 TRAUMA

Revisiting the ‘bag of bones’

FUNCTIONAL OUTCOME AFTER THE CONSERVATIVE
MANAGEMENT OF A FRACTURE OF THE DISTAL HUMERUS

S. A. Aitken, The best method of managing a fracture of the distal humerus in a frail low-demand patient
P. J. Jenkins, with osteoporotic bone remains controversial. Total elbow arthroplasty (TEA) has been
L. Rymaszewski recommended for patients in whom open reduction and internal fixation (ORIF) is not
possible. Conservative methods of treatment, including the ‘bag of bones’ technique
From Glasgow Royal (acceptance of displacement of the bony fragments and early mobilisation), are now rarely
Infirmary, Glasgow, considered as they are believed to give a poor functional result.
United Kingdom We reviewed 40 elderly and low-demand patients (aged 50 to 93 years, 72% women) with
a fracture of the distal humerus who had been treated conservatively at our hospital
between March 2008 and December 2013, and assessed their short- and medium-term
functional outcome.
In the short-term, the mean Broberg and Morrey score improved from 42 points (poor; 23 to
80) at six weeks after injury to 67 points (fair; 40 to 88) by three months.
In the medium-term, surviving patients (n = 20) had a mean Oxford elbow score of 30
points (7 to 48) at four years and a mean Disabilities of the Arm, Shoulder and Hand score of
38 points (0 to 75): 95% reported a functional range of elbow flexion. The cumulative rate of
fracture union at one year was 53%. The mortality at five years approached 40%.
Conservative management of a fracture of the distal humerus in a low-demand patient
only gives a modest functional result, but avoids the substantial surgical risks associated
with primary ORIF or TEA.
Cite this article: Bone Joint J 2015;97-B:1132–8.

Fractures of the distal humerus account for 1% surgery were substantial. Our reasoning was
 S. A. Aitken, MD, FRCS (Tr &
of fractures sustained by adults: two-thirds of that conservative treatment might give an
Orth), Orthopaedic Registrar, those affected are aged 50 years or older.1 Most acceptable result, thereby avoiding unneces-
Department of Trauma and
Orthopaedics
distal humeral fractures are routinely treated by sary surgery. Furthermore, we took the view
Royal Infirmary of Edinburgh, open reduction and internal fixation (ORIF), that patients who had a poor result from con-
51 Little France Crescent,
Edinburgh, EH16 4SA, UK.
but this is controversial in the frail, elderly and servative treatment could undergo TEA at a
low-demand patient with osteoporotic bone. later date in a virgin joint.
 P. J. Jenkins, MD, FRCSEd
(Tr & Orth), Consultant Total elbow arthroplasty (TEA) has been rec- We are aware of only two reports in the
Orthopaedic Surgeon, ommended in cases in which the fracture is literature which document the functional out-
Department of Trauma and
Orthopaedics often very distal, displaced and comminuted.2 come of conservative management using a
 L. Rymaszewski, MBChB, Conservative methods of treating a fracture of modern validated scoring system.7,8
FRCS, Consultant Orthopaedic
Surgeon, Department of the distal humerus, including the ‘bag of bones’ The aim of this study was to present the
Trauma and Orthopaedics technique in which the position of the displaced short- and medium-term functional outcomes
Glasgow Royal Infirmary, 84
Castle Street, Glasgow, G4 0SF, fragments is accepted and early movement of primary conservative treatment of a fracture
UK. encouraged, are now rarely considered as they of the distal humerus in elderly and low-
Correspondence should be sent are thought to give poor functional results.3 This demand patients.
to Mr S. A. Aitken; e-mail:
stuart.aitken@nhs.net
is, in part, because of selected results, historical
reports and small case series.4,5 There has, how- Patients and Methods
©2015 The British Editorial
Society of Bone & Joint
ever, been little written on the subject since the This study describes the clinical outcomes of a
Surgery early report of 12 conservatively managed cases retrospectively compiled case series of patients
doi:10.1302/0301-620X.97B8.
35410 $2.00
by Eastwood in 1937.6 managed using a standard method of treat-
We present our experience of the conservative ment. Consequently, formal ethics committee
Bone Joint J
2015;97-B:1132–8. management of fractures of the distal humerus approval was not required from the Regional
Received 4 November 2014; in selected elderly and low-demand patients for Ethics Committee. There was no external
Accepted after revision 2 April
2015 whom the inherent risks of anaesthesia and funding for this study.

1132 THE BONE & JOINT JOURNAL

 REVISITING THE ‘BAG OF BONES’
We reviewed the case notes and radiographs of all
patients aged 50 years or more with a fracture of the distal
humerus which had been treated conservatively between
March 2008 and December 2013 at our hospital. Our hos-
pital serves a predominantly urban population, 50% of
whom reside in the most deprived socioeconomic national
quintile, as measured by the Scottish Index of Multiple
Deprivation.9 The detrimental effect of deprivation on gen-
eral health is well recognised.10 Many of our patients have
multiple medical co-morbidities and are deemed to be at a
higher risk for anaesthesia and surgery. Patients were iden-
tified through the hospital picture archiving and communi-
cation system by performing a search of all radiographs
taken in our elbow clinic. All patients were managed under
the care of the senior author (LAR). The electronic patient
record (EPR) and patient case files were used to obtain
demographic data (age, gender, Charlson co-morbidity
index)11 and information about complications and subse-
quent surgical procedures.
Fracture classification and radiographic measurements. All
anteroposterior (AP) and lateral radiographs of the
elbow joint were reviewed and classified by one author
(SAA) according to the Arbeitsgemeinshaft für
Osteosynthesfragen (AO) system.12 Patients were
included if they had a 13-A (extra-articular), 13-B (partial
articular) or 13-C (complete articular) type of fracture. The
presence of comminution was noted, as was fracture dis-
placement. Any intra-articular step in type B and C frac-
tures was measured on the AP radiograph. Union was
defined radiologically by the presence of new bone forma-
tion across the fracture site on two views, supplemented by
supporting information provided in the EPR by the exam-
ining clinician.
Treatment protocol. Conservative management of a frac-
ture of the distal humerus was defined as non-operative
treatment or surgical intervention limited to the early exci-
sion of potentially impinging bony fragments. Conservative
management was offered to selected patients after careful
consideration of the injury pattern and the patients’ general
health, medical comorbidities and level of function. The
management options were discussed with the patient and a
shared decision made. Patients were initially treated in an
above-elbow plaster splint, but had this changed to a simple
sling at the first outpatient elbow clinic appointment
(within 14 days of injury). Patients were not referred for
physiotherapy, but were encouraged to use and move the
elbow as discomfort allowed. Notably, there was no pre-
determined out-patient review protocol: patients were
reviewed in the clinic at various time-points until comfort-
able and satisfied, or until surgical intervention was deemed
necessary (delayed ORIF, TEA, ulnar nerve release).
Short-term functional data. The EPR was examined to
determine the clinical examination findings at out-patient
review within one year of injury. Patients were evaluated
retrospectively according to the 100-point rating system of
Broberg and Morrey,13 which is based on the arcs of flex-
VOL. 97-B, No. 8, AUGUST 2015
1133
ion, pronation and supination (40 points), strength
(20 points), stability (5 points) and pain (35 points). A total
of 95 to 100 points is rated excellent; 80 to 94 points, good;
60 to 79 points, fair; and less than 60 points, poor. The
number and timing of review appointments varied between
patients and were pragmatically determined by the clinical
and social demands of this vulnerable group. For the pur-
pose of analysis, available data from various time points
were pooled and evaluated at approximately six weeks and
three months post injury. Patients with missing data were
excluded from the short-term analysis.
Medium-term functional data. Surviving patients were con-
tacted by telephone and invited to participate in the study
by providing medium-term functional data. Patients were
excluded at this point if they were unable or did not wish to
respond for any reason. Data were obtained for 20 patients
(50%). Of the remainder, 12 (30%) had died, five (12.5%)
had developed cognitive impairment, one patient could not
talk because of laryngeal cancer and one patient preferred
not to be interviewed. Contact details were unobtainable
for the one remaining patient (Fig. 1).
Patients were asked to complete the Oxford elbow score
(OES)14 and Disabilities of the Arm, Shoulder and Hand
(QuickDASH)15 questionnaires. The OES is a validated,
elbow-specific, 12-question outcome measure providing a
score from 0 (poor) to 48 (excellent). It served as our pri-
mary outcome measure for the medium-term time-point.
The QuickDASH is a validated measure of upper limb dis-
ability, but is not specific to the elbow joint. It provides a
score from 0 (no disability) to 100 (severe disability).
Patients were also asked about their current elbow pain
from 0 (none) to 10 (worst) while at rest, at night, during
heavy lifting, and during repetitive activities. They were
asked if they could get hand to mouth on the injured side, as
a marker of elbow flexion. Finally, patients were asked to
rate their overall satisfaction with their course of treatment
from 0 (totally unsatisfied) to 10 (entirely satisfied).
Baseline characteristics. A total of 40 patients aged 50
years or more with distal humeral fractures were treated
conservatively, of whom 29 (72.5%) were women. The
mean age of the cohort was 73.5 years (50 to 93).
Statistical analyses. The chi-squared test was used to com-
pare differences between proportions. Normally distrib-
uted continuous data were presented as the mean, standard
deviation (SD) and range. Medians with interquartile ranges
(IQR) were used when data were skewed. The Mann–
Whitney U or t-tests were used to compare continuous data
between two groups. Where more than two groups existed
(e.g. AO fracture types), the Kruskal–Wallis test was used.
As this was a retrospective observational study, each
patient had a different period of follow-up and some had
died. The Kaplan–Meier method was used to estimate the
cumulative proportion of patients achieving union without
intervention, and the proportion of patients requiring inter-
vention.16 The cut-off points studied were one and five years
post-injury. The log-rank test was used to compare cumula-
1134 S. A. AITKEN, P. J. JENKINS, L. RYMASZEWSKI
Baseline
X-rays and EPR reviewed
n = 40 (100%)
Short-term review
Adequate clinic data
< 40 days
n = 32 (80%)
Short-term review
Adequate clinic data
40 to 115 days
n = 24 (60%)
Final
medium-term review
Telephone response
n = 20 (50%)
Participant flow diagram. The reasons for exclusion at final follow-up are also shown. EPR, electronic patient record.
tive proportions between groups. Bivariate correlation was
performed with age and articular displacement and the
functional outcomes of OES, QuickDASH and satisfaction.
The level of significance was set at p < 0.05.
Results
A Charlson comorbidity index of 2 or more was found in
22 (55.0%) patients and a history of alcohol abuse noted in
16 (40%). A fall from a standing height accounted for 37
(92.5%) fractures: the remainder were the result of a fall
down multiple stairs. One patient sustained an associated
fracture of the ipsilateral olecranon and seven (17.5%) an
injury elsewhere in the same limb. One fracture was open.
In total 28 fractures (70.0%) were displaced, 15 (37.5%)
comminuted and 17 (42.5%) had articular incongruity,
with a mean articular step of 5.2 mm (0 to 17, SD 3.8). As
shown in Table I, 19 (47.5%) fractures were AO type A,
seven (17.5%) type B and 14 (35.0%) type C.
Short-term functional outcome. The first pooled out-patient
dataset was recorded at a mean of 40 days (5 to 78; SD 31.7)
post-injury and the second at 115 days (23 to 209; SD 88).
After excluding missing information, adequate data were
available for 32 (80%) patients at the first review and 24
(60%) at subsequent review. There were 21 (53%) patients
with flexion-extension data for both the first and second
visit, and 13 (33%) with forearm rotation data. Mean
Lost to follow-up
n = 8 (20%)
Exclusions from final follow-up:
Lost to follow-up Died n = 12
n = 8 (20%) Cognitive impairment n = 5
Communication difficulty n = 1
Declined to participate n = 1
Unable to contact n = 1
Lost to follow-up
n = 4 (10%)
Fig. 1
extension improved from 60° (20° to 85°; SD 18.8) to 49°
(30° to 80°; SD 18.6), (p < 0.001, paired t-test), mean flex-
ion from 107° (90° to 140°; SD 8.3) to 120° (95° to 140°; SD
14.6), (p = 0.075, paired t-test), and mean forearm rotation
from 112° (45° to 170°; SD 28.0) to 141° (90° to 175°; SD
18.0), (p = 0.01, paired t-test). The mean Broberg and Mor-
rey score improved by 25 points during short-term out-
patient review: from a “poor” 42.5 points (23 to 80;
SD 12.2) to a “fair” 67.1 points (40 to 88; SD 13.5),
(p < 0.001, paired t-test).
Union and surgical intervention. The early excision of
potentially impinging bony fragments was undertaken as a
planned procedure in five patients at a mean of 20 days (5 to
49; SD 19.8) from injury. One patient died 20 days after
fracturing. Of the remaining 34 patients in whom bony
union could be assessed, 19 (55.9%) progressed to union
and 15 developed nonunion (44.1%). Of those with united
fractures, one patient (5.3%) underwent TEA after three
months for stiffness and poor function in an already
severely eroded rheumatoid elbow. Of the 15 patients with
nonunion, surgery was carried out in five (33.3%): one
ulnar nerve release at 18 months; two delayed ORIF for
pain at three and 13 months and two TEA for pain at nine
and 17 months. There was no statistically significant differ-
ence in the incidence of surgical intervention between union
and nonunion groups (p = 0.066, Fisher’s exact test). The
THE BONE & JOINT JOURNAL
 REVISITING THE ‘BAG OF BONES’ 1135

Table I. Demographic data, functional outcomes and the incidence of surgical intervention, arranged by Arbeitsgemeinshaft für
Osteosynthesfragen (AO) fracture type

AO fracture type
A B C p-value
Total number (n, %) 19 (47.5) 7 (17.5) 14 (35.0) -

Age (yrs) (SD, range) 78.9 (9.1, 62 to 93) 62.9 (11.7, 50 to 87) 71.6 (7.6, 52 to 81) 0.001 KW

Gender ratio (male:female) 6:13 2:5 3:11 0.810 CHI

Union without intervention (n, %) 8 of 18 (44.4) 2 of 4 (50.0) 9 of 12 (75.0)

Surgical intervention (n, %)

None 17 (89.4) 2 (28.6) 10 (71.4)
Excision of fragments 0 3 (42.8) 2 (14.3)
Ulnar nerve release 0 1 (14.3) 0
Late ORIF 1 (5.3) 1 (14.3) 0
TEA 1 (5.3) 0 2 (14.3)

Medium-term outcome (n = 20) (IQR) All MWU

OES 19 (14.5 to 34.5) 45 (10.5 to 46.0) 33 (20.3 to 44.3) 0.706
QuickDASH score 61.4 (31.8 to 70.5) 2.3 (2.3 to 70.5) 30.6 (16.0 to 59.7) 0.388
Pain rating
At rest 6 (2 to 7) 0 (0 to 5) 2.5 (0 to 5) 0.250
At night 6 (2.5 to 8) 0 (0 to 5.5) 3 (0.75 to 6.25) 0.217
On heavy lifting 9 (4.5 to 9.5) 2 (1 to 9.5) 5.5 (2.25 to 9) 0.560
On repetitive movement 8 (4.5 to 9) 2 (1 to 8.5) 5 (1.5 to 6.25) 0.283
Satisfaction rating 7 (3.5 to 9.0) 9 (3.5 to 9.5) 7 (5.0 to 9.0) 0.940
SD, standard deviation; KW, Kruskal–Wallis test; CHI, chi-squared test; ORIF, open reduction and internal fixation; TEA, total elbow
arthroplasty; IQR, interquartile range; MWU, Mann–Whitney U test; QuickDASH, Disabilities of the Arm, Shoulder and Hand;
OES, Oxford elbow score

Table II. Fracture union at one and five years post-injury, patient mortality and surgical inter-
vention, constructed according to the Kaplan–Meier method. For union or intervention,
patients were censored from follow-up at death or the end of the study period

One year (%) (95% CI) Five years (%) (95% CI)
Cumulative union 52.6 (34.7 to 67.8) 73.3 (57.7 to 83.9)

Cumulative mortality 10.5 (0.2 to 43.0) 38.8 (16.3 to 61.1)

Cumulative intervention (all)

All 18.9 (2.9 to 45.4) 28.9 (9.6 to 51.8)
Type A 11.5 (3 to 38.7) 11.5 (3 to 38.7)
Type B 42.9 (16.3 to 82.8) 71.4 (38.8 to 95.9)
Type C 22.1 (7.7 to 54.1) 29.9 (12.4 to 61.5)
Log-rank test p = 0.309

Cumulative intervention (excluding fragment excision)

Type A 11.5 (0 to 46.8) 11.5 (0 to 46.8)
Type B 0 33.3 (1.2 to 76.2)
Type C 7.7 (0 to 69.7) 15.4 (0 to 62.7)
Log-rank test p = 0.966
CI, confidence interval

greatest overall incidence of surgical intervention occurred
in the AO type B group: three out of five of these proce-
dures, however, involved the planned removal of fragments
(Table I). Table II shows the cumulative rates of fracture
union, patient mortality, and surgical intervention for the
study cohort.
Medium-term functional outcome. A total of 20 patients
provided data at a mean of 46 months (5 to 73; SD 20) from
injury. Of these, eight had fractures which had united, eight
had a nonunion and four had an early planned excision of
fragments. Overall, 19 (95%) patients were able to reach
their mouth with their hand, suggesting a functional range
of elbow flexion. The mean satisfaction score was 7.1 (0 to
10; SD 2.7) and 15 (75%) patients provided a score of 7 or
greater. The mean overall OES was 30.0 points (7 to 48;
SD 14.3), with a mean QuickDASH of 38.5 (0 to 75;

VOL. 97-B, No. 8, AUGUST 2015

1136
Table III. Medium-term function and satisfaction arranged by union status. Data are presented as medians with interquartile ranges
(IQR) unless otherwise stated
Final result
Union (n = 12)
Nonunion (n = 8)
p-value*
* Mann–Whitney U test
OES, Oxford elbow score; QuickDASH, Disabilities of the Arm, Shoulder and Hand
10
Visual analogue scale (median, IQR)
5 our results support this approach in selected ‘high-risk’
0
Rest pain Night pain
Fig. 2
Graph showing the results of the medium-term pain assessment
(n = 20), from 0 = no pain to 10 = worst pain, presented according
to patient activity. The median scores and interquartile ranges
(IQR) are shown.
SD 28.2). There was no difference seen in the distribution of
functional outcome scores (OES, QuickDASH) between
AO fracture types (Table I) or between those patients with
fractures which united and those which did not (Table III).
No difference in outcome between men and women
was noted (OES p = 0.314; QuickDASH p = 0.826; satis-
faction p = 0.586). There was no correlation (Spearman’s
rho) between patient age and OES (p = 0.087, p = 0.715),
QuickDASH (p = 0.016, p = 0.945) or satisfaction
(p = 0.134, p = 0.562). Similarly, fracture displacement
had no association with OES (p = 0.012, p = 0.959),
QuickDASH (p = -0.183, p = 0.440), or satisfaction
(p = -0.034, p = 0.883).
The medium-term distribution of pain scores provided is
shown in Figure 2. There was no difference in the distribu-
tion of pain scores between patients with united and unu-
nited fractures in terms of rest pain (p = 0.080, Mann–
Whitney U test), night pain (p = 0.182, Mann–Whitney
U test) or pain on heavy lifting (p = 0.133, Mann–Whitney
U test). The pain was greater on repetitive activity in
patients with a nonunion (median 8, IQR 5.5 to 8.75) than
S. A. AITKEN, P. J. JENKINS, L. RYMASZEWSKI
Function and satisfaction
OES QuickDASH Satisfaction
39.5 (IQR 20.5 to 45) 28.7 (IQR 2.3 to 58.0) 8 (IQR 4.5 to 9.5)
20.0 (IQR 12.3 to 39) 59.1 (IQR 29.6 to 72.7) 7 (IQR 4.8 to 8.8)
0.231 0.069 0.557
in those whose fracture had united (median 3, IQR 0.5
to 6), (p = 0.032, Mann–Whitney U test).
Discussion
We have described the patient-reported functional out-
comes in a series of low-demand patients with a conserva-
tively managed fracture of the distal humerus. We believe
cases if doubt exists as to whether stable fixation can be
achieved. Elbow movement and pain can be expected to
improve in the short-term. At around four years most of
our patients reported a functional range of elbow flexion
and satisfaction with their treatment. We found our cumu-
lative surgical intervention rate to be less than 30% in the
Heavy Repetitive five years after injury.
lifting activity The increased risk of ORIF in patients with a commi-
nuted fracture and osteoporotic bone is well recognised. In
2005, Korner et al reported the results of ORIF in 45
patients with a median age of 73 years (IQR 61 to 92).17
Implant failure and/or loosening of the distal screws
occurred in 12 patients, necessitating revision surgery in
seven. Similarly, TEA for elbow trauma and its sequelae is
not without risk; high re-operation rates have been
reported, even from the most experienced centres.2,3 As the
incidence of elective TEA for arthritis has been steadily fall-
ing over the last 20 years, and implant survivorship is
related to surgeon volume,18 it seems appropriate that com-
plex trauma cases requiring TEA should be managed elec-
tively by the most appropriate surgeon rather than as a
‘trauma’ procedure.
The available literature on the outcomes of conserva-
tively treated fractures of the distal humerus contains a
small number of conflicting reports, published over many
decades. During this time, there has been a shift from the
use of surgeon-reported measures to patient-reported out-
come measures and a change in the expectations of patients
as to what constitutes an acceptable outcome following
injury. In 1937, Eastwood reported a “most satisfactory”
result in 14 cases treated by manipulation and temporary
immobilisation, with 12 of 14 patients able to return to
their previous employment.6 In 1969, Riseborough and
Radin identified 13 good, five fair and four poor results,
using a measure primarily based on the range of movement
achieved after either manipulation or skeletal traction.19 By
the 1970s, Brown and Morgan noted five good, four fair
THE BONE & JOINT JOURNAL
 REVISITING THE ‘BAG OF BONES’
and one poor result after a regimen of early active elbow
movement.4
In 1983, Zagorski et al5 reported mostly unsatisfactory
results (one good, three fair and seven poor) after non-
operative treatment using a number of different methods.
Similarly, Srinivasan et al,8 reporting on a small series of
eight patients in 2005, found 75% unsatisfactory results
(fair or poor) according to the Orthopaedic Trauma Associ-
ation grading system, despite no cases of fracture nonunion.
In contrast, Pidhorz et al7 have recently (2013) published
largely successful results from a combined retrospective
and prospective series of 56 patients aged 65 years or more
with a fracture of the distal humerus treated by temporary
splintage then mobilisation. Remarkably, 75% were pain
free by 20 months with a mean QuickDASH of 31 and
75% good or excellent results as measured by the Mayo
Elbow Performance Score.
We chose the OES as our primary measure of functional
outcome in the medium-term, as it was not logistically fea-
sible to recall each patient for a more thorough clinical
examination. When measured against a ‘normative’ or
‘excellent’ score of 47 or 48 in age-matched and uninjured
individuals,20 the median score of 30 identified in our
cohort reflects a ‘fair’ outcome. However, as depicted in
Tables I and III, the IQRs around the median score values
are large, suggesting that the best 25% of patients function
well with this conservative protocol while the poorest 25%
are left with very poor elbow function.
By comparison, examination of the literature reveals that
patients with a conservatively managed fracture of the dis-
tal humerus tend to have poorer elbow function in the
medium-term than patients with a conservatively managed
displaced fracture of the olecranon (OES 47/48),21 a simple
elbow dislocation (43/48),22 or a rupture of the distal ten-
don of biceps which has been treated operatively (42/48).23
However, they may attain better function than patients who
have undergone a revision TEA (28/48).24
The main strength of this study is that is addresses the
short- and medium-term functional results for a method of
treating fractures of the distal humerus that is rarely used in
current practice, but may still be appropriate in certain
groups of patients. We believe our results will help surgeons
to provide patients with the information they need to make
a balanced judgement about how they would prefer their
fracture to be treated.
In keeping with many retrospective reports, our study
was limited by the analysis of available data from the EPR
and patient case notes. In some instances, only 50% of the
desired information was retrievable and this hampered a
more detailed analysis of our functional results by AO frac-
ture type in the short term. By the time we conducted tele-
phone interviews at a mean of four years (0.5 to 6), we were
unable to gather information from 50% of the cohort
(largely because of death or the development of cognitive
impairment). This precluded attempts at regression analysis
VOL. 97-B, No. 8, AUGUST 2015
1137
to identify predictors of a poor functional result, but was
perhaps to be expected given that we were examining an
elderly and high-risk cohort whose cumulative five-year
mortality approached 40%.
In conclusion, the conservative management of a fracture
of the distal humerus in a low demand patient gives only a
modest functional result but avoids the potential surgical
risks associated with ORIF or TEA. The relevant advan-
tages and disadvantages of both surgical and non-surgical
options should be discussed, before any informed decision
is made. If there is failure to improve, delayed TEA can still
be offered at a later date as an elective procedure. While
potentially technically more demanding than acute arthro-
plasty, a delayed TEA procedure does not necessarily com-
promise functional outcome or confer a greater risk of
complications to the patient.25
Author contributions:
S. A. Aitken: Concept, Data collection, Analysis, Paper writing, Revisions.
P. J. Jenkins: Concept, Analysis, Paper writing.
L. Rymaszewski: Concept, Performed operations, Paper writing, Revisions.
No benefits in any form have been received or will be received from a commer-
cial party related directly or indirectly to the subject of this article.
This article was primary edited by P. Page and first proof edited by A. C. Ross.
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