Complications of Early Versus Delayed Total Elbow Arthroplasty for the Treatment of Distal Humerus Fractures.

PURPOSE: The purpose of this study was to compare the rates of wound complications and heterotopic ossification (HO) between patients who underwent acute total elbow arthroplasty (TEA) and those who underwent delayed TEA performed for the treatment of distal humerus fractures. Our hypothesis was that delayed surgery will have fewer wound complications but a higher rate of HO. METHODS: We retrospectively reviewed 104 patients who had undergone TEA performed at 1 of 3 institutions following a distal humerus fracture. The acute cohort, comprising 69 patients, underwent TEA within 2 weeks; the delayed cohort, comprising 35 patients, received treatment between 2 weeks and 6 months. The rates of wound complications, HO, clinically relevant HO (requiring excision or resulting in loss of functional range of motion), and reoperation were recorded. These patients were followed up for an average of 52 (interquartile range, 18.5-117) weeks. RESULTS: Wound complications occurred in 10 patients (14.5%) in the early group and 7 (20.0%) in the delayed group. The overall rate of HO was 56.7% (59 patients). The rate of clinically relevant HO was 26.0% (27 patients), which was similar between the groups. Reoperation occurred in 20 patients (19.2%), which was similar between the groups. In the early group, 3 reoperations were performed for wound complications and 4 for HO. No patients required reoperation for these indications in the delayed group. The mean flexion-extension and supination-pronation arcs were 20°-130° and 80°-80°, respectively, which were similar between the groups. Rheumatoid arthritis and younger age were associated with increased odds of wound complications and reoperation. CONCLUSIONS: The rates of reoperation, wound complications, and HO were overall higher than those previously reported; however, the study was underpowered to determine a difference between early and delayed treatment. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Side-to-side differences in postoperative function and patient satisfaction after bilateral total shoulder arthroplasties.

BACKGROUND: As the number of anatomic and reverse total shoulder arthroplasty (TSA) procedures increase, there will be a natural increase in patients who undergo staged bilateral TSA procedures. Bilateral TSAs have been shown to improve patient outcomes; however, it is unknown whether these patients experience side-to-side differences in clinical outcomes and satisfaction between shoulders. Understanding these differences is imperative for accurate patient and provider expectations. METHODS: An international multicenter registry was used to identify patients who underwent staged bilateral TSAs from April 2007 to October 2019 with a minimum of 2-year follow-up. American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) outcomes and satisfaction ratings were compared between dominant and nondominant shoulders, and first and second arthroplasties. Side-to-side differences in postoperative ASES and unequal satisfaction ratings were also explored by using regression analyses to identify potential factors influencing these differences. RESULTS: A total of 60 patients (22 bilateral anatomic TSAs, 38 bilateral reverse TSAs) were identified for inclusion. Group analyses revealed that bilateral TSA patients demonstrated similar functional outcomes and satisfaction regardless of dominance and surgery sequence. Type of TSA, specifically bilateral reverse TSAs, significantly predicted greater side-to-side differences in postoperative ASES scores (P = .025), indicating reverse TSA patients demonstrated greater between-sides differences in postoperative functional outcomes compared with those undergoing anatomic TSAs. Additionally, a larger proportion of bilateral reverse TSA patients reported unequal satisfaction between shoulders (31.6%) compared with anatomic TSA patients (9.1%). Logistic regression analysis revealed that greater side-to-side differences in postoperative ASES scores were found to increase the likelihood of reporting unequal satisfaction between shoulders (odds ratio 1.11, P < .001), which may explain this outcome. CONCLUSIONS: Most patients who undergo bilateral TSAs can expect similar outcomes on both shoulders regardless of dominance and surgery sequence. However, we did find patients who had discordant results between shoulders. Those who underwent reverse TSAs more frequently reported unequal satisfaction with their TSA procedures, which is likely due to larger side-to-side differences in postoperative function. It is unclear why these differences occurred, but this information may be important for providers to remember when counseling these patients for accurate postoperative expectations.

Shoulder Hemiarthroplasty with Nonprosthetic Glenoid Arthroplasty: The Ream-and-Run Procedure.

¼: Glenoid component wear and loosening are the principal failure modes of anatomic total shoulder arthroplasty (aTSA). ¼: The ream-and-run (RnR) procedure is an alternative glenohumeral arthroplasty for patients who wish to avoid the risks and limitations of a prosthetic glenoid component. ¼: During the RnR procedure, the arthritic glenoid is conservatively reamed to a single concavity, while the prosthetic humeral component and soft tissues are balanced to provide both mobility and stability of the joint. ¼: The success of the RnR procedure depends on careful patient selection, preoperative education and engagement, optimal surgical technique, targeted rehabilitation, and close postoperative communication between the surgeon and the patient. ¼: While the RnR procedure allows high levels of shoulder function in most patients, the recovery can be longer and more arduous than with aTSA. ¼: Patients who have undergone an RnR procedure occasionally require a second closed or open procedure to address refractory shoulder stiffness, infection, or persistent glenoid-sided pain. These second procedures are more common after the RnR than with aTSA.

Prevalence of rotator cuff tears in adults with traumatic brachial plexus injuries.

BACKGROUND: Restoration of shoulder function is a primary goal when treating patients with traumatic brachial plexus injury. A concomitant rotator cuff tear may alter the treatment approach and prognosis for these individuals. The purpose of this study was to define the prevalence of rotator cuff tears in patients with traumatic brachial plexus injuries. METHODS: This is a retrospective review of 280 adult patients with traumatic brachial plexus injury treated at a single institution over a twelve-year period. An upper-extremity magnetic resonance imaging (MRI) scan was acquired for all patients as part of the initial evaluation for posttraumatic brachial plexus injury. The radiographic and clinical data on these patients were reviewed to document partial or full-thickness rotator cuff tears, mechanism and location of the brachial plexus injury, and age. RESULTS: Twenty-three patients (8.2%) had a full-thickness rotator cuff tear: one patient had tears involving three tendons, eight patients had tears involving two tendons, twelve patients had a single-tendon tear, one patient had a single-tendon tear in each shoulder, and one patient had a single-tendon tear in one shoulder and a two-tendon tear in the other. Twenty-one tears involved the supraspinatus, eight involved the infraspinatus, and seven involved the subscapularis. Thirteen patients underwent surgical repair of the rotator cuff. The average age of the patients in this cohort was 33.4 years, and older age was associated with an increased risk of full-thickness rotator cuff tears (odds ratio [OR], 1.06 per year). Patients with infraclavicular brachial plexus injury had a significantly higher rate of full-thickness rotator cuff tears. CONCLUSIONS: Concomitant rotator cuff tears are present in approximately one in ten patients with traumatic brachial plexus injury. These injuries may contribute to shoulder dysfunction; therefore, evaluation of the rotator cuff with imaging studies is appropriate when formulating treatment strategies. LEVEL OF EVIDENCE: Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Origin of propionibacterium in surgical wounds and evidence-based approach for culturing propionibacterium from surgical sites.

BACKGROUND: To explore the origin of Propionibacterium in surgical wounds and to suggest an optimized strategy for culturing this organism at the time of revision surgery, we studied the presence of this organism on the skin and in the surgical wounds of patients who underwent revision arthroplasty for reasons other than apparent infection. METHODS: Specimens were cultured in broth and on aerobic and anaerobic media. The presence and degree of positivity of Propionibacterium cultures were correlated with sex. The results of dermal and deep cultures were correlated. Times to positivity and the yields of each media type and specimen source were investigated. RESULTS: Propionibacterium grew in twenty-three of thirty cultures of specimens obtained preoperatively from the unprepared epidermis over the area where a skin incision was going to be made for a shoulder arthroplasty; males had a greater average degree of positivity than females (p < 0.002). Twelve of twenty-one male subjects and zero of twenty female subjects who had cultures of dermal specimens obtained during revision shoulder arthroplasty had positive findings for Propionibacterium (p = 0.0001). Twelve of twenty male subjects and only one of twenty female subjects had positive deep cultures (p = 0.0004). The positivity of dermal cultures for Propionibacterium was significantly associated with the positivity of deep cultures for this organism (p = 0.0001). If Propionibacterium was present in deep tissues, it was likely that it would be recovered by culture if four different specimens were obtained and cultured for a minimum of seventeen days on three different media: aerobic, anaerobic, and broth. CONCLUSIONS: Because the surgical incision of dermal sebaceous glands may be a source of Propionibacterium in deep wounds, strategies for minimizing the risk of Propionibacterium infections may need to be directed at minimizing the contamination of surgical wounds from these bacteria residing in rather than on the skin. Obtaining at least four specimens, observing them for seventeen days, and using three types of culture media optimize the recovery of Propionibacterium at the time of revision surgery.

Iatrogenic nerve injuries during shoulder surgery.

INTRODUCTION: The current literature indicates that neurologic injuries during shoulder surgery occur infrequently and result in little if any morbidity. The purpose of this study was to review one institution's experience treating patients with iatrogenic nerve injuries after shoulder surgery. METHODS: A retrospective review of the records of patients evaluated in a brachial plexus specialty clinic from 2000 to 2010 identified twenty-six patients with iatrogenic nerve injury secondary to shoulder surgery. The records were reviewed to determine the operative procedure, time to presentation, findings on physical examination, treatment, and outcome. RESULTS: The average age was forty-three years (range, seventeen to seventy-two years), and the average delay prior to referral was 5.4 months (range, one to fifteen months). Seven nerve injuries resulted from open procedures done to treat instability; nine, from arthroscopic surgery; four, from total shoulder arthroplasty; and six, from a combined open and arthroscopic operation. The injury occurred at the level of the brachial plexus in thirteen patients and at a terminal nerve branch in thirteen. Fifteen patients (58%) did not recover nerve function after observation and required surgical management. A structural nerve injury (laceration or suture entrapment) occurred in nine patients (35%), including eight of the thirteen who presented with a terminal nerve branch injury and one of the thirteen who presented with an injury at the level of the brachial plexus. CONCLUSIONS: Nerve injuries occurring during shoulder surgery can produce severe morbidity and may require surgical management. Injuries at the level of a peripheral nerve are more likely to be surgically treatable than injuries of the brachial plexus. A high index of suspicion and early referral and evaluation should be considered when evaluating patients with iatrogenic neurologic deficits after shoulder surgery.

Nerve injuries resulting from arthroscopic treatment of lateral epicondylitis: report of 2 cases.

Arthroscopic management of lateral epicondylitis is a commonly performed procedure that has a good track record of efficacy and safety based on the current literature. Here, we report 2 cases of nerve injuries resulting from this operation: 1 posterior interosseous nerve transection and 1 partial median nerve laceration.

Gene therapy applications for fracture-healing.

Biologic therapies to promote fracture-healing such as use of bone morphogenetic proteins (BMPs) are being increasingly employed in multiple clinical scenarios. However, it has been challenging to design therapies that deliver sufficient quantities of protein over a sustained time period. A potential solution is the application of gene therapy that transfers genetic information to host cells at the fracture site, resulting in the continuous and localized production of the desired proteins. This approach has demonstrated tremendous potential in preclinical animal models of fracture-healing. This article will review the current state of gene therapy approaches to fracture-healing with an emphasis on potential clinical applications.

Olecranon fractures repaired with FiberWire or metal wire tension banding: a biomechanical comparison.

PURPOSE: Tension band constructs are commonly used for olecranon fracture fixation. The purpose of this study was to determine if a tension band constructed of FiberWire (Arthrex, Naples, FL), a high-strength polyester and polyethylene suture, will provide fixation that is equivalent to an 18-gauge metal wire tension band. METHODS: The following 4 fixation methods were biomechanically tested in cadaveric elbows with a simulated transverse olecranon fracture: (1) Kirschner wires (K-wires) with an 18-gauge metal wire tension band, (2) K-wires with a FiberWire tension band, (3) intramedullary screw with an 18-gauge metal wire tension band, and (4) intramedullary screw with a FiberWire tension band. Each elbow underwent all 4 repair methods. The K-wire repairs were performed first followed by the intramedullary screw repairs. The order of the tension band (FiberWire or metal wire) was randomly assigned. Specimens were tested under cyclic loading conditions that simulated stresses generated by (1) active range of motion and (2) pushing up from a chair. Fracture displacement was recorded by using transducers placed at the articular surface of the fracture and on the posterior surface of the olecranon. RESULTS: There were no significant differences in fracture displacement associated with the use of a high-strength suture or metal wire tension band under conditions simulating active range of motion or a more vigorous physiologic stress. Also, there were no significant differences associated with the use of an intramedullary screw versus K-wire fixation under either condition. CONCLUSIONS: The biomechanical characteristics of high-strength suture tension bands are equivalent to 18-gauge metal wire tension bands when used with either an intramedullary screw or K-wires. The fatigue patterns of high-strength suture tension bands and metal wire tension bands are similar. There is not a significant difference between the biomechanical strength of intramedullary screw fixation constructs and K-wire constructs. CLINICAL RELEVANCE: FiberWire tension bands may be used in place of metal wire tension bands without sacrificing fixation strength.

The anatomy of the bicipital tuberosity and distal biceps tendon.

The anatomy of the distal biceps tendon and bicipital tuberosity (BT) is important in the pathophysiology of tendon rupture, as well as surgical repair. Understanding the dimensions of the BT and its angular relationship to the radial head and radial styloid will facilitate surgical procedures such as reconstruction of the distal biceps tendon, radial head prosthesis implantation, and reconstruction of proximal radius trauma. We examined 178 dried cadaveric radii, and the following measurements were collected: radial length, length and width of the BT, diameter of the radius just distal to the BT, distance from the radial head to the BT, radial head diameter, width of the radius at the BT, radial neck-shaft angle, and styloid angle. Furthermore, the morphology of the BT ridge was defined as smooth (absent), small, medium, large, or bifid. Of the specimens, 48 were further analyzed with a computed tomography scanner at the level of the BT to determine the distance to traverse both the anterior and posterior cortex and the anterior cortex alone. Eighteen fresh-frozen cadaveric elbows were dissected, and the insertion footprint of the distal biceps tendon was defined. The BT has a mean length of 22 +/- 3 mm and a mean width of 15 +/- 2 mm. The tendon insertion footprint is a ribbon-shaped configuration on the most ulnar aspect of the BT, and it occupies 63% of the length and 13% of the width of the BT. The BT ridge is absent in 6% of specimens and bifid in 6%, and the remaining 88% of specimens have a single ridge that may be classified as small, medium, or large. The mean diameter of the radial head is 22 +/- 3 mm. The mean radial neck-shaft angle is 7 degrees +/- 3 degrees , and the mean BT-radial styloid angle is 123 degrees +/- 10 degrees . None of the measurements correlated with patient age, sex, or race. We concluded that the morphology of the BT ridge is variable. The insertion footprint of the distal biceps tendon is on the ulnar aspect of the BT ridge. The dimensions of the radius and BT are applicable to several surgical procedures about the elbow.