O’Driscoll, Shawn W.

Aims Total elbow arthroplasty (TEA) has shown favourable outcomes in the management of severely comminuted distal humeral fractures in low-demand elderly patients, leading to its increased use in recent years. Less is known about the outcomes of TEA when used for the failure of either internal fixation or conservative management, particularly whether not performing TEA acutely influences the options for further management if fixation fails. This systematic review aimed to assess the clinical and functional outcomes following TEA when used for the post-traumatic sequelae of a distal humeral fracture, and to compare these outcomes with those in patients with a distal humeral fracture who undergo TEA acutely. Methods MEDLINE, Embase, Cochrane Central Register of Controlled Trials, and Scopus databases were searched from January 2000 to September 2024 for studies reporting complications, reoperations, the range of motion of the elbow, or functional outcomes following the use of TEA in the management of the post-traumatic sequelae of distal humeral fractures, including those due to failed fixation, nonunion, and post-traumatic arthritis. Demographic and clinical data were collected, descriptive statistics were summarized, and meta-analyses were undertaken to compare the outcomes between salvage and acute TEA. Results A total of 16 studies were included, with a total of 380 patients who underwent salvage TEA and 251 who underwent TEA as the initial management. Salvage TEA was associated with a significantly higher overall risk of complications (odds ratio (OR) 2.5 (95% CI 1.0 to 5.9)), though the rate of reoperations did not differ from those who underwent TEA acutely (OR 1.4 (95% CI 0.8 to 2.4)). Pooled analyses revealed a similar postoperative range of flexion (mean difference (MD) -2.4° (95% CI -9.1 to 4.3)) and extension of the elbow (MD 1.1° (95% CI -2.3 to 4.5)) and pronation (MD 0.0° (95% CI -1.1 to 1.1)) and supination (MD -0.0° (95% CI -1.0 to 0.9)) of the forearm. However, salvage TEA showed significantly inferior functional outcomes, as assessed by the Mayo Elbow Performance Score (MD 9.7 (95% CI -18.8 to -0.6)). Conclusion These findings indicate that salvage TEA represents a viable option for the management of post-traumatic sequelae following the teatment of a distal humeral fracture, although patients who underwent salvage TEA had a significantly increased rate of complications and significantly inferior functional outcomes compared with those who underwent TEA acutely. Cite this article: Bone Joint J 2026;108-B(1):21–29.

Abstract This study examined in vitro glenohumeral instability under two simulated biomechanical models of rotator cuff tear: 1) tendon-defect model and 2) muscle-unloaded model. The results indicated that rotator cuff tear significantly increased the joint instability. Significant difference also existed between the two tested models. The tendon-defect model underestimated the joint instability in most simulated shoulder positions.

AbstractThe success of radial head arthroplasty (RHA) relies on the design of the implant and precision of the surgical technique, with preoperative planning potentially playing a crucial role. The accurate establishment of a patient‐specific anatomical coordinate system (ACS) is essential for this planning process. This study tested the hypothesis that an innovative automated method would be an accurate, reliable, and efficient framework to determine the ACS of the proximal radius, which would be a step toward improving the precision of RHA planning. We used advanced computational techniques to analyze 50 forearm CT scans, comparing the accuracy, reproducibility, reliability, and efficiency of the automated method with manually derived ACS using expert observers as benchmarks. The results showed that the automated approach was more accurate in identifying anatomical landmarks, with smaller mean distance discrepancies (0.6 mm) than manual observers (1 mm). Its reproducibility was also superior, with narrower reproducibility limits, particularly for ulnar notch landmarks (0.6 to 0.8 mm compared to manual selection 1.2 to 1.4 mm) (p = .01). In addition, the limits of agreement and the mean absolute rotational and translational differences of the axes were narrower for the automated method, which also reduced the construction time to an average of 46 s compared to 150 s manually (p < .001). These findings suggest that the automated method has the potential to enhance the accuracy and efficiency of preoperative and postoperative computer‐assisted procedures for RHA. Further research is needed to fully understand the utility of this automated system for enhancing RHA computer‐assisted surgical planning.

Background: Traditionally, the reconstruction of severe distal humeral bone loss at the time of revision total elbow arthroplasty (TEA) has used allograft-prosthetic composites (APCs) stabilized with cerclage wires or cables. We have migrated to plate fixation when revision TEA using a humeral APC is performed. This study shows the outcomes of patients treated with a humeral APC with plate fixation during revision TEA. Methods: Between 2009 and 2019, 41 humeral APCs with plate fixation of distal humeral allograft to the native humerus were performed in the setting of revision TEA. There were 12 male patients (29%) and 29 female patients (71%), with a mean age of 63 years (range, 41 to 87 years). The mean allograft length was 12 cm. All elbows had a minimum follow-up of 2 years (mean follow-up, 3.3 years). Patients were evaluated for visual analog scale pain scores, range of motion, the ability to perform select activities of daily living, and the Mayo Elbow Performance Score (MEPS). Outcomes including reoperations, complications, and revisions were noted. The most recent radiographs were evaluated for union at the allograft-host interface, failure of the plate-and-screw construct, or component loosening. Results: The mean postoperative flexion was 124° (range, 60° to 150°) and the mean postoperative extension was 26° (range, 0° to 90°); the mean arc of motion was 99° (range, 30° to 150°). The mean MEPS was 58 points (range, 10 to 100 points). Two surgical procedures were complicated by neurologic deficits. The overall reoperation rate was 14 (34%) of 41. Of the 33 patients with complete radiographic follow-up, 12 (36%) had evidence of nonunion at the allograft-host interface with humeral component loosening, 1 (3%) had evidence of partial union, and 1 (3%) had ulnar stem loosening. Conclusions: Revision TEA with a humeral APC using compression plating was successful in approximately two-thirds of the elbows. Further refinement of surgical techniques is needed to improve union rates in these complex cases. Level of Evidence: Therapeutic Level IV . See Instructions for Authors for a complete description of levels of evidence.

BACKGROUND Many benign and malignant tissue or bony lesions have been reported as causes of extrinsic or intrinsic posterior interosseous nerve (PIN) neuropathy at the proximal forearm/elbow region. The authors describe an unusual cause of external compression of the PIN due to a ganglion cyst arising from a radial neck pseudarthrosis (a false joint). OBSERVATIONS Decompression of the PIN with the release of the arcade of Frohse was performed with resection of the radial head and the ganglion cyst. By 6 months postoperatively, the patient had a complete neurological recovery. LESSONS This case illustrates a previously unreported cause of extraneural compression of the PIN from a pseudarthrosis. The mechanism for compression in this case from the radial head pseudarthrosis is likely attributable to the sandwich effect, in which the PIN is sandwiched between the arcade of Frohse at the supinator from above and the cyst below.

Objectives: Osteochondritis dissecans (OCD) of the humeral capitellum is an often painful condition that typically affects the adolescent athlete. There is little consensus on treatment and a scarcity of long-term outcomes data. The purpose of this study was to (1) report the long-term outcomes associated with both operative and non-operative management of capitellar OCD, (2) identify factors associated with failure of non-operative management, and (3) determine whether delay in surgery affects final outcomes. Methods: All patients diagnosed with OCD of the capitellum from 1995-2020 within a defined geographic cohort were included. Medical records, imaging studies, and operative reports were manually reviewed to record demographic data, treatment strategies, and outcomes. Surgical treatment was considered delayed if it occurred more than 6 months after symptom onset. Results: A total of 50 elbows with a mean follow-up of 9.4 years were included. Of these, 7 (14%) were treated non-operatively and never underwent surgery during follow-up, while 43 (86%) underwent surgical intervention: 27 had early surgery and 16 underwent delayed surgery after ≥ 6 months of non-operative treatment. When compared to non-operative management, surgical management resulted in superior MEPI scores (90 vs 83, p=0.05), decreased persistence of mechanical symptoms (9% vs 50%, p<0.01), and better elbow flexion (141° vs 131°, p=0.01) at long-term follow up. Older patients had a trend toward increased failure of non-operative management (p=0.06). The presence of an intra-articular loose body strongly predicted failure of non-operative management (p=0.01; OR 13). Plain radiography and MRI had poor sensitivities for identifying loose bodies (27% and 40%, respectively). Differences in outcomes following early versus delayed surgical management were not demonstrated. Conclusions: Patients with capitellar OCD initially treated nonoperatively failed nonoperative management 70% of the time. Elbows that did not undergo surgery had slightly increased symptoms and decreased functional outcomes compared to those treated surgically. In this cohort, the greatest predictors for failure of non-operative treatment were older age and presence of a loose body; however, an initial trial of non-operative treatment did not adversely impact the success of future surgery at long term follow-up. [Table: see text][Table: see text][Table: see text][Table: see text]

Purpose To (1) report the long‐term outcomes associated with both operative and nonoperative management of capitellar osteochondritis dissecans (OCD), (2) identify factors associated with failure of nonoperative management, and (3) determine whether delay in surgery affects final outcomes. Methods All patients who received a diagnosis of capitellar OCD from 1995‐2020 within a geographic cohort were included. Medical records, imaging studies, and operative reports were manually reviewed to record demographic data, treatment strategies, and outcomes. The cohort was divided into 3 groups: (1) nonoperative management, (2) early surgery, and (3) delayed surgery. Delayed surgery (surgery ≥6 months after symptom onset) was considered failure of nonoperative management. Results Fifty elbows with a mean follow‐up period of 10.5 years (median, 10.3 years; range, 1‐25 years) were studied. Of these, 7 (14%) were definitively treated nonoperatively, 16 (32%) underwent delayed surgery after at least 6 months of failed nonoperative treatment, and 27 (54%) underwent early surgical intervention. When compared with nonoperative management, surgical management resulted in superior Mayo Elbow Performance Index pain scores (40.1 vs 33, P = .04), fewer mechanical symptoms (9% vs 50%, P < .01), and better elbow flexion (141° vs 131°, P = .01) at long‐term follow‐up. Older patients trended toward increased failure of nonoperative management ( P = .06). The presence of an intra‐articular loose body predicted failure of nonoperative management ( P = .01; odds ratio, 13). Plain radiography and magnetic resonance imaging had poor sensitivities for identifying loose bodies (27% and 40%, respectively). Differences in outcomes after early versus delayed surgical management were not observed. Conclusions Nonoperative management of capitellar OCD failed 70% of the time. Elbows that did not undergo surgery had slightly more symptoms and decreased functional outcomes compared with those treated surgically. The greatest predictors of failure of nonoperative treatment were older age and presence of a loose body; however, an initial trial of nonoperative treatment did not adversely impact the success of future surgery. Level of Evidence Level III, retrospective cohort study.

Background This study aimed to validate the concept of notching of the ulna component of the first-generation latitude total elbow prosthesis to reduce the rate of aseptic loosening and improve implant survival. Methods A total of 18 total elbow arthroplasty cases were performed between June 2001 and May 2002 using the latitude first-generation ulnar stem. A total of 14 cases with at least 2 years of follow-up were evaluated following the exclusion of four infected cases. The senior author roughened the stem surface with notches in 10 cases (notched group) to prevent loosening. The effects of notching on implant failure were retrospectively analyzed. Results Average participant age and follow-up were 56 ± 20 years and 72 ± 44 months, respectively. The notched and unnotched implant groups were demographically equivalent. 3/4(75%) of unnotched group implants failed due to aseptic loosening. 1/10(10%) of the notched group implants failed. All unnotched group aseptic loosening cases occurred at the bone–cement interface within 2 years after total elbow arthroplasty. The single patient with aseptic loosening in the notched group had a history of multiple surgeries due to an open fracture preceding the primary total elbow arthroplasty. Discussion Notching of the ulna component of the first-generation latitude total elbow prosthesis reduced the rate of aseptic loosening and improved implant survival. Level of evidence Level IV, retrospective comparative study.

Background: Arthroscopic debridement for osteochondritis dissecans (OCD) lesions of the capitellum is a relatively common and straightforward surgical option for failure of nonoperative management. However, the long-term outcomes of this procedure remain unknown. Hypothesis: Arthroscopic debridement of capitellar OCD would provide satisfactory long-term improvement in patient-reported outcomes. Study Design: Case series; Level of evidence, 4. Methods: Patients aged ≤18 years who underwent arthroscopic debridement procedures for OCD lesions (International Cartilage Repair Society grades 3 and 4) were identified. Procedures included loose body removal when needed and direct debridement of the lesion; marrow stimulation with drilling or microfracture was added at the discretion of each surgeon. The cohort consisted of 53 elbows. Patient evaluation included visual analog scale for pain; motion; subjective satisfaction; Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) scores; reoperation; and rate of return to sports. Results: At a mean 11 years of follow-up (range, 5-23 years), the median visual analog scale score for pain was 0, and 96% of patients reported being improved as compared with how they were before surgery. The mean ± SD QuickDASH score was 4 ± 9 points (range, 0-52 points), and 80% of patients returned to their sports of interest. The arc of motion significantly improved from 115°± 28° preoperatively to 130°± 17° at latest follow-up ( P = .026). Seven elbows (13%) required revision surgery for OCD lesions, resulting in high rates of overall survivorship free of revision surgery: 90% (95% CI, 80%-96%) at 5 years and 88% (95% CI, 76%-94%) at 10 years. At final follow-up, 7 all-cause reoperations were performed without revision surgery on the OCD lesion. Conclusion: Arthroscopic debridement of grade 3 or 4 OCD lesions of the capitellum produced satisfactory patient-reported outcomes in a majority of elbows, although a subset of patients experienced residual symptoms. The inherent selection bias of our cohort should be considered when applying these results to the overall population with OCD lesions, as we do not recommend this procedure for all patients.

Osteochondritis dissecans (OCD) is a focal joint defect that is prevalent among youth athletes. With the application of medical ultrasound, OCD of the humeral capitellum could be detected earlier and prevent surgery. In this work, we tested a modified Delay-Multiply-and-Sum (DMAS) reconstruction algorithm to evaluate how it affects medical ultrasound’s ability to detect OCD. Starting with the DMAS reconstruction algorithm described by Matrone et al. (2015), we modified the implementation of filtering and envelope detection steps. Delay-and-Sum (DAS), DMAS, and modified DMAS algorithms were tested on phantom and cadaveric models of capitellar OCD. The DMAS and modified DMAS images were histogram matched to the DAS image for quantitative comparison. By taking several profiles across the images of the artificial OCD lesions, we compared the lesion contrast and bone surface clarity produced by each algorithm. We found that the unmodified DMAS algorithm showed little improvement over the DAS algorithm, particularly after histogram matching. The modified DMAS algorithm showed a much greater improvement in the detection of OCD lesions compared to the DMAS algorithm. This modified DMAS algorithm could be used for other bone surface imaging applications. Future work includes evaluating these algorithms in vivo with patients diagnosed with OCD.