Aims: Reliable assessment of joint stiffness is essential for studying arthrofibrosis in preclinical animal models. This study presents a new dedicated biomechanics device for measuring knee stiffness in mouse, rat, and rabbit models of arthrofibrosis, with the aim of validating its performance and comparing it to a previously validated device. Methods: The new system integrates a torque load cell, stepper motor, and absolute encoder in a through-hole, unified configuration for precise continuous torque-angle measurement, with custom limb brackets ensuring species-specific alignment at the joint’s centre of rotation. To validate this device and compare it to a previously validated device, arthrofibrosis was induced using established models of extra-articular immobilization in mice and intra-articular violation with immobilization in rats and rabbits, followed by defined remobilization periods. Torque-angle curves were recorded ex vivo across species-specific torque ranges, and measurement variability between the new and a previous validated device was statistically compared using Brown-Forsythe’s test. Results: The onset of hyperextension in contralateral limbs occurred at mean angles of 152.4° (mice), 154.4° (rats), and 152.8° (rabbits), and at maximum torque, mean flexion angles were 79.2°, 87.3°, and 140.5°, respectively. No significant differences in measurement variability were observed between devices across all species. Conclusion: These findings demonstrate that our new device provides reproducible torque-angle data while maintaining the statistical robustness of the previous device and offering improved mechanical design and operational standardization. By enabling standardized, cross-species joint stiffness quantification, this platform improves cross-study comparability and strengthens the translational reliability of preclinical arthrofibrosis research. Cite this article: Bone Joint Res 2026;15(6):716–725.

BACKGROUND:Failure of radial head implants secondary to loosening, painful capitellar wear, and other reasons is not uncommon. When radial head implants fail, the relative indications for implanting a new radial head implant vs. implant removal with or without soft-tissue interposition remain unclear. Removal theoretically reduces the risk of radiocapitellar pain; however, little is known about the outcomes following removal of failed radial head replacements. The purpose of this study was to evaluate the outcomes, complications, and rates of proximal radioulnar impingement pain following removal of failed radial head implants. METHODS:Our institution's Total Joint Registry database was queried to identify all elbows that had undergone removal of a failed radial head arthroplasty without implantation of a new prosthesis. Patients with radiocapitellar or total elbow arthroplasty at the index surgery were excluded. Thirty-seven elbows met inclusion criteria, but 12 had less than 2 years of follow-up; the remaining 25 elbows form the basis for this study. Demographics, complications, reoperations, pre-operative and post-operative range of motion, development of symptomatic proximal radioulnar impingement, and patient-reported outcome measures were collected. The mean age at the time of resection was 50 years (range, 16-75 years). The mean follow-up was 7 years (range, 2-15 years). RESULTS:The mean time to removal following implantation was 31 months (range, 2-135 months). Compared to how they felt before surgery, 21/25 patients gave their elbows a Summary Outcome Determination score of "Improved" or better, while 4/25 rated their elbows as "Worse". Implants removed included 21 press-fit, 3 loose-fit, and 1 cemented radial head implant. The most common indication for removal was painful loosening (17/25, 68%), followed by head/neck uncoupling (3/25, 12%), overstuffing (2/25, 8%), maltracking (2/25, 8%), and infection (1/25, 4%). All the patients with loose implants (n = 17) reported radial-sided proximal forearm pain before resection, which had improved at the final follow-up in 76% (13/17), was unchanged in 6% (1/17), and was not recorded in 3 patients. The mean flexion-extension and pronation-supination arcs following resection did not significantly change. CONCLUSION:Implant removal is a viable treatment strategy for failed radial head arthroplasty with good outcomes at an average 7-year follow-up. In our study, 76% of patients with loose painful implants reported improvement in proximal radial-sided forearm pain. However, patients should be counseled about the risk of developing symptomatic proximal radioulnar impingement following implant removal and the occasional progression of osteoarthritis requiring further surgery.

BACKGROUND:Olecranon osteotomy is a common surgical exposure technique used for internal fixation of distal humerus fractures. Unfortunately, retained ulnar hardware and potential osteotomy complications (malunion, nonunion, or extensor mechanism insufficiency) may negatively impact subsequent total elbow arthroplasty (TEA) if needed. Although TEA is a reasonable option for management of failed distal humerus internal fixation or posttraumatic arthritis, little is known about how prior olecranon osteotomy influences TEA outcomes. This study aimed to identify operative considerations, evaluate outcomes, and assess implant survivorship following TEA in patients with a history of prior olecranon osteotomy. METHODS:Adult patients who underwent primary TEA between 1990 and 2024 with a history of distal humerus open reduction internal fixation with olecranon osteotomy and >2 years of clinical follow-up were identified using our institutional Total Joint Registry Database. Medical records were reviewed to collect demographic information, surgical indications, complications, reoperations, and revisions. Implant survivorship free of revision or resection for any reason, for infection, and for mechanical failure, or loosening was assessed using Kaplan-Meier analyses. Functional outcomes including range of motion and the Mayo Elbow Performance Score were assessed at final follow-up. RESULTS:Twenty-seven patients (mean age 62 years [range 30-86], 70% female) with a mean follow-up of 6 years (range 2-19) were included. The index distal humerus fracture was classified as Arbeitsgemeinschaft für Osteosynthesefragen-Orthopaedic Trauma Association type C in 22 (81%) cases, and the prior olecranon osteotomy had united in most (89%) elbows prior to TEA. Indications for TEA included nonunion (n = 14), post-traumatic arthritis (n = 7), failed fixation (n = 3), malunion (n = 1), refracture (n = 1), and ankylosis (n = 1). Overall rates of complications, nonrevision reoperations, and revision TEA were 37%, 11%, and 26%, respectively. Aseptic loosening (n = 3), infection (n = 2), and component failure (n = 2) accounted for all revisions. Ten-year survivorship free of revision or resection for any reason was 76%, for infection was 89%, and for mechanical failure or loosening was 85%. At final follow-up, patients achieved satisfactory flexion (140°), extension (31°), supination (60°), and pronation (67°), as well as a mean Mayo Elbow Performance Score of 78 ± 17, indicating good elbow function. CONCLUSIONS:TEA following prior olecranon osteotomy was associated with a 76% rate of survivorship free of revision or resection for any reason at 10 years. Aseptic loosening, infection, and component failure accounted for all revision indications. Despite slightly inferior outcomes compared to those following primary TEA, underscoring the increased complexity of the procedure following prior olecranon osteotomy, these findings suggest TEA can reliably restore function and achieve acceptable implant survivorship in this context.

BACKGROUND:In the United States, more than 50% of total elbow arthroplasties (TEAs) are performed for acute trauma or post-traumatic sequelae. Outcomes of TEA performed for distal humerus fracture or nonunion have been well-documented; however, less is known regarding outcomes of TEA for sequelae of complex proximal ulna or radius fractures. This study aimed to (1) identify operative considerations and outcomes and (2) determine TEA survivorship when performed for post-traumatic sequalae after proximal ulna or radius fracture or fracture-dislocation. MATERIALS AND METHODS:Patients who underwent TEA for sequelae of proximal ulna or radius fractures between 1990 and 2024 at a single institution were identified using a total joint registry. Forty elbows (mean age 59 ± 10 years, 58% female) with a mean follow-up of 9 ± 6 years were included. Post-traumatic arthritis after transolecranon fracture [n = 13], Monteggia-variant [n = 9], transulnar basal coronoid fracture [n = 8], radial head fracture [n = 2] accounted for 80% of cases. Complex elbow instability (terrible triad [n = 5], varus posteromedial rotatory instability [n = 3]) comprised the remaining 20%. The mean number of prior operations was 3 ± 2, and 75% of elbows had a history of radial head resection (n = 18) or a poorly tracking radiocapitellar joint (n = 12). Forty percent had preoperative ulnar nerve symptoms. Implant survival free of revision or resection was estimated using the Kaplan-Meier method. RESULTS:When successful, TEA provided adequate pain relief and good functional restoration. However, the overall revision rate was 28%. Operative times were long (158 ± 74 minutes) and difficulty with ulnar preparation was common (35%). Prior hardware was retained in 23% of elbows, and 10% required ulnar component modification. The ulnar nerve had not been previously decompressed or transposed in 63% of elbows; most were then decompressed (n = 5) or transposed (n = 17) at the time of TEA. The most common postoperative complications were neurologic complications (20%), aseptic loosening (18%), and deep infection (13%). Ulnar sided aseptic loosening (n = 4) and infection (n = 4) accounted for 72% of revisions. At 10 years, implant survival free from revision or resection for infection, mechanical failure or radiographic loosening, and for any reason were 88%, 83%, and 73%, respectively. DISCUSSION:TEA for salvage of post-traumatic sequelae after proximal ulna or radius fracture or fracture dislocation demonstrated 73% survival free of revision at 10 years, comparable to TEA for distal humerus fracture sequelae. Surgeons performing this procedure should be prepared for potential technical difficulties in the setting of prior surgery, retained hardware, malunion/nonunion, pre-existing ulnar neuropathy, or radial head absence.

Background:Reverse shoulder arthroplasty is considered for displaced geriatric proximal humerus fractures (PHFs). This study compared clinical and radiographic outcomes of "Grammont-style" medialized and contemporary lateralized implants, hypothesizing that contemporary implants yield greater range of motion and tuberosity healing. Methods:This retrospective single-institution case series reviewed 74 shoulders (74 patients) treated for acute PHFs from 2008-2020. Patients received a medialized reverse shoulder arthroplasty (M-rTSA) (Delta Xtend; n = 31) or lateralized reverse shoulder arthroplasty (L-rTSA) prosthesis (ReUnion RFX; n = 43). Outcomes included visual analog scale pain scores, American Shoulder and Elbow Surgeons scores, and range of motion. Tuberosity healing was classified radiographically as anatomic, malunion, nonunion, partial migration, or resorption. Results:The mean follow-up was 34.2 and 19.9 months for the M-rTSA and L-rTSA groups, respectively, with no significant demographic differences. L-rTSA shoulders demonstrated greater external rotation (45° vs. 31°; P = .02). Healing rates of 48% and 86% were observed for M-rTSA and L-rTSA shoulders, respectively. There were no significant differences in forward elevation, complications, or American Shoulder and Elbow Surgeons or pain scores. Anatomic tuberosity healing was associated with better rotation and pain scores. Conclusion:Lateralized implants were associated with improved tuberosity healing and external rotation compared to Grammont-style implants for acute PHFs. Tuberosity healing was correlated with better clinical outcomes.

Total elbow arthroplasty (TEA) has shown favourable outcomes in the management of severely comminuted distal humeral fractures in low-demand elderly patients, leading to its increased use in recent years. Less is known about the outcomes of TEA when used for the failure of either internal fixation or conservative management, particularly whether not performing TEA acutely influences the options for further management if fixation fails. This systematic review aimed to assess the clinical and functional outcomes following TEA when used for the post-traumatic sequelae of a distal humeral fracture, and to compare these outcomes with those in patients with a distal humeral fracture who undergo TEA acutely. MEDLINE, Embase, Cochrane Central Register of Controlled Trials, and Scopus databases were searched from January 2000 to September 2024 for studies reporting complications, reoperations, the range of motion of the elbow, or functional outcomes following the use of TEA in the management of the post-traumatic sequelae of distal humeral fractures, including those due to failed fixation, nonunion, and post-traumatic arthritis. Demographic and clinical data were collected, descriptive statistics were summarized, and meta-analyses were undertaken to compare the outcomes between salvage and acute TEA. A total of 16 studies were included, with a total of 380 patients who underwent salvage TEA and 251 who underwent TEA as the initial management. Salvage TEA was associated with a significantly higher overall risk of complications (odds ratio (OR) 2.5 (95% CI 1.0 to 5.9)), though the rate of reoperations did not differ from those who underwent TEA acutely (OR 1.4 (95% CI 0.8 to 2.4)). Pooled analyses revealed a similar postoperative range of flexion (mean difference (MD) -2.4° (95% CI -9.1 to 4.3)) and extension of the elbow (MD 1.1° (95% CI -2.3 to 4.5)) and pronation (MD 0.0° (95% CI -1.1 to 1.1)) and supination (MD -0.0° (95% CI -1.0 to 0.9)) of the forearm. However, salvage TEA showed significantly inferior functional outcomes, as assessed by the Mayo Elbow Performance Score (MD 9.7 (95% CI -18.8 to -0.6)). These findings indicate that salvage TEA represents a viable option for the management of post-traumatic sequelae following the teatment of a distal humeral fracture, although patients who underwent salvage TEA had a significantly increased rate of complications and significantly inferior functional outcomes compared with those who underwent TEA acutely. Cite this article: Bone Joint J 2026;108-B(1):21–29.

Aims:Total elbow arthroplasty (TEA) has shown favourable outcomes in the management of severely comminuted distal humeral fractures in low-demand elderly patients, leading to its increased use in recent years. Less is known about the outcomes of TEA when used for the failure of either internal fixation or conservative management, particularly whether not performing TEA acutely influences the options for further management if fixation fails. This systematic review aimed to assess the clinical and functional outcomes following TEA when used for the post-traumatic sequelae of a distal humeral fracture, and to compare these outcomes with those in patients with a distal humeral fracture who undergo TEA acutely. Methods:MEDLINE, Embase, Cochrane Central Register of Controlled Trials, and Scopus databases were searched from January 2000 to September 2024 for studies reporting complications, reoperations, the range of motion of the elbow, or functional outcomes following the use of TEA in the management of the post-traumatic sequelae of distal humeral fractures, including those due to failed fixation, nonunion, and post-traumatic arthritis. Demographic and clinical data were collected, descriptive statistics were summarized, and meta-analyses were undertaken to compare the outcomes between salvage and acute TEA. Results:A total of 16 studies were included, with a total of 380 patients who underwent salvage TEA and 251 who underwent TEA as the initial management. Salvage TEA was associated with a significantly higher overall risk of complications (odds ratio (OR) 2.5 (95% CI 1.0 to 5.9)), though the rate of reoperations did not differ from those who underwent TEA acutely (OR 1.4 (95% CI 0.8 to 2.4)). Pooled analyses revealed a similar postoperative range of flexion (mean difference (MD) -2.4° (95% CI -9.1 to 4.3)) and extension of the elbow (MD 1.1° (95% CI -2.3 to 4.5)) and pronation (MD 0.0° (95% CI -1.1 to 1.1)) and supination (MD -0.0° (95% CI -1.0 to 0.9)) of the forearm. However, salvage TEA showed significantly inferior functional outcomes, as assessed by the Mayo Elbow Performance Score (MD 9.7 (95% CI -18.8 to -0.6)). Conclusion:These findings indicate that salvage TEA represents a viable option for the management of post-traumatic sequelae following the teatment of a distal humeral fracture, although patients who underwent salvage TEA had a significantly increased rate of complications and significantly inferior functional outcomes compared with those who underwent TEA acutely.

Background: Periprosthetic joint infection after total elbow arthroplasty (TEA) is associated with substantial morbidity and the need for revision surgery. The aim of this systematic review and meta-analysis was to summarize studies on 2-stage exchange and débridement, antibiotics, and implant retention (DAIR) to determine differences in rates of recurrent infection, risk factors for recurrent infection, noninfectious complications, and functional outcomes. Methods: A systematic search was conducted of the MEDLINE, EMBASE, Cochrane, Scopus, and Web of Science databases in March 2024 to identify studies on infected TEAs treated with either 2-stage revision surgery or DAIR. Exclusion criteria included duplicate publications, review articles, and studies with a mean follow-up of less than 1 year. Fourteen studies were included in the final analysis. Data abstracted included demographics, treatment modalities, bacterial speciation, rates of recurrent infection, and functional outcomes (range of motion data and Mayo Elbow Performance Score. Results: Two hundred ninety infected TEAs were included across all 14 studies, 131 treated with DAIR and 159 treated with 2-stage exchange. The overall pooled random-effects rate of recurrent infection was 34% (95% confidence interval: 21%-47%). The rate of recurrent infection was significantly lower following 2-stage exchange compared to DAIR (18% vs. 51%, P = .004). The overall pooled rate of noninfectious complications was 34% (95% confidence interval: 22%-46%). With the numbers available, the rate of noninfectious complications between 2-stage exchange and DAIR was smaller for 2-stage exchange, although the difference did not achieve statistical significance (27% vs. 43%, P = .244). Patients infected with coagulase-negative Staphylococci experienced a higher rate of recurrent infection than those infected with other species (44% vs. 14%), although again this difference did not reach statistical significance (P = .060). In patients undergoing 2-stage exchange, incomplete cement removal was associated with a significantly higher rate of recurrent infection than complete removal (56% vs. 19%, P = .001), but intentional retention of 1 component was not significantly associated with a higher rate of recurrent infection (37% vs. 20%, P = .315). Discussion: The results of this systematic review and meta-analysis of the outcomes associated with the treatment of TEA periprosthetic joint infection with either DAIR or 2-stage reimplantation, 2-stage exchange was associated with a lower rate of recurrent infection. Incomplete cement removal was a risk factor for recurrent infection. Although it did not reach significance, it appeared that infection with coagulase-negative Staphylococci could also be a risk factor for failure of infection eradication.

BACKGROUND:Native and periprosthetic joint infections are devastating conditions fraught with patient morbidity and mortality. Aseptic and septic joints are often debrided and irrigated to decrease bacterial loads when preventing or treating infection. However, the effect of clinically used irrigation solutions on the native cellular components of the synovial joint is unknown. METHODS:Patients consented, and their suprapatellar knee tissue was surgically excised for fibroblast isolation. Cultured knee fibroblasts were treated with normal saline for three minutes or one of the following experimental solutions: acetic acid, chlorhexidine-gluconate, Dakin's solution, hydrogen peroxide, or povidone-iodine. The exposure time for the antiseptic solutions was one and three minutes. At 24 hours after irrigation treatment, metabolic activity was measured via MTS [3-(4,5-dimethylthiazol-2-yl)-5-(3-carboxymethoxyphenyl)-2-(4-sulfophenyl)-2H-tetrazolium] activity assay, and deoxyribonucleic acid content was assessed by Hoechst staining as a surrogate for cell number. Phase-contrast imaging elucidated proliferation potential, progressive cell loss, and cell morphology over a 5-day period. All experiments were repeated in triplicate. RESULTS:All experimental antiseptic irrigation solutions, regardless of application time, caused a significant reduction in metabolic activity and DNA content, indicating extensive cell death. Phase-contrast imaging showed halted cellular proliferation, progressive cell loss, and distinct changes in cellular morphology, indicating decreased cellular viability and progressive cell death. CONCLUSIONS:All antiseptic irrigation solutions investigated in this study were severely cytotoxic to human knee fibroblasts regardless of their chemical composition. The concentrations of these solutions are commonly used in orthopaedic surgery. Although these solutions have high bactericidal properties, it may be beneficial to use them in combination at lower doses to retain their effect on bacteria while remaining benign to native synovial cells.

Aims: Arthrofibrosis affects a notable percentage of patients after total knee arthroplasty (TKA). Elevated serum mast cell tryptase (SMCT) levels have been linked to fibrosis, suggesting that SMCT could serve as a biomarker for arthrofibrosis. As such, the aims of this study were to assess SMCT levels in TKA patients, and their possible association with arthrofibrosis and clinical outcomes in a prospective clinical trial. Methods: We conducted a prospective study involving 219 patients undergoing primary TKA at a single academic medical centre between January 2018 and December 2022. SMCT levels were measured preoperatively, immediately postoperatively, and at six weeks, three months, and one year postoperatively. Secondary outcomes included revision rates, complications, and Knee Society Scores (KSSs). Allergic and inflammatory conditions were assessed for their influence on SMCT levels. Results: At one year postoperatively, eight patients had developed arthrofibrosis (4%), and three (1.5%) had undergone manipulation under anaesthesia. The mean preoperative SMCT level was 5.6 µg/L (SD 3.4), which decreased significantly to 4.1 µg/L (SD 2.7) immediately postoperatively (p < 0.001). At six weeks the mean SMCT level was 6.4 µg/l (SD 4.1), and was 6.1 µg/l at both three months (SD 4.1) and one year (SD 4.0). Elevated preoperative SMCT levels were not significantly associated with the risk of arthrofibrosis development (OR 3; p = 0.370), nor were immediate postoperative levels (OR 2; p = 0.754) or those at six weeks (OR 1; p = 0.989). Of note, elevated SMCT levels at three months (OR 5; 95% CI 0.4 to 64; p = 0.191) and one year (OR 13; 95% CI 1 to 232; p = 0.077) trended toward an increased risk of arthrofibrosis development, without reaching significance. Conclusion: In patients undergoing TKA, with the numbers included in this study, there was no significant difference in SMCT levels between patients who did and did not develop arthrofibrosis at any timepoint. However, there was a trend towards elevated SMCT levels at three months and one year in those who developed arthrofibrosis, which merits further study. Cite this article: Bone Joint Res 2025;14(11):1045–1052.

This study describes the development of a novel, affordable, and accessible simulation model designed to teach arthroscopic rotator cuff repair to orthopedic surgery trainees. The model was created using commercially available, cost-effective products to provide a portable representation of an in vivo intraoperative rotator cuff repair. The technique was developed at a major academic tertiary care center. The rotator cuff repair simulator was designed with clear learning objectives to help train orthopedic residents in shoulder arthroscopic skills, including proper anchor placement, bimanual instrument handling, and knot tying. Key components of the design include a tactile surface for anchor placement, tendon attachment with adjustable tension, and a simulated intraoperative environment using standard arthroscopic portals. The simulator was constructed using household items at a low cost. Trainees can access instructional videos to guide them in constructing the simulator and performing rotator cuff repairs. This innovative model provides a cost-effective, "at-home" simulator for honing essential surgical skills related to arthroscopic rotator cuff repair. Given the challenges of intraoperative training and the impracticality of expensive lab-based models, this surgical training technique offers a financially viable and effective alternative. By providing residents and fellows with an affordable yet high-quality training solution, the simulator supports equitable access to comprehensive surgical rehearsal exercises. It allows hands-on practice in rotator cuff repair within a low-risk, controlled environment. Consistent simulation and practice improve surgical proficiency and confidence, ultimately enhancing patient outcomes by refining the technical skills of future surgeons.

Based on the OPTIMAL (Optimizing Performance Through Intrinsic Motivation and Attention for Learning) theory, we hypothesized that enhancing expectancies by decreasing the perceived difficulty of a surgical task through an optical illusion that decreased perceived task difficulty would improve surgical skill acquisition. We also hypothesized that men would report higher confidence than women, while demonstrating similar task performance. We conducted a randomized controlled trial comparing the Ebbinghaus illusion (which makes targets appear larger than reality) (enhanced expectancies [Enhanced]) to no illusion (normal expectancies [Normal]) while learning an arthroscopic targeting task. Medical student participants of all years were randomized to Enhanced or Normal groups. Both groups underwent pre-test, training (10 task repetitions), immediate post-test (training model without illusion and transfer model), and retention test (same as immediate post-test, 24-hours later). Sixty-seven medical students (52

OBJECTIVE:To present a novel evaluation technique for assessing three-dimensional (3D) prosthesis alignment after radial head arthroplasty (RHA) and to identify potential measurement errors associated with this method. MATERIALS/METHODS:Virtual surgical planning of a simulated irreparable fracture of the radial head was performed to select and place optimal implants. Of the six 3D-printed bone models, three were fitted with 3D-printed implants and three with metallic implants. After the procedure, 3D models were derived from 3D scans and dual-energy computed tomography with and without metal artifact reduction. Deviations in rotation and translation from the pre-procedure plan as well as measurement errors were assessed. RESULTS:The technique demonstrated the ability to accurately identify minor deviations in prosthesis alignment post-RHA. Deviations ranged from 0 to 14° in rotation and 0 to 1.3 mm in translation. The method also showed high measurement accuracy against 3D reference models, with mean rotational errors of 0.3-0.5° and translation errors of 0.1-0.3 mm. CONCLUSION:This technique provides an accurate and precise method for assessing prosthesis alignment in RHA, with minimal measurement errors. Its potential as a valuable clinical tool has substantial implications in improving preoperative planning and postoperative evaluation. Further validation and advancements in reducing operator dependency are necessary for clinical adoption.

Several lateral approaches to the lateral elbow have been described for management of a variety of elbow pathologies, and each poses unique technical challenges given the complexity of surrounding neurologic, vascular, and ligamentous anatomy. This article reviews 6 common lateral elbow approaches—the Kaplan, modified Kocher, extensor digitorum communis splitting, extensor digitorum communis splitting with proximal extension, lateral column, and lateral epicondyle osteotomy—and outlines the relevant surgical indications, anatomic considerations, and operative steps for each with illustrative examples provided using cadaveric dissections. Pearls and pitfalls and technical tips and tricks will hopefully be useful for the practicing orthopedic surgeon.

BACKGROUND/AIM:The humerus is the most common site for malignant tumors in the upper extremity. Rarely, a total humeral resection with combined replacements of both the shoulder and the elbow are necessary. The aim of this study was to evaluate outcomes after total humeral reconstruction at our institution. PATIENTS AND METHODS:Nine patients (5 females, 4 males, mean age 48±26 years) with a malignant tumor of the humerus were included in this study. This included five endoprostheses and four allograft prosthetic composites. RESULTS:Postoperative complications occurred in eight patients, most commonly deep vein thrombosis (DVT, n=3) and elbow contractures (n=3). Complications led to a revision procedure in one patient, with a cumulative incidence of failure of 25% at 5-years and a 5-year overall patient survival rate of 13%. At the most recent follow-up, the median Musculoskeletal Tumor Society Score was 50%. CONCLUSION:Total humerus reconstruction is a rare surgical procedure that is associated with a high rate of complications with relatively poor functional outcomes. However, this option does offer a means of limb salvage for patients with limited options.

Substantial bone loss at the time of complex primary and revision shoulder or elbow arthroplasty is challenging. Large bone defects compromise component support and important muscle-tendon units. Megaprosthesis, osteoarticular allografts, vascularized bone transfers, fusions, and allograft prosthetic composites (APCs) have all been described for reconstruction in these difficult situations. APCs increase bone stock and provide a better opportunity for soft-tissue reconstruction; however, they are prone to other complications, including graft resorption, nonunion, and fracture. This article provides a comprehensive understanding and review of the benefits and disadvantages of APC utilization in shoulder and elbow arthroplasty. Technical considerations are discussed to maximize functional outcomes. Moreover, advances in templating and three-dimensional printing offer a promising future for planning, precise preparation, and surgical efficiency of APC use in upper extremity arthroplasty.

Background: Proximal humerus nonunion is a challenging complication of fractures that can be treated surgically with either open reduction internal fixation (ORIF) or reverse total shoulder arthroplasty (RTSA). The few studies published on this subject have shown high rates of complications and revision surgery when RTSA has been performed for proximal humerus nonunion. The purpose of this study was to determine the rates of complications and revision of this procedure at our institution, as well as to identify any variables that may impact risks of complications and reoperations. Methods: A single-institution retrospective review of all patients who underwent RTSA for proximal humerus nonunion between 2005 and 2021 was performed. Nonunion was defined as imaging evidence of lack of union, at least 90 days after the index fracture. Patients with less than 1 year of clinical follow-up were excluded. Fifty patients were included, with the majority being female (78%). The mean age at time of RTSA was 71 (range: 54-86) years and most patients were initially treated nonoperatively (74%). Mean total follow-up was 49 (range: 11-130) months. Demographic and surgical variables were recorded. Primary outcomes were complications and reoperations. Complications were divided into surgical (those directly related to RTSA), or other (those unrelated to RTSA). Secondary outcomes included visual analog scale pain scores and range of motion. Results: A total of 17 shoulders (34%) sustained complications after revision shoulder arthroplasty, with 10 (20%) requiring reoperation. Six patients (12%) sustained dislocations and 5 (10%) had radiographic evidence of humeral loosening. No variables examined, including nonoperative vs. surgical management of the index fracture, prosthesis type, or management of tuberosities, influenced the risk of dislocation. Survivorship free from reoperation at 2 years was 73%. Younger age at time of RTSA and the presence of diabetes mellitus both increased the risk of reoperation significantly (P = .013 and P = .037, respectively). There was a trend towards increased risk of reoperation in patients who were treated with initial ORIF (hazard ratio = 2.95); however, this did not reach statistical significance (P = .088). Three patients (6%) sustained a periprosthetic fracture after a fall. Conclusion: RTSA provides improved pain and function for properly selected patients with proximal humerus nonunion. Dislocation, humeral loosening, and reoperation rates remain high when RTSA is performed for nonunion compared to other diagnoses. In this study, younger age and diabetes mellitus increased the odds of reoperation. Every effort must be made to optimize implant stability and humeral component fixation when RTSA is performed for proximal humerus nonunion. Level of evidence: Level IV; Case Series; Treatment Study (c) 2024 Journal of Shoulder and Elbow Surgery Board of Trustees. All rights are reserved, including those for text and data mining, AI training, and similar technologies.

Background Periprosthetic joint infection (PJI) after total elbow arthroplasty (TEA) is associated with substantial morbidity and the need for revision surgery. The aim of this systematic review and meta-analysis was to summarize studies on two-stage exchange and débridement, antibiotics, and implant retention (DAIR) to determine differences in rates of recurrent infection, risk factors for recurrent infection, non-infectious complications, and functional outcomes. Methods A systematic search was conducted of the MEDLINE, EMBASE, Cochrane, Scopus, and Web of Science databases in March 2024 to identify studies on infected total elbow arthroplasties treated with either two-stage revision surgery or DAIR. Exclusion criteria included duplicate publications, review articles, and studies with a mean follow-up of less than 1 year. 14 studies were included in the final analysis. Data abstracted included demographics, treatment modalities, bacterial speciation, rates of recurrent infection, and functional outcomes (range of motion data and Mayo Elbow Performance Score (MEPS). Results 290 infected TEAs were included across all 14 studies, 131 treated with DAIR and 159 treated with two-stage exchange. The overall pooled random-effects rate of recurrent infection was 34% (95% CI: 21-47%). The rate of recurrent infection was significantly lower following two-stage exchange compared to DAIR (18% vs 51%, P = 0.004). The overall pooled rate of non-infectious complications was 34% (95% CI: 22-46%). With the numbers available, the rate of non-infectious complications between two-stage exchange and DAIR was smaller for two-stage exchange, although the difference did not achieve statistical significance (27% vs 43%, P = 0.244). Patients infected with coagulase-negative Staphylococci experienced a higher rate of recurrent infection than those infected with other species (44% vs 14%), although again this difference did not reach statistical significance (P = 0.060). In patients undergoing two-stage exchange, incomplete cement removal was associated with a significantly higher rate of recurrent infection than complete removal (56% vs 19%, P = 0.001), but intentional retention of one component was not significantly associated with a higher rate of recurrent infection (37% vs 20%, P = 0.315). Discussion The results of this systematic review and meta-analysis of the outcomes associated with the treatment of TEA PJI with either DAIR or two-stage reimplantation, two-stage exchange was associated with a lower rate of recurrent infection. Incomplete cement removal was a risk factor for recurrent infection. Although it did not reach significance, it appeared that infection with coagulase-negative Staphylococci could also be a risk factor for failure of infection eradication.