Objective:. Total elbow joint arthroplasty has limited longevity and is therefore not appropriate for younger rheumatoid arthritis patients. Arthroplasty using an inter-positional membrane may be another surgical option for this population. However, clinical results for joint arthroplasty using the inter-positional membrane have not traditionally been favorable because rheumatoid activity could not be controlled. Today, rheumatoid activity can be controlled with biologics; therefore, the utility of the inter-positional membrane procedure was re-evaluated. Methods:. An 8×6 cm sheet of fascia was detached from the patient's tensor fascia lata muscle to produce a JK membrane. The fascia was stretched on a frame and kept in a 2% chromic acid potassium solution for 24 hours. Then, the fascia was exposed to direct sunlight in order to reduce the dichromic acid. The fascia was washed out in running water for 24 hours and was then stored in phenol with the addition of 70% alcohol. Elbow arthroplasties were performed on three elbow joints in two young female patients. The first case had a significantly damaged right elbow joint with severe joint dysfunction. A JK membrane arthroplasty was done for the first case in 2003, when this patient was 34 years old. Biologics were administered with methotrexate after the surgery. The second case demonstrated bilateral ankylosed elbows due to idiopathic juvenile arthritis. Bilateral JK membrane arthroplasties were performed in 2010, when this patient was 32 years old. Several operative and manual manipulations were necessary in order to increase the range of motion following surgery. Biologics were administered with cyclosporine. Results:. Joint function was significantly improved in all three joints without pain after the JK membrane elbow arthroplasties. In case one, the JOA (Japan Orthopaedic Association) elbow score improved from 21 points before surgery to 85 points after surgery and active elbow flexion improved to 110 degrees following surgery. In case two, the JOA elbow score was 55 and 82 points in the right elbow and 52 and 83 points in left elbow before and after surgery, respectively. In case two, active flexion improved to 120 degrees for the right elbow and 110 degrees for the left elbow following surgery. RA was well controlled in both patients. Conclusion:. Elbow arthroplasty using an inter-positional membrane appears to be useful in young patients when RA activity is controlled with biologics

Introduction. Cement pressurisation in the distal humerus is technically difficult due to the anatomy of the humeral intramedullary (IM) cavity. Conventional cement restrictors often migrate proximally or leak, reducing the effect of pressurisation during implantation. Theoretically with a better cement bone interdigitation, the longevity of the elbow replacement can be improved. The aim of this cadaveric study was to evaluate the usefulness of a novel technique for cementation. Method. Eight paired fresh frozen cadaveric elbows were randomly allocated to conventional cementing techniques or cementing using a paediatric foley catheter as a temporary restrictor. The traditional cementing technique consisted of canal preparation using irrigation, brushing and drying prior to cementation, with no use of a cement restrictor. The new technique involved same canal preparation but prior to cementation a size 8 foley catheter was introduced and the balloon inflated to act as a temporary cement restrictor. The humeri were cut into 10mm sections. Each slice was photographed and radiographed. This dual imaging technique was used to establish the best methodology for evaluation of cement penetration. Cement penetration was calculated as a ratio of the area of intra-medullary cavity occupied by the cement. Results. There was no significant difference between the photographic and radiographic method of measuring cement penetration. Cement penetration was significantly better in the foley catheter group (P = 0.002-0.037). The maximum penetration was observed in the most distal 2-5cm. Conclusion. The foley catheter technique consistently and significantly achieved a better cement interdigitation into the cancellous bone, without leaving a void in the cement. This study has demonstrated a new cementing technique for elbow arthroplasty, utilising a paediatric foley catheter as a temporary humeral intra-medullary plug, increasing cement pressurisation and restricting proximal cement migration. Future studies using this methodology will not require supplementation of photographs with radiographic analysis

Aims. Our primary aim was to establish the proportion of female orthopaedic consultants who perform arthroplasty via cases submitted to the National Joint Registry (NJR), which covers England, Wales, Northern Ireland, the Isle of Man, and Guernsey. Secondary aims included comparing time since specialist registration, private practice participation, and number of hospitals worked in between male and female surgeons. Methods. Publicly available data from the NJR was extracted on the types of arthroplasty performed by each surgeon, and the number of procedures of each type undertaken. Each surgeon was cross-referenced with the General Medical Council (GMC) website, using GMC number to extract surgeon demographic data. These included sex, region of practice, and dates of full and specialist registration. Results. Of 2,895 surgeons contributing to the NJR in 2023, 102 (4%) were female. The highest proportions of female surgeons were among those who performed elbow (n = 25; 5%), shoulder (n = 24; 4%), and ankle (n = 8; 4%) arthroplasty. Hip (n = 66; 3%) and knee arthroplasty (n = 39; 2%) had the lowest female representation. Female surgeons had been practising for a median of 10.4 years since specialist registration compared to 13.7 years for males (p < 0.001). Northern Ireland was the region with the highest proportion of female arthroplasty surgeons (8%). A greater proportion of male surgeons worked in private practice (63% vs 24%; p < 0.001) and in multiple hospitals (74% vs 40%; p < 0.001). Conclusion. Only 4% of surgeons currently contributing cases to the NJR are female, with the highest proportion performing elbow arthroplasty (5%). Female orthopaedic surgeons in the NJR are earlier in their careers than male surgeons, and are less involved in private practice. There is a wide geographical variation in the proportion of female arthroplasty surgeons. Cite this article: Bone Jt Open 2024;5(8):637–643

Vascularised soft tissue transfer may be helpful in the salvage of severe sepsis involving avascular tissues hosting joint replacements or other metal work. Transferred tissue covers the exposed implants and delivers intravenous antibiotics. Twenty-one cases for the knee, elbow and shoulder are presented. Gastrocnemius flaps were used for seven knee replacements and 10 knee fractures. Antegrade radial artery flaps were used for two elbow replacements. Pectoralis major or minor flaps were used for two shoulder replacements. All procedures were performed by an orthopaedic surgeon with supplementary plastics training. Synchronous bony surgery included revision arthroplasty in seven cases, conversion to fusion in one case and preservation of existing hardware in the remainder. Sepsis was eliminated in the longterm in 9 of 10 knee fracture fixation cases, 5 out of 7 knee replacements and both elbow replacements. Both shoulder replacements remained septic despite multiple repeat procedures. Complications included necrosis of two gastrocnemius flaps, one from pre-existing partial compartment syndrome and one when combined with fusion of the knee. One other knee replacement developed further sepsis three years post procedure. No limb required amputation. These procedures are well within the remit of orthopaedic surgeons, the non reliance on plastics surgeons allowed prompt treatment combined with bony procedures. Results were good for the knee and elbow but disappointing for the shoulder—this, probably related to the natural mobility of the joint

Background. The procedures of total elbow and shoulder replacements increased 6% to 13% annually from 1993 to 2007 with revision-related burden increasing from 4.5% to 7%. The revisions of the shoulder and elbow prostheses due to aseptic loosening, periprosthetic fractures, infections have led to the use of standard or custom-made implants due to significant bone loss. This study reports our experience in the management of complicated primary and revisions of total shoulder and elbow replacements with significant humeral bone loss and in metabolic diseases of the elbow and shoulder treated with bone resection using The Mosaic Humeral Replacement System. Patients and Materials. A total of 20 patients underwent total elbow or shoulder arthroplasty using the Mosaic Humeral Replacement System (Biomet, UK). The Mosaic system was used in 8 shoulder arthroplasties (Group A) and in 12 elbow arthroplasties (Group B). The underlying pathologis in Group A included 2 malunited proximal humerus fracture, 1 humeral osteomyelitis, 1 shoulder chondrosarcoma, 1 aggressive Gigantic Cell Tumor with prosthetic fracture, 2 metastatic lytic lesion, and 1 failed fixation of non-union proximal humerus. Figure 1 shows Mosaic implant after complex fracture of proximal humerus. Reasons for Mosaic arthroplasty in Group B included 3 humeral component revisions due to periprosthetic fracture, 1 prosthesis breaking-up with fractures, 1 revision of loose Souter Strathclyde prosthesis, 1 loose prosthesis due to infection, 1 highly comminuted elbow fracture, 1 aseptic loosening of humeral component of total elbow replacement, 3 revision of total elbow replacement due loosening and 1 pathological distal humerus fracture due to metastasis. Figure 2&3 shows pre- and post-operative Mosaic implant following complex periprosthetic fracture of distal humerus. Clinical Observation/Discussion. The Mosaic Humeral Replacement System is a complete system for complex revision, salvage/oncology, and complex humeral fractures. It is a completely modular system which can be adapted to different patient anatomies and indications. It has been designed to face several surgical challenges, including reattaching soft tissues, properly tensioning the glenohumeral joint and restoring joint function. It is a cost-effective procedure with the benefits of a custom made humeral component in a standard tray. Our study shows that good results can be achieved with this form of treatment. Radiological assessment of all patients showed a satisfactory position of the implant with appropriate margin of bony resection. One patient with proximal and another one with distal humeral Mosaic replacement had late infection. One patient had aseptic loosening 3 years after distal humeral replacement. Most of the patients had satisfactory improvement in range of movement and chronic pain. While primary clinical observations and imaging results indicate acceptable results with Mosaic arthroplasty; a realistic assessment can only be achieved in long-term using the appropriate outcome measures. At the present we continue to regularly assess the patients clinically and radiologically and by means of Liverpool elbow score for distal and Quick- DASH for proximal Mosaic Humeral Replacement System and plan to report the long-term results in due time

Thermal injury to the radial nerve caused by cement leakage is a rare complication after revision elbow arthroplasty. Several reports have described nerve palsy caused by cement leakage after hip arthroplasty. However, little information is available regarding whether radial nerve injury due to cement leakage after humeral stem revision will recover. In a recent study, radial nerve palsy occurred in 2 of 7 patients who had thermal injury from leaked cement during humeral component revisions. These patients did not regain function of the radial nerve after observation. We present a case of functional recovery from a radial nerve palsy caused by cement leakage after immediate nerve decompression in revision elbow arthroplasty[Fig. 1.2]

In bone and joint infections, several materials can be used for local antibiotic elution at site of infection. Polymethylmethacrylate (PMMA) cement is often used. Recently the use of antibiotic impregnated dissolvable synthetic pure calcium sulphate beads [Stimulan R]1 has been used as an alternative, due to several perceived advantages. We present our experience of using Calcium sulphate beads in infections involving the upper limb. From Jan 2012 to Jan 2015, we used Calcium sulphate beads in 7 complex upper limb infections including 1 elbow replacement, 2 infected non unions, 2 shoulder replacement, 1 wrist fusion and I ORIF elbow. We used combination of Vancomycin and Gentamicin in the beads, using manufacturer's mixing guide for optimum setting. Arthroplasty infections underwent explantation, addition of antibiotic impregnated calcium sulphate beads in the joint space, followed by a second stage, and systemic antibiotics. Fracture non-union cases had surgical debridement, calcium sulphate beads and systemic antibiotics. Follow up (6months to 2 years) indicate no recurrence of infection in any case. The most common organisms isolated were Coagulase negative staphylococcus and Staphylococcus aureus. Others included Group B Streptococcus, Serratia marscesens and Corynebacterium spp. In 2 of 7 cases there was significant drainage from the wound. This settled without further input. For fracture non-union fixation, there was no need to do second procedure to remove beads as they dissolve. In cases of staged revisions, the beads were inserted at first stage with microbiological clearance at 2nd stage. At present there are no reports in the literature of the use of this product in the upper limb. Our experience suggests use of dissolvable pure Calcium sulphate beads impregnated with selected antibiotics, is an effective adjunct to current treatments. Aseptic drainage has been reported and this was seen in some of our cases. It is postulated that the use of Calcium sulphate beads in more superficial joints may lead to more drainage. It may be necessary to avoid packing any beads in the subcutaneous spaces and using lower volumes in upper limb. Further work will include long-term follow up and any evidence of relapse or recurrence of infection

Peri-prosthetic fractures around implants in the proximal humerus can present substantial challenges. Most individuals who undergo upper limb arthroplasty tend to be osteopenic to begin with, and the anatomy of the proximal humerus does not provide an excess of bone to work with. Therefore, peri-prosthetic fractures pose difficulties to rotator cuff function and implant stability. There are multiple classification systems, but series are small and the classification does not always lead to treatment algorithms. Risk factors for humeral fractures after shoulder arthroplasty include endosteal notching, cortical perforation, varus malalignment, stem perforation, ipsilateral shoulder and elbow arthroplasties, and loose stems. Many of these risk factors are directly related to technical errors at the time of surgery. Poor exposure can lead to aberrant starting point and errors in reaming. Oversized prostheses can lead to cortical perforation or even stem perforation. Proper positioning of the patient on the table and surgical releases help avoid these technical errors. Peri-prosthetic fractures should be carefully evaluated radiographically for stability. Two important considerations: 1. Is the implant stable? 2. Is the fracture stable? Generally, if the implant is unstable, the implant must be revised. In the setting of a stable implant, many humeral fractures can be treated nonoperatively. Many fractures at or below the level of the tip of the implant can be treated as typical humeral fractures. Options for fixation include plates with cables or long stem prostheses which bypass the fracture. Displaced tuberosity fractures are treated with suture or wire fixation. Risk factors for a poor outcome include increased time to union, skin breakdown, and stiff shoulder

Aims

Orthopaedic surgeries are complex, frequently performed procedures associated with significant haemorrhage and perioperative blood transfusion. Given refinements in surgical techniques and changes to transfusion practices, we aim to describe contemporary transfusion practices in orthopaedic surgery in order to inform perioperative planning and blood banking requirements.

Total elbow arthroplasty (TEA) has been shown to be a treatment option for elderly patients with complex distal humeral fractures and osteoporotic bone. The published results have often included rheumatoid patients who traditionally would be expected to do well from elbow arthroplasty. Only short-term results have been published using this technique in non-rheumatoid patients. The current study contains the largest number and longest follow-up of non-rheumatoid patients whose fractures have been treated with a non-custom TEA. In total there were 26 patients, mean age 72 years, 22 female and 4 male, 25% dominant arm. The mean follow-up was of 5 years. There was 1 case of loosening, 1 radial nerve palsy and 2 cases of heterotrophic ossification. At final review the mean range of flexion/extension was 97.5 degrees and the mean range of pronation/supination was 151.75 degrees. The mean Mayo Elbow Performance score was 92. We would suggest that TEA provides a very satisfactory outcome in elderly patients with complex distal humeral fractures, the benefit of which can be observed at a mean of 5 years

Introduction. Although the majority of adult distal humeral fractures are successfully treated with ORIF, the management in frail patients, often elderly with multiple co-morbidities and osteoporotic bone, remains controversial. Elbow replacement is frequently recommended if stable internal fixation cannot be achieved, especially in low, displaced, comminuted fractures. The “bag-of-bones” method ie early movement with fragments accepted in their displaced position, is rarely considered as there has been little in the literature since 10 successful cases were reported by Brown & Morgan in 1971 (JBJS 53-B(3):425–428). We present the experience of three units in which conservative management has been actively adopted in selected cases. Methods. 44 distal humeral fractures were initially treated conservatively - 2004–2010. Mean age 73.9 yrs (40–91) and 34 F: 10 M. Clinical and radiological review at a mean follow-up of 2 years (1–6). Results. There were 18 AO Type A, 7 B and 19 C fractures. The range of elbow movement was extension/flexion 38/124, and pronation/supination 75/76 at their last follow-up. Using the Oxford elbow score (0 = worst/4 best result), the mean pain score was 2.44 (range 1–4), 2.26 (0–4) for function, and 2.04 (0–4) for psycho-social, although several patients had early dementia. Only 5 subsequently underwent replacement out of 44 patients whose residual symptoms have not been sufficient to require surgery. Discussion. We believe that there is a role for initial conservative treatment in selected higher-risk patients, as initial early mobilisation within the limits of discomfort can give good functional results. There is a significant complication rate after fixation or replacement in elderly, frail patients, which includes infection, stiffness and loosening. Unnecessary operations can be avoided in the majority of cases, with replacement of a virgin joint at a later date only if required

Aims

There is little published on the outcomes after restarting elective orthopaedic procedures following cessation of surgery due to the COVID-19 pandemic. During the pandemic, the reported perioperative mortality in patients who acquired SARS-CoV-2 infection while undergoing elective orthopaedic surgery was 18% to 20%. The aim of this study is to report the surgical outcomes, complications, and risk of developing COVID-19 in 2,316 consecutive patients who underwent elective orthopaedic surgery in the latter part of 2020 and comparing it to the same, pre-pandemic, period in 2019.