Techniques in Shoulder & Elbow Surgery

Treatment of Sagittal Split Olecranon Fractures Using Dorsal Plates Combined With Tension Band Wiring or Cerclage Wires We evaluated the results of olecranon fractures with an intra-articular sagittal plane fracture treated by dorsal plates in combination with tension band wiring or cerclage wires. We included patients with comminuted olecranon fractures with sagittal split treated with combination fixation. Postoperative functional assessment, Mayo Elbow Performance Score (MEPS) and complications were recorded. The mean age of patients was 52 years (SD±16). There were 7 female and 5 male patients. There were 2 1B, 7 2B, and 3 3B fractures according to Mayo classification. All patient’s fractures healed satisfactorily. There was one minor skin breakdown, which we managed conservatively. The most common problem was symptomatic hardware, which led us to implant removal surgery (33%). Mean loss of motion for the elbow and forearm were as follows: extension 7.5 degrees (SD±5.8 degrees), flexion 9.5 degrees (SD±3.9 degrees), pronation 4.5 degrees (SD±3.3 degrees), and supination 5 degrees (SD±3.7 degrees). The mean MEPS score was 93.7 (SD±7.7). We successfully treated these challenging fractures with our combination fixation technique in our case series. Level of Evidence: Level IV—diagnostic case series.

Clinical Results of Conservative Treatment of Severe Proximal Humerus Fractures Requiring Surgical Treatment in Old Patients The purpose of this study was to investigate the clinical outcomes of nonsurgically treated proximal humerus fractures that would have been otherwise treated surgically had it not been for reasons precluding surgical treatment. A retrospective search for patients treated nonsurgically for a proximal humerus fracture was performed. Injury x-rays of all patients were reviewed independently by 3 orthopedic surgeons. Patients for whom at least 2 surgeons recommended surgical treatment were included. Of 96 eligible patients, 22 patients completed the data collection. There were six 2-part, seven 3-part, five 4-part fractures, and 4 head-split fractures. The mean ASES and QuickDASH scores were 82.7 and 21.9, respectively. The mean VAS pain score was 1.1. No significant effects of head-shaft angles or the presence of a head-split fracture were found. Ultimately, patients with a proximal humerus fracture that would have normally necessitated surgical treatment showed favorable outcomes following nonsurgical treatment. Fracture pattern or articular involvement had no significant effect on the outcomes. This finding suggests that nonsurgical management of proximal humerus fractures that would traditionally necessitate surgical treatment can be a viable option in certain patients whose circumstances preclude surgical treatment.

Glenoid Fractures Treated by Percutaneous Osteosynthesis Under Arthroscopic Control Glenoid fractures are scarce and their treatment is discussed. Osteosynthesis under arthroscopy has been essentially described in bony Bankart lesions. Concerning bigger fractures of the glenoid cavity, eventually combined with a scapula body fracture, the arthroscopic treatment is difficult and still less practiced. Here, we describe 3 cases of external osteosynthesis by pins and/or cannulated screws under arthroscopic control. We put forward the case of a transclavicular approach for an associated fracture of the lateral quarter of the clavicle. The radiologic and functional results are good, with a rapid recovery of usual activities. The aim of this work is to highlight the feasibility of arthroscopic treatment for fractures of very different topology.

Anterior Capsular Reconstruction of the Shoulder for Chronic Instability Using a Dermal Allograft Chronic anterior shoulder instability after failed surgical stabilization procedures poses a significant challenge to orthopedic surgeons. Here, a novel technique of an anterior capsular reconstruction with a dermal allograft is presented. The shoulder remained stable with no recurrent dislocations at a final follow-up of 24 months. Excellent range of motion, strength, and good patient satisfaction is noted. Outcomes following the use of a dermal allograft for anterior capsular reconstruction have not been previously reported in the literature, and its use for chronic anterior shoulder instability shows promising initial results.

Reconstruction of the Acromioclavicular Joint With 360-degree Control Background: The TightRope/Endobutton techniques achieve good vertical reduction of the acromioclavicular joint, however anteroposterior and mediolateral stability may persist. Aims: The primary aim is to present our modification of the twin-tailed Dog Bone technique, using FibreTape and divergent clavicular limbs. The secondary aim is to report postsurgical outcomes. Hypothesis: By separating these divergent limbs widely the overall stability of the construct will be improved, limiting undesired mobility in all planes and assisting favorable postoperative outcomes. Materials and Methods: Included participants sustained acute Rockwood III to V acromioclavicular joint dislocations. Outcomes included the Oxford Shoulder Score (OSS), Nottingham Clavicle Score (NCS), the Specific Acromioclavicular Score (SACs), and return to sport time frames. Data were analyzed with descriptive statistics. Results: Forty-nine patients underwent this technique. Twenty-six patients returned their postoperative outcomes. Favorable results were shown by all outcomes after surgery (mean score: OSS, 46.3; NCS, 81.8; SACs, 15.9). The mean return to sport time was 17.5 weeks (contact sport) and 32.7 weeks (noncontact sport). There were no infections, no fractures, and 3 complications. Discussion/Conclusion: This modification of the twin-tailed Dog Bone technique using FibreTape resulted in a high patient self-rating of their shoulder function and a low rate of complications.

Correction of Elbow Flexion Deformity in Patients Affected With Spasticity Through the Lateral Approach: Surgical Technique and Results Fixed and dynamic elbow flexion deformity due to spasticity represents a common, yet challenging, clinical entity. Several surgical options have been described in literature, the majority of which utilize the anterior approach, through the antecubital fossa to release biceps. We propose a novel technique, using the lateral approach, as a safer and simpler option that allows release of the brachialis while leaving biceps intact to act as a supinator. All patients that were referred to our institution for treatment of an elbow flexion deformity due to spasticity between 2012 and 2016 were assessed. Patients with a previous history of trauma in the affected elbow or who failed to attend their follow-up appointments were excluded from the study. The lateral approach was used and all procedures were carried out by the senior author. Minimum follow-up was 12 months with a mean follow-up time of 20 months (range, 12 to 48 mo). Overall, 18 patients were assessed. One patient was excluded due to previous elbow trauma and another 3 were lost to follow-up. The rest 14 patients were included in the study. The underlying etiology was cerebral palsy in 3 patients, head injury in 5 patients, cerebrovascular accidents in 5 patients and multiple sclerosis in 1 patient. Elbow extension was significantly improved in all patient groups. Preoperative flexed elbow contracture measured 74 degrees on average (range, 10 to 150 degrees), whereas postoperatively these figures were 21 degrees on average (range, 0 to 50 degrees). No major postoperative complications were noted, including neurovascular compromise and surgical wound healing problems. On the basis of our results, we believe that the lateral approach for elbow contracture release may be safer and technically less demanding, compared with the anterior approach, while its results are comparable to the latter. Furthermore, leaving biceps intact preserves a powerful supinator to resist overactivity in the pronator muscles. Level of Evidence: Level IV—case series.