Can preoperative imaging predict the outcomes after arthroscopic release for elbow arthritis?

INTRODUCTION: The primary symptoms of elbow osteoarthritis are the progressive development of stiffness along with pain at the end range of motion due to osteophyte impingement. Surgical treatment involves resecting these "bone stops". In the literature, these osteophytic lesions are more common than cartilage lesions, which suggests they may occur beforehand. The aim of our study was to confirm osteophytes are more common than cartilage lesions, and also to establish a link between these lesions and the functional outcomes. METHODS: This was a prospective multicenter (8 hospitals) study conducted in the context of a symposium of the Francophone Arthroscopy Society (SFA). Eighty-seven patients with elbow osteoarthritis treated by arthroscopic release were included. The clinical outcomes (range of motion in flexion, extension and pronation-supination; strength; pain at rest and during activity; satisfaction; Andrews and Carson score; QuickDASH, Patient-Rated Elbow Evaluation (PREE), Mayo Elbow Performance Score (MEPS), Self-Evaluation Elbow (SEE) were determined before the procedure and at the 6-month follow-up visit. A standard radiographic assessment was done before the surgery and at the last follow-up visit. A CT arthrogram was done before the procedure. The presence of joint narrowing, osteophytes, filling of fossa along with secondary osteochondroma was evaluated in terms of their location, severity, size and/or number. The presence of radial head subluxation was recorded. The Bröberg & Morrey and Rettig & Hastings classification systems were applied. All the postoperative clinical data along with their change (difference between preoperative and postoperative values) were compared to the imaging findings. RESULTS: Osteophytes were found in 95% of our patients. They were located at the olecranon in 85% of cases and at the coronoid process in 81%. Filled fossae found in 94% of cases. The olecranon, coronoid and radial fossa were filled in 83%, 80% and 60% of elbows, respectively. On the initial X-rays, joint narrowing was found in 68% of elbows. CT arthrogram identified narrowing in 70% of cases. Narrowing was present in the humeroradial joint in 60% of cases and in the humeroulnar joint in 23% of cases. The presence of joint narrowing on CT arthrogram was a negative prognostic factor for pain during activity (p<0.05) along with the Quick DASH (p<0.01) and PREE (p<0.05). Involvement of the humeroradial joint impacted pain at rest (p<0.01). Narrowing of the humeroulnar joint was associated with worse outcomes in terms of pain at rest (p<0.05) and during activity (p<0.05), QuickDASH (p<0.005), MEPS (p<0.05), PREE (p<0.05) and the SEE (p<0.05). The presence of loose bodies before the procedure was associated with better outcomes in terms of pain at rest (p<0.05), QuickDASH (p<0.001), MEPS (p<0.001), Andrews & Carson score (p<0.05) and PREE (p<0.005). The osteoarthritis stage in the Bröberg & Morrey or the Rettig & Hastings classification systems did not impact the various clinical parameters or functional outcome scores. DISCUSSION/CONCLUSION: In the imaging work-up, signs of impingement (osteophytes and filling of fossa) are more common than signs of joint narrowing. The presence of humeroulnar and/or humeroradial impingement when there are no cartilage lesions visible may correspond to a pre-arthritic stage. The outcomes of arthroscopic release are better in elbows with isolated impingement than in those with cartilage lesions, especially at the humeroulnar joint. Excision of secondary osteochondromas is also an excellent surgical indication. Current classification systems cannot be used to determine the prognosis before arthroscopic release of elbow osteoarthritis cases. LEVEL OF EVIDENCE: III, Prospective multicenter observational cohort study.

Arthroscopic debridement for osteoarthritis of the elbow: Results and analysis of predictive factors.

INTRODUCTION: Osteoarthritis is the second most frequent cause of elbow stiffness, after trauma sequelae. Surgical treatment mainly consists of debridement. The main aim of the present study was to assess the efficacy of arthroscopic treatment of osteoarthritis of the elbow on Andrews-Carson score. Secondary objectives comprised assessment of the impact of associated procedures and of epidemiological factors on functional results. METHOD: A prospective multicenter study involving 8 centers, in a symposium held by the French Society of Arthroscopy (SFA), included patients treated by arthroscopy for primary or secondary osteoarthritis of the elbow between January 2017 and March 2018, with a minimum 6 months' follow-up. Clinical assessment was based on change in Andrews-Carson functional score (AC), specific to osteoarthritis of the elbow, and on other functional scores: QuickDash (QD), Patient-Rated Elbow Evaluation (PREE), Mayo Elbow Performance Score (MEPS) and Self-Evaluation Elbow (SEE). Progression in pain on visual analog scale (VAS) and range of motion (RoM) was also assessed. Initial imaging work-up comprised standard X-ray and CT arthrography; paraclinical follow-up was based on X-ray. The impact of the following procedures associated to arthroscopic debridement was analyzed: radial head resection, ulnar nerve release, humeral fenestration, lateral ramp release, and medial collateral ligament posterior bundle release. The functional impact of epidemiological factors (age, handedness, manual occupation, smoking, body-mass index, and work accident/occupational disease status) and radiographic factors (foreign bodies, joint impingement, osteophytes, and fossa filling) was also assessed. RESULTS: The series comprised 87 patients: 75 male (86.2%); mean age, 49 years (range, 18-73 years). Arthroscopic debridement significantly improved all functional scores at a minimum 6 months, and notably the specific AC score: 113.6±25.4 (40-180) versus 178.7±20.2 (110-200) (P<0.0001). Pain diminished significantly: 6.4±2.1 (0-10) versus 1.7±1.8 (0-8) (P<0.0001). RoM increased significantly: flexion/extension, 93.44±20.5° (5-130°) versus 124.2±13.8° (90-160°) (P<0.0001); pronation/supination, 147.6±25.6° (60-180°) versus 162.5±20.6° (100-180°) (P<0.0001). Strength (kg) increased in flexion (8.8±4.0 (4 to 20) versus 15.3±5.1 (3 to 32) (P<0.0008) and in grip [33.1±12.3 (10 to 58) versus 42.1±14.0 (2 to 68) (P<0.0001)]. Epidemiologically, males showed better recovery than females for both pain and strength. There was a significant positive impact of manual work on functional recovery, pain and also strength. There was a significant negative impact of work-accident/occupational disease on pain and strength. Regarding associated procedures, lateral ramp debridement improved AC score, with a gain of 75.4±25.3 points (-5 to 110) vs. 49.6±23.5 (10 to 100) (P<0.0001), and pain on VAS, with a fall of -5.6±2.1 points (-10 to -1) vs. -3.6±3.0 (-8.5 to 1) (P=0.0013). Ulnar nerve release, radial head resection and humeral fenestration had no positive impact. Preoperative foreign body was a factor for good prognosis. Cartilage wear, especially in the humeroulnar compartment, was associated with poorer functional results. DISCUSSION/CONCLUSION: Arthroscopic treatment of osteoarthritis of the elbow significantly improved clinical results at 6 months, with significant improvements in functional scores, pain, strength and range of motion. Gender, type of work and work-accident/occupational disease status influenced clinical results. Lateral ramp release is an often overlooked technical factor improving functional results. Radiologically, the best candidates are those presenting with a foreign body and no humeroulnar impingement. LEVEL OF EVIDENCE: III, Prospective observational multicenter cohort study.

Prospective comparative analysis of arthroscopic debridement for primary and post-traumatic elbow osteoarthritis.

INTRODUCTION: The main aim of the present study was to compare the preoperative profiles and the efficacy of arthroscopic debridement for elbow osteoarthritis between patients with primary versus post-traumatic osteoarthritis. The study hypothesis was that the two groups would show no difference on either criterion. METHOD: In the framework of a symposium of the French Arthroscopy Society (SFA), a prospective comparative multicenter study included 87 patients with 6 months' follow-up of arthroscopic debridement for elbow osteoarthritis: 53 primary (G1) and 34 secondary (G2). Pre- and post-operative clinical assessment in both groups compared Andrews-Carson specific functional score for elbow osteoarthritis (main endpoint), and the QuickDash (QD), Patient-Related Elbow Evaluation (PREE) and Mayo Elbow Performance Score (MEPS) functional scores, pain on VAS, range of motion (RoM) and strength. RESULTS: Arthroscopic debridement significantly improved all functional scores at 6 months, notably including the specific Andrews-Carson score, which showed gain in both groups: 68.5±28.7 (range, -5 to 110) in G1 and 62.6±25.4 (18 to 110) in G2 (P=0.35). Pain decreased significantly in both groups, by 5.1±2.6 points (range, 10 to 1) in G1 and 4.4±2.7 points (range, 8.5 to 1) in G2 (P=0.28). RoM in flexion-extension improved comparably in both groups, by 42.9±22.1 (-15 to 105) in G1 and 49.3±24.5 (10 to 90) in G2 (P=0.22). Strength in flexion improved comparably, by 7.6±4.7kg (-2 to 17.5) in G1 and 6.1±4.8kg (-1 to 13) in G2 (P=0.23). DISCUSSION/CONCLUSION: The study hypothesis was confirmed: there were no differences according to primary versus secondary osteoarthritis in preoperative profile or results. Elbow osteoarthritis entails mechanical impingement. Arthroscopic debridement gave good results independently of primary or post-traumatic etiology. LEVEL OF EVIDENCE: III, prospective comparative observational multicenter cohort study.

One and two-year clinical outcomes for a polyethylene glenoid with a fluted peg: one thousand two hundred seventy individual patients from eleven centers.

PURPOSE: Clinical shoulder science lacks a benchmark against which the early clinical value of new glenoid components can be compared; such a benchmark may be derived from a multicenter study of patients receiving an established, internationally used design of glenoid component. METHODS: We obtained data from 11 centers on 1270 patients having total shoulder arthroplasty using an all-polyethylene component with a fluted central peg. We analyzed individual patient outcomes at 1 and 2 years after surgery. We compared the improvement for each patient to the minimal clinically important difference (MCID) and calculated each patient's improvement as a percent of maximal possible improvement (MPI). RESULTS: The preoperative scores improved from SST 3 ± 2, ASES 37 ± 15, Constant score 36 ± 16, and Penn score 30 ± 19 to SST 10 ± 2, ASES 90 ± 12, Constant 76 ± 13, and Penn 80 ± 24 (p < 0.001 for each). A high percentage of patients improved by more than the MCID (SST 96%, ASES 98%, Constant 94%, Penn 93%) and obtained improvement of at least 30% of the MPI (SST 95%, ASES 98%, Constant 91%, Penn 87%). The clinical outcomes realized with this glenoid design were not worse for the 41% of shoulders with preoperative type B glenoids or for the 30% of shoulders with more than 15 degrees of glenoid retroversion. CONCLUSIONS: Individual patients from 11 international practices having total shoulder arthroplasty using a basic glenoid component design obtained highly significant clinical outcomes, providing a benchmark against which the early outcomes of new designs can be compared to determine whether they provide increased clinical value.

Shoulder arthroscopy combined to hardware removal in proximal humeral fractures: a series of 58 cases with a mean follow-up of 2 years.

BACKGROUND: Proximal humerus fractures are common injuries. Locking plates and anterograde medullary nails are the two most common fixation devices used when open reduction and internal fixation (ORIF) is indicated. Complications related to fracture and to hardware are numerous, especially shoulder stiffness. The goal of this study is to report the clinical outcomes of gleno-humeral arthroscopic arthrolysis combined with hardware removal. METHODS: A total of 58 patients (25 men, 33 women) with a mean age of 58 years (24-79) were reviewed retrospectively. Forty of them were active workers (5 heavy workers), and 18 were retired. A total of 24 fractures were reported after sport accident, 26 after domestic accident, and 8 after high energy trauma. Thirty-four patients with 3 or 4 part fractures (fracture through the anatomic neck and tuberosities), 20 patients with two part (displaced surgical neck) fracture and 4 cases of fracture of the tuberosities were operated. We combined a gleno-humeral arthrolysis by arthroscopy and a removal of the hardware using the previous incision for the plate or by arthroscopy for the nail. RESULTS: The average follow-up was 23 months (range 6-60). Pain in Constant Murley score (CS) increased from 7.3 ± 3.8 points preoperatively to 13 ± 2.76 points post-operatively (p < 0.05). CS increased from 36.8 ± 12.25 points to 68.45 ± 15.24 points. Subjective shoulder value (SSV) score increased from 45.8 ± 16.6 to 78.23 ± 14.74. A gain in all active range of motion was reported (forward flexion: 37.6°, abduction: 39.5°, external rotation: 24.3°, internal rotation: from L5-S1 to T12-L1). CONCLUSIONS: Gleno-humeral arthrolysis by arthroscopy combined with hardware removal after proximal humerus ORIF in one step is safe and beneficial for post-traumatic stiffness of the shoulder. It provides significant pain relief and increase of range of motion and allows to treat associated articular pathology.