Aims. The aim of this study was to determine the consensus best practice approach for the investigation and management of children (aged 0 to 15 years) in the UK with musculoskeletal infection (including septic arthritis, osteomyelitis, pyomyositis, tenosynovitis, fasciitis, and discitis). This consensus can then be used to ensure consistent, safe care for children in UK hospitals and those elsewhere with similar healthcare systems. Methods. A Delphi approach was used to determine consensus in three core aspects of care: 1) assessment, investigation, and diagnosis; 2) treatment; and 3) service, pathways, and networks. A steering group of paediatric orthopaedic surgeons created statements which were then evaluated through a two-round Delphi survey sent to all members of the British Society for Children’s Orthopaedic Surgery (BSCOS). Statements were only included (‘consensus in’) in the final agreed consensus if at least 75% of respondents scored the statement as critical for inclusion. Statements were discarded (‘consensus out’) if at least 75% of respondents scored them as not important for inclusion. Reporting these results followed the Appraisal Guidelines for Research and Evaluation. Results. A total of 133 children’s orthopaedic surgeons completed the first survey, and 109 the second. Out of 43 proposed statements included in the initial Delphi, 32 reached ‘consensus in’, 0 ‘consensus out’, and 11 ‘no consensus’. These 11 statements were then reworded, amalgamated, or deleted before the second Delphi round of eight statements. All eight were accepted as ‘consensus in’, resulting in a total of 40 approved statements. Conclusion. In the many aspects of medicine where relevant evidence is not available for clinicians to base their practice, a Delphi consensus can provide a strong body of opinion that acts as a benchmark for good quality clinical care. We would recommend clinicians managing children with musculoskeletal infection follow the guidance in the consensus statements in this article, to ensure care in all medical settings is consistent and safe. Cite this article: Bone Joint J 2023;105-B(7):815–820

The October 2015 Wrist & Hand Roundup360 looks at: Base of thumb arthritis – steroids not a waste of time; De Quervain’s tenosynovitis and steroids; Use your therapy time wisely!; Excision osteotomy for the carpometacarpal joint?; CORDLESS at five years?; Arthroscopy again of no benefit?; Distal radius stirring up trouble again!; Scaphoid arthroscopy under the spotlight

Background. Implants based on the polyetheretherketon (PEEK) polymer have been developed in the last decade as an alternative to conventional metallic devices. PEEK devices may provide several advantages over the use of conventional orthopedic materials, including the lack of metal allergies, radiolucency, low artifacts on magnetic resonance imaging scans and the possibility of tailoring mechanical properties. The purpose of this study was to evaluate the clinical results at mean 24-month follow-up using a new plate made of carbon-fiber-reinforced polyetheretherketon (CFR-PEEK) for the treatment of distal radius fractures. Materials and methods. We performed a prospective study including all patients who were treated for unstable distal radius fracture with a CFR-PEEK volar fixed angle plate. We included 70 consecutive fractures of AO types B and C that remained displaced after an initial attempt at reduction. The fractures were classified according to the AO classification: 35 fractures were type C1, 13 were type C2, 6 were type C3, 5 were type B1 and 11 were type B2. Results. All fractures healed, and radiographic union was observed at an average of 6 weeks. The final Disabilities of Arm, Shoulder and Hand score was 5.2 points. The average grip strength, expressed as a percentage of the contralateral limb, was 94 %. Three cases of hardware breakage were reported. Two cases were due to intraoperative plate rupture caused by the attempt to achieve the reduction of the fracture in 1 case and while inserting a distal screw in the other case. In the last case hardware breakage was caused by a fall on the injuried arm 1 week after surgery. No cases of loss of the surgically achieved fracture reduction were documented. Hardware removal was performed in 3 cases, for the occurrence of extensor tenosynovitis in 2 patients and tenosynovitis of flexor pollicis longus in 1 case. Conclusion. The major advantage of CFR-PEEK plate is its radiolucency. This characteristic allows direct visualization of osseous callus formation, allowing monitoring of the healing of the fracture, thereby improving clinical assessment and accuracy. Therefore, specific indications for this new radiolucent plate can be represented by fractures with significant metaphyseal comminution and in cases of nascent malunion where a distal radius osteotomy with bone grafting is usually performed to correct the wrong angle. At early follow-up this device showed good clinical results and allowed maintenance of reduction in complex, AO fractures. The occurrence of tendon complications related to this implant was similar to that reported in literature for the other new-generation plates. However, attention should be payed when stressing the plate to achieve the desired fracture reduction to avoid hardware failure

Acute peroneal tendon tears present as a relatively sudden onset of lateral ankle or hindfoot pain, frequently in conjunction with a traumatic episode or injury. Underlying or causative factors, including recurrent ankle sprains, hindfoot varus leading to ankle instability, or dislocating peroneal tendons may be associated and can often lead to peroneal tendon tears being overlooked as a cause of persistent lateral ankle or foot pain. Some apparently acute peroneal tendon tears may represent an acute manifestation of an underlying chronic or subclinical abnormality. The spectrum of peroneal tendinopathies includes tenosynovitis, tendinosis, subluxation or dislocation, stenosing tenosynovitis, disorders of the os peroneum, and conditions related to accessory peroneal tendons, as well as acute and chronic tendon tears. These abnormalities of the peroneal tendons may coexist, and one may lead to another, as evidenced by the significant incidence of tears in the presence of dislocating peronei and ankle instability. Suspicion of the possibility of peroneal tendon injury, coupled with careful clinical examination and appropriate investigation, allows the clinician to identify the extent of damage and to implement a successful management plan. Because peroneal tears signify a mechanical abnormality, this management often entails surgical intervention

This study investigates the efficacy of the AO Pi-plate in the treatment of complex, unstable, intra-articular fractures of the distal radius. A retrospective study of 17 patients was carried out who underwent open reduction and internal fixation for dorsally displaced, intra-articular fractures of the distal radius using the AO Pi-plate. All patients were assessed clinically and radiologically post-operatively. The final functional outcome was assessed using the Gartland & Werley scoring system. The average follow-up period was 34.3 months. 94% (16 patients) of the fractures were classified as AO type C fractures. The wrist movement was restored to a near normal range in all cases. The mean grip strength was 67% of the uninjured hand. The functional outcome as measured by the Gartland & Werley scoring system showed excellent and good results in 88% of the patients. Radiographic assessment revealed an average articular step-off of 0mm post-operatively. The implant removal rate was 29% (5 patients) and the main reason for that was extensor tenosynovitis. Conclusion: Our study demonstrates that although the functional outcome after using the Pi-plate for complex distal radius fractures is good, there is a significant incidence of extensor tenosynovitis. We recommend that the implant is best used for Type C fractures and be removed electively after fracture union

Injection of corticosteroids into the digital flexor tendon sheath is an accepted and effective treatment for stenosing tenosynovitis. However, despite long historical experience with this procedure, there remains no guide in the literature as to the optimal dose of steroid. Furthermore, the accuracy of these injections has not been well established. Using a prospective, randomized, blinded design, this study compares the outcomes of high (20 mg) and low (10 mg) dose depomedrol injection. Furthermore, the accuracy of tendon sheath injections was assessed radiographically. The findings demonstrate increased effectiveness of the higher steroid dose and a significant learning curve associated with intra-thecal injections. Injection of corticosteroids into the digital flexor tendon sheath is an accepted and effective treatment for stenosing tenosynovitis (trigger finger). However, despite long historical experience with this procedure, there remains no guide in the literature as to the safe and effective dose of steroid to be administered. Furthermore, the accuracy of digital tendon sheath injections has not been well established. One study has suggested that steroid injected outside the tendon sheath was as effective as intra-thecal injection and may result in reduced complications of infection and tendon rupture. Using a prospective, blinded design, patients were randomized to receive either high (20 mg) or low (10 mg) dose depomedrol injection. The accuracy of the steroid injections was determined radiographically using non-ionic radio-opaque dye. Outcome measures included pain, tenderness, presence of a palpable nodule, triggering, and limitation of activities (work, hobbies, ADLs). Complications such as pain, stiffness, bruising, thinning of the fat or skin, infection and tendon rupture were also recorded. Higher dose depomedrol (20 mg) was found to be more effective for relieving pain and triggering than lower dose depomedrol (10 mg). No increase in complication rate was encountered. Stenosing tenosynovitis in diabetic patients was markedly less responsive to treatment. Injection accuracy was found to increase with clinical experience from approximately 50% for beginners to over 90% for experienced hand surgeons. At the time of submission of this abstract, patient numbers (currently forty-one participants) do not allow analysis regarding the effect of injection accuracy on clinical outcome

Locking of the MCP joint of the finger, except with stenosing tenosynovitis, is relatively rare. The middle finger is most frequently involved. We treated 7 patients who had locking of the MCP joint of the middle finger because of osteophyte of the metacarpal head. The locking of the MCP joint usually occurred in the older patient as a result of significant osteophyte around the metacarpal head. Unlocking of the MCP joint was done by closed manipulation under local anaesthesia. Locking of the MCP joint of the finger because of other causes than tenosynovitis has been reported infrequently. Locking of the MCP joint caused by osteophyte of the head of the metacarpal is characterised by painful loss of extension of the MCP joint without loss of flexion. We have treated 7 patients who had locking of the MCP joint occurring in the middle finger with an obvious osteophyte of the metacarpal head. Seven patients, 4 women and 3 men, were treated in our Department. None of the patients had a history of trauma to their hands, and in all of them it was the dominant hand which was affected and usually due to powerful full flexion movement of the fingers. The average age was 73.8 years (65 – 81). The duration of locking was from 3 hours to 14 days. All the patients were treated within 30–60 minutes after reporting to our Clinic. The presentation of the patients was extremely similar. In all cases active and passive extension was blocked and they had pain around the finger. Full flexion was possible. The MCP joint was tender around the palmar aspect with slight diffuse swelling around the dorsal aspect. Radiographs of the MCP showed degenerative changes in all the patients and oblique views demonstrated an osteophyte either on the ulnar or the radial side of the head. Local anaesthetic Lignocaine 1% 5ml was injected in the MCP and around the joint and after 5–10 minutes manipulation was performed, unlocking achieved and the patients straightaway extended and flexed the finger fully. No-one underwent surgical release. Follow-up from 3 to 8 months, average 6 months. No recurrence of the locking. Akio Minami reported 4 cases of MCP joint locking of the middle finger, treated surgically. Williams classified the locking of the MCP joint in 3 groups. Langenskiold reported 2 cases of intrinsic locking of the MCP due to catching of the collateral ligament on the lateral bony projection of the metacarpal head. It is very difficult to explain why the middle finger is most likely affected. Kessler noted that the MCP joint seldom participates in a generalised degenerative OA

Aims

Posterior malleolar (PM) fractures are commonly associated with ankle fractures, pilon fractures, and to a lesser extent tibial shaft fractures. The tibialis posterior (TP) tendon entrapment is a rare complication associated with PM fractures. If undiagnosed, TP entrapment is associated with complications, ranging from reduced range of ankle movement to instability and pes planus deformities, which require further surgeries including radical treatments such as arthrodesis.

It is well recognised that patients with diabetes mellitus have a predisposition towards stenosing flexor tenosynovitis (FTS). However, recent research has suggested an association between the development of FTS and haemoglobin A1c (HbA1c) level which is used as a marker of glycaemic control. National guidelines on management of diabetes suggest treatment should aim to maintain HbA1c at <6.5%. The aim of our study is to quantify glycaemic control in patients undergoing surgical A1 pulley release. We retrospectively reviewed the blood results of 78 patients who underwent FTS surgery. 27 of these had an HbA1c checked within 6 months of their surgery and we therefore presumed these patients were diabetic. For diabetic patients the average HbA1c was 7.9% (range 5.3–11.4) and only 7 of the 27 patients had an HbA1c within the recommended range. In this cohort 33% of patients were presumed diabetic and 74% of these had a documented HbA1c above the national target suggesting a significant number presenting for surgery have poor glycaemic control. Therefore it may be of benefit to screen for this in patients undergoing FTS surgery

Introduction. The exact action of the Peroneus Longus muscle on the foot is not fully understood. It is involved in a number of pathological processes like tendonitis, tenosynovitis, chronic rupture and neurological conditions. It is described as having a consistent insertion to the base of the first metatarsal, but there have also been reports of significant variations and additional slips. Our aim was to further clarify the anatomy of the main insertion of the Peroneus Longus tendon and to describe the site and frequency of other variable insertion slips. Methods and Materials. The course of the distal peroneus longus tendon and its variable insertion was dissected in 12 embalmed, cadaveric specimens. The surface area of the main insertion footprint and angle of insertion was measured using an Immersion Digital Microscribe and 3D mapping software. The site and frequency of the other insertion slips is also presented. Results. There was a consistent, main insertion to the infero-lateral aspect of the first metatarsal in all specimens. The only additional slip was to the medial cuneiform. This did not increase the total footprint. Discussion. The main footprint of the Peroneus Longus tendon is on the first metatarsal. There was an additional slip to the medial cuneiform in 33% of our specimens. Although we are unsure about the significance of this additional slip, we hope it will lead to a better understanding of the mechanism of action of this muscle and its role both in the normal and pathological foot

The exact action of the Peroneus Longus muscle on the foot is not fully understood. It is involved in a number of pathological processes like tendonitis, tenosynovitis, chronic rupture and neurological conditions. It is described as having a consistent insertion to the base of the first metatarsal, but there have also been reports of significant variations and additional slips. Our aim was to further clarify the anatomy of the main insertion of the Peroneus Longus tendon and to describe the site and frequency of other variable insertion slips. The course of the distal peroneus longus tendon and its variable insertion was dissected in 20 embalmed, cadaveric specimens. The surface area of the main insertion footprint was measured using an Immersion Digital Microscibe and 3D mapping software. The site and frequency of the other variable insertion slips is presented. There was a consistent, main insertion to the infero-lateral aspect of the first metatarsal in all specimens. The surface area of this insertion was found to be proportional to the length of the foot. The insertion in males was found to be significantly larger than females. The most frequent additional slip was to the medial cuneiform. Other less frequent insertion slips were present to the lesser metatarsals. The main footprint of the Peroneus Longus tendon is on the first metatarsal. There appears to an additional slip to the medial cuneiform frequently. Although we are unsure about the significance of these additional slips, we hope it will lead to a better understanding of the mechanism of action of this muscle and its role both in the normal and pathological foot

Percutaneous A1 pulley release is being increasingly used as an alternative to open surgical release and injection of local steroids for the treatment of the trigger digit. We treated 43 patients, average age 57 years (range12-78). All trigger digits were grade III-IV (Quinnell classification). A mean duration of pre-operative symptoms was 7.3 months (range 2-13 months). A percutaneous release was performed with a 19-gauge hypodermic needle under local anaesthesia in the outpatient setting. All patients were evaluated with respect to clinical resolution of symptoms and general satisfaction. We report a 97% successful release and only one case of incomplete release. A result in terms of abolishing triggering was immediate and patient acceptance was excellent. By two weeks, all the patients had no pain at the operative site. After a mean follow-up of 30.2 months (range12-50), there had been no recurrences. There were no digital nerve injuries, flexor tendon injuries, and infections. The percutaneous release is a safe and effective technique, which provides significant cost savings. The time from onset of symptoms and grading prognostically is significant and affects the treatment outcome. We recommend the percutaneous technique for typical cases of trigger finger with a palpable nodule and reproducible mechanical triggering. This technique can be the treatment of choice for the established trigger finger (grade III and IV) with symptoms of more than few months' duration. The open technique is reserved for complicated cases such as florid tenosynovitis, locked digit, failed percutaneous release or those involving the thumb

This study reports the results of open reduction and internal fixation of 26 unstable, intra-articular, dorsally displaced fractures of the distal radius using a bio absorbable dorsal distal radius (Reunite) plate and calcium phosphate (Biobon) bone substitute. The bio absorbable plate has the advantages of being low profile, easily contourable due to temporary malleability and is angularly stable. It retains its strength for 6 to 8 weeks and undergoes complete mass loss within one year, thereby allowing gradual load transfer to the healing bone. In the majority of cases, this plate produces functional results comparable with metal plates. The Gartland and Werley score was excellent or good in 21 patients. The most important advantage over metal plates is in eliminating the need to remove the plate and hence the need for a second operation if implant related extensor tenosynovitis occurs. Inflammatory tissue reaction to the degradation products of the plate is a potential concern, although the co-polymer ratio used in this plate appears to have reduced the severity of this reaction, which was seen in two patients in this series. The reduction was lost in five patients with severe dorsal comminution. For such fractures, the plate did not retain its strength for long enough to allow adequate healing for satisfactory load transfer. Following this experience, we do not recommend this plating system for fractures with a metaphyseal gap of greater than 7 mm following reduction. For fractures that cannot be treated by closed means but where the metaphyseal gap following reduction is less than 7 mm, this plate provides all the theoretical advantages. Further developments allowing the plate to retain its strength for longer while maintaining the low incidence of inflammatory reactions will make it more universally applicable for the treatment of a greater spectrum of unstable distal radius fractures

Athletes are more prone to injury because of their prolonged training, dedication and body contact, and the injuries they sustain, with some unusual exceptions, are the same as those occurring in the general population but there is more pressure to return the athlete to their chosen sport with some times, little concern for the future. Australia, and South Australia in particular, enjoys a wonderful climate that allows year round outdoor activities with a consequent potential increase in the risk of injury. The history and clinical examination remain the mainstay of diagnosis and coupled with the knowledge of the type and extent of injury, sport involved and level of competition, appropriate investigation can be arranged leading to a conclusive diagnosis and a positive therapeutic approach. Injuries to the wrist and hand vary from overuse type tenosynovitis through to major carpal injuries with possible neurological and vascular compromise. and as well as helping the athlete return to sport as effectively and quickly as possible, it is also important to consider the implications for the patient in the future, once he or she has retired from competitive involvement. This aspect is further accentuated by monetary gain which may influence the athlete, coaches, etc. As well as discussing management of selected injuries to the wrist and hand, several more unusual “sporting injuries” will be addressed

Material and Methods: This prospective study included 15 patients, 9 males and 6 females, who have been scoped for peroneal tendon disorder between 1999 and 2004. All patients were diagnosed clinically to have chronic peroneal tendon dysfunction and all had conventional x-ray films, ultrasonographic assessment and magnetic resonance imaging. The mean age was 44 (range 23 to 65). The mean duration of symptoms were 16 (range from 2 to 65). All patient had a trial of conservative treatment before being referred to us. Results: 7 patients was found to have tenosynovitis, which could be resected endoscopically in all cases. In 2 patients a low lying muscle belly (LLMB) of peroneus brevis was present; this could be resected with a shaver very easily. 1 patient had a peroneal tendon instability. This was surgical treated in an open technique with reconstruction of the retinaculum. In 5 patients we could document partial lesions of the peroneal tendons (fig.6,7). This were posttraumtic after a supination trauma in 2 patients and degenerative in the remaining 3 patients. In 4 patients this could be treated minimal invasive with debridement. In one patient a traumatic longitudinal splitting tear was reconstructed with open surgery. At time of follow up (average 2.8 years; range: 78– 18 months) all patients where without symptom on average 3 months (range: 4 – 17 weeks) after surgery. They where able to perform all activities of daily living as well as moderate athletic activities such as jogging and biking. These clinical results where stable until the time of follow-up. Clincal relevance: Tendoscopy of the peroneal tendons is an effective and minimal invasive management tool, that can be indicated in many of peroneal disorders. Further studied are needed at that respect to improve results and promote minimal invasive surgical techniques

Aims: Peroneal tendons possess a vascular supply through a mesotendineal structure named vinculum; vincula are identifiable with tendoscopy and are supposed to play a role in tendon healing response, due to prominent vascularity; aim of the study is to verify the feasibility of tendoscopy in evaluating peroneal tendons, to clarify the histological structure of peroneal vincula and to investigate the presence of nervous tissue, so formulating a hypothesis regarding the functional role of vincula. Methods: cadaver study was performed on 8 fresh-frozen ankles; dissection were conducted to verify accessibility of endoscope, proximity with superficial peroneal nerve and presence of vincula; samples of vincula were obtained; light microscopy and immunohisto-chemistry (anti-human S100 antibody) were performed, describing structure of vincula and identifying peripheral nerve fibers. 5 peroneal vincula biopsies were analyzed from patients affected by ankle instability and undergoing tendoscopy for peroneal tenosynovitis. Results: peroneal tendons are accessible along the whole common tendon sheath and a discrete distance between the endoscope and the superficial peroneal nerve is present in all specimens; a membranous mesotendineal structure was found in all specimens between both tendons and tendon sheath; macroscopic inspection revealed the presence of a vessel network, arising from the sheath toward the tendon; light microscopy of cadaver samples confirmed the presence of multiple vessel branches crossing the entire structure of the vinculum and identified nervous structures close to the vessels, resembling a neurovascular bundle; immunohistochemical analysis revealed nerve fibers in each specimen;tendoscopy in patients affected by ankle instability showed lesions of the vincula and histology from intraoperative biopsies showed presence of nerve fibers. Conclusions: tendoscopy is a useful tool to visualize peroneal tendons and to diagnose and treat different disorders; although literature provides no data about innervations of peroneal vincula, the study shows nervous fibers consistently present inside the intimate structure of vinculum; besides its function in repair and healing processes, this suggests a proprioceptive role of the vinculum in peroneal tendon physiology and lesion of vinculum could be an important element acting synergistically with joint capsule and surrounding tissues lesions and ultimately leading to clinical pictures of ankle instability

Introduction: Ankle inversion injuries are common, with an incidence of 1 per day per 10,000 of the population. Chronic instability is a frequent sequela, and has been estimated to occur after approximately 10 to 20% patients, regardless of the type of initial treatment. Magnetic Resonance Imaging (MRI) has become a routine diagnostic tool in investigating knee injuries, but little has been published concerning ankle injuries and ankle instability. Aim: To compare the efficacy of conventional magnetic resonance (MR) imaging and stress radiography in the detection of lateral collateral ligament abnormalities in patients with chronic ankle instability. Materials and Methods: All patients presenting to the senior author’s OPD with clinical impression of ankle instability were investigated prospectively using MRI and stress x-rays (Telos). These films were officially reported and then, these reports were subsequently reviewed post-anatomical reconstruction. Results: Over a two-year period, 18 patients underwent anatomical reconstruction using the modified Brostrom technique. MRI identified a tear of the anterior talofibular (AFT) ligament in 12 (66%) patients, and the calcaneofibular (CF) ligament was torn in 9 (50%) patients. Stress radiography identified instability of 14 of the 18 (77%) patients. Stress radiography identified instability of 14 of the 18 (77%) patients. Surgical exploration revealed either attenuation or rupture of either the AFT and/or CF ligaments in all 18 patients. MRI demonstrated concomitant injuries to the ankle and subtalar joints, including peroneal tenosynovitis (76%), anterolateral impingement syndrome (66%) and attenuated peroneal retinaculum (55%). Conclusion: Ankle instability may be more reliably demonstrated using stress x-rays than MRI: however, lowfield MRI is a very useful diagnostic tool in the study of concomitant ankle injuries and we would suggest that both modalities be considered, especially if surgical intervention is anticipated

Background: Osteoarticular disease is the most common complication of brucellosis and has been described in 10–85% of patients. Spondylitis is the most prevalent clinical form, also arthritis, bursitis, tenosynovitis, sacroileitis and osteomyelitis have been also described. Method: We describe our experience concerning three patients with brucellar prosthetic joint infection in Israel. Results. Case 1: A 38 year old artist was admitted for revision of total hip replacement due to increased pain accompanied by loosening of the prosthesis. Four years prior admission total hip arthroplasty was performed due to psoriatic arthritis treated by methotrexate. Revision surgery demonstrated necrotic tissue which grew Brucella melitensis. Doxycycline and rifampicin were administered for 12 weeks. Second stage revision was performed on the 6th week of antibiotic therapy with favorable results. Case 2: A 62 year old Arab male underwent right total knee arthroplasty 4 years prior admission due to osteoarthritis. Past medical history included hip arthritis. A second TKA was performed due to septic arthritis caused by Staphylococcus epidermidis and Acinetobacter baumanii. The first stage of the arthroplasty grew Brucella melitensis. Antibiotic treatment and second stage revision surgery were followed successfully. Case 3: A 67 year old Arab male was admitted due to fever, right pelvic and back pain lasting for 6 weeks. Five years prior admission the patient underwent left total knee arthroplasty. Computerized tomography was normal. Following admission severe left knee pain developed. Joint aspirate grew Brucella melitensis. Antibiotic treatment and two stages revision surgery were performed successfully. In all three cases consumption of unpasteurized dairy products was documented. All three patients had serum brucella antibody titer of 1:1600. Conclusion: Brucella melitensis should be added to the differential diagnosis of prosthetic joint infection, mainly in the Mediterranean basin and the Arabian Gulf. Only two other cases of brucella prosthetic joint infections were reported involving prosthetic knees

Purpose of the study: Injury of the long head of the biceps (LHB) can cause pain in rotator cuff tears (RCT). Our objectives were to:. establish an epidemiological database on LHB injuries in RCT;. study the dynamic behaviour of LHB in RCT;. search for a correlation between injected imaging findings and arthroscopic findings. Materials and Methods: Prospective, consecutive, multi-centric study (April 2005-June 2006). Inclusion criteria:. partial or full-thickness RCT demonstrated arthroscopically,. arthorscopic description of LHB,. imaging with injection (arthroscan or arthro-MR),. data collected on the internet site of the Socité Française d’Arthroscopie (SFA). Other reasons for arthroscopy, past surgery and MRI were excluded. The dynamic examination consisted in a search for the incapacity to glide the LHB in its gutter during passive abduction of the arm leading to intra-articular fold (hourglass test) and instability of the LHB in its groove during external rotation (medial instability) or internal rotation (lateral instability) with the arm at 90° abduction (RE2 and RI2 tests). Extension of the RCT in the frontal and sagittal plane were determined using the classification of the French Arthroscopic Society. Results: 378 patients (378 shoulders, 211 women, 167 men, mean age 57.9 years, age range 28–93 years). Arthroscan for 312 shoulders and arthroMR for 66 shoulders revealed 61 partial deep RCT and 317 full-thickness RCT. Among the full-thickness tears, 15 involved the subscapularis (SSc) alone, one the infraspinatus (ISp) alone and 301 the supraspinatus (SSp) alone (with 52 posterior extensions to the ISp, 90 anterior to the SSc and 31 mixted). Epidemiological data (static test): LHB intact 21%, tenosynovitis 51%, hypertrophy 21%, delamination 12%, pre-tears 7%, subluxation 18%, dislocation 9%, tear 2%. No influence of age, gender or side operated. Conversely, the rate of lesions increased significantly with extention of the RCT in the frontal and sagittal plane. Dynmaic study: positive hourglass test 29%, instability in RE2 26%, instability in RI2 8%. Hourglass test correlated with intra-articular hypertrophy of the LHB (76% versus 2%). Subscapularis tears lead to medial instability in 82% of cases. Among the 81 shoulders with an intact LBH statically, 17% presented a dynamic anomaly. In all the static and dynamic tests only left 18% of the LHB intact. Imaging-dynamic arthroscopy correlation: 25% of LHB lesions were not diagnosed by injected imaging. Inversely, there was a good correlation to determine the position of the LHB in its groove

Purpose: Endoscopy provides an attractive alternative to open surgery for diagnostic and therapeutic purposes in patients with ankle tendon disease. Early work was published by Van Dijk in 1994. Material and methods: Twenty patients (mean age 34.7 years, range 20–59 years), 16 with posttraumatic lesions, underwent 22 tendinoscopy procedures using a slightly modified technique with a 4.5 optical. The procedures, conducted under general anaesthesia, were performed to explore fibular (n=15), posterior tibial (n=6), and anterior tibial (n=1) tendons. Prospective follow-up was at least six months (6 – 30). Preoperatively, all patients presented more or less localised pain with signs of tendon suffering. Fifteen had undergone prior explorations (ultrasound=4, MRI=7, CT scan=1, MRI+ultrasound=3) which had not revealed any anomaly in seven. Results: Peritendinous adherences were observed intra-operatively in 18 cases with inflammatory reactions requiring resection in 13. A lesion of the tendon itself was found in seven cases-fissure (n=2), superficial dilaceration (n=2), induration (n=2), strangulation (n=1)-which required specific cure with forceps or motorised instrumentation. No explanation of the pain could be identified in one patient. Postoperatively, 17 patient achieved complete pain relief which persisted for at least six months. At last follow-up, one patient had not been reviewed, twelve were totally pain free and five had developed associated symptoms (cracking, swelling). Overall, four patients were very satisfied, eight were satisfied, four were disappointed, and three were dissatisfied (no improvement). There were no signs of worsening and no complications directly related to the method. Conclusion: These results of early experience in France are less satisfactory than those reported by Van Dijk who had 80% good results for 85 tendinoscopic procedures in 70 patients. They do however confirm the usefulness of this technique for the management of patients with tenosynovitis, adherences, and partial ruptures of the ankle tendons which cannot always be identified with classical imaging techniques. Definitive evaluation will require analysis of a larger series of well selected patients