Shields, Maegan N.

Background: Continuous passive motion (CPM) has been used for decades, but we are not aware of any randomized controlled trials (RCTs) in which CPM has been compared with physical therapy (PT) for rehabilitation following release of elbow contracture. Methods: In this single-blinded, single-center RCT, we randomly assigned patients undergoing arthroscopic release of elbow contracture to a rehabilitation protocol involving either CPM or PT. The primary outcomes were the rate of recovery and the arc of elbow motion (range of motion) at 1 year. The rate of recovery was evaluated by measuring range of motion at 6 weeks and 3 months. The secondary outcomes included other range-of-motion-related outcomes, patient-reported outcome measures (PROMs), flexion strength and endurance, grip strength, and forearm circumference at multiple time points. Results: A total of 24 patients were assigned to receive CPM, and 27 were assigned to receive PT. At 1 year, CPM was superior to PT with regard to the range of motion, with an estimated treatment difference of 9° (95% confidence interval [CI], 3° to 16°; p = 0.007). Similarly, the use of CPM led to a greater range of motion at 6 weeks and 3 months than PT. The percentage of lost motion recovered at 1 year was higher in the CPM group (51%) than in the PT group (36%) (p = 0.01). The probability of restoring a functional range of motion at 1 year was 62% higher in the CPM group than in the PT group (risk ratio for functional range of motion, 1.62; 95% CI, 1.01 to 2.61; p = 0.04). PROM scores were similar in the 2 groups at all time points, except for a difference in the American Shoulder and Elbow Surgeons (ASES) elbow function subscale, in favor of CPM, at 6 weeks. The use of CPM decreased swelling and reduced the loss of flexion strength, flexion endurance, and grip strength on day 3, with no between-group differences thereafter. Conclusions: Among patients undergoing arthroscopic release of elbow contracture, those who received CPM obtained a faster recovery and a greater range of motion at 1 year, with a higher chance of restoration of functional elbow motion than those who underwent routine PT. Level of Evidence: Therapeutic Level I . See Instructions for Authors for a complete description of levels of evidence.

Purpose To generate an evidence‐based opioid‐prescribing guideline by assessing the pattern of total opioid consumption and the factors that may predict opioid consumption following arthroscopic release of elbow contracture and to investigate whether the use of continuous passive motion (CPM), as compared to physical therapy (PT), was associated with a decrease in pain and opioid consumption after arthroscopic release of elbow contracture. Methods Data collected from a randomized controlled trial that compared continuous passive motion (CPM) ( n = 24) to physical therapy (PT) ( n = 27) following arthroscopic release of elbow contracture was analyzed for opioid use. Fifty‐one participants recorded their daily opioid consumption in a postoperative diary for 90 days. Multivariate analysis was performed to identify factors associated with opioid use. Recommended quantities for postoperative prescription were generated using the 50th percentile for patients without and the 75th percentile for patients with factors associated with higher opioid use. Results The median total opioid prescription was 437.5‐mg morphine milligram equivalents (MMEs) (58 pills of 5 mg oxycodone) and the median total opioid consumption was 75 MMEs (10 pills of 5‐mg oxycodone). Twenty‐two percent of patients took no opioid medication, 53% took ≤10 pills, 69% took ≤20 pills and 75% took ≤30 pills. Predictors of higher opioid use were preoperative opioid use, age <60 years and inflammatory arthritis. The total opioid consumption appeared similar between the CPM and the PT group. Seventy‐five percent of patient’s home opioid requirements would be satisfied using the following guideline: Patients undergoing contracture release for osteoarthritis or post‐traumatic contracture should be given a prescription for 10 pills of 5 mg oxycodone or its equivalent at discharge. Patients with inflammatory conditions or those taking preoperative opioids should be prescribed 30 pills of 5 mg oxycodone or its equivalent. Conclusion This study suggests that most patients undergoing arthroscopic release of elbow contracture use relatively few opioid pills after surgery. Use of an evidence‐based guideline could decrease opioid prescriptions substantially, while still effectively treating patients’ pain.

Background To determine if self-taken photographs (“selfies”), performed independently after instruction by video or illustrated handout, would be an accurate and reliable tool for capturing elbow range of motion in patients with elbow contractures. Methods Fifty patients presenting with elbow contractures participated in the study. After completion of the selfie, the senior author clinically measured flexion and extension with a goniometer. The angles from the photographs were measured and analyzed. Results The agreement between goniometer and “selfie” measurements correlated closely (R 2 = 0.98) and agreement was excellent in both extension and in flexion with intra-class correlation coefficients of 0.95 (95% CI 0.92 to 0.97) in extension with a mean difference of 2° (95% CI −3° to 7°), and 0.93 (95% CI 0.89 to 0.96) in flexion with a mean difference of 4° (95% CI 0° to 8°). Systematic errors were low in extension, 0° (95% CI, ±11°) and in flexion −3° (95% CI, ±10°). Six patients demonstrated ≥10° difference between clinical and selfie measurements. Ability to take a usable selfie was inversely correlated with age (R 2 = 0.97). Discussion Self-taken flexion–extension photographs are a reliable and accurate tool for measuring elbow range of motion. Errors in the selfie technique are well tolerated and appear to have a negligible effect upon measurements of motion. This important parameter of elbow function can therefore be obtained outside a normal clinic visit, thereby improving frequency of follow-up assessments (and minimizing loss to follow-up) necessary for quality control and research.

Background: Safe and effective portal placement is crucial for successful elbow arthroscopy. Various techniques for anterolateral portal placement in elbow arthroscopy have been described, yet radial nerve injuries are commonly reported. Purpose: To report on the technique and safety of anterolateral portal placement by the needle-and-knife method and its clinical applications. Study Design: Case series; Level of evidence, 4. Methods: A retrospective review was completed of patients who underwent an arthroscopic procedure in the anterior compartment of the elbow and anterolateral portal placement. Patients were evaluated immediately postoperatively and at subsequent visits and were monitored for signs of radial nerve injury. Results: A total of 460 patients met the inclusion criteria, of which 309 (67%) underwent the needle-and-knife technique. There was 1 case (0.3%) of temporary radial nerve palsy. For the remaining 151 patients who underwent anterolateral portal placement by other techniques, there were 2 cases of temporary radial nerve palsy (1.3%). There were no cases of the needle-and-knife technique being unsuccessful or abandoned in lieu of a different technique. Use of the needle-and-knife technique increased over time with experience and practice. Initially, contraindications to this technique included impaired view of the lateral side of the anterior compartment of the elbow caused by severe intra-articular scar (65%), extensive synovitis (10%), or large osteophytes or loose bodies (10%). For the remaining patients (15%) who did not have portals placed via the needle-and-knife technique, alternate techniques were used for teaching purposes. Conclusion: The needle-and-knife technique is reproducible and easy to perform by a clinician instructed in its use and trained in elbow arthroscopy. Its main advantage is that it permits the surgeon to safely slide the knife along the lateral supracondylar ridge, releasing the scarred capsule and thereby increasing the available space in which to work. Enlarging the working space inside scarred and contracted elbows cannot be accomplished by distending the capsule.

Aims The aim of this study was to evaluate two hypotheses. First, that disruption of posterior bundle of the medial collateral ligament (PMCL) has to occur for the elbow to subluxate in cases of posteromedial rotatory instability (PMRI) and second, that ulnohumeral contact pressures increase after disruption of the PMCL. Materials and Methods Six human cadaveric elbows were prepared on a custom-designed apparatus which allowed muscle loading and passive elbow motion under gravitational varus. Joint contact pressures were measured sequentially in the intact elbow (INTACT), followed by an anteromedial subtype two coronoid fracture (COR), a lateral collateral ligament (LCL) tear (COR + LCL), and a PMCL tear (COR + LCL + PMCL). Results There was no subluxation or joint incongruity in the INTACT, COR, and COR + LCL specimens. All specimens in the COR + LCL + PMCL group subluxated under gravity-varus loads. The mean articular contact pressure of the COR + LCL group was significantly higher than those in the INTACT and the COR groups. The mean articular contact pressure of the COR + LCL + PMCL group was significantly higher than that of the INTACT group, but not higher than that of the COR + LCL group. Conclusion In the presence of an anteromedial fracture and disruption of the LCL, the posterior bundle of the MCL has to be disrupted for gross subluxation of the elbow to occur. However, elevated joint contact pressures are seen after an anteromedial fracture and LCL disruption even in the absence of such subluxation. Cite this article: Bone Joint J 2018;100-B:1060–5.

Abstract Reconstruction of the lateral ulnar collateral ligament of the elbow is the primary treatment for recurrent symptomatic posterolateral rotatory instability. Although a number of lateral ulnar collateral ligament reconstruction techniques have been described, the docking technique has received general acceptance. In this technique, the graft is passed through a tunnel on the ulnar side and the 2 free limbs are docked into the humerus at the isometric point on the lateral condyle. Advantages of this method of reconstruction include reduced bone removal, decreased soft tissue damage, and precise control of graft tensioning. When precise surgical steps are followed, this technique can be performed in a reliable, efficient, and reproducible manner for patients with posterolateral rotatory instability of the elbow. Technique Video video See video under supplementary data.