Indicators and medical tests to identify lower limb swelling causes after total knee arthroplasty: a Delphi study with multidisciplinary experts.

BACKGROUND: Lower limb swelling after total knee arthroplasty (TKA) hinders surgical effectiveness. The poor results of studies on swelling interventions are due to the lack of a classification of swelling causes through appropriate medical tests. A gold standard is missing. This study aimed to clarify the causes of TKA postoperative swelling and how to identify them through indicators and medical tests by consulting a wide range of experts from multiple disciplines. METHOD: The Delphi method was used. A first draft of the index was prepared based on a systematic search of the literature. A total of 11 experts from several disciplines were invited to evaluate the rationality of the indicators and suggest modifications. After two rounds of consultation, the experts reached a consensus, and the consultation was stopped. RESULTS: The response rate of the 11 experts was 100%, and the authoritative Cr was 0.896. Kendall's W values for opinion coordination of the two rounds of consultation were 0.262 and 0.226, respectively (P < 0.001). Among the final indicators, there were 4 primary indicators for swelling cause classification (inflammatory response, poor venous return, joint hematoma, muscle damage, and healing), 19 secondary and 19 tertiary indicators. CONCLUSION: The indications obtained by systematic literature review and multidisciplinary expert consultation are reliable and scientific. Multiple causes of lower extremity swelling after TKA were identified. Blood test indicators can reflect an inflammatory response, suggest poor venous return, and reflect muscle damage and healing progress. Ultrasound scans are needed to identify underlying thrombotic or valvular problems, joint hematomas, and muscle damage. These tests help clinicians and researchers determine the cause of swelling after TKA and take appropriate management.

Exploring expectations of Chinese patients for total knee arthroplasty: once the medicine is taken, the symptoms vanish.

BACKGROUND: Preoperative expectations of total knee arthroplasty (TKA) outcomes are important determinants of patient satisfaction. However, expectations of patients in different countries are affected by cultural background. The general goal of this study was to describe Chinese TKA patients' expectations. METHODS: Patients scheduled for TKA were recruited in a quantitative study(n = 198). The Hospital for Special Surgery Total Knee Replacement Expectations Survey Questionnaire was used for survey TKA patients' expectations. Descriptive phenomenological design was used for the qualitative research. Semi-structured interviews were conducted with 15 TKA patients. Colaizzi's method was used for interview data analysis. RESULTS: The mean expectation score of Chinese TKA patients was 89.17 points. The 4 highest score items were walk short distance, remove the need for walker, relieve pain and make knee or leg straight. The 2 lowest score items were employed for monetary reimbursement and sexual activity. Five main themes and 12 sub-themes emerged from the interview data, including multiple factors raised expectations, expectations of physical comfort, expect various activities back to normal, hope for a long joint lifespan, and expect a better mood. CONCLUSIONS: Chinese TKA patients reported a relatively high level of expectations, and differences across cultures result in different expectation points than other national populations, requiring adjustment of items when using assessment tools across cultures. Strategies for expectation management should be further developed. LEVEL OF EVIDENCE: Level IV.

Rational application of gefitinib in NSCLC patients with sensitive EGFR mutations based on pharmacokinetics and metabolomics.

Gefitinib has been available in the market for 20 years, but its pharmacokinetic mechanism of response is little known. In this study, we examined the pharmacokinetic and metabolomic profiles in non-small cell lung cancer (NSCLC) patients with sensitive EGFR mutations. A total of 216 advanced NSCLC patients were enrolled, and administered gefitinib at the standard dosage of 250 mg/day, which was established in heterogeneous subjects with non-sensitive mutations. We identified and quantified three main metabolites (named as M1, M2 and M3) in the plasma of patients, the correlations between the concentration of gefitinib/metabolites and efficacy were analyzed. In exploratory and validation set, gefitinib concentration was not correlated with clinical effects. Considering the result that the therapeutic effects of 250 mg/2-day was better than that of 250 mg/day in a multiple center clinical trial, the standard dose might be higher than that for maximal efficacy according to the hypothetical dose-response curve. Among the three metabolites, the IC50 of M2 in HCC827 and PC9 cell lines was significantly lower, and Conc.brain/Conc.plasma of M2 in mice was significantly higher than those of gefitinib, suggesting its higher potential to penetrate blood-brain barrier and might be more effective in the treatment of brain metastatic tumor than gefitinib. Consistently and attractively, higher M2 plasma concentration was found to be correlated with better clinical outcome in patients with brain metastases (the median PFS of CM2 < 12 ng/mL and CM2 ≥ 12 ng/mL were 17.0 and 27.1 months, respectively, P = 0.038). The plasma concentration of M2 ≥ 12 ng/mL was a strong predictor of the PFS of NSCLC patients. In conclusion, for NSCLC patients with EGFR sensitive mutations, the standard dose is suspectable and could be decreased reasonably. M2 plays an important role in efficacy and may be more effective in the treatment of metastatic tumor than gefitinib.

[Analysis of information needs of patients with dentofacial deformities at different stages of treatment].

PURPOSE: To investigate the treatment experience and information needs of patients with dentofacial deformities in the process of surgical program design, surgical treatment and postoperative rehabilitation. METHODS: Thirty-six patients with dentofacial deformities at different treatment stages from March to July 2019 were selected for semi-structured interview. Colaizzi content analysis method and QSR NVivo 12.0 software were used to analyze and code the data, as well as extract the theme and genus. RESULTS: Three themes and eight categories were extracted, including① information needs in different treatment stages, mainly specific content of information needs at pre-operative preparation stage, orthognathic perioperative stage and post-operative rehabilitation stage; ② information support methods, i.e., diversified information support methods and patients' recognition of internet information;③ patients' cognition difference,namely the difference between patients' psychological expectation and the results of operation. CONCLUSIONS: Due to the treatment characteristics of orthognathic surgery and individual cognitive differences of patients, there is a large demand for information support at different stages of treatment. However, the current information support mode is limited, so it is necessary to further improve and provide scientific, professional and targeted information support for patients with dentofacial deformities.

[Construction of perioperative oral care program for elderly patients with oral cancer based on Delphi method].

PURPOSE: To construct an oral care program for elderly patients with oral cancer during perioperative period. METHODS: Based on the content analysis of the guidelines and personal in-depth interviews of the doctors, nurses and patients, according to the clinical characteristics of the elderly patients with oral cancer and treatments, combined with PDCA cycle, the first draft of perioperative oral care program for the elderly patients with oral cancer was constructed. Delphi method was used to carry out two rounds of mail inquiry to 16 experts in related fields to determine the scheme. Excel 2016, SPSS 25.0 software package were used for statistical description and analysis. RESULTS: The questionnaire return rate of the two rounds of expert consultation was 100% and the overall expert authority coefficient was 0.84. After two rounds of expert consultation, the variation coefficient of each index was 0-0.240, and the overall coordination coefficient was 0.171. The oral care program was formed in three stages: preoperative, postoperative, and during radiotherapy and chemotherapy. The preoperative stage included 4 dimensions, 12 first-level items, 56 second-level items; the postoperative stage included 4 dimensions, 18 first-level items, 102 second-level items; the radiochemotherapy stage included 4 dimensions, 13 first-level items and 35 second-level items. CONCLUSIONS: The perioperative oral care program of the elderly patients with oral cancer accords with the characteristics of the elderly patients with oral cancer during perioperative period, which meets the oral care needs of this group of patients. The construction of the program is reliable and provides a reference for clinical practice.

Serum proteomics analysis of feline mammary carcinoma based on label-free and PRM techniques.

BACKGROUND: Feline mammary carcinoma is the third most common cancer that affects female cats. OBJECTIVES: The purpose of this study was to screen differential serum proteins in feline and clarify the relationship between them and the occurrence of feline mammary carcinoma. METHODS: Chinese pastoral cats were used as experimental animals. Six serum samples from cats with mammary carcinoma (group T) and six serum samples from healthy cats (group C) were selected. Differential protein analysis was performed using a Label-free technique, while parallel reaction monitoring (PRM) was performed to verify the screened differential proteins. RESULTS: A total of 82 differential proteins were detected between group T and group C, of which 55 proteins were down regulated and 27 proteins were up regulated. Apolipoprotein A-I, Apolipoprotein A-II (ApoA-II), Apolipoprotein B (ApoB), Apolipoprotein C-III (ApoC-III), coagulation factor V, coagulation factor X, C1q, albumen (ALB) were all associated with the occurrence of feline mammary carcinoma. Differential proteins were involved in a total of 40 signaling pathways, among which the metabolic pathways associated with feline mammary carcinoma were the complement and coagulation cascade and cholesterol metabolism. According to the Label-free results, ApoB, ApoC-III, ApoA-II, FN1, an uncharacterized protein, and ALB were selected for PRM target verification. The results were consistent with the trend of the label-free. CONCLUSIONS: This experimen is the first to confirm ApoA-II and ApoB maybe new feline mammary carcinoma biomarkers and to analyze their mechanisms in the development of such carcinoma in feline.

Influence of Collective Esophageal Speech Training on Self-efficacy in Chinese Laryngectomees: A Pretest-posttest Group Study.

Total laryngectomy affects the speaking functions of many patients. Speech deprivation has great impacts on the quality of life of patients, especially on self-efficacy. Learning esophageal speech represents a way to help laryngectomees speak again. The purpose of this study was to determine the influence of collective esophageal speech training on self-efficacy of laryngectomees. In this study, 28 patients and 30 family members were included. The participants received information about training via telephone or a WeChat group. Collective esophageal speech training was used to educate laryngectomees on esophageal speech. Before and after collective esophageal speech training, all participants completed the General Self-Efficacy Scale (GSES) to assess their perceptions on self-efficacy. Through the training, laryngectomees recovered their speech. After the training, the self-efficacy scores of laryngectomees were higher than those before the training, with significant differences noted (T<0.05). However, family members' scores did not change significantly. In conclusion, collective esophageal speech training is not only convenient and economical, but also improves self-efficacy and confidence of laryngectomees. Greater self-efficacy is helpful for laryngectomees to master esophageal speech and improve their quality of life. In addition, more attention should be focused on improving the self-efficacy of family members and making them give full play to their talent and potential on laryngectomees' voice rehabilitation.

[Comparative study on infection rate of different adeno-associated virus for knee joint cartilage in mice].

OBJECTIVE: To explore infection rate of different adeno-associated virus (AAV) on knee joint cartilage in mice and to find a good gene editing tool for mice chondrocytes of knee joint. METHODS: Forty-five 4-week-old SPF C57BL/6 weighed(14.3±0.2) g were selected. According to different injections(6 µl) for right knee joint, mice were divided into 9 different groups, 5 mice in each group. The groups were such as following:control group (normal saline), Vigene 2 group (AAV2 from vigene biosciences, titer for 1×10¹³ vg/ml), Vigene 5 group (AAV5 from vigene biosciences, titer for 1×10¹³ vg/ml), Vigene 6 group (AAV6 from vigene biosciences, titer for 1×10¹³ vg/ml), Vigene 7 group (AAV7 from vigene biosciences, titer for 1×10¹³ vg/ml), Vigene 8 group (AAV8 from vigene biosciences, titer for 1×10¹³ vg/ml), Vigene 9 group (AAV9 from vigene biosciences, titer for 1×10¹³ vg/ml), Hanbio DJ group(AAV2-DJ from Hanbio, titer for 1×10¹² vg/ml), Hanbio 5 group (AAV5 from Hanbio, titer for 1×10¹² vg/ml). All AAVs were over-expressed green fluorescent protein(GFP). Knee joint specimens were taken and observed injury of cartilage under stereomicroscope at 30 days after injection, then 10 µm thick frozen sections were prepared. Distribution of green fluorescent protein of meniscus and cartilage of knee joint was observed under fluorescence microscope. RESULTS: Stereomicroscope observation indicated that no obvious lesion was observed in knee joint cartilage of mice after intra-articular injection of AAV. According to frozen sections of knee joints, strong green fluorescence was observed in knee joint cartilage in all AAV experimental groups. Compared with other groups, significantly stronger green fluorescence were observed both in AAV2 and AAV7 groups, whose average fluorescence density was 0.077±0.020 and 0.061±0.022. There were significant differences between two groups and other groups. CONCLUSIONS: AAV could infect chondrocyte of knee joint in vivo by injecting into knee joint cavity. Higher infection efficiency of AAV2 and AAV7 on knee joint cartilage were observed. Local injection of AAV into knee joint cavity could be used as an effective tool for gene editing of knee joint chondrocyte.

[Qualitative study on the decision-making of orthognathic surgery in adult patients with malocclusion].

PURPOSE: The main purpose of this study was to explore the experience associated with patient's decision to have or not have orthognathic treatment. METHODS: Phenomenological methodology was used in this study. Ten patients were collected from January 2018 to March 2018, who were consulted in the Department of Oral and Craniomaxillofacial Surgery, Center of Craniofacial Orthodontics in Shanghai Ninth People's Hospital. They were interviewed by semi-structured, face to face in-depth interviews. Data were organized and analyzed by Colaizzi methods. RESULTS: By reading, analysis and extraction, two topics, i.e, motivation and interference factor were obtained. CONCLUSIONS: The treatment information service was limited. Further research is needed to improve the information services that support the treatment decision of malocclusion patients and help them to make the best choice.

Biofunctionalized self-assembly of peptide amphiphile induces the differentiation of bone marrow mesenchymal stem cells into neural cells.

Bone marrow mesenchymal stem cells (BMSCs) are multipotential differentiation cells which can differentiate into different cell types such as osteoblasts, chondrocytes, adipocytes, cardiomyocytes, hepatocytes, endothelial cells, and neuronal cells. Such multipotential differentiation makes them attractive for stem cell-based therapy aimed at treating previously incurable disorders. In the present work, we encapsulated BMSCs into a hydrogel with a three-dimensional (3D) network of nanofibers, formed from self-assembling of peptide amphiphile. The self-assembling of peptide amphiphile into hydrogel was triggered by mixing cell suspensions with dilute aqueous solutions of amphipathic peptide. Moreover, this hydrogel was designed to present cells the neurite-promoting laminin epitope IKVAV at nearly van der Waals density, which induced the successful differentiation of BMSCs into neural cells.

RBBP6 promotes human cervical carcinoma malignancy via JNK signaling pathway.

Previous studies have shown that retinoblastoma binding protein 6 (RBBP6) was overexpressed in malignant tumors and was correlated with poorer prognosis in various cancers. However, its role in cervical carcinoma has not been elucidated. This study was to investigate the relationship between RBBP6 and cervical carcinoma. Cervical carcinoma cell lines SiHa and C33a were used to assess the effect of RBBP6 on cell viability, migration, and proliferation. RBBP6 mRNA and protein levels in cervical cancer tissues increased at least three times as that in the adjacent non-cancerous tissues. Overexpression of RBBP6 in SiHa and C33a cell lines resulted in increased phosphorylated c-Jun NH2-terminal kinase (p-JNK) as well as increased cell viability, migration, and proliferation. Moreover, this effect was suppressed by specific JNK inhibitor SP600125. RBBP6 might potentiate cervical carcinoma cell viability, migration and proliferation through JNK signaling pathway. RBBP6 and JNK inhibitor may be beneficial as a novel preventive and therapeutic target for cervical cancer.

Accumulated Spinal Axial Biomechanical Loading Induces Degeneration in Intervertebral Disc of Mice Lumbar Spine.

OBJECTIVE: To investigate the effect of accumulated spinal axial biomechanical loading on mice lumbar disc and the feasibility of applying this method to establish a mice intervertebral disc degeneration model using a custom-made hot plate cage. In previous studies, we observed that the motion pattern of mice was greatly similar to that of humans when they were standing and jumping on their lower limbs. There is little data to demonstrate whether or not accumulated spinal axial biomechanical loading could induce intervertebral disc degeneration in vivo. METHODS: Twenty-four 0-week-old mice were randomly divided into model 1-month and 3-month groups, and control 1-month and 3-month groups (n = 6 per group). The model groups was transferred into the custom-made hot plate cage three times per day for modeling. The control group was kept in a regular cage. The intervertebral disc samples of the L3 -L5 were harvested for histologic, molecular, and immunohistochemical studies after modeling for 1 and 3 months. RESULTS: Accumulated spinal axial biomechanical loading affects the histologic, molecular, and immunohistochemical changes of mice L3- L5 intervertebral discs. Decreased height of disc and endplate, fissures of annulus fibrosus, and ossification of cartilage endplate were found in morphological studies. Immunohistochemical studies of the protein level showed a similar expression of type II collagen at 1 month, but a slightly decreased expression at 3 months, and an increased expression level of type X collagen and matrix metalloproteinase 13 (MMP13). Molecular studies showed that ColIIa1 and aggrecan mRNA expression levels were slightly increased at 1 month (P > 0.05), but then decreased slightly (P > 0.05). ColXa1, ADAMTS-5, and MMP-13 expression levels werer increased both at 1 and 3 months (P < 0.05). In addition, increased expression of Runx2 was observed. CONCLUSION: Accumulated spinal axial loading provided by a custom-made hot plate accelerated mice lumbar disc and especially endplate degeneration. However, this method requires further development to establish a lumbar disc degeneration model.

KLF7 overexpression in human oral squamous cell carcinoma promotes migration and epithelial-mesenchymal transition.

Krüppel-like factor 7 (KLF7) is a member of the KLF family of zinc finger transcription factors, and was the first KLF cloned using complementary DNA and polymerase chain reaction (PCR) techniques with human vascular endothelial cells as a template. In addition, KLF7 is known as the ubiquitous Krüppel-like factor, as it is widely expressed in numerous human tissues at low levels. In the present study, the function of KLF7 in migration and epithelial-mesenchymal transition (EMT), which are associated with tumor progression, was investigated in human oral squamous cell carcinoma (OSCC) cells. Genes that were differentially expressed in normal vs. OSCC tissue were identified in the Gene Expression Omnibus database, which identified upregulation of KLF7 in OSCC. The expression and subcellular location of KLF7 was then analyzed using immunohistochemistry. KLF7 expression was measured in three OSCC cell lines, and the two cell lines with the highest (HN13) and lowest (CAL27) KLF7 expression were selected for further analysis. Subsequently, HN13 cells with reduced KLF7 expression (sh-HN13) and CAL27 cells overexpressing KLF7 (OE-CAL27) were constructed. Transwell migration and wound healing assays were then used to analyze the migration of the cells. In addition, mRNA and protein expression levels of the EMT markers E-cadherin, N-cadherin, vimentin and snail were detected using reverse transcription-quantitative PCR and western blotting. KLF7 overexpression in OSCC was validated using tissue immunohistochemistry, which identified moderate to high cytoplasmic staining of KLF7 in OSCC cells. KLF7 knockdown and overexpression altered the migration ability of sh-HN13 and OE-CAL27 cells, which decreased and increased significantly respectively. Expression of E-cadherin, N-cadherin, vimentin and snail was markedly altered in sh-HN13 and OE-CAL27 cells, indicating changes in EMT status. The results of the present study suggest that KLF7 overexpression changes the migratory behavior of OSCC cells, and induces EMT and lymph node metastasis through the expression of snail.

Anticancer effects of valproic acid on oral squamous cell carcinoma via SUMOylation in vivo and in vitro.

Aberrant histone deacetylase (HDAC) has a key role in the neoplastic process associated with the epigenetic patterns of tumor-related genes. The present study was performed to investigate the effects and determine the mechanism of action of the HDAC inhibitor, valproic acid (VPA), on the CAL27 cell line derived from oral squamous cell carcinoma (OSCC). The effects of VPA on the viability of CAL27 cells were investigated using MTT assays. Alterations in the cell cycle and apoptosis were also examined using propidium iodide (PI) and Annexin V-PI assays, and were subequently analyzed by flow cytometry. Small ubiquitin-related modifier (SUMO)-related genes were evaluated by reverse transcription-quantitative polymerase chain reaction analysis. In addition, the effects of VPA were assessed using a xenograft model in vivo. The present results demonstrated significant dose-dependent inhibition of cell viability following VPA treatment. Treatment with VPA increased the distribution of CAL27 cells in the G1 phase and reduced cells in the S phase, and significantly increased the expression levels of SUMO1 and SUMO2 (P<0.01). Using a xenograft model, the mean tumor volume in VPA-treated animals was demonstrated to be significantly reduced, and the rate of apoptosis was significantly increased, as compared with the control animals. These results suggested that VPA may regulate SUMOylation, producing an anticancer effect in vivo. Further investigation into the role of VPA in tumorigenesis may identify novel therapeutic targets for OSCC.

Analysis of Risk Factors for Pneumonia in 482 Patients Undergoing Oral Cancer Surgery With Tracheotomy.

PURPOSE: Elective tracheostomy is a common procedure used in patients with oral cancer. However, secondary tracheotomy-associated pneumonia (TAP) is an important complication after surgery. This study investigated the risk factors related to postoperative TAP complications in patients with oral cancer. MATERIALS AND METHODS: A retrospective study was performed from January 2012 to October 2013. Data on patients who had oral cancer and underwent neck dissection or reconstructive surgery with tracheotomy were collected from the Hospital Information System. The predictive variables were age, gender, alcohol history, smoking history, basic disease (including diabetes, hypertension, and cardiovascular disease), tumor location, and duration of tracheotomy, which were extracted from electronic medical records. The outcome variable was TAP. Descriptive single factors and bivariate statistics were computed and the P value was set at .05. RESULTS: Four hundred eighty-two patients who received tracheotomy after oral cancer surgery were included in this study and 95 (19.7%) developed TAP. Univariate analysis showed that male gender (odds ratio [OR] = 1.853; 95% confidence interval [CI], 1.083-3.17; P = .024 to <.05), long duration of tracheotomy (OR = 1.673; 95% CI, 1.343-2.083; P < .0001), and smoking (OR = 1.656; 95% CI, 1.053-2.604; P = .029 to <.05) were risk factors for TAP. Then, 2 variables independently related to an increased risk of postoperative TAP were found by multivariate regression analysis, which were male gender (OR = 1.945; P = .018) and long duration of tracheotomy (OR = 1.694; P = .0001). CONCLUSIONS: The present findings indicate that male gender and tracheotomy duration are important risk factors for TAP in patients undergoing major oral cancer surgery.

The time point in surgical excision of heterotopic ossification of post-traumatic stiff elbow: recommendation for early excision followed by early exercise.

BACKGROUND: Post-traumatic heterotopic ossification (HO) around the elbow may severely impair joint function. Although surgical excision is effective at restoring range of motion (ROM), traditional surgical treatment is postponed for at least 1 year to prevent recurrence, which leads to secondary contracture of the elbow. Because the optimal timing of resection is controversial, our study was performed to compare recurrence and elbow function between early and late excision in our patients to determine whether the delay is necessary. METHODS: We retrospectively reviewed 164 patients during a 4-year period. In the control group (112 patients), HO was excised at an average of 23.0 months after initial injury (range, 9-204 months); in the early excision group (52 patients), resection was performed at an average of 6.1 months (range, 3-8 months). HO recurrence was assessed by the Hastings classification system. Final ROM and Mayo Elbow Performance Scores were also evaluated. RESULTS: Recurrent HO was observed in 30 of 112 patients (26.8%) in the control group and 15 of 52 (28.9%) in early excision group. No significant difference in HO recurrence was found between the 2 groups (P = .942). Moreover, there were no notable differences regarding ROM, Mayo Elbow Performance Scores, and complications postoperatively. CONCLUSIONS: Early excision associated with early exercise is effective for the treatment of HO aiming at a low recurrence rate and satisfactory function. The conventional surgical delay of more than 1 year may be shortened.

Limited Medial and Lateral Approaches to Treat Stiff Elbows.

Open arthrolysis is an effective way to treat elbow stiffness. However, previous approaches led to significant surgical trauma. The goal of the current study was to evaluate the outcome of open arthrolysis with limited medial and lateral approaches combined with hinged external fixation to treat elbow stiffness. A total of 18 patients (18 elbows) with elbow stiffness were retrospectively reviewed. The same inclusion and exclusion criteria were used for all patients. Preoperatively, the mean flexion arc was 43°±28° and the mean Mayo Elbow Performance Score was 62 points. Limited medial and lateral approaches were used to provide safe and complete arthrolysis. The other protocols included ulnar nerve transposition, medial epicondyle osteotomy, radial head resection, ligament repair, and hinged external fixation. Patients were encouraged to begin early rehabilitation 24 hours after surgery. At a mean follow-up of 20 months, the flexion arc improved to 130°±11° and the mean Mayo Elbow Performance Score was 97 points (15 excellent, 3 good). One patient had elbow instability, but function met the requirements of his daily life. Transient ulnar nerve palsy without infection occurred in 4 patients. With limited medial and lateral approaches, elbow stiffness can be treated effectively with open arthrolysis. This method is trauma controlled. Furthermore, a hinged external fixator can provide sufficient and safe rehabilitation. The use of open arthrolysis with limited medial and lateral approaches combined with hinged external fixation is an effective and safe method to treat elbow stiffness.

Arthrolysis and delayed internal fixation combined with hinged external fixation for elbow stiffness associated with malunion or nonunion of capitellum fracture.

BACKGROUND: This study assessed outcomes after treatment of patients with capitellum fracture diagnosed >4 weeks after the trauma (delayed) who presented with stiff elbow. METHODS: We reviewed 7 patients with stiff elbows after delayed diagnosis of capitellum fractures between February 2007 and February 2012. They were treated with arthrolysis by twin incisions, late open reduction and internal fixation, and a hinged external fixator. According to the Bryan-Morrey-McKee classification, 3 patients had type I capitellum fractures and 4 patients had type IV. RESULTS: Mean follow-up was 28 months (range, 24-38 months). The mean delay from the initial trauma was 3.7 months. The flexion arc improved from a preoperative mean of 24° to a postoperative mean of 122°. The Mayo Elbow Performance Score increased from a mean of 56 points to 93 points. Anatomic fracture union occurred in all cases, and there was no secondary displacement. CONCLUSIONS: Arthrolysis, late internal fixation, and use of a hinged external fixator can solve problems associated with stiff elbow after delayed diagnosis of capitellum fracture. Combined use of these techniques may be a safe and effective treatment option.

Comparative study of radial head resection and prosthetic replacement in surgical release of stiff elbows.

PURPOSE: Elbow trauma can compromise the arc of elbow flexion and forearm rotation. This study aimed at comparing the outcomes of radial head resection and prosthetic replacement in the surgical release of post traumatic elbow stiffness and associated restriction in forearm rotation. METHODS: We retrospectively reviewed the data of patients who underwent open arthrolysis with radial head resection (n = 15; resection group) or radial head replacement (n = 19; replacement group). The pre- and postoperative measurements of the elbow range of motion (ROM) were recorded. Elbow function was evaluated by the Broberg and Morrey Evaluation System; the Mayo Elbow Performance Index (MEPI); and the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire. RESULTS: Over a mean follow-up duration of 22 months, the improvement in the arc of flexion and extension was 79° (range, 45-125°) and 82° (range, 10-110°), while that in the ROM for forearm rotation was 96° (range, 40-150°) and 102° (range, 15-150°) in the resection and replacement groups, respectively. There were no significant intergroup differences in the elbow ROM measured at the last follow up. The Broberg and Morrey, MEPI, and Dash scores in the two groups were comparable. CONCLUSIONS: Both resection and prosthetic replacement of the radial head with open arthrolysis of post traumatic elbow stiffness were feasible in treating the associated restriction of forearm rotation. We recommend that if the elbow is stable after complete release, radial head resection is preferable to prosthetic replacement because it is technically less demanding.

Stability of severely stiff elbows after complete open release: treatment by ligament repair with suture anchors and hinged external fixator.

BACKGROUND: Instability is a crucial issue in severe post-traumatic elbow stiffness during complete-release surgery. This study aimed to evaluate the efficacy of ligament repair using a suture anchor in the operative treatment of severely stiff elbows for which a hinged external fixator was indicated. METHODS: We retrospectively reviewed 46 cases of severely stiff elbows (flexion arc <60°) undergoing open release. During the operation, all 46 elbows were noted to have instability. Suture anchors were applied to restore the ligament if it was impossible to repair the ligament directly, and a hinged external fixator was simultaneously applied to protect the vulnerable ligament and facilitate rehabilitation. No allograft or autograft was used in any of our cases. The stability, arc of motion, Mayo Elbow Performance Score, ulnar nerve symptoms, and radiographs were evaluated. RESULTS: At a mean follow-up of 24.3 months, the postoperative Mayo Elbow Performance Score was 91 points, as compared with 63 points preoperatively. The mean flexion arc improved from 25° to 126°. Three patients presented with moderate elbow instability when the hinged external fixator was removed; however, all of them regained stability by the last follow-up. Furthermore, 7 cases of new-onset nerve palsy were noted; however, all of them resolved with conservative management. None of the patients required secondary surgery for any reason. CONCLUSIONS: Repair of an avulsed collateral ligament with suture anchors and hinged external fixation was effective in restoring functional mobility in patients with severe post-traumatic elbow stiffness after complete release. This could be an option for treating ankylosed, severely or very severely stiff elbows.