Classification system for partial distal biceps tendon tears: a descriptive 3-Tesla magnetic resonance imaging study of tear morphology.

BACKGROUND: There is minimal literature on the morphology of partial distal biceps tendon (DBT) tears. We sought to investigate tear morphology by retrospectively reviewing 3-Tesla magnetic resonance imaging (3T MRI) scans of elbows with partial DBT tears and to propose a basic classification system. METHODS: 3T MRI scans of elbows with partial DBT tears were retrospectively reviewed by two experienced observers. Basic demographic data were collected. Tear morphology was recorded including type, presence of retraction (>5 mm), and presence of discrete long-head and short-head tendons at the DBT insertion. RESULTS: For analysis, 44 3T MRI scans of 44 elbows with partial DBT tears were included. There were 9 isolated long-head tears (20%), 13 isolated short-head tears (30%), 2 complete long-head tears with a partial short-head tear (5%), 5 complete short-head tears with a partial long-head tear (11%), and 15 peel-off tears (34%). Retraction was seen in 5 or 44 partial tears (11%), and 13 of the 44 DBTs were bifid tendons at the insertion (30%). CONCLUSIONS: Partial DBT tears can be classified into five sub-types: long-head isolated tears, short-head isolated tears, complete long-head tears with partial short-head involvement, complete short-head tears with partial long-head involvement, and peel-off tears. Classification of tears may have implications for operative and non-operative management. Level of evidence: III.

Pyrocarbon radial head arthroplasty offers satisfactory clinical and radiological outcomes with low revision rate: A systematic review.

INTRODUCTION: Pyrocarbon promises to be an optimal material choice for radial head arthroplasty (RHA) due to an elastic modulus comparable to the radial diaphysis and thus providing higher biocompatibility. Primary objective was to determine the complications and revision rates related to the usage of these prostheses. The secondary objective was to assess the clinical and radiological outcomes of Pyrocarbon RHAs. HYPOTHESIS: Pyrocarbon RHAs have good clinical and radiological outcomes with low complications and revisions. METHODS: Ovid MEDLINE and Embase databases were used to search for studies on outcomes and complications of the RHAs using Pyrocarbon radial head prostheses. The systematic review was designed in accordance with the PRISMA guidelines and included studies were appraised using the MINORS tool. Complications and RHA revision rates were assessed. Functional outcomes were reviewed using PROMs (like MEPI, DASH and BMS), post-op range of motion (using goniometer) and grip strength (using the dynamometer). Postoperative radiological outcomes like peri-prosthetic lucency, radial neck osteolysis, radio-capitellar congruence, capitellar erosion, overstuffing/understuffing and osteoarthritis were reported using radiographs. RESULTS: A total of 12 studies cumulatively reporting 353 patients who underwent Pyrocarbon RHAs were included in the review. The mean age of patients across the studies ranged from 47 to 54 years of which 50.5% were males. The majority of radial head replacements were done for acute trauma (87.5%) with the remainder done for arthritis (1.7%) and trauma sequelae (10.8%). Mean follow-up period in the selected studies ranged from 18 to 110 months with minimum follow-up across all studies being 12 months. Modular Pyrocarbon (MoPyC, Tornier™) was the implant of choice in ten studies while two studies used the Ascension Pyrocarbon radial head (Ascension Orthopaedics™). Ten studies demonstrated mean MEPI ranging from 75.5 to 96. Mean extension deficit ranged from 6 to 19 degrees, mean flexion from 120 to 140 degrees, mean pronation from 71 to 87 degrees and mean supination from 63 to 85 degrees. Relative grip strength ranged from 69 to 96% of the contralateral limb. Revisions due to implant-related reasons (intra-prosthetic dissociation, prosthetic fracture, peri-prosthetic loosening, radio-capitellar subluxation and understuffed/overstuffed elbow) was 6.8% (24/353). Radial stress shielding and peri-prosthetic lucency was reported in 10 to 100% of patients across different studies but symptomatic implant loosening leading to revision remained rare (2%, 7/353). Radio-capitellar congruence was reported in 81% to 100% cases while capitellar erosion ranged from 0% to 89%. Pyrocarbon implants specific complications included head-neck intra-prosthetic decoupling (1.1%) and pyrocarbon head fractures (0.9%). In total, 5.7% cases underwent re-surgery due to non-RHA related reasons. DISCUSSION: The pyrocarbon RHA shows good functional outcome, range of motion and low revision rates. This aligns with the working hypothesis of this review. However, pyrocarbon radial head implants have implant-specific complications like pyrocarbon radial head fractures and intra-prosthetic decoupling between stem and head. Despite promising in vitro biomechanical properties, capitellar wear is still a common finding with pyrocarbon RHAs. Despite these factors, pyrocarbon radial head implants are a viable option for radial head arthroplasty. LEVEL OF EVIDENCE: II; Systematic review.

Lunate Fracture Morphology in Kienbock's Disease-A Computed Tomography Study.

Background The pathogenesis of Kienbock's disease is poorly understood. The coronal fracture line is acknowledged as a poor prognostic marker in the disease. Other fracture types in the Kienbock's wrist have subsequently been identified. Questions/Purposes The aim is to study the fracture morphology of the lunate in a cohort of patients using computed tomography. Methods Patient images were acquired using a set protocol with four-dimensional computed tomography scanning. Images were reviewed by two orthopaedic surgeons and a consultant radiologist. Static and dynamic images were assessed and a fracture map created. The relationship of fracture type to other parameters was then analyzed. Results Twenty-three patients were included in the study, including 11 males and 12 females, with a mean age of 43 years. Total frequency of fracture lines in the cohort was coronal - 26, proximal subchondral bone plate type - 24, avulsion - 19, sagittal - 16, and distal subchondral bone plate type - 11. There were statistically significantly more proximal than distal subchondral bone plate fractures ( p = 0.03), and more coronal fractures than distal subchondral bone plate fractures ( p = 0.01). There were statistically significantly more radiolunate ligament-avulsion types ( p <0.001) than other types. The sagittal fracture line through the lunate approximated closely to the ulnar edge of the capitate and the ulnar edge of the radius. Conclusion Study on the fracture morphology in the Kienbock's wrist has improved our understanding of the disease pathogenesis. Fracture lines may correspond to loading points, intrinsic and extrinsic ligament avulsions. These fracture types may play a role in disease progression and are important to identify when considering lunate salvage surgery.

Risk factors for intra-articular involvement in proximal humeral fractures.

INTRODUCTION: Identification of intra-articular involvement in proximal humeral fractures is important for operative decision making. The aim of this study was to identify the risk factors associated with intra-articular involvement in proximal humeral fractures. MATERIALS AND METHODS: One hundred consecutive three-dimensional computed tomography reconstructions of proximal humeral fractures were identified. The fracture lines were then accurately transcribed onto a two-dimensional superior view of the humeral head and each fracture was assessed for intra-articular involvement. Statistical analyses were undertaken to identify risk factors for intra-articular involvement and extent of involvement. Furthermore, for each risk factor, common fracture patterns were identified and compared to anatomical landmarks. RESULTS: Overall, 58% of the fractures involved the articular surface. High-energy mechanism, female gender, age ≥ 65, and posterior dislocation were risk factors for intra-articular involvement. Low-energy mechanism, female gender, age ≥ 65, varus angulation, and posterior dislocation were risk factors for increased extension of the fracture onto the articular surface. CONCLUSION: Intra-articular involvement in proximal humeral fractures is influenced by demographics and fracture characteristics (mechanism of injury, angulation, and dislocation). Patients with identified risk factors should be appropriately evaluated for intra-articular fractures during preoperative planning to assist in operative decision making. LEVEL OF EVIDENCE: Basic science; anatomy study.

Preoperative topical benzoyl peroxide treatment is effective in reducing Cutibacterium acnes in shoulder surgery: a systematic review.

BACKGROUND: Cutibacterium acnes (C acnes) colonization can have a significant impact on patients undergoing both arthroscopic and open shoulder surgery with regard to postoperative infection. Its resistance to standard preoperative skin preparations and prophylactic antibiotics has led to a need for a more targeted therapy. Topical benzoyl peroxide (BPO) has been used by dermatologists in the treatment for acnes due to its bactericidal and penetrative effects through the dermal layer. The aim of this systematic review is to review the effectiveness of topical BPO preoperatively in shoulder surgery in reducing C acnes colonization and postoperative infection. METHODS: A review of the online databases Medline and Embase was conducted on December 15, 2021, according to Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. The review was registered prospectively in the PROSPERO database. Clinical studies reporting superficial and deep sample microbiology and postoperative complications were included. The studies were appraised using the revised Cochrane Risk of Bias 2 (ROB 2) tool for randomized studies and the Methodological Index for Non-Randomized Studies (MINORS) tool. RESULTS: The search strategy identified 10 studies for inclusion (6 randomized control trials, 2 prospective cohort studies, and 2 case series), including a total of 482 patients. Seven studies were comparable, testing BPO against alternative standard skin preparations. Of the 10 studies, 7 showed a decrease in the load of C acnes on the skin and/or deep tissues, of which 6 demonstrated statistical significance. Men were shown to have a statistically significant increase in the colonization rate of C acnes. Scheer et al (2021) demonstrated 4500 colony-forming units/mL in males and 900 colony-forming units/mL in females. In studies where the number of BPO applications was higher, BPO appeared more effective. Dizay et al demonstrated C acnes elimination in 78.9% with more than 1 application compared with 66.7% if only applied once. Three studies looked at the effectiveness of BPO during the operative timeline with 1 demonstrating its statistically significant effectiveness at reducing colonization 2 hours into the operation (P = .048). CONCLUSION: BPO is effective as a topical treatment at reducing C acnes colonization before shoulder surgery. However, the relationship between duration of treatment, frequency of application, and gender requires further research.

An assessment of burnout in New Zealand orthopaedic resident medical officers.

AIMS: Burnout and fatigue are common in the medical profession. The primary aim was to assess rates of burnout in trainee and non-trainee orthopaedic registrars in New Zealand. A secondary aim was to establish which specific factors are associated with burnout. METHODS: In 2021, a 53-question online survey was sent to New Zealand trainee and non-trainee orthopaedic registrars. The survey included questions addressing demographics, modifiable factors known to lead to burnout, information on respective orthopaedic departments, and how respondents had fared with COVID-19. Registrars also completed the Maslach Burnout Inventory-Human Services Survey for Medical Personnel (MBI-HSS MP), a 22-question validated survey that is designed to assess the frequency and intensity of perceived burnout among medical personnel. RESULTS: Fifty of 62 (80.6%) trainees and 66 of 70 (estimated number) (94.3%) of non-trainees completed the survey. Trainees and non-trainees both exhibited moderate levels of burnout. The trainee mean score emotional exhaustion (EE) 22.5, depersonalisation (DP) 8.8, personal achievement (PA) 35.9; non-trainee mean score EE 22.4, DP 8.9, PA 35.9. Fifty-two point two percent of trainees and 50% of non-trainees scored in the severe range for at least one of EE or DP. Factors shown to reduce burnout are the presence of a senior colleague (P<0.001), participation in professional assistance (P=0.049), working in a department with a full complement of staff (P=0.020) and being able to attend health maintenance appointments (P=0.050). CONCLUSION: Our study shows that approximately half of both trainee and non-trainee orthopaedic registrars are exhibiting signs of burnout. This is comparable to other developed nations with a similar healthcare system.

Volar Lunate Facet Fractures of the Distal Radius: Fracture Mapping Using 3D CT Scans.

Background Fractures of the distal radius involving the lunate facet at the volar articular surface are unstable injuries and are usually managed operatively. Management of these fractures is challenging as our understanding of the exact fracture characteristics and associated injuries to the carpus is poor. Purpose This study aims to define the anatomy and associated injuries of lunate facet fractures using three-dimensional computed tomography (CT) scans and fracture mapping techniques. Methods A consecutive series of CT wrists was analyzed to identify intra-articular fractures involving the lunate facet at the volar distal radius. Fractures were mapped onto standardized templates of the distal radius using previously described fracture mapping techniques. We also identified instabilities of the carpus including volar carpal translation, ulnar translocation, scapholunate diastasis, and distal radioulnar joint (DRUJ) instability. Results We present 23 lunate facet fractures of the distal radius. The lunate facet fragment displaces in a volar and proximal direction and the lunate always articulates with the displaced fragment. The smaller fragments displace a greater amount, in a volar direction, with pronation. The fracture tends to occur between the origin of the short and long radiolunate ligaments. Conclusion Lunate facet fractures are frequently comprised of osteoligamentous units of the distal radius involving the short and long radiolunate ligaments and the radioscaphocapitate ligament. Assessment and management of volar carpal subluxation, scapholunate instability, ulnar translocation, and DRUJ instability should be considered. Clinical relevance Our mapping of these fractures contributes to our understanding of the anatomy and associated instabilities and will aid in surgical planning and decision making.

The Pathoanatomy and Biomechanics of Kienböck Disease.

Kienböck disease (KD) involves osseous, vascular, and chondral aspects of the lunate and wrist. We present our theories on the etiology and pathogenesis of the condition based on basic science models, seminal literature, personal case experience, and kinematic observations of the Kienböck wrist. Three phenotypes of Kienböck disease occur, and each tends to have different morphology, rates of progression, and disease pattern. The lunate fracture in KD is well-recognized but different fracture types can occur. Dynamic assessment of the Kienböck wrist allows assessment of the complex kinematics of KD. Disease onset and progression require a "perfect storm" of risk factors.

Preiser's Disease-Current Concepts of Etiology and Management.

The term Preiser's disease typically is used to describe idiopathic avascular necrosis of the scaphoid, but there have been a number of putative etiologies considered. It is rare and the natural history is not fully understood. Management of the condition should be based on patient factors as well as the stage of disease with regard to the scaphoid and the surrounding wrist. This chapter appraises the available evidence and aims to provide the reader with a framework to manage this rare condition.

Fatty infiltration in the intact supraspinatus tendon; a normal physiological response with increasing age and female gender.

Background: Fatty infiltration and muscle atrophy of supraspinatus are used as markers of chronicity in rotator cuff tears and are known to both be independently related to poorer outcomes following surgical repair.1 We hypothesized that supraspinatus muscle atrophy and fatty infiltration increases with age irrespective of whether the rotator cuff is intact and therefore cannot be used as accurate markers for chronicity. Method: Retrospective review of 280 patients who underwent 3.0 T shoulder MRI's with either a normal scan or rotator cuff tear. Two independent observers reviewed the images. Data collected included intact rotator cuff tendons looking specifically at supraspinatus muscle height/length: suprascapular fossa ratio, tangent sign and Goutallier grade for fatty infiltration. Results: There were 90 scans with intact rotator cuff tendons. Mean age was 51 years (range 17-86); 52 males, 38 females. On multiple regression analysis, there was a positive correlation of age with fatty infiltration and muscle atrophy on all parameters in the normal intact cuff. Females were significantly more likely than males to have a higher grade of fatty infiltration. Conclusion: Age and female gender are risk factors for rotator cuff atrophy and fatty infiltration in patients with normal rotator cuffs. Therefore, these parameters should be used with caution by surgeons when deciding on tear chronicity and the potential to repair the torn rotator cuff.

Management of osteochondritis dissecans (OCD) of the elbow trochlea in the adolescent population: A systematic review.

Background: Elbow trochlea osteochondritis dissecans (OCD) is rare with limited information on it. The aim of this systematic review is to assess the published evidence on trochlea OCD in terms of presenting symptoms, location of OCD and outcome of management in adolescent patients. Patient & Methods: A review of the online databases MEDLINE and Embase was conducted according to PRISMA guidelines. The review was registered prospectively in the PROSPERO database. Clinical studies reporting on any aspect of trochlea OCD management were eligible for inclusion and appraised using the Methodological Index for Non-Randomized Studies (MINORS) tool. Results: 16 studies were eligible for inclusion with a total of 75 elbow. Mean age was 14 years (8-19) of which 46 were males. The main presenting symptoms were pain (95%). Non-operative care was reported in 86% of elbows with resolution of symptoms in 76%. Surgical management was described in 14%. There were equal number of arthroscopic and open procedures. 94% had successfully resolution of symptoms post-operatively. Conclusion: Elbow trochlea OCD is a rare pathology and one that can be managed non-operatively in the majority of cases with good resolution of symptoms. However, if this fails, operative options are available with excellent results reported. Level of evidence: Level IV, Systematic review.

Volar Marginal Rim Fractures of the Distal Radius Have a Higher Rate of Associated Carpal Injuries-A Comparative Cohort Study.

Background Volar marginal rim distal radius fractures can be challenging due to volar instability of the carpus. The associated carpal injuries, however, have not previously been reported. Purpose The aim of this study was to compare volar marginal rim fractures to other distal radius fractures to determine if there is any association with other carpal injuries. If so, do these injuries lead to further instability and fixation failure? Materials and Methods A retrospective radiological review of 25 volar marginal rim fractures was conducted. This was compared with a comparison cohort of 25 consecutive intra-articular distal radius fractures not involving the volar marginal rim. All radiographs were reviewed for associated carpal injuries, including carpal and ulnar styloid fractures, scapholunate instability, and carpal translocation. Results Volar marginal rim fractures had a significantly higher incidence of associated carpal injuries per patient (2.52 vs. 1.64), scapholunate diastasis (36 vs. 12%), and carpal dislocation (80 vs. 48%). The fixation chosen was more likely to involve a volar rim-specific plate (44 vs. 0%). Following surgical fixation, the volar marginal rim fractures had a significantly higher incidence of carpal instability (56 vs. 24%), failure of fixation (24 vs. 0%), and revision surgery (12 vs. 0%). Conclusions Volar marginal rim fractures have significantly more carpal injuries, scapholunate instability, and volar carpal instability, compared with other distal radius fractures. Despite the use of volar rim-specific plating, volar marginal rim fractures have a significantly higher incidence of persistent carpal instability, including scapholunate instability, ulnar translocation, volar subluxation, failure of fixation, and revision surgery. Level of Evidence This is a level III, retrospective review.

Anatomical and Clinical Concepts in Distal Radius Volar Ulnar Corner fractures.

Background Volar ulnar corner fractures are a subset of distal radius fractures that can have disastrous complications if not appreciated, recognized, and appropriately managed. The volar ulnar corner of the distal radius is the "critical corner" between the radial calcar, distal ulna, and carpus and is responsible for maintaining stability while transferring force from the carpus. Description Force transmitted from the carpus to the radial diaphysis is via the radial calcar. A breach in this area of thickened cortex may result in the collapse of the critical corner. The watershed ridge (line) is clinically important in these injuries and must be appreciated during planning and fixation. Fractures distal to the watershed ridge create an added level of complexity and associated injuries must be managed. An osteoligamentous unit comprises bone-ligament-bone construct. Volar ulnar corner fractures represent a spectrum of osteoligamentous injuries each with their own associated injuries and management techniques. The force from the initial volar ulnar corner fracture can propagate along the volar rim resulting in an occult volar ligament injury, which is a larger zone of injury than appreciated on radiographs and computerized tomography scan. These lesions are often underestimated at the time of fixation, and for this reason, we refer to them as sleeper lesions. Unfortunately, they may become unmasked once the wrist is mobilized or loaded. Conclusions Management requires careful planning due to a relatively high rate of complications after fixation. A systematic approach to plate positioning, utilizing several fixation techniques beyond the standard volar rim plate, and utilizing fluoroscopy and/or arthroscopy is the key strategy to assist with management. In this article, we take a different view of the volar ulnar corner anatomy, applied anatomy of the region, associated injuries, and management options.

Precision Medicine for Kienböck Disease in the 21st Century.

One of the most popular treatment algorithms for Kienböck disease is based on a progression of successive radiographic changes that was developed in the 1970s. Since then, 2 other important classifications systems have been introduced. One is centered on contrasted magnetic resonance imaging findings and the other, articular cartilage degeneration. All 3 systems have been used, in isolation, to recommend specific treatment modalities. To coordinate all available clinical data and to simplify the treatment selection process, we combined the 3 classification systems into 1 unified classification and treatment algorithm. With the added consideration of some recently introduced surgical options and further knowledge of how Kienböck disease affects children and the elderly, we anticipate that this unified classification system will allow for a more precise and individualized treatment plan.

Anatomic factors associated with partial distal biceps tendon tears: a comparative control study.

BACKGROUND: There is minimal literature on the anatomic factors associated with partial distal biceps tendon (DBT) tears. It has been proposed that a larger radial tuberosity size-and, therefore, a smaller radioulnar space during pronation-may cause mechanical impingement of the DBT predisposing to tears. We sought to investigate the anatomic factors that may be associated with partial DBT tears by retrospectively reviewing the DBT anatomy using 3-T magnetic resonance imaging (MRI) scans of elbows with partial DBT tears and a comparison group of normal elbows. METHODS: Two independent observers retrospectively reviewed 3-T MRI scans of elbows with partial DBT tears and elbows without visible pathology. Basic demographic data were collected, and measurements of radial tuberosity length, radial tuberosity thickness, radioulnar space, and radial tuberosity-ulnar space were made using simultaneous tracker lines and a standardized technique. The ratio of radial tuberosity thickness to radial diameter and the ratio of radioulnar space to radial tuberosity-ulnar space were calculated. The presence or absence of enthesophytes and the presence of a single DBT vs. double DBTs were noted. RESULTS: This study included twenty-six 3-T MRI scans of 26 elbows with partial DBT tears and thirty 3-T MRI scans of 30 elbows without pathology. Basic demographic data were comparable between the 2 groups. The tear group showed statistically significantly larger mean measurements for radial tuberosity length (24.3 mm vs. 21.3 mm, P = .002) and radial tuberosity thickness (5.5 mm vs. 3.7 mm, P < .0001). The tear group also showed statistically significantly smaller measurements for radioulnar space (8.2 mm vs. 10.0 mm, P = .010) and radial tuberosity-ulnar space (7.2 mm vs. 9.1 mm, P = .013). The ratio of radial tuberosity thickness to radial diameter was statistically significantly larger in the tear group (0.389 vs. 0.267, P < .0001). There was a statistically significant positive correlation between partial DBT tears and the presence of enthesophytes (P = .007), as well as between partial DBT tears and the presence of 2 discrete DBTs rather than a single tendon or 2 DBTs that interdigitated prior to insertion (P < .0001). CONCLUSION: Larger radial tuberosities and smaller radioulnar and radial tuberosity-ulnar spaces are associated with partial DBT tears. Larger tuberosities and a smaller functional space for the DBT may lead to chronic impingement, tendon delamination, and consequent weakness, which ultimately lead to tears. Enthesophytes may be associated with tears for the same reason. The presence of 2 discrete DBTs that do not interdigitate prior to insertion is also associated with partial tears. This study will help clinicians understand the pathogenesis of partial DBT tears.

Hamate vs. capitate grafting for proximal interphalangeal joint fracture-dislocation: an MRI-based study of 35 hands.

We examined the MRI scans of 35 adult hands to assess the feasibility of the hamate and the capitate as potential donor grafts in the management of comminuted intra-articular fractures at the base of the middle phalanges. Essentially neither the hamate nor the capitate were perfect anatomic matches in most digits, but the capitate had the advantage of having more uniform facets, and the capitate facet shapes were similar to those of the little finger. The measurement of angles in the coronal and sagittal plane showed that in some respects the differences between the potential graft and the base of the middle phalanges were smaller for the capitate than for the hamate. Moreover, the sagittal morphology of the capitate made it less prone to joint overstuffing than the hamate. We conclude that the capitate may be considered as a graft donor in selected cases, especially for the little finger.

Anatomy of the distal biceps tendon: an in vivo 3-T magnetic resonance imaging study.

BACKGROUND: On the basis of the current literature, the optimal surgical technique for distal biceps tendon tears remains controversial. Cadaveric studies have investigated distal biceps anatomy but are limited by cohort size and tissue factors. We sought to investigate distal biceps anatomy in vivo by retrospectively reviewing magnetic resonance imaging (MRI) scans. An improved understanding of the anatomy of the distal biceps tendon will lead to better definition of the optimal anatomic surgical repair. METHODS: Two independent observers retrospectively reviewed 3-T MRI scans of elbows. Basic demographic data were collected, and measurements of tendon length, footprint width, footprint length, and footprint angle were taken using simultaneous tracker lines and a standardized technique. From the biceps muscle belly distally, the presence of a single tendon or double tendons was recorded and the tendon interdigitation point was measured if relevant. RESULTS: A total of 106 3-T MRI scans of 106 elbows of 103 patients were included. There were 71 male and 32 female patients, and the mean age was 44.7 years. Most distal biceps tendons exited the biceps muscle belly as separate entities (91%, 96 of 106 elbows) and then coalesced prior to insertion on the radial tuberosity (91%, 87 of 96 elbows). There was a positive correlation between tendon length and footprint length (P < .05), as well as between tendon length and footprint width (P < .05). The mean tendon length was 65.2 mm (95% confidence interval [CI], 63.3-66.8 mm; range, 44.3-86.8 mm), the mean distance from the musculotendinous junction to the interdigitation point was 38.3 mm (95% CI, 35.8-40.9 mm; range, 8.9-64.8 mm), the mean footprint width was 10.3 mm (95% CI, 9.9-10.7 mm; range, 5.9-16.3 mm), the mean footprint length was 16.2 mm (95% CI, 15.6-16.9; range, 7.3-25.4 mm), and the mean footprint angle was 32.1° (95% CI, 29.5°-34.6°; range, 8.5°-84.3°). CONCLUSION: An in vivo, high-resolution study of the anatomy of the distal biceps tendon improves our understanding of its complex morphology and hence our ability to perform an anatomic "footprint repair."

Long-Term Outcome of Surgical Treatment for Kienböck Disease Using an Articular-Based Classification.

PURPOSE: The aim of this study was to report the outcomes of surgery using the Bain and Begg articular-based classification for the treatment of Kienböck disease. METHODS: We identified and followed patients who had surgery for Kienböck disease between 1995 and 2014. Assessment included functional scoring using a modification of the Gartland and Werley score, pain levels, and grip strength. RESULTS: Thirty-one patients were operated on for Kienböck disease between 1995 and 2014. Twenty-seven patients were assessed (12 men and 15 women). Mean age at the index procedure was 45.1 years (range, 20-82 years). Median follow-up after the index procedure was 10 years (range, 2-18 years). On the Bain and Begg classification, 5 patients had grade 0, 4 had grade 1, 5 had grade 2a, 10 had grade 2b, 1 had grade 3, and 1 had grade 4. The median pain visual analog scale improved from a preoperative score of 5 (interquartile range [IQR], 5-6) to a postoperative score of 2 (IQR, 0-3). The median functional scores from the modified Gartland and Werley score improved from 67 (IQR, 57.0-78.5) to 97 (IQR, 90.0-97.0). Eighteen out of 20 working patients returned to the same level of work. There was a significant improvement in power grip and tip pinch following surgery. One patient required a secondary salvage procedure. No patient required a full wrist fusion or arthroplasty. CONCLUSIONS: This study confirms that the Bain and Begg arthroscopic classification and an articular-based approach to Kienböck disease provide a high probability of good long-term relief of pain and a minimal chance of requiring a salvage procedure. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.