Background: The biceps tendon is a known source of shoulder pain. Few high-level studies have attempted to determine whether biceps tenotomy or tenodesis is the optimal approach in the treatment of biceps pathology. Most available literature is of lesser scientific quality and shows varying results in the comparison of tenotomy and tenodesis. Purpose: To compare patient-reported and objective clinical results between tenotomy and tenodesis for the treatment of lesions of the long head of the biceps brachii. Study Design: Randomized controlled trial; Level of evidence, 1. Methods: Patients aged ≥18 years undergoing arthroscopic surgery with intraoperative confirmation of a lesion of the long head of the biceps tendon were randomized. The primary outcome measure was the American Shoulder and Elbow Surgeons (ASES) score, while secondary outcomes included the Western Ontario Rotator Cuff Index (WORC) score, elbow and shoulder strength, operative time, complications, and the incidence of revision surgery with each procedure. Magnetic resonance imaging was performed at postoperative 1 year to evaluate the integrity of the procedure in the tenodesis group. Results: A total of 114 participants with a mean age of 57.7 years (range, 34 years to 86 years) were randomized to undergo either biceps tenodesis or tenotomy. ASES and WORC scores improved significantly from pre- to postoperative time points, with a mean difference of 32.3% ( P < .001) and 37.3% ( P < .001), respectively, with no difference between groups in either outcome from presurgery to postoperative 24 months. The relative risk of cosmetic deformity in the tenotomy group relative to the tenodesis group at 24 months was 3.5 (95% CI, 1.26-9.70; P = .016), with 4 (10%) occurrences in the tenodesis group and 15 (33%) in the tenotomy group. Pain improved from 3 to 24 months postoperatively ( P < .001) with no difference between groups. Cramping was not different between groups, nor was any improvement in cramping seen over time. There were no differences between groups in elbow flexion strength or supination strength. Follow-up magnetic resonance imaging at postoperative 12 months showed that the tenodesis was intact for all patients. Conclusion: Tenotomy and tenodesis as treatment for lesions of the long head of biceps tendon both result in good subjective outcomes but there is a higher rate of Popeye deformity in the tenotomy group. Registration: NCT01747902 ( ClinicalTrials.gov identifier)

Purpose Patella alta is a risk factor for patellofemoral pain and instability. Several measurement methods and imaging modalities are in use to measure patellar height. The first aim of this study was to determine the intra-and interrater reliability of different patellar height measurement methods on conventional radiography (CR), CT and MRI. The second aim was to examine the applicability of patellar height measurement methods originally designed for CR on CT and MRI. Methods Forty-eight patients who were treated for patellar instability were included. All patients had undergone a pre-operative conventional radiograph, CT scan and MRI. Five methods for measuring patellar height were performed on radiographs, CT and MRI by four observers. For each measurement, the intra-and interrater reliability was determined by calculating the intra-class correlation coefficient (ICC). A Bland-Altman analysis was performed for measurements with an ICC ≥ 0.70. ResultsThe Insall-Salvati (IS) ratio was the only measurement that showed good intra-and inter-observer reliability on CR, CT and MRI. The intra-and inter-observer reliability of the patellotrochlear index (PTI) for MRI was good to excellent for all observers. The IS ratio showed a moderate to good reliability for comparison of all three imaging modalities with the best agreement between radiography and MRI. The other patellar height measurements showed only poor to moderate inter-method agreement. Conclusion In this study, the Insall-Salvati ratio shows better intra-and inter-observer reliability than the Blackburne-Peel ratio, the Caton-Deschamps ratio and the modified Insall-Salvati ratio on all imaging modalities. Radiography and CT seem to have better reliability than MRI. The patellotrochlear index, however, shows good inter-and intra-observer reliability on MRI. Only for the IS method was there acceptable agreement between CR and MRI. This means that the established Insall-Salvati normal values could be used for MRI as well. This study shows that the most reliable method to measure patella height is the Insall-Salvati ratio measured on conventional radiographs or the patellotrochlear index on MRI. Level of evidence Level II diagnostic.

Isolated posterior cruciate ligament (PCL) injuries are uncommon and can be easily missed with physical examination. The purpose of this article is to give an overview of the clinical, diagnostic and arthroscopic evaluation of a PCL injured knee. There are some specific injury mechanisms that can cause a PCL including the dashboard direct anterior blow and hyperflexion mechanisms. During the diagnostic process it is important to distinguish between an isolated or multiligament injury and whether the problem is acute or chronic. Physical examination can be difficult in an acutely injured knee because of pain and swelling, but there are specific functional tests that can indicate a PCL tear. Standard x-ray’s and stress views are very useful imaging modalities but magnetic resonance imaging remains the gold standard imaging study for detecting ligament injuries. Every knee scope should be preceded by an examination under anesthesia. Specific arthroscopic findings are indicative of a PCL tear such as the “floppy ACL sign” and the posteromedial drive through sign. History, physical examination and imaging should all be combined to make an accurate diagnosis and initiate appropriate treatment.

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A 52-year-old man presented to the emergency department with acute severe epigastric pain that had existed for 2 hours. He had no prior medical history or recent abdominal trauma. Physical examination revealed normal hemodynamic parameters and tenderness over the epigastric area without rebound tenderness. Laboratory blood tests were normal except for an elevated serum lactate (4.1 mmol/l). An abdominal ultrasound scan was without pathological findings.Abdominal computed tomographic angiography (CTA) showed an isolated dissection of the superior mesenteric artery (SMA), without ischemic changes of the bowel (Panel A). Digital subtraction angiography (DSA) confirmed the dissection (Panel B). Via transfemoral approach, two stents were placed proximally in the SMA (Panel C). Postprocedural angiography showed filling of the true lumen of the SMA with good outflow. Three hours post-intervention, serum lactate levels had normalized and pain was resolved.The post-procedural course was uneventful and the patient was discharged on the second post-procedural day with prophylactic acetylsalicylic acid. After 6 months' follow-up, repeated abdominal duplex ultrasonography showed normal flow in the SMA and the patient remained in a good clinical condition and was free of complaint.Isolated spontaneous dissection of the SMA is rare. Several reported risk factors include atherosclerosis, fibromuscular dysplasia, pregnancy, connective tissue disorders, Vascular Medicine 16(1) 79-80