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Purpose: We sought to determine the safest drill trajectory to avoid injury to the posterior interosseous nerve (PIN) when performing a repair of a distal biceps tendon to an anatomic location through an anterior, single-incision approach using cortical button fixation., Methods: A standard anterior approach was performed in 10 cadaveric specimens to expose the distal biceps attachment. Three drill holes were made in the radial tuberosity from the center of the anatomic footprint for the distal biceps tendon insertion with the forearm fully supinated. Holes were made in 30° distal, transverse, and 30° proximal directions. Each hole was made by angling the trajectory from an anterior to posterior and ulnar to radial direction, leaving adequate bone on the ulnar side to accommodate an 8-mm tunnel for the purpose of docking the biceps tendon into bone. The proximity of each drill trajectory to the PIN was determined by making a second incision on the dorsum of the proximal forearm. A K-wire was passed through each hole, and the distance between the PIN and K-wire was measured for each trajectory., Results: The distally directed drill hole placed the trajectory wire closest to the PIN (mean distance, 5.4 mm), contacting the K-wire in 3 cases. The transverse drill trajectory resulted in contact with the PIN in 1 case (mean distance, 7.6 mm). The proximal drill trajectory appeared safest, with no PIN contact (mean distance, 13.3 mm)., Conclusions: In this cadaveric study, the proximal drill trajectory resulted in the widest clearance from the PIN., Clinical Relevance: When performing repair of a distal biceps tendon to the anatomic location on the tuberosity, the drill trajectory from the center of the biceps footprint should be radial and proximal to provide the greatest separation between the drill guide and the PIN., (Copyright © 2023. Published by Elsevier Inc.)

Background  Pisotriquetral pain and instability is an elusive cause of ulnar-sided wrist pain. Initial treatment of chronic pisotriquetral pathology should involve a trial of nonoperative therapy such as neutral wrist splint, anti-inflammatories, and intra-articular steroid injections. The mainstay of surgical management of pisotriquetral pain is pisiform excision. Purpose  This prospective study seeks to understand patient satisfaction after pisiform excision in patients with isolated pisotriquetral pathology. Patients and Methods  A consecutive series of nine cases of pisiform excision was performed by the senior surgeon. The primary outcome measure was determined a priori to be the Patient-Rated Wrist Evaluation (PRWE) score. Wrist range of motion, grip strength, and QuickDASH (shortened version of Disabilities of the Arm, Shoulder and Hand) scores were also collected preoperatively and at 3 and 12 months postoperatively as secondary outcome measures. Results  There was a very rapid improvement in the PRWE by 3 months, which was maintained at 12 months. The QuickDASH score was slower to improve, with a significant improvement by 12 months. There was no change in grip strength or wrist range of motion at any time point. Conclusion  Pisiform excision results in a very rapid improvement of symptoms and should be considered in cases of pisotriquetral instability or arthritis that fail conservative management. Level of Evidence  Level IV, case series., Competing Interests: Conflict of Interest None declared., (Thieme. All rights reserved.)

Background: Varus posteromedial rotatory instability is a difficult clinical problem to diagnose and treat. Fixation of the anteromedial coronoid fracture is often necessary to achieve elbow stability. We describe an extensile surgical approach to the anteromedial coronoid., Methods: A retrospective review was performed of all patients at our institution who had anteromedial coronoid fracture fixed with this approach between 2012 and 2020., Results: Six patients were identified. They all achieved a stable elbow. Four of 6 developed heterotopic ossification and 2/6 required further surgery for this. Only 1 patient had a transient ulnar sensory loss., Conclusion: We describe an approach to the coronoid that allows great visualization of the joint and access to large coronoid fractures. The approach is extensile and does not require extensive dissection or work around the ulnar nerve. Access to fracture and for fixation can be improved by release of the common flexor pronator origin and the medial collateral ligament., (© 2022 The Author(s).)

Background: Distal biceps tendon tears can cause weakness and fatigue with activities requiring elbow flexion and supination. Surgical management of chronic tears (>21 days) is not well described in the literature., Purpose: To determine the clinical outcomes of chronic distal biceps repairs and reconstructions., Study Design: Systematic review; Level of evidence, 4., Methods: We performed a search of Medline (PubMed and Ovid), EMBASE, CINAHL physical therapy, Cochrane Database of Systematic Reviews and Central Register of Controlled Trials, and PubMed Central from inception until September 29, 2020, to identify articles on chronic distal biceps ruptures. The inclusion criteria were studies with at least 1 outcome measure and 10 patients with chronic distal biceps ruptures treated surgically. The quality of the included studies was assessed with the methodological index for nonrandomized studies (MINORS) score. Functional outcomes and complications were reviewed., Results: A total of 12 studies were included after systematic database screenings. The MINORS scores ranged from 5 to 19. There were a total of 1704 distal biceps ruptures, of which 1270 were acute and 434 were chronic. Average follow-up time was 12 months to 5.1 years. Single-incision (n = 3), 2-incision (n = 2), or both (n = 6) surgical techniques were used in these studies. Four studies described the use of autografts, and 4 articles used allografts in the chronic repair. Range of motion, function, and strength outcomes were similar when compared with the contralateral arm. Pain was reduced to minimal levels. Main postoperative complications were of paresthesia (specifically to the lateral antebrachial cutaneous nerve), which were temporary in 69.1% of cases., Conclusion: The results of this review indicate that surgical management of chronic distal biceps ruptures demonstrates improvement in outcomes including pain reduction and functional ability. Although there may be a slightly higher immediate complication rate, the functional outcomes remain comparable with those seen in the patient population with acute distal biceps., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: J.M.L. has received teaching fees from Arthrex. T.J.G. has received teaching fees from Acumed and ConMed Linvatec. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto., (© The Author(s) 2022.)

Background: Posterolateral rotator instability (PLRI) is the most common pattern of recurrent elbow instability, and current imaging to aid PLRI diagnosis is limited. Thus, we sought to define use of ultrasound (US) to determine normal lateral ulnohumeral joint measurements, with and without posterolateral drawer testing to provide an insight into how US may aid diagnosis., Methods: Sixty elbows were evaluated in thirty healthy volunteers. The lateral ulnohumeral gap (LUHG) was measured with US in the resting position while the posterolateral drawer stress test maneuver was applied. Joint laxity was calculated as the difference between maximum stress and average rest measurements. Two independent readers assessed each elbow with comparison performed between stress and rest positions., Results: Differences in the LUHG were evident between stress and rest conditions (reader 1: P  < .0001 and reader 2: P  = .0002). At rest, median LUHG values were 2.31 mm and 2.05 mm for readers 1 and 2 respectively, while at stress 2.88 mm and 2.9 mm for readers 1 and 2. Median joint laxity was 0.8 mm for reader 1 and 1.1 mm for reader 2. Pearson correlation was r = 0.457 (absolute intraclass correlation coefficient [ICC] = 0.608) while under stress and r = 0.308 (absolute intraclass correlation coefficient [ICC] = 0.417) at rest. Median joint laxity demonstrated a Pearson correlation of r = 0.161 and absolute intraclass correlation coefficient [ICC] = 0.252., Conclusions: This study demonstrates a dynamic US assessment for PLRI, which aimed to assess the usefulness and feasibility of a laxity measurement after the application of a posterolateral drawer stress maneuver in a healthy population. Although establishing concordance between readers in measuring an LUHG under stress, the utility of a laxity measurement alone is not clear as correlation of measurements is not excellent; hence, an upper limit of normal for the ulnohumeral gap under stress may be more useful. Further evaluation of this technique is required in patients with PLRI., (© 2021 Published by Elsevier Inc. on behalf of American Shoulder and Elbow Surgeons.)

Background: Compared with single-incision (SI) distal biceps repair, double-incision (DI) repair has been described as permitting a more anatomic repair. We hypothesized that DI repair would result in greater terminal supination torque compared with SI repair for acute distal biceps ruptures., Methods: Patients were included if they sustained an isolated, acute distal biceps rupture repaired between January 2012 and December 2017. Isometric forearm supination torque in 4 positions was measured using a validated uniaxial torque-testing device. Testing took place at least 12 months from surgery. The primary outcome was supination torque in the 60° supinated position. Secondary outcomes included supination torque in other forearm positions and functional outcome scores., Results: The study included 37 patients: 15 underwent repair with the DI technique and 22 with the SI technique. The mean age was 47.3 years, the median follow-up time was 28.1 months, and demographic data were similar between cohorts. Mean supination torque, relative to the unaffected side, was 61% (95% confidence interval, 45%-77%) for DI repair vs. 80% (95% confidence interval, 69%-92%) for SI repair in the 60° supinated position (P = .036). In a multivariable linear regression model controlling for arm dominance, age, follow-up time, and workers' compensation status; SI repair was associated with greater mean supination torque than DI repair by 20% (P = .015)., Conclusions: Contrary to our hypothesis, we found a 20% mean improvement in terminal supination torque for acute distal biceps ruptures repaired with the SI technique compared with the DI technique. This finding may have clinical significance for the more discerning, high-demand patient., (Copyright © 2019 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Background  Ulnocarpal impaction (UCI) is a described cause of ulnar side wrist pain. Questions  Does absolute ulnar variance (UV) or change in UV with grip affect patient-rated outcome scores (PROS) in patients with symptomatic UCI undergoing surgery? Does UV differ between symptomatic and contralateral wrists? Does arthroscopic grade of triangular fibrocartilaginous complex (TFCC) tears and lunotriquetral (LT) ligament tears influence PROS? Do PROS improve following ulnar shortening osteotomy (USO) or wafer procedures and does improvement depend on the amount of shortening or achievement of negative UV? Patients and Methods  We analyzed information on patients undergoing USO or wafer procedures for UCI as recorded in a database of prospectively collected information on individuals with ulnar side wrist pain. This included (1) patient-rated wrist evaluation and QuickDASH scores on enrolment, 3 and 12 months postoperatively; (2) standardized bilateral posteroanterior (PA) wrist radiographs, including PA grip views of the symptomatic wrist; and (3) arthroscopic findings. Results  Larger changes in UV between PA neutral and grip views prior to surgery were associated with smaller improvements in PROS, 12 months after surgery. Actual UV value before and after surgery did not affect PROS. There was no difference in UV between symptomatic and contralateral wrists. The presence of TFCC or LT ligament tears did not influence PROS. Mean PROS improved postoperatively. Conclusions  Ulnar shortening procedures result in improvement in PROS in patients with UCI. Variation in UV with rotation and grip results in variable outcomes. Level of Evidence  This is a Level II, cohort study.

Objectives: To identify associated injuries that occur in varus posteromedial rotatory instability (VPMRI) of the elbow and present their surgical management., Design: Level II retrospective study., Setting: Tertiary referral center., Patient/participants: Twenty-seven patients with VPMRI injuries treated surgically over an 8-year period., Intervention: Open reduction and internal fixation of anteromedial coronoid facet fracture, lateral collateral ligament repair, and associated injured soft-tissue repairs., Main Outcome Measured: Radiographic classification, associated medial and lateral bony and soft-tissue injuries, surgical fixation method, and complications were recorded., Results: According to the O'Driscoll classification, there were 15 (55%) type 2-2, 11 (41%) type 2-3, and 1 (4%) type 3-1 fractures. Lateral and medial collateral ligament tears were found in 100% and 63%, respectively. Common extensor and flexor origin injuries occurred in 19 (70%) and 2 (7%) elbows, respectively. A marginal radial head fracture was found in 1 patient. Most patients were treated with a combination of fixation methods. Complications occurred in 7 (26%) patients., Conclusions: This study documents both associated findings and surgical fixation methods. In all cases, the lateral collateral ligament was disrupted, often in association with an injured common extensor origin. Medial collateral ligament injuries are commonly involved. Radial head fractures are rarely associated. The surgeon should have a high index of suspicion if an isolated coronoid fracture is encountered. Clinical and functional outcome scores are needed in future studies to further inform treatment of VPMRI of the elbow., Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Purpose: To evaluate the functional outcome after removal of digital calcinosis cutis in patients with scleroderma using a high-speed burr., Methods: A retrospective analysis was performed of 9 consecutively enrolled scleroderma patients who underwent surgery by the senior author. A debulking procedure using a high-speed micro-burr to soften and express calcific material in digits was performed. Demographics, complications, recurrence, and postoperative functional outcome measurements including the Disabilities of the Arm, Shoulder, and Hand questionnaire, the Michigan Hand Questionnaire, a study-specific questionnaire, a visual analog scale, and the Short Form-12 were collected., Results: Mean follow-up time was 2 years. Four of 9 patients were very or somewhat satisfied with the procedure. Eight complications were recorded in 6 patients, including weakness, decreased motion, numbness, and superficial wound infection. The mean Disabilities of the Arm, Shoulder, and Hand score in patients who would have surgery again was 27 (4 of 9), versus 54 (5 of 9) for those who would not. Two patients had no recurrence. There were 7 cases of recurrence; 3 patients had late recurrence to a small degree, 3 had early complete recurrence, and 1 had recurrence at an unknown onset. No patient reported complete resolution of calcinosis. Patient satisfaction appeared inversely correlated to the number of digits involved., Conclusions: Patients with discrete areas of calcinosis cutis, including those with 1 or 2 digits affected, did much better than patients with diffuse disease and multiple affected digits. Patients should be counseled that the benefit might be more limited than previously reported, and recurrence is likely., Type of Study/level of Evidence: Therapeutic IV., (Copyright © 2014 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

In September 2010, the first International Scientific Tendinopathy Symposium (ISTS) was held in Umeå, Sweden, to establish a forum for original scientific and clinical insights in this growing field of clinical research and practice. The second ISTS was organised by the same group and held in Vancouver, Canada, in September 2012. This symposium was preceded by a round-table meeting in which the participants engaged in focused discussions, resulting in the following overview of tendinopathy clinical and research issues. This paper is a narrative review and summary developed during and after the second ISTS. The document is designed to highlight some key issues raised at ISTS 2012, and to integrate them into a shared conceptual framework. It should be considered an update and a signposting document rather than a comprehensive review. The document is developed for use by physiotherapists, physicians, athletic trainers, massage therapists and other health professionals as well as team coaches and strength/conditioning managers involved in care of sportspeople or workers with tendinopathy.

Synovial osteochondromatosis of the distal radioulnar joint is a rare entity with only 14 cases reported in the literature. Malignant transformation of synovial osteochondromatosis is the most worrisome complication of the disease. It has been described in joints such as the hip and knee but never for the distal radioulnar joint. We report a case of synovial osteochondromatosis of the distal radioulnar joint which presented with radiographic features which were worrisome for malignant transformation and required a comprehensive preoperative workup. Discussed are the preoperative management, surgical treatment, and a literature review of this rare disease.

Purpose: To estimate the contribution of the flexor pollicis longus (FPL) to key pinch strength. Secondary outcomes include tip pinch, 3-point chuck pinch, and grip strength., Methods: Eleven healthy volunteers consented to participate in the study. We recorded baseline measures for key, 3-point chuck, and tip pinch and for grip strength. In order to control for instability of the interphalangeal (IP) joint after FPL paralysis, pinch measurements were repeated after immobilizing the thumb IP joint. Measures were repeated after subjects underwent electromyography-guided lidocaine blockade of the FPL muscle. Nerve conduction studies and clinical examinations were used to confirm FPL blockade and to rule out median nerve blockade. Paired t-tests were used to compare pre- and postblock means for both unsplinted and splinted measures. The difference in means was used to estimate the contribution of FPL to pinch strength., Results: All 3 types of pinch strength showed a significant decrease between pre- and postblock measurements. The relative contribution of FPL for each pinch type was 56%, 44%, and 43% for key, chuck, and tip pinch, respectively. Mean grip strength did not decrease significantly. Splinting of the IP joint had no significant effect on pinch measurements., Conclusions: FPL paralysis resulted in a statistically significant decrease in pinch strength. IP joint immobilization to simulate IP joint fusion did not affect results., Clinical Relevance: Reconstruction after acute or chronic loss of FPL function should be considered when restoration of pinch strength is important., (Copyright © 2012 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Primary total elbow arthroplasty is a treatment option for elderly patients with osteopenic bone, increased comminution, and articular fragmentation. Recently, there has been a renewed interest in distal humerus hemiarthroplasty for the treatment of distal humerus fractures, including coronal shear fractures of the capitellum and trochlea. This article focuses on the evaluation and management of distal humerus fractures with prosthetic replacement.

We performed a structural investigation of several fixation devices for radial head and neck fixation. Fourteen pairs of fresh-frozen human elbows were used to simulate unstable radial neck fractures fixed with each of the following plates: 2.0-mm T-plate, 2.0-mm blade plate, 2.7-mm T-plate, and 2.7-mm T-plate modified with a fixed-angle blade. The plate constructs were axially loaded in compression with a materials testing machine, and stiffness was calculated from a load-deformation curve. Through use of paired comparisons, the average stiffness of the modified 2.7-mm plate was found to be significantly greater than that of either 2.0-mm plate, whereas a trend was observed for increased stiffness of the modified 2.7-mm T-plate in comparison with the standard 2.7-mm T-plate. The results indicate that two important variables affecting construct stiffness are plate thickness and incorporation of a fixed-angle blade. Given these findings, the addition of a fixed blade to the 2.7-mm plate may improve the stability of fixation of comminuted radial neck fractures.