Scandinavian Olecranon Research in the Elderly (SCORE): protocol for a non-inferiority, randomised, controlled, multicentre trial comparing operative and conservative treatment of olecranon fractures in the elderly.

INTRODUCTION: The incidence of olecranon fractures is growing in the elderly population. The traditional operative approach is giving way among the elderly to conservative treatment, which seems to provide a comparable functional outcome with a lower complication burden. However, there is still a lack of reliable evidence to support this shift.The objective of this trial is to investigate whether conservative treatment of displaced olecranon fractures in patients aged 75 or older yields comparable results to those of operative treatment in terms of pain and daily function. METHODS AND ANALYSIS: Scandinavian Olecranon Research in the Elderly (SCORE) is a randomised, controlled, multicentre, non-inferiority trial. Eligible patients will be randomised to either conservative or operative treatment. The sample size will be 68 patients and allocation done at a 1:1 ratio (34 patients per group). The randomisation is stratified according to the participating hospital and patient's sex. Both groups will receive the same postoperative physiotherapy and pain management. The primary outcome is Disabilities of the Arm, Shoulder and Hand at 1-year follow-up. Secondary outcomes are pain and satisfaction measured on visual analogue scales, Patient Reported Elbow Evaluation, range of motion of the elbow and extension strength of the elbow compared with the unaffected arm. Radiographs will be taken at each follow-up. Primary analysis of the results will be conducted on an intention-to-treat basis. ETHICS AND DISSEMINATION: The study protocol for this clinical trial has been approved by the Ethics Committee of the Hospital District of Southwest Finland and will be submitted for approval to the Regional Ethics Committees in Linköping, Sweden and Copenhagen, Denmark. Every recruiting centre will apply local research approvals. The results of this study will be submitted for publication in peer-reviewed journals. TRIAL REGISTRATION NUMBER: NCT04401462. PROTOCOL VERSION: This is the second protocol version dated on 16 April 2020.

Hemiarthroplasty for irreparable distal humeral fractures: medium-term follow-up of 42 patients.

We report our experience of performing an elbow hemiarthroplasty in the treatment of comminuted distal humeral fractures in the elderly patients. A cohort of 42 patients (three men and 39 women, mean age 72; 56 to 84) were reviewed at a mean of 34.3 months (24 to 61) after surgery. Functional outcome was measured with the Mayo Elbow Performance Score (MEPS) and range of movement. The disabilities of the arm, shoulder and hand questionnaire (DASH) was used as a patient rated evaluation. Complications and ulnar nerve function were recorded. Plain radiographs were obtained to assess prosthetic loosening, olecranon wear and heterotopic bone formation. The mean extension deficit was 23.5° (0° to 60°) and mean flexion was 126.8° (90° to 145°) giving a mean arc of 105.5° (60° to 145°). The mean MEPS was 90 (50 to 100) and a mean DASH score of 20 (0 to 63). Four patients had additional surgery for limited range of movement and one for partial instability. One elbow was revised due to loosening, two patients had sensory ulnar nerve symptoms, and radiographic signs of mild olecranon wear was noted in five patients. Elbow hemiarthroplasty for comminuted intra-articular distal humeral fractures produces reliable medium-term results with functional outcome and complication rates, comparable with open reduction and internal fixation and total elbow arthroplasty.

Radioulnar laxity and clinical outcome do not correlate after a distal radius fracture.

Injury to the triangular fibrocartilage complex associated with distal radius fracture may cause symptoms of ulnar instability. Assessed by a radioulnar stress test, increased laxity of the distal radioulnar joint has in two previous studies been depicted to be associated with poorer outcome. This prospective study of 40 adults investigates the correlation of this test with functional outcome as measured by DASH. No clinically significant difference was found in relation to this test at two and five years after injury. Therefore using this test alone to decide whether or not to perform an acute repair of the TFCC cannot be recommended.

Radioulnar ratio in detection of distal radioulnar joint instability associated with acute distal radius fractures.

Lesions of the triangular fibrocartilage complex (TFCC) are commonly associated with distal radius fractures and may adversely affect the functional outcome. This prospective study evaluated computed tomography, using the radioulnar ratio (RUR), to detect laxity of the distal radioulnar joint in 48 consecutive patients with acute distal radius fractures and compared the results with a radioulnar stress test. We found the clinical stress test to be reliable in chronic cases, but the RUR method of questionable value in both acute and chronic cases.

Conservative treatment of the cubital tunnel syndrome.

Conservative treatment of the cubital tunnel syndrome was evaluated in a randomised study of 70 patients with mild or moderate symptoms (Dellon, 1989). All patients were informed about the cause of symptoms and allocated to three groups: night splinting, nerve gliding and control. Evaluation consisted of Canadian Occupational Performance Measure, visual analogue pain scales, strength measurements and neurophysiological examination, before treatment and after six months. Fifty-seven patients were followed for six months. Fifty-one (89.5%) were improved at the follow-up. There were no significant differences between the groups in any of the recorded variables. Night splints and nerve gliding exercises did not add favourably. Routine neurophysiological examination seems unnecessary since 76% of the patients with typical symptoms had normal findings and 75% with pathological findings improved. Patients with mild or moderate symptoms have a good prognosis if they are informed of the causes of the condition and how to avoid provocation.

Arthroscopic findings in wrists with severe post-traumatic pain despite normal standard radiographs.

This study assessed the role of diagnostic arthroscopy following a wrist injury in patients with normal standard radiographs, an unclear clinical diagnosis and persistent severe pain at 4 to 12 weeks. Forty-three patients were included after conservative management had failed to improve their wrist pain so that a stability test could be performed satisfactorily and underwent arthroscopy within 12 weeks. Arthroscopy revealed recent pathology in 41 wrists, of which 17 had significant ligament lesions that might have benefited from acute repair. We conclude that patients with marked persistent post-traumatic symptoms despite conservative management are likely to have sustained ligament injuries despite normal radiographs. We therefore recommend that under these circumstances an arthroscopy is carried out within 4 weeks if the patient and surgeon wish to acutely repair significant ligament injuries.

Radial nerve entrapment in the upper arm as a cause of lateral arm pain: a report of four cases.

Four patients with no history of trauma presented with lateral arm pain, local tenderness, and a tingling sensation at the distal end of the arm when the radial nerve was percussed in the mid-third of the upper arm (Tinel's sign), but no clinical or subjective signs of muscular weakness. They were treated by decompression of the radial nerve in the fibrous canal proximal to the lateral intermuscular septum. Three of the patients had a complete or pronounced reduction in pain, while the fourth had only a slight improvement. Non-traumatic radial nerve entrapment in the upper arm may be the cause of lateral arm pain without clinical signs of muscular weakness.

Acutrak screw fixation versus cast immobilisation for undisplaced scaphoid waist fractures.

Fifty-three patients with less than 14 day-old, undisplaced fractures of the waist of the scaphoid were randomized to two groups. Twenty-eight patients were treated by immobilisation in a below elbow plaster cast for 10 weeks while 25 were treated by percutaneous insertion of an Acutrak standard screw. There were no statistically significant differences between the two treatment groups with regard to either the rate of union or the time to union. Patients who underwent surgery had a significantly better range of motion at 16 weeks but there were no significant differences for grip strength. Acute percutaneous internal fixation of undisplaced scaphoid waist fractures using the Acutrak screw allows early mobilisation without adverse effects on fracture healing.

Different effect on axonal outgrowth of application of non-absorbable or absorbable tubes around a nerve repair.

We studied regeneration distance of rat sciatic nerve, with the sensory pinch reflex test and immunocytochemical staining for neurofilaments, four to 21 days after transsection, repair, and enclosure of the repair site in either a non-absorbable silicone tube or an absorbable polyglycolic acid (PGA) tube. The size of both tube-types was carefully selected so that they did not compress the repaired nerve. The opposite nerve was repaired and not inserted in a tube (control). The regeneration distances in repaired nerves enclosed in silicone tube were significantly longer than the control side at all time points, a result not seen when PGA tube was used. The number of proliferating non-neuronal cells (incorporation of 5-bromodeoxyuridine (BrdU)) was studied just proximal to the site of nerve repair after six days. Numerous stained cells were seen, but there where no significant differences between the groups. We conclude that outgrowth of sensory axons after transsection and repair of rat sciatic nerve with sutures can be increased by enclosing the site of repair in a silicone tube but not in a PGA tube. The effect is probably not related to the number of proliferative non-neuronal cells.

Non-operative treatment regime including eccentric training for lateral humeral epicondylalgia.

In a pilot study 38 patients with lateral humeral epicondylalgia were randomly allocated to two treatment groups. Group S (stretching) was treated with a contract-relax-stretching program while group E (eccentric exercise) underwent an eccentric exercise program. Both groups also received forearm bands and wrist support nightly. The programs were carried out daily at home during 12 weeks. Evaluation before and 3, 6 and 12 months after treatment, included subjective assessment of symptoms using visual analogue scales and grip strength measurements. Thirty-five patients were available for follow-up. Five patients, three in group S and two in group E, did not complete the programs due to increased pain while 30 (86%) reported complete recovery or improvement. Reduced pain and increased grip strength were seen in both treatment groups but 12 out of 17 patients (71%) in group E rated themselves as completely recovered as compared to 7 out of 18 (39%) in group S (P=0.09), and in group E the increase in grip strength after 6 months was statistically significantly larger than in group S. In a second study the eccentric training regime was used in a consecutive series of 129 patients with lateral epicondylalgia. The patients were divided into two groups with one group consisting of patients with less than one year duration of symptoms and the other comprised patients with a duration of symptoms for more than one year. The results of treatment were evaluated in the same way as in the pilot study, and also after 3.4 years using the scoring system by Verhaar et al. At the end of the treatment period statistically significant improvements were seen in all VAS recordings and in grip strength. After 3.4 years 38% had excellent, 28% good, 25% fair and 9% poor results according to the score. In the self-rated outcome 54% regarded themselves as completely recovered, 43% improved, 2% unchanged and 2% worse. No significant differences were seen between patients with a duration of symptoms for more than one year compared to patients with symptoms for less than one year. The eccentric training regime can considerably reduce symptoms in a majority of patients with lateral humeral epicondylalgia, regardless of duration, and is possibly superior to conventional stretching.

Arthroscopic removal of os centrale carpi causing wrist pain.

The os centrale carpi is a relatively rare accessory carpal bone of the wrist that infrequently has been reported to cause symptoms. This report describes 2 cases where an apparently mobile os centrale carpi caused painful clicking and crepitus and where the symptoms disappeared after arthroscopic removal of the ossicles.

Complete transection of the median and radial nerves during arthroscopic release of post-traumatic elbow contracture.

Arthroscopic debridement and capsular release was performed in a 57-year-old woman because of post-traumatic stiffness in the dominant right elbow joint. During this procedure, the median and radial nerves were completely transected. A few recent reports of small series have described encouraging results after arthroscopic capsular release of post-traumatic elbow contracture, but the present case demonstrates the inherent risk of damage to neurovascular structures.

Attitudes toward management of patients with subacromial pain in Swedish primary care.

OBJECTIVE: We aimed to describe the attitudes among GPs and physiotherapists toward the diagnostic approach and management of patients with a common shoulder disorder. METHOD: A questionnaire was sent out to 188 GPs and 71 physiotherapists. The total response rate was 71.8%. The questions were based on a written case simulation with cues about history and symptoms. RESULTS: The results showed a unanimous opinion of the diagnosis. Rotator cuff tendinitis was marked as the most probable. The two groups showed similarities in the way that they would examine the patient. The GPs referred the patients to the physiotherapists significantly more often than the other way around. The most probable choice of treatment made by the GPs was non-steroidal anti-inflammatory drugs (NSAIDs) and by the physiotherapists, movement exercises together with ergonomics. Most treatment alternatives had at least 20% of the responders marking a neutral attitude, and few treatments were disregarded. CONCLUSIONS: We conclude that in Swedish primary care GPs and physiotherapists have a uniform diagnostic approach towards patients with subacromial pain, but their choice of treatment reflects an uncertainty about the effectiveness of conservative treatments. The questioned pathogenesis of the suggested diagnosis and lack of research regarding the efficacy of conservative treatments could explain this uncertainty.

4.5 year follow-up after surgical correction of upper extremity deformities in spastic cerebral palsy.

Reconstructive surgery was carried out on 27 upper extremities in 24 children with deformities due to spastic cerebral palsy. Functional evaluation of the affected extremities was made preoperatively, at 6 months and at a mean of 4.5 years postoperatively using a score added to the assessment system described by the Committee on Spastic Hand Evaluation. According to the score, dysfunction of the arm was significantly reduced 6 months after the reconstructive surgery and the improvements remained essentially unchanged at the later follow-up. The addition of a score to the original assessment system facilitated the overall assessment of postoperative results.

Arthroscopically-assisted reduction of intra-articular fractures of the distal radius.

Twenty-seven patients with intraarticular fractures of the distal radius with a step of more than 1 mm in the joint surface after attempted closed reduction, were treated by reduction under arthroscopic control and percutaneous fixation. All fractures healed without measurable incongruity of the joint surface and at follow-up 3 to 38 months after surgery 19 patients had excellent and eight patients good results according to the Mayo modified wrist score.

Touch allodynia following endoscopic (single portal) or open decompression for carpal tunnel syndrome.

We investigated if single-portal endoscopic carpal tunnel decompression equipment (Agee, 3M, USA) would cause increased carpal tunnel pressure during the release and if endoscopic release would reduce postoperative touch allodynia. Measurements on cadavers of the pressure produced during endoscopic release showed similar pressures to those produced during maximal range of motion. One hundred patients underwent either open or endoscopic decompressions. Twenty normal individuals served as controls. At 1 month after surgery both groups had significant allodynia compared with the controls, but at 3 months the endoscopic group had returned to normal though the open group was still significantly abnormal. The reported endoscopic release may therefore be of particular advantage to patients who would seriously be disadvantaged if postoperative touch allodynia should develop. The Agee endoscope is unlikely to cause disturbance of the nerve function due to increased carpal pressure during the release.

Arthroscopic synovectomy of the rheumatoid wrist. A 3.8 year follow-up.

Twenty-four wrists in 19 patients with rheumatoid arthritis affecting the wrist were treated by arthroscopic synovectomy. Range of motion, subjective pain, wrist function and X-ray changes were recorded preoperatively and at an average of 3.8 years after operation. Arthroscopic synovectomy of the rheumatoid wrist reduced pain and improved wrist function in the majority of patients. Progress of arthritic degeneration was significantly less common in patients with no, or very early changes at the time of surgery.

The effects of a shortened postoperative mobilization programme after flexor tendon repair in zone 2.

The effects of a shortened post-operative mobilization programme following flexor tendon repair in zone 2 in the hand were examined in a prospective, randomized study. 91 digits in 82 patients were included in the study. All injured tendons were repaired within 24 hours and all patients were subjected to the same mobilization programme during the first 6 weeks using a passive flexion-active extension régime. After 6 weeks the patients were randomized into two groups; in group A full activity was allowed after 8 weeks while in group B unrestricted use of the injured hand was not allowed until 10 weeks after the tendon repair. Functional results were compared using the Louisville, Tsuge and Buck-Gramcko assessment systems. Grip-strength was measured 16 weeks after repair, subjective assessment of hand function was recorded on a visual analogue scale, and absence from work was registered. No significant differences were observed between the groups regarding functional results, rupture rates, grip strength or subjective assessment, but absence from work was reduced by 2.1 weeks with the shorter mobilization programme. Using the described régime, full activity can be encouraged 8 weeks after flexor tendon repair in zone 2 of the hand without adverse effects on functional results or increased risk of rupture of the repair.