In Which Cases Do We Operate? Posterior Malleolar Fractures-Intraobserver and Interobserver Reliability of the Bartonícek/Rammelt Classification and Corresponding Surgery Rates.

INTRODUCTION: The Bartonícek/Rammelt classification is established for posterior malleolar fractures. It subdivides the fractures into 5 types and outlines treatment recommendations. This study aims to determine the intraobserver and interobserver reliability of the Bartonícek/Rammelt classification and investigates its applicability regarding treatment recommendations. MATERIALS AND METHODS: Computed tomography (CT) scans of 80 ankle fractures with a posterior malleolar fracture were analyzed by four observers at two different time points 30 days apart (d1 and d2). Intrarater and interrater reliability was measured using kappa values. The corresponding surgery rates of the fracture subtypes were analyzed, and the surgery rates were correlated with fragment sizes and displacements. RESULTS: A moderate interobserver reliability for d1 0.41 (CI 0.35-0.47) and d2 0.42 (CI 0.36-0.48) was detected. Intraobserver reliability was documented as perfect, with a mean kappa of 0.83. Type II fractures were operated on in 50% of cases. In 50% of type II cases, a nonoperative treatment was chosen. Fragment size correlated strongly with the chosen therapy, and osteosynthesis was performed significantly more often when the fragment size exceeded 3 cm3 (P < .01). CONCLUSIONS: The Bartonícek/Rammelt classification system showed moderate interobserver reliability and perfect to substantial intraobserver reliability. In clinical practice of this study cohort, the size of the posterior malleolar fragment rather than the dislocation and joint impaction seemed to have the decision to operate on type II or III fractures. Existing treatment recommendations based on the Bartonícek/Rammelt classification correspond to the therapy algorithm carried out in this cohort of patients.Levels of Evidence: Level III: Retrospective study.

Early range of motion results in good elbow function following conservative treatment of non-displaced radial head fractures.

INTRODUCTION: The aim of this study was to evaluate the range of motion (ROM), elbow function and predictors for good elbow function after conservative treatment of non-displaced radial head fractures. MATERIAL AND METHODS: All patients with non-displaced radial head fractures (displacement < 2 mm), that were diagnosed between January 1st 2017 and December 31st 2021 in a level I trauma center, were included in this retrospective case series and the charts were evaluated for ROM and elbow function. Elbow function was categorized as "good" or "bad" depending on the ROM measured defined by Morrey et al. Overall, 73 patients (33 male, 40 female) with an average age of 38 years (+/- 13 years) could be included. RESULTS: Conservative treatment had good clinical results for ROM and elbow function. After 6 weeks mean flexion was 131° (SD 13°), extension 8° (SD 7°), Pronation 83° (SD 11°) and Supination 83° (SD 13). Patients with a good elbow function after one week showed a good elbow function after completing the treatment. CONCLUSIONS: A clinical assessment after one week should always be performed and the study showed that it is a good predictor for good elbow function. In cases of bad elbow function further controls should be considered.

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

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

The importance of interdigitating screw fixation of the trochlea in double plate osteosynthesis of low transcondylar distal humerus fractures: A biomechanical study.

OBJECTIVE: The trochlea is of great importance for the stability of the elbow and its fixation in low transcondylar fractures of the distal humerus is especially challenging. The aim of this study was to determine the optimal trochlea fixation in double plate osteosynthesis of intraarticular distal humerus fractures. METHODS: A low transcondylar, C3-type distal humerus fracture was created in 20 fresh-frozen human cadaveric humeri. The samples were then randomly divided into two groups of 10 specimens each. Double plate osteosynthesis was performed in both groups. In group A, the two most distal screws of the lateral plate were inserted into the trochlea fragment. In group B, these screws did not extend into the trochlea. Displacement under cyclic loading and ultimate failure loads were determined for all specimens. RESULTS: Group A showed significantly less displacement under cyclic loading in each measurement interval (0.92 mm vs. 1.53 mm after 100 cycles, p = 0 0.006; 1.10 mm vs. 1.84 mm after 1000 cycles, p = 0.007; 1.18 mm vs. 1.98 mm after 2000 cycles, p = 0.008). The ultimate failure load was significantly higher in group A than in group B (345.61 ± 120.389 N vs. 238.42 ± 131.61 N, p = 0.037). CONCLUSIONS: Fixation of the trochlea with interdigitating screws in double plate osteosynthesis of low-condylar type C distal humerus fractures results in superior construct stability. LEVEL OF EVIDENCE: not applicable (biomechanical).

Comprehensive analysis and classification of retrocondylar ulnar groove morphology using CT imaging in an average population of adults.

PURPOSE: Anatomical variations of the concave shaped retrocondylar ulnar groove (RUG) can contribute to ulnar nerve instability. However, there are currently limited available standardized data describing the anatomy of the RUG based on radiologic imaging, such as computed tomography (CT). This study aims to provide a comprehensive description and classification of RUG anatomy based on RUG angle measurements. METHODS: 400 CT scans of the elbows of adults showing no signs of osseous damage were evaluated. RUG angles were measured in four anatomically defined axial planes that spanned from the proximal to the distal end of the RUG. Furthermore, distance measurements at the medial epicondyle were conducted. A classification system for the RUG is proposed based on the acquired RUG angles, aiming to categorize the individual angles according to the 25th and 75th percentiles. RESULTS: RUG angles were significantly larger in males compared to females (p < 0.001) accompanied by larger distances including the off-set and height of the medial epicondyle (p < 0.001). RUG angles decreased from proximal to distal locations (p < 0.05). CONCLUSION: This study revealed that men exhibited larger RUG angles compared to women, indicating a less-concave shape of the RUG in men. Introducing an objective RUG classification system can improve our understanding of anatomical variations and potentially find application in diagnostics and preoperative planning.

Unilateral Technique for Interposition Arthroplasty of the Elbow-A Technical Note.

Stiffness and pain secondary to end-stage dysfunctional osteoarthritis of the elbow can pose a therapeutic dilemma. Although total elbow arthroplasty is successful in older patients with low functional demand, alternatives to joint replacement must be found in the younger, more active individual. Interposition arthroplasty provides a salvage option for young, high-demand patients who hope to minimize functional restrictions of the affected extremity. The procedure traditionally involves release of both collateral ligaments and the joint capsule, resulting in a higher risk for postoperative instability and complications. The present unilateral technique demonstrates an approach maintaining the integrity of the medial or lateral collateral ligament while still allowing secure graft fixation. Stability can usually be preserved without ligament reconstruction or hinged external fixation if the elbow was stable before surgery.

Do We Need a Strictly Lateral Radiograph for Fracture Management of Forearm Buckle Fractures in Children?

OBJECTIVES: Buckle fractures of the distal forearm are a common fracture entity in children treated conservatively. Diagnostics primarily include radiographs in 2 planes. Inadequate images may occur in the mostly very young patients. Therefore, additional lateral radiographs are often obtained to assess a possible angular tilt. The aim of this study is to investigate whether a strictly lateral x-ray image has an influence on fracture management. METHODS: Seventy-three children with buckle fractures of the distal forearm were included in this retrospective analysis. All cases were analyzed by quality of radiographs, necessity to obtain an additional lateral radiograph, and what influence on fracture management resulted. Follow-up was performed 2 to 4 weeks after immobilization. RESULTS: Thirty-five girls and 38 boys with a mean age of 7.16 years were included; 40 had fractured right and 33 had fractured left arms, respectively. Isolated distal radius fractures occurred in 48 cases, isolated distal ulna fractures in 6 cases, and both bones in 19 cases. Initial radiographic images were evaluated as inadequate in 25 cases. In each of those cases, an additional lateral image was obtained by fluoroscopy without resulting in an alternated fracture management protocol, which was chosen conservatively in each case and resulted in excellent clinical outcome at follow-up examination. CONCLUSIONS: Based on our results, the acquisition of additional lateral radiographs seems to be unnecessary in the diagnostic procedure of buckle fractures of the distal forearm, in case a possible palmar or dorsal angulation cannot be entirely assessed on the initial set of radiographs. An additional lateral image had no influence on fracture management, which was chosen conservatively in every case and led to excellent clinical results.Level of evidence: level III.

Intraoperative visualization of the posterolateral ulnohumeral joint space is reliable to indicate overlengthening in radial head arthroplasty.

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.

Postoperative swelling after elbow surgery: influence of a negative pressure application in comparison to manual lymphatic drainage-a randomized controlled trial.

PURPOSE: Postoperative soft tissue swelling is a significant factor influencing outcomes after elbow surgery. It can crucially affect important parameters such as postoperative mobilization, pain, and subsequently the range of motion (ROM) of the affected limb. Furthermore, lymphedema is considered a significant risk factor for numerous postoperative complications. Manual lymphatic drainage is nowadays part of the standardized post-treatment concept, basing on the concept of activating the lymphatic tissue to absorb stagnated fluid from the tissue into the lymphatic system. This prospective study aims to investigate the influence of technical device-assisted negative pressure therapy (NP) on early functional outcomes after elbow surgery. NP was therefore compared to manual lymphatic drainage (MLD). Is a technical device-based NP suitable for treatment of lymphedema after elbow surgery? METHODS: A total of 50 consecutive patients undergoing elbow surgery were enrolled. The patients were randomized into 2 groups. 25 participants per group were either treated by conventional MLD or NP. The primary outcome parameter was defined as the circumference of the affected limb in cm postoperative up to seven days postoperatively. The secondary outcome parameter was a subjective perception of pain (measured via visual analogue scale, VAS). All parameters were measured on each day of postoperative inpatient care. RESULTS AND CONCLUSION: NP showed an overall equivalent influence compared to MLD in reducing upper limb swelling after surgery. Moreover, the application of NP showed a significant decrease in overall pain perception compared to manual lymphatic drainage on days 2, 4 and 5 after surgery (p < 0.05). CONCLUSION: Our findings show that NP could be a useful supplementary device in clinical routine treating postoperative swelling after elbow surgery. Its application is easy, effective and comfortable for the patient. Especially due to the shortage of healthcare workers and physical therapists, there is a need for supportive measures which NP could be.

The impact of the SARS-CoV-2 pandemic-related lockdowns on orthopedic trauma emergencies at a level-one trauma center.

INTRODUCTION: The SARS-CoV-2 pandemic and its associated lockdowns had a profound effect on orthopedic trauma emergencies. This study aimed to investigate the patient volume and injury patterns at a level-one trauma center during the SARS-CoV-2 pandemic and compare them to the pre-pandemic conditions. MATERIALS AND METHODS: A retrospective chart review of all patients who presented to the orthopedic trauma emergency department of a level-one trauma center in Cologne, Germany within a 2 year period from March 16th, 2019 to March 15th, 2020 (pre-pandemic control) and from March 16th, 2020 and March 15th, 2021 (pandemic) was performed. The pandemic year was separated into three periods: (1) first lockdown, (2) between lockdowns and (3) second lockdown. The absolute numbers of patient presentations, the Manchester triage score (MTS) and the relative proportion of patients with structural organ injuries, fractures and dislocations, of polytraumatized patients, of hospital admissions, of subsequent emergency or semi-elective surgeries and of work-related accidents were evaluated in comparison to the pre-pandemic control. RESULTS: A total of 21,642 patient presentations were included in this study. Significantly less weekly orthopedic trauma emergency patient presentations were recorded during the pandemic (p < 0.01). The MTS was significantly lower during the first lockdown and between lockdowns (p < 0.01). The proportional incidence of overall structural organ injuries, fractures and dislocations, of upper limb fractures/dislocations, of hospital admissions and of patients requiring surgery was significantly increased during the pandemic (p ≤ 0.03). The proportional incidence of work-related injuries was significantly decreased during the pandemic (p < 0.01). CONCLUSIONS: Orthopedic trauma emergency presentations were reduced during the SARS-CoV-2 pandemic. Due to the reluctancy of patients to visit the emergency department during the pandemic, the proportions of relevant injuries in general and of upper limb injuries in particular as well as of patients requiring hospital admission and trauma-related surgery were significantly increased.

Lessons learned? Increasing injury severity of electric-scooter accidents over a period of one year: a monocentric follow-up study at a level 1 trauma center.

PURPOSE: After major COVID-19 lockdown measures were suspended in 2021, E-scooter mobility regrew rapidly. In the meantime, multiple studies were published on the potential risks for e-scooter drivers and the necessity for wearing protective equipment. But did the drivers learn their lessons? METHODS: We observed data of E-scooter-related accidents admitted to the emergency department of a level 1 German trauma center in the year 2021 and compared the data with our previous report (July 2019-July 2020). RESULTS: N = 97 E-scooter-related accidents were included, marking a 50% increase when compared to the previous observation. Most patients were young adults (28.18 ± 1.13 years) with a notable shift towards a male population (25 vs. 63, p = 0.007). While the injury pattern remained unchanged, injury severity, reflected by a significant increase in shock room treatments (p = 0.005), hospital admissions (p = 0.45), and ICU admissions (p = 0.028), increased. Lastly, we report a higher injury severity of patients driving under the influence of alcohol, expressed by significant differences in hospital admissions, shock room treatments, ICU admissions, intracerebral bleeding (p < 0.0001), and injuries requiring surgery (p = 0.0017). CONCLUSION: The increase in injury severity and especially the substantial number of accidents due to driving under the influence of alcohol, are alarming for both trauma- and neurosurgeons. As the controversy surrounding the general use of E-scooters will continue, we urge representatives to intensify their efforts regarding prevention campaigns focusing on the potential dangers of E-scooters, especially when driving under the influence of alcohol.

[Follow-up treatment concepts for elbow injuries]. / Nachbehandlungskonzepte bei Ellenbogenverletzungen.

So far there are no clear recommendations for postoperative follow-up treatment of elbow injuries and individual concepts are often chosen. Due to the susceptibility for posttraumatic or postoperative impaired movement up to stiffness of the elbow joint, early mobilization plays a crucial role. Therefore, mid-term to long-term immobilization should be avoided. In addition to the necessary cryotherapy and compression therapy for swelling and pain control in the initial period, early actively assisted mobilization now has an important role. Additionally, active flexion and extension in an overhead position, so-called overhead motion, was recently established. After a short initial immobilization in a cast, mostly 3-5 days, the cast is changed to a dynamic movement orthosis, which when possible enables a free range of motion. Care is taken that varus and valgus loading is avoided. In general loading is avoided for the first 6 weeks, followed by a stepwise increase of loading up to maximum loading. In most cases return to sport is possible after 3 months. After implantation of an elbow prosthesis a maximum loading of 5 kg for single loading and 1 kg for repetitive loading are recommended.

[Monteggia-like injuries : Pitfalls of surgical treatment]. / Monteggia-like-Verletzungen : Pitfalls der operativen Versorgung.

The term Monteggia-like lesions or Monteggia equivalent injuries includes fractures of the proximal ulna with dislocation and dislocation fractures of the radial head from the proximal radio-ulnar joint. The complexity of the injury requires a dedicated understanding of the anatomical structures and their biomechanical properties. Particularly due to the rarity, the complication and revision rates are high. A conservative treatment is not usually effective. Three-dimensional imaging by computed tomography is part of the surgical preparation. The goal of surgical treatment is osteosynthetic reconstruction of the fractures and restoration of joint congruency. In cases of nonreconstructable radial head fractures, radial head arthroplasty may be necessary. In addition to reconstruction of the bony stabilizers, refixation of the ligamentous structures is essential for treatment success. The combination of complex fracture patterns and possible dislocation positions in the ulnohumeral, radiohumeral and proximal radio-ulnar joints poses a great challenge to the surgeon. The most frequent complications are peri-implant infections, implant failure, loss of reduction, stiffness or instability. Especially the anatomical configuration of the proximal ulna is complex and requires accurate reconstruction. Therefore, reconstruction of the proximal ulna in length and rotation, including the coronoid process, is considered to be a key factor in the surgical treatment of Monteggia-like injuries.

[Clinical results of total elbow arthroplasty after treatment failure for Monteggia-like injuries]. / Klinische Ergebnisse der Ellenbogentotalendoprothetik nach Therapieversagen bei Monteggia-like-Verletzungen.

BACKGROUND: Monteggia-like fractures (MLF) are complex injuries with high complication rates and frequently unsatisfying clinical results. Total elbow arthroplasty (TEA) represents the only option to salvage the functional requirements in some patients with pronounced posttraumatic arthropathy. This case series provides clinical results of TEA following failed treatment of MLF. METHODS: All patients who underwent TEA from 2017 to 2022 for failed treatment of MLF were retrospectively included in this study. Complications and revisions before and after TEA and functional results, measured by the Broberg/Morrey score, were evaluated. RESULTS: In this study 9 patients with a mean age of 68 (±7; 54-79) years were included. The mean follow-up was 12 (±9; 2-27) months. The main reasons leading to posttraumatic arthropathy were chronic infections (44.4%), bony instability due to coronoid deficiency (33.3%) or a combined coronoid and radial head deficiency (22.2%) and non-union of the proximal ulna with radial head necrosis (11.1%). The mean number of surgical revisions between primary fixation and TEA was 2.7 (±1.8; 0-6). The revision rate following TEA was 44%. The mean Broberg/Morrey score at the time of the latest follow-up was 83 (±10; 71-97) points. CONCLUSION: Chronic infection and coronoid deficiency are the main reasons for posttraumatic arthropathy after MLF leading to TEA. While the overall clinical results are satisfying, the indications should be reserved for selected cases due to high revision rates.

Semi-Synthesis of Different Pyranoflavonoid Backbones and the Neurogenic Potential.

Flavonoids and chalcones are known for their manifold biological activities, of which many affect the central nervous system. Pyranochalcones were recently shown to have a great neurogenic potential, which is partly due to a specific structural motif-the pyran ring. Accordingly, we questioned if other flavonoid backbones with a pyran ring as structural moiety would also show neurogenic potential. Different semi-synthetic approaches starting with the prenylated chalcone xanthohumol, isolated from hops, led to pyranoflavanoids with different backbones. We identified the chalcone backbone as the most active backbone with pyran ring using a reporter gene assay based on the promoter activity of doublecortin, an early neuronal marker. Pyranochalcones therefore appear to be promising compounds for further development as a treatment strategy for neurodegenerative diseases.

Correlation of head screw lengths in proximal humerus nailing: a CT-based study on 289 cases.

INTRODUCTION: Nailing of the proximal humerus is an established method for the treatment of proximal humerus fractures. Choice of the correct length for potentially four proximal locking screws is essential for postoperative outcome. Due to positioning of the patient, intraoperative determination of the correct length of the anteroposterior (AP) screw with the x-ray beam is particularly challenging even for experienced surgeons. We hypothesized that there would be a correlation between the projected lengths of the different proximal locking screws and therefore the length of the AP-screw could be determined based on the three lateromedial (LM) screws. MATERIALS AND METHODS: In this retrospective study (level of evidence: III) CT-scans of shoulders of 289 patients were 3D reconstructed with the program Horos. Using the manufacturer Stryker's instructions, the four proximal locking screws of the T2 Humeral Nail system were reproduced in the 3D reconstructed shoulders. The length of the AP-screw was correlated with the lengths of the LM-screws by Linear Regression and Multiple Linear Regression. RESULTS: The results of this study showed that the lengths of proximal locking screws in proximal humeral nailing correlated significantly with each other. Based on the given data, a formula could be established to calculate the length of the AP-screw based on the lengths of the LM-screws with a probability of 76.5%. CONCLUSIONS: This study was able to show that the length of the AP-screw could be determined from the intraoperatively measured lengths of the LM-screws. As our findings base on measurements performed in CT scans, clinical studies are needed to support our data.

Anteromedial coronoid facet fractures and associated ligament lesions: A case series.

INTRODUCTION: Varus posteromedial rotational injury mechanisms lead to fractures of the coronoids process' anteromedial facet. As these fractures are often unstable, rapid fracture treatment is vital to prevent progressive osteoarthritis. MATERIALS AND METHODS: Twelve patients with a fracture of the anteromedial facet treated surgically were enrolled in the study. Computed tomography images were used to classify the fractures according to the system by O'Driscoll et al. Clinical follow-up included each patient's medical record, surgical treatment algorithm, all complications encountered during the follow-up period, Disabilities of the arm, shoulder, and hand score, subjective elbow value, and pain. RESULTS: A total of 8 men (66.7%) and 4 women (33.3%) were treated surgically and followed-up after a mean period of 45 ± 23 months. The mean DASH score was 11.9 ± 12.9 points. One patient complained of transient neuropathy in the innervation area of the ulnar nerve, however, this existed already pre-operatively and resolved after less than three months. CONCLUSIONS: The presented patient cohort shows that AMF fracture of the coronoid process are unstable lesions according to the bony instability and the frequently ruptured collateral ligament complexes which need to be addressed. The MCL seems to be affected more frequently than previously appreciated. LEVEL OF EVIDENCE: Level IV; Case Series; Treatment Study.

Computed tomography-based angle measurements of the sagittal capitulum and trochlea position in relation to the humeral shaft.

The radiologic evaluation of the sagittal angulation of the distal humerus is commonly based on standard lateral radiographs. However, lateral radiographs do not allow to examine the lateral angulation of the capitulum and the trochlea, separately. Although this problem could be approached via computed tomography, there are no data available describing the difference between the angulation of the capitulum and trochlea. Therefore, we aimed to assess sagittal angles of the capitulum and trochlea in relation to the humeral shaft based on 400 CT-scans of the elbow in healthy adults. Angles were measured in sagittal planes at the capitulum center and three anatomically defined trochlea locations and were spanned between the axis of the joint component and the humerus shaft. Angles were tested for differences between measurement locations and correlation with patient characteristics (age, sex, trans-epicondylar distance). Angles increased from lateral to medial measurement locations (107.4 ± 9.6°, 167.4 ± 8.2°, 171.8 ± 7.3°, 179.1 ± 7.0°; p < 0.05). Largest angle differences were detected between the capitulum and trochlea with smallest angles measured at the capitulum. Patient characteristics did not correlate with angles (p > 0.05). Intra-rater-reliability was r = 0.79-0.86. As CT-imaging allows to distinguish between sagittal capitulum and trochlea locations, it might benefit the radiologic diagnostic of sagittal malalignments of the distal humerus at the capitulum and trochlea, separately.

Management of Irreparable Posterosuperior Rotator Cuff Tears-A Current Concepts Review and Proposed Treatment Algorithm by the AGA Shoulder Committee.

Posterosuperior rotator cuff tears range among the most common causes of shoulder complaints. While non-operative treatment is typically reserved for the elderly patient with low functional demands, surgical treatment is considered the gold standard for active patients. More precisely, an anatomic rotator cuff repair (RCR) is considered the most desirable treatment option and should be generally attempted during surgery. If an anatomic RCR is impossible, the adequate choice of treatment for irreparable rotator cuff tears remains a matter of debate among shoulder surgeons. Following a critical review of the contemporary literature, the authors suggest the following evidence- and experience-based treatment recommendation. In the non-functional, osteoarthritic shoulder, treatment strategies in the management of irreparable posterosuperior RCT include debridement-based procedures and reverse total shoulder arthroplasty as the treatment of choice. Joint-preserving procedures aimed at restoring glenohumeral biomechanics and function should be reserved for the non-osteoarthritic shoulder. Prior to these procedures, however, patients should be counseled about deteriorating results over time. Recent innovations such as the superior capsule reconstruction and the implantation of a subacromial spacer show promising short-term results, yet future studies with long-term follow-up are required to derive stronger recommendations.

Surgical arthrolysis of the stiff elbow: a systematic review.

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