Supracondylar Ostectomy and Shortening (S.O.S) for Distal Humerus Nonunions.

INTRODUCTION: Many distal humerus nonunions are associated with bone loss and rigid internal fixation is difficult to obtain, especially for low transcondylar nonunions and those with severe intraarticular comminution. The purpose of this study was to analyze the results of a strategy to address this challenge utilizing internal fixation using the Supracondylar Ostectomy + Shortening (i.e. S.O.S.) procedure for distal humerus nonunions. The goals of this procedure are to (1) optimize bony contact and compression through re-shaping the nonunited fragments at the supracondylar level with selective humeral metaphyseal shortening, (2) maximize fixation using parallel-plating, and (3) provide biologic and structural augmentation with bone graft. MATERIALS AND METHODS: Between 1995 and 2019, 28 distal humerus nonunions underwent internal fixation using the S.O.S. procedure at a single Institution. There were 14 males and 14 females with mean age of 47 (range 14-78) years at the time of the S.O.S procedure and an average of 1.7 prior surgeries. Medical records and radiographs were reviewed to determine rates of union, reoperations, complications, and Mayo Elbow Performance Scores (MEPS). Patients were also prospectively contacted to update their MEPS and gather additional information on complications and reoperations. Mean clinical exam follow-up was 17 months, mean clinical contact follow-up was 19 months, and mean radiographic follow-up was 32 months. RESULTS: Four patients did not have adequate follow-up to determine union. Of the remaining 24 elbows, 22 achieved union. Two elbows developed collapse of the articular surface and were converted to a total elbow arthroplasty (TEA). There were complications in 10 elbows: contracture (5), superficial infection (2), ulnar neuropathy (1), deep infection (1), and hematoma (1). Twelve elbows underwent reoperation: 4 for contracture release, 3 for hardware removal, 2 for total elbow arthroplasty, 1 for bone grafting, 1 for hematoma evacuation, and 1 for ulnar nerve neurolysis. Compared to preoperative data, there was a significant improvement in postoperative flexion, extension and pronation (p<0.01). The mean range of motion was 21° of extension, 119° of flexion, 79° of pronation, and 77° of supination. The mean MEPS was 80 points (range, 25 to 100 points) and 19 elbows (76%) rated as excellent or good. DISCUSSION: Stable fixation and high union rates are possible in distal humerus nonunions with bone loss using a technique that combines supracondylar humeral shortening, parallel plating, and bone grafting. Secondary procedures are commonly needed to restore function in this challenging patient population.

Complications of antibiotic cement spacers used for elbow infections.

BACKGROUND: Antibiotic cement spacers have been widely used in the treatment of joint infections. There are no commercially available antibiotic spacers for the elbow. Instead, they are typically fashioned by the surgeon at the time of surgery using cement alone or a combination of cement with sutures, Steinmann pins, external fixator components, or elbow arthroplasty components. There is no consensus regarding the ideal elbow antibiotic spacer and no previous studies have examined the complications associated with these handmade implants in relation to their unique structural design. METHODS: We retrospectively reviewed 55 patients who had 78 static antibiotic cement spacers implanted between January 1998 and February 2021 as part of a 2-stage treatment plan for infection of an elbow arthroplasty, other elbow surgery, or primary elbow infection. Several antibiotic spacer structures were used during the study period. For analysis purposes, the spacers were classified into linked and unlinked spacers based on whether there was a linking mechanism between the humerus and the ulna. Complications related to these spacers that occurred either during the implantation, between implantation and removal, or during removal were recorded and analyzed from chart review and follow-up x rays. Reoperations due to spacer-related complications were also recorded. RESULTS: Among the 55 patients (78 spacers), there were 23 complications, including 17 minor and 6 major complications. The most common complication of unlinked spacers (intramedullary [IM] dowels, beads and cap spacer) was spacer displacement. Other complications included IM dowel fracture and difficulty locating beads during spacer removal. The major complications of linked cement spacers included two periprosthetic humerus fractures after internal external fixator cement spacers and re-operation due to breakage and displacement of one bushing cement spacer. The major complications of unlinked cement spacers included two reoperations due to IM dowel displacement and one reoperation due to displacement of beads. Among patients who had removal of all components and those with native joints, there was no statistically significant difference between internal external fixator cement spacers and unlinked cement spacers in minor complication rates (30% vs. 16%, P = .16), major complication rates (7% vs. 8%, P = .85) and reoperation rates (0% vs. 8%, P = .12). CONCLUSIONS: Static handmade antibiotic elbow spacers have unique complications related to their structural designs. The most common complication of linked and nonlinked cement spacers were failure of the linking mechanism and displacement, respectively. Surgeons should keep in mind the possible complications of different structures of cement spacers when choosing 1 antibiotic spacer structure over another.

Surgical Treatment and Outcomes of Trans-Ulnar Basal Coronoid Fracture-Dislocations.

BACKGROUND: Trans-ulnar fracture-dislocations of the elbow are complex injuries that can be difficult to classify and treat. Trans-ulnar basal coronoid injuries, in which the coronoid is not attached to either the olecranon or the metaphysis, present substantial challenges to achieve anatomic reduction and stable internal fixation. The purpose of this study was to analyze the outcome of surgical treatment of trans-ulnar basal coronoid fracture-dislocations. MATERIALS & METHODS: Between 2002 and 2019, 32 consecutive trans-ulnar basal coronoid fracture-dislocations underwent open reduction and internal fixation (ORIF) at our institution. Four elbows were lost to follow-up within the first 6 months after surgery and were excluded. Among the 28 elbows remaining, there were 13 females and 15 males with a mean age of 56 (range 28-78) years at the time of injury. The mean clinical and radiographic follow-up times were 37 months and 29 months, respectively. Radiographs were reviewed to determine rates of union, Hastings and Graham heterotopic ossification (HO) grade, and Broberg and Morrey arthritis grade. RESULTS: Union occurred in 25 elbows. Union could not be determined for 1 elbow at most recent follow-up and the remaining 2 elbows developed nonunion of the coronoid. Complications occurred in 10 elbows (36%): deep infection (4), ulnar neuropathy (2), elbow contracture (2), and nonunion (2). There were reoperations in 11 elbows (39%): irrigation and débridement with hardware removal (4), hardware removal (2), ulnar nerve transposition (2), contracture release with HO removal (2), and revision ORIF with iliac crest autograft (1). At most recent follow-up, the mean flexion-extension arc was 106° (range 10-150°), and the mean pronation-supination arc was 137° (range 0-170°). The mean Quick Disabilities of Arm, Shoulder, and Hand score was 11 (range 0-39) points with a mean Single Assessment Numeric Evaluation-Elbow score of 81 (range 55-100) points. At final radiographic follow-up, 16 elbows (57%) had HO (8 class I and 8 class II), and 20 elbows (71%) had arthritis (8 grade 1, 6 grade 2, and 6 grade 3). DISCUSSION: Trans-ulnar basal coronoid fracture dislocations are severe injuries associated with high rates of reoperation, heterotopic ossification, and post-traumatic arthritis. However, the majority of elbows achieve union, a functional range of motion, and reasonable patient reported outcome measures. Over the study period, surgeons were more likely to utilize multiple deep approaches and separate fixation of the coronoid (either with lag screws or anteromedial plates) to ensure anatomic reduction.

Non-cefazolin antibiotic prophylaxis is associated with higher rates of elbow periprosthetic joint infection.

BACKGROUND: Periprosthetic joint infection (PJI) is a common source of failure following elbow arthroplasty. Perioperative prophylactic antibiotics are considered standard of care. However, there are no data regarding the comparative efficacy of various antibiotics in the prevention of PJI for elbow arthroplasty. Previous studies in shoulder, hip, and knee arthroplasty have demonstrated higher rates of PJI with administration of non-cefazolin antibiotics. The elbow has higher rates of PJI than other joints. Therefore, this study evaluated whether perioperative antibiotic choice affects rates of PJI in elbow arthroplasty. MATERIALS AND METHODS: A single-institution, prospectively collected total joint registry database was queried to identify patients who underwent primary elbow arthroplasty between 2003 and 2021. Elbows with known infection prior to arthroplasty (25) and procedures with incomplete perioperative antibiotic data (7) were excluded, for a final sample size of 603 total elbow arthroplasties and 19 distal humerus hemiarthroplasties. Cefazolin was administered in 561 elbows (90%) and non-cefazolin antibiotics including vancomycin (32 elbows, 5%), clindamycin (27 elbows, 4%), and piperacillin/tazobactam (2 elbows, 0.3%) were administered in the remaining 61 elbows (10%). Univariate and multivariate analyses were conducted to determine the association between the antibiotic administered and the development of PJI. Infection-free survivorship was estimated using the Kaplan-Meier method. RESULTS: Deep infection occurred in 47 elbows (7.5%), and 16 elbows (2.5%) were diagnosed with superficial infections. Univariate analysis demonstrated that patients receiving non-cefazolin alternatives were at significantly higher risk for any infection (hazard ratio [HR] 2.6, 95% confidence interval [CI] 1.4-5.0; P < .01) and deep infection (HR 2.7, 95% CI 1.3-5.5; P < .01) compared with cefazolin administration. Multivariable analysis, controlling for several independent predictors of PJI (tobacco use, male sex, surgical indication other than osteoarthritis, and American Society of Anesthesiologists score), showed that non-cefazolin administration had a higher risk for any infection (HR 2.8, 95% CI 1.4-5.3; P < .01) and deep infection (HR 2.9, 95% CI 1.3-6.3; P < .01). Survivorship free of infection was significantly higher at all time points for the cefazolin cohort. DISCUSSION: In primary elbow arthroplasty, cefazolin administration was associated with significantly lower rates of PJI compared to non-cefazolin antibiotics, even in patients with a greater number of prior surgeries, which is known to increase the risk of PJI. For patients with penicillin or cephalosporin allergies, preoperative allergy testing or a cefazolin test dose should be considered before administering non-cefazolin alternatives.

Trans-ulnar fracture dislocations of the elbow: a systematic review and clarification of classification systems.

BACKGROUND: Complex elbow dislocations in which the dorsal cortex of the ulna is fractured can be difficult to classify and therefore treat. These have variably been described as either Monteggia variant injuries or trans-olecranon fracture dislocations. Additionally, O'Driscoll et al classified coronoid fractures that exit the dorsal cortex of the ulna as "basal coronoid, subtype 2" fractures. The Mayo classification of trans-ulnar fracture dislocations categorizes these injuries in 3 types according to what the coronoid remains attached to: trans-olecranon fracture dislocations, Monteggia variant fracture dislocations, and trans-ulnar basal coronoid fracture dislocations. The purpose of this study was to evaluate the outcomes of these injury patterns as reported in the literature. Our hypothesis was that trans-ulnar basal coronoid fracture dislocations would have a worse prognosis. MATERIALS AND METHODS: We conducted a systematic review to identify studies with trans-ulnar fracture dislocations that had documentation of associated coronoid injuries. A literature search identified 16 qualifying studies with 296 fractures. Elbows presenting with basal subtype 2 or Regan/Morrey III coronoid fractures and Jupiter IIA and IID injuries were classified as trans-ulnar basal coronoid fractures. Patients with trans-olecranon or Monteggia fractures were classified as such if the coronoid was not fractured or an associated coronoid fracture had been classified as O'Driscoll tip, anteromedial facet, basal subtype I, or Regan Morrey I/II. RESULTS: The 296 fractures reviewed were classified as trans-olecranon in 44 elbows, Monteggia variant in 82 elbows, and trans-ulnar basal coronoid fracture dislocations in 170 elbows. Higher rates of complications and reoperations were reported for trans-ulnar basal coronoid injuries (40%, 25%) compared to trans-olecranon (11%, 18%) and Monteggia variant injuries (25%, 13%). The mean flexion-extension arc for basal coronoid fractures was 106° compared to 117° for Monteggia (P < .01) and 121° for trans-olecranon injuries (P = .02). The mean Mayo Elbow Performance Score was 84 points for trans-ulnar basal coronoid, 91 for Monteggia (P < .01), and 93 for trans-olecranon fracture dislocations (P < .05). Disabilities of the Arm, Shoulder and Hand and American Shoulder and Elbow Surgeons scores were 22 and 80 for trans-ulnar basal coronoid, respectively, compared to 23 and 89 for trans-olecranon fractures. American Shoulder and Elbow Surgeons was not available for any Monteggia injuries, but the mean Disabilities of the Arm, Shoulder and Hand was 13. DISCUSSION: Trans-ulnar basal coronoid fracture dislocations are associated with inferior patient reported outcome measures, decreased range of motion, and increased complication rates compared to trans-olecranon or Monteggia variant fracture dislocations. Further research is needed to determine the most appropriate treatment for this difficult injury pattern.

Artificial intelligence-based three-dimensional templating for total joint arthroplasty planning: a scoping review.

PURPOSE: The purpose of this review is to evaluate the current status of research on the application of artificial intelligence (AI)-based three-dimensional (3D) templating in preoperative planning of total joint arthroplasty. METHODS: This scoping review followed the PRISMA, PRISMA-ScR guidelines, and five stage methodological framework for scoping reviews. Studies of patients undergoing primary or revision joint arthroplasty surgery that utilised AI-based 3D templating for surgical planning were included. Outcome measures included dataset and model development characteristics, AI performance metrics, and time performance. After AI-based 3D planning, the accuracy of component size and placement estimation and postoperative outcome data were collected. RESULTS: Nine studies satisfied inclusion criteria including a focus on computed tomography (CT) or magnetic resonance imaging (MRI)-based AI templating for use in hip or knee arthroplasty. AI-based 3D templating systems reduced surgical planning time and improved implant size/position and imaging feature estimation compared to conventional radiographic templating. Several components of data processing and model development and testing were insufficiently covered in the studies included in this scoping review. CONCLUSIONS: AI-based 3D templating systems have the potential to improve preoperative planning for joint arthroplasty surgery. This technology offers more accurate and personalized preoperative planning, which has potential to improve functional outcomes for patients. However, deficiencies in several key areas, including data handling, model development, and testing, can potentially hinder the reproducibility and reliability of the methods proposed. As such, further research is needed to definitively evaluate the efficacy and feasibility of these systems.

Effect of Radiocapitellar Joint Over/Under Stuffing on Elbow Joint Contact Pressure.

PURPOSE: Comminuted radial head fractures are commonly treated by surgical resection or replacement with a prosthesis. A potential problem with radial head replacement is overlengthening of the radial neck ("overstuffing" of the radial head), which has been shown to affect both ulnohumeral kinematics and radiocapitellar pressures. We hypothesized that an overstuffed radial head prosthesis increases capitellar pressure and reduces coronoid pressure. METHODS: Seven human cadaveric elbows were prepared on a custom-designed apparatus simulating stabilizing muscle loads, and passively flexed from 0° to 90° under gravity valgus torque while joint contact pressures were measured. Each elbow was tested sequentially with different neck lengths, starting with the intact specimen followed by insertion of understuffed (-2 mm), standard-height (0 mm), and overstuffed (+2 mm) radial head prostheses in neutral forearm rotation, 40° pronation, and 40° supination positions, respectively. RESULTS: Capitellar mean contact pressures significantly increased after insertion of an overstuffed radial head prosthesis. In valgus position with neutral forearm rotation, capitellar mean contact pressure on the joint with an intact radial head averaged 227 ± 70 kPa. Insertion of understuffed, standard-height, and overstuffed radial head prostheses changed the mean contact pressures to 152 ± 76 kPa, 212 ± 68 kPa, and 491 ± 168 kPa, respectively. The overstuffed radial head group had significantly lower whole coronoid mean contact pressures (153 ± 56 kPa) compared with the intact (390 ± 138 kPa) and standard-height (376 ± 191 kPa) radial head groups. CONCLUSIONS: An increase in radial prosthesis height significantly increases capitellar contact pressures and reduces coronoid contact pressures. CLINICAL RELEVANCE: Restoration of the anatomic radial head height is critical when performing radial head arthroplasty to maintain normal joint biomechanics. Elevated capitellar contact pressures can potentially lead to pain and early degenerative changes.

The role of the lateral part of the distal triceps and the anconeus in varus stability of the elbow: a biomechanical study.

BACKGROUND: The role of the lateral part of the distal triceps as a stabilizer in the lateral collateral ligament-deficient elbow and whether its effect in improving the stability is independent of that of the anconeus are unclear. METHODS: Seven cadaveric elbows were tested under gravity varus stress using a custom-made machine designed to simulate muscle loads while allowing passive flexion of the elbow. An injury model was created by sectioning the lateral collateral ligament and sparing the common extensor origin. The lateral part of the distal triceps tendon was loaded sequentially with 0 N, 10 N, 25 N, and 40 N. Each stage of the lateral part of the distal triceps loading was tested with the anconeus unloaded (inactive) or with a 25-N load applied (active). Articular contact pressures on the coronoid, the medial facet, and the lateral facet were collected and processed using Tekscan sensors and software. RESULTS: A significant decrease in the mean coronoid contact pressure was seen with sequential loading of the lateral part of the distal triceps (P < .001). The ratio of medial to lateral facet contact pressures significantly decreased with sequential loading of the lateral part of the distal triceps (P < .001), indicating a better distribution of the contact pressure between the medial and lateral facets as the lateral part of the distal triceps was loaded. These effects were statistically significant, both with and without anconeus loading. There was no significant modification of the effect of the lateral part of the distal triceps loading on the contact pressure by the anconeus loading (P = .47). However, with active anconeus loading, the contact pressure and the ratio of medial to lateral facet contact pressures were significantly lower for any stage of lateral triceps loading (P < .001), indicating a synergistic effect of the anconeus. CONCLUSIONS: In a lateral collateral ligament-deficient elbow, the lateral part of the distal triceps loading prevents the increased contact pressure on the coronoid under varus stress and improves the distribution of contact pressures on the coronoid. Anconeus loading further decreases and improves the distribution of the contact pressures; however, its effect is independent of that of the lateral part of the distal triceps. These results substantiate a role of the lateral part of the distal triceps as a dynamic constraint against elbow varus and have clinical implications for prevention and rehabilitation of elbow instability.

The role of the lateral collateral ligament-capsule complex of the elbow under gravity varus.

BACKGROUND: The lateral collateral ligament complex along with the capsule is likely to be at risk during arthroscopic extensor carpi radialis brevis release for lateral epicondylitis. We hypothesized that disruption of the lateral collateral ligament-capsule complex (LCL-cc) would increase the mean contact pressure on the coronoid under gravity varus. MATERIALS AND METHODS: Eight cadaveric elbows were tested via gravity varus and weighted varus (2 Nm) stress tests using a custom-made machine designed to simulate muscle loads while allowing passive flexion of the elbow. Mean articular surface contact pressure data were collected and processed using intra-articular thin-film sensors and software. Sequential testing was performed on each specimen from stage 0 to stage 3 (stage 0, intact; stage 1, release of anterior one-third of LCL-cc; stage 2; release of anterior two-thirds of LCL-cc; and stage 3, release of entire LCL-cc). The mean contact pressure on the coronoid and the mean ratio of contact pressure on the medial coronoid to that on the lateral coronoid (M/L ratio) were used for comparisons among the stages and the intact elbow. RESULTS: The overall mean contact pressure significantly increased in stage 2 (P = .0004 in gravity varus and P = .0001 in weighted varus) and stage 3 (P < .0001 in gravity varus and P < .0001 in weighted varus) compared with that in stage 0. In contrast, release of the anterior one-third of the LCL-cc (stage 1) did not significantly increase the mean contact pressure on the coronoid in any degree of flexion under gravity varus (P = .09) or weighted varus loading (P = .6). The M/L ratio difference between stage 0 and stage 1 was 1.1 ± 1.1 under gravity varus (P = .8) and 2.1 ± 1.0 under weighted varus (P = .2). The overall M/L ratios in stage 2 and stage 3 were significantly higher than those seen in stage 0 under gravity varus (P = .04 in stage 2 and P = .02 in stage 3) and weighted varus (P = .006 in stage 2 and P < .0001 in stage 3). CONCLUSIONS: Loss of the anterior two-thirds or more of the LCL-cc significantly increases the overall mean contact pressure on the coronoid, especially the medial coronoid, under both gravity varus and weighted varus. The LCL-cc also plays a role in the distribution of coronoid contact pressure against gravity varus loads.

Intraoperative modification of total elbow arthroplasty implants.

BACKGROUND: Modification of total elbow arthroplasty (TEA) implants may be necessary in selected patients with substantial anatomic bone deformity or those undergoing revision surgery. The purpose of this study was to investigate the prevalence and consequences of implant modifications during TEA at our institution. We hypothesized that TEA implant modification would be more common in revisions than in primary replacements, and that it would not be associated with worse clinical outcomes or increased rates of radiographic or surgical complications directly related to the implant modification. METHODS: Elbows that had undergone TEA by any of 3 surgeons at our institution with use of intraoperative implant modification between January 1992 and October 2019 were retrospectively reviewed for the type of modification and complications. Complications were classified as definitely related, probably related, possibly related, or nonrelated to the implant's modification according to the consensus review by the 3 senior surgeons. A survey was sent out to surgeons outside of our institution to investigate whether intraoperative modification to TEA implants is a common clinical practice. RESULTS: A total of 106 implant components were modified during 94 of 731 TEA procedures (13%) in 84 of 560 patients. Implant modifications were performed in 60 of 285 revision cases (21%) compared with 34 of 446 (8%) primary cases (P < .0001). These included shortening the stem in 40 (44%), bending the stem in 16 (15%), notching the stem in 16 (15%), tapering the stem in 9 (9%), and a combination of 2 or more of these modifications in 19 implants (17%). Among the 55 index surgeries available for complication analysis, 40 complications occurred in 28 index surgeries (11 primary and 17 revisions; 25 patients), making the overall complication rate 51%. Of these 40 complications, 23 were considered independent of any implant modification. Of the remaining 17 complications, 9 were considered nonrelated to the implant modification, 6 were possibly related, and 2 were probably related to the implant modification. Therefore, the complication rate possibly related or probably related to implant modification was 15% (8 of 55). No complication was classified as definitely related to the implant modification. No implant breakage or malfunction occurred after any modification. A total of 442 survey responses were received representing 29 countries, of which 144 surgeons (39%) performed modification to implants during TEA procedures. DISCUSSION: This study confirmed our hypothesis that modification of TEA implants is not uncommon at our institution, particularly in revision arthroplasty. Surgeons should keep in mind that complications possibly related or probably related to implant modification were at minimum 15% and could have been as high as 30% if the patients lost to follow-up had all had complications. Implant modification may be necessary in some cases but should be exercised with thoughtful consideration and caution.

A coronoid-centric classification system of proximal trans-ulnar fracture-dislocations has almost perfect intraobserver and interobserver agreement.

BACKGROUND: Fracture-dislocations of the elbow, particularly those that involve a fracture through the proximal ulna, are complex and can be difficult to manage. Moreover, current classification systems often cannot discriminate between Monteggia-variant injury patterns and trans-olecranon fracture-dislocations, particularly when the fracture involves the coronoid. The Mayo classification of proximal trans-ulnar fracture-dislocations categorizes these fractures into 3 types according to what the coronoid is still attached to: trans-olecranon fracture-dislocations (the coronoid is still attached to the ulnar metaphysis); Monteggia-variant fracture-dislocations (the coronoid is still attached to the olecranon); and ulnar basal coronoid fracture-dislocations (the coronoid is not attached to either the olecranon or the ulnar metaphysis). The purpose of this study was to evaluate the intraobserver and interobserver agreement of the Mayo classification system when assessing elbow fracture-dislocations involving the proximal ulna based on radiographs and computed tomography scans. METHODS: Three fellowship-trained shoulder and elbow surgeons and 2 fellowship-trained orthopedic trauma surgeons blindly and independently evaluated the radiographs and computed tomography scans of 90 consecutive proximal trans-ulnar fracture-dislocations treated at a level I trauma center. The inclusion criteria included subluxation or dislocation of the elbow and/or radioulnar joint with a complete fracture through the proximal ulna. Each surgeon classified all fractures according to the Mayo classification, which is based on what the coronoid remains attached to (ulnar metaphysis, olecranon, or neither). Intraobserver reliability was determined by scrambling the order of the fractures and having each observer classify all the fractures again after a washout period ≥ 6 weeks. Interobserver reliability was obtained to assess the overall agreement between observers. κ Values were calculated for both intraobserver reliability and interobserver reliability. RESULTS: The average intraobserver agreement was 0.87 (almost perfect agreement; range, 0.76-0.91). Interobserver agreement was 0.80 (substantial agreement; range, 0.70-0.90) for the first reading session and 0.89 (almost perfect agreement; range, 0.85-0.93) for the second reading session. The overall average interobserver agreement was 0.85 (almost perfect agreement; range, 0.79-0.91). CONCLUSION: Classifying proximal trans-ulnar fracture-dislocations based on what the coronoid remains attached to (olecranon, ulnar metaphysis, or neither) was associated with almost perfect intraobserver and interobserver agreement, regardless of trauma vs. shoulder and elbow fellowship training. Further research is needed to determine whether the use of this classification system leads to the application of principles specific to the management of these injuries and translates into better outcomes.

Acute versus delayed radial head arthroplasty for the treatment of radial head fractures.

BACKGROUND: Radial head arthroplasty (RHA) is an important tool in the acute treatment of comminuted radial head and neck fractures. RHA is also performed in a delayed manner after failed open reduction and internal fixation, for fracture malunion or nonunion, and other chronic post-traumatic elbow disorders where restoration of the lateral column of the elbow is considered necessary. The relative efficacy and longevity of acute vs. delayed RHA is unknown. We sought to compare clinical, radiographic, and patient-reported outcomes between these groups. METHODS: We identified patients ≥18 years old who underwent an RHA between 2000 and 2018 and then extracted 135 total elbows with a mean follow-up of 2.3 years that sustained isolated radial head fractures (30%), terrible triad injuries (66%), or Essex-Lopresti injuries (4%). The acute cohort (RHA: <12 weeks) contained 101 elbows that underwent surgery at a mean of 0.6 weeks (range, 0 days to 7 weeks, 96% <2 weeks) from injury, whereas the delayed cohort (RHA: 12 weeks to 2 years) contained 34 elbows that underwent surgery at a mean of 36 weeks (range, 14-82 weeks) from injury. Patients in the acute group had a higher percentage of terrible triad injuries (75% vs. 40%, P < .001) and Mason 3 fractures (98% vs. 45%, P < .001). RESULTS: At the final follow-up, 13 of 101 patients in the acute cohort (13%) and 7 of 34 patients in the delayed cohort (21%) required implant revision or resection. A total of 25 patients (25%) in the acute cohort and 12 patients (35%) in the delayed cohort required a reoperation. Kaplan-Meier 2-year survival estimates free of implant resection or revision (90% acute, 86% delayed) and reoperation (76% acute, 70% delayed) were similar between groups. In patients with 5-year follow-up, there was an increased rate of revision or resection in the delayed group (30% vs. 13%). Two-year survival estimates free of radiographic loosening were 80% in the acute cohort vs. 57% in the delayed cohort (P = .04). Mayo Elbow Performance Score at 2 years demonstrated mean scores of 83 and 79 in the acute and delayed groups, respectively, with 71% of the acute cohort and 64% of the delayed cohort achieving good or excellent scores. CONCLUSIONS: Our results demonstrated that although 2-year Kaplan-Meier survival free of revision or resection estimates and reoperation rates was equivalent between the groups, the delayed group experienced worse Mayo Elbow Performance Score outcomes, a higher revision or resection rate at 5 years, and an increased rate of radiographic loosening.

Does proximal versus distal injury location of the medial ulnar collateral ligament of the elbow differentially impact elbow stability? An ultrasound-guided and robot-assisted biomechanical study.

BACKGROUND: The location (proximal vs. distal) of elbow medial ulnar collateral ligament (MUCL) tears impacts clinical outcomes of nonoperative treatment. The purposes of our study were to (1) determine whether selective releases of the MUCL could be performed under ultrasound (US) guidance without disrupting overlying soft tissues, (2) assess the difference in medial elbow stability for proximal and distal releases of the MUCL using stress US and a robotic testing device, and (3) elucidate the flexion angle that resulted in the greatest amount of medial elbow laxity after MUCL injury. METHODS: Sixteen paired, fresh-frozen elbow specimens were used. Valgus laxity was evaluated with both US and robotic-assisted measurements before and after selective MUCL releases. A percutaneous US-guided technique was used to perform proximal MUCL releases in 8 elbows and to perform distal MUCL releases in their matched pairs. The robot was used to determine the elbow flexion angle at which the maximum valgus displacement occurred for both proximally and distally released specimens. Open dissection was then performed to assess the accuracy of the percutaneous releases. RESULTS: Percutaneous US-guided releases were successfully performed in 15 of 16 specimens. The proximal release resulted in greater valgus angle displacement (11° ± 2°) than the distal release (8° ± 2°) between flexion angles of 30° and 70° (P < .0001 at 30°, P < .0001 at 40°, P = .001 at 50°, P = .005 at 60°, and P = .020 at 70°). Valgus displacement between release locations did not reach the level of statistical significance between 80° and 120° (P = .051 at 80°, P = .131 at 90°, P = .245 at 100°, P = .400 at 110°, and P = .532 at 120°). When we compared the values for the mean increase in US delta gap (stressed - supported state) from before to after MUCL release, the proximally released elbows had larger increases than the distally released elbows (5.0 mm proximal vs. 3.7 mm distal, P = .032). After MUCL release, maximum mean valgus displacement occurred at 49° of flexion. CONCLUSIONS: US-guided selective releases of the MUCL can be performed reliably without violating the overlying musculature. Valgus instability is not of greater magnitude for distal releases when compared with proximal releases. This findings suggests there must be alternative factors to explain the difference in clinical prognosis between distal and proximal tears. The observed flexion angle for maximum valgus laxity could have important implications for elbow positioning during US or fluoroscopic stress examination, as well as surgical repair or reconstruction of the MUCL.

Radial Head Prosthetic Replacement in Adolescents: A Report of 5 Cases.

BACKGROUND: The management of severe radiocapitellar joint pathologies in young patients is challenging. Radial head arthroplasty (RHA) is a treatment option in the adult population, but most surgeons avoid implementing it in younger patients, and there are no published results for patients younger than 16 years. METHODS: Our retrospective cohort describes 5 patients (4 male 1 female) who underwent cementless modular RHA at an average age of 14 years (range: 13 to 15). The preoperative diagnoses were post-traumatic radiocapitellar incongruity and arthrosis because of previous Salter-Harris type 3 or 4 fractures of the radial head in 3 cases; and axial instability of the forearm following failed radial head excision in 2 cases. Because of the complexity of the elbow pathology in these cases, all underwent concomitant procedures including: contracture release (5 cases), corrective ulnar osteotomy (2 cases), distal ulnar shortening osteotomy, excision of radioulnar synostosis, microfracture of the capitellum, and partial excision of the medial triceps (1 case each). Collected data included patient-reported outcomes, visual analog scale pain score at rest and during physical activity and radiographic assessment of arthritis and prosthesis loosening. RESULTS: Average clinical follow-up was 8 years (range: 3 to 13). All 5 patients were pain-free at rest, and 3 reported moderate elbow pain (visual analog scale: 5 to 6) with physical activity. At an average radiographic follow-up of 3 years (range: 0.5 to 5), 3 patients showed mild progression of elbow arthrosis, but there were no signs of progressive capitellar erosion or implant loosening. Only 1 complication was noted-development of heterotopic ossification in 1 patient, which required open heterotopic ossification excision and contracture release 2 years following the RHA. None of the patients required prosthesis revision or removal. CONCLUSION: RHA was successful in improving pain and axial forearm stability in this very small series of adolescent patients. Concerns regarding long-term longevity and complications still exist. Considering the lack of other reliable treatment options, RHA may be indicated in this challenging patient population. LEVEL OF EVIDENCE: Level IV: therapeutic study-case series.

Preoperative sonographic ulnar nerve mapping in the postoperative elbow.

OBJECTIVE: To describe the technique of sonographic ulnar nerve mapping in the postoperative elbow for surgical planning. MATERIALS AND METHODS: A retrospective review of a surgical databank identified 24 patients, all aged 18 years and older with a history of orthopedic elbow surgery, who were referred for preoperative sonographic mapping of the ulnar nerve prior to subsequent surgery. All cases were reviewed for patient demographics, clinical presentation, prior surgical interventions, and ultrasound technique. Charts were reviewed for intraoperative and postoperative outcomes, including nerve injury. RESULTS: The cohort included 12 males and 12 females with a mean age of 51 years (range 22-68 years) and a mean BMI of 29 (range 20-48). Preoperative sonographic ulnar nerve mapping occurred following various elbow surgeries including ulnar nerve transposition to assess nerve location prior to subsequent elbow surgery. Of the 24 patients with preoperative sonographic ulnar nerve mapping, subsequent surgery was performed arthroscopically in 14 and open in 10 cases. In 11 of the 24 cases, there was specific mention of a modified approach to joint access which was guided by the ulnar nerve map. There were no perioperative ulnar nerve-related complications, such as nerve transection. CONCLUSION: Preoperative mapping can facilitate planning of surgical access and ulnar nerve dissection. Sonographic mapping of the ulnar nerve reduces the potential uncertainty of nerve palpation in a complex postoperative elbow following ulnar nerve transposition. This technique may mitigate the risk of ulnar nerve injury.

Safety of Arthroscopic Versus Open or Combined Heterotopic Ossification Removal Around the Elbow.

PURPOSE: To analyze the complications of arthroscopic heterotopic ossification (HO) excision and compare them with those of open removal of HO or a combined open-arthroscopic approach. METHODS: We performed a retrospective review of elbow HO removal cases performed by a single surgeon from 1997 to 2014. In all cases studied, the intention was to restore range of motion owing to the presence of HO causing functional impairment. The arthroscopic, open, and combined treatment groups were compared. RESULTS: The study cohort consisted of 223 surgical procedures performed on 213 elbows in 211 patients. Fifty major complications occurred in 46 cases (21%): 17 hematomas (8%) treated by irrigation and debridement, 8 cases of HO requiring reoperation (4%), 7 deep infections (3%), 4 contractures (2%), 3 cases of delayed-onset ulnar neuritis (1%), 2 cases of distal humeral avascular necrosis (1%), 2 tendon ruptures (1%), 2 cases of instability requiring reconstruction (1%), 2 postoperative fractures (1%), 1 intraoperative fracture (<0.5%), 1 case of worsening of pre-existing neuropathic pain (<0.5%), and 1 permanent partial posterior interosseous nerve injury (<0.5%). Of these 46 cases, the major complications occurred in 6 of the 41 (15%) performed arthroscopically, in 36 of the 158 (23%) performed open and in 4 of the 21 (17%) with combined (i.e. open + arthroscopic) HO removal. Preventive strategies, introduced to prevent hematomas and delayed-onset ulnar neuritis, reduced the rate of major complications from 35% during the period from 1997 to 2005 to 10% during the period from 2006 to 2014 (P < .0001). Moreover, the rate of reoperations was reduced from 34% to 10% in the same periods (P < .0001). Minor complications occurred in 36 cases (16%), including 17 cases of transient nerve palsy, 9 cases of superficial infection or delayed wound healing, 6 cases of mild instability, and 4 cases of hematoma resolved by aspiration. CONCLUSIONS: The use of arthroscopy-or a combination of arthroscopic and open techniques-to remove HO around the elbow by a surgeon skilled in both arthroscopic and open elbow surgery does not increase the risk of major complications or need for reoperation compared with traditional open surgery. Preventive strategies, such as avoiding raising skin flaps by using multiple separate incisions for open and prophylactic ulnar nerve decompression in arthroscopic cases, were developed during the study period. These strategies were monitored prospectively and found to be effective in preventing two-thirds of the major complications needing reoperation with both open and arthroscopic HO removal. LEVEL OF EVIDENCE: Level III, retrospective comparative study of prospectively collected data.

Capitellar Osteochondritis Dissecans Lesions of the Elbow: A Systematic Review of Osteochondral Graft Reconstruction Options.

PURPOSE: To systematically evaluate the outcomes and complications of osteochondral autograft transfer (OAT) and osteochondral allograft transplantation (OCA) for the surgical treatment of capitellar osteochondritis dissecans (OCD). METHODS: A literature search was conducted across 3 databases (PubMed, Cochrane, and CINAHL [Cumulative Index to Nursing and Allied Health Literature]) from database inception through December 2019 in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. Individual study quality was assessed using the Methodological Index for Non-randomized Studies scale. Studies were published between 2005 and 2019. RESULTS: Eighteen studies consisting of 446 elbow OCD lesions treated with OAT surgery were included. There was a single OCA study eligible for inclusion. Patient ages ranged from 10 to 45 years. Of the OAT studies, 4 used autologous costal grafts whereas the remainder used autografts from the knee. Outcome measures were heterogeneously reported. A significant improvement in Timmerman-Andrews scores from preoperatively to postoperatively was reported in 9 of 10 studies. Return-to-play rates to the preinjury level of competitive play ranged from 62% to 100% across 16 studies. Significant improvement in motion, most often extension, was noted in most studies. Reported complication, reoperation, and failure rates ranged from 0% to 11%, 0% to 26%, and 0% to 20%, respectively. When used, knee autografts resulted in low donor-site morbidity (Lysholm scores, 70-100). CONCLUSIONS: OAT surgery for large, unstable OCD lesions of the capitellum reliably produced good outcomes, few complications, and a high rate of return to competitive play. Complications are relatively uncommon, and donor-site morbidity is low. Less is known about the performance of OCA given the paucity of available literature. LEVEL OF EVIDENCE: Level IV, systematic review of Level II to IV studies.

Establishing the learning curve for elbow arthroscopy: surgeon and trainee perspectives on number of cases needed and optimal methods for acquiring skill.

BACKGROUND: Elbow arthroscopy has increased in frequency as its indications have widened. Despite this growth, a learning curve has not yet been defined. HYPOTHESIS: We hypothesized that there would be significant differences in perspective between trainees and established surgeons for the number of cases needed to reach each skill level and what they felt are the most valuable training tools. METHODS: Orthopedic attending physicians and trainees were asked to complete a questionnaire assessing participant demographics, case volumes required to reach defined skill levels (novice, safe, competent, proficient, and expert), and the efficacy of various learning methodologies for elbow arthroscopy. The value of educational methods was assessed using a 5-point Likert scale (1 = not at all valuable; 5 = extremely valuable). RESULTS: The study population consisted of 323 total participants, of whom 224 (69.3%) were attending surgeons and 99 (30.7%) were trainees (resident or fellow physicians). According to the attending physicians, the mean numbers of cases needed to reach each skill level were 19 to be safe, 42 to be competent, 93 to be proficient, and 230 to be expert. These case numbers were not significantly different from the perspectives of trainees. Across the respondents, there were no significant differences in the number of cases needed to reach each level of skill based on the respondents' level of training, years of experience, type of fellowship, or self-reported skill level.Although both groups highly valued live surgery (4.7 of 5) and cadaveric practice (4.6 of 5) for acquiring skill, attendings placed higher value on reading (4.0 vs. 3.3, P < .001), videos/live demos (4.2 vs. 3.6, P < .001), and formal courses (4.5 vs. 4.1, P < .001) than trainees. Both groups place relatively low value on surgical simulators (2.8-3.6). CONCLUSIONS: There was considerable agreement among attending surgeons and trainees in terms of the number of cases needed to attain various skill levels of elbow arthroscopy, which was consistent regardless of fellowship background, self-reported skill level, career length, and elbow arthroscopy case volume. However, there was some disagreement between attending surgeons and trainees over the most valuable methods for acquiring surgical skill with trainees placing less value on textbooks, surgical videos, and formal courses compared with attending surgeons. An understanding of the elbow arthroscopy learning curve will help trainees and their training programs establish case volume targets before safe, independent practice. Future studies should aim to clinically validate this learning curve.

Management of the Posttraumatic Coronoid-Deficient Elbow.

Posttraumatic coronoid deficiency is one of the most challenging scenarios even for the most experienced elbow surgeon. Surgical options can be grouped into soft tissue reconstructions, autogenous corticocancellous bone graft reconstructions, osteochondral reconstructions, and prosthetic replacement. However, the literature is inconclusive with limited cases, short follow-up, and no conclusive clinical comparative studies of these techniques. This article provides a review of the current surgical options, and we offer the senior author's (S.W.O.) perspective after years of experience with many of these techniques.

Stem Length and Neck Resection on Fixation Strength of Press-Fit Radial Head Prosthesis: An In Vitro Model.

PURPOSE: Various radial head prosthesis designs are currently in use. Few studies compare different prosthetic designs. We hypothesized that increasing a cementless implant stem's length would reduce stem-bone micromotion, with both short and long neck cuts. We also hypothesized that a minimum stem length might be required for the initial fixation strength of a press-fit implant. METHODS: In 16 fresh-frozen cadaveric elbows (8 pairs), the radial head and neck were cut either 10 or 21 mm below the top of the head. Modular cementless stems were inserted and sequentially lengthened in 5-mm increments. Micromotion under eccentric loading was tested after each incremental change. RESULTS: Incremental lengthening of the prosthetic stem and the amount of neck resection (10-mm cut vs 21-mm cut) both had a significant effect on micromotion. After a 10-mm radial head-neck resection, we observed a significant decrease in micromotion with stem lengths of 25 mm or greater, whereas with 21 mm of neck resection there was no further reduction in micromotion with increased stem length. These differences can be explained, at least in part, by the concept of the cantilever quotient: the ratio of the head-neck length outside the bone to the total length of the implant. CONCLUSIONS: The length of the stem affects the initial stability of press-fit radial head prostheses when the level of head and neck resection is at the minimum (ie, 10 mm) for currently available prosthetic designs. At this resection level, stems 25 mm or greater had significantly higher initial stability, but all stem lengths tested had mean micromotion values within the threshold for bone ingrowth. CLINICAL RELEVANCE: The length of a radial head prosthetic stem affects the initial stability of press-fit radial head prostheses when the level of head and neck resection is at the minimum (ie, 10 mm) for currently available prosthetic designs.