Postoperative Elbow Instability: Options for Revision Stabilization.

Persistent and recurrent postoperative elbow instability includes a spectrum of pathologies ranging from joint incongruity and subluxation to dislocation. Restoration of osseous anatomy, particularly the coronoid, is a priority in restoring elbow alignment and maintaining ulnohumeral joint stability. After managing bony deficiencies, soft-tissue and ligamentous structures are typically addressed. When required, both static and dynamic adjunctive stabilization procedures have been described, which aid in maintaining a concentric reduction. In these complex procedures, both complication avoidance and early recognition of postoperative complications assist in obtaining a good result. In this review, we discuss current treatment options for revision stabilization for patients with persistent and recurrent elbow subluxation or dislocation after primary stabilization.

Ulnohumeral Cross-Pinning in the Management of Traumatic Elbow Instability.

PURPOSE: Traumatic elbow instability (subluxation and dislocation) represents a challenging clinical entity that can be complicated by persistent intraoperative instability after attempted stabilization or recurrent postoperative instability. Both static and dynamic supplemental stabilization procedures have been described for cases where fracture fixation and ligament repair fail to restore stability. There is a paucity of prior studies involving ulnohumeral cross-pinning (UCP), which is a type of static supplemental stabilization. Our purpose was to assess complications and outcomes after UCP. METHODS: We reviewed all surgical cases involving primary and revision UCP for traumatic elbow instability at a single center from 2017-2023. Baseline demographics were recorded. Outcomes including radiographs, range of motion, patient-reported outcome measures, and surgical complications were analyzed. RESULTS: Fourteen patients undergoing UCP were included with a mean follow-up of 27 months. Five cross-pinnings (36%) were performed during revision procedures. Mean visual analog scale (VAS) pain, Disabilities of the Arm, Shoulder, and Hand (QuickDASH), and the Single Assessment Numeric Evaluation (SANE) scores were 2.4, 34, and 69, respectively. The mean flexion-extension and pronation-supination arcs were 114° and 140°, with 85% achieving at least a 100° arc for flexion and forearm rotation. Five patients (36%) had complications, all of which required reoperation. Two complications involved postoperative instability: one radial head subluxation and one radial head dislocation. Both occurred in revision UCP cases indicated for recurrent postoperative instability. CONCLUSIONS: Ulnohumeral cross-pinning for persistent and recurrent elbow instability results in maintained ulnohumeral joint alignment, functional arcs of elbow range of motion, and acceptable patient-reported outcome measures, particularly in the setting of a primary procedure indicated for persistent intraoperative instability. Ulnohumeral cross-pinning is a reasonable supplemental stabilization procedure for complex elbow instability. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

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 AND METHODS: Between 2002 and 2019, 32 consecutive trans-ulnar basal coronoid fracture-dislocations underwent open reduction and internal fixation 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 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, HO, 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.

Bridge plating is an effective adjunct treatment for complex elbow instability.

BACKGROUND: Managing persistent elbow instability and chronic dislocations presents challenges despite traditional treatments. Supplementary methods like immobilization and various fixations, though common, can carry high complication rates. This study assesses the efficacy of bridge plating in treating complex elbow instability through a retrospective review of patients. Data on characteristics, treatment duration, range of motion, complications, and evaluation scores were analyzed, providing insights into outcomes complications associated with bridge plating. RESULTS: Eleven patients were reviewed at a mean follow-up of 80 ± 68 weeks postoperatively. The mean age was 53 ± 14 years and there were 5 females and 6 males. The mean body mass index was 38. Bridge plating was used for a spectrum of complex elbow injuries. The mean time from injury to bridge plating in acute cases was 29 ± 19 days and 344 ± 381 days in chronic cases. The mean duration of bridge plating was 121 ± 72 days. At the time of plate removal, mean intraoperative elbow motion was extension 58° ± 12°, flexion 107° ± 14°, supination 66° ± 23° and pronation 60° ± 26°. At the latest follow-up visit, mean elbow motion was extension 37° ± 22°, flexion 127° ± 17°, supination 72° ± 15°, and pronation 63° ± 18°. There were 6 complications (55%): heterotopic ossification, ulnar neuropathy, wound failure over the plate in a thin patient, an ulnar shaft periprosthetic fracture due to a seizure-induced fall, and persistent elbow subluxation despite bridge plate fixation. Finally, 1 patient sustained a fracture of a 3.5-mm locking bridge plate. One patient required a contracture release for persistent stiffness. Four of these complications can be directly attributed to the use of the bridge plate (36%). At final follow-up, the mean patient-rated elbow evaluation score was 34, with 0 indicating no pain and disability. The mean Single Assessment Numeric Evaluation score was 66% for the 8 patients who had this available, with 100% being the best possible attainable score. CONCLUSION: Bridge plating effectively maintains joint reduction in selected complex elbow instability cases. However, patients with bridge plates often require a second surgery for removal and experience high rates of general complications because of the complexity of their condition.

Supracondylar ostectomy and shortening (S.O.S.) for distal humerus nonunions.

BACKGROUND: 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 intra-articular 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 (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. 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 < .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, 25-100 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.

Mid- to long-term functional outcome and return to sport after elbow dislocation in bouldering: a clinical retrospective cohort study.

INTRODUCTION: Traumatic elbow dislocations are among the most common injuries in sport climbing. They occur most frequently in bouldering (a climbing discipline with strong upward trend often performed indoors) due to the typical low-height backward fall into crashpads. There is still no data about the functional outcome and return to sport of this typical bouldering injury. MATERIALS AND METHODS: All Patients with elbow dislocations due to a bouldering associated fall between 2011 and 2020 were identified retrospectively in our level I trauma centre. Trauma mechanisms, injury types and therapies were obtained. Follow-up was performed with an online questionnaire including sports-related effects, return to sport and the Elbow Self-Assessment Score (ESAS). RESULTS: 30 patients with elbow dislocations after bouldering accidents were identified. In 22 (73.3%) patients the injury was a simple dislocation. The questionnaire was completed by 20 patients. The leading mechanism was a low-height fall into crashpads. Surgical procedures were performed in every second patient. 18 patients (90%) reported return to bouldering after 4.7 ± 2.1 months. 12 patients (66.7%) regained their pre-injury level. Mid-/Long-term follow-up (mean 105 ± 37.5 months) showed excellent results in ESAS score (97.2 ± 3.9 points). Persistent limited range of motion or instability was reported by only 3 patients (15%). CONCLUSION: Most athletes are able to return to bouldering but only two thirds regain their pre-injury performance level in this demanding upper-extremity sport. The unique low-height trauma mechanism may create a false sense of security. Specific awareness and safety features should be placed for climbing athletes to reduce elbow injuries.

Short-Term Patient Outcomes after Placement of an Internal Joint Stabilizer for Terrible Triad Injuries: A Multicenter Study.

PURPOSE: The purpose of this study was to assess the functional and patient-reported outcomes after the use of the internal joint stabilizer (IJS) for unstable terrible triad injuries. Specifically, we sought to determine our complication rate and the impact of complications on patient outcomes. METHODS: We identified all patients who had an IJS placed as a supplemental fixation for a terrible triad injury at two urban, level 1 academic medical centers. We reviewed these patients' charts for demographic information, complication profiles, postoperative range of motion (ROM), and pain-level data. We also collected the QuickDASH and Patient-Rated Elbow Evaluation (PREE) scores. Descriptive statistics were reported. Final visit data were compared between patients who returned to the OR for a complication and those who did not. RESULTS: From 2018 to 2020, 29 patients had an IJS placed for a terrible triad injury. The median final follow-up was 6.3 months after surgery (IQR: 6.2 months). There were 38 complications in 19 patients (65.5%) that required 12 patients to return to the OR (41.3%) for procedures beyond simple IJS removal. There were no significant differences in the ROM between patients who returned to the OR for a complication and those who did not. QuickDASH and PREE scores were greater (indicating more disability) in patients who had a complication that required a secondary surgical procedure. CONCLUSIONS: Patients who receive an IJS incur a high rate of complications. When patients sustain complications that require secondary surgeries, their ultimate functional outcome scores worsen. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Controversies in the Management of Bicolumnar Fractures of the Distal Humerus.

Bicolumnar fractures of the distal humerus pose numerous treatment challenges for upper-extremity surgeons. Although open reduction and internal fixation demonstrates advantages compared with nonsurgical treatment, restoration of osseous anatomy can be difficult, particularly for comminuted, intra-articular fractures. Despite well-recognized complications, total elbow arthroplasty remains an option for elderly patients with fractures not amenable to fixation. Although indications remain controversial, distal humerus hemiarthroplasty has emerged as a potential alternative to total elbow arthroplasty in carefully selected patients with nonreconstructable fractures. Numerous controversies remain with respect to the management decisions for these complex injuries, including the optimal surgical approach, management of the ulnar nerve, and ideal fixation constructs for open reduction internal fixation. Our purpose is to review the management of bicolumnar distal humerus fractures in adult patients and discuss current controversies related to treatment.

Mid-term outcome following radial head arthroplasty in acute trauma: risk factors for poor outcome.

BACKGROUND: The aims of this study were to evaluate the outcomes of a single type of radial head implant in a large cohort of patients at mid-term follow-up and to determine the associated risk factors for inferior functional outcomes. METHODS: We performed a retrospective follow-up assessment of 65 patients (33 women and 32 men; mean age, 53.3 years [range, 22-81 years]) who underwent radial head arthroplasty (RHA) for acute trauma between 2012 and 2018, after a minimum follow-up period of 3 years. The Mayo Elbow Performance Score, Oxford Elbow Score, Disabilities of the Arm, Shoulder and Hand score, and Mayo Modified Wrist Score were evaluated, and all available radiographs were analyzed. All complications and revision procedures were assessed. Bivariate and multivariate regression analyses were performed to identify potential risk factors for a poor outcome following RHA. RESULTS: After an average follow-up period of 4.1 years (range, 3-9.4 years), the mean Mayo Elbow Performance Score was 77.2 (standard deviation [SD], 18.9); mean Oxford Elbow Score, 32.0 (SD, 10.6); mean Mayo Modified Wrist Score, 74.6 (SD, 13.7); and mean Disabilities of the Arm, Shoulder and Hand score, 29.0 (SD, 21.2). Average range of motion measured 10° (SD, 15°) in extension, 125° (SD, 14°) in flexion, 81° (SD, 14°) in pronation, and 63° (SD, 24°) in supination. The overall complication and reoperation rates were 38.5% and 30.8%, respectively, with severe elbow stiffness being the most common reason for revision. Patient age >50 years, the use of an external fixator, the presence of accompanying medial collateral ligament injuries, and the development of higher-grade osteoarthritis were associated with a poor outcome. CONCLUSION: Satisfactory medium-term outcomes can be achieved using a monopolar, long-stemmed RHA in patients with acute trauma. However, complication and revision rates are high, frequently leading to inferior outcome scores. Additionally, a higher patient age, the use of an external fixator, the presence of accompanying medial collateral ligament injuries, and the occurrence of higher-grade osteoarthritis were associated with a poor outcome; these factors should raise awareness by the treating trauma surgeon.

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.

Monteggia fractures and Monteggia-like-lesions: a systematic review.

Monteggia injuries are rare, but severe injuries of the elbow including various injury patterns. Treatment of these injuries is still topic of debate and strategies differ widely. In this systematic review on Monteggia injuries in adults, we aimed to clarify the incidence of different injury patterns within Monteggia injuries, investigate the main reasons leading to revision surgery and explore which surgical treatments should be favored to achieve satisfactory clinical results.We initially identified 182 publications and ultimately included 17 retrospective studies comprising 651 cases. All patients were classified using the Bado classification, leading to 30.5% Bado type I fractures, 60.4% type II fractures, 5.1% type III and 3.1% type IV fractures. Mean revision rate was 23%. Ulna non-union (28%) and limited range-of-motion (22%) are the main reasons for revision surgery. Meta-analysis shows a trend toward the use of locking plates for ulna fixation which may lead to less revision surgery and fewer ulna non-unions. Further biomechanical and clinical research is necessary to clarify the role of radial head surgery.

Three Years of COVID-19 on Orthopaedic Trauma; Are We Going Back to Normality?

Background and Objective: On March 2020, our country became a protected area due to the COVID-19 pandemic. The consequences of COVID-19 on trauma surgery were great. We aimed to evaluate the activity of the Trauma Centre of a highly populated suburban area over 30 days starting from the first day of restrictions, to compare it with the same period of 2019 and 2022 and to evaluate whether a progressive return to normality has taken place. Materials and Methods: All patients older than 18 years managed in our Trauma Unit between 8 March 2020 and 8 April 2020 (the first COVID-19 period) were compared to the same period of 2019 (a COVID-19 free period) and 2022 (the second COVID-19 period). Clinical records were examined. Five categories of diagnoses and six mechanisms of injury were distinguished. Results: There were 1351 patients [M:719-F:632; mean age (SD):49.9 (18.7)], 451 [M:228-F:223; mean age (SD):55.9 (18.4)] and 894 [M:423-F:471;mean age (SD):54.1 (16.7)] in the COVID-19 free and in the first and second COVID-19 periods, respectively (p < 0.05). In 2020, the most significant decrease was registered for sprains/subluxations (80%); contusions decrease by 77% while fractures decrease only by 37%. The lowest reduction was found for dislocations (26%). In 2022, dislocations decreased by only 16% and both fractures and sprains decreased by about 30% with respect to the pre-pandemic period. Patients with minor trauma (contusions) were half compared to 2019. Accidental falls remain the most frequent mechanism of injury. The incidence of proximal femur, proximal humerus and distal radius fractures remained almost unchanged during both pre-pandemic and pandemic periods. Conclusions: COVID-19 has markedly altered orthopaedic trauma. Injuries related to sports and high energy trauma/traffic accidents drastically reduced in 2020; however, we are slowly going back to normality: the same injuries increased in 2022 due to the progressive easing of restrictions. Elderly fractures related to accidental falls remained unchanged.

The coronoid opening angle: a novel radiographic technique to assess bone loss in coronoid trauma.

BACKGROUND: Elbow fracture dislocations are complex injuries that often require surgical treatment in order to obtain a stable and congruent elbow joint. The coronoid plays a key role in the stability of this joint. Accurately identifying the degree of coronoid bone loss in the setting of traumatic elbow injuries is challenging. The purpose of this study is to describe a new radiographic measure, the coronoid opening angle (COA), to assist in estimating bone loss in these challenging fractures. METHODS: Radiographs were drawn from a regional database in a consecutive fashion. Candidate radiographs were excluded on the basis of radiographic evidence of degenerative changes, previous surgery or injury, bony deformity, and inadequate lateral view of the elbow. Normal COA, coronoid height, and calculated COA at varying amounts of bone loss were determined by 3 reviewers. RESULTS: A total of 120 subjects were included. The normal coronoid opening angle was 34° (95% CI 32.9°-34.0°) and the coronoid height, 18.8 mm (18.1-19.6). Ninety-five percent of the population had an opening angle greater than 29° (95% CI 27.2°-29°). The COA limit was calculated at 20%, 33%, and 50% of baseline coronoid height corresponding to degree of bone loss. Coronoid opening angles of 24°, 20°, and 16°, respectively, indicate the minimum bone loss of interest in 95% of the population. The intraclass correlation coefficient was found to be 0.89 or higher. CONCLUSION: In the setting of elbow trauma, it is often challenging to predict the amount of coronoid bone loss. The coronoid opening angle is a new technique and an adjunct for lateral elbow radiographs to predict the minimum coronoid bone loss. This can be used to guide clinical decision making, aid in predicting instability, and guide treatment. Future research will aim to validate this tool in the clinical trauma setting.

The Unsalvageable Radial Head in Patients Aged 30 Years and Younger.

PURPOSE: Concern exists regarding the use of radial head arthroplasty (RHA) in younger patients. This study assessed clinical, functional, and radiographic outcomes of RHA in patients aged 30 years and younger. METHODS: A retrospective review identified 26 elbows that underwent a smooth stem modular RHA in patients aged 30 years and younger at a median follow-up of 3.3 years clinically and 2.9 years radiographically. The mean age was 24 ± 5 years. Indications were acute trauma in 13 patients and chronic pathologies in the remaining 13, and these 2 groups were evaluated separately. Patients underwent clinical, functional, and radiographic evaluation. RESULTS: Average arc of motion was 137° ± 16° in the cohort with acute trauma and 120° ± 24° in the cohort with chronic pathologies. Mean Patient-Rated Elbow Evaluation scores were 23 ± 18 (acute) and 31 ± 19 (chronic). Mean Quick Disabilities of the Arm, Shoulder, and Hand scores were 18 ± 15 (acute) and 23 ± 20 (chronic). Average Mayo Elbow Performance Index scores were 90 ± 9 (acute) and 80 ± 13 (chronic). Severe capitellar erosion was present in 1 patient (4%) in the cohort with chronic pathologies. Radiographic stem lucency was seen in all cases with 10 of these (38%) graded as severe. Moderate-to-severe ulnohumeral arthritis developed in 4 patients (15%), 3 of whom were in the chronic reconstruction group. Two patients (8%) required reoperation, 1 for persistent instability and 1 for stiffness, both in the cohort with chronic pathologies. CONCLUSIONS: For acute trauma and challenging chronic conditions involving the radial head in patients aged 30 years and younger, a smooth stem modular RHA is an option. Although reoperation rates based on this series are low, osteoarthritis is common when used for posttraumatic conditions and severe radiographic stem lucency was seen in greater than one-third of patients. These concerning features warrant close follow-up, and further long-term outcomes are needed. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Thirty-day readmissions and reoperations after total elbow arthroplasty: a national database study.

BACKGROUND: The purpose of this study was to determine the rate of short-term complications after total elbow arthroplasty (TEA) and identify predictors of readmission and reoperation. We hypothesized that TEA performed for acute elbow trauma would have higher rates of 30-day readmission and reoperation than TEA performed for osteoarthritis (OA). METHODS: Using the National Surgical Quality Improvement Program for the years 2011-2017, we identified patients undergoing TEA for fracture, OA, or inflammatory arthritis. Patient demographic characteristics, comorbidities, reoperations, and readmissions within 30 days of surgery were analyzed. Potential predictors of reoperation and readmission in the model included age, sex, race, body mass index (BMI), diabetes, hypertension, chronic obstructive pulmonary disease, congestive heart failure, smoking, bleeding disorders, American Society of Anesthesiologists classification, wound classification, operative time, and indication for surgery. RESULTS: A total of 414 patients underwent TEA from 2011-2017. Of these patients, 40.6% underwent TEA for fracture; 37.0%, for OA; and 22.7%, for inflammatory arthritis. The overall rate of unplanned readmissions was 5.1% (21 patients). The rate of unplanned reoperations was 2.4% (10 patients). Infection was the most common reason for both unplanned readmissions and reoperations. The rates of reoperations and readmissions were not significantly associated with any of the 3 operative indications: fracture, OA, or inflammatory arthritis. Multiple logistic regression analysis found increased BMI to be associated with lower odds of an unplanned readmission (odds ratio [OR], 0.883; 95% confidence interval [CI], 0.798-0.963; P = .0035) and found wound classification ≥ 3 to be associated with increased odds of an unplanned reoperation (OR, 16.531; 95% CI, 1.300-167.960; P = .0144) and total local complications (OR, 17.587; 95% CI, 2.207-132.019; P = .0057). Patients who were not functionally independent were more likely to experience local complications (OR, 4.181; 95% CI, 0.983-15.664; P = .0309) than were functionally independent patients. CONCLUSIONS: The 30-day unplanned reoperation rate after TEA was 2.4%, and the unplanned readmission rate was 5.1%. Low BMI was predictive of readmission. Wounds classified as contaminated or dirty were predictive of reoperation. Dependent functional status and contaminated wounds were predictive of local complications. The indication for TEA (fracture vs. OA vs. inflammatory arthritis) was not found to be a risk factor for reoperation or readmission after TEA.

The impact of COVID-19 on shoulder and elbow trauma: an Italian survey.

BACKGROUND: Because of the rapid spread of COVID-19, on March 8, 2020 Italy became a "protected area": people were told not to leave their homes unless it was essential. The aim of this study was to evaluate the activity of our trauma center, relative to shoulder and elbow, in the 30 days starting from March 8, 2020, the first day of restrictions in Italy, and to compare it with the same days of 2019 to weigh the impact of COVID-19 on shoulder and elbow trauma. MATERIALS AND METHODS: Patients managed in our trauma center between March 8, 2020, and April 8, 2020 (COVID period), for shoulder and elbow trauma were retrospectively included and compared to patients admitted in the same period of 2019 (no-COVID period). Clinical records of all participants were examined to obtain information regarding age, sex, mechanism of injury, and diagnosis. RESULTS: During the no-COVID period, 133 patients were admitted for a shoulder or elbow trauma; in the COVID period, there were 47 patients (65% less first aid). In the no-COVID and COVID period, patients with shoulder contusion totaled 60 (14.78% of all; male [M]: 34; female [F]: 26; mean age 51.8 years, range 18-88) and 11 (12.09% of all contusions; M: 7, F: 4; mean age 43 years, range 24-60), respectively. In the no-COVID period, 27 fractures (9.34% of all fractures) involved the shoulder, whereas 18 fractures (8.69%) were registered in the COVID period. In the no-COVID period, 14 elbow fractures were treated (4.8% of all fractures), compared with 4 in the COVID period. In the no-COVID and COVID periods, 6 patients (M: 5, F: 1; mean age 42 years, range 21-64) and 2 patients (M: 1, F: 1; mean age 29.5 years, range 24-35) reported having a feeling of momentary post-traumatic shoulder instability, and 0 and 1 patients (M: 1, F: 0; age 56 years), respectively, reported similar symptoms at the elbow. Finally, first or recurrent dislocations in the no-COVID period were 10, and in the COVID period, 7; elbow dislocations in the no-COVID period were 2, and in the COVID period, there were 3. CONCLUSIONS: During the COVID period, we provided a reduced number of health services, especially for patients with low-energy trauma and for those who underwent sports and traffic accidents. However, during the COVID period, elderly subjects remain exposed to shoulder and elbow trauma due to low-energy (domestic) falls. The subsequent hospitalization of these patients has contributed to making it more difficult to manage the hospital wards that are partly occupied by COVID-19 patients.

Neurologic complications after surgical management of complex elbow trauma requiring radial head replacement.

BACKGROUND: Radial head arthroplasty (RHA) has become a successful procedure for addressing acute unreconstructible radial head fractures that compromise elbow stability in complex elbow trauma. The purpose of this study was to investigate the incidence of and risk factors for the development of neurologic complications after surgical treatment of complex elbow fractures that require an RHA. METHODS: Sixty-two patients with an unreconstructible radial head fracture and complex elbow instability treated with RHA were included. There were 33 men and 29 women, with a mean age of 54 years (range, 22-87 years). The average follow-up period was 5.2 years (range, 3-16 years). All patients were neurologically intact before surgery. The arthroplasty was implanted through a Kocher approach in 55 cases, whereas a Kaplan approach was used in 7. An uncemented smooth stem arthroplasty (Evolve) was used in 27 patients, and an anatomic ingrowth system (Anatomic Radial Head), in 35. At the time of surgery, 23 patients underwent fixation of a coronoid fracture and 15 underwent plating of the proximal ulna. All patients were clinically examined immediately after surgery and during follow-up to detect any degree of neurologic deficit. Radial and ulnar nerve injuries were classified according to the Hirachi and McGowan classifications, respectively. Functional outcomes were evaluated with the Mayo Elbow Performance Score. RESULTS: A complete posterior interosseous nerve palsy occurred postoperatively in 2 patients. Hand function had completely recovered in both at 2 months after surgery without sequelae. Nine patients complained of ulnar nerve symptoms (immediately after surgery in 6 and as delayed ulnar neuropathy in 3). Most patients with ulnar nerve deficits had undergone additional surgical procedures to address ulnar fractures. Among patients with ulnar neuropathies, only 3 complained of mild sensory symptoms at the latest follow-up. No significant differences in range of motion and Mayo Elbow Performance Score were found between patients with and without neurologic complications. Associated olecranon or coronoid fixation and a prolonged tourniquet time were identified as risk factors for neurologic complications. CONCLUSION: This study shows that the incidence of neurologic complications associated with the surgical treatment of complex elbow fractures requiring implantation of a radial head prosthesis may be underestimated in the literature. Inappropriate retraction in the anterior aspect of the radial neck, a prolonged ischemia time, and concomitant coronoid or olecranon fracture fixation represent the main risk factors for the development of this complication. Although the great majority of patients have full recovery of their nerve function, they should be advised on the risk of this stressful complication.

The column procedure preserves elbow stability on biomechanical testing.

PURPOSE: The effect of open release of a post-traumatic elbow contracture on the stability of the joint has not been so far studied in vivo. Resection of elbow joint capsule, the key element of surgery, was reported to have no effect on the stability of cadaveric elbows. The joint capsule is yet known to participate in maintaining elbow stability as one of secondary stabilizers. METHODS: We assessed elbow joint laxity in 39 patients who underwent an open contracture release via the 'column procedure' described by B. Morrey and P. Mansat within the preceeding three to nine months. The measurements were taken with an apparatus designed particularly for this experiment according to the predetermined protocol. A preliminary part of the experiment showed that there was no significant difference between laxity of two elbow joints in healthy volunteers. Laxity of the operated elbows could be then compared with the contralateral joints. RESULTS: Mean absolute difference of laxity between healthy and operated elbows was 1.55° (0.1°-4.1°, SD = 1.1) being significantly lower than 2°, p = 0.0056. The difference of the joint laxity between the operated and healthy elbows did not differ statistically significantly by more than 0.6° from the difference of the laxity of two healthy elbows and, therefore, is not clinically noticeable. CONCLUSIONS: Our experiment confirmed that the 'column procedure' is a safe procedure which does not compromise the stability of the elbow joint.

The use of static progressive and serial static orthoses in the management of elbow contractures after complex fracture dislocation injuries: A pediatric case study.

INTRODUCTION: Contractures are the most common complication after traumatic injury to the elbow. Although evidence supporting the use of static progressive and serial static orthoses to help recover range of motion after these complex injuries is growing, there is currently a paucity of literature exploring its efficacy in pediatric populations. CASE DESCRIPTION: The following case study presents the results of the use of static progressive and serial static orthoses with a young patient who presented with both elbow extension and flexion contractures after a complex fracture dislocation injury. RESULTS: A noted and consistent improvement in both elbow extension and flexion can be observed after commencement of the static progressive and serial static orthoses. These results are consistent with the literature exploring the efficacy of these orthoses with adult populations with traumatic elbow injuries. DISCUSSION: Further studies evaluating the use of static progressive and serial static orthoses in the management of elbow contractures after traumatic injuries in pediatric populations is needed to establish best practices with this particular patient population.

Proximal radioulnar translocations in adults: a tertiary centre study.

We present three cases of proximal radioulnar translocation in adults. Although rare, it is most commonly seen in paediatric cases. There have been three previously documented cases in adults, all requiring surgery and associated with ulnohumeral dislocations. Two of our cases required operative intervention, whilst one was reduced closed and did not require stabilisation. Furthermore, we have for the first time shown that proximal radioulnar translocations can occur in isolation in adults without an ulnohumeral dislocation. LEVEL OF EVIDENCE: Level IV.