Arthroscopic matched osteoplasty of the radial head for painful radiocapitellar osteoarthritis: surgical technique and case series.

Background: Radiocapitellar arthritis can cause pain, loss of motion, and impaired elbow function. Current surgical treatment options are limited. We have developed an original and simple surgical technique to address this, called arthroscopic matched osteoplasty of the radial head (AMOR). In AMOR, the radial head is partially resected and recontoured to match the capitellum and decompress the degenerate radiocapitellar articulation while preserving the ulnohumeral articulation where the cartilage is usually well preserved. Methods: Indications and the surgical technique of the AMOR procedure are described. A retrospective observational service evaluation study was conducted from electronic patient records. Collected clinical outcomes included range of motion, pain level, subjective functional score, and general satisfaction with the results of the procedure. The radiographic outcome was radiocapitellar joint space. Results: Between 2017 and 2021, eight consecutive patients underwent AMOR as part of an arthroscopic osteocapsular arthroplasty procedure. Radiographically, the mean radiocapitellar joint space improved from an average of 1.7 mm to 4.6 mm. Clinically, the mean pain score decreased from 8/10 to 3/10. Six of the eight patients (75%) were satisfied with their results. In two cases, initial improvement following surgery lasted less than 1 year, and one of these patients underwent total elbow arthroplasty for painful ulnohumeral osteoarthritis. There were no complications of surgery recorded. Conclusions: AMOR is a safe treatment option for painful radiocapitellar osteoarthritis and can be incorporated as an "add-on" procedure by surgeons performing elbow osteocapsular arthroplasty. Level of evidence: IV.

Adherence of Patients to Methods of Self-Reduction of Shoulder Dislocation Taught via Smartphones: A Medium-Term Follow-up Survey.

INTRODUCTION: Self-reduction of a shoulder dislocation may reduce the time from injury to reduction and to the relief of patient discomfort. The purpose of this study was to assess adherence to earlier acquired self-reduction techniques during real-time recurrent shoulder dislocation. METHODS: A telephone survey was conducted among 58 patients previously taught shoulder self-reduction via an instructional video sent to their smartphones during a visit to the emergency department (ED) for the treatment of anterior shoulder dislocation. Participants were queried on recurrent dislocations, use of self-reduction methods, success rate, the effect that instruction in self-reduction had on their willingness to participate in recreational sports activities, on the decision to avoid surgery, and on the overall level of satisfaction with self-reduction methods. RESULTS: Forty-five patients (77.6%; average age 31.4±11.7 y, 10 females) were available for follow-up at an average 60.8±11.0 mo after the index visit to the ED. Eighteen of 23 patients (78.2%) who experienced a recurrent dislocation during the follow-up period attempted self-reduction, and 12 of them successfully achieved self-reduction. Sixteen patients (35.6%) reported that the knowledge in self-reduction increased their willingness to participate in recreational sports activities, whereas 4 (8.9%) patients reported that knowledge in self-reduction affected their decision not to undergo surgical stabilization. CONCLUSIONS: Individuals who sustain recurrent shoulder dislocations should be educated on shoulder self-reduction with the aims of minimizing discomfort, obviating referral to the ED, and motivating participation in recreational activities.

Central band interosseus membrane reconstruction for longitudinal instability injuries of the forearm.

Aims: Acute and chronic injuries of the interosseus membrane can result in longitudinal instability of the forearm. Reconstruction of the central band of the interosseus membrane can help to restore biomechanical stability. Different methods have been used to reconstruct the central band, including tendon grafts, bone-ligament-bone grafts, and synthetic grafts. This Idea, Development, Exploration, Assessment, and Long-term (IDEAL) phase 1 study aims to review the clinical results of reconstruction using a synthetic braided cross-linked graft secured at either end with an Endobutton to restore the force balance between the bones of the forearm. Methods: An independent retrospective review was conducted of a consecutive series of 21 patients with longitudinal instability injuries treated with anatomical central band reconstruction between February 2011 and July 2019. Patients with less than 12 months' follow-up or who were treated acutely were excluded, leaving 18 patients in total. Preoperative clinical and radiological assessments were compared with prospectively gathered data using range of motion and the abbreviated version of the Disabilities of the Arm, Shoulder and Hand questionnaire (QuickDASH) functional outcome score. Results: Of the 18 patients (nine male, nine female) who met the inclusion criteria, the median follow-up was 8.5 years (interquartile range (IQR) 5.6 to 10). Their mean age was 49 years (SD 11). The mean extension improved significantly from 38° (SD 15°) to 24° (SD 9°) (p = 0.027), with a mean flexion-extension arc change from 81° (SD 27°) to 93° (SD 30°) (p = 0.172) but with no forearm rotational improvement (p = 0.233) at latest follow-up. The QuickDASH functional score improved significantly from 80 (SD 14) to 52 (SD 26) following reconstruction (p = 0.031), but generally the level of disability remains high. Radiological assessment showed no progression of proximal migration of the radius, with a stable interbutton distance and ulnar variance from immediate postoperative radiograph to the latest follow-up. Conclusion: Central band interosseus membrane reconstruction using a synthetic braided cross-linked graft can improve patient-rated arm function and range of motion, but significant functional deficits remain in patients with chronic injuries.

Patient Expectations of Pain Versus Experienced Expectations of Pain Following Shoulder Injection.

PURPOSE: Corticosteroids, platelet-rich plasma, and hyaluronic acid injections to either the subacromial space (SAS) or the glenohumeral joint (GHJ) of the shoulder are commonly used for diagnostic and therapeutic purposes in outpatient settings. The first aim of this study was to determine whether the anticipated pain level differed significantly from the actual pain level experienced by patients who underwent shoulder injections. The second aim was to determine whether there was a significant difference in these pain levels between SAS and GHJ injections. The secondary goal was to investigate the correlation between patients' demographic data, anxiety characteristics, and pain scores. DESIGN: Prospective clinical study. METHODS: This study involved patients who completed a three-part questionnaire prior as well as following an injections to the GHJ\SAS. FINDINGS: Sixty-three patients (28 males; 35 females), mean age of 54.28 years (standard deviation 13.95, range 25 to 84) met the inclusion criteria. There was a significant difference between the anticipated and the experienced pain (visual analog score 6.03 vs 3.17, P < .001). Experienced pain of the GHJ injections (n = 34) was rated as being greater than that of the SAS injections (n = 29) with borderline significance (visual analog scale 3.79 vs 2.36; P = .05). Forty-five patients (71.42%) reported a decrease in at least one pain category between anticipated and experienced pain compared to an increase reported by two patients (3.17%). CONCLUSIONS: Injections to the GHJ and SAS were shown to be significantly less painful than anticipated by the patients. GHJ injections were perceived as more painful than SAS injections. Communicating this evidence-based reassuring information with patients prior to an injection may alleviate fear of the procedure, reduce the perception of pain, and ultimately improve compliance with the procedure.

The posterolateral ligament of the elbow: anatomy and clinical relevance.

BACKGROUND: The posterolateral capsule was recognized in the past as an important structure for elbow stability but was later disregarded. Two recent biomechanical studies demonstrated its role in preventing posterolateral instability, and thus it should be identified as a distinct ligament: the posterolateral ligament (PLL). This study includes 2 parts: an anatomic study of the PLL's footprint and a collection of 5 cases of pathologic lesions of the PLL. METHODS: Six cadaveric upper limbs were assessed. The attachments of the PLL were dissected, the footprints were marked and photographed, and the 2-dimensional area and length were measured. RESULTS: The mean proximal attachment dimensions were a length of 13 mm and an area of 101 mm2, and the mean distal attachment dimensions were 19 mm and 111 mm2, respectively. There were 2 cases of posterolateral elbow pain in professional cricket bowlers, diagnosed radiographically as enthesopathy of the PLL's proximal attachment on the posterior capitellum, probably due to repeated forced hyperextension of the elbow. Both patients were treated by débridement of the posterior capitellum and reattachment of the PLL, with complete resolution of symptoms. In addition, there were 3 cases of clinical posterolateral rotatory instability in young patients. Two athletes had an isolated acute tear of the PLL, and on physical examination, both had positive posterior draw test results but negative pivot-shift test results. Both underwent elbow arthroscopy and repair of the PLL with resolution of symptoms. The third patient had long-standing recurrent elbow instability, following a failed lateral ulnar collateral ligament reconstruction, in the presence of an Osborne-Cotterill lesion. He underwent revision lateral ulnar collateral ligament reconstruction, bone grafting of the bony lesion, and reattachment of the PLL, with complete resolution of symptomatic posterolateral rotatory instability. CONCLUSIONS: The PLL of the elbow has a significant role in the elbow's posterolateral stability. Its footprints were described, and its clinical significance was demonstrated in cases of elbow instability caused by acute ligament tears and elbow pain due to ligament enthesopathy. Surgeons should be aware of this structure and potential pathology related to its injury.

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.

Arthroscopic rotator cuff repair in fibromyalgia patients had comparable outcomes to a matched control group.

BACKGROUND: Although fibromyalgia is associated with poor outcomes following orthopedic surgeries, several studies show some benefit from surgical intervention and nevertheless recommend operative treatment when indicated. There is sparse evidence of the effect of fibromyalgia on the outcomes of shoulder surgery. The purpose of this study was to investigate the effect of fibromyalgia on patient-reported outcomes of arthroscopic rotator cuff repair (ARCR). METHODS: All patients with a confirmed diagnosis of fibromyalgia who underwent ARCR in one institution between 2010 and 2021 were included. Data retrieved from medical records included demographics, characteristics of the cuff tear and the surgical procedure, and preoperative and last follow-up (minimum 1 year) postoperative Disabilities of the Arm, Shoulder and Hand (DASH) score, Subjective Shoulder score (SSV), and Numeric Pain Rating Scale (NPRS). A matched controlled group of patients without fibromyalgia who had undergone ARCR was selected according to age, sex, and preoperative DASH, SSV, and NPRS scores. RESULTS: There were no significant differences in demographics, cuff tear and surgical procedure characteristics, and preoperative scores between the fibromyalgia and control groups. The fibromyalgia patients' postoperative scores for all 3 measurements showed significant improvement: SSV by 32.1 (P = 0.004), DASH by 20.3 (P = 0.016), and NPRS by 2.33 (P = 0.017). There were no significant differences in the postoperative DASH, SSV, and NPRS between the fibromyalgia and control groups. CONCLUSION: Fibromyalgia patients with rotator cuff tears who undergo ARCR do not have inferior patient-reported outcomes compared with non-fibromyalgia controls. Fibromyalgia should not be a considered a contraindication for ARCR. LEVEL OF EVIDENCE: III.

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.

Inter and intra-observer agreement of the 3-dimensional CT based anterior inferior iliac spine classification system shows fair-to-moderate agreement among high volume hip surgeons.

PURPOSE: The purpose of this multicenter, multinational study is to evaluate the agreement level of the Hetsroni's classification system across high-volume hip surgeons who specialize in hip preservation surgeries. METHODS: Four surgeons from three countries reviewed a digital survey that included 93 3D CT images of the hip from 53 patients. The population was composed of individuals who had undergone a pelvis CT scan in a tertiary hospital between 2000 and 2016. Each rater reviewed the images and classified each image according to AIIS subtype I, II, or III. After a minimum of two months, the raters repeated the survey. The inter-rater and intra-rater agreement was then assessed. The kappa values were calculated to determine variability. RESULTS: Inter-rater agreement levels yielded fair agreement for both sessions (Kappa = 0.4, p value < 0.001 in the first and Kappa = 0.27, p value < 0.001 in the second). Inter-rater agreement levels separating non-pathological Type I from pathological Types II and III yielded moderate to fair inter-rater agreement levels (K = 0.47, p value < 0.001 in the first session and k = 0.32, p value < 0.001 in the second). Intra-rater reliability displayed moderate agreement (average K = 0.53). CONCLUSION: The current 3D CT-based AIIS classification system shows fair-to-moderate inter- and intra-rater agreement among high-volume hip surgeons. According to this study, the agreement of the Hetsroni classification system is not able to be sufficiently reproduced. Since accurate classification of the AIIS morphology is imperative in establishing proper treatment for SSI, this classification system there is therefore limited in its clinical value. LEVEL OF EVIDENCE: III.

Efficacy of Oral Nutritional Supplements in Patients Undergoing Surgical Intervention for Hip Fracture.

Introduction: Malnutrition is considered a risk factor among geriatric individuals with hip fracture, affecting functional healing and recovery, increasing healthcare spending, and associated with high mortality. In this study, we sought to evaluate the clinical efficacy of oral nutritional supplements in geriatric patients undergoing surgery for hip fracture. Material and Methods: We retrospectively analyzed data of 1625 consecutive patients who underwent fixation or arthroplasty for hip fracture in a tertiary medical center between 2017 and 2020. Patients who had no available albumin or body mass index levels were excluded. The study group is of patients who received an advanced formula in the form of an oral nutritional supplement (ONS), and the control group of patients that received no ONS. Peri- and postoperative complications, readmissions, short-term mortality, and albumin levels were compared between the 2 groups. Results: The final cohort included 1123 patients, 298 in the study group and 825 controls, with a follow-up of at least 1-year. Provision of the advanced enriched formula was not associated with 30-day, 90-day, or 1-year mortality (P = .62, P = .52, and P = .72, respectively) or any perioperative complications, such as 30-day or 90-day readmission (P = .37 and P = .1, respectively), revision surgery of any cause (P = .35), and postoperative infection rates (P = .73). Albumin levels on admission and the minimum albumin levels during hospitalization were similar between the groups, but they were significantly higher in the study group before discharge (33.42 g/L vs. 32.79 g/L, P = .01). Discussion: The use of an ONS was not associated with reduced perioperative complications or mortality, although it did affect nutritional status, as indicated by increased albumin levels, a known marker of nutritional status. Conclusions. While current findings do not support ONS use to minimize major postoperative complication after hip fracture surgery, further long-term study is warranted to evaluate subjective and functional outcomes associated with improved nutritional status.

Trans tibial amputation with or without a tourniquet in patients with diabetic foot infection and peripheral vascular disease: Comparison of postoperative outcomes.

Background: Transtibial amputation (TTA) due to complications of diabetic foot infection (DFI) or peripheral vascular disease (PVD) is a high-risk procedure in fragile patients. The risks of reoperation, blood loss requiring blood transfusion, and mortality are high. The use of a tourniquet in this procedure is controversial and scarcely reported. Objective: this study aimed to compare the outcomes of TTAs with or without a tourniquet in a single tertiary medical center. Methods: We retrospectively identified all patients who had undergone TTA in our institution (1/2019-1/2020) and included only those who underwent the procedure due to complications of DFI or PVD (n = 69). The retrieved data included demographics, comorbidities, ASA score, the use of a tourniquet, operation duration, pre- and postoperative hemoglobin levels, administration of blood transfusions, hospitalization length, surgical site infection and 60-days reoperation and mortality rates. Results: TTA with a tourniquet was superior to TTA without a tourniquet in reducing the average operation length by 11 min (p = 0.05), the median postoperative hospitalization by 6 days (p = 0.04), and the use of blood transfusions (odds ratio [OR] = 0.176, 95% confidence interval [CI]: 0.031-0.996). Conclusions: Our findings demonstrated advantages in operative time, hospitalization length, and blood transfusion requirement for TTA with a tourniquet compared to TTA without a tourniquet.

Radial Head Prosthetic Replacement in Adolescents: A Report of 5 Cases.

BACKGROUND: The management of severe radiocapitellar joint pathologies in young patients is challenging. Radial head arthroplasty (RHA) is a treatment option in the adult population, but most surgeons avoid implementing it in younger patients, and there are no published results for patients younger than 16 years. METHODS: Our retrospective cohort describes 5 patients (4 male 1 female) who underwent cementless modular RHA at an average age of 14 years (range: 13 to 15). The preoperative diagnoses were post-traumatic radiocapitellar incongruity and arthrosis because of previous Salter-Harris type 3 or 4 fractures of the radial head in 3 cases; and axial instability of the forearm following failed radial head excision in 2 cases. Because of the complexity of the elbow pathology in these cases, all underwent concomitant procedures including: contracture release (5 cases), corrective ulnar osteotomy (2 cases), distal ulnar shortening osteotomy, excision of radioulnar synostosis, microfracture of the capitellum, and partial excision of the medial triceps (1 case each). Collected data included patient-reported outcomes, visual analog scale pain score at rest and during physical activity and radiographic assessment of arthritis and prosthesis loosening. RESULTS: Average clinical follow-up was 8 years (range: 3 to 13). All 5 patients were pain-free at rest, and 3 reported moderate elbow pain (visual analog scale: 5 to 6) with physical activity. At an average radiographic follow-up of 3 years (range: 0.5 to 5), 3 patients showed mild progression of elbow arthrosis, but there were no signs of progressive capitellar erosion or implant loosening. Only 1 complication was noted-development of heterotopic ossification in 1 patient, which required open heterotopic ossification excision and contracture release 2 years following the RHA. None of the patients required prosthesis revision or removal. CONCLUSION: RHA was successful in improving pain and axial forearm stability in this very small series of adolescent patients. Concerns regarding long-term longevity and complications still exist. Considering the lack of other reliable treatment options, RHA may be indicated in this challenging patient population. LEVEL OF EVIDENCE: Level IV: therapeutic study-case series.

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.

Radial Head Lag: A Possible Biomechanical Mechanism for Osteochondritis Dissecans of the Capitellum in Baseball Pitchers.

BACKGROUND: Osteochondritis dissecans (OCD) of the capitellum is common in throwing athletes and is believed to result from repetitive overloading on the radiocapitellar (RC) joint, although the cause and mechanism remain unclear. The torsional forces (moments) generated by the triceps during elbow extension pull only on the ulna; therefore, the radial head moves passively across the capitellum and is effectively "dragged along" by the ulna. Any laxity in the proximal radioulnar joint could lead to asynchronous motion between the radius and ulna, resulting in the radial head lagging behind the coronoid and possibly malarticulating with the capitellum during such motion. HYPOTHESIS: Radial head motion on the capitellum lags behind ulnohumeral joint motion during simulated throwing. STUDY DESIGN: Controlled laboratory study. METHODS: A total of 8 cadaveric elbows were tested under simulated throwing, including active extension of the elbow generated by pulling of the triceps under valgus stress, as well as during passive extension under valgus stress to serve as a reference. Ulnohumeral motion was tracked using a video camera. Radial head motion was tracked using an intra-articular, thin-film pressure sensor mounted on the capitellum, and the longitudinal movement of the center of force (COF) of the radial head was measured. Radial head motion was compared between passive and active motion for each 10° of elbow extension from 90° to 20°. RESULTS: Elbow motion during simulated active extension reached an angular velocity of 366 deg/s. Radial head motion during simulated active extension significantly lagged compared with its motion during passive extension at every elbow extension angle examined between 70° and 20° (P < .001). The maximal lag reached a mean of 4 mm (range, 2-7 mm). In other words, RC and ulnohumeral motion were asynchronous during simulated throwing. CONCLUSION: This study describes a novel phenomenon: motion of the radial head across the capitellum during rapid extension, such as in baseball pitching, lags behind that seen during passive elbow motion. According to a new proposed theory of OCD lesion development, this lag should result in RC incongruency and elevated shear forces on the capitellum due to edge loading. CLINICAL RELEVANCE: We propose a new biomechanical explanation for OCD of the capitellum in baseball pitchers: radial head lag. Understanding this process is the first step in efforts to prevent this common injury.

Assessing hip fracture risk in type-2 diabetic patients using CT-based autonomous finite element methods : a feasibility study.

AIMS: Type 2 diabetes mellitus (T2DM) impairs bone strength and is a significant risk factor for hip fracture, yet currently there is no reliable tool to assess this risk. Most risk stratification methods rely on bone mineral density, which is not impaired by diabetes, rendering current tests ineffective. CT-based finite element analysis (CTFEA) calculates the mechanical response of bone to load and uses the yield strain, which is reduced in T2DM patients, to measure bone strength. The purpose of this feasibility study was to examine whether CTFEA could be used to assess the hip fracture risk for T2DM patients. METHODS: A retrospective cohort study was undertaken using autonomous CTFEA performed on existing abdominal or pelvic CT data comparing two groups of T2DM patients: a study group of 27 patients who had sustained a hip fracture within the year following the CT scan and a control group of 24 patients who did not have a hip fracture within one year. The main outcome of the CTFEA is a novel measure of hip bone strength termed the Hip Strength Score (HSS). RESULTS: The HSS was significantly lower in the study group (1.76 (SD 0.46)) than in the control group (2.31 (SD 0.74); p = 0.002). A multivariate model showed the odds of having a hip fracture were 17 times greater in patients who had an HSS ≤ 2.2. The CTFEA has a sensitivity of 89%, a specificity of 76%, and an area under the curve of 0.90. CONCLUSION: This preliminary study demonstrates the feasibility of using a CTFEA-based bone strength parameter to assess hip fracture risk in a population of T2DM patients. Cite this article: Bone Joint J 2021;103-B(9):1497-1504.

Radial head excision and Achilles allograft interposition arthroplasty for the treatment of chronic pediatric radiocapitellar pathologies: A report of four cases.

BACKGROUND: Severe radiocapitellar pathologies represent a unique problem in the pediatric population, as radial head excision can lead to substantial long-term complications. We present a case series of four pediatric patients treated by a novel technique-radial head excision followed by Achilles allograft interposition arthroplasty. METHODS: Four children (ages 12-15 years) are described. Their clinical and radiographic outcomes were assessed by a visual analog scale, the Mayo Elbow Performance Score, the Disabilities of the Arm, Shoulder and Hand questionnaire, grip strength, and range of motion. RESULTS: At a mean follow-up of two years, the average flexion-extension arc of motion improved from 107° to 131°, and the rotation arc improved from 100° to 154°. The average visual analog scale, Mayo Elbow Performance Score, and Disabilities of the Arm, Shoulder and Hand scores were 2, 92.5, and 11.5, respectively. Two patients required subsequent additional procedures-manipulation under anesthesia and ulnar shortening osteotomy. Proximal migration of the radius was observed in three out of the four patients. DISCUSSION: Combined radial head excision and Achilles allograft interposition arthroplasty represents a viable option for the treatment of chronic pediatric radiocapitellar pathologies, with good results in terms of clinical and functional outcomes as well as patient satisfaction in the short-medium term.

Computer-assisted surgical planning of complex bone tumor resections improves negative margin outcomes in a sawbones model.

PURPOSE: Several technologies have been implemented in orthopedic surgery to improve surgical outcomes, usually focusing on more accurate execution of a surgical plan, but the development of the plan itself is also of great importance. The purpose of this study is to examine whether the use of preoperative computer planning platforms can improve the surgical plan? METHODS: Eight surgeons created a preoperative surgical plan to resect a distal femur parosteal osteosarcoma in two settings: (1) Using a 2-D and 3-D CT scan only (current standard); and (2) using a computer-assisted planning platform. The plans were thereafter virtually executed using a novel surgical navigation system and a Sawbones model. This simulated model was derived from, and identical to, an actual patient scenario. The outcomes of interest were the number of positive margin cuts, and the volume of the resected specimen. RESULTS: Using the surgical plan developed with computer assistance, there were 4 positive margin cuts made by 2 surgeons. In comparison, using standard planning, there were 14 positive margin cuts made by all 8 surgeons (p = 0.02). The resection volume was larger in the computer-assisted plans (96 ± 10 mm3) than in the standard plans (88 ± 7 mm3) (p = 0.055). CONCLUSIONS: Computer-assisted planning significantly decreased the risk of a positive margin resection in this Sawbones tumor model used to simulate resection of a primary bone sarcoma. This proof of concept study highlights the importance of advanced surgical planning and sets the ground for developing beneficial surgical planning systems.

Adding a First Metatarsal Pin to An Ankle Tubular External Fixator Does Not Reduce the Incidence of Early Reduction Loss.

External fixation with a bilateral frame configuration (delta frame, DF) is a routine approach for treating ankle fractures and dislocations with severe soft tissue damage. The purpose of this study was to evaluate to what extent adding a first metatarsal fixation contributes to the stability of the fixation as evidenced by reduced frequency of early loss of reduction. A retrospective study was performed to compare the rate of early reduction loss in patients treated with a bilateral frame external fixation as part of a 2-stage treatment protocol for periarticular ankle fractures, in a level one trauma center between 2006 and 2016. The cohort was divided into 2 groups according to the frame configuration that had been used: DF only and DF with first metatarsal fixation (DF+1MT). A multivariate analysis assessing risk factors for postoperative loss of reduction was conducted. A total of 67 patients were included in the study, of which 30 underwent fixation by DF and 37 by DF+1MT. Early loss of reduction was recorded in 13 (19.4%) patients, 6 (20%) in the DF group and 7 (18.9%) in the DF+1MT group (p = .576). None of the assessed risk factors reached statistical significance. To conclude, the addition of a first metatarsal pin as an enhancement of external fixation with a delta frame configuration did not reduce the incidence of early loss of reduction. There is no evidence to support the claim that adding this pin contributes to the stability of the fixation in a clinically relevant manner.

Patients Use Fewer Opioids Than Prescribed After Arthroscopic Release of Elbow Contracture: An Evidence-Based Opioid Prescribing Guideline to Reduce Excess.

PURPOSE: To generate an evidence-based opioid-prescribing guideline by assessing the pattern of total opioid consumption and the factors that may predict opioid consumption following arthroscopic release of elbow contracture and to investigate whether the use of continuous passive motion (CPM), as compared to physical therapy (PT), was associated with a decrease in pain and opioid consumption after arthroscopic release of elbow contracture. METHODS: Data collected from a randomized controlled trial that compared continuous passive motion (CPM) (n = 24) to physical therapy (PT) (n = 27) following arthroscopic release of elbow contracture was analyzed for opioid use. Fifty-one participants recorded their daily opioid consumption in a postoperative diary for 90 days. Multivariate analysis was performed to identify factors associated with opioid use. Recommended quantities for postoperative prescription were generated using the 50th percentile for patients without and the 75th percentile for patients with factors associated with higher opioid use. RESULTS: The median total opioid prescription was 437.5-mg morphine milligram equivalents (MMEs) (58 pills of 5 mg oxycodone) and the median total opioid consumption was 75 MMEs (10 pills of 5-mg oxycodone). Twenty-two percent of patients took no opioid medication, 53% took ≤10 pills, 69% took ≤20 pills and 75% took ≤30 pills. Predictors of higher opioid use were preoperative opioid use, age <60 years and inflammatory arthritis. The total opioid consumption appeared similar between the CPM and the PT group. Seventy-five percent of patient's home opioid requirements would be satisfied using the following guideline: Patients undergoing contracture release for osteoarthritis or post-traumatic contracture should be given a prescription for 10 pills of 5 mg oxycodone or its equivalent at discharge. Patients with inflammatory conditions or those taking preoperative opioids should be prescribed 30 pills of 5 mg oxycodone or its equivalent. CONCLUSION: This study suggests that most patients undergoing arthroscopic release of elbow contracture use relatively few opioid pills after surgery. Use of an evidence-based guideline could decrease opioid prescriptions substantially, while still effectively treating patients' pain.