Aims. The management of fractures of the medial epicondyle is one of the greatest controversies in paediatric fracture care, with uncertainty concerning the need for surgery. The British Society of Children’s Orthopaedic Surgery prioritized this as their most important research question in paediatric trauma. This is the protocol for a randomized controlled, multicentre, prospective superiority trial of operative fixation versus nonoperative treatment for displaced medial epicondyle fractures: the Surgery or Cast of the EpicoNdyle in Children’s Elbows (SCIENCE) trial. Methods. Children aged seven to 15 years old inclusive, who have sustained a displaced fracture of the medial epicondyle, are eligible to take part. Baseline function using the Patient-Reported Outcomes Measurement Information System (PROMIS) upper limb score, pain measured using the Wong Baker FACES pain scale, and quality of life (QoL) assessed with the EuroQol five-dimension questionnaire for younger patients (EQ-5D-Y) will be collected. Each patient will be randomly allocated (1:1, stratified using a minimization algorithm by centre and initial elbow dislocation status (i.e. dislocated or not-dislocated at presentation to the emergency department)) to either a regimen of the operative fixation or non-surgical treatment. Outcomes. At six weeks, and three, six, and 12 months, data on function, pain, sports/music participation, QoL, immobilization, and analgesia will be collected. These will also be repeated annually until the child reaches the age of 16 years. Four weeks after injury, the main outcomes plus data on complications, resource use, and school absence will be collected. The primary outcome is the PROMIS upper limb score at 12 months post-randomization. All data will be obtained through electronic questionnaires completed by the participants and/or parents/guardians. The NHS number of participants will be stored to enable future data linkage to sources of routinely collected data (i.e. Hospital Episode Statistics). Cite this article: Bone Jt Open 2024;5(1):69–77

Introduction

Total elbow arthroplasty (TEA) is a widely accepted for the treatment for damaged rheumatoid elbows to achieve sufficient joint function. The current prospective study reports the long term follow-up of TEA with an unlinked stem type (Stemmed Kyocera type I, SKC-I) with a solid trochlea on patients who have rheumatoid arthritis (RA). SKC-1 is derived from an unlinked surface replacement prosthesis using polycrystalline alumina ceramics on high-density polyethylene (Kyocera type I), which was developed in 1979, based on the measurement study on the cadaveric elbows.

Materials and Methods

57 elbows (Larsen’s grade IV and V) from 45 RA patients replaced by SKC-1 were investigated. Cement fixation was used in all cases. The duration of follow-up ranged from 36 to 154 (average 73. 7) months. The clinical condition of each elbow before and after operation was assessed according to the scoring system of Japanese Orthopaedic Association (JOA) elbow scoring system (maximum 100 points), which is composed of scores for pain, activity of daily life, muscle strength, range of motion, instability, and deformity of the joint. On the basis of this system, the results are defined as excellent (90–100 points), good (75–89), fair (60–74), and poor (< 60). Radiographic loosening was defined as a progressive radiolucent line of more than two millimeters that completely surrounded the prosthesis.

Results

The average postoperative JOA score improved from 43. 5±10. 2^° to 81. 0±}10. 3^°, with marked pain relief. The mean range of motion (ROM) of extension/flexion before the surgery was –35. 7±}22. 4/117. 1±}19. 1^° and at last follow-up was −17 5±}12. 7/136. 3±}11. 4^°. The mean ROM of pronation /supination improved from 51. 1±}23. 4/56. 5±}28. 5^° to 78. 3±}16. 8/82. 3±}16. 5^°. Of the 57 elbows, 9 elbows were judged to have excellent results, 37 had good results, 8 had fair results, and 3 had poor results.

There were no instances of ulnar nerve palsy, triceps avulsion, or postoperative infection. Medial or lateral epicondylar fracture occurred in 2 cases during the operation, and union was achieved 3 months later. Massive instability with joint dislocation was seen in 3 cases of mutilans arthritis, resulting in poor results. Aseptic loosening was seen in 3 elbows. Revision surgery was performed in 1 case of accidental post-operative distal humerus fracture, and in another of olecranon fracture with the breakage of the ulnar component. With loosening defined as the end point, Kaplan-Meier curve of the cumulative probability of survivorship demonstrates the likelihood of survival of the prosthesis at 93. 8 percent for as long as 10 years.

Discussion

The results of the current study showed a high reliability of the SKC-1 prosthesis with the novel alumina ceramic component over a long period when implanted with cement. However, the use of non-constrained devices is limited by the amount of bone and by the need for ligamentous stability. If soft tissues are damaged along with marked bone loss or inflammatory changes, the ligament should be repaired or a semiconstrained type of prosthesis is indicated. It is important to note that a high level of surgical technique is required for TEA in RA elbows to avoid typical postoperative complications.

40 linked total elbow replacements were inserted into 35 patients over a 12-year period. The mean age was 67. 3 years, (range 48 to 87 years) and the mean follow up 50 months (range 8 to 134 months). Each patient had undergone at least 1 operation prior to the index arthroplasty (range 1 to 10). 27 elbows were flail and 13 unstable due to previous failed total elbow replacements in 23, gross bony erosion due to rheumatoid arthritis in 9, distal humeral non-union in 6 and Charcot joints due to syringomyelia in 2.

A Coonrad Morrey sloppy hinge prosthesis was implanted in 25 elbows and a snap-fit Souter Strath-clyde prosthesis in 15. The technique included preservation of the triceps mechanism and early mobilisation in most cases. At review 38 elbows had no or mild pain, 2 moderate, and no patient had severe pain. All patients achieved a functional range of movement. There was no linkage failure of any implant.

Complications included revision for aseptic loosening of one humeral and one ulnar component, debridement for infection in one and curettage and bone grafting of a cement granuloma in one. One patient with a Charcot joint developed a non-union after failure of plating and grafting of a periprosthetic fracture at the tip of the humeral component. In addition six had delayed wound healing, two ulnar nerve symptoms and two triceps weakness.

In conclusion, a linked elbow replacement can reliably provide stability, mobility and pain relief in a flail or unstable joint allowing the hand to be positioned in space and therefore the function of the limb is dramatically improved. This method is especially appropriate in elderly frail patients.

Purpose

Clinical outocome of revision total elbow arthroplasty(TEA) in rheumatoid arthritis(RA) patients were evaluated.

Purpose: We conducted a retrospective study of 20 total elbow prostheses GUEPAR humerocubital and humeroradial (G3) implanted in 19 patients with rheumatoid arthritis. This anatomic metal-polyethylene prosthesis is available in a left and right model and in two sizes, large and small. A radial head prosthesis is now available in addition to the humerocubital prosthesis. The radial head prosthesis has an intramedullary metallic stem and a mobile polyethylene cup which comes in several sizes.

Material and methods: Among 20 prostheses implanted between 1997 and 2001, four were first-generation prostheses which did not have a radial head. At three to four years, these four prostheses developed valgus instability with deterioration of the polyethylene of the cubital piece requiring revision with a new generation GUEPAR associated with a radial head. This gave two good results and two failures revised with a semi-constrained prosthesis. For the 16 other cases of rheumatoid disease, the G3 humerocubital prosthesis associated with a radial head was inserted. These 16 prostheses were followed two years and were retained for this analysis. The posterior approach was used with inverted-V section of the triceps using the surgical technique recommended by the promoters. Patients had permanent severe to moderate pain. The Mayo Clinic score (1992 including daily life activities) was 33/100. Radiographically, seven elbows were Larsen grade III, nine grade IV, seven grade IIA and nine grade IIIb (Larsen classification modified by the Mayo Clinic).

Results: All patients were reviewed with mean follow-up of two years (1–5). The Mayo Clinic score improved from 33/100 to33/90 with outcome considered excellent in 15 elbows and fair in one.

Discussion: We recommend total elbow prostheses for rheumatoid arthritis patients. Semi-constrained prostheses have indications in certain cases of massive destruction, but the minimally or non-constrained gliding prostheses, such as the GUEPAR prosthesis, are part of the evolution of these prostheses, just as was the case for knee prostheses. These good results can be expected to persist over time.

Aim: 40 linked total elbow replacements were inserted into 35 patients over a 12-year period. The mean age was 67.3 (48–87) years and the mean follow up 50 (8–134) months. Each patient had undergone at least 1 operation prior to the index arthroplasty (1–10). 27 elbows were ßail and 13 unstable due to previous failed total elbow replacements in 23, gross bony erosion due to rheumatoid arthritis in 9, distal humeral non-union in 6 and Charcot joints due to syringomyelia in 2. Methods: A Coonrad Morrey sloppy hinge prosthesis was implanted in 25 elbows and a Snap þt Souter Strathclyde prosthesis in 15. The technique included preservation of the triceps mechanism and early mobilisation in most cases. Results: At review 38 elbows had no or mild pain, 2 moderate, and no patient with severe pain. All patients achieved a functional range of movement. There was no linkage failure of any implant. Complications included revision for aseptic loosening of one humeral and one ulnar component, debridement for infection in 1 and curettage and bone grafting of a cement granuloma in 1. One patient with a Charcot joint developed a non- union after failure of plating and grafting of a periprosthetic fracture at the tip of the humeral component. In addition 6 had delayed wound healing, 2 ulnar nerve symptoms and 2 triceps weakness. Conclusions: In conclusion, a linked elbow replacement can reliably provide stability, mobility and pain relief in a ßail or unstable joint allowing the hand to be positioned in space and therefore the function of the limb is dramatically improved. This method is especially appropriate in elderly frail patients.

Aim: To determine the effectiveness of arthroscopic surgery, without excision of the radial head, in elbows with end stage arthritis of the radiocapitellar joint.

Methods: Twenty-three elbows with bone-on-bone degeneration of the radio-capitellar joint, but with only minor degeneration of the humeroulnar joint, had arthroscopic surgery, with synovectomy, removal of loose bodies and excision of impinging tissues and bone. The average age was 51 years (range: 16 years to 59 years). Evaluation was by a questionnaire and the follow-up was after a minimum of one year.

Results: The average follow up was 41 months (range 12 months to 83 months). Twenty-one of 22 patients reported improvements. Six patients were pain free, 12 had mild residual pain and six had significant, continuing pain. Only three patients reported residual lateral elbow pain. The average visual analogue pain score was 3.4. According to the Mayo elbow function score, there were eight excellent, seven good, six fair, and three poor outcomes.

Conclusions: Satisfactory improvements in symptoms and function were obtained in arthritic elbows with arthroscopic surgery, even in the presence of severe radiocapitellar arthritis.

Introduction Complex fracture dislocation of the elbow can often be either irreducible or unstable with inability to hold the reduction or delayed subluxation or dislocation. This study looks at the aetiology of the instability, bony and ligamentous, and the results following stabilisation with a combination of internal fixation, ligament repair, radial head arthroplasty and or hinged external fixation.

Methods Twenty-one consecutive unstable elbows referred to three tertiary centres were prospectively recruited for this study. All cases had fine-cut CT scans with sagittal, coronal and 3D reconstructions. All elbows were approached using a posterior ‘global’ incision. Ulnar neurolysis was routinely performed. Medial and lateral ligament complexes were inspected and repaired. Internal fixation of the radial head was attempted where indicated, or a radial head arthroplasty was performed. The coronoid-brachialis complex was repaired using pull-through sutures. Elbow stability was tested and a hinged external fixator used where indicated. The fixator was removed at six weeks. Indomethacin prophylaxis against heterotopic ossification was used routinely. Follow-up range of motion, articular congruity and DASH score were assessed at one year. All cases required a repair of the coronoid-brachialis complex. Radial head reconstruction was attempted in four cases, but abandoned in three. The radial head was replaced in 13 cases. A lateral repair alone was required in 12 cases, a medial repair alone in two cases and a combined medial and lateral repair in seven cases. Eighteen cases required a hinged device (nine Compass hinges and nine OpteROM distractors).

Results The mean less of extension at one year was 12° (range 0 to 20) and the mean loss of flexion was 14° (range 0 to 20). All cases achieved at least a functional arc of motion from 30° to 130°. Three cases achieved a full range of motion. Despite Indomethacin prophylaxis three cases developed minor heterotopic ossification. The average DASH score was 23.

Conclusions If managed appropriately, a very good anatomical and functional outcome can be achieved in difficult unstable elbows post fracture dislocation. Repair of the coronoid-brachialis complex is the key to stability, along with radial head reconstruction or replacement. A hinged external fixation device allows early mobilisation.

We operated on 16 patients for ulnar neuropathy associated with osteoarthritis of the elbow. They were all male manual workers, with an average age of 51 years at the time of surgery. The severity of the symptoms was McGowan grade 1 in five patients, grade 2 in nine and grade 3 in two. The mean follow-up was 36 months.

The operation consists of resecting the osteophytes around the postcondylar groove. The shallow and narrow cubital tunnel is made deep and wide and the ulnar nerve is replaced with its surrounding soft tissues in the enlarged groove.

All patients were relieved of discomfort and all showed some improvement or full recovery of motor and sensory function. The ulnar nerve showed no evidence of irritation or adhesion. This procedure also allows early movement of the elbow after operation, because the subcutaneous tissues and muscles have not been detached.

Thirty-four patients with an average age of 64 years had forty consecutive total elbow replacements done using Souter-Strathclyde prostheses between 1991 & 1994. Six patients had died, however useful data was available in three that were included in the series, two patients failed to attend review clinic due to other medical problems and were excluded from this study. The results of thirty-five elbows were analysed and are presented in this paper. Mean follow up at the final evaluation was 79 months.

All patients were evaluated before and after the operation using Modified Mayo’s Performance index with maximum score of 100. An independent observer performed the latest clinical evaluation.

The average score before the operation was 51. 4, this improved to 82. 4 (p< 0. 001), pain score (maximum 50) improved from 23. 4 before the operation to 47. 1 (p< 0. 001) and the functional component of the score (maximum 30) also improved from 12. 5 to 18. 57 at the time of follow up. The range of motion score (maximum 20) showed least improvement with slight improvement in flexion from 127. 57 before the operation to 134. 34 (p=0. 387) at the time of last follow up.

Four elbows were removed, one due to early and three due to late onset deep infection; there has been no incidence of aseptic loosening requiring revision. Other complications were ulnar nerve dysthesia (two), minor intra-operative fracture (two), dislocation (one).

The Souter-Strathclyde elbow provides sustained pain relief, and functional improvement in the upper extremity. Motion remains unaffected, with some improvement in flexion. We believe that the Souter-Strathclyde elbow replacement can help patients with rheumatoid elbow disease, and we continue to evaluate prospectively a larger series of patients.

The purpose of the study was to define the anatomy of the distal biceps tendon and it’s attachment to the proximal radius (bicipital tuberosity). Distal ruptures of the biceps tendon are not uncommon. Surgical treatment needs an understanding of the precise anatomy of the distal biceps tendon and it’s insertion; of which there are no reports in the literature.

Eighty cadaver elbows were dissected. Six were damaged, hence they were excluded from the study. The skin over the cadaver elbows was removed. The distal biceps tendon was dissected and followed to it’s insertion on to the bicipital tuberosity. Measurements of tendon dimensions were taken at the elbow joint and at it’s insertion.

The whole distal biceps tendon twists in a predictable manner. The tendon fibres too change orientation. The tendon inserts on the posterior margin of the bicipital tuberosity in a thin C-shaped manner. All the biceps insertions had a significantly large bursa associated with it.

Both the biceps tendon and it’s intra-tendinous fibres twist. This has biomechanical implications. The dimensions of the biceps tendon at the elbow and at it’s insertion affect the biomechanics. The insertion into bone in a thin C shaped fashion has connotations on methods of repair.

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

Introduction – Electronic storage of X-rays is becoming standard. It would therefore, be highly desirable to use a computer as a tool for obtaining useful measurements from radiographs. The current study investigates the reliability of computerised measurements of radiographs of the Souter-Strathclyde elbow. Materials and Methods – 56 AP radiographs of Souter-Strathclyde Elbows were assessed for the parameters described by Trail et al (1999). The respective x-rays were digitised using a transparency flatbed scanner with a resolution of 80 ï m/pixel. The radiographs were then measured for the migration and movement of the prosthesis using the following lines: Hapd1, Hapd2, Hapd3 Hapd4. All the radiographs were measured twice manually with at least one week interval, the observer being blind to the initial results at the time of the second measurement. The x-rays were again measured twice using the computer and a measuring software developed in our own department. The results were analysed for intra observer variability, using paired t-test and Pearson correlations. Results – Table 1 shows the results of the paired measurements, with the confidence intervals for the mean error, the p for the paired t-test and the correlations between the paired readings. M1 and M2 represent the manual readings, while C1 and C2 the computerised readings. Conclusions – The mean error of all paired readings was below 1 mm. The correlation between all paired readings was highly significant, with all the paired readings with the computer as a tool being .99. The only difference that was statistically significant was Hapd3M1-M2, between two manual measurements, although the mean error is not clinically relevant, still being less than 1mm. We conclude that computerised measurements of radiographs are at least as reliable as those conducted directly on film

Introduction: Electronic storage of X-rays is becoming standard. It would therefore, be highly desirable to use a computer as a tool for obtaining useful measurements from radiographs. The current study investigates the reliability of computerised measurements of radiographs of the Souter-Strathclyde elbow. Materials and Methods: 56 AP radiographs of Souter-Strathclyde Elbows were assessed for the parameters described by Trail et al (1999). The respective x-rays were digitised using a transparency flatbed scanner with a resolution of 80 _m/pixel. The radiographs were then measured for the migration and movement of the prosthesis using the following lines: Hapd1, Hapd2, Hapd3 Hapd4. All the radiographs were measured twice manually with at least one week interval, the observer being blind to the initial results at the time of the second measurement. The x-rays were again measured twice using the computer and a measuring software developed in our own department. The results were analysed for intra observer variability, using paired t-test and Pearson correlations. Results: Table 1 shows the results of the paired measurements, with the confidence intervals for the mean error, the p for the paired t-test and the correlations between the paired readings. M1 and M2 represent the manual readings, while C1 and C2 the computerised readings. Conclusions: The mean error of all paired readings was below 1 mm. The correlation between all paired readings was highly significant, with all the paired readings with the computer as a tool being .99. The only difference that was statistically significant was Hapd3M1-M2, between two manual measurements, although the mean error is not clinically relevant, still being less than 1mm. We conclude that computerised measurements of radiographs are at least as reliable as those conducted directly on film

Aims

Arthroplasty is being increasingly used for the management of distal humeral fractures (DHFs) in elderly patients. Arthroplasty options include total elbow arthroplasty (TEA) and hemiarthroplasty (HA); both have unique complications and there is not yet a consensus on which implant is superior. This systematic review asked: in patients aged over 65 years with unreconstructable DHFs, what differences are there in outcomes, as measured by patient-reported outcome measures (PROMs), range of motion (ROM), and complications, between distal humeral HA and TEA?

Aims

Gram-negative periprosthetic joint infection (PJI) has been poorly studied despite its rapidly increasing incidence. Treatment with one-stage revision using intra-articular (IA) infusion of antibiotics may offer a reasonable alternative with a distinct advantage of providing a means of delivering the drug in high concentrations. Carbapenems are regarded as the last line of defense against severe Gram-negative or polymicrobial infection. This study presents the results of one-stage revision using intra-articular carbapenem infusion for treating Gram-negative PJI, and analyzes the characteristics of bacteria distribution and drug sensitivity.

Aims

This study investigates the effects of intra-articular injection of adipose-derived mesenchymal stem cells (AdMSCs) and platelet-rich plasma (PRP) on lameness, pain, and quality of life in osteoarthritic canine patients.

Aims

The aim of this study was to report the mid-term clinical outcome of cemented unlinked J-alumina ceramic elbow (JACE) arthroplasties when used in patients with rheumatoid arthritis (RA).