Roger Van Riet

Clinical results of endoscopic distal biceps tendon repair have been shown to be comparable to open techniques in small series. This study evaluates safety and accuracy of the endoscopic technique. Sixteen fresh-frozen paired cadaveric upper extremities were used. The distal biceps tendons were cut and then repaired with the classic single incision bone button technique. Eight were done through an open technique, and eight were repaired endoscopically. Safety and accuracy were assessed by comparing the distance of the repair to neurovascular structures as well as the distance of the bone tunnel to the native biceps insertion. Paired t-tests were used to compare measurements. Significance level was set at p=0.05. There were no significant differences between the open and endoscopic groups, for any of the anatomic measurements. The ulnar artery was the closest neurovascular structure to the tunnel, with an average of 1 mm. The radial and recurrent radial arteries were located at 3 and...

Chronic posterolateral rotatory instability (PLRI) is the most common form of chronic elbow instability. PLRI usually occurs from a fall on the outstretched hand. On impact, the radial head and ulna rotate externally coupled with valgus displacement of the forearm. This leads to posterior displacement of the radial head relative to the capitellum, thus causing disruption of some or all of the lateral-sided stabilisers. PLRI is mainly a clinical diagnosis with a history of instability, clicking and lateral-sided pain, with a positive clinical examination including the pivot-shift test, push-up, chair and tabletop test. MRI can often help guide diagnosis but more commonly assists in surgical planning. Surgery is indicated in patients with persistent, symptomatic instability of the elbow causing pain or functional deficit. There are several surgical techniques to treat PLRI, often leading to good to excellent results. An open or arthroscopic technique has been successfully used in pati...

Distal biceps tendon ruptures are relatively rare. Patients are usually middle-aged men involved in heavy labor. Patients usually present with the history of a pop and a proximal migration of the biceps muscle belly. Clinical exam should be sufficient to diagnose a complete rupture. Several specific tests have been described. Ultrasound scanning or MRI can help confirm the diagnosis. Radiographs are not needed to diagnose distal biceps tendon rupture but may show typical findings. Imaging, more specifically the flexion-abduction-supination (FABS) view MRI, is particularly helpful in the case of a partial rupture or chronic rupture of the distal biceps tendon. Results of surgical reinsertion of the distal biceps have been shown to be superior to conservative treatment. Different techniques and approaches have been described with specific advantages and disadvantages. Primary repair of the tendon is preferred. If this is no longer possible in chronic tears, an augmentation can be done...

Comminuted radial head fractures associated with an injury of the medial collateral ligament can be treated with a radial head implant. We hypothesized that lengthening and shortening of the radial neck would alter the kinematics and the pressure through the radiocapitellar joint in the medial collateral ligament-deficient elbow. The effects of lengthening (2.5 and 5 mm) and shortening (2.5 and 5 mm) of the radial neck were assessed in six human cadaveric upper extremities in which the medial collateral ligament had been surgically released. The three-dimensional spatial orientation of the ulna was recorded during simulated active motion from extension to flexion. Total varus-valgus laxity and ulnar rotation were measured. Radiocapitellar joint pressure was assessed with use of pressure-sensitive film. Radial neck lengthening or shortening of >/=2.5 mm significantly changed the kinematics in the medial collateral ligament-deficient elbow. Lengthening caused a significant decrease...

Geleidelijk ontstond vage diffuse pijn aan de laterale zijde van de dominante rechterelleboog bij een 43-jarige vrouw. De pijn straalde vaak uit naar de onderarm, soms tot in de vingers. De pijn was niet duidelijk gerelateerd aan een bepaalde beweging maar leek wel inspanningsgebonden. Patiente kon zich geen duidelijk uitlokkend moment herinneren, ook geen trauma of een periode van overbelasting.

Elbow instability may be medial or lateral and presents as an acute or chronic problem. Traumatic or iatrogenic insufficiency of the lateral collateral ligament is reviewed, with emphasis on the clinical presentation, diagnostic exam, and appropriate imaging tests. Current trends on lateral elbow instability treatment are reviewed including both open and arthroscopic techniques. Medial instability is more prevalent among throwing athletes and may be associated with a valgus overload syndrome. Key aspects of the pathoanatomy, diagnosis, and treatment of this entity are reviewed.

Slipped capital femoral epiphysis (SCFE) is considered to be one of the most common disorders of the hip in children and adolescents. If left untreated, it may lead to progressive deformity, pain and decreased range of motion, and predisposes to early onset degenerative arthritis. Surgical treatment is advised, with in situ pinning across the physis being the gold standard for stable slips. Closed or open reduction can be considered in unstable or severe types. We report the arthroscopically assisted reduction of an unstable severe SCFE, followed by canulated screw fixation. A follow-up of 2.5 years shows an excellent clinical and acceptable radiological outcome. Our case demonstrates that arthroscopically assisted reduction of a slipped capital femoral epiphysis is feasible. Although the technique is technically challenging and requires familiarity with arthroscopy of the hip, it has some clear benefits as compared with both closed and open reduction techniques. Arthroscopically as...

We report a very rare case of a congenital cervical spine anomaly. The low occurrence rate of this anatomic variant combined with the high frequency of cervical injuries in sports medicine made this case a diagnostic challenge on both emergency and orthopaedic departments. After reading, it should give the clinician a more consistent view in differentiating the traumatic or congenital origin of the disorder seen on radiographs, as well as what can be expected in the future when diagnosis is set.

Distal triceps tendon ruptures occur rarely, and the diagnosis is often missed when the injury is acute. The literature provides little guidance regarding treatment or the outcome of treatment of these injuries. The goal of this report was to present our experience with the diagnosis, timing and technique of surgical treatment, and outcome of treatment of distal triceps tendon ruptures in twenty-two patients. None of the ruptures followed joint replacement. Twenty-three procedures were performed in twenty-two patients with an average age of forty-seven years. The average duration of follow-up was ninety-three months (range, seven to 264 months). Data were obtained by a retrospective review of records and radiographs before and after surgery. Also, thirteen patients returned for follow-up and were examined clinically. Six additional patients responded to a telephone questionnaire. One patient was lost to follow-up, and two had died. Formal biomechanical evaluation of isokinetic stren...

A prospective study was established to assess the sensitivity of the newly described Bell-van Riet (BvR) test for isolated AC pathology, and compare with 4 commonly used clinical tests. The BvR test is essentially the cross-adduction test, with the addition of attempted elevation against resistance. In a positive test, this results in some pain and the inability of the patient to maintain the arm in the adducted and elevated position against resistance. Fifty-eight patients with isolated AC joint symptoms were assessed in random order with the BvR test and 4 other tests. A corticosteroid and local anaesthetic injection was administered into the AC joint space. The BvR test and 4 other tests were then repeated following the injection. After the injection, a symptom free clinical examination was used as a measure of truly positive tests. The BvR test showed a sensitivity of 98%. All 4 other tests were less sensitive. The BvR test is a highly sensitive test in patients presenting with isolated AC related symptoms, and demonstrates AC joint pathology better than other accepted tests.

Comminuted radial head fractures can be treated with a radial head implant. The effects of lengthening (2.5 mm, 5 mm) and shortening (2.5 mm, 5 mm) of the radial neck, were compared to the nominal length in six human upper extremity cadavers. Total varus-valgus laxity and ulnar rotation were recorded. We hypothesized that restoring the exact length of the radius is important to maintain normal kinematics in the elbow joint. Lengthening or shortening of more than 2.5 mm significantly changed elbow kinematics. Lengthening caused a significant decrease (p < 0.001) in varus-valgus laxity, with the ulna tracking in varus and external rotation. Shortening caused a significant increase in varus-valgus laxity (p < 0.001) and ulnar rotation (p < 0.001), with the ulna tracking in valgus and internal rotation. Our study suggests that a restoration of radial length is important and that axial understuffing or overstuffing the radiohumeral joint by 2.5 mm or more, will alter elbow kinematics.

Arthroscopy of the elbow has become a standard treatment option for many indications. The purpose of this article is to review literature concerning the use of arthroscopy for acute elbow injuries. The main medical literature databases were searched for articles on the use of elbow arthroscopy in acute injuries. A total of 13 publications relevant to the topic were included. The Coleman methodology score was used to assess the methods of each article. All published articles have been case reports or retrospective case series. In fracture treatment, arthroscopy has been used in the treatment of displaced radial head, coronoid and capitellum fractures in adults and displaced radial neck and lateral humeral condyle fractures in children with good results. Endoscopic techniques have been used in distal biceps rupture and medial avulsion of the triceps. And also new techniques have been developed for the treatment of intra-articular soft-tissue lesions like rupture of the radial ulnohumeral ligament complex. One of the 13 studies analyzed was considered of good quality, 5 of moderate quality and all others of poor quality with inconsistent methodology and outcomes. The range of treatments using elbow arthroscopy in acute injuries is expanding and brings new controversies and challenges. Single reports of arthroscopically treated bony and soft-tissue injuries of the elbow showed satisfactory results. However, further randomized prospective studies are needed to evaluate their safety and efficacy compared with open 'gold standard' techniques. IV.

Proximal ulna fractures can be difficult to manage because of the elbow's complex anatomy. Advances in understanding elbow anatomy and biomechanics, however, have led to new insights. Careful preoperative evaluation is critical because failure to restore normal anatomy of the proximal ulna could have a detrimental effect on postoperative elbow function. Management options include anatomic plates, intramedullary devices, and strong tension band materials. Determining the most appropriate option for an individual fracture is based on analysis of radiographs and CT scans, including three-dimensional reconstruction. Coronoid fractures, olecranon fractures, and associated elbow instability influence the indications for any given fixation device. Appreciating the subtleties of proximal ulna anatomy and biomechanics can lead to improved clinical outcomes. Recent concepts affecting fracture management include proximal ulna dorsal angulation, the importance of the anteromedial facet of the coronoid, and intermediate fragments of the olecranon.

Results of the treatment of the deficient coronoid and chronic elbow instability have not been reported. The purpose of this study was to analyze the results of structural bone graft for reconstruction of the coronoid process. Structural bone graft was used to reconstruct the coronoid process of 6 patients. All injuries were of the terrible triad: fracture of the coronoid, radial head fracture, and collateral ligament disruption. All cases had persistent posterior subluxation averaging 6 months (range, 1-13 months before reconstruction. Patient charts, surgical records, and radiographs were reviewed. All patients were contacted at a mean of 64 months after treatment to answer a specific set of questions to determine the Mayo Elbow Performance score. In 1 patient, radiographs showed complete resorption of the graft and severe osteoarthritis of the elbow at 54 months after surgery (case 4). The Mayo Elbow Performance score showed 1 excellent, 2 good, 1 fair, and 2 poor results. Structural bone graft may be a useful option for a deficient coronoid process and an unstable elbow, but the outcome is unpredictable.

Arthroscopic resection of the superomedial corner of the scapula was performed in 20 fresh frozen cadaveric specimens to define clinically safe and useful margins for arthroscopic bony resection. The lateral border of resection was delineated by directing the burr either toward a specifically chosen arthroscopic resection target (ART) situated equidistant between the inferior scapular angle and scapular spine or more lateral to the inferior angle of the scapula. The minimum distances between the suprascapular notch and the lateral edge of the resection were 25 mm (average, 31 mm) in the ART group and 10 mm (average, 21 mm) in the inferior angle group (P < .01). From the results of our study, we recommend a safe zone for arthroscopic removal of bone and soft tissue from the superomedial corner of the scapula. The medial border is defined by the medial scapula and scapular spine; the lateral border is drawn between Bell's portal and the ART.

Although the triceps tendon has been used as a graft for ligament reconstruction about the elbow, and has been postulated to be useful as a graft in the treatment of massive rotator cuff tears, no data exists on the tensile properties of the triceps tendon. The purpose of this study was to define the tensile properties of the medial, lateral, and central thirds of the triceps tendon, in order to examine its potential as an autograft for upper extremity pathology. Ten fresh frozen upper extremity specimens were used. The triceps tendon was dissected from its musculotendinous junction and left attached to its insertion at the olecranon. The tendon was split into thirds and its tensile properties were recorded using a materials testing machine. The lateral portion was significantly thinner and less stiff than the medial and central portions (P < .05). It failed at significantly lower ultimate load than the central portion (P < .05). There were no significant differences between the medial, central, and lateral portions of the triceps tendons with regards to ultimate stress (P = .20) or modulus of elasticity (P = .64). Data from the current study were compared to available literature regarding tensile properties of the rotator cuff and elbow ligaments. Both the medial and central portions of the triceps tendon offer sufficient strength to be used in the reconstruction of the rotator cuff or ligament reconstruction in the elbow.

Documentation of the long-term effectiveness of 3-part unlinked elbow replacement is limited. The value of replacing the radial humeral articulation has not been addressed to any extent in the currently available literature. A retrospective study of patient charts and radiographs of 37 patients receiving 46 primary Pritchard ERS arthroplasties between 1983 and 1992 were reviewed. Thirty-two implants (70%) failed after an average of 83 months (range, 0-198). Causes of failure were analyzed in detail. Kaplan Meier survivor analysis showed a 10-year survival of 54% (confidence interval: 40-71%). Main reasons for failure were instability, wear, and loosening. Immediate postoperative radiographs showed ulnohumeral malposition (valgus or varus) in 19 elbows, which directly correlated to subsequent failure. While this design has proven to be unsuccessful, it does document the need for precise technique and highlights the issue of replacing the radio/capitellar joint in future designs deserves further study. An explanation of these disappointing outcomes resides both in an inadequate design and a poorly understood and executed surgical technique. The value of refined instrumentation to allow accurate and reproducible component implantation and soft tissue balancing is highlighted. These considerations are particularly relevant if the radial head component is to be used.

A prospective study was established to assess the effect of an intra-articular injection of corticosteroid and local anaesthetic into the acromioclavicular (AC) joint. Fifty-eight patients with isolated AC joint symptoms were included. Clinical tests were repeated immediately following the injection, as well as at 1-month follow-up. If symptoms failed to improve at this time, arthroscopic surgery was offered. All other patients were dismissed from standard care and contacted for this study. Both American Shoulder and Elbow Surgeons (ASES) and University of California at Los Angeles (UCLA) scores were obtained at final follow-up. Sixteen patients had improved sufficiently. Between the 1 month and average final follow-up of 42 months, 1 patient had arthroscopic resection of the distal clavicle. Four of the 15 patients reported occasional mild pain. Average visual analogue scale (VAS) score for pain was 0.5 (0-3). Average ASES score was 94.1 (70-100) and average UCLA score was 33.9 (28-35). Pain relief achieved with an injection into the AC joint has both a diagnostic and therapeutic value. The decrease of pain with clinical testing affirms the correct position of the injection. Only a minority of patients has sufficient pain relief from the injection at 1 month follow-up; however, this is sustained at the longer-term follow-up in the patients that have a positive reaction. The diagnostic value of the injection of a local anaesthetic in the AC joint is immediate. Only 28% have a clear positive result at 1 month; but, this result is sustained at long-term follow-up. There were no complications.