ABSTRACT Purposes Open elbow arthrolysis (OEA) is a common method for treating post‐traumatic elbow stiffness, which may lead to severe bleeding when resecting heterotopic ossification (HO) and fibrous scar tissue. The purpose of this study is to compare the efficacy and safety among three different ways of using tranexamic acid (TXA) in reducing total blood loss and drainage volume in OEA. Patients and Methods This was a pilot, double‐blinded, randomized controlled trial involving a total of 60 patients of post‐traumatic elbow stiffness. Patients in the IV group (n = 20) received TXA intravenously, those in the intra‐articular group (n = 20) received TXA topically, and those in the combined group (n = 20) received TXA both intravenously and topically. The primary outcome measure was postoperative blood loss and drainage volume. The secondary outcome measures included elbow function, complications, and secondary surgery. Results The postoperative blood loss on the first and third days and the drainage volume on the first day was similar among the three groups (p > 0.05). The total postoperative drainage volume in the IV group was significantly higher than in the combined and intra‐articular group, with no significant difference observed between the combined and intra‐articular group (534.5 mL vs. 378.0 mL vs. 356.5 mL; p < 0.05). There were no significant differences in elbow flexion‐extension and rotation range of motion (ROM) and the Visual Analogue Scale (VAS) and Mayo Elbow Performance Score (MEPS) scores at the follow‐up (p > 0.05). Conclusion Intravenous, topical, or combined TXA administration showed no significant difference in reducing postoperative blood loss after OEA. However, both combined and topical TXA significantly reduced postoperative drainage volume compared to intravenous administration. Level of Evidence Therapeutic Level I.

ABSTRACT Objective Total elbow arthroplasty (TEA) is a commonly performed surgical technique for the management of elbow disorders. The Coonrad–Morrey (CM) prosthesis is the most commonly used prosthesis in TEA. The study from Chinese cohorts remains limited, particularly regarding differences between patients with and without RA. Therefore, the purpose of this study was to evaluate the medium‐ to long‐term clinical outcomes using the CM prosthesis in a Chinese cohort, and to compare clinical outcomes between patients with and without RA. Methods A retrospective cohort study was conducted involving 74 patients (75 elbows) who underwent TEA using CM prostheses between March 2015 and February 2019. All patients were followed up for a minimum of 5 years (mean follow‐up: 83.4 months) and were assessed for elbow range of motion (ROM), Mayo Elbow Performance Score (MEPS), Quick‐Disabilities of the Arm, Shoulder and Hand (Quick‐DASH) score, pain, complications, and revision surgeries. Kaplan–Meier survivorship analysis was conducted. The differences between patients with and without rheumatoid arthritis (RA) were compared in the subgroup analysis. Results At the final follow‐up, the average flexion‐extension ROM was 105.3° ± 33.6°. The mean MEPS was 85.5 ± 14.3, with a good‐to‐excellent rate of 81.3%. The mean Quick‐DASH score was 30.8 ± 18.1. A total of 26 complications (26/75, 34.7%) were observed in 22 elbows (22/75, 29.3%). Nine elbows (9/75, 12.0%) underwent reoperation. The revision‐free rates were 98.7% at 1 year, 94.7% at 2 years, and 90.7% at 5 years. There were no significant differences in elbow function or revision‐free rate between patients with and without RA. Conclusion TEA using CM prosthesis in Chinese patients can achieve favorable functional outcomes regardless of RA status, with a high 5‐year prosthesis survival rate. However, a larger sample size and a longer follow‐up period are still required.

BACKGROUND:The development of heterotopic ossification (HO) is a common yet debilitating complication after elbow injuries and related surgical procedures. We intend to evaluate the regional distribution features of HO around the elbow joint in patients with post-traumatic elbow stiffness (PTES), and explore the independent risk factors for HO development in different regions. MATERIALS AND METHODS:Patients who presented with PTES attributed to HO from January 2018 to December 2019 were consecutively enrolled. The pattern of HO distribution was analyzed using Mimics software (Mimics 21.0, Materialise NV, Leuven, Belgium) and classified into 8 distinct regions: anteromedial (AM), anterolateral (AL), posteromedial (PM), posterolateral (PL), posterior (P), medial (M), lateral (L), and proximal radioulnar (PRU) regions. The initial injuries were further categorized based on the presence or absence of 5 fundamental injury types: distal humerus fracture, olecranon fracture, radial head fracture, coronoid fracture, and elbow dislocation. With the occurrence of HO in a specific region as the dependent variable and the initial injury patterns and baseline clinical data as independent variables, logistic regression analyses were conducted to identify the associated independent risk factors for HO development in different regions. RESULTS:A total of 170 patients were included. We identified PM HO in 166 patients (97.6%), P HO in 135 patients (79.4%), PL HO in 128 patients (75.3%), AM HO in 92 patients (54.1%), AL HO in 57 patients (33.5%), PRU HO in 32 patients (18.2%), M HO in 12 patients (7.1%), and L HO in 11 patients (6.5%). The results of logistic regression analyses: (1) AM HO: time interval between the initial injury and this admission ≥1 year (odds ratio [OR] = 2.338), the presence of elbow dislocation (OR = 3.193) and olecranon fracture (OR = 0.305); (2) AL HO: high energy trauma (OR = 2.073) and the presence of olecranon fracture (OR = 0.367); (3) P HO: immobilization for more than 2 weeks after the initial injury or subsequent surgical procedures (OR = 2.466); (4) PL HO: the presence of radial head fracture (OR = 2.805); (5) PRU HO: the presence of radial head fracture (OR = 8.186); (6) PM + P + PL HO: the presence of radial head fracture (OR = 2.235). CONCLUSION:The regional distribution of HO in patients with PTES exhibits distinct features, and PM HO is observed in almost all patients. The type of initial injury and its subsequent management are closely related to the occurrence and development of HO in different regions. Our findings provide valuable insights and serve as a useful reference for the clinical assessment of HO in patients with PTES.

ABSTRACTObjectivePlate fixation is the preferred method for treating forearm shaft fractures. However, it remains controversial regarding the necessity of implant removal after bone union. This review aims to assess refracture risk after plate removal.MethodsWe searched various data sources, including PubMed, Embase, Web of Science, and Cochrane Library. A total of 6749 papers were identified, of which 23 studies were eligible for final quantitative syntheses. Subgroup analyses and sensitivity analyses were conducted to reduce heterogeneity and make the results more reliable.ResultsThe total risk difference (RD) was 0.06 (0.04–0.09), indicating that the difference was significant. In the “Reasons for Removal” subgroup analysis, the RD of the “No Symptom” subgroup was 0.07 (95% CI = 0.04–0.11), while the RD of the “Symptoms” subgroup was 0.04 (95% CI = −0.02 to 0.10). In the “Plate Type” subgroup analysis, the RD of the “LCP” subgroup was 0.07 (95% CI = 0.02–0.13), while the RD of the “DCP” subgroup was 0.07 (95% CI = 0.01–0.13). After omitting each study one by one, the RDs were all significant.ConclusionsPlate retention is significantly associated with a lower rate of refracture than plate removal. Consequently, it is not recommended to remove implants, especially for patients without implant‐related symptoms, but more reliable evidence is still needed.Trial RegistrationThe review was registered on PROSPERO and the registration ID is CRD42023424743, and a protocol was not prepared

Objective:To investigate the efficacy of TiRobot navigation for hinged external fixation in elbow arthrolysis.Methods:The 11 patients were retrospectively analyzed who had been treated by elbow arthrolysis at Department of Traumatology and Orthopedics, Beijing Jishuitan Hospital using TiRobot navigation for hinged external fixation. There were 9 males and 2 females with a mean age of 39.3 years (from 21 to 66 years). Their elbow range of motion (ROM) was compared between preoperation and the final follow-up. Their visual analogue scale (VAS) and Mayo elbow performance score (MEPS) and complications were documented at the final follow-up.Results:The rotation axis of the elbow joint was positioned with the aid of intraoperative robot navigation in 11 patients.The deviation of entry point averaged 0.21 mm (from 0.05 to 0.41 mm) and the deviation of exit point 0.23 mm (from 0.06 to 0.38 mm). The follow-up time for the 11 patients averaged 25.8 months (from 16 to 32 months). Their elbow flexion and extension was 133.0° (134.9°, 138.7°) and rotation 164.6° ±17.5° at the final follow-up, significantly improved compared with their preoperative values [0.8°(0°, 33.7°) and 122.9°±49.0°] ( P<0.05). Their VAS averaged 0.2 (from 0 to 1) and MEPS 96.8 (from 85 to 100) at the final follow-up, giving 9 excellent and 2 good cases. There was no case of radial nerve injury, pin instability, pin breakage, pin infection or peri-pin fracture. Conclusion:When TiRobot navigation is used for hinged external fixation in elbow arthrolysis, the axis of rotation can be accurately located, leading to satisfactory functional outcomes for the patients.

Objective To compare the clinical outcomes between young and elderly patients with humeral intercondylar fracture treated by open reduction and internal fixation (ORIF) with either parallel or orthogonal double-plate.Methods From January 2013 to December 2017,54 patients with humeral intercondylar fracture were treated at Department of Orthopedic Trauma,Jishuitan Hospital by ORIF with anatomical locking compression plate (LCP) (either parallel or orthogonal double-plate configuration).According to their age,the patients were divided into a young group (from 18 to 30 years old) of 29 cases with an age of 25.5 ± 3.6 years and an elderly group (≥60 years old) of 25 cases with an age of 67.1 ± 5.8 years.The 2 groups were compared in terms of perioperative data,ranges of motion (flextion,extension and rotation),numeric rating scale for pain (NRS),Mayo Elbow Performance Score (MEPS) and quick Disabilities of the Arm,Shoulder and Hand (Quick-DASH) at the last follow-up,complications and secondary surgery.Results The 2 groups were comparable because there were no significant differences in the preoperative general data except in injury energy,combined injury and gender between them (P ＞ 0.05).The young group had significantly more cases of high-energy injury and combined injuries than the elderly group (P ＜ 0.05).All patients were followed up for 33.6 ± 15.0 months (from 12 to 63 months).The total blood loss in the elderly group (643.9 ± 298.7 mL)was significantly less than that in the young group (953.9 ± 554.6 mL) (P ＜ 0.05).At the last follow-up,there were no significant differences between the 2 groups in ranges of motion,NRS or MEPS (P ＞ 0.05),but the elderly group had significantly higher Quick-DASH scores (13.9 ± 14.4 points) than the young group (5.7 ± 8.9 points) (P ＜ 0.05).There was no significant difference in postoperative elbow stiffness or postoperative ulnar nerve symptoms betwee the 2 groups (P ＞ 0.05),but the rate of secondary surgery in the young group (37.9％,11/29) was significantly higher than that in the elderly group (4.0％,1/25)(P ＜ 0.05).Conclusions In the treatment of humeral intercondylar fractures,ORIF with LCP (either parallel or orthogonal double-plate configuration) can lead to similarly safe and effective clinical outcomes for both young and elderly patients.

Objective To explore the risk factors for elbow stiffness after open reduction and internal fixation (ORIF) for intercondylar fractures of the distal humerus.Methods From January 2013 to May 2017,159 patients underwent ORIF for intercondylar fractures of the distal humerus with dual plating.They were 83 males and 76 females with a mean age of 42.6 years (from 14 to 79 years).They were divided into 2 groups according to their range of motion at the latest follow-up and the secondary elbow arthrolysis they had undergone or not.The stiffness group had extension-flexion and/or pronation-supination ＜ 100° and secondary elbow arthrolysis while the non-stiffness group had extension-flexion and pronation-supination ≥ 100° and no secondary elbow arthrolysis.Age,gender,fracture side,mechanism of injury,AO fracture classification,open/close fracture,additional fracture,preoperative nerve injury,time from injury to surgery,surgical approach,configuration of plating,medication for anti-heterotopic ossification and implant removal were analyzed as risk factors for elbow stiffness using Logistic regression analysis.Results The mean follow-up period for this cohort was 32.0 months (from 10 to 63 months).The latest follow-up showed fracture union in all the patients.The stiffness group had 38 patients and the non-stiffness group 121.Multivariate regression analysis showed that high energy trauma (OR =3.141,95％ CI 1.396 ～ 7.070,P =0.006) and time from injury to surgery ＞ one week (OR =2.596,95％ CI 1.123 ～ 6.000,P =0.026) were independent risk factors for elbow stiffness after ORIF for intercondylar fractures of the distal humerus.Conclusion The patients with high energy trauma and time from injury to surgery ＞ one week should be treated with caution and special care in clinical practice because the 2 factors are closely related to posttraumatic elbow stiffness after ORIF for intercondylar fracture of the distal humerus.

Objective To compare the function outcome and complication of emergency operation and staged operation with enhanced recovery after surgery (ERAS) for Gustilo type Ⅰ &Ⅱ open distal humeral fractures.Methods Retrospective analysis of 22 patients with Gustilo type Ⅰ & Ⅱ open distal humeral fractures who were treated in Department of Orthopeaedic Trauma,Beijing Jishuitan Hospital from July 2013 to June 2017 was conducted.There were 18 males and 4 females,aged (42.5± 13.0) years,with an age range of 14-65 years.According to different treatment methods,all patients were divided into two groups:emergency operation group (n =6),direct internal fixation after emergency debridement;staged operation group (n =16),emergency debridement and suture,performed the second period of fixed treatment after the soft tissue condition to improve.Patient's waiting time from emergency to surgery,fasting time,surgery time,intra-op blood loss,hospital stay time,elbow range of motion,Mayo elbow performance score (MEPS),secondary surgery rate and complication at the last outpatient visit at 1,3,6,12 and June 2018,post-operatively were recorded.The measurement data of normal distribution and homogeneity of variance were expressed as mean ± standard deviation (Mean ± SD),and the independent sample t test was used for comparison between the two groups;the measurement data not conforming to the normal distribution were expressed as [M(P25,P75)].The rank sum test was used for comparison between the two groups.Comparison of count data between the two groups was performed by x2 test or Fisher exact probability method.Results The time from emergency to surgery of emergency group and staged group was [5.1(4.5,7.3) h],[160.0(102.9,221.2) h],respectively,P ＜0.001.Fasting time was [5.1(4.5,7.3) h],[12.1(9.7,13.2)h],P＜0.001.Hospital stay time was [5.5(5.0,6.5) d],[11.5(9.0,13.0) d],P=0.001.These differences were significant.Surgery time was [3.0 (2.0,3.6) h,2.6 (2.0,3.4) h].Intra-op blood loss was [75.0(25.0,225.0)ml,100.0(100.0,200.0)ml].Elbow range of motion was [155.0(141.3,155.0)°,155.0 (143.8,155.0) °].MEPS was [95.0 (83.8,100.0) scores,90.0 (80.0,100.0) scores].Secondary surgery rate was(33.3％ vs.31.2％).Complication rate was (83.3％ vs.68.7％).These differences were not significant (P ＞0.05).Conclusions ERAS's quick emergency surgery for Gustilo type Ⅰ&Ⅱ open distal humeral fractures significantly reduces the waiting time from emergency to surgery,fasting time and hospital stay time.Function outcome is comparable to the staged group.Therefore,emergency surgical procedures are recommended for patients with Gustilo typeⅠ&Ⅱ open distal humeral fractures.

Objective To compare the clinical outcomes between emergency and delayed definitive management of open distal humeral fractures of Gustilo types ofⅠ& Ⅱ. Methods A retrospective study was conducted of the 24 patients who had been treated at Department of Orthopaedic Trauma, Beiiing Jishuitan Hospital from January 2013 to June 2017 for open distal humeral fractures of Gustilo types Ⅰ& Ⅱ. Of them, 8 received irrigation, debridement and definitive open reduction and internal fixation in the emergency oper-ation room; the other 16 received only irrigation, debridement and wound suture for the emergency manage-ment and their definitive open reduction and internal fixation was delayed until recovery of their soft tissues. The 2 groups were compared in terms of elbow range of motion, visual analogue scale ( VAS ) , Mayo Elbow Performance Score ( MEPS ) , Quick Disabilities of the Arm, Shoulder and Hand, ( QuickDASH ) , complica-tions and reoperations at the last follow-up. Results All the patients were followed up for more than one year; the average follow-up time was 40.5 months for the emergency treatment group and 30.9 months for the delayed treatment group. There were no significant differences between the 2 groups regarding elbow range of motion, VAS [ 0 ( 0, 1.0 ) versus 0 ( 0, 2.0 ) ] , MEPS [ 95.00 ( 85.00, 100 ) versus 90.00 ( 80.00, 98.75 ) ] , or QuickDASH [ 7.96 ( 2.84, 14.77 ) versus 3.41 ( 0, 13.64 ) ] ( P ＞ 0.05 ). The 2 groups also had similar rates of complications and reoperations. Conclusions Both emergency and staged definitive management can lead to satisfactory clinical outcomes for open distal humeral fractures of Gustilo types ofⅠ&Ⅱ. A proper treatment method should depend on the experience of surgeons concerned and the local and general conditions of the patient.