To prevent insufficiency of the triceps after
total elbow arthroplasty, we have, since 2008, used a triceps-sparing ulnar
approach. This study evaluates the clinical results and post-operative
alignment of the prosthesis using this approach. We reviewed 25 elbows in 23 patients. There were five men and
18 women with a mean age of 69 years (54 to 83). There were 18 elbows
with rheumatoid arthritis, six with a fracture or pseudoarthrosis
and one elbow with osteoarthritis. Post-operative complications included one intra-operative fracture,
one elbow with heterotopic ossification, one transient ulnar nerve
palsy, and one elbow with skin necrosis, but no elbow was affected
by insufficiency of the triceps. Patients were followed for a mean of 42 months (24 to 77). The
mean post-operative Japanese Orthopaedic Association Elbow Score
was 90.8 (51 to 100) and the mean Mayo Elbow Performance score 93.8
(65 to 100). The mean post-operative flexion/extension of the elbow
was 135°/-8°. The Manual Muscle Testing score of the triceps was
5 in 23 elbows and 2 in two elbows (one patient). The mean alignment
of the implants examined by 3D-CT was 2.8° pronation (standard deviation
( The triceps-sparing ulnar approach allows satisfactory alignment
of the implants, is effective in preventing post-operative triceps
insufficiency, and gives satisfactory short-term results. Cite this article: 2015;97-B:1096–1101.
The primary aim of this retrospective study was to identify the
incidence of heterotopic ossification (HO) following elective and
trauma elbow arthroplasty. The secondary aim was to determine clinical
outcomes with respect to the formation of heterotopic ossification. A total of 55 total elbow arthroplasties (TEAs) (52 patients)
performed between June 2007 and December 2015 were eligible for
inclusion in the study (29 TEAs for primary elective arthroplasty
and 26 TEAs for trauma). At review, 15 patients (17 total elbow
arthroplasties) had died from unrelated causes. There were 14 men
and 38 women with a mean age of 70 years (42 to 90). The median
clinical follow-up was 3.6 years (1.2 to 6) and the median radiological follow-up
was 3.1 years (0.5 to 7.5).Aim
Patients and Methods
We report our experience of performing an elbow
hemiarthroplasty in the treatment of comminuted distal humeral fractures
in the elderly patients. A cohort of 42 patients (three men and 39 women, mean age 72;
56 to 84) were reviewed at a mean of 34.3 months (24 to 61) after
surgery. Functional outcome was measured with the Mayo Elbow Performance
Score (MEPS) and range of movement. The disabilities of the arm,
shoulder and hand questionnaire (DASH) was used as a patient rated
evaluation. Complications and ulnar nerve function were recorded.
Plain radiographs were obtained to assess prosthetic loosening,
olecranon wear and heterotopic bone formation. The mean extension deficit was 23.5° (0° to 60°) and mean flexion
was 126.8° (90° to 145°) giving a mean arc of 105.5° (60° to 145°).
The mean MEPS was 90 (50 to 100) and a mean DASH score of 20 (0
to 63). Four patients had additional surgery for limited range of
movement and one for partial instability. One elbow was revised
due to loosening, two patients had sensory ulnar nerve symptoms,
and radiographic signs of mild olecranon wear was noted in five
patients. Elbow hemiarthroplasty for comminuted intra-articular distal
humeral fractures produces reliable medium-term results with functional
outcome and complication rates, comparable with open reduction and
internal fixation and total elbow arthroplasty. Cite this article:
In order to achieve satisfactory reduction of
complex distal humeral fractures, adequate exposure of the fracture fragments
and the joint surface is required. Several surgical exposures have
been described for distal humeral fractures. We report our experience
using the anconeus pedicle olecranon flip osteotomy approach. This
involves detachment of the triceps along with a sliver of olecranon,
which retains the anconeus pedicle. We report the use of this approach
in ten patients (six male, four female) with a mean age of 38.4
years (28 to 51). The mean follow-up was 15 months (12 to 18) with
no loss to follow-up. Elbow function was graded using the Mayo Score.
The results were excellent in four patients, good in five and fair
in one patient. The mean time to both fracture and osteotomy union
was 10.6 weeks (8 to 12) and 7.1 weeks (6 to 8), respectively. We
found this approach gave reliably good exposure for these difficult
fractures enabling anatomical reduction and bicondylar plating without
complications. Cite this article:
Fractures in patients aged ≥ 65 years constitute
an increasing burden on health and social care and are associated with
a high morbidity and mortality. There is little accurate information
about the epidemiology of fractures in the elderly. We have analysed
prospectively collected data on 4786 in- and out-patients who presented
with a fracture over two one-year periods. Analysis shows that there
are six patterns of the incidence of fractures in patients aged ≥ 65
years. In males six types of fracture increase in incidence after
the age of 65 years and 11 types increase in females aged over 65
years. Five types of fracture decrease in incidence after the age
of 65 years. Multiple fractures increase in incidence in both males
and females aged ≥ 65 years, as do fractures related to falls. Analysis of the incidence of fractures, together with life expectancy,
shows that the probability of males and females aged ≥ 65 years
having a fracture during the rest of their life is 18.5% and 52.0%,
respectively. The equivalent figures for males and females aged ≥ 80
years are 13.3% and 34.8%, respectively. Cite this article:
We assessed the long-term (more than ten-year) outcomes of the
Kudo type-5 elbow prosthesis in patients with rheumatoid arthritis
(RA). 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).Aims
Materials and Methods
Most fractures of the radial head are stable
undisplaced or minimally displaced partial fractures without an associated
fracture of the elbow or forearm or ligament injury, where stiffness
following non-operative management is the primary concern. Displaced
unstable fractures of the radial head are usually associated with other
fractures or ligament injuries, and restoration of radiocapitellar
contact by reconstruction or prosthetic replacement of the fractured
head is necessary to prevent subluxation or dislocation of the elbow
and forearm. In fractures with three or fewer fragments (two articular
fragments and the neck) and little or no metaphyseal comminution,
open reduction and internal fixation may give good results. However,
fragmented unstable fractures of the radial head are prone to early
failure of fixation and nonunion when fixed. Excision of the radial
head is associated with good long-term results, but in patients
with instability of the elbow or forearm, prosthetic replacement
is preferred. This review considers the characteristics of stable and unstable
fractures of the radial head, as well as discussing the debatable
aspects of management, in light of the current best evidence. Cite this article:
The objective of this retrospective study was to correlate the Bado and Jupiter classifications with long-term results after operative treatment of Monteggia fractures in adults and to determine prognostic factors for functional outcome. Of 63 adult patients who sustained a Monteggia fracture in a ten-year period, 47 were available for follow-up after a mean time of 8.4 years (5 to 14). According to the Broberg and Morrey elbow scale, 22 patients (47%) had excellent, 12 (26%) good, nine (19%) fair and four (8%) poor results at the last follow-up. A total of 12 patients (26%) needed a second operation within 12 months of the initial operation. The mean Broberg and Morrey score was 87.2 (45 to 100) and the mean DASH score was 17.4 (0 to 70). There was a significant correlation between the two scores (p = 0.01). The following factors were found to be correlated with a poor clinical outcome: Bado type II fracture, Jupiter type IIa fracture, fracture of the radial head, coronoid fracture, and complications requiring further surgery. Bado type II Monteggia fractures, and within this group, Jupiter type IIa fractures, are frequently associated with fractures of the radial head and the coronoid process, and should be considered as negative prognostic factors for functional long-term outcome. Patients with these types of fracture should be informed about the potential risk of functional deficits and the possible need for further surgery.
Four men who presented with chronic dislocation of the radial head and nonunion or malunion of the ulna were reviewed after open reduction of the radial head and internal fixation of the ulna in attempted overcorrection. Their mean age was 37 years (28 to 46) and the mean interval between injury and reconstruction was nine months (4 to 18). The mean follow-up was 24 months (15 to 36). One patient who had undergone secondary excision of the radial head was also followed up for comparison. The three patients who had followed the treatment protocol had nearly normal flexion, extension and supination and only very occasional pain. All had considerable loss of pronation which did not affect patient satisfaction. Preservation of the radial head in chronic adult Monteggia fractures appears to be a promising mode of treatment.
Using an osteotomy of the olecranon as a model of a transverse fracture in 22 cadaver elbows we determined the ability of three different types of suture and stainless steel wire to maintain reduction when using a tension-band technique to stabilise the bone. Physiological cyclical loading simulating passive elbow movement (15 N) and using the arms to push up from a chair (450 N) were applied using an Instron materials testing machine whilst monitoring the osteotomy site with a video extensometer. Each osteotomy was repaired by one of four materials, namely, Stainless Steel Wire (7), No 2 Ethibond (3), No 5 Ethibond (5), or No 2 FiberWire (7). There were no failures (movement of >
2 mm) with stainless steel wire or FiberWire and no significant difference in the movements measured across the site of the osteotomy (p = 0.99). The No. 2 Ethibond failed at 450 N and two of the five of No. 5 Ethibond sutures had a separation of >
2 mm at 450 N. FiberWire as the tension band in this model held the reduction as effectively as stainless steel wire and may reduce the incidence of discomfort from the hardware. On the basis of our findings we suggest that a clinical trial should be undertaken
The type II Monteggia (posterior) lesion is a rare injury which is sometimes associated with ulnohumeral instability. We have reviewed 23 of 28 patients with this injury. A clinical and radiographic assessment was undertaken at follow-up. Functional outcome scores, including the Broberg and Morrey Index and the Disabilities of the Arm, Shoulder or Hand (DASH), were used. The results from the six patients with associated posterior ulnohumeral dislocation were compared with 17 without ulnohumeral injury. Those with dislocation had reduced movement of the elbow and had outcome scores indicative of greater disability compared to those without associated dislocation.
We studied, ten patients (11 elbows) who had
undergone 14 allograft-prosthesis composite reconstructions following
failure of a previous total elbow replacement with massive structural
bone loss. There were nine women and one man with a mean age of
64 years (40 to 84), who were reviewed at a mean of 75 months (24
to 213). One patient developed a deep infection after 26 months
and had the allograft-prosthesis composite removed, and two patients
had mild pain. The median flexion-extension arc was 100° (95% confidence
interval (CI) 76° to 124°). With the exception of the patient who
had the infected failure, all the patients could use their elbows
comfortably without splints or braces for activities of daily living.
The mean Mayo Elbow Performance Index improved from 9.5 (95% CI
4.4 to 14.7) pre-operatively to 74 (95% CI 62.4 to 84.9) at final
review. Radiologically, the rate of partial resorption was similar in
the humeral and ulnar allografts (three of six and four of eight,
respectively; p >
0.999). The patterns of resorption, however, were
different. Union at the host-bone-allograft junction was also different
between the humeral and ulnar allografts (one of six and seven of
eight showing union, respectively; p = 0.03). At medium-term follow-up, allograft-prosthesis composite reconstruction
appears to be a useful salvage technique for failed elbow replacements
with massive bone loss. The effects of allograft resorption and
host-bone-allograft junctional union on the longevity of allograft-prosthesis
composite reconstruction, however, remain unknown, and it is our
view that these patients should remain under long-term regular review.
We present a retrospective study of 25 patients treated by open arthrolysis of the elbow for post-traumatic stiffness. The mean follow-up was for 7.8 years (5 to 10.8). The range of movement of the elbow, pain scores and functional outcomes were recorded pre- and postoperatively. An improvement in the mean range of movement from 55° (0° to 95°) to 105° (55° to 135°) was obtained in our patients at one year. This improvement was maintained over the mean follow-up period of 7.8 years (5 to 10.8). Improvement in pain, function and patient satisfaction was recorded in 23 of the 25 patients at final follow-up. On the basis of this study, we believe that the results of open arthrolysis for post-traumatic stiffness of the elbow are durable over the medium term.
The October 2013 Children’s orthopaedics Roundup360 looks at: Half a century of Pavlik treatment; Step away from the child!: trends in fracture management; Posterolateral rotatory elbow instability in children; Osteochondral lesions undiagnosed in patellar dislocations; Oral bisphosphonates in osteogenesis imperfecta; Crossed or parallel pins in supracondylar fractures?; Not too late nor too early: getting epiphysiodesis right; Fixation of supramalleolar osteotomies.
Rarely, the extent of a malignant bone tumour
may necessitate resection of the complete humerus to achieve adequate
oncological clearance. We present our experience with reconstruction
in such cases using a total humeral endoprosthesis (THER) in 20
patients (12 male and eight female) with a mean age of 22 years
(6 to 59). We assessed the complications, the oncological and functional
outcomes and implant survival. Surgery was performed between June
2001 and October 2009. The diagnosis included osteosarcoma in nine,
Ewing’s sarcoma in eight and chondrosarcoma in three. One patient
was lost to follow-up. The mean follow-up was 41 months (10 to 120)
for all patients and 56 months (25 to 120) in survivors. There were
five local recurrences (26.3%) and 11 patients were alive at time
of last follow-up, with overall survival for all patients being
52% (95% confidence interval (CI) 23.8 to 74) at five years. The
mean Musculoskeletal Tumor Society score for the survivors was 22
(73%; 16 to 23). The implant survival was 95% (95% CI 69.5 to 99.3)
at five years. The use of a THER in the treatment of malignant tumours of bone
is oncologically safe; it gives consistent and predictable results
with low rates of complication.
The use of passive stretching of the elbow after
arthrolysis is controversial. We report the results of open arthrolysis in
81 patients. Prospectively collected outcome data with a minimum
follow-up of one year were analysed. All patients had sustained
an intra-articular fracture initially and all procedures were performed
by the same surgeon under continuous brachial plexus block anaesthesia
and with continuous passive movement (CPM) used post-operatively
for two to three days. CPM was used to maintain the movement achieved
during surgery and passive stretching was not used at any time.
A senior physiotherapist assessed all the patients at regular intervals.
The mean range of movement (ROM) improved from 69° to 109° and the
function and pain of the upper limb improved from 32 to 16 and from
20 to 10, as assessed by the Disabilities of the Arm Shoulder and
Hand score and a visual analogue scale, respectively. The greatest
improvement was obtained in the stiffest elbows: nine patients with
a pre-operative ROM <
30° achieved a mean post-operative ROM
of 92° (55° to 125°). This study demonstrates that in patients with
a stiff elbow after injury, good results may be obtained after open
elbow arthrolysis without using passive stretching during rehabilitation.
Cadaveric models of the shoulder evaluate discrete motion segments
using the glenohumeral joint in isolation over a defined trajectory.
The aim of this study was to design, manufacture and validate a
robotic system to accurately create three-dimensional movement of
the upper body and capture it using high-speed motion cameras. In particular, we intended to use the robotic system to simulate
the normal throwing motion in an intact cadaver. The robotic system
consists of a lower frame (to move the torso) and an upper frame
(to move an arm) using seven actuators. The actuators accurately
reproduced planned trajectories. The marker setup used for motion
capture was able to determine the six degrees of freedom of all
involved joints during the planned motion of the end effector.Objectives
Methods
This is a retrospective review of the results of the Acclaim total elbow replacement in 11 older patients aged ≥ 65 years with primary osteoarthritis of the elbow, with a mean follow-up of 57.6 months (30 to 86.4). Significant reductions in pain and improvement in range of movement and function were recorded. Radiological review revealed two patients with 1 mm lucencies in a single zone, and one patient with 1 mm lucencies in two zones. No components required revision. There were no deep infections, dislocations or mechanical failures. Complications included one intra-operative medial condylar fracture and one post-operative transient ulnar neuropathy, which resolved. This study demonstrates that the Acclaim prosthesis provides good symptomatic relief and improvement of function in patients with primary osteoarthritis, with low rates of loosening or other complications. This prosthesis can therefore be considered for patients aged ≥ 65 years with primary osteoarthritis of the elbow.
We undertook a study on eight arms from fresh cadavers to define the clinical usefulness of the lesser sigmoid notch as a landmark when reconstructing the length of the neck of the radius in replacement of the head with a prosthesis. The head was resected and its height measured, along with several control measurements. This was compared with The results were highly reproducible with intra- and interclass correlations of >
0.99. The mean difference between the measurement on the excised head and the distance from the stump of the neck and the lesser sigmoid notch was −0.02 mm (−1.24 to +0.97). This difference was not statistically significant (p = 0.78). The proximal edge of the lesser sigmoid notch provides a reliable landmark for positioning a replacement of the radial head and may have clinical application.
We have evaluated the clinical outcomes of simple excision, ulnar lengthening and the Sauvé-Kapandji procedure in the treatment of deformities of the forearm in patients with multiple hereditary osteochondromas. The medical records of 29 patients (33 forearms) were reviewed; 22 patients (22 forearms) underwent simple excision (four with ulnar lengthening) and seven the Sauvé-Kapandji procedure. Simple excision increased the mean supination of the forearm from 63.2° to 75.0° (p = 0.049). Ulnar lengthening did not significantly affect the clinical outcome. The Sauvé-Kapandji technique improved the mean pronation from 33.6° to 55.0° (p = 0.047) and supination from 70.0° to 81.4° (p = 0.045). Simple excision may improve the range of movement of the forearm but will not halt the progression of disease, particularly in younger patients. No discernable clinical or radiological improvement was noted with ulnar lengthening. The Sauvé-Kapandji procedure combined with simple excision of osteochondromas can improve stability of the wrist, movement of the forearm and the radiological appearance.