Comparison of time-efficiency of individually wrapped screws and sterile screw racks in distal radius fracture treatment

INTRODUCTION

Time-efficiency of individually wrapped screws versus screws in a screw rack is not well established.

MATERIALS AND METHODS

We performed a prospective single-center clinical study timing the interval between the surgeon asking and receiving a screw during plate and screw osteosynthesis of distal radius fractures. Patients were randomized for individually wrapped screws or screws in a screw rack. The study was conducted in a Level 1 Trauma Center and surgeries were performed between March and June 2023.

RESULTS

Average handling time for screws from a screw rack was 9 s (SD 5.5; range 3-28) and 22 s for individually wrapped screws (SD 6.1; range 6-38). This average difference of 13 s is significant (p < 0.0001).

CONCLUSION

There is a significant increase in handling time using individually wrapped screws over using a screw rack.

LEVEL OF EVIDENCE

Level I (therapeutic, randomized controlled trial).

De Quervain tendinitis after total trapeziometacarpal joint arthroplasty: Biomechanical evaluation of tendon excursion in the first extensor tendon compartment

De Quervain's tenosynovitis is the most common complication after total trapeziometacarpal joint replacement. Etiology is unclear. Implantation of a ball-in-socket implant changes the biomechanics of the normal trapeziometacarpal saddle joint and increases its range of motion. The present study demonstrates that this procedure also significantly increases excursion of the abductor pollicis longus and extensor pollicis brevis tendons during thumb flexion-extension, and not during thumb abduction-adduction. Increased tendon gliding under the retinaculum of the first extensor tendon compartment could predispose to the development frictional tenosynovitis and play a role in the development of de Quervain's syndrome after total trapeziometacarpal joint replacement. LEVEL OF EVIDENCE: Not applicable (laboratory study).

Perioperative steroid injection in elbow arthroscopy

The goal of the present study was to evaluate the incidence of infection after perioperative intra-articular steroid injection during elbow arthroscopy. Starting from May 2019, we prospectively included all patients that underwent an elbow arthroscopy for various indications. All patients received preoperative antibiotics intravenously and a corticosteroid injection immediately after portal closure. Patients who needed ligamentous repair and aged below 18 years old were excluded. Final follow up of all patients was 3 months. In total, 108 elbow arthroscopies were performed in 100 patients. No major complications and 1 minor complication were seen. One patient developed a seroma that resolved spontaneously after 14 days without intervention or antibiotics. In this patient group, a perioperative corticosteroid injection following elbow arthroscopy did not increase the chance of infection.

Does trapezium remodeling correlate with cup shape?

We investigated whether trapezium bone reaction was different following implantation of a trapeziometacarpal total joint replacement with a hemispheric or a conical cup. Fifty-three Keri Medical Touch implants with hemispheric cup and 53 with conical cup were prospectively followed up radiographically. We compared radiographs taken immediately and one year after surgery for cup subsidence, tilt, heterotopic ossification and loosening. Cup subsidence of at least 1 mm was detected in 4% of cases for both cup types. Additive bone reaction around the cup of more than 1 mm was present in 62% of conical cups and 47% of hemispheric cups. These were minor and there were no large ossifications with risk of impingement. Minor radiolucency was seen superficially at the implant-bone interface of 13% of the hemispheric cups and 9% of the conical cups. None of these bone reactions differed significantly according to cup design.

Minimally invasive corrective derotational osteotomy for proximal phalanx malrotation

Fractures of the phalanges may result in a challenging complication known as malrotation, which can adversely affect the functionality of the fingers during flexion, leading to scissoring. The standard surgical approach for correcting this condition involves open corrective osteotomy and derotation, often at the level of the metacarpal, which includes the use of different techniques for osteotomy and fixation. However, postoperative complications such as finger stiffness and hardware irritation are common. To overcome these limitations, we present a novel and minimally invasive corrective osteotomy technique for malunited proximal phalanx fractures with rotational malalignment, which offers several advantages, such as accelerated rehabilitation and no prominent hardware.

Prevalence and clinical implications of heterotopic ossification after distal biceps tendon repair

Complete distal biceps tendon ruptures are relatively uncommon. Conservative treatment may result in persistent pain and weakness. Therefore, surgical repair is usually indicated in order to restore strength. Different surgical techniques and fixation methods have been described. The most reported complications after surgery are iatrogenic nerve damage, heterotopic ossification (HO) and re-rupture. Heterotopic ossification can be variable in size. Significant HO can limit range of motion while minor HO often remains asymptomatic. The overall presence of HO is likely underreported in literature, as imaging is reserved for symptomatic patients. The purpose of this study is to report the prevalence and clinical implications of heterotopic ossification after surgical repair of the distal biceps tendon. This retrospective study assessed the prevalence and clinical relevance of postoperative HO after distal biceps tendon repair. CT-scans were used to evaluate size and location of the HO. VAS scores, DASH scores, MEPI, and range of motion (ROM) were assessed to evaluate pain, patient satisfaction and elbow function. HO was observed on CT images of 19 out of 35 patients (54%). The use of interference screws, timing of surgery after rupture and timing of radiographic assessment postoperatively did not influence the prevalence of HO. The presence of HO had no statistically significant impact on the VAS scores, ROM measurements and MEPI and DASH scores. According to our findings, the overall incidence of HO is higher than previously reported but there are no differences in clinical outcomes when compared to patients without HO.

Reconstruction of flexor pollicis longus tendon with palmaris longus interposition graft: results in 14 patients

The flexor pollicis longus tendon is prone to attritive rupture and retraction. Direct repair is often not possible. Interposition grafting is a treatment option to restore tendon continuity, although the surgical technique and postoperative results have not been well defined. We report our experience with this procedure. 14 patients were prospectively followed for a minimum of 10 months after surgery. There was one postoperative failure of the tendon reconstruction. Postoperative strength was comparable to the contralateral side, but thumb range of motion was significantly reduced. In general, patients reported excellent postoperative hand function. This procedure seems a viable treatment option with lower donor site morbidity than tendon transfer surgery.

Radial tuberosity anatomy in intramedullar repair of distal biceps tendon ruptures. A radiological study

The aim of this study was to measure cortex thickness and medullar canal width of the bicipital tuberosity, to evaluate the accessibility of a intramedullar fixation device and the resistance to pullout strengths of the anterior cortex. The final objective was to determine the length of tendon ingrowth size that will be expected when using this surgical technique. A total of 144 computer tomography images of the proximal radius were used. Bone thickness of the anterior and posterior cortex and medullar canal size were measured. The possible ingrowth of the tendon was measured both for an anatomical and non- anatomical reinsertion. Statistical and concordance analyses of results were performed. The average width of the medullar canal was 8,7mm proximal, 7,9mm distal and 7,7mm at the tuberosity. The average posterior and anterior cortex measured respectively 2,5mm and 2,9mm proximal, 3,2mm and 3,2mm distal and 2,8mm and 1,9mm at the radial tuberosity. The possible non-anatomical ingrowth was 7,6 mm on average and the possible anatomical ingrowth was 7,6mm on average. The radial tuberosity anatomy can accommodate the new distal biceps fixation device. The anterior cortex on which the new device relies for support has a similar thickness as the posterior cortex used in bicortical fixation devices which may suggest similar resistance to pull-out strengths. The availability for intra-osseous fixation of the tendon stump may avoids tendon gapping. The intra-osseous length for the tendon stump surpassed reported tendon slippage during mobilization and active contraction of the distal biceps tendon.

Evaluation of clinical tests for partial distal biceps tendon ruptures and tendinitis

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.

Motor-Sparing Nerve Blocks Can Improve the Results of Digit Tendon Surgery: A Case Report

A 56-year-old woman presented with flexion dysfunction of the fifth digit 6 weeks after surgical repair of a flexor digitorum profundus laceration. She was scheduled for surgical adhesiolysis and restoration of the functionality of the finger. Intraoperative monitoring of the range of motion by active flexion was deemed important to prevent incomplete release of the tendon and residual dysfunction. Distal median and ulnar nerve blocks were used for anesthesia with the patient's ability to flex the finger. This case suggests that motor-sparing peripheral nerve blocks can improve functional outcome in certain hand surgeries.

Scaphoidectomy and 4-corner arthrodesis with headless compression screws: results, complications and their treatment

Scaphoidectomy and 4-corner arthrodesis is a common salvage surgery for degenerative wrist pathology. The purpose of this study was to evaluate the results of this procedure performed with headless compression screws, with a special focus on postoperative complications and their treatment. We assessed 36 wrists in 31 patients that were treated between 2009 and 2017. Mean follow-up was 5.2 years (range 2.9- 9.4). Pain was expressed on a Visual Analog Scale. The Quick Disabilities of the Arm, Shoulder and hand (qDASH) questionnaire and Michigan Hand Outcome Questionnaire (MHOQ) were used to assess patient functionality and satisfaction. Range of motion and grip strength of both wrists were measured. Radiographs of the operated wrist were evaluated. Mean pain score was 1.5 ± 2.3 with 19% of patients being completely free of pain also during activity. Mean qDASH was 44 ± 20 and mean MHOQ was 10 ± 5. Mean flexion-extension arc of the operated wrist was 69° and 61% of the contralateral wrist. Mean grip strength was 35kg and 89% of the opposite wrist. Non-union was observed in two patients. Two patients required hardware removal and in three patients a pisiformectomy was performed. Conversion to total wrist arthrodesis was needed in one patient. We observed postoperative complications in 28% of our patients. Most complications can successfully be treated with additional surgery. The presence of pisotriquetral arthritis should be assessed before surgery and treated with pisiform excision.

In vivo evaluation of a new intramedullary distal biceps tendon fixation device

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 rupture 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.

Acute complete and partial distal biceps tendon ruptures: what have we learned? A review

Acute distal biceps tendon (DBT) pathology includes bicipitoradial bursitis, tendinosis, partial and complete tears.

Diagnosis of complete DBT tears is mainly clinical, whereas in partial tears medical imaging is a valuable addition to the clinical diagnosis.

New insights in clinical and medical imaging of partial tears may reduce time to diagnosis and may guide the treatment plan.

Most complete tears are best treated with primary repair using either a single-incision or double-incision approach with good clinical outcome.

The double-incision technique has a higher risk of heterotopic ossification, whereas a single-incision technique carries a higher risk of nerve-related complications.

Intramedullary fixation may be a viable solution to negate the risk of posterior interosseus nerve lesions in single-incision repairs.

DBT endoscopy can be used to treat low-grade partial tears and tendinosis.

Cite this article: EFORT Open Rev 2021;6:956-965. DOI: 10.1302/2058-5241.6.200145

Postoperative rehabilitation in elbow surgery

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.

Minimally Invasive Corrective Osteotomy for Metacarpal Malrotation

Metacarpal fractures can be complicated by malrotation. This can cause functional problems with overriding or underriding of the fingers with flexion. Surgical treatment consists of corrective osteotomy and derotation. This is typically performed open and different techniques for osteotomy and fixation have been described. Postoperative complications include finger stiffness and hardware irritation. We propose a technique for minimally invasive corrective osteotomy of malunited metacarpal fractures with rotational malalignement. Advantages are quick rehabilitation and no prominent hardware.

In vitro Biomechanical Analysis of Proximal Phalangeal Osteotomy Fixation

Background  Corrective osteotomies of the proximal phalanx are typically stabilized with plate and screws. Although intramedullary headless screws form an alternative fixation method in the treatment of acute phalangeal fractures, reports about fixation of opening wedge corrective osteotomies with these implants are lacking. Objective  The goal of the present study was to biomechanically compare the failure force of both fixation methods for this specific indication. Methods  Twenty-four cadaver phalanges were equally distributed between apex volar and apex lateral opening wedge osteotomy groups. In each group, half of the osteotomies were fixed with a 1.3-mm dorsal locking plate, the other half with a 2.4-mm intramedullary headless screw. A three-point bending test was performed. Results  The mean maximal failure force after apex lateral osteotomy was 178.4 N for the plate-screw construct and 144.0 N after intramedullary headless screw fixation. After apex volar osteotomy, mean maximal force was 237.6 N in the plate-screw group and 160.9 N in the intramedullary headless screw group. Mean stiffness after apex lateral osteotomy was 63.3 N/mm in the plate-screw group, and 55.9 N/mm in the intramedullary headless screw group. Mean stiffness after apex volar osteotomy was 197.5 N/mm and 60.0 N/mm for the plate-screw and intramedullary headless screw group, respectively. Conclusion  For apex volar osteotomies, dorsally applied angular stable plate and screws provide significantly stronger fixation than intramedullary headless screws. For apex lateral osteotomies, fixation force is comparable. Clinical relevance  These data are useful when considering fixation of opening wedge osteotomies with intramedullary screws.

Is the flexion-abduction-supination magnetic resonance imaging view more accurate than standard magnetic resonance imaging in detecting distal biceps pathology?

BACKGROUND AND HYPOTHESIS

Partial biceps tendon pathology is difficult to diagnose. The flexion-abduction-supination (FABS) magnetic resonance imaging (MRI) view has been advocated to improve the accuracy of MRI investigation. The purpose of this study was to evaluate the accuracy of the FABS view MRI in the diagnosis of distal biceps tendon pathology.

METHODS

The study included 50 patients with surgically confirmed distal biceps tendon pathology and 50 patients with other elbow disorders. In both groups, standard elbow MRI (retrospective review of previously obtained MRI data) was performed in half of the patients whereas FABS views MRI were obtained in the other half. These were evaluated by 2 independent musculoskeletal radiologists. The sensitivity and specificity of both MRI views were determined. Tendinosis and grade of rupture were reported from MRI and then compared with surgical findings.

RESULTS

There were no significant differences in sensitivity and specificity in detecting partial distal biceps injuries when the FABS view MRI (sensitivity, 84%; specificity, 86%) and standard MRI (sensitivity, 76%; specificity, 98%) were compared. The interobserver reliability was 92% for the FABS view MRI with biceps pathology and 68% for standard MRI. In the control group, the interobserver reliability was 88% for the FABS view MRI and 96% for standard MRI. FABS MRI was significantly better regarding grade of injury.

CONCLUSIONS

No significant differences in sensitivity and specificity were found between the FABS view and standard elbow MRI in the diagnosis of partial distal biceps tendon injuries, with high sensitivity and specificity for both views. Inter-rater reliability was better for FABS views, and FABS views were significantly more accurate than surgical findings in grading the extent of pathology.

Accuracy and safety of the endoscopic repair of the distal biceps : a cadaveric study

Clinical results of endoscopic distal biceps tendon repair have been shown to be comparable to open techniques in small series. This study evaluates safety and accuracy of the endoscopic technique. Sixteen fresh-frozen paired cadaveric upper extremities were used. The distal biceps tendons were cut and then repaired with the classic single incision bone button technique. Eight were done through an open technique, and eight were repaired endoscopically. Safety and accuracy were assessed by comparing the distance of the repair to neurovascular structures as well as the distance of the bone tunnel to the native biceps insertion. Paired t-tests were used to compare measurements. Significance level was set at p=0.05. There were no significant differences between the open and endoscopic groups, for any of the anatomic measurements. The ulnar artery was the closest neurovascular structure to the tunnel, with an average of 1 mm. The radial and recurrent radial arteries were located at 3 and 19 mm respectively. The median nerve was an average 10 mm from the tunnel, and both the SBRN and PIN at 12 mm. The distance between the PIN and the endobutton at the posterior side of the radius was an average 6 mm. There were no significant differences in variance between both groups related to the placement of the tunnel relative to the native biceps insertion. The single incision endoscopic-assisted technique of distal biceps repair can be performed consistently and with no added risk to neurovascular structures when compared to the classic open technique.

A new intramedullary fixation method for distal biceps tendon ruptures: a biomechanical study

BACKGROUND

Various techniques have been described for distal biceps tendon reinsertion. Although high success rates have been reported, all current techniques have specific shortcomings, with complications such as heterotopic ossification, nerve damage, and gap formation. The purpose of the present study was to biomechanically evaluate a new intramedullary fixation device that might reduce the risk of posterior interosseous nerve lesions. We therefore compared the fixation strength of this new intramedullary button with an extramedullary placed classic extracortical button.

METHODS

A standard bicortical button was compared to the new intramedullary fixation device using fresh-frozen cadaveric specimens. The fixation strengths were tested both cyclically and statically. Load to failure and method of failure were also recorded.

RESULTS

There were no failures during the cyclic load testing. The mean tendon-bone displacement was 0.87 ± 0.13 mm for the bicortical group and 0.83 ± 0.13 mm for the new button. During static loading, the mean load to failure for the bicortical group was 296 ± 97 N, whereas the new button group showed a higher mean load to failure of 356 ± 37 N. Breakout through the anterior cortex was recorded in 2 of 6 bicortically placed buttons and 1 of 6 in the new device.

CONCLUSIONS

The new intramedullary fixation device yields comparable loads to failure compared with currently used techniques in a biomechanical setup. These findings together with the theoretical advantages suggest that this technique may be a valuable solution for the repair of distal biceps tendon rupture.

Trapeziometacarpal total joint arthroplasty: The effect of capsular release on range of motion

It has been suggested that trapeziometacarpal total joint arthroplasty be combined with complete release of the joint capsule to prevent ligament tethering and implant dislocation. Our goal was to evaluate the consequences of capsular release on range of motion. Trapeziometacarpal joint motion was measured with a 3D motion tracking system in seven fresh frozen human cadaver hands before and after capsular release and total joint arthroplasty with subsequently longer neck lengths. Relative to the native trapeziometacarpal joint with intact joint capsule, mean flexion-extension was significantly increased after the arthroplasty with released capsule and lengthening up to 6 mm. Mean abduction-adduction did not increase significantly. Total joint replacement combined with capsular release increases the trapeziometacarpal joint's range of motion, but not beyond the limits of most trapeziometacarpal implant designs. Lengthening of the implant neck progressively decreases the excess motion.

Can a ratio between medial and lateral meniscal volumes be calculated to determine critical meniscal volume in view of post-meniscectomy symptoms?

Partial meniscectomy is a frequently performed treatment strategy for non-suturable meniscal tears. However, the meniscal volume which can be resected without compromising the load-bearing, shock-absorbing function of the meniscus remains a topic of ongoing research. The aim of this study was to calculate the medio-lateral meniscal volume ratio to estimate this volume. In 90 patients (98 pairs of menisci) without meniscal injury, medial and lateral menisci were segmented on MRI imaging and 3D surface models were created to calculate volume. The mean medial meniscal volume was 1928,9mm3 and the mean lateral meniscal volume was 1681,7mm3. A fixed ratio of the medial over the lateral meniscal volume was calculated to be 1,16. The standard deviation of the prediction errors based on this ratio equals 217mm3. This ratio seems a useful parameter in follow-up research to determine whether there is a critical volume which can be resected without post-operative pain and osteoarthritis.

The effect of cup orientation on stability of trapeziometacarpal total joint arthroplasty: a biomechanical cadaver study

It has been suggested that the cup of a trapeziometacarpal total joint replacement should be positioned parallel with the proximal articular surface of the trapezium to align it with the centre of motion. This would diminish the chance of dislocation. The goal of this study was to test this idea biomechanically. A linked trapeziometacarpal prosthesis was implanted in seven cadaver hands and combined with three-dimensional printed trapezium cups in 17 different orientations. For every combination, stability of the prosthesis was assessed through its entire passive range of motion. Dorsal inclination of the cup relative to the proximal articular surface increased the risk of dislocation with thumb flexion and opposition. The risk of dislocation was also increased with lateral or medial inclination of the cup exceeding 20°. Our results demonstrate that cup orientation is an important factor in prosthetic joint stability. Cup placement parallel to the proximal articular surface is ideal.

Can surgical guidelines minimize complications after Maïa® trapeziometacarpal joint arthroplasty with unconstrained cups?

The most important complications of trapeziometacarpal arthroplasty are dislocation and component loosening. Incorrect cup position is often a contributing factor. Intra-operative guidelines to optimize cup orientation have recently been described. We evaluated the functional and radiological outcome of 50 Maïa® trapeziometacarpal prostheses that were implanted according to these guidelines. The minimum follow-up was 56 months. No constrained cups were used. Functional outcome was good to excellent. No spontaneous dislocations occurred. No radiological signs of loosening were observed. There was one case of premature wear. The survival rate was 96% (95% confidence interval 85 to 99%) at a mean of 65 months, with two prosthesie removed for posttraumatic trapezial fractures. This study shows that correct implant position can lead to reliable medium-term results after trapeziometacarpal joint arthroplasty.

LEVEL OF EVIDENCE

IV.

Lateral collateral ligament injuries of the elbow - chronic posterolateral rotatory instability (PLRI)

Chronic posterolateral rotatory instability (PLRI) is the most common form of chronic elbow instability.

PLRI usually occurs from a fall on the outstretched hand. On impact, the radial head and ulna rotate externally coupled with valgus displacement of the forearm. This leads to posterior displacement of the radial head relative to the capitellum, thus causing disruption of some or all of the lateral-sided stabilisers.

PLRI is mainly a clinical diagnosis with a history of instability, clicking and lateral-sided pain, with a positive clinical examination including the pivot-shift test, push-up, chair and tabletop test.

MRI can often help guide diagnosis but more commonly assists in surgical planning.

Surgery is indicated in patients with persistent, symptomatic instability of the elbow causing pain or functional deficit. There are several surgical techniques to treat PLRI, often leading to good to excellent results.

An open or arthroscopic technique has been successfully used in patients with symptomatic PLRI following one or more episodes of dislocation or subluxation. At the pre-operative examination under general anaesthesia, all of our patients had a positive pivot-shift test but not a frank dislocation. We prefer to perform a lateral collateral ligament (LCL) reconstruction with an allograft tendon.

The outcomes after repair are good to excellent in the majority of patients. Results of acute repair are generally better compared with reconstruction. This is due to the fact that predictive factors for a poor outcome include the number of previous surgeries and the prevalence of degenerative changes at the elbow.

Recurrent instability is not uncommon following repair or reconstruction and has been reported in up to 25% of patients after medium- to longer-term follow-up.

Cite this article: EFORT Open Rev 2016;1:461-468. DOI: 10.1302/2058-5241.160033

Radiological and Clinical Evaluation of the Transosseous Cortical Button Technique in Distal Biceps Tendon Repair

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.

Trapezium anatomy as a radiographic reference for optimal cup orientation in total trapeziometacarpal joint arthroplasty

In trapeziometacarpal arthroplasty, correct implant position may be necessary to prevent complications such as dislocation, component loosening and premature wear. The metacarpal stem more easily fits anatomically. However, the cup in the trapezium is not anatomical and guidelines for its orientation are not uniformly defined. We determined the centre of the range of motion of the trapeziometacarpal joint in 30 healthy patients on postero-anterior and lateral radiographs and its relationship to the proximal articular surface of the trapezium. Our study suggests that in thumb carpo-metacarpal total joint arthroplasty, the prosthetic cup in the trapezium should be placed parallel to the proximal articular surface of the trapezium and combined with a metacarpal neck with 7° palmar offset. This should optimize arthroplasty ranges of motion and may minimize the risk of postoperative complications. Our study provides a reference for the surgeon to check correct cup alignment intra-operatively with fluoroscopy.

Distal biceps tendon repair: comparison of clinical and radiological outcome between bioabsorbable and nonabsorbable screws

BACKGROUND

Distal biceps tendon repair to the radial tuberosity can be conducted by means of an interference screw in combination with a transosseous button. Bioabsorbable interference screws have been associated with complications such as severe osteolytic reactions. We questioned whether patients with a distal biceps tendon repair with bioabsorbable poly-L-lactide (PLLA) screws had different functional, clinical, and radiologic outcome than patients with nonabsorbable poly-ether ether ketone (PEEK) screws.

METHODS

Between 2010 and 2014, 23 patients with an acute distal biceps tendon rupture were treated with reinsertion of the distal biceps tendon in a bone tunnel at the radial tuberosity through a single anterior incision using a transosseous button combined with an interference screw. A PLLA screw was used in 12 patients and a PEEK screw in 11 patients. All patients were retrospectively evaluated with a minimal follow-up of 1 year clinically and by means of the visual analog scale for pain, Mayo Elbow Performance Score, and Disabilities of Arm, Shoulder and Hand Outcome Measure score. Bone tunnel volume was measured with computed tomography segmentation.

RESULTS

Elbow mobility and arm and forearm circumference were symmetric for all patients. The visual analog scale for pain was 0.2 in the PLLA group and 0.7 in the PEEK group. The Disabilities of Arm, Shoulder and Hand score and Mayo Elbow Performance Score were 5.4 and 98.7 in the PLLA group vs. 3.1 and 95.9 in the PEEK group. Bone tunnel enlargement of 43% in the PLLA and 38% in the PEEK group was noted.

CONCLUSIONS

Clinical and functional outcome at more than 1 year after distal biceps tendon repair was excellent in both groups. Bone tunnel widening occurred in all patients.

Sublaminar devices for the correction of scoliosis: metal wire versus polyester tape

The authors conducted a retrospective study comparing the corrective effect of two sublaminar techniques on scoliosis: the classical one, based on metal wire, and a more recent one, based on polyester tape (thoracic Universal Clamp), known to be safer (less risk of neurological damage, less laminar breakthrough) and compatible with MRI. Lumbar screws were used in both groups. The authors composed two groups of 25 scoliosis patients, matched for gender, age, aetiology, anterior release, number of levels fused, number of infections, major curve and flexibility: there was no significant difference. Only the follow-up period was different: 55 months in the metal wire group, versus 17 months in the polyester tape group (p < 0.001), but this was immaterial because the curves were compared one year after surgery. After one year there was no significant difference between both groups, as to correction in the coronal or in the sagittal plane. This means that the polyester tape technique offers an interesting alternative, given that it yields supplementary advantages, as mentioned above.