Purpose: To calculate a clinically relevant and intra-operatively accessible measure of olecranon length that could be reliably applied by the operating surgeon to optimise comminuted olecranon fracture fixation. Materials: One hundred normal adult anteroposterior and lateral radiographs of the elbow were studied with respect to the proximal olecranon width (OW), greater sigmoid notch width (SW) on lateral views, trans-epicondylar distance (TED), and trochlear width distance (TWD) on AP views. The mean ratios of TWD/SW and TED/SW and an index OW X SW/TED along with their standard deviation and normal ranges were calculated. Results: The average olecranon width was 24mm (range 21mm–28mm), sigmoid width was 25.8 mm (range 21mm–32 mm), trans-epicondylar distance was 58.53mm (range 49mm–74 mm), and the trochlear width distance was 27.1mm (range 22mm–32 mm). The average ratio of TWD: SW was 1.05 with a standard deviation of 0.09 and that of TED: SW was 2.27 with a standard deviation of 0.19. The average index worked out to be 10.58 with a standard deviation of 0.2. Conclusions: Comminuted fractures of olecranon are a surgical challenge since it is often impossible to gauge the correct length of the olecranon process. There have been no objective data described to prevent shortening or lengthening of the greater sigmoid notch after reconstruction. Our data can be easily applied to the clinical situation, by taking intra-operative radiographs, and calculating the index as demonstrated above. This index will guide the surgeon to obtain a more reliable length of the olecranon, and devolve surgical guesswork from the final outcome

The clinical diagnosis of distal radioulnar joint (DRUJ) instability remains challenging. The current diagnostic gold standard is a dynamic computerized topography (CT) scan. This investigation compares the affected and normal wrists in multiple static positions of forearm rotation.. However, its accuracy has been questioned, as the wrist is unloaded and not placed under stress. This may fail to capture DRUJ instability that does not result in static malalignment between the ulnar head and sigmoid notch. The purpose of this biomechanical study was to evaluate the effectiveness of both dynamic and stress CT scans in detecting DRUJ instability. A customized DRUJ arthrometer was designed that allows for both static positioning, as well as dorsal and volar loading at the DRUJ in various degrees of forearm rotation. Ten fresh frozen cadavers were prepared and mounted in the apparatus. CT scans were performed both in the unloaded condition (dynamic CT) and with each arm subjected to a standardized 50N volar and dorsal force (stress CT) in neutral and maximum pronation/ supination. The TFCC (triangular fibrocartilage complex)was then sectioned peripherally to simulate DRUJ instability and the methodology was repeated. CT scans were then evaluated for displacement using the radioulnar ratio method. When calculating the radioulnar ratio for intact wrists using the dynamic CT technique, values were 0.50, 0.64, 0.34 for neutral, pronation and supination, respectively. When the TFCC was sectioned and protocol repeated, the values for the simulated unstable wrist for dynamic CT were 0.54, 0.62, 0.34 for neutral, pronation and supination, respectively. There was no statistically significant difference between the intact and sectioned states for any position of forearm rotation using dynamic CT. Usingstress CT, mean radioulnar ratios for the intact specimens were calculated to be 0.44, 0.36 and 0.31 for neutral, pronation and supination, respectively. After sectioning the TFCC, the radioulnar ratios increased to 0.61, 0.39 and 0.46 for neutral, pronation and supination. There was a statistically significant difference between intact and simulated-unstable wrists in supination (p = 0.002) and in neutral (p=0.003). The radioulnar ratio values used to measure DRUJ translation for dynamic CT scans were unable to detect a statistically significant difference between stable and simulated unstable wrists. This was true for all positions of forearm rotation. However, when a standard load was placed across the DRUJ, statically significant changes in the radioulnar ratio were seen in neutral and supination between stable and simulated unstable wrists. This discrepancy challenges the current gold standard of dynamic CT in its ability to accurately diagnosis DRUJ instability. It also introduces stress CT as a possible solution for diagnosing DRUJ instability from peripheral TFCC lesions

Purpose: Injury to the distal radioulnar joint can result in ulna sided wrist pain and instability. Stabilisation of the distal radioulnar ligaments described by Adams and Berger uses a tendon graft run along the anatomical course of the distal radioulnar ligaments from the lip of the radial sigmoid notch to the fovea of the ulna. The graft wraps around the ulna head and is fixed with a simple suture; this can be challenging for the surgeon and requires a considerable length of tendon. The length of graft required could be reduced by fixing the graft directly to the ulna. Alternative fixation methods when the graft is short would include bone anchors and interference screws. We therefore compared the fixation strength achieved with simple suture, by bone anchor and by interference screw (Mini Bio-suture Tack and 3mm Biotenodesis interference screw, Arthrex, UK). Methods: Four ulna bones were harvested along with four corresponding tendons. Tendons were divided into 2mm wide strips and run through a 3.5mm hole in the ulna. Maximum load was measured after fixing the tendon with 1) simple suture, 2) a bone anchor, and 3) an interference screw. Paired data was tested with the paired T-test and Wilcoxon test. Results: Maximum load recorded was highest for the Mini Bio-Suture Tack bone anchor (99.28 ± 47.39) followed by the simple suture method (96.23 ± 24.14 N), and the Biotenodesis interference screw (46.90 ± 11.29). Differences approached significance when comparing simple suture fixation with interference screws (p=0.02/0.068). Conclusions: No study has investigated the use of interference screws to secure two tendons in one graft tunnel. Previous work using a single graft and a single tendon has consistently shown that interference screws are superior to other methods of fixation. However, when performing Adam’s procedure for stabilisation of the distal radioulnar joint suturing the tendon together or using a bone anchor provide the greatest fixation strength. This might be due to loss of the interference effect when placing two grafts in the tunnel

Purpose: Presently, tension band figure-of-eight fixation of olecranon fractures is usually performed with stainless steel wire. A polyethylene cable cerclage has been proposed as an alternative to lessen the complications associated with wire. This study compared the stability of tension band constructs for olecranon fracture fixation using a polyethylene cable cerclage or a stainless steel wire cerclage. Methods: Ten matched pairs of fresh-frozen cadaveric elbows, without radiographic abnormality, were selected for the study. In each specimen, a transverse fracture was created by an osteotomy at the middle of the sigmoid notch of the olecranon. One elbow of each pair was randomized for tension band fixation with a figure-of-eight construct while the other was fixed by tension banding with a loop cerclage. Two different materials, stainless steel wire and isoelastic polyethylene cable, were randomly selected to create the cerclage constructs in each elbow. The triceps tendon was controlled and cyclic loads were applied to the dorsal cortex of the ulna 8 cm distal to the fracture site to create a bending moment. The elbow was initially preconditioned at 45 N for 100 cycles, followed by four periods of 300 cycles each, from 45 N to 120 N in 25 N increments. Dynamic and static fracture gap for the different configurations and materials were recorded. Results: No difference in static gap was found between the metal figure-of-eight, cable figure-of-eight and cable loop constructs (p> 0.05). The metal loop was found to have significantly greater gap (p=0.0013) than the other 3 constructs. No difference was observed in dynamic gap at the peak loads for any of the constructs (p=0.3379). Conclusion: This study demonstrated that the biomechanical performance of tension band fixation in an olecranon fracture model using a polyethylene cable in either figure-of-eight or loop construct is similar to that of the stainless steel wire figure-of-eight construct and should be considered as an option to the traditional stainless steel wire. This type of soft and tissue tolerant fixation may lessen the known clinical complications of wire fixation while providing equivalent stability under physiologic loads which would permit early rehabilitation

Introduction and Aims: Rotational malalignment following fracture of the distal radius results in subluxation of the distal radioulnar joint, alteration of the normal contact area of the ulnar head in the sigmoid notch of the radius, arthrosis, pain, limited pronation and supination and dysfunction. This paper describes the technique for restoration of appropriate rotation, as well as length and angulation following malunion. Method: Eleven cases of derotational osteotomy of the distal radius with low-profile plate fixation have been performed for correction of rotational malalignment with restoration of appropriate articular tilt, length and alignment. In eight cases, the articular surface of the distal ulna was found to be too degenerated to salvage the distal radioulnar joint and resection of the distal ulna with soft tissue reconstruction was performed. Results: Healing of the osteotomy of the distal radius was achieved in all 11 patients. None of the patients undergoing distal resection demonstrated instability of the distal radioulnar joint but one demonstrated distal radioulnar impingement. One patient with a preserved ulnar head demonstrated ulnocarpal abutment and required late secondary ulna head resection. Pre-operative pronation/supination arc was 40 degrees and postoperative arc was 130 degrees. In eight of the 11, pain was rated as zero on a 10-point scale, while the other three ranged between two and five on the same scale. At a two-year follow-up, grip strength measured 80% of the contralateral side while total range of motion measured 76% of the contralateral side. All 11 patients were functional at daily household activities, five out of seven previously working patients were back to work, and all patients felt that their post-operative status was a significant improvement over their pre-operative status. Conclusion: Rotatory malpositioning following distal radius fracture provides significant disability. Derotational osteotomy can be effective in restoring pronation and supination, diminishing pain and increasing function. Late treatment may also require resection of the distal ulnar articular surface due to post-traumatic arthrosis. Soft tissue stabilisation at the time of osteotomy provides stability of the distal radioulnar joint in the majority of cases

PURPOSE: We describe a new technique for the treatment of painful instability of the distal ulna after Darrach procedure using an allograft as a mechanical interposition. The purpose of the study is to evaluate the results of this technique. Methods: In this study we report on 17 patients who underwent revision of their Darrach procedure using an allograft (human Achilles tendon allograft). The average age of the patients was 47 years (range 39–68) and the average time after the original procedure was 15 months. The indication for the revision surgery in all patients was incapacitating pain over the distal stump of the ulna which increased during pronation or supination and with active grip. Pain was assessed using a VAS (Visual Analog Scale). Grip strength was measured using a dynamometer. All patients had instability of the distal ulna, and crepitus or palpable “clicking” during forearm rotation. Radiographs of all patients demonstrated erosion of the medial cortex of the radius, indicating impingment. Technique: 2 or 3 suture anchors were placed into the medial cortex of the radius, proximal to the sigmoid notch where the impingment occurred. An adequate amount of the allograft was then sutured into an anchovy. The size of the allograft was determined by pronating and supinating the involved forearm with pressure applied to the ulnar aspect of the ulna to assess crepitus. Sutures were placed through the allograft, creating a pillow-shaped spacer. Two or three drill holes were then placed into the distal ulna for fixation of the allograft to the ulna. With final allograft placement there should be significant padding between the radius and the ulna to prevent any palpable crepitus during forearm rotation under compression. Results: After an average follow-up time of 34 months all patients were re-evaluated by subjective assessment, range of motion, grip strength, pain relief and radiographs. We report 16 patients with good and excellent results and 1 patient with persistent complaints (our first patient). There were no radiographic changes noted. Conclusions: The use of an allograft as a mechanical interposition between the radius and the ulna has not been described previously. With this technique there is no need for a metallic prosthesis and as much bulk graft as necessary is obtainable. We believe that this technique is an excellent alternative to metal arthroplasty for reconstruction of difficult cases of failed distal ulna resection

Aims

The aim of this study is to report the results of a case series of olecranon fractures and olecranon osteotomies treated with two bicortical screws.

The August 2012 Wrist & Hand Roundup³⁶⁰ looks at: the Herbert ulnar head prosthesis; the five-year outcome for wrist arthroscopic surgery; four-corner arthrodesis with headless screws; balloon kyphoplasty for Kienböck's disease; Mason Type 2 radial head fractures; local infiltration and intravenous regional anaesthesia for endoscopic carpal tunnel release; perilunate injuries; and replanting the amputated fingertip.