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1.  Rheumatoid Synovectomy: Does the Surgical Approach Matter? 
Background
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.
Questions/purposes
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.
Methods
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.
Results
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.
Conclusions
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.
doi:10.1007/s11999-010-1744-3
PMCID: PMC3111799  PMID: 21213089
2.  Total elbow replacement with the Coonrad-Morrey prosthesis: our medium to long-term results 
INTRODUCTION
Semiconstrained total elbow replacement is now a well recognised and reliable surgical option for advanced elbow disease, mainly rheumatoid arthritis.
METHODS
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.
RESULTS
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.
CONCLUSIONS
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.
doi:10.1308/003588412X13171221589775
PMCID: PMC3705234  PMID: 22507725
Elbow; Arthroplasty; Coonrad-Morrey; Loosening
3.  Valgus deformity and proximal subluxation of the rheumatoid elbow: a radiographic 15 year follow up study of 148 elbows 
Annals of the Rheumatic Diseases  2001;60(8):765-769.
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.


doi:10.1136/ard.60.8.765
PMCID: PMC1753812  PMID: 11454640
4.  Long-term results of arthroscopic synovectomy for seropositive rheumatoid arthritis: 6–16 year review 
International Orthopaedics  2002;26(2):98-100.
Abstract.
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.
doi:10.1007/s00264-001-0309-1
PMCID: PMC3620874  PMID: 12078886
5.  Comparison of short- to medium-term results of Coonrad-Morrey elbow replacement in patients with rheumatoid arthritis versus patients after elbow injuries 
Background
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.
Material/Methods
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).
Results
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.
Conclusions
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.
doi:10.12659/MSM.883725
PMCID: PMC3628944  PMID: 23291737
elbow joint; elbow prosthesis; rheumatoid arthritis; distal humerus fractures
6.  Short-term Evaluation of Synovectomy in Haemophilia 
British Medical Journal  1972;2(5810):378-381.
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.
PMCID: PMC1788256  PMID: 5023912
7.  Inverted 'V' osteotomy excision arthroplasty for bony ankylosed elbows 
Background
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.
Materials
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.
Results
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.
Conclusion
We conclude that inverted 'V' osteotomy excision arthroplasty is a viable option in the treatment of bony ankylosis of the elbow in young patients.
doi:10.1186/1749-799X-6-60
PMCID: PMC3259103  PMID: 22142391
8.  Primary total elbow arthroplasty 
Indian Journal of Orthopaedics  2013;47(6):608-614.
Background:
Primary total elbow arthroplasty (TEA) is a challenging procedure for orthopedic surgeons. It is not performed as frequently as compared to hip or knee arthroplasty. The elbow is a nonweight-bearing joint; however, static loading can create forces up to three times the body weight and dynamic loading up to six times. For elderly patients with deformity and ankylosis of the elbow due to posttraumatic arthritis or rheumatoid arthritis or comminuted fracture distal humerus, arthroplasty is one of the option. The aim of this study is to analyze the role of primary total elbow arthroplasty in cases of crippling deformity of elbow.
Materials and Methods:
We analyzed 11 cases of TEA, between December 2002 and September 2012. There were 8 females and 3 males. The average age was 40 years (range 30-69 years). The indications for TEA were rheumatoid arthritis, comminuted fracture distal humerus with intraarticular extension, and posttraumatic bony ankylosis of elbow joint. The Baksi sloppy (semi constrained) hinge elbow prosthesis was used. Clinico-radiological followup was done at 1 month, 3 months, 6 months, 1 year, and then yearly basis.
Results:
In the present study, average supination was 70° (range 60-80°) and average pronation was 70° (range 60-80°). Average flexion was 135° (range 130-135°). However, in 5 cases, there was loss of 15 to 35° (average 25°) of extension (45°) out of 11 cases. The mean Mayo elbow performance score was 95.4 points (range 70-100). Arm length discrepancy was only in four patients which was 36% out of 11 cases. Clinico-radiologically all the elbows were stable except in one case and no immediate postoperative complication was noted. Radiolucency or loosening of ulnar stem was seen in 2 cases (18%) out of 11 cases, in 1 case it was noted after 5 years and in another after 10 years. In second case, revision arthroplasty was done, in which only ulnar hinge section, hinge screw and lock screw with hexagonal head were replaced.
Conclusion:
Elbow arthroplasty remains a valuable option for deformed and ankylosed elbows especially in the demanding patients with crippling deformity of the elbow.
doi:10.4103/0019-5413.121592
PMCID: PMC3868144  PMID: 24379468
Ankylosis; comminuted fracture of distal humerus; total elbow arthroplasty
9.  Debridement Arthroplasty for Post-traumatic Stiff Elbow: Intraoperative Factors Affecting the Clinical Results of Surgical Treatment 
Clinics in Orthopedic Surgery  2009;1(1):27-33.
Background
This study evaluated the outcomes of debridement arthroplasty for stiff elbows, as well as the factors affecting clinical outcomes after surgical treatment.
Methods
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.
Results
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%).
Conclusions
Debridement arthroplasty is a predictable procedure for the treatment of intractable stiff elbow, provided that the elbow is stable and congruous.
doi:10.4055/cios.2009.1.1.27
PMCID: PMC2766694  PMID: 19884994
Elbow; Stiffness; Debridement arthroplasty
10.  Is tension band wiring technique the "gold standard" for the treatment of olecranon fractures? A long term functional outcome study 
Background
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.
Methods
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).
Results
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).
Conclusion
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.
doi:10.1186/1749-799X-3-9
PMCID: PMC2265682  PMID: 18294381
11.  The Natural Progression of Adult Elbow Osteonecrosis Related To Corticosteroid Treatment 
Background
In patients with corticosteroid treatment, the elbow is a rare site of osteonecrosis; there is little information about the rate and risk factors of disease progression in symptomatic and asymptomatic elbows.
Question/Purposes
We determined the delay between the beginning of corticosteroid treatment and different stages of osteonecrosis and which stage and dose of steroids influenced disease progression.
Methods
Osteonecrosis related to corticosteroids was diagnosed by MRI in 50 elbows of 35 adult patients. Thirty elbows were asymptomatic at initial evaluation (19 with Stage I, 11 with Stage II osteonecrosis). Among the 20 elbows symptomatic at initial evaluation, 13 had radiographic evidence of osteonecrosis without collapse (Stage II) and seven had lesions evident only on MRI (Stage I).
Results
At latest followup (average, 17 years; range, 10–25 years), of the 30 previously asymptomatic elbows, pain developed in 24 and collapse occurred in 14; of the 20 previously symptomatic elbows, 15 showed collapse (seven initially with Stage I, eight with Stage II osteonecrosis). The average time between diagnosis and collapse was 8 and 5 years, respectively, for symptomatic elbows with Stages I and II osteonecrosis. Stage at initial visit, development of pain, and continuation of peak doses of corticosteroids were risk factors for disease progression in asymptomatic elbows. In symptomatic elbows, the extent in contact with the articular surface and lesion location were the main risk factors for disease progression.
Conclusions
Untreated asymptomatic and symptomatic elbow osteonecrosis related to corticosteroids has a moderate likelihood of elbow collapse, with decrease in ROM, but none of the patients in this case series followed for 10 to 20 years had elbow arthroplasty.
Level of Evidence
Level IV, prognostic study. See Guidelines for Authors for a complete description of levels of evidence.
doi:10.1007/s11999-012-2550-x
PMCID: PMC3492606  PMID: 22926494
12.  Bone destruction, upward migration, and medialisation of rheumatoid shoulder: a 15 year follow up study 
Annals of the Rheumatic Diseases  2001;60(4):322-326.
OBJECTIVE—To evaluate bone destruction, upward migration, and medialisation of the glenohumeral (GH) joint in a cohort of 74 patients with seropositive and erosive rheumatoid arthritis followed up prospectively.
METHODS—At the 15 year follow up 148 shoulders were radiographed by a standard method. Bone destruction in the GH joint was examined from the radiographs by four methods, of which three measured the migration and one the remodelling of the humeral head. The distances from the greater tuberosity of the humeral head to the coracoid process (medialisation distance (MD)) and to the articular surface of the humeral head (GA) have been previously developed to evaluate the preoperative offsets of the arthritic GH joint. Medial displacement index (MI) and upward migration index (UI) have been recently developed to evaluate the destructive pattern of the rheumatoid GH joint. Destruction of the GH joints was assessed by the Larsen method on a scale of 0 to 5. The relation between the measurements and the grade of destruction of the GH joints was examined. UI was compared with our previous measurements of the subacromial space.
RESULTS—Both the MI and the UI had a negative correlation with the GH joint destruction (Larsen grade), r=−0.49 (95% CI −0.36 to −0.60) and r=−0.58 (95% CI −0.46 to −0.68). The UI correlated significantly with the subacromial space, r=0.90 (95% CI 0.86 to 0.93). The mean MI and UI measurements of the non-affected joints were within the reported normal variation. The mean MD collapsed between Larsen grades 4 (83.0 mm) and 5 (65.5 mm). The morphology of the humeral head began to flatten and erode from the grade 3 onwards and medial head destruction was detected at grade 5.
CONCLUSIONS—Medialisation seems to be preceded by upward migration of the humeral head, indicating rotator cuff damage. Symptomatic Larsen grade 3 shoulders should be intensively followed up by clinical and radiological means. If a total shoulder arthroplasty is considered, an orthopaedic consultation is worthwhile at a sufficiently early stage (Larsen 3 and 4), when soft tissue structures responsible for function are still in proper condition and timing of the operative procedure can be well planned.


doi:10.1136/ard.60.4.322
PMCID: PMC1753606  PMID: 11247859
13.  Primary total elbow arthroplasty in complex fractures of the distal humerus 
World Journal of Orthopedics  2014;5(3):368-372.
AIM: To evaluate short- to medium term outcome of total elbow arthroplasty (TEA) in complex fractures of the distal humerus.
METHODS: A consecutive series of 24 complex distal humerus fractures operated with TEA in the period 2006-2012 was evaluated with the Mayo Elbow Performance score (MEPS), plain radiographs, complications and overall satisfaction. The indications for surgery were 1: AO type B3 or C3 or Sheffield type 3 fracture and age above 65 or 2: fracture and severe rheumatoid arthritis. Mean follow-up time was 21 mo.
RESULTS: Twenty patients were followed up. Four patients, of which 3 had died, were lost to follow up. According to the AO classification there were 17 C3, 1 B2 and 2 A2 fractures. Mean follow-up was 21 months (range 4-54). Mean MEPS was 94 (range 65-100). Mean flexion was 114 degrees (range 80-140). According to MEPS there were 15 excellent, 4 good and 1 fair result. Patient satisfaction: 8 excellent, 10 good, 2 fair and 1 poor. There were two revisions due to infection treated successfully with revision and three months of antibiotics. In two patients the locking split had loosened. One was referred to re-insertion and one chose yearly controls. Two patients had persistent dysaesthesia of their 5th finger, but were able to discriminate between sharp and blunt.
CONCLUSION: Our study suggests that TEA in complex fractures of the distal humerus in elderly patients can result in acceptable short- to medium term outcome.
doi:10.5312/wjo.v5.i3.368
PMCID: PMC4095031  PMID: 25035841
Elbow arthroplasty; Distal humeral fracture; Elbow prosthesis; Elbow replacement; Humeral fractures
14.  Revision total elbow arthroplasty with the linked Coonrad-Morrey total elbow arthroplasty: a retrospective study of twenty procedures 
International Orthopaedics  2013;37(5):853-858.
Purpose
In this retrospective study we evaluated the short- to medium-term results after 20 Coonrad-Morrey revision total elbow arthroplasties (TEAs).
Methods
We included a consecutive series of revision TEAs performed at our institution from 2004 to 2010. At a mean follow-up of 4.4 years, patients were evaluated using the Mayo Elbow Performance Score (MEPS), the Oxford Elbow Score (OES) and standard radiographs.
Results
The mean age at revision TEA was 65.8 years. The median time of implant survival for primary prosthesis was 9.5 years. The mean post-operative MEPS was 79. The mean OES was 58, 66 and 53 for function, pain and social-psychological dimensions, respectively. At follow-up the range of motion had improved significantly. There were two cases of radiolucent lines and two cases of minor bushing wear; however, none of the implants were clinically loose. In one case deep infection led to a further revision. Two patients had post-operative ulnar nerve paraesthesia.
Conclusions
Results after revision TEA using the Coonrad-Morrey prosthesis are acceptable with a low short- to midterm failure rate. Revision improves range of motion and provides pain relief. One case of deep infection with recurrent revision is of concern. The treatment can be used as an option for failed TEA.
doi:10.1007/s00264-013-1821-9
PMCID: PMC3631495  PMID: 23420324
15.  Tuberculosis of the elbow: A clinicoradiological analysis 
Indian Journal of Orthopaedics  2012;46(2):200-205.
Background:
The incidence of Tuberculosis (TB) of elbow is 2-5% of all skeletal locations. Most reports of TB elbow have focused attention on the diagnosis. The management options and classification has been missing. We present a retrospective clinicoradiological analysis of 38 cases (40 elbows) of TB of elbow joint.
Materials and Methods:
The patients presented with pain, swelling and loss of motion. Two cases had bilateral involvement. The average delay between onset of symptoms and presentation was 8 months. The elbows were classified according to modified Martini's radiological classification, which distinguishes between osseous lesions close to joint line (e.g. coronoid, condyles) and lesions away from the joint line (e.g. epicondyles, olecranon). We modified the classification to subdivide into para-articular bony lesions that had invaded the joint and those that were threatening to invade joint. All patients received antitubercular chemotherapy and immobilization in above-elbow plaster slab for 4–8 weeks. Twenty patients underwent surgical interventions (synovectomy, intraarticular debridement).
Results:
The average followup period was 5.3 years (range 1.5-14.2 years). The range of movement at final followup averaged 107° for stage 2, 90° for stage 3A, 47° for stage 3B and 32° for stage 4. Range of supination and pronation was less satisfactory as compared to flexion and extension and all elbows with bony involvement had less than 90° arc of supination and pronation.
Conclusion:
Surgical intervention could appreciably alter the outcome especially in patients with extra-articular involvement close to the joint. We have classified this subgroup separately.
doi:10.4103/0019-5413.93684
PMCID: PMC3308662  PMID: 22448059
Elbow; infection; tuberculosis
16.  A hinged external fixator for complex elbow dislocations: A multicenter prospective cohort study 
Background
Elbow dislocations can be classified as simple or complex. Simple dislocations are characterized by the absence of fractures, while complex dislocations are associated with fractures of the radial head, olecranon, or coronoid process. The majority of patients with these complex dislocations are treated with open reduction and internal fixation (ORIF), or arthroplasty in case of a non-reconstructable radial head fracture. If the elbow joint remains unstable after fracture fixation, a hinged elbow fixator can be applied. The fixator provides stability to the elbow joint, and allows for early mobilization. The latter may be important for preventing stiffness of the joint. The aim of this study is to determine the effect of early mobilization with a hinged external elbow fixator on clinical outcome in patients with complex elbow dislocations with residual instability following fracture fixation.
Methods/Design
The design of the study will be a multicenter prospective cohort study of 30 patients who have sustained a complex elbow dislocation and are treated with a hinged elbow fixator following fracture fixation because of residual instability. Early active motion exercises within the limits of pain will be started immediately after surgery under supervision of a physical therapist. Outcome will be evaluated at regular intervals over the subsequent 12 months. The primary outcome is the Quick Disabilities of the Arm, Shoulder, and Hand score. The secondary outcome measures are the Mayo Elbow Performance Index, Oxford Elbow Score, pain level at both sides, range of motion of the elbow joint at both sides, radiographic healing of the fractures and formation of periarticular ossifications, rate of secondary interventions and complications, and health-related quality of life (Short-Form 36).
Discussion
The outcome of this study will yield quantitative data on the functional outcome in patients with a complex elbow dislocation and who are treated with ORIF and additional stabilization with a hinged elbow fixator.
Trial Registration
The trial is registered at the Netherlands Trial Register (NTR1996).
doi:10.1186/1471-2474-12-130
PMCID: PMC3121661  PMID: 21658252
17.  Percutaneous Tennis Elbow Release Under Local Anaesthesia 
Introduction:
When the non-operative treatment of tennis elbow fails to improve the symptoms a surgical procedure can be performed. Many different techniques are available. The percutaneous release of the common extensor origin was first presented by Loose at a meeting in 1962. Despite the simplicity of the operation and its effectiveness in relieving pain with minimal scarring this procedure is still not widely accepted. This study presents the long-term results of percutaneous tennis elbow release in patients when conservative measures including local steroid injections have failed to relieve the symptoms.
Patients and Methods:
Percutaneous release of the extensor origin was performed in 24 consecutive patients (seven male and seventeen female), providing 30 elbows for this study. The age of the patients ranged from 26 to 71 years with mean age of 55 years. The technique involved a day case procedure in the operating theatre using local anaesthesia without the need for a tourniquet. The lateral elbow was infiltrated with 5mls 1% lignocaine and 5mls 0.5% bupivicaine with 1:200,000 adrenaline. All operations were performed by the senior author. The patients were assessed post operatively by using DASH (disabilities of arm, shoulder and hand) score and Oxford elbow scores. The mean follow up period was 36 months (1-71months).
Results:
Twenty one patients returned the DASH and Oxford elbow questionnaires. Four patients were lost in the follow up. The post operative outcome was good to excellent in most patients. Eighty seven percent of patients had complete pain relief. The mean post-op DASH score was 8.47 (range 0 to 42.9) and the mean Oxford elbow score was 42.8 (range 16 to 48). There were no complications reported. All the patients returned to their normal jobs, hobbies such as gardening, horse riding and playing musical instruments.
Conclusion:
In our experience Percutaneous release of the epicondylar muscles for humeral epicondylitis has a high rate of success, is relatively simple to perform, is done as a day case procedure and has been without complications. Percutaneous release is a viable treatment option after failed conservative management of tennis elbow.
doi:10.2174/1874325001206010129
PMCID: PMC3322435  PMID: 22509230
Tennis elbow; percutaneous; release; tendinitis; Mill's Manipulation; local anaesthesia.
18.  Monobloc radial head prostheses in complex elbow injuries: results after primary and secondary implantation 
International Orthopaedics  2012;37(4):631-639.
Purpose
Dislocations of components, loosening of the stem, overstuffing and removal in up to 24 % of common radial head prostheses (RHP) after implantation in complex elbow injuries signal the need for improvement. The latest biomechanical evidence shows advantages for monopolar designs. Clinical results after primary and secondary implantation of the newly designed press-fit monobloc monopolar RHP in cases of complex elbow injury are evaluated.
Methods
Twenty-nine patients [median age 60 years (29–86)] were followed up retrospectively for a median of 25 months (7–54) post-operatively. Subjective parameters, the Mayo Elbow Performance Score (MEPS), the Broberg and Morrey score (BMS), latest radiographs and complications were evaluated.
Results
MEPS and BMS averaged 87.2 ± 12.9 and 81.1 ± 11.9 points, respectively. No case of implant loosening was observed; the RHP had to be removed in one case (3 %). The overall complication and revision rate was higher after secondary (53 %) than after primary (19 %) implantation.
Conclusions
Satisfactory clinical results and low short-term removal rates emphasise the practicality of monobloc monopolar RHP. Differentiated treatment of complex elbow fracture-dislocations is compulsory to avoid the need for secondary RHP implantation which carries a higher complication rate.
doi:10.1007/s00264-012-1747-7
PMCID: PMC3609984  PMID: 23271690
19.  Surgery of the rheumatoid elbow. 
Annals of the Rheumatic Diseases  1990;49(Suppl 2):871-882.
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.
Images
PMCID: PMC1030336  PMID: 2241304
20.  Elbow interposition arthroplasty in children and adolescents: long-term follow-up 
International Orthopaedics  2007;32(2):247-250.
A long-term follow-up was made of 12 elbows operated upon between 1971 and 1986, with more than 20 years’ follow-up, in nine males and three females, age at the time of surgery between 10 and 19 years . Eight right and four left elbows were involved, and there were three aetiological causes. Seven cases were sequelae of elbow fractures, of which five were supracondylar and two were of the olecranon. There were four cases of juvenile rheumatoid arthritis and one was post-osteomyelitis. The surgical technique involved a modification made by Vainio of MacAusland’s technique (wider resection of the osseous ends and total covering of the bloody surfaces) [5, 9]. After extirpating the tissue blocking the joint, we proceeded to remodel the distal humerus in a wide V shape, the proximal end of the ulnar and, if necessary, the radial head. The proximal end of the ulna was sectioned transversely. All surgery was carried out sub-periosteally. Then, an interposition material was placed in one piece and sutured over the distal humerus and cut ends of the ulna and radius. The articular ends were brought together, and the capsule was closed using equidistant stitching, as is the skin. A small compression bandage was applied, and the arm was immobilised with a collar and cuff sling, with the forearm flexed to slightly less than a right angle. In ten cases, the interposition material was fascia lata grafts; in one case, skin graft and in one case, Gelfoam graft. Early rehabilitation began when post-operative pain allowed. Follow-up ranged from 25 to 32 years. Pre-surgical movement ranged between 90° and 120° of flexion and 30° and 90° of extension. Post-operative range varied between 90° and 150° of flexion. The five cases of full pre-operative ankylosis achieved between 90° and 150° of flexion and between 0° and 70° of extension. The total range of motion at the latest follow-up varied from 35° to 150°. Patients who were able to perform flexion of 120° or more were considered to be excellent, those between 90° and 119° were graded good, from 60° to 89° fair and those 59° or less poor. The ability to attain a hand to mouth position requires a mobility of 120°. We obtained excellent results in two patients, good results in three, fair results in four and poor results in three. The fascia lata was used in 83% of cases, obtaining excellent to good results in five patients (41%). Elbow interposition arthroplasty has its indications in children and adolescents where arthrodesis or total joint replacement cannot be performed.
doi:10.1007/s00264-006-0299-0
PMCID: PMC2269022  PMID: 17308908
21.  Secondary Procedures for Elbow Flexion Restoration in Late Obstetric Brachial Plexus Palsy 
Hand (New York, N.Y.)  2009;5(2):125-134.
Even though total absence of elbow flexion in obstetric brachial plexus palsy (OBPP) is rare, weakness is a frequent problem. Numerous procedures for elbow flexion restoration in late obstetric brachial plexus palsy have been described. In this study, children with OBPP who underwent secondary reconstruction for elbow flexion restoration were studied. A retrospective review of 15 patients (16 elbows) who underwent 16 pedicled and eight free-muscle transfers for elbow flexion restoration was conducted. The mean follow-up period was 8.4 ± 2.9 years (range, 25 months to 12.2 years). The mean age at operation (elbow surgery) was 5.4 ± 1.9 years. The total arc of elbow motion was the result of the active elbow flexion less the flexion contracture. There was significant improvement in biceps muscle power from an average grading of 2.49 ± 0.80 preoperatively to 3.64 ± 0.46 postoperatively (p < 0.001). Thirteen of 16 elbows (81%) achieved good and excellent results (≥M3+); and three elbows (19%) fair results (M3− or M3). The average arc of motion was significantly improved from 36° ± 25° preoperatively to 94° ± 26° postoperatively (p < 0.001). The preoperative and postoperative average elbow flexion contracture was 10.9° ± 8.9° and 20° ± 12.2°, respectively. Pedicled and/or free-muscle transfers can significantly improve elbow flexion in late obstetric brachial plexus palsy. Choice of the procedure should be individualized and determined on the basis of the type of paralysis, availability of donor muscles, previous reconstruction, and experience of the surgeon.
doi:10.1007/s11552-009-9198-3
PMCID: PMC2880668  PMID: 19430848
Obstetric brachial plexus palsy; Secondary elbow flexion restoration; Free-muscle transfer
22.  Neglected synovial osteochondromatosis of the elbow: a rare case 
Background
Synovial osteochondromatosis is a benign metaplastic proliferative disorder of the synovium characterised by the formation of multiple cartilaginous nodules in the synovium, many of which detach and become loose bodies. The disease is characteristically monoarticular, most commonly involving the knee. A site in the elbow was first reported in 1918 by Henderson, but any joint may be involved. Very few cases of synovial osteochondromatosis of the elbow have been reported in the literature. The presenting symptoms are usually diffuse discomfort in the affected joint and decreased range of motion with an accompanying gritty or locking sensation. The treatment of choice is excision of the synovium and removal of the loose bodies.
Case presentation
We report a rare neglected case covering a 32-year period of a locally aggressive synovial osteochondromatosis of the elbow in a 47-year-old man. Clinical examination revealed a significant increase in size of the left elbow compared to the contralateral one. The simple radiographs and the computed tomography showed multiple rounded, calcified bodies widespread throughout the elbow joint. At surgery we removed and counted a total of 312 loose bodies, varying in size from a few millimeters to 3 cm. The evaluation at 6 months postoperatively showed marked reduction in the volume of the elbow, improvement of extension and flexion and an increase of the Mayo elbow performance score from 50 points before surgery to 80 points at 6 months postoperative.
Conclusion
Synovial osteochondromatosis is an uncommon condition characterized by the formation of multiple nodules of hyaline cartilage within the sub-synovial connective tissue. The differential diagnosis includes chronic articular infection, osteoarthritis, pigmented villonodular synovitis, mono-articular inflammatory arthritis and periarticular neoplasms like synovial sarcoma. The treatment of choice is excision of the synovium and removal of the loose bodies. The prognosis is good, but recurrences may occur if the removal is incomplete.
doi:10.1186/1477-7819-11-233
PMCID: PMC4015745  PMID: 24044684
Synovial Chondromatosis; Elbow joint; Metaplastic disorder; Tumor; Open synovectomy
23.  Pigmented villonodular synovitis: a retrospective study of seventy five cases (eighty one joints) 
International Orthopaedics  2013;37(6):1165-1170.
Purpose
Pigmented villonodular synovitis (PVNS) is a relatively rare, benign proliferation lesion of the synovium of large joints, but there is not much information available about the disease’s aetiology, clinical history, differential diagnosis, treatment, and long-term effects. We conducted a study to analyse these aspects of PVNS.
Methods
We reviewed all clinical data for 75 patients with PVNS (81 joints) who were treated either by synovectomy alone or synovectomy plus arthroplasty.
Results
In all cases, the diagnosis of PVNS was confirmed by pathological examination. The ratio of males to females was 27:48, and the average age of patients was 46 years (range, 15–80 years). Lesions were located in the knee, hip, or ankle, and pain and swelling were the main symptoms. Of 75 patients, 42 had a history of trauma to the involved joint. Forty-one patients (43 joints) underwent synovectomy alone, and 34 patients (38 joints) underwent synovectomy and arthroplasty together. Of the 75 patients, 61 had full follow-up data. Twelve patients had recurrent legions detected by pathological examinations; four patients had more than two recurrences. Moreover, five patients developed PVNS after arthroplasty.
Conclusions
PVNS occurs most often in middle-aged women and most frequently involves the knee, followed by the hip and ankle. The disease’s etiology is varied and unclear. Surgical excision alone or with arthroplasty is an effective treatment, but there is a high rate of recurrence.
doi:10.1007/s00264-013-1858-9
PMCID: PMC3664172  PMID: 23503697
24.  Lateral Condyle Fracture of the Humerus in Children Treated with Bioabsorbable Materials 
The Scientific World Journal  2013;2013:869418.
The aim of this study was to compare clinical and radiological outcome of lateral condyle fracture of the elbow in children treated with bioabsorbable or metallic material. From January 2008 to December 2009, 16 children with similar fractures and ages were grouped according to the fixation material used. Children were seen at 3, 6, and 12 months and more than 4 years (mean 51.8 months) postoperatively. The clinical results were compared using the Mayo Elbow Performance Score (MEPS). Radiographic studies of the fractured and opposite elbow were assessed at last follow-up control. Twelve children had a sufficient followup and could be included in the study. Seven could be included in the traditional group and 5 in the bioabsorbable group. At 12 months, the MEPS was 100 for every child in both groups. Asymptomatic bony radiolucent visible tracks and heterotopic ossifications were noted in both groups. There were no significant differences in terms of clinical and radiological outcome between the two groups. The use of bioabsorbable pins or screws is a reasonable alternative to the traditional use of metallic materials for the treatment of lateral condyle fracture of the elbow in children.
doi:10.1155/2013/869418
PMCID: PMC3817636  PMID: 24228016
25.  Long-term outcome of displaced radial neck fractures in adulthood 
Acta Orthopaedica  2009;80(3):368-370.
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.
doi:10.3109/17453670902967307
PMCID: PMC2823199  PMID: 19421911

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