We report the effectiveness of revision of total elbow replacement by re-cementing. Between 1982 and 2004, 53 elbows in 52 patients were treated with re-cementing of a total elbow replacement into part or all of the existing cement mantle or into the debrided host-bone interface, without the use of structural bone augmentation or a custom prosthesis. The original implant revision was still in situ and functional in 42 of 53 elbows (79%) at a mean of 94.5 months (26 to 266) after surgery. In 31 of these 42 elbows (74%) the Mayo Elbow Performance Score was good or excellent. Overall, of the 53 elbows, 18 (34%) required re-operation, ten (19%) for loosening. A classification system was developed to identify those not suitable for revision by this technique, and using this we have showed that successful re-implantation is statistically correlated to properly addressing the bone deficiency for both the humeral (p = 0.005) and the ulnar (p = 0.039) components.

Aims. For paediatric and adolescent patients with growth potential, preservation of the physiological joint by transepiphyseal resection (TER) of the femur confers definite advantages over arthroplasty procedures. We hypothesized that the extent of the tumour and changes in its extent after neoadjuvant chemotherapy are essential factors in the selection of this procedure, and can be assessed with MRI. The oncological and functional outcomes of the procedure were reviewed to confirm its safety and efficacy. Methods. We retrospectively reviewed 16 patients (seven male and nine female, mean age 12.2 years (7 to 16)) with osteosarcoma of the knee who had been treated by TER. We evaluated the MRI scans before and after neoadjuvant chemotherapy for all patients to assess the extent of the disease and the response to treatment. Results. The mean follow-up period was 64.3 months (25 to 148) after surgery and no patients were lost to follow-up. On MRI evaluation, 13 tumours were near but not in contact with the physes and three tumours were partially in contact with the physes before neoadjuvant chemotherapy. Bone oedema in the epiphysis was observed in eight patients. After neoadjuvant chemotherapy, bone oedema in the epiphysis disappeared in all patients. In total, 11 tumours were not in contact and five tumours were in partial contact with the physes. The postoperative pathological margin was negative in all patients. At the last follow-up, 12 patients were continuously disease-free and three had no evidence of disease. One patient died due to the disease. Functionally, the patients with retained allograft or recycled autograft had a mean knee range of flexion of 126° (90° to 150°). The mean Musculoskeletal Tumor Society functional score was 27.6 (23 to 30). Conclusion. TER is an effective limb-salvage technique for treating malignant metaphyseal bone tumours in paediatric and young osteosarcoma patients with open physes when a good response to chemotherapy and no progression of the tumour to the epiphysis have been confirmed by MRI. Cite this article: Bone Joint J 2020;102-B(6):772–778

Introduction. The interaction between the mobile components of total elbow replacements (TER) provides additional constraint to the elbow motion. Semi-constrained TER depend on a mechanical linkage to avoid dislocation and have greater constraint than unconstrained TER that rely primarily in soft tissue for joint stability. Greater constraint increases the load transfer to the implant interfaces and the stresses in the polyethylene components. Both of these phenomena are detrimental to the longevity of TER, as they may result in implant loosening and increased damage to the polyethylene components, respectively[1]. The objective of this work was to compare the constraint profile in varus-valgus and internal-external rotation and the polyethylene stresses under loads from a common daily activity between two semi-constrained TER, Coonrad/Morrey (Zimmer-Biomet) and Discovery® (DJO), and an unconstrained TER, TEMA (LimaCorporate). Methods. We developed finite element (FE) models of the three TER mechanisms. To reduce computational cost, we did not include the humeral and ulnar stems. Materials were linear-elastic for the metallic components (E. Ti6Al4V. =114.3 GPa, E. CoCr. =210 GPa, v=0.33) and linear elastic-plastic for the polyethylene components (E=618 MPa, v=0.46; S. Y. =22 MPa; S. U. =230.6 MPa; ε. U. =1.5 mm/mm). The models were meshed with linear tetrahedral elements of sizes 0.4–0.6 mm. We assumed a friction coefficient of 0.02 between metal and polyethylene. In all simulations, the ulnar component was fixed and the humeral component loaded. We computed the constraint profiles in full extension by simulating each mechanism from 8° varus to 8° valgus and from 8° internal to 8° external rotation. All other degrees-of-freedom except for flexion extension were unconstrained. Then, we identified the instant during feeding that generated the highest moments at the elbow[2], and we applied the joint forces and moments to each TER to evaluate the stresses in the polyethylene. To validate the FE results, we experimentally evaluated the constraint of the design with highest polyethylene stresses in pure internal-external rotation and compared the results against those from a FE model that reproduced the experimental setup (Fig.1-a). Results. For each design, the constraint profiles in varus-valgus (Fig.2-a) were similar to internal-external rotation (Fig.2-b). All designs showed a lax zone in which the mechanisms rotated freely and an engagement zone in which the mobile components contacted, resulting in load transfer. The laxity of the Coonrad/Morrey and the Discovery® was similar and lower than that of the TEMA. After engagement, the stiffness of the TEMA was less than that of the Discovery® and the Coonrad/Morrey. The TEMA showed the lowest polyethylene stresses of all three designs under demanding loads during feeding. Only Discovery® and Coonrad/Morrey had zones reaching permanent deformation (Fig.3). For the Coonrad/Morrey, with the highest polyethylene stresses, the experimental and computational constraint profiles were similar (Fig.1-b). Discussion. The TEMA unconstrained design transferred less moment than semi-constrained designs, reducing the burden on the implant interfaces. Moreover, the TEMA design had lower stresses in the polyethylene components due to the combination of less constraint and a lack of sharp edges on the articular surfaces. For any figures or tables, please contact the authors directly

Treatment of an infected total elbow replacement (TER) is often successful in eradicating or suppressing the infection. However, the extensor mechanism may be compromised by both the infection and the surgery. The goal of this study was to assess triceps function in patients treated for deep infection complicating a TER. Between 1976 and 2007 a total of 217 TERs in 207 patients were treated for infection of a TER at our institution. Superficial infections and those that underwent resection arthroplasty were excluded, leaving 93 TERs. Triceps function was assessed by examination and a questionnaire. Outcome was measured using the Mayo Elbow Performance Score (MEPS). Triceps weakness was identified in 51 TERs (49 patients, 55%). At a mean follow-up of five years (0.8 to 34), the extensor mechanism was intact in 13 patients, with the remaining 38 having bone or soft-tissue loss. The mean MEPS was 70 points (5 to 100), with a mean functional score of 18 (0 to 25) of a possible 25 points. Infection following TER can often be eradicated; however, triceps weakness occurs in more than half of the patients and may represent a major functional problem. Cite this article: Bone Joint J 2014;96-B:82–7

Summary Statement. Discovery system produced effective functional improvement in both primary and revision total elbow replacement. The incidence of major complications was in an acceptable range. Introduction. The search for the ideal elbow prosthesis continues as instability and loosening remain the prime reasons for total elbow replacement (TER) failure. The Discovery Elbow System (Biomet) is one of the latest generations of linked prosthesis and has been used in UK since 2003. We report outcome of TER using this system. Methods. A total of 100 TERs (75 primary, 25 revisions) were performed between 2003 and 2010. The main primary underlying pathologies for TER were advanced rheumatoid arthritis (N=58), osteoarthritis (N=35), acute fractures (N=7). There were 60 female and 40 male patients with an average age of 62 years. The outcome assessment included pain, patient satisfaction, Liverpool Elbow Score (LES), range of movement, and imaging during a mean follow-up period of 48.5 months. Major complications are also reported. Results. For the whole patient group (primary + revision), the LES was significantly (p<0.001) improved from 3.79+/−1.71 to 6.36+/−1.85There were significant improvements in elbow flexion from 100°+/−24 to 118°+17, supination from 38°+/−26 to 50°+/−25 and pronation from 48°+/−22 to 61°+/−21. Mean improvement in flexion-extension and pronation-supination arc was 20° and 25°, respectively. 64% of cases were completely pain-free and at the final follow-up (compared to 7% preoperatively). Only 6% of patients scored “Not Satisfied” at the final follow-up. LES improvement was significantly higher in the primary TER compared to revision TER (p<0.05). Imaging reviewed for 60 cases showed loosening in 4% of patients. Other main complications included deep infection (N=2), ulnar neuropathy (N=3), pre-prosthetic fracture (N=2), and prosthetic failure (N=1). Discussion. TER using the Discovery Elbow System is an effective arthroplasty in terms of functional improvement, pain relief and range of motion in both primary and revision patients. TER resulted in no/mild pain in 78% of cases. Patients undergoing Acclaim, Souter-Strathclyde, GSB III, and Coonrad-Morrey TER have been reported to have no/mild pain in 64%, 67%, 50–92% and 60–100% of cases, respectively. A 20° improvement in flexion-extension arc is comparable to that of Acclaim (23°), Souter-Strathclyde (15°), GSBIII (19–33°), and Coonrad-Morrey (17–26°) TER. An improvement of 25° in pronation-supination arc in our series is also comparable to that of 21–28° reported the Coonrad-Morrey and 27–33° for Discovery prostheses. An infection rate of 2% is lower than several other reports for GSB III TER (7–11%) and Coonrad-Morrey (6–8%). The incidence of persistent ulnar neuropathy (3%) was lower compared to GSBIII TER (11–14%), Coonrad-Morrey (12–26%), and Acclaim (8%)

As a treatment for end-stage elbow joint arthritis, total elbow replacement (TER) results in joint motions similar to the intact joint; however, bearing wear, excessive deformations and/or early fracture may necessitate early revision of failed implant components. Compared to hips, knees and shoulders, very little research has been focused on the evaluation of the outcomes of TER, possible failure mechanisms and the development of optimal designs. The current study aims to develop computational models of TER implants in order to analyze implant behaviour; considering contact stresses, plastic deformations and damage progression. A geometrical model of a TER assembly was developed based on measurements from a Coonrad-Morrey TER implant (Zimmer, Inc., Warsaw, IN). Ultra high molecular weight polyethylene (UHMWPE) nonlinear elasto-plastic material properties were assigned to the humeral and ulnar bushings. A frictional penalty contact formulation with a coefficient of friction of 0.04 was defined between all of the surfaces of the model to take into account every possible interaction between different implant components in vivo. The loading scenario applied to the model includes a flexion-extension motion, a joint force reaction with variable magnitude and direction and a time varying varus-valgus (VV) moment with a maximum magnitude of 13 N.m, simulating a chair-rise scenario as an extreme loading condition. An explicit dynamic finite element solver was used (ABAQUS Explicit, Dassault Systèmes, Vélizy-Villacoublay, France), due to improved capabilities when performing large deformation analyses. Model results were compared directly with corresponding experimental data. Experimental wear tests were performed on the abovementioned implants using a VIVO (AMTI, Watertown, MA) six degree-of-freedom (6-DOF) joint motion simulator apparatus. The worn TER bushings were scanned after the test using micro computed tomography (µCT) imaging techniques, and reconstructed as 3D models. Comparisons were made based on the sites of damage and deformed geometries between the numerical results and experimental test data. In addition to that, parametric geometrical models were developed using worn geometry of the retrievals in order to account for primary wear and deformations while simulating long-term contact stress and secondary damage progression on the bushings (Fig. 1). Contact pressure distributions on the humeral and ulnar bushings correlate with the sites of damage as represented by the µCT data and gross observation of clinical retrievals. Furthermore, deformation patterns and kinematics of the components are in good agreement with the experimental results (Fig.2). Excessive plastic deformations are evident in both the numerical and the experimental results close to the regions with high contact pressures. Simulating parametric initially-worn geometries results in the formation of secondary damage zones, as well as redistribution of contact stresses and contact locations (Fig. 3). The results demonstrate UHMWPE bushing damage due to different loading protocols. Numerical results demonstrate strong agreement with experimental data based on the location of deformation and creep on bushings and exhibit promising capabilities for predicting the damage and failure mechanisms of TER implants. For figures/tables, please contact authors directly.

Background. The quest for the perfectly designed elbow prosthesis continues as instability and loosening remain the foremost reasons for the failure of total elbow replacement (TER). The Discovery® Elbow System (Biomet, UK) (Figure 1), which has been used in UK since 2003, is one of the latest generations of linked prosthesis. This system was designed to decrease polyethylene-bushing wear, improve anatomic stem design, restore elbow joint biomechanics, and produce a hinge that could be easily revised. This report describes the short term outcome of TER using the Discovery® Elbow System. Patients and Methods. A total of 60 TERs including 48 primary and 12 revisions were performed between 2003 and 2008. Patients included 21 males (37%) and 36 females (63%) with a mean age of 63 years. The indications for primary TER were advanced rheumatoid arthritis (n=19), osteoarthritis (n=16), post traumatic osteoarthritis (n=9), acute fractures (n=3), and haemophilic arthropathy (n=1). The outcome was assessed using pain score, Liverpool Elbow Score (LES), and range of movement during a mean follow-up of 26 months. Associated complications were documented. Radiological assessment included evaluation for loosening, instability and periprosthetic fractures. Results. The mean LES was significantly (p<0.001) improved from 3.8 (±1) pre-operatively to 6.9 (±2) at the final follow- up. Significant improvements were noted in elbow flexion from 100° (±22) to 120° (±15), supination from 41° (±28) to 65° (±20) and pronation from 52° (±22) to 72° (±18). There was no significant change in elbow extension. Mean improvement in flexion-extension and pronation-supination arc was 22° and 44°, respectively. 46 cases (77%) were completely pain-free at the final follow-up. The main complications included deep infection (4 cases – treated with staged revision TER), postoperative ulnar neuropathy (3 cases–treated with decompression), intra-operative fractures of medial condyle (3 cases – treated non-operatively with brace), and elbow haemarthrosis (1 case). Discussion. TER with Discovery® Elbow System resulted in either no pain or mild pain in 87% of cases. Patients undergoing Acclaim, Souter-Strathclyde, GSB III, and Coonrad-Morrey TER have been reported to have no/mild pain in 64%, 67%, 50–92% and 60–100% of cases, respectively. A 22° improvement in flexion-extension arc is comparable to that of Acclaim (23°), Souter-Strathclyde (15°), GSB III (19–33°), and Coonrad-Morrey (17–26°) TER. An improvement of 44° in pronation-supination arc in our series is also comparable to that of 31–67° reported for GSB III and higher than the Coonrad-Morrey prosthesis (21–28°). In terms of complications, an infection rate of 6.7% is consistent with those reported for GSB III TER (7–11%) and Coonrad-Morrey (6–8%). The incidence of persistent ulnar neuropathy was lower compared to GSB III TER (11–14%), Coonrad-Morrey (12–26%), and Acclaim (8%). While the survival of Discovery TER was 93%, the survival of GSB III (5–6 years) and Coonrad-Morrey (5 years) has been reported as 71–85% and 72–90%. The results indicate that Discovery® Elbow System is an effective device for total elbow arthroplasty in terms of functional improvement, pain relief and range of motion at short-term follow-up

Purpose of study:. Total elbow replacement (TER) is one of the surgical options for treatment of severe haemophilic arthropathy of the elbow. There are only a few small series described in the literature. The goal of our study was to evaluate our cases and add these data to the known literature. Methods:. A retrospective analysis of a series of 8 TER's (5 patients) was performed. Patients were seen in clinic and evaluated by physical examination, a VAS score for pain, the Mayo Elbow Performance Score (MEPS, 100 points=excellent) and X-rays of the affected elbow. Mean follow-up was 91 (4–236) months, and 103 months when we excluded a patient with only 4 months follow-up. Primary diagnosis was Hemophilia type A in 4 and von Willebrand disease in 1 patient. 2 patients were positive for Hepatitis C and 3 for HIV. Mean age at primary surgery was 46.7 (31.8–63.1) years. Results:. The mean VAS score for pain improved from 7.9 to 0.5 and the mean Mayo Elbow Performance Score from 36 to 93. The arc for flexion/extension improved from 68° to 91° and from to 75° to 153° for pro- and supination. Revision surgery was performed in 3 out of 8 TER's; 1 because of loosening of the humeral component (18.7 years postop), 1 for loosening of the ulnar component (9.9 years postoperatively) and 1 due to a late deep infection, 4 years postoperatively. The last case was treated with an excision arthroplasty, the others with a revision. No replacement currently shows signs of loosening. Conclusion:. This is a small retrospective study, as are the other studies on TER in haemophilic patients. It demonstrated excellent clinical outcome and an acceptable survival rate of a TER, with a mean follow-up of 7.6 years even in this young patient population

Of 81 elbow replacements performed over a seven-year period, 11 were total elbow revision (TER) procedures, which were done on two men and nine women with a mean age of 61 years (40 to 70). Seven of the patients had rheumatoid arthritis, three had post-traumatic osteoarthritis and one had haemophilia. The reason for revision was aseptic loosening in eight patients and aseptic loosening with fracture in the other three. The prostheses revised were the Souter in eight patients, the Kudo in one, the GSB I in one and the Dee in one. In revision TER, one long stem Souter prosthesis was used, two Pretoria, one GSB 3 and seven Morrey. The mean time from primary to revision TER was 10 years (2 to 31). At a mean follow-up of 30 months (6 to 48), all except one patient were pain-free and the arc of flexion had increased by 30°. Complications included one dislocation, one radial nerve palsy, which recovered after six months, and one aseptic loosening. There were no cases of sepsis. Revision TER is a technically demanding procedure with a high risk of complications. In this series patient satisfaction was high. Our policy is to use a hinged prosthesis, preferably the Morrey, in revision TER

TER is a viable surgical option in patients with advanced RA with painful stiff elbows. We retrospectively analysed 22 TER performed in 21 patients over a 12 year period by a single surgeon, with a mean follow up of 64 months (10–145). Disability of the arm, shoulder and hand (DASH) scores were performed pre-operatively and post-operatively in patients through postal questionnaires. The mean age was 59.1 years (32–78). There were 12 women and 9 men. The mean pre-operative DASH score was 72.3 (45.0–91.7) and post-operatively improved to 46.8 (21.7–94.2). Complications included infection, peri-operative fracture, peri-prosthetic fracture and aseptic loosening. There were 6 revisions performed, 2 for peri-prosthetic fracture, 2 for infection, 1 for intra-operative fracture and 1 for symptomatic aseptic loosening. Four patients had died due to unrelated causes. The 10 year survival rate with symptomatic aseptic loosening as the end point was 93% and revisions for all reasons was 69%. Follow up radiographs (in those without revision) were reviewed and 10 had satisfactory positioning of the prosthesis, 5 had loosening of the humeral or radial component and 1 had inadequate cement mantle but was clinically asymptomatic. TER is a rewarding procedure in with advanced RA. Our results are comparable to other published studies

Medium-term results of the Discovery elbow replacement are presented. We reviewed 51 consecutive primary Discovery total elbow replacements (TERs) implanted in 48 patients. The mean age of the patients was 69.2 years (49 to 92), there were 19 males and 32 females (37%:63%) The mean follow-up was 40.6 months (24 to 69). A total of six patients were lost to follow-up. Statistically significant improvements in range movement and Oxford Elbow Score were found (p < 0.001). Radiolucent lines were much more common in, and aseptic loosening was exclusive to, the humeral component. Kaplan–Meier survivorship at five years was 92.2% (95% CI 74.5% to 96.4%) for aseptic loosening. In four TERs, periprosthetic infection occurred resulting in failure. A statistically significant association between infection and increased BMI was found (p = 0.0268). Triceps failure was more frequent after the Mayo surgical approach and TER performed after previous trauma surgery. No failures of the implant were noted. . Our comparison shows that the Discovery has early clinical results that are similar to other semi-constrained TERs. We found continued radiological surveillance with particular focus on humeral lucency is warranted and has not previously been reported. Despite advances in the design of total elbow replacement prostheses, rates of complication remain high. Cite this article: Bone Joint J 2014;96-B:1359–65

We retrospectively analysed a single surgeon series of 22 TER in 21 patients over a 12 year period. The mean age and follow up was 59.1 years and 64 months respectively. DASH scores assessed pre and post op confirmed a significant improvement. Complications included infection, intra-operative fracture, peri-prosthetic fracture and aseptic loosening. 6 revisions were performed for various reasons.4 patients had died due to unrelated causes. The 10 year survival rate with symptomatic aseptic loosening as the end point was 93%. 5 patients had radiological loosening but were clinically asymptomatic. TER is a rewarding procedure in with advanced RA

Introduction. Primary Total Elbow Replacement (TER) is gaining popularity as a primary treatment option for osteoporotic fractures of the elbow, particularly in patients with low demand. The aim of this study was to assess the clinical and functional efficacy of TER as a primary treatment for comminuted distal humerus fractures in the elderly. Methods. We retrospectively reviewed twenty-three patients (22 females and 1 male) who were treated with primary total elbow replacement for complex, intra-articular fractures of the distal humerus in the elderly between March 2000 and January 2010. The average age of the patients was seventy-five years (ranging from 66 to 94 years). Postoperative elbow function was assessed using the Mayo Elbow Performance Score. The radiological assessment was performed using antero-posterior and lateral radiographs done at follow-up appointments. Results. The average duration of follow up was 6 years. Overall, the mean Mayo elbow performance score was 93 points out of 100. The arc of flexion averaged at 94.3degrees. One patient developed blisters at her arm postoperatively but resolved with dressings. Two patients (8.6%) had mild pain at two years post surgery but there was no evidence of implant loosening or evidence of infection. One patient developed superficial infection which was treated with antibiotics. Nineteen (82%) of the twenty-three elbows had neither a complication nor further surgery from the time of TER to the recent follow up. Conclusions. Our review suggests that total elbow replacement as a primary treatment for comminuted distal humerus fractures in the elderly can give good to excellent results both in the short and the long term basis. When osteosynthesis is not a feasible option, especially in older patients who place lower demands on the joint, total elbow replacement can be considered a the primary treatment

An inclusive classification system is required if valid comparisons are to be made between the various types of implants used for total elbow replacement (TER). The aim of the study was to consider the characteristics of the prostheses developed for TER in order to classify these into clearly defined categories. A descriptive term such as ‘surface replacement’ is unhelpful as this would embrace every design.A classification based solely upon degree of resistance to movement –‘constraint’-is untenable. ‘Constrained’ or ‘fully constrained’ accurately describes a uni-axial hinge, but the term ‘semi-constrained’ defies description. The terms ‘unconstrained’ or ‘non-constrained’ applied to a joint defy understanding. If articulating surfaces offer no resistance to movement as these terms imply, then there can be no contact between those articulating surfaces. A definable, inclusive classification can be formulated by considering the mechanical characteristics of the articulating surfaces of each design. Every design of TER can be classified into one of two broad groups, Linked or Unlinked. We define linked components as those offering resistance to distraction which includes snap-fit designs. Each of these two groups can then be sub-divided into ‘congruous’ or ‘non-congruous’ designs depending upon the shape of the articulating surfaces. This classification can therefore be summarised as: Linked Congruous – original uni-axial hinge, snap fit designs; Linked Non-congruous – ‘sloppy hinge’; Unlinked Congruous – eg. Capitellocondylar,Souter/ Strathclyde,Roper-Tuke etc; and Unlinked Non-congruous – Kudo, iBP

Cobb and Morrey (1997) reported the use of Total Elbow Replacement (TER) for patients with distal humerus fractures. In this paper, 48% of the patients had a previous history of inflammatory arthropathy. Our aim was to determine the role of TER as treatment for complex distal humeral fractures in elderly patients with no previous history of inflammatory arthropathy. These patients have greater functional demands. The complexity of the original injury was graded according to the AO Mullers’ classification of supracondylar humeral fractures. All patients were reviewed clinically and radiographically. Their daily activities and general post-operative quality of life was estimated with the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire. The Mayo elbow performance score was used for functional evaluation. Implant survivorship was assessed. Fourteen patients (11 female and three male) underwent a Coonrad-Morrey TER via a standard posterior approach for humeral fractures. Their mean age was 73 years (range 61–84 years) at the time of injury. Ten patients had suffered a C3 injury, two a B3 and two an A3 according to the AO classification. The mean time to surgery after their injury was 8 days (range: 1–21 days). Complications: one myocardial infarct and one superficial wound infection. Mean time to follow-up was three years and two months (range: 9–66 months). Nine (64%) reported no pain, four (29%) had mild pain with activity and one had mild pain at rest. The mean arc of extension-flexion movement was 24°–125°. Supination: mean = 90° (range: 70°–100°). Pronation: mean = 70° (range: 50°–110°). No elbow was unstable. The mean DASH score was 22.6 (range: 0.92–63.3). Zero reflects no disability, 100 reflects most severe disability. The mean Mayo elbow performance score was 90 (range: 80–100). X-rays revealed that all implants were well fixed with no evidence of loosening. One patient had severe hypertrophic bone

Aims: The mid- and long-term results of uncemented cups are uncertain. The aim of this study was to assess their results and to compare them with the most common cemented cup, the Charnley. Material and methods: In the study we included only patients under the age of 60 that had been operated with one of the 10 most common uncemented cup brands or the Charnley cup. Only brands that had been in use for at least 6 years were included. There were only minor differences among the brands concerning age, gender and diagnosis. Survival percentages were calculated with the Kaplan-Meier method. Results: With all cup revisions (change of cup or polyethylene liner) as end-point, the overall 5 year survival probability was 97% (95% CI: 96.3 97.3) which decreased to 86% (95% CI: 84.4 Ð 87.5) at 10 years. The 10 years survival varied from 74% for the Atoll cup to 88% for the Optiþx and the Harris-Galante cup, whereas for the cemented Charnley cup the 10 years survival probability was 94%. For the uncemented cups the increase in revision risk after 6 years was mainly due to wear and osteolysis. For the HA-coated cups also aseptic loosening increased after 6 years of follow-up. Conclusion: Uncemented cups in young patients had good short-term results. At 10 years of follow-up for the investigated uncemented cup brands, the results were inferior to the Charnley cup.

Introduction. The aim of this study is to analyse the effect of the degree of coverage of the Total Elbow implant with cement and the significance of cementation index as a predictor of failure. Material/methods. Fifty elbows in forty seven patients who had undergone the Coonrad-Morrey TER were included in the study. The post-operative radiographs were evaluated for the cementation index. Failures and revisions were documented. Statistical analysis was done to evaluate the cementation index as a predictor of failure. Results. The mean period of follow up was 4.67 ± 2.85 years. The mean cementation index of the humerus (CIH) was 1.22 ± 0.28 (range 0.7 to 2.1). The mean cementation index of the ulna (CIU) was 1.10 ± 0.18 (range 0.77 to 1.72). The Kolmogorov-Smirnov test, used to test the type of distribution, showed that both the indices had a normal distribution (p > 0.05). Both the humeral and ulnar cementation indices were not found to be statistically significant predictors of failure (p > 0.05). Conclusions. The cementation index is an objective method of assessment of the coverage of the implant with cement. In the present series, the cementation index of the humerus varied from 0.7 to 2.1 and that of the ulna varied from 0.77 to 1.72 but both were not found to be statistically significant. A larger study with adequate follow-up should be done to establish the minimum cement mantle that can be considered adequate for the long term survivorship of the prosthesis

The treatment of multifragmentary, intra-articular fractures of the distal humerus is difficult, even in young patients with bone of good quality, but is worse in elderly patients who have varying degrees of osteopenia. We have evaluated the functional outcome of primary total elbow replacement (TER) in the treatment of these fractures in ten elderly patients followed for a minimum of one year. There were no complications in regard to the soft tissues, bone or prosthesis. The mean range of flexion obtained was 125° (110 to 140) and loss of extension was 23.5° (0 to 50). The mean Mayo score was 94 points (80 to 100) and patient satisfaction was high. We feel that TER provides an alternative to open reduction and internal fixation in the management of these complicated fractures in the elderly

Aims

The aims of this study were to identify and evaluate the current literature examining the prognostic factors which are associated with failure of total elbow arthroplasty (TEA).

Introduction: Distal humeral fractures represent a constant challenge to the most experienced surgeon. This is the first report of the use of an unlinked prosthesis for the treatment of distal humeral fractures in elderly persons. Materials and Methods: From July 2000 to June 2001, 9 iBP elbow arthroplasties were performed in patients with acute fractures of the distal humerus. The average age of the group was 71 years. The mean interval between injury and TER was 11 days. The follow-up period averaged 12 months (range 5 to 16). Results: Functional outcome was evaluated with patient-completed questionnaires. All patients had a flexion contracture of the elbow ranging from 15 to 30 degrees. All patients were able to perform daily activities, pain relief was satisfactory and patient satisfaction was high. All elbows met the criteria for functional motion and were stable at the latest follow-up examination. There were no major complications such as dislocation, ulnar nerve dysfunction or deep infection. Conclusion: Unlinked non-congruous elbow arthroplasty when combined with a surgical exposure that allows proper soft tissue balance and instrumentation that enables correct positioning of the components can be a successful alternative in the management of acute distal humeral fractures in selected patients when conventional fixation is not a viable option