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Background: Intramedullary fixation in distal biceps tendon repair may be a solution to address specific shortcomings of current fixation techniques. Most investigations are limited to biomechanical evaluation. The purpose of this study was to report the short-term outcomes of an intramedullary fixation device. Methods: We evaluated functional and radiographic outcomes at up to 6 months of follow-up. Patients with an acute distal biceps tendon nipture eligible for surgical repair were invited to take part in the study. Ten patients were included in the final analysis. All patients were evaluated both clinically and radiographically at 2 weeks, 6 weeks, 3 months, and 6 months. Outcomes were recorded using a visual analog scale score for pain, the Mayo Elbow Performance Score, and the Disabilities of the Arm, Shoulder and Hand score. Radiographic evaluation comprised radiographic and computed tomography evaluation. Results: There were no failures of fixation in the patient group examined. Elbow mobility was symmetrical for all patients from 3 months onward. Supination strength was 86% of the uninjured side at final follow-up. The mean Disabilities of the Arm, Shoulder and Hand score and Mayo Elbow Performance Score at final follow-up were 0 and 100, respectively. Computed tomography images showed no signs of button migration, cortical thinning due to button pressure, or button breakout. The tendon could be followed to the button in all cases. Conclusions: The intramedullary fixation button technique to repair the distal biceps tendon has excellent functional outcomes at 6 months. No adverse reactions of the button on the bone were seen. As this technique minimizes the risk of posterior interosseous nerve injury and has a sufficient bone tunnel to avoid gap formation, this may be a promising new technique for distal biceps tendon rupture refixation. (C) 2021 Journal of Shoulder and Elbow Surgery Board of Trustees. All rights reserved.

Background: The clinical diagnosis of partial distal biceps tendon ruptures or tendinosis can be challenging. Three clinical tests have been described to aid in an accurate and timely diagnosis: biceps provocation test, tilt sign, and resisted hook test. However, not much is known about the sensitivity, specificity, and inter-rater reliability as the available evaluations are based on small groups or are case based. Furthermore, these tests have not been compared together in the same patient group. Methods: Two dedicated elbow surgeons each included 20 consecutive patients in whom distal biceps tendon pathology was suspected. Patients with a complete distal biceps tendon tear were excluded. As a control, the same number of consecutive patients with various elbow pathologies other than distal biceps tendon problems was included. All 3 tests were performed both in control patients and in patients with suspected biceps tendon pathology. Magnetic resonance imaging (MRI) in the flexion-abduction-supination view and/or surgical exploration was performed in both groups. The findings of the clinical tests were determined before the results of MRI and other technical investigations were analyzed. The values of sensitivity, specificity, and accuracy were calculated. Results: The combined sensitivity, specificity, and accuracy values for the biceps provocation test were 95%, 97%, and 96%, respectively. For the resisted hook test, the combined values were 78%, 76%, and 77%, respectively. The combined values for the tilt sign were 58%, 55%, and 56%, respectively. When the biceps provocation test and the resisted hook test were combined in a parallel testing setup, the sensitivity increased to 98% whereas the specificity was 73%. The sensitivity and specificity of the biceps provocation test and the tilt sign in a parallel testing setup were 97% and 53%, respectively. Finally, the sensitivity and specificity of the tilt sign and the resisted hook test in a parallel testing setup were 90% and 41%, respectively. Conclusions: The biceps provocation test yielded higher accuracy than the resisted hook test and the tilt sign. When the biceps provocation test and the resisted hook test were combined, the sensitivity increased to 98%. We advise integration of these tests in daily practice to minimize delays in the diagnosis of partial distal biceps tendon ruptures, distal biceps tendon bursitis, or tendinosis. MRI in the flexion-abduction-supination view is still advised to distinguish between a partial biceps tendon rupture and tendinosis or bursitis at the distal biceps tendon insertion as this may influence further treatment. (C) 2021 Journal of Shoulder and Elbow Surgery Board of Trustees. All rights reserved.

Background Although revision arthroplasty surgery is a frequently used treatment for failed total elbow arthroplasty (TEA), published results are conflicting. The aim of this systematic review was to provide an overview of the outcomes of revision TEA surgery. Methods A systematic literature search was performed in major databases to find articles relating to outcomes after revision of TEA. Two reviewers independently screened the articles for inclusion, and a third reviewer screened them before final inclusion. Results Twenty-one articles containing 532 cases were included. The mean age at revision was 61 years. The mean interval between primary and revision arthroplasty was 77 months, and the average follow-up period was 65 months. Different types of prostheses were included, with 69% of the revision prostheses having linked designs and 31% having unlinked designs. The visual analog scale score, Mayo Elbow Performance Score, Oxford Elbow Score, and range of motion improved significantly after revision surgery. Complications were reported in 232 of 532 cases (44%), leading to reoperations in 22%. After revision with linked prostheses, the Mayo Elbow Performance Score, range of flexion-extension, and pronation improved significantly more than with unlinked designs. Conclusion Improved functional outcomes can be expected after revision TEA, but the complication rate remains high. Revision TEA should still be considered a salvage procedure for failed TEA. Linked designs for revision TEA result in better outcomes than unlinked designs in the midterm follow-up.

Background: The aim of this study was to analyze indications, outcomes, and complications in patients treated with radiocapitellar arthroplasty. Methods: This prospective analysis of clinical and radiographic results included 16 elbows in 15 patients. Results: This study included 4 men and 11 women (mean age, 51.9 years; age range, 32-65 years). The mean follow-up period was 3.4 years (range, 2-6 years). The indications were post-traumatic (n = 10) and primary radiohumeral osteoarthritis (n = 6). A mean of 2 surgical procedures (range, 0-4) had been performed before radiocapitellar arthroplasty. The mean Mayo Elbow Performance Score significantly improved from 46 points to 85 points (P < .01). The arc of motion improved from 106 degrees to 117 degrees (P = .27). Radiographic ulnohumeral degeneration progressed in 40% of cases but was not symptomatic in any. Subsequent surgery was required in 5 elbows (31%). Revision of the radial head component was necessary in 4 patients (25%). In 3 patients this was a result of loosening of the stem. The radial component was subsequently removed because of persistent pain in 1. Radiographic loosening not requiring revision was found in 2 patients. Conclusion: The overall Mayo Elbow Performance Score was good to excellent after radiocapitellar arthroplasty. Both the revision and reoperation rates were high, and one should consider this before performing this procedure. Loosening of the radial head component was a problem. An improved fixation technique or an adaptation of the design is needed before this type of surgery can be recommended as a standard procedure. (C) 2018 Published by Elsevier Inc. on behalf of Journal of Shoulder and Elbow Surgery Board of Trustees.

Background: Contact stresses of radial head prostheses remain a concern, potentially leading to early capitellar cartilage wear and erosion. In particular, point contact or edge loading could have a detrimental effect. The purpose of this study was to compare 3 different types of radial head prostheses in terms of joint contact areas with each other and with the native situation. The hypothesis was that the joint contact areas would be lower after monopolar arthroplasty. Methods: Seven fresh-frozen cadaveric upper limbs were used. Radiocapitellar contact areas of a monopolar design, a straight-neck bipolar design, and an angled-neck bipolar design were compared with each other and with the native joint. After standardized preparation, polysiloxane was injected into the loaded radiocapitellar joint to create a cast from which the joint contact area was measured. Measurements were performed at 3 angles of elbow flexion and in 3 different forearm positions. Results: In the native elbow, contact areas were highest in supination. Elbow flexion had no significant effect on native and prosthetic joint contact areas. Contact areas were decreased for all types of arthroplasties compared with the native joint (from 11% to 53%). No significant contact area difference was found between the 3 designs. However, bipolar prostheses showed lateral subluxation in neutral forearm rotation, resulting in a significant decrease in the contact areas from pronation to the neutral position. Conclusions: All types of radial head prostheses tested showed a significant decrease in radiocapitellar contact area compared with the native joint. Bipolar designs led to subluxation of the radial head, further decreasing radiocapitellar contact., SCOPUS: ar.j, info:eu-repo/semantics/published

Purpose One of the options to repair a ruptured distal biceps tendon to the radial tuberosity is by means of a transosseous cortical button. Although excellent functional outcomes have been reported, no studies have been performed to quantify the effect of the transosseous fixation technique on the radius. Our study evaluated the clinical outcome and radiological outcome of this technique. The main goal of this study was to evaluate the radiographic evolution of the bone tunnel in the radius. Methods Patients with an acute distal biceps tendon rupture treated with a transosseous cortical button were invited to take part in the study. Fourteen patients were included in the final analysis. All patients were evaluated both clinically and by computed tomography scanning of the proximal radius after a minimum follow-up of 2 years. Outcomes were recorded using the visual analog scale score for pain, the Mayo Elbow Performance Score, and Disabilities of the Arm, Shoulder, and Hand scores. Bone tunnel volume was measured with semiautomated computed tomography segmentation using image-processing software. Results There were no failures of fixation in the patient group examined. Elbow mobility, arm, and forearm circumference were symmetric for all patients. Average visual analog scale for pain was less than 2. Mean Disabilities of the Arm, Shoulder, and Hand score and Mayo Elbow Performance Score were 2.3 and 97.6, respectively. Computed tomography images showed an average closure of the radial bony tunnel of 64% of the initial volume. Conclusions Biceps tendon repair with cortical button fixation only shows partial tunnel closure. This could reduce the risk of potential complications due to osteolysis, such as radius fracture or hardware failure. Functional results were excellent and comparable to other fixation methods. The role of interference screws in transosseous cortical button techniques to strengthen the repair and to avoid osteolysis may therefore be questioned. Type of study/level of evidence Therapeutic IV.

Purpose Double plating has been promoted, in recent years, as an alternative treatment method for proximal ulna fractures. This study aimed to compare the biomechanical properties of double-plate osteosynthesis with posterior plate fixation using a novel investigational design utilizing a 3-dimensional camera system to analyze fracture micromotion. Methods Fourteen fresh-frozen specimens were available for this study. Mayo type IIA fractures of the olecranon were created and internal fixation was performed with either an angular stable posterior plate or angular stable double plates. Fracture micromotion was evaluated by means of digital image correlation with a 3-dimensional camera system before and after dynamic cyclic loading from 15° to 90° of elbow flexion with a pulling force of 25 N to 80 N. Results Micromotion of fragments was less pronounced in double-plate osteosynthesis when compared with single plates before and after cyclic loading. However, overall results were similar. Two of the single plates failed during cyclic loading but there were no failures in the double plates. Conclusions This biomechanical analysis shows that single and double plating results in comparable stability of fixation. Although the double-plating technique tends to provide more stable fixation, relevant differences were not observed. Clinical relevance Double plating potentially represents an efficient option for fixation of proximal ulna fractures. It could decrease the risk of soft tissue complications owing to their low profile and the superior soft tissue coverage.

Elbow instability is common and may occur after a variety of injuries, including falls or direct blows. Instability can be classified as either acute or chronic. Acute instability is classified as simple (without fracture) or complex (with associated fracture). Chronic instability is classified as a chronically dislocated or recurrently unstable elbow. Recurrent instability commonly presents as isolated medial or lateral collateral ligament insufficiency. A chronically dislocated elbow is often more complex, involving both osseous and ligamentous injuries. The treatment of simple dislocations typically involves closed reduction and nonsurgical management. Chronic recurrent lateral and medial collateral ligament insufficiencies have very different clinical characteristics, but definitive treatment frequently involves ligament reconstruction. Complex instability usually requires surgery, which includes open reduction and internal fixation of coronoid and olecranon fractures, repair or replacement of radial head fractures, and lateral collateral ligament repair. Medial collateral ligament repair and/or external fixation are rarely required to restore stability. It is important for surgeons to understand current concepts in the diagnosis and management of acute and chronic elbow instability as well as the preferred surgical treatments and techniques for the management of these injuries.

Background Controversy still exists regarding the location and nature (static or dynamic) of the forearm joint axis. This might be due to inconsistent results from in-vitro data and less precise methods of analysis. We present the first in-vivo kinematic analysis of normal forearm joint rotation described by helical axis analysis. Methods Data obtained from computed tomography images of both forearms of five healthy volunteers was used to calculate finite helical axis parameters from transformation matrices. Four positions were analyzed: maximum pronation, maximum supination, 60° pronation, and 60° supination. Kinematic analysis focused on the motion of the radius around the ulna. Findings The forearm axis as defined by finite helical axis extended from the radial head between its kinematic center and the proximal radioulnar joint, to the dorsal region of the ulnar head at the distal radioulnar joint. The axis was found to be variable. Interpretations Helical axis analysis has precisely defined the nature and location of the forearm axis. This new information of forearm kinematics defined by finite helical analysis, may be useful in implant design, and in guiding surgeons in their reconstruction of instabilities of the distal and proximal radioulnar joint.

Background and purpose Radial head fractures are common, and may be associated with other injuries of clinical importance. We present the results of a standard additional MRI scan for patients with a radial head fracture. Patients and methods 44 patients (mean age 47 years) with 46 radial head fractures underwent MRI. 17 elbows had a Mason type-I fracture, 23 a Mason type-II fracture, and 6 elbows had a Mason type-III fracture. Results Associated injuries were found in 35 elbows: 28 elbows had a lateral collateral ligament lesion, 18 had capitellar injury, 1 had a coronoid fracture, and 1 elbow had medial collateral ligament injury. Interpretation The incidence of associated injuries with radial head fractures found with MRI was high. The clinical relevance should be investigated.

The goal of this study was to look at the pattern of osteophyte distribution on a 3-dimensional computed tomography scan of patients with symptomatic osteoarthritis in the elbow. We recruited 22 consecutive patients with symptomatic osteoarthritis of the elbow for the study. Three-dimensional reconstructed anterior, posterior, medial, and lateral views of the elbow were reviewed. Ulnohumeral osteophytes were found in 21 patients (95%), and radiohumeral osteophytes were found in 13 (59%). Cadaveric and biomechanical studies suggest that the radiohumeral joint appears to be more prone to wear and stress than the ulnohumeral joint. Our study showed that the percentage of patients with ulnohumeral joint osteophytes (95%) was higher than that of radiohumeral joint (59%). Therefore, this study challenges the conventional belief that osteoarthritis starts from the radiohumeral joint and progress toward the ulnohumeral joint.

Purpose To develop a method for in-vivo kinematic study of normal forearm rotation using computed tomographic (CT) images and a custom apparatus which allows for control of amount of forearm rotation. Methods The forearm of one asymptomatic volunteer was CT-scanned in five positions: neutral, 60° pronation, maximal pronation, 60° supination, and maximal supination. Surface registration of the pronated/supinated image datasets with the neutral position was performed. The resulting transformation matrices were decomposed into finite helical axis (FHA) parameters. Kinematics were expressed as motion of the radius relative to the ulna. Results The axes of the forearm passed through the volar region of the radial head at the proximal radioulnar joint (PRUJ), extending towards the dorsal region of the ulnar head at the distal radioulnar joint (DRUJ). Distinct FHAs were calculated for each forearm position analyzed relative to neutral rotation. Forearm pronation FHAs were different from forearm supination FHAs. Conclusions Our experimental methodology is capable of describing the in-vivo kinematics of the forearm with good accuracy and reliability. Future in-vivo studies would need to be performed using a larger sample size to further validate our preliminary results. An ideal clinical application of this methodology would be in the comparative study of patients with forearm dysfunction.

Reconstructing elbow instability remains a challenging problem. Techniques described have included techniques for the lateral ligamentous complex, including the lateral ulnar collateral ligament, and techniques to reconstruct the medial collateral ligament. We describe a new circumferential technique to reconstruct both the lateral and medial ligament complexes, using 1 circular graft. A hole is drilled through the center of rotation of the distal humerus and through the insertion sites of the medial and lateral ligament complexes. A hamstring tendon graft is passed through the humerus twice to reconstruct the anterior and posterior bands of the medial collateral ligament and sutured onto itself. Endobutton fixation is used to fix the graft on either side of the ulna. The graft is tightened on the lateral and medial sides and fixed into the humerus using interference fit screws. Advantages of the technique described include stabilization of both the medial and lateral ligament complexes with 1 graft. The strength of fixation allows for individual tensioning in all limbs of the reconstruction and the multiple passes of the graft through a single humeral tunnel increasing the strength of the reconstruction. Potential complications could include ulnar nerve damage, recurrent instability, elbow stiffness, and wound breakdown. Complications related to the potential use of a hinged external fixator are not specific to this procedure but can be associated. Early active mobilization can be initiated because of the strong stability provided by the circumferential graft and good fixation.

A patient presented with chronic shoulder pain from a rare plasmocytoma in the distal humerus that resolved following a pathologic fracture. Staged reconstruction of the elbow after resection of the tumor in the distal humerus resulted in resolution of the patient's elbow and shoulder symptoms.

Treatment of radial head fractures may be complicated because of the presence of associated lesions. However, little is known about the frequency or relevance of associated lesions in different types of radial head fractures. We studied the demographics of radial head fractures focusing on associated lesions in 333 adults from 1997 to 2002. The mean age of the patients was 45 years (range, 18-82 years). Two hundred twenty-three (67%) patients had Mason Type 1 fractures, 46 patients had Mason Type 2 (14%) fractures, and 64 patients had Mason Type 3 (19%) fractures. One hundred eighteen of 333 patients (39%) had associated fractures or soft tissue injury. Fifty-three (16%) patients had coronoid fractures, and 45 patients (14%) had elbow dislocations. Two hundred thirty-five (71%) patients had nonoperative treatment, which failed in six (3%) patients. Sixty-six (20%) patients had open reduction and internal fixation, which failed in six (9%) patients. Resection was used in 20 (6%) patients, and radial head replacement was used in 31 (9%) patients, one of which was revised. The ligamentous injury required surgical repair or reconstruction in 44 patients. A concurrent coronoid fracture was the most common associated injury prompting referral to this tertiary medical center.Diagnostic study, Level IV (case-control study). See the Guidelines for Authors for a complete description of levels of evidence.

Results of the treatment of the deficient coronoid and chronic elbow instability have not been reported. The purpose of this study was to analyze the results of structural bone graft for reconstruction of the coronoid process. Structural bone graft was used to reconstruct the coronoid process of 6 patients. All injuries were of the terrible triad: fracture of the coronoid, radial head fracture, and collateral ligament disruption. All cases had persistent posterior subluxation averaging 6 months (range, 1-13 months before reconstruction. Patient charts, surgical records, and radiographs were reviewed. All patients were contacted at a mean of 64 months after treatment to answer a specific set of questions to determine the Mayo Elbow Performance score. In 1 patient, radiographs showed complete resorption of the graft and severe osteoarthritis of the elbow at 54 months after surgery (case 4). The Mayo Elbow Performance score showed 1 excellent, 2 good, 1 fair, and 2 poor results. Structural bone graft may be a useful option for a deficient coronoid process and an unstable elbow, but the outcome is unpredictable.

Purpose The purpose of this study was to define the shape of the radial head by identifying the relationship between precisely defined axes of the radial head. Methods An anatomic study was done to define the shape of the radial head and specifically the relationship between the long and the short axis. Twenty-seven cadaveric upper extremities were used. The x and y axes of the radial head were defined in relationship to the radial notch of the ulna, with the forearm in neutral position. Outer diameters of the x and y axis were measured. These were compared with the actual maximum and minimum diameters of the radial head. X and y diameters of the articulating surface of the radial head also were measured. Paired 1-tailed Student's t -tests were used to compare the x and y diameters of the radial head. Regression analysis of x and y diameters of the radial head was done to identify a correlation between these parameters. Results Paired 1-tailed Student's t -tests showed a significant difference between X and Y diameters of the radial head. Regression analysis of x and y diameters of the radial head showed a strong correlation between these 2 axes. Conclusions The radial head is not round. A strong correlation exists between the x and y diameters of the radial head. The orientation of the long axis is perpendicular to the radial notch with the forearm in neutral rotation. This finding will make it possible to approach the anatomy of the radial head more closely when designing radial head prostheses. The definition of the axes can be used as a guide when implanting the radial head prosthesis.

Background: When a surgeon uses a percutaneous volar approach to treat scaphoid waist fractures, central screw placement is complicated by the shape of the scaphoid and by obstruction by the trapezium. In this study, we used radiographs and biomechanical tests to compare the standard volar percutaneous approach with the transtrapezial approach, with regard to central screw placement at the distal pole of the scaphoid. Methods: Fourteen matched pairs of cadaveric wrists were randomly assigned to two treatment groups. Under fluoroscopic control, a guidewire was drilled into the scaphoid, either through a transtrapezial approach or through a standard volar approach that avoided the trapezium. Guidewire position was measured in the coronal and sagittal planes. A transverse osteotomy was performed along the scaphoid waist, and this was followed by the insertion of the longest possible cannulated headless bone screw. Each specimen was placed into a fixture with a pneumatically driven plunger resting on the surface of the distal pole. Load was applied by using a load-controlled test protocol in a hydraulic testing machine. Results: All guidewires were inside the central one-third of the proximal pole. The guidewire positions at the distal pole differed significantly between the transtrapezial and standard volar approach groups (p < 0.001). The load to 2 mm of displacement and the load to failure averaged, respectively, 324.4 N (standard error of the mean [SEM] = 73.5 N) and 386.4 N (SEM = 65.6 N) for the transtrapezial approach group compared with 125.7 N (SEM = 22.6 N) (p = 0.002) and 191.4 N (SEM = 36.30 N) (p = 0.005) for the standard volar approach group. Conclusions: The data suggest that, in a cadaveric osteotomy-simulated scaphoid waist fracture model, the transtrapezial approach reliably achieves central positioning of a screw in the proximal and distal poles. This position offers a biomechanical advantage compared with central placement in only the proximal pole.

Osteoarthritis is the most common joint disease and a major cause of disability. Distinct biological processes are considered crucial for the development of osteoarthritis and are assumed to act in concert with additional risk factors to induce expression of the disease. In the classical weightbearing joints, one such risk factor is an unfavourable biomechanical environment about the joint. While the elbow has long been considered a non-weightbearing joint, it is now assumed that the tissues of the upper extremity may be stressed to similar levels as those of the lower limb, and that forces across the elbow are in fact very high when the joint is extended from a flexed position. This review examined the available basic science, preclinical and clinical evidence regarding the role of several unfavourable biomechanical conditions about the elbow on the development of osteoarthritis: post-traumatic changes, osteochondritis dissecans, instability or laxity and malalignment. Post-traumatic osteoarthritis following fractures is well recognized, however, the role of overload or repetitive microtrauma as risk factors for post-traumatic osteoarthritis is unclear. The natural course of untreated cartilage defects in general, and osteochondritis dissecans at the elbow in particular, remains incompletely understood to date. However, larger lesions and older age seem to be associated with more symptoms and radiographic changes in the long term. Instability seems to play a role, although the association between instability and osteoarthritis is not yet clearly defined. No data are available on the association of malalignment and osteoarthritis, but based on force estimations across the elbow joint, it seems reasonable to assume an association.

Although the triceps tendon has been used as a graft for ligament reconstruction about the elbow, and has been postulated to be useful as a graft in the treatment of massive rotator cuff tears, no data exists on the tensile properties of the triceps tendon. The purpose of this study was to define the tensile properties of the medial, lateral, and central thirds of the triceps tendon, in order to examine its potential as an autograft for upper extremity pathology.Ten fresh frozen upper extremity specimens were used. The triceps tendon was dissected from its musculotendinous junction and left attached to its insertion at the olecranon. The tendon was split into thirds and its tensile properties were recorded using a materials testing machine.The lateral portion was significantly thinner and less stiff than the medial and central portions (P.05). It failed at significantly lower ultimate load than the central portion (P.05). There were no significant differences between the medial, central, and lateral portions of the triceps tendons with regards to ultimate stress (P = .20) or modulus of elasticity (P = .64).Data from the current study were compared to available literature regarding tensile properties of the rotator cuff and elbow ligaments. Both the medial and central portions of the triceps tendon offer sufficient strength to be used in the reconstruction of the rotator cuff or ligament reconstruction in the elbow.

Purpose To address the factors that surgeons use to decide between 2 options for treatment when the evidence is inconclusive. Methods We tested the null hypothesis that the factors surgeons use do not vary by training, demographics, and practice. A total of 337 surgeons rated the importance of 7 factors when deciding between treatment and following the natural history of the disease and 12 factors when deciding between 2 operative treatments using a 5-point Likert scale between "very important" and "very unimportant." Results According to the percentages of statements rated very important or somewhat important, the most popular factors influencing recommendations when evidence is inconclusive between treatment and following the natural course of the illness were "works in my hands," "familiarity with the treatment," and "what my mentor taught me." The most important factors when evidence shows no difference between 2 surgeries were "fewer complications," "quicker recovery," "burns fewer bridges," "works in my hands" and "familiarity with the procedure." Europeans rated "works in my hands" and "cheapest/most resourceful" of significantly greater importance and "what others are doing," "highest reimbursement," and "shorter procedure" of significantly lower importance than surgeons in the United States. Observers with fewer than 10 years in independent practice rated "what my mentor taught me," "what others are doing" and "highest reimbursement" of significantly lower importance compared to observers with 10 or more years in independent practice. Conclusions Surgeons deciding between 2 treatment options, when the evidence is inconclusive, fall back to factors that relate to their perspective and reflect their culture and circumstances, more so than factors related to the patient's perspective, although this may be different for younger surgeons. Clinical relevance Hand surgeons might benefit from consensus fallback preferences when evidence is inconclusive. It is possible that falling back to personal comfort makes us vulnerable to unhelpful commercial and societal influences.

Full article available online at Healio.com/Orthopedics. Search: 20120822-24 Soccer players frequently experience acute and chronic groin pain. Sportsman’s hernia is a common injury in professional soccer players, that causes inguinal pain. The authors discuss their experience with the management of sportsman’s hernia in professional soccer players competing in national and international competition in a retrospective review of prospectively collected data. Between March 2004 and December 2009, seventy-one professional soccer players were surgically treated for sportsman’s hernia. Average age at surgery was 24 years, and average duration of symptoms from onset to surgical repair was 11 months. Conservative treatment improved symptoms temporarily or to some extent in 18 athletes. All athletes underwent a bilateral open hernia repair with concurrent adductor tendon release. Average follow-up was 4 years, and average time to return to competitive sport was 4 months. At final follow-up, 95% of soccer players were still active, 48 at the same level and 19 at a lower level. Four athletes had stopped their careers because of another injury (n52) or recurrence (n52). Sportsman’s hernia is a potentially career-ending injury in professional soccer players. Conservative management is often unsuccessful. An open surgical hernia repair combined with an adductor longus tenotomy relieves the symptoms caused by a sportsman’s hernia and restores activity in 95% of athletes. This study offers insight into the management of sportsman’s hernia and offers a successful treatment to salvage the careers of professional soccer players.

This study aimed to evaluate the long-term results of arthroscopic thermal shrinkage of the anterior capsule in athletes with internal shoulder impingement. In recent years, opinion with regards to the aetiology of internal shoulder impingement has changed significantly. The traditional treatment of internal impingement consisted of debridement of labral and/or undersurface cuff lesions. The use of concomitant thermal capsulorrhaphy, based on the concept of anteroinferior laxity, has also been advocated with excellent short-term results. In this study we investigated the long-term effects of this technique. Twelve overhead athletes with internal impingement underwent traditional arthroscopic treatment plus thermal capsulorrhaphy for internal impingement. All patients were evaluated 1, 2 and 7 years postoperatively using a questionnaire regarding their sports activity, and the modified Rowe score. At 1, 2 and 7 years postoperatively there was a significant improvement in the modified Rowe score when compared to the preoperative scores. However, follow-up at 7 years showed a significant deterioration of the initial 1 and 2 year results (p0.001), with only 25% of the athletes able to perform sports at their preoperative level.Excellent short-term results with thermal capsulorrhaphy, in addition to traditional arthroscopic treatment, in patients with internal shoulder impingement were not sustained over time. After 7 years, only 25% of the athletes were able to perform sports at their preoperative level.

Chronic groin pain in athletes is a difficult diagnostic and therapeutic condition. Between March 2004 and December 2009, 241 male athletes (mean age: 25.8 years, range: 16-41) in whom chronic sportsman's hernia was diagnosed, were surgically treated using a standardised technique. In this retrospective study, charts were analyzed for preoperative duration of symptoms and prior treatment. Perioperative complications were noted. Patients were contacted and were asked to answer a telephone questionnaire: 162 patients agreed to be questioned as part of the current study. A surgical intervention with reinforcement of the posterior inguinal wall and tenotomy of the adductors has lead to satisfactory results in over 90% of athletes with chronic groin pain who failed to improve with conservative treatment.

A case is presented of a 78-year-old woman who sustained a re-fracture of the distal radius after initial fixation with a volar locking plate. The fracture was located in the mid-portion of the volar plate with palmar apex bending of the plate and signs of median nerve compression. A successful closed reduction was performed without hardware failure. The fracture united uneventfully.

Arthroscopy of the elbow has become a standard treatment option for many indications. The purpose of this article is to review literature concerning the use of arthroscopy for acute elbow injuries.The main medical literature databases were searched for articles on the use of elbow arthroscopy in acute injuries. A total of 13 publications relevant to the topic were included. The Coleman methodology score was used to assess the methods of each article.All published articles have been case reports or retrospective case series. In fracture treatment, arthroscopy has been used in the treatment of displaced radial head, coronoid and capitellum fractures in adults and displaced radial neck and lateral humeral condyle fractures in children with good results. Endoscopic techniques have been used in distal biceps rupture and medial avulsion of the triceps. And also new techniques have been developed for the treatment of intra-articular soft-tissue lesions like rupture of the radial ulnohumeral ligament complex. One of the 13 studies analyzed was considered of good quality, 5 of moderate quality and all others of poor quality with inconsistent methodology and outcomes.The range of treatments using elbow arthroscopy in acute injuries is expanding and brings new controversies and challenges. Single reports of arthroscopically treated bony and soft-tissue injuries of the elbow showed satisfactory results. However, further randomized prospective studies are needed to evaluate their safety and efficacy compared with open 'gold standard' techniques.IV.

Background: Recent studies report that magnetic resonance imaging (MRI) shows a high incidence of associated injuries in patients with a radial head fracture. This retrospective study describes the clinical relevance of these injuries. Materials and methods: Forty patients with 42 radial head fractures underwent a MRI scan after a mean of 7.0 days after trauma and were reviewed after a mean of 13.3 months. Results: MRI showed 24 of 42 elbows had a lateral collateral ligament (LCL) lesion, 1 had a medial collateral ligament (MCL) and LCL lesion, 16 had an injury of the capitellum, 1 had a coronoid fracture, and 2 had loose osteochondral fragments. Clinical evaluation after a mean of 13.3 months showed that 3 elbows had clinical MCL or LCL laxity, of which 2 elbows had no ligamentous injuries diagnosed with MRI. One elbow with a loose osteochondral fragment showed infrequent elbow locking. The mean Mayo Elbow Performance Scale was 97.5 (range, 80-100) after a mean of 13.3 months after trauma, with no significant difference between patients with and without associated injuries (P ¼ .8). Conclusion: Most injuries found with MRI in patients with radial head fractures are not symptomatic or of clinical importance in short-term follow-up. Level of evidence: Level II, Retrospective Design, Prognosis Study. 2011 Journal of Shoulder and Elbow Surgery Board of Trustees.

Purpose To investigate whether volar percutaneous screw fixation of scaphoid waist fractures via a transtrapezial approach causes degenerative changes at the scaphotrapezial (ST) joint at short- to medium-term follow-up. Methods A total of 34 patients were available for follow-up at a mean of 6.1 years (minimum follow-up, 3.7 y) after volar percutaneous fixation of acute scaphoid waist fractures via a transtrapezial approach. The clinical follow-up examination included assessment of pain using a visual analog scale, range of motion, grip strength, and key pinch strength. We obtained radiographs of both hands in 3 views. We staged degenerative changes at the ST joint according to the modified Eaton and Glickel classification. Results The modified Mayo wrist score showed excellent clinical results using the described technique. One patient showed asymptomatic unilateral stage 2 osteoarthritic changes at the ST joint. We noted 6 screw protrusions, which required screw removal in 2 patients, in the early stages of use of the transtrapezial technique. One patient was treated surgically for a bone cyst. Conclusions Volar percutaneous screw fixation of nondisplaced scaphoid waist fractures using a transtrapezial approach does not lead to symptomatic scaphotrapezial osteoarthritis at short- to medium-term follow-up. (J Hand Surg 2011;36A:1753-1758. Copyright (C) 2011 by the American Society for Surgery of the Hand. All rights reserved.)

The purpose of this study was to analyse the clinical and radiological results of meniscal repairs and identify factors that correlate with the success of this procedure. A retrospective review of 119 meniscal repairs was completed. The average follow-up was 70 months. Successful meniscal repairs were observed critically in terms of radiographic changes and clinical outcomes and compared with failed meniscal repairs. The overall success rate of meniscal repairs was 74%. Meniscal repairs that were performed within 6 weeks of injury had better results (83%) than late repairs (52%). The best results were obtained with the inside-out technique using #0 PDS suture (80%) compared to all-inside Biofix arrows (70%) and combined repairs (63%). Patients with associated ACL injury had a better chance of a successful outcome, but this was only significant when the ACL was reconstructed at the time of repair (P < 0.05). Those patients who had failed meniscal repair had increased radiographic osteoarthritic changes (81%) on long-term follow-up compared to patients with successful repair (14%). This retrospective study shows the clinical and radiological importance of meniscal repair. Successful results in this study were associated with younger age and earlier repair using inside-out technique. Furthermore, increased success was seen in meniscal repairs performed in association with ACL reconstruction.

A biomechanical in vitro study was performed on 16 fresh frozen cadaver forearms to investigate the role of the transverse carpal ligament (TCL) in carpal stability. The distance between the scaphoid and hamate was measured, as a reference for the length of the TCL. Distances were recorded in both loaded and unloaded conditions after gradual sectioning of the transverse carpal ligament, the palmar scapholunate, long radiolunate ligament and radioscapholunate ligament. The largest increase in spread of the carpal bones (55.3% of total spread) was noted after loading with the ligament intact. Thereafter, sectioning of the TCL resulted in a further 32.9% increase in the distance between the scaphoid and the hamate. We conclude that the intact carpal bones-ligament complex displays some elasticity. Progressive sectioning of the TCL ligament under loading further opens the palmar arch. Nevertheless it appears that the carpal arch will still retain reasonable intrinsic stability even without an intact TCL.

Background A prospective study was established to assess the sensitivity of the newly described Bell-van Riet (BvR) test for isolated AC pathology, and compare with 4 commonly used clinical tests. Materials and methods The BvR test is essentially the cross-adduction test, with the addition of attempted elevation against resistance. In a positive test, this results in some pain and the inability of the patient to maintain the arm in the adducted and elevated position against resistance. Fifty-eight patients with isolated AC joint symptoms were assessed in random order with the BvR test and 4 other tests. A corticosteroid and local anaesthetic injection was administered into the AC joint space. The BvR test and 4 other tests were then repeated following the injection. After the injection, a symptom free clinical examination was used as a measure of truly positive tests. Results The BvR test showed a sensitivity of 98%. All 4 other tests were less sensitive. Conclusion The BvR test is a highly sensitive test in patients presenting with isolated AC related symptoms, and demonstrates AC joint pathology better than other accepted tests.

Radial head resection has yielded excellent long-term results in isolated radial head fractures. Most comminuted radial head fractures are complicated by associated lesions, however, and acute radial head replacement is often indicated in these patients. Metal radial head prostheses have become the standard treatment of irreparable radial head fractures with associated lesions to the elbow or forearm that render the elbow or forearm unstable. The prosthesis has been postulated to act as a temporary spacer while the injured soft tissues heal. Subsequent removal of the prosthesis to decrease pain and increase mobility yielded good to excellent results in previously reported cases. However, we present a patient whose in whom the soft tissues did not heal over a prolonged period, leading to a poor result after removal of a radial head implant.

Background Chronic longitudinal radioulnar dissociation has been associated with unpredictable and generally unfavorable outcomes. Metallic radial head replacement may address this treatment deficiency. Methods Eight patients were treated with a metallic radial head replacement for chronic longitudinal radioulnar dissociation. The average treatment delay was 3.3 years. All eight patients were seen for a clinical and radiographic assessment. Results Five of the 8 failed after a mean of 3 years (range, 1-5.7). Revision to bipolar metallic radial head replacement was successful in the short term in 2 of 3 that failed from aseptic loosening. One of 2 failures due to painful radiocapitellar arthritis was salvaged with a capitellar replacement. Discussion Reconstruction for symptoms following an Essex-Lopresti injury remains problematic. A metalic radial head implant appears to be an effective adjunct, but not a perfect solution in all patients. Recognition of the negative impact of residual lateral ulnar collateral ligament laxity is an important observation and should be specifically addressed with the reconstructive procedure. Conclusion Metallic monoblock radial head replacement did not reliably address the functional deficiency from chronic radioulnar dissociation primarily due to malalignment and implant loosening. A cemented bipolar radial head implant may provide a better alternative as a long-term solution. Regardless, ligamentous integrity at the elbow should also be addressed at the time of the reconstruction.

Background Pain in the buttock radiating to the popliteal fossa associated with hamstring weakness can be caused by tethering of the sciatic nerve to the proximal hamstring tendons. Contraction of the hamstring muscles produces traction on the sciatic nerve and subsequent symptoms. Hypothesis Surgical release of the proximal hamstring tendons, in particular from the sciatic nerve, will improve symptoms and function. Study Design Case series; Level of evidence, 4. Methods Forty-seven proximal hamstring surgical releases were performed in 44 patients (28 males, 16 females). The initial clinical findings and imaging were obtained from the medical notes, and additional data were obtained from a later questionnaire. The average age at the time of surgery was 29 years (range, 15–58 years). All patients were involved in high-level sports. Long-term follow-up was with a comprehensive postal questionnaire. Results Full follow-up was obtained in 43 patients (46 operations). Average follow-up was 53 months (range, 9–110). No major complications were encountered from the surgery. The average visual analog scale pain score decreased from 6.5 preoperatively to 2.0 ( P < .001). Two patients had increased pain, and pain was unchanged in 4. The average subjective weakness score decreased from 6.6 to 2.8 ( P < .001). Three patients reported increased weakness at follow-up, and 3 patients reported that the hamstring muscles felt equally weak. Thirty-four patients (77%) had returned to their previous sporting activities, with 30 patients still competing at or above state level, or professionally, after surgery. The average satisfaction score was 7.8. Six patients (14%) were not satisfied with the outcome of the procedure, 5 patients (11%) were somewhat satisfied, and 33 patients (75%) were very satisfied. Conclusion Proximal hamstring syndrome occurs mainly in patients participating in competitive sports. Release of the proximal hamstring tendons in this active group resulted in decreased pain and increased strength, and the majority of patients were satisfied with the procedure.

Background Documentation of the long-term effectiveness of 3-part unlinked elbow replacement is limited. The value of replacing the radial humeral articulation has not been addressed to any extent in the currently available literature. Materials A retrospective study of patient charts and radiographs of 37 patients receiving 46 primary Pritchard ERS TM arthroplasties between 1983 and 1992 were reviewed. Thirty-two implants (70%) failed after an average of 83 months (range, 0-198). Causes of failure were analyzed in detail. Results Kaplan Meier survivor analysis showed a 10-year survival of 54% (confidence interval: 40-71%). Main reasons for failure were instability, wear, and loosening. Immediate postoperative radiographs showed ulnohumeral malposition (valgus or varus) in 19 elbows, which directly correlated to subsequent failure. While this design has proven to be unsuccessful, it does document the need for precise technique and highlights the issue of replacing the radio/capitellar joint in future designs deserves further study. Conclusion An explanation of these disappointing outcomes resides both in an inadequate design and a poorly understood and executed surgical technique. The value of refined instrumentation to allow accurate and reproducible component implantation and soft tissue balancing is highlighted. These considerations are particularly relevant if the radial head component is to be used. Level of evidence Level IV, Case Series, Treatment Study.

The purpose of this study was to evaluate supraspinatus and subscapularis strength following repair of either isolated or anterosuperior subscapularis tears associated with a supraspinatus tear. Open subscapularis repairs were done in 24 patients, 12 isolated and 12 anterosuperior. At an average follow-up of 40 months, UCLA, ASES, and Constant scores were recorded. Subscapularis and supraspinatus strengths were tested using a spring gauge. Ultrasound scanning was performed in 20 patients. Average scores were 27 UCLA, 77 ASES and 90 relative Constant. Subscapularis strength was 92% of the non-operated shoulder. Supraspinatus strength was 90%. Statistical analysis showed a significant decrease in supraspinatus strength in the anterosuperior group. No other significant differences were noted. Ultrasound scanning showed an intact subscapularis tendon in all. Full thickness supraspinatus tears were found in 5 and partial thickness in 1. Not the subscapularis, but the supraspinatus determines the outcome of anterosuperior repairs, with more re-tears and decreased strength.

We believe a better way is needed to accurately describe the spectrum of associated injuries that commonly occur in conjunction with a radial head fracture. A review of our institution’s experience with 333 radial head fractures from 1997 to 2002 documented 88 (26%) associated injuries. Based on this clinical experience, our goal was to develop an accurate and comprehensive description of associated injuries. A shorthand suffix method first recognizes the type of radial head fracture with the traditional Mason classification, followed by abbreviations designating the articular injuries, coronoid (c) and olecranon (o), and the ligamentous injuries, lateral collateral ligament (l), medial collateral ligament (m), and distal radioulnar joint (d). The proposed system offers a logical and reproducible (98%) extension of the current Mason fracture classification to document the presence of additional articular and ligamentous injuries. This provides an opportunity to standardize the communication of fracture type with further details of other injuries that ultimately can help with better understanding of treatment outcome based on the precise injury complex.

Painful snapping of the scapula may have an anatomical cause but is usually idiopathic. Most patients respond well to conservative measures such as physiotherapy or non-steroidal anti-inflammatory drugs. Surgery can be performed if conservative treatment is unsuccessful. Conservative measures are less likely to be successful if a clear anatomical cause can be found. Several surgical techniques have been described, ranging from bursectomy to resection of the lesion or of part of the scapula. The lesion is usually resected by an open technique. Scapulothoracic arthroscopy has previously been shown to be a safe procedure with low morbidity in idiopathic cases. A case is described in which painful crepitus of the scapula not responding to conservative measures was caused by an inferior subscapular osteochondroma. Arthroscopic resection of the osteochondroma was performed using a custom, lesion specific, inferior portal. This resulted in restoration of a full and painless function of the shoulder within two weeks of surgery.

A review of the literature was performed to survey the history of the radial head prosthesis in traumatology. Radial head resection was the treatment of choice before Speed first reconstructed the radial head with a metal prosthesis. Over the years, the indication for the use of a radial head prosthesis changed from the prevention of heterotopic ossification to the prevention of proximal migration of the radius and instability of the elbow. Currently, the optimal indication for the use of radial head prostheses is a non-reconstructible radial head fracture with associated injuries that would leave the elbow, or forearm unstable if the radial head were resected.

The long-term results of resection of the radial head for the treatment of a simple radial head fracture have been generally satisfactory1-5. However, some late complications, such as proximal migration of the radius, can disable the patient and are difficult to treat. Proximal migration of the radius is usually asymptomatic3-5, although wrist pain develops in a minority of patients3-8. The options for treatment are limited, and clinical studies have shown poor and unreliable results9,10. Sowa et al. described a case in which a silicone radial head prosthesis was implanted for the treatment of wrist symptoms10. Proximal migration of the radius progressed, and it was concluded that a more rigid implant would be necessary. Sellman et al. reached a similar conclusion after performing a biomechanical study of this problem11. We report the case of a patient who had early progressive erosion of the capitellum after the insertion of a metal radial head prosthesis for the treatment of wrist pain following radial head resection after trauma. This complication has not been reported previously, to our knowledge. Our patient was informed that data concerning the case would be submitted for …

Background: Distal triceps tendon ruptures occur rarely, and the diagnosis is often missed when the injury is acute. The literature provides little guidance regarding treatment or the outcome of treatment of these injuries. The goal of this report was to present our experience with the diagnosis, timing and technique of surgical treatment, and outcome of treatment of distal triceps tendon ruptures in twenty-two patients. None of the ruptures followed joint replacement. Methods: Twenty-three procedures were performed in twenty-two patients with an average age of forty-seven years. The average duration of follow-up was ninety-three months (range, seven to 264 months). Data were obtained by a retrospective review of records and radiographs before and after surgery. Also, thirteen patients returned for follow-up and were examined clinically. Six additional patients responded to a telephone questionnaire. One patient was lost to follow-up, and two had died. Formal biomechanical evaluation of isokinetic strength and isokinetic work was performed in eight patients, at an average of eighty-eight months after surgery. Isokinetic strength data were available from the charts of two additional patients. Results: Ten of the triceps tendon ruptures were initially misdiagnosed. At the time of diagnosis, triceps weakness with a decreased active range of motion was found in most patients, and a palpable defect in the tendon was noted after sixteen ruptures. Operative findings revealed a complete tendon rupture in eight cases and partial injuries in fifteen. Fourteen primary repairs and nine reconstructions of various types were performed. Three of the primary repairs were followed by rerupture. At the time of follow-up, the range of elbow motion averaged 10° to 136°. All but two elbows had a functional range of motion; however, the lack of a functional range in the two elbows was probably due to posttraumatic arthritis and not to the triceps tendon rupture. Triceps strength was noted to be 4/5 or 5/5 on manual testing in all examined subjects. Isokinetic testing of ten patients showed that peak strength was, on the average, 82% of that of the untreated extremity. Testing showed the average endurance of the involved extremity to be 99% of that of the uninvolved arm. The results after repair and reconstruction were comparable, but the patients' recovery was slower after reconstruction. Conclusions: The diagnosis of distal triceps tendon rupture is often missed when the injury is acute because of swelling and pain. Primary repair of the ruptured tendon is always possible when it is performed within three weeks after the injury. When the diagnosis is in doubt immediately after an injury, the patient should be followed closely and should be reexamined after the swelling and pain have diminished so that treatment can be instituted before the end of this three-week period. Reconstruction of the tendon is a much more complex, challenging procedure, and the postoperative recovery is slower. Thus, we believe that early surgical repair, within three weeks after the injury, is the treatment of choice for distal triceps tendon ruptures. Level of Evidence: Therapeutic study, Level IV (case series [no, or historical, control group]). See Instructions to Authors for a complete description of levels of evidence.