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

Post-traumatic elbow stiffness is a disabling condition that remains challenging for upper limb surgeons. Open elbow arthrolysis is commonly used for the treatment of stiff elbow when conservative therapy has failed. Multiple questions commonly arise from surgeons who deal with this disease. These include whether the patient has post-traumatic stiff elbow, how to evaluate the problem, when surgery is appropriate, how to perform an excellent arthrolysis, what the optimal postoperative rehabilitation is, and how to prevent or reduce the incidence of complications. Following these questions, this review provides an update and overview of post-traumatic elbow stiffness with respect to the diagnosis, preoperative evaluation, arthrolysis strategies, postoperative rehabilitation, and prevention of complications, aiming to provide a complete diagnosis and treatment path. Cite this article: Bone Joint Open 2020;1-9:576–584

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. Methods. All TEAs recorded in the Dutch national registry between 2014 and 2020 were included. The Kaplan-Meier method was used for survival analysis, and a logistic regression model was used to assess the factors associated with revision. Results. A total of 514 TEAs were included, of which 35 were revised. The five-year implant survival was 91%. Male sex, a higher BMI, and previous surgery to the same elbow showed a statistically significant association with revision (p < 0.036). Of the 35 revised implants, ten (29%) underwent a second revision. Conclusion. This study reports a five-year implant survival of TEA of 91%. Patient factors associated with revision are defined and can be used to optimize informed consent and shared decision-making. There was a high rate of secondary revisions. Cite this article: Bone Jt Open 2023;4(2):110–119

Hinged elbow orthoses (HEO) are often used to allow protected motion of the unstable elbow. However, biomechanical studies have not shown HEO to improve the stability of a lateral collateral ligament (LCL) deficient elbow. This lack of effectiveness may be due to the straight hinge of current HEO designs which do not account for the native carrying angle of the elbow. The aim of this study was to determine the effectiveness of a custom-designed HEO with adjustable valgus angulation on stabilizing the LCL deficient elbow. Eight cadaveric upper extremities were mounted in an elbow motion simulator in the varus position. An LCL injured (LCLI) model was created by sectioning of the common extensor origin, and the LCL. The adjustable HEO was secured to the arm and its effect with 0°, 10°, and 20° (BR00, BR10, BR20) of valgus angulation was investigated. Varus-valgus angles and ulnohumeral rotations were recorded using an electromagnetic tracking system during simulated active elbow flexion with the forearm pronated and supinated. We examined 5 elbow states, intact, LCLI, BR00, BR10, BR20. There were significant differences in varus and ER angulation between different elbow states with the forearm both pronated and supinated (P=0 for all). The LCLI state with or without the brace resulted in significant increases in varus angulation and ER of the ulnohumeral articulation compared to the intact state (P 0.05). The difference between each of the brace angles and the LCLI state ranged from 1.1° to 2.4° for varus angulation and 0.5° to 1.6° for ER. Although there was a trend toward decreasing varus and external rotation angulation of the ulnohumeral articulation with the application of this adjustable HEO, none of the brace angles examined in this biomechanical investigation was able to fully restore the stability of the LCL deficient elbow. This lack of stabilizing effect may be due to the weight of the brace exerting unintentional varus and torsional forces on the unstable elbow. Previous investigations have shown that the varus arm position is highly unstable in the LCL deficient elbow. Our results demonstrate that application of an HEO with an adjustable carrying angle does not sufficiently stabilize the LCL deficient elbow in this highly unstable position and varus arm position should continue to be avoided in the rehabilitation programs of an LCL deficient elbow

Aims. This study aimed to determine the minimal detectable change (MDC), minimal clinically important difference (MCID), and substantial clinical benefit (SCB) under distribution- and anchor-based methods for the Mayo Elbow Performance Index (MEPI) and range of movement (ROM) after open elbow arthrolysis (OEA). We also assessed the proportion of patients who achieved MCID and SCB; and identified the factors associated with achieving MCID. Methods. A cohort of 265 patients treated by OEA were included. The MEPI and ROM were evaluated at baseline and at two-year follow-up. Distribution-based MDC was calculated with confidence intervals (CIs) reflecting 80% (MDC 80), 90% (MDC 90), and 95% (MDC 95) certainty, and MCID with changes from baseline to follow-up. Anchor-based MCID (anchored to somewhat satisfied) and SCB (very satisfied) were calculated using a five-level Likert satisfaction scale. Multivariate logistic regression of factors affecting MCID achievement was performed. Results. The MDC increased substantially based on selected CIs (MDC 80, MDC 90, and MDC 95), ranging from 5.0 to 7.6 points for the MEPI, and from 8.2° to 12.5° for ROM. The MCID of the MEPI were 8.3 points under distribution-based and 12.2 points under anchor-based methods; distribution- and anchor-based MCID of ROM were 14.1° and 25.0°. The SCB of the MEPI and ROM were 17.3 points and 43.4°, respectively. The proportion of the patients who attained anchor-based MCID for the MEPI and ROM were 74.0% and 94.7%, respectively; furthermore, 64.2% and 86.8% attained SCB. Non-dominant arm (p = 0.022), higher preoperative MEPI rating (p < 0.001), and postoperative visual analogue scale pain score (p < 0.001) were independent predictors of not achieving MCID for the MEPI, while atraumatic causes (p = 0.040) and higher preoperative ROM (p = 0.005) were independent risk factors for ROM. Conclusion. In patients undergoing OEA, the MCID for the increased MEPI is 12.2 points and 25° increased ROM. The SCB is 17.3 points and 43.3°, respectively. Future studies using the MEPI and ROM to assess OEA outcomes should report not only statistical significance but also clinical importance. Cite this article: Bone Joint J 2021;103-B(2):366–372

Aims. The aim of this study was to develop and internally validate a prognostic nomogram to predict the probability of gaining a functional range of motion (ROM ≥ 120°) after open arthrolysis of the elbow in patients with post-traumatic stiffness of the elbow. Methods. We developed the Shanghai Prediction Model for Elbow Stiffness Surgical Outcome (SPESSO) based on a dataset of 551 patients who underwent open arthrolysis of the elbow in four institutions. Demographic and clinical characteristics were collected from medical records. The least absolute shrinkage and selection operator regression model was used to optimize the selection of relevant features. Multivariable logistic regression analysis was used to build the SPESSO. Its prediction performance was evaluated using the concordance index (C-index) and a calibration graph. Internal validation was conducted using bootstrapping validation. Results. BMI, the duration of stiffness, the preoperative ROM, the preoperative intensity of pain, and grade of post-traumatic osteoarthritis of the elbow were identified as predictors of outcome and incorporated to construct the nomogram. SPESSO displayed good discrimination with a C-index of 0.73 (95% confidence interval 0.64 to 0.81). A high C-index value of 0.70 could still be reached in the interval validation. The calibration graph showed good agreement between the nomogram prediction and the outcome. Conclusion. The newly developed SPESSO is a valid and convenient model which can be used to predict the outcome of open arthrolysis of the elbow. It could assist clinicians in counselling patients regarding the choice and expectations of treatment. Cite this article: Bone Joint J 2022;104-B(4):486–494

A particular pattern of complex instability of the elbow is “the terrible triad”, in which elbow dislocation is associated with fractures of the coronoid and radial head. Other frequent patterns are the variant of Monteggia lesions (Bado II) described by Jupiter which is characterized by ulnar fracture associated with fracture-dislocation of proximal radius, and the articular fracture of the distal humerus associated with elbow dislocation. The goal of treatment is to restore the primary stabilizers of the elbow such as the coronoid process, olecranon and both collateral ligaments by internal fixation and reconstruction of the ligaments. If elbow stability obtained at operation is unsatisfactory or internal fixation not enough stable, there an indication for applying a dynamic external fixator (DEF). The latter allows:. the articular congruence to be maintained and the ligaments to heal in adequate tension and position,. internal fixation and ligaments reconstruction to be protected, and. immediate joint motion to be carried out. From 2005 to 2008, we treated surgically 31 patients with complex instability of the elbow. DEF was applied in 38% of cases, namely 3 terrible triads, 5 fracture-dislocations of Monteggia and 4 articular fractures of the humerus associated with elbow dislocation. The mean age of patients was 44 years (range 30–74). All patients underwent ORIF, reconstruction of ligaments and dynamic external fixation. The OptiROM elbow fixator was used In 2 patients, the Orthofix fixator in 1 and the DJD fixator in 9. In all cases, active elbow motion was allowed without restrictions from the second postoperative day. Indomethacin was consistently administered for 5 weeks to prevent heterotopic ossifications. The DEF was removed after 6 weeks. The mean follow-up was 25 months (range 5–44 months). At last follow-up, the clinical results, evaluated according to the MEPS, were excellent in 10 patients (83%), who had had a fast recovery of range of motion (ROM). The elbow was painless in all patients and stable in all but 1. Moderate osteoarthrosis was found in 60% of cases. Complications included: 1 elbow stiffness, 1 pseudarthrosis of capitulum humeri and trochlea, 1 transitory radial nerve palsy, and 1 superficial pin tract infection. In conclusion, DEF is a helpful tool for treatment of complex elbow instability, particularly when stable internal fixation cannot be obtained or instability persists after ligaments reconstruction. However, DEF increases morbidity, and implies a longer operative time and prolonged exposure to radiation

The choice of whether to perform antegrade intramedullary nailing (IMN) or plate fixation (PF) poses a conundrum for the surgeon who must strike the balance between anatomical restoration while reducing elbow and shoulder functional impairment. Most humeral middle third shaft fractures are amenable to conservative management given the considerable acceptable deformity and anatomical compensation by patients. This study is concerned with the patient reported outcomes regarding shoulder and elbow function for IMN and PF respectively. A prospective cohort study following up all the cases treated surgically for middle third humeral fractures from 2016 to 2022 at a single centre. Telephonically an analogue pain score, an American Shoulder and Elbow Society (ASES) score for shoulder function and the Oxford Elbow score (OES) for elbow function were obtained. One hundred and three patients met the inclusion criteria. Twenty four patients participated in the study, fifteen had IMN (62.5%) and nine had PF (37.5%.). The shoulder function outcomes showed no statistical difference with an average ASES score of sixty-six for the IMN group and sixty-nine for the PF group. Women and employed individuals expressed greater functional impairment. Hand dominance has no impact on the scores of elbow and shoulder function post operatively. The impairment of abduction score post antegrade nailing was higher in the antegrade nailing group than the plated group. The OES demonstrated greater variance in elbow function in the PF group with the IMN group expressing greater elbow disfunction. This study confirms that treatment of middle third humerus shaft fractures by plate fixation is marginally superior to antegrade intramedullary nailing in preserving elbow function and abduction ability

Heterotopic ossification (HO) is a well-known complication of traumatic elbow injuries. The reported rates of post-traumatic HO formation vary from less than 5% with simple elbow dislocations, to greater than 50% in complex fracture-dislocations. Previous studies have identified fracture-dislocations, delayed surgical intervention, and terrible triad injuries as risk factors for HO formation. There is, however, a paucity of literature regarding the accuracy of diagnosing post-traumatic elbow HO. Therefore, the purpose of our study was to determine the inter-rater reliability of HO diagnosis using standard radiographs of the elbow at 52 weeks post-injury, as well as to report on the rate of mature compared with immature HO. We hypothesized inter-rater reliability would be poor among raters for HO formation. Prospectively collected data from a large clinical trial was reviewed by three independent reviewers (one senior orthopedic resident, one senior radiology resident, and one expert upper extremity orthopedic surgeon). Each reviewer examined anonymized 52-week post-injury radiographs of the elbow and recorded: 1. the presence or absence of HO, 2. the location of HO, 3. the size of the HO (in cm, if present), and 4. the maturity of the HO formation. Maturity was defined by consensus prior to image review and defined as an area of well-defined cortical and medullary bone outside the cortical borders of the humerus, ulna, or radius. Immature lesions were defined as an area of punctate calcification with an ill-defined cloud-like density outside the cortical borders of the humerus, ulna or radius. Data were collected using a standardized online data collection form (CognizantMD, Toronto, ON, CA). Inter-rater reliability was calculated using Fleiss’ Kappa statistic and a multivariate logistic regression analysis was performed to identify risk factors for HO formation in general, as well as mature HO at 52 weeks post injury. Statistical analysis was performed using RStudio (version1.4, RStudio, Boston, MA, USA). A total of 79 radiographs at the 52-week follow-up were reviewed (54% male, mean age 50, age SD 14, 52% operatively treated). Inter-rater reliability using Fleiss’ Kappa was k= 0.571 (p = 0.0004) indicating moderate inter-rater reliability among the three reviewers. The rate of immature HO at 52 weeks was 56%. The multivariate logistic regression analysis identified male sex as a significant risk factor for HO development (OR 5.29, 1.55-20.59 CI, p = 0.011), but not for HO maturity at 52 weeks. Age, time to surgery, and operative intervention were not found to be significant predictors for either HO formation or maturity of the lesion in this cohort. Our study demonstrates moderate inter-rater reliability in determining the presence of HO at 52 weeks post-elbow injury. There was a high rate (56%) of immature HO at 52-week follow-up. We also report the finding of male sex as a significant risk factor for post traumatic HO development. Future research directions could include investigation into possible male predominance for traumatic HO formation, as well as improving inter-rater reliability through developing a standardized and validated classification system for reporting the radiographic features of HO formation around the elbow

Aims. The aim of this study was to develop and evaluate machine-learning-based computerized adaptive tests (CATs) for the Oxford Hip Score (OHS), Oxford Knee Score (OKS), Oxford Shoulder Score (OSS), and the Oxford Elbow Score (OES) and its subscales. Methods. We developed CAT algorithms for the OHS, OKS, OSS, overall OES, and each of the OES subscales, using responses to the full-length questionnaires and a machine-learning technique called regression tree learning. The algorithms were evaluated through a series of simulation studies, in which they aimed to predict respondents’ full-length questionnaire scores from only a selection of their item responses. In each case, the total number of items used by the CAT algorithm was recorded and CAT scores were compared to full-length questionnaire scores by mean, SD, score distribution plots, Pearson’s correlation coefficient, intraclass correlation (ICC), and the Bland-Altman method. Differences between CAT scores and full-length questionnaire scores were contextualized through comparison to the instruments’ minimal clinically important difference (MCID). Results. The CAT algorithms accurately estimated 12-item questionnaire scores from between four and nine items. Scores followed a very similar distribution between CAT and full-length assessments, with the mean score difference ranging from 0.03 to 0.26 out of 48 points. Pearson’s correlation coefficient and ICC were 0.98 for each 12-item scale and 0.95 or higher for the OES subscales. In over 95% of cases, a patient’s CAT score was within five points of the full-length questionnaire score for each 12-item questionnaire. Conclusion. Oxford Hip Score, Oxford Knee Score, Oxford Shoulder Score, and Oxford Elbow Score (including separate subscale scores) CATs all markedly reduce the burden of items to be completed without sacrificing score accuracy. Cite this article: Bone Jt Open 2022;3(10):786–794

Clinical assessment of elbow deformity in children at present is mainly based on physical examination and plain X-ray images, which may be inaccurate if the elbow is not in fully supination; furthermore, the rotational deformity is even harder to be determined by such methods. Morrey suggested that the axis of rotation of the elbow joint can be simplified to a single axis. Based on such assumption, we are proposing a method to assess elbow deformity using rotational axis of the joint, and an optimized calculation algorithm is presented. The rotation axis of elbow in respective to the upper arm can be obtained from the motion tract of markers placed at the forearm. Cadaver study was done, in which three skeletal motion trackers were placed over both the anterior aspect of humerus, as well as distal ulna. Osteotomy was created at the supracondylar region of humerus through lateral approach, and the bone fragments were stabilized with a set of external skeletal fixator, leaving the soft tissue intact. The amount of deformity was created manually by adjusting the position of the distal fragment via skeletal fixator. Ultrasound 3D motion tracking system from Zebris® was used in this study, and the program was developed under the Matlab environment. Cycles of passive elbow flexion/extension motion were carried out for each set of deformity. The data were initially transformed to humerus coordinate, and since the upper arm was not absolutely stationary, its influence on the measured position of ulna was adjusted. With this adjusted data, a best fit plane that would include most of the ulna positions (MU) within a minimal distance was obtained. The rotation axis was calculated as the normal vector to this plane, and the carrying angle could subsequently be assessed according to the relationship between this axis and the x-axis on the xy-plane as well as on the xz-plane. Fresh frozen cadaver study was conducted in the Medical Simulation Center at Tzu-Chi University. After adjustment of the raw data to eliminate the influence of humerus motion, the ulna motion could be narrowed down from a band of 10mm to 3mm, with a significant smaller standard deviation. The rotation axis was obtained by the normal vector to the best fit plane. Two different approaches were attempted to find the plane. In the first method, the plane was obtained via least square method from the adjusted ulna positions, and the second method found the plane via RANSAC method. Calculations were repeated several times for each method, and the results showed a variation of 5 degrees in the first method and about 2 degrees in the second method. Rotational axis can be used to define the 3-dimensional deformity of elbow joint; however, it is difficult to obtain such axis accurately due to hypermobility and multi-directional motion of the shoulder joint. In this study, we have developed another method to assess the elbow deformity using motion analysis system instead of the conventional image studies, and this may be applicable clinically if the facility becomes more accessible in the future. (This research was supported by the project TCRD-TPE-99-30 granted by the Buddhist Tzu-Chi General Hospital, Taipei Branch)

The aim of the study is to assess the humero radial plica which could be a factor in causing lateral elbow pain. The cause of lateral elbow pain has been an enigma for the orthopaedic surgeons over the years. The synovial fold of the humeroradial joint has been well documented and considered as a meniscus between the articulation. They can also present as symptoms suggesting intra articular loose bodies causing pain in these patients. Our study included 117 consecutive elbow arthroscopies performed by two surgeons for a period of 18 months. All patients were initially treated non-operatively as a ‘tennis elbow’ before undergoing arthroscopy. Conservative treatment included rest, activity modification, physiotherapy including ultrasound bracing, nsaids and local corticosteroid injection. All patients were assessed using the Mayo clinic performance index for elbows both pre and post operatively. Radial head plica was found in 21(18%) out of 117 elbow arthroscopies and was resected using a soft tissue resector. There were 16 (76%) men and 5(24%) women in this affected group and all of whom were young and active with a mean age 38 years. Of the 21 patients 16(76%) had a post operative score of 90 or more (excellent) and 5(24%) had a score 75–89(good). This study addresses the fact that cause of lateral elbow pain can be due to various pathologies in the elbow and in the cases of ‘resistant tennis elbows’ we recommend that the existence of a radial head synovial plica should be considered and if present treatment should be directed at this. Our study demonstrates that by resecting the synovial plical fold, pain will be relieved and these patients regained elbow function. Since this was noted in the young active age group this could reduce the morbidity and the time for rehabilitation required especially for those involved in active sports. A similar series has not been cited in English literature

Aim: To assess the functional and occupational outcome of open elbow arthrolysis for post-traumatic contractures. Materials and Methods: Prospective evaluation of 60 consecutive cases (86% male,14%female) of post-traumatic extrinsic elbow stiffness. Average age was 37 years (24–48). Moderate to high physical demand at work in 96% of cases. 56% of cases involved the right side. Open arthrolysis (column procedure) trough a lateral (72%) or posterior (28%) approach followed a minimum rehabilitation period of 6 months post original injury. In 8 cases, an anterior transposition of the ulnar nerve was required. Patients received postoperative analgesia with Bupivacaine 0,0125% trough an indwelling catheter. No chemical or radiotherapy ectopic calcification prophylaxis was used. Postoperative complications, range of motion, X-ray evaluation, time to return to work, activity level and workers’ compensation were evaluated at the end of follow-up (24 months, range 12–36). Results: Complications occurred in 14% of cases. Two patients required revision surgery for ectopic calcifications restricting prono-supination. The flexo-extension (FE) arc of motion improved from 49 ° to 115 ° and that of prono-supination (PS) from 100 ° to 158 ° The results were found to be statistically significant for FE (p= 0.054) and PS (p> 0,00001). In 20% of cases, patients returned to their previous job with some restrictions (33% disability) and 12% changed to a less physically demanding occupation. Conclusions: Open arthrolysis is an effective surgical procedure to improve mobility in post-traumatic stiff elbows. It is indicated when the joint interline is preserved. Good functional and occupational outcome in a high percentage of case in the working population was observed

We have previously reported on the medium-term outcomes following a non-operative protocol of a short period of splinting followed by early movement to treat simple dislocations of the elbow. We undertook extended follow up of our original patient study group to determine whether the excellent results previously reported were maintained in the very long-term. A secondary question was to determine the rate and need for any late surgical intervention. We attempted to contact all patients in the original patient study group. Patients were requested to complete the Oxford elbow score (OES), the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire and a validated patient satisfaction questionnaire. Patients were requested to attend a face-to-face assessment where they underwent a clinical examination including neurovascular assessment, range-of-motion and an assessment of ligamentous stability. Seventy-one patients (65%) from the original patient study group agreed to participate in the study. The mean duration of follow-up was 19.3 years. At final follow-up patients reported excellent functional outcome scores and a preserved functional range of movement in the injured elbows. The mean DASH score was 5.22 points and the mean Oxford Elbow Score was 91.6 points. The mean satisfaction score was 90.9 points. Our study shows that the excellent outcomes following treatment with a protocol of a short period of splinting and early movement remain excellent and are maintained into the very long term. These findings support our hypothesis that this treatment protocol is appropriate and suitable for most patients with simple dislocations of the elbow. The role for primary ligamentous repair for this patient group should be carefully considered. Work to more clearly define the anticipated benefits of surgery for specific patient groups or injury patterns would help to support informed decision making

We undertook a prospective, single blinded, randomized, controlled trial of one hundred children treated with either an above or below elbow cast for treatment of closed, distal third forearm fractures requiring reduction. The re-manipulation rate in the below elbow group was 2% (95%CI: 0–11%) compared to 6% (95%CI: 2–15%) in the above elbow group, p=0.62. Above elbow casts do not appear to improve fracture immobilization nor reduce the requirement for re-manipulation in pediatric distal third forearm fractures. Debate exists regarding the benefits of using below elbow casts instead of above elbow casts for maintaining reduction in pediatric distal third forearm fractures. The literature indicates a loss of reduction rate of 14.6% of children treated in an above elbow cast and 2.5% in those treated with a below elbow cast. We undertook a prospective, single blinded, randomized, controlled trial of one hundred children treated with either an above or below elbow cast for treatment of closed, distal third forearm fractures requiring reduction. Outcome measures included re-manipulation rate, fracture displacement during cast wear, and cast complications. One hundred patients were suitably enrolled; fifty-four received an above elbow cast, forty-six received a below elbow cast. The two groups were similar in terms of age and gender. The above elbow group contained a higher proportion of both bone fractures (41/54) than the below elbow group (27/46). There were no significant differences between the two cast groups in initial, post-reduction or cast-off fracture angulation; nor any difference in the amount of fracture displacement during cast wear. The number of cast complications was similar between the two groups. The re-manipulation rate in the below elbow group was 2% (95%CI: 0–11%) compared to 6% (95%CI: 2–15%) in the above elbow group, p=0.62. Above elbow casts do not appear to improve fracture immobilization nor reduce the requirement for re-manipulation in pediatric distal third forearm fractures. Funding Hip Hip Hooray, Saskatoon

Objective. Neurological injuries are most common complication, which has refrained many surgeons from opting elbow arthroscopy for indicated surgeries. The objective of this study was to evaluate the safety of anterolateral (AL) and posterolateral (PL) portals and chances of injury to the radial nerve and posterior interosseous nerve around the elbow joint during elbow arthroscopy. Material & Methods. A cadaveric study was conducted on 16 non dissected cadavers (32 elbow specimens) between the period of January 2021 to June 2022. Four portals were established using 4 mm Steinmann pins which are Proximal AL Portal, Mid-AL Portal, Distal AL Portal and PL Portal. The measurements of each portal were taken for each nerve and compared with each other. Results. In our study, the mean age was 56.5 years. Proximal AL Portal was found to be at an average distance of 12.03 mm from radial nerve, 9.48 mm from the PIN and 9.35 mm from the PACN (Posterior Antebrachial Cutaneous Nerve). Distal AL Portal was at an average distance of 7.95 mm away from the radial nerve which closest to radial nerve amongst all portals. The radial nerve had the most risk of being injured out of all the nerves in the AL and PL portals followed by PIN and PACN in AL portal. Ulnar nerve was found safe in the PL portal. Conclusion. The PL portal was safer than the AL portal for conducting elbow arthroscopy. Care should be taken specially to protect radial nerve while performing elbow arthroscopy

Purpose: The purpose of this study is to evaluate the arthroscopic findings in patients who presented with persistent lateral elbow pain despite conventional conservative measures, with special regard to diagnosis specific results. The controversy regarding the etiopathogenesis, whether intraarticular, extraarticular or both continues to exist. Method: This is a retrospective review of 280 arthroscopies of elbow in 262 patients over a period of 6 years with a minimum follow-up of 6 months. All of them are therapeutic procedures involving ECRB release, excision of plica, synovectomy or debridement of the joint. The functional outcome was assessed and recorded independently by two experienced upper limb physiotherapists using the Mayo elbow performance score. Results: Dominant hand was involved in 68% of the cases. The average age was 54 years. Isolated pathology such as common extensor inflammation was identified in 138 (49%), synovial plica in 24 (8%) and degenerative changes confined to lateral compartment with normal appearance of articular cartilage of medial compartment is noted in 31 (11%). In the rest mixed pathology with various combinations were identified. Conclusion: Good to excellent results were seen in those with isolated common extensor inflammation and poor outcomes were noted in 20 (7%) of patients and the common intraoperative finding seen was degenerative changes of radiocapitellar joint. This was found to be statistically significant

Surgical debridement for medial epicondylitis (ME) is indicated for patients with refractory ME. The clinical efficacy of simple debridement has not been studied sufficiently. Moreover, authors experienced surgical outcome of ME was not as good as lateral epicondylitis. In this regard, authors have combined the atelocollagen injection in the debridement surgery of ME. The purpose of study was to compare clinical outcomes between simple debridement and debridement combined with atelocollagen injection in the ME. Twenty-five patients with refractory ME and underwent surgical debridement were included in the study. Group A (n=13) was treated with isolated debridement surgery, and group B (n=12) was treated with debridement combined with 1.0 mL of type I atelocollagen. Pain and functional improvements were assessed using visual analogue scale, Mayo Elbow Performance Score (MEPS) and quick Disabilities of the Arm, Shoulder and Hand (DASH) scale respectively before surgery, at 3, 6 months after surgery and at the final follow-up. Demographic data did not show significant difference between two groups before surgical procedures. Both groups showed improvement in pain and functional score postoperatively. However, at the 3 months after surgery, group B showed significantly better improvement as compared to group A(VAS 3.1 / 2.0, MEPS 71/82 qDASH 29/23). At the 6 months after surgery and final follow-up, both groups did not show any difference. Surgical debridement combined with atelocollagen is effective treatment option in refractory ME and showed better short-term outcomes compared to isolated surgery

The role of anconeus in elbow stability has been a long-standing debate. Anatomical and electromyographic studies have suggested a potential role as a stabilizer. However, to our knowledge, no clinical or biomechanical studies have investigated its role in improving the stability of a lateral collateral ligament (LCL) deficient elbow. Seven cadaveric upper extremities were mounted in an elbow motion simulator in the varus position. An LCL injured model was created by sectioning of the common extensor origin, and the LCL. The anconeus tendon and its aponeurosis were sutured in a Krackow fashion and tensioned to 10N and 20N through a transosseous tunnel at its origin. Varus-valgus angles and ulnohumeral rotations were recorded using an electromagnetic tracking system during simulated active elbow flexion with the forearm pronated and supinated. During active motion, the injured model resulted in a significant increase in varus angulation (5.3°±2.9°, P=.0001 pronation, 3.5°±3.4°, P=.001 supination) and external rotation (ER) (8.6°±5.8°, P=.001 pronation, 7.1°±6.1°, P=.003 supination) of the ulnohumeral articulation compared to the control state (varus angle −2.8°±3.4° pronation, −3.3°±3.2° supination, ER angle 2.1°±5.6° pronation, 1.6°±5.8° supination). Tensioning of the anconeus significantly decreased the varus angulation (−1.2°±4.5°, P=.006 for 10N in pronation, −3.9°±4°, P=.0001 for 20N in pronation, −4.3°±4°, P=.0001 for 10N in supination, −5.3°±4.2°, P=.0001 for 20N in supination) and ER angle (2.6°±4.5°, P=.008 for 10N in pronation, 0.3°±5°, P=.0001 for 20N in pronation, 0.1°±5.3°, P=.0001 for 10N in supination, −0.8°±5.3°, P=.0001 for 20N in supination) of the injured elbow. Comparing anconeus tensioning to the control state, there was no significant difference in varus-valgus angulation except with anconeus tensioning to 20N with the forearm in supination which resulted in less varus angulation (P=1 for 10N in pronation, P=.267 for 20N in pronation, P=.604 for 10N in supination, P=.030 for 20N in supination). Although there were statistically significant differences in ulnohumeral rotation between anconeus tensioning and the control state (except with anconeus tensioning to 10N with the forearm in pronation which was not significantly different), anconeus tensioning resulted in decreased external rotation angle compared to the control state (P=1 for 10N in pronation, P=.020 for 20N in pronation, P=.033 for 10N in supination, P=.001 for 20N in supination). In the highly unstable varus elbow orientation, anconeus tensioning restores the in vitro stability of an LCL deficient elbow during simulated active motion with the forearm in both pronation and supination. Interestingly, there was a significant difference in varus-valgus angulation between 20N anconeus tensioning with the forearm supinated and the control state, with less varus angulation for the anconeus tensioning which suggests that loads less than 20N is sufficient to restore varus stability during active motion with the forearm supinated. Similarly, the significant difference observed in ulnohumeral rotation between anconeus tensioning and the control state suggests that lesser degrees of anconeus tensioning would be sufficient to restore the posterolateral instability of an LCL deficient elbow. These results may have several clinical implications such as a potential role for anconeus strengthening in managing symptomatic lateral elbow instability

The December 2013 Shoulder & Elbow Roundup. 360 . looks at: Platelet-rich plasma; Arthroscopic treatment of sternoclavicular joint osteoarthritis; Synchronous arthrolysis and cuff repair; Arthroscopic arthrolysis; Regional blockade in the beach chair; Recurrent instability; Avoiding iatrogenic nerve injury in elbow arthroscopy; and Complex reconstruction of total elbow revisions