Tag Archive | Elbow

JBJS 100: Talar Neck Fractures and Elbow Biomechanics

JBJS 100Under one name or another, The Journal of Bone & Joint Surgery has published quality orthopaedic content spanning three centuries. In 1919, our publication was called the Journal of Orthopaedic Surgery, and the first volume of that journal was Volume 1 of what we know today as JBJS.

Thus, the 24 issues we turn out in 2018 will constitute our 100th volume. To help celebrate this milestone, throughout the year we will be spotlighting 100 of the most influential JBJS articles on OrthoBuzz, making the original content openly accessible for a limited time.

Unlike the scientific rigor of Journal content, the selection of this list was not entirely scientific. About half we picked from “JBJS Classics,” which were chosen previously by current and past JBJS Editors-in-Chief and Deputy Editors. We also selected JBJS articles that have been cited more than 1,000 times in other publications, according to Google Scholar search results. Finally, we considered “activity” on the Web of Science and The Journal’s websites.

We hope you enjoy and benefit from reading these groundbreaking articles from JBJS, as we mark our 100th volume. Here are two more:

Fractures of the Neck of the Talus: Long-Term Evaluation of 71 Cases
S T Canale and F B Kelly Jr: JBJS, 1978 Jan; 60 (2): 143
One of the most challenging diagnoses for general orthopedic surgeons and fracture specialists alike is a fracture of the talar neck. In this landmark JBJS article, the authors focused attention on the importance of quality of reduction and created an enduring fracture classification that paralleled complication rates and potential outcomes.

A Biomechanical Study of Normal Functional Elbow Motion
B F Morrey, L J Askew, E Y Chao: JBJS, 1981 Jan; 63 (6): 872
This JBJS article convincingly answered the question about the minimal range of elbow motion needed to accomplish activities of daily living. Using modern 3-dimensional optical tracking technology 30 years after Dr. Morrey’s study appeared, Sardelli et al. found only minimal ROM differences compared to findings in the Morrey study.

JBJS Case Connections—Osteochondritis Dissecans: Baseball and Genetics

Shoulder_OCD_12_29_16.png The exact mechanism by which osteochondritis dissecans (OCD) lesions develop is poorly understood. This month’s “Case Connections” spotlights 3 case reports of OCD in young baseball players, 2 of whom developed the condition in the shoulder. A fourth case report details 3 presentations of bilateral OCD of the femoral head that occurred in the same family over 3 generations.

The springboard case report, from the December 28, 2016, edition of JBJS Case Connector, describes a 16-year-old Major League Baseball (MLB) pitching prospect in whom an OCD lesion of the shoulder healed radiographically and clinically after 8 months of non-throwing and physical therapy focused on improving range of motion and throwing mechanics. Three additional JBJS Case Connector case reports summarized in the article focus on:

Among the take-home points emphasized in this Case Connections article:

  • MRI arthrograms are the best imaging modality to determine the stability of most OCD lesions. Radiographs in such cases often appear normal.
  • Early-stage OCD has the potential to heal spontaneously. Activity modification and physical therapy are effective treatments.
  • There is not a “gold-standard” surgical intervention for treating unstable/late-stage OCD. Surgery frequently provides clinical benefits but often does not result in radiographic improvement.

JBJS Classics: Biomechanics of the Normal Elbow

jbjsclassics-2016OrthoBuzz regularly brings you a current commentary on a “classic” article from The Journal of Bone & Joint Surgery. These articles have been selected by the Editor-in-Chief and Deputy Editors of The Journal because of their long-standing significance to the orthopaedic community and the many citations they receive in the literature. Our OrthoBuzz commentators highlight the impact that these JBJS articles have had on the practice of orthopaedics. Please feel free to join the conversation by clicking on the “Leave a Comment” button in the box to the left.

The classic 1981 JBJS article by B.F. Morrey et al. begs to be read carefully, in part because of the name of the lead author. More importantly, this study answers the question that arises with almost every patient with an elbow disorder: Is the achieved range of motion sufficient for activities of daily living? We can answer this question “yes” or “no” after reading this article, and in my own practice, I repeatedly refer to the information provided in it.

Dr. Morrey was an aerospace engineer who worked at NASA for two years before he attended medical school at the University of Texas Medical Branch. After his residency at the Mayo Clinic and after achieving a master’s degree in biomechanics from the University of Minnesota, he joined the staff at Mayo in 1978.

In this article, which integrates Dr. Morrey’s engineering and medical disciplines, he applied a high-tech device of that period (the triaxial electrogoniometer) to answer simple but eternal questions such as what degree of elbow flexion is needed to eat or perform personal hygiene.

It is the nature of human beings to notice particular joint impairments only when they disturb activities of daily living. Patient-reported outcome scores assessing subtle disturbances have recently been published, but we learned from Dr. Morrey’s article that patients with elbow flexion less than 130° will probably be reminded of their elbow problem whenever they try to use a telephone. (With today’s small cellular phones the problem might be even more accentuated.)

There is not much that a contemporary reviewer would criticise if this study were to be submitted today. Yes, the graphics would be nicer, and there would be more than 12 references. Modern computer-aided tools and methods for motion analysis might be more precise (and produce a mass of partially redundant data), but the results would remain essentially the same.

In fact, the question of functional elbow range of motion was revisited in JBJS by Sardelli et al. exactly 30 years after Dr. Morrey’s study appeared. Using modern three-dimensional optical tracking technology, Sardelli et al. found only minimal differences compared to findings in the Morrey et al. study. Only a few contemporary tasks like working on a computer (greater pronation) or using a cellular phone (greater flexion) appeared to require slightly more range of motion than previously reported.

Finally, it is the succinct and pointed results that amaze me whenever I recall the information from Dr. Morrey’s study. All we need to remember are four numbers: 100, 30, 130, and 50. Therein we are reminded that the patient needs to achieve a 100° arc of motion for flexion /extension (from 30° to 130°) and forearm rotation (50° of pronation and 50° of supination).

The authors were able to omit the conclusion sentence we see so often these days: “Further studies are needed…” The question about the minimal range of elbow motion needed to accomplish activities of daily living has been convincingly answered in this article. All residents should read this JBJS classic early, certainly before they examine their first patient with an elbow disorder.

Bernhard Jost, M.D.
JBJS Deputy Editor

JBJS Editor’s Choice: Arthroscopic Progress in Limiting Tissue Damage

Arthroscopic LCL RepairDuring the last two decades, we have made tremendous progress in orthopaedic surgery in terms of limiting the negative impact of surgical dissection on patient functional outcomes. The expanding use of the arthroscope has been at the forefront of these advances. Limiting the breadth, depth, and imprecision of surgical dissection has obvious benefits that have been well documented in hundreds of musculoskeletal procedures.

In the August 3, 2016 issue of The Journal, Kim et al. demonstrate arthroscopic repair of elbow instability following elbow dislocations with injury to the lateral ulnar collateral ligament. Despite the notable success reported by the authors in 13 patients, arthroscopic elbow ligament repair is obviously a technique that requires careful preparation, and patients should be advised to work with a surgeon who is experienced in this specific application of arthroscopy.

This study does not address the question of whether or not surgery is indicated for an individual patient with post-dislocation elbow instability. Comparing outcomes among surgically managed and non-surgically managed patients would be the mode of addressing that important question. Nevertheless, we should continue efforts to advance “limited surgical damage” approaches by applying appropriate clinical research designs to clarify the reward /risk tradeoffs related to patient outcomes.

Marc Swiontkowski, MD
JBJS Editor-in-Chief

New JBJS CME Subspecialty Exams

OEC LogoNew subspecialty CME exams are now available from The Journal of Bone & Joint Surgery in the following topic areas:

  • Adult Hip Reconstruction
  • Adult Knee Reconstruction
  • Shoulder and Elbow
  • Spine
  • Sports Medicine
  • Trauma

Each exam consists of 10 questions based on articles published in JBJS within the past 12 months. Exams can be used for study purposes at no cost. Each exam activity may be submitted for a maximum of 5 AMA PRA Category 1 Credits™.

Arms at Risk: Elbow Abnormalities Common Among Little Leaguers

LL Pitcher.jpgHere we are in the heart of Little League season, with an estimated 2.5 million kids out there playing. However, the rate of arm injuries in the 10- to 13-year-old population of baseball players has increased in the last two decades, despite the implementation of pitching guidelines.

In the May 4, 2016 edition of The Journal, Pennock et al. report findings from a prospective study of 26 Little League players whose elbows were physically examined and evaluated with MRI before the start of the season. Here are some salient results:

  • Nine players (35%) had 12 positive MRI findings, including seven instances of edema of the medial epicondyle apophysis.
  • Surprisingly, the prevalence of positive MRI findings and a history of arm pain were not greater in pitchers and catchers when compared to other position players.
  • Those with a positive MRI finding had greater reduction in shoulder internal rotation compared with the nondominant arm.
  • Year-round play (i.e., playing ≥8 months per year) and working with a private coach were associated with positive MRI findings and a history of elbow pain.

Noting that 27% of the players in this study used a private coach, Pennock et al. concluded that “ultimately, a balance must be found between teaching proper throwing mechanics and excessive throwing.” The authors also suggest that guidelines be revisited to address year-round play.

What’s New in Shoulder and Elbow Surgery: Level I and II Studies

Every month, JBJS publishes a Specialty Update—a review of the most pertinent and impactful studies published in the orthopaedic literature during the previous year in 13 subspecialties. Here is a summary of selected findings from Level I and II studies cited in the October 21, 2015 Specialty Update on shoulder and elbow surgery:

Shoulder

–A prospective evaluation of 224 subjects with asymptomatic rotator cuff tears followed annually for an average of five years found that the risk of tear enlargement and muscle degeneration was greater in full-thickness tears, and that pain and supraspinatus muscle degeneration were associated with tear enlargement.

–The authors of a randomized trial comparing physical therapy and primary surgical repair for initial management of degenerative rotator cuff tears concluded that the effects of surgery were not profound enough to justify surgical management for patients who present initially with painful degenerative cuff tears.

–A randomized trial comparing clinical outcomes in 58 patients with a rotator cuff tear and symptomatic acromioclavicular joint arthritis found no differences in function or pain scores between those who underwent cuff repair + distal clavicle resection and those who underwent cuff repair alone.1

–After two years of follow-up, no differences in functional outcomes or rate or quality of postoperative tendon healing were found in a randomized trial comparing patients who received platelet-rich plasma following surgical cuff repair and those who did not.2

–In a three-way randomized trial comparing physical therapy, acromioplasty + physical therapy, and cuff repair + acromioplasty + physical therapy for treating symptomatic, nontraumatic supraspinatus tendon tears in patients older than 55, there were no between-group differences in the mean Constant score one year after treatment.3

–A randomized trial comparing treatments for calcific tendinitis found that ultrasound-guided needling plus a subacromial corticosteroid injection resulted in better functional scores and larger decreases in calcium-deposit size than extracorporeal shock wave therapy.4

–A randomized trial of 196 patients with recurrent traumatic anterior shoulder instability found no significant differences in WOSI and ASES scores or range of motion between groups that underwent open or arthroscopic stabilization procedures.

–A randomized study comparing the effectiveness of immobilization in abduction (15°) and external rotation (10°) versus adduction and internal rotation after primary anterior shoulder dislocation found that after two years, only 3.9% of patients in the abduction/external-rotation group had repeat instability, compared to 33.3% in the adduction/internal-rotation group.5 A separate randomized trial found no significant difference in instability recurrence after one year between a group immobilized in internal rotation (sling) and a group immobilized in adduction and external rotation (brace).6

–A randomized trial of 250 patients (mean age of 65 years) with displaced surgical neck fractures of the proximal humerus compared surgical treatment (internal fixation or hemiarthroplasty) with conservative treatment. Finding no statistically or clinically significant difference in outcomes, the authors concluded that these results do not support the recent trend toward surgical management for proximal humeral fractures.7

–A randomized trial comparing reverse shoulder arthroplasty with hemiarthroplasty for acute proximal humeral fractures found that after two years of follow-up, reverse arthroplasty yielded better functional scores, better active elevation, and fewer complications than hemiarthroplasty.8

–A randomized trial comparing the use of concentric and eccentric glenospheres in reverse shoulder arthroplasty revealed no differences in scapular notching rates or clinical outcomes at a minimum follow-up of two years.

–A systematic review comparing radiographic and clinical survivorship of all-polyethylene versus metal-backed glenoid components used in total shoulder arthroplasty found that all-poly glenoids had a higher rate of radiolucencies and radiographic loosening but a much lower rate of revision after a mean follow-up of 5.8 years.

–A retrospective review found that arthroscopic biopsy was much more accurate than fluoroscopically guided fluid aspiration in diagnosing periprosthetic shoulder infections caused by Propionibacterium acnes.

–In a randomized trial of 76 workers’-comp patients with a displaced midshaft clavicular fracture, those receiving surgical management had faster time to union and return to work and better Constant scores than those managed conservatively.9

–Two studies compared plate fixation with intramedullary fixation for stabilizing clavicular fractures. One that randomized 59 patients found no differences in functional outcomes or time to healing. The other, which randomized 120 patients, found no between-group differences in DASH or Constant-Murley scores, but shoulder function improved more quickly in the plate-fixation group.

–A study that compared standard arthroscopic capsular release with capsular release extending to the posterior capsule for treating frozen shoulder found no difference in postoperative clinical or range-of-motion outcomes between the two groups.10

Elbow

–A randomized trial comparing regional analgesia to local anesthetic injections in patients undergoing elbow arthroscopy found no differences in pain, oral analgesic use, or patient satisfaction within 48 hours after surgery.11

–A randomized trial comparing eccentric and concentric resistance exercises for the treatment of chronic lateral epicondylitis found that the eccentric-exercise group had faster pain regression, lower pain scores at 12 months, and greater strength increases.12

References

  1. Park YB, Koh KH, Shon MS, Park YE, Yoo JC. Arthroscopic distal clavicle resection in symptomatic acromioclavicular joint arthritis combined with rotator cuff tear: a prospective randomized trial. Am J Sports Med. 2015 Apr;43(4):985-90.Epub 2015 Jan 12.
  2. Malavolta EA, Gracitelli ME, Ferreira Neto AA, Assunção JH, Bordalo-RodriguesM, de Camargo OP. Platelet-rich plasma in rotator cuff repair: a prospective randomized study. Am J Sports Med. 2014 Oct;42(10):2446-54. Epub 2014 Aug 1.
  3. Kukkonen J, Joukainen A, Lehtinen J, Mattila KT, Tuominen EK, Kauko T, Aärimaa V.Treatment of non-traumatic rotator cuff tears: a randomised controlled trial with one-year clinical results. Bone Joint J. 2014 Jan;96-B(1):75-81.
  4. Kim YS, Lee HJ, Kim YV, Kong CG. Which method is more effective in treatment of calcific tendinitis in the shoulder? Prospective randomized comparison between ultrasound-guided needling and extracorporeal shock wave therapy. J Shoulder Elbow Surg. 2014 Nov;23(11):1640-6. Epub 2014 Sep 12.
  5. Heidari K, Asadollahi S, Vafaee R, Barfehei A, Kamalifar H, Chaboksavar ZA,Sabbaghi M. Immobilization in external rotation combined with abduction reduces the risk of recurrence after primary anterior shoulder dislocation. J Shoulder Elbow Surg. 2014 Jun;23(6):759-66. Epub 2014 Apr 13.
  6. Whelan DB, Litchfield R, Wambolt E, Dainty KN; Joint Orthopaedic Initiative for National Trials of the Shoulder (JOINTS).External rotation immobilization for primary shoulder dislocation: a randomized controlled trial. Clin Orthop Relat Res. 2014 Aug;472(8):2380-6.
  7. Rangan A, Handoll H, Brealey S, Jefferson L, Keding A, Martin BC, Goodchild L,Chuang LH, Hewitt C, Torgerson D; PROFHER Trial Collaborators. Surgical vs nonsurgical treatment of adults with displaced fractures of the proximal humerus: the PROFHER randomized clinical trial. JAMA. 2015 Mar 10;313(10):1037-47.
  8. Sebastiá-Forcada E, Cebrián-Gómez R, Lizaur-Utrilla A, Gil-Guillén V. Reverse shoulder arthroplasty versus hemiarthroplasty for acute proximal humeral fractures. A blinded, randomized, controlled, prospective study. J Shoulder Elbow Surg. 2014Oct;23(10):1419-26. Epub 2014 Jul 30
  9. Melean PA, Zuniga A, Marsalli M, Fritis NA, Cook ER, Zilleruelo M, Alvarez C.Surgical treatment of displaced middle-third clavicular fractures: a prospective, randomized trial in a working compensation population. J Shoulder Elbow Surg.2015 Apr;24(4):587-92. Epub 2015 Jan 22.
  10. Kim YS, Lee HJ, Park IJ. Clinical outcomes do not support arthroscopic posterior capsular release in addition to anterior release for shoulder stiffness: a randomized controlled study. Am J Sports Med. 2014 May;42(5):1143-9. Epub 2014 Feb 28.
  11. Wada T, Yamauchi M, Oki G, Sonoda T, Yamakage M, Yamashita T. Efficacy of axillary nerve block in elbow arthroscopic surgery: a randomized trial. J Shoulder Elbow Surg. 2014 Mar;23(3):291-6. Epub 2014 Jan 15.
  12. Peterson M, Butler S, Eriksson M, Svärdsudd K.A randomized controlled trial of eccentric vs. concentric graded exercise in chronic tennis elbow (lateral elbow tendinopathy). Clin Rehabil. 2014 Sep;28(9):862-72. Epub 2014 Mar 14.