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

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

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

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

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

Aims. The aim of this study is to report the results of a case series of olecranon fractures and olecranon osteotomies treated with two bicortical screws. Methods. Data was collected retrospectively for all olecranon fractures and osteotomies fixed with two bicortical screws between January 2008 and December 2019 at our institution. The following outcome measures were assessed; re-operation, complications, radiological loss of reduction, and elbow range of flexion-extension. Results. Bicortical screw fixation was used to treat 17 olecranon fractures and ten osteotomies. The mean age of patients being treated for olecranon fracture and osteotomy were 48.6 years and 52.7 years respectively. Overall, 18% of olecranon fractures were classified as Mayo type I, 71% type II, and 12% type III. No cases of fracture or osteotomy required operative re-intervention. There were two cases of loss of fracture reduction which occurred in female patients ≥ 75 years of age with osteoporotic bone. In both cases, active extension and a functional range of movement was maintained and so the loss of reduction was managed non-operatively. For the fracture fixation cohort, at final follow-up mean elbow extension and flexion were -5. °. ± 5. °. and 136. °. ± 7. °. , with a mean arc of motion of 131. °. ± 11. °. . Conclusion. This series has shown that patients regain near full range of elbow flexion-extension and complication rates are low following bicortical screw fixation of olecranon fractures and osteotomy. Cite this article: Bone Joint Open 2020;1-7:376–382

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

Purpose: This study reviews the early results of elbow hemiarthroplasty for distal humeral fractures. Method: Elbow hemiarthroplasty was performed on 30 patients (mean 65 years; 29–91) for unreconstruc-table fractures of the distal humerus or salvage of failed internal fixation. A ‘triceps on’ approach was used in six and an olecranon osteotomy in 24. A Sorbie Questor prosthesis (Wright Medical Technology) was used in 14 patients and a Lattitude (Tornier) in 16. Clinical review at a mean of 25 months (3–88) included the American Shoulder and Elbow Surgeons elbow outcomes instrument (ASES), Mayo Elbow Performance Index (MEPI) and radiological assessment. Results: At follow up of 28 patients mean flexion deformity was 25 degrees, flexion 128 degrees, range of pro-nosupination 165 degrees, mean ASES 83, MEPI 77 and satisfaction 8/10. Acute cases scored better than salvage cases. Re-operation was required in 16 patients (53%); two revisions to a linked prosthesis for periprosthetic fracture and aseptic loosening at 53 and 16 months, 12 metalwork removals and four ulnar nerve procedures. Posterolateral rotatory instability was present in one elbow, four had laxity and pain on loading (two with prosthesis or pin loosening), four had laxity associated with column fractures (two symptomatic) and ten had asymptomatic laxity only. The triceps on approach had worse laxity and clinical scores. Uncomplicated union occurred in all olecranon osteotomies and 86% of column fractures. One elbow had an incomplete cement mantle and seven had lucencies > 1 mm; one was loose but acceptable. Five prostheses were in slight varus and two were flexed. Two elbows had early degenerative changes and 15 developed an osteophytic lip on the medial trochlea. Conclusion: Early results of elbow hemiarthroplasty show good outcomes after complex distal humeral fractures, despite a technically demanding procedure, met-alware removal in 40%, symptomatic laxity in 12% and column non-union in 8%. Better results are obtained for treatment in the acute setting and with use of an olecranon osteotomy

This study reviews the early results of elbow hemiarthroplasty for distal humeral fracture. Elbow hemiarthroplasty was performed on 30 patients (mean 65 years; 29–91) for unreconstructable fractures of the distal humerus or salvage of failed internal fixation. A ‘triceps on’ approach was used in 6 and an olecranon osteotomy in 24. A Sorbie Questor prosthesis (Wright Medical Technology) was used in 14 patients and a Lattitude (Tornier) in 16. Clinical review at a mean of 25 months (3 – 88) included the American Shoulder and Elbow Surgeons elbow outcomes instrument (ASES), Mayo Elbow Performance Index (MEPI) and radiological assessment. At follow up of 28 patients, mean flexion deformity was 25 degrees, flexion 128 degrees, range of pronosupination 165 degrees, mean ASES 83, MEPI 77 and satisfaction 8/10. Acute cases scored better than salvage cases. Re-operation was required in 16 patients (53%); 2 revisions to a linked prosthesis for periprosthetic fracture and aseptic loosening at 53 and 16 months, 12 metalwork removals and 4 ulnar nerve procedures. Posterolateral rotatory instability was present in one elbow, 4 had laxity and pain on loading (2 with prosthesis or pin loosening), 4 had laxity associated with column fractures (2 symptomatic) and 10 had asymptomatic laxity only. The triceps on approach had worse laxity and clinical scores. Uncomplicated union occurred in all olecranon osteotomies and 86% of column fractures. One elbow had an incomplete cement mantle and 7 had lucencies > 1 mm; one was loose but acceptable. 5 prostheses were in slight varus and 2 were flexed. 2 elbows had early degenerative changes and 15 an osteophytic lip on the medial trochlea. Elbow hemiarthroplasty has good early results after complex distal humeral fractures, despite a demanding procedure, metalware removal in 40%, symptomatic laxity in 12% and column non-union in 8%. Better results are obtained for treatment in the acute setting and with use of an olecranon osteotomy

The aim of the current study was to assess the amount of the distal humerus articular surface exposed through the Newcastle approach, a posterior triceps preserving exposure of the elbow joint. 24 cadaveric elbows (12 pairs) were randomized to receive one of the four posterior surgical approaches: triceps reflecting, triceps splitting, olecranon osteotomy and Newcastle approach. The ratio of the articular surface exposed for each elbow was calculated and compared. The highest ratio observed was for Newcastle approach (0.75 ± 0.12) followed by olecranon osteotomy (0.51 ± 0.1), triceps reflecting (0.37 ± 0.08) and triceps splitting (0.35 ± 0.07). The differences between Newcastle approach and other approaches were statistically significant (p=0.003 vs osteotomy and < 0.0001 vs triceps reflecting and splitting). The Newcastle approach sufficiently exposes the distal humerus for arthroplasty or fracture fixation purposes. Its use is supported by the current study

Fractures of the distal humerus present a challenge. The fractures are often intra-articular and the bone osteoporotic. The elbow tolerates surgery and immobilisation poorly, and it is difficult to secure rigid fixation. Union must be achieved and elbow motion preserved. The results of fixation of fractures of the distal humerus are unpredictable. Fixation with two plates at 90° angles to one another has become the standard against which all other treatment is measured. Following up patients for a mean of 24 months, the author conducted a prospective study evaluating posterior plating of the two columns of the distal humerus with reconstruction plates and intercondylar fixation. Between 1996 and 2000, 18 women and seven men with unilateral intra-articular fractures of the distal humerus were treated. Their mean age was 46 years (35 to 71). The fractures were classified according to the AO classification: there were 22 type-CII and three type-CIII. Four fractures were compound. One of two posterior approaches was used, either through the triceps aponeurosis or using an olecranon osteotomy. Postoperative management included prophylactic intravenous antibiotics for 48 hours and a posterior splint for 7 to 10 days. Active movement commenced once sutures were removed, but patients avoided active or resisted extension for six weeks. The mean time to union was 16 weeks. Patients attained a mean range of elbow movement of 105° (35° to 135°). One patient developed superficial sepsis but recovered after treatment with antibiotics. One patient with a compound injury developed a deep infection, which required multiple debridements, gentamycin beads and bone grafting to achieve union. There were no implant failures or cases of nerve paralysis. This study demonstrated no differences in functional outcome between triceps aponeurosis or olecranon osteotomy approach. Union and satisfactory functional results were achieved with posterior plating of the columns and intercondylar fixation

Purpose: In the younger population there is substantial body of evidence that the outcome is better following open reduction and internal fixation of distal humerus fractures. In the elderly however, there is a need to assess the value of internal fixation of these fractures where osteoporosis is almost a rule than exception and poses considerable challenge to even very experienced trauma surgeon. The purpose of this study therefore was to assess the functional outcome of operative fixation of fractures of the distal humerus in a cohort of elderly patients (aged 75 and above). The reproducibility of four different scoring systems is also evaluated. Patients and Methods: Between 1996 and 2000 out 125 patients who were treated in our institution, elderly patients above 75 years of age were studied. Demographic data such as age, sex, associated injuries and the pre-admission elbow function were recorded. All the fractures were classified according to the AO/ASIF system. At final follow up elbow function was analyzed using OTA’s rating system and these results were compared using three other scoring systems (Jupiter’s criteria, Aitkin’s and Rorabeck criteria, and the scoring system of Caja et al). Treatment options, surgical or non surgical was based on the medical condition of the patient and the personality of the fracture. Intra-operative details including ulnar nerve transposition, olecranon osteotomy and quality of fixation were recorded and analysed. Serial radiographs were studied in detail for union, loss of reduction, certain prognostic indicators such as anterior tilt of distal humerus, cubitus angle, any articular step, gap, heterotopic ossification and development of degenerative changes. Radiological analysis was correlated with functional outcome. The minimum follow up was 16 months (range 16–92). Results: Out of 125 patients, 29 (23.2%) were above the age of 75 (5 male). The mean age of the patients was 84.6 years (range 75–100). One patient was lost to follow-up. In total 28 patients were studied with 29 fractures (one bilateral), five open (Gustilo’s grade I). Mechanism of injury included 24 falls and 4 motor vehicle accidents. In seven cases associated injuries (three with ipsilateral upper limb injuries) were noted. Twenty patients (69.8%) had noticeable osteopenia in the x rays. According to the AO/ASIF classification, there were eight type A, eight type B and thirteen type C fractures. Eight patients were treated non-operatively (3 type A, 2 type B, 3 type C) and 21 (5 type A, 6 type B, 10 type C) operatively. The injury-surgery interval ranged from 6hours to 5days. An olecranon osteotomy (chevron type, Jupiter’s technique) was performed in 21 cases, 2 underwent Triceps ‘tongue’ reflection and 7 had triceps splitting. Only one case had anterior transposition of the ulnar nerve and none in the series developed ulnar nerve symptoms. Local complications included one case of deep infection (leading to non-union), three cases of superficial infection treated with antibiotics, 3 non-unions (two affecting the fracture and the other one the site of the olecranon osteotomy). The former patients declined further intervention and the latter patient was asymptomatic. One patient needed removal of olecranon metal ware, one developed olecranon bursitis. Heterotopic ossification was present in one patient with no effect on the elbow function. Overall, the mean loss of extension was 22.5° (range 5–40°) and the mean flexion 98.6° (ranged 40o–132°). In the non-operative group the mean loss of extension and mean flexion achieved were 33.5oand 70.1° respectively whereas in the operative group were 22.7oand 106.6°. OTA grading revealed 3‘excellent’, 9‘good’, 7‘fair’and 2 ‘poor’ results in the operated group whereas in the non-operative group there were no ‘excellent’, 2‘good’, 3‘fair’, 3‘poor’results. It is of note that in the non-operative group there was a 37.5% incidence of poor results significantly higher than the operative group. The number of ‘acceptable’ (excellent + good) results was higher in the surgically treated group (52%) than in the non-surgically treated group (25.0%). The functional outcome was most closely related to anatomical reduction of the fracture (particularly articular step < 2mm) and anterior tilt of the distal humerus and was unaffected by the injury-surgery interval. It was found that the Jupiter score was less rigid for the range of movement but produced similar scores to OTA with less potential inter observer error compared to the two other scoring systems. 18 of the 21(85.7%) the patients had no limitation of rotation. Conclusion & Significance: This study supports the view that the functional outcome following distal humerus fractures is better with operative treatment in patients above the age of 75. Out of the 4 functional assessment scoring systems evaluated only the OTA and Jupiter gave similar results

Purpose: Tension band wiring is the most common surgical procedure for fixation of fractures of the Olecranon, but it is associated with high rate of metal work complications and implant failure leading to re-operation. Method: We present a new fixation technique for olecranon fractures that avoids reoperation to remove hardware as compared with the standard fixation technique with Kirschner wires and tension band wiring as advocated by the AO technique. We describe fixation of displaced transverse and oblique olecranon fractures with anchor sutures, each of which has two pairs of suture strands. Prior to the insertion of the anchor sutures, the fracture is reduced through a standard open approach. Results: Twelve patients have been treated with this technique so far, with a mean follow-up of 6 months. The mean age of the patients was 46.7 years (range 14–75 yrs). We have followed all these patients till union of the fractures. No immediate complications have been noted. Radiographic results are good, with no loss of reduction. Conclusion: This technique avoids the need for reop-eration for hardware removal without compromising the quality of reduction. It may be argued that anchor sutures may cost more than tension band wiring which is a very low cost procedure. At the same time, we should also consider the future cost involved because of reoperation rate and morbidity. Our newly described technique would be particularly useful in dealing with olecranon fractures in children where it is undesirable to cross the physeal plate by metal work. It would also be of great value in dealing with intra articular distal humeral fractures where fixation is planned initially but conversion to total elbow replacement becomes essential intra-operatively. In such cases an olecranon osteotomy can be fixed by this technique, even in presence of a total elbow replacement

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

We reviewed the functional outcome of cominnuted intraarticular fractures of the distal humerus managed with internal fixation with plates and screws. 15 patients (10 men-5 women) were reviewed over a mean of 29 months postoperatively. The age of the patients at operation ranged from 18 to 72 years. Patients were treated within 7 days of injury, using a posterior approach,with or without olecranon osteotomy and with anterior transposition of the ulnar nerve. Bone grafting was used in 7 cases in addition to internal fixation. Postoperative mobilisation was prompt in all patients,who were meticously reviewed for : 1)Function of the upper extremity,with the aid of the scale of DASH (Disabilities of the arm,shoulder and hand), 2)Ulnar nerve (pain, sensitive and movement dissability, functionality), 3)Range of elbow motion, 4) strength of the muscles controlling the elbow, wrist and hand. 5)Post-operative radiographic appearance, 6)Subjective evaluation, 7)Complications. All the patients were satisfied with the outcome of the operation,as well as with the activities which could postoperatively be undertaken. The mean range of motion for elbow (flexion-extension) was 118° in average,while muscle strength for elbow motion was moderately reduced. No case of ulnar neuropathy was observed. On the other hand postoperative complications were considerably frequent, yet they were mild and subsided eventually without further operation

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

To discover the long-term outcome of internal fixation for displaced fractures of the distal adult humerus, we have re-assessed a cohort of 57 patients studied 10 years ago. Forty patients (70%) were identified, 13 had died, leaving 27 adult patients at an average of 17 years after operation (14–20 years). Eighteen were Müller type C, (five open), eight type B and two type A. All were treated with stable internal fixation. Early active mobilisation was mandatory. The majority were approached using a chevron olecranon osteotomy. The patients were assessed radiographically and using a modification of the Mayo Clinic Performance Index for the Elbow. The patients were also asked about their perception of the outcome of surgery, and overall satisfaction. Based upon the Mayo Score, 33% had an excellent result, 63% good and four percent fair. None had a poor outcome. Pain was generally only mild if present at all, with only three stating that it interfered with hobbies or work. Only one required regular use of analgesics. Sensory abnormalities were found in eight patients, four in the ulnar distribution, one median, two whole hand and one whole arm. None considered this unpleasant or a problem. Discomfort attributed to the metalwork was found in four patients, six have had some or all removed. All but one was able to attend to all activities of daily living without problems. Patient satisfaction was excellent or good in 83% and satisfactory in 17%. This study is the first to demonstrate that early stable internal fixation of distal humeral fractures by an experienced surgeon, gives excellent long term results with few complications, together with high rates of patient satisfaction and little functional morbidity

To assess the functional outcome of operative and non-operative treatment of distal humeral fractures in the elderly, patients above 75 years of age were studied. Demographic data including associated injuries and co-morbid conditions were recorded. The minimum follow-up was 16 months (range 16–92 months). Elbow function was analysed according to the OTA rating system. Radiographs were monitored for possible predictors of final functional outcome. Out of 125 patients with distal humeral fractures, 29 were above the age of 75 years. The mean age at the time of admission was 84.6 years (range 75–100). One patient was lost to follow-up. In total there were 28 patients with 29 fractures. 5 of these were open fractures. As per the AO classification, there were 8 type A, 8 type B, and 13 type C fractures. 8 patients were treated non-operatively (3 type A, 2 type B, 3 type C) and 21 (5 type A, 6 type B, 10 type C) operatively. An olecranon osteotomy was performed in 12 cases, 2 underwent triceps tongue reflection, and 7 had triceps splitting. Local complications included 4 cases (1 deep and 3 superficial) of infection and 3 non-unions (including one at the olecranon osteotomy). In the non-operative group the mean loss of extension and mean flexion achieved were 34.0 and 70.0 degrees respectively, whereas in the operative group the corresponding values were 23.0 and 107 degrees. OTA grading revealed 3 excellent, 9 good, 7 fair and 2 poor results in the operated group whereas in the non-operated group there were 0 excellent, 2 good, 3 fair, and 3 poor results. There was direct correlation between loss of anterior tilt of the distal humerus and adverse outcome. Conclusion: Our study showed that improved functional outcome can be achieved following surgical treatment in these difficult fracture This study supports the view that we need to re-examine the conventional view of ‘bag of bones’ method as blanket treatment and signifies the need for further studies on similar cohorts of patients

Aims

The aim of this study is to report the implant survival and factors associated with revision of total elbow arthroplasty (TEA) using data from the Dutch national registry.

Purpose: Distal humeral fractures are often difficult injuries to treat. We hypothesise that more complex distal humeral fractures have unacceptable functional outcomes due to multi-factorial reasons. Methods: 42 patients with AO/ASIF type B and C fractures of the distal humerus who were treated with open reduction and internal fixation over a six year period were included in the study. All patients were from a single district general hospital. 37 (88%) were clinically, radiologically, and functionally assessed for this study, with the remainder either lost to follow-up or expired. Results: There were 21 type B and 16 type C fractures, all managed by open reduction and internal fixation. Various fixation techniques were utilised. These were performed by consultant surgeons in 14 cases and by surgeons in training in 23 cases. Average follow up was 38 months (range 22–54 months). The arc of elbow motion was 94 degrees (range 58–130), with an average extension deficit of 28 degrees (range 20–55) and an average flexion deficit of 32 degrees (range 15–45). The average arc of forearm rotation was 136 degrees (range 45–140), with an average supination of 68 (range 35–85) and an average pronation of 72 (range 45–90). The complications (n=20/37) included superficial skin infection (n=4), ulnar nerve neurapraxia (n=3), non-union of the humerus fracture (n=2), non-union of olecranon osteotomy site (n=1), intra-articular screw placement (n=1), loosened plate (n=1), loose/backed out screw (n=2), fixed flexion deformity (n=4) and mild elbow instability (n=2). Second surgery was performed in 24% (n=9/37), revision of metal work (n=2), bone grafting (n=2), anterior capsulectomy (n=4), and removal of screw (n=1). Conclusions: Fractures of the distal humerus are often more complex than appreciated, and challenging to treat, with respect to fracture union and functional outcome. A generalist practice appears adequate for achieving bony union, but inadequate for obtaining low complication rates and functional outcomes. Our data suggest that such injuries may constitute a fracture group requiring the acute intervention by centres that have specific sub-specialisation and adequate rehabilitation facilities