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Friday May 13th
14:30 – 15:30

Chairmen: Janne Ovesen (DK) & Søren Skyt Christensen (DK)

Discovery Elbow System – a consecutive study of 109 patients – one year follow-up

Jacobsen PK, Andresen A, Kristensen SS. Odense University Hospital, Denmark

Semi-constrained total elbow arthroplasty is used to improve function and reduce pain. Indications for surgery include patients with severe rheumatoid arthritis (RA), severe osteoarthritis (OA), osteogenesis imperfecta (OI) or very comminuted distal humerus fractures in the elderly (CF).

Aim of study
To present short-term complications and results in 140 consecutive patients.

Materials and methods
From September 2002 to April 2015 a consecutive series of 109 patients, aged 30-87 years, was operated using Discovery Elbow System. 81 females, 28 males. The indication for surgery was RA in 51, OA in 5, OI  in 2 and CF in 44 patients. 7 were revised. All patients were operated by one of three senior surgeons. All using posterior approach, release of the ulnar nerve and triceps split. All components were cemented by use of gentamycin-cement. All received prophylactic antibiotics for at least 24 hours and all were immobilized by a plaster of Paris. After two days the plaster was removed and the patients were provided with a removable bandage with upstart of active exercises. Patients were evaluated inclusive X-ray after 3 and 12 months. In all patients pre- and postoperative pain and range of motion (ROM) were recorded. Data are obtained by journal audit.

Deep infection necessitating removal of implant was detected in 2 patients. One was amputated and one was later reoperated inserting a new total prosthesis. No nerve lesions or triceps rupture were found. In all patients there was a significant reduction in pain and improvement of ROM. There was no difference in pain and ROM between RA, OA or CF groups after one year. No X-ray signs of early loosening.

We showed promising results after one year observation. The ulnar nerve was released in all patients and we found no postoperative ulnar nerve lesion. Release of the ulnar nerve seems a valid procedure. Deep infection is a concern, but we showed a frequency equal to other studies evaluating prosthesis surgery. However, long term studies are needed to estimate prosthesis survival and late complications.

Clinical outcome after radial head replacement in complex fractures evaluated by Oxford Elbow Scores.

Abstract for the 7th Triennial Nordic Shoulder and Elbow Conference:
K. Modin1, N. Nissen2, I. Hvass1, Søren Skydt Kristensen3
1Hospital of South West Jutland, Orthopaedic department in Esbjerg
2Hospital of Lillebaelt, Orthopaedic department in Kolding
3Odense University Hospital, Orthopaedic department.

Radial head replacement (RHR) is used in the treatment of unstable articular and displaced multi-fragmented fractures of the radial head. However, only limited evidence exits on long term follow up regarding both patient performance and complications. In this study we evaluate the clinical outcome and elbow performance using the Oxford Elbow scores (OES).
A retrospective study of patients treated with RHR was carried out at the Odense University Hospital from 2004 to 2014. Patient records were reviewed based on diagnoses and procedural codes. Inclusion criteria were patients above 15 years with radial head dislocation and fracture. Follow up was done by telephone interviews, where any secondary surgery or removal of the prosthesis was registered and information about elbow performance collected by completing the Oxford Elbow Scores (OES), which has been proven to be valid, reliable and sensitive to changes and also to be independent of age and sex. Participants with a total elbow arthroplasty or who had passed away in the period were excluded.
A total of 35 patients were identified, but 7 patients were excluded due to lack of respond to follow up, insertion of a total elbow arthroplasty or dead, leaving 28 patients for analysis. The mean age was 49 yrs. (range 15-72 yrs.) with 39.5 months mean follow up (range 12-144 months). Overall median OES were 38 (range 19-48). In this study the overall OES were found to improve together with increasing age at surgery. The males tended to be younger and to achieve better OES compared to females. A significant lower median OES of was found in six patients who had secondary revision (21.4 %) and in all three prostheses were removed (10.7 %).
We conclude that decreased elbow performance after RHR in complex fractures is common. When using the OES to assess outcomes, our results show that younger patients tend to have less favourable outcome.

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

Posterolateral instability (PLI) of the elbow was prior described to be the most common presentation of posttraumatic elbow joint instability1. The condition presents clinically as external rotation of radius and ulna as a unit, that leads to a posterior displacement of the radius relative to the humerus (capitellum), ultimately leading to joint dislocation. The pathology is insufficiency or laxity of the posterior part of the lateral collateral ligament (LCL)2.
Different surgical procedures has been described to correst the joint instability. All the techniques includes a reconstruction of the LCL3-5. The studies reports almost the same results. None of the studies have a mean follow up time more than 6 years6.

The aim of the present study was to report the long-term clinical outcome following surgical LCL reconstruction.

We included 18 consecutive patients prior treated for posterolateral elbow instability in the period 1993- 1999 and prior in 2003 evaluated for clinical result5. 1 patient had immigrated and was inaccessible for follow up 4 refused to participate, but stated that they had no elbow symptoms and 1 had died of unrelated causes. 12 of 18 patients were reexamined in 2015 at a clinical follow-up. The patients were followed for a minimum of 200 months (16,6 years) and a mean follow-up of 230 months (19,1 years, range 16,6 – 22,1 years).
We performed the clinical follow-up with clinical examination of stability, ROM, Pain VAS score, Mayo elbow performance score, functional elbow score and Danish version of Oxford elbow score. Furthermore a conventional antero-posterior and sideview x-ray of the elbow was performed to evaluate osteoarthritis, calcifications in the ligaments and joint subluxation. We evaluated the x-ray by the size of osteophytes, joint space narrowing and subchondral sclerosis into three categories: No osteoarthritis, mild osteoarthritis and severe osteoarthritis.

None of the patients reported pain during rest. During activity the patients had a VAS mean of 2,83 (Range 0 – 8). None used regular pain medication due to their elbow condition.
3 patients had a loss of flexion ranging from 5-150. The rest of the patients had no reduction in range of movement (ROM).
All the patients had a stable elbow.  2(16,67%) patients had apprehension to the pivot-shift stress test. None had apprehension to the moving valgus test. All of the assessed patients had no trouble during ”chair stand up” test.
Functional elbow score without testing strength gave unchanged result since the examination in 2003.
 The mean Mayo elbow score was 86,24 which is a 8,76 point decrease sense the first follow-up. According to this score, 9 (75%) patients had an excellent or good result after surgery, and 3 (25%) had a fair result.
The mean Oxford Elbow score was 44,41, which is a “satisfying elbow function”.
Post traumatic osteoarthritis was seen on X-ray in 5 (41%).
All of the patients were satisfied with the outcome.


In conclusion we observed a high percentage of patients with radiographic arthrosis but without clinical symptoms. The results reported in 2003 seem durable over time. The technique reported by Olsen & Søjbjerg in 2003 gives good long-term results in the treatment of symptomatic posterolateral elbow joint instability, though the development of elbow joint arthrosis may decrease the surgical result in the coming years.

Christian Kastenskov Medical student.
Department of Orthopaedic Surgery
Herlev Hospital

Jeppe Vejlgaard Rasmussen MD, PhD
Department of Orthopaedic Surgery
Herlev Hospital

Janne Ovesen MD, PhD
Department of Orthopaedic Surgery
Aarhus Hospital

Bo Sanderhoff Olsen MD, PhD
Department of Orthopaedic Surgery
Herlev Hospital

1.                   O'Driscoll SW. Classification and evaluation of recurrent instability of the elbow. Clinical orthopaedics and related research 2000; (370): 34-43.
2.                   Olsen BS, Sojbjerg JO, Nielsen KK, Vaesel MT, Dalstra M, Sneppen O. Posterolateral elbow joint instability: the basic kinematics. Journal of shoulder and elbow surgery / American Shoulder and Elbow Surgeons  [et al] 1998; 7(1): 19-29.
3.                   Dehlinger FI, Ries C, Hollinger B. [LUCL reconstruction using a triceps tendon graft to treat posterolateral rotatory instability of the elbow]. Operative Orthopadie und Traumatologie 2014; 26(4): 414-27, 29.
4.                   Gong HS, Kim JK, Oh JH, Lee YH, Chung MS, Baek GH. A new technique for lateral ulnar collateral ligament reconstruction using the triceps tendon. Techniques in hand & upper extremity surgery 2009; 13(1): 34-6.
5.                   Olsen BS, Sojbjerg JO. The treatment of recurrent posterolateral instability of the elbow. The Journal of bone and joint surgery British volume 2003; 85(3): 342-6.
6.                   Sanchez-Sotelo J, Morrey BF, O'Driscoll SW. Ligamentous repair and reconstruction for posterolateral rotatory instability of the elbow. The Journal of bone and joint surgery British volume 2005; 87(1): 54-61.

Reconstruction of anterior sternoclavicular joint (SCJ) instability using a tendon autograft.

Martin Rathcke and Michael Krogsgaard

Few orthopaedic surgeons do procedures on the SCJ. The causes of SCJ instability in the younger population is often minor trauma, and a predisposition is possible. The condition is an unpleasant and sometimes painful condition, which impairs many overhead activities including ADL and sport. Former procedures include reconstruction of the costoclavicular ligament (Speed), reinforcement of the anterior sternoclavicular ligament with a figure of eight graft (Spencer) and a tendon interposition arthroplasty (Bak). We have evolved a method since 2002, and now prefers a gracilis autograft immersed into the manubrium as an anchor to the medial clavicle end, which is attached through drill holes. The technique makes it possible to preserve the biomechanical important SCJ disc.
A surgical procedure for chronic sternoclavicular instability using a gracilis autograft is introduced.
Sternoclavicular instability is a rare condition, and is usually atraumatic in origin. Symptoms is functional impairment due to unpleasant clicking, pain and swelling. In the literature operations includes reconstruction of the costoclavicular ligament, reinforcement with fascia lata or subclavius tendons and interposition arthroplasty with a tendon graft. Based on anatomical and biomechanical studies, we have used a triangular reconstruction of the anterior capsule anchoring a gracilis autograft to both the manubrium and the medial clavicle, and at the same time preserving the sternoclavicular disk and joint.
Material and Methods
20 Patients and 25 SCJ (10 right /15 Left) were operated in the period 2010 -2015.
Mean age was 21 years(14 – 46)
All patient did a DASH questionnaire before the operation, and is followed after 3 month, 1, 2 and 5 years.
Results includes
In 5 patients operation for SCJ instability was bilateral, one patient had a torn discus resected, while two patients had a suture of a torn disc. After 3 month all SCJ were stable. We have until now been able to follow 16 patients at 1 year, 2 patients have had mild residual instability and one were reoperated after 2 years.
Scarring and donor-site morbidity is a concern.
A surgical procedure for chronic SCJ instability using a gracilis autograft and joint preservation is introduced. Short term results results seems promising, but fixation until healing can be a limitation for the success rate, and the time for tendon to bone healing is unknown.

Non-union of displaced midshaft fractures of the clavicle: A predictor model using pain scores.

A. Qvist, M. T. Væsel, C. Moss, T. Jakobsen, S. L. Jensen

Aim: To identify early predictors for non-union in displaced midshaft clavicular fractures and to develop a predictor
model for non-union.

Material and Methods: We examined prospectively collected data from 64 non-operatively treated patients aged 18-60
years from a multicentre RCT. Odds ratios for various predictors of non-union were calculated using logistic
For selected predictors we used receiver operating characteristic (ROC) curve analysis to identify cut-off values for a
predictor model. We calculated Youden’s index for a predictor model combining changes in pain on a visual analogous
scale (pVAS) from week two to week four with pain VAS at week four.

Results: We identified 11 (17 %) patients with symptomatic non-union. Smoking status (odds ratio (OR) 6.6, 95%
confidence intervals (CI) 1.14 to 36.1), per cent reduction in pVAS from week two to week four (OR 1.06, 95% CI 1.02
to 1.10, for each point decrease) and pVAS score at week four (OR 2.28, 95% CI 1.4 to 3.6, for each point increase)
were predictors of non-union.
ROC curve analysis identified a reduction in pVAS at 50 per cent as the cut-off value to predict non-union. Youden’s
index increased up to a four-week pVAS score at 1.5 and decreased hereafter.
The predictor model with highest Youden’s index identifies 22 (34 %) patients at high risk of developing non-union. In
the high risk group 11 (50%) patients developed non-union whereas none of the patients in the low risk group
developed non-union (p<0.0001). This predictor model has a sensitivity of 100 per cent and a specificity of 79 per cent.

Discussion and Conclusion: Smoking status is an early predictor for non-union. However, smoking status is an
unreliable parameter in a clinical setting and smoking cessation should be considered an option before surgery. We do
not recommend systematic surgery of all smokers following displaced midshaft clavicular fractures.
It is possible to identify patients at high risk of non-union using changes in pVAS score from week two to week four
combined with absolute pVAS score at week four.
Patients at high risk should be considered as surgical candidates to reduce the risk of non-union.