1. The pathological anatomy of total rupture of the ulnar collateral ligament of the metacarpo-phalangeal joint of the thumb has been studied at operation in thirty-nine patients. 2. It has been found that the ligament, when ruptured distally (the most usual type) is often displaced so that the ulnar expansion of the dorsal aponeurosis–here referred to as the adductor aponeurosis–becomes interposed between the ruptured end of the ligament and the site of its attachment on the phalanx; the ligament gets folded over to a greater or lesser extent and the ruptured end sticks out beyond the proximal edge of the adductor aponeurosis. Such displacement of the ligament with interposition of the adductor aponeurosis was found in twenty-five of the thirty-nine cases. The ligament may also be displaced without the adductor aponeurosis being interposed (with a gap between the ruptured end and the site of itsattachment on the phalanx). 3. Variations in the pathological anatomy are illustrated by more detailed descriptions of nine cases. In one of these the adductor aponeurosis had got caught between the two surfaces of the joint, and in another the adductor aponeurosis was found ruptured as well as the ulnar collateral ligament. 4. On the basis of dissection studies on forty-two fresh post-mortem specimens, a rational explanation is given of the pathological anatomy. 5. The results of the present investigation on clinical and anatomical material provide a strong argument in favour of operative treatment for total rupture of the ulnar collateral ligament of the metacarpo-phalangeal joint of the thumb. 6. Aspects of diagnosis and operative technique are discussed

We used high-resolution ultrasonography to image the ulnar collateral ligament in 39 patients who had sustained recent injuries of the metacarpophalangeal joint of the thumb. All the patients were subsequently operated on and the lesions of the ligament were recorded. In 36 patients the preoperative ultrasonographic diagnosis was correct. Five of these showed no rupture of the ligament. In the other 31, ultrasonography correctly distinguished between rupture in situ (15) and rupture with dislocation of the ligament (16). Misdiagnosis by ultrasonography in three cases was due to delay of the investigation (three weeks after injury) in one, to technical error in one and to misinterpretation of the image in one

Aims. The aim of this study was to prepare a scoping review to investigate the use of biologic therapies in the treatment of musculoskeletal injuries in professional and Olympic athletes. Methods. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) extension for scoping reviews and Arksey and O’Malley frameworks were followed. A three-step search strategy identified relevant published primary and secondary studies, as well as grey literature. The identified studies were screened with criteria for inclusion comprising clinical studies evaluating the use of biologic therapies in professional and Olympic athletes, systematic reviews, consensus statements, and conference proceedings. Data were extracted using a standardized tool to form a descriptive analysis and a thematic summary. Results. A total of 202 studies were initially identified, and 35 met criteria for the scoping review; 33 (94.3%) were published within the last eight years, and 18 (51.4%) originated from the USA. Platelet rich plasma was the most studied biologic therapy, being evaluated in 33 (94.3%) studies. Ulnar collateral ligament and hamstring injuries were the conditions most studied (nine (25.7%) studies and seven (20.0%) studies, respectively). Athletes most frequently participated in baseball, soccer, and American football. Only two (5.7%) studies were level 1 evidence, with interpretation and comparison between studies limited by the variations in the injury profile, biologic preparations, and rehabilitation protocols. Conclusion. There is diverse use of biologic therapies in the management of musculoskeletal injuries in professional and Olympic athletes. There is currently insufficient high-level evidence to support the widespread use of biologic therapies in athletes. Further research priorities include the development of condition/pathology-specific preparations of biologic therapies, and of outcome measures and imaging modalities sufficiently sensitive to detect differences in outcomes, should they exist. Cite this article: Bone Joint J 2021;103-B(7):1189–1196

1. Five cases of a sudden block to extension in the metacarpo-phalangeal joint of the middle finger, in middle-aged patients, are described. 2. A possible explanation is that the ulnar collateral ligament gets caught on an osteophyte on the metacarpal head

We report the use of a free tendon graft in 70 patients to repair lesions of the capsuloligamentous complex of the metacarpophalangeal joint of the thumb. Of these 37 had a lesion of the ulnar collateral ligament, 18 of the radial collateral and 11 of the volar plate. Four patients had combined lesions. We outline our techniques and review 51 of the patients. Of those 47 (92%) were satisfied, and all but one had regained full stability. Pinch grip strength was normal in 48. About one-third of the patients had some loss of flexion/extension; this was seldom noticed by the patients and caused no significant disability. Free tendon graft reconstruction is indicated for severe fresh lesions, for old lesions with chronic disability and for lesions which have not responded to conservative management

This annotation reviews current concepts on the three most common surgical approaches used for proximal interphalangeal joint arthroplasty: dorsal, volar, and lateral. Advantages and disadvantages of each are highlighted, and the outcomes are discussed.

Cite this article: Bone Joint J 2022;104-B(12):1329–1333.

Aims

To evaluate the outcomes of terrible triad injuries (TTIs) in mid-term follow-up and determine whether surgical treatment of the radial head influences clinical and radiological outcomes.

Aims

The purpose of this study was to evaluate the relationships between the degree of injury to the medial and lateral collateral ligaments (MCL and LCL) and associated fractures in patients with a posterolateral dislocation of the elbow, using CT and MRI.

Posterolateral rotatory instability is the most common type of symptomatic chronic instability of the elbow. In this condition the forearm complex rotates externally in relation to the humerus, causing posterior subluxation or dislocation of the radial head. The lateral ligament complex, radial head and coronoid process are important constraints to posterolateral rotatory instability, and their disruption is involved in the pathogenesis of this condition. The diagnosis relies on a high index of clinical suspicion, active and passive apprehension tests, and examination under anaesthesia. Surgical treatment has given consistently successful results. Open reconstruction of the lateral ligaments with a tendon graft has been the procedure of choice, with arthroscopic techniques emerging as a potential alternative.

The lateral ligament complex is the primary constraint to posterolateral rotatory laxity of the elbow, and if it is disrupted during surgery, posterolateral instability may ensue. The Wrightington approach to the head of the radius involves osteotomising the ulnar insertion of this ligament, rather than incising through it as in the classic posterolateral (Kocher) approach. In this biomechanical study of 17 human cadaver elbows, we demonstrate that the surgical approach to the head can influence posterolateral laxity, with the Wrightington approach producing less posterolateral rotatory laxity than the posterolateral approach.

Aims

Radial head arthroplasty (RHA) may be used in the treatment of non-reconstructable radial head fractures. The aim of this study was to evaluate the mid-term clinical and radiographic results of RHA.

The purpose of this study was to assess the long-term results (more than ten years) of two types of cemented ulnar component with type-5 Kudo total elbow arthroplasty in a consecutive series of 56 patients (60 elbows) with rheumatoid arthritis, and to compare the results in elbows above and below a Larsen grade IV.

There was no radiolucency around the humeral component. Patients in whom a metal-backed ulnar component and a porous-coated stem were used had better clinical results and significantly less progression of radiolucent line formation around the ulnar component. They also had a significantly better long-term survival than patients with an all-polyethylene ulnar component. The clinical results of arthroplasty using all-polyethylene ulnar components were inferior, regardless of the degree of joint destruction.

We conclude that the type-5 Kudo total elbow arthroplasty with cementless fixation of the porous-coated humeral component and cemented fixation of a metal-backed ulnar component is acceptable and well-tolerated by rheumatoid patients.

We describe a case of rotational dislocation of the proximal interphalangeal joint of the ring finger. This injury was not initially appreciated and therefore closed reduction failed. The clinical findings included puckering of the skin on the dorsum of the joint and rotational incongruity on radiographs. At open reduction there was interposition of the lateral band. Identification of the pathology allows early successful treatment.

There are few reports describing dislocation of the metacarpophalangeal joint of the thumb in children. This study describes the clinical features and outcome of 37 such dislocations and correlates the radiological pattern with the type of dislocation.

The mean age at injury was 7.3 years (3 to 13). A total of 33 children underwent closed reduction (11 under general anaesthesia). Four needed open reduction in two of which there was soft-tissue interposition. All cases obtained a good result. There was no infection, recurrent dislocation or significant stiffness.

So-called ‘simple complete’ dislocations that present with the classic radiological finding of the joint at 90° dorsal angulation may be ‘complex complete’ injuries and require open reduction.

Between 1995 and 2006, five intra-articular osteotomies of the head of the radius were performed in patients with symptomatic healed displaced articular fractures. Pre-operatively, all patients complained of persistent painful clicking on movement. Only patients with mild or no degenerative changes of the radial head and capitellum were considered for osteotomy. The operations were performed at a mean of 8.2 months (4 to 13) after injury and the patients were reviewed at a mean of 5.5 years (15 months to 12 years) after the osteotomy.

The average Mayo Elbow Performance Index Score improved significantly from 74 before to 88 after operation, with four patients rated as good or excellent (p < 0.05). The subjective patient satisfaction score was 8.4 on a ten-point scale. All osteotomies healed and there were no complications.

In this small series intra-articular osteotomy of the head of the radius was a safe and effective treatment for symptomatic intra-articular malunion without advanced degenerative changes.

We measured the tension in the interosseous membrane in six cadaveric forearms using an in vitro forearm testing system with the native radial head, after excision of the radial head and after metallic radial head replacement. The tension almost doubled after excision of the radial head during simulated rotation of the forearm (p = 0.007). There was no significant difference in tension in the interosseous membrane between the native and radial head replacement states (p = 0.09). Maximal tension occurred in neutral rotation with both the native and the replaced radial head, but in pronation if the radial head was excised. Under an increasing axial load and with the forearm in a fixed position, the rate of increase in tension in the interosseous membrane was greater when the radial head was excised than for the native radial head or replacement states (p = 0.02). As there was no difference in tension between the native and radial head replacement states, a radial head replacement should provide a normal healing environment for the interosseous membrane after injury or following its reconstruction. Load sharing between the radius and ulna becomes normal after radial head Replacement. As excision of the radial head significantly increased the tension in the interosseous membrane it may potentially lead to its attritional failure over time.

Cite this article: Bone Joint J 2013;95-B:1383–7.

The use of passive stretching of the elbow after arthrolysis is controversial. We report the results of open arthrolysis in 81 patients. Prospectively collected outcome data with a minimum follow-up of one year were analysed. All patients had sustained an intra-articular fracture initially and all procedures were performed by the same surgeon under continuous brachial plexus block anaesthesia and with continuous passive movement (CPM) used post-operatively for two to three days. CPM was used to maintain the movement achieved during surgery and passive stretching was not used at any time. A senior physiotherapist assessed all the patients at regular intervals. The mean range of movement (ROM) improved from 69° to 109° and the function and pain of the upper limb improved from 32 to 16 and from 20 to 10, as assessed by the Disabilities of the Arm Shoulder and Hand score and a visual analogue scale, respectively. The greatest improvement was obtained in the stiffest elbows: nine patients with a pre-operative ROM < 30° achieved a mean post-operative ROM of 92° (55° to 125°). This study demonstrates that in patients with a stiff elbow after injury, good results may be obtained after open elbow arthrolysis without using passive stretching during rehabilitation.

We assessed the long-term results of 58 Souter-Strathclyde total elbow replacements in 49 patients with rheumatoid arthritis. The mean length of follow-up was 9.5 years (0.7 to 16.7). The mean pre-operative Mayo Elbow Performance Score was 30 (15 to 80) and at final follow-up was 82 (60 to 95). A total of 13 elbows (22.4%) were revised, ten (17.2%) for aseptic loosening, one (1.7%) for instability, one (1.7%) for secondary loosening after fracture, and one elbow (1.7%) was removed because of deep infection. The Kaplan-Meier survival rate was 70% and 53% at ten and 16 years, respectively. Failure of the ulnar component was found to be the main problem in relation to the loosening. Anterior transposition of the ulnar nerve had no influence on ulnar nerve paresthaesiae in these patients.

We describe the intermediate results of lateral ligamentous repair or reconstruction for posterolateral rotatory instability of the elbow. Between 1986 and 1999, we performed 12 direct repairs and 33 ligament reconstructions with a tendon autograft. One patient was lost to follow-up and 44 were retrospectively studied at a mean of six years (2 to 15).

Surgery restored stability in all except five patients. In two the elbow became stable after a second procedure. The mean post-operative Mayo elbow performance score was 85 points (60 to 100). The result was classified as excellent in 19, good in 13, fair in seven and poor in five patients. Thirty-eight patients (86%) were subjectively satisfied with the outcome of the operation. Better results were obtained in patients with a post-traumatic aetiology (p = 0.03), those with subjective symptoms of instability at presentation (p = 0.006) and those who had an augmented reconstruction using a tendon graft (p = 0.04).

Reconstruction using a tendon graft seems to provide better results than ligament repair and the results do not seem to deteriorate with time. The outcome of this procedure is less predictable in patients with no subjective instability.