Validity, reliability and responsiveness of a French translation of the Western Ontario Osteoarthritis of the Shoulder index (WOOS).

INTRODUCTION: While several general questionnaires can be used to evaluate shoulder conditions, very few tools specifically evaluate the impact of shoulder osteoarthritis. The Western Ontario Osteoarthritis of the Shoulder index (WOOS) is a patient-reported outcome measure with excellent psychometric properties intended for patients suffering from shoulder osteoarthritis. Unfortunately, there is no validated French version of this questionnaire. OBJECTIVE: Produce a validated French version of the WOOS that is suitable for the Francophone populations of Europe and North America. MATERIAL AND METHODS: A validated protocol was used to create a French version of the WOOS (WOOS-Fr). Included were patients whose first language was French, who could read French and who had shoulder osteoarthritis destined for treatment (surgical treatment=arthroplasty). The WOOS-Fr was compared to the Disability of the Arm, Shoulder and Hand-French translation (F-QuickDASH-D/S) to assess its validity. Reliability and responsiveness were also analyzed. RESULTS: A French version of the WOOS (WOOS-Fr) was accepted by a multinational committee. The WOOS-Fr was validated in 71 French-speaking subjects. A strong positive correlation was found between the WOOS-Fr and the F-QuickDASH-D/S during the initial evaluation. The intra-class correlation (ICC) of the total WOOS-Fr score indicated good reliability between the initial WOOS and the 1-week WOOS (ICC: 0.84; 95% CI: [0.767; 0.896]; p-value: <0.001) in 57 patients. The responsiveness between the initial WOOS-Fr and at 1 year postoperative was high in the 36 operated patients (standardized mean response of 1.95). DISCUSSION: A French translation of the WOOS questionnaire was created and validated for use in French-speaking populations. This questionnaire will make it easier to evaluate the psychometric results of patients with shoulder osteoarthritis in Francophone countries. LEVEL OF EVIDENCE: III; multicenter cohort study.

A systematic scoping review of the latest data on orthobiologics in the surgical treatment of non-union.

INTRODUCTION: Recent studies have shown a growing concern regarding the cost-effectiveness and the lack of supporting data for the biologic agents that are being increasingly used in the orthopedic field. Our aim was to conduct a systematic scoping review of recent publications (last five years) on the use of orthobiologics to treat fracture non-union and summarize the latest available data. PATIENTS AND METHODS: The inclusion criteria for this review were articles published in English, from 2016 to 2022, and focusing on the use of orthobiologics for the surgical treatment of non-union. Searches were conducted in March 2023 using Pubmed/MEDLINE and Embase. Studies on spinal fusion or gene therapy were excluded. Reviews, case reports with five cases or less, conference proceedings, preliminary reports, pediatric or non-human studies were excluded as well. RESULTS: The search found 1807 articles, 15 were eligible after PRISMA checklist and exclusions. The evidence was heterogenous and there was only one level II RCT. Recent data suggests that bone morphogenic protein (BMP-2) products could be effective for septic and aseptic tibial non-unions. However, the evidence was not conclusive regarding BMP-7, plasma rich platelets (PRP), stem cells or demineralized bone matrix (DBM). DISCUSSION: Every non-union case is different in terms of bone defect, biology, mechanical stability, surgical technique and host factors, which contributes to the conflicting reports on the efficacy of orthobiologics in the literature. We might never see a level 1, high powered and robust study defining the efficacy, safety profile and cost-effectiveness of such products. LEVEL OF EVIDENCE: IV.

A novel fragment specific classification of complex olecranon fractures: 3-dimensional model design, radiological validation, and proposed surgical algorithm.

BACKGROUND: Current classifications for proximal ulna fracture patterns rely on qualitative data and cannot inform surgical planning. We propose a new classification system based on a biological and anatomical stress analysis. Our hypothesis is that fragment types in complex fractures can be predicted by the tendon and ligament attachments on the proximal ulna. METHODS: First, we completed a literature review to identify quantitative data on proximal ulna soft tissue attachments. On this basis, we created a 3-dimensional model of ulnar anatomy with SliceOMatic and Catia V5R20 software and determined likely locations for fragments and fracture lines. The second part of the study was a retrospective radiological study. A level-1 trauma radiological database was used to identify computed tomography scans of multifragmentary olecranon fractures from 2009 to 2021. These were reviewed and classified according to the "fragment specific" classification and compared to the Mayo and the Schatzker classifications. RESULTS: Twelve articles (134 elbows) met the inclusion criteria and 7 potential fracture fragments were identified. The radiological study included 67 preoperative computed tomography scans (mean 55 years). The fragments identified were the following: posterior (40%), intermediate (42%), tricipital (100%), supinator crest (25%), coronoid (18%), sublime tubercle (12%), and anteromedial facet (18%). Eighteen cases (27%) were classified as Schatzker D (comminutive) and 21 (31%) Mayo 2B (stable comminutive). Inter-rater correlation coefficient was 0.71 among 3 observers. CONCLUSION: This proposed classification system is anatomically based and considers the deforming forces from ligaments and tendons. Having a more comprehensive understanding of complex proximal ulna fractures would lead to more accurate fracture evaluation and surgical planning.

Validity, reliability and responsiveness of the French translation of the Patient-Rated Wrist Evaluation Questionnaire (PRWE).

INTRODUCTION: The patient-rated wrist evaluation questionnaire (PRWE) is a specific wrist questionnaire, developed in Canada that has been validated and proved reliable and sensitive. It assesses pain and function. Unfortunately, there was no validated French-language version. It is important that a translation should be methodologically rigorous, as both linguistic and cultural factors come into play. OBJECTIVE: To produce a French-language version of the PRWE, culturally adapted to the French-speaking populations of Europe and North America. MATERIALS AND METHODS: A validated protocol was used to produce a French-language version of the PRWE (PRWE-Fr) that would be culturally acceptable for the French-speaking populations of Europe and North America. Reliability and responsiveness analyses were performed and PRWE-Fr scores were compared to F-QuickDASH-D/S (French translation of short-form Disabilities of the Arm, Shoulder and Hand-Disability/Symptoms) scores to assess validity. RESULTS: A French-language version of the PRWE (PRWE-Fr) was accepted by a multinational committee, then validated in 65 French-speaking subjects, divided into 2 groups for analyses. A strong positive correlation was found between PRWE-Fr and F-QuickDASH-D/S scores. Comparison of results between two PRWE-Fr sessions at a 1-week interval found a very strong correlation (ρ=0.93; r2=0.868; p<0.001). The intraclass correlation coefficient for total PRWE-Fr score demonstrated excellent reliability (ICC: 0.93; 95% CI: [0.859; 0.969]; p<0.001). Responsiveness analysis revealed greater sensitivity to change than for the F-QuickDASH-D/S (standardized response mean [SRM], 1.14 versus 1.04 respectively). DISCUSSION: A French-language version of the PRWE was produced and validated for use in French-speaking populations. It should facilitate evaluation of results in French-speaking settings, collaboration in multinational studies and comparison between studies performed in different countries. LEVEL OF EVIDENCE: II; Multicenter cohort study.

2021 Chitranjan S. Ranawat Award: Intraosseous vancomycin reduces periprosthetic joint infection in primary total knee arthroplasty at 90-day follow-up.

AIMS: Infection complicating primary total knee arthroplasty (TKA) is a common reason for revision surgery, hospital readmission, patient morbidity, and mortality. Increasing incidence of methicillin-resistant Staphylococcus aureus (MRSA) is a particular concern. The use of vancomycin as prophylactic agent alone or in combination with cephalosporin has not demonstrated lower periprosthetic joint infection (PJI) rates, partly due to timing and dosing of intravenous (IV) vancomycin administration, which have proven important factors in effectiveness. This is a retrospective review of a consecutive series of primary TKAs examining incidence of PJI, adverse reactions, and complications using IV versus intraosseous (IO) vancomycin at 30-day, 90-day, and one-year follow-up. METHODS: A retrospective review of 1,060 patients who underwent TKA between May 2016 to July 2020 was performed. There were 572 patients in the IV group and 488 in the IO group, with minimal 30 days of follow-up. Patients were followed up at regularly scheduled intervals (two, six, and 12 weeks). No differences between groups for age, sex, BMI, or baseline comorbidities existed. The IV group received an IV dose of 15 mg/kg vancomycin given over an hour preceding skin incision. The IO group received a 500 mg dose of vancomycin mixed in 150 ml of normal saline, injected into proximal tibia after tourniquet inflation, before skin incision. All patients received an additional dose of first generation cephalosporin. Evaluation included preoperative and postoperative serum creatinine values, tourniquet time, and adverse reactions attributable to vancomycin. RESULTS: Incidence of PJI with minimum 90-day follow-up was 1.4% (eight knees) in the IV group and 0.22% (one knee) in IO group (p = 0.047). This preliminary report demonstrated an reduction in the incidence of infection in TKA using IO vancomycin combined with a first-generation cephalosporin. While the study suffers from limitations of a retrospective, multi-surgeon investigation, early findings are encouraging. CONCLUSION: IO delivery of vancomycin after tourniquet inflation is a safe and effective alternative to IV administration, eliminating the logistical challenges of timely dosing. Cite this article: Bone Joint J 2021;103-B(6 Supple A):13-17.

Impact of Valgus vs Varus Mechanical Axis Correction During Primary Total Knee Arthroplasty on Postoperative Periarticular Bone Mineral Density.

BACKGROUND: Knee periarticular bone mineral density (BMD) is influenced by limb malalignment. The purpose of this study is to determine if the nature and magnitude of alignment correction (ΔAlign°) performed during primary total knee arthroplasty (TKA) had an impact on BMD at the metaphysis of the distal femur (DFmr) and proximal tibia (PTb). METHODS: Seventy-one patients (male = 37 |female = 34; age: 65 ± 2 years) underwent full-length standing X-rays and knee-specific BMD measurements using dual-energy X-ray absorptiometry before and 3 and 6 months following TKA. A t-test was used to compare baseline demographics and knee-specific BMD measures (medial/lateral DFmr/PTb) between patients with preoperative valgus (VAL, N = 18) and varus (VAR, N = 53) malalignment. Pearson correlation analysis was used to determine if ΔAlign° correlated with site-specific knee BMD changes. A 2 (varus/valgus) by 3 (time) analysis of variance was used to compare site-specific BMD (%ΔBMD) changes following TKA. Type I error was set at α = 0.05 for all analyses. RESULTS: VAR patients had higher preoperative BMD for medial measurement at both the DFmr (VAR: 1.17 ± 0.06 g/cm2; VAL: 1.00 ± 0.09 g/cm2) and PTb (VAR: 1.41 ± 0.07 g/cm2; VAL: 1.29 ± 0.14 g/cm2) (P < .05). ΔAlign° and %ΔBMD were correlated on the medial side of the DFmr (r = 0.393, P < .05) and lateral/medial BMD ratio at the PTb (r = -0.670, P < .01) in VAL patients. Only VAL patients had significant %ΔBMD changes at 6 months postoperative with increases on the medial side only for the DFmr and PTb (+4%-8%, P < .05). CONCLUSION: Valgus patients exhibited reduced medial BMD at DFmr and PTb and showed sustained improvements 6 months postsurgery. Mechanical axis correction may be clinically impactful to bone remodeling when correcting valgus malalignment. LEVEL OF EVIDENCE: Level II, prospective cohort study.

Postoperative alignment in revision total knee arthroplasty, a comparison between intra and extra-medullary tibial alignment.

BACKGROUND: Revision total knee arthroplasty commonly involves stemmed components. If the diaphysis is engaged, this technique may be problematic for mechanical alignment (MA) in cases of tibial bowing, which are not infrequent (up to 30%). The aim of this study is to compare an intra-medullary(IM) and extra-medullary(EM) alignment method. We hypothesized that IM technique and canal-filling stems may result more frequently in valgus MA. On the other hand, an EM technique could produce less valgus knees but is at risk of creating MA outliers. METHOD: A retrospective radiographic analysis of revision TKAs was performed. The patients were divided to either the EM or IM alignment group and compared on the overall post-operative MA. The following parameters were measured on standing, long leg x-rays: Hip-knee-Ankle angle (HKA), mechanical lateral distal femoral angle and mechanical medial proximal tibial angle (mMPTA). RESULTS: 119 cases of revision TKAs were included (EM = 80, IM = 39). There was a difference between the EM and IM group for the mean mMPTA (89.94° vs 90.92°, effect size = 0.45, p = 0.013) and HKA angle (1.64° vs 0.05°, effect size = 0.52, p = 0.0064). A higher proportion of IM patients were in overall valgus alignment (16/39, 41%) vs EM group (16/80, 20%, p = 0.0134). Both techniques showed the same proportion of outliers, defined as HKA angle more than 5 degrees from neutral mechanical alignment (11/80 vs 5/39, p = 0.286). CONCLUSION: The extra-medullary alignment method with short cemented stems creates less valgus mechanical alignment than the intra-medullary technique with press-fit stems, without creating more MA outliers.

Novel Technical Factors Affecting Proximal Humerus Fixation Stability.

OBJECTIVES: Intra-articular screw cut-out is a common complication after proximal humerus fracture (PHF) fixation using a locking plate. This study investigates novel technical factors associated with mechanical failures and complications in PHF fixation. DESIGN: A retrospective radiological study. SETTING: Level 1 trauma center. PATIENTS/PARTICIPANTS: Clinical and radiological data from consecutive PHF patients treated between January 2007 and December 2013 were reviewed. INTERVENTION: Open reduction and internal fixation with the Synthes Philos locking plate. MAIN OUTCOME MEASUREMENTS: Postoperative radiographs were assessed for quality of initial reduction, humeral head offset, screw length, number and position, restoration of medial calcar support or the presence of calcar screws, and intra-articular screw perforations. Using SliceOMatic software, we validated a method to accurately identify screws of 45 mm or longer on AP radiographs. Follow-up radiographs were reviewed for complications. RESULTS: Among 110 patients included [mean age 60 years, 78 women (71%), follow-up 2.5 years] and the following factors were associated with a worse outcome. (1) Screws >45 mm in proximal rows [Odds Ratio (OR) = 5.3 for screw cut-out); (2) lateral translation of the humeral diaphysis over 6 mm (OR = 2.7 for loss of reduction); (3) lack in medial support by bone contact (OR = 4.9 for screw cut-out); (4) varus reduction increased the risk of complications (OR = 4.3). CONCLUSION: The importance of reduction and calcar support in PHF fixation is critical. This study highlights some technical factors to which the surgeon must pay attention: avoid varus reduction, maximize medial support, avoid screws longer than 45 mm in the proximal rows, and restore the humeral offset within 6 mm or less. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Factors affecting outcome of partial radial head fractures: A Retrospective Cohort Study.

BACKGROUND: The purpose of this study is to evaluate which factors will affect range of motion (ROM) and function in partial radial head fractures. The hypothesis is that conservative treatment yields better outcomes. MATERIALS AND METHODS: This retrospective comparative cohort study included 43 adult volunteers with partial radial head fracture, a minimum 1-year follow up, separated into a surgical and non-surgical group. Risk factors were: associated injury, heterotopic ossification, worker's compensation, and proximal radio ulnar joint (PRUJ) implication. Outcomes included radiographic ROM measurement, demographic data, and quality of life questionnaires (PREE, Q-DASH, MEPS). RESULTS: Mean follow up was 3.5 years (1-7 years). Thirty patients (70%) had associated injuries with decreased elbow extension (-11°, p=0.004) and total ROM (-14°, p=0.002) compared to the other group. Heterotopic ossification was associated with decreased elbow flexion (-9.00°, p=0.001) and fractures involved the PRUJ in 88% of patients. Only worker's compensation was associated with worse scores. There was no difference in terms of function and outcome between patients treated non-surgically or surgically. DISCUSSION: We found that associated injuries, worker's compensation and the presence of heterotopic ossification were the only factors correlated with a worse prognosis in this cohort of patients. Given these results, the authors reiterate the importance of being vigilant to associated injuries. LEVEL OF EVIDENCE: IV, Retrospective study.

Involvement of the proximal radial ulnar joint in partial radial head fractures: a novel three-dimensional computed tomography scan evaluation method.

BACKGROUND: Partial radial head fractures (PRHF) can involve the proximal radioulnar joint (PRUJ) or be restricted to the 'safe zone' (SZ) during forearm rotation. The objective of the present study was to develop an assessment method for PRUJ involvement in radial head fractures using axial computed tomography (CT) scans. METHODS: The area of the radial head in contact with the PRUJ zone was identified, and defined on 18 cadaveric elbows CT scans; the quantitative relationship between PRUJ zone and radial tuberosity was established. Then, four evaluators validated it on PRHF CT scan axial views, classifying the fractures as involving the PRUJ or not. RESULTS: Using the radial tuberosity as the 0° of a 360° circle, the SZ was within 108° to 212° clockwise for a right elbow and counter clockwise for the left elbow. Fifty-five consecutive (30 men, 25 women, mean age of 49 years) partial radial head fracture CT scans were classified: four in the SZ only, three in the PRUJ zone and 48 in both the PRUJ and SZ. The kappa for the inter- and intra-observer agreement was 0.517 and 0.881, respectively. CONCLUSIONS: Ninety-three percent of partial radial head fractures will involve the PRUJ and the geometric model developed allows their classification, potentially helping surgeons decide on optimal treatment. LEVEL OF EVIDENCE: Retrospective basic science study. Level III: anatomic study, imaging.

Impact of olecranon fracture malunion: Study on the importance of PUDA (Proximal Ulna Dorsal Angulation).

PURPOSE: The Proximal Ulna Dorsal Angulation (PUDA) is part of the proximal ulna's normal anatomy. The importance of restoring ulnar anatomy characteristics precisely after olecranon fracture is not known, however, failure to recreate the PUDA after surgery may result in poorer functional outcomes. The purpose of this study is to evaluate the impact of minimal proximal ulna malunion on elbow ROM and function at least one year after olecranon ORIF. METHOD: A retrospective comparative cohort study took place in three level-1 trauma centers. Forty-nine adult volunteers who underwent ORIF for olecranon fracture were included. Patients were separated into two groups according to PUDA malreduction-defined as more than 5° of difference between the fractured and the contralateral elbow. OUTCOME MEASUREMENTS: Radiographic ROM measurement, demographic data and quality of life questionnaires were recorded (PREE, MEPS, Q-DASH, SF12, VAS). RESULTS: The mean follow up was 3 years and 9 months (1-7 years). There was no difference in terms of outcome, quality of reduction or range of motion between patients treated with plate or tension band. The mean PUDA on the fracture side was different from the normal side (2.20 vs 4.90, p<0.001). Fourteen patients (29%) had PUDA malunion. Those patients had decreased elbow flexion (-7°, p=0.011), extension (-11.2°, p=0.013) and total ROM (-18.6°, p=0.006) as opposed to the control group. Both groups had comparable quality of life questionnaire scores. Alcohol consumption was the only risk factor associated with worse scores. CONCLUSION: Incidence of olecranon malunion-as defined by PUDA measurement - was 29% and it was associated with decreased elbow range of motion. Alcohol consumption was correlated with a worse prognosis in our series of patients. Tension band and plate fixation can maintain a good reduction in terms of PUDA and the choice of fixation method does not influence outcome. LEVEL OF EVIDENCE: III Therapeutic study.

Does malpositioning of the arm influence radiographic range of motion measurement?

PURPOSE: Radiographic range of motion measurement of the elbow has been shown to be both precise and reliable. For this method to be used routinely in research studies, it is important to describe its limits regarding: (1) rotation of the arm from the perfect lateral position and (2) the length of humerus and ulna visible on the radiograph. MATERIAL AND METHODS: A 3D bone reconstruction was performed from an upper limb CT scan. Planar radiographs were simulated for rotations of the elbow within a range of ±30o from the perfect lateral position. The field of view was modified, ranging from five visible centimeters of diaphysis on the radiograph to full visibility of the upper limb. RESULTS: The disparity was less than 2.5° (mean=0.68°, SD=0.43°) when the flexed arm was rotated between -30.0° (external rotation, ER) and + 18.0° (internal rotation, IR). When considering the extended arm, measured angles differed by less than 2.5° (mean=0.79°, SD=0.57°) within a range of -15.0° (ER) to +30.0° (IR). When a minimum of 12 cm of humerus and ulna, from the capitellum, were visible on the radiograph measured angles varied very slightly (mean disparity of 0.71°, SD= 0.71°). Finally a qualitative description of the appearance of the radiographs was included to help surgeons estimate acceptable degrees of rotation. CONCLUSION: Range of motion (ROM) measurement shows consistent results, despite 15 to 30 degrees of internal or external rotation. The middle third of the humeral and ulnar diaphyses should be visible on the radiographs to ensure the validity of measurement. Radiographic ROM measurement is still recommended over the goniometer for research purposes because of its high reliability and precision. Moreover, malpositioning of the elbow should not jeopardize results since it will most likely be an angle measurement variation of less than 2.5°.

Demographic and anthropometric factors affecting elbow range of motion in healthy adults.

BACKGROUND: To use elbow range of motion routinely as a diagnostic index, it is important to explain the normal variability among the population. Consequently, this study assessed the possible associations between age, sex, laterality, body mass index, joint laxity, level of physical activities, upper limb dimensions, and the elbow range of motion in flexion/extension. MATERIALS AND METHODS: Maximal flexion and extension were measured on the lateral radiographs of 102 elbows of 51 volunteers. The difference of range of motion regarding sex and laterality was assessed with Student t tests. The Pearson correlation coefficient was used to evaluate the relationship between elbow mobility and the other factors, and a stepwise multiple regression analysis was performed. RESULTS: Among the 51 volunteers, a correlation was found between flexion and body mass index, age, and midbrachial and forearm circumferences (r = -0.234 to -0.594). Age (r = 0.268) and hyperlaxity (r = -0.323) were the only factors associated with a change in elbow extension. No correlation was found between the level of physical activity or with the laterality and changes in elbow mobility. Finally, women presented with more flexion and total elbow range of motion than men. CONCLUSIONS: This study confirms the association between various demographic and anthropometric factors and elbow range of motion in healthy adults. Among these, the body mass index and forearm circumference are the most likely responsible for mobility variations among the population.

The influence of proximal ulnar morphology on elbow range of motion.

BACKGROUND: Physiologic dorsal apex angulation of the proximal ulna is present in 96% of the population. We hypothesize that a correlation exists between the physiologic dorsal ulnar angulation and elbow range of motion (ROM). METHODS: Fifty healthy adults underwent bilateral lateral elbow radiographs in neutral forearm rotation in the following positions: terminal flexion (TF), 90° of flexion, and terminal extension (TE). The proximal ulna dorsal angulation (PUDA), TF, and TE were measured on the digital lateral radiographs by 2 independent observers. ROM was calculated as the difference between TF and TE measurements. Subjects were divided into 2 groups: those with PUDA measurements less than the median and those with PUDA measurements equal to or greater than the median. The relationship between the PUDA and TE, TF, and ROM was evaluated by use of Pearson correlation coefficients. RESULTS: The mean age of the cohort was 31 ± 9 years, and there were 30 women among the 50 volunteers. The sample of 100 elbow radiographs had a mean TF of 150.8° ± 4.5°, a mean TE (ie, flexion contracture) of 11.5° ± 7.3°, and a mean ROM of 139.3° ± 8.4°. The mean PUDA was 5.2° ± 2.8°. Elbows with a greater PUDA had significantly less TE (r = 0.381, P ≤ .001) and ROM (r = -0.351, P ≤ .001). The group of elbows with a lesser PUDA had better TE (9.4° vs 13.6°, P = .004) and ROM (142.0° vs 136.7°, P = .001) than elbows with a greater PUDA. CONCLUSION: The increasing magnitude of the PUDA is associated with decreased maximal elbow extension and global elbow ROM.

Validity of goniometric elbow measurements: comparative study with a radiographic method.

BACKGROUND: A universal goniometer is commonly used to measure the elbow's ROM and carrying angle; however, some authors question its poor intertester reliability. QUESTIONS/PURPOSES: We (1) assessed the validity of goniometric measurements as compared with radiographic measurements in the evaluation of ROM of the elbow and (2) determined the reliability of both. METHODS: The ROM and carrying angle of 51 healthy subjects (102 elbows) were measured using two methods: with a universal goniometer by one observer three times and on radiographs by two independent examiners. Paired t-test and Pearson's correlation were used to compare and detect the relationship between mean ROM. The maximal error was calculated according to the Bland and Altman method. RESULTS: The intraclass correlation coefficients (ICC) ranged from 0.945 to 0.973 for the goniometric measurements and from 0.980 to 0.991 for the radiographic measurements. The two methods correlated when measuring the total ROM in flexion and extension. The maximal errors of the goniometric measurement were 10.3° for extension, 7.0° for flexion, and 6.5° for carrying angle 95% of the time. We observed differences for maximum flexion, maximal extension, and carrying angle between the methods. CONCLUSION: Both measurement methods differ but they correlate. When measured with a goniometer, the elbow ROM shows a maximal error of approximately 10°. CLINICAL RELEVANCE: The goniometer is a reasonable and simple clinical tool, but for research protocols, we suggest using the radiographic method because of the higher level of precision required.