Search

Purpose: Searching for quick determinable biomarkers with high sensitivity and specificity is necessary to improve and optimise the early diagnosis of periprosthetic elbow infection (PEI). Therefore, this study's objective was to evaluate the diagnostic value of synovial fluid interleukin-6 (IL-6) levels for diagnosing PEI in total elbow arthroplasty., Method: Twelve prospective enrolled patients underwent total elbow arthroplasty revision surgery, during which synovial fluid was obtained. Between the initial implantation and the revision procedure were 33.5 ± 41 months (range, 2-144 months). Synovial fluid was collected for immediate IL-6 analysis parallel to the revision surgery. Furthermore, microbiological samples were obtained and analysed. Two groups were defined based on the microbiological results: non-infection and infection group. The ability of synovial fluid IL-6 analysis to predict infection status was explored using receiver operating characteristic curves and further statistical analysis., Results: Synovial fluid IL-6 analysis had a good diagnostic accuracy of 83% for PEI with an area under the curve of 0,79 and an ideal cutoff value (determined using Youden's criterion) of 15244 pg/mL., Discussion: This is the first study to clinically evaluate IL-6 as a diagnostical marker for periprosthetic joint infection (PJI) in total elbow arthroplasty. Our results suggest a good accuracy and high sensitivity for IL-6 to identify a PEI. The analysis of IL-6 can improve surgical decision-making regarding managing total elbow arthroplasty in terms of one- or two-staged revision., Conclusion: IL-6 can play an important role in the perioperative differentiation of infected and non-infected situations., (© 2024. The Author(s) under exclusive licence to SICOT aisbl.)

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., (© 2024. The Author(s).)

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

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., (© 2023. The Author(s).)

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., (© 2023. The Author(s).)

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., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Purpose: The optimal screw placement in arthroscopically assisted fixation of radial head fractures is still an issue and no guiding methods have been evaluated in the recent literature. The study hypothesis was that using a "reference k-wire" percutaneously inserted in and parallel to the radiocapitellar joint would enable to achieve a trajectory more parallel to the radial head articular surface as compared to a free-hand k-wire placement., Methods: Arthroscopically assisted placement of a k-wire in the radial head was performed in seven fresh-frozen human cadaver specimens by three surgeons. Three different techniques were evaluated: freehand drilling (technique A), placement using a "reference" k-wire in the radiocapitellar joint as a reference without (technique B), and with the AO parallel k-wire guide (technique C). Radiographs from all procedures were obtained and the inclination angle "α" between the k-wire and the articular surface of the radial head was measured and compared among the techniques., Results: Angles of 84 radiographs were obtained and showed a mean α angle of 30.1° ± 13° for technique A, 5.7° ± 4.5° for technique B, and 5.4° ± 3.7° for technique C. The angle α was significantly higher with technique A as compared to B (p < 0.0001) and C (p < 0.0001). There was no difference between methods B and C (n.s.). No difference was observed among the surgeons for all three methods (p = 0.66)., Conclusion: With the use of an additional "reference" k-wire placed in the radiocapitellar joint, the guiding k-wire for screw drilling can be placed almost parallel to the radial head joint line with limited variability and a good reproducibility during arthroscopically assisted radial head fracture fixation., Clinical Relevance: The here-presented method of an additional, percutaneous introduced "reference" k-wire is easily applicable and helpful to achieve parallel screw placement during arthroscopically assisted radial head fracture fixation., Level of Evidence: IV, biomechanical cadaver study., (© 2022. The Author(s).)

Introduction: The aim of the present study was to develop a technical process to reproducibly generate terrible triad injuries (TTI) in fresh-frozen human cadaveric specimens, while leaving the skin intact. Such "pre-fractured" specimens, used for scientific analysis and for surgical education, might help to improve current treatment, which is complex and prone to complications., Materials and Methods: To induce the desired fractures, a custom-made fracturing unit was used to apply an axial force on the extended cadaveric elbow specimens, with the forearm pronated and under valgus load. To simulate the valgus load, a pneumatic cylinder was developed to apply valgus stress to the joint by an additional force vector from the lateral side of the joint., Results: The success rate of TTI induction was 92.3% (12/13). Of the 12 radial head fractures, 3 (25%) were classified Mason type II and 9 (75%) Mason type III. The coronoid fractures were grouped in tip subtype 2 (5 fractures, 41.7%), anteromedial facet (AMF) subtype 2 (4 fractures, 33.3%), AMF subtype 3 (1 fracture, 8.3%) and basal subtype 1 (2 fractures, 16.7%)., Conclusions: The present study provides an instrument for successful and reproducible production of dislocation fracture patterns with their typical accompanying soft tissue lesions. The methodology might be applied on a broad basis to be able to perform biomechanical studies regarding primary stability of fixation concepts for TTI and to educate surgeons in a fairly realistic scenario with the surgical treatment of TTI., (© 2022. The Author(s).)

Introduction: Open reduction and internal fixation (ORIF) of comminuted coronal shear fractures of the distal humerus is challenging. When a concomitant lateral condyle fracture is present, it may be used for a trans-fracture approach to facilitate exposure and fracture reduction. This study aimed to investigate the frequency of lateral condyle fractures in coronal shear fractures of the distal humerus and analyze fracture reduction, fracture union and clinical results following ORIF through a trans-fracture approach., Materials and Methods: All adult patients who underwent treatment for an acute distal humerus fracture during a three-year period in our level-one trauma center were identified. All fractures were classified according to the Orthopaedic Trauma Association (OTA/AO) fracture classification system and all B3 fractures were classified according to the Dubberley classification. B3 fractures with a concomitant radial condyle fracture were identified. The clinical and radiological results, (Mayo Elbow Performance Score = MEPS, Visual Analogue Scale = VAS, range of motion), complications and revision surgeries were analyzed., Results: 53 patients (mean age 52 ± 19 years) were identified. 13 fractures (24.5%) were B3 fractures. Four of them (30.8%) had a concomitant radial condyle fracture. All of these patients underwent ORIF with headless cannulated compression screws and a (postero-)lateral locking plate through a trans-fracture approach. At a minimum follow-up of 24 months, the MEPS was 88 ± 12 points, the VAS was 2 ± 1 and the range of motion was 118° ± 12°. All fractures showed anatomic reduction. One patient developed partial avascular necrosis and underwent arthrolysis at 6 months. One patient underwent partial hardware removal and lateral collateral ligament bracing at 6 months., Conclusions: Lateral condyle fractures are present in about one third of coronal shear fractures of the distal humerus. This injury can be used for a trans-fracture approach to facilitate exposure and to reliably achieve anatomic fracture reduction., (© 2022. The Author(s).)

Introduction: In regard of surgical training, the reproducible simulation of life-like proximal humerus fractures in human cadaveric specimens is desirable. The aim of the present study was to develop a technique that allows simulation of realistic proximal humerus fractures and to analyse the influence of rotator cuff preload on the generated lesions in regards of fracture configuration., Materials and Methods: Ten cadaveric specimens (6 left, 4 right) were fractured using a custom-made drop-test bench, in two groups. Five specimens were fractured without rotator cuff preload, while the other five were fractured with the tendons of the rotator cuff preloaded with 2 kg each. The humeral shaft and the shortened scapula were potted. The humerus was positioned at 90° of abduction and 10° of internal rotation to simulate a fall on the elevated arm. In two specimens of each group, the emergence of the fractures was documented with high-speed video imaging. Pre-fracture radiographs were taken to evaluate the deltoid-tuberosity index as a measure of bone density. Post-fracture X-rays and CT scans were performed to define the exact fracture configurations. Neer's classification was used to analyse the fractures., Results: In all ten cadaveric specimens life-like proximal humerus fractures were achieved. Two III-part and three IV-part fractures resulted in each group. The preloading of the rotator cuff muscles had no further influence on the fracture configuration. High-speed videos of the fracture simulation revealed identical fracture mechanisms for both groups. We observed a two-step fracture mechanism, with initial impaction of the head segment against the glenoid followed by fracturing of the head and the tuberosities and then with further impaction of the shaft against the acromion, which lead to separation of the tuberosities., Conclusion: A high energetic axial impulse can reliably induce realistic proximal humerus fractures in cadaveric specimens. The preload of the rotator cuff muscles had no influence on initial fracture configuration. Therefore, fracture simulation in the proximal humerus is less elaborate. Using the presented technique, pre-fractured specimens are available for real-life surgical education., Level of Evidence: III., (© 2022. The Author(s).)

Background: Complex proximal humeral fracture ranks among the most common fracture types, especially in elderly patients. In locked plate fixation of proximal humerus fractures, the calcar is deciding for screws providing further medial column support. To date, the biomechanical effect of the length of these calcar screws is not well known. The purpose of this study was to analyze the effect of long calcar screws on fresh frozen prefractured cadaveric specimens., Methods: In the present biomechanical study, 8 pairs of cadaveric proximal humeri were fractured identically using a custom-made fracture simulator. ORIF was performed using a locking plate (PHILOS; Fa. Synthes). The specimens were tested in a biomechanical setup under increased axial load without any calcar screws installed, with short calcar screws and long calcar screws installed. Strain gages (4-wire-120 Ohm, Fa. Vishay) mounted on the locking plate were used to evaluate the fixation strain and to give an estimate for primary stability.., Results: The measured strain of the locking plate without calcar screws (804,64 µm/m) at maximum load (200 N) was significantly higher than with short (619,07 µm/m; p = 0.02) or long calcar screws (527,31 µm/m; p = 0.007). Additionally, strain with short calcar screws was noticeably higher in comparison to long calcar screws (619,07 µm/m vs. 527,31 µm/m; p = 0.03)., Conclusion: Use of calcar screws improves the stability of realistically impacted 3-part varus humeral fractures. Long calcar screws that are positioned as close as possible to the joint provide further primary stability compared to short calcar screws., Level of Evidence: Basic science study., (© 2022. The Author(s).)

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., (© 2022. The Author(s).)

Background: Lateral collateral ligament (LCL) tears are frequently observed in fractures and dislocations of the elbow. Recent biomechanical evidence suggests that additional ligament augmentation may improve repair stability. The aim of this biomechanical in-vitro study was to compare the resistance of a locking suture repair of the LCL with a ligament augmentation technique., Material and Methods: Eight fresh frozen cadaveric elbows were evaluated for stability against varus/posterolateral rotatory forces (3 Nm). A strain gauge (µm/m; negative values) was placed at the origin and insertion of the lateral ulnar collateral ligament (LUCL) and cyclic loading was performed for 1000 cycles. We analyzed three distinct scenarios: (A) native LCL, (B) locking transosseou suture repair of the LCL, (C) simple LCL repair with additional ligament augmentation of the LUCL., Results: The mean measured strain was - 416.1 µm/m (A), - 618 µm/m (B) and - 288.5 µm/m (C) with the elbow flexion at 90°; the strain was significantly higher in scenario B compared to C (p = .01). During the cyclic load (1000) the mean measured strain was - 523.1 µm/m (B) and - 226.3 µm/m (C) with the elbow flexion at 60°; the strain was significantly higher in scenario B compared to C (p = .01). No significant difference between the first and the last cycles was observed (p = .09; p = .07). One failure of the LCL repair was observed after 1000 cycles; none of the ligament augmentations failed., Conclusion: Ligament augmentation (C) provides higher resistance compared to the native LCL (A) and to the locking suture repair technique (B). Both techniques, however, hold up during 1000 cycles. While ligament augmentation might enhance the primary stability of the repair, future clinical studies have to show whether this increase in resistance leads to negative effects like higher rates of posttraumatic elbow stiffness., Level of Evidence: Basic science study, biomechanics., (© 2022. The Author(s).)

Purpose: Interposition arthroplasty for the post-traumatic osteoarthritic elbow is a salvage procedure used in young and active patients and remains a rare and unexplored therapeutic option., Methods: We systematically reviewed the available literature searching electronic databases, MEDLINE using the PubMed interface and EMBASE. The primary objective was to synthesize functional outcomes and to investigate revision frequencies, but also complication and subsequent surgery rates among patients with surviving grafts. The preferred reporting guidelines for systematic reviews and meta-analyses guidelines were applied., Results: Five studies were left for inclusion, all retrospective in design, comprising 67 patients. The mean age was 40 years, the mean follow-up period was 61 months, and 68.2% of the patients treated were male. Eleven patients (16.4%) were treated with fascia lata autografts, and 56 patients (83.6%) were treated with Achilles tendon allografts. The graft survived in 53 patients (79.1%); the post-operative Mayo Elbow Performance Score averaged 69 points. Fourteen patients (20.9%) required revision surgery. In the setting of graft survival, 39.1% of patients had complications not requiring further surgical treatment and 5.7% of patients with surviving grafts needed subsequent operative treatment within the follow-up period., Conclusion: Given graft survival, this systematic review demonstrated satisfactory functional outcomes following interposition arthroplasty of the post-traumatic osteoarthritic elbow, however, associated with a cumulative complication and subsequent operative treatment rate of 44.8%. In addition, a revision rate of 20.9% needs to be expected. Varus-valgus instability in the pre-operative clinical assessment seems to be associated with unsatisfactory post-operative elbow function. The superiority of either of the two main reported graft methods (fascia lata autograft and Achilles tendon allograft) remains pending, and the role of an external fixator in preventing post-operative instability remains unresolved., (© 2022. The Author(s).)

Introduction: In this study we investigated if realistic fracture patterns around the hip can be produced on human cadaveric specimens with intact soft tissue envelope. Possible applications of such fractured specimens would be in surgical training., Materials and Methods: 7 cadaveric specimens (2 male, 5 female, 2 formalin-fixed, 5 fresh-frozen) were fractured. 2 specimens were fractured on both femurs, 5 only on one side, resulting in 9 fractures total. 5 fractures were set in our custom-made drop-test bench, 2 fractures by inducing axial force using a hammer, and the remaining 2 fractures by a direct dorsal approach and a chisel. AO/OTA and Pauwels classification were used to classify the fractures on the specimens by two independent trauma surgeons., Results: In our drop-test bench, axial load with the femur adducted by 10° resulted in an intertrochanteric fracture (AO type A1.3), adducted by 20° resulted in a femoral neck fracture (Pauwels type III). Fracture induction using a hammer resulted in two intertrochanteric fractures (AO type A2.2 right, A3.3 left). The use of a chisel resulted in both cases in a femoral neck fracture. The acetabulum could be fractured multifragmentarily through use of a hemiprosthesis as a stamp., Conclusion: A high energetic impulse induced by a custom-made drop-test bench can successfully simulate realistic proximal femur and acetabular fractures in cadaveric specimens with intact soft tissue. Furthermore, axial load using a hammer as well as using a chisel through a direct dorsal approach represent additional methods for fracture induction. These pre-fractured specimens can be utilized in surgical education to provide a realistic teaching experience for specialized trauma education courses., (© 2020. Springer-Verlag GmbH Germany, part of Springer Nature.)

Introduction: Radial head fractures account for the majority of bony elbow injuries. The individual treatment options have been described in detail. In some cases, however, an unusual concomitant injury occurs, which can significantly impede primary osteosynthesis and healing. This concomitant injury can be an interposing cartilaginous capitellar fragment., Methods: This retrospective study describes four cases of trapped cartilage fragments of the capitellum that compromised primary osteosynthesis or primary conservative healing of a radial head fracture. Radiological imaging, function and pain level are presented pre- and postoperatively (mean follow-up 9.25 months)., Results: None of the four cases showed preoperative evidence of an incarcerated cartilage fragment of the capitellum. They all showed limited elbow range of motion. CT examinations were performed in all cases. In each case, the cartilage fragment was first sighted upon surgery, subsequently removed and the fractures treated with ORIF. Mean follow-up was of 9.25 months. All fractures healed, with excellent function and low pain scores., Conclusions: This study presents rare cases of a trapped humeral cartilage fragment in radial head fractures. Radiological imaging including CT scans cannot reliably detect this concomitant injury. Therefore, this problem becomes apparent and treatable only during surgery. A high degree of suspicion is necessary especially in patients with minimally displaced fractures associated with limited elbow motion and a gap at the fracture site as treating these injuries conservatively may lead to poor outcome., (© 2021. The Author(s).)

Introduction: Surgical education consists often times of a discrepancy between necessary amount of provided operative teaching and amount of organizational and ward duties. Operative education is often cut to a minimum. As public awareness toward surgical competence raises, so must the educational system. Courses that provide pre-fractured cadaveric specimens can facilitate surgical teaching realistically, prior to operating on living patients. The aim of this study is to introduce a realistic distal radius fracture simulation setup., Materials and Methods: 12 cadaveric specimens (3 male, 9 female) were fixed onto a custom drop-test-bench in the hyperextension of the wrist. The forearm was cut midway between elbow and carpus. The distal part of the forearm was potted, and the specimen was exposed to a high energetic impulse. CT imaging was performed after fracture simulation to detect the exact fracture patterns. We used the AO/ASIF recommendations and four-corner concept to classify the achieved fractures by two independent trauma surgeons., Results: All cadaveric specimens could be successfully fractured. 11 fractures were classified as type 23C3.2 and one was classified as type 23C3.3, as additional fracture of diaphysis occurred. Subclassification according to the four-corner concept showed all fractures to be type C. A concomitant ulnar styloid fracture was observed in 4 cases. Furthermore, all cases showed at least one fragment involving the sigmoid notch. There was no statistically significant correlation found regarding Hounsfield Units (HU) and age (p value 0.402), as well as HU and required kinetic energy (p value 0.063)., Conclusion: A high energetic impulse induced by a custom-made drop-test bench can successfully simulate realistic distal radius fractures in cadaveric specimens with intact soft tissue. Furthermore, these pre-fractured specimens can be utilized in surgical education to provide a teaching experience as realistic as possible without harming living patients.

Purpose: The purpose of the study was to evaluate the position of the subscapular nerves relative to surgical landmarks during exposure and to analyze the pattern of innervation of the subscapularis to avoid injury during anterior shoulder surgery., Methods: 20 embalmed human cadaveric shoulder specimens were used in the study. The muscular insertions of the subscapular nerves were marked and their closest branches to the musculotendinous junction and the coracoid process were measured in horizontal and vertical distances. In addition, the innervation pattern of each specimen was documented., Results: 14/20 specimens showed an innervation of the subscapularis with an upper, middle and lower subscapular nerve branch. Even though the nerve branches were in average more than 2 cm medial to the musculotendinous junction, minimal distances of 1.1-1.3 cm were found. The mean vertical distance as measured from the medial base of the coracoid to the nerve innervation point into the muscle was 0.7 cm for the upper nerve branch, 2.2 cm for the middle nerve branch and 4.4 cm for the lower nerve branch., Conclusions: The subscapularis has a variable nerve supply, which increases the risk of muscle denervation during open shoulder surgery. Dissection or release should be avoided at the anterior aspect of the subscapularis muscle more than 1 cm medial to the musculotendinous junction. In approaches with a horizontal incision of the subscapularis, splitting should be performed at a vertical distance of 3.2-3.6 cm to the coracoid base to avoid iatrogenic subscapular nerve injuries.

Purpose: Exclusion or detection of non-displaced radial head fractures can be difficult in radiographs, because they might lack conclusive radiographic signs, such as fracture lines or distracted articular fragments. Based on the typical injury mechanism of a radial head fracture, causing the head to hit the capitulum and leading to a depression of the anterolateral border of the radial head, we hypothesized that even slight cortical irregularities in the transition zone of the radial neck and head result from that depression and may be a reliable radiographic sign of an underlying radial head fracture. Secondarily, we tested the null hypothesis that the lack of cortical irregularities is sufficient to exclude a fracture of the radial head., Methods: 84 patients with sets of anteroposterior and lateral radiographs of the elbow were identified from the database of a level 1 trauma center and divided into 2 groups. Group A was formed out of 42 patients with non-displaced radial head fractures, group B out of 42 patients without a history of previous elbow trauma, whose medical history also contained radiographic images. After the radial head was blackened, the transition zone of the radial neck and head was assessed by two attending orthopedic surgeons for presence of a cortical irregularity. The sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of cortical irregularity were calculated for the assessment of radial head fractures. The kappa measure of agreement was utilized to evaluate interrater agreement., Results: The specificity was 87.80 and 97.56 %, respectively, its sensitivity 86.04 and 75.61 %. A high NPV (85.71 %; 80.00 %) and PPV (96.88 %; 88.10 %.) were observed. The interrater agreement for the proposed diagnostic method was high, with a Cohen kappa score of 0.737 (p < 0.001)., Conclusions: A cortical irregularity in the transition zone of the radial neck and head seems to be a reliable radiographic sign of an underlying radial head fracture. The absence of the cortical irregularity can be used to correctly identify a non-fractured radial head.

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

Purpose: Radial neuropathy represents a devastating complication in a posterior approach to the distal humerus. This study aimed to propose "safe zones" regarding the radial nerve (RN) location at the posterior aspect of the humerus to minimize the risk of iatrogenic injury., Methods: In 100 embalmed specimens, the distances of the proximal edge of the olecranon fossa (OF) to the radial nerve at the medial edge (R1), at the center (R2) and at the lateral edge (R3) of the posterior aspect of humeral shaft were measured. Humeral length (HL) and transcondylar width (TW) were evaluated and correlated to R1, R2 and R3., Results: R1 was 15.0 (±2.1; 10.6-19.5) cm, R2 averaged 12.7 (±1.6; 8.9-15.7) cm, R3 was 10.6 (±1.3; 7.6-13.7) cm. HL was 30.8 (±1.9) cm. TW averaged 6.3 (±0.6) cm. TW and HL correlate with R1, R2, R3 (r = 0.451-0.565 [95% CI 0.279-0.685]). The mean ratio was 2.3 (±0.18) for HL/R1, 2.6 (±0.23) for HL/R2 and 3.1 (±0.31) for HL/R3. The ratio averaged 2.2 (±0.20) for R1/TW, 1.9 (±0.18) for R2/TW and 1.6 (±0.15) for R3/TW., Conclusions: We present the OF as an osseous landmark to reduce the risk of iatrogenic radial neuropathy. HL and TW can be reliably used to estimate the RN location. The consistent "safe zones" of the RN in relation to the OF are 10.5 cm at the medial edge, 9 cm at the center and 7.5 cm at the lateral edge of the posterior aspect of the humeral shaft.

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