Damian M. Rispoli

Periprosthetic Humeral Fractures During Shoulder Arthroplasty

BACKGROUND Currently, there is little information available on the treatment and outcome of intraoperative periprosthetic humeral fractures that occur during shoulder arthroplasty. The purpose of this study was to report on the incidence, treatment, and outcome of, as well as the risk factors for, intraoperative periprosthetic humeral fractures. METHODS Between 1980 and 2002, forty-five intraoperative periprosthetic humeral fractures occurred during shoulder arthroplasty at our institution. Twenty-eight fractures occurred during primary total shoulder arthroplasty, three occurred during primary hemiarthroplasty, and fourteen occurred during revision arthroplasty. Nineteen fractures involved the greater tuberosity, sixteen involved the humeral shaft, six involved the metaphysis, three involved the greater tuberosity and the humeral shaft, and one involved both the greater and lesser tuberosities. All patients were followed for a minimum of two years. At the time of the latest follow-up, outcomes were assessed, radiographs were examined, and relative risks were calculated. RESULTS Over the twenty-two-year study period, the rate of intraoperative humeral fractures at our institution was 1.5%. All fractures healed at a mean of seventeen weeks. In the primary arthroplasty group (thirty-one patients), range of motion and pain scores improved significantly (p < 0.05) at the time of follow-up. In the revision arthroplasty group (fourteen patients), range of motion remained unchanged whereas pain scores improved significantly (p < 0.005). Transient nerve injuries occurred in six patients. Four fractures displaced postoperatively and were then treated nonoperatively; all four healed. Significant relative risks for intraoperative fracture were female sex, revision surgery, and press-fit implants (p < 0.05). CONCLUSIONS The data from the present study suggest that although intraoperative humeral fractures are associated with a high rate of healing, there was a substantial rate of associated complications, including transient nerve injuries and fracture displacement. Significant risk factors for intraoperative fractures include female sex, revision surgery, and press-fit humeral implants.

Precontoured Parallel Plate Fixation of AO/OTA Type C Distal Humerus Fractures

Objectives: To determine the clinical effectiveness of precontoured parallel plating for the management of Orthopaedic Trauma Association (OTA) type C distal humerus fractures. Design: Retrospective case series. Setting: Level I trauma center. Patients/Participants: Between 2001 and 2005, 37 patients with OTA type C distal humerus fractures underwent open reduction and internal fixation exclusively with the Mayo Elbow Congruent Plating system. Thirty-two patients consented to participate in the study. Intervention: All patients underwent open reduction and internal fixation with a precontoured bicolumn parallel plating system. Main Outcome Measurements: Range of motion, Mayo Elbow Performance Score, Disabilities of the Arm, Shoulder and Hand score (DASH), complication rate, and radiographic evaluation. Results: At a mean of 27 months follow up, the mean arc of elbow flexion-extension motion was 97° (range, 10°-145°). The mean Mayo Elbow Performance Score was 82 points and the mean DASH score was 24 points. There were no implant failures and all distal humerus fractures healed. A total of 24 complications occurred in 17 patients (53%) with five patients (16%) having postoperative nerve injuries. Conclusions: Open reduction and internal fixation with a precontoured parallel plating system is an effective treatment method for OTA type C distal humerus fractures. Despite this, the fact that over half of the patients had a significant complication will require utmost vigilance on the part of the surgeon to avoid intraoperative complications. Patient counseling is paramount.

The anconeus flap transolecranon approach to the distal humerus.

The transolecranon approach for the treatment of distal humerus fractures and nonunions is commonly used. A complication of the standard osteotomy is denervation of the anconeus muscle, which provides dynamic stability to the lateral side of the elbow by preventing varus and posterolateral rotatory instability. This article describes the anconeus flap transolecranon (AFT) approach, which utilizes an internervous plane to preserve the anconeus muscle and a chevron-shaped osteotomy for maximal joint exposure. The approach is straightforward to perform with limited complications.

Options in meniscal repair.

Meniscal repair is an important technique for the orthopaedic surgeon. As familiarity, equipment, and techniques improve, the interest in expanding the indications for application of meniscal repair also increases toward improving patient outcomes and long-term function. An overview of the indications, techniques, complications, and future direction of meniscal repair is presented in this article.

Radioulnar space available at the level of the biceps tuberosity for repaired biceps tendon: a comparison of 4 techniques

HYPOTHESIS It is unknown whether certain methods of distal biceps tendon repair lead to an increased propensity of impingement of the repaired tendon. The purpose of this study was to evaluate various repair techniques in a cadaveric model to determine the radioulnar space available for the repaired biceps tendons. METHODS Nine matched pairs of quartered, fresh-frozen cadaveric arms were transected at the level of the humeral mid shaft and the distal radiocarpal joint. Distance measurements and the angular relation of the bicipital tuberosity were measured at 5 forearm pronation-supination positions. These measurements were taken under each of the following conditions: intact native biceps, resected native tendon, suture anchor fixation of the biceps, suspensory suture device fixation of the biceps, tendon repair using a tenodesis technique, and fixation of the tendon using a trough technique. RESULTS There were no significant differences in radioulnar space available after biceps tendon repair with the forearm in a supinated position. However, when the forearm was in a neutral or pronated position, the suture anchor method consistently had the lowest biceps insertion-to-ulna distance (0.6 to 2.1 cm). All forearm positions, except full supination, showed significant differences in terms of radioulnar space available for the repaired biceps. DISCUSSION This study shows that the space available for the biceps tendon decreases with forearm pronation after reconstruction for all repair techniques. It appears that using suture anchors to repair the biceps tendon may predispose the repaired tendon to impingement when compared with other fixation techniques.