We present a case of idiopathic osteonecrosis of the humeral capitellum in a 44-year-old female in the absence of any associated risk factors. Arthroscopy was undertaken to remove the loose bodies and debride the capitellum, with a satisfactory outcome

Introduction. A prospective study was done using Kirschner (K) wires to internally fix capitellum fractures and its results were analysed. Materials/Methods. Since 1989, unstable displaced 17 capitellum fractures were anatomically reduced and internally fixed by inserting K wires in coronal plane from the capitellum into trochlea. The lateral end of wires were bent in form of a staple behind the fracture plane and anchored into the lateral humeral condyle with pre-drilled holes. Additional screws were used in 2 cases to stabilise the lateral pillar comminution. The capitellum was exposed with a limited modified lateral elbow approach between anconeus and extensor carpi ulnaris. The capsule was reflected anteriorly to expose the capitellum and trochlea. The deeper dissection was limited anterior to lateral collateral ligament (LCL) keeping it intact. The capitellum fragment was reposition under the radial head and anatomically reduced by full flexion of elbow and then internally fixed. Total 17 patients (7 males and 10 females) with average ages 34.8 years(14 to 75) had fractures, Type I: (Hans Steinthal #) 12, Type II: (Kocher Lorez #) 1, and Type III: (Broberg and Morrey #) 4. Post-operatively the patients were not given any immobilisation and were mobilised immediately. Results. Patients were assessed clinically and radiologically. Average followup was 31.7 (18–35) months. Capitellum fractures healed in all the patients. Mayo elbow score was excellent in 12, good in 4, and fair in 1 patient. Average elbow ROM was 5 to 132 degrees, pronation 84.5 (79–90) degrees and supination 88 (85–91) degrees. Complications seen were wire pain in 4 patients, loosening of wires in 2 which required early removal. We did not see any infection, non-union or avascular necrosis in the time scale we studied. Conclusions. We found a simple manoeuvre of hyper-flexion of elbow reduced the capitellum anatomically, and K wires stapling technique to be very easy and stable. A limited exposure of capitellum helped to restore immediate stable elbow with good function

The functional outcomes of twenty-eight patients with capitellum and trochlea fractures treated with open reduction and internal fixation were evaluated at a mean follow-up of fifty-five ± thirty-three months. Patients were independently evaluated by a series of questionnaires, radiographs, physical examination and strength testing. Patients with simple fractures did better than those with complicated fractures. The average DASH score was 19/100 and the average ROM was 20 – 130°. Two fractures did not unite and required conversion to total elbow arthroplasty. A classification system is proposed based on fracture patterns, surgical technique and clinical outcomes. Capitellum and trochlea fractures are uncommon fractures of the distal humerus. There is limited information about the functional outcome of patients managed with open reduction and internal fixation. The functional outcome of twenty-eight patients (average age: forty-three ± thirteen years [range, twenty – seventy-one]) who were treated with open reduction and internal fixation for capitellum and trochlea fractures was evaluated at a mean follow-up of fifty-five ± thirty-three months (range, fourteen – one hundred and twenty-one). Patient outcomes were assessed by physical examination, radiographs, range of motion measurements, strength testing and self reported questionnaires (DASH, SF-36 ASES and PREE elbow scales). There were eleven fractures involving the capitellum, four involving the capitellum and trochlea as one piece and thirteen in which the capitellum and trochlea were separate fragments. These fractures were further defined by the presence or absence of posterior comminution. Fourteen had isolated fractures and fourteen were associated with other elbow, forearm or wrist injuries. Patients with complicated fractures required more extensive surgery, had more complications resulting in secondary procedures and had poorer outcomes compared to those with simple fractures. The average DASH score (19/100), quality of life scores (SF-36: Physical=46, Mental=49) and the average ROM (20 – 130°) suggest favorable patient outcomes overall. Patients with simple fractures had better results than those with more complicated fractures. A fracture classification system based on fracture patterns, surgical technique and clinical outcomes is proposed

Purpose: The identification of anatomical landmarks is an important aspect of joint surgery, to ensure proper placement and alignment for implants and other reconstructive procedures. At the elbow, the center of the capitellum (derived via a digitization of the surface and subsequent sphere fitting) has been well established as a key landmark to identify the axis of rotation of the joint. For some cases, and in particular minimally invasive surgery, only small regions of the capitellum may be exposed which may lead to errors in determining the centre. The purpose of this study was to identify the optimal location of digitizations of the capitellum. Method: Twenty-five fresh frozen cadaveric distal humeri (19 left, 6 right) were studied. Using an x-ray computed tomography scanner, volumetric images of each specimen were acquired and used to reconstruct a 3-dimensional digital model of the specimen using the Visualization Toolkit (VTK). A sphere-fit algorithm was used to determine the centre of the spherical capitellum based on manually chosen (digitized) points across the 3D capitellar surface. The true geometric centre was located by digitizing points across the entire capitellar surface. Three sub-regions of the capitellum, commensurate with typical surgical approaches with minimal dissection, were then digitized. These were superior anterior lateral (SAL), inferior anterior lateral (IAL) and a combination of these two regions. These regions were compared to the true center using a 1-way Repeated Measures ANOVA with significance set to p = 0.05. Results: Digitizations of only SAL and IAL sub-regions resulted in the largest differences relative to the true centre: SAL = 3.9±3.4 mm, IAL = 4.2±3.4 mm, (p < 0.0005). There was no difference between SAL and IAL (p = 1.0). Digitization of the combined SAL + IAL regions, while significantly different from the entire capitellum, resulted in the smallest mean difference of 0.87±0.84 mm. Conclusion: These data show that the region of digitization affects the accuracy of predicting the capitellum centre. In a previous study by our group, we showed that an accurate determination of the centre of a sphere can be achieved with a small surface area of digitization. In the current study, the large errors that occurred when a small surface was digitized (i.e. SAL and IAL alone), are in all likelihood, due the non-spherical nature of the capitellum. In summary, while the most precise method in locating the true centre is to digitize the entire capitellar surface where possible, an alternative approach is to digitize both the superior and inferior anterior lateral regions

Aims. To propose a new method for evaluating paediatric radial neck fractures and improve the accuracy of fracture angulation measurement, particularly in younger children, and thereby facilitate planning treatment in this population. Methods. Clinical data of 117 children with radial neck fractures in our hospital from August 2014 to March 2023 were collected. A total of 50 children (26 males, 24 females, mean age 7.6 years (2 to 13)) met the inclusion criteria and were analyzed. Cases were excluded for the following reasons: Judet grade I and Judet grade IVb (> 85° angulation) classification; poor radiograph image quality; incomplete clinical information; sagittal plane angulation; severe displacement of the ulna fracture; and Monteggia fractures. For each patient, standard elbow anteroposterior (AP) view radiographs and corresponding CT images were acquired. On radiographs, Angle P (complementary to the angle between the long axis of the radial head and the line perpendicular to the physis), Angle S (complementary to the angle between the long axis of the radial head and the midline through the proximal radial shaft), and Angle U (between the long axis of the radial head and the straight line from the distal tip of the capitellum to the coronoid process) were identified as candidates approximating the true coronal plane angulation of radial neck fractures. On the coronal plane of the CT scan, the angulation of radial neck fractures (CTa) was measured and served as the reference standard for measurement. Inter- and intraobserver reliabilities were assessed by Kappa statistics and intraclass correlation coefficient (ICC). Results. Angle U showed the strongest correlation with CTa (p < 0.001). In the analysis of inter- and intraobserver reliability, Kappa values were significantly higher for Angles S and U compared with Angle P. ICC values were excellent among the three groups. Conclusion. Angle U on AP view was the best substitute for CTa when evaluating radial neck fractures in children. Further studies are required to validate this method. Cite this article: Bone Joint J 2024;106-B(9):964–969

Purpose: The literature contains little information on an objective method of measuring radiocapitellar joint translations, as would be seen with joint instability. The purpose of this study was to develop and validate a measurement method that was simple and that could be easily reproducible in a clinical setting or intra-operatively to assess radiocapitellar joint translations. Method: We performed a radiological study on a synthetic elbow specimen in order to quantify radial head translations as related to the capitellum: the Radio-capitellum ratio (RCR). Thirty (30) lateral elbow x-rays were taken in different magnitude of subluxation of the radial head. The subluxation was created randomly by manipulation. X-rays where taken by fluoroscopy to obtain a perfect lateral view of the distal humerus. First, the evaluators determined the long axis of the radius and the center of the capitellum. The displacement of the radial head (in mm) was obtained by measuring the distance of the line perpendicular to the long axis of the radius passing through the center of the capitellum. Then, in order to adjust for variation of magnification, a ratio of the displacement of the radial head about the diameter of the capitellum was done. The RC ratio would be of zero because the long axis of the radius always crosses the center of the capitellum in a perfectly aligned joint. A five mm translation of the radial head and a capitellum diameter of twenty (20) mm would give a RCR of 25% and would be positive if anterior and negative if posterior. The measurements were done two times at one week intervals by three independent evaluators to test inter-observer agreement and intra-observer consistency. The radiological incidences were randomly ordered to minimize observer recall bias. Intra/inter-observer reliability was calculated using Intra-Class Correlation (ICC) and paired T-tests. Results: The mean translation in the trial group was of 6,06% (SD 70.7%) from – 167% to 125%. A result over 100% means that it is a complete dislocation ie – the axis of the radius is outside of the capitellum. Negative values signify posterior translation and positive values an anterior translation. Intra-observer reliability was excellent for the Radio-capitellum ratio (ICC 0.988 and 0.995) and inter-observer reliability was excellent (ICC 0.984 in average). Paired T-test results confirm a high intra-observer repeatability (p=0.97 and p=0.99) as well as a large inter-observer reproducibility (p=0.98 in average). Conclusion: The proposed measurement of radial head translation about the capitellum (in percent): radio-capitellum ratio (RCR) has excellent inter – and intra-observer reliability when using our measurement method

Purpose: Osteochondritis dissecans (OCD) of the capitellum most commonly affects adolescent pitchers and gymnasts, and presents with pain and mechanical symptoms. Fragment excision is the most commonly employed surgical treatment; however, patients with larger lesions have been reported to have poorer outcomes. It’s not clear whether this is due to increased contact pressures on the surrounding articular surface, or if fragment excision causes instability of the elbow. The purpose of this study was to determine if fragment excision of simulated OCD lesions of the capitellum alters kinematics and stability of the elbow. Method: Nine fresh-frozen cadaveric arms were mounted in an upper extremity joint motion simulator, with cables attaching the tendons of the major muscle tendons to motors and pneumatic actuators. Electromagnetic receivers attached to the radius and ulna enabled quantification of the kinematics of both bones with respect to the humerus. Three-dimensional CT scans were used to plan lesions of 12.5% (mean 0.8cm2), 25%, 37.5%, 50%, and 100% (mean 6.2cm2) of the capitellar surface, which were marked on the capitellum using navigation. Lesions were created by burring through cartilage and subchondral bone. The arms were subjected to active and passive flexion in both the vertical and valgus-loaded positions, and passive forearm rotation in the vertical position. Results: No significant differences in varus-valgus or rotational ulnohumeral kinematics were found between any of the simulated OCD lesions and the elbows with an intact articulation with active and passive flexion, regardless of forearm rotation and the orientation of the arm (p> 0.7). Radiocapitellar kinematics were not significantly affected during passive forearm rotation with the arm in the vertical position (p=0.07–0.6). Conclusion: In this in-vitro biomechanical study even large simulated OCD lesions of the capitellum did not alter the kinematics or laxity of the elbow at either the radiocapitellar or ulnohumeral joints. These data suggest that excision of capitellar fragments not amenable to fixation can be considered without altering elbow kinematics or decreasing stability. Further study is required to examine other factors, such as altered contact stresses on the remaining articulation, that are thought to contribute to poorer outcomes in patients with larger lesions

Aims: This study aimed to assess the outcome of arthroscopic debridement and removal of loose bodies from the elbows of patients with OCD of the capitellum who had previously failed non-operative treatment. Methods: Patients who had been treated arthroscopically for symptomatic OCD of the capitellum after failing non-operative management for 6 months were invited for review. They were assessed clinically, by an independent examiner using a modern elbow outcome score, and radiologically. In addition details of sporting involvement and satisfaction of outcome were ascertained. Results: 29 patients/elbows (91% follow up rate) were assessed at a mean follow up period of 77 months. There were 20 males and 9 females with an average age at operation of 22 years. There were no operative complications. 26 patients had none or mild pain and were able to complete activities of daily living with minimal impairment. 27 patients had been regularly involved in sports (Olympic and professional to recreational levels) only 4 of whom had to give up the sport because of ongoing problems. 5 of 6 elite gymnasts and 10 of 11 rugby players were able to fully resume their sport. 11 patients (38%) had recurrence of locking episodes. There was an average 5û loss of ßexion and a 10û loss of extension while the grip strength remained normal. Radiographs demonstrated that most of the capitella had not remodelled. 28 (97%) patients had a good or excellent outcome. Conclusions: This study has demonstrated that arthroscopic treatment of recalcitrant OCD of the capitellum is a safe procedure resulting in satisþed patients most of whom can return their previous level of sports but there is a risk of recurrent locking symptom

The purpose of this study is to describe a surgical procedure for unstable osteochondritis dissecans (OCD) of the capitellum and its results. Between 1992 and 1997, 11 elbows of 11 patients with OCD of the capitellum were treated in our institution. The average age at surgery was 14.7 years and the ages ranged from 12 to 16 years. All patients were male baseball players affected in the throwing side. The follow-up period was from 31 to 95 months (average: 57 months). All patients underwent internal fixation using the pull out wiring method and bone graft (this procedure was established by Kondo in 1989). All lesions of OCD were not only softening or cracked but also unstable with early separation or partially detached fragment. After surgery, a long arm cast was applied for 3 weeks. After confirming bony union of OCD by X-ray, the wires were removed ranged from 15 to 21 weeks (average 17 weeks) postoperatively. Throwing activity was allowed 6 months after surgery. At the follow-up, all patients were relieved pain and all except one returned to previous throwing levels. Radiographs showed good healing of OCD and minimum degenerative changes were found in only a few joints. We concluded that this surgical procedure was an effective treatment for adolescent baseball players with unstable OCD of the capitellum

Displaced supracondylar fractures of the paediatric elbow are a serious, but well described injury. Although complications are common, avascular necrosis (AVN) of the capitellum has not been described or reported before. We describe a case with this complication. A review of the relevant literature is also presented. A three-year-old boy presented to our emergency department with a painful swollen left elbow after a fall. X-ray done in Accident and Emergency, reveal, a displaced, extension type, supracondylar fracture (Gartland Grade III. 1. ). An open reduction (medial approach) was done and the fracture reduced and stabilised with two crossed K wires. The fracture healed in an excellent position. However, at the three-month follow up, the elbow remained stiff with flexion from only 20 to 90 degrees and with very little supination. Eight months after the injury an arthrogram was undertaken which confirmed diagnosis of avascular necrosis of capitellum. No specific treatment for AVN given. Check radiographs showed healing of capitellum with no functional limitations

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

Introduction Osteochondritis Dissecans of the elbow is a rare condition classically affecting teenage males playing throwing sports. The aim of this study was to evaluate the longer term outcome following arthroscopic debridement in patients with osteochondritis of the elbow that had failed conservative management.

Methods All clinically, radiologically and arthroscopically proven patients (since 1989) with Osteochondritis Dissecans (OCD) that had failed six months of non-operative management were recalled for clinical, performance indices and radiological review. A 91% follow-up rate was achieved (62% full clinical and radiological follow-up). The group consisted of 29 patients (20 male, nine female) with an average age of 22 years. Patients were mobilised post-operatively as symptoms allowed.

Results At an average of 77 months after the operation, the majority of patients had mild or no pain with activities of daily living but with some discomfort during heavy lifting/sports. Only four out of 27 had to give up their preferred sport because of persistent elbow problems. Thirty-eight percent had recurrence of locking or catching, though these symptoms were described as much better than prior to the operation and were not felt severe enough to consider any further intervention.

Conclusions We conclude that arthroscopic debridement and removal of loose bodies is a safe and reliable procedure for patients with persistent symptoms from OCD of the elbow.

Hemiarthroplasty is a common procedure that is an attractive alternative to total arthroplasty because it conserves natural tissue, allows for quicker recovery, and has a lower cost. One significant issue with hemiarthroplasties is that they lead to accelerated wear of the opposing native cartilage, likely due to the high stiffness of the implant. The purpose of this study was to investigate the range of currently available biomaterials for hemiarthroplasty applications. We employed a finite-element (FE) model of a radial head implant against the native capitellum as our joint model. The FE model was developed in ABAQUS v6.14 (Dassault Systèmes Simulia Corp., Providence, RI, USA). A solid axisymmetric concave implant with seven different materials and the native radial head were evaluated, six modelled as elastic materials with different Young's moduli (E) and Poisson's Ratios (ν), and one modelled as a Mooney-Rivlin hyperelastic material. The materials investigated were CoCr (E=230 GPa, ν = 0.3), PEEK (E=3.7 GPa, ν = 0.36), HDPE (E=2.7 GPa, ν = 0.42), UHMWPE (E=0.69 GPa, ν = 0.49), Bionate 75D (E=0.288 GPa, ν = 0.39), Bionate 55D (E=0.039 GPa, ν = 0.45), and Bionate 80A (modelled as a Mooney-Rivlin hyperelastic material). A load of 100 N was applied to the radius through the center of rotation representing a typical load through the radius. The variable of interest was articular contact stress on the capitellum. The CoCr implant had a maximum contact stress over 114% higher than the native radial head. By changing the material to lower the stiffness of the implant, the maximum contact stress was 24%, 70%, 105%, 111%, 113%, and 113% higher than the native radial head for Bionate 80A, Bionate 55D, Bionate 75D, UHMWPE, HDPE, and PEEK respectively. This work shows that lowering implant stiffness can reduce the contact stress on cartilage in hemiarthroplasty implants. By changing the material below a Young's modulus of ∼100 MPa elevated stresses on the capitellum can be markedly reduced and hence potentially reduce or prevent degenerative changes of the native articulating cartilage. Low stiffness implant materials are not a novel concept, but to date there have been few that investigate materials (such as Bionate) as a potential load bearing material for implant applications. Further work is required to assess the efficacy of these materials for articular bearing applications

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

Purpose: Coronal shear fractures of the humerus include the Kocher-Lorenz fracture, an osteochondral fracture of the capitellar articular surface, the Hahn-Steinthal fracture, a substantial shear fragment, extension into the trochlea, and complete involvement of the capitellum and trochlea. If the fracture proves irreparable, it is not known what the impact of fragment excision would have on the biomechanics of the elbow. The purpose of this study was to examine the effect of the sequential loss of the capitellum and trochlea on the kinematics and stability of the elbow. Method: Eight fresh-frozen cadaveric arms were mounted in an upper extremity joint testing system, with cables attaching the tendons of the major muscles to motors and pneumatic actuators. Electromagnetic receivers attached to the radius and ulna enabled quantification of the kinematics of both bones with respect to the humerus. The distal humeral articular surface was sequentially excised to replicate clinically relevant coronal shear fractures while leaving the collateral ligaments intact. Active flexion in both the vertical and valgus-loaded positions, and passive rotation in the vertical position was conducted for each excision. Results: Excision of the capitellum had no effect on ulnohumeral stability or kinematics in both the vertical or valgus positions (p=1.0). Excision of the entire capitellum and trochlea led to significant valgus instability with the arm in the valgus position (p=0.01), while excision of the lateral trochlea led to increased valgus instability with pronated flexion in the valgus position (p=0.049). Progressive loss of the articular surface led to posterior, inferior, and medial displacement of the radial head with respect to the capitellum and increased external rotation of the ulna with respect to the humerus in the vertical position (p< 0.05). Conclusion: Excision of the capitellum did not result in valgus or rotational instability, while excision of the trochlea resulted in multiplanar instability. The radial head displaced medially because it is constrained to the ulna by the annular ligament, and the ulna pivoted into valgus and external rotation on the residual trochlea and medial collateral ligament. In patients with coronal shear fractures, the trochlea must be reconstructed to prevent instability and the potential for secondary degenerative change

Three 3mm transverse slices were sectioned from the distal cancellous region of seven fresh-frozen cadaveric humerii. Each slice was marked with a 3x3mm grid, and subjected to compressive testing using a flat cylindrical indenter (1.6mm diameter). Indentation modulus and strength were calculated for each site, and pooled into nine anatomically-defined regions. The most distal slice had higher moduli values (p< 0.05), and the posterior capitellar region had lower moduli values (p< 0.05). There were no slice or regional differences in strength. This suggests that surgical procedures requiring cancellous fixation utilize the most distal aspect of the humerus while avoiding the posterior capitellum. To quantify the indentation strength and modulus of distal humeral cancellous bone, and identify any regional variations. Cancellous bone modulus in the distal humerus decreases from distal to proximal. The posterior capitellum has a lower modulus than the other regions of the distal humerus. The influence of slice depth emphasizes the importance of minimizing the amount of bone removed during prosthetic replacement. Regional variations in modulus suggest that the posterior capitellum should be avoided during fixation of implants or placement of screws. Three 3mm transverse cancellous bone slices obtained from the distal end of each of seven fresh-frozen cadaveric specimens were subjected to compressive testing using a materials testing machine with a 1.6mm flat cylindrical indenter. Testing was performed in a 3x3mm grid. The indentation modulus and local strength were calculated for each test site, and then averaged into nine regions defined by the capitellum, medial and lateral trochlea, and anterior, central and posterior sections for each slice. Mean modulus was found to be 309.8±242.0 MPa (range: 2.9–1041.7 MPa). Yield strength averaged 4.4±2.5 MPa (range: 0.6–16.3 MPa). The highest modulus was found in the distal-most slice (p< 0.05). The lowest modulus region was the posterior capitellum (p< 0.05). There were no differences in strength between slices or across the nine regions. A comparison with proximal tibial cancellous bone properties suggests the distal humerus may carry loads approaching 30% of those at the knee, assuming that bone adapts to stress magnitudes. Funding: Natural Sciences and Engineering Research Council; University of Western Ontario

Purpose. Capitellum hemiarthroplasty is an emerging concept. The current metallic capitellar implants have spherical surface shapes, but the native capitellum is not spherical. This study evaluated the effect of capitellar implant shape on the contact mechanics of the radiocapitellar joint when articulating with the native radial head. Method. Eight paired radii and humeri were potted in a custom jig. Articular casts were made with medium-viscosity resin while 85 N of axial load was applied to the reduced radiocapitellar joint at 0, 45, and 90 of elbow flexion, and at neutral, 50 pronation and 50 supination at each flexion angle. The native radiocapitellar articulation was compared to capitellar hemiarthroplasties of two surface designs (anatomical and spherical). Contact area and shape (circularity) were determined. Circularity was defined as the ratio of the minor axis and major axis of the shape. Results. At 0 of flexion, the anatomical hemiarthroplasty had a contact area of 52–70% that of the native articulation (p=0.03), while the spherical hemiarthroplasty had a contact area 40–42% that of the native articulation (p=0.003). At 45 of flexion, both hemiarthroplasties displayed contact area <53% that of the native joint (p<0.007). At 90 of flexion, the hemiarthroplasties had contact areas ranging from 40–70% that of the native articulation (p=0.1). The two capitellar implants had similar contact areas at all flexion angles tested (p>0.05). The contact shape of the native radiocapitellar articulation was ellipsoid, with a range of circularity values from 0.530.19 to 0.720.16, depending on the flexion and rotation angle. At 0 and 90 flexion, there was no difference in contact shape between the native articulation, the anatomical, or spherical implant (p>0.05). At 45 flexion, the anatomical implant contact was less circular than either the native articulation (p=0.006) or the spherical hemiarthroplasty (p=0.002). Conclusion. Metallic capitellar hemiarthroplasty causes a significant reduction in contact area at 0 and 45 elbow flexion, which may have important long-term implications for wear of the radial head cartilage. This reduction is similar to previous reports, which have evaluated the effect of metallic radial head hemiarthroplasty articulating with the native capitellum. More compliant alternative materials are needed to improve the contact characteristics of metallic capitellar hemiarthroplasties. Although the anatomical hemiarthroplasty was created from a detailed morphological study of the capitellum, the anatomical implant failed to completely reproduce the contact native shape. The theoretical advantages of a more anatomical capitellar implant shape may not be realized clinically, suggesting a spherical implant, which is easier to manufacture and implant, may be adequate for patient application. Further studies are required to delineate the effect of this altered contact morphology on implant function and radial head wear in-vivo

Background. Fractures of the radial head result from an axial force that causes impaction against the capitellum. Associated lesions of the capitellum in this pattern of injury have been previously reported in the orthopaedic literature as an uncommon occurrence. Methods. All patients presenting to the clinics of the senior surgeon between 1998-2008 with radial head fractures requiring surgery were included. Data collected included demographics (age, gender, side of injury), mechanism, timing of injury and injury type (Mason classification). Intraoperative findings including evidence of union, capitellar injury, associated joint dislocation, collateral ligament injury, and any other fractures around the elbow were documented. Results. We reviewed 109 consecutive patients presenting with radial head fractures. 67% of the patients were found to have the PLUCCAR lesion, a capitellar slither of cartilage impacted in the radial fracture. Of these, 76.9% of patients with a Mason I injury had a PLUCCAR lesion, 76.7% of patients with Mason II injury had a PLUCCAR lesion, and only 33.3% of patients with Mason III lesion had a PLUCCAR lesion. 13 patients had a pre-existing non-union, 84% of whom had a PLUCCAR lesion. 19 patients were found to have a malunion, 84% of whom were found to have the PLUCCAR lesion. Conclusion. Injury to the capitellum is commonly associated with radial head fracture. We term impaction of a capitellar fragment in the radius a PLUCCAR lesion. There is an increased incidence of this injury in less comminuted radial head fractures, and in patients presenting with non union or malunion of a radial head fracture

Summary. The significance of matching radius of curvature of the radial head implant and the capitellum in implant selection is evaluated. A mismatch of radius of curvature could lead to point loading, reducing contact area, creating large contact stresses, resulting in arthritis, pain, and other complications. Introduction. Radial head (RH) implant size is chosen by reconstruction outside of the radiocapitellar joint capsule measuring the RH diameter and length, which is replicated for implant selection. RH radius of curvature (RC) is rarely part of the decision although important in determining contact area. Methods. Eleven fresh-frozen cadaver humeri were denuded, with articular cartilage intact. These were held horizontally in an MTS machine; capitellum faced up, and covered with a Tekscan transducer. RH implants were attached by vice to the MTS driving piston. Four different RH implant models were compared: Ascension, Integra Katalyst, Stryker Small and Medium, all CoCr. All implants were 21mm in outer diameter, except the Stryker small implant (18mm). Cyclic axial loading was applied through the RH implant to the capitellum. Contact area and stress concentrations were captured by the transducer. Loading was applied with stroke control until steady state loading occurred between specified values of 115N-65N, within 1N of peak and 5N of base values. Using the Stryker 21mm implant loading at 155N-65N and 195N-105N simulated over-sizings of +2mm and +4mm. Results. Percent difference between RH and Capitellar RC's were plotted against corresponding Contact Areas of 21mm sized RH implants, and a linear regression done. Negative values corresponded with larger RH than capitellar RC values. The resulting slope was 92.19, showing a significant increase in contact area with decreased RH to capitellar ratios, with an R. 2. value of 0.8122, showing a linear trend. Total stresses were calculated for all maximum contact areas, using the peak values. Discussion. Clinical RH implant sizing comes from native head diameter, not curvature. Improper RC could lead to point loading, reducing contact area, creating large contact stresses, resulting in arthritis, pain, and other complications. This can be seen through the linear relation between contact area and RC. With an RH implant RC of greater value than capitellar RC, the contact area decreases significantly, resulting in increased stress. The significance of RC matching in implant selection. Increases in stress are greater for differences in RC values, than for improper sizing of diameter (D=85.7%) or length (+2mm, +4mm). With the decrease in contact area with increased implant RC, and the changes in stress compared to improper sizings (length and diameter), it can be seen that implant RC is an important feature in RH implant selection

Repeated trauma to the radial head may be one of the causative factors in the genesis of osteochondritis dissecans of the capitellum. We measured the force, contact area and pressure across the radiocapitellar articulation of the elbow before and after radial shortening osteotomy in five fresh-frozen cadaver upper limbs with loads of 45, 90 and 135 N, respectively. Measurements were made on pressure-sensitive film placed in the radiocapitellar articulation with the forearm in the supinated, neutral and pronated positions before and after radial shortening. Radial shortening significantly reduced the mean force and contact area across the radiocapitellar articulation in all positions of the forearm

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

Between 1995 and 2006, five intra-articular osteotomies of the head of the radius were performed in patients with symptomatic healed displaced articular fractures. Pre-operatively, all patients complained of persistent painful clicking on movement. Only patients with mild or no degenerative changes of the radial head and capitellum were considered for osteotomy. The operations were performed at a mean of 8.2 months (4 to 13) after injury and the patients were reviewed at a mean of 5.5 years (15 months to 12 years) after the osteotomy. The average Mayo Elbow Performance Index Score improved significantly from 74 before to 88 after operation, with four patients rated as good or excellent (p < 0.05). The subjective patient satisfaction score was 8.4 on a ten-point scale. All osteotomies healed and there were no complications. In this small series intra-articular osteotomy of the head of the radius was a safe and effective treatment for symptomatic intra-articular malunion without advanced degenerative changes

Excision is not a suitable treatment for all comminuted fractures of the radial head. In elbows where instability can be predicted, a replacement arthroplasty of the radial head is more effective. The aim of this paper was to present the medium-term results of the Judet floating radial head prosthesis. This operation was performed on 14 patients between 1992 and 2003, of whom 12 were reviewed at a mean follow-up of five years and three months (1 to 12 years). The outcome was assessed using the Mayo elbow performance score and a modified Disability of Arm Shoulder Hand (DASH) questionnaire. There were six excellent results, four good, one fair and one poor, as graded by the Mayo score. The mean DASH score was 23.9/100 (0 to 65.8/100). The only significant complication occurred in one patient who developed a severe complex regional pain syndrome. There were no patients with secondary instability of the elbow, implant loosening, cubitus valgus, osteoporosis of the capitellum, or pain in the forearm and wrist. Our experience, combined with that of other authors using this device, has encouraged us to continue using the Judet prosthesis in comminuted fractures of the elbow where instability is a potential problem

Total elbow arthroplasty (TEA) usage is increasing owing to expanded surgical indications, better implant designs, and improved long-term survival. Correct humeral implant positioning has been shown to diminish stem loading in vitro, and radiographic loosening in in the long-term. Replication of the native elbow centre of rotation is thought to restore normal muscle moment arms and has been suggested to improve elbow strength and function. While much of the focus has been on humeral component positioning, little is known about the effect of positioning of the ulnar stem on post-operative range of motion and clinical outcomes. The purpose of this study is to determine the effect of the sagittal alignment and positioning of the humeral and ulnar components on the functional outcomes after TEA. Between 2003 and 2016, 173 semi-constrained TEAs (Wright-Tornier Latitude/Latitude EV, Memphis, TN, USA) were performed at our institution, and our preliminary analysis includes 46 elbows in 41 patients (39 female, 7 male). Patients were excluded if they had severe elbow deformity precluding reliable measurement, experienced a major complication related to an ipsilateral upper limb procedure, or underwent revision TEA. For each elbow, saggital alignment was compared pre- and post-operatively. A best fit circle of the trochlea and capitellum was drawn, with its centre representing the rotation axis. Ninety degree tangent lines from the intramedullary axes of the ulna and humerus, and from the olecranon tip to the centre of rotation were drawn and measured relative to the rotation axis, representing the ulna posterior offset, humerus offset, and ulna proximal offset, respectively. In addition, we measured the ulna stem angle (angle subtended by the implant and the intramedullary axis of the ulna), as well as radial neck offset (the length of a 90o tangent line from the intramedullary axis of the radial neck and the centre of rotation) in patients with retained or replaced radial heads. Our primary outcome measure was the quickDASH score recorded at the latest follow-up for each patient. Our secondary outcome measures were postoperative flexion, extension, pronation and supination measured at the same timepoints. Each variable was tested for linear correlation with the primary and secondary outcome measures using the Pearson two-tailed test. At an average follow-up of 6.8 years (range 2–14 years), there was a strong positive correlation between anterior radial neck offset and the quickDASH (r=0.60, p=0.001). There was also a weak negative correlation between the posterior offset of the ulnar component and the qDASH (r=0.39, p=0.031), and a moderate positive correlation between the change in humeral offset and elbow supination (r=0.41, p=0.044). The ulna proximal offset and ulna stem angle were not correlated with either the primary, or secondary outcome measures. When performing primary TEA with radial head retention, or replacement, care should be taken to ensure that the ulnar component is correctly positioned such that intramedullary axis of the radial neck lines up with the centre of elbow rotation, as this strongly correlates with better function and less pain after surgery

Introduction. Isolated trochlea fractures are very rare and have only been described previously as case reports. Aims. To report on a case of isolated trochlea fracture and to present a review of the literature. Results. There have only been four previous reports of isolated trochlea fracture. Our fifth case is included in the analysis of the literature given below. Average age 26 (Range 12–33). 60% female, 80% left sided. Dominance only stated in 40% of cases- 50% dominant side. Mechanism of injury: 60% low velocity fall onto an outstretched hand, 40% high velocity- RTA & fall off horse- exact mechanism of injury unknown. Patients all presented with elbow held in flexion, pain and swelling over the medial aspect and a painfully reduced range of motion. Diagnosis made on plain radiographs in 80%, tomograms required in 20%. AP noted to be essential to differentiate from more common capitellum fracture. 20% of fractures associated with comminution. Management consisted of open reduction through a medial approach and internal fixation in 80% (20% headless screw, 20% k-wire, 40% 4.0mm partially threaded cancellous screws) and olecranon traction in 20%. Elbows were immobilised from 3 to 8 weeks. Time to union ranged from 6 weeks (80%) to 13 weeks (20%). Outcomes were uniformly excellent with 40% being asymptomatic with a FROM, 20% asymptomatic with 10 degrees loss of extension and 40% asymptomatic with 5–20 degrees loss of flexion. There were no reported complications. Conclusion. These are rare injuries and can occur through high and low energy mechanisms. They tend to occur in younger age groups. Diagnosis can be made readily with plain radiographs- the AP is essential in differentiating it from the more common capitellum fracture. The prognosis for this intra-articular fracture is good to excellent

Aims

To investigate the risk factors for unsuccessful radial head reduction (RHR) in children with chronic Monteggia fractures (CMFs) treated surgically.

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Acute and chronic injuries of the interosseus membrane can result in longitudinal instability of the forearm. Reconstruction of the central band of the interosseus membrane can help to restore biomechanical stability. Different methods have been used to reconstruct the central band, including tendon grafts, bone-ligament-bone grafts, and synthetic grafts. This Idea, Development, Exploration, Assessment, and Long-term (IDEAL) phase 1 study aims to review the clinical results of reconstruction using a synthetic braided cross-linked graft secured at either end with an Endobutton to restore the force balance between the bones of the forearm.

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The aim of this study was to analyze how proximal radial neck resorption (PRNR) starts and progresses radiologically in two types of press-fit radial head arthroplasties (RHAs), and to investigate its clinical relevance.

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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.

Background. Humeral version is the twist angle of the humeral head relative to the distal humerus. Pre-operatively, it is most commonly measured referencing the transepicondylar axis, although various techniques are described in literature (Matsumura et al. 2014, Edelson 1999, Boileau et al., 2008). Accurate estimation of the version angle is important for humeral head osteotomy in preparation for shoulder arthroplasty, as deviations from native version can result in prosthesis malalignment. Most humeral head osteotomy guides instruct the surgeon to reference the ulnar axis with the elbow flexed at 90°. Average version values have been reported at 17.6° relative to the transepicondylar axis and 28.8° relative to the ulnar axis (Hernigou, Duparc, and Hernigou 2014), although it is highly variable and has been reported to range from 10° to 55° (Pearl and Volk 1999). These studies used 2D CT images; however, 2D has been shown to be unreliable for many glenohumeral measurements (Terrier 2015, Jacxsens 2015, Budge 2011). Three-dimensional (3D) modeling is now widely available and may improve the accuracy of version measurements. This study evaluated the effects of sex and measurement system on 3D version measurements made using the transepicondylar and ulnar axis methods, and additionally a flexion-extension axis commonly used in biomechanics. Methods. Computed tomography (CT) scans of 51 cadaveric shoulders (26 male, 25 female; 32 left) were converted to 3D models using medical imaging software. The ulna was reduced to 90° flexion to replicate the arm position during intra-operative version measurement. Geometry was extracted to determine landmarks and co-ordinate systems for the humeral long axis, epicondylar axis, flexion-extension axis (centered through the capitellum and trochlear groove), and ulnar long axis. An anatomic humeral head cut plane was placed at the head-neck junction of all shoulders by a fellowship trained shoulder surgeon. Retroversion was measured with custom Matlab code that analysed the humeral head cut plane relative to a reference system based on the long axis of the humerus and each elbow axis. Effects of measurement systems were analyzed using separate 1-way RM ANOVAs for males and females. Sex differences were analyzed using unpaired t-tests for each measurement system. Results. Changing the measurement reference significantly affected version (p<0.001). The ulnar axis method consistently resulted in higher measured version than either flexion-extension axis (males 9±1°, females 14±1°, p<0.001) or epicondylar axis (males 8±1°, females 12±1°, p<0.001). See Figure 1. Version in males (38±11°) was 7° greater than females (31±12°) when referencing the flexion-extension axis (p=0.048). Conclusion. Different measurement systems produce different values of version. This is important for humeral osteotomies; if version is assessed using the epicondyles pre-operatively and subsequently by the ulna intra-operatively, then the osteotomy will be approximately 10° over-retroverted. For any figures or tables, please contact authors directly (see Info & Metrics tab above).

Aims

This is a multicentre, prospective assessment of a proportion of the overall orthopaedic trauma caseload of the UK. It investigates theatre capacity, cancellations, and time to surgery in a group of hospitals that is representative of the wider population. It identifies barriers to effective practice and will inform system improvements.

We analysed the axis of movement in the normal elbow during flexion in vivo using radiostereometric analysis (RSA). The results show an intraindividual variation in the inclination of the axis ranging from 2.1° to 14.3° in the frontal and from 1.6° to 9.8° in the horizontal plane analysed at 30° increments. The inclination of the mean axis of rotation varied within a range of 12.7° in the frontal and 4.6° in the horizontal plane. In both planes, the mean axes were located close to a line joining the centres of the trochlea and capitellum. The intra- and interindividual variations of the axes of flexion of the elbow were greater than previously reported. These factors should be considered in the development of elbow prostheses

A simple method of radiological assessment has been used to measure the angle between the long axis of the humeral shaft and the growth plate of the capitellum (the Baumann angle). In the normal arm a significant relationship was found between the Baumann angle and the carrying angle. The Baumann angle was also measured after reduction of supracondylar fractures of the humerus and was found to correlate well with the final carrying angle measured at follow-up. There was no significant difference between the Baumann angle after reduction and that measured at follow-up; and it is suggested that this angle after reduction can be reliably used to predict accurately the final carrying angle

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

Purpose: The treatment of extension type II pediatric supracondylar humerus fractures remains controversial. Some argue that closed reduction and cast immobilization is sufficient to treat these fractures, while others advocate closed reduction and pinning. The purpose of this radiographic outcomes study was to determine whether closed reduction and cast immobilization could successfully obtain and maintain appropriate position of extension type II supracondylar humerus fractures. Method: The radiographs of 1017 pediatric patients treated for supracondylar fractures between 1987 and 2007 were retrospectively reviewed. Pre-reduction, immediate post-reduction, and final radiographs of 155 extension type II fractures were measured in order to assess the position and alignment of the fracture fragments. Measurements included the anterior humeral line, humeral-capitellar angle, Baumann’s angle, the Gordon index, and the Griffet index. The latter two indices calculate the rotational instability of the fracture, which can be predictive of reduction loss. Patients were excluded if insufficient radiographs failed to allow complete assessment of the measurement parameters, or if open reduction was required. Results: The average age of the subjects was 5.3 years (range 1–13 years) and had a mean follow-up of 5.3 months. Analysis of the final radiographs demonstrated that in 80% of subjects, the anterior humeral line remained anterior to the mid third segment of the capitellum (radiographic extension deformity), the mean humeral-capitellar angle was 23.8° (range – 11°–50°), the mean Baumann’s angle was 79.4° (range 62°–97°), the mean Gordon index was 4.59%, and 44% of subjects had a Griffet index between 1–3 (potentially indicative of unstable reduction due to malrotation of the fragments, which can allow the development of a cubitus varus deformity). Conclusion: From this radiographic review, a significant proportion of fractures treated with closed reduction and cast immobilization failed to achieve anatomic position and alignment on final x-rays. However, the clinical significance of these results and the potential for long-term re-modeling of these fractures remains unknown

This in-vitro study evaluated the influence of ligament tensioning and the effectiveness of lateral collateral ligament (LCL) repair using transosseous sutures on the initial kinematics and stability of the elbow. Six fresh upper-extremities were mounted in a motion simulator with tracking system, which enabled both passive and simulated active elbow flexion. The intact elbow was tested then the LCL was sectioned from its humeral origin and repaired with a transosseous suture technique. Locking sutures were placed in the LCL and passed through a humeral bone tunnel entering at the centre of curvature of the capitellum with exit holes in the lateral epicondyle. An actuator pulled on the sutures to achieve 20, 40 and 60 N of LCL repair tension and the sutures were then secured. The dependent variable of this study was the motion pathways of the ulna relative to the humerus. The data were analyzed using a two-way, repeated-measures ANOVA with relevant post-hoc paired t-tests. With the arm oriented in the horizontal position under varus gravity loading, the repairs tracked in greater valgus than the intact LCL regardless of the repair tension. The larger the initial repair tension, the more the elbows tracked in valgus. Initial tension of 60 N was statistically different than the intact LCL with the forearm in pronation (p=0.04). Both the 40 and 60 N initial tensions were statistically different than the intact LCL with the forearm in supination (p< 0.01). Repair of the LCL using transosseous sutures effectively restores the varus stability of the elbow. The initial tension of LCL repairs affects the kinematics of the elbow, with a tendency to over-tighten the ligament and pull the elbow into valgus. These data suggest that acute repair of the LCL should be performed using a transosseous suture technique, and that a tension of 20N or perhaps less is sufficient to restore stability

Osteochondral autologous transplantation (OATS) is a new technique for the treatment of osteochondral defects. In a prospective study between April 1996 und May 2001 we used the OATS technique to treat 201 patients (125 male, 76 female) with a mean osteochondral defect of 3,3 cm. 2. The defect was in the medial femoral condyle in 96 cases, the lateral femoral condyle in 16, the patella in 22, the trochlea in seven, the tibial plateau in one, the talus in 48, the tibial plafond in two and capitellum in four. There were 17 other locations. The procedure was performed either open or arthroscopically. A mean of 2,2 cylinders was transplanted. The Lysholm score in the lower limbs increased from a preoperative mean of 58,3 (20 to77) to a mean of 90,2 (70 to 100). Treatment by OATS alone increased the score from 65,2 to 91,6. With additional ACL/PCL reconstruction, the score increased from 49,9 to 82,6. The combination of OATS, HTO, ACL/PCL reconstruction increased the Lysholm score from 55,5 to 85,5. Ten per cent of patients complained of pain at the donor site in the lateral femoral condyle. There were no complications related to OATS performed in the upper limbs, and control MRI three months postoperatively showed incorporation of all cylinders. The results are encouraging, and give rise, to the hope that this cost-effective and safe treatment for limited osteochondral defects may delay or even prevent the onset of osteoarthritis

Purpose: The successful placement of elbow prostheses, external fixators and ligament reconstructions is dependent on the accurate identification of the elbow’s flexion-extension (FE) axis. In the case of periarticular bone loss, the FE axis must be visually estimated, as the necessary anatomical landmarks may not be available. Hence, referencing the uninjured elbow anatomy may prove beneficial in accurately defining this axis. However, this is contingent on the morphological features being similar between the two sides. Our objective was to compare distal humeral morphology between paired specimens. Our hypothesis was that anthropometric measurements from the distal humerus would be similar to the contralateral side. Method: CT Images of 25 paired distal humeri were obtained. A right-to-left surface registration was then performed on each pair using the iterative closest point (icp) least-squares algorithm, thus placing each specimen in the same coordinate system.. Anthropometric characteristics measured (and compared between the left and right sides) included the angles of the FE and epicondylar axes in both the coronal and transverse planes, the anterior offset of the FE axis with respect to the humeral shaft axis, the length of the FE axis and the radius of curvature of the capitellum and trochlea. Results: There was no statistically significant difference between the left and right humeri for the eight anthropometric characteristics studied (p > 0.05). The mean difference in magnitude for the FE axis angle was approximately 1.0° in both the coronal and transverse planes and the difference in magnitude for 80% of the paired specimens was less than 1.5°. Conclusion: The anthropometric features of the distal humerus that are typically employed during elbow surgery are similar from side to side. Preoperative imaging of the contralateral normal elbow should be considered in patients with periarticular bone loss where referencing anatomical landmarks of the injured side is not possible. This information can be used as part of a preoperative plan to determine the ideal position of the implant, ligament reconstruction or external fixator during surgery. Contralateral imaging should be particularly useful when combined with computer-assisted elbow surgery

Introduction Osteochondral autologous transplantation (OATS) is a technique to treat hyaline cartilage injuries in different joints. It delivers high quality hyaline cartilage to the defect. Methods In a prospective study we used the OATS technique in 201 patients (125 male, 76 female). The mean defect size was 3.3 sq cm. The medial femoral condyle was treated in 96 cases, the lateral femoral condyle in 16, the patella in 22, the trochlea in seven, the tibial plateau in one, the talus in 48, the tibial plafond in two and the capitellum in four. There were 17 other locations. The procedure was performed either open or arthroscopically. A mean of 2.2 cylinders were implanted. Mal-alignment was corrected in 20 cases with an osteotomy and instability of the knee by anterior (ACL) or posterior (PCL) reconstruction. Five patients required reconstruction of both the ACL and PCL. Results The Lysholm score increased from 58.3 (20 to 77) to a mean of 90.2 (70 to 100) in the lower extremity. Treatment by OATS alone increased the score from 65.2 to 91.6. With additional ACL/PCL reconstruction, the score increased from 49.9 to 82.6. The combination of OATS, HTO and ACL/PCL reconstruction increased the Lysholm score from 55.5 to 85.5. Post-operative MR imaging with intravenous contrast showed incorporation of all but one cylinder. Complications included one case of arthrofibrosis and sinking of one cylinder. One patient developed regional pain syndrome and three had pain at the malleolar osteotomy site resolved by screw removal. Ten percent of the patients developed pain at the donor site. Conclusions The results are encouraging. It is a cost effective and safe treatment

Osteochondral autologous transplantation (OATS) is a new technique for the treatment of osteochondral defects. In a prospective randomised study, between November 1996 and June 2000 we used the OATS technique to treat 136 patients (90 male, 46 female) with a mean osteochondral defect of 3.3 cm2. The defect was in the medial femoral condyle in 54 cases, the lateral femoral condyle in nine, the patella in 15, the trochlea in six, the tibial plateau in one, the talus in 29, the tibial plafond in two, the capitellum in four. There were 16 other locations. The procedure was performed either open or arthroscopically. A mean of 2.2 cylinders was transplanted. At the same time, we treated malalignment by high tibial osteotomy (HTO) in 20 patients, and instability by anterior (ACL) or posterior cruciate ligament (PCL) reconstruction in 16. Five patients required reconstruction of both ACL and PCL. The Lysholm score in the lower limbs increased from a preoperative mean of 58.3 (20 to 77) to a mean of 90.2 (70 to 100). Treatment by OATS alone increased the score from 62.9 to 91.6. The combination of OATS and HTO increased the score from 65.2 to 91.6. With additional ACL/PCL reconstruction, the score increased from 49.9 to 82.6. The combination of OATS, HTO and ACL/PCL reconstruction increased the Lysholm score from 55.5 to 85.5. Control postoperative MRI with IV contrast (Gd-DTPA) showed incorporation of all but one cylinder. Complications included one case of arthrofibrosis and sinking of one cylinder. One patient developed regional pain syndrome and three had pain at the malleolar osteotomy site, resolved by screw removal. For four weeks after the operation, 10% of patients complained of pain at the donor side in the lateral femoral condyle. There were no complications related to OATS performed in the upper limbs, and control MRI three months postoperatively showed incorporation of all cylinders. The results are encouraging, and give rise to the hope that this cost-effective and safe new treatment for limited osteochondral defects may delay or even prevent the onset of osteoarthritis

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.

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.

Non operative treatment of supracondylar fractures of the humerus has almost always resulted in failure. Closed reduction followed by prolonged immobilization until union, may be associated with an acceptable X-ray but with unacceptable function because of marked stiffness. Traction and early motion preserves movement but the incongruity of the joint leads to instability, early post-traumatic arthritis and pain. Traction also requires prolonged hospital admission which is not possible in modern health care settings. Attempts at early motion without reduction, the so called “bag of bones treatment” leads to gross malunions, non-unions and poor function. In order to function normally an elbow requires stability, a congruent articulation, freedom from pain, and a functional range of motion. After fracture one can achieve a normal elbow only after anatomic reduction fracture which is combined with absolutely stable fixation and early motion. These fractures are classified according to the Comprehensive Classification into Types: A, B, and C, with their respective groups and subgroups, all arranged in an ascending order of severity. Once a surgeon classifies a fracture he gains insight into the associated problems in treating it. Classification thus helps in proper decision making. In young patients these fractures are usually the result of a high energy trauma. Although multifragmentary and at times open, these are fractures of normal bone and are therefore often amenable to secure fixation. In the elderly the commonest mechanism is a slip and fall on to the point of the elbow. The olecranon is driven into the trochlea and splits the osteoporotic condyle of the humerus into a multitude of fragments. The resultant fractures are multifragmentary, displaced and often defy attempts at reduction and fixation. When one is deciding on treatment the factors which must be considered are patient factors, the fracture factors, and the treatment factors. The most important factors are: the patients age and the degree of osteoporosis, the comminution and displacement of the fractures, the association of neurovascular injuries, and whether the fracture is open or closed. An open reduction and internal fixation is best performed with the patient on the side with the injured elbow uppermost, or with the patient prone. The best surgical approach is posterior. Once the skin is incised one must isolate and protect the ulnar nerve. The facture is exposed by carrying out an osteotomy of the olecranon. In elderly patients in whom a prostheses might become the salvage, one should consider using a triceps splitting approach or a triceps peal as for an elbow arthroplasty. Commence fixation with an anatomic reduction of the trochlear fragment to the capitellar fragment. If bone is missing than instead of lag screws one uses fully threaded screws to prevent the narrowing of the distal articulation. Once securely fixed, the articular complex is fixed to the metaphysis and shaft. The fixation is carried out with two plates which should be positioned at 90 degrees to each other to achieve the strongest biomechanical construct. The plates commonly used are the 3.5mm LCDCP plates or the 3.5mm reconstruction plates. The choice of one or the other plate depends on the fracture pattern and on the necessary contouring of the plates. The usual choice are two reconstruction plates one medially and one posteriorly contoured to fit the posterior aspect of the capitellum which is devoid of articular cartilage. Such fixation is particularly useful in distal fractures. If there is metaphyseal bone loss one should use at least one LCDCP since these are stronger than the reconstruction plates. Post-operatively the elbow is immobilized in 120–150 degrees of extension and is elevated for 24–48 hours. Early active motion should commence no later than day three in order to regain a range of motion. Delay in internal fixation beyond day 5 often leads to the formation of heterotopic bone with marked stiffness. If surgery is delayed the patient should receive Indocid to prevent heterotopic bone formation. If heterotopic bone develops and blocks motion it should be resected early. One should not delay until the alkaline phosphatase and the bone scans return to normal. Supracondular fractures in the elderly present special problems since they defy attempts at reduction and stable fixation. As a result many elderly patients, whether operated or not, end up with poor and painful elbow function. To prevent these therapeutic disasters recently primary total elbow arthroplasty has been used as a primary form of treatment. Bernard Morrey published encouraging early results of elderly patients with supracondylar fractures treated primarily with the semi-constrained Coonrad Morrey prosthesis. Since then this rationale has been adopted by a number of trauma centers and there are numerous multicenter trials underway to evaluate this form of treatment and place it in its proper perspective. Open supracondylar fractures present a special problem. If they occur in young patients with good bone and if they are reconstructible, then after a thorough irrigation and debridement a primary open reduction and internal fixation should be carried out. If stable fixation is not possible one should carry out an open reduction and fixation of the articular component, and span the elbow with an external fixator. Once a stable and closed soft tissue envelope has been achieved one can carry out a delayed reconstruction of the metaphyseal component. This greatly reduced risks of infection. In elderly patients with osteoporotic bone this may not be possible as indicated. Every open fracture must be irrigated and debrided. Stable internal fixation greatly lessens the risk of infection. Because of poor bone mobilization of the joint in these patients must be delayed and the internal fixation often supplemented with external fixation to prevent fixation failure. A primary arthroplasty should not be considered because of the risk of sepsis. In young patients with good bone with Type C1 and C2 fractures 80–90% of good functional results are to be expected. C3 fractures particularly if open and fractures in the elderly, except those treated with primary arthroplsty, lead to unsatisfactory outcomes

Aim

The aim of this study was to report the long-term outcome and implant survival of the lateral resurfacing elbow (LRE) arthroplasty in the treatment of elbow arthritis.

Aims

The aim of this study was to evaluate the outcome of Monteggia-like lesions at midterm follow-up and to determine whether the surgical treatment of the radial head influences the clinical and radiological results.

Aims

Radial head arthroplasty (RHA) may be used in the treatment of non-reconstructable radial head fractures. The aim of this study was to evaluate the mid-term clinical and radiographic results of RHA.

This retrospective study was designed to evaluate the outcomes of re-dislocation of the radial head after corrective osteotomy for chronic dislocation. A total of 12 children with a mean age of 11 years (5 to 16), with further dislocation of the radial head after corrective osteotomy of the forearm, were followed for a mean of five years (2 to 10). Re-operations were performed for radial head re-dislocation in six children, while the other six did not undergo re-operation (‘non-re-operation group’). The active range of movement (ROM) of their elbows was evaluated before and after the first operation, and at the most recent follow-up.

In the re-operation group, there were significant decreases in extension, pronation, and supination when comparing the ROM following the corrective osteotomy and following re-operation (p < 0.05).

The children who had not undergone re-operation achieved a better ROM than those who had undergone re-operation.

There was a significant difference in mean pronation (76° vs 0°) between the non- re-operation and the re-operation group (p = 0.002), and a trend towards increases in mean flexion (133° vs 111°), extension (0° vs 23°), and supination (62° vs 29°). We did not find a clear benefit for re-operation in children with a re-dislocation following corrective osteotomy for chronic dislocation of the radial head.

Cite this article: Bone Joint J 2015;97-B:1582–7.

Aims

Displaced fractures of the lateral condyle of the humerus are frequently managed surgically with the aim of avoiding nonunion, malunion, disturbances of growth and later arthritis. The ideal method of fixation is however not known, and treatment varies between surgeons and hospitals. The aim of this study was to compare the outcome of two well-established forms of surgical treatment, Kirschner wire (K-wire) and screw fixation.

The February 2015 Children’s orthopaedics Roundup³⁶⁰ looks at: Hip dislocation in children with CTEV: two decades of experience; Population-based prevention of DDH in cerebral palsy: 20 years’ experience; Shoulder derotation in congenital plexus palsy; Back pain in the paediatric population: could MRI be the answer?; Intercondylar fracture of the humerus in children; The Dunn osteotomy in SUFE; Radiocapitellar line a myth!; Do ‘flatfooted’ children suffer?

Aims

The primary aim of this study was to define the standard minimum follow-up required to produce a reliable estimate of the rate of re-operation after radial head arthroplasty (RHA). The secondary objective was to define the leading reasons for re-operation.

Most fractures of the radial head are stable undisplaced or minimally displaced partial fractures without an associated fracture of the elbow or forearm or ligament injury, where stiffness following non-operative management is the primary concern. Displaced unstable fractures of the radial head are usually associated with other fractures or ligament injuries, and restoration of radiocapitellar contact by reconstruction or prosthetic replacement of the fractured head is necessary to prevent subluxation or dislocation of the elbow and forearm. In fractures with three or fewer fragments (two articular fragments and the neck) and little or no metaphyseal comminution, open reduction and internal fixation may give good results. However, fragmented unstable fractures of the radial head are prone to early failure of fixation and nonunion when fixed. Excision of the radial head is associated with good long-term results, but in patients with instability of the elbow or forearm, prosthetic replacement is preferred.

This review considers the characteristics of stable and unstable fractures of the radial head, as well as discussing the debatable aspects of management, in light of the current best evidence.

Cite this article: Bone Joint J 2013;95-B:151–9.

Fractures of the distal humeral articular surface which do not involve the medial and lateral columns are often more extensive than is apparent from plain radiographs. This retrospective study describes the epidemiology of this injury using modern classification systems and compares pre-operative radiography with operative findings. The study group included 79 patients with a mean age of 47 years (13 to 91). The annual incidence was 1.5 per 100 000 population, and was highest in women over the age of 60. The majority of the fractures (59; 75%) were sustained in falls from standing height. Young males tended to sustain more high-energy injuries with more complex fracture patterns. In 24% of cases (19) there was a concomitant radial head fracture. Classification from plain radiographs often underestimates the true extent of the injury and computed tomography may be of benefit in pre-operative planning, especially in those over 60 years of age.

We present a case of post-traumatic osteonecrosis of the radial head in a 13-year-old boy which was treated with costo-osteochondral grafts. A satisfactory outcome was seen at a follow-up of two years and ten months.

Although costo-osteochondral grafting has been used in the treatment of defects in articular cartilage, especially in the hand and the elbow, the extension of the technique to manage post-traumatic osteonecrosis of the radial head in a child has not previously been reported in the English language literature. Complete relief of pain was obtained and an improvement in the range of movement was observed. The long-term results remain uncertain.

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 Essex-Lopresti injury (ELI) of the forearm is a rare and serious condition which is often overlooked, leading to a poor outcome.

The purpose of this retrospective case study was to establish whether early surgery can give good medium-term results.

From a group of 295 patients with a fracture of the radial head, 12 patients were diagnosed with ELI on MRI which confirmed injury to the interosseous membrane (IOM) and ligament (IOL). They were treated by reduction and temporary Kirschner (K)-wire stabilisation of the distal radioulnar joint (DRUJ). In addition, eight patients had a radial head replacement, and two a radial head reconstruction.

All patients were examined clinically and radiologically 59 months (25 to 90) after surgery when the mean Mayo Modified Wrist Score (MMWS) was 88.4 (78 to 94), the mean Mayo Elbow Performance Scores (MEPS) 86.7 (77 to 95) and the mean disabilities of arm, shoulder and hand (DASH) score 20.5 (16 to 31): all of these indicate a good outcome.

In case of a high index of suspicion for ELI in patients with a radial head fracture, we recommend the following: confirmation of IOM and IOL injury with an early MRI scan; early surgery with reduction and temporary K-wire stabilisation of the DRUJ; preservation of the radial head if at all possible or replacement if not, and functional bracing in supination. This will increase the prospect of a good result, and avoid the complications of a missed diagnosis and the difficulties of late treatment.

Cite this article: Bone Joint J 2014;96-B:1385–91.

Posterolateral rotatory instability is the most common type of symptomatic chronic instability of the elbow. In this condition the forearm complex rotates externally in relation to the humerus, causing posterior subluxation or dislocation of the radial head. The lateral ligament complex, radial head and coronoid process are important constraints to posterolateral rotatory instability, and their disruption is involved in the pathogenesis of this condition. The diagnosis relies on a high index of clinical suspicion, active and passive apprehension tests, and examination under anaesthesia. Surgical treatment has given consistently successful results. Open reconstruction of the lateral ligaments with a tendon graft has been the procedure of choice, with arthroscopic techniques emerging as a potential alternative.

Aim

Nail patella syndrome (NPS) is a skeletal dysplasia with patellofemoral dysfunction as a key symptom. We present the first in-depth radiological evaluation of the knee in a large series of NPS patients and describe the typical malformations.

There is little information available at present regarding the mechanisms of failure of modern metallic radial head implants. Between 1998 and 2008, 44 consecutive patients (47 elbows) underwent removal of a failed metallic radial head replacement. In 13 patients (13 elbows) the initial operation had been undertaken within one week of a fracture of the radial head, at one to six weeks in seven patients (seven elbows) and more than six weeks (mean of 2.5 years (2 to 65 months)) in 22 patients (25 elbows). In the remaining two elbows the replacement was inserted for non-traumatic reasons. The most common indication for further surgery was painful loosening (31 elbows). Revision was undertaken for stiffness in 18 elbows, instability in nine, and deep infection in two. There were signs of over-lengthening of the radius in 11 elbows. Degenerative changes were found in all but one. Only three loose implants had been fixed with cement. Instability was not identified in any of the bipolar implants.

We reviewed 15 patients, nine girls and six boys, with chronic anterior dislocation of the radial head which was treated by ulnar osteotomy, external fixation and open reconstruction of the elbow joint but without repair of the annular ligament. Their mean age was 9.5 years (5 to 15) and the mean interval between the injury and reconstruction was 22 months (2 months to 7 years).

All radial heads remained reduced at a mean follow-up of 20 months (6 months to 5 years). Normal ranges of movement for flexion, extension, pronation and supination were unchanged in 96.1% (49/51) and worse in 3.9% (2/51). Limited ranges of movement were improved in 77.8% (7/9), unchanged in 11% (1/9) and further decreased in 11% (1/9).There were two superficial pin-track infections and two cases of delayed union but with no serious complications. Reconstruction of the radiocapitellar joint is easier using external fixation since accurate correction of the ulna can be determined empirically and active functional exercises started immediately. Only patients with a radial head of normal shape were selected for treatment by this method.

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.

Surgical access to the head of the radius is usually performed through a lateral approach. We present an alternative technique through a modified posterior approach which was developed following dissections of 22 human cadavers. An osteotomy of the supinator tuberosity was performed and reflected as a single unit with the attached annular ligament. Excellent exposure of the head of the radius was achieved, replacement of the head was undertaken and the osteotomy site repaired. The elbows were stable and had a full range of movement. The approach was then carried out on 13 patients for elective replacement of the head and was found to be safe and reproducible. In the patient group all osteotomies united, the elbows were stable and had an improved range of supination and pronation. There was no change in flexion and extension of the elbow. Complications included a haematoma and a reflex sympathetic dystrophy.

The modified posterior approach provides excellent access to the head and neck of the radius, gives good stability of the elbow and allows early mobilisation of the joint.

We undertook a study on eight arms from fresh cadavers to define the clinical usefulness of the lesser sigmoid notch as a landmark when reconstructing the length of the neck of the radius in replacement of the head with a prosthesis. The head was resected and its height measured, along with several control measurements. This was compared with in situ measurements from the stump of the neck to the proximal edge of the lesser sigmoid notch of the ulna. All the measurements were performed three times by three observers acting independently.

The results were highly reproducible with intra- and interclass correlations of > 0.99. The mean difference between the measurement on the excised head and the distance from the stump of the neck and the lesser sigmoid notch was −0.02 mm (−1.24 to +0.97). This difference was not statistically significant (p = 0.78).

The proximal edge of the lesser sigmoid notch provides a reliable landmark for positioning a replacement of the radial head and may have clinical application.

Objectives

Local corticosteroid infiltration is a common practice of treatment for lateral epicondylitis. In recent studies no statistically significant or clinically relevant results in favour of corticosteroid injections were found. The injection of autologous blood has been reported to be effective for both intermediate and long-term outcomes. It is hypothesised that blood contains growth factors, which induce the healing cascade.

The use of passive stretching of the elbow after arthrolysis is controversial. We report the results of open arthrolysis in 81 patients. Prospectively collected outcome data with a minimum follow-up of one year were analysed. All patients had sustained an intra-articular fracture initially and all procedures were performed by the same surgeon under continuous brachial plexus block anaesthesia and with continuous passive movement (CPM) used post-operatively for two to three days. CPM was used to maintain the movement achieved during surgery and passive stretching was not used at any time. A senior physiotherapist assessed all the patients at regular intervals. The mean range of movement (ROM) improved from 69° to 109° and the function and pain of the upper limb improved from 32 to 16 and from 20 to 10, as assessed by the Disabilities of the Arm Shoulder and Hand score and a visual analogue scale, respectively. The greatest improvement was obtained in the stiffest elbows: nine patients with a pre-operative ROM < 30° achieved a mean post-operative ROM of 92° (55° to 125°). This study demonstrates that in patients with a stiff elbow after injury, good results may be obtained after open elbow arthrolysis without using passive stretching during rehabilitation.

Disruption of the interosseous membrane is easily missed in patients with Essex-Lopresti syndrome. None of the imaging techniques available for diagnosing disruption of the interosseous membrane are completely dependable.

We undertook an investigation to identify whether a simple intra-operative test could be used to diagnose disruption of the interosseous membrane during surgery for fracture of the radial head and to see if the test was reproducible.

We studied 20 cadaveric forearms after excision of the radial head, ten with and ten without disruption of the interosseous membrane. On each forearm, we performed the radius joystick test: moderate lateral traction was applied to the radial neck with the forearm in maximal pronation, to look for lateral displacement of the proximal radius indicating that the interosseous membrane had been disrupted. Each of six surgeons (three junior and three senior) performed the test on two consecutive days.

Intra-observer agreement was 77% (95% confidence interval (CI) 67 to 85) and interobserver agreement was 97% (95% CI 92 to 100). Sensitivity was 100% (95% CI 97 to 100), specificity 88% (95% CI 81 to 93), positive predictive value 90% (95% CI 83 to 94), and negative predictive value 100%).

This cadaveric study suggests that the radius joystick test may be useful for detecting disruption of the interosseous membrane in patients undergoing open surgery for fracture of the radial head and is reproducible. A confirmatory study in vivo is now required.

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.

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

We have reviewed five adult patients treated with endoprosthetic reconstruction of the proximal radius following resection of non-traumatic lesions. The patients had a mean age of 33.4 years (20 to 60) at the time of surgery and the mean follow-up was 7.6 years (0.8 to 16).

Following surgery, all elbows were clinically stable and there was 100% survivorship of the prosthesis. Evaluation of function was assessed clinically and by the Mayo Elbow Performance Score, achieving a mean of 86% (70 to 100).

Results at medium-term follow-up are encouraging with regards to elbow stability, implant survivorship and functional outcome.

Arthrolysis and dynamic splinting have been used in the treatment of elbow contractures, but there is no standardised protocol for treatment of severe contractures with an arc of flexion < 30°. We present our results of radical arthrolysis with twin incisions with the use of a monolateral hinged fixator to treat very severe extra-articular contracture of the elbow. This retrospective study included 26 patients (15 males and 11 females) with a mean age of 30 years (12 to 60). The mean duration of stiffness was 9.1 months (5.4 to 18) with mean follow-up of 5.2 years (3.5 to 9.4). The mean pre-operative arc of movement was 15.6° (0° to 30°), with mean pre-operative flexion of 64.1° (30° to 120°) and mean pre-operative extension of 52.1° (10° to 90°). Post-operatively the mean arc improved to 102.4° (60° to 135°), the mean flexion improved to 119.1° (90° to 140°) and mean extension improved to 16.8° (0° to 30°) (p < 0.001). The Mayo elbow score improved from a mean of 45 (30 to 65) to 89 (75 to 100) points, and 13 had excellent, nine had good, three had fair and one had a poor result. We had one case of severe instability and one wound dehiscence which responded well to treatment. One case had deep infection with poor results which responded well to treatment.

Our findings indicate that this method is very effective in the treatment of severe elbow contracture; however, a randomised controlled study is necessary for further evaluation.

We describe two cases of osteochondritis dissecans (OCD) affecting both femoral condyles in the same knee. The patients presented with recurrent episodes of pain and swelling, but these were initially thought to be ‘growing pains’. Eventually, a delayed diagnosis of bicondylar OCD was established and both patients were referred for further management. After assessing the extent of the disease on MRI, matrix-induced autologous chondrocyte implantation was performed to treat the defects of the lateral condyle in each case, with a plan to address the medial defects at a later stage. Proposed theories on the aetiology of the condition and available methods of treatment are discussed. A diagnosis of OCD should be considered in young patients with persistent knee pain and effusions, and MRI is the investigation of choice for early detection.

We describe a rare variant of mirror hand in a 20-year-old man who presented with multiple fingers. Radiographs revealed two ulnae (one vestigial) and a radius. There was duplication of the humeral head. The unique features of this case are the age of patient before the start of treatment and extension of the duplication proximal to the elbow.

The Essex-Lopresti injury is rare. It consists of fracture of the head of the radius, rupture of the interosseous membrane and disruption of the distal radioulnar joint. The injury is often missed because attention is directed towards the fracture of the head of the radius. We present a series of 12 patients with a mean age of 44.9 years (26 to 54), 11 of whom were treated surgically at a mean of 4.6 months (1 to 16) after injury and the other after 18 years. They were followed up for a mean of 29.2 months (2 to 69). Ten patients had additional injuries to the forearm or wrist, which made diagnosis more difficult. Replacement of the head of the radius was carried out in ten patients and the Sauve-Kapandji procedure in three. Patients were assessed using standard outcome scores. The mean post-operative Disabilities of the Arm, Shoulder and Hand score was 55 (37 to 83), the mean Morrey Elbow Performance score was 72.2 (39 to 92) and the mean Mayo wrist score was 61.3 (35 to 80). The mean grip strength was 68.5% (39.6% to 91.3%) of the unaffected wrist.

Most of the patients (10 of 12) were satisfied with their operation and in 11 the pain was relieved. When treating the chronic Essex-Lopresti injury, we recommend accurate realignment of the radius and ulna and replacement of the head of the radius. If this fails a Sauve-Kapandji procedure to arthrodese the distal radioulnar joint should be undertaken to stabilise the forearm while maintaining mobility.

Sixteen patients who underwent a revision operation for nonunion of fractures of the distal humerus following previous internal fixation were reviewed at a mean follow-up of 39 months (8 to 69).

The Mayo elbow performance score was excellent in 11, good in two, fair in two and poor in one. In 15 patients union was achieved and in one with an infected nonunion a subsequent bone graft was necessary in order to obtain union.

Age, gender, a history of smoking, mechanism of the injury and the AO classification of the initial fracture did not correlate with the development of nonunion. In 12 patients (75%), the initial fixation was assessed as being suboptimal. The primary surgery was regarded as adequate in only three patients. Our findings suggest that the most important determinant of nonunion of a distal humeral fracture after surgery is the adequacy of fixation.

The objective of this retrospective study was to correlate the Bado and Jupiter classifications with long-term results after operative treatment of Monteggia fractures in adults and to determine prognostic factors for functional outcome. Of 63 adult patients who sustained a Monteggia fracture in a ten-year period, 47 were available for follow-up after a mean time of 8.4 years (5 to 14). According to the Broberg and Morrey elbow scale, 22 patients (47%) had excellent, 12 (26%) good, nine (19%) fair and four (8%) poor results at the last follow-up. A total of 12 patients (26%) needed a second operation within 12 months of the initial operation. The mean Broberg and Morrey score was 87.2 (45 to 100) and the mean DASH score was 17.4 (0 to 70). There was a significant correlation between the two scores (p = 0.01). The following factors were found to be correlated with a poor clinical outcome: Bado type II fracture, Jupiter type IIa fracture, fracture of the radial head, coronoid fracture, and complications requiring further surgery.

Bado type II Monteggia fractures, and within this group, Jupiter type IIa fractures, are frequently associated with fractures of the radial head and the coronoid process, and should be considered as negative prognostic factors for functional long-term outcome. Patients with these types of fracture should be informed about the potential risk of functional deficits and the possible need for further surgery.

Between January 1995 and December 2000, 112 children with a closed displaced supracondylar fracture of the humerus without vascular deficit, were managed by elevated, straight-arm traction for a mean of 22 days. The final outcome was assessed using clinical (flexion-extension arc, carrying angle and residual rotational deformity) and radiographic (metaphyseal-diaphyseal angle and humerocapitellar angle) criteria. Excellent results were achieved in 71 (63%) patients, 33 (29%) had good results, 5 (4.4%) fair, and 3 (2.6%) poor. All patients with fair or poor outcomes were older than ten years of age.

Elevated, straight-arm traction is safe and effective in children younger than ten years. It can be effectively used in an environment that can provide ordinary paediatric medical care and general orthopaedic expertise. The outcomes compare with supracondylar fractures treated surgically in specialist centres.

We describe the intermediate results of lateral ligamentous repair or reconstruction for posterolateral rotatory instability of the elbow. Between 1986 and 1999, we performed 12 direct repairs and 33 ligament reconstructions with a tendon autograft. One patient was lost to follow-up and 44 were retrospectively studied at a mean of six years (2 to 15).

Surgery restored stability in all except five patients. In two the elbow became stable after a second procedure. The mean post-operative Mayo elbow performance score was 85 points (60 to 100). The result was classified as excellent in 19, good in 13, fair in seven and poor in five patients. Thirty-eight patients (86%) were subjectively satisfied with the outcome of the operation. Better results were obtained in patients with a post-traumatic aetiology (p = 0.03), those with subjective symptoms of instability at presentation (p = 0.006) and those who had an augmented reconstruction using a tendon graft (p = 0.04).

Reconstruction using a tendon graft seems to provide better results than ligament repair and the results do not seem to deteriorate with time. The outcome of this procedure is less predictable in patients with no subjective instability.