Compared to single-incision distal biceps repair (SI), double-incision repair (DI) theoretically allows for reattachment of the tendon to a more anatomically favorable position. We hypothesized that DI repair would result in greater terminal supination torque compared to SI repair for acute distal biceps ruptures. In this retrospective cohort study, patients were included if they sustained an isolated, acute (° supinated position. Secondary outcomes included supination torque in 45° supinated, neutral, and 45° pronated positions, ASES elbow score, DASH, SF-12, and VAS. Power analysis revealed that at least 32 patients were needed to detect a minimum 15% difference in the primary outcome (β = 0.20). Statistical analysis was performed with significance level α = 0.05 using R version 3.4.1 (R Core Team 2017, Vienna, Austria). Of 53 eligible patients, 37 consented to participate. Fifteen were repaired using DI technique and 22 using SI technique. Mean age was 47.3yrs and median follow-up time was 28.1months. The groups did not differ with respect to age, time-to-follow-up, dominance of arm affected, Workers Compensation or smoking status. Mean supination torque, measured as the percentage of the unaffected side, was 60.9% (95%CI 45.1–76.7) for DI repair versus 80.4% (95%CI 69.1–91.7) for SI repair at the 60°supinated position (p=0.036). There were no statistically significant differences in mean supination torque at the 45°supinated position: 67.1% (95%CI 49.4–84.7) for DI versus 81.8% (95%CI 72.2–91.4) for SI (p=0.102), at the neutral position: 88.8% (95%CI 75.2–102.4) for DI versus 97.6% (95%CI 91.6–103.7) for SI (p=0.0.170), and at the 45°pronated position: 104.5% (95%CI 91.1–117.9) for DI versus 103.4 (95%CI 97.2–109.6) for SI (p=0.0.862). No statistically significant differences were detected in the secondary outcomes ASES Pain, ASES Function, DASH scores, SF-12 PCS or MCS, or VAS Pain. A small difference was detected in VAS Function (median 1.3 for DI repair versus 0.5 for SI repair, p=0.023). In a multivariate linear regression model controlling for arm dominance, age, and follow-up time, SI repair was associated with a greater mean supination torque than DI repair by 19.6% at the 60°supinated position (p=0.011). Contrary to our hypothesis, we found approximately a 20% mean improvement in terminal supination torque for acute distal biceps ruptures repaired with the single-incision technique compared to the double-incision technique. Patients uniformly did well with either technique, though we contend that this finding may have clinical significance for the more discerning, high-demand patient.
Compared to single-incision distal biceps repair (SI), double-incision repair (DI) theoretically allows for reattachment of the tendon to a more anatomically favorable position. We hypothesized that DI repair would result in greater terminal supination torque compared to SI repair for acute distal biceps ruptures. In this retrospective cohort study, patients were included if they sustained an isolated, acute (° supinated position. Secondary outcomes included supination torque in 45° supinated, neutral, and 45° pronated positions, ASES elbow score, DASH, SF-12, and VAS. Power analysis revealed that at least 32 patients were needed to detect a minimum 15% difference in the primary outcome (β = 0.20). Statistical analysis was performed with significance level α = 0.05 using R version 3.4.1 (R Core Team 2017, Vienna, Austria). Of 53 eligible patients, 37 consented to participate. Fifteen were repaired using DI technique and 22 using SI technique. Mean age was 47.3yrs and median follow-up time was 28.1months. The groups did not differ with respect to age, time-to-follow-up, dominance of arm affected, Workers Compensation or smoking status. Mean supination torque, measured as the percentage of the unaffected side, was 60.9% (95%CI 45.1–76.7) for DI repair versus 80.4% (95%CI 69.1–91.7) for SI repair at the 60°supinated position (p=0.036). There were no statistically significant differences in mean supination torque at the 45°supinated position: 67.1% (95%CI 49.4–84.7) for DI versus 81.8% (95%CI 72.2–91.4) for SI (p=0.102), at the neutral position: 88.8% (95%CI 75.2–102.4) for DI versus 97.6% (95%CI 91.6–103.7) for SI (p=0.0.170), and at the 45°pronated position: 104.5% (95%CI 91.1–117.9) for DI versus 103.4 (95%CI 97.2–109.6) for SI (p=0.0.862). No statistically significant differences were detected in the secondary outcomes ASES Pain, ASES Function, DASH scores, SF-12 PCS or MCS, or VAS Pain. A small difference was detected in VAS Function (median 1.3 for DI repair versus 0.5 for SI repair, p=0.023). In a multivariate linear regression model controlling for arm dominance, age, and follow-up time, SI repair was associated with a greater mean supination torque than DI repair by 19.6% at the 60°supinated position (p=0.011). Contrary to our hypothesis, we found approximately a 20% mean improvement in terminal supination torque for acute distal biceps ruptures repaired with the single-incision technique compared to the double-incision technique. Patients uniformly did well with either technique, though we contend that this finding may have clinical significance for the more discerning, high-demand patient.
Based on anatomic studies, it appears that the short head (SH) and long head (LH) of the distal biceps tendons have discreet distal attachments on the radial tuberosity. The SH attaches distally and therefore may function as a stronger flexor, whereas the LH attaches more proximal and ulnar which would make it a greater supinator. The contribution of each of the two heads to flexion and supination has not yet been defined. The rationale of this study was to directly measure the contribution of the SH and LH of the biceps to elbow flexion and forearm supination and provide biomechanical evidence for what is inferred in the anatomical studies. Twelve fresh-frozen cadaveric arms were secured using in vitro elbow simulator, while controlled loads were applied to the individual biceps tendons short and long heads. Isometric supination torque and flexion force were recorded with the forearm in 45 degrees supination, neutral rotation and 45 degrees pronation.Purpose
Method
Increased use of locking volar plates for distal radius fractures led to a number of reports in literature of flexor tendon injuries from impingement and attrition against hardware. Repair of the pronator quadratus is critical in preventing tendon injury. We present a pronator quadratus sparing approach to the distal radius. The senior author has used a pronator quadratus sparing lateral pillar approach for for the past five years. A lateral incision is used over the radial styloid. The first dorsal compartment is released and APL and EPB tendons retracted. The underlying brachio-radialis tendon and insertion fascia is split and the palmar portion elevated off the distal radius with the pronator quadratus as a single contiguous sheet. The distal edge of the pronator quadratus is elevated from the wrist capsule by sharp dissection. The radial artery is protected by the retracted tissue. Repair of the brachio-radialis tendon and insertion fascia is much more robust than that of the pronator quadratus covering the entire plate. Since 2004, the senior author has used the pronator quadratus sparing approach for volar plating of the distal radius, in 183 cases. At last follow-up there were no instances of flexor tendon injury, which was considered to be one of the outcome measures and end-points. There was no impingement in the first dorsal compartment, except in two cases of lateral pillar hardware impingement from additional lateral pillar plate fixation through the same approach. Nine cases had minor persistent superficial radial nerve parasthesia. One case had a superficial wound infection requiring drainage. The repaired pronator quadratus formed a barrier protecting the plate. The infection was aggressively treated and the plate left in situ for three months till fracture union. Cultures from the retrieved plate showed no organisms. Another implant had two of the locking screws back out. The pronator quadratus fascia was tented with an underlying haematoma. The fascia however only showed minimum screw penetration and no flexor tendon injury. Average wrist dorsiflexion was 72 deg and palmar flexion 65 deg. Average pronation was 81 deg and average supination 69 deg.
This is largest collection of outcomes of distal biceps reconstruction in the literature. 8 subjects prospectively measured pre and post reconstruction Strength deficit in patients with chronic tendon deficit is described. To describe outcomes for 53 chronic distal biceps reconstructions with tendon graft. Clinical outcomes as well as strength and endurance in supination and flexion are reported. To examine eight patients measured pre- and post-reconstruction. To identify deficit in supination and flexion in chronic reconstruction. 53 reconstructions of chronic distal biceps with tendon graft were carried out between 1999 and 2015. 26 subjects agreed to undergo strength testing after minimum one year follow up. Eight subjects were tested both before and after reconstruction. Primary outcomes were strength in elbow flexion and forearm supination. Strength testing of supination and flexion included maximum isokinetic power and endurance performed on a Biodex. Clinical outcomes measures included pre-operative retraction severity, surgical fixation technique, postoperative contour, range of motion, subjective satisfaction, SF-12, DASH, MAYO elbow score, ASES and pain VAS Non-parametric data was reported as median (interquartile range), while normally-distributed data was reported as mean with 95% Confidence Limits. Hypothesis testing was performed according to two-tailed, paired t-tests. Median time from index rupture to reconstructions 9.5 (range 3–108) months. Strength measurements were completed at a median follow-up time of 29 (range 12–137) months on 26 subjects. The proportion of patients that achieved 90% strength of the contralateral limb post-reconstruction was 65% (17/26) for peak supination torque, and 62% (16/26) for peak flexion torque.
The radius has a sagittal and coronal bow. Fractures are often treated with volar anterior plating. However, the sagittal bow is often overlooked when plating. This study looks at radial morphology and the effect of plating the proximal radius, with straight plates then contoured plates bowed in the sagittal plane. We report our findings and their effect on forearm rotation. Morphology was investigated using fourteen radii. Attention was made to the proximal shaft of the radius and its sagittal bow, from this 6, 7 and 8 hole plates were contoured to fit this bow. A simple transverse fracture was then made at the apex of this bow.
Introduction. Foot and ankle injuries are a common occurrence amongst all footballers. The aim of this study was to establish the frequency and variation of foot and ankle injuries within one English Premier League (EPL) professional football club over the course of a season and attempt to identify any factors associated with the injuries. Method. Data was collected prospectively for all foot and ankle injuries suffered by first team players over the 2008–09 and 2009–10 EPL season at one EPL club. Each player's demographics were recorded along with various factors concerning or influencing the injury including ground conditions, foot posture index score (FPIS), type of injury, ability to continue playing, recovery time, mechanism of injury and footwear type. Results. The most common injury was 5th metatarsal fracture seen in 33%. Lateral ligament sprain was seen in 28% and syndesmosis injury in 17%. The mean recovery time following 5th metatarsal fractures was 76 days. 67% of all injuries (100% of 5th metatarsal fractures) were sustained while wearing blade footwear, 17% wearing the more traditional studded footwear.
In this study we reviewed all Total Elbow Replacements (TER) done in our hospital over eight years period (1997 – 2005), 21 patients (16 females, 5 males) were available for follow up and four were lost (two died and two moved out of the region) with average age of 65 years (range 44 – 77), all procedures were done by two upper limb surgeons (CHB & RGW). 16 patients (14 females, 2 males) had the procedure for Rheumatoid Arthritis and 5 patients (3 males, 2 females) undergone the procedure for post-traumatic arthritis. The average follow up was 61 months (range 12 – 120 months), the Mayo Clinic performance index, the DASH scores and activities of daily living (adopted from Secec Elbow Score) assessment tools were used. In addition, all patients were assessed for loosening using standard AP and lateral radiographs. Sixteen patients had Souter-Starthclyde prosthesis whilst three had Kudo and two had Conrad-Moorey prosthesis. All procedures were done through dorsal approach and all were cemented, the ulnar nerve was not transposed in any of the cases. The average elbow extension lag was 27 degrees (range 15 – 35) with flexion up to 130 degrees (range 110 – 140).
In this study we reviewed all Total Elbow Replacements (TER) done in our hospital over eight years period (1997 – 2005), 21 patients (16 females, 5 males) were available for follow up and four were lost (two died and two moved out of the region) with average age of 65 years (range 44 – 77), all procedures were done by two upper limb surgeons (CHB & RGW). 16 patients (14 females, 2 males) had the procedure for Rheumatoid Arthritis and 5 patients (3 males, 2 females) undergone the procedure for post-traumatic arthritis. The average follow up was 61 months (range 12 – 120 months), the Mayo Clinic performance index, the DASH scores and activities of daily living (adopted from Secec Elbow Score) assessment tools were used. In addition, all patients were assessed for loosening using standard AP and lateral radiographs. Sixteen patients had Souter-Starthclyde prosthesis whilst three had Kudo and two had Conrad-Moorey prosthesis. All procedures were done through dorsal approach and all were cemented, the ulnar nerve was not transposed in any of the cases. The average elbow extension lag was 27 degrees (range 15 – 35) with flexion up to 130 degrees (range 110 – 140).
Objectives. Surgical treatment is standard for advanced osteochondritis dissecans (OCD) of the humeral capitellum. When cartilage is seen to be separated or completely detached, this fragment fixation is not usually applied. There have been reports of cases in which advanced OCD of the humeral capitellum progressed to osteoarthritis (Fig), particularly in cases which involved the lateral wall. In these cases, every attempt should be made to reconstruct the lateral wall to avoid osteoarthritis. In this study, we followed up cases with rib osteochondral autograft transplantation technique. Methods. Subjects were 20 cases who were followed up until after they started pitching. The mean age was 13.8 years old and the mean observation period was 2 years and 6 months (from 7 months to 6 year 3 months). Kocher's approach was used to give a good access to the aspect of the radiohumeral joint. The majority of cases suffered from extensive OCD of the elbow. Detached fragment was removed (Fig. 2a) and graft from 5. th. or 6. th. rib with screw fixation was performed on 12 patients and 8 received fixation with no material (Fig. 2b). Follow-up assessment included the range of motion, start time of playing catch and throwing a ball with full power, sports activity, evaluation of radiography, a subjective (including Pain, Swelling, Locking/Catching and Sport activity) and objective (Flexion contracture, Pronation/
Distal radial volar locking plating systems (DRVLP) are increasingly used for complex fractures of the distal radius. There have been limited studies on volar locking plating systems focusing on functional outcome and complications data. The aim of this study is to assess whether the surgeon can predict which fractures will have a good or poor outcome in terms of clinical, radiological and functional outcome assessment. Patients who sustained a distal radial fracture managed with a radial volar locking plate were identified from hospital audit data systems. Data was collected on all patients from patient notes including radiographs performed pre- and post-operatively and functional scores using the Patient Rated Wrist Evaluation score (PRWE). The study was approved by the Barwon Health Research and Ethics Advisory Committee. In total, there were 153 patients (105 female, 48 male) from all 11 surgeons in the unit. Patients ranged in age from 17 to 91 years, average age of 53.7 years at time of injury (IQR 41-70yr). A quarter had concomitant other injuries, and 60% had type C1-C3 fractures. Most of the patients (n = 147) had the AO Synthes DRVLP, six patients had other volar locking plate systems. Twenty-seven percent of patients (n = 42) had exogenous bone graft insertion for more unstable fracture patterns. The major complication rate was 12% (18/153) with 17 cases requiring further surgery. Post-operative radiographs demonstrated no increase in ulnar variance (median 0.0mm IQR 2.0 to1.0 mm) but an increase in radial inclination by 5 deg (IQR 0-12 deg), radial length by 3.5 mm (IQR 1.0-6.3 mm) and radial tilt by 17 deg (IQR 3-32 deg) (volar angulation) compared to pre-operative radiographs, which was statistically significant (all p<0.001). Ninety percent of patients returned a PRWE form with an average follow-up of 1.16 years (IQR 0.46-2.16yr). Median score for those aged less than 50 years was 14.00 (IQR 6.00-41.50) and did not differ from those greater than 50 years (median 16.00 IQR 4.50-36.00) (p = 1.00). PRWE score across groups categorised by classification of fracture showed large variance within each category and were not significantly different: Class A median 8.00 (IQR 3.50-26.25), Class B 13.00 (IQR 6.75-34.00) and Class C 17 (IQR 5.00-38.50) (p = 0.65). The majority of patients were female and had a type C fracture. Post-operative x-rays displayed an increase in radial inclination, length and tilt, and restoration of radial antatomy. PRWE scores were not different across age groups or classification of the fracture. This demonstrates that predictable outcomes can be achieved with volar locking plates despite fracture complexity if attention is paid to anatomical restoration of the radius, and in more unstable patterns with void support using injectable graft. Quadratus can act as an effective barrier to prominent hardware and superficial infection.
