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The management of a clavicle nonunion with segmental bone loss and shoulder deformity
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J Shoulder Elbow Surg Volume 25, Number 6
Paper #17 SURGEON-CONTROLLED VARIABLES FOR TUBEROSITY HEALING AFTER SHOULDER HEMIARTHROPLASTY FOR FRACTURE
Anshuman Singh, MD, Michael A. Padilla, MD, Eric Nyberg, BS, Mary Chocas, BS, Oke A. Anakwenze, MD, Raffy Mirzayan, MD, Ronald A. Navarro, MD, Department of Orthopaedics, Kaiser Permanente, San Diego, California, USA; Albany Medical School, Albany, New York, USA; Department of Orthopaedics, Kaiser Permanente, Baldwin Park, California, USA; Department of Orthopaedics, Kaiser Permanente, Harbor City, California, USA Introduction: Hemiarthroplasty for four-part proximal humerus fractures (4PHF) results in a bimodal distribution of pain and functional outcomes. Tuberosity healing positively correlates with outcome. The primary objective of this study is to examine surgeon-controlled variables that may influence tuberosity healing after hemiarthroplasty for 4PHFs. Methods: This is a retrospective comparative study of individuals who underwent hemiarthroplasty for 4PHFs between April 2011 and December 2013, inclusive. Procedures were performed by multiple surgeons in a single medical group operating at 13 different hospitals in the United States. Preoperative, immediate postoperative, and final radiographs were analyzed by an orthopaedic surgeon blinded to the demographic variables. The demographic variables were extracted from the electronic medical record by an analyst blinded to the radiographs. Patients were divided into 2 groups. One with anatomically healed tuberosities, and the other with tuberosity resorption or nonunion. Univariate and Multivariate analyses were performed to compare the outcomes of interest between groups on a set of data points that were decided a priori. Primary variables analyzed include: time between injury and surgery, prosthesis fenestration, cement mantle classification, and both vertical and horizontal tuberosity reduction. Secondary demographic factors analyzed include age, gender, osteoporosis status, diabetes status, and smoking. Results: 109 patients met the inclusion criteria. At minimum 1 year follow up, 5 individuals passed away, 4 had severe concomitant ipsilateral shoulder disease (such as a prior diaphyseal fracture or endstage osteoarthritis) that may significantly impact outcomes, 8 individuals were lost to follow-up, 8 had inadequate pre or post-operative imaging studies to analyze and were thus excluded from analysis, resulting in a final cohort of 84 patients. Of the 84 remaining individuals, 37 (44%) had anatomically healed tuberosities at final evaluation, and 47 (56%) had either tuberosity nonunion or resorption. There were no significant differences in age, osteoporosis status, smoking status, diabetes diagnosis, or time between diagnosis and surgery between groups. Males, however, had nearly double the rate of tuberosity healing in this cohort (P = .03). In terms of tuberosity reduction, anatomical horizontal reduction (between the lesser and greater tuberosities) was significantly associated with tuberosity healing (P < .001). Anatomical vertical reduction (tuberosity height), however, was not associated with tuberosity healing (P = .41, Table 1). Cement technique had a statistically significant impact on tuberosity healing. Individuals with healed tuberosities had cement under the tuberosities 32% of the time, while individuals with tuberosity nonunion or resorption had cement under the tuberosities 87% of the time (P < .001, Table 1).There was no statistically significant association between tuberosity healing and fenestration of the humeral stem implant (P = .84, Table 1). Discussion/Conclusion: The classification and effect of cement technique on tuberosity healing has not previously been described in the literature. We suggest limiting cementation to a minimum of 5 mm below the level of the tuberosity fracture. The ideal candidate for hemiarthroplasty for fracture is male with anatomic tuberosity reduction and limited use of cement.
Paper #18 DECISION MAKING FOR PROXIMAL HUMERAL FRACTURES: ANALYSIS OF THE APPLICABILITY OF OUR NEW EVIDENCE BASED ALGORITHM
Bernhard Jost, MD, Vilijam Zdravkovic, MD, Christian Spross, MD, Department of Orthopaedics and Traumatology, Kantonsspital St. Gallen, St. Gallen, Switzerland
Table 1
Reduction on Postoperative Radiographs Anatomic Tuberosity Healing
YES
NO
Number of patients Vertical reduction (IMTV) over 5 mm High Acceptable over 10 mm low Horizontal Reduction (IMTH) Anatomic Non-Anatomic
37
47
8.1% 40.5% 51.4%
10.6% 23.4% 65.9%
P-value
P = .41
P = <.001 80.6% 19.4%
40.9% 39.1%
Cement Classification and Implant Selection Anatomic Tuberosity Healing Cement Classification A: Under Tuberosities B: Below tuberosities C: Distal tip/no cement Implant Fenestration yes no
YES (37pts)
NO (47pts)
32.4% 37.8% 29.7%
87.2% 0.0% 12.8%
27.7% 72.3%
29.7% 71.3%
P-value P = <.001
P = .84
Introduction: Proximal humeral fractures are well studied common injuries, but decision making in daily practice remains a challenge. We defined an algorithm based on the current state of knowledge about proximal humeral fracture. Aim of the study: The aim of this study was to prove the applicability of the algorithm, the adherence to it, and causes for divergence. Materials and Methods: We applied the algorithm on 114 patients (26.3% male, mean age 60.4 y, 73.7% female, mean age 68.9 y) admitted to our emergency unit for proximal humeral fracture starting from 1.1.2014. After one year we analysed the causes for not entering the algorithm, changing the path within, or leaving the algorithm before the therapy could be closed. Results: According to Neer classification, we rated 23.9% of cases as 3 or 4 part humeral head fractures. Conservative treatment was initiated in 55.8%, an operation performed in 44.2% of patients. In the operative group we performed an osteosynthesis in 42.1%, and a prosthetic replacement in 57.9%. The study protocol could not be applied to the end (non-adherence) in 8% of cases, mainly because of degraded patient mental status. Until now there were 6% of patients changing the therapy path in the algorithm (e.g. osteosynthesis to prosthesis). Conclusion: Our new evidence based algorithm is an applicable decision making tool for proximal humeral fractures. The adherence to the protocol is high, and switching between the paths within the protocol is rare. Potential impact of the protocol on therapy outcome will be studied at two years follow up.
Paper #19 THE MANAGEMENT OF A CLAVICLE NONUNION WITH SEGMENTAL BONE LOSS AND SHOULDER DEFORMITY
Jesse B. Jupiter, MD, Massachusetts General Hospital, Boston, Massachusetts, USA Introduction: The management of an ununited clavicle fracture characterized by segmental bone loss and shoulder girdle deformity
e176
is exceptionally challenging. In addition to pain at the nonunion site, neurologic symptoms and deficient soft tissue compliance are commonplace. Material and Methods: This is a retrospective study of 20 patients treated over an 18 year period by a single surgeon. The average patient age at surgery was 42 years (range 24-69 yr) with the average duration of the nonunion 40 months (range 8-100 mo). All but one had prior surgery. Eighteen patients had pain, 15 had a adducted, shortened, and protracted shoulder girdle, and 8 had symptoms of thoracic outlet syndrome. The average bony defect was 3.3 cm (range 2-8 cm). Five had been treated for a P. Acnes infection. The surgical tactics included extensive debridement of the synovial nonunion and bony ends to create a recess for the bone graft, realignment with a small distractor to regain length, placement of a sculptured corticocancellous graft with dowels at each end, and stable plate fixation. Results: At an average follow up of 36 months (range 12-60 mo) all nonunions had healed. One patient with an infected nonunion required a second procedure. Clavicle length was restored to within 1 cm, nearly full rotation returned in all, and the average DASH score of the 8 patients treated more recently was 22. Conclusions: Careful preoperative planning and combining segmental bone graft and stable internal fixation can restore clavicle length, alignment, and shoulder girdle function.
Paper #20 PATIENT FACTORS INFLUENCING RETURN TO WORK AND CUMULATIVE FINANCIAL CLAIMS AFTER CLAVICLE FRACTURES IN WORKERS COMPENSATION CASES
Edward J. Shields, MD, Caroline Thirukumaran, Robert J. Thorsness, MD, Katia Noyes, PhD, MPH, Ilya Voloshin, MD, University of Rochester Medical Center, Rochester, New York, USA Background: Workers compensation status is consistently cited as a predictor of poor outcome after orthopaedic procedures. This study analyzes a cohort of all workers compensation patients after surgical or non-operative treatment of clavicle fractures to identify factors that influence the time for return to work and total healthcare reimbursement claims, including a comparison of surgical and non-operative treatments. Operative treatment has been associated with faster time to boney union. We hypothesized that return to work for operative patients would be faster and the reimbursement claims for operative cases would be higher. Methods: The International Classification of Diseases, Ninth Revision, Clinical Modification (ICD9-CM) diagnosis codes and Current Procedural Terminology (CPT) codes were used to retrospectively query the Workers’ Compensation national database managed by University of Illinois, Chicago. Claims for clavicular fractures treated surgically and non-operatively were identified from 2003 to 2013. The outcomes of interest were the number of days for return to full work (RTW) following surgery and the total reimbursement for healthcare-related claims. The primary independent variable was treatment modality. Multivariate analysis was performed to control for relevant employee, employer and treatment covariates that were likely to confound associations. We used two-tailed hypothesis tests and P < .05 to indicate statistical significance. Averages are ± standard deviation. Results: There were 169 settled claims for clavicle fractures within the database. Only 20% (n = 34) of these claims related to surgical treatment, while 80% (n = 135) related to non-operative treatment. For claims with complete follow-up, the average time for RTW was 196 ± 287 days for surgical treatment, and 69 ± 94 days for non-operative treatment. The average healthcare claims reimbursed were $29,136 ± 26,998 for surgical management, compared to $8366 ± 14,758 for nonoperative treatment. From multivariate RTW analysis, we did not find a significant difference between non-operative and surgical treatment groups in their time to RTW (P = .06) Claims from workers with one or more dependents (Reference Group [RG]: No dependents), from the West (RG: Midwest), from injuries related to athletics/Police/ Firefighters (RG: Driving/flying/boating) were significant predicators of earlier RTW. Claims with a higher percentage of impairment, filing
J Shoulder Elbow Surg June 2016
of a legal suit, and incident report only claims (RG: Employer’s liability) were associated with later RTW. From multivariate reimbursement analysis, total healthcare reimbursement for claims with surgical treatment were 330% higher as compared to claims for non-operative treatment (P < .01). Claims with an associated legal suit, from working professionals (RG: Driving/Flying/Boating related injuries), from workers with at least 20 years of service (RG: < 10 years), and between 180 and 360 lost working days (RG: < 45 days) were predictors of higher healthcare claims. Injuries from pushing/pulling/lifting, and from falls (RG: Motor vehicle related injuries), and incident report only claims (RG: Employer’s liability) were significant predictors of lower healthcare claim amount. Conclusion: Contrary to our hypothesis, the patients treated under workers compensation status for clavicle fractures return to work at roughly the same time whether they are treated surgically or non-operatively, when controlling for relevant covariates. Workers compensation patients treated with surgery accumulate significantly higher healthcare claims than those treated without surgery. Although many variables that independently influence return to work timing and cumulative health care claims in this study are nonmodifiable, attempting to minimize legal suits may help expedite patients return to work. As the indications for operative treatment of clavicle fractures continues to be elucidated, non-operative treatment of fractures may help reduce overall financial burden in workers compensation patient population.
Paper #21 ARTHROSCOPIC VERSUS OPEN LATERAL RELEASE FOR THE TREATMENT OF LATERAL EPICONDYLITIS: A PROSPECTIVE RANDOMIZED CONTROLLED TRIAL
Peter B. MacDonald, MD, FRCSC, Tod Clark, MD, FRCSC, Sheila McRae, MSc, PhD, Jeff Leiter, MSc, PhD, Jamie Dubberley, MD, FRCSC, Pan Am Clinic, University of Manitoba, Winnipeg, Manitoba, Canada Purpose: The primary objective of this study was to determine if quality of life and function are different following arthroscopic versus open tennis elbow release surgery. Based on retrospective studies, both approaches have been found to be beneficial, but no prospective randomized comparison has been conducted to date. Method: Following a minimum six-months of conservative treatment, seventyone patients (>16 yrs old) were randomized intraoperatively to undergo either arthroscopic or open lateral release. Outcome measures were the Disabilities of the Arm, Shoulder and Hand questionnaire (DASH), a 5-question VAS Pain Scale, and grip strength. Study assessments took place pre-, and 6-week, 3-, 6-, and 12-months post-surgery. Comparisons between groups and within groups over time were conducted with P < .05. Results: Fifteen women and 19 men underwent the open procedure with a mean age of 47.1 years (6.7) and 13 women and 21 men were in the arthroscopic group with a mean age of 45.0 (6.9). No pre-surgery differences were found between groups based on age, sex, DASH or VAS scores. Both groups demonstrated a significant improvement in subjective measures and grip strength by 12-months post-surgery, and no significant differences were found between groups at any time point. The DASH, our primary outcome, decreased from a mean (SD) of 47.5 (14.5) pre-surgery to 21.9 (21.8) at 12-months post-surgery in the Open group and from 52.7 (16.0) to 22.6 (21.1) in the Arthroscopic group. VASpain scores (%) decreased in the Open group from 62.5 (17.2) preoperatively to 30.0 (26.5) at 12-months. In the arthroscopic group, scores decreased from 63.7 (15.9) to 26.2 (24.6). Grip strength (kg) increased on the affected side from 23.6 (14.9) to 29.3 (16.3) and 21.4 (15.4) to 29.8 (15.4) for Open and Arthroscopic groups, respectively. Conclusion: Based on this study, there is no difference in patient quality of life and function between arthroscopic and open tennis elbow release surgery at 12-months post-operative. Factors such as sex, age, smoking status, third party claims (WCB) may also influence patient outcome, but this study was not adequately powered to draw any statistical conclusions.
J Shoulder Elbow Surg Volume 25, Number 6
Paper #17 SURGEON-CONTROLLED VARIABLES FOR TUBEROSITY HEALING AFTER SHOULDER HEMIARTHROPLASTY FOR FRACTURE
Anshuman Singh, MD, Michael A. Padilla, MD, Eric Nyberg, BS, Mary Chocas, BS, Oke A. Anakwenze, MD, Raffy Mirzayan, MD, Ronald A. Navarro, MD, Department of Orthopaedics, Kaiser Permanente, San Diego, California, USA; Albany Medical School, Albany, New York, USA; Department of Orthopaedics, Kaiser Permanente, Baldwin Park, California, USA; Department of Orthopaedics, Kaiser Permanente, Harbor City, California, USA Introduction: Hemiarthroplasty for four-part proximal humerus fractures (4PHF) results in a bimodal distribution of pain and functional outcomes. Tuberosity healing positively correlates with outcome. The primary objective of this study is to examine surgeon-controlled variables that may influence tuberosity healing after hemiarthroplasty for 4PHFs. Methods: This is a retrospective comparative study of individuals who underwent hemiarthroplasty for 4PHFs between April 2011 and December 2013, inclusive. Procedures were performed by multiple surgeons in a single medical group operating at 13 different hospitals in the United States. Preoperative, immediate postoperative, and final radiographs were analyzed by an orthopaedic surgeon blinded to the demographic variables. The demographic variables were extracted from the electronic medical record by an analyst blinded to the radiographs. Patients were divided into 2 groups. One with anatomically healed tuberosities, and the other with tuberosity resorption or nonunion. Univariate and Multivariate analyses were performed to compare the outcomes of interest between groups on a set of data points that were decided a priori. Primary variables analyzed include: time between injury and surgery, prosthesis fenestration, cement mantle classification, and both vertical and horizontal tuberosity reduction. Secondary demographic factors analyzed include age, gender, osteoporosis status, diabetes status, and smoking. Results: 109 patients met the inclusion criteria. At minimum 1 year follow up, 5 individuals passed away, 4 had severe concomitant ipsilateral shoulder disease (such as a prior diaphyseal fracture or endstage osteoarthritis) that may significantly impact outcomes, 8 individuals were lost to follow-up, 8 had inadequate pre or post-operative imaging studies to analyze and were thus excluded from analysis, resulting in a final cohort of 84 patients. Of the 84 remaining individuals, 37 (44%) had anatomically healed tuberosities at final evaluation, and 47 (56%) had either tuberosity nonunion or resorption. There were no significant differences in age, osteoporosis status, smoking status, diabetes diagnosis, or time between diagnosis and surgery between groups. Males, however, had nearly double the rate of tuberosity healing in this cohort (P = .03). In terms of tuberosity reduction, anatomical horizontal reduction (between the lesser and greater tuberosities) was significantly associated with tuberosity healing (P < .001). Anatomical vertical reduction (tuberosity height), however, was not associated with tuberosity healing (P = .41, Table 1). Cement technique had a statistically significant impact on tuberosity healing. Individuals with healed tuberosities had cement under the tuberosities 32% of the time, while individuals with tuberosity nonunion or resorption had cement under the tuberosities 87% of the time (P < .001, Table 1).There was no statistically significant association between tuberosity healing and fenestration of the humeral stem implant (P = .84, Table 1). Discussion/Conclusion: The classification and effect of cement technique on tuberosity healing has not previously been described in the literature. We suggest limiting cementation to a minimum of 5 mm below the level of the tuberosity fracture. The ideal candidate for hemiarthroplasty for fracture is male with anatomic tuberosity reduction and limited use of cement.
Paper #18 DECISION MAKING FOR PROXIMAL HUMERAL FRACTURES: ANALYSIS OF THE APPLICABILITY OF OUR NEW EVIDENCE BASED ALGORITHM
Bernhard Jost, MD, Vilijam Zdravkovic, MD, Christian Spross, MD, Department of Orthopaedics and Traumatology, Kantonsspital St. Gallen, St. Gallen, Switzerland
Table 1
Reduction on Postoperative Radiographs Anatomic Tuberosity Healing
YES
NO
Number of patients Vertical reduction (IMTV) over 5 mm High Acceptable over 10 mm low Horizontal Reduction (IMTH) Anatomic Non-Anatomic
37
47
8.1% 40.5% 51.4%
10.6% 23.4% 65.9%
P-value
P = .41
P = <.001 80.6% 19.4%
40.9% 39.1%
Cement Classification and Implant Selection Anatomic Tuberosity Healing Cement Classification A: Under Tuberosities B: Below tuberosities C: Distal tip/no cement Implant Fenestration yes no
YES (37pts)
NO (47pts)
32.4% 37.8% 29.7%
87.2% 0.0% 12.8%
27.7% 72.3%
29.7% 71.3%
P-value P = <.001
P = .84
Introduction: Proximal humeral fractures are well studied common injuries, but decision making in daily practice remains a challenge. We defined an algorithm based on the current state of knowledge about proximal humeral fracture. Aim of the study: The aim of this study was to prove the applicability of the algorithm, the adherence to it, and causes for divergence. Materials and Methods: We applied the algorithm on 114 patients (26.3% male, mean age 60.4 y, 73.7% female, mean age 68.9 y) admitted to our emergency unit for proximal humeral fracture starting from 1.1.2014. After one year we analysed the causes for not entering the algorithm, changing the path within, or leaving the algorithm before the therapy could be closed. Results: According to Neer classification, we rated 23.9% of cases as 3 or 4 part humeral head fractures. Conservative treatment was initiated in 55.8%, an operation performed in 44.2% of patients. In the operative group we performed an osteosynthesis in 42.1%, and a prosthetic replacement in 57.9%. The study protocol could not be applied to the end (non-adherence) in 8% of cases, mainly because of degraded patient mental status. Until now there were 6% of patients changing the therapy path in the algorithm (e.g. osteosynthesis to prosthesis). Conclusion: Our new evidence based algorithm is an applicable decision making tool for proximal humeral fractures. The adherence to the protocol is high, and switching between the paths within the protocol is rare. Potential impact of the protocol on therapy outcome will be studied at two years follow up.
Paper #19 THE MANAGEMENT OF A CLAVICLE NONUNION WITH SEGMENTAL BONE LOSS AND SHOULDER DEFORMITY
Jesse B. Jupiter, MD, Massachusetts General Hospital, Boston, Massachusetts, USA Introduction: The management of an ununited clavicle fracture characterized by segmental bone loss and shoulder girdle deformity
e176
is exceptionally challenging. In addition to pain at the nonunion site, neurologic symptoms and deficient soft tissue compliance are commonplace. Material and Methods: This is a retrospective study of 20 patients treated over an 18 year period by a single surgeon. The average patient age at surgery was 42 years (range 24-69 yr) with the average duration of the nonunion 40 months (range 8-100 mo). All but one had prior surgery. Eighteen patients had pain, 15 had a adducted, shortened, and protracted shoulder girdle, and 8 had symptoms of thoracic outlet syndrome. The average bony defect was 3.3 cm (range 2-8 cm). Five had been treated for a P. Acnes infection. The surgical tactics included extensive debridement of the synovial nonunion and bony ends to create a recess for the bone graft, realignment with a small distractor to regain length, placement of a sculptured corticocancellous graft with dowels at each end, and stable plate fixation. Results: At an average follow up of 36 months (range 12-60 mo) all nonunions had healed. One patient with an infected nonunion required a second procedure. Clavicle length was restored to within 1 cm, nearly full rotation returned in all, and the average DASH score of the 8 patients treated more recently was 22. Conclusions: Careful preoperative planning and combining segmental bone graft and stable internal fixation can restore clavicle length, alignment, and shoulder girdle function.
Paper #20 PATIENT FACTORS INFLUENCING RETURN TO WORK AND CUMULATIVE FINANCIAL CLAIMS AFTER CLAVICLE FRACTURES IN WORKERS COMPENSATION CASES
Edward J. Shields, MD, Caroline Thirukumaran, Robert J. Thorsness, MD, Katia Noyes, PhD, MPH, Ilya Voloshin, MD, University of Rochester Medical Center, Rochester, New York, USA Background: Workers compensation status is consistently cited as a predictor of poor outcome after orthopaedic procedures. This study analyzes a cohort of all workers compensation patients after surgical or non-operative treatment of clavicle fractures to identify factors that influence the time for return to work and total healthcare reimbursement claims, including a comparison of surgical and non-operative treatments. Operative treatment has been associated with faster time to boney union. We hypothesized that return to work for operative patients would be faster and the reimbursement claims for operative cases would be higher. Methods: The International Classification of Diseases, Ninth Revision, Clinical Modification (ICD9-CM) diagnosis codes and Current Procedural Terminology (CPT) codes were used to retrospectively query the Workers’ Compensation national database managed by University of Illinois, Chicago. Claims for clavicular fractures treated surgically and non-operatively were identified from 2003 to 2013. The outcomes of interest were the number of days for return to full work (RTW) following surgery and the total reimbursement for healthcare-related claims. The primary independent variable was treatment modality. Multivariate analysis was performed to control for relevant employee, employer and treatment covariates that were likely to confound associations. We used two-tailed hypothesis tests and P < .05 to indicate statistical significance. Averages are ± standard deviation. Results: There were 169 settled claims for clavicle fractures within the database. Only 20% (n = 34) of these claims related to surgical treatment, while 80% (n = 135) related to non-operative treatment. For claims with complete follow-up, the average time for RTW was 196 ± 287 days for surgical treatment, and 69 ± 94 days for non-operative treatment. The average healthcare claims reimbursed were $29,136 ± 26,998 for surgical management, compared to $8366 ± 14,758 for nonoperative treatment. From multivariate RTW analysis, we did not find a significant difference between non-operative and surgical treatment groups in their time to RTW (P = .06) Claims from workers with one or more dependents (Reference Group [RG]: No dependents), from the West (RG: Midwest), from injuries related to athletics/Police/ Firefighters (RG: Driving/flying/boating) were significant predicators of earlier RTW. Claims with a higher percentage of impairment, filing
J Shoulder Elbow Surg June 2016
of a legal suit, and incident report only claims (RG: Employer’s liability) were associated with later RTW. From multivariate reimbursement analysis, total healthcare reimbursement for claims with surgical treatment were 330% higher as compared to claims for non-operative treatment (P < .01). Claims with an associated legal suit, from working professionals (RG: Driving/Flying/Boating related injuries), from workers with at least 20 years of service (RG: < 10 years), and between 180 and 360 lost working days (RG: < 45 days) were predictors of higher healthcare claims. Injuries from pushing/pulling/lifting, and from falls (RG: Motor vehicle related injuries), and incident report only claims (RG: Employer’s liability) were significant predictors of lower healthcare claim amount. Conclusion: Contrary to our hypothesis, the patients treated under workers compensation status for clavicle fractures return to work at roughly the same time whether they are treated surgically or non-operatively, when controlling for relevant covariates. Workers compensation patients treated with surgery accumulate significantly higher healthcare claims than those treated without surgery. Although many variables that independently influence return to work timing and cumulative health care claims in this study are nonmodifiable, attempting to minimize legal suits may help expedite patients return to work. As the indications for operative treatment of clavicle fractures continues to be elucidated, non-operative treatment of fractures may help reduce overall financial burden in workers compensation patient population.
Paper #21 ARTHROSCOPIC VERSUS OPEN LATERAL RELEASE FOR THE TREATMENT OF LATERAL EPICONDYLITIS: A PROSPECTIVE RANDOMIZED CONTROLLED TRIAL
Peter B. MacDonald, MD, FRCSC, Tod Clark, MD, FRCSC, Sheila McRae, MSc, PhD, Jeff Leiter, MSc, PhD, Jamie Dubberley, MD, FRCSC, Pan Am Clinic, University of Manitoba, Winnipeg, Manitoba, Canada Purpose: The primary objective of this study was to determine if quality of life and function are different following arthroscopic versus open tennis elbow release surgery. Based on retrospective studies, both approaches have been found to be beneficial, but no prospective randomized comparison has been conducted to date. Method: Following a minimum six-months of conservative treatment, seventyone patients (>16 yrs old) were randomized intraoperatively to undergo either arthroscopic or open lateral release. Outcome measures were the Disabilities of the Arm, Shoulder and Hand questionnaire (DASH), a 5-question VAS Pain Scale, and grip strength. Study assessments took place pre-, and 6-week, 3-, 6-, and 12-months post-surgery. Comparisons between groups and within groups over time were conducted with P < .05. Results: Fifteen women and 19 men underwent the open procedure with a mean age of 47.1 years (6.7) and 13 women and 21 men were in the arthroscopic group with a mean age of 45.0 (6.9). No pre-surgery differences were found between groups based on age, sex, DASH or VAS scores. Both groups demonstrated a significant improvement in subjective measures and grip strength by 12-months post-surgery, and no significant differences were found between groups at any time point. The DASH, our primary outcome, decreased from a mean (SD) of 47.5 (14.5) pre-surgery to 21.9 (21.8) at 12-months post-surgery in the Open group and from 52.7 (16.0) to 22.6 (21.1) in the Arthroscopic group. VASpain scores (%) decreased in the Open group from 62.5 (17.2) preoperatively to 30.0 (26.5) at 12-months. In the arthroscopic group, scores decreased from 63.7 (15.9) to 26.2 (24.6). Grip strength (kg) increased on the affected side from 23.6 (14.9) to 29.3 (16.3) and 21.4 (15.4) to 29.8 (15.4) for Open and Arthroscopic groups, respectively. Conclusion: Based on this study, there is no difference in patient quality of life and function between arthroscopic and open tennis elbow release surgery at 12-months post-operative. Factors such as sex, age, smoking status, third party claims (WCB) may also influence patient outcome, but this study was not adequately powered to draw any statistical conclusions.