Medial elbow injuries in the throwing athlete.

There has been an epidemic increase in injuries to the elbow in our youth sports over the past 15 years. Initially, career-ending elbow injuries occurred almost exclusively in the professional population. The landmark procedure developed by Dr. Frank Jobe, colloquially termed "Tommy John surgery" after the initial player in whom he performed the surgical procedure, allowed roughly two-thirds of professional athletes to return to play at or near the same level. As the surgical procedure became more widespread, modifications of the technique by Jobe and many other contributors raised the return-to-play level to 85%-94% of players regaining the ability to return to sport at the preinjury level. Almost simultaneously, the emphasis on velocity in the professional ranks led to an unintentional increase in stress on the throwing elbow. This was magnified in our athletes by the advent of year-round sports, as well as the formation of "showcase" events to demonstrate skills and measure velocity. This, unfortunately, has resulted in an increase in both repetitive stress injuries and acute traumatic injuries in our young athletes. The purpose of this article is to discuss age-related injuries from both a preventative standpoint and a treatment standpoint.

How do the top 10 known offending drug classes associated with decreased bone mineral density affect total shoulder arthroplasty outcomes?

BACKGROUND: Many regularly prescribed classes of drugs are known to negatively impact bone health. However, it is unclear if perioperative use of these drugs impacts total shoulder arthroplasty (TSA) outcomes. The purpose of this study was to analyze the impact of perioperative use of 10 drug classes with known negative effects on bone health on prosthesis-related outcomes of TSA. METHODS: Patients who underwent primary TSA were retrospectively identified in the PearlDiver database. Within this population, patients prescribed proton pump inhibitors (PPIs), thiazolidinediones (TZDs), loop diuretics, glucocorticoids, aromatase inhibitors, calcineurin inhibitors, selective serotonin reuptake inhibitors (SSRIs), antiepileptic drugs (AEDs), first-generation antipsychotics (FGAs), and second-generation antipsychotics (SGAs) within 6 months before or 6 months after primary TSA were identified (n = 23,748). These patients were propensity score matched 1:1 with controls (n = 23,748) on age, sex, and several comorbidities. After matching, patients with perioperative drug exposure were divided into 10 subgroups (ie, 1 for each drug class). Rates of prosthesis-related complications among patients taking each medication class vs. controls were compared with multivariable logistic regression. RESULTS: Relative to controls, SGA exposure was associated with significantly higher rates of all-cause revision (odds ratio [OR] 1.68) and aseptic revision (OR 1.57). Loop diuretic exposure was associated with significantly higher rates of all-cause revision (OR 1.44) and aseptic revision (OR 1.43). Glucocorticoid exposure was associated with significantly higher rates of all-cause revision (OR 1.32) and aseptic revision (OR 1.30). SSRI exposure was associated with significantly higher rates of all-cause revision (OR 1.27) and aseptic revision (OR 1.24). Periprosthetic fracture, aseptic loosening, and septic revision was comparable for all drug cohorts compared to matched controls (all P > .05). Patients with perioperative exposure to PPIs, TZDs, FGAs, AEDs, aromatase inhibitors, and calcineurin inhibitors displayed comparable rates of all queried complications compared with controls (all P > .05). CONCLUSION: Compared with matched controls, patients with perioperative exposure to SGAs, loop diuretics, glucocorticoids and SSRIs exhibited significantly higher rates of all-cause and aseptic revisions following primary TSA. Several other medications that are risk factors for osteoporosis and fragility fractures did not demonstrate significant associations with any complications, including periprosthetic fracture. These results highlight the need for a thorough review of patients' medical history and current medication usage prior to preoperative risk counseling for patients seeking TSA.

Addition of the Sartorius Tendon Improves Biomechanics of a Four-Strand Hamstring Anterior Cruciate Ligament Autograft.

PURPOSE: The purpose of this study was to quantify and compare the biomechanical properties and change in graft size when adding the sartorius tendon as a fifth strand to a four-strand ST-G hamstring autograft. Additionally, the sartorius tendon was tested individually to quantify its independent biomechanical properties. METHODS: Four-strand and five-strand hamstring tendon grafts were harvested from matched cadaveric knees (mean age: 81.6 ± 9.8). These matched grafts were biomechanically tested using a MTS servohydraulic test system at a rate of testing representative of physiologic tears. The mean diameter, cross-sectional area, and ultimate load to failure were quantified and compared with a one-sided, paired Student's t-test. A P < .05 was considered statistically significant. RESULTS: The mean diameter of the five-strand graft was significantly larger than the four-strand graft (9.30 ± .84 mm vs 8.10 ± .42 mm; P = .002). The average ultimate load to failure of the five-strand graft was 65.3% higher than the four-strand graft (2984.05 ± 1085.11 N vs. 1805.03 ± 557.69 N; P = .009) and added 14.8% to the diameter of the four strand ST-G autograft. CONCLUSIONS: The addition of the sartorius tendon to a four-strand hamstring autograft significantly increased ultimate load to failure by 65%, graft cross-sectional area by 32%, and graft diameter by 15% compared to a traditional four-strand ST-G autograft. This information can be helpful to surgeons who wish to improve the strength of a four-strand ST-G autograft and for undersized grafts as an alternative to allograft supplementation. CLINICAL RELEVANCE: The addition of the sartorius to the four-strand ST-G hamstring autograft significantly increases the ultimate load to failure and overall graft diameter, which can be particularly helpful in undersized autografts as an alternative to allograft supplementation.

Tranexamic Acid Use in Knee and Shoulder Arthroscopy Leads to Improved Outcomes and Fewer Hemarthrosis-Related Complications: A Systematic Review of Level I and II Studies.

PURPOSE: To systematically review the literature to compare the efficacy and safety of tranexamic acid (TXA) as a means to minimize hemarthrosis-related complications after arthroscopic procedures of the knee, hip, and shoulder. METHODS: A systematic review according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines was performed by searching PubMed, Cochrane Library, and Embase databases to locate randomized controlled trials comparing the clinical outcomes and postoperative complications of patients undergoing arthroscopy with and without TXA. Search terms used were "tranexamic acid," "arthroscopy," "knee," "hip," and "shoulder." Patients were evaluated based on early (<6 weeks) postoperative signs of hemarthrosis using the Coupens and Yates classification, postoperative complications (myocardial infarction, stroke, venous thromboembolism events), range of motion (ROM), and patient-reported outcome scores (Visual analog scale, Subjective International Knee Documentation Committee, Lysholm, and Tegner activity scores). RESULTS: Five studies (2 level I and 3 level II) met inclusion criteria, including a total of 299 patients undergoing arthroscopy with TXA and 299 patients without TXA. The average follow-up duration for all patients was 43.9 days. Procedures performed were partial meniscectomy, anterior cruciate ligament reconstruction, and rotator cuff repair. No studies evaluating TXA use in hip arthroscopy were identified. Coupens-Yates hemarthrosis grades significantly improved in the TXA groups across all studies. Three studies found TXA patients to experience significantly less postoperative pain at latest follow-up, 1 study found TXA patients to have significantly better postoperative Lysholm scores, and 1 study found TXA patients to have significantly more ROM at latest follow-up compared with non-TXA patients (P < .05). CONCLUSION: Patients undergoing arthroscopy, particularly arthroscopic meniscectomy, arthroscopic-assisted anterior cruciate ligament reconstruction, and arthroscopic rotator cuff repair, with TXA can be expected to experience improved outcomes and less hemarthrosis-related complications in the early postoperative period compared with non-TXA patients. LEVEL OF EVIDENCE: II, systematic review of level I and II studies.

Traumatic Elbow Instability: How to Fix It and When to Phone a Friend.

Traumatic elbow instability is a difficult condition to manage. Many surgeons consider the elbow a perplexing black box and evaluating damaged structures in the setting of pain and swelling a diagnostic challenge. Injury most commonly occurs from a fall onto an outstretched hand but also results from elbow dislocation, direct trauma, and sporting activities. The injury can initiate on the medial or lateral side, depending on forearm position at the time of injury, and usually follows a predictable pattern, with progressive instability caused by soft-tissue disruption and fractures of the medial or lateral column. Primary medial instability, lateral instability, and combined injury patterns have been described and discussed. Simple elbow dislocations and certain fractures can be managed nonsurgically, whereas complex patterns of instability and fracture-dislocations routinely require surgery. Stiffness and nerve injury are the most common complications and occur from both surgical and nonsurgical management. This chapter describes the diagnosis and management of traumatic elbow instability and the management of its sequela.

Is Patient-reported Penicillin Allergy Independently Associated with Increased Risk of Prosthetic Joint Infection After Total Joint Arthroplasty of the Hip, Knee, and Shoulder?

BACKGROUND: Patients with a patient-reported penicillin allergy may be at greater risk for postoperative prosthetic joint infection (PJI) after total joint arthroplasty of the hip, knee, or shoulder. The increased risk of PJI in these patients has been attributed to these patients receiving a less-effective perioperative antibiotic. However, prior reports did not fully address the clinical characteristics of these unique patients, who may inherently be at greater risk of having a PJI, which may confound prior findings. QUESTIONS/PURPOSES: After controlling for risk factors for PJI such as BMI, anxiety, depression, and other comorbidities, we asked: Are patients with a patient-reported penicillin allergy more likely to have a PJI after THA, TKA, or total shoulder arthroplasty than patients without such a reported allergy? METHODS: We queried patient records from 2010 to 2017 from a nationwide administrative claims database of 122 million patients to adequately power an investigation comparing the 1-year incidence of PJI after TKA, total shoulder arthroplasty, and THA in patients with patient-reported penicillin allergy versus patients without a patient-reported penicillin allergy. Operative treatments for deep joint infection, identified by Current Procedural Terminology and ICD-9 and ICD-10 codes were used as a surrogate for PJI. Clinical characteristics such as age, sex, BMI, length of stay, and Charlson comorbidity index and specific comorbidities including alcohol abuse, anemia, anxiety, cardiac disease, diabetes, immunocompromised status, rheumatoid arthritis, depression, liver disease, chronic kidney disease, tobacco use, and peripheral vascular disease were queried for each study group. The odds of PJI within 1 year of THA, TKA, or total shoulder arthroplasty were compared using multiple logistic regression after adjusting for potential confounders. RESULTS: After adjusting for potential confounding factors such as BMI, anxiety, depression and other comorbidities, we found that patient-reported penicillin allergy was independently associated with an increased odds of PJI after TKA (odds ratio 1.3 [95% confidence interval 1.1 to 1.4]; p < 0.01) and total shoulder arthroplasty (OR 3.9 [95% CI 2.7 to 5.4]; p < 0.01). However, patient-reported penicillin allergy was not independently associated with an increased odds of PJI after THA (OR 1.1 [95% CI 0.9 to 1.3]; p = 0.36) after controlling for the same risk factors. CONCLUSIONS: In this study, we found that patients with patient-reported penicillin allergy were at an increased risk for PJI after TKA and total shoulder arthroplasty, which we suspect-but cannot prove-is likely a function of those patients receiving a second-line antibiotic for presurgical prophylaxis. Since prior research has found that many patients listed in medical records as having a penicillin allergy are in fact not allergic to penicillin, we suggest that surgeons consider preoperative allergy testing, such as using an intraoperative test dose, to aid in choosing the most appropriate antibiotic choice before knee or shoulder arthroplasty and to amend patient medical records based on testing results. Future studies should determine whether this additional diagnostic maneuver is cost-effective. LEVEL OF EVIDENCE: Level III, therapeutic study.

Editorial Commentary: Shoulder Superior Capsular Reconstruction: When a Systematic Review of a Procedure Can Be Misleading.

Shoulder superior capsular reconstruction as described by Mihata et al. achieves excellent results using 6 to 8 mm thick autologous fascia lata. Superior capsular reconstruction using 3-mm-thick dermal allograft is not equivalent and may yield results no better than technically well performed rotator cuff repairs, partial repairs, or tendon transfers.

Rotator Cuff Repair: Patch the Shoulder.

Rotator cuff tears are a common problem in our growing and aging population. Because of this, rotator cuff repair is consistently one of the most frequently performed operations by orthopaedic surgeons every year. Successful outcomes have been directly correlated to a successful repair to the tuberosity; however, healing rates have varied greatly depending on tear size, tear type, and tear chronicity. Despite advances in techniques and repair technology, healing rates have remained relatively stable. Improving the biology at the site of a rotator cuff repair has been proposed as a way of increasing healing rates. A recent bio-inductive patch has been introduced to improve the vascularity and collagen formation at the site of tendon repair. The implant is made from type I bovine collagen that is highly porous. It is nonstructural and does not provide any tensile strength. The patch improves collagen formation at the site of a repair, thus decreasing strain on the repaired tendon. Limited clinical trials involving the collagen patch have shown healing rates from 89% to 96% in small sample sizes. The patch has been successfully and safely applied in tear sizes ranging from partial thickness tears to massive tears, as well as primary and revision repair settings. To date, no adverse clinical reactions to the patch have been observed; however, no randomized clinical trials have been performed, and the patch is a significantly increased cost to the procedure.

Safety of Anteromedial Portals in Elbow Arthroscopy: A Systematic Review of Cadaveric Studies.

PURPOSE: To systematically review available literature comparing location and safety of 2 common anteromedial portals with nearby neurovascular structures in cadaveric models and to determine the correct positioning and preparation of the joint before elbow arthroscopy. METHODS: The review was devised in accordance with Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. Inclusion criteria consisted of original, cadaveric studies performed by experienced surgeons on male or female elbows evaluating anteromedial portal placement with regard to proximity of the arthroscope to neurovascular structures. Exclusion criteria consisted of case reports, clinical series, non-English language studies, and noncadaveric studies. Statistical analysis was done to measure reviewer reliability after scoring of each study. RESULTS: During screening, 2,596 studies were identified, and 10 studies met final inclusion as original, cadaveric investigations of anteromedial portal proximity to neurovascular structures. The difference in distance between proximal and distal portals was <1 mm for the brachial artery and <1.5 mm for the medial antebrachial cutaneous nerve, whereas the ulnar nerve was 4.17 mm further from the distal portal and the median nerve was 5.07 mm further from the proximal portal. Joint distension increased the distances of neurovascular structures to portal sites, with the exception of the ulnar nerve in distal portals. Elbow flexion to 90° increased distances of all neurovascular structures to portal sites. CONCLUSION: The results show that the proximal anteromedial portal puts fewer structures at risk compared with the distal portal. Elbows in 90° flexion with joint distension carry a lower risk for neurovascular injury during portal placement. These findings suggest the proximal anteromedial portal to be the safer technique in anteromedial arthroscopy of the elbow. CLINICAL RELEVANCE: Discrepancies in placement of portals have existed in the literature, indicating differing safety margins regarding surrounding neurovascular anatomy. The present study aims to link together the literature-based evidence to describe the safest anteromedial portal variation.

Editorial Commentary: Danger Zone: The Posteromedial Elbow: Don't Go Looking for Trouble and It Won't Find You! Arthroscopic Management of the Arthritis Elbow.

Arthroscopy for elbow arthritis has been used by this author for 30 years. There are many benefits to arthroscopic management of the arthritic elbow. A complete understanding of the pathology is essential to correct surgical management. Excision of spurs and osteophytes, deepening of the coronoid or olecranon fossa, removal of loose bodies, and synovectomy are essential. Arthritis is usually not a capsular problem, so the releases needed for post-traumatic ankylosis takedown are not usually necessary in the arthritic elbow.

Editorial Commentary: Is Shoulder Joint Preservation an Endangered Species? Let's Save the Glenoid.

Joint preservation in young patients has always been the mission of arthroscopists worldwide since Bob Jackson visited Dr. Watanabe and brought the arthroscope to North America. In patients with shoulder glenohumeral arthritis, joint preservation is paramount and advanced arthroscopic techniques are of significant benefit. A recent publication shows 77% satisfactory outcomes, provides critical details on patient selection, and shows that a cohort of (younger) patients with shoulder osteoarthritis may do well after isolated glenoid resurfacing. A benefit of shoulder glenohumeral resurfacing is that shoulder replacement surgery, if required, could be delayed until a more appropriate age.

Modified Anterolateral Portals in Elbow Arthroscopy: A Cadaveric Study on Safety.

PURPOSE: To evaluate the proximity to the radial nerve on cadaveric specimens of 2 modified anterolateral portals used for elbow arthroscopy. METHODS: Ten fresh cadaveric elbow specimens were prepared. Four-millimeter Steinman pins were inserted into 3 anterolateral portal sites in relation to the lateral epicondyle: (1) the standard distal anterolateral portal, (2) a modified direct anterolateral portal, and (3) a modified proximal anterolateral portal. These were defined as follows: direct portals 2 cm directly anterior to the lateral epicondyle, and proximal portals 2 cm proximal and 2 cm directly anterior to the lateral epicondyle. Each elbow was then dissected to reveal the course of the radial nerve. Digital photographs were taken of each specimen, and the distance from the Steinman pin to the radial nerve was measured. RESULTS: The modified proximal anterolateral and direct anterolateral portals were found to be a statistically significant distance from the radial nerve compare to the distal portal site (P = .011 and P = .0011, respectively). No significant difference was found in the proximity of the radial nerve between the modified proximal and direct anterolateral portals (P = .25). Inadequate imaging was found at a single portal site for the proximal site; 9 specimens were used for analysis of this portal with 10 complete specimens for the other 2 sites. CONCLUSIONS: In cadaveric analysis, both the modified proximal and direct lateral portals provide adequate distance from the radial nerve and may be safe for clinical use. In this study, the distal anterolateral portal was in close proximity of the radial nerve and may result in iatrogenic injury in the clinical setting. CLINICAL RELEVANCE: This is a cadaveric analysis of 2 modified portal locations at the anterolateral elbow for use in elbow arthroscopy. Further clinical studies are needed prior to determining their absolute safety in comparison to previously identified portal sites.

Arthroscopic Rotator Cuff Repair: Indication and Technique.

Shoulder arthroscopy and rotator cuff repair techniques are frequently used by most practicing orthopaedic surgeons. A thorough patient history and physical examination can often confirm the presence of a rotator cuff tear, and imaging can be used to evaluate the extent of the injury. The indication for rotator cuff repair is a painful shoulder refractory to nonsurgical management. Arthroscopic techniques, including capsular and coracohumeral ligament releases to decrease tension on the repair, facilitate successful rotator cuff repair. Biomechanically, a double-row transosseous-equivalent rotator cuff repair provides excellent results for medium-size rotator cuff tears. Larger, retracted rotator cuff tears may be better repaired with oblique convergence sutures and a medial single-row rotator cuff repair. The biology of healing, the preservation of blood supply, and the trephination of the bony healing bed are essential parts of all rotator cuff repair procedures. Protection of the rotator cuff repair with an abduction sling for 4 to 8 weeks postoperatively and the delay of active motion until early healing has occurred will improve outcomes.

Distal biceps tendon history, updates, and controversies: from the closed American Shoulder and Elbow Surgeons meeting-2015.

Understanding of the distal biceps anatomy, mechanics, and biology during the last 75 years has greatly improved the physician's ability to advise and to treat patients with ruptured distal tendons. The goal of this paper is to review the past and current advances on complete distal biceps ruptures as well as controversies and future directions that were discussed and debated during the closed American Shoulder and Elbow Surgeons meeting in 2015.

Decreasing Orthopaedic Surgical Site Infections: A New Perioperative Protocol.

BACKGROUND: Little data exist regarding the effects of prophylactic perioperative protocol on reducing surgical site infections. Based on national efforts to prevent SSIs and current evidence in the literature supporting the importance of perioperative prophylaxis, it would seem logical that expanding upon current perioperative protocol would help prevent SSIs. HYPOTHESIS: Multiple variables present risk factors in the development of SSIs in the perioperative period, and optimization of patient management during this time with a series of non-invasive and inexpensive protocols may help prevent SSIs. METHODS: A six-step perioperative protocol was developed and instituted in our community hospital performing mostly outpatient orthopaedic surgical procedures. The rates of SSIs, diagnosed clinically according to the Center of Disease Control SSI criteria by two orthopaedic surgeons performing the operations during postoperative visits, were recorded in all patients whose index procedure fell within a two-month period before and after the introduction of our protocol. Proportions of infections were compared using Pearson's x2 test. RESULTS: There were a total of 312 cases performed by two surgeons; evaluated two months before, 153, and two months after, 159, the implementation of our protocol. The incidence of SSIs before initiation of the protocol was 9.1% n=14; and after implementation, the incidence was zero 14 vs. 0, p less than 0.0001. CONCLUSION: Multiple variables in the perioperative period can contribute to the incidence of SSIs and can be controlled with diligent attention to prophylactic measures such as those presented in this paper. Our new perioperative protocol represents a cost-effective, and noninvasive method to prevent SSIs in an orthopaedic practice.

Arthroscopic tennis elbow release.

Lateral epicondylitis, originally referred to as tennis elbow, affects between 1% and 3% of the population and is usually found in patients aged 35 to 50 years. Although it was initially thought that lateral epicondylitis was caused by an inflammatory process, most microscopic studies of excised tissue demonstrate a failure of reparative response in the extensor carpi radialis brevis tendon and in any of the associated structures. Most cases of lateral epicondylitis respond to appropriate nonsurgical treatment protocols, which include medication, bracing, physical therapy, corticosteroid injections, shock wave therapy, platelet-rich plasma, and low-dose thermal or ultrasound ablation devices. However, when these protocols are unsuccessful, surgical measures may be appropriate and have a high rate of success. The results of arthroscopic surgical procedures have documented satisfactory results, with improvement rates reported between 91% and 97.7%. Recent advances in arthroscopic repair and plication of these lesions, along with recognizing the presence and repair of coexisting lesions, have allowed arthroscopic techniques to provide excellent results.

The subscapularis-sparing approach in humeral head replacement.

BACKGROUND: This report represents a prospective case series evaluating an open deltopectoral approach, both radiologically and clinically, without tenotomy or complete takedown of the subscapularis tendon insertion. We hypothesized that this novel technical approach would allow preservation of the upper tendon border, thus decreasing subscapularis repair failures and fatty infiltration while simultaneously allowing accelerated rehabilitation. METHODS: Fifty patients underwent humeral head replacement surgery through a subscapularis-sparing approach. In this approach, we take down only the inferior 30% to 50% of the subscapularis tendon, leaving the critical superior aspect of the tendon attached to the lesser tuberosity. Forty-three patients were included in the postoperative results (7 were lost to follow-up). Nineteen patients had a postoperative magnetic resonance imaging study, and 24 patients had ultrasound evaluation. Physical examination included belly-press and lift-off tests; follow-up included visual analog scale, American Shoulder and Elbow Surgeons, Constant, modified UCLA, Rowe, and Short Form 12 scores. RESULTS: All patients had a minimum 2-year follow-up. All patients had subscapularis strength equal to the opposite side as measured by lift-off, belly-press, and bear hug tests. Average postoperative scores all showed statistically significant improvement except for general health. All had an intact subscapularis tendon attachment as evaluated by either magnetic resonance imaging or ultrasound imaging. None had atrophy in the muscle belly. CONCLUSIONS: The subscapularis-sparing, minimally invasive approach to the glenohumeral joint provides adequate exposure to allow humeral head replacement. When the upper border of the subscapularis insertion is left intact, there is a decreased risk of postoperative failure (rupture or atrophy) of the subscapularis tendon.

Arthroscopically assisted shoulder arthrodesis: is it an effective technique?

PURPOSE: The purpose of this study was to compare clinical and radiographic outcomes of open and mini-open arthroscopic arthrodesis. METHODS: Twelve patients underwent arthroscopically assisted glenohumeral arthrodesis over a 5-year period; none were lost to follow-up. Surgery was performed with the patient in the lateral decubitus position, with the arm positioned in 30° each of flexion, internal rotation, and abduction. The articular cartilage was arthroscopically removed from the humerus and glenoid, creating flat opposing surfaces. One to 2 Kirschner wires were inserted percutaneously through the deltoid and across the glenohumeral joint in the center of the articulation; screws were then inserted arthroscopically. The glenohumeral joint was accessed through a mini-open posterior approach beneath the deltoid and was then reassessed before cannulated screws were tightened completely to compress the joint. Two dynamic compression plates were applied to the posterior glenohumeral joint to neutralize rotatory forces. Each patient was immobilized for 6 weeks. Follow-up radiographic imaging was performed at 2, 6, 12, and 24 months after surgery. These patients were then compared with a similar group who underwent a classic open approach. Success of arthrodesis was determined by bone growth across the glenohumeral joint as visualized on axillary radiographs. RESULTS: At 2-year follow-up, complete fusion was achieved in 12 (100%) arthroscopically treated patients, with 2 patients (17%) having early bone grafting (within 6 weeks) through a percutaneous approach. Four patients in the classic open approach group ("open group") required additional grafting. Two patients in the group undergoing arthroscopic surgery ("arthroscopic group") had solid fusion but persisting infection from previously failed operations. Comparison of the 2 groups showed no difference in patient satisfaction or infection rates (2 in each group, all of whom had active infection at the time of the index surgery). One patient in the open group sustained a humeral shaft fracture 5 years after arthrodesis, which required additional surgery. No patient who underwent an arthroscopic procedure required additional surgery other than the 2 early bone grafts. CONCLUSIONS: Arthroscopically assisted mini-open glenohumeral arthrodesis provides results that are at least equal to those of open arthrodesis, with a much less invasive approach. Success and complication rates are the same as for the completely open procedure. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

A preliminary report of acute and subacute arthroscopic repair of the radial ulnohumeral ligament after elbow dislocation in the high-demand patient.

PURPOSE: The purpose of this study was to evaluate functional outcomes, range of motion (ROM), elbow stability, and time to return to full activities after acute and subacute arthroscopic repair of a simple elbow dislocation in high-demand patients. METHODS: "High-demand patients" were defined as in-season athletes and individuals who required use of both hands for their profession and believed that they could not miss the 6 weeks of work that may be required with conservative treatment in an elbow brace. We retrospectively reviewed 14 consecutive patients with a simple elbow dislocation who underwent arthroscopic repair of the radial ulnohumeral ligament from 2008-2012. Outcomes measures included the Mayo Elbow Performance Score (MEPS), elbow ROM, elbow stability, and time to return to full activities. Each patient was contacted once by telephone to determine the current activity level and presence of any pain or functional limitations. RESULTS: The mean patient age was 25 years, with telephone follow-up at a mean of 30 months and clinical examination after a minimum of 6 months. The postoperative MEPS was excellent (mean, 99.6; range, 95 to 100) for all 14 patients, and all returned to their preinjury level of function with no restrictions or instability. Final ROM averaged -3° of full extension to greater than 130° of flexion. The mean time to return to full activities in and out of a brace was 2.7 weeks and 6.6 weeks, respectively, in the acute group and 4.6 weeks and 8.9 weeks, respectively, in the subacute group. All patients were satisfied with their outcome. CONCLUSIONS: Conservative management remains the gold standard for most simple elbow dislocations. We believe that certain high-demand patients may be candidates for acute arthroscopic ligamentous repair. Our preliminary data show that acute arthroscopic repair of the radial ulnohumeral ligament is a safe, effective procedure that restores stability to the elbow and allows patients to quickly return to full activities. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

Primary versus revision arthroscopic reconstruction with remplissage for shoulder instability with moderate bone loss.

PURPOSE: This study aims to evaluate our outcomes of arthroscopic remplissage in this setting. METHODS: A retrospective review was performed to identify patients who underwent arthroscopic remplissage of an engaging Hill-Sachs lesion along with anterior capsulolabral reconstruction for anterior glenohumeral instability with moderate glenohumeral bone loss at our institution. Thirty-five patients, with a minimum of 2 years' follow-up, were identified. We assessed the American Shoulder and Elbow Surgeons score, incidence of recurrent instability, and postoperative Rowe instability score. RESULTS: Follow-up was available for 30 patients (31 shoulders). The mean age was 24.6 years, with a mean follow-up period of 41 months. Prior instability surgery had failed in 11 patients, and they underwent capsulolabral reconstruction and remplissage ("revision surgery"). The failure rate in revision cases (36%) was significantly higher than the failure rate in primary surgery cases (0%) (P = .01). Failure resulted from trauma in all 4 patients, and none required further surgery. The mean American Shoulder and Elbow Surgeons score for all patients improved from 50 preoperatively to 91 postoperatively (P < .001), with no significant postoperative difference between primary and revision patients (P = .13). The patients with clinical failure showed nonsignificant improvement from 41 preoperatively to 72 postoperatively (P = .08). The mean postoperative Rowe score for the entire cohort was 90. The Rowe score was significantly lower in the 4 cases of failure than in the 27 non-failure cases (51 v 96, P < .001). CONCLUSIONS: In our experience, aggressive capsulolabral reconstruction with remplissage in traumatic instability patients with moderate bone loss and engaging humeral Hill-Sachs lesions yields acceptable outcomes for primary instability surgery. However, a significantly higher failure rate occurred when arthroscopic reconstruction with remplissage was performed in the revision setting. LEVEL OF EVIDENCE: Level IV, therapeutic case series.