Chronic disruption of the distal biceps tendon is a challenging problem and can lead to considerable disability. We conducted a group-matched retrospective study comparing clinical outcomes of chronic distal biceps reconstruction using our previously described “Anatomic Length Method” and those with an acute distal rupture and primary repair. Forty-six patients were included into the analysis; 23 underwent acute distal biceps repair, and 23 underwent chronic distal biceps reconstruction. Demographic and surgical data were reviewed retrospectively. Patients were evaluated and clinical outcome measures were obtained at least 1 year after surgical treatment. There were no significant differences in Patient-Rated Elbow Evaluation scores (6.0 vs. 4.4, respectively; P=0.53) and biceps shape contour satisfaction (19/19 vs. 6/7, respectively; P=0.093). No significant difference emerged in complication rates. This study suggests that chronic reconstruction of the distal biceps tendon using the “Anatomic Length Method” is a safe technique that produces similar clinical results to acute distal biceps primary repair.
Symptomatic nonunion of medial epicondyle fractures of the humerus is a rare entity. The surgical technique can be difficult due to anatomic and biomechanical factors, such as the high tension and the torsional forces applied from the flexor-pronator tendon origin. The most common complications of nonunion of the medial humeral epicondyle fracture are chronic pain, instability in valgus of the elbow, and neuropathy of the ulnar nerve. We described the case of 1 patient with symptomatic medial humeral epicondyle nonunion, who underwent open reduction and internal fixation with excellent clinical evolution after 1 year of follow-up from time of surgery. The purpose of this study was to evaluate the outcome of open reduction and internal fixation of a medial epicondyle nonunion fragment in 1 case and present a review of the literature.
Infection after total elbow arthroplasty can be a devastating problem. Eradication of the infection can often be difficult and may compromise the already tenuous bone and soft tissue, particularly the elbow extensor mechanism. Resection arthroplasty with the complete removal of all foreign material is often necessary to adequately treat the infection. Components may be well fixed and removal may further compromise bone and soft tissue. The authors present a technique of ulnar cortical window that facilitates the removal of a well-fixed ulnar component and the associated cement mantle. An illustrative surgical case is also included with pertinent intraoperative and radiographic images. This technique provides reliable, atraumatic access to the ulnar canal, cement mantle, and component for safe extraction of a well-fixed implant. When comparing with other techniques in the removal of the ulnar component, such as transverse ulnar osteotomy, and extended olecranon osteotomy, our technique did not breach the bony integrity of ulna, and it did not require wiring for rigid fixation of the bony fragment. This may be more applicable in excisional arthroplasty for the management of infected total elbow arthroplasty.
Chronic tears of the distal triceps tendon are extremely uncommon lesions. Surgical therapy can be performed with a direct reattachment of the 2 sides of the lesion or-in case of significant tendon retraction-using grafts to fill the resulting gap. Herein, we report a case of a torn distal triceps tendon that occurred in a 33-year-old patient suffering from paraplegia. The resulting functional impairment of the elbow impeded her to use a wheelchair, causing a substantial limitation to her mobility and autonomy. Preoperative clinical evaluation, x-rays, muscle-tendon ultrasound, and magnetic resonance imagingwas been performed. In consideration of a 6 cm retraction at the surgery, we reconstructed the tendon using a combination of suture anchors (5 mm Super Reevo ConMed) and a cadaver fascia lata allograft. After surgery, the elbow was immobilized in extension inside a brachio-metacarpal cast for 30 days. In the following month, the cast was replaced with a hinged elbow brace and progressive mobilization was permitted. Five months postoperatively, the patient regained her previous active flexion-extension articular ROM and was able to use her wheelchair again. No complication occurred.
The authors describe the treatment of a 13-year-old patient with a severe, posteriorly dislocated, epiphysiolysis fracture of the proximal radius. This is called a Jeffery type II lesion when the epiphysiolysis fracture takes place at the radial neck during the reduction of elbow posterior dislocation, thus causing radial head posterior displacement. There are <30 cases described in the literature about such kind of lesion, and only. Chotel and colleagues has carried out the percutaneous form of treatment. He advocated a varus stress onto the elbow joint so that its subluxation would open the lateral space to facilitate manipulation and head reduction toward its anatomic position. The authors also describe a closed reduction technique for such fracture by using 2 Kirschner wires, whereas the first is inserted into the fracture site, thus acting as a guide and fulcrum, so that the second wire would push the radial head toward its anatomic position. The authors regard that such modification of Chotel and colleagues’ technique is an effective and less aggressive maneuver that reduces the risk of iatrogenic ligament and chondral injuries. The purpose is to demonstrate the surgical technique of the novel, effective, and safe method of treatment to Jeffery type II radial neck pediatric fractures.
Triceps-off approaches of the elbow detach not only the central tendinous insertion but also the medial and lateral peripheral muscular extensions, which are often replaced by scar tissue instead of functioning contractile muscular tissue when re-attached firmly with suture. These muscular extensions have been shown to be important for terminal elbow extension and may explain why triceps-off approaches have a higher rate of triceps insufficiency in terminal, antigravity elbow extension. Triceps-on approaches of the elbow lead to difficulty accessing the ulna for preparation and insertion of the ulna component of elbow replacements, with malpositioning of the ulna component a common concern. We present an elbow “triple window” surgical approach that preserves the contractile medial and lateral footprints of the triceps, while affording a better in-line access than a pure “triceps-on” approach. This approach only violates 50% of the central tendinous insertion, with the remainder of the central tendon and the medial and lateral muscular extensions preserved.
The most utilized approach for minimally invasive plate osteosynthesis (MIPO) of humeral fractures has been an anterior percutaneous approach. Other approaches include posterior, which places the radial nerve at risk. We performed a cadaveric study to evaluate safe intervals for screw placement using a posterior approach. MIPO fixation of the humeral shaft was performed on 11 fresh frozen cadaveric specimens following a standard protocol using a 10-hole 4.5 locking compression plate (LCP) plate and cortical screws. After fixation, anatomic dissection of the radial nerve was performed and location of the nerve delineated with regards to radiographic landmarks and the fixation construct. A 10-hole LCP plate centered on the humerus will position a screw in the third hole from top of plate only 3.08 cm (+/- SD 1.05 cm) from the radial nerve. The distal screws in the LCP plate construct do not the place the radial nerve at risk. The literature reports rates of iatrogenic radial nerve injury during formal open reduction and internal fixation approaching 20%, and during MIPO between 0% and 5%. With a posterior MIPO approach the radial nerve is most at risk with screw placement in the fifth and sixth holes from the top of a 10-hole plate.
Isolated acromion fractures, although unusual, are not uncommon. Traditionally treated conservatively, an improved understanding of shoulder biomechanics has extended the indications for surgical treatment. Surgical modalities described in the literature are plating, cortical lag screw, Kirschner wiring, and tension-band wiring. We describe a novel surgical technique for both fixation of an acute fracture or revision surgery of the base of acromion fracture. The technique involves the insertion of an intramedullary screw from the lateral tip of the acromion toward the tapered medial part of the scapular spine. This is supplemented by an anatomic locking reconstruction plating placed on the superior border of the acromion and scapular spine. We share an illustrated case of a 39-year-old woman, who successfully underwent a revision surgery with this technique and recovered well with excellent radiologic and functional outcomes. A long intramedullary screw provides good interfragmentary compression, 3-point fixation, and better bony purchases. A supplementary plate helps to resist rotational and muscular-pulling forces. In conclusion, intramedullary screw fixation, supplemented with plating, offers a viable surgical treatment for acromion fractures, and combined with a proper postoperative rehabilitation regime, it helps patients to achieve excellent outcomes.
In displaced supracondylar humerus fractures, closed reduction percutaneous pinning is recommended and is most commonly performed in the supine position with the arm held in hyperflexion. The risk of iatrogenic ulnar nerve injury with medial pin placement is high in this position. We performed a retrospective case series of 149 patients with displaced supracondylar humerus fractures treated in the prone position. The aim of this study was to evaluate the incidence of iatrogenic ulnar nerve injury with medial pin placement, report our technique, and conduct a literature review to serve as historical control. The rate of iatrogenic ulnar nerve injury was evaluated and compared with a historical control cohort of 1029 patients treated supine. A total of 131 patients were included: 74 (56%) patients received a medial pin, and 57 (44%) patients received lateral pins only. Postoperative complications included 2 cases of pin migration (1.5%). No patients sustained iatrogenic ulnar nerve injury, compared with a historical control rate of 4.95%. Our technique is correlated with a lower incidence of ulnar nerve injuries than historical controls performed in the supine position. We believe this technique can facilitate safer pin placement in cases that require a medial pin. Level of Evidence: Level IV.
Various fixation methods have been used to fix olecranon fractures including the plate fixation, intramedullary screws, and tension band technique. Open reduction with tension band wire fixation (TBW) has been widely accepted for the treatment of transverse displaced olecranon fractures. The aim of this study was to determine the stress developed in different types of TBW fixations in olecranon fractures on the basis of finite element analysis. A 3-dimension model of the elbow joint was created on the basis of the computerized tomography scan images. Three different configurations of TBW fixations were evaluated in this study. The stress developed in various fragments and implant parts and relative motion of implant in various degrees of elbow flexion was assessed in this study. The stress of K-wires was higher in condition 1 (K-wire inserted from the posterior side to the posterior side) compared with other conditions. The relative displacement of the pin was the highest in condition 2 (K-wire from posterior to anterior) (higher than 2 mm), which occurred in elbow flexion angle of 40 to 50, followed by condition 3 (with K-wire, one from posterior to anterior and another one from posterior to posterior). It seems that the lowest value of displacement occurs in condition 1, compared with other conditions. The new methods suggested herein (conditions 2 and 3) provided sufficient stability for fracture fixation, similar to the conventional method (condition 1). In these 2 methods, the amount of complications seems to be lower because of the placement of K-wires, therefore, these 2 methods are recommended to reduce the complications of surgery.
The aim of this study was to compare the early clinical and functional outcomes of patients who received the 2 major variations of reverse shoulder arthroplasty (RSA). The nonlateralized Aequalis Reversed Shoulder System (Tornier, Nice, France) was followed by the lateralized Encore Reverse Shoulder Prosthesis (DJO Surgical, Austin, Texas). Patient-determined pain and functional scores and examiner-determined range of motion and strength were assessed preoperatively and postoperatively at 1, 6, 12 weeks, and 6 months. Seventy RSAs performed in 66 consecutive patients: 35 shoulders in the lateralized group and 35 shoulders in the nonlateralized group met the inclusion criteria and formed the cohorts. Both groups experienced similar excellent clinical outcomes, with the exception that the lateralized group had better internal rotation range of motion (L3-4 vs. S1, P=0.03), lower frequency of pain during sleep (P=0.04), less severe pain at rest (P=0.03) and higher involvement in sporting activities (P=0.04) at 24 weeks. In conclusion, patients who underwent RSA with a lateralized glenosphere had better internal rotation range of motion, less pain, and better function than those who received a nonlateralized prosthesis. These differences were apparent within 6 months postsurgery. Level of Evidence: Level III.
Olecranon fractures are common injuries of the upper extremity that frequently require operative fixation to restore elbow congruity and function. Surgery is often performed in the lateral or prone position, presenting challenges for anesthesia, nursing, and the surgical team to safely and appropriately position the patient. Supine positioning with the use of a hand table provides limited visualization of the olecranon and often requires an assistant for maintenance of limb position. We describe an easy and quick surgical setup requiring only 2 total knee arthroplasty foot positioners (commonly known as "paint rollers") attached to a surgical table with the patient in a supine position. A retrospective review of 28 patients undergoing operative fixation of olecranon fractures utilizing this positioning method was performed. No patients were found to require repositioning (ie, supine to lateral) for any reason and no airway-related or positioning-related complications were noted. This setup provides excellent exposure to the operative site and stable positioning of the arm with minimal risk to the patient. In keeping the patient supine, monitored anesthesia care (intravenous general anesthesia) with regional blockade may be performed without the need for endotracheal or laryngeal mask anesthesia, thereby lowering anesthesia-related risks.
Periprosthetic humerus fractures remain problematic complications that are difficult to adequately reduce and maintain reduction. Patient-related risk factors, including poor bone quality, add an additional level of complexity to maintaining fixation in the setting of relatively narrow cortical margins adjacent to the shoulder prosthesis. Based on the challenges of obtaining adequate proximal fixation and the need to minimize dependence on cerclage fixation because of nerve injury risks and inadequate fracture reduction, the authors propose an alternative method intraoperative fixation. The technique described is a method of fixation utilizing a small fragment instrumentation set for periprosthetic humerus fractures as demonstrated in a Sawbones model and intraoperatively in a patient-specific case.
The authors describe a novel split capsule technique for the open treatment of chronic locked anterior shoulder dislocation. The described technique is easily reproducible and focuses on preservation of the native joint with open reduction of the humeral head and soft tissue repair. The steps entail the creation of a neocapsule of the shoulder, elimination of the pseudoglenoid space with a medial capsular repair, and a combined medial and lateral capsular shift. In the present article, the procedure is outlined in detail with technical pearls, 3 case examples, and a review of treatment options.
The acromioclavicular joint (ACJ) ganglion (producing the "geyser sign") produces poor quality skin and risk of infection with repeated aspirations and arthroscopic resection. The primary aim is to present our pedicled muscle flap procedure to prevent wound breakdown and recurrent infection over the ACJ. The secondary aim is to report our case series' outcomes. By using a distally based rotation flap of the trapezius muscle to the ACJ defect after lateral clavicle excision the overlying skin can be supported by a well vascularized soft tissue bed. Included participants sustained recurrent ganglion cysts producing the geyser sign with poor quality skin and/or recurrent infection. Three patients underwent this technique. Favorable results were shown by excellent outcomes in all cases after surgery. There were no recurrent infections, and no other complications. This technique of using a local muscle flap resulted in a high patient satisfaction and a low rate of complications.
On basis of a newly proposed classification of type-V superior labrum anterior to posterior (SLAP) lesion, this study was conducted to investigate this question: "Does concurrent anterosuperior labral anchor repair limit postoperative range of external rotation and increase postoperative pain compared with isolated Bankart repair?." This prospective cohort study, conducted between September 2014 and December 2017, included 20 patients who were divided into the following groups: group-S (12 patients) of concurrent Bankart and type-IIA SLAP repair by 3 anchors, with one of them above the glenoid mid-equator, and group-B (8 patients) of isolated Bankart repair by 2 anchors. Patients were evaluated for demographics and preoperative and 2-year postoperative shoulder range of motion, Rowe Instability Score, University of California Los Angeles score, and instability recurrence. Statistically, group-S patients had significantly older mean age at first time of dislocation (24.7 vs. 18.2 y, respectively;P=0.034). Postoperatively, there was an insignificant difference between groups with regard to external rotation deficits at 0 and 90 degrees abduction compared with sound contralateral shoulder (10.0 vs. 5.00 degrees;P=0.080) and (17.1 vs. 12.5 degrees;P=0.087), respectively. The current study demonstrated that concurrent Bankart and anterosuperior labral anchor repair can offer outcomes comparable to isolated Bankart repair as regards postoperative pain, range of external rotation, function, return to work, and instability recurrence. Age at first time of glenohumeral dislocation can be a predictor for severity of labral detachment. The currently reported classification system can assist in more precise decision making and outcome assessment of type-V SLAP repair.
Acute latissimus dorsi tendon rupture is a rare injury, occurring nearly exclusively in athletes engaging in overhead motions. Given this patient population, return to elite function is a goal of treatment, often requiring surgery. When planning surgery, one finds a lack of sufficient evidence to recommend a specific fixation technique. We report a case of acute rupture of the latissimus dorsi in a competitive gymnast. Initial magnetic resonance imaging confirmed the injury and showed that the tendon had retracted 6 cm. Primary repair using bicortical button fixation, a novel fixation technique, was performed. The patient successfully returned to competition and reported personal best scores on high bar and parallel bars. Cadaveric studies comparing cortical buttons to sutures and suture anchors for tendon reattachment found cortical buttons to have higher loads to failure. Overall, this suggests the technique described here may provide superior outcomes for a patient population who will stress the repair at elite levels. Level of Evidence: Level V.
Untreated lesions of the long head of the biceps tendon are a common cause of shoulder pain and dysfunction. Although the use of in-office arthroscopy has been described for biceps tenotomy, advances have led to portable arthroscopy devices. Tenotomy was performed in 10 cadaveric shoulders (average age 62.8) with an intact elbow and distal insertion point of the biceps tendon. A biceps tendon in the bicipital groove was confirmed using ultrasound. The portable arthroscopy device was introduced through an anterior-superior portal. Tenotomies were carried out under direct visualization with a standard straight arthroscopic punch through a separate adjacent portal. Following tenotomy, a second-look was performed to identify injuries caused by the procedure. Specimens were disarticulated and examined for iatrogenic injury to cartilage and completion of tenotomy. Biceps stump lengths were measured. Tenotomies were confirmed in 9 of 10 specimens with an average residual stump of 4.23±2.08 mm (range: 0 to 6.94 mm). Stability of the labrum was confirmed post-tenotomy. No iatrogenic injuries were observed on arthroscopy. This study demonstrates the safety and efficacy of an intra-articular, minimally invasive tenotomy of the long head of the biceps in a cadaveric model using a portable arthroscopy device as a possible alternative to operating room arthroscopic tenotomy.
Snapping scapula syndrome is characterized by painful crepitus at the scapulothoracic articulation, which is worse on movement, in the particular overhead activity. A number of bony causes of snapping scapula syndrome due to ventral scapular exostoses have been previously reported. However, we present a rare case of snapping scapula syndrome resulting from an osteochondroma of the second rib, causing pain at the superior scapula with shoulder movement. This required a novel surgical multidisciplinary approach. Surgical resection was performed via a posterior trapezius-splitting approach resulting in symptom resolution.
The meso-acromion is the most common type of os acromiale and has been associated with subacromial impingement and rotator cuff tears. Surgical treatment might be indicated when nonoperative treatment has been nonsuccessful and depends on the size and location of the os acromiale. Numerous surgical procedures have been described in the current literature, most of them focusing on the os acromiale union. To this, fusion rates depend mostly on the surgical approach and fixation technique and when achieved, is generally associated with good clinical outcomes. The purpose of this article is to describe our preferred technique of internal fixation for a symptomatic meso-type os acromiale. An all-arthroscopic technique has the advantages of optimal visualization of the undersurface of the acromion and nonunion site minimizing morbidity of the open approach.
