The August 2023 Shoulder & Elbow Roundup360 looks at: Motor control or strengthening exercises for rotator cuff-related shoulder pain? A multi-arm randomized controlled trial; Does the choice of antibiotic prophylaxis influence reoperation rate in primary shoulder arthroplasty?; Common shoulder injuries in sport: grading the evidence; The use of medial support screw was associated with axillary nerve injury after plate fixation of proximal humeral fracture using a minimally invasive deltoid-splitting approach; MRI predicts outcomes of conservative treatment in patients with lateral epicondylitis; Association between surgeon volume and patient outcomes after elective shoulder arthroplasty; Arthroscopic decompression of calcific tendinitis without cuff repair; Functional outcome after nonoperative management of minimally displaced greater tuberosity fractures and predictors of poorer patient experience.

Aims

The aim of this study was to analyze how proximal radial neck resorption (PRNR) starts and progresses radiologically in two types of press-fit radial head arthroplasties (RHAs), and to investigate its clinical relevance.

Aims. The outcomes following nonoperative management of minimally displaced greater tuberosity (GT) fractures, and the factors which influence patient experience, remain poorly defined. We assessed the early patient-derived outcomes following these injuries and examined the effect of a range of demographic- and injury-related variables on these outcomes. Methods. In total, 101 patients (53 female, 48 male) with a mean age of 50.9 years (19 to 76) with minimally displaced GT fractures were recruited to a prospective observational cohort study. During the first year after injury, patients underwent experiential assessment using the Disabilities of the Arm, Shoulder and Hand (DASH) score and assessment of associated injuries using MRI performed within two weeks of injury. The primary outcome was the one-year DASH score. Multivariate analysis was used to assess the effect of patient demographic factors, complications, and associated injuries, on outcome. Results. The mean DASH score improved from 42.3 (SD 9.6) at six weeks post-injury, to 19.5 (SD 14.3) at one-year follow-up (p < 0.001), but outcomes were mixed, with 30 patients having a DASH score > 30 at one year. MRI revealed a range of associated injuries, with a full-thickness rotator cuff tear present in 19 patients (19%). Overall, 11 patients (11%) developed complications requiring further operative intervention; 20 patients (21%) developed post-traumatic secondary shoulder stiffness. Multivariate analysis revealed a high-energy mechanism (p = 0.009), tobacco consumption (p = 0.033), use of mobility aids (p = 0.047), a full-thickness rotator cuff tear (p = 0.002), and the development of post-traumatic secondary shoulder stiffness (p = 0.035) were independent predictors of poorer outcome. Conclusion. The results of nonoperative management of minimally displaced GT fractures are heterogeneous. While many patients have satisfactory early outcomes, a substantial subgroup fare much worse. There is a high prevalence of rotator cuff injuries and post-traumatic shoulder stiffness, and their presence is associated with poorer patient experience. Furthermore, patients who have a high-energy injury, smoke, or use walking aids, have worse outcomes. Cite this article: Bone Joint J 2023;105-B(5):534–542

This annotation reviews current concepts on the three most common surgical approaches used for proximal interphalangeal joint arthroplasty: dorsal, volar, and lateral. Advantages and disadvantages of each are highlighted, and the outcomes are discussed.

Cite this article: Bone Joint J 2022;104-B(12):1329–1333.

Aims. The aim of this study was to develop and internally validate a prognostic nomogram to predict the probability of gaining a functional range of motion (ROM ≥ 120°) after open arthrolysis of the elbow in patients with post-traumatic stiffness of the elbow. Methods. We developed the Shanghai Prediction Model for Elbow Stiffness Surgical Outcome (SPESSO) based on a dataset of 551 patients who underwent open arthrolysis of the elbow in four institutions. Demographic and clinical characteristics were collected from medical records. The least absolute shrinkage and selection operator regression model was used to optimize the selection of relevant features. Multivariable logistic regression analysis was used to build the SPESSO. Its prediction performance was evaluated using the concordance index (C-index) and a calibration graph. Internal validation was conducted using bootstrapping validation. Results. BMI, the duration of stiffness, the preoperative ROM, the preoperative intensity of pain, and grade of post-traumatic osteoarthritis of the elbow were identified as predictors of outcome and incorporated to construct the nomogram. SPESSO displayed good discrimination with a C-index of 0.73 (95% confidence interval 0.64 to 0.81). A high C-index value of 0.70 could still be reached in the interval validation. The calibration graph showed good agreement between the nomogram prediction and the outcome. Conclusion. The newly developed SPESSO is a valid and convenient model which can be used to predict the outcome of open arthrolysis of the elbow. It could assist clinicians in counselling patients regarding the choice and expectations of treatment. Cite this article: Bone Joint J 2022;104-B(4):486–494

Post-traumatic elbow stiffness is a disabling condition that remains challenging for upper limb surgeons. Open elbow arthrolysis is commonly used for the treatment of stiff elbow when conservative therapy has failed. Multiple questions commonly arise from surgeons who deal with this disease. These include whether the patient has post-traumatic stiff elbow, how to evaluate the problem, when surgery is appropriate, how to perform an excellent arthrolysis, what the optimal postoperative rehabilitation is, and how to prevent or reduce the incidence of complications. Following these questions, this review provides an update and overview of post-traumatic elbow stiffness with respect to the diagnosis, preoperative evaluation, arthrolysis strategies, postoperative rehabilitation, and prevention of complications, aiming to provide a complete diagnosis and treatment path. Cite this article: Bone Joint Open 2020;1-9:576–584

The August 2015 Shoulder & Elbow Roundup³⁶⁰ looks at: Clavicular fractures are being fixed – but how?; Propionibacterium acnes: a pain in the shoulder?; Bacteria, armpits and arthroplasty; Living longer, but unhappy: the woes of shoulder arthroplasty in the under 50s; Recurrent dislocations in the adolescent population; Splinting for elbow stiffness; Revision Bankart repair

Aim:. To investigate the clinical outcomes of elbows with post-traumatic stiffness treated by open surgical release. Methods:. A retrospective review was completed on thirty-five consecutively managed patients who underwent an open elbow release for post-traumatic stiffness between 2007 and 2012. Pre-operative and post-operative range of motion (ROM), pain scores and functional outcomes were recorded. Results:. Mean follow-up was 31 months (6–84). The cohort consisted of 20 male and 15 female patients with an average age at time of surgery of 34 years (17–59). The interval from injury to time of release was 26 months (6–180). An improvement in mean ROM from 49° (0°–105°) to 102° (55°–150°) was obtained. The improvement in ROM in patients with pre-operative heterotopic bone was 61° compared to 45° in patients without heterotopic bone. The mean Mayo Elbow Performance Score improved from 44 pre-operatively to 82 at most recent follow-up. Mean VAS scores improved from 5.9 pre-operatively to 2.8 at most recent follow-up. Patients rated the affected elbow a mean of 73% as compared to the contralateral/normal side (50–100%). Apart from a 10% incidence of transient ulnar nerve neurapraxia in patients who had a medial or combined approach, complication rates and functional outcomes were comparable between medial, lateral and combined approaches. Conclusion:. Open release for post-traumatic elbow stiffness results in satisfactory functional outcomes in the majority of cases, with no significant differences between medial, lateral or combined approaches

The August 2014 Shoulder & Elbow Roundup. 360 . looks at: Myofibroblasts perhaps not implicated in post-traumatic elbow stiffness; olecranon tip biomechanically sound for coranoid reconstruction; obesity and elbow replacement don’t mix; single column plating successful for extra-articular distal humeral fractures; satisfaction not predictable in frozen shoulder; tenodesis and repair both acceptable in Grade II SLAP tears; glenoid bone grafting is effective and glenohumeral articular lesions best seen with an arthroscope

The April 2014 Shoulder & Elbow Roundup³⁶⁰ looks at: arthroscopic capsular release successful after six months; MCIC in cuff surgery; analgesia following arthroscopic cuff repair; platelet-rich fibrin; and cuff tear and suprascapular nerve neuropathy?

There is little published information on the health impact of frozen shoulder. The purpose of this study was to assess the functional and health-related quality of life outcomes following arthroscopic capsular release (ACR) for contracture of the shoulder. Between January 2010 and January 2012 all patients who had failed non-operative treatment including anti-inflammatory medication, physiotherapy and glenohumeral joint injections for contracture of the shoulder and who subsequently underwent an ACR were enrolled in the study. A total of 100 patients were eligible; 68 underwent ACR alone and 32 had ACR with a subacromial decompression (ASD). ACR resulted in a highly significant improvement in the range of movement and functional outcome, as measured by the Oxford shoulder score and EuroQol EQ-5D index. The mean cost of a quality-adjusted life year (QALY) for an ACR and ACR with an ASD was £2563 and £3189, respectively.

ACR is thus a cost-effective procedure that can restore relatively normal function and health-related quality of life in most patients with a contracture of the shoulder within six months after surgery; and the beneficial effects are not related to the duration of the presenting symptoms.

Cite this article: Bone Joint J 2013;95-B:942–6.

The causes of a stiff elbow are numerous including: post-traumatic elbow, burns, head injury, osteoarthritis, inflammatory joint disease and congenital. Types of stiffness include: loss of elbow flexion, loss of elbow extension and loss of forearm rotation. All three have different prognoses in terms of the timing of surgery and the likelihood of restoration of function. Contractures can be classified into extrinsic and intrinsic (all intrinsic develop some extrinsic component). Functional impairment can be assessed medicolegally; however, in clinical practice the patient puts an individual value on the arc of motion. Objectively most functions can be undertaken with an arc of 30 to 130 degrees. The commonest cause of a Post-traumatic Stiff elbow is a radial head fracture or a complex fracture dislocation. Risk factors for stiffness include length of immobilisation, associated fracture with dislocation, intra-articular derangement, delayed surgical treatment, associated head injury, heterotopic ossification. Early restoration of bony columns and joint stability to allow early mobilisation reduces incidence of joint stiffness. Heterotopic ossification (HO) is common in fracture dislocation of the elbow. Neural Axis trauma alone causes HO in elbows in 5%. However, combined neural trauma and elbow trauma the incidence is 89%. Stiffness due to thermal injury is usually related to the degree rather than the site. The majority of patients have greater than 20% total body area involved. Extrinsic contractures are usually managed with a sequential release of soft tissues commencing with a capsular excision (retaining LCL/MCL), posterior bundle of the MCL +/− ulna nerve decompression (if there is loss of flexion to 100 degrees). This reliably achieved via a posterior incision, a lateral column exposure +/− ulna nerve mobilisation. A medial column exposure is a viable alternative. Arthroscopic capsular release although associated with a quicker easier rehabilitation is associated with increased neural injury. Timing of release is specific to the type of contracture, i.e. flexion contractures after approx. six months, extension contractures ASAP but after four months, loss of forearm rotation less 6 to 24 months. The use of Hinged Elbow Fixators is increasing. The indications include reconstructions that require protection whilst allowing early movement, persistent instability or recurrent/late instability or interposition arthroplasty. Post-operative rehabilitation requires good analgesia, joint stability and early movement. The role of CPM is often helpful but still being evaluated

Successful ORIF of proximal humeral fractures requires a careful assessment of the patient factors (age/osteoporosis/functional expectations), accurate identification the fracture segments (head/shaft/tuberosities) and accessory factors which are of vascular and surgical relevance (length of posteromedial metaphyseal head extension, integrity of medial soft tissue hinge, head split segments, tuberosity/head segments impacted to-gether or distracted apart). Fixation of the fracture can be achieved by a number of techniques because of the multiple factors that often apply—numerous techniques are usually required of the surgeon. The principles of fixation require accurate restoration of the head and tuberosity orientation, fixation of the metaphyseal segments (tuberosities) results in a stable circular platform on which the head segment rests. Thus, the fixation of choice acts as a load sharing device not a load bearing device. This fixation is often augmented with tension band and circlage suture fixation. These concepts are especially applicable to the osteoporotic patient. The order of fixation requires that the medial hinge not be disrupted. If it is disrupted in the younger patient it requires fixation first. All tuberosity segments are tagged with ethibond sutures. The head and the largest tuberosity segment are reduced and held with k-wire or canulated scews, avoiding the central medullary canal entry point. If the head tuberosity segment is unstable in relation to the shaft, the fixation implant of choice (plate/intramedullary) is chosen and the head/tuberosity complex is reduced to the shaft. Depending on the fracture segments and the degree of comminution this may require compression of distraction. Post-op the patient is immobilised in external rotation to balance the cuff forces. If very rigid fixation is achieved then early mobilisation is undertaken to minimise the adhesions due to opening of the subdeltoid space. If fixation is tenuous movement is commenced a 3–4 weeks. AVN of the humeral head with good tuberosity head architecure can be salvaged. The diagnosis of AVN is determned at three months with a MRI and consideration given to Zolidronate therapy. Post-traumatic stiffness with good architecture can be salvaged with an arthroscopic capsular release

Aim. Over the last 15 years there has been a series of publications reporting the beneficial effects of elbow arthrolysis, with considerable variation in operative technique and post-operative management. Many advocate the use of passive stretching techniques in the early post-operative period if range of motion fails to improve satisfactorily. The purpose of this study was to assess our results of open elbow arthrolysis in patients who did not receive any passive stretching after discharge from hospital. Methods. Prospectively collected data of 55 patients with a minimum follow-up of 1 year after arthrolysis were analysed. All procedures were performed by the same surgeon (LR), achieving as much improvement in elbow motion as possible at operation. All patients had continuous brachial plexus blocks and continual passive motion for 2-3 days post-operatively but none received any passive stretching after discharge. At review, a senior physiotherapist (BD) formally assessed all the patients. Results. All patients' arc of movement improved from 68 degrees to 104 degrees (flexion 18 degrees/extension 23 degrees). Upper limb function (Disabilities of the Arm, Shoulder and Hand score) improved by 50%. Pain decreased from 20 to 9, measured with a Visual Analogue Score. The greatest improvement in motion was obtained in the stiffest elbows - 7 patients with an arc of 30 degrees or less pre-operatively achieved an arc of 100 degrees by the time of the last review. Conclusions. Good results of open arthrolysis for post-traumatic elbow stiffness can be achieved with continuous brachial plexus blocks and continual passive motion for 2-3 days post-operatively. There appears to be little evidence to support treatment with passive stretching techniques after discharge from hospital, as our results are similar to other reported series

Aim: To assess the functional and occupational outcome of open elbow arthrolysis for post-traumatic contractures. Materials and Methods: Prospective evaluation of 60 consecutive cases (86% male,14%female) of post-traumatic extrinsic elbow stiffness. Average age was 37 years (24–48). Moderate to high physical demand at work in 96% of cases. 56% of cases involved the right side. Open arthrolysis (column procedure) trough a lateral (72%) or posterior (28%) approach followed a minimum rehabilitation period of 6 months post original injury. In 8 cases, an anterior transposition of the ulnar nerve was required. Patients received postoperative analgesia with Bupivacaine 0,0125% trough an indwelling catheter. No chemical or radiotherapy ectopic calcification prophylaxis was used. Postoperative complications, range of motion, X-ray evaluation, time to return to work, activity level and workers’ compensation were evaluated at the end of follow-up (24 months, range 12–36). Results: Complications occurred in 14% of cases. Two patients required revision surgery for ectopic calcifications restricting prono-supination. The flexo-extension (FE) arc of motion improved from 49 ° to 115 ° and that of prono-supination (PS) from 100 ° to 158 ° The results were found to be statistically significant for FE (p= 0.054) and PS (p> 0,00001). In 20% of cases, patients returned to their previous job with some restrictions (33% disability) and 12% changed to a less physically demanding occupation. Conclusions: Open arthrolysis is an effective surgical procedure to improve mobility in post-traumatic stiff elbows. It is indicated when the joint interline is preserved. Good functional and occupational outcome in a high percentage of case in the working population was observed

Fractures and nonunions of the proximal humerus are increasingly treated by open reduction and internal fixation. The extended deltopectoral approach remains the most widely used for this purpose. However, it provides only limited exposure of the lateral and posterior aspects of the proximal humerus. We have previously described the alternative extended deltoid-splitting approach. In this paper we outline variations and extensions of this technique that we have developed in the management of further patients with these fractures.