Ultrasound evaluation shows increase in laxity after partial common extensor origin detachment but not after additional lesion of the radial band of the lateral collateral ligament.

PURPOSE: The lateral elbow musculature conveys a dynamic valgus moment to the elbow, increasing joint stability. Muscular or tendinous lesions to the anterior half of the common extensor origin (CEO) may provoke a deficiency in the elbow dynamic stabilizers, regardless of their traumatic, degenerative, or iatrogenic aetiology. Furthermore, a role for the radial band of the lateral collateral ligament (R-LCL) has been postulated in the aetiology of lateral elbow pain. This study aimed to evaluate the effects of sequential lateral releases with dynamic ultrasound, evaluating its capability to detect lesions of the CEO and of the R-LCL. METHODS: Ultrasound investigation of the lateral compartment of the elbow was performed on nine cadaveric specimens with a 10 MHz linear probe in basal conditions, after the release of the anterior half of the CEO and after complete R-LCL release. The lateral joint line widening (λ) was the primary outcome parameter, measured as the linear distance between the humeral and radial articular surfaces. RESULTS: The release of the anterior half of the CEO significantly increased λ by 200% compared to the starting position (p = 0.0008) and the previously loaded position (p = 0.0015). Conversely, further release of the R-LCL caused only a marginal, non-significant increase in λ. CONCLUSIONS: Ultrasound evaluation can detect changes related to tendon tears or muscular avulsions of the CEO and can depict lateral elbow compartmental patholaxity by assessing articular space widening while scanning under dynamic stress. However, it cannot reliably define if the R-LCL is injured. Iatrogenic damage to the CEO should be carefully avoided, since it causes a massive increase in compartmental laxity.

Novel Radiographic Indexes for Elbow Stability Assessment: Part A-Cadaveric Validation.

INTRODUCTION: Elbow bony stability relies primarily on the high anatomic congruency between the humeral trochlea and the ulnar greater sigmoid notch. No practical tools are available to distinguish different morphotypes of the proximal ulna and herewith predict elbow stability. The aim of this study was to assess inter-observer reproducibility, evaluate diagnostic performance and determine responsiveness to change after simulated coronoid process fracture for three novel elbow radiographic indexes. METHODS: Ten fresh-frozen cadaver specimens of upper limbs from human donors were available for this study. Three primary indexes were defined, as well as two derived angles: Trochlear Depth Index (TDI); Posterior Coverage Index (PCI); Anterior Coverage Index (ACI); radiographic coverage angle (RCA); olecranon-diaphisary angle (ODA). Each index was first measured on standardized lateral radiographs and subsequently by direct measurement after open dissection. Finally, a type II coronoid fracture (Regan and Morrey classification) was created on each specimen and both radiographic and open measurements were repeated. All measurements were conducted by two orthopaedic surgeons and two dedicated musculoskeletal radiologists. RESULTS: All three indexes showed good or moderate inter-observer reliability and moderate accuracy and precision when compared to the gold standard (open measurement). A significant change between the radiographic TDI and ACI before and after simulated coronoid fracture was observed [TDI: decrease from 0.45 ± 0.03 to 0.39 ± 0.08 (p = 0.035); ACI: decrease from 1.90 ± 0.17 to 1.58 ± 0.21 (p = 0.001)]. As expected, no significant changes were documented for the PCI. Based on these data, a predictive model was generated, able to identify coronoid fractures with a sensitivity of 80% and a specificity of 100%. CONCLUSION: New, simple and easily reproducible radiological indexes to describe the congruency of the greater sigmoid notch have been proposed. TDI and ACI change significantly after a simulated coronoid fracture, indicating a good responsiveness of these parameters to a pathological condition. Furthermore, combining TDI and ACI in a regression model equation allowed to identify simulated fractures with high sensitivity and specificity. The newly proposed indexes are, therefore, promising tools to improve diagnostic accuracy of coronoid fractures and show potential to enhance perioperative diagnostic also in cases of elbow instability and stiffness. LEVEL OF EVIDENCE: Basic science study. CLINICAL RELEVANCE: The newly proposed indexes are promising tools to improve diagnostic accuracy of coronoid fractures as well as to enhance perioperative diagnostic for elbow instability and stiffness.

Novel Radiographic Indexes for Elbow Stability Assessment: Part B-Preliminary Clinical Study.

INTRODUCTION: The coronoid process plays a key-role in preserving elbow stability. Currently, there are no radiographic indexes conceived to assess the intrinsic elbow stability and the joint congruency. The aim of this study is to present new radiological parameters, which will help assess the intrinsic stability of the ulnohumeral joint and to define normal values of these indexes in a normal, healthy population. METHODS: Four independent observers (two orthopaedic surgeons and two radiologists) selected lateral view X-rays of subjects with no history of upper limb disease or surgery. The following radiographic indexes were defined: trochlear depth index (TDI); anterior coverage index (ACI); posterior coverage index (PCI); olecranon-coronoid angle (OCA); radiographic coverage angle (RCA). Inter-observer and intra-observer reproducibility were assessed for each index. RESULTS: 126 subjects were included. Standardized lateral elbow radiographs (62 left and 64 right elbows) were obtained and analysed. The mean TDI was 0.46 ± 0.06 (0.3-1.6), the mean ACI was 2.0 ± 0.2 (1.6-3.1) and the mean PCI was 1.3 ± 0.1 (1.0-1.9). The mean RCA was 179.6 ± 8.3° (normalized RCA: 49.9 ± 2.3%) and the mean OCA was 24.6 ± 3.7°. The indexes had a high-grade of inter-observer and intra-observer reliability for each of the four observers. Significantly higher values were found for males for TDI, ACI, PCI and RCA. CONCLUSION: The novel radiological parameters described are simple, reliable and easily reproducible. These features make them a promising tool for radiographic evaluation both for orthopaedic surgeons and for radiologists in the emergency department setting or during outpatient services. LEVEL OF EVIDENCE: Basic Science Study (Case Series). CLINICAL RELEVANCE: The novel radiological parameters described are reliable, easily reproducible and become handy for orthopaedic surgeons as well as radiologists in daily clinical practice.

Lateral Elbow Laxity Is Affected by the Integrity of the Radial Band of the Lateral Collateral Ligament Complex: A Cadaveric Model With Sequential Releases and Varus Stress Simulating Everyday Activities.

BACKGROUND: An elongation of the radial lateral collateral complex (R-LCL) can provoke symptomatic minor instability of the lateral elbow leading to lateral elbow pain. Biomechanical models investigating the effects of elongation and partial or complete lesions of the R-LCL on lateral elbow stability are lacking. PURPOSE: To evaluate how partial and complete R-LCL release affects radiocapitellar joint stability in a setting of controlled varus load and progressive soft tissue release. STUDY DESIGN: Controlled laboratory study. METHODS: Ten fresh-frozen cadaveric specimens were obtained and mounted on a custom-made support to control elbow flexion and extension and to allow for controlled varus loading. Stress tests were performed on all intact specimens under gravity load alone, a 0.5-kg load applied to the hand, and a 1-kg load applied to the hand. After load application, anteroposterior radiographs were obtained. The following release sequence was applied to all specimens: release of the anterior half of the common extensor origin, pie crusting of the R-LCL, and R-LCL release. After each release, stress tests and radiographs were performed. The varus joint angulation of the elbow (α) was measured by 2 examiners as the main outcome parameter. RESULTS: Significant changes in α from the initial condition occurred after each release, and a significant effect of varus load on α was documented for all release steps. A significant effect of the releases on α could be documented for all identical varus load conditions. A linear regression model was generated to describe the effect of varus load on α. CONCLUSION: Varus loads simulating everyday activities produce changes in the varus joint angulation of the elbow already in the intact specimen, which are linearly dependent on the applied moment and persist after release of the lateral stabilizing structures. With progressive load, a pie crusting of the R-LCL is the minimal procedure able to provoke a significant change in the varus joint angulation, and a complete R-LCL release produces additional increase in the varus joint angulation in all testing conditions. CLINICAL RELEVANCE: These findings confirm the role of the R-LCL as static lateral stabilizer, supporting a pathological model based on its insufficiency and culminating with a symptomatic minor instability of the lateral elbow.

Petroclival meningiomas: radiological features essential for surgeons.

Petroclival meningiomas (PCMs) have always been a challenge for surgeons because of their difficult anatomical location. The role of radiology in providing precise indications regarding the tumour site and aggressiveness plays a major part in guiding the subsequent therapeutic process. The purpose of this review is to provide a set of the main radiological features helpful in the management of PCMs towards the most correct therapeutic approach. We aim to offer a radiological overview to allow the patient to be directed to surgery with the least possible risk of complications.

Rotator cuff calcific tendinopathy: from diagnosis to treatment.

Rotator cuff calcific tendinopathy (RCCT) is a very common condition caused by the presence of calcific deposits in the rotator cuff (RC) or in the subacromial-subdeltoid (SASD) bursa when calcification spreads around the tendons. The pathogenetic mechanism of RCCT is still unclear. It seems to be related to cell-mediated disease in which metaplastic transformation of tenocytes into chondrocytes induces calcification inside the tendon of the RC. RCCT is a frequent finding in the RC that may cause significant shoulder pain and disability. It can be easily diagnosed with imaging studies as conventional radiography (CR) or ultrasound (US). Conservative management of RCCT usually involves rest, physical therapy, and oral NSAIDs administration. Imaging-guided treatments are currently considered minimally-invasive, yet effective methods to treat RCCT with about 80% success rate. Surgery remains the most invasive treatment option in chronic cases that fail to improve with other less invasive approaches.

Differences between orthopaedic evaluation and radiological reports of conventional radiographs in patients with minor trauma admitted to the emergency department.

INTRODUCTION: During night and on weekends, in our emergency department there is no radiologist on duty or on call: thus, X-ray examinations (XR) are evaluated by the orthopaedic surgeon on duty and reported the following morning/monday by radiologists. The aim of our study was to examine the discrepancy rate between orthopaedists and radiologists in the interpretation of imaging examinations performed on patients in our tertiary level orthopaedic institution and the consequences of delayed diagnosis in terms of patient management and therapeutic strategy. MATERIALS AND METHODS: We retrospectively reviewed all cases of discrepancy between orthopaedists and radiologists, which were categorized according to anatomical location of injury, initial diagnosis and treatment, change in diagnosis and treatment. We used the Chi square test to compare the frequencies of discrepancies between patients ≤14 and >14years of age. RESULTS: From January to December 2016, 19,512 patients admitted to our emergency department performed at least an imaging examination; among these patients, 13,561 underwent XR in absence of an attending radiologist. A discrepant diagnosis was found in 337/13,561 (2.5%; 184 males; mean age: 36.7±23.7, range 2-95); 151/337 (45%) discrepancies were encountered in the lower limbs, with ankle being the most common site of misdiagnosis (64/151), and 103/337 (30%) in the upper limbs, with the elbow being the most frequent site in this district (35/103). We found 293/337 false negatives (87%) and 44/337 false positives (13%), with 134 and 13 patients needing treatment change, respectively. We found 85/337 discrepancies (25%) in patients ≤14 years of age, and 252/337 (75%) in those >14years. The distribution of discrepancies per anatomic district was significantly different (P<0.001) in these two groups of patients. CONCLUSIONS: A low rate of discrepancy between orthopaedists and radiologists in evaluating images of patients admitted to our emergency department was found, although treatment change occurred in about half of cases. A thorough and accurate clinical evaluation is crucial to provide a correct treatment and prognosis.