Update in diagnosis, treatment, and prevention of osteochondritis dissecans of the capitellum.

Osteochondritis dissecans of the capitellum is debilitating and is a potentially sports career-ending injury in a young and athletic population. Osteochondritis dissecans typically occurs in patients between the ages of 10 and 24 years, and boys are more commonly affected than girls. Conventional radiographs have low diagnostic accuracy, and magnetic resonance imaging (with or without contrast) or computed tomography may aid in accurate diagnosis. The primary indication for non-operative treatment is the presence of an intact cartilage cap on magnetic resonance imaging, indicating a "stable lesion." However, if operative treatment is necessary, various surgical procedures are available when operative treatment for an osteochondritis dissecans of the capitellum is considered, including open or arthroscopic removal of loose bodies, with or without microfracturing, fragment fixation, osteochondral autograft transplantation, and osteochondral allograft transplantation. The decision-making process for selecting the appropriate treatment considers factors such as the patient's characteristics, functional limitations, and lesion morphology.

Patient perceptions after the operative and nonoperative treatment of shoulder instability: A qualitative focus group study.

Background: Little evidence is available regarding patient perceptions of the treatment of shoulder instability. The aim of this study is to investigate patient perceptions regarding the operative and nonoperative treatment of anterior shoulder instability. Methods: Patients who presented to the emergency department or outpatient clinic between 2016 and 2020 were retrospectively selected using diagnosis and procedure codes. Online focus groups and semistructured interviews were conducted, systematically recorded and subsequently transcribed to MaxQDA 2007 for qualitative analysis. Coded transcripts of all focus groups were subjected to a grounded theory-based analysis. Results: Six focus groups and two semistructured interviews were hosted with 35 included patients. The mean age of included patients was 34.1 years (±11.5). Eight patients were female (23%), and 27 patients were male (77%). Fear of (recurrent) dislocation, preoperative counseling, communication between surgeon and physiotherapists and need for a consistent postoperative rehab protocol turned out to be important patient perceptions. The most crucial factor for discontent was a lack of communication from the surgeon. Discussion: This patient-centered focus group study revealed that fear of (recurrent) dislocation, preoperative counseling, communication between surgeons and physiotherapists and the need for a consistent postoperative rehabilitation protocol was the most frequently discussed themes.

Elbow joint biomechanics during ADL focusing on total elbow arthroplasty - a scoping review.

BACKGROUND: Overloading is hypothesized to be one of the failure mechanisms following total elbow arthroplasty (TEA). It is unclear whether the current post-operative loading instruction is compliant with reported failure mechanisms. Aim is therefore to evaluate the elbow joint load during activities of daily living (ADL) and compare these loads with reported failure limits from retrieval and finite element studies. METHODS: A scoping review of studies until 23 November 2021 investigating elbow joint load during ADL were identified by searching PubMed/Medline and Web of Science. Studies were eligible when: (1) reporting on the elbow joint load in native elbows or elbows with an elbow arthroplasty in adults; (2) full-text article was available. RESULTS: Twenty-eight studies with a total of 256 participants were included. Methodological quality was low in 3, moderate in 22 and high in 3 studies. Studies were categorized as 1) close to the body and 2) further away from the body. Tasks were then subdivided into: 1) cyclic flexion/extension, 2) push-up, 3) reaching, 4) self-care, 5) work. Mean flexion-extension joint load was 17 Nm, mean varus-valgus joint load 9 Nm, mean pronation-supination joint load 8 Nm and mean bone-on-bone contact force 337 N. CONCLUSION: The results of our scoping review give a first overview of the current knowledge on elbow joint loads during ADL. Surprisingly, the current literature is not sufficient to formulate a postoperative instruction for elbow joint loading, which is compliant with failure limits of the prosthesis. In addition, our current instruction does not appear to be evidence-based. Our recommendations offer a starting point to assist clinicians in providing informed decisions about post-operative instructions for their patients.

History of closed reduction techniques and initial management for shoulder dislocations: From classical antiquity to modern times.

This review gives a summary of the records of shoulder dislocation management throughout history until the point that anaesthetics were introduced and modern medicine improved dislocation management exponentially. A dislocation is a mechanical injury that has been managed in different ways throughout history. The shoulder reduction methods described in Hippocrates Corpus have been described and adjusted throughout history by later physicians. For example, in ancient Greek, Hippocrates considered the ambe, a device used to reduce the shoulder, to be the most powerful tool. However, Cooper, a physician in the 19th century, considered it to be the last resort due to substantial damage to the ribs and discomfort of the patient. This review demonstrates that there were many physicians that contributed to shoulder dislocation management. These physicians paved the way for modern shoulder dislocation treatment strategies.

Complications of olecranon osteotomy in the treatment of distal humerus fracture.

anaDistal humerus fractures (DHFs) are challenging to treat due to the locally complex osseous and soft tissue anatomy. Adequate exposure of the articular surface of the distal humerus is crucial when performing an anatomical reconstruction of the elbow. Even though "triceps-on" approaches are gaining popularity, one of the most commonly used surgical treatments for DHF is olecranon osteotomy. The incidence of complications related to this approach is unclear. This review was performed to assess the type and frequency of complications that occur with the olecranon osteotomy approach in the treatment of DHF. A literature search was conducted in the PubMed/Medline, Embase, and Cochrane Library digital databases up to February 2020. Only English articles describing complications of olecranon osteotomy in the treatment of DHF were included. Data on patient and surgical characteristics and complications were extracted. Statistical analysis was performed using SPSS. A total of 41 articles describing 1,700 osteotomies were included, and a total of 447 complications were reported. Of these 447 complications, wound infections occurred in 4.2% of osteotomies, of which 1.4% were deep infections and 2.8% were superficial. Problems related with union occurred in 3.7% of osteotomies, 2% of which represented non-union and 1.7% delayed union. The high risk of complications in olecranon osteotomy must be considered in the decision to perform this procedure in the treatment of DHF.

Alexander 'Lippy' William Lipmann Kessel, from 'Surgeon at Arms' to 'Surgeon of Arms'.

Alexander William Lipmann Kessel (1914-1986) was as surgeon connected to the 16th Parachute Field Ambulance Royal Army Medical Corps and as such he was dropped in The Netherlands in September 1944 to care for the wounded during the battle for the Rhine bridge at Arnhem. His military and post military career were inspirational and led to preservation of lives during the war and progress in orthopaedic surgery after the war. In this paper, we discuss his biography and the contributions he made to orthopaedic surgery.

Interobserver reliability of the classification of capitellar osteochondritis dissecans using magnetic resonance imaging.

AIM: (1) To determine the interobserver reliability of magnetic resonance classifications and lesion instability criteria for capitellar osteochondritis dissecans lesions and (2) to assess differences in reliability between subgroups. METHODS: Magnetic resonance images of 20 patients with capitellar osteochondritis dissecans were reviewed by 33 observers, 18 orthopaedic surgeons and 15 musculoskeletal radiologists. Observers were asked to classify the osteochondritis dissecans according to classifications developed by Hepple, Dipaola/Nelson, Itsubo, as well as to apply the lesion instability criteria of DeSmet/Kijowski and Satake. Interobserver agreement was calculated using the multirater kappa (k) coefficient. RESULTS: Interobserver agreement ranged from slight to fair: Hepple (k = 0.23); Dipaola/Nelson (k = 0.19); Itsubo (k = 0.18); DeSmet/Kijowksi (k = 0.16); Satake (k = 0.12). When classifications/instability criteria were dichotomized into either a stable or unstable osteochondritis dissecans, there was more agreement for Hepple (k = 0.52; p = .002), Dipaola/Nelson (k = 0.38; p = .015), DeSmet/Kijowski (k = 0.42; p = .001) and Satake (k = 0.41; p < .001). Overall, agreement was not associated with the number of years in practice or the number of osteochondritis dissecans cases encountered per year (p > .05). CONCLUSION: One should be cautious when assigning grades using magnetic resonance classifications for capitellar osteochondritis dissecans. When making treatment decisions, one should rather use relatively simple distinctions (e.g. stable versus unstable osteochondritis dissecans; lateral wall intact versus not intact), as these are more reliable.

Do we publish what we present? The publication rate of a national arthroscopy society and a review of the literature.

The publication rate (PR) of full-text articles after presentation at medical society meetings varies widely. The purpose of this study is (1) to determine the PR of abstracts presented at the Dutch Arthroscopy Society's (NVA) annual meeting from 2006 until 2016, (2) to determine the time between presentation and publication, and (3) to review the known literature on the PR of orthopaedic scientific meetings. We retrospectively reviewed the programs of the NVA annual meetings from 2006 to 2016. All podium presentations reported were included. The search for subsequent journal publication was performed using PubMed, EMBASE, and Google Scholar databases. A systematic literature search was performed in PubMed. All studies regarding the publication rates of orthopaedic scientific meetings were included. From 2006 to 2016 a total of 131 papers were presented at the NVA annual meetings, of which 83 were published as full text articles (63%). The mean time to publication was 16.5 months. The overall PR at orthopaedic scientific meetings ranges from 21% to 71%.

Radiographic assessment of calcifying tendinitis of the rotator cuff : an inter- and intraobserver study.

The radiographic appearance of calcific tendinitis of the rotator cuff varies according to the stage of the disease. We compared currently used classification systems in a large group of observers to identify the most reliable classification system. Thirty-seven orthopaedic surgeons evaluated shoulder radiographs of 25 patients to classify the stage of the calcific tendinitis according to the classifications by (1) Gärtner and (2) Molé on a Web-based study platform. Inter and intraobserver agreement among observers was measured using the Siegel and Castellan multirater κ. Both classification systems had fair interobserver agreement : κ was 0.25 for the Molé classification and 0.34 for the Gärtner classification. The Gärtner classification was significantly more reliable than the Molé classification. Currently there is no radiographic classification that can serve the purpose of guiding the treatment in a reliable way.

Tennis elbow.

Tennis elbow is the most common cause of lateral-sided elbow pain with a major socioeconomic impact. The etiology of tennis elbow is not completely understood, but there are many different treatment options. This review gives an overview of the current concepts of diagnosis and treatment of tennis elbow and the impact on work participation.

Direct and indirect costs associated with nonoperative treatment for shoulder instability: an observational study in 132 patients.

BACKGROUND: Shoulder instability is associated with decreased functioning. The associated costs could be substantial and interesting to clinicians, researchers, and policy makers. This prospective observational study aims to (1) estimate productivity losses and healthcare expenses following the nonoperative treatment of shoulder instability and (2) identify patient characteristics that influence societal costs. METHODS: One hundred and thirty-two patients completed a questionnaire regarding production losses and healthcare utilization following consecutive episodes of shoulder instability. Productivity losses were calculated using the friction cost approach. Healthcare utilization was evaluated using standard costs. analysis of variance test was used to assess which patient characteristics are related to productivity losses and healthcare expenses. Societal costs were assessed using multilevel analyses. Bootstrapping was used to estimate statistical uncertainty. RESULTS: Mean productivity losses are €1469, €881, and €728 and mean healthcare expenses are €3759, €3267, and €2424 per patient per dislocation for the first, second, and third dislocation. Productivity losses decrease significantly after the second (mean difference €-1969, 95%CI= -3680 to -939) and third (mean difference €-2298, 95%CI= -4092 to -1288) compared to the first dislocation. CONCLUSIONS: Nonoperative treatment of shoulder instability has substantial societal costs. LEVEL OF EVIDENCE: III, economic analysis.

Normative values and affecting factors for the elbow range of motion.

INTRODUCTION: Abnormalities in the elbow range of motion (ROM) can be subtle; therefore, it is important that the examiner can compare findings with reliable reference values, matching the patients' characteristics. Primarily, we aimed to provide normative values for the elbow ROM in subpopulations based on age, sex, dominance and body mass index (BMI). The secondary objective was to determine intra- and inter-rater reliability. METHODS: aROM (active range of motion) and pROM (passive range of motion) were measured bilaterally in healthy adults using a universal goniometer. The influence of factors affecting the ROM was calculated using Pearson's correlation coefficient. In two samples of subjects, intra-rater and inter-rater reliability were determined. RESULTS: The study population (n = 352) consisted of 47.2% male and 52.8% female subjects. For aROM (dominant hand), mean flexion was 146°, extension -2°, pronation 80° and supination 87°. Male subjects had smaller ROM compared to females (p < 0.001). Differences between dominant and nondominant hand were less than one degree. pROMs were 3° to 5° larger than aROMs (p < 0.001). Intra- and inter-rater reliability was good. CONCLUSIONS: Elbow ROM is influenced by age, sex and BMI. In the general population, the ROM of the uninjured side can serve as a reference in case of an injured elbow.

The reliability and validity of goniometric elbow measurements in adults: A systematic review of the literature.

BACKGROUND: The universal goniometer is a simple measuring tool. With this review we aimed to investigate the reliability and validity of the universal goniometer in measurements of the adults' elbow. METHODS: Preferred Reporting Items for Systematic reviews and Meta-Analysis guidelines were followed and our study protocol was published online at PROSPERO. A literature search was conducted on relevant studies. Methodological quality was assessed using the Quality Appraisal of Diagnostic Reliability (QAREL) scoring system. RESULTS: Out of 697 studies yielded from our literature search, 12 were included. Six studies were rated as high quality. The intrarater reliability intraclass correlation coefficient ranged from 0.45 to 0.99, the interrater reliability ranged from intraclass correlation coefficient 0.53-0.97. One study providing instructions on goniometric alignment did not find a difference in expert versus non-expert examiners. Another study in which examiners were not instructed found a higher interrater reliability in expert examiners. One study investigating the validity of the goniometer in elbow measurements found a maximum standard error of the mean of 11.5° for total range of motion. DISCUSSION: Overall, the studies showed high intra- and interrater reliability of the universal goniometer. The reliability of the universal goniometer in non-expert examiners can be increased by clear instructions on goniometric alignment.

Corticosteroid injection alone vs additional physiotherapy treatment in early stage frozen shoulders.

AIM: To investigate the additional value of physiotherapy after a corticosteroid injection in stage one or two idiopathic frozen shoulders (FSs). METHODS: A two center, randomized controlled trial was done. Patients with a painful early stage idiopathic FS were eligible for inclusion. After written consent, patients were randomly allocated into two groups. All patients received an ultrasound-guided intra-articular corticosteroid injection. One group underwent additional physiotherapy treatment (PT) and the other group did not (non-PT). The primary outcome measure was the Shoulder Pain and Disability Index (SPADI). Secondary outcomes were pain (numeric pain rating scale), range of motion (ROM), quality of life (RAND-36 score), and patient satisfaction. Follow-up was scheduled after 6, 12 and 26 wk. RESULTS: Twenty-one patients were included, 11 patients in the non-PT and ten in the PT group, with a mean age of 52 years. Both treatment groups showed a significant improvement at 26 wk for SPADI score (non-PT: P = 0.05, PT: P = 0.03). At the 6 wk follow-up, median SPADI score was significant decreased in the PT group (14 IQR: 6-38) vs the non-PT group (63 IQR: 45-76) (P = 0.01). Pain decreased significantly in both groups but no differences were observed between both treatment groups at any time point, except for night pain at 6 wk in favor of the PT group (P = 0.02). Significant differences in all three ROM directions were observed after 6 wk in favor of the PT group (P ≤ 0.02 for all directions). A significantly greater improvement in abduction (P = 0.03) and external rotation (P = 0.04) was also present in favor of the PT group after 12 wk. RAND-36 scores showed no significant differences in health-related quality of life at all follow-up moments. At 26 wk, both groups did not differ significantly with respect to any of the outcome parameters. No complications were reported in both groups. CONCLUSION: Additional physiotherapy after corticosteroid injection improves ROM and functional limitations in early-stage FSs up to the first three months.

Midshaft clavicle fractures: Current concepts.

Clavicle fractures are common fractures and the optimal treatment strategy remains debatable. The present paper reviews the available literature and current concepts in the management of displaced and/or shortened midshaft clavicle fractures.Operative treatment leads to improved short-term functional outcomes, increased patient satisfaction, an earlier return to sports and lower rates of non-union compared with conservative treatment. In terms of cost-effectiveness, operative treatment also seems to be advantageous.However, operative treatment is associated with an increased risk of complications and re-operations, while long-term shoulder functional outcomes are similar.The optimal treatment strategy should be one tailor-made to the patient and his/her specific needs and expectations by utilizing a shared decision-making model. Cite this article: EFORT Open Rev 2018;3:374-380. DOI: 10.1302/2058-5241.3.170033.

Physical examination of the elbow, what is the evidence? A systematic literature review.

OBJECTIVE: Primary to provide an overview of diagnostic accuracy for clinical tests for common elbow (sport) injuries, secondary accompanied by reproducible instructions to perform these tests. DESIGN: A systematic literature review according to the PRISMA statement. DATA SOURCES: A comprehensive literature search was performed in MEDLINE via PubMed and EMBASE. ELIGIBILITY CRITERIA: We included studies reporting diagnostic accuracy and a description on the performance for elbow tests, targeting the following conditions: distal biceps rupture, triceps rupture, posteromedial impingement, medial collateral ligament (MCL) insufficiency, posterolateral rotatory instability (PLRI), lateral epicondylitis and medial epicondylitis. After identifying the articles, the methodological quality was assessed using the QUADAS-2 checklist. RESULTS: Our primary literature search yielded 1144 hits. After assessment 10 articles were included: six for distal biceps rupture, one for MCL insufficiency, two for PLRI and one for lateral epicondylitis. No articles were selected for triceps rupture, posteromedial impingement and medial epicondylitis. Quality assessment showed high or unclear risk of bias in nine studies. We described 24 test procedures of which 14 tests contained data on diagnostic accuracy. CONCLUSIONS: Numerous clinical tests for the elbow were described in literature, seldom accompanied with data on diagnostic accuracy. None of the described tests can provide adequate certainty to rule in or rule out a disease based on sufficient diagnostic accuracy.