Prognostic factors associated with failure of total elbow arthroplasty

Aims

The aims of this study were to identify and evaluate the current literature examining the prognostic factors which are associated with failure of total elbow arthroplasty (TEA).

Methods

Electronic literature searches were conducted using MEDLINE, Embase, PubMed, and Cochrane. All studies reporting prognostic estimates for factors associated with the revision of a primary TEA were included. The risk of bias was assessed using the Quality In Prognosis Studies (QUIPS) tool, and the quality of evidence was assessed using the modified Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) framework. Due to low quality of the evidence and the heterogeneous nature of the studies, a narrative synthesis was used.

Results

A total of 19 studies met the inclusion criteria, investigating 28 possible prognostic factors. Most QUIPS domains (84%) were rated as moderate to high risk of bias. The quality of the evidence was low or very low for all prognostic factors. In low-quality evidence, prognostic factors with consistent associations with failure of TEA in more than one study were: the sequelae of trauma leading to TEA, either independently or combined with acute trauma, and male sex. Several other studies investigating sex reported no association. The evidence for other factors was of very low quality and mostly involved exploratory studies.

Conclusion

The current evidence investigating the prognostic factors associated with failure of TEA is of low or very low quality, and studies generally have a moderate to high risk of bias. Prognostic factors are subject to uncertainty, should be interpreted with caution, and are of little clinical value. Higher-quality evidence is required to determine robust prognostic factors for failure of TEA.

Comparison of Interventions for Lateral Elbow Tendinopathy: A Systematic Review and Network Meta-Analysis for Patient-Rated Tennis Elbow Evaluation Pain Outcome

PURPOSE

There is controversy regarding the optimal treatment for lateral elbow tendinopathy (LET), and not all available treatment options have been compared directly with placebo/control. A network meta-analysis was conducted to compare the effectiveness of different LET treatments directly and indirectly against control/placebo based on a validated outcome, the Patient-Rated Tennis Elbow Evaluation (PRTEE) pain score.

METHODS

Randomized, controlled trials comparing different treatment methods for LET were included, provided they reported outcome data using the PRTEE pain score. A network meta-analysis with random effect was used to combine direct and indirect evidence between treatments compared with placebo in the short term (up to six weeks) and midterm (more than six weeks and up to six months) after intervention.

RESULTS

Thirteen studies with 12 comparators including control/placebo were eligible. The results indicated no significant improvement in PRTEE pain score in the short term across all treatments compared with control/placebo. In the midterm, physiotherapy/exercise showed benefit against placebo (mean difference: -4.32, 95% confidence interval: -7.58 and -1.07). Although steroid injections, dry needling, and autologous blood also exhibited potential treatment effects, it is crucial for the clinician to consider certain pitfalls when considering these treatments. The limited number of small studies and paucity of data call for caution in interpreting the results and need for further evidence.

CONCLUSIONS

Patients should be informed that there is currently no strong evidence that any treatment produces more rapid improvement in pain symptoms when compared with control/placebo in the short and medium terms.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic I.

The posterolateral ligament of the elbow: anatomy and clinical relevance

BACKGROUND

The posterolateral capsule was recognized in the past as an important structure for elbow stability but was later disregarded. Two recent biomechanical studies demonstrated its role in preventing posterolateral instability, and thus it should be identified as a distinct ligament: the posterolateral ligament (PLL). This study includes 2 parts: an anatomic study of the PLL's footprint and a collection of 5 cases of pathologic lesions of the PLL.

METHODS

Six cadaveric upper limbs were assessed. The attachments of the PLL were dissected, the footprints were marked and photographed, and the 2-dimensional area and length were measured.

RESULTS

The mean proximal attachment dimensions were a length of 13 mm and an area of 101 mm2, and the mean distal attachment dimensions were 19 mm and 111 mm2, respectively. There were 2 cases of posterolateral elbow pain in professional cricket bowlers, diagnosed radiographically as enthesopathy of the PLL's proximal attachment on the posterior capitellum, probably due to repeated forced hyperextension of the elbow. Both patients were treated by débridement of the posterior capitellum and reattachment of the PLL, with complete resolution of symptoms. In addition, there were 3 cases of clinical posterolateral rotatory instability in young patients. Two athletes had an isolated acute tear of the PLL, and on physical examination, both had positive posterior draw test results but negative pivot-shift test results. Both underwent elbow arthroscopy and repair of the PLL with resolution of symptoms. The third patient had long-standing recurrent elbow instability, following a failed lateral ulnar collateral ligament reconstruction, in the presence of an Osborne-Cotterill lesion. He underwent revision lateral ulnar collateral ligament reconstruction, bone grafting of the bony lesion, and reattachment of the PLL, with complete resolution of symptomatic posterolateral rotatory instability.

CONCLUSIONS

The PLL of the elbow has a significant role in the elbow's posterolateral stability. Its footprints were described, and its clinical significance was demonstrated in cases of elbow instability caused by acute ligament tears and elbow pain due to ligament enthesopathy. Surgeons should be aware of this structure and potential pathology related to its injury.

Bacterial Emission Factors: A Foundation for the Terrestrial-Atmospheric Modeling of Bacteria Aerosolized by Wildland Fires

Wildland fire is a major global driver in the exchange of aerosols between terrestrial environments and the atmosphere. This exchange is commonly quantified using emission factors or the mass of a pollutant emitted per mass of fuel burned. However, emission factors for microbes aerosolized by fire have yet to be determined. Using bacterial cell concentrations collected on unmanned aircraft systems over forest fires in Utah, USA, we determine bacterial emission factors (BEFs) for the first time. We estimate that 1.39 × 1010 and 7.68 × 1011 microbes are emitted for each Mg of biomass consumed in fires burning thinning residues and intact forests, respectively. These emissions exceed estimates of background bacterial emissions in other studies by 3-4 orders of magnitude. For the ∼2631 ha of similar forests in the Fishlake National Forest that burn each year on average, an estimated 1.35 × 1017 cells or 8.1 kg of bacterial biomass were emitted. BEFs were then used to parametrize a computationally scalable particle transport model that predicted over 99% of the emitted cells were transported beyond the 17.25 x 17.25 km model domain. BEFs can be used to expand understanding of global wildfire microbial emissions and their potential consequences to ecosystems, the atmosphere, and humans.

Central band interosseus membrane reconstruction for longitudinal instability injuries of the forearm

Aims

Acute and chronic injuries of the interosseus membrane can result in longitudinal instability of the forearm. Reconstruction of the central band of the interosseus membrane can help to restore biomechanical stability. Different methods have been used to reconstruct the central band, including tendon grafts, bone-ligament-bone grafts, and synthetic grafts. This Idea, Development, Exploration, Assessment, and Long-term (IDEAL) phase 1 study aims to review the clinical results of reconstruction using a synthetic braided cross-linked graft secured at either end with an Endobutton to restore the force balance between the bones of the forearm.

Methods

An independent retrospective review was conducted of a consecutive series of 21 patients with longitudinal instability injuries treated with anatomical central band reconstruction between February 2011 and July 2019. Patients with less than 12 months' follow-up or who were treated acutely were excluded, leaving 18 patients in total. Preoperative clinical and radiological assessments were compared with prospectively gathered data using range of motion and the abbreviated version of the Disabilities of the Arm, Shoulder and Hand questionnaire (QuickDASH) functional outcome score.

Results

Of the 18 patients (nine male, nine female) who met the inclusion criteria, the median follow-up was 8.5 years (interquartile range (IQR) 5.6 to 10). Their mean age was 49 years (SD 11). The mean extension improved significantly from 38° (SD 15°) to 24° (SD 9°) (p = 0.027), with a mean flexion-extension arc change from 81° (SD 27°) to 93° (SD 30°) (p = 0.172) but with no forearm rotational improvement (p = 0.233) at latest follow-up. The QuickDASH functional score improved significantly from 80 (SD 14) to 52 (SD 26) following reconstruction (p = 0.031), but generally the level of disability remains high. Radiological assessment showed no progression of proximal migration of the radius, with a stable interbutton distance and ulnar variance from immediate postoperative radiograph to the latest follow-up.

Conclusion

Central band interosseus membrane reconstruction using a synthetic braided cross-linked graft can improve patient-rated arm function and range of motion, but significant functional deficits remain in patients with chronic injuries.

"How the Wrightington classification of traumatic elbow instability can simplify the algorithm for treatment"

There are numerous injury patterns of elbow-fracture dislocation that can lead to confusion about the best surgical management. The Wrightington classification aims to provide a simple categorization based on the injury to the coronoid process and the three column concept of the elbow osseous stability that describes a medial column consisting of the anteromedial coronoid facet and sublime tubercle, the middlecolumn is the anterolateral coronoid facet, and the lateral column is the radial head and lateral ligament complex with a fulcrum for varus/valgus stability between the two coronoid facets. Injuries are classified as type A (anteromedial facet/medial-column), B (bifacet/ medial and middle-columns), B+ (bifacet with radial head/all three columns), C (combined radial head and anterolateral facet/middle and lateral-columns), D (distal to coronoid where coronoid is in continuity with olecranon process), and D+ (distal to coronoid with radial head fracture). With each bony injury pattern, we can anticipate which soft tissue constraints are likely to be involved and the importance of their repair to restore stability, and thereby develop algorithms for management. The Wrightington classification has been shown to be reliable and valid. A consecutive series of 60 patients with elbow-fracture dislocation managed according to the surgical algorithms of the Wrightington classification have been reported to have excellent outcomes with a median Mayo Elbow Performance Score of 100 (interquartile 85-100) and flexion/extension arc of movement of 123° (interquartile 101°-130°). In conclusion, the Wrightington classification of elbow-fracture dislocation is a comprehensive, reliable, and valid classification with treatment algorithms that are associated with good functional outcomes.

Prognostic factors associated with failure of total elbow replacement: a protocol for a systematic review

INTRODUCTION

Total elbow replacement (TER) has higher failure rates requiring revision surgery compared with the replacement of other joints. Understanding the factors associated with failure is essential for informed decision-making between patients and clinicians, and for reducing the failure rate. This review aims to identify, describe and appraise the literature examining prognostic factors for failure of TER.

METHODS AND ANALYSIS

This systematic review will be conducted and reported in line with the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols guidelines. Electronic literature searches will be conducted using Medline, EMBASE, PubMed and Cochrane. The search strategy will be broad, including a combination of subject headings (MESH) and free text search. This search will be supplemented with a screening of reference lists of the included studies and relevant reviews. Two independent reviewers will screen all search results in two stages (title and abstract, and full text) based on the Population, Index prognostic factor, Comparator prognostic factor, Outcome, Time and Setting criteria. The types of evidence included will be randomised trials, non-randomised trials, prospective and retrospective cohort studies, registry studies and case-control studies. If the literature lacks enough studies, then case series with 50 or more TERs will be considered for inclusion. Data extraction and risk of bias assessment for included studies will be performed by two independent reviewers using the Checklist for Critical Appraisal and Data Extraction for Systematic Reviews of Prediction Modelling Studies for Prognostic Factors and Quality In Prognostic Studies tools.Meta-analyses of prognostic estimates for each factor will be undertaken for studies that are deemed to be sufficiently robust and comparable. Several challenges are likely to arise due to heterogeneity between studies, therefore, subgroup and sensitivity analyses will be performed to account for the differences between studies. Heterogeneity will be assessed using Q and I2 statistics. If I2>40% then pooled estimates will not be reported. When quantitative synthesis is not possible, a narrative synthesis will be undertaken. The quality of the evidence for each prognostic factor will be assessed using the Grades of Recommendation Assessment, Development and Evaluation tool.

PROSPERO REGISTRATION NUMBER

CRD42023384756.

BESS patient care pathway: Tennis elbow

This article provides a guidance summary for the management of lateral elbow tendinopathy (LET) using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system of the rating quality of the literature and grading the strength of available evidence. The process began by assembling a guideline development group of volunteers including orthopaedic surgeons, trainees, physiotherapists, rheumatologists, radiologists and patients. Virtual meetings were organised to set out explicit PICO questions, including specification of all important outcomes (including patient reported tennis elbow evaluation (PRTEE) as an important primary outcome) to determine the clinical effectiveness of common treatment options for LET compared with no treatment or placebo. Clinical librarian searched (date 31 April 2022) for available systematic reviews and randomised controlled trials reviewing the management of the LET January 2011 onwards and evidence was collected and summarized using explicit GRADE criteria for rating the quality of evidence that include study design, risk of bias, imprecision, inconsistency, indirectness, and magnitude of effect. Recommendations were characterized as strong or weak (alternative terms conditional or discretionary) according to the quality of the supporting evidence and the balance between desirable and undesirable consequences of alternative management options. This informative summary provides the quality of available evidence for the management of LET.

Functional outcomes of elbow injuries managed according to the Wrightington classification of elbow fracture-dislocations

Background

This study aims to review the functional outcomes of patients managed by the application of the Wrightington elbow fracture-dislocation classification system and its corresponding management algorithms.

Methods

This is a retrospective consecutive case series of patients over the age of 16 with an elbow fracture-dislocation managed according to the Wrightington classification. The primary outcome was the Mayo Elbow Performance Score (MEPS) at the last follow-up. Range of movement (ROM) and complications were collected as a secondary outcome.

Results

Sixty patients qualified for inclusion (32 female, 28 male) with a mean age of 48 years (19-84). Fifty-eight (97%) patients completed a minimum of three months follow-up. Mean follow-up was six months (3-18). The median MEPS at the final follow-up was 100 (interquartile range [IQR] 85-100) and median ROM of 123° (IQR 101-130) degrees. Four patients underwent secondary surgery and had improved outcomes with the average MEPS score improving from 65 to 94 following the second surgery.

Conclusions

The results of this study show that good outcomes can be achieved for complex elbow fracture-dislocations through pattern recognition and management with an anatomically based reconstruction algorithm as described by the Wrightington classification system.

Olecranon fractures : current treatment concepts

Despite being one of the most common injuries around the elbow, the optimal treatment of olecranon fractures is far from established and stimulates debate among both general orthopaedic trauma surgeons and upper limb specialists. It is almost universally accepted that stable non-displaced fractures can be safely treated nonoperatively with minimal specialist input. Internal fixation is recommended for the vast majority of displaced fractures, with a range of techniques and implants to choose from. However, there is concern regarding the complication rates, largely related to symptomatic metalwork resulting in high rates of implant removal. As the number of elderly patients sustaining these injuries increases, we are becoming more aware of the issues associated with fixation in osteoporotic bone and the often fragile soft-tissue envelope in this group. Given this, there is evidence to support an increasing role for nonoperative management in this high-risk demographic group, even in those presenting with displaced and/or multifragmentary fracture patterns. This review summarizes the available literature to date, focusing predominantly on the management techniques and available implants for stable fractures of the olecranon. It also offers some insights into the potential avenues for future research, in the hope of addressing some of the pertinent questions that remain unanswered.Cite this article: Bone Joint J 2023;105-B(2):112-123.

A randomized controlled trial to compare clinical and cost-effectiveness of suture fixation versus tension band wiring for simple olecranon fracture fixation in adults: The Simple Olecranon Fracture Fixation Trial (SOFFT) protocol

AIMS

Olecranon fractures are usually caused by falling directly on to the olecranon or following a fall on to an outstretched arm. Displaced fractures of the olecranon with a stable ulnohumeral joint are commonly managed by open reduction and internal fixation. The current predominant method of management of simple displaced fractures with ulnohumeral stability (Mayo grade IIA) in the UK and internationally is a low-cost technique using tension band wiring. Suture or suture anchor techniques have been described with the aim of reducing the hardware related complications and reoperation. An all-suture technique has been developed to fix the fracture using strong synthetic sutures alone. The aim of this trial is to investigate the clinical and cost-effectiveness of tension suture repair versus traditional tension band wiring for the surgical fixation of Mayo grade IIA fractures of the olecranon.

METHODS

SOFFT is a multicentre, pragmatic, two-arm parallel-group, non-inferiority, randomized controlled trial. Participants will be assigned 1:1 to receive either tension suture fixation or tension band wiring. 280 adult participants will be recruited. The primary outcome will be the Disabilities of the Arm, Shoulder and Hand (DASH) score at four months post-randomization. Secondary outcome measures include DASH (at 12, 18, and 24 months), pain, Net Promotor Score (patient satisfaction), EuroQol five-dimension five-level score (EQ-5D-5L), radiological union, complications, elbow range of motion, and re-operations related to the injury or to remove metalwork. An economic evaluation will assess the cost-effectiveness of treatments.

DISCUSSION

There is currently no high-quality evidence comparing the clinical and cost effectiveness of the tension suture repair to the traditional tension band wiring currently offered for the internal fixation of displaced fractures of the olecranon. The Simple Olecranon Fracture Fixation Trial (SOFFT) is a randomized controlled trial with sufficient power and design rigour to provide this evidence for the subtype of Mayo grade IIA fractures.Cite this article: Bone Jt Open 2023;4(1):27-37.

Olecranon Fractures: A Critical Analysis Review

»

Olecranon fractures account for 10% of all elbow fractures and are more likely to result from a low-energy injury. A displaced fracture with a stable ulnohumeral joint (Mayo type 2) is the most common type of injury.

»

The management of an isolated olecranon fracture is based on patient factors (age, functional demand, and if medically fit to undergo surgery) and fracture characteristics including displacement, fragmentation, and elbow stability.

»

Nonoperative management can be successfully used in undisplaced fractures (Mayo type 1) and in displaced fractures (Mayo type 2) in frail patients with lower functional demands.

»

Patients with displaced olecranon fractures with a stable ulnohumeral joint without significant articular surface fragmentation (Mayo type 2A) can be managed with tension band wiring, plate osteosynthesis (PO), intramedullary fixation, or suture repair.

»

PO is advocated for multifragmentary fractures and fractures that are associated with ulnohumeral instability. It is essential to consider the variable anatomy of the proximal ulna during surgery.

Elbow arthroplasty research methods, outcome domains, and instruments used in clinical outcome studies : a scoping review

AIMS

Arthroplasties of the elbow, including total elbow arthroplasty, radial head arthroplasty, distal humeral hemiarthroplasty, and radiocapitellar arthroplasty, are rarely undertaken. This scoping review aims to outline the current research in this area to inform the development of future research.

METHODS

A scoping review was undertaken adhering to the Joanna Briggs Institute guidelines using Medline, Embase, CENTRAL, and trial registries, limited to studies published between 1 January 1990 and 7 February 2021. Endnote software was used for screening and selection, and included randomized trials, non-randomized controlled trials, prospective and retrospective cohort studies, case-control studies, analytical cross-sectional studies, and case series of ten or more patients reporting the clinical outcomes of elbow arthroplasty. The results are presented as the number of types of studies, sample size, length of follow-up, clinical outcome domains and instruments used, sources of funding, and a narrative review.

RESULTS

A total of 362 studies met the inclusion criteria. Most were of total elbow arthroplasty (246; 68%), followed by radial head arthroplasty (100; 28%), distal humeral hemiarthroplasty (11; 3%), and radiocapitellar arthroplasty (5; 1%). Most were retrospective (326; 90%) and observational (315; 87%). The median sample size for all types of implant across all studies was 36 (interquartile range (IQR) 21 to 75). The median length of follow-up for all studies was 56 months (IQR 36 to 81). A total of 583 unique outcome descriptors were used and were categorized into 18 domains. A total of 105 instruments were used to measure 39 outcomes.

CONCLUSION

We found that most of the literature dealing with elbow arthroplasty consists of retrospective observational studies with small sample sizes and short follow-up. Many outcomes have been used with many different instruments for their measurement, indicating a need to define a core set of outcomes and instruments for future research in this area.Cite this article: Bone Joint J 2022;104-B(10):1148-1155.

Treatment of acute distal biceps tendon ruptures - A survey of the British Elbow and Shoulder Society surgical membership

Background

Acute distal biceps tendon ruptures result in weakness and deformity. While in other jurisdictions the rate of surgical repair has outpaced rises in incidence, UK practice for distal biceps tendon ruptures is unknown. The aim of this survey was to characterise current UK clinical practice.

Methods

An online survey was sent to the surgeon members of the British Elbow and Shoulder Society. Questions covered respondent demographics, clinical decision making, surgical experience and willingness to be involved in future research.

Results

A total of 242 surgeons responded; 99% undertook acute distal biceps tendon repairs with 83% repairing at least half of all distal biceps tendon ruptures, and 84% of surgeons would have their own, hypothetical, acute distal biceps tendon rupture repaired in their dominant arm and 67% for their non-dominant arm. Patient age, occupation and restoration of strength were the commonest factors underpinning a recommendation of surgical fixation. Most surgeons (87%) supported a national trial to study operative and non-operative treatments.

Conclusions

UK upper limb surgeons currently advise surgical repair of acute distal biceps tendon ruptures for the majority of their patients. This is despite a paucity of evidence to support improved outcomes following surgical, rather than non-operative, management. There is a clear need for robust clinical evaluation in this area.

Survivorship of anatomic press-fit short-stem radial head replacement with a pyrocarbon bearing

BACKGROUND

Restoring the radial head as a stabiliser of the elbow is considered important in cases where there is an associated bony or ligamentous injury. A variety of radial head prostheses are available. There are no reports of the survivorship of a short-stem press-fit radial head prostheses with pyrocarbon bearing.

PATIENTS AND METHODS

With institutional review board approval, a retrospective case-note analysis was performed of a consecutive single-surgeon case series of the Integra LifeScience pyrocarbon radial head prostheses (Carbon Modular Radial Head) from October 2010 to October 2019 in a tertiary referral centre. The series was divided into acute trauma and salvage cohorts. Kaplan-Meier survivorship analysis was conducted.

RESULTS

36 patients were included, 23 (64%) for acute injuries and 13 (36%) for failed initial treatment. Of the acute injuries, 20 (87%) had a Wrightington type-C elbow fracture-dislocation. Reoperation was performed in 4 (11%) patients; 10 (28%) had possible loosening on radiographs. The implant survival rate was 94% at shortest follow-up of 17 months (mean 70 months).

DISCUSSION

Treatment of complex radial head fractures using a pyrocarbon-bearing, anatomic press-fit design provides satisfactory short-term survivorship in this case series. The implant should be used with caution in salvage cases, due to higher rates of loosening seen in this cohort.

Distal biceps tendon repairs and reconstructions-an analysis of demographics, prodromal symptoms and complications

INTRODUCTION

The purpose of this study was to evaluate the demographics, complications and prodromal symptoms (any pain or unpleasant sensation in the area distal biceps tendon preceding the injury) of distal biceps tendon tears (DBTTs) of patients treated with primary repair or Achilles allograft reconstruction.

MATERIALS AND METHODS

228 consecutive DBTTs in 226 patients from a single centre were evaluated. The demographic data, prodromal symptoms and postoperative adverse events were documented.

RESULTS

There were 225 males and 1 female patient. The age distribution showed a bimodal pattern in the whole cohort, but once the 48 (20%) elite athletes were excluded, the age was normally distributed, peaking in the 5^th decade. Direct repairs were performed in 184 cases and reconstruction with Achilles tendon allograft in 45 cases. An adverse event was observed in 34 (19%) patients who underwent direct repair and in 3 (7%) cases with graft reconstruction, corresponding to RR of 0.32 (95% CI 0.1-0.96, p = 0.04). Adjusting with the potential confounders (age, occupation and smoking), the OR was 0.35; 95% CI 0.09-1.3, p = 0.11). Adverse events included 28 (12.3% of all adverse events) lateral antebrachial cutaneous nerve (LABCN) neurapraxias, 5 (2.1%) other neurapraxias, 6 (2.6%) heterotopic ossifications and 1 (0.4%) re-rupture. Twenty-three (10%) patients reported prodromal symptoms before the tear.

CONCLUSIONS

DBTT is a condition that affects men predominantly. The observed bimodal incidence distribution was related to elite athletes, but in the normal population the peak occurs at the age typical to tendinopathies. LABCN neurapraxia was the most common adverse event, and graft use does not seem to predispose to adverse events.

The radiological findings in complex elbow fracture-dislocation injuries

Elbow fracture-dislocation is a complex injury which can lead to significant bony and soft tissue damage. Surgical intervention is guided towards restoring joint stability, allowing early mobilization and preventing long-term joint stiffness. The most common types are posterolateral, posteromedial, Monteggia type (and variants), and anterior trans-olecranon fracture-dislocations. Posterolateral fracture-dislocation is characterized by a radial head fracture (± anterolateral coronoid fracture) and typically capsuloligamentous disruption (lateral collateral ligaments injury is the most common). A posterolateral fracture-dislocation with radial head and coronoid anterolateral facet fractures is termed a terrible triad injury. In posteromedial fracture-dislocation, there is a fracture of the anteromedial facet of the coronoid, typically with proximal avulsion of the lateral collateral ligaments (± injury to the posterior bundle of the ulnar collateral ligament). Monteggia fracture-dislocation injuries demonstrate proximal ulnar fracture (with possible involvement of the olecranon and the coronoid) and radial head dislocation. These can be divided into apex anterior or apex posterior variants. The latter are commonly associated with radial head fractures and lateral ligamentous injury, and have a worse prognosis. In trans-olecranon fracture-dislocation, there is significant disruption of the greater sigmoid notch and the olecranon, with various involvement of the coronoid and the proximal ulna. The article describes the radiological findings and outlines the management principles in complex elbow fracture-dislocation injuries.

Greater sigmoid notch dysplasia causing elbow instability: Lateral ligament reconstruction and Stamp osteotomy

The coronoid is one of the elbow's primary static stabilisers, and the importance of reconstruction following fracture with instability has been established. In the developing elbow, instability can lead to greater sigmoid notch dysplasia that can make reconstruction challenging. A novel technique to improve osseous stability with an opening wedge 'stamp osteotomy' reconstruction of the coronoid is described combined with a lateral ligament reconstruction, in two patients with recurrent posteromedial rotatory instability. The technique improves congruity and coverage of the greater sigmoid notch with the trochlea whilst maintaining articular cartilage. Extra-articular iliac crest bone graft is used to maintain the position with buttress plate support. The surgical technique is described and the clinical and radiographic outcome reported in two patients. Level of evidence: IV.

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.

Wildland fire smoke alters the composition, diversity, and potential atmospheric function of microbial life in the aerobiome

The atmosphere contains a diverse reservoir of microbes but the sources and factors contributing to microbial aerosol variability are not well constrained. To advance understanding of microbial emissions in wildfire smoke, we used unmanned aircraft systems to analyze the aerosols above high-intensity forest fires in the western United States. Our results show that samples of the smoke contained ~four-fold higher concentrations of cells (1.02 ± 0.26 × 105 m-3) compared to background air, with 78% of microbes in smoke inferred to be viable. Fivefold higher taxon richness and ~threefold enrichment of ice nucleating particle concentrations in smoke implies that wildfires are an important source of diverse bacteria and fungi as well as meteorologically relevant aerosols. We estimate that such fires emit 3.71 × 1014 microbial cells ha-1 under typical wildfire conditions in western US forests and demonstrate that wildland biomass combustion has a large-scale influence on the local atmospheric microbial assemblages. Given the long-range transport of wildfire smoke emissions, these results expand the concept of a wildfire's perimeter of biological impact and have implications to biogeography, gene flow, the dispersal of plant, animal, and human pathogens, and meteorology.

The three-column concept of elbow joint stability and the Wrightington elbow fracture-dislocation classification, emphasizing the role of cross-sectional imaging

Elbow fracture-dislocation is a complex injury with a combination of osseous and soft tissue disruption. Different classification systems have been used to describe the injury pattern and help guide the management. The article describes the important cross-sectional findings in complex elbow fracture-dislocation injuries based on the relatively new Wrightington classification. This includes the various elements and patterns seen in elbow fracture-dislocations providing a simple and comprehensive system to classify these injuries and help guide the surgical management. The article also describes the three-column concept of elbow joint stability, dividing the elbow joint osseous structures into lateral, middle and medial columns. Detailed radiological assessment of the fractures pattern is vital to understand the mechanism of injury, allowing clinicians to predict the associated capsuloligamentous injury and help guide the management decisions. The Wrightington elbow fracture-dislocation classification categorizes the injuries according to the ulnar coronoid process and radial head fractures. Type A is an anteromedial coronoid fracture. Type B is a bifacet or basal coronoid fracture, with B + indicating associated radial head fracture. Type C is a combined anterolateral facet and radial head or comminuted radial head fractures. Type D is a diaphyseal ulnar fracture, with D + indicating associated radial head fracture.

Current concepts in elbow fracture dislocation

BACKGROUND

Elbow fracture dislocations are complex injuries that can provide a challenge for experienced surgeons. Current classifications fail to provide a comprehensive system that encompasses all of the elements and patterns seen in elbow fracture dislocations.

METHODS

The commonly used elbow fracture dislocation classifications are reviewed and the three-column concept of elbow fracture dislocation is described. This concept is applied to the currently recognised injury patterns and the literature on management algorithms.

RESULTS

Current elbow fracture dislocation classification systems only describe one element of the injury, or only include one pattern of elbow fracture dislocation. A new comprehensive classification system based on the three-column concept of elbow fracture dislocation is presented with a suggested algorithm for managing each injury pattern.

DISCUSSION

The three-column concept may improve understanding of injury patterns and treatment and leads to a comprehensive classification of elbow fracture dislocations with algorithms to guide treatment.

Tension Suture Fixation of Olecranon Fractures

Background

Mayo type-IIA olecranon fractures are characterized by a transverse or short oblique fracture without articular comminution or ulnohumeral instability. Traditionally, these fractures are treated with a tension-band wiring technique. Despite good rates of fracture union, tension-band wiring is associated with a reoperation rate of 30% to 60%, usually for removal of prominent metalwork. The tension suture technique was developed as an alternative method of fixing Mayo type-IIA fractures using only high-tensile braided nonabsorbable number-2 sutures, with the aim of reducing the reoperation rate associated with tension-band wiring without compromising outcomes. The tension suture technique has subsequently become the only technique we use when treating these fractures.

Description

The patient is positioned in the lateral decubitus position under general or regional anesthesia. A direct posterior approach is made, centered over the fracture. The fracture is identified, cleared of hematoma, and reduced with use of a large, pointed reduction clamp to provide interfragmentary compression. A 2.5-mm transverse drill hole is made through the ulna distal to the fracture site. Two sets of number-2 braided nonabsorbable sutures are utilized. The first sutures are passed lateral to medial through the drill hole and used to grasp the medial triceps insertion onto the proximal fragment, then passed back through the transverse drill hole from medial to lateral and used to grasp the lateral triceps insertion onto the proximal fragment. The suture ends are tensioned to remove slack and tied on the lateral aspect of the olecranon. The second sutures are then passed lateral to medial through the transverse drill hole but this time used to grasp the posterolateral triceps insertion on the proximal fragment, then re-passed through the transverse drill hole from medial to lateral, and finally used to grasp the posteromedial triceps insertion. The suture limbs are tensioned and tied on the lateral aspect of the ulna next to the first suture. The clamp is removed, and the construct is tested under full range of motion to ensure there is no evidence of gapping. Fluoroscopy is utilized to confirm reduction before the wound is irrigated and closed in a standard fashion.

Alternatives

Mayo type-IIA fractures may be treated nonoperatively in frail or low-demand patients. Surgical treatment is traditionally performed with the tension-band wiring technique, but plate or intramedullary fixation may also be utilized.

Rationale

This technique negates the metalwork-related complications associated with all other surgical techniques for this fracture type.

Expected Outcomes

In a recent study comparing the tension suture technique with tension-band wiring and plate fixation for Mayo type-IIA fractures, the tension suture technique had a significantly lower reoperation rate compared with tension-band wiring and a lower complication rate compared with plate fixation.

Important Tips

The tension-suture technique is primarily for Mayo type-IIA fractures without ulnohumeral instability or marked articular comminution.Ensure the transverse tunnel in the ulna is at least 3 cm distal to the fracture site and 1 cm anterior to the dorsal cortex of the ulna in order to prevent fracture of the tunnel.Grasp as much of the triceps tendon as possible when placing the sutures through the proximal fragment to prevent pull-out.Tension and tie the sutures with the elbow semi-extended to prevent the construct slackening in elbow extension and to facilitate interfragmentary compression during flexion.

Posteromedial rotatory instability of the elbow: What the radiologist needs to know

Varus posteromedial rotatory instability of the elbow joint is a relatively new subject described for the first time in 2003. It occurs secondary to axial loading of the elbow with varus force and internal rotation of the forearm. There is usually a specific pattern of osseous and soft tissue injuries that can be recognized on imaging. This includes an anteromedial coronoid fracture and avulsion of the lateral collateral ligament complex from its humeral attachment. Ulnar collateral ligament complex injury is also reported, particularly its posterior bundle which plays an important role in posteromedial elbow joint stability. There is high incidence of early osteoarthritis secondary to the resultant varus instability and increased contact pressure at the ulnohumeral joint. Surgical fixation of the coronoid fracture and ligamentous reconstruction maybe indicated to prevent this recurrent instability. The article reviews the key radiological features of posteromedial rotatory instability with multiple examples from different imaging modalities. The relevant anatomy of the elbow joint stabilising structures will be illustrated, in particular the coronoid process anatomy and the O'Driscoll classification for coronoid process fractures. Radiologists should be familiar with the imaging findings of posteromedial rotatory instability.

The post-traumatic stiff elbow: A review

Upper extremity function is highly dependent on elbow motion in order to adequately position the hand in space. Loss of this motion due to stiffness following trauma can cause patients substantial disability, leading to difficulties with performing activities of daily living. Post-traumatic elbow stiffness is challenging to treat, and therefore prevention is of paramount importance. Key measures that can be used to prevent elbow stiffness are early surgical intervention for fracture or joint instability, as well as active mobilisation, which helps to prevent oedema and an increase in viscosity of inflammatory exudates. Other options include splinting and continuous passive mobilisation. Once non-operative methods of addressing post-traumatic stiffness have been exhausted, arthrolysis of the stiff elbow can be performed via open or arthroscopic means depending on the type of pathology involved (intrinsic or extrinsic contracture) and experience of the surgeon with elbow arthroscopy. The particular open approach used depends on several factors, which include the formation and location of any heterotopic ossification present. Improvements in range of motion can be expected with both open and arthroscopic techniques, which can be effective and rewarding for patients. Post-operative rehabilitation, particularly early active mobilisation, should be considered essential in order to optimise patient outcomes following surgery. This review aims to explore elbow stiffness following traumatic aetiology, assessing its pathogenesis and prevention, as well as reviewing surgical treatment options and post-operative rehabilitation.

Protocol for the development of a core outcome set for lateral elbow tendinopathy (COS-LET)

BACKGROUND

Lateral elbow tendinopathy (LET) is a common condition that can cause significant disability and associated socioeconomic cost. Although it has been widely researched, outcome measures are highly variable which restricts evidence synthesis across studies. In 2019, a working group of international experts, health care professionals and patients, in the field of tendinopathy (International Scientific Tendinopathy Symposium Consensus (ICON) Group), published the results of a consensus exercise defining the nine core domains that should be measured in tendinopathy research. The aim of this study is to develop a core outcome set (COS) for LET mapping to these core domains. The primary output will provide a template for future outcome evaluation of LET. In this protocol, we detail the methodological approach to the COS-LET development.

METHODS

This study will employ a three-phase approach. (1) A systematic review of studies investigating LET will produce a comprehensive list of all instruments currently employed to quantify the treatment effect or outcome. (2) Instruments will be matched to the list of nine core tendinopathy outcome domains by a Steering Committee of clinicians and researchers with a specialist interest in LET resulting in a set of candidate instruments. (3) An international three-stage Delphi study will be conducted involving experienced clinicians, researchers and patients. Within this Delphi study, candidate instruments will be selected based upon screening using the Outcome Measures in Rheumatology (OMERACT) truth, feasibility and discrimination filters with a threshold of 70% agreement set for consensus.

CONCLUSIONS

There is currently no COS for the measurement or monitoring of LET in trials or clinical practice. The output from this project will be a minimum COS recommended for use in all future English language studies related to LET. The findings will be published in a high-quality journal and disseminated widely using professional networks, social media and via presentation at international conferences.

TRIAL REGISTRATION

Registered with the Core Outcome Measures in Effectiveness Trials (COMET) database, November 2019. https://www.comet-initiative.org/Studies/Details/1497 .

Indications and outcome in total elbow arthroplasty: A systematic review

BACKGROUND

Total elbow arthroplasty (TEA) is the established treatment for end-stage rheumatoid arthritis but improved surgical techniques have resulted in expanded indications. The aim of this study is to review the literature to evaluate the evolution of surgical indications for TEA.

METHODS

A systematic review of PubMed and EMBASE databases was conducted. Case series and comparative studies reporting results after three types of primary TEA were eligible for inclusion.

RESULTS

Forty-nine eligible studies were identified (n = 1995). The number of TEA cases published annually increased from 6 cases in 1980 to 135 cases in 2008. The commonest indication for TEA throughout the review period was rheumatoid arthritis but its annual proportion reduced from 77% to 50%. The mean Mayo Elbow Performance Score significantly improved for all indications. Three comparative studies reported statistically improved functional outcomes in rheumatoid arthritis over the trauma sequelae group. Complication and revision rates varied; rheumatoid arthritis 5.2-30.9% and 11-13%, acute fracture 0-50% and 10-11%, trauma sequelae 14.2-50% and 0-30%, osteoarthritis 50% and 11%, respectively.

DISCUSSION

TEA can provide functional improvements in inflammatory arthritis, acute fractures, trauma sequelae and miscellaneous indications. Long-term TEA survivorship appears satisfactory in rheumatoid arthritis and fracture cases; however, further research into alternative surgical indications is still required.

Distal biceps hook test - Sensitivity in acute and chronic tears and ability to predict the need for graft reconstruction

BACKGROUND

The aim of this study was to assess the sensitivity of distal biceps hook test - O'Driscoll hook test - in a retrospective series of acute and chronic distal biceps tendon tears and investigate the ability of the test to predict the need for graft reconstruction.

METHODS

We retrospectively evaluated 234 consecutive distal biceps tendon tears operated in a single centre. The result of O'Driscoll hook test and perioperative findings of distal biceps were documented in standard fashion.

RESULTS

The perioperative and O'Driscoll hook test data were available in 202 cases. The sensitivity for the distal biceps hook test was 78% in all tears and 83% in complete tears. The sensitivity was significantly lower in partial tears (30%) and in cases where lacertus fibrosus was found to be intact (45 %). When O'Driscoll hook test was positive and the delay from initial injury to operative intervention was eight weeks or more, there was over 75% probability of achilles tendon allograft reconstruction. When O'Driscoll hook test was negative, the probability of reconstruction even after 12 weeks' delay was only 20%.

DISCUSSION

O'Driscoll hook test is useful when establishing distal biceps tendon tear diagnosis, but a negative test does not exclude rupture. In delayed cases, a positive test may predict the need for reconstruction.

Reliability and validity of the Wrightington classification of elbow fracture-dislocation

Aims

The Wrightington classification system of fracture-dislocations of the elbow divides these injuries into six subtypes depending on the involvement of the coronoid and the radial head. The aim of this study was to assess the reliability and reproducibility of this classification system.

Methods

This was a blinded study using radiographs and CT scans of 48 consecutive patients managed according to the Wrightington classification system between 2010 and 2018. Four trauma and orthopaedic consultants, two post CCT fellows, and one speciality registrar based in the UK classified the injuries. The seven observers reviewed preoperative radiographs and CT scans twice, with a minimum four-week interval. Radiographs and CT scans were reviewed separately. Inter- and intraobserver reliability were calculated using Fleiss and Cohen kappa coefficients. The Landis and Koch criteria were used to interpret the strength of the kappa values. Validity was assessed by calculating the percentage agreement against intraoperative findings.

Results

Of the 48 patients, three (6%) had type A injury, 11 (23%) type B, 16 (33%) type B+, 16 (33%) Type C, two (4%) type D+, and none had a type D injury. All 48 patients had anteroposterior (AP) and lateral radiographs, 44 had 2D CT scans, and 39 had 3D reconstructions. The interobserver reliability kappa value was 0.52 for radiographs, 0.71 for 2D CT scans, and 0.73 for a combination of 2D and 3D reconstruction CT scans. The median intraobserver reliability was 0.75 (interquartile range (IQR) 0.62 to 0.79) for radiographs, 0.77 (IQR 0.73 to 0.94) for 2D CT scans, and 0.89 (IQR 0.77 to 0.93) for the combination of 2D and 3D reconstruction. Validity analysis showed that accuracy significantly improved when using CT scans (p = 0.018 and p = 0.028 respectively).

Conclusion

The Wrightington classification system is a reliable and valid method of classifying fracture-dislocations of the elbow. CT scans are significantly more accurate than radiographs when identifying the pattern of injury, with good intra- and interobserver reproducibility. Cite this article: Bone Joint J 2020;102-B(8):1041–1047.

Radial head fractures

The shape and size of the radial head is highly variable but correlates to the contralateral side. The radial head is a secondary stabilizer to valgus stress and provides lateral stability. The modified Mason-Hotchkiss classification is the most commonly used and describes three types, depending on the number of fragments and their displacement. Type 1 fractures are typically treated conservatively. Surgical reduction and fixation are recommended for type 2 fractures, if there is a mechanical block to motion. This can be done arthroscopically or open. Controversy exists for two-part fractures with >2 mm and <5 mm displacement, without a mechanical bloc as good results have been published with conservative treatment. Type 3 fractures are often treated with radial head replacement. Although radial head resection is also an option as long-term results have been shown to be favourable. Radial head arthroplasty is recommended in type 3 fractures with ligamentous injury or proximal ulna fractures. Failure of primary radial head replacement may be due to several factors. Identification of the cause of failure is essential. Failed radial head arthroplasty can be treated by implant removal alone, interposition arthroplasty, revision radial head replacement either as a single stage or two-stage procedure.

Comparing leukocyte-rich platelet-rich plasma injection with surgical intervention for the management of refractory tennis elbow. A prospective randomised trial

BACKGROUND

Patients with ongoing symptoms after non-operative treatment of lateral epicondylosis are usually treated with surgical release. Platelet-rich plasma injection is an alternative treatment option. This study aims to determine whether there is a difference in outcome from platelet-rich plasma injection or surgical release for refractory tennis elbow.

METHOD

Eighty-one patients with a diagnosis of tennis elbow for a minimum of six months, treated with previous steroid injection and a minimum visual analogue scale pain score of 50/100 were randomised to open surgery release (41 patients) or leucocyte rich platelet-rich plasma (L-PRP) (40 patients). Patients completed the Patient-Rated Tennis Elbow Evaluation and Disability of the Arm Shoulder and Hand at baseline, 1.5, 3, 6 and 12 months post-intervention. The primary endpoint was change in Patient-Rated Tennis Elbow Evaluation pain score at 12 months.

RESULTS

Fifty-two patients completed final follow-up. Functional and pain scores improved in both groups. No differences in functional improvements were found but greater improvements in Patient-Rated Tennis Elbow Evaluation pain scores were seen after surgery. Thirteen patients crossed over from platelet-rich plasma to surgery within 12 months, and one surgical patient underwent a platelet-rich plasma injection.

CONCLUSION

L-PRP and surgery produce equivalent functional outcome but surgery may result in lower pain scores at 12 months. Seventy per cent of patients treated with platelet-rich plasma avoided surgical intervention.

Scoping review: Diagnosis and management of periprosthetic joint infection in elbow arthroplasty

BACKGROUND

Total elbow arthroplasty is an effective treatment for patients with painful elbow arthritis. Infection can be a serious complication. The aim of this scoping review was to document the available evidence on periprosthetic elbow infection.

METHODS

A search of Medline, Embase and PubMed was performed; two authors screened results independently. Systematic reviews, randomised controlled trials, cohort studies, case-control studies and case series including periprosthetic elbow infection were eligible.

RESULTS

A total of 46 studies were included. The median rate of periprosthetic elbow infection reported from recent published studies is 3.3%. The most commonly identified causative organisms are Staphylococcus aureus and Staphylococcus epidermidis. Risk factors include younger age, rheumatoid arthritis, obesity, previous surgery or infection to the elbow, and postoperative wound complications. Debridement, antibiotics and implant retention results in implant survival rates of 50-90%. Two-stage revision results in improved functional outcome scores, but with recurrent infection rates of 12-28%.

CONCLUSIONS

Total elbow arthroplasty carries a higher risk of infection when compared to other major joint replacements. The current body of literature is limited and is almost exclusively low volume retrospective case series. The best management of periprosthetic elbow infection is difficult to determine, but two-stage revision appears to be the gold standard.

The combined shoulder assessment: a convenient method for obtaining equivalent outcome scores

BACKGROUND

Outcome scores are useful tools with respect to quantifying how pain and limitations in strength and movement affect the patient's functionality and lifestyle. Three shoulder outcome methods [Oxford, Constant and QuickDASH (Disability of the Arm, Shoulder and Hand)] are commonly used in practice but collectively consist of 34 questions, taking approximately 7 min to complete. We have developed a concise shoulder assessment to derive three equivalent outcome scores in a 12-item patient-reporting questionnaire.

METHODS

Outcome scores from 1285 outpatients of an upper limb clinic were collected. The patient cohort consisted of 462 females and 823 males with a mean (SD) age of 47.2 (16.79) years (range 13 years to 90 years). Using a correlation matrix, a 12-item questionnaire was drafted. The combined shoulder assessment was validated by 227 patients; consisting of 101 females and 126 males with a mean (SD) age of 47.91 (16.63) years (range 13 years to 88 years).

RESULTS

Agreement was achieved between the two methods, with an equivalent Oxford Shoulder Score intraclass correlation (ICC) of 0.930, equivalent Constant Shoulder Score ICC of 0.942 and equivalent QuickDASH ICC of 0.869. Bland-Altman analyses showed no systematic differences. Large effect sizes highlighted the responsiveness to change.

CONCLUSIONS

The new combined shoulder assessment is a more convenient and patient-friendly method to obtain equivalent Oxford, Constant and QuickDASH shoulder outcome scores.

Primary Ligament Repair for Acute Elbow Dislocation

The elbow is the second most common site for joint dislocation after the shoulder. Elbow dislocations are classified according to the direction of dislocation, with most (80%) being posterolateral. A spectrum of soft-tissue injury may also be present, depending on the direction of dislocation and the energy applied. Most dislocations of the elbow can be treated nonoperatively, but recurrent instability and/or stiffness occur in up to 10% and 40% of patients, respectively. The aim of early surgical stabilization is to prevent these long-term complications. To avoid overtreatment, magnetic resonance imaging is used to identify patients at a greater risk of complications by determining the grade of soft-tissue injury. Those with grade-3 or 4 injuries are managed with fluoroscopic examination under anesthesia. (1) The patient is positioned supine. Fluoroscopic examination is performed with the elbow in full extension and in 30° of flexion. Varus stress is applied with the forearm in pronation. If >10° of joint opening is found, open surgical repair of the lateral ligament complex and common extensor origin is performed. (2) A 5-cm incision is made using a direct lateral approach centered on the lateral epicondyle. The tough lateral fascia may be intact and should be incised in line with the anconeus interval. (3) A rent in the common extensor origin may be found, which can be used for the approach; otherwise, proceed with a Kocher approach to identify the sleeve avulsion of the lateral ligament complex from the humerus. (4) A number-2 synthetic braided suture is used to whip-stitch the lateral ulnar collateral ligament, which is repaired to the lateral epicondyle with use of a bone anchor. The trailing suture ends from the anchor are used to repair the common extensor tendon origin with use of a Mayo needle. (5) With the forearm in supination to externally rotate the humerus and lock the shoulder, valgus instability is assessed with the elbow in full extension and in 30° of flexion. If the medial joint line opens >10°, repair the medial structures in the same manner as the lateral ligament complex through an incision posterior to the medial epicondyle while protecting the ulnar nerve. (6) The patient is referred to physiotherapy for immediate hourly overhead exercises. This approach should prevent complications of recurrent instability or stiffness, as early results have been encouraging with no complications recorded.

Analysis of magnetic resonance imaging-confirmed soft tissue injury pattern in simple elbow dislocations

BACKGROUND

The elbow is the second most commonly dislocated joint. Stability depends on the degree of soft tissue injury, with 2 proposed patterns, one starting laterally and the other medially. The purpose of this study was to describe the injured structures observed in magnetic resonance images (MRIs) in a prospective cohort of simple elbow dislocations.

METHODS

We evaluated 17 consecutive cases of simple elbow dislocations. Two musculoskeletal radiologists assessed the initial x-ray images and MRIs performed for all elbows. Radiologists evaluated the following soft tissue structures: medial collateral ligament complex (MCL), flexor-pronator muscle mass origin, anterior capsule (AC), posterior capsule, lateral collateral ligament complex (LCL), and extensor muscle mass origin. The radiologists were blinded to the study hypothesis.

RESULTS

The initial radiographs in 16 patients showed the dislocation was posterolateral in 12, posterior in 3, and posteromedial in 1. We observed complete AC tear in 12 patients, MCL in 10, and LCL in 9. The inter-rater reliability for the radiologists was 0.70 (substantial) for MRI.

CONCLUSIONS

In our series after simple elbow dislocation, complete AC tears were most common, followed by MCL and LCL tears. No single mechanism-related soft tissue injury pattern of simple elbow dislocation was observed, and different grades of soft tissue injury exist.

Development of a Multispectral Albedometer and Deployment on an Unmanned Aircraft for Evaluating Satellite Retrieved Surface Reflectance over Nevada's Black Rock Desert

Bright surfaces across the western U.S. lead to uncertainties in satellite derived aerosol optical depth (AOD) where AOD is typically overestimated. With this in mind, a compact and portable instrument was developed to measure surface albedo on an unmanned aircraft system (UAS). This spectral albedometer uses two Hamamatsu micro-spectrometers (range: 340⁻780 nm) for measuring incident and reflected solar radiation at the surface. The instrument was deployed on 5 October 2017 in Nevada's Black Rock Desert (BRD) to investigate a region of known high surface reflectance for comparison with albedo products from satellites. It was found that satellite retrievals underestimate surface reflectance compared to the UAS mounted albedometer. To highlight the importance of surface reflectance on the AOD from satellite retrieval algorithms, a 1-D radiative transfer model was used. The simple model was used to determine the sensitivity of AOD with respect to the change in albedo and indicates a large sensitivity of AOD retrievals to surface reflectance for certain combinations of surface albedo and aerosol optical properties. This demonstrates the need to increase the number of surface albedo measurements and an intensive evaluation of albedo satellite retrievals to improve satellite-derived AOD. The portable instrument is suitable for other applications as well.

The contribution of the posterolateral capsule to elbow joint stability: a cadaveric biomechanical investigation

BACKGROUND

Elbow posterolateral rotatory instability occurs after an injury to the lateral collateral ligament complex (LCLC) in isolation or in association with an osteochondral fracture of the posterolateral margin of the capitellum (Osborne-Cotterill lesion [OCL]). The contribution to elbow stability of the posterolateral capsule, attached to this lesion, is unknown. This study quantified the displacement of the radial head on simulated posterior draw with sectioning of the posterior capsule (a simulated OCL) or LCLC.

METHODS

Biomechanical testing of the elbow was performed in 8 upper limb cadavers. With the elbow 0°, 30°, 60°, and 90° degrees of flexion, posterior displacement of the radius was measured at increments of a load of 5 N up to 50 N. A simulated OCL and LCLC injury was then performed.

RESULTS

A simulated OCL results in significantly more displacement of the radial head compared with the intact elbow at 30° to 60° of elbow flexion. LCLC resection confers significantly more displacement. An OCL after LCLC resection does not create further displacement.

CONCLUSIONS

The degree of radial head displacement is greater after a simulated OCL at 30° to 60° of flexion compared with the intact elbow with the same load but not as great as seen with sectioning of the LCLC. This study suggests that the posterior capsule attaching to the back of the capitellum is important to elbow stability and should be identified as the Osborne-Cotterill ligament. Clinical studies are required to determine the importance of these biomechanical findings.

Tension band suture fixation for olecranon fractures

Olecranon fractures are common and often require surgical treatment when displaced. Traditional methods of stabilization using tension band wire fixation and plate fixation achieve adequate union and function but are associated with a high rate of re-operation and wound problems because of prominent metalwork. The purpose of the present article is to describe an all suture technique for fixation of simple olecranon fractures that maintains inter-fragmentary compression, provides bony union and reduces the rate of re-operation caused by prominent metalwork.

Early results of Latitude primary total elbow replacement with a minimum follow-up of 2 years

BACKGROUND

The aim of this study was to present outcomes of primary Latitude total elbow replacement (TER) with a minimum follow-up of 2 years.

METHODS

A retrospective cohort study was undertaken with prospective outcome data collection for the latest outcome. Included were 63 consecutive primary Latitude TERs in 58 patients performed during a period of 5 years at a specialist orthopedic hospital.

RESULTS

The mean age of the patients was 62 years (33-85 years). Five primary TERs (4 patients) were lost to follow-up. The primary diagnosis was rheumatoid arthritis in 49, osteoarthritis in 8, and trauma in 6 elbows. The mean flexion-extension arc was 75° preoperatively and 97° postoperatively. Mean postoperative Elbex pain score was 19/100, and function score was 37/100. Mean postoperative scores were 42/100 for the Quick Disabilities of the Arm, Shoulder, and Hand and 38/50 for the elbow-specific American Shoulder and Elbow Surgeons assessment. Four patients died of unrelated causes, and 8 of 63 underwent further surgical intervention, including explantation and conversion from unlinked to linked implant. On radiographic review of 41 surviving TERs, aseptic radiologic loosening was observed of the humeral component in 4 elbows and of the ulnar component in 9. Seven elbows had no radial component, and of the remaining 34 elbows, 16 (47%) had signs of loosening of the radial implant. Complications included 1 heterotopic ossification, 1 olecranon fracture, and 3 further procedures for ulnar nerve entrapment.

CONCLUSION

The results indicate that the early outcome of Latitude TER is comparable to that of other prostheses. There is concern about early radiologic loosening of the radial component.

Simple elbow dislocation

The elbow is the second most commonly dislocated major joint in adults. Good long-term outcomes have been reported after non-operative management; however, a small proportion (<10%) of patients have a poor outcome and some do require surgical intervention. A review of the anatomy, pathoanatomy, management and outcomes of simple elbow dislocations is presented. Emphasis is placed on emerging concepts regarding the soft tissue injury, the stabilising structures that are injured, the sequence and mechanism of injury and the relationship to elbow stability. The benefits of nonsurgical and surgical management are discussed and a treatment algorithm based on the pathoanatomy is proposed.

Boxer's elbow: internal impingement of the coronoid and olecranon process. A report of seven cases

BACKGROUND

Boxer's elbow has been described in the literature as an extension and hyperextension injury. However, in our experience, there is a coexisting impingement lesion in the anterior compartment of the elbow that has not previously been described. We report a series of professional boxers with elbow disease treated arthroscopically. The aim of the paper was to accurately describe the pathoanatomy of the condition, the key points in its diagnosis, and the outcomes of surgical treatment.

METHODS

Seven professional boxers were treated for symptomatic elbow disease. Clinical evaluation included range of motion and Disabilities of the Arm, Shoulder, and Hand score. The arthroscopic findings and procedures were documented.

RESULTS

Symptoms were mainly those of anterior and posterior impingement; 6 elbows had an anterior impingement lesion and 6 had a posterior impingement lesion. Postoperatively, the mean Disabilities of the Arm, Shoulder, and Hand score was 2.7 (range, 0-13.3) at a median of 15 (range, 6-36) months postoperatively. All boxers returned to their previous level of competition and 5 won their next bout. All of the boxers used an orthodox stance, and in all but 1 case the left elbow was the pathologic elbow.

CONCLUSION

Boxers are prone to development of anterior and posterior elbow impingement. The side of the pathologic process is related to the boxer's stance, with the lead arm being more vulnerable. Arthroscopic débridement is an effective treatment, enabling return to a high competitive level. Surgeons, sports medicine physicians, and physiotherapists should be aware of the condition.

Medium-term outcomes of the Universal-2 total wrist arthroplasty in patients with rheumatoid arthritis

AIMS

The aims of this study were to evaluate the clinical and radiological outcomes of the Universal-2 total wrist arthroplasty (TWA) in patients with rheumatoid arthritis.

PATIENTS AND METHODS

This was a retrospective review of all 95 Universal-2 TWAs which were performed in our institution between 2003 to 2012 in patients with rheumatoid arthritis. A total of six patients were lost to follow-up and two died of unrelated causes. A total of ten patients had bilateral procedures. Accordingly, 75 patients (85 TWAs) were included in the study. There were 59 women and 16 men with a mean age of 59 years (26 to 86). The mean follow-up was 53 months (24 to 120). Clinical assessment involved recording pain on a visual analogue score, range of movement, grip strength, the Quick Disabilities of the Arm, Shoulder and Hand (DASH) and Wrightington wrist scores. Any adverse effects were documented with particular emphasis on residual pain, limitation of movement, infection, dislocation and the need for revision surgery. Radiographic assessment was performed pre-operatively and at three, six and 12 months post-operatively, and annually thereafter. Arthroplasties were assessed for distal row intercarpal fusion and loosening. Radiolucent zones around the components were documented according to a system developed at our institution.

RESULTS

The mean worst pain was 8.1 (3 to 10) pre-operatively and 5.4 (0 to 10) at latest follow-up (p < 0.001). Movements were preserved with mean dorsiflexion of 29^o (0 ^o to 70 ^o) and palmar flexion of 21^o (0^o to 50^o). The mean grip strength was 4.8 kg (1.7 to 11.5) pre-operatively and 10 kg (0 to 28) at final follow-up (p < 0.001). The mean QuickDASH and Wrightington wrist scores improved from 61 (16 to 91) to 46 (0 to 89) and 7.9 (1.8 to 10) to 5.7 (0 to 7.8) (p < 0.001). A total of six patients (7%) had major complications; three required revision arthroplasty and three an arthrodesis. The Kaplan-Meier probability of survival using removal of the components as the endpoint was 91% at 7.8 years (95% confidence interval 84 to 91).

CONCLUSION

The Universal-2 TWA is recommended for use in patients with rheumatoid arthritis. Cite this article: Bone Joint J 2016;98-B:1642-7.

Randomized Trial of Buffered Versus Plain Lidocaine for Local Anaesthesia in open Carpal Tunnel Decompression

We performed a randomized double-blind case–control study in 64 consecutive patients undergoing open carpal tunnel decompression under local anaesthetic to assess the pain experienced on injection of plain lidocaine (pH 6.4) compared with lidocaine buffered with sodium bicarbonate (pH 7.4). The results showed no statistical difference in the pain scores reported by patients. The mean pain scores for all patients were low, and most patients reported that they were “not at all anxious” about receiving a similar injection in the future.

Polycyclic aromatic hydrocarbons in biomass-burning emissions and their contribution to light absorption and aerosol toxicity

In recent years, brown carbon (BrC) has been shown to be an important contributor to light absorption by biomass-burning atmospheric aerosols in the blue and near-ultraviolet (UV) part of the solar spectrum. Emission factors and optical properties of 113 polycyclic aromatic hydrocarbons (PAHs) were determined for combustion of five globally important fuels: Alaskan, Siberian, and Florida swamp peat, cheatgrass (Bromus tectorum), and ponderosa pine (Pinus ponderosa) needles. The emission factors of total analyzed PAHs were between 1.9±0.43.0±0.6 and 9.6±1.2-42.2±5.4mgPAHkg(-1)fuel for particle- and gas phase, respectively. Spectrophotometric analysis of the identified PAHs showed that perinaphthenone, methylpyrenes, and pyrene contributed the most to the total PAH light absorption with 17.2%, 3.3 to 10.5%, and 7.6% of the total particle-phase PAH absorptivity averaged over analyzed emissions from the fuels. In the gas phase, the top three PAH contributors to BrC were acenaphthylene (32.6%), anthracene (8.2%), and 2,4,5-trimethylnaphthalene (8.0%). Overall, the identified PAHs were responsible for 0.087-0.16% (0.13% on average) and 0.033-0.15% (0.11% on average) of the total light absorption by dichloromethane-acetone extracts of particle and gas emissions, respectively. Toxic equivalency factor (TEF) analysis of 16 PAHs prioritized by the United States Environmental Protection Agency (EPA) showed that benzo(a)pyrene contributed the most to the PAH carcinogenic potency of particle phase emissions (61.8-67.4% to the total carcinogenic potency of Σ16EPA PAHs), while naphthalene played the major role in carcinogenicity of the gas phase PAHs in the biomass-burning emission analyzed here (35.4-46.0% to the total carcinogenic potency of Σ16EPA PAHs). The 16 EPA-prioritized PAHs contributed only 22.1±6.2% to total particle and 23.4±11% to total gas phase PAH mass, thus toxic properties of biomass-burning PAH emissions are most likely underestimated.