Ossification of the posterior capitellum: description of a new pathology and its radiological appearance.

BACKGROUND: Boxer elbow and handball goalkeeper elbow are causes of impingement characterized by osteophytes formation at the olecranon and coronoid tip as well as their corresponding fossae. Herein, we present another distinct pathology in these patients: the formation of an exostosis at the posterolateral aspect of the elbow. METHODS: Between April 2016 and May 2020, 12 athletes with boxer elbow and handball goalkeeper elbow (mean age of 22 years) suffering from elbow pain were enrolled in the present study. Plain radiography, magnetic resonance imaging (MRI), and computer tomography (CT) scans were used to evaluate the bone conformation of the posterolateral aspect of the elbow. Assessment and staging of the ossification was performed by two independent fellowship-trained elbow surgeons. RESULTS: Bone marrow edema of the posterior aspect of the elbow at the origin of the anconeus muscle was initially detected in MRI scans. With the progression of the condition, imaging revealed an ossification posterior to the capitellum with bony bridges. In the advanced stage of the disease, the exostoses was unstable as the ossification had no adherence to the posterior capitellum during surgical excision. Plain radiographs are limited in their ability to detect the condition, whereas MRI and CT scans allow to identify a signal enhancement at the posterolateral aspect of the elbow. CONCLUSION: In patients without history of elbow trauma, bony irregularities of the posterior aspect of the capitellum may indicate ossification of the posterolateral aspect of the elbow, most likely caused by repetitive hyperextensions.

Reliability, validity and critical appraisal of the cross-cultural adapted German version of the Mayo Elbow Performance Score (MEPS-G).

BACKGROUND: The Mayo Elbow Performance Score (MEPS) is a rating system consisting of four dimensions to evaluate elbow performance. It is a common tool for assessment of elbow impairments worldwide. We determined the validity and reliability of its German version (MEPS-G) after cross-cultural adaptation. METHODS: Six investigators examined 57 patients with elbow pathologies. The MEPS-G was compared to validated elbow scores such as the German versions of DASH, the Oxford Elbow Score, pain level and subjective elbow performance on a VAS. Inter-rater reliability (IRR) and validity of the score and its dimensions were also reviewed. Verification was performed using the intraclass correlation coefficient (ICC), the prevalence and bias with adjusted Kappa (PABAK) and the Spearman correlation. RESULTS: The IRR of the MEPS-G score was moderate (ICC (2.1) = 0.65). The IRR of the four individual dimensions was moderate to high (KPABAK = 0.55 -0.81). Validity for the sum score (r = 0.52-0.65) and the dimensions pain (r = 0.53-0.62), range of motion (r = 0.7) and stability (r = - 0.61) was verified. The function subscale reached insufficient validity (r = 0.15-0.39). CONCLUSION: The MEPS-G is not sufficiently valid, which is consistent with its English version. The patient-based dimensions were a weakness, demonstrating high risk of bias. There is no general recommendation for the utilization of the MEPS-G as outcome measurement for patients with elbow pathologies.

Results after arthroscopic treatment of iliopsoas impingement after total hip arthroplasty.

BACKGROUND: A cause of groin pain after total hip arthroplasty (THA) is mechanical irritation or impingement of the iliopsoas tendon. The incidence is about 4%. If conservative therapy fails, an arthroscopic release of the iliopsoas tendon can be performed. The aim of the study was to assess the mid-term clinical outcome after arthroscopic release. We hypothesize that good results can be achieved by a minimally invasive endoscopic procedure. METHODS: Using our in-house database, all patients who received an endoscopic release of the iliopsoas tendon due to mechanical irritation after THA were identified. Inclusion criteria were mechanical irritation of the iliopsoas tendon after cementless THA with minimal acetabular component prominence. Exclusion criteria were marked prominence of the acetabular component and groin pain after THA for any other reason. In these patients, the modified Harris Hip Score (mHHS), the pain level using the numerical analogue scale and the UCLA Activity Score were measured. The mean follow-up period was 7 ± 3.8 (2.6-11.7) years. RESULTS: 25 patients were identified in whom an arthroscopic release of the iliopsoas tendon had been performed since 2007. The data of 20 patients were available at follow-up. The gender ratio was 1:1, the average age at the time of arthroscopy was 59 ± 27.7 (52-78) years. The average interval between THA and arthroscopy was 6.3 ± 4.0 (1.7-15) years. The mHHS showed a significant improvement from preoperative 31.2 ± 9.8 (17.6-47.3) to 82.0 ± 9.8 (46.2-100) points (p = 0.001). The pain level on the NAS decreased significantly from 8.5 ± 1.2 (7-10) to 2.5 ± 1.8 (0-6) points (p = 0.001). The activity level based on the UCLA Activity Score raised from 4.0 ± 2.7 (0-7) to 6.5 ± 1.8 (3-9) (p = 0.09). CONCLUSION: Mechanical irritation and impingement of the iliopsoas tendon is an important diagnosis to be considered in persistent groin pain after total hip arthroplasty. In failure of non-operative treatment, good clinical results can be achieved with arthroscopic release and the pain level can be significantly reduced. LEVEL OF EVIDENCE: IV.

[Bony contact in arthritic and healthy elbow joints : Studies in cadaveric specimens]. / Knöcherne Kontaktpunkte im arthrotischen und gesunden Ellenbogengelenk : Studie am humanen Leichenpräparat.

BACKGROUND: Arthroscopic and open debridement arthroplasty for elbow arthrosis produce excellent results. Resection of the tip of the olecranon and coronoid, as well as debridement of the associated fossae, is frequently described as sufficient for restoring range of motion and reducing pain. OBJECTIVES: The purpose of this study was to demonstrate that medial and lateral osteophytes of the olecranon and the coronoid usually mark the first bony contact and may, therefore, restrict range of motion. MATERIAL AND METHODS: 11 fresh-frozen elbows were dissected. The fossae were coated with Optosil P Plus (C-silicone), and maximal flexion and extension was simulated. The distribution of C­silicone impressions was documented. 6/7 donors were male. The mean age at the time of death was 82 . RESULTS: Out of 11 elbows, 4 exhibited arthritic changes. All arthritic elbows showed marginal osteophytes of the olecranon without characteristic dipping of the olecranon into its fossa. In 1/4 cases, additional osteophytes at the side of the coronoid were detected (in comparison to 1/7 in healthy elbows). CONCLUSION: The distribution of osteophytes in elbow arthrosis may be underestimated. Many clinicians describe a resection of the tip of the olecranon and the coronoid and debridement of the related fossa as sufficient. Our study supports the theory that marginal osteophytes, especially of the olecranon, should be resected during debridement arthroplasty, since the distribution of bony contact differs in arthritic and healthy elbows.

[Performance control after arthroscopic arthrolysis with capsulectomy in fresh-frozen elbow joints]. / Erfolgskontrolle nach arthroskopischer Arthrolyse mit Kapsulektomie am Ellenbogengelenk im Fresh-frozen-Präparat.

BACKGROUND AND OBJECTIVE: Posttraumatic or postoperative movement restrictions in elbow joints can often occur (including capsular contracture) and can generate everyday limitations. In persistent elbow stiffness, arthroscopic arthrolysis with removal of the dorsal and ventral capsule portions can be carried out. The purpose of this study was to assess the efficacy of arthroscopic capsulectomy by means of an in vitro anatomical study. METHODS: A standardized elbow arthroscopy with ventral and dorsal capsulectomy was performed and image-documented in five fresh-frozen elbow specimens. Subsequently, open dissection of the elbow joint was performed to analyze the amount of residual capsule by means of photodocumentation of the specimens. RESULTS: Regardless of the surgeon and surgical experience, anterior and posterior remnants of the capsule remained in all specimens. Dorsal capsule strands around the standard arthroscopy portals were noticed particularly more often in the area of the high dorsolateral camera portal. An incomplete capsulectomy was seen on the ulnar side at the level of the posterior medial ligament (PML) in the immediate vicinity of the ulnar nerve. Ventrally, a capsulectomy was performed from the radial side and also the ulnar side until the brachialis muscle and additionally a complete capsulectomy as far as the anterior medial ligament (AML) and radial collateral ligament (RCL) was achieved. The capsule was completely resected in a proximal direction. Distally, irrelevant capsular remnants were found in the region of the annular ligament and distal of the tip of the coronoid process. CONCLUSION: Arthroscopic arthrolysis can be performed with a high degree of radicality. The radicality must be self-critically taken into account in one's own action. The radicality of the portal change may even be higher ventrally than with an isolated column procedure. On the other hand, it must be critically considered that posteriorly, the PML cannot be adequately addressed by means of arthroscopy due to the risk of ulnar nerve injury. Portal changes might help to enable a more complete visualization of the joint capsule and may avoid leaving possibly relevant remnants of the capsule. If a release of the PML is required, this may have to be carried out in combination with an ulnar nerve release in a mini-open technique.

Reasons for surgical revision after conservatively treated radial head fractures-retrospective study of 70 patients.

BACKGROUND: An inadequate clinical outcome after conservatively treated radial head fractures is not uncommon. We analyzed the subjective limitations, objective complaints, and surgical procedures for radial head fractures initially treated conservatively. PATIENTS AND METHOD: Between 2007 and 2016, 70 patients (42 men, 28 women) who suffered from fracture sequelae after conservatively treated radial head fractures were examined. Demographic (age, 41.8 years, range, 16-75 years) and clinical data (pain, range of motion, instability) were retrospectively evaluated. RESULTS: The average time to surgery after trauma was 50 months (range, 5-360 months). In 38 cases, radial head fractures were initially treated with immobilization for 3.4 weeks (range, 1-8 weeks). Physiotherapeutic treatment was performed in 39 cases. In only half of the cases was retrospective Mason classification possible: 20 type I, 8 type II, 5 type III, and 2 type IV. Of the 70 patients, 53 had posttraumatic elbow stiffness; 34 had isolated lateral and four patients isolated medial ligament instability. There were eight cases with a combination of lateral and medial ligament instability and 27 cases of elbow stiffness combined with instability. An average of 1.2 (range, 1-4) surgical procedures per patient were performed. In all, 64 patients underwent elbow arthroscopy with arthrolysis and additional treatment depending on other injuries. The range of motion improved on average from preoperative flexion/extension of 131-15-0° to postoperative flexion/extension of 135-5-0° (gain in flexion: 4.2° and extension: 10.6°). CONCLUSION: Conservative treatment of radial head fractures does not always yield good results. Reasons for a poor outcome include chronic instability, cartilage damage, stiffness, or a combination thereof. Improved outcomes can be achieved via arthroscopic arthrolysis.

[Destruction of the radial head : Endoprosthesis, autologous reconstruction or anconeus arthroplasty?] / Destruktion des Radiuskopfes : Endoprothese, autologer Aufbau oder Anconeusplastik?

BACKGROUND: Radiocapitellar arthritis or defects most often result from trauma. Most of the patients are young and have high functional demands with high load capacities. Therefore, endoprosthetic options should be postponed for as long as possible. If conservative treatment cannot relieve symptoms sufficiently, radial head preservation, resection or replacement options are at the surgeon's disposal. In early stages of radiocapitellar arthritis, radial head preservation options can be taken into account. The chances ofgood results decrease with increasing cartilage damage. TREATMENT OPTIONS: In addition to radial head preservation options this article discusses radial head resection with and without anconeus interposition and radial head as well as radiocapitellar replacement. Clinical data are rare. The advantages and disadvantages of each option must be discussed with the patient and the decision should be made individually on the basis of patient specific factors. The aim must be to postpone endoprosthetic options - especially total elbow arthroplasty - for as long as possible, while assuring a functional range of motion with an acceptable pain level.