Revision Arthroplasty in the Challenging Elbow.

Compared with hip and knee arthroplasty, total elbow arthroplasty (TEA) has a higher complication rate and lower survivorship. Modern TEA implants most commonly require revision due to implant loosening, infection, and periprosthetic fracture. Concerns with revision TEA include handling of the soft tissues and possible necessity of flap coverage, triceps management, preservation of bone stock, and management of concurrent infection or fracture. In this review, we will discuss preoperative evaluation of the failed elbow arthroplasty, surgical approaches, techniques for revision, outcomes, and complications following revision total elbow arthroplasty.

Epidemiology of Hand and Wrist Injuries in Collegiate-Level Athletes in the United States.

PURPOSE: Hand and wrist injuries are common among competitive athletes and can have a substantial impact on playing time and future participation. The purpose of this study was to provide epidemiological data from the National Collegiate Athletic Association Injury Surveillance Program to correlate injury diagnosis with the need for surgery and time loss. METHODS: Using the National Collegiate Athletic Association Injury Surveillance Program, this retrospective study extracted data of hand and wrist injuries for all 25 National Collegiate Athletic Association sports from the academic years 2004-2005 to 2013-2014. The "severe" category was defined as injuries resulting in the following: (1) surgery, (2) season-ending status, or (3) more than 30 days of playing time loss. The epidemiologic data included injury rate per 100,000 athlete exposures (defined as 1 athlete participating in 1 practice or competition) based on diagnoses and demographic information such as sports and sex. We used a Poisson regression model to estimate the incidence rate and 95% confidence interval. RESULTS: Overall, 4,851 hand injuries were identified, with an injury rate of 41.2 per 100,000 athlete exposures. The most common diagnoses were metacarpal or phalangeal fractures (19.9%), lacerations or contusions (15.4%), and wrist sprains (14.7%). The surgical rate was 9.6%, and the season-ending rate was 5.8%. Severe injuries occurred in 17.5% of the hand and wrist injuries; within this subset, the most common diagnoses included metacarpal or phalangeal fractures (43.8%), scaphoid fractures (12.8%), and thumb ulnar collateral ligament tears (8.7%). Scaphoid fractures and metacarpal or phalangeal fractures had the highest surgical rate and season-ending rate among all the injuries. CONCLUSIONS: The injury rate of hand and wrist injuries is comparable with those of other common sports injuries. Approximately one fifth of the injuries were considered severe, which led to a high surgical rate, and these had a considerable impact on the athletes' ability to finish the season. TYPE OF STUDY/LEVEL OF EVIDENCE: Outcome research level II.

The Outcomes of Intra-Articular Distal Humerus Open Reduction and Internal Fixation Using Parallel Precontoured Plates in the Elderly.

PURPOSE: Inconsistent outcomes have been reported in several prior studies of elderly patients with distal humerus fractures treated with open reduction and internal fixation (ORIF). We evaluated the outcomes of ORIF using modern precontoured plates exclusively in a parallel orientation. METHODS: A retrospective review was performed to identify the patients aged over 65 years who sustained an isolated distal humerus fracture between 2015 and 2019. We identified 22 patients who underwent distal humerus ORIF using parallel, precontoured locking plates. Electronic medical records were reviewed for demographic characteristics, physical examination findings, and radiographic data. Outcomes were assessed with Quick Disabilities of the Arm, Shoulder, and Hand scores and Mayo Elbow Performance scores. Complications were evaluated by a review of the patient's medical record and postoperative radiographs. RESULTS: Of the included patients, 18 were women and 4 were men; the average age was 78 years (SD, 8.5 years), and the patients were followed for an average of 33 months. The sample consisted of 19 AO type C, 1 type B, and 2 type A fractures. At the final follow-up, the mean arc of total elbow flexion was 107° (SD, 18.9°; range 40° to 130°), with mean elbow flexion of 129° (SD, 11.7°; range, 120° to 140°) and mean extension of 22° (SD, 12.9°; range 0° to 90°). The mean Quick Disabilities of the Arm, Shoulder, and Hand score was 19 (SD, 14.4), and the mean Mayo Elbow Performance score was 86 (SD, 10.2). Complications occurred in 5 (23%) patients, requiring 4 subsequent surgeries, of which 1 was a conversion to total elbow arthroplasty. CONCLUSIONS: Older patients who underwent ORIF of the distal humerus using a parallel construct demonstrated good functional outcomes and similar complications to those in previously reported studies. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Treatment patterns and failure rates associated with prosthetic joint infection in unicompartmental knee arthroplasty: A systematic review.

Background: Prosthetic joint infection (PJI) following unicompartmental knee arthroplasty (UKA) is a rare but challenging complication. A paucity of literature exists regarding the management of PJI in UKA. This systematic review aims to assess current treatment patterns in UKA PJI and analyze the failure rates associated with treatment. Methods: PubMed, Scopus, and EMBASE were systematically searched for studies that presented cases of PJI following UKA. Data regarding study design, country of publication, index procedure type, diagnosis of PJI, number and incidence of PJI, timing of PJI (acute versus chronic), treatment, and outcomes were recorded. Failure rates in acute and chronic PJI as well as total failure rates were analyzed. Results: Sixteen articles were identified that met inclusion criteria. These included 97 PJI cases (37 acute, 58 chronic, 2 unknown timing); incidence across all studies of 0.80%. The most common treatment for all PJI cases was debridement, antibiotics, and implant retention (DAIR) (40.2%), followed by two-stage conversion to total knee arthroplasty (TKA) (33.0%), one-stage conversion to TKA (23.7%), and one-stage exchange UKA (3.1%). There were no significant differences in failure rates across procedures for acute, chronic or overall PJI management (p > 0.05 for all). Conclusion: This systematic review found relatively few studies reporting on PJI after UKA compared to the available TKA evidence. Further research is warranted to better elucidate the most appropriate treatment of PJI after UKA in both the acute and chronic setting along with risk factors for failure.

Surgical Management of Complex Adult Monteggia Fractures.

Monteggia fractures classically involve a proximal ulna fracture with an associated radial head dislocation. The presence of radial head/neck fracture and comminution of the proximal ulna with coronoid involvement elevates the complexity of surgical reconstruction considerably. The Jupiter classification captures this injury pattern as a subgroup of Bado posterior Monteggia lesions. Access to the critical coronoid fragment can be problematic from the posterior approach and may result in tenuous reduction and fixation, directly affecting the functional outcome. Multiple operative techniques have been described to address the broad spectrum of injuries seen in Monteggia fractures. This article will cover commonly used fixation techniques for Monteggia fractures with a comprehensive literature review, including technical tips, outcomes, and complications.

A Web-Based Lifestyle Medicine Curriculum: Facilitating Education About Lifestyle Medicine, Behavioral Change, and Health Care Outcomes.

BACKGROUND: Lifestyle medicine is the science and application of healthy lifestyles as interventions for the prevention and treatment of disease, and has gained significant momentum as a specialty in recent years. College is a critical time for maintenance and acquisition of healthy habits. Longer-term, more intensive web-based and in-person lifestyle medicine interventions can have a positive effect. Students who are exposed to components of lifestyle medicine in their education have improvements in their health behaviors. A semester-long undergraduate course focused on lifestyle medicine can be a useful intervention to help adopt and sustain healthy habits. OBJECTIVE: To describe a novel, evidence based curriculum for a course teaching the concepts of Lifestyle Medicine based on a web-based course offered at the Harvard Extension School. METHODS: The course was delivered in a web-based format. The Lifestyle Medicine course used evidence based principles to guide students toward a "coach approach" to behavior change, increasing their self-efficacy regarding various lifestyle-related preventive behaviors. Students are made to understand the cultural trends and national guidelines that have shaped lifestyle medicine recommendations relating to behaviors. They are encouraged to engage in behavior change. Course topics include physical activity, nutrition, addiction, sleep, stress, and lifestyle coaching and counseling. The course addressed all of the American College of Preventive Medicine/American College of Lifestyle Medicine competencies save for the competency of office systems and technologies to support lifestyle medicine counseling. RESULTS: The course was well-received, earning a ranking of 4.9/5 at the school. CONCLUSIONS: A novel, semester-long course on Lifestyle Medicine at the Harvard Extension School is described. Student evaluations suggest the course was well-received. Further research is needed to evaluate whether such a course empowers students to adopt behavior changes.

Corticosteroid Injections for Adhesive Capsulitis: A Review.

OBJECTIVE: Adhesive capsulitis is a self-limiting condition in a majority of patients and is often treated nonoperatively. However, symptoms may take 2 to 3 years to resolve fully. A small, but significant, portion of patients require surgical intervention. The purpose of this systematic review is to evaluate the efficacy of corticosteroid injections for the treatment of adhesive capsulitis (AC). DATA SOURCES: A review of articles indexed by the United States National Library of Medicine was conducted by querying the PubMed database for studies involving participants with AC, frozen shoulder, stiff shoulder, or painful shoulder. Articles that included corticosteroids, glucocorticoids, steroids, and injections were included. MAIN RESULTS: Corticosteroid injections provide significant symptom relief for 2 to 24 weeks. Injections can be performed intra-articularly or into the subacromial space. Evidence suggests that a 20 mg dose of triamcinolone may be as effective as a 40 mg injection. It remains unclear whether image-guided injections produce a clinically significant difference in outcomes when compared with landmark-guided (blind) injections. Corticosteroids may be less beneficial for diabetic patients. Patients using protease inhibitors (antiretroviral therapy) should not receive triamcinolone because the drug-drug interaction may result in iatrogenic Cushing syndrome. CONCLUSIONS: Corticosteroid injections for AC demonstrate short-term efficacy, but may not provide a long-term benefit. More high quality, prospective studies are needed to determine whether corticosteroid injections using ultrasound guidance significantly improve outcomes.

Evaluating Nonoperative Treatments for Adhesive Capsulitis.

Patients commonly present with shoulder complaints to the primary care and orthopaedic setting. The differential includes rotator cuff tears, subacromial impingement, osteoarthritis, and adhesive capsulitis, also known as frozen shoulder. Despite the prevalence of adhesive capsulitis, it is commonly misdiagnosed and management remains unclear. This article reviews the presentation of adhesive capsulitis, presents an overview of the pathophysiology of this poorly understood disease, and evaluates nonoperative treatment options for adhesive capsulitis. (Journal of Surgical Orthopaedic Advances 26(4):193-199, 2017).

Increasing Knowledge and Confidence in Behavioral Change: A Pilot Study.

OBJECTIVE: To assess whether and how effectively an interactive presentation about lifestyle medicine could impact the knowledge and attitudes of medical students to prepare them for managing chronic conditions in their patients. Chronic diseases are increasingly prevalent and problematic. Although chronic disease management involves lifestyle modification, few physicians are adequately trained in effective motivational interventions. METHODS: We surveyed first- and second-year Harvard Medical School students in October 2015 before and after a presentation on lifestyle medicine and quantified changes in their knowledge, attitudes/confidence, and skills. RESULTS: Medical students learned the basics of behavioral change after a 1-hour presentation, and their confidence with regard to implementing interventions increased. Median scores of confidence in counseling patients on lifestyle changes improved as did their ability to counsel patients on exercise, nutrition, sleep, stress management, and smoking cessation. CONCLUSIONS: After a brief intervention, medical students can learn principles of behavioral management and how to implement the skills with patients suffering from chronic illnesses.