Neuromuscular Electrical Stimulation-Enhanced Physical Therapist Intervention for Functional Posterior Shoulder Instability (Type B1): A Multicenter Randomized Controlled Trial.

OBJECTIVE: Functional posterior shoulder instability (FPSI) (type B1) is a severe type of instability, mainly in teenagers and young adults, that leads to loss of function, pain, and stigmatization among peers. An experimental nonsurgical treatment protocol based on neuromuscular electrical stimulation (NMES) showed very promising early results in the treatment of FPSI. The hypothesis of this study was that NMES-enhanced physical therapy leads to better outcomes than physical therapy alone as the current gold standard of treatment in patients with FPSI. METHODS: In this multicenter randomized controlled trial, patients with FPSI were randomly allocated in a 1:1 ratio to either 6 weeks of physical therapy or 6 weeks of physical therapy with simultaneous motion-triggered NMES. Baseline scores as well as outcome scores at 6 weeks, 3 months, 6 months, and 12 months after the intervention were obtained. The predefined primary outcome of this trial was the Western Ontario Shoulder Instability Index (WOSI) at the 3-month time point. RESULTS: Forty-nine patients were randomized and eligible for the trial. The group that received physical therapy with simultaneous motion-triggered NMES showed a significantly better main outcome measurement in terms of the 3-month WOSI score (64% [SD = 16%] vs 51% [SD = 24%]). Two-thirds of the patients from the physical therapist group crossed over to the group that received physical therapy with simultaneous motion-triggered NMES due to dissatisfaction after the 3-month follow-up and showed a significant increase in their WOSI score from 49% [SD = 8%] to 67% [SD = 24%]. The frequency of instability episodes showed a significant improvement in the group that received physical therapy with simultaneous motion-triggered NMES at the 3-month follow-up and beyond, while in the physical therapist group, no significant difference was observed. CONCLUSION: The current study shows that NMES-enhanced physical therapy led to statistically significant and clinically relevant improvement in outcomes in the treatment of FPSI compared to conventional physical therapy alone-from which even patients with prior unsatisfactory results after conventional physical therapy can benefit. IMPACT: Based on the results of this study, NMES-enhanced physical therapy is an effective new treatment option for FPSI, a severe type of shoulder instability. NMES-enhanced physical therapy should be preferred over conventional physical therapy for the treatment of patients with FPSI.

Clinical and Biological Differences between Upper Tract Carcinoma and Bladder Urothelial Cancer, Including Implications for Clinical Practice.

Upper tract urothelial carcinoma (UTUC) is a rare disease included, along with the much more frequent urothelial bladder cancer (BUC), in the family of urothelial carcinomas (UCs). However, while UTUCs and BUCs share several features, their epidemiological, clinical, pathological, and biological differences must be considered to establish an optimal therapeutic strategy. This review examines the clinical differences between UTUC and BUC, as well as the main results obtained by molecular screening of the two diseases. The findings of clinical trials, performed in peri-operative and metastatic settings and assessing systemic treatments in UC, are summarised. A comparison of the data obtained for UTUC and BUC suggests improved therapeutic approaches, both in regards to routine practice and future drug development.

Statistical Morphology and Fragment Mapping of Complex Proximal Humeral Fractures.

Background and Objectives: Proximal humerus fractures (PHFs) are common in the elderly, but the treatment results are often poor. A clear understanding of fracture morphology and distribution of cortical bone loss is important for improved surgical decision making, operative considerations, and new implant designs. The aim of this study was to develop a 3D segmentation fracture mapping technique to create a statistical description of the spatial pattern and cortical bone loss of complex PHFs. Materials and Methods: Fifty clinical computed tomography (CT) scans of complex PHFs and their contralateral intact shoulders were collected. In-house software was developed for semi-automated segmentation and fracture line detection and was combined with manual fracture reduction to the contralateral template in a commercial software. A statistical mean model of these cases was built and used to describe probability maps of the fracture lines and cortical fragments. Results: The fracture lines predominantly passed through the surgical neck and between the tuberosities and tendon insertions. The superior aspects of the tuberosities were constant fragments where comminution was less likely. Some fracture lines passed through the bicipital sulcus, but predominantly at its edges and curving around the tuberosities proximally and distally. Conclusions: A comprehensive and systematic approach was developed for processing clinical CT images of complex fractures into fracture morphology and fragment probability maps and applied on PHFs. This information creates an important basis for better understanding of fracture morphology that could be utilized in future studies for surgical training and implant design.

Two cases of sternoclavicular joint replacement arthroplasty: A case report. A novel prosthesis and surgical technique for recalcitrant instability, arthropathy of the sternoclavicular joint with medial clavicular bone loss.

Instability arthropathy of the sternoclavicular joint is most commonly managed by rehabilitation, injection, and either arthroscopic or open debridement with or without interposition arthroplasty. When these options fail to achieve symptom relief, excision arthroplasty is an option. This is associated with a risk of persistent instability and incomplete pain relief. We describe two cases in which custom sternoclavicular joint replacement was performed for painful insufficiency of scapular suspension. Although the prostheses remained secure in both cases, the first case was complicated by persistent instability due to insufficient reconstruction of the intrinsic sternoclavicular capsular ligaments. This was recognised and corrected for in the second case, in which stability of the sternoclavicular joint replacement has been noted on more than a 5-year review. We conclude that sternoclavicular joint replacement is an option for patients in whom instability arthropathy remains an intrusive problem in daily life after other conventional treatments have not controlled symptoms. Stability of the joint remains a concern. We offer one method of achieving stability through an iterative design process including the ability to reconstruct the intrinsic capsular ligaments around the articulation.

Homogeneity in Surgical Series: Image Reporting to Improve Evidence.

Good clinical practice guidelines are based on randomized controlled trials or clinical series; however, technical performance bias among surgical trials is under-assessed. The heterogeneity of technical performance within different treatment groups diminishes the level of evidence. Surgeon variability with different levels of experience-technical performance levels even after certification-influences surgical outcomes, especially in complex procedures. Technical performance quality correlates with the outcomes and costs and should be measured by image or video-photographic documentation of the surgeon's view field during the procedures. Such consecutive, completely documented, unedited observational data-in the form of intra-operative images and a complete set of eventual radiological images-improve the surgical series' homogeneity. Thereby, they might reflect reality and contribute towards making necessary changes for evidence-based surgery.

Quantifying osteosynthesis plate prominence - mathematical definitions and case study on a clavicle plate.

Hardware prominence remains a clinical challenge in focus for implant design in subcutaneous plate applications. Existing evaluation of hardware prominence relies on plate-to-bone distance at a single point or on average. A reproducible measure for plate prominence remains undefined. This study mathematically defines the plate prominence linked to the cross-sectional area change due to the plate presence on the bone. Two anatomical plate designs were fitted to 100 clavicles, and afterwards plate prominence parameters were evaluated and compared. This methodology enables the quantification of hardware prominence for different plate designs to inform the development of implants targeting low prominence.

Real-world patient data: Can they support decision making and patient engagement?

Patient-reported outcomes (PROs) capture data related to patients' perception of their health status and aspects of health care delivery. In parallel, digital innovations have advanced the administration, storage, processing, and accessibility of PROs, allowing these data to become actively incorporated in day-to-day clinical practice along the entire patient care pathway. Further, the emergence of shared decision making, where patients are engaged in informed treatment selection aligned with their preferences, values, and needs, can be realized by PROs and technology. This technology-enabled, data-driven approach provides insights which, when actioned, can enhance musculoskeletal care of patients and populations, while enriching the clinician-patient experience of decision making. In this review, we provide an overview of the opportunities enabled by PROs and technology for the cycle of orthopedic care.

The influence of three-dimensional structure on naïve T cell homeostasis and aging.

A breakdown in cellular homeostasis is thought to drive naïve T cell aging, however the link between naïve T cell homeostasis and aging in humans is poorly understood. To better address this, we developed a lymphoid organoid system that maintains resting naïve T cells for more than 2 weeks, in conjunction with high CD45RA expression. Deep phenotypic characterization of naïve T cells across age identified reduced CD45RA density as a hallmark of aging. A conversion from CD45RAhigh naive cells to a CD45RAlow phenotype was reproduced within our organoid system by structural breakdown, but not by stromal cell aging or reduced lymphocyte density, and mediated by alternative CD45 splicing. Together, these data suggest that external influences within the lymph node microenvironment may cause phenotypic conversion of naïve T cells in older adults.

Specific Binding of Primary Ammoniums in Aqueous Media by Homooxacalixarenes Incorporated into Micelles.

The development of artificial receptors for efficient recognition of analytes in water is a challenging task. Homooxacalix[3]arene-based receptor 1, which is selective toward primary ammoniums in organic solvents, was transferred into water following two different strategies: direct solubilization and micellar incorporation. Extensive 1H NMR studies showed that recognition of ammoniums is only observed in the case of micellar incorporation, highlighting the beneficial effect of the microenvironment of the micellar core. The selectivity of the system for primary ammoniums over secondary and tertiary ones was also maintained. The hydrophobic effect plays an important role in the recognition properties, which are counterion-dependent due to the energy penalty for the dissociation of certain ammonium salts in the apolar micellar core. This study shows that the straightforward self-assembly process used for the encapsulation of artificial receptors in micelles is an efficient strategy for developing water-soluble nanosized supramolecular recognition systems.

Understanding and strengthening wildlife and zoonotic disease policy processes: A research imperative.

The COVID-19 pandemic highlights the urgency and importance of monitoring, managing and addressing zoonotic diseases, and the acute challenges of doing so with sufficient inter-jurisdictional coordination in a dynamic global context. Although wildlife pathogens are well-studied clinically and ecologically, there is very little systematic scholarship on their management or on policy implications. The current global pandemic therefore presents a unique social science research imperative: to understand how decisions are made about preventing and responding to wildlife diseases, especially zoonoses, and how those policy processes can be improved as part of early warning systems, preparedness and rapid response. To meet these challenges, we recommend intensified research efforts towards: (i) generating functional insights about wildlife and zoonotic disease policy processes, (ii) enabling social and organizational learning to mobilize those insights, (iii) understanding epistemic instability to address populist anti-science and (iv) anticipating evolving and new zoonotic emergences, especially their human dimensions. Since policy processes for zoonoses can be acutely challenged during the early stages of an epidemic or pandemic, such insights can provide a pragmatic, empirically-based roadmap for enhancing their robustness and efficacy, and benefiting long-term decision-making efforts.

International consensus for a core radiological monitoring protocol of proximal humerus fractures.

BACKGROUND: Proximal humerus fractures (PHF) should be subject to standardized monitoring during treatment, whether non-operative or operative, to document and adequately assess bone healing. The purpose of this study was to develop a standardized protocol for an image-based monitoring of PHF for joint-preserving treatment options, including a minimum set of descriptors or definitions of features of radiographic images, to be applied in clinical routine practice and studies. METHODS: A Delphi exercise was implemented with an international panel of experienced shoulder trauma surgeons self-selected after invitation of all AO Trauma members. Using open questions participants recommended the type and timing of desired diagnostic images, and formulated definitions for the imaging parameters they considered most important. Formulated recommendations for the type and timing of radiological fracture monitoring and clarification of the definitions of the proposed radiological parameter set were subjected to further survey. Consensus for each factor was considered to have been reached when there was at least a two-thirds agreement in the survey participants. RESULTS: Response rates of 231 interested surgeons were 66% and 44% for the first and second survey respectively. Sixty percent of participants to the first survey responded to the second (131/219). 93% of respondents considered radiographic monitoring to be an important part of fracture care. 92% of respondents to the first survey considered that 'malreduction' should be assessed, and 165 of 189 respondents provided a suggestion for a definition for this parameter. 88% of respondents to the second survey agreed on a redefinition of the term 'malreduction' as 'non-anatomical fracture reduction'. There was substantial agreement about the radiographic views and orientation of radiographs to be recorded (80%) and the timing of radiological reviews (67- 78% for time points during follow up). Just over half of respondents recommended cessation of radiological review when fracture healing was considered to have occurred by radiological evaluation. CONCLUSION: Our work confirmed the need for clear definitions of radiological features that should be considered in the follow-up of proximal humeral fractures. It has resulted in the development of an international consensus monitoring protocol for PHF treatment with a structured core set of radiological parameters. Clinical application and validation of the monitoring process are needed.

Developing, Implementing, and Evaluating an Artificial Intelligence-Guided Mental Health Resource Navigation Chatbot for Health Care Workers and Their Families During and Following the COVID-19 Pandemic: Protocol for a Cross-sectional Study.

BACKGROUND: Approximately 1 in 3 Canadians will experience an addiction or mental health challenge at some point in their lifetime. Unfortunately, there are multiple barriers to accessing mental health care, including system fragmentation, episodic care, long wait times, and insufficient support for health system navigation. In addition, stigma may further reduce an individual's likelihood of seeking support. Digital technologies present new and exciting opportunities to bridge significant gaps in mental health care service provision, reduce barriers pertaining to stigma, and improve health outcomes for patients and mental health system integration and efficiency. Chatbots (ie, software systems that use artificial intelligence to carry out conversations with people) may be explored to support those in need of information or access to services and present the opportunity to address gaps in traditional, fragmented, or episodic mental health system structures on demand with personalized attention. The recent COVID-19 pandemic has exacerbated even further the need for mental health support among Canadians and called attention to the inefficiencies of our system. As health care workers and their families are at an even greater risk of mental illness and psychological distress during the COVID-19 pandemic, this technology will be first piloted with the goal of supporting this vulnerable group. OBJECTIVE: This pilot study seeks to evaluate the effectiveness of the Mental Health Intelligent Information Resource Assistant in supporting health care workers and their families in the Canadian provinces of Alberta and Nova Scotia with the provision of appropriate information on mental health issues, services, and programs based on personalized needs. METHODS: The effectiveness of the technology will be assessed via voluntary follow-up surveys and an analysis of client interactions and engagement with the chatbot. Client satisfaction with the chatbot will also be assessed. RESULTS: This project was initiated on April 1, 2021. Ethics approval was granted on August 12, 2021, by the University of Alberta Health Research Board (PRO00109148) and on April 21, 2022, by the Nova Scotia Health Authority Research Ethics Board (1027474). Data collection is anticipated to take place from May 2, 2022, to May 2, 2023. Publication of preliminary results will be sought in spring or summer 2022, with a more comprehensive evaluation completed by spring 2023 following the collection of a larger data set. CONCLUSIONS: Our findings can be incorporated into public policy and planning around mental health system navigation by Canadian mental health care providers-from large public health authorities to small community-based, not-for-profit organizations. This may serve to support the development of an additional touch point, or point of entry, for individuals to access the appropriate services or care when they need them, wherever they are. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/33717.

Numerical simulation of wave propagation through interfaces using the extended finite element method for magnetic resonance elastography.

Magnetic resonance elastography (MRE) is an elasticity imaging technique for quantitatively assessing the stiffness of human tissues. In MRE, finite element method (FEM) is widely used for modeling wave propagation and stiffness reconstruction. However, in front of inclusions with complex interfaces, FEM can become burdensome in terms of the model partition and computationally expensive. In this work, we implement a formulation of FEM, known as the eXtended finite element method (XFEM), which is a method used for modeling discontinuity like crack and heterogeneity. Using a level-set method, it makes the interface independent of the mesh, thus relieving the meshing efforts. We investigate this method in two studies: wave propagation across an oblique linear interface and stiffness reconstruction of a random-shape inclusion. In the first study, numerical results by XFEM and FEM models revealing the wave conversion rules at linear interface are presented and successfully compared to the theoretical predictions. The second study, investigated in a pseudo-practical application, demonstrates further the applicability of XFEM in MRE and the convenience, accuracy, and speed of XFEM with respect to FEM. XFEM can be regarded as a promising alternative to FEM for inclusion modeling in MRE.

Three-dimensional morphometric analysis of the lateral clavicle and acromion: Implications for surgical treatment using subacromial support.

Objectives: Dislocations and periarticular fractures of the acromioclavicular joint are common injuries of the shoulder girdle. When surgical intervention is indicated, subacromial support is one option to restore the alignment between scapula and the distal/lateral clavicle. Devices used for subacromial support rely on a form of subacromial 'hook'. The shape, inclination and orientation of which is often mismatched to the anatomy of the inferior surface of the acromion, which may lead to painful acromial osteolysis and rotator cuff abrasion causing impingement. The primary goal of this study was to characterize the geometrical parameters of the acromion and distal clavicle, and their orientation at the acromioclavicular joint. Methods: Computed tomography scans of 120 shoulders were converted into digital three-dimensional models. Measurements of the acromion inclination and acromion width relative to the torsional angle as well as the clavicle depth were taken. A numerical optimization of the anatomical parameters (including torsional and inclination angles, height and width) was performed to find the combination of those parameters with the lowest interpatient variability. Results: The mean clavicle depth was found to be 11.1 mm. The mean acromion width was 27 mm. The combination of torsional and inclination angles with lowest interpatient variability was found at 80° and 16°, respectively. Conclusion: There is a high interpatient variability in the morphology of the inferior surface of the acromion. Subacromial support using a 'hook' can be optimized for contact surface area, which should lead to fewer complications after the restoration of acromioclavicular orientation using acromial support strategies.

Ensuring Equity and Inclusion in Virtual Care Best Practices for Diverse Populations of Youth with Chronic Pain.

Poor access to care is a top patient-oriented research priority for youth with chronic pain in Canada, and the COVID-19 pandemic has exacerbated these concerns. Our patient-oriented project team engaged with marginalized and racialized youth with chronic pain (Black youth with sickle cell disease, Indigenous youth and youth with complex medical needs) and their families to ensure that best practice recommendations for virtual care are inclusive and equitable. Input provided through virtual round-table discussions improved recommendations for leveraging, implementing and selecting best platforms for virtual care for youth with chronic pain and identified new gaps for future research, practice and policy change.

Surgical treatment, complications, reoperations, and healthcare costs among patients with clavicle fracture in England.

INTRODUCTION: The clinical and economic burden of clavicle fractures in England is not well documented. This study evaluated rates of surgical treatment, post-surgical complications, reoperations and costs in patients with clavicle fractures using the Clinical Practice Research Datalink (CPRD) database. METHODS: CPRD data were linked to National Health Service Hospital Episode Statistics data. Patients with a diagnosis of clavicle fracture between 2010-2018 were selected in CPRD (date of fracture = index date). Of those, patients with surgical intervention within 180 days from index fracture were identified. Rates of post-surgical complications (i.e., infection, non-union, and mal-union), reoperations (for device removal or for postoperative complications), post-operative costs and median time to reoperations were evaluated up to 2 years after surgery. RESULTS: 21,340 patients with clavicle fractures were identified (mean age 35.0 years(standard deviation (SD): 26.5), 66.7% male). Surgery was performed on 672 patients (3.2% of total cohort) at an average 17.1 (SD: 25.2) days post-fracture. Complications (i.e., infection, non-union, or malunion) affected 8.1% of surgically treated clavicle fracture patients; the rate of infection was 3.5% (95% CI, 1.7%- 5.2%), non-union 4.4% (95% CI, 2.4%-6.5%), and mal-union 0.3% (95% CI, 0%-0.7%). Adjusting for age, gender, comorbidities and time to surgery, the all-cause reoperation rate was 20.2% (13.2%-30.0%) and the adjusted rate of reoperation for implant removal was 17.0% (10.7%-25.9%)-84% of all-cause reoperations were thus performed for implant removal. Median time to implant removal was 254 days. The mean cost of reoperations for all causes was £5,000. The most expensive reoperations were for cases that involved infection (mean £6,156). CONCLUSIONS: Complication rates following surgical clavicle fracture care averaged 8.1%. However, reoperation rates exceed 20%, the vast majority of reoperations being performed for device removal. Technologies to alleviate secondary device removal surgeries would address a significant clinical unmet need.

The anatomy and variation of the coracoid attachment of the subclavius muscle in humans.

The functions of the subclavius muscle (SM) are described as stabilization of the sternoclavicular joint (SCJ) and resisting elevation of the lateral end of the clavicle. During systematic cadaveric dissections, we observed additional fibrous structures, previously described as variants of the anatomy, extending from the SM and inserting into the coracoid process (CP). Due to the high incidence of these structures in our dissections, we hypothesized that the attachment at the CP is more common than appreciated and that, as a corollary, the function of the SM was (or has been) more complex than simply depressing the clavicle and generating stability at the SCJ. For our investigation, fifty-two upper extremities of 26 human cadavers were dissected. The SM was demonstrated from costal to clavicular attachment. We documented additional fibrous structures apparently derived from the SM inserting into the CP. Measurements of the length of the SM, the length of its attachment, and the length of the clavicle were taken in situ, with the specimens supine and the upper extremity in the anatomical position. Variations in the anatomy of the SM and its coracoidal attachment were recorded, and potential correlations were investigated. For documentation purposes photographs and video sequences of passive motion of the shoulder girdle of the specimens were taken. In 49 of the 52 specimens we found additional fibrous structures passing from the SM to the CP. We differentiated three types: (1) a strong cord-like structure; (2) a small or thin cord-like structure or structures; and (3) a planar twisted sheet-like structure. The SM and its extension to the CP appears to contribute to a 'functional scapular suspension system' together with the other muscles enveloped by the clavipectoral fascia (pectoralis minor, coracobrachialis and the short head of the biceps brachii). This system assists in the control of the position of the scapula in relation to the thorax, particularly in elevated positions of the upper extremity. We speculate that the differentiation of the fibrous structure depends on the functional demands of the individual. Level of Evidence: Basic science study.

Core set of unfavorable events of proximal humerus fracture treatment defined by an international Delphi consensus process.

BACKGROUND: Proximal humerus fracture (PHF) complications, whether following surgery or nonoperative management, require standardization of definitions and documentation for consistent reporting. We aimed to define an international consensus core event set (CES) of clinically-relevant unfavorable events of PHF to be documented in clinical routine practice and research. METHODS: A Delphi exercise was implemented with an international panel of experienced shoulder trauma surgeons selected by survey invitation of AO Trauma members. An organized list of PHF events after nonoperative or operative management was developed and reviewed by panel members using on-line surveys. The proposed core set was revised regarding event groups along with definitions, specifications and timing of occurrence. Consensus was reached with at least a two-third agreement. RESULTS: The PHF consensus panel was composed of 231 clinicians worldwide who responded to at least one of two completed surveys. There was 93% final agreement about three intraoperative local event groups (device, osteochondral, soft tissue). Postoperative or nonoperative event terms and definitions organized into eight groups (device, osteochondral, shoulder instability, fracture-related infection, peripheral neurological, vascular, superficial soft tissue, deep soft tissue) were approved with 96 to 98% agreement. The time period for documentation ranged from 30 days to 24 months after PHF treatment depending on the event group and specification. The resulting consensus was presented on a paper-based PHF CES documentation form. CONCLUSIONS: International consensus was achieved on a core set of local unfavorable events of PHF to foster standardization of complication reporting in clinical research and register documentation. TRIAL REGISTRATION: Not applicable.

The cell-surface 5'-nucleotidase CD73 defines a functional T memory cell subset that declines with age.

Memory T cells exhibit considerable diversity that determines their ability to be protective. Here, we examine whether changes in T cell heterogeneity contribute to the age-associated failure of immune memory. By screening for age-dependent T cell-surface markers, we identify CD4 and CD8 memory T cell subsets that are unrelated to previously defined subsets of central and effector memory cells. Memory T cells expressing the ecto-5'-nucleotidase CD73 constitute a functionally distinct subset of memory T cells that declines with age. They resemble long-lived, polyfunctional memory cells but are also poised to display effector functions and to develop into cells resembling tissue-resident memory T cells (TRMs). Upstream regulators of differential chromatin accessibility and transcriptomes include transcription factors that facilitate CD73 expression and regulate TRM differentiation. CD73 is not just a surrogate marker of these regulatory networks but is directly involved in T cell survival.

Revision total elbow replacement.

The range of general and specific adverse event in total elbow arthroplasty is similar in principle and practice to all other revision prosthetic arthroplasty but with three particular challenges: loss of humeral and ulnar bone stock; insufficiency of the extensor 'mechanism'; and the management of the ulnar nerve. Total elbow replacement is presently performed for the management of complex non-reconstructable distal humeral fractures in osteoporotic bone, for post-traumatic arthropathy, and for medically managed inflammatory arthritides in which metaphyseal bone architecture is often preserved while the articular surface is degenerate. In all these conditions the patient often presents for revision total elbow arthroplasty with relevant co-morbidities and relevant musculoskeletal dysfunction (for example: ipsilateral shoulder, wrist, thumb or hand dysfunction). Infection is a universal concern for revision arthroplasty but where the soft tissue 'envelope' is compromised and already limited, as in the proximal forearm, it is difficult to eradicate, particularly in immunocompromised patients. Bone loss compromises subsequent implantation of a revision prosthesis, while failure to restore the working lengths of the humerus and ulna reduces the strength of the flexor and extensor compartment muscles for elbow motion. Failure to restore the continuity of the triceps aponeurosis - antebrachial fascia and triceps medial head-olecranon components of the extensor 'mechanism' also compromises extensor power. Prior triceps-dividing surgical approaches will determine the elasticity, and therefore pliability, of the extensor 'mechanism': this will have a role in determining how much gain in length of the humeral side can be safely achieved. The ulnar nerve, and its management during elbow arthroplasty, is a source of frequent concern, particularly for revision of an elbow arthroplasty undertaken for distal non-reconstructable humeral articular fractures or post-traumatic arthropathy, in which the position of the ulnar nerve is never anatomic. For these reasons revision total elbow replacement (RTER) is challenging: it requires experience with surgical exposures of the elbow including the major nerve trunks, familiarity with the restoration of bone stock, a range of prostheses and techniques for prosthetic implantation, the ability to achieve adequate soft tissue cover and primary closure, and a logical approach to individualised rehabilitation.