Efficacy of a high-intensity home stretching device and traditional physical therapy in non-operative management of adhesive capsulitis - a prospective, randomized control trial.

BACKGROUND: Historically, in-person physical therapy serves as a foundational component of nonoperative treatment of adhesive capsulitis (AC). This study compares the effectiveness of an at-home high-intensity stretch (HIS) device to traditional physical therapy (PT) and to PT in combination with the HIS device. We hypothesize that the HIS device will be as effective as PT alone or as combination therapy in the first-line treatment of AC and use of the HIS device will exhibit improvement at higher rate. METHODS: Thirty-four patients with idiopathic adhesive capsulitis and a minimum of 12 months follow-up were included in this study. Patients were randomized into one of the three groups: HIS device, PT alone, or HIS device + PT. Passive range of motion (ROM), American Shoulder and Elbow Surgeons (ASES), and Simple Shoulder Test (SST) scores were measured. Additionally, patient satisfaction, compliance and complications were recorded. Paired t-test, ANOVA and Chi-squared tests were used in analysis. RESULTS: Final ROM in all planes improved for all groups compared to baseline (p < 0.001), with only HIS device group able to restore > 95% of contralateral ROM in all planes at final follow-up. Patients with PT alone were on average slowest to improve ROM from baseline, at 3 months, 6 months, and 1 year in all planes except internal rotation. ASES and SST scores improved for all groups when compared to baseline (p < 0.001). Use of HIS-device resulted in greater improvement in SST and ASES Total scores compared to PT alone (p = 0.045, and p = 0.048, respectively). CONCLUSIONS: Use of an at-home high-intensity stretching device for conservative treatment of idiopathic adhesive capsulitis improves outcomes in ROM and in ASES and SST scores both when used as an adjunct to physical therapy and when used alone. TRIAL REGISTRATION: The study protocol was registered at www. CLINICALTRIALS: gov (20/05/2022, NCT05384093).

Improvements in Sleep After Shoulder Arthroscopy Are Correlated With Improvements in Various Patient-Reported Outcomes: A Systematic Review.

Purpose: To determine the prevalence of sleep disturbances in patients before and after arthroscopic surgery of the shoulder and to evaluate the association between patient-reported outcomes and standardized sleep disturbance tools after shoulder arthroscopy. Methods: A systematic review, following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines, was conducted by searching the PubMed, Embase, and Scopus databases using the terms "arthroscopic surgery" and "sleep." Two independent reviewers evaluated the studies based on the inclusion criteria focused on the effects of shoulder arthroscopy on sleep disturbance and the use of outcome measures related to sleep. Data on sleep quality and functional outcomes were collected and analyzed using various assessment tools, including the Pittsburgh Sleep Quality Index and American Shoulder and Elbow Surgeons score. The methodologic quality of included studies was assessed using the Methodological Index for Non-randomized Studies (MINORS) criteria. Results: The review included 15 studies (9 Level IV, 5 Level III, and 1 Level II) comprising 1,818 arthroscopic patients (average age, 57.4 ± 8.86 years; follow-up range, 6 months to 75.7 months). The prevalence rates of sleep disturbances before and after shoulder arthroscopy ranged from 75.8% to 100% and from 19% to 62%, respectively. Every study included in this analysis reported an improvement in rates of sleep disturbances postoperatively compared with preoperatively. Improvements in standardized sleep disturbance scores were associated with functional outcomes. Conclusions: Sleep disturbances are commonly observed before and after arthroscopic surgery of the shoulder. Arthroscopic surgery of the shoulder appears to improve sleep quality, and surgeons can expect functional outcomes, specifically the American Shoulder and Elbow Surgeons score, Simple Shoulder Test score, numeric rating scale or visual analog scale score, and Constant-Murley score, to improve in line with sleep quality. Level of Evidence: Level IV, systematic review of Level II to IV studies.

Radiographic Description of Soft Tissue Attachments around the Elbow.

Objectives: Quantitatively define the radiographic locations of the major soft-tissue attachments about the elbow. Methods: In 10 cadaveric elbows, the attachments of the medial ulnar collateral ligament, lateral ulnar collateral ligament, annular ligament, triceps, and biceps were marked with radiopaque spheres. Measurements were made on calibrated AP and lateral fluoroscopic images from known osseous landmarks. Results: On AP radiographs; the anterior bundle of the MUCL (aMUCL) measured 28.6mm (95% CI, 27. 5-29.8mm) from the humeral attachment to the midpoint of the MUCL ridge on the ulna and 14.3mm, (95% CI 13.0-15.5) to the olecranon. The LUCL was 39.9mm (95% CI, 38.6 - 41.1mm) from the humeral attachment to the supinator crest attachment and 8.9mm (95% CI, 8.1-9.8mm) to the lateral epicondyle. On the lateral radiographs, the humeral attachment of the aMUCL to the medial coronoid was 27.1mm (95% CI, 25.9-28.2mm) and 9.3mm (95%CI, 17.5 -21.2mm) to the tip. The LUCL humeral attachment to the supinator crest was 45.4mm (95%CI, 44.1-46.8mm). The LUCL humeral attachment was located 8.9mm (95%CI, 8.0-9.7mm) posterior from the anterior humeral line. Conclusion: The soft-tissue attachments about the elbow were reproducibly demonstrated on radiographs in relation to osseous landmarks and radiographic lines. The radiographic relationships will allow for improved identification of the ligament and tendon attachment sites of the elbow for intraoperative assessment and postoperative evaluation following reconstruction.

An Injectable Calcium Phosphate Bone Graft Substitute Improves the Pullout Strength of Various Suture Anchor Designs in an Osteoporotic Bone Model.

Purpose: To compare various suture anchor designs with and without calcium phosphate (CaP) augmentation in an osteoporotic foam block model and decorticated proximal humerus cadaveric model. Methods: This was a controlled biomechanical study, consisting of 2 parts: (1) an osteoporotic foam block model (0.12 g/cc; n = 42) and (2) a matched pair cadaveric humeral model (n = 24). Suture anchors selected were an all-suture anchor, PEEK (polyether ether ketone)-threaded anchor, and a biocomposite-threaded anchor. For each study arm, one half the samples were first filled with injectable CaP and the other half were not augmented with CaP. For the cadaveric portion, the PEEK- and biocomposite-threaded anchors were assessed. Biomechanical testing consisted of a stepwise, increasing load protocol for a total of 40 cycles, followed by ramp to failure. Results: For the foam block model, the average load to failure for anchors with CaP was significantly greater when compared with anchor fixation augmented without CaP; the all-suture anchor was 135.2 ± 20.2 N versus 83.3 ± 10.3 N (P = .0006); PEEK was 131 ± 34.3 N versus 58.5 ± 16.8 N (P = .001); and biocomposite was 182.2 ± 64.2 N versus 80.8 ± 17.4 N (P = .004). For the cadaveric model, the average load to failure for anchors augmented with CaP was again greater than anchor fixation without CaP; PEEK anchors went from 41.1 ± 21.1 N to 193.6 ± 63.9 N (P = .0034) and biocomposite anchors went from 70.9 ± 26.6 N to 143.2 ± 28.9 N (P = .004). Conclusions: Augmenting various suture anchors with CaP has shown to significantly increase pull-out strength and stiffness in an osteoporotic foam block and time zero cadaveric bone model. Clinical Relevance: Rotator cuff tears are common in the elderly patients, in whom poor bone quality jeopardizes treatment success. Exploring methods that increase the strength of fixation in osteoporotic bone to improve outcomes in this patient population is important.

What factors can reduce the need for repeated revision for humeral loosening in revision total elbow arthroplasty?

BACKGROUND: This study aimed to determine the re-revision rate in a cohort of patients who underwent revision total elbow arthroplasty (rTEA) for humeral loosening (HL) and identify factors contributing to re-revision. We hypothesized that proportional increases in the stem and flange lengths would stabilize the bone-implant interface significantly more than a disproportional increase in stem or flange length alone. Additionally, we hypothesized that the indication for the index arthroplasty would impact the need for repeated revision for HL. The secondary objective was to describe the functional outcomes, complications, and presence of radiographic loosening after rTEA. METHODS: We retrospectively reviewed 181 rTEAs performed from 2000-2021. We included 40 rTEAs for HL performed on 40 elbows that either required a subsequent revision for HL (10 rTEAs) or had a minimum of 2 years of clinical or radiographic follow-up. One hundred thirty-one cases were excluded. Patients were grouped based on stem and flange length to determine the re-revision rate. Patients were divided based on re-revision status into the single-revision group and the re-revision group. The stem-to-flange length (S/F) ratio was calculated for each surgical procedure. The mean length of clinical and radiographic follow-up was 71 months (range, 18-221 months and 3-221 months, respectively). RESULTS: Rheumatoid arthritis was statistically significant in predicting re-revision total elbow arthroplasty for HL (P = .024). The overall re-revision rate for HL was 25% at an average of 4.2 years (range, 1-19 years) from the revision procedure. There was a significant increase in stem and flange lengths from the index procedure to revision, on average by 70 ± 47 mm (P < .001) and 28 ± 39 mm (P < .001), respectively. In the cases of re-revision (n = 10), 4 patients underwent an excisional procedure; in the remaining 6 cases, the size of the re-revision implant increased on average by 37 ± 40 mm for the stem and 73 ± 70 mm for the flange (P = .075 and P = .046, respectively). Furthermore, the average flange in these 6 cases was 7 times shorter than the average stem (S/F ratio, 6.7 ± 2.2). This ratio was significantly different from that in cases that were not re-revised (P = .03; S/F ratio, 4.2 ± 2). Mean range of moion was 16° (range, 0°-90°; standard deviation, 20°) extension to 119° (range, 0°-160°; standard deviation, 39°) flexion at final follow-up. Complications included ulnar neuropathy (38%), radial neuropathy (10%), infection (14%), ulnar loosening (14%), and fracture (14%). None of the elbows were considered radiographically loose at final follow-up. CONCLUSION: We show that a primary diagnosis of rheumatoid arthritis and a humeral stem with a relatively short flange relative to the stem length significantly contribute to re-revision of total elbow arthroplasty. The use of an implant where the flange can be extended beyond one-fourth of the stem length may increase implant longevity.

Unstable Middle Phalanx Base Fractures Treated With an Internal Joint Stabilizer: Preliminary Results.

BACKGROUND: Unstable fractures of the base of the middle phalanx are notorious for causing chronic loss of proximal interphalangeal (PIP) joint function, and they remain a challenge for the hand surgeon. We report on a temporary intraoperatively constructed internal joint stabilizer for unstable PIP joint injuries. METHODS: Across 2 institutions, a retrospective chart review was performed for cases with acute presentation of pilon fracture or fracture-dislocation of the base of the middle phalanx which were surgically treated with an internal joint stabilizer. Information collected included time from injury to surgical intervention, time from implantation to device removal, complications, and preoperative and postoperative range of motion. RESULTS: Seven patients met the inclusion criteria with a mean age of 51 (range: 24-72) years and a mean follow-up of 29 (range: 11-72) months. After removal of the fixator, the mean arc of PIP joint motion was 8° to 88° (range: 0°-100°). There were no infections, no hardware loosening or failures, and no revision procedures. CONCLUSION: The current findings are comparable to the results for dynamic external fixators. An internal joint stabilizer for unstable injuries to the base of the middle phalanx provides satisfactory functional outcomes, allows early postoperative motion, and mitigates the routine complications which may arise with external fixation.

Impact of State Opioid Regulation on Postoperative Opioid Prescribing Patterns for Total Knee Arthroplasty: A Retrospective Analysis.

BACKGROUND: Limited studies have assessed the impact of state regulations on opioid prescribing patterns for patients undergoing total knee arthroplasty (TKA). This study evaluates how Florida House Bill 21 (FL-HB21) affected postoperative opioid prescribing for patients after TKA. METHODS: Institutional review board approval was obtained to retrospectively review all patients who underwent TKA during 3 months of 2017 (pre-law) and 2018 (post-law) by five arthroplasty surgeons in Florida. Prescribed opioid quantity in morphine milligram equivalents (MME), quantity of refills, and number of prescribers were recorded for each patient's 90-day postsurgical episode. The differences between pre-law and post-law prescription data and short-term postoperative pain levels were compared. RESULTS: The average total MME was notably reduced by over 30% for all time periods for the post-law group. The average MME per patient decreased by 169 MME at the time of discharge, by 245 MME during subsequent postoperative visits, and by 414 MME for the 90-day postsurgical episode ( P < 0.001 for all). The quantity of refills was unchanged (1.6 vs. 1.6, P = 0.885). The total number of prescribers per patient for the 90-day postsurgical episode was unchanged (1.31 vs. 1.24 prescribers/patient, P = 0.16). Postoperative pain levels were similar at discharge (3.6 pre-law vs. 3.3 post-law, P = 0.272). DISCUSSION: Restrictive opioid legislation was associated with notably reduced postoperative opioid (MME) prescribed per patient after TKA at the time of discharge and for the entire 90-day postsurgical episode. There was no increase in the number of prescribers or refills required by patients. LEVEL OF EVIDENCE: Level III retrospective cohort.

Outcomes of femoral head allograft for the management of glenoid bone defects in revision reverse shoulder arthroplasty: a case-controlled study.

BACKGROUND: Revision shoulder arthroplasty often requires management of glenoid bone defects. Options include using allograft, harvesting iliac crest autograft, or using augmented metal components. The purpose of this study is to report outcomes of revision shoulder arthroplasty requiring management of glenoid bone defects with femoral head allograft in a large cohort of patients using a single reverse shoulder implant system and compare them to a matched cohort based on the indication for surgery. Outcomes of patients who had successful glenoid reconstruction were compared to those that required a re-revision, and to a control group that was revised without the need for bone graft. METHODS: This was a retrospective review of data collected from 2009 to 2018. There were 36 patients in the bone graft group and 52 in the control group. All patients underwent revision to a reverse shoulder arthroplasty to manage a failed total shoulder arthroplasty (n = 29 and 11), hemiarthroplasty (n = 1 and 24), or reverse shoulder arthroplasty (n = 6 and 17). All patients had a minimum of 2 yr of clinical follow-up. The primary endpoint was survival of baseplate fixation. Secondary outcomes included range of motion and functional outcome scores. Patients that had recurrent baseplate failure and were re-revised were compared to patients with bone graft that did not require additional surgery, and to patients who were revised without the need for bone graft. Patients who required revisions for reasons other than recurrent baseplate failure were also recorded. RESULTS: Five of 36 (14%) patients had recurrent baseplate failure. Mean time to failure was 12 mo. Three of 5 had successful re-implantation of another baseplate. Two of 5 were revised to a hemi arthroplasty after failure of their revisions. Preoperative American Shoulder and Elbow Surgeons scores were 31 in the grafted patients that did not require re-revision, 39 in the grafted patients that required re-revision, and 33 in the control group. Final American Shoulder and Elbow Surgeons scores were 64, 36, and 56, respectively. One patient required revision surgery not related to baseplate failure. There were no baseplate failures in the control group. CONCLUSION: The use of femoral head allograft to manage glenoid bone defects in the revision setting produces predictable improvement in functional outcomes that is not inferior to those in patients revised without bone graft. However, there is a 14% rate of baseplate failure.

Ovarian vein thrombosis: a potential clinical consequence of ruptured ectopic pregnancy.

A healthy 32-year-old G3P3 woman with an unknown last menstrual period presented to the emergency department with intense abdominal pain and pain in the right chest that radiated down the right arm. Further workup showed that she had a ruptured ectopic pregnancy with significant haemoperitoneum. After successful laparoscopic evacuation of the ectopic pregnancy and haemoperitoneum, the patient subsequently developed a right ovarian vein thrombosis 4 weeks after the procedure. She was treated with anticoagulation, and further haematological studies did not show any significant findings. Postpartum ovarian vein thrombosis is extremely rare and can be life- threatening if not accurately diagnosed and treated with anticoagulation or surgical management in a timely manner.