Denise Eygendaal

Posterolateral Dislocation of the elbow joint : Relationship to medial instability

Background: Dislocation of the elbow joint is the second most common dislocation in the upper extremity, dislocation of the shoulder being the most common. It has been reported that uncomplicated dislocation of the elbow joint may be associated with a decreased range of motion, degenerative changes in the elbow joint, ectopic calcification, or neurological deficits. As the medial collateral ligament complex can be completely disrupted during dislocation, we evaluated the association between the long-term results of treatment of simple posterolateral dislocation of the elbow and the presence of persistent medial or valgus elbow instability. Methods: Fifty patients who had a mean age of thirty-three years (range, eighteen to fifty-eight years) had closed reduction of a posterolateral dislocation of the elbow without associated fractures. The extremity was immobilized in an above-the-elbow plaster cast for three weeks. After a mean duration of follow-up of nine years (range, six to thirteen years), forty-one patients were evaluated with an interview, a physical examination, and radiographs made while a valgus load was applied to the elbow. Results: The average score according to the system of The Hospital for Special Surgery was 91 points (range, 49 to 100 points), and thirty-one patients described their elbow function as good or excellent. Twenty-four patients had evidence of medial instability on radiographs made while a valgus load was applied to the elbow. Twenty-one patients had signs of degeneration of the joint, and twenty-five patients had ectopic ossification. Magnetic resonance imaging combined with arthrography was performed for the first twenty patients; eight had evidence of rupture of the medial collateral ligament, seven had generalized degenerative changes of the cartilage, and four had a chondral defect of the capitellum. (The study could not be completed for the remaining patient.) Medial instability on radiographs was correlated with signs of degeneration (p = 0.001), ectopic ossification (p = 0.01), a worse score according to the system of The Hospital for Special Surgery (p = 0.002), and persistent pain (p = 0.04). Conclusions: Posterolateral dislocation of the elbow joint can lead to persistent valgus instability that is associated with a worse overall clinical and radiographic result.

The epidemiology of radial head fractures

INTRODUCTION Recent literature shows an increased mean age of female patients with radial head fractures compared with male patients with radial head fractures. However, data on epidemiology of radial head fractures and specifically in relation to age distribution and male-female ratios of radial head fracture are scarce. MATERIALS AND METHODS A retrospective database search was performed to identify all patients with a radial head fracture over a 3-year period. RESULTS A total of 328 radial head fractures were diagnosed in 322 patients. The incidence was 2.8 per 10,000 inhabitants per year. The male-female ratio was 2:3. The mean age was 48.0 years (range, 14-88 years; SD, 14.8). The mean age of female patients (52.8 years) was significantly higher than that of male patients (40.5 years) (P = .001). As the age increases above 50 years, the number of female patients becomes significantly higher than the number of male patients (P = .001). An associated osseous injury was present in 40 patients (12.4%). CONCLUSIONS Radial head fractures are common, and associated injuries are frequent.

Results of arthroscopic debridement for osteochondritis dissecans of the elbow

Objective: To determine the clinical outcome of arthroscopic debridement for osteochondritis dissecans of the elbow. Methods: A prospective cohort study was started in 2000; between 2000 and 2005, 15 patients (six male, nine female, mean age 28 years (range 16–49)) were treated for osteochondritis dissecans of the elbow with arthroscopic debridement. The lesion was graded during surgery using the classification of Baumgarten. The dominant side was operated on in seven of 15 patients, and all patients were involved in a sport in which the elbow is used extensively. Elbow function was assessed before and after surgery using the modified Andrews elbow scoring system (MAESS); pain was scored on a visual analogue scale (0, no pain; 10, severe pain). Evaluation was performed an average of 45 (range 18–59) months after surgery. Statistical analysis (Student’s t test) was carried out using SPSS statistical software. p<0.005 was considered significant. Results: There were no complications. The range of motion did not improve significantly. The mean MAESS score improved from 65.5 (poor) before surgery to 90.8 (excellent) after (p<0.001). The mean level of pain at rest decreased from 3 to 1, and the level of pain after provocation decreased from 7 to 2 (p<0.001). All patients were able to return to work 3 months after surgery, and 80% were able to resume their pre-injury level of sport activity. Conclusion: The clinical outcome after arthroscopic debridement for osteochondritis dissecans of the elbow shows good results, with pain relief during activities of daily living and sport. The function of the elbow, as reflected by the MAESS score, improved from poor to excellent. All patients in this series will be reviewed after 5 years to determine long-term results.

Surgical treatment of post-traumatic elbow stiffness: a systematic review

BACKGROUND Trauma to the elbow is a common cause of joint stiffness that might require surgical release. Release of the stiff elbow can be done by open or arthroscopic approach. There is no high-level evidence for the best surgical treatment modality for post-traumatic elbow stiffness. The objective of this article was to review current available literature of studies reporting on open or arthroscopic release of post-traumatic elbow stiffness. METHODS A comprehensive literature search was performed. All titles and abstracts of potentially relevant studies were reviewed, with a set of predefined inclusion and exclusion criteria. After the initial assessment for inclusion, 2 authors extracted data independently from the included articles. RESULTS Thirty articles were included, with an overall enrolment of 798 patients. No randomized controlled trials were retrieved. The first article was published in 1989 and the most recent in 2012. There were 4 different kinds of treatment modalities identified from the included studies: 1) open arthrolysis; 2) arthroscopic arthrolysis; 3) open arthrolysis with external fixation; and 4) open arthrolysis with distraction arthroplasty. The gain in range of motion was 51°, 40°, 88°, and 56° for groups 1-4, respectively. The average percentage of complications was 23, 5, 73, and 58 for groups 1-4, respectively. CONCLUSION Current literature is not sufficient enough to draw firm statistically based conclusions. However, as the amount of complications seems to rise with the extent of the surgical procedure, we would advise to treat as less invasive as possible (grade C).

Treatment of sequelae of radial head fractures with a bipolar radial head prosthesis: Good outcome after 1–4 years follow-up in 11 patients

Background In the presence of additional disruption of the distal radioulnar ligaments, the interosseous membrane, or the lateral- and/or medial collateral ligament, radial head fractures treated by resection will result in valgus elbow instability, proximal radial migration and/or posterolateral rotatory instability. Radial head replacement has been used to treat or prevent this. We report our experience with the Judet CRF II radial head prosthesis. Patients and methods We treated 11 patients with a bipolar radial head prosthesis because of elbow instability after previous treatment for Mason-Johnston type III or IV radial head fractures. The outcome was assessed clinically using two standardized elbow function assessment scales, and radiographically after a mean follow-up of 2 years. Results Clinical outcome was either good or excellent in all patients; all elbows were stable. Radiographically, there were no signs of loosening, fracture or heterotopic ossification. 2 patients required reoperation for subluxation of the prosthesis; both were treated by reducing the size of the modular head of the prosthesis. There was erosion of the capitellum in 1 patient. Interpretation Bipolar radial head replacement can be used successfully for treatment of the sequelae of radial head fractures. The long-term outcome is, however, unknown.   ▪

Magnetic resonance imaging findings in 46 elbows with a radial head fracture

Background and purpose Radial head fractures are common, and may be associated with other injuries of clinical importance. We present the results of a standard additional MRI scan for patients with a radial head fracture. Patients and methods 44 patients (mean age 47 years) with 46 radial head fractures underwent MRI. 17 elbows had a Mason type-I fracture, 23 a Mason type-II fracture, and 6 elbows had a Mason type-III fracture. Results Associated injuries were found in 35 elbows: 28 elbows had a lateral collateral ligament lesion, 18 had capitellar injury, 1 had a coronoid fracture, and 1 elbow had medial collateral ligament injury. Interpretation The incidence of associated injuries with radial head fractures found with MRI was high. The clinical relevance should be investigated.

The incidence of associated fractures of the upper limb in fractures of the radial head

Radial head fractures are common injuries. In American publications, one-third of the patients with these fractures have been shown to have associated injuries. The aim of this retrospective study is to describe the epidemiology of radial head fractures and associated fractures of the ipsilateral upper extremity in a European population. This study describes the epidemiology of radial head and associated fractures of the upper extremity in a Dutch population by a retrospective radiographic review of all patients with a radial head fracture between 1 January 2006 and 1 July 2007. A total of 147 radial head fractures were diagnosed in 145 patients. The incidence in the general population was 2.5 per 10.000 per year. The average age was 45.9 (SD 17.3) years and male–female ratio was 2:3. The mean age of males was significantly lower (37.1, SD 14.2 years) than of women (53.9, SD 16.4 years). Associated fracture of the upper extremity was found in 10.2%. Coronoid fractures were most common (4.1%). Associated upper limb fractures in patients with a radial head fracture are common in the European population. It is of clinical importance to suspect associated lesions and to perform a thorough physical examination and additional radiological examination on demand.

Biomechanics of the elbow joint in tennis players and relation to pathology

Elbow injuries constitute a sizeable percentage of tennis injuries. A basic understanding of biomechanics of tennis and analysis of the forces, loads and motions of the elbow during tennis will improve the understanding of the pathophysiology of these injuries. All different strokes in tennis have a different repetitive biomechanical nature that can result in tennis-related injuries. In this article, a biomechanically-based evaluation of tennis strokes is presented. This overview includes all tennis-related pathologies of the elbow joint, whereby the possible relation of biomechanics to pathology is analysed, followed by treatment recommendations.

Failure mechanisms in uncemented Kudo type 5 elbow prosthesis in patients with rheumatoid arthritis: 7 of 49 ulnar components revised because of loosening after 2–10 years

Background Both components of the Kudo type 5 elbow prosthesis can be inserted with or without the use of cement. There have been no reports on the use of this prosthesis with all components uncemented in patients with rheumatoid arthritis. Patients and methods We reviewed 49 primary uncemented Kudo type 5 elbow prostheses, inserted in 36 patients with rheumatoid arthritis, after mean 6 (2–10) years. Patients were assessed clinically both pre- and postoperatively (pain, instability, motion, ulnar neuropathy) and radiographically. Furthermore, at the time of follow-up clinical outcome was assessed using the Elbow Function Assessment Scale. Results At review, 7 of 49 elbows had undergone revision because of symptomatic loosening of the ulnar component. In 42 unrevised elbows, clinical outcome was excellent in 29, good in 7, fair in 5, and poor in one. 31 of 42 elbows had no pain; 11 were painful at rest (VAS 1–2) and/or as a result of activity (VAS 1–8). With revision as endpoint, survival was 86% at 6 years. Intraoperative malpositioning of the ulnar component with a valgus or varus alignment of < 5° was associated with worse survival. Interpretation We found an unexpectedly high rate of loosening of the ulnar component, which was associated with intraoperative malpositioning of the prosthesis. The ulnar component of this prosthesis should not be inserted without cement in patients with rheumatoid arthritis.

Arthroscopic elbow surgery, is it safe?

BACKGROUND During the past 10 years, the use of arthroscopic elbow surgery has increased tremendously. The proximity of neurovascular structures and narrow joint spaces make it a technically demanding procedure with many potential complications. The purpose of this study was to report the complications in a large series of patients and identify factors that might have contributed to their occurrence. MATERIALS AND METHODS During an 8-year period, 200 elbow arthroscopies were performed by a single surgeon. All procedures were performed in a standardized fashion. Patient records were reviewed by independent observers. The minimum follow-up for all patients was 8 weeks. RESULTS The only major permanent complication (0.5%) identified was an ulnar nerve injury. Minor complications were identified in 14 patients (7%): 3 transient nerve palsies, 4 prolonged serous drainages or superficial wound infections, 6 persistent elbow contractures, and 1 mild increase in contracture. Of reported patients with complications, 9 (60%) had a history of trauma, fracture, or previous surgery. In 11 patients with direct surgery-related complications, 8 (73%) had a similar history. CONCLUSION The complications encountered in our series are well within the limits of earlier reports and show that with only a 0.5% rate of major complications, elbow arthroscopy is a relatively safe procedure for a wide variety of indications when performed in a standardized fashion. In patients with a history of trauma or previous surgery, the procedure is more challenging and, in less experienced hands, might lead to higher complication rates.