Return to sports following distal biceps tendon repair: A current concepts review

Distal biceps tendon ruptures are relatively rare injuries but tend to occur in active and athletic populations, especially in weightlifting and contact sports. The distal biceps tendon is an important supinator of the forearm and flexor of the elbow, thus an injury to this ligament can be invalidating for athletes. The aim of this review was to determine the ability and the time to return to sports following distal biceps tendon repair in athletes and the level of performance. The literature is scarce about the return to sports among athletes. Most studies include athletes are National Football League (NFL) players, others are weightlifters and a few recreational athletes. The return to play rate after distal biceps tendon repair is high. The performances of the returned players were similar to matched players and most players returned to the same level. Most players-depending on the sport-were not able to return to competition within the same season. In order to manage expectations, it should be discussed preoperatively with the athlete (and their coach) that the return to sports rate is high, but the return will probably be the following season.

Operative vs. nonoperative treatment for Mason type 2 radial head fractures: a randomized controlled trial

BACKGROUND

The optimal treatment of isolated displaced partial articular radial head fractures remains controversial. The aim of this randomized controlled trial was to compare the functional outcome of operative treatment with nonoperative treatment in adults with an isolated Mason type 2 radial head fractures.

METHODS

In this multicenter randomized controlled trial, patients from 18 years of age with an isolated partial articular fracture of the radial head were randomly assigned to operative treatment by means of open reduction and screw fixation or nonoperative treatment with a pressure bandage. The primary outcome was function assessed with the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire. Questionnaires and clinical follow-up was conducted at admission and at 3, 6, and 12 months.

RESULTS

In total, 45 patients were randomized, 23 patients to open reduction and screw fixation and 22 patients to nonoperative treatment with a pressure bandage. At 3, 6, and 12 months, patients treated operatively had similar functional outcomes compared to patients treated nonoperatively (DASH score at 12 months: 0.0 [0.0-4.2] vs. 1.7 [0.0-8.5]; P = .076).

CONCLUSIONS

Nonoperatively treated adults with an isolated Mason type 2 radial head fracture have similar functional results after 1 year compared with operatively treated patients. In addition, complication rates were low for both operative and nonoperative treatment.

Greater radial tuberosity size is associated with distal biceps tendon rupture: a quantitative 3-D CT case-control study

PURPOSE

During pronation, the distal biceps tendon and radial tuberosity internally rotate into the radioulnar space, reducing the linear distance between the radius and ulna by approximately 50%. This leaves a small space for the distal biceps tendon to move in and could possibly cause mechanical impingement or rubbing of the distal biceps tendon. Hypertrophy of the radial tuberosity potentially increases the risk of mechanical impingement of the distal biceps tendon. The purpose of our study was to determine if radial tuberosity size is associated with rupturing of the distal biceps tendon.

METHODS

Nine patients with a distal biceps tendon rupture who underwent CT were matched 1:2 to controls without distal biceps pathology. A quantitative 3-dimensional CT technique was used to calculate the following radial tuberosity characteristics: 1) volume in mm³, 2) surface area in mm², 3) maximum height in mm and 4) location (distance in mm from the articular surface of the radial head).

RESULTS

Analysis of the 3-dimensional radial tuberosity CT-models showed larger radial tuberosity volume and maximum height in the distal biceps tendon rupture group compared to the control group. Mean radial tuberosity volume in the rupture-group was 705 mm³ (SD: 222 mm³) compared to 541 mm³ (SD: 184 mm³) in the control group (p = 0.033). Mean radial tuberosity maximum height in the rupture-group was 4.6 mm (SD: 0.9 mm) compared to 3.7 mm (SD: 1.1 mm) in the control group, respectively (p = 0.011). There was no statistically significant difference in radial tuberosity surface area (ns) and radial tuberosity location (ns).

CONCLUSION

Radial tuberosity volume and maximum height were significantly greater in patients with distal biceps tendon ruptures compared to matched controls without distal biceps tendon pathology. This supports the theory that hypertrophy of the radial tuberosity plays a role in developing distal biceps tendon pathology.

LEVEL OF EVIDENCE

Level III.

Management of the failed radial head arthroplasty

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

Global trends in indications for total elbow arthroplasty: a systematic review of national registries

National registries provide useful information in understanding outcomes of surgeries that have late sequelae, especially for rare operations such as total elbow arthroplasty (TEA).A systematic search was performed and data were compiled from the registries to compare total elbow arthroplasty outcomes and evaluate trends. We included six registries from Australia, the Netherlands, New Zealand, Norway, the United Kingdom and Sweden.Inflammatory arthritis was the most common indication for total elbow arthroplasty, followed by acute fracture and osteoarthritis. When comparing 2000-2009 to 2010-2017 data, total elbow arthroplasty for inflammatory arthritis decreased and total elbow arthroplasty for fracture and osteoarthritis increased. There was an increase in the number of revision TEAs over this time period.The range of indications for total elbow arthroplasty is broadening; total elbow arthroplasty for acute trauma and osteoarthritis is becoming increasingly more common. However, inflammatory arthritis remains the most common indication in recent years. This change is accompanied by an increase in the incidence of revision surgery. Cite this article: EFORT Open Rev 2020;5:215-220. DOI: 10.1302/2058-5241.5.190036.

Outcomes after revision total elbow arthroplasty: a systematic review

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.

Interobserver reliability of radiographic assessment after radial head arthroplasty

BACKGROUND

Radiographs are part of routine clinical care after radial head arthroplasty (RHA). Therefore, the aim of this diagnostic study was to assess the interobserver reliability of radiographic assessment following RHA.

METHODS

Anteroposterior (AP) and lateral radiographs of 24 consecutive patients who underwent press-fit bipolar RHA were evaluated with respect to 14 parameters by 14 orthopaedic surgeons specializing in the elbow: shaft loosening (AP, lateral), subcollar bone resorption, nonbridging heterotopic ossification, capitellar erosion, capitellar osteopenia, implant size, ulnohumeral joint gapping, ulnohumeral joint degeneration, proximal radio-ulnar joint congruency, stem size, stem positioning (AP, lateral) and component dissociation or polyethylene wear of the head with increased angulation. Observer agreement was evaluated using the multirater kappa (κ) measure.

RESULTS

Nine of 14 parameters had poor interobserver agreement [κ = 0.0 to 0.20, confidence interval (CI) = 0.0 to 0.31). Four parameters had fair agreement: subcollar bone resorption (κ = 0.27, CI = 0.12 to 0.40), capitellar erosion (κ = 0.30, CI = 0.20 to 0.40), ulnohumeral joint degeneration (κ = 0.35, CI = 0.22 to 0.51) and stem positioning in AP view (κ = 0.24, CI = 0.14 to 0.36). One parameter had moderate agreement: nonbridging heterotopic ossification (κ = 0.47, CI = 0.31 to 0.64).

CONCLUSIONS

The overall interobserver reliability of radiographic assessment following press-fit bipolar RHA was poor among experienced elbow surgeons. Therefore, radiographic evaluation after RHA should be interpreted with caution when making treatment decisions.

Clinical and radiographic outcome of revision surgery of total elbow prosthesis: midterm results in 19 cases

BACKGROUND

The aim of this study is to report on the midterm outcomes and complications of revision surgery of total elbow arthroplasty.

METHODS

All patients who had undergone total elbow arthroplasty revision surgery between 2009 and 2014 with semiconstrained total elbow prostheses were prospectively enrolled in the study. Records were reviewed for demographic data; baseline measurements; and several follow-up assessments including the Mayo Elbow Performance Score (MEPS), visual analog scale (VAS) score for pain, Oxford Elbow Score, range of motion, satisfaction, and radiographs.

RESULTS

A total of 19 revision arthroplasties were included. At a mean follow-up of 57 months, there had been 1 rerevision and 2 removals. One patient was excluded from follow-up because of confounding comorbidity. At last follow-up, MEPS values and VAS pain scores both improved (P < .01). The rate of combined good and excellent results on the MEPS was 53%. The mean VAS scores for pain at rest and with activity were 2 and 4, respectively. Fair results for the Oxford Elbow Score were reported, with a mean score of 28 points. Range of motion improved to an average flexion-extension arc of 108° (P < .01), and the pronation-supination arc improved to an average of 123° (P < .01). All elbows were stable at last follow-up (P < .01). Radiographs showed nonprogressive osteolysis around the prosthesis in 3 cases (19%) and suspicion of loosening in 1 (6%). In 11 patients postoperative complications occurred. Of 15 patients, 13 (87%) were satisfied with the result of the revision procedure.

CONCLUSION

Revision of total elbow prostheses leads to satisfactory results, less pain, and better elbow function. This procedure is related to a relatively high complication rate.

Press-fit bipolar radial head arthroplasty, midterm results

BACKGROUND

Theoretical advantages of bipolar compared with monopolar radial head arthroplasty include better accommodation of radiocapitellar malalignment, reduction of capitellar abrasion, and reduction of stress at the bone-implant interfaces. Our purpose was to report the midterm results of press-fit bipolar radial head arthroplasty.

METHODS

Thirty patients were treated by press-fit bipolar radial head arthroplasty for acute fracture of the radial head, failed earlier treatment, or post-traumatic sequelae. Three patients were lost to follow-up. Results are presented for the remaining 27 patients.

RESULTS

At mean follow-up of 48 months (range, 28-73), there had been 3 (11%) revisions. Two involved conversion to prosthetic radiocapitellar hemiarthroplasty for symptomatic capitellar abrasion; a third involved exchange of the articular component (ie, head) for instability. In all, the stems appeared well fixed. A prosthesis in a subluxed position accounted for the 1 (4%) additional radiologic failure. The average flexion-extension arc was 136° (range, 120°-145°), and the average pronation-supination arc was 138° (range, 70°-180°). According to the Mayo Elbow Performance Score, the combined excellent and good results accounted for 70%.

CONCLUSIONS

The overall midterm outcome of this series of 30 press-fit bipolar radial head arthroplasties can be considered favorable. Although the revision rate was 11%, the stems were well fixed in all. There was 1 (4%) additional radiologic failure. We suggest considering a press-fit bipolar radial head prosthesis for acute comminuted radial head fractures with limited bone loss of the proximal radius.

Clinical relevance of distal biceps insertional and footprint anatomy

PURPOSE

The aim of this review was to present an overview, based on a literature search, of surgical anatomy for distal biceps tendon repairs, based on the current literature.

METHODS

A narrative review was performed using Pubmed/Medline using key words: Search terms were distal biceps, insertional, and anatomy.

RESULTS

Last decade, the interest in both reconstruction techniques, as well as surgical anatomy of the distal biceps tendon, has increased. The insights into various aspects of distal biceps tendon anatomy (two tendons, bicipital tuberosity, lacertus fibrosis, bicipital-radial bursa, posterior interosseous nerve, and lateral antebrachial cutaneous nerve) have evolved significantly in the last years.

CONCLUSION

Thorough knowledge of the anatomy is essential for the surgeon in order to understand the biomechanics of rupture and reconstruction of the distal biceps tendon and to avoid injuries of the nerves. Some tips and tricks are provided, and some pitfalls were described to avoid complications and optimize surgical outcome.

LEVEL OF EVIDENCE

IV.

The Size of the Radial Tuberosity is Not Related to the Occurrence of Distal Biceps Tendon Ruptures: A Case-Control Study

Introduction:

Hypertrophic changes at the radial tuberosity have traditionally been related to distal biceps tendon degeneration and rupture. From supination to pronation of the forearm, the space available for the distal biceps tendon between de lateral ulna and radial bicipital tuberosity (RBT) decreases by almost 50%. A hypertrophic change at the radial tuberosity further reduces this space with impingement of the distal biceps tendon as a result. The purpose of this study was to evaluate whether the size of the RBT plays a role in the pathophysiology of distal biceps tendon ruptures.

Materials and Methods:

Twenty-two consecutive patients with a surgically proven distal biceps tendon rupture were matched to controls, in a 1:1 ratio. The size of the RBT was expressed as a ratio of the maximum diameter of the radius at the RBT to the diameter of the diaphysis just distal to the RBT (RD ratio), measured on standard radiographs of the elbow. The RD ratio of patients and matched controls were compared.

Results:

The mean RD ratio in control group was 1.25 and not significantly different from the mean 1.30 in the group of patients with a distal biceps tendon rupture. Each 0.1 point increase in RD ratio results in an estimated 60% increase of the rupture odds, which was not significant either.

Conclusion:

Based on the RD ratio on conventional radiographs of the elbow, there was no significant difference in RBT size between patients with a distal biceps tendon rupture and matched controls without biceps tendon pathology.

Hip arthroscopy in obese, a successful combination?

Discussion persists about the outcome and results of hip arthroscopy in obese patients. Hip arthroscopy gained popularity over time. A current discussion is if obese patients can reach similar results after surgery compared with non-obese. To our knowledge, this is the first systematic review of literature about hip arthroscopy and obesity. We searched the Pubmed/Medline databases for literature and included three studies that compared the outcome of hip arthroscopy between different BMI groups. We extracted and pooled the data. For continues data a weighted mean difference was calculated, for dichotomous variables a weighted odds ratio (OR) was calculated using Review Software Manager. Heterogeneity of the included studies was calculated using I² statistics. Data were extracted from two studies. In the Obese group, there was significant more conversion to total hip replacement or resurfacing hip replacement (OR = 2.21, 95% CI 1.07–4.56) and more re-arthroscopy (OR = 4.68, 95% CI 1.41–15.45). Any reoperation occurred more often in the obese group (OR = 2.87, 95% CI 1.53–5.38). In the Non Arthritic Hip Score obese scored lower than the non-Obese group [10.9 (−14,6 to 7.1)]. For the modified Harris Hip Score the score is − 6,6, according to the MCID this difference is clinically relevant. For both scores obese show lower outcomes but similar improvement after hip arthroscopy. Regarding a higher chance of needing a re-operation and lower subjective outcome scores obesity appears to have a negative influence on the outcome of hip arthroscopy.

The effect of trauma and patient related factors on radial head fractures and associated injuries in 440 patients

Background

Radial head fractures are commonly interpreted as isolated injuries, and it is assumed that the energy transferred during trauma has its influence on the risk on associated ipsilateral upper limb injuries. However, relationships between Mason classification, mechanism of injury, and associated injuries have been reported only once before in a relatively small population. The purpose of this study was to define whether trauma mechanism and patient related factors are of influence on the type of radial head fracture and associated injuries to the ipsilateral upper limb in 440 patients.

Methods

The radiographs and medical records of 440 patients that presented with a fracture of the radial head were retrospectively analyzed. The medical records of all patients were searched for (1) the trauma mechanism and (2) associated injuries of the ipsilateral upper limb. The mechanism of injury was classified as being low-energy trauma (LET) or high-energy trauma (HET).

Results

Associated injuries to the ipsilateral upper limb were present in 46 patients (11 %). The mean age of patients with associated injuries (52 years) was significantly higher compared to patients without associated injuries (47 years) (P = 0.038), and female patients with a radial head fracture were older than males. Injury patterns were classified as LET in 266 patients (60 %) and as HET in 174 patients. HETs were significantly more common in young men. Associated injuries were not significantly different distributed between HET versus LET (P = 0.82).

Conclusions

Injuries concomitant to radial head fractures were present in 11 % of patients and the risk for these associated injuries increases with age. Trauma mechanism did not have a significant influence on the risk of associated injuries. Complex elbow trauma in patients with a radial head fracture seems therefore to be suspected based on patient characteristics, rather than mechanism of injury.

Semiconstrained total elbow arthroplasty for posttraumatic arthritis or deformities of the elbow: a prospective study

PURPOSE

To report the short-term results for posttraumatic total elbow arthroplasty.

METHODS

We included patients presenting to our hospital with symptomatic chronic posttraumatic arthritis or deformities of the elbow, aged 55 to 90 years. All patients had reconstruction with a Coonrad-Morrey prosthesis. We performed clinical follow-up after 2, 6, 12, 24, and 36 months, consisting of physical examination, standard radiographs, and calculation of the Mayo elbow performance index.

RESULTS

A total of 17 patients were enrolled in this study and had a mean follow-up of 32 months. Mean preoperative flexion arc was 67° and 105° postoperatively. The mean preoperative Mayo elbow performance index score was 54 (range, 30-80) and improved to a postoperative score of 93 (range, 60-100). We encountered 6 complications in 5 patients. Four complications required surgical intervention and 2 minor complications were treated noninvasively.

CONCLUSIONS

Short-term functional outcomes after total elbow arthroplasty in this prospective cohort of patients with posttraumatic arthritis or deformities of the elbow were good according to mean postoperative measurements.

Surgical treatment of post-traumatic elbow stiffness: a systematic review

BACKGROUND

Trauma to the elbow is a common cause of joint stiffness that might require surgical release. Release of the stiff elbow can be done by open or arthroscopic approach. There is no high-level evidence for the best surgical treatment modality for post-traumatic elbow stiffness. The objective of this article was to review current available literature of studies reporting on open or arthroscopic release of post-traumatic elbow stiffness.

METHODS

A comprehensive literature search was performed. All titles and abstracts of potentially relevant studies were reviewed, with a set of predefined inclusion and exclusion criteria. After the initial assessment for inclusion, 2 authors extracted data independently from the included articles.

RESULTS

Thirty articles were included, with an overall enrolment of 798 patients. No randomized controlled trials were retrieved. The first article was published in 1989 and the most recent in 2012. There were 4 different kinds of treatment modalities identified from the included studies: 1) open arthrolysis; 2) arthroscopic arthrolysis; 3) open arthrolysis with external fixation; and 4) open arthrolysis with distraction arthroplasty. The gain in range of motion was 51°, 40°, 88°, and 56° for groups 1-4, respectively. The average percentage of complications was 23, 5, 73, and 58 for groups 1-4, respectively.

CONCLUSION

Current literature is not sufficient enough to draw firm statistically based conclusions. However, as the amount of complications seems to rise with the extent of the surgical procedure, we would advise to treat as less invasive as possible (grade C).

Long-term results after ulnar collateral ligament reconstruction of the elbow in European athletes with interference screw technique and triceps fascia autograft

BACKGROUND

In the last decade, there has been increasing interest in medial ulnar collateral ligament (MUCL) reconstruction techniques for MUCL insufficiency of the elbow. All case series are based on American and Asian Athletes and use primarily a palmaris longus tendon or gracilis tendon as an autograft in reconstructions. A new technique is the interference screw fixation. Evidence that supports the use of this technique is mainly from controlled laboratory studies. The purpose was to evaluate the interference screw technique for MUCL reconstructions in a European, clinical setting, with a triceps tendon fascia autograft.

METHODS

Twenty consecutive athletes with diagnosed MUCL insufficiency who underwent a MUCL reconstruction using the interference screw technique were reviewed retrospectively. Indications for reconstruction were medial elbow pain and/or instability caused by insufficiency of the MUCL that prevented the athlete from sport activity after a minimum of 3 months of conservative treatment.

RESULTS

At a mean follow-up of 55 months (range, 36-94), the mean Mayo Elbow Performance Index (MEPI) score improved from 82 to 91 points (range, 80-100); P < .001. In the end, 6 patients (30%) quit the sport activities they were preoperatively participating in, all because of reasons unrelated to the MUCL reconstruction. There were excellent results on the Conway scale in 18 patients.

CONCLUSION

Good results are reported based on the postoperative MEPI and Conway scores with clinically stable MUCL reconstructions without signs of break-out or fractures on radiographic follow-up. However, the dropout, even after successful reconstruction in European athletes, is high.