Ultrasound-determined healing rates with subscapularis tenotomy versus peel after anatomic shoulder arthroplasty.

BACKGROUND: Several techniques have been described for mobilizing the subscapularis tendon in anatomic total shoulder arthroplasty (TSA). The purpose of this study was to compare subscapularis tendon healing rates, as determined by ultrasound, in patients following anatomic TSA with either a subscapularis tenotomy or subscapularis peel. METHODS: This study was a secondary analysis of patients from a previous randomized controlled trial in which patients underwent anatomic TSA and were randomized to either a tenotomy or peel approach. The primary outcome was postoperative tendon healing rates determined on ultrasound at >12 months after surgery. Secondary outcomes included postoperative tendon thickness measured on ultrasound; elbow position (neutral alignment in the belly-press position vs. posterior); internal rotation function measured with the third and fourth questions of the American Shoulder and Elbow Surgeons questionnaire; and Western Ontario Osteoarthritis of the Shoulder index. Radiographs were analyzed in patients with torn tendons. RESULTS: One hundred patients were randomized to a tenotomy (n = 47) or peel (n = 53) approach. Postoperative ultrasound results were available in 88 patients. Tendon healing rates were 95% for tenotomy vs. 75% for peel (P = .011). The mean postoperative tendon thickness was 4 mm (standard deviation, 1.0 mm) and 4 mm (standard deviation, 1 mm) in the tenotomy and peel groups, respectively (P = .37). Internal rotation function was not associated with healing status (P = .77 and P = .22 for questions 3 and 4, respectively, of the American Shoulder and Elbow Surgeons questionnaire), nor was elbow position (P = .2) in the belly-press position. DISCUSSION: We observed that subscapularis tenotomy had a higher healing rate than peel as determined by ultrasound in TSA patients. There was no statistically significant difference in postoperative tendon thickness in intact tendons as measured on ultrasound when comparing subscapularis mobilization techniques, nor was there any association between healing status and internal rotation function or elbow position.

A randomized controlled trial comparing subscapularis tenotomy with peel in anatomic shoulder arthroplasty.

BACKGROUND: Controversy exists regarding the optimal technique of subscapularis tendon mobilization during anatomic shoulder arthroplasty. The purpose of this prospective, randomized, double-blind study was to compare internal rotation strength in the belly-press position and functional outcomes between the subscapularis tenotomy and subscapularis peel approaches during shoulder arthroplasty. METHODS: Patients undergoing anatomic shoulder arthroplasty were randomized to either a tenotomy or peel approach. The primary outcome was internal rotation strength in the belly-press position, measured by an electronic handheld dynamometer at 24 months postoperatively. Secondary outcomes included the Western Ontario Osteoarthritis of the Shoulder (WOOS) index score, American Shoulder and Elbow Surgeons (ASES) score, range of motion, radiographic lucencies, and adverse events. RESULTS: We randomized 100 patients to subscapularis tenotomy (n = 47) or peel (n = 53). Eighty-one percent of the cohort returned for 24 months' follow-up. Compared with baseline measures, mean internal rotation strength in the belly-press position and WOOS and ASES scores improved in both groups at final follow-up (P < .0001). Intention-to-treat analysis for internal rotation strength at 24 months revealed no significant difference (P = .57) between tenotomy (mean, 4.9 kg; SD, 3.8 kg) and peel (mean, 5.4 kg; SD, 3.9 kg). Comparison of WOOS and ASES scores demonstrated no significant differences between groups at any time point. The healing rates by ultrasound were 72% for tenotomy and 71% for peel (P = .99). DISCUSSION: No statistically significant difference in internal rotation strength was identified between the tenotomy and peel groups. The secondary outcomes were not significantly different between groups.

Proper placement of the distal biceps tendon during repair improves supination strength--a biomechanical analysis.

BACKGROUND: Anatomic repair of the distal biceps tendon can be difficult to achieve. This study was designed to compare the effect of anatomic and nonanatomic repairs on forearm supination torque. A nonanatomic repair re-establishes the footprint radial and more anterior to the tuberosity apex, whereas an anatomic repair re-establishes the footprint ulnar and more posterior to the tuberosity apex. METHODS: Eight fresh frozen cadaver arms were surgically prepared and mounted on an elbow simulator. Controlled loads were applied to the long head and short head in positions of pronation, neutral, and supination. This was done with intact tendons and then repeated with repaired tendons that were repaired either anatomically (ulnar position) or nonanatomically (radial position). RESULTS: All anatomic repairs showed no difference compared with intact tendon measurements. In comparing anatomic and nonanatomic repairs, we found no differences in the supination torque when the forearm was in 45° of pronation. However, when the arm was in neutral rotation, we found that 15% less supination torque was generated by the nonanatomic repair. When the arm was tested in 45° of supination, we found that 40% less supination torque was generated in the nonanatomic repair (P = .01). CONCLUSION: This study supports the idea that an anatomic repair of the biceps tendon onto the ulnar side of the radial tuberosity is important. If the tendon is repaired too radially, the biceps will lose the cam effect and may not be able to generate full supination torque when the forearm is in neutral rotation or in supination.

Anatomic repair of the distal biceps tendon cannot be consistently performed through a classic single-incision suture anchor technique.

BACKGROUND: Distal biceps tendon ruptures commonly occur in active men, and surgical repair through a single-incision technique using suture anchors has become common. The current study assessed whether an anatomic repair of the biceps to the radial tuberosity can be consistently achieved through a single-incision technique. METHODS: Acute distal biceps tendon repairs using the single-incision technique were retrospectively reviewed. Computed tomography (CT) scans were obtained to investigate tuberosity dimensions and the position of the suture anchors. An isokinetic dynamometer was used to obtain flexion and supination strength. Disabilities of the Arm, Shoulder and Hand (DASH) scores were collected. RESULTS: CT scans were performed in 27 patients, of which, 21 underwent strength testing. The suture anchor placement averaged 50° radial to the apex of the tuberosity. Strength testing showed flexion strength of the repaired side was equal (97%-106%) to the normal side. Supination strength (80%-86%) and work (66%-75%) performed were both weaker on the repaired side (66%-75%; P < .05). The average DASH score was 10.7. CONCLUSIONS: Ideal suture anchor placement, in the ulnar aspect of the tuberosity, could not be reliably achieved through this single-incision technique. This could have clinical importance because supination strength was not fully restored in this group of patients.

What outcomes are important in the recovery from acromio-clavicular (AC) joint pathology? A focus group study with patients and surgeons.

INTRODUCTION: Acromio-clavicular (AC) joint pathology is a disabling condition that can restrict quality of life through chronic pain and functional limitation. The objective of this study was to determine symptoms and patient-centred outcomes identified by patients with AC pathology and from experienced shoulder surgeons. METHODS: Qualitative research methods were undertaken with patient and surgeon focus groups. Patients with AC-joint pathology were invited to participate and were stratified into two cohorts: AC instability and AC osteoarthritis (OA). RESULTS: Sixteen patients participated in five patient focus group discussions including 10 patients with AC instability and six patients with AC OA. Four surgeons participated in two focus groups. Although some themes were common to both AC Instability and AC OA, a number of themes were unique to each. A number of themes were identified that do not appear in existing AC joint scores. CONCLUSION: Although many factors affecting the AC joint were common to instability and OA pathology, several factors appear to be unique to each and do not appear in existing AC joint metrics. These symptoms and patient-centered outcomes may be used by clinicians in the assessment of patients with AC pathology and in the development of rehabilitation programs.Implications for rehabilitationA thorough understanding of symptoms and patient-centred outcomes associated with acromio-clavicular arthritis and instability is necessary in order to conduct an accurate clinical assessment and design an effective rehabilitation program that meets the clinical needs of patients.Patients in this study identified several themes relevant to assessment and rehabilitation program development including pain location, type of pain (eg. burning pain), and specific activities that induced pain that do not exist in current existing tools.Our finding that certain themes were only raised in either acromio-clavicular instability or osteoarthritis suggests that there may be differences in important outcomes for patients depending on the underlying cause of the acromio-clavicular joint pathology. By incorporating these themes into clinical assessments, outcomes important to patients may be elicited to monitor response to rehabilitation following injury or surgery.

Effect of the posterior bundle of the medial collateral ligament on elbow stability.

PURPOSE: The role of the posterior bundle of the medial collateral ligament in stability of the elbow remains poorly defined. The purpose of this study was to determine the effect of sectioning the posterior bundle of the medial collateral ligament on the stability of the elbow. METHODS: Varus and valgus gravity-loaded passive motion and simulated active vertical motion were performed on 11 cadaveric arms using an in vitro elbow motion simulator. Varus/valgus angle and internal/external rotation of the ulna with respect to the humerus were recorded using an electromagnetic tracking system in varus, valgus, and vertical orientations. Testing was performed on the intact elbow and after sectioning of the posterior bundle of the medial collateral ligament. RESULTS: With active flexion in the vertical position, the varus/valgus kinematics were unchanged after sectioning of the posterior bundle of the medial collateral ligament. However, in pronation, there was an increase in internal rotation after sectioning of the posterior bundle of the medial collateral ligament compared with that of the intact elbow. This rotational difference was not detected with the forearm in supination. During supinated passive flexion in the varus position, sectioning of the posterior bundle of the medial collateral ligament resulted in increased varus angulation at all flexion angles. In pronation, varus angulation and internal rotation both increased. In supination, sectioning of the posterior bundle of the medial collateral ligament had no effect on maximum varus-valgus laxity or maximum internal rotation. However, in pronation, the maximum varus-valgus laxity increased by 3.5 degrees (30%) and maximum internal rotation increased by 1.0 degrees (29%). CONCLUSIONS: These results indicate that isolated sectioning of the posterior bundle of the medial collateral ligament causes a small increase in varus angulation and internal rotation during both passive varus and active vertical flexion. This study suggests that isolated sectioning of the posterior bundle of the medial collateral ligament may not be completely benign and may contribute to varus and rotation instability of the elbow. In patients with insufficiency of the posterior bundle of the medial collateral ligament, appropriate rehabilitation protocols (avoiding forearm pronation and shoulder abduction) should be followed when other injuries permit.

The influence of type II coronoid fractures, collateral ligament injuries, and surgical repair on the kinematics and stability of the elbow: an in vitro biomechanical study.

PURPOSE: This study determined whether elbow stability could be restored with open reduction and internal fixation (ORIF) of type II coronoid fractures and evaluated the role of collateral ligament repair. METHODS: Passive varus and valgus and simulated active vertical motion were performed using an in vitro elbow motion simulator. Varus/valgus angle and internal/external rotation were measured with the coronoid intact, with 50% removed, and after ORIF. Testing was performed with the collateral ligaments detached and repaired. RESULTS: Vertical: stability was normal when both the lateral collateral ligament (LCL) and medial collateral ligament (MCL) were repaired, irrespective of the coronoid state. Kinematics were altered with a repaired LCL, incompetent MCL, and type II coronoid fracture (P < .05). Varus: LCL repair restored coronal stability but did not restore internal rotation (P < .05). CONCLUSIONS: These findings suggest that repair of type II coronoid fractures and injured collateral ligaments should be performed where possible. Over-tensioning the LCL, in the setting of MCL and coronoid deficiency, may contribute to instability.

The effect of implant linking and ligament integrity on humeral loading of a convertible total elbow arthroplasty.

BACKGROUND: Both unlinked and linked total elbow arthroplasty (TEA) implants have been employed with no consensus as to the optimal design. The present study aimed to evaluate the effect of collateral ligament integrity and implant linkage on wear-inducing loads in a convertible TEA. METHODS: Eight fresh frozen upper extremities were tested in an elbow motion simulator. A convertible TEA with an instrumented humeral stem was inserted using computer navigation. Elbow kinematics and humeral loading were recorded with the TEA both linked and unlinked. The collateral ligaments were then sectioned and testing was repeated. RESULTS: In the dependent position, there was no effect of implant linkage or ligament sectioning on humeral loading. Humeral loading was significantly greater following sectioning of the collateral ligaments but not after linking the TEA with the arm in the valgus position. Humeral loading was significantly greater after linking the TEA but not after sectioning of the collateral ligaments and with the arm in the varus position. CONCLUSIONS: Collateral ligament integrity reduces wear-inducing loads for both an unlinked and linked TEA. Linkage of a convertible TEA increases humeral loading, which may have detrimental effects on implant longevity.

Distal humerus fractures.

Intra-articular fractures of the distal humerus are among the most challenging fractures to manage. Nonoperative treatment, although appropriate for some patients, often leads to loss of motion and unsatisfactory functional outcomes. Over the last 2 decades, enhanced operative techniques and implant designs have improved the reduction and stability of distal humerus fractures leading to better outcomes. Careful preoperative planning, adequate exposure, and stable fixation facilitating early mobilization are essential to achieve successful outcomes with internal fixation.

Prosthetic replacement for distal humerus fractures.

Primary total elbow arthroplasty is a treatment option for elderly patients with osteopenic bone, increased comminution, and articular fragmentation. Recently, there has been a renewed interest in distal humerus hemiarthroplasty for the treatment of distal humerus fractures, including coronal shear fractures of the capitellum and trochlea. This article focuses on the evaluation and management of distal humerus fractures with prosthetic replacement.

Surgical exposures for distal humerus fractures: a review.

The majority of distal humerus fractures have complex fracture patterns, with displaced articular segments, requiring operative intervention. The goals of surgery are anatomic reduction and rigid internal fixation via an operative approach that balances maximum required exposure with minimum soft tissue or bony disruption that may necessitate postoperative protection. The selection of a surgical approach depends on multiple factors, including, fracture pattern, extent of articular involvement, associated soft tissue injury, rehabilitation protocols, and surgeon preference. This review focuses on the various surgical approaches to the distal humerus.

Fixation of Anteromedial Coronoid Facet Fractures: A Biomechanical Evaluation of Plated Versus Screw Constructs.

OBJECTIVE: To examine the stability of plate (locking and non-) versus screw constructs in the fixation of these fractures. METHODS: An anteromedial coronoid facet fracture (OTA/AO type 21-B1, O'Driscoll type 2, subtype 3) was simulated in 24 synthetic ulna bones that were then assigned to 3 fracture fixation groups: non-locking plate, locking plate (LP), or screw fixation. Each construct was first cycled in tension (through a simulated medial collateral ligament) and then in compression. They were then loaded to failure (displacement >2 mm). Fracture fragment displacement was recorded with an optical tracking system. RESULTS: During tension testing, a mean maximum fragment displacement of 12 ± 13 and 14 ± 9 µm was seen in the locking and non-locking constructs, respectively. There was no difference in fragment motion between the plated constructs. All screw-only fixed constructs failed during the tension protocol. During compression testing, the mean maximum fragment displacement for the screw-only construct (64 ± 79 µm) was significantly greater than locking (9 ± 5 µm) and non-locking constructs (10 ± 9 µm). During load to failure testing, the maximum load to failure in the screw-only group (316 ± 83 N) was significantly lower than locking (650.4 ± 107 N) and non-locking constructs (550 ± 76 N). There was no difference in load to failure between the plated groups. CONCLUSION: Fixation of anteromedial coronoid fractures (type 2, subtype 3) is best achieved with a plating technique. Although LPs had greater stiffness, they did not offer any advantage over conventional non-LPs with respect to fracture fragment displacement in this study. CLINICAL RELEVANCE: Isolated screw fixation showed inferior stability when compared with plate constructs for these fractures. This could result in loss of fracture reduction leading to instability and posttraumatic arthrosis.

Lateral Elbow Exposures: The Extensor Digitorum Communis Split Compared with the Kocher Approach.

INTRODUCTION: In comparison with the frequently used modified Kocher approach, the extensor digitorum communis (EDC) splitting approach allows improved access to the anterior half of the radial head, which is most commonly fractured, while reducing the risk of iatrogenic injury to the lateral collateral ligament. STEP 1 MAKE THE INCISION MODIFIED KOCHER APPROACH: Make an oblique 7-cm lateral incision beginning at the proximal edge of the lateral epicondyle and extending distally over the center of the radial head toward the posterior ulnar border of the extensor carpi ulnaris muscle belly. STEP 2 DEVELOP THE INTERVAL BETWEEN THE ANCONEUS AND THE EXTENSOR CARPI ULNARIS: Identify and develop the intermuscular interval between the anconeus and the extensor carpi ulnaris. STEP 3 PERFORM THE LATERAL ELBOW CAPSULOTOMY: Longitudinally incise the lateral elbow capsule and annular ligament anterior to the lateral ulnar collateral ligament. STEP 4 THE EXTENDED MODIFIED KOCHER APPROACH: Extend the exposure by elevating the common extensor origin (extensor carpi radialis brevis, EDC, and extensor carpi ulnaris) proximally off the lateral epicondyle and reflect it anteriorly. STEP 5 MAKE THE INCISION EDC SPLITTING APPROACH: Make a longitudinal oblique 5 to 6-cm lateral incision beginning at the proximal edge of the lateral epicondyle and extending distally over the radial head toward the Lister tubercle. STEP 6 IDENTIFY AND SPLIT THE EDC: The EDC tendon is identified and bisected longitudinally starting proximally at its origin on the lateral epicondyle and extending 20 mm distally from the radiocapitellar joint. STEP 7 PERFORM THE LATERAL ELBOW CAPSULOTOMY: The annular ligament and joint capsule are then incised collinear with the EDC split anterior to the equator of the capitellum. STEP 8 EXTENDED EDC SPLITTING APPROACH: Extend the exposure by detaching the anterior half of the EDC tendon and the extensor carpi radialis brevis tendon from the lateral epicondyle. STEP 9 LAYERED CLOSURE: Perform an interrupted layered closure. RESULTS: In our recent cadaveric study, we quantitatively compared the modified Kocher and EDC splitting approaches in order to determine which provided the greatest exposure of the anterior aspect of the radial head, which is most commonly fractured.IndicationsContraindicationsPitfalls & Challenges.

Objective analysis of lateral elbow exposure with the extensor digitorum communis split compared with the Kocher interval.

BACKGROUND: The most widely used surgical approach to treat radial head fractures is through the Kocher interval. However, the extensor digitorum communis (EDC) splitting approach is thought to allow easier access to the anterior half of the radial head, which is more commonly fractured. The aim of this cadaveric study was to compare the osseous and articular surface areas visible through the EDC split and the Kocher interval. METHODS: Four approaches were used in fresh frozen cadaveric upper extremities: EDC splitting (n = 6), modified Kocher (n = 6), extended EDC splitting (n = 6), and extended modified Kocher (n = 4). For each approach, the osseous and articular surface areas visualized were outlined with use of a burr. Each elbow was then stripped of soft tissue and a digitized three-dimensional model was created with use of a surface scanning system. The visible surface area obtained with each approach was mapped and quantified with use of the markings created with the burr. RESULTS: The EDC splitting approach provided greater exposure of the anterior half of the radial head (median, 100%) compared with the modified Kocher approach (68%, p < 0.05). The extended modified Kocher and extended EDC splitting approaches provided comparable visualization of the distal aspect of the humerus, capitellum, radial head, and coronoid process. CONCLUSIONS: The results suggest that the EDC splitting approach provides more reliable visualization of the anterior half of the radial head while minimizing soft-tissue dissection and reducing the risk of iatrogenic injury to the lateral ulnar collateral ligament.

The reliability of determining "leg dominant pain".

BACKGROUND CONTEXT: Patients with back dominant pain generally have a worse prognosis after spine surgery when compared with patients with leg dominant pain. Despite the importance of determining whether patients with lumbar spine pain have back or leg dominant pain as a predictor for success after decompression surgery, there are limited data on the reliability of methods for doing so. PURPOSE: To assess the test-retest reliability of a patient's ability to describe whether their lumbar spine pain is leg or back dominant using standardized questions. STUDY DESIGN/SETTING: Prospective, blinded, test-retest cohort study performed in an academic spinal surgery clinic. PATIENT SAMPLE: Consecutive patients presenting for consultation to one of three spinal surgeons for lumbar spine pain were enrolled. OUTCOME MEASURES: Eight questions to ascertain a patient's dominant location of pain, either back dominant or leg dominant, were identified from the literature and local experts. METHODS: These eight questions were administered in a test-retest format over two weeks. The test-retest reliability of these questions were assessed in a self-administered questionnaire format for one group of patients and by a trained interviewer in a second group. RESULTS: The test-retest reliability of each question ranged from substantial (eg, interviewer-administered percent question, weighted kappa=0.77) to slight (eg, self-administered pain diagram, weighted kappa=0.09). The Percent question was the most reliable in both groups (self-administered, interviewer). All questions in the interviewer-administered group were significantly (p<.001) more reliable than the self-administered group. Depending on the question, between 0% and 32% of patients provided a completely opposite response on test-retest. There was variability in prevalence of leg dominant pain, depending on which question was asked and there was no single question that identified all patients with leg dominant pain. CONCLUSION: A patient's ability to identify whether his or her lumbar spine pain is leg or back dominant may be unreliable and depends on which questions are asked, and also how they are asked. The Percent question is the most reliable method to determine the dominant location of pain. However, given the variability of responses and the generally poorer reliability of many specific questions, it is recommended that multiple methods be used to assess a patient's dominant location of pain.

The effect of anteromedial facet fractures of the coronoid and lateral collateral ligament injury on elbow stability and kinematics.

BACKGROUND: It is postulated that fractures of the anteromedial facet of the coronoid process and avulsion of the lateral collateral ligament lead to posteromedial subluxation and arthritis of the elbow. It is not clear which injuries require internal fixation and whether repair of the lateral collateral ligament is sufficient. We hypothesized that increasing sizes and subtypes of anteromedial facet fractures cause increasing instability and that isolated lateral collateral ligament repair without fracture fixation would restore elbow stability in the presence of small subtype-I fractures. METHODS: Ten fresh-frozen cadaveric arms from donors with a mean age of 66.3 years at the time of death were used in this biomechanical study. Passive elbow flexion was performed with the plane of flexion oriented horizontally to achieve varus and valgus gravitational loading. An in vitro unconstrained elbow-motion simulator was used to simulate active elbow flexion in the vertical position. Varus-valgus angle and internal-external rotational kinematics were recorded with use of an electromagnetic tracking system. Testing was repeated with the coronoid intact and with subtype-I, subtype-II, and subtype-III fractures. Instability was defined as an alteration in varus-valgus angle and/or in internal-external rotation of the elbow. All six coronoid states were tested with the lateral collateral ligament detached and after repair. RESULTS: In the vertical position, the kinematics of subtype-I and subtype-II anteromedial coronoid fractures with the lateral collateral ligament repaired were similar to those of the intact elbow. In the varus position, the kinematics of 2.5-mm subtype-I fractures with the lateral collateral ligament repaired were similar to those of the intact elbow. However, 5-mm fractures demonstrated a mean (and standard deviation) of 6.2 degrees +/- 4.5 degrees of internal rotation compared with a mean of 3.3 degrees +/- 3.1 degrees of external rotation in the intact elbow (p < 0.05). In the varus position, subtype-II 2.5-mm fractures with the lateral collateral ligament repaired demonstrated increased internal rotation (mean, 7.0 degrees +/- 4.5 degrees; p < 0.005). Subtype-II 5-mm fractures demonstrated instability in both the varus and valgus positions (p < 0.05). Subtype-III fractures with the lateral collateral ligament repaired were unstable in all three testing positions (p < 0.05). CONCLUSIONS: This study suggests that the size of the anteromedial coronoid fracture fragment affects elbow kinematics, particularly in varus stress. The size of an anteromedial coronoid fracture and the presence of concomitant ligament injuries may be important determinants of the need for open reduction and internal fixation.