To develop a reliable and effective radiological score to assess the healing of isolated ulnar shaft fractures (IUSF), the Radiographic Union Score for Ulna fractures (RUSU). Initially, 20 patients with radiographs six weeks following a non-operatively managed ulnar shaft fracture were selected and scored by three blinded observers. After intraclass correlation (ICC) analysis, a second group of 54 patients with radiographs six weeks after injury (18 who developed a nonunion and 36 who united) were scored by the same observers. In the initial study, interobserver and intraobserver ICC were 0.89 and 0.93, respectively. In the validation study the interobserver ICC was 0.85. The median score for patients who united was significantly higher than those who developed a nonunion (11 vs 7, p<0.001). A ROC curve demonstrated that a RUSU ≤8 had a sensitivity of 88.9% and specificity of 86.1% in identifying patients at risk of nonunion. Patients with a RUSU ≤8 (n = 21) were more likely to develop a nonunion (n = 16/21) than those with a RUSU ≥9 (n = 2/33; OR 49.6, 95% CI 8.6–284.7). Based on a PPV of 76%, if all patients with a RUSU ≤8 underwent fixation at 6-weeks, the number of procedures needed to avoid one nonunion would be 1.3. The RUSU shows good interobserver and intraobserver reliability and is effective in identifying patients at risk of nonunion six weeks after fracture. This tool requires external validation but may enhance the management of patients with isolated ulnar shaft fractures

Aims. Isolated fractures of the ulnar diaphysis are uncommon, occurring at a rate of 0.02 to 0.04 per 1,000 cases. Despite their infrequency, these fractures commonly give rise to complications, such as nonunion, limited forearm pronation and supination, restricted elbow range of motion, radioulnar synostosis, and prolonged pain. Treatment options for this injury remain a topic of debate, with limited research available and no consensus on the optimal approach. Therefore, this trial aims to compare clinical, radiological, and functional outcomes of two treatment methods: open reduction and internal fixation (ORIF) versus nonoperative treatment in patients with isolated ulnar diaphyseal fractures. Methods. This will be a multicentre, open-label, parallel randomized clinical trial (under National Clinical Trial number NCT01123447), accompanied by a parallel prospective cohort group for patients who meet the inclusion criteria, but decline randomization. Eligible patients will be randomized to one of the two treatment groups: 1) nonoperative treatment with closed reduction and below-elbow casting; or 2) surgical treatment with ORIF utilizing a limited contact dynamic compression plate and screw construct. The primary outcome measured will be the Disabilities of the Arm, Shoulder and Hand questionnaire score at 12 months post-injury. Additionally, functional outcomes will be assessed using the 36-Item Short Form Health Survey and pain visual analogue scale, allowing for a comparison of outcomes between groups. Secondary outcome measures will encompass clinical outcomes such as range of motion and grip strength, radiological parameters including time to union, as well as economic outcomes assessed from enrolment to 12 months post-injury. Ethics and dissemination. This trial has been approved by the lead site Conjoint Health Research Ethics Board (CHREB; REB14-2004) and local ethics boards at each participating site. Findings from the trial will be disseminated through presentations at regional, national, and international scientific conferences and public forums. The primary results and secondary findings will be submitted for peer-reviewed publication. Cite this article: Bone Jt Open 2024;5(5):411–418

Introduction. This study aims to investigate the relationship between ulnar fixation and postoperative satisfaction among patients with distal radius fractures accompanied by ulna styloid fractures, with a particular focus on how sociodemographic factors influence outcomes. Method. A retrospective cohort study was conducted involving 120 patients aged 26-53 who underwent surgical treatment for distal radius fractures with concomitant ulna styloid fractures between January 2018 and December 2022. Patients were divided into two groups based on whether ulnar fixation was performed. Sociodemographic data, including age, gender, socioeconomic status, education level, and occupation, were collected. All patients underwent similar physical therapy protocols in the postoperative period, and no complications were observed in any patient. Postoperative satisfaction was assessed using the Patient-Rated Wrist Evaluation (PRWE) and the Disabilities of the Arm, Shoulder, and Hand (DASH) scores at 6 and 12 months post-surgery. Statistical analysis was conducted to evaluate the influence of ulnar fixation and sociodemographic factors on patient satisfaction. Result. Patients who underwent ulnar fixation (n=60) reported significantly higher satisfaction levels compared to those who did not (n=60), as evidenced by lower PRWE and DASH scores (p < 0.05). Age, gender, and socioeconomic status were significant predictors of postoperative satisfaction. Younger patients, females, and those with higher socioeconomic status exhibited greater improvements in functional outcomes and satisfaction. However, education level and occupation did not significantly influence satisfaction scores. Conclusion. Ulnar fixation in the surgical treatment of distal radius fractures accompanied by ulna styloid fractures is associated with improved postoperative satisfaction. Sociodemographic factors, particularly age, gender, and socioeconomic status, play a crucial role in patient-reported outcomes. Tailoring postoperative care to address these sociodemographic differences may enhance overall patient satisfaction and recovery

Aims. Complete ruptures of the ulnar collateral ligament (UCL) of the thumb are a common injury, yet little is known about their current management in the UK. The objective of this study was to assess the way complete UCL ruptures are managed in the UK. Methods. We carried out a multicentre, survey-based cross-sectional study in 37 UK centres over a 16-month period from June 2022 to September 2023. The survey results were analyzed descriptively. Results. A total of 37 centres participated, of which nine were tertiary referral hand centres and 28 were district general hospitals. There was a total of 112 respondents (69 surgeons and 43 hand therapists). The strongest influence on the decision to offer surgery was the lack of a firm ‘endpoint’ to stressing the metacarpophalangeal joint (MCPJ) in either full extension or with the MCPJ in 30° of flexion. There was variability in whether additional imaging was used in managing acute UCL injuries, with 46% routinely using additional imaging while 54% did not. The use of a bone anchor was by far the most common surgical option for reconstructing an acute ligament avulsion (97%, n = 67) with a transosseous suture used by 3% (n = 2). The most common duration of immobilization for those managed conservatively was six weeks (58%, n = 65) and four weeks (30%, n = 34). Most surgeons (87%, n = 60) and hand therapists (95%, n = 41) would consider randomizing patients with complete UCL ruptures in a future clinical trial. Conclusion. The management of complete UCL ruptures in the UK is highly variable in certain areas, and there is a willingness for clinical trials on this subject. Cite this article: Bone Jt Open 2024;5(8):708–714

Ulnar shortening osteotomy (USO) is a procedure performed to alleviate ulnar sided wrist pain caused by ulnar impaction syndrome (UIS) and/or triangular fibrocartilage complex (TFCC) injury. Presently, non-union rates for ulnar shortening osteotomy is quoted to be 0–18% in the literature. However, there is a dearth of literature on the effect of site of osteotomy and plate placement on the rate of complications like a delayed union, symptomatic hardware and need for second surgery for hardware removal. In this study, we performed a multi-centered institutional review of ulnar shortening osteotomies performed, focusing on plate placement (volar vs. dorsal) and osteotomy site (distal vs. proximal) and determining if it plays a role in reducing complications. This study was a multi-centered retrospective chart review. All radiographs and charts for patients that have received USO for UIS or TFCC injury between 2013 and 2017 from hand and wrist fellowship-trained surgeons in Calgary, Alberta and Winnipeg, Manitoba were examined. Basic patient demographics including age, sex, past medical history, and smoking history were recorded. Postoperative complications such as delayed union, non-union, infection, chronic regional pain syndrome, hardware irritation requiring removal were evaluated with a two-year follow-up period. Osteotomy sites were analyzed based on the location in relation to the entire length of the ulna on forearm radiographs. Surgical techniques including volar vs. dorsal plating, oblique vs. transverse osteotomy cuts, and plate type were documented. Continuous variables of interest were summarized as mean or medians with standard deviation or inter-quartile range as appropriate. Differences in baseline characteristics were determined by t-test or one-way ANOVA for continuous variables and chi-square or Fischer exact test for dichotomous variables. All analyses were conducted using SPSS V24.0 (Chicago, IL, USA). All statistical tests were considered significant if p < 0.05. Between 2013–2017 there were 117 ulnar shortening osteotomies performed. The average age of patients was 46.2 ± 16.2, with 62.4% being female. The mean pre-operative ulnar variance was +3.89 ± 2.17 mm and post-operative ulnar variance was −1.90 ± 1.80 mm. 84.6% of the plates were placed on the volar aspect of the ulna and 14.5% were placed on the dorsal aspect. An oblique osteotomy was made 99.1% of the time. In measuring osteotomy placement, the average placement was made in the distal 1/3 of the ulna. Overall, there was a 40% complication rate. Hardware irritation requiring removal encompassed 23%, non-union 14%, and wound infection covered 0.8%. When comparing dorsal vs volar plating, there was no statistically significant difference for non-union or hardware removal. Similarly, in evaluating osteotomy level, there was no statistical difference between proximal vs distal osteotomy for non-union and hardware removal. In this multi-centered retrospective review of ulnar shortening osteotomies, we found that there was an overall complication rate of 40%. There was no statistically significant difference in complication rates between dorsal vs volar plate placement or proximal vs distal osteotomy sites. Further studies examining other potential risk factors in lowering the complication rate would be beneficial

There is no consensus for the appropriate surgical management of chronic ulnar collateral ligament (UCL) injuries of the thumb. A systematic review of Pubmed, MEDLINE, EMBASE and ePub Ahead of Print was performed in accordance with Preferred Reporting of Items in Systematic Review and Meta-analysis (PRISMA) guidelines and formal protocol registered with PROSPERO. Two authors collated data from 10 studies that met strict inclusion criteria, using various surgical techniques in 131 thumbs. Results were heterogenous and metanalysis of results not possible. These data were, therefore, qualitatively assessed and synthesised. Bias was assessed using the ROBINS-I tool. Direct repair, reconstruction with free tendon or bone-tissue-bone grafts and arthrodesis all demonstrated favourable outcomes with Patient Reported Outcome Measures. Direct repair can be safely performed more than two months following injury, with a positive mean Disabilities of the Arm, Shoulder and Hand (DASH) score of 13.5 despite evidence of radiographic osteoarthritis. Arthrodesis should be considered in heavy manual laborers or those at risk of osteoarthritis as it provides significant reduction in pain (Mean Visual Analogue Score of 1.2) when compared to other methods. Free tendon grafting has been criticised for failure rates and poor functional grip strength, however collated analysis of 97 patients found a single graft rupture and mean grip strength of 97% (of the contralateral thumb). Bone-tissue-bone grafting was the least effective method across all outcome measures. Studies included were at high risk of bias, however, it can be concluded that delayed direct repair can be performed safely, while arthrodesis may benefit certain patient subgroups. New findings suggest poor efficacy of bone-tissue-bone grafts, but that free tendon grafting with palmaris longus are in fact safe with good restoration of grip strength. The optimal graft and configuration are yet to be determined for reconstructive methods

To evaluate effectiveness and safety of acute ulnar lengthening osteotomy in Madelung's deformity associated with Hereditary Multiple Exostoses (HME). Seventeen ulnas in 13 patients had acute ulnar lengthening for HME associated forearm deformity. Defined radiographic parameters were compared pre- and post-operatively using student's t-test; ulnar variance, carpal slip, radial bowing, radial articular angle. All complications were noted. Mean follow-up was 27 months (range 1.5 – 72months). An increase in ulna length by a mean of 15.4mm (range 4.5 – 29.3mm) was achieved acutely, corresponding to an increase of 9.3% of total ulnar length. Negative ulnar variance was improved from a pre-operative mean of 12.4mm (range 6.1–16.5mm) to a post-operative mean of 4.6mm (range 0–11.25mm) (p=<0.00001). Carpal slip was significantly improved by a mean of 2.2mm (p=0.02). No significant change in radial bowing (p=0.98) or radial articular angle (p=0.74) was observed. Inter-rater reliability was excellent (r=0.96, Pearson Correlation). Three patients required second procedures for recurrence of deformity at 18 months – 6 years following their primary operation. There were no incidences of compartment syndrome, neurovascular injury nor infection. One ulna fractured intra-operatively requiring a longer plate. One patient had a non union which united on revision surgery. Significant radiographic improvements in forearm and wrist alignment were seen with acute ulnar lengthening. The procedure is safe, with no compartment syndrome nor neurovascular injury and low complications rate. Recurrence rates in the skeletally immature patients are comparable to that reported with gradual lengthening. Acute ulnar lengthening for forearm deformity associated with HME has been demonstrated to be a safe, reproducible and effective surgical procedure

Introduction. Ulnar shortening osteotomy has become an accepted treatment for a variety of ulnar sided wrist disorders. We have been performing ulnar shortening with an oblique osteotomy cut with the aid of a commercially available jig. The osteotomy is then fixed with a Dynamic Compression Plate. The aim of this study was to report the complications following ulnar shortening. Methods. We retrospectively analysed 56 consecutive ulnar shortening osteotomies. There were 36 female and 19 male patients. The mean age was 45 years. The mean follow-up was 399 days. 25 patients had pre-operative MRI scans and in 34 arthroscopy of the wrist had been performed. 22 tears of the triangular fibrocartilage complex were recorded on arthroscopy. In all cases shortening had been performed with the aid of a jig and bone resection performed in an oblique orientation. Dynamic Compression Plates were used for fixation and a lag screw was inserted through one of the plate-holes and across the osteotomy site. Radiographs were evaluated for pre-operative and post-operative ulnar variances and post-operatively for bony union. Results. The average post-operative ulna variance was 0.12mm. The average time for osteotomy union was 82 days. There were four delayed unions. There were three non-unions. The average time of revision surgery was ten months. All cases have gone onto radiographic union. 19 patients underwent a second operation to have their plates removed. Average time to plate removal was 494 days. There were two cases of re-fracture following plate removal. Conclusion. The rate of delayed and non-union following ulnar shortening osteotomy is higher in our series when compared to the literature. We also noted a higher incidence of plate removal and re-fracture through the osteotomy site. These complications are under-reported in the literature and more emphasis should be given when consent is taken for this procedure

Ulnar styloid fractures may contribute to negative outcomes after distal radius fractures due to its association with distal radioulnar (DRUJ)instability and injuries of the triangular fibrocartilaginous (TFCC) complex. This study assesses clinical outcomes of untreated ulnar styloid fractures after internal fixation of distal radius fractures. Patients undergoing operative fixation for distal radius fractures from January 2004 to June 2006 were divided into those with and without ulnar styloid fractures. The two groups were compared in terms of wrist range of motion, ulnar sided wrist pain, extensor carpi ulnaris (ECU) tendinitis, TFCC grind test, and DASH scores. Thirty-one males and 23 females aged 50.9 years(18–88 yrs, SD 16.5) were assessed. At 24 months, the presence of ulnar styloid fractures had no impact on ulnar-sided wrist pain (p=0.331), TFCC grind test(p=0.917) and distal radioulnar joint instability (p=0.957). There was a tendency towards ECU tendinitis (23.8% vs 6.1%, p= 0.058) in patients with ulnar styloid fractures. There was no significant difference in the range of motion and overall DASH scores (8.0 vs 5.9, p=0.474). No association was found between ulnar styloid fractures and DRUJ instability in this study. Ulnar styloid fractures behave like avulsion injuries. In the absence of DRUJ instability, conservative management of ulnar styloid fractures during operative treatment of distal radius fractures do not compromise clinical outcome

Forearm deformity is common in Hereditary Multiple Exostoses, for which multiple surgical treatments exist. Acute ulnar lengthening has been described in the literature, though in small numbers and not independent of adjunctive procedures. We hypothesise that acute ulnar lengthening as a primary procedure is safe and effective in correcting forearm deformity. Seventeen ulnas in 13 patients had acute ulnar lengthening for HME associated forearm deformity, over an eight-year period. Radiographic parameters were assessed and compared preoperatively and postoperatively. Mean follow-up was 27 months. Complications and revisions were noted. The mean pre-operative ulnar variance, 12.4mm (range 6.1 – 16.5), was significantly reduced post-operatively to a mean 4.6mm (p=<0.00001). A significant acute difference was achieved in carpal slip, (mean change of −2.2mm, p=0.02) but no significant change was seen with regard to radial bowing (p=0.98) or radial articular angle (p=0.74). There were three episodes of recurrence requiring revision. There were no major complications. Significant radiographic improvements in forearm and wrist alignment were seen with acute ulnar lengthening. Complications were infrequent. Recurrence rates in the skeletally immature patients are comparable to that reported with gradual lengthening techniques. Acute ulnar lengthening for forearm deformity associated with HME, has been demonstrated to be a safe, reproducible and effective surgical procedure

An anatomical cadaver dissection was used to compare two approaches to the volar aspect of the distal radius. The traditional approach between flexor carpi radialis and the radial artery limits the exposure of the ulnar aspect distal radius. In the trauma setting, it is difficult to perform a carpal tunnel release whilst protecting the palmar branch of the median nerve and gain sufficient exposure of the volar ulnar fragments and the DRUJ. An extensile ulnar sided approach to the distal radius is described which permits wide exposure of the volar aspect of the distal radius including the DRUJ and radial styloid. This exposure utilises the plane between flexor carpi ulnaris/ulnar neurovascular bundle and flexor digitorum profundus. It permits easy and safe release of the carpal tunnel and Guyon’s canal. Its use in the trauma and post traumatic setting will be shown with intra-operative pictures

Negative ulnar variance, lunate shape and increased load transmission are associated with Kienbock’s disease. This may reflect trabecular alignment being more susceptible to shear forces along “fault planes” in Type 1 lunates, causing microfractures and avascular necrosis. The aim of this study was to assess the relationship between lunate bone structure, density and ulnar variance. Standard 90/90 radiographs of 22 cadaveric wrists were taken for ulnar variance and lunate shape. The lunates were harvested and routine CT scans (1mm) were taken in 22/22 in the coronal, sagittal and transverse planes. DICOM files were analysed using Mimics (Materialise, Belgium) to measure Hounsfield units. MicroCT scans (SkyScan, Belgium) (40 μm) were taken in 10/22 in the coronal plane and measured for trabecular angle at the proximal and distal joint surfaces and the ‘tilting angle’ (between scaphoid and radius joint surfaces). Data was anlaysed using one-way ANOVA tests using SPSS for Windows. Negative ulnar variance was noted in 7/22, neutral 10/22 and positive 5/22. Lunate shape according to Zapico was 0/22 Type 1, 18/22 Type 2 and 4/22 Type 3. Lunate bone density was significantly lower in the ulnar positive specimens compared to ulnar negative and neutral (p< 0.001) (fig. 1). The average trabecular angle measured 84.7° (+/− 4.5°) at the proximal and 90.3° (+/− 2.6°) at the distal joint surfaces and tilting angle was 115.7° (+/− 12.0°) (fig. 2). The 50% slice on the microCT correlated best with xray measurements of this angle. This study quantifies the previous finding that load transmission through the lunate and hence lunate bone density is related to ulnar variance and that this is higher in ulnar negative wrists. MicroCT is a useful modality to assess trabecular structure and supports the ‘fault plane’ hypothesis of Kienbock’s Disease

We performed a new operation for ulnar neuropathy caused by recurrent dislocation at the medial epicondyle. There were eleven patients, eight men and three women, with an average age of 52 years (24–74 years) at the time of surgery. The mean duration of symptoms was 23 months. The severity of the symptoms was McGowan grade 1 in five patients, grade 2 in five patients, and grade 3 in one patient. The operation consisted of ulnar groove plasty proximal to the cubital tunnel. The ulnar nerve was replaced into this reconstructed groove. The nerve was confirmed to be stable throughout the full range of elbow motion. The cubital tunnel retinaculum of all patients was hypoplastic and the dislocated portion of the ulnar nerves was hard. One nerve showed severe adhesion around the dislocation site. One patient had a pseudo-neuroma. All patients were relieved of discomfort, and motor and sensory function were recovered. The ulnar nerve in the groove showed neither irritation nor adhesion. In patients with grade 1, symptoms or numbness of the fingers was relieved within three months of the operation. Sensory disturbances in patients with grade 2 symptoms also improved within six months. Grade 2 patients with intrinsic muscle weakness regained normal muscular power, and these with patients with intrinsic muscle atrophy had showed increasing muscular power. The patient with grade 3 symptomes recovered normal sensation after 1 year; clawing of the ring and little fin-gers recovered, and the muscle volume was increased. Friction ulnar neuropathy has been treated traditionally by anterior transpositon or medial epicondylectomy. The ulnar nerve may become entrapped in scar tissue after these operations. We believe that this anatomical position is optimum for the nerve and that this procedure is essential for treatment of friction neuropathy

Introduction: Ulnocarpale Impaction Syndrom is defined as a degenerative disease on the basis of a relative mis-proportion in lenghth ratio between ulnar and radius, caused either by posttraumatic degeneration or idiopathic history. This causes an unusual high load bearing in the ulnar carpale joint as well as in the distal radio – ulnar joint. All these factors lead to a degeneration of the triangular discus, secondary lunotriqutral instability and chondromalazia of ulna, lunate bone and the triquetral bone. Ulnocarpale Impaction Syndrom is diagnosed by clinical evaluation as well as typical radiologic findings. If non operative treatment leads to unsatisfactory results few operative options can be considered. Ulnar shortening osteotomy is one of them. Material and Methods: From 2003 until 2006, 10 Patients were treated. 3 female patients and 7 male patients, with an average age of 46 years and/or 42,7 years were operated on. We evaluated forearm rotation, power, DASH Score, Numeral Analogue scale and radiologic findings considering ulnar lenghth and bone consolidation. Results: Painfree forearm rotation increased significantly postoperatively. An increase in power was seen as well as a reduction of the DASH score of 51,6 points. Also the numeral analogue scale showed a reduction of 5 points. Postoperatively the ratio of ulnar to radial lenghth was nearly equal (average of ulnar -1mm) and all osteotomies showed normal bony healing. Conclussion: Surgical therapy of painful ulnar impaction syndrom using ulnar shortening osteotomy seems to be a very feasible and practical procedure. In comparison to resection arthroplasty and the wafer procedure, ulnar shortening osteotomy shows no significant increase of pressure in the sigmoid fossa. Therefor it is the treatment of joice in our departement

Introduction and purpose: The ulnar carpal impaction syndrome (UCIS) is a common cause of pain in the ulnar aspect of the wrist. It has numerous causes, although most cases are due to rupture of the triangular fibrocartilaginous complex (TFC), either traumatic or degenerative. Materials and methods: We carried out a prospective study of the results of ulnar shortening osteotomy in 41 wrists. The osteotomy (transverse) was performed in the middle third of the ulnar and the shortening ranged from 3 to 10 mm. For stabilisation we used a 3.5-mm AO LC-DCP and LCP plate. Minimum follow-up was 6 months and maxim was 8 years. Results: The mean age was 37; there were 28 women and 12 men. The ulnar variance ranged from 5 mm positive to 2 mm negative. All the wrists had Tolat type I or II distal radioulnar morphology. Pain and pain frequency were reduced to levels below surgical indication in 89% of cases within 2 and 4 months after the operation. All the ulnae consolidated satisfactorily between 12 and 14 weeks, except for one case of pseudoarthrosis, which was treated with an iliac crest graft and further bone synthesis. Conclusions: The results obtained in this series reveal adequate progression of wrist pain and function in patients treated for UCIS by ulnar shortening. There were very few complications and revisions

Introduction. Ulnar nerve entrapment is the second most common nerve entrapment syndrome of the upper extremity. Despite this, only a few studies have assessed the outcome of ulnar nerve decompression. The objectives of the study were to review the pre-operative symptoms, nerve conduction studies, the co-morbidities, operative procedures undertaken and the post-operative outcomes; and investigate and ascertain prognostic factors particularly in cases of persistence of symptoms after the surgery. Methods. We reviewed the case notes of ulnar nerve decompressions surgery performed over a period of six year period. A structured proforma was created to document the demographics, patient complaints, method of decompression, per-operative findings and symptom status at the last follow up. Outcome grading was recorded as completely relieved, improved, unchanged or worse. Analysis of data was carried out using the SPSS software (Version 16.0; Illinois). The significance level was set at 5%. Results. 136 ulnar nerve decompressions formed the study group. Minimum follow-up was three months. Numbness and paresthesia in ulnar distribution were the two most common presenting symptoms (96%). The cause of compression was identified as idiopathic in 58.2%; flexor carpi ulnaris aponeurosis in 36.7% and Arcade of Stuthers in 5.1% extremities. The outcome was satisfactory in 85.2% of patients. No obvious association was demonstrated between the outcome of surgery and duration of symptoms, presence of co-morbidities or the type of surgery performed. Interestingly out of 12 patients who got worse or had no improvement, nine (75%) had either normal nerve conduction studies or none done pre-operatively. Conclusion. This is the largest review of outcomes after ulnar nerve decompressions at elbow. The study showed that good results (85.2%) of ulnar nerve decompression at elbow in majority of patients regardless of level of surgeon's experience or procedure undertaken

A 55-year-old woman who was diagnosed as RA (stage, class ) in 1995 had undergone right total elbow arthroplasty (TEA) in October 2006. We implanted her prosthesis FINE ELBOW. ®. (Nakashima Medical, Japan). Prosthesis of the humerus side is made of Co-Cr-Mo, and the ulna side is of polyethylene. Radius side is metal back system which inserts a polyethylene joint part in metal holder made by Co-Cr-Mo. All components were fixed by cement. She complained her right elbow uncomfortable gradually from January 2008. X-ray radiograph showed loosening of the ulnar component. So we performed revision surgery using ulnar revision sack in May 2008. This ulnar component had only a product made in polyethylene and we inserted the component of the product made in the polyethylene in a metal sack. The operation was successed and now she does housework. We think that strength is not worthy of the ulnar component made by polyethylene in TEA for the patient with terrible joint destruction and high daily activity patient of rheumatoid arthritis

Introduction. The main postoperative complications in fixation of ulna shaft fractures are non-union and implant irritation using currently recommended 3.5-mm locking compression plates. An alternative approach using a combination of two smaller plates in orthogonal configuration has been proposed. The aim of this study was to compare the biomechanical properties of a single 3.5-mm locking compression plate versus double plating using one 2.5-mm and one 2.0-mm mandible plate in a human ulna shaft fracture model. Method. Eight pairs human ulnar specimens with a standardized 10-mm fracture gap were pairwise assigned for instrumentation with either a single 3.5-mm plate placed posteriorly, or for double plating using a 2.5-mm and a 2.0-mm mandible plate placed posteriorly under the flexor muscles and laterally under the extensor muscles. All constructs were initially non-destructively biomechanically tested in axial compression, torsion, and bending, which was followed by cyclic torsional loading to failure. Interfragmentary movements were monitored by means of optical motion tracking. Result. There were no significant differences between the two plating techniques for axial stiffness (p=0.335), torsional stiffness in supination (p=0.462), torsional stiffness in pronation (p=0.307), medio-lateral bending stiffness (p=0.522), and antero-posterior bending stiffness (p=0.143). During cyclic torsional loading over the first 3000 cycles, there were no significant differences between the two plating techniques for shear displacement across the fracture gap, p=0.324. The numbers of cycles until clinically relevant failure of 5° angular deformation were 1366±685 for double plating and 2024±958 for single plating, which was statistically non-significantly different, p>0.05. The constructs treated with both plating techniques failed due to bone breakage at the most distal screw. Conclusion. From a biomechanical perspective double plating of ulna shaft fractures using a 2.5-mm and a 2.0-mm locking mandible plate demonstrated equivalent fixation strength as conventional plating using a single 3.5-mm locking compression plate

Purpose: Loosening remains a problem with semi-constrained total elbow prostheses. The trend in recent years has been to improve prosthesis design to achieve stability of the humeral implant. We report a small series of nine Coonrad-Morrey total elbow prostheses where three early loosenings were observed in the ulnar implant. We attempt to analyse the causes and present a review of the recent literature. Material and methods: Nine patients, mean age 60 years, age range 57–63 years, underwent total elbow arthroplasty with a Coonrad-Morrey prosthesis for rheumatoid disease (n=5), stiff degenerative joints after trauma (n=3, flexion-extension 20°), floating joint after trauma (n=1). The posterolateral approach described by Bryan and Morrey was used for eight elbows and the posterior approach for one. Clinical and radiological results were assessed with the performance index and the Mayo clinic score respectively. Results: Mean follow-up was 3.6 years (1.5–4.7). Outcome was very good or good for seven elbows (score > 75 and > 50), fair for one (< 50) and poor for one (< 25). Three elbows were pain free, two presented pain during movement against force. Flexion was greater than 120° in four elbows (all four rheumatoid polyarthritis). Radiologically, we observed three cases of ulnar implant loosening with two type IV lucent lines, and one type III line. There was one humeral implant with a lucent line which did not change over time (type I). The two cases of type IV lines were associated with radial and anterior translation migration of the prosthetic stem with effraction or lysis of the ulnar cortical. The three ulnar loosenings appeared between the second and third postoperative year on two post-trauma stiff degenerative elbows (flexion-extension < 20°) and one rheumatoid elbow. At last follow-up, there was one poor result requiring revision surgery, one fair result, and one very good result (totally asymptomatic type 4 lucent line). Discussion: The causes of these loosenings were studied: difficult cementing technique in a tight canal, mediocre primary stability of the ulnar implant opposing the excellent fit of the humeral implant with an encased graft under the anterior wing, excessive constraint. Our results are similar to those reported by Hilebrand who had 30% evolving ulnar lucent lines and suggest that we should reserve this prosthesis for unstable elbows

The purpose of this study is to evaluate the long-term results of the surgical treatment of cubital tunnel syndrome by comparing the in-situ decompression and release of the ulnar nerve with or without partial medial epicondylectomy and the anterior transposition and release respectively. Material and Method: From 1991 since 2008, 119 patients, (81 men and 38 women) with an average age of 51(13–72 years) years were treated surgically for ulnar nerve compression at the elbow. The average duration of symptoms before surgery was 15 months (2–48 months). Preoperatively 2 patients were grade I, 52 patients were grade IIA, 31 patients were IIB and 34 were grade III according to the modified McGowan score. We performed in-situ decompression of the ulnar nerve in 35 patients, release with partial medial epicon-dylectomy in 44 patients and release with anterior transposition of the nerve in 40 patients. 17 patients were lost to follow-up. 108 patients were clinically assessed. Comparing the results among different surgical procedures, an improvement of at least one McGowan grade was obtained in 26 of 30 patients treated with simple decompression, in 29 of 35 patients treated with release and anterior transposition of the nerve and in 38 of 43 patients treated with release and medial epicondylectomy. The results of this study show that the possibility for complete recovery is inversely related to the initial neuropathy grade. Partial medial epicondylectomy is a valuable surgical procedure for treating grade I to IIB ulnar neuropathy because is an anatomic method with minimal nerve manipulation preserving regional blood supply