Acetabular dysplasia and the risk of developing hip osteoarthritis at 2,5,8, and 10 years follow-up in a prospective nationwide cohort study (CHECK).

OBJECTIVE: To assess the relationship between acetabular dysplasia (AD) and the risk of incident and end-stage radiographic hip osteoarthritis (RHOA) over 2,5,8 and 10 years. DESIGN: Individuals (n = 1002) aged between 45 and 65 from the prospective Cohort Hip and Cohort Knee (CHECK) were studied. Anteroposterior pelvic radiographs were obtained at baseline and 2,5,8, and 10-years follow-up. False profile radiographs were obtained at baseline. AD was defined as a lateral center edge angle, an anterior center edge angle, or both <25° at baseline. The risk of developing RHOA was determined at each follow-up moment. Incident RHOA was defined by Kellgren & Lawrence (KL) grade ≥2 or total hip replacement (THR), end-stage RHOA by a KL grade ≥3 or THR. Associations were expressed in odds ratios (OR) using logistic regression with generalized estimating equations. RESULTS: AD was associated with the development of incident RHOA at 2 years follow-up (OR 2.46, 95% CI 1.00-6.04), 5 years follow-up (OR 2.28, 95% CI 1.20-4.31), and 8 years follow-up (OR 1.86, 95%CI 1.22-2.83). AD was only associated with end-stage RHOA at 5 years follow-up (OR 3.75, 95% CI 1.02-13.77). No statistically significant associations were observed between AD and RHOA at 10-years follow-up. CONCLUSION: Baseline AD in individuals between 45 and 65 years is associated with an increased risk of developing RHOA within 2- and 5 years. However, this association seems to weaken after 8 years and disappears after 10 years.

Return to sports following distal biceps tendon repair: A current concepts review.

Distal biceps tendon ruptures are relatively rare injuries but tend to occur in active and athletic populations, especially in weightlifting and contact sports. The distal biceps tendon is an important supinator of the forearm and flexor of the elbow, thus an injury to this ligament can be invalidating for athletes. The aim of this review was to determine the ability and the time to return to sports following distal biceps tendon repair in athletes and the level of performance. The literature is scarce about the return to sports among athletes. Most studies include athletes are National Football League (NFL) players, others are weightlifters and a few recreational athletes. The return to play rate after distal biceps tendon repair is high. The performances of the returned players were similar to matched players and most players returned to the same level. Most players-depending on the sport-were not able to return to competition within the same season. In order to manage expectations, it should be discussed preoperatively with the athlete (and their coach) that the return to sports rate is high, but the return will probably be the following season.

Surgical treatment of chronic anterior radial head dislocations in missed Monteggia lesions in children: A rationale for treatment and pearls and pitfalls of surgery.

INTRODUCTION: The treatment of chronic radial head dislocations after Monteggia lesions in children can be challenging. This article provides a detailed description of the most frequently performed surgical technique: an ulna osteotomy followed by annular ligament reconstruction. Accordingly, we present the clinical and radiological results of 10 paediatric cases. MATERIAL AND METHODS: All paediatric patients that had a corrective osteotomy of the ulna for a missed Monteggia lesion between 2008 and 2014 were evaluated with standard radiographs and clinical examination. A literature search was performed to identify the relevant pearls and pitfalls of surgery. Primary outcome was range of motion. RESULTS: We included 10 patients, with a mean follow-up of 2.5 years. Postoperative range of motion generally improved 30.7°. Even in a patient with obvious deformity of the radial head, range of motion improved after surgery, without residual dislocation of the radial head. CONCLUSION: Corrective proximal ulna osteotomy with rigid plate fixation and annular ligament reconstruction yields good results in patients with chronic radial head dislocation following a Monteggia lesion. Surgery should be considered regardless of patient age or time since trauma. Given substantial arguments in literature, we discourage surgery if a CT scan shows dome-shaped radial head dysmorphic features in work-up to surgery.

The Pellegrini-Stieda Lesion of the Knee: An Anatomical and Radiological Review.

The Pellegrini-Stieda lesion is a calcification on the medial side of the knee. The origin of this tissue is controversial. The purpose of our study is to investigate the origin of the Pellegrini-Stieda lesion using conventional radiography as to recreate the circumstances in which Pellegrini and Stieda had to study this pathology. Six nonpaired fresh-frozen cadaveric knees were used. A surgical approach to the medial side of the knee was performed using the layered approach. The origin of the gastrocnemius muscle (GM) (n = 3) or the superficial medial collateral ligament (sMCL) (n = 3) were marked with a radio-opaque fluid. X-ray analysis was performed by measuring the distance from the proximal part of the marking to the medial tibial plateau, multilayer views, and comparison to the original X-rays by Pellegrini-Stieda. Two out of three markings in both the GM and sMCL group were matched with the correct structure. The images were digitally processed so that the osseous structures became partly transparent. After overlaying the images, we found a random distribution of the markings. The Stieda/GM group had no overlap of the markings at all. Compared with the original images from the publications by Pellegrini and Stieda, no comparable position could be found between the original lesions and the markings in our specimens. Conventional X-ray of the knee could not reproduce a distinction between the sMCL and GM as origins for the Pellegrini-Stieda lesion as suggested by Pellegrini and Stieda.

Does surgeon volume influence the outcome after hip hemiarthroplasty for displaced femoral neck fractures; early outcome, complications, and survival of 752 cases.

INTRODUCTION: Surgeon volume of hip arthroplasties is of importance with regard to complication and revision rates in total hip arthroplasty. For hip hemiarthroplasty, the effect of surgeon volume on outcome is far less studied. We analyzed the outcome of hip hemiarthroplasties performed by orthopedic surgeons in a retrospective cohort in different volume categories, focusing on early survival of the prosthesis and complications. METHODS: Between March 2009 and January 2014, 752 hemiarthroplasties were performed for intracapsular femoral neck fracture by 27 orthopedic surgeons in a large Dutch teaching hospital. Surgeons were divided into four groups, a resident group and three groups based on the number of total hip arthroplasties and hemiarthroplasties performed per year: a low-volume (< 10 arthroplasties per year), moderate-volume (10-35 arthroplasties per year), and high-volume groups (> 35 arthroplasties per year). Outcome measures were stem survival using a competing risk analysis, complication rates, and mortality. Chi-square tests were used to compare complication rates and mortality between groups. RESULTS: Patients were followed for a minimum of 2 years or until revision or death. Overall 60% of the patients included had died at time of follow-up. We found comparable stem survival rates in the low-volume group (n = 48), moderate-volume group (n = 201), high-volume group (n = 446), and resident group (n = 57). There were no significant differences between the groups with regard to dislocation rate, incidence of periprosthetic fracture, infection, and mortality. CONCLUSION: Surgeon volume and experience did not influence early outcome and complication rates in hip hemiarthroplasty. Hemiarthroplasty can safely be performed by both experienced hip surgeons and low-volume surgeons.

There is a role for allografts in reconstructive surgery of the elbow and forearm.

PURPOSE: Allografts play an important role in tendon, ligament, and bone reconstruction surgery, particularly when suitable available autologous tissue is limited. Enthusiasm for the use of allografts in reconstructive orthopedic surgery has increased over the past decade, with an increase in allograft use in a variety of procedures. The purpose of this review is to provide an overview of the various applications and indications for the use of allografts in reconstructive surgical procedures of the elbow and forearm. METHODS: MEDLINE/PubMed was searched from 1990 through October 2018 for studies on tendon and bony allografts in elbow and forearm reconstructive surgery. RESULTS: The Achilles tendon allograft is the most frequently used tendinous allograft, predominantly used in distal biceps and triceps reconstruction. Although reconstruction of the ulnar collateral ligament of the elbow is generally performed using autografts, it has been shown that semitendinosus and gracilis allografts may be equally effective. Extensor hallucis longus allografts are recommended for reconstruction of the lateral collateral ligaments in patients with posterolateral rotatory instability, and there may be a role for osteochondral allograft transplantation in capitellar osteochondral defects. In addition, the use of allografts in reconstruction of the interosseous membrane and various bone pathologies (fractures, bone tumors, forearm nonunions) has been described in current literature. CONCLUSION: There is a large variety of pathology and procedures involving the use of various types of allografts in orthopedic reconstructive surgery of the elbow and forearm.

Short-term clinical results of revision elbow arthroplasty using the Latitude total elbow arthroplasty.

AIMS: Revision total elbow arthroplasty (TEA) is often challenging. The aim of this study was to report on the clinical and radiological results of revision arthroplasty of the elbow with the Latitude TEA. PATIENTS AND METHODS: Between 2006 and 2010 we used the Latitude TEA for revision in 18 consecutive elbows (17 patients); mean age 53 years (28 to 80); 14 women. A Kudo TEA was revised in 15 elbows and a Souter-Strathclyde TEA in three. Stability, range of movement (ROM), visual analogue score (VAS) for pain and functional scores, Elbow Functional Assessment Scale (EFAS), the Functional Rating Index of Broberg and Morrey (FRIBM) and the Modified Andrews' Elbow Scoring System (MAESS) were assessed pre-operatively and at each post-operative follow-up visit (six, 12 months and biennially thereafter). Radiographs were analysed for loosening, fractures and dislocation. The mean follow-up was 59 months (26 to 89). RESULTS: The ROM of the elbow did not improve significantly. The mean EFAS and MAESS scores improved significantly six months post-operatively (18.6 points, standard deviation (sd) 7.7; p = 0.03 and 28.8 points, sd 8.6; p = 0.006, respectively) and continued to improve slightly or reached a plateau. The mean pain scores at rest (Z = -3.2, p = 0.001) and during activity (Z = -3.2, p = 0.001), and stability (Z = -3.0, p = 0.003) improved significantly six months post-operatively. Thereafter scores continued to improve slightly or a plateau was reached. There were no signs of loosening. CONCLUSION: Revision surgery using the Latitude TEA results in improvement of functionality, reduced pain and better stability of the elbow. Improvement of ROM of the elbow should not be expected. Cite this article: Bone Joint J 2016;98-B:1086-92.

Mid-term clinical results of a modern convertible total elbow arthroplasty.

Unlinked, linked and convertible total elbow arthroplasties (TEAs) are currently available. This study is the first to report the clinical results of the convertible Latitude TEA. This was a retrospective study of a consecutive cohort of 63 patients (69 primary TEAs) with a mean age of 60 years (23 to 87). Between 2006 and 2008 a total of 19 men and 50 women underwent surgery. The mean follow-up was 43 months (8 to 84). The range of movement, function and pain all improved six months post-operatively and either continued to improve slightly or reached a plateau thereafter. The complication rate is similar to that reported for other TEA systems. No loosening was seen. Remarkable is the disengagement of the radial head component in 13 TEAs (31%) with a radial head component implanted. Implantation of both the linked and the unlinked versions of the Latitude TEA results in improvement of function and decreased pain, and shows high patient satisfaction at mid-term follow-up.

Accuracy of a computer-assisted planning and placement system for anatomical femoral tunnel positioning in anterior cruciate ligament reconstruction.

BACKGROUND: Femoral tunnel positioning is a difficult, but important factor in successful anterior cruciate ligament (ACL) reconstruction. Computer navigation can improve the anatomical planning procedure besides the tunnel placement procedure. METHODS: The accuracy of the computer-assisted femoral tunnel positioning method for anatomical double bundle ACL-reconstruction with a three-dimensional template was determined with respect to both aspects for AM and PL bundles in 12 cadaveric knees. RESULTS: The accuracy of the total tunnel positioning procedure was 2.7 mm (AM) and 3.2 mm (PL). These values consisted of the accuracies for planning (AM:2.9 mm; PL:3.2 mm) and for placement (about 0.4 mm). The template showed a systematic bias for the PL-position. CONCLUSIONS: The computer-assisted templating method showed high accuracy for tunnel placement and has promising capacity for application in anatomical tunnel planning. Improvement of the template will result in an accurate and robust navigation system for femoral tunnel positioning in ACL-reconstruction.

Open reduction and corrective ulnar osteotomy for missed radial head dislocations in children.

The treatment of chronic radial head dislocation remains controversial. Open reduction of the radial head in combination with correction of malalignment with ulnar osteotomy can be the key to a good surgical result. Between 2001 and 2006, 9 (6 female, 3 male, average age 8.4 (5-11) years) patients were treated surgically for chronic radial head dislocation by one surgeon. The time between trauma and surgery was 7 (1.5-14) months. The procedure consisted of open reduction of the dislocated radial head and reconstruction of the annular ligament in combination with an ulnar osteotomy. An upper arm cast was applied with the forearm in neutral rotation for six weeks. Plates were removed in all patients. Clinical and radiological evaluation took place preoperatively and after an average of 23 (10-49) months. At radiograph 8/9 showed a reduced radial head; in one an anterior subluxation was seen. The range of motion remained the same in 4 patients who had a full range of motion preoperatively. In 2/5 patients with loss of range of motion preoperatively, improvement was seen. There were no serious surgical complications beside one infection. Open reduction and corrective ulnar osteotomy shows good results for missed radial head dislocations in children.

Results of arthroscopic debridement for osteochondritis dissecans of the elbow.

OBJECTIVE: To determine the clinical outcome of arthroscopic debridement for osteochondritis dissecans of the elbow. METHODS: A prospective cohort study was started in 2000; between 2000 and 2005, 15 patients (six male, nine female, mean age 28 years (range 16-49)) were treated for osteochondritis dissecans of the elbow with arthroscopic debridement. The lesion was graded during surgery using the classification of Baumgarten. The dominant side was operated on in seven of 15 patients, and all patients were involved in a sport in which the elbow is used extensively. Elbow function was assessed before and after surgery using the modified Andrews elbow scoring system (MAESS); pain was scored on a visual analogue scale (0, no pain; 10, severe pain). Evaluation was performed an average of 45 (range 18-59) months after surgery. Statistical analysis (Student's t test) was carried out using SPSS statistical software. p<0.005 was considered significant. RESULTS: There were no complications. The range of motion did not improve significantly. The mean MAESS score improved from 65.5 (poor) before surgery to 90.8 (excellent) after (p<0.001). The mean level of pain at rest decreased from 3 to 1, and the level of pain after provocation decreased from 7 to 2 (p<0.001). All patients were able to return to work 3 months after surgery, and 80% were able to resume their pre-injury level of sport activity. CONCLUSION: The clinical outcome after arthroscopic debridement for osteochondritis dissecans of the elbow shows good results, with pain relief during activities of daily living and sport. The function of the elbow, as reflected by the MAESS score, improved from poor to excellent. All patients in this series will be reviewed after 5 years to determine long-term results.

Posterolateral dislocation of the elbow joint. Relationship to medial instability.

BACKGROUND: Dislocation of the elbow joint is the second most common dislocation in the upper extremity, dislocation of the shoulder being the most common. It has been reported that uncomplicated dislocation of the elbow joint may be associated with a decreased range of motion, degenerative changes in the elbow joint, ectopic calcification, or neurological deficits. As the medial collateral ligament complex can be completely disrupted during dislocation, we evaluated the association between the long-term results of treatment of simple posterolateral dislocation of the elbow and the presence of persistent medial or valgus elbow instability. METHODS: Fifty patients who had a mean age of thirty-three years (range, eighteen to fifty-eight years) had closed reduction of a posterolateral dislocation of the elbow without associated fractures. The extremity was immobilized in an above-the-elbow plaster cast for three weeks. After a mean duration of follow-up of nine years (range, six to thirteen years), forty-one patients were evaluated with an interview, a physical examination, and radiographs made while a valgus load was applied to the elbow. RESULTS: The average score according to the system of The Hospital for Special Surgery was 91 points (range, 49 to 100 points), and thirty-one patients described their elbow function as good or excellent. Twenty-four patients had evidence of medial instability on radiographs made while a valgus load was applied to the elbow. Twenty-one patients had signs of degeneration of the joint, and twenty-five patients had ectopic ossification. Magnetic resonance imaging combined with arthrography was performed for the first twenty patients; eight had evidence of rupture of the medial collateral ligament, seven had generalized degenerative changes of the cartilage, and four had a chondral defect of the capitellum. (The study could not be completed for the remaining patient.) Medial instability on radiographs was correlated with signs of degeneration (p = 0.001), ectopic ossification (p = 0.01), a worse score according to the system of The Hospital for Special Surgery (p = 0.002), and persistent pain (p = 0.04). CONCLUSIONS: Posterolateral dislocation of the elbow joint can lead to persistent valgus instability that is associated with a worse overall clinical and radiographic result.

Clinical reliability and validity of elbow functional assessment in rheumatoid arthritis.

OBJECTIVES: (1) To investigate the measurement characteristics of the Hospital for Special Surgery (HSS) and Mayo Clinic elbow assessment instruments, utilizing methodological criteria including feasibility, reliability, validity, and discriminative ability; and (2) to develop an efficient and disease-specific rating system for elbow function assessment (EFA) in adult patients with RA, using a combination of self-reported subjective items and objective measures, and comparing its characteristics with the HSS and Mayo Clinic scales. METHODS: (1) Selection of elbow-specific items. (2) Investigation of reliability and validity of all separate items, as well as the total HSS and Mayo Clinic scores, in 42 patients with RA (mean age 60 yrs). Direct observation of functional elbow performance was defined as the gold standard against which criterion validity was compared. (3) Reaching agreement within a team of professionals on the different scale dimensions and the assigned weight. (4) Item reduction by eliminating unreliable, inaccurate, unfeasible, and ambiguous items. Finally, the EFA scale was constructed by selecting the most reliable and accurate items. RESULTS: The EFA scale showed a superior or equal degree of reliability as reflected in intraclass correlation coefficients of more than 0.88, and also superior validity, compared with the HSS and Mayo Clinic measures. CONCLUSION: Although the elbow scoring systems currently available provide a reliable measure, they seem restricted in evaluating elbow-specific functional ability. The EFA scale was found to be most suitable to measure elbow functional ability in RA, and was also shown to be highly reliable and practical in clinical practice.

Kinematics of partial and total ruptures of the medial collateral ligament of the elbow.

In this study the kinematics of partial and total ruptures of the medial collateral ligament of the elbow are investigated. After selective transection of the medial collateral ligament of 8 osteoligamentous intact elbow preparations was performed, 3-dimensional measurements of angular displacement, increase in medial joint opening, and translation of the radial head were examined during application of relevant stress. Increase in joint opening was significant only after complete transection of the anterior part of the medial collateral ligament was performed. The joint opening was detected during valgus and internal rotatory stress only. After partial transection of the anterior bundle of the medial collateral ligament was performed, there was an elbow laxity to valgus and internal rotatory force, which became significant after transection of 100% of the anterior bundle of the medial collateral ligament and was maximum between 70 degrees to 90 degrees of flexion. No radial head movement was seen after partial or total transection of the anterior bundle of the medial collateral ligament was performed. In conclusion, this study indicates that valgus or internal rotatory elbow instability should be evaluated at 70 degrees to 90 degrees of flexion. Detection of partial ruptures in the anterior bundle of the medial collateral ligament based on medial joint opening and increased valgus movement is impossible.

Anterior cruciate ligament reconstruction with alternative tibial tunnel: early results after accelerated weight-bearing.

In this study an autologous graft of 50%-60% of the patellar tendon (mid portion) was used for anterior cruciate ligament (ACL) reconstruction in 50 patients (19 women, 31 men; mean age 26 years). The distal part of the graft was fixed in a tunnel running from the centre of the anatomical tibial attachment of the ACL to the place where the bone block of the graft was removed from the tibial tubercle. A rehabilitation programme with accelerated weight-bearing postoperatively without external protection was followed. Evaluation consisting of function and stability tests, activity level and Lysholm's subjective function score took place an average of 26 months postoperatively; 35 of 50 patients had an additional evaluation monthly for 1 year and 6 monthly after 1 year. The stability tested manually after an average of 26 months postoperatively was good in 45 patients; 5 of them had a positive Pivot shift test (one 1+, two 2+, two 3+). Only 2 of these patients complained of giving way of the knee. All patients regained good knee function. The average postoperative Lysholm score was 85 (SD 14.5) and the subjective stability of the knee was described as 'good' in 41 patients, and 'poor' in 9. The objective stability was good in 7 of these 9 patients. The mean Tegner score was 6.5 (SD 1.9). The mean time to resuming activities was 5.4 weeks for full weight-bearing, 10 weeks for running, 13.5 weeks for going back to work and 6 months for returning to previous sports. In the group of 35 patients who underwent an additional evaluation, no change in manual stability was found during observation except for 3 of them. No patellar ruptures were seen. The operation technique used in this study appears to allow accelerated knee rehabilitation after ACL reconstruction.