Purpose: Open reduction internal fixation with a volar plate is a popular surgical option for distal radius fractures. The pronator quadratus (PQ) must be stripped from the distal radius in this procedure. PQ is an important pronator of the forearm and stabilizer of the distal radioulnar joint. The purpose of this study was to investigate pronation torque in healthy volunteers before and after temporary paralysis of the PQ with lidocaine under EMG guidance. Method: A custom-made apparatus was built to allow isometric testing of pronation torque at 5 positions of rotation: 90° of supination, 45° of supination, neutral, 45° of pronation and 80° of pronation. It was validated using a test-retest design with 10 subjects. For the study, 17 (9 male, 8 female) right hand dominant volunteers were recruited. They were tested at all 5 positions in random order and then had their PQs paralyzed with lidocaine. Repeat testing was performed in the same random order 30 minutes after injection. Three subjects underwent unblinded testing with saline injected instead of lidocaine. Results: After paralysis of PQ with lidocaine, pronation torque decreased by 23.2% (p=0.0010) at 90° of supination, 16.7% (p=0.0001) at 45° of supination, 22.9% (p=0.0002) in the neutral position, 20.4% (p=0.0066) at 45° of pronation and 22.2% (p=0.0754) at 80° of pronation. All were statistically significant except 80° of pronation. Peak torque values before and after injection were highest in the supinated positions (8.2 Nm at 45° supination) and decreased gradually as the subjects were in more pronated positions (1.8 Nm at 80° pronation). The test-retest trial demonstrated no evidence of fatigue with repeated testing. The subjects who underwent injection of saline demonstrated no evidence of pronation torque loss secondary to pain or a pressure effect of the injectate. Conclusion: This study demonstrated a significant decrease in pronation torque with controlled elimination of PQ function. Open reduction internal fixation of distal radius fractures damages the PQ. This may result in a pronation torque deficit. Functional significance of this loss should be shown. Pronation torque measurement may add to postoperative outcome analysis of surgical procedures about the wrist

Aim: The PASA (proximal articular surface angle) is a very useful measurement of the hallux metatarsal articular orientation for the preoperative evaluation and the selection of the surgical procedure. The measurement of PASA is found to be dependent mostly to the evaluator. The spatial orientation of the hallux can affect the measurement of PASA. In this study we try to evaluate the effect of pronation and the inclination of the first metatarsal on the measurement of PASA in 10 cadaver first metatarsals. Material and Methods: The study is made on 10 cadaver first metatarsals. The metatarsals are fixed to a device. The metatarsal inclination and pronation of the metatarsal can be changed by this device. 15-30-45 degrees inclination and 0-10-20 degrees pronation are applied to the metatarsals. After applying radio opaque putty to the medial and lateral articular edges; metatarsal dorsal diaphysial ridge, the x-ray and digital images are taken at different degrees of inclination and pronation. The measurement of PASA is done by graphic software on computer. The statistical analysis is performed by paired sample T-test. Results: We found that changing the inclination has no effect on PASA (p> 0.1). The pronation of first metatarsal has found to have a positive effect on PASA (p< 0.005). As the degree of pronation increases, the degree of PASA is found to be increased also. No difference was found between the measurements of x-ray and digital photography images. Discussion: Inclination of the first metatarsal can change depending on the height of the medial longitudinal arch. By this experimental study we tried to simulate the pes cavus and pes planus deformity on the radiologic measurement of the hallux by modifying the inclination and pronation of the first metatarsal. According to the current study, inclination has no effect on measurement of PASA. Pronation of the first metatarsal accompanies some hallux deformities. As pronation influences the measurement of PASA, the current data suggests that the measurement of PASA is not suitable for making clinical and surgical decisions

In hallux valgus (HV), toe pronation is frequently seen, although there may be some with no pronation.

Introduction: The choice of whether to use absorbable or non-absorbable suture in the closure of wounds following hand or upper limb surgery is usually surgeon dependent. In our unit both continuous absorbable subcutaneous suture and interrupted non-absorbable suture are utilised. The use of absorbable sutures offers a potential advantage to the patient and clinician in not requiring a clinic appointment for suture removal. The quality and aesthetic appearance of hand and upper limb surgical scars are of great importance to patients. Few studies have compared the aesthetic appearance of scars following the use of absorbable and non-absorbable suture in hand and upper limb surgical wound closure.

Method: 50 consecutive patients having undergone day case hand surgery between August 2007 and May 2008 with absorbable suture wound closure were identified along with 50 consecutive patients over the same time period who underwent non-absorbable wound closure. Each was sent a questionnaire comprising a visual analogue scale (VAS) for wound satisfaction, a validated 6 point patient scar assessment tool and the short version of the Disabilities of the Arm, Shoulder and Hand questionnaire (QuickDASH).

Results: 100 patients were contacted by post and 70 responses were received (37 absorbable, 33 non-absorbable). Both groups had undergone a similar spectrum of procedures including carpal tunnel decompression, Dupuytrens fasciectomy, excision of lesions and trigger finger release. Age, sex and QuickDASH scores were not significantly different between groups. Mean VAS was not significantly different between groups (Non-absorbable group 82.4 (95% CI 74.7–90.2) Absorbable group 80.4 (95% CI 71.9–89.0)). No significant difference was found between groups in terms of pain, itching, scar colour, stiffness, thickness or irregularity.

Conclusion: No significant difference in aesthetic appearance of scars exists following the closure of hand and upper limb wounds with either absorbable or non-absorbable suture. Either suture material can be used with confidence with respect to aesthetic outcome.

Background

CRUS is difficult to treat. Many techniques have been tried in an effort to restore forearm rotation; however, they have not been successful. It is inadvisable by many authors to perform any operation with the hope of obtaining pronation and supination.

Study of olecranon fractures in childhood and evaluation of the treatment approach. During a 20 year period, 64 children with olecranon fractures were treated in our clinic. 51 children (41 males and 10 females) aged from to 2.5 to 14 years were reviewed. The follow up period was 1 to 20 years(average 9 years). Coexisting skeletal injury appeared in 31 patients. 36 children were treated conservatively while we follow operative treatment (open reduction and stabilization with Kirschner wires with or without tension-band or screws) in 15 children. At the very last examination 2 children complained of mild pain during weather changes. Elbow extension was reduced from 5° to 15° in 6 patients and elbow flexion was reduced up to 5° in 3 patients. Pronation shortage was observed in 3 patients from 5° to 20° and a 10° supination shortage was observed in 1 patient. One case with pronation – supination shortage (40° and 70° respectively) while persisting subluxation of radial head was in 1 patient. The greatest degree of mobility limitation was observed in patients with comminuted fractures and associated injuries. Transient paresis of the radial nerve was observed in 1 patient. The usual therapeutic approach to olecranon fractures is conservative. In cases of displaced fractures, especially when the intraarticular displacement is greater than 3mm, surgical approach is indicated. Complications tend to occur more frequently among those cases with associated injuries. Olecranon paramorphosis in varus needs special attention since it usually coexists with radial head dislocation

The aim of management of an adult distal humeral fracture is to restore mobility, stability and pain-free elbow function. Good results are usually achieved in the majority of fractures treated with ORIF, but the management of comminuted fractures in elderly, frail patients with osteoporotic bone remains controversial. The literature focuses on elbow replacement if stable internal fixation cannot be achieved, with “bag-of-bones” management now rarely discussed eg. key-note paper - 10 successful cases reported by Brown RF & Morgan RG in 1971 (JBJS 53-B(3):425-428). We present the experience in two units in which conservative management has been actively adopted in selected cases by consultants with a subspecialty interest in the elbow. All patients over the age of 60 with distal humeral fractures (2007 – 2009) who had been treated conservatively were reviewed clinically and radiologically. Duration of follow-up and outcome, including the Oxford and quick DASH scores, were recorded, with the fractures classified using the AO system. There were 25 patients, 19 female and 6 male. 19/25 patients have been successfully treated conservatively with a mean Range Of Movement: Extension/Flexion: 45/125, Pronation/Supination 74/70. Only 5 underwent subsequent total elbow replacement and one delayed ORIF. There is a significant complication rate following surgical treatment with ORIF or elbow replacement in elderly, frail patients, including infection, painful non-union and/or stiffness. We believe that there is a role for initial conservative treatment in selected patients with low, displaced, comminuted humeral fractures in osteoporotic bone. Initial early mobilisation as pain allows can give good functional results without the risks of operation. It does not preclude future surgery if conservative treatment fails, but this is not required in the majority of cases

Aims

It is not clear which type of casting provides the best initial treatment in adults with a distal radial fracture. Given that between 32% and 64% of adequately reduced fractures redisplace during immobilization in a cast, preventing redisplacement and a disabling malunion or secondary surgery is an aim of treatment. In this study, we investigated whether circumferential casting leads to fewer fracture redisplacements and better one-year outcomes compared to plaster splinting.

Aims

There are concerns regarding complications and longevity of total elbow arthroplasty (TEA) in young patients, and the few previous publications are mainly limited to reports on linked elbow devices. We investigated the clinical outcome of unlinked TEA for patients aged less than 50 years with rheumatoid arthritis (RA).

The majority of diaphyseal forearm fractures in children are treated by closed reduction and plaster immobilisation. There is a small subset of patients where operative treatment is indicated. Recent reports indicate that elastic intramedullary nailing (EIN) is gaining popularity over plate fixation. We report the results of EIN for diaphyseal fractures of the forearm in 44 children aged between 5 and 15 years during a three-year period. The indications were instability (26), redisplacement (14), and open fractures (4). Closed reduction and nailing was carried out in 18 cases. A single bone had to be opened in 16 cases and in 10 cases both bones were opened for achieving reduction. Out of the 39 both bone forearm fractures, 35 patients had stabilisation of both radius and ulna and in 4 cases only a single bone was nailed (Radius 3, Ulna 1). Union was achieved in all the 44 cases at an average time of 7 weeks with one delayed union. All patients regained full flexion and extension of the elbow and wrist. Pronation was restricted by an average of 20° in 30% patients. Complications were seen in 10 patients (20%). 4 patients had prominent metal work which required early removal. There was refracture in one case, which was treated by nail removal and re-fixation. Two patients developed post operative compartment syndrome requiring fasciotomy. EIN of the radius alone in a patient with fractures of both the bones of forearm, led to secondary displacement of the ulna. This resulted in ulnar malunion and a symptomatic distal radio-ulnar joint subluxation. This was successfully treated by ulnar osteotomy. Compared to forearm plating EIN involves minimal scarring, easier removal and less risk of nerve damage. We therefore recommend EIN for the treatment of unstable middle and proximal third forearm fractures

Displaced comminuted intra-and extra-articular fractures of distal radius require anatomical reduction for optimum results. To assess clinical, functional and radiological results of volar-ulnar tension band plating of dorsally displaced comminuted fractures of distal radius, we used volar-ulnar tension band plating technique (without bone grafting) and early mobilisation to treat dorsally displaced and comminuted fractures of distal radius in 47 patients with an average age of 48 years (range, 19–76 years). Volar tilt, radial height, ulnar inclination and volar cortical angles were measured on the unaffected side. AO volar plate was pre-contoured to match the volar cortical angle of the unaffected side. The horizontal arm of the plate was fixed to the distal fragment first. When the longitudinal arm of the plate was brought onto the radial shaft, the displaced distal fragment was levered out anteriorly to restore the normal volar tilt. Adjustment in ulnar inclination and radial height can be made by medio-lateral and cephalo-caudal movement of the longitudinal arm of the plate. The average follow-up was 26 months (range 12–41 months). According to Gartland and Werley’s system 25 patients had excellent, 15 had good, 7 had fair functional results. The median Disability of Arm, Shoulder and Hand (DASH) score was 10 (range 0–60). Average grip strength as percentage of the unaffected side was 80 %. Average Palmarflexion was 61 degrees, Dorsiflexion 66 degrees, Ulnar deviation 34 degrees, Radial deviation 19 degrees, Supination 74 degrees and Pronation 80 degrees. According to Lidstrom and Frykman’s radiological scoring system 39 patients had excellent and 8 had good anatomical results. Conclusion: This relatively new technique has given good results in majority of patients. We recommend its use in displaced and comminuted fractures of distal radius in physiologically young patients with high need and demand

Objectives. Surgical treatment is standard for advanced osteochondritis dissecans (OCD) of the humeral capitellum. When cartilage is seen to be separated or completely detached, this fragment fixation is not usually applied. There have been reports of cases in which advanced OCD of the humeral capitellum progressed to osteoarthritis (Fig), particularly in cases which involved the lateral wall. In these cases, every attempt should be made to reconstruct the lateral wall to avoid osteoarthritis. In this study, we followed up cases with rib osteochondral autograft transplantation technique. Methods. Subjects were 20 cases who were followed up until after they started pitching. The mean age was 13.8 years old and the mean observation period was 2 years and 6 months (from 7 months to 6 year 3 months). Kocher's approach was used to give a good access to the aspect of the radiohumeral joint. The majority of cases suffered from extensive OCD of the elbow. Detached fragment was removed (Fig. 2a) and graft from 5. th. or 6. th. rib with screw fixation was performed on 12 patients and 8 received fixation with no material (Fig. 2b). Follow-up assessment included the range of motion, start time of playing catch and throwing a ball with full power, sports activity, evaluation of radiography, a subjective (including Pain, Swelling, Locking/Catching and Sport activity) and objective (Flexion contracture, Pronation/Supination and sagittal arc of motion) modified elbow rating system by Timmeman et al. We also investigated the details of the arthroscopy observations and the 2nd arthroscopy findings for 4 cases. Results. Preoperative elbow extension increased from −13.5 to −10 degrees and elbow flexion increased from 117 to 123 degrees, but no significant differences were found. All but one patient resumed baseball sporting activity. Catching was started at an average of 3.5 (2 to 5.5 months) months postoperatively and pitching the ball with full power was achieved at 6.7 months. One case was found to have degenerative changes on plain X-ray, and two cases were found to have deviated screws. The mean elbow rating system subjective score improved significantly from 63.9.5 to 89.5 points, as did the overall rating, increasing from 131.6 to 164.8 points. The 2. nd. arthroscopy observations for 4 patients showed that 2 experienced pain due to the loose body, 1 had a limitation in range of motion due to spur formation, and 1 had a screw deviation. Graft survival was observed in two out of four cases. Partial detachment was observed in two cases. Conclusion. Recovery of articular facets with hyaline cartilage were possible using this surgical technique, and in addition, the costal-costochondral grafts, comprising cortical and cancellous bone, were simultaneously transplanted en bloc. This indicates that it is adequate treatment for extensive OCD. All the patients started pitching 3 months postoperatively and returned to full baseball activities after 6 months. Even in cases with extensive OCD, with large osseous and cartilaginous deficits, the surgical technique was useful and showed favorable results

The results of surgical treatment of post-traumatic elbow contractures in adolescence have been conflicting in the literature. Some authors suggest that contracture release in this age group is less predictable and results less favorable than in adults. A retrospective review of the senior author’s patients produced 16 patients under the age of 21 that had post-traumatic elbow contracture releases. Three patients with arthroscopic releases and one patient lost to follow up were excluded from this study. Twelve adolescent patients (mean age 16.7 years, range 13–21) had open release of post-traumatic elbow contractures. All releases were initiated through a lateral approach with anterior capsular release and were supplemented by posterior release (in 4 patients) through the same incision. Medial-sided pathology was addressed through a separate medial incision in 3 patients. In three patients the radial head was excised. Muscle lengthening was used in only one patient. The mean follow-up was 18.9 months (range 10–42 months). Preoperative flexion was increased from 113 to 129deg (p< 0.01), extension from −51 to −15deg (p< 0.001) for a mean total gain of 54deg in the flexion-extension arc (p< 0.001). Pronation was improved from 58 to 77deg and supination from 56 to 62deg, but these improvements did not reach statistical significance. At the final follow-up the patients maintained 93% of the motion that was achieved intraoperatively. All patients achieved a functional ROM of at least 100deg in the flexion-extension arc. No patient lost motion. One patient had a superficial infection that was treated conservatively. Our experience with post-traumatic contracture release in adolescent patients has been rewarding; all patients reached a functional range of motion. The advantage of the lateral approach used in these patients is that it allows simple and safe access to the anterior capsule, which is often adequate to regain full extension. Through the same approach the posterior structures can also be addressed without violating the lateral collateral ligament. The medial approach is more demanding and was reserved only for patients with medial sided pathology. Fractional musculotendinous lengthening was rarely necessary in post-traumatic contractures. Open release in adolescent patients with congruent stiff elbows has yielded satisfactory results in our hands

Cobb and Morrey (1997) reported the use of Total Elbow Replacement (TER) for patients with distal humerus fractures. In this paper, 48% of the patients had a previous history of inflammatory arthropathy. Our aim was to determine the role of TER as treatment for complex distal humeral fractures in elderly patients with no previous history of inflammatory arthropathy. These patients have greater functional demands. The complexity of the original injury was graded according to the AO Mullers’ classification of supracondylar humeral fractures. All patients were reviewed clinically and radiographically. Their daily activities and general post-operative quality of life was estimated with the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire. The Mayo elbow performance score was used for functional evaluation. Implant survivorship was assessed. Fourteen patients (11 female and three male) underwent a Coonrad-Morrey TER via a standard posterior approach for humeral fractures. Their mean age was 73 years (range 61–84 years) at the time of injury. Ten patients had suffered a C3 injury, two a B3 and two an A3 according to the AO classification. The mean time to surgery after their injury was 8 days (range: 1–21 days). Complications: one myocardial infarct and one superficial wound infection. Mean time to follow-up was three years and two months (range: 9–66 months). Nine (64%) reported no pain, four (29%) had mild pain with activity and one had mild pain at rest. The mean arc of extension-flexion movement was 24°–125°. Supination: mean = 90° (range: 70°–100°). Pronation: mean = 70° (range: 50°–110°). No elbow was unstable. The mean DASH score was 22.6 (range: 0.92–63.3). Zero reflects no disability, 100 reflects most severe disability. The mean Mayo elbow performance score was 90 (range: 80–100). X-rays revealed that all implants were well fixed with no evidence of loosening. One patient had severe hypertrophic bone

Fracture dislocations of the elbow are complex injuries that have a significant risk of long term instability and loss of function. The more severe injuries are fortunately rare and the published series are relatively small. This in turn means that there is less precise evidence and guidance as to the optimal treatment. With the improvements in the understanding of this injury we consider that the prognosis is not necessarily as poor as has been previously reported and we have attempted to quantify this in a prospective, single surgeon series with standard surgical and rehabilitation protocols using dedicated upper limb physiotherapists. Methods All patients presenting to the hospital with a terrible triad injury were seen by the senior author for assessment and treatment. Early surgical reconstruction was performed under general anaesthetic by the senior author. Radial head fractures were treated by fixation or prosthetic replacement. Ligament reconstruction or reinforcement was performed where needed. Following surgery early mobilisation was performed using dedicated upper limb physiotherapists. Information was collected prospectively recording function and stability. All patients were assessed with the Mayo clinic elbow score and the AAOS Disability of the Arm Shoulder and Hand score (DASH). Results Eleven patients were admitted with a terrible triad injury to their elbow. All were the result of an acute traumatic episode. Follow up was for a mean of 21 months and no patients were lost to follow up. All fractures had united and there were no cases of migration or failure of metal fixation devices. There were no cases of symptomatic instability and no patient had signs of instability when assessed at clinically. A mean flexion arc of 106 degrees was recorded (range 60–145) with a mean extension limit of 23 degrees (range 0–40). Pronation and supination arcs were recorded with a mean of 127 degrees of rotation (range 0–160). There were no reoperations for infection or instability amongst this group of patients. Mayo clinic performance index for the elbow produced a mean score of 91.5 with a range of 85–100 which equates to a good or excellent outcome for all patients. Conclusion We have demonstrated that with a combination of early surgical stabilisation of bony injuries and restoration of ligamentous stability coupled with a specialised rehabilitation programme can give excellent results in what was once felt to be a catastrophic injury

Purpose: All displacements can be described with x, y, z coordinates. We propose an anterior view of the first metatarsal associated with a peroperative test to determine the precise position in the frontal plane, both statically and dynamically. Lateral release is an important step in surgical treatment of hallux valgus. Both the extent of release and the potential benefit of no release must be carefully evaluated. We propose a view allowing an assessment of the metatarsophalangeal reducibility. Material and method: Peroperative test. This test explores cuneometatarsal laxity. We conducted a prospective study in 100 cases. A 12/100 pin was used to immobilise the first cuneiform and a 20/100 pin was placed in the base of the first metatarsal. A third distal pin in the neck was used to pivot the bone on its axis. A small protractor was used to measure the angle by projection with ±2.5° precision. Modified Guntz view. This is a weight-bearing anterior view of the first metatarsal. The cassette is positioned posteriorly. The patient stands with the heal raised 40 mm on a 20mmx20mm plexiglass bar. The metatarsal diaphysis must appear perfectly vertical. An isosceles triangle is constructed on the articular facets; the base of the triangle is perfectly horizontal and defines the pronation-supination angle. We made 100 measurements and checked correlation with the peroperative test. Reduction view. A Zimmer brace was used to reduce the varus metatarsus and adduct the toe. The metatarsophalangeal angle and the position of the sesamoids were used to assess reducibility. Results: Pronation and/or pronation instability was = 10° in 96% of the patients. The reduction view enabled classifiation by three grades of reducibility. Discussion: Our contribution is determining for correction of displacements taking into account the frontal plane. No other study has shown so clearly the existence of metatarsal pronation. We also confirmed the presence of a large proportion of cuneometatarsal instability. The extent of lateral release or the potential benefit of no release can now be assessed. Conclusion: A certain number of failures have undoubtedly been related to neglect of the parameters studied here. It is indispensable to explore the frontal plane and the dynamic parameters before establishing indications for new flat-oblique metatarsal osteotomies using conventional or minimally invasive techniques

The influence of the supinator and pronator quadratus (PQ) muscles on distal radioulnar joint stability were evaluated using a joint simulator capable of producing forearm rotation, before and after ulnar head excision. Multiple pronation trials were conducted with incremental loading of the PQ relative to the pronator teres; supination trials were similarly conducted with the supinator and biceps. Incremental supinator muscle loading did not alter forearm kinematics. Increased PQ loading did not affect intact kinematics, but did alter joint motion following ulnar head excision. PQ activation will likely aggravate forearm instability following ulnar head excision; suggesting rehabilitation should incorporate immobilization in supination. The purpose of this study was to study the effect of pronator quadratus (PQ) and supinator loads on forearm kinematics in both an intact distal radioulnar joint (DRUJ) and following ulnar head excision. The PQ muscle appears to aggravate instability of the DRUJ following ulnar head excision, while incremental loading of the supinator muscle had no effect. Patients with DRUJ instability and/or who have undergone surgical removal of the ulnar head should be rehabilitated in supination to limit the influence of the PQ muscle. Eight cadaveric upper extremities were tested in a custom joint simulator employing motion and load-controlled tendon loading to produce forearm rotation. Pronation was achieved via loading of the pronator teres and PQ muscles. Repeated trials were conducted in which the ratio of the PQ load was increased incrementally relative to the pronator teres load. Supination trials were similarly conducted using the biceps and supinator muscles. Testing was conducted in the intact forearm and following ulnar head excision. An electromagnetic tracking device was used to record motion of the radius and ulna. Kinematic data was analyzed with a planar analysis that measured dorsal palmar displacements and diastasis of the DRUJ. Greater diastasis and dorsal translation of the radius relative to the ulna were noted under increased PQ loading following ulnar head excision (p< 0.05). Increased supinator load had no effect on kinematics before or after ulnar head excision. This effect is likely due to the location of the two muscles. The effect of PQ muscle loading was only noted in neutral to full pronation. These results suggest that rehabilitation of the forearm following ulnar head excision should be conducted with the forearm in supination to minimize joint instability. Funding: Natural Sciences and Engineering Research Council of Canada, The Arthritis Society (Canada)

Purpose: We report a series of 16 GUEPAR total elbow prostheses implanted in a single centre. Material and methods: Between 1988 and 1996, sixteen GUEPAR prostheses were implanted in 13 patients (three bilateral implantations). There were 11 women and two men, mean age 61 years (51–81). Twelve patients (14 elbows) had rheumatoid polyarthritis and one patient (two elbows) had post-traumatic degenerative disease. The V transtricepital approach was used in 15 cases and the Bryan-Morrey approach in one. Postoperatively, the elbows were immobilised at 45° flexion for the normal period (18 days) followed by active mobilisation. Results were analysed with the Mayo Clinic score. The radiographs were examined in search for lucent lines and signs of loosening and prosthetic instability. Results: At a mean follow-up of four years (2–12), the mean Mayo Clinic score had improved from 33 to 75 points (45–100). Eleven elbows were pain free at last follow-up. Extension and flexion progressed 22° giving a postoperative amplitude of 34° to 129°. Pronation supination progressed by 15° giving a 154° rotation amplitude. The function score improved from 6 to 18 points. Seven of the sixteen elbows achieved normal function. Outcome was excellent for seven elbows, good for one, fair for three and poor for five. In two elbows, instability required changing the ulnar implant. There were four implant loosenings that required revision at 24, 36 ,36 and 48 months after the initial implantation. The radiographic analysis demonstrated a complete lucent line around the humeral and ulnar implant in one case, around the ulnar implant in one case. There were two peroperative fractures of the humerus and on postoperative fracture due to a fall. Ulnar paresthesia was observed in two cases requiring secondary neurolysis in one. There were no infections or secondary injury to the triceps. Discussion: The GUEPAR prosthesis is a non-constrained prosthesis essentially indicated for rheumatoid polyarthritis. If the intrinsic stability is lost, the implant is contraindicated if there is loss of bone stock or if the instability is major. In selected cases, a generally painless elbow with recovery of the functional amplitude can be achieved with this prosthesis. Nevertheless, the presence of four early loosenings in our series as well as two instabilities suggest this implant should be abandoned in favour of a semi-constrained implant

Pronation of the foot is an essential motion of the normal function of the lower extremity. Its main contribution to the gait cycle is shock absorption and adaptation of the weight bearing foot to the surface. Hyperpronation is defined when hind foot motion is excessive, prolonged, and/or occurs in inappropriate timing of the stance phase. Hyperpronation of the foot may cause malalignment of the lower extremity and frequently leads to injuries to joints, tendons, knee pain and stress fractures. A review of the literature indicates that a correlation is found between hyperpronation of the foot and tibial rotation, patella and knww joint alignment. To our knowledge there is no evidence documented on the relationship between hyperpronation and pelvic alignment although, several researchers do suggest a possible connection. The purpose of this study is to examine the effect of hyperpronation of the feet on the lower limb and pelvic alignment. Thirty-five healthy subjects (15 men and 20 women, age ranged from 23 to 33 years) were put into hyperpronation in standing position induced by wedges of different slopes of 10, 15 and 20 degrees. The base line for comparison was natural standing position and the sequence of trials was random. Each setting was maintained for 20 seconds and a sample of 4 seconds was processed and measured. Changes in the alignment of the lower extremity and pelvic were measured by a computerized system of motion analysis (VICON®). Standing on the wedges induced hyperpronation with statistically significant increase in calcaneal eversion (p< .000). The results indicated that as a consequence to the usage of wedging on limb alignment, a statistically significant increase (paired t-test) in calcaneal valgus (p< .000), internal tibial rotation (p< .000), internal femoral rotation (p< .000) nd anterior pelvic tilt (p< .000) was found. A strong correlation (Pearson correlation coefficient) was found between segmental alignments in every two sequences positions (r = .612 up to .985). Five sets of mixed effects models for repeated measurement were built in all four positions. Results showed that the effect of the tibial alignment itself is responsible for the change in the pelvic position (p=.002). These findings suggest that a correlation exists between motion at the distal segment (the foot) and the proximal segment (the pelvic) aof the body and indicate that hyperpronation and proximal postural malalignment are linked. This interaction between the foot and pelvic occurs in a chain reaction manner. Foot hyperpronation can influence pelvic alignment, only if significant change arises at the tibia. The implication of this study advocates that when addressing pelvic and lower back dysfunction, the alignment of the foot should be examined as a contributing factor. In addition, addressing foot malalignment is essential for treating and preventing pelvic and low back dysfunction

Aims

The aims of this study were to validate the outcome of total elbow arthroplasty (TEA) in patients with rheumatoid arthritis (RA), and to identify factors that affect the outcome.