Incidence and risk factors for shoulder stiffness after open and arthroscopic rotator cuff repair.

INTRODUCTION: The aim of this study was to estimate the incidence of stiffness during the first 6 months after rotator cuff repair and to evaluate postoperative stiffness with respect to its risk factors and its influence on the outcome at 6 months postoperatively. METHODS: In a prospective cohort of 117 patients (69 women, 48 men; average age 59) from our institutional rotator cuff registry, who underwent either arthroscopic (n = 77) or open (n = 40) rotator cuff repair, we measured shoulder range of motion (ROM) at 3 and 6 months post-surgery. We evaluated the incidence of stiffness and analyzed functional outcomes, comparing various preoperative and intraoperative factors in patients with stiffness to those without at the 6-month mark. RESULTS: Shoulder stiffness was observed in 31% of patients (36/117) at 3 months postoperatively, decreasing to 20% (23/117) at 6 months. No significant link was found between stiffness at 6 months and demographic factors, preoperative stiffness, tear characteristics, or the type of repair. Notably, patients undergoing arthroscopic repair exhibited a 4.3-fold higher risk (OR 4.3; 95% CI 1.2-15.6, p = 0.02) of developing stiffness at 6 months compared to those with mini-open repair. Despite these differences in stiffness rates, no significant variation was seen in the American Shoulder and Elbow Surgeons (ASES) score, Single Assessment Numeric Evaluation (SANE) score, or Visual Analog Scale (VAS) scores at 6 months between the groups. CONCLUSION: The incidence of postoperative shoulder stiffness following rotator cuff repair was substantial at 31% at 3 months, reducing to 20% by 6 months. Mini-open repair was associated with a lower 6-month stiffness incidence than arthroscopic repair, likely due to variations in rehabilitation protocols. However, the presence of stiffness at 6 months post-surgery did not significantly affect functional outcomes or pain levels.

A proposed modification to the Kellgren and Lawrence classification for knee osteoarthritis using a compartment-specific approach.

Purpose: Since Kellgren and Lawrence (KL) originally classified knee osteoarthritis, several authors have reported varying levels of reliability and a lack of uniformity in the use of this classification system. We propose several modifications to the KL classification including the use of a compartment-specific approach that we hypothesize will lead to a better understanding of knee OA while maintaining an adequate interobserver and intraobserver reliability. Methods: We propose the addition of the lateral and skyline-view radiographs to the standard anteroposterior (AP) and lateral projections in the evaluation. Also suggest a more precise definition of the evaluated parameters; the addition of the subchondral cancellous bone as parameter of evaluation; and the assessment of medial tibiofemoral compartment (MTFC), lateral tibiofemoral compartment (LTFC) and patellofemoral compartment (PFC) separately resulting in a compartment-specific KL staging score rather than a single overall KL score. Six evaluators (two knee surgeons, two radiologists and two knee fellows) used the modified KL classification to classify 230 randomly selected knees on two separate occasions. Reliabilities were assessed by calculating Krippendorff's ⍺ coefficients. Results: Two hundred and ten knees were included for final evaluation and analyses (53% left knees; 65% females; mean age 56 years old). Average interobserver reliability was moderate for all compartments (0.51 for the MTFC; 0.51 for the LTFC; and 0.56 for the PFC). Average intraobserver reliability was substantial for all compartments (0.63 for the MTFC; 0.65 for the LTFC; and 0.7 for the PFC). Experienced evaluators showed a higher intraobserver reliability than less-experienced evaluators. Conclusions: A modified compartment-specific KL classification enables a practical and detailed description of knee OA involvement and demonstrates acceptable interobserver and intraobserver reliability. Level of Evidence: Level III.

Prosthetic resurfacing of engaging posterior capitellar defects in recurrent posterolateral rotatory instability of the elbow.

BACKGROUND: Posterolateral rotatory instability (PLRI) is a common mechanism of recurrent elbow instability. While the essential lesion is a deficiency in the lateral ulnar collateral ligament (LUCL), there are often associated concomitant bony lesions, such as an Osborne-Cotterill lesions (posterior capitellar fractures) and marginal radial head fractures, that compromise stability. Currently, there is no standard treatment for posterior capitellar deficiency associated with recurrent PLRI. METHODS: We conducted a retrospective review of five patients with recurrent PLRI of the elbow associated with a posterior capitellar impaction fracture engaging with the radial head during normal range of motion. The patients were treated surgically with LUCL reconstruction or repair and off-label reconstruction of the capitellar joint surface using a small metal prosthesis designed for metatarsal head resurfacing (HemiCAP toe classic). RESULTS: Five patients (three adolescent males, two adult females) were treated between 2007 and 2018. At a median follow-up of 5 years, all patients had complete relief of their symptomatic instability. No patients had pain at rest, but two patients had mild pain (visual analog scale 1-3) during physical activity. Three patients rated their elbow as normal, one as almost normal, and one as greatly improved. On short-term radiographic follow-up there were no signs of implant loosening. None of the patients needed reoperation. CONCLUSIONS: Recurrent PLRI of the elbow associated with an engaging posterior capitellar lesion can be treated successfully by LUCL reconstruction and repair and filling of the capitellar defect with a metal prosthesis. This treatment option has excellent clinical results in the short-medium term. Level of evidence: IV.

The role of the lateral part of the distal triceps and the anconeus in varus stability of the elbow: a biomechanical study.

BACKGROUND: The role of the lateral part of the distal triceps as a stabilizer in the lateral collateral ligament-deficient elbow and whether its effect in improving the stability is independent of that of the anconeus are unclear. METHODS: Seven cadaveric elbows were tested under gravity varus stress using a custom-made machine designed to simulate muscle loads while allowing passive flexion of the elbow. An injury model was created by sectioning the lateral collateral ligament and sparing the common extensor origin. The lateral part of the distal triceps tendon was loaded sequentially with 0 N, 10 N, 25 N, and 40 N. Each stage of the lateral part of the distal triceps loading was tested with the anconeus unloaded (inactive) or with a 25-N load applied (active). Articular contact pressures on the coronoid, the medial facet, and the lateral facet were collected and processed using Tekscan sensors and software. RESULTS: A significant decrease in the mean coronoid contact pressure was seen with sequential loading of the lateral part of the distal triceps (P < .001). The ratio of medial to lateral facet contact pressures significantly decreased with sequential loading of the lateral part of the distal triceps (P < .001), indicating a better distribution of the contact pressure between the medial and lateral facets as the lateral part of the distal triceps was loaded. These effects were statistically significant, both with and without anconeus loading. There was no significant modification of the effect of the lateral part of the distal triceps loading on the contact pressure by the anconeus loading (P = .47). However, with active anconeus loading, the contact pressure and the ratio of medial to lateral facet contact pressures were significantly lower for any stage of lateral triceps loading (P < .001), indicating a synergistic effect of the anconeus. CONCLUSIONS: In a lateral collateral ligament-deficient elbow, the lateral part of the distal triceps loading prevents the increased contact pressure on the coronoid under varus stress and improves the distribution of contact pressures on the coronoid. Anconeus loading further decreases and improves the distribution of the contact pressures; however, its effect is independent of that of the lateral part of the distal triceps. These results substantiate a role of the lateral part of the distal triceps as a dynamic constraint against elbow varus and have clinical implications for prevention and rehabilitation of elbow instability.

The role of the lateral collateral ligament-capsule complex of the elbow under gravity varus.

BACKGROUND: The lateral collateral ligament complex along with the capsule is likely to be at risk during arthroscopic extensor carpi radialis brevis release for lateral epicondylitis. We hypothesized that disruption of the lateral collateral ligament-capsule complex (LCL-cc) would increase the mean contact pressure on the coronoid under gravity varus. MATERIALS AND METHODS: Eight cadaveric elbows were tested via gravity varus and weighted varus (2 Nm) stress tests using a custom-made machine designed to simulate muscle loads while allowing passive flexion of the elbow. Mean articular surface contact pressure data were collected and processed using intra-articular thin-film sensors and software. Sequential testing was performed on each specimen from stage 0 to stage 3 (stage 0, intact; stage 1, release of anterior one-third of LCL-cc; stage 2; release of anterior two-thirds of LCL-cc; and stage 3, release of entire LCL-cc). The mean contact pressure on the coronoid and the mean ratio of contact pressure on the medial coronoid to that on the lateral coronoid (M/L ratio) were used for comparisons among the stages and the intact elbow. RESULTS: The overall mean contact pressure significantly increased in stage 2 (P = .0004 in gravity varus and P = .0001 in weighted varus) and stage 3 (P < .0001 in gravity varus and P < .0001 in weighted varus) compared with that in stage 0. In contrast, release of the anterior one-third of the LCL-cc (stage 1) did not significantly increase the mean contact pressure on the coronoid in any degree of flexion under gravity varus (P = .09) or weighted varus loading (P = .6). The M/L ratio difference between stage 0 and stage 1 was 1.1 ± 1.1 under gravity varus (P = .8) and 2.1 ± 1.0 under weighted varus (P = .2). The overall M/L ratios in stage 2 and stage 3 were significantly higher than those seen in stage 0 under gravity varus (P = .04 in stage 2 and P = .02 in stage 3) and weighted varus (P = .006 in stage 2 and P < .0001 in stage 3). CONCLUSIONS: Loss of the anterior two-thirds or more of the LCL-cc significantly increases the overall mean contact pressure on the coronoid, especially the medial coronoid, under both gravity varus and weighted varus. The LCL-cc also plays a role in the distribution of coronoid contact pressure against gravity varus loads.

Prospective Randomized Trial of Continuous Passive Motion Versus Physical Therapy After Arthroscopic Release of Elbow Contracture.

BACKGROUND: Continuous passive motion (CPM) has been used for decades, but we are not aware of any randomized controlled trials (RCTs) in which CPM has been compared with physical therapy (PT) for rehabilitation following release of elbow contracture. METHODS: In this single-blinded, single-center RCT, we randomly assigned patients undergoing arthroscopic release of elbow contracture to a rehabilitation protocol involving either CPM or PT. The primary outcomes were the rate of recovery and the arc of elbow motion (range of motion) at 1 year. The rate of recovery was evaluated by measuring range of motion at 6 weeks and 3 months. The secondary outcomes included other range-of-motion-related outcomes, patient-reported outcome measures (PROMs), flexion strength and endurance, grip strength, and forearm circumference at multiple time points. RESULTS: A total of 24 patients were assigned to receive CPM, and 27 were assigned to receive PT. At 1 year, CPM was superior to PT with regard to the range of motion, with an estimated treatment difference of 9° (95% confidence interval [CI], 3° to 16°; p = 0.007). Similarly, the use of CPM led to a greater range of motion at 6 weeks and 3 months than PT. The percentage of lost motion recovered at 1 year was higher in the CPM group (51%) than in the PT group (36%) (p = 0.01). The probability of restoring a functional range of motion at 1 year was 62% higher in the CPM group than in the PT group (risk ratio for functional range of motion, 1.62; 95% CI, 1.01 to 2.61; p = 0.04). PROM scores were similar in the 2 groups at all time points, except for a difference in the American Shoulder and Elbow Surgeons (ASES) elbow function subscale, in favor of CPM, at 6 weeks. The use of CPM decreased swelling and reduced the loss of flexion strength, flexion endurance, and grip strength on day 3, with no between-group differences thereafter. CONCLUSIONS: Among patients undergoing arthroscopic release of elbow contracture, those who received CPM obtained a faster recovery and a greater range of motion at 1 year, with a higher chance of restoration of functional elbow motion than those who underwent routine PT. LEVEL OF EVIDENCE: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Ultrasonographic Measurement of Elbow Varus Laxity With a Sequential Injury Model of the Lateral Collateral Ligament-Capsular Complex.

BACKGROUND: There is no consensus how to determine the varus laxity due to the LCL injury using the ultrasonography. There is a risk of lateral collateral ligament injury during or after arthroscopic extensor carpi radialis brevis release for tennis elbow. The equator of the radial head has been suggested as a landmark for the safe zone to not increase this risk; however, the safe zone from the intra-articular space has not been established. HYPOTHESIS: Increased elbow varus laxity due to lateral collateral ligament-capsular complex (LCL-cc) injury could be assessed reliably via ultrasound. STUDY DESIGN: Descriptive laboratory study. METHODS: Eight cadaveric elbows were evaluated using a custom-made machine allowing passive elbow flexion under gravity varus stress. The radiocapitellar joint (RCJ) space was measured via ultrasound at 30° and 90° of flexion during 4 stages: intact elbow (stage 0), release of the anterior one-third of the LCL-cc (stage 1), release of the anterior two-thirds (stage 2), and release of the entire LCL-cc (stage 3). Two observers conducted the measurements separately, and the mean RCJ space in the 3 LCL-cc injury models (stages 1-3) at both flexion angles was compared with that of the intact elbow (stage 0). We also compared the measurements at 30° versus 90° of flexion. RESULTS: At 30° of elbow flexion, the RCJ space increased 2 mm between stages 0 and 2 (95% confidence interval [CI], 1-3 mm; P < .01) and 4 mm between stages 0 and 3 (95% CI, 2-5 mm; P < .01). At 90° of elbow flexion, the RCJ space increased 1 mm between stages 0 and 2 (95% CI, 1-2 mm; P < .01) and 2 mm between stages 0 and 3 (95% CI, 2-3 mm; P < .01). CONCLUSION: Elbow varus laxity under gravity stress can be reliably assessed via ultrasound by measuring the RCJ space. CLINICAL RELEVANCE: Because ultrasonographic measurement of the RCJ space can distinguish the increasing varus laxity seen with release of two-thirds or more of the LCL-cc, the anterior one-third of the LCL-cc, based on the diameter of the radial head, can be considered the safe zone in arthroscopic extensor carpi radialis brevis release for tennis elbow.