Experience of living with chronic pain in conjunction with surgery for ulnar nerve entrapment at the elbow-A qualitative study.

PURPOSE: Pain in conjunction with surgery for ulnar nerve entrapment at the elbow is seldom highlighted in the literature. This study aimed to explore patients' experiences of living with chronic pain (≥3 months duration) in conjunction with surgery for ulnar nerve entrapment at the elbow, the consequences and the coping strategies applied. MATERIAL AND METHODS: In-depth interviews were conducted with 10 participants aged 18-60 years. The narratives were analyzed using an inductive approach and content-analysis. RESULTS: The analysis revealed seven main categories: "Physical symptoms/impairments" and "Mood and emotions"comprise symptoms caused by ulnar nerve entrapment at the elbow and chronic pain; "Consequences in daily life" includes challenges and obstacles in every-day life, impact on leisure activities and social life; "Struggling with self-image" embraces experiences closely related to identity; "Coping strategies" covers adaptive resources; "Experience of relief "describes perceived improvements; "Key message for future care" comprises important aspects for healthcare providers to consider. CONCLUSIONS: The results clarify the need for healthcare personnel to adopt a biopsychosocial approach when treating patients with ulnar nerve entrapment at the elbow. Emotional symptoms and sleep disturbances should be identified and treated properly since they contribute to the heavy burden experienced by the individual.

Double entrapment neuropathy of the ulnar nerve at the elbow and the wrist : double crush syndrome?

BACKGROUND: Double crush syndrome refers to a nerve in the proximal region being compressed, affecting its proximal segment. Instances of this syndrome involving ulnar and cubital canals during ulnar neuropathy are rare. Diagnosis solely through clinical examination is challenging. Although electromyography (EMG) and nerve conduction studies (NCS) can confirm neuropathy, they do not incorporate inching tests at the wrist, hindering diagnosis confirmation. We recently encountered eight cases of suspected double compression of ulnar nerve, reporting these cases along with a literature review. METHODS: The study included 5 males and 2 females, averaging 45.6 years old. Among them, 4 had trauma history, and preoperative McGowan stages varied. Ulnar neuropathy was confirmed in 7 cases at both cubital and ulnar canal locations. Surgery was performed for 4 cases, while conservative treatment continued for 3 cases. RESULTS: In 4 cases with wrist involvement, 2 showed ulnar nerve compression by a fibrous band, and 1 had nodular hyperplasia. Another case displayed ulnar nerve swelling with muscle covering. Among the 4 surgery cases, 2 improved from preoperative McGowan stage IIB to postoperative stage 0, with significant improvement in subjective satisfaction. The remaining 2 cases improved from stage IIB to IIA, respectively, with moderate improvement in subjective satisfaction. In the 3 cases receiving conservative treatment, satisfaction was significant in 1 case and moderate in 2 cases. Overall, there was improvement in hand function across all 7 cases. CONCLUSION: Typical outpatient examinations make it difficult to clearly differentiate the two sites, and EMG tests may not confirm diagnosis. Therefore, if a surgeon lacks suspicion of this condition, diagnosis becomes even more challenging. In cases with less than expected postoperative improvement in clinical symptoms of cubital tunnel syndrome, consideration of double crush syndrome is warranted. Additional tests and detailed EMG tests, including inching tests at the wrist, may be necessary. We aim to raise awareness double crush syndrome with ulnar nerve, reporting a total of 7 cases to support this concept.

A 23-year analysis of litigation in orthopedic elbow surgery.

BACKGROUND: The reasons for malpractice litigation in elbow surgery are not well understood. The aim of this study is to report the most frequently litigated surgeries of the elbow and analyze the reasons for litigation and case outcomes. METHODS: A retrospective review of the Westlaw legal database was performed, and all federal and state jurisdiction litigation cases involving the elbow from 2000 to 2023 were queried. Cases were excluded if they did not involve an orthopedic surgeon, nor primary elbow injury or procedure. Cases were reviewed for demographic information, surgical procedure based on reference Current Procedural Terminology codes, complications, symptoms, and reasons for litigation. Quantitative information, including settlement and indemnity cost to the defendant orthopedic surgeon, was analyzed. Cases were subdivided based on United States Census Bureau regions and states to assess regional frequency of litigation with analyses of variance. RESULTS: There were 59 cases meeting inclusion criteria from 2000 to 2023. The most litigated cases involved were ulnar nerve transposition/release and open reduction and internal fixation of the proximal radius and/or ulna at the elbow. The most litigated complication was claimed nerve damage (46%) and permanent disability (27%). Of the total cases, the most frequently litigated symptoms were nerve damage (46%) and loss of function (37%), whereas the least frequent was postoperative stiffness (2%). The Pacific region demonstrated the highest litigation rate (20%), whereas the East South Central, Mountain, and New England regions had the lowest litigation rate (3% each). A favorable verdict was given to the defendant orthopedic surgeon in 59% of the cases. The average loss incurred through settlement was $245,590, whereas the average indemnity paid through verdict was $523,334. CONCLUSION: Operative fixation of the proximal ulna/radius and ulnar nerve release/transposition are the most litigated procedures of the elbow. Litigation is most associated with nerve injury. Across Census Bureau regions, there is no significant difference in monetary cost incurred through settlements and verdict losses. Although a majority of litigated cases are won by the defending orthopedic surgeon, thorough informed consent and perioperative expectation management may mitigate litigation risk.

Current concepts of surgical approach for radial nerve entrapment around the elbow.

Radial nerve entrapment is an uncommon diagnosis. The entrapment can occur at any location within the course of the nerve distribution, but the most frequent location of entrapment occurs around the elbow and involves the posterior interosseous nerve. Several potential sites of radial nerve entrapment around the elbow are identified: the capsular tissue of the radiocapitellar joint; hypertrophic crossing branches of leash of henry; the leading proximal tendinous and medial edge of extensor carpi radialis brevis; the arcade of Frohse and distal border of the supinator between its two heads. The arcade of Frohse is the most common site of compression. The aim of this manuscript is to describe the common surgical methods to approach the radial nerve entrapments around the elbow and define the preferred surgical approach based on the site of compression.

Free flap reconstruction of elbow soft tissue defects: Lessons learned from 15 years of experience.

BACKGROUND: The elbow is a complex joint that is vital for proper function of the upper extremity. Reconstruction of soft tissue defects over the joint space remains challenging, and outcomes following free tissue transfer remain underreported in the literature. The purpose of this analysis was to evaluate the rate of limb salvage, joint function, and clinical complications following microvascular free flap coverage of the elbow. METHODS: This retrospective case series utilized surgical logs of the senior authors (Stephen J Kovach and L Scott Levin) to identify patients who underwent microvascular free flap elbow reconstruction between January 2007 and December 2021. Patient demographics and medical history were collected from the medical chart. Operative notes were reviewed to determine the type of flap procedure performed. The achievement of definitive soft tissue coverage, joint function, and limb salvage status at 1 year was determined from postoperative visit notes. RESULTS: Twenty-one patients (14 male, 7 female, median age 43) underwent free tissue transfer for coverage of soft tissue defects of the elbow. The most common indication for free tissue transfer was traumatic elbow fracture with soft tissue loss (n = 12, [57%]). Among the 21 free flaps performed, 71% (n = 15) were anterolateral thigh flaps, 14% (n = 3) were latissimus dorsi flaps, and 5% (n = 1) were transverse rectus abdominis flaps. The mean flap size was 107.5 cm2. Flap success was 100% (n = 21). The following postoperative wound complications were reported: surgical site infection (n = 1, [5%]); partial dehiscence (n = 5, [24%]); seroma (n = 2, [10%]); donor-site hematoma (n = 1, [5%]); and delayed wound healing (n = 5, [24%]). At 1 year, all 21 patients achieved limb salvage and definitive soft tissue coverage. Of the 17 patients with functional data available, 47% (n = 8) had regained at least 120 degrees of elbow flexion/extension. All patients had greater than 1 year of follow-up. CONCLUSION: Microvascular free flap reconstruction is a safe and effective method of providing definitive soft tissue coverage of elbow defects, as evidenced by high rates of limb salvage and functional recovery following reconstruction.

Comparison of decrease in elbow flexion strength in patients after tenotomy and tenodesis of the long head of the biceps brachii.

NTRODUCTION: The last two decades have been leading to the development of several types of surgical techniques and procedures to manage the LHB lesions. This paper analyses and compares the difference in muscle strength pre- and post-operatively in two most commonly used surgical procedures - LHB tenotomy and tenodesis. METHOD: The study includes 68 patients who underwent surgery between 2016 and 2020. The patients who had met the prospective study inclusion criteria were divided into two groups based on type of surgery they had undergone (LHB tenotomy or tenodesis); each group consisted of 34. The muscle strength during elbow flexion was measured preoperatively and postoperatively using the Commander Echo Console ultrasound muscle testing device. All patients enrolled in the study had been assessed for elbow flexion strength preoperatively. The muscle strength was measured preoperatively and then 3 years postoperatively (12 to 60 months) on average. CONCLUSION: The study confirmed that the patients who had undergone LHB tenodesis show a significantly lower decrease in elbow flexion strength and a significantly lower incidence of "Popeye" deformity than the patients after LHB tenotomy. Moreover, in the tenodesis group, it was possible to initiate rehabilitation earlier. The incidence of postoperative complications was almost identical in both groups of patients (Tab. 10, Fig. 6, Ref. 40).

The Top 100 Classical and Contemporary Papers on Elbow Surgery: A Trend Analysis of Elbow Surgery Literature.

INTRODUCTION: Bibliometric analyses provide an aggregate of the most frequently cited literature in a given field. The purpose of this study was to analyze the top 100 most-cited classical and contemporary papers relating to elbow surgery to serve as a reference for surgeons and trainees for educational and research purposes. METHODS: A search was conducted for all papers containing the term "elbow" in the categories Orthopedics, Surgery, and Sports Science in the Clarivate Web of Science. Classical papers were those published from 1980 to 2009, and contemporary papers were those published from 2010 to 2019. Articles were assessed by country of origin, authors and their credentials, parent journal, level of evidence, and topic. RESULTS: Citation frequency ranged from 86 to 867. Among the classical group, there were more level IV papers compared with level I papers; however, the opposite was true in the contemporary group. The most common topic in the classical group was elbow anatomy and function, and the most common topic in the contemporary group was lateral epicondylitis and medial epicondylitis and associated therapies. DISCUSSION: This bibliometric analysis serves to help guide surgeons and trainees on the highly cited articles and important topics in elbow surgery, demonstrating a shift to prospective randomized controlled trials in recent years. LEVEL OF EVIDENCE: Level V (Systematic Review with Level V as Lowest LOE).

Reconstruction of the elbow with distal humerus endoprosthetic replacement after tumor resection: a systematic review of the literature and institutional case series.

BACKGROUND: Distal humerus replacement (DHR) is a modular endoprosthesis mainly used for bone reconstruction after resection of primary or metastatic bone lesions. Studies on DHR failure rates and postoperative functional outcomes are scarce. We sought to assess implant survival, modes of failure, and functional outcomes in patients undergoing DHR for oncologic indications. METHODS: A systematic review of the PubMed and Embase databases was performed. PRISMA guidelines were followed for this manuscript. Our study was registered on PROSPERO (457,260). Quality appraisal of included studies was conducted using the STROBE checklist. Prosthetic failure was assessed using the Henderson classification for megaprosthetic failures. We additionally performed a retrospective review of patients treated with a DHR for oncologic indications at a large tertiary care academic center. Weighted means were calculated to pool data. RESULTS: Eleven studies with a total of 162 patients met the inclusion criteria. Mean follow-up was 3.7 years (range, 1.66-8 years). Henderson type 2 failures (aseptic loosening) were the most common mode of failure, occurring in 12% of cases (range, 0%-33%). Five-year implant survival was 72% (range, 49%-93.7%). Mean postoperative Musculoskeletal Tumor Society (MSTS) score was 81.1 (range, 74-84.3). In our institutional case series, 2 out of 5 patients had DHR revision for periprosthetic fracture and aseptic loosening at 16 and 27 months after surgery, respectively. CONCLUSIONS: Distal humerus replacement is a successful reconstruction strategy for tumors of the distal humerus, with high implant survival and good to excellent functional outcomes.

Dynamic Stress Ultrasound Assessment of Professional Baseball Players' Elbows After Ulnar Collateral Ligament Reconstruction.

BACKGROUND: There is a paucity of data analyzing dynamic stress ultrasound (SUS) findings in elite pitchers who have undergone ulnar collateral ligament (UCL) reconstruction (UCLR) and returned to sport. PURPOSE: To identify longitudinal, perioperative changes in the elbows of professional baseball pitchers who have undergone UCLR and to compare these findings with a matched cohort of healthy pitchers. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: This study used prospectively collected data from dynamic elbow SUS analyses of professional baseball pitchers within a single Major League Baseball organization. Pitchers were divided into 2 cohorts: a UCLR cohort and healthy cohort. The UCLR cohort eligibility included availability of (1) SUS from preseason of injury/UCLR and (2) SUS from ≥2 years after surgery. These players were 1:1 matched to players with no history of upper extremity injury to form the healthy cohort. Ligament thickness and ulnohumeral joint space at rest and under stress were directly measured. Joint laxity was calculated by subtracting joint space at rest from joint space under stress. The term "relative" was used to describe calculated differences where nondominant measurements were subtracted from dominant-side measurements. RESULTS: Eight pitchers were included in the UCLR group and matched to 8 healthy pitchers (mean age at initial SUS examination, 19.6 years). At a minimum follow-up of 2 years, there were no significant differences between groups in terms of relative or dominant arm rest space, stress space, or laxity. Longitudinally (final measurements - baseline measurements), the mean relative ulnohumeral rest space decreased in the UCLR group and increased in the healthy group (-0.36 mm vs +0.50 mm; P = .032). The finding of increased UCL thickness in the UCLR group was expected, as UCL grafts are typically thicker than native ligaments. CONCLUSION: Ulnhohumeral joint stability was achieved after UCLR as indicated by similar rest space, stress space, and joint laxity in dominant arms compared with a matched healthy cohort. A significant decrease in relative rest space after UCLR may represent the achievement of stability in surgery patients. Alternatively, the increase in ulnohumeral rest space seen in the healthy cohort may represent adaptive changes from pitching at a professional level.

The Utility of Stress Ultrasound in Identifying Risk Factors for Elbow Ulnar Collateral Ligament Tear: A Longitudinal Study of 203 Professional Baseball Players.

BACKGROUND: Injuries to the medial ulnar collateral ligament (UCL) are common among baseball pitchers due to repetitive stress on the soft tissue stabilizers of the elbow during pitching. Dynamic stress ultrasound (SUS) can be used to evaluate the UCL and ulnohumeral joint to identify anatomic risk factors of those who will require UCL reconstruction (UCLR). PURPOSE: To determine whether any adaptive or morphological changes detectable on SUS can predict injury to the UCL in professional baseball pitchers. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: A total of 203 professional baseball pitchers who underwent SUS at preseason training sessions over the course of 18 years were categorized into 1 of 2 groups: those without a history of shoulder, arm, elbow, or forearm surgery or injuries (healthy cohort; n = 184) and those who underwent UCLR the same season as SUS (UCLR cohort; n = 19). Ligament thickness, joint spacing, and laxity were compared. An additional matched cohort analysis was conducted using 10 players from each group to detect differences in the progression of UCL and ulnohumeral joint measures in the year before injury. RESULTS: The UCLR cohort, when compared with the healthy cohort, had higher relative (ie, nondominant-side measurements subtracted from dominant-side measurements) resting ulnohumeral joint space (median, 0.50 vs 0.20 mm, respectively; P = .006) and higher rates of hypoechoic foci (57.9% vs 30.4%, respectively; P = .030). Players of both groups had similar dominant UCL thickness (P = .161), ulnohumeral joint space at rest (P = .321), space under stress (P = .498), and laxity (P = .796). Groups did not differ in terms of relative UCL thickness, ulnohumeral joint space under stress, or relative laxity. In the year before UCL injury, the UCLR cohort, compared with the matched healthy cohort, had a greater increase in mean dominant UCL thickness (0.94 vs -0.60 mm, respectively; P = .038) and a greater increase in relative median UCL thickness (1.35 vs -0.35 mm, respectively; P = .045). Players in the healthy cohort were statistically older than those in the UCLR cohort (23 vs 22 years, respectively; P = .004). No differences in ulnohumeral stress spacing or laxity were detected. CONCLUSION: SUS of players who underwent UCLR demonstrated a progressive increase in UCL thickness over 1 year, higher rates of hypoechoic foci, and increased ulnohumeral rest space compared with SUS of uninjured players.

Anconeus-sparing minimally invasive approach for lateral ulnar collateral ligament reconstruction using a triceps tendon autograft is an effective and safe treatment for chronic posterolateral instability of the elbow.

BACKGROUND: Surgical treatment helps to restore stability of the elbow in patients with posterolateral rotatory instability (PLRI). The anconeus muscle is one of the most important active stabilizers against PLRI. A minimally invasive anconeus-sparing approach for lateral ulnar collateral ligament (LUCL) reconstruction using a triceps tendon autograft has been previously described. The purpose of this study was to evaluate the outcome of this intervention and identify risk factors that influenced the clinical and patient-reported outcomes. METHODS: Sixty-one patients with chronic PLRI and no previous elbow surgery who underwent surgical reconstruction of the LUCL using a triceps tendon autograft in a minimally invasive anconeus-sparing approach during 2012 and 2018 were evaluated. Outcome measures included a clinical examination and the Oxford Elbow Score (OES) and the Mayo Elbow Performance Score (MEPS) questionnaires. Subjective patient outcomes were evaluated with the visual analog scale (VAS) for pain and the Subjective Elbow Value (SEV). Integrity of the common extensor tendons and centering of the radial head were assessed preoperatively on standardized magnetic resonance images (MRIs). RESULTS: Fifty-two patients were available at final follow-up. The mean age of patients was 51 ± 12 years with a mean follow-up of 53 ± 14 months (range 20-76). Clinical examination after surgery (n = 41) showed no clinical signs of instability in 98% of the patients (P < .001) and a nonsignificant improvement in range of motion. OES, MEPS, and VAS scores averaged 40 ± 10 of 48 points, 92 ± 12 of 100 points, and 1 ± 2 points, respectively, all corresponding with good or excellent outcomes. The SEV was 88%, indicating very high satisfaction with the surgery. Only 1 patient had revision surgery due to pain, and there were no reported postoperative complications in this cohort. A radial head subluxation in the MRI correlated significantly with worse postoperative outcomes. CONCLUSIONS: The anconeus-sparing minimally invasive technique for posterolateral stabilization of the elbow using a triceps tendon autograft is an effective and safe treatment for chronic posterolateral instability of the elbow with substantial improvements in elbow function and pain relief with a very low rate of persistent clinical instability.

Bony encasement of the ulnar nerve secondary to heterotopic ossification of the elbow: an evaluation of long-term outcomes.

BACKGROUND: Ulnar neuropathy at the elbow caused by heterotopic ossification (HO) is a rare condition. This retrospective study aims to report on 32 consecutive cases of ulnar nerve encasement caused by elbow HO and evaluate long-term outcomes of operative management and a standardized postoperative rehabilitation regimen. METHODS: A retrospective case series was conducted on 32 elbows (27 patients) that underwent operative management of bony ulnar nerve encasement. All procedures were performed in the inpatient setting at an Academic Level 1 Trauma Center from September 1999 to July 2021 by one of 3 fellowship-trained shoulder and elbow. Postoperatively, all patients received formal physical therapy, HO prophylaxis (30 received indomethacin, 2 received radiation), and a structured continuous passive motion machine regimen. Patient demographics, age, gender, type of injury, history of tobacco use, and medical comorbidities were obtained to include in the analysis. Long-term follow-up examinations were performed to evaluate elbow flexion-extension arc of motion, Mayo Elbow Performance Score, and visual analog scale pain scores. RESULTS: Thirty-two elbows with complete bony ulnar nerve encasement secondary to HO were identified (14 from burns, 15 from trauma, 3 closed head injuries). Following surgery, the mean flexion-extension arc of motion improved significantly, increasing from 21° to 100° at long-term follow-up (average 8.7 years, range 2-17 years), with statistically significant improvements in preoperative vs. long-term postoperative elbow extension (P < .001), flexion (P < .001), and total arc of motion (P < .001). There was a statistically significant improvement in pre- vs. postprocedure ulnar nerve function, as demonstrated by a decrease in average McGowan grade (1.2-0.7; P = .002). Additionally, 63% of patients with preoperative ulnar neuropathy symptoms (20/32) had either complete resolution or subjective improvement after surgery. The mean time from injury to surgery was 518 days (range 65-943 days). Age, gender, time to surgery, and medical comorbidities were not associated with outcomes. The complication rate was 9% (3/32). Patients had an average flexion-extension arc of motion of 97° and average Mayo Elbow Performance Score of 80 ("good") at long-term follow-up. CONCLUSIONS: The combination of operative management, postoperative HO prophylaxis, and a regimented rehabilitation program has proven to be a durable solution for treating and ensuring good long-term functional outcomes for patients with elbow HO and bony ulnar nerve encasement. This treatment approach leads to superior range of motion, improved or resolved ulnar neuropathy, and good to excellent long-term functional outcomes.

Editorial Commentary: Ulnar Collateral Ligament Repair With Suture Augmentation May Be Superior to Reconstruction for Proximal or Distal Tears With Good- Quality Tissue.

Ulnar collateral ligament (UCL) tears in the elbow have been rising in recent years, most specifically in baseball players. Although many of these tears occur in professional (minor and major league) baseball pitchers, there has been a dramatic rise in UCL injuries in adolescents, at a rate of 9% per year. Although some UCL tears can be treated conservatively, those that fail conservative treatment often require surgical intervention to allow players to return to sport. Although UCL reconstruction has been the gold standard in surgical treatment for many years, UCL repair with suture augmentation has grown in popularity. Initial results of UCL repair with suture augmentation have been promising, and a recent review comparing UCL repair with suture augmentation from both a biomechanical and clinical outcome perspective confirms that UCL repair may be superior to reconstruction for patients with proximal or distal tears and good quality UCL tissue for repair.

Rehabilitation of the painful elbow.

Although lateral elbow pain and medial ulnar collateral ligament injury are common musculoskeletal pathologies in overhead athletes, the evidence supporting specific interventions for managing these conditions is scarce. Management of these conditions has been guided mostly by expert opinion rather than empirical evidence, yet the lack of comparative data in the literature has not negatively affected return-to-play rates following surgery. However, an understanding of what is known regarding unimodal and multimodal treatments for lateral elbow pain and medial ulnar collateral ligament injury is needed for clinicians to select evidence-based treatment pathways and highlight what is not known to develop future high-quality investigations.

Similar return to sport between double cortical button and docking techniques for ulnar collateral ligament reconstruction in baseball players.

BACKGROUND AND HYPOTHESIS: A double cortical button technique for ulnar collateral ligament reconstruction (UCLR) has advantages including significant control over graft tensioning, less concern about graft length, and minimized risk of bone tunnel fracture compared with traditional UCLR techniques. This double cortical button technique was recently found to be noninferior in mechanical performance to the traditional docking technique regarding joint strength, joint stiffness, and graft strain. However, clinical outcomes have not been compared between these UCLR techniques. Therefore, the purpose of this study was to determine whether baseball players who underwent UCLR with a double cortical button (double button) technique have similar return-to-sport (RTS) outcomes to baseball players who underwent UCLR with the traditional docking (docking) technique. MATERIALS AND METHODS: Baseball players who underwent primary UCLR from 2011 to 2020 across 2 institutions were identified. Included patients were contacted to complete a follow-up survey evaluating reoperations, RTS, and functional outcome scores. Functional outcome surveys include the Kerlan-Jobe Orthopaedic Clinic score, the Conway-Jobe score, the Andrews-Timmerman elbow score, and the Single Assessment Numeric Evaluation score. RESULTS: Overall, 78 male baseball players (age: 18.9 ± 2.4 years) with an average follow-up of 3.1 ± 2.4 years were evaluated, with 73 of the players being baseball pitchers. Players in the double button group more frequently received palmaris longus autografts (78% vs. 30%) and less frequently received gracilis autografts (22% vs. 58%) compared with players in the docking group (P = .001); however, all other demographic factors were similar between the groups. All players in the double button group were able to RTS in 11.1 ± 2.6 months, whereas 96% of players in the docking group were able to RTS in 13.5 ± 3.4 months (P > .05). All postoperative outcomes and patient-reported outcomes were statistically similar between the groups and remained similar after isolating pitchers only and after separating partial-thickness from full-thickness UCL tears (all P > .05). CONCLUSION: RTS and other postoperative outcomes may be similar between baseball players who underwent UCLR with the double button technique and the docking technique. Although future research may be necessary to strengthen clinical recommendations, these findings provide the first clinical outcomes in light of a recent cadaveric study finding similar elbow strength, joint stiffness, and graft strain compared with the docking technique.

Elbow stiffness: Interview with professor Bernard Morrey.

Stiff elbow is a complex condition whose diagnosis and management are sometimes quite a challenge. Compared to the other joints, the elbow is disproportionately affected by loss of motion following trauma or surgery. It is unclear why the elbow tends to develop stiffness; its anatomical complexity, namely the presence of three highly congruent joints in the same capsule and synovial space, the tautness of the lateral and medial collateral ligaments through the whole range of motion, and the very close relationship among tendons, muscles, and skin 2 may account for this characteristic. In a stiff elbow, it is critical to assess the possible involvement of articular and periarticular tissues, particularly the degree of preservation of the articular surfaces and joint congruency. Morrey et al have classified post-traumatic stiff elbow into three types: 1) extrinsic contracture, which involves the soft tissue around the joint (capsule, ligaments, muscles) and heterotopic ossification across the joint, 2) intrinsic contracture, secondary to intra-articular fractures that have altered the anatomy of the articular surface, and 3) mixed contracture, combining intrinsic and extrinsic contracture. In the preoperative clinical assessment, we assume capsule contracture to be present in all patients with a stiff elbow. Two main associated lesions can affect prognosis and surgical management: heterotopic ossification and an altered bone joint anatomy. According to Morrey et al, most activities of daily living can be accomplished within an arc of motion from 30° to 130° in extension and flexion and of 50° in pronation and supination. The elbow arc of motion is not compensated for by the wrist and shoulder, thus loss of extension impairs the use of the hand in the space around the body and loss of flexion limits its use for grooming and self-care. The elbow should carefully be tested for deformity of the axial bone alignment (varus and valgus deformity) and rotational stability. Several treatment options are available for stiff elbow, from conservative management with a dedicated rehabilitation program to surgical treatment and from arthroscopic capsulectomy to joint replacement.

Graft choice and techniques used in elbow ulnar collateral ligament reconstruction over the last 20 years: a systematic review and meta-analysis.

BACKGROUND: Elbow medial ulnar collateral ligament (mUCL) injuries have become increasingly common, leading to a higher number of mUCL reconstructions (UCLR). Various techniques and graft choices have been reported. The purpose of this study was to evaluate the prevalence of each available graft choice, the surgical techniques most utilized, and the reported complications associated with each surgical method. METHODS: A systematic review was performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analysesguidelines. We queried PubMed/MEDLINE, Embase, Web of Science, and Cochrane databases to identify all articles that included UCLR between January 2002 and October 2022. We included all studies that referenced UCLR graft choice, surgical technique, and/or ulnar nerve transposition. Studies were evaluated in a narrative fashion to assess demographics and report current trends in utilization and complications of UCLR as they pertain to graft choice and surgical techniques over the past 20 years. Where possible, we stratified based on graft and technique. RESULTS: Forty-seven articles were included, reporting on 6671 elbows. The cohort was 98% male, had a weighted mean age of 21 years and follow-up of 53 months. There were 6146 UCLRs (92%) performed with an autograft and 152 (2.3%) that utilized an allograft, while 373 (5.6%) were from mixed cohorts of autograft and allograft. Palmaris longus autograft was the most utilized mUCL graft choice (64%). The most utilized surgical configuration was the figure-of-8 (68%). Specifically, the most common techniques were the modified Jobe technique (37%), followed by American Sports Medicine Institute (ASMI) (22%), and the docking (22%) technique. A concomitant ulnar nerve transposition was performed in 44% of all patients, with 1.9% of these patients experiencing persistent ulnar nerve symptoms after ulnar nerve transposition. Of the total cohort, 14% experienced postoperative ulnar neuritis with no prior preoperative ulnar nerve symptoms. Further, meta-analysis revealed a significantly greater revision rate with the use of allografts compared to autograft and mixed cohorts (2.6% vs. 1.8% and 1.9%, P = .003). CONCLUSIONS: Most surgeons performed UCLR with palmaris autograft utilizing a figure-of-8 graft configuration, specifically with the modified Jobe technique. The overall rate of allograft use was 2.3%, much lower than expected. The revision rate for UCLR with allograft appears to be greater compared to UCLR with autograft, although this may be secondary to limited allograft literature.

The examination and treatment of soft tissue contracture of the elbow.

Treatment of the stiff elbow can be a challenging task. A thorough understanding of normal elbow anatomy and the potential causes of elbow contracture are essential for the development of effective treatment strategies. This chapter provides a review of key points for the treating surgeon including normal elbow anatomy, etiological factors that commonly contribute to elbow stiffness, physical examination and imaging of the stiff elbow, and treatment options for contracture correction.

Failure of the linkage mechanism in a semi-constrained total elbow arthroplasty is a rare and unpredictable event: a review of seven cases.

PURPOSE: Linked component of total elbow arthroplasty (TEA) consisted of bushing and locking pins. Failure of linked components is a rare complication of TEA. This study aims to investigate the mechanism and consequence of failure of the linkage mechanism in TEA surgeries. METHODS: Between 2010 and 2021, five patients received revision operation due to linked component failure. Besides, two patients underwent primary operation at another institute were also analyzed due to failure of the linkage mechanism. RESULTS: All seven patients underwent primary TEA and mean age for primary TEA was 48 (range, 27-62). Two patients had TEA for post-traumatic arthritis, three patients for rheumatoid arthritis, and two patients for comminuted distal humerus fracture. The average time between primary TEA and revision TEA for linked component failure was 13.6 years. Three bushing wear and four locking pin dissociation were diagnosed according to pre-operative radiography. Elbow pain and swelling are the most common clinical symptoms. Severe osteolysis, periprosthetic fracture, and stem loosening were noted in three bushing wear cases. In four dissociation of locking pin cases, breakage of male locking pin phalanges was demonstrated in two patients. For revision procedures, both the locking pins and bushings were replaced. No patients in the study required additional surgery after the revision operation for linked component failure. CONCLUSION: Osteolysis, component loosening, periprosthetic fracture may be expected after linked component failure. Patients should be regularly followed up from short-term to long-term with radiography. Early diagnosis and intervention with linked component exchange can prevent extensive revision surgery.

Long-term outcomes of Kudo type-5 unlinked surface-replacing total elbow arthroplasty for rheumatoid arthritis: a 15-year average follow-up study.

BACKGROUND: Total elbow arthroplasty (TEA) has been used for various conditions including rheumatoid arthritis (RA). While the Kudo TEA has been associated with favorable short-term outcomes, there is limited information on the longer term outcomes of this device. The aim of this study was to investigate the average 15-year outcome of Kudo type-5 TEA in patients with RA. METHODS: For this retrospective cohort study, we reviewed 29 elbows in 28 patients (Larsen grade III, n = 8; IV, n = 19; V, n = 2) with RA who underwent Kudo type-5 TEA between 1999 and 2010. The patients were followed up for a mean of 15 (range: 10-21) years. We investigated the survival with setting revision/removal as the endpoints. The risk factors for revision/loosening were assessed. RESULTS: There was a significant improvement in elbow flexion after Kudo TEA. Preoperative and postoperative Mayo Elbow Performance Score improved significantly from 60.3 to 94.7. Complications included intraoperative medial humeral epicondyle fracture (n = 2), postoperative dislocations (n = 4), deep infections (n = 1), and persistent ulnar nerve neuropathy (n = 1). Aseptic loosening was observed in 7 elbows (24.1%; humerus, n = 3; ulna, n = 3; both sides, n = 1). The causes of the 5 revisions were postoperative dislocation (n = 1), deep infection (n = 1), aseptic loosening of the humerus (n = 2), and aseptic loosening of the ulna (n = 1). All 5 elbows underwent revision of the ulnar component (n = 2) or the linked TEA (n = 3). The survival rate was 81% at 15 years after surgery with setting revision/removal as the endpoints. A deviation of ulnar component insertion angle of over 5° in any plane was associated with more revision compared to those with accurately placed implants. CONCLUSION: The Kudo type-5 elbow showed good results for up to 15 years of follow-up. However, excessive deviation of insertion angle of the ulnar component (over 5°) was associated with more revision. Due to the small sample size, robust statistical analysis of risk factors for postoperative complications or revision could not be performed, and further research is warranted to resolve this limitation.