All-endoscopic approach for distal biceps tendon pathology: analysis of long-term outcomes in partial and complete ruptures.

BACKGROUND: Distal biceps tendon (DBT) pathology is a spectrum that ranges from tendinopathy to complete retracted ruptures, and surgical treatment is usually performed via open approaches. The purpose of this study was to analyze safety and long-term outcomes of all-endoscopic surgery for entire spectrum of primary DBT pathology. The hypothesis was that at an all-endoscopic technique would result in satisfactory clinical outcomes and a low complication rate. METHODS: Consecutive patients who underwent all-endoscopic surgery for primary isolated DBT pathology (bursitis, partial and acute/chronic complete tears) between January 2013 and December 2021 were assessed and analyzed retrospectively. Refractory bursitis and low-grade partial tears underwent endoscopic débridement, and high-grade partial tears and complete ruptures underwent all-endoscopic repair or graft reconstruction. Preoperative and follow-up assessment included functional assessment using Mayo Elbow Performance Score and a Patient-Reported Distal Biceps Score, and radiological assessment was performed using plain biplanar radiographs and sonography. Pre- and postoperative scores for the overall group, and for partial and complete tears, were compared using a paired t test. RESULTS: Overall, 26 male patients underwent an all-endoscopic surgery for DBT tears; the pathology was classified by endoscopic findings into 6 types, and follow-up period ranged from 21 to 125 months (mean 79.4 months). Nine chronic partial tears (35%) included predominantly bursitis (type I, n = 2) and predominantly partial tears (type IIA and B, n = 7). The complete tear group (65%) included isolated short or long head tears (type IIIA and IIIB, n = 2) and complete tendon ruptures (types IV, V, and VIA-C, n = 15). Endoscopic débridement of the bursitis/low-grade tears and repair of the high-grade and complete ruptures resulted in complete resolution of symptoms and significant improvement in both Mayo Elbow Performance Score and Patient-Reported Distal Biceps Score (P < .001). Autografts were necessary in 35% (6/17) of complete tears, and no significant difference was found in functional scores in this group as compared to those where primary repairs were possible. There were 2 minor complications (7.6%) that involved transient lateral antebrachial cutaneous nerve neuropraxia. Follow-up sonography and radiographs showed an intact tendon and absence of heterotopic ossification or synostosis. CONCLUSIONS: An all-endoscopic approach for treating DBT pathology was safe and reliable and was associated with significant improvement in subjective and functional outcomes in the long-term. The dual-anchor onlay repair technique showed long-term radiologically demonstrable structural integrity of the tendon and was associated with a low minor complication rate and absence of heterotopic ossification.

How does dynamic arthroscopic tracking compare with radiologic glenoid track for identification of on- and off-track lesions in anterior shoulder instability?

BACKGROUND: Current treatment paradigms for anterior shoulder instability are based on radiologic measurements of glenohumeral bone defects, and mathematical calculation of the glenoid track (GT) is used to classify lesions into on-track and off-track morphology. However, radiologic measurements have shown high variability, and GT widths under dynamic conditions have been reported to be significantly smaller than those under static radiologic conditions. The purpose of this study was to assess the reliability, reproducibility, and diagnostic validity of dynamic arthroscopic standardized tracking (DAST) in comparison to the gold-standard radiologic track measurement method for the identification of on- and off-track bony lesions in patients with anteroinferior shoulder instability. METHODS: Between January 2018 and August 2022, 114 patients with traumatic anterior shoulder instability were evaluated using 3-T magnetic resonance imaging or computed tomography scans; glenoid bone loss, Hill-Sachs interval, GT, and Hill-Sachs occupancy ratio (HSO) were measured, and defects were classified as on-track or off-track defects and peripheral-track defects (based on HSO percentage) by 2 independent researchers. During arthroscopy, a standardized method (DAST method) was used by 2 independent observers to classify defects into on-track defects (central and peripheral) and off-track defects. Interobserver reliability of the DAST and radiologic methods was calculated using the κ statistic and reported as percentage agreement. Diagnostic validity (sensitivity, specificity, positive predictive value, and negative predictive value) of the DAST method was calculated using the radiologic track (HSO percentage) as the gold standard. RESULTS: The radiologically measured mean glenoid bone loss percentage, Hill-Sachs interval, and HSO in off-track lesions were lower with the arthroscopic method (DAST) as compared with the radiologic method. The DAST method showed nearly perfect agreement between the 2 observers for the on-track/off-track classification (κ = 0.96, P < .001) and the on-track central or peripheral /off-track classification (κ = 0.88, P < .001). The radiologic method showed greater interobserver variability (κ = 0.31 and κ = 0.24, respectively) with only fair agreement for both classifications. Inter-method agreement varied between 71% and 79% (95% confidence interval, 62%-86%) between the 2 observers, and reliability was assessed as slight (κ = 0.16) to fair (κ = 0.38). Overall, for identification of an off-track lesion, the DAST method showed maximum specificity (81% and 78%) when radiologic peripheral-track lesions (HSO percentage of 75%-100%) were considered off-track and showed maximum sensitivity when arthroscopic peripheral-track lesions were classified as off-track. CONCLUSION: Although inter-method agreement was low, a standardized arthroscopic tracking method (DAST method) showed superior interobserver agreement and reliability for lesion classification in comparison to the radiologic track method. Incorporating DAST into current algorithms may help reduce variability in surgical decision making.

Concomitant Posteromedial Elbow Dislocation with Lateral Condyle Humerus Fracture in a 7 Years Old - A Rare Case Report and Review of the Literature.

Introduction: Traumatic dislocations of the elbow are a rare injury in children. Concomitant elbow dislocations and lateral condyle fractures are even rarer. There is a wide variability in the outcomes of these injuries as there is no consensus regarding its management. We report one such rare case in a 7-year-old child. Case Report: A 7-year-old child was brought to the emergency room with an alleged history of fall on outstretched hand sustaining injury to the left elbow. He was diagnosed with a posteromedial elbow dislocation, along with fracture of the lateral condyle. The patient underwent emergency reduction of the elbow under appropriate anesthesia following which there was persistence of varus and valgus instability, for which the lateral condyle was fixed with a standard pinning through a lateral approach with three Kirschner wires. The patient was immobilized for 6 weeks in a plaster, after which mobilization was started. At 3 months follow-up, the patient showed good functional outcome with full range of motion. Conclusion: We report an exceedingly rare case of concomitant elbow dislocation and fracture of the lateral condyle in children. If emergent reduction of the dislocation and anatomic reduction of the fracture is achieved, satisfactory outcomes can be expected. Delayed recovery of the elbow motion is common, but full range of motion can be expected in the long run.

Scurvy Masquerading as Septic Arthritis in a Case of Cerebral Palsy.

INTRODUCTION: Scurvy is a rarely seen in pediatric patients nowadays, seen more in those with developmental delay, autism or those who are severely malnourished. Epiphyseal separations are known to occur in scurvy, but only a few such cases have been reported in children with cerebral palsy. The diagnosis is often misleading since other morbidities as trauma, malignancies, coagulopathies, septic arthritis, osteomyelitis, or rheumatologic disorders are often considered at first. We report the case of 4-year-old female child with cerebral palsy in whom the initial concern was septic arthritis/osteomyelitis based upon clinical presentation, ultrasonic and magnetic resonance imaging, led to a surgery revealing subperiosteal hematomas. CASE REPORT: A 4-year-old girl was admitted in the pediatrics department for fever and bilateral knee joint pain for 3 days. She was a diagnosed case of with cerebral palsy, psyco-developmental delay, and epileptogenic disorder put under valproic acid. She was toxic and febrile. Within 4 h after admission, both knees developed tense shiny intense swelling associated with pain, redness, and local rise of temperature with limited active range of motion. Near-complete passive range of motion was noted. There were no abnormal findings on the rest of the musculoskeletal examination. Aspiration of the knee revealed subperiosteal hematoma diagnostic of scurvy. CONCLUSION: Scurvy is exceedingly rare in children nowadays; however, its presentation among risky populations should not be forgotten. Musculoskeletal revelations, mostly subperiosteal hematoma, are the main manifestation of scurvy in the pediatric population. Scurvy as a differential diagnosis for trauma, osteomyelitis, septic arthritis will always be a bane for orthopedic surgeons. A heightened awareness is needed to avoid unnecessary surgery, unnecessary tests, and procedures and to be able to start treatment for a potentially fatal but easily curable disease.