The development and validation of a patient-reported questionnaire to assess outcomes of elbow surgery

Complex elbow fracture-dislocations- what factors are associated with a poor post-operative outcome?

PURPOSE

Despite standardized treatment algorithms, patients with complex elbow fracture-dislocation frequently suffer from poor post-operative elbow function leading to reduced quality of life. Up to now, there is no valuable data regarding risk factors that lead to poor post-operative outcome after surgical reconstruction of complex elbow fracture-dislocations.

METHODS

From 06/2010 to 12/2020 134 patients (51.3 ± 15.1 years, 44% women) undergoing surgical treatment of complex elbow fracture-dislocations could be included in this study. Follow-up period was 4.4 years (SD 2.5). All patients were clinically evaluated for elbow movement, elbow stability and common elbow scores (MEPS, OES, DASH-Score). Potential risk factors for poor post-operative outcome were identified using bi- and multivariate analyses.

RESULTS

Overall good post-operative outcome has been achieved, mean MEPS was 88.8 ± 17.6. Post-operative complications occurred in 31.3% of the cases, while 25.4% required surgical revision. Patients with transolecranon dislocation fractures showed the significantly worst functional outcomes (p = 0.01). In addition, it has been shown that a patient's age of more than 70 years (OR = 10, p = 0.003) and a BMI of more than 35 kg/m2 (OR = 7.6, p = 0.004) are independent risk factors for a poor post-operative outcome. In contrast, gender and time to surgery showed no significant influence on post-operative outcome.

CONCLUSION

In most cases, good post-operative functional results can be achieved using standardized treatment protocols. However, complication and revision rates remain high. Patients older than 70 years of age or with a BMI over 35 kg/m2 are at risk for an inferior outcome and require close follow-up monitoring.

In the Treatment of Lateral Epicondylitis by Percutaneous Perforation, Injectables Have No Added Value

BACKGROUND

No single injection therapy has been proven to be superior in the treatment of lateral epicondylitis. In most studies, the injection technique is not standardized, which makes it challenging to compare outcomes.

QUESTIONS/PURPOSES

(1) Does injection with autologous blood, dextrose, or needle perforation only at the extensor carpi radialis brevis tendon origin produce better VAS pain scores during provocation testing at 5 months of follow-up? (2) Which percutaneous technique resulted in better secondary outcome measures: VAS during rest and activity, VAS during maximum grip, Oxford elbow score (OES), QuickDASH, Patient-related Tennis Elbow Evaluation (PRTEE), or EuroQol-5D (EQ-5D)?

METHODS

In this multicenter, randomized controlled trial performed from November 2015 to January 2020, 166 patients with lateral epicondylitis were included and assigned to one of the three treatment groups: autologous blood, dextrose, or perforation only. Complete follow-up data were available for the primary outcome measures at the 5-month follow-up interval for 77% (127 of 166) of patients. Injections of the extensor carpi radialis brevis tendon were conducted in an accurate and standardized way. The three groups did not differ in terms of key variables such as age, gender, duration of symptoms, smoking habits, pain medication, and physiotherapy use. Data were collected at baseline and 8 weeks, 5 months, and 1 year after treatment and compared among the groups. The primary endpoint was the VAS pain score with provocation at 5 months. Our secondary study outcomes were VAS pain scores during rest, after activity, and after maximum grip strength; functional recovery; and quality of life. Therefore, we report the VAS pain score (0 to 100, with higher scores representing more-severe pain, minimum clinically important difference [MCID] 10), OES (0 to 48, with higher scores representing more satisfactory joint function, MCID 10), QuickDASH (0 to 100, with higher scores representing more severe disability, MCID 5.3), PRTEE (0 to 100, with higher scores representing more pain or more disability, MCID 20), EQ-5D/QALY (EQ-5D sumscore 0 to 1, with the maximum score of 1 representing the best health state, MCID 0.04), and EQ-5D VAS (0 to 100, with higher scores representing the best health status, MCID 8). For analysis, one-way analysis of variance and a linear mixed-model analysis were used. The analyses were performed according to the intention-to-treat principle. Four patients from the perforation group opted to crossover to autologous blood after 5 months.

RESULTS

No injection therapy proved to be superior to any other in terms of VAS pain scores during the provocation test at 5 months of follow-up (VAS for perforation: 25 ± 31; autologous blood: 26 ± 27; dextrose: 29 ± 32; p = 0.35). For the secondary outcomes, only a clinically important difference was found for the QuickDASH score. Both the perforation-only group (-8 [98% CI -4 to -12]) and autologous blood (-7 points [98% CI -3 to -11]) had improved QuickDASH scores over time compared with the dextrose group (MCID 5.3; p < 0.01). For the other outcomes, no clinically important differences were found.

CONCLUSION

There is no benefit to injectable autologous blood and dextrose over perforation alone to treat lateral epicondylitis, and they are therefore not indicated for this condition.

LEVEL OF EVIDENCE

Level I, therapeutic study.

The "Bag of Bones" Treatment of Comminuted Intra-articular Distal Humerus Fractures in the Elderly

BACKGROUND

Extensively comminuted intra-articular distal humerus fractures in the elderly present a challenging therapeutic dilemma. The purpose of this study was to investigate the results of nonoperative treatment of these fractures in a select subset of patients.

METHODS

Patients treated with nonoperative management for a comminuted intra-articular distal humerus fracture between 2007 and 2018 were reviewed. Patients were administered 3 elbow-specific functional outcomes instruments.

RESULTS

A total of 8 patients (2 men, 6 women) were treated with brief immobilization followed by early range of motion. All had fractures with extensive comminution of the articular surface such that open reduction and internal fixation was not feasible. Average age was 70 years. At an average of 33 months postinjury, average flexion was 124°, and extension was -27°, with full forearm rotation. No patients required pain medications at the latest follow-up. At 33 months of follow-up, the average Mayo Elbow Performance Score was 92/100 (100 optimal), Oxford Elbow Score was 43/48 (48 optimal), and Quick Disabilities of the Arm, Shoulder, and Hand Score was 10/100 (0 optimal). All patients were satisfied with the nonsurgical treatment that they received.

CONCLUSIONS

Nonoperative treatment for comminuted intra-articular distal humerus fractures results in acceptable functional outcome in elderly patients and should be considered when the fracture is not amenable to internal fixation and in lower-demand patients with higher surgical risk.

Prevalence of lower limb pain and disability in football, hockey, and floorball players

BACKGROUND

Currently there are not enough studies that compared frequent types of collective sports with regard to the prevalence of pain and disability of the lower limb.

OBJECTIVE

To determine the prevalence of lower limb pain and disability in team sports players.

METHODS

388 athletes with average age 27.26 ± 4.69, from sports clubs at the national level were included in the study. The Oxford Hip Score was used to determine the prevalence of hip pain. The International Knee Documentation Committee was used to determine the prevalence of knee pain. The Foot and Ankle Disability Index was used to determine the prevalence of ankle pain.

RESULTS

Hockey players had a prevalence of hip pain of 97.2% and a 14.3 times higher risk of developing hip pain compared with football and floorball players. Floorball players had a 81.9% prevalence of knee pain, with a 3.8 times higher the risk of knee pain compared with football and hockey. Floorball players had a 62.3% prevalence of ankle pain and a 1.8 times higher the risk of developing ankle pain compared with football and hockey players.

CONCLUSIONS

The highest percentage of knee 81.9% and ankle 62.3% pain, as well as the greatest risk of pain, was found among floorball players. Hockey players had the highest prevalence (97.2%) and risk of developing hip pain.

Radial head replacement for acute complex elbow instability: a long-term comparative cohort study of 2 implant designs

BACKGROUND

Radial head fractures not amenable to reconstruction should be treated by radial head replacement (RHR) when there is associated elbow or forearm instability. There are multiple RHR designs with different philosophies, but 2 of the most commonly used implants include the anatomic press-fit radial head system and the loose-fit metallic spacer. There is little information available specifically comparing the long-term clinical and radiographic outcomes of these 2 systems. The objective of this study was to compare the long-term clinical and radiologic outcomes of 2 RHR designs in the context of complex acute elbow instability.

MATERIALS AND METHODS

Ninety-five patients with an average age of 54 years (range, 21-87 years) underwent an acute RHR (46 press-fit Acumed anatomic and 49 loose-fit Evolve metallic spacer) and were prospectively followed for an average of 61 months (range, 24-157 months). There were 34 terrible triads; 36 isolated RH fractures with medial, lateral, or longitudinal instability; and 25 RH fractures associated with a proximal ulnar fracture. Clinical outcome and disability were evaluated with the Mayo Elbow Performance Score (MEPS), the Oxford Elbow Score, and the Disabilities of the Arm, Shoulder, and Hand (DASH) score. Pain and satisfaction were assessed using a visual analog scale. Radiographic analysis included presence of loosening, bone loss, and overstuffing related to the RHR.

RESULTS

Eight patients with an anatomic RHR (2 with overstuffing, 3 for stiffness, and 3 with loose implants) and 1 patient with a spacer (with stiffness) required implant removal. There were no significant differences between spacer RHR and anatomic RHR in arc of motion (120° vs. 113°, P = .14), pain relief (1 vs. 1.7, P = .135), MEPS (94 vs. 88; P = .07), Oxford Elbow Score (42.3 vs. 42.2, P = .4), or DASH score (12.2 vs. 14.4, P = .5). However, patients with a spacer RHR were significantly more satisfied (9 vs. 7.7; P = .004) than those with an anatomic implant. Radiographically, 19 anatomic implants had significant proximal bone loss and 10 showed complete lucent lines around the stem. Lucent lines were common around the spacer RHR. These radiographic changes were not always related to worse clinical outcomes.

CONCLUSION

Both the anatomic and spacer RHR designs can provide good clinical long-term outcomes. However, patients with a spacer showed a higher degree of satisfaction and those with an anatomic press-fit RHR had a higher revision rate, with radiographic changes that warrant continued follow-up.

Long-Term Follow-up (14 to 25 Years) Following Closed Reduction and Early Movement for Simple Dislocation of the Elbow

BACKGROUND

We have previously reported on the midterm outcomes after a nonoperative protocol to treat simple dislocations of the elbow that included a short period of splinting followed by early movement. We have now performed extended follow-up of the original patient group from the prior study to determine whether the excellent results that previously had been reported were maintained in the long term and also to determine the rate of and need for any late surgical intervention.

METHODS

We attempted to contact all of the patients from the original study group. We requested that they complete the Oxford Elbow Score (OES) survey, the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire, and a validated patient satisfaction questionnaire. Patients also were requested to attend a face-to-face assessment to have a clinical examination that included neurovascular, range-of-motion, and ligamentous stability assessments.

RESULTS

Seventy-one patients from the original patient group agreed to participate in the new study. The mean duration of follow-up was 19.3 years. At the time of the final follow-up, patients reported excellent functional outcome scores and a preserved functional range of movement in the injured elbow. The mean OES was 91.6 points, the mean DASH score was 5.22 points, and the mean satisfaction score was 90.9 points. None of the patients had undergone delayed or secondary surgery for instability during the interval period.

CONCLUSIONS

This study demonstrated that the original excellent outcomes following treatment with a protocol of a short period of splinting and early movement remained excellent and were maintained into the very long term.

LEVEL OF EVIDENCE

Therapeutic Level IV . See Instructions for Authors for a complete description of levels of evidence.

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.

Is Tension Band Wire Fixation Superior to Plate Fixation for Simple Displaced Olecranon Fractures? A Randomized Trial With Median Follow-up of 7.5 Years

BACKGROUND

Surgeons disagree about the best surgical treatment for simple, displaced olecranon fractures. Although the tension band wiring technique and plate fixation are the most common surgical options for fixation, studies comparing both are limited. To date, there have been no randomized trials comparing patient-reported outcomes and complications at more than 5 years of follow-up.

QUESTIONS/PURPOSES

(1) Does tension band wiring or plate fixation result in better ROM and patient-reported outcome scores for simple displaced olecranon fractures? (2) What is the risk of complications associated with each technique?

METHODS

Between November 2012 and October 2017, 68 patients were treated for acute, displaced olecranon fracture in a hand and upper extremity surgery unit at a tertiary-care center. Patients 18 years or older with traumatic, nonpathologic, simple olecranon fractures who presented within 2 weeks of injury were considered potentially eligible. Based on that, 74% (50) of patients met the inclusion criteria; 16% (11) of patients declined to participate in the study, and another 10% (seven) were excluded because they did not meet the prespecified inclusion criteria. Patients were randomized on a 1:1 basis to either tension band wiring or plate fixation and were evaluated at 2 weeks, 6 weeks, 3 months, 6 months, and 1 year after surgery. At the final follow-up interval, 16% (eight) were lost to follow-up: 4% (two) in the tension band wiring group and 12% (six) in the plate fixation group. The median follow-up time was 8 years (IQR 7 to 9 years). We evaluated complications at a minimum of 6 years after surgery. The primary outcome measure was the 1-year postoperative DASH score. Additional outcome measures included the patient-reported Oxford Elbow Score, ROM, and the proportion of patients in each group who reported hardware-related symptoms and had subsequent implant removal or postoperative infection.

RESULTS

No differences were observed in the DASH score (tension band wiring 18 [range 3 to 65] versus plate fixation 24 [range 3 to 52], median difference -6 [95% CI -12.7 to 14.9]; p = 0.73), Oxford Elbow Score (tension band wiring 36 [range 10 to 48] versus plate fixation 39 [range 17 to 47], median difference -3; p = 0.53), or all ROM measurements (p > 0.05) between the groups at 1 year of follow-up. The odds of having surgery for symptomatic implant removal were lower for plate fixation than for tension band wiring (one of 19 versus eight of 23, OR 9.6 [95% CI 1.08 to 85.7]; p =0.02); the odds of infection, however, were higher in the plate group (three of 19 versus 0 of 23; p = 0.048).

CONCLUSION

No differences were observed between the two techniques in terms of ROM or patient-reported outcomes. Surgeons should consider that although the risk of implant removal is higher in tension band wiring, patients older than 85 years undergoing plate fixation for simple olecranon fractures are at a greater risk of postoperative infection.

LEVEL OF EVIDENCE

Level I, therapeutic study.

High correlation of the subjective elbow value with Mayo Elbow Performance Score and Oxford Elbow Score in patients with elbow dislocation

Background

The purpose of this study was to analyze the correlation of the Subjective Elbow Value (SEV) with 2 widely used elbow scoring systems: Mayo Elbow Performance Score (MEPS) and Oxford Elbow Score (OES) in patients following elbow dislocation.

Methods

In this retrospective single-center study, patients who sustained an elbow dislocation between January 2008 and December 2019 and were at least 2 years out from injury were included. SEV, OES and MEPS were assessed and statistical correlation was calculated using Pearson's correlation coefficient.

Results

A total of 114 patients (61 male, 53 female) with a mean age of 47.1 years (range, 16-70) were analyzed following elbow dislocation. The mean SEV was 87.4% (95% confidence interval (CI) 84.2-90.7), mean MEPS was 88.1 (95% CI 85.1-91.0) points and mean OES was 40.0 (95% CI 38.4-41.7) points. Both MEPS (r = 0.710, P < .001), and OES (r = 0.764, P < .001) demonstrated high correlation with the SEV.

Conclusion

This study demonstrates that the SEV is a valid tool to assess overall status of the elbow in patients following elbow dislocations and presents an expressive but easy to perform addition to more complex scoring systems.

Ultrasound-guided tenotomy for lateral epicondylitis with TenJet improves physical functional and decreased pain outcomes at 1 year: a case series review

Background

Common extensor tendinopathy is a common cause of lateral elbow pain. Ultrasound-guided minimally invasive tenotomy (MIT) has been utilized successfully as a treatment for several years, but the use of TenJet device has not been well described.

Purpose

To evaluate the effectiveness and safety of MIT with TenJet who failed nonsurgical management of common extensor tendinopathy in an outpatient setting.

Methods

A total of 100 patients with common extensor tendinopathy who failed conservative treatment underwent ultrasound-guided MIT with TenJet device in the outpatient setting at a single institution. All 100 patients prior to MIT underwent diagnostic musculoskeletal ultrasound showing common extensor tendinosis. The findings were interpreted by a fellowship-trained and board-certified musculoskeletal radiologist. Patients were evaluated with the Oxford Elbow Score prior to the procedure and at 1-year follow-up. Exclusion criteria included prior corticosteroid injection within the past 6 weeks of the MIT intervention, active local or systemic infection, complete full thickness tear of the common extensor tendon, and pregnancy.

Results

Oxford Elbow Score had a statistically significant difference in baseline to 1 year (P < .001). No complications were reported and zero patients went on to require open surgical intervention.

Conclusion

MIT with TenJet is a safe, effective, and well-tolerated treatment for common extensor tendinopathy.

Minimal important difference, patient acceptable symptom state and longitudinal validity of oxford elbow score and the quickDASH in patients with tennis elbow

BACKGROUND

The Oxford Elbow Score (OES) and the short version of Disabilities of Arms, Shoulder and Hand (QuickDASH) are common patient-reported outcomes for people with elbow problems. Our primary objective was to define thresholds for the Minimal Important Difference (MID) and Patient-Acceptable Symptom State (PASS) for the OES and QuickDASH. The secondary aim was to compare the longitudinal validity of these outcome measures.

METHODS

We recruited 97 patients with clinically-diagnosed tennis elbow for a prospective observational cohort study in a pragmatic clinical setting. Fifty-five participants received no specific intervention, 14 underwent surgery (11 as primary treatment and 4 during follow-up), and 28 received either botulinum toxin injection or platelet rich plasma injection. We collected OES (0 to 100, higher is better) and QuickDASH (0 to 100, higher is worse), and global rating of change (as an external transition anchor question) at six weeks, three months, six months and 12 months. We defined MID and PASS values using three approaches. To assess the longitudinal validity of the measures, we calculated the Spearman's correlation coefficient between the change in the outcome scores and external transition anchor question, and the Area Under the Curve (AUC) from a receiver operating characteristics (ROC) analysis. To assess signal-to-noise ratio, we calculated standardized response means.

RESULTS

Depending on the method, MID values ranged from 16 to 21 for OES Pain; 10 to 17 for OES Function; 14 to 28 for OES Social-psychological; 14 to 20 for OES Total score, and - 7 to -9 for QuickDASH. Patient-Acceptable Symptom State (PASS) cut offs were 74 to 84 for OES Pain; 88 to 91 for OES Function; 75 to 78 with OES Social-psychological; 80 to 81 with OES Total score and 19 to 23 with Quick-DASH. OES had stronger correlations with the anchor items, and AUC values suggested superior discrimination (between improved and not improved) compared with QuickDASH. OES also had superior signal-to-noise ratio compared with QuickDASH.

CONCLUSION

The study provides MID and PASS values for OES and QuickDASH. Due to better longitudinal validity, OES may be a better choice for clinical trials.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02425982 (first registered April 24, 2015).

High return to sport rate and good patient-reported outcomes in recreational athletes following simple elbow dislocations

BACKGROUND

The purpose of this study was to investigate outcomes and return to sport metrics in recreational athletes who suffered simple elbow dislocations and were treated operatively or nonoperatively.

METHODS

The study included patients between the ages of 16 and 65 who were recreational athletes and had experienced a simple elbow dislocation, with at least 2 years having passed since the injury. Patient-reported outcomes including Mayo Elbow Performance Score (MEPS), Subjective Elbow Value (SEV), Oxford Elbow Score (OES) and Visual Analog Scale (VAS) were collected. Return to sport metrics were assessed.

RESULTS

A total of 44 patients (21 females, mean age 43.8 years [95% CI, 39.1-48.5]) who were recreational athletes before their injury completed follow-up at mean 7.6 years (95% CI, 6.7-8.5). There were 29 patients (65.9%) who were treated operatively. Mean MEPS was 93.3 (95% CI, 90.2-96.4), mean SEV was 94.9 (95% CI, 91.9-97.9) and mean OES was 43.3 (95% CI, 41.3-45.4). A total of 36 (81.8%) patients returned to their pre-injury sport. Mean time to return to sport was 21.7 (95% CI, 16.8-26.5) weeks. There was a significant difference in OES (P = .019) and SEV (P = .030) that favored the nonoperative group; however, no significant differences for MEPS, VAS, satisfaction, arc of motion and return to sport were present between groups. A total of five (11.4%) complications were observed and one (2.3%) required revision.

CONCLUSIONS

Good outcomes and a high return to sport rate can be expected in recreational athletes following operative and nonoperative treatment of simple elbow dislocations. However, as many as one-in-five patients may not return to pre-injury sport.

Coronoid tip fractures in terrible triad injuries can be safely treated without fixation

INTRODUCTION

The optimal treatment of terrible triad injuries of the elbow (TTI) remains topic of ongoing discussion. The aim of this study was to determine whether different treatment strategies for coronoid tip fractures in terrible triad injuries influences the clinical and radiological results in a mid-term follow-up.

METHODS

A total of 62 patients with surgical treatment of a TTI including a coronoid tip fracture (37 women, 25 men; mean age, 51 years) were available for follow-up assessment after an average of 4.2 years (range 24-110 months). Thirteen patients had O'Driscoll 1.1 and 49 O'Driscoll 1.2 coronoid fractures, of which 26 were treated with and 36 without fixation. Range of motion, the Mayo Elbow Performance Score (MEPS), Oxford Elbow Score (OES), and Disabilities of the Arm, Shoulder and Hand (DASH) score as well as grip strength were evaluated. Radiographs were analyzed for all participants.

RESULTS

No significant benefit in outcome variables could be detected between patients, whose coronoid had been fixed, compared to patients without fixation of the coronoid. In the coronoid fixation group, patients had mean outcome scores of 81.5 ± SD 19.1 (range 35-100) for MEPS, 31.0 ± SD 12.5 (range 11-48) for OES and 27.7 ± SD 23 (range 0-61) for DASH score, while in the no-fixation group, mean MEPS was 90.8 ± SD 16.5 (range 40-100), mean OES was 39.0 ± SD 10.4 (range 16-48) and mean DASH score was 14.5 ± SD 19.9 (range 0-48). Mean range of motion was 116° ± SD 21° (range 85-140°) versus 124° ± SD 24° (range 80-150°) in extension-flexion and 158° ± SD 23° (range 70-180°) versus 165° ± SD 12° (range 85-180°) in pronation-supination. Overall complication rate was 43.5% and revision rate was 24.2%, with no significant differences between both groups. Suboptimal results were more frequently seen in patients who had degenerative or heterotopic changes on their latest radiograph.

CONCLUSIONS

Sufficient elbow stability and good outcomes can be achieved in most patients with TTI and coronoid tip fractures. Although some bias in treatment allocation and group heterogeneity cannot be completely omitted, our analysis detected no significant benefit in outcome when the coronoid tip fracture has been fixed compared to patients with non-fixed coronoid tip. Therefore, we would suggest a no-fixation approach for coronoid tip fractures as primary treatment in TTI of the elbow.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Elbow Arthroscopy for the Treatment of Radial Head Fractures: Surgical Technique and 10 Years of Follow Up Results Compared to Open Surgery

BACKGROUND

This study aimed to describe the ARIF (Arthroscopic Reduction Internal Fixation) technique for radial head fractures and to compare the results with ORIF (Open Reduction Internal Fixation) at mean 10 years.

METHODS

A total of 32 patients affected by Mason II or III fractures of the radial head who underwent ARIF or ORIF by screws fixation were retrospectively selected and evaluated. A total of 13 patients were treated (40.6%) by ARIF and 19 patients (59.4%) by ORIF. Mean follow-up was 10 years (7-15 years). All patients underwent MEPI and BMRS scores at follow-up, and statistical analysis was performed.

RESULTS

No statistical significance was reported in Surgical Time (p = 0.805) or BMRS (p = 0.181) values. Significative improvement was recorded in MEPI score (p = 0.036), and between ARIF (98.07, SD ± 4.34) and ORIF (91.57, SD ± 11.67). The ARIF group showed lower incidence of postoperative complications, especially regarding stiffness (15.4% with ORIF at 21.1%).

CONCLUSIONS

The radial head ARIF surgical technique represents a reproducible and safe procedure. A long learning curve is required, but with proper experience, it represents a tool that might be beneficial for patients, as it allows a radial head fracture to be treated with minimal tissue damage, evaluation and treatment of the concomitant lesions, and with no limitation of the positioning of screws.

Hemiarthroplasty versus open reduction internal fixation for intra-articular distal humerus fractures in older patients

Background

Intra-articular distal humerus fractures in the older population remain a challenge to fix, due to the comminution of fragments and poor bone stock. Recently Elbow Hemiarthroplasty (EHA) has gained popularity to treat these fractures, however no studies exist comparing EHA to Open Reduction Internal Fixation (ORIF).

Objectives

To compare the clinical outcomes of patients over the age of 60 years treated with ORIF or EHA for multi-fragmentary distal humerus fractures.

Methods

Thirty-six patients (mean age 73 years) treated surgically for a multi-fragmentary intra-articular distal humeral fracture were followed up for a mean duration of thirty-four months (12-73 months). Eighteen patients were treated with ORIF and eighteen with EHA. The groups were matched for fracture type, demographic characteristics and follow up time. Outcome measures collected included Oxford Elbow Score (OES), Visual Analogue pain Score (VAS), range of motion (ROM), complications, re-operations and radiographic outcomes. The quality of ORIF was judged against set radiographic criteria in order to understand the effect of sub-optimal ORIF technique.

Results

No significant clinical difference was found between EHA and ORIF in mean OES (42.5 vs 39.6, p = 0.28), mean VAS (0.5 vs 1.7, p = 0.08) or mean flexion-extension arc (123° vs 112°, p = 0.12). There were significantly more complications associated with ORIF compared to EHA (39% vs 6%, p = 0.04). ORIF executed with satisfactory fixation technique had a comparable complication rate compared to EHA (17% vs 6%, p = 0.6). Two ORIF patients required revision to Total Elbow Arthroplasty (TEA). None of the EHA patients required revision surgery.

Conclusion

This study demonstrated similar short-term functional outcomes between EHA and ORIF for the treatment of multi-fragmentary intra-articular distal humeral fractures in patients >60 years of age. Early complications and re-operations were higher in the ORIF group, although this could be related to improper ORIF technique and patient selection.

Proximal ulna non-union: treatment concept and postoperative outcome

PURPOSE

Non-union of the proximal ulna is a serious complication after surgical treatment of olecranon and complex elbow fractures, frequently leading to poor functional outcome. To date, there is a lack of data regarding optimal treatment strategies and functional outcome parameters after surgical revision.

METHODS

From 02/2010 to 12/2018, 31 patients undergoing surgical treatment of proximal ulna non-union could be included. Follow-up period was seven years (SD 2.5 years). All patients were clinically assessed using a clinical assessment tool set and standard elbow scores (MEPS, OES, DASH score). All complications and unplanned revision surgeries were recorded and all radiographic material was analyzed.

RESULTS

Initial non-union procedures were performed at an average of 6.6 months (SD 3 months) after the index procedures. Those included the use of autologous spongiosa graft in all patients and concomitant compression re-osteosynthesis in 28 patients. Radiological consolidation was achieved in all patients. Overall, patients achieved a good to fair functional outcome with Mayo elbow performance score measuring 78.5 (SD 9.1), DASH score 34.7 (SD 14.4), and Oxford elbow score 31.2 (SD 6.6) points. Initial malreduction/implant-malposition could be identified as a main reason for the occurrence of the non-union. Furthermore, inferior postoperative outcome was detected in patients > 60 years and BMI > 30 kg/m².

CONCLUSION

Using a standardized protocol, bony union and acceptable functional outcomes can be achieved in proximal ulna non-unions. However, surgeons should be aware of potential risk factors and proper initial fracture reduction as key to achieve sufficient bone healing.

New Computerized Elbow and Forearm Clinical Scores

Background  Current elbow clinical scores are scarce with limited comparability between them. None of them are computerized yet. There is no forearm clinical score assessing all anatomical components of forearm disorders such as the Essex-Lopresti injuries. The aims of this paper were to present new computerized elbow and forearm clinical scores. Methods  These new computerized elbow and forearm clinical scores include four clinical criteria: pain, function, active range of motion and muscle strength. To each criterion is given a numerical value among 5 grades. The weight of each criterion is equivalent so that patient's and physician's related scores are equally balanced. Results  Clinical scores components are automatically included into diamond-shape graphs and tables that can be directly exported into PowerPoint presentations for demonstration and comparison purposes. Discussion  These user-friendly updatable clinical elbow and forearm scores are based on four classic clinical criteria, pain, function, motion, and strength that are expressed into grades. They were designed to evaluate any osteoarticular elbow or forearm disorder regardless of the etiology. These scores are open since they may be modified in future versions.

Olecranon Osteotomy by a Gigli Saw versus Chevron's Osteotomy for Exposure of Intra-articular Distal Humerus: A Comparative Study

Introduction

Olecranon osteotomy is employed for the fixation of intraarticular distal humeral fractures. We conducted a prospective, randomised study comparing Chevron's osteotomy with olecranon osteotomy by a Gigli saw for exposure of the intraarticular distal humerus in terms of functional outcome and intra-operative ease of the surgery.

Materials and methods

Thirty patients with skeletally mature AO/OTA type 13- B and 13-C distal humerus fractures were randomly allocated to Chevron's or Gigli saw groups. Each group consisted of a total of 15 patients. Both the groups were assessed on post-operative parameters including arm, shoulder or hand pain, ability to perform certain routine activities, tingling sensations and pain while sleeping.

Results

In the Gigli saw group, 12 patients had no gross limitation of activity and 13 were able to perform moderate activities with ease. Similar results were observed in the Chevron's group. The mean difference between the two groups in Oxford Score was 0.60, within the 95% confidence interval and in line with QuickDASH-11 Score.

Conclusion

Chevron's technique offers stability and better healing, providing a larger surface area for bone union. However, it is challenging and time-consuming. Also, literature suggests that the Gigli saw has multiple benefits, saves time and effort, and heals by switching blood supply from centrifugal to centripetal post-operatively. Our study suggests that both Chevron's technique and the use of the Gigli saw are effective in distal humeral intra-articular fractures as assessed by multiple parameters. Hence both techniques can be equally used depending on the surgeon's preference.

Computerized adaptive testing for the Oxford Hip, Knee, Shoulder, and Elbow scores : accurate measurement from fewer, and more patient-focused, questions

AIMS

The aim of this study was to develop and evaluate machine-learning-based computerized adaptive tests (CATs) for the Oxford Hip Score (OHS), Oxford Knee Score (OKS), Oxford Shoulder Score (OSS), and the Oxford Elbow Score (OES) and its subscales.

METHODS

We developed CAT algorithms for the OHS, OKS, OSS, overall OES, and each of the OES subscales, using responses to the full-length questionnaires and a machine-learning technique called regression tree learning. The algorithms were evaluated through a series of simulation studies, in which they aimed to predict respondents' full-length questionnaire scores from only a selection of their item responses. In each case, the total number of items used by the CAT algorithm was recorded and CAT scores were compared to full-length questionnaire scores by mean, SD, score distribution plots, Pearson's correlation coefficient, intraclass correlation (ICC), and the Bland-Altman method. Differences between CAT scores and full-length questionnaire scores were contextualized through comparison to the instruments' minimal clinically important difference (MCID).

RESULTS

The CAT algorithms accurately estimated 12-item questionnaire scores from between four and nine items. Scores followed a very similar distribution between CAT and full-length assessments, with the mean score difference ranging from 0.03 to 0.26 out of 48 points. Pearson's correlation coefficient and ICC were 0.98 for each 12-item scale and 0.95 or higher for the OES subscales. In over 95% of cases, a patient's CAT score was within five points of the full-length questionnaire score for each 12-item questionnaire.

CONCLUSION

Oxford Hip Score, Oxford Knee Score, Oxford Shoulder Score, and Oxford Elbow Score (including separate subscale scores) CATs all markedly reduce the burden of items to be completed without sacrificing score accuracy.Cite this article: Bone Jt Open 2022;3(10):786-794.

Conflicts of interest among patients: do they exist and can they bias patient-reported outcome measures? A survey of shoulder and elbow patients

BACKGROUND

Potential conflicts of interest (COIs) are common among physicians and may bias physician-reported outcome assessment in orthopedic research. It is unclear whether patients have COIs and whether these COIs could affect patient-reported outcome measures (PROMs). The purposes of this study were to investigate (1) the existence of COIs among patients and (2) the potential of these COIs to bias PROMs with a pseudonymized survey among consecutive shoulder and elbow patients.

MATERIALS AND METHODS

Between February and May 2021, 144 shoulder and elbow patients who underwent consultation at our outpatient clinic were included in the survey study. Of these patients, 79.2% (n = 114) completed the 11-item questionnaire. Variables including sex, existence of chronic diseases, level of education, and economic status were also assessed to investigate any association between these variables and patients' perceptions of COIs.

RESULTS

Whereas 33.3% of respondents (n = 38) believe that COIs exist among patients and 28.1% (n = 32) believe that COIs could bias PROMs in general, fewer patients admit to personal COIs (24.6%, n = 28) and COIs biasing their self-assessment (23.7%, n = 27). Patients more frequently suggest COIs in their personal environment, such as among family members or friends (27.2%, n = 31), than in their own medical treatment. Financial factors such as sick pay (34.2%, n = 39) are thought to be the most likely reason for having COIs, followed by interpersonal reasons such as maintaining medical affection or bonds (29.8%, n = 34). Of respondents, 42.1% (n = 48) believe that sole usage of PROMs poses risks in treatment evaluation and only 21% (n = 24) consider PROMs reliable. In addition, 43% of respondents (n = 49) believe that patients should disclose COIs routinely in medical treatment. Multinomial logistic regression analysis revealed that wealthier patients are more likely to believe COIs could bias PROMs (odds ratio for poor vs. middle class, 0.23 [95% confidence interval, 0.053-0.963]; odds ratio for lower-middle class vs. middle class, 0.19 [95% confidence interval, 0.052-0.677]).

CONCLUSIONS

Although the majority of shoulder and elbow patients deny having self-experienced COIs and deny biased PROMs due to COIs in their own medical treatment, a considerable number of patients admit to having experienced both. Further studies might be justified to investigate the actual clinical relevance of patients' COIs and their impact on value-based health care.

Functional outcomes and complications following convertible primary total elbow arthroplasty: A single surgeon series

BACKGROUND

The data on convertible total elbow arthroplasty are limited and primarily based on multiple centre/multiple surgeon series. The aim of this study was to report the mid-term functional outcomes, radiological findings, complications and survivorship of the Latitude total elbow arthroplasty performed by a single surgeon.

STUDY DESIGN & METHODS

The study included 13 patients (10 females, mean age of 72 years and varying indications) over eight years. The Oxford Elbow Score (OES), Mayo Elbow Performance Score (MEPS), range of movements (ROM), Subjective Elbow Value (SEV), satisfaction score (SS) and the revision rate of the implant per 100 observed component years (OCY) were assessed.

RESULTS

The mean follow-up was 5.9 years (3-10 years). The Oxford Elbow Score/Mayo Elbow Performance Score improved from 15 to 42 (p value < 0.005)/26% to 93% (p value < 0.005) respectively. The arc of extension-flexion/supination-pronation improved from 63° to 106° (p = 0.00002)/123° to 142° (p = 0.32) respectively. The Subjective Elbow Value/Satisfaction Score was 83/98 respectively. There was one re-operation for a deep infection. There were no radiologic signs of loosening and the revision rate was 0.15 per 100 observed component years.

CONCLUSIONS

With careful patient selection, convertible total elbow arthroplasty provides patients with good to excellent outcomes and substantial improvements in the range of movements.

Outcomes of AO/OTA C-type fractures of the distal humerus after open reduction and internal fixation with locking plate constructs in patients at least 65 years old

Background

Modern treatment options of distal humerus fractures of active elderly patients are osteosynthesis and total elbow arthroplasty. The evidence of outcomes of ORIF after AO/OTA C-type fractures mostly predates the adoption of locking plates. We evaluated the results of open reduction and internal fixation of these fractures treated exclusively with anatomic locking plates.

Methods

A retrospective cohort of 39 patients aged 65 years or above with ORIF for AO/OTA C-type distal humerus fracture using locking plates was analysed. 23 provided follow-up data and 14 attended a follow-up visit. Primary outcome was the Oxford Elbow Score. Secondary outcomes were Mayo Elbow Performance Score, quickDASH, satisfaction, range of motion, complications and revision surgeries.

Results

Mean Oxford Elbow Score pain was 83 (SD 17), Oxford Elbow Score function 83 (17) and Oxford Elbow Score social-psychological 79 (20). Mean total Oxford Elbow Score was 81 (15). Among the 14 patients who attended a follow-up visit, Mayo Elbow Performance Score was 85 (17), qDASH 19 (16), active arc of motion 119 (19) degrees. Mayo Elbow Performance Score and arc of motion were worse than on the healthy side. One patient had a serious deep infection. Eleven patients had at least one revision surgery, of which 6 were implant removals and 2 subsequent total elbow arthroplasties.

Conclusions

Distal AO/OTA C-type distal humerus fractures in older adults can be treated reliably and with good outcomes with ORIF using modern locking plates. The mean qDASH scores are similar to population normal values, but when compared to the healthy arm, single-arm outcomes indicated somewhat impaired function. About 1 in 4 patients had at least one revision surgery.

Intratendinous Injection of Autologous Conditioned Serum for Treatment of Lateral Epicondylitis of the Elbow: A Pilot Study

BACKGROUND

Autologous conditioned serum (ACS) has been effectively used in treatment of osteoarthritis. However, less is known about its efficacy in tendon disorders. In this pilot study, we aimed to evaluate the short- and long-term effects of intratendinous injection of ACS in lateral epicondylitis (LE) of the elbow.

METHODS

This prospective cohort included 42 patients with LE of the elbow who received 4 intratendinous injections of Orthokine^® (Orthogen Lab Services GmbH, Düsseldorf, Germany) under local anesthesia over 2 weeks in an outpatient setting. The clinical and functional outcomes of injections were evaluated at 3 months and 1 year after the procedure. Pain was assessed using a visual analog scale (VAS) and functional assessment was made using the Mayo Elbow Performance Score (MEPS) and Oxford Elbow Score (OES).

RESULTS

The pre-injection VAS score (7.07±1.19) improved significantly after the procedure at both 3 months (3.55±0.56, P<0.001) and 1 year (1.73±0.82, P<0.001). Similarly, the mean MEPSs were significantly different between baseline and 3 months (56.42±7.51 vs. 79.76±3.81, P<0.001) and between baseline and 1 year (56.42±7.51 vs. 94.28±4.06, P<0.001). The baseline OESs (84.17±6.07) also improved with intratendinous injection of ACS at 3 months (41.96±9.23, P<0.001) and 1 year (7.43±4.31, P<0.001). Only six patients (14.2%) had mild ecchymosis and swelling around the injection site which resolved spontaneously.

CONCLUSION

ACS is a promising option for treatment of LE of the elbow, given its early onset of pain-relieving action and longlasting functional effects. These findings await confirmation by large-scale and prospective trials.

Review of pediatric functional outcomes measures used to evaluate surgical management in pediatric patients with an upper extremity fracture

For two decades, many scores, questionnaires, and rating systems have been used to evaluate the functional outcome of children with an upper extremity fracture (UEF). However, only a few of these were created specifically for children, and many assess only elbow function. In the absence of any published review on this topic, we set out to identify and categorize different scores used to evaluate the clinical and functional outcomes of surgically treated pediatric UEFs. A literature search was performed, and 38 studies were identified. The scores used more often were the shortened version of the Disability of the Arm, Shoulder and Hand questionnaire and the Mayo Elbow Performance Score/Index. In a lower number of studies, authors used other scoring systems, including the Mayo Wrist Score, the Patient-Rated Wrist Evaluation, the Patient-Rated Elbow Evaluation, the Métaizeau functional scoring system, the Oxford Elbow Score, the Price and Flynn criteria, the Hardacre Functional Score, the Neer Shoulder Score, the Constant-Murley Shoulder Score, the Modified Orthopedic Trauma Association Score, the Medical Outcomes Study Short Form-36, and the Pediatric Outcomes Data Collection Instrument. Some specific pediatric scoring systems to evaluate the functional outcome of children with a UEF have been suggested, but a single tool that is valid and reliable for skeletally immature patients of all ages is not yet available. Further studies are needed to identify specific pediatric measurements to increase validity, responsiveness, sensitivity, and interpretability of upper limb functional outcome scores in common clinical practice.

Development of a core outcome set for lateral elbow tendinopathy (COS-LET) using best available evidence and an international consensus process

Objectives

To develop a core outcome set for lateral elbow tendinopathy (COS-LET) and to provide guidance for outcome evaluation in future studies.

Methods

We implemented a multi-stage mixed-methods design combining two systematic reviews, domain mapping of outcome measurement instruments to the core domains of tendinopathy, psychometric analysis of instruments, two patient focus groups and a Delphi study incorporating two surveys and an international consensus meeting. Following the OMERACT guidelines, we used a 70% threshold for consensus.

Results

38 clinicians/researchers and 9 patients participated. 60 instruments were assessed for inclusion. The only instrument that was recommended for the COS-LET was Patient Rated Tennis Elbow Evaluation (PRTEE) for the disability domain. Interim recommendations were made to use: the PRTEE function subscale for the function domain; PRTEE pain subscale items 1, 4 and 5 for the pain over a specified time domain; pain-free grip strength for the physical function capacity domain; a Numerical Rating Scale measuring pain on gripping for the pain on activity/loading domain; and time off work for the participation in life activities domain. No recommendations could be made for the quality-of-life, patient rating of condition and psychological factors domains.

Conclusions

The COS-LET comprises the PRTEE for the disability domain. Interim-use recommendations included PRTEE subscales, time off work, pain-free grip strength and a Numerical Rating Scale measuring pain on gripping. Further work is required to validate these interim measures and develop suitable measures to capture the other domains.

Cross-cultural validation of the Oxford Elbow Score and Mayo Elbow Performance Score in Greek

BACKGROUND

Oxford Elbow Score (OES) and Mayo Elbow Performance Score (MEPS) are two of the most commonly used instruments for the functional assessment of elbow joint. The aim of this study was to cross-culturally validate the OES and MEPS into Greek language and examine their convergent validity, internal consistency, test-retest reliability and floor and ceiling effects.

METHODS

The two instruments were translated into Greek with the back translation method. Their final Greek versions (OES-GR and MEPS-GR) were completed by 40 patients with elbow disorders. The patients completed also the Greek version of the Disabilities of the Arm Shoulder and Hand (DASH-GR). The patients re-completed the OES-GR after 24 h.

RESULTS

The OES-GR was found to have good internal consistency (Cronbach's α = 0.85, 95%CI = 0.74-0.92), in contrast to the MEPS-GR (Cronbach's α = 0.47, 95%CI = 0.15-0.70). Both instruments were found to have good convergent validity with the DASH-GR (for MEPS-GR r_s = -0.64, 95% CI -0.79 to -0.41; for OES-GR r_s = -0.84, 95%CI = -0.91 to -0.72). Good was also the convergent validity of the OES-GR with the MEPS-GR (r_s = 0.71, 95%CI = 0.51 to 0.84). The test-retest reliability for each domain of the OES-GR was found good to excellent (total score ICC = 0.91, 95%CI = 0.83-0.95; pain ICC = 0.90, 95%CI = 0.81-0.95; function ICC = 0.81, 95%CI = 0.68-0.90; social-psychological ICC = 0.91, 95%CI = 0.84-0.95).

CONCLUSION

The findings about the internal consistency, test-retest reliability, convergent validity and ceiling/floor effects of the OES-GR suggest that it is a quite valid and reliable instrument which can be used with confidence in Greek patients with elbow disorders.

LEVEL OF EVIDENCE

N/A.

Does preservation of columns affect the medium-term outcome in distal humerus hemiarthroplasty for acute unreconstructable fractures?

BACKGROUND

We assessed distal humeral column preservation effects on clinical, radiographic and patient reported outcomes following distal humerus hemiarthroplasty for acute unreconstructable fractures.

METHODS

Thirty-seven consecutive patients (mean age, 75; range, 29-93 years) with an average follow-up of 61 months (range, 24-105 months) after distal humerus hemiarthroplasty using a triceps preserving approach were studied. QuickDASH and Oxford Elbow Score assessed patient reported outcomes. Clinical and radiographic assessments comprised range of motion, grip strength, instability, implant loosening, chondral wear, heterotopic ossification and condylar union.

RESULTS

Average QuickDASH was 14.9 (range, 0-63) and Oxford Elbow Score 40.35 (range, 25-48). Mean flexion arc was 108°, extension deficit 17° and pronosupination arc 155°. Average operative sided grip strength was 31.05 kg versus 31.13 kg contralaterally. Column preservation had no statistically significant effect on QuickDASH (p = 0.75), Oxford Elbow Score (p = 0.78), flexion-extension (p = 0.87), pronosupination (p = 0.78) or grip strength (p = 0.87). No progressive radiographic loosening or symptomatic chondral wear occurred. All fixed columns united. Three cases of immediate post-operative laxity fully resolved on elbow mobilisation. Four post-operative complications required further surgery: one ulnar neuropathy, one heterotopic ossification, one wound breakdown and one traumatic dislocation.

CONCLUSION

Medium-term outcome of distal humerus hemiarthroplasty for acute unreconstructable distal humeral fractures is reliable irrespective of condylar preservation.

Good functional outcomes after open reduction and internal fixation for AO/OTA type 13-C2 and -C3 acute distal humeral fractures in patients aged over 45 years

BACKGROUND

The purpose of this study was to report the functional outcomes and complications after open reduction and internal fixation (ORIF) for Arbeitsgemeinschaft für Osteosynthesefragen (AO)/Orthopaedic Trauma Association (OTA) type 13-C2 and -C3 acute distal humeral fractures with minimum 2-year follow-up. Our hypothesis was that ORIF would provide functional outcomes that are comparable to those of total elbow arthroplasty and elbow hemiarthroplasty reported in the literature.

MATERIALS AND METHODS

During a 6-year period, 23 patients aged > 45 years were treated with double plating for AO/OTA type 13-C2 or -C3 fractures. The mean age was 62 years (range, 46-80 years). The Oxford Elbow Score was used as the primary outcome; the Mayo Elbow Performance Score, pain severity score (on a visual analog scale), range of motion, reoperations, and complications were used as secondary outcomes.

RESULTS

The median Oxford Elbow Score was 42 (range, 25-48), where a score of 48 represents a normal elbow; 20 patients achieved good to excellent outcomes, and 3 achieved fair outcomes. The median Mayo Elbow Performance Score was 85 (range, 60-100), where a score of 100 represents a normal elbow; 18 patients achieved good to excellent outcomes, and 5 achieved fair outcomes. The median visual analog scale score was 2 (range, 0-5). The median flexion-extension and supination-pronation arcs were 120° (range, 70°-155°) and 160° (range, 75°-170°), respectively. Eight complications were recorded in 7 patients; 4 of them required reoperation because of fracture pseudarthrosis or elbow stiffness. Ten patients were working at the time of trauma, and nine of them returned to the same occupation. Our results are comparable to the results of previously published studies regarding the outcome of ORIF, elbow hemiarthroplasty, or total elbow arthroplasty for AO/OTA type 13-C fractures.

CONCLUSION

ORIF is a reliable treatment option for AO/OTA type 13-C2 and -C3 acute distal humeral fractures in middle-aged and elderly patients, despite the considerable rate of complications. Good to excellent results can be obtained in most patients.

Early Improvement in Patient-Reported Outcome Scores After Operative Treatment of Osteochondritis Dissecans of the Humeral Capitellum

PURPOSE

Outcome measures that lack sensitivity for the detection of clinical changes early after surgery for capitellar osteochondritis dissecans (OCD) make it difficult to determine the optimal treatment for these defects. We sought to evaluate the early responsiveness of patient-reported outcomes measurement information system (PROMIS) scores in a cohort of patients operatively treated for capitellar OCD.

METHODS

Four PROMIS questionnaires (mobility, upper extremity [UE], pain interference, and peer relations) were electronically administered to patients treated for capitellar OCD at a single tertiary academic medical center between January 1, 2015, and July 1, 2018. The questionnaires were administered at the initial preoperative outpatient clinic visit as well as at the 2-week, 6-week, and final return-to-play (RTP) visits.

RESULTS

Twenty-nine patients (31 elbows, mean age 12.9 years) with available preoperative and postoperative PROMIS data were included. The mean final follow-up period was 26 weeks. Compared with that before surgery, there was a significant improvement in the mobility, pain interference, and UE scores at 6 weeks following surgery. The scores improved most significantly by 6 weeks, reached a relative plateau, and remained significantly improved through the RTP visit thereafter. Patients with preoperative, intra-articular loose bodies scored significantly better than those without them during the 6-week and RTP visits. Patients with lesions >1 cm², compared with those with lesions ≤1 cm², demonstrated greater improvement in the UE scores during the RTP visit.

CONCLUSIONS

In patients undergoing operative treatment for capitellar OCD, a significant improvement in the PROMIS domains of mobility, pain interference, and UE can be expected early in the postoperative period, with majority of patients reaching their greatest improvement in scores by 6 weeks following surgery.

CLINICAL RELEVANCE

This is important information for preoperative counseling. In addition, this information is helpful in confirming that PROMIS scores are responsive in the detection of changes in outcomes during the early postoperative period in this population.

[Single Assessment Numeric Evaluation (SANE)-a promising and valid measuring tool related to patient-reported outcome measures (PROM)]

Patient-reported outcome measures (PROMs) are clinical measurement tools that capture the health status and outcomes of medical interventions from the patient's perspective. The aim of this study was to investigate the correlation between the Oxford Elbow Score (OES) and Single Assessment Numeric Evaluation (SANE) retrospectively. The study examined 86 patients between December 2018 and February 2019 using the Pearson correlation coefficient between SANE and OES. OES and SANE correlated significantly (r = 0.903, p < 0.001), so that SANE can be considered a promising outcome parameter alongside established scores.

A meta-analysis of union rate after proximal scaphoid fractures: terminology matters

Heterogeneity in the anatomical definition of 'proximal' affects the comparison of outcomes of these scaphoid fractures. This study aims to review published outcomes of all variants to determine both, differences in terminology, and union rate based upon definition. A literature search was conducted to identify articles that reported descriptions and union rate of all acute (<8 weeks of injury) proximal scaphoid fractures in adult patients (>16 years old). Proximal fractures were grouped as reported ('third', 'pole', 'fifth' or 'undefined'). The data were pooled using a fixed-effects method, and a meta-analysis was conducted to compare relative risk (RR) of non-union against non-proximal fractures. Qualitative analysis of 12 articles included three main definitions: 'proximal' (1 article), 'proximal third' (3 articles), and 'proximal pole' (8 articles). Only 6 articles adopted a specific anatomical or ratio description. In a pooled meta-analysis of union rates (15 articles), 'proximal third' and 'proximal pole' fractures demonstrated a relative risk (RR) of non-union of 2.3 and 3.4 in comparison to non-proximal fractures, respectively. Operative management yielded lower non-union rates than non-operative for all fracture types (6% vs. 18%). In conclusion, non-union risk varies depending on definition, with non-standardised classifications adding heterogeneity to reported outcomes. We recommend an approach utilizing fixed anatomical landmarks on plain radiographs (referencing scaphoid length and scapho-capitate joint) to standardise reporting of proximal fracture union in future studies. Abbreviations: CI: confidence intervals; CT: computer tomography; Df: degrees of freedom; DL: dersimonian and laird estimator; MRI: magnetic resonance imaging; NICE: national institute for health and care excellence; OTA: orthopaedic trauma association; PA: posterior-anterior; PRISMA: preferred reporting items for systematic reviews and meta analyses; RCT: randomised controlled trial; RR: relative risk; SNAC: scaphoid non-union advanced collapse; UK: United Kingdom.

Autologous triceps tendon graft for LUCL reconstruction of the elbow: clinical outcome after 7.5 years

PURPOSE

The objective of this study was to assess mid- to long-term functional outcomes in patients treated for symptomatic posterolateral instability of the elbow (PLRI) using an autologous ipsilateral triceps tendon as graft.

METHODS

A total of 196 patients were treated with autologous triceps tendon graft for symptomatic PLRI at single orthopedic institution from 2006 to 2013. The surgical treatment contained arthroscopic instability testing, reconstruction of the lateral ulnar collateral ligament (LUCL) and harvesting autologous ipsilateral triceps tendon as graft. The follow-up outcomes included range of motion (ROM), pain measured on a visual analogue scale (VAS), Mayo Elbow Performance Score (MEPS), Oxford Elbow Score (OES) and ultrasound to evaluate the integrity of the refixation of the common extensor.

RESULTS

A total of 178 patients (female: 73; male: 105) were available for follow-up at a mean of 91 months (range 48-144). No patient reported pain at rest; VAS during activity was 1.8 (range 0-5). The ROM decreased slightly compared to preoperative measurements. Flexion decreased significantly from 135.4 to 131.1, though still within the functional arc of motion. All but 13 patients (8.5%) were clinically stable. However, only two patients received a revision of the LUCL reconstruction due to subjective instability. The mean MEPS in the final follow-up was 91.3 (range 73-100). The mean OES was 46.5 (range 39-48). Three patients reported a pain-free clicking of the elbow. No patient complained about donor site morbidity of the ipsilateral triceps tendon. Ultrasound evaluation showed integrity of the common extensors in all patients.

CONCLUSIONS

LUCL reconstruction using the ipsilateral triceps tendon as graft shows good to excellent mid- to long-term results in the treatment of symptomatic posterolateral elbow joint instability with a low re-instability and complication rate.

Operative vs. nonoperative treatment for Mason type 2 radial head fractures: a randomized controlled trial

BACKGROUND

The optimal treatment of isolated displaced partial articular radial head fractures remains controversial. The aim of this randomized controlled trial was to compare the functional outcome of operative treatment with nonoperative treatment in adults with an isolated Mason type 2 radial head fractures.

METHODS

In this multicenter randomized controlled trial, patients from 18 years of age with an isolated partial articular fracture of the radial head were randomly assigned to operative treatment by means of open reduction and screw fixation or nonoperative treatment with a pressure bandage. The primary outcome was function assessed with the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire. Questionnaires and clinical follow-up was conducted at admission and at 3, 6, and 12 months.

RESULTS

In total, 45 patients were randomized, 23 patients to open reduction and screw fixation and 22 patients to nonoperative treatment with a pressure bandage. At 3, 6, and 12 months, patients treated operatively had similar functional outcomes compared to patients treated nonoperatively (DASH score at 12 months: 0.0 [0.0-4.2] vs. 1.7 [0.0-8.5]; P = .076).

CONCLUSIONS

Nonoperatively treated adults with an isolated Mason type 2 radial head fracture have similar functional results after 1 year compared with operatively treated patients. In addition, complication rates were low for both operative and nonoperative treatment.

Outcomes of press-fit radial head arthroplasty following complex radial head fractures

INTRODUCTION

Press-fit radial head arthroplasty (RHA) is increasingly popular in treating complex radial head fractures. This study assessed the outcome of RHA, including the outcome following re-operation, and explored potentially influencing factors.

HYPOTHESIS

Complex radial head fractures treated with press-fit radial head prosthesis would have a favourable outcome.

MATERIAL AND METHODS

Data on all consecutive patients treated with anatomic press-fit RHA from February 2002 to February 2015 were analysed. Post-surgery clinical and X-rays assessments included a post-discharge evaluation of function. Standardised methods implemented include the assessment of range of motion (ROM), the Mayo Elbow Performance Score (MEPS) and subjective satisfaction scales.

RESULTS

Forty-five patients were recruited and 71% were classified in Mason IV and 62.2% had the "terrible triad". Re-operation was performed in 26.7% and prosthesis removal in 15.6%. Mean follow-up was 140.8 months (95% CI 117.7-164) and prosthesis survival was 69.5% at 24 months. Mean MEPS before re-operations was 86.3±15.9. Pain and/or instability were the most common reasons for re-operation, and re-operations were significantly more frequent in patients having one or more "associated injuries" (p=0.05), but not the terrible triad; and in patients with radiological "loosening" signs (p<0.01). Subjective scores were relatively good in most patients, although the functionality perceived in the re-operation with implant removal group was rather low.

DISCUSSION

Several studies of complex radial head fractures treated with press-fit radial head prosthesis have also shown favourable results, but the patients in such studies generally had less severe lesions. Moreover, differently from previous reports, this study with a long follow-up has included a younger population with high functionality requirements. Pain and/or instability, as observed in several previous reports, were the most common reasons for re-operation, but contrary to the expectation, the terrible triad was not associated with unfavourable outcome.

CONCLUSION

Treatment of complex fractures with press-fit radial head prosthesis, including re-operation with implant removal yields satisfactory results. Most scores of functional and subjective outcome improved following the re-intervention and most patients returned to their usual occupation.

LEVEL OF EVIDENCE

Level IV; case series; treatment study.

Indications, Outcomes, and Complications of Lateral Ulnar Collateral Ligament Reconstruction of the Elbow for Chronic Posterolateral Rotatory Instability: A Systematic Review

BACKGROUND

Posterolateral rotatory instability (PLRI) of the elbow can lead to pain, recurrent dislocations, and, in the worst-case scenario, disability.

PURPOSE

To report the indications, outcomes, and complication rates of lateral ulnar collateral ligament (LUCL) reconstruction for chronic PLRI of the elbow.

STUDY DESIGN

Systematic review.

METHODS

This systematic review was registered with PROSPERO and performed in accordance with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. The review entailed 17 studies that included 168 patients with isolated LUCL reconstruction for chronic PLRI. Patients with concurrent medial collateral ligament reconstruction were excluded. The primary outcome measures were patient characteristics, indication for surgery, surgical technique, functional outcomes, and complications.

RESULTS

Chronic PLRI commonly occurred after a previous traumatic injury (n = 168). Of these, there were 119 simple instabilities (no fracture) and 33 complex instabilities (associated fracture). In 11 patients, PLRI was iatrogenic. The cause was unknown in 5 patients. Grafts used were autograft (n = 102; 61%), allograft (n = 18; 11%), synthetic graft (n = 15; 9%), and unknown (n = 33; 20%). The most common surgical technique was a docking procedure or a modification of this (n = 145; 86%). Other techniques included suture anchors (n = 18; 11%), nonanatomic (n = 1; 0.6%), and unknown (n = 4; 2%). There were 45 complications reported in 37 patients (22%). The most frequent complication was recurrent instability (21/138; 15%). No other major complications were reported. The rate of recurrent instability was significantly higher in revision reconstructions (6/15 elbows; 40%) compared with primary reconstructions (15/123 elbows; 12.2%) (P = .005). The mean Mayo Elbow Performance Score and abbreviated Disabilities of the Arm, Shoulder and Hand score were 87.5 (range, 40-100) and 18.8 (range, 0-77), respectively. Of the patients in whom range of motion was measured, 134 of 144 patients (93%) regained a functional range (30L-130L).

CONCLUSION

LUCL reconstruction for chronic PLRI proved a reliable method of reconstruction, save for the moderate rate of recurrent instability, which was highest in revision reconstructions.

The effects of manual therapy and exercises on pain, muscle strength, joint health, functionality and quality of life in haemophilic arthropathy of the elbow joint: A randomized controlled pilot study

INTRODUCTION

Effective physiotherapy interventions are required for haemophilic arthropathy (HA) of the elbow due to its biomechanical differences and contribution to upper limb functionality.

AIM

To investigate the effects of manual therapy & exercises on bleeding frequency, pain, range of motion (ROM), strength, joint health, functionality and quality of life (QoL) in HA of the elbow.

METHODS

Seventeen participants with HA of the elbow were randomized as Manual Therapy & Exercises Group (MTEG = 9) and Home Exercises Group (HEG = 8). Soft tissue mobilization, joint traction (grade I-II) and Mulligan's mobilization with movement as manual therapy, and stretching/strengthening exercises were applied to MTEG, while HEG had only same exercises as home programme. The interventions lasted 3 days/weekly for 5 weeks. Bleeding frequency was evaluated with patients' records; pain with Numeric Pain Scale; ROM with goniometer; strength with digital dynamometer; joint health with HJHS; functionality with Quick-Disability of Arm, Shoulder and Hand questionnaire; and QoL with Oxford Elbow Score.

RESULTS

Bleeding frequency and activity pain were decreased, while elbow ROMs and flexor strength were increased in MTEG (P ˂ 0.05). Also significantly improvements were seen in joint health, functionality and QoL in MTEG. HEG showed improvements in activity pain, QoL and some ROMs. MTEG had better results in ROMs, joint health and functionality (P ˂ 0.05).

CONCLUSION

Manual therapy & exercises may be used without causing bleeding and pain to increase the functionality, joint health and QoL, and is superior to home exercise for joint health and functionality. Home exercises may be ameliorated in pain, QoL and some ROMs.

Validation of the cross-cultural adapted Italian version of the Oxford Elbow Score

Background

The Oxford Elbow Score (OES) is an English-language questionnaire specifically designed to evaluate surgical elbow outcomes. This scoring system has been translated into other languages. Given the lack of an Italian version of the OES, the present study was designed to establish, culturally adapt, and validate the Italian version.

Methods

The OES questionnaire was culturally adapted to Italian patients in accordance with the literature guidelines with a pilot phase including seven patients with elbow problems and seven healthy subjects. The study includes 110 participants from three hospitals, who underwent elbow surgery for acute (70%) or chronic diseases. At least one month after elbow surgery, at the “index visit”, the physician completed the Mayo Elbow Performance Index and patients completed the following questionnaires: the Italian OES, the shortened version of the Disability of Arm, Shoulder and Hand Questionnaire (QuickDASH) and the Short-Form 36 Health Survey. Internal consistency was evaluated using Cronbach's alpha. Reproducibility was assessed using the intraclass correlation coefficient in ten patients who completed the OES again two-three days after the index visit. Construct validity was assessed using Spearman correlation coefficients. Responsiveness was evaluated in 68 patients who answered the questionnaires four months after the index visit, using the Wilcoxon signed-rank test, the effect size and the standardized response mean calculation.

Results

Cronbach's alpha was excellent: 0.86 (0.82-0.90) for OES pain, 0.92 (0.90-0.94) for OES function, and 0.90 (0.87-0.93) for OES social/psychological. The intraclass correlation coefficient was 0.94 (0.78-0.98) for OES pain, 0.91 (0.71-0.97) for OES function, 0.95 (0.83-0.98) for OES social-psychological and 0.93 (0.76-0.98) for OES total. The Spearman ρ was >0.7 for OES pain and QuickDASH, for OES function and both QuickDASH and Mayo Elbow Performance Index, and for OES social-psychological and QuickDASH. Regarding responsiveness, the mean of the changes between the two visits ranged from 33.9 for OES pain, to 44 points for OES function and OES social/psychological. The effect size and the standardized response mean were >0.8 for all OES domains.

Conclusion

This study demonstrates that the Italian version of the OES, translated in accordance with the international standardized guidelines, is reliable, valid, and responsive in patients who have undergone elbow surgery.

Hidden instability in posttraumatic stiff elbows

BACKGROUND

Hidden instability could be one of the reasons for reoccurring stiffness after arthrolysis in posttraumatic elbows. Associated instability in stiff posttraumatic elbows is clinically hard to detect. Surgical treatment for instability and stiffness in the same surgical setting is challenging and has not been evaluated as of yet.

HYPOTHESIS

The primary hypothesis assumes (1) the existence of a posttraumatic "stiff and unstable elbow" and (2) that coexisting instability can be detected by arthroscopic instability testing. The secondary objective was to report the midterm results after arthrolysis and ligament stabilization in the stiff and unstable elbow.

METHODS

From 2005 to 2015, 55 patients received arthroscopic arthrolysis of the elbow due to posttraumatic elbow stiffness at our institution. The arthroscopic instability was categorized into three grades with a switching stick: grade I (= stable), grade II (mild instability) and grade III (grossly instable). In cases of persisting instability (grade II-III), a ligament stabilization procedure was performed and all patients were followed up clinically at a minimum of 12 months. Besides ROM and clinical joint stability, PROs (patient reported outcomes) were assessed with the PREE-score (patient-rated elbow evaluation) and the Oxford-Elbow-score (OES). Furthermore, the MEPS (Mayo-elbow-performance-score) was assessed.

RESULTS

Out of 55 cases presenting for arthrolysis, coexisting elbow instability was detected during arthroscopic instability testing in 22 cases (40%). All 22 patients received additional ligament stabilization. At final follow-up 62.7 ± 35.7 months postoperatively, 20 patients (12 men; 8 women) with a mean age of 42 ± 16.8 were available. PREE, OES and MEPS were 19.8 ± 25.3, 37.5 ± 9.8 and 80 ± 14.5, respectively. ROM improved significantly from 95° ± 29° to 110° ± 24° postoperatively (p = 0.045). Five patients required revision arthrolysis within the follow-up period (20%). One patient demonstrated persisting instability (5%).

CONCLUSION

Intraoperative instability diagnostics during arthroscopic arthrolysis helps detect persisting posttraumatic instability and may provide a solid indication for a concurrent ligament stabilization procedure. This study is the first to present the postoperative results after arthrolysis with stabilization of the posttraumatic, stiff and unstable elbow. However, the results are heterogenic with 25% requiring revision arthrolysis. Therefore, the stiff but unstable elbow remains a complex clinical presentation in need of further investigations.

LEVEL OF EVIDENCE

IV.

Comparison of tension band wiring and plate fixation in Mayo type 2A olecranon fractures

OBJECTIVES

This study aims to compare clinically and functionally patients who had previously undergone tension band wiring (TBW) or plate fixation (PF) procedure due to the diagnosis of Mayo type 2A olecranon fracture in our clinic.

PATIENTS AND METHODS

Data of 92 patients (51 males, 41 females; mean age 42.3±12.6 years; range, 16 to 75 years) operated on for olecranon fractures between January 2014 and December 2018 were recorded retrospectively. Forty-four patients received TBW and 48 patients received PF treatment. Their Disabilities of the Arm, Shoulder, and Hand (DASH) and Mayo scores and elbow range of motion (ROM) measurements were used for clinical and functional evaluations. Data including the time to return to work, revision rate, and follow-up time were also recorded.

RESULTS

The mean follow-up time was 38.2±17.2 months. Patients returned to work in 9.2±4.1 weeks in the TBW group and 7.8±3.6 weeks in the PF group (p=0.279). The revision rate was 14% in the TBW group and 2% in the PF group (p=0.335). The mean DASH score was 10.0±1.8 in the TBW group and 7.7±1.2 in the PF group (p=0.001). The mean Mayo score was 84.0±9.3 in the TBW group and 88.3±9.1 in the PF group (p=0.049). For elbow flexion-extension ROM, 4° of difference was measured in favor of the PF group (p=0.043). Mean Mayo score, mean DASH score, and mean flexion-extension ROM values were statistically significantly different between the two groups.

CONCLUSION

Both surgical techniques are suitable and reliable in the treatment of olecranon fractures. Although TBW treatment is low-cost and simple to apply, its biggest disadvantage is a high rate of secondary surgery for implant removal due to irritation of the skin.

Percutaneous ultrasonic tenotomy with the TX-1 device versus surgical tenotomy for the treatment of common extensor tendinosis

OBJECTIVE

To compare outcomes in patients treated for chronic common extensor tendinosis with percutaneous ultrasonic tenotomy (TX-1 device) versus surgical tenotomy.

MATERIALS AND METHODS

Outcomes from consecutive patients who underwent percutaneous tenotomy with the TX-1 device were compared with outcomes from consecutive patients who underwent surgical tenotomy. Patients were contacted to retrospectively assess their outcomes at 4 time points: before treatment, 2 weeks after treatment, 3 to 6 months after treatment, and 12 months after treatment. Outcomes were assessed using the quick disabilities of the arm, shoulder, and hand score (QuickDASH) and the Oxford elbow score (OES). Student's t tests were used to compare postprocedural versus preprocedural scores and percutaneous versus surgical tenotomy scores.

RESULTS

Response rates were 23 of 43 and 10 of 47 for surveyed percutaneous and surgical tenotomy patients, respectively. There were significant improvements from preprocedural scores in all primary outcome measures at 3-to-6-month and 12-month time points for both procedures. No significant changes from preprocedural scores were seen for either procedure at 2 weeks after treatment or between percutaneous and surgical tenotomy in preprocedural or postprocedural scores for any outcome measure. At 2 weeks, improved percutaneous tenotomy scores approached significance compared with percutaneous preprocedural QuickDASH (p = 0.060) and surgical 2-week OES function domain (p = 0.074) scores.

CONCLUSION

Ultrasonic percutaneous tenotomy with the TX-1 device and surgical tenotomy have similar outcomes for chronic common extensor tendinosis, with significant symptomatic improvement occurring after 3 to 6 months. Larger studies are needed to assess for differences at 2 weeks.

Autologous Platelet Rich Plasma (PRP) in the treatment of elbow epicondylitis and plantar fasciitis: medium to long term clinical outcome

Background and aim:

Platelet-Rich-Plasma(PRP) is a popular biological therapy especially used to regenerate different musculoskeletal tissues by releasing growth-factors and cytokines promoting cell proliferation, chemotaxis, differentiation, and angiogenesis. The

aim

was to evaluate the clinical effectiveness and safety of PRP for Lateral-Epicondylitis (LE) of the elbow and Plantar-Fasciitis (PF).

Methods:

A retrospective study was conducted including patients treated with a single topic autologous-PRP-injection between 1-1-2009 and 7-18-2019 for LE or PF at our institution; patients operated for the same problem, patients refusing the study or not traceable were excluded. Patients were assessed with VAS for pain and clinical scales.

Results:

33 patients were treated with PRP and 13 (8F, 5M) included: 4LE and 9PF for a total of 16 cases. The average pain level was 0.61±0.63: 1±1.41 for LE and 0,44±0 for PF. No significant side effect was reported. 4 PRP-treatments failed: 2LE and 2PF. OES and PRTEE gave excellent results for elbow. Average foot scores were AOFAS 98.2±5 and FADI 91.3±1. Patients were stratified and compared according to plantar arch conformation, follow-up length, healing time, time from diagnosis to PRP-treatment, therapies before PRP (physiotherapy, steroid infiltration or shock-waves), risk factors (standing work, sport, age, sex).

Conclusions:

As in other studies, our results do not allow to draw sufficiently valid conclusions regarding the effectiveness and safety of PRP in the treatment of LE and PF: in particular the statistical significance is limited by the small sample size. PRP can be chosen as a non-first-line treatment for LE and PF.

Surgical treatment of the radial head is crucial for the outcome in terrible triad injuries of the elbow

AIMS

To evaluate the outcomes of terrible triad injuries (TTIs) in mid-term follow-up and determine whether surgical treatment of the radial head influences clinical and radiological outcomes.

METHODS

Follow-up assessment of 88 patients with TTI (48 women, 40 men; mean age 57 years (18 to 82)) was performed after a mean of 4.5 years (2.0 to 9.4). The Mayo Elbow Performance Score (MEPS), Oxford Elbow Score (OES), and Disabilities of the Arm, Shoulder and Hand (DASH) score were evaluated. Radiographs of all patients were analyzed. Fracture types included 13 Mason type I, 16 type II, and 59 type III. Surgical treatment consisted of open reduction and internal fixation (ORIF) in all type II and reconstructable type III fractures, while radial head arthroplasty (RHA) was performed if reconstruction was not possible.

RESULTS

At follow-up the mean MEPS was 87.1 (20 to 100); mean OES, 36.9 (6 to 48); and mean DASH score, 18.6 (0 to 90). Mean movement was 118° (30° to 150°) for extension to flexion and 162° (90° to 180°) for pronation to supination. The overall reoperation rate was 24%, with nine ORIF, ten RHA, and two patients without treatment to the radial head needing surgical revision. When treated with RHA, Mason type III fractures exhibited significantly inferior outcomes. Suboptimal results were also identified in patients with degenerative or heterotopic changes on their latest radiograph. In contrast, more favourable outcomes were detected in patients with successful radial head reconstruction after Mason type III fractures.

CONCLUSION

Using a standardized protocol, sufficient elbow stability and good outcomes can be achieved in most TTIs. Although some bias in treatment allocation, with more severe injuries assigned to RHA, cannot be completely omitted, treatment of radial head fractures may have an independent effect on outcome, as patients subjected to RHA showed significantly inferior results compared to those subjected to reconstruction, in terms of elbow function, incidence of arthrosis, and postoperative complications. As RHA showed no apparent advantage in Mason type III injuries between the two treatment groups, we recommend reconstruction, providing stable fixation can be achieved. Cite this article: Bone Joint J 2020;102-B(12):1620-1628.

First steps in PROMs and PREMs collection in Wales as part of the prudent and value-based healthcare agenda

Purpose

Patients are experts in their own health and should be treated as equal partners in their care. Patient-reported outcome measures (PROMs) are an effective way of gathering patient feedback and can facilitate effectiveness and cost-effectiveness analysis to improve decision making and service improvement. The PROMs, PREMs & Effectiveness Programme was initiated in 2016 and aimed to develop an electronic platform to facilitate collection of PROMs and Patient-reported experience measures (PREMs) from secondary care patients across Wales.

Methods

We worked with all Health Boards in Wales, the NHS Wales Informatics Service (NWIS), and Cedar (a healthcare technology research centre) to identify and meet technical requirements to develop a platform which is fit for purpose. Patient groups were included throughout the development to gather feedback and for extensive testing. Clinical teams helped identify the most appropriate tools, with licences, translations and electronic formatting issues being managed centrally.

Results

The developed platform is integrated with patient administration systems minimising the need for manual input, with processes in place to allow automatic collection triggers according to nationally agreed schedules. We have over 30 nationally agreed PROMs ‘pathways’ with over 110,000 PROMs collected to date. Responses are fed back to clinicians via the electronic patient record and to each health board via feeds to the national data warehouse, making data easily accessible to different teams, maximising use and application.

Discussion

The national platform has provided a co-ordinated approach to PROMs collection in Wales, offering an effective means of communicating with patients outside the traditional clinic visit.

Cross-cultural adaptation and validity of the Chinese version of the Oxford elbow score

Background

The Oxford Elbow score (OES) is a patient-reported outcome measure designed to evaluate patients before and after elbow surgery. Although various translated versions of the score are available, there is no Chinese mandarin version. The aim of this study was to develop a Chinese language version of the OES and evaluate its psychometric properties for clinical use.

Methods

The English version of the OES was forward translated into Chinese, followed by a backward translation into English. Then a final Chinese version was produced following expert committee discussions and pilot study of 11 patients. A smart device compatible electronic version of the OES was designed and completed by 70 patients with elbow pathology alongside the Quick-Dash and the SF-36. Reliability was assessed by measuring intraclass correlation coefficient (ICC) for test-retest reliability and Cronbach’s alpha for internal consistency. Spearman’s correlation coefficient was used to test the construct validity. Confirmatory factor analysis (CFA) was performed to evaluate the 3-factor structure of the OES.

Results

The overall Cronbach’s α coefficient was 0.906 and for the 3 different domains Function, Pain, and Social-psychological was 0.806, 0.796, and 0.776 respectively. The overall intraclass correlation coefficient was 0.764 and for the three different domains Function, Pain, and Social-psychological was 0.764, 0.624, and 0.590 respectively. The Spearman’s coefficient for correlation, between the QuickDASH and OES domains Function, Pain, and Social-psychological, was − 0.824, − 0.734, and − 0.622 respectively, showing strong correlation (r > 0.5; p < 0.01). There were moderate correlations between OES domains and the physical functioning, role physical, and strong correlations with bodily pain subscales of the PCS domain of the SF-36; results were insignificant for all other subscales.

Conclusion

Our translated Chinese mandarin OES version (mainland) was reliable and valid, suitable for evaluating elbow disorders in the Chinese population. Reliability was measured using both the Cronbach’s α for internal consistency and the intraclass correlation. Results were classified as “excellent” and were similar to results from the original OES. Electronic PROMs were used instead of the traditional paper-based PROMs for collection of data which was well tolerated by patients.

Primary open elbow arthrolysis in post-traumatic elbow stiffness - A comparison of outcomes in severity of elbow injury

PURPOSE

Stiffness is a sequelae of elbow trauma. Arthrolysis may be considered to increase range of movement (ROM). Little is published on the outcomes/complications of elbow arthrolysis. We present our series of primary open arthrolysis in posttraumatic elbow stiffness.

METHODS

A consecutive series of patients that underwent primary open arthrolysis for posttraumatic elbow stiffness in our unit (2011-2018) were analysed. All procedures were performed by an elbow surgeon. Postoperative rehabilitation followed protocol with early motion; continuous passive motion (CPM) was utilised if requested. Data collected included patient demographics, traumatic injury type, arthrolysis technique, preoperative, intraoperative and postoperative elbow ROM, complications and postoperative Oxford Elbow Score (OES).

RESULTS

41 patients were included. 59% were male. Mean age at time of arthrolysis was 43 years (range 12-79 years). Mean duration of follow-up was 53 months (range 8-100 months). Median duration from time of injury to arthrolysis was 11 months (range 2-553 months). Mean preoperative flexion-extension arc (FEA) was 70°, improving to 104° postoperatively (p < 0.001). Mean preoperative pronosupination arc (PSA) was 125°, improving to 165° postoperatively (p < 0.001). Mean postoperative OES was 37 (n = 28). Complication rate was 24% with 7 recurrence requiring surgery, 2 nerve injuries and 1 infection. CPM, 10 patients, saw mean FEA improvement of 56°. Mean PSA improvement was 36°. Complication rate for these patients was 40%. Severe traumatic injury was associated with increased preoperative stiffness (FEA 61° vs 84°, PSA 111° vs 149°) but larger improvements in ROM (postoperative FEA 98° [p < 0.001], PSA 165° [p < 0.001]).

CONCLUSION

This series demonstrates improvement in elbow ROM following open arthrolysis with significantly higher gain in pronosupination for those withsevere injury. Moderate results were seen in a patient reported outcome measure. Patients considering arthrolysis should be counselled regarding expectations/complication rate.

Distal Biceps Tendon Repair Using a Modified Double-Incision Technique: Patient-Reported Outcomes With 10-Year Follow-up

Background:

In the setting of complete distal biceps tendon rupture, surgical repair has become the standard of care to restore optimal elbow function, but the optimal approach and method of tendon fixation are still subjects of debate and have remained controversial for more than half a century.

Purpose:

To evaluate patient-reported long-term outcomes after distal biceps tendon repair using a modified double-incision technique.

Study Design:

Case series; Level of evidence, 4.

Methods:

We reviewed primary distal biceps tendon repairs after isolated tendon rupture using the modified muscle-splitting double-incision approach and transosseous suture fixation technique described by Morrey et al (1985), which had been performed at our level 1 trauma center between January 2000 and December 2013. Outcome measures included the subjective elbow value (SEV), the Oxford Elbow Score (OES) with its 3 domains (function, pain, and social-psychological), a self-performed hook test, and the 3-level version of the EuroQoL 5-dimensional instrument (EQ-5D-3L) as a measure of health status. Levels of overall satisfaction were determined by asking whether the patient would consent to the operation again. In addition, patients were asked to report any complications.

Results:

A total of 30 patients met the inclusion criteria, and 25 patients were available for the survey. Mean age at the time of rupture was 47 years. All patients were male. Mean follow-up was 120 months (range, 57-207 months). The follow-up rate was 83.34%. The following outcome results were obtained: SEV, 88.16% ± 25.18%; OES, 43.80 ± 10.56 out of 48 points; OES Pain, 92.50% ± 23.03%; OES Function, 92.25% ± 22.19%; OES Social-Psychological, 89% ± 23.68%; EQ-5D-3L, 0.93 ± 0.21. All patients described a negative hook test. Patient-reported complications included painless limitation in forearm rotation in 8% of patients (n = 2); reduced flexion and forearm rotation strength with and without pain in 8% (n = 2) and 4% (n = 1), respectively; synostosis after 1 year requiring revision surgery in 4% (n = 1); and transient wrist drop in 4% (n = 1). The overall complication rate was 28% (7/25), and 96% (n = 24) would consent to the operation again.

Conclusion:

Despite the cited approach-related morbidity, we report an excellent patient-reported long-term outcome for the double-incision distal biceps repair technique.

Mid-term outcomes of surgical management of complex, isolated radial head fractures: a multicentre collaboration

OBJECTIVES

The available literature discussing optimal surgical management of Mason II and III radial head (RH) fractures without concomitant bone or ligamentous injuries is limited. We aim to help determine the appropriate management of these functionally significant injuries.

DESIGN

We present our retrospective cohort study of outcomes of surgically managed isolated, displaced RH fractures SETTING: Study from three trauma centres.

PATIENTS/PARTICIPANTS

Adults who underwent surgical treatment for isolated displaced RH fractures.

INTERVENTION

RH open reduction internal fixation (ORIF), replacement or excision MAIN OUTCOME MEASUREMENTS: Elbow range of motion (ROM), pain and function using Oxford Elbow Score (OES), Mayo Elbow Performance Score (MEPS), Patient-Rated Elbow Evaluation (PREE) and QuickDASH (QD).

RESULTS

Of 46 patients included (mean age 47 years and mean follow-up 48 months), 12 type II fractures were treated with ORIF and 34 type III injuries had ORIF (16), replacement (12) or resection (6). ROM was comparable in all groups, with mean arcs of flexion-extension of 131° and pronation-supination of 147°. Mean visual analogue score for pain was 1.3 in those treated with ORIF compared to 1.9 with arthroplasty and 2.5 with excision. Mean functional scores were 41, 92, 14 and 14 for OES, MEPS, PREE and QD, respectively. Complication rates were 39% for ORIF, 33% for arthroplasty and 33% for resection. Overall re-operation rate was 13%.

CONCLUSIONS

Functional outcome is similar in all groups of surgically treated patients with isolated, displaced RH fractures. Complication rates are higher than that reported previously in the literature but with low re-operation rates.

LEVEL OF EVIDENCE

IV.

Elbow hemiarthroplasty versus open reduction and internal fixation for AO/OTA type 13 C2 and C3 fractures of distal humerus in patients aged 50 years or above: a randomized controlled trial

Background

Intraarticular distal humeral fractures of AO/OTA type 13 C2 and C3 pose a surgical challenge despite the evolution of surgical implants and techniques. Open reduction and internal fixation (ORIF) is often preferred as the first choice of treatment, but the results vary and are sometimes disappointing. Total elbow arthroplasty (TEA) has been widely used for fractures that are not amenable to ORIF in elderly patients, but the mechanical complications remain a challenge, especially in active patients. Elbow hemiarthroplasty (EHA) provides a modern alternative that might avoid the mechanical complications and weight bearing restrictions related to the linked articulation in semi-constrained TEA. No studies have compared the results of EHA to that of ORIF, but case series have reported promising results.

Methods/design

This is a study protocol describing an investigator-initiated, non-blinded randomized controlled trial comparing the outcome of EHA with ORIF for AO/OTA type 13 C2 and C3 fractures of the distal humerus in patients who are 50 years or older. Forty-four patients with AO/OTA type 13 C2 and C3 fractures of distal humerus will be randomized to either EHA or ORIF. The Oxford Elbow Score (OES) will be used as primary outcome. Mayo Elbow Performance Score (MEPS), pain severity score (VAS), range of motion, and patient satisfaction will be used as secondary outcomes. Reoperations, complications, and the length of sick leave will be recorded. The patients will be examined after the operation and at 3 months and 1, 2, 5, and 10 years.

Discussion

The main objective of this study is to investigate the best treatment option for AO/OTA type 13 C2 and C3 fractures of distal humerus in patients aged 50 years or above. We hypothesize that EHA results in fewer complications and superior functional outcome compared with ORIF and that the mechanical complications related to the linked articulation of TEA can be avoided.

Trial registration

ClinicalTrials.gov, PRS, NCT04163172. Registered November 13, 2019. https://clinicaltrials.gov/ct2/results?cond=&term=evori&cntry=&state=&city=&dist= (Table 2).

The protocol has been approved by The Scientific Ethics Committee of the Capital Region of Denmark (Jr. no.: H^{− 19,035,590}).

The processing of personal data has been approved by the Danish Data Protection Agency (Jr. no. P-2019-246). Inclusion started on February 1, 2020.