Aims. The aim of this study was to analyze the association between the shape of the distal radius sigmoid notch and triangular fibrocartilage complex (TFCC) foveal tear. Methods. Between 2013 and 2018, patients were retrospectively recruited in two different groups. The patient group comprised individuals who underwent arthroscopic transosseous TFCC foveal repair for foveal tear of the wrist. The control group comprised individuals presenting with various diseases around wrist not affecting the TFCC. The study recruited 176 patients (58 patients, 118 controls). The sigmoid notch shape was classified into four types (flat-face, C-, S-, and ski-slope types) and three radiological parameters related to the sigmoid notch (namely, the radius curvature, depth, and version angle) were measured. The association of radiological parameters and sigmoid notch types with the TFCC foveal tear was investigated in univariate and multivariate analyses. Receiver operating characteristic curves were used to estimate a cut-off for any statistically significant variables. Results. Univariate analysis showed that the flat-face type was more prevalent in the patients than in the control group (43% vs 21%; p = 0.002), while the C-type was lower in the patients than in the control group (3% vs 17%; p = 0.011). The depth and version angle of sigmoid notch showed a negative association with the TFCC foveal tear in the multivariate analysis (depth: odds ratio (OR) 0.380; p = 0.037; version angle: OR 0.896; p = 0.033). Estimated cut-off values were 1.34 mm for the depth (area under the curve (AUC) = 0.725) and 10.45° for the version angle (AUC = 0.726). Conclusion. The proportion of flat-face sigmoid notch type was greater in the patient group than in the control group. The depth and version angle of sigmoid notch were negatively associated with TFCC foveal injury. Cite this article: Bone Joint J 2020;102-B(6):749–754

We undertook a study on eight arms from fresh cadavers to define the clinical usefulness of the lesser sigmoid notch as a landmark when reconstructing the length of the neck of the radius in replacement of the head with a prosthesis. The head was resected and its height measured, along with several control measurements. This was compared with in situ measurements from the stump of the neck to the proximal edge of the lesser sigmoid notch of the ulna. All the measurements were performed three times by three observers acting independently. The results were highly reproducible with intra- and interclass correlations of > 0.99. The mean difference between the measurement on the excised head and the distance from the stump of the neck and the lesser sigmoid notch was −0.02 mm (−1.24 to +0.97). This difference was not statistically significant (p = 0.78). The proximal edge of the lesser sigmoid notch provides a reliable landmark for positioning a replacement of the radial head and may have clinical application

Aims. The aims of this study were: firstly, to investigate the influence of the thickness of cartilage at the sigmoid notch on the inclination of the distal radioulnar joint (DRUJ), and secondly, to compare the sensitivity and specificity of MRI with plain radiographs for the assessment of the inclination of the articular surface of the DRUJ in the coronal plane. . Patients and Methods. Contemporaneous MRI images and radiographs of 100 wrists from 98 asymptomatic patients (mean age 43 years, (16 to 67); 52 male, 53%) with no history of a fracture involving the wrist or surgery to the wrist, were reviewed. The thickness of the cartilage at the sigmoid notch, inclination of the DRUJ and Tolat Type of each DRUJ were determined. . Results. The assessment using MRI scans and cortical bone correlated well with radiographs, with a kappa value of 0.83. The mean difference between the inclination using the cortex and cartilage on MRI scans was 12°, leading to a change of Tolat type of inclination in 66% of wrists. No reverse oblique (Type 3) inclinations were found when using the cartilage to assess inclination. . Conclusion . These data revealed that when measuring the inclination of the DRUJ using cartilage, reverse oblique inclinations might not exist. The data suggest that performing an ulna shortening osteotomy might be reasonable even in distal radioulnar joints where the plain radiographic appearance suggests an unfavourable reverse oblique inclination in the coronal plane. We recommend using MRI to validate radiographs in those that appear to be reverse oblique (Tolat Type 3), as the true inclination might be different, thereby removing one possible contraindication to ulnar shortening. Cite this article: Bone Joint J 2017;99-B:369–75

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 aims of this study were to identify means to quantify coronal plane displacement associated with distal radius fractures (DRFs), and to understand their relationship to radial inclination (RI).

Aims

The aim of this study was to assess and compare active rotation of the forearm in normal subjects after the application of a short-arm cast (SAC) in the semisupination position and a long-arm cast (LAC) in the neutral position. A clinical study was also conducted to compare the functional outcomes of using a SAC in the semisupination position with those of using a LAC in the neutral position in patients who underwent arthroscopic triangular fibrocartilage complex (TFCC) foveal repair.

Injury to the triangular fibrocartilage complex (TFCC) may result in ulnar wrist pain with or without instability. One component of the TFCC, the radioulnar ligaments, serve as the primary soft-tissue stabilizer of the distal radioulnar joint (DRUJ). Tears or avulsions of its proximal, foveal attachment are thought to be associated with instability of the DRUJ, most noticed during loaded pronosupination. In the absence of detectable instability, injury of the foveal insertion of the radioulnar ligaments may be overlooked. While advanced imaging techniques such as MRI and radiocarpal arthroscopy are well-suited for diagnosing central and distal TFCC tears, partial and complete foveal tears without instability may be missed without a high degree of suspicion. While technically challenging, DRUJ arthroscopy provides the most accurate method of detecting foveal abnormalities. In this annotation the spectrum of foveal injuries is discussed and a modified classification scheme is proposed.

Cite this article: Bone Joint J 2023;105-B(1):5–10.

Aims

In patients with a failed radial head arthroplasty (RHA), simple removal of the implant is an option. However, there is little information in the literature about the outcome of this procedure. The aim of this study was to review the mid-term clinical and radiological results, and the rate of complications and removal of the implant, in patients whose initial RHA was undertaken acutely for trauma involving the elbow.

Aims

The aim of this study was to evaluate the kinematics of the elbow following increasing length of the radius with implantation of radial head arthroplasties (RHAs) using dynamic radiostereometry (dRSA).

Despite being one of the most common injuries around the elbow, the optimal treatment of olecranon fractures is far from established and stimulates debate among both general orthopaedic trauma surgeons and upper limb specialists. It is almost universally accepted that stable non-displaced fractures can be safely treated nonoperatively with minimal specialist input. Internal fixation is recommended for the vast majority of displaced fractures, with a range of techniques and implants to choose from. However, there is concern regarding the complication rates, largely related to symptomatic metalwork resulting in high rates of implant removal. As the number of elderly patients sustaining these injuries increases, we are becoming more aware of the issues associated with fixation in osteoporotic bone and the often fragile soft-tissue envelope in this group. Given this, there is evidence to support an increasing role for nonoperative management in this high-risk demographic group, even in those presenting with displaced and/or multifragmentary fracture patterns. This review summarizes the available literature to date, focusing predominantly on the management techniques and available implants for stable fractures of the olecranon. It also offers some insights into the potential avenues for future research, in the hope of addressing some of the pertinent questions that remain unanswered.

Cite this article: Bone Joint J 2023;105-B(2):112–123.

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.

Aims

The primary aim of this study was to assess if traumatic triangular fibrocartilage complex (TFCC) tears can be treated successfully with immobilization alone. Our secondary aims were to identify clinical factors that may predict a poor prognosis.