Closure of Persistent, Small, Posterior Elbow Soft Tissue Defects Using a Rotation Flap: A Retrospective Study.

Treating soft tissue defects occurring over the posterior elbow is challenging. PURPOSE: This study aimed to evaluate the long-term outcomes of using rotation flaps for soft tissue defects over the posterior elbow. METHODS: A retrospective study was conducted among patients who had sustained posterior elbow defects and underwent rotation flap under local anesthesia between January 2, 2011, and December 31, 2014. Patient inclusion criteria stipulated the soft tissue defect had to be small (<12 cm2), was the result of wound dehiscence following posterior approach surgery immediately following trauma, and had failed to heal using nonsurgical treatment or primary closure. Patients with an active infection, malignancies, a defect of any etiology other than trauma, or incomplete operative data were excluded. Patient demographics, medical history, operative reports, and outcomes were abstracted. Flap failure and surgical complications were monitored for a minimum of 2 years after surgery. Range of motion (ROM; 0˚ to normal 130˚) and Mayo Elbow Performance Scores (MEPS) were evaluated and recorded before surgery and after 2 years' follow-up and included evaluating pain, ROM, stability, and daily function. Patient, wound, surgical, and wound healing variables were compared between the flap survival and flap failure/complication groups using Mann-Whitney U and chi-squared tests. The Wilcoxon signed-rank test was used to compare pre- and postoperative MEPS and elbow ROM. RESULTS: Thirty (30) patients (13 male, 17 female; mean age 55 ± 15.6 [range 19-74] years) had complete records. Eighteen (18) flaps were created using the transolecranon approach, and 12 rotation flaps involved an olecranon fracture; 24 flaps survived and 6 patients experienced flap failure/complications (wound dehiscence or infection). Mean procedure duration was 25.6 ± 10.1 minutes. All defects were located over the olecranon with exposed bone or hardware. Mean defect size was 7.4 cm2 ± 2.9 cm2, the average defect duration was 60.4 (range 31-89) days, average time to wound healing was 21.9 ± 11.5 days, and mean follow-up time was 29.4 (range 24-56) months. All flaps successfully survived without recurrence. Mean pre- and postoperative MEPS were significantly different (56.4 vs. 90.2 points; P <.001). ROM did not differ significantly between mean preoperative range (extension 9.8˚ ± 3.2˚ and flexion 116.7˚ ± 10.2˚) and mean final follow-up range (extension 9.6˚ ± 2.6˚ and flexion 118.5˚ ± 11.3˚; P = .459). CONCLUSION: Rotation flap surgery performed under local anesthesia may offer a simple and safe option in the treatment of small (<12 cm2) trauma-related defects over the posterior elbow. More research is needed to develop evidence-based guidelines for optimal approaches to posterior elbow soft tissue defect closure techniques.

Open cubital and carpal tunnel release using wide-awake technique: reduction of postoperative pain.

PURPOSE: This study aimed to compare the efficacy of and patient satisfaction with the wide-awake local anesthesia with no tourniquet (WALANT) technique in open cubital and carpal tunnel release surgery. METHODS: From January 2016 to February 2017, 20 cubital tunnel syndrome (CuTS) patients were in a wide-awake (WA) group and 22 in a general (GA) anesthesia group in . Also, 20 carpal tunnel syndrome (CTS) patients were in a WA group, 22 in a local anesthesia (LA) group, and 20 in a GA group. Injection pain, perioperative pain, and postoperative pain were assessed using a 10-point pain VAS. In CuTS, functional outcome on the "quick" Disabilities of the Arm, Shoulder, and Hand questionnaire were evaluated. In CTS, subjective outcomes were assessed using the Korean version of the Michigan Hand Outcomes Questionnaire. RESULTS: Both CuTS and CTS showed significant postoperative pain reduction in group WA. In CuTS, group WA had less pain than group GA up to 48 hours after surgery (P<0.05). Supplemental opioid injections were used on hospitalization day by 12% of group WA and 35% of group GA. In CTS, the postoperative VAS scores in group WA were lower during the first 24 hours than groups LA and GA (P<0.05). Opioid injections were used on hospitalization day by 5% of WA, 18% of LA, and 32% of group GA. There was no difference in postoperative functional outcomes according to anesthesia method in CuTS or CTS. CONCLUSION: Cubital and carpal tunnel surgery using the WALANT technique was comparable in function to other anesthesia methods and superior for pain. Immediate postoperative pain was much lower than other groups, which could reduce the use of opioids during hospitalization.

Evaluation of Inferior Capsular Laxity in Patients with Atraumatic Multidirectional Shoulder Instability with Magnetic Resonance Arthrography.

OBJECTIVE: To compare inferior capsular redundancy by using magnetic resonance arthrography (MRA) images in patients with multidirectional instability (MDI) of the shoulder and control subjects without instability and thereby develop a screening method to identify the presence of shoulder MDI. MATERIALS AND METHODS: The MRA images of patients with MDI of the shoulder (n = 65, 57 men, 8 women; mean age, 24.5 years; age range, 18-42 years) treated over an eight-year period were retrospectively reviewed; a control group (n = 65, 57 men, 8 women; mean age, 27.4 years; age range, 18-45 years) without instability was also selected. The inferior capsular redundancy was measured using a new method we named the glenocapsular (GC) ratio method. MRA images of both groups were randomly mixed together, and two orthopedic surgeon reviewers measured the cross-sectional areas (CSAs) and sagittal capsule-head ratios on oblique sagittal images, as well as the axial capsule-head ratios on axial images and GC ratios on oblique coronal images. RESULTS: The CSAs and GC ratios were significantly higher in patients than in controls (both, p < 0.001); however, the sagittal capsule-head ratios and axial capsule-head ratios were not significantly different (p = 0.317, p = 0.053, respectively). In addition, GC ratios determined the presence of MDI more sensitively and specifically than did CSAs. A GC ratio of > 1.42 was found to be most suggestive of MDI of the shoulder, owing to its high sensitivity (92.3%) and specificity (89.2%). CONCLUSION: GC ratio can be easily measured and used to accurately screen for MDI of the shoulder.

A ligament reattachment technique for high-demand athletes with chronic ankle instability.

The present prospective study was conducted to evaluate the clinical outcomes of the new ligament reattachment procedure for chronic lateral ankle instability in high-demand athletes. A total of 24 athletes <30 years old were followed for >2 years after undergoing the modified Brostrom procedure using the suture bridge technique. The clinical evaluation included the Karlsson score, the Sefton grading system, and the period to return to exercise. As an evaluation of mechanical stability, the talar tilt angle and anterior talar translation were measured on stress radiographs. The Karlsson score had improved significantly from a preoperative average of 43.5 points to 92.2 points. Using the Sefton grading system, 22 (91.7%) patients achieved satisfactory results. The period to return to exercise was as follows: a mean of 8.4 weeks for jogging, 12.5 weeks for spurt running, 10.5 weeks for jumping, 9.2 weeks for 1 leg standing for >1 minute, 10.6 weeks for walking on uneven ground, and 11.2 weeks for going downstairs. The talar tilt angle and anterior talar translation had improved significantly from the preoperative average of 15.4° and 13.3 mm to 3.8° and 4.2 mm at 2 months postoperatively and 4.9° and 4.8 mm at the final follow-up visit, respectively. The modified Brostrom procedure using the suture bridge technique resulted in satisfactory clinical outcomes comparable to those with conventional ligament reattachment techniques. The suture bridge technique appears to be an effective treatment option for chronic ankle instability in high-demand athletes.