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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.

Coronoid fractures are often a part of extensive elbow trauma and persistent elbow instability can occur after a coronoid fracture. The decision to perform surgery is based less on fragment size and more on the impact on elbow joint stability. To lessen the impact on the elbow joint and to accelerate rehabilitation, arthroscopic repair is gaining popularity. Repair can be performed as an arthroscopic reduction and internal fixation (ARIF) or, when the fragment is too small, as an anterior capsulodesis. Good functional outcome has been reported with the arthroscopic fixation technique.

Posterolateral rotatory instability (PLRI) involves an avulsion of the lateral collateral ligament complex, including the lateral ulnar collateral ligament. It is usually caused by a traumatic simple dislocation but can also be iatrogenic after surgery on the lateral elbow. If conservative treatment fails, surgery may be indicated. The ligament is classically reinserted or reconstructed with an open procedure, but arthroscopic treatment is gaining popularity. In this chapter we present our arthroscopic imbrication technique to treat posterolateral rotatory instability. Results are generally excellent with low complication rates or recurrence of instability.

Primary radial head arthroplasty (RHA) produces good or excellent results in approximately 85% of patients. However, complications are not uncommon and have been described in up to 23% of cases. The number of RHA is increasing, and consequently the absolute number of complications is expected to rise as well. The decision on whether to revise or remove the prosthesis seems more likely to depend on the preference of the surgeon or the hospital, rather than on objectifying problems with the prosthesis. The current article presents an algorithm for the work-up and treatment of most complications that can occur following RHA. Five subgroups of problems were identified: osteoarthritis, stiffness, instability, infection and implant-related issues. In short, the preferred treatment depends mainly on the chondral condition and stability of the elbow joint.Cite this article: EFORT Open Rev 2020;5:398-407. DOI: 10.1302/2058-5241.5.190055

In malunion cases, restoration of anatomy is a key factor in obtaining a good functional outcome, but this can be technically very challenging. Three-dimensional printed bone models can further improve understanding of the malunion pattern. The use of three-dimensional (3D) computer planning, and the assembly of patient-specific instruments and implants, especially in complex deformities of the upper limb, allow accurate correction while reducing operation time, blood loss volume and radiation exposure during surgery. One of the major disadvantages of the 3D technique is the additional cost because it requires specific computer software, a dedicated clinical engineer, and a 3D printer. Further technical developments and clinical investigations are necessary to better define the added value and cost/benefit relationship of 3D in the treatment of complex fractures, non-unions, and malunions. Cite this article: EFORT Open Rev 2019;4 DOI: 10.1302/2058-5241.4.180074

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.

Elbow injuries in the throwing athlete have distinct injury patterns. They commonly develop medial elbow problems due to the tensile forces applied to the medial stabilising structures, combined with lateral compartment compression and posterior shear forces. Repetitive valgus stresses may lead to a selection of chronic overuse problems, but athletes can also present with acute and acute-on-chronic injuries. The spectrum of throwing injuries encompasses ulnar collateral ligament tears, flexor-pronator tendinopathy, medial epicondyle apophysitis, and valgus extension overload syndrome. Non-operative treatment begins with a period of rest from throwing, followed a rehabilitation programme promoting elbow range of motion, flexor-pronator strengthening, ultimately leading to retraining in throwing mechanics at approximately 3 months. Acute surgical repair of ulnar collateral ligament tears is indicated in cases of acute avulsion from the humeral origin or the coronoid insertion. Chronic insufficiency may warrant ulnar collateral ligament reconstructive surgery involving a free tendon graft, usually placed in bone tunnels in the humerus and ulna.

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.

There has been an increase in thrower-specific elbow injuries in recent years. High valgus stresses during the late cocking and acceleration phases of throwing need to be compensated by the flexor pronator muscles as these can exceed the tensile strength of the medial collateral ligament complex. Prevention of injuries is the priority, with a focus on strengthening, reducing throwing frequency, decreasing force, and promoting a technique. The spectrum of thrower injuries ranges from a simple sprain to complete failure of the valgus stabilizing factors. The medial collateral ligament can stretch, leading to posteromedial impingement and radiocapitellar compression forces. This in turn can result in arthrosis and the formation of osteophytes. Ligament failure may eventually occur, making it impossible for the athlete to continue their throwing activities. The outcome of conservative treatment with strengthening, improvement of technique, and relative rest is often disappointing. Direct repair may no longer be possible in these acute-on-chronic injuries and a reconstruction with a tendon graft may be necessary.In den letzten Jahren gab es einen Anstieg wurfspezifischer Ellenbogenläsionen. Eine hohe Valgusbelastung während der späten Anspannungs- und Beschleunigungsphasen des Werfens muss durch die Flexoren und Pronatoren ausgeglichen werden, da diese die Zugkraft des medialen kollateralen Bandkomplexes übersteigen können. Der Prävention von Verletzungen wird der Vorzug gegeben, dabei liegt ein Fokus auf der Stärkung, der Verminderung der Wurfhäufigkeit, der Verminderung des Krafteinsatzes und einer ausgefeilten Technik. Werferverletzungen umfassen ein Spektrum von Verletzungen von einer einfachen Zerrung bis zum vollständigen Ausfall der valgusstabilisierenden Faktoren. Das mediale kollaterale Band kann gedehnt werden, was zu einem posteromedialen Impingement und Kompressionskräften zwischen dem Radius und dem Capitulum humeri führt. Dies kann in einer Arthrose und der Bildung von Osteophyten enden. Das Ligament kann schließlich reißen, was es für den Sportler unmöglich macht, seine Wurfsportart weiter auszuführen. Das Ergebnis der konservativen Therapie mit Stärkung, Verbesserung der Technik und relativer Ruhe ist oftmals enttäuschend. Eine direkte Rekonstruktion ist bei diesen chronischen Verletzungen mit akuter Phase ggf. nicht mehr möglich, und u. U. bedarf es einer Rekonstruktion mit einem Sehnenimplantat.

For those patients with instability of the medial and lateral sided of the elbow, there is a place for a circumferential graft. This has the main advantage of simplifying the bone tunnel creation and graft fixation, compared to having both medial- and lateral-sided reconstructions.

Postoperative rehabilitation plays a crucial role in the treatment of elbow pathology. Depending on the type of surgery, the elbow may need to be protected. As a general rule, the elbow should not be immobilized for a prolonged period after surgery. A removable splint can be used to protect the soft-tissues immediately postoperative and the patient is encouraged to remove the splint several times daily to mobilize the elbow. Dynamic articulated braces can be used to encourage movement while ligament or tendon repairs are being protected. Literature on postoperative elbow rehab is scarce. In this paper we provide practical guidelines for specific surgical procedures.

Background Medial epicondylitis is a common orthopedic condition that typically results from overuse or previous microtrauma of the flexor-pronator mass. Repetitive eccentric loading of the muscles leads to subsequent degeneration of the flexor tendons. Diagnosis Patients present with a painful elbow. In the case of concomitant elbow pathologies, including ulnar neuritis and ulnar collateral ligament injury, there should be a detailed examination. Generally, the diagnosis is based on the clinical examination. T2-weighted magnetic resonance imaging can be useful for chronic courses, over 6 months. Treatment Nonsurgical management is the mainstay of treatment. Hence, surgical treatment may be indicated for patients with persistent symptoms after conservative treatment. In the case of a surgical treatment, arthroscopy can be useful to capture concomitant elbow pathologies.

Instability is stratified between acute and chronic and according to the direction of the instability. Acute elbow dislocations are treated by closed reduction. Further treatment is determined by clinical exam following the reduction. Chronic instability is classified as lateral, medial, or multidirectional. Advanced imaging is often helpful next to taking a thorough history and performing a clinical exam with specific testing of the direction and mechanism of instability.

Triceps injuries, including triceps tendon ruptures, are relatively rare. Recently, the knowledge of tendon lesions has increased, and it seems to be related to more precise diagnostic and clinical assessments. The most common mechanism of injury remains a forceful eccentric contraction of the muscle. Several other risk factors have been studied, such as chronic renal failure, endocrine disorders, metabolic bone diseases, and steroid use. Olecranon bursitis and local corticosteroid injections may also play a role. The most common site of rupture is at the tendon’s insertion into the olecranon and rarely at the myotendinous junction or intramuscularly. Surgical intervention is recommended in acute complete ruptures; non-operative treatment is reserved for patients with major comorbidities, as well as for partial ruptures with little functional disability and in low demand patients. Various techniques and approaches have been proposed for the management of these challenging injuries. The goal of surgical management should be an anatomical repair of the injured tendon by selection of a procedure with a low complication rate and one that allows early mobilization.

Snapping and pain at the medial elbow can be caused by a snapping of the triceps tendon and muscle belly. It can be accompanied by a shooting pain in the distribution of the ulnar nerve. Eccentric loading of the triceps tendon is the most specific test to confirm a snapping triceps syndrome. Two snaps may be experienced during clinical exam. A first snap occurs at around 90°. This is the ulnar nerve subluxating out of its groove. A second snap usually occurs at around 115° when the triceps dislocates over the medial epicondyle. Surgical treatment consists of an anterior transposition of the ulnar nerve and removal of the medial part of the triceps.

The indication for surgery in a patient with an acute simple elbow dislocation remains debatable. The decision to perform surgery depends on the patient and the severity of the instability. Surgery can be performed with an open or an arthroscopic technique. Arthroscopic evaluation of the unstable elbow is helpful in both acute and chronic cases. Medial and lateral laxity can be evaluated under direct view of the ulnohumeral and radiohumeral joint spaces. Varus and valgus testing can show opening of the joint space. Arthroscopic repair is possible, as well as open repair. We prefer to use a bone anchor. Postoperatively the patient is protected in a brace that allows for progressive extension.

Malunions around the elbow can be a disabling condition for the patient and may warrant corrective surgery. Precise restoration of normal alignment, in order to improve pain and function, is the goal, but may be difficult to obtain with conventional techniques. The use of 3D technology can therefore be helpful to improve the outcome of corrective surgery. The technique requires a CT scan of both arms and further 3D assessment of the deformity. Using dedicated software, virtual planning of the surgical correction, based on the normal contralateral side, is possible. Based on the virtual 3D planning, patient-specific instrumentation (PSI) can be designed, 3D printed, and used during the surgical procedure. The technique allows predictable correction of elbow deformities with excellent clinical results, as will be illustrated.

In some patients, a primary repair of the ruptured triceps tendon may not be possible. A tendon augmentation will be necessary. This can be done in multiple ways. We prefer to use an Achilles tendon allograft technique to reconstruct the distal triceps tendon and to obtain a firm fixation to the proximal ulna. It is imperative to debride scar tissue from the triceps tendon stump up to healthy tendon. The native tendon is released to mobilize it as far as possible toward the proximal ulna, with the elbow extended. The proximal part of the Achilles tendon is draped over at least 10 cm of the triceps tendon stump. It is fixed with multiple rows of suture to obtain a strong fixation and to decrease the risk of a seroma between the native and allograft tendons. The distal part of the allograft Achilles tendon is fixed to the bone with bone tunnels and a bone anchor. The calcaneum can be used to achieve a bone-to-bone fixation, but as it is bulky, we prefer not to use this if the bone stock of the patient is sufficient. Postoperatively, the elbow is protected with a dynamic brace that allows for progressive flexion over a period of 6 weeks.

Isolated arthritis of the lateral compartment of the elbow is rare. Arthroscopic debridement and removal of loose bodies and osteophytes usually lead to good results, when conservative measures fail. The indications for radiocapitellar replacements therefore remain limited. Patients who suffer from post-traumatic or primary radiocapitellar osteoarthritis, who have failed other treatment options, may be considered candidates for a radiocapitellar arthroplasty. Other treatment modalities that could be considered include radial head resection or interposition of tissue. This could also be considered as salvage when a radiocapitellar replacement fails. Placement of a radiocapitellar arthroplasty is technically more challenging, but the incidence of complications should be decreased with a correct surgical technique. Special attention should be paid to perfect alignment and solid placement of the components. Current literature is scarce on outcome data. With the right selection of patients and without postoperative complications, patients’ satisfaction rate is high, with excellent pain relief and functional results.

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

Simple elbow dislocations are usually treated conservatively. Radiographs are negative in simple dislocations. Results are generally good, although a small percentage of patients may develop chronic instability. Ligamentous repair can be indicated in high demand patients or if the elbow remains unstable following a closed reduction. Chronic instability is classified per their direction. Surgery is often indicated in the chronically unstable elbow.

Purpose We evaluated clinical and radiographic outcome of percutaneous transtrapezial fixation of the scaphoid delayed union or nonunion using a headless bone screw without bone grafting. Methods Sixteen patients with delayed union or nonunion of the scaphoid were included in this retrospective study between 2006 and 2011. All patients had a delayed presentation of scaphoid fracture, and none of them was treated conservatively elsewhere. Patients with bone graft, sclerotic bone debridement, or displacement of the fragment at the nonunion site were excluded. A percutaneous transtrapezial fixation technique was used in all cases. Patients were reviewed until clinical and radiographic union was observed. At the final follow-up, DASH (Disabilities of the Arm, Shoulder and Hand) and PRWHE (Patient-Rated Wrist and Hand Evaluation) outcome scores were completed. Results Radiographic union was obtained in 15 out of 16 patients (94%) at an average follow-up of 36 months (range: 12–98 months). No complications from the percutaneous technique were noted. The average DASH score was 6 (range: 0–39) and the average PRWHE score was 10 (range: 0–56). No statistical significant difference in range of motion and grip strength was found between the operated side and the contralateral side. Conclusion Percutaneous transtrapezial screw fixation for delayed or nonunion of selected scaphoid fractures without bone grafting is promising. At a mean of 4 months, 94% union was obtained with good functional results when there was no sclerosis, minimal osteolysis, and no displacement at the scaphoid nonunion site. Type of Study Therapeutic study. Level of Evidence IV.

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.

Background The transverse carpal ligament is well known for its involvement in carpal tunnel syndrome, and sectioning of this ligament remains the definite treatment for this pathology. Some authors believe that the transverse carpal ligament is an important stabilizer of the carpal arch, whereas others do not consider it to be significant. Several studies have been performed, both in vivo and in in vitro. Sectioning of the transverse carpal ligament does not seem to have any effect on the width of the carpal arch in the unloaded condition. However, patients will load the arch during their activities of daily living. Materials and Methods A cadaveric study was done with distraction of the carpal bones before and after sectioning the transverse carpal ligament. Results With the transverse carpal ligament intact, the carpal arch is mobile, with distraction leading up to 50% widening of the arch. Sectioning of the transverse carpal ligament resulted in a significant widening of the carpal arch by a further 30%. Conclusions Loading of the carpal arch after sectioning of the transeverse carapal ligament leads to a significant increase in intracarpal mobility. This will inevitably influence carpal kinematics in the patient and might be responsible for some complications after simple carpal tunnel releases, such as pillar pain, palmar tenderness, and loss of grip strength.

The ulnar collateral ligament is the primary static constraints of the elbow to valgus stress. Injuries to this ligament may lead to significant functional impairment and potential secondary intra-articular damage to the elbow. A diverse group of patients can present with symptoms related to ulnar collateral ligament insufficiency, ranging from children with acute elbow dislocations to professional athletes with chronic overload injuries. The current review will discuss, anatomy, biomechanics and clinical findings regarding ulnar collateral ligament injuries. An overview of treatment options will also be presented.

Dit hoofdstuk geeft een overzicht van wat we weten over de totale elleboogprothese, inclusief de geschiedenis, de typen prothesen die er bestaan, de indicaties om een prothese te plaatsen, de resultaten van een implantatie en de complicaties die kunnen voorkomen.

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.

Although triceps tendon ruptures can result from a traumatic incident, chronic overuse causing degenerative changes to the insertion and leading to a complete or partial rupture is more common. In our practice, we have found that anabolic steroid abuse by weightlifters is the most common predisposing factor. The initial diagnosis is often missed. A thorough clinical examination is imperative to avoid missing a partial or complete rupture. Ultrasound or magnetic resonance imaging can confirm the diagnosis. Early diagnosis increases the chance of a direct repair. Operative treatment with direct repair is usually indicated for full-thickness or large partial-thickness tears. Direct repair may be possible for selected chronic tears. Triceps tendon repair is performed with the following steps.Step 1: The patient is placed in lateral decubitus.Step 2: The stump is debrided, and retraction of the tendon is evaluated.Step 3: Two crossed bone tunnels are drilled, and an anchor is placed centrally in the olecranon.Step 4: The elbow is extended, and the tendon is reduced and sutured centrally to the anchor and medially and laterally with use of the sutures from the bone tunnels.Step 5: The elbow is flexed to evaluate tension. If gapping occurs, the repair should be reinforced with extra sutures. Tension-free range of motion will guide postoperative rehabilitation.Step 6: A posterior splint is applied in the operating room with the elbow extended.Step 7: A dynamic brace is applied on the first postoperative day. Extension is free but flexion is blocked at the tension-free range; 30° of extra flexion is permitted every 2 weeks. Full flexion is always allowed after 6 weeks. Strengthening starts at 3 months. Pitfalls of the procedure include difficulty in differentiating between tendon and scar in subacute and chronic ruptures. It may not be possible to directly repair the triceps back to bone, and a graft may be needed to reconstruct the tendon. It is important to know where the ulnar nerve is and to release it if needed. It is important not to debride past the cortical surface of the olecranon if an anchor is used because, if this is done, fixation may be insufficient. The anchor should be predrilled as the cortical bone of the tip of the olecranon is very dense. Reruptures occur in up to 21% of cases. A functional range of motion is usually achieved with an average loss of extension of 10° and average flexion to 136°. At 1 year, one can expect a peak strength of approximately 80% of that on the uninjured side and endurance strength of 99%1.

Snapping triceps syndrome is a rare and therefore often unknown cause of medial elbow pain. It is a condition in which the distal portion of the triceps dislocates over the medial epicondyle during flexion and extension of the elbow. It can occur, with or without ulnar neuropathy symptoms. The available literature on this subject is scarce and consists mainly of case reports. This report reviews the current literature and will provide guidance in diagnosis and treatment of this uncommon condition.

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.