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). Methods. We retrospectively reviewed the records of 26 elbows of 21 patients with RA who were aged less than 50 years who underwent primary TEA with an unlinked elbow prosthesis. The mean patient age was 46 years (35 to 49), and the mean follow-up period was 13.6 years (6 to 27). Outcome measures included pain, range of motion, Mayo Elbow Performance Score (MEPS), radiological evaluation for radiolucent line and loosening, complications, and revision surgery with or without implant removal. Results. The mean MEPS significantly improved from 47 (15 to 70) points preoperatively to 95 (70 to 100) points at final follow-up (p < 0.001). Complications were noted in six elbows (23%) in six patients, and of these, four with an ulnar neuropathy and one elbow with postoperative traumatic fracture required additional surgeries. There was no revision with implant removal, and there was no radiological evidence of loosening around the components. With any revision surgery as the endpoint, the survival rates up to 25 years were 78.1% (95% confidence interval 52.8 to 90.6) as determined by Kaplan-Meier analysis. Conclusion. The clinical outcome of primary unlinked TEA for young patients with RA was satisfactory and comparable with that for elderly patients. A favourable survival rate without implant removal might support the use of unlinked devices for young patients with this disease entity, with a caution of a relatively high complication rate regarding ulnar neuropathy. Level of Evidence: Therapeutic Level IV. Cite this article: Bone Jt Open 2023;4(1):19–26

Aims. The aim of this meta-analysis was to compare the outcome of total elbow arthroplasty (TEA) undertaken for rheumatoid arthritis (RA) with TEA performed for post-traumatic conditions with regard to implant failure, functional outcome, and perioperative complications. Materials and Methods. We completed a comprehensive literature search on PubMed, Web of Science, Embase, and the Cochrane Library and conducted a systematic review and meta-analysis. Nine cohort studies investigated the outcome of TEA between RA and post-traumatic conditions. The preferred reporting items for systematic reviews and meta-analysis (Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)) guidelines and Newcastle-Ottawa scale were applied to assess the quality of the included studies. We assessed three major outcome domains: implant failures (including aseptic loosening, septic loosening, bushing wear, axle failure, component disassembly, or component fracture); functional outcomes (including arc of range of movement, Mayo Elbow Performance Score (MEPS), and the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire), and perioperative complications (including deep infection, intraoperative fracture, postoperative fracture, and ulnar neuropathy). Results. This study included a total of 679 TEAs for RA (n = 482) or post-traumatic conditions (n = 197). After exclusion, all of the TEAs included in this meta-analysis were cemented with linked components. Our analysis demonstrated that the RA group was associated with a higher risk of septic loosening after TEA (odds ratio (OR) 3.96, 95% confidence interval (CI) 1.11 to 14.12), while there was an increased risk of bushing wear, axle failure, component disassembly, or component fracture in the post-traumatic group (OR 4.72, 95% CI 2.37 to 9.35). A higher MEPS (standardized mean difference 0.634, 95% CI 0.379 to 0.890) was found in the RA group. There were no significant differences in arc of range of movement, DASH questionnaire, and risk of aseptic loosening, deep infection, perioperative fracture, or ulnar neuropathy. Conclusion. The aetiology of TEA surgery appears to have an impact on the outcome in terms of specific modes of implant failures. RA patients might have a better functional outcome after TEA surgery. Cite this article: Bone Joint J 2019;101-B:1489–1497

The February 2015 Research Roundup360 looks at: Markers of post-traumatic ankle arthritis; Mangoes, trees and Solomon Islanders; Corticosteroid injection and ulnar neuropathy; Moral decision-making: the secret skill?; Biomechanical studies under the spotlight; Anaesthetic risk and hip replacement

Aims. The aim of this study was to report the mid-term clinical outcome of cemented unlinked J-alumina ceramic elbow (JACE) arthroplasties when used in patients with rheumatoid arthritis (RA). Patients and Methods. We retrospectively reviewed 87 elbows, in 75 patients with RA, which was replaced using a cemented JACE total elbow arthroplasty (TEA) between August 2003 and December 2012, with a follow-up of 96%. There were 72 women and three men, with a mean age of 62 years (35 to 79). The mean follow-up was nine years (2 to 14). The clinical condition of each elbow before and after surgery was assessed using the Mayo Elbow Performance Index (MEPI, 0 to 100 points). Radiographic loosening was defined as a progressive radiolucent line of >1 mm that was completely circumferential around the prosthesis. Results. The mean MEPI scores significantly improved from 40 (10 to 75) points preoperatively to 95 (30 to 100) points at final follow-up (p < 0.0001). Complications were noted in ten elbows (ten patients; 11%). Two had an intraoperative humeral fracture which was treated by fixation and united. One had a postoperative fracture of the olecranon which united with conservative treatment and one had a radial neuropathy which resolved. Further surgery was required for one with a dislocation, three with an ulnar neuropathy and one with a postoperative humeral fracture. Revision with removal of the components was performed in one elbow due to deep infection. There was no radiographic evidence of loosening around the components.With any revision surgery or revision with implant removal as the endpoint, the rates of survival up to 14 years were 93% (95% confidence interval (CI), 83.9 to 96.6) and 99% (95% CI 91.9 to 99.8), respectively, as determined by Kaplan-Meier analysis. Conclusion. With the appropriate indications, the mid-term clinical performance of the cemented JACE TEA is reliable and comparable to other established TEAs in the management of the elbow in patients with RA. Cite this article: Bone Joint J 2018;100-B:1066–73

Summary Statement. Discovery system produced effective functional improvement in both primary and revision total elbow replacement. The incidence of major complications was in an acceptable range. Introduction. The search for the ideal elbow prosthesis continues as instability and loosening remain the prime reasons for total elbow replacement (TER) failure. The Discovery Elbow System (Biomet) is one of the latest generations of linked prosthesis and has been used in UK since 2003. We report outcome of TER using this system. Methods. A total of 100 TERs (75 primary, 25 revisions) were performed between 2003 and 2010. The main primary underlying pathologies for TER were advanced rheumatoid arthritis (N=58), osteoarthritis (N=35), acute fractures (N=7). There were 60 female and 40 male patients with an average age of 62 years. The outcome assessment included pain, patient satisfaction, Liverpool Elbow Score (LES), range of movement, and imaging during a mean follow-up period of 48.5 months. Major complications are also reported. Results. For the whole patient group (primary + revision), the LES was significantly (p<0.001) improved from 3.79+/−1.71 to 6.36+/−1.85There were significant improvements in elbow flexion from 100°+/−24 to 118°+17, supination from 38°+/−26 to 50°+/−25 and pronation from 48°+/−22 to 61°+/−21. Mean improvement in flexion-extension and pronation-supination arc was 20° and 25°, respectively. 64% of cases were completely pain-free and at the final follow-up (compared to 7% preoperatively). Only 6% of patients scored “Not Satisfied” at the final follow-up. LES improvement was significantly higher in the primary TER compared to revision TER (p<0.05). Imaging reviewed for 60 cases showed loosening in 4% of patients. Other main complications included deep infection (N=2), ulnar neuropathy (N=3), pre-prosthetic fracture (N=2), and prosthetic failure (N=1). Discussion. TER using the Discovery Elbow System is an effective arthroplasty in terms of functional improvement, pain relief and range of motion in both primary and revision patients. TER resulted in no/mild pain in 78% of cases. Patients undergoing Acclaim, Souter-Strathclyde, GSB III, and Coonrad-Morrey TER have been reported to have no/mild pain in 64%, 67%, 50–92% and 60–100% of cases, respectively. A 20° improvement in flexion-extension arc is comparable to that of Acclaim (23°), Souter-Strathclyde (15°), GSBIII (19–33°), and Coonrad-Morrey (17–26°) TER. An improvement of 25° in pronation-supination arc in our series is also comparable to that of 21–28° reported the Coonrad-Morrey and 27–33° for Discovery prostheses. An infection rate of 2% is lower than several other reports for GSB III TER (7–11%) and Coonrad-Morrey (6–8%). The incidence of persistent ulnar neuropathy (3%) was lower compared to GSBIII TER (11–14%), Coonrad-Morrey (12–26%), and Acclaim (8%)

We performed a new operation for ulnar neuropathy caused by recurrent dislocation at the medial epicondyle. There were eleven patients, eight men and three women, with an average age of 52 years (24–74 years) at the time of surgery. The mean duration of symptoms was 23 months. The severity of the symptoms was McGowan grade 1 in five patients, grade 2 in five patients, and grade 3 in one patient. The operation consisted of ulnar groove plasty proximal to the cubital tunnel. The ulnar nerve was replaced into this reconstructed groove. The nerve was confirmed to be stable throughout the full range of elbow motion. The cubital tunnel retinaculum of all patients was hypoplastic and the dislocated portion of the ulnar nerves was hard. One nerve showed severe adhesion around the dislocation site. One patient had a pseudo-neuroma. All patients were relieved of discomfort, and motor and sensory function were recovered. The ulnar nerve in the groove showed neither irritation nor adhesion. In patients with grade 1, symptoms or numbness of the fingers was relieved within three months of the operation. Sensory disturbances in patients with grade 2 symptoms also improved within six months. Grade 2 patients with intrinsic muscle weakness regained normal muscular power, and these with patients with intrinsic muscle atrophy had showed increasing muscular power. The patient with grade 3 symptomes recovered normal sensation after 1 year; clawing of the ring and little fin-gers recovered, and the muscle volume was increased. Friction ulnar neuropathy has been treated traditionally by anterior transpositon or medial epicondylectomy. The ulnar nerve may become entrapped in scar tissue after these operations. We believe that this anatomical position is optimum for the nerve and that this procedure is essential for treatment of friction neuropathy

Background. The quest for the perfectly designed elbow prosthesis continues as instability and loosening remain the foremost reasons for the failure of total elbow replacement (TER). The Discovery® Elbow System (Biomet, UK) (Figure 1), which has been used in UK since 2003, is one of the latest generations of linked prosthesis. This system was designed to decrease polyethylene-bushing wear, improve anatomic stem design, restore elbow joint biomechanics, and produce a hinge that could be easily revised. This report describes the short term outcome of TER using the Discovery® Elbow System. Patients and Methods. A total of 60 TERs including 48 primary and 12 revisions were performed between 2003 and 2008. Patients included 21 males (37%) and 36 females (63%) with a mean age of 63 years. The indications for primary TER were advanced rheumatoid arthritis (n=19), osteoarthritis (n=16), post traumatic osteoarthritis (n=9), acute fractures (n=3), and haemophilic arthropathy (n=1). The outcome was assessed using pain score, Liverpool Elbow Score (LES), and range of movement during a mean follow-up of 26 months. Associated complications were documented. Radiological assessment included evaluation for loosening, instability and periprosthetic fractures. Results. The mean LES was significantly (p<0.001) improved from 3.8 (±1) pre-operatively to 6.9 (±2) at the final follow- up. Significant improvements were noted in elbow flexion from 100° (±22) to 120° (±15), supination from 41° (±28) to 65° (±20) and pronation from 52° (±22) to 72° (±18). There was no significant change in elbow extension. Mean improvement in flexion-extension and pronation-supination arc was 22° and 44°, respectively. 46 cases (77%) were completely pain-free at the final follow-up. The main complications included deep infection (4 cases – treated with staged revision TER), postoperative ulnar neuropathy (3 cases–treated with decompression), intra-operative fractures of medial condyle (3 cases – treated non-operatively with brace), and elbow haemarthrosis (1 case). Discussion. TER with Discovery® Elbow System resulted in either no pain or mild pain in 87% of cases. Patients undergoing Acclaim, Souter-Strathclyde, GSB III, and Coonrad-Morrey TER have been reported to have no/mild pain in 64%, 67%, 50–92% and 60–100% of cases, respectively. A 22° improvement in flexion-extension arc is comparable to that of Acclaim (23°), Souter-Strathclyde (15°), GSB III (19–33°), and Coonrad-Morrey (17–26°) TER. An improvement of 44° in pronation-supination arc in our series is also comparable to that of 31–67° reported for GSB III and higher than the Coonrad-Morrey prosthesis (21–28°). In terms of complications, an infection rate of 6.7% is consistent with those reported for GSB III TER (7–11%) and Coonrad-Morrey (6–8%). The incidence of persistent ulnar neuropathy was lower compared to GSB III TER (11–14%), Coonrad-Morrey (12–26%), and Acclaim (8%). While the survival of Discovery TER was 93%, the survival of GSB III (5–6 years) and Coonrad-Morrey (5 years) has been reported as 71–85% and 72–90%. The results indicate that Discovery® Elbow System is an effective device for total elbow arthroplasty in terms of functional improvement, pain relief and range of motion at short-term follow-up

The purpose of this study is to evaluate the long-term results of the surgical treatment of cubital tunnel syndrome by comparing the in-situ decompression and release of the ulnar nerve with or without partial medial epicondylectomy and the anterior transposition and release respectively. Material and Method: From 1991 since 2008, 119 patients, (81 men and 38 women) with an average age of 51(13–72 years) years were treated surgically for ulnar nerve compression at the elbow. The average duration of symptoms before surgery was 15 months (2–48 months). Preoperatively 2 patients were grade I, 52 patients were grade IIA, 31 patients were IIB and 34 were grade III according to the modified McGowan score. We performed in-situ decompression of the ulnar nerve in 35 patients, release with partial medial epicon-dylectomy in 44 patients and release with anterior transposition of the nerve in 40 patients. 17 patients were lost to follow-up. 108 patients were clinically assessed. Comparing the results among different surgical procedures, an improvement of at least one McGowan grade was obtained in 26 of 30 patients treated with simple decompression, in 29 of 35 patients treated with release and anterior transposition of the nerve and in 38 of 43 patients treated with release and medial epicondylectomy. The results of this study show that the possibility for complete recovery is inversely related to the initial neuropathy grade. Partial medial epicondylectomy is a valuable surgical procedure for treating grade I to IIB ulnar neuropathy because is an anatomic method with minimal nerve manipulation preserving regional blood supply

Purpose: The pisitriquetral articulation can be a source of pain, particularly after trauma. If conservative treatment fails, pisiformectomy appears to be the best alternative. The purpose of this work was to assess clinical and functional outcome after pisiformectomy. Material and method: Thirteen patients were reviewed 31.5 months (mean) after pisiformectomy. Two patients had a bilateral procedure giving 15 pisiformectomies. Occupation-related trauma was the principal cause. Four patients also had ulnar neuropathy. The same operative technique was used for all patients and a visual analogue scale was used to assess pain. Results: There were no postoperative complications. At last follow-up, outcome was excellent in twelve cases, good in two and fair in one (n=15). Residual pain was scored a mean 0.8 points versus 6.4 points preoperatively (p< 0.001). Wrist motion was improved after surgery. Conclusion: There are many causes of pisotriquetral disease, but trauma, or microtraum, predominates. Pisiformectomy is the best treatment after failure or deterioration of results of conservative treatment. It must be remembered however that pisotriquetral disease may be a revealing sign of a regional disorder that must be identified

We reviewed the functional outcome of cominnuted intraarticular fractures of the distal humerus managed with internal fixation with plates and screws. 15 patients (10 men-5 women) were reviewed over a mean of 29 months postoperatively. The age of the patients at operation ranged from 18 to 72 years. Patients were treated within 7 days of injury, using a posterior approach,with or without olecranon osteotomy and with anterior transposition of the ulnar nerve. Bone grafting was used in 7 cases in addition to internal fixation. Postoperative mobilisation was prompt in all patients,who were meticously reviewed for : 1)Function of the upper extremity,with the aid of the scale of DASH (Disabilities of the arm,shoulder and hand), 2)Ulnar nerve (pain, sensitive and movement dissability, functionality), 3)Range of elbow motion, 4) strength of the muscles controlling the elbow, wrist and hand. 5)Post-operative radiographic appearance, 6)Subjective evaluation, 7)Complications. All the patients were satisfied with the outcome of the operation,as well as with the activities which could postoperatively be undertaken. The mean range of motion for elbow (flexion-extension) was 118° in average,while muscle strength for elbow motion was moderately reduced. No case of ulnar neuropathy was observed. On the other hand postoperative complications were considerably frequent, yet they were mild and subsided eventually without further operation

Introduction: The presence of atypical muscle groups especially in sportsmen population is one of the causes of ulnar nerve entrapmnet. To treat this problem a close cooperation in between neurophysiologist, US-diagnost, surgeon and physiotherapist is mandatory. The inching (short segment study – SSS) of the peripheral nerves was introduced for testing the ulnar neuropathy at the elbow (UNE). The conventional fractionated ulnar nerve conduction studies localize the lesion only approximately to the elbow region, should be followed by inching of the ulnar nerve at the elbow. Dynamic, functional US also precise the character and localise the lesion and region of mechanical obstacles for the nerve. These methods can disclose the degree of focal conduction block or pinpoint the region of focal slowing, giving complementary information about the character of the lesion and help to choose a therapy by neuromobilisation or operative treatment. Aim: To compare results of SSS and US with intraoperative observations in a group of 24 patients operated due to peripheral neuropathy. Results: US and SSS shows a 97–100% diagnostic specificity and sensitivity These methods are also useful among patients with functional disturbances due to joint instability or presence of abnormal muscle groups like the anconeus epitrochlearis muscle, additional triceps aponeurosis or abnormality of the medial head of triceps brachii. Conclusions: Precise diagnosis helps to choose optimal therapy of UNE directed at the specific site of involvement. In our observations muscular pathology is responsible for UNE in about 40% of cases among sportsmen

Total Elbow arthroplasty can be a valuable treatment option in the painful or stiff elbow but outcomes have been disappointing previously. The history of total elbow arthroplasty has been disappointing in the past. Implants initially were a coupled articulation and were a rigid hinge. There was then a move to resurfacing type of designs although there was an issue with instability postoperatively with these implants. The semiconstrained coupled implant was developed in the mid 1970s by Coonrad. The idea behind the implant was that the loose polyethylene coupling provides inherent stability while decreasing the amount of loosening that was seen with the rigid hinge implants previously. We are reporting our results of our experience with a single type of semiconstrained implant that has been used in our unit since 1999. A semiconstrained total elbow arthroplasty was performed in thirteen patients over a period of 7 years period in our unit. Mean age at time of surgery was 60 years (44–70) M:F ratio 11:2. The aetiology of the joint pathology was Rheumatoid Arthritis (n= 10), psoriatic arthritis (n= 2) & posttraumatic (n =1). The patients were followed up for a mean duration of 4.5 years. They were assessed for range of motion, Mayo elbow function scores and radiographic evaluation and complication rate. 9 of the 13 elbows had a good to excellent result. There were 5 complications overall. There was two ulnar neuropathies that eventually resolved and one ulnar component that had to be revised 2 weeks after initial insertion. 3 had condylar fractures none of which required further operation. One patient had evidence of radiographic loosening but was asymptomatic. In our experience the semiconstrained total elbow replacement is a valuable option in the treatment of painful stiff the elbow

We present the early results of 36 primary total elbow arthroplasties using the Acclaim prosthesis. The Acclaim prosthesis was used in 46 primary total elbow arthroplasties between July 2000 and August 2002. All operations were performed or directly supervised by the two senior authors (IAT and JKS). There were 32 females and 14 males. The mean age at surgery was 64 years (range, 34–93). The underlying pathology was rheumatoid arthritis in 39, osteoarthritis in five and post-traumatic arthritis in two. The early results of 36 cases are presented at a minimum follow-up of two years. Patients were assessed using the American Shoulder and Elbow Surgeons patient self assessment form and the range of movement of the elbow measured. The Wrightington method was used for radiographic analysis of lucencies. There was good relief of pain and range of movement improved. The mean preoperative pain score was 8.1 and decreased to 2.1 at latest follow up. The mean disability score increased from 34.2 to 66.1. The mean overall satisfaction rating following surgery was 9.3 on a visual analogue scale from zero to ten. The mean range of flexion increased from 83. o. to105. o. The mean flexion gain was just over 10. o. and the mean extension gain was just over 12. o. There were 11 cases of intraoperative fracture of the humeral condyle. One of these fractures failed to unite and required revision to a linked prosthesis because of persistent instability. There was one case of deep infection. There were three cases of ulnar neuropathy, one of which resolved. There was no evidence of loosening. The Acclaim total elbow arthroplasty gives good symptomatic relief and improvement in function according to the American Shoulder and Elbow Surgeons patient self assessment form. These early results are encouraging but the frequency of intra-operative fractures is of some concern

Aim: Patients with advanced rheumatoid arthritis who were managed with ipsilateral shoulder and elbow arthroplasties were reviewed to determine appropriate sequence of surgery, operative technique and the functional outcome. Methods: Between 1992 and 2002, twenty-two patients underwent ipsilateral elbow and shoulder arthroplasties. Nineteen patients were available for final review. Clinical and radiological assessments were done on these patients. Results: Twenty-four upper limbs in nineteen patients were reviewed. Mean age at final follow-up was 61.1 years (49.9 to 73.3yrs; SD 8.2). Mean duration of follow-up from the last operation was 55.5 months (12 to 129.3m; SD 33.5). The average interval between the operations was 40.1 months; it was 41.2 months when elbow operated first and 38.7 months when shoulder was operated first. This difference was not significant (p=0.82). All movements showed significant improvement after respective joint replacements. There was a significantly greater improvement in external rotation of the shoulder when it was operated first (p=0.48). The average improvement in Constant-Murley scores was 28.8 points; with no statistically significant difference between either sequence of operations (p=0.49). However, there was statistically significant improvement in the average Mayo elbow performance score after the elbow arthroplasty when it was operated first (p=0.03). Two patients needed conversion of shoulder hemi-arthroplasty to total shoulder replacement due to subsequent erosion of the glenoid. One elbow replacement was revised because of recurrent dislocations. There were four patients who developed ulnar neuropathy, of which two were permanent. There were no peri-prosthetic fractures in this series. One patient needed custom-made short-stemmed shoulder prosthesis due to the presence of a long-stemmed humeral component of total elbow prosthesis in situ. Conclusion: Ipsilateral shoulder and elbow replacements significantly improve pain and function of the limb, when there is advanced arthritis. The joint that appears clinically and radiologically worse should be replaced first. However if both the joints are equally involved we feel that elbow should be replaced first as the functional improvement seems to be better. Careful preoperative planning is required in choosing the type and size of prosthesis, to avoid potential complications

Aims

The aim of this study was to develop and internally validate a prognostic nomogram to predict the probability of gaining a functional range of motion (ROM ≥ 120°) after open arthrolysis of the elbow in patients with post-traumatic stiffness of the elbow.

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.

The April 2014 Wrist & Hand Roundup³⁶⁰ looks at: diagnosis of compressive neuropathy; relevant reviews; the biomechanics of dorsal PIP fracture dislocation; the more strands the better; and state of mind the best predictor of outcome.