Techniques in Shoulder & Elbow Surgery

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Clinical Outcomes of Lateral Ulnar Collateral Ligament Repair of the Elbow Using a Cortical Button

imageThe purpose of this retrospective case series was to report a new surgical technique for lateral ulnar collateral ligament (LUCL) repair using a cortical button and the clinical results. Twenty patients underwent a LUCL repair using a cortical button at a single institution were included for evaluation of the demographic, radiologic, and clinical examination data. Nine patients returned for a separate study visit for further clinical examination and outcome surveys. Eighteen patients (mean age: 48 y, 10 males) received at least 1 additional procedure other than a LUCL repair. For the 9 patients who returned for a study visit (average follow-up: 27 mo), the mean QuickDASH score was 22.4 and the mean Mayo Elbow Performance Score 90. Six patients reported no pain, 1 moderate, and 2 mild. All 9 patients were satisfied. Average flexion-extension and supination-pronation arc of motion was 91% and 89% of the contralateral elbow, respectively. LUCL repair using a cortical button resulted in satisfactory clinical outcomes and can be a viable surgical option in acute elbow instability, especially in elderly patients with osteopenic bone.

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High-grade Common Extensor Tendon Tears Maintaining Chronic Lateral Epicondylitis: Clinical and Structural Outcome Following Knotless Suture Anchor Repair

imageWe describe the reconstruction of high-grade extensor tendon tears using a knotless suture anchor and hypothesize that this will result in improved elbow pain and function with a high healing rate. Twenty chronic lateral epicondylitis patients with magnetic resonance imaging–confirmed high-grade extensor tendon tears underwent surgery using a knotless suture anchor technique. All underwent clinical and ultrasound assessments and completed the quick Disabilities of the Arm, Shoulder, and Hand and patient-rated tennis elbow evaluation questionnaires at final follow-up. Preoperative and postoperative Mayo Elbow Performance Scores were also determined. Mean patient age at surgery was 48 years with 11 women and 7 men available at final follow-up. Diagnostic arthroscopy was performed for all patients before repair; cartilage lesions were found in 8 patients. Mayo Elbow Performance Score improved from 55 to 100 points. At final follow-up, the median grip strength was 100% (range, 52 to 114) of the nonaffected side and patient-rated scores were almost 0. We did not observe any retears. Some tennis elbow patients may present with high-grade tears that contribute to chronic symptoms. Our repair technique resulted in a satisfactory outcome for these patients and may reduce the risk of secondary posterolateral instability following complete tendon release.

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The Mini-open Plication of Medial Collateral Ligament of the Elbow: A New Arthroscopically Assisted Technique

imageThe stability of the medial elbow compartment is not only important for everyday life but also plays a key role in throwing gestures. Valgus stress is a fundamental part of popular sport activities (baseball, squash, tennis, and volleyball). Even the isolated medial collateral ligament (MCL) lesion might develop symptomatic medial instability, which interrupts everyday life. This instability may be symptomatic and patients may refer medial elbow pain. Several techniques for MCL treatment have been described. Most of them are reconstructions in which there are tunnels and free cylindrical grafts. The aim of our study is to describe step-by-step a new surgical procedure for minimally invasive plication of aMCL arthroscopically assisted. This procedure should be performed after 6 months of conservative treatment failure. After arthroscopic MCL laxity diagnosis, the standard bioabsorbable double-loaded anchor with high resistance sutures was inserted into the anteroinferior surface of the medial epicondyle. After adequate restraint and preparation of proximal aMCL, 2 bioresorbable sutures were passed through the ligament considering 1 to 1.5 cm of tissue to be plicated. The procedure is considered less invasive and safe in comparison with graft reconstructions of MCL.

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Reconstruction of Chronic Distal Biceps Tendon Rupture With Autogenous Semitendinosis Graft Using the “Anatomic Length Method” and Concomitant Bicipital Aponeurosis Repair

imageWe present a novel variation of a surgical technique for reconstruction of chronic distal biceps tendon ruptures using the “Anatomic Length Method.” Graft length for chronic distal biceps tendon rupture reconstruction is extremely variable and typically empirically determined by elbow position during final fixation. These techniques do not account for chronicity and varying degrees of retraction and muscle shortening. For this unique variation in the surgical technique, the graft length used is based on previous anatomic cadaveric measurements done in our center with an external distal biceps tendon length mean of 6.3 cm. In addition, our technique routinely reconstructs the bicipital aponeurosis. This allows for a highly reproducible surgical technique and restores a more normal biceps anatomy and muscle length-tension relationship.

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An Approach to the Management of Bilateral Posterior Shoulder Dislocations Following Seizure: Case Report, Literature Review, and Proposed Treatment Algorithm

imageBilateral posterior shoulder dislocations in patients with seizure disorders are an uncommon injury that is difficult to treat. Surgery is typically required and impaction lesions often require bone reconstruction procedures. Seizures in the early postoperative period can have disastrous consequences when bone restoration procedures are disrupted. However, delaying treatment of persistent instability can cause further joint damage and bone loss potentially leading to the need for humeral head replacement. Our purpose is to introduce an approach to treating the young patient who presents with bilateral posterior dislocations related to a seizure. We report a case, describe the surgical techniques used, and propose an algorithm for managing the treatment of a young patient who presents with bilateral posterior dislocations related to a seizure. At her most recent follow-up (57 mo postoperative for the left shoulder and 41 mo postoperative for the right shoulder), she denied any apprehension or instability in either shoulder and had no further dislocations. She reported mild chronic pain in both shoulders, worse in the right than the left. She has a smooth passive range of motion with no crepitus in either shoulder. Her range of motion in forward elevation/external rotation/internal rotation is 150/45/L3 on the left and 50/150/L3 on the right. Strength is 5/5 in all planes and her subscapularis is clinically intact bilaterally. Our case illustrates the importance of early surgical intervention, resulting in functional, stable shoulders even in the face of medically and surgically intractable epilepsy. This algorithm highlights the importance of multidisciplinary cooperation and early surgical intervention to minimize bone loss and avoid joint replacement.

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Core Decompression for Class I Avascular Necrosis of Humeral Head

Avascular necrosis of the humeral head is a diagnosis of multiple etiologies and unclear prognosis. Prompt diagnosis and treatment are essential to prevent head collapse and avoid resurfacing or joint replacement procedures. Imaging modalities including standard radiography and magnetic resonance imaging establish the diagnosis and stage it according to the degree of necrosis, head collapse, or extension into the glenoid. If the patient stays persistently symptomatic despite conservative treatments and is still in the early stages of the disease course, humeral head core decompression is a reasonable option as it has been shown to decrease disease progression and provide symptomatic relief. Here, we present a case of a 52-year-old female with a history of adhesive capsulitis status postmanipulation and arthroscopic lysis of adhesions, now presenting with Cruess Stage I avascular necrosis of the humeral head. This technique (Supplemental Video, Supplemental Digital Content 1, demonstrates core decompression and grafting of the humeral head using a percutaneous expandable reamer.
Level of Evidence: Level V (expert opinion).

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