Roger van Riet

The epidemiology of radial head fractures

INTRODUCTION Recent literature shows an increased mean age of female patients with radial head fractures compared with male patients with radial head fractures. However, data on epidemiology of radial head fractures and specifically in relation to age distribution and male-female ratios of radial head fracture are scarce. MATERIALS AND METHODS A retrospective database search was performed to identify all patients with a radial head fracture over a 3-year period. RESULTS A total of 328 radial head fractures were diagnosed in 322 patients. The incidence was 2.8 per 10,000 inhabitants per year. The male-female ratio was 2:3. The mean age was 48.0 years (range, 14-88 years; SD, 14.8). The mean age of female patients (52.8 years) was significantly higher than that of male patients (40.5 years) (P = .001). As the age increases above 50 years, the number of female patients becomes significantly higher than the number of male patients (P = .001). An associated osseous injury was present in 40 patients (12.4%). CONCLUSIONS Radial head fractures are common, and associated injuries are frequent.

Magnetic resonance imaging findings in 46 elbows with a radial head fracture

Background and purpose Radial head fractures are common, and may be associated with other injuries of clinical importance. We present the results of a standard additional MRI scan for patients with a radial head fracture. Patients and methods 44 patients (mean age 47 years) with 46 radial head fractures underwent MRI. 17 elbows had a Mason type-I fracture, 23 a Mason type-II fracture, and 6 elbows had a Mason type-III fracture. Results Associated injuries were found in 35 elbows: 28 elbows had a lateral collateral ligament lesion, 18 had capitellar injury, 1 had a coronoid fracture, and 1 elbow had medial collateral ligament injury. Interpretation The incidence of associated injuries with radial head fractures found with MRI was high. The clinical relevance should be investigated.

Surgical Release for Proximal Hamstring Syndrome

Background Pain in the buttock radiating to the popliteal fossa associated with hamstring weakness can be caused by tethering of the sciatic nerve to the proximal hamstring tendons. Contraction of the hamstring muscles produces traction on the sciatic nerve and subsequent symptoms. Hypothesis Surgical release of the proximal hamstring tendons, in particular from the sciatic nerve, will improve symptoms and function. Study Design Case series; Level of evidence, 4. Methods Forty-seven proximal hamstring surgical releases were performed in 44 patients (28 males, 16 females). The initial clinical findings and imaging were obtained from the medical notes, and additional data were obtained from a later questionnaire. The average age at the time of surgery was 29 years (range, 15–58 years). All patients were involved in high-level sports. Long-term follow-up was with a comprehensive postal questionnaire. Results Full follow-up was obtained in 43 patients (46 operations). Average follow-up was 53 months (range, 9–110). No major complications were encountered from the surgery. The average visual analog scale pain score decreased from 6.5 preoperatively to 2.0 (P < .001). Two patients had increased pain, and pain was unchanged in 4. The average subjective weakness score decreased from 6.6 to 2.8 (P < .001). Three patients reported increased weakness at follow-up, and 3 patients reported that the hamstring muscles felt equally weak. Thirty-four patients (77%) had returned to their previous sporting activities, with 30 patients still competing at or above state level, or professionally, after surgery. The average satisfaction score was 7.8. Six patients (14%) were not satisfied with the outcome of the procedure, 5 patients (11%) were somewhat satisfied, and 33 patients (75%) were very satisfied. Conclusion Proximal hamstring syndrome occurs mainly in patients participating in competitive sports. Release of the proximal hamstring tendons in this active group resulted in decreased pain and increased strength, and the majority of patients were satisfied with the procedure.

Pattern of osteophyte distribution in primary osteoarthritis of the elbow

The goal of this study was to look at the pattern of osteophyte distribution on a 3-dimensional computed tomography scan of patients with symptomatic osteoarthritis in the elbow. We recruited 22 consecutive patients with symptomatic osteoarthritis of the elbow for the study. Three-dimensional reconstructed anterior, posterior, medial, and lateral views of the elbow were reviewed. Ulnohumeral osteophytes were found in 21 patients (95%), and radiohumeral osteophytes were found in 13 (59%). Cadaveric and biomechanical studies suggest that the radiohumeral joint appears to be more prone to wear and stress than the ulnohumeral joint. Our study showed that the percentage of patients with ulnohumeral joint osteophytes (95%) was higher than that of radiohumeral joint (59%). Therefore, this study challenges the conventional belief that osteoarthritis starts from the radiohumeral joint and progress toward the ulnohumeral joint.

Safe zone for arthroscopic resection of the superomedial scapular border in the treatment of snapping scapula syndrome

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 Bells portal and the ART.

Magnetic resonance imaging in radial head fractures: most associated injuries are not clinically relevant

BACKGROUND Recent studies report that magnetic resonance imaging (MRI) shows a high incidence of associated injuries in patients with a radial head fracture. This retrospective study describes the clinical relevance of these injuries. MATERIALS AND METHODS Forty patients with 42 radial head fractures underwent a MRI scan after a mean of 7.0 days after trauma and were reviewed after a mean of 13.3 months. RESULTS MRI showed 24 of 42 elbows had a lateral collateral ligament (LCL) lesion, 1 had a medial collateral ligament (MCL) and LCL lesion, 16 had an injury of the capitellum, 1 had a coronoid fracture, and 2 had loose osteochondral fragments. Clinical evaluation after a mean of 13.3 months showed that 3 elbows had clinical MCL or LCL laxity, of which 2 elbows had no ligamentous injuries diagnosed with MRI. One elbow with a loose osteochondral fragment showed infrequent elbow locking. The mean Mayo Elbow Performance Scale was 97.5 (range, 80-100) after a mean of 13.3 months after trauma, with no significant difference between patients with and without associated injuries (P = .8). CONCLUSION Most injuries found with MRI in patients with radial head fractures are not symptomatic or of clinical importance in short-term follow-up.

Radiocapitellar joint contacts after bipolar radial head arthroplasty.

PURPOSE The purpose of this study was to determine radiocapitellar contacts before and after radial head replacement, using the bipolar design of Judet. METHODS Joint contacts were measured by moulding the joint surfaces of 6 fresh-frozen cadaveric specimens, in various positions of elbow flexion and forearm rotation. RESULTS Expressed as function of the radial cup, contact areas averaged 44% in the normal elbow, decreasing with flexion and increasing with supination (P < .05). After prosthetic implantation, contact areas averaged 33% and remained quite similar, irrespective of elbow position. Subluxation of the prosthetic head over the lateral margin of the trochlea was seen systematically with supination. CONCLUSIONS Because of intraprosthetic mobility, contact areas were not dependant on elbow position. This adaptability, however, also led to abnormal positioning of the prosthetic radial head with supination, subluxing over the trochlea lateral margin.

Comparison of Two Percutaneous Volar Approaches for Screw Fixation of Scaphoid Waist Fractures Radiographic and Biomechanical Study of an Osteotomy-Simulated Model

BACKGROUND When a surgeon uses a percutaneous volar approach to treat scaphoid waist fractures, central screw placement is complicated by the shape of the scaphoid and by obstruction by the trapezium. In this study, we used radiographs and biomechanical tests to compare the standard volar percutaneous approach with the transtrapezial approach, with regard to central screw placement at the distal pole of the scaphoid. METHODS Fourteen matched pairs of cadaveric wrists were randomly assigned to two treatment groups. Under fluoroscopic control, a guidewire was drilled into the scaphoid, either through a transtrapezial approach or through a standard volar approach that avoided the trapezium. Guidewire position was measured in the coronal and sagittal planes. A transverse osteotomy was performed along the scaphoid waist, and this was followed by the insertion of the longest possible cannulated headless bone screw. Each specimen was placed into a fixture with a pneumatically driven plunger resting on the surface of the distal pole. Load was applied by using a load-controlled test protocol in a hydraulic testing machine. RESULTS All guidewires were inside the central one-third of the proximal pole. The guidewire positions at the distal pole differed significantly between the transtrapezial and standard volar approach groups (p < 0.001). The load to 2 mm of displacement and the load to failure averaged, respectively, 324.4 N (standard error of the mean [SEM] = 73.5 N) and 386.4 N (SEM = 65.6 N) for the transtrapezial approach group compared with 125.7 N (SEM = 22.6 N) (p = 0.002) and 191.4 N (SEM = 36.30 N) (p = 0.005) for the standard volar approach group. CONCLUSIONS The data suggest that, in a cadaveric osteotomy-simulated scaphoid waist fracture model, the transtrapezial approach reliably achieves central positioning of a screw in the proximal and distal poles. This position offers a biomechanical advantage compared with central placement in only the proximal pole.

The Pritchard ERS total elbow prosthesis: Lessons to be learned from failure

BACKGROUND 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. MATERIALS 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. RESULTS 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. CONCLUSION 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.

Clinical evaluation of acromioclavicular joint pathology: Sensitivity of a new test

BACKGROUND 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. MATERIALS AND METHODS 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. RESULTS The BvR test showed a sensitivity of 98%. All 4 other tests were less sensitive. CONCLUSION 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.