Ulnar Nerve Symptoms Research Articles

Return to Play Rates and Clinical Outcomes of Baseball Players Following Concomitant Ulnar Collateral Ligament Reconstruction and Indicated Ulnar Nerve Transposition (130)

Objectives:Injury to the ulnar collateral ligament (UCL)—leading to medial elbow instability and concomitant ulnar neuropathy symptoms—is common in the overhead throwing athlete secondary to the repetitive stress that these individuals place on the elbow during the throwing motion. Treatment customarily involves UCL reconstruction (UCLR) and for those with preoperative ulnar neuropathy symptoms, concomitant ulnar nerve transposition (UNT) may also be warranted. The purpose of this study was to evaluate the return to play rates, clinical outcomes and more specifically rates of persistent ulnar nerve symptoms after concomitant UCLR and UNT in a cohort of baseball players with confirmed preoperative ulnar neuropathy symptoms.Methods:Patients who underwent concomitant UCLR and UNT from January 2008 to June 2018 were identified at one institution with a minimum of 2 years of follow-up. Additional inclusion criteria included athletes who identified as baseball players with a confirmed history of ulnar neuropathy symptoms. Exclusion criteria included patients who had any other concomitant open procedures at the time of surgery. After identifying the cohort, patients were contacted via phone to complete a Kerlan-Jobe Orthopedic Clinic Shoulder and Elbow Score (KJOC), Andrews-Timmerman (AT) Elbow Score, Mayo Elbow Performance Score (MEPS), Single Assessment Numeric Evaluation (SANE) score and a custom return to play questionnaire. Evidence for preoperative and postoperative ulnar nerve symptoms was elicited within the custom survey and corroborated with the provider’s clinical notes. Sensory ulnar nerve symptoms were defined as having numbness and/or tingling sensations in the 5th and ulnar half of the 4th fingers. Motor ulnar nerve symptoms were defined as either exhibiting 1st dorsal interosseous muscle weakness by inability to maintain finger abduction resistance, ulnar-sided hand grip weakness of inability to control precise movement of the 5th digit.Results:During this time period, a total of 22 male baseball players underwent concomitant UCLR and UNT at a mean age of 18.9+/-2.1 years (range, 16-25). The mean follow-up was 6.1+/-2.4 years (range, 2.5-11.7 years). The cohort consisted of 15 pitchers and 7 position players. In total, 7 players competed in high school and 15 competed in college. Preoperatively, all 22 patients reported ulnar nerve sensory symptoms while only 4 (18.2%) patients reported ulnar nerve motor symptoms. Overall, 16 (72.3%) players were able to return to competitive play at an average of 11.2 months. Of the 6 that failed to return to play after surgery, 3 reported that persistent elbow symptoms were the reason for not returning to play while the other 3 reported losing the desire to return to play. At final follow-up, 7 (31.8%) patients reported of persistent sensory ulnar nerve sensory symptoms while 1 (4.5%) of these patients additionally reported persistent ulnar nerve motor symptoms. The mean postoperative patient reported outcome scores were as follows: KJOC: 77.9+/-20.9 (range, 14-100); MEPS: 92.7+/-12.7 (range, 45-100); AT Elbow Score: 86.1+/-17.1 (range, 30-100); SANE score: 85.5+/-14.8 (range, 50-100).Conclusions:While patient-reported outcome scores and return to play rates are reasonably high, this study demonstrates that following concomitant UCL reconstruction and ulnar nerve transposition for UCL insufficiency and associated ulnar neuropathy, rates of persistent ulnar neuropathy symptoms are persistently present in over 30% of patients. Currently, handling of the ulnar nerve in the setting of UCL insufficiency is debated and thus further investigation is warranted to optimize outcomes for this group of patients.

Lateral minimal approach to the terrible triad of the elbow: a treatment protocol in Beijing Jishuitan Hospital.

BackgroundThis study aimed to report the surgical techniques and results of treating coronoid process and radial head fracture combined with dislocation of the elbow (terrible triad of the elbow) using a single lateral incision, known as the extensor digitorum communis (EDC) split approach.MethodsA retrospective analysis was performed of 109 patients with terrible triad of the elbow who had been treated by the authors from January 2013 to December 2019. The participants included 67 males and 42 females, with a mean age of 42.2 years (14–71 years). All participants were treated via a single lateral approach. The coronoid process was fixated with Kirschner wires combined with anterior capsule suture lasso fixation. For the radial head fracture, 58 cases were fixated by AO headless cannulated screw (AO HCS) and 51 cases by acumed radial head replacement. In repair of the lateral collateral ligament (LCL) complex and the common extensor tendon, 28 cases used ETHIBOND suture through bone holes at the humeral lateral epicondyle, and the other 81 cases used suture anchors. No medial collateral ligament was repaired. A total of 46 participants were fixated with a Stryker dynamic joint distractor (DJD) II hinged external fixator to protect the bone and soft tissue.ResultsAll participants were followed up from 6 to 60 months (mean, 36.1 months). Their elbow range of flexion and extension averaged 123.4°±20.7°, forearm rotation 151.0°±25.6°, and Mayo elbow performance score (MEPS) 92.3±8.8. There were 22 participants (19.5%) with ulnar nerve symptoms, 16 (14.7%) who had elbow stiffness, and 7 underwent secondary surgery, including 6 removals of internal fixation, 5 arthrolyses of the elbow, and 2 ulnar neurolyses.ConclusionsCoronoid fractures, radial head fractures, and LCL injuries of the terrible triad of the elbow can be treated satisfactorily through a lateral minimal incision, combined with a hinged external fixation if necessary.

Intravenous tranexamic acid reduce postoperative drainage and pain after open elbow arthrolysis: a randomized controlled trial.

Open elbow arthrolysis (OEA), which has become an established treatment for post-traumatic elbow stiffness (PTES), requires complete release of contracture tissue and wide excision of ectopic bone, which results in extensive bleeding. The aim of the present study is to evaluate the efficacy of intravenous tranexamic acid (TXA) on postoperative drainage, calculated blood loss, and early clinical outcomes in patients undergoing OEA. A double-blind, randomized, placebo-controlled trial including 96 patients undergoing OEA was undertaken. Patients received intravenously either 100 mL saline (placebo group, n = 48), or 100 mL saline plus 1 g TXA (TXA group, n = 48) before skin incision. The primary outcome was the drainage volume on postoperative days (PODs) 1-3. Secondary outcomes included the calculated blood loss, elbow pain score measured by visual analog scale (VAS), elbow function valued by Mayo Elbow Performance Score (MEPS), and rate of complications after OEA. Mean total postoperative drainage volume (TXA group: 182 mL vs. placebo group: 214 mL, P = .003) and mean calculated total blood loss (TXA group: 582 mL vs. placebo group: 657 mL, P = .004) were significantly lower in the TXA group. No transfusions were necessary in either group. Mean VAS pain scores in elbow motion showed marked differences between both groups on POD 1 (TXA: 5 vs. placebo: 6, P = .003) and POD 2 (TXA: 4 vs. placebo: 5, P = .023) but not in other postoperative time points. No differences were detected in complications, such as pin-related infection, hematoma, new or exacerbation of ulnar nerve symptoms, and recurrent heterotopic ossification. At the 6-month follow-up, no statistical differences were found between the 2 groups with respect to the elbow functions including range of motion, VAS score, and MEPS. Intravenous administration of TXA significantly decreased the postoperative drainage volume and the total estimated blood loss and alleviated the elbow pain with motion during early postoperative days in patients undergoing OEA.

Displaced distal radius fracture: reduction, follow-up, and clinical outcomes : learning from a pragmatic approach during the 2020 COVID-19 lockdown transition.

AimsDisplaced distal radius fractures were investigated at a level 1 major trauma centre during the COVID-19 2020 lockdown due to the implementation of temporary changes in practice. The primary aim was to establish if follow-up at one week in place of the 72-hour British Orthopaedic Association Standards for Trauma & Orthopaedics (BOAST) guidance was safe following manipulation under anaesthetic. A parallel adaptation during lockdown was the non-expectation of Bier’s block. The secondary aim was to compare clinical outcomes with respect to block type.MethodsOverall, 90 patients were assessed in a cross-sectional cohort study using a mixed, retrospective-prospective approach. Consecutive sampling of 30 patients pre-lockdown (P1), 30 during lockdown (P2), and 30 during post-lockdown (P3) was applied. Type of block, operative status, follow-up, and complications were extracted. Primary endpoints were early complications (≤ one week). Secondary endpoints were later complications including malunion, delayed union or osteotomy.ResultsIn P1, 86.6% of patients were seen between days one to three, 26.7% in P2, and 56.7% in P3. There were no documented complications from days one to three. Operative rate was 35.5%, which did not vary significantly (p= 0.712). Primary endpoints occurred between day four to seven, and included one patient each period treated for plaster cast pain. Secondary endpoints in P1 included delayed union (one patient). During P2, this included malunion (one patient), a pressure sore (one patient) and ulnar cutaneous nerve symptoms (two patients). In P3, malunion was identified in one patient. Mean follow-up was six months (4 to 9) with union rate 96%. Change in block practice varied significantly (p =＜0.05). The risk ratio of complications using regional block (Bier’s) over haematoma block was 0.65.ConclusionFollow-up adaptations during lockdown did not adversely affect patient outcomes. Regional anaesthesia is gold standard for manipulation of displaced distal radial fractures.Cite this article: Bone Jt Open 2021;2(5):338–343.

Fragment Excision With Flexor-Pronator Mass Repair for Chronic Medial Humeral Epicondyle Nonunions.

Athletes with medial epicondyle nonunions typically present with medial elbow pain, an elbow flexion contracture, and the inability to compete. The purpose of this study was to evaluate the clinical outcomes of patients who underwent medial epicondyle excision with ulnar collateral ligament and flexor-pronator mass repair for symptomatic medial epicondyle non-unions. Four patients with a mean age of 15 years (range, 11-19 years) diagnosed with symptomatic medial epicondyle nonunions were evaluated. All were treated with medial epicondyle excision with ulnar collateral ligament and flexor-pronator mass repair. Two of the patients were followed for 12 months, whereas the other 2 patients were followed for 18 months. All patients returned to their preinjury level of sports without difficulty. Two patients with preoperative flexion contracture had residual flexion contractures of 4° and 5° postoperatively, respectively, as measured by a goniometer. All other patients regained full elbow motion equal to that of the contralateral extremity at final follow-up. The patients with preoperative ulnar nerve symptoms had complete resolution postoperatively at a mean follow-up of 18 months. In overhead and upper extremity weight-bearing athletes who have symptomatic medial epicondyle nonunions, fragment excision with flexor-pronator mass repair can yield satisfactory results. [Orthopedics. 2021;44(3):e337-e342.].

Midterm Outcomes After Open Arthrolysis for Posttraumatic Elbow Stiffness in Children and Adolescents.

Background:Open arthrolysis is used for treating elbow stiffness in adults. This study evaluated the midterm outcomes after open arthrolysis in children and adolescents with posttraumatic elbow stiffness.Methods:Data of 31 children and adolescents with posttraumatic elbow stiffness following open arthrolysis with or without hinged external fixation from 2010 to 2014 were retrospectively analyzed. Their mean age was 15 (range: 6 to 19) years. At baseline and the follow-up (>4 y), we evaluated the outcomes (range of motion and Mayo Elbow Performance Index) and postoperative complications (pain, ulnar nerve symptoms, infections, and instability) and analyzed the association between outcomes and clinical variables.Results:The Mayo Elbow Performance Index improved from 67.9 (range: 35 to 95 points) to 93.7 points (range: 65 to 100 points; P<0.001). The elbow active flexion/extension arc increased significantly from 49 degrees (range: 0 to 120 degrees) to 108 degrees (range: 0 to 120 degrees; P<0.001), with a mean flexion of 123 degrees (range: 70 to 140 degrees; P<0.001) and mean extension of 15 degrees (range: 0 to 85 degrees; P<0.001) postoperatively. The increasing age at surgery was associated with improved elbow motions (P=0.004). Patients with increased preoperative serum alkaline phosphatase level demonstrated decreased arc of motion (P=0.015). Patients with extra-articular fractures had better outcomes than the other patients. At the final follow-up, 8 patients experienced recurrent contracture in the flexion arc with heterotopic ossification. Two patients had postoperative pain, 1 elbow instability, and 1 ulnar neuropathy.Conclusions:Most patients showed satisfactory functional outcomes after arthrolysis, indicating that open release with or without hinged external fixation is an effective and maintained technique for children and adolescents with posttraumatic elbow stiffness. The age at surgery, preoperative alkaline phosphatase level, and injury type should be considered to achieve good outcomes.Level of Evidence:Therapeutic level III.

Arthroscopic Osteocapsular Arthroplasty with Mini-Open Ulnar Nerve Decompression for Elbow Arthritis

Patients with elbow osteoarthritis present with painful limited motion and report ulnar nerve symptoms occasionally. Arthroscopic osteocapsular arthroplasty for arthritis have showed pain relief and improved range of motion. However, few studies about treatment and outcomes of concomitant ulnar neuropathy have been reported. The purpose of this study was to evaluate clinical outcomes after arthroscopic osteocapsular arthroplasty combined with ulnar nerve decompression for the treatment of elbow osteoarthritis with concomitant ulnar neuropathy. Among 45 patients with elbow osteoarthritis underwent arthroscopic osteocapsular arthroplasty, 22 patients with preoperative concomitant ulnar neuropathy were included in this study. Surgical procedures included arthroscopic debridement and capsulectomy with miniopen ulnar nerve decompression. Preoperatively, extent of ulnar nerve dysfunction was classified according to the McGowan stage. Postoperative elbow function was assessed using VAS, range of motion, and Mayo Elbow Performance Index (MEPI) and ulnar nerve function was assessed using the modified Bishop score. At a mean follow-up of 21 months, significant improvement occurred in the mean pain, from VAS 4.1 to 1.5and total arc of motion, from 95° to 115°. Average MEPI scores were 67 preoperatively and 85 at final follow-up and 81% of patients showed good to excellent results according to MEPI scores. Improvement of paresthesia and weakness were noted in 18 cases and and 16 cases respectively. According to the modified Bishop score, 10 patients had excellent, 7 good, 3 fair and 2 poor results. Arthroscopic osteocapsular arthroplasty combined with miniopen decompression of the ulnar nerve showed satisfactory outcomes in patients with elbow arthritis concomitant ulnar neuropathy. Miniopen ulnar nerve decompression was safe and effective procedure and can be indicated for ulnar neuropathy in the setting of elbow osteoarthritis.

Number of screws in the articular segment of distal humerus AO/OTA C-type fractures treated with open reduction internal fixation is associated with complication rate.

Introduction: Surgical treatment of distal humerus fractures can lead to numerous complications. Data suggest that the number of screws in the distal (articular) segment may be associated with complication rate. The purpose of this study is to evaluate the association between a number of screws in the distal segment and complication rate for surgical treatment of distal humerus fractures. We hypothesize that the number of screws in the articular segment of distal humerus AO/OTA C-type fractures treated with open reduction internal fixation (ORIF) will be inversely proportional to the complication rate. Methods: We performed a single-center retrospective cohort study of 27 patients who underwent ORIF of distal humerus fractures C-type with at least six months of radiographic and clinical follow-up. Clinical outcomes including a range of motion, pain, revision surgery for stiffness and/or heterotopic ossification (HO), nonunion, and persistent ulnar nerve symptoms requiring revision neurolysis were recorded. Results: In C-type fractures, the use of three or fewer articular screws was significantly associated with nonunion or loss of fixation (RR 17, p = 0.006). Nineteen of 36 (53%) patients experienced at least one complication. The surgical approach, plate configuration, age, and ulnar nerve treatment (none, in situ release, transposition) were not associated with the need for revision surgery. Men had a higher risk of requiring surgical contracture release due to improving post-operative stiffness (RR 12, p = 0.02). Conclusion: In this retrospective study, the use of three or fewer screws to fix articular fragments in AO type C fractures was a significant risk for nonunion or loss of fixation. Plate configuration and surgical approach did not correlate with outcomes. Men had higher rates of complications and required more frequent revision surgery compared to women.

Outcomes following revision of the revision total elbow arthroplasty

There is very little information in the literature on the outcomes of revision of revision total elbow arthroplasty (RRTEA). Our aim was to report the outcomes of this rarely performed procedure. We retrospectively identified all patients who had undergone RRTEA between 2007 and 2016. Outcomes were assessed clinically using a number of validated systems, and radiographs were reviewed for prosthesis alignment, cementation by Morrey grading, and heterotopic ossification. We identified 22 patients who underwent RRTEA. Of these patients, 14 were available for assessment (2 died of unrelated causes, 2 could not be contacted, 2 declined to participate because of travel difficulties, and 2 had incomplete data). At the final review, the median age was 73 years (range, 57-83 years), with a median follow-up period of 4.5 years (range, 2-7 years) since the last surgical procedure. The median number of previous revision arthroplasty procedures per patient was 3 (range, 2-6). The indications for RRTEA were aseptic loosening (60%), bushing wear (16%), fracture (14%), and infection (10%). Of the patients, 30% required extra-long or custom-made implants and 50% needed allograft augmentation. At final clinical assessment, 56% of patients had triceps insufficiency, the median flexion-extension arc was 90°, and the median prono-supination arc was 95°. The functional elbow scores revealed good outcomes in the majority of patients (median visual analog scale score, 5; median Oxford Elbow Score, 22; median Mayo Elbow Performance Index score, 55; and median QuickDASH [short version of Disabilities of the Arm, Shoulder and Hand questionnaire] score, 63). Eighty-one percent of patients were satisfied with their RRTEAs. Complications included infection in 2 patients (1 superficial and 1 deep), symptomatic aseptic humeral component loosening in 1, sensory ulnar nerve symptoms in 2, and radial nerve injury in 1. One patient required ulnar nerve release. Radiologic review revealed asymptomatic loosening in 1 patient (humeral component), and overall prosthesis alignment with cementation was adequate in 81%. Heterotopic ossification was present in 38% of cases. RRTEA is a satisfactory treatment option in these complex cases, with good short- to mid-term survival rates but a relatively high complication rate.

Cubitus Valgus with Tardy Ulnar Nerve Palsy - Functional Outcome of Milch Osteotomy without Anterior Transposition of Ulnar Nerve.

Introduction:To assess the results of Milch osteotomy in terms of deformity correction and functional outcome in the absence of ulnar nerve transposition.Material and Methods:Nine patients with cubitus valgus deformity greater than 20° with tardy ulnar nerve palsy (TUNP) operated between 2012 and 2017 were evaluated. Correction by Milch osteotomy and fixation was done in each case, without osteosynthesis of the non-union lateral condyle humerus or transposition of the ulnar nerve. At one year post-operatively, carrying angle, elbow function (Mayo Elbow Performance Score) and ulnar nerve symptoms were assessed.Results:The mean carrying angle pre-operatively was 30.8° on the affected side which improved to a mean of 8.3° postoperatively with an average correction of 22.5°. The mean elbow flexion pre-operatively was 129.4° which improved to 133.3° post-operatively. The mean preoperative MEP score was 76.7 which improved to a mean of 92.2 post-operatively (p < 0.01). TUNP recovered completely in all the patients.Conclusion:Milch osteotomy is an effective procedure for cubitus valgus deformity correction and its associated tardy ulnar nerve palsy without a decrease in elbow ROM. Correction of even severe valgus deformities without concurrent anterior transposition of the ulnar nerve is likely to improve ulnar nerve symptoms.

Long-Term Results of Pisiformectomy in a Cohort of 57 Patients.

Background Excision of the pisiform is an infrequently used option for pisotriquetral joint dysfunction when nonoperative treatment is ineffective. This study reviews the patient-reported outcomes of patients treated with pisiformectomy, and furthermore focuses on the complications and the need for and time to revision procedure. Materials and Methods Medical records of 57 patients were manually reviewed and assessed for complications, rate of unplanned reoperations, and type of reoperations. Thirty-seven patients (65%) completed patient-rated outcomes surveys at a median of 10 years after their procedure. Results The complication rate was 13% ( n = 7). Ulnar nerve symptoms were noted in three patients. No reoperations were performed after the pisiform excision. Out of the 16 patients who had preoperative symptoms of ulnar nerve compression at the wrist, 10 patients reported that their symptoms had completely resolved after the surgery. The median Quick Disability of Arm, Shoulder and Hand (QuickDASH) score after surgery was 4.5 (2.3-16), median score for pain 0 (interquartile range [IQR]: 0-2), and median score for overall satisfaction 10 (IQR: 8-10). Conclusions Pisiformectomy is a surgery used sparingly in cases with refractory pain associated with arthrosis of the pisotriquetral joint or enthesopathy of the flexor carpi ulnaris/pisiform interface. When utilized in this fashion, patients report limited disability on patient-rated outcome measures, low pain scores, and high satisfaction at mid- to late follow-up.

Functional outcomes of ulnar collateral ligament reconstruction with a novel double suspensory fixation

Ulnar collateral ligament reconstruction (UCLR) has allowed the return of overhead athletes to throwing sports. We describe a new double suspensory (DS) technique using a single tunnel in the ulna and humerus, achieving fixation with adjustable loop buttons. Inclusion criteria included skeletally mature baseball players with clinical and magnetic resonance imaging diagnosis of UCL insufficiency who failed a trial of structured nonoperative treatment. A total of 36 baseball players underwent DS UCLR, between 2011 and 2017, by 1 surgeon with minimum 2-year follow-up. The graft was fixated with an adjustable button loop on the humeral side and a tension slide technique with a button on the ulnar side. Pre- and postoperative Kerlan-Jobe Orthopaedic Clinicand Single Assessment Numerical Evaluationand postoperative Conway scores were obtained. The mean age was 19.8 ± 4.6 years (range, 14-35 years). All were male. Mean years played before surgery was 14.3 ± 4.6 years (range, 8-28 years). There were 32 (89%) pitchers and 4 (11%) position players. There were 13 (36%) high school, 20 (55%) college, 2 (6%) minor league, and 1 (3%) adult league athletes. The mean follow-up was 55.3 ± 23.7 months (range, 26-97 months). There was significant improvement in Kerlan-Jobe Orthopaedic Clinic (33.2 ± 19.9 to 89.7 ± 15.1, P < .0001) and Single Assessment Numerical Evaluation (20.7 ± 16.7 to 93.6 ± 11.9, P < .0001) scores. Using Conway scoring, 25 (69%) had excellent, 5 (14%) good, 3 (8%) fair, and 3 (8%) poor scores. Mean return to play was 9 ± 1.5 months (range, 6-16 months). Only 1 (3%) athlete required a revision surgery and ultimately returned to play and 1 (3%) hardware removal. None developed ulnar nerve symptoms. DS fixation for UCLR in baseball players can lead to excellent clinical results and early return to play.

Neurologic complications after surgical management of complex elbow trauma requiring radial head replacement

Radial head arthroplasty (RHA) has become a successful procedure for addressing acute unreconstructible radial head fractures that compromise elbow stability in complex elbow trauma. The purpose of this study was to investigate the incidence of and risk factors for the development of neurologiccomplications after surgical treatment of complex elbow fractures that require an RHA. Sixty-two patients with an unreconstructible radial head fracture and complex elbow instability treated with RHA were included. There were 33 men and 29 women, with a mean age of 54 years (range, 22-87 years). The average follow-up period was 5.2 years (range, 3-16 years). All patients were neurologically intact before surgery. The arthroplasty was implanted through a Kocher approach in 55 cases, whereas a Kaplan approach was used in 7. An uncemented smooth stem arthroplasty (Evolve) was used in 27 patients, and an anatomic ingrowth system (Anatomic Radial Head), in 35. At the time of surgery, 23 patients underwent fixation of a coronoid fracture and 15 underwent plating of the proximal ulna. All patients were clinically examined immediately after surgeryand during follow-up to detect any degree of neurologic deficit. Radial and ulnar nerve injuries were classified according to the Hirachi and McGowan classifications, respectively. Functional outcomes were evaluated with the Mayo Elbow Performance Score. A complete posterior interosseous nerve palsy occurred postoperatively in 2 patients. Hand function had completely recovered in both at 2 months after surgery without sequelae. Nine patients complained of ulnar nerve symptoms (immediately after surgery in 6andasdelayed ulnar neuropathy in 3). Most patients with ulnar nerve deficits had undergone additional surgical procedures to address ulnar fractures. Among patients with ulnar neuropathies, only 3 complained of mild sensory symptoms at the latest follow-up. Nosignificant differences in range of motion and Mayo Elbow Performance Score were found between patients with and without neurologic complications. Associated olecranon or coronoid fixation and a prolonged tourniquet time were identified as risk factors for neurologic complications. This study shows that the incidence of neurologic complications associated with the surgical treatment of complex elbow fractures requiring implantation of a radial head prosthesis may be underestimated in the literature. Inappropriate retraction in the anterior aspect of the radial neck, a prolonged ischemia time, and concomitant coronoid or olecranon fracture fixation represent the main risk factors for the development of this complication. Although the great majority of patients have full recovery of their nerve function, they should be advised on the risk of this stressful complication.

Clinical outcomes of open reduction and internal fixation in treating Gustilo typeI and II patients with open distal humeral fractures

To analysis clinical effects of open reduction and internal fixation in treating Gustilo type I and II patients with open distal humeral fracture. From 2013 May to 2017 June, 24 patient with Gustilo grade I and II open distal humeral fractures were treated with open reduction and internal fixation, including 20 males and 4 females, aged from 14 to 65 years old with an average of (41.3±13.1) years old. According to Gustilo classification, 16 patients were type I, 8 patients were typeII. Range of motion, complications and secondary surgery were recorded; elbow function were evaluated with VAS (visual analogue scale), MEPS (Mayo elbow performance score) and QuickDASH (quick disabilities of the arm, shoulder, and hand) at 12 months after operation. All patients were followed up from 15 to 60 years with an average of (34.1±11.9) months. VAS score was 0(0, 2); flexion and extension ranged from 50 °to 145° with an average of (115.2±26.1)°; the range of rotation ranged from 100° to 160° with an average of (147.7±17.0)°. MEPS score was for 75 to 90 (90.0±9.1), and 14 patients got excellent result, 10 patients moderate. Quick DASH score was 4.6(0, 14.8). There were 22 patients occurred complications, such as ulnar nerve symptom and internal fixation irritation, and 10 patients accepted the second operation. Open reduction and internal fixation is a safe and efficient method in treating Gustilo type I and II patients with open distal humeral fractures, which has an advantages of good range of movement and function score.

Use of a modified Outerbridge-Kashiwagi procedure for the treatment of posttraumatic elbow sequelae

To review our 10-year experience treating posttraumatic sequelae of the elbow using a modified Outerbridge-Kashiwagi (O-K) procedure. Twenty-one patients with posttraumatic sequelae of the elbow treated using the technique were evaluated clinically using the Mayo Elbow Performance Score, range of motion testing, and pain level. We noted the presence of preoperative and postoperative ulnar nerve symptoms, complications, and reoperations. Open contracture release was selected to address either removal of hardware or ulnar nerve pathology. At a mean of 39 months (range, 12-116 months), the Mayo Elbow Performance Score improved from 52 to 84 (P < .0001)and the mean arc of motion improved from 44° to 98° (P < .0001). At the final follow-up, 90% of patients reported no pain or mild pain, and 81% of patients had a satisfactory objective result. In 15 of 21 cases (71%), it was necessary to mobilize the ulnar nerve. After contracture release, 1 patient developed new onset ulnar nerve symptoms. Three patients underwent reoperation: 2 for recalcitrant contracture and 1 for new onset ulnar nerve symptoms. The mini-open O-K procedure is safe and effective in restoring function in patients with retained hardware and posttraumatic contracture. Posttraumatic arthritic patients often require both removal of hardware and neurolysis of the ulnar nerve. The mini-open O-K procedure allows complete access to the elbow joint, which facilitates release for both intrinsic and extrinsic contracture.

Arthroscopic release for the severely stiff elbow.

Arthroscopic release for the stiff elbow has been widely used, but there are no reports limited to severe stiffness. The purpose of this study was to investigate the outcomes of severe cases. Ten patients with 10 severely stiff elbows defined by a limited arc of ≤ 60° underwent this arthroscopic release. Causes of stiffness were post-traumatic stiffness (one patient), osteoarthritis (three patients), and rheumatoid arthritis (six patients). Using arthroscopy, the capsule contracture and the intra-articular fibrosis were removed and the impinging osteophyte and part of the radial head were resected. For four patients with preoperative ulnar nerve symptoms or contracture of the posterior oblique ligament of the medial collateral ligament, mini-open ulnar nerve neurolysis and release of the posterior oblique ligament were performed. Patients were followed up for an average of 24months. Arthroscopic release could be performed without any intraoperative complications. Range of motion for the elbow significantly improved from 95° of flexion and - 55° of extension to 109° of flexion and - 32° of extension. The Mayo Elbow Performance Score also improved from 56 points to 80 points. Two patients underwent a second arthroscopic surgery and gained further arc of motion. One patient showed osteophyte reformation and needed revision open surgery 1year after the initial surgery. Arthroscopic release for the severely stiff elbow could improve range of motion. Careful attention should be given during surgery to avoid complications such as intramuscular bleeding or nerve damage.

Determining the effective timing of an open arthrolysis for post-traumatic elbow stiffness: a retrospective cohort study

BackgroundFollowing trauma, the elbow is the most susceptible to restricted motion among all joints. Open arthrolysis is often performed for post-traumatic elbow stiffness if that stiffness does not improve with non-operative management. However, the optimal timing for performing an open arthrolysis remains controversial. The purpose of this study was to compare the outcome (elbow motion and function) and the rate of complications among patients who had undergone early, median and late release procedures to establish an optimal time interval following the injury, after which, an effective open arthrolysis can be performed.MethodsIn this retrospective cohort study, we included total 133 patients, who had undergone open arthrolysis for post-traumatic elbow stiffness. The subjects were divided into 3 groups, with 31 patients in the early release group (arthrolysis performed at 6–10 months after injury), 78 patients in the median release group (at 11–20 months), and 24 patients in the late release group (at > 20 months). The release procedure in all patients was performed by the same surgeon, using the same technique. The general data, functional performance, and complications, if any, were retrospectively documented for all patients and statistically analysed.ResultsThe demographic data and disease characteristics of all patients were comparable at baseline. Postoperatively, no significant differences were found among the three groups with respect to the range of motion (p = 0.067), Mayo Elbow Performance Score (p = 0.350) and its ratings (p = 0.329), visual analog scale score for pain (p = 0.227), Dellon classification for ulnar nerve symptoms (p = 0.497), and each discrete complication (all p values > 0.05).ConclusionsAt the final follow-up, our results showed no significant difference in the postoperative elbow motion capacities, functional scores and the rates of complications among patients who had undergone an early, median, and late release. Therefore, we have recommended that an early arthrolysis would be preferable due to its multiple advantages, and the conventionally observed interval of > 1 year after the injury, could be shortened.Level of evidenceLevel III; Retrospective Cohort Design; Therapeutic Study.

Arthroscopic Treatment of Lateral Elbow Pain Mimicking Lateral Epicondylitis: Long-term Follow-up of a Unique Surgical Protocol.

The failure rate of extensor carpi radialis brevis debridement for refractory lateral epicondylitis is reported around 15%. Our novel arthroscopic treatment is predicated on the hypothesis that lateral epicondylitis is an intra-articular problem related to a variation of the capsule-meniscal anatomy that impinges on the radiocapitellar joint. We report long-term outcomes of 35 patients treated with a novel arthroscopic resection of their capsulosynovial fringe. All patients failed nonoperative treatment but had temporary improvement with an intra-articular injection. Arthroscopic treatment involved resecting the meniscus and the proximal edge of the orbicular ligament, followed by a tendon-sparing anterolateral capsulectomy. 35 patients underwent evaluation on average 9.2 years after surgery. Outcome measures included VAS, DASH, and questions on return to sports, satisfaction, and perceived benefit of surgery. Median pain scores improved from 8 of 10 preoperatively to 0 of 10 postoperatively. This change was clinically and statistically significant, with 1 patient still requiring pain medication. Median DASH score at final follow-up was 1. Overall, 30 patients rated their postoperative outcome as much better, 5 rated it as better, and 0 reported their symptoms to be unchanged or worsened. All 35 patients stated they were happy they underwent the procedure and perceived a benefit. Totally, 4 of 35 patients had postoperative complications (2 with ulnar nerve symptoms, 2 with persistent pain), with one requiring revision surgery for persistent pain. We report promising long-term clinical and functional results of a novel arthroscopic resection of the capsulosynovial complex in lateral epicondylitis.

Tobacco use predicts poorer clinical outcomes and higher post-operative complication rates after open elbow arthrolysis.

Tobacco use is a worldwide public health problem, and has been found to be a predisposing factor for adverse functional outcomes and increased postoperative complication rates after various orthopedic operations. The purpose of this study was to determine the potential impact of tobacco use on open arthrolysis for post-traumatic elbow stiffness. A database search identified 145 patients with open arthrolysis performed for post-traumatic elbow stiffness; these were divided into three groups: current tobacco users (37), former users (28), and nonusers (80). All surgeries were performed using the same technique by the same doctor. General patient data, functional performance, and complications were documented and analyzed. Demographic data and disease characteristics were comparable at baseline. Postoperatively, significant differences were found among the three groups in terms of range of motion (P < 0.001), Mayo Elbow Performance Score (P = 0.006), visual analog scale score for pain (P = 0.015), Dellon classification for ulnar nerve symptoms (P = 0.013), and total complication rates (P < 0.001). The current tobacco users group had the poorest clinical outcomes and highest complication rates, while no significant differences were found between former users and nonusers. Current tobacco users reported increased risk of poorer clinical outcomes and higher postoperative complication rates after open arthrolysis. Former users were found to have outcomes similar to those of nonusers. This study underlines the importance of discontinuing tobacco use for patients with post-traumatic elbow stiffness who are considering open arthrolysis. Level III; Retrospective Cohort Design; Therapeutic Study.

Outcome measures after medial ulnar collateral ligament reconstructions in a military population

Medial ulnar collateral ligament (MUCL) reconstruction outcomes are well described in competitive throwers but not in nonthrowers. This investigation elucidated epidemiologic variables, functional outcomes, and prognostic factors after MUCL reconstruction in young active patients. United States military service members undergoing MUCL reconstruction were isolated using the Management Analysis and Reporting Tool (M2) database from 2009 to 2016. Demographics, injury characteristics, and surgical variables were extracted. Multivariate analysis was performed, discerning variables predictive of postoperative functional outcomes, complications, and reoperation. Sixty-six patients met inclusion criteria, and 47% participated in throwing sports. Of these, 36.4% reported a throwing mechanism of injury (MOI), 60.6% reported an acute trauma MOI, 59% reported preoperative ulnar nerve symptoms, and 39.4% experienced symptoms postoperatively. At final follow-up, average Disabilities of the Arm, Shoulder and Hand (DASH) and Mayo Elbow Performance Score (MEPS) scores were 10.8 ± 16.2 and 87.6 ± 17.1, respectively. A total of 86.4% reported no disability (DASH < 30), and 83.3% experienced good or excellent outcomes (MEPS >74). Age < 30 years, dominant arm injury, competitive throwing history, and throwing MOI correlated with improved DASH and MEPS scores, push-up count, postoperative pain and instability, and rates of ulnar nerve symptoms (P < .05). Psychiatric diagnosis and preoperative stiffness and instability were associated with lower outcome scores (P < .05). Ulnar nerve interventions did not correlate with presence or absence of postoperative ulnar nerve symptoms. MUCL reconstruction demonstrates a high good-to-excellent outcome rate and low complication and revision rates in young active individuals with intense upper extremity demands. Nonthrowing MOIs and psychiatric pathology are associated with postoperative complications and poorer outcomes.