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Background: Instabilities of the elbow joint can occur acutely in the context of elbow dislocation as well as chronically after inadequate healing of atraumatic ligament tear or due to repetitive microtraumata, especially in throwers. Method: Comparative review using PubMed. Inductive reasoning.Results: The diverse reasons for elbow instability cant always be reliably detected in individual cases,. The basis for specific diagnostics may often be found in the anamnesis. The duration of trauma or alternatively in case of non-traumatic complaints the beginning of symptomatology should be determined. A variety of known clinical tests can assist in searching for instability. But an established objective diagnostic is not yet known. In general, this might be the greatest diagnostic and therapeutic difficulty of elbow instability.Discussion: Decisive in the therapeutic procedure is the correct detection of the prevailing instability and the observation of the therapeutic time window for the refixation of the ligament complex in acute traumatic cases. In case of chronic microinstability, the patients personal level of suffering at the maximum load of the affected extremity in terms of occupation, everyday life and sports must also be taken into account in order to make recommendations for surgery. Correspondingly, the anatomically correct reconstruction of the injured structures must be achieved in order to meet biomechanical requirements and to avoid secondary degenerative sequelae.KEY WORDS: Instability, Elbow Luxation, Thrower Elbow, Posterolateral Rotation Instability, Lucl Ligament Repair

Introduction: Avoiding overlengthening in radial head arthroplasty (RHA) is essential for the prognosis of the elbow joint. An overlengthening from 2 mm is visible due to widening of the anterolateral ulnohumeral joint space but intraoperatively, this particular joint space is difficult to visualize. The commonly used Kocher approach allows visualization of the posterolateral joint space without additional instruments or further surgical release of the already unstable elbow. The aim of our study was to investigate whether the visualization of the posterolateral joint space is also a reliable method to indicate overlengthening in RHA., Material and Methods: RHA was performed in five human cadaveric specimens with the forearm, wrist, and hand intact. The lateral ligament complex was detached and an anatomic transosseous refixation was performed. Six stages of implantation heights were documented: native joint (1), RHA at the anatomic height (2), + 2 mm (3), + 4 mm (4), + 6 mm (5) and - 2 mm (6). Macroscopic measurement and digital image analysis of the posterolateral and anterolateral ulnohumeral joint spaces were performed., Results: All stages of overlengthening showed a significant increase in posterolateral and anterolateral joint space widening (p < 0.05). The posterior and anterior joint space showed excellent intraclass correlation., Conclusion: Visualization of the posterolateral aspect of the ulnohumeral joint space is a reliable indicator for overlengthening in RHA without further compromising an already unstable elbow. Correlation to the findings of the anterolateral ulnohumeral joint space in different implants leads to the assumption that visualization of either the anterior or posterior ulnohumeral joint space is universally applicable to determine overlengthening in RHA, regardless of the type of the radial head implant., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

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., (© 2022. The Author(s).)

Background: Epicondylosis of the elbow are common pathologies, with a higher incidence for radial epicondylosis. Approximately 90% are self-limiting under conservative treatment., Treatment: Multiple surgical procedures exist for the treatment of refractory cases. Arthroscopic treatment has been described for both radial and medial pathologies. Open and arthroscopic procedures show equivalent results in the surgical treatment of radial epicondylosis. This paper describes the most common open surgical procedures for the treatment of radial epicondylosis. Furthermore, the pros and cons of the arthroscopic versus the open approach are discussed, and the indications for an open surgical procedure for radial pathologies are highlighted. The authors believe that the open technique represents the standard treatment in the surgical treatment of ulnar epicondylosis., Limitations: Arthroscopic procedures have been described, but studies comparing the clinical outcome versus open surgical treatment are lacking. The anatomic proximity of the flexor origin to the ulnar nerve with the risk of iatrogenic damage is another limiting factor. In addition, concomitant pathologies on the ulnar side can better be ruled out preoperatively, so that arthroscopy has a rather low significance in the treatment of ulnar epicondylosis., (© 2023. The Author(s), under exclusive licence to Springer Medizin Verlag GmbH, ein Teil von Springer Nature.)

Objective: Neutralizing a posteromedial rotatory instability (PMRI) caused by coronoid deficiency by restoration of the humeroulnar joint surface with an autologous iliac crest bone graft., Indications: Surgery is indicated in patients with chronic deficiency of the anteromedial facet of the coronoid with subsequent PMRI., Contraindications: Coronoid reconstruction is not recommended in patients with advanced osteoarthritis of the elbow caused by subluxation of the humeroulnar joint. General contraindications like acute infection, pregnancy and lack of operability should also be taken into account., Surgical Technique: First, a medial approach is established and the base of the coronoid is prepared. Afterwards an autologous iliac crest bone graft is placed onto the defect and secured by screws or a plate. In addition, a reconstruction of the anterior bundle of the medial collateral ligament with an autologous tendon graft is performed., Postoperative Management: An elbow orthesis is worn for 6 weeks after surgery to avoid valgus or varus stress. There is no restriction in range of motion. A continuous passive motion elbow chair supports the patient in regaining elbow mobility., Results: Between 2015 and 2017, we treated 10 patients suffering from chronic coronoid defects with coronoid reconstruction. Eight of the patients were available for follow-up 86 weeks after surgery. The mean age was 41.4 years. In all patients, elbow range of motion and patient-related outcome measures were improved after surgery. Plain radiographs illustrated correct centering of the elbow joint. One patient had to undergo elbow arthroplasty and was excluded. Coronoid reconstruction with an autologous iliac crest bone graft restored humeroulnar joint congruency and improved satisfaction in patients suffering from chronic coronoid deficiency., (© 2022. The Author(s).)

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 (K PABAK  = 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., (© 2022. The Author(s).)

Background: In patients with chronic lateral epicondylitis who have failed nonoperative treatment, open or percutaneous release of the common extensor origin (CEO) without subsequent reconstruction tends to result in good clinical outcomes. However, surgery can lead to iatrogenic injuries of the lateral collateral ligamentous complex, causing posterolateral rotatory instability (PLRI)., Purpose: To determine the clinical outcomes of lateral ulnar collateral ligament (LUCL) reconstruction using a triceps tendon graft after failed open CEO surgery., Study Design: Case series; Level of evidence, 4., Methods: A total of 103, patients underwent revision surgery at a single institution because of PLRI after failed open release of the CEO (Hohmann procedure) between January 2007 and October 2016. The primary surgery had been performed at other institutions in all cases. Of these patients, 72 were available for follow-up (49 by clinical examination, 23 by telephone interview). Standardized clinical examination; Mayo Elbow Performance Score (MEPS); 11-item version of the Disabilities of the Arm, Shoulder and Hand Score (QuickDASH); subjective elbow value (SEV); and patient satisfaction were assessed at least 2 years after LUCL reconstruction., Results: The mean age of patients in the study was 46.9 years (range, 21-74 years), and the mean follow-up was 2.8 years after revision surgery. The mean MEPS was 78.9, and the mean QuickDASH score reached 20.4. The mean SEV was 78.6%, and 75% of the patients rated the surgery as good to excellent. Complications were detected in 14% of the patients, and 9 needed revision surgery, primarily owing to graft failure with recurrent instability (n = 5)., Conclusion: LUCL reconstruction in patients with PLRI after release of the CEO can restore elbow stability and achieve high patient satisfaction. However, outcome scores and revision rates in this cohort were inferior to published outcomes of primary LUCL reconstruction for treatment of noniatrogenic or traumatic PLRI., Competing Interests: The authors declared that there are no conflicts of interest in the authorship and publication of this contribution. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto., (© The Author(s) 2022.)

Background: Radial head arthroplasty is a common procedure in elbow surgery. It has been shown to be of benefit for the patients, but there also are relevant complications that should be prevented if possible. One significant complication is overlengthening of the radial head prosthesis. In overlengthening, the head of the prosthesis overextends the physiological level of the native radial head and leads to overcompression in the radiohumeral joint. Rapid erosion and arthritic changes may then impede the clinical outcome. The incidence of overlengthening is not precisely known, but estimations range to up to 20% of all implanted prostheses., Methods: The present review discusses the available body of literature on overlengthening and lines out a classification system that may be used to guide treatment algorithms. The classification is based on the personal experiences of the author during their clinical practice., Results: In low-grade overlengthening (type I) conservative treatment can be an option. In Types II-IV usually revision surgery is needed. Depending on the state of the capitulum and joint stability, it is possible re-implant a prosthesis, or rely on implant removal alone., Discussion: The present review aimed at shedding light into overlengthening as a complication radial head replacement and to help identify and treat it., (© 2020. The Author(s).)

Background: The Mayo Elbow Performance Score is a clinical assessment to rate the performance of the elbow from a medical and/or therapeutic perspective. It is simple and efficient to operate and therefore frequently used in research as well as in clinics. However, an adequate translation of the MEPS into the German language and a verification of the quality criteria for the use in the German health system are currently lacking., Goal of the Study: The aim of this study is to translate the MEPS and to review the applicability of the German version (MEPS-G) in Germany., Materials and Methods: The translation was undertaken on the basis of a guideline for cultural adaptation. Two independent translations were created, combined and translated back into English by two native speakers. The back translations were reviewed and the German version was amended accordingly. The suitability of the final questionnaire was verified in a pretest with 73 participants., Results: The MEPS was converted into the German version MEPS-G and was tested. Apart from minor adjustments, the questionnaire was translated into German without difficulty. The time to complete the assessment was on average 2.5 min (± 1.6)., Conclusion: First analyses of the psychometric properties of the German MEPS showed identical values as the English version. The detailed quality criteria will be reviewed in a subsequent study., Competing Interests: The authors declare that they have no conflict of interest./Die Autoren geben an, dass kein Interessenkonflikt besteht., (Thieme. All rights reserved.)

Purpose: Currently, surgical training in the clinical scenario is limited by duty-hour restrictions as well as an increasing specialization within the numerous surgical fields. In such an environment, surgical training in subspecialties becomes both, more important and challenging. Against this background, purpose of the present study was to evaluate a new course format for advanced training in fracture treatment. In the studied course format, cadaveric wrist or elbow specimens with prefabricated fractures were used with the aim of improving the learning effect for the attendees. On these specimens, operative treatment with specific osteosynthetic implants was performed under radiographic control. We hypothesized that simulation in a complex scenario such as the one used in the studied course format leads to a subjectively better learning effect regardless of prior surgical experience., Methods: 205 participants in 16 courses between 2016 and 2018 were surveyed regarding their operative experience, previously attendances of trauma care trainings and subjective learning effect in the surveyed course and the trainings attended previously. Based on a ten-step scale, results in the subjective learning effect were compared between the investigated course and other trainings and to the individual operative experience., Results: The learning effect of the surveyed fracture courses was assessed with a median of 9/10 for the theoretical part and 10/10 for the practical part, significantly better than in trainings attended previously. The surveyed participants reported that they each performed 308 operations per year on average. Other course formats were attended significantly more frequent than courses on prefractured human specimens. The respondents reported a subjectively higher learning effect of the evaluated course concept in comparison to previously attended courses in practical and theoretical aspects., Conclusions: The reported innovative course format is an efficient concept for education in surgical trauma care, suited for more novice and advanced surgeons., Competing Interests: The authors are organising the course which is described in the present article. V. Rausch, K. J. Burkhart, T. Leschinger and M. Hackl do not indicate any conflicts of interest. K. Wegmann and L. P. Müller are consultants for Arthrex, Medartis and Tornier. L. P. Müller receives subsidies for travel from Wright/Tornier and research funding from Medartis and Arthrex., (Georg Thieme Verlag KG Stuttgart · New York.)

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.

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 C‑silicone 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.

The movement of the forearm follows a complex interplay of three main components: the proximal and distal radioulnar joint and the interosseous membrane. Injuries to one or even all components have a huge impact on the integrity of this system. The Essex-Lopresti lesion presented a high challenge in clinical diagnostics as well as therapy. Reconstructions of the length and stability are essential for a satisfactory postoperative outcome. If a reconstruction of the radial head by osteosynthesis is not possible, a radial head prosthesis should be implanted in the case of longitudinal instability - avoiding overlapping and/or oversizing. The reconstruction of the interosseous membrane should be considered, as well as the assessment of the distal radioulnar joint and/or the triangular fibrocartilage complex. Various reconstruction options are available in this regard.

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., Competing Interests: Compliance with ethical guidelinesR. Nietschke, K.J. Burkhart, B. Hollinger, F.I. Dehlinger, A. Zimmerer, and M.M. Schneider declare that they have no competing interests. This article does not contain any studies with human participants or animals performed by any of the authors.

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.

Purpose: Double plating has been promoted, in recent years, as an alternative treatment method for proximal ulna fractures. This study aimed to compare the biomechanical properties of double-plate osteosynthesis with posterior plate fixation using a novel investigational design utilizing a 3-dimensional camera system to analyze fracture micromotion., Methods: Fourteen fresh-frozen specimens were available for this study. Mayo type IIA fractures of the olecranon were created and internal fixation was performed with either an angular stable posterior plate or angular stable double plates. Fracture micromotion was evaluated by means of digital image correlation with a 3-dimensional camera system before and after dynamic cyclic loading from 15° to 90° of elbow flexion with a pulling force of 25 N to 80 N., Results: Micromotion of fragments was less pronounced in double-plate osteosynthesis when compared with single plates before and after cyclic loading. However, overall results were similar. Two of the single plates failed during cyclic loading but there were no failures in the double plates., Conclusions: This biomechanical analysis shows that single and double plating results in comparable stability of fixation. Although the double-plating technique tends to provide more stable fixation, relevant differences were not observed., Clinical Relevance: Double plating potentially represents an efficient option for fixation of proximal ulna fractures. It could decrease the risk of soft tissue complications owing to their low profile and the superior soft tissue coverage., (Copyright © 2017 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Background: Long-term results and complication rates in shoulder arthroplasty are related to implant positioning. Current literature reports increased precision in glenoid component positioning using 3-dimensional (3D) computed tomography (CT) planning tools. This study evaluated the accuracy of glenoid version and inclination measurements using 2D CT scans compared with a validated 3D software program and its influence on decision making on implant selection., Methods: Preoperative CT scans were obtained from 50 patients undergoing total shoulder arthroplasty. Glenoid version and inclination measurements were performed in random order by 3 independent qualified orthopedic surgeons on reformatted 2D CT scans. Indication for anatomic or reverse shoulder arthroplasty was based on glenoid deformity and on rotator cuff conditions. Results were compared with those from a validated 3D computer software program, and the final decision was made according to the 3D planning., Results: Mean preoperative glenoid retroversion on reformatted 2D CT scans was 11.9° ± 9.6° and mean superior inclination was 10.7° ± 8.6°. When the 3D software was used, glenoid retroversion averaged 15.1° ± 10.6° and superior inclination averaged 8.9° ± 9.9°. The 2D CT demonstrated good interobserver and intraobserver reliability for glenoid version and inclination. Decision on the choice of implant was adjusted in 7 patients after the 3D planning., Conclusions: Our findings show that measurements of glenoid version and inclination on reformatted 2D CT scans are less accurate compared with 3D measurements. A preoperative 3D planning software allows for improvement of virtual glenoid positioning and influences the decision making process., (Copyright © 2017 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Background: Revision of failed shoulder arthroplasty is often associated with poor results and a high rate of complications. Significant humeral bone loss after removal of long stems poses a considerable surgical challenge. Therefore, the aim of our study was the evaluation of the clinical and radiologic outcome of cemented long-stem humeral components in revision reverse shoulder arthroplasty with a minimum 5 years' follow-up., Methods: Between June 2001 and June 2009, revision reverse shoulder arthroplasty using long-stem cemented humeral components was performed in 124 patients. Mean age at time of surgery was 69.6 years (range, 42-87 years). Complete clinical and radiographic data were available in 50 patients at a mean of 7 years (range, 5-11.6 years). Postoperative radiographs were evaluated for radiolucent lines, implant migration, fracture, and glenoid notching., Results: The mean Constant score improved from 11.1 points (range, 0-27 points) to 39.5 points (range, 14-73 points) at the latest follow-up. Progressive humeral radiolucency was present in 24 patients, including 6 patients demonstrating complete loosening or progressive distal migration of the humeral stem. We noted an overall of 12 additional complications in 8 patients, necessitating revision surgery in 16., Conclusion: The use of long-stem humeral components is a beneficial treatment in revision reverse shoulder arthroplasty. Nevertheless, the high percentage of patients with humeral loosening is concerning. Modular cementless revision stems that are adapted to the distal humeral medullary canal and additional distal screw and cable fixation might enhance durable distal fixation in case of advanced bone loss., (Copyright © 2017 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Background: In the young patient, treatment of post-traumatic elbow arthritis remains difficult. Total elbow arthroplasty must be delayed for as long as possible. Therapy starts with nonoperative treatment. If this fails, operative options can be discussed., Treatment Aim: The aim of surgery is to provide a functional range of motion with acceptable pain without obstructing future treatment options., Therapy: Patients with pain at terminal extension and/or flexion may benefit from arthroscopic or open debridement. Patients with advanced osteoarthritis and pain throughout the complete range of motion, who are too young for total elbow arthroplasty, are offered interposition arthroplasty or arthrodesis. Arthrodesis of the elbow leads to significant restrictions in daily life due to the complete loss of extension/flexion. Therefore, arthrodesis is only offered as treatment in exceptional circumstances. Interposition arthroplasty is a reasonable option for the young patient without significant bony defects, which may provide a stable, functional flexion arc with an acceptable pain level. Interposition arthroplasty preserves the revision options of re-interposition arthroplasty as well as the withdrawal to total elbow arthroplasty. Partial and total elbow arthroplasty are treatment options of elbow arthritis but are not subjects of this article.

Introduction: The field of shoulder endoprothetics has undergone a rapid development in the last years. The purpose of the study was to provide an overview of the development of shoulder arthroplasties in Germany from 2005 until 2012. This study hypothesized that the surgical procedures of the shoulder joint is still increasing and have not reached a plateau until 2012., Methods: Data of the German federal statistical office from 2005 until 2012 were analyzed to quantify hemiarthroplasty, anatomic total shoulder and reversed total shoulder arthroplasty rates depending on age, gender and main coded indications. Procedure codes and diagnosis were analyzed for each year. Comparative analyses were used to visualize the difference between the types of shoulder endoprostheses., Results: A total number of 139.272 shoulder arthroplasties were performed between 2005 and 2012. Total should arthroplasties have increased continuously until 2009. In 2009 more total shoulder arthroplasties have been performed than hemiprothesis implantations, which have culminated in 2008. All in all, women have been treated 3-fold higher than men regarding hemiarthroplasty, total shoulder arthroplasties or reversed total shoulder arthroplasties. Under the age of 60 years the majority of treated patients were male., Conclusion: Since 2005 shoulder arthroplasties are still increasing in Germany, whereas a slight reduction could be detected for shoulder hemiarthroplasty from 2009 up until 2012. Meanwhile total shoulder arthroplasties and reversed total shoulder arthroplasties are still increasing. Women have experienced a 3-fold higher hemiarthroplasty, total shoulder and reversed shoulder arthroplasties than men except for individual younger than 60 years.

Background: Overlengthening by radial head prosthetic replacement leads to insufficient functionality and increased capitellar wear. It has been shown that in monopolar prostheses, the radial overlengthening by an overstuffed prosthesis leads to significant differences in the distal radioulnar variance at the wrist. This study evaluated ipsilateral ulnar variance as a predictor for overlengthening after implantation of a multipolar prosthesis., Methods: The radial heads of seven fresh frozen upper extremities were resected and a multipolar radial head prosthesis was implanted. Thereafter, the native radioulnar variance at the wrist was documented via fluoroscopy. The alignment of the distal radioulnar joint in neutral, pronated and supinated rotational positions of the forearm was recorded fluoroscopically, and digital image analysis was performed regarding radioulnar shifting., Results: Statistical analysis of the difference between native height and the manipulated states did not show consistent significant differences with stepwise overlengthening of +1.5, +3, +4.5 and +6 mm and with respect to rotational position of the forearm (p > 0.05). Interclass correlation coefficients showed excellent interobserver reliability (ICC 96%), as did tests for intraobserver reliability (ICC 98-99%)., Conclusions: No consistent influence of overlengthening on the alignment of the radius and ulna at the distal radioulnar joint was found after sequential overlengthening with a multipolar prosthesis. Maybe the ligamentous structures of the forearm prevent significant longitudinal dislocation of the radius, as the multipolar prosthesis gives way by at the radiocapitellar joint. According to the data of the present study, the ipsilateral wrist is not useful in diagnosing overlengthening of the radial column in multipolar prosthetic replacement of the radial head-in contrast to the reported results with monopolar prostheses.

Background: Ligament reconstruction with a circumferential graft represents an innovative technique for treatment of multidirectional elbow instability. This biomechanical study compared the stability of the intact elbow joint with the circumferential graft technique and the conventional technique., Methods: Seven fresh frozen cadaveric elbows were evaluated for stability against valgus and varus/posterolateral rotatory forces (3 Nm) over the full range of motion. Primary stability was determined for intact specimens, after sectioning of the collateral ligaments, after applying the circumferential graft technique (box-loop), and after conventional collateral ligament reconstruction. Cyclic loading (1000 cycles) was performed to assess joint stability and stiffness of the native ligaments and the tendon grafts., Results: Primary stability of both reconstruction techniques was equal to the native specimens (P = .17-.91). Sectioning of the collateral ligaments significantly increased joint instability (P < .001). The reconstruction techniques provided equal stability after 1000 cycles (P = .78). Both were inferior to the intact specimens (P = .02). Cyclic loading caused a significantly lower increase in stiffness of the native ligaments compared with the tendon grafts of either reconstruction technique (P = .001-.008). Significantly better graft stiffness was retained with the circumferential graft technique compared with conventional reconstruction (P = .04)., Conclusion: Neither reconstruction technique fully reproduces the biomechanical profile of the native collateral ligaments. The circumferential graft technique seems to resist cyclic loading slightly better than the conventional reconstruction technique, yet both reconstruction techniques provide comparable stability., (Copyright © 2016 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Introduction: Overlengthening of the radial column leads to insufficient functionality and increased capitellar wear. Methods to detect or prevent overlengthening have been described for monopolar prostheses. The aim of this study was to evaluate whether one such method described by Athwal et al. is also applicable for a bipolar prosthesis., Materials and Methods: The radial heads of six fresh frozen upper extremities were resected. A bipolar radial head prosthesis was implanted in each, and the effects of sequential overlengthening on the alignment of the radiocapitellar and ulnohumeral joint line were recorded by fluoroscopic images. Digital image analysis and estimation of overlengthening followed according to the method described by Athwal et al., Results: Statistical analysis of the estimated and actual differences between the native state and bipolar replacement of the radial head with stepwise overlengthening of 1.5, 3, 4.5, and 6 mm showed a specificity of 86 % but consistently underestimated the amount of overlengthening with a sensitivity of only 61 %., Discussion: The method described by Athwal et al. for the identification of overlengthening by a monopolar prosthesis was not found to be reliable for ruling out or quantifying overlengthening of the tested bipolar prosthesis. However, the use of the method to detect (rule in) overlengthening may be acceptable in certain circumstances. A reliable method for postoperative quantification of overlengthening by bipolar prostheses has still to be found.

Background: Radial head arthroplasty is an established method to restore the anatomy and biomechanics of the elbow joint - especially for non-reconstructable radial head fractures., Aims: This video article aims to explain the indications, the surgical procedure and the postoperative rehabilitation protocol for radial head replacement. We also present our own results with this procedure., Material and Methods: Since 2014, we have prospectively evaluated all patients undergoing surgery for radial head replacement (MoPyC, Tornier, France). A 6 month follow-up of 11 patients is now available. Moreover, 3 retrospective cases with rare complications are reported which were not part of our prospective evaluation., Results: 8 of 11 procedures were performed due to acute, non-reconstructable radial head fractures. Secondary radial head replacement as a result of failed osteosynthesis was performed in the remaining 3 cases. 8 patients had clinically relevant concomitant injuries to the elbow joint. The mean Mayo Elbow Performance Score was 88 points (65 to 100 points). The arc of motion averaged 124° (± 18°). At 6 months, the mean extension lag was 8°. There were no complications requiring revision surgery at 6 months. Retrospective evaluation found one patient with extensive osteolysis due to oversizing of the shaft, one with disconnection of the prosthesis and one with a broken prosthesis shaft., Conclusions: The clinical results with radial head arthroplasty are promising. Accurate implantation is crucial to minimise the risk of complications requiring revision surgery., (Georg Thieme Verlag KG Stuttgart · New York.)

Background: The median and radial nerves are at risk of iatrogenic injury when performing arthroscopic arthrolysis with anterior capsulectomy. Although prior anatomic studies have identified the position of these nerves, little is known about how elbow positioning and joint insufflation might influence nerve locations., Questions/purposes: In a cadaver model, we sought to determine whether (1) the locations of the median and radial nerves change with variation of elbow positioning; and whether (2) flexion and joint insufflation increase the distance of the median and radial nerves to osseous landmarks after correcting for differences in size of the cadaveric specimens., Methods: The median and radial nerves were marked with a radiopaque thread in 11 fresh-frozen elbow specimens. Three-dimensional radiographic scans were performed in extension, in 90° flexion, and after joint insufflations in neutral rotation, pronation, and supination. Trochlear and capitellar widths were analyzed. The distances of the median nerve to the medial and anterior edge of the trochlea and to the coronoid were measured. The distances of the radial nerve to the lateral and anterior edge of the capitulum and to the anterior edge of the radial head were measured. We analyzed the mediolateral nerve locations as a percentage function of the trochlear and capitellar widths to control for differences regarding the size of the specimens., Results: The mean distance of the radial nerve to the lateral edge of the capitulum as a percentage function of the capitellar width increased from 68% ± 17% in extension to 91% ± 23% in flexion (mean difference = 23%; 95% confidence interval [CI], 5%-41%; p = 0.01). With the numbers available, no such difference was observed regarding the location of the median nerve in relation to the medial border of the trochlea (mean difference = 5%; 95% CI, -13% to 22%; p = 0.309). Flexion and joint insufflation increased the distance of the nerves to osseous landmarks. The mean distance of the median nerve to the coronoid tip was 5.4 ± 1.3 mm in extension, 9.1 ± 2.3 mm in flexion (mean difference = 3.7 mm; 95% CI, 2.04-5.36 mm; p < 0.001), and 12.6 ± 3.6 mm in flexion and insufflation (mean difference = 3.5 mm; 95% CI, 0.81-6.19 mm; p = 0.008). The mean distance of the radial nerve to the anterior edge of the radial head increased from 4.7 ± 1.8 mm in extension to 7.7 ± 2.7 mm in flexion (mean difference = 3.0 mm; 95% CI, 0.96-5.04 mm; p = 0.005) and to 11.9 ± 3.0 mm in flexion with additional joint insufflation (mean difference = 4.2 mm; 95% CI, 1.66-6.74 mm; p = 0.002)., Conclusions: The radial nerve shifts medially during flexion from the lateral to the medial border of the inner third of the capitulum. The median nerve is located at the medial quarter of the joint. The distance of the median and radial nerves to osseous landmarks doubles from extension to 90° flexion and triples after joint insufflation., Clinical Relevance: Elbow arthroscopy with anterior capsulectomy should be performed cautiously at the medial aspect of the joint to avoid median nerve lesions. Performing arthroscopic anterior capsulectomy in flexion at the lateral aspect of the joint and in slight extension at the medial edge of the capitulum could enhance safety of this procedure.

Background: Therapy of radial head fractures is still controversially discussed. Especially comminuted fractures are at risk of complications such as radial head necrosis, nonunion and secondary loss of reduction after open reduction and internal fixation. The aim of this study was to evaluate clinical and radiographic results of ORIF (open reduction internal fixation) of radial head fractures using a new radial head-specific locking plate system., Patients and Methods: A total of 21 patients (13 men and 8 women) were treated with locking plate osteosynthesis of radial head fractures. Mean age was 50 years (range 29-67 years). According to the Mason classification, 15 were type III and 6 type IV. Mean time between trauma and surgery was 5.6 days (range 0-23 days). These patients were reexamined using the Mayo Elbow Performance Score and x-rays in two planes., Results: In all, 21 patients were reexamined with a mean follow-up of 12.1 months (range 5-23 months). The mean Mayo Elbow Performance Score was 87.1. Excellent results were obtained in 12 patients, good results in 6 patients, and fair results in 3 patients. Mean extension deficit was 12.1°, mean flexion 135.2°, mean pronation 70.9°, and mean supination 63.6°. All fractures healed uneventfully. There was no complete radial head necrosis but one partial. Four cases of heterotopic ossification were detected: Hastings classification I (n = 2), IIb (n = 1), IIIb (n = 1)., Conclusion: ORIF of radial head fractures using locking plates can lead to good and excellent results. Modern implants may allow for reconstruction of comminuted fractures avoiding arthroplasty in these young patients.

Purpose: The aim of this biomechanical study was to analyse the influence of plate and screw positioning on peri-implant failure in dual plate osteosynthesis. We hypothesized that screw positioning rather than plate configuration influences the risk of peri-implant fractures., Methods: Twenty macerated humerus specimens were available. 5 groups of 4 were built according to specimen size. Locking dual plates (Medartis, Switzerland) were randomly applied to the distal humerus of the specimens in 4 types of configuration: Bending forces were applied using a universal testing machine until peri-implant fracture occurred., Results: Mean failure loads for respective configuration types were as follows: P1: 428.7 (±84.2) N, A1: 410.0 (±54.7) N, A0: 297.8 (±48.3) N, P0: 261.0 (±65.0) N. Configurations with positioning of the most proximal screws at different levels (P1, A1) reached significantly higher failure loads when compared to screw placement at the same level (P0, A0) (0.01≤p≤0.03). Altering the plate configuration did not significantly influence failure loads (0.34≤p≤0.58)., Conclusions: The results of this study suggest that placement of the most proximal screws rather than the configuration of the plates is critical regarding the predetermined risk of peri-implant failure in dual plate osteosynthesis of the distal humerus. Varying levels of the outermost screws of corresponding double plates seem to be crucial to avoid complications related to the osteosynthesis., (Copyright © 2015 Elsevier Ltd. All rights reserved.)

Radial head fractures are the most common fractures around the elbow. Because they are often accompanied by ligamentous injuries, we recommend considering them to be osteoligamentous injuries rather than simple fractures, even in undisplaced or minimally displaced fractures. Surgeons should always suspect and actively exclude concomitant ligament tears. The incidence of these associated injuries increases with greater severity of the radial head fracture. However, the standard Mason classification system does not adequately address this problem, and all attempts to establish a new classification system that provides concise treatment algorithms have failed. This article discusses the current treatment options and the current controversies in nonsurgical therapy, open reduction and internal fixation (ORIF) and radial head replacement., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Purpose: The purpose of this study was to determine the anatomic relationship between the radial head and the lateral collateral ligament (LCL) and when the LCL would be at risk of iatrogenic injury during arthroscopic resection of the synovial fold., Methods: Thirty-four formalin-fixed upper extremities were dissected. A projection of the LCL onto the radial head was marked with a needle. The percentage of the posterior border of the radial head overlaid by the LCL was digitally measured. A portion of the projection of the LCL was statistically correlated with the overall diameter of the radial head., Results: The overall diameter of the radial head was 21.2 mm ± 2.3. The proportionate projection of the medial border of the LCL onto the radial head was 5.3 ± 1.6 mm on average. The lateral 25 % of the radial head was overlaid by the LCL with a maximum value of 40 % on average. The inter- and intraobserver reliability showed very good accordance with the digital measurements (r > 0.8)., Conclusion: Care must be taken when performing a resection in the lateral 40 % of the radial head, whereas resection in the medial 60 % of the radial head appears to be safe. The LCL is an important stabiliser of the elbow joint, a lesion of which by undeliberate arthroscopic dissection may lead to joint instability. Iatrogenic injury to the LCL presumably can be prevented when respecting the given data., Level of Evidence: Experimental study.

Background: Proximal radial fractures are common elbow injuries. Because of the fracture pattern, stability criteria, or plate configuration, a plate position outside the "safe zone" (SZ) may be required in some cases when performing a radial head plate osteosynthesis. We examined the gross anatomy of the radial head and analyzed different so-called low-profile and precontoured radial head and neck plates with respect to the SZ., Materials and Methods: Macroscopic measurements of the radial head and neck of 22 formalin-fixed human cadaveric upper extremities were obtained. The SZ was determined by maximum forearm rotation. If the edge of a plate could be extended beyond the respective SZ boundary without jeopardizing the proximal radioulnar joint (PRUJ) in maximum forearm rotation, a new plate-specific SZ boundary was set., Results: The mean SZ was 133° (SD, 14°). Among the 5 plates studied, only the 2 radial neck designs allowed the anterior edge of the plate to partially pass the lesser sigmoid notch of the ulna and consequently afforded a significant extension of the SZ in maximum pronation. All 3 radial head designs had to remain within the SZ to avoid interference with the PRUJ. A safe plate position depends on individual plate dimensions, particularly the proximal plate width, and the diameter of the radial head. The smaller the head diameter, the more accurately a plate must be placed within the SZ., Conclusions: If an extension of the SZ in radial head plate osteosynthesis is not essential, we recommend respecting the SZ to minimize the possibility of interference with the PRUJ., (Copyright © 2015 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Due to technical progress, the indication for total elbow arthroplasty could be expanded in recent years. As a result, the demand regarding functionality and mobility of the replaced joint has risen as well. Elbow arthroplasty has to be considered as technically demanding. Only with detailed knowledge of this surgical procedure and its possible intraoperative pitfalls can one provide the best possible results. In this instructional video we explain the implantation of the Latitude elbow prosthesis (Tornier) putting emphasis on the correct approach as well as implantation of the prosthesis and subsequent wound closure., (Georg Thieme Verlag KG Stuttgart · New York.)

Purpose: The fitting accuracy of radial head components has been investigated in the capitulo-radial joint, and reduced contact after prosthetic replacement of the radial head has been observed. The kinematics of the proximal radioulnar joint (PRUJ) are affected by radial head arthroplasty as well, but have not yet been investigated in this regard., Methods: The elbow joints of 60 upper extremities of formalin-fixed body donors were disarticulated to obtain a good view of the PRUJ. Each specimen was mounted on the examining table and radial head position in the native PRUJ was assessed in neutral position, full pronation, and full supination. Measurements were repeated after implantation of mono- and bi-polar prostheses., Results: Analysis of the distribution of the joint contacts in the compartments showed significant differences after radial head replacement. In comparison to the native joint, after bipolar and monopolar radial head replacement, the physiological shift of the proximal radius was altered., Discussion: The physiological shift of the joint contact of the radial head from anterior to posterior during forearm rotation that was found in the native joint in our cadaver model was not observed after prosthetic replacement. With higher conformity and physiological kinematic of radial head prostheses, possibly lower shear forces and lower contact pressures would be generated., Clinical Relevance: The tested radial head prostheses do not replicate the physiological kinematics of the radial head. Further development in the prosthesis design has to be made. The meticulous reconstruction of the annular ligament seems to be of importance to increase joint contact.

Objective: Stable osteosynthesis during early postoperative functional treatment, particularly in patients with osteoporosis., Indications: Metaphyseal fractures, small proximal fragments or avulsion fracture of the triceps tendon, osteotomy of the olecranon, and pseudarthrosis of the olecranon or proximal ulna., Contraindications: Skin infection, severe soft tissue lesions., Surgical Technique: Dorsal approach to the olecranon. Open reduction and internal fixation by two side-mounted angular locking compression (double) plates., Postoperative Management: Early functional treatment. Full load-bearing after 6-12 weeks postoperatively., Results: A total of 14 patients were treated with double-plate osteosynthesis between 2011 and 2012. Clinical data were analysed retrospectively. The average follow-up was 11.7 months (range, 4-21 months). The mean flexion-extension radius was 123° (100°-140°), the pro-supination radius 166° (160°-170°). Using the Mayo Elbow Performance Score, eight patients had excellent and six good results. The mean Quick-DASH score was 15 (0-50).

Purpose: To evaluate radiographic signs of posterolateral rotatory instability (PLRI) on magnetic resonance imaging (MRI). The goal was to establish objective radiographic criteria to aid in the diagnosis of PLRI., Methods: The MRI scans of 60 patients were evaluated retrospectively. Two study groups were compared. Group 1 (n = 30) consisted of unstable elbows in which PLRI was confirmed by clinical examination and arthroscopy. Group 2 (stable; n = 30) served as the control group. Patients in group 2 had transient epicondylitis without clinical suspicion of instability. Joint incongruity was analyzed for sagittal views through the radial head and the coronoid tip and for coronal and axial views. Interobserver and intra-observer reliability were evaluated., Results: In the sagittal view through the radial head, average radiocapitellar incongruity differed significantly between groups 1 and 2. In addition, mean ulnohumeral incongruity in an axial view through the motion axis of the distal humerus showed significant differences between groups. Sagittal views through the tip of the coronoid and coronal views did not reveal significant differences in patients with unstable elbows compared with the control group., Conclusions: The current study provides useful MRI criteria indicative of PLRI when combined with physical examination. Cutoff points of 1.2 mm for radiocapitellar incongruity (sagittal view) and 0.7 mm for axial ulnohumeral incongruity (axial view) are suitable to screen for PLRI. Radiocapitellar incongruity greater than 2 mm and axial ulnohumeral incongruity greater than 1 mm are highly suspicious of elbow instability., Type of Study/level of Evidence: Diagnostic IV., (Copyright © 2015 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Introduction: Nerve transection has been described as complication of arthroscopic elbow arthrolysis. Therefore, the goal of this study was to define bony landmarks for intraoperative orientation regarding the location of the median and radial nerve., Methods: In 22 formalin-fixated upper extremities, the radial and median nerves were dissected and marked with respect to their native course. A 3D X-ray scan was performed. The distances of the radial nerve to the radial head (R1), the capitulum (R2), and its lateral border (RC) were measured. The location of the radial nerve in relation to the transversal diameter of the humeral condyle (HC) was calculated. Similarly, the distances of the median nerve to the trochlea (M1), the medial border of the trochlea (M2), and its relation to HC were calculated., Results: The mean value for R1 was 8 mm (±2.9 mm), for R2 was 11.3 mm (±3.8 mm), and for RC was 10.6 mm (±5.1 mm). RC/HC averaged 24 % (±11 %). M1 averaged 11.7 mm (±5.2 mm), and M2 was 2.4 mm (±4.1 mm). M2/HC averaged 6 % (±9 %)., Conclusions: The radial nerve is located ventral to the central third of the capitulum. The median nerve lies ventral to the medial quarter of the humeral condyle. When performing arthroscopic arthrolysis, this information should be kept in mind during anterior capsulectomy.

Background: Most surgeons don't repair the pronator quadratus (PQ) muscle in palmar plate fixation of a distal radius fracture because experience has shown that PQ repair yields no functional advantage. However, repair of the PQ may offer finger flexor tendon protection., Methods: In 9 human cadavers, the PQ was detached with a strong rim of connective tissue consisting of a fibrous portion of the roof of the first extensor compartment (RFEC) and the palmar limb of the brachioradialis muscle (BR) insertion. The gross anatomy and the dimensions of the dissected tissue were measured. After fixation of a palmar plate, the PQ was repaired. Stability was tested with 100 passive maximum pronation and supination repetitions., Results: The average total width of the PQ with the strong rim of connective tissue consisting of the RFEC and the palmar limb of the BR insertion was 28 mm. Suture repair was possible in each specimen, and each palmar plate was completely covered distally., Conclusion: This dissection of the PQ with a strong rim of connective tissue consisting of the RFEC and the palmar limb of the BR insertion may offer a way to cover the distal edge of a palmar plate in open reduction and internal fixation of a distal radius fracture that affords finger flexor tendon protection., (© Georg Thieme Verlag KG Stuttgart · New York.)