We prospectively studied a consecutive series of 25 knees (21 patients) treated with arthroscopic synovectomy for seropositive rheumatoid arthritis. All patients had pain and swelling and were in the early stages of the disease process (Larsen grade 2 or less). Three patients were lost to follow-up. At a mean of 8 years from operation two knees underwent total knee replacement with another two knees required a further arthroscopic synovectomy. One patient continued to experience intermittent mild synovitis. The range of movement was maintained or improved by surgery in 73% of cases but radiological evidence of degenerative change was seen in all knees. We discuss the technical difficulties associated with arthroscopic synovectomy that were associated with a small complication rate. In appropriately selected patients unresponsive to medical therapy, arthroscopic synovectomy can give safe and reliable results.
Semiconstrained total elbow replacement is now a well recognised and reliable surgical option for advanced elbow disease, mainly rheumatoid arthritis.
We report a retrospective analysis of 31 primary total elbow replacements in 28 patients with a mean follow-up duration of 55 months. The mean age of the patients was 65 years. The indications included 27 cases of rheumatoid arthritis, 3 fractures and 1 case of osteoarthritis. Twenty-one elbows in nineteen patients were assessed using the Mayo elbow performance score (MEPS) in a special follow-up clinic. In the other nine patients (ten elbows), the assessment was carried out with case notes and x-rays.
The mean pre-operative MEPS in the 21 elbows recalled was 40. This improved to 89 post-operatively (range: 55-100). Sixteen of the twenty-one elbows were considered excellent, two good, two fair and one poor. The range of movement was recorded in eight of the other ten elbows and the mean was 98°. At the last follow-up visit, x-rays were normal in 23 elbows although the ulnar component was loose in 3, the humeral component loose in 2. There were also two cases of nonunion of the medial epicondyle and one patient had mild heterotopic ossification. Complications included one infection, which needed irrigation and debridement with a satisfactory final result, and two cases of ulnar nerve palsy/neurapraxia. Two elbows were considered failures due to severe pain caused by prosthetic loosening. These were referred for revision surgery.
Excellent pain relief and good function can be achieved in the medium and long term with the Coonrad-Morrey semiconstrained total elbow replacement prosthesis in patients with severe destructive elbow arthropathy.
Elbow; Arthroplasty; Coonrad-Morrey; Loosening
The aim of this study was to assess the utility of the Coonrad-Morrey elbow prosthesis in patients with severe elbow dysfunction secondary to rheumatoid arthritis (RA) or post-traumatic elbow dysfunction.
The study involved 35 patients followed up for a mean of 36 months. The patients were divided into those with RA (Group I) and those with post-traumatic elbow dysfunction (Group II). Treatment outcomes were evaluated according to the Mayo Elbow Performance Score (MEPS) and the Disabilities of the Arm, Shoulder and Hand Score (Quick DASH).
According to the MEPS, there were 20 (57.15%) excellent, 12 (34.3%) good, 1 (2.85%) fair, and 2 (5.7%) poor outcomes. The mean post-operative Quick-DASH score for the entire study group was 37.73 points. In subgroup analysis, the MEPS-based evaluation revealed: 14 (70%) excellent, 5 (25%) good, and 1 (5%) satisfactory outcome in Group I, versus 6 (40%) excellent, 7 (46.7%) good, and 2 (13.3%) poor outcomes in Group II. The mean Quick Dash scores were 78.64 points in Group I and 76.36 points in Group II. The final MEPS scores in Group I (p=0.000018) and Group II (p=0.00065) were most markedly influenced by reduction in elbow pain and improvement in the ability to perform activities of daily living (ADL): p=0.000018 in Group I and p=0.000713 in Group II.
The treatment outcomes confirm the utility of arthroplasty for severe elbow dysfunctions; they were most strongly influenced by pain reduction and improved ability to perform activities of daily living.
elbow joint; elbow prosthesis; rheumatoid arthritis; distal humerus fractures
Bony ankylosis of elbow is challenging and difficult problem to treat. The options are excision arthroplasty and total elbow replacement. We report our midterm results on nine patients, who underwent inverted 'V' osteotomy excision arthroplasty in our hospital with good functional results.
Our case series includes 9 patients (seven males and two females) with the mean age of 34 years (13-56 years). Five patients had trauma, two had pyogenic arthritis, one had tuberculous arthritis, and one had pyogenic arthritis following surgical fixation.
The average duration of follow up is 65 months (45 months-80 months). The mean Mayo's elbow performance score (MEPS) preoperatively was 48 (35-70). The MEPS at final follow up was 80 (60-95). With no movement at elbow and fixed in various degrees of either flexion or extension preoperatively, the mean preoperative position of elbow was 64°(30°to 100°). The mean post operative range of motion at final follow up was 27°of extension (20-500), 116°of flexion (1100-1300), and the arc of motion was 88°(800-1000). One patient had ulnar nerve neuropraxia and another patient developed median nerve neuropraxia, and both recovered completely in six weeks. No patient had symptomatic instability of the elbow. All patients were asymptomatic except one patient, who had pain mainly on heavy activities.
We conclude that inverted 'V' osteotomy excision arthroplasty is a viable option in the treatment of bony ankylosis of the elbow in young patients.
Surgical synovectomy relieves pain in patients with rheumatoid arthritis (RA). The comparative effect of arthroscopic versus open synovectomy on pain reduction, recurrence of synovitis, radiographic progression, and need for subsequent total joint arthroplasty (TJA) is unclear. Whether synovectomy relieves pain in patients with advanced degenerative joint changes is also controversial.
We therefore asked whether arthroscopic synovectomy resulted in equal pain relief, recurrence rates, rates of radiographic progression, likelihood of arthroplasty, and whether surgical synovectomy relieved pain and halted progression in the presence of advanced RA.
We searched PubMed, Cochrane Database of Systematic Reviews, and BMJ Clinical Evidence. After appropriate selection criteria, 58 studies were identified, including 36 on open synovectomy and 22 on arthroscopic synovectomy, with a total of 2589 patients and a mean followup of 6.1 years. Meta-analysis was performed for knees and elbows, comparing open versus arthroscopic synovectomy. Variables included the percentage of patients with pain reduction, recurrence of synovitis, radiographic progression, and need for subsequent TJA or arthrodesis.
Patients undergoing arthroscopic synovectomy had similar pain reduction, but more frequent recurrences of synovitis and radiographic progression than patients with open synovectomy. Patients undergoing arthroscopic synovectomy had similar and decreased risks of subsequent elbow and knee arthroplasties, respectively. Advanced preoperative radiographic RA did not correlate with worse pain scores nor increased need for subsequent arthroplasty when compared with minimal degenerative joint changes.
Arthroscopic synovectomy, while providing similar pain relief, may place patients at higher risk for recurrence and radiographic progression of RA. Advanced preoperative degenerative joint disease should not be an absolute contraindication to synovectomy.
Level of Evidence
Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.
OBJECTIVE—To evaluate the nature of positional changes of humeroulnar (HU) and humeroradial (HR) joints in a cohort of 74 patients with seropositive and erosive rheumatoid arthritis (RA) followed up prospectively.
METHODS—At the 15 year follow up standard anteroposterior and lateral radiographs of 148 elbow joints were evaluated. The mediolateral HU angle of the elbow was measured from anteroposterior radiographs. The proximal subluxation of the HU joint was measured from lateral radiographs as the distance between the posterior aspect of the olecranon process and the posterior surface of the humerus. The anteroposterior subluxation of the HR joint was measured from lateral radiographs as the relation of the midpoint of head of the radius to the midpoint of the capitellum of the humerus. Destruction of the elbow joints was assessed with the Larsen method on a scale of 0 to 5 and compared with the measurements.
RESULTS—Mean HU angle in 148 elbows of patients with RA was 11.5° (SD 6.1), range −21° (varus) to 34° (valgus); 9.9° (SD 4.3) in men and 12.0° (SD 6.4) in women. The mean HU angle, 14.4° (SD 6.0) of the affected joints (Larsen grades 2-4), showed more valgus than the mean 9.8° (SD 2.5) of the non-affected (Larsen grades 0 to 1) joints; totally destroyed and unstable Larsen 5 joints were excluded. Mean HU and HR subluxations, 2.0 mm (SD 3.8) and 0.8 mm, of the affected joints (Larsen 2-5) were greater than the means, −1.1 mm (SD 1.5) and −0.4 mm (SD 0.9), of the non-affected joints. Both the HU proximal subluxation and the HR anterior subluxation correlated, rs=0.64 (95% CI 0.53 to 0.73 ) and rs=0.48 (95% CI 0.34 to 0.60), with the destruction of the elbow joint.
CONCLUSIONS—The elbow seems to turn into valgus during rheumatoid destruction and excision of the radial head may speed up this process. However, totally unstable Larsen grade 5 joints may also have varus deformity owing to mutilating bone destruction. The ulna subluxates proximally in relation to the humerus, whereas the radius moves slightly anteriorly as a consequence of elbow involvement.
Arthritis and Rheumatism Council and British Orthopaedic Association (1976).Annals of the Rheumatic Diseases, 35, 437-442. Controlled trial of synovectomy of knee and metacarpophalangeal joints in rheumatoid arthritis. In a multicentre study patients with rheumatoid arthritis judged by prevailing criteria to be suitable for synovectomy of the knee or metacarpophalangeal (MCP) joints were randomly allocated to one of two groups. One group had the operation, the other was observed without operation from a notional corresponding date. 3 years later the outcome of synovectomy was compared with that of observation without synovectomy. Synovectomy of the knee was followed by significantly less pain and tenderness, smaller effusions, and smaller and less frequent erosions and geodes. By contrast, MCP joints were no better clinically or radiographically than those treated conservatively. The results have been compared with those of two other controlled trials, one concerned with the knee and MCP joints, the other only with MCP joints. In the present trial results were more favourable in the knee but comparable in the MCP joints with those reported in the first of these two trials but less favourable in the MCP joints than those observed in the second.
Between 1990 and 1997 we undertook 57 Kudo type-4 total elbow replacements in 45 patients with rheumatoid arthritis. A total of 34 patients (44 elbows) were evaluated at an average of 7 (4.4–11.2) years using the Mayo Clinic Performance Index. At review 29 elbows were excellent or good and four were fair or poor. The main complications were intraoperative fractures and ulnar neuropathy. No luxations were seen. Loosening of the ulnar component and breakage of the humeral component were most frequent indications for revision. Preoperative radiographic joint destruction was not correlated with revision rate.
The objective of this retrospective multicentre cohort study was to prospectively assess the long-term functional outcomes of simple and complex elbow dislocations.
We analysed the hospital and outpatient records of 86 patients between 01.03.1999 and 25.02.2009 with an elbow dislocation. After a mean follow-up of 3.3 years, all patients were re-examined at the outpatient clinic for measurement of different outcomes.
The mean range of motion was ROM 135.5°. The Mayo elbow performance index (MEPI) scored an average of 91.9 (87.5% of the patients were rated excellent or good). The average Quick disabilities of the arm, shoulder and hand (Quick- DASH) score was 9.7, the sports/music score 11.5 and work score 6.1. The Oxford function score was 75.7, Oxford pain score 75.2 and Oxford social-psychological score 73.9.
Elbow dislocation is a mild disease and generally, the outcome is excellent. Functional results might improve with early active movements.
Elbow; elbow joint; injury; dislocations.
Background There have been no reports on the long-term outcome of radial neck Mason type IIIb fractures in adults.
Methods 3 women and 2 men, aged 46 (22–69) years when they sustained a radial neck Mason type IIIb fracture, were evaluated after an average of 18 (16–21) years. All had been treated with radial head excision.
Results 3 individuals had no subjective elbow complaints while 2 reported occasional weakness. None had severe elbow complaints. The maximum elbow-to-elbow difference in range of motion was a deficit of mean 10° in extension in the injured elbow. Mean deficits in elbow flexion, forearm pronation, and forearm supination were below 5° and the mean difference in cubitus valgus angle was only 2° . There was no instability and no recurrent elbow dislocations. Radiographically, there were cysts, sclerosis, and osteophytes in all formerly injured elbows but none in the uninjured elbows. We found reduced joint space in 1 elbow that had been formerly injured.
Interpretation Mason type IIIb fracture in adults, treated with radial head excision, appears to have a favorable long-term outcome.
Elbow dislocations in children are uncommon injuries. Dislocations with associated fractures or so-called complex dislocations of the elbow can be challenging to diagnose and treat.
A 14-year-old male had a posterolateral elbow dislocation after a fall. Closed reduction with traction was performed. Radiographs after initial reduction showed a fragment entrapped into the humero-cubital joint. Computerized tomography scan showed the fragment belonging to the medial epicondyle. Open reduction and internal fixation with a 3.0 millimeter cannulated screw was performed, with restoring of the normal function of the elbow at final follow up.
Elbow dislocations in children can be associated with bone lesions. These injuries must be suspected to avoid misleading diagnosis and achieve good results.
Twenty-three operations of synovectomy (15 on the knee, 5 on the ankle, and 3 on the elbow) were carried out over a three-year period in 19 patients with severe haemophilia A and B who were followed for an average period of 15 months postoperatively. Short-term evaluation of the results was mainly based on the postoperative incidence of haemarthrosis and on the range of joint motion, which were compared with the preoperative findings. Synovectomy reduced, but did not abolish, the occurrence of haemarthrosis; however, after the operation bleeding episodes were usually less severe and incapacitating. Joint mobility was often reduced despite an intensive and prolonged programme of physiotherapy. Nevertheless, most of the patients were pleased with the results of the operation as they could lead a more active life because of the decreased risk of joint bleeding.
In the light of these findings we conclude that synovectomy is not the elective treatment of choice for haemophilic arthropathy. It may be indicated in a few selected cases when conservative treatment has failed to control repeated haemarthrosis and synovitis. Controlled clinical trials and long-term evaluation are needed to establish its effect on the final outcome of haemophilic arthropathy.
OBJECTIVES—To evaluate the relation of glenohumeral (GH) and acromioclavicular (AC) joint involvement in a cohort of 74 patients with seropositive and erosive rheumatoid arthritis (RA) followed up prospectively.
METHODS—At the 15 year follow up radiographs of 148 shoulders were evaluated, and the grade of destruction of GH and AC joints were assessed by the Larsen method. One GH joint arthroplasty had been performed after 13 years of the disease onset and the preoperative radiograph was evaluated.
RESULTS—Erosive involvement (Larsen grade ⩾ 2) was observed in 96 of 148 (65%) of the shoulders. Both GH and AC joints were affected in 62 of 148 (42%) shoulders. GH joint alone was involved in nine (6%) shoulders and only AC joint was affected in 25 (17%) shoulders. AC joint destruction correlated with the GH joint destruction, r=0.74 (95% confidence intervals (CI) 0.65 to 0.80 ).
CONCLUSION—In RA AC joint is affected more often than the GH joint, but in half of the patients both joints are involved. This should be remembered when treating painful rheumatoid shoulder.
This study evaluated the outcomes of debridement arthroplasty for stiff elbows, as well as the factors affecting clinical outcomes after surgical treatment.
Eighteen patients with post-traumatic stiff elbows were treated with debridement arthroplasty using a posterior approach. The mean patient age was 33 years (range, 16 to 59 years), and the average follow-up period was 59 months (range, 24 to 141 months). The patient's ability to perform activities of daily living, including combing their hair, feeding themselves, performing hygiene, and putting on shirt and shoes, were evaluated using the Mayo Elbow Performance Score.
At the last follow-up, 16 elbows had painless motion. Two patients continued to complain of mild intermittent pain. The flexion and extension improved to 121° and 10° after surgery, respectively, indicating an average 34° increase in elbow flexion range and an average 25° increase in elbow extension range (p < 0.001, p < 0.001). The Mayo Elbow Performance Score at the last follow-up was excellent in nine elbows (50%) and good in nine elbows (50%).
Debridement arthroplasty is a predictable procedure for the treatment of intractable stiff elbow, provided that the elbow is stable and congruous.
Elbow; Stiffness; Debridement arthroplasty
Elbow stiffness is a common disorder, which restricts daily activities. Between 30° and 130° of elbow movement is usually enough to perform most daily activities. However, a 10° to 15° loss of elbow extension may be a problem when the patient is an athlete. From 1996 to 2004, 20 elbows of 20 patients (who were available for follow-up examination) were treated by lateral and medial release at Kocaeli University, for post-traumatic elbow contracture. Preoperative and the postoperative 12-month follow-up measurements were performed. The mean preoperative arc of motion was 35° and this value improved to 86.2°. The maximum improvement at the arc of motion was 105°. In an effort to understand the pathophysiology of the condition, surgical approaches may be used safely. The purpose of this study was to assess the functional outcome of the elbow joint after using a combination of lateral and medial approaches to treat elbow stiffness.
From January 1996 to January 2001, arthroscopic synovectomies were performed in 28 knees with haemophilic arthropathy. The mean follow-up period was 5 years and 11 months. Six portals (two anterior, two suprapatellar, two posterior) and a posterior trans-septal portal were used in all cases. The average Hospital for Special Surgery (HSS) knee score increased from 56.4 to 71.5 points at the last follow-up. The average frequency of haemarthrosis reduced from five times per month before operation to once per month. The amount of factor replacement decreased from a mean of 4,633 U to 1,505 U. Progression of arthritis was observed radiographically in three cases at the last follow-up. An arthroscopic synovectomy of the knee using appropriate arthroscopic portals is a useful method in treating haemophilic patients as it decreases bleeding episodes, amount of factor replacement and knee pain.
Surgical management of posttraumatic elbow stiffness has been reported with poor outcome following treatment. Sequential release in earlier stages of stiffness yielded much better results. The goal of our study was to assess the outcome in improvement of the range of motion of the elbow after surgical release and to analyze a tailor-made approach according to individual needs to yield good result.
Materials and Methods:
A prospective study was conducted in 47 cases of elbow stiffness due to various types of injuries. All the cases were treated with sequential release if there was no progress after adequate supervised conservative management except in unreduced dislocations. All the cases were followed up for a minimum period of 24 months. Overall outcome was rated with the functional scoring system by Mayo Clinic Performance Index.
Twenty-five (44.68%) out of 47 patients had excellent results with a mean preoperative range of motion of 33.9° and postoperative range of motion of 105° with net gain in range of motion of 71.1° (‘t’ test value is 19.27, P < 0.01). None of the patients had elbow instability. Patients not having heterotopic ossification, who underwent surgery from three to six months post injury had a mean gain of 73.5°. In patients who waited for more than six months had mean gain of 66.8°. However, the results in cases having heterotopic ossification followed a slightly different pattern. In cases where release was performed from three months to six months had mean gain of 77.5°. Cases in which release was performed after six months had gain of 57.1°.
In cases of posttraumatic elbow stiffness after a failed initial conservative treatment, early arthrolysis with sequential surgical soft tissue release yields good result than delayed surgery.
Post traumatic stiff elbow; fractures around elbow; myositis ossification; dislocation elbow
To determine the clinical outcome of arthroscopic debridement for osteochondritis dissecans of the elbow.
A prospective cohort study was started in 2000; between 2000 and 2005, 15 patients (six male, nine female, mean age 28 years (range 16–49)) were treated for osteochondritis dissecans of the elbow with arthroscopic debridement. The lesion was graded during surgery using the classification of Baumgarten. The dominant side was operated on in seven of 15 patients, and all patients were involved in a sport in which the elbow is used extensively. Elbow function was assessed before and after surgery using the modified Andrews elbow scoring system (MAESS); pain was scored on a visual analogue scale (0, no pain; 10, severe pain). Evaluation was performed an average of 45 (range 18–59) months after surgery. Statistical analysis (Student's t test) was carried out using SPSS statistical software. p<0.005 was considered significant.
There were no complications. The range of motion did not improve significantly. The mean MAESS score improved from 65.5 (poor) before surgery to 90.8 (excellent) after (p<0.001). The mean level of pain at rest decreased from 3 to 1, and the level of pain after provocation decreased from 7 to 2 (p<0.001). All patients were able to return to work 3 months after surgery, and 80% were able to resume their pre‐injury level of sport activity.
The clinical outcome after arthroscopic debridement for osteochondritis dissecans of the elbow shows good results, with pain relief during activities of daily living and sport. The function of the elbow, as reflected by the MAESS score, improved from poor to excellent. All patients in this series will be reviewed after 5 years to determine long‐term results.
arthroscopic debridement; elbow; osteochondritis dissecans
Fourteen patients with displaced fractures of the humeral capitellum were treated by open reduction and internal fixation of the capitellar fragments with Herbert screws. As per Bryan and Morrey classification, there were seven type I fractures, one type II fracture, three type III fractures, and three non-unions. Patient outcomes were evaluated using the Mayo elbow performance score. The follow-up period ranged from three to seven years (mean 4.8 years). All patients had a stable, pain-free elbow with good range of motion at follow-up. There was no evidence of avascular necrosis or degenerative change.
The use of bioabsorbable pins with prolonged degradation periods for fracture fixation has raised concerns about adverse soft tissue reactions, including seromas, discharging sinuses, or osteolytic changes. We asked whether bioabsorbable pins of self-reinforced polylactic acid polymer used in radial head fractures resulted in such reactions. We retrospectively reviewed 21 patients followed a minimum of 36 months (mean, 81 months; range, 36–136 months). There were nine Mason II, 10 Mason III, and two Mason IV fractures, which were evaluated clinically and radiographically. All fractures healed well with no radiographic signs of osteolysis. The mean Mayo Elbow Performance score was 93.8 (range, 20–100), which is comparable to the outcome of historical groups with radial head arthroplasty. The mean range of flexion of the elbow was 9° to 132°, with 79° pronation and 77° supination. The grip strength of the operated arm was not affected in comparison to the contralateral arm (mean range, 38.6 versus 40.9 kg). No material-related adverse effects were observed during and beyond the degradation period. Our data suggest concerns about soft tissue or bony reactions from these materials in radial head fractures are not justified.
Level of Evidence: Level IV, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.
Background and purpose Although total elbow arthroplasty (TEA) is a recognized procedure for the treatment of the painful arthritic elbow, the choice of implant is still obscure. We evaluated the survival of different TEA designs and factors associated with survival using data from a nationwide arthroplasty register.
Methods 1,457 primary TEAs for rheumatoid elbow destruction were performed during 1982 to 2006 in one hospital specialized in the treatment of rheumatoid arthritis (n = 776) and in 19 other hospitals (n = 681). The mean age of the patients was 59 years and 87% of the TEAs were performed in women. We selected different contemporary TEA designs, each used in more than 40 operations including the Souter-Strathclyde (n = 912), i.B.P./Kudo (n = 218), Coonrad-Morrey (n = 164), and NESimplavit/Norway (n = 63) to assess their individual survival rates. Kaplan-Meier analysis and the Cox regression model were used for survival analysis.
Results The most frequent reason for revision was aseptic loosening (47%). We found no differences in survival rates between different TEA designs. We did, however, find a 1.5-fold (95% CI: 1.1–2.1) elevated risk of revision in unspecialized hospitals as compared to the one hospital specialized in treatment of rheumatoid arthritis. In the Souter-Strathclyde subgroup, there was a reduced risk of revision (RR 0.6, p = 0.001) in TEAs implanted over 1994–2006 as compared to those implanted earlier (1982–1993). The 10-year survivorship for the whole TEA cohort was 83% (95% CI: 81–86), which agrees with earlier reports.
Interpretation The influence of implant choice on the survival of TEA is minor compared to hip and knee arthroplasties. Inferior survival rates of the TEAs performed in the unspecialized hospitals demonstrates the importance of proper indications, surgical technique, and postoperative follow-up, and endorses the need for centralization of these operations at specialized units.
Tension band wiring (TBW) remains the most common operative technique for the internal fixation of olecranon fractures despite the potential occurrence of subjective complaints due to subcutaneous position of the hardware. Aim of this long term retrospective study was to evaluate the elbow function and the patient-rated outcome after TBW fixation of olecranon fractures.
We reviewed 62 patients (33 men and 29 women) with an average age of 48.6 years (range, 18–85 years) who underwent TBW osteosynthesis for isolated olecranon fractures. All patients were assessed both clinically with measurement of flexion-extension and pronation-supination arcs and radiologically with elbow X-Rays. Functional outcome was estimated using the Mayo Elbow Performance Score (MEPS), Visual Analogue Scale (VAS) subjective pain score and VAS patient satisfaction score. Follow up: 6–13 years (average 8.2 years).
There was a higher prevalence of fractures among men until the 5th decade of life and among women in elderly (p = 0.032). Slip or simple fall onto the arm was the main mechanism of injury for 38 fractures (61.3%) while high energy trauma, such as fall from a height (> 2 m) or road accident, was reported in 24 fractures (38.7%). Hardware removal performed in 51 patients (82.3%) but 34 of them (66.6% of removals) were still complaining for mild pain during daily activities. The incidence of pin migration and loosening was not statistically decreased when penetration of the anterior ulnar cortex was accomplished (p = 0.304). Supination was more often affected than pronation (p = 0.027). According to MEPS, 53 patients (85.5%) had a good to excellent result, 6 (9.7%) fair and 3 (4.8%) poor result. The average satisfaction rating was 9.3 out of 10 (range, 6–10) with 31 patients (50%) to remain completely satisfied from the final result. Degenerative changes recorded in 30 elbows (48.4%). However, no correlation could be found between radiographic findings and MEPS (p = 0.073).
Tension band wiring fixation remains the "gold standard" for the treatment of displaced and minimally comminuted olecranon fractures. In long term, low levels of pain may be evident regardless of whether the metalware is removed and degenerative changes have been developed.
I suggest that for too long the problem of the rheumatoid elbow, particularly the need for surgical intervention, has been underestimated. Where the latter has been advocated the philosophy has been adopted that synovectomy and debridement with excision of the head of the radius is probably all that is required, or that in the late case excision arthroplasty may yield an adequate result. I suggest that these approaches are no longer tenable. Synovectomy and debridement with or without excision of the head of the radius does indeed retain an extremely valuable place in the management of stage 1, 2, and early stage 3 disease. In the later stages of the disease, however, serious consideration must now be given to total joint replacement, the results of which can be remarkably successful and durable, and the complications from which can now be contained within acceptable limits provided that the operating team is fully experienced. It must also be stressed how necessary it is in the medical or combined clinic to pursue careful clinical and radiological monitoring of the rheumatoid elbow so that signs of dangerous deterioration can be recognised early, and surgery applied at a time when optimal conditions for the particular surgical weapons to be used still exist.
Background There have been few reports on the long-term outcome of comminuted radial head fractures in adults.
Method 10 women and 9 men with a mean age of 45 (21–65) years when they sustained a comminuted fracture of the radial head were re-evaluated after 15–25 years. 6 patients had been nonoperatively (NO) treated while 13 had had a radial head excision. The uninjured elbow served as a control.
Results At follow-up, 11 patients (4 NO patients) rated their fractured elbow as being without deficits, 7 (1 NO) as being slightly impaired, and 1 (NO) as being severely impaired. Range of motion and elbow strength were not impaired, and even though there were more degenerative changes such as cysts, osteophytes, and sclerosis in the injured elbows by radiography, the prevalence of joint space reduction was not higher.
Interpretation Most patients with an isolated comminuted fracture of the radial head treated nonoperatively or with a radial head excision report no or only minor long-term complaints.
Pulled elbow or nursemaid’s elbow is a radial head subluxation caused by a sudden pull on the extended pronated forearm. Children with pulled elbow usually respond dramatically for reduction, yet others show delayed improvement with no clear pathologic explanation. The aim of our study is to propose an explanation for the varying clinical response after the reduction of pulled elbow aided by ultrasound classification of the underlying pathology and its impact on management.
Patients and methods
Fifty children with a mean age of 3.8 ± 1.1 (standard deviation [SD]) years with pulled elbow were scanned by static and dynamic ultrasound utilizing the other elbow as the standard. The radial annular ligament (RAL) was examined for integrity and interposition, with measurement of the radiocapitellar distance. Reduction was performed following the hyperpronation technique, and postreduction splinting was guided by ultrasound findings. Postreduction scans and 1-year follow up were performed.
Of the 50 included children, 39 (78%) had intact, yet interposed annular ligament (classified as type I) and 11 (22%) had torn annular ligament (classified as type II). The latter underwent splinting for 7 days. Three out of the 50 children had recurrent subluxation and constituted false-negative cases for the detection of torn ligament and represented the reoccurrence rate of 6%. The sensitivity, specificity, and accuracy for the ultrasound diagnosis of torn RAL were 76.9, 92.3, and 92%, respectively.
Pulled elbow is classified as follows: type I, with an interposed RAL, and type II, with torn ligament.
Pulled elbow; Annular ligament; Ultrasound; Classification