Fitzsimmons, James S

AbstractThe success of radial head arthroplasty (RHA) relies on the design of the implant and precision of the surgical technique, with preoperative planning potentially playing a crucial role. The accurate establishment of a patient‐specific anatomical coordinate system (ACS) is essential for this planning process. This study tested the hypothesis that an innovative automated method would be an accurate, reliable, and efficient framework to determine the ACS of the proximal radius, which would be a step toward improving the precision of RHA planning. We used advanced computational techniques to analyze 50 forearm CT scans, comparing the accuracy, reproducibility, reliability, and efficiency of the automated method with manually derived ACS using expert observers as benchmarks. The results showed that the automated approach was more accurate in identifying anatomical landmarks, with smaller mean distance discrepancies (0.6 mm) than manual observers (1 mm). Its reproducibility was also superior, with narrower reproducibility limits, particularly for ulnar notch landmarks (0.6 to 0.8 mm compared to manual selection 1.2 to 1.4 mm) (p = .01). In addition, the limits of agreement and the mean absolute rotational and translational differences of the axes were narrower for the automated method, which also reduced the construction time to an average of 46 s compared to 150 s manually (p < .001). These findings suggest that the automated method has the potential to enhance the accuracy and efficiency of preoperative and postoperative computer‐assisted procedures for RHA. Further research is needed to fully understand the utility of this automated system for enhancing RHA computer‐assisted surgical planning.

Purpose To (1) report the long‐term outcomes associated with both operative and nonoperative management of capitellar osteochondritis dissecans (OCD), (2) identify factors associated with failure of nonoperative management, and (3) determine whether delay in surgery affects final outcomes. Methods All patients who received a diagnosis of capitellar OCD from 1995‐2020 within a geographic cohort were included. Medical records, imaging studies, and operative reports were manually reviewed to record demographic data, treatment strategies, and outcomes. The cohort was divided into 3 groups: (1) nonoperative management, (2) early surgery, and (3) delayed surgery. Delayed surgery (surgery ≥6 months after symptom onset) was considered failure of nonoperative management. Results Fifty elbows with a mean follow‐up period of 10.5 years (median, 10.3 years; range, 1‐25 years) were studied. Of these, 7 (14%) were definitively treated nonoperatively, 16 (32%) underwent delayed surgery after at least 6 months of failed nonoperative treatment, and 27 (54%) underwent early surgical intervention. When compared with nonoperative management, surgical management resulted in superior Mayo Elbow Performance Index pain scores (40.1 vs 33, P = .04), fewer mechanical symptoms (9% vs 50%, P < .01), and better elbow flexion (141° vs 131°, P = .01) at long‐term follow‐up. Older patients trended toward increased failure of nonoperative management ( P = .06). The presence of an intra‐articular loose body predicted failure of nonoperative management ( P = .01; odds ratio, 13). Plain radiography and magnetic resonance imaging had poor sensitivities for identifying loose bodies (27% and 40%, respectively). Differences in outcomes after early versus delayed surgical management were not observed. Conclusions Nonoperative management of capitellar OCD failed 70% of the time. Elbows that did not undergo surgery had slightly more symptoms and decreased functional outcomes compared with those treated surgically. The greatest predictors of failure of nonoperative treatment were older age and presence of a loose body; however, an initial trial of nonoperative treatment did not adversely impact the success of future surgery. Level of Evidence Level III, retrospective cohort study.

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.

Background: Chronic tendon retraction subsequent to distal biceps tendon rupture significantly increases repair difficulty and potential for tendon grafting. Biceps tendons that appear short or absent with magnetic resonance imaging (MRI) or that cannot be readily identified at surgery may erroneously be classified as irreparable. These apparent “absent” biceps tendons may actually be retracted and curled up inside the muscle, visually resembling the head-neck of a turtle retracted inside its shell (the “turtle neck sign”). When located, these tendons could be unfolded and repaired primarily. This type of tendon retraction seems to be associated with high-degree ruptures and larcertus fibrosus tears. Purpose: To test the hypothesis that tendon retractions with a turtle neck sign on MRI are more associated with high-degree ruptures and larcertus fibrosus tears versus tendon tears with simple linear retraction. Study Design: Cross-sectional study; Level of evidence, 3. Methods: Retracted distal biceps tendon ruptures on sagittal MRI were categorized as linear retraction or curled-up (turtle neck) retraction. Retraction length, injury severity, and lacertus fibrosus tears were analyzed. Results: The authors retrospectively analyzed the patient records of 85 consecutive traumatic distal biceps tendon ruptures from 2003 to 2019; the final study cohort was 37 patients. Injury-to-surgery timing was as follows: <3 weeks, 43% (16 cases); 3 weeks to 3 months, 32% (12 cases); and >3 months, 24% (9 cases). Overall, 19 patients had linear retraction <7 cm (mean, 3.3 ± 1.9 cm) and 18 patients had a turtle neck retraction ≥7 cm (mean, 9.1 ± 1.6 cm). The injury-to-surgery time (median [± interquartile range]) was 27 days (±90 days) in the linear retraction group and 23 days (±65 days) in the turtle neck retraction group. The turtle neck retraction group had a significantly higher occurrence of abnormal hook test findings, complete distal biceps tendon rupture, and lacertus fibrosus tears compared with the linear retraction group (100% vs 58%, 100% vs 68%, and 100% vs 37%, respectively; P ≤ .02). However, significant repairability differences were not found. Conclusion: Highly retracted distal biceps turtle neck sign tendon ruptures occur frequently in association with high-degree ruptures and lacertus fibrosus tears. The presence of a turtle neck retraction did not affect reparability. Surgeons should be aware of this curled-up retraction to avoid mistaking it for an absent tendon or a muscle-tendon disruption.

Background: The management of severe radiocapitellar joint pathologies in young patients is challenging. Radial head arthroplasty (RHA) is a treatment option in the adult population, but most surgeons avoid implementing it in younger patients, and there are no published results for patients younger than 16 years. Methods: Our retrospective cohort describes 5 patients (4 male 1 female) who underwent cementless modular RHA at an average age of 14 years (range: 13 to 15). The preoperative diagnoses were post-traumatic radiocapitellar incongruity and arthrosis because of previous Salter-Harris type 3 or 4 fractures of the radial head in 3 cases; and axial instability of the forearm following failed radial head excision in 2 cases. Because of the complexity of the elbow pathology in these cases, all underwent concomitant procedures including: contracture release (5 cases), corrective ulnar osteotomy (2 cases), distal ulnar shortening osteotomy, excision of radioulnar synostosis, microfracture of the capitellum, and partial excision of the medial triceps (1 case each). Collected data included patient-reported outcomes, visual analog scale pain score at rest and during physical activity and radiographic assessment of arthritis and prosthesis loosening. Results: Average clinical follow-up was 8 years (range: 3 to 13). All 5 patients were pain-free at rest, and 3 reported moderate elbow pain (visual analog scale: 5 to 6) with physical activity. At an average radiographic follow-up of 3 years (range: 0.5 to 5), 3 patients showed mild progression of elbow arthrosis, but there were no signs of progressive capitellar erosion or implant loosening. Only 1 complication was noted—development of heterotopic ossification in 1 patient, which required open heterotopic ossification excision and contracture release 2 years following the RHA. None of the patients required prosthesis revision or removal. Conclusion: RHA was successful in improving pain and axial forearm stability in this very small series of adolescent patients. Concerns regarding long-term longevity and complications still exist. Considering the lack of other reliable treatment options, RHA may be indicated in this challenging patient population. Level of Evidence: Level IV: therapeutic study—case series.

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: There is no consensus how to determine the varus laxity due to the LCL injury using the ultrasonography. There is a risk of lateral collateral ligament injury during or after arthroscopic extensor carpi radialis brevis release for tennis elbow. The equator of the radial head has been suggested as a landmark for the safe zone to not increase this risk; however, the safe zone from the intra-articular space has not been established. Hypothesis: Increased elbow varus laxity due to lateral collateral ligament–capsular complex (LCL-cc) injury could be assessed reliably via ultrasound. Study Design: Descriptive laboratory study. Methods: Eight cadaveric elbows were evaluated using a custom-made machine allowing passive elbow flexion under gravity varus stress. The radiocapitellar joint (RCJ) space was measured via ultrasound at 30° and 90° of flexion during 4 stages: intact elbow (stage 0), release of the anterior one-third of the LCL-cc (stage 1), release of the anterior two-thirds (stage 2), and release of the entire LCL-cc (stage 3). Two observers conducted the measurements separately, and the mean RCJ space in the 3 LCL-cc injury models (stages 1-3) at both flexion angles was compared with that of the intact elbow (stage 0). We also compared the measurements at 30° versus 90° of flexion. Results: At 30° of elbow flexion, the RCJ space increased 2 mm between stages 0 and 2 (95% confidence interval [CI], 1-3 mm; P < .01) and 4 mm between stages 0 and 3 (95% CI, 2-5 mm; P < .01). At 90° of elbow flexion, the RCJ space increased 1 mm between stages 0 and 2 (95% CI, 1-2 mm; P < .01) and 2 mm between stages 0 and 3 (95% CI, 2-3 mm; P < .01). Conclusion: Elbow varus laxity under gravity stress can be reliably assessed via ultrasound by measuring the RCJ space. Clinical Relevance: Because ultrasonographic measurement of the RCJ space can distinguish the increasing varus laxity seen with release of two-thirds or more of the LCL-cc, the anterior one-third of the LCL-cc, based on the diameter of the radial head, can be considered the safe zone in arthroscopic extensor carpi radialis brevis release for tennis elbow.

AbstractObjectivesMany guidelines for septic olecranon bursitis recommend aspiration of the bursa prior to initiation of antimicrobial therapy despite the absence of robust clinical data to support this practice and known risk of aspiration complications. Our objective was to describe outcomes associated with empiric antibiotic therapy without bursal aspiration among emergency department (ED) patients with suspected septic olecranon bursitis.MethodsWe conducted a retrospective observational cohort study of patients presenting to an academic ED from January 1, 2011, to December 31, 2018, with olecranon bursitis. The health record was reviewed to assess patient characteristics and outcomes within 6 months of the ED visit. Olecranon bursitis was considered “suspected septic” if the patient was treated with antibiotics. The primary outcome of interest was complicated versus uncomplicated bursitis resolution. Uncomplicated resolution was defined as bursitis resolution without subsequent bursal aspiration, surgery, or hospitalization.ResultsDuring the study period, 264 ED patients were evaluated for 266 cases of olecranon bursitis. The median age was 57 years and 85% were men. Four (1.5%) patients had bursal aspiration during their ED visit, 39 (14.7%) were admitted to the hospital, 76 (28.6%) were dismissed without antibiotic therapy, and 147 (55.3%) were dismissed with empiric antibiotic therapy for suspected septic olecranon bursitis. Among these 147 patients, 134 had follow‐up available including 118 (88.1%, 95% confidence interval [CI] = 81.1%–92.8%) with an uncomplicated resolution, eight (6.0%, 95% CI = 2.8%–11.8%) who underwent subsequent bursal aspiration, and nine (6.7%, 95% CI = 3.3%–12.7%) who were subsequently admitted for inpatient antibiotics.ConclusionsEighty‐eight percent of ED patients with suspected septic olecranon bursitis treated with empiric antibiotics without aspiration had resolution without need for subsequent bursal aspiration, hospitalization, or surgery. Our findings suggest that empiric antibiotics without bursal aspiration may be a reasonable initial approach to ED management of select patients with suspected septic olecranon bursitis.

Background Persistent infection rate after 2-stage reimplantation complicating elbow arthroplasty has been reported to be as high as 25%. The purposes of this retrospective study were to determine the infection eradication rates, complications and outcomes in a cohort of patients treated with two-stage reimplantation for deep periprosthetic joint infection (PJI) following total elbow arthroplasty (TEA) and to determine possible associated risk factors for treatment failure. Methods Between 2000 and 2017, 52 elbows underwent a two-stage reimplantation for PJI after TEA. There were 22 males and 30 females with a mean age of 61 (range, 25–82) years. The most common bacterium was Staphylococcus epidermidis (28 elbows). Mayo Elbow Performance Scores were calculated at the latest follow-up. Mean follow-up time was 6 years (range, 2–14 years). Results PJI was eradicated in 36 elbows (69%). The remaining 16 elbows were considered treatment failures secondary to recurrent infection. The risk of persistent infection was 3.3 times higher in elbows with retained cement (p 0.04), and 3.5 times higher when the infecting organism was Staphylococcus epidermidis (p 0.06). Conclusion Two-stage reimplantation for PJI after TEA was successful in eradicating deep infection in 69% of cases. The eradication of PJI after TEA still needs to be improved substantially.