Can Secondary Adhesive Capsulitis Complicate Calcific Tendinitis of the Rotator Cuff? An Ultrasound Imaging Analysis.

BACKGROUND: Adhesive capsulitis (AC) of the glenohumeral joint is a recognized cause of pain associated with both active and passive restricted ranges of movement. AC can be subdivided into primary and secondary forms. Trauma, surgery, immobilization, and diabetes mellitus are the leading well-recognized causes of secondary AC. Calcific tendinitis/tendinitis (CT) of the rotator cuff is considered a possible trigger for AC, as reported in a few previous articles. However, there are no original investigations that assess the frequency and characteristics of this association. The aim of our research was to evaluate the presence of AC in a cohort of patients with a known CT condition of the rotator cuff by an ultrasound (US) examination. MATERIALS AND METHODS: We prospectively enrolled all the patients admitted at our single institution (October 2022-June 2023) for the preoperative US evaluation of a known CT condition. In these patients, we searched for parameters related to secondary AC. An axillary pouch (AP) thickness equal to or greater than 4 mm (or greater than 60% of the contralateral AP) was considered diagnostic of AC. Moreover, rotator interval (RI) thickness and the presence of effusion within the long-head biceps tendon (LHBT) sheath was also assessed in all patients. RESULTS: A total of 78 patients (54F, 24M-mean age = 50.0 and range = 31-71 y.o.) were enrolled in the study. In 26 of those patients (26/78-33.3%), US signs of AC were detected. Notably, the mean AP thickness in patients with AC and CT was 3.96 ± 1.37 mm (Group 1) and 2.08 ± 0.40 mm in patients with CT only (Group 2). RI thickness was significantly greater in patients with superimposed AC: 2.54 ± 0.38 mm in Group 1 and 1.81 ± 0.41 mm in Group 2 (p < 0.00001). Moreover, effusion within the LHBT was significantly more frequently detected in patients with AC: 84.61% in Group 1 versus 15.79% in Group 2-p < 0.00001. CONCLUSION: US signs of AC are found in one-third of patients with CT of the rotator cuff, demonstrating that AC represents a frequent complication that should be routinely evaluated during US investigation to provide more personalized treatment strategies.

Prolactin Inhibition to Treat Postpartum Arrhythmic Storm.

Postpartum electrical storm due to torsade de pointes is a rare but life-threatening condition. The uniqueness of this case lies in the use of cabergoline to suppress postpartum ventricular arrhythmias in absence of heart disease. Timely multidisciplinary management is crucial to achieve final diagnosis, deliver proper treatment and improve prognosis.

Classification of elbow stiffness.

Stiffness is a clinical disorder that affects the patient's function of the entire upper limb. Many classifications systems have been developed for elbow stiffness based on the plane of motion, severity, aetiology, prognosis or anatomical location. A new classification, the Stiffness types and Influencing Factors Classification System, is proposed as a treatment algorithm to guide the surgical treatment and the preferred operative approach (open or arthroscopic).

Elbow Arthroscopy for the Treatment of Radial Head Fractures: Surgical Technique and 10 Years of Follow Up Results Compared to Open Surgery.

BACKGROUND: This study aimed to describe the ARIF (Arthroscopic Reduction Internal Fixation) technique for radial head fractures and to compare the results with ORIF (Open Reduction Internal Fixation) at mean 10 years. METHODS: A total of 32 patients affected by Mason II or III fractures of the radial head who underwent ARIF or ORIF by screws fixation were retrospectively selected and evaluated. A total of 13 patients were treated (40.6%) by ARIF and 19 patients (59.4%) by ORIF. Mean follow-up was 10 years (7-15 years). All patients underwent MEPI and BMRS scores at follow-up, and statistical analysis was performed. RESULTS: No statistical significance was reported in Surgical Time (p = 0.805) or BMRS (p = 0.181) values. Significative improvement was recorded in MEPI score (p = 0.036), and between ARIF (98.07, SD ± 4.34) and ORIF (91.57, SD ± 11.67). The ARIF group showed lower incidence of postoperative complications, especially regarding stiffness (15.4% with ORIF at 21.1%). CONCLUSIONS: The radial head ARIF surgical technique represents a reproducible and safe procedure. A long learning curve is required, but with proper experience, it represents a tool that might be beneficial for patients, as it allows a radial head fracture to be treated with minimal tissue damage, evaluation and treatment of the concomitant lesions, and with no limitation of the positioning of screws.

Elbow hemiarthroplasty in distal humeral fractures: Indication, surgical technique and results.

The surgical management of distal humerus fractures in adults generally consists in open reduction internal fixation (ORIF) or total elbow arthroplasty (TEA). Hemi humeral hemiarthroplasty (EHA) is a treatment option for unreconstructable intra-articular distal humerus fractures. It is a reasonable option in patients over the fifth decade and its potential advantages are to eliminate the complications related to the ulnar component such as wear of the hinge (busching wear) or the aspetic loosening of the ulnar component. The potential disadvantages are the risk of instability with the possibility of a wear and progressive joint osteoarthrosis. The aims of this manuscript are to evaluate the indications in which we used the EHA, analyzing the correct surgical technique and describe the outcomes in medium and long-term follow-ups. Between 2006 and 2019, we performed 51 EHAs at the Hesperia Hospital in Modena and at the Rizzoli Orthopedic Institute. Taking into consideration only the cases of acute fractures, 27 patients (27 elbows) with a minimum follow-up of 12 months were identified. The patient's mean age at the time of surgery was 64 years old (range from 45 to 78 years old) and they were 78% female (21 out of 27). The Latitude Tornier implant was used in all the patients of our group. The mean MEPS was 89.3 points (from 50 to 100 pts) with excellent results in 19 patients, good in 5, one fair and 2 poor;the mean DASH was 12.6 (from 3.3 to 45.8); the mean OES was 42.3 (from 22 to 47). Complications, were found in 12 patients and any patients required a TEA conversion. Distal humerus hemiarthroplasty from our experience is a good option for the surgical management of unrecostructible distal humeral fractures in selected patients. It is important to perform a precise surgical technique; preserve the triceps insertion, preserve or repair the collateral ligaments, fix the condylar bones implant the prosthesis at the correct size, depth and rotation. The majority of the complication that we observed are related to the stiffness and not to the progressive degenerative changes of the articular surface.

Choice of treatments of the coronal shear fractures of the humerus. A national survey of Italian AO members.

INTRODUCTION: Coronal shear fractures of the distal humerus are uncommon injuries representing 6% of distal humeral fractures. There is no univocal consensus about the correct management of this type of fracture. A national survey was conducted to gain more insight into the current classification, diagnosis and treatment of coronal shear fractures in Italy. MATERIALS AND METHODS: A postal survey was sent to all AO Italian members including residency orthopaedic surgeons. The survey consisted of general questions about personal experience in the management of these fractures: types of classification systems used, surgical approaches, treatment options and rehabilitation programs. RESULTS: 114 orthopaedic surgeons answered a 13-items questionnaire. The most used classification system was AO/OTA (72,8%). Independent screws and if necessary plates were the most answered regarding surgical treatment (81,6%). The most encountered post-surgical complication was stiffening of the elbow (81,6%). CONCLUSION: An algorithm of treatment has been proposed. To better classify coronal shear fractures, the authors recommended the integration of two classification systems: AO and Dubberley classifications. In the case of posterior wall comminution, a Kocher extensile approach is recommended, otherwise, if a posterior wall is intact, Kocher or Kaplan approach can be used. The posterior transolecranic approach can be reserved to Dubberley type III or AO 13B3.3. The best treatment choice is represented by independent screws and plates placed according to fracture patterns while arthroplasty is indicated when a stable ORIF is not possible. Mobilization is postponed for about 2 weeks.

Computer-Aided Planning and 3D-Printed Surgical Guide in Patients with Extreme Cubitus Varus Deformity: A Report of 2 Cases.

CASE: We describe 2 patients with extreme triplanar cubitus varus deformity, treated with step-cut corrective virtually planned osteotomies and performed with custom-made surgical guides. The surgery was simulated on the patients' bone 3D-printed model to verify the effectiveness of the surgical plans. At a medium 21-month follow-up after surgery, in both patients, clinical and radiological results were fully satisfactory, and no complications have been reported. CONCLUSION: The precision of computer-aided surgical planning and custom-made surgical guides allow to perform reproducible and relatively safe surgeries even in extreme deformities where the surgical complexity could discourage attempts at surgical correction.

Ultrasound-guided percutaneous irrigation of calcific tendinopathy outside the rotator cuff: short-term evaluation.

RATIONALE AND OBJECTIVES: While ultrasound-guided percutaneous irrigation for painful calcific tendinopathy (US-PICT) is the treatment of choice for the rotator cuff, there is a lack of knowledge regarding the treatment of this condition with atypical location. The purpose of our study is to assess if US-PICT can be applied safely and successfully in atypical sites, outside of the rotator cuff. MATERIALS AND METHODS: We retrospectively reviewed the US-PICT performed outside the rotator cuff, in the last 5 years in a single institution. A total of 16 patients have been included in this study. We collected the values of the numerical rating scale (NRS) for pain pre- and post-procedure (7 days and 3-month follow-up). Moreover, we assessed the imaging studies available pre- and post-procedure (ultrasound and plain radiography) to assess complications. RESULTS: In all the 16 patients (10F, 6 M; mean age 50.2; range 24-65-year-old), no complications have been observed during and after the procedures. The mean pain NRS before treatment was 8.7 (range 10-6) and dropped to 1.1 (6-0) after 1 week as well after 3 months 1.1 (6-0). The NRS pain reduction from baseline resulted to be statistically significant after 7 days and 3 months (p < 0.001). CONCLUSION: Our results suggest the safety and efficacy of this procedure, underlining the great potential of US-PICT applied even in different atypical locations.

Ultrasound-guided Treatments for the Painful Shoulder.

Shoulder pain is an extremely common condition. The painful shoulder may be the result of a wide spectrum of underlying pathological conditions, including calcific tendinopathy of the rotator cuff, subacromial-subdeltoid bursitis, acromioclavicular or glenohumeral arthritis, tenosynovitis of the long biceps tendon, rotator cuff lesions, and many other less common conditions. Ultrasound imaging is an effective tool for the diagnosis and also for the image guidance of treatment of the majority of these conditions. Several ultrasound-guided procedures are effective for pain relief, such as percutaneous irrigation, intra-bursal or intra-articular drugs injection, fluid aspiration, neural block. This review article aims to summarize and discuss the most common treatment possibilities with ultrasound guidance for the painful shoulder.

Treatment of elbow instability: state of the art.

The elbow is a congruent joint with a high degree of inherent stability, provided by osseous and soft-tissue constraints; however, when substantial lesions of these stabilising structures happen, instability of the elbow occurs. Significant improvements in surgical elbow instability diagnosis and treatment have been recently introduced both for acute and chronic cases. Specific stress tests, recently introduced in the clinical practice, and different imaging techniques, both static and dynamic, allow assessment of the elbow stabilisers and detection of the instability direction and mechanism even in subtle forms. Many surgical techniques have been standardised and surgical instruments and devices, specifically dedicated to elbow instability treatment, have been developed. Specific rehabilitation protocols have been designed to protect the healing of the elbow stabilisers while minimising elbow stiffness. However, despite the progress, surgical treatments can be challenging even for expert surgeons and the rate of persistent instability, post-traumatic arthritis, stiffness and pain can be still high especially in most demanding cases. The biology of the soft-tissue healing remains one of the most important aspects for future investigation. If future research will help to understand, correct or modulate the biological response of soft-tissue healing, our confidence in elbow instability management and the reproducibility of our treatment will tremendously improve. In this paper, the state of the art of the current knowledge of elbow instability is presented, specifically focusing on modern surgical techniques used to solve instability, with repair or reconstruction of the damaged elbow stabilisers.

Clinico-Radiological Features of Tumor-like Lesions of the Upper Limbs: don't worry about those lumps.

Tumor-like lesions of the upper limb are more frequent than malignant neoplastic lesions and they represent a wide and heterogeneous group of disorders. The combination of clinical evaluation and imaging is the first pivotal step to attempt a distinction between benign and malignant masses, since there are important implications for further management, such as the requirement for conservative or interventional treatment. The classification of these pseudo tumoral lumps remains arbitrary and is still a matter of debate, currently based on a conjunct clinico-radiologic approach. In this article, we review various types of tumor-like lesions of the upper limb in terms of imaging approach and related clinic features, proponing a descriptive classification, useful in clinical practice to recognize these disorders, and to avoid unnecessary or potentially harmful procedures.

Imaging the Postsurgical Upper Limb: The Radiologist Perspective.

Imaging has a paramount role in postsurgical assessment. Radiologists need to be familiar with the different surgical procedures to be able to identify expected postsurgical appearances and also detect potential complications. This article reviews the indications, normal expected postsurgical appearances, and complications of the most frequently used surgical procedures in the shoulder, elbow, and wrist. The emphasis is on points that should not be overlooked in the surgical planning.

Does the presence of posterior comminution modify the treatment and prognosis in capitellar and trochlear fractures? Study performed on 45 consecutive patients.

INTRODUCTION: Only few case series of capitellar and trochlear fractures have been reported. Some of them assume that the presence of a posterior comminution (type B according to Dubberley classification) can represent a negative risk factor for treatment and prognosis respect to the type A cases (without posterior comminution). Nevertheless, how this parameter impacts the treatment and the prognosis has never been quantified before. MATERIALS AND METHODS: All the capitellar and trochlear fractures treated from 2007 to 2015 have been retrospectively reviewed. The presence of posterior comminution on a pre-operative CT-scan was correlated to the surgical technique, to the timing of initiation of rehabilitation and to clinical outcomes. RESULTS: 45 Consecutive patients have been selected, 17 not presenting a posterior comminution (type A), and 28 with posterior comminution (type B). In all the type A fractures a lateral approach (Kocher o Kocher extensile) was used and the fragment fixation was always performed using only screws. Elbow replacement or olecranon osteotomy were performed only to treat type B fractures. Augmented fixations, using plates and k-wires, or prosthetic replacement have been used only in type B fractures. The post-operative immobilization was significantly inferior for type A fracture. Better results have been obtained in type A fractures: mean MEPI score was 86 in type A and 73 in type B, the range of motion was significatively higher in type A both in flexion-extension and in pronation-supination. In type B fractures a significant higher number of complications have been observed (64% vs 29%) along with more reoperations. DISCUSSION: The study has confirmed that, even without considering the extension of the fracture on the coronal plane, the presence of posterior comminution represents an evident negative risk factor, influencing the surgical approach and treatment, the fixation technique, the post-operative rehabilitation, the clinical outcomes, the complications and re-operation rates. CONCLUSIONS: The analysis of the present case series shows how the treatment and the outcomes can be significantly anticipated based on the presence or absence of posterior comminution. Patients with type A fracture are more likely treated with a Kocher approach, screw fixation, an early rehabilitation is performed. In type A fractures better outcomes and low complications rate are expected.

Distance of the Posterior Interosseous Nerve from the Radial Head during Elbow Arthroscopy: An Anatomical Study.

Purpose The aims of this study were to measure the distance of the posterior interosseous nerve (PIN) from the radial head (RH) and its variations with forearm movements. Methods Five fresh frozen cadaver specimens were dissected under arthroscopy. An anterior capsulectomy extended to the entire lateral compartment was performed. The need of soft tissue dissection to isolate the nerve in the extracapsular space was recorded. The distance between the nerve and the anterior part of the RH was then measured with a graduated caliper inserted via the midlateral portal with the forearm in neutral position, full pronation, and full supination. Results The PIN was identifiable in all the specimens. In four cases, it was surrounded by a thick layer of adipose tissue, and further dissection was necessary to isolate it. Damage of the PIN during dissection occurred in one case, in which the proximal part of the nerve was accidentally cut. In three of the remaining cases, an increased distance was measured with the forearm in supination, as compared with neutral and full pronation position. Conclusion This anatomical study suggests that in most of the cases, the PIN does not lay just extracapular at the level of the radiocapitellar joint, but is surrounded by a thick layer of adipose tissue. Furthermore, its distance from the RH appears to increase with forearm supination. This position could increase the safe working space between RH and PIN. Clinical Relevance Knowledge of PIN position in relation to the anterior elbow capsule and its changes with forearm movements can help reduce the iatrogenic injuries during elbow arthroscopy.

Coronoid reconstruction with an osteochondral radial head graft.

BACKGROUND: Chronic coronoid deficiency can occur subsequent to coronoid fracture malunion/nonunion or to coronoid hypoplasia or dysplasia resulting from injury during development. Several surgical options have been described to treat this difficult condition, but results are equivocal. We hypothesized that a modified coronoid reconstruction using a radial head osteochondral graft could restore elbow stability and congruity and that a technique involving rigid internal fixation would promote graft union. METHODS: The coronoid was reconstructed using an osteochondral fragment from a frozen allograft radial head in 3 young women affected by complex post-traumatic elbow instability and incongruity resulting from coronoid deficiency. To promote bone healing, the fragment was kept as large as could be fitted in place, the cut surface compressed onto the remaining coronoid was as large as possible, the medial portion of the radial head (containing dense bone) was used, and 3 lag screws were inserted in different directions. RESULTS: At a mean follow-up of 26 months, all 3 patients achieved a painless, congruent stable joint with a functional range of motion. Computed tomography scans performed 3 months after surgery showed complete union of the graft in all the patients. Each patient rated herself as "almost normal" or "greatly improved" on the Summary Outcome Determination scale. CONCLUSION: Coronoid reconstruction with a radial head osteochondral allograft was successful in restoring stability and function in chronically unstable elbows with coronoid deficiency. Strong fixation using a large segment of the medial radial head achieved rapid graft healing.

Radial head replacement with unipolar and bipolar SBi system: a clinical and radiographic analysis after a 2-year mean follow-up.

Radial head prosthetic replacement is indicated in case of comminuted fracture not amenable to internal fixation, especially when the radial head fracture is part of a pattern of lesions configuring a complex instability of the elbow. Thirty-one SBi radial head prostheses were implanted in 30 patients (one bilateral simultaneous fracture) over a 2 years period. In 10 patients, the mean time from trauma to surgical treatment was 2.4 days, while the remaining 20 patients were treated as "second opinion" cases presenting with elbow stiffness or instability after an average of 19 days from trauma. The implants were monopolar in 12 cases and bipolar in 19. The clinical results were evaluated through the Mayo Elbow performance scoring system. At an average follow-up of 2 years (range 13-36 months), the mean MEPS was 90 points (range 65-100). At late radiographic analysis, radiolucent lines around the stem were found in 11 of the 31 cases. Heterotopic ossifications were found in 14 cases. Bone resorption was observed in 9 cases. Two of the 31 prostheses were removed after 16 and 20 months, in one case to correct stiffness in pronation/supination, in the other one for asymptomatic aseptic mobilization. These short-term results are satisfactory, especially when considering that they were obtained in complex elbow lesions treated in many cases at a delayed stage. Our preference over time went more and more to bipolar implants, but from a comparison of the results we could find no evidence of a superiority of bipolar or monopolar implants. The evolution of these prostheses needs to be evaluated with further studies to assess mid-term and long-term follow-up results.