Distal radial fractures: a nationwide register study on corrective osteotomies after malunion.

The aim of the present study was to explore the incidence of corrective osteotomies after conservatively treated distal radial fracture and the risk for late correction depending on the patient's age. Based on data from the Finnish National Care Register of Health Care, Specialist Care, on all corrective osteotomies carried out in Finland during 2015-2019 in adults aged ≥20 years, we calculated the mean annual incidence rates per 100,000 person-years, standardized with the European Standard Population 2013. Using multivariable logistic regression, we calculated the risk of corrective osteotomies in various age groups. In total, 41,418 distal radial fractures were identified. Of those, 10,577 received surgical treatment in the acute phase. The incidence rate of primary operations for distal radial fractures was 47.9 per 100, 000 person-years. A total of 321 conservatively treated fractures needed corrective osteoteomy, with a surprisingly low mean annual incidence rate of 1.5 per 100,000 person-years. The risk for this was highest in patients in their fourth or fifth decade.Level of evidence: III.

Orchestra Musicians' Work Environment and Health Versus General Workforce.

OBJECTIVE: Our cross-sectional epidemiological study compared the work-environment harms and job uncertainties of orchestral musicians to those of the general population and their impact on health, work, and quality of life. METHODS: Musicians of all the Finnish domestic symphony orchestras and a population sample from the Finnish work force completed questionnaires, each group answering the same questions on their work environment and on health, ability to work, and quality of life. RESULTS: Noise disturbed the musicians 8 and poor lighting 22 times as often as these problems disturbed the controls. Musicians experienced mental violence or bullying considerably more often than did controls, with an odds ratio (95% confidence interval) of 3.0 (2.0-4.7). CONCLUSIONS: Noise issues and poor lighting are well-known problems for orchestra musicians, but mental violence or bullying are less well known. Research should focus on such areas.

Epidemiology and Treatment of Distal Radius Fractures in Finland-A Nationwide Register Study.

A distal radius fracture (DRF) is one of the most common fractures in emergency units, the treatment of which requires considerable health care resources. We analyzed the incidence rate for DRFs and the incidence rate of operative treatment over a five-year period, 2015-2019, for the entire population of Finland and all ages. Data was obtained from the Finnish National Care Register for Health Care. The results were counted as cases per 100,000 person/years and standardized with the European Standard Population 2013. The mean annual incidence rate of DRF was 204.90 (203.21-206.59) in specialist care and 69.53 (68.55-70.52) in primary care. It peaked among the pediatric population and among elderly women, in whom it was more than four times as common compared to men of the same age. No increase in the incidence rate of DRFs was found. The mean incidence rate of operative treatment was 45.66 (45.66-45.66)/100,000 person/years, 2015-2019; women were more likely to undergo operative treatment. Altogether, 15-18% of DRFs were operated on over the study period. The annual incidence rate of operations seemed to plateau compared to earlier studies in Finland.

Neurogenic Thoracic Outlet Syndrome with Supraclavicular Release: Long-Term Outcome without Rib Resection.

Our aim was to define clinical long-term outcome of surgery for neurogenic thoracic outlet syndrome without rib resection, and to find factors predicting long-term results. For the 94 patients, the main outcomes were pain, numbness, weakness, and upper-extremity function. The Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) survey, the Cervical-Brachial Symptom Questionnaire (CBSQ), and a numerical rating system served as functional outcome measures. Mean follow-up was 12.9 years. Preoperative pain diminished from 7.8 to 2.2, numbness from 7.4 to 4.0, and weakness from 7.3 to 3.8. Grip strength increased from 25.7 to 31.8 kg. QuickDASH averaged at follow-up 37.1 and CBSQ 51.5. No correlation appeared between smoking and long-term results regarding pain, numbness, weakness, or functioning. Positive TOS provocative tests or intraoperative anatomical findings like consistency of the scaleni muscles showed no correlation with outcome. 82% of female and 57% of male patients reported that aid from this surgery had been excellent or good; 69% reported that surgery helped considerably for at least a mean 9.9 years. The risk for worse self-reported long-term outcome was higher among men, but neither BMI nor age at surgery associated with self-reported outcome. Pain, numbness, and weakness significantly decreased and function improved after supraclavicular release without rib resection. We found no significant preoperative nor per-operative factors predicting long-term results.

Violists and Violinists Report More Intense Hand Pain on NRS Than Other Orchestra Musicians.

AIMS: Among musicians, string players have the highest prevalence for musculoskeletal overuse. Playing a violin or viola requires rapid, repetitive, and complicated movements of the hands and fingers. This cross-sectional study aimed to examine whether violin/viola, violin/cello, and violin/French horn players experience more intense musculoskeletal pain than other instrumentalists. METHODS: The study sample consisted of 590 orchestra musicians (354 male, 236 female, mean age 36 yrs). Self-administered questionnaires were used to assess pain of the back, neck, shoulder, face, jaw, and upper extremity. Pain intensity during the last 7 days was measured by an 11-point numeric rating scale (NRS) with a score from 0 to 10, as well as was disadvantage at work and leisure. RESULTS: Of the interviewed musicians, 20% presented playing-related musculoskeletal disorders at the time of the interview. Compared to other professional orchestra musicians, violin and viola players reported significantly more intense pain in the hand during the last week. Also, they had experienced more frequent neck pain ever and in 5 years than the others. During the past 30 days, violin and viola players had also perceived more harm in their upper limb joints. Violin/cello and violin/French horn players did not differ from the others. CONCLUSIONS: Our study showed that musicians playing the violin or viola have more intense hand pain and more frequent neck pain than other musicians, but these seem to disturb their daily tasks only a little.

Arthroscopic Coracoclavicular Ligament Reconstruction of Chronic Acromioclavicular Dislocations Using Autogenous Semitendinosus Graft: A Two-Year Follow-up Study of 58 Patients.

PURPOSE: To determine the results of operatively treated chronic acromioclavicular (AC) joint dislocations after 2-year follow-up. METHODS: Fifty-eight patients with chronic acromioclavicular separations underwent arthroscopic coracoclavicular ligament reconstructions using semitendinosus autografts. Constant and Simple Shoulder Test scores were determined before and 2 years after surgery as a part of standard clinical practice. General patient satisfaction with the outcome (poor, fair, or excellent) also was assessed. In addition, for purposes of routine clinical follow-up, the coracoclavicular distance was measured from the inferior cortex of the clavicle to the superior cortex of the coracoid using anteroposterior radiographs taken 2 years after surgery. The results were compared with postoperative radiographs and changes in the distance were recorded. The clavicular drill hole was similarly measured 2 years after surgery to detect possible tunnel widening. RESULTS: The mean preoperative Constant score increased from a preoperative mean of 52.6 ± 16.5 to 94.7 ± 7.9 at 2 years postoperatively (P = .000). The Simple Shoulder Test score increased from a preoperative mean of 7.7 ± 1.64 to 11.8 ± 0.7 (P = .000). The mean coracoclavicular distance increased from 10.5 ± 3.4 to 12.4 ± 3.9 mm (P = .009). The diameter of the clavicular drill hole increased from 6.0 mm to a mean of 8.4 mm. Two coracoid fractures were observed, but no clavicular fractures. One patient experienced a deep infection, leading to total reconstruction failure, and 2 patients had superficial postoperative infections. Forty-five patients (85%) reported excellent subjective outcomes, and 8 (15%) reported a fair outcome. CONCLUSIONS: The outcomes of this series of coracoclavicular ligament reconstruction were favorable and the number of serious complications was small. However, clavicular wound issues were a significant problem. Coracoclavicular ligament reconstruction is a challenging procedure, but satisfactory results can be achieved with careful patient selection and good technique. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

Deterioration of initially accepted radiological alignment of conservatively treated AO type-C distal radius fractures: mid-term outcome.

BACKGROUND AND AIMS: It still remains controversial how often the once-accepted radiological alignment of an AO type-C distal radius fracture deteriorates after conservative treatment, and to what extent this deterioration is perhaps associated with patient-rated outcome measures (PROms). Thus, we aimed to evaluate this radiological deterioration and its association with mid-term functional follow-up. PATIENTS AND METHODS: We retrospectively reviewed 66 patients (mean age at fracture 53 years, SD 14.1, range 18-73, female 65%) with 68 C-type distal radius fractures at a mean of 6.7 years (SD 0.5 years, range 5.8-7.7 years) after primary closed reduction and cast immobilization. Radiographs of the wrists were taken and analysed for any radial shortening, dorsal tilt or step-off at the joint surface. Range of motion and grip strength were measured. In addition to the radiological result, primary outcome measures included Quick Disabilities of the Arm, Shoulder and Hand (QDash) and Patient-Rated Wrist Evaluation (PRWE). RESULTS: At mid-term follow-up, an acceptable anatomical radiological result was seen in only 22 wrists (32%). Deterioration of the once-achieved and accepted primary alignment was seen in a majority of cases (68%). Radial shortening of ≥ 2 mm was found in 34 wrists (51%, mean 4 mm, range 2-8 mm), with no association with QDash (12.8 vs. 5.5, p = 0.22) or PRWE (9.1 vs. 5.7, p = 0.40). Only four patients (6%) showed step-off at the joint surface (mean 1.1 mm, range 0.5-2 mm). Twenty-two wrists (32%) showed dorsal tilt of ≥ 10° (five with volar tilt of 15°-25°), with no effect on QDash or PRWE (14.7 vs. 6.5, p = 0.241 and 10.1 vs. 5.8, p = 0.226). Altogether, patients with dorsal tilt, step-off or shortening did not show significantly worse QDash (10.3 vs. 5.7, p = 0.213) or PRWE (8.1 vs. 5.1, p = 0.126) versus those with none. Twenty-nine (43%) of the patients had deficits in range of motion (ROM), either in extension (39%), flexion (43%), supination (16%) or pronation (4%), or combinations of these. Worse extension was associated with worse QDash (15.9 vs. 5.0, p = 0.037), flexion deficit with worse PRWE (11.5 vs. 4.4, p = 0.005) and supination deficit with both QDash (21.7 vs. 6.8, p = 0.025) and PRWE (18.9 vs. 5.2, p = 0.007). CONCLUSIONS: The initially accepted radiological alignment of AO type-C radius fractures deteriorated in a majority of cases during conservative treatment. However, this deterioration was fairly mild and showed no significant association with functional outcome. Restricted ROM showed some association with PROms. LEVEL OF EVIDENCE: IV.

Validity and internal consistency of the thoracic outlet syndrome index for patients with thoracic outlet syndrome.

BACKGROUND: No validated scales exist specifically for measuring quality of life (QoL) and functioning level in patients with thoracic outlet syndrome (TOS). This cross-sectional survey examined whether some items adopted from validated QoL scales could be suitable for patients with TOS. METHODS: To find an optimal thoracic outlet syndrome index (TOSI), a panel of 14 specialists experienced in treating TOS independently evaluated the relevance of 19 items adopted from scales used in other upper-extremity syndromes. After undergoing surgery for TOS, 52 patients rated the relevance of those items found by experts to be relevant. Content validity was measured by a content validity index, content validity ratio, and modified κ. The internal consistency of 15 retained items was assessed with the Cronbach α, and its construct validity was assessed by an exploratory factor analysis. RESULTS: Of the 19 items, 15 were considered relevant for TOS by the panelists, with an overall test content validity index of 0.93. The internal consistency of these 15 items was excellent. The exploratory factor analysis accompanied by a parallel analysis confirmed the uni-dimensionality of the TOSI. All 15 items that the panelists considered relevant were also items that the patients marked with scores over 7 points on an 11-point scale of relevance. CONCLUSION: The internally consistent, face- and content-valid TOSI scale is proposed for use in evaluating specifically the QoL in TOS patients, as well as improving future longitudinal studies comparing functioning before and after interventions or spontaneous recovery in TOS patients.

Validity and internal consistency of the Helsinki Serratus Palsy Index for patients with serratus palsy.

BACKGROUND: To our knowledge, no validated scales exist as yet for measuring quality of life and functioning level in patients with serratus palsy. This cross-sectional survey study examined whether a broadly validated Western Ontario Rotator Cuff Index (WORC) could be partially adapted for patients with serratus palsy. METHODS: The relevancy of WORC, 21 items, along with 4 additional new items, was tested by 95 patients with serratus palsy and a panel of 9 medical experts. Its content validity was measured by a content validity index (CVI), a content validity ratio (CVR), and a modified κ. The internal consistency of 11 retained items was assessed with the Cronbach α. Its construct validity was assessed by exploratory factor analysis. RESULTS: Of the 25 items, 11 were considered relevant (CVI ≥0.78) for serratus palsy by the panelists, with overall test CVI (S-CVI) of 0.86. The internal consistency of these 11 items was excellent, with a Cronbach α of 0.94. The exploratory factor analysis accompanied by a parallel analysis confirmed the unidimensionality of a new test. All except 2 items of WORC that were considered relevant by the panelists were also marked with scores of >5 by the patients on an 11-point scale of relevancy. CONCLUSIONS: Adapted from the WORC, the new 11-item Helsinki Serratus Palsy Index scale was internally consistent and face and content valid for serratus palsy patients.

Thoracic outlet syndrome.

It is important to remember the possibility of nonspecific thoracic outlet syndrome (TOS) when treating patients with neck and upper extremity symptoms. There are no specific diagnostic criteria for the syndrome. Diagnosis is based on symptoms, clinical examination and the ruling out of other causes. The first-line option of clinical care is conservative treatment, which in most cases is sufficient for the patient to regain normal functioning. However, some of the most difficult TOS patients need surgical treatment, especially when persistent symptoms have already begun in adolescence, and if compression of neural or vascular structures is thought to result from anatomical structures. Conservative treatment options are essential also for surgically treated patients.

Confirmatory Factor Analysis of the Finnish Job Content Questionnaire (JCQ) in 590 Professional Musicians.

BACKGROUND: Poorly functioning work environments may lead to dissatisfaction for the employees and financial loss for the employers. The Job Content Questionnaire (JCQ) was designed to measure social and psychological characteristics of work environments. OBJECTIVE: To investigate the factor construct of the Finnish 14-item version of JCQ when applied to professional orchestra musicians. METHODS: In a cross-sectional survey, the questionnaire was sent by mail to 1550 orchestra musicians and students. 630 responses were received. Full data were available for 590 respondents (response rate 38%).The questionnaire also contained questions on demographics, job satisfaction, health status, health behaviors, and intensity of playing music. Confirmatory factor analysis of the 2-factor model of JCQ was conducted. RESULTS: Of the 5 estimates, JCQ items in the "job demand" construct, the "conflicting demands" (question 5) explained most of the total variance in this construct (79%) demonstrating almost perfect correlation of 0.63. In the construct of "job control," "opinions influential" (question 10) demonstrated a perfect correlation index of 0.84 and the items "little decision freedom" (question 14) and "allows own decisions" (question 6) showed substantial correlations of 0.77 and 0.65. CONCLUSION: The 2-factor model of the Finnish 14-item version of JCQ proposed in this study fitted well into the observed data. The "conflicting demands," "opinions influential," "little decision freedom," and "allows own decisions" items demonstrated the strongest correlations with latent factors suggesting that in a population similar to the studied one, especially these items should be taken into account when observed in the response of a population.

Isolated serratus palsy etiology influences its long-term outcome.

HYPOTHESIS AND BACKGROUND: The cause of isolated serratus palsy is multifactorial, but evaluation of the mechanism of the injury indicates that the lesion to the long thoracic nerve is mechanical in origin in most cases. What is unknown, however, is how etiology influences its long-term outcome. We believed that overuse injuries may recover sooner and better than acute traumatic, infectious, or inflammatory injuries. METHODS: We determined the presumed etiology of isolated serratus palsy in 92 patients treated by brace or observation only and compared it with its long-term outcome after a mean follow-up of 18.1 years (range, 2.1-26.9) by measuring pain, range of motion, and winging of the scapula. RESULTS: Trauma preceded 22 (24%) of the cases, exertion 37 (40%), infection 14 (15%), and surgery/anesthesia 10 (11%). In 9 (10%) cases, no etiologic factor was evident. Serratus palsy preceded by infection recovered better than did cases with no infection, and those with palsy preceded by surgery/anesthesia had a poorer outcome than did those with no surgery (axilla, chest, or any other areas) or anesthesia. Those palsies caused by acute trauma or acute or chronic overuse/exertion had the same recovery course. DISCUSSION AND CONCLUSION: Etiology of isolated serratus palsy influenced long-term outcome less than we had expected. It seems, however, that palsies caused by infection recover better and those caused by surgery wherever in the body recover most poorly.

Is Alcohol Consumption Associated with Job Strain Among Professional Musicians?

OBJECTIVE: To assess the strength of the relationship between alcohol consumption and job strain experienced by professional musicians. METHODS: Cross-sectional survey among professional orchestra musicians (n=1,550, response rate 41%, data available for 590 respondents). The difference between groups with and without job strain was assessed by two-way analysis of variance. RESULTS: The median alcohol consumption was 48 g/wk (range 1-648, IQR 12-96). There were only 25 (4%) heavy drinkers, defined as people who consume >210 g of pure alcohol a week. The average frequency of drinking was 2.1 times/wk (SD 2.0, range 0-7). Of the respondents, 125 (21%) reported an elevated level of job strain as defined by the responses to Job Content Questionnaire. There was no significant interaction between the effects of gender and job strain on alcohol consumption: F(1, 586) = 0.82, p=0.365. Simple main effects analysis showed that males were consuming alcohol significantly more than females were (p=0.0005), but there were no differences between participants with elevated level of job strain compared with the rest of the sample (p=0.546). CONCLUSIONS: The amount of alcohol consumed was not associated with the presence or absence of perceived occupational strain among professional orchestra musicians.

Range of motion of diabetic frozen shoulder recovers to the contralateral level.

Objective To determine whether frozen shoulder heals equally well in patients with and without diabetes and whether dependency on insulin affects the outcome. Methods We retrospectively examined 178 patients with idiopathic frozen shoulder; 27 patients had diabetes. We evaluated range of motion, pain, and functional results. The mean follow-up was 9.7 years (SD, 7.1 years). Results In the presence of frozen shoulder, range of motion did not differ between patients with and without diabetes. At follow-up, range of motion in all directions of both the affected and unaffected shoulders of patients with diabetes was inferior to that of patients without diabetes. Among patients with diabetes, range of motion of the once-frozen shoulder reached the level of the unaffected shoulder. Patients with and without diabetes experienced similar pain except during exertion. The Constant-Murley score was not significantly different between the two groups, and insulin dependency did not lead to worse outcomes. Conclusion Frozen shoulder heals well in patients with diabetes.

Psychometric Properties of the Pain Numeric Rating Scale When Applied to Multiple Body Regions among Professional Musicians.

BACKGROUND: Despite the broad popularity of a numeric rating scale (NRS) its psychometric properties are not well known. The objective was to determine if there is any difference in the discrimination ability of the NRS when used for measuring pain severity separately in different body regions. METHODS: Cross-sectional survey study of 630 professional musicians. Item Response Theory (IRT) was used to define the psychometric properties of the NRS. RESULTS: The discrimination ability of the pain NRS was dependent on the body area to which it was applied. The discrimination was low 0.5 (95% CI 0.4. to 0.7) for the hand region and perfect for the shoulder and upper part of the neck- 3.2 (95% CI 1.2 to 5.2) and 10.5 (95% CI 10.0 to 10.9), respectively. Both shoulder and neck NRSs showed a great shift towards higher levels of pain severity meaning that the ability of the NRS to discriminate low levels of pain is poor. NRS scores obtained from all other regions did not demonstrate any discrimination ability. CONCLUSIONS: The pain NRS might have different psychometric properties depending on the body area to which it is applied. Overall, the modest discrimination ability of the pain NRS implies that it should be used in screening questionnaires with some reservations.

Open Surgical Treatment for Snapping Scapula Provides Durable Pain Relief, but so Does Nonsurgical Treatment.

BACKGROUND: Resection of the medial upper corner of the scapula is one option for treating patients with a painful chronic snapping scapula. However, the degree to which this procedure results in sustained relief of pain during long-term followup, and whether surgical treatment offers any compelling advantages over nonsurgical approaches at long-term followup, are not known. QUESTIONS/PURPOSES: We asked: (1) At long-term followup after surgical treatment of a painful snapping scapula, did patients' pain decrease? (2) Did scapulocostal crepitation improve? (3) Did patients return to work? METHODS: Between 1971 and 1992, 15 patients underwent surgery by one surgeon for persistent (> 1 year) and severely painful crepitus around the superomedial scapula that did not respond to nonsurgical approaches. The procedure consisted of an open resection of the superomedial corner of the scapula and release of the levator scapulae muscle. Patients treated surgically were compared with a group of nine patients treated nonsurgically between 1975 and 1997; their treatments included temporary physiotherapy, massage, and NSAIDs. In general, the patients treated nonsurgically presented with less pain. However, during much of this study period, objective pain and functional scales were not in common use, and so baseline scores were not available. Of the 15 patients treated surgically, nine participated in a clinical and questionnaire survey at a mean of 22 years (range, 16-35 years), and 12 participated in a questionnaire survey a mean 27 years after surgery (range, 23-43 years). Of the nine patients treated nonsurgically, seven participated in a clinical followup and questionnaire survey at a mean followup of 16 years (range, 10-25 years), and all nine completed a questionnaire survey at a mean of 22 years (range, 17-33 years). Patient age at onset of symptoms was a mean of 27 years. The clinical followup and questionnaires focused on pain, crepitation, and work status. RESULTS: With the numbers available, there was no difference in pain scores between patients treated surgically and those treated nonsurgically (mean VAS pain with exertion 0.8 ± 1.3 versus 1.5 ± 1.6; p = 0.357); in fact, pain scores were quite low in both groups. Pain improved promptly in seven of 12 patients treated surgically, but lasted for at least several years in all patients treated nonsurgically. Crepitus persisted variably in both groups at final followup, with no apparent difference between the groups in terms of its frequency, but it was not consistently associated with pain at final followup in either group (six of 12 patients treated surgically, all painless; and all of seven clinically examined patients treated nonsurgically, two without pain, had crepitus at latest followup; p = 0.004), whereas at initial presentation, the crepitus had been painful in all patients. All patients in both groups had returned to work after surgery or the first consultation. CONCLUSIONS: Carefully selected patients who undergo this procedure appear to obtain sustained relief of painful crepitus at long term, but so do patients treated nonsurgically. Since the decision to treat these patients surgically was somewhat subjective, and since patients treated nonsurgically did so well (although the surgically treated patients improved faster), we cannot conclude that surgery is better than nonsurgical treatment. Multicenter comparative studies with carefully applied indications are needed. LEVEL OF EVIDENCE: Level III, therapeutic study.

Scapular Bracing is Effective in Some Patients but Symptoms Persist in Many Despite Bracing.

BACKGROUND: A scapular-protecting brace is one option for treating patients with a winging scapula in isolated serratus palsy. However, outcomes after brace treatment have been reported in only a few studies, and to our knowledge, none has results reported at long-term beyond 10 years. QUESTIONS/PURPOSE: We asked: (1) What was the average length of time patients wore the brace? (2) Did scapular winging and ROM improve with brace treatment? (3) Was pain decreased? (4) Did the duration of symptoms before brace treatment influence the outcome? PATIENTS AND METHODS: Between 1980 and 1999, we treated 110 patients with a scapular-protecting brace. General indications for this treatment included electroneuromyography-verified isolated serratus palsy, 3 cm or greater scapular winging, and limited ROM. For patients with scapular winging less than 3 cm we used observation and avoidance of all heavy work or lifting. Of the patients treated with a brace, 55 (50%) were available at a minimum followup of 10 years (mean, 22 years; range, 10-28 years). Mean patient age was 30 years at the onset of symptoms (range, 15-52 years). Brace use was based on patient self-report, and we determined the degree of scapular winging and ROM clinically and level of pain by chart review before and after treatment. RESULTS: The brace was applied a mean 6 months (median, 5 months) after onset of symptoms. Mean duration of brace use was 10 months for 12 hours per day. Winging of the scapula, measured in 90° flexion without resistance, disappeared in 35 patients (64%) with brace use. Flexion averaged 153° and abduction 168°. Ten patients (18%) were pain-free during exertion and 18 (33%) at rest. Pain at rest was present in 37 patients (67%); of those, it was present only seldom in 15 (27%), sometimes present in 21 (38%), and one patient (2%) experienced continuous pain at rest despite brace treatment. With the number of patients available, there were no differences between patients who started brace treatment early (within 6 months of onset of symptoms) and those who started later (more than 6 months after symptom onset) in terms of improvement of scapular winging in flexion at 90° with resistance (mean, 1.2±2.0 cm vs 1.7±2.3 cm; p=0.415; 95% CI, -1.6 to 0.7), better flexion (mean, 156°±17° flexion vs 149°±28° flexion; p<0.253; 95% CI, -5 to 19), or improvement in other parameters that we measured. CONCLUSIONS: Compliance was high for scapular-protecting brace treatment in patients with serratus palsy but recovery was incomplete for many patients, most of whom still had some pain and a large proportion still had some degree of scapular winging. We continue to use scapular bracing for treating patients who have 3 cm or more scapular winging and limited ROM, and whose work or hobbies demand motions causing winging, although we counsel our patients that recovery is likely to be incomplete. LEVEL OF EVIDENCE: Level IV, therapeutic study.

Motion and pain relief remain 23 years after manipulation under anesthesia for frozen shoulder.

BACKGROUND: Manipulation under anesthesia (MUA) as treatment for idiopathic frozen shoulder increases motion, provides pain relief, and restores function, but it is unclear whether the improvements persist long term. QUESTIONS/PURPOSES: We therefore investigated whether (1) ROM was restored, (2) pain was relieved, and (3) function was restored and maintained after several decades in patients with idiopathic frozen shoulder treated by MUA. METHODS: We followed 15 patients (16 shoulders; 12 in women) at 3 months, 7 years, and 19 to 30 years after MUA for frozen shoulder. Their mean age at MUA was 48.5 years. Four patients had diabetes. The time between the onset of symptoms and manipulation averaged 7.6 months. We determined pain by a patient-generated VAS (range, 0-10; 0=none, 10=maximal). We recorded ROM and Constant-Murley scores at last followup. RESULTS: At 7 years, improvement had occurred in forward flexion to 155°, abduction to 175°, external rotation to 51°, and internal rotation to the T7 level. During the next 16 years, ROM deteriorated by 8° to 23° at last followup, but still equaled ROM of the contralateral shoulder. On the VAS, pain at last followup averaged 1.5 with exertion, 0.3 at rest, and 0.8 at night. The Constant-Murley score was 70 (range, 34-88); 12 patients reached the age- and sex-adjusted normal Constant-Murley score. CONCLUSIONS: In this group of patients treatment of idiopathic frozen shoulder by MUA led to improvement in shoulder motion and function at a mean 23 years after the procedure. LEVEL OF EVIDENCE: Level IV, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.

The natural history of idiopathic frozen shoulder: a 2- to 27-year followup study.

BACKGROUND: The natural history of spontaneous idiopathic frozen shoulder is controversial. Many studies claim that complete resolution is not inevitable. Based on the 40-year clinical experience of the senior author, we believed most patients with idiopathic frozen shoulder might have a higher rate of resolution than earlier thought. QUESTIONS/PURPOSES: We determined the length of symptoms, whether spontaneous frozen shoulder recovered without any treatment, and whether restored ROM, pain relief, and function persisted over the long term. METHODS: We retrospectively reviewed 83 patients treated for frozen shoulder (84 shoulders; 56 women) 2 to 27 years (mean, 9 years) after initial consultation. The mean age at onset of symptoms was 53 years. Fifty-one of the 83 patients (52 shoulders) were treated with observation or benign neglect only (untreated group), and 32 had received some kind of nonoperative treatment before the first consultation with the senior author (nonoperative group). We also evaluated all 20 patients (22 shoulders; 13 women) with spontaneous frozen shoulder who underwent manipulation under anesthesia during the same time (manipulation group). The mean age of these patients was 49 years. The minimum followup was 2 years (mean, 14 years; range, 2-24 years). We determined duration of the disease, pain levels, ROM, and Constant-Murley scores. RESULTS: The duration of the disease averaged 15 months (range, 4-36 months) in the untreated group, and 20 months (range, 6-60 months) in the nonoperative group. At last followup the ROM had improved to the contralateral level in 94% in the untreated group, in 91% in the nonoperative group, and in 91% in the manipulation group. Fifty-one percent of patients in the untreated group, 44% in the nonoperative group, and 30% in the manipulation group were totally pain free at rest, during the night, and with exertion. Pain at rest was less than 3 on the VAS in 94% of patients in the untreated group, 91% in the nonoperative group, and 90% of the manipulation group. The Constant-Murley scores averaged 83 (86%) in the untreated group, 81 (77%) in the nonoperative group, and 82 (71%) in the manipulation group, reaching the normal age- and gender-related Constant-Murley score. CONCLUSIONS: We found 94% of patients with spontaneous frozen shoulder recovered to normal levels of function and motion without treatment. LEVEL OF EVIDENCE: Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

A simple grafting method to repair irreparable distal biceps tendon.

UNLABELLED: Irreparable distal biceps tendon tears typically are treated using a free tendon graft. We asked whether our new method to fix the graft--using two suture anchors--yields similar results to our previous bone canal method. We compared the two methods for strength, endurance, and clinical findings. There were two groups, the suture anchor group (Group A, seven patients) and the bone canal group operated on before suture anchors (Group B, seven patients). The patients were males with a mean age at surgery of 44.9 years. The operative delay from primary trauma to index surgery averaged 5.9 months. The minimum followup was 2 years (mean, 11.1 years; range, 2-23 years). The mean arc of elbow motion was 0 degrees to 132 degrees, pronation 83 degrees, and supination 80 degrees. Compared with the contralateral side, the maximal peak torque was 84% in supination and 91% in pronation, and the maximal static elbow flexion strength was 94%. The Mayo elbow score averaged 99 in Group A and 100 in Group B. There were no major differences between the two groups. Our novel modification to fix a tendon graft yields equal clinical outcomes compared with the bone canal method for treatment of irreparable distal biceps tendon injuries. LEVEL OF EVIDENCE: Level IV, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.