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.

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.

Correlation between hemolytic profile and phylotype of Cutibacterium acnes (formerly Propionibacterium acnes) and orthopedic implant infection.

INTRODUCTION: Cutibacterium acnes is a recognized culprit for implant-associated infections, but positive cultures do not always indicate clinically relevant infection. Studies have shown a correlation between the ß-hemolytic phenotype of C. acnes and its infectious capacity, but correlation with genetic phylotype has not been performed in literature. The purpose of this study is to evaluate ß-hemolysis phenotype, genetic phylotype, and mid-term clinical outcomes of C. acnes isolated from orthopedic surgical sites. METHODS: Fifty-four C. acnes isolates previously obtained from surgical wounds of patients undergoing hip, knee, shoulder, or spine implant removal were re-cultured. There were 21 females and 33 males with an average age of 59 years (range, 18-84). Twenty-four were from clinically infected sites whereas 30 were considered contaminants. De novo ß-hemolysis was analyzed and a retrospective chart review was performed to evaluate clinical outcomes at 7.1 years (range, 0.1-12.8). RESULTS: On Brucella agar with 5% rabbit blood, 46% of contaminant and 43% of infectious isolates were hemolytic. Type II phylotype was significantly more nonhemolytic regardless of infectious or contaminant status (p < 0.05). Type 1B correlated with a hemolytic-infectious phenotype and Type 1A with a hemolytic-contaminant phenotype but was not statistically significant. CONCLUSION: The ß-hemolytic profile of C. acnes did not correlate with phylotype or clinically relevant orthopedic infection.

Automated three-dimensional measurements of version, inclination, and subluxation.

BACKGROUND: Preoperative planning software has been developed to measure glenoid version, glenoid inclination, and humeral head subluxation on computed tomography (CT) for shoulder arthroplasty. However, most studies analyzing the effect of glenoid positioning on outcome were done prior to the introduction of planning software. Thus, measurements obtained from the software can only be extrapolated to predict failure provided they are similar to classic measurements. The purpose of this study was to compare measurements obtained using classic manual measuring techniques and measurements generated from automated image analysis software. METHODS: Ninety-five two-dimensional computed tomography scans of shoulders with primary glenohumeral osteoarthritis were measured for version according to Friedman method, inclination according to Maurer method, and subluxation according to Walch method. DICOM files were loaded into an image analysis software (Blueprint, Wright Medical) and the output was compared with values obtained manually using a paired sample t-test. RESULTS: Average manual measurements included 13.8° version, 13.2° inclination, and 56.2% subluxation. Average image analysis software values included 17.4° version (3.5° difference, p < 0.0001), 9.2° inclination (3.9° difference, p < 0.001), and 74.2% for subluxation (18% difference, p < 0.0001). CONCLUSIONS: Glenoid version and inclination values from the software and manual measurement on two-dimensional computed tomography were relatively similar, within approximately 4°. However, subluxation measurements differed by approximately 20%.

An Anatomic Intraoperatively Prepared Antibiotic Spacer in Two-Stage Shoulder Reimplantation for Deep Infection: The Potential for Early Rehabilitation.

Molded antibiotic shoulder spacers allow for intraoperative customization of antibiotics and multiple size options. The purpose of this study was to evaluate the efficacy of an anatomic intraoperatively molded spacer in the two-stage treatment of infection and to assess the safety of early rehabilitation when the capsule and rotator cuff are present. During 2014 and 2015, 27 shoulders were treated with a molded antibiotic cement spacer as part of a two-stage treatment. Indications included periprosthetic joint infection (n=18), native shoulder infection (n=8), and infection after internal fixation (n=1). All patients were followed for a minimum of 2 years. Mean follow-up time was 29.6 months. Patients were allowed to perform motion exercises (group I; n=16) or were instructed to avoid motion (group II; n=11) after spacer implantation, depending on the condition of their rotator cuff. Infection was eradicated in 23 of the 27 shoulders (85%). At most recent follow-up, pain scores were lower in group I. Mean final elevation was 115° in group I compared with 93° in group II. Mean final active external rotation was 36°, with no difference between the groups. In 3 (4%) shoulders with significant proximal humeral bone loss, the spacer became rotationally unstable. An anatomic intraoperatively molded spacer can be implanted safely in two-stage treatment for deep infection and has a reasonable rate of eradication. When adequate capsule and rotator cuff tissue is present, early motion in between stages can be safely recommended with a trend toward improved forward elevation at final follow-up and may facilitate the second stage reimplantation. [Orthopedics. 2019; 42(4):211-218.].

Interobserver and intraobserver comparison of imaging glenoid morphology, glenoid version and humeral head subluxation.

BACKGROUND: Glenoid morphology, glenoid version and humeral head subluxation represent important parameters for the treating physician. The most common method of assessing glenoid morphology is the Walch classification which has only been validated with computed tomography (CT). METHODS: CT images and magnetic resonance imaging (MRI) images of 25 patients were de-identified and randomized. Three reviewers assessed the images for each parameter twice. The Walch classification was assessed with a weighted kappa value. Glenoid version and humeral head subluxation were comparted with a reproducibility coefficient. RESULTS: The Walch classification demonstrated almost perfect intraobserver agreement for MRI and CT images (k = 0.87). Weighted interobserver agreement values for the Walch classification were fair for CT and MRI (k = 0.34). The weighted reproducibility coefficient for glenoid version measured 9.13 (CI 7.16-12.60) degrees for CT and 13.44 (CI 10.54-18.55) degrees for MRI images. The weighted reproducibility coefficient for percentage of humeral head subluxation was 17.43% (CI 13.67-24.06) for CT and 18.49% (CI 14.5-25.52) for MRI images. DISCUSSION: CT and MRI images demonstrated similar efficacy in classifying glenoid morphology, measuring glenoid version and measuring posterior humeral head subluxation. MRI can be used as an alternative to CT for measuring these parameters.

Stem Length and Neck Resection on Fixation Strength of Press-Fit Radial Head Prosthesis: An In Vitro Model.

PURPOSE: Various radial head prosthesis designs are currently in use. Few studies compare different prosthetic designs. We hypothesized that increasing a cementless implant stem's length would reduce stem-bone micromotion, with both short and long neck cuts. We also hypothesized that a minimum stem length might be required for the initial fixation strength of a press-fit implant. METHODS: In 16 fresh-frozen cadaveric elbows (8 pairs), the radial head and neck were cut either 10 or 21 mm below the top of the head. Modular cementless stems were inserted and sequentially lengthened in 5-mm increments. Micromotion under eccentric loading was tested after each incremental change. RESULTS: Incremental lengthening of the prosthetic stem and the amount of neck resection (10-mm cut vs 21-mm cut) both had a significant effect on micromotion. After a 10-mm radial head-neck resection, we observed a significant decrease in micromotion with stem lengths of 25 mm or greater, whereas with 21 mm of neck resection there was no further reduction in micromotion with increased stem length. These differences can be explained, at least in part, by the concept of the cantilever quotient: the ratio of the head-neck length outside the bone to the total length of the implant. CONCLUSIONS: The length of the stem affects the initial stability of press-fit radial head prostheses when the level of head and neck resection is at the minimum (ie, 10 mm) for currently available prosthetic designs. At this resection level, stems 25 mm or greater had significantly higher initial stability, but all stem lengths tested had mean micromotion values within the threshold for bone ingrowth. CLINICAL RELEVANCE: The length of a radial head prosthetic stem affects the initial stability of press-fit radial head prostheses when the level of head and neck resection is at the minimum (ie, 10 mm) for currently available prosthetic designs.

Intraobserver and interobserver reliability of the modified Walch classification using radiographs and computed tomography.

BACKGROUND: The Walch classification was introduced to classify glenoid morphology in primary glenohumeral osteoarthritis. A modified Walch classification was recently proposed, with 2 additional categories, B3 (monoconcave glenoid with posterior bone loss leading to retroversion > 15° or subluxation > 70%) and D (excessive anterior subluxation), as well as a more precise definition of subtypes A2 and C. The purpose of this study was to evaluate the intraobserver and interobserver agreement of the modified Walch classification system using both plain radiographs and computed tomography (CT). METHODS: Three fellowship-trained shoulder surgeons blindly and independently evaluated radiographs and CT scans of 100 consecutive shoulders (98 patients) with primary glenohumeral osteoarthritis and classified all shoulders according to the modified Walch classification in 4 separate sessions, each 4 weeks apart. Statistical analysis with the κ coefficient was used to evaluate reliability. RESULTS: The first reading by the most senior observer on the basis of CT scans was used as the gold standard (distribution: A1, 18; A2, 12; B1, 20; B2, 25; B3, 22; C, 1; and D, 2). The average intraobserver agreement for radiographs and CT scans was 0.73 (substantial; 0.72, 0.74, and 0.72) and 0.73 (substantial; 0.77, 0.69, and 0.72), respectively. The average interobserver agreement was 0.55 (moderate; 0.61, 0.51, and 0.53) for radiographs and 0.52 (moderate; 0.63, 0.50, and 0.43) for CT scans. CONCLUSION: Intraobserver agreement of the modified Walch classification was substantial both for axillary radiographs and for CT scans. Interobserver agreement was fair. Although the modified Walch classification represents an improvement over the original classification, automated computer-based analysis of CT scans may be needed to further improve the value of this classification.

Validation of a Simple Overlay Device to Assess Radial Head Implant Length.

PURPOSE: A simple overlay device (SOD) was developed to measure radial head implant length. The purpose of this study was to determine the accuracy and reliability of this device for measuring experimental radial head implant length. METHODS: Five fresh frozen cadavers were implanted with sequentially longer implants, adjusted by neck length (0, 2, 4, and 8 mm). Fluoroscopic images were obtained in 4 forearm positions: anteroposterior in supination in full extension, anteroposterior in pronation in full extension, supinated in 45° of flexion, and neutral in 45° of flexion. The SOD measurements (made by 2 observers) were compared with the native original radial head (control) to assess implant length. In addition, gapping of the ulnohumeral joint space was measured for comparison purposes. RESULTS: The measured radial head and neck lengths for the specimens were 33, 39, 31, 34, and 42 mm. The difference between the actual radial head and neck lengths and those measured with the SOD template averaged less than 2 mm for all 4 collar sizes, except in 1 measurement in which the bicipital tuberosity could not be visualized. The median intraclass correlation coefficients for observer 1 compared with the SOD were 0.94 to 0.99. The median intraclass correlation coefficients between observers were 0.88 to 0.95. For both observers, elbow position, collar height, and the 2 variables combined did not significantly affect the SOD values. The other method that was evaluated, that of measurement of the ulnohumeral joint space, had higher interobserver variability versus the SOD, and allowed detection of lengthening of over 4 mm. CONCLUSIONS: The SOD is a reliable method for simply assessing radial head length with radiographs and can accurately detect 2 mm or more of proximal radial lengthening. CLINICAL RELEVANCE: The SOD is a simple and accurate method that can help to optimize radial head sizing.

Varus posteromedial rotatory instability: a biomechanical analysis of posterior bundle of the medial ulnar collateral ligament reconstruction.

BACKGROUND: Recently, there has been growing interest in the involvement of the posterior bundle of the medial ulnar collateral ligament (pMUCL) in varus posteromedial rotatory instability (PMRI). Varus PMRI has been observed clinically, but the degree of involvement of the pMUCL remains unclear. This study assessed the degree to which the pMUCL is involved in stabilizing the elbow and the feasibility of a pMUCL reconstruction to restore stability. METHODS: Movements simulating PMRI were performed in 8 cadaveric elbows. Joint gapping values were obtained by 3-dimensional motion capture for the proximal and distal aspects of the ulnohumeral joint. Specimens were assessed at "intact," "cut coronoid + pMUCL," "reconstruction," and "cut anterior aspect MUCL + reconstruction" conditions with mechanical testing at 30°, 60°, and 90° of elbow flexion. RESULTS: Proximal joint gapping significantly increased from intact to cut coronoid + pMUCL at 60° and 90°, and distal joint gapping significantly increased at 90°. In the reconstruction condition, joint gapping across the proximal joint at 60° and 90° significantly recovered, as did distal joint gapping at 90°. In the cut anterior aspect MUCL + reconstruction condition, no significant increase occurred in proximal or distal joint gapping. CONCLUSIONS: Transection of the pMUCL with a coronoid fracture leads to increased joint gapping, suggesting the presence of PMRI. PMRI can still occur with an intact lateral ligamentous complex. A pMUCL tendon graft reconstruction confers some elbow stability in this injury mechanism.

Anthropometric Study of the Radiocapitellar Joint.

PURPOSE: There is scant knowledge about the relationship between the size of the radial head and the size of the capitellum. Also, no data exist comparing the size of the capitellum between the left and the right elbow. METHODS: Eight pairs of elbows and 12 single elbows from fresh-frozen cadavers were obtained for this study. The vertical height and anterior width of the capitellum were measured with digital calipers. Four different measurements were performed at the radial head: longest outer diameter, shortest outer diameter, the long dish diameter, and short dish diameter. The Pearson intrarater intraclass correlation coefficients were obtained for all measurements. RESULTS: For the paired elbows, the correlations ranged between 0.95 and 0.96 for the capitellar dimensions and 0.77 and 0.98 for the radial head dimensions. The correlations between the long outer diameter of the radial head with the vertical height and the anterior width of the capitellum were 0.8 and 0.9, respectively. CONCLUSIONS: There is a high correlation between the long outer diameter of the radial head and the vertical height of the capitellum as well its anterior width. There is also a high correlation between the left and the right elbow. CLINICAL RELEVANCE: These findings are relevant to radiocapitellar arthroplasty and may be useful for radiocapitellar prosthetic design as well as in the preoperative planning of cases in which the radial head and/or the capitellum is destroyed.

Management of Failed Rotator Cuff Repair in Young Patients.

Management of failed rotator cuff repair may be very difficult, especially in young patients. Various nonmodifiable and modifiable patient factors, including age, tendon quality, rotator cuff tear characteristics, acute or chronic rotator cuff tear, bone quality, tobacco use, and medications, affect rotator cuff repair healing. Surgical variables, such as the technique, timing, tension on the repair, the biomechanical construct, and fixation, as well as the postoperative rehabilitation strategy also affect rotator cuff repair healing. Variable outcomes have been reported in patients who undergo revision rotator cuff repair; however, a systematic surgical approach may increase the likelihood of a successful outcome. Numerous cellular and mechanical biologic augments, including platelet-rich plasma, platelet-rich fibrin matrix, mesenchymal stem cells, and acellular dermal matrix grafts, have been used in rotator cuff repair; however, conflicting or inconclusive outcomes have been reported in patients who undergo revision rotator cuff repair with the use of these augments. A variety of tendon transfer options, including latissimus dorsi, teres major, lower trapezius, pectoralis minor, pectoralis major, combined pectoralis major and latissimus dorsi, and combined latissimus dorsi and teres major, are available for the management of massive irreparable rotator cuff tears. Ultimately, the optimization of surgical techniques and the use of appropriate biologic/tendon transfer techniques, if indicated, is the best method for the management of failed rotator cuff repair.

The effect of a radial neck notch on press-fit stem stability: a biomechanical study on 7 cadavers.

BACKGROUND: Minimal micromotion is necessary for osteointegration of cementless radial head prostheses. When radial head fractures extend longitudinally, where the neck cut for prosthetic replacement should be made is uncertain. We hypothesized that complete resection of the notched portion of a radial neck confers no advantage in initial stability compared with not resecting the defect and inserting the implant into a notched radial neck. MATERIALS AND METHODS: The radii of 7 cadavers underwent radial head resection and implantation with a 25-mm-long press-fit radial head stem. Before implantation, a 5-mm-long notch that was less than 1-mm wide was made in the radial neck. After the stem-bone micromotion was recorded, the proximal 5 mm of radial neck, incorporating the entire notch, was cut away, the stem was inserted 5 mm further, and the resulting micromotion was recorded. RESULTS: The mean micromotion measured in the presence of a cortical notch was 51 ± 6 µm. After the neck was circumferentially cut and the stem was advanced, the micromotion (46 ± 9 µm) was not statistically significantly different. DISCUSSION: Initial stability of an adequately sized cementless stem in the presence of a 5-mm-long cortical notch was well within the threshold needed for bone ingrowth (<100 µm). In addition, there was no reduction of micromotion after the notch-containing portion of the radial neck was resected and the stem was advanced. Making a neck cut distal to a 5-mm-long, 1-mm-wide cortical notch does not confer added stability. Thus, surgeons can preserve bone stock and avoid an aggressive neck cut.

Patient-Physician Agreement Using Summary Outcome Determination Scores.

OBJECTIVE: To determine whether the Summary Outcome Determination (SOD) score had exhibited a high level of physician-patient agreement in surgical patients. PATIENTS AND METHODS: The medical records of 320 postoperative patients were reviewed, of whom 164 patients were included in the study. Patients were included if both physician-assigned and patient-assigned SOD scores had been recorded. The SOD is administered as follows: the patient is asked "Compared to before surgery, is your elbow/shoulder better, worse or no different?" If better: "Is it improved, greatly improved, almost normal or normal?" If worse: "Is it worse or profoundly worse, or as bad as dying?" Each category is associated with a numerical value and definition for further clarification. The patient is asked to assign a category and a numerical value after the physician has already done so. These categories and values were evaluated between raters (ie, physician and patient) to assess reliability. RESULTS: The intraclass correlation coefficient of physician-patient numerical ratings was "excellent" (0.93). The Bland-Altman 95% limits of agreement on the differences between the physician and the patient ranged from -1.3 to 1.3. The physician and patient numerical rankings matched exactly in 118 patients (72%) or differed by a factor of no more than 1 (26%) in 161 (98%) patients. CONCLUSION: The SOD score can be used as both a surgeon-based and a patient-based outcome score, given the high level of agreement. Given its brevity, ease of understanding, and high interrater reliability, the SOD has the potential to be used across multiple specialties to rate outcomes.

The Posterior Bundle's Effect on Posteromedial Elbow Instability After a Transverse Coronoid Fracture: A Biomechanical Study.

PURPOSE: There has been increased interest in the role of the posterior bundle of the medial collateral ligament (pMUCL) in the elbow, particularly its effects on posteromedial rotatory stability. The ligament's effect in the context of an unfixable coronoid fracture has not been the focus of any study. The purposes of this biomechanical study were to evaluate the stabilizing effect of the pMUCL with a transverse coronoid fracture and to assess the effect of graft reconstruction of the ligament. METHODS: We simulated a varus and internal rotatory subluxation in 7 cadaveric elbows at 30°, 60°, and 90° elbow flexion. The amount of ulnar rotation and medial ulnohumeral joint gapping were assessed in the intact elbow after we created a transverse coronoid injury, after we divided the pMUCL, and finally, after we performed a graft reconstruction of the pMUCL. RESULTS: At all angles tested, some stability was lost after cutting the pMUCL once the coronoid had been injured, because mean proximal ulnohumeral joint gapping increased afterward by 2.1, 2.2, and 1.3 mm at 90°, 60°, and 30°, respectively. Ulnar internal rotation significantly increased after pMUCL transection at 90°. At 60° and 30° elbow flexion, ulnar rotation increased after resection of the coronoid but not after pMUCL resection. CONCLUSIONS: An uninjured pMUCL stabilizes against varus internal rotatory instability in the setting of a transverse coronoid fracture at higher flexion angles. Further research is needed to optimize graft reconstruction of the pMUCL. CLINICAL RELEVANCE: The pMUCL is an important secondary stabilizer against posteromedial instability in the coronoid-deficient elbow. In the setting of an unfixable coronoid fracture, the surgeon should examine for posteromedial instability and consider addressing the pMUCL surgically.

Subscapularis tears: hidden and forgotten no more.

The subscapularis tendon, at one point, was thought of as the forgotten tendon, with "hidden lesions" that referred to partial tears of this tendon. Better understanding of anatomy and biomechanics combined with improved imaging technology and the widespread use of arthroscopy has led to a higher rate of subscapularis tear diagnoses and repairs. The bulk mass of the subscapularis muscle is more than that of all 3 other rotator cuff muscles combined. It functions as the internal rotator of the shoulder as the stout, rolled border of its tendon inserts onto the superior portion of the lesser tuberosity. A thorough history combined with specific physical examination maneuvers (including the bear hug, lift-off, and belly-press tests) is critical for accurate diagnosis. A systematic approach to advanced shoulder imaging also improves diagnostic capacity. Once identified, most subscapularis tendon tears can be successfully repaired arthroscopically. The Lafosse classification is useful as part of a treatment algorithm. Type I and II tears may be addressed while viewing from the standard posterior glenohumeral portal; larger Lafosse type III and IV tears are best repaired with anterior visualization at the subacromial or subdeltoid space. Tendon mobilization for larger tears is critical for adequate repair. In Lafosse type V tears, in which there is glenohumeral imbalance, tendon transfers and reverse replacement are commonly considered salvage options.

Management of Failed Rotator Cuff Repair in Young Patients.

Management of failed rotator cuff repair may be difficult, especially in young patients. Various nonmodifiable and modifiable patient factors, including age, tendon quality, rotator cuff tear characteristics, acute or chronic rotator cuff tear, bone quality, tobacco use, and medications, affect rotator cuff repair healing. Surgical variables, such as the technique, timing, tension on the repair, the biomechanical construct, and fixation, as well as the postoperative rehabilitation strategy also affect rotator cuff repair healing. Variable outcomes have been reported in patients who undergo revision rotator cuff repair; however, a systematic surgical approach may increase the likelihood of a successful outcome. Numerous cellular and mechanical biologic augments, including platelet-rich plasma, platelet-rich fibrin matrix, mesenchymal stem cells, and acellular dermal matrix grafts, have been used in rotator cuff repair; however, conflicting or inconclusive outcomes have been reported in patients who undergo revision rotator cuff repair with the use of these augments. A variety of tendon transfer options, including latissimus dorsi, teres major, lower trapezius, pectoralis minor, pectoralis major, combined pectoralis major and latissimus dorsi, and combined latissimus dorsi and teres major, are available for the management of massive irreparable rotator cuff tears. Ultimately, the optimization of surgical techniques and the use of appropriate biologic/tendon transfer techniques, if indicated, is the best method for the management of failed rotator cuff repair.

The Influence of Incision Type on Patient Satisfaction After Plate Fixation of Clavicle Fractures.

BACKGROUND: Open reduction and internal fixation (ORIF) of the clavicle is a common procedure that has been shown to have improved outcomes over nonoperative treatment. Several incisions can be used to approach clavicle fractures, the decision of which is variable among surgeons. PURPOSE: To compare patient satisfaction and subjective outcomes between patients with a longitudinal incision versus those with a necklace incision for the treatment of diaphyseal clavicle fractures. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: Thirty-six patients with a diaphyseal clavicle fracture (Orthopaedic Trauma Association type 15-B) were treated by 1 of 7 orthopaedic surgeons. The intervention was ORIF with anatomic contoured plates. Patients were divided into a necklace incision group and a longitudinal incision group depending on the surgical approach used. Medical records were reviewed, and participants completed an online survey with questions related to pain, numbness, scar appearance, and satisfaction. Function was assessed using the American Shoulder and Elbow Surgeons score. Statistical significance was determined with P < .05. RESULTS: There were 16 patients in the necklace incision group and 20 in the longitudinal incision group. Patients in the necklace incision group were significantly more satisfied with the appearance of their scars (P = .01), which correlated with overall satisfaction (P = .05). There were no differences in overall satisfaction, pain, numbness, or reoperation rates for hardware removal between the necklace (6%) and longitudinal groups (15%). CONCLUSION: Patients undergoing clavicle ORIF with a necklace incision are more satisfied with their scar appearance than those with a longitudinal incision. The overall satisfaction, rate of numbness, and plate removal were similar in both groups.

The results of tension band rotator cuff suture fixation of locked plating of displaced proximal humerus fractures.

INTRODUCTION: The purpose of this study was to assess 1-year outcomes of patients with displaced proximal humerus fractures who underwent treatment with locked plate fixation with rotator cuff suture augmentation. METHODS: A total of 86 patients who had sustained 2, 3 and 4-part displaced proximal humerus fractures underwent locked plate fixation with multiple sutures placed in the cuff tendons. Clinical outcome variables included active forward elevation (AFE), active external rotation (AER), and Constant and American Shoulder and Elbow Surgeons (ASES) scores. Post-operative variables included the following complications: varus re-collapse, loss of fixation, osteonecrosis of the humeral head (AVN), screw cut out, hardware failure and infection. RESULTS: Forty-one patients were available with minimum of 1-year follow-up. Mean AFE was 142±17.0° and AER was 41±13.0°. The overall complication rate was 14.6%, with osteonecrosis being the most common (12.2%). Of the 21 patients (51.2%) that initially had varus displacement, all but one maintained anatomic reduction and fixation. Mean ASES score was 78.2±20.0 and average Constant score was 72.7±17.6. Bivariate analyses demonstrated that pre-operative medial comminution (p=0.297) or varus collapse (p=0.95) were not associated with an increased likelihood of sustaining a complication. CONCLUSIONS: Follow-up of patients in this series demonstrated a low overall complication rate and excellent functional outcomes. We believe suture augmentation of the rotator cuff can counteract varus forces on proximal humerus fractures fixed with locked plates, and should be performed routinely in displaced 2, 3 and 4 part fractures.

Isolated ligamentous injury can cause posteromedial elbow instability: a cadaveric study.

BACKGROUND: Elbow posteromedial rotatory instability (PMRI) is known to occur with fracture of the anteromedial coronoid and injury to the posterior bundle of the medial ulnar collateral ligament (pMUCL). However, whether instability results from isolated pMUCL injury remains unclear. The purpose of this study was to quantify displacement about the ulnohumeral joint to evaluate whether isolated sectioning of the pMUCL results in elbow PMRI. METHODS: Nine cadaveric elbows underwent movements simulating PMRI by application of axial compression with varus and internal rotation moments. Gapping values at both the proximal and distal aspects of the medial ulnohumeral joint were then recorded for "intact" and "pMUCL-sectioned" elbows at positions of 30°, 60°, and 90° of flexion. RESULTS: After pMUCL transection, torsion increased by 2.6° ± 0.7° (P = .054) at 30° and 4.5° ± 1.2° (P = .039) at 60° of flexion. Proximal ulnohumeral joint gapping also increased at 30° (1.4 ± 0.4 mm; P = .039), 60° (1.5 ± 0.6 mm; P = .039), and 90° (1.5 ± 0.7 mm; P = .017), respectively. No increases in distal ulnohumeral gapping occurred at any angle of flexion. DISCUSSION: Sectioning of the pMUCL results in significant increases in torsion and displacement about the proximal ulnohumeral joint. Our findings demonstrate that elbow PMRI can occur secondary to isolated ligamentous injury. Clinicians mindful of this previously unrecognized role of the pMUCL as a stabilizer may wish to consider methods of restoring pMUCL integrity when treating medial elbow instability.