Risk Factors for Dysfunctional Elbow Stiffness following Operative Fixation of Distal Humerus Fractures.

BACKGROUND: Elbow stiffness is one of the most common complications after operative fixation of distal humerus fractures; however, there is relatively limited literature assessing which factors are associated with this problem. The purpose of this study is to identify risk factors associated with dysfunctional elbow stiffness in distal humerus fractures after operative fixation. METHODS: A retrospective review of all distal humerus fractures that underwent operative fixation (AO/OTA 13A-C) at a single level 1 trauma center from November 2014 to October 2021. A minimum six-month follow-up was required for inclusion or the outcome of interest. Dysfunctional elbow stiffness was defined as a flexion-extension arc of less than 100° at latest follow-up or any patient requiring surgical treatment for limited elbow range of motion. RESULTS: A total of 110 patients with distal humerus fractures were included in the study: 54 patients comprised the elbow stiffness group and 56 patients were in the control group. Average follow-up of 343 (59 to 2,079) days. Multiple logistic regression showed that orthogonal plate configuration (aOR: 5.70, 95% CI: 1.91-16.99, p=0.002), and longer operative time (aOR: 1.86, 95% CI: 1.11-3.10, p=0.017) were independently associated with an increased odds of elbow stiffness. OTA/AO 13A type fractures were significantly associated with a decreased odds of stiffness (aOR: 0.16, 95% CI: 0.03-0.80, p=0.026). Among 13C fractures, olecranon osteotomy (aOR: 5.48, 95% CI: 1.08-27.73, p=0.040) was also associated with an increased odds of elbow stiffness. There were no significant differences in injury mechanism, Gustilo-Anderson classification, reduction quality, days to surgery from admission, type of fixation, as well as rates of ipsilateral upper extremity fracture, neurovascular injury, nonunion, or infection between the two groups. CONCLUSION: Dysfunctional elbow stiffness was observed in 49.1% of patients who underwent operative fixation of distal humerus fractures in the present study. Orthogonal plate configuration, olecranon osteotomy, and longer operative time were associated with an increased odds of dysfunctional elbow stiffness; however, 13A type fractures were associated with decreased odds of stiffness. Patients with these injuries should be counseled on their risk of stiffness following surgery, and modifiable risk factors like plate positioning and performing an olecranon osteotomy should be considered by surgeons.

Extensor Mechanism Reconstruction for Chronic Patellar Tendon Tears.

OBJECTIVES: Reconstruction for a chronic patellar tendon rupture in a native knee is an uncommon surgical procedure. Although there have been case series investigating patient-reported outcomes, there is no systematic review of these studies to date. The purpose of this review is to synthesize the literature on this procedure to better understand its outcomes, complications, and surgical technique options. METHODS: A systematic review was performed following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines to identify studies that reported outcomes and techniques of patellar tendon reconstruction for chronic disruption in native knees. Searches were conducted through MEDLINE using PubMed, Cochrane Database of Systematic Reviews, and clinicaltrials.gov. RESULTS: Ten studies with 103 patients and 105 knees were included. Results for nonnative (arthroplasty) knees were excluded. The mean patient age was 40.3 years, and the mean postsurgical follow-up time was 53.8 months. Of the 105 knees, 75% received a hamstring tendon graft, whereas 13% received a bone-tendon-bone graft and 7% received a whole extensor mechanism allograft. The mean preoperative range of motion was 113.8°, which improved to 126.0° postoperatively. The mean preoperative Lysholm score was 58.6, which improved to 86.0 postoperatively; 100% of patients returned to their normal work activities and 76% returned to their prior level of physical activity. There were no major complications reported in any of the included studies. CONCLUSIONS: Chronic patellar tendon disruption in a native knee is an uncommon injury that can result in significant limitations for patients. Although more research is needed to better elucidate which graft is best, outcomes after patellar tendon reconstruction for chronic tears appear to be satisfactory with current techniques.

Is outpatient shoulder arthroplasty safe? A systematic review and meta-analysis.

BACKGROUND: Amid rising health care costs and recent advances in surgical and anesthetic protocols, the rate of outpatient joint arthroplasty has risen steadily in recent years. Although the safety of outpatient total knee arthroplasty and total hip arthroplasty has been well established, outpatient shoulder arthroplasty is still in its infancy. The purpose of this study was to synthesize the current literature and provide further data regarding the outcomes and safety of outpatient shoulder arthroplasty. METHODS: A systematic review was conducted following the standard PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Included were studies that evaluated the outcomes of patients undergoing outpatient total shoulder arthroplasty (TSA) or reverse TSA. Meta-analysis was conducted using Mantel-Haenszel statistics to generate odds ratios (ORs) and their corresponding 95% confidence intervals (CIs) comparing outpatient and inpatient shoulder arthroplasty. RESULTS: Twelve studies were included, with a total of 194,513 patients, of whom 7162 were outpatients. Of the studies, 8 were level III and 4 were level IV. The average age of the outpatients was 66.6 years, and the average age of the inpatients was 70.1 years. The overall OR for complications was significantly lower in outpatients (OR, 0.40; 95% CI, 0.35-0.45) than in inpatients. There was no significant difference in rates of 90-day readmission (OR, 0.88; 95% CI, 0.75-1.03), revision (OR, 0.96; 95% CI, 0.65-1.41), and infection (OR, 0.93; 95% CI, 0.64-1.35) when comparing outpatients with inpatients. CONCLUSION: Outpatient TSA, in an appropriately selected patient population, is safe and results in comparable patient outcomes to those of inpatient shoulder arthroplasty. Given the expected increase in the number of patients requiring TSA, surgeons, hospital administrators, and insurance carriers should strongly consider the merits of a cost- and care-efficient approach to total shoulder replacement.

Corticosteroid Injections May Increase Retear and Revision Rates of Rotator Cuff Repair: A Systematic Review.

PURPOSE: To synthesize the clinical outcome data of preoperative and postoperative corticosteroid injections (CIs) and their effect on rotator cuff repairs (RCRs). METHODS: A systematic review was performed to identify studies that reported the results or clinical outcomes of RCRs in patients receiving either preoperative or postoperative CIs. The searches were performed using MEDLINE, Google Scholar, and Embase, and studies were chosen following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines. RESULTS: A total of 11 studies were included with data for 176,352 shoulders: 6 studies involving 175,256 shoulders with data regarding preoperative CIs, 4 studies involving 1,096 shoulders with data regarding postoperative CIs, and 1 study with 212 shoulders containing preoperative and postoperative data. Preoperative CIs were found in 3 studies to increase the risk of revision surgery when administered within 6 months (odds ratio [OR], 1.38-1.82) and up to 1 year (OR, 1.12-1.52) prior to RCR, with revision rates in 2 studies being highest when patients received 2 or more injections (OR, 2.12-3.26) in the prior year. Postoperative CIs reduced pain and improved functional outcomes in 5 studies without increasing the retear rates (5.7%-19% for CI and 14%-18.4% for control) in most studies. CONCLUSIONS: CIs provide benefit by relieving pain and improving functional outcome scores. However, repeated preoperative CIs may increase retear rates and the likelihood of revision surgery. A lower frequency of CI and longer preoperative waiting period after CI should be considered to decrease such risks. Postoperative CIs several weeks after RCR do not appear to increase retear rates. LEVEL OF EVIDENCE: Level IV, systematic review of Level I through IV studies.

Pediatric fractures following implant removal: A systematic review.

Objectives: To evaluate the available literature for postoperative fracture rates following implant removal in the pediatric population. Methods: A systematic review of articles in the PubMed and Embase computerized literature databases from January 2000 to June 2022 was performed using PRISMA guidelines. Randomized controlled trials, case-control studies, cohort studies (retrospective and prospective), and case series involving pediatric patients that included data on fracture rate following removal of orthopedic implants were eligible for review. Two authors independently extracted data from selected studies for predefined data fields for implant type, anatomic location of the implant, indication for implantation, fracture or refracture rate following implant removal, mean time to implant removal, and mean follow-up time. Results: Fifteen studies were included for qualitative synthesis. Reported fracture rates following implant removal vary based on several factors, with an overall reported incidence of 0%-14.9%. The available literature did not offer sufficient data for conduction of a meta-analysis. Conclusion: Our systematic review demonstrates that fracture following implant removal in pediatric patients is a relatively frequent complication. In children, the forearm and femur are the most commonly reported sites of fracture following removal of implants. Traumatic fractures treated definitively with external fixation have the highest reported aggregate rate of refracture. Knowledge of the incidence of this risk is important for orthopedic surgeons. There remains a need for well-designed studies and trials to further clarify the roles of the variables that contribute to this complication.