The Outcomes of Intra-Articular Distal Humerus Open Reduction and Internal Fixation Using Parallel Precontoured Plates in the Elderly.

PURPOSE: Inconsistent outcomes have been reported in several prior studies of elderly patients with distal humerus fractures treated with open reduction and internal fixation (ORIF). We evaluated the outcomes of ORIF using modern precontoured plates exclusively in a parallel orientation. METHODS: A retrospective review was performed to identify the patients aged over 65 years who sustained an isolated distal humerus fracture between 2015 and 2019. We identified 22 patients who underwent distal humerus ORIF using parallel, precontoured locking plates. Electronic medical records were reviewed for demographic characteristics, physical examination findings, and radiographic data. Outcomes were assessed with Quick Disabilities of the Arm, Shoulder, and Hand scores and Mayo Elbow Performance scores. Complications were evaluated by a review of the patient's medical record and postoperative radiographs. RESULTS: Of the included patients, 18 were women and 4 were men; the average age was 78 years (SD, 8.5 years), and the patients were followed for an average of 33 months. The sample consisted of 19 AO type C, 1 type B, and 2 type A fractures. At the final follow-up, the mean arc of total elbow flexion was 107° (SD, 18.9°; range 40° to 130°), with mean elbow flexion of 129° (SD, 11.7°; range, 120° to 140°) and mean extension of 22° (SD, 12.9°; range 0° to 90°). The mean Quick Disabilities of the Arm, Shoulder, and Hand score was 19 (SD, 14.4), and the mean Mayo Elbow Performance score was 86 (SD, 10.2). Complications occurred in 5 (23%) patients, requiring 4 subsequent surgeries, of which 1 was a conversion to total elbow arthroplasty. CONCLUSIONS: Older patients who underwent ORIF of the distal humerus using a parallel construct demonstrated good functional outcomes and similar complications to those in previously reported studies. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Two Parallel Headless Compression Screws for Scaphoid Fractures: Radiographic Analysis and Preliminary Outcome.

BACKGROUND: Despite surgical fixation, the scaphoid nonunion rate remains at 3% to 5%. Recent biomechanical studies have demonstrated increased stability with 2-screw constructs. The objective of our study is to determine the preliminary union rate and anatomic feasibility of 2-screw surgical fixation for scaphoid fractures. METHODS: This study is a retrospective case series of 25 patients (average age 32 years) with scaphoid fractures treated with 2 parallel headless compression screws (HCS). Postoperative evaluation included Mayo Wrist Score (MWS), range of motion, time to union, and return to activity. Bivariate analysis for gender and Pearson correlation coefficient for body size (height, weight, and body mass index) was conducted against radiographically measured scaphoid width, screw lengths, and the distance between the 2 screws. RESULTS: All fractures healed with an average time to union of 9.9 weeks (median 7.6 weeks; range: 4.1-28.3). The mean MWS was 93.3 (range: 55-100), with 3 complications (12%), one of which affected the outcome of the surgery. The bivariate analysis demonstrated that the female gender was associated with significantly smaller scaphoid width (P = .004) but a similar distance between the 2 screws (P = .281). The distance between the 2 screws and the body size demonstrated a weak-to-no correlation. CONCLUSIONS: The 2-screw construct for scaphoid fracture achieved a favorable union rate and clinical outcome. Gender was the only variable significantly associated with scaphoid width and screw length. The distance between the screws was constant regardless of gender and body size, indicating that the technique for parallel screw placement can remain consistent. TYPE OF STUDY: Therapeutic. LEVEL OF EVIDENCE: Level IV.

Second Harmonic Generation Microscopy as a Novel Intraoperative Assessment of Rat Median Nerve Injury.

PURPOSE: Nerves that are functionally injured but appear macroscopically intact pose the biggest clinical dilemma. Second Harmonic Generation (SHG) Microscopy may provide a real-time assessment of nerve damage, with the ultimate goal of allowing surgeons to accurately quantify the degree of nerve damage present. The aim of this study was to demonstrate the utility of SHG microscopy to detect nerve damage in vivo in an animal model. METHODS: Ten Sprague-Dawley rats were anesthetized and prepared for surgery. After surgical exposure and using a custom-made stretch applicator, the right median nerves were stretched by 20%, corresponding to a high strain injury, and held for 5 minutes. The left median nerve served as a sham control (SC), only being placed in the applicator for 5 minutes with no stretch. A nerve stimulator was used to assess the amount of stimulation required to induce a flicker and contraction of the paw. Nerves were then imaged using a multiphoton laser scanning microscope. RESULTS: Immediately after injury (day 0), SHG images of SC median nerves exhibited parallel collagen fibers with linear, organized alignment. In comparison with SC nerves, high strain nerves demonstrated artifacts indicative of nerve damage consisting of wavy, undulating fibers with crossing fibers and tears, as well as a decrease in the linear organization, which correlated with an increase in the mean stimulation required to induce a flicker and contraction of the paw. CONCLUSIONS: Second Harmonic Generation microscopy may provide the ability to detect an acute neural stretch injury in the rat median nerve. Epineurial collagen disorganization correlated with the stimulation required for nerve function. CLINICAL RELEVANCE: In the future, SHG may provide the ability to visualize nerve damage intraoperatively, allowing for better clinical decision-making. However, this is currently a research tool and requires further validation before translating to the clinical setting.

Two Cases of Delayed Flexor Tendon Rupture Decades After Reconstruction.

Two patients are presented with late-term ruptures of their flexor tendon grafts 10 and 40 years, respectively, after reconstruction. Both occurred from low-energy mechanisms. Their ruptures were intratendinous and not at the proximal or distal insertions. Electron microscopy demonstrated degeneration and increased matrix deposition. Immunohistology showed viable tenocytes, but no clear vascular organization to the disrupted grafts. Even after clinically successful flexor tendon autograft, tendons may still be at risk of degeneration and rupture a decade or more after reconstruction.

Applications of Vascular Imaging and Interventional Radiology Modalities in the Upper Extremity: A Review.

Hand and upper extremity (HUE) vascular disorders are encountered frequently by hand surgeons in clinical practice. A wide array of imaging and vascular interventional radiology modalities exists for the diagnosis and treatment of HUE vascular disorders, some of which may not be familiar to the HUE surgeons. In this review article, we summarize the vascular imaging and vascular interventional radiology modalities and their relative advantages, disadvantages, and indications with respect to HUE pathology. We aim to familiarize HUE surgeons with the available types of diagnostic and therapeutic options for HUE vascular pathologies and aid interdisciplinary communication with vascular interventional radiology specialists during the clinical decision-making process.

Mid-term outcomes after reverse total shoulder arthroplasty with latissimus dorsi transfer.

Background: Reverse total shoulder arthroplasty is a common treatment for patients with rotator cuff arthropathy who have failed a prior rotator cuff repair. Latissimus dorsi transfer can be performed simultaneously to reverse total shoulder arthroplasty for patients with preoperative external rotation deficiency. Current literature is limited with several studies providing functional and pain improvements at short-term follow-up; however, there is a deficit in data regarding mid-term outcomes. The purpose of this study was to evaluate the clinical and radiographic outcomes following reverse total shoulder arthroplasty with latissimus dorsi transfer with mid-term follow-up. We hypothesized significant improvement in external rotation and shoulder functionality for patients with preoperative external rotation lag. Methods: We retrospectively reviewed patients who underwent reverse total shoulder arthroplasty with latissimus dorsi transfer. Preoperative and postoperative changes in range of motion were assessed. American Shoulder and Elbow Surgeon Score and the Simple Shoulder Test were used to evaluate changes in shoulder function while pain scores were assessed using the Visual Analog Scale (VAS). Radiographs were reviewed for rotator cuff arthropathy, fatty infiltration, scapular notching, baseplate loosening, and osteolysis. We reported frequency and mean ± standard deviation for categorical and continuous variables, respectively. Means were compared using the paired Student's t-test and proportions using the Chi-square test. Results: Fifteen patients met the inclusion criteria. The mean age of the cohort was 71.7 ± 8.4 years (range 51.2-87.8 years) with a mean follow-up of 6.3 ± 4.1 years (range 1.0-14.5 years). Reverse total shoulder arthroplasty with latissimus dorsi transfer improved external rotation (-7 ± 21.3° to 38 ± 15.8°; p value = 0.001). There was no statistically significant difference regarding forward flexion (116.3 ± 45.4° to 133.7 ± 14.7°; p value = 0.17) and internal rotation (T12 to L2; p value = 0.57). The procedure led to an increase in American Shoulder and Elbow Surgeon Score scores (37 ± 19 to 62 ± 22; p = 0.005) and Simple Shoulder Test scores (2 ± 2 to 6 ± 3; p value = 0.001) with a significant reduction in Visual Analog Scale scores (5 ± 3 to 2 ± 3; p value = 0.022). The procedure corrected external rotation lag in 10 patients. Radiographically, rotator cuff arthropathy was found to be grade 3 in two patients, grade 4 A in four patients, grade 4B in eight patients, and grade 5 in one patient. On postoperative imaging, scapular notching was found in six patients (40%). Twelve patients had cortical humeral erosion at the site of the latissimus dorsi transfer. Only one patient experienced a shoulder-related complication which was aseptic baseplate loosening and required a revision reverse total shoulder arthroplasty with allograft. Conclusions: In this study, patients undergoing reverse total shoulder arthroplasty with latissimus dorsi transfer experienced improvements in range of motion, functional scores, and pain at mid-term follow-up. The shoulder-related complication rate was low.Level of evidence: IV; Case series.

Casting Position for Distal Radius Fractures Changes Radiocarpal Joint Forces: A Cadaveric Study.

PURPOSE: Nonsurgical distal radius fracture treatment requires immobilization and classical teaching suggests varying cast positions. We investigated the effect of cast position on the force and pressure experienced by the articular cartilage in the scaphoid and lunate fossae. METHODS: Ten fresh-frozen cadaveric specimens were used. A standardized extra-articular distal radius fracture was made. Force sensors were affixed to the articular cartilage of the scaphoid and lunate fossae. Baseline data were obtained. Specimens were then placed into a short arm cast with the wrist either neutrally aligned or flexed and ulnarly deviated (FUD). Specimens had a standard load applied, and a force profile was obtained. The cast was removed and the other cast type was placed and measurements were repeated. Overall force and pressure values were compared between baseline data and the 2 cast types. Additionally, differences in volar and dorsal scaphoid and lunate fossa forces and pressures were compared pairwise within the 2 cast types. The relative force and pressure values across cast types were also compared. RESULTS: Both cast types significantly reduced the median force and pressure experienced by the radiocarpal joint compared with no cast. In the FUD cast, the volar and dorsal lunate fossa experienced significantly greater force, and the dorsal lunate fossa experienced significantly greater pressure compared with the dorsal scaphoid fossa. There were no differences for any fossae in the neutral cast. When comparing between casts, the volar lunate fossa experienced a significantly greater relative force in the FUD cast compared with the neutral cast. CONCLUSIONS: Casting a distal radius fracture decreases the forces and pressures in the radiocarpal joint. Placing the wrist in a FUD position results in greater forces and pressures on the lunate fossa compared with the scaphoid fossa. CLINICAL RELEVANCE: When immobilization is needed, we advocate for the placement of patients in a relatively neutral short-arm cast with minimal FUD to avoid this increased pressure.

Outcomes of Arthroscopic Elbow Contracture Release: Improvement for Severe Prosupination and Flexion Contracture.

PURPOSE: The purpose of this study was to investigate outcomes following arthroscopic elbow contracture release to describe the use of arthroscopy for improvement in extension/flexion and pronation/supination arcs of motion at a single institution for degenerative and posttraumatic etiologies. METHODS: Consecutive arthroscopic elbow arthrolysis performed between 2003 and 2015 were retrospectively reviewed. Basic patient demographics, indications for surgery, preoperative and postoperative elbow range of motion, postoperative patient outcome score, and all complications were recorded and analyzed. RESULTS: Fifty-two patients were included with an average follow-up of 5.1 years (range 1.4 to 9.4). Severe contractures made up 50% of cases, followed by 23% moderate, and 27% mild. Average extension/flexion for the post-traumatic group (n = 30) increased by 63° ± 31 and by 29° ± 24 for the degenerative group (n = 22). Average gain in pronosupination was 38° ± 62 in the post-traumatic group and 13°±23 in the degenerative group. Postoperative DASH scores were 17.5 ± 18.4 for post-traumatic cases and 12.8 ± 19.3 for degenerative cases. CONCLUSION: Arthroscopic elbow contracture release is an effective intervention for degenerative and post-traumatic elbow contracture for both flexion/extension and pronosupination contracture. Furthermore, a two-stage release should be considered when both flexion and pronosupinaton contractures are present. LEVEL OF EVIDENCE: IV, case series, treatment study.

An Analysis of Profundus Tendon Repairs After Distal Phalanx Amputation in a Cadaveric Model of Little Finger Superficialis Deficiency.

PURPOSE: The flexor digitorum superficialis tendon to the little finger (FDS-5) has been observed to have a higher degree of functional and structural variation than the FDS of other digits. FDS-5-deficient individuals necessarily rely on the flexor digitorum profundus tendon to the little finger (FDP-5) for flexion in their little fingers. FDS-5 deficient patients who experience a considerable injury to their FDP-5 are therefore at a risk of losing substantial little finger flexion. The purpose of this study was to evaluate the degree of flexion of the little finger at the metacarpophalangeal and proximal interphalangeal (PIP) joints in a cadaveric model of FDS-5 deficiency following amputation of the distal phalanx. METHODS: Ten fresh-frozen cadaveric upper extremities with no prior trauma were used. Loads were applied to the FDP-5. Flexion at the PIP and metacarpophalangeal joints was measured in degrees with a goniometer. Little finger flexion testing was conducted under 5 different conditions: "baseline," "FDS-deficient," "no repair," "bone anchor" repair, and "A4 pulley" repair. RESULTS: The results were as follows: (1) no significant differences in the flexion between baseline and FDS-deficient conditions; (2) a significant decline in PIP flexion in the no repair condition after FDP-5 division compared with the FDS-deficient condition; (3) a significant restoration in PIP flexion in both surgical repair groups compared with the no repair group; and (4) no significant differences in PIP flexion between the A4 pulley and bone anchor groups. CONCLUSIONS: The bone anchor repair and the A4 pulley repair demonstrate similar abilities to restore flexion of the little finger at the PIP joint to baseline levels in this cadaveric model. CLINICAL RELEVANCE: A clinical protocol is yet to be established for the surgical treatment in FDS-5-deficient patients requiring amputation of the distal phalanx of the little finger. This study aims to address this area of uncertainty by comparing the little finger flexion after 2 different approaches to profundus tendon reattachment that may be applicable in this clinical scenario.

Solutions for the Unstable and Arthritic Elbow Joint.

An unstable, arthritic elbow presents a therapeutic challenge. Patients may have painful, limited range of motion, often due to trauma or progressive joint destruction from rheumatologic disease. The options for management may be particularly challenging when treating young, active patients. While elbow arthroplasty usually provides predictable pain relief and joint range of motion, concerns exist regarding postoperative activity limitations and implant survival. Therefore, these procedures are limited to select subsets of patients, typically low-demand, elderly patients. Interposition arthroplasty is an option for the young, active patient with a painful arthritic elbow.

Betadine-Soaked Alcohol Pad and Rigid Immobilization: An Inexpensive and Effective Method to Diminish Infections With Exposed Kirschner Wires in Hand Fractures.

This study describes a novel method of pin care with a Betadine-soaked alcohol pad in conjunction with immobilization to reduce pin site complications in hand fractures treated with exposed Kirschner wires (K-wires). We conducted a retrospective review of all phalangeal and metacarpal fractures from 2010 to 2016 treated with K-wire fixation, a Betadine-soaked alcohol pad, and immobilization in a well-moulded plaster cast. A total of 155 patients with metacarpal or phalangeal fractures were identified, of which 149 were included with 164 fractures treated with 217 exposed K-wires. Overall complication rate was 6.1% (10/164), of which 3 fractures (1.8%) developed infections. Two infections occurred in patients with a history of organ transplantation. The most common complication was stiffness requiring closed manipulation under anesthesia (2.4%, 4/164), resulting in full range of motion in 3 of 4 patients. Exposed K-wires remain an effective method of hand fracture fixation associated with a low complication rate.

La présente étude décrit une nouvelle méthode de soins des broches avec un tampon d'alcool imprégné de bétadine conjointement avec l'immobilisation pour réduire les complications au foyer des broches en cas de fractures de la main traitées par des broches K exposées. Les chercheurs ont effectué une analyse rétrospective de toutes les fractures phalangiennes et métacarpiennes traitées par des broches K entre 2010 et 2016, un tampon d'alcool imprégné de bétadine et une immobilisation dans un plâtre bien moulé. Ils ont repéré 155 patients victimes de fractures métacarpiennes ou phalangiennes et en ont inclus 149 qui ont été traités par 217 broches K exposées. Le taux de complication globale s'élevait à 6,1 % (dix sur 164) et trois fractures (1,8 %) se sont infectées. Deux infections se sont produites chez des patients ayant subi une transplantation d'organe. La complication la plus courante était une rigidité exigeant une manipulation fermée sous anesthésie (2,4 %, quatre sur 164), qui a favorisé une pleine amplitude de mouvement chez trois des quatre patients. Les broches K exposées demeurent une méthode efficace de fixation des fractures de la main, associées à un faible taux de complication.

Is Wikipedia a complete and accurate source for musculoskeletal anatomy?

PURPOSE: Wikipedia is a popular online encyclopedia generating over 5.4 billion visits per month, and it is also a common resource for the general public and professionals for medical information. The goal of this study is to determine the accuracy and completeness of Wikipedia as a resource for musculoskeletal anatomy. METHODS: The origin, insertion, innervation, and function of all muscles of the upper and lower extremities as detailed on Wikipedia was compared to the available corresponding information in Grant's Atlas of Anatomy (14th edition). Entries were scored for both accuracy and completeness. Descriptive statistics were calculated and associations between and within entries for accuracy and completeness were assessed by McNemar's tests. Information on Wikipedia's references was also collected. RESULTS: Overall, data on Wikipedia was 97.6% complete and 98.8% accurate when compared to Grant's Atlas of Anatomy. 78.6% of all entries were fully complete and accurate, with 15.3% of entries containing one error and 6.1% containing two errors. There were no associations between or within entries' accuracy and completeness. Only 62% of references from Wikipedia included were from academic sources. CONCLUSIONS: Musculoskeletal anatomy entries on Wikipedia are imperfect; they have inaccurate and missing information. Furthermore, a considerable proportion of references cited in entries are from poorly identified sources. While Wikipedia is an easily accessible resource for a large number of people and much of the anatomic information is appropriate, it cannot be considered to be an equivalent resource when compared to anatomic texts.

Treatment of Traumatic Elbow Instability With an Internal Joint Stabilizer.

PURPOSE: Current options for treating elbow instability include bony and/or ligamentous fixation with orthosis or cast immobilization, transarticular cross-pinning, temporary bridge plating, and hinged or rigid external fixation. Our purpose was to evaluate the recently developed internal joint stabilizer (IJS), which acts as an internal external fixator of the elbow. Our primary end point was to assess whether use of the device results in a stable and congruent reduction of the ulnohumeral and radiocapitellar joints in patients with acute or chronic elbow instability as a result of trauma. In our series, patients with elbow instability as a result of acute or chronic trauma were treated with an IJS. METHODS: This retrospective study reviewed 20 patients who underwent placement of a U.S. Food and Drug Administration (FDA)-approved IJS for elbow instability. Serial physical examinations and radiographs were performed to verify stability. Patients were instructed that, if they are dissatisfied with their postoperative motion, a secondary contracture release operation will be offered to them. Patients were asked to complete outcome-scoring questionnaires including the Disabilities of the Arm, Shoulder, and hand (DASH) and Mayo Elbow Performance (MEP) score. Complications were monitored for all patients. RESULTS: Twenty patients who underwent placement of an IJS for persistent elbow instability were reviewed. Patients with a flexion-extension arc of 70° or less at 12 weeks were offered a staged arthroscopic contracture release. The average MEP score improved from 12.2 ± 12.4 to 82.5 ± 14.3 and the average DASH score improved from 85.3 ± 23.0 to 37.26 ± 29.3. The average postoperative flexion-extension arc at most recent follow-up was 124.3° ± 14.9°, with a median follow-up of 17 months (8 weeks-25 months). CONCLUSIONS: Use of an IJS allows for early, congruent, and stable ulnohumeral and radiocapitellar range of motion in instances of persistent elbow instability. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Comparative strength of elbow splint designs: a new splint design as a stronger alternative to posterior splints.

BACKGROUND: Musculoskeletal injuries of the upper extremity are frequently treated with temporary external immobilization. Traditionally, long arm posterior splints have been used to limit flexion/extension of the elbow. However, long arm posterior splints have been observed to fail clinically, necessitating a stronger alternative. In this study, we assessed the biomechanical strength of the long arm posterior splint compared with a new spiral splint design. METHODS: One male and one female participant were placed 10 times in long arm posterior splints and 10 times in spiral splints. Both splint types were subjected to a downward mechanical load of 39.2 N (4 kg) and assessed for a change in both flexion/extension and pronation/supination. RESULTS: There was no significant difference in starting position or starting flexion/extension between the 2 splint designs. Posterior splints allowed significantly greater initial pronation/supination compared with spiral splints. Both splint groups had significant increases in flexion/extension and pronation/supination compared with their starting ranges of motion. There was no significant difference in the change in pronation/supination between the 2 splint groups. Finally, posterior splints allowed a significantly greater change in flexion/extension compared with spiral splints. CONCLUSION: Spiral splints offered less initial pronation/supination than long arm posterior splints. Furthermore, spiral splints are able to resist flexion/extension of the elbow after application of a downward mechanical load better than posterior splints, thus suggesting spiral splints are mechanically superior to long arm posterior splints.

Arthroscopic Treatment of Lateral Elbow Pain Mimicking Lateral Epicondylitis: Long-term Follow-up of a Unique Surgical Protocol.

HYPOTHESIS AND/OR BACKGROUND: The failure rate of extensor carpi radialis brevis debridement for refractory lateral epicondylitis is reported around 15%. Our novel arthroscopic treatment is predicated on the hypothesis that lateral epicondylitis is an intra-articular problem related to a variation of the capsule-meniscal anatomy that impinges on the radiocapitellar joint. We report long-term outcomes of 35 patients treated with a novel arthroscopic resection of their capsulosynovial fringe. METHODS: All patients failed nonoperative treatment but had temporary improvement with an intra-articular injection. Arthroscopic treatment involved resecting the meniscus and the proximal edge of the orbicular ligament, followed by a tendon-sparing anterolateral capsulectomy. 35 patients underwent evaluation on average 9.2 years after surgery. Outcome measures included VAS, DASH, and questions on return to sports, satisfaction, and perceived benefit of surgery. RESULTS: Median pain scores improved from 8 of 10 preoperatively to 0 of 10 postoperatively. This change was clinically and statistically significant, with 1 patient still requiring pain medication. Median DASH score at final follow-up was 1. Overall, 30 patients rated their postoperative outcome as much better, 5 rated it as better, and 0 reported their symptoms to be unchanged or worsened. All 35 patients stated they were happy they underwent the procedure and perceived a benefit. Totally, 4 of 35 patients had postoperative complications (2 with ulnar nerve symptoms, 2 with persistent pain), with one requiring revision surgery for persistent pain. DISCUSSION AND/OR CONCLUSIONS: We report promising long-term clinical and functional results of a novel arthroscopic resection of the capsulosynovial complex in lateral epicondylitis.

Arthroscopic Elbow Contracture Release in the Pediatric Patient.

BACKGROUND: Elbow contracture is a sequelae of elbow trauma in pediatric patients. Arthroscopic contracture release has been shown to provide equivalent results to open contracture release with less associated morbidity and complications in the adult population. However, open contracture release is still commonly utilized in pediatric patients. The goal of this study is to determine the clinical results and safety profile of arthroscopic elbow contracture release in the pediatric population. METHODS: A retrospective review of all patients 18 years of age and younger who underwent arthroscopic elbow contracture release was performed. Demographic statistics, indication for surgery, preoperative and postoperative flexion-extension and pronation-supination range of motion, and all complications were recorded and analyzed. RESULTS: Twenty-five patients were identified as having undergone 29 arthroscopic elbow contracture releases. The most common index injury was elbow contracture after radial head fracture. The flexion-extension arc of motion improved from 93.0±39.9 degrees to 128.0±19.2 degrees for a total improvement of 35.2 degrees (P=0.0002), whereas the pronation-supination arc of motion improved from 141.0±58.6 degrees to 153±49.3 degrees for a total improvement of 12.2 degrees (P=0.097). There were 7 total complications. CONCLUSIONS: Arthroscopic elbow contracture release allows for restoration of range of motion with an acceptable safety profile and can be considered as a less invasive alternative to open contracture release in the pediatric population. LEVEL OF EVIDENCE: Level IV.

A Novel Algorithmic Approach to Chronic Forearm Longitudinal Instability.

Essex-Lopresti Lesions are rare injuries that are often missed in the acute setting. Delayed intervention may lead to chronic wrist and elbow pain and overall poor outcomes. The literature currently supports treatments that involve shortening of the ulna to reduce the relative degree of ulnar impaction, followed by attempted reduction of the distal radioulnar joint. Although such techniques may help to temporarily reduce wrist pain secondary to ulnar impaction, they do not address the proximal migration of the radius and ipsilateral radial head dislocation at the elbow. Subsequent procedures are often needed to replace or resect the radial head. We present a novel approach to chronic Essex-Lopresti lesions resulting in anatomic restoration of forearm length with return of elbow and wrist flexion/extension as well as improved forearm pronation/supination.

Varus posteromedial rotatory instability: a biomechanical analysis of posterior bundle of the medial ulnar collateral ligament reconstruction.

BACKGROUND: Recently, there has been growing interest in the involvement of the posterior bundle of the medial ulnar collateral ligament (pMUCL) in varus posteromedial rotatory instability (PMRI). Varus PMRI has been observed clinically, but the degree of involvement of the pMUCL remains unclear. This study assessed the degree to which the pMUCL is involved in stabilizing the elbow and the feasibility of a pMUCL reconstruction to restore stability. METHODS: Movements simulating PMRI were performed in 8 cadaveric elbows. Joint gapping values were obtained by 3-dimensional motion capture for the proximal and distal aspects of the ulnohumeral joint. Specimens were assessed at "intact," "cut coronoid + pMUCL," "reconstruction," and "cut anterior aspect MUCL + reconstruction" conditions with mechanical testing at 30°, 60°, and 90° of elbow flexion. RESULTS: Proximal joint gapping significantly increased from intact to cut coronoid + pMUCL at 60° and 90°, and distal joint gapping significantly increased at 90°. In the reconstruction condition, joint gapping across the proximal joint at 60° and 90° significantly recovered, as did distal joint gapping at 90°. In the cut anterior aspect MUCL + reconstruction condition, no significant increase occurred in proximal or distal joint gapping. CONCLUSIONS: Transection of the pMUCL with a coronoid fracture leads to increased joint gapping, suggesting the presence of PMRI. PMRI can still occur with an intact lateral ligamentous complex. A pMUCL tendon graft reconstruction confers some elbow stability in this injury mechanism.