We present a review of claims made to the NHS
Litigation Authority (NHSLA) by patients with conditions affecting the
shoulder and elbow, and identify areas of dissatisfaction and potential
improvement. Between 1995 and 2012, the NHSLA recorded 811 claims
related to the shoulder and elbow, 581 of which were settled. This
comprised 364 shoulder (64%), and 217 elbow (36%) claims. A total
of £18.2 million was paid out in settled claims. Overall diagnosis,
mismanagement and intra-operative nerve injury were the most common
reasons for litigation. The highest cost paid out resulted from
claims dealing with incorrect, missed or delayed diagnosis, with
just under £6 million paid out overall. Fractures and dislocations
around the shoulder and elbow were common injuries in this category.
All 11 claims following wrong-site surgery that were settled led
to successful payouts. This study highlights the diagnoses and procedures that need
to be treated with particular vigilance. Having an awareness of
the areas that lead to litigation in shoulder and elbow surgery
will help to reduce inadvertent risks to patients and prevent dissatisfaction
and possible litigation. Cite this article:
We assessed the short- to mid-term survival of
metallic press-fit radial head prostheses in patients with radial
head fractures and acute traumatic instability of the elbow. The medical records of 42 patients (16 males, 26 females) with
a mean age of 56 years (23 to 85) with acute unstable elbow injuries,
including a fracture of the radial head requiring metallic replacement
of the radial head, were reviewed retrospectively. Survival of the
prosthesis was assessed from the radiographs of 37 patients after
a mean follow-up of 50 months (12 to 107). The functional results
of 31 patients were assessed using range-of-movement, Mayo elbow
performance score (MEPS), Disabilities of the Arm, Shoulder and
Hand (DASH) score and the RAND 36-item health survey. At the most recent follow-up 25 prostheses were still well fixed,
nine had been removed because of loosening, and three remained implanted
but were loose. The mean time from implantation to loosening was
11 months (2 to 24). Radiolucent lines that developed around the
prosthesis before removal were mild in three patients, moderate
in one and severe in five. Range of movement parameters and mass
grip strength were significantly lower in the affected elbow than
in the unaffected side. The mean MEPS score was 86 (40 to 100) and
the mean DASH score was 23 (0 to 81). According to RAND-36 scores,
patients had more pain and lower physical function scores than normal population
values. Loosening of press-fit radial head prostheses is common, occurs
early, often leads to severe osteolysis of the proximal radius,
and commonly requires removal of the prosthesis.
Mason type III fractures of the radial head are treated by open reduction and internal fixation, resection or prosthetic joint replacement. When internal fixation is performed, fixation of the radial head to the shaft is difficult and implant-related complications are common. Furthermore, problems of devascularisation of the radial head can result from fixation of the plate to the radial neck. In a small retrospective study, the treatment of Mason type III fractures with fixation of the radial neck in 13 cases (group 2) was compared with 12 cases where no fixation was performed (group 1). The mean clinical and radiological follow-up was four years (1 to 9). The Broberg-Morrey index showed excellent results in both groups. Degenerative radiological changes were seen more frequently in group 2, and removal of the implant was necessary in seven of 13 cases. Post-operative evaluation of these two different techniques revealed similar ranges of movement and functional scores. We propose that anatomical reconstruction of the radial head without metalwork fixation to the neck is preferable, and the outcome is the same as that achieved with the conventional technique. In addition degenerative changes of the elbow joint may develop less frequently, and implant removal is not necessary.
Between 1995 and 2006, five intra-articular osteotomies of the head of the radius were performed in patients with symptomatic healed displaced articular fractures. Pre-operatively, all patients complained of persistent painful clicking on movement. Only patients with mild or no degenerative changes of the radial head and capitellum were considered for osteotomy. The operations were performed at a mean of 8.2 months (4 to 13) after injury and the patients were reviewed at a mean of 5.5 years (15 months to 12 years) after the osteotomy. The average Mayo Elbow Performance Index Score improved significantly from 74 before to 88 after operation, with four patients rated as good or excellent (p <
0.05). The subjective patient satisfaction score was 8.4 on a ten-point scale. All osteotomies healed and there were no complications. In this small series intra-articular osteotomy of the head of the radius was a safe and effective treatment for symptomatic intra-articular malunion without advanced degenerative changes.
The lateral ligament complex is the primary constraint to posterolateral rotatory laxity of the elbow, and if it is disrupted during surgery, posterolateral instability may ensue. The Wrightington approach to the head of the radius involves osteotomising the ulnar insertion of this ligament, rather than incising through it as in the classic posterolateral (Kocher) approach. In this biomechanical study of 17 human cadaver elbows, we demonstrate that the surgical approach to the head can influence posterolateral laxity, with the Wrightington approach producing less posterolateral rotatory laxity than the posterolateral approach.
Contracture of the collateral ligaments is considered to be an important factor in post-traumatic stiffness of the elbow. We reviewed the results of isolated release of the medial collateral ligament in a series of 14 patients with post-traumatic loss of elbow flexion treated between 1998 and 2002. There were nine women and five men with a mean age of 45 years (17 to 76). They were reviewed at a mean follow-up of 25 months (9 to 48). The operation was performed through a longitudinal posteromedial incision centred over the ulnar nerve. After decompression of the ulnar nerve, release of the medial collateral ligament was done sequentially starting with the posterior bundle and the transverse component of the ligament, with measurement of the arc of movement after each step. If full flexion was not achieved the posterior half of the anterior bundle of the medial collateral ligament was released. At the latest follow-up, the mean flexion of the elbow improved significantly from 96° (85° to 115°) pre-operatively to 130° (110° to 150°) at final follow-up (p = 0.001). The mean extension improved significantly from 43° (5° to 90°) pre-operatively to 22° (5° to 40°) at final follow-up (p = 0.003). There was a significant improvement in the functional outcome. The mean Broberg and Morrey score increased from a mean of 54 points (29.5 to 85) pre-operatively to 87 points (57 to 99) at final follow-up (p <
0.001). All the patients had normal elbow stability. Our results indicate that partial surgical release of the medial collateral ligament is associated with improved range of movement of the elbow in patients with post-traumatic stiffness, but was less effective in controlling pain.
We analysed the outcome of the Coonrad-Morrey total elbow replacement used for fracture of the distal humerus in elderly patients with no evidence of inflammatory arthritis and compared the results for early One patient in the early group developed chronic regional pain syndrome and another type 4 aseptic loosening. Two elbows in the early group also showed type 1 radiological loosening. Two patients in the delayed group had an infection, two an ulnar nerve palsy, one developed heterotopic ossification and one type 4 aseptic loosening. Two elbows in this group also showed type 1 radiological loosening. The Kaplan-Meier survivorship analysis for the early and delayed treatment groups was 93% at 88 months and 76% at 84 months, respectively. No significant difference was found between the two groups.
