Orthopedics Commons^™

Short-Term Outcomes Of Lower Trapezius Tendon Transfer With Achilles Allograft For Irreparable Posterosuperior Rotator Cuff Tears., Michael A. Stone, Liam T. Kane, Jason C. Ho, Surena Namdari

Rothman Institute Papers

Purpose: To evaluate functional outcomes, return to work, and reoperations associated with lower trapezius tendon transfer (LTT) for irreparable rotator cuff tears.

Methods: This is a retrospective study performed by a single surgeon with minimum 1-year follow-up. LTT was performed using an open (n = 9; 60%) or arthroscopically assisted (n = 6, 40%) technique. Outcomes included failure rate, range of motion, satisfaction, return to work, and pre- and postoperative functional scores, as well as American Shoulder and Elbow Surgeons score, Single Assessment Numeric Evaluation, and the Simple Shoulder Test.

Results: Fifteen patients were included. LTT was performed using an …

Plasma Flow Distal To Tourniquet Placement Provides A Physiological Mechanism For Tissue Salvage, Emily Busse, Cheryl Hickey, Nicole Vasilakos, Kennon Stewart, Fred O’Brien, Jessica Rivera, Luis Marrero, Michelle Lacey, Rebecca Schroll, Keith Van Meter, Mimi C. Sammarco

School of Medicine Faculty Publications

Military literature has demonstrated the utility and safety of tourniquets in preventing mortality for some time, paving the way for increased use of tourniquets in civilian settings, including perioperatively to provide a bloodless surgical field. However, tourniquet use is not without risk and the subsequent effects of tissue ischemia can impede downstream rehabilitative efforts to regenerate and salvage nerve, muscle, tissue and bone in the limb. Limb ischemia studies in both the mouse and pig models have indicated not only that there is residual flow past the tourniquet by means of microcirculation, but also that recovery from tissue ischemia is …

Outcomes Of Chronic Distal Biceps Reconstruction With Tendon Grafting: A Matched Comparison With Primary Repair., Benjamin A. Hendy, Eric M. Padegimas, Thomas Harper, Mark D Lazarus, Joseph A Abboud, Surena Namdari, John Horneff Iii, Md

Rothman Institute Papers

Background: The purpose of this analysis was to analyze outcomes of distal biceps reconstruction with soft tissue allograft in the setting of chronic, irreparable distal biceps ruptures. The outcomes of these cases were then compared with a matched cohort of distal biceps ruptures that were able to be repaired primarily.

Methods: Retrospective review of an institutional elbow surgery database was conducted. All cases of distal biceps repairs were identified by Common Procedural Terminology, ICD-9, and ICD-10 codes from January 2009 to March 2018. A direct review of operative reports was then conducted to identify which cases required allograft reconstruction. After …

Hips That Harm: When Medical Devices Fail Women, Sophie N. Putka

Capstones

Medical devices that save the lives of thousands of Americans each year advance at a rapid pace - but some of them consistently leave women behind. When it comes to joint replacements and even heart devices, women have worse health outcomes. Behind this preventable problem is a system that overlooks women from start to finish. Female bodies are different from male bodies, but women are often underrepresented in medical trials for device approval. Women’s participation in clinical testing for devices has increased, but there’s rarely a detailed analysis of performance by sex, and even less information on women by race …

Local Injections Of Β-Ngf Accelerates Endochondral Fracture Repair By Promoting Cartilage To Bone Conversion., Kevin O. Rivera, Fabrizio Russo, Ryan M. Boileau, Ryan E. Tomlinson, Theodore Miclau, Ralph S. Marcucio, Tejal A. Desai, Chelsea S. Bahney

Department of Orthopaedic Surgery Faculty Papers

There are currently no pharmacological approaches in fracture healing designed to therapeutically stimulate endochondral ossification. In this study, we test nerve growth factor (NGF) as an understudied therapeutic for fracture repair. We first characterized endogenous expression of Ngf and its receptor tropomyosin receptor kinase A (TrkA) during tibial fracture repair, finding that they peak during the cartilaginous phase. We then tested two injection regimens and found that local β-NGF injections during the endochondral/cartilaginous phase promoted osteogenic marker expression. Gene expression data from β-NGF stimulated cartilage callus explants show a promotion in markers associated with endochondral ossification such as Ihh, Alpl, …

Does Early Surgery Prevent Postoperative Icu Admission After Surgery For The Fracture Of The Hip. Nested Case Control Study Of 911 Patients, Obada Hasan, Laraib Mazhar, Umar Rabbani, Amna Rabbani, Fatima Mahmood, Shahryar Noordin

Department of Medicine

Introduction: Since most hip fractures are treated surgically, it is imperative to find an optimum fracture-to-surgery time to decrease the potential complications and enhance postoperative outcomes. In comparison to the vast plethora of literature available on surgical delay and its implications on mortality, very little, if any, research is available on the impact of delayed surgery on postoperative ICU admission. The primary objective of our study is to examine the factors influencing post-surgical ICU admission in order to work on preventive strategies to reduce the potential associated morbidity.
Material and methods: Investigators did a nested case control study in a …

Return-To-Play Guidelines After Patellar Instability Surgery Requiring Bony Realignment: A Systematic Review., Rishi Chatterji, Alex E. White, Christopher J. Hadley, Steven B. Cohen, Kevin B. Freedman, Christopher C. Dodson

Rothman Institute Papers

Background: Recurrent patellar instability can be treated nonoperatively or surgically, and surgical management may vary based on the causative pathology in the structures surrounding the patella. Although isolated soft tissue reconstruction is among the most common operative treatments, certain patient populations require bony realignment for adequate stabilization.

Purpose: To evaluate postoperative guidelines, including return to play and rehabilitation, after bony procedures involving the tibial tubercle for patellar instability.

Study Design: Systematic review; Level of evidence, 4.

Methods: A systematic review on return-to-play guidelines was conducted with studies published from 1997 to 2019 that detailed procedures involving bony realignment by tibial …

A Comparison Of 4-Year Total Medical Care Costs, Adverse Outcomes, And Opioid/Prescription Analgesic Use For 3 Knee Osteoarthritis Pain Treatments: Intra-Articular Hyaluronic Acid, Intra-Articular Corticosteroids, And Knee Arthroplasty., John Mackowiak, John T Jones, Vinod Dasa

School of Medicine Faculty Publications

To compare the medical costs associated with treatments for knee osteoarthritis (OA): intra-articular corticosteroids (ICS) and intra-articular hyaluronic acid (IHA) primarily, and ICS/IHA vs knee arthroplasty (TKA) secondarily. This was a retrospective analysis of an insurance claims database. Eligible members had diagnosed OA and no claims for ICS, IHA, or TKA during the 6–18-month look-back period. Cohorts of interest over the 4-year observation period were: patients who received ICS only, those who received IHA only, and those who received TKA only. Outcomes assessed included: (1) total allowed medical costs, (2) claims for pre-specified, treatment-related adverse outcomes and costs, and (3) …

Three Decades Of Research On Recombinant Collagens: Reinventing The Wheel Or Developing New Biomedical Products?, Andrzej Fertala

Department of Orthopaedic Surgery Faculty Papers

Collagens provide the building blocks for diverse tissues and organs. Furthermore, these proteins act as signaling molecules that control cell behavior during organ development, growth, and repair. Their long half-life, mechanical strength, ability to assemble into fibrils and networks, biocompatibility, and abundance from readily available discarded animal tissues make collagens an attractive material in biomedicine, drug and food industries, and cosmetic products. About three decades ago, pioneering experiments led to recombinant human collagens' expression, thereby initiating studies on the potential use of these proteins as substitutes for the animal-derived collagens. Since then, scientists have utilized various systems to produce native-like …

Salvage Of Failed Femoral Neck Fracture Fixation With Conversion Total Hip Arthroplasty Using The Direct Anterior Approach., Andrew G Yun, Marilena Qutami, Kory B Dylan Pasko

Articles, Abstracts, and Reports

Purpose: Failed femoral neck fracture (FNF) fixation with

Materials and Methods: Medical records for 42 patients with a prior history of FNF fixation who underwent conversion THA with hardware removal between 2009 and 2019 were retrospectively reviewed. Surgery was performed by a single surgeon at a single institution. All patients underwent hardware removal followed by direct anterior approach (DAA) THA using two separate incisions. Clinical outcomes, radiographic findings, and perioperative morbidity and mortality are reported.

Results: Clinically, there were no postoperative dislocations, periprosthetic fractures, or infections at follow-up. After a mean follow-up of 4 years, the mean hip disability and …

Conversion From Knee Arthrodesis Back To Arthroplasty: A Particular Challenge In Combination With Fungal Periprosthetic Joint Infection., Sven Frieler, Emre Yilmaz, Ryan Goodmanson, Yannik Hanusrichter, Thomas A Schildhauer, Hinnerk Baecker

Articles, Abstracts, and Reports

A 58-year-old female treated at an outside facility with knee arthrodesis due to persistent periprosthetic joint infection fulfilled all prerequisites for a conversion back to arthroplasty, as part of a 2-stage revision. Owing to the detection of Candida parapsilosis, the treatment concept was converted to a three-stage procedure. A scheduled spacer exchange with additional amphotericin B-loaded polymethylmethacrylate was conducted as an intermediate revision before reimplantation. Conversion in the setting of fungal periprosthetic joint infection presents a challenge, and successful treatment hinges on the use of proper antifungal and antimicrobial protocols, advanced surgical techniques, and a multidisciplinary team approach. At …

Clinical Outcomes Of Superior Capsular Reconstruction For Massive, Irreparable Rotator Cuff Tears: A Systematic Review Comparing Acellular Dermal Allograft And Autograft Fascia Lata, Tyler J. Smith, Anirudh K. Gowd, John Kunkel, Lisa Kaplin, John B. Hubbard, Kevin E. Coates, Benjamin R. Graves, Brian R. Waterman

Orthopedic Surgery Resident Research

Purpose: To investigate clinical outcomes after superior capsular reconstruction (SCR) for the treatment of massive and/or irreparable rotator cuff tears treated with either allograft or autograft. Methods: Using the Preferred Reporting Items for Systematic Reviews and Meta Analyses (PRISMA) guidelines, in April 2020 a systematic review was performed using PubMed, MEDLINE, EMBASE, and Cochrane databases. Clinical studies were assessed for patient-reported outcomes and range of motion, comparing dermal allografts to fascia lata autografts, with a minimum follow-up of 12 months. Results: A total of 16 clinical studies involving 598 patients (606 shoulders) were included for data analysis, with a weighted …

Risk Factors Associated With Infection In Open Fractures Of The Upper And Lower Extremities, Paul Tornetta, Gregory J. Della Rocca, Saam Morshed, Clifford Jones, Diane Heels-Ansdell, Sheila Sprague, Brad Petrisor, Kyle J. Jeray, Gina Del Fabbro, Sofia Bzovsky, Mohit Bhandari, Gordon H. Guyatt, Stephen D. Walter, Emil H. Schemitsch, Jeffrey Anglen, Michael Bosse, Susan Liew, Parag Sancheti, Paula Mckay, Kim Madden, Kerry Tai, Lisa Buckingham, Aravin Duraikannan, Stephanie L. Tanner, Rebecca G. Snider, Douglas Altman, Rajiv Gandhi, Markus Bischoff, Bill Ristevski, Krishan Rajaratnam, Dale Williams, Flow Investigators

Orthopaedic Surgery Faculty Publications

Introduction: Open fractures are associated with a high risk of infection. The prevention of infection is the single most important goal, influencing perioperative care of patients with open fractures. Using data from 2,500 participants with open fracture wounds enrolled in the Fluid Lavage of Open Wounds trial, we conducted a multivariable analysis to determine the factors that are associated with infections 12 months postfracture. Methods: Eighteen predictor variables were identified for infection a priori from baseline data, fracture characteristics, and surgical data from the Fluid Lavage of Open Wounds trial. Twelve predictor variables were identified for deep infection, which included …

Covid-19 Pandemic: Economic Burden On Patients With Musculoskeletal Injuries In A Tertiary Care Hospital Of Lmic; Retrospective Cross Sectional Study, Pervaiz Hashmi, Shah Fahad, Hammad Naqi Khan, Marij Zahid, Anum Sadruddin Pidani, Shahryar Noordin

Section of Orthopaedic Surgery

Covid-19 has adversely impacted the health care organizations by over burdening with Covid patients and suspending the elective surgeries and clinics. Hospitalization during pandemic may increase health cost of patients for elective and emergency procedure due to extra cost of covid testing and isolation. A single center retrospective study was conducted to quantify losses due to postponement of elective surgeries and extra cost for procurement of PPEs. The secondary objective was to see the effect of Covid -19 on the total costs of inpatient care during Covid era.
Patient and method: We included all the patients admitted in orthopedic section …

Change In The Spectrum Of Orthopedic Trauma: Effects Of Covid-19 Pandemic In A Developing Nation During The Upsurge; A Cross-Sectional Study, Pervaiz Mahmood Hashmi, Marij Zahid, Syed Arif Ali, Hammad Naqi Khan, Anum Sadruddin Pidani, Alizah Pervaiz Hashmi, Shahryar Noordin

Section of Orthopaedic Surgery

Background: The COVID-19 pandemic has caused a great impact on orthopedic surgery with a significant curtailment in elective surgeries which is the major bread and butter for orthopedic surgeons. It was also observed that the spectrum of orthopedic trauma injuries has shifted from more severe and frequent road traffic accidents (high energy trauma) to general, low energy house-hold injuries like low energy fractures in the elderly, pediatric fractures, house-hold sharp cut injuries and nail bed lacerations. The aim of this study is to appraise the effect of the COVID-19 pandemic on orthopedic surgical practice, both inpatient and outpatient facility.
Materials …

Spinal Cord Injury Provider Knowledge And Attitudes Toward Bacteriuria Management And Antibiotic Stewardship, Felicia Skelton, Sarah May, Larissa Grigoryan, Ivy Poon, Sally Ann Holmes, Lindsey Martin, Barbara W Trautner

Faculty, Staff and Students Publications

INTRODUCTION: Bacteriuria, either asymptomatic or urinary tract infection, is common in persons with spinal cord injury or disorder (SCI/D). In the Veterans Health Administration (VHA), conflicting clinical practice guidelines make appropriate bacteriuria management and antibiotic stewardship challenging.

OBJECTIVE: To explore SCI/D provider knowledge, attitudes, and teamwork around bacteriuria management during the VHA SCI/D annual examination.

DESIGN: Mixed methods.

SETTING: VHA SCI/D centers.

PARTICIPANTS: SCI/D staff providers and physical medicine and rehabilitation resident physicians.

MAIN OUTCOME MEASUREMENTS: Knowledge, safety, and teamwork scores on bacteriuria management using a validated questionnaire. Themes on barriers and facilitators to bacteriuria management during the SCI/D annual …

Towards Pragmatic Adaptations: Orthopedic Surgery Amidst The Coronavirus Disease 2019 Pandemic, Maryam Ehtesham, Talal Almas, Muhammad Ali Niaz, Absam Akbar

Medical College Documents

No abstract provided.

Mycobacterium Fortuitum And Mycobacterium Abscessus Infections In The Foot And Ankle In Two Immunocompetent Patients, Khai Phang Wong, Zhi Hao Tang, Gek Meng Tan

BioMedicine

Nontuberculous mycobacteria (NTM) infections of the musculoskeletal system are commonly missed due to its rarity and the absence of systemic symptoms. A high clinical index of suspicion is required to recognize such infections as they may occur in immunocompetent hosts. We present two cases of foot and ankle NTM infections involving Mycobacterium fortuitum and Mycobacterium abscessus in two such patients. The first case involves an 83-year old lady who presented with a two-month history of multiple foot abscesses initially treated at a rural hospital. She underwent drainage and debridement of her foot, with eventual cultures growing Pseudomonas aeruginosa and Mycobacterium …

Innovation And New Technologies In Spine Surgery, Circa 2020: A Fifty-Year Review., G. Bryan Cornwall, Andrea Davis, William R. Walsh, Ralph J. Mobbs, Alexander Vaccaro

Rothman Institute Papers

Spine surgery (lumbar, cervical, deformity, and entire spine) has increased in volume and improved in outcomes over the past 50 years because of innovations in surgical techniques and introduction of new technologies to improve patient care. Innovation is described as a process to add value or create change in an enterprise's economic or social potential. This mini review will assess two of three assessments of innovation in spine surgery: scientific publications and patents issued. The review of both scientific publications and issued patents is a unique assessment. The third assessment of innovation: regulatory clearances of medical devices and equipment for …

Factors Associated With Patient Rating Of Physician Communication Effectiveness And Satisfaction In Musculoskeletal Care, Amirreza Fatehi, Amanda Gonzalez Md, David Bandell, Joost Kortlever, Léon Rijk, David Ring

Patient Experience Journal

Effective communication is associated with adherence to healthy habits. This study sought factors associated with communication effectiveness and satisfaction with musculoskeletal specialty care in order to inform efforts to improve communication effectiveness using measurement, feedback, and coaching. After a new or return upper extremity specialist visit, 146 adult patients completed a survey recording demographics, measures of catastrophic thinking in response to nociception, symptoms of depression, and symptoms of anxiety, and they rated communication effectiveness (5 questions answered on a 4-point Likert scale) and satisfaction with the visit (slider with anchors of 0 and 100). Patients also provided text answers to …

Return To Play After Isolated Meniscal Repairs In Athletes: A Systematic Review., Erica R Blanchard, Christopher J Hadley, Eric D Wicks, William Emper, Stephen B. Cohen

Rothman Institute Papers

Background: Meniscal tears are a common knee injury. Isolated meniscal tears are less common; however, unaddressed tears can be troublesome, particularly for athletes. There is currently a lack of data in the literature on athletes returning to play after isolated meniscal repair.

Purpose: To evaluate the return to play rate and time to return to play for athletes with isolated meniscal injuries.

Study Design: Systematic review; Level of evidence, 4.

Methods: A search of the PubMed, EMBASE, and Cochrane electronic databases was conducted to identify studies that reported the time and the rate of return to play in athletes after …

Adipose Tissue As Pain Generator In The Lower Back And Lower Extremity: Application In Musculoskeletal Medicine, Se Won Lee, Craig Van Dien, Sun Jae Won

HCA Healthcare Journal of Medicine

Adipose tissue (AT) has diverse and important functions in body insulation, mechanical protection, energy metabolism and the endocrine system. Despite its relative abundance in the human body, the clinical significance of AT in musculoskeletal (MSK) medicine, particularly its role in painful MSK conditions, is under-recognized. Pain associated with AT can be divided into intrinsic (AT as a primary pain generator), extrinsic (AT as a secondary pain generator) or mixed origin. Understanding AT as an MSK pain generator, both by mechanism and its specific role in pain generation by body region, enhances the clinical decision-making process and guides therapeutic strategies in …

Bioactivating A Bone Substitute Accelerates Graft Incorporation In A Murine Model Of Vertical Ridge Augmentation, Jinlong Chen, Xue Yuan, Zhijun Li, Daniel J Bahat, Jill A Helms

Department of Orthopaedic Surgery Faculty Papers

OBJECTIVE: Compared to autologous bone grafts, allogeneic bone grafts integrate slowly, which can adversely affect clinical outcomes. Here, our goal was to understand the molecular mechanisms underlying graft incorporation, and then test clinically feasible methods to accelerate this process.

METHODS: Wild-type and transgenic Wnt "reporter" mice were used in a vertical ridge augmentation procedure. The surgery consisted of tunneling procedure to elevate the maxillary edentulous ridge periosteum, followed by the insertion of bone graft. Micro-computed tomographic imaging, and molecular/cellular analyses were used to follow the bone graft over time. Sclerostin null mice, and mice carrying an activated form of β-catenin …

Association Of Laminar Airflow During Primary Total Joint Arthroplasty With Periprosthetic Joint Infection., Qiaojie Wang, Chi Xu, Karan Goswami, Timothy L. Tan, Javad Parvizi Md

Rothman Institute Papers

Importance: Whether laminar airflow (LAF) in the operating room is effective for decreasing periprosthetic joint infection (PJI) after total joint arthroplasty remains a clinically important yet controversial issue.

Objective: To investigate the association between operating room LAF ventilation systems and the risk of PJI in patients undergoing total joint arthroplasty.

Design, Setting, and Participants: A retrospective cohort study was conducted of 6972 consecutive patients undergoing primary total knee arthroplasty or total hip arthroplasty at 2 surgical facilities within a single institution from January 1, 2013, to September 15, 2017, with a minimum of 1 year of follow-up. All procedures were …

Osseous Changes Following Reverse Total Shoulder Arthroplasty Combined With Latissimus Dorsi Transfer: A Case Series, Jason S Klein, Peter S Johnston, Benjamin W Sears, Manan S Patel, Armodios M Hatzidakis, Mark D. Lazarus

Department of Orthopaedic Surgery Faculty Papers

Background: This is the first report on the incidence of proximal humerus osseous changes and associated clinical consequences in reverse total shoulder arthroplasty combined with a latissimus dorsi tendon transfer (RTSA+LDT).

Methods: A multicenter, retrospective review identified all patients who had undergone a primary RTSA+LDT and had at least 3-month radiographic follow-up between 2012 and 2017. Data collection included demographics, oral steroid use, repair technique for LDT fixation, radiographic humeral osseous changes, complications, and need for revision surgery.

Results: Twenty-four patients were included with an average age of 70.7 ± 7.9 years and follow-up of 16.3 (3-50) months. Ten patients …

Early General Hypothermia Improves Motor Function After Spinal Cord Injury In Rats; A Systematic Review And Meta-Analysis., Mahmoud Yousefifard, Mohammad Hossein Vazirizadeh-Mahabadi, Leila Haghani, Farhad Shokraneh, Alex R. Vaccaro, Vafa Rahimi-Movaghar, Mostafa Hosseini

Rothman Institute Papers

Introduction: There is still controversy about the effect of early hypothermia on the outcome of spinal cord injury (SCI). The aim of this review article is to investigate the effect of local or general hypothermia on improving the locomotion after traumatic SCI.

Methods: Electronic databases (Medline and Embase) were searched from inception until May 7, 2018. Two independent reviewers screened and summarized the relevant experimental studies on hypothermia efficacy in traumatic SCI. The data were analyzed and the findings were presented as pooled standardized mean difference (SMD) and 95% confidence interval (95% CI).

Results: 20 papers contain-ing 30 separate experiments …

Training For A Marathon – Responding To A Pandemic, Mary I. Fisher

Physical Therapy Faculty Publications

No abstract provided.

Post-Influenza Vaccine Subdeltoid Bursitis, Marenda Jenkins, David Rupp, Lynne J. Goebel

Internal Medicine

A 61-year-old female presented three months following an influenza vaccination with ongoing pain since the injection and was diagnosed by MRI with subdeltoid bursitis. The patient received a short course of prednisone and several months of physical therapy before returning to pain-free function. The primary reason for injection-related subdeltoid bursitis is improper administration. It is a preventable issue, and improved training of healthcare workers on proper vaccine administration may decrease its occurrence.

Assessment Of Surgical Procedural Time, Pedicle Screw Accuracy, And Clinician Radiation Exposure Of A Novel Robotic Navigation System Compared With Conventional Open And Percutaneous Freehand Techniques: A Cadaveric Investigation, Alex R. Vaccaro, Jonathan A Harris, Mir M Hussain, Rishi Wadhwa, Victor W Chang, Samuel R Schroerlucke, Walter P Samora, Peter G Passias, Rakesh D Patel, Ripul R Panchal, Sabino D'Agostino, Nathaniel L Whitney, Neil R Crawford, Brandon S Bucklen

Rothman Institute Papers

STUDY DESIGN: Cadaveric study.

OBJECTIVE: To evaluate accuracy, radiation exposure, and surgical time of a new robotic-assisted navigation (RAN) platform compared with freehand techniques in conventional open and percutaneous procedures.

METHODS: Ten board-certified surgeons inserted 16 pedicle screws at T10-L5 (n = 40 per technique) in 10 human cadaveric torsos. Pedicle screws were inserted with (1) conventional MIS technique (L2-L5, patient left pedicles), (2) MIS RAN (L2-L5, patient right pedicles), (3) conventional open technique (T10-L1, patient left pedicles), and (4) open RAN (T10-L1, patient right pedicles). Output included (1) operative time, (2) number of fluoroscopic images, and (3) screw accuracy. …

A Unique Cause Of Elbow Pain And Loss Of Range Of Motion In A 13-Year-Old, Thomas Munro, Brian S. Harvey

Posters

A 13-year-old right hand dominant young lady presented to a pediatric sports medicine clinic for evaluation of decreased ROM and pain in her left elbow with an associated locking sensation that had been occurring for over a year. Two weeks prior to presentation, these symptoms had been acutely worsening as she was practicing for over 10 hours per day for an upcoming dance competition. The patient’s pain is described as a “tightness” and is localized to her antecubital fossa medial to her biceps tendon. The feeling of tightness occurs most prominently with end extension and flexion of the elbow. She …