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Osteochondritis dissecans of the humeral trochlea is a rare cause of elbow pain adolescents. Despite being a juvenile form of osteochondritis dissecans, spontaneous resolution is not uniform, and more than one-half of patients experience ongoing pain, crepitus and loss of motion. Traditionally, nonsurgical management has been favoured as distal trochlea articular lesions were only accessible via olecranon osteotomy. Consequently, the threshold for intervention is high as the recovery prolonged. We present our technique of accessing the trochlear osteochondritis dissecans via ulnohumeral joint arthroscopy with transolecranon microfracture, which enables these lesions to be managed with reduced morbidity.

Stress fractures of the upper limb affect athletes from a wide range of sports. Athletes involved in throwing sports are particularly susceptible along with athletes from sports involving high repetitive and compressive loads such as gymnastics. Diagnosis can be made from clinical history, examination and radiography in some cases however MRI imaging is often required for definitive diagnosis. The mainstay of management is rest and activity modification however advanced pathology often requires surgical management for successful resolution and return to play. In the elbow, the bones susceptible to excessive stress in sport are the distal humerus, the olecranon process of the ulna, the coronoid process of the ulna, the sublime tubercle and the radial head. In immature patients, medial epicondyle apophysis is the most common location. The article presents a narrative review of the literature.

The lower trapezius tendon (LTT) transfer has been described for the management of irreparable posterosuperior rotator cuff tears. Here we describe our technique of an arthroscopic-assisted LTT transfer using an Achilles tendon-bone allograft. This technique allows for augmentation of the tendon transfer using an Achilles tendon allograft while also keeping the calcaneal bone insertion, which allows for added bony fixation into the humerus and also minimizing the risk of the ''killer turn'' phenomenon at the aperture of fixation.

Arthroscopic repair of subscapularis tendon tears has shown to be a reliable and reproducible technique and is now considered the gold standard method over open repair. However, most arthroscopic techniques use several working portals and the procedure can be technically challenging and time-consuming, especially when knot-tying is required and when multiple anchors are used. Recently, single-portal knotless techniques have been popularized for upper-third lesions (e.g. Lafosse type 1 or 2 tears). Here, we describe a technique of repairing complete tears of the subscapularis tendon (Lafosse type 3 and 4) using knotless suture anchors through a single portal. This technique is quick and allows a safe anatomic footprint repair to the lesser tuberosity.

Purpose High bone density and quality is associated with improved screw fixation in fracture fixation. The objective of this study was to assess bone density and quality in the proximal and distal scaphoid to determine optimum sites for placement of 2 screws in scaphoid fracture fixation. Methods Twenty-nine cadaveric human scaphoid specimens were harvested and scanned using micro–computed tomography. Bone density (bone volume fraction) and bone quality (relative bone surface area, trabecular number, and trabecular thickness) were evaluated in 4 quadrants within each of the proximal and distal scaphoid. Results The proximal radial quadrant of the scaphoid had significantly greater bone volume than the distal ulnar (mean difference, 33.2%) and distal volar quadrants (mean difference, 32.3%). There was a significantly greater trabecular number in the proximal radial quadrant than in the distal ulnar (mean difference, 16.7%) and in the distal volar quadrants (mean difference, 15.9%) and between the proximal ulnar and the distal ulnar quadrants (mean difference, 12%). There was a significantly greater bone surface area in the proximal radial and distal radial quadrants than in the distal ulnar and distal volar quadrants. There were no significant differences in trabecular thickness between the 8 analyzed quadrants Conclusions Although there are differences in bone volume, trabecular number, and bone surface area between the proximal pole of the scaphoid and that of the distal pole, there were no significant differences in the bone quality (trabecular thickness, trabecular number, and relative bone surface area) and density (bone volume fraction) between the 4 quadrants of the proximal or distal pole of the cadaveric scaphoids studied. Clinical relevance Insertion of 2 headless compression screws can be determined by ease of surgical access and ease of screw positioning and not by differences in bone quality or density of the proximal or distal scaphoid.

Purpose To evaluate the biomechanical properties of 3 scapholunate repair techniques. Methods In 51 cadavers, the scapholunate ligament was exposed through a dorsal approach, incised at its scaphoid insertion, and repaired using 1 of 3 techniques: 2 single-loaded suture anchors, 2 double-loaded suture anchors, or 2 transosseous sutures. Twenty-four repaired specimens underwent load to failure (LTF) testing using tensile distraction on a servo-hydraulic machine. Twenty-seven specimens underwent cyclical testing to measure gap formation at the scapholunate joint. Results The mode of failure was suture pullout through the substance of the ligament in 22 specimens, failure at the bone suture interface in 1, and anchor pullout in 1. Double-loaded anchor repairs demonstrated a significantly higher mean ultimate LTF compared with single-loaded anchor (91 N vs 35 N) and transosseous (91 N vs 60 N) repairs. Transosseous repairs demonstrated a higher mean ultimate LTF compared with single-loaded suture repairs (60 N vs 35 N). After 300 cycles, the average gap for the transosseous repair group was double that for the single- and double-loaded repairs, although not statistically significant. Conclusions Primary scapholunate ligament repairs using double-loaded suture anchors demonstrated significantly higher strength compared with single-loaded anchors and transosseous repairs. On cyclic loading, transosseous repairs demonstrated the greatest gap formation with no measurable difference between single- and double-loaded repairs. Clinical relevance In a cadaveric model for primary repairs, double-loaded suture anchors demonstrated the highest LTF and offer a similar but unproven performance in vivo .

Open rotator cuff repair remains the gold standard for addressing large, retracted rotator cuff tears. Despite advances in arthroscopic techniques, to date, there is a lack of consistent evidence that one technique is superior. We review anatomical considerations in rotator cuff tear development as well as clinical examination and useful investigations. Open approach to rotator cuff repair is used in combination with arthroscopic assessment and preparation. Indications for an open approach relate to size, mobility, and configuration of the tear. The open approach to cuff repair cannot compensate for irreparable, chronic, immobile tears. In this article, we review the technical considerations of open rotator cuff repair.

Background It is still unclear which patients with isolated type II superior labrum anterior-posterior (SLAP) lesions benefit from either superior labral repair or biceps tenodesis. This study evaluates the indications and outcomes of patients with isolated type II SLAP lesions who have undergone either procedure. Methods A retrospective analysis was performed of patients who had surgery for an isolated type II SLAP lesion between 2008 and 2011. There were 25 patients: 15 underwent biceps tenodesis, with a mean follow-up of 31 months (range, 26-43 months), and 10 underwent SLAP repair, with a mean follow-up of 35 months (range, 25-52 months). The mean age was 47 years (range, 30-59 years) in the tenodesis group and 31 years (range, 21-43 years) in the repair group. Results At latest follow-up, both groups showed significant improvements in subjective shoulder value and pain score. No difference was observed in American Shoulder and Elbow Surgeons score (93.0 vs 93.5, P = .45), patient satisfaction (93% vs 90%, P = .45), or return to preinjury sporting level (73% vs 60%, P = .66). Analysis of the indications for treatment showed that in the large majority, tenodesis was performed in older patients (>35 years) and patients who showed degenerative or frayed labrums whereas SLAP repairs were performed in younger and more active patients with healthy-appearing labral tissue. There was only 1 failure in the tenodesis group, and in the SLAP repair group, there were 2 cases of postoperative stiffness; all were treated nonoperatively. Conclusion In this study, we show that both biceps tenodesis and SLAP repair can provide good to excellent results if performed in appropriately selected patients with isolated type II SLAP lesions.

Carpal fractures are exceedingly rare clinical entities and are often associated with concomitant injuries. In this review, we focus on fractures of the carpus, excluding the scaphoid, and provide an update on the current consensus as to mechanism, diagnosis, management, outcomes, and complications after such injuries.

Purpose To describe an uncommon subset of fractured lunates in Kienbock disease that is salvageable by internal fixation. Methods We performed a retrospective review for patients with Kienbock disease treated by internal fixation. Demographic data, objective and radiographic measurements, patient-reported outcome measures (Disabilities of the Arm, Shoulder, and Hand and Patient-Rated Wrist Evaluation) and pain (visual analog scale) scores were collected. Results Of the 7 patients treated, 5 were available for review. At an average follow-up of 7.1 years (range, 1.5–15 years), all patients had activity-related wrist pain but were pain-free at rest. Radiographic assessment showed union in all lunates and a normal radioscaphoid angle and Stahl index. The modified carpal height ratio was reduced in 4 patients and normal in one. There was no observed narrowing or irregularity of the radiocarpal or midcarpal joints. Patient-reported outcome measures in 2 patients were unsatisfactory. Conclusions Computed tomography of the lunate in Kienbock disease is an important investigative tool. A coronal split fracture of these lunates can be salvageable by internal fixation. Revascularization of the lunate can be performed when the fragment is of sufficient size. Type of study/level of evidence Therapeutic V.

Background Little is known of the mechanisms that lead to the muscle changes associated with rotator cuff disorders. We have observed that the magnetic resonance imaging (MRI) appearance of fatty infiltration (FI) and muscle atrophy (MA) differ between chronic cuff tears and suprascapular neuropathy, suggesting different pathophysiology. This study compares the different MRI changes that occur in chronic cuff tears and suprascapular neuropathy. Methods Two groups were retrospectively identified: (1) RCT group (20 shoulders): patients with chronic tears of the supraspinatus and/or infraspinatus without electromyographic (EMG) evidence of suprascapular neuropathy; (2) neuro group (17 shoulders): patients with EMG documented suprascapular nerve dysfunction and absence of a rotator cuff tear. Magnetic resonance arthrograms were analyzed for the degree of FI and MA, and the morphology of the muscle was assessed, in particular the muscle border, pattern of FI, and extent of involvement. Results The muscle changes that occur following chronic cuff tears differ from that following denervation secondary to suprascapular neuropathy, especially with respect to the muscle border, degree of perineural fat, and overall distribution of FI. Highly specific and characteristic morphological patterns of FI exist for both chronic cuff tears and suprascapular neuropathy. Conclusion Chronic rotator cuff tendon tears and suprascapular neuropathy are both associated with FI and MA of the rotator cuff muscles. The pattern of FI is markedly different in the 2 situations. These findings have diagnostic potential and may serve as a basis for further research concerning type, severity, and evolution of FI under different conditions and after treatment.

article i nfo Background: The mechanical alignment of the knee is an important factor in planning for, and subsequently assessing the success of a knee replacement. It is most commonly measured using a long-leg anteroposterior radiograph (LLR) encompassing the hip, knee and ankle. Other modalities of measuring alignment include computer tomography (CT) and intra-operative computer navigation (Cas). Recent studies comparing LLRs to Cas in measuring alignment have shown significant differences between the two and have hypothesized that Cas is a more accurate modality. This study aims to investigate the accuracy of the above mentioned mo- dalities. Methodology: A prospective study was undertaken comparing alignment as measured by long-leg radio- graphs and computer tomography to intra-operative navigation measurements in 40 patients undergoing a primary total knee replacement to test this hypothesis. Alignment was measured three times by three ob- servers. Intra- and inter-observer correlation was sought between modalities. Results: Intra-observer correlation was excellent in all cases (>0.98) with a coefficient of repeatability b1.1°. Inter-observer correlation was also excellent measuring >0.960 using LLRs and >0.970 using CT with coef- ficient of repeatability b2.8°. Inter-modality correlation proved to be higher when comparing LLRs and CT (>0.893), than when comparing either of these modalities with Cas (>0.643 and >0.671 respectively). Pre-operative values had the greatest variability. Conclusion: Given its availability and reduced radiation dose when compared to CT, LLRs should remain the mainstay of measuring the mechanical alignment of the lower limb, especially post-operatively. Level of evidence: II

The purposes of this study were (1) to establish a reproducible, standardized testing protocol to evaluate the performance of different shaver systems and blades in a controlled, laboratory setting, and (2) to determine the optimal use of different blades with respect to the influence of contact pressure and speed of blade rotation.A holding device was developed for reproducible testing of soft-tissue (tendon and meniscal) resection performance in a submerged environment, after loading of the shaver with interchangeable weights. The Karl Storz Powershaver S2 (Karl Storz, Tuttlingen, Germany), the Stryker Power Shaver System (Stryker, Kalamazoo, MI), and the Dyonics Power Shaver System (SmithNephew, Andover, MA) were tested, with different 5.5-mm shaver blades and varied contact pressure and rotation speed. For quality testing, serrated shaver blades were evaluated at 40× image magnification. Overall, more than 150 test cycles were performed.No significant differences could be detected between comparable blade types from different manufacturers. Shavers with a serrated inner blade and smooth outer blade performed significantly better than the standard smooth resectors (P.001). Teeth on the outer layer of the blade did not lead to any further improvement of resection (P = .482). Optimal contact pressure ranged between 6 and 8 N, and optimal speed was found to be 2,000 to 2,500 rpm. Minimal blunting of the shaver blades occurred after soft-tissue resection; however, with bone resection, progressive blunting of the shaver blades was observed.Arthroscopic shavers can be tested in a controlled setting. The performance of the tested shaver types appears to be fairly independent of the manufacturer. For tendon resection, a smooth outer blade and serrated inner blade were optimal.This is one of the first established independent and quantitative assessments of arthroscopic shaver systems and blades. We believe that this study will assist the surgeon in choosing the optimal tool for the desired effect.

Introduction Limb-salvage surgery, including endoprosthetic reconstruction after tumour resection, has become the standard management for local control of tumours around the knee. As the nature of surgery is technically complex and demanding, there is potential for significant morbidity arising from complications. This study describes our experience with complications following endoprosthetic reconstruction around the knee. Methods Retrospective analysis of consecutive resections and endoprosthetic reconstructions for tumours around the knee between 1996 and September 2005 performed at St Vincent's Hospital, Melbourne. Results Fifty consecutive cases were reviewed, with a median follow-up of 24.5 (range, 2–124) months. Median age was 41 (range, 13–79) years. Tumour types included 38 primary musculoskeletal malignancies, 8 metastatic tumours, 2 bony lymphomas and 2 benign lesions. There were eight deaths, nine cases of subsequent metastatic spread and no local recurrences. There were six cases of deep infection, two each of non-resolving nerve palsy, fracture and mechanical wear, and one each of symptomatic patellofemoral impingement, aseptic loosening and intraoperative popliteal artery trauma. Five patients required endoprosthetic revision, and three subsequent amputations were described. Excellent functional outcome and emotional acceptance was observed amongst patients that underwent revision. Conclusion Resection and endoprosthetic reconstruction of tumours around the knee is both technically challenging and resource-intensive. It is imperative that morbidity from complications is limited through the minimisation of their incidence and the provision of optimal management. This series demonstrates that good patient outcomes can be achieved in specialist centres with experienced surgeons and adoption of a multidisciplinary approach.

A prospective study was conducted comparing the early clinical and radiological results between the triple-tapered C-Stem (DePuy International, Leeds, UK) and the double-tapered Exeter Universal (Stryker Howmedica Osteonics, Mahwah, NJ) in cemented total hip arthroplasty. A total of 192 patients (200 hips) received the C-Stem and 189 patients (205 hips) received the Exeter Universal. Average follow-up was 29 and 31 months in the C-Stem and Exeter groups, respectively. From the short-term results, we found similar mean improvements in clinical scores and no difference was noted in the incidence of complications. Average subsidence was comparable (C-Stem, 0.77 mm +/- 0.56; Exeter, 0.82 +/- 0.63). Radiolucencies in the cement-stem and cement-bone interfaces were seen primarily in the proximal zones in both groups. No stems were considered at risk of aseptic loosening and the extent of proximal femoral resorption was comparable.

Surgical treatment of ultrasmall proximal pole scaphoid fractures poses a number of challenges. The fragment may be too small to fix with conventional headless screw fixation owing to the high risk of fragmentation upon insertion. However, excision of the fragment risks compromising the scapholunate ligament complex and also exposes the radioscaphoid joint to potential degenerative changes. Under these circumstances, we describe the use of bioabsorbable osteochondral fixation nails that allows stable low-profile fixation while minimizing the risk of fracturing the proximal pole.