Acetabular cup size trends in total hip arthroplasty

BACKGROUND Total hip arthroplasty(THA)is a common procedure for end stage osteoarthritis.The learning curve for THA is complex and challenging.One of the most difficult skills to master is acetabular reaming.We wish to identify if experience in arthroplasty leads to preservation of more bone stock.AIM To investigate if increasing surgeon experience will predict an ever decreasing acetabular cup size.METHODS A retrospective case series of four attending orthopaedic surgeons was completed.All uncemented elective total hip arthroplasties since appointment were selected for inclusion.The size of acetabular cup used was noted and logistic regression was used to identify if a trend to smaller cups existed.RESULTS A total of 1614 subjects were included with a mean age of 64 years.Overall cups were on average 0.18mm smaller per year(95%confidence interval-0.25 to-0.11,P<0.001).Individual surgeon trends showed cup sizes to decrease 0.27 mm/year for surgeon A,0.02 mm/year for surgeon B,0.15 mm/year for surgeon C and 0.29 mm/year for surgeon D.Three of the four surgeons had a more pronounced trend to smaller cups for male subjects than their female counterparts.CONCLUSION We found increasing surgeon experience to be associated with an ever-decreasing acetabular cup size.Smaller acetabular cup size may act as a surrogate marker of surgical proficiency by virtue of decreased acetabular reaming.

Discoid meniscus:Treatment considerations and updates

A discoid meniscus is a morphological abnormality wherein the meniscus loses its normal‘C’shape.Although most patients are asymptomatic,patients might still present with symptoms such as locking,pain,swelling,or giving way.Magnetic resonance imaging is usually needed for confirmation of diagnosis.Based on a constellation of factors,including clinical and radiological,different approaches are chosen for the management of discoid meniscus.The purpose of this review is to outline the treatment of discoid meniscus,starting from conservative approach,to the different surgical options for this condition.The PubMed and Google Scholar databases were used for this review.Studies discussing the treatment of discoid meniscus from 2018 to 2023 were searched.Initially there were 369 studies retrieved,and after removal of studies using the exclusion criteria,26 studies were included in this review.Factors such as stability,presence of tear,and morphology can help with surgical planning.Many approaches have been used to treat discoid meniscus,where the choice is tailored for each patient individually.Postoperatively,factors that may positively impact patient outcomes include male sex,body mass index<18.5,age at symptom onset<25 years,and duration of symptoms<24 months.The conventional approach is partial meniscectomy with or without repair;however,recently,there has been an increased emphasis on discoid-preserving techniques such as meniscoplasty,meniscopexy,and meniscal allograft transplantation.

Effectiveness of platelet-rich plasma in the treatment of Achilles tendon disease

BACKGROUND The effectiveness of Platelet-Rich Plasma(PRP)in the treatment of patients with Achilles tendon rupture(ATR)and Achilles tendinopathy(AT)has been controversial.AIM To assess PRP injections’effectiveness in treating ATR and AT.METHODS A comprehensive review of relevant literature was conducted utilizing multiple databases such as Cochrane Library,PubMed,Web of Science,Chinese Science and Technology Journal,EMBASE,and China Biomedical CD-ROM.The present investigation integrated randomized controlled trials that assessed the effectiveness of platelet-rich plasma injections in managing individuals with Achilles tendon rupture and tendinopathy.The eligibility criteria for the trials encompassed publications that were published within the timeframe of January 1,1966 to December 2022.The statistical analysis was performed utilizing the Review Manager 5.4.1,the visual analogue scale(VAS),Victorian Institute Ankle Function Scale(VISA-A),and Achilles Tendon Thickness were used to assess outcomes.RESULTS This meta-analysis included 13 randomized controlled trials,8 of which were randomized controlled trials of PRP for AT and 5 of which were randomized controlled trials of PRP for ATR.PRP for AT at 6 wk[weighted mean difference(WMD)=1.92,95%CI:-0.54 to 4.38,I2=34%],at 3 mo[WMD=0.20,95%CI:-2.65 to 3.05,I2=60%],and 6 mo[WMD=2.75,95%CI:-2.76 to 8.26,I2=87%)after which there was no significant difference in VISA-A scores between the PRP and control groups.There was no significant difference in VAS scores between the PRP group and the control group after 6 wk[WMD=6.75,95%CI:-6.12 to 19.62,I2=69%]and 6 mo[WMD=10.46,95%CI:-2.44 to 23.37,I2=69%]of treatment,and at mid-treatment at 3 mo[WMD=11.30,95%CI:7.33 to 15.27,I2=0%]after mid-treatment,the PRP group demonstrated better outcomes than the control group.Post-treatment patient satisfaction[WMD=1.07,95%CI:0.84 to 1.35,I2=0%],Achilles tendon thickness[WMD=0.34,95%CI:-0.04 to 0.71,I2=61%]and return to sport[WMD=1.11,95%CI:0.87 to 1.42,I2=0%]were not significantly different between the PRP and control groups.The study did not find any statistically significant distinction between the groups that received PRP treatment and those that did not,regarding the Victorian Institute of Sport Assessment-Achilles scores at 3 mo[WMD=-1.49,95%CI:-5.24 to 2.25,I2=0%],6 mo[WMD=-0.24,95%CI:-3.80 to 3.32,I2=0%],and 12 mo[WMD=-2.02,95%CI:-5.34 to 1.29,I2=87%]for ATR patients.Additionally,no significant difference was observed between the PRP and the control groups in improving Heel lift height respectively at 6 mo[WMD=-3.96,95%CI:-8.61 to 0.69,I2=0%]and 12 mo[WMD=-1.66,95%CI:-11.15 to 7.83,I2=0%]for ATR patients.There was no significant difference in calf circumference between the PRP group and the control group after 6 mo[WMD=1.01,95%CI:-0.78 to 2.80,I2=54%]and 12 mo[WMD=-0.55,95%CI:-2.2 to 1.09,I2=0%]of treatment.There was no significant difference in ankle mobility between the PRP and control groups at 6 mo of treatment[WMD=-0.38,95%CI:-2.34 to 1.58,I2=82%]and after 12 mo of treatment[WMD=-0.98,95%CI:-1.41 to-0.56,I2=10%]there was a significant improvement in ankle mobility between the PRP and control groups.There was no significant difference in the rate of return to exercise after treatment[WMD=1.20,95%CI:0.77 to 1.87,I2=0%]and the rate of adverse events[WMD=0.85,95%CI:0.50 to 1.45,I2=0%]between the PRP group and the control group.CONCLUSION The use of PRP for AT improved the patient’s immediate VAS scores but not VISA-A scores,changes in Achilles tendon thickness,patient satisfaction,or return to sport.Treatment of ATR with PRP injections alone improved long-term ankle mobility but had no significant effect on VISA-A scores,single heel lift height,calf circumference or return to sport.Additional research employing more extensive sampling sizes,more strict experimental methods,and standard methodologies may be necessary to yield more dependable and precise findings.

Triggering,clicking,locking and crepitus of the finger:A comprehensive overview

Triggering,locking,clicking,and crepitus of the fingers are common symptoms patients present with.Even though crepitus and triggering can occur as part of the same underlying diagnosis,it is important to differentiate between them,as they usually indicate different possible diagnoses.The differential diagnoses that should be considered include trigger finger,metacarpophalangeal joint(MCPJ)arthritis,fractures or dislocations,extensor digitorum communis subluxation or dislocation,locked MCPJ,avascular necrosis of the metacarpal head,and Dupuytren’s disease.A thorough clinical examination with appropriate special investigations can permit the clinician to make the correct diagnosis.Appropriate management of a confirmed diagnosis is successful in providing symptomatic improvement.

COVID-19 and its effects upon orthopaedic surgery: The Trinidad and Tobago experience

The World Health Organisation(WHO)declared coronavirus disease 2019(COVID-19)a pandemic on March 11,2020.COVID-19 is not the first infectious disease to affect Trinidad and Tobago.The country has faced outbreaks of both Chikungunya and Zika virus in 2014 and 2016 respectively.The viral pandemic is predicted to have a significant impact upon all countries,but the healthcare services in a developing country are especially vulnerable.The Government of Trinidad and Tobago swiftly established a parallel healthcare system to isolate and treat suspected and confirmed cases of COVID-19.Strick‘lockdown’orders,office closures,social distancing and face mask usage recommendation were implemented following advice from the WHO.This approach has seen Trinidad and Tobago emerge from the second wave of infections,with the most recent Oxford COVID-19 Government Response Tracker report indicating a favourable risk of openness index for the country.The effects of the pandemic on the orthopaedic services in the public and private healthcare systems show significant differences.Constrained by shortages in personal protective equipment and inadequate testing facilities,the public system moved into emergency mode prioritizing the care of urgent and critical cases.Private healthcare driven more by economic considerations,quickly instituted widespread safety measures to ensure that the clinics remained open and elective surgery was not interrupted.Orthopaedic teaching at The University of the West Indies was quickly migrated to an online platform to facilitate both medical students and residents.The Caribbean Association of Orthopedic Surgeons through its frequent virtual meetings provided a forum for continuing education and social interaction amongst colleagues.The pandemic has disrupted our daily routines leading to unparalleled changes to our lives and livelihoods.Many of these changes will remain long after the pandemic is over,permanently transforming the practice of orthopaedics.

Robotic exoskeletons: The current pros and cons

Robotic exoskeletons have emerged as rehabilitation tool that may ameliorate several of the existing healthrelated consequences after spinal cord injury(SCI).However,evidence to support its clinical application is still lacking considering their prohibitive cost.The current mini-review is written to highlight the main limitations and potential benefits of using exoskeletons in the rehabilitation of persons with SCI.We have recognized two main areas relevant to the design of exoskeletons and to their applications on major health consequences after SCI.The design prospective refers to safety concerns,fitting time and speed of exoskeletons.The health prospective refers to factors similar to body weight,physical activity,pressure injuries and bone health.Clinical trials are currently underway to address some of these limitations and to maximize the benefits in rehabilitation settings.Future directions highlight the need to use exoskeletons in conjunction with other existing and emerging technologies similar to functional electrical stimulation and brain-computer interface to address major limitations.Exoskeletons have the potential to revolutionize rehabilitation following SCI;however,it is still premature to make solid recommendations about their clinical use after SCI.

Knee osteoarthritis:Therapeutic alternatives in primary care

AIM To discusses pharmacological and non-pharmacological therapeutic alternatives for managing knee osteoarthritis in primary care by primary health care nurse practitioners.METHODS A case example is presented, the evidence-based guideline recommendations of the Osteoarthritis Research Society International and the American Academy of Orthopaedic Surgeons are reviewed, and a plan of care is developed.RESULTS Osteoarthritis is the most common form of arthritis seen in primary care, and it is a major public health issue because the aging population and widespread obesity have drastically increased incidence. Osteoarthritis is clinically associated with escalating chronic pain, physical disability, and decreased quality of life. Early diagnosis of mild osteoarthritis in relatively young patients presents an opportunity for primary health care providers to manage pain, increase quality of life, and decrease risk of disability. CONCLUSION Primary health care providers can implement these recommendations in their own practices to provide care to patients with knee osteoarthritis based on current best evidence.

Worldwide orthopaedic research activity 2010-2014:Publication rates in the top 15 orthopaedic journals related to population size and gross domestic product

AIM To perform a bibliometric analysis of publications rates in orthopedics in the top 15 orthopaedic journals. METHODS Based on their 2015 impact factor, the fifteen highest ranked orthopaedic journals between January 2010 and December 2014 were used to establish the total number of publications; cumulative impact factor points(IF) per country were determined, and normalized to population size, GDP, and GDP/capita, comparison to the median country output and the global leader. RESULTS Twenty-three thousand and twenty-one orthopaedic articles were published, with 66 countries publishing. The United States had 8149 publications, followed by the United Kingdom(1644) and Japan(1467). The highest IF was achieved by the United States(24744), United Kingdom(4776), and Japan(4053). Normalized by population size Switzerland lead. Normalized by GDP, Croatia was the top achiever. Adjusting GDP/capita, for publications and IF, China, India, and the United Stateswere the leaders. Adjusting for population size and GDP, 28 countries achieved numbers of publications to be considered at least equivalent with the median academic output. Adjusting GDP/capita only China and India reached the number of publications to be considered equivalent to the current global leader, the United States. CONCLUSION Five countries were responsible for 60% of the orthopaedic research output over this 5-year period. After correcting for GDP/capita, only 28 of 66 countries achieved a publication rate equivalent to the median country. The United States, United Kingdom, South Korea, Japan, and Germany were the top five countries for both publication totals and cumulative impact factor points.

Posterolateral dislocation of the knee:Recognizing an uncommon entity

Posterolateral dislocations of the knee are rare injuries.Early recognition and emergent open reduction is crucial.A 48-year-old Caucasian male presented with right knee pain and limb swelling 3 d after sustaining a twisting injury in the bathroom.Examination revealed the pathognomonic anteromedial "pucker" sign.Anklebrachial indices were greater than 1.0 and symmetrical.Radiographs showed a posterolateral dislocation of the right knee.He underwent emergency open reduction without an attempt at closed reduction.Attempts at closed reduction of posterolateral dislocations of the knee are usually impossible because of incarceration of medial soft tissue in the intercondylar notch and may only to delay surgical management and increase the risk of skin necrosis.Magnetic resonance imaging is not crucial in the preoperative period and can lead to delays of up to 24 h.Instead,open reduction should be performed once vascular compromise is excluded.

Biomechanics of the anterior cruciate ligament:Physiology,rupture and reconstruction techniques

The influences and mechanisms of the physiology,rupture and reconstruction of the anterior cruciate ligament(ACL)on kinematics and clinical outcomes have been investigated in many biomechanical and clinical studies over the last several decades.The knee is a complex joint with shifting contact points,pressures and axes that are affected when a ligament is injured.The ACL,as one of the intra-articular ligaments,has a strong influence on the resulting kinematics.Often,other meniscal or ligamentous injuries accompany ACL ruptures and further deteriorate the resulting kinematics and clinical outcomes.Knowing the surgical options,anatomic relations and current evidence to restore ACL function and considering the influence of concomitant injuries on resulting kinematics to restore full function can together help to achieve an optimal outcome.

Use of Teriparatide to improve fracture healing: What is the evidence?

Teriparatide is a recombinant form of the biologicallyactive component of Parathyroid hormone. It has been shown to increase bone mass and prevent fractures in osteoporotic bone. It is licensed by the Food and Drug Administration for the treatment of Osteoporosis. Over the last decade, a growing body of evidence has accumulated suggesting a role for Teriparatide in the management of fractures. Studies in both normal and delayed healing models have shown improvement in callus volume and mineralisation, bone mineral content, rate of successful union and strength at fracture sites. However most of these results have been derived from animal studies. The majority of this research on humans has comprised low level evidence, with few randomised controlled trials, many case reports and case series. Nevertheless, the results from these studies seem to support research from animal models. This has led to a growing number of clinicians using Teriparatide "off license" to treat fractures and non-unions in their patients. This review presents a critical appraisal of the current evidence supporting the use of Teriparatide for fracture healing, delayed unions and non unions and in the setting of osteoporotic fractures, the studies producing this evidence and their transferability to human beings.

Cervical adjacent segment pathology following fusion:Is it due to fusion?

Adjacent segment pathology affects 25% of patients within ten years of anterior cervical diskectomy and fusion(ACDF). Laboratory studies demonstrate fused segments increase adjacent level stress including elevated intradiscal pressure and increased range of motion. Radiographic adjacent segment pathology(RASP) has been associated to ACDF in multiple statistically significant studies. Randomized controlled trials(RCTs) comparing anterior cervical discectomy and arthroplasty(ACDA) and ACDF have confirmed ACDF accelerates RASP. The question of greatest clinical interest is whether ACDA, artificial disc surgery, results in fewer adjacent level surgeries than ACDF. Current RCT follow up results reveal only non statistically significant trends favoring ACDA yet the post operative periods are only two to four years. Statistically significant increased RASP in ACDF patients however is already documented. The RCT patients' average ages are in the mid forties with an expected longevity of up to forty more years. Early statistically significant increased RASP in the ACDF patients supports our prediction that given sufficient follow up of ten or more years, fusion will lead to statistically significant higher rate of adjacent level surgery compared to artificial disc surgery.

Comparison of straight median sternotomy and interlocking sternotomy with respect to biomechanical stability

AIM: To increase the stability of sternotomy and so decrease the complications because of instability. METHODS: Tests were performed on 20 fresh sheep sterna which were isolated from the sterno-costa joints of the ribs. Median straight and interlocking sternotomies were performed on 10 sterna each, set as groups 1 and 2, respectively. Both sternotomies were performed with an oscillating saw and closed at three points with a No. 5 straight stainless-stee wiring. Fatigue testing was performed in craniocaudal, anterio-posterior(AP) and lateral directions by a computerized materials-testing machine cycling between loads of 0 to 400 N per 5 s(0.2 Hz). The amount of displacement in AP, lateral and craniocaudal directions were measured and also the op-posing bone surface at the osteotomy areas were calculated at the two halves of sternum. RESULTS: The mean displacement in cranio-caudal direction was 9.66 ± 3.34 mm for median sternotomy and was 1.26 ± 0.97 mm for interlocking sternotomy, P < 0.001. The mean displacement in AP direction was 9.12 ± 2.74 mm for median sternotomy and was 1.20 ± 0.55 mm for interlocking sternotomy, P < 0.001. The mean displacement in lateral direction was 8.95 ± 3.86 mm for median sternotomy and was 7.24 ± 2.43 mm for interlocking sternotomy, P > 0.001. The mean surface area was 10.40 ± 0.49 cm2 for median sternotomy and was 16.8 ± 0.78 cm2 for interlocking sternotomy, P < 0.001. The displacement in AP and cranio-caudal directions is less in group 2 and it is statistically significant. Displacement in lateral direction in group 2 is less but it is statistically not significant. Surface area in group 2 is significantly wider than group 1.CONCLUSION: Our test results demonstrated improved primary stability and wider opposing bone surfaces in interlocking sternotomy compared to median sternotomy. This method may provide better healing and less complication rates in clinical setting, further studies are necessary for its clinical implications.

Diagnosis and treatment of chronic osteomyelitis based on nanomaterials

Chronic osteomyelitis is a painful and serious disease caused by infected surgical prostheses or infected fractures.Traditional treatment includes surgical debridement followed by prolonged systemic antibiotics.However,excessive antibiotic use has been inducing rapid emergence of antibiotic-resistant bacteria worldwide.Additionally,it is difficult for antibiotics to penetrate internal sites of infection such as bone,thus limiting their efficacy.New approaches to treat chronic osteomyelitis remain a major challenge for orthopedic surgeons.Luckily,the development of nanotechnology has brought new antimicrobial options with high specificity to infection sites,offering a possible way to address these challenges.Substantial progress has been made in constructing antibacterial nanomaterials for treatment of chronic osteomyelitis.Here,we review some current strategies for treatment of chronic osteomyelitis and their underlying mechanisms.

Bone mineral density in fracture neck of femur patients:What's the significance?

BACKGROUND The National Institute for Health and Care Excellence(NICE)guidelines have advised further research is required into investigating the added prognostic value of bone mineral density(BMD)in the assessment of fracture risk with the Fracture Risk Assessment Tool(FRAX)score.AIM To investigate the significance of BMD in fracture neck of femur patients and compare it to the outcome of the FRAX score.METHODS Inclusion criteria for this study were all patients who underwent dual-energy Xray absorptiometry(DXA)scan following fracture neck of femur between 2015 and 2017.Analysis of BMD,FRAX scores and patient demographic data was undertaken.RESULTS A total of 69 patients were included in the study,mean age 74.1 years.There was no significant difference between mean BMD of the femoral neck in males(0.65)as compared to females(0.61)(P=0.364).Analyses showed no significant correlation between BMD and menopause age(rs=-0.28,P=0.090).A significant difference was seen of the femoral neck BMD between the different fracture pattern types(P=0.026).A stronger correlation was observed between BMD of femoral neck and FRAX major score(rs=-0.64,P<0.001)than with BMD of lumbar spine and FRAX major score(rs=-0.37,P=0.003).CONCLUSION This study demonstrated that BMD of the femoral neck measured by DXA scan is of added prognostic value when assessing patients for risk of fracture neck of femur in combination with the FRAX predictive scoring system.

Anterior glenohumeral instability:Current review with technical pearls and pitfalls of arthroscopic soft-tissue stabilization

The glenohumeral joint(GHJ)allows for a wide range of motion,but is also particularly vulnerable to episodes of instability.Anterior GHJ instability is especially frequent among young,athletic populations during contact sporting events.Many first time dislocators can be managed non-operatively with a period of immobilization and rehabilitation,however certain patient populations are at higher risk for recurrent instability and may require surgical intervention for adequate stabilization.Determination of the optimal treatment strategy should be made on a case-by-case basis while weighing both patient specific factors and injury patterns(i.e.,bone loss).The purpose of this review is to describe the relevant anatomical stabilizers of the GHJ,risk factors for recurrent instability including bony lesions,indications for arthroscopic vs open surgical management,clinical history and physical examination techniques,imaging modalities,and pearls/pitfalls of arthroscopic soft-tissue stabilization for anterior glenohumeral instability.

Impact of gender and race on expectations and outcomes in total knee arthroplasty

BACKGROUND Total joint arthroplasty is one of the most common surgeries performed in the United States with total knee arthroplasty(TKA)being one of the most successful surgeries for restoring function and diminishing pain.Even with the demonstrated success of TKA and a higher prevalence of arthritis and arthritis related disability among minorities,racial and gender disparity remains a constant issue in providing care for the adult reconstruction patient.AIM To assess the role of demographics and expectations on differences in perioperative patient reported outcomes(PRO)following TKA.METHODS One hundred and thirty-three patients scheduled for primary unilateral TKA secondary to moderate to severe osteoarthritis were enrolled in this twoinstitution prospective study.Validated PRO questionnaires were collected at four time points.Statistical analysis was conducted to determine the impact of gender,ethnic background and expectation surveys responses to assess PRO at these time points.RESULTS Females were associated with worse preoperative Knee Injury and Osteoarthritis Outcome Scores(KOOS)for symptoms,pain,and activities of daily living.African Americans were associated with worse KOOS for pain,activities of daily living,and quality of life.Despite worse preoperative scores,no difference was noted in these categories between the groups postoperatively.Additionally,all pre-operative psychometric scales were equivalent across groups except Geriatric Depression scale,which was significantly different between groups within the Race and Age Group(P<0.05).Conversely,Pain Catastrophizing Scale,was significantly different for all subscales and total score within Age Group(P<0.05),and the Magnification,Helplessness subscales as well as the Total score were significantly different between groups for Race and Relationship Status(P<0.01).CONCLUSION We conclude that female and African American patients have lower preoperative KOOS scores compared to white male patients.No postoperative differences in outcomes between these groups.

Single rod instrumentation in patients with scoliosis and comorbidities: Indications and outcomes

AIM To present our results on the use of a single rod instrumentation correction technique in a small number of patients with major medical co-morbidities.METHODS This study was a prospective single surgeon series. Patients were treated with single rod hybrid constructs and had a minimum 2-year follow-up. Indications included complex underlying co-morbidities, conversion of growing rods to definitive fusion, and moderate adolescent idiopathic primarily thoracic scoliosis with severe eczema and low body mass index(BMI).RESULTS We included 99 consecutive patients. Mean age at surgery was 12.8 years(SD 3.5 years). Mean scoliosis correction was 62%(SD 15%) from 73°(SD 22°) to 28°(SD 15°). Mean surgical time was 153 min(SD 34 min), and blood loss was 530 mL(SD 327 mL); 20% BV(SD 13%). Mean clinical and radiological follow-up was 3.2 years(range: 2-12) post-operatively. Complications included rod failure, which occurred in three of our complex patients with severe syndromic or congenital kyphoscoliosis(3%). Only one of these three patientsrequired revision surgery to address a non-union. Our revision rate was 2%(including a distal junctional kyphosis in a Marfan's syndrome patient).CONCLUSION The single rod technique has achieved satisfactory deformity correction and a low rate of complications in patients with specific indications and severe underlying medical conditions. In these children with significant co-morbidities, where the risks of scoliosis surgery are significantly increased, this technique has achieved low operative time, blood loss, and associated surgical morbidity.

Distal triceps injuries(including snapping triceps):A systematic review of the literature

AIM To review current literature on types of distal triceps injuryand determine diagnosis and appropriate management.METHODS We performed a systematic review in PubM ed, Cochrane and EMBASE using the terms distal triceps tears and snapping triceps on the 10 th January 2017. We excluded all animal, review, foreign language and repeat papers. We reviewed all papers for relevance and of the papers left we were able to establish the types of distal triceps injury, how these injuries are diagnosed and investigated and the types of management of these injuries including surgical. The results are then presented in a review paper format.RESULTS Three hundred and seventy-nine papers were identified of which 65 were relevant to distal triceps injuries. After exclusion we had 47 appropriate papers. The papers highlighted 2 main distal triceps injuries: Distal triceps tears and snapping triceps. Triceps tear are more common in males than females occurring in the 4th-5th decade of life and often due to a direct trauma but are also strongly associated with weightlifting and American football. The tears are diagnosed by history and clinically with a palpable gap. Diagnosis can be confirmed with the use of ultrasound(US) and magnetic resonance imaging. Treatment depends on type of tear. Partial tears can be treated conservatively with bracing and physio whereas acute tears need repair either open or arthroscopic using suture anchor or bone tunnel techniques with similar success. Chronic tears often need augmenting with tendon allograft or autograft. Snapping triceps are also seen more in men than women but at a mean age of 32 years. They are characterized by a snapping sensation mostly medially and can be associated with ulna nerve subluxation and ulna nerve symptoms. US is the diagnostic modality of choice due to its dynamic nature and to differentiate between snapping triceps tendon or ulna nerve. Treatment is conservative initially with activity avoidance and if that fails surgical management includes resection of triceps edge or transposition of the tendon plus or minusulna nerve transposition.CONCLUSION Distal triceps injuries are uncommon. This systematic review examines the evidence base behind diagnosis, imaging and treatment options of distal triceps injuries including tears and snapping triceps.

Anterolateral rotatory instability in vivo correlates tunnel position after anterior cruciate ligament reconstruction using bone-patellar tendon-bone graft

AIM To quantitatively assess rotatory and anterior-posterior instability in vivo after anterior cruciate ligament(ACL) reconstruction using bone-patellar tendon-bone(BTB) autografts, and to clarify the influence of tunnel positions on the knee stability.METHODS Single-bundle ACL reconstruction with BTB autograft was performed on 50 patients with a mean age of 28 years using the trans-tibial(TT)(n = 20) and trans-portal(TP)(n = 30) techniques. Femoral and tibial tunnel positions were identified from the high-resolution 3 D-CT bone models two weeks after surgery. Anterolateral rotatory translation was examined using a Slocum anterolateral rotatory instability test in open magnetic resonance imaging(MRI) 1.0-1.5 years after surgery, by measuring anterior tibial translation at the medial and lateral compartments on its sagittal images. Anterior-posterior stability was evaluated with a Kneelax3 arthrometer.RESULTS A total of 40 patients(80%) were finally followed up. Femoral tunnel positions were shallower(P < 0.01) and higher(P < 0.001), and tibial tunnel positions were more posterior(P < 0.05) in the TT group compared with the TP group. Anterolateral rotatory translations in reconstructed knees were significantly correlated with the shallow femoral tunnel positions(R = 0.42, P < 0.01), and the rotatory translations were greater in the TT group(3.2 ± 1.6 mm) than in the TP group(2.0 ± 1.8 mm)(P < 0.05). Side-to-side differences of Kneelax3 arthrometer were 1.5 ± 1.3 mm in the TT, and 1.7 ± 1.6 mm in the TP group(N.S.). Lysholm scores, KOOS subscales and reinjury rate showed no difference between the two groups.CONCLUSION Anterolateral rotatory instability significantly correlated shallow femoral tunnel positions after ACL reconstruction using BTB autografts. Clinical outcomes, rotatory and anterior-posterior stability were overall satisfactory in both techniques, but the TT technique located femoral tunnels in shallower and higher positions, and tibial tunnels in more posterior positions than the TP technique, thus increased the anterolateral rotation. Anatomic ACL reconstruction with BTB autografts may restore knee function and stability.