Aims. There are concerns regarding complications and longevity of total elbow arthroplasty (TEA) in young patients, and the few previous publications are mainly limited to reports on linked elbow devices. We investigated the clinical outcome of unlinked TEA for patients aged less than 50 years with rheumatoid arthritis (RA). Methods. We retrospectively reviewed the records of 26 elbows of 21 patients with RA who were aged less than 50 years who underwent primary TEA with an unlinked elbow prosthesis. The mean patient age was 46 years (35 to 49), and the mean follow-up period was 13.6 years (6 to 27). Outcome measures included pain, range of motion, Mayo Elbow Performance Score (MEPS), radiological evaluation for radiolucent line and loosening, complications, and revision surgery with or without implant removal. Results. The mean MEPS significantly improved from 47 (15 to 70) points preoperatively to 95 (70 to 100) points at final follow-up (p < 0.001). Complications were noted in six elbows (23%) in six patients, and of these, four with an ulnar neuropathy and one elbow with postoperative traumatic fracture required additional surgeries. There was no revision with implant removal, and there was no radiological evidence of loosening around the components. With any revision surgery as the endpoint, the survival rates up to 25 years were 78.1% (95% confidence interval 52.8 to 90.6) as determined by Kaplan-Meier analysis. Conclusion. The clinical outcome of primary unlinked TEA for young patients with RA was satisfactory and comparable with that for elderly patients. A favourable survival rate without implant removal might support the use of unlinked devices for young patients with this disease entity, with a caution of a relatively high complication rate regarding ulnar neuropathy. Level of Evidence: Therapeutic Level IV. Cite this article: Bone Jt Open 2023;4(1):19–26

Introduction. Total Elbow Arthroplasty (TEA) is recognized as an effective treatment solution for patients with rheumatoid arthritis or for traumatic conditions. Current total elbow devices can be divided into linked or unlinked design. The first design usually presents a linking element (i.e. an axle) to link together the ulnar and humeral components to stabilize the joint; the second one does not present any linkage and the stability is provided by both intrinsic design constraints and the soft tissues. Convertible modular solutions allow for an intraoperative decision to link or unlink the prosthesis; the modular connections introduce however additional risks in terms of both mechanical strength and potential fatigue and fretting phenomena that may arise not only due to low demand activities loads, but also high demand (HD) ones that could be even more detrimental. The aim of this study was to assess the strength of the modular connection between the axle and the ulnar component in a novel convertible elbow prosthesis design under simulated HD and activities of daily living (ADLs) loading. Methods. A novel convertible total elbow prosthesis (LimaCorporate, IT) comprising both ulnar and humeral components that can be linked together by means of an axle, was used. Both typical ADLs and HD torques to be applied to the axle were determined based on finite element analysis (FEA); the boundary load conditions for the FEA were determined based on kinematics analysis on real patients in previous studies. The FEA resultant moment acting on the axle junction during typical ADLs (i.e. feeding with 7.2lbs weight in hand) was 3.2Nm while for HD loads (i.e. sit to stand) was 5.7 Nm. In the experimental setup, 5 axle specimens coupled with 5 ulnar bodies through a tapered connection (5 Nm assembly torque) were fixed to a torque actuator (MTS Bionix) and submerged in a saline solution (9g/l). A moment of 3.2 Nm was applied to the axle for 5M cycles through a fixture to test it under ADLs loading. After 5M cycles, the axles were analyzed with regards to fretting behavior and then re-assembled to test them against HD loading by applying 5.7 Nm for 200K cycles (corresponding to 20 years function). Results. All 5 samples withstood all 5.2M loading cycles without any mechanical failure. At the end of 5M cycles, each axle was still stable as the measured disassembly torque was 3.96 +/−0.18 Nm. Slight signs of fretting were detected on the tapered connection after 5M cycles, however they did not compromise the mechanical connection nor the stability. Discussion and Conclusions. Currently there are no reference standards that properly define protocols for biomechanical testing of elbow prostheses. In the present study, a test to mechanically assess the strength of an axle connection under both typical ADLs and HD loads was set. The connection was able to withstand the imposed conditions. In general, testing of TEA devices should include not only standard ADLs loads but also HD loads, which could be more detrimental for the long-term survivorship. For any figures or tables, please contact authors directly

Introduction: The Kudo total elbow prosthesis (TEP) is a well established implant, with good mid-term results. In the last decades this implant underwent several modifications. The last modification (type 5) has overcome the problems of stem breakage of the humeral component by modifications of the stem. The ulnar component can be placed with or without cement; the humeral component is always placed without cement. Aims of this study: To examine the mid-term results of the Kudo type 5 TEP and to compare the results of the uncemented Kudo total elbow prosthesis (TEP), with the hybrid Kudo TEP (uncemented humeral component and cemented ulnar component). Material and methods: Between 1994 and 2004 89 Kudo type 5 TEPs were placed for joint destruction due to rheumatoid arthritis (RA). The mean age of the patients was 55 years (range 21–84 years). Twenty-two prostheses were placed in males, 66 in females. Forty-nine TEPs (group 1) were fully uncemented and 40 TEPs (group 2) were hybrid (humeral component uncemented, ulnar component cemented). The groups were comparable as related to age, sex and indication for surgery. After implantation of the prosthesis a radiograph was made every two years or sooner when indicated. Evaluation took place after an average of 5.3 years of follow up (range 1.7–10.6 years) and consisted of a questionnaire, elbow function assessment and anteroposterior and lateral radiographs in a standard way. Pre- and postoperative range of motion was analysed with the paired T-test. Pain scores and EFAS scores postoperatively were analysed using the independent sample T-test. The survival of the prosthesis was calculated from the time of implant to the time of revision or occurrence of radiolucencies. Results: In group 1, seven ulnar components had to be revised due to aseptic loosening after a mean follow-up of 4 years (range 1.5–6.3 years). Three of these ulnar components were short-stemmed, four were long stemmed uncemented. In group 2 five patients died of an unrelated course and no revisions have taken place, one TEP is loose on X-ray (after two years) with a suspicion of septic loosening The EFAS scores (87 in group 1 and 91 in group 2) and range of motion (84 degrees in group 1 and 90 degrees in group 2) were the same in both groups. Conclusion: In this group of patients with RA the survival of the Kudo type 5 TEP with cemented ulnar component is better as compared to the uncemented ulnar component

Mechanical loosening which begins with early-onset migration of the prosthesis is the major reason for failure of the Souter-Strathclyde elbow replacement. In a prospective study of 18 Souter-Strathclyde replacements we evaluated the patterns of migration using roentgen stereophotogrammetric analysis. We had previously reported the short-term results after a follow-up of two years which we have now extended to a mean follow-up of 8.2 years (1 to 11.3). Migration was assessed along the co-ordinal axes and overall micromovement was expressed as the maximum total point movement. The alignment of the prosthesis and the presence of radiolucent lines were examined on conventional standardised radiographs.

All the humeral components showed increased and variable patterns of migration at the extended follow-up and four humeral components were revised. The maximum total point movement at two years in the revised prostheses was 1.8 mm (sd 1.0) and in the non-revised 0.7 mm (sd 0.5, p = 0.01). Most humeral components migrated into external rotation resulting in an anterior and varus tilt. The ulnar components remained stable.

Introduction and Objectives: The goal of this study is to present results from a series of arthroplasties performed in our hospital in the past 3 years in terms of pain and mobility.

Materials and Methods: In this study, a total of 14 arthroplasties were performed on 12 patients (including 2 revisions). Follow-up was lost on 3 patients. Of the 9 remaining patients, 5 were females and 4 were male. Average age was 59 years (42–75) at time of surgery. Two prosthetic models were used: Coonrad-Morrey in 5 cases (including one revision) and GSB-III in 6 cases (including one revision). The following conditions were treated: 5 cases of post-traumatic arthrosis of the elbow, one haemophilic arthropathy of the elbow with the elbow as the target joint, one case of rheumatoid arthritis, one supracondylar fracture with nonunion in an elderly patient, and one humeral fracture with post-traumatic arthrosis of the elbow.

Results: At the functional level, a postoperative articular balance of 118° flexion and −20° extension and free pronosupination was obtained, with the exception of 2 cases. There was complete elimination or a significant decrease in pain except in 2 cases where a certain level of pain persisted. Radiographically, poor positioning was not seen, but there was one case of septic loosening (resulting in resective arthroplasty) and one peri-prosthetic fracture requiring revision, since it led to instability and repeated dislocation. Other complications included neurologic problems (2), extension deficit > 30° (2), and residual pain (2).

Discussion and Conclusions: Although this study is still in the early stages and follow-up time is short (the study was initiated in 2000), we are seeing promising results in terms of mobility and cessation of pain, similar to various other studies. In terms of the percentage of revisions, complications, and patient satisfaction, results are also comparable to other studies, even though our study thus far has the disadvantage of being shorter. Nonetheless, we wish to present this study to demonstrate that even though elbow arthroplasties are in their infancy, results are promising, and there is hope that they will improve further in future with improved selection criteria, as happened in the past with knee and hip arthroplasties.

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.

Eighty elbows in 65 patients with an average age of 57 years have had two-part non-constrained Liverpool elbow arthroplasties performed since 1974. Fifty-five had rheumatoid arthritis, eight osteoarthritis or ankylosis secondary to injury, one osteochondritis dissecans and one pyknodysostosis. The average preoperative range of movement was 42 degrees to 112 degrees with 47 degrees of pronation and 42 degrees of supination. There was significant gain in the arc of movements at follow-up: 32 degrees in the extension-flexion range (average range 32 degrees to 134 degrees of flexion) and 42 degrees in forearm rotation (average pronation 69 degrees and supination 62 degrees). Before operation severe pain was the predominating symptom in 43 elbows (53.8%) but after replacement there was only moderate pain in five elbows (6.2%). The results were excellent in 42 (52.5%), good in 15 (18.7%), fair in 9 (11.3%) and unsatisfactory or poor in 14 (17.5%). Eight elbows required revision of the arthroplasty: three were post-traumatic, disorganised or osteoarthritic joints, three rheumatoid and both elbows in the patient with pyknodysostosis. Loosening of the prosthesis (particularly the humeral component) was the common factor necessitating revision. Of six rheumatoid elbows needing removal of the implant, four had deep infection, one had a dislodged humeral component as a result of injury and in one a divided olecranon had developed non-union. Rheumatoid elbows benefited more than post-traumatic arthritic elbows from the operation. (ABSTRACT TRUNCATED AT 250 WORDS)

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.

Purpose: We report our experience with 23 Coonrad-Morrey total elbow prostheses.

Material and methods: Between July 1997 and February 2001, we implanted 34 Coonrad-Morrey total elbow pros-theses in 33 patients. Twenty-three patients (23 implants) were reviewed at a mean 24 months follow-up, maximum 40 months. There were three men and 20 women, mean age 62 years (42–69). Twelve patients had rheumatoid polyarthritis, the principal indication. There were also four recent fractures of the distal humerus, two nonunions, and one patient with post-traumatic osteoarthritis. One patient had sequelar osteoarthritis since childhood. Finally three revisions were performed for loosening of a GUEPAR prosthesis in two cases and a GSBIII prosthesis in one. Results were assessed with the Mayo Clinic score. We searched for lucent lines around the implants, polyethylene wear, and incorporation of the bone graft behind the anterior wing of the implant on plain radiographs.

Results: At last follow-up, the mean Mayo Clinic score had improved from 25 to 89 points (70–100). Before surgery, 17 patients had severe pain. At last follow-up, eight patients had occasional pain. Extension was improved by 10°, flexion by 27° giving a postoperative amplitude of 29° to 132°. Prona-tion supination progressed by 37° giving a rotation amplitude of 127°. The function score improved from 4 to 21 points. Sixteen of the 23 patients had normal elbow function. Outcome was excellent in 13 patients, good in eight, and fair in two. There were no lucent lines visible on the radiographs. There was no sign of polyethylene wear. The bon graft was incorporated behind the implant in 20 cases and was not visible in three. Complications included one peroperative fracture, one cutaneous dehiscence, one post-operative fracture of the olecranon due to a fall, and persistent ulnar paresthesia in four patients requiring secondary neurolysis in one.

Discussion, conclusion: The Coonrad-Morrey semi-constrained prosthesis provides a response to a large range of situations. The dominant indication is rheumatoid polyarthritis, but trauma patients can benefit from this reliable therapeutic solution giving a satisfactory rate of success. A satisfactory functional amplitude is generally achieved with this implant and the elbow is generally pain free.

In rheumatoid arthritis (RA), non constrained or semi-constrained prostheses can be used. The authors used the Kudo III, IV or V or iBP prostheses 54 times from 1994 to 2003. After initial satisfactory results, they had to change one or both implants for several reasons: humeral stem fracture (5 cases), unipolar humeral loosening (1 case), ulnar loosening without laxity (8 cases), polyethylene wear (11 cases), due to progressive ulnar collateral ligament lengthening and progressive valgus deformity, without or with metallosis, due to contact between Cr-Co humeral component and titanium alloy ulnar component, chronic infection (1 case). When the local conditions were satisfactory (bone stock, ligament balance), the fractured or loosened component was changed. When the conditions were bad (poor bone stock, ligament misbalance, metallosis), both implants were removed; posterior humeral and/or medial or lateral ulnar window were used to removed the uncemented stems still osteointegrated. All the bipolar operations used the Coonrad-Morrey prosthesis, but the last case a Discovery prosthesis. The operative tricks are described, the management of the extensor apparatus is discussed, the clinical outcomes (especially the extensor apparatus function, most often weak) and the radiographic outcomes are presented.

Aims. We assessed the long-term (more than ten-year) outcomes of the Kudo type-5 elbow prosthesis in patients with rheumatoid arthritis (RA). Materials and Methods. We reviewed 41 elbows (Larsen Grade IV, n = 21; Grade V, n = 20) in 31 patients with RA who had undergone a Kudo type-5 total elbow arthroplasty (TEA) between 1994 and 2003, and had been followed up for more than ten years. The humeral component was cementless and the all-polyethylene ulnar component cemented in every patient. Clinical outcome was assessed using the Mayo elbow performance score. We calculated the revision rate and evaluated potential risk factors for revision. The duration of follow-up was a mean 141 months (120 to 203). Results. Aseptic loosening of the ulnar component occurred in 11 elbows. There was no radiolucency around any humeral component. There was one deep infection. The survival rate according to Kaplan-Meier survivorship analysis was 87.8% after five years and 70.7% after ten years. The range of extension/flexion was a mean -38° (-80° to 0°)/105° (30° to 150°) before surgery and -40° (-70° to -20°)/132° (100° to 150°) at the final follow-up, while the mean Mayo elbow performance score was 43 before surgery and 80 at final follow-up. Disease duration of RA up to the TEA of < 15 years and a pre-operative range of movement (ROM) of > 85° were significant risk factors for revision or aseptic loosening. Conclusion. Although Kudo type-5 prostheses gave satisfactory results in the short-term, aseptic loosening increased after five years. In most cases, elbow function was maintained in the long-term without loosening of the implant. A short duration from the onset of RA to TEA and a large pre-operative ROM were significant risk factors for revision or aseptic loosening. Cite this article: Bone Joint J 2017;99-B:818–23

The aim of this study was to assess the long-term results of the Kudo type-5 total elbow prosthesis and compare the results of two types of cemented ulnar components. The Kudo type-5 unlinked total elbow prosthesis (Biomet UK Ltd, Bridgend Wales) was developed in 1993. The stem of humeral component is porous-coated with a plasma spray of titanium alloy for cementless use. The ulnar component may be metal-backed with a porous-coated stem or polyethylene alone; the latter designed mainly for cement use. A metal-backed type without a porous-coated stem designed for cement use also came into being after 2003. Between 1993 and 2010, the Kudo type-5 total elbow arthroplasty was performed on 364 elbows in 274 consecutive patients with rheumatoid arthritis. The mean age of the patients at the time of the operation was 60.7 (27–86) years. Twenty elbows had Larsen grade III, 224 had grade IV, and 120 had grade V changes pre-operatively. Before the operation, 346 elbows had severe or moderate pain, 95 had gross valgus-varus instability. Clinical symptoms and revision rates were assessed 4 to 20 years (mean, 9 years) postoperatively. The mean Mayo elbow performance scores were all poor except for three initially (mean overall score, 39.5 points). The overall score had improved substantially both at the early follow-up (1 to 3 years after the operation) and the latest follow-up (4 to 20 years after the operation), with 89.5 and 84.7 points, respectively. At the latest follow-up the overall result was excellent for 185 elbows, good for 103, fair for 11 and poor for 30, with almost complete relief from pain for 298. The arc of movement had increased from a mean of 85.7 °pre-operatively to 95.1 ° post-operatively, and to 98.1 °at the latest follow-up. Spot welds around the humeral stem suggesting solid osseous integration were often seen in the elbows with cementless fixation of the porous humeral stem. At the latest follow-up, implants were removed due to infection in 3 elbows. Twenty-five elbows required ulnar component revision due to loosening of the all-polyethylene component. Two elbows required ulnar component revision due to loosening of the metal-backed component. Seven elbows required humeral component revision due to loosening of the humeral components. One elbow required revision due to dislocation. A survival analysis with revision or removal of one or both components as the end point was performed according to the Kaplan and Meier method. The overall survival rate of the prosthesis was 75.2% at 19 years. The survival of 87.0% in the metal-backed group was higher than the 74.3% in the all-polyethylene group. Loosening of the all-polyethylene ulnar component was the main reason for deterioration in the long-term outcome. We conclude that the long-term results of the Kudo type-5 total elbow arthroplasty is acceptable and cemented fixation of metal-backed ulnar component had better long-term survival than the all-polyethylene component

Between 1978 and 1986, 59 patients received a GSB III elbow prosthesis, six of them in both elbows. Rheumatoid arthritis (RA) was the underlying cause in 51 of the patients and post-traumatic osteoarthritis (PTOA) in eight. Of these, 24 patients (28 prostheses) have since died; two, both operated on bilaterally, had had their implants for more than ten years and had already been assessed for inclusion in the long-term follow-up. Two patients, each with one elbow prosthesis, have been lost to follow-up and three males who are still living (two with PTOA, one with juvenile RA) had their prosthesis removed before ten years had elapsed. The remaining 32 patients (28 RA, 4 PTOA) with 36 GSB III elbows were examined clinically and radiologically after a mean period of 13.5 years. Pain was considerably reduced in 91.6%. Mobility was increased by 37° in those with RA and by 67° in those with PTOA. There were three cases of aseptic loosening and three of deep infection. The main complication was disassembly of the prosthetic component in nine elbows (13.8%). This last group included two patients with postoperative fractures unrelated to the operative technique and one with neuropathic arthritis. Ulnar neuritis occurred in two patients. Since 87.7% of all the GSB III prostheses implanted in this period remained in situ, our results are comparable with those for hip and knee arthroplasty

Aims

The aim of this study was to investigate the feasibility of application of a 3D-printed megaprosthesis with hemiarthroplasty design for defects of the distal humerus or proximal ulna following tumour resection.

Aims

Despite numerous studies focusing on periprosthetic joint infections (PJIs), there are no robust data on the risk factors and timing of metachronous infections. Metachronous PJIs are PJIs that can arise in the same or other artificial joints after a period of time, in patients who have previously had PJI.

Aims

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

We used 11 cadaver elbows and a three-dimensional electromagnetic tracking device to record elbow movements before and after implantation of a 'loose-hinged' elbow prosthesis (modified Coonrad). During simulated active motion there was a maximum of 2.7 degrees (+/- 1.5 degrees) varus/valgus laxity in the cadaver joints. This increased slightly after total elbow arthroplasty to 3.8 degrees (+/- 1.4 degrees). These values are lower than those recorded for the cadaver joints and for the prostheses at the limits of their varus/valgus displacements, indicating that both behave as 'semi-constrained' joints under physiological conditions. They suggest that the muscles absorb some of the forces and moments that in a constrained prosthesis would be transferred to the prosthesis-bone interface

The Norway elbow prosthesis is a non-constrained cemented total replacement. It depends on intact collateral ligaments for stability, and allows a full range of movement. The system includes several sizes of components, all freely interchangeable, and semi-constraint can be provided by a locking ring if damaged collateral ligaments make dislocation possible. The prosthesis has been used in more than 350 elbows in Norway and the detailed results for 118 elbows studied prospectively since 1987 are reported. It is inserted through a posterolateral triceps-splitting incision with minimal muscle disruption and bone resection, preserving the collateral ligaments. The results as regards pain relief and range of movement were comparable with those of other elbow prostheses, but there were fewer serious complications. At a mean follow-up of 4.3 years, the failure rate was 3.4%

Summary Statement. Discovery system produced effective functional improvement in both primary and revision total elbow replacement. The incidence of major complications was in an acceptable range. Introduction. The search for the ideal elbow prosthesis continues as instability and loosening remain the prime reasons for total elbow replacement (TER) failure. The Discovery Elbow System (Biomet) is one of the latest generations of linked prosthesis and has been used in UK since 2003. We report outcome of TER using this system. Methods. A total of 100 TERs (75 primary, 25 revisions) were performed between 2003 and 2010. The main primary underlying pathologies for TER were advanced rheumatoid arthritis (N=58), osteoarthritis (N=35), acute fractures (N=7). There were 60 female and 40 male patients with an average age of 62 years. The outcome assessment included pain, patient satisfaction, Liverpool Elbow Score (LES), range of movement, and imaging during a mean follow-up period of 48.5 months. Major complications are also reported. Results. For the whole patient group (primary + revision), the LES was significantly (p<0.001) improved from 3.79+/−1.71 to 6.36+/−1.85There were significant improvements in elbow flexion from 100°+/−24 to 118°+17, supination from 38°+/−26 to 50°+/−25 and pronation from 48°+/−22 to 61°+/−21. Mean improvement in flexion-extension and pronation-supination arc was 20° and 25°, respectively. 64% of cases were completely pain-free and at the final follow-up (compared to 7% preoperatively). Only 6% of patients scored “Not Satisfied” at the final follow-up. LES improvement was significantly higher in the primary TER compared to revision TER (p<0.05). Imaging reviewed for 60 cases showed loosening in 4% of patients. Other main complications included deep infection (N=2), ulnar neuropathy (N=3), pre-prosthetic fracture (N=2), and prosthetic failure (N=1). Discussion. TER using the Discovery Elbow System is an effective arthroplasty in terms of functional improvement, pain relief and range of motion in both primary and revision patients. TER resulted in no/mild pain in 78% of cases. Patients undergoing Acclaim, Souter-Strathclyde, GSB III, and Coonrad-Morrey TER have been reported to have no/mild pain in 64%, 67%, 50–92% and 60–100% of cases, respectively. A 20° improvement in flexion-extension arc is comparable to that of Acclaim (23°), Souter-Strathclyde (15°), GSBIII (19–33°), and Coonrad-Morrey (17–26°) TER. An improvement of 25° in pronation-supination arc in our series is also comparable to that of 21–28° reported the Coonrad-Morrey and 27–33° for Discovery prostheses. An infection rate of 2% is lower than several other reports for GSB III TER (7–11%) and Coonrad-Morrey (6–8%). The incidence of persistent ulnar neuropathy (3%) was lower compared to GSBIII TER (11–14%), Coonrad-Morrey (12–26%), and Acclaim (8%)

Aim: To describe and evaluate the use of the limited contact plate in complex humeral shaft fractures. Certain sub-groups of humeral shaft fractures can be very difficult to treat. These ‘complex fractures’ include fractures in very osteoporotic bone, those associated with shoulder or elbow prosthesis, non-unions and those associated with intra articular extensions and dislocations. The AO limited contact plate (LCP) is a new form of fixation whether the screw heads lock into the holes in the plate. The plate is not designed to cause compression and does not need to lie perfectly adjacent to the bone. Methods: A prospective study of six consecutive complex humeral shaft fractures treated with LCP plate. Rate of union, complications, and subjective and objective outcome (DASH scores) are analyzed. Results: Union occurred in 9/10 patients. The final patient is progressing to union. There were no serious complications. Good subjective and objective outcome in all patients. Conclusion: This heterogeneous series of complex and complicated humeral shaft fractures all pose significant management problems. Treatment with the LCP plate demonstrated good results with no significant complications. This completely new rational for treatment seems particularly suitable for the treatment of complex or complicated humeral shaft fractures