal Zone I FDP lacerations using the VP flap technique and were assessed at a mean of 9 months for range of motion as well as DIPJ deformities. Results: The results of the anatomical study showed that the intact collateral ligaments can still maintain the stability of the DIPJ after loss of joint support from the VP. In the clinical series, none of the patients showed joint hyper-extension or flexion contracture at the DIPJ. Using Moiemen-Elliot criteria, the post-operative active range of motion at the DIPJ was rated as excellent in one, good in three, and fair in two patients. Conclusion: It was concluded that the use of the entire VP as a distally based flap is an acceptable technique to repair distal FDP injuries and the technique does not result in DIPJ instability or flexion contracture.