B Vrettos

Total elbow arthroplasty: outcomes after triceps-detaching and triceps-sparing approaches.

BACKGROUND Total elbow arthroplasty (TEA) is associated with high complication rates compared with other large-joint arthroplasties. The frequency and type of complication may differ, depending on the surgical approach. A comparison of outcomes with triceps-off and triceps-on approaches was investigated. METHODS Seventy-three patients underwent 83 primary TEAs between 2003 and 2012. Forty-six elbows had a triceps-off approach, and 37 had a triceps-on approach. Results were reviewed at a mean of 4.2 years. Cementing technique was graded according to Morreys criteria, and clinical outcomes were assessed by means of the Mayo Elbow Performance Score. RESULTS There was no statistically significant difference between the triceps-off and triceps-on groups with regard to the patients age, gender, preoperative Mayo Elbow Performance Score or range of motion, or previous surgery on the affected elbow. Among patients who underwent a TEA for an inflammatory arthropathy, there was a significant difference in outcome between groups with regard to final flexion, extension, arc of motion, and pronation. Cementing technique in the triceps-off group was adequate in 70%. In the triceps-on group, cementing technique was adequate in 92%. The complication rate in the triceps-off group was 32.6% and included 7 triceps ruptures. Three patients who had attempted repairs of the triceps rupture developed deep infections requiring multiple further surgeries. The complication rate in the triceps-on group was 8.1%. CONCLUSION A triceps-on approach in TEA results in consistently good clinical outcomes with no risk of triceps rupture, and the approach does not compromise the cement mantle. We believe that this approach will reduce complication rates in TEA.

Angular stable fixation of displaced distal-third clavicle fractures with superior precontoured locking plates

HYPOTHESIS We reviewed the outcome of angular stable plates in addressing displaced lateral-third clavicle fractures. We investigated union, shoulder function, request for implant removal, and return to sport. Our hypothesis was that these implants provide predictable union and return to sports without the negative consequence of leaving plates in situ, reducing the requirement for a second surgery. METHODS We undertook a retrospective review of a consecutive series of patients who underwent this surgery between 2007 and 2010. Nineteen patients with a mean follow-up of 25 months were included. Postoperative follow-up was performed at 2 weeks and monthly thereafter until union was assessed as achieved clinically and radiographically. Two telephone interviews at a mean of 7 months and 25 months postoperatively assessed shoulder function by Oxford Shoulder Score, presence of any plate or scar discomfort, need for implant removal, and return to sport. RESULTS Nineteen patients achieved union by 4 months (median, 12 weeks; range, 6-16 weeks). The mean Oxford Shoulder Score was 46 (range, 41-48) at a mean of 7 months (range, 3-18 months) and 47 (range, 44-48) at 25 months (range, 18-48 months). Initially, 2 patients requested implant removal; later, however, both declined surgery. No plates have been removed. Four patients complained of mild plate discomfort but did not wish removal. All patients had returned to sporting activities. CONCLUSION Angular stable plate fixation of Neer group II, type II clavicle fractures resulted in a 100% union rate with excellent return of function with no mandatory need for removal.

Low velocity gun shot wounds of the brachial plexus

28 patients with low velocity gunshot wounds of the brachial plexus were treated at Groote Schuur Hospital from 1980 to 1991. Delayed exploration of the brachial plexus (up to 7 months after injury) was performed in nine (30%) of the patients. The other 19 patients did not have exploration of the plexus; most of these patients showed signs of recovery within 2 to 4 weeks of injury. Injury to the subclavian or axillary artery occurred in nine (30%) of the cases. The average length of follow-up of the patients was 19 months (range 2–90 months). Of the 19 patients treated non-operatively, 15 (79%) had an excellent or good result and four (21%) a fair result. The indications for surgery were the absence of improvement within 3 months of injury or persistent pain. Surgery was indicated for significant pain in five of the nine patients; post-operatively two had complete relief of pain, two improvement in the pain and one no improvement. Of the nine surgically treated patients, three (33%) had a good result, two (22%) a fair result and four (45%) a poor result. The potential for recovery was not dependent on the severity of the injury at presentation or the presence of vascular injury but on the appearance of signs of recovery within 4 weeks of injury.

Tuberculosis of the elbow in children

Ten children with tuberculosis of the elbow treated over a 21-year period from 1979 to 1999 were reviewed retrospectively. At presentation, they had pain and swelling of the joint mainly due to synovitis, and the median symptom duration was 10 weeks. All had a decreased range of movement. All were treated with 9 months of antituberculous chemotherapy without synovectomy. The radiologic stage at presentation, rather than duration of symptoms, predicted outcome. Of the 9 patients with stage 1 or 2 disease (synovitis), 8 had an excellent or good outcome. One stage 2 patient had a posterior dislocation of the radial head and had a fair outcome. The one stage 3 (arthritic) patient had a poor outcome.

Total elbow arthroplasty in bleeding disorders: an additional series of 8 cases

BACKGROUND Total elbow arthroplasty (TEA) is a surgical option for an arthropathy secondary to a bleeding disorder. The literature consists of small case series. Our series provides further understanding into the outcomes of TEA in this population of patients. METHODS Five patients underwent 8 primary TEAs for a bleeding disorder. Average age at time of surgery was 47 years. Four patients had hemophilia type A and 1 had von Willebrand disease. Clinical outcomes were evaluated with the Mayo Elbow Performance Score (MEPS) and the visual analog scale (VAS) for pain. Follow-up radiographs were evaluated for signs of loosening and infection. RESULTS Revision surgery was performed in 3 TEAs. Two revisions were performed for aseptic loosening (104 and 118 months postoperatively). The third elbow underwent an excision arthroplasty for a deep infection 44 months postoperatively. Mean follow-up for the primary TEAs still in situ (5 elbows) was 114 months. The mean VAS score improved from 8 to 0 and MEPS from 35 to 95. The mean flexion arc improved from 70° to 100°, and rotation improved from 60° to 160°. Mean follow-up for the revised TEAs (3 elbows) was 94 months. The mean VAS score improved from 7 to 0 and the MEPS from 40 to 85. The mean flexion arc improved from 60° to 95°, and rotation improved from 70° to 160°. CONCLUSIONS Excellent clinical outcomes and an acceptable survival rate for TEAs, comparable with the nonhemorrhagic population, can be achieved in patients with bleeding disorders. Revision arthroplasty in this group of patients yields good clinical outcomes at medium-term follow-up.

Outcomes After Ulnar Nerve In Situ Release During Total Elbow Arthroplasty

PURPOSE Ulnar nerve (UN) lesions are a significant complication after total elbow arthroplasty (TEA), with potentially debilitating consequences. Outcomes from a center, which routinely performs an in situ release of the nerve without transposition, were investigated. METHODS Eighty-three primary TEAs were retrospectively reviewed for the intraoperative management of the UN and presence of postoperative UN symptoms. RESULTS Three patients had documented preoperative UN symptoms. One patient had a prior UN transposition. The nerve was transposed at the time of TEA in 4 of the remaining 82 elbows (5%). The indication for transposition in all cases was abnormal tracking or increased tension on the nerve after insertion of the prosthesis. Of the 4 patients who underwent UN transposition, 2 had postoperative UN symptoms. Both were neuropraxias, which resolved in the early postoperative period. The remaining 78 TEAs received an in situ release of the nerve. The incidence of postoperative UN symptoms in the in situ release group was 5% (4 of 78). Two patients had resolution of symptoms, whereas 2 continued to experience significant UN symptoms requiring subsequent transposition. Seven patients had preoperative flexion of less than 100°. Of these, 2 had a UN transposition at the time of TEA. Of the remaining 5 elbows with preoperative flexion less than 100°, 2 had postoperative UN symptoms after in situ release, with 1 requiring subsequent UN transposition. CONCLUSIONS A 3% incidence of significant UN complications after TEA compares favorably with systematic reviews. We do not believe that transposition, which adds to the handling of the nerve and increases surgical time, is routinely indicated and should rather be reserved for cases with marked limitation of preoperative elbow flexion or when intraoperative assessment by the surgeon deems it necessary. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic IV.

A retrospective review of a series of interposition arthroplasties of the elbow

Background Interposition arthroplasty (IA) is mostly performed in younger patients where total joint replacement is contraindicated and an arthrodesis is unattractive. The outcome and complications of an IA were evaluated. Methods We retrospectively reviewed 18 consecutive cases of interposition arthroplasty (IA) (one case was excluded as a result of incomplete records). Pre- and postoperative pain and function were evaluated. Complications, re-operations and revisions were recorded. Results The mean age was 41 years (range 19 years to 59 years) at time of surgery. The primary diagnosis was post-traumatic osteoarthritis in 12 cases and inflammatory arthritis in five cases. The median follow-up was 54 months (range 8 months to 120 months). In 15 cases, at least one re-operation was performed. Seven cases were revised, with four of these to a total elbow replacement, an arthrodesis was performed in two cases and a re-do interposition was carried out in one case. The median interval from the interposition to revision was 23 months (range 8 months to 88 months). In 10 patients with the interposition currently in situ, mean visual analogue scale score for pain improved from 7.4 to 2.4 and mean Mayo Elbow Performance Score improved from 42 to 76 points. Conclusions IA offered an improvement in pain and function but at a high cost. It is associated with a high complication rate the need for revision surgery.

Arthrofibrosis after total elbow arthroplasty: a case report

Total elbow arthroplasty (TEA) has proved successful in achieving pain control and an increased range of motion and function in a broad range of elbow pathologic processes. Known complications including nerve palsies, infection, aseptic loosening, triceps avulsion, prosthetic failure, and periprosthetic fractures are well described. To our knowledge, arthrofibrosis has not previously been described after TEA. We present a case of a painful stiff elbow in a patient after TEA refractory to multiple surgical and rehabilitative interventions. Extensive investigation failed to identify any cause other than excessive scar formation with a resultant painful restriction in range of motion.

The modified Latarjet procedure in female patients: clinical outcomes and complications

BACKGROUND The aim of this study was to assess the short- and medium-term complications and clinical outcomes of female patients after a modified Latarjet procedure. A review of the literature was also conducted for outcomes of the modified Latarjet procedure in female patients and differences reported between male and female patients. METHOD We retrospectively reviewed the clinical notes of all female patients who had modified Latarjet procedures from 2001 with at least 1 year of follow-up. Patients were interviewed for an Oxford Shoulder Score, Western Ontario Shoulder Instability Index, Oxford Shoulder Instability Score, and subjective shoulder value. A literature review was performed of the electronic database PubMed; 343 papers were assessed for clinical outcomes based on gender. RESULTS Twenty-nine patients were available for inclusion in the study. There were 13 complications in 11 patients (34%). The median postoperative Western Ontario Shoulder Instability Index score was 433; Oxford Shoulder Score, 42; and Oxford Shoulder Instability Score, 36. The median subjective shoulder value was 87%. Of these patients, 37.5% returned to sport. The reoperation rate was 13.8%. We found no literature reporting the outcomes of the modified Latarjet procedure in female patients. CONCLUSION There are no published data comparing outcomes of the modified Latarjet procedure in male and female patients. Female patients had a lower postoperative return to sport and shoulder scores after the modified Latarjet procedure compared with literature reports. Whereas female gender should not be a contraindication to the Latarjet procedure, selection of patients in this group may need to be more stringent.

Distal biceps tendinopathy: conservative treatment

Background Non-traumatic distal biceps tendinopathy related to overuse, has not been previously reported in the literature. We describe the symptoms and signs, a novel injection technique onto the bicipital tuberosity of the radius and outcomes of this treatment. Materials and Methods We retrospectively reviewed the clinical notes of 20 patients (24 elbows), in whom the diagnosis of distal biceps tendinopathy was made. Twenty-two of 24 elbows were treated with one or more cortisone injections. The patients were followed up via a telephonic questionnaire. Results Average duration of follow-up was 3 years and 4 months. Eighteen elbows returned to full function. Five elbows (four patients) had partial resolution of symptoms, and one had no relief. In these six elbows, symptoms had been ongoing for ≥ 8 months prior to injection. Conclusion Distal biceps tendinopathy is often misdiagnosed. The majority of cases respond well to steroid injections without the risk of rupture or neurological injury. Resolution of pain with restoration to previous function is more likely when symptoms have been present for less than 8 months.