We carried out a survival analysis of elbow synovectomy (ES) and excision of the radial head (RHE) performed on 171 rheumatoid elbows. The failure criteria were revision surgery (performed or desired) and/or the presence of significant or severe pain.

The cumulative survival was 81% at one year which thereafter decreased by an average of 2.6% per year. The strongest predictor for success was a low preoperative range of supination-pronation when corresponding survival curves were compared. A low range of flexion-extension also predicted failure. Combining both factors gave better prediction (failure: 6.3% v 67%), but a long duration of elbow symptoms before surgery predicted failure (72%, p = 0.04).

At review, there was a mean gain of 50° in supination-pronation and 11° in flexion-extension; both correlated with success. Failure correlated with recurrence of synovitis, elbow instability, ulnar neuropathy, poor general mobility and poor upper-limb function. The last was independently affected by the severity of RA in the ipsilateral shoulder.

Our findings show that although the short-term result of ES and RHE in rheumatoid arthritis is good, the long-term outcome is poor except in a subgroup with more than 50% limitation of forearm rotation.

We measured the tension in the interosseous membrane in six cadaveric forearms using an in vitro forearm testing system with the native radial head, after excision of the radial head and after metallic radial head replacement. The tension almost doubled after excision of the radial head during simulated rotation of the forearm (p = 0.007). There was no significant difference in tension in the interosseous membrane between the native and radial head replacement states (p = 0.09). Maximal tension occurred in neutral rotation with both the native and the replaced radial head, but in pronation if the radial head was excised. Under an increasing axial load and with the forearm in a fixed position, the rate of increase in tension in the interosseous membrane was greater when the radial head was excised than for the native radial head or replacement states (p = 0.02). As there was no difference in tension between the native and radial head replacement states, a radial head replacement should provide a normal healing environment for the interosseous membrane after injury or following its reconstruction. Load sharing between the radius and ulna becomes normal after radial head Replacement. As excision of the radial head significantly increased the tension in the interosseous membrane it may potentially lead to its attritional failure over time. Cite this article: Bone Joint J 2013;95-B:1383–7

A primary mode of failure for total elbow arthroplasty is osteolysis caused by wear debris. Loading of the polyethylene components by off-axis bearing loads is the likely cause of this debris. Load transfer at the elbow is affected by many factors, including the state of the radial head. New implant designs provide the option to use the intact, resected, or implant reconstructed radial head. However, the effect of the radial head state on stability and loading has not yet been investigated in these new implant designs. We postulated that the presence of the native or prosthetic radial head would reduce the wear-inducing loading patterns experienced by the humeral component and improve joint stability compared to when the radial head is resected. Seven cadaveric upper extremities, amputated at the mid humerus, were tested in a joint motion simulator equipped with an electromagnetic tracking system to quantify motion. Simulated active flexion was tested with the arm in the dependent position. Passive elbow flexion was conducted with the arm in the varus and valgus gravity-loaded orientations. After testing the intact elbow, the collateral ligaments were sectioned and a linked Latitude ulno-humeral joint replacement was performed (Tornier, Stafford, TX). The humeral component was instrumented with strain gauges for measuring varus-valgus bending and internal-external torsion. Ulno-humeral kinematics and humeral component loading were measured when the radial head was intact, resected, and following radial head arthroplasty. An increase in varus-valgus laxity was noted following replacement of the ulno-humeral joint with the prosthesis (p< 0.05). There was no difference in joint laxity between the intact radial head, radial head excision or radial head arthroplasty (p> 0.05). Torsion moments increased, while bending loads decreased in the humeral component following radial head excision and were restored following radial head arthroplasty (p< 0.05). No significant effect of radial head state on varus-valgus joint laxity was observed for the linked ulno-humeral prosthesis. In the absence of collateral ligaments, the observed post-operative increase in varus-valgus laxity can be attributed to the difference in laxity between the native joint and the articular components of the linked implant. Load transfer was altered by radial head excision, which may affect the magnitude of bearing wear and the incidence of aseptic loosening. Further studies are required to determine whether these changes in load transfer influence wear of the polyethylene components or implant loosening

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

Where reconstruction is deemed impossible, excision of the radial head has been the mainstay of treatment for shattered radial head and neck fractures. While some patients seem to do well after the procedure, some develop progressive instability and pain because of proximal translocation of the radius. We looked at a new procedure in which a metal radial head is inserted to provide greater stability after the excision. Historically silicone prostheses have been used, but these were found to fail dramatically after a time. We recruited 11 patients requiring radial head replacements. Their ages ranged from 26 to 54 years. In five patients the dominant arm was affected. The radial head was deemed non-reconstructable in all patients, and the alternative method of treatment would have been radial head excision. In one patient, radial head replacement was performed 14 years after previous radial head excision. A standardised procedure was performed, replacing the radial head with an Evolve modular radial head prosthesis. At follow-up, we assessed patient satisfaction, range of movement, overall stability of the prostheses, grip strength and return to full activity. The postoperative range of movement was assessed at three and six weeks, and the outcome in terms of mobility at six months. Supination ranged between 40( and 90( and pronation between 40( and 85(. Elbow extension ranged between -5( and -30 and flexion between 100( and 150(. We concede that the follow-up period has been short, but early results suggest that radial head replacement may be a good option in patients in whom radial head reconstruction is not possible

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

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

Aim. To review the natural history of upper limb osteochondromas and assess their functional effect. Materials. We performed a retrospective casenote review of a consecutive patient cohort presenting between 1997–2012 with upper limb osteochondromas. Indications for surgical intervention were noted and considered to be cosmetic, functional (including pain relief) and ‘prophylactic’ in terms of deformity prevention. All patients were invited to complete questionnaires for the PODCI, DASH, OSS and MHS scores. Results. We identified 102 patients (62 male: 40 female; mean age = 13.3 years; range 3–31 years). 84 patients had multiple exostoses whilst 18 had a solitary lesion. 52 patients had shoulder girdle involvement (scapula, clavicle and proximal humerus), 51 forearm (Masada I (n=31) Masada II (n=9) Masada III (n=11)), and 38 hand involvement. 46/102 patients had concurrent lower limb lesions. 56 operative procedures were performed primarily for functional benefit. Shoulder girdle procedures (n=21) improved pressure related pain, scapular pseudowinging/dyskinesia and cuff impingement. Forearm procedures (n=35) were performed for functional and prophylactic reasons and involved excision with ulnar lengthening and radial deformity correction (n=15, Masada I), realignment osteotomy or radial head excision for subluxation (n=7, Masada II) and excision with internal fixation of concomitant osteotomy (n=13, Masada I/III). No hand surgery was performed. Radial head dislocations are associated with large ulnar lesions causing shortening > 0.15 total ulnar length. Osteochondromas of the upper limb are generally well tolerated: functional effects were most commonly present in lesions involving the forearm but significant patient benefit was noted following shoulder girdle procedures. The scoring systems used failed to discriminate well between the various procedures used and the perceived benefit. Conclusion:. Patient outcomes are related to surgical indications. Currently available PROMs are either inappropriate Qs (DASH) and/or non-validated (OSS, MHS) and/or non-specific (PODCI*) only 8 parameters for the upper extremity. Better-validated measures may be required. Level of evidence: IV

Introduction The close proximity of the cutaneous and major nerves around the elbow have caused orthopaedic surgeons to feel uncomfortable about the prospect of performing basic and advanced elbow arthroscopy. The aim of this study was to review the proximity of the nerves with arthroscopic vision in a cadaveric model and selected clinical cases. Methods Open exploration of the major nerves in the elbow was performed in alcohol preserved cadaveric specimens. Arthroscopic assessment of the elbow joint was performed before and after the capsule adjacent to the nerve was excised. The arthroscopic assessment of the major nerves in these specimens provided an excellent way to visualise the nerves. Results The radial nerve was found to be in contact with the anterior capsule of the joint and was at great risk with portal placement, lateral sided procedures including synovectomy, radial head excision, capsulotmy and capsulectomy. The medial nerve was protected by the brachialis muscle. The ulnar nerve was also at risk in the medial gutter. Conclusions The close proximity of the major nerves to the elbow joint places them at risk, with elbow arthroscopy. The radial and ulnar nerves are particularly close and their exact position can be dissected free with arthroscopic techniques

Radial head fractures with fragment displacement should be reduced and fixed, when classified as Mason II type injuries. We describe a method of arthroscopic fixation which is performed as a day case trauma surgery, and compare the results with a more traditional fixation approach, in a case controlled manner. We prospectively reviewed six Mason II radial head fractures which were treated using an arthroscopic reduction and fixation technique. The technique allows the fracture to be mobilised, reduced, and anatomically fixed using headless screws. All arthroscopic surgeries were conducted as day-cases. We retrospectively collected age and sex matched cases of open reduction and fixation of Mason II fractures using headless screws. The arthroscopic cases required less analgesia, shorter hospital admissions, and had fewer complications. The averaged final range of follow-up, at 1 year post-operation was 15 to 140 degrees in the arthroscopic group and 35 to 120 degrees in the open group. The Mayo Elbow Performance Score was 95/100 and 90/100 respectively. No acute complications were noted in the arthroscopic group, and a radial nerve neuropraxia [n=1], superficial wound infection [n=1], and loose screw [n=1]. Two patients of the arthroscopic group required secondary motion gaining operations [n=1 arthroscopic anterior capsulectomy for a fixed flexion contracture of 35 degrees, and n=1 loss of supination requiring and arthroscopic radial scar excision]. Three patients in the open group required secondary surgery [n=2 arthroscopic anterior capsulectomy for fixed flexion deformities, and n=1 arthroscopic anterior capsulectomy for fixed flexion deformities, and n=1 arthroscopic radial head excision for prominent screws, loss of forearm rotation, and radiocapitellar arthrosis pain]. The technique of arthroscopic fixation of Mason II radial head fractures appears to be valid, with respect to anatomical restoration of the fracture, minimal hospital admission, reduction in analgesia requirement, fewer complications, and a decreased need for secondary surgery

To date there has been only one published series of elbow arthroplasty in patients with Juvenile Idiopathic arthritis. These patients pose particular problems because of the size and variable shape of the humerus and ulna together with the soft tissue contractures and bony erosion which can sometimes be severe. We have reviewed the results of elbow arthroplasty using the unlinked Kudo 5 and the linked Coonrad-Morrey implants which in our practice have different indications dependent upon bone stock and stability. Methods 19 total elbow replacements in 13 patients with juvenile idiopathic arthritis were performed by 1 specialist elbow surgeon, the senior author. 13 of these are Kudo 5 and 6 are Coonrad-Morrey implants. The mean age at operation was 39 years. 6 of the elbow replacements had undergone previous surgery, 4 had an interposition arthroplasty and 2 a synovectomy and radial head excision. No patients were lost to follow up. All were evaluated at a mean follow up of 49 months [6–84 months] using the Mayo Clinic Performance Index. Postoperative radiographs were also reviewed for loosening using standard anteroposterior and lateral films. Results Preoperatively 7 had moderate pain and 12 had severe pain. Postoperatively the pain was rated as none by 13 and mild by 6. The average Mayo Elbow Score improved from 26 preoperatively to 81 postoperatively. The mean arc of flexion/extension improved from 85 to 108 degrees.12 elbow replacements had intra and post-operative complications and 2 elbows have been revised. Conclusions The medium-term results of Total Elbow Replacements in patients with Juvenile Chronic Arthritis are acceptable and comparable to the only other published series which also records a high complication rate

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

Purpose: Metal radial head arthroplasty is a proven technique for the treatment of complex radial head fractures. Little previous research is available on the utility and longevity of metal radial head arthroplasty for elbow reconstruction. The purpose of this study was to evaluate the functional outcome of patients with metal radial head arthroplasty (RHA) for elbow reconstruction. Methods: This was a retrospective review from one institution with three senior orthopaedic surgeons. 23 consecutive patients with 23 RHA were included in the study, 4 patients were lost to follow up. RHA was performed for conditions of rheumatoid arthritis, post traumatic radial head nonunion, post traumatic radial head malunion, elbow instability following previous radial head excision and failed silicone radial head implants. Patients were excluded from the study if they were treated for an acute injury with RHA (under 2 months from injury). There were 8 males and 15 females with a minimum of 2 year follow up. Analysis included chart review, personal interview, physical examination, radiographs and strength testing. Region specific questionnaires were used including: DASH, ASES, MEPI, PRWE, WOS and SF-36. Mean follow up was 9 yrs. Results: Mayo elbow performance scores were excellent in 11 patients, good in 4 patients, fair in 4 patients and poor in 4 patients. Subjective patient satisfaction was averaged at 8.4 out of 10. Patients demonstrated significantly less isometric strength and grip strength in the affected versed unaffected elbow. There was no statistically significant difference seen in ulnar variance or ulnohumeral joint space between the affected and unaffected limbs. Conclusions: In conclusion, RHA for elbow reconstruction is a safe procedure that provides patients with long term functional ROM and pain relief

Aim. To investigate the responsiveness to change of four different elbow-scoring instruments, two Hospital for Special Surgery (HSS) elbow assessment scales, the Mayo Clinic elbow-performance index (Mayo) and the Elbow Functional Assessment (EFA) scale. Methods. A group of 24 RA patients (median age 60 years) undergoing either elbow arthroplasty (22 elbows) or synovectomy with radial head excision (3 elbows), were evaluated both prior and after surgery (median: seven months postoperatively). Score changes, obtained by using the scales under study, were calculated. The patient’s opinion of global perceived effect of the intervention was used as a criterion to classify them as ‘improved’ or ‘non-changed’. Responsiveness was evaluated with use of three approaches: using paired t-statistics (pre- and post-surgery scores), effect size statistics (standardized response mean, effect size and responsiveness ratios) and Receiver Operator Characteristic (ROC) curves. Results. Each of the elbow rating measures under study proved to be responsive to change when evaluating RA patients undergoing elbow arthroplasty or synovectomy. The EFA scale demonstrated the highest power to detect a clinically meaningful difference and had the best discriminative ability to distinguish improved from non-changed patients, as was revealed by all responsiveness statistics applied. Conclusions. The HSS, the Mayo and the EFA elbow-scoring scales can all be used as an evaluative instrument to assess the efficacy of surgical treatment of the rheumatoid elbow joint. However, using the EFA scale will require smaller sample sizes to achieve a fixed level of statistical power than the other scales under study

Purpose: Ligaments and osseous constraints are the only static stabilizers in a healthy elbow. Following arthroplasty, the use of semi-constrained, or linked, implants provides a potential third static stabilizer. However, this constraint may increase loading on the prosthesis, and hence accelerate polyethylene wear. The presence of competent collateral ligaments and the radial head would be expected to improve elbow stability and decrease loading on the ulnohumeral articulation. This in vitro study determined the effects of the collateral ligaments, radial head, and implant linkage on kinematics and wear-inducing loads in total elbow arthroplasty. Method: Eight cadaveric upper extremities (age 73.5yrs; 5 male), were tested using an elbow motion simulator. Humeral, ulnar, and radial components of an elbow arthroplasty were positioned using a computer-assisted technique. Varus-valgus and internal-external bending loads were measured during flexion using an instrumented humeral component. A tracking receiver attached to the ulna recorded its position during active and passive flexion in the vertical orientation, and passive flexion in the varus and valgus orientations. Kinematics and loading were measured with and without implant linkage, with an intact, resected and replaced radial head, and before and after sectioning of the collateral ligaments. Results: There were no differences in the bending loads with the arm in the vertical orientation regardless of the status of the ligaments, radial head or implant linkage (p> 0.2). Radial head excision produced an increase in valgus angulation of the ulna (6.7±6.4°) but did not influence bending loads in the vertical orientation (p< 0.05). Loading was lowest with the unlinked implant, and with ligaments and radial head intact, with the arm in the valgus (1065±466Nmm) (p< 0.01) and varus (1333±698Nmm) (p< 0.05) orientations. Conclusion: Our results show that the radial head is an important valgus stabilizer for the prosthesis employed in this investigation. Linkage of the articulation increases implant loading during passive flexion with the arm in the varus and valgus orientations, which may increase implant wear. This suggests that, when using prostheses of this design, linkage of the articulation may be unnecessary if adequate bone stock and ligaments are available, whilst preserving or repairing the collateral ligaments and preserving or replacing the radial head

Dislocation of the elbow with associated fractures of the radial head and the coronoid process of the ulna have been referred to as the “terrible triad of the elbow” because of the difficulties in treating this injury and the poor outcomes. The orthopaedic database, Orthoscope, was used to identify all patients with dislocation of the ulnohumeral joint and fracture of both the head of the radius and the coronoid process of the ulna, seen and treated at Auckland City Hospital since 1998. All patients were invited to follow up appointments to evaluate the outcomes achieved. The research protocol was approved by the local research committee. Follow up appointments consisted of clinic al examination, assessing the range of elbow motion, an elbow radiograph and a functional assessment, using the DASH score and the American Shoulder and Elbow Society scoring systems. There were 32 patients identified, from Orthoscope, and invited for follow up. Six patients, who had moved overseas, were lost to follow up and two others declined follow up. 23 patients (24 elbows) remained for evaluation. All patients returned for the described assessment protocol. There were 10 male patients and 13 female patients, with a mean age of 46.9 (range, 29 to 67 years). The average arc of ulnohumeral motion was 122 degrees (range; 110 degrees to 140 degrees) and that of forearm rotation was 138 degrees (range, 35 degrees to 170 degrees). The radial head component was fixed in a standard fashion with repair, or replacement, and no radial head excisions were undertaken. Coronoid fractures were treated with screw fixation or suturing, with drill holes or anchors. To augment stability, a lateral ligament repair was undertaken in most patients. All patients, except one, would undergo the procedure again if needed. Elbow fracture-dislocations are historically very unstable and are prone to numerous complications. With operative treatment of the radial head, with repair or replacement, to restore stability through radiocapitellar contact, coronoid and lateral ligament repair, good range of movement and stability can be achieved

Purpose. There have been a number of described techniques for sizing the diameter of radial head implants. All of these techniques, however, are dependent on measurements of the excised native radial head. When accurate sizing is not possible due to extensive comminution or due to a previous radial head excision, it has been postulated that the proximal radioulnar joint (PRUJ) may be used as an intraoperative landmark for correct sizing. The purpose of this study was to: 1) determine if the PRUJ could be used as a reliable landmark for radial head implant diameter sizing when the native radial head in unavailable, and (2) determine the reliability of measurements of the excised radial head. Method. Twenty-seven fresh-frozen denuded ulnae and their corresponding radial heads (18 males, 9 females) were examined. The maximum diameter (MaxD), minimum diameter (MinD) and dish diameter (DD) of the radial heads were measured twice, 3–5 weeks apart, using digital calipers. Two fellowship-trained upper extremity surgeons, an upper extremity fellow and a senior orthopedic resident were then asked to independently select a radial head implant diameter based on the congruency of the radius of curvature of the PRUJ to that of the radial head trial implants. The examiners were blinded to the native radial head dimensions. This selection was repeated 3–5 weeks later by two of the investigators. Correlation between radial head measurements and radial head implant diameter sizes was assessed using Pearsons correlation coefficient (PCC) and inter and intra-observer reliability were assessed using intra-class correlation coefficient (ICC). Results. There was a positive correlation between each of the radial head measurements (MaxD, MinD and DD) and the selected radial head implant diameters (PCC of 0.56, 0.59 and 0.51 respectively; p<0.01). Measuring the MaxD, MinD and DD of the radial head showed excellent inter-observer reliability (ICC of 0.99, 1.00 and 0.82 respectively) and excellent intra-observer reliability (ICC of 0.99, 0.98 and 0.75 respectively). The PRUJ sizing method used to determine the diameter of the radial head implant showed poor inter-observer reliability with an ICC of 0.34 but good intra-observer reliability (ICC = 0.76). Conclusion. Measurements of the diameter of the excised radial head showed excellent intra and inter-observer reliability suggesting that the excised radial head, when available, should be used to select the radial head implant diameter. The inter-observer reliability of using the PRUJ for sizing the diameter of radial head implants was poor, indicating that this method is an unreliable technique for radial head implant diameter sizing. However, the high intra-observer reliability of the PRUJ method indicates that an observer tends to make the same size estimation, even weeks apart. This study suggests that the PRUJ radius of curvature may be different than that of the radial head. Further studies are needed to verify this hypothesis

The proximal radio-ulnar joint (PRUJ) is expendable, as radial head excision for fracture is known to leave an acceptable deficit. This paper discusses a technique for turning the PRUJ en bloc and using it to replace the elbow joint after destruction of the ulnohumeral joint or resection of the distal humerus. PRUJ-plasty can also be used to restore function after arthrodesis of the elbow. The prerequisite for the procedure is an intact PRUJ. After olecranon osteotomy (or after osteotomy at the same level if there is ankylosis between humerus and ulna), another more distal osteotomy of both the radius and ulna is done, just proximal to the biceps insertion into the radius, using a posterior approach. This creates a segment of proximal radius and ulna, including the PRUJ. This segment is then rotated 90° and fixed to the distal end of the humeral shaft and proximal end of the ulnar shaft. Interposed between humerus and ulna, the PRUJ functions as a vascularised, innervated synovial elbow joint. The range of motion of this new ‘elbow’ is potentially the same as pronation-supination, i.e., 160°. Three young adults have had the procedure. One young woman had undergone resection of the distal humerus for chondrosarcoma. Later a vascularised fibular graft was used to replace the shaft, but she had no elbow joint and had to use a sling because of instability. The second patient had nonunion of the distal humerus and an ankylosed elbow, with motion only through the nonunion. The third patient had a 10-year old arthrodesis of the elbow following a childhood infection. The PRUJ was intact in all three. Postoperative elbow movement ranged from 70° to 120°. There was some mild lateral instability. The lost function was that of a radial head resection, so adequate pronation and supination were retained. Because it uses a vascularised, innervated synovial joint, PRUJ-plasty is potentially good for life, making it superior to any synthetic prosthesis

Purpose: To review the clinical outcome of patients who have had complex radial head fractures managed with titanium radial head replacement. Methods: There were 17 patients who had insertion of the radial head replacement. The indications for the prosthesis included acute Mason type III fracture which could not be stabilised satisfactorily with internal fixation. Other indications included delayed presentation including previously failed treatment. Patients were managed with radial head excision and insertion of the Wright Medical titanium radial head replacement. The lateral ligamentous complex was stabilised. A back slab was applied for a period of one week and then the elbow mobilised. The patients were followed up for a minimum of one year. The Mayo elbow performance index was used. Results: There were 7 patients with acute injuries of which 6 had associated injuries such as dislocation or coronoid process fracture. 6 of these patients had an excellent result and 1 had a good result. There were 9 patients with a delayed insertion of the radial head replacement. There were 3 patients who had an isolated radial head fracture and 6 patients with associated injuries, there were 2 excellent, 3 fair and 4 poor. Three of the 4 poor results had associated capitellar chondral injury. Two patients with fair results had other significant pathology in the upper limb. In the delayed presentation group the average flexion arc improved from 78 degrees to 102 degrees and the pro-supination improved from 117 degrees to 142 degrees. The average level of satisfaction on a visual analog score was 92 per cent. Conclusion: Patients who present with acute complex radial head fractures (including associated injuries), the results of radial head replacement are generally excellent. If there are significant associated injuries and a delay in presentation, then the outcome is often only fair. However, this group of patients have improvement in their pain, level of satisfaction and range of motion. Associated capitellar damage is a poor prognostic indicator

The purpose of this study was to evaluate the outcomes of treatment of rheumatoid elbows with Kudo Total Elbow Replacements. Between 1993–1997 we performed 39 Kudo Total Elbow Replacements in 35 patients with Rheumatoid Arthritis, aged 39–81 years old (mean age: 60,7 yrs). Eleven patients (13 elbows) were male and 24 (26 elbows) were female. Twenty-eight (28) replacements were performed on the right side and eleven (11) on the left. All the patients were evaluated clinically (pre-op and post-op, using Mayo score system) and radiographically. In seven elbows another procedure (radial head excision (three), radial head excision & synovectomy (three), arthroscopy & interposition arthroplasty(one)) had been performed previously for the rheumatoid arthritis. Eight elbows seemed to have ulnar nerve problems pre-op. We followed-up 31 patients (35 elbows). Mean follow-up was 5years (range: 4–8 years). The pre-operative pain had been reduced significantly in almost all patients. In the majority, the movement had also been improved post-operatively. Two elbows were unstable (one subluxated, one dislocated). Both presented early postoperatively. Only one patient developed a postoperative ulnar nerve problem and that resolved. One elbow had a delay in wound healing. Radiolucency appeared around both the humeral and ulnar components in five elbows, around humeral component in two and around ulnar component also in two. Five elbow replacements were revised. Four of them due to aseptic loosening and one due to instability problem (dislocation). No deep infection was noticed in any elbow. In our hands, Kudo Elbow Replacements seemed to have aseptic loosening rates comparable to other series and low dislocation rates