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Nayar SK, Mohamed F, Bashir K, Abukar A, Prinja A, Rashid A. Total elbow arthroplasty and hemiarthroplasty in the treatment of distal humerus fractures in the elderly: Experience from a tertiary referral centre. Injury 2024; 55:111754. [PMID: 39094349 DOI: 10.1016/j.injury.2024.111754] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2024] [Revised: 07/23/2024] [Accepted: 07/25/2024] [Indexed: 08/04/2024]
Abstract
BACKGROUND There is no clear consensus on whether total elbow arthroplasty (TEA) or hemiarthroplasty (HA) is superior for treating distal humerus fractures in the elderly. This study analysed the functional outcomes and re-operation rates following TEA and HA for intra-articular distal humerus fractures in patients aged ≥65 years. METHODS 19 patients (TEA = 12, HA = 7) treated between 2016 and 2022 were retrospectively reviewed. Mean age was 73 years and mean follow-up was 46 months. Functional outcomes and quality of life were assessed using the Mayo Elbow Performance Score (MEPS), Quick-DASH (Q-DASH), Oxford Elbow Score (OES), SF-12 Physical Component Score (PCS) and Mental Component Score (MCS), and EQ-5D. Complications requiring re-operation were recorded. RESULTS HA showed superior outcomes in MEPS (93.6 vs 75.0, p = 0.0339), Q-DASH (13.3 vs 31.3, p = 0.0182), OES (41.7 vs 33.2, p = 0.0346), SF-12 PCS (55.5 vs 36.9, p = 0.0008) and EQ-5D (83 vs 67, p = 0.0023). One HA patient required revision to TEA for prosthetic joint infection. One TEA patient required revision for a periprosthetic ulna fracture. CONCLUSION HA provides better functional outcomes compared to TEA in the treatment of distal humerus fractures in the elderly. Data is limited by selection bias and low patient numbers with a multicentre randomised controlled trial warranted.
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Affiliation(s)
- Sandeep Krishan Nayar
- Whittington Health NHS Trust, United Kingdom; University College Hospitals NHS Foundation Trust, United Kingdom.
| | - Foad Mohamed
- University College Hospitals NHS Foundation Trust, United Kingdom
| | - Khayam Bashir
- University College Hospitals NHS Foundation Trust, United Kingdom
| | - Amin Abukar
- University College Hospitals NHS Foundation Trust, United Kingdom
| | - Aditya Prinja
- Whittington Health NHS Trust, United Kingdom; University College Hospitals NHS Foundation Trust, United Kingdom
| | - Abbas Rashid
- University College Hospitals NHS Foundation Trust, United Kingdom
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Weber MM, Rausch V, Leschinger T, Müller LP, Hackl M. [Elbow hemiarthroplasty for coronal shear fractures of the distal humerus]. OPERATIVE ORTHOPADIE UND TRAUMATOLOGIE 2024; 36:159-166. [PMID: 39037599 DOI: 10.1007/s00064-024-00852-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Revised: 10/10/2023] [Accepted: 11/09/2023] [Indexed: 07/23/2024]
Abstract
OBJECTIVE The aim of the operation is to replace the articular surface of the distal humerus in cases of nonreconstructible fractures of the distal humerus. INDICATIONS Active patients with high functional requirements, in whom weight limitation of total elbow arthroplasty should be avoided. CONTRAINDICATIONS Contraindications include fractures with irreconstructible epicondyles and/or irreconstructible collateral ligaments, as well as ulnohumeral, or radiohumeral osteoarthritis. SURGICAL TECHNIQUE Following subcutaneous anterior transposition of the ulnar nerve, surgical dislocation of the elbow joint is achieved through a paratricipital approach with release of the soft tissue structures from the humerus. After resection of the trochlea, the intramedullary canal of the humerus is prepared using rasps in order to implant the hemiprosthesis with retrograde cementing. Finally, the medial and lateral collateral ligaments as well as the flexors and extensors are repaired. POSTOPERATIVE MANAGEMENT Early functional rehabilitation in a hinged elbow orthosis while avoiding varus/valgus stress after wound healing is completed. RESULTS Between 2018 and 2022, 18 patients with coronal shear fractures were treated with elbow hemiarthroplasty. The mean Mayo Elbow Performance Score (MEPS) was 79 (70-95) after a mean follow-up of 12 months. The mean range of motion was 99° (70-130°) in extension-flexion and 162° (90-180°) in pronation-supination.
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Affiliation(s)
- Marc Maximilian Weber
- Klinik und Poliklinik für Orthopädie, Unfallchirurgie und Plastisch-Ästhetische Chirurgie, Universitätsklinikum Köln (AöR), Kerpener Str. 62, 50937, Köln, Deutschland.
| | - Valentin Rausch
- Klinik und Poliklinik für Orthopädie, Unfallchirurgie und Plastisch-Ästhetische Chirurgie, Universitätsklinikum Köln (AöR), Kerpener Str. 62, 50937, Köln, Deutschland
| | - Tim Leschinger
- Klinik und Poliklinik für Orthopädie, Unfallchirurgie und Plastisch-Ästhetische Chirurgie, Universitätsklinikum Köln (AöR), Kerpener Str. 62, 50937, Köln, Deutschland
| | - Lars Peter Müller
- Klinik und Poliklinik für Orthopädie, Unfallchirurgie und Plastisch-Ästhetische Chirurgie, Universitätsklinikum Köln (AöR), Kerpener Str. 62, 50937, Köln, Deutschland
| | - Michael Hackl
- Klinik und Poliklinik für Orthopädie, Unfallchirurgie und Plastisch-Ästhetische Chirurgie, Universitätsklinikum Köln (AöR), Kerpener Str. 62, 50937, Köln, Deutschland
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Mahajan UD, Memon K, Mehta S, Chan S, Spurrier E, Kalogrianitis S. Primary Elbow Arthroplasty in the Management of Complex Distal Humerus Fractures. Cureus 2024; 16:e65851. [PMID: 39219946 PMCID: PMC11364086 DOI: 10.7759/cureus.65851] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/31/2024] [Indexed: 09/04/2024] Open
Abstract
Introduction Complex distal humerus fractures pose significant challenges in orthopedic surgery, especially when traditional open reduction and internal fixation (ORIF) is not feasible. Primary elbow arthroplasty has emerged as an alternative treatment option for these fractures, but its application remains limited. This study aimed to evaluate the functional outcomes, patient selection criteria, and follow-up results of primary elbow arthroplasty in the management of complex distal humerus fractures. Methods A retrospective review was conducted on 15 patients who underwent primary elbow arthroplasty for Orthopaedic Trauma Association (OTA) type C distal humerus fractures between 2017 and 2023 at our institution. Inclusion criteria were patients aged 18 years or older who were offered either total elbow or hemiarthroplasty for acute complex distal humerus fracture. Data were collected from patient medical records, including demographic information, fracture classification, surgical details, and postoperative follow-up. Functional outcomes were assessed using the Oxford Elbow Score (OES) and Mayo Elbow Performance Score (MEPS). Complications were documented, and descriptive statistics were used to summarise the findings. Results The mean age of the patients was 71.8 years (IQR 17 years), with 12 females and three males. The mean time to surgery was 14.7 days post-injury (IQR: 12 days). The mean follow-up duration was 52 weeks (range: 8-234 weeks, IQR: 27 weeks) and variability was noted. The mean flexion-extension arc at the final follow-up was 93° (IQR: 32.5°). The mean OES was 46 (IQR: 22), and the mean MEPS was 75 (IQR: 37), indicating good to excellent functional outcomes. Scores for two patients were not available due to dementia. Reported complications included one case of ulnar sensory symptoms and one case requiring metalwork removal following olecranon osteotomy. Conclusion Primary elbow arthroplasty provides a viable treatment option for complex distal humerus fractures, demonstrating significant functional improvements and high patient satisfaction. However, the variability in follow-up and subjective decision-making underscores the need for standardized protocols. Future multicenter, prospective studies with larger cohorts and standardized follow-up protocols are recommended to confirm these findings and optimize patient care.
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Affiliation(s)
- Uday D Mahajan
- Trauma and Orthopedics, Queen Elizabeth Hospital Birmingham, Birmingham, GBR
| | - Kashif Memon
- Trauma and Orthopedics, Queen Elizabeth Hospital Birmingham, Birmingham, GBR
| | - Sonu Mehta
- Trauma and Orthopedics, Glan Clwyd Hospital, Rhyl, GBR
| | - Samuel Chan
- Trauma and Orthopedics, Queen Elizabeth Hospital Birmingham, Birmingham, GBR
| | - Edward Spurrier
- Trauma and Orthopedics, Queen Elizabeth Hospital Birmingham, Birmingham, GBR
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Saleh J, Patterson ED, Aillerie C, Tohmé P, White NJ. Ligament Sparing Elbow Hemiarthroplasty: A Novel Technique for the Management of Distal Humeral Fractures. Tech Hand Up Extrem Surg 2024; 28:92-95. [PMID: 38506471 DOI: 10.1097/bth.0000000000000469] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/21/2024]
Abstract
Intra-articular distal humerus fractures present various challenges with a wide array of treatment options. Open reduction internal fixation remains the treatment of choice. In older patient populations with poor bone quality and short-end segment fractures with articular comminution, open reduction internal fixation, however, may bring on unsurmountable technical challenges. Total elbow arthroplasty and elbow hemiarthroplasty (EHA) may offer superior functional outcomes in these cases. During EHA for fractures, the medial and lateral columns are reconstructed with the collateral ligaments to restore elbow stability. We hypothesize that in coronal sheer fracture patterns where the columns are intact, maintaining the native collateral ligaments and columns will provide both an anatomic and stable elbow joint. We introduce the ligament sparing EHA technique for unreconstructible coronal shear fractures. We describe this novel technique and compare our postoperative outcomes in 2 patients who underwent this surgery to those described in the literature. The postoperative Disabilities of the Arm, Shoulder, and Hand scores for the 2 patients were 13.8 and 10.3, respectively. The Mayo Elbow Performance Score for the 2 patients were 80 and 85, respectively. The operative arm presented a grip strength of 82% and 89% when compared with the contralateral arm, for the patients respectively. The range of motion varied between 78% and 100% of the contralateral arm for both patients. Although our results are promising and the ligament sparing EHA technique may be a more anatomic option in certain fracture patterns, further research with larger cohorts and multiple surgeons is needed to reinforce our results.
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Affiliation(s)
- Joseph Saleh
- Department of Surgery, University of Montreal, Quebec
| | | | | | - Patrick Tohmé
- Department of Surgery, University of Montreal, Quebec
| | - Neil J White
- Department of Orthopedic Surgery, Cumming School of Medicine, University of Calgary, AB, Canada
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Loisel F, Amar Y, Rochet S, Obert L. Distal humerus fracture in older patients: ORIF vs. total elbow arthroplasty. Orthop Traumatol Surg Res 2024; 110:103759. [PMID: 37992865 DOI: 10.1016/j.otsr.2023.103759] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Accepted: 06/16/2023] [Indexed: 11/24/2023]
Abstract
Distal humerus fractures are a contemporary problem because the life expectancy, autonomy and functional demands of older patients continue to grow. This is combined with surgical advances in bone reconstruction, especially in fragile patients. A distal humerus fracture in an older adult is a serious injury with an uncertain prognosis. In fact, damage to the elbow joint in this complex anatomical area overwhelmed by low-quality bone occurs in patients who often have unfavorable characteristics (fragile skin, low physiological reserves, organ failure) combined with pharmaceutical treatments that can be iatrogenic. The treatment indication must not be based solely on the conventional radiographs used for classification purposes; the fracture and bone quality must be analyzed in three dimensions. Also, the surgeon must understand the patient's needs, worries and risks fully to decide between conservative treatment and anatomical locking plate fixation or elbow arthroplasty (hemi or total). In the end, the chosen treatment must allow at least 100̊ and preferably 120̊ of flexion-extension at the elbow. In this age range, the choice between arthroplasty and plate fixation is definitive; the surgical approach must make it possible to carry out either option, with arthroplasty implants available in case the trochlear fracture cannot be plated. The aim of this lecture is to provide a fresh perspective on the anatomy of the distal humerus, its fracture and the best surgical approaches, discuss how to decide on the indication, outline the safest and most reliable ways to reconstruct and stabilize the elbow, and lastly, summarize the expected outcomes and potential complications of each treatment option. Level of evidence: V; expert opinion.
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Affiliation(s)
- François Loisel
- Department of Orthopedic, Trauma, Plastic, Reconstructive and Hand Surgery, EA Laboratoire de Nano médecine Imagerie Thérapeutique (LNIT), CHRU of Besançon & CIC IT, 808, boulevard Fleming, 25033 Besançon, France
| | - Yassine Amar
- Department of Orthopedic, Trauma, Plastic, Reconstructive and Hand Surgery, EA Laboratoire de Nano médecine Imagerie Thérapeutique (LNIT), CHRU of Besançon & CIC IT, 808, boulevard Fleming, 25033 Besançon, France
| | - Severin Rochet
- Department of Orthopedic, Trauma, Plastic, Reconstructive and Hand Surgery, EA Laboratoire de Nano médecine Imagerie Thérapeutique (LNIT), CHRU of Besançon & CIC IT, 808, boulevard Fleming, 25033 Besançon, France
| | - Laurent Obert
- Department of Orthopedic, Trauma, Plastic, Reconstructive and Hand Surgery, EA Laboratoire de Nano médecine Imagerie Thérapeutique (LNIT), CHRU of Besançon & CIC IT, 808, boulevard Fleming, 25033 Besançon, France.
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Jonsson EÖ, Ekholm C, Hallgren HB, Nestorson J, Etzner M, Adolfsson L. Elbow hemiarthroplasty and total elbow arthroplasty provided a similar functional outcome for unreconstructable distal humeral fractures in patients aged 60 years or older: a multicenter randomized controlled trial. J Shoulder Elbow Surg 2024; 33:343-355. [PMID: 37778655 DOI: 10.1016/j.jse.2023.08.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Revised: 08/11/2023] [Accepted: 08/27/2023] [Indexed: 10/03/2023]
Abstract
BACKGROUND Semiconstrained total elbow arthroplasty (TEA) is an established treatment for elderly patients with distal humeral fractures not amenable to stable internal fixation (unreconstructable). In recent years, there has been increasing interest in elbow hemiarthroplasty (EHA), a treatment option which does not entail restrictions on weight-bearing as opposed to TEA. These 2 treatments have not been compared in a randomized controlled trial (RCT). The aim of this study was to compare the functional outcome of EHA and TEA for the treatment of unreconstructable distal humeral fractures in elderly patients. MATERIAL AND METHODS This was a multicenter randomized controlled trial (RCT). Patients were included between January 2011 and November 2019 at one of 3 participating hospitals. The inclusion criteria were an unreconstructable distal humeral fracture, age ≥60 years and independent living. The final follow-up took place after ≥2 years. The primary outcome measure was the Disabilities of the Arm, Shoulder, and Hand (DASH) score. Secondary outcome measures were the Mayo Elbow Performance Score (MEPS), the EQ-5D index, range of motion (flexion, extension, pronation, and supination) and grip strength. RESULTS Forty patients were randomized to TEA (n = 20) and EHA (n = 20). Five patients died before completing the final follow-up, leaving 18 EHA and 17 TEA patients for analysis. There were 31 women. The mean age was 74.0 (SD, 8.5) years in the EHA group and 76.9 (SD, 7.6) in the TEA group (P = .30). The mean DASH score was 21.6 points in the EHA group and 27.2 in the TEA group (P = .39), a difference of -5.6 points (95% CI: -18.6 to 7.5). There were no differences between treatment with EHA and TEA for the mean values of the MEPS (85.0 vs. 88.2, P = .59), EQ-5D index (0.92 vs. 0.86, P = .13), extension (29° vs. 29°, P = .98), flexion (126° vs. 136°, P = .05), arc of flexion-extension (97° vs. 107°, P = .25), supination (81° vs. 75°, P = .13), pronation (78° vs. 74°, P = .16) or grip strength (17.5 kg vs. 17.2 kg, P = .89). There were 6 adverse events in each treatment group. CONCLUSION In this RCT, both elbow hemiarthroplasty (EHA) and total elbow arthroplasty (TEA) resulted in a good and similar functional outcome for unreconstructable distal humeral fractures in elderly patients at a minimum of 2 years of follow-up.
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Affiliation(s)
- Eythor Ö Jonsson
- Department of Orthopaedics, Institute of Clinical Sciences, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Department of Orthopaedics, Sahlgrenska University Hospital, Mölndal, Sweden.
| | - Carl Ekholm
- Department of Orthopaedics, Institute of Clinical Sciences, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Department of Orthopaedics, Sahlgrenska University Hospital, Mölndal, Sweden
| | - Hanna Björnsson Hallgren
- Division of Orthopaedic Surgery, Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Jens Nestorson
- Division of Orthopaedic Surgery, Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | | | - Lars Adolfsson
- Division of Orthopaedic Surgery, Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden; Department of Orthopaedics, Örebro University, Örebro, Sweden
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Flanagan CD, Vallier HA. What's New in Orthopaedic Trauma. J Bone Joint Surg Am 2023; Publish Ahead of Print:00004623-990000000-00803. [PMID: 37192304 DOI: 10.2106/jbjs.23.00244] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/18/2023]
Affiliation(s)
- Christopher D Flanagan
- Department of Orthopaedic Surgery, Orthopaedic Trauma Service, Florida Orthopaedic Institute, University of South Florida, Tampa, Florida
| | - Heather A Vallier
- Department of Orthopaedic Surgery, Case Western Reserve University School of Medicine, Cleveland, Ohio
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Macken AA, Prkić A, van Oost I, Spekenbrink-Spooren A, The B, Eygendaal D. Implant survival of total elbow arthroplasty: analysis of 514 cases from the Dutch Arthroplasty Registry. Bone Jt Open 2023; 4:110-119. [PMID: 37051858 PMCID: PMC9999123 DOI: 10.1302/2633-1462.42.bjo-2022-0152.r1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/14/2023] Open
Abstract
The aim of this study is to report the implant survival and factors associated with revision of total elbow arthroplasty (TEA) using data from the Dutch national registry. All TEAs recorded in the Dutch national registry between 2014 and 2020 were included. The Kaplan-Meier method was used for survival analysis, and a logistic regression model was used to assess the factors associated with revision. A total of 514 TEAs were included, of which 35 were revised. The five-year implant survival was 91%. Male sex, a higher BMI, and previous surgery to the same elbow showed a statistically significant association with revision (p < 0.036). Of the 35 revised implants, ten (29%) underwent a second revision. This study reports a five-year implant survival of TEA of 91%. Patient factors associated with revision are defined and can be used to optimize informed consent and shared decision-making. There was a high rate of secondary revisions.
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Affiliation(s)
- Arno A Macken
- Department of Orthopaedics and Sports Medicine, Erasmus Medical Centre, Rotterdam, the Netherlands
- Department of Orthopaedic Surgery, Amphia Hospital, Breda, the Netherlands
| | - Ante Prkić
- Department of Orthopaedics and Sports Medicine, Erasmus Medical Centre, Rotterdam, the Netherlands
- Department of Orthopaedic Surgery, Amphia Hospital, Breda, the Netherlands
| | - Iris van Oost
- Foundation for Orthopaedic Research Care & Education (FORCE), Amphia Hospital, Breda, the Netherlands
| | | | - Bertram The
- Department of Orthopaedic Surgery, Amphia Hospital, Breda, the Netherlands
| | - Denise Eygendaal
- Department of Orthopaedics and Sports Medicine, Erasmus Medical Centre, Rotterdam, the Netherlands
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Stone A, Chan G, Sinclair L, Phadnis J. Elbow arthroplasty in trauma-current concepts review. J Orthop 2023; 35:126-133. [PMID: 36471696 PMCID: PMC9718957 DOI: 10.1016/j.jor.2022.11.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2022] [Revised: 11/17/2022] [Accepted: 11/21/2022] [Indexed: 11/24/2022] Open
Abstract
Introduction Despite advancements in modern locking plate technology, distal humerus fractures in the elderly remain difficult to treat. A subset of fractures in this osteoporotic bone includes multiple, shallow articular fragments that renders fixation unreliable, precluding early motion and acceptable functional outcomes. Arthroplasty, in the form of either Total Elbow Arthroplasty (TEA) or Distal Humeral Hemiarthroplasty (DHH) are alternative treatment options in this cohort and are being increasingly used. Methods This article reviews the use of TEA or DHH for acute distal humerus fracture, including patient selection, pre-operative planning, surgical approach, implant positioning, rehabilitation, outcomes and complications. Results Arthroplasties are being increasingly used for acute distal humerus fractures, however they introduce potential complications not seen with fixation. Due care must be employed to correct implant positioning which is a function of implant rotation, implant length and implant sizing. We describe a robust technique for epicondyle repair in DHH and unlinked TEA to avoid instability. Outcomes of DHH and TEA for acute distal humerus fracture are encouraging, however further long-term outcome and comparative data regarding arthroplasty is required. Conclusions Short to medium term outcomes demonstrate that both DHH and TEA are valuable options for selected patients, although attention to technique is required to minimise potential complications.
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Affiliation(s)
- A. Stone
- Shoulder & Elbow Post-CCT Fellow, University Hospitals Sussex NHS Foundation Trust, UK
| | - G. Chan
- Specialty Registrar, University Hospitals Sussex NHS Foundation Trust, Honorary Clinical Lecturer, Brighton & Sussex Medical School, UK
| | - L. Sinclair
- Clinical Librarian, University Hospitals Sussex NHS Foundation Trust, UK
| | - J. Phadnis
- Consultant Trauma & Orthopaedic Surgeon, University Hospitals Sussex NHS Foundation Trust, Honorary Clinical Reader, Brighton & Sussex Medical School, UK
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