Latissimus-dorsi-Transfer bei nichtrekonstruierbarem Rotatorenmanschettendefekt

Objective

Improvement of glenohumeral dynamic centering and active external rotation by a transfer of the latissimus dorsi tendon to the greater tuberosity or the lateral proximal humerus.

Indications

Irreparable posterosuperior rotator cuff tears.

Contraindications

Cuff tear arthropathy, subscapularis tendon tear, deltoid insufficiency, palsy of the axillary nerve.

Surgical technique

Diagnostic arthroscopy in lateral decubitus position. Placement of suture through the biceps tendon and supragleonidal tenotomy. Posterior approach. Preparation and mobilization of a pedicled latissimus dorsi flap. Second anterior incision with delta split. Debridement of the torn rotator cuff. Insertion of suture anchors in the greater tuberosity. Passing of the muscle flap inferior to the posterior deltoid and fixation with suture anchors to the greater tuberosity (where applicable suturing with remaining rotator cuff tissue).

Postoperative management

Immobilization in a thorax abduction cast for 6?weeks. Passive exercises out of the cast (IR/ER 0-0-free and ABD/ADD free-45-0°). Active assistive exercises from week?4 postoperatively. Stepwise increase of passive range of motion from week?7. Unlimited active range of motion from week?10.

Results

After an average follow-up of 57.6 (SD?27.5) months 17?patients were examined clinically. The average age at time of surgery was 55.6 (SD?7.7) years. At follow-up the patients showed an average Constant score of 64.4?points (SD?17.4). The active external rotation in 0° abduction was 16° (SD?17). The 4?patients (23%) with a sonographically-detected retear of the latissimus flap presented worse clinical results.     

High complication rate following distal biceps refixation with cortical button

Purpose

There are several methods for the refixation of the distal biceps tendon which show a variable complication rate. The aim of the present study was to evaluate the clinical outcome and complication rate after distal biceps repair in cortical button technique.

Methods

Clinical results, complications, strength of elbow flexion and supination and radiological evidence of heterotopic ossification in patients reporting persistent pain were evaluated in 27 male patients after an average of 36.1 month following distal biceps tendon repair in cortical button technique.

Results

The mean Mayo elbow performance score was 95.9 (SD 11.9), the mean disabilities of the arm, shoulder and hand score was 1.9 (SD 4.9) and the mean American shoulder and elbow surgeons (ASES) score was 94.6 (SD 11.6). The mean flexion and supination strength of the involved side relative to the uninvolved side was 91.7 % (SD 12.6) and 87.8 % (SD 15.9). Nine patients had 14 different complications including four transient lesions of the posterior interosseous nerve, two persistent lesions of the superficial branch of the radial nerve, one symptomatic massive heterotopic ossification and one disengaged cortical button. Three patients had six revisions. Patients with complications had a significantly lower relative supination strength, Mayo elbow performance score, ASES score, pain on VAS (p < 0.05 each) and satisfaction (p = 0.005).

Conclusions

As described for other techniques there is a high complication rate of distal biceps tendon repair in cortical button technique which resulted in inferior functional results and satisfaction. Surgeons treating patients with distal biceps tendon rupture should know the specific complications and know how to avoid them.

Level of evidence

Case series with no comparison group, Level IV.     

Suture anchor tenodesis in repair of distal Achilles tendon injuries

Background

Distal Achilles tendon avulsions are in the form of either bony and nonbony avulsion of Achilles tendon from its calcaneal insertion.

Methods

Four patients with distal Achilles tendon avulsions or ruptures which were treated with tendon to bone repair using suture anchors are presented here. Operated leg was immobilized in above-knee cast for 4 weeks while the patient walked non-weight-bearing. Then, cast was changed to below knee, and full weight-bearing was allowed. Patients underwent gait analysis minimum at first postoperative year.

Results

Mean American Orthopedics Foot Ankle Society ankle/hindfoot score of patients at last visit was 88.75 (range 85–100), and Achilles tendon total rupture score was 77.75 (range 58–87). Mean passive dorsiflexion of injured ankles (14° ± 5°) was lower than uninjured ankles (23° ± 9°). All the kinematic parameters of gait analysis were comparable to the uninjured side. Maximum plantar flexion power of injured ankle was 1.40 W/kg, and this was significantly lower than the contralateral side value 2.38 W/kg; (P = 0.0143).

Conclusions

There were no visually altered gait or problems in daily life. Suture anchor tenodesis technique of distal Achilles tendon avulsions was successful in achieving durable osteotendinous repairs.     

Die Behandlung von Radiusköpfchenfrakturen Typ Mason II durch perkutane Drahtreposition

Background

The therapeutic algorithm for the treatment of Mason type II radial head fractures is still controversially discussed. This study describes the technique of percutaneous fracture reduction without additional internal fixation of the radial head as an alternative to open reduction and presents the results of the method.

Material and methods

The data from 26 out of 30 patients with a Mason type II radial head fracture who had been consecutively treated with percutaneous fracture reduction were evaluated retrospectively. The analysis comprised the disabilities of shoulder and hand (DASH) score, the Mayo elbow performance score (MEPS) and data from the radiological examinations.

Results

The average follow-up time was 21 months (range 6-47 months). In 22 cases (85 %) an anatomical reduction could be achieved, 2 cases (8 %) showed a complete redislocation of the fragment and 2 cases (8 %) a partial redislocation. The average DASH score was 5.6 points (range 0–56) and the average MEPS was 93.8 (range 60–100). Only 4 patients (15 %) reported persisting functional impairment with a DASH score >10.

Conclusions

The method of percutaneous reduction of radial head fractures without additional internal fixation in Mason type II fractures has been demonstrated to be a good alternative to open reduction.     

Lacertus fibrosus augmentation for distal biceps brachii rupture repair: surgical technique

Background

Repair of distal biceps tendon ruptures has become widely accepted. Unfortunately, care of retracted-degenerated injuries remains a challenge for orthopedic surgeons. Complication rates appear to increase when surgery is performed in chronic cases compared to those operated acutely. Multiple techniques for chronic reconstruction with the use of grafts have been described. Recently Morrey, from the Mayo Clinic, proposed a direct anatomic repair of retracted distal biceps tendon ruptures in extreme flexion (60°–90°) to avoid grafting.

Materials and methods

The authors propose and describe a new surgical technique using the lacertus fibrosus (LF) as augmentation-elongation for retracted-degenerated distal biceps tendon tears. We present four cases with chronic ruptures with 2-year follow-up. The mean age was 45 years old (33–51), the time of surgery was 13 weeks (4–24) after the trauma, dominant arm was involved in two cases.

Results

The mean MEPS was 95/100 at 2-year follow-up. With this technique we increase the length of the tendon up to 2.5 cm. The major complication in our study was transient sensitive radial nerve paresthesia. We did not have any hardware mobilization or muscular herniation.

Conclusion

With this study we want to present our experience in the treatment of retracted distal biceps tendon tear with lacertus fibrosus augmentation. Our surgical technique is an effective and cheap option for chronic-retracted distal biceps tendon lesions. Recovery time is quicker, and integration is faster due to the use of an autologous vascularized graft. Preoperative ultrasound scan is mandatory in order to evaluate LF integrity, thickness and size.

     

Reattachment of an avulsed distal biceps tendon in athletes

Refixation of the ruptured distal biceps tendon to the radial tuberosity in a two-incision technique restores power and function. Between 1995 and 1999 a refixation of the ruptured distal biceps brachii tendon on the tuberositas radii was performed in four athletes (three gymnasts and one American football player) using a two-incision-technique according to Boyd and Anderson (J Bone Joint Surg 43A:1041–1043, 1961) modified by Bourne and Morrey (Clin Orthop 271:143–148, 1991). The average age at surgery was 36 (23–48) years. The patients were followed up with a clinical examination and a questionnaire at an average of 82 (70–108) months postoperative. Flexion, extension and pronation was normal in all patients, although two patients had a reduction of forearm supination of 10° on the operated side. On a visual analogue scale, a subjective 5–10% reduction of forearm-flexion strength was reported by three patients. No decrease of flexion- or supination-strength was observed upon clinical examination. The subjective rating of the overall clinical outcome was “excellent” in three and “good” in one patient. Three patients rated “excellent” and one patient “good” according to the criteria of Rantanen and Orava (Am J Sports Med 27:128–132, 1999). We conclude that power and function can be restored through a refixation of the ruptured distal biceps tendon to the radial tuberosity in a two-incision technique. We recommend the method in athletes.     

Anatomical evaluation of a cortical button for distal biceps tendon repairs

Background

The posterior interosseous nerve (PIN) is at risk for injury during one-incision distal biceps tendon repair using a cortical button. The purpose of this study was to evaluate the proximity of a cortical button to the PIN during one-incision repairs of the distal biceps tendon using human cadaveric models.

Methods

In ten cadaveric elbows the biceps tendon was identified, traced to its insertion, and transected. With the forearm supinated, a guide pin was drilled through the radial tuberosity at a 0°, perpendicular to the table. A dorsal incision was used to identify the PIN. The tendon was repaired with a cortical button, ensuring the device lay in line with the radial shaft. The distance from the device to the PIN was measured using digital calipers. This process was repeated with the guide pin aimed at 20° proximal toward the radiocapitellar joint (RCJ) and 30° distal toward the wrist. The data were compared using a Student’s paired t-test.

Results

The average distance from the device to the PIN with the straight posterior insertion was 8.94 mm, 11.86 mm with 20° proximal, and 0.55 mm with 30° distal angles. The distance between the button and the PIN was significantly greater when aiming the device 20° toward the RCJ compared to the straight insertion technique (p?=?0.0061).

Conclusions

The distance between the PIN and cortical button can be significantly increased by aiming the guide pin between 0° and 20° proximal toward the RCJ and placing the device in line with the radial shaft.     

Primärer endoprothetischer Ellbogengelenkersatz bei komplexen intraartikulären distalen Humerusfrakturen

Introduction

Open reduction and internal fixation of multifragmentary intra-articular fractures of the distal humerus often do not provide satisfactory results in elderly patients with osteoporosis.

Method

From December 2001 to January 2008 a total elbow arthroplasty (Coonrad-Morrey, Zimmer, USA) was performed on 12 patients (average age 81±9  ears) who presented with a type C distal humeral fracture. The mean time of follow-up with clinical and radiological assessment was 28±17 months.

Results

The Mayo score showed a good functional result with an average of 81±9 out of 100. DASH and SECEC scores showed a fair result with respect to elbow function (43±8 and 68±7 points, respectively). The average range of motion of all patients was 120-33-0°. Heterotopic ossifications were found by X-ray examination in 4 cases and asymptomatic radiolucent lines in 4 cases.

Conclusion

Primary total elbow arthroplasty for complex intra-articular distal humerus fractures in elderly patients has good functional results and is an alternative to osteosynthesis.     

Wiederherstellung der Daumenendgelenkbeugung durch Transposition der oberflächlichen Beugesehne des Ringfingers

Objective

Restoration of active thumb flexion at the distal joint.

Indications

Loss of active flexion of the interphalangeal (IP) joint of the thumb if there is a transection of the flexor pollicis longus (FPL) tendon at the tendon channel of the thumb or thenar and direct suture is not possible but the tendon channel is intact, as alternative procedure to a free tendon graft if the transection is proximal to the tendon channel and the muscle of the FPL is contracted/injured or the FPL tendon is unharmed but the FPL muscle is partially or complete paralyzed.

Contraindications

Insufficiency of the FPL tendon channel, impairment of the superficial or deep flexor tendon of the ring finger, limited passive motion of the proximal and distal thumb joints, acute local general infection and non-compliance or incapacity of the patient.

Surgical technique

The surgical technique depends on the necessity of transosseous refixation of the FDS IV at the base of the distal phalanx of the thumb or the possibility of woven sutures through the FPL proximal to the tendon channel. If the tendon channel is intact the distal part of the FPL tendon is shortened to 1 cm, the FDS IV tendon is cut distal to the chiasma of Camper, pulled through the carpal tunnel and moved into the channel of the FPL tendon and fixed transosseously through the base of the distal phalanx of the thumb. If the transection of the FPL tendon is located proximal to the tendon channel and muscle of the FPL is injured, FDS IV tendon will be woven using the Pulvertaft technique through the FPL tendon at the distal forearm.

Postoperative management

Postoperative 6 weeks motion of thumb flexion without resistance in relieved position of the thumb through a thermoplast splint and 6 weeks of functional use of the hand with increasing weight bearing.

Results

In this study 10 patients with FDS IV transposition to reconstruct an isolated rupture of the FPL tendon could be followed for an average of 4.1 years postoperatively. The active range of motion of the IP joint of the thumb averaged 65° (10–100°), 8/10 patients achieved an equal active and passive range of motion of the IP joint of the thumb, in 2 patients some flexion insufficiency remained, 9 patients could reach the fingertip of the small finger with the thumb and 1 patient lacked 3 mm. Contracture of the proximal thumb joint developed in two patients. After removal of the FDS IV tendon two patients developed contracture of the PIP joint of the ring finger. The grip force was reduced to 81?%, lateral grip to 83?% and pinch grip to 77?%. The DASH score averaged 18 (0–31) and 8/10 patients would choose to undergo this surgery again.     

Functional outcomes and complications of open elbow dislocations

Background

The current study investigated the clinical outcome of open elbow dislocations, focusing on the influence of associated soft tissue and bone injury.

Patients and methods

From October 2008 to August 2015, 230 patients with elbow dislocations were treated at the study center. Our retrospective study comprised 21 cases of open elbow dislocations. The mean age of patients was 49 years (20–83 years); there were six (29%) female and 15 (71%) male patients. The range of motion (ROM) of the injured and uninjured elbow was measured, and the Mayo Elbow Performance Score (MEPS), Mayo Wrist Score (MWS), and Disability of Arm, Shoulder and Hand (DASH) score were assessed. Complications and revision surgeries were recorded. The influence of the severity of soft tissue injury (I°/II° open vs. III° open) and type of dislocation (simple vs. complex) was evaluated.

Results

After a 57-month follow-up (range, 24–98 months), the mean DASH score was 20?±?15, the MEPS was 82?±?11, and the MWS was 74?±?22. The ROM of the injured elbow was significantly decreased compared with the uninjured one (arc of ulnohumeral motion: 104° vs. 137°; p?=?0.001). Patients with I°/II° open elbow dislocations had a better clinical outcome according to the MEPS (86?±?11 vs. 76?±?9; p?=?0.045) and a comparable outcome according to the DASH score (19?±?18 vs. 21?±?9; p?=?0.238). In all, 11 patients (52%) had postoperative complications and 11 patients underwent at least one revision surgery. Complex elbow dislocations had significantly more complications and revision surgeries than simple dislocations (77% vs. 13%; p?=?0.008).

Conclusion

Favorable clinical outcomes can be achieved after treatment of open elbow dislocations. These injuries are prone to neurovascular damage and complex dislocations are linked to high rates of complications and revision surgeries.

     

The utility of botulinum toxin A in the repair of distal biceps tendon ruptures

Purpose

The purpose of our study is to report the outcomes and complications in patients who underwent distal biceps tendon repair with the use of Botulinum toxin A (BoNT-A) as an adjunct to surgery.

Methods

A retrospective review of 14 patients who underwent 15 distal biceps tendon repairs was performed. All repaired tendons had their correlating muscle bellies injected intraoperatively with a mixture of 100U of BoNT-A and 10 ml of normal saline. Each patient was evaluated for surgical and post-operative complications and followed with Disabilities of the Arm, Shoulder and Hand (DASH) Disability Scores.

Results

The cohort was exclusively male, 14/14 (100%). The mean age at procedure was 52.1 years (range: 29–65 years). Types of injuries repaired included: 12 acute biceps tendon ruptures, one chronic partial (> 50% of tendon) biceps tear, and two chronic biceps ruptures. Average final follow-up was 32.9 months (SD: 19.6; range: 7.07–61.72). Average time to repair of chronic injury was 5.75 months (range: 2–12 months). There were no intraoperative complications, and all patients were discharged home on the day of surgery. Average DASH score at latest follow-up was 4.9 (range: 0.0–12.5). All patients had return of function of paralyzed muscle prior to final follow-up. One patient required an incision and drainage for a deep infection 1 week post-operatively, without any further complications. Another patient required operative removal of heterotopic ossification located around the tendon fixation site, which was the result of a superficial infection treated with antibiotics 2 weeks post-operatively. This patient later healed with improvement in supination/pronation range-of-motion and no further complications.

Conclusions

Injection of BoNT-A is safe and effective to protect distal biceps tendon repair during the early phases of bone-tendon healing.

Clinical relevance

BoNT-A may is safe and effective to protect distal biceps tendon repair. The utility of BoNT-A as an adjunct to surgical repair may be applicable to acute or chronic tears as well as repairs in the non-compliant patient without decreases in functional scores after return of function of the biceps muscle.

Level of evidence

Level 4.

     

Neglected patellar tendon ruptures—a simple modified reconstruction using hamstrings tendon graft

Purpose

We hereby describe a cost effective and simple anatomical reconstruction without requirement for allograft or implants for neglected chronic patellar tendon injuries. This has been validated in seven patients with an average follow up of greater than three years resulting in good outcome.

Methods

Seven patients (six males, one female) of mean age 41.8 years (range up to 57 years) presented with neglected patellar tendon injury. The time since injury ranged between three months and three years (average nine months). Active extension was not possible in three patients, and four patients had an extensor lag between 40° and 80° (average 62.5°). Four patients had quadriceps strength of grade 2/5 and three patients had grade 3/5. All patients had severe functional limitation with an average IKDC score of 46.8 (range 39–57). They all underwent patellar tendon reconstruction using hamstrings tendon autograft.

Results

Postoperatively with a mean follow up of 40.7 months (range 31–52 months), all patients had a stable knee with mean flexion of 125° (range 120°–130°) and without any extension lag. Quadriceps power was regained in five cases to 5/5 and in two cases to 4/5. With an improvement in the IKDC score to 86.8 (range 80–92), excellent outcome was noted in five patients and good outcome in two patients. The average postoperative Lysholm score was 92.4 (range 89–95) and the average Kujala score was 94.5 (range 92–97).

Conclusion

Patellar tendon reconstruction using hamstrings autograft for neglected patellar tendon injuries provides good stability and excellent outcome. Compared to previous techniques described, our technique is unique in being cost effective and a simple anatomical reconstruction without the requirement for allograft or implants.     

Lesser Tuberosity Avulsions in Adolescents

Background

Subscapularis tendon avulsions of the lesser tuberosity are relatively rare and often missed acutely and their characteristic appearance is frequently not recognized or is misinterpreted for an osteochondroma or a neoplastic process.

Questions/Purposes

This report reviews our experience with six adolescents who had subscapularis tendon avulsions of the lesser tuberosity.

Methods

Six male adolescents (12–15 years) presented with shoulder pain following history of trauma during amateur sport. Clinical notes including range of motion, strength tests, and pain assessment were reviewed along with imaging studies pre- and post treatment. Treatment consisted of either surgical or conservative measures.

Results

Two of the six patients had a large avulsion that simulated an exostosis of the proximal humerus that was misdiagnosed as an osteochondroma at two different outside institutions. All six cases were diagnosed with subscapularis tendon avulsion of the lesser tuberosity following clinical and imaging evaluation at our institution. Five of the patients underwent surgical repair and fixation of the tendon and the lesser tuberosity with suture anchors. One patient was treated conservatively. All patients had a good outcome with recovery of full shoulder strength and motion upon follow-up.

Conclusion

Clinicians should have a high index of suspicion of lesser tuberosity avulsions in adolescents who present with loss of internal rotation and anterior shoulder pain following traumatic injuries. In addition, an osseous fragment or exostosis along the inferomedial humeral head should suggest a subscapularis tendon avulsion and also should not be confused with an osteochondroma or a neoplastic process.     

A comparative clinical and functional assessment of cortical button versus suture anchor in distal biceps brachii tendon repair

Purpose

The studies comparing the fixation methods being used for the ruptured distal biceps brachii tendon reinsertion show similar outcomes of cortical button and suture anchors usage, however, longer follow-up studies remain necessary. The goal of this study was to compare the clinical and functional three-year outcomes of the cortical button in contrast to the suture anchor fixation.

Distal biceps tendon reconstruction in chronic ruptures

The purpose of this retrospective study was to evaluate the results of anatomic reattachment with reconstruction of the distal biceps tendon using an Achilles tendon allograft in 7 male patients with chronic distal biceps ruptures. Through a 1-incision anterior approach, the tendon allograft was attached to the bicipital tuberosity by using suture anchors and then secured to the biceps remnant. Follow-up averaged 29 months. Mean elbow flexion was 145 degrees, an extension deficit of 20 degrees was observed in 1 patient, and mean pronosupination was 170 degrees. All patients had 5/5 strength in flexion and supination on manual testing, and all returned to their employment. Mean supination strength was 87% of the contralateral healthy extremity. Six achieved an excellent and 1 a good rating in the Mayo elbow performance score. No complications were encountered. This technique is an excellent alternative to nonanatomic reattachment to the brachialis muscle for patients with high functional demands in pronosupination.     

Rerouting des Musculus brachioradialis zur Verbesserung der Unterarmsupination oder -pronation

Objective

Improvement of active forearm supination or pronation. Reduction of paralytic pronation or supination posture.

Indications

Disability or impairment of active supination or pronation due to cerebral palsy, obstetric palsy or traumatic brachial plexus palsy, quadriplegia or paralysis from other causes.

Contraindications

Inadequate passive range of motion of forearm supination or pronation. Insufficient power of brachioradialis muscle < M4. Insufficient rehabilitation after conservative treatment or neurosurgical intervention with possible improvement of supination or pronation. Lack of patient’s cooperation and compliance.

Surgical technique

Exposure and mobilisation of brachioradialis muscle. Division of brachioradialis tendon distally with Z-plasty. Passing distal tendon through the interosseus space in dorsal to palmar direction for restoration of supination respectively in palmar to dorsal direction for restoration of pronation. Suturing both tendon ends.

Postoperative management

Management includes an above elbow cast with the elbow in 70° flexion for 4 weeks. Then active physiotherapy to learn new brachioradialis muscle function for supination or pronation over 1–1.5 years. If needed dynamic orthesis.

Results

Özkan et al. performed brachioradialis rerouting to restore supination in 5 children between 4 and 14 years with pronation deformity and to restore pronation in 4 children aged 5–9 years with supination deformity. Mean active gain for supination was 81° (40–140°). Active pronation improved from 28 to 49° (30–75°; Özkan et al., J Hand Surg Br 29:263–268, 2004; Özkan et al., J Hand Surg Am 29:22–27, 2004). Between April 2006 and January 2011 we used this technique in 4 patients aged 7–26 years (mean 14 years). Three patients could be followed up. One patient had preoperative a fixed pronation deformity of the forearm in 80° pronation. In this case active range of motion could be improved to 80/30/0° pronation/supination. One patient improved from preoperative 0/0/90° pronation/supination to 30/0/90° postoperatively. In one case no functional improvement of forearm rotation could be achieved in long-term follow-up. No functional loss in forearm rotation to the opposite direction or of the elbow function was observed. Mean follow-up time was 51 months (21–77 months).     

Arthroskopisch assistierte Stabilisierung bei akuter und chronischer Akromioklavikulargelenksprengung

Objective

The surgical procedure aims at anatomic reduction and stabilization of the acromioclavicular joint in vertical and horizontal planes for acute separations using a trans-clavicular and trans-coracoidal suture tape fixation with additional acromioclavicular joint augmentation with a PDS cord cerclage. For chronic instability adding a tendon graft is essential for sustainable stability.

Indications

Acute und chronic acromioclavicular joint separations type Rockwood III–VI. Recurrent AC-joint instability with intact coracoid process (with tendon graft).

Contraindications

Acromioclavicular joint separations type Rockwood I–II. Asymptomatic chronic AC-separations type Rockwood III–IV. Fracture close to base of coracoid process General contraindications for (elective) surgery.

Surgical technique

Vertical reconstruction of the coraco-clavicular ligaments using a drill-guide for trans-clavicular and trans-coracoidal tunnel placement for high-strength suture tapes over titanium buttons. Additional stabilization of the AC-joint with a transosseus figure of 8 PDS suture cord cerclage.

Postoperative management

Postoperatively the arm is put in a regular sling for 6 weeks. Free active range of motion of wrist and elbow. Shoulder range of motion is limited to 30° of flexion and abduction and 80° internal and 0° external rotation for 2 weeks. Extended to active-assisted 45° flexion and abduction in weeks 3 and 4 and advanced to 60° flexion/abduction and free internal/external rotation in weeks 5 and 6. Range of motion is unlimited from week 7. Full daily life activities after 3 months, high-impact sports after 5–6 months postoperatively.

Results

The presented surgical technique reliably stabilizes the acromioclavicular joint. It’s biomechanical properties with only the single-tunnel coracoclavicular suture tapes is on the level of the native vertical stability, which can be additionally improved for better horizontal stability with the cerclage over the AC-joint.     

Patient-oriented functional outcome after repair of distal biceps tendon ruptures using a single-incision technique

Using a patient-oriented outcome questionnaire, in addition to standard outcome measures, we sought to determine the outcome of patients who had repair of a complete rupture of the distal biceps tendon via a single anterior incision technique with suture anchors. We identified 62 patients who were treated operatively by a single surgeon over an 8-year period for a diagnosis of complete rupture of the distal biceps tendon. Of the patients, 9 could not be located for final follow-up, and 53 of 62 (85%) participated in the study. All patients were men, and their mean age was 42 years. All repairs were performed via a single anterior incision by use of 2 suture anchors in the bicipital tuberosity on an outpatient basis. There were 4 complications (4/53 [7.5%]): 1 wound infection, 2 transient paresthesias in the lateral cutaneous nerve distribution, and 1 posterior interosseous nerve palsy that resolved in 6 weeks (no reoperations). There were no reruptures, and no patient lost more than 5 degrees of elbow flexion- extension or forearm rotation. All patients completed the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire. The mean DASH score was 8.2 +/- 11.6 (95% CI, 5.2 to 11.9), which was similar to the mean DASH score in population controls of 6.2 (DASH User Manual). The strengths of our study include the consistent surgical technique by a single surgeon, the large number of patients, and the use of a patient-oriented outcome measure. Distal biceps tendon rupture repair via a single-incision technique with suture anchors was effective in restoring injured arms to normal, as measured by limb-specific patient-oriented measures, with minimal morbidity and a low complication rate.     

Operative Behandlung der Krallenhand mittels Lassoplastik

Objectives

The aim is correction of claw deformity of the fingers by intrinsic paralysis.

Indications

Indications are claw deformity of fingers caused by palsy or functional loss of the interosseus or lumbrical muscles as far as the function of the superficial and deep flexors of the finger is intact.

Contraindications

Contraindications are loss or paralysis of finger flexors supplied by the median nerve, fixed extension or flexion contracture of the finger joints, osteoarthritis and other malfunctions of the finger joints, no active flexion and extension of the interphalangeal joints due to compromised tendon gliding. Relative: Upper ulnar nerve palsy with functional loss of the deep flexor of the small and ring finger and possibly of the middle finger.

Surgical technique

The operation technique involves detachment of the flexor digitorum superficialis IV tendon (FDS IV) distal to Camper’s chiasm, division of the tendon into separate strips, interweaving of each tendon strip into the proximal part of the A2 pulley of the affected fingers. In cases of claw deformity of all fingers it may be advantageous to apply the superficial flexor tendon of the long finger in addition to the FDS IV tendon as otherwise the FDS IV tendon has to be divided into four strips resulting in relatively thin tendon strips. If the FDS III and IV tendons are applied, the two strips of the FDS IV tendon are used for lassoplasty of the small and ring fingers and the FDS III tendon for lassoplasty of the middle and index fingers.

Postoperative management

Postoperative management includes immobilization of the operated fingers by a dorsoulnar forearm plaster cast including the metacarpophalangeal joints which are flexed to 70°. After 2 weeks replacement of the cast by a thermoplastic splint for another 4 weeks. During the whole period exercises for the finger and thumb should be carried out.

Results

From April 2003 to June 2012 a total of 17 patients, 8 female and 9 male were surgically treated for claw deformity. The dominant hand was affected in seven patients. The average age was 46?±?15 (22–80) years, the average interval from onset of ulnar palsy to lassoplasty was 61?±?91 (3–288) months. The final follow-up was performed after an average of 42?±?32 (2–112) months. Claw deformity was resolved in 14 out of the 17 patients. The grip strength was on average 58?±?28?% (11–96 %) of the unaffected hand, the mean disabilities of the arm, shoulder and hand (DASH) score was 32?±?18 (5–68) points and the degree of patient satisfaction 7?±?2 (0–10). According to own results and those in the literature lassoplasty can be recommended for the treatment of claw deformity.