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Purpose To determine if long head of the biceps (LHB) tenotomy is not inferior to suprapectoral LHB tenodesis when performed in conjunction with arthroscopic repair of small- to medium-sized nontraumatic rotator cuff tears. Methods This multicenter, randomized, non-inferiority trial recruited 100 participants older than 50 years who had a supraspinatus and/or infraspinatus tear sagittally smaller than 3 cm and arthroscopically confirmed LHB pathology. During arthroscopic rotator cuff repair, we randomized 48 patients to undergo suprapectoral LHB tenodesis and 52 patients to undergo LHB tenotomy. Data were collected preoperatively and at 6 weeks, 3 months, and 1 year postoperatively. The primary outcome was non-inferiority of the Constant-Murley score (CMS) at 1-year follow-up. Secondary outcomes included the Dutch Oxford Shoulder Score; Disabilities of the Arm, Shoulder and Hand questionnaire; Popeye deformity; elbow flexion strength index; arm cramping pain; and quality of life (EQ-5D score). The integrity of the rotator cuff repair was assessed with magnetic resonance imaging. Differences between intervention groups were analyzed by mixed modeling. Results The mean CMS in the LHB tenotomy group improved from 44 (95% confidence interval [CI], 39-48) to 73 (95% CI, 68-79). In patients with LHB tenodesis, the mean CMS improved from 42 (95% CI, 37-48) to 78 (95% CI, 74-82). The difference between groups at 1-year follow-up was 4.8 (97.5% CI, –∞ to 11.4), with a P value for non-inferiority of .06. The secondary outcomes also improved over time, with no remarkable differences between groups. A Popeye deformity occurred in 33% of tenodesis patients and 47% of tenotomy patients (P = .17). Tenotomy was performed with a shorter operative time (73 minutes vs 82 minutes, P = .03). Magnetic resonance imaging showed a recurrent rotator cuff tear in 20% of all cases. Conclusions Although statistically “inconclusive” regarding non-inferiority of the CMS at 1-year follow-up, any observed differences between patients with LHB tenotomy and those with LHB tenodesis in all outcome scores were small. Level of Evidence Level I, randomized controlled trial and treatment study.

Background:This study was aimed at identifying the criteria for the diagnosis of Radiocarpal instability in rheumatoid arthritis RA).Methods:The main databases were searched to identify studies describing the pathophysiology of Radiocarpal instability in patients with RA. We focussed on the epidemiology, radiographic parameters, criteria for instability and on treatment options. Results. In the search 108 articles were found, of these 12 studies were included for this review. Instability occurs in at an average of 35.2% of the rheumatoid wrists. The instability was found between 8 and 13 years after onset of rheumatoid arthritis. A strong correlation was found between instability, duration of RA and Larsen score. Several radiographic methods were described to evaluate Radiocarpal instability in RA. Several treatment options for instability in patients with RA are described. All with their own indications and limitations.Conclusion:OOn a standard AP radiograph deformity can be measured using the carpal height and the ulnar translation index of Chamay. This gives an indication for instability. For describing the deterioration of the joints the Larsen score is most used. If there are more radiographs in time the Simmen classification can be used. For real assessment of instability dynamic radiographs are needed.Level of Evidence:Level IV.

The distal tibiofibular syndesmosis is essential for the stability of the ankle joint that is required for weight transmission and walking.4,9,42 The syndesmosis consists of the anterior-inferior tibiofibular ligament, posterior-inferior tibiofibular ligament, inferior transverse tibiofibular ligament, and interosseous ligament. This complex stabilizes the mortise by securing the fibula in the fibular notch (incisura fibularis tibiae). Syndesmotic injuries most commonly are caused by pronation-external rotation, pronation-abduction and, less frequently, a supination-external rotation mechanism (DanisWeber C injuries).31 These forces cause the talus to abduct or to rotate externally in the mortise, leading to disruption of the syndesmotic ligaments.31,55 Anatomical restoration of the disrupted distal tibiofibular syndesmosis is essential.54 Widening and chronic instability of the distal tibiofibular syndesmosis have been correlated with poor functional outcomes and the development of osteoarthritis.11,16,41,44,52 Because nonoperative treatment cannot effectively stabilize the distal tibiofibular syndesmosis during healing, operative fixation often is recommended. However, the need for transsyndesmotic fixation of the distal tibiofibular joint is controversial, and recommendations for fixation for specific ankle injury patterns are conflicting.6 Other areas of controversy include the optimal number of cortices, the appropriate size of the screws, the position of the ankle joint during screw

In this case report, we describe the arthroscopic removal of an osteoid osteoma from the acetabulum in a young adolescent. After identifying the osteoid osteoma close to the cartilage with MRI and CT investigations, we decided that in this case, arthroscopic removal was the best treatment. In the case of an osteoid osteoma in the acetabulum close to the cartilage, arthroscopic removal should be considered as one can treat the associated osteochondritic lesion during this procedure. Level of evidence IV.

We enjoyed reading the well-illustrated report of 2 cases published by Valkering et al. [6]. They describe 2 patients with persisting anterior ankle impingement after an ankle sprain due to a web-like intra-articular fibrous band. One year after arthroscopic dissection of these bands, both patients were free of complaints. The authors and also others suggest that these transarticular fibrous strands could be induced by the intra-articular accumulation of blood after a trauma [2, 6]. Therefore, they advise that considering the aetiology of these bands, the consequence of observing one should prompt a careful inspection of the ankle joint for additional post-traumatic pathology. However, we have two comments on this article, and the conclusions of the authors should be seen in this light. We agree that anterior ankle arthroscopy is of great value in the diagnostic work-up and treatment for these post-traumatic intra-articular bands; however, the authors did not discuss that these bands should be differentiated from a distal/associated fascicle of the antero-inferior tibiofibular ligament (one of the syndesmotic ligaments). The fibres of the accessory ligament descended obliquely from the lateral, anterior, and distal borders of the tibia to the anteromedial aspect of the lateral malleolus, approximating the fibular insertion of the anterior talofibular ligament [1, 7]. The incidence of the accessory fascicle differs very widely in several studies and could be a normal finding [5]. When the band restricts plantar flexion, the diagnosis of post-traumatic anterior fibrous bundle is more probable because this accessory ligament only causes pain complaints [4]. The anatomical and pathomechanical aspects of these two pathologies differ and are interesting for the ankle arthroscopist. The diagnosis with arthroscopy and treatment with resection are, however, very similar. The second comment is concerning the pathomechanism of the pain complaints. After non-operative treatment for ankle sprains, some degree of laxity will persist [3] and this could result in contact between the talus and the band in the ankles, which showed no contact previously [1, 7]. As Valkering et al. already suggested, an arthroscopic impingement test (bending of the band caused by impingement of the talus) could be performed and an anterior abraded articular region of the talus due to the impingement could be observed [6, 7]. The authors do not know whether the band already exists before the ankle sprain and becomes symptomatic due to the laxity caused by injury of the anterior talofibular joint and the subsequent altered biomechanics of the ankle joint. Can this band also be observed in (post-traumatic) ankles without an anterior impingement syndrome?

Purpose We evaluated long-term results for radiolunate and radioscapholunate arthrodeses for patients with rheumatoid or psoriatic arthritis to determine the durability and efficacy of the procedures. The results are described and compared with those in the literature. Methods We carried out arthrodesis of the radiolunate joint (33 wrists) and the radioscapholunate joint (13 wrists) to achieve pain reduction and ulnar translation of the carpus in patients with rheumatoid (42 wrists) or psoriatic arthritis (4 wrists). At follow-up, 11 patients (13 wrists) had died, 2 patients (4 wrists) were lost to follow-up, and in 6 wrists an additional midcarpal arthrodesis had been performed. We evaluated the remaining 23 wrists (19 radiolunate and 4 radioscapholunate, and 1 psoriatic arthritic wrist) after a mean of 11 years. Results Clinical outcome was good, with a mean visual analog score of 2 out of 10 for pain, mean grip strength of 13 kg, and mean range of flexion-extension of 60°. Outcomes as measured by questionnaires were good. Radiographs demonstrated deterioration of all intracarpal joints as noted by an increased Larsen score and evidence of carpal translation. We noted no significant change in carpal height. Conclusions Despite radiographic progression, radiolunate and radioscapholunate arthrodeses yield good clinical results at long-term follow-up. Type of study/level of evidence Therapeutic IV.

ObjectiveThe Disability of Arm, Shoulder and Hand (DASH) questionnaire is a tool for measuring physical function and symptoms of the upper extremity. Although widely used, it is not validated for rheumatoid arthritis (RA). In this study the DASH was validated for this patient group.MethodsIn total, 102 patients participated in this study. For the validation, the questionnaires of the DASH, the Health Assessment Questionnaire (HAQ), the Medical Outcomes Study Short Form-36 (SF-36), and the Arthritis Impact Measurement Scale (AIMS2) were used. Patients were examined clinically before completing the questionnaires. Pain was scored by each patient using a visual analog scale (VAS). The DiseaseActivity Score (DAS28) was obtained and grip strength was measured. Reliability was tested by a second DASH questionnaire after 2 days. Validity was tested using a Pearson correlation analysis for the relevant domains of the questionnaires and for the clinical aspects.ResultsThe reliability of the DASH was excellent (intraclass correlation coefficient 0.97). Internal consistency was strong (Cronbach’s alpha 0.97). Validity was proven with excellent results for Pearson correlation with the relevant domains of the questionnaires: HAQ, r = 0.88; SF-36, r = 0.70; and AIMS2, r = 0.85. The clinical scores had a relatively low correlation with the DASH (DAS28, r = 0.42; and grip strength, r = 0.41–0.48), except for the VAS (r = 0.60–0.65).ConclusionThe DASH is a reliable and valid questionnaire in patients with RA. It can be used as a measurement tool of physical disability of the upper extremity.

Arthroscopic debridement has been used to treat patients with degenerative knee osteoarthritis, although there is sometimes conflicting evidence documenting its efficacy. This study evaluates the success of arthroscopic debridement in elderly patients with grade III and IV chondromalacia of the knee as measured by patient satisfaction and the need for additional surgery. From December 1998 to August 2001, a total of 102 consecutive cases of knee arthroscopy in 99 patients > 60 years were performed. Average follow-up was 34 months (range: 7-104 months). Patients were asked about their satisfaction using a visual analog scale, and the presence of meniscal lesions during arthroscopy and the treatment for these lesions were evaluated. Knees also were assessed for articular surface degeneration using Outerbridge's classification for chondromalacia. The need for and type of additional surgery was evaluated. During arthroscopy, meniscal lesions requiring a partial meniscectomy were found in 95 knees. Chondromalacia was found in 92 knees; 53 knees had grade I or II chondromalacia and 39 knees had grade III or IV chondromalacia. Additional surgery was performed in 17 knees. Mean patient satisfaction score was 73 (range: 50-100) in the 39 knees with grade III or IV chondromalacia after arthroscopic debridement was performed. These findings suggest arthroscopic debridement in elderly patients has a place in the treatment algorithm for grade III or IV chondromalacia of the knee.

Introduction: We compared the results of patients with symptomatic osteoarthritis of the first carpametacarpal joint treated with either trapezio-metacarpal arthrodese or resection arthroplasty (without tendon interposition). Method: From 1978 until 2000 fourteen CMC I arthrodeses in 13 patients (3 male, LO female; average age 67 years; average follow-up 6 years) and 15 resection arthoplasties were performed in 13 patients (4 male, 9 female: average age 72 years; average follow-up 11 years). Results: De visual analogue score for pain and satisfaction was for the arthrodesis 85 and 91 and for the arthroplasty 84 and 89. The average function score (maximum 30 points) was for both procedures 24 points. The average grip strength with the Jamarmeter was for the arthrodesis 20 N for the arthroplasty 18 N. The tip pinch aud chuck pinch strength (maximum for both 5 points) were for the arthrodesis both 3 points and for the arthroplasty both 2 points. Complications for the arthrodesis: 2 non-unions, treated with rearthrodesis, 1 Sudeckse dystrophy. In the arthroplasty group 2 patients were treated for recurrent symptoms 2 and 8 years after initial surgery with reresection. In 9 patients the osteosynthesis material was removed due to patients complaints. Conclusion: In this study both procedures lead to equal results.

Impingement syndromes of the ankle involve either osseous or soft tissue impingement and can be anterior, anterolateral, or posterior. Ankle impingement syndromes are painful conditions caused by the friction of joint tissues, which are both the cause and the effect of altered joint biomechanics. The distal fascicle of the anterior inferior tibiofibular ligament (AITFL) is possible cause of anterior impingement. The objective of this article was to review the literature concerning the anatomy, pathogenesis, symptoms and treatment of the AITFL impingement and finally to formulate treatment recommendations. The AITFL starts from the distal tibia, 5 mm in average above the articular surface, and descends obliquely between the adjacent margins of the tibia and fibula, anterior to the syndesmosis to the anterior aspect of the lateral malleolus. The incidence of the accessory fascicle differs very widely in the several studies. The presence of the distal fascicle of the AITFL and also the contact with the anterolateral talus is probably a normal finding. It may become pathological, due to anatomical variations and/or anterolateral instability of the ankle resulting from an anterior talofibular ligament injury. When observed during an ankle arthroscopy, the surgeon should look for the criteria described to decide whether it is pathological and considering resection of the distal fascicle. The presence of the AITFL and the contact with the talus is a normal finding. An impingement of the AITFL can result from an anatomical variant or anteroposterior instability of the ankle. The diagnosis of ligamentous impingement in the anterior aspect of the ankle should be considered in patients who have chronic ankle pain in the anterolateral aspect of the ankle after an inversion injury and have a stable ankle, normal plain radiographs, and isolated point tenderness on the anterolateral aspect of the talar dome and in the anteroinferior tibiofibular ligament. The impingement syndrome can be treated arthroscopically.