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Orthopaedic Proceedings
Vol. 94-B, Issue SUPP_XXVIII | Pages 21 - 21
1 Jun 2012
Bell S Young P Mahendra A
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Primary bone tumours of the talus are rare. Currently the existing literature is limited to a single case series and case reports or cases described in series of foot tumours. Information regarding the patient's demographics and tumour types is therefore limited.

The aim of this study was to investigate these questions and also suggest a management protocol for suspected primary bone tumours of the talus. We retrospectively reviewed the Scottish Bone Tumour Register from January 1954 to May 2010 and included all primary bone tumours of the talus. We identified only twenty three bone tumours over fifty six years highlighting the rarity of these tumours. There were twenty benign and three malignant tumours with a mean age of twenty eight years. A delay in presentation was common with a mean time from onset of symptoms to diagnosis of ten months. Tumour types identified were consistent with previous literature. We identified cases of desmoplastic fibroma and intraosseous lipodystrophy described for the first time.

We suggest an investigatory and treatment protocol for patients with a suspected primary bone tumour of the talus. This is the largest series of primary bone tumours of the talus in the literature.


Orthopaedic Proceedings
Vol. 94-B, Issue SUPP_XI | Pages 16 - 16
1 Apr 2012
Joseph J Pillai A Ritchie D Mcduff E Mahendra A
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Bizarre parosteal osteochondromatous proliferation (BPOP) is a benign lesion of bone originally described by Nora et al in 1983. To date there are no UK-based case series in the literature. Here we present the Scottish Bone Tumour Registry (SBTR) experience of this rare lesion.

A retrospective analysis of SBTR records was performed. Histological specimens were re-examined by a consultant musculoskeletal oncology pathologist. Radiographs were re-reported by a consultant musculoskeletal radiologist. From 1983-2009, 13 cases were identified; 6 male, 7 female. Age ranged from 13-65. All patients presented with localised swelling. Pain was present in 5 and trauma in 2. 9 lesions affected the hand, 3 the foot, and 1 the tibial tuberosity. 12 lesions were excised and 1 curetted. There were 7 recurrences of which 6 were excised. 1 patients' recurrence was not treated. 1 lesion recurred a second time. This was excised. There were no metastases. Radiographs typically showed densely mineralised lesions contiguous with an uninvolved cortex. Cortical breakthrough was present in 1 case and scalloping in another. Histology characteristically showed hypercellular cartilage with pleomorphism and calcification/ossification without atypia; bone undergoing maturation; and a spindle-cell stroma.

SBTR records indicate that BPOP is a rare lesion with no sex predilection that affects patients over a wide age range. Minor antecedent trauma was present in only 2 cases. In agreement with Nora et al. we feel that trauma is unlikely to represent an aetiological factor. Recurrence was over 50% in this series. Although this is similar to that found in other reports, it may indicate that more extensive resection is required for this aggressive lesion. Finally, although radiological/histological findings are often bizarre there have been no reported metastases and so it is important that BPOP is not mistaken for, or treated as, a malignant process such as chondrosarcoma.


Orthopaedic Proceedings
Vol. 94-B, Issue SUPP_XI | Pages 19 - 19
1 Apr 2012
Crane E Mahendra A
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Osteoid osteoma is a classically described benign bone tumour. Traditionally, the surgical treatment of choice was excision, but this can have significant morbidity. In recent years, percutaneous Radiofrequency Ablation (RFA) has grown in popularity as an alternative treatment. This study reports the outcomes using this technique in our regional bone tumour unit. Between May 2003 and October 2007, 14 patients (female, n=4; male, n = 10) aged 15 - 32yrs (mean age, 20.4yrs) underwent CT guided radiofrequency ablation treatment. These patients had typical radiograph, CT, MRI or isotope bone scan features of osteoid osteoma and had significant pain symptoms. The protocol for ablation in our institute is heating the tip of the electrode to 90°C for 6 minutes. All patients were subsequently offered follow up in the out-patient clinic. Outcomes were taken from the Scottish Bone Tumour Registry database.

11 patients (78.6%) patients had complete resolution of symptoms after one RF treatment. 3 (21.4%) cases were unsuccessful but 1 of these was due to technical failure. All 3 of the above patients had complete relief of symptoms after one further RF treatment. 1 (7.1%) patient initially had complete relief of symptoms, but suffered a recurrence after 9 months. This patient also had a second curative treatment. Follow up ranged from 3 – 18 months (mean 10 months). Percutaneous RFA for osteoid osteoma is an attractive treatment due to its efficacy and low morbidity. Our results showed a primary success rate of 78%, a secondary success rate of 100% (after one additional procedure) and a recurrence rate of 7.1%. These are comparable to previous reported series.

We believe our results add to the growing literature supporting radiofrequency ablation as the treatment of choice for osteoid osteoma.


Orthopaedic Proceedings
Vol. 94-B, Issue SUPP_XI | Pages 18 - 18
1 Apr 2012
Holloway N Mahendra A
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The role of perioperative antibiotic prophylaxis in sarcoma surgery is well established. There are no guidelines for their use in this context but there is pressure from microbiologists to comply with agreed prophylaxis for joint arthroplasty despite major differences between patient groups and risks of infection in sarcoma surgery.

Two simple surveys were conducted online, the first for bone sarcoma surgery, the second for soft tissue sarcomas. An email was sent to the major centres worldwide conducting such surgery with links to the online surveys to assess current practice regarding antibiotic prophylaxis and surgical drains. The survey was limited to 8 questions, the emphasis being a simple survey, but included questions on indications, choice, duration of therapy as well as use, size and duration of surgical drains.

We received 38 responses from 15 countries to the bone sarcoma survey and 33 responses from 12 countries to the soft tissue sarcoma survey. Current antibiotic prophylaxis regimens varied widely among surgeons, emphasising the controversy that exists regarding what constitutes best clinical practice.

Opinions regarding use of perioperative antibiotic prophylaxis in sarcoma surgery vary widely among orthopaedic surgeons worldwide, illustrating the controversy as to what constitutes best clinical practice. This survey suggests the need for a randomised clinical trial to aid in the development of guidelines in this area.


Orthopaedic Proceedings
Vol. 93-B, Issue SUPP_I | Pages 78 - 78
1 Jan 2011
Joseph JJ Pillai A Ritchie D McDuff E Mahendra A
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Introduction: Bizarre parosteal osteochondromatous proliferation(BPOP) is a benign lesion of bone originally described by Nora et al in 1983. To date there are no UK-based case series in the literature. Here we present the Scottish Bone Tumour Registry(SBTR) experience of this rare lesion.

Method: A retrospective analysis of SBTR records was performed.

Histological specimens were re-examined by a consultant musculoskeletal oncology pathologist. Radiographs were re-reported by a consultant musculoskeletal radiologist.

Results: From 1983–2009, 13 cases were identified; 6 male, 7 female. Age ranged from 13–65.

All patients presented with localised swelling. Pain was present in 5 and trauma in 2.

9 lesions affected the hand, 3 the foot, and 1 the tibial tuberosity.

12 lesions were excised and 1 curetted. There were 7 recurrences of which 6 were excised. 1 patients’ recurrence was not treated. 1 lesion recurred a second time. This was excised. There were no metastases.

Radiographs typically showed densely mineralised lesions contiguous with an uninvolved cortex. Cortical breakthrough was present in 1 case and scalloping in another.

Histology characteristically showed: hypercellular cartilage with pleomorphism and alcification/ossification without atypia; bone undergoing maturation; and a spindle-cell stroma.

Discussion: SBTR records indicate that BPOP is a rare lesion with no sex predilection that affects patients over a wide age range.

Minor antecedent trauma was present in only 2 cases. In agreement with Nora et al. we feel that trauma is unlikely to represent an aetiological factor.

Recurrence was over 50% in this series. Although this is similar to that found in other reports, it may indicate that more extensive resection is required for this aggressive lesion.

Finally, although radiological/histological findings are often bizarre there have been no reported metastases and so it is important that BPOP is not mistaken for, or treated as, a malignant process such as chondrosarcoma.


Orthopaedic Proceedings
Vol. 92-B, Issue SUPP_I | Pages 64 - 64
1 Mar 2010
Gortzak Y Mahendra A Griffin AM Wunder JS Ferguson PC
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Objectives: A stable shoulder is essential for proper elbow and hand function after oncologic resection of the shoulder girdle. We describe a surgical technique for replacing the shoulder joint capsule using synthetic mesh after resections of the shoulder girdle that resulted in gross intraoperative instability of the shoulder joint.

Methods: 68 patients who underwent shoulder girdle resection between 1989 and 2006 were identified in our prospective database. This report focuses on nine patients whose shoulder joint was reconstructed with synthetic mesh. All patients were followed on a 3 monthly basis. Shoulder joint instability was determined from clinical records, database and radiographs.

Results: Nine patients underwent shoulder joint reconstruction with synthetic mesh. One patient underwent a shoulder disarticulation within 30 days of the index surgery and was excluded from this rapport.

No dislocations were noted during follow-up (range 3–48 months). Radiographs revealed an average vertical displacement of the humeral head compared to its original position of 0.7 cm (range 0–1.7 cm). There were two surgical complications. In one patient the humeral prosthesis migrated proximally and eroded through the skin requiring additional surgery. In another case erosion of the distal clavicle was noted. This was biopsied and foreign body reaction identified.

Conclusions: Joint instability following major resections of the shoulder girdle is a source of morbidity and affects the function of the salvaged limb. Synthetic capsular reconstruction using Marlex mesh is a useful adjunct in patients where insufficient shoulder musculature and joint capsule remains after resection to allow for stable suspension of the upper limb.


Orthopaedic Proceedings
Vol. 92-B, Issue SUPP_I | Pages 63 - 63
1 Mar 2010
Gortzak Y Mahendra A Griffin AM Lockwood G Wang Y Deheshi B Wunder JS Ferguson PC
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Objectives: To formulate a scoring system enabling decision making for prophylactic stabilization of the femur following surgical resection of a soft tissue sarcoma (STS) of the thigh.

Methods: A logistic regression model was developed using patient variables collected from a prospective database. The test group included 22 patients with radiation-related pathological femur fracture following surgery and radiation for a thigh STS. The control group of 79 patients had similar treatment but without a fracture. No patients received chemotherapy. Mean follow-up was 8.6 years. Variables examined were: Age (< 49, 50–70, > 70 years), gender, tumor size (0–7, 8–14, > 14 cm), radiation dose (low=5000 cGy, high> 6000 cGy), extent of periosteal stripping (< 10, 10–20, > 20 cm) and thigh compartment (posterior, adductor, anterior). A score was assigned to each variable category based on the coefficients obtained in the logistic regression model.

Results: Based on the regression model and an optimal cut-point, the ability to predict radiation associated fracture risk was 91% sensitive and 86% specific. The area under the Receiver Operating Characteristic (ROC) curve was 0.9, which supports this model as a very accurate predictor.

Conclusions: Radiation-related femur fractures following combined surgery and radiation treatment for STS are uncommon, but are difficult to manage and their non-union rate is extremely high. These results suggest that it is possible to predict radiation-associated pathological fracture risk with high sensitivity and specificity. This would allow identification of high risk patients and treatment with prophylactic IM nail stabilization. Presentation of this model as a clinical nomogram will facilitate its clinical use.


Orthopaedic Proceedings
Vol. 92-B, Issue SUPP_I | Pages 64 - 64
1 Mar 2010
Mahendra A Griffin AM Yu C Gortzak Y Bell Ferguson PC Wunder JS Davis A
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Objectives: To investigate whether components of MSTS-87 (Pain, ROM, Strength, Stability, Deformity, Acceptance and Function) correlate with function as measured by TESS following endoprosthetic replacement (EPR) for patients with bone sarcoma.

Methods: 255 patients with extremity bone sarcoma treated by resection & EPR were identified from a prospective database. From this group we investigated 111 patients with primary bone sarcoma with > 2 years follow up, evaluated by both MSTS-87 & TESS, no local recurrence, metastasis or major complication for at least 2 years prior to the follow-up. Upper extremity patients were excluded due to small numbers. We examined the influence of patient demographics and tumour characteristics on functional outcome scores. Correlation between MSTS-87 & TESS was performed using linear regression analysis.

Results: Age, gender, tumour size, anatomical site, chemotherapy treatment and presence of pathological fracture did not significantly correlate with TESS. Linear regression analysis of MSTS-87 individual criteria and total score revealed that only pain, ROM and function helped explain the TESS score (p < 0.05) while strength, stability, deformity & acceptance had no significant effect on overall functional outcome.

Conclusions: Of the seven MSTS-87 variables, only pain, ROM and function significantly correlate with overall functional outcome as measured by TESS following EPR for bone sarcoma. This suggests that patients with decreased strength, stability, deformity and acceptance as defined by MSTS-87 scores, may still adapt well with good overall functional outcomes.


Orthopaedic Proceedings
Vol. 92-B, Issue SUPP_I | Pages 38 - 38
1 Mar 2010
Gortzak Y Lockwood G Mahendra A Wang Y Griffin A Deheshi B Wunder JS Ferguson PC
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Purpose: To formulate a scoring system enabling decision making for prophylactic stabilization of the femur following surgical resection of a soft tissue sarcoma (STS) of the thigh.

Method: A logistic regression model was developed using patient variables collected from a prospective database. The test group included 22 patients with radiation-related pathological femur fracture following surgery and radiation for a thigh STS. The control group of 79 patients had similar treatment but without a fracture. No patients received chemotherapy. Mean follow-up was 8.6 years. Variables examined were: Age (70 years), gender, tumor size (0–7, 8–14, > 14 cm), radiation dose (low=5000 cGy, high> 6000 cGy), extent of periosteal stripping (20 cm) and thigh compartment (posterior, adductor, anterior). A score was assigned to each variable category based on the coefficients obtained in the logistic regression model.

Results: Based on the regression model and an optimal cut-point, the ability to predict radiation associated fracture risk was 91% sensitive and 86% specific. The area under the Receiver Operating Characteristic (ROC) curve was 0.9, which supports this model as a very accurate predictor.

Conclusion: Radiation-related femur fractures following combined surgery and radiation treatment for STS are uncommon, but are difficult to manage and their non-union rate is extremely high. These results suggest that it is possible to predict radiation-associated pathological fracture risk with high sensitivity and specificity. This would allow identification of high risk patients and treatment with prophylactic IM nail stabilization. Presentation of this model as a clinical nomogram will facilitate its clinical use.


Orthopaedic Proceedings
Vol. 92-B, Issue SUPP_I | Pages 64 - 65
1 Mar 2010
Mahendra A Gortzak Y Griffin AM Wunder JS Ferguson PC
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Objectives: Well fixed, ingrown stems in patients with infected, uncemented knee tumor prostheses are difficult to remove. We have shown that it?s not necessary to remove them for infection control. We describe a technique for intraoperative fabrication of antibiotic-impregnated temporary cement prostheses using rush pin endoskeleton during first stage revision of infected, uncemented knee tumor prostheses.

Methods: We used this method in 7 patients with infected uncemented tumor prostheses around the knee. Two patients are awaiting second stage procedures. Surgery involved removing exchangeable components and retaining well-ingrown stemmed intramedullary components. Spacers were made of Rush pins that were bent and placed through hinge of retained component to allow knee movement. Antibiotic impregnated cement was placed around pins.

Results: This method allowed partial weight-bearing, knee movement, stability and pain control between first and second stages. In 4/5 patients infection was eradicated. Second-stage reimplantations were accomplished successfully in 3/5 patients with no obvious metal wear. Mean interval between the 2 stages was 12 weeks. One patient had residual infection requiring amputation and one patient did not agree to further surgery. Overall functional outcome following revision was TESS 82.3/100, MSTS93 73.3/100, MSTS87 23.3/35.

Conclusions: The technique allows maintenance of length, stability and knee joint movement, thus subsequent revision becomes technically simpler. Cement construct has large surface area to maximize antibiotic elution. This method has advantages of low cost, availability of numerous pin dimensions, which allows a custom component. Although there is no obvious wear, this remains a potential concern at articulation of rush rods and retained component.


Orthopaedic Proceedings
Vol. 90-B, Issue SUPP_III | Pages 495 - 495
1 Aug 2008
Mahendra A Jain UK Shah K Khanna M
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Background: In developing countries, many patients are seen with neglected, residual or recurrent CTEV. Treatment of resistant & neglected CTEV has been a subject of much controversy as the pathoanatomy becomes complex & the true cause of disability becomes difficult to ascertain at times. We treated such patients by controlled, differential, distraction using Joshi’s external stabilisation system (JESS).

Aim of study: To explore the role & long term results (minimum follow up 3 years) of controlled, differential, distraction using JESS in relapsed & neglected clubfeet.

Methods: 82 patients with 24 bilateral cases (106 feet) treated by JESS at the department of Orthopaedics, KGMU, India from 1992 onwards; followed up for a minimum of 3 years post surgery (average follow up 6.5 years). Patients with non-idiopathic club foot were not included in this study. Outcome evaluation was done by clinical, podographic(footprint), radiological & functional outcomes using Hospital for Joint diseases Orthopaedic Institute functional rating system for clubfoot surgery.

Results: Excellent results were obtained in 63%, good in 30% & poor in 7% of the cases. 21% had a partial relapse with only 5% requiring further surgery for deformity correction. 11% of cases needed further surgery in the form of flexor tenotomies, subtalar & mid-foot fusion for persistent pain

Conclusion: Controlled, differential, fractional distraction with JESS is a safe & effective procedure for neglected, resistant & relapsed CTEV. It is effective even in patients after skeletal maturity in correcting the deformity. The procedure is less invasive and the results are good irrespective of the severity of the deformity or age of the patient.


Orthopaedic Proceedings
Vol. 90-B, Issue SUPP_II | Pages 402 - 402
1 Jul 2008
Mahendra A Jane MJ Mullen M Sharma H Rana B
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Limb salvage surgery includes all of the surgical procedures designed to accomplish removal of a malignant tumour and reconstruction of the limb in order to achieve an acceptable oncological, functional, and cosmetic result. The aim of this study was to evaluate the functional outcome following endoprosthetic replcament for primary upper & lower extremity musculoskeletal neolplasms.

Between 1983 and 2004, we found 68 patients from the Scottish Tumor Register having had an endoprosthetic reconstruction for upper and lower-extremity malignant musculoskeletal tumours, of which 32 were alive for performing functional assessment (lower extremity-26, upper extremity-6). The clinical, radiological and oncological outcomes were evaluated. The functional outcome was measured by the Musculoskeletal Tumor Society and Toronto Extremity Salvage Score.

The average follow-up was 59 months (range, 1 to 21 years). There were 19 female and 13 male patients. These were anatomically distributed as around the knee (n=18 cases), hip (n=8) and shoulder (n=4). The most common diagnosis was chondrosarcoma (n=10) and osteosarcoma (n=11). Most of the patients were completely satisfied with their condition, with a decreased walking distance as the only notable restriction. There was no correlation between the functional outcome and the type or site of resection. Complications occurred in ten cases, including two cases of aseptic loosening and one case each of recurrent instability, sciatic nerve palsy and femoral nerve palsy. The median functional score using the Musculoskeletal Tumour Society system was 56% and Toronto Extremity Salvage Score was 72%.

Limb salvage for malignant musculoskeletal tumours continues to pose therapeutic and oncological challenges with considerable functional issues, but the good function and local tumour control in most patients justifies its continued use.


Orthopaedic Proceedings
Vol. 90-B, Issue SUPP_II | Pages 399 - 399
1 Jul 2008
Mahendra A Singh OP Khanna M Kumar P
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Giant cell tumor of bone is a benign lesion that is ‘locally aggressive and potentially malignant’. The most common specific location of ‘GCT’ is about the knee (50–65%), followed by the distal radius (10–12%), sacrum (4–9%) and proximal humerus (3%–8%). The pelvis is recognized as an infrequent site of involvement accounting for as few as 2% to 3% of all giant cell tumors. Giant cell tumors often can reach an alarming size in the pelvis jeopardizing the surrounding structures.

Treatment options described in literature for pelvic giant cell tumors include radiation therapy; surgery with intralesional margin; surgery with an intralesional margin and physical adjuvants, and surgery with wide margins.

Following Type II (Periacetabular) resections the two preferred modes of reconstruction are either Saddle Prosthesis or Ilio femoral fusion. But, in patients with extensive periacetabular involvement with tumor extension into ilium the type II resection has to be combined with a Type I (Ilial) resection. This may result in insufficient ilium being available for reconstruction to consider either a iliofemoral fusion or a saddle prosthesis. In such situations we recommend Sacroiliofemoral fusion as a novel variation of iliofemoral arthrodesis.

We present two cases of GCT of pelvis with significant periacetabular involvement treated by Sacroiliofemoral fusion. A follow up at 2 years in both cases showed no recurrences, mean MSTS of 21 & TESS of 70.

This paper discusses the various treatment options for such extensive periacetbular giant cell tumors, operative technique for sacroiliofemoral fusion, outcome evaluation after 2 years by MSTS & Toronto Extremity Salvage scores.


Orthopaedic Proceedings
Vol. 86-B, Issue SUPP_III | Pages 280 - 280
1 Mar 2004
Shah N Mahendra A Rymaszewski L
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Aim: 40 linked total elbow replacements were inserted into 35 patients over a 12-year period. The mean age was 67.3 (48–87) years and the mean follow up 50 (8–134) months. Each patient had undergone at least 1 operation prior to the index arthroplasty (1–10). 27 elbows were ßail and 13 unstable due to previous failed total elbow replacements in 23, gross bony erosion due to rheumatoid arthritis in 9, distal humeral non-union in 6 and Charcot joints due to syringomyelia in 2. Methods: A Coonrad Morrey sloppy hinge prosthesis was implanted in 25 elbows and a Snap þt Souter Strathclyde prosthesis in 15. The technique included preservation of the triceps mechanism and early mobilisation in most cases. Results: At review 38 elbows had no or mild pain, 2 moderate, and no patient with severe pain. All patients achieved a functional range of movement. There was no linkage failure of any implant. Complications included revision for aseptic loosening of one humeral and one ulnar component, debridement for infection in 1 and curettage and bone grafting of a cement granuloma in 1. One patient with a Charcot joint developed a non- union after failure of plating and grafting of a periprosthetic fracture at the tip of the humeral component. In addition 6 had delayed wound healing, 2 ulnar nerve symptoms and 2 triceps weakness. Conclusions: In conclusion, a linked elbow replacement can reliably provide stability, mobility and pain relief in a ßail or unstable joint allowing the hand to be positioned in space and therefore the function of the limb is dramatically improved. This method is especially appropriate in elderly frail patients.


Orthopaedic Proceedings
Vol. 85-B, Issue SUPP_II | Pages 121 - 121
1 Feb 2003
Shah NA Mahendra A Rymaszewski LA
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40 linked total elbow replacements were inserted into 35 patients over a 12-year period. The mean age was 67. 3 years, (range 48 to 87 years) and the mean follow up 50 months (range 8 to 134 months). Each patient had undergone at least 1 operation prior to the index arthroplasty (range 1 to 10). 27 elbows were flail and 13 unstable due to previous failed total elbow replacements in 23, gross bony erosion due to rheumatoid arthritis in 9, distal humeral non-union in 6 and Charcot joints due to syringomyelia in 2.

A Coonrad Morrey sloppy hinge prosthesis was implanted in 25 elbows and a snap-fit Souter Strath-clyde prosthesis in 15. The technique included preservation of the triceps mechanism and early mobilisation in most cases. At review 38 elbows had no or mild pain, 2 moderate, and no patient had severe pain. All patients achieved a functional range of movement. There was no linkage failure of any implant.

Complications included revision for aseptic loosening of one humeral and one ulnar component, debridement for infection in one and curettage and bone grafting of a cement granuloma in one. One patient with a Charcot joint developed a non-union after failure of plating and grafting of a periprosthetic fracture at the tip of the humeral component. In addition six had delayed wound healing, two ulnar nerve symptoms and two triceps weakness.

In conclusion, a linked elbow replacement can reliably provide stability, mobility and pain relief in a flail or unstable joint allowing the hand to be positioned in space and therefore the function of the limb is dramatically improved. This method is especially appropriate in elderly frail patients.