Mayo classification of olecranon fractures revisited - Assessment of intra- and interobserver reliability based on CT scans.

Purpose: Olecranon fractures are classified using the commonly accepted Mayo classification. Its reliability has been analyzed by means of radiographs. A CT scan is often obtained due to joint involvement. Purpose of this study was to evaluate the intra- and interobserver reliability of the Mayo classification based on CT examination. Methods: Radiographic and CT images of 20 olecranon fractures were classified by four surgeons at two time points 30 days apart. Intra- and interobserver reliability were assessed using kappa coefficients. Results: Mean intraobserver reliability between X-rays was substantial and between CTs almost perfect (0.76 and 0.82, respectively). Mean interobserver reliability was fair for X-rays and moderate for CTs (0.32 and 0.44, respectively). Conclusion: Despite the more detailed imaging compared with radiography only moderate interobserver reliability was found for the classification of olecranon fractures based on CT imaging. This might lead to inconsistent fracture classification in both scientific and clinical setting.

Surgical arthrolysis of the stiff elbow: a systematic review.

INTRODUCTION: Stiffness after elbow injuries can severely limit daily life. If adequate conservative treatment does not result in satisfactory improvement of elbow function, surgical intervention should be considered. Whether an open or arthroscopic procedure is preferable is still a topic of debate and a systematic review of functional outcomes is lacking. MATERIALS AND METHODS: We systematically reviewed the available literature searching electronic databases, MEDLINE using the PubMed interface and EMBASE, for studies published between 2013 and 2021. Primary objective was to compare open and arthroscopic arthrolysis' functional outcomes, respectively, especially ROM and MEPS, as well as the accompanied complications. The PRISMA guidelines were applied. RESULTS: 27 studies comprising 1666 patients were included. 1059 patients (63.6%) were treated with open arthrolysis, and 607 patients (36.4%) were treated with arthroscopic arthrolysis. The results presented indicate satisfactory outcomes in open and arthroscopic arthrolysis with regard to functional outcome parameters. Treatment success, defined as excellent or good results according to the Mayo Elbow Performance Score, among the patients treated with an open procedure was 88.8%; 6.3% required revision whereas 18.1% had complications without the need for revision surgery. Within the cohort of arthroscopically treated patients, treatment success was 91.8%. Revisions and complications without further surgical intervention were significantly less frequent than in the open cohort, at 1.6% and 9.1%, respectively. CONCLUSIONS: Both open and arthroscopic arthrolysis provide good to excellent functional outcomes. Since the number of complications and revision increases with the invasiveness of the treatment, an arthroscopic procedure might be favored if feasible by indication. The role of forearm rotation and the use of a hinged external fixator remains of interest. STUDY DESIGN: Level IV; Systematic review.

Interposition arthroplasty for post-traumatic osteoarthritis of the elbow: a systematic review.

PURPOSE: Interposition arthroplasty for the post-traumatic osteoarthritic elbow is a salvage procedure used in young and active patients and remains a rare and unexplored therapeutic option. METHODS: We systematically reviewed the available literature searching electronic databases, MEDLINE using the PubMed interface and EMBASE. The primary objective was to synthesize functional outcomes and to investigate revision frequencies, but also complication and subsequent surgery rates among patients with surviving grafts. The preferred reporting guidelines for systematic reviews and meta-analyses guidelines were applied. RESULTS: Five studies were left for inclusion, all retrospective in design, comprising 67 patients. The mean age was 40 years, the mean follow-up period was 61 months, and 68.2% of the patients treated were male. Eleven patients (16.4%) were treated with fascia lata autografts, and 56 patients (83.6%) were treated with Achilles tendon allografts. The graft survived in 53 patients (79.1%); the post-operative Mayo Elbow Performance Score averaged 69 points. Fourteen patients (20.9%) required revision surgery. In the setting of graft survival, 39.1% of patients had complications not requiring further surgical treatment and 5.7% of patients with surviving grafts needed subsequent operative treatment within the follow-up period. CONCLUSION: Given graft survival, this systematic review demonstrated satisfactory functional outcomes following interposition arthroplasty of the post-traumatic osteoarthritic elbow, however, associated with a cumulative complication and subsequent operative treatment rate of 44.8%. In addition, a revision rate of 20.9% needs to be expected. Varus-valgus instability in the pre-operative clinical assessment seems to be associated with unsatisfactory post-operative elbow function. The superiority of either of the two main reported graft methods (fascia lata autograft and Achilles tendon allograft) remains pending, and the role of an external fixator in preventing post-operative instability remains unresolved.

What to expect? Injury patterns of Electric-Scooter accidents over a period of one year - A prospective monocentric study at a Level 1 Trauma Center.

PURPOSE: E-scooters are a new type of urban transportation utilized in Germany since June 2019, primarily in larger cities in the context of sharing offers. Such electrically operated standing scooters can be driven at a maximum speed of 20 km/h. A helmet is not mandatory. The aim of this prospective study is to document the injury patterns over the period of 1 year and compare our findings with already available data. METHODS: Over a period of 1 year (July 2019-July 2020), data on E-scooter-related accidents treated at a level 1 trauma center of a major German city were prospectively documented. Injury patterns were analyzed, and epidemiological data evaluated. RESULTS: Fifty-nine (35 female, 24 male) accidents were included in the observation period. Mean age of accident victims was 30.03 years (± 9.32). Alcohol influence at the time of accident was detected in 9 cases (15.25%). Many of the accident victims suffered multiple injuries. Most of the injuries were upper (50.84%) and lower extremity (47.45%) as well as craniofacial injuries (62.71%). A helmet was not worn in any of the cases. CONCLUSION: In the year following their introduction, E-scooter-related accidents have led to an additional burden on the emergency capacities of the involved University Hospital, especially in the summer months of 2019. Protective equipment is de facto not worn. Injuries to the extremities, head, and face were most common. None of the accident victims died. This coincides with results from other major cities in national and international comparison. A more intensive education about injury consequences of unprotected E-scooter use and the discussion of a possible obligation to wear a helmet and further protection equipment for the extremities should take place.

The effect of metaglene lateralization on joint mobility of reverse shoulder arthroplasty: A cadaveric biomechanical study.

INTRODUCTION: Lateralization of the metaglene reduces scapular notching or impingement. However, the effect on joint mobility remains unclear. With increased attention to reverse shoulder arthroplasty over the past years, the aim of this biomechanical study is to analyze the effect of metaglene lateralization on range of motion in reverse shoulder arthroplasty. METHODS: Reverse shoulder arthroplasty (DeltaXtend; Fa. Depuy/Synthes) was performed in 7 cadaveric shoulders. Lateralization of the metaglene was performed in increments, using spacers of +0 mm (subgroup I), +5 mm (subgroup II), +10 mm (subgroup III). Deltoid muscle (pars clavicularis, acromialis and spinalis), teres minor (TMI), infraspinatus (IF) and subscapularis muslces (SSC) were loaded separately. Range of motion was measured by using a motion capture system (Optotrak Certus) in the sagittal plane (z-axis), coronar plane (x-axis) and transversal plane (y-axis). A custom-made biomechanical test set up was used to test the samples with a constant preload with additional testing load up to 4 kg on each muscle. RESULTS: Specimens showed a tendency towards increased range of motion in abduction (deltoid, pars acromialis), external rotation (IS/TMI) and internal rotation (SSC) in subgroup II, compared to subgroups I and III, without reaching the level of significance Abduction at maximum used load was 46° (subgroup I), 62° (subgroup II) and 22° (subgroup III). The mean external rotation (ISF) at maximum used load was 25° (I), 28° (II) and 24° (III). Mean internal rotation was 22° (subgroup I), 48° (subgroup II) and 26° (subgroup III). CONCLUSION: Moderate lateralization of the glenosphere of +5 mm has improved the range of motion in our experimental cadaveric setup. Especially a higher internal and external rotation can be reached with less load.Level of evidence III.

Fractures around the hip: inducing life-like fractures as a basis for enhanced surgical training.

INTRODUCTION: In this study we investigated if realistic fracture patterns around the hip can be produced on human cadaveric specimens with intact soft tissue envelope. Possible applications of such fractured specimens would be in surgical training. MATERIALS AND METHODS: 7 cadaveric specimens (2 male, 5 female, 2 formalin-fixed, 5 fresh-frozen) were fractured. 2 specimens were fractured on both femurs, 5 only on one side, resulting in 9 fractures total. 5 fractures were set in our custom-made drop-test bench, 2 fractures by inducing axial force using a hammer, and the remaining 2 fractures by a direct dorsal approach and a chisel. AO/OTA and Pauwels classification were used to classify the fractures on the specimens by two independent trauma surgeons. RESULTS: In our drop-test bench, axial load with the femur adducted by 10° resulted in an intertrochanteric fracture (AO type A1.3), adducted by 20° resulted in a femoral neck fracture (Pauwels type III). Fracture induction using a hammer resulted in two intertrochanteric fractures (AO type A2.2 right, A3.3 left). The use of a chisel resulted in both cases in a femoral neck fracture. The acetabulum could be fractured multifragmentarily through use of a hemiprosthesis as a stamp. CONCLUSION: A high energetic impulse induced by a custom-made drop-test bench can successfully simulate realistic proximal femur and acetabular fractures in cadaveric specimens with intact soft tissue. Furthermore, axial load using a hammer as well as using a chisel through a direct dorsal approach represent additional methods for fracture induction. These pre-fractured specimens can be utilized in surgical education to provide a realistic teaching experience for specialized trauma education courses.

Inducing life-like distal radius fractures in human cadaveric specimens: a tool for enhanced surgical training.

INTRODUCTION: Surgical education consists often times of a discrepancy between necessary amount of provided operative teaching and amount of organizational and ward duties. Operative education is often cut to a minimum. As public awareness toward surgical competence raises, so must the educational system. Courses that provide pre-fractured cadaveric specimens can facilitate surgical teaching realistically, prior to operating on living patients. The aim of this study is to introduce a realistic distal radius fracture simulation setup. MATERIALS AND METHODS: 12 cadaveric specimens (3 male, 9 female) were fixed onto a custom drop-test-bench in the hyperextension of the wrist. The forearm was cut midway between elbow and carpus. The distal part of the forearm was potted, and the specimen was exposed to a high energetic impulse. CT imaging was performed after fracture simulation to detect the exact fracture patterns. We used the AO/ASIF recommendations and four-corner concept to classify the achieved fractures by two independent trauma surgeons. RESULTS: All cadaveric specimens could be successfully fractured. 11 fractures were classified as type 23C3.2 and one was classified as type 23C3.3, as additional fracture of diaphysis occurred. Subclassification according to the four-corner concept showed all fractures to be type C. A concomitant ulnar styloid fracture was observed in 4 cases. Furthermore, all cases showed at least one fragment involving the sigmoid notch. There was no statistically significant correlation found regarding Hounsfield Units (HU) and age (p value 0.402), as well as HU and required kinetic energy (p value 0.063). CONCLUSION: A high energetic impulse induced by a custom-made drop-test bench can successfully simulate realistic distal radius fractures in cadaveric specimens with intact soft tissue. Furthermore, these pre-fractured specimens can be utilized in surgical education to provide a teaching experience as realistic as possible without harming living patients.

Reverse shoulder arthroplasty: the role of physical therapy on the clinical outcome in the mid-term to long-term follow-up.

INTRODUCTION: Reverse shoulder arthroplasty shifts the rotational center of the shoulder joint caudally and medially to restore shoulder function in a rotator cuff deficient shoulder. Despite promising results in early- and mid-term follow-up, long-term loss in shoulder function has been described in the literature. A lack of exercise in elderly patients may be one reason for this loss in function. This study examines the functional benefits of physical therapy in the mid-term to long-term follow-up regarding the subjective and objective shoulder function. MATERIALS AND METHODS: Twenty patients with a mean age of 73 years were included in this series. The study was performed as a single-center, prospective study. Initial indications for reverse shoulder arthroplasty were cuff tear arthropathy, failed anatomical shoulder arthroplasty, and fracture sequelae. The patients were clinically examined at a mean follow-up of 62 months using the Constant score (CS) and the DASH score for the operated and the non-operated shoulder. They were reevaluated using the same scores following a standardized physical therapy program of 6 weeks' duration. RESULTS: The mean CS as well as the mean age- and gender-adjusted CS of the affected shoulder improved significantly from 53.5 to 59.3 points, and 72.7-80.8%, respectively. The subcategories activities of daily living (ADL) and range of motion (ROM) of the CS improved significantly, whereas no significant improvement was observed for the subcategories pain and strength. Evaluating the contralateral shoulder, no significant change was observed for the age- and gender-adjusted CS and the CS as well as its subcategories. We found no significant difference in the CS comparing the different etiologies prior to physical therapy. DISCUSSION: Physical therapy plays an important role subsequent to reverse shoulder arthroplasty. It also has an effect in the mid-term to long-term follow-up regarding the range of motion as well as activities of daily living. However, physical therapy seems to have limited effect on the strength and the residual pain level. LEVEL OF EVIDENCE: Level III.

Reverse shoulder arthroplasty: the role of physical therapy on the clinical outcome in the mid-term to long-term follow-up.

INTRODUCTION: Reverse shoulder arthroplasty shifts the rotational center of the shoulder joint caudally and medially to restore shoulder function in a rotator cuff deficient shoulder. Despite promising results in early- and mid-term follow-up, long-term loss in shoulder function has been described in the literature. A lack of exercise in elderly patients may be one reason for this loss in function. This study examines the functional benefits of physical therapy in the mid-term to long-term follow-up regarding the subjective and objective shoulder function. MATERIALS AND METHODS: Twenty patients with a mean age of 73 years were included in this series. The study was performed as a single-center, prospective study. Initial indications for reverse shoulder arthroplasty were cuff tear arthropathy, failed anatomical shoulder arthroplasty, and fracture sequelae. The patients were clinically examined at a mean follow-up of 62 months using the Constant score (CS) and the DASH score for the operated and the non-operated shoulder. They were reevaluated using the same scores following a standardized physical therapy program of 6 weeks' duration. RESULTS: The mean CS as well as the mean age- and gender-adjusted CS of the affected shoulder improved significantly from 53.5 points to 59.3 points, and 72.7-80.8%, respectively. The subcategories activities of daily living and range of motion of the CS improved significantly, whereas no significant improvement was observed for the subcategories pain and strength. Evaluating the contralateral shoulder, no significant change was observed for the age- and gender-adjusted CS and the CS as well as its subcategories. We found no significant difference in the CS comparing the different etiologies prior to physical therapy. DISCUSSION: Physical therapy plays an important role subsequent to reverse shoulder arthroplasty. It also has an effect in the mid-term to long-term follow-up regarding the range of motion as well as activities of daily living. However, physical therapy seems to have limited effect on the strength and the residual pain level. LEVEL OF EVIDENCE: Level III.

Is the stemless humeral head replacement clinically and radiographically a secure equivalent to standard stem humeral head replacement in the long-term follow-up? A prospective randomized trial.

BACKGROUND: Stemless humeral head replacement represents a young generation of shoulder arthroplasty. This study evaluated the differences of this new stemless design compared with the fourth-generation standard stemmed design. METHODS: Total shoulder arthroplasty was performed in 20 patients with a stemless shoulder prosthesis (group 1) and in 20 patients with a standard stem humeral head replacement (group 2). Twenty-nine patients were examined clinically and radiographically at a minimum follow-up of 2 years and a minimum follow-up of 5 years. Functional results were assessed using the age- and gender-related Constant Score (CS). The radiographic analysis used native x-rays in 3 planes. RESULTS: The postoperative CS improved significantly in both groups, with no significant difference between the minimum of 2-year and 5-year follow-up. The difference in the CS, its subcategories, and active range of motion between the implant groups was not significant. A significant difference was observed in the radiographic analysis for the zone adjacent to the humeral calcar, with a lower bone mineral density in 41% of group 2 and in 0% in group 1. Radiolucent lines were statistically more frequent in group 2. No statistical differences were observed between the implant groups for the change of the inclination angle, the medial offset, and the lateral offset. CONCLUSION: Both implants showed consistently good functional and radiologic results without a significant difference and achieved an anatomic reconstruction of the humeral head geometry in the coronal plane.

The metaphyseal bone defect predicts outcome in reverse shoulder arthroplasty for proximal humerus fracture sequelae.

Reverse shoulder arthroplasty (RSA) represents an established procedure for treatment of fracture sequelae (FS) after proximal humerus fractures. The present work evaluates which factors are of influence for the clinical outcome. Fifty cases (mean age 69, range 44-89) have been evaluated postoperatively clinically [Constant Score (CS)] and radiographically (mean FU 34; range 24-93 months). The type of primary treatment, the amount of a metaphyseal bone defect, the preoperative status of the rotator cuff, the number of previous operative interventions and the type of FS according to Boileau were analysed whether they are of influence for clinical outcome. The mean CS increased significantly from 16.9 ± 6.7 preoperatively to 54.1 ± 15.7 points postoperatively. The CS of primary conservative treatment was significantly higher in comparison to primary operative treatment. Patients with a metaphyseal bone defect of more than 3 cm had significantly lower CS results. Degenerative changes of the teres minor muscle also had a significant negative influence on clinical results. Score results decreased with increasing number of previous operations. There were no significant difference in between patients classified as Boileau type I and II (category 1) compared to types III and IV (category 2). RSA significantly improved the clinical result. A metaphyseal bone defect and preoperative degeneration of the teres minor showed to be negative prognostic factors. Primary operative treatment and the number of previous operations also negatively influenced the clinical result.