Elbow hemiarthroplasty and total elbow arthroplasty provided a similar functional outcome for unreconstructable distal humeral fractures in patients aged 60 years or older: a multicenter randomized controlled trial.

BACKGROUND: Semiconstrained total elbow arthroplasty (TEA) is an established treatment for elderly patients with distal humeral fractures not amenable to stable internal fixation (unreconstructable). In recent years, there has been increasing interest in elbow hemiarthroplasty (EHA), a treatment option which does not entail restrictions on weight-bearing as opposed to TEA. These 2 treatments have not been compared in a randomized controlled trial (RCT). The aim of this study was to compare the functional outcome of EHA and TEA for the treatment of unreconstructable distal humeral fractures in elderly patients. MATERIAL AND METHODS: This was a multicenter randomized controlled trial (RCT). Patients were included between January 2011 and November 2019 at one of 3 participating hospitals. The inclusion criteria were an unreconstructable distal humeral fracture, age ≥60 years and independent living. The final follow-up took place after ≥2 years. The primary outcome measure was the Disabilities of the Arm, Shoulder, and Hand (DASH) score. Secondary outcome measures were the Mayo Elbow Performance Score (MEPS), the EQ-5D index, range of motion (flexion, extension, pronation, and supination) and grip strength. RESULTS: Forty patients were randomized to TEA (n = 20) and EHA (n = 20). Five patients died before completing the final follow-up, leaving 18 EHA and 17 TEA patients for analysis. There were 31 women. The mean age was 74.0 (SD, 8.5) years in the EHA group and 76.9 (SD, 7.6) in the TEA group (P = .30). The mean DASH score was 21.6 points in the EHA group and 27.2 in the TEA group (P = .39), a difference of -5.6 points (95% CI: -18.6 to 7.5). There were no differences between treatment with EHA and TEA for the mean values of the MEPS (85.0 vs. 88.2, P = .59), EQ-5D index (0.92 vs. 0.86, P = .13), extension (29° vs. 29°, P = .98), flexion (126° vs. 136°, P = .05), arc of flexion-extension (97° vs. 107°, P = .25), supination (81° vs. 75°, P = .13), pronation (78° vs. 74°, P = .16) or grip strength (17.5 kg vs. 17.2 kg, P = .89). There were 6 adverse events in each treatment group. CONCLUSION: In this RCT, both elbow hemiarthroplasty (EHA) and total elbow arthroplasty (TEA) resulted in a good and similar functional outcome for unreconstructable distal humeral fractures in elderly patients at a minimum of 2 years of follow-up.

Ultrasonographic examination of acute soft tissue lesions in the elbow has good inter-rater reliability and acceptable agreement with magnetic resonance imaging.

BACKGROUND: Ultrasonography (US) has been suggested as a valuable complement to clinical and radiologic examinations in elbow trauma. Magnetic resonance imaging (MRI) has been the method of choice, despite fair to moderate inter-rater reliability (IRR). US has potential advantages but is assessor dependent and the IRR scarcely examined. The primary aim of the present study was to investigate IRR for US and secondarily interobserver agreement (IOA) between US and MRI in the acute phase after elbow trauma. Acute phase was defined as 2 weeks and, if applicable, the following weekend. The hypothesis was that US reliability would be at least substantial for complete muscle or ligament lesions. METHODS: A total of 116 patients (50 men, median age 47 [range 19-87] years) who had an elbow trauma with dislocation and/or fracture were included. Exclusion criteria were prior injury to the same elbow, and US and/or MRI not possible within 16 days. During US, the condition of muscle origins at the epicondyles and collateral and annular ligament complexes was recorded in a predesigned protocol, with the alternatives intact, partially or completely torn. Seventy-two patients had a second US examination the same day by an independent upper extremity surgeon, and 58 of the 116 patients underwent an MRI before or after the US, evaluated by 2 radiologists using the same protocol. IOA and IRR between assessors and modalities were analyzed with kappa statistics and interpreted according to Landis and Koch. Perfect agreement (PA) was reported in percentages. RESULTS: US examination within 2 weeks was feasible with tolerable discomfort. Defining muscle origins and ligaments as intact or completely torn, the US IRR ranged from substantial to near perfect (kappa 0.63-1, PA 93%-100%). Intact tissues vs. tear (partial and complete tear combined) or intact vs. partial vs. complete tear resulted in kappa values from moderate to substantial and PA 74%-96% with lowest reliability for the muscle origins. The IOA between MRI and US ranged from fair to near perfect for no tear vs. complete tear (kappa 0.25-1, PA 65%-100%). Agreement between no tear and tear (partial and complete together) ranged from fair to substantial (0.25-0.66, PA 63%-89%) and no tear vs. partial or complete tear ranged from fair to moderate (0.25-0.53, PA 50%-79%). CONCLUSION: US in the acute setting is suitable and reliable for diagnosis of ligament injuries in the elbow and is in addition fast, cheap, and easily accessible. The agreement with MRI seems to vary with the structure assessed and severity of the lesions, ranging from fair to near perfect.

The Choice of Antibiotic Prophylaxis Influences the Infection Reoperation Rate in Primary Shoulder Arthroplasty: Analysis From the Swedish Shoulder Arthroplasty Register.

BACKGROUND: Periprosthetic joint infection is a serious complication and a major reason for revision surgery after primary shoulder arthroplasty. The prophylactic antibiotics for primary shoulder arthroplasty that have predominantly been used in Sweden are cloxacillin and clindamycin. To address Cutibacteriumacnes , benzylpenicillin has recently increasingly been added to cloxacillin, but it is unclear which antibiotic prophylaxis regimen is the most effective to prevent periprosthetic joint infection. QUESTIONS/PURPOSES: After controlling for baseline differences among patients such as age, gender, previous surgery, cement fixation, and arthroplasty type, was the risk of reoperation for infection higher in patients who received cloxacillin than in those who received clindamycin or the combination of benzylpenicillin and cloxacillin? METHODS: Data from the Swedish Shoulder Arthroplasty Register were used for this study. The inclusion criterion was registered antibiotic prophylaxis in primary arthroplasty. Between January 1, 1999, and December 31, 2019, 22,470 primary shoulder arthroplasties, including total shoulder, hemiarthroplasty, and reverse shoulder arthroplasties, were entered into the Swedish Shoulder Arthroplasty Register. Reporting of antibiotic prophylaxis to the register was introduced on January 1, 2013. Since then, the completeness of information on the type of antibiotic prophylaxis in the reports has been 85.3%. Consequently, 10,706 arthroplasties were eligible and fulfilled the inclusion criterion of reported antibiotic prophylaxis. A further 129 were excluded because of unusual prophylaxis regimens, leaving 10,577 shoulder arthroplasties for analysis. The Swedish Shoulder Arthroplasty Register gathers information from all 60 hospitals performing shoulder arthroplasty in Sweden, and through a comparison with the National Patient Register, it has been estimated that more than 90% of all primary shoulder arthroplasties and shoulder reoperations are reported to the register. The age of the study population ranged between 16 and 98 years; the mean age at the primary surgery was 70 ± 10 years for the entire cohort, with a mean age of 67 ± 10 years and 72 ± 9 years for men and women, respectively. The mean observation period was 989 ± 669 days. From 2013 to 2019, there was a clear change in prophylaxis; in particular, the use of the combination of benzylpenicillin and cloxacillin increased dramatically and the use of cloxacillin alone decreased. Clindamycin prophylaxis increased moderately. The primary study endpoint was reported reoperation for infection. In the register, this is defined as repeat procedures of any kind, including biopsy, lavage of the joint, or revision, defined as secondary surgery in which a component was exchanged, removed, or added. To compare the reoperation rate in relation to the different antibiotics used, which changed over time, we controlled for age, gender, previous surgery, cement fixation, and arthroplasty type using a Cox proportional hazards model. RESULTS: When adjusting for age, gender, previous surgery, cement fixation, and arthroplasty type, cloxacillin prophylaxis was associated with an increased relative risk of reoperation for infection compared with the combination of cloxacillin and benzylpenicillin (hazard ratio [HR] 2.40 [95% confidence interval (CI) 1.35 to 4.25]; p = 0.003) and compared with clindamycin alone (HR 1.78 [95% CI 1.11 to 2.85]; p = 0.02). No difference was found between the cloxacillin and benzylpenicillin combination and clindamycin (HR 0.74 [95% CI 0.42 to 1.32]; p = 0.31). CONCLUSION: Our results indicate that prophylaxis against C. acnes may be warranted in shoulder arthroplasty. Because the absolute number of infections was low and infections could have been underreported to the register, our results should be interpreted with caution. There is no available information about the causative microorganisms. The study lays the groundwork for further investigations of antibiotic prophylaxis regimens in shoulder arthroplasty. Because large randomized controlled trials would be impractical to perform, prospective register-based randomized controlled studies might be a viable method. LEVEL OF EVIDENCE: Level Ⅲ, therapeutic study.

Factors associated with healing failure after early repair of acute, trauma-related rotator cuff tears.

BACKGROUND: Healing failure after rotator cuff repair is a challenging problem. Acute, trauma-related tears are considered a separate entity and are often treated surgically. The aim of this study was to identify factors associated with healing failure in previously asymptomatic patients with trauma-related rotator cuff tears treated with early arthroscopic repair. METHODS: This study included 62 consecutively recruited patients (23% women; median age, 61 years; age range, 42-75 years) with acute symptoms in a previously asymptomatic shoulder and a magnetic resonance imaging-verified full-thickness rotator cuff tear after shoulder trauma. All patients were offered, and underwent, early arthroscopic repair, during which a biopsy specimen was harvested from the supraspinatus tendon and analyzed for signs of degeneration. Of the patients, 57 (92%) completed 1-year follow-up and underwent assessment of repair integrity on magnetic resonance images according to the Sugaya classification. Risk factors for healing failure were investigated using a causal-relation diagram where age, body mass index, tendon degeneration (Bonar score), diabetes mellitus, fatty infiltration (FI), sex, smoking, tear location regarding integrity of the rotator cable, and tear size (number of ruptured tendons and tendon retraction) were included and analyzed. RESULTS: Healing failure at 1 year was identified in 37% of patients (n = 21). A high degree of FI of the supraspinatus muscle (P = .01), a tear location including disruption of rotator cable integrity (P = .01), and old age (P = .03) were associated with healing failure. Tendon degeneration as determined by histopathology was not associated with healing failure at 1-year follow-up (P = .63). CONCLUSION: Older age, increased FI of the supraspinatus muscle, and a tear including disruption of the rotator cable increased the risk of healing failure after early arthroscopic repair in patients with trauma-related full-thickness rotator cuff tears.

Distal ulna fractures in adults-subcapitular, transverse fractures did not benefit from surgical treatment.

INTRODUCTION: Fractures of the distal ulna, excluding the styloid, are rare. The cause of injury is often a fall on an outstretched hand with an extended wrist, and in most cases there is a concomitant distal radius fracture. The aims of this retrospective study were to investigate the results of the current treatment of distal ulna fractures in adults, with or without a concomitant distal radius fracture, and if a recently presented fracture classification could predict outcome. MATERIALS AND METHODS: Patients, 18 years or older, treated for a fracture of the distal third of ulna in our county, were included. Fractures of the styloid tip were excluded. The radiographs of the fractures were independently classified by two specialists in radiology according to the 2018 AO/OTA classification. Follow-up was performed 5-7 years after the injury, through the questionnaire Patient-Rated Wrist Evaluation (PRWE) and new radiographs of both wrists. RESULTS: Ninety-six patients with 97 fractures were included and filled out the PRWE. 65 patients also had new radiographs taken. 79 patients were women and the mean age at the time of injury was 63 years (SD 14.5). The most common fracture class was the extra-articular transverse fracture, 2U3A2.3 (42%). We found that 40% of the fractures had been treated by internal fixation and only 2 fractures had not healed, one conservatively treated and one operated. The median PRWE was 15 (IQR 33.5). The PRWE score was significantly worse in the operated ulna fractures (p = 0.01) and this was also true for extra-articular transverse fractures 2U3A2.3 (p = 0.001). Initial displacement was more common in operated transverse fractures, but it could not be proven that this was the reason for the inferior result. CONCLUSIONS: Distal ulna fractures almost always unite and the result is comparable to that of isolated distal radius fractures when measured by PRWE. Based on the opinions of the radiologists and how often a consensus discussion was needed for classification, we found the updated AO classification system difficult to use, if dependent only on standard radiographic views. In the present study, transverse extra-articular ulna fractures did not benefit from internal fixation regardless if associated with a distal radius fracture or isolated.

Poor reliability and reproducibility of 3 different radiographical classification systems for distal ulna fractures.

BACKGROUND AND PURPOSE: Classification of fractures can be valuable for research purposes but also in clinical work. Especially with  are fractures, such as distal ulna fractures, a treatment algorithm based on a classification can be helpful. We compared 3 different  classification systems of distal ulna fractures and investigated their reliability and reproducibility. PATIENTS AND METHODS: patients with 97 fractures of the distal ulna, excluding the ulnar styloid, were included. All fractures were  independently classified by 3 observers according to the classification by Biyani, AO/OTA 2007, and AO/OTA 2018. The classification process was repeated after a minimum of 3 weeks. We used Kappa value analysis to determine inter- and intra-rater agreement. RESULTS: The inter-rater agreement of the AO/OTA 2007 classification was judged as fair, ĸ 0.40, whereas the agreement of AO/OTA 2018 and Biyani was moderate at ĸ 0.42 and 0.43 respectively. The intra-rater agreement was judged as moderate for all classifications. INTERPRETATION: The differences between the classifications were small and the overall impression was that neither of them was good enough to be of substantial clinical value. The Biyani classification, being developed specifically for distal ulna fractures, was the easiest and most fitting for the fracture patterns seen in our material, but lacking options for fractures of the distal diaphysis. Standard radiographs were considered insufficient for an accurate classification. A better radiographic method combined with a revised classification might improve accuracy, reliability, and reproducibility.

Neither critical shoulder angle nor acromion index were related with specific pathology 20 years later!

PURPOSE: The critical shoulder angle (CSA) and the acromion index (AI) are measurements of acromial shape reported as predictors of degenerative rotator cuff tears (RCT) and glenohumeral osteoarthritis (GH OA). Whether they are the cause or effect of shoulder pathologies is uncertain since pre-morbid radiographs most often are lacking. The main aim of this study was to investigate if CSA or AI were related to the development of RCT or GH OA after 20 years. A secondary aim was to investigate if the CSA and AI had changed over time. METHODS: In the hospital archive, 273 preoperative plain shoulder radiographs were found of patients scheduled for elective surgery other than cuff repair and arthroplasty. Forty-five images fulfilled the strict criteria published by Suter and Henninger (2015) and were used to measure CSA and AI with two independent assessors. No patient had any sign of OA in the index radiographs or any information in the medical records indicating RCT. After a median of 20 (16-22) years, 30 of these patients were radiologically re-examined with bilateral true frontal views and ultrasound of the rotator cuff. There were 19 men (20 study shoulders) and 11 females (12 study shoulders). RESULTS: Mean age at follow-up was 56 (32-78) years. There was no correlation between CSA (r = 0.02) (n.s) or AI (r = - 0.13) (n.s) in the primary radiographs and OA at follow-up. Nor was any correlation found between index CSA (r = 0.12) (n.s) or AI (r = - 0.13) (n.s) and RCT at follow-up. Mean difference in CSA was - 1.7 (- 10-3) degrees and mean AI difference was - 0.04 (- 0.13-0.09) between the first and the second radiographs, 20 years later. Bilaterally, mean CSA was 32 and AI 0.61 at follow-up. CONCLUSION: In this study, no correlation between the CSA, AI and development of OA or RCT could be found. The mean CSA and AI decreased over a 20-year period but the difference was very small. No difference was found between the study shoulders and the contralaterals. These findings question previously reported etiological associations between scapular anatomy and the development of OA or RCT and thereby the use of these calculations as the basis of treatment. LEVEL OF EVIDENCE: III.

Biomechanical significance of the collateral ligaments in transolecranon fracture-dislocations.

BACKGROUND: It is widely accepted that transolecranon fracture-dislocations are not associated with collateral ligament disruption. The aim of the present study was to investigate the significance of the collateral ligaments in transolecranon fractures. METHODS: Twenty cadaveric elbows with a mean age of 46.3 years were used. All soft tissue was dissected to the level of the capsule, leaving the anterior band of the medial collateral ligament (MCL) and lateral collateral ligament (LCL) intact. A standardized, oblique osteotomy starting from the distal margin of the cartilage bare area of the ulna was made. The elbows were loaded with an inferiorly directed force of 5 and 10 N in the intact, MCL cut, LCL cut, and both ligaments cut states. All measurements were recorded on lateral calibrated radiographs. RESULTS: The mean inferior translation with intact ligaments (n = 20) when the humerus was loaded with 5 and 10 N was 1.52 mm (95% confidence interval [CI], 1.02-2.02) and 2.23 mm (95% CI, 1.61-2.85), respectively. When the LCL was cut first (n = 10), the inferior translation with 5 and 10 N load was 4.11 mm (95% CI, 0.95-7.26) and 4.82 mm (95% CI, 1.91-7.72), respectively. When the MCL was cut first (n = 10), the inferior translation when loaded with 5 and 10 N was 3.94 mm (95% CI, 0.796-7.08) and 5.68 mm (95% CI, 3.03-8.33), respectively. The inferior translation when loaded with 5 and 10 N and both ligaments cut was 15.65 mm (95% CI, 12.59-18.79) and 17.50 mm (95% CI, 14.86-20.13), respectively. There was a statistical difference between the intact and MCL cut first at 10 N and when both ligaments were cut at 5 and 10 N. CONCLUSIONS: The findings suggest that collateral ligament disruption is a prerequisite for a transolecranon fracture-dislocation. An inferior translation of more than 3 mm suggests that at least one of the collateral ligaments is disrupted, and more than 7.5 mm indicates that both collateral ligaments are disrupted.

An intact lacertus fibrosus improves strength after reinsertion of the distal biceps tendon.

PURPOSE: The importance of an intact lacertus fibrosus in distal biceps tendon injury is uncertain. This study aimed to assess long-term outcome following distal biceps tendon repair with focus on the significance of the lacertus fibrosus. METHODS: Thirty-six patients surgically treated for primary distal biceps tendon rupture were identified. Medical records were reviewed for patient demographics in addition to surgery-related data. All patients underwent a targeted clinical examination to assess elbow function and they completed a patient reported questionnaire. Radiographs were obtained at time of follow-up and evaluated for the presence of osteoarthritis (OA) and heterotopic ossification (HO). RESULTS: All patients were male. Median age at injury was 48 years (34-69) and median time of follow-up of was 71 months (23-165). All patients presented functional range of motion in the elbow. Median flexion strength was 76 Nm (45-135) (median 99% of uninjured side; range 66-128) with intact lacertus fibrosus and 70 Nm (43-124) (88%, 62-114) with torn lacertus fibrosus. Median supination strength was 6 Nm (3-11) (86%, range 36-144) with intact lacertus fibrosus and 8 Nm (3-17) (67%, 28-118) with torn lacertus fibrosus. No signs of OA were revealed, but three patients had major HO of which one patient had minor limitations in range of elbow motion. CONCLUSION: An intact lacertus fibrosus contributes to elbow strength and should be preserved in distal biceps tendon repair. LEVEL OF EVIDENCE: III.

Surgery and physiotherapy were both successful in the treatment of small, acute, traumatic rotator cuff tears: a prospective randomized trial.

BACKGROUND: Previous randomized trials on cuff repair have included mainly degenerative tears, but studies on acute traumatic tears are lacking. We aimed to compare early surgical repair with nonoperative treatment for traumatic supraspinatus tears. METHODS: We did a 2-center randomized controlled trial of patients with small rotator cuff tears mainly involving supraspinatus, comparing surgical repair (n = 32) and physiotherapy (n = 26). The primary outcome was a group difference in the Constant-Murley score at 12-month follow-up. Secondary outcomes were differences in the Western Ontario Rotator Cuff index, pain (Numerical Rating Scale 0-10), and Euro quality-of-life-visual analog scale. We used magnetic resonance imaging to assess retear rate, tear progression, fatty infiltration, and atrophy. RESULTS: The mean age was 59.7 years (range, 44-77 years), median sagittal tear size was 9.7 mm (range, 4-21 mm), and baseline characteristics were well balanced between the 2 groups. The repair group had a median Constant-Murley of 83 (25 quartile range [QR]) and the physiotherapy group 78 (QR, 22) at 12 months, with the between-group difference in medians of 4.5 (-5 to 9, 95% confidence interval; P = .68). The corresponding values for the Western Ontario Rotator Cuff index were 91% (QR, 24) vs. 86% (QR, 24), with the between-group difference of 5.0 (-4 to 9, 95% confidence interval; P = .62). There was no difference in Numerical Rating Scale or in Euro quality-of-life-visual analog scale. Retear was found in 6.5% of repaired patients and tear progression >5 mm in 29.2% of unrepaired patients. CONCLUSIONS: We found no significant differences in clinical outcomes between cuff repair and nonoperative treatment at 12-month follow-up. Approximately one third of unrepaired patients had a tear enlargement of more than 5 mm.

Incidence of distal ulna fractures in a Swedish county: 74/100,000 person-years, most of them treated non-operatively.

Background and purpose - Fractures of the distal ulna can occur in isolation or in conjunction with a distal radius fracture. They may result in incongruence and instability of the distal radioulnar joint. We investigated the incidence of distal ulna fractures, whether any fracture types were more common, and the methods of treatment used.Patients and methods - Data were collected from patients 18 years or older, treated for a fracture of the distal ulna in Östergötland, Sweden, during 2010-2012. Patients were identified in the patient registry. The fractures were classified according to the AO comprehensive classification of fractures.Results - The incidence of distal ulna fractures was 74/100,000 person-years. The most common fracture type was that of the ulnar styloid Q1 (79%), followed by the ulnar neck Q2 (11%). Rarest was ulna head fracture, type Q4 (1%). Incidental findings were a mean age of 63 years (SD 18), a concomitant distal radius fracture in 92% of the patients and that 79% were caused by falling from standing height. Internal fixation was performed in 30% of the Q2-Q6 fractures. This indicates that most were considered stable without internal fixation or stable after fixation of a concomitant radius fracture.Interpretation - Our results show that fractures of the distal ulna are not very common, and some fracture types are even rare. There seem to be no consensus on treatment.

Arthroplasty as primary treatment for distal humeral fractures produces reliable results with regards to revisions and adverse events: a registry-based study.

BACKGROUND: Primary prosthetic replacement has become an accepted method for the treatment of complex distal humeral fractures. The present study investigated implant survival and adverse events related to this procedure based on available Swedish registries and examined the completeness of the Swedish Elbow Arthroplasty register. MATERIALS AND METHODS: Patients treated in Sweden with a primary elbow replacement due to a distal humeral fracture between 1999 and 2014 were identified through 3 different registries: The Swedish Elbow Arthroplasty Register, National Board of Health and Welfare inpatient register, and local registries of all orthopedic departments. Prosthetic survival was examined using Cox regression analysis with Kaplan-Meier plots. Adverse events, defined as medical treatment of the affected elbow besides revision, were analyzed separately. The study included 406 elbows in 405 patients, and no register was complete. RESULTS: Implant survival at 10 years was 90% (95% confidence interval, 85%-96%), but only 45 patients had an observation time of 10 years or more because 46% of the patients had died, resulting in a mean observation time of 67 (standard deviation, 47) months. An increase in the use of hemiarthroplasties and a proportional decrease of total elbow arthroplasties was detected. There were 18 revisions (4%), and 26 patients (6%) experienced an adverse event, of whom 16 (4%) required surgery. The completeness of the Swedish Elbow Arthroplasty Register regarding primary arthroplasty was 81%. CONCLUSION: Primary arthroplasty as treatment of distal humeral fractures produces reliable results with regards to revisions and other adverse events.

Patients with a long-standing cuff tear in one shoulder have high rates of contralateral cuff tears: a study of patients with arthroscopically verified cuff tears 22 years ago.

BACKGROUND: The prevalence of contralateral full-thickness cuff tears (FTTs) and cuff tear arthropathy (CTA) is presumed to be higher in patients with long-standing cuff tears than in those with newly diagnosed tears, but data are currently lacking. METHODS: Sixty-one patients with 38 partial and 23 full-thickness tears of 1 shoulder at arthroscopy were examined with bilateral radiographs, ultrasound, and the Constant-Murley score at a mean of 22 years (range, 21-25 years) after arthroscopy. RESULTS: The overall rate of full-thickness tears in the contralateral shoulder was 50.8%. In patients with a full-thickness tear and CTA (Hamada grade ≥2) in the index shoulder at follow-up, 18 of 20 (90%) had a contralateral full-thickness tear and 4 of 20 (20%) had CTA. In patients with a partial tear in the index shoulder at follow-up, 3 of 22 (13.6%) had a contralateral full-thickness tear and none had CTA. CTA changes were more common in patients with FTT and a previous acromioplasty (P < .001). The correlation between shoulders was 0.72 for the number of tendons with FTT (P <.001), 0.31 for the Hamada grade (P = .016), and 0.65 for the absolute Constant-Murley score (P <.001). The number of tendons with a full-thickness tear at follow-up was a risk factor (odds ratio, 3.28; 95% confidence interval, 1.67-6.44; P <.001) for a contralateral full-thickness tear. Patients with a partial or full-thickness tear in the contralateral shoulder had pain in 39.2% of cases. CONCLUSION: Patients with long-standing cuff tears have high rates of contralateral cuff tears. The severity of the condition is strongly correlated between the shoulders. Patients with full-thickness tears and a previous acromioplasty have a significantly higher frequency of CTA than patients with cuff tears who had not undergone a previous acromioplasty.

Long-term clinical and radiographic outcome of rotator cuff repair with a synthetic interposition graft: a consecutive case series with 17 to 20 years of follow-up.

BACKGROUND: Treatment options for irreparable cuff tears include synthetic interposition grafts, but whether such grafts can maintain acceptable shoulder function and prevent cuff tear arthropathy in the long-term is unknown. METHOD: This was a retrospective case series of 13 consecutive patients treated with a synthetic interposition graft made of Dacron (DuPont, Wilmington, DE, USA). Patients were examined with bilateral ultrasonography, bilateral x-ray imaging, Constant-Murley score, and Western Ontario Rotator Cuff score. RESULTS: After a mean of 18 years (range, 17-20 years), 1 patient had died, and 12 were available for x-ray imaging and 10 also for ultrasonography and clinical scores. Cuff tear arthropathy (Hamada grade ≥2) had developed in 9 of 12 (75%; 95% confidence interval, 43%-95%), including 3 patients operated on with arthroplasty in the follow-up period. The mean absolute Constant-Murley score was 46 (standard deviation, 26), and the mean Western Ontario Rotator Cuff score was 59 (standard deviation, 20). In 7 of 10 patients (70%) with available ultrasonography, the graft was interpreted as not intact. All patients had a contralateral full-thickness tear, and 7 of 12 patients (58 %; 95% confidence interval, 28%-85%) had contralateral cuff tear arthropathy. The number of patients with cuff tear arthropathy was not significantly different between the shoulder repaired with a Dacron graft and the contralateral shoulder (P = .667). CONCLUSION: These results indicate that a synthetic interposition graft with screw fixation could not prevent cuff tear arthropathy and preserve cuff integrity in a long-term perspective.

Extensive soft tissue lesions in redislocated after simple elbow dislocations.

BACKGROUND: The majority of simple elbow dislocations (no associated fractures) can be treated nonoperatively with a short period of immobilization followed by guided aftercare. This case series describes the soft tissue injuries in a rare subset of patients in whom the elbow redislocated despite adequate immobilization. METHODS: During a 6-year period, 8 patients were identified. They were all treated with reduction and casting in 90° of flexion or more. At 1 week of follow-up, redislocation had occurred in all patients and open soft tissue repair was performed. The injuries were documented and the patients were followed up clinically and with radiographs. RESULTS: Extensive soft tissue injuries, including both collateral ligament injuries and muscle origin avulsions from either or both sides, were found in all patients. The functional result at follow-up was satisfactory in all patients. CONCLUSION: Vast soft tissue injuries including both collateral ligaments and muscle origins should be expected in the event of early severe instability of a dislocated elbow joint.

Clinical and structural outcome 22 years after acromioplasty without tendon repair in patients with subacromial pain and cuff tears.

BACKGROUND: Long-term results regarding tear progression, arthropathy, and clinical scores of unrepaired rotator cuff tears are largely unknown. This study investigated whether the condition of the glenohumeral joint and rotator cuff had deteriorated at a minimum of 20 years after an acromioplasty without cuff repair and assessed the clinical results. METHODS: A retrospective analysis was conducted of a consecutive series of patients treated between 1989 and 1993 with acromioplasty without cuff repair due to subacromial pain and cuff tear. At follow-up results of x-ray, ultrasonography, and clinical scores were recorded. RESULTS: At a mean of 22 years (range, 21-25 years), 69 patients were available for follow-up with Western Ontario Rotator Cuff Index, Constant-Murley (CM) score, x-ray, and ultrasonography. Mean age at operation was 49 years (range, 19-69 years). There were 45 partial-thickness tears (PTT) and 24 full-thickness tears (FTT). Of 23 patients with FTT, 17 (74% with x-ray) had developed cuff tear arthropathy (Hamada ≥2) and 20 (87% with ultrasonography) had progressed in tear size. Mean relative CM in patients with FTT and cuff tear arthropathy was 62 (standard deviation [SD], 27), and the mean WORC was 58% (SD, 26%). In the 43 PTT patients, 3 (7% with x-ray) had developed cuff tear arthropathy and 16 (42% with ultrasonography) had tear progression. With PTT at follow-up, the mean relative CM was 101 (SD, 22), and the mean WORC was 81% (SD, 20%). CONCLUSIONS: After an acromioplasty, most unrepaired full-thickness tears will, in long-term, increase in size and be accompanied by cuff tear arthropathy changes. Most partial thickness tears remain unchanged; cuff tear arthropathy is rare, and clinical scores generally good.

A radial head prosthesis appears to be unnecessary in Mason-IV fracture dislocation.

Background and purpose - Previous reports on elbow injuries with concomitant comminute radial head fracture are difficult to interpret, since they include an array of different soft-tissue and bony injuries around the elbow. We focused on Mason-IV fracture dislocations of the elbow and retrospectively reviewed 2 treatment options: radial head resection or replacement with a radial head arthroplasty, both in combination with lateral ligament repair. Patients and methods - In Linköping, 18 consecutive patients with Mason-IV fracture dislocation and with a median age of 56 (19-79) years were treated with a radial head arthroplasty. In Malmö, 14 consecutive patients with a median age of 50 (29-70) years were treated for the same injury with radial head resection. With a follow-up of at least 2 years (Linköping: median 58 months; Malmö: median 108 months), the outcome was assessed using the Mayo elbow performance score (MEPS), the Disabilities of Arm, Shoulder, and Hand questionnaire (DASH), range of movement, instability, and plain radiographs. Results - There was no statistically significant difference between the groups regarding MEPS, DASH, or range of motion. The rate of additional surgery was higher in patients treated with arthroplasty. Ulno-humeral osteoarthritis was more pronounced in the group treated with radial head resection, but the follow-up time was longer in these patients. Functional results and range of motion tally well with previous reports on similar injuries. Interpretation - Functional results did not improve by using a press-fit radial head arthroplasty in Mason-IV fracture dislocation of the elbow. Secondary osteoarthritis after resection of the radial head is a concern, but it did not affect the functional outcome during the follow-up time.

Specific exercises for subacromial pain.

Background and purpose - We have previously shown that specific exercises reduced the need for surgery in subacromial pain patients at 1-year follow-up. We have now investigated whether this result was maintained after 5 years and compared the outcomes of surgery and non-surgical treatment. Patients and methods - 97 patients were included in the previously reported randomized study of patients on a waiting list for surgery. These patients were randomized to specific or unspecific exercises. After 3 months of exercises the patients were asked if they still wanted surgery and this was also assessed at the present 5-year follow-up. The 1-year assessment included Constant-Murley score, DASH, VAS at night, rest and activity, EQ-5D, and EQ-VAS. All these outcome assessments were repeated after 5 years in 91 of the patients. Results - At the 5-year follow-up more patients in the specific exercise group had declined surgery, 33 of 47 as compared with 16 of 44 (p = 0.001) in the unspecific exercise group. The mean Constant-Murley score continued to improve between the 1- and 5-year follow-ups in both surgically and non-surgically treated groups. On a group level there was no clinically relevant change between 1 and 5 years in any of the other outcome measures regardless of treatment. Interpretation - This 5-year follow-up of a previously published randomized controlled trial found that specific exercises reduced the need for surgery in patients with subacromial pain. Patients not responding to specific exercises may achieve similar good results with surgery. These findings emphasize that a specific exercise program may serve as a selection tool for surgery.

Non-union in 3 of 15 osteotomies of the distal radius without bone graft.

BACKGROUND AND PURPOSE: Open-wedge osteotomies of the distal radius create a void that is usually filled with either iliac crest bone graft or bone substitute. Previous studies have suggested that this is unnecessary. We investigated the safety of omitting the filling procedure. PATIENTS AND METHODS: We included 15 patients with a dorsal malunion of a distal radius fracture. A palmar approach and angle-stable plates were used. The patients were followed until there was radiographic and clinical healing. RESULTS: Non-union occurred in 3 of the 15 patients. The study, which had been planned to include 25 patients, was then discontinued. 6 osteotomies created a trapezoid void (no cortical contact); 3 of these did not unite after the index procedure (p = 0.04), but did subsequently, after autogenous bone grafting. A trapezoid void was significantly associated with non-union (p = 0.04). INTERPRETATION: When a trapezoid defect is created, one should consider bone substitute or autogenous bone graft. This has been shown to be safe in other studies.

Effect of specific exercise strategy on need for surgery in patients with subacromial impingement syndrome: randomised controlled study.

STUDY QUESTION: Can a specific exercise strategy improve shoulder function and pain in patients with subacromial impingement syndrome, thereby decreasing the need for arthroscopic subacromial decompression? SUMMARY ANSWER: Compared with a control exercise group, patients in the specific exercise group had significantly greater improvements in shoulder function and pain and fewer patients needed surgery at the three month assessment. WHAT IS KNOWN AND WHAT THIS PAPER ADDS: Different exercise programmes are used as first line treatment in patients with subacromial impingement syndrome, but conclusive evidence to support the efficacy for these programmes is lacking. This specific exercise strategy proved effective in improving shoulder function and pain in patients in whom earlier conservative treatment had failed.