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The use of three-dimensional (3-D) technology in upper extremity surgery has the potential to revolutionize the way that hand and upper limb procedures are planned and performed. 3-D technology can assist in the diagnosis and treatment of conditions, allowing virtual preoperative planning and surgical templating. 3-D printing can allow the production of patient-specific jigs, instruments and implants, allowing surgeons to plan and perform complex procedures with greater precision and accuracy. Previously, cost has been a barrier to the use of 3-D technology, which is now falling rapidly. This review article will discuss the current status of 3-D technology and printing, including its applications, ethics and challenges in hand and upper limb surgery. We have provided case examples to outline how clinicians can incorporate 3-D technology in their clinical practice for congenital deformities, management of acute fracture and malunion and arthroplasty.

Background Wedge-shaped porous metal augments were used to address bone deficiency in shoulder arthroplasty as part of a hybrid combination of high-density polyethylene, polymethyl methacrylate bone cement, and porous metal implant. This article presents an ongoing review of the use of the generically designed augments in the shoulder to address glenoid retroversion as part of anatomic total shoulder arthroplasty (aTSA). Materials Seventy-five shoulders in 66 patients (23 women and 43 men, aged 42-85 years) with Walch grade B2 or C glenoids underwent porous metal glenoid augment (PMGA) insertion as part of aTSA. Patients underwent preoperative 3-dimensional (3D) templating; based on that planning, patients received either a 15° or 30° PMGA wedge (secured by screws to the native glenoid) to correct excessive glenoid retroversion before a standard glenoid component was implanted using bone cement. Neither patient-specific guides nor navigation were used. Intraoperative glenoid alignment was assessed using a reusable guide that referenced the anterior scapular neck. Patients were prospectively assessed using shoulder functional assessments (Oxford Shoulder Score [OSS], American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form [ASES], visual analog scale [VAS] pain scores, and forward elevation [FE]) preoperatively; at 3, 6, and 12 months postoperation; and yearly thereafter, with similar radiologic surveillance. Results Of the total consecutive series, 49 shoulders had a follow-up of greater than 24 months, with a median follow-up of 48 months (range: 24-87 months). For this cohort, median outcome scores improved for OSS (21 to 44), ASES (24 to 92), VAS (7 to 0), and FE (90° to 140°) from preoperative outcomes to the most recent review, respectively. Four patients died, but no others were lost to follow-up. Apart from 1 infection at 18 months postoperatively and 1 minor peg perforation, there were no complications, hardware failures, implant displacements, significant lucency, or posterior resubluxations. Radiographs showed good incorporation of the wedge augment, with correction of glenoid retroversion from median 22° (13° to 46°) to 4° (17° to anteversion 16°). All but 4 glenoids were corrected to within the target range (less than 10° retroversion), and only 2 glenoid components were implanted outside 15° of neutral glenoid version. Conclusions The porous metal wedge–shaped augments effectively addressed posterior glenoid deficiency as part of aTSA for rotator cuff intact osteoarthritis, producing satisfactory clinical outcomes with no signs of impending future failure.

Background This article reviews the clinical and radiographic outcomes in a noninferiority trial use of a transosseous knotless anchor to perform arthroscopic rotator cuff repairs in a patient cohort that have an increased incidence of osteoporosis. Methods Patients aged over 60 with a documented rotator cuff tear and who failed a rehab program underwent repair using an arthroscopic transosseous knotless (ATOK) anchor. Patients were prospectively reviewed using shoulder functional assessments (age-adjusted Constant score, Oxford Shoulder Score, American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form [ASES], visual analog scale [VAS] pain scores), and underwent preoperative as well as 1-, 3-, and 12-month postoperative magnetic resonance imaging. Results 15 patients had undergone rotator cuff repair using the ATOK and were followed for a minimum of 24 months (range 24-30 months). From preoperative to 24 months post repair, median scores improved for ASES (61-89), Oxford (26-44), Constant (62-91), and VAS Pain (5-0.5). Four patients developed a partial retear of their repair, but only 1 patient sustained a complete retear: Sugaya type I, 10; type II, 1; type III, 2; type IV, 1; and type V, 1. No anchors were displaced, and there were no osteolysis, neurologic, or technique-related complications. Conclusions Arthroscopic rotator cuff repairs using a transosseous knotless technique has achieved a satisfactory outcome in this group of patients, who typically have poor bone quality, increasing the risk of antegrade anchor pullout. This approach would appear to combine the potential biomechanical and biological advantages of a transosseous repair technique, with the benefits of the lower morbidity arthroscopic surgical approach.

Importance of the Problem: Distal radius fractures are a common injury, and diagnosis of fracture patterns and stability are critical factors in the management of these fractures. Identification of fracture patterns in intraarticular fractures can affect the determination of optimal fixation technique. Preoperative computed tomography (CT) can aid in the identification of intraarticular fracture patterns and guide treatment. CT can also be a beneficial adjunct in the treatment of distal radius malunion correction, especially when combined with 3D modalities. Confusion over the functionality of the various forms of 3D imaging has created challenges in expanding the use of such technology, with cost, time and access convenience being potential issues. Sandow (2014) has detailed some of the technical aspects of both volume rendering (which is the predominant 3D modality in medical CT) and surface rendering (which is the predominant 3D modality use outside of the field of medicine). 3D printing technology can be utilized as a preoperative planning tool and can decrease operative time, blood loss, and fluoroscopy use. However, improved surgeon access to computer-based digital 3D simulation may improve the contribution and utility of such advanced imaging techniques to improve preoperative planning, implant selection, and optimal technique in malunion correction. Main Question: What is the utility of advanced imaging techniques in the diagnosis, preoperative planning, and treatment of distal radius fractures? Current Opinion: Displaced intraarticular distal radius fractures are often treated surgically. Current opinion is variable with regard to preoperative imaging and the utility of advanced imaging (CT scan, 3D reconstruction, etc.) in surgical decision making.

Background Options to address glenoid retroversion include eccentric reaming, bone grafting, modifications to component shape, and reverse shoulder arthroplasty. Trabecular metal (TM) augments have been used extensively in the hip and knee to address bone deficiency in arthroplasty as part of a hybrid combination of high-density polyethylene, polymethyl methacrylate, and TM. This study presents the initial results of the use of specifically designed augments in the shoulder to address glenoid retroversion as part of total shoulder arthroplasty (TSA). Materials Ten patients (4 women and 6 men; aged 60 to 79 years) with Walch grade B2 or C glenoids have undergone TM glenoid augment insertion as part of a TSA, with a longer than 24-month follow-up. Patients received a 15° or 30° TM wedge to correct excessive glenoid retroversion before the glenoid component was cemented. Outcome analysis was performed preoperatively, at 3, 6, and 12 months, and yearly thereafter. Results All patients have been satisfied, and all scores have improved. There have been no complications and no hardware failures or displacement. All glenoid components were implanted to within 10° of neutral glenoid version. Radiographs at 24 months show good incorporation of the TM augment and the glenoid component. Conclusions The TM augments have the advantage of immediate secure fixation, no tendency to collapse, and the ability to correct retroversion of 25° or more. This study confirms the successful short-term outcome of wedge-shaped TM augments to correct glenoid retroversion as part of TSA.

Background: The carpus is a complicated and functionally challenged mechanical system, advancements in the understanding of which have been compromised by the recognition that there is no standard carpal mechanical system and no typical wrist. This paper covers components of a larger project that seeks to develop a kinetic model of wrist mechanics to allow reverse analysis of the specific biomechanical controls or rules of a specific patient’s carpus. Those rules, unique to each patient, could be used to create a forward synthesis mathematical model to reproduce the individual’s anatomical motion in a virtual environment. Objective and Methods: Based on the previous observations, the carpus essentially moves with only two degrees of freedom-pitch (flexion/extension) and yaw (radial deviation/ulnar deviation)-while largely preventing roll (pronation/supination). The objective of this paper is, therefore, to present the background and justification to support the rules-based motion (RBM) concept, which states that the motion of a mechanical system, such as the wrist, is the net interplay of four rules: morphology, constraint, interaction, and load. The stable central column theory (SCCT) of wrist mechanics applies the concept of RBM to the carpus, and by using a reverse engineering computational analysis model, a consistent pattern of isometric constraints was identified, creating a “two-gear four-bar” linkage. This study assessed the motion of the carpus using a 3D (three-dimensional) dynamic visualization model. The hypothesis was that the pattern and direction of motion of the proximal row and the distal row with respect to the immediately cephalad carpal bones or radius would be similar in all directions of wrist motion. To identify the unique motion segments, 3D models were created from five normal wrists that underwent CT scanning in multiple positions of radial and ulnar deviation as well as flexion and extension. Each carpal row (proximal and distal) was animated in a virtual environment with the cephalad carpal bones or radius held immobile. The rotational axis and position of each bone and each row were then compared in sagittal (flexion-extension) and coronal (radial and ulnar deviation) motion. Results: The carpus appeared to have only two degrees of freedom, and yet was stable in those arcs with the loads applied proximally in the forearm. The proximal row moved in a singular arc, but with a varying extent during sagittal and coronal motion. The isometric constraints were consistent in both directions. The distal row moved on an axis formed by a pivot joint laterally (between the trapezium and scaphoid) and a saddle joint medially (between hamate and triquetrum). The sagittal and coronal alignment of this axis changed as the proximal row moved. This created a distinct pattern of row motion to achieve the various required positions of wrist function. On wrist radial deviation, the scaphoid (with the proximal row) was flexed and the distal row was extended, whereas, in wrist flexion, the scaphoid flexed (with the proximal row) and so did the distal row. The pattern was reversed in the opposite wrist movements. While the general direction of motion of each row was consistent, the extent was quite variable. Conclusion: This review supports the SCCT of carpal mechanics and the carpus acting as a twogear four-bar linkage, as well as the concept of RBM as a means to understand the biomechanics of the wrist, and how this is translated into specific functional tasks. More sophisticated 3D modelling will be required to further understand the specifics of carpal motion; however, reverse engineering of the specific rules that define each individual wrist can also be applied to a mathematical model to provide a “what if” test of particular surgical interventions for a variety of wrist injuries. The use of quantitative 3D Computed Tomography Scan (CT) analysis, surgical planning and virtual surgical intervention allows potential surgical solutions to be applied to a computer model of an injured wrist to test the possible outcomes and prognosis of a proposed treatment.

This study was part of a larger project to develop a (kinetic) theory of carpal motion based on computationally derived isometric constraints. Three-dimensional models were created from computed tomography scans of the wrists of ten normal subjects and carpal spatial relationships at physiological motion extremes were assessed. Specific points on the surface of the various carpal bones and the radius that remained isometric through range of movement were identified. Analysis of the isometric constraints and intercarpal motion suggests that the carpus functions as a stable central column (lunate–capitate–hamate–trapezoid–trapezium) with a supporting lateral column (scaphoid), which behaves as a ‘two gear four bar linkage’. The triquetrum functions as an ulnar translation restraint, as well as controlling lunate flexion. The ‘trapezoid’-shaped trapezoid places the trapezium anterior to the transverse plane of the radius and ulna, and thus rotates the principal axis of the central column to correspond to that used in the ‘dart thrower’s motion’. This study presents a forward kinematic analysis of the carpus that provides the basis for the development of a unifying kinetic theory of wrist motion based on isometric constraints and rules-based motion.

In this article, a group of international leaders in tendon surgery of the hand provide details of their current methods of primary flexor tendon repair. They are from recognized hand centers around the world, from which major contributions to the development of methods for flexor tendon repair have come over the past 2 decades. Changes made since the early 1990s regarding surgical methods and postoperative care for the flexor tendon repair are also discussed. Current practice methods used in the leading hand centers are summarized, and key points in providing the best possible clinical outcomes are outlined.

Balanced forces around the shoulder are important for normal function; however, rehabilitation guidelines are not well defined because the muscle contributions and optimal exercise technique to recruit them are poorly understood. This study aimed to determine (1) the conditions of resisted isometric external rotation that optimized the contribution of infraspinatus and (2) the load of external rotation at which the adduction strategy was most effective at reducing deltoid contributions. Eighteen subjects with healthy shoulders (n = 36) performed resisted isometric external rotation at 3 increasing loads--10%, 40%, and 70% of their maximal resisted external rotation voluntary isometric contraction--with and without adduction. Surface electromyographic activity of the infraspinatus, posterior and middle deltoid, and pectoralis major was recorded and normalized against the average activity of all 4 muscles, representing each muscle's relative contribution to the task. To optimize the relative contribution of the infraspinatus with the least deltoid involvement during isometric external rotation, a load between 10% and 40% maximal voluntary isometric contraction is appropriate. At low loads, use of the adduction strategy during external rotation reduces middle deltoid involvement. In contrast, the posterior deltoid is activated in parallel with the infraspinatus at low loads and may even act as an adductor with the arm by the side. This study provides a useful guide to optimize rehabilitative exercises for rotator cuff dysfunction; in particular, highlighting that activation of the deltoid could be counterproductive to infraspinatus retraining.

With advances in imaging and computing technology the greater capacity to diagnose, plan and deliver care to patients with hand and wrist disorder is being realised. Work in our laboratory, has been able to identify certain specific rules that control wrist motion, and is a step on the pathway to creating a unified theory of carpal mechanics which will incorporate a kinetic biomechanical model. This will allow more precise anatomically based as well as quantitative diagnoses, but also an ability to test a proposed intervention in a “what if” scenario.

Background: A systematic review of the literature was performed to estimate the impact of hemiarthroplasty compared with total shoulder arthroplasty on function and range of motion in patients suffering from osteoarthritis of the shoulder. Methods: We conducted an electronic search for relevant studies published in any language from 1966 to 2004, a manual search of the proceedings from five major orthopaedic meetings from 1995 to 2003, and a review of the reference lists from potentially relevant studies. Four randomized clinical trials, with similar eligibility criteria and surgical techniques, that compared hemiarthroplasty and total shoulder arthroplasty for the treatment of primary osteoarthritis of the shoulder were found to be eligible. Authors from three of the four studies provided original patient data. Analysis of covariance focused on the two-year outcome and included a comparison of the aggregate University of California at Los Angeles shoulder score, four University of California at Los Angeles domain scores, and range of motion. Results: A total of 112 patients (fifty managed with hemiarthroplasty and sixty-two managed with total shoulder arthroplasty), who had a mean age of sixty-eight years, were included in this analysis. A significant moderate effect was detected in the function domain of the University of California at Los Angeles shoulder score (p < 0.001) in favor of total shoulder arthroplasty (mean [and standard deviation], 8.1 ± 0.3) compared with hemiarthroplasty (mean, 6.6 ± 0.3). A significant difference in the pain score was found in favor of the total shoulder arthroplasty group (p < 0.0001). However, the large degree of heterogeneity (p = 0.006, I2 = 80.2%) among the studies decreased our confidence that total shoulder arthroplasty provides a true, consistent benefit with regard to pain. There was a significant difference in the overall change in forward elevation of 13° (95% confidence interval, 0.5° to 26°) in favor of the total shoulder arthroplasty group (p = 0.008). Conclusions: At a minimum of two years of follow-up, total shoulder arthroplasty provided better functional outcome than hemiarthroplasty for patients with osteoarthritis of the shoulder. Since continuous degeneration of the glenoid after hemiarthroplasty or glenoid loosening after total shoulder arthroplasty may affect the eventual outcome, longer-term (five to ten-year) results are necessary to determine whether these findings remain consistent over time. Level of Evidence: Therapeutic Level I. See Instructions to Authors for a complete description of levels of evidence.

Hand surgeons continue to search for the best surgical flexor tendon repair and treatment of the tendon sheaths and pulleys, and they are attempting to establish postoperative regimens that fit diverse clinical needs. It is the purpose of this report to present the current views, methods, and suggestions of six senior hand surgeons from six different countries — all experienced in tendon repair and reconstruction. Although certainly there is common ground, the report presents provocative views and approaches. The report reflects an update in the views of the committee. We hope that it is helpful to surgeons and therapists in treating flexor tendon injuries.

During the 10 year interval 1979-1989, 20 patients underwent nerve grafting of a radial nerve lesion, 13 high radial and 7 posterior interosseous. Average follow-up was 38 months (range 12 months-10 years). Overall 72% of patients achieved a Highet Scale rating of M3 or better function and 44% M4 or better recovery. Age of the patient and length of the nerve graft did not seem to influence outcome. Time from initial injury to nerve grafting did affect outcome, with 85% of patients grafted within 6 months obtaining M3 or better recovery. No patient grafted 12 months after injury recovered any useful function. Lesions of the posterior interosseous nerve had a consistently superior recovery. Power grip strength in the affected hand of patients averaged 60% of the unaffected hand while key pinch averaged 74%. There was good correlation between the Highet Scale rating of recovery and the ultimate power grip or key pinch strength obtained. Hand dexterity, as assessed by the turning and displacing tests of the Minnesota Rate of Manipulation Test, displayed a wide range of scores in both affected and unaffected hands. Nevertheless, a relative score derived from the results obtained in the displacing test did show correlation with the Highet Scale rating. All patients with M4 or better recovery obtained relative scores for the affected hand that were in the middle of the range of scores considered an average performance for a normal population. Patients who achieved M4 or better nerve recovery following radial nerve grafting also obtained a functional hand as evidenced by the results of grip, key pinch strength, and hand dexterity testing. Lesser degrees of recovery were accompanied by poorer strength and dexterity ratings reflecting inferior function.

We compared hemiarthroplasty (HA) and total shoulder replacement (TSR) for the treatment of osteoarthritis at minimum of 10 years from primary arthroplasty.Thirty-three patients (13 HA and 20 TSR) were intraoperatively randomized to HA or TSR after glenoid exposure and were assessed to a minimum of 10 years postoperatively. Apart from those who died, no patients were lost to follow-up.At 6 months and 1 year, the TSR patients had less pain than the HA patients (P.05), and this became more apparent at 2 years postoperatively (P.02). There were no statistically significant differences between the groups at 10 years with respect to pain, function, and daily activities. No patients in the HA group rated their shoulders as pain-free at 10 years; however, 42% of the surviving TSR patients rated their shoulders as pain-free at 10 years. Four HA patients were revised to TSR due to severe pain secondary to glenoid erosion. Two shoulders in the TSR group have been revised. Nine of the 13 HA patients (69%) and 18 of the 20 TSR patients (90%) remained in situ at death or at the 10-year review.TSR has advantages over HA with respect to pain and function at 2 years, and there has not been a reversal of the outcomes on longer follow-up. This longer-term review does not support the contention that HA will avoid later TSR complications, and in particular, an unacceptable rate of glenoid component failure.

Background This study assessed the intraobserver and interobserver reliability of a binary classification system using an easy-to-remember acronym (the HGLS system—based on the reappraisal of Codman's description by Hertel et al) and compared it with the AO and Neer systems. Materials and methods Forty-seven proximal humeral fractures in 47 patients treated at the Department of Orthopaedics and Trauma, Royal Adelaide Hospital, Adelaide, Australia, were identified in the period from July 2007 until January 2008. Fractures of the proximal humerus were examined with anteroposterior, lateral, and axillary radiographs. Three independent reviewers classified the fractures using the AO, Neer, and HGLS systems. Reclassification of the same fractures was undertaken after a 6-month interval, and interobserver and intraobserver correlation, by use of the κ statistic, was calculated for all 3 classification systems. Results The mean age of patients was 64.5 years (range, 16-95 years). The interobserver correlations for the AO system (κ value, 0.47) and Neer system (κ value, 0.44) were graded as poor and were consistent with the values of previously published studies. The HGLS classification showed good interobserver agreement for all 3 examiners at the first interpretation (κ value, 0.73) and second interpretation (κ value, 0.61). Good intraobserver agreement after a 6-month period was also seen for the HGLS classification (κ values, 0.87-0.92) compared with the AO system (κ, 0.61-0.71) and Neer system (κ, 0.42-0.77). Conclusion The HGLS system provided a more reliable description of fractures of the proximal humerus compared with the Neer and AO systems. Further studies are necessary to assess the validity of the HGLS system.

This paper presents our initial experience using a single cross grasp, four-strand repair with an active mobilization regimen in a general trauma hospital setting. Variably experienced members of the trauma service of a large general hospital used a four-strand single cross grasp tenorrhaphy technique for acute repair of 73 zone one and two flexor digitorum profundus tendon lacerations in 53 patients. Postoperatively, all patients commenced an active mobilization program within 12 hours of the surgical repair. With a minimum 3 months post-repair follow-up of 89% of the repaired flexor digitorum profundus tendons, 71% of fingers achieved a good or excellent outcome. There were three (4.6%) flexor digitorum profundus ruptures post surgery. A four-strand single cross grasp repair using 3-0 braided polyester suture and active post-repair mobilization can achieve satisfactory outcomes in the general trauma service setting; however, patient compliance remains a problem.

Department of Orthopaedics and Trauma, Royal Adelaide Hospital, Adelaide, South Australia, AustraliaSoft-tissue sarcomas are the most common malignancyof the extremities. Treatment is intense, and morbidity andmortality rates are high. The upper extremity accounts foraround 20% of all soft-tissue sarcomas

Successful intercarpal arthrodesis requires a stable fusion with maintenance of correct alignment and spatial relationship of the carpus. The technique described utilizes a series of tube saws to fashion the arthrodesis bed and then insert a sized iliac crest dowel bone graft with a tight interference fit. This technique has been used in 24 patients over a two-year period in both medial and lateral column intercarpal fusions. All wrists had fused by the tenth post-operative month. The technique is precise, reproducible and technically simple with a high fusion rate and minimal donor site morbidity.

A principal cause of subacromial impingement (SAI) is failure of the rotator cuff to center the humeral head in the glenoid during shoulder motion, counteracting the effect of the deltoid. As rehabilitation of the rotator cuff endeavors to restore balance between these muscle groups, the purpose of this companion study was to evaluate, in the symptomatic shoulders of patients with SAI, (1) the conditions of resisted isometric external rotation (ER) that optimized the contribution of the infraspinatus and (2) the load of ER at which adduction was most effective at reducing the deltoid contribution and then to compare this with the relative contribution of the infraspinatus and the posterior and middle deltoid in asymptomatic shoulders. In 14 subjects (18 shoulders) with SAI, surface electromyographic activity of the infraspinatus and the posterior and middle deltoid and pectoralis major was recorded at low, medium, and high loads of resisted isometric ER, with and without adduction. These data were normalized to find each muscle's relative contribution to the task and were compared with normalized data from subjects with healthy shoulders. In subjects with SAI, low loads of isometric ER (10%-40% maximum voluntary isometric contraction) optimized the relative contribution of the infraspinatus. Adduction with isometric ER at 10% maximum voluntary isometric contraction reduced the middle deltoid involvement. Higher loads preferentially activated the middle deltoid over the infraspinatus and may have effected unwanted humeral head superior translation, counteracting the presumed benefits of rotator cuff ER exercises. An individualized loading regimen and the use of surface electromyography may have significant implications during rotator cuff rehabilitation. Refereed/Peer-reviewed

Atraumatic delivery of the retracted flexor tendon ends following laceration is crucial for accurate tenorrhaphy. Sourmelis and McGrouther (1987) developed a useful method of delivering the proximal flexor tendon and a modification is presented here which further aids atraumatic tenorrhaphy.

Selective denervation of the infraspinatus muscle producing weakness and wasting has been reported in certain sports (eg, volleyball and baseball). Nerve kinking or friction caused by excessive infraspinatus motion and compression by superior or inferior transverse scapular ligament or ganglions have been proposed as possible causes. However, in extreme abduction with full external rotation of the shoulder, the medial tendinous margin between the infraspinatus and supraspinatus muscles impinges strongly against the lateral edge of scapular spine, compressing the intervening infraspinatus branch of the suprascapular nerve. Spinaglenoid notchplasty has been performed in 5 elite volleyball players with infraspinatus neuropathy, allowing recovery of shoulder function in all patients and correction of infraspinatus muscle wasting. All returned to the same or higher level of volleyball by 8 months after surgery. An alternative cause of infraspinatus compromise in volleyball players is proposed and has been treated surgically with satisfactory outcome.

Deficiency of the proximal pole of the scaphoid due to fracture or necrosis was treated by costo-osteochondral replacement arthroplasty using rib bone/cartilage autografts in 22 patients who were followed prospectively and assessed at a median 24 month follow-up (range, 12–72 months). Improvement of wrist function occurred in all patients with increased motion, improved grip strength and less pain. The average modified Green and O’Brien Wrist Function Score improved from 53 out of 100 preoperatively to 80 at the most recent review. All patients were graded fair or poor at initial review and all but three improved to good or excellent at the most recent assessment. Despite the absence of the scapholunate ligament, carpal alignment did not deteriorate in any patient and there were no graft non-unions or significant complications. In the short and medium term a costo-osteochondral autograft can satisfactorily restore mechanical integrity of the scaphoid proximal pole and maintain wrist motion while avoiding the potential complications of alternative replacement arthroplasty techniques.

We describe a consecutive series of girls with idiopathic anterior knee pain in adolescence and who were treated nonoperatively. At a mean follow-up of 16 years, 22% had no pain, 71% thought that their symptoms were better than at presentation, 88% used analgesics rarely or not at all, and 90% continued to participate regularly in sports. Nevertheless, about one in four of the patients continued to have significant symptoms for < or = 20 years after presentation. No features were identified that predicted those patients in whom symptoms would persist. We conclude that surgical treatment of idiopathic anterior knee pain in adolescents is not justified until a procedure has been shown to provide a better outcome than that reported here or until a way has been found to distinguish the few patients who will not get better spontaneously from the majority who will.

Anterior knee pain in adolescents is generally recognised as a common but benign self-limiting condition. Although many operative procedures for its treatment have been proposed, there is little statistical evidence that they are more effective than expectant management. A group of 54 adolescent girls has been followed for two to eight years from presentation with anterior knee pain. Although some pain persisted in the majority, in many the symptoms declined in severity. This study provides a baseline for comparison with the results of operative intervention; it is suggested that surgical treatment is unproven and unnecessary.

The technique described allows the surgeon to perform a quick, secure, controlled double primary throw when tying the standard surgeon's knot, further enhancing the advantages of hand tying.