Abstract. Introduction. Displaced olecranon fractures in the elderly are challenging due to associated comorbidities, poor tissue quality, high risk of complications, and the possible need for implant removal. Treatment options with such fractures range from non-operative management to internal fixation with various types of implants. Currently, there is no consensus on the treatment of olecranon fractures in the elderly with relatively low functional demand. Aim. The aim of this systematic review was to analyse the clinical outcomes of various treatment modalities for olecranon fracture in the elderly. Methods. We systematically reviewed the literature covering the treatment of olecranon fractures in the elderly according to PRISMA guidelines. We used search tools of Medline, Embase, Wiley online library, Cochrane and Scopus. Keywords used in the search were Olecranon fracture and Elderly OR Geriatric in all fields. Studies involving patients older than 60 years of age and all modalities of treatment were included. Results. 14 papers studying 270 patients were identified of which, 112 were treated non-operatively, 25 with limited fixation, 98 with tension band wire fixation, 34 with plate fixation, and 1 patient was treated with excision. Conclusions. Nonoperative as well as limited fixation were shown to provide satisfactory results in the elderly. Treatment decisions in this age group should be individualised to factors such as fracture stability, quality of bone & soft tissues, and patient's functional demand. We recommend a treatment protocol for treating olecranon fracture in the elderly based on the above factors

Olecranon fractures are common injuries representing roughly 5% of pediatric elbow fractures. The traditional surgical management is open reduction and internal fixation with a tension band technique where the pins are buried under the skin and tamped into the triceps. We have used a modification of this technique, where the pins have been left out of the skin to be removed in clinic. The purpose of the current study is to compare the outcomes of surgically treated olecranon fractures using a tension-band technique with buried k-wires (PINS IN) versus percutaneous k-wires (PINS OUT). We performed a retrospective chart review on all pediatric patients (18 years of age or less) with olecranon fractures that were surgically treated at a pediatric academic center between 2015 to present. Fractures were identified using ICD-10 codes and manually identified for those with an isolated olecranon fracture. Patients were excluded if they had polytrauma, metabolic bone disease, were treated non-op or if a non-tension band technique was used (ex: plate/screws). Patients were then divided into 2 groups, olecranon fractures using a tension-band technique with buried k-wires (PINS IN) and with percutaneous k-wires (PINS OUT). In the PINS OUT group, the k-wires were removed in clinic at the surgeon's discretion once adequate fracture healing was identified. The 2 groups were then compared for demographics, time to mobilization, fracture healing, complications and return to OR. A total of 35 patients met inclusion criteria. There were 28 patients in the PINS IN group with an average age of 12.8 years, of which 82% male and 43% fractured their right olecranon. There were 7 patients in the PINS OUT group with an average age of 12.6 years, of which 57% were male and 43% fractured their right olecranon. All patients in both groups were treated with open reduction internal fixation with a tension band-technique. In the PINS IN group, 64% were treated with 2.0 k-wires and various materials for the tension band (82% suture, 18% cerclage wire). In the PINS OUT group, 71% were treated with 2.0 k-wires and all were treated with sutures for the tension band. The PINS IN group were faster to mobilize (3.4 weeks (range 2-5 weeks) vs 5 weeks (range 4-7 weeks) p=0.01) but had a significantly higher complications rate compared to the PINS OUT group (6 vs 0, p =0.0001) and a significantly higher return to OR (71% vs 0%, p=0.0001), mainly for hardware irritation or limited range of motion. All fractures healed in both groups within 7 weeks. Pediatric olecranon fractures treated with a suture tension-band technique and k-wires left percutaneously is a safe and alternative technique compared to the traditional buried k-wires technique. The PINS OUT technique, although needing longer immobilization, could lead to less complications and decreased return to the OR due to irritation and limited ROM

The purpose of this study is to determine the re-operation rate following plate fixation of the olecranon with contoured anatomic plates. Plate fixation of the olecranon allows for management of different fracture patterns as well as osteotomies with anatomic reduction and stable fixation for early elbow mobilization. However, olecranon hardware prominence can be troublesome. Our hypothesis was with the newer generation of low profile contoured anatomic plates, the rate of hardware removal should be lower compared to previously described literature. Retrospective review for patients treated with operative fixation of the olecranon between 2010 and 2015 in the Edmonton zone was identified using population level administrative data. Radiographic screening of these patients was then carried out to identify those who received plate fixation. Fracture patterns were also characterized. Chart reviews followed to determine the indications for re-operation and other post-operative complications. Main outcome measures were re-operation rate and their indications, including hardware prominence. During the screening process, 600 surgically treated olecranon patients were identified and 321 patients were found to have plate fixation of the olecranon. Chart review determined 90 patients had re-operations demonstrating a 28% re-operation rate. Re-operation due to hardware prominence was found to be 15.6%. Other indications included hardware failure (5.3%), infection (2.8%), or contracture (2.8%). Compared to patients that did not require re-operation, the re-operation group had a higher incidence of Type III olecranon fractures (17.4% vs 8.4%, p = 0.036) and Monteggia pattern injuries (13.5% vs 4.9%, p = 0.008). Recent heteregenous data suggests the hardware removal rate related to implant prominence is between 17–54%. Compared to the literature, this study demonstrated a lower rate at 15.6% with contoured anatomic plating. Also, those with more complex fracture patterns were more likely to require re-operation

Olecranon Osteotomy is a common approach used in the management of intraarticular distal humerus fractures. Significant complication rates have been associated with this procedure, including non-union rates of 0–13% and implant removal rates between 12–86%. This study is a multicentre retrospective study involving the largest cohort of olecranon osteotomies in the literature, examining implant fixation types, removal rates and associated complications. Patients were identified between 2007 and 2017 (minimum one year follow-up) via Canadian Classification of Health Interventions (CCI) coding and ICD9/10 codes by our health region's data information service. CCI intervention codes were used to identify patients who underwent surgery for their fracture with an olecranon osteotomy. Reasons for implant removal were identified from a chart review. Our primary outcome was implant removal rates. Categorical data was assessed using Chi square test and Fischer's Exact test. Ninety-nine patients were identified to have undergone an olecranon osteotomy for treatment of a distal humerus fracture. Twenty patients had their osteotomy fixed with a plate and screws and 67 patients were fixed with a tension band wire. Eleven patients underwent “screw fixation”, consisting of a single screw with or without the addition of a wire. One patient had placement of a cable-pin system. Of patients who underwent olecranon osteotomy fixation, 34.3% required implant removal. Removal rates were: 28/67 for TBW (41.8%), 6/20 plates (30%), 0/1 cable-pin and 0/11 for osteotomies fixed with screw fixation. Screw fixation was removed less frequently than TBW p<.006. TBW were more commonly removed than all other fixation types p<.043. Screws were less commonly removed than all other fixation types p<.015. TBW were more likely to be removed for implant irritation than plates, p<.007, and all other implants p<.007. The average time to removal was 361 days (80–1503 days). A second surgeon was the surgeon responsible for the removal in 10/34 cases (29%). TBWs requiring removal were further off the olecranon tip than those not removed p=.006. TBWs were associated with an OR of 3.29 (CI 1.10–9.84) for implant removal if implanted further than 1mm off bone. Nonunion of the osteotomy occurred in three out of 99 patients (3%). K-wires through the anterior ulnar cortex did not result in decreased need for TBW removal. There was no relation between plate prominence and the need for implant removal. There was no association between age and implant removal. The implant removal rate was 34% overall. Single screw fixation was the best option for osteotomy fixation, as 0/11 required hardware removal, which was statistically less frequent than TBW at 28/67. Screw fixation was removed less frequently than TBW and screw fixation was less commonly removed than all other fixation types. Only 6/20 (30%) plates required removal, which is lower than previously published rates. Overall, TBW were more commonly removed than all other fixation types and this was also the case if hardware irritation was used as the indication for removal. Nonunion rates of olecranon osteotomy were 3%

Osteotomy through the bare area of olecranon minimises the damage to articular cartilage in the trans-olecranon approach to the distal humerus. In this study we have identified a reliable and easily reproducible anatomical land mark to make sure that the osteotomy passes through the bare area. Two methods were used to determine the line for the osteotomy, in the first a line from the lateral epicondyle perpendicular to the olecranon and in the second an intra-articular marker was used to determine the osteotomy. In 5 cadavers the osteotomy with lateral epicondylar line as a marker went 2 mm proximal to the bare area. Of the 5 cadavers dissected with a marker passed to the angle of olecranon the osteotomy went through the bare area of olecranon in three specimens and just proximal in the other two. In conclusion a cheveron osteotomy with the base of the chevron on the lateral epicondylar line will be the ideal site to make sure that the osteotomy passes through the bare area of the olecranon

We investigated whether an alternative tension band wire technique will produce greater compression and less displacement at olecranon (elbow) fracture sites compared to a standard figure of eight tension band technique. Olecranon fractures are commonly treated with tension band wiring using stainless steel wire in a figure of eight configuration. However recently published studies have raised doubts over the validity of the tension band concept proving that the standard figure of eight configuration does not provide fracture compression when the elbow is flexed. We propose an alternative tension band technique where the figure of eight is applied in a modified configuration producing greater compression across the fracture. An artificial elbow joint was simulated using artificial forearm (ulna) and arm (humerus) bones. The design simulated the action of the muscles around the elbow joint to produce flexion and extension. There were two arms to this investigation. (1) Standard tension band wire configuration with stainless steel. (2) Modified tension band wire configuration with stainless steel. The simulated elbow was put through a range of movement and sensors measured the compression at the articular and non-articluar surfaces of the fracture. Measurements were taken for compression with different weights applied to challenge both the techniques of tension band wiring. Measurements from the non articular surface of the fracture demonstrated greater compression with alternative tension band technique. However it was not statistically significant (ANOVA). Compression at the articular surface of the fracture exhibited statistically significant (p<0.05) greater compression with the alternative technique. Neither technique produced greater compression during flexion of the simulated elbow. The alternative tension band wiring technique proved superior in providing greater compression over the fracture site

Avulsion fractures of the tip of the olecranon are a common traumatic injury. Kirshner-wire fixation (1.6mm) with a figure of eight tension band wire (1.25mm) remains the most popular technique. Hardware removal mat be required in up to 80% of cases. Modern suture materials have very high tensile strength coupled with excellent usability. In this study we compare a repair using 1.6mm k-wires with a 1.25mm surgical steel, against a repair that uses two strands of 2 fibrewire. Twelve Pairs of cadaveric arms were harvested. A standard olecranon osteotomy was performed to mimic an avulsion fracture. In each pair one was fixed using standard technique, 2 × 1.6mm transcortical ?-wire plus figure of 8 loop of 1.25mm wire. The other fixed with the same ?-wires with a tension band suture of 2.0 fibrewire (two loops, one figure of 8 and one simple loop). The triceps tendon was cyclically loaded (10-120 Newtons) to simulate full active motion 2200 cycles. Fracture gap was measured with the ‘Smart Capture’ motion analysis system. The arm was fixed at 90 degrees and triceps tendon was loaded until fixation failure, ultimate load to failure and mode of failure was noted. The average gap formation at the fracture site for the suture group was 0.91mm, in the wire group 0.96mm, no specimen in either group produced a significant gap after cyclical loading. Mean load to failure for the suture group was 1069 Newtons (SD=120N) and in the wire group 820 Newtons (SD=235N). Both types of fixation allow full early mobilisation without gap formation. The Suture group has a significantly higher load to failure (p=0.002, t-test). Tension Band suture allows a lower profile fixation, potentially reducing the frequency of wound complications and hardware removal

Intraarticular fractures of the distal humerus comprise 1% of all fractures in adults. Triceps reflecting and olecranon osteotomy approach provide adequate exposure in intraarticular fracture with its own advantage and disadvantages. Forty consecutive patients with fractures of the distal humerus were treated over a 36-month period. The patients were randomly allotted into two groups; group A consists of twenty patients with olecranon osteotomy and group B consists of twenty patients with triceps reflecting approach. In both the groups fracture was fixed using orthogonal or parallel plating techniques. Clinical outcome was assessed using the DASH SCORE, radiological union and complications was noted in both the group and compared. In group A the mean DASH score was 15.9 points. Three patients underwent a second procedure for hardware removal, 2 patients had non-union at osteotomy site, one patient had transient ulna nerve neuropraxia and one patient had superficial infection. In group B the mean DASH score was 14 points. There was no statistical significance between both groups regarding final outcome except complications were more in osteotomy approach. We conclude both approach is an effective procedure with an excellent or good functional outcome but osteotomy approach has more complications

Adequate exposure is a prerequisite for treatment of distal humeral fractures. In this study, we compared the clinico-radiological and functional outcome of TRAP approach with that of olecranon osteotomy for distal humerus fractures. 27 patients with distal humerus fractures were randomized into 2 groups: Group 1 (n=14, TRAP approach), Group 2 (n=13, Olecranon osteotomy). All patients were operated with bi-columnar fixation. All patients were mobilized from day 2. Follow-up evaluation was done at 1, 3, 6 and 12 months. All patients achieved union. The mean surgical time was higher in group 1 (120 min) as compared to group 2 (100 min). The final ROM was higher in group 1 (1160) as compared to group 2 (850). Two patients in group 2 needed posterior release. 5 patients in group 2 had hardware complications related to olecranon osteotomy and needed removal. Two patients in Group 1 had transient ulnar nerve paraesthesias. There was no difference in triceps power in both groups. Our results demonstrate that TRAP approach is extensile and safe enough in treating these complex fractures with better final ROM and fewer complications

Aims. Compression and absolute stability are important in intra-articular fractures such as transverse olecranon fractures. This biomechanical study aims to compare tension band wiring (TBW) with plate fixation by measuring compression within the fracture. Methods. A cross-over design and synthetic ulna models were used to reduce variation between samples. Identical transverse fractures were created using a 0.5mm saw blade and cutting jig. A Tekscan(tm) force transducer was calibrated and placed within the fracture gap. Twenty TBW or Acumed(tm) plate fixations were performed according to the recommended technique. Compression was measured while the constructs were static and during simulated elbow range of movement exercises. Dynamic testing was performed using a custom jig reproducing cyclical triceps contraction of 20N and reciprocal brachialis contraction of 10N. Both fixation methods were tested on each sample. Half were randomly allocated to TBW first and half to plating first. Data was recorded using F-scan (v 5.72) and analysed using SPSS(tm) (v 16). Paired T-tests compared overall compression and compression at the articular side of the fracture. Results. The mean overall compression for plating was 819N (+/− 602N 95%CI), TBW overall compression: 77N (+/−19N 95%CI) (P=0.039). Articular side compression for plating: 343N (+/− 276N 95%CI), TBW: 1N (+/− 2N 95%CI). (P=0.038). During simulated movements, overall compression reduced in both groups: TBW -14N (+/−7N) Plating -173N (+/−32N) and no increase in articular side compression was detected in the TBW group. Conclusion. Precontoured plates such as the Acumed(tm) olecranon system can provide significantly greater compression, compared to TBW in transverse olecranon fractures. This was significant for compression over the whole fracture surface and specifically at the articular side of the fracture. Also, in TBW, overall compression reduced and articular side compression remained negligible during simulated triceps contraction, challenging the tension band principle

In the setting of traumatic elbow injuries involving coronoid fractures, the relative size of the coronoid fragment has been shown to relate to the stability of the joint. Currently, the challenge lies in accurately classifying the amount of bone loss in coronoid fractures. In comminuted fractures, bone loss is difficult to measure with plain radiographs or computed tomography. The purpose of this study is to describe a novel radiographic measure, the Coronoid Opening Angle (COA), on lateral elbow radiographs. We demonstrate the relationship of the COA to coronoid height and describe how this measure can be used to estimate bone loss and potentially predict elbow instability following coronoid fracture. Radiographs were drawn from a regional database in a consecutive fashion. Candidate radiographs were excluded on the basis of radiographic evidence of degenerative changes, previous surgery or injury, bony deformity, and inadequate lateral view of the elbow. The COA was measured as the angle between the long axis of the ulna at the level of the trochlear notch, and the tip of coronoid, from a common origin at the posterior cortex of the olecranon. Images were reviewed by a fellowship trained upper extremity surgeon, an upper extremity fellow, and a junior resident. Normal COA, coronoid height, and calculated COA at varying amounts of bone loss were calculated by three reviewers. A sensitivity analysis was performed to determine how the COA can most effectively predict bone loss at varying coronoid heights. Intraclass correlation coefficient (ICC) was calculated for 39 subjects. Seventy-two subjects were included for analysis (M=40, F=32). The normal coronoid opening angle is 33.19 degrees [32.2 – 34.2]. Coronoid height is 18.8 mm [18.1 – 19.6]. Extrapolating this baseline data, the COA at 20%, 33%, and 50% of coronoid bone loss was calculated to be 27.5, 23.5, and 18 degrees, respectively. ICC was found to be 0.90 or higher. Cutoff values were determined to maximize the sensitivity of the COA. A cutoff value of 21 degrees has a 92% sensitivity in detecting a minimum of 50% bone loss. The COA with similar sensitivity in predicting 20% and 33% bone loss are 32 and 27 degrees. The coronoid opening angle is a novel technique that can be used on a lateral elbow radiograph to predict the minimum coronoid bone loss. This can be used to guide clinical decision making and potentially predict instability. Future research will aim to validate this tool in the clinical setting in predicting instability

This study reviews the early results of Distal Humeral Hemiarthroplasty(DHH) for distal humeral fracture and proposed a treatment algorithm incorporating the use of this technique in the overall management of distal humeral fractures. DHH was performed on 30 patients (mean 65 years; 29-91) for unreconstructable fractures of the distal humerus or salvage of failed internal fixation. A triceps on approach was used in six and an olecranon osteotomy in 24. A Sorbie Questor prosthesis (Wright Medical Technology) was used in 14 patients and a Latitude (Tornier) in 16. Clinical review at a mean of 25 months (3–88) included the American Shoulder and Elbow Surgeons elbow outcomes instrument (ASES), Mayo Elbow Performance Index (MEPI) and radiological assessment. At follow up of 28 patients mean flexion deformity was 25 degrees, flexion 128 degrees, range of pronosupination 165 degrees, mean ASES 83, MEPI 77 and satisfaction 8/10. Acute cases scored better than salvage cases. Re- operation was required in 16 patients (53%); two revisions to a linked prosthesis for periprosthetic fracture and aseptic loosening at 53 and 16 months, 12 metalwork removals and four ulnar nerve procedures. Posterolateral rotatory instability was present in one elbow, four had laxity and mild pain on loading (two with prosthesis or pin loosening), four had laxity associated with column fractures (two symptomatic) and 10 had asymptomatic mild laxity only. The triceps on approach had worse instability and clinical scores. Uncomplicated union occurred in all olecranon osteotomies and 86% of column fractures. One elbow had an incomplete cement mantle and seven had lucencies >1 mm; one was loose but acceptable. Five prostheses were in slight varus. Two elbows had early degenerative changes and 15 developed a medial spur on the trochlea. This is the largest reported experience of DHH. Early results of DHH show good outcomes after complex distal humeral fractures, despite a technically demanding procedure. Better results are obtained for treatment in the acute setting and with use of an olecranon osteotomy. As a result of this experience anatomical and clinical pre-requisites and advise on technique are outlined. An algorithm for use of DHH in relation to total elbow arthroplasty and ORIF for the treatment of complex intra-articular distal humeral fractures with or without column fractures is proposed

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

Aim. Skeletal tuberculosis (TB) accounts for up to one third of cases of extra-pulmonary TB but comprises a minority of osteoarticular infection in areas with low TB incidence. Consequently, unexpected cases may receive surgical management targeted at non-tuberculous orthopaedic infections. This study reviewed treatment and outcomes of non-spinal osteoarticular TB to assess outcomes from modern surgical techniques. Method. All patients with a diagnosis of non-spinal osteoarticular TB between 2009–2017 from one tertiary referral centre were included. Retrospective review of surgical intervention, antibiotic treatment and outcome was conducted. Results. Fourteen patients with an average age of 48 (range 20–77) were identified; all were HIV-negative. Articular infections affected 7 patients, including one prosthetic joint infection. Osteomyelitis affecting the carpus, femur, tibia, olecranon and metatarsals was diagnosed in the remaining patients. Only 4 patients had radiological findings consistent with prior pulmonary TB, and only 3 had a history of prior TB or TB exposure. In 2 cases, symptom exacerbation was associated with local steroid injection. Diagnostic biopsy was employed in 5 cases, of whom 4 proceeded to medical management. Diagnosis was made following positive culture in 86% of cases; all TB isolates were fully sensitive. 71% of cases underwent surgical treatment according to best practice for biofilm-forming infection, including excision of osteomyelitis with local antibiotic therapy for three patients, and first-stage excision with spacer implantation for four patients. Quadruple therapy for an average of 8.5 months, range 6–12 months, was administered. Patients were followed up for a mean of 15.2 months. Half of the patients treated with surgery reported ongoing pain at 3 months and 4 patients underwent further surgery for persistent signs of infection (2 for probable persistent TB, 2 for bacterial super-infection). Conclusions. The role of surgical debridement in management of osteoarticular TB is unclear. In patients with a previous history of TB exposure a pre-operative diagnosis of TB could prevent unnecessary surgery and therefore prevent associated post-operative complications including bacterial super-infection and pain. Pre-op biopsy should therefore be considered in all patients with a history of TB exposure

Trans-articular coronal shear fractures of the distal humerus pose a significant challenge to the surgeon in obtaining an anatomical reduction and rigid fixation and thereby return of good function. A variety of approaches have been described which include the extended lateral and anterolateral approaches and arthroscopically-assisted fixation for non-comminuted fractures. Fixation methods include open or percutaneous cannulated screws and headless compression screws directed either anterior to posterior or posterior to anterior. We describe an illustrated, novel approach to this fracture which is minimally invasive but enables an anatomical reduction to be achieved. A 15 year old male presented with a Bryan and Morrey type 4 fracture as described by McKee involving the left distal humerus. He was placed in a lateral position with the elbow over a support. A posterior longitudinal incision and a 6cm triceps split from the tip of the olecranon was made. The olecranon fossa was exposed and a fenestration made with a 2.5mm drill and nibblers as in the OK (Outerbridge-Kashiwagi) procedure. A bone lever was then passed though the fenestration and used to reduce the capitellar and trochlear fracture fragments into an anatomical position with use of an image intensifier to confirm reduction. The fracture was then fixed with two headless compression screws from posterior to anterior into the capitellar and trochlear fragments (see images). Early mobilisation and rehabilitation were commenced. Follow-up clinical examination and radiographs at six weeks revealed excellent range-of-motion and function with anatomical bony union. We believe that this novel approach to this fracture reduces the amount of soft tissue dissection associated with conventional approaches and their associated risks and also enables earlier return to function with restoration of anatomy

Aim. Treatment for distal third shaft fractures of humerus is very challenging especially if its comminuted and bone is osteopenic. They are commonly treated with plating. Plating has complications of iatrogenic radial nerve palsy. We report our case series of distal third fractures of humerus treated with retrograde Halder Humeral Nail. Materials and methods. Since 1994 to 2010 we have 576 fractures of humerus treated with retrograde Halder Humeral nail. Of these 45 were distal third extra articular fractures of humerus. Average age of patients at the time of surgery was 30.4 years (Range 15–82 years, Median 33 years). Of 45 patients 26 were females and 19 males.3 out of 45 had non union at the time of presentation. The nail was locked distally with one or two screws and proximally with a screw and tripwire. The entry point of the nail was roof of olecranon fossa (contrary to standard retrograde nails where it is an inch above olecranon fossa) This design of nail allows it be used for even very distal fractures. All patients were followed till clinical and radiological signs of union. 1 patient was lost to follow up. Results. Average time to fracture healing was 13.9 weeks (Range 9–36 weeks). There were 2 cases of non union, one healed at 9 months with 2. nd. surgery. The other non union was asymptomatic and did not agree for further surgery. There was one reported case of infection.7 patients had nail removal electively on request. All the patients achieved full range of elbow and shoulder movement. No reported cases of iatrogenic radial nerve palsy. Conclusion. Our results of distal third fractures of humerus treated with retrograde Halder Humeral Nail are excellent. It avoids big exposure as needed in plating and complication of iatrogenic radial nerve palsy

Aim. To assess clinical outcome of massive rotator cuff tear repair using triceps myotendinous flap. Method. This is a prospective cohort of 43 patients (24 male, 19 female) with average age of 62 years. The primary indication of surgery was pain. Patients with massive rotator cuff tear involving supraspinatus and infraspinatus, showing retraction and fatty infiltration in MRI were selected. Few (8/43) were with failed surgical treatment and rest had conservative treatment failed. They underwent rotator cuff repair during Feb 1999 to Jan 2004. The long head of the triceps was detached from the olecranon, rotated 180 degrees from its pivot point with its major vascular pedicle under the deltoid and acromion through the posterior capsule and attached to the greater tuberosity and any remnant of remaining cuff. All patients were assessed pre-operatively, at 3, 6 and 12 months post-operatively clinically and also using UCLA pain and functional score for shoulder. Shoulder range of motion was assessed before and after the surgery. 24 patients had minimum of 1 year and 19 had 2 year minimum follow-up. Results. The mean total UCLA score of 9.7 pre-operatively improved to 27.8 (p<0.0001) following the operation. The mean pre-operative UCLA pain score 2.2 improved to 7.8 post-operatively (p<0.001). The UCLA functional score improved from a pre-operative average of 3.4 to 8.2 (p<0.0001) following the operation. There was significant improvement in forward elevation, external and internal rotation but not abduction. There was no weakness in elbow extension. Complications: 3 superficial infections, 1 ulnar neuritis (resolved in 6 weeks), 1 olecranon bursitis (resolved in 3 months). Conclusion. Long head triceps tendon transfer is an effective technique to alleviate pain and improve functions in patients with massive rotator cuff tear, specially in difficult group of patients with limited options

Introduction. Although Total elbow arthroplasty (TEA) generally provides favorable clinical outcomes, its complications have been reported with high rate compared with other joints. Previously, we used the Bryan & Morrey approach in TEA, which included separating the triceps muscle subperiosteally from the olecranon; however, since 2008, in order to prevent skin trouble and deficiency of the triceps, we performed TEA by MISTEA method, which required no removal of the subcutaneous tissue in the region of the olecranon and no release or stripping of the triceps tendon. Objectives. The purpose of this study was to examine the utility of the MISTEA method by evaluating and comparing muscle strength and complications by using both the Bryan & Morrey approach and MISTEA method. Materials and Methods. The study was conducted on 23 elbows, on which elbow muscle strength could be measured postoperatively at more than 6 months after TEA. Thirteen elbows were operated on the Bryan & Morrey approach (BM group; mean age, 62.3 years; mean follow-up period, 27 months), and 10 elbows on the MISTEA method (MIS group; mean age, 67.6 years; mean follow-up period, 19.1 months). To determine the elbow extensor and flexor strengths, measurements were conducted on the affected side for the BM group, and on both the affected and healthy sides for the MIS group. Further, the “extension/flexion ratio” as well as the “affected/healthy side ratio” and complications were assessed. Results. Excluding the elbow extensor strength of 3 elbows in the BM group, which could not be measured too week. The extension/flexion ratio was as follows: in the BM group, 0.61 and in the MIS group, 0.93 on the affected side and 0.81 on the healthy side. For the MIS group, in which measurements could be performed on both the sides, the “affected/healthy side ratio” was 0.72 in flexion and 0.91 in extension. In terms of complications, skin trouble was found on 2 elbows in the BM group and on 1 elbow in the MIS group; further, rupture of the triceps tendon was suspected in 3 elbows in the BM group but was not found in the MIS group. Discussion. In our study, deficiency in triceps muscle was found in 3 of 13 elbows with the Bryan & Morrey approach. MISTEA method may be the reason for prevention of deficiency or rupture of the triceps tendon. The MIS group had higher extension/flexion ratio in the affected side, suggesting the possibility that either the extensor strength had increased or the flexor strength had weakened. Further, in the MIS group, the extension showed an “affected/healthy side” ratio, which means that an extensor strength almost equivalent to that of the healthy side was maintained, whereas the flexor strength was 72% of that on the healthy side, suggesting that the flexor strength may have decreased. Loss of the flexor strength may be because the MISTEA method involves partial release of the brachialis muscle and the joint's center of rotation to move slightly towards the proximal side

Background. The optimal treatment for symptomatic elbow osteoarthritis remains debatable especially in patients still involved in heavy manual work. The Outerbridge-Kashiwagi (OK) procedure has been used when simple measures fail. The aim of this study is to analyse the results of the OK procedure in patients with symptomatic osteoarthritis. Methods. Twenty-two patients were included in the study. The male:female ratio was 18:4. The mean age was 60 years with mean follow-up of 38 months (24–60 months). 17 were manual workers, 3 involved in sports activities and 2 non-manual workers. All patients were assessed using Mayo Elbow Performance Index Score system. Preoperative radiological assessment showed osteophytes around olecranon and coronoid process and joint space narrowing in radio-humeral articulationin all cases. Results. There was a significant improvement (p<0.05) in movement in the flexion-extension axis from 78.2° to 107.3°. There was a significant reduction in pain post-operatively (p<0.001). Mean MEPI score improved from 50 to 87.4 post surgery which was significant (p<0.05). One patient had ulnar nerve palsy which resolved in six months with conservative management. The results were excellent in six patients (27%), good in fifteen (68%), fair in one (5%) and one (5%) had poor result. Discussion and conclusion. The present study indicates that the OK procedure provides significant pain relief and a functionally useful range of movement of more than 100°. The procedure can be used in high demand patients, wherein total elbow replacement is not indicated. It significantly reduces the disability in patients with significant elbow arthritis

The purpose of this study is to describe the use of the PHILOS plate (Synthes) in reverse configuration to treat complex distal humeral non-unions. Non-union is a frequent complication of distal humeral fracture. It is a challenging problem due to the complex anatomy of the distal humerus, small distal fragment heavily loaded by the forearm acting as a long lever arm with powerful forces increasing the chances of displacement. Rigid fixation and stability with a device of high “pull-out” strength is required. The PHILOS plate has been used in reverse configuration to achieve good fixation while allowing central posterior placement of the implant. 11 patients with established non-union of distal humeral fractures were included in this study. No patient in whom this implant was used has been excluded. Initial fixation was revised using the PHILOS plate in reverse configuration and good fixation was achieved. Bone graft substitutes were used in all cases. Patients were followed to bony union, and functional recovery. All fractures united. One required revision of plate due to fatigue failure. Average time to union was 8 months with excellent restoration of elbow function. A reversed PHILOS plate provides an excellent method of fixation in distal humeral non-union, often complicated by distorted anatomy and previous surgical intervention. It has a high “pull-out” strength and may be placed in the centre of the posterior humerus, allowing proximal extension of the fixation as far as is required. It provides secure distal fixation without impinging on the olecranon fossa. It is more versatile and easier to use than available pre contoured plating systems