David S. Ruch

The arthroscopic management of osteochondritis dissecans of the adolescent elbow.

The management of avascular necrosis of the capitellum of the adolescent elbow continues to be a dilemma. This article is a critical retrospective analysis of 12 pediatric patients (mean age at surgery 14.5 years) who underwent arthroscopic debridement alone followed by early range of motion. Follow-up at a mean of 3.2 years (range, 2.0 to 5.7 years) indicated that the average flexion contracture improved from 23 degrees preoperatively to 10 degrees postoperatively. All patients had remodeling of the capitellum by plain radiographs; however, five patients had associated enlargement of the radial head. Eleven patients had minimal mechanical symptoms after the procedure and were highly satisfied. One patient had substantial enlargement of the radial head with continued loss of supination and mechanical symptoms requiring radial head resection 2 years after the index procedure. Five patients had a triangular avulsion fragment present off the lateral capsule. A statistically significant worse subjective outcome was associated with the presence of this fragment (P < .005). There were no complications.

Radius Pull Test: Predictor of Longitudinal Forearm Instability

Background: Longitudinal instability of the forearm (the Essex-Lopresti lesion) following radial head excision may be difficult to detect. This cadaveric study examines a stress test that can be performed in the operating room to identify injury to the ligamentous structures of the forearm.Methods: Twelve cadaveric upper extremities were randomized into two groups and underwent radial head resection. Group 1 underwent sequential transection of the triangular fibrocartilage complex and the interosseous membrane. Group 2 underwent sequential transection of the interosseous membrane and the triangular fibrocartilage complex. Ulnar variance and radial migration were examined with use of fluoroscopy of the wrist before, during, and after the application of a 9.1-kg load via longitudinal traction on the proximal part of the radius.Results: Group 1 demonstrated no significant changes in proximal radial migration with load (compared with the findings after radial head resection alone) after transection of the triangular fibrocartilage complex. However, Group 2 demonstrated significant changes in proximal radial migration with load after transection of the interosseous membrane (p = 0.03; median, 3.5 mm). In both groups, transection of both the triangular fibrocartilage complex and the interosseous membrane resulted in significant changes in proximal radial migration with load (p = 0.001; median, 9.5 mm). When the load was removed, specimens were ulnar positive (median, 3.0 mm), with no specimen returning to the preload position of ulnar variance (p = 0.001).Conclusion: After radial head resection, 3 mm of proximal radial migration with longitudinal traction indicated disruption of the interosseous membrane. In all specimens, proximal radial migration of ≥6 mm with load indicated gross longitudinal instability with disruption of all ligamentous structures of the forearm.Clinical Relevance: Early detection of longitudinal instability of the forearm is essential for successful management. If radial head resection is necessary, longitudinal traction on the proximal part of the radius may provide useful information regarding the ligamentous support of the forearm and assist in deciding whether to simply excise or to repair or replace the radial head.

Fixation of three-part proximal humeral fractures: a biomechanical evaluation.

OBJECTIVES To examine the biomechanical stability of three constructs currently used for the management of three-part proximal humerus fractures. Tension band wires (TBW) with supplemental Enders nails, modified cloverleaf plate and screws, and intramedullary (IM) nailing with proximal and distal interlocks were tested to determine relative stability. DESIGN A reproducible three-part fracture was made in fresh-frozen stripped proximal humeri. The fracture was stabilized using TBW/Enders nail (n = 6), plate/screws (n = 5), or IM nailing (n = 5). MAIN OUTCOME MEASUREMENTS Mechanical testing was performed with a small preload followed by deflection of five millimeters at a rate of one millimeter per second in flexion, extension, and varus and valgus relative to the humeral shaft. A load-displacement curve was obtained. Torsional testing was performed in internal and external rotation, and torque-rotation curves were recorded. RESULTS In cantilever bending, the plate/screws construct and the IM nail construct were superior to the TBW/Enders nail construct for all parameters except extension. There was no statistically significant difference between the IM nail and the plate/screws groups. Torsional stiffness testing revealed that the plate/screws and the IM nail were superior to the TBW/Enders nail construct. There was no statistical difference between the IM nail and the plate/screws groups. CONCLUSIONS In a cadaveric model of three-part proximal humerus fractures stripped of soft tissue, plate/screws fixation and IM nailing provide greater torsional and bending stiffness than does fixation with TBW/Enders nail. There was no statistically significant difference in torsional or bending stiffness between IM nailing with interlocks and plate/screws fixation in this model.

Anterior interosseus nerve injury following elbow arthroscopy.

Elbow arthroscopy is becoming an increasingly invaluable tool for both evaluation of and treatment of a variety of interarticular disease processes. Case reports have documented radial and posterior interosseus injuries following anterior capsular release. To date, this is the first report of an anterior interosseus nerve injury following arthroscopic surgery of the elbow. Arthroscopic surgery offers unparalleled visualization of the multiple articulations and facets of the elbow. It has been reported as useful for removal of loose bodies, synovectomy, release of arthrofibrosis, and the treatment of osteochondritis dessicans. However, the technique does require thorough knowledge of neurovascular structures about the elbow as well as appreciation of the protective layers including the capsule, brachialis, and brachioradialis muscles. This report documents direct injury to the anterior interosseus branch of the median nerve during an elbow debridement and synovectomy in a 65-year-old patient with rheumatoid arthritis.

Use of a Distraction Plate for Distal Radial Fractures with Metaphyseal and Diaphyseal Comminution

BACKGROUND Distal radial fractures with extensive comminution involving the metaphyseal-diaphyseal junction present a major treatment dilemma. Of particular difficulty are those fractures involving the articular surface. One approach is to apply a dorsal 3.5-mm plate extra-articularly from the radius to the third metacarpal, stabilizing the diaphysis and maintaining distraction across the radiocarpal joint. METHODS Twenty-two patients treated with a distraction plate for a comminuted distal radial fracture were included in the study. With use of three limited incisions, a 3.5-mm ASIF plate was applied in distraction dorsally from the radial diaphysis, bypassing the comminuted segment, to the long-finger metacarpal, where it was fixed distally. The articular surface was anatomically reduced and was secured with Kirschner wires or screws. Eleven of the twenty-two fractures were treated with bone-grafting. The plate was removed after fracture consolidation (at an average of 124 days), and wrist motion was initiated. All patients were followed prospectively with use of radiographs, physical examination, and DASH (Disabilities of the Arm, Shoulder and Hand) scores. RESULTS All fractures united by an average of 110 days. Radiographs showed an average palmar tilt of 4.6 degrees and an average ulnar variance of neutral (0 degrees), whereas loss of radial length averaged 2 mm. Flexion and extension averaged 57 degrees and 65 degrees, respectively, and pronation and supination averaged 77 degrees and 76 degrees , respectively. The average DASH scores were 34 points at six months, 15 points at one year, and 11.5 points at the time of final follow-up (at an average of 24.8 months). According to the Gartland-Werley rating system, fourteen patients had an excellent result, six had a good result, and two had a fair result. Grip strength and the range of motion of the wrist at one year correlated inversely with the proximal extent of fracture comminution into the diaphysis. The duration of plate immobilization did not correlate with the range of motion of the wrist or with the DASH score at one year. CONCLUSIONS The use of a distraction plate combined with reduction of the articular surface and bone-grafting when needed can be an effective technique for treatment of fractures of the distal end of the radius with extensive metaphyseal and diaphyseal comminution. A functional range of motion with minimal disability can be achieved despite a prolonged period of fixation with a distraction plate across the wrist joint.

Arthroscopic resection of the common extensor origin: anatomic considerations

This study examines the intra-articular anatomy and safe zones for arthroscopic resection of the common extensor origin for the treatment of lateral epicondylitis. The extensor complex was arthroscopically debrided in 7 cadaveric elbows to determine the percentage of each tendinous origin that was resectable. Elbow stability was assessed, and safe zones of resection were determined. The extensor carpi radialis brevis and extensor digitorum communis origin was resected a mean of 100% and 90%, respectively. Elbow stability was maintained when resection did not extend posteriorly to an intra-articular line bisecting the radial head. Posterolateral rotatory instability occurred when debridement was continued posteriorly to the axis of the radial head. In conclusion, complete resection of the extensor carpi radialis brevis-extensor digitorum communis common origin is achievable via standard arthroscopic techniques. The lateral ulnar collateral ligament remains intact and elbow stability is maintained when debridement of the extensor origin does not extend posteriorly to a line bisecting the radial head.

Hinged elbow fixation for recurrent instability following fracture dislocation

The purpose of this study was to evaluate the use of an articulated external fixator of the elbow in the management of instability after fracture dislocation. We retrospectively reviewed results of eight patients treated with an articulated external fixator between 1998 and 1999. Study inclusion criteria included recurrent/chronic dislocation following fracture dislocation. Patients were divided into two groups based on the onset of instability. Group I (n=3) included patients with acute instability. The indication for use of the articulated external fixator in this subset of patients was the inability to accomplish complete osseous and ligamentous repair secondary to high degrees of comminution and/or severe soft tissue defects. Group II (n=5) patients presented at least 6 weeks after the original injury; the indication for use of the external fixator was inability to maintain joint congruity following open reduction. Application of the fixator was performed as an alternative to reconstruction of both medial and lateral ligaments. Follow-up at 1.5 years consisted of radiographs, occupational therapy ROM and DASH outcome measurement. At follow-up, Group I patients maintained an average total arc of motion of 120 degree, average flexion contracture: 25 degree, average pronation: 90 degree, and average supination: 67 degree. Group II patients had an average total arc of motion of 84 degree, average flexion contracture: 33 degree, average pronation: 68 degree, and average supination: 43 degree. Radiographic appearance of patients in both groups revealed a congruent humero-ulnar joint. DASH forms indicated patients experienced mild difficulty with activities of daily living. In conclusion, global instability of the elbow after fracture dislocation remains a difficult problem. High-energy injuries may result in an inability to maintain a congruous humero-ulnar articulation despite osteosynthesis and direct repair of the medial collateral ligament (MCL) and LUCL. When repair of the coronoid process and MCL is not feasible secondary to excessive comminution or soft tissue defect, the use of an articulated external fixator permits concentric stability and reduction of the humero-ulnar articulation. In cases of chronic instability, application of an articulated external fixator provides an alternative to complete osseous and ligamentous reconstruction. In both acute and chronic situations, the use of the articulated elbow fixator results in most patients regaining very good functional use of the elbow.

Volar Approach to Distal Radius Fractures

The volar approach to the distal radius fracture is an important exposure in the treatment of these fractures, particularly with the growing enthusiasm for fixed-angle volar plating. With reports in the literature documenting complications associated with external fixation and dorsal plating, the volar approach has become ever more popular. Moreover, advancements in locking plate technology have expanded the indications for palmar plating beyond volar shear and volarly displaced fractures to include unstable intra-articular distal radius fractures. The surgical approach remains the same as when Henry recommended the interval between the flexor carpi radialis and the radial artery. Critical elements of the surgical technique include releasing the brachioradialis, gaining exposure all the way to the sigmoid notch, and building the intra-articular reduction, beginning with the intermediate column and moving radially. The relevant anatomy, indications and contraindications, postoperative care, and a pertinent case presentation are discussed.

Electrospun cartilage-derived matrix scaffolds for cartilage tissue engineering.

Macroscale scaffolds created from cartilage-derived matrix (CDM) demonstrate chondroinductive or chondro-inductive properties, but many fabrication methods do not allow for control of nanoscale architecture. In this regard, electrospun scaffolds have shown significant promise for cartilage tissue engineering. However, nanofibrous materials generally exhibit a relatively small pore size and require techniques such as multilayering or the inclusion of sacrificial fibers to enhance cellular infiltration. The objectives of this study were (1) to compare multilayer to single-layer electrospun poly(ɛ-caprolactone) (PCL) scaffolds for cartilage tissue engineering, and (2) to determine whether incorporation of CDM into the PCL fibers would enhance chondrogenesis by human adipose-derived stem cells (hASCs). PCL and PCL-CDM scaffolds were prepared by sequential collection of 60 electrospun layers from the surface of a grounded saline bath into a single scaffold, or by continuous electrospinning onto the surface of a grounded saline bath and harvest as a single-layer scaffold. Scaffolds were seeded with hASCs and evaluated over 28 days in culture. The predominant effects on hASCs of incorporation of CDM into scaffolds were to stimulate sulfated glycosaminoglycan synthesis and COL10A1 gene expression. Compared with single-layer scaffolds, multilayer scaffolds enhanced cell infiltration and ACAN gene expression. However, compared with single-layer constructs, multilayer PCL constructs had a much lower elastic modulus, and PCL-CDM constructs had an elastic modulus approximately 1% that of PCL constructs. These data suggest that multilayer electrospun constructs enhance homogeneous cell seeding, and that the inclusion of CDM stimulates chondrogenesis-related bioactivity.

Elbow Tendinopathy and Tendon Ruptures: Epicondylitis, Biceps and Triceps Ruptures

Lateral and medial epicondylitis are common causes of elbow pain in the general population, with the lateral variety being more common than the medial by a ratio reportedly ranging from 4:1 to 7:1. Initially thought to be an inflammatory condition, epicondylitis has ultimately been shown to result from tendinous microtearing followed by an incomplete reparative response. Numerous nonoperative and operative treatment options have been employed in the treatment of epicondylitis, without the emergence of a single, consistent, universally accepted treatment protocol. Tendon ruptures about the elbow are much less frequent, but result in more significant disability and loss of function. Distal biceps tendon ruptures typically occur in middle-aged males as a result of an event that causes a sudden, eccentric contraction of the biceps. Triceps tendon ruptures are exceedingly rare but usually have a similar etiology with a forceful eccentric contraction of the triceps that causes avulsion of the tendon from the olecranon. The diagnosis of these injuries is not always readily made. Complete ruptures of the biceps or triceps tendons have traditionally been treated surgically with good results. With regard to biceps ruptures, there continues to be debate about the best surgical approach, as well as the best method of fixation of tendon to bone. This article is not meant to be an exhaustive review of the broad topics of elbow tendinopathy and tendon ruptures, but rather is a review of recently published information on the topics that will assist the clinician in diagnosis and management of these conditions.