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The surgical management of distal humerus fractures in adults generally consists in open reduction internal fixation (ORIF) or total elbow arthroplasty (TEA). Hemi humeral hemiarthroplasty (EHA) is a treatment option for unreconstructable intra-articular distal humerus fractures. It is a reasonable option in patients over the fifth decade and its potential advantages are to eliminate the complications related to the ulnar component such as wear of the hinge (busching wear) or the aspetic loosening of the ulnar component. The potential disadvantages are the risk of instability with the possibility of a wear and progressive joint osteoarthrosis. The aims of this manuscript are to evaluate the indications in which we used the EHA, analyzing the correct surgical technique and describe the outcomes in medium and long-term follow-ups. Between 2006 and 2019, we performed 51 EHAs at the Hesperia Hospital in Modena and at the Rizzoli Orthopedic Institute. Taking into consideration only the cases of acute fractures, 27 patients (27 elbows) with a minimum follow-up of 12 months were identified. The patient's mean age at the time of surgery was 64 years old (range from 45 to 78 years old) and they were 78% female (21 out of 27). The Latitude Tornier implant was used in all the patients of our group. The mean MEPS was 89.3 points (from 50 to 100 pts) with excellent results in 19 patients, good in 5, one fair and 2 poor;the mean DASH was 12.6 (from 3.3 to 45.8); the mean OES was 42.3 (from 22 to 47). Complications, were found in 12 patients and any patients required a TEA conversion. Distal humerus hemiarthroplasty from our experience is a good option for the surgical management of unrecostructible distal humeral fractures in selected patients. It is important to perform a precise surgical technique; preserve the triceps insertion, preserve or repair the collateral ligaments, fix the condylar bones implant the prosthesis at the correct size, depth and rotation. The majority of the complication that we observed are related to the stiffness and not to the progressive degenerative changes of the articular surface., Competing Interests: Declaration of Competing Interest The authors declare that they have no conflict of interest., (Copyright © 2020. Published by Elsevier Ltd.)

Introduction: Coronal shear fractures of the distal humerus are uncommon injuries representing 6% of distal humeral fractures. There is no univocal consensus about the correct management of this type of fracture. A national survey was conducted to gain more insight into the current classification, diagnosis and treatment of coronal shear fractures in Italy., Materials and Methods: A postal survey was sent to all AO Italian members including residency orthopaedic surgeons. The survey consisted of general questions about personal experience in the management of these fractures: types of classification systems used, surgical approaches, treatment options and rehabilitation programs., Results: 114 orthopaedic surgeons answered a 13-items questionnaire. The most used classification system was AO/OTA (72,8%). Independent screws and if necessary plates were the most answered regarding surgical treatment (81,6%). The most encountered post-surgical complication was stiffening of the elbow (81,6%)., Conclusion: An algorithm of treatment has been proposed. To better classify coronal shear fractures, the authors recommended the integration of two classification systems: AO and Dubberley classifications. In the case of posterior wall comminution, a Kocher extensile approach is recommended, otherwise, if a posterior wall is intact, Kocher or Kaplan approach can be used. The posterior transolecranic approach can be reserved to Dubberley type III or AO 13B3.3. The best treatment choice is represented by independent screws and plates placed according to fracture patterns while arthroplasty is indicated when a stable ORIF is not possible. Mobilization is postponed for about 2 weeks., Competing Interests: Declaration of Competing Interest None., (Copyright © 2022. Published by Elsevier Ltd.)

The term "unstable lesions of the forearm" (ULF) was born to more easily describe how a partial or complete instability of the forearm unit might occur due to a traumatic loss of the transverse or longitudinal connection between the radius and ulna. For such an alteration to occur, at least two of the three main osteoligamentous locks (proximal, middle and distal) must be interrupted, often in association with a radial and/or ulnar fracture. Examining the historical patterns (Monteggia, Galeazzi, Essex-Lopresti and criss-cross lesions) and variants described in the literature, out of a total of 586 recorded interventions for forearm trauma, two elbow teams and one wrist team selected 75 cases of ULF. The aim was to describe the instability depending on its clinical and radiographic features, together with the anatomopathological evolution of the lesions based on the time of diagnosis and treatment. The clinical results, evaluated using a new score (FIPS) the Forearm Italian Performance, revealed a correlation between earlier diagnosis and treatment and a better score. The authors suggest a synoptic table that describes 1) the type of instability (proximal transverse, distal transverse, longitudinal and transverse, proximal and distal transverse), 2) classic patterns and variants with characteristic lesions and evolution over time (acute, chronic dynamic, chronic static) and 3) the three forearm constraints and segmental involvement of radius and/or ulna using an alphanumeric classification. Finally, some generic surgical suggestions are proposed., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2022. Published by Elsevier Ltd.)

Case: We describe 2 patients with extreme triplanar cubitus varus deformity, treated with step-cut corrective virtually planned osteotomies and performed with custom-made surgical guides. The surgery was simulated on the patients' bone 3D-printed model to verify the effectiveness of the surgical plans. At a medium 21-month follow-up after surgery, in both patients, clinical and radiological results were fully satisfactory, and no complications have been reported., Conclusion: The precision of computer-aided surgical planning and custom-made surgical guides allow to perform reproducible and relatively safe surgeries even in extreme deformities where the surgical complexity could discourage attempts at surgical correction., Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJSCC/B925)., (Copyright © 2022 by The Journal of Bone and Joint Surgery, Incorporated.)

Background: The earliest distal humeral hemiarthroplasty (or elbow hemiarthroplasty [EHA]) implants, which date back to the late 1940s, were performed in patients with severe elbow joint injuries as an alternative to arthrodesis. After some clinical reports and case studies with a short follow-up, published in the 1990s, a new "anatomically convertible" EHA model was introduced in 2005 and became a common surgical option to treat complex elbow fractures and their sequelae. We describe the mid- and long-term outcomes of EHA performed to treat acute intra-articular fractures or their sequelae., Methods: From 2006 to 2017, 51 patients underwent EHA for acute intra-articular fractures or their sequelae. A total number of 41 patients (80.5% female) with a minimum follow-up of 2 years, 24 with acute lesions and 17 with sequelae, were identified retrospectively. Clinical evaluation was according to the Disabilities of the Arm, Shoulder, and Hand (DASH) score (subjective), and the Oxford Elbow Score (OES) and Mayo Elbow Performance Score (MEPS) (objective). Radiographic follow-up was with standard radiographs., Results: Mean follow-up was 92.2 months (range, 24-151). Mean patient age at surgery was 62.8 years (range, 45-81). The mean MEPS was 87.1 points, with excellent results in 26 cases, good results in 9 cases, fair in 2, and poor results in 4. The mean DASH score was 15.9 and the mean OES was 40.5, with satisfactory results in 30 cases. Twenty patients experienced complications and 2 required revision surgery., Discussion: EHA is a valuable surgical option in selected patients with comminuted distal humeral joint fractures that cannot be reconstructed with stable fixation and in those with malunion of the articular surface of the humerus. EHA offers potential advantages, especially in active elderly patients and in those aged less than 70 years. It is essential to achieve joint stability, restoring medial and lateral ligament function besides the integrity of the coronoid process. An intact olecranon surface without signs of degenerative changes is also critical for EHA success., Conclusion: Our mid- and long-term experience with EHA is favorable, with a high proportion of satisfactory results and long survival rates for both lesion types. In selected patients with acute and post-traumatic injuries, EHA is a valuable surgical option., (Copyright © 2022 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Aim: Intra-articular non-union of fractures is an uncommon but complex problem because in general, it is characterised by marked instability, pain, strength loss and significant functional limitation. The aim of this study is to report our prospective medium-term outcomes of the treatment of intra-articular, distal humeral aseptic non-unions using open reduction and internal fixation, augmented with artificial bone., Materials and Methods: A retrospective case series of 16 patients with intra-articular, aseptic non-unions of the distal humerus was analysed for range of motion, pain, Mayo Elbow Performance Scores (MEPS) and Oxford Elbow Scores (OES) after 12 months. Mean age was 44 years (range, 18-84 years) and mean total follow-up was 43 months (range, 24-62 months)., Results: All subjective and objective scores were significantly higher 12 months after treatment with internal fixation and artificial bone augmentation; the mean improvement on the MEPS was 18 points and 17 points on the OES. All patients returned to work, most without limitations. Autografts had worse outcomes compared to allografts regarding post-operative pain and time to return to work. No adverse events related to the artificial bone augmentation were seen and all fractures consolidated., Conclusion: The use of two locking plates and bone graft augmentation with autografts or allografts with artificial bone grafts is a successful treatment of intra-articular distal humeral non-unions after hardware failure or biological limitations., Clinical Significance: The use of artificial bone in the treatment of septic non-unions of the upper limb is safe. When no autograft is possible because of concurrent morbidity, it can be used alone or combined with an allograft to reconstruct the affected bone without leading to extra morbidity or complications., How to Cite This Article: Rollo G, Vicenti G, Rotini R, et al. Open Reduction and Internal Fixation Using Double Plating with Biological and Artificial Bone Grafting of Aseptic Non-unions of the Distal Humerus: Clinical Results. Strategies Trauma Limb Reconstr 2021;16(3):144-151., Competing Interests: Source of support: Nil Conflict of interest: None, (Copyright © 2021; The Author(s).)

Tumor-like lesions of the upper limb are more frequent than malignant neoplastic lesions and they represent a wide and heterogeneous group of disorders. The combination of clinical evaluation and imaging is the first pivotal step to attempt a distinction between benign and malignant masses, since there are important implications for further management, such as the requirement for conservative or interventional treatment. The classification of these pseudo tumoral lumps remains arbitrary and is still a matter of debate, currently based on a conjunct clinico-radiologic approach. In this article, we review various types of tumor-like lesions of the upper limb in terms of imaging approach and related clinic features, proponing a descriptive classification, useful in clinical practice to recognize these disorders, and to avoid unnecessary or potentially harmful procedures., (Copyright© Bentham Science Publishers; For any queries, please email at epub@benthamscience.net.)

Background: Surgical repair of critical-sized bone defects still remains a big challenge in orthopedic surgery. Biological enhancement, such as growth factors or cells, can stimulate a better outcome in bone regeneration driven by well-established treatments such as allogenic bone graft. However, despite the surgical options available, correct healing can be slowed down or compromised by insufficient vascular supply to the injured site., Materials and Methods: In this pilot study, critical size bone defects in rabbit radius were treated with allograft bone, in combination with vascular bundle and autologous bone marrow concentrate seeded onto a commercial collagen scaffold. Microtomographical, histological and immunohistochemical assessments were performed to evaluate allograft integration and bone regeneration., Results: Results showed that the surgical deviation of vascular bundle in the bone graft, regardless from the addition of bone marrow concentrate, promote the onset of healing process at short experimental times (8 wk) in comparison with the other groups, enhancing graft integration., Conclusion: The surgical procedure tested stimulates bone healing at early times, preserving native bone architecture, and can be easily combined with biological adjuvant., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Imaging has a paramount role in postsurgical assessment. Radiologists need to be familiar with the different surgical procedures to be able to identify expected postsurgical appearances and also detect potential complications. This article reviews the indications, normal expected postsurgical appearances, and complications of the most frequently used surgical procedures in the shoulder, elbow, and wrist. The emphasis is on points that should not be overlooked in the surgical planning., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Introduction: The biceps brachii lesion needs to be treated surgically. A modified two incisions technique is proposed and reviewed. Material and Methods: All patients were treated with the same technique. The outcomes were measured with the Quick-DASH Score (QDS), and the Mayo Elbow Performance Score (MEPS). Postoperative complications and distal biceps tendon strength were registered also., Results: At one year from the trauma, the QDS and the MEPS were excellent in all patients. 72.97% fully recovered and returned to work after 6 months from the trauma., Discussion: This technique, thanks to its preservation of anatomical structures, provides great outcomes.

Background: In patients with osteoarthritis (OA) and an intact rotator cuff, hemi-shoulder arthroplasty (HSA) can be a viable option as it offers the advantage of keeping the native glenoid intact. However, glenoid erosion has frequently been reported. The aim of this study was to report preliminary clinical results of HSA with a new pyrolytic carbon (pyrocarbon) humeral head., Methods: This prospective multicenter study included a continuous series of 65 patients who underwent pyrocarbon HSA in 5 centers., Results: At the time of analysis, 1 patient was lost to follow-up, 3 patients underwent revision, and 61 patients were evaluated at a mean follow-up of 25.9 ± 3.3 months. The mean age at index surgery was 57.9 ± 13.3 years. The indications were primary glenohumeral OA in 37 patients, osteonecrosis in 11, secondary OA in 11, and rheumatoid arthritis in 2. The mean Constant score increased from 31.0 ± 15.8 points at baseline to 74.6 ± 17 points at last follow-up. Radiographic analyses showed that 86% of glenoids remained unchanged whereas 14% evolved slightly., Conclusions: Pyrocarbon HSA grants improvement in pain and function in patients with primary OA or secondary OA after instability but at a lower level in patients with post-traumatic sequelae (secondary OA or osteonecrosis). These preliminary clinical and radiologic results are encouraging, although they need to be confirmed by longer-term follow-up observations.

Periprosthetic shoulder infection (PSI) is an emerging pathology which requires many improvements in diagnosis and treatment to obtain a satisfying success rate. Different approaches have been described. This article summarizes current concepts of diagnostic process and main treatments described in the literature.

Introduction: Only few case series of capitellar and trochlear fractures have been reported. Some of them assume that the presence of a posterior comminution (type B according to Dubberley classification) can represent a negative risk factor for treatment and prognosis respect to the type A cases (without posterior comminution). Nevertheless, how this parameter impacts the treatment and the prognosis has never been quantified before., Materials and Methods: All the capitellar and trochlear fractures treated from 2007 to 2015 have been retrospectively reviewed. The presence of posterior comminution on a pre-operative CT-scan was correlated to the surgical technique, to the timing of initiation of rehabilitation and to clinical outcomes., Results: 45 Consecutive patients have been selected, 17 not presenting a posterior comminution (type A), and 28 with posterior comminution (type B). In all the type A fractures a lateral approach (Kocher o Kocher extensile) was used and the fragment fixation was always performed using only screws. Elbow replacement or olecranon osteotomy were performed only to treat type B fractures. Augmented fixations, using plates and k-wires, or prosthetic replacement have been used only in type B fractures. The post-operative immobilization was significantly inferior for type A fracture. Better results have been obtained in type A fractures: mean MEPI score was 86 in type A and 73 in type B, the range of motion was significatively higher in type A both in flexion-extension and in pronation-supination. In type B fractures a significant higher number of complications have been observed (64% vs 29%) along with more reoperations., Discussion: The study has confirmed that, even without considering the extension of the fracture on the coronal plane, the presence of posterior comminution represents an evident negative risk factor, influencing the surgical approach and treatment, the fixation technique, the post-operative rehabilitation, the clinical outcomes, the complications and re-operation rates., Conclusions: The analysis of the present case series shows how the treatment and the outcomes can be significantly anticipated based on the presence or absence of posterior comminution. Patients with type A fracture are more likely treated with a Kocher approach, screw fixation, an early rehabilitation is performed. In type A fractures better outcomes and low complications rate are expected., (Copyright © 2018. Published by Elsevier Ltd.)

Purpose  There is still conflicting evidence to support postoperative rehabilitation protocols using immobilization following rotator cuff repair over early motion. The objective of the study was to evaluate the evolution of pain, shoulder function, and patients' perception of their health status up to 1 year after cuff rotator repair and a standard postoperative rehabilitation protocol consisting of 4 weeks of immobilization followed by a 2-week assisted controlled rehabilitation. Methods  Descriptive, longitudinal, uncontrolled case-series study was performed on 49 patients who underwent arthroscopic rotator cuff repair following traumatic or degenerative lesions. VAS scale for pain, Constant-Murley score for function, and SF-12 score for quality of life were used as outcome measures and were administered before the rehabilitation treatment, at the end of the 2-week rehabilitation, 3 months, and 1 year after surgery. Results  VAS pain score decreased significantly along the follow-up reaching almost a nil value after 1 year (0.2). Function as measured by Constant-Murley score had a significant improvement during follow-up, reaching a mean value of 84.6. The short form (SF)-12 score increased over time reaching 46.3 for the physical and 43.8 for the psychological dimension, respectively, at 1 year. Conclusion  The present study confirmed an excellent outcome at 1 year after rotator cuff repair using a traditional 4-week immobilization followed by a 2-week rehabilitation protocol without evidence of tendon un-healing or re-tearing. Level of Evidence  This is a level IV, therapeutic case series.

Background: Acute Essex-Lopresti injury is a rare and disabling condition of longitudinal instability of the forearm. When early diagnosed, patients report better outcomes with higher functional recovery. Aim of this study is to focus on the different lesion patterns causing forearm instability, reviewing literature and the cases treated by the Authors and to propose a new terminology for their identification., Methods: Five patients affected by acute Essex-Lopresti injury have been enrolled for this study. ELI was caused in two patients by bike fall, two cases by road traffic accident and one patient by fall while walking. A literature search was performed using Ovid Medline, Ovid Embase, Scopus and Cochrane Library and the Medical Subject Headings vocabulary. The search was limited to English language literature. 42 articles were evaluated, and finally four papers were considered for the review., Results: All patients were operated in acute setting with radial head replacement and different combinations of interosseous membrane reconstruction and distal radio-ulnar joint stabilization. Patients were followed for a mean of 15 months: a consistent improvement of clinical results were observed, reporting a mean MEPS of 92 and a mean MMWS of 90.8. One case complained persistent wrist pain associated to DRUJ discrepancy of 3 mm and underwent ulnar shortening osteotomy nine months after surgery, with good results., Discussion: The clinical studies present in literature reported similar results, highlighting as patients properly diagnosed and treated in acute setting report better results than patients operated after four weeks. In this study, the definitions of "Acute Engaged" and "Undetected at Imminent Evolution" Essex-Lopresti injury are proposed, in order to underline the necessity to carefully investigate the anatomical and radiological features in order to perform an early and proper surgical treatment., Conclusions: Following the observations, the definitions of "Acute Engaged" and "Undetected at Imminent Evolution" injuries are proposed to distinguish between evident cases and more insidious settings, with necessity of carefully investigate the anatomical and radiological features in order to address patients to an early and proper surgical treatment.

Background: Anatomic surgical reduction of intra-articular fractures of the distal humerus is important to achieve the best long-term outcomes and prevent post-traumatic arthritis. In this study we compared the radiographic reduction using the trochleocapitellar index. We also correlated the trochleocapitellar index to the functional outcomes next to the comparison of the triceps brachii lifting approach and olecranon osteotomy approach, 2 common approaches for distal humeral fractures., Methods: From January 2006 to June 2016, patients with elbow fractures were registered in 4 centers. The trochleocapitellar index, a ratio between the angle of the capitellum and the trochlea to the midline of the distal humerus on anterior-posterior radiographs, was calculated for included patients. Functional outcomes were measured using the Oxford Elbow Score and the Mayo Elbow Performance Score. Bone healing was measured using radiographic union scoring., Results: There were 86 patients enrolled: 46 in the olecranon osteotomy group and 40 in the triceps lifting group. Functional outcomes and bone healing did not differ between the approaches. Functional results had a medium correlation with the trochleocapitellar index, which did not differ between the 2 approaches (olecranon osteotomy group, κ = 0.56; triceps lifting group, κ = 0.57; P = .7932)., Conclusions: The trochleocapitellar index has a moderate predictive value on the functional results after 12 months after open reduction and internal fixation of intra-articular distal humeral factures. There is no difference in reduction, as measured by trochlear index and functional outcome scores, between the olecranon osteotomy approach and the triceps brachii lifting approach groups., (Copyright © 2018 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

We investigated functional and radiological outcome in 57 cases of midshaft clavicle nonunion treated with open reduction and internal fixation with plate and screws over a 13 year-period. Intercalary bone graft was used in 42 patients; opposite autologous strut graft was used in 31 cases to provide mechanical support to the host bone. Patients were analysed using chart and radiological review and assessed with DASH questionnaire obtained at the latest follow-up. 37 patients were male while 20 were females, with a mean age of 35 years (63-17). All cases were of nonunion, 35 atrophic and 22 hypertrophic. The dominant side was injured in 32 cases and the non dominant in 25 cases. Primarily, 43 cases were treated conservatively with a figure of eight bandage. Time between fracture and our operative treatment was on average 44 months (13-72 months). Only those patients who were symptomatic were included in this study. We used straight reconstruction LCP and low profile precontoured plates. By reviewing patients charts all the cases but one of nonunion progressed to osseous healing at a mean time of 14 weeks (range 12-16). The patient with non-union refused further surgery. 49 patients were available for a final follow up. DASH score was 16.7 at an average of 42 months. Open surgery and internal fixation, using plate and screws in a compression construct is the treatment of choice for symptomatic clavicular non-unions. Intercalary autologous or allograft bone graft should be used especially in patient with significant bone loss; autologous cortical strut graft provides optimum mechanical stability, thus assuring optimal screw purchase and allowing immediate limb movement., (© 2017 Elsevier Ltd. All rights reserved.)

Background: Fractures of the proximal part of the humerus represent almost 4-5% of all fractures. The rate of non union is estimated to be 1.1 to 10%. Non union, displacement, and fixation failure can be hazardous complications for these injuries. The purpose of our study was to evaluate the outcomes of plate and bone strut allograft with bone chips grafting augmentation in the management of proximal humeral aseptic non union., Methods: We treated 16 aseptic non union proximal humeral fractures by the medial humeral shaft bone strut allograft and lateral plate and screws with bone chips grafting. The patients' ages were between 55 and 70 years. The chosen criteria to evaluate the group during the clinical and radiological follow-up were the quality of life measured by The Short Form (12) Health Survey (SF-12), shoulder function and related quality of life measured by the Constant Shoulder Score (CSS) compared with healthy side, bone healing measured by X-rays, and postoperative complications. The follow-up was perfor med with clinical and radiographic controls at 1, 3, 6 and 12 months. Surgical time and international units of red blood cells transfused were also calculated. The evaluation endpoint was set at 12 months., Results: The X-rays bone healing occurred in our group on average of 126.4 days after surgery. The surgical time and blood loss were consistent with standard surgical procedures. The quality of life and functional recovery were excellent after plate and bone strut allograft., Conclusions: Surgical techniques that increase mechanical stability, while incorporating bone biology, are effective aids for treating problematic fractural patterns.

Scapular winging secondary to dorsal scapular nerve (DSN) damage is an underestimated condition. It is often caused by entrapment of the nerve due to a hypertrophic middle scalene muscle, or by stretching of the DSN during traumatic movements. The condition has also been attributed to myofascial pain syndrome of the rhomboids with entrapment of the DSN. The non-specific symptomatology reported by patients is often incorrectly diagnosed, and this can result in a high level of disability of the upper limb. A clinical case of misdiagnosed dorsal scapula entrapment is presented. Satisfactory shoulder function recovery, pain relief and reduction of disability were obtained after correct diagnosis of the condition and a comprehensive rehabilitation approach.

The incidence of primary total elbow arthroplasty (TEA) in young patients is increasing. The indications for revision surgery are also rising. Here, we report a rare case of pseudotumor detected in a patient 16 years after TEA. Intraoperative findings revealed a necrotic mass characterized by a conspicuous metallosis in the soft tissues around the prosthesis, which caused ulnar nerve dislocation. Due to this anatomical change, a lesion of the nerve was accidentally produced during revision surgery. The case report emphasizes that the indications for elbow replacement, as well as the patient education about the permanent physical limitations, should be carefully considered. Moreover, the high risks of complications related to the revision procedure and pseudotumor removal need to be addressed before surgery. The technique should be done carefully and a preliminary thorough imaging should be performed, since a newly formed mass can cause significant distortion of the anatomy.

Background: Chronic coronoid deficiency can occur subsequent to coronoid fracture malunion/nonunion or to coronoid hypoplasia or dysplasia resulting from injury during development. Several surgical options have been described to treat this difficult condition, but results are equivocal. We hypothesized that a modified coronoid reconstruction using a radial head osteochondral graft could restore elbow stability and congruity and that a technique involving rigid internal fixation would promote graft union., Methods: The coronoid was reconstructed using an osteochondral fragment from a frozen allograft radial head in 3 young women affected by complex post-traumatic elbow instability and incongruity resulting from coronoid deficiency. To promote bone healing, the fragment was kept as large as could be fitted in place, the cut surface compressed onto the remaining coronoid was as large as possible, the medial portion of the radial head (containing dense bone) was used, and 3 lag screws were inserted in different directions., Results: At a mean follow-up of 26 months, all 3 patients achieved a painless, congruent stable joint with a functional range of motion. Computed tomography scans performed 3 months after surgery showed complete union of the graft in all the patients. Each patient rated herself as "almost normal" or "greatly improved" on the Summary Outcome Determination scale., Conclusion: Coronoid reconstruction with a radial head osteochondral allograft was successful in restoring stability and function in chronically unstable elbows with coronoid deficiency. Strong fixation using a large segment of the medial radial head achieved rapid graft healing., (Copyright © 2016 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Background: The treatment of complex distal humerus fractures is challenging and is often associated with unsatisfactory results. Anatomic reduction and stable internal fixation is difficult to obtain, especially in elderly osteoporotic patients. For these reasons, total elbow arthroplasty (TEA) has recently evolved as a valid procedure in selected cases following these injuries. The aim of this study was to analyze outcomes of TEA for the treatment of complex distal humerus fractures in 20 low-demanding patients over 65 years of age., Materials and Methods: All patients, at a mean follow-up of 60 months, were evaluated clinically using the Mayo Elbow Performance Score (MEPS) and radiographically in order to assess the positioning of the prosthetic components and signs of loosening. Statistical analyses investigated the presence of clinical and radiographic variables as predictive factors of poor functional outcomes., Results: Similar MEPSs were observed in the affected and unaffected arm. Results were good or excellent in 90% of the patients, even if a high rate of complications (35%) was encountered. The development of postoperative complications and concomitant cognitive impairment and rheumatoid arthritis were predictive factors of unsatisfactory outcomes., Conclusions: According to the results observed, TEA can be considered as a valid treatment for complex fractures of the distal humerus in low-demanding patients older than 65 years of age, in which a stable fixation is difficult to obtain. Several variables may influence the final outcomes.

Objective: Rotator cuff calcific tendinitis (RCCT) is a common cause of shoulder pain in adults and typically presents as activity-related shoulder pain. Between non-surgical and surgical treatment options, today a few minimal invasive techniques are available to remove the calcific deposit, and they represent a cornerstone in the management of this painful clinical condition. The aim of the work was a retrospective evaluation of double-needle ultrasound-guided percutaneous fragmentation and lavage (DNL), focused on understanding the factors which are of major importance in determining a quick and good response at 1 month., Methods: A series of 147 patients affected by RCCT and suitable for DNL were evaluated. A systematic review of anamnestic, clinical and imaging data was performed in 144 shoulders treated in a single-centre setting. Clinical reports and imaging examinations were revisited. The inclusion criteria were submission to DNL, therefore fitness for the percutaneous procedure, and following 1-month follow-up. There was no exclusion owing to risk of bias. The treatment was defined as successful for constant shoulder modified score (CSS) improvement of >50% at 1 month., Results: In 70% of shoulders, the treatment resulted in a quick and significant reduction of symptoms (successful). On the whole, CSS increase at 1 month was estimated at 91.5 ± 69.1%. CSS variations were significantly related to age of patients (better results between 30 and 40 years old), calcification size (more relevant improvement for middle-sized calcifications, 12-17 mm), sonographic and radiographic features of calcific deposits (softer calcifications) and thickening of subacromial/subdeltoid bursa walls. In the final model of stepwise regression for CSS variation, ultrasound score pre-treatment and post-treatment, the distance between bursa and calcification before treatment and the size of post-treatment calcification area were shown to be independently correlated to success. Numeric rating scale score for pain showed similar results. Pain at admission was also related to age, calcification size, ultrasound and Gärtner score, power Doppler positivity, bursal wall thickening and biceps tenosynovitis., Conclusion: The success of the procedure with quick improvement in function and symptoms is warranted in soft and middle-sized calcifications, in young adults., Advances in Knowledge: Ultrasound-guided percutaneous procedures for RCCT must be safe, effective and with prompt pain relief and function restoration. This study shows which clinical picture is more favourable to this purpose and actual prognostic factors for DNL (soft and middle-sized calcifications, in young adults, are more favourable).

Background: Total elbow arthroplasties (TEAs) are usually indicated in chronic inflammatory arthropathies. This procedure has also recently been used in complex distal humeral fractures and nonunions in selected patients. This study analyzed the clinical and radiographic outcomes in patients treated for nonunions around the elbow region with a minimum follow-up of 3 years., Methods: Between May 2002 and June 2012, 20 patients affected with distal humeral nonunions were treated with TEA. All patients were assessed clinically using the Mayo Elbow Performance Score and radiographically to evaluate the positioning of the prosthetic components and signs of loosening. Statistical analyses were performed to investigate the presence of clinical and radiographic variables as predictive factors of poor functional outcomes., Results: The Mayo Elbow Performance Score of the affected arm improved significantly between the preoperative period and follow-up. Results were good or excellent in 90% of the patients even if a high rate of complications (30%) was encountered. The development of complications after surgery and stages II, III, and IV radiolucency, according to the Morrey criteria, were predictive factors of poor outcomes., Conclusions: According to the satisfactory results observed in this study, TEA could be indicated in selected patients aged older than 70 years with low functional demands and affected with distal humeral nonunions in which obtaining a stable fixation is difficult., (Copyright © 2015 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Background: Chronic dislocation of the radial head treatment in Monteggia fracture dislocation is still controversial. We present a large series of patients treated in our Institution., Materials and Methods: The outcome of 22 children treated surgically between 1988 and 2011 for post-traumatic chronic radial head dislocation is reported. There were 12 girls and 10 boys with a mean age at surgery of 7.2 years (4.1-13.6). The mean interval between injury and treatment was 15.7 months (1-128). Nine patients underwent open reduction with removal of interposed tissue and repair (7) or Bell-Tawse reconstruction (2) of the annular ligament. Ten patients underwent osteotomy, gradual lengthening and angulation of the ulna by external fixation. Two patients underwent angular osteotomy of the proximal ulna with open wedge, open reduction in the radial head and reconstruction of the annular ligament. One patient admitted to the hospital 10 years after injury underwent radial head excision at 13.7 years of age., Results: After a mean follow-up of 5.5 years (1-24.3), the radial head stayed reduced in 15 patients and subluxated in 5. In one case, redislocation occurred. All patients but five were pain-free. The elbow performance score (Kim score) was excellent in 14 cases, good in four and fair in four, with a mean score of 91, corresponding to a good result. Complications included a transient posterior interosseus nerve palsy (1), and one non-union of the ulna., Discussion and Conclusion: Chronic Monteggia lesions must be treated. The clinical outcomes are usually better than the congruency of the radiocapitellar joint.

Shoulder disorders due to overexertion include joint and soft tissues chronic conditions and are an important cause of disability. Shoulder pain is one of the most common musculoskeletal disorders and has been associated to manual handling of heavy loads, high repetition jobs, exposure to hand-arm vibration and to overhead activities. Diagnosis of shoulder disorders is primarily based on clinical examination; selected cases should be referred to an orthopedic specialist and to imaging. Return to normal activities should be encouraged.

The elbow, the middle joint of the upper limb, enables the hand to be placed at various distances from the body. The articular, muscular and neuromotor complexity of the elbow is such that it is often prone to stiffness, especially if immobilized for long periods of time. Therefore, mobilization of the posttraumatic elbow must be started early. In the presence of lesions to the ligamentous structures, the joint must be protected to prevent these structures from being placed under tension during movement. Rehabilitation of the elbow includes the use of braces. Different types of brace are used depending on clinical situation and the objectives to be achieved. They can have fixed protection or locked articulation, allow an adjustable range of movement to restrict flexion-extension and pronation-supination, or allow dynamic and static progressive movement. The latter plays a special role in conservative treatment and following surgical release. However, the effectiveness of braces in the rehabilitation treatment of elbow stiffness depends on the patient's compliance. Their use requires a considerable amount of physician time to achieve the objectives envisaged by the rehabilitation program.

Background: Total elbow arthroplasty (TEA) has been normally indicated for chronic inflammatory arthropathy. In the last decades this surgery has also evolved as an acceptable procedure following traumatic lesions of this joint. The aim of this study was to analyze the mid-term outcomes of TEA for the treatment of complex fractures and non-unions of the elbow in selected patients., Methods: Between May 2002 and December 2011, 34 patients with these indications were surgically treated with TEA and divided in two groups. Group 1 included 16 cases of fractures and Group 2 18 of non-union. All patients were clinically assessed using the Mayo Elbow Performance Score (MEPS). A statistical analysis was performed in order to investigate the outcomes of these patients and compare the two groups., Results: Similar results were observed in both groups between operated and non-operated arms. No differences in clinical results were documented between groups., Conclusions: TEA following traumas can be considered as a valid treatment in old patients in complex fractures of the elbow region with low functional demands and in non-unions. Outcomes are influenced by the collaborative capacities of the patients.

Background: This article presents the experience at the Rizzoli Orthopaedic Institute in the treatment of intracapsular osteoid osteoma (OO) of the elbow by computed tomography-guided percutaneous radiofrequency thermal ablation (RFA)., Materials and Methods: Our team performed more than 800 RFA procedures to treat OO up to 2010. In 27 cases, the lesion site was the articular area of the elbow (humerus in 13 cases, ulna in 13, and radius in 1). These patients were reviewed and assessed for eradication rate, incidence of complications, and functional results measured by the Mayo Elbow Performance Score. The outcome was evaluated after a mean follow-up period of 67.4 ± 35.3 months (range, 24-128 months)., Results: The mean duration of symptoms at the time of diagnosis was 31.0 ± 19.8 months (range, 5-72 months). All patients complained about pain, and in 24 of 27 cases (88.8%), the joint function was significantly impaired by the presence of OO (pretreatment score, 54.8). After RFA, the Mayo Elbow Performance Score improved by a mean of 37.7 ± 14.8 points, with 25 of 27 patients (92.5%) scoring 90 to 100 points at final follow-up. OO recurred in only 1 patient (3.7%), 5 months after the procedure. However, this was successfully retreated by RFA. No adverse effects were observed, and all patients were free of disease at the final follow-up., Discussion: The RFA procedure can be technically challenging in difficult sites such as the elbow joint. The low invasiveness of RFA compared with traditional surgery allows excellent functional recovery. RFA of elbow OO is effective and safe, and it should be considered the first-choice treatment for this disease., (Copyright © 2014 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Mosby, Inc. All rights reserved.)

Background: Although progress has been made in the treatment of articular cartilage lesions, they are still a major challenge because current techniques do not provide satisfactory long-term outcomes. Tissue engineering and the use of functional biomaterials might be an alternative regenerative strategy and fulfill clinical needs. Decellularized extracellular matrices have generated interest as functional biologic scaffolds, but there are few studies on cartilage regeneration. The aim of this study was to evaluate in vitro the biological influence of a newly developed decellularized human dermal extracellular matrix on two human primary cultures., Methods: Normal human articular chondrocytes (NHAC-kn) and human mesenchymal stromal cells (hMSC) from healthy donors were seeded in polystyrene wells as controls (CTR), and on decellularized human dermis batches (HDM&#95;derm) for 7 and 14 days. Cellular proliferation and differentiation, and anabolic and catabolic synthetic activity were quantified at each experimental time. Histology and scanning electron microscopy were used to evaluate morphology and ultrastructure., Results: Both cell cultures had a similar proliferation rate that increased significantly (p < 0.0005) at 14 days. In comparison with CTR, at 14 days NHAC-kn enhanced procollagen type II (CPII, p < 0.05) and aggrecan synthesis (p < 0.0005), whereas hMSC significantly enhanced aggrecan synthesis (p < 0.0005) and transforming growth factor-beta1 release (TGF-β1, p < 0.0005) at both experimental times. Neither inflammatory stimulus nor catabolic activity induction was observed. By comparing data of the two primary cells, NHAC-kn synthesized significantly more CPII than did hMSC at both experimental times (p < 0.005), whereas hMSC synthesized more aggrecan at 7 days (p < 0.005) and TGF-β1 at both experimental times than did NHAC-kn (p < 0.005)., Conclusions: The results obtained showed that in in vitro conditions HDM&#95;derm behaves as a suitable scaffold for the growth of both well-differentiated chondrocytes and undifferentiated mesenchymal cells, thus ensuring a biocompatible and bioactive substrate. Further studies are mandatory to test the use of HDM&#95;derm with tissue engineering to assess its therapeutic and functional effectiveness in cartilage regeneration.

Radial head prosthetic replacement is indicated in case of comminuted fracture not amenable to internal fixation, especially when the radial head fracture is part of a pattern of lesions configuring a complex instability of the elbow. Thirty-one SBi radial head prostheses were implanted in 30 patients (one bilateral simultaneous fracture) over a 2 years period. In 10 patients, the mean time from trauma to surgical treatment was 2.4 days, while the remaining 20 patients were treated as "second opinion" cases presenting with elbow stiffness or instability after an average of 19 days from trauma. The implants were monopolar in 12 cases and bipolar in 19. The clinical results were evaluated through the Mayo Elbow performance scoring system. At an average follow-up of 2 years (range 13-36 months), the mean MEPS was 90 points (range 65-100). At late radiographic analysis, radiolucent lines around the stem were found in 11 of the 31 cases. Heterotopic ossifications were found in 14 cases. Bone resorption was observed in 9 cases. Two of the 31 prostheses were removed after 16 and 20 months, in one case to correct stiffness in pronation/supination, in the other one for asymptomatic aseptic mobilization. These short-term results are satisfactory, especially when considering that they were obtained in complex elbow lesions treated in many cases at a delayed stage. Our preference over time went more and more to bipolar implants, but from a comparison of the results we could find no evidence of a superiority of bipolar or monopolar implants. The evolution of these prostheses needs to be evaluated with further studies to assess mid-term and long-term follow-up results.

Interest is increasing in biological scaffolds for tissue regeneration such as extracellular matrix membranes, developed through soft tissue decellularization. Extracellular matrix membranes were developed to heal different tendon and soft tissue lesions that are very frequent in the general population with high health-care costs and patient morbidity. The aim of this research was to evaluate a human dermal matrix (HDM) decellularized by a chemico-physical method. A primary culture of rat tenocytes was performed: tenocytes were seeded on HDM samples and on polystyrene wells as controls (CTR). Cell viability and synthetic activity were evaluated at 3 and 7 days. An in vitro microwound model was used to evaluate HDM bioactivity: after tenocyte expansion, artificial wounds were created, HDM extracts were added, and closure time and decorin synthesis were monitored histomorphometrically at 1, 4, 24, and 72 hr. A significant higher amount of collagen I was observed when cells were cultured on HDM in comparison with that on CTR (3 days: p < 0.0001; 7 days: p < 0.05). In HDM group, fibronectin synthesis was significantly higher at both experimental times (p < 0.0001). At 3 days, proteoglycans and transforming growth factor-β1 releases were significantly higher on HDM (p < 0.0001 and p < 0.005, respectively). The artificial microwound closure time and decorin expression were significantly enhanced by the addition of 50% HDM extract (p < 0.05). In vitro data showed that the decellularization technique enabled the development of a matrix with adequate biological and biomechanical properties.

The high incidence of recurrent tendon tears after repair of massive cuff lesions is prompting the research of materials aimed at mechanically or biologically reinforcing the tendon. Among the materials studied upto now, the extracellular matrix (ECM) scaffolds of human origin have proved to be the safest and most efficient, but the current laws about grafts and transplants preclude their use in Europe. In order to overcome this condition in 2006, we started a project regarding the production of an ECM scaffold of human origin which could be implanted in Europe too. In 2009, the clinical study began with the implantation of dermal matrix scaffolds in 7 middle-aged patients affected with large/massive cuff lesions and tendon degeneration. Out of 5 cases, followed for at least 1 year in which the scaffold was employed as an augmentation device, there were 3 patients with complete healing, 1 partial re-tear, and 1 total recurrence. The absence of adverse inflammatory or septic complications allows to continue this line of research with a prospective controlled study in order to define the real advantages and correct indications offered by scaffold application.

A new HPLC-ESI-MS/MS method for the determination of glucosamine (2-amino-2-deoxy-d-glucose) in rabbit cartilage was developed and optimized. Glucosamine was extracted from cartilage by cryogenic grinding followed by protein precipitation with trichloroacetic acid. The HPLC separation was achieved with a polymer-based amino column using a mobile phase composed of 10mM ammonium acetate (pH 7.5)-acetonitrile (20:80%, v/v) at 0.3 mL min flow rate. d-[1-(13)C]Glucosamine was used as internal standard. Selective detection was performed by tandem mass spectrometry with electrospray source, operating in positive ionization mode and in multiple reaction monitoring acquisition (m/z 180→72 and 181→73 for glucosamine and internal standard, respectively). Limit of quantification was 0.045 ng injected, corresponding to 0.25 μg g⁻¹ in cartilage. Linearity was obtained up to 20 μg g⁻¹ (R(2)>0.991). Precision values (%R.S.D.) were <10%. Accuracy (% bias) ranged from -6.0% to 12%. Mean recoveries obtained at 3 concentration levels were higher than 81% (%R.S.D.≤8%). The method was applied to measure glucosamine levels in rabbit cartilage and plasma after single oral administration of glucosamine sulfate at a dose of 98 mg kg⁻¹(n=6). Glucosamine was present in cartilage in physiological condition before the treatment. After dosing, mean concentration of cartilage glucosamine significantly increased from 461 to 1040 ng g⁻¹. Cartilage glucosamine levels resulted to be well correlated with plasma concentrations, which therefore are useful to predict the target cartilage concentration and its pharmacological activity., (Copyright © 2011 Elsevier B.V. All rights reserved.)

This article presents a case of a 71-year-old woman with a humeral fracture between a cementless reverse total shoulder arthroplasty and a cemented total elbow arthroplasty and discusses our treatment plan. Surgical treatment was performed after the patient was informed of possible complications and the benefits of surgery including: early, complete restoration of arm anatomy, greater functional improvement of the adjacent joints, and increased risk of nonunion with nonoperative treatment.The fracture was comminuted and extended proximally around the shoulder prosthesis. Through the posterior approach, the radial nerve was identified and protected. Both prostheses were found firmly fixed to bone. The fracture around the shoulder prosthesis was reduced first using a strut allograft and reduction clamps. Next, arm alignment restoration and distal humerus reduction were performed. The construct was neutralized with a 3.5-mm locking plate spanning the whole length of the humerus. The locking plate was positioned posterolaterally and the strut medially in a 90° to 90° configuration secured with wires and cables.A hinged elbow brace was applied for 6 weeks postoperatively. Active range of motion exercises of the wrist and hand and passive motion of the elbow and shoulder were started at 4 to 5 days postoperatively. At 2 weeks postoperatively, passive motion of the elbow and shoulder progressed to strengthening exercises. Thereafter, the patient underwent several weeks of physical therapy to restore motion, strength, and function of the upper extremity with instructions not to overload the arm and avoid heavy work and sports for as long as 1 year. At 10 months postoperatively, radiographs of the arm showed a stable construct; the patient had resumed full activities of daily living., (Copyright 2011, SLACK Incorporated.)

Sterno Clavicular Joint (SCJ) dislocations are rare injuries of the shoulder girdle. Their management is controversial due to a not guaranteed outcome after any kind of treatment (conservative or open). Open reduction is challenging because of the anatomical site, while the conservative treatment does not always improve pain or instability discomfort. We report a case of traumatic and painful anterior SCJ dislocation of a young policewoman treated with open reduction by a new surgical technique. Functional result is extremely good at 2 years of follow-up.

Invalidating elbow contractures, a frequent problem after injury, are commonly treated by physical therapy or surgical release. In both cases, results can be frustrating: physical therapy is often not sufficient to gain functional range of motion, and after surgical release it is common to lose part of the motion gained in operating room. Thanks to the viscous-elastic properties of the soft tissue, the mobilization elbow braces can stretch the retracting or retracted tissues inducing a biological lengthening of collagen fibres. In post-traumatic contracture, mobilization braces are effectively employable in two main critical situations: to treat recent onset contractures which do not respond to simple physical therapy and to help in preserving range of motion gained after surgical release. We report our experience with mobilization brace used in 42 patients, 5 for post-traumatic contracture, 4 for contracture following articular fracture fixation and 33 after surgical release. Classification, indications and treatment protocols of the mobilization braces utilized are reported.

We report two cases of scapula-thoracic dyskinesia with different etiologies where both patients complained of functional limitation and pain in the shoulder. The first case was caused by a road accident, the second by sequelae of surgery to remove aggressive scapula-axillary fibromatosis. In both patients, therapy with botulin toxin type A (Botox) was performed, which determined a reduction in pain. In the first case, there was also an improvement in function. There were no side effects in the two patients after the injections.