What Factors Are Associated with Reoperation After Operative Treatment of Terrible Triad Injuries?

BACKGROUND: Terrible triad injuries of the elbow, consisting of posterior ulnohumeral joint dislocation with associated fractures of the radial head and coronoid process, are challenging injuries due to the difficulty in restoring stability to the joint surgically while also attempting to allow early ROM to prevent stiffness. Furthermore, complications are both debilitating and relatively common, frequently requiring reoperation. QUESTIONS/PURPOSES: (1) What patient-, injury-, or surgery-related factors are associated with reoperation after surgical treatment of terrible triad injuries of the elbow? (2) What are the most common causes of reoperation after these injuries? METHODS: Between January 2000 and June 2017, we identified 114 patients who had surgery for terrible triad injuries at two tertiary-care referral centers. Of those, 40% (46 of 114) were lost to follow-up before 1 year, and an additional 5% (6 of 114) were excluded because they underwent the index surgery at an outside institution (n = 4) or underwent closed reduction with or without percutaneous pinning (n = 2). That left 62 patients for analysis in this retrospective study with a minimum of 1-year follow-up (median 22 months; range 12 to 65) or who met the endpoint of reoperation before 1 year. During the study period, indications for surgical treatment of terrible triad injuries of the elbow included joint incongruity or instability precluding early ROM. In our study cohort, 45% (28 of 62) underwent reoperation. Indications for reoperation after surgical treatment included stiffness that interfered with activities of daily life, symptomatic prominent hardware, ulnar neuropathy, instability of the elbow joint at rest or with range of motion, and infection. Patient-related (such as age, sex, race), injury-related (for example, ipsilateral extremity fracture, open fracture), and surgery-related factors (for instance, time to surgery, radial head treatment) as well as outcomes were collected by the treating surgeon at the time of follow-up and ascertained using chart review. The primary outcome measure was reoperation after surgical treatment of a terrible triad injury of the elbow. Bivariate analysis was used to assess whether explanatory variables were associated with reoperation after surgical treatment of terrible triad injuries of the elbow. RESULTS: Of the patient-, injury-, and surgery-related factors that were analyzed, only radial head treatment was associated with an increased reoperation risk (p = 0.03). No other variable met criteria for inclusion in our multivariable logistic regression model (p < 0.10), and therefore, a multivariable logistic regression model was not performed. The most common indication for reoperation was stiffness (21% [13 of 62 patients]), followed by symptomatic hardware (18% [11 of 62 patients]), nerve symptoms (ulnar neuropathy 16% [10 of 62 patients] and incisional neuroma 2% [1 of 62 patients]), instability (6% [4 of 62 patients]), and wound problems (infection 2% [1 of 62 patients]). CONCLUSION: The reoperation risk after surgical treatment of terrible triad injuries of the elbow is high. No patient- or injury-related factors were associated with the reoperation risk. Based on our finding, we recommend fixation of radial head fractures in these injuries when feasible and compatible with early postoperative motion, and we suggest the use of radial head excision or arthroplasty as a secondary options. LEVEL OF EVIDENCE: Level III, therapeutic study.

A Novel Blue-Red Photobiomodulation Therapy Patch Effects on a Repetitive Elbow-Flexion Fatigue Task.

BACKGROUND: Photobiomodulation (laser/light) therapy has reduced skeletal muscle fatigue and improved performance in previous research. OBJECTIVE: To determine if the application of a novel blue (450 nm) and red (645 nm) light-emitting diode photobiomodulation therapy patch improves muscle function and decreases perceived exertion after an elbow-flexion fatigue protocol. PARTICIPANTS: Thirty-four strength-trained individuals (male = 32 and female = 2, age = 22.5 [2.7] y). METHODS: Participants were randomly assigned to an active or placebo treatment. On  visit 1, participants' 1-repetition maximal biceps curl was determined, and an orientation session of the fatigue task occurred to ensure no learning effects. Fifty percent of the participants' 1-repetition maximum was used during the fatigue protocol. On visit 2, participants performed biceps curl repetitions at a speed of 25 repetitions per minute until they could not physically move the weight past 90° of elbow flexion or stay with the set pace. After the fatigue protocol, a 30-minute blue/red light (wavelength = 450 and 645 nm, peak irradiance = 9 mW/cm2, duty cycle = pulsed 33%, and fluence = 5.4 J/cm2) or sham treatment was administered based on the randomized group assignment. Immediately following, the participants repeated the fatigue protocol. The number of complete repetitions was counted, and the participants rated their perceived level of exertion on the Borg scale immediately after each fatigue bout. RESULTS: Overall, fatigue occurred between the 2 exercise bouts (pretreatment = 44.1 [12.3] and posttreatment = 37.4 [9.6] repetitions, P = .02). However, less fatigue was noted in the number of participants of the active treatment group than the sham treatment group. During the posttreatment fatigue task, 29.4% of participants in the active treatment group improved compared to 0% in the sham treatment (P = .045). CONCLUSION: Nearly 30% of participants had an increase benefit during a repeated-bout fatigue task due to the blue/red light-emitting diode photobiomodulation light patch.

Revision surgery for refractory cubital tunnel syndrome: A systematic review.

BACKGROUND: Indications for revision surgery are unclear in refractory cubital tunnel syndrome patients, and the optimal surgical method has not been determined. The systematic review evaluates the evidence of functional outcome for revision surgery in refractory cubital tunnel syndrome patients. HYPOTHESIS: We hypothesize that functional outcome of revision surgery in refractory cubital tunnel syndrome will be favorable. METHODS: We searched PubMed, Ovid/MEDLINE, Cochrane, Google Scholar, and EMBASE databases using the keywords "cubital tunnel syndrome" or "recurrent cubital tunnel syndrome" and "revision surgery" according to the MeSH index for English-language studies. We performed a systematic review using PRISMA guidelines. The review was registered in PROSPERO (CRD42018096622). RESULTS: Based on the Oxford Centre for Evidence-Based Medicine criteria, one level 3b study and nine level 4 studies were identified, including 195 elbows of 192 patients aged 15-75 years. The remission period for recurrent cubital tunnel syndrome was 6-21 months, and the follow-up period was 6-113 months. Transposition surgery was the primary surgery in 99 (51%) of 178 elbows. The most common intraoperative finding at revision surgery was perineural scarring (79%), with the most frequent entrapment site being the medial intermuscular septum (33%). The most common revision surgery was submuscular transposition of the ulnar nerve (75%). Most studies reported favorable outcomes, although outcomes varied widely among studies. CONCLUSION: This is the first study to summarize the functional outcomes of revision surgery for refractory cubital tunnel syndrome which showed to be favorable. Functional outcomes were averagely reported and varied widely. A consensus regarding the functional outcomes parameter after surgery for cubital tunnel syndrome is urgently needed. LEVEL OF EVIDENCE: III, systematic review.

Effect of radiosynoviorthesis on the progression of arthropathy and haemarthrosis reduction in haemophilic patients.

INTRODUCTION: Repeated haemarthrosis is widely accepted as the triggering cause of synovitis and haemophilic arthropathy. A first-line treatment of chronic synovitis is radiosynoviorthesis (RS). The aim of this study was to evaluate the RS effects on the progression of arthropathy and on a reduction in bleeding in patients with haemophilia. METHODS: An observational-retrospective study was performed. Bleeding episodes in the 12 months following and in the 12 months preceding RS was compared. The arthropathy was clinically and radiologically analysed by age range, joint and subject, comparing those undergoing RS (Radiosynoviorthesis Group, RSG) against those not undergoing this treatment (Non-Radiosynoviorthesis Group, Non-RSG). RESULTS: One hundred and seventy-four RS were performed in 71 patients (90 Y in Knees and 186 Re in elbows/ankles/shoulder). RS resulted in significant reduction in bleeding (582 preintervention and 168 postintervention, P < .001). In general, the level of arthropathy measured clinically and radiologically was greater with age increase in both groups (RSG and Non-RSG), especially in the 25-40 age range. A significant increase (P < .05) in the progression of arthropathy was also observed, both globally by patient and specifically for each joint, in non-RSG and RSG group. CONCLUSION: RS is an effective method to reduce the number of haemarthrosis episodes in chronic synovitis. Moreover, RS can positively affect arthropathy by slowing down its progression. However, the results obtained suggest that arthropathy may be conditioned by the subject's age, regardless of whether or not the joint has undergone RS.

Treatment options for haemophilic arthropathy of the elbow after failed conservative therapy. A single centre experience.

UNLABELLED: After ankle and knee, the elbow is the most frequent joint affected by haemophilic arthropathy. The objective of this retrospective single centre study is to evaluate the results of treatment of elbow arthropathy after failed conservative therapy. PATIENTS, METHODS: In 21 consecutive patients, 11 radiosynoviortheses (RSO), four arthroscopic and six open synovectomies were performed, among them four with additional resection of the radial head. The mean duration of follow-up was 4.8 (RSO) and 5.3 years (surgery), respectively. Pain status (visual analogue scale, VAS), bleeding frequency, range of motion (ROM) as well as patient satisfaction were evaluated. RESULTS: Both, RSO and surgical synovectomy, achieved a significant reduction of pain and bleeding frequency (p < 0.05). Surgical synovectomies were associated with a marked yet not statistically significant increase of postoperative ROM. Radial head resection improved forearm rotation in all cases. No complications occurred. 20 out of 21 patients were satisfied or highly satisfied with the result of the treatment and would undergo the respective procedure again. CONCLUSION: Due to the effectiveness and safety RSO is considered to be the primary treatment option in haemophilic arthropathy of the elbow after failed conservative therapy. Arthroscopic synovectomy should be considered if RSO shows inadequate effect or in the presence of contraindications. Open synovectomy with resection of the radial head yields good results in the case of advanced arthropathy with radial head impingement.

Benign painful elbow syndrome. First results of a single center prospective randomized radiotherapy dose optimization trial.

BACKGROUND AND PURPOSE: The goal of the present study was to evaluate the efficacy of two different dose-fractionation schedules for radiotherapy (RT) of patients with painful elbow syndrome. PATIENTS AND METHODS: Between February 2006 and February 2010, 199 consecutive evaluable patients were recruited for this prospective randomized trial. All patients received RT in orthovoltage technique. One RT course consisted of 6 single fractions/3 weeks. In case of insufficient remission of pain after 6 weeks a second radiation series was performed. Patients were randomly assigned to receive either single doses of 0.5 or 1.0 Gy. Endpoint was pain reduction. Pain was measured before, right after, and 6 weeks after RT by a visual analogue scale (VAS) and a comprehensive pain score (CPS). RESULTS: The overall response rate for all patients was 80% direct after and 91% 6 weeks after RT. The mean VAS values before, after and 6 weeks after treatment for the 0.5 and 1.0 Gy groups were 59.6 ± 20.2 and 55.7 ± 18.0 (p = 0.463), 32.1 ± 24.5 and 34.4 ± 22.5 (p = 0.256), and 27.0 ± 27.7 and 23.5 ± 21.6 (p = 0.818). The mean CPS before, after, and 6 weeks after treatment was 8.7 ± 2.9 and 8.1 ± 3.1 (p = 0.207), 4.5 ± 3.2 and 5.0 ± 3.4 (p = 0.507), 3.9 ± 3.6 and 2.8 ± 2.8 (p = 0.186), respectively. No statistically significant differences between the two single dose trial arms for early (p = 0.103) and delayed response (p = 0.246) were found. CONCLUSION: RT is an effective treatment option for the management of benign painful elbow syndrome. For radiation protection reasons the dose for a RT series is recommended not to exceed 3.0 Gy.

Radiation therapy for heterotopic ossification prophylaxis afer high-risk elbow surgery.

Heterotopic ossification (HO) is a common complication of elbow trauma or surgery. HO can impair joint function; when it does, surgical removal is required. Radiotherapy (RT) prevents HO formation in the hip. However, few data exist on the efficacy of RT in preventing HO formation in the elbow. We retrospectively analyzed the outcomes of elbow surgery followed by prophylactic single-fraction RT and use of nonsteroidal anti-inflammatory drugs (NSAIDs). All patients had ectopic bone resected at surgery or significant risk factors for development of ectopic bone. Of the 52 patients who underwent RT after high-risk elbow surgery, 44 had postoperative radiographs of the treated elbow available for evaluation. At a median follow-up of 136 days, 21 patients (48%) had radiographic evidence of HO. In all cases, however, the HO was small and not functionally significant. No complications were attributed to RT use. This retrospective review represents the largest published series of patients who have undergone postoperative RT to prevent HO formation in the elbow. Our findings support the idea that RT, in combination with NSAID use, is safe and efficacious in preventing development of clinically significant HO in the elbow.

Safety and efficacy of radiation therapy as secondary prophylaxis for heterotopic ossification of non-hip joints.

INTRODUCTION: Prophylactic radiation therapy (RT) is an established adjuvant therapy for heterotopic ossification (HO) of the hip when delivered in the immediate pre- or postoperative setting. Its role in prevention of recurrence after excision of HO is supported by randomised trials for HO of the hip, but there is scant evidence to demonstrate the safety and efficacy of a similar approach in non-hip joints. In the current study, we evaluate radiological and functional outcomes after prophylactic RT for prevention of HO of the knee and upper extremity. METHODS: With institutional review board (IRB) approval, patients treated at our institution with prophylactic RT for non-hip HO from 1998 to 2009 were identified. Records were reviewed, including pre- and postoperative records, operative reports and radiography. The primary objectives were to determine the safety of RT and rate of treatment failure, as defined by need for further surgical intervention. RESULTS: A total of 30 patients received prophylactic RT for HO of the elbow (n=21), MCP joint (n=1) and knee (n=8). Twenty-nine of the 30 patients were treated within 24-48h postoperatively, and one patient was treated within 24h preoperatively. Based on institutional policy, only patients considered to be at high risk of recurrence were selected to receive prophylactic RT. Patients were treated to a dose of 7Gy in one fraction, with two parallel opposed. Complications following treatment included two patients with postoperative wound infections, one patient with a ruptured triceps tendon and one patient with a fracture within the treatment field. Follow-up information was available for 26 of 30 patients, with a median follow-up time of 16months (range, 2-143months). Recurrent HO, requiring surgical re-excision, developed in 10.5% (n=2) of patients who were followed for upper extremity HO (n=19). For patients followed after RT for HO of the knee (n=7), there were no recurrences of HO that required further intervention. CONCLUSION: In this group of patients at high risk for developing further HO, prophylactic RT appears to be a safe adjunct to surgery and is effective in prevention of HO recurrence. Results are similar to published reports of HO of the hip and support the use of surgical excision and perioperative, prophylactic RT for HO of non-hip joints.

Postoperative single-fraction radiation for prevention of heterotopic ossification of the elbow.

PURPOSE: Heterotopic ossification (HO) about the elbow has been described after surgery, trauma, and burns. Even limited deposits can lead to significant functional deficits. Little data exist regarding outcomes of patients treated with radiation therapy (RT) after elbow surgery. We report here the Cleveland Clinic experience with single-fraction radiation following surgery to the elbow. The primary endpoint was the rate of new HO after RT. Secondary endpoints were range of motion, functional compromise, and toxicity. METHODS AND MATERIALS: From May 1993 to July 2006, 36 patients underwent elbow surgery followed by single-fraction RT. Range of motion data were collected before and during surgery and at last follow-up. Radiographs were reviewed for persistent or new HO. Patient and treatment factors were analyzed for correlation with development of HO or functional compromise. RESULTS: Median follow-up was 8.7 months, median age was 42 years, and 75% of patients were male. Twenty-six (72%) patients had HO prior to surgery. All patients had significant limitations in flexion/extension or pronation/supination at baseline. Thirty-one (86%) patients had prior elbow trauma, and 26 (72%) patients had prior surgery. RT was administered a median of 1 day postoperatively (range, 1-4 days). Thirty-four patients received 700 cGy, and 2 patients received 600 cGy. Three (8%) patients developed new HO after RT. All patients had improvement in range of motion from baseline. No patient or treatment factors were significantly associated with the development of HO or functional compromise. CONCLUSIONS: Single-fraction RT after surgery to the elbow is associated with favorable functional and radiographic outcomes.

Prevention of heterotopic ossification at the elbow following trauma using radiation therapy.

The objective of this study was to determine the efficacy of postoperative single dose radiation therapy of 700 centigray on fracture/dislocations of the elbow in the prevention of heterotopic ossification. Eleven patients were reviewed for this study. Each patient sustained high-energy trauma to the extremity causing a fracture/dislocation of the elbow. After open reduction and internal fixation, a postoperative single dose of 700-centigray radiation therapy was administered to the patients within 72 hours of surgery. Primary outcome measurements were clinical physical examination of range of motion and radiographic analysis of heterotopic bone formation at 12 months follow-up. Three of eleven patients (27%) had radiographic evidence of heterotopic ossification formation. Ten of eleven patients (91%) however, were without functional limitations. All fractures healed without complications. There were no complications from the radiation therapy. A single dose of 700-centigray radiation therapy postoperatively within 72 hours may lessen the functional loss from heterotopic ossification formation without effecting healing at the fracture site.

Delayed-onset muscle soreness: lack of effect of combined phototherapy/low-intensity laser therapy at low pulse repetition rates.

A double-blind, placebo-controlled study using male subjects (n = 60), was conducted to investigate the efficacy of three different frequencies of combined phototherapy/low-intensity laser therapy (CLILT) in alleviating the signs and symptoms of delayed-onset muscle soreness (DOMS). The study was approved by the University's ethical committee. After screening for relevant pathologies, recent analgesic or steroid drug usage, current pain, diabetes, or current involvement in regular weight-training activities, subjects were randomly allocated to one of five experimental groups: Control, Placebo, or 2.5-Hz, 5-Hz, or 20-Hz CLILT groups (660-950 nm; 31.7 J/cm2; pulsed at the given frequencies for a duration of 12 min; n = 12 all groups). Once baseline measurements were obtained, DOMS was induced in the nondominant arm, which was exercised in a standardized fashion until exhaustion, using repeated eccentric contractions of the elbow flexors. The procedure was repeated twice more to ensure exhaustion was achieved, after which subjects were treated according to group allocation. In the CLILT/placebo groups, the treatment head was applied directly to the affected arm at the level of the musculotendinous junction. Subjects returned on two consecutive days for further treatment and assessment. The range of variables used to assess DOMS included range of movement (universal goniometer), mechanical pain threshold/tenderness (algometer) and pain (visual analogue scale and McGill Pain Questionnaire). Measurements were taken before and after treatment on each day, except for the McGill Pain questionnaire, which was completed at the end of the study. Analysis of results using repeated measures and one-factor analysis of variance with relevant post hoc tests showed significant changes in ranges of movement accompanied by increases in subjective pain and tenderness for all groups over time (p = 0.0001); however, such analysis failed to show any significant differences between groups on any of the days. These results thus provide no convincing evidence for any putative hypoalgesic effect of CLILT upon DOMS at the parameters used here.

The rheumatoid elbow: patterns of joint involvement and the outcome of synoviorthesis.

Rheumatoid arthritis of the elbow is a common condition. A group of 86 patients has been reviewed. Patterns of joint involvement are described. These patients have been subjected to 137 radioisotopic synoviortheses. 72% achieved a result classed as "good" and this review underlines the efficacy of the procedure of synoviorthesis. Radiological staging has been shown to have prognostic significance; 89% of good results were obtained in management of Steinbrocker grade I. No complications were recorded.

[Radiosynoviorthesis with yttrium-90-silicate. Results compared to aurum-198-colloid and whole body radiation load]. / Die Radiosynoviorthese mit Yttrium-90-Silikat. Ergebnisse im Vergleich zu Aurum-198-Kolloid und Ganzkörperstrahlenbelastung.

The results of the radiosynoviorthesis with yttrium-90 silicate in 36 joints, are reported. In comparison to the radiogold therapy in 64 joint, yttrium-90 was a little more effective. Additionally, the body distribution of radioactive yttrium after radiosynoviorthesis of knee joints, was measured in 6 patients. It could be shown that the uptake of the regional lymphnodes was between 4 and 5% of the yttrium administered. The radiation dose of the regional lymphnodes certainly exceeds 1000 rad. The results point to the importance of a careful selection of patients for radiosynoviorthesis.