Introduction and Aims: Distal radioulnar joint surgery in the past have been dominated by different types of partial or complete ulnar head excision. However, in the long run this can create a number of problems; hence we have used Herbert modular prosthesis to tackle these very difficult situations. This prosthesis comprises of a press fit stem in three sizes and a ceramic head also available in three sizes.

Method: In Wrightington Hospital upper limb unit, 61 patients underwent Herbert ulnar head replacement. Fifty-eight were clinically and radiologically reviewed. This is the largest series from a single centre of this type of surgery.

Between December 1998 and December 2002, 21 male and 27 female patients were operated. The mean age was 49.8 (range 28–72 years). Twenty-two left, eighteen right and two bilateral replacements were performed. The mean follow-up was 20.02 months (range 3–60 months).

An independent observer, using range of motion, grip strength and satisfaction as outcome, reviewed all patients.

Results: Primary diagnoses included failed Darrach, Bower, Sauve Kapandji and traumatic ulnar head excision. Forty-five patients were satisfied with the outcome. Pain score showed a mean improvement of four, with a range of 0–10. The grip strength compared to normal side was decreased in 50% of the patients. The range of motion compared to normal side improved by a mean of 10 degrees (range 3–20) in supination and 13 (range 4–23) in pronation.

Conclusion: Radiological review showed new bone (eight) and notch formation (nine). Stress shielding of 0–19mm was observed in distal ulna with revision or emergency stem. Complication occurred in eight patients: instability (four), RSD (one), implant failure (one) and two others. Twelve patients required further surgery. No loosening was observed at revision. There are no long-term results available at present.

This study describes percutaneous method of tennis elbow release and medium term results.

Materials and Methods: Eighteen patients (20 elbows) were reviewed following percutaneous tennis elbow release. All patients in this series underwent non-operative management with limited or no relief prior to surgery. The mean duration of treatment was 34.04 months prior to surgery. A percutaneous release of common extensor origin was performed under local anaesthetic. A small 1 cm skin incision was employed in all cases. Mean follow- up was 73 months with a range of 8–121 months. All patients except returned to work and normal level of activity. There was one poor result. The mean time to return to work was 5 weeks, with a range of 1 day –12 weeks. Thirteen patients (fifteen elbows) have been clinically examined. Five patients were contacted by phone.

Results: Pain after surgery was evaluated with a visual analogue scale. Eighteen elbows (90% of cases) had an excellent result. Pain was rated at zero in seventeen cases. One case rated at zero at rest and two after heavy activity. One elbow (5%) had a good result with pain at zero at rest and raising four on the visual analogue scale after sporting activities (playing tennis for more than one hour). There was no improvement in one case (5%) with a visual analogue score of eight before and after surgery. There were no complications recorded. These results prove that percutaneous elbow release is a viable option in treatment of failed conservative tennis elbow management though astringent selection criteria should be observed.

This novel modification of the posterior approach allows a low hazard exposure and easier surgery to the radial head.

Methods and Materials: The most commonly used approaches are from the lateral aspect. The limitations of this approach in particular for radial head replacement is that it is a tight exposure, there is a risk of damage to the posterior interosseous nerve and there is always a difficulty in dislocation due to the presence of the interosseous membrane. The posterolateral approach to the proximal radius and ulna was described by Boyd, Gordon and Thompson. This approach avoids damage to the posterior interosseous nerve but the annular ligament requires incision and repair.

Approach: Position the forearm in pronation aligning the ulnar styloid with lateral epicondyle of the humerus. A tencentimetre long incision is then made on the lateral border of the ulna exposing deep fascia. Following this a 1cm flap of fascia is left on the ulna and anconeus is lifted off the bone. This exposes underlying radial head, annular ligament and interosseous membrane. After identifying the ulnar insertion of annular ligament a 0.5 cm bone is osteotomised with annular ligament attached from the supinator tuberosity. The radial head osteotomy is performed with the radial head in pronation to align it with shaft of radius using specially designed jig. Osteotomy of the radial head has to be at right angles to the axis of the forearm. This is a line between centre of the radial neck to the ulnar styloid process. Radial head can now be subluxed out of the wound and preparing for a replacement. The trial prosthetic radial head is then inserted and reduced. The bone fragment with annular ligament attachment is then reduced back into the original slot. This allows one to judge the size of prosthetic radial head if ligament is too tight a small diameter implant is required. The bone fragment is reattached using especially devised washer with, wire holes and a 2mm AO screw.

Results: This approach is easier, safer and reproducible. When compared to lateral approach it provides an easier access and excellent stability in radial head replacement. We recommend this approach for radial head replacements and difficult trauma cases.