Surgical Treatment of Post-traumatic Elbow Stiffness by Wide Posterior Approach.

Objective To demonstrate the clinical outcomes and complication rates of the surgical release with a single posterior approach in the treatment of post-traumatic elbow stiffness. Methods A prospective study with patients submitted to surgery between May 2013 and June 2018 in a single center. The access to the elbow was made through the posterior approach. The patients were followed up by an occupational therapy team, and were submitted to a standardized rehabilitation protocol, with static progressive orthoses and dynamic orthoses. The primary outcome was the range of flexion-extension of the elbow after 6 months. Results A total of 26 patients completed the minimum follow-up of 6-months. The mean range of flexion-extension of the elbow at the end of 6 months was of 98.3 ± 22.0°, with an amplitude gain of 40.0 ± 14.0° in relation to the pre-operative period ( p < 0.001). The average flexion-extension gain at the end of 6 months was of 51.7% ± 17.1% ( p < 0.001). The mean pronosupination at the end of 6 months was of 129.0 ± 42.7° ( p < 0.001). Half of the cases had moderate and severe stiffness in the pre-operative period, compared with 7.7% at 6 months post-operatively ( p < 0.001). The mean score for the Mayo Elbow Performance Score (MEPS) and Disabilities of the Arm, Shoulder and Hand (DASH) instruments was 74.4 ± 16.8 points and 31.7 ± 21.9 points respectively ( p < 0.001 for both). The visual analogue scale (VAS) score presented no statistically significant difference compared to the pre-operative period ( p = 0.096). Complications were observed in 6 (23%) patients, and no new surgical procedures were necessary. Conclusions The surgical release of the elbow associated with a rehabilitation protocol is a safe technique, with satisfactory results and low rate of complications.

Surgical Treatment of Post-traumatic Elbow Stiffness by Wide Posterior Approach / Tratamento cirúrgico da rigidez pós-traumática do cotovelo por via posterior ampla

Abstract Objective To demonstrate the clinical outcomes and complication rates of the surgical release with a single posterior approach in the treatment of post-traumatic elbow stiffness. Methods A prospective study with patients submitted to surgery between May 2013 and June 2018 in a single center. The access to the elbow was made through the posterior approach. The patients were followed up by an occupational therapy team, and were submitted to a standardized rehabilitation protocol, with static progressive orthoses and dynamic orthoses. The primary outcome was the range of flexion-extension of the elbow after 6 months. Results A total of 26 patients completed the minimum follow-up of 6-months. The mean range of flexion-extension of the elbow at the end of 6 months was of 98.3 ± 22.0°, with an amplitude gain of 40.0 ± 14.0° in relation to the pre-operative period (p< 0.001). The average flexion-extension gain at the end of 6 months was of 51.7% ± 17.1% (p< 0.001). The mean pronosupination at the end of 6 months was of 129.0 ± 42.7° (p< 0.001). Half of the cases had moderate and severe stiffness in the pre-operative period, compared with 7.7% at 6 months post-operatively (p< 0.001). The mean score for the Mayo Elbow Performance Score (MEPS) and Disabilities of the Arm, Shoulder and Hand (DASH) instruments was 74.4 ± 16.8 points and 31.7 ± 21.9 points respectively (p< 0.001 for both). The visual analogue scale (VAS) score presented no statistically significant difference compared to the pre-operative period (p= 0.096). Complications were observed in 6 (23%) patients, and no new surgical procedures were necessary. Conclusions The surgical release of the elbow associated with a rehabilitation protocol is a safe technique, with satisfactory results and low rate of complications.

Resumo Objetivo Demonstrar os resultados clínicos e a taxa de complicações da liberação cirúrgica por via única posterior no tratamento da rigidez pós-traumática de cotovelo. Métodos Estudo prospectivo, com pacientes submetidos a cirurgia entre maio de 2013 e junho de 2018 em um único centro. Foi realizado acesso ao cotovelo por via posterior. O seguimento dos pacientes foi feito por uma equipe de terapia ocupacional, e eles foram submetidos a um protocolo de reabilitação padronizado, com órteses estáticas progressivas e dinâmicas. O desfecho primário foi a amplitude de flexoextensão do cotovelo após 6 meses. Resultados Um total de 26 pacientes completaram o seguimento mínimo de 6 meses. A média de flexoextensão do cotovelo, ao final de 6 meses, foi de 98,3° ± 22,0°, com um ganho de amplitude de 40,0° ± 14,0° em relação ao pré-operatório (p< 0,001). A média de ganho relativo de flexoextensão, ao final de 6 meses, foi de 51,7% ± 17,1% (p< 0,001). A média de pronossupinação, ao final de 6 meses, foi de 129,0° ± 42,7° (p< 0,001). Metade dos casos apresentava rigidez moderada e grave no pré-operatório, contra 7,7% aos 6 meses de pós-operatório (p< 0,001). A pontuação nos instrumentos Mayo Elbow Performance Score (MEPS) e Disabilities of the Arm, Shoulder and Hand (DASH) apresentou melhora estatisticamente significativa em relação ao pré-operatório, atingindo 74,4 ± 16,8 pontos e 31,7 ± 21,9 pontos, respectivamente. A escala visual analógica (EVA) não apresentou diferença estatisticamente significativa em relação ao pré-operatório (p= 0,096). Complicações foram observadas em 6 (23%) pacientes, não sendo necessária nova abordagem cirúrgica em nenhum paciente. Conclusões A liberação cirúrgica do cotovelo associada a protocolo de reabilitação é técnica segura, com resultados satisfatórios e baixa taxa de complicações.

Randomized trial for the treatment of post-traumatic elbow stiffness: surgical release vs. rehabilitation.

BACKGROUND: There are no previous randomized trials comparing surgical to conservative treatment for post-traumatic elbow stiffness. The aim of our study was to compare elbow range of motion (ROM) and clinical outcomes among patients undergoing surgical treatment or a standardized rehabilitation for post-traumatic elbow stiffness. METHODS: Randomized clinical trial of patients with post-traumatic elbow stiffness for more than 6 months who failed conventional physical therapy for 4 months. Patients were randomized into 2 treatment groups. The conservative group underwent the rehabilitation protocol associated with the use of orthoses (static progressive for extension and dynamic for flexion) and continuous passive motion. The surgical group underwent surgical release by a posterior approach without triceps detachment, followed by a rehabilitation protocol similar to the conservative group. The primary outcome of the study was flexion-extension ROM at 6 months of follow-up. Secondary outcomes included the visual analog scale for pain, the Mayo Elbow Performance Score, the Disabilities of the Arm, Shoulder, and Hand score, absolute and relative increase in flexion-extension ROM, and complication rates. RESULTS: Thirty patients were analyzed in the study, 15 in each group. The mean elbow flexion-extension ROM at the end of 6 months of follow-up was 108° in the surgical group and 88° in the conservative group (P = .002). The mean absolute and the relative increase of elbow flexion-extension at 6 months were, respectively, 17° and 27% in the conservative group and 41° and 59% in the surgical group (P < .001). CONCLUSION: Surgical elbow release associated with the rehabilitation protocol resulted in a greater flexion-extension ROM, as well as a greater absolute and relative increase compared with rehabilitation alone at 6 months of follow-up. The groups did not differ regarding clinical scores and complication rates.

Accuracy of preoperative MRI in the diagnosis of subscapularis tears.

INTRODUCTION: The subscapularis has received little attention in the orthopedic literature, although such lesions are evident in up to 40 % of arthroscopies. An accurate diagnosis is important in clinical practice, as it affects both patient prognosis and surgical planning. The aim of this study was to evaluate the accuracy of preoperative MRI for the identification of subscapularis tears. Our secondary aim involved the identification of factors that may be predictive for the presence of subscapularis tears. MATERIALS AND METHODS: This retrospective case series included patients undergoing shoulder arthroscopy due to rotator cuff injury. MRI was performed using a 1.5 T unit, and the results were assessed by a musculoskeletal radiologist. The findings were compared to those of arthroscopic inspection. RESULTS: A total of 93 shoulders were analyzed. The overall accuracy was 82 %, with values of 79 % for partial tears and 89 % for full-thickness tears. Tears requiring repair demonstrated an accuracy of 88 %. Infraspinatus tears, fatty degeneration of the subscapularis, biceps instability and age were identified as predictive factors for the presence of injury. CONCLUSIONS: MRI of the shoulder demonstrated an accuracy of 82 % for the diagnosis of subscapularis tears. The accuracy values for partial and full-thickness tears were 79 and 89 %, respectively. LEVEL DE EVIDENCE: III, development of diagnostic criteria with universally applied reference-nonconsecutive patients.

Accuracy of preoperative MRI in the diagnosis of disorders of the long head of the biceps tendon.

OBJETIVES: To evaluate the accuracy of magnetic resonance imaging (MRI) in the detection of disorders of the long head of the biceps tendon (LHBT). The secondary objective was to investigate predictive factors for tears and instability. METHODS: This retrospective case series involved patients undergoing shoulder arthroscopy due to rotator cuff injury. MRI was performed in a 1.5T scanner and was evaluated by a musculoskeletal radiologist. The findings were compared with those of arthroscopic inspection. RESULTS: A total of 90 shoulders were analyzed. Regarding tears, there was 67% sensitivity and 98% specificity. Regarding instabilities, the values were 53% and 72%, respectively. Tears and fatty degeneration of the infraspinatus are predictive factors for tears of the LHBT. Tears of the subscapularis and infraspinatus, retraction of the supraspinatus and infraspinatus equal to or greater than 30mm, and fatty degeneration of the infraspinatus and subscapularis are predictive factors for instability. CONCLUSION: Compared to arthroscopy, the shoulder MRI has a sensitivity of 67% and a specificity of 98% for the detection of complete tears of the LHBT. For instability, the values are 53% and 72%, respectively.