The December 2022 Shoulder & Elbow Roundup. 360. looks at: Biceps tenotomy versus soft-tissue tenodesis in females aged 60 years and older with rotator cuff tears; Resistance training combined with corticosteroid injections or tendon needling in patients with lateral elbow tendinopathy; Two-year functional outcomes of completely displaced midshaft clavicle fractures in adolescents; Patients who undergo rotator cuff repair can safely return to driving at two weeks postoperatively; Are two plates better than one? A systematic review of dual plating for acute midshaft clavicle fractures; Treatment of acute distal biceps tendon ruptures; Rotator cuff tendinopathy: disability associated with depression rather than pathology severity; Coonrad-Morrey total elbow arthroplasty implications in young patients with post-traumatic sequelae

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. Methods. We developed the Shanghai Prediction Model for Elbow Stiffness Surgical Outcome (SPESSO) based on a dataset of 551 patients who underwent open arthrolysis of the elbow in four institutions. Demographic and clinical characteristics were collected from medical records. The least absolute shrinkage and selection operator regression model was used to optimize the selection of relevant features. Multivariable logistic regression analysis was used to build the SPESSO. Its prediction performance was evaluated using the concordance index (C-index) and a calibration graph. Internal validation was conducted using bootstrapping validation. Results. BMI, the duration of stiffness, the preoperative ROM, the preoperative intensity of pain, and grade of post-traumatic osteoarthritis of the elbow were identified as predictors of outcome and incorporated to construct the nomogram. SPESSO displayed good discrimination with a C-index of 0.73 (95% confidence interval 0.64 to 0.81). A high C-index value of 0.70 could still be reached in the interval validation. The calibration graph showed good agreement between the nomogram prediction and the outcome. Conclusion. The newly developed SPESSO is a valid and convenient model which can be used to predict the outcome of open arthrolysis of the elbow. It could assist clinicians in counselling patients regarding the choice and expectations of treatment. Cite this article: Bone Joint J 2022;104-B(4):486–494

Aims. Management of displaced paediatric supracondylar elbow fractures remains widely debated and actual practice is unclear. This national trainee collaboration aimed to evaluate surgical and postoperative management of these injuries across the UK. Methods. This study was led by the South West Orthopaedic Research Division (SWORD) and performed by the Supra Man Collaborative. Displaced paediatric supracondylar elbow fractures undergoing surgery between 1 January 2019 and 31 December 2019 were retrospectively identified and their anonymized data were collected via Research Electronic Data Capture (REDCap). Results. A total of 972 patients were identified across 41 hospitals. Mean age at injury was 6.3 years (1 to 15), 504 were male (52%), 583 involved the left side (60%), and 538 were Gartland type 3 fractures (55%). Median time from injury to theatre was 16 hours (interquartile range (IQR) 6.6 to 22), 300 patients (31%) underwent surgery on the day of injury, and 91 (9%) underwent surgery between 10:00 pm and 8:00 am. Overall, 910 patients (94%) had Kirschner (K)-wire) fixation and these were left percutaneous in 869 (95%), while 62 patients (6%) had manipulation under anaesthetic (MUA) and casting. Crossed K-wire configuration was used as fixation in 544 cases (59.5%). Overall, 208 of the fixation cases (61%) performed or supervised by a paediatric orthopaedic consultant underwent lateral-only fixation, whereas 153 (27%) of the fixation cases performed or supervised by a non-paediatric orthopaedic consultant used lateral-only fixation. In total, 129 percutaneous wires (16%) were removed in theatre. Of the 341 percutaneous wire fixations performed or supervised by a paediatric orthopaedic consultant, 11 (3%) underwent wire removal in theatre, whereas 118 (22%) of the 528 percutaneous wire fixation cases performed or supervised by a non-paediatric orthopaedic consultant underwent wire removal in theatre. Four MUA patients (6%) and seven K-wire fixation patients (0.8%) required revision surgery within 30 days for displacement. Conclusion. The treatment of supracondylar elbow fractures in children varies across the UK. Patient cases where a paediatric orthopaedic consultant was involved had an increased tendency for lateral only K-wire fixation and for wire removal in clinic. Low rates of displacement requiring revision surgery were identified in all fixation configurations. Cite this article: Bone Joint J 2023;105-B(1):82–87

The February 2023 Shoulder & Elbow Roundup. 360. looks at: Arthroscopic capsular release or manipulation under anaesthesia for frozen shoulder?; Distal biceps repair through a single incision?; Distal biceps tendon ruptures: diagnostic strategy through physical examination; Postoperative multimodal opioid-sparing protocol vs standard opioid prescribing after knee or shoulder arthroscopy: a randomized clinical trial; Graft healing is more important than graft technique in massive rotator cuff tear; Subscapularis tenotomy versus peel after anatomic shoulder arthroplasty; Previous rotator cuff repair increases the risk of revision surgery for periprosthetic joint infection after reverse shoulder arthroplasty; Conservative versus operative treatment of acromial and scapular spine fractures following reverse total shoulder arthroplasty

The August 2024 Shoulder & Elbow Roundup. 360. looks at: Comparing augmented and nonaugmented locking-plate fixation for proximal humeral fractures in the elderly; Elevated five-year mortality following shoulder arthroplasty for fracture; Total intravenous anaesthesia with propofol reduces discharge times compared with inhaled general anaesthesia in shoulder arthroscopy: a randomized controlled trial; The influence of obesity on outcomes following arthroscopic rotator cuff repair; Humeral component version has no effect on outcomes following reverse total shoulder arthroplasty: a prospective, double-blinded, randomized controlled trial; What is a meaningful improvement after total shoulder arthroplasty by implant type, preoperative diagnosis, and sex?; The safety of corticosteroid injection prior to shoulder arthroplasty: a systematic review; Mortality and subsequent fractures of patients with olecranon fractures compared to other upper limb osteoporotic fractures

The August 2023 Shoulder & Elbow Roundup360 looks at: Motor control or strengthening exercises for rotator cuff-related shoulder pain? A multi-arm randomized controlled trial; Does the choice of antibiotic prophylaxis influence reoperation rate in primary shoulder arthroplasty?; Common shoulder injuries in sport: grading the evidence; The use of medial support screw was associated with axillary nerve injury after plate fixation of proximal humeral fracture using a minimally invasive deltoid-splitting approach; MRI predicts outcomes of conservative treatment in patients with lateral epicondylitis; Association between surgeon volume and patient outcomes after elective shoulder arthroplasty; Arthroscopic decompression of calcific tendinitis without cuff repair; Functional outcome after nonoperative management of minimally displaced greater tuberosity fractures and predictors of poorer patient experience

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. Methods. From June 2018 to January 2020, 13 patients with aggressive or malignant tumours involving the distal humerus (n = 8) or proximal ulna (n = 5) were treated by en bloc resection and reconstruction with a 3D-printed megaprosthesis with hemiarthroplasty, designed in our centre. In this paper, we summarize the baseline and operative data, oncological outcome, complication profiles, and functional status of these patients. Results. Preparation of the prosthesis was a mean of 8.0 days (SD 1.5), during which time no patients experienced tumour progression. The mean operating time and intraoperative blood loss were 158.1 minutes (SD 67.6) and 176.9 ml (SD 187.8), respectively. All of the prostheses were implanted successfully. During a mean follow-up of 25.7 months (SD 7.8), no patients died, but four had complications (two superficial wound problems, one temporary palsy of radial nerve, and one dislocation). No aseptic loosening, structural failure, infection, heterotopic ossification, or degenerative arthritis was seen in this study. The mean flexion of the elbow was 119.6° (SD 15.9°) and the mean extension lag was 11.9° (SD 13.8°). The mean Musculoskeletal Tumor Society 93 score and Mayo Elbow Performance Score were 28.4 (SD 0.9) and 97.7 (SD 4.4), respectively. Conclusion. The custom-made, 3D-printed megaprosthesis with hemiarthroplasty is a feasible option for functional reconstruction after resection of a tumour in the distal humerus or proximal ulna. Cite this article: Bone Joint J 2022;104-B(6):747–757

The June 2023 Shoulder & Elbow Roundup. 360. 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

The December 2013 Shoulder & Elbow Roundup. 360 . looks at: Platelet-rich plasma; Arthroscopic treatment of sternoclavicular joint osteoarthritis; Synchronous arthrolysis and cuff repair; Arthroscopic arthrolysis; Regional blockade in the beach chair; Recurrent instability; Avoiding iatrogenic nerve injury in elbow arthroscopy; and Complex reconstruction of total elbow revisions

We present a review of claims made to the NHS Litigation Authority (NHSLA) by patients with conditions affecting the shoulder and elbow, and identify areas of dissatisfaction and potential improvement. Between 1995 and 2012, the NHSLA recorded 811 claims related to the shoulder and elbow, 581 of which were settled. This comprised 364 shoulder (64%), and 217 elbow (36%) claims. A total of £18.2 million was paid out in settled claims. Overall diagnosis, mismanagement and intra-operative nerve injury were the most common reasons for litigation. The highest cost paid out resulted from claims dealing with incorrect, missed or delayed diagnosis, with just under £6 million paid out overall. Fractures and dislocations around the shoulder and elbow were common injuries in this category. All 11 claims following wrong-site surgery that were settled led to successful payouts. This study highlights the diagnoses and procedures that need to be treated with particular vigilance. Having an awareness of the areas that lead to litigation in shoulder and elbow surgery will help to reduce inadvertent risks to patients and prevent dissatisfaction and possible litigation. . Cite this article: Bone Joint J 2014; 96-B:574–9

The October 2015 Shoulder & Elbow Roundup. 360 . 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

The August 2015 Shoulder & Elbow Roundup. 360 . looks at: Clavicular fractures are being fixed – but how?; Propionibacterium acnes: a pain in the shoulder?; Bacteria, armpits and arthroplasty; Living longer, but unhappy: the woes of shoulder arthroplasty in the under 50s; Recurrent dislocations in the adolescent population; Splinting for elbow stiffness; Revision Bankart repair

The April 2015 Shoulder & Elbow Roundup. 360 . looks at: Distal clavicular resection not indicated in cuff repair?; Platelet-rich plasma in rotator cuff repair; Radial head geometry: time to change?; Heterotopic ossification in elbow trauma; Another look at heterotopic ossification in the humerus; Triceps on for total elbow arthroplasty?; Predicting outcomes in rotator cuff repair; Deltoid fatty infiltration and reverse shoulder arthroplasty

The zona conoidea comprises the area of the lateral trochlear ridge of the humerus. The purpose of this study is to reintroduce this term ‘zona conoidea’ to the discussion of the human elbow and to investigate its significance in the development of osteoarthritis of the elbow. The upper extremities of 12 cadavers were prepared. With the forearm in neutral, pronation and supination, the distance between the bevel of the radial head and zona conoidea was inspected. A total of 12 healthy volunteers had a CT scan. The distance between the zona conoidea and the bevelled rim of the radial head was measured in these positions. In the anatomical specimens, early osteo-arthritic changes were identified in the posteromedial bevelled rim of the radial head, and the corresponding zona conoidea in supination. Measurement in the CT study showed that in full supination, the distance between the bevel of the radial head and the zona conoidea was at a minimum. This study suggests that the significant contact between the bevel of the radial head and the zona conoidea in supination is associated with the initiation of osteoarthritis of the elbow in this area

The August 2014 Shoulder & Elbow Roundup. 360 . looks at: Myofibroblasts perhaps not implicated in post-traumatic elbow stiffness; olecranon tip biomechanically sound for coranoid reconstruction; obesity and elbow replacement don’t mix; single column plating successful for extra-articular distal humeral fractures; satisfaction not predictable in frozen shoulder; tenodesis and repair both acceptable in Grade II SLAP tears; glenoid bone grafting is effective and glenohumeral articular lesions best seen with an arthroscope

The February 2015 Shoulder & Elbow Roundup. 360 . looks at: Proximal Humerus fractures a comprehensive review, Predicting complications in shoulder ORIF, The Coronoid Revisited, Remplissage and bankart repair for Hill-Sach’s lesions, Diabetes and elbow arthroplasty, Salvage surgery for failed bankart repair, Sternoclavicular Joint Reconstruction, Steroids effective in the short-term for tennis elbow

The December 2014 Shoulder & Elbow Roundup. 360 . looks at: cuff tears and plexus injury; . corticosteroids and physiotherapy in SAI; diabetes and elbow arthroplasty; distal biceps tendon repairs; shockwave therapy in frozen shoulder; hydrodilation and steroids for adhesive capsulitis; just what do our patients read?; and what happens to that stable radial head fracture?

The June 2014 Shoulder & Elbow Roundup. 360 . looks at: suprascapular nerve and rotator cuff pathology; anchors in Bankart repair: it’s not what you’ve got, but how you use it; not all shoulder PROMs are equal; reverse shoulder arthroplasty OK in trauma; not all in the mind: frozen shoulder personality debunked; open and arthroscopic repair equivalent in shoulder instability; natural history of olecranon fractures not so bleak?; and resurfacing of the shoulder: a Danish perspective

The October 2013 Shoulder & Elbow Roundup. 360 . looks at: Deltoid impairment not necessarily a contra-indication for shoulder arthroplasty; The tricky radiograph; Not so asymptomatic cuff tears; Total shoulder arthroplasty: kinder on the glenoid; Barbotage for calcific tendonitis; What happens to the arthritic glenoid?; Two screws a screw too few?; Sloppy hinge best for elbow arthroplasty

The October 2014 Shoulder & Elbow Roundup. 360 . looks at: PRP is not effective in tennis elbow; eccentric physiotherapy effective in subacromial pain; dexamethasone in shoulder surgery; arthroscopic remplissage for engaging Hill-Sach’s lesions; a consistent approach to subacromial impingement; delay in fixation of proximal humeral fractures detrimental to outcomes

The August 2012 Shoulder & Elbow Roundup. 360. looks at: platelet-rich fibrin matrix and the torn rotator cuff; ultrasound, trainees, and ducks out of water; the torn rotator cuff and conservative treatment; Bankart repair and subsequent degenerative change; proprioception after shoulder replacement; surgery for a terrible triad, with reasonable short-term results; and the WORC Index

The February 2014 Shoulder & Elbow Roundup. 360 . looks at: whether arthroscopic acromioplasty is a cost-effective intervention; shockwave therapy in cuff tear; whether microfracture relieves short-term pain in cuff repair; the promising early results from L-PRF augmented cuff repairs; rehabilitation following cuff repair; supination strength following biceps tendon rupture; whether longer is better in humeral components; fatty degeneration in a rodent model; and the controversial acromioclavicular joint dislocation

The February 2013 Shoulder & Elbow Roundup. 360 . looks at: whether we should replace fractured shoulders; the limited evidence for shoulder fractures; cuffs and early physio; matrix proteins and cuff tears; long-term SLAP tear outcomes; suture anchors; recurrent Bankart repairs; and acromial morphology and calcific tendonitis

The December 2012 Shoulder & Elbow Roundup. 360. looks at: whether allograft is biomechanically superior in large Hill-Sachs defects; glenoid bone loss in shoulder dislocators; repairing irreparable cuff tears; acromioclavicular joint injuries; whether more radiographs equals more surgery; whether reverse TSR is cheaper than hemiarthroplasty; autologous chondrocyte implantation in the shoulder; and fracture of the clavicle

The June 2012 Shoulder & Elbow Roundup. 360. looks at: reverse shoulder replacement; torn rotator cuffs and platelet-rich fibrin; rotator cuff repair; frozen shoulder; whether an arthroscopic rotator cuff repair actually heals; the torn rotator cuff’s effect on activities of daily living; subacromial impingement; how to improve the reliability of the Constant-Murley score; and failure of the Neer modification of an open Bankart procedure.

The April 2014 Shoulder & Elbow Roundup. 360 . looks at: arthroscopic capsular release successful after six months; MCIC in cuff surgery; analgesia following arthroscopic cuff repair; platelet-rich fibrin; and cuff tear and suprascapular nerve neuropathy?

The October 2012 Shoulder & Elbow Roundup. 360. looks at: fast-absorbing suture anchors for use in shoulder labral tears; double-row rotator cuff repair; degenerate massive rotator cuff tears addressed with partial repair; open and arthroscopic stabilisation of Bankart lesions; predicting the risk of revision humeral head replacement; arthroscopic treatment for frozen shoulder; and long-term follow-up of the Bristow-Latarjet procedure

Post-traumatic elbow stiffness is a disabling condition that remains challenging for upper limb surgeons. Open elbow arthrolysis is commonly used for the treatment of stiff elbow when conservative therapy has failed. Multiple questions commonly arise from surgeons who deal with this disease. These include whether the patient has post-traumatic stiff elbow, how to evaluate the problem, when surgery is appropriate, how to perform an excellent arthrolysis, what the optimal postoperative rehabilitation is, and how to prevent or reduce the incidence of complications. Following these questions, this review provides an update and overview of post-traumatic elbow stiffness with respect to the diagnosis, preoperative evaluation, arthrolysis strategies, postoperative rehabilitation, and prevention of complications, aiming to provide a complete diagnosis and treatment path. Cite this article: Bone Joint Open 2020;1-9:576–584

We undertook this study to determine the minimum amount of coronoid necessary to stabilise an otherwise intact elbow joint. Regan–Morrey types II and III, plus medial and lateral oblique coronoid fractures, collectively termed type IV fractures, were simulated in nine fresh cadavers. An electromagnetic tracking system defined the three-dimensional stability of the ulna relative to the humerus. The coronoid surface area accounts for 59% of the anterior articulation. Alteration in valgus, internal and external rotation occurred only with a type III coronoid fracture, accounting for 68% of the coronoid and 40% of the entire articular surface. A type II fracture removed 42% of the coronoid articulation and 25% of the entire articular surface but was associated with valgus and external rotational changes only when the radial head was removed, thereby removing 67% of the articular surface.

We conclude that all type III fractures, as defined here, are unstable, even with intact ligaments and a radial head. However, a type II deficiency is stable unless the radial head is removed. Our study suggests that isolated medial-oblique or lateral-oblique fractures, and even a type II fracture with intact ligaments and a functional radial head, can be clinically stable, which is consistent with clinical observation.

Hinged elbow orthoses (HEO) are often used to allow protected motion of the unstable elbow. However, biomechanical studies have not shown HEO to improve the stability of a lateral collateral ligament (LCL) deficient elbow. This lack of effectiveness may be due to the straight hinge of current HEO designs which do not account for the native carrying angle of the elbow. The aim of this study was to determine the effectiveness of a custom-designed HEO with adjustable valgus angulation on stabilizing the LCL deficient elbow. Eight cadaveric upper extremities were mounted in an elbow motion simulator in the varus position. An LCL injured (LCLI) model was created by sectioning of the common extensor origin, and the LCL. The adjustable HEO was secured to the arm and its effect with 0°, 10°, and 20° (BR00, BR10, BR20) of valgus angulation was investigated. Varus-valgus angles and ulnohumeral rotations were recorded using an electromagnetic tracking system during simulated active elbow flexion with the forearm pronated and supinated. We examined 5 elbow states, intact, LCLI, BR00, BR10, BR20. There were significant differences in varus and ER angulation between different elbow states with the forearm both pronated and supinated (P=0 for all). The LCLI state with or without the brace resulted in significant increases in varus angulation and ER of the ulnohumeral articulation compared to the intact state (P 0.05). The difference between each of the brace angles and the LCLI state ranged from 1.1° to 2.4° for varus angulation and 0.5° to 1.6° for ER. Although there was a trend toward decreasing varus and external rotation angulation of the ulnohumeral articulation with the application of this adjustable HEO, none of the brace angles examined in this biomechanical investigation was able to fully restore the stability of the LCL deficient elbow. This lack of stabilizing effect may be due to the weight of the brace exerting unintentional varus and torsional forces on the unstable elbow. Previous investigations have shown that the varus arm position is highly unstable in the LCL deficient elbow. Our results demonstrate that application of an HEO with an adjustable carrying angle does not sufficiently stabilize the LCL deficient elbow in this highly unstable position and varus arm position should continue to be avoided in the rehabilitation programs of an LCL deficient elbow

The February 2024 Shoulder & Elbow Roundup. 360. looks at: Does indomethacin prevent heterotopic ossification following elbow fracture fixation?; Arthroscopic capsular shift in atraumatic shoulder joint instability; Ultrasound-guided lavage with corticosteroid injection versus sham; Combined surgical and exercise-based interventions following primary traumatic anterior shoulder dislocation: a systematic review and meta-analysis; Are vascularized fibula autografts a long-lasting reconstruction after intercalary resection of the humerus for primary bone tumours?; Anatomical versus reverse total shoulder arthroplasty with limited forward elevation; Tension band or plate fixation for simple displaced olecranon fractures?; Is long-term follow-up and monitoring in shoulder and elbow arthroplasty needed?

The December 2023 Shoulder & Elbow Roundup. 360. looks at: Clavicle fractures: is the evidence changing practice?; Humeral shaft fractures, and another meta-analysis…let’s wait for the trials now!; Hemiarthroplasty or total elbow arthroplasty for distal humeral fractures…what does the registry say?; What to do with a first-time shoulder dislocation?; Deprivation indices and minimal clinically important difference for patient-reported outcomes after arthroscopic rotator cuff repair; Prospective randomized clinical trial of arthroscopic repair versus debridement for partial subscapularis tears; Long-term follow-up following closed reduction and early movement for simple dislocation of the elbow; Sternoclavicular joint reconstruction for traumatic acute and chronic anterior and posterior instability

The April 2023 Shoulder & Elbow Roundup. 360. looks at: Arthroscopic Bankart repair in athletes: in it for the long run?; Functional outcomes and the Wrightington classification of elbow fracture-dislocations; Hemiarthroplasty or ORIF intra-articular distal humerus fractures in older patients; Return to sport after total shoulder arthroplasty and hemiarthroplasty; Readmissions after shoulder arthroplasty; Arthroscopic Bankart repair in the longer term; Bankart repair with(out) remplissage or the Latarjet procedure? A systematic review and meta-analysis; Regaining motion among patients with shoulder pathology: are all exercises equal?

Aims. This study aimed to determine the minimal detectable change (MDC), minimal clinically important difference (MCID), and substantial clinical benefit (SCB) under distribution- and anchor-based methods for the Mayo Elbow Performance Index (MEPI) and range of movement (ROM) after open elbow arthrolysis (OEA). We also assessed the proportion of patients who achieved MCID and SCB; and identified the factors associated with achieving MCID. Methods. A cohort of 265 patients treated by OEA were included. The MEPI and ROM were evaluated at baseline and at two-year follow-up. Distribution-based MDC was calculated with confidence intervals (CIs) reflecting 80% (MDC 80), 90% (MDC 90), and 95% (MDC 95) certainty, and MCID with changes from baseline to follow-up. Anchor-based MCID (anchored to somewhat satisfied) and SCB (very satisfied) were calculated using a five-level Likert satisfaction scale. Multivariate logistic regression of factors affecting MCID achievement was performed. Results. The MDC increased substantially based on selected CIs (MDC 80, MDC 90, and MDC 95), ranging from 5.0 to 7.6 points for the MEPI, and from 8.2° to 12.5° for ROM. The MCID of the MEPI were 8.3 points under distribution-based and 12.2 points under anchor-based methods; distribution- and anchor-based MCID of ROM were 14.1° and 25.0°. The SCB of the MEPI and ROM were 17.3 points and 43.4°, respectively. The proportion of the patients who attained anchor-based MCID for the MEPI and ROM were 74.0% and 94.7%, respectively; furthermore, 64.2% and 86.8% attained SCB. Non-dominant arm (p = 0.022), higher preoperative MEPI rating (p < 0.001), and postoperative visual analogue scale pain score (p < 0.001) were independent predictors of not achieving MCID for the MEPI, while atraumatic causes (p = 0.040) and higher preoperative ROM (p = 0.005) were independent risk factors for ROM. Conclusion. In patients undergoing OEA, the MCID for the increased MEPI is 12.2 points and 25° increased ROM. The SCB is 17.3 points and 43.3°, respectively. Future studies using the MEPI and ROM to assess OEA outcomes should report not only statistical significance but also clinical importance. Cite this article: Bone Joint J 2021;103-B(2):366–372

The October 2023 Shoulder & Elbow Roundup. 360. looks at: Arthroscopic capsular shift surgery in patients with atraumatic shoulder joint instability: a randomized, placebo-controlled trial; Superior capsular reconstruction partially restores native glenohumeral loads in a dynamic model; Gene expression in glenoid articular cartilage varies in acute instability, chronic instability, and osteoarthritis; Intra-articular injection versus interscalene brachial plexus block for acute-phase postoperative pain management after arthroscopic shoulder surgery; Level of pain catastrophizing rehab in subacromial impingement: secondary analyses from a pragmatic randomized controlled trial (the SExSI Trial); Anterosuperior versus deltopectoral approach for primary reverse total shoulder arthroplasty: a study of 3,902 cases from the Dutch National Arthroplasty Registry with a minimum follow-up of five years; Assessment of progression and clinical relevance of stress-shielding around press-fit radial head arthroplasty: a comparative study of two implants; A number of modifiable and non-modifiable factors increase the risk for elbow medial ulnar collateral ligament injury in baseball players: a systematic review

Aims. Heterotopic ossification (HO) is a common complication after elbow trauma and can cause severe upper limb disability. Although multiple prognostic factors have been reported to be associated with the development of post-traumatic HO, no model has yet been able to combine these predictors more succinctly to convey prognostic information and medical measures to patients. Therefore, this study aimed to identify prognostic factors leading to the formation of HO after surgery for elbow trauma, and to establish and validate a nomogram to predict the probability of HO formation in such particular injuries. Methods. This multicentre case-control study comprised 200 patients with post-traumatic elbow HO and 229 patients who had elbow trauma but without HO formation between July 2019 and December 2020. Features possibly associated with HO formation were obtained. The least absolute shrinkage and selection operator regression model was used to optimize feature selection. Multivariable logistic regression analysis was applied to build the new nomogram: the Shanghai post-Traumatic Elbow Heterotopic Ossification Prediction model (STEHOP). STEHOP was validated by concordance index (C-index) and calibration plot. Internal validation was conducted using bootstrapping validation. Results. Male sex, obesity, open wound, dislocations, late definitive surgical treatment, and lack of use of non-steroidal anti-inflammatory drugs were identified as adverse predictors and incorporated to construct the STEHOP model. It displayed good discrimination with a C-index of 0.80 (95% confidence interval 0.75 to 0.84). A high C-index value of 0.77 could still be reached in the internal validation. The calibration plot showed good agreement between nomogram prediction and observed outcomes. Conclusion. The newly developed STEHOP model is a valid and convenient instrument to predict HO formation after surgery for elbow trauma. It could assist clinicians in counselling patients regarding treatment expectations and therapeutic choices. Cite this article: Bone Joint J 2022;104-B(8):963–971

Aims. The conventionally described mechanism of distal biceps tendon rupture (DBTR) is of a ‘considerable extension force suddenly applied to a resisting, actively flexed forearm’. This has been commonly paraphrased as an ‘eccentric contracture to a flexed elbow’. Both definitions have been frequently used in the literature with little objective analysis or citation. The aim of the present study was to use video footage of real time distal biceps ruptures to revisit and objectively define the mechanism of injury. Methods. An online search identified 61 videos reporting a DBTR. Videos were independently reviewed by three surgeons to assess forearm rotation, elbow flexion, shoulder position, and type of muscle contraction being exerted at the time of rupture. Prospective data on mechanism of injury and arm position was also collected concurrently for 22 consecutive patients diagnosed with an acute DBTR in order to corroborate the video analysis. Results. Four videos were excluded, leaving 57 for final analysis. Mechanisms of injury included deadlift, bicep curls, calisthenics, arm wrestling, heavy lifting, and boxing. In all, 98% of ruptures occurred with the arm in supination and 89% occurred at 0° to 10° of elbow flexion. Regarding muscle activity, 88% occurred during isometric contraction, 7% during eccentric contraction, and 5% during concentric contraction. Interobserver correlation scores were calculated as 0.66 to 0.89 using the free-marginal Fleiss Kappa tool. The prospectively collected patient data was consistent with the video analysis, with 82% of injuries occurring in supination and 95% in relative elbow extension. Conclusion. Contrary to the classically described injury mechanism, in this study the usual arm position during DBTR was forearm supination and elbow extension, and the muscle contraction was typically isometric. This was demonstrated for both video analysis and ‘real’ patients across a range of activities leading to rupture. Cite this article: Bone Jt Open 2022;3(10):826–831

Aims. This study aimed to answer the following questions: do 3D-printed models lead to a more accurate recognition of the pattern of complex fractures of the elbow?; do 3D-printed models lead to a more reliable recognition of the pattern of these injuries?; and do junior surgeons benefit more from 3D-printed models than senior surgeons?. Methods. A total of 15 orthopaedic trauma surgeons (seven juniors, eight seniors) evaluated 20 complex elbow fractures for their overall pattern (i.e. varus posterior medial rotational injury, terrible triad injury, radial head fracture with posterolateral dislocation, anterior (trans-)olecranon fracture-dislocation, posterior (trans-)olecranon fracture-dislocation) and their specific characteristics. First, fractures were assessed based on radiographs and 2D and 3D CT scans; and in a subsequent round, one month later, with additional 3D-printed models. Diagnostic accuracy (acc) and inter-surgeon reliability (κ) were determined for each assessment. Results. Accuracy significantly improved with 3D-printed models for the whole group on pattern recognition (acc. 2D/3D. = 0.62 vs acc. 3Dprint. = 0.69; Δacc = 0.07 (95% confidence interval (CI) 0.00 to 0.14); p = 0.025). A significant improvement was also seen in reliability for pattern recognition with the additional 3D-printed models (κ. 2D/3D. = 0.41 (moderate) vs κ. 3Dprint. = 0.59 (moderate); Δκ = 0.18 (95% CI 0.14 to 0.22); p ≤ 0.001). Accuracy was comparable between junior and senior surgeons with the 3D-printed model (acc. junior. = 0.70 vs acc. senior. = 0.68; Δacc = -0.02 (95% CI -0.17 to 0.13); p = 0.904). Reliability was also comparable between junior and senior surgeons without the 3D-printed model (κ. junior. = 0.39 (fair) vs κ. senior. = 0.43 (moderate); Δκ = 0.03 (95% CI -0.03 to 0.10); p = 0.318). However, junior surgeons showed greater improvement regarding reliability than seniors with 3D-printed models (κ. junior. = 0.65 (substantial) vs κ. senior. = 0.54 (moderate); Δκ = 0.11 (95% CI 0.04 to 0.18); p = 0.002). Conclusion. The use of 3D-printed models significantly improved the accuracy and reliability of recognizing the pattern of complex fractures of the elbow. However, the current long printing time and non-reusable materials could limit the usefulness of 3D-printed models in clinical practice. They could be suitable as a reusable tool for teaching residents. Cite this article: Bone Joint J 2023;105-B(1):56–63

A particular pattern of complex instability of the elbow is “the terrible triad”, in which elbow dislocation is associated with fractures of the coronoid and radial head. Other frequent patterns are the variant of Monteggia lesions (Bado II) described by Jupiter which is characterized by ulnar fracture associated with fracture-dislocation of proximal radius, and the articular fracture of the distal humerus associated with elbow dislocation. The goal of treatment is to restore the primary stabilizers of the elbow such as the coronoid process, olecranon and both collateral ligaments by internal fixation and reconstruction of the ligaments. If elbow stability obtained at operation is unsatisfactory or internal fixation not enough stable, there an indication for applying a dynamic external fixator (DEF). The latter allows:. the articular congruence to be maintained and the ligaments to heal in adequate tension and position,. internal fixation and ligaments reconstruction to be protected, and. immediate joint motion to be carried out. From 2005 to 2008, we treated surgically 31 patients with complex instability of the elbow. DEF was applied in 38% of cases, namely 3 terrible triads, 5 fracture-dislocations of Monteggia and 4 articular fractures of the humerus associated with elbow dislocation. The mean age of patients was 44 years (range 30–74). All patients underwent ORIF, reconstruction of ligaments and dynamic external fixation. The OptiROM elbow fixator was used In 2 patients, the Orthofix fixator in 1 and the DJD fixator in 9. In all cases, active elbow motion was allowed without restrictions from the second postoperative day. Indomethacin was consistently administered for 5 weeks to prevent heterotopic ossifications. The DEF was removed after 6 weeks. The mean follow-up was 25 months (range 5–44 months). At last follow-up, the clinical results, evaluated according to the MEPS, were excellent in 10 patients (83%), who had had a fast recovery of range of motion (ROM). The elbow was painless in all patients and stable in all but 1. Moderate osteoarthrosis was found in 60% of cases. Complications included: 1 elbow stiffness, 1 pseudarthrosis of capitulum humeri and trochlea, 1 transitory radial nerve palsy, and 1 superficial pin tract infection. In conclusion, DEF is a helpful tool for treatment of complex elbow instability, particularly when stable internal fixation cannot be obtained or instability persists after ligaments reconstruction. However, DEF increases morbidity, and implies a longer operative time and prolonged exposure to radiation

The April 2024 Shoulder & Elbow Roundup. 360. looks at: Acute rehabilitation following traumatic anterior shoulder dislocation (ARTISAN): pragmatic, multicentre, randomized controlled trial; Prevalence and predisposing factors of neuropathic pain in patients with rotator cuff tears; Are two plates better than one? The clavicle fracture reimagined; A single cell atlas of frozen shoulder capsule identifies features associated with inflammatory fibrosis resolution; Complication rates and deprivation go hand in hand with total shoulder arthroplasty; Longitudinal instability injuries of the forearm; A better than “best-fit circle” method for glenoid bone loss assessment; 3D supraspinatus muscle volume and intramuscular fatty infiltration after arthroscopic rotator cuff repair

The June 2024 Shoulder & Elbow Roundup. 360. looks at: Reverse versus anatomical total shoulder replacement for osteoarthritis? A UK national picture; Acute rehabilitation following traumatic anterior shoulder dislocation (ARTISAN): pragmatic, multicentre, randomized controlled trial; acid for rotator cuff repair: a systematic review and meta-analysis of randomized controlled trials; Metal or ceramic humeral head total shoulder arthroplasty: an analysis of data from the National Joint Registry; Platelet-rich plasma has better results for long-term functional improvement and pain relief for lateral epicondylitis: a systematic review and meta-analysis of randomized controlled trials; Quantitative fatty infiltration and 3D muscle volume after nonoperative treatment of symptomatic rotator cuff tears: a prospective MRI study of 79 patients; Locking plates for non-osteoporotic proximal humeral fractures in the long term; A systematic review of the treatment of primary acromioclavicular joint osteoarthritis

Aims. The aim of this study was to develop and evaluate machine-learning-based computerized adaptive tests (CATs) for the Oxford Hip Score (OHS), Oxford Knee Score (OKS), Oxford Shoulder Score (OSS), and the Oxford Elbow Score (OES) and its subscales. Methods. We developed CAT algorithms for the OHS, OKS, OSS, overall OES, and each of the OES subscales, using responses to the full-length questionnaires and a machine-learning technique called regression tree learning. The algorithms were evaluated through a series of simulation studies, in which they aimed to predict respondents’ full-length questionnaire scores from only a selection of their item responses. In each case, the total number of items used by the CAT algorithm was recorded and CAT scores were compared to full-length questionnaire scores by mean, SD, score distribution plots, Pearson’s correlation coefficient, intraclass correlation (ICC), and the Bland-Altman method. Differences between CAT scores and full-length questionnaire scores were contextualized through comparison to the instruments’ minimal clinically important difference (MCID). Results. The CAT algorithms accurately estimated 12-item questionnaire scores from between four and nine items. Scores followed a very similar distribution between CAT and full-length assessments, with the mean score difference ranging from 0.03 to 0.26 out of 48 points. Pearson’s correlation coefficient and ICC were 0.98 for each 12-item scale and 0.95 or higher for the OES subscales. In over 95% of cases, a patient’s CAT score was within five points of the full-length questionnaire score for each 12-item questionnaire. Conclusion. Oxford Hip Score, Oxford Knee Score, Oxford Shoulder Score, and Oxford Elbow Score (including separate subscale scores) CATs all markedly reduce the burden of items to be completed without sacrificing score accuracy. Cite this article: Bone Jt Open 2022;3(10):786–794

Heterotopic ossification (HO) is a well-known complication of traumatic elbow injuries. The reported rates of post-traumatic HO formation vary from less than 5% with simple elbow dislocations, to greater than 50% in complex fracture-dislocations. Previous studies have identified fracture-dislocations, delayed surgical intervention, and terrible triad injuries as risk factors for HO formation. There is, however, a paucity of literature regarding the accuracy of diagnosing post-traumatic elbow HO. Therefore, the purpose of our study was to determine the inter-rater reliability of HO diagnosis using standard radiographs of the elbow at 52 weeks post-injury, as well as to report on the rate of mature compared with immature HO. We hypothesized inter-rater reliability would be poor among raters for HO formation. Prospectively collected data from a large clinical trial was reviewed by three independent reviewers (one senior orthopedic resident, one senior radiology resident, and one expert upper extremity orthopedic surgeon). Each reviewer examined anonymized 52-week post-injury radiographs of the elbow and recorded: 1. the presence or absence of HO, 2. the location of HO, 3. the size of the HO (in cm, if present), and 4. the maturity of the HO formation. Maturity was defined by consensus prior to image review and defined as an area of well-defined cortical and medullary bone outside the cortical borders of the humerus, ulna, or radius. Immature lesions were defined as an area of punctate calcification with an ill-defined cloud-like density outside the cortical borders of the humerus, ulna or radius. Data were collected using a standardized online data collection form (CognizantMD, Toronto, ON, CA). Inter-rater reliability was calculated using Fleiss’ Kappa statistic and a multivariate logistic regression analysis was performed to identify risk factors for HO formation in general, as well as mature HO at 52 weeks post injury. Statistical analysis was performed using RStudio (version1.4, RStudio, Boston, MA, USA). A total of 79 radiographs at the 52-week follow-up were reviewed (54% male, mean age 50, age SD 14, 52% operatively treated). Inter-rater reliability using Fleiss’ Kappa was k= 0.571 (p = 0.0004) indicating moderate inter-rater reliability among the three reviewers. The rate of immature HO at 52 weeks was 56%. The multivariate logistic regression analysis identified male sex as a significant risk factor for HO development (OR 5.29, 1.55-20.59 CI, p = 0.011), but not for HO maturity at 52 weeks. Age, time to surgery, and operative intervention were not found to be significant predictors for either HO formation or maturity of the lesion in this cohort. Our study demonstrates moderate inter-rater reliability in determining the presence of HO at 52 weeks post-elbow injury. There was a high rate (56%) of immature HO at 52-week follow-up. We also report the finding of male sex as a significant risk factor for post traumatic HO development. Future research directions could include investigation into possible male predominance for traumatic HO formation, as well as improving inter-rater reliability through developing a standardized and validated classification system for reporting the radiographic features of HO formation around the elbow

Clinical assessment of elbow deformity in children at present is mainly based on physical examination and plain X-ray images, which may be inaccurate if the elbow is not in fully supination; furthermore, the rotational deformity is even harder to be determined by such methods. Morrey suggested that the axis of rotation of the elbow joint can be simplified to a single axis. Based on such assumption, we are proposing a method to assess elbow deformity using rotational axis of the joint, and an optimized calculation algorithm is presented. The rotation axis of elbow in respective to the upper arm can be obtained from the motion tract of markers placed at the forearm. Cadaver study was done, in which three skeletal motion trackers were placed over both the anterior aspect of humerus, as well as distal ulna. Osteotomy was created at the supracondylar region of humerus through lateral approach, and the bone fragments were stabilized with a set of external skeletal fixator, leaving the soft tissue intact. The amount of deformity was created manually by adjusting the position of the distal fragment via skeletal fixator. Ultrasound 3D motion tracking system from Zebris® was used in this study, and the program was developed under the Matlab environment. Cycles of passive elbow flexion/extension motion were carried out for each set of deformity. The data were initially transformed to humerus coordinate, and since the upper arm was not absolutely stationary, its influence on the measured position of ulna was adjusted. With this adjusted data, a best fit plane that would include most of the ulna positions (MU) within a minimal distance was obtained. The rotation axis was calculated as the normal vector to this plane, and the carrying angle could subsequently be assessed according to the relationship between this axis and the x-axis on the xy-plane as well as on the xz-plane. Fresh frozen cadaver study was conducted in the Medical Simulation Center at Tzu-Chi University. After adjustment of the raw data to eliminate the influence of humerus motion, the ulna motion could be narrowed down from a band of 10mm to 3mm, with a significant smaller standard deviation. The rotation axis was obtained by the normal vector to the best fit plane. Two different approaches were attempted to find the plane. In the first method, the plane was obtained via least square method from the adjusted ulna positions, and the second method found the plane via RANSAC method. Calculations were repeated several times for each method, and the results showed a variation of 5 degrees in the first method and about 2 degrees in the second method. Rotational axis can be used to define the 3-dimensional deformity of elbow joint; however, it is difficult to obtain such axis accurately due to hypermobility and multi-directional motion of the shoulder joint. In this study, we have developed another method to assess the elbow deformity using motion analysis system instead of the conventional image studies, and this may be applicable clinically if the facility becomes more accessible in the future. (This research was supported by the project TCRD-TPE-99-30 granted by the Buddhist Tzu-Chi General Hospital, Taipei Branch)

The choice of whether to perform antegrade intramedullary nailing (IMN) or plate fixation (PF) poses a conundrum for the surgeon who must strike the balance between anatomical restoration while reducing elbow and shoulder functional impairment. Most humeral middle third shaft fractures are amenable to conservative management given the considerable acceptable deformity and anatomical compensation by patients. This study is concerned with the patient reported outcomes regarding shoulder and elbow function for IMN and PF respectively. A prospective cohort study following up all the cases treated surgically for middle third humeral fractures from 2016 to 2022 at a single centre. Telephonically an analogue pain score, an American Shoulder and Elbow Society (ASES) score for shoulder function and the Oxford Elbow score (OES) for elbow function were obtained. One hundred and three patients met the inclusion criteria. Twenty four patients participated in the study, fifteen had IMN (62.5%) and nine had PF (37.5%.). The shoulder function outcomes showed no statistical difference with an average ASES score of sixty-six for the IMN group and sixty-nine for the PF group. Women and employed individuals expressed greater functional impairment. Hand dominance has no impact on the scores of elbow and shoulder function post operatively. The impairment of abduction score post antegrade nailing was higher in the antegrade nailing group than the plated group. The OES demonstrated greater variance in elbow function in the PF group with the IMN group expressing greater elbow disfunction. This study confirms that treatment of middle third humerus shaft fractures by plate fixation is marginally superior to antegrade intramedullary nailing in preserving elbow function and abduction ability

Aims. To evaluate the outcomes of terrible triad injuries (TTIs) in mid-term follow-up and determine whether surgical treatment of the radial head influences clinical and radiological outcomes. Methods. Follow-up assessment of 88 patients with TTI (48 women, 40 men; mean age 57 years (18 to 82)) was performed after a mean of 4.5 years (2.0 to 9.4). The Mayo Elbow Performance Score (MEPS), Oxford Elbow Score (OES), and Disabilities of the Arm, Shoulder and Hand (DASH) score were evaluated. Radiographs of all patients were analyzed. Fracture types included 13 Mason type I, 16 type II, and 59 type III. Surgical treatment consisted of open reduction and internal fixation (ORIF) in all type II and reconstructable type III fractures, while radial head arthroplasty (RHA) was performed if reconstruction was not possible. Results. At follow-up the mean MEPS was 87.1 (20 to 100); mean OES, 36.9 (6 to 48); and mean DASH score, 18.6 (0 to 90). Mean movement was 118° (30° to 150°) for extension to flexion and 162° (90° to 180°) for pronation to supination. The overall reoperation rate was 24%, with nine ORIF, ten RHA, and two patients without treatment to the radial head needing surgical revision. When treated with RHA, Mason type III fractures exhibited significantly inferior outcomes. Suboptimal results were also identified in patients with degenerative or heterotopic changes on their latest radiograph. In contrast, more favourable outcomes were detected in patients with successful radial head reconstruction after Mason type III fractures. Conclusion. Using a standardized protocol, sufficient elbow stability and good outcomes can be achieved in most TTIs. Although some bias in treatment allocation, with more severe injuries assigned to RHA, cannot be completely omitted, treatment of radial head fractures may have an independent effect on outcome, as patients subjected to RHA showed significantly inferior results compared to those subjected to reconstruction, in terms of elbow function, incidence of arthrosis, and postoperative complications. As RHA showed no apparent advantage in Mason type III injuries between the two treatment groups, we recommend reconstruction, providing stable fixation can be achieved. Cite this article: Bone Joint J 2020;102-B(12):1620–1628

Aims. The aim of this study was to analyze the results of two radiocapitellar prostheses in a large case series followed prospectively, with medium-term follow-up. Patients and Methods. A total of 31 patients with a mean age of 54 years (27 to 73) were analyzed; nine had primary osteoarthritis (OA) and 17 had post-traumatic OA, three had capitellar osteonecrosis, and two had a fracture. Overall, 17 Lateral Resurfacing Elbow (LRE) and 14 Uni-Elbow Radio-Capitellum Implant (UNI-E) arthroplasties were performed. Pre- and postoperative assessment involved the Mayo Elbow Performance Score (MEPS), the Quick Disabilities of the Arm, Shoulder and Hand (Q-DASH) score, and the modified American Shoulder Elbow Surgeons (m-ASES) score. Results. The mean follow-up was 6.8 years (3.8 to 11.5). The mean MEPS, m-ASES, and Q-DASH scores improved significantly by 50 (p < 0.001), 55 (p < 0.001), and 54 points (p < 0.001), respectively, with no differences being detected between the implants. Preoperative pronation and supination were worse in patients in whom the UNI-E was used. Two patients with the UNI-E implant had asymptomatic evidence of gross loosening. Conclusion. Radiocapitellar arthroplasty yielded a significant improvement in elbow function at a mean follow-up of 6.8 years, with a high implant survival rate when the LRE was used in patients with primary or post-traumatic OA, without radial head deformity, and when the UNI-E was used in patients in whom radial head excision was indicated. Cite this article: Bone Joint J 2019;101-B:1362–1369

The aim of the study is to assess the humero radial plica which could be a factor in causing lateral elbow pain. The cause of lateral elbow pain has been an enigma for the orthopaedic surgeons over the years. The synovial fold of the humeroradial joint has been well documented and considered as a meniscus between the articulation. They can also present as symptoms suggesting intra articular loose bodies causing pain in these patients. Our study included 117 consecutive elbow arthroscopies performed by two surgeons for a period of 18 months. All patients were initially treated non-operatively as a ‘tennis elbow’ before undergoing arthroscopy. Conservative treatment included rest, activity modification, physiotherapy including ultrasound bracing, nsaids and local corticosteroid injection. All patients were assessed using the Mayo clinic performance index for elbows both pre and post operatively. Radial head plica was found in 21(18%) out of 117 elbow arthroscopies and was resected using a soft tissue resector. There were 16 (76%) men and 5(24%) women in this affected group and all of whom were young and active with a mean age 38 years. Of the 21 patients 16(76%) had a post operative score of 90 or more (excellent) and 5(24%) had a score 75–89(good). This study addresses the fact that cause of lateral elbow pain can be due to various pathologies in the elbow and in the cases of ‘resistant tennis elbows’ we recommend that the existence of a radial head synovial plica should be considered and if present treatment should be directed at this. Our study demonstrates that by resecting the synovial plical fold, pain will be relieved and these patients regained elbow function. Since this was noted in the young active age group this could reduce the morbidity and the time for rehabilitation required especially for those involved in active sports. A similar series has not been cited in English literature

Aim: To assess the functional and occupational outcome of open elbow arthrolysis for post-traumatic contractures. Materials and Methods: Prospective evaluation of 60 consecutive cases (86% male,14%female) of post-traumatic extrinsic elbow stiffness. Average age was 37 years (24–48). Moderate to high physical demand at work in 96% of cases. 56% of cases involved the right side. Open arthrolysis (column procedure) trough a lateral (72%) or posterior (28%) approach followed a minimum rehabilitation period of 6 months post original injury. In 8 cases, an anterior transposition of the ulnar nerve was required. Patients received postoperative analgesia with Bupivacaine 0,0125% trough an indwelling catheter. No chemical or radiotherapy ectopic calcification prophylaxis was used. Postoperative complications, range of motion, X-ray evaluation, time to return to work, activity level and workers’ compensation were evaluated at the end of follow-up (24 months, range 12–36). Results: Complications occurred in 14% of cases. Two patients required revision surgery for ectopic calcifications restricting prono-supination. The flexo-extension (FE) arc of motion improved from 49 ° to 115 ° and that of prono-supination (PS) from 100 ° to 158 ° The results were found to be statistically significant for FE (p= 0.054) and PS (p> 0,00001). In 20% of cases, patients returned to their previous job with some restrictions (33% disability) and 12% changed to a less physically demanding occupation. Conclusions: Open arthrolysis is an effective surgical procedure to improve mobility in post-traumatic stiff elbows. It is indicated when the joint interline is preserved. Good functional and occupational outcome in a high percentage of case in the working population was observed

We have previously reported on the medium-term outcomes following a non-operative protocol of a short period of splinting followed by early movement to treat simple dislocations of the elbow. We undertook extended follow up of our original patient study group to determine whether the excellent results previously reported were maintained in the very long-term. A secondary question was to determine the rate and need for any late surgical intervention. We attempted to contact all patients in the original patient study group. Patients were requested to complete the Oxford elbow score (OES), the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire and a validated patient satisfaction questionnaire. Patients were requested to attend a face-to-face assessment where they underwent a clinical examination including neurovascular assessment, range-of-motion and an assessment of ligamentous stability. Seventy-one patients (65%) from the original patient study group agreed to participate in the study. The mean duration of follow-up was 19.3 years. At final follow-up patients reported excellent functional outcome scores and a preserved functional range of movement in the injured elbows. The mean DASH score was 5.22 points and the mean Oxford Elbow Score was 91.6 points. The mean satisfaction score was 90.9 points. Our study shows that the excellent outcomes following treatment with a protocol of a short period of splinting and early movement remain excellent and are maintained into the very long term. These findings support our hypothesis that this treatment protocol is appropriate and suitable for most patients with simple dislocations of the elbow. The role for primary ligamentous repair for this patient group should be carefully considered. Work to more clearly define the anticipated benefits of surgery for specific patient groups or injury patterns would help to support informed decision making

We undertook a prospective, single blinded, randomized, controlled trial of one hundred children treated with either an above or below elbow cast for treatment of closed, distal third forearm fractures requiring reduction. The re-manipulation rate in the below elbow group was 2% (95%CI: 0–11%) compared to 6% (95%CI: 2–15%) in the above elbow group, p=0.62. Above elbow casts do not appear to improve fracture immobilization nor reduce the requirement for re-manipulation in pediatric distal third forearm fractures. Debate exists regarding the benefits of using below elbow casts instead of above elbow casts for maintaining reduction in pediatric distal third forearm fractures. The literature indicates a loss of reduction rate of 14.6% of children treated in an above elbow cast and 2.5% in those treated with a below elbow cast. We undertook a prospective, single blinded, randomized, controlled trial of one hundred children treated with either an above or below elbow cast for treatment of closed, distal third forearm fractures requiring reduction. Outcome measures included re-manipulation rate, fracture displacement during cast wear, and cast complications. One hundred patients were suitably enrolled; fifty-four received an above elbow cast, forty-six received a below elbow cast. The two groups were similar in terms of age and gender. The above elbow group contained a higher proportion of both bone fractures (41/54) than the below elbow group (27/46). There were no significant differences between the two cast groups in initial, post-reduction or cast-off fracture angulation; nor any difference in the amount of fracture displacement during cast wear. The number of cast complications was similar between the two groups. The re-manipulation rate in the below elbow group was 2% (95%CI: 0–11%) compared to 6% (95%CI: 2–15%) in the above elbow group, p=0.62. Above elbow casts do not appear to improve fracture immobilization nor reduce the requirement for re-manipulation in pediatric distal third forearm fractures. Funding Hip Hip Hooray, Saskatoon

Aims. Improvements in the evaluation of outcomes following peripheral nerve injury are needed. Recent studies have identified muscle fatigue as an inevitable consequence of muscle reinnervation. This study aimed to quantify and characterize muscle fatigue within a standardized surgical model of muscle reinnervation. Patients and Methods. This retrospective cohort study included 12 patients who underwent Oberlin nerve transfer in an attempt to restore flexion of the elbow following brachial plexus injury. There were ten men and two women with a mean age of 45.5 years (27 to 69). The mean follow-up was 58 months (28 to 100). Repeated and sustained isometric contractions of the elbow flexors were used to assess fatigability of reinnervated muscle. The strength of elbow flexion was measured using a static dynamometer (KgF) and surface electromyography (sEMG). Recordings were used to quantify and characterize fatigability of the reinnervated elbow flexor muscles compared with the uninjured contralateral side. Results. The mean peak force of elbow flexion was 7.88 KgF (. sd. 3.80) compared with 20.65 KgF (. sd . 6.88) on the contralateral side (p < 0.001). Reinnervated elbow flexor muscles (biceps brachialis) showed sEMG evidence of fatigue earlier than normal controls with sustained (60-second) isometric contraction. Reinnervated elbow flexor muscles also showed a trend towards a faster twitch muscle fibre type. Conclusion. The assessment of motor outcomes must involve more than peak force alone. Reinnervated muscle shows a shift towards fast twitch fibres following reinnervation with an earlier onset of fatigue. Our findings suggest that fatigue is a clinically relevant characteristic of reinnervated muscle. Adoption of these metrics into clinical practice and the assessment of outcome could allow a more meaningful comparison to be made between differing forms of treatment and encourage advances in the management of motor recovery following nerve transfer. Cite this article: Bone Joint J 2019;101-B:867–871

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 purpose of this study was to evaluate the relationships between the degree of injury to the medial and lateral collateral ligaments (MCL and LCL) and associated fractures in patients with a posterolateral dislocation of the elbow, using CT and MRI. Methods. We retrospectively reviewed 64 patients who presented between March 2009 and March 2018 with a posterolateral dislocation of the elbow and who underwent CT and MRI. CT revealed fractures of the radial head, coronoid process, and medial and lateral humeral epicondyles. MRI was used to identify contusion of the bone and collateral ligament injuries by tear, partial or complete tear. Results. A total of 54 patients had a fracture; some had more than one. Radial head fractures were found in 25 patients and coronoid fractures in 42. Lateral and medial humeral epicondylar fractures were found in eight and six patients, respectively. Contusion of the capitellum was found in 43 patients and rupture of the LCL was seen in all patients (partial in eight and complete in 56), there was complete rupture of the MCL in 37 patients, partial rupture in 19 and eight had no evidence of rupture. The LCL tear did not significantly correlate with the presence of fracture, but the MCL rupture was complete in patients with a radial head fracture (p = 0.047) and there was significantly increased association in those without a coronoid fracture (p = 0.015). Conclusion. In posterolateral dislocation of the elbow, LCL ruptures are mostly complete, while the MCL exhibits various degrees of injury, which are significantly associated with the associated fractures. Cite this article: Bone Joint J 2020;102-B(2):227–231

Aims. The Wrightington classification system of fracture-dislocations of the elbow divides these injuries into six subtypes depending on the involvement of the coronoid and the radial head. The aim of this study was to assess the reliability and reproducibility of this classification system. Methods. This was a blinded study using radiographs and CT scans of 48 consecutive patients managed according to the Wrightington classification system between 2010 and 2018. Four trauma and orthopaedic consultants, two post CCT fellows, and one speciality registrar based in the UK classified the injuries. The seven observers reviewed preoperative radiographs and CT scans twice, with a minimum four-week interval. Radiographs and CT scans were reviewed separately. Inter- and intraobserver reliability were calculated using Fleiss and Cohen kappa coefficients. The Landis and Koch criteria were used to interpret the strength of the kappa values. Validity was assessed by calculating the percentage agreement against intraoperative findings. Results. Of the 48 patients, three (6%) had type A injury, 11 (23%) type B, 16 (33%) type B+, 16 (33%) Type C, two (4%) type D+, and none had a type D injury. All 48 patients had anteroposterior (AP) and lateral radiographs, 44 had 2D CT scans, and 39 had 3D reconstructions. The interobserver reliability kappa value was 0.52 for radiographs, 0.71 for 2D CT scans, and 0.73 for a combination of 2D and 3D reconstruction CT scans. The median intraobserver reliability was 0.75 (interquartile range (IQR) 0.62 to 0.79) for radiographs, 0.77 (IQR 0.73 to 0.94) for 2D CT scans, and 0.89 (IQR 0.77 to 0.93) for the combination of 2D and 3D reconstruction. Validity analysis showed that accuracy significantly improved when using CT scans (p = 0.018 and p = 0.028 respectively). Conclusion. The Wrightington classification system is a reliable and valid method of classifying fracture-dislocations of the elbow. CT scans are significantly more accurate than radiographs when identifying the pattern of injury, with good intra- and interobserver reproducibility. Cite this article: Bone Joint J 2020;102-B(8):1041–1047

The role of anconeus in elbow stability has been a long-standing debate. Anatomical and electromyographic studies have suggested a potential role as a stabilizer. However, to our knowledge, no clinical or biomechanical studies have investigated its role in improving the stability of a lateral collateral ligament (LCL) deficient elbow. Seven cadaveric upper extremities were mounted in an elbow motion simulator in the varus position. An LCL injured model was created by sectioning of the common extensor origin, and the LCL. The anconeus tendon and its aponeurosis were sutured in a Krackow fashion and tensioned to 10N and 20N through a transosseous tunnel at its origin. Varus-valgus angles and ulnohumeral rotations were recorded using an electromagnetic tracking system during simulated active elbow flexion with the forearm pronated and supinated. During active motion, the injured model resulted in a significant increase in varus angulation (5.3°±2.9°, P=.0001 pronation, 3.5°±3.4°, P=.001 supination) and external rotation (ER) (8.6°±5.8°, P=.001 pronation, 7.1°±6.1°, P=.003 supination) of the ulnohumeral articulation compared to the control state (varus angle −2.8°±3.4° pronation, −3.3°±3.2° supination, ER angle 2.1°±5.6° pronation, 1.6°±5.8° supination). Tensioning of the anconeus significantly decreased the varus angulation (−1.2°±4.5°, P=.006 for 10N in pronation, −3.9°±4°, P=.0001 for 20N in pronation, −4.3°±4°, P=.0001 for 10N in supination, −5.3°±4.2°, P=.0001 for 20N in supination) and ER angle (2.6°±4.5°, P=.008 for 10N in pronation, 0.3°±5°, P=.0001 for 20N in pronation, 0.1°±5.3°, P=.0001 for 10N in supination, −0.8°±5.3°, P=.0001 for 20N in supination) of the injured elbow. Comparing anconeus tensioning to the control state, there was no significant difference in varus-valgus angulation except with anconeus tensioning to 20N with the forearm in supination which resulted in less varus angulation (P=1 for 10N in pronation, P=.267 for 20N in pronation, P=.604 for 10N in supination, P=.030 for 20N in supination). Although there were statistically significant differences in ulnohumeral rotation between anconeus tensioning and the control state (except with anconeus tensioning to 10N with the forearm in pronation which was not significantly different), anconeus tensioning resulted in decreased external rotation angle compared to the control state (P=1 for 10N in pronation, P=.020 for 20N in pronation, P=.033 for 10N in supination, P=.001 for 20N in supination). In the highly unstable varus elbow orientation, anconeus tensioning restores the in vitro stability of an LCL deficient elbow during simulated active motion with the forearm in both pronation and supination. Interestingly, there was a significant difference in varus-valgus angulation between 20N anconeus tensioning with the forearm supinated and the control state, with less varus angulation for the anconeus tensioning which suggests that loads less than 20N is sufficient to restore varus stability during active motion with the forearm supinated. Similarly, the significant difference observed in ulnohumeral rotation between anconeus tensioning and the control state suggests that lesser degrees of anconeus tensioning would be sufficient to restore the posterolateral instability of an LCL deficient elbow. These results may have several clinical implications such as a potential role for anconeus strengthening in managing symptomatic lateral elbow instability

Aims. We assessed the long-term (more than ten-year) outcomes of the Kudo type-5 elbow prosthesis in patients with rheumatoid arthritis (RA). Materials and Methods. We reviewed 41 elbows (Larsen Grade IV, n = 21; Grade V, n = 20) in 31 patients with RA who had undergone a Kudo type-5 total elbow arthroplasty (TEA) between 1994 and 2003, and had been followed up for more than ten years. The humeral component was cementless and the all-polyethylene ulnar component cemented in every patient. Clinical outcome was assessed using the Mayo elbow performance score. We calculated the revision rate and evaluated potential risk factors for revision. The duration of follow-up was a mean 141 months (120 to 203). Results. Aseptic loosening of the ulnar component occurred in 11 elbows. There was no radiolucency around any humeral component. There was one deep infection. The survival rate according to Kaplan-Meier survivorship analysis was 87.8% after five years and 70.7% after ten years. The range of extension/flexion was a mean -38° (-80° to 0°)/105° (30° to 150°) before surgery and -40° (-70° to -20°)/132° (100° to 150°) at the final follow-up, while the mean Mayo elbow performance score was 43 before surgery and 80 at final follow-up. Disease duration of RA up to the TEA of < 15 years and a pre-operative range of movement (ROM) of > 85° were significant risk factors for revision or aseptic loosening. Conclusion. Although Kudo type-5 prostheses gave satisfactory results in the short-term, aseptic loosening increased after five years. In most cases, elbow function was maintained in the long-term without loosening of the implant. A short duration from the onset of RA to TEA and a large pre-operative ROM were significant risk factors for revision or aseptic loosening. Cite this article: Bone Joint J 2017;99-B:818–23

Purpose: The purpose of this study is to evaluate the arthroscopic findings in patients who presented with persistent lateral elbow pain despite conventional conservative measures, with special regard to diagnosis specific results. The controversy regarding the etiopathogenesis, whether intraarticular, extraarticular or both continues to exist. Method: This is a retrospective review of 280 arthroscopies of elbow in 262 patients over a period of 6 years with a minimum follow-up of 6 months. All of them are therapeutic procedures involving ECRB release, excision of plica, synovectomy or debridement of the joint. The functional outcome was assessed and recorded independently by two experienced upper limb physiotherapists using the Mayo elbow performance score. Results: Dominant hand was involved in 68% of the cases. The average age was 54 years. Isolated pathology such as common extensor inflammation was identified in 138 (49%), synovial plica in 24 (8%) and degenerative changes confined to lateral compartment with normal appearance of articular cartilage of medial compartment is noted in 31 (11%). In the rest mixed pathology with various combinations were identified. Conclusion: Good to excellent results were seen in those with isolated common extensor inflammation and poor outcomes were noted in 20 (7%) of patients and the common intraoperative finding seen was degenerative changes of radiocapitellar joint. This was found to be statistically significant

We report the technique and results of a new method of debridement arthroplasty for advanced primary osteoarthritis of the elbow. Triceps and the periosteum of the olecranon are reflected towards the ulnar side and the joint is opened by dividing the radial collateral ligament. Osteophytes are removed, the olecranon and coronoid fossae are deepened and the fibrosed anterior joint capsule is excised. The degenerative changes are always more advanced on the radial side, with erosion of the capitellum, and it is usually necessary to remodel the head of the radius. In 29 elbows reviewed at a mean of 64 months, the average gain of range of motion was 34 degrees, with good pain relief and improved grip in most patients. Two elbows required reoperation but there were no other serious complications

Surgical debridement for medial epicondylitis (ME) is indicated for patients with refractory ME. The clinical efficacy of simple debridement has not been studied sufficiently. Moreover, authors experienced surgical outcome of ME was not as good as lateral epicondylitis. In this regard, authors have combined the atelocollagen injection in the debridement surgery of ME. The purpose of study was to compare clinical outcomes between simple debridement and debridement combined with atelocollagen injection in the ME. Twenty-five patients with refractory ME and underwent surgical debridement were included in the study. Group A (n=13) was treated with isolated debridement surgery, and group B (n=12) was treated with debridement combined with 1.0 mL of type I atelocollagen. Pain and functional improvements were assessed using visual analogue scale, Mayo Elbow Performance Score (MEPS) and quick Disabilities of the Arm, Shoulder and Hand (DASH) scale respectively before surgery, at 3, 6 months after surgery and at the final follow-up. Demographic data did not show significant difference between two groups before surgical procedures. Both groups showed improvement in pain and functional score postoperatively. However, at the 3 months after surgery, group B showed significantly better improvement as compared to group A(VAS 3.1 / 2.0, MEPS 71/82 qDASH 29/23). At the 6 months after surgery and final follow-up, both groups did not show any difference. Surgical debridement combined with atelocollagen is effective treatment option in refractory ME and showed better short-term outcomes compared to isolated surgery

Aims. The aim of this study was to evaluate two hypotheses. First, that disruption of posterior bundle of the medial collateral ligament (PMCL) has to occur for the elbow to subluxate in cases of posteromedial rotatory instability (PMRI) and second, that ulnohumeral contact pressures increase after disruption of the PMCL. Materials and Methods. Six human cadaveric elbows were prepared on a custom-designed apparatus which allowed muscle loading and passive elbow motion under gravitational varus. Joint contact pressures were measured sequentially in the intact elbow (INTACT), followed by an anteromedial subtype two coronoid fracture (COR), a lateral collateral ligament (LCL) tear (COR + LCL), and a PMCL tear (COR + LCL + PMCL). Results. There was no subluxation or joint incongruity in the INTACT, COR, and COR + LCL specimens. All specimens in the COR + LCL + PMCL group subluxated under gravity-varus loads. The mean articular contact pressure of the COR + LCL group was significantly higher than those in the INTACT and the COR groups. The mean articular contact pressure of the COR + LCL + PMCL group was significantly higher than that of the INTACT group, but not higher than that of the COR + LCL group. Conclusion. In the presence of an anteromedial fracture and disruption of the LCL, the posterior bundle of the MCL has to be disrupted for gross subluxation of the elbow to occur. However, elevated joint contact pressures are seen after an anteromedial fracture and LCL disruption even in the absence of such subluxation. Cite this article: Bone Joint J 2018;100-B:1060–5

Previous biomechanical studies of lateral collateral ligament (LCL) injuries and their surgical repair, reconstruction and rehabilitation have primarily relied on gravity effects with the arm in the varus position. The application of torsional moments to the forearm manually in the laboratory is not reproducible, hence studies to date likely do not represent forces encountered clinically. The aim of this investigation was to develop a new biomechanical testing model to quantify posterolateral stability of the elbow using an in vitro elbow motion simulator. Six cadaveric upper extremities were mounted in an elbow motion simulator in the varus position. A threaded screw was then inserted on the dorsal aspect of the proximal ulna and a weight hanger was used to suspend 400g, 600g, and 800g of weight from the screw head to allow torsional moments to be applied to the ulna. An LCL injured (LCLI) model was created by sectioning of the common extensor origin, and the LCL. Ulnohumeral rotation was recorded using an electromagnetic tracking system during simulated active and passive elbow flexion with the forearm pronated and supinated. A repeated measures analysis of variance was performed to compare elbow states (intact, LCLI, and LCLI with 400g, 600g, and 800g of weight). During active motion, there was a significant difference between different elbow states (P=.001 pronation, P=.0001 supination). Post hoc analysis showed that the addition of weights did not significantly increase the external rotation (ER) of the ulnohumeral articulation (10°±7°, P=.268 400g, 10.5°±7.1°, P=.156 600g, 11°±7.2°, P=.111 800g) compared to the LCLI state (8.4°±6.4°) with the forearm pronated. However, with the forearm supinated, the addition of 800g of weight significantly increased the ER (9.2°±5.9°, P=.038) compared to the LCLI state (5.9°±5.5°) and the addition of 400g and 600g of weights approached significance (8.2°±5.7°, P=.083 400g, 8.7°±5.9°, P=.054 600g). During passive motion, there was a significant difference between different elbow states (P=.0001 pronation, P=.0001 supination). Post hoc analysis showed that the addition of 600g and 800g but not 400g resulted in a significant increase in ER of the ulnohumeral articulation (9.3°±7.8°, P=.103 400g, 11.2°±6.2°, P=.004 600g, 12.7°±6.8°, P=.006 800g) compared to the LCLI state (3.7°±5.4°) with the forearm pronated. With the forearm supinated, the addition of 400g, 600g, and 800g significantly increased the ER (11.7°±6.7°, P=.031 400g, 13.5°±6.8°, P=.019 600g, 14.9°±6.9°, P=.024 800g) compared to the LCLI state (4.3°±6.6°). This investigation confirms a novel biomechanical testing model for studying PLRI. Moreover, it demonstrates that the application of even small amounts of torsional moment on the forearm with the arm in the varus position exacerbates the rotational instability seen with the LCL deficient elbow. The effect of torsional loading was significantly worse with the forearm supinated and during passive elbow motion. This new model allows for a more provocative testing of elbow stability after LCL repair or reconstruction. Furthermore, this model will allow for smaller sample sizes to be used while still demonstrating clinically significant differences. Future biomechanical studies evaluating LCL injuries and their repair and rehabilitation should consider using this testing protocol

A total of 14 women and seven men with a mean age of 43 years (18 to 68) who sustained a Mason type IV fracture of the elbow, without an additional type II or III coronoid fracture, were evaluated after a mean of 21 years (14 to 46). Primary treatment included closed elbow reduction followed by immobilisation in a plaster in all cases, with an additional excision of the radial head in 11, partial resection in two and suturing of the annular ligament in two. Delayed radial head excision was performed in two patients and an ulnar nerve transposition in one. The uninjured elbows served as controls. Nine patients had no symptoms, 11 reported slight impairment, and one severe impairment of the elbow. Elbow flexion was impaired by a mean of 3° (. sd. 4) and extension by a mean of 9° (. sd. 4) (p < 0.01). None experienced chronic elbow instability or recurrent dislocation. There were more degenerative changes in the formerly injured elbows, but none had developed a reduction in joint space. We conclude that most patients with a Mason type IV fracture of the elbow report a good long-term outcome

This study reports our experience with total elbow replacement for fused elbows. Between 1982 and 2004, 13 patients with spontaneously ankylosed elbows were treated with a linked semi-constrained non-custom total elbow implant. The mean age at operation was 54 years (24 to 80). The stiffness was a result of trauma in ten elbows, juvenile rheumatoid arthritis in one, and rheumatoid arthritis in two. The patients were followed for a mean of 12 years (2 to 26) and were evaluated clinically using the Mayo Elbow Performance Score, as well as radiologically. A mean arc from 37° of extension to 118° of flexion was achieved. Outcomes were good or excellent for seven elbows at final review. Ten patients felt better or much better after total elbow replacement. However, there was a high complication rate and re-operation was required in over half of patients. Two developed peri-operative soft-tissue breakdown requiring debridement. A muscle flap with skin grafting was used for soft-tissue cover in one. Revision was undertaken in one elbow following fracture of the ulnar component. Three patients developed a deep infection. Three elbows were manipulated under anaesthesia for post-operative stiffness. Prophylactic measures for heterotopic ossification were unsuccessful. Total elbow replacement for the ankylosed elbow should be performed with caution. However, the outcome can be reliable in the long term and have a markedly positive impact on patient function and satisfaction. The high potential for complications must be considered. We consider total elbow replacement to be an acceptable procedure in selected patients with reasonable expectations

Aims. Revision total elbow arthroplasty (TEA) is often challenging. The aim of this study was to report on the clinical and radiological results of revision arthroplasty of the elbow with the Latitude TEA. Patients and Methods. Between 2006 and 2010 we used the Latitude TEA for revision in 18 consecutive elbows (17 patients); mean age 53 years (28 to 80); 14 women. A Kudo TEA was revised in 15 elbows and a Souter-Strathclyde TEA in three. Stability, range of movement (ROM), visual analogue score (VAS) for pain and functional scores, Elbow Functional Assessment Scale (EFAS), the Functional Rating Index of Broberg and Morrey (FRIBM) and the Modified Andrews’ Elbow Scoring System (MAESS) were assessed pre-operatively and at each post-operative follow-up visit (six, 12 months and biennially thereafter). Radiographs were analysed for loosening, fractures and dislocation. The mean follow-up was 59 months (26 to 89). Results. The ROM of the elbow did not improve significantly. The mean EFAS and MAESS scores improved significantly six months post-operatively (18.6 points, standard deviation (. sd. ) 7.7; p = 0.03 and 28.8 points, . sd . 8.6; p = 0.006, respectively) and continued to improve slightly or reached a plateau. The mean pain scores at rest (Z = -3.2, p = 0.001) and during activity (Z = -3.2, p = 0.001), and stability (Z = -3.0, p = 0.003) improved significantly six months post-operatively. Thereafter scores continued to improve slightly or a plateau was reached. There were no signs of loosening. Conclusion. Revision surgery using the Latitude TEA results in improvement of functionality, reduced pain and better stability of the elbow. Improvement of ROM of the elbow should not be expected. Cite this article: Bone Joint J 2016;98-B:1086–92

Driven by increasing emphasis on problem-based and self-directed learning, medical students and doctors in orthopedic specialty training rely increasingly on the internet as learning resource. As students or residents performance on physical examination may be less supervised in comparison to other clinical skills (for example surgical competence), online videos may provide a valuable source for education of physical examination skills. Cognitive psychological research has shown that videos can help viewers to understand techniques and manage the sequential steps of physical examination and approach to patients. YouTube is the largest open-access video platform available and provides access to thousands of educational videos on orthopedics-related topics. VuMedi, G9MD, and Orthobullets are examples of online platforms requiring user-registration with video content that is more directly focused on orthopedic topics. The objective of this study was to investigate the accuracy and quality of instructional videos on the physical examination of the elbow and identify factors influencing the educational usefulness. A YouTube, VuMedi, Orthobullets, and G9MD search was performed on October 7, 2018 for videos on the physical examination of the elbow. We included both basic examination and disease specific tests. The included videos were rated for accuracy and quality by two independent authors using a modified version of a validated scoring system. Inter-rater reliability was analyzed using mean difference and intra-class correlation coefficient. Twenty-three out of 126 videos were indicated as useful for educational purposes. Accuracy, quality and total scores were statistically significant higher for videos from specialized platforms compared to YouTube: 16.5 (95% CI 16 to 17) vs. 12.816 (95% CI 12.3 to 13.3) respectively. Video accuracy and quality were highly variable and did not correlate. The number of days online, views, and likes showed no or weak correlation with accuracy and quality. For the total score, our assessment tool showed excellent inter-rater reliability of 0.93 (95% CI 0.09–0.95) and a mean difference of 0.024 point between the two observers (p=0.871). There is considerable variation in accuracy and quality of online available videos on the physical examination of the elbow. We indicated 23 educationally useful videos and provided an assessment method. This assessment method can be useful for both viewers to assess reliability of a video and educators interested in creating videos

Advancements in treating the unstable elbow. We will review and discuss the kinematics and biomechanics of the forearm, concentrating on the role of soft tissue structures and how they affect forearm and elbow function. During this session, we will review the latest techniques for treating the terrible triad, including solutions to complex injuries of the olecranon, coronoid, and radial head. Techniques presented will address fixation, reconstruction, and salvaging of complex unstable elbow injuries

Elevated fat pads on a paediatric elbow radiograph may represent an intraarticular fracture. If no obvious fracture is visible, the injury may be treated with a collar and cuff until discomfort resolves. In some centres these patients are discharged directly from A&E, easing the load on fracture clinics and reducing the number of visits required by the patient. A retrospective study was carried out to review patient journey for children referred to clinic with elevated fat pads only and to investigate whether such a protocol could be established locally. Notes for all children attending fracture clinic in May 2018 were reviewed. X-rays for patients with any elbow injury were then reviewed. Patients with raised fat pads only were included in the study. Outcome following clinic review was recorded. 818 patients (315 new referrals) attended 15 clinics. 31 were referred with raised fat pads only. Mean age was 7.7 years with mean time to clinic of 4 days. 74.2% required no further treatment and were discharged at first clinic appointment. 8 patients were kept in cast for another 1–2 weeks due to parental apprehension, patient apprehension or patient being uncomfortable without cast. None of our patients required surgical intervention or re-attended following discharge. This study showed that patients with raised fat pads only can be treated with collar and cuff, analgesia and discharged from A&E with an advice leaflet. This would reduce the number of patients unnecessarily attending clinics thereby reducing patient distress and enabling more efficient use of clinic appointments

Postero-lateral rotator instability (PLRI) is the most common pattern of recurrent elbow instability. Unfortunately, current imaging to aid PLRI diagnosis is limited. We have developed an ultrasound (US) technique to measure ulnohumeral joint gap with and without stress of the lateral ulnocollateral ligament. We sought to define lateral ulnohumeral joint gap measurements in the resting and stressed state to provide insight into how US may aid diagnosis of PLRI. Sixteen elbows were evaluated in eight healthy volunteers. Lateral ulnohumeral gap was measured on US in the resting position and with posterolateral drawer stress test maneuver applied. Joint laxity was calculated as the difference between stress and rest conditions. Measurements were performed by two independent readers with comparison performed between stress and rest positions. A highly significant difference in ulnohumeral gap was seen between stress and rest conditions (Reader 1: p < 0 .0001 and Reader 2: p=0.0002) with median values of 2.93 mm and 2.50 mm at rest and 3.92 mm and 3.40 mm at stress for Reader 1 and 2 respectively. Median joint laxity was 1.02 mm and 0.74 mm respectively for each reader. Correlation and agreement between readers was good. This study provides key new insight into use of US for diagnosis as PLRI as it defines normal ulnohumeral distances and demonstrates widening when applying the posterolateral drawer stress maneuver. Further evaluation of this technique is required in patients with PLRI

We evaluated the morphological changes to the ulnar nerve of both elbows in the cubital tunnel by sonography in a total of 237 children, of whom 117 were aged between six and seven years, 66 between eight and nine years, and 54 between ten and 11 years. We first scanned longitudinally in the extended elbow and then transversely at the medial epicondyle with the elbow extended to 0°. We repeated the scans with the elbow flexed at 45°, 90°, and 120°. There were no significant differences in the area of the ulnar nerve, but the diameter increased as the elbow moved from extension to flexion in all groups. More importantly, the ulnar nerve was subluxated anteriorly on to the medial epicondyle by 1.5% to 1.9% in extended elbows, by 5.9% to 7.9% in those flexed to 45°, by 40.0% to 44% in those flexed to 90°, and by 57.4% to 58.1% in those flexed to 120°, depending on the age group. Sonography clearly and accurately showed the ulnar nerve and was useful for localising the nerve before placing a medial pin. Because the ulnar nerve may translate anteriorly onto the medial epicondyle when the elbow is flexed to 90° or more, it should never be overlooked during percutaneous medial pinning

The causes of a stiff elbow are numerous including: post-traumatic elbow, burns, head injury, osteoarthritis, inflammatory joint disease and congenital. Types of stiffness include: loss of elbow flexion, loss of elbow extension and loss of forearm rotation. All three have different prognoses in terms of the timing of surgery and the likelihood of restoration of function. Contractures can be classified into extrinsic and intrinsic (all intrinsic develop some extrinsic component). Functional impairment can be assessed medicolegally; however, in clinical practice the patient puts an individual value on the arc of motion. Objectively most functions can be undertaken with an arc of 30 to 130 degrees. The commonest cause of a Post-traumatic Stiff elbow is a radial head fracture or a complex fracture dislocation. Risk factors for stiffness include length of immobilisation, associated fracture with dislocation, intra-articular derangement, delayed surgical treatment, associated head injury, heterotopic ossification. Early restoration of bony columns and joint stability to allow early mobilisation reduces incidence of joint stiffness. Heterotopic ossification (HO) is common in fracture dislocation of the elbow. Neural Axis trauma alone causes HO in elbows in 5%. However, combined neural trauma and elbow trauma the incidence is 89%. Stiffness due to thermal injury is usually related to the degree rather than the site. The majority of patients have greater than 20% total body area involved. Extrinsic contractures are usually managed with a sequential release of soft tissues commencing with a capsular excision (retaining LCL/MCL), posterior bundle of the MCL +/− ulna nerve decompression (if there is loss of flexion to 100 degrees). This reliably achieved via a posterior incision, a lateral column exposure +/− ulna nerve mobilisation. A medial column exposure is a viable alternative. Arthroscopic capsular release although associated with a quicker easier rehabilitation is associated with increased neural injury. Timing of release is specific to the type of contracture, i.e. flexion contractures after approx. six months, extension contractures ASAP but after four months, loss of forearm rotation less 6 to 24 months. The use of Hinged Elbow Fixators is increasing. The indications include reconstructions that require protection whilst allowing early movement, persistent instability or recurrent/late instability or interposition arthroplasty. Post-operative rehabilitation requires good analgesia, joint stability and early movement. The role of CPM is often helpful but still being evaluated

We retrospectively assessed the value of identifying impinging osteophytes using dynamic computer simulation of CT scans of the elbow in assisting their arthroscopic removal in patients with osteoarthritis of the elbow. A total of 20 patients were treated (19 men and one woman, mean age 38 years (19 to 55)) and followed for a mean of 25 months (24 to 29). We located the impinging osteophytes dynamically using computerised three-dimensional models of the elbow based on CT data in three positions of flexion of the elbow. These were then removed arthroscopically and a capsular release was performed. The mean loss of extension improved from 23° (10° to 45°) pre-operatively to 9° (0° to 25°) post-operatively, and the mean flexion improved from 121° (80° to 140°) pre-operatively to 130° (110° to 145°) post-operatively. The mean Mayo Elbow Performance Score improved from 62 (30 to 85) to 95 (70 to 100) post-operatively. All patients had pain in the elbow pre-operatively which disappeared or decreased post-operatively. According to their Mayo scores, 14 patients had an excellent clinical outcome and six a good outcome; 15 were very satisfied and five were satisfied with their post-operative outcome. We recommend this technique in the surgical management of patients with osteoarthritis of the elbow. Cite this article: Bone Joint J 2014;96-B:237–41

Aims. The aim of the study was to analyze the results of primary tendon reinsertion in acute and chronic distal triceps tendon ruptures (DTTRs) in the general population. Patients and Methods. A total of 28 patients were operated on for primary DTTR reinsertions, including 21 male patients and seven female patients with a mean age of 45 years (14 to 76). Of these patients, 23 sustained an acute DTTR and five had a chronic injury. One patient had a non-simultaneous bilateral DTTR. Seven patients had DTTR-associated ipsilateral fracture or dislocation. Comorbidities were present in four patients. Surgical treatment included transosseous and suture-anchors reinsertion in 22 and seven DTTRs, respectively. The clinical evaluation was performed using Mayo Elbow Performance Score (MEPS), the modified American Shoulder and Elbow Surgeons Score (m-ASES), the Quick Disabilities of the Arm, Shoulder and Hand score (QuickDASH), and the Medical Research Council (MRC) Scale. Results. A total of 27 patients (28 DTTRs) were available for review at a mean of 47.5 months (12 to 204). The mean MEPS, QuickDASH, and m-ASES scores were 94 (60 to 100), 10 (0 to 52), and 94 (58 to 100), respectively. Satisfactory results were observed in 26 cases (93%). Muscle strength was 5/5 and 4/5 in 18 and ten DTTRs, respectively. One patient with chronic renal failure experienced a traumatic rerupture of distal triceps. One patient (1 DTTR) experienced mild elbow stiffness. Conclusion. Primary repair of acute and chronic DTTRs in a general population yields satisfactory results in the majority of patients with a low rerupture rate. Cite this article: Bone Joint J 2018;100-B:610–16

We report the effectiveness of revision of total elbow replacement by re-cementing. Between 1982 and 2004, 53 elbows in 52 patients were treated with re-cementing of a total elbow replacement into part or all of the existing cement mantle or into the debrided host-bone interface, without the use of structural bone augmentation or a custom prosthesis. The original implant revision was still in situ and functional in 42 of 53 elbows (79%) at a mean of 94.5 months (26 to 266) after surgery. In 31 of these 42 elbows (74%) the Mayo Elbow Performance Score was good or excellent. Overall, of the 53 elbows, 18 (34%) required re-operation, ten (19%) for loosening. A classification system was developed to identify those not suitable for revision by this technique, and using this we have showed that successful re-implantation is statistically correlated to properly addressing the bone deficiency for both the humeral (p = 0.005) and the ulnar (p = 0.039) components

Introduction. The stability of the elbow joint following an acute elbow dislocation is dependent on associated injuries. The ability to identify these concomitant injuries correctly directs management and improves the chances of a successful outcome. Interpretation of plain radiographs in the presence of either a dislocation or post-reduction films with plaster in-situ is difficult. This study aimed to assess the ability of orthopaedic registrars to accurately identify associated bony injuries on initial plain radiographs using CT as the gold standard for comparison. Methods. Patients over the age of 16 years undergoing an elbow CT scan within one week of a documented elbow dislocation between 1st June 2010 and 1st June 2014 were included in the study. Three orthopaedic registrars independently reviewed both the initial dislocation and immediate post reduction plain radiographs to identify any associated bony injuries. This radiograph review was repeated by each registrar after two weeks. The incidence of associated injuries as well as the inter- and intra-observer variability was calculated. Results. 28 patients were included in the study. 54% of the patients were female and the mean age was 45 years (range 16 to 90 years). The incidence of a radial head fracture was 54%, coronoid fracture 43% and epicondyle avulsion 18% on CT. The inter-observer reliability was only shown to be fair amongst registrars and the intra-observer variability moderate. Conclusions. Computerised tomography is a useful adjunct in the assessment of associated osseous injuries following an elbow dislocation due to the presence of a high number of injuries. Plain radiographs alone have been shown to have only a fair and moderate inter and intra-observer variability respectively, therefore a low threshold to obtain further 3D imaging should be practised. Level of Evidence. IV

Our aim was to determine the clinical value of MRI and CT arthrography in predicting the presence of loose bodies in the elbow. A series of 26 patients with mechanical symptoms in the elbow had plain radiography, MRI and CT arthrography, followed by routine arthroscopy of the elbow. The location and number of loose bodies determined by MRI and CT arthrography were recorded. Pre-operative plain radiography, MRI and CT arthrography were compared with arthroscopy. Both MRI and CT arthrography had excellent sensitivity (92% to 100%) but low to moderate specificity (15% to 77%) in identifying posteriorly-based loose bodies. Neither MRI nor CT arthrography was consistently sensitive (46% to 91%) or specific (13% to 73%) in predicting the presence or absence of loose bodies anteriorly. The overall sensitivity for the detection of loose bodies in either compartment was 88% to 100% and the specificity 20% to 70%. Pre-operative radiography had a similar sensitivity and specificity of 84% and 71%, respectively. Our results suggest that neither CT arthrography nor MRI is reliable or accurate enough to be any more effective than plain radiography alone in patients presenting with mechanical symptoms in the elbow

Between 1996 and 2008, nine patients with severe post-traumatic arthritis underwent revision of a failed interposition arthroplasty of the elbow with a further interposition procedure using an allograft of tendo Achillis at a mean of 5.6 years (0.7 to 13.1) after the initial procedure. There were eight men and one woman with a mean age of 47 years (36 to 56). The mean follow-up was 4.7 years (2 to 8). The mean Mayo Elbow Performance score improved from 49 (15 to 65) pre-operatively to 73 (55 to 95) (p = 0.04). The mean Disability of the Arm, Shoulder and Hand score was 26 (7 to 42). One patient was unavailable for clinical follow-up and one underwent total elbow replacement three months post-operatively. Of the remaining patients, one had an excellent, two had good, three fair and one a poor result. Subjectively, five of the nine patients were satisfied. Four continued manual labour. Revision interposition arthroplasty is an option for young, active patients with severe post-traumatic arthritis who require both mobility and durability of the elbow

Aims. Improvements in the evaluation of outcome after nerve transfers are required. The assessment of force using the Medical Research Council (MRC) grades (0 to 5) is not suitable for this purpose. A ceiling effect is encountered within MRC grade 4/5 rendering this tool insensitive. Our aim was to show how the strength of flexion of the elbow could be assessed in patients who have undergone a re-innervation procedure using a continuous measurement scale. Methods. A total of 26 patients, 23 men and three women, with a mean age of 37.3 years (16 to 66), at the time of presentation, attended for review from a cohort of 52 patients who had undergone surgery to restore flexion of the elbow after a brachial plexus injury and were included in this retrospective study. The mean follow-up after nerve transfer was 56 months (28 to 101, standard deviation (. sd. ) 20.79). The strength of flexion of the elbow was measured in a standard outpatient environment with a static dynamometer. Results. In total, 21 patients (81%) gained MRC grade 4 strength of flexion of the elbow. The mean force of flexion was 7.2 kgf (3 to 15.5, . sd. 3.3). Conclusion. This study establishes that the dynamometer may be used for assessing the strength of flexion of the elbow in the outpatient department after nerve reconstructive surgery. Cite this article: Bone Joint J 2016;98-B:1517–20

We developed a questionnaire to assess patient-reported outcome after surgery of the elbow from interviews with patients. Initially, 17 possible items with five response options were included. A prospective study of 104 patients (107 elbow operations) was carried out to analyse the underlying factor structure, dimensionality, internal and test-retest reliability, construct validity and responsiveness of the questionnaire items. This was compared with the Mayo Elbow performance score clinical scale, the Disabilities of the Arm, Shoulder and Hand questionnaire, and the Short-Form (SF-36) General Health Survey. In total, five questions were considered inappropriate, which resulted in the final 12-item questionnaire, which has been referred to as the Oxford elbow score. This comprises three unidimensional domains, ‘elbow function’, ‘pain’ and ‘social-psychological’; with each domain comprising four items with good measurement properties. This new 12-item Oxford elbow score is a valid measure of the outcome of surgery of the elbow

Aims. We describe the use of a protocol of irrigation and debridement (I& D) with retention of the implant for the treatment of periprosthetic infection of a total elbow arthroplasty (TEA). This may be an attractive alternative to staged re-implantation. . Patients and Methods. Between 1990 and 2010, 23 consecutive patients were treated in this way. Three were lost to follow-up leaving 20 patients (21 TEAs) in the study. There were six men and 14 women. Their mean age was 58 years (23 to 76). The protocol involved: component unlinking, irrigation and debridement (I& D), and the introduction of antibiotic laden cement beads; organism-specific intravenous antibiotics; repeat I& D and re-linkage of the implant if appropriate; long-term oral antibiotic therapy. . Results. The mean follow-up was 7.1 years (2 to 16). The infecting micro-organisms were Staphylococcus aureus in nine, coagulase-negative Staphylococcus in 13, Corynebacterium in three and other in six cases. Re-operations included three repeat staged I& Ds, two repeat superficial I& Ds and one fasciocutaneous forearm flap. One patient required removal of the implant due to persistent infection. All except three patients rated their pain as absent or mild. Outcome was rated as good or excellent in 15 patients (mean Mayo Elbow Performance Score 78 points, (5 to 100) with a mean flexion-extension arc of 103° (40° to 150°)). . Conclusion. A staged protocol can be successful in retaining stable components of an infected TEA. Function of the elbow may compare unfavourably to that after an uncomplicated TEA. Cite this article: Bone Joint J 2016;98-B:976–83

Background. The pattern of appearance of secondary ossification centers in the elbow has been based on historical studies and is popularly referred to with the mnemonic CRITOL. However the six secondary ossification centers can be variable in their presentation and pose a challenge in assessment of children with elbow injuries. Furthermore limited studies available in the current literature have reported an aberration to the sequence of appearance especially with the ossification centers of trochlea and olecranon. Aims. The aim of the study was to evaluate the relative sequence of appearance of secondary ossification centers for the trochlea and olecranon. Methods. Children between 8 and 10 years of age who had radiographs of elbow following trivial trauma between July 2013 and Feb 2015 were identified using the hospital PACS database. Cases with radiographic markers of significant trauma ie. fat pad sign, displaced fracture were excluded. Anteroposterior and lateral views of elbow were reviewed for the presence of the six ossification centers. Results. A total of 114 radiographs were reviewed of which 51 were boys and 63 were girls with a mean age of 9.03 years (±0.59). 60 radiographs were of right elbow and 54 were of the left elbow. The capitulum, radial head and medial epicondyle ossification centers were present in all patients. Both trochlea and olecranon ossification centers were noted in 51/114 (44.7%) children. 12/114 (10.5%) of the children were noted to have trochlea ossification center with no olecranon ossification center. Of these 12 children 7 were boys and 5 were girls. On the other hand 19/114 (16.7%) of the children had an olecranon ossification center but without a trochlea ossification center. Amongst these 7 were boys and 12 were girls. Discussion and Conclusions. The results of this limited cross sectional study demonstrate that the CRITOL sequence may not followed in 16.7% of cases and more so in girls. Historical studies were based on conventional radiographs. However the current digital radiographs with image enhancement tools help in accurate identification of relatively small ossification centers which may not be apparent on conventional radiographs. The current study has helped to quantify the violators to CRITOL sequence. Level of Evidence. Level III (Cross-sectional study among non-consecutive patients)

Introduction. The epicondylar axis of the elbow is a surface anatomical approximation of the true flexion-extension (F-E) axis used in the application of an external fixator/elbow arthroplasty. We hypothesise that the epicondylar axis coincides with the true F-E axis in terms of both angular displacement and position (ie. offset). This suggests that it can serve as a good landmark in total dynamic external fixator application and elbow arthroplasty. Methods. Three-dimensional elbow models were obtained through manual segmentation and reconstruction from 142±40 slices of CT scans per elbow in 15 cadeveric specimens. Epicondylar axis was defined to be the axis through the 2 epicondyles manually identified on the elbow models. F-E axis was defined to be the normal of a circle fitted on 20 points identified on the trochlear groove. The long axis of the elbow was identified through a line fit through the center of the distal humerus on several slices along the elbow CT. Angle between the long axis and epicondylar axis was measured. Angular deviation of the epicondylar axis and the F-E axis was calculated in reference to the long axis. All axes were projected onto the orthogonal planes on the elbow CTs and all measurements were repeated. Angular differences in the axial, saggital and coronal planes are described in internal/external rotation, flexion/extension and valgus/varus respectively. Offset in the axial and coronal planes are described in the following directions respectively: proximal/distal and anterior/posterior respectively. Comparisons between angles were performed using student's t-test. Results. Angle between the long axis and the epicondylar axis in our study (85.9±5.30) was not significantly different when compared to an existing study (87.3±2.80) (p=0.327). The epicondylar axis deviates from the true F-E axis by 1.9±4.50 (p=0.523) in flexion, 2.1±3.40 (p=0.442) varus, and 0.5±2.70 (p=0.851) in external rotation with an overall angular deviation of 2.2±4.80 (p=0.204). There was no statistical significance difference in the angle deviations mentioned. The offset between the epicondylar axis and the F-E axis was 15.6±3.4 mm anterior and 9.4±2.9 mm distal with an overall offset of 17.6±2.5 mm. Discussion. Our study demonstrated small and statistically insignificant angular difference between the epicondylar axis and the F-E axis. However, offset between the axes exists and may be clinically significant. When the epicondylar axis is used as an approximation to the natural F-E axis, this offset may introduce a moment on elbow flexion resulting in additional strain on the elbow collateral ligaments and dynamic external fixators. Implications of this as well as ligament balancing and implant stress-strain patterns in elbow arthroplasty merit further research with potential modification of technique and jigs. Significance. Although the angular difference between between the epicondylar and F-E axes was not statistically significant, an offset between the axes exist. Further research is required to elucidate its impact and the need for modification on elbow implants and external fixators

Purpose. The measurement of radial head translation about the capitellum (in percent): the radio-capitellum ratio (RCR) has proven to have excellent inter- and intra-observer reliabilities when measuring the RCR on a lateral radiological view of elbows at 90° of flexion and in the neutral position of the forearm. However, in the clinical setting, radiographs may be taken with the elbow in different positions. However, the purpose was to validate the RCR measurement method on elbows in different positions in flexion-extension and in different positions of the forearm in pronation-supination. Method. Fifty-one healthy volunteers were recruited to evaluate the RCR in different elbow positions. Lateral elbow radiographs were taken with the elbow in different magnitude of ROM: maximal extension, maximal flexion, elbow at 90° and forearm in neutral, elbow at 90° and forearm in supination and elbow at 90° and forearm in pronation. The measurements of the RCR were done using the software SliceOmatic. ANOVA and paired T-test were used to assess the difference of the RCR depending on the position of the elbow and of the forearm. Pearson coefficients were calculated to obtain the correlation between the RCR in each different position. Results. The mean RCR for each position were the following: elbow in maximal extension: −2%±7%, elbow in maximal flexion: −5%±9%, elbow at 90° and forearm in neutral: −2%±5%, elbow at 90° and forearm in supination: 1%±6% and elbow at 90° and forearm in pronation: 1%±5%. According to the Anova results, a significant difference exists between the RCR in different elbow positions (p=0.01) and in the different forearm positions (p<0.001). Paired T-test confirmed a significant difference between maximal elbow flexion and elbow flexion at 90° (p=0.003), as well as for maximal elbow extension and maximal elbow flexion (p=0.034). According to the Pearson coefficient, significant correlations exist between: elbow flexion at 90° and in maximal flexion (r=0.19, p=0.050); the forearm in neutral and in supination (r=0.34, p<0.001); the forearm in neutral and in pronation (r=0.42, p<0.001). Conclusion. The RCR method is dependent on elbow (flexion-extension) and forearm (pronation-supination) positions. At both maximal elbow positions in flexion and extension, the measurements of the RCR have a higher standard deviation. In order to decrease its variability, we recommend as a convention measuring the RCR on lateral radiographs with the elbow at 90° and the forearm in neutral position. However, 95% of the values of RCR (except in maximal flexion which is unusual in trauma) are included in the normal range of RCR from −5% to 13%. Thus a value outside this range in any elbow positions (except maximal flexion) or any forearm positions must raise doubt on elbow alignment. Then, with a capitellum of 25 mm of diameter, the translation of the radial head must be less than 1 mm posterior and less than 3 mm anterior from the center of the capitellum

We present a retrospective study of 25 patients treated by open arthrolysis of the elbow for post-traumatic stiffness. The mean follow-up was for 7.8 years (5 to 10.8). The range of movement of the elbow, pain scores and functional outcomes were recorded pre- and postoperatively. An improvement in the mean range of movement from 55° (0° to 95°) to 105° (55° to 135°) was obtained in our patients at one year. This improvement was maintained over the mean follow-up period of 7.8 years (5 to 10.8). Improvement in pain, function and patient satisfaction was recorded in 23 of the 25 patients at final follow-up. On the basis of this study, we believe that the results of open arthrolysis for post-traumatic stiffness of the elbow are durable over the medium term

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

Lack of full extension of the elbow is a common abnormality in patients with achondroplasia. We studied 23 patients (41 elbows) clinically and radiologically. Extension of the elbow was assessed clinically and the angle of posterior bowing of the distal humerus was measured from lateral radiographs. There was limited extension of the elbow in 28 (68.3%) and the mean loss of extension was 13.1°. Posterior bowing of the humerus was seen in all elbows with a mean angle of 17.0°. There was a positive correlation between these two measurements. Posterior bowing greater than 20° caused a loss of full elbow extension. Posterior dislocation of the radial head was seen in nine elbows (22.0%). The mean loss of extension of the elbows was 28.7° which was significantly greater than that of these elbows in which the head was not dislocated (8.7°), although posterior bowing was not significantly different between these two groups (19.3° and 16.3°). Posterior bowing of the distal humerus is a principal cause of loss of extension of the elbow. Posterior dislocation of the radial head causes further limitation of movement in the more severely affected joints

Aims. The aim of this retrospective multicentre study was to evaluate mid-term results of the operative treatment of Monteggia-like lesions and to determine the prognostic factors that influence the clinical and radiological outcome. Patients and Methods. A total of 46 patients (27 women and 19 men), with a mean age of 57.7 years (18 to 84) who had sustained a Monteggia-like lesion were followed up clinically and radiologically after surgical treatment. The Mayo Modified Wrist Score (MMWS), Mayo Elbow Performance Score (MEPS), Broberg and Morrey Score, and Disabilities of the Arm, Shoulder and Hand (DASH) score were used for evaluation at a mean of 65 months (27 to 111) postoperatively. All ulnar fractures were stabilized using a proximally contoured or precontoured locking compression plate. Mason type I fractures of the radial head were treated conservatively, type II fractures were treated with reconstruction, and type III fractures with arthroplasty. All Morrey type II and III fractures of the coronoid process was stabilized using lag screws. Results. Good results were found for the MMWS, with a mean of 88.4 (40 to 100). There were 29 excellent results (63%), nine good (20%), seven satisfactory (15%), and one poor (2%). Excellent results were obtained for the MEPS, with a mean of 90.7 (70 to 100): 31 excellent results (68%), 13 good (28%), and two fair (4%). Good results were also found for the functional rating index of Broberg and Morrey, with a mean score of 86.6 (57 to 100). There were 16 excellent results (35%), 22 good (48%), six fair (13%), and two poor (4%). The mean DASH score was 15.1 (0 to 55.8). Two patients had delayed wound healing; four patients had nonunion requiring bone grafting. One patient had asymptomatic loosening of the radial head prosthesis. Conclusion. Monteggia-like lesions are rare. With correct identification, classification, and understanding using CT scans followed by appropriate surgical treatment that addresses all components of the injury, good to excellent mid-term results can be achieved. Cite this article: Bone Joint J 2018;100-B:212–18

The purpose of this study was to demonstrate the beneficial effects of elbow arthrolysis. This was a prospective study on 88 patients with post-traumatic elbow stiffness with a mean follow-up of 51 months (1 year - 11 years), who had failed to improve their range of movement at a mimimum period of 6 months after their injury. All patients had an open arthrolysis. Post-operatively patients received continuous passive movement (CPM) for 48 to 72 hours. This was facilitated by good analgesia afforded by a continuous brachial plexus block. All patients received no physiotherapy thereafter and were advised to actively mobilise their elbow. ROM was assessed using a goniometer and function assessed using the Mayo elbow performance index. The ROM improved from a mean of 56 degrees pre-operatively to 106 degrees post-operatively. This improvement in ROM was reflected in the improvement of pre-operative flexion from 107 to 138 degrees and improvement of extension from 60 to 31 degrees. Function improved from a mean of 65 to 85 on the Mayo elbow performance score. 95% of the patients were satisfied with the outcome. Complications included ulnar nerve paraesthesia in 3 patients, 1 triceps avulsion and 1 superficial infection. 3 patients required a manipulation of the elbow in the postoperative period. This was performed within 2 weeks of the operation. There were no cases of elbow instability or heterotopic ossification in this series. Conclusion: Open elbow arthrolysis combined with continuous brachial plexus block and CPM in the postoperative period is a safe, reliable and durable procedure for improving ROM and function in patients with post-traumatic elbow stiffness

Introduction and Aims: The close proximity of the major nerves to the elbow places them at risk with elbow arthroscopy. New techniques of endoscopic ulnar nerve release, biceps bursoscopy and anterior elbow arthroscopy portal will be presented. Method: In a cadaveric model needles were used to transfix the major nerves to the elbow joint capsule. From an arthroscopic perspective the needles were located to assess the position of each nerve. Capsular windows were created to provide arthroscopic visualisation of each nerve. A technique of endoscopic ulnar nerve release using the Agee system will be presented including a cadaveric study assessing its safety. Endoscopic biceps bursoscopy will also be demonstrated. Results: The ulnar nerve passes on the postero-medial capsule and is at risk with debridement of the medial gutter. The radial nerve passes on the anterior-lateral capsule and is at risk during lateral portal placement, anterior capsular release, synovectomy and radial head excision. The median nerve passes anterior to the brachialis muscle and is protected. In a cadaveric model we were able to reproducibly perform a release of the arcade of Struthers, cubital retinaculum and Osborne’s FCU fascia with no injuries to the ulnar nerve or branches. Biceps bursoscopy can be performed for partial tears of the biceps tendon. Through the biceps bed an anterior elbow arthroscopy portal can safely be created. Conclusion: An understanding of the proximity radial and ulnar nerves allows elbow arthroscopy to be more safely performed. The endoscopic ulnar nerve release, biceps bursoscopy and anterior elbow arthroscopy portal are new techniques extending the therapeutic options

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Contracture of the collateral ligaments is considered to be an important factor in post-traumatic stiffness of the elbow. We reviewed the results of isolated release of the medial collateral ligament in a series of 14 patients with post-traumatic loss of elbow flexion treated between 1998 and 2002. There were nine women and five men with a mean age of 45 years (17 to 76). They were reviewed at a mean follow-up of 25 months (9 to 48). The operation was performed through a longitudinal posteromedial incision centred over the ulnar nerve. After decompression of the ulnar nerve, release of the medial collateral ligament was done sequentially starting with the posterior bundle and the transverse component of the ligament, with measurement of the arc of movement after each step. If full flexion was not achieved the posterior half of the anterior bundle of the medial collateral ligament was released. At the latest follow-up, the mean flexion of the elbow improved significantly from 96° (85° to 115°) pre-operatively to 130° (110° to 150°) at final follow-up (p = 0.001). The mean extension improved significantly from 43° (5° to 90°) pre-operatively to 22° (5° to 40°) at final follow-up (p = 0.003). There was a significant improvement in the functional outcome. The mean Broberg and Morrey score increased from a mean of 54 points (29.5 to 85) pre-operatively to 87 points (57 to 99) at final follow-up (p < 0.001). All the patients had normal elbow stability. Our results indicate that partial surgical release of the medial collateral ligament is associated with improved range of movement of the elbow in patients with post-traumatic stiffness, but was less effective in controlling pain

Hinged external fixators of the elbow joint can be a valuable tool in managing complicated trauma associated with instability, instability after contracture release, and distraction interposition arthroplasty or distraction arthroplasty alone. This retrospective study focuses on the performance of the device in acute and chronic elbow instability associated with complex injuries around the elbow. Thirteen hinged external fixators were applied in 13 patients with an average age of 46 years. All fixators were applied for various types of fractures around the elbow joint associated with elbow dislocation. In 12 patients prior to the application of the fixator, a formal open reduction and internal fixation was performed so as to neutralise the whole construct and permit early mobilisation of the joint. In one patient with a minimally displaced fracture which required no internal fixation the fixator was used to permit early mobilisation. A circular multiplanar frame was used in 4 patients and a unilateral one in the rest of them. Eight out of 13 patients with fracture-dislocation had an uneventful outcome. Three patients required a revision surgery to correct a fracture malalignment and a subluxation of the joint. The results were evaluated according to the Mayo Elbow Performance score. Complications included 4 cases of pin tract infection and 2 of transient ulnar neuritis. Despite the complexity of its application and the complications that may follow such device, an articulating external fixator can be a valuable tool in treating complex elbow instability