The efficacy of celecoxib in preventing heterotopic ossification recurrence after open arthrolysis for post-traumatic elbow stiffness in adults

Resection Outcomes of Posttraumatic Elbow Heterotopic Ossification: Multicenter Case Series at a Minimum 5-Year Follow-Up

BACKGROUND

Heterotopic ossification (HO), a common complication after elbow trauma, causes severe limb disability. Resection is usually performed for posttraumatic elbow HO (PTEHO) to regain mobility, and although heavily reported, there has been no long-term (minimum, 5-year) follow-up.

METHODS

A total of 173 patients who underwent PTEHO resection were followed up for a minimum of 5 years in 4 hospitals between January of 2015 and August of 2016. Demographics, disease characteristics, and preoperative and minimum 5-year assessments were collected. After controlling for potential variables when dividing long-term range of motion (ROM) into less than 120 degrees and greater than or equal to 120 degrees, risk factors for ROM recovery to modern functional arc were identified through multivariable regression analysis.

RESULTS

Clinically important improvements in ROM from 39 degrees to 124 degrees were obtained at final follow-up, and 74.6% achieved modern functional arc (≥120 degrees). Mayo Elbow Performance Index had clinically important increases from 69 to 93 points at final follow-up, and 96.5% reported excellent to good. Pain (numeric rating scale, from 1.9 to 0.6 points) and ulnar nerve symptoms were improved. The total complication rate was 15.6%, including new-onset ulnar nerve symptoms (5.8%), HO recurrence with clinical symptoms (6.9%), elbow instability (1.7%), and joint infection (1.2%). Previously reported high body mass index ( P = 0.002) and long disease duration ( P = 0.033) were equally identified as risk factors for not achieving modern functional arc; meanwhile, tobacco use ( P = 0.024) and ankylosed HO ( P < 0.001) were found to be new risk factors.

CONCLUSIONS

Resection yields satisfactory outcomes for PTEHO at long-term follow-up of a minimum of 5 years. High body mass index, tobacco use, long disease duration, and ankylosed HO would negatively affect ROM recovery to a modern functional arc (≥120 degrees).

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, III.

Heterotopic ossification of the elbow joint in a child: Successful surgical resection - A case report

Background

This case report describes the occurrence of a rare heterotopic ossification of the elbow joint in a child, caused by inappropriate movement after trauma. A successful operation to remove heterotopic ossification was described in the report with satisfactory results.

Case presentation

A 7-year-old boy suffered a supracondylar fracture of the humerus after an accidental fall, and after immobilization with a cast, improper movement resulted in heterotopic ossification of the elbow joint, which severely affected joint function. The heterotopic ossification was surgically removed and a complete recovery was demonstrated at 18 months follow-up. The heterotopic ossification was successfully removed with good elbow function and no recurrence at 18 months follow-up.

Conclusions

The purpose of this report is to show the good results with surgical treatment of heterotopic ossification of the elbow joint in children,when conservative treatment does not work.

Classification and Incidence of Heterotopic Ossifications in Relation to NSAID Prophylaxis after Elbow Trauma

Heterotopic ossification (HO) after elbow trauma can be responsible for significant motion restrictions. The study's primary aim was to develop a new X-ray-based classification for HO of the elbow. This retrospective study analyzed elbow injury radiographs from 138 patients aged 6-85 years (mean 45.9 ± 18) who underwent operative treatment. The new classification was applied at 6 weeks, 12 weeks, and 6 months postoperatively. The severity of HO was graded from 0 to 4 and localization was defined as r (radial), p (posterior), u (ulnar) or a (anterior) by two observers. The patients were categorized based on injury location and use of non-steroidal anti-inflammatory drugs (NSAIDs) for HO prophylaxis. The correlations between the generated data sets were analyzed using Chi-square tests (χ2) with a significance level of p < 0.05. The inter- and intraobserver reliability was assessed using Cohen's Kappa. In 50.7% of the evaluated X-rays, the formation of HO could be detected after 12 weeks, and in 60% after 6 months. The analysis showed a significant correlation between the injury's location and the HO's location after 12 weeks (p = 0.003). The use of an NSAID prophylaxis did not show a significant correlation with the severity of HO. The classification showed nearly perfect inter- (κ = 0.951, p < 0.001) and intrareliability (κ = 0.946, p < 0.001) according to the criteria of Landis and Koch. Based on the presented classification, the dimension and localization of HO in the X-ray image can be described in more detail compared to previously established classifications and, thus, can increase the comparability of results across studies.

Tranexamic acid in patients with post-traumatic elbow stiffness: protocol for a randomised, double-blind, placebo-controlled trial investigating the effectiveness of tranexamic acid at reducing the recurrence of heterotopic ossification after open elbow arthrolysis

INTRODUCTION

Exaggerated inflammatory response is one of the main mechanisms underlying heterotopic ossification (HO). It has been suggested that the antifibrinolytic drug tranexamic acid (TXA) can exert a significant anti-inflammatory effect during orthopaedic surgery. However, no prospective studies have yet investigated the effects of TXA on HO recurrence in patients following open elbow arthrolysis (OEA).

METHODS AND ANALYSIS

Here, we present a protocol for a single-centre, randomised, double-blind, placebo-controlled trial to investigate the effectiveness of TXA on HO recurrence after OEA in a single hospital. A minimum sample size of 138 eligible and consenting participants randomised into treatment and control groups in a 1:1 manner will be included. Patients will receive 2 g of intravenous TXA (experimental group) or placebo (normal saline, control group) administered before skin incision. The primary outcome is HO recurrence rate within 12 months after surgery. The secondary outcomes are the serum immune-inflammatory cytokines including erythrocyte sedimentation rate, C reactive protein, interleukin (IL)-6, IL-1β, IL-13 at the first and third day postoperatively, and elbow range of motion and functional score at 1.5, 6, 9 and 12 months after surgery. After completion of the trial, the results will be reported in accordance with the extensions of the Consolidated Standards of Reporting Trials Statement for trials. The results of this study should determine whether TXA can reduce the rates of HO occurrence after OEA.

ETHICS AND DISSEMINATION

Ethical approval has been granted by the Medical Ethics Committee of the Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine (reference number 2022-123-(1)). The results of this study will be disseminated through presentations at academic conferences and publication in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

ChiCTR2300068106.

3D-printing of the elbow in complex posttraumatic elbow-stiffness for preoperative planning, surgery-simulation and postoperative control

BACKGROUND

Restoration of mobility of the elbow after post-traumatic elbow stiffening due to osteophytes is often a problem.

METHODS

The anatomical structures were segmented within the CT-scan. Afterwards, the Multi Jet Fusion 3D-printing was applied to create the model made of biocompatible and steam-sterilizable plastic. Preoperative simulation of osteophyte resection at the 3D-model was performed as well as the direct comparison with the patient anatomy intraoperatively.

RESULTS

The patient-specific was very helpful for the preoperative simulation of the resection of elbow osteophytes. The 3D anatomical representation improved the preoperative plan its implementation. A high degree of fidelity was found between the 3D Printed Anatomical representation and the actual joint pathology.

CONCLUSIONS

Arthrolysis of complex post-traumatic bony changes is an important indication for the use of 3D models for preoperative planning. Due to the use of 3D printing and software simulation, accurate resection planning is feasible and residual bony stiffening can be avoided. 3D printing models can lead to an improvement in surgical quality.

Comparative Study Between the Mini-Open (≤2.5 Cm) Approach and Conventional Open Lateral Approach in the Surgical Treatment of Radial Head Fractures

Purpose

The conventional lateral approach is widely used to treat radial head fractures with screws. However, the traditional incision may have shortcomings, including excessive exposure and significant scarring. We propose an innovative method – a mini-open lateral approach of less than 2.5 cm for surgical treatment of radial head fractures with screws.

Methods

From Jan 2017 to Dec 2020, 34 patients diagnosed with closed radial head fracture were treated with open reduction and internal fixation (ORIF) in this study. The novel group (mini-open group) included 15 patients, and the other 19 patients were in the traditional group. The time of operation and the blood loss during operation were recorded. Postoperative clinical outcomes and radiographic results were recorded and compared between the two groups. The range of motion (ROM) in the elbow, the Visual Analogue Scale (VAS), the Mayo Elbow Performance Score (MEPS), Rating Scale of the American Shoulder and Elbow Surgeons (ASES), and the Shortened Disabilities of the Arm, Shoulder and Hand Questionnaire (Q-DASH) score and complications, such as wound infection, vascular and nerve damage, and fragment redisplacement were observed in the two groups.

Results

In the comparison between the two groups, there was no significant difference in age, sex, cause of radial head fracture, or other basic information. The operation time, intraoperative blood loss, and VAS score at 3 days postoperation were significantly reduced in the novel group (p < 0.05). The follow-up results showed that there was no significant difference in MEPS, ASES, or Q-DASH scores between the two groups.

Conclusion

The mini-open approach reduced intraoperative blood loss, shortened operation time, relieved patient pain, and achieved a satisfactory postoperative clinical result, which demonstrates that the novel approach is a safe and effective option for treating radial head fractures.

Effectiveness and safety of a less-invasive MCL reconstruction technique for contracted or ossified ligaments in patients with elbow stiffness: An open-label, non-randomised, prospective, multicentre trial in China

BACKGROUND

The elbow joint is sensitive to trauma from accidents, sports injuries, and surgical trauma. Some patients develop ossification or contracture of the medial collateral ligament (MCL) after elbow trauma. A less invasive reconstruction of the MCL can be performed after resection of diseased MCL. The biomechanical characteristics of this technique have been demonstrated and validated. However, its clinical effectiveness and safety require further confirmation in clinical practice.

METHODS

This open-label, non-randomised, prospective, multicentre trial included consecutive patients with elbow stiffness from five orthopaedic centres in China. Patients willing to participate in the study, with elbow stiffness caused by traumatic injury, who had reached skeletal maturity, and who had a range of motion of <100° were eligible for inclusion. Patients with immunological or metabolic causes of elbow stiffness, burns, or central nervous system injuries were excluded. In addition, patients who did not require MCL release and reconstruction after intraoperative release of other structures were also excluded. All patients underwent resection of the diseased MCL part in an open arthrolysis. Medial stability of the elbow was reconstructed using a less invasive MCL reconstruction technique that uses fascia and tendon patches. In this study, the primary outcomes, including stability, Mayo Elbow Performance Score (MEPS), Amadio score, were used to comprehensively evaluate this technique. Outcomes were assessed at 6 weeks, 6 months, and 1 year postoperatively and annually thereafter. This study reports the results of one arm of the trial that has been registered with the Chinese Clinical Trial Registry (chictr.org.cn), ChiCTR-INC-16010019.

FINDINGS

Between January 1, 2017 and March 1, 2020, 104 eligible patients were enrolled. The mean follow-up time was 43·47 (95% CI, 41·45 - 45·49) months. Among all 104 patients, 100 (96%) patients who underwent MCL reconstruction retained medial stability at the last follow-up. All outcomes from the last follow-up were used for comparison with the preoperative outcomes. No differences in preoperative and postoperative stability scores were observed (P = 0·7820). Extension, flexion, pronation, and supination of the injured elbow improved significantly (P < 0·0001, P < 0·0001, P < 0·0001, P < 0·0001). The mean range of motion (ROM) and forearm rotational range of motion (FRR) increased by 71·25° (152%) (P < 0·0001) and 30·83° (25%) (P < 0·0001), respectively. Additionally, the Mayo Elbow Performance Score (MEPS) and muscle strength had increased after evaluation at follow-ups (P < 0·0001, P < 0·0001). Drastic pain relief and nerve symptom reduction were observed, as evaluated using VAS scores and Amadio scores, respectively (P < 0·0001, P < 0·0001). Seventeen (16%) patients experienced a recurrence of elbow stiffness of varying severity, but only two patients had poor or fair results. Several common and non-severe complications, including infection in one (1%) patient, new nerve symptoms in seven (7%) patients, new pain in one (1%) patient, fracture in one (1%) patient, and valgus instability in four (4%) patients, were observed and properly treated in this study.

INTERPRETATION

The less invasive MCL reconstruction technique using fascia and tendon patches is an effective method for restoring medial stability in patients with elbow stiffness after complete arthrolysis with certain safety. The technique shows prospects for elbow MCL reconstruction in clinical practice.

FUNDING

The study was supported by the National Key Research and Development Program of China (No. 2021YFC2400805), National Natural Science Foundation of China (No. 81830076), Young Elite Scientist Sponsorship Program by Cast (No. YESS20200153), Shanghai Sailing Program (No. 20YF1436000), Shanghai Municipal Science and Technology Commission Foundation (No.19ZR1439200), Municipal Hospital Newly-developing Cutting-edge Technologies Joint Research Program of Shanghai Shenkang Hospital Development Centre (No. SHDC12018130).

Heterotopic ossification after alloplastic temporomandibular joint replacement: a case cohort study

Background

Heterotopic ossification (HO) is one of the serious complications leading to the failure of alloplastic temporomandibular joint replacement (TJR). However, there was few research on its exact incidence and occurrence. Severe HO might result in pain and limited mouth opening after surgery. Therefore, it is necessary to clarify its clinical and imaging manifestations. The purpose of this study was to study the occurrence and classify HO after the alloplastic TJR.

Method

Patients who underwent standard TJR (Zimmer Biomet stock prostheses or Chinese stock prostheses) with fat graft and at least 1-year-follow-up were included. HO was classified into 4 types according to postoperative computed tomography (CT) scans. Type and occurrence in different TMJ disease were compared. Joint space within 1 week after operation was measured and compared between HO and non-HO TJRs. Maximum incisal opening (MIO), pain, and quality of life (QoL) were recorded and their relevance with HO was analyzed statistically.

Result

81cases with 101 joints were included in the study. The mean follow-up time was 22.9 months (12 ~ 56 months). Among the 48 joints, 27 (56.3%) were type I (bone islands); 16 (33.3%) were type II (bone spurs from the mandibular ramus); 3 (6.3%) were type III (bone spurs from the fossa); and 2 (4.2%) were type IV (bone spurs from both the mandibular ramus and fossa). In HO patients, joint space in type IV was smaller than the other 3 types. Pain scores in HO were significantly greater than non-HO patients before and after operations (p < 0.05). 1 patient in Type IV HO developed ankylosis and had prosthesis revision which accounted for 2.1% in HO patients and 1.0% in all TJR patients.

Conclusion

HO after alloplastic TJR with fat graft was not severe except for type IV, which was easy to cause ankylosis. Preserving sufficient TJR space was important for ankylosis prevention.

Interposition Arthroplasty in Untreated Chronic Dislocation of the Elbow

To describe the clinical outcomes of interposition arthroplasty with transposition of the medial epicondyle to the coronoid process and articulated external fixation in patients with untreated chronic dislocation of the elbow.

Clinical results of a 10-year follow-up of surgical treatment for elbow stiffness in rheumatoid arthritis: A case series

BACKGROUND

Rheumatoid arthritis commonly causes transient limitation of joint motion, but the treatment of persistent stiffness in the rheumatoid elbow has rarely been reported. The purpose of this study was to evaluate the long-term clinical results of surgical treatment of rheumatoid elbow stiffness.

METHODS

Surgical treatment, including open arthrolysis with hinged external fixation, total synovectomy, and ulnar nerve release and anteriorization, was performed in 48 elbows in 43 patients with rheumatoid arthritis and early joint destruction. Mobility (flexion-extension and pronation-supination), Mayo Elbow Performance Score (MEPS), visual analog scale (VAS) score, muscle strength, nerve symptoms, postoperative complications, and recurrent synovitis were evaluated 9-11 years (average, 9.88 years) postoperatively.

RESULTS

The mobility of the elbow was significantly improved over the preoperative period either in extension, flexion, protonation, supination (P < .001, P < .001, P < .001, P = .002). The mean MEPS was significantly improved from 56.25 points (range, 30-90) to 87.40 points (range, 40-100) (P < .001). The pain was relieved, and the mean VAS score was reduced from 3.56 (range, 0-8) to 1.08 (range, 0-5) points (P < .001). Preoperative ulnar nerve symptoms were observed in 17 patients and relieved in 10 (59%) patients, and the mean Amadio score was raised from 6.9 (range, 3-9) to 7.96 (range, 4-9) points (P < .001). Through surgical treatment and postoperative rehabilitation, the mean grip strength of the patients was significantly improved from an average of 9.01 (range, 3.4-18.5) to 17.56 kg (range, 3.9-40.2) (P < .001). Five elbows developed recurrent synovitis, and one underwent total elbow arthroplasty. Postoperative complications were uncommon and not severe.

CONCLUSION

Surgical treatment is a reliable procedure for rheumatoid elbow stiffness and can be effective in improving elbow mobility, function, muscle strength, pain relief, and relief of nerve symptoms.

Treatment of Temporomandibular Joint Heterotopic Ossificans: A Novel Protocol With Multimodal Therapy Based on Literature Review and Presentation of a Unique Case Reportc

PURPOSE

The purpose of this study was to create a treatment protocol for cases of heterotopic ossification (HO) of the temporomandibular joint (TMJ), particularly those refractory to current TMJ HO protocols. In addition, we demonstrate the success of this protocol on a unique case of recurrent HO that failed multiple TMJ HO protocols in the setting of an improvised explosive device (IED) blast in a wounded warrior.

METHODS

An electronic literature review was conducted via PubMed and Web of Science. Twenty-five studies were identified to provide supporting evidence for a proposed, up-to-date protocol for the treatment of refractory TMJ HO. The authors present a case report of a wounded warrior with HO ankylosis of bilateral TMJs in the setting of IED blast and demonstrate successful use of our surgical and pharmacotherapeutic protocol.

RESULTS

Based on the literature review, our proposed protocol consists of pharmacotherapy with celecoxib and etidronate, with weekly forced dilation (brisement) and home physical therapy with the TheraBite Jaw Motion Rehab System. Surgically, the TMJ should be treated with two-stage reconstruction using initial polymethyl methacrylate spacers and subsequent total joint reconstruction with custom prostheses, fat grafting, and 3-dimensional-navigated total resection of HO. This protocol was successfully utilized in our patient's refractory HO ankylosed TMJ secondary to IED blast, and the patient's maximal incisal opening was regained and has remained stable 2 years after surgery without recurrent HO.

CONCLUSIONS

Our method for treatment in this case deviated from the standard TMJ Concepts HO protocol in that it included multimodal pharmacotherapy with celecoxib and etidronate. Based on our literature review and experience, we advise that clinicians utilize our protocol for the management of all craniofacial HO cases, particularly in cases of recurrent HO that fail conventional therapies and/or involving high-order blast trauma.

Comparing Options for Heterotopic Ossification Prophylaxis following Elbow Trauma: A Systematic Review and Meta-Analysis

Introduction  Heterotopic ossification (HO) can be a potentially serious and devastating complication following traumatic injury to the elbow. HO prophylaxis options include nonsteroidal anti-inflammatory drugs (NSAIDs) and radiation therapy (RT) but neither has been proven more effective. The purpose of this review is to compare effectiveness and outcomes between NSAID and RT prophylaxis for HO about the elbow following a traumatic injury. Materials and Methods  We performed a systematic review of PubMed and Cochrane Library for cases of HO prophylaxis following elbow trauma utilizing PRISMA guidelines to determine the most effective form of prophylaxis. Outcomes of interest included recurrence of HO, range of motion (ROM), and Mayo elbow performance index (MEPI). A total of 36 articles and 826 elbows of which 203 received RT and 623 received NSAID were identified and included in the final analysis. Results  Rates of HO formation or recurrence following elbow trauma were similar between radiation and NSAID prophylaxis (15.6% vs. 22.2%, respectively p = 0.457). ROM was similar in flexion and extension arc (109.0 degrees in radiation vs. 112.8 in NSAIDs, p = 0.459) and in pronation and supination arc (118.9 degrees radiation vs. 134.7 degrees NSAIDs, p = 0.322). MEPI scores were 79.19 in the radiation group and 88.82 in the NSAIDs group at the final follow-up. Conclusion  There is no statistical difference in HO development, recurrence, or final ROM between NSAIDs and RT prophylaxis following trauma to the elbow. We recommend the choice of modality based on patient characteristics, cost, and surgeon preference. Level of Evidence  Level III.

The post-traumatic stiff elbow: A review

Upper extremity function is highly dependent on elbow motion in order to adequately position the hand in space. Loss of this motion due to stiffness following trauma can cause patients substantial disability, leading to difficulties with performing activities of daily living. Post-traumatic elbow stiffness is challenging to treat, and therefore prevention is of paramount importance. Key measures that can be used to prevent elbow stiffness are early surgical intervention for fracture or joint instability, as well as active mobilisation, which helps to prevent oedema and an increase in viscosity of inflammatory exudates. Other options include splinting and continuous passive mobilisation. Once non-operative methods of addressing post-traumatic stiffness have been exhausted, arthrolysis of the stiff elbow can be performed via open or arthroscopic means depending on the type of pathology involved (intrinsic or extrinsic contracture) and experience of the surgeon with elbow arthroscopy. The particular open approach used depends on several factors, which include the formation and location of any heterotopic ossification present. Improvements in range of motion can be expected with both open and arthroscopic techniques, which can be effective and rewarding for patients. Post-operative rehabilitation, particularly early active mobilisation, should be considered essential in order to optimise patient outcomes following surgery. This review aims to explore elbow stiffness following traumatic aetiology, assessing its pathogenesis and prevention, as well as reviewing surgical treatment options and post-operative rehabilitation.

The efficacy of nonsteroidal anti-inflammatories in the prevention of heterotopic ossification following elbow trauma surgery

Background

Heterotopic ossification (HO) is common following surgery for elbow trauma and can have a significant impact on elbow function. The use of nonsteroidal anti-inflammatories (NSAIDs) for HO prophylaxis following total hip arthroplasty is well described, with the gold standard of indomethacin 25 mg tid for 6 weeks. However, there is sparse evidence relating to the elbow joint, particularly after elbow trauma surgery. We aim to investigate the efficacy of NSAIDs in the primary prevention of HO amongst all adult patients undergoing surgery for elbow trauma and identify risk factors for HO formation.

Methods

A search of the Fiona Stanley Hospital electronic theater database for procedures undertaken for elbow trauma from January 2015 to June 2020 was performed. Electronic medical records and radiographs were reviewed to determine the incidence of HO, prescription of NSAIDs, biographical data, and complications.

Results

One hundred and fifty-three patients were identified of which 78 patients received NSAIDs postoperatively, compared to 72 who did not. The prescribing history of the remaining 3 patients was unknown. In the NSAID group, the typical patient was prescribed 3-7 days of NSAIDs. Ten patients received a prophylactic course (4-6 weeks). The incidence of HO was similar in both groups (24% in those taking NSAIDs vs. 21% in those not taking NSAIDs). Of those specifically prescribed a prophylactic course, 50% developed HO and 50% did not. Statistical analysis demonstrated that patients with increased body mass index and high energy injuries were more likely to develop HO. Overall complications were low within the cohort. Only 1 patient, who was prescribed NSAIDs, suffered a fracture nonunion (1.3%).

Conclusion

NSAIDs did not affect the incidence of HO about the elbow following surgery for trauma amongst our cohort. There was no appreciable difference in the rates of HO amongst those prescribed NSAIDs and those who were not. Increased body mass index and high energy trauma were predictive for higher incidence of HO. Risks of NSAID therapy were low, with only 1 (1.3%) patient suffering a nonunion.

How effective is periarticular multimodal drug injection in open elbow arthrolysis? A prospective double-blind randomized controlled trial

BACKGROUND

Evidence on the efficacy and safety of periarticular multimodal drug injection (PMDI) in open elbow arthrolysis (OEA) is limited. This study aimed to investigate differences in postoperative pain, blood loss, and range of motion (ROM) between PMDI vs. no injection among patients undergoing OEA, and the presence of PMDI-related complications.

METHODS

This prospective, double-blind randomized controlled trial included 59 patients who underwent OEA. Patients randomly received PMDI (ropivacaine, epinephrine, ketoprofen) before wound closure or no injection. The primary outcomes were elbow pain over the first postoperative week at rest and during motion, measured using the visual analog scale (VAS). VAS scores were compared to attain the 20-mm threshold values for a minimum clinically important difference. Parecoxib consumption on OEA night and postoperative days (PODs) 1-3 and total consumption during the first postoperative week were recorded. Blood loss was recorded every 24 hours until POD 3. ROM during rehabilitation was measured daily from day 1 to day 7 after surgery, as well as at 3-month follow-up. Medication-related side effects were recorded prospectively.

RESULTS

The mean VAS score showed clinically important differences between PMDI and control groups at rest on OEA night (mean difference [MD], 25 mm; P < .001) and first 3 PODs with motion (POD 1: MD, 28 mm, P < .001; POD 2: MD, 21 mm, P < .001; POD 3: MD, 21 mm, P < .001) but not in other postoperative assessments. Parecoxib consumption was lower in the PMDI group on OEA night and PODs 1-3. Total parecoxib consumption during the first postoperative week was lower in the PMDI group vs. the control group (MD, 148 mg; P < .001). Blood drainage was less in the PMDI group vs. the control group on POD 1 (MD, 38 mL; P = .016) but not on POD 2 (P = .950), POD 3 (P = .259), or total (P = .184). The PMDI group exhibited significantly better ROM during the first 4 PODs than the control group, whereas there was no difference at 3-month follow-up. No medication-related side effects were noted in the PMDI group.

CONCLUSION

PMDI effectively relieves pain and reduces analgesic consumption for OEA patients, without an apparent increase in risks.

Midterm Outcomes After Open Arthrolysis for Posttraumatic Elbow Stiffness in Children and Adolescents

BACKGROUND

Open arthrolysis is used for treating elbow stiffness in adults. This study evaluated the midterm outcomes after open arthrolysis in children and adolescents with posttraumatic elbow stiffness.

METHODS

Data of 31 children and adolescents with posttraumatic elbow stiffness following open arthrolysis with or without hinged external fixation from 2010 to 2014 were retrospectively analyzed. Their mean age was 15 (range: 6 to 19) years. At baseline and the follow-up (>4 y), we evaluated the outcomes (range of motion and Mayo Elbow Performance Index) and postoperative complications (pain, ulnar nerve symptoms, infections, and instability) and analyzed the association between outcomes and clinical variables.

RESULTS

The Mayo Elbow Performance Index improved from 67.9 (range: 35 to 95 points) to 93.7 points (range: 65 to 100 points; P<0.001). The elbow active flexion/extension arc increased significantly from 49 degrees (range: 0 to 120 degrees) to 108 degrees (range: 0 to 120 degrees; P<0.001), with a mean flexion of 123 degrees (range: 70 to 140 degrees; P<0.001) and mean extension of 15 degrees (range: 0 to 85 degrees; P<0.001) postoperatively. The increasing age at surgery was associated with improved elbow motions (P=0.004). Patients with increased preoperative serum alkaline phosphatase level demonstrated decreased arc of motion (P=0.015). Patients with extra-articular fractures had better outcomes than the other patients. At the final follow-up, 8 patients experienced recurrent contracture in the flexion arc with heterotopic ossification. Two patients had postoperative pain, 1 elbow instability, and 1 ulnar neuropathy.

CONCLUSIONS

Most patients showed satisfactory functional outcomes after arthrolysis, indicating that open release with or without hinged external fixation is an effective and maintained technique for children and adolescents with posttraumatic elbow stiffness. The age at surgery, preoperative alkaline phosphatase level, and injury type should be considered to achieve good outcomes.

LEVEL OF EVIDENCE

Therapeutic level III.

Open elbow arthrolysis for post-traumatic elbow stiffness: an update

Post-traumatic elbow stiffness is a disabling condition that remains challenging for upper limb surgeons. Open elbow arthrolysis is commonly used for the treatment of stiff elbow when conservative therapy has failed. Multiple questions commonly arise from surgeons who deal with this disease. These include whether the patient has post-traumatic stiff elbow, how to evaluate the problem, when surgery is appropriate, how to perform an excellent arthrolysis, what the optimal postoperative rehabilitation is, and how to prevent or reduce the incidence of complications. Following these questions, this review provides an update and overview of post-traumatic elbow stiffness with respect to the diagnosis, preoperative evaluation, arthrolysis strategies, postoperative rehabilitation, and prevention of complications, aiming to provide a complete diagnosis and treatment path. Cite this article: Bone Joint Open 2020;1-9:576-584.

Management of the failed radial head arthroplasty

Primary radial head arthroplasty (RHA) produces good or excellent results in approximately 85% of patients. However, complications are not uncommon and have been described in up to 23% of cases.

The number of RHA is increasing, and consequently the absolute number of complications is expected to rise as well. The decision on whether to revise or remove the prosthesis seems more likely to depend on the preference of the surgeon or the hospital, rather than on objectifying problems with the prosthesis.

The current article presents an algorithm for the work-up and treatment of most complications that can occur following RHA.

Five subgroups of problems were identified: osteoarthritis, stiffness, instability, infection and implant-related issues.

In short, the preferred treatment depends mainly on the chondral condition and stability of the elbow joint.

Cite this article: EFORT Open Rev 2020;5:398-407. DOI: 10.1302/2058-5241.5.190055

Global Excision of Severe Heterotopic Ossification of the Shoulder: A Case Report

CASE

A 21-year-old man sustained a closed glenohumeral fracture/dislocation as a pedestrian struck by a motor vehicle. He was treated nonoperatively and developed severe post-traumatic heterotopic ossification (HO) with near-complete shoulder ankylosis. We present our technique for safe surgical excision.

CONCLUSIONS

Excision led to improvements in motion and quality of life at 1 year postoperatively. Recommendations for successful HO excision around the shoulder include excision after at least 180 days, appropriate preoperative imaging to include cross-sectional imaging and a 3D model, intraoperative fluoroscopy, well-serviced instruments, preparation for iatrogenic fracture and/or neurovascular injury, meticulous hemostasis, postoperative HO prophylaxis, immediate postoperative therapy, and involvement of a multidisciplinary team.

A new pathologic classification for elbow stiffness based on our experience in 216 patients

BACKGROUND

Elbow stiffness commonly causes functional impairment and upper-limb disability. This study aimed to develop a new pathologic classification to further understand and standardize elbow arthrolysis from a new perspective, as well as to determine clinical outcomes.

METHODS

Extension-flexion dysfunction was classified into 4 types: EF_I, tethers alone; EF_II, tethers with blocks; EF_III, articular malformation; and EF_IV, bony ankylosis. Forearm rotation dysfunction was classified into 3 types: FR_I, contracture alone; FR_II, radial head malunion or nonunion; and FR_III, proximal radioulnar bony ankylosis. A total of 216 patients with elbow stiffness were prospectively included and categorized preoperatively. All surgical procedures were performed by the same chief surgeon; different types underwent specific procedures. Patient data, elbow motion, and functional scores were analyzed.

RESULTS

Mean range of motion (ROM) increased from 40° preoperatively to 118° at final follow-up; 88% of patients regained ROM of 100° or greater. The forearm rotation arc (FRA) with forearm rotation dysfunction increased from a preoperative mean of 76° to 128°; 82% of patients regained an FRA of 100° or greater. The mean Mayo Elbow Performance Index (MEPI) increased from 63 to 91 points; the proportion of patients with good or excellent results was 95%. EF_I patients had the best ROM (129°) and MEPI (93 points) and EF_IV patients achieved the most-changed ROM (116°), whereas EF_III patients had the worst ROM (104°) and MEPI (84 points) and the least-changed ROM (64°). The FRA was best in FR_I patients (142°), followed by FR_II patients (118°), and worst in FR_III patients (82°); in contrast, the changed FRA was greatest in FR_III patients (82°), followed by FR_II patients (64°), and least in FR_I patients (37°).

CONCLUSION

This study suggests that the proposed pathologic classification provides a new perspective on the understanding and standardization of elbow arthrolysis, providing satisfactory clinical outcomes.

Celecoxib cannot inhibit the progression of initiated traumatic heterotopic ossification

BACKGROUND AND HYPOTHESIS

Heterotopic ossification (HO) is a recognized sequela after trauma and arthroplasty. The purpose of this study was to evaluate the therapeutic effect of celecoxib on HO. We hypothesized that celecoxib may inhibit the progression of initiated HO.

METHODS

We performed a retrospective review of 37 patients who underwent elbow joint surgery between January 2014 and June 2018. Seventeen patients were prescribed orally administered celecoxib (200 mg/dose, twice daily) for 2 months after the diagnosis of HO, whereas the remaining 20 patients were administered celecoxib for 1 month starting immediately after surgery. HO progression was evaluated by plain radiographs. By use of an Achilles tendon puncture-induced HO mouse model, the curative effect of celecoxib was illustrated at different HO progression stages. The mice were assigned to 1 of 4 groups: sham group, vehicle group, group receiving celecoxib on day 1, and group receiving celecoxib in week 6. Achilles tendons were analyzed by micro-computed tomography and histochemistry after 12 weeks.

RESULTS

Celecoxib did not inhibit the progression of initiated HO in the patients in whom HO was diagnosed, whereas those who received celecoxib after surgery had lower morbidity. Achilles tendon puncture effectively induced typical HO in mice. The ectopic bone volume was significantly reduced in the day 1 celecoxib group compared with the vehicle group; however, the difference was not statistically significant in the week 6 celecoxib group.

CONCLUSIONS

Administration of celecoxib starting immediately after surgery can significantly inhibit the formation of HO. Once HO is visible on plain radiographs or micro-computed tomography, celecoxib cannot effectively attenuate further progression of HO in humans and mice.

Tamoxifen Inhibits the Progression of Trauma-Induced Heterotopic Ossification in Mice

BACKGROUND Heterotopic ossification (HO) is a kind of abnormal mineralized bone which usually occurs in muscle, tendon, or ligament. There are currently no effective drugs for the treatment and prevention of HO. Developing effective drugs that can inhibit HO is of profound significance and would provide new strategies for clinical treatment of this disease. The present investigation evaluated the inhibitory effect of tamoxifen against HO. MATERIAL AND METHODS Using an Achilles tendon trauma-induced HO female mice model, we screened different doses of tamoxifen (1, 3, and 9 mg/kg) in mice to determine the optimal dosage on the inhibition of the HO formation. The curative effect of tamoxifen was also illustrated at different HO progression stages including inflammation, chondrogenesis, osteogenesis, and HO maturation. RESULTS Heterotopic bone was formed with typical endochondral ossification in Achilles tendons 6 weeks after surgery and continued to enlarge up to 12 weeks. The formation of HO was significantly inhibited with the treatment of tamoxifen at the dosage of 9 mg/kg, whereas 1 mg/kg and 3 mg/kg did not reduce HO bone volume remarkably. The progression of HO was both attenuated by tamoxifen from Day 1 and Week 4 post-surgery, whereas no inhibitory effect was shown at the osteogenesis and maturation stages treated with tamoxifen. CONCLUSIONS Tamoxifen exerts an inhibitory effect on the heterotopic bone progression at inflammation and chondrogenesis stages, with the TGF-ß signaling pathway suppressed following the increase in estrogen receptor alpha activity.

What Range of Motion and Functional Results Can Be Expected After Open Arthrolysis with Hinged External Fixation For Severe Posttraumatic Elbow Stiffness?

BACKGROUND

The elbow is more susceptible to loss of motion after trauma than any other joint. Open arthrolysis often is performed for posttraumatic elbow stiffness if the stiffness does not improve with nonsurgical treatment, but the midterm results of this procedure and factors that may limit recovery have not been widely studied.

QUESTIONS/PURPOSES

We reviewed patients who had undergone open arthrolysis with hinged external fixator for severe posttraumatic elbow stiffness (ROM ≤ 60°) with a minimum of 5 years followup to (1) analyze ROM gains; (2) assess functional improvement with the Mayo Elbow Performance Index (MEPI) and DASH, quality of life with the SF-36, pain with VAS, and ulnar nerve function with the Amadio rating scale and Dellon classification; and (3) identify complications and risk factors that might hinder mid-term elbow motion recovery after this procedure.

METHODS

Between March 2011 and December 2012, we generally offered patients with elbow stiffness an open arthrolysis procedure when function did not improve with 6 months of nonoperative therapy, and no contraindications such as immature heterotopic ossification or complete destruction of articular cartilage were present. During that time, 161 patients underwent open arthrolysis for posttraumatic elbow stiffness at our institution; 49 of them satisfied the study inclusion criteria (adults with elbow ROM ≤ 60° as a result of trauma) and exclusion criteria (stiffness caused by burns or central nervous system injuries, causative trauma associated with nonunion or malunion of the elbow, severe articular damage that would have necessitated joint arthroplasty, or prior elbow release). In general, a combined medial-lateral approach to the elbow was performed to address the soft tissue tethers and any blocks to elbow motion, and a hinged external fixator was applied for 6 weeks to maintain elbow stability and improve the efficacy of postoperative rehabilitation. These patients were evaluated retrospectively at a mean followup period of 69 months (range, 62-83 months), and demographics, disease characteristics, arthrolysis details, pre- and postoutcome measures as noted, and complications were recorded via an electronic database. Multivariate regression analysis was performed to identify factors associated with ROM recovery.

RESULTS

At final followup, total ROM increased from a preoperative mean of 27 ± 20° to a postoperative mean of 131 ± 11° (mean difference, 104°; 95% CI, 98°-111°; p < 0.001), and 98% (48 of 49) of patients achieved a functional ROM of 30° to 130°. Improvements were also found in functional scores (MEPI: 54 ± 12 to 95 ± 7, mean difference, 41 points; DASH: 48 ± 17 to 8 ± 8, mean difference, 40 points; both p < 0.001), life quality (physical SF-36: 46 ± 11 to 81 ± 12, mean difference, 35 points; mental SF-36: 43 ± 14 to 80 ± 9, mean difference, 37 points; both p < .001), pain (VAS: 2.5 ± 2.4 to 0.4 ± 0.8; mean difference, 2.0 points; p < 0.001), and ulnar nerve function (Amadio score: 7.8 ± 1.9 to 8.4 ± 0.8; mean difference, 0.6 points; p = 0.004). A total of 18% (nine of 49 patients) developed complications, including new-onset or exacerbated nerve symptoms (four patients), recurrent heterotopic ossification (two patients), and pin-related infections (three patients). No patients underwent subsequent surgery for any of the above complications. Lastly, the medium-term ROM was divided into ROM ≤ 120° (n = 9) and ROM > 120° (n = 40). After controlling for potential confounding variables such as duration of stiffness and tobacco use, we found that tobacco use was the only independent risk factor examined (odds ratio, 9; 95% CI, 2-47; p = 0.009) associated with recovery of ROM.

CONCLUSIONS

Satisfactory medium-term results were found for open arthrolysis with hinged external fixation with our protocol in patients who had severe posttraumatic elbow stiffness. Appropriate and sufficient releases of tethered soft tissues and correction of any blocks that affect elbow motion intraoperatively, a dedicated team approach, and an aggressive and systematic postoperative rehabilitation program are the core steps for this procedure. Additionally, the importance of preoperative discontinuation of tobacco use should be emphasized.

LEVEL OF EVIDENCE

Level IV, therapeutic study.

Heterotopic Ossification: A Comprehensive Review

Heterotopic ossification (HO) is a diverse pathologic process, defined as the formation of extraskeletal bone in muscle and soft tissues. HO can be conceptualized as a tissue repair process gone awry and is a common complication of trauma and surgery. This comprehensive review seeks to synthesize the clinical, pathoetiologic, and basic biologic features of HO, including nongenetic and genetic forms. First, the clinical features, radiographic appearance, histopathologic diagnosis, and current methods of treatment are discussed. Next, current concepts regarding the mechanistic bases for HO are discussed, including the putative cell types responsible for HO formation, the inflammatory milieu and other prerequisite “niche” factors for HO initiation and propagation, and currently available animal models for the study of HO of this common and potentially devastating condition. © 2019 The Authors. JBMR Plus published by Wiley Periodicals, Inc. on behalf of American Society for Bone and Mineral Research.

Characterizing the Circulating Cell Populations in Traumatic Heterotopic Ossification

Heterotopic ossification (HO) occurs secondary to trauma, causing pain and functional limitations. Identification of the cells that contribute to HO is critical to the development of therapies. Given that innate immune cells and mesenchymal stem cells are known contributors to HO, we sought to define the contribution of these populations to HO and to identify what, if any, contribution circulating populations have to HO. A shared circulation was obtained using a parabiosis model, established between an enhanced green fluorescent protein-positive/luciferase⁺ donor and a same-strain nonreporter recipient mouse. The nonreporter mouse received Achilles tendon transection and dorsal burn injury to induce HO formation. Bioluminescence imaging and immunostaining were performed to define the circulatory contribution of immune and mesenchymal cell populations. Histologic analysis showed circulating cells present throughout each stage of the developing HO anlagen. Circulating cells were present at the injury site during the inflammatory phase and proliferative period, with diminished contribution in mature HO. Immunostaining demonstrated that most early circulatory cells were from the innate immune system; only a small population of mesenchymal cells were present in the HO. We demonstrate the time course of the participation of circulatory cells in trauma-induced HO and identify populations of circulating cells present in different stages of HO. These findings further elucidate the relative contribution of local and systemic cell populations to HO.

Post-traumatic stiff elbow

Post-traumatic and post-operative stiffness of the elbow joint is relatively common and may in pronounced cases markedly interfere with normal upper extremity function.Soft-tissue contractures and heterotopic bone formation are two major causes of limited movement.Extensive recent research has elucidated many of the pathways contributing to these conditions, but the exact mechanisms are still unknown.In the early phase of soft-tissue contractures conservative treatment may be valuable, but in longstanding cases operative treatment is often necessary.Several different options are available depending on the severity of the condition and the underlying offending structures. Surgical treatment may allow significant gains in movement but rarely complete restoration, and complications are not uncommon.The following presentation reviews the recent literature on pathomechanisms and treatment alternatives. Cite this article: EFORT Open Rev 2018;3 DOI: 10.1302/2058-5241.3.170062.

[Treatment of elbow joint stiffness by open release combined with distal radius fixation hinged external fixation]

Objective

To observe the effectiveness of open release combined with distal radius fixation hinged external fixation for the treatment of elbow stiffness.

Methods

A total of 77 patients with elbow stiffness caused by trauma were enrolled in this study between October 2014 and October 2015. The patients were divided into control group (39 cases) and observation group (38 cases) by random number table method. The patients in the observation group were treated with elbow joint opening and release combined with distal radial fixation hinged external fixation, while the control group was treated with traditional release. There was no significant difference in gender, age, disease causes, original damage diagnosis, the time from injury to operation, preoperative flexion and extension activity of elbow joint, and preoperative Mayo elbow joint function score between 2 groups ( P>0.05). After operation, the function of elbow joint was evaluated by the flexion and extension activity of the elbow joint and the Mayo elbow joint function evaluation standard.

Results

The incisions healed by first intention in 2 groups. In observation group, there were 1 case infection of nail tract, 2 cases ulnar nerve symptoms, 1 case elbow ossification, and 1 case moderate pain in the elbow; while in control group, there were 2 cases of infection of nail tract, 2 cases of ulnar nerve symptoms, and 3 cases moderate pain in the elbow. The patients in 2 groups were followed up 6 weeks to 12 months, with an average of 6 months. The flexion and extension activity of elbow joint and Mayo elbow joint function score at last follow-up were significantly improved when compared with preoperative ones ( P<0.05); at last follow-up, the flexion and extension activity of elbow joint and Mayo elbow joint function score in observation group patients were significantly better than those in control group ( P<0.05). According to the Mayo elbow function evaluation standard, the results were excellent in 27 cases, good in 10 cases, and fair in 1 case, with an excellent and good rate of 97.4% in observation group; and the results were excellent in 12 cases, good in 21 cases, fair in 4 cases, and poor in 2 cases, with an excellent and good rate of 84.6% in control group; showing no significant difference between 2 groups ( P=0.108).

Conclusion

Open release combined with distal radius fixation hinged external fixation can significantly improve the elbow function of patients with traumatic elbow stiffness, its recovery of elbow function was superior to the traditional release.

Effect on muscle strength of the upper extremities after open elbow arthrolysis

Background

Open elbow arthrolysis manipulates tendons and soft tissues surrounding the elbow and may lead to strength decline after the operation. We hypothesized that strength of elbow and wrist motions and handgrip could be compromised after the procedure and that the strength recovery pattern may differ between men and women and between the dominant and nondominant side.

Methods

This was a prospective cohort study. We monitored 32 patients with post-traumatic elbow stiffness who underwent open arthrolysis between June 2014 and December 2014. All patients underwent standardized postoperative physical therapy. Preoperative and postoperative isometric strength were measured by a handheld dynamometer. Mayo Elbow Performance Score (MEPS) and arc of motion (AOM) were also analyzed.

Results

Mean follow-up was 26.13 months. Significant improvement was noticed in mean AOM (from 46° to 127°) and MEPS (from 67.97 to 96.86). No significant decline was noted in isometric strength at the last follow-up day. The strength ratios between men and women showed no significant difference from postoperative day 7 to the last follow-up day. At all follow-up assessments, isometric strength showed no significant difference between the dominant and nondominant side.

Conclusions

AOM and MEPS achieved significant enhancement after open elbow arthrolysis. The procedure did not lead to isometric strength decline. Postoperative gain of strength was proportional to the baseline strength level of each muscle group, and men had a more prominent gain of strength than women during the entire follow-up. Dominance had no effect on postoperative strength recovery.

Strategic Targeting of Multiple BMP Receptors Prevents Trauma-Induced Heterotopic Ossification

Trauma-induced heterotopic ossification (tHO) is a condition of pathologic wound healing, defined by the progressive formation of ectopic bone in soft tissue following severe burns or trauma. Because previous studies have shown that genetic variants of HO, such as fibrodysplasia ossificans progressiva (FOP), are caused by hyperactivating mutations of the type I bone morphogenetic protein receptor (T1-BMPR) ACVR1/ALK2, studies evaluating therapies for HO have been directed primarily toward drugs for this specific receptor. However, patients with tHO do not carry known T1-BMPR mutations. Here we show that, although BMP signaling is required for tHO, no single T1-BMPR (ACVR1/ALK2, BMPR1a/ALK3, or BMPR1b/ALK6) alone is necessary for this disease, suggesting that these receptors have functional redundancy in the setting of tHO. By utilizing two different classes of BMP signaling inhibitors, we developed a translational approach to treatment, integrating treatment choice with existing diagnostic options. Our treatment paradigm balances either immediate therapy with reduced risk for adverse effects (Alk3-Fc) or delayed therapy with improved patient selection but greater risk for adverse effects (LDN-212854).

The efficacy of a multimodal analgesia protocol in preventing heterotopic ossification after acetabular fractures surgery

Background Heterotopic ossification (HO) after joint surgery is always a disturbing problem for patients and surgeons. Prophylaxis is the most effective therapy. Objective To assess the efficacy and safety of a multimodal analgesia protocol that included parecoxib and celecoxib in preventing HO after acetabular fracture surgery. Setting Selecting patients from trauma registry of our hospital. Method We identified 259 patients who had acetabular fracture surgery between January 2008 and December 2014. Hundredsixty-three patients received parecoxib and celecoxib (Group A) and 96 patients received no prophylaxis (Group B). The presence of HO was assessed according to the classification of Brooker et al. at the 12 month postoperative visit. Main outcome measure The differences in HO incidence and severity between the two groups. Results 49 patients (30.0%) developed HO in the Group A and 44(45.8%) in Group B. The difference in total HO incidence between the two groups was significant (P = 0.011 < 0.05, χ² = 6.530, OR 0.508, 95% CI (0.301-0.857). Severe HO (Brooker grade III or IV) developed in 15 patients (9.2%) in Group A and 17 patients (17.7%) in Group B. Brooker grade I + II was 34(20.9%) and 27(28.1%) in each group. The difference in the severity of HO between the two Groups was significant (P = 0.008 < 0.05). Conclusion A short-term administration of parecoxib and celecoxib aids in the prevention of HO after acetabular fractures surgery.

Serum biomarkers in patients with ossification of the posterior longitudinal ligament (OPLL): Inflammation in OPLL

Backgroud

Ossification of the posterior longitudinal ligament (OPLL) is characterized by replacement of ligamentous tissue by ectopic new bone formation. OPLL causes narrowing of the spinal canal, resulting in neurological impairment. However, the pathogenesis of OPLL has not been fully elucidated. We investigated whether inflammation occurs in OPLL or not using high-sensitivity CRP (hs-CRP) in a case-control study.

Methods and findings

This study included 103 patients with OPLL in the patient group and 95 age- and sex-matched volunteers with degenerative spinal disease in the control group. Of the 103 OPLL patients, 88 patients who were available for more than 2 years follow-up were checked for OPLL progression. A blood sample was obtained and Hs-CRP, and other routine data, including total protein (TP), albumin (ALB), lactate dehydrogenase (LDH), alkaline phosphatase (ALP), glucose (Glu), calcium (Ca), inorganic phosphate (Pi), white blood cell count (WBC), hemoglobin (Hb) and platelet (PLT), were analyzed. The data were compared between the patients with OPLL and the controls. The severity of the ossified lesions in the whole spine were evaluated by the ossification index (OS index) in patients with OPLL. The data were also compared between the patients with OPLL progression (the progression group) and the patients without OPLL progression (the non-progression group). In the results, the mean hs-CRP in the OPLL group was higher than that in the controls. The Pi in the OPLL group was lower than that in the control group. A negative correlation was found between the Pi and the OS index. The mean hs-CRP in the progression group was higher than that in the non-progression group. There was a positive correlation between the average length of the OPLL progression per year and the hs-CRP.

Conclusions

The results may suggest the occurrence of local inflammation in OPLL and the inflammation might cause OPLL progression. These facts are important for understanding the pathology of OPLL.

Heterotopic Ossification Following Upper Extremity Injury

Heterotopic ossification (HO) presents a substantial barrier to rehabilitation for patients with severe burns or trauma. Although surgical excision is a mainstay of management for this condition, this is unable to address the chronic sequelae of HO, including chronic pain, joint contractures, nerve dysfunction, and open wounds. Current therapeutic modalities are aimed at excision and the prevention of recurrence using nonsteroidal antiinflammatory drugs (NSAIDs) or radiation therapy. Research is now focused on identifying alternative strategies to prevent the initial occurrence of HO through NSAIDs and novel inhibitors of the bone morphogenetic protein signaling pathway.

A figure-eight suture loop with Kirschner wires for fixation of anteromedial coronoid process fractures: A case series

•

Eleven cases with a fracture of the anterior or anteromedial facet of the coronoid process were treated by coronoid fixation using a figure-eight suture loop.

•

All 11 fractures were united at final follow-up with no joint incongruity, dislocation, or subluxation of the injured elbow.

•

The figure-eight suture pattern technique is an easy and effective technique to fix anterior or anteromedial facet fractures of the coronoid process.

Purpose

Sufficient fixation of an anterior or anteromedial facet fracture of the coronoid process in fracture-dislocation of elbow is important to maintain joint stability. The purpose of this study was to report our experience with 11 patients who were managed with an original fixation technique using a “figure-eight” suture loop.

Methods

From February 2010 to March 2011, 11 cases with a fracture of the anterior or anteromedial facet of the coronoid process were treated by coronoid fixation using a figure-eight suture loop. For cases with comminuted fractures, to prevent a suture from sliding into the fracture line, a 3- or 4-hole phalanx plate was enclosed in the suture loop to compress multiple fragments. Accompanying injuries, such as a radial head fracture or olecranon fracture, were fixed with repair of lateral collateral ligament injuries.

Results

On final evaluations at an average of 18 months after injury, the mean elbow arc of motion was 125.5° and the mean forearm rotation arc of 124.1°. All fractures were united with an average postoperative score according to the Mayo Elbow Performance Index of 91 points. All patients achieved satisfactory scores (seven excellent, four good). All 11 fractures were united at final follow-up with no joint incongruity, dislocation, or subluxation of the injured elbow.

Conclusions

The figure-eight suture loop technique is an easy and effective technique to fix anterior or anteromedial facet fractures of the coronoid process.

Does Excision of Heterotopic Ossification of the Elbow Result in Satisfactory Patient-Rated Outcomes?

Introduction

Treatment of heterotopic ossification (HO) of the elbow is challenging and fraught with complications. Patients who sustain direct trauma to the elbow joint, the central nervous system, and thermal burns are at increased risk for development of HO. There is a paucity of studies and reports on patient’s self-evaluation after the excision of the heterotopic ossification.

Materials and Methods

This retrospective study assessed outcomes after excision of heterotopic ossification around the elbow in a cohort of ten patients operated from 2012 to 2015. The outcome assessment was done by the Mayo Elbow Performance index (MEPI) and the American Shoulder and Elbow Surgeons-Elbow score (ASES-E scores).

Results

The mean follow-up was 18.11 months after the operation. The Mayo Elbow Performance Score was excellent in two elbows, good in six and fair in two. The mean gain in flexion-extension arc after excision of HO was 80 degrees. All of the patients had residual flexion deformity postoperatively. Eight of the nine patients were able to do activities requiring flexion at final follow-up.

Conclusion

Excision of HO around the elbow is associated with satisfactory patient-rated outcomes in spite of failure to regain full range of motion.

Application of distal radius-positioned hinged external fixator in complete open release for severe elbow stiffness

BACKGROUND

Radical release for severe stiff elbows may lead to instability. Hinged external fixation is used to treat unstable elbows. We hypothesized that extensive open release combined with a distal radius-positioned hinged external fixator would have good performance and low complications rate in treating severe elbow stiffness. Thus, the efficacy and security of this technique were assessed in this study.

METHODS

We retrospectively reviewed 38 post-traumatic elbows with severe stiffness that underwent arthrolysis between February 2011 and February 2014. All patients were assessed as having elbow instability after complete arthrolysis. Ligament repair was combined with implantation of a hinged external fixator (fixed to the humerus and distal radius) to maintain elbow stability. Flexion arc, forearm rotation, Mayo Elbow Performance Score, elbow stability, and radiographs were evaluated preoperatively and postoperatively, and complications were documented.

RESULTS

Mean follow-up was 31 months. Significant improvement was noted in flexion-extension arc (from 27° to 126°), forearm rotation (from 148° to 153°), and mean Mayo Elbow Performance Score (from 68 points to 96 points). Mean pronation arc decreased from 66° preoperatively to 6° at 1.5 months of follow-up and showed a transient reduction during first 6 months postoperatively. Pin-related infection occurred in 2 patients, which was cured with conservative treatment. Two patients had moderate instability after removal of the fixator and regained stability at the 12-month follow-up. At the last follow-up, complications included ulnar nerve paralysis in 3, recurrence of heterotopic ossification in 1, and moderate pain in 1.

CONCLUSIONS

Complete open release combined with a distal radius-positioned hinged external fixator is an effective treatment for severe stiff elbows. This technique had a low complication rate.

Open arthrolysis for elbow stiffness increases carrying angle but has no impact on functional recovery

BACKGROUND

With the exception of normal anatomic changes in the medial collateral ligament and radial head, other factors related to carrying angle changes have not been systematically studied. We reviewed patients who underwent open arthrolysis of the elbow, and evaluated if open arthrolysis could change carrying angle. We then identified factors associated with carrying angle changes.

METHODS

Fifty patients with a minimum of 24 months of follow-up after open arthrolysis were evaluated retrospectively. Preoperative and postoperative carrying angles were compared.

RESULTS

The carrying angles of 36 elbows in 36 patients were unchanged after surgery (Group A), while the carrying angles of 14 elbows in 14 patients increased postoperatively (Group B). In Group A, mean postoperative extension and flexion were 7° (range 0-24°) and 125° (range 10-135°) respectively, while mean postoperative pronation and supination were 60° (range 50-80°) and 65° (range 30-85°), respectively. In Group B, mean postoperative extension and flexion were 25° (range 0-40°) and 128° (range 60-138°), while mean postoperative pronation and supination were 65° (range 45-85°) and 60° (range 45-75°), respectively. No significant difference in range of motion and Mayo Elbow Performance Score was observed between the two groups.

CONCLUSIONS

During open arthrolysis, humeral trochlea debridement and techniques for improving forearm rotation could increase carrying angle. However, this had no impact on elbow functional recovery.

Ulnar neuritis after open elbow arthrolysis combined with ulnar nerve subcutaneous transposition for post-traumatic elbow stiffness: outcome and risk factors

BACKGROUND

Ulnar neuritis (UN) is a common complication of open elbow arthrolysis for elbow stiffness. The purpose of this study was to evaluate the outcome of subcutaneous anterior transposition of the ulnar nerve during open elbow arthrolysis and to describe the risk factors for UN.

METHODS

We retrospectively studied 260 patients with post-traumatic elbow stiffness who underwent routine ulnar nerve transposition during open elbow arthrolysis. Patient demographics, clinical characteristics, and incidence and reoperation rate of UN were recorded. UN was defined as new-onset ulnar nerve symptoms and no relief or worsening of pre-existing ulnar nerve symptoms during the period of postoperative rehabilitation. Factors affecting the development of UN were analyzed by univariate and multivariate analyses.

RESULTS

A total of 9.2% of the patients had UN, 25% of whom required reoperation for progressive neuropathy. The Dellon grade of patients associated with UN at last follow-up improved significantly compared with that preoperatively. The mean arc of motion in patients with UN decreased during follow-up in a time-dependent manner. Univariate analysis showed that male sex, limited preoperative flexion and arc of motion, preoperative heterotopic ossification (HO), and preoperative ulnar nerve symptoms were significantly associated with the development of UN. Multivariate regression analysis revealed that preoperative HO was the only independent risk factor for the development of UN.

CONCLUSIONS

UN is still an important complication, although ulnar nerve subcutaneous transposition was performed during open arthrolysis for post-traumatic elbow stiffness. Identified risk factors for UN, especially preoperative HO, should be taken into consideration before surgery.