Reliability of the CURL classification for proximal ulna fracture-dislocations of the elbow.

Background: Proximal ulna fracture-dislocations are challenging injuries with a myriad of existing classification systems. The Coronoid, proximal Ulna, Radius, and Ligaments classification (CURL) is a simple framework designed to focus attention on the key components affecting outcome and guide surgical management. This study evaluates interobserver and intraobserver reliability of this new classification. Methods: Four observers independently reviewed plain radiographs and computed tomography (CT) scans of patients with proximal ulna fracture-dislocations. Each observer scored the Coronoid (C), proximal Ulna (U), and Radius (R) components for each fracture on 2 occasions. The osseous components were subclassified as 'intact', 'simple', or 'complex'. The Ligament component (L) was not rated as this requires intraoperative classification. Interobserver and intraobserver reliability was calculated using Cohen's weighted kappa coefficients. X-ray and CT were compared for patients with both imaging modalities. The Landis and Koch criteria were used to interpret the strength of the kappa statistics. Results: One hundred seventy seven patients had plain X-rays; 58 patients had both X-ray and CT scans. Overall, in the X-ray only cohort, there was 'almost perfect' interobserver reliability for the radial head (k = 0.94) and coronoid (k = 0.83), and 'substantial' reliability (k = 0.68) for the proximal ulna. For the X-ray and CT cohort, interobserver reliability was 'almost perfect' across both modalities for the radial head (k = 0.88 and k = 0.93, respectively) and 'moderate' for the proximal ulna (k = 0.48 and k = 0.52, respectively). For the coronoid, interobserver reliability for X-ray interpretation was 'substantial' (k = 0.74) and for CT was 'almost perfect' (k = 0.89). Intraobserver reliability was 'almost perfect' for all components, other than CT assessment of the proximal ulna which demonstrated 'substantial' reliability (k = 0.74). Conclusion: The Coronoid, proximal Ulna, Radius, and Ligaments classification demonstrates strong interobserver and intraobserver reliability, supporting use of the classification for proximal ulna fracture-dislocations. CT is recommended for improved characterization of any fracture with a coronoid component.

Considerable variation in current coronoid height and fracture measurement techniques: a systematic review.

BACKGROUND: Coronoid fractures usually occur in the presence of a significant osseoligamentous injury to the elbow. Fracture size and location correlate with degree of instability and many authors have attempted to analyze the effect of fracture variation on decision making and outcome. There remains no standardized technique for measuring coronoid height or fracture size. The aim of this study was to appraise the literature regarding techniques for coronoid height measurement in order to understand variation. METHODS: Preferred Reporting Items of Systematic Reviews and Meta-Analyses guidelines were followed. A search was performed to identify studies with either a description of coronoid height, fracture size, or bone loss using the terms (Coronoid) AND (Measurement) OR (Size) OR (Height). Articles were shortlisted by screening for topic relevance based on title, abstract and, if required, full-text review. Exclusion criteria were non-English articles, those on nonhuman species or parts other than the ulna coronoid process, and studies that included patients with pre-existing elbow pathology. Shortlisted articles were grouped based on study type, imaging modality, measurement technique, and measurement parameter as well as its location along the coronoid. RESULTS: Thirty out of the initially identified 494 articles met the inclusion criteria. Twenty-one articles were clinical studies, 8 were cadaveric studies, and 1 combined patients as well as cadavers. A variety of imaging modalities (plain radiographs, 2-dimensional computed tomography [CT], 3-dimensional CT, magnetic resonance imaging or a combination of these) were used with CT scan (either 2-dimensional images or 3-dimensional reconstructions or both) being the most common modality used by 21 studies. Measurement technique also varied from uniplanar linear measurements in 15 studies to multiplanar area and volumetric measurements in 6 studies to techniques describing various angles and indices as an indirect measure of coronoid height in 8 studies. Across the 30 shortlisted studies, 19 different measurement techniques were identified. Fifteen studies measured normal coronoid height while the other 15 measured intact coronoid and/or fracture fragment height. The location of this measurement was also variable between studies with measurements at the apex of the coronoid in 24/30 (80%) of studies. Measurement accuracy was assessed by only 1 study. A total of 12/30 (40%) studies reported on the interobserver and intraobserver reliability of their measurement technique. CONCLUSION: The systemic review demonstrated considerable variability between studies that report coronoid height or fracture size measurements. This variability makes comparison of coronoid height or fracture measurements and recommendations based on these between studies unreliable. There is need for development of a consistent, easy to use, and reproducible technique for coronoid height and bone loss.

Biomechanical comparison of headless compression screws versus independent locking screw for intra-articular fractures.

PURPOSE: Headless compression screws (HCS) have a variable thread pitch and headless design enabling them to embed below the articular surface and generate compression force for fracture healing without restricting movement. Locking screws have greater variety of dimensions and a threaded pitch mirroring the design of the HCS. The objective of this study is to determine whether locking screws can generate compression force and compare the compressive forces generated by HCS versus locking screws. METHOD: A comparison between 3.5-mm HCS versus 3.5-mm locking screws and 2.8-mm HCS versus 2.7-mm locking screws was performed using a synthetic foam bone model (Synbone) and FlexiForce sensors to record the compression forces (N). The mean peak compression force was calculated from a sample of 3 screws for each screw type. Statistical analysis was performed using the one-way ANOVA test and statistical significance was determined to be p = < 0.05. RESULTS: The 3.5-mm Synthes and Smith and Nephew locking screws generated similar peak compression forces to the 3.5-mm Acutrak 2 headless compression screws with no statistically significant difference between them. The smaller 2.7-mm Synthes and Smith and Nephew locking screws initially generated similar compressive forces up to 1.5 and 2 revolutions, respectively, but their peak compression force was less compared to the 2.8-mm Micro Acutrak 2 HCS. CONCLUSION: Locking screws are able to generate compressive forces and may be a viable alternative to headless compressive screws supporting their use for intra-articular fractures.

Acute and chronic coronoid reconstruction using the olecranon Tip.

Post-traumatic coronoid deficiency in the elbow can lead to chronic pain, instability and arthritis. A variety of osteochondral grafts have been used to reconstruct the coronoid, and restore elbow stability. The radial head and iliac crest grafts are the most common in the literature but have limitations. The olecranon tip is a promising alternative, with both cadaveric and computer models demonstrating superior congruency, without compromising elbow stability or disrupting the extensor mechanism. We present a small, case series demonstrating the technique for contralateral and ipsilateral grafts in both the acute and chronic setting.

Sensitivity and specificity of the posterolateral rotatory drawer test in the diagnosis of lateral collateral ligament insufficiency of the elbow.

BACKGROUND: Numerous clinical tests are described for the diagnosis of chronic lateral collateral ligament (LCL) insufficiency of the elbow; however, none of these tests have been adequately assessed for sensitivity, with at most 8 patients included in previous studies. Furthermore, no test has had specificity assessed. The posterolateral rotatory drawer (PLRD) test is thought to have improved diagnostic accuracy over other tests in the awake patient. The aim of this study is to formally assess this test using reference standards in a large cohort of patients. METHODS: A total of 106 eligible patients were identified for inclusion from a single-surgeon database of operative procedures. Examination under anesthetic (EUA) and arthroscopy were chosen as the reference standards to compare the PLRD test against. Only patients with a clearly documented PLRD test finding performed preoperatively in the clinic, and a clearly documented EUA and/or arthroscopic findings from surgery were included. A total of 102 patients underwent EUA, 74 of whom also underwent arthroscopy. Twenty-eight patients had EUA, and then an open procedure without arthroscopy. Four patients had arthroscopy without a clearly documented EUA. Sensitivity, specificity, and positive (PPV) and negative predictive values (NPV) were calculated with 95% confidence intervals. RESULTS: Thirty-seven patients had a positive PLRD test, and 69 had a negative test. Compared to the reference standard of EUA (n = 102), the PLRD test had a sensitivity of 97.3% (85.8%-99.9%) and a specificity of 98.5% (91.7%-100%) (PPV = 0.973, NPV = 0.985). Compared to the reference standard of arthroscopy (n = 78), the PLRD test had a sensitivity of 87.5% (61.7%-98.5%) and a specificity of 98.4% (91.3%-100%) (PPV = 0.933, NPV = 0.968). Compared to either reference standard (n = 106), the PLRD test has a sensitivity of 94.7% (82.3%-99.4%) and a specificity of 98.5% (92.1%-100%) (PPV = 0.973, NPV = 0.971). CONCLUSION: The PLRD test demonstrated an overall sensitivity of 94.7% and specificity of 98.5% with high positive and negative predictive values. This test is recommended as the primary diagnostic tool for LCL insufficiency in the awake patient and should be widely incorporated into surgical training.

Hemiarthroplasty versus open reduction internal fixation for intra-articular distal humerus fractures in older patients.

Background: Intra-articular distal humerus fractures in the older population remain a challenge to fix, due to the comminution of fragments and poor bone stock. Recently Elbow Hemiarthroplasty (EHA) has gained popularity to treat these fractures, however no studies exist comparing EHA to Open Reduction Internal Fixation (ORIF). Objectives: To compare the clinical outcomes of patients over the age of 60 years treated with ORIF or EHA for multi-fragmentary distal humerus fractures. Methods: Thirty-six patients (mean age 73 years) treated surgically for a multi-fragmentary intra-articular distal humeral fracture were followed up for a mean duration of thirty-four months (12-73 months). Eighteen patients were treated with ORIF and eighteen with EHA. The groups were matched for fracture type, demographic characteristics and follow up time. Outcome measures collected included Oxford Elbow Score (OES), Visual Analogue pain Score (VAS), range of motion (ROM), complications, re-operations and radiographic outcomes. The quality of ORIF was judged against set radiographic criteria in order to understand the effect of sub-optimal ORIF technique. Results: No significant clinical difference was found between EHA and ORIF in mean OES (42.5 vs 39.6, p = 0.28), mean VAS (0.5 vs 1.7, p = 0.08) or mean flexion-extension arc (123° vs 112°, p = 0.12). There were significantly more complications associated with ORIF compared to EHA (39% vs 6%, p = 0.04). ORIF executed with satisfactory fixation technique had a comparable complication rate compared to EHA (17% vs 6%, p = 0.6). Two ORIF patients required revision to Total Elbow Arthroplasty (TEA). None of the EHA patients required revision surgery. Conclusion: This study demonstrated similar short-term functional outcomes between EHA and ORIF for the treatment of multi-fragmentary intra-articular distal humeral fractures in patients >60 years of age. Early complications and re-operations were higher in the ORIF group, although this could be related to improper ORIF technique and patient selection.

Elbow conditions: research priorities setting in partnership with the James Lind Alliance.

OBJECTIVE: To undertake a UK-based James Lind Alliance (JLA) Priority Setting Partnership for elbow conditions and be representative of the views of patients, carers and healthcare professionals (HCPs). SETTING: This was a national collaborative study organised through the British Elbow and Shoulder Society. PARTICIPANTS: Adult patients, carers and HCPs who have managed or experienced elbow conditions, their carers and HCPs in the UK involved in managing of elbow conditions. METHODS: The rigorous JLA priority setting methodology was followed. Electronic and paper scoping surveys were distributed to identify potential research priority questions (RPQs). Initial responses were reviewed and a literature search was performed to cross-check categorised questions. Those questions already sufficiently answered were excluded and the remaining questions were ranked in a second survey according to priority for future elbow conditions research. Using the JLA methodology, responses from HCP and patients were combined to create a list of the top 18 questions. These were further reviewed in a dedicated multistakeholder workshop where the top 10 RPQs were agreed by consensus. RESULTS: The process was completed over 24 months. The initial survey resulted in 467 questions from 165 respondents (73% HCPs and 27% patients/carers). These questions were reviewed and combined into 46 summary topics comprising: tendinopathy, distal biceps pathology, arthritis, stiffness, trauma, arthroplasty and cubital tunnel syndrome. The second (interim prioritisation) survey had 250 respondents (72% HCP and 28% patients/carers). The top 18 ranked questions from this survey were taken to the final workshop where a consensus was reached on the top 10 RPQs. CONCLUSIONS: The top 10 RPQs highlight areas of importance that currently lack sufficient evidence to guide diagnosis, treatment and rehabilitation of elbow conditions. This collaborative process will guide researchers and funders regarding the topics that should receive most future attention and benefit patients and HCPs.

Challenging the mechanism of distal biceps tendon rupture using a video analysis study.

AIMS: The conventionally described mechanism of distal biceps tendon rupture (DBTR) is of a 'considerable extension force suddenly applied to a resisting, actively flexed forearm'. This has been commonly paraphrased as an 'eccentric contracture to a flexed elbow'. Both definitions have been frequently used in the literature with little objective analysis or citation. The aim of the present study was to use video footage of real time distal biceps ruptures to revisit and objectively define the mechanism of injury. METHODS: An online search identified 61 videos reporting a DBTR. Videos were independently reviewed by three surgeons to assess forearm rotation, elbow flexion, shoulder position, and type of muscle contraction being exerted at the time of rupture. Prospective data on mechanism of injury and arm position was also collected concurrently for 22 consecutive patients diagnosed with an acute DBTR in order to corroborate the video analysis. RESULTS: Four videos were excluded, leaving 57 for final analysis. Mechanisms of injury included deadlift, bicep curls, calisthenics, arm wrestling, heavy lifting, and boxing. In all, 98% of ruptures occurred with the arm in supination and 89% occurred at 0° to 10° of elbow flexion. Regarding muscle activity, 88% occurred during isometric contraction, 7% during eccentric contraction, and 5% during concentric contraction. Interobserver correlation scores were calculated as 0.66 to 0.89 using the free-marginal Fleiss Kappa tool. The prospectively collected patient data was consistent with the video analysis, with 82% of injuries occurring in supination and 95% in relative elbow extension. CONCLUSION: Contrary to the classically described injury mechanism, in this study the usual arm position during DBTR was forearm supination and elbow extension, and the muscle contraction was typically isometric. This was demonstrated for both video analysis and 'real' patients across a range of activities leading to rupture.Cite this article: Bone Jt Open 2022;3(10):826-831.

Development of a core outcome set for lateral elbow tendinopathy (COS-LET) using best available evidence and an international consensus process.

OBJECTIVES: To develop a core outcome set for lateral elbow tendinopathy (COS-LET) and to provide guidance for outcome evaluation in future studies. METHODS: We implemented a multi-stage mixed-methods design combining two systematic reviews, domain mapping of outcome measurement instruments to the core domains of tendinopathy, psychometric analysis of instruments, two patient focus groups and a Delphi study incorporating two surveys and an international consensus meeting. Following the OMERACT guidelines, we used a 70% threshold for consensus. RESULTS: 38 clinicians/researchers and 9 patients participated. 60 instruments were assessed for inclusion. The only instrument that was recommended for the COS-LET was Patient Rated Tennis Elbow Evaluation (PRTEE) for the disability domain. Interim recommendations were made to use: the PRTEE function subscale for the function domain; PRTEE pain subscale items 1, 4 and 5 for the pain over a specified time domain; pain-free grip strength for the physical function capacity domain; a Numerical Rating Scale measuring pain on gripping for the pain on activity/loading domain; and time off work for the participation in life activities domain. No recommendations could be made for the quality-of-life, patient rating of condition and psychological factors domains. CONCLUSIONS: The COS-LET comprises the PRTEE for the disability domain. Interim-use recommendations included PRTEE subscales, time off work, pain-free grip strength and a Numerical Rating Scale measuring pain on gripping. Further work is required to validate these interim measures and develop suitable measures to capture the other domains.

Elbow arthroplasty is safe for the management of simple open distal humeral fractures.

BACKGROUND: Elbow arthroplasty (EA) is an established technique for the treatment of select distal humeral fractures, yet little data exists regarding the safety and outcome of EA in the presence of an open distal humeral fracture where the risk of periprosthetic infection is an even greater concern. We hypothesized that EA does not carry an increased risk of infection or other postoperative complications when performed for simple open distal humeral fractures. METHODS: Seventeen patients underwent total EA (n = 9) or hemiarthroplasty (n = 8) for an open distal humeral fracture. The open fracture component was classified according to the Orthopaedic Trauma Society system as "simple" or "complex." Outcome measures collected included the Mayo Elbow Performance Score (MEPS), range of motion, complications, and reoperations. Patients who underwent primary débridement and implantation were compared with those who underwent preliminary débridement procedures and subsequent staged arthroplasty. A systematic review of the existing literature was performed to analyze other reported cases and contextualize our findings. RESULTS: The mean follow-up was 46 months (range, 12-138 months). All fractures were multifragmentary and intra-articular. Sixteen patients had a "simple" open fracture and 1 had a "complex" fracture. The overall mean MEPS was 83 (range, 30-100; standard deviation ± 17), with a mean flexion-extension arc of 96°. Patients who underwent primary débridement and implantation demonstrated a higher mean flexion arc (116° vs. 79°, P = .02) than those who underwent staged arthroplasty. The mean MEPS was not significantly different between the groups (90 vs. 78, P = .12). Complications included asymptomatic ulna component loosening (n = 1), joint instability (n = 1), and symptomatic heterotopic ossification (n = 3). There were no deep or superficial infections recorded. CONCLUSION: EA is safe and effective when performed for simple open distal humeral fractures. Primary débridement and implantation may offer functional benefits over a staged approach.

Coronal shear fractures of the distal humerus managed according to the Modified Dubberley Classification System.

BACKGROUND: Coronal shear fractures of the capitellum and trochlea are relatively uncommon and can be challenging to treat because of variable articular comminution and poor bone stock. Classification is valuable to help guide surgical decision making and prognosis. The aim of this study was to present a large series of coronal shear fractures treated according to the Modified Dubberley Classification System (MDCS). METHODS: Forty-five patients with a coronal shear fracture were followed up (12-93 months, mean: 28 months) after surgical intervention. Fractures were classified according to the MDCS by 3 observers, and outcome data collected included Oxford elbow score (OES), visual analog pain score (VAS), range of motion, complications, and radiographic findings. RESULTS: There were 10 type 1, 12 type 2, 8 type 3, and 15 type 4 fractures. There were 26 subtype B fractures (posterior comminution). A total of 37 patients underwent open reduction and internal fixation (ORIF) and 8 primary arthroplasty. The median OES and VAS were 43(16-48) and 2 (0-9), respectively. Median flexion extension arc was 125° (range, 70°-140°). There was no significant difference in OES, VAS, or range of motion according to fracture type (types 1-4), subtype (type a or b), or treatment method (arthroplasty vs. ORIF). The overall complication and reoperation rates were 31% and 33%, respectively. A total of 75% of complications occurred in type 3 and 4 fractures, and there was a nonsignificant trend toward higher complication rate in type B fractures than type A fractures (34% vs. 16%, P = .19). Patients with a type B fracture who underwent screw-only fixation had a significantly lower OES and higher complication rate compared with when they had combined plating with screws (OES, P = .03; complications P = .04) and compared with when an arthroplasty was performed (OES, P = .05; complications P = .04). CONCLUSION: Consistently good outcomes can be achieved by classification and management according to the MDCS. It is recommended that type B fractures undergo combined plate and screw fixation and that type 4 fractures should be considered for arthroplasty because of the higher risk of complications with ORIF.

Quotation errors related to the Proximal Fracture of the Humerus Evaluation by Randomization (ProFHER) study.

AIM: The aim of this study was to assess the accuracy of quotations of the Proximal Fracture of the Humerus Evaluation by Randomization (ProFHER) study in the published literature. METHODS: A literature search was performed from March 2015 to November 2019 to identify all papers that reference ProFHER since its publication. Full text articles were reviewed by two independent reviewers using a validated framework of assessing quotation errors. A kappa co-efficient was calculated to assess interobserver reliability of the reviewers. RESULTS: There were 260 individual ProFHER quoted references within the 138 included articles. We identified 35/260 quotation errors (13%). Of these, 10/35 (29%) were major quotation errors and 25/35 (71%) minor quotation errors. There was substantial interobserver agreement when errors were classified. Of the 10 major errors, six quotations were not substantiated by the results of ProFHER and three were unrelated to ProFHER. One paper contained a quotation error that contradicted the results of ProFHER. Of the 25 minor errors, 19 oversimplified or generalised the conclusions of ProFHER and six contained numerical or grammatical errors. CONCLUSION: The current study demonstrated substantial inaccuracies in quotations of the Proximal Fracture of the Humerus Evaluation by Randomization study. Vigilance is recommended when quoting the literature and reviewing submitted papers in order to prevent the perpetuation of misquoted data.

Outcome and complications following revision shoulder arthroplasty : a systematic review and meta-analysis.

AIMS: It is important to understand the rate of complications associated with the increasing burden of revision shoulder arthroplasty. Currently, this has not been well quantified. This review aims to address that deficiency with a focus on complication and reoperation rates, shoulder outcome scores, and comparison of anatomical and reverse prostheses when used in revision surgery. METHODS: A Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) systematic review was performed to identify clinical data for patients undergoing revision shoulder arthroplasty. Data were extracted from the literature and pooled for analysis. Complication and reoperation rates were analyzed using a meta-analysis of proportion, and continuous variables underwent comparative subgroup analysis. RESULTS: A total of 112 studies (5,379 shoulders) were eligible for inclusion, although complete clinical data was not ubiquitous. Indications for revision included component loosening 20% (601/3,041), instability 19% (577/3,041), rotator cuff failure 17% (528/3,041), and infection 16% (490/3,041). Intraoperative complication and postoperative complication and reoperation rates were 8% (230/2,915), 22% (825/3,843), and 13% (584/3,843) respectively. Intraoperative and postoperative complications included iatrogenic humeral fractures (91/230, 40%) and instability (215/825, 26%). Revision to reverse total shoulder arthroplasty (TSA), rather than revision to anatomical TSA from any index prosthesis, resulted in lower complication rates and superior Constant scores, although there was no difference in American Shoulder and Elbow Surgeons scores. CONCLUSION: Satisfactory improvement in patient-reported outcome measures are reported following revision shoulder arthroplasty; however, revision surgery is associated with high complication rates and better outcomes may be evident following revision to reverse TSA. Cite this article: Bone Jt Open 2021;2(8):618-630.

Tension Suture Fixation of Olecranon Fractures.

BACKGROUND: Mayo type-IIA olecranon fractures are characterized by a transverse or short oblique fracture without articular comminution or ulnohumeral instability. Traditionally, these fractures are treated with a tension-band wiring technique. Despite good rates of fracture union, tension-band wiring is associated with a reoperation rate of 30% to 60%, usually for removal of prominent metalwork. The tension suture technique was developed as an alternative method of fixing Mayo type-IIA fractures using only high-tensile braided nonabsorbable number-2 sutures, with the aim of reducing the reoperation rate associated with tension-band wiring without compromising outcomes. The tension suture technique has subsequently become the only technique we use when treating these fractures. DESCRIPTION: The patient is positioned in the lateral decubitus position under general or regional anesthesia. A direct posterior approach is made, centered over the fracture. The fracture is identified, cleared of hematoma, and reduced with use of a large, pointed reduction clamp to provide interfragmentary compression. A 2.5-mm transverse drill hole is made through the ulna distal to the fracture site. Two sets of number-2 braided nonabsorbable sutures are utilized. The first sutures are passed lateral to medial through the drill hole and used to grasp the medial triceps insertion onto the proximal fragment, then passed back through the transverse drill hole from medial to lateral and used to grasp the lateral triceps insertion onto the proximal fragment. The suture ends are tensioned to remove slack and tied on the lateral aspect of the olecranon. The second sutures are then passed lateral to medial through the transverse drill hole but this time used to grasp the posterolateral triceps insertion on the proximal fragment, then re-passed through the transverse drill hole from medial to lateral, and finally used to grasp the posteromedial triceps insertion. The suture limbs are tensioned and tied on the lateral aspect of the ulna next to the first suture. The clamp is removed, and the construct is tested under full range of motion to ensure there is no evidence of gapping. Fluoroscopy is utilized to confirm reduction before the wound is irrigated and closed in a standard fashion. ALTERNATIVES: Mayo type-IIA fractures may be treated nonoperatively in frail or low-demand patients. Surgical treatment is traditionally performed with the tension-band wiring technique, but plate or intramedullary fixation may also be utilized. RATIONALE: This technique negates the metalwork-related complications associated with all other surgical techniques for this fracture type. EXPECTED OUTCOMES: In a recent study comparing the tension suture technique with tension-band wiring and plate fixation for Mayo type-IIA fractures, the tension suture technique had a significantly lower reoperation rate compared with tension-band wiring and a lower complication rate compared with plate fixation. IMPORTANT TIPS: The tension-suture technique is primarily for Mayo type-IIA fractures without ulnohumeral instability or marked articular comminution.Ensure the transverse tunnel in the ulna is at least 3 cm distal to the fracture site and 1 cm anterior to the dorsal cortex of the ulna in order to prevent fracture of the tunnel.Grasp as much of the triceps tendon as possible when placing the sutures through the proximal fragment to prevent pull-out.Tension and tie the sutures with the elbow semi-extended to prevent the construct slackening in elbow extension and to facilitate interfragmentary compression during flexion.

Current concepts in distal humeral hemiarthroplasty.

Multi-fragmentary intra-articular fractures of the distal humerus remain a challenge for both patients and surgeons. Open Reduction internal fixation remains the gold standard, however in older patients with comminuted fractures this might not be feasible. There is a growing interest in hemi-arthroplasty as a solution for these cases. However the current experience and follow-up in limited. This review article intends to describe the current concepts in elbow hemiarthroplasty in dept. we will discuss the historical use of these implants, as well as the intricacies of more modern devices. Next we will elaborate an surgical planning, approach, and technical pearls. We will lay out a rehab protocol used by the senior author, and with some considerations for the future.

Protocol for the development of a core outcome set for lateral elbow tendinopathy (COS-LET).

BACKGROUND: Lateral elbow tendinopathy (LET) is a common condition that can cause significant disability and associated socioeconomic cost. Although it has been widely researched, outcome measures are highly variable which restricts evidence synthesis across studies. In 2019, a working group of international experts, health care professionals and patients, in the field of tendinopathy (International Scientific Tendinopathy Symposium Consensus (ICON) Group), published the results of a consensus exercise defining the nine core domains that should be measured in tendinopathy research. The aim of this study is to develop a core outcome set (COS) for LET mapping to these core domains. The primary output will provide a template for future outcome evaluation of LET. In this protocol, we detail the methodological approach to the COS-LET development. METHODS: This study will employ a three-phase approach. (1) A systematic review of studies investigating LET will produce a comprehensive list of all instruments currently employed to quantify the treatment effect or outcome. (2) Instruments will be matched to the list of nine core tendinopathy outcome domains by a Steering Committee of clinicians and researchers with a specialist interest in LET resulting in a set of candidate instruments. (3) An international three-stage Delphi study will be conducted involving experienced clinicians, researchers and patients. Within this Delphi study, candidate instruments will be selected based upon screening using the Outcome Measures in Rheumatology (OMERACT) truth, feasibility and discrimination filters with a threshold of 70% agreement set for consensus. CONCLUSIONS: There is currently no COS for the measurement or monitoring of LET in trials or clinical practice. The output from this project will be a minimum COS recommended for use in all future English language studies related to LET. The findings will be published in a high-quality journal and disseminated widely using professional networks, social media and via presentation at international conferences. TRIAL REGISTRATION: Registered with the Core Outcome Measures in Effectiveness Trials (COMET) database, November 2019. https://www.comet-initiative.org/Studies/Details/1497 .

Treatment Strategies and Outcomes for Osteochondritis Dissecans of the Capitellum.

BACKGROUND: The optimum management of osteochondritis dissecans (OCD) of the capitellum is a widely debated subject. PURPOSE: To better understand the efficacy of different surgical modalities and nonoperative treatment of OCD as assessed by radiological and clinical outcomes and return to sports. STUDY DESIGN: Systematic review; Level of evidence, 4. METHODS: A systematic review of all treatment studies published between January 1975 and June 2020 was performed following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. A total of 76 clinical studies, including 1463 patients, were suitable for inclusion. Aggregate analysis and subgroup analysis of individual patient data were performed to compare the functional and radiographic outcomes between the various nonoperative and surgical treatment options for capitellar OCD. A unified grading system (UGS; grades 1-4) was developed from existing validated classification systems to allow a comparison of patients with similar-grade OCD lesions in different studies according to their treatment. Patient-level data were available for 352 patients. The primary outcome measures of interest were patient-reported functional outcome, range of motion (ROM), and return to sports after treatment. The influences of the capitellar physeal status, location of the lesion, and type of sports participation were also assessed. Each outcome measure was evaluated according to the grade of OCD and treatment method (debridement/microfracture, fragment fixation, osteochondral autograft transplantation [OATS], or nonoperative treatment). RESULTS: No studies reported elbow scores or ROM for nonoperatively treated patients. All surgical modalities resulted in significantly increased postoperative ROM and elbow scores for stable (UGS grades 1 and 2) and unstable lesions (UGS grades 3 and 4). There was no significant difference in the magnitude of improvement or overall scores according to the type of surgery for stable or unstable lesions. Return to sports was superior with nonoperative treatment for stable lesions, whereas surgical treatment was superior for unstable lesions. Patients with an open capitellar physis had superior ROM for stable and unstable lesions, but there was no correlation with lesion location and the outcomes of OATS versus fragment fixation for high-grade lesions. CONCLUSION: Nonoperative treatment was similar in outcomes to surgical treatment for low-grade lesions, whereas surgical treatment was superior for higher grade lesions. There is currently insufficient evidence to support complex reconstructive techniques for high-grade lesions compared with microfracture/debridement alone.

A Systematic Review of Arthroscopic Versus Open Debridement of the Arthritic Elbow.

PURPOSE: To systematically review the available data with regard to clinical and functional outcomes of arthroscopic and open debridement for elbow arthritis to determine the complication rate with transition to arthroscopic surgery. METHODS: Using the Preferred Reporting Items for Systematic Reviews and Meta Analyses protocol, a systematic review was performed including studies reporting clinical and functional outcomes following open or arthroscopic debridement of elbow arthritis. The primary outcome measures analyzed were functional outcome (Mayo Elbow Performance Score), range of motion, and complication rate. Data were extracted for the whole group and then compared between the techniques using ranges and forest plots. RESULTS: In total, 39 level IV and 3 level III studies with 1097 elbows were eligible for inclusion; 684 elbows were treated using an open technique and 413 using an arthroscopic technique. Regarding functional outcome scores, mean Mayo Elbow Performance Score improved significantly with comparable magnitude of improvement in both groups (arthroscopic group: range 28-34, open group: range 25-31). Regarding range of motion, mean flexion-extension arc improved significantly in both groups (arthroscopic group: range 8-26°, open group: range 13-49°). The open group had a lower preoperative flexion-extension arc (range 63-96) in comparison with the arthroscopic group (range 84-119). The overall incidence of complications was 5.7% (range 0%-19%) in the arthroscopic group and 6.1% (range 0%-25%) in the open group. The most common complication type was neurologic, with an incidence of 2.1% (range 0%-8%) in the arthroscopic group and 1.9% (range 0%-12%) in the open group. The deep infection rate was 0.7% (range 0%-10%) in the open group with no reported incidence in the arthroscopic group. CONCLUSIONS: This systematic review demonstrated good mid-term functional outcomes following debridement arthroplasty of the arthritic elbow. There was no increase in complications with an arthroscopic technique confirming its safety and efficacy. LEVEL OF EVIDENCE: IV, Systematic Review of Level III and IV articles.