Paper 107: Elbow Arthrolysis: Arthroscopic vs Open Technique: Results of a Multicentric Study

ABSTRACTS Paper 106: The “Muscular Hernia Sign:” An Original Ultrasonographic Sign to Detect Lesions of the Forearm’s Interosseous Membrane MARC SOUBEYRAND, RESIDENT, FRANCE, PRESENTING AUTHOR CLARISSE LAFONT, FRANCE CHRISTIAN A. DUMONTIER, MD, FRANCE IVAN MAULAT, FRANCE RENAUD DE GEORGES, FRANCE ABSTRACT Introduction: The total disruption of the forearm’s interosseous membrane can lead to an Essex-Lopresti syndrome. The diagnosis must be done early for a better prognostic. Incomplete lesions can aggravate and an early diagnosis of incomplete lesions is a challenging problem. Magnetic resonance imaging is the gold standard but remains expensive, and is hard to obtain in an emergency. On the contrary, ultrasonography is cheap, accessible in an emergency, and dynamical tests can be performed easily. Material & Methods: Twelve fresh frozen forearms were randomized in four groups. The membrane was divided into three parts (proximal, middle, and distal thirds). Each group was prepared with variable patterns of lesions. Two radiologists performed an ultrasonographic (US) examination of these forearms. They were blinded with respect to the lesional status of the forearms. Each examination consisted of two stages: static and dynamic. During the dynamic examination, the radiologist looked for the “muscular hernia sign”. The results of their examinations were compared with the real lesional status. Results: The static examination was very efficient in the proximal and middle parts of the membrane, and less reliable in the distal third. With the dynamical examination, no mistake occurred at the proximal and middle parts of the forearm, and there was only one at the distal part. Conclusion: The US examination of the interosseous membrane is very efficient to detect incomplete lesions, mostly, if dynamical tests are performed looking for a “muscular hernia sign”. Paper 107: Elbow Arthrolysis: Arthroscopic vs Open Technique: Results of a Multicentric Study FRANCOIS M. KELBERINE, MD, FRANCE, PRESENTING AUTHOR JL MARMORAT, FRANCE THIERRY JUDET, FRANCE FRANÃOIS BONNOMET, MD, FRANCE ABSTRACT Introduction: The goal of this study is to compare the efficacy of two techniques of elbow arthrolysis: 59 ar-

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throscopically performed (group A) and 80 through open surgery (group O). Based upon a multicentric retrospective study (levelXXX), it is, in our knowledge, the largest comparative survey reported up to now. Material and Methods: To avoid the influence of learning curve, we selected specialized surgeons (for both groups) who performed the technique they were used with. Patients selection was mandatory strict to keep the two groups comparable. Inclusion criteriae were from 18 to 65 years old, mechanical passive stiffness, radiological assessment. Exclusion criteriae were extraarticular causing factor or surgical procedure (eg ostetomy), synovitis, infection or Sudeck syndrom. The datas assessed preop, postop and at the final follow up were clinical (ROM, pain, swelling, locking, unability in daily living activities) and radiological (loose bodies, bony and/or fibrous filling of fossae, spurs, arthosis). Time to resume to activities and subjective opinion were finally checked. Two groups were considered: post-trauma stiffness and arthritis (localized or global). Groups A & O were comparable for age, sex, dominant side, delay to surgery, clinical signs, rate of worker compensation. But they were different in etiology: group A was rather sport related with microtrauma and arthritis which was confirmed at surgery (more cartilaginous damages). Group O was more posttrauma related with a worse and significant lack of flexion (107 vs 116). The mean lack of extension was 42 degrees, mean pronation 73 degrees and supination 70 degrees. On the operative point of view, we note more capsular release, more posterior spurs removal and ulnar nerve release and more postoperative analgesic block in group O. In group A, even in experts hands only capsulotomy and no capsulectomy was performed. There was no difference regarding fenestration (22%) and radial head excision (11%). Results: 13% of complications occured in both groups (e.g: One radial nerve palsy, transient ulnar or radial nerve palsy, sudeck syndrom, superficial infection) The post-operative ROM was similar for extension (10 degrees) pronation (83 degrees) and supination (83 degrees). But the the flexion was better in group O (132 degrees vs 127 degrees, p⫽0,03) and the global gain in FE was clearly better (60 degrees vs 34 degrees p⬍0,001) as the initial lack of flexion was highter. Radiologically, anterior (p⫽ 0,03) and medial (p⫽ 0,04) spurs resection was more extensive in group O despite there arthritis was less frequent. At 6 years FU (1-14y), there was no difference regarding PS, gain in PS (20 degrees) nor extension (19 degrees). Final flexion was better in group A (129 degrees

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ABSTRACTS

vs 124 degrees, p ⫽ 0,02). The overall improvement of FE remains better (p ⬍ 0,001) for group O (43 vs 31 degrees) splitted in both flexion (5 degrees, p⫽0,05) and extension (7 degrees, p⫽0,01). Finally, open surgery got a better ROM with a larger loss of mobility after surgery (17 degrees vs 8 degrees). Patients reported occasional and few complains in ADL. Return to activities was 18 weeks. However, subjective opinion was only scored 3/5. Other remarkable results: return to work was delayed for worker compensation (52 weeks vs 13 weeks), previous surgery or mobilization under anesthesia do not influence the results. Improvement of ROM was significantly better when surgery was done prior the second year after first symptoms. Conclusion: Arthro CT scan is in our opinion the best examination to assess preoperatively the stiff elbow. Paper 108: Comparison of Elbow Valgus Laxity Using Radiographic and Non-Radiographic Objective Measurements MARC RAYMOND SAFRAN, MD, USA, PRESENTING AUTHOR THAY Q. LEE, PHD, USA ABSTRACT Introduction: Diagnosis of ulnar collateral ligament (UCL) injury is difficult. Stress radiographs are currently the only objective tool to confirm the diagnosis, but can be misleading. This study compares a clinical testing device with the current gold standard Telos Stress Test Radiographic Device. Methods: 18 subjects, 7 subjects (6 male, 1 female) with an average age of 33 (range 19 - 52) with a history of UCL injury, but not symptomatic enough to undergo surgical reconstruction, and 11 (10 male, 1 female) normal subjects with an average age of 29 years (range 19 41) underwent valgus laxity testing of both elbows. All patients filled out an elbow questionnaire, including information about injury and surgery and sports participation. All subjects then underwent a clinical examination of both elbows, including range of motion, carrying angle, location of tenderness, and valgus stress tests. Subjects with current elbow pain, elbow arthritis or elbow surgery were excluded. All patents underwent the same testing protocol. Both arms of each subject were placed in a custom non-invasive instrumented testing device that permits the application of varus-valgus force and measurement of laxity. Angular displacement was measured with a Microscribe Digitizing system connected to a laptop computer after applying a 2N-m valgus force from a neutral starting position. Neutral start-

ing postion was identified by applying a 1N-m varus force before each application of valgus force. This was repeated 5 times for each elbow. Lastly, a manual maximum valgus force (approximately 7.7 N-m) was applied and the resulting displacement measured. These subjects also underwent instrumented valgus stress radiographs (Telos GA-/IIE Stress Device) using zero and 12 decaNewtons force (27 lbs). Radiographs were recorded using a PACS system and medial joint space was digitally measured on the PACS system. Comparisons were then made. Results: The stress radiographs failed to show a significant difference between normal [3.3mm (⫹0.52)] and injured [3.0mm (⫹0.63)] elbows (p⫽0.6). The clinical non-invasive device was able to show a significant difference (p⫽.03) in laxity on manual maximum testing when comparing the normal [0.46 (SD⫽⫹ 0.17)] to the injured [0.56 (SD⫽⫹ 0.22)] elbow. No significant difference was found in normals subjects on non-invasive and stress radiographs when comparing dominant [0.23 radians (⫹0.14), 3.7mm (⫹0.79)] to non-dominant [0.21 radians (⫹0.12), 3.7mm (⫹0.65)] elbows. Spearman rank correlations were performed to evaluate the relationship between the stress radiographs and clinical stress device revealing poor correlation (r⫽0.07 and r⫽0.15). Conclusions: The non-invasive device is more sensitive in detecting valgus elbow laxity than standardized stress radiographs. This device may increase a clinician’s ability to accurately diagnosis UCL laxity without the expense and invasiveness of radiography. Paper 109: Differential Forces Within the Proximal Patellar Tendon as an Explanation for the Characteristic Lesion of Patellar Tendinopathy EDWIN MARK DILLON, MBCHB, MMED ORTHO, SOUTH AFRICA, PRESENTING AUTHOR COBUS MULLER, SOUTH AFRICA CORNIE SCHEFFER, SOUTH AFRICA RICHARD DE VILLIERS, SOUTH AFRICA ABSTRACT The lesion in patellar tendinopathy is located within the posterior fibres of the proximal patellar tendon. The aetiology and pathogenesis of patellar tendinopathy are still unknown and hence the reason for this typical location remains unclear. The cause has generally been considered to be chronic stress overload resulting in microscopic tears of the tendon and degeneration. As the characteristic lesion in patellar tendinopathy is located in the deep posterior fibres of the proximal patellar tendon, it has been hypothesised that loading exposes this region