Initial joint stability affects the outcome after conservative treatment of simple elbow dislocations: a retrospective study

Background: Conservative treatment of simple elbow dislocations can lead to complications such as persisting pain and restricted joint mobility. The current aim was to identify patients with deteriorated outcome after conservative treatment and to investigate a possible association with initial joint (in)stability. Methods: Sixty-eight patients (mean age 37.1 ± 17.2 years) with simple elbow dislocations received conservative treatment. After closed reduction, joint stability was tested by varus and valgus stress under fluoroscopy. According to the findings under fluoroscopy, three different groups of instability could be identified: (1) slight instability (joint angulation <10°; n = 49), (2) moderate instability (angulation ≥10°; n = 19) and (3) gross instability. Patients with gross instability (re-dislocation under stability testing) were treated with primary surgical ligament repair and therefore excluded from this study. Additionally, MRIs and radiographs were analysed regarding warning signs of instability such as the drop sign and joint incongruence. Main outcome parameters were the Mayo Elbow Performance Score (MEPS), range of motion (ROM), complications and revision rates. Results: After 40.7 ± 20.4 months, the overall MEPS was excellent (94.2 ± 11.3) with a trend of slightly worse clinical results in group 2 (95.8 ± 9.0 vs. 90.0 ± 15.2 points; p = 0.154). In group 1, significantly more patients achieved an excellent result regarding the MEPS scoring system (77.6 vs. 52.6 %; p = 0.043) and elbow extension was significantly worse in group 2 (5.3 ± 9.9° vs. 1.4 ± 3.0°; p = 0.015). Seven treatment complications occurred in group 2 (36.8 %) compared with two in group 1 (4.1 %, p < 0.0001). Six patients (8.8 %) needed secondary surgery with an 8.4-fold higher risk for revision surgery in group 2 (p = 0.007). The presence of a positive drop sign or joint incongruence led to higher odds ratio (OR) for complications (OR = 15.9) and revision surgery (OR = 10.3). Conclusions: This study demonstrates that patients with moderate joint instability after simple elbow dislocation have a significantly worse clinical outcome, more complications and a higher need for secondary revision surgery following conservative treatment compared to patients with slight elbow instability

Development and validation of a novel questionnaire for self-determination of the range of motion of wrist and elbow

Background: The aim of this study was to develop and validate a novel self-administered questionnaire for assessing the patient’s own range of motion (ROM) of the wrist and the elbow. Methods: In a prospective clinical study from January 2015 to June 2015, 101 consecutive patients were evaluated with a novel, self-administered, diagram-based, wrist motion assessment score (W-MAS) and elbow motion assessment score (E-MAS). The questionnaire was statistically evaluated for test-retest reliability, patient-physician agreement, comparison with healthy population, and influence of covariates (age, gender, affected side and involvement in workers’ compensation cases). Results: Assessment of patient-physician agreement demonstrated almost perfect agreement (k > 0.80) with regard to six out of eight items. There was substantial agreement with regard to two items: elbow extension (k = 0.76) and pronation (k = 0.75). The assessment of the test-retest reliability revealed at least substantial agreement (k = 0.70). The questionnaire revealed a high discriminative power when comparing the healthy population with the study group (p = 0.007 or lower for every item). Age, gender, affected side and involvement in workers’ compensation cases did not in general significantly influence the patient-physician agreement for the questionnaire. Conclusion: The W-MAS and E-MAS are valid and reliable self-administered questionnaires that provide a high level of patient-physician agreement for the assessments of wrist and elbow ROM. Level of evidence: Diagnostic study, Level I

Interobserver and intraobserver agreement of ligamentous injuries on conventional MRI after simple elbow dislocation

Background: The primary objective of this study was to assess the interobserver and intraobserver agreement on ligamentous injuries on conventional magnetic resonance imaging (MRI) in acute simple elbow dislocation. The secondary objectives were to determine the interobserver agreement on the assessment of joint congruity, joint effusion, loose bodies and chondral lesions on conventional MRI. Methods: Conventional MRIs (1.5 Tesla, elbow specific surface coil) of 30 patients (40.7 years; range 14–72) with simple elbow dislocations were evaluated by four blinded examiners. An analysis of the interobserver agreement of all raters and for several subgroups (radiologists, orthopaedics, experienced, non-experienced) was performed. The examiners assessed the integrity (intact, partial tear, complete tear) of the lateral collateral ligament (LCL), medial collateral ligament (MCL), extensor and flexor tendons, as well as the presence of joint congruity, joint effusion, loose bodies and chondral lesions. Agreement strength, correlation and proportion of exact agreement were determined for interobserver agreement, and intraobserver agreement analyses. Results: Interobserver agreement of all examiners was fair to moderate for collateral ligaments (LCL: 0.441, MCL: 0.275). Exact agreement of all raters was found in 33.3% for the LCL and in 26.7% for the MCL. The both experienced examiners showed highest agreement strength for the LCL (0.619) and the radiologists showed highest agreement strength for the MCL (0.627), the proportion of exact agreement was 60.0% in both categories. A high proportion of exact agreement regarding joint congruity (90%), joint effusion (100%), loose bodies (96.7%) and chondral lesion (80%) was found among the radiologists. The evaluation of the intraobserver agreement revealed slight to substantial agreement (0.227 to 0.718) for the collateral ligaments. Conclusions: This study shows difficulties in the evaluation of ligaments by conventional MRI technique as demonstrated by a weak inter- and intraobserver agreement. This should be the basis to develop new MRI quality standards with special focus on coronal oblique reconstructions to improve the evaluation of ligament injuries after simple elbow dislocations

Hook plate fixation of Neer type II distal clavicle fractures results in satisfactory patient-reported outcomes but complications and revisions are high

Abstract Background Surgical treatment of distal clavicle fractures Neer type II is challenging. A gold standard has not yet been established, thus various surgical procedures have been described. The purpose of this study is to report the radiological and clinical outcomes using hook plate fixation in Neer type II distal clavicle fractures. Methods We retrospectively reviewed data of 53 patients who underwent hook plate fixation between December 2009 and December 2019 with ≥ 2 years of follow-up. Patients with preexisting pathologies or concomitant injuries of the ipsilateral shoulder were excluded. Pre- and postoperative coracoclavicular distance (CCD), bony union and patient-reported outcomes were collected, including the Constant Score (CS) and Subjective Shoulder Value (SSV). Complications and revisions were recorded. Results At a mean final follow-up of 6.2 years, mean SSV was 91.0% (range, 20–100) and mean CS was 80.9 points (range, 25–99). The mean preoperative CCD was 19.0 mm (range, 5.7–31.8), the mean postoperative CCD was 8.2 mm (range, 4.4–12.2) and the mean CCD following hardware removal was 9.7 mm (range, 4.7–18.8). The loss of reduction following hardware removal was statistically significant (P = 0.007). Eleven (20.8%) patients had complications, with 5 cases of deep or superficial infection (9.4%), four non-unions (7.5%), one periosteosynthetic fracture, one postoperative seroma, one implant failure and one symptomatic acromioclavicular joint arthritis (all 1.9%). A total of 10 patients (18.9%) underwent revision surgery at a mean of 113 (range, 7–631) days. Conclusion Medium-term patient-reported outcomes for hook plate fixation of Neer type II distal clavicle fractures are satisfactory; however, one in five patients suffers a complication with the majority of them requiring revision surgery

Injury patterns following simple elbow dislocation: radiological analysis implies existence of a pure valgus dislocation mechanism

Introduction!#!The aim of the present study was to analyze the injury pattern and thus the dislocation mechanism after simple elbow dislocation using radiographs and magnetic resonance imaging (MRI) data sets.!##!Materials and methods!#!The MRI data sets of 64 patients with a mean age of 44 years (18-77 years) were analyzed retrospectively. The inclusion criteria for the study were (1) radiograph with confirmed simple elbow dislocation, (2) low-energy trauma, (3) MRI of the affected elbow ≤ 3 weeks after trauma. The dislocation direction was determined using radiographs. The integrity of the lateral collateral ligament complex (LCLC), common extensor origin (CEO), anterior capsule (AC), medial collateral ligament (MCL), and common flexor origin (CFO) as well as the joint congruity were assessed based on MRI.!##!Results!#!34 patients (53%) had a posterolateral, 26 patients (41%) a posterior, and 4 patients (6%) a posteromedial dislocation. LCLC and AC were affected in 64 out of 64 patients (100%). MCL was affected in 58 patients (91%). CEO were affected in 25 patients (39%) and the CFO in 20 patients (31%). In 11 patients (17%) the injury pattern was more pronounced medially than laterally (MCL, CFO, LCLC), with 2 of these patients exhibiting only a partial LCLC tear. All cases with joint incongruency (n = 12, 19%) showed CEO and/or CFO involvement.!##!Conclusions!#!Simple elbow dislocation leads to a very heterogeneous spectrum of soft tissue injury pattern. A small proportion of patients showed medially pronounced injury patterns. These findings strongly indicate existence of a 'reversed Horii circle' with an underlying valgus mechanism (medial force induction) originating and continuing from medial to anterior

Validation of radiological reduction criteria with intraoperative cone beam CT in unstable syndesmotic injuries

Purpose!#!Acute unstable syndesmotic lesions are regularly treated with closed or open reduction and fixation with either a positioning screw or tight rope. Conventional fluoroscopy is limited to identify a malreduction of the ankle mortise. The aim of the study was to validate the reduction criteria of intraoperative cone beam CT in unstable syndesmotic injuries by analyzing the clinical outcome.!##!Methods!#!Acute unstable syndesmotic injuries were treated with a positioning screw fixation, and the reduction in the ankle mortise was evaluated with intraoperative cone beam CT. The patients were grouped postoperatively according to the radiological reduction criteria in the intraoperative 3D images. The reduction criteria were unknown to the surgeons. Malreduction was assumed if one or more reduction criteria were not fulfilled.!##!Results!#!Seventy-three of the 127 patients could be included in the study (follow-up rate 57.5%). For 41 patients (56.2%), a radiological optimal reduction was achieved (Group 1), and in 32 patients (43.8%) a radiological adverse reduction was found (Group 2). Group 1 scored significantly higher in the Olerud/Molander score (92.44 ± 10.73 vs. 65.47 ± 28.77) (p = 0.003), revealed a significantly higher range of motion (ROM) (53.44 vs. 24.17°) (p = 0.001) and a significantly reduced Kellgren/Lawrence osteoarthritis score (1.24 vs. 1.79) (p = 0.029). The linear regression analysis revealed a correlation for the two groups with the values scored in the Olerud/Molander score (p &amp;lt; 0.01).!##!Conclusion!#!The reduction criteria in intraoperative cone beam CT applied to unstable syndesmotic injuries could be validated. Patients with an anatomic reduced acute unstable syndesmotic injury according to the criteria have a significantly better clinical outcome

Determination of Elbow Laxity in a Sequential Soft-Tissue Injury Model

Background: The objective of our study was to analyze, under fluoroscopy, joint angulation of uninjured elbows and elbows with distinct induced collateral ligament injury. Methods: Twelve elbow specimens were tested for varus and valgus joint angulation using 4 different examination methods (application of both varus and valgus stress by each of 2 examiners [Examiner 1 and Examiner 2] and application of 1 and 2 Nm of torque using a calibrated electric force scale) in 4 elbow positions (in full extension with 90 degrees of supination and 90 degrees of pronation, and in 30 degrees of flexion with 90 degrees of supination and 90 degrees of pronation). Six elbow specimens were examined under varus stress at each of 5 sequential stages: (1) intact, (2) transection of the lateral ulnar collateral ligament (LUCL), (3) complete transection of the lateral collateral ligament complex (LCLC), (4) transection of the anterior aspect of the capsule (AC), and (5) transection of the medial collateral ligament (MCL). An additional 6 elbow specimens were examined under valgus stress at 5 sequential stages: (1) intact, (2) transection of the anteromedial collateral ligament (AML), (3) complete transection of the MCL, (4) transection of the AC, and (5) transection of the LCLC. Examinations under fluoroscopy were made to measure the joint angulation. Intraclass correlation coefficients (ICCs) were calculated. Results: Testing of the intact elbow specimen by both examiners showed a joint angulation of 20 degrees in some positions in both the medial and the lateral series. Under varus stress, elbow dislocations occurred only after dissection of the LCLC+AC (26% of the examinations) and additional dissection of the MCL (59%). Under valgus stress, elbow dislocations occurred only after dissection of the MCL+AC (30%) and additional dissection of the LCLC (47%). Very good to excellent ICCs were found among Examiners 1 and 2 and the tests done with the standardized torques at stages 1 through 4. Conclusions: Dynamic fluoroscopy makes it possible to distinguish among different stages of collateral ligament injury of the elbow and therefore might be helpful for guiding treatment of simple elbow dislocations

High return to sport rate and good patient-reported outcomes in recreational athletes following simple elbow dislocations

Abstract Background The purpose of this study was to investigate outcomes and return to sport metrics in recreational athletes who suffered simple elbow dislocations and were treated operatively or nonoperatively. Methods The study included patients between the ages of 16 and 65 who were recreational athletes and had experienced a simple elbow dislocation, with at least 2 years having passed since the injury. Patient-reported outcomes including Mayo Elbow Performance Score (MEPS), Subjective Elbow Value (SEV), Oxford Elbow Score (OES) and Visual Analog Scale (VAS) were collected. Return to sport metrics were assessed. Results A total of 44 patients (21 females, mean age 43.8 years [95% CI, 39.1–48.5]) who were recreational athletes before their injury completed follow-up at mean 7.6 years (95% CI, 6.7–8.5). There were 29 patients (65.9%) who were treated operatively. Mean MEPS was 93.3 (95% CI, 90.2–96.4), mean SEV was 94.9 (95% CI, 91.9–97.9) and mean OES was 43.3 (95% CI, 41.3–45.4). A total of 36 (81.8%) patients returned to their pre-injury sport. Mean time to return to sport was 21.7 (95% CI, 16.8–26.5) weeks. There was a significant difference in OES (P = .019) and SEV (P = .030) that favored the nonoperative group; however, no significant differences for MEPS, VAS, satisfaction, arc of motion and return to sport were present between groups. A total of five (11.4%) complications were observed and one (2.3%) required revision. Conclusions Good outcomes and a high return to sport rate can be expected in recreational athletes following operative and nonoperative treatment of simple elbow dislocations. However, as many as one-in-five patients may not return to pre-injury sport

Pay for performance – motivation to succeed in Advanced Trauma Life Support courses – a question of background or funding?

Objective: To correlate students’ performance with their professional background and motivation to take part in Advanced Trauma Life Support (ATLS) courses. We base our analysis on the self-determination theory that differentiates intrinsic (ambition to perform by individual itself) from extrinsic motivation (incentive by external stimuli).Design: We present a non-blinded, monocentric, non-randomized descriptive study of 376 students taking part in an ATLS course at one course site in Germany. Part of a two-day ATLS course are two written tests; we correlate test scores with background information provided by the students in a questionnaire of 13 items (age, sex, adress, board certification, specialty, subspecialty, position, hospital level of care, hospital operator and hospital participation in trauma network, motivation, funding source, condition of funding).Setting: The students were recuited at the BG Trauma Center Ludwigshafen (Germany), a large 528-bed trauma center and one of 13 ATLS course sites in Germany.Participants: 449 ATLS course students taking part in ATLS courses at the above-mentioned course site from February 2009 to May 2010 were sent a questionnaire asking for their background. All 449 course students were eligible to participate. 376 (83.7%) questionnaires were returned, pre- and post-test results of all students aquired and included into our calculations. 312 (83%) were male and 64 (17%) female. The majority (59.3%) of recruited students came from trauma surgery, 21.8% from anesthesiology, 8% from general surgery, 4% from abdominal surgery, 0.5% from vascular or thoracic surgery each and 5.9% from other specialties.Results: Neither age, sex, subspecialty, hospital level of care, hospital operator, or hospital participation in trauma network played a role with respect to motivation or test results. The high degree of intrinsic motivation of consultants (92.3%) had no impact on their test results. Anesthesiologists were higher motivated (75.6% intrinsically motivated) in contrast to all surgical colleagues (63.6%), which showed significant differences in the pre- (89.8% vs. 85.3%, p=0.03) but not the post-test. Of all 13.6% students who were self-payers, 94.1% were intrinsically motivated; the 86.2% whose course fee was accounted for were less likely to be intrinsically motivated (63.9%). Sponsoring however did not have a negative impact on test results. Conditional funding (sponsored only on passing both tests) was detrimental to motivation: 0% of these individuals were intrinsically motivated and they scored significantly lower (82.5%) than all other students in the post-test (86.9%, p=0.002). Overall, intrinsically motivated students overtopped extrinsically motivated students in the post-test (88.0% vs. 83.4%, p<0.001).Conclusions: ATLS course participation is not compulsory for medical doctors in Germany. Intrinsic motivation to take part in these courses is a key prerequisite to increase performance, irrespective of the background of the students. Intrinsically motivated students are ready to invest into their education and vice versa. Conditional funding (course fee only sponsored on passing the course) evokes no intrinsic motivation at all and causes worse results