Considerable variation in current coronoid height and fracture measurement techniques: a systematic review.

BACKGROUND: Coronoid fractures usually occur in the presence of a significant osseoligamentous injury to the elbow. Fracture size and location correlate with degree of instability and many authors have attempted to analyze the effect of fracture variation on decision making and outcome. There remains no standardized technique for measuring coronoid height or fracture size. The aim of this study was to appraise the literature regarding techniques for coronoid height measurement in order to understand variation. METHODS: Preferred Reporting Items of Systematic Reviews and Meta-Analyses guidelines were followed. A search was performed to identify studies with either a description of coronoid height, fracture size, or bone loss using the terms (Coronoid) AND (Measurement) OR (Size) OR (Height). Articles were shortlisted by screening for topic relevance based on title, abstract and, if required, full-text review. Exclusion criteria were non-English articles, those on nonhuman species or parts other than the ulna coronoid process, and studies that included patients with pre-existing elbow pathology. Shortlisted articles were grouped based on study type, imaging modality, measurement technique, and measurement parameter as well as its location along the coronoid. RESULTS: Thirty out of the initially identified 494 articles met the inclusion criteria. Twenty-one articles were clinical studies, 8 were cadaveric studies, and 1 combined patients as well as cadavers. A variety of imaging modalities (plain radiographs, 2-dimensional computed tomography [CT], 3-dimensional CT, magnetic resonance imaging or a combination of these) were used with CT scan (either 2-dimensional images or 3-dimensional reconstructions or both) being the most common modality used by 21 studies. Measurement technique also varied from uniplanar linear measurements in 15 studies to multiplanar area and volumetric measurements in 6 studies to techniques describing various angles and indices as an indirect measure of coronoid height in 8 studies. Across the 30 shortlisted studies, 19 different measurement techniques were identified. Fifteen studies measured normal coronoid height while the other 15 measured intact coronoid and/or fracture fragment height. The location of this measurement was also variable between studies with measurements at the apex of the coronoid in 24/30 (80%) of studies. Measurement accuracy was assessed by only 1 study. A total of 12/30 (40%) studies reported on the interobserver and intraobserver reliability of their measurement technique. CONCLUSION: The systemic review demonstrated considerable variability between studies that report coronoid height or fracture size measurements. This variability makes comparison of coronoid height or fracture measurements and recommendations based on these between studies unreliable. There is need for development of a consistent, easy to use, and reproducible technique for coronoid height and bone loss.

Biomechanical comparison of headless compression screws versus independent locking screw for intra-articular fractures.

PURPOSE: Headless compression screws (HCS) have a variable thread pitch and headless design enabling them to embed below the articular surface and generate compression force for fracture healing without restricting movement. Locking screws have greater variety of dimensions and a threaded pitch mirroring the design of the HCS. The objective of this study is to determine whether locking screws can generate compression force and compare the compressive forces generated by HCS versus locking screws. METHOD: A comparison between 3.5-mm HCS versus 3.5-mm locking screws and 2.8-mm HCS versus 2.7-mm locking screws was performed using a synthetic foam bone model (Synbone) and FlexiForce sensors to record the compression forces (N). The mean peak compression force was calculated from a sample of 3 screws for each screw type. Statistical analysis was performed using the one-way ANOVA test and statistical significance was determined to be p = < 0.05. RESULTS: The 3.5-mm Synthes and Smith and Nephew locking screws generated similar peak compression forces to the 3.5-mm Acutrak 2 headless compression screws with no statistically significant difference between them. The smaller 2.7-mm Synthes and Smith and Nephew locking screws initially generated similar compressive forces up to 1.5 and 2 revolutions, respectively, but their peak compression force was less compared to the 2.8-mm Micro Acutrak 2 HCS. CONCLUSION: Locking screws are able to generate compressive forces and may be a viable alternative to headless compressive screws supporting their use for intra-articular fractures.

Sensitivity and specificity of the posterolateral rotatory drawer test in the diagnosis of lateral collateral ligament insufficiency of the elbow.

BACKGROUND: Numerous clinical tests are described for the diagnosis of chronic lateral collateral ligament (LCL) insufficiency of the elbow; however, none of these tests have been adequately assessed for sensitivity, with at most 8 patients included in previous studies. Furthermore, no test has had specificity assessed. The posterolateral rotatory drawer (PLRD) test is thought to have improved diagnostic accuracy over other tests in the awake patient. The aim of this study is to formally assess this test using reference standards in a large cohort of patients. METHODS: A total of 106 eligible patients were identified for inclusion from a single-surgeon database of operative procedures. Examination under anesthetic (EUA) and arthroscopy were chosen as the reference standards to compare the PLRD test against. Only patients with a clearly documented PLRD test finding performed preoperatively in the clinic, and a clearly documented EUA and/or arthroscopic findings from surgery were included. A total of 102 patients underwent EUA, 74 of whom also underwent arthroscopy. Twenty-eight patients had EUA, and then an open procedure without arthroscopy. Four patients had arthroscopy without a clearly documented EUA. Sensitivity, specificity, and positive (PPV) and negative predictive values (NPV) were calculated with 95% confidence intervals. RESULTS: Thirty-seven patients had a positive PLRD test, and 69 had a negative test. Compared to the reference standard of EUA (n = 102), the PLRD test had a sensitivity of 97.3% (85.8%-99.9%) and a specificity of 98.5% (91.7%-100%) (PPV = 0.973, NPV = 0.985). Compared to the reference standard of arthroscopy (n = 78), the PLRD test had a sensitivity of 87.5% (61.7%-98.5%) and a specificity of 98.4% (91.3%-100%) (PPV = 0.933, NPV = 0.968). Compared to either reference standard (n = 106), the PLRD test has a sensitivity of 94.7% (82.3%-99.4%) and a specificity of 98.5% (92.1%-100%) (PPV = 0.973, NPV = 0.971). CONCLUSION: The PLRD test demonstrated an overall sensitivity of 94.7% and specificity of 98.5% with high positive and negative predictive values. This test is recommended as the primary diagnostic tool for LCL insufficiency in the awake patient and should be widely incorporated into surgical training.

Development of a core outcome set for lateral elbow tendinopathy (COS-LET) using best available evidence and an international consensus process.

OBJECTIVES: To develop a core outcome set for lateral elbow tendinopathy (COS-LET) and to provide guidance for outcome evaluation in future studies. METHODS: We implemented a multi-stage mixed-methods design combining two systematic reviews, domain mapping of outcome measurement instruments to the core domains of tendinopathy, psychometric analysis of instruments, two patient focus groups and a Delphi study incorporating two surveys and an international consensus meeting. Following the OMERACT guidelines, we used a 70% threshold for consensus. RESULTS: 38 clinicians/researchers and 9 patients participated. 60 instruments were assessed for inclusion. The only instrument that was recommended for the COS-LET was Patient Rated Tennis Elbow Evaluation (PRTEE) for the disability domain. Interim recommendations were made to use: the PRTEE function subscale for the function domain; PRTEE pain subscale items 1, 4 and 5 for the pain over a specified time domain; pain-free grip strength for the physical function capacity domain; a Numerical Rating Scale measuring pain on gripping for the pain on activity/loading domain; and time off work for the participation in life activities domain. No recommendations could be made for the quality-of-life, patient rating of condition and psychological factors domains. CONCLUSIONS: The COS-LET comprises the PRTEE for the disability domain. Interim-use recommendations included PRTEE subscales, time off work, pain-free grip strength and a Numerical Rating Scale measuring pain on gripping. Further work is required to validate these interim measures and develop suitable measures to capture the other domains.

Coronal shear fractures of the distal humerus managed according to the Modified Dubberley Classification System.

BACKGROUND: Coronal shear fractures of the capitellum and trochlea are relatively uncommon and can be challenging to treat because of variable articular comminution and poor bone stock. Classification is valuable to help guide surgical decision making and prognosis. The aim of this study was to present a large series of coronal shear fractures treated according to the Modified Dubberley Classification System (MDCS). METHODS: Forty-five patients with a coronal shear fracture were followed up (12-93 months, mean: 28 months) after surgical intervention. Fractures were classified according to the MDCS by 3 observers, and outcome data collected included Oxford elbow score (OES), visual analog pain score (VAS), range of motion, complications, and radiographic findings. RESULTS: There were 10 type 1, 12 type 2, 8 type 3, and 15 type 4 fractures. There were 26 subtype B fractures (posterior comminution). A total of 37 patients underwent open reduction and internal fixation (ORIF) and 8 primary arthroplasty. The median OES and VAS were 43(16-48) and 2 (0-9), respectively. Median flexion extension arc was 125° (range, 70°-140°). There was no significant difference in OES, VAS, or range of motion according to fracture type (types 1-4), subtype (type a or b), or treatment method (arthroplasty vs. ORIF). The overall complication and reoperation rates were 31% and 33%, respectively. A total of 75% of complications occurred in type 3 and 4 fractures, and there was a nonsignificant trend toward higher complication rate in type B fractures than type A fractures (34% vs. 16%, P = .19). Patients with a type B fracture who underwent screw-only fixation had a significantly lower OES and higher complication rate compared with when they had combined plating with screws (OES, P = .03; complications P = .04) and compared with when an arthroplasty was performed (OES, P = .05; complications P = .04). CONCLUSION: Consistently good outcomes can be achieved by classification and management according to the MDCS. It is recommended that type B fractures undergo combined plate and screw fixation and that type 4 fractures should be considered for arthroplasty because of the higher risk of complications with ORIF.

Elbow arthroplasty is safe for the management of simple open distal humeral fractures.

BACKGROUND: Elbow arthroplasty (EA) is an established technique for the treatment of select distal humeral fractures, yet little data exists regarding the safety and outcome of EA in the presence of an open distal humeral fracture where the risk of periprosthetic infection is an even greater concern. We hypothesized that EA does not carry an increased risk of infection or other postoperative complications when performed for simple open distal humeral fractures. METHODS: Seventeen patients underwent total EA (n = 9) or hemiarthroplasty (n = 8) for an open distal humeral fracture. The open fracture component was classified according to the Orthopaedic Trauma Society system as "simple" or "complex." Outcome measures collected included the Mayo Elbow Performance Score (MEPS), range of motion, complications, and reoperations. Patients who underwent primary débridement and implantation were compared with those who underwent preliminary débridement procedures and subsequent staged arthroplasty. A systematic review of the existing literature was performed to analyze other reported cases and contextualize our findings. RESULTS: The mean follow-up was 46 months (range, 12-138 months). All fractures were multifragmentary and intra-articular. Sixteen patients had a "simple" open fracture and 1 had a "complex" fracture. The overall mean MEPS was 83 (range, 30-100; standard deviation ± 17), with a mean flexion-extension arc of 96°. Patients who underwent primary débridement and implantation demonstrated a higher mean flexion arc (116° vs. 79°, P = .02) than those who underwent staged arthroplasty. The mean MEPS was not significantly different between the groups (90 vs. 78, P = .12). Complications included asymptomatic ulna component loosening (n = 1), joint instability (n = 1), and symptomatic heterotopic ossification (n = 3). There were no deep or superficial infections recorded. CONCLUSION: EA is safe and effective when performed for simple open distal humeral fractures. Primary débridement and implantation may offer functional benefits over a staged approach.

A Systematic Review of Arthroscopic Versus Open Debridement of the Arthritic Elbow.

PURPOSE: To systematically review the available data with regard to clinical and functional outcomes of arthroscopic and open debridement for elbow arthritis to determine the complication rate with transition to arthroscopic surgery. METHODS: Using the Preferred Reporting Items for Systematic Reviews and Meta Analyses protocol, a systematic review was performed including studies reporting clinical and functional outcomes following open or arthroscopic debridement of elbow arthritis. The primary outcome measures analyzed were functional outcome (Mayo Elbow Performance Score), range of motion, and complication rate. Data were extracted for the whole group and then compared between the techniques using ranges and forest plots. RESULTS: In total, 39 level IV and 3 level III studies with 1097 elbows were eligible for inclusion; 684 elbows were treated using an open technique and 413 using an arthroscopic technique. Regarding functional outcome scores, mean Mayo Elbow Performance Score improved significantly with comparable magnitude of improvement in both groups (arthroscopic group: range 28-34, open group: range 25-31). Regarding range of motion, mean flexion-extension arc improved significantly in both groups (arthroscopic group: range 8-26°, open group: range 13-49°). The open group had a lower preoperative flexion-extension arc (range 63-96) in comparison with the arthroscopic group (range 84-119). The overall incidence of complications was 5.7% (range 0%-19%) in the arthroscopic group and 6.1% (range 0%-25%) in the open group. The most common complication type was neurologic, with an incidence of 2.1% (range 0%-8%) in the arthroscopic group and 1.9% (range 0%-12%) in the open group. The deep infection rate was 0.7% (range 0%-10%) in the open group with no reported incidence in the arthroscopic group. CONCLUSIONS: This systematic review demonstrated good mid-term functional outcomes following debridement arthroplasty of the arthritic elbow. There was no increase in complications with an arthroscopic technique confirming its safety and efficacy. LEVEL OF EVIDENCE: IV, Systematic Review of Level III and IV articles.

Management of anteromedial coronoid fractures according to a protocol focused on instability assessment provides good outcomes with infrequent need for coronoid fixation.

BACKGROUND: Anteromedial coronoid fractures (AMCFs) are associated with persistent elbow instability and post-traumatic arthritis if managed incorrectly. It is unclear exactly which AMCFs require surgical intervention and how to make this decision. The aims of this study were to report outcomes of AMCFs managed using a protocol based on reproduction of instability using radiographic and clinical testing and to ascertain a threshold size of AMCF associated with instability. METHODS: Forty-three AMCFs were studied. Thirty-two patients formed the primary study group (group A). All were treated using a protocol in which the decision to perform coronoid fixation was based on the presence of radiographic or clinical evidence of instability. Functional outcomes (Oxford Elbow Score), radiographic outcomes, complications, and reoperations were collected, and a receiver operating characteristic curve analysis was performed to assess the optimal coronoid fracture height to recommend coronoid fixation. The results were compared with a historical group of 11 patients with AMCFs not treated according to the protocol (group B). RESULTS: Of the patients, 23 had an isolated AMCF and 20 had a concurrent radial head injury. Complete nonoperative treatment of the elbow was performed in 16 patients (37%) (11 of 32 [34%] in group A vs. 5 of 11 [45%] in group B, P = .46). In 10 patients (23%), only repair of the lateral collateral ligament was performed (9 in group A and 1 in group B), whereas 8 patients (19%) underwent repair of the lateral collateral ligament and radial head fixation or replacement (6 in group A and 2 in group B). Acute coronoid fixation was performed in 9 patients (21%) (6 in group A and 3 in group B). At a mean follow-up of 20 months (range, 12-56 months), group A showed a significantly better Oxford Elbow Score (42 vs. 31, P = .02), lower complication rate (3 of 32 [9%] vs. 8 of 11 [72%], P < .001), and lower reoperation rate (1 of 32 [3%] vs. 6 of 11 [54%], P < .001) than group B. Persistent instability was found in 6 patients in group B and none in group A. The receiver operating characteristic curve analysis demonstrated 6.5 mm to be the optimal AMCF size for surgery to prevent persistent instability. CONCLUSION: Patients treated according to a protocol in which preoperative reproduction of instability determined the degree of surgical intervention had good clinical and radiographic outcomes. Our study demonstrated that AMCFs > 6.5 mm are likely to be more unstable and require intervention. If these principles are followed, a specifically defined subset of AMCFs can be treated nonsurgically without adverse outcomes.

Distal biceps short head tears: repair, reconstruction, and systematic review.

BACKGROUND: Isolated short head tears of the distal biceps are uncommon and often underappreciated. The aim of this study was to describe the presenting features and management of acute and chronic short head ruptures treated at our unit and in the published literature. METHODS: Six short head ruptures in 5 patients are described. The clinical and radiographic findings, operative techniques, and postoperative outcomes are reported for all patients. A systematic review of the existing literature was also performed. RESULTS: All patients presented with pain and weakness following an acute traumatic event. One patient presented with bilateral tears 3 years apart. Four of the ruptures underwent acute repair. Two ruptures presented chronically with retracted short head tears and were treated with allograft reconstruction of the short head. Preoperative magnetic resonance imaging findings demonstrated retraction of the short head affecting only 1 muscle belly, and in all patients the hook test was intact. All patients reported excellent functional outcome scores with no postoperative complications. The systematic review identified 9 previously reported cases, of which 8 were treated surgically with a successful outcome. Detailed analysis of these cases demonstrated clinical findings consistent with our cases, and these are outlined in depth in the article. DISCUSSION/CONCLUSIONS: Isolated short head ruptures are a rare and distinct form of distal biceps tear that present with consistent clinical findings that can aid in diagnosis. They present acutely, have a poor natural history akin to complete tears, and have good outcomes with acute and delayed reconstruction.

The arthroscopic Latarjet: a multisurgeon learning curve analysis.

BACKGROUND: The open Latarjet procedure is a standard surgical treatment option for anterior shoulder instability in patients with a high risk of failure following soft tissue stabilization. The arthroscopic technique has potential advantages of minimal invasiveness, reduced postoperative stiffness, and faster rehabilitation but is regarded as technically challenging with concern over surgical risk during the learning curve. The aim of this study was to undertake a multisurgeon, large-volume learning curve analysis of the arthroscopic Latarjet procedure using continuous learning curve analysis. METHODS: Individual patient data from 12 surgeons across 5 countries were retrospectively reviewed. A total of 573 patients undergoing the arthroscopic Latarjet procedure were included. Outcome measures of learning were collected, including operative time, computed tomography (CT) bone-block positioning, complications, and patient-reported outcome measures (PROMs). A segmented linear regression modeling technique was used for learning curve analysis. RESULTS: High-volume surgeons converged to an operative time steady state after 30-50 cases. Surgeons completing fewer procedures demonstrated a constant reduction in operative time without reaching a plateau. Low-volume surgeons completing fewer than 14 operations did not demonstrate a reduction in operative time. Accuracy of bone-block positioning on postoperative CT demonstrated constant improvement without reaching a plateau after 53 cases. There was no change in PROMs or complications with increased operative volume. CONCLUSION: Specialist shoulder surgeons require 30-50 arthroscopic Latarjet procedures to attain steady-state operative efficiency, during which there is improvement in bone-block positioning. Only surgeons expecting to undertake the arthroscopic Latarjet in high volume should consider adopting this procedure.

A new radiographic view of the scaphotrapeziotrapezoid joint-a cadaveric study.

BACKGROUND: The scaphotrapeziotrapezoid joint (STTJ) has a complex osseous and ligamentous anatomy. Precise radiographic assessment is paramount when assessing osteoarthritic, post-traumatic, or post-operative patients. There has been no described technique to image the STTJ without any wrist movement, unobscured by the rest of the carpus. The aim of this study was to define an optimal radiographic method to assess the STTJ while maintaining the wrist in neutral position. METHODS: Computer tomography 3-D reconstructions of three uninjured wrists were initially used to determine an approximate beam angle. Serial radiographs of 12 cadaveric wrists were taken. The forearms were positioned in varying degrees of pronation and supination. The beam angle was concurrently adjusted to varying degrees of caudal tilt. From the images obtained, we assessed if the adjacent carpus obscured the view of the STTJ. RESULTS: Optimal STTJ imaging was in the semi-pronated wrist position with the X-ray beam tilted caudal. We found that the STTJ was best visualized at 48° supination from a fully pronated wrist and a caudal beam angle of 22°. CONCLUSIONS: The described wrist and beam orientation can aid in achieving an unobstructed view of the STTJ with little technical effort. This can aid in imaging ambulatory patients where symptoms prevent using other imaging techniques as well as patients in the operating room where imaging timing can be critical.

Fracture line morphology of complex proximal humeral fractures.

BACKGROUND: The aim of this study was to assess proximal humeral fracture patterns using 3-dimensional computed tomography images and relate them to the normal osseous landmarks and soft-tissue attachments. METHODS: Forty-eight 3-dimensional computed tomography scans of proximal humeral fractures were retrospectively collected, and the fractures were transcribed onto proximal humeral templates. We analyzed the common location and orientation of the fracture lines, with a focus on fractures of the articular surface, tuberosities, metaphysis, and proximal diaphysis. These fractures were compared with the attachments of the rotator cuff and glenohumeral capsule. RESULTS: Fifty-two percent of the fractures involved the articular surface. No fractures passed through the bicipital groove, and fractures were more commonly found on the posterior lesser tuberosity and on the anterior greater tuberosity, coinciding with the intervals between the rotator cuff tendon insertions. Intracapsular fractures of the calcar were more common (68%) than extracapsular fractures (32%). On the anterolateral aspect of the proximal humerus, fractures radiated from the articular margin, vertically down through the tuberosity zone between the rotator cuff footprints, meeting horizontally oriented fractures in the metaphyseal zone. On the posterior aspect, vertical fractures from the tuberosity zone continued downward to the metaphyseal zone adjacent to the infraspinatus and teres minor footprints. CONCLUSIONS: Fractures of the proximal humerus follow characteristic patterns. Fractures frequently split the greater tuberosity and are closely related to the intervals of the rotator cuff attachments.

Distal biceps reconstruction using an Achilles tendon allograft, transosseous EndoButton, and Pulvertaft weave with tendon wrap technique for retracted, irreparable distal biceps ruptures.

BACKGROUND: Distal biceps ruptures can result in ongoing pain and weakness when treated nonoperatively. If retraction of the tendon renders primary repair impossible, reconstruction using a graft is recommended. The current literature includes a variety of techniques with studies reporting small patient numbers. The aim of this study was to report the results of a larger cohort of patients using a technique modified from those previously described in the literature. METHODS: Twenty-one consecutive male patients underwent distal biceps reconstruction through 2 small anterior incisions using an Achilles tendon allograft that was fixed distally using a transosseous EndoButton and secured proximally using a Pulvertaft weave and tendon wrap. The mean age was 44 years, and the mean time to surgery was 25 months (range, 2-96 months). Functional outcomes were collected prospectively. RESULTS: The mean preoperative Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) score (11 patients) was 1.9 (range, 0-4.5). The mean postoperative Oxford Elbow Score, QuickDASH score, and Mayo Elbow Performance Score were 44.7 (range, 35-48), 4 (range, 0-20.5), and 92.9 (range, 70-100), respectively, at a mean follow up of 15 months (range, 6-35 months). The mean postoperative QuickDASH score was significantly improved compared with preoperatively (P < .001). All patients were satisfied and all returned to their previous level of activity. There were 2 transient lateral antebrachial cutaneous nerve paresthesias, and 2 patients had a 5° extension lag. There were no other complications. CONCLUSION: Achilles allograft reconstruction of retracted irreparable distal biceps ruptures provides consistently good results with few complications using this technique.

Frequent isolation of Propionibacterium acnes from the shoulder dermis despite skin preparation and prophylactic antibiotics.

BACKGROUND: In vitro, Propionibacterium acnes (P acnes) is highly susceptible to commonly used antibiotics and antiseptics, yet in vivo, it still causes postsurgical infections of the shoulder. We hypothesized that the local environment within the pilosebaceous glands protects P acnes and that incision of the skin transects these glands, exposing viable P acnes to the wound. METHODS: Fifty consecutive patients undergoing open shoulder surgery were prospectively studied. Prophylactic antibiotics were administered to all patients. Microbiologic swabs of the skin surface were taken before and after skin preparation with 70% alcoholic chlorhexidine. The skin was incised, and a further swab and dermal biopsy specimen were taken. RESULTS: P acnes was cultured in 21 of 50 prepreparation skin surface swabs (42%), 7 of 50 postpreparation skin surface swabs (14%), 26 of 50 dermal swabs (52%), and 20 of 50 dermal biopsy specimens (40%). There was a significantly higher incidence of P acnes growth from the skin surface (P = .009) and dermis (P = .01) of patients aged ≤50 years old and in the dermal biopsy specimens of patients undergoing revision surgery (P = .01) and a trend toward increased incidence of P acnes in men. P acnes growth from a prepreparation skin surface swab had a sensitivity of 69%, specificity of 88%, positive predictive value of 86%, and negative predictive value of 72% at predicting subsequent P acnes growth from the dermal swab or biopsy specimen. CONCLUSIONS: Viable P acnes persists within the skin dermis, despite standard antimicrobial precautions. These findings suggest that incising the skin is likely to lead to deep seeding of the surgical wound, which has implications for the pathogenesis and prevention of postsurgical shoulder infections.

Inferior angle of scapula fractures: a review of literature and evidence-based treatment guidelines.

BACKGROUND: Inferior angle of scapula (IAS) fractures are rare, with very few cases reported. They typically present with pain, loss of shoulder motion, and scapula winging. Operative and nonoperative treatments have been trialed with varying success. The aim of this study was to gather data relating to IAS fractures to develop evidence-based treatment guidelines as none are currently available. METHODS: A search was conducted of the PubMed and Google Scholar databases to identify cases of IAS fractures. Data collected about each case included age and gender of the patient, mechanism of injury, fracture displacement, treatment, and outcome. The authors report 2 additional IAS fracture cases. RESULTS: Ten cases were identified for inclusion in this study, 8 from the literature and 2 described by the authors. Of the 10 cases, 7 described displaced IAS fractures and 3 described undisplaced fractures. All displaced fractures treated nonoperatively resulted in a painful nonunion. All that underwent operative fixation, whether acutely or after failed nonoperative treatment, had resolution of pain and a good functional outcome. All undisplaced fractures were treated nonoperatively; 1 had persisting pain. Surgical exploration identified the fracture fragment attached to serratus anterior in 2 cases and attached to both serratus anterior and latissimus dorsi in 2 cases. DISCUSSION AND CONCLUSIONS: There are limited data available about IAS factures. From the cases reviewed, treatment recommendations include the following: (1) displaced IAS fractures should undergo operative fixation to prevent the development of a painful nonunion; (2) suture repair provides adequate fixation; and (3) undisplaced fractures have a variable outcome when treated nonoperatively.

Arthroscopy for mechanical symptoms in osteoarthritis: a cost-effective procedure.

PURPOSE: The place of knee arthroscopy as a therapeutic option for osteoarthritis (OA) has been the subject of some debate. The hypothesis for this study was that arthroscopic debridement is beneficial in patients with OA who have significant mechanical symptoms. METHODS: Forty-three patients with radiological OA on plain radiographs and mechanical symptoms were prospectively followed. No further imaging was obtained. They were assessed pre- and postoperatively with an Oxford Knee Score (OKS) and pain visual analogue score (VAS). Postoperative patient satisfaction was measured with a VAS. A cost-benefit analysis was performed using a transformed OKS to generate a quality-adjusted life year (QALY) measurement. RESULTS: At a mean of 1.5 years, seven patients (16 %) had undergone total knee arthroplasty at a mean of 8.2 months postarthroscopy. For the remaining 35 patients, there were significant improvements in pain (median 7-5, p < 0.05) and OKS (median 24-36.5, p < 0.05). Satisfaction was a median 6.2 for all patients. The mean calculated EQ-5D improved from 0.43 (SD 0.16) to 0.79 (SD 0.23), which gave a gain of 0.52 QALYs in the study period. This generated a cost per QALY of £2,088, well below the threshold of £30,000 quoted by the UK National Institute for Health and Care Excellence as demonstration of cost-effective treatment. CONCLUSIONS: This prospective study demonstrates that although not universally effective, arthroscopic debridement for patients with knee OA and mechanical symptoms can result in significant improvements in pain and function. The procedure gave good patient satisfaction, and even at an early follow-up period proves to be cost-effective. LEVEL OF EVIDENCE: IV.

Comparison of the clinical and functional outcomes following 3- and 4-corner fusions.

PURPOSE: To explore the clinical and functional outcomes of 3-corner fusion (3CF) for stage 2 and 3 scapholunate advanced collapse and scaphoid nonunion advanced collapse. We compared the results with 4-corner fusion (4CF) using a recent published report. METHODS: Twelve patients (8 men and 4 women) who had a 3CF, mean age 60 years (range, 34-75 y) were reviewed in clinic more than 1 year after surgery. Subjective outcome measures included the Michigan Hand Questionnaire and Patient Evaluation Measure. Objective outcome measures included range of motion with a flexible electrogoniometer and grip strength measured with a digital dynamometer. The results were compared using a recent report of 24 patients (17 men and 7 women) with a 4CF, mean age 55 years (range, 34-68 y) assessed with similar techniques. RESULTS: The patients receiving 3CF had better subjective scores with the Michigan Hand Questionnaire, including the sub-scores for activities of daily living and satisfaction. The radioulnar arc was greater after the 3CF than after the 4CF. Circumduction of the 3CF was more like a normal wrist than the 4CF. This included having faster and smoother motion, with an axis of circumduction closer to the normal wrist. Peak grip strength was similar after either a 3CF or 4CF but grip strength in the 3CF was 82% of the contralateral wrist compared with 59% for the 4CF. CONCLUSIONS: The 3CF provided better patient-rated scores and the arc of wrist motion was more extended, with greater ulnar deviation. Motion was smoother and more closely replicated the normal axis and functional motion of the wrist. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic III.

Elbow hemiarthroplasty using a "triceps-on" approach for the management of acute distal humeral fractures.

BACKGROUND: Total elbow arthroplasty is an established option for the primary treatment of acute distal humeral fractures, but there are sparse data regarding elbow hemiarthroplasty (EHA) as an alternative. We present the outcome of EHA performed with a modular anatomic prosthesis and a "triceps-on" surgical technique. METHODS: Eighteen consecutive patients underwent EHA for an acute fracture. Two patients died, leaving a study group of 16 patients with minimum 2-year follow-up. Clinical evaluation included range of motion; Mayo Elbow Performance Score; Quick Disabilities of the Arm, Shoulder, and Hand score; and Oxford Elbow Score. Radiographic assessment looked at alignment, evidence of loosening, ulnar and radial head wear, heterotopic ossification, and whether healing of the condyles had occurred. RESULTS: Mean follow-up was 35 months (24-79 months). The mean scores were as follows: Mayo Elbow Performance Score, 89.6; shortened Disabilities of the Arm, Shoulder, and Hand score, 11.2; and Oxford Elbow Score, 43.7. The mean flexion and pronation-supination arcs were 116° and 172° respectively. Radial head wear was absent in 13 patients and mild in 3. Ulnar wear was absent in 6 patients, mild in 8, and moderate in 2. Wear was not associated with greater pain or inferior functional scores. There was no sign of aseptic loosening, and complete condylar bone union occurred in 15 elbows. There was 1 complication, a transient ulnar nerve neurapraxia that resolved without intervention. CONCLUSION: EHA with a modular anatomic implant using a triceps-on approach is a reliable technique for the management of acute unreconstructible distal humeral fractures in older patients.

Reliability of the CURL classification for proximal ulna fracture-dislocations of the elbow.

Background: Proximal ulna fracture-dislocations are challenging injuries with a myriad of existing classification systems. The Coronoid, proximal Ulna, Radius, and Ligaments classification (CURL) is a simple framework designed to focus attention on the key components affecting outcome and guide surgical management. This study evaluates interobserver and intraobserver reliability of this new classification. Methods: Four observers independently reviewed plain radiographs and computed tomography (CT) scans of patients with proximal ulna fracture-dislocations. Each observer scored the Coronoid (C), proximal Ulna (U), and Radius (R) components for each fracture on 2 occasions. The osseous components were subclassified as 'intact', 'simple', or 'complex'. The Ligament component (L) was not rated as this requires intraoperative classification. Interobserver and intraobserver reliability was calculated using Cohen's weighted kappa coefficients. X-ray and CT were compared for patients with both imaging modalities. The Landis and Koch criteria were used to interpret the strength of the kappa statistics. Results: One hundred seventy seven patients had plain X-rays; 58 patients had both X-ray and CT scans. Overall, in the X-ray only cohort, there was 'almost perfect' interobserver reliability for the radial head (k = 0.94) and coronoid (k = 0.83), and 'substantial' reliability (k = 0.68) for the proximal ulna. For the X-ray and CT cohort, interobserver reliability was 'almost perfect' across both modalities for the radial head (k = 0.88 and k = 0.93, respectively) and 'moderate' for the proximal ulna (k = 0.48 and k = 0.52, respectively). For the coronoid, interobserver reliability for X-ray interpretation was 'substantial' (k = 0.74) and for CT was 'almost perfect' (k = 0.89). Intraobserver reliability was 'almost perfect' for all components, other than CT assessment of the proximal ulna which demonstrated 'substantial' reliability (k = 0.74). Conclusion: The Coronoid, proximal Ulna, Radius, and Ligaments classification demonstrates strong interobserver and intraobserver reliability, supporting use of the classification for proximal ulna fracture-dislocations. CT is recommended for improved characterization of any fracture with a coronoid component.