Aims. The ulna is an extremely rare location for primary bone tumours of the elbow in paediatrics. Although several reconstruction options are available, the optimal reconstruction method is still unknown due to the rarity of proximal ulna tumours. In this study, we report the outcomes of osteoarticular ulna allograft for the reconstruction of proximal ulna tumours. Methods. Medical profiles of 13 patients, who between March 2004 and November 2021 underwent osteoarticular ulna allograft reconstruction after the resection of the proximal ulna tumour, were retrospectively reviewed. The outcomes were measured clinically by the assessment of elbow range of motion (ROM), stability, and function, and radiologically by the assessment of allograft-host junction union, recurrence, and joint degeneration. The elbow function was assessed objectively by the Musculoskeletal Tumor Society (MSTS) score and subjectively by the Toronto Extremity Salvage Score (TESS) and Mayo Elbow Performance Score (MEPS) questionnaire. Results. The mean follow-up of patients was 60.3 months (SD 28.5). The mean elbow flexion-extension ROM was 95.8° (SD 21). The mean MSTS of the patients was 84.4 (SD 8.2), the mean TESS was 83.8 (SD 6.7), and the mean MEPS was 79.2 (SD 11.5). All the patients had radiological union at the osteotomy site. Symptomatic osteoarthritic change was observed in three patients (23%), one of whom ended up with elbow joint fusion. Two patients (15.4%) had recurrence during the follow-up period. Surgical complications included two allograft fractures, two plate fractures, three medial instabilities, and two infections. Conclusion. Osteoarticular ulna allograft reconstruction provides acceptable functional outcomes. Despite a high rate of complications, it is still a valuable reconstruction method, particularly in skeletally immature patients who need their distal humerus physis for the rest of hand growth. Cite this article: Bone Jt Open 2024;5(9):749–757

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

Summary Statement. This 3-dimensional CT study on cadaveric proximal ulna provides further insight into the size and geometry of the proximal ulna intramedullary cavity with potential applications to design and sizing of proximal ulna components. Introduction. Total elbow arthroplasty (TEA) is an established treatment for varying pathologies of the elbow with very good functional outcomes. Optimal fit of ulna components in TEA is predicated on a detailed appreciation of the 3-dimensional anatomy of the proximal ulna intra-medullary cavity, but literature remains scarce. Three-dimensional (3D) models of the proximal ulna have been constructed using computed tomography (CT) programs, accurately defining the angular relations with the cross-sectional extra-medullary dimensions. However, current CT-based thresholding techniques lack accuracy in differentiating cortical from cancellous bone in the metaphyseal region, and thus cannot properly define the intra-medullary region of uncored proximal ulnae. We investigate the geometric dimensions of the proximal ulna intra-medullary cavity using CT studies of cored cadaveric ulnae. Patients & Methods. Three-dimensional models based on CT data of 17 manually cored cadaveric proximal ulnae were created using Matlab program and analyzed. The cadaveric specimens were dissected to identify the medullary canal and coring of the canal of the proximal ulna to exclude the cancellous bone was performed as for ulna canal preparation during TEA. Using the center of a circle fitted over the trochlear ridge as the origin, the diameter, coronal and sagittal angulation of the canal were determined. The diameter, posterior and lateral offsets of the proximal medullary canal were plotted against the normalised axial distance from the origin which was represented in terms of R, the radius of the circle fitted to the trochlear ridge. The normalization of the axial distance was done to compensate for the varying individual ulna lengths. Results. The mean of the radius of the circle which was fitted to the trochlear ridge, R, was found to be 16.64 ± 2.71 mm. The minimum diameter of the canal increased from the origin and peak at 2.3R (just distal to the coronoid process) with a value of 7.08 ± 1.74 mm, decreasing in a linear fashion to 4.48 ± 0.91 mm at 6R. There was an increasing posterior offset which was linear in nature (R. 2. = 0.954) up to 6R (approximately 97mm from the origin). Likewise, the lateral offset increased in a linear fashion (R. 2. = 0.996). Discussion. The findings of our study most likely represent the effective minimum diameter for optimal implant placement, which are consistent with previously documented cadaveric dimensions. The findings also support the current tapered component design of the proximal ulna stemmed implants without the need for significant angulation. Conclusion. Our study provides further insight into the size and geometry of the proximal ulna intramedullary cavity with potential applications to design and sizing of proximal ulna components

Fixation of comminuted olecranon and proximal ulna fractures can be a challenge. The goal of surgery is for stable fixation to encourage union and allow early elbow movement. Over a 3 year period, a low profile titanium, precon-toured olecranon plate (Acumed LLC, Hillsboro, Portland, Oregon) was used in 16 patients with comminuted olecranon and proximal ulna fractures, using a standard universal posterior approach to the olecranon with the patient in a lateral position and active flexion/extension of the elbow was started 48 hours postoperatively. Functional outcomes were measured during follow-up (FU), including range of movement (ROM), Disabilities of the Arm, Shoulder and Hand (DASH) and Mayo Elbow Performance Score (MEPS). There were 9 isolated olecranon fractures, including one open fracture in a multiple injured patient and one an infected non-union and 7 with associated ipsilateral upper limb injuries. Mean age was 52 years (13 to 84) and mean FU was 12.8 months (3 to 33). All had achieved radiological union at 3 months. Overall mean ROM for both groups was 19.3 to 130.7 degrees flexion, 71.8 degrees pronation and 72.1 degrees supination. DASH was 19.1 and MEPS was 87.7. When comparing the 2 groups, there was no significant difference in supination or pronation but all other mean outcomes measurements showed statistical significance in favour of isolated, comminuted olecranon fractures. Extension 9.4 versus 35.0 degrees (p< 0.005), Flexion 140.6 versus 117.5 (p< 0.05), DASH 7.5 versus 34.7 (p=0.0007) and MEPS 96.3 (excellent) versus 78.3 (good) (p< 0.05). There were no infections or failure of metalwork, but two patients had the metalwork removed after union as they required further surgery to their elbows. We demonstrate this is a safe and reliable method of fixation and can expect excellent results when treating isolated comminuted olecranon/proximal ulna fractures and good results when there are associated ipsilateral injuries

Determining and accurately restoring the flexion-extension axis of the elbow is essential for functional recovery after total elbow arthroplasty (TEA). We evaluated the effect of morphological features of the elbow on variations of alignment of the components at TEA. Morphological and positioning variables were compared by systematic CT scans of 22 elbows in 21 patients after TEA.

There were five men and 16 women, and the mean age was 63 years (38 to 80). The mean follow-up was 22 months (11 to 44).

The anterior offset and version of the humeral components were significantly affected by the anterior angulation of the humerus (p = 0.052 and p = 0.004, respectively). The anterior offset and version of the ulnar components were strongly significantly affected by the anterior angulation of the ulna (p < 0.001 and p < 0.001).

The closer the anterior angulation of the ulna was to the joint, the lower the ulnar anterior offset (p = 0.030) and version of the ulnar component (p = 0.010). The distance from the joint to the varus angulation also affected the lateral offset of the ulnar component (p = 0.046).

Anatomical variations at the distal humerus and proximal ulna affect the alignment of the components at TEA. This is explained by abutment of the stems of the components and is particularly severe when there are substantial deformities or the deformities are close to the joint.

Cite this article: Bone Joint J 2015;97-B:1539–45.

We have investigated the anatomy of the proximal part of the ulna to assess its influence on the use of plates in the management of fractures at this site. We examined 54 specimens from cadavers. The mean varus angulation in the proximal third was 17.5° (11° to 23°) and the mean anterior deviation 4.5° (1° to 14°). These variations must be considered when applying plates to the dorsal surface of the ulna for Monteggia-type fractures. A pre-operative radiograph of the contralateral elbow may also be of value.

Proximal ulnar fractures may be difficult to treat and may result in chronic instability, non-union heterotrophic ossification, synostosis, stiffness and post-traumatic arthritis. The aim of this study is to study success of treatment in achieving stable reduction and early rehabilitation.

Between December 2003 and January 2007 fifty patients (fifty-one elbows) which had sustained 21.A3 and 21.C3 fractures were identified and retrospectively studied.

There were two broad groups of patients. Young males following high energy injuries (average age=38+/−16) and old females with osteoporotic fractures (average age=65+/−17). Twenty-two patients had associated monteggia and seven patients had trans-olacrenon dislocation. Twenty-three patients had radial sided injury. This included two capitelar fractures, nineteen radial head and neck fractures and one radial shaft fracture. Fortyfive patients were treated with plating and two patients were treated with tension band wiring. Five different plating techniques were used to stabilize the fractures.

Eighteen patients had incongruent reduction. Eighteen patients had complications of the treatment. There were seven cases of non-union, one case of loss of fixation, three cases of heterotrophic ossification, three cases of synostosis, one case of deep infection and five complications resulting from radial head fractures.

There was no relationship between loss of fixation and plating techniques. There was a direct relation between comminution and post fixation incongruence. Heterotrophic ossification was associated with comminution, radial head fracture, monteggia fracture-dislocation and non-union. Radio-ulnar synostosis was associated with comminution of the ulnar fracture.

In conclusion, the main predictor of poor outcome is the comminution of proximal ulnar fracture and the ability to achieve congruous fracture fixation.

The purpose of this study was to evaluate the results of custom-made endoprosthetic reconstruction for both tumourous and non-tumourous conditions around the elbow joint. 28 consecutive cases of endoprosthetic elbow reconstruction, performed between 1989 and 2003, were identified using the unit database. There were 12 males and 16 females, with a mean age 48.9 years, (range 14–84). There were 16 cases of malignant tumour (10 primary, 6 secondary), 3 cases of benign tumour (one each of giant cell tumour, osteoblastoma and pigmented villonodular synovitis) and 10 non-oncological cases, (5 cases of fracture, 3 failed total elbow replacements and 1 infected synostosis). A distal humeral prosthesis was used in 16 patients, distal humeral and proximal ulna in 10 patients, proximal ulna with a humeral component in one patient and proximal radial replacement in one patient. Clinical and radiographic review of all available patients, including a functional assessment with The Toronto Extremity Salvage score (TESS) was undertaken. 28 consecutive cases of endoprosthetic elbow reconstruction, performed between 1989 and 2003, were identified using the unit database. There were 12 males and 16 females, with a mean age 48.9 years, (range 14–84). There were 16 cases of malignant tumour (10 primary, 6 secondary), 3 cases of benign tumour (one each of giant cell tumour, osteoblastoma and pigmented villonodular synovitis) and 10 non-oncological cases, (5 cases of fracture, 3 failed total elbow replacements and 1 infected synostosis). A distal humeral prosthesis was used in 16 patients, distal humeral and proximal ulna in 10 patients, proximal ulna with a humeral component in one patient and proximal radial replacement in one patient. Clinical and radiographic review of all available patients, including a functional assessment with The Toronto Extremity Salvage score (TESS) was undertaken. Endoprosthetic reconstruction around the elbow joint is effective in a wide range of pathologies, allowing in most cases a reasonable level of function, even following two-stage revision for infection

Coronoid fractures account for 2 to 15% of the cases with elbow dislocations and usually occur as part of complex injuries. Comminuted fractures and non-unions necessitate coronoid fixation, reconstruction or replacement. The aim of this biomechanical study was to compare the axial stability achieved via an individualized 3D printed prosthesis with curved cemented intramedullary stem to both radial head grafted reconstruction and coronoid fixation with 2 screws. It was hypothesized that the prosthetic replacement will provide superior stability over the grafted reconstruction and screw fixation. Following CT scanning, 18 human cadaveric proximal ulnas were osteotomized at 40% of the coronoid height and randomized to 3 groups (n = 6). The specimens in Group 1 were treated with an individually designed 3D printed stainless steel coronoid prosthesis with curved cemented intramedullary stem, individually designed based on the contralateral coronoid scan. The ulnas in Group 2 were reconstructed with an ipsilateral radial head autograft fixed with two anteroposterior screws, whereas the osteotomized coronoids in Group 3 were fixed in situ with two anteroposterior screws. All specimens were biomechanically tested under ramped quasi-static axial loading to failure at a rate of 10 mm/min. Construct stiffness and failure load were calculated. Statistical analysis was performed at a level of significance set at 0.05. Prosthetic treatment (Group 1) resulted in significantly higher stiffness and failure load compared to both radial head autograft reconstruction (Group 2) and coronoid screw fixation, p ≤ 0.002. Stiffness and failure load did not reveal any significant differences between Group 2 and Group 3, p ≥ 0.846. In cases of coronoid deficiency, replacement of the coronoid process with an anatomically shaped individually designed 3D printed prosthesis with a curved cemented intramedullary stem seems to be an effective method to restore the buttress function of the coronoid under axial loading. This method provides superior stability over both radial head graft reconstruction and coronoid screw fixation, while achieving anatomical articular congruity. Therefore, better load distribution with less stress at the bone-implant interface can be anticipated. In the clinical practice, implementation of this prosthesis type could allow for early patient mobilization with better short- and long-term treatment outcomes and may be beneficial for patients with irreparable comminuted coronoid fractures, severe arthritic changes or non-unions

Purpose: Recognition of the proximal ulna dorsal angulation (PUDA) is important for anatomic reduction of proximal ulnar fractures or osteotomies, especially when using newer straight precontoured proximal ulnar plates. The purpose of this study was to characterize the PUDA in 50 patients with bilateral elbow radiographs. Method: Bilateral elbow radiographs (100 radiographs) were magnified four times using commercial software. The PUDA was measured from the intersection of lines tangent to the subcutaneous border of the olecranon and the proximal ulnar shaft. The olecranon tip-to-apex distance of the PUDA was also measured. Three orthopaedic surgeons independently examined the radiographs and intra/inter-observer reliability was calculated using Intra-Class-Correlation (ICC). Results: A PUDA was present in 96% of radiographs. The average PUDA was 5.7° (range, 0°to14°). The Pearson Correlation coefficient for a side-to-side comparison was 0.86(p< 0.001). The average tip-to-apex distance was 47 mm (34 mm–78mm). No correlation was identified with sex or age. Intra-observer reliability was excellent for the PUDA (ICC 0.892 and 0.863) and good for tip-to-apex distance (ICC 0.762 and 0.827). Inter-observer reliability was good for PUDA (ICC 0.784 and 0.925) and for tip-to-apex distance (ICC 0.711 and 0.769). Conclusion: A mean proximal ulna dorsal angulation of 5.7° is present in 96% of patients at an average of 47 mm distal to the olecranon tip. Measurement of the PUDA has good/excellent inter/intra-observer reliability. Recognition of the PUDA may be helpful in anatomic plating of the ulna. Contralateral PUDA measurements are useful for surgical planning in cases with comminution or distorted anatomy

Anterior elbow dislocations often occur as a fracture-dislocation in which the distal humerus is driven through the olecranon, causing either a simple oblique fracture of the olecranon or a complex, comminuted fracture of the proximal ulna. The purpose of this study was to characterise the morphology and to evaluate the surgical treatment of this injury. Thirteen patients (8 women and 5 men) with a mean age of 42 years were included in this study. Four patients had a simple, oblique fracture of the olecranon and 9 a complex, comminuted fracture of the proximal ulna. Six patients had an associated fracture of the coronoid process which was detached as a large fragment and 7 an additional fracture of the radial head. In all cases the collateral ligaments were found intact. All fractures were treated by open reduction and internal fixation through a midline dorsal approach. Simple fractures of the olecranon were treated with tension-band wiring while comminuted fractures were fixed with a plate and screws. Fractures of the coronoid process were stabilised by interfragmentary screws or small plates. The concomitant radial head fractures were treated by excision of small fragments, internal fixation or radial head replacement. The average follow up was 71 months. According to the functional scale of Broberg and Morrey, the results were excellent in 8 patients, good in 2, and poor in 3. Mild arthritis was observed in one patient. Transolecranon fracture –dislocation of the elbow is often misidentified as an anterior Monteggia lesion or a simple fracture of the olecranon. Differential diagnosis between these lesions is imperative. Consequently, anatomical restoration of the trochlear notch in cases of transolecranon fracture –dislocations can be achieved leading to good long-term results

Purpose. In total elbow arthroplasty (TEA), especially for elbows with condyle defect due to rheumatoid arthritis or trauma, determination of rotation alignment of implants is often difficult. To develop a navigation system for TEA, selecting bony landmarks that can be identified intraoperatively is important. Therefore, we developed a new roentgen free navigation system such as special alignment jigs for TEA based on CT data of normal elbows. The aim of this study was to evaluate alignments of implants after MIS-TEA using the new systems. And also, we reported that 6 bony landmarks on the elbow showed small variability in normal elbows by CT examinations and were considered to be usable as intraoperative landmarks for determining rotational position of implants last year. Especially in RA elbow, posterior aspect of humerus and ulnar aspect of proximal part of ulna were able to be identified even if there is a large bone defect that extends to the lateral or/and medial epicondyle. We used a new roentgen free navigation system in TEA with using Solar elbow from 2009. The aim of this study was to evaluate alignments of implants after MIS-TEA using the new systems by CT examinations. MATERIALS AND METHODS. For determination of alignment and anatomical landmarks to develop the jigs, 3D-CT data of 11 normal elbows was investigated. The posterior aspect of humeral shaft and ulnar aspect of proximal ulna were selected as bony landmarks. Because these can be identified intraoperatively and remain in elbows with extensive bone loss. MIS-TEA with Solar Elbow (Stryker) using these new systems were investigated with postoperative 3D-CT in 14 elbows of 13 patients. Their average age was 68.8 years old. Basic diseases were 10 rheumatoid arthritis and 4 distal humerus injuries. The alignments of humeral and ulnar component were measured on postoperative 3D-CT. RESULTS. Rotational alignment (humerus / ulna) was pronation 6.8° ± 5.7° / pronation 4.6° ± 9.1°; frontal alignment was valgus 0.1° ± 2.7° / valgus 0.1° ± 3.7°; and sagittal alignment was extension 0.6° ± 3.0° / extension 8.9° ± 2.5°. In condyle-defect group (n=5), comparable alignment with condyle-preserved group was obtained. DISCUSSION. The new systems were effective in determining intraoperative alignment even in elbows with extensive bone defect. Extension alignment of the ulna component is because the short component of Solar Elbow was placed along the center axis of the proximal ulna, which inclines in the extension direction relative to the axis of distal ulna

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

Purpose: The purpose of this study was to evaluate the results of custom-made endoprosthetic reconstruction for both tumourous and non-tumourous conditions around the elbow joint. Methods and Results: 28 consecutive cases of endoprosthetic elbow reconstruction, performed between 1989 and 2003, were identified using the unit database. There were 12 males and 16 females, with a mean age of 48.9 years, (range 14–84). There were 16 cases of malignant tumour (10 primary, 6 secondary), 3 cases of benign tumour (one each of giant cell tumour, osteoblastoma and pigmented villonodular synovitis) and 10 non-oncological cases, (5 cases of fracture, 3 failed total elbow replacements and 1 infected synostosis). A distal humeral prosthesis was used in 16 patients, distal humeral and proximal ulna in 10 patients, proximal ulna with a humeral component in one patient and proximal radial replacement in one patient. Clinical and radiographic review of all available patients, including a functional assessment with The Toronto Extremity Salvage (TES) score was undertaken. The average follow-up was 54.9 months (range 5–144). 5 patients with malignancy died of their disease. One patient required amputation for local recurrence at 5 months. There were two revisions at 4 and 7 years for aseptic loosening of the humeral component. Six patients developed deep prosthetic infection at an average of 21 months (range 6–31), necessitating two-stage revision, of which one patient required subsequent excision arthroplasty. There were no cases of permanent nerve palsy. 18 patients (64.3%) were available for functional follow-up. Average flexion deformity was 33 degrees (7–80) and average flexion was 85 degrees (30–133). The mean TES score was 67.8 (range 36.6–96.6). The mean TES score following two-stage revision for infection, (available in 4/5 patients) was 73.9 (range 54.8–91.6). Conclusion: Custom-made endoprosthetic reconstruction around the elbow joint is effective in a wide range of pathologies, allowing in most cases a reasonable level of function, even following two-stage revision for infection

Fracture or resection of the radial head can cause unbalance and long-term functional complications in the elbow. Studies have shown that a radial head excision can change elbow kinematics and decrease elbow stability. The radial head is also important in both valgus and varus laxity and displacement. However, the effect of radial head on ulnohumeral joint load is not known. The objective of this experimental study was to compare the axial loading produced at the ulnohumeral joint during active flexion with and without a radial head resection. Ten cadaveric arms were used. Each specimen was prepared and secured in an elbow motion simulator. To simulate active flexion, the tendons of the biceps, brachialis, brachioradialis, and triceps were attached to servo motors. The elbow was moved through a full range of flexion. To quantify loads at the ulnohumeral joint, a load cell was implanted in the proximal ulna. Testing was conducted in the intact then radial head resected case, in supination in the horizontal, vertical, varus and valgus positions. When comparing the average loads during flexion, the axial ulnar load in the horizontal position was 89±29N in an intact state compared to 122±46N during radial head resection. In the vertical position, the intact state produced a 67±16N load while the resected state was 78±23N. In the varus and valgus positions, intact state resulted in loads of 57±26N and 18±3N, respectively. Conversely, with a radial head resection, varus and valus positions measured 56±23N and 54±23N loads, respectively. For both joint configurations, statistical differences were observed for all flexion angles in all arm positions during active flexion (p=0.0001). When comparing arm positions and flexion angle, statistical differences were measured between valgus, horizontal and vertical (p<0.005) except for varus position (p=0.64). Active flexion caused a variation in loads throughout flexion when comparing intact versus radial head resection. The most significant variation in ulnar loading occurred during valgus and horizontal flexion. The vertical and varus position showed little variation because the position of the arm is not affected by the loss of the radial head. However, in valgus position, the resected radial head creates a void in the joint space and, with gravity, causes greater compensatory ulnar loading. In the horizontal position, the forearm is not directly affected by gravitational pull and cannot adjust to counterbalance the resected radial head, therefore loads are localised in the ulnohumeral joint. These findings prove the importance of the radial head and that a radial head resection can overload the ulnohumeral side

Aims

Low-grade central osteosarcoma (LGCOS), a rare type of osteosarcoma, often has misleading radiological and pathological features that overlap with those of other bone tumours, thereby complicating diagnosis and treatment. We aimed to analyze the clinical, radiological, and pathological features of patients with LGCOS, with a focus on diagnosis, treatment, and outcomes.

Aims

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

Despite being one of the most common injuries around the elbow, the optimal treatment of olecranon fractures is far from established and stimulates debate among both general orthopaedic trauma surgeons and upper limb specialists. It is almost universally accepted that stable non-displaced fractures can be safely treated nonoperatively with minimal specialist input. Internal fixation is recommended for the vast majority of displaced fractures, with a range of techniques and implants to choose from. However, there is concern regarding the complication rates, largely related to symptomatic metalwork resulting in high rates of implant removal. As the number of elderly patients sustaining these injuries increases, we are becoming more aware of the issues associated with fixation in osteoporotic bone and the often fragile soft-tissue envelope in this group. Given this, there is evidence to support an increasing role for nonoperative management in this high-risk demographic group, even in those presenting with displaced and/or multifragmentary fracture patterns. This review summarizes the available literature to date, focusing predominantly on the management techniques and available implants for stable fractures of the olecranon. It also offers some insights into the potential avenues for future research, in the hope of addressing some of the pertinent questions that remain unanswered.

Cite this article: Bone Joint J 2023;105-B(2):112–123.

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

We report the case of a 12-year-old boy with flexion loss in the left elbow caused by deficient of the concavity corresponding to the coronoid fossa in the distal humerus. The range of motion (ROM) was 15°/100°, and pain was induced by passive terminal flexion. Plain radiographs revealed complete epiphyseal closure, and computed tomography (CT) revealed a flat anterior surface of the distal humerus; the coronoid fossa was absent. Then, the bony morphometric contour was surgically recreated using a navigation system and a three-dimensional elbow joint model. A three-dimensional model of the elbow joint was made preoperatively and the model comprising the distal humerus was milled so that elbow flexion flexion of more than 140° could be achieved against the proximal ulna and radius. Navigation-assisted surgery (contouring arthroplasty) was performed using CT data from this milled three-dimensional model. Subsequently, an intraoperative passive elbow flexion of 135° was obtained. However, active elbow flexion was still inadequate one year after operation, and a triceps lengthening procedure was performed. At the final follow-up one year after triceps lengthening, a considerable improvement in flexion was observed with a ROM of −12°/125°. Plain radiographs revealed no signs of degenerative change, and CT revealed the formation of the radial and coronoid fossae on the anterior surface of the distal humerus. Navigation-assisted surgery for deformity of the distal humerus based on a contoured three-dimensional model is extremely effective as it facilitates evaluation of the bony morphometry of the distal humerus. It is particularly useful as an indicator for milling the actual bone when a model of the mirror image of the unaffected side cannot be applied to the affected side as observed in our case

Purpose. Assess and report the functional and post-operative outcomes of complex acute radial head fractures with elbow instability treated by arthroplasty using an uncemented modular anatomic prosthesis. Methods. Over a 3-year period (2007–2010), 21 patients (mean age 51.9 years) were treated primarily with modular radial head arthroplasty (mean follow up of 27.1 months). Data was collected retrospectively using clinical notes, operation documentation and prospectively using validated scoring systems namely the Oxford Elbow Index, Quick DASH and the Mayo Elbow Performance Score. Associated elbow fractures, ligamentous injury and short to mid term post-operative outcomes including radiographic assessment were recorded. Results. The mean Oxford Elbow Score was 34.80 (range 20–48). The mean Quick Dash score was 26.01 (range 0–68.2). The Mayo Performance score showed 6 scored excellent, 5 scored good, 3 scored fair and 2 scored poor. Regarding post-operative outcomes, 1 patient had a radial head dislocation, 1 patient had prosthesis removal for ongoing pain and 1 patient had a total elbow replacement due to associated proximal ulna fracture non-union. 11 patients had an associated ligamentous injury of which 6 had an associated coronoid fracture. Of note, 7 patient's radiographs showed early signs of implant loosening; this was mainly asymptomatic. Conclusions. With regard to complex radial head fractures with elbow instability, patient outcome measures showed good functionality and overall patient satisfaction despite radiographic evidence of loosening. Post-operative complication rates were low. These findings support the use of this radial head prosthesis in arthoplasty surgery for the treatment of complex acute radial head fractures with elbow instability

Purpose of the study: The outcomes of different stabilization methods for unstable forearm fractures are described. Material and methods: From January 1980 through December 2000, 29 patients were treated at the central military hospital orthopedics uint for proximal forearm fractures, 27 underwent surgery. We used the Beaufils classification, depending on the localization of the ulnar fracture. Type 1: metaphyseal fracture (n=12) with dislocation of the radial cup; type 2: epiphyseal fracture with transolecraneal dislocation (n=6); type 3: metaphyso-epiphyseal fracture with anterior dislocation (n=5); type 4: metaphyso-epiphyseal fracture with posterior dislocation (n=5). Results: Outcome was assessed at six months to 20 years follow-up. According to the Morrey classification, outcome was excellent for six patients, good for nine, fair for seven and poor for three. Six patients had a stiff joint, one had a synostosis and three nonunion. Conclusion: To achieve satisfactory outcome, it is crucial to achieve internal fixation of the proximal ulna and reconstruction of the radial length. Resection without replacement of the radial cup is contraindicated in these associated fractures

The April 2024 Children’s orthopaedics Roundup³⁶⁰ looks at: Ultrasonography or radiography for suspected paediatric distal forearm fractures?; Implant density in scoliosis: an important variable?; Gait after paediatric femoral shaft fracture treated with intramedullary nail fixation: a longitudinal prospective study; The opioid dilemma: navigating pain management for children’s bone fractures; 12- to 20-year follow-up of Dega acetabuloplasty in patients with developmental dysplasia of the hip; Physeal fractures of the distal ulna: incidence and risk factors for premature growth arrest; Analysis of growth after transphyseal anterior cruciate ligament reconstruction in children; Management of lateral condyle humeral fracture associated with elbow dislocation in children: a retrospective international multicentre cohort study.

Aims

Paediatric fractures are highly prevalent and are most often treated with plaster. The application and removal of plaster is often an anxiety-inducing experience for children. Decreasing the anxiety level may improve the patients’ satisfaction and the quality of healthcare. Virtual reality (VR) has proven to effectively distract children and reduce their anxiety in other clinical settings, and it seems to have a similar effect during plaster treatment. This study aims to further investigate the effect of VR on the anxiety level of children with fractures who undergo plaster removal or replacement in the plaster room.

Aims

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.

Aims

Arthroplasties of the elbow, including total elbow arthroplasty, radial head arthroplasty, distal humeral hemiarthroplasty, and radiocapitellar arthroplasty, are rarely undertaken. This scoping review aims to outline the current research in this area to inform the development of future research.

Introduction: Radial Head Arthroplasty is considered the treatment of choice for unreconstructable radial head fractures. Short-term results in the current literatue are promising. Due to the lack of long-term results, radial head arthroplasty is looked at critically by many surgeons. In our the study we provide the 8.4 years results after treatment with the floating radial head prosthesis by Judet (Tornier, France). Methods: In our department 19 patients were treated with bipolar radial head arthroplasty between 1997 and 2001. 11 prostheses were implantated primary and 6 secondary. The other two were implanted because of a loosening of a prior implanted prosthesis and one after resection of a vast chondrosarcoma. 12 of these patients − 10 men and 2 women – were now examined retrospectively after 101 months (78–132). Results: 6 Patients were treated primary, 5 secondary and one was treated because of a vast chondrosarcoma. There were 5 proximal ulna fractures and 8 processus coronoideus fractures as concomitant injuries of the elbow. Following complications were seen: 2 dislocations, 2 capitellar erosions and 4 cases of heterotopic ossifications. According to the Mayo Elbow Performance Score 4 patients achieved an excellent result, 7 a good, and one a satisfactory result. The mean DASH was 13.7 (0–44). No differences were seen between primary and secondary implantation. The flexion arc was 123° (110–140°), the extension deficit was 20° (0–40°), pronation 61° (30–90°) and supination 62° (40–90°). Conclusion: Our 8.4 years results show that radial head arthroplasty with Judet’s bipolar prosthesis leads to mostly excellent and good – subjective as well as objective – results

Purpose of study: To report the use of a forearm fascial strip to repair the annular ligament and treat late diagnosed or irreducible Monteggia fracture. Methods: Through Boyd’s approach nineteen patients with Monteggia fractures were treated with a technique to reconstruct the annular ligament using forearm fascia, retaining its proximal attachment to the ulna. The radial head was dislocated and the fascial strip wound around the neck of the radius. After reducing the radial head, forearm rotation was checked. The strip was sutured to the residual annular ligament on the proximal ulna after correction of any ulna deformity. In late diagnosis, the ulna deformity was managed with ulna lengthening of approximately 0.5 cm and stabilization with a 4- or 5- hole semi-tubular AO plate. The stability of the radial head was then assessed using intra-operative fluoroscopy. Results: Stability of the radial head was achieved in all cases. According to the Anderson classification, the final outcome was excellent in ten cases satisfactory in eight cases and unsatisfactory in one late diagnosed patient with an associated radioulnar synostosis secondary to a compartment syndrome. There were no failures. Two radiocapitellar K-wires broke while in plaster in the initial period, so the use of a K wire was subsequently abandoned. Conclusions: We have found this technique to be reliable for stabilizing the proximal radioulnar joint. The length of the incision is less than that required for the Bell Tawse (triceps tendon) technique and permits a tourniquet on the upper arm. Poorer results were achieved with delay in diagnosis beyond 6 months. Patients must be warned of potential reduction of forearm rotation

Post-traumatic synostosis of the forearm are challenging situations after elbow trauma, injuries of the forearm or the wrist. According to Vince or Hastings classification, therapeutic options are still controversial, due to an unpredictive outcome with recurrence of the synostosis or progressive loss of mobility from post-op to definitive situations. A retrospective study of 13 cases, including 3 Vince Type 1, 6 Vince Type 2 and 4 Vince type 3 with a minimum follow-up of 3 years was analyzed as well as a review of 47 worldwide publications for defining the optimal therapeutic options. All data files were reviewed including extensive analysis of the CT-scans, and detailed surgical procedures. For Vince 1 synostosis, in post-traumatic situations, Sauve-Kapandji procedure give excellent or good results when no recurrence of the synostosis is seen. Instability of the proximal ulna after segmental resection is the major complication to be described. In Vince 2 synostosis, an extensive resection of the synostosis is mandatory to obtain a potential good result. Knowledge of the entire anatomy of the forearm is needed for accurate neurolysis of radial nerve and branches. The ulnar approach to the synostosis must be completed with an anterior approach to the radius for a complete resection. In Vince 3 synostosis, resection is easy but recurrence is frequent, due to the associated lesions of the elbow. Based on the litterature review, no additive treatment is necessary for better results Therapeutic options in post-traumatic synostosis of the forearm is a rare complications of elbow lesions (Vince 3), forearm comminutive or complex fractures (Vince 2), or wrist injuries (Vince 1). The latter give the more predictable results after complete resection. Elbow lesions associated with radio-ulnar synostosis are easy to treat but with important recurrence rate, whatever treatment was done. Vince 2 post-traumatic radio-ulnar synostosis are the most challenging situation as bone resection must be extensive meanwhile neurolysis of forearm nerves must be done in the same time. No adjuvant treatment is indicated in either situation according to Vince classification

Aims: To treat posttraumatic stiffness of elbow by distraction arthrodiastasis and mobilisation. Standard operative procedures were combined for 4 patients with bony blocks due to myositis ossiþcans. Methods: We reviewed 8 patients, 5:M, 3:F aged 20–42 years. 3 x 2.5mm k-wires were passed in lower-third humerus from lateral to medial side and 3 x 2.5mm k-wires in proximal ulna. Distractors were applied on anterior and posterior aspect of elbow and hinge-joint at the level of elbow-joint. Elbow was gradually distracted to achieve arthro-diastatic state of joint. Maintaining arthrodiastatic state now elbow deformity is gradually corrected by distracting anterior distractors. Than distractors and hinge are locked for tissue reaction to subside over 2–3 weeks followed by dynamic mobilization. Movement gradually improves over 2–3weeks (sometimes prolonged in severe cases). Than þxator is removed and appropriate dynamic splint is applied to maintain correction while allowing mobility. In 4cases bone block was removed surgically and followed by distraction arthrodiastatic procedure. No steroid in any form was used in any stage of treatment. Results: Average follow-up: 2years (maximum 4years). All elbows were stable and extension increased by 30û and ßexion increased by 50û. One case had minor pin-tract infection, responded to basic treatment. No neurovascular deþcit was not seen post procedure in any patients. Conclusion: This technique may be considered before arthrolysis is undertaken for stiff elbow

Summary. Increased lateral ulnotrochlear joint space due to improper sizing in radial head arthroplasty may result in medial collateral ligament laxity, leading to increased osteophytes and arthritis. Introduction. Radial head (RH) arthroplasty is a common response to comminuted RH fractures. Typical complications include improper sizing, leading to changes in joint kinematics. Evidence of these changes should be visible through fluoroscopic images of affected joints. The two examined changes in this study are the ulnar deviation from distal radial translation (DRT), and the widening of the lateral ulnotrochlear joint space (LUT). Methods. Eight fresh-frozen cadaver arms were used. Initial images were taken with the native RH intact. The Kocher approach exposed the radiocapitellar (RC) joint capsule, preserving all ligaments. The RH was excised and Integra Katalyst CoCr (Plainsboro, NJ) telescoping, bipolar, RH inserted. Images were taken with implant sizings: −2mm, 0mm, +2mm, and +4mm, (from native) using 1mm washers preventing implant bipolarity. AP fluoroscopic images of the elbow were taken at full extension. Joint spaces were measured using image analysis, normalised using known radio-opaque lengths. Four LUT measurements were made, two medially and two laterally, and normalised by measuring the RH implant diameter. Each set (medial and lateral) were averaged together and the resulting value used for all comparisons. Images of distal ulnar deviation at the wrist were taken with the wrist in supination, the hand rotated medially. Measurements were from the distal medial radial tip to the distal lateral ulnar tip. Images were normalised by placing a scalpel in the same plane as measurement. Results. DRT values were difference paired for each arm using the 0mm values as baselines. One-way ANOVA of the paired values resulted in significant DT with sizing increases (p<0.01). The quotient of DRT and sizing determined comparative impact with the LUT increase. LUT joint gap measurements were percentage paired, with natives as the baseline, and One-way ANOVA used. A significant increase in LUT spacing occurred with increased sizings (p<0.01). Discussion. Increased ulnar deviation can increase loading on the TFCC, leading to possible TFCC tear, increased articular cartilage wear from carpal misalignment, and eventual wrist instability and arthritis. The percentage of the radial lengthening is represented in DRT. Over-sizing results in small percentages of increased radial length at the wrist, therefore deviation at the elbow must take place, either through rotation of the ulna, or translation. Either of these can be seen through LUT measurements. Previous measurements of the LUT space were made by Frank (2009), with similar results. This was being used as a method of improper sizing detection using radiographs. The percentage difference of LUT space for corresponding sizing: there is an increase in LUT space for every sizing; maybe due to loosening of the soft tissue from arthroplasty. Increased LUT space indicates the medial translation of proximal ulna. This can result in Medial Collateral Ligament laxity, leading to increased osteophytes, and arthritis. Use and non-treatment, can create a chronic, painful, disorder

Reconstruction of deficient bone stock during total elbow arthroplasty in rheumatoid arthritis represents a challenge for the surgeon. Fracture and osteolysis of the olecranon process is a very rare condition in rheumatoid arthritis. The consequence of a deficient olecranon is an instable and painful elbow. We report a case of successful olecranon reconstruction with bone graft associated to total elbow arthroplasty with a 8 years follow up and discuss surgical aspects. This case concerns a 44 years old woman with a very severe rheumatoid arthritis. She complains of pain and instability of her right elbow. X-rays show fracture and major osteolysis of the olecranon process with only some persistent bone at the insertion of the triceps tendon. The humeral condyles were subluxated posteriorly. We performed a total elbow replacement with a GSB3 implant and reconstruction of the olecranon with two cancellous iliac bone strut fixed by 2.7 diameter screws to the proximal ulna. The triceps tendon with remnant olecranon bone chips was secured to the bone graft by tension band wiring. Postoperatively, the elbow was immobilized for 3 weeks. With a follow up of more than 8 years the elbow is pain free with excellent function. The active range of motion of flexion – extension is 140° / −20°. The elbow is stable and triceps function is very satisfying authorizing the use of crutches. X-rays show good bony integration of the reconstructed olecranon process and no signs of loosening of the GSB3 implant. The literature concerning olecranon reconstruction during total elbow arthroplasty in rheumatoid patients is very poor. Kamineni and Morrey reported on one case of olecranon reconstruction with strut allograft in revision total elbow arthroplasty with an unsatisfying result. Their fixation technique was different. We prefer an autograft whenever it is possible and we recommend our fixation technique using screws and tension band wiring

Aims

Periprosthetic joint infections (PJIs) and fracture-related infections (FRIs) are associated with a significant risk of adverse events. However, there is a paucity of data on cardiac complications following revision surgery for PJI and FRI and how they impact overall mortality. Therefore, this study aimed to investigate the risk of perioperative myocardial injury (PMI) and mortality in this patient cohort.

Introduction: Olecranon fractures comprise 4–7% of all fractures around the elbow in the pediatric age group. 80% of these fractures can be treated expectantly. Fractures with 2 mm of displacement or more require surgical intervention. The surgical procedure commonly used is ORIF with 2 Kirschner wires and tension band wire as advocated by the AO technique. All open interventions require removal of hardware under anesthesia. We present our experience of five cases treated with percutaneously placed K-wires and absorbable sutures. Patients and Methods: Five patients, 4 boys and one girl, average age 6 8/12 years (range 4½-14¼ years) with displaced fractures of the olecranon were treated with ORIF during the years 2000–2004. In two cases additional injuries were noted [a displaced lateral condyle fracture in one and a dislocated radial head (Monteggia variant) in another patient]. Under general anesthesia, the olecranon is approached through a posterior incision. After reduction, fixation is achieved with two K-wires, which are inserted percutaneously. Additional fixation is obtained with a heavy absorbable suture (Dexon, PDS) which is fashioned in a figure of eight around the protruding pins and through a hole in the proximal ulna. Stability is checked under vision before wound closure. K-wires are trimmed and a plaster cast is fitted with the elbow in flexion. The plaster cast and K-wires are removed 4 weeks post surgery after X-rays confirm that the fracture is healed and range of motion is started. Results: Five patients have been treated with our technique; all fractures were reduced and stable in flexion and extension under vision at the end of surgery. K-wires were removed 4 weeks postoperatively and patients were allowed free range of motion. No immediate complications were noted, none became infected and no loss of fixation was observed. Conclusions: Anatomic reduction and stable fixation can be achieved by the surgical technique presented. The usual complication of hardware irritation and the need for additional surgery to remove K-wires and the metal TBW are avoided by the use of absorbable sutures and protruding K-wires. Functional outcome is excellent on short term follow-up. Larger numbers and prospective follow-up will tell whether this technique can replace the commonly used methods of olecranon fracture fixation in the pediatric age group

Introduction: The main features of osteogenesis imperfecta (OI) are excessive fragility and deformability of the long bones owing to poor bone quality and reduced bone mass, what leads to frequent fractures and residual deformity. Fractures in patients with OI usually heal rapidly, and conservative treatment is mostly successful. However, in displaced and unstable fractures surgical treatment is the only option. Aim: To present our experience in surgical treatment of fractures and deformities as a consequence of OI. Patients and methods: There are 41 individuals with OI in Croatian OI Register. We retrospectively analyzed 18 patients (12 males, 6 females) who were surgically treated from 1979 to June 2004 due to fractures and deformities of the long bones. At the time of the first surgical procedure in our Department, the youngest patient was 23 months old, and the oldest patient was 34 years old (average: 9.6 years). In two patients birth fractures were noticed, and in four patients fractures occurred in the first three months of their lives. In 9 patients severe form of OI was observed. There were 63 operative procedures in 18 patients, with the range from one to seven procedures per patient. We performed 36 reoperations mostly due to fractures of overgrown bone on solid intramedullary nail. Results: Different intramedullary rods were used on 34 occasions. We used solid intramedullary nails (Kuntchner’s nail, Rush’s nail) in 14 operations, Kirschner wires in 12 operations, and expandable intramedullary rod (Sheffield) in five operations. Elastic titanium nail (Nancy) was used in three operations. Other modes of fixation i.e. plates and screws, ASIF external fixator, and Ilizarov system (one patient) were used in total 29 operative procedures. None of the patients had infection related to operative procedure. Operations were mostly performed on femur (43 operations, 68%) and tibia (13 operations, 21%). There were 7 procedures (11%) on the upper extremities. We observed delayed union in three patients who were treated with bisphosphonates, and in two patients on proximal ulna. At the last follow-up ten patients were outdoor walkers, with or without one hand aid. Conclusion: Using correct indication, surgical technique and appropriate fixation device, surgical treatment can be safely performed in patients with OI. Surgery, rehabilitation, and medical treatment may significantly improve mobility and function in OI patients. The rarity of the disease, leading to small numbers of operations performed in a year, and the variable surgical findings, support centralization of surgery in OI patients with complex limb fractures and/or deformities

Aims

The aim of this study is to report the results of a case series of olecranon fractures and olecranon osteotomies treated with two bicortical screws.

Aims

Elective surgery has been severely curtailed as a result of the COVID-19 pandemic. There is little evidence to guide surgeons in assessing what processes should be put in place to restart elective surgery safely in a time of endemic COVID-19 in the community.

Aims

The aim of this retrospective multicentre study was to evaluate mid-term results of the operative treatment of Monteggia-like lesions and to determine the prognostic factors that influence the clinical and radiological outcome.

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

Delayed diagnosis is a well-known complication of a Monteggia fracture-dislocation. If left untreated, the dislocated radial head later becomes symptomatic. The purposes of this study were firstly, to evaluate the clinical and radiological results of open reduction of the radial head and secondly, to identify the factors that may affect the outcome of this procedure.

To prevent insufficiency of the triceps after total elbow arthroplasty, we have, since 2008, used a triceps-sparing ulnar approach. This study evaluates the clinical results and post-operative alignment of the prosthesis using this approach.

We reviewed 25 elbows in 23 patients. There were five men and 18 women with a mean age of 69 years (54 to 83). There were 18 elbows with rheumatoid arthritis, six with a fracture or pseudoarthrosis and one elbow with osteoarthritis.

Post-operative complications included one intra-operative fracture, one elbow with heterotopic ossification, one transient ulnar nerve palsy, and one elbow with skin necrosis, but no elbow was affected by insufficiency of the triceps.

Patients were followed for a mean of 42 months (24 to 77). The mean post-operative Japanese Orthopaedic Association Elbow Score was 90.8 (51 to 100) and the mean Mayo Elbow Performance score 93.8 (65 to 100). The mean post-operative flexion/extension of the elbow was 135°/-8°. The Manual Muscle Testing score of the triceps was 5 in 23 elbows and 2 in two elbows (one patient). The mean alignment of the implants examined by 3D-CT was 2.8° pronation (standard deviation (sd) 5.5), 0.3° valgus (sd 2.7), and 0.7° extension (sd 3.2) for the humeral component, and 9.3° pronation (sd 9.7), 0.3° valgus (sd 4.0), and 8.6° extension (sd 3.1) for the ulnar component. There was no radiolucent line or loosening of the implants on the final radiographs.

The triceps-sparing ulnar approach allows satisfactory alignment of the implants, is effective in preventing post-operative triceps insufficiency, and gives satisfactory short-term results.

Cite this article: 2015;97-B:1096–1101.

Aim

The primary aim of this retrospective study was to identify the incidence of heterotopic ossification (HO) following elective and trauma elbow arthroplasty. The secondary aim was to determine clinical outcomes with respect to the formation of heterotopic ossification.

We report our experience of performing an elbow hemiarthroplasty in the treatment of comminuted distal humeral fractures in the elderly patients.

A cohort of 42 patients (three men and 39 women, mean age 72; 56 to 84) were reviewed at a mean of 34.3 months (24 to 61) after surgery. Functional outcome was measured with the Mayo Elbow Performance Score (MEPS) and range of movement. The disabilities of the arm, shoulder and hand questionnaire (DASH) was used as a patient rated evaluation. Complications and ulnar nerve function were recorded. Plain radiographs were obtained to assess prosthetic loosening, olecranon wear and heterotopic bone formation.

The mean extension deficit was 23.5° (0° to 60°) and mean flexion was 126.8° (90° to 145°) giving a mean arc of 105.5° (60° to 145°). The mean MEPS was 90 (50 to 100) and a mean DASH score of 20 (0 to 63). Four patients had additional surgery for limited range of movement and one for partial instability. One elbow was revised due to loosening, two patients had sensory ulnar nerve symptoms, and radiographic signs of mild olecranon wear was noted in five patients.

Elbow hemiarthroplasty for comminuted intra-articular distal humeral fractures produces reliable medium-term results with functional outcome and complication rates, comparable with open reduction and internal fixation and total elbow arthroplasty.

Cite this article: Bone Joint J 2015;97-B:1377–84.

In order to achieve satisfactory reduction of complex distal humeral fractures, adequate exposure of the fracture fragments and the joint surface is required. Several surgical exposures have been described for distal humeral fractures. We report our experience using the anconeus pedicle olecranon flip osteotomy approach. This involves detachment of the triceps along with a sliver of olecranon, which retains the anconeus pedicle. We report the use of this approach in ten patients (six male, four female) with a mean age of 38.4 years (28 to 51). The mean follow-up was 15 months (12 to 18) with no loss to follow-up. Elbow function was graded using the Mayo Score. The results were excellent in four patients, good in five and fair in one patient. The mean time to both fracture and osteotomy union was 10.6 weeks (8 to 12) and 7.1 weeks (6 to 8), respectively. We found this approach gave reliably good exposure for these difficult fractures enabling anatomical reduction and bicondylar plating without complications.

Cite this article: Bone Joint J 2014;96-B:1252–7.

Fractures in patients aged ≥ 65 years constitute an increasing burden on health and social care and are associated with a high morbidity and mortality. There is little accurate information about the epidemiology of fractures in the elderly. We have analysed prospectively collected data on 4786 in- and out-patients who presented with a fracture over two one-year periods. Analysis shows that there are six patterns of the incidence of fractures in patients aged ≥ 65 years. In males six types of fracture increase in incidence after the age of 65 years and 11 types increase in females aged over 65 years. Five types of fracture decrease in incidence after the age of 65 years. Multiple fractures increase in incidence in both males and females aged ≥ 65 years, as do fractures related to falls.

Analysis of the incidence of fractures, together with life expectancy, shows that the probability of males and females aged ≥ 65 years having a fracture during the rest of their life is 18.5% and 52.0%, respectively. The equivalent figures for males and females aged ≥ 80 years are 13.3% and 34.8%, respectively.

Cite this article: Bone Joint J 2014;96-B:366–72.

Aims

We assessed the long-term (more than ten-year) outcomes of the Kudo type-5 elbow prosthesis in patients with rheumatoid arthritis (RA).

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.

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.

Four men who presented with chronic dislocation of the radial head and nonunion or malunion of the ulna were reviewed after open reduction of the radial head and internal fixation of the ulna in attempted overcorrection. Their mean age was 37 years (28 to 46) and the mean interval between injury and reconstruction was nine months (4 to 18).

The mean follow-up was 24 months (15 to 36). One patient who had undergone secondary excision of the radial head was also followed up for comparison.

The three patients who had followed the treatment protocol had nearly normal flexion, extension and supination and only very occasional pain. All had considerable loss of pronation which did not affect patient satisfaction.

Preservation of the radial head in chronic adult Monteggia fractures appears to be a promising mode of treatment.

Using an osteotomy of the olecranon as a model of a transverse fracture in 22 cadaver elbows we determined the ability of three different types of suture and stainless steel wire to maintain reduction when using a tension-band technique to stabilise the bone. Physiological cyclical loading simulating passive elbow movement (15 N) and using the arms to push up from a chair (450 N) were applied using an Instron materials testing machine whilst monitoring the osteotomy site with a video extensometer. Each osteotomy was repaired by one of four materials, namely, Stainless Steel Wire (7), No 2 Ethibond (3), No 5 Ethibond (5), or No 2 FiberWire (7).

There were no failures (movement of > 2 mm) with stainless steel wire or FiberWire and no significant difference in the movements measured across the site of the osteotomy (p = 0.99). The No. 2 Ethibond failed at 450 N and two of the five of No. 5 Ethibond sutures had a separation of > 2 mm at 450 N.

FiberWire as the tension band in this model held the reduction as effectively as stainless steel wire and may reduce the incidence of discomfort from the hardware. On the basis of our findings we suggest that a clinical trial should be undertaken

The type II Monteggia (posterior) lesion is a rare injury which is sometimes associated with ulnohumeral instability. We have reviewed 23 of 28 patients with this injury. A clinical and radiographic assessment was undertaken at follow-up. Functional outcome scores, including the Broberg and Morrey Index and the Disabilities of the Arm, Shoulder or Hand (DASH), were used. The results from the six patients with associated posterior ulnohumeral dislocation were compared with 17 without ulnohumeral injury. Those with dislocation had reduced movement of the elbow and had outcome scores indicative of greater disability compared to those without associated dislocation.

We studied, ten patients (11 elbows) who had undergone 14 allograft-prosthesis composite reconstructions following failure of a previous total elbow replacement with massive structural bone loss. There were nine women and one man with a mean age of 64 years (40 to 84), who were reviewed at a mean of 75 months (24 to 213). One patient developed a deep infection after 26 months and had the allograft-prosthesis composite removed, and two patients had mild pain. The median flexion-extension arc was 100° (95% confidence interval (CI) 76° to 124°). With the exception of the patient who had the infected failure, all the patients could use their elbows comfortably without splints or braces for activities of daily living. The mean Mayo Elbow Performance Index improved from 9.5 (95% CI 4.4 to 14.7) pre-operatively to 74 (95% CI 62.4 to 84.9) at final review.

Radiologically, the rate of partial resorption was similar in the humeral and ulnar allografts (three of six and four of eight, respectively; p > 0.999). The patterns of resorption, however, were different. Union at the host-bone-allograft junction was also different between the humeral and ulnar allografts (one of six and seven of eight showing union, respectively; p = 0.03).

At medium-term follow-up, allograft-prosthesis composite reconstruction appears to be a useful salvage technique for failed elbow replacements with massive bone loss. The effects of allograft resorption and host-bone-allograft junctional union on the longevity of allograft-prosthesis composite reconstruction, however, remain unknown, and it is our view that these patients should remain under long-term regular review.

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

On the basis of this study, we believe that the results of open arthrolysis for post-traumatic stiffness of the elbow are durable over the medium term.

The October 2013 Children’s orthopaedics Roundup³⁶⁰ looks at: Half a century of Pavlik treatment; Step away from the child!: trends in fracture management; Posterolateral rotatory elbow instability in children; Osteochondral lesions undiagnosed in patellar dislocations; Oral bisphosphonates in osteogenesis imperfecta; Crossed or parallel pins in supracondylar fractures?; Not too late nor too early: getting epiphysiodesis right; Fixation of supramalleolar osteotomies.

Rarely, the extent of a malignant bone tumour may necessitate resection of the complete humerus to achieve adequate oncological clearance. We present our experience with reconstruction in such cases using a total humeral endoprosthesis (THER) in 20 patients (12 male and eight female) with a mean age of 22 years (6 to 59). We assessed the complications, the oncological and functional outcomes and implant survival. Surgery was performed between June 2001 and October 2009. The diagnosis included osteosarcoma in nine, Ewing’s sarcoma in eight and chondrosarcoma in three. One patient was lost to follow-up. The mean follow-up was 41 months (10 to 120) for all patients and 56 months (25 to 120) in survivors. There were five local recurrences (26.3%) and 11 patients were alive at time of last follow-up, with overall survival for all patients being 52% (95% confidence interval (CI) 23.8 to 74) at five years. The mean Musculoskeletal Tumor Society score for the survivors was 22 (73%; 16 to 23). The implant survival was 95% (95% CI 69.5 to 99.3) at five years.

The use of a THER in the treatment of malignant tumours of bone is oncologically safe; it gives consistent and predictable results with low rates of complication.

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.

Objectives

Cadaveric models of the shoulder evaluate discrete motion segments using the glenohumeral joint in isolation over a defined trajectory. The aim of this study was to design, manufacture and validate a robotic system to accurately create three-dimensional movement of the upper body and capture it using high-speed motion cameras.

This is a retrospective review of the results of the Acclaim total elbow replacement in 11 older patients aged ≥ 65 years with primary osteoarthritis of the elbow, with a mean follow-up of 57.6 months (30 to 86.4).

Significant reductions in pain and improvement in range of movement and function were recorded. Radiological review revealed two patients with 1 mm lucencies in a single zone, and one patient with 1 mm lucencies in two zones. No components required revision. There were no deep infections, dislocations or mechanical failures. Complications included one intra-operative medial condylar fracture and one post-operative transient ulnar neuropathy, which resolved.

This study demonstrates that the Acclaim prosthesis provides good symptomatic relief and improvement of function in patients with primary osteoarthritis, with low rates of loosening or other complications. This prosthesis can therefore be considered for patients aged ≥ 65 years with primary osteoarthritis of the elbow.

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.

We have evaluated the clinical outcomes of simple excision, ulnar lengthening and the Sauvé-Kapandji procedure in the treatment of deformities of the forearm in patients with multiple hereditary osteochondromas. The medical records of 29 patients (33 forearms) were reviewed; 22 patients (22 forearms) underwent simple excision (four with ulnar lengthening) and seven the Sauvé-Kapandji procedure.

Simple excision increased the mean supination of the forearm from 63.2° to 75.0° (p = 0.049). Ulnar lengthening did not significantly affect the clinical outcome. The Sauvé-Kapandji technique improved the mean pronation from 33.6° to 55.0° (p = 0.047) and supination from 70.0° to 81.4° (p = 0.045). Simple excision may improve the range of movement of the forearm but will not halt the progression of disease, particularly in younger patients. No discernable clinical or radiological improvement was noted with ulnar lengthening. The Sauvé-Kapandji procedure combined with simple excision of osteochondromas can improve stability of the wrist, movement of the forearm and the radiological appearance.

We present the outcome of 47 Souter-Strathclyde replacements of the elbow with a mean follow-up of 82 months (12 to 129). The clinical results were assessed using a condition-specific outcome measure. The mean total score (maximum 100) before the operation was 47.21 and improved to 79.92 (p < 0.001). The mean pain score (maximum 50) improved from 21.41 to 46.70 (p < 0.001) and the mean functional component of the score (maximum 30) from 11.19 to 18.65 (p < 0.001). There was negligible change in the score for the range of movement although a significant improvement in mean flexion from 124° to 136° was noted (p < 0.001).

Revision surgery was required in four patients, for dislocation, wound dehiscence and early infection in one, late infection in two and aseptic loosening in one. The cumulative survival was 75% at nine years for all causes of failure and 97% at ten years for aseptic loosening alone. Our study demonstrates the value of the Souter-Strathclyde total elbow arthroplasty in providing relief from pain and functional improvement in rheumatoid patients.