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Purpose: To report the clinical outcomes from 2 academic centers of the flexor carpi ulnaris (FCU) flap for coverage of posterior elbow soft tissue defects., Methods: We retrospectively reviewed 17 patients who underwent an FCU flap for posterior elbow wound reconstruction over an 8-year period at 2 academic centers. Outcome measures included visual analog score for pain; Disabilities of the Arm, Shoulder, and Hand score; Mayo Elbow Performance score; range of motion; wound healing; grip strength; and isokinetic dynamometry for wrist flexion. Wilcoxon signed-rank test was used to make side-to-side comparisons between the operative and nonsurgical extremities, and nonparametric statistical methods were used to analyze results., Results: All wounds healed successfully without need for revision surgery. Average visual analog, Disabilities of the Arm, Shoulder, and Hand, and Mayo Elbow Performance scores in the operative elbow were 1.8, 34, and 86, respectively. Average elbow arc of motion was 11° to 140° with 70° forearm pronation and 73° forearm supination. Compared with the nonsurgical side, grip strength on the operated side was 97% and wrist flexion peak torque was 89%. The operative limb had an average wrist flexion fatigue of 7%, compared with 22% for the nonsurgical arm., Conclusions: Patients receiving an FCU flap had reliable healing, minimal pain, good functional outcomes, and no meaningful deficits in grip strength or wrist flexion strength., Type of Study/level of Evidence: Therapeutic IV., (Copyright © 2015 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Purpose: The use of a pedicled flexor carpi ulnaris (FCU) muscle proximal turnover flap has been described previously for soft tissue reconstruction at the posterior elbow. Whereas consistent arterial supply to the FCU has been reported, the reliability of distal flap perfusion has not been confirmed. This study evaluated the vascular perfusion of an FCU turnover flap, based on the most proximal primary vascular pedicle that would permit a proximal turnover flap reconstruction to include the olecranon tip., Methods: In 12 fresh-frozen, proximal humeral human amputation specimens, the FCU flap was elevated from distal to proximal, preserving the most proximal primary vascular pedicle to the muscle belly that would permit flap coverage of the olecranon tip. The axillary artery was injected with India ink after ligation of radial and ulnar arteries at the wrist. After injection, each specimen was sectioned transversely at 0.5-cm increments to assess vascular perfusion of the muscle using loupe magnification., Results: The distance from the olecranon tip to the distal FCU muscle belly was 25.9 cm. The primary vascular pedicle that would facilitate creation of a proximal turnover flap was, on average, 5.9 cm distal to the olecranon tip. Perfusion of FCU muscle as measured distal to this primary pedicle was present in 50% to 100% of the muscle belly at an average of 8.9 cm beyond the pedicle. Perfusion of 25% to 50% of the FCU muscle belly was present at an average of 11.1 cm beyond the pedicle. Perfusion became less consistent (<25%) within the muscle belly at an average distance of 11.6 cm., Conclusions: Use of a proximally based, pedicled FCU muscle turnover flap provides a reliable option for soft tissue reconstruction at the posterior elbow. We observed consistent arterial perfusion of the muscle flap when preserving a proximal vascular pedicle 5.9 cm distal to the olecranon tip., (Copyright © 2011 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Prosthetic radial head replacement is a well-documented procedure; however, loss of elbow flexion after radial head arthroplasty has only recently been reported. This study reviews 6 patients who received modular prosthetic radial heads and had a clinically significant decrease in elbow flexion. The implant was removed in 4 of these patients because of reduced elbow motion and pain. This clinical finding is correlated with biomechanical data obtained by use of matched-pair, fresh-frozen upper extremity specimens loaded to 330 N with the forearm in positions of neutral, pronation, and supination for each of three elbow positions (0 degrees, 90 degrees, and 135 degrees). The radiocapitellar gap was monitored and was significantly smaller under load during elbow flexion compared with extension. This study indicates the need for verification of the radiocapitellar gap throughout elbow range of motion in order to prevent these complications.

A comprehensive understanding of both surgical care costs and the factors influencing these costs is critical to make progress toward value-based care in orthopedics. Therefore, the purpose of this study was to assess 90-day health system costs in primary total elbow arthroplasty (TEA), the proportion of contribution from each cost group to total hospital cost, and to determine key drivers of 90-day costs in primary TEA. Consecutive patients who underwent primary TEA between 2014 and 2021 at a tertiary care academic medical center were included. An institutional accounting database was queried to determine direct costs to the health system attributed to TEA. All costs within 90 days of the surgical encounter were included for analysis to reflect the global postoperative period. Descriptive statistics were used to summarize patient and surgical characteristics, as well as cost data. Subcategories were determined to assess the key cost groups that contribute to total hospital fees for the entire cohort, and subanalysis was performed to evaluate only readmitted patients. Furthermore, a linear regression analysis was used to determine key drivers of 90-day costs in the setting of primary TEA. Thirty-five patients who underwent primary TEA were identified from 2014 to 2021; 28 patients with 90-day cost data were included in this study. The mean surgical encounter cost was $18,075 (+/− $9772) and mean 90-day cost was $19,875 (+/− $9885). The largest proportion of health system costs in primary TEA was surgical implants (48%), followed by operating room fees (18%), surgical supplies (9%), and anesthesia (7%). Among readmitted patients, the most significant share of health system costs was attributed to surgical implants (30%) followed by operating room fees (22%). However, hospital fees (19%) experienced a substantial increase. In assessing the key drivers of 90-day health system costs, length of stay (B = 1304.30, 95% confidence interval [CI] 674.54 to 1934.05; P <.001), readmission (B = 16,148.55, 95% CI 7055.01 to 25,240.08; P =.001∗), and Charlson comorbidity index (B = 2247.43, 95% CI 68.64 to 4426.22; P =.044) were statistically significant predictors of increased 90-day costs. Implant costs comprise nearly half of total 90-day costs in primary TEA, with operating room costs making the second largest contribution. Additionally, length of stay, readmission, and patient comorbidity burden were significantly associated with increased 90-day costs. [ABSTRACT FROM AUTHOR]

Case: The lateral ulnar collateral ligament (LUCL) is one of the primary stabilizers of the elbow. Disruption typically occurs from the humeral origin and may be because of an elbow dislocation or fracture/dislocation. If not identified and properly managed, posterolateral rotatory instability may result from LUCL insufficiency. We describe the case of a patient with bipolar LUCL disruption consisting of an avulsion fracture of the crista supinatoris and a soft-tissue avulsion from the lateral epicondyle. Conclusion: Bipolar disruption of the LUCL is a previously unreported injury pattern that may lead to posterolateral instability if not identified and treated. [ABSTRACT FROM AUTHOR]

Background Ulnar collateral ligament injury (UCLI) has significantly increased in overhead sports during the past 2 decades. Differences in return to sport (RTS) and RTS at previous level (RTSP) after UCLI have not been differentiated. Methods A computer-assisted literature search of PubMed, CINAHL, Embase, and SportDiscus databases using keywords related to RTS for UCLI was implemented. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were used for study methodology. Quality assessment was conducted using a modified Downs and Black scale. Results A total of 22 retrospective, level 3b or 4, studies (n = 2289) qualified for analysis. Overall RTS proportion was 90% (95% confidence interval [CI], 86%-94%) and overall RTSP proportion was 79% (95% CI, 75%-84%), both with significant heterogeneity ( P  < .001, I 2  = 74%-84%). RTS and RTSP proportions were 89% (95% CI, 83%-94%) and 78% (95% CI, 72%-83%) for Major League Baseball players, 91% (95% CI, 77%-99%) and 67% (95% CI, 52%-81%) for Minor League Baseball players, 95% (95% CI, 75%-100%) and 92% (95% CI, 82%-98%) for collegiate players, and 93% (95% CI, 81%-100%) and 83% (95% CI, 77%-89%) for high school players, respectively. Increased earned run average, walks, and hits per inning pitched, decreased innings pitched, and decreased fastball velocity were found after UCLI. Conclusion Low-level, high-bias evidence demonstrates overall RTS proportion is higher than RTSP, regardless of treatment type for UCLI. Although RTS proportions remained consistent across various levels of play, RTSP proportions were lower in professional players, particularly Minor League Baseball compared with collegiate and high school players. Pitching performance significantly decreased postoperatively in most studies. [ABSTRACT FROM AUTHOR]

Background: Heterotopic ossification (HO) is a well-known complication following the surgical treatment of fractures and dislocations about the elbow but it is not commonly discussed as a complication following arthroscopy. We present a case of a young athlete who developed HO after the arthroscopic treatment of lateral epicondylitis. Methods: This is a case report chart review of a 24 year old male with lateral epicondylitis. After failing conservative measures, arthroscopic debridement of the extensor carpi radialis brevis (ECRB) origin ensued. The treatment and patient’s final disposition were reported. Results: The patient developed heterotopic ossification of the elbow follow arthroscopic debridement of the ECRB origin. Further surgery was required to excise the heterotopic ossification. Good recovery of motion was achieved. Conclusion: To our knowledge, we present the first case of HO development after elbow arthroscopy for lateral epicondylitis. As the use of elbow arthroscopy continues to grow, there is a need for identification of the risk factors and primary prophylaxis for HO. [ABSTRACT FROM AUTHOR]

Lateral epicondylitis is one of the most common upper extremity pain syndromes. We report the results of patients in whom conservative treatment was unsuccessful and who were finally treated arthroscopically for symptomatic plicae. Ten patients (mean age, 40 years [range, 18-60 years]) who were misdiagnosed as having lateral epicondylitis were included in this study. Examination revealed the site of maximal tenderness to be posterior to the lateral epicondyle and centered at the posterior radiocapitellar joint. Preoperatively, all patients received conservative treatment (physical therapy or corticosteroid injections [or both]). The mean follow-up was 25 months (range, 6-68 months). The mean score on the Disabilities of the Arm, Shoulder and Hand questionnaire was 9 (range, 0-37). Preoperatively, 7 patients had full elbow range of motion; however, in 3 patients, there was a loss of extension at the elbow ranging from 7° to 20° preoperatively. The range of elbow motion was full in all patients postoperatively. No patient demonstrated posterolateral pain after the operation. Synovial plicae of the elbow may be the cause of lateral elbow pain in patients with vague clinical symptoms. Arthroscopic management may provide a successful treatment option for such patients. [Copyright &y& Elsevier]

Background: Controlled joint extension followed by gradual distraction with use of an external fixator may facilitate primary repair of peripheral nerve defects by permitting end-to-end repair without tension. The hypothesis of the present study was that gradual lengthening of nerve repairs with use of incremental distraction would provide superior results compared with grafting or repair under tension. Methods: A median nerve segment measuring four times the diameter of the nerve was resected in thirty-six rabbits to create a 7-mm gap in the nerve. Neurorrhaphy was performed with use of one of three techniques. In Group 1 (cable graft), a tension-free medial antebrachial cutaneous graft was placed to allow full range of motion of the elbow postoperatively. In Group 2 (end-to-end repair without distraction), the elbow was externally fixed in hyperflexion and the nerve was repaired end-to-end. At fourteen days, the fixator was removed and unprotected elbow motion was permitted. In Group 3 (end-to-end repair with gradual distraction), the elbow was externally fixed in hyperflexion and primary neurorrhaphy was performed. At fourteen days, the elbow was extended 10° every other day with use of the articulated external fixator until full extension was achieved. Median nerve amplitude, latency, and nerve-conduction velocity; flexor digitorum superficialis single-twitch force generation and maximum tetanic force generation; muscle mass; and elbow range of motion were measured at three or six months. In addition, histologic analysis of the median nerve distal to the repair site and the morphometry of the neuromuscular junction in the flexor digitorum superficialis were performed at six months. Results: All rabbits regained full active and passive range of motion. At three months, the nerve-conduction velocities in Groups 2 and 3 were significantly greater than that in Group 1. At six months, the nerve-conduction velocities and amplitudes in Group 3 were significantly greater than those in Groups 1 and 2. At six months, the tetanic force in Group 3 was significantly greater than those in Groups 1 and 2. There were no significant differences in muscle mass among the groups. There were no significant differences in histological findings among the three groups, although there was a trend toward larger fiber size in Group 3 as compared with the other two groups. The neuromuscular junctions in Group 3 had a significantly larger surface area than did those in Group 1 (p = 0.002) and Group 2 (p = 0.034). Conclusion: The use of an articulated external fixator and controlled gradual distraction appears to facilitate the treatment of peripheral nerve defects. Clinical Relevance: This nerve repair technique may prove useful in clinical situations involving peripheral nerve defects. [ABSTRACT FROM AUTHOR]

Background: Longitudinal instability of the forearm (the Essex-Lopresti lesion) following radial head excision may be difficult to detect. This cadaveric study examines a stress test that can be performed in the operating room to identify injury to the ligamentous structures of the forearm.Methods: Twelve cadaveric upper extremities were randomized into two groups and underwent radial head resection. Group 1 underwent sequential transection of the triangular fibrocartilage complex and the interosseous membrane. Group 2 underwent sequential transection of the interosseous membrane and the triangular fibrocartilage complex. Ulnar variance and radial migration were examined with use of fluoroscopy of the wrist before, during, and after the application of a 9.1-kg load via longitudinal traction on the proximal part of the radius.Results: Group 1 demonstrated no significant changes in proximal radial migration with load (compared with the findings after radial head resection alone) after transection of the triangular fibrocartilage complex. However, Group 2 demonstrated significant changes in proximal radial migration with load after transection of the interosseous membrane (p = 0.03; median, 3.5 mm). In both groups, transection of both the triangular fibrocartilage complex and the interosseous membrane resulted in significant changes in proximal radial migration with load (p = 0.001; median, 9.5 mm). When the load was removed, specimens were ulnar positive (median, 3.0 mm), with no specimen returning to the preload position of ulnar variance (p = 0.001).Conclusion: After radial head resection, 3 mm of proximal radial migration with longitudinal traction indicated disruption of the interosseous membrane. In all specimens, proximal radial migration of > or =6 mm with load indicated gross longitudinal instability with disruption of all ligamentous structures of the forearm. [ABSTRACT FROM AUTHOR]