High rate of clinically relevant improvement following anatomical total shoulder arthroplasty for glenohumeral osteoarthritis.

BACKGROUND: The minimal clinically important difference (MCID) is defined as the smallest meaningful change in a health domain that a patient would identify as important. Thus, an improvement that exceeds the MCID can be used to define a successful treatment for the individual patient. AIM: To quantify the rate of clinical improvement following anatomical total shoulder arthroplasty for glenohumeral osteoarthritis. METHODS: Patients were treated with the Global Unite total shoulder platform arthroplasty between March 2017 and February 2019 at Herlev and Gentofte Hospital, Denmark. The patients were evaluated preoperatively and 3 months, 6 months, 12 months, and 24 months postoperatively using the Western Ontario Osteoarthritis of the Shoulder index (WOOS), Oxford Shoulder Score (OSS) and Constant-Murley Score (CMS). The rate of clinically relevant improvement was defined as the proportion of patients who had an improvement 24 months postoperatively that exceeded the MCID. Based on previous literature, MCID for WOOS, OSS, and CMS were defined as 12.3, 4.3, and 12.8 respectively. RESULTS: Forty-nine patients with a Global Unite total shoulder platform arthroplasty were included for the final analysis. Mean age at the time of surgery was 66 years (range 49.0-79.0, SD: 8.3) and 65% were women. One patient was revised within the two years follow-up. The mean improvement from the preoperative assessment to the two-year follow-up was 46.1 points [95% confidence interval (95%CI): 39.7-53.3, P < 0.005] for WOOS, 18.2 points (95%CI: 15.5-21.0, P < 0.005) for OSS and 37.8 points (95%CI: 31.5-44.0, P < 0.005) for CMS. Two years postoperatively, 41 patients (87%) had an improvement in WOOS that exceeded the MCID, 45 patients (94%) had an improvement in OSS that exceeded the MCID, and 42 patients (88%) had an improvement in CMS that exceeded the MCID. CONCLUSION: Based on three shoulder-specific outcome measures we find that approximately 90% of patients has a clinically relevant improvement. This is a clear message when informing patients about their prognosis.

Low risk of postoperative ulnar nerve affection in surgically treated distal humeral fractures when the nerve is released in situ.

BACKGROUND: Adult distal humeral fractures (DHF) comprise 2%-5% of all fractures and 30% of all elbow fractures. Treatment of DHF may be technically demanding due to fracture complexity and proximity of neurovascular structures. Open reduction and internal fixation (ORIF) are often the treatment of choice, but arthroplasty is considered in case of severe comminution or in elderly patients with poor bone quality. Ulnar nerve affection following surgical treatment of distal humerus fractures is a well-recognized complication. AIM: To report the risk of ulnar nerve affection after surgery for acute DHFs. METHODS: We retrospectively identified 239 consecutive adult patients with acute DHFs who underwent surgery with ORIF, elbow hemiarthroplasty (EHA) or total elbow arthroplasty (TEA) between January 2011 and December 2019. In all cases, the ulnar nerve was released in situ without anterior transposition. We used our institutional database to review patients' medical records for demographics, fracture morphology, type of surgery and ulnar nerve affection immediately; records were reviewed after surgery and at 2 wk and 12 wk of routine clinical outpatient follow-up. Twenty-nine percent patients were excluded due to pre- or postoperative conditions. Final follow-up examination was a telephone interview in which ulnar nerve affection was reported according to the McGowen Classification Score. A total of 210 patients were eligible for interview, but 13 patients declined participation and 17 patients failed to respond. Thus, 180 patients were included. RESULTS: Mean age at surgery was 64 years (range 18-88 years); 121 (67.3%) patients were women; 59 (32.7%) were men. According to the AO/OTA classification system, we recorded 47 patients with type A3, 55 patients with type B and 78 patients with type C fractures. According to the McGowen Classification Score, mild ulnar nerve affection was reported in nine patients; severe affection, in two. A total of 69 patients were treated with ORIF of whom three had mild temporary ulnar nerve affection and one had severe ulnar nerve affection. In all, 111 patients were treated with arthroplasty (67 EHA, 44 TEA) of whom seven had mild ulnar nerve affection and one had severe persistent ulnar nerve affection. No further treatment was provided. CONCLUSION: The risk of ulnar nerve affection after surgical treatment for acute DHF is low when the ulnar nerve is released in situ without nerve transposition, independently of the treatment provided.

Minimal Clinically Important Differences (MCID) for the Western Ontario Osteoarthritis of the Shoulder Index (WOOS) and the Oxford Shoulder Score (OSS).

BACKGROUND: The minimal clinically important difference (MCID) is an important instrument in the interpretation of changes in patient-reported outcome measures (PROM). To our knowledge, no MCID of the Western Ontario Osteoarthritis of the Shoulder Index (WOOS) score has ever been reported and no studies have reported an MCID for the Oxford Shoulder Score (OSS) based on patients with glenohumeral osteoarthritis, treated with an anatomical total shoulder arthroplasty (aTSA). The aim of this study was to determine MCID for WOOS and OSS in a cohort of patients with glenohumeral osteoarthritis treated with an aTSA. METHODS: All patients treated with an aTSA for glenohumeral osteoarthritis at our institution between March 2017 and February 2019 were included. Each patient completed the WOOS and the OSS preoperatively and one year postoperatively. At one year, the patients were asked to rate their overall improvement on a 7-point scale. We used an anchor-based method as our primary method to calculate the MCID, supported by two different distribution-based methods. RESULTS: A total of 45 primary aTSA were included. The MCID of WOOS was 12.3 according to the anchor-based method and 14.2 and 10.3 according to the two distribution-based methods. The MCID of OSS was 4.3 according to the anchor-based method and 5.8 and 4.3 according to the two distribution-based methods. CONCLUSION: The anchor-based method is considered superior to the distribution-based method, and therefore we advocate to use this as MCID. For patients with glenohumeral osteoarthritis treated with an aTSA, the MCID values were 12.3 points for WOOS and 4.3 points for OSS. To our knowledge, this is the first study to report a MCID value for WOOS and the first study to report a MCID value for OSS in this subgroup of patients.

[Traumatic rupture of subscapularis with avulsion of tuberculum minor and subluxation of the biceps tendon in a 13-year-old].

Traumatic ruptures of the subscapularis tendon in children are rare and often missed. In this case report, a 70 kg person landed on a 13-year-old boy with his arm abducted and rotated, causing pain and restricted motion. An MRI showed a total rupture of the subscapularis with avulsion of the minor tubercle and subluxation of the biceps tendon. The avulsion was fixed to the foot print and the biceps tendon in the bicipital groove, by delto-pectoral approach, using three anchors. It is important to avoid missing these injuries. They may cause chronic shoulder pain and decreased motion if left untreated.

[Osteoarthritis of the shoulder, the elbow and the acromioclavicular joint].

Osteoarthritis of the shoulder is common in elderly, and arthroplasty surgery is increasing in Denmark. This review summarises the current knowledge. Results are good, and revision rates are low at ten years. Symptomatic osteoarthritis in the acromioclavicular joint are common. Most patients can be treated conservatively. Resection arthroplasty complications are rare, and the results are good. Osteoarthritis of the elbow is rare, and only a few arthroplasties are performed. Complications are common, but revision rates are relatively low, and results are improving.

What Factors are Associated with Revision or Worse Patient-reported Outcome after Reverse Shoulder Arthroplasty for Cuff-tear Arthropathy? A Study from the Danish Shoulder Arthroplasty Registry.

BACKGROUND: Reverse shoulder arthroplasty has been proven to improve function in shoulders with cuff-tear arthropathy, but existing studies are primarily single-center studies with a small number of patients, which limits their ability to identify patients who have an increased risk of revision or a worse functional outcome. QUESTIONS/PURPOSES: (1) What is the estimated 10-year cumulative revision rate after reverse shoulder arthroplasty for cuff-tear arthropathy, and what factors are associated with the risk of revision? (2) What is the patient-reported outcome 1 year after surgery, and what factors are associated with a worse patient-reported outcome? METHODS: We included all patients treated with reverse shoulder arthroplasty for cuff-tear arthropathy reported in the Danish Shoulder Arthroplasty Registry from 2006 to 2015. During the study period, the completeness of reporting was 93% for both primary and revision arthroplasties. Estimated revision rates were illustrated using the Kaplan-Meier method, and hazard ratios were calculated using a Cox regression model. Patient-reported outcome was measured with a postal survey at 12 months (range 10-14 months) postoperatively using the Western Ontario Osteoarthritis of the Shoulder (WOOS) index. The WOOS is a patient-administered questionnaire that measures the quality of life of patients with glenohumeral osteoarthritis. A visual analog scale that ranges from 0 to 100 is used for each question. There are 19 questions, giving a total score ranging from 0 to 1900, with 1900 being the worst. For simplicity of presentation, raw scores were converted to a percentage of the maximum score, with 100 being the best. There is no defined minimal clinically important difference of the WOOS, but the Danish Shoulder arthroplasty registry has for many years regarded an arbitrary difference of 10 or above as being clinically relevant. The rate of response to the WOOS was 71%. RESULTS: The estimated 10-year cumulative revision rate was 8.5% (95% confidence interval, 5.7%-11.3%) with differences between the arthroplasty model (21.0%; 95% CI, 11.8% to 30.8% for the Delta Mark III and 5.5%; 95% CI, 3.7% to 7.3% for the Delta Xtend) and gender (6.0%; 95% CI, 3.0% to 9.0% for women and 13.1%; 95% CI, 7.1% to 19.1% for men). After controlling for potential confounding variables including gender, previous surgery, arthroplasty model, and period of surgery, the risk of revision was higher with the Delta Mark III than with the Delta Xtend (hazard ratio 2.7; 95% CI, 1.3 to 5.4; p < 0.01) and higher in men than in women (hazard ratio 2.7; 95% CI, 1.6 to 4.7; p < 0.01). Thirty-three percent (19 of 57) of the revision arthroplasties were performed for dislocation and 32% (18 of 57) were to treat periprosthetic joint infection. After controlling for confounding variables, only previous surgery was associated with a worse WOOS score (mean difference -10.6; 95% CI, -15.2 to -5.9; p < 0.01); there were no associations between a worse score and gender, arthroplasty model, age group, or period of surgery. CONCLUSIONS: The results from the present study can be used to inform patients about their individual risk of revision or a disappointing functional outcome. The study also demonstrates the need for proper patient selection and attention to technical details to reduce the risk of revision, especially for men. Our follow-up time was, however, short, with only an estimate of the 10-year revision rate. Future studies with a long-term follow-up duration are needed to confirm our results. LEVEL OF EVIDENCE: Level III, therapeutic study.

Poor patient-reported outcome after shoulder replacement in young patients with cuff-tear arthropathy: a matched-pair analysis from the Danish Shoulder Arthroplasty Registry.

Background and purpose - Reverse shoulder arthroplasty (RSA) has become the treatment of choice for cuff-tear arthropathy. There are, however, concerns about the longevity and the outcome of an eventual revision procedure. Thus, resurfacing hemiarthroplasty (RHA) with extended articular surface has been suggested for younger patients. We compared the patient-reported outcome of these arthroplasty designs for cuff-tear arthropathy. Patients and methods - We included patients operated on because of cuff-tear arthropathy and reported to the Danish Shoulder Arthroplasty Registry (DSR) from January 1, 2006 to December 31, 2013. 117 RHA cases were matched by age and sex with 233 RSA controls. 34 of the RHAs were conventional and 67 were RHAs with extended articular surface. The Western Ontario Osteoarthritis of the Shoulder (WOOS) Index at 1 year was used as primary outcome. The score was converted to a percentage of a maximum score. Revision, defined as removal or exchange of any component or the addition of a glenoid component, was used as secondary outcome. Results - Median WOOS was 49 (30-81) for RHA and 77 (50-92) for RSA (p < 0.001). For patients younger than 65 years, median WOOS was 58 (44-80) after RHA, similar to the 54 after RSA (37-85). For patients older than 65 years, median WOOS was 48 (28-82) after RHA and 79 (55-92) after RSA (p < 0.001). Interpretation - In all patients RSA had a clinically and statistically better patient-reported outcome than RHA. However, in patients younger than 65 years the functional outcome was similar and poor for either arthroplasty type. The optimal treatment of CTA in young patients remains a challenge.

High risk for revision after shoulder arthroplasty for failed osteosynthesis of proximal humeral fractures.

Background and purpose - It is unclear whether previous osteosynthesis is a risk factor for inferior outcome following shoulder arthroplasty for a proximal humeral fracture. We used data from the Danish Shoulder Arthroplasty Registry (DSR) to examine this question. Patients and methods - All 285 patients treated with a shoulder arthroplasty after failed osteosynthesis of a proximal humeral fracture reported to DSR from 2006 to 2013 were included. Each case was matched with 2 controls (570) treated with a primary shoulder arthroplasty for an acute proximal humeral fracture. Patient reported outcome was assessed using the Western Ontario Osteoarthritis of the Shoulder index (WOOS) and the relative risk of revision was reported. Results - The mean WOOS was 46 (SD 25) for a shoulder arthroplasty after failed osteosynthesis and 52 (27) after a primary shoulder arthroplasty. The relative risk of revision for a shoulder arthroplasty after failed osteosynthesis was 2 with a primary arthroplasty for fracture as reference. In a separate analysis of patients treated by locking plate the mean WOOS was 46 (24), with a relative risk of revision at 1.5 with a primary arthroplasty as reference. Interpretation - Compared with primary arthroplasty for proximal humeral fracture, we found an inferior patient-reported outcome and a substantial risk of revision for patients treated with a shoulder arthroplasty after failed osteosynthesis for a proximal humeral fracture. The risk and burdens of additional surgery should be accounted for when deciding on the primary surgical procedure.

Long-term clinical results in patients treated for recurrent posterolateral elbow joint instability using an ipsilateral triceps tendon graft.

BACKGROUND: The aim was to report the long-term functional and radiologic outcomes in patients treated for recurrent posterolateral elbow joint instability using an ipsilateral triceps tendon graft. METHODS: We included 18 patients previously treated for posterolateral elbow joint instability and evaluated for clinical results in 2003. Fifteen patients were examined with a mean follow-up period of 19 years (range, 17-22 years). We performed the clinical follow-up with clinical examination of stability, range of motion, pain score on a visual analog scale, Mayo Elbow Performance Score, and Danish version of Oxford Elbow Score. Furthermore, conventional anteroposterior and side-view radiographs of the elbow were obtained to evaluate osteoarthritis, calcifications in the ligaments, and joint subluxation. We evaluated the radiographs by the size of osteophytes, joint space narrowing, and subchondral sclerosis and classified the findings into 3 categories: no osteoarthritis, osteoarthritis, and severe osteoarthritis. RESULTS: All patients had a clinically stable elbow. None had pain while inactive or locking of the joint, and 4 had decreased range of motion. Two patients had a positive pivot-shift stress test, indicating laxity. The mean Mayo Elbow Performance Score was 93 (range, 70-100). The mean Oxford Elbow Score was 45. We observed 5 patients with osteoarthritis and 1 patient with severe osteoarthritis. CONCLUSION: The technique reported by Olsen and Søjbjerg in 2003 gives good long-term results in the treatment of symptomatic posterolateral elbow joint instability, though the development of elbow joint osteoarthritis may decrease the surgical result in the coming years.

Primary total elbow arthroplasty in complex fractures of the distal humerus.

AIM: To evaluate short- to medium term outcome of total elbow arthroplasty (TEA) in complex fractures of the distal humerus. METHODS: A consecutive series of 24 complex distal humerus fractures operated with TEA in the period 2006-2012 was evaluated with the Mayo Elbow Performance score (MEPS), plain radiographs, complications and overall satisfaction. The indications for surgery were 1: AO type B3 or C3 or Sheffield type 3 fracture and age above 65 or 2: fracture and severe rheumatoid arthritis. Mean follow-up time was 21 mo. RESULTS: Twenty patients were followed up. Four patients, of which 3 had died, were lost to follow up. According to the AO classification there were 17 C3, 1 B2 and 2 A2 fractures. Mean follow-up was 21 months (range 4-54). Mean MEPS was 94 (range 65-100). Mean flexion was 114 degrees (range 80-140). According to MEPS there were 15 excellent, 4 good and 1 fair result. Patient satisfaction: 8 excellent, 10 good, 2 fair and 1 poor. There were two revisions due to infection treated successfully with revision and three months of antibiotics. In two patients the locking split had loosened. One was referred to re-insertion and one chose yearly controls. Two patients had persistent dysaesthesia of their 5th finger, but were able to discriminate between sharp and blunt. CONCLUSION: Our study suggests that TEA in complex fractures of the distal humerus in elderly patients can result in acceptable short- to medium term outcome.

Validation of the Danish version of the Oxford Elbow Score.

INTRODUCTION: The Oxford Elbow Score (OES) is a patient-related outcome measure quantifying quality of life in relation to elbow disorders. This 12-item patient-administered English questionnaire comprises three domains: function, social-psychological status and pain. The purpose of this study was to examine the structure and reliability of the Danish version of the OES (D-OES). MATERIAL AND METHODS: A total of 130 patients who had total elbow arthroplasty (TEA) surgery performed in the period from 1981 to 2008 completed the D-OES. The Disability of the Arm, Shoulder and Hand score (DASH) and the Mayo Elbow Performance Score (MEPS) were also completed with a view to examining the convergent validity of the D-OES. In 45 cases, the questionnaire was completed twice to allow for calculation of test-retest reliability. The structure of the questionnaire was tested using Rasch analysis. RESULTS: Overall internal consistency tested by Cronbach's alpha was 0.99. The test-retest reliability correlation coefficient was 0.99. Expressed in terms of Pearson's correlation coefficient, the convergent validity of the D-OES's functional, social-psychological and pain domain was 0.78, 0.80 and 0.81, respectively, for the MEPS and -0.66, -0.58 and -0.49, respectively, for the DASH. The 12 items of the D-OES fitted the Rasch model, and the multidimensionality of the OES was confirmed. CONCLUSION: The Danish 12-item OES is a valid and reliable-patient administered questionnaire that can be used to quantify quality of life in patients with TEA.

Surgeons agree more on treatment recommendations than on classification of proximal humeral fractures.

BACKGROUND: Orthopaedic surgeons disagree considerably when classifying fractures of the proximal humerus. However, the clinical implications of low observer agreement remain unclear. The purpose of the study was to compare the agreement on Neer classification with the agreement on treatment recommendations. METHODS: We conducted a multi-centre observer-study. Five experienced shoulder surgeons independently assessed a consecutive series of 193 radiographs at two occasions three months apart. All pairs of radiographs were classified according to Neer. Subsequently, the observers were asked to recommend one of three treatment modalities for each case: non-operative treatment, locking plate osteosynthesis, or hemiarthroplasty. RESULTS: At both classification rounds mean kappa-values for inter-observer agreement on treatment recommendations (0.48 and 0.52) were significantly higher than the agreement on Neer classification (0.33 and 0.36) (p < 0.001 at both rounds). The highest mean kappa-values were found for inter-observer agreement on non-surgical treatment (0.59 and 0.55). In 36% (345 out of 965) of observations an observer changed Neer category between first and second classification round. However, in only 34% of these cases (116 out of 345) the observers changed their treatment recommendations. CONCLUSIONS: We found a significantly higher agreement on treatment recommendations compared to agreement on fracture classification. The low observer agreement on the Neer classification reported in several observer studies may have less clinical importance than previously assumed. However, inter-observer agreement did not exceed moderate levels.

Benefits and harms of locking plate osteosynthesis in intraarticular (OTA Type C) fractures of the proximal humerus: a systematic review.

INTRODUCTION: Locking plate osteosynthesis of proximal humeral fractures are widely recommended and used, even in complex intraarticular fracture patterns such as AO/OTA Type C fractures. We systematically reviewed clinical studies assessing the benefits and harms of osteosynthesis with angle stable plates in AO/OTA Type C fractures of the proximal humerus. METHODS: We conducted an iterative search in PubMed, Embase, Cochrane Library, Web of Science, Cinahl, and PEDro in all languages from 1999 to November 2010. Eligible studies should study the outcome for Type C fractures after primary osteosynthesis with locking plate within two weeks of injury, and a follow-up period of six months or more. Patients should be evaluated with the Constant-Murley Score (CS). Two observers extracted data independently. RESULTS: Twelve studies and 282 Type C fractures were included. Results were categorised according to study type and synthesised qualitatively. No randomised clinical trials were identified. Two comparative, observational studies reported a mean CS of 71 (relative to contralateral shoulder) and 75 (non-adjusted Constant Score) for Type C fractures. For all studies mean non-adjusted CS ranged from 53 to 75. Mean age- and sex-adjusted CS ranged from 60 to 88. Mean CS relative to the contralateral shoulder ranged from 71 to 85. The most common complications were avascular necrosis (range, 4-33%), screw perforations (range, 5-20%), loss of fixation (range, 3-16%), impingement (range, 7-11%) and infections range 4-19%. Reoperation rate ranged from 6 to 44%. CONCLUSIONS: Insufficient study designs and unclear reporting preclude safe treatment recommendations. Complication and reoperation rates were unexpected high. Based on the studies included we cannot routinely recommend the use of locking plates in AO/OTA Type C fractures.

[Luxatio erecta--a rare type of shoulder dislocation]. / Luxatio erecta--en sjaelden form for skulderluksation.

Inferior dislocation of the shoulder (luxatio erecta) is a rare type of shoulder dislocation. In this short article we review a case of a 56-year-old man who sustained a subcoracoid inferior dislocation of the right shoulder after accidental axial loading of the right arm. Post-reduction magnetic resonance scan showed supraspinatus tendon rupture. Such type of shoulder dislocation is associated with significant complications (such as rotator cuff tears) and also late complications (including instability, chronic pain and reduced motion). A brief description of presentation, diagnosis and management of this injury is presented.

Effect of osteosynthesis, primary hemiarthroplasty, and non-surgical management for displaced four-part fractures of the proximal humerus in elderly: a multi-centre, randomised clinical trial.

BACKGROUND: Fractures of the proximal humerus are common injuries and account for 4-5 percent of all fractures, second only to hip and wrist fractures. The incidence is positively correlated with age and osteoporosis, and is likely to increase. Displaced four-part fractures are among the most severe injuries, accounting for 2-10 percent of proximal humeral fractures. The optimal intervention is disputed. Two previous randomised trials were very small and involved a noticeable risk of bias, and systematic reviews consequently conclude that there is inadequate basis for evidence-based treatment decisions. We aim to compare the effect of osteosynthesis with angle-stable plate with non-surgical management, and the effect of primary hemiarthroplasty with both osteosynthesis and non-surgical management. METHODS/DESIGN: We will conduct a randomised, multi-centre, clinical trial including patients from ten national shoulder units within a two-year period. We plan to include 162 patients. A central randomisation unit will allocate patients. All patients will receive a standardised three-month rehabilitation program of supervised physiotherapy regardless of treatment allocation. Patients will be followed at least one year. The primary outcomes will be the overall score on the Constant Disability Scale, and its pain subscale, measured at 12 months. A blinded physiotherapist will carry out the assessments. Other secondary outcomes are Oxford Shoulder Score, and general health status (Short Form-36).

Long-term results with the Kudo type 3 total elbow arthroplasty.

From 1992 to 1993, 17 elbows were replaced with the unlinked Kudo type 3 total elbow arthroplasty in 16 patients with arthritic joint destruction. Of these elbows, 8 were available for clinical examination after a mean of 9.5 years. Of the 17 elbow implants, 5 were revised: 2 because of loosening of the ulnar component, 1 because of dislocation, 1 because of a periprosthetic fracture, and 1 because of a late deep infection. At 9.5 years' follow-up, 67.9% of the prostheses had survived, and the mean survival of the implant was 8.7 years (95% confidence interval, 7.5-10 years). In this study, we observed high rates of progressive valgus tilting of the ulnar component. This valgus tilting is of major concern because it provides more stress to a smaller area on the polyethylene. It may, therefore, cause an increased degree of polyethylene wear and, thereby, reduce the final implant survival rate.

[Elbow arthroplasty]. / Albueartroplastik.

Each year, about 80 elbow arthroplasties are performed in Denmark. Approximately two thirds are done due to rheumatoid arthritis, the others due to comminuted fractures of the elbow, especially in elderly patients. The prosthesis is fixed with or without bone cement, and there are two different types of elbow prostheses: linked, in which the humerus and ulna are connected by a sloppy hinge, and non-linked, in which stability is dependent on the soft tissues of the elbow. Good pain relief can be expected, but the range of motion will usually be permanently affected.

Capitellocondylar total elbow replacement in late-stage rheumatoid arthritis.

Between 1994 and 2000, 51 capitellocondylar elbow replacements were inserted in 41 patients. All patients had late-stage rheumatoid arthritis. The mean age at operation was 56 years (range, 25-78 years). There were 12 men and 29 women. At follow-up, 6 patients had died of unrelated causes with the implant in situ and without radiographic loosening, and 1 patient was lost to follow-up. The remaining 43 elbows in 34 patients were followed up clinically and radiographically at a mean of 6.9 years (range, 26-119 months). Relief of pain was complete in 91% of the surviving elbows, and in 9%, there was only mild pain. Pain-free range of motion at follow-up was significantly improved. Flexion increased a mean of 43 degrees ; extension, 16 degrees ; supination, 24 degrees and pronation, 26 degrees . Of the elbows, 7 underwent revision, 3 because of deep infection, 1 for aseptic loosening, and 3 because of instability. Other complications included 2 maltracking elbows, 2 triceps tendon ruptures, 2 cases of operative olecranon bursitis, and 2 ulnar nerve palsies. One elbow showed radiolucent lines of more than 1 mm in the circumference of the ulnar component; none of the other elbows showed any signs of progressive radiographic loosening. At a mean follow-up of 6.9 years, a functional prosthesis was retained in 82.7% of the elbows, and the mean survival of the implant was 8.6 years (95% CI, 7.8-9.5 years).

Wrist stability after experimental traumatic triangular fibrocartilage complex lesions.

PURPOSE: The aim of this study was to evaluate changes in stability of the wrist after experimental traumatic triangular fibrocartilage complex lesions. METHODS: Sixteen cadaver wrist specimens were included: 8 were fixed in neutral rotation of the forearm, 4 in maximal supination, and 4 in maximal pronation. The specimens were tested in a multiangle and torque measuring instrument. First the intact specimen was tested, second a dorsal arthrotomy was performed, and the third test was with 1 of 4 different experimental lesions according to Palmer's classification of traumatic triangular fibrocartilage complex lesions (1A-1D). Forced radioulnar deviation and internal/external rotation were recorded with a load of 0.75 Nm in the interval -60 degrees to +60 degrees of flexion. RESULTS: We found the 1C lesion to be highly significantly related to wrist stability. Forced radioulnar deviation and forced internal/external rotation were altered significantly in 35 degrees of wrist extension. The other lesions did not alter the stability of the wrist significantly and the rotation of the forearm had no influence on the outcome. CONCLUSIONS: The 1A lesion does not alter significantly wrist stability and hence the common treatment by a two-third excision of the central part of the disk will not affect wrist stability. A 1C lesion alters significantly the stability of the wrist. At 35 degrees of wrist extension forced radioulnar deviation and forced internal/external rotation were altered significantly; this might be used in a clinical test for a 1C lesion. The rotation of the forearm has no influence on the outcome.