All-Arthroscopic Modified Rotator Interval Slide for Massive Anterosuperior Cuff Tears Using the Subdeltoid Space: Surgical Technique and Early Results

Background

Traditional intra-articular arthroscopic repair techniques for massive anterosuperior rotator cuff tears are technically demanding and necessitate sacrifice of the rotator interval to enable visualization. An interval slide allows mobilization through release of the medial aspect of the rotator interval, while leaving the lateral, bridging fibers intact.

Questions/Purposes

The purpose of this study was to report a novel, arthroscopic, open-equivalent technique using the subdeltoid space to address these tears along with early clinical results.

Methods

A retrospective review of prospectively collected data identified 11 consecutive arthroscopic massive anterosuperior rotator cuff repairs with a concomitant biceps tenodesis performed by the senior surgeon using a uniform technique. Outcome measures included range of motion, visual analog scale for pain, rotator cuff strength, American Shoulder and Elbow Surgeons (ASES) outcome scale, and Short Form-12 (SF-12).

Results

Average length of follow-up was 22.2 months (range 12.5–30.0 months). Visual analog scale (VAS) pain scores, ASES, and SF-12 all demonstrated significant improvement from pre-op to final follow-up from 6.2 to 0.9 (p?<?0.05), 27.4 to 82.8 (p?<?0.05), and 26.6 to 45.5 (p?<?0.05) respectively. Average forward flexion improved from 145° to 160° (p?<?0.05). Seven of the nine patients with a positive preoperative belly press had a negative test at final follow-up. Nine of the 10 patients with a positive lift off test demonstrated a negative test on final follow-up. Ninety-one percent reported they were satisfied with their outcome.

Conclusions

The described modified all-arthroscopic subdeltoid approach for anterosuperior cuff repairs enabled an open-equivalent interval slide technique that preserved the bridging lateral fibers of the rotator interval and demonstrated promising early-term clinical results.

     

Rehabilitation nach Rotatorenmanschettenrekonstruktion

Background

Tears and lesions of the rotator cuff are a frequent cause of shoulder pain and disability. Surgical repair of the rotator cuff is a valuable procedure to improve shoulder function and decrease pain. However, there is no consensus concerning the rehabilitation protocol following surgery.

Objectives

To review and evaluate current rehabilitation contents and protocols after rotator cuff repair by reviewing the existing scientific literature and providing an overview of the clinical practice of selected German Society of Shoulder and Elbow Surgery e.V. (DVSE) shoulder experts.

Materials and methods

A literature search for the years 2004–2014 was conducted in relevant databases and bibliographies including the Guidelines International Network, National Guidelines, PubMed, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and the Physiotherapy Evidence Database. In addition, 63 DVSE experts were contacted via an online questionnaire.

Results

A total of 17 studies, four reviews, and one guideline fulfilled the inclusion criteria. Based on these results and the obtained expert opinions, a four-phase rehabilitation protocol could be developed.

     

A Systematic Review of Preoperative Fatty Infiltration and Rotator Cuff Outcomes

Background

Fatty infiltration (FI) of the muscle as graded by the Goutallier classification (GC) is a well-known sequela following rotator cuff injury. The degree to which this predicts the success of rotator cuff repair is unknown.

Questions/Purposes

We conducted a systematic review to address the following questions: (1) Does the grade of FI of the rotator cuff muscles present preoperatively predict retear rates postoperatively? (2) Are amounts of preoperative FI predictive of functional outcomes following repair?

Methods

Medline, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and the Cochrane Central Register of Controlled Trials online databases were searched for all literature published between January 1966 and March 2015. Keywords were chosen to achieve a broad search category. All articles were reviewed by three of the authors, and those meeting the study inclusion criteria were selected for data abstraction.

Results

The systematic literature review yielded 11 studies reporting on a total of 925 shoulders. Rotator cuffs with moderate or significant FI preoperatively (grades 2–4) had a significantly higher retear rate than those with no or minimal FI (grades 0–1) (59 vs. 25%, p?=?0.045). Four studies reported postoperative Constant scores and preoperative GC scores. One study found that lower GC scores were associated with higher Constant scores postoperatively, one found no association, and the data was inconclusive in the other two.

Conclusions

While lower preoperative GC scores are associated with lower rates of rotator cuff retear following repair, there is insufficient data to make conclusions on the effects of FI on functional outcomes following repair.

     

Offene Double-row-Rotatorenmanschettenrekonstruktion mit der LASA-DR-Screw

Objective

Safe and cost-effective rotator-cuff repair.

Indication

All types of rotator cuff lesions.

Contraindications

Frozen shoulder, rotator cuff mass defect, defect arthropathy.

Surgical technique

Extensive four-point fixation on the bony footprint is performed using the double-row lateral augmentation screw anchor (LASA-DR) with high biomechanical stability. Following mobilization of the tendons, these are refixed in the desired configuration first medially and then laterally. To this end, two drilling channels (footprint and lateral tubercle) are created for each screw. Using the shuttle technique, a suture anchor screw is reinforced with up to four pairs of threads. The medial row is then pierced and tied, and the sutures that have been left long are tied laterally around the screw heads (double row).

Postoperative management

4 Weeks abduction pillow, resulting in passive physiotherapy, followed by initiation of active assisted physiotherapy. Full weight-bearing after 4–6 months.

Results

Prospective analysis of 35 consecutive Bateman-III lesions with excellent results and low rerupture rate (6?%).

     

A Comparison of Two Arthroscopic Techniques for Interpositional Polytetrafluoroethylene Patch Repair for Massive Irreparable Rotator Cuff Tears: Speed and Biomechanics

Background

Interpositional synthetic patch repairs are a novel method of treating massive irreparable rotator cuff tears. However, surgeons experience difficulty in the arthroscopic insertion of these patches.

Questions/Purposes

We compared two methods of arthroscopic interpositional synthetic patch repair: the newly devised slide-and-grip technique, using pre-loaded sliding knots and no arthroscopic knots, and the weave technique, using less arthroscopic knot tying than the earlier mattress technique. Study questions were as follows: (1) Would the slide-and-grip technique take less time than the weave technique? (2) Would the biomechanical strength of the two methods be comparable?

Methods

Fourteen paired ovine infraspinatus tendon ex vivo models of the degenerative human rotator cuff underwent timed repair with a synthetic polytetrafluoroethylene (PTFE) patch, using either the weave technique (n?=?7) or the slide-and-grip technique (n?=?7). Each was pulled to failure using a tensile testing machine, the Instron 8874.

Results

The time to complete the slide-and-grip repairs was shorter (12?±?0.9 min) than that of the weave repairs (23?±?1 min). Ultimate load to failure was comparable for the slide-and-grip and weave techniques (211?±?27 N vs. 295?±?35 N, respectively), and the slide-and-grip was less stiff (14?±?1 N/mm vs. 19?±?1 N/mm).

Conclusions

The slide-and-grip technique took less time than the weave technique for the interpositional patch repair of massive irreparable rotator cuff tears and when correctly performed had comparable biomechanical strength.

     

Arthroskopische subakromiale Dekompression

Objective

Coracoacromial ligament release to widen the subacromial space, resection of the anterior undersurface of the acromion and, if needed, caudal exophytes at the acromioclavicular joint.

Indications

All types of outlet impingement after 3 months of conservative treatment.

Contraindications

Impingement syndrome with instability/muscular imbalance, massive rotator cuff tear, unstable os acromionale, posterior–superior impingement, joint infection, freezing phase of a secondary frozen shoulder.

Surgical technique

Lateral decubitus position with traction device for the arm. Diagnostic arthroscopy of the glenohumeral joint via standard portals. With arthroscope moved to the subacromial space, bursectomy, electrosurgical release of coracoacromial ligament, resection of acromial hook through standard posterior portal.

Postoperative management

Physiotherapy or self-exercises on postoperative day 1, pain-adapted analgesia to avoid shoulder stiffness.

Results

Several studies present positive long-term results compared to conservative treatment (and open acromioplasty) for partial rotator cuff tears and for elderly patients. With a 20-year follow-up, successful results have been achieved for all patients with isolated impingement syndrome.

     

Predictors of disease-specific quality of life after arthroscopic rotator cuff repair

Purpose

Disease-specific instruments of quality of life (QOL) are more sensitive to disease-specific changes. The purpose of this study is to identify prognostic factors for disease-specific QOL after all-arthroscopic rotator cuff (RC) repair using the Western Ontario Rotator Cuff Index (WORC).

Methods

A total of 140 patients were evaluated after an RC repair with a mean follow-up of 22?±?6.7 months. Evaluations included the WORC, EQ-5D and anchor questions. Preoperative patient demographics and radiologic characteristics were assessed to identify predictors of disease-specific QOL.

Results

Most patients (81.4 %) were satisfied with their surgical result. Minor tear retraction (odds ratio [OR] 2.97, p?=?0.030), male gender (OR 3.67, p?=?0.003), no social benefits (OR 3.67, p?=?0.042) and pre-surgical complaints for more than six months (OR 3.03, p?=?0.021) were independent predictors for superior postoperative WORC score in multivariable analysis. None of these factors were predictive for a higher EQ-5D score.

Conclusion

These findings highlight the important impact of retraction on QOL after RC repair and underline the utility of disease-specific instruments. Future studies should focus on how these significant predictors can be used to improve decision making and to develop new treatment approaches.

     

Effects of Abduction Pillows on Rotator Cuff Repair: A Biomechanical Analysis

Background

After rotator cuff repair, some surgeons use abduction pillows to unload or protect the repair construct, while others do not.

Question/Purpose

The aim of this study was to determine which type of sling—one with a small or large abduction pillow or one without a pillow—places the repaired rotator cuff in the best position to reduce tension on the supraspinatus.

Methods

An X-ray study was performed on asymptomatic subjects to determine what position the shoulder is placed in when wearing a sling with or without an abduction pillow. Positions were then reproduced in human cadaveric shoulders using a custom-made testing jig, and tension on the repaired supraspinatus was measured.

Results

X-rays showed that abduction of the glenohumeral joint with a sling was only 4°, with a sling with a small pillow was 13°, and with a sling with a large abduction pillow was 25°. Placing the cadaveric shoulders in the position of a sling with a small abduction pillow caused a reduction in tension on the supraspinatus of 27% anteriorly and 55% posteriorly compared to placing the shoulder in the position of a sling without an abduction pillow; a large abduction pillow caused a further reduction in tension, of 42% anteriorly and 56% posteriorly.

Conclusion

These findings show that abduction pillows reduce tension on the repaired supraspinatus tendon.

     

Rotatorenmanschettenheilung

Background

Rotator cuff tears are associated with significant shoulder dysfunction and pain. Despite conservative management, many patients persistently have decreased quality of life warranting surgical repair as a more appropriate treatment option. Using new arthroscopic methods, a wider range of rotator cuff tears can be reconstructed using minimally invasive techniques.

Methods

Biomechanical studies which focus on the repair or reconstruction of the rotator cuff in order to restore function have been published. However, the re-tear rate remains high. This is partially due to the complexity of tendon regeneration, which is largely described as a three-stage process consisting of inflammation, followed by reparation, and finally a remodeling phase. Despite investigation of the biological principles in tendon healing, the mechanism is not yet completely understood. The ability to recreate a native enthesis between tendon and bone after rotator cuff repair is the ideal treatment goal. In addition to surgical treatment, postoperative rehabilitation is also critical to achieve full shoulder function. The appropriate time to start rehabilitation and passive motion is still controversial. To begin immediately may lead to an improvement in range of motion as well as enhanced collagen synthesis by stimulating fibroblasts, while, initiating rehabilitation too soon could risk re-tear or result in inferior healing of the tendon.

Conclusion

Biological augmentation may be an option to improve the healing process, therefore, allowing more rapid rehabilitation without compromising the repair. This article provides an overview of tendon healing principles as well as presumed enthesis stability during the healing process.

     

Strength recovery after arthroscopic anterosuperior cuff repair: analysis of a consecutive series

Purpose

The purpose of this study was to look at the functional outcomes of arthroscopic repair of anterosuperior rotator cuff tears.

Methods

Sixty-one patients who underwent arthroscopic repair of anterosuperior cuff tears were retrospectively reviewed. At a minimum 6 months of follow-up, shoulder functional outcome scores including the Constant score (CS), simple shoulder test (SST) and visual analogic scale (VAS) were collected. Strength recovery for supraspinatus and subscapularis was investigated.

Results

All patients (mean age 59 ± 7) were available at a mean follow-up of 18 ± 7 months. The average CS improved from 30.8 ± 10.2 preoperatively to 76.5 ± 12.0 postoperatively, average SST from 2.6 ± 2.0 to 8.8 ± 2.9 and average VAS pain scale from 3.8 ± 1 to 0.5 ± 0.5 (p < 0.0001). Strength at belly-press and Jobe tests significantly improved (p < 0.0001). All patients with the exception of one were satisfied with the intervention.

Conclusions

Arthroscopic repair of anterosuperior rotator cuff tears provides a significant improvement in pain relief and shoulder function. Strength recovery is demonstrated in medium correlation with tendon healing.

Level of evidence

Level IV, therapeutic case series.

     

Prevalence of subscapularis tears and accuracy of shoulder ultrasound in pre-operative diagnosis

Purpose

Subscapularis tears can be difficult to diagnose and their treatment requires advanced arthroscopic skills. The objective of this study was to find the prevalence of subscapularis tears on arthroscopic examination of shoulders with rotator cuff pathology and to determine the accuracy of pre-operative ultrasound in diagnosing these tears.

Method

Ultrasound and intra-operative reports of 236 patients who underwent shoulder arthroscopy for rotator cuff pathology by the senior author at his institution were compared. Prevalence of subscapularis tear was noted and classified using Lafosse classification system. Ultrasound reports and intra-operative findings were compared to determine the accuracy, sensitivity and specificity of ultrasound in detecting subscapularis tears.

Results

The prevalence of subscapularis tears in patients needing rotator cuff repair was found to be 31.4 %. A total of 6.4 % of patients needing a rotator cuff repair had an isolated subscapularis tear. The sensitivity of ultrasound was 39.5 % and specificity 93.1 % in detection of these tears. The overall accuracy of ultrasound was 75.8 %. Sensitivity of ultrasound was low (42.8 %) for smaller (type 1 and 2) tears and higher (79 %) for larger (types 3, 4, 5) tears. The overall positive predictive value of USS was 73.1 % and negative predictive value 76.4 %.

Conclusion

The shoulder surgeon should be skilled in diagnosing and repairing subscapularis tendon tears arthroscopically and cannot completely rely on pre-operative ultrasound scans in ruling out smaller tears as its sensitivity in diagnosing smaller tears is quite low. Unsettling anterior shoulder pain with a normal ultrasound may need further arthroscopic evaluation to rule out missed subscapularis tears.

     

Lesions of the rotator cuff footprint: diagnostic performance of MR arthrography compared with arthroscopy

Background

To evaluate the diagnostic performance of magnetic resonance arthrography (MR-A) of the shoulder in the diagnosis of rotator cuff tears involving the humeral insertion of the supraspinatus and infraspinatus tendon (footprint), using arthroscopy as the reference standard.

Materials and methods

The study population included 90 consecutive patients with history and clinical diagnosis of instability of the shoulder, rotator cuff tear or posterosuperior glenoid impingement. A total of 108 MR arthrograms were performed, since 18 patients had undergone a bilateral procedure. Arthroscopy, which was performed within 45 days after MR-A, was used as the reference standard. Sensitivity, specificity, accuracy, positive and negative predictive values were then calculated.

Results

Magnetic resonance arthrography showed a sensitivity of 92 % and a specificity of 78 % for the overall detection of tears involving the rotator cuff footprint. The diagnostic accuracy was 90 %, and the positive and negative predictive values were 95 and 64 %, respectively. Ten lesions were non-classifiable on surgery, of which eight were non-classifiable on MR-A also.

Conclusions

Magnetic resonance arthrography is extremely accurate for the detection and classification of rotator cuff footprint tears. Most of these lesions are articular-sided (partial articular-sided supraspinatus tendon avulsion lesions) with predominance in younger patients and concealed type of tear (concealed interstitial delamination lesions).

     

Do functional outcomes and cuff integrity correlate after single- versus double-row rotator cuff repair? A systematic review and meta-analysis study

Purpose

The purpose of this study is to perform a systematic review and meta-analysis of all available level I prospective randomized controlled trials comparing arthroscopic single-row (SR) with double-row (DR) rotator cuff repairs by both clinical outcomes and radiological re-tear rates.

Methods

PubMed, EMBASE, Google Scholar, and Cochrane databases search was done for level I RCTs comparing clinical and radiological outcomes after SR versus DR rotator cuff repair. Clinical outcomes included UCLA, ASES, Constant, WORC, and SANE scores; structural outcomes included MRI, MRA, or US.

Results

Seven level I studies were included (5 mid-term and 2 short-term). Postoperative ASES, Constant, WORC, and SANE scores showed nonsignificant slightly better function of DR groups. Only, UCLA score showed significantly better scores with DR repair (p = 0.007). Full-thickness re-tear incidence was reported in 15/174 (8.6%) in DR group and 20/175 (11.4%) in SR group (p = 0.44). Partial-thickness re-tear rate was reported in 18/174 patients (10.3%) in DR group and 41/175 patients (23.4%) in SR group (p = 0.009).

Conclusion

Within the domain of level I mid-term and short-term studies, DR repair showed significant better UCLA score only. (ASES, Constant, WORC, and SANE scores showed no significance.) This may correlate weakly with the significant lower partial-thickness re-tear rates of DR repairs. In contrary, long-term level III studies showed a direct correlation of both functional outcomes and cuff structural integrity, with significant superiority of DR over SR repair techniques.

Level of evidence

Level 1, systematic review and meta-analysis.

     

Why a surgically treated humeral shaft fracture became a nonunion: review of 11 years in two trauma centers

Purpose

To report the outcomes and complications of reverse shoulder arthroplasty (RSA) in massive irreparable rotator cuff tears (MIRCT) and cuff tear arthropathy (CTA).

Methods

A systematic review of the literature contained in Medline, Cochrane, EMBASE, Google Scholar and Ovid databases was conducted on May 1, 2016, according to PRISMA guidelines. The key words “reverse total shoulder arthroplasty” or “reverse total shoulder prostheses” with “rotator cuff tears”; “failed rotator cuff surgery”; “massive rotator cuff tears”; “irreparable rotator cuff tears”; “cuff tear arthropathy”; “outcomes”; “complications” were matched. All articles reporting outcomes and complications of RSA for the management of MIRCT or CTA were included. The comparison between preoperative and postoperative clinical scores, as well as range of motion (ROM), was performed using the Wilcoxon–Mann–Whitney test. P values lower than 0.05 were considered statistically significant.

Results

Seven articles were included in our qualitative synthesis. A statistically significant improvement in all clinical scores and ROM was found comparing the preoperative value with the postoperative value. The degrees of retroversion of the humeral stem of the RSA do not influence the functional outcomes in a statistically significant fashion. There were 17.4% of complications. The most frequent was heterotopic ossification, occurring in 6.6% of patients. Revision surgery was necessary in 7.3% of patients.

Conclusions

RSA restores pain-free ROM and improves function of the shoulder in patients with MIRCT or CTA. However, complications occur in a high percentage of patients. The lack of level I studies limits the real understanding of the potentials and limitations of RSA for the management of MIRCT and CTA.

     

The experience of the RIPO,a shoulder prosthesis registry with 6-year follow-up

Background

Implant registries have proved valuable in assessing the outcomes of arthroplasty procedures. Moreover, by identifying lesser quality implants they have indirectly improved the quality of care. The registry of prosthetic shoulder implants was established in 2008.

Methods

It records information on all types of primary and revision arthroplasty procedures involving the glenohumeral joint, including reverse and total arthroplasty, hemiarthroplasty, resurfacing, removal, and any other surgical procedures that are required to manage these patients. The collected data include patient demographics, weight, height, operated side, cuff status, and diagnosis/reason for revision surgery, information on previous surgical procedures involving either shoulder, comorbidities, antibiotic and thromboembolic prophylaxis, blood transfusions, surgical approach, cuff repair procedures performed during arthroplasty, bone grafts, drains, and perioperative complications, and data about the prosthetic components implanted, including the fixation method.

Results

Procedures were performed on 3754 shoulders. They included 2226 RSA, 320 TSA, 730 HA, 233 resurfacing procedures, 245 revisions, and 77 “other” procedures. The survival curves of the implants are greater than 90%, and no differences were found among prosthesis from different manufacturers. The diagnosis that prompted to arthroplasty was: osteoarthritis in 60.9% of cases and fractures, bone necrosis, sequelae of fracture and rotator cuff tear arthropathy for the rest of implants.

Discussion and conclusion

This study describes the epidemiological data and mid-term implant outcomes of the shoulder arthroplasty procedures performed in our region, from 2008 to 2014, and compares them with published data from national registries of similar size.

Level of evidence

III.

     

Stromal vascular stem cell treatment decreases muscle fibrosis following chronic rotator cuff tear

Purpose

Rotator cuff injuries are associated with atrophy and fat infiltration into the muscle, commonly referred to as “fatty degeneration.” As the poor function of chronically torn muscles may limit recovery after surgical repair, there is considerable interest in finding therapies to enhance muscle regeneration. Stromal vascular fraction stem cells (SVFCs) can improve muscle regeneration in other chronic injury states, and our objective was to evaluate the ability of SVFCs to reduce fibrosis and fat accumulation, and enhance muscle fibre specific force production after chronic rotator cuff tear.

Methods

Chronic supraspinatus tears were induced in adult immunodeficient rats, and repaired one month following tear. Rats received vehicle control, or injections of 3?×?10⁵ or 3?×?10⁶ human SVFCs into supraspinatus muscles.

Results

Two weeks following repair, we detected donor human DNA and protein in SVFC treated muscles. There was a 40 % reduction in fibrosis in the treated groups compared to controls (p?=?0.03 for 3?×?10⁵, p?=?0.04 for 3?×?10⁶), and no differences between groups for lipid content or force production were observed.

Conclusions

As there has been much interest in the use of stem cell-based therapies in musculoskeletal regenerative medicine, the reduction in fibrosis and trend towards an improvement in single fiber contractility suggest that SVFCs may be beneficial to enhance the treatment and recovery of patients with chronic rotator cuff tears.

     

Does a brace influence clinical outcomes after arthroscopic rotator cuff repair?

Purpose

The goal of this study was to report the clinical effects of two different braces after rotator cuff repair.

Methods

Forty patients who underwent an arthroscopic rotator cuff repair were prospectively allocated in this study. Twenty patients were immobilized in 15° external rotation brace (ER Group), and twenty were immobilised in an internal rotation sling (IR Group). For all patients, four surveys were done: in the immediate pre-operative period (T0), at 1 month (T1), at 3 months (T2) and at 6 months after surgery (T3). Range of motion and pain were evaluated by an independent physician. Self-Assessment Scales [(University California Los Angeles Shoulder Rating Scale (UCLA), Disability of the Arm Shoulder and Hand (DASH), Visual Analog Scale (VAS), Simple Shoulder Test (SST) and Physician Assessment Scale (Constant)] were also administered.

Results

Abduction and ER2 (external rotation with arm in abduction) were significantly greater in the ER group at T1, T2 and T3, ER1 (external rotation with arm at side) was significantly greater in the ER group at T1 and T2, IR2 (internal rotation) was significantly greater in the ER group at T1, and FFL (forward flexion) was significantly greater in the ER group at T1. VAS was significantly lower in the ER group at T1 and T2 and T3. About the Self-Assessment Shoulder Scales after 3 and 6 months, no differences were found. SST showed a lesser functional limitation for the ER group at T3.

Conclusions

Patients operated with isolated superior or posterosuperior rotator cuff tear immobilised with brace in 15° of ER position showed less pain and a better passive range of motion at short time after surgery.

     

Operative Behandlung der ulnaren Seitenbandläsion am Daumengrundgelenk

Objective

Reconstruction of the ruptured ulnar collateral ligament of the metacarpophalangeal (MP) joint of the thumb.

Indications

Ruptured ulnar collateral ligament of the thumb MP joint with instability: joint opening of more than 30° in flexion and more than 20° in extension, Stener lesion, displaced avulsion fractures.

Contraindications

Abrasions, wound-healing disturbance, skin disease, osteoarthritis.

Surgical technique

Curved skin incision dorsoulnar above the thumb MP joint. Protection of the branches of the superficial radial nerve. Incision of the adductor aponeurosis. Exposing the ulnar collateral ligament; opening and examination of the joint. Depending on the injury, primary suture repair, transosseous suture, repair with a bone anchor, osteosynthesis with K-wires or small screws in avulsion fracture, ligament reconstruction in chronic instability or older injury.

Postoperative treatment

Cast splint of the MP joint until swelling subsides; cast immobilization for 6 weeks; range-of-motion exercises, avoiding forced radial deviation of the MP joint for 3 months.

Results

Complete joint stability 3 months postoperatively in all 34 patients with rupture of the ulnar collateral ligament.