The use of medial support screw was associated with axillary nerve injury after plate fixation of proximal humeral fracture using minimal invasive deltoid-splitting approach.

BACKGROUND: The purpose of this study was to evaluate the incidence and risk factors for axillary nerve injury after plate fixation of humeral fractures using minimal invasive deltoid-splitting approach. We hypothesized that the use of medial support screw (MSS) would be associated with the outcome of axillary nerve injury. METHODS: This study retrospectively evaluated consecutive 32 patients who underwent surgical treatments for proximal or midshaft humeral fractures. Of them, we included 26 patients who were examined by electromyography/nerve conduction (EMG/NCV) study at 3-4 weeks postoperatively. We excluded 6 patients because two of them were not compliant to EMG/NCV and the remaining two died due to unrelated medical illness. Outcome assessments included pain, functional scores, range of motion, and radiographic results. RESULTS: There were 8 male and 18 female patients with mean age of 67 ± 15 years. Mean duration of follow-up period was 31 ± 11 months. The mean time to EMG/NCS after surgery was 3.5 ± 0.6 weeks. EMG/NCS examinations revealed incomplete axillary nerve injury in 8 patients (31%) without complete nerve injury. Active forward elevation at 3 months postoperatively was significantly lower in patients with axillary nerve injury than in those without it (99° ± 12 and 123° ± 37, respectively, p = 0.047), although final clinical outcomes were not different. At surgery, MSS was used in 17 patients (65%), and 8 of them were associated with nerve injury. The use of MSS was only correlated with the outcome of axillary nerve injury, because the axillary nerve injury developed only in MSS group (p = 0.047). The MMT grade 4 in abduction strength was more common in patients with axillary nerve injury than in those without (p = 0.037). CONCLUSIONS: Axillary nerve injury was a concern after plate fixation of proximal humeral fracture using minimal invasive deltoid-splitting approach. The use of medial support screw to improve the stability could increase a risk of axillary nerve injury when used with this approach.

Proximal vs Distal Approach of Ultrasound-guided Suprascapular Nerve Block for Patients With Adhesive Capsulitis of the Shoulder: Prospective Randomized Controlled Trial.

OBJECTIVES: To evaluate the early clinical outcomes of ultrasound (US)-guided suprascapular nerve block (SSNB) using a proximal approach compared with a distal approach for outpatient treatment of adhesive capsulitis. DESIGN: Randomized controlled trial. SETTING: Outpatient clinic PARTICIPANTS: Participants (N=47) with symptomatic adhesive capsulitis. INTERVENTIONS: Participants were randomly assigned to either US-guided SSNB using a proximal approach (n=23, proximal group) or a distal approach (n=24, distal group). MAIN OUTCOME MEASURES: The primary outcome measure was the visual analog scale (VAS) for pain at week 12. Secondary outcomes included the American Shoulder Elbow Surgeon's (ASES) score, University California Los Angeles score, Short Form-36 mental and physical component summaries, and range of motion. All patients completed clinical follow-up at 2, 6, and 12 weeks after treatment. On US images, depth and insertion angle of needle during injection were measured. RESULTS: The VAS significantly improved in both groups at week 12. After treatment, no significant differences were found in early clinical outcomes (weeks 2, 6, and 12) between groups (all P>.05), except that ASES at 2 weeks showed a significantly higher score in the distal group than in the proximal group (87.1±4.8 and 83.0±6.3, respectively; P=.014). The mean depth and insertion angle of needle was significantly lower (depth: 13.4±3.9 and 30.6±4.3 mm, respectively; P<.001; insertion angle: 19.6°±6.4° and 38.7°±5.8°; P<.001) in the proximal group than in the distal group. CONCLUSIONS: This study demonstrated that proximal approach of US-guided SSNB provided favorable short-term outcomes of pain and functional improvement and that outcomes were comparable to those of the distal approach in adhesive capsulitis. The suprascapular nerve was located more superficially and easily identified in the proximal approach, suggesting that this method might improve the accuracy of injection.

Clinical outcome and repair integrity after arthroscopic rotator cuff repair significantly improved during the surgeon's learning curve.

HYPOTHESIS AND BACKGROUND: Whether learning curve could affect the surgical outcome after arthroscopic rotator cuff repair is still unknown. The purpose of this study was to evaluate surgical learning curve for clinical outcome and retear rate after arthroscopic rotator cuff repairs that were performed by the beginner shoulder surgeon. We hypothesized that clinical outcome and retear rate would improve over time with the accumulation of a surgeon's experience. METHODS: This retrospective study consisted of 200 consecutive patients who had arthroscopic rotator cuff repairs, performed by a single surgeon between 2011 and 2018. We included symptomatic rotator cuff tears involving the supraspinatus/infraspinatus and/or subscapularis tendon and follow-up magnetic resonance imaging evaluations of repair integrity 6 months after surgery. Surgeon's learning was evaluated with calculation of cumulative retear rate and cumulative summation (CUSUM) analysis. Clinical outcomes and the retear rates were compared between group A (the first-half 100 patients) and group B (the latter-half of 100 patients). RESULTS: The mean follow-up period was 21 months (range, 12-55). The overall retear rate was 13% (26 patients). The CUSUM analysis showed that after patient number 97, the curve was maintained below the level of acceptable failure rate, suggesting the competency was obtained consistently. Comparing between groups, retear rate showed significant decrease from 18% in group A to 8% in group B (P = .036). Notably, retear rate in small to medium-sized tears (<3 cm) significantly decreased from 26% (12 of 46 patients) in group A to 2% (1 of 49 patients) in group B (P = .001). However, analysis in large to massive tears (≥3 cm) failed to show difference between groups (30%, 6 of 20, in group A and 25%, 6 of 24, in group B; P = .711). In multivariate analysis, higher fatty infiltration of the supraspinatus muscle (P = .008), more severe muscle atrophy of the teres minor (P = .010), and belonging to group A (P = .011) were associated with retear. CONCLUSION: Clinical outcomes and retear rate after arthroscopic rotator cuff repairs significantly improved during the learning curve period of a beginner shoulder surgeon.

Is the arthroscopic modified tension band suture technique suitable for all full-thickness rotator cuff tears?

BACKGROUND: We aimed to identify the clinical and structural outcomes after arthroscopic repair of full-thickness rotator cuff tears of all sizes with a modified tension band suture technique. METHODS: Among 63 patients who underwent arthroscopic rotator cuff repair for a full-thickness rotator cuff tear with the modified tension band suture technique at a single hospital between July 2011 and March 2013, 47 were enrolled in this study. The mean follow-up period was 29 months. Visual analog scale scores, range of motion, American Shoulder and Elbow Surgeons scores, Constant scores, and Shoulder Strength Index were measured preoperatively and at the final follow-up. For radiologic evaluation, we conducted magnetic resonance imaging 6 months postoperatively and ultrasonography at the final follow-up. We allocated the small and medium tears to group A and the large and massive tears to group B and then compared clinical outcomes and repair integrity. RESULTS: Postoperative clinical outcomes at the final follow-up showed significant improvements compared with those seen during preoperative evaluations (P < .001). However, group B showed worse clinical results than group A. Evaluation with magnetic resonance imaging performed 6 months postoperatively and ultrasonography taken at the final follow-up revealed that group B showed a significantly higher retear rate than did group A (69% vs. 6%, respectively; P < .001). CONCLUSION: Arthroscopic repair with the modified tension band suture technique for rotator cuff tears was a more suitable method for small to medium tears than for large to massive tears.

Arthroscopic treatment of lateral epicondylitis: comparison of the outcome of ECRB release with and without decortication.

PURPOSE: The purpose of this study was to compare the early clinical results of arthroscopic extensor carpi radialis brevis (ECRB) release with and without bone decortication in the treatment of lateral epicondylitis. MATERIALS AND METHODS: Thirty-eight patients who were surgically treated for lateral epicondylitis between 2004 and 2008 were included in this retrospective review. Among these 38 patients, 19 underwent arthroscopic ECRB release and 19 patients underwent both ECRB release with decortication of the lateral epicondyle. Outcome measures included pain assessment measured by visual analog scale (VAS) preoperatively, on postoperative day one, at two and 4 weeks postoperatively, and at the final follow-up visit. Functional evaluation was made with the Mayo Elbow Performance Index and grip strength measurement. RESULTS: Patients who underwent simple ECRB release had significantly less pain than patients who underwent ECRB release and decortication immediately postoperatively (p < 0.05). This group also showed a lower VAS score on exertion 2 weeks and 4 weeks after simple ECRB release (p < 0.05). The mean time taken to return to work was 24.2 ± 18.3 days in the group that underwent simple ECRB release and 39 ± 22.7 days in the group that underwent ECRB release with decortication (p < 0.05). CONCLUSIONS: Arthroscopic release of the ECRB is an effective method of treatment in patients with recalcitrant lateral epicondylitis. Decortication of the lateral epicondyle leads to increased pain postoperatively and did not improve clinical results.

Arthroscopic-assisted Latissimus Dorsi Tendon Transfer for the Management of Irreparable Rotator Cuff Tears in Middle-aged Physically Active Patients.

BACKGROUND: Latissimus dorsi (LD) tendon transfer is used as a treatment option for massive irreparable posterosuperior rotator cuff tears, and recently, an arthroscopic-assisted technique was introduced. This study was undertaken to evaluate the clinical and radiological outcomes of arthroscopic-assisted LD tendon transfer for the management of irreparable rotator cuff tears in active middle-aged patients. METHODS: The records of five patients (two males) with irreparable tears involving the supraspinatus and infraspinatus tendons managed by arthroscopic-assisted LD tendon transfer were retrospectively reviewed. Clinical outcomes were assessed using the visual analogue scale (VAS) pain scale, American Shoulder and Elbow Surgeon's (ASES) scores, the University of California Los Angeles (UCLA) scale, and ranges of motion. Postoperative integrities of transferred tendon were evaluated by magnetic resonance imaging in 4 patients and by ultrasound in one. RESULTS: Mean patient age was 55 years (range, 48-61 years), and mean follow-up period was 20 months (range, 12.0-27.2 months). Mean VAS score significantly improved from 6.6 ± 2.6 preoperatively to 1.8 ± 2.5 postoperatively (p=0.009), mean ASES score increased from 67.6 ± 9.2 to 84.6 ± 15.1, and mean UCLA score from 18.0 ± 1.4 to 28.8 ± 8.5 (all p<0.001). Postoperative imaging of the transferred LD tendon showed intact repair in 4 patients. The remaining patient experienced LD transfer rupture and a poor outcome. CONCLUSIONS: Arthroscopic-assisted LD tendon transfer improved shoulder pain and function in patients with massive, irreparable rotator cuff tears, and may be an option for this condition, especially in physically active patients.

Proximal Approach of Ultrasound-guided Suprascapular Nerve Block: Comparison with Subacromial Steroid Injection.

BACKGROUND: This study was undertaken to evaluate early clinical outcomes of ultrasound-guided suprascapular nerve block (SSNB) using a proximal approach, as compared with subacromial steroid injection (SA). METHODS: This retrospective study included a consecutive series of 40 patients of SSNB and 20 patients receiving SA, from August 2017 to August 2018. The visual analogue scale (VAS), American Shoulder Elbow Surgeon's score (ASES), University of California, Los Angeles score (UCLA), the 36 health survey questionnaire mental component summary (SF36-MCS), physical component summary (PCS), and range of motion (forward elevation, external rotation, and internal rotation) were assessed for clinical evaluations. RESULTS: Compared with the baseline, VAS, and ranges of motion in the SSNB group significantly improved at the 4-week follow-up (VAS scores improved from 6.7 ± 1.6 to 4.3 ± 2.4, p<0.001; all ranges of motion p<0.05), while other variables showed no statistically significant differences. All clinical variables were significantly improved in the SA group (p<0.05). However, all clinical scores at the 4-week follow-up showed no significant difference between groups. CONCLUSIONS: Ultrasound-guided SSNB using proximal approach provides significant pain relief at 4-weeks after treatment, with statistically significant difference when compared with SA, suggesting that SSNB using proximal approach is a potentially useful option in managing shoulder pain. However, in the current study, it was less effective in improving shoulder function and health-related quality of life, compared with SA.

Candy Closure Technique for Chronic Open Infective Lateral Malleolus Bursitis.

The aim of this study was to report the effectiveness of the Candy closure technique as a treatment for chronic open infective lateral malleolus bursitis. From June 2014 to March 2018, we performed the Candy closure technique as a treatment for chronic open infective lateral malleolus bursitis in nine patients without secondary operation. We first performed infectious tissue debridement to control infection, and if primary closure was not possible, we performed the Candy closure technique for small wounds. The duration of the wound prior to surgery varied from 4 weeks to 2 years. Seven cases were due to infection on the bursa and two cases were ulcer-type bursitis. All the wounds were small (average, 3.80 cm2; range, 2.25-4 cm2) and circular. Seven wounds showed complete healing at 4 weeks after surgery, one wound showed complete healing at 8 weeks after surgery, and one wound with infected state was lost to missing follow-up. Of the seven wounds that showed complete healing, one wound recurred 6 months after surgery. The Candy closure technique is a simple method for ensuring healing and coverage of chronic open lateral malleolus bursitis, especially for small wounds with dead space.

Clinical Outcome after Arthroscopic Capsular Release for Adhesive Capsulitis of the Shoulder.

BACKGROUND: This study was undertaken to evaluate the outcome of the arthroscopic capsular release for adhesive capsulitis of the shoulder. METHODS: This study retrospectively investigated thirty shoulders in 29 patients who presented with recalcitrant adhesive capsulitis and underwent arthroscopic treatments. Other than typical findings of adhesive capsulitis, combined pathologies in the glenohumeral joint and subacromial space were evaluated by arthroscopy. Clinical evaluations were performed using the Constant's score and ranges of motion (ROM) at preoperative, 6 months postoperatively and at the final follow-up. RESULTS: Our study included 17 women and 12 men with a mean age of 53.8 years (range, 34-74). Mean follow-up duration was 24 months (range, 12-40 months). Assessment of combined pathologies revealed that partial rotator cuff tear of less than 25% thickness, was most common (overall 83.3%; with bursal 57% and articular 23%). Subacromial synovitis and adhesion were also frequent (53.3%). The Constant score and ranges of motion significantly improved at the final follow-up, compared with preoperative levels. However, clinical results at 6 months postoperatively were found to be significantly inferior to those observed at the final follow-up (p≤0.001 for all factors). Functional impairment was the major complaint in 59.3% patients at the 6 months follow-up. CONCLUSIONS: Although arthroscopic capsular release yielded favorable outcome at the mean 24 months follow-up, pain and motion limitations at 6-month postoperatively persisted in more than 50% of our patients. While combined pathologies were commonly encountered during arthroscopy, although their effects on surgical outcome in adhesive capsulitis remains unclear in this study.

A chronic sinus tract infection developing after suture anchoring of the ankle: A case report.

RATIONALE: Suture anchors are increasingly used to fix soft tissue to bone. Favorable outcomes of the modified Brostrom operation (MBO) using suture anchors have been reported. However, to the best of our knowledge, few complications of suture anchors used in ankle surgery have been described. Here, we present a rare case of successful treatment of a chronic sinus tract infection developing after the MBO using a suture anchor. PATIENT CONCERNS: A healthy 18-year-old high school student presented with a chronic ulcerative wound in his right ankle 1 year after anterior talofibular and calcaneofibular ligament repair using a suture anchor at a local clinic. Clinical examination revealed a 1.5 × 2-cm-sized ulcerative wound, accompanied by a red-black discharge, on the anterior border of the right lateral malleolus. The wound could be approximated to the joint capsule level using a forceps. DIAGNOSIS: A simple standing anteroposterior radiograph of the right ankle revealed mild, lateral soft-tissue swelling. Magnetic resonance imaging showed that a sinus tract running from the wound to the talar body crossed the anterior joint capsule, and bone marrow edema surrounding the talus. INTERVENTIONS: We removed the sinus tract and the infected suture anchor. We rendered the wound zigzag-shaped and then performed simple suturing and applied a short leg cast. OUTCOMES: The wound healed completely by 4 weeks after surgery. The patient reported no complication or recurrence of infection at the 1-year follow-up. LESSONS: To obtain wound healing, the chronic sinus tract must be removed. If the suture anchor is the cause of infection, it should be removed.

Arthroscopic Lateral Collateral Ligament Repair.

BACKGROUND: Lateral ulnar collateral ligament injury following unstable elbow dislocation can induce posterolateral rotatory instability that requires surgery. The aim of this study was to determine the effectiveness of arthroscopic repair of the lateral collateral ligament (LCL) complex in an unstable elbow joint. METHODS: The study group consisted of 13 patients who experienced posterolateral rotatory instability after an unstable elbow dislocation with an injury to the lateral ulnar collateral ligament. The diagnosis was confirmed with computed tomography (CT), magnetic resonance imaging (MRI), and physical examination. The patients underwent arthroscopically assisted surgery between May 2011 and January 2013 and were followed for a minimum of 18 months postoperatively. Coronoid and/or radial head fractures combined with the ligament injury were treated through an arthroscopic technique. Range of motion, pain, outcomes according to the Mayo Elbow Performance Score (MEPS) and Nestor grading system, and surgical complications were evaluated. CT and MRI were performed at 3 months postoperatively, and isometric muscle strength was measured at the time of final follow-up. RESULTS: At the time of final follow-up, at a minimum of 18 months, all 13 patients reported complete resolution of the instability and average (and standard deviation) extension of 3° ± 1°, flexion of 138° ± 6°, supination of 88° ± 5°, and pronation of 87° ± 6. The mean MEPS was 92 points and, according to this validated outcome score, the results were rated as excellent in 12 patients and good in 1 patient. According to the Nestor grading system, the results were rated as excellent in 11 patients and good in 2. Complete healing was seen on the 3-month follow-up MRI in 12 patients; however, 1 patient had mild widening of the radiocapitellar joint space with incomplete healing but no instability symptoms. All patients demonstrated normal strength on elbow flexion, extension, pronation, and supination at the final follow-up visit. CONCLUSIONS: Arthroscopic repair of the LCL complex in patients with posterolateral rotatory instability after an unstable elbow dislocation, with or without an intra-articular fracture, is an alternative treatment option for restoring elbow stability and achieving satisfactory clinical and radiographic results. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.