Monteggia-like lesions encompass a wide spectrum of fractures of the forearm and elbow associated with dislocations, subluxations and ligamentous lesions. Many attempts have been made to classify these injuries, not only to understand their pathology but also to develop optimal treatments. Unfortunately, although some of these classifications are complete, they are either complex, not immediately usable, or not exhaustive. An orthopedic surgeon who aims to rapidly treat this kind of injury needs a visual classification, and knowledge of the best surgical approach. Monteggia like lesions do not allow for mistakes during surgery, as even a minor error could be prove detrimental to performing and completing all surgical steps. In this paper, based on our extensive experience in treating these rare lesions, we suggest a practical guide to the best surgical approach for various types of Monteggia like lesions. Some technical tips and pitfalls are also described.

Introduction: Various classifications of radial head fractures have been reported in the literature, most of them are based solely on conventional radiographic criteria. The Mason–Johnston classification, currently the most widely used system worldwide, is affected by the limitations of conventional radiographs. The aim of our study is to confirm or refute the low reliability and reproducibility of the Mason–Johnston classification. Materials and Methods: The study collected elbow X-rays showing radial head fractures from 2011 to 2021. Images were evaluated by eight orthopedic surgeons and one radiologist consultant from different hospitals for classification. The first phase assessed inter-observer agreement, comparing classifications among participants. After four months, the same images were randomly reordered and then reclassified to evaluate intra-observer agreement. A total of 90 elbow X-rays from 50 women and 40 men were analyzed. Inter- and intra-observer agreement was assessed using Fleiss’ kappa, Krippendorff alpha, and Cohen’s kappa. Results: Overall inter-observer agreement by unweighted Fleiss’ κ was moderate in both sessions (κ = 0.49 and κ = 0.50), with overall pairwise percent agreement 63% and prevalence- and bias-adjusted κ (PABAK, k = 4) ≈ 0.50. As an ordinal sensitivity analysis, Krippendorff’s α (ordinal) was 0.726 and 0.744, indicating substantial agreement. Type-specific reliability was moderate for Types II–III and higher for Type IV. Unweighted Cohen’s kappa coefficients were calculated to assess intra-observer agreement, demonstrating moderate to substantial levels of concordance. Conclusions: The Mason–Johnston classification shows moderate inter-observer reliability, especially for Types II–III, and moderate to substantial intra-observer agreement.

Purpose: The current indication for comminuted radial head fractures is radial head arthroplasty (RHA). The main purpose of this study was to investigate any statistical differences in terms of prosthesis revision or removal and radiographic-degenerative changes by comparing patients who underwent RHA and ligaments repair to those who underwent only RHA implant at minimum two-years follow up. The secondary aim was to delineate a trend profile of RHA implants.Methods: All patients who underwent RHA surgery for traumatic pathology between January 2012 and December 2017 were eligible. Two researchers independently and retrospectively reviewed the patients’ charts and collected the following data: type of prosthesis, associated surgical procedures and revision surgery. They also looked for any radiographic sign of prosthesis loosening, overstuffing, capitellar osteopenia, heterotopic ossification and degenerative changes. No clinical evaluation was performed. Results: In six years 124 RHA were implanted (74 Female, 50 Male, mean age 56). The main diagnoses were: terrible-triad, trans-olecranon fracture and isolated radial head fracture. It was found no significant statistical difference between the two groups, nevertheless the cohort of patients that underwent ligaments repair had a lower revision rate in comparison to the other. Suture of the annular ligament seems to be critical. The overall revision rate was 10.5%.Conclusion:This multi-center study found no evidence that ligaments repair, as an associated surgical procedure, improves RHA longevity, except for annular ligament. Nevertheless, it seems to prevent degenerative changes at mid-term follow-up.