Sanchez-Sotelo J, Morrey BF. Surgical techniques for reconstruction of chronic insufficiency of the triceps: rotation flap using anconeus and tendo achillis allograft. J Bone Joint Surg [Br]2002;84-B:1116-20.

Triceps insufficiency is an uncommon problem and seen most frequently following elbow joint replacement. Yet, because the disability associated with inadequate triceps function is functionally disabling information regarding its management is of value.

This particular contribution is the first of which we are aware in the literature which documents the clinical presentation and effective reconstructive options to address the disparate pathology that is frequently encountered.

In our personal practice we have seen a good many patients who have benefited rather dramatically from the simple anconeus rotational flap procedure. The technical simplicity of this approach is particularly attractive. The important insight is to identify the interval between the anconeus and extensor carpi ulnaris. The anconeus may then be readily elevated from the lateral aspect of the ulna and its humeral attachment is then easily separated. The confluence of the anconeus with the triceps makes it an ideal tissue when rotated medially to provide continuity of the extensor mechanism. This provides excellent extensor function when the triceps attachment to the olecranon is deficient. The surgical technique is clearly diagramed in the original article and importantly the outcome of the four patients is also clearly documented. In all four instances the important outcome of being able to elevate their arm against gravity was achieved. One additional point regarding this technique not maintained in the manuscript is that this same technique may be used very effectively in the patient with rheumatoid arthritis undergoing total elbow as a prophylactic measure. If the triceps is deficient after a Bryan-Morrey exposure, or after any approach in which the triceps tendon attachment to the olecranon is inadequate or very thin, we perform the anconeus rotational flap at the time of the primary repair.

More difficult problems are encountered when there is no effective anconeus present often due to transsection from a prior olecranon osteotomy. Additional clinical settings in which there have been multiple procedures or after management that results in deficiency of the tendon or olecranon require some form of an augmentation procedure. In both these settings an allograft calcaneal composite graft has proven to be exceptionally useful as a reconstructive tissue. Extensive tissue deficiency with loss of triceps/osseous continuity is commonly seen in those in whom the posterior aspect of the joint has been debrided for infection. Use of a large allograft should be avoided if there is a history of previous sepsis due to the fairly significant amount of inanimate tissue which is employed with this reconstructive option. On the other hand, if there are no issues of infection, the reconstruction is extremely effective. With olecranon deficiency, careful fashioning of the calcaneus to serve as a reconstructed olecranon is a reliable strategy and this can generally be well fixed with a cancellous screw. The particular attraction of this technique is the extent and quality of the Achilles fascia and tissue which can be used to obtain a broad-based purchase of both the medial, lateral, and central aspects of the triceps mechanism. An illustration this technique is also included in this article.

The documented effectiveness is particularly impressive in those with olecranon deficiency. It might be noted that two of the seven patients reported in this series did have a slight amount of pain and one patient was subjectively unsatisfied with the outcome due to that feature. Nonetheless, the contribution does provide insight into relatively straight forward and reliable reconstructive techniques for an extremely deficient clinical problem that has not been previously described in the literature.

Garcia JA, Mykula R, Stanley D. Complex fractures of the distal humerus in the elderly: the role of total elbow replacement as primary treatment. J Bone Joint Surg [Br] 2002;84-B:812-16.

This is one of several papers that has appeared in the last several years documenting the outcome of joint elbow replacement for acute distal humeral fractures. This article documents a moderately large series of 19 patients, all treated with the same linked Coonrad-Morrey prosthesis. The authors clearly emphasise the inclusion criteria as being primarily the highly comminuted osteoporotic articular fracture in the elderly patient. The authors documented experience is consistent with this selection criteria with a mean age of 73 years and a range of 61 to 95 in their patient sample. The technical aspects of this procedure have been documented elsewhere. In our personal practice the triceps is left attached to the ulna and there is no effort to retain any fracture fragments. All fragments are excised. This allows the humeral component to be fully seated and the elbow to be articulated with both the ulna and the humeral component inserted to their proper anatomic positions. The lack of distal humerus allows easy articulation and placement of the pin for the linked implant. The follow-up surveillance in this study is modest ranging from one to five years but this is adequate compared with the outcome of osteosynthesis. The final reported results are quite impressive. Functional arc of motion measuring more than 100 degrees was obtained in 11 of the 16 patients. Even more impressive is the effectiveness in eliminating posttraumatic pain in all but one of the 16 patients. One attractive feature documented with this procedure is the shortened hospital stay, relatively rapid rehabilitation and minimal need of intensive physical therapy. Also of particular interest is the relatively low complication rate particularly when compared to those with a similar injury and in a similar age group treated by osteosynthesis.

The best way to put this experience in perspective is to contrast these outcomes with those of osteosynthesis for similar injuries in a similar age population. In the discussion the authors do contrast the increasing acceptance by the orthopedic community of the use of joint replacement arthroplasty for comminuted fractures of the distal humerus in the elderly patient. The experience of osteosynthesis particularly when correlated to the older age group reveals a high complication rate often exceeding 20 to 30% with a success rate that typically is less than 75 to 80%. These authors document patient satisfaction in 15 of the 16 patients so treated. Furthermore, these are prospective randomised studies comparing replacement and osteosynthesis that clearly document the advantages of joint replacement.

Overall this is a very favorable outcome from an experienced surgeon and a well known center for elbow surgery. It should be noted that these results have been replicated by others thus providing some additional legitimacy to the findings and recommendations.

Crowther MAA, Bannister GC, Huma H, Rocker GD. A prospective, randomised study to compare extracorporeal shock-wave therapy and injection of steroid for the treatment of tennis elbow. J Bone Joint Surg [Br] 2002;84-B:678-9.

The attractiveness of this article is that it addresses probably the most common ailment of the elbow, that of lateral epicondylitis. The subject matter is also relevant in that it studies the effectiveness of extracorporeal shock wave therapy which is rapidly becoming accepted as an attractive alternative non-invasive modality. The prospective randomised nature of this study lends significant credence to the findings and recommendations. In this particular study a total of 111 patients were enrolled. Fifty-one randomised to the extracorporeal shock waver therapy, and 42 to a cortisone injection treatment option. Based primarily on a pain analog scale, the results demonstrated a statistically significant advantage in the short term in the patients treated with the traditional cortisone injection. Using somewhat arbitrary criteria of 50% improvement in pain, 81% with a cortisone injection and 60% of patients with the shock wave therapy were satisfied with the intervention (p < 0.05). Of note is that these authors do also provide a comment with regard to the technique of the shock wave therapy and the expense of the two modalities. In their particular clinical setting the shock wave treatment cost approximately £300 which according to the authors is 100 times more expensive than the cortisone injection. Of equal importance is that the shock wave therapy was conducted in three different sessions over a two week period making it much less convenient and time consuming. Considering this study and other recently published prospective, randomised studies, a considerable body of evidence is being generated to suggest that although shock waver therapy may be effective, it is no more so than a simple cortisone injection. Furthermore, since the shock wave therapy must be performed over several days. Compliance and patient convenience are practical issues to consider.

Finally, the rather significant expense of the shock waver therapy compared to the cortisone injection all tend to mitigate against accepting this as a standard treatment in the manner employed in this study. It might be noted however that the basis for this conclusion could change. There is great interest in this modality. Its effectiveness is dependent on the frequency of and amplitude of the shock wave, as well as the duration and frequency of application. Uncertainty of the best indication for early or late lesions and whether best for limited or extensive pathology still deserve further scrutiny. Further, if it is determined that a single treatment is effective and if the cost for this treatment could be curtailed, then it is conceivable that in certain selected lesions, based on yet to be defined criteria, could be still considered a viable candidates for this noninvasive treatment modality.

Jensen SL, Deutch SR, Olsen BS, Søjbjerg JO, Sneppen O. Laxity of the elbow after experimental excision of the radial head. J Bone Joint Surg [Br] 2003;85-B:1006-10.

This article was chosen as one of the more important ones pertaining to the elbow over the last several years. The reason for this is that first it is a very well recognised laboratory and clinical practice with great impact referable to elbow problems. The second, and most relevant, is that the specific topic being discussed is emerging as an increasingly relevant one to the orthopedic surgeon. The rationale and effectiveness of acute treatment of fracture dislocation of the elbow remains one of the most important concepts in the management of elbow trauma. These authors have a great experience with such problems and address the common dilemma of fractured radial head with medial collateral ligament. The important additional feature of this assessment is to study the posterior medial rotatory instability of the medial colateral deficient elbow. This article may thus be reviewed in the context to that review of Sanchez-Sotelo, et al. with the Mayo Clinic’s experience of reconstruction for lateral rotatory insufficiency by reconstruction or repairing the lateral collateral ligament.

Those interested in this topic should read the entire article as I found the abstract does not contain all relevant material. Comments with regard to the greater effectiveness of the isolated radial head replacement to stabilise the elbow are technically correct, but are based on relatively small angular and rotatory displacements. With regard to the methodology, these are experienced investigators. Unfortunately, the article does not detail the manner in which passive motion is imparted to the elbow without biasing the very sensitive rotatory and angular displacements which are being measured. That the methodology did not call for changing the order with which the deficiency of the medial collateral ligament was introduced lessens the comprehensiveness of their findings. Finally, that the same specimen was used for the full series of five experiments does cause some question with regard to the validity of the findings from those tests later in the sequence. This does pose some relevance to the significance of the findings, particularly in view of the relatively small angular displacement from which the authors draw conclusions. Nonetheless, their findings are consistent with our laboratory and clinical observations as well as an emerging body of clinical experience literature.

The important findings are nicely summarised in the abstract, specifically, the division of the medial collateral ligament does increase the valgus angulation in addition to imparting a posteromedial rotatory instability (internal) which should be contrasted with posterolateral versus rotatory instability which occurs with lateral ligament deficiencies. That the radial head is effective in addressing valgus instability is not surprising nor the negligible effect of the radial head on posteromedial rotatory instability. This lateral ligament has clearly been demonstrated in the past to contribute to lateral rotatory but not medial rotatory instability as confirmed by this experiment. Hence, that the major stabilisers both from the valgus and posterior medial rotatory perspective is the medial collateral ligament is well established. The obvious role of the radial head as an important secondary stabiliser, particularly to valgus and less so to the rotatory deficiency is likewise confirmed.

Sanchez-Sotelo J, Morrey BF, O’Driscoll SW. Ligamentous repair and reconstruction for posterolateral rotatory instability of the elbow. J Bone Joint Surg [Br] 2005;87-B:54-61.

This article as well as that by Jensen et al. call attention to the rotatory nature of elbow instability. In contrast to the experimental studies of Jensen summarised in this section, this report is of a pure clinical experience and relates to lateral deficiency rather than medial collateral ligament injury. The reason this particular contribution has been selected for review is it is the largest series in the literature with the longest follow-up of the management of this injury and emphasises emerging features of surgical technique. The single most important issue, in our judgment, is that the prognosis for the reconstruction is very much dependent upon whether or not the patient has subjective instability. The relevance of this is the high degree of variability observed with the presentation of these patients. This ranges from those with a clear mechanism to cause ligament injury to those with symptoms that became present only after surgical intervention. In a few no adequate explanation could be documented. This observation is important since it relates to prognosis and outcome. This underscores the importance of an accurate diagnosis of this entity, particularly given that the etiology and presentation may be somewhat variable and unpredictable. The classic posterolateral rotatory instability pivot shift test which was defined with the original description of the injury continues to be valid but unless the instability is extensive, a positive test may be difficult to demonstrate. The more subtle elbow drawer test, as well as apprehension with the pivot shift maneuver are possibly more sensitive and valid in the majority of patients with less extensive injuries. Those with clear evidence or symptoms of instability as a chief complaint realise the greatest improvement from a stabilization procedure. Similarly, those in whom the rotatory deficiency occurred after a surgical intervention had a smaller percentage of satisfactory outcomes compared to those with a post-traumatic etiology. This implies that objective factors came to play in this instance. Several points of the technique presented in this paper are worth mentioning. The first is that an allograft is a more predictable and reliable reconstructive strategy than is plication of the native tissue. This is consistent with others’ observations referable to the medial collateral ligament repair and reconstruction. The use of the so called ‘yoke’ stitch is particularly valuable in this reviewer’s opinion as it allows an effective means of tensioning the graft at the completion of the plication by placing final tension on the ‘yoke’ stitch and sewing it to the reconstructed ligament. This manoeuvre is done with the elbow flexed to approximately 70º in a valgus position and with the forearm in full pronation. The overall success rate in approximately 85% is an accurate reflection of our expectation and because of the sise of this sample it might be considered the standard expectation. The fact that these patients had a significantly long follow-up is also quite important since several patients sustained significant injuries that resulted in recurrence of instability. Of special note is that reconstruction was a more reliable means of stabilizing the elbow compared to plication or repair. Finally, these patients had a relatively low complication rate providing a favorable ‘risk benefit’ ratio for this operation. The only significant complication is that of a potential recurrence of the condition.

Mazda K, Boggione C, Fitoussi F, Penneçot GF. Systematic pinning of displaced extension-type supracondylar fractures of the humerus in children: a prospective study of 116 patients. J Bone Joint Surg [Br] 2001;83-B:888-93.

After carefully reviewing the literature, these authors embark upon a treatment protocol that has proven to be quite effective in this well documented practice. This manuscript documents a large number of patients followed for an adequate period of time after being randomised into two treatment arms. Of 116 procedures, 90 were treated closed, and 26 required open reduction and fixation. The inclusion criteria considered for this study was an open physis and displacement of more than 2 mm. Using these criteria, 26 patients could not be adequately reduced and required open reduction. The intervention was carried out by six surgeons. An important finding is the result of those patients treated by the four junior surgeons was as satisfactory as was that demonstrated by the two senior surgeons. The closed lateral percutaneous pinning technique emphasises the need for parallel K-wire application less than 10 mm apart. The open procedure has three major elements: first, it is indicated primarily to accurately reduce the fracture; second, identity of the ulnar nerve; and third, both medial and lateral crossed K-wires are used. Both clinical and basic investigators suggest the crossed K-wire is the more stable of the two constructs.

Interestingly enough the outcome does not correlate to whether an open or closed procedure was carried out. This is a testament to the fact that these authors accurately selected their patients. That approximately 95% did well underscores this observation and is also a testament to their surgical skill. The one problem that occurred, but in only five patients, was a residual of greater than 5 degrees of varus. These authors do appropriately indicate that this was considered an unsatisfactory outcome. The result is based more on the cosmetic feature than loss of function. What these authors did not note is that in our and others experience residual varus from supracondylar fractures can predispose to late stretch of the lateral collateral ligament complex. This can result in posterolateral rotatory instability due to the eccentric contracture of the triceps over time. In some instances we have been obliged to osteotomise the distal humerus in order to correct the varus alignment so the chronic instability resulting from the angular deformity can be corrected by ligament reconstruction. Overall, this is a valuable contribution in emphasizing indications describing the technique and documenting outcome of their treatment protocol.

Rasool MN. Dislocations of the elbow in children. J Bone Joint Surg [Br] 2004;86-B:1050-8.

This is an interesting study coming from a society with variable primary health care. The source, therefore, of this article has certain cultural features that should be considered but does not alter the insights provided. The value of this particular contribution is that it emphasises the relatively high percentage of associated injuries which is not generally considered when treating elbow dislocation in a child. The mean age of the patient sample in this study was 9 years (5 to 13), which is quite typical for this injury.

Furthermore, the mechanism of injury was a fall on the outstretched hand in every instance, which is also quite typical. What is not typically appreciated is the extremely high incidence of associated injuries, especially fracture. What is not commonly documented from prior reports is the delay to surgery of up to five days of the acute event. The authors note that the delay was primarily because of a lack of recognition of the additional injury and referral from rural hospitals rather than availability of health care. By most standards the follow-up is relatively brief with a minimum of four months in some and with a maximum of only 48 months. This poses a concern that this perio d does not provide sufficient surveillance to fully or accurately assess outcome. Final motion is particularly of importance since this is the function most sensitive to and adversely effected by elbow dislocation and the final arc cannot be accurately documented for at least six months after injury. In spite of these limitations this remains an important contribution in that it emphasises the presence of associated fractures and more importantly, some of these fractures may be missed at the initial assessment. The authors also outline and contrast the distribution of the associated injuries which occurred in 25 of 33 with dislocation (72%). The most frequently encountered fracture (11 of 25) was of the medial epicondyle. Of the 25 fractures, five involved the lateral condyle which is a relatively high incidence for this uncommon injury. The high incidence of the additional injuries and fractures explains the 60% occurrence of open procedures which were performed on these children. This high frequency of surgical intervention is much greater than is usually considered in this setting and greater than suggested by the literature. The final outcome is also worthy of note since only two-thirds of the patients were considered to have a satisfactory outcome at latest assessment. This outcome is primarily related to the presence and type of associated injury including 4 of 23 (13%) neurological injuries documented at the time of dislocation. As noted above, the article does not provide insight with regard to the final arc of motion. Of greater significance is the study does not correlate treatment type to the injury and subsequent function. It is possible that with more detailed assessment and with longer duration the outcomes could be considered somewhat different than that reported here.

Ikävalko M, Lehto MUK, Repo A, Kautiainen H, Hamalainen M. The Souter-Strathclyde elbow arthroplasty. A clinical and radiological study of 525 consecutive cases. J Bone Joint Surg [Br] 2002;84-B:77-82.

This is a very impressive series documenting a 15 year experience with this particular implant which was inserted in over 500 patients by several surgeons from a single institution. It might be noted that the patient sample is exclusively that of an inflammatory etiology, primarily rheumatoid arthritis. A retrospective assessment for a series of this size collected over a long period of time does introduce some inherent weaknesses. First, the surgical technique of necessity varies and changes over time. In addition, implant modification, either subtle or more significant, is also introduced as a confounding variable in the assessment. Both features are present in this experience. Nonetheless, it is a valuable contribution to the literature and is the definitive experience with this implant.

The summary offers the most important message which is a satisfactory outcome was documented in 85% of patients at ten years. A major reason for failure was that 26 patients (5%) required a re-operation for instability. In addition, another 30 patients required re-operation for infection or loosening. That the mean surveillance is five years is somewhat surprising given that the range of surveillance is from 0 to 17 years, indicating the follow-up is skewed towards a more abbreviated rather than a longer period. Nonetheless, the ultimate correlation that the ten-year outcome is approximately 82% with intact implants, serves as a valid frame of reference for this particular implant design. The concerning rate of loosening of this uncoupled implant has been observed by others and is due to its high level of articular constraint of this particular design. This would appear to be confirmed by these investigators’ outcomes. This implies that an unconstrained implant descriptions is not synonymous with an unlinked device, since the Souter is an unlinked implant that is the most constrained of any elbow replacement currently available. Today implant design description of linked versus unlinked is preferable to constrained and unconstrained. The seemingly high complication rate reported here is not uncommon with elbow replacement surgery. The most common problems, other than loosening and instability, is ulnar nerve irritation and infection. Both occurred at acceptable rates in this experience.

Finally, a more detailed and prolonged assessment of this experience is necessary to determine whether the longer stem will decrease the incidence of loosening. Further, the captive articulation does appear to have lessened the frequency of instability. Yet, the value of these design modifications cannot necessarily be extrapolated to the long-term. Of particular concern is whether the captive articulation while decreasing the incidence of instability may not also increase the incidence of loosening. It does appear these design features also allow the surgeon to broaden the surgical indications. If this occurs, the outcome data will need to be stratified by underlying diagnoses and extent of pathology, as this report primarily documents the management of inflammatory conditions.

Professor B. F. Morrey
Department of Orthopaedic Surgery, Mayo Clinic, Rochester, USA