Aims

The aim of this audit was to assess and improve the completeness and accuracy of the National Joint Registry (NJR) dataset for arthroplasty of the elbow.

Aims

A review of the literature on elbow replacement found no consistency in the clinical outcome measures which are used to assess the effectiveness of interventions. The aim of this study was to define core outcome domains for elbow replacement.

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The aim of this study was to review the provision of total elbow arthroplasties (TEAs) in England, including the incidence, the characteristics of the patients and the service providers, the types of implant, and the outcomes.

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The aims of this study were to identify and evaluate the current literature examining the prognostic factors which are associated with failure of total elbow arthroplasty (TEA).

The June 2023 Shoulder & Elbow Roundup³⁶⁰ looks at: Proximal humerus fractures: what does the literature say now?; Infection risk of steroid injections and subsequent reverse shoulder arthroplasty; Surgical versus non-surgical management of humeral shaft fractures; Core outcome set needed for elbow arthroplasty; Minimally invasive approaches to locating radial nerve in the posterior humeral approach; Predictors of bone loss in anterior glenohumeral instability; Does the addition of motor control or strengthening exercises improve rotator cuff-related shoulder pain?; Terminology and diagnostic criteria used in patients with subacromial pain syndrome.

Aims. Arthroplasties of the elbow, including total elbow arthroplasty, radial head arthroplasty, distal humeral hemiarthroplasty, and radiocapitellar arthroplasty, are rarely undertaken. This scoping review aims to outline the current research in this area to inform the development of future research. Methods. A scoping review was undertaken adhering to the Joanna Briggs Institute guidelines using Medline, Embase, CENTRAL, and trial registries, limited to studies published between 1 January 1990 and 7 February 2021. Endnote software was used for screening and selection, and included randomized trials, non-randomized controlled trials, prospective and retrospective cohort studies, case-control studies, analytical cross-sectional studies, and case series of ten or more patients reporting the clinical outcomes of elbow arthroplasty. The results are presented as the number of types of studies, sample size, length of follow-up, clinical outcome domains and instruments used, sources of funding, and a narrative review. Results. A total of 362 studies met the inclusion criteria. Most were of total elbow arthroplasty (246; 68%), followed by radial head arthroplasty (100; 28%), distal humeral hemiarthroplasty (11; 3%), and radiocapitellar arthroplasty (5; 1%). Most were retrospective (326; 90%) and observational (315; 87%). The median sample size for all types of implant across all studies was 36 (interquartile range (IQR) 21 to 75). The median length of follow-up for all studies was 56 months (IQR 36 to 81). A total of 583 unique outcome descriptors were used and were categorized into 18 domains. A total of 105 instruments were used to measure 39 outcomes. Conclusion. We found that most of the literature dealing with elbow arthroplasty consists of retrospective observational studies with small sample sizes and short follow-up. Many outcomes have been used with many different instruments for their measurement, indicating a need to define a core set of outcomes and instruments for future research in this area. Cite this article: Bone Joint J 2022;104-B(10):1148–1155

Aims

The aim of this study was to investigate the feasibility of application of a 3D-printed megaprosthesis with hemiarthroplasty design for defects of the distal humerus or proximal ulna following tumour resection.

Introduction. Hemiarthroplasty is a treatment option for comminuted fractures and non-unions of the distal humerus. Unfortunately, the poor anatomical fit of off-the-shelf distal humeral hemiarthroplasty (DHH) implants can cause altered cartilage contact mechanics. The result is reduced contact area and higher cartilage stresses, thus subsequent cartilage erosion a concern. Previous studies have investigated reverse-engineered DHH implants which reproduce the shape of the distal humerus bone or cartilage at the articulation, but still failed to match native contact mechanics. In this study, design optimization was used to determine the optimal DHH implant shape. We hypothesized that patient-specific optimal implants will outperform population-optimized designs, and both will optimize simple reverse-engineered designs. Methods. The boney geometries of six elbow joints were created based on cadaver arm CT data using a semi-automatic threshold technique in 3D Slicer. CT scans were also obtained with the elbows denuded and disarticulated, such that the high contrast between hydrated cartilage and air could be exploited in order to reconstruct cartilage geometry. Using this 3D model data, finite element contact models were created for each elbow, where bones (distal humerus, proximal ulna and radius) were modelled as rigid surfaces covered by non-uniform thickness layers of cartilage. Cartilage was modelled as a Neo-Hookean hyperelastic material (K = 0.31 MPa, G = 0.37 MPa), and frictionless contact was assumed. In order to simulate hemiarthroplasty, the distal humerus cartilage surface was replaced by either a rigid surface in the shape of the subchondral bone (bone reverse engineered or BRE design), or a surface offset from the bone by some distance, which was defined parametrically and modified by an optimization algorithm. Simple flexion-extension with constant balanced muscle loads was simulated in ABAQUS (Fig 1), and resulting contact areas and contact stresses were calculated. For each specimen, the contact mechanics of the intact and DHH reconstructed joints were calculated. A design optimization algorithm in Matlab was used to determine the optimal offset distance which resulted in contact stress distributions on the ulna and radius which most closely resembled their intact conditions. This procedure was repeated in order to generate specimen-optimal offsets, as well as population-optimal offsets. Results. The population-optimal offset distance was 0.72 mm; whereas the specimen-optimal offsets ranged from 0.52 to 1.04 mm. Compared to the BRE design, which is effectively an offset distance of 0 mm, contact area generally increased at both the ulna (Fig 2) and radius (Fig 3) when either optimized design was used. On average, the specimen-optimal implant designs yielded only slightly larger contact areas than the population-optimal offsets, and only at mid-flexion (40–60 deg). Neither optimization strategy increased contact areas to those of the intact joint. Conclusions. Design optimization is a promising technique for improving patient-specific implants by offering customization in terms of contact mechanics, instead of simply reproducing osseous geometry. In this study, our models predict a large increase in contact area if optimal offsets are used when designing subject-specific DHH, and a population-optimal offset distance seems to be just as good as a subject-optimal offset. For any figures or tables, please contact authors directly (see Info & Metrics tab above).

The October 2015 Shoulder & Elbow Roundup³⁶⁰ looks at: Culture time important in propionibacterium acnes; Microvascularisation of the cuff footprint; Degenerative cuff tears: evidence for repair; Middle ground in distal humeral fractures?; Haste needed in elbow heterotopic ossification; Iatrogenic frozen shoulder; Salvage of failed humeral fixation

This study reviews the early results of Distal Humeral Hemiarthroplasty(DHH) for distal humeral fracture and proposed a treatment algorithm incorporating the use of this technique in the overall management of distal humeral fractures.

DHH was performed on 30 patients (mean 65 years; 29-91) for unreconstructable fractures of the distal humerus or salvage of failed internal fixation. A triceps on approach was used in six and an olecranon osteotomy in 24. A Sorbie Questor prosthesis (Wright Medical Technology) was used in 14 patients and a Latitude (Tornier) in 16. Clinical review at a mean of 25 months (3–88) included the American Shoulder and Elbow Surgeons elbow outcomes instrument (ASES), Mayo Elbow Performance Index (MEPI) and radiological assessment.

At follow up of 28 patients mean flexion deformity was 25 degrees, flexion 128 degrees, range of pronosupination 165 degrees, mean ASES 83, MEPI 77 and satisfaction 8/10. Acute cases scored better than salvage cases. Re- operation was required in 16 patients (53%); two revisions to a linked prosthesis for periprosthetic fracture and aseptic loosening at 53 and 16 months, 12 metalwork removals and four ulnar nerve procedures. Posterolateral rotatory instability was present in one elbow, four had laxity and mild pain on loading (two with prosthesis or pin loosening), four had laxity associated with column fractures (two symptomatic) and 10 had asymptomatic mild laxity only. The triceps on approach had worse instability and clinical scores. Uncomplicated union occurred in all olecranon osteotomies and 86% of column fractures. One elbow had an incomplete cement mantle and seven had lucencies >1 mm; one was loose but acceptable. Five prostheses were in slight varus. Two elbows had early degenerative changes and 15 developed a medial spur on the trochlea.

This is the largest reported experience of DHH. Early results of DHH show good outcomes after complex distal humeral fractures, despite a technically demanding procedure. Better results are obtained for treatment in the acute setting and with use of an olecranon osteotomy. As a result of this experience anatomical and clinical pre-requisites and advise on technique are outlined. An algorithm for use of DHH in relation to total elbow arthroplasty and ORIF for the treatment of complex intra-articular distal humeral fractures with or without column fractures is proposed.

In light of the growing number of elderly osteopenic patients with distal humeral fractures, we discuss the history of their management and current trends. Under most circumstances operative fixation and early mobilisation is the treatment of choice, as it gives the best results. The relative indications for and results of total elbow replacement versus internal fixation are discussed.